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.

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)