A 50-year-old patient presented with markedly excessive upper eyelid skin and ptosis of upper eyelids. He had severe brow ptosis, hyperactivity of the frontalis, corrugator, and procerus muscles (Figs 7 through 12). He also had severe sagging of the midface with moderate to severe nasolabial folds. There was a significant laxity and hypotonicity of lower eyelids and lateral ligaments. There was festooning of the lower eyelids.

Although a biplanar facelift could have given him more dramatic results, he elected to have endoforehead and endomidface without skin excision The patient underwent this operation in the way that has been described in this text. He had resection of the corrugator and procerus muscles, however, the frontalis muscle was kept intact. He also had a repair of the levator aponeurosis dehiscence and bilateral upper and lower blepharoplasty with extensive lower eyelid skin excision. A lateral canthopexy was performed. He had asymmetric brows before surgery. Despite the slight overcorrection in left side, he still presented the slight asymmetry of brow position. The patient was not interested in a secondary repair of this asymmetry. However, upon questioning which eyebrow he liked more, he pointed to the right side. This is probably a reflection that a slight overelevation of the brow position is not as negative a factor as many let us believe.

Postoperatively, you can see the significant improvement of the activity of the frontalis, corrugator, and procerus muscles. The patient has an open and rested kook of his eyes. The midface has keen elevated with significant improvement of the ptotic cheek mounds and significant improvement of the periocular tissues. In general, the patient looks much younger and rested (This case was done in conjunction with Joseph C. Orlando, MD.)

REFERENCES

1. Keller GS Use of the KTP laser in cosmetic surgery American Journal of Cosmetic Surgery 9 i77-180, 1992
2. Ramirez OM: Oneal R: First international workshop on facial rejuvenation: The subperiosteal and other deep plane techniques. Baltimore, MD. April 1992
3. Core GB, Vasconez LO: Asken C, et al: Coronal face-lift with endoscopic techniques. Plastic Surgery Forum 15:227-229, 1992
4. Liang M. Narayanan K: Endoscopic ablation of the frontalis and corrugator muscles-A clinical study: Plastic Surgery Forum 15:54-56, 1992
5. Isse NG: Endoforehead. Presented at the Second International Workshop on Facial Rejuvenation: Subperiosteal Facelift, Ancillary and Alternative Techniques Baltimore, MD, April 1993
6. Ramirez OM: Endoscopic Forehead and Facelift. Presentation at the Endoscopic Plastic Surgery Educational Seminar. Newport Beach, CA, June 1993
7. Ramirez OM: Daniel RK: Endoscopic aesthetic surgery: A video manual. New York, NY, Springer Verlag, 1995
8. Ramirez OM: Endoscopic full facelift. Aesthetic Plast Surg 18: 363-371, 1994
9. Ramirez OM: Endoscopic subperiosteal facelift. Clin Plast Surg (in press)
10. Ramirez OM: Classification of facial rejuvenation techniques based on the subperiosteal approach and ancillary procedures. Plast Reconstr Surg (in press)