Endoscopic assisted face lift.

Review of 200 cases

Hisham Seify, John Bostwick M.D, Glyn Jones M.D. Roderick Hester M.D. Division of Plastic

Reconstructive and Maxillofacial surgery, Emory University School Of Medicine, Atlanta, GA

Correspondence: Division of Plastic Reconstructive and Maxillofacial surgery. Emory University School Of

Medicine.

Correspondence address:

Phone: 404-993-9870

Fax: 770-270-9204

E-mail: Houshy@aol.com
Abstract:

A total of 200 patients, seeking facial rejuvenation, underwent Endoscopic assisted face-lifts alone or in combination

with other aesthetic procedures. Thirty-four cases were secondary face-Lifts (17%). The study of this experience serves as the

basis of this paper. Data cards were completed for each patient retrospectively. We divided the patients into four

groups according to the type of incisions and the surgical approach utilized in each of them.

The technique described utilizes limited access incisions in order to reposition the ptotic facial elements . Under

endoscopic visualization, the composite lift elevates the malar fat pad above the zygomaticus muscle to the

nasolabial fold. The lower- lid orbicularis oculi muscle is incorporated and lifted with composite flap through the

lower blepharoplasty incision. .The jowl area is contoured by tangential excision with scissors and tightening the

lateral platysma .Pre-tunneling and hydro dissection defines the plane of dissection and helps to reduce the bleeding

during facial and cervical flap elevation.

In this study, the group of patients who benefited from the endoscopic approach was the group with tight skin and

good elasticity (Young or redo cases). A patient with excess skin would benefit from a standard cervico- facial

incision; the endoscope could still be used as a tool for better magnification and illumination.

Our study identified a higher satisfaction rate, decreased postoperative pain, lower incidence of Haematoma as well

as lower redo rates in the group where Endoscopic face lift was used.

Introduction:

Over the past thirty years the practice of facelift surgery has been altered considerably as our understanding of

the mechanism of facial aging evolved (1). The current emphasis is on selecting a number of face-lifting and

ancillary procedures (face lift, laser, chemical peel etc.), which, in combination, provide the optimum overall result

for a given patient. The recent advent in facial Endoscopic surgery has stimulated a fresh surgical interest in the

detailed anatomy of the face .The most obvious advantage for plastic surgeons is that the endoscope allows minimally

invasive surgery to be applied to a number of common procedures. Providing that skin excess is not part of the

problem, visible skin scarring can be reduced to small access "port" incisions, hidden in favorable locations, while

achieving as much beneath the skin as might be done by open technique. (2)
Open procedures have required an extensive temporal, preauricular/postauricular skin incision to allow access for

deep tissue repositioning, and removal of excess skin. Minimally invasive techniques have enabled to re-evaluate this

approach to selected patients. (3)

Patients requesting facial rejuvenating procedures have different degrees of rhytidosis. The face lift technique

and the access incisions are individualized according to the need of each patient.

Material and methods:

A total of 200 patients (196 females, and 4 males), underwent rhytidectomy alone or in combination with other

aesthetic procedures. Thirty-four cases were secondary face-lifts (17 %). The patients were divided into four groups

according to the access incision utilized in each of them. Data cards were filled retrospectively and included the

patient age, sex; type of incision used and associated procedures. Average follow up consisted of one year.

Surgical technique:

All patients are infiltrated with local anaesthesia using (50 cc zylocaine 1% + 1 mg epinephrine 1:1000 +250 cc

saline). After the hair is prepared, the lines of incision are drawn, as well as the site of the facial nerve and the sentinel

vein. The operative sites are cleansed and draped in a sterile fashion. A first generation cephalosporin (Ancef) l-g is

administered intravenously if the patient is not allergic to the drug. Decadron (8 mg I. V) is given in the same time.

Pre-tunneling of the face is done in all patients through the temporal incision using a 3 mm blunt-liposuction cannula.

Tunneling is done in the subcutaneous plane laterally, and deep to the malar pad of fat medially, the latter being left

attached to the skin. The same cannula inserted through a 2-mm incision behind the earlobe is used to pretunnel the

neck. (Figure 1)
Undermining is then done in the brow area. The brow is undermined in the subperiosteal plane and the subgaleal

plane centrally and over the deep temporal fascia laterally. The brow dissection is completed under endoscopic

visualization , releasing the arcus marginalis and avulsing the corrugator and the procerus muscles as required. (Figure

2).Dissection is completed laterally over the deep temporal fascia, to communicate the central dissection, care to

avoid injury to the facial nerve or the sentinel vein.

Next blunt scissors dissection is performed in the subcutaneous plane of the lateral face. The scope is used to check

homeostasis and for the completion of dissection. (Figure 3)

If an Endo-brow lift has been formed, the level of dissection changes at the superior aspect of the ear from a deep

subgaleal to a superficial subcutaneous level. This transition creates the mesotemporalis protecting the temporal

branch of the facial nerve.

The skin and subcutaneous flap are then elevated in a supra-SMAS plane across the cheek, releasing the zygomatic

and the mandibular retaining ligaments. At the level of the malar eminence and the lateral extent of the malar fat pad

the blunt scissors dissection extends beneath the fat pad. The malar fat pad is left attached to the overlying skin and

will be mobilized upwards and outwards .

After hemostasis is achieved dissection is carried on the opposite side of the face and neck as described. A transverse

incision is made in the submental skin crease (if required), and a subcutaneous dissection of the anterior aspect of the

neck is joined with the lateral preplatysmal neck dissections. The endoscope and insulated graspers are used primarily

for visualization of the optical cavity of the neck and cautery control of bleeding points. (Figure 4)

Blunt scissors dissection is used to elevate the neck flap laterally to beyond the ear, inferiorly to just above the

clavicle, and superiorly over the jowl to connect with the facial dissection. With the face and neck connected, this

cervico-facial space is a potential optical cavity, Procedures such as fat contouring, SMAS and muscle plication,

maintenance of homeostasis can be carried out with the use of the scope.

The jowl fat is visualized over the mid mandibular region, contouring is achieved by means of tangential excision

with scissors. (Figure 5)

Under Endoscopic visualization a 3/0-vicryl suture is placed in the SMAS just lateral to the jowl region. This suture

tightens the jaw line and supports the jowl. The suture is then secured in the SMAS just below the zygomatic arch

.(Figure 6)
The sub mental region is contoured first by trimming excess fat from the subcutaneous tissue .A central 1.5 cm strip of

platysma is excised to expose the subplatysmal fat, which is excised under direct vision.

The platysma is tightened in the midline with two running layers of 3-0 vicryl to provide a tight central platysmal

contour and for overall tightening of the muscular neck support. The skin is lifted superiorly and posteriorly; the

excess skin is trimmed and secured with proximate sutures in the hair bearing area, 6/0 prolene pre-auricular and 5/0

plain retro auricular. Drains are placed in the face and the neck. A sterile dressing is applied.

Results:

200 patients (196 females, 4 males). Mean age 49 y (range 38-60). Ninety two percent of the procedures were done

under general anaesthesia (n=184), and eight percent were done under intravenous conscious sedation (IVCS)

(n=16 patients).

The standard cervico-facial incision was used in 76 patients.(38%),and with the submental in 40 Pt (n=30%).The

post-auricular incision avoided in 50 patients (25%) , the preauricular incision avoided in 34 patient (17%). Thirty-

four secondary face-lifts (17 %). Complications included two Hematomas that required surgical evacuation (1%).

Stratification of the patients' blood pressure was done .One of 42 patients with peri-operative systolic blood

pressure> 150 had hematoma (2.38 percents). The other Hematoma occurred with peri-operative systolic>150 mmHg

and diastolic>90 mmHg. Both were detected within two hours after surgery.
We divided the patients into four groups according to the access incision used in each patient. (Figure 6)

Group (1): 34 patients in which only temporal and submental incisions were used to approach the face. Figure

Group (2): 50 patients in which the limited post-auricular incision was used, together with a preauricular incision.

The post auricular incision extends for 2 cm only in the conchal groove. (Figure 7)

The Sub mental incision was added if the central neck area needed to be corrected (liposuction, direct excision, and

plication of the platysma), other wise neck suction could be done tl1fough the lateral face incision. The endoscope

was used to visualize the lateral neck and jowl for recontouring.

Group (3): 76 patients in whom the standard cervico facial incision was used without a sub mental incision. The

incision is patterned around the ear. The temporal incision is placed within the hairline beginning at a point

immediately superior to the junction of the ear with the temporal skin; the incision then conforms to the margins of

the tragus and inferiorly contours to the margins of the earlobe. The post auricular incision is placed directly within

the conchal groove. The incision then extends into the occipital hairline, where the concha joins the hairline. Figure

Group (4): 40 patients in which the standard cervico-facial incision is used together with the sub mental incision.

Figure
Group 1: Temporal incision, no pre-auricular incisions
Discussion:

Since Lexer's description of a skin tightening technique for the face lifting in 1910, rhytidectomy procedures have

undergone a dramatic transformation as our understanding of facial anatomy has become more advanced. (4)

Duffy and Friedland (5) classified the modern face-lift surgery into four generations: The first generation being

subcutaneous dissection only with variable skin undermining. The second generation deals with the SMAS layer

together with subcutaneous dissection. SMAS treatment includes plication, imbrication, or rotation.

Third generation consists of subcutaneous dissection, SMAS treatment and deep midface dissections. (Subperiosteal

face lift).

The fourth generation addresses correction of excess skin, ptotic orbicularis, malar fat pad, and platysma by

elevation of a bipedicled musculocutaneous flap.

We reviewed 200 cases done at the Emory clinic. We divided the patients into four- groups according to the type of

incisions and the surgical approach utilized in them.

Group (1): 76 patients in which the standard cervico facial incision was used in patients with excess skin laxity.

Group (2): 40 patients in which the standard cervico-facial incision is used together with the sub mental incision.

Group (3): 50 patients in which the limited post-auricular incision was used, together with a preauricular incision.

The post auricular incision extends for 2 cm only in the conchal groove.

Sub mental incision was added if the central neck area needed to be corrected.

Otherwise neck suction could be done through the lateral face incision. The endoscope was used to visualize the

lateral neck and jowl for recon touring.

Group (4):

The temporal and submental incisions were used to approach the face in 34 patients. (17 %). This classification is

useful for proper understanding of the specific needs of every case, (according to the extent of facial aging), and

accordingly deciding the proper operative plan. (6, 7,8,9).

Hamra (10) analyzed the mechanism of aging as reflected by the change in position of the deep anatomic elements,

which are the platysma, cheek fat and the orbicularis oculi muscle. He stressed that these progressive changes keep
the intimate relation between the components of aging constant. The composite rhytidectomy allows elevation of a

composite musculocutaneous flap containing all these elements for repositioning while maintaining their intimate

relationship with each other and with the skin. (11)

The technique described here takes advantage of minimally invasive techniques to reposition the ptotic elements of

facial aging through limited skin incisions. A composite lift elevates the malar fat pad in the deep plane just above the

zygomaticus muscle to the nasolabial fold a lower blepharoplaty is included in the procedure, the lower lid orbicularis

oculi muscle is incorporated and lifted with this composite flap, a strip of muscle is excised and the orbicularis is

supported upwards.

The upper platysma is not incorporated in our flap but rather the jowl area is contoured by tangential excision with

scissors and tightening the lateral platysma. Pre-tunneling and hydro dissection defines the plane of dissection and

helps to reduce the bleeding during facial and cervical flap elevation. A minor, but significant advantage of the

endoscope in facial aesthetics is in the control of bleeding. The superior illumination, and the magnification offered by

the endoscope make identification and control of bleeding points both easier and more efficient.

One potential disadvantage of the endoscopic techniques in face lifting is the risk of trying to do too much with them.

As with any other technique, the key to success is patient selection. In our study, patients with tight skin with good

elasticity (Young or redo cases), benefited from an isolated temporal and sub mental or a limited retro auricular

approach (n=34, 17 %). Patient with excess skin benefited from a standard cervico facial incision. (n= 76, 38 %). A

limited post auricular incision was used in patients with minimal skin excess in the neck area. (N=50, 25 %). In all

cases the scope served as a tool for better illumination and magnification and in neck contouring.

The most compelling advantage of the Endoscopic techniques in aesthetic surgery of the face and neck are that they

allow considerable sub-surface tissue rearrangement with far fewer, or at least, shorter, skin incisions. Since each case

is assessed on its merits, the surgeon has the capability to judiciously combine elements of both open and Endoscopic

techniques for the individual patient. Most patients are very receptive to the idea that certain incisions such as the post

auricular or even the preauricular might be dispensed with entirely. The former, particularly, is often a problem with

postoperative irregularities of healing and a relatively high index of patient dissatisfaction. Again, the caveat must be

mentioned that the Endoscopic approach is not for every patient and the degree of skin laxity and probable excess

needs to be very carefully assessed preoperatively.

Conclusion:

Endoscopic assisted face-lift is still a valid tool in facial aesthetic surgery, especially in the group of patient

with minimal skin excess or in redo cases.

References:

1) Ristow, B. Milestones in the evolution of facelift techniques. Perspectives in Plastic Surgery 8(2): 121, 1994.

2) Bostwick J. Evaluation and planning for aesthetic surgery of the face and neck. In Bostwick J., Eaves F.F., Nahai F.

Endoscopic Plastic Surgery. (PP 137-164) Quality Medical Publishing St.Louis, Mo. 1995.

3) Bostwick. Face and neck lift. In Bostwick J., Eaves F.F., Nahai F. Endoscopic Plastic Surgery. (PP 231-338) Quality

Medical Publishing St.Louis, Mo. 1995.

4) Lexer E: Zur Geischtsplastik.Arch Klin Chir 92:749, 1910.

5) Duffy MJ, Friedland JA: The superficial-plane rhytidectomy revisited. Plast Reconstr Surg93: 1392,1994.

6) Baker, T.J., Gordon, R.I., Stuzin, J.M. Surgical rejuvenation of the face. 2nd Edition. C.V.Mosby, St.Louis, 1993.

7) Hester, R. Subperiosteal malar fat pad elevation through a blepharoplaty approach. Emory International Aesthetic

Surgery Symposium, Atlanta, June 1995.

8) Maillayd, G.F., Cornette de St.Cyr B., and Scheflan M. The Subperiosteal bicoronal approach to total facelifting:

the SMAS deep musculoaponeurotic system. Aesth.Plast.Surg. 15: 285-91, 1991.

9) Ramirez, O.M. Endoscopic full face-lift. Aesthetic Plast. Surg.18: 363,1994

10) Ramirez, 0. Endoscopy in facial rejuvenation. Perspectives in plastic surgery, 1995.

11) Schuster, R.H., Gamble, B.W., Hamra, S.T., Manson, P.N. Acomparison of flap vascular anatomy in three

rhytidectomy techniques. Plast Reconstr.Surg 95:683,1995.

12) Hamra, ST The deep plane rhytidectomy. Plast Reconstr surg 86:53,1990.

13) Hamra, ST: Composite rhytidectomy. Plast Reconstr. Surg 90: 1,1992.