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.

Midface Dissection

The only incisions I use for the midface are the lower blepharoplasty incisions. Only in rare circumstances when I do not want to do the lower eyelid or this is contraindicated, the Caldwell-Luc approach is used. In that circumstance, the suborbicularis oculi fat (SOOF) sutures are applied from the intraoral approach and guided to the temporal area for anchoring. The blepharoplasty is done by dissecting skin and then skinmuscle flap leaving intact the pretarsal orbicularis oculi muscle. Dissection is continued down to the inferior orbital rim. The periosteum and the SOOF are elevated in a unit. Dissection is proceeded laterally toward the zygomatic arch and the lateral orbital rim. A cuff of periosteum around the lateral orbital rim is left intact to protect the insertion of the lateral canthal tendon. The endoscope is introduced when the dissection is about 1 cm from the margins of the orbital rim. Inferiorly, the dissection is continued to elevate the periosteum off the rest of the zygoma and the maxilla down to the canine fossa. The levator labii superioris, which originates on the bone superior to the infraorbital nerve, is elevated but the nerve itself is well protected during dissection. The periosteum covering the Bichat's fat pad is broken. Laterally, the fascia of the masseter muscle is elevated off the tendinous portion of the masseter muscle. More laterally, the entire zygomatic arch periosteum is elevated. This is dissected in continuity with the fascia of the masseter muscle and with the intermediate temporal fascia. The intermediate temporal fascia with its attached intermediate fat pad is elevated off the deep fascia for about 2.5 cm above the arch (from inferior to superior direction). The sequence of dissection is as depicted in Figure 1. When the entire pocket on the midface and the zygomatic arch is developed, neurosurgical pledgets moistened in 1:50,000 epinephrine solution is packed temporarily. Next, attention to the upper face is given.

Typically five incisions are used to perform the endoscopic forehead portion of the dissection (Fig 2). One incision is located in the midline, two lateral frontal incisions about 4 cm from the midline, and two incisions in the temporal area, each measuring about 1.5 cm. The temporal incision can be extended up to 2.5 cm because on most occasions the endoscope and one elevator is introduced through the same incision. In general, I prefer to do the incision a little bit larger and do a meticulous closure at the end rather than make a small incision and traumatize the edges of incision with subsequent loss of hair.

The dissection in the temporal area is proceeded in the plane described up to about 1 cm above the zygomatic arch. Observe that at this point, there are two planes of dissection around the intermediate fascia, one dissection under the intermediate fascia coming from the zygomatic arch, and the other plane of dissection over the intermediate fascia coming from the temporal area. When you approach the zygomatic arch, three veins, the middle one accompanied by the small artery and the zygomaticotemporal nerve branches, are found. For a typical endoforehead, this is the lower limits of the dissection; however, if the dissection is continued toward the midface, these vessels need to be dissected free, separated from the attached fascias, and a clean electrocauterization needs to be done using the U-shape endoscopic electrocoagulator made by Snowden-Pencer, Inc. (Tucker, GA). The zygomaticotemporal nerve is sharply transected close to the subgaleal fascia. The temporal pockets are packed with neurosurgical pledgets and the dissection is now concentrated to develop the frontal pocket. The subpreiosteal dissection of the frontal area is done through the central and the paramedian incisions previously mentioned. Initially the dissection is done with slightly curved periosteal elevators (Ramirez periosteal elevator #1 and #2, Snowden-Pencer, Inc). This dissection is proceeded blindly up to about the midforehead level. Posteriorly the subperiosteal dissection is continued with the elevator #3. Then the planes of dissection between the temporal and frontal pockets are connected in the upper most portion of the dissection. This dissection is carried out up to the vertex, and this dissection follows a gentle curve toward the posterior auricular areas. The temporal line of fusion is elevated very clearly using the elevator #4.