The technique of endoscopy in facial rejuvenation is a new approach that has fascinated surgeons and patients for their ability to do face-lifting without removing skin. The combination endoforehead-endomidface lift is very appealing for the younger individual with sagging of the brows and midface. Typically, the operation starts with the midface dissection via lower blepharoplasty incisions. The endoforehead is performed using five slit incisions. A fascicular dissection of the supratrochlear nerve is mandatory to avoid damaging this nerve and to assure an accurate excision of the corrugator muscles. The midface subperiosteal-deep fascial pocket is connected with the temporal pocket through the splitting of the intermediate temporal fascia. Anchoring and suspension are done in a step-ladder fashion starting with the canthopexy, proceeding with the suborbicularis oculi fat suspension to the temporal fascia proper, and superficial temporal fascia to temporal fascia proper suspension. The frontal scalp is suspended to a percutaneous self-tapping screw post using skin staples. All the slit incisions are closed without removing skin except the lower blepharoplasty, that in most cases, skin muscle excision is required. The operation is finished with well-applied frontal and midface taping.

Endoscopic techniques in facial rejuvenation are relatively new. Several authors in different centers began exploring this possibility about 3 years ago.^1-5 My personal involvement started in January 1992 when I did my first endoscopic-assisted biplanar forehead lift using the flexible endoscope.² In April 1992, myself and Robert Oneal used the endoscope for an endoscopic-assisted open subperiosteal face-lift in two clinical cases during a live surgery demonstration as a part of the First International Workshop for Facial rejuvenation at The Johns Hopkins Hospital in Baltimore, MD.² In June 1993 at the First Endoscopic Seminar hosted by Isse in Newport Beach, I presented several cases of subperiosteal endoforehead lift, endoscopic-assisted biplanar forehead lift, cases of combined endoforehead and midface lift, and full endoscopic face and neck lifts with and without skin excisions. The first recorded full face-lift without skin excision was performed in April 1993.⁶ This preceeded Isse's first combination endoforehead-endofacelift performed by him in July or August of the same year. After the initial presentations, several plastic surgeons in different centers embraced these techniques and began exploring their own versions of facial rejuvenation using the endoscope.

I have described several variations and combinations of techniques that can be found elsewhere.^7-10 The aim of this article is to present my personal preference in regards to the plane of dissection and one particular type of technique out of the several variations of my classification: Subperiosteal lift Type V B, which is the combination endoforehead-endomidface without skin excision.¹⁰

SURGICAL TECHNIQUE

The combined technique of upper and midface endoscopic lift are described in this article. For systematic reasons, the operation can be divided sequentially: (1) midface dissection, (2) endoforehead dissection, (3) temporomalar tunnelization, (4) fixation, and (5) dressing. Although the operation could start with the endoforehead first, I prefer to start with the midface for several reasons:

1. The larger access (blepharoplasty incisions) allows application of neurosurgical pledgets moistened in 1: 50,000 epinephrine solution for temporary control of capillary bleeding while the dissection on the forehead is carried out.
2. The elevation of the periosteum off the zygomatic arch early on assures the protection of the frontal branch of the facial nerve.
3. As soon as the endoforehead portion of the operation is done, you can immediately do the midface and forehead fixation.
4. The interval between endoforehead and dressing is short and decreasing the likelihood of periorbital edema particularly of the upper eyelids.