The convexity in the male and female differs significantly in extent and projection. In a female, the convexity, as mentioned, extends to the upper lip. However, in the male, the convexity is short and ends at the level of the projection of the nasal ala. In general, this outline gives to the male midface a more angular and bony look. Conversely, in the female, the large convexity gives an impression of softer and delicate features without significant angularity, or a rounder look. It also shows a less bony facial appearance. As I mentioned, one of the important goals of midface rejuvenation is to create this reciprocal multicurvilinear line of beauty, or ogee line. The first step in this goal is to identify that you are creating a female or on a male – midface appearance.

20.8Technique

Midface remodeling and lifting via an intraoral incision alone can be used in younger patients. This procedure called an endomidface lift can be done via a single intraoral 2.5 cm incision. However, the inclusion of the temporal component of the forehead provides superior results. This procedure is called an endotemporo-midface lift. This is used in most of the older patients because you will need the added lift and remodeling of the lateral periorbita and the temple, otherwise crowding and folding of tissue in those areas can be an unsightly appearance after the surgery. For logistic reasons, the most common endoscopic facial procedure that I perform is the combination endoforehead/endomidface lift. For the purposes of this chapter, I will only describe the endotemporo-midface lift which is the optimal technique for midface rejuvenation and beautification. Before going into the technique, it will be important to become familiar with the author’s relevant anatomical nomenclature (Table 20.1), instruments (Ramirez Endoscopic Instrument Set, Snowden Pencer and Black & Black, Tucker, GA), and relevant anatomy (see Chap. 2).

Surgery starts with a 2 cm temporal incision done within the hair-bearing portion of the temporal scalp (Fig. 20.4). This incision is normally located perpendicular to a line joining the nasal ala and lateral orbital rim extending into the temple. The incisions should be 2 cm posterior to the temporal hairline, and directed parallel to the hair follicles to prevent alopecia. Caution is advised not to make the incision too anterior in patients with significant and excess temporal hair. In these cases, the incision can be at or close to where the branches of the frontal nerve travel, and inadvertent injury is possible. In patients with sparse hair or with high temporal hairlines, do not make the incision too posterior or superior, to prevent overshooting the location of the temporal fascia proper (TFP) which will effect tissue suspension. After the skin incision, continue dissection to the white glistening surface of the TFP and proceed with dissection under direct visualization (directly on top of the TPF and below the superficial temporal fascia (STF)) for several centimeters in radius. The Guyuron’s Endoscopic Access Device (Applied Medical Technologies, Brecksville, OH) is introduced at the incision for protection

Table 20.1 Ramirez anatomical nomenclature of the temporal and midface areas

Fig. 20.4 The midface portion of the surgery starts with the temporal component for which a 2 cm incision is made. This is located in the temporal scalp on a line tangent to a line that joins the nasal ala and the lateral canthal area

of the hair follicles and to avoid penetration of hair into the surgical wound. Further dissection is done under endoscopic visualization. I use a 5 mm diameter, 30° downangled endoscope over which the “Ramirez cobra sleeve” is applied (Snowden Pencer, Tucker, GA; Black and Black, Tucker, GA).

With a No. 4 Ramirez periosteal elevator, in the same surgical plane, the soft tissue is elevated until the temporal line of fusion (TLF) and the area of the sentinel vein, or temporal vein No. 2 (TV2), are identified. The TLF is a curvilinear linear structure extending from the level of the lateral margin of the superior orbital rim superiorly toward the parietal bone. It is present approximately 3 cm above the zygomatic arch and consists of a horizontal line of fascial blending where the TFP splits into a superficial and deep layer, with the intermediate temporal fat pad in-between (see Table 20.1). Posterior to the axis where the temporal branch (frontal nerve) of the facial nerve is located, dissection can continue to the root of the helix and posterior zygomatic soft tissue area.

Although the central forehead is not usually entered in standard midface surgery, most of the time elevation of the tail of the brow and crow’s feet area are preferred. Therefore, dissection should continue for 1–2 cm medial to the TLF, and to the lateral one third of the brow. To do this, a curved Ramirez periosteal elevator No. 8 is used. This splits the periosteal and temporal fascia attachments (conjoined tendon), and dissection continues under the periosteum of the frontal bone. Inferiorly, dissection continues subperiosteally to incise the lateral extent of the arcus marginalis at the superior orbital rim, and to elevate the galea off the lateral orbital rim periosteum, but the periosteum of the lateral orbital rim is left intact (Fig. 20.5).

The “zero” Ramirez periosteal elevator is then introduced to dissect toward the zygomatic arch again in a safe plane between the STF and TFP. Tunnels anterior to the TV2 and in between this and the zygomatic temporal nerve (ZTN) are made. Near the zygomatic frontal suture line, a small vein (TV1) is usually split and electrocoagulated. Through the mentioned tunnels and with the aid of the endoscope and the Ramirez periosteal elevator No. 9, the zygomatic arch periosteum is entered and elevated just at the superior border of the arch and on its anterior one third. When this plane of dissection (subperiosteal) has been indentified, lateral dissection over the middle third of the zygomatic arch is performed. This subperiosteal plane is needed to protect the frontal branch of the facial nerve.

Rarely, the lateral one third of the arch is elevated. This lateral zygomatic arch dissection is needed when a more lateral vertical lift of the cheek is required. If the masseter tendon/ muscle fascia is easily elevated from the temporal approach this can be continued 1–2 cm inferiorly. If not, this part of the dissection should proceed from the intraoral approach.

Fig. 20.5 On the lateral orbital rim, the subperiosteal dissection continues with a supraperiosteal dissection. This ensures periosteal integrity if canthopexy procedures are added to the operation.Laterally, a superiosteal dissection is done to connect the temporal and midface pockets across the zygomatic arch

The sequential endoscopic views in Fig. 20.6 show the midface dissection. The intraoral incision is obliquely/vertically oriented at the level of the first and second premolar, away from the opening of the Stenson’s duct. The ends of the incision can be extended in a Z-shape if additional access is needed. Initially, the mucosa is incised with a No. 15 blade.The underlying buccinator muscle is bluntly separated during deepening of the incision toward the maxillary bone. With a No. 9 Ramirez periosteal elevator and with the aid of an Autfricht lighted retractor, a subperiosteal dissection ensues until the infraorbital nerve is identified. The dissection continues medially to the piriformis aperture and laterally to the masseter tendon insertion to the malar bone. If the visualization becomes cumbersome or difficult, the endoscope and the Ramirez periosteal elevator No. 8 are introduced and the dissection is continued laterally, elevating the fascia of the masseter muscle in continuity with the subperiosteal plane of dissection above the malar bone. Superolaterally, the periosteum of the zygoma body is elevated until the pre-dissected section (coming from the temporal approach) of the zygomatic

Fig. 20.6 This sequential endoscopic view on the left side of the patient shows: (a) Intraoral incision at the level of first premolar (pm). (b) Dissection over the maxilla and zygoma towards the infraorbital rim (arrows) with the Ramirez minus 4 (R−4) elevator. (c) The infraorbital rim (arrows) is exposed after the arcus marginalis (interrupted

points) has been elevated. More laterally observe two branches of the zygomatico facial nerve (ZFN). (d) More laterally and inferiorly the masseter fascia is being elevated off the masseter tendon/muscle. Observe the location of the SOOF (Suborbicularis oculi fat)

arch (also in a subperiosteal plane) is made continuous with the malar dissection. Extension of the surgery around the inferior and lateral orbital rim should preserve the zygomatico facial nerve (ZFN).

In most cases, a 2–3 cm dissection over the masseter tendon is required. A wide connection between the midface and temporal pockets facilitates vertical lift and repositioning of the tissue elements that produce volumetric changes (Bichat’s fat pad, imbrication of SOOF, etc.) at the zygomaxillary point. Superiorly, the periosteum and soft tissue attachments to the inferior orbital rim are manipulated using a combination of No. 9 and a −4 (minus 4) Ramirez periosteal elevators. The inferior arcus marginalis is elevated as is the periorbita 2 or 3 mm inside of the inferior orbital rim (Fig. 20.7). Dissection superior and medial to the infraorbital nerve is not yet performed. This portion of the procedure is completed after all the midface suspension sutures are applied and just before anchoring the midface to the temporal fascia is carried out. The attached surrounding muscles and soft tissues will protect the infraorbital nerve from inadvertent excessive traction during the midface manipulation.

Traction is usually the cause for neuropraxia and numbness of the cheek, and upper lip postoperatively. The levator labii superioris and the orbicularis oculi muscle attachments to the medial and infraorbital rim are detached using the −4 (minus four) or the “zero” elevator.

The next critical step is the fixation of the midface. The number of fixation sutures placed and tension applied to these sutures is individualized. Only experience will dictate this part of the procedure. The inferior arcus marginalis is grasped with a 4–0 PDS suture on an RB1 needle. This is done in a vertical plane of the lateral limbus of the eye. The suborbicularis oculi fat (SOOF) is grasped approximately 1.5 cm inferior to the orbital rim and at the level of the medial limbus (Fig. 20.8). Both ends of the suture are either tied or driven to the temple pocket through a tunnel in between the orbital rim and ZFN and anterior to the temporal vein No. 2 (TV2). This suture is then anchored to the most anterior portion of the TFP using the sliding endoscopic “Peruvian” fisherman’s knot [8]. This will vertically elevate the infraorbital SOOF (as opposed to the next suture – the lateral SOOF) in a superior and superolateral position over the infraorbital rim.

Fig. 20.8 These sequential endoscopic views (a–d) show the elevation of the Medial (infraorbital) SOOF towards the arcus marginalis (AM) using 4–0 PDS suture. Arrows show the orbital rim. The suture engages

the fixed AM at the level of the lateral limbus, and the mobile Medial SOOF at the level of the medial limbus. As the suture is tied, the Medial SOOF is elevated superolaterally to efface the tear trough

Fig. 20.9 Diagram showing the additional three suspension points for midface remodeling: the lateral SOOF, the Modiolus, and Bichat’s fat pad (BF). Observe the decussation and orientation of the sutures. All are suspended in the temporal fascia proper (TFP) below the endoscopic entrance point. Also observe the frontal fixation (when endoscopic browlift is added) with the Ramirez self stabilizing percutaneous screws (Synthes, Paoli, PA)

In addition to the infraorbital SOOF suture above, three additional suspension sutures are applied (Fig. 20.9). These are anchored after final dissection medial to the infraorbital nerve is completed (as described previously). The first of these suspension sutures is to the lateral SOOF. This tissue is located 3–4 cm inferior to the lateral canthal tendon and is the bulkiest portion of the cheek mound. It is engaged with a 3–0 PDS suture on an RB1 needle.

The next suspension suture (modiolus suspension) is applied to the fascio-adipose tissue just superior to the modiolus, using a 4–0 PDS suture with an RB1 needle. The tissue is engaged near the mucosa, just anterior at the intraoral incision. The suture is woven 2 or 3 times tangentially to the plane of exposure to prevent catching a branch of the buccal nerve. (I have not had a neuropraxia related to this suture.)

The last suture is applied to Bichat’s fat pad (BFP also called the buccal fat pad); BFP is exposed and extruded from the buccal space after the modiolus stitch is applied. If either of the cheeks, inferior orbital rim and/or piriformis implants, are used, these implants are fixated before BFP is mobilized. Inadvertent exposure of Bichat’s fat pad prior to carrying out all these maneuvers will interfere with visualization as the fat pad will constantly protrude from the buccal space. BFP is extruded from its containment box with a blunt scissors, dividing the buccal space fascia between the

anterior border of the masseter tendon and the lateral aspect of the maxilla. The constitution of the fat pad is very similar to that of eyelid fat, and its associated fascia is finely vascularized. The fat pad is mobilized using two blunt and smooth forceps or by similar neurosurgical forceps. With one forceps, BFP is pulled gently and with the other forceps, the fascia of the buccal space is teased away. This maneuver is similar to the mobilization of an inguinal hernia’s sac from the peritoneal wall. It is critical to maintain BFPs fine protective fascia to allow its mobilization as a pedicle flap.

BFP tends to herniate down in front and anterior to the masseter tendon and muscle and lateral to the zygomatic major muscle in a trajectory from deep to superficial. This triangle is bounded inferiorly by the mandibular bone. This is a weak area of the midface covered only by thin SMAS layer. The buccal space fascia is similar to the peritoneal sac and tends to follow the migration of the “hernial content” in this case the BFP. This entity has been described by Matarasso in the past [9]. Gently pushing with the index finger from the outside of face at the level of the jowl toward the maxillary bone helps to further mobilize the low lying fat pad. The fat pad is mobilized for about 3 cm outside the buccal space into the intraoral incision. Here, it is grabbed with two or three woven 4–0 PDS sutures on an RB1 needles. A trial of mobilization toward the upper dental arcade outside the intraoral incision is made pulling the anchoring suture very gently. This is done to check if the fat pad is free without obstruction. The buccal fat pad is pushed back into the buccal space and both ends of the suture are driven to the temporal area and are brought out through the temporal incision. If the goal is to fill the submalar space with the uppermost projection at the level of the SOOF, then the suture is tied “piggy back” to the loop of the SOOF suspension suture. This will limit the upper ascent of the fat pad. If the goal is to give a more generalized volumetric augmentation of the cheekbone then the suture is anchored to the TFP.

As you have noticed, the sequence of suture placement in the midface started with a vertical (infraorbital) SOOF suspension which is secured to the TFP. Then the lateral SOOF, the modiolus, and BFP are secured as described. The sequence of anchoring and tying the last three sutures to the TFP is reversed. BFP is anchored first, then the modiolus, and the lastly the lateral SOOF. The placement of the sutures in the temporal plane also follows a sequence: the BFP suture is located anteriorly, the modiolus suture in the center, and the SOOF suture more laterally. This way, all the sutures are crisscrossed at the level of the zygomaxillary point with a maximum volumetric augmentation at this desired maximal point of projection. The effect of each one of the sutures is different, and when they are combined, the effect is synergistic.