This part of the operation is critical when you combine the endoforehead with the endomidface. The safest way to do this portion of the operation is to apply several neurosurgical pledgets under the zygomatic arch periosteum and the intermediate temporal fascia through the eyelid approach. Then come through the temporal approach, either with the scissors or with the Colorado tip cautery and transect the intermediate temporal fascia. This transection is done about 1.5 to 2 cm above the zygomatic arch. Remember the intermediate temporal fascia should be clean from the overlying subgaleal fascia and the superficial fat pad in its most lower portions from the temporal approach to make a clean incision in the intermediate temporal fascia itself. It is extremely difficult to separate the intermediate fat pad from the intermediate temporal fascia. Although technically it is possible to do that, however, in practicality, little advantage is gained with this unless the patient presents some tendency of temporal depression preoperatively. The intermediate fascia and the intermediate fat pad are widely separated parallel to the length of the zygomatic arch. The zygomatic arch is entered from above and the temporal with the malar pockets are connected (Fig 5). During this maneuver it is important to identify the superficial temporal fat pad and the trajectory and location of the frontal branch of the facial nerve in a tridimensional orientation. A more extensive anatomy of the subject and the new nomenclature of these temporal fascias and fat pads can be found in an article by Ramirez and Daniel.⁷

The first step in the fixation process is to do the lateral canthal ligament plication or transosseous canthopexy depending on the clinical situation (Fig 6). If the lower eyelid is lax without mal position, then a plication canthopexy will be enough. However, if the patient has a displaced lateral canthal ligament, a transosseous canthopexy may be needed. This is beyond the scope of this article, therefore, I will not elaborate on this. After the canthopexy is performed, then we proceeded with identification of the SOOF with its attached periosteum. Two horizontal sutures in the SOOF periosteum are applied to avoid taking into your bite any muscle fibers of the midface. One of the sutures is applied 0.5 cm medial to the level of the lateral canthal ligament and another one 0.5 cm lateral to the same. I usually use 2-0 Polydioxanone (PDS) sutures (Ethicon, Somerville, NJ). These sutures are guided to the temporal pocket through the tunnel made in the previous step of the operation. Each one of these PDS sutures are anchored to the temporal fascia proper maneuvering these through the temporal incision. Both sutures should be applied parallel to each other avoiding crisscrossing. Each one of the sutures are applied 1 cm below the level of the temporal scalp incision. The application of the sutures into the fascia and the endoscopic fisherman's knots are done initially without applying the locking sutures. The locking sutures are applied only when the contralateral SOOF-temporal fascia proper anchoring stitches are applied and symmetry of elevation and traction are considered to be equal. From that point on, we proceed with applying the locking sutures. If the patient presents too much redundancy of tissue in the temple areas, I recommend suspending the free border of the intermediate fascia to the temporal fascia proper.

Next, the frontal scalp is fixed using the technique of "adjustable screw staple scalp fixation."⁹ Preoperatively, according to your aesthetic goals, a decision should be made as to which part of the brow is going to be elevated more: the head, the central arch, or the tail. The tail of the brow is usually controlled by the temporal anchoring sutures, the arch of the brow is controlled by the paramedian screw fixation, and the head of the brow is controlled by the central frontal screw fixation. Usually screws at the paramedian incisions are the only ones needed and only very rarely a screw is needed in the midline. If a screw is going to be applied in the midline, this can be moved a little bit off the center to potentially avoid the sagittal sinus. However, in this area the thickness of the frontal or parietal bone seems to be the highest. I use a 1.5-diameter drill with a 4-mm stopper to make the bone drilling. A 14-mm long, 2-mm diameter self-tapping screw is applied in these external cortical holes. The location of this is done according to preestablished measurements. A ratio of scalp elevation-brow elevation of 2 to 3:1 is used. This variation is in relation to the thickness and heaviness of the skin on the forehead. For heavy forehead, a 3:1 ratio is used and for the thinnest one a 2:1 ratio. In other words, for every millimeter of brow that needs to be elevated, 2 mm of the scalp position in relation to the bone needs to be elevated. After the self-tapping screws are applied through the paramedian incisions, the assistant pulls the scalp from the posterior end of the slit incisions using a blunt hook, and skin staples are applied posterior to the screw post on the scalp. These screws will hold the position of the scalp in relation to the screw posts. The remaining incisions are also closed with skin staples. The staples are applied every 2 mm or so. If an adjustment is needed to elevate or to decrease the height of the brow, then adjustment of the scalp position is made changing the position of the staples in relation to the screws up to 48 hours following surgery. The remaining incisions are closed with skin staples.

Excess skin is removed from the lower eyelid. Although the vertical lifting will allow removal of huge amounts of lower eyelid skin, conservatism is always a good approach to avoid shortening of the lower eyelid skin. In general, the amount of skin removed is two and sometimes three times as much as that removed using standard techniques. The lower eyelid incision is closed in a standard fashion.

Dressing

Mastisol (Ferndale Laboratories, Ferndale, MI) and well-contoured tape to the forehead and cheek are applied. I usually use 1/2-inch Micropore (3M, St Paul, MN) flesh-colored tape which I leave on for about 5 days or more. This tape will allow edema to decrease in the elevated flaps and will potentially allow quicker redraping of the frontal and cheek soft tissues. A soft dressing around the head can be applied for a couple of days. This avoids the patient looking and touching the screw posts, at least during the initial few days of the healing process.