anchoring devices [13, 14]. The technique described below uses suture fixation from the periosteum to the galea.

The endoscopic forehead lift technique performed by the authors is designed to create a harmonious natural-looking result and to give the patient a non surgical look.

For this reason, it does not aim to eliminate mobility of the procerus, corrugator supercilii, and orbicularis oculi muscles. It seeks to diminish the lines created as a result of the action of these muscles, and to elevate the brow naturally.

Glabellar, forehead, and crow’s feet lines may reappear after surgery if the patient has a habit of frequent muscle contraction. Consequently, the periodic use of botulinum toxin is required in order to avoid their reappearance in many cases. However, since the eyebrows are set at a higher position, the patient does not feel the need to contract the frontalis muscle frequently and there is a smaller chance of the forehead lines forming again in the short run.

Endoscopic forehead lift may be combined with other facial plastic procedures in order to produce a more harmonious overall result. When performed simultaneously with upper lid blepharoplasty, skin resection must be very accurate if postoperative openeye complications are to be avoided. This technique can also be combined with an endoscopic middle third face-lift.

Fig. 44.10 Infiltration of working incisions

emerge. In some instances it is important to have a long cautery tip at hand for hemostasis.

44.6.2 Anesthesia

The procedure may be performed under local anesthesia and mild sedation. The incision areas in the scalp and the areas where sensory nerves (supratrochlear, supraorbital, and temporomalar nerves) emerge in the forehead are infiltrated with lidocaine 1:200,000, with 1% epinephrine (Fig. 44.10).

44.6 Technique

44.6.1 Instruments

Only three dissectors are required in the vast majority of cases: a sharp dissector, a blunt dissector, and a 90° angled dissector used to detach the arcus marginalis at the upper orbital rim. The 30° endoscope with its protective sheath and continuous saline solution irrigation channel allows for constant flushing of the lens and clear visualization of the surgical field. Metzembaum scissors may be used instead of endoscopic scissors, because they enable an accurate sectioning of muscle and periostium and dissection at the sites where the supratrochlear and supraorbital neurovascular bundles

44.6.3 Delimitation of the Working Areas

1.Hair implantation line: serves as a guide for hiding scalp incisions.

2.Middle vertical line: reference for the vertical incision.

3.Vertical line on the lateral corneoscleral limbus: reference for intermediate incisions.

4.Superior temporal line: defines the point of insertion of the temporalis muscle on the frontal and parietal bones and the place where the lateral and medial dissection planes will meet.

5.Zygomatic arch: helps determine the inferior extension of the dissection and the safe dissection area in order to protect the frontal branch of the facial nerve.

7.Site for the periosteum and bilateral orbicularis oculi sectioning.

8.Marking of the horizontal lines of the forehead, crow’s feet, and horizontal and vertical glabellar lines.

9.The following working incisions are marked:

(a)Vertical midline, 5 mm superior to the hairline, approximately 2.5 cm in length.

(b)Bilateral vertical lines crossing the lateral scle-

(c)Oblique incisions in the temporal region, 2.5–1 cm from the hairline and parallel to it (Fig. 44.11).

44.6.4 Skin Incisions

A number 15 blade is used for skin and subcutaneous cellular tissue incisions. Scissors are used to find the supraperiosteal subaponeurotic plane in the frontal c vertical incisions and the interfascial plane (between

the superficial temporalis fascia and the superficial layer of the deep temporalis fascia) in the temporal region. This plane is readily identifiable because the deep temporalis fascia does not move when skin edges are pulled. However, when in doubt, a small incision will reveal the characteristic temporalis muscle (Fig. 44.12).

44.6.5Subaponeurotic Supraperiosteal Dissection

The subaponeurotic supraperiosteal dissection is performed through the vertical frontal incisions using the blunt dissector over a length of approximately 4 cm toward the vertex. This is an avascular plane that usually has little or no bleeding (Fig. 44.13).

Fig. 44.11 Incision and dissection delimitation. (a) Hairline. (b) Middle vertical line. (c) Vertical line that crosses the lateral sclerocorneal limbus. (d) Superior temporal line. (e) Zygomatic arch. (f) Supratrochlear and supraorbital neurovascular bundles emergence site. (g) Site for periosteal and bilateral orbicularis oculi sectioning. (i) Midline incision. (j) Paramedian vertical line incision. Note the marking of the horizontal forehead lines, crow’s feet, vertical and horizontal glabellar lines, and incision in the temporal region

Fig. 44.12 Skin incisions

44.6.6 Subperiosteal Dissection

A frontal periosteal incision is performed using a number 15 blade through the frontal vertical incisions, and the sharp dissector is then used to elevate the

a

periosteum of the frontal region, up to 1 cm above the brow implantation and laterally out to the upper temporal line at the site of implantation of the temporalis fascia (Fig. 44.14).

44.6.7 Interfascial Dissection

Once the plane between the deep and superficial layers of the deep temporalis fascia (interfascial plane) has been identified, the blunt dissector is then used to bring the dissection up to the upper temporal line, 1 cm short of the lateral orbital rim (Fig. 44.15).

44.6.8Communication Between the Two Pockets

The same dissector is then used to connect both pockets – the interfascial pocket of the temporal region and the subperiosteal pocket of the frontal region. This creates a sufficiently broad flap to allow the use of the endoscope and the surgical instruments (Fig. 44.16).

b

Fig. 44.14 Subperiosteal dissection. (a) Endoscopic view of periosteal flap elevation using a blunt dissector. (b) Endoscopic view of the raised periosteal flap. (c) External view of the placement of the endoscop and the dissector

44.6.9 Endoscope Placement and Use

Fig. 44.15 Dissection along the interfascial plane down to 1 cm off the lateral orbital rim. (a) Identification of the dissection plane. (b) Blunt dissection. (c) Endoscopic view of the interfascial dissection

The endoscope is placed through the lateral vertical incision in the frontal region, and blunt dissection is then performed through the temporal incision. This

dissection proceeds up to the lateral orbital rim until the sentinel vein is encountered. This vein is protected as much as possible, working around it in order to