Oscar M. Ramirez

Endoscopic techniques in facial rejuvenation: an overview. Part I.

The use of endoscopic techniques in orthopedic, gynecological, and general surgery has had a significant effect on the traditional techniques in those specialties. The introduction of those techniques to plastic surgery, particularly to aesthetic surgery, has been very slow. However, recent interest in using endoscopic techniques in forehead plasty, corrugator—procerus resection, and breast augmentation has opened up countless possibilities in these and other areas of aesthetic and reconstructive surgery.

Endoscopic full facelift

This article demonstrates the efficacy of endoscopic techniques in total facial rejuvenation. The author has introduced the total subperiosteal dissection to the endoscopic forehead lift. This concept has been extended to the rejuvenation of the central and lower third of the face. Patients up to the late 40s can have a total facelift without skin excisions. In older patients, the introduction of endoscopic techniques helps to minimize some of the undesirable sequelae of the traditional open procedures such as alopecia, scalp paresthesias, and facial edema of the subperiosteal lift. The author also introduces a new, more efficacious method of midface suspension.

Three-dimensional endoscopic midface enhancement: a personal quest for the ideal cheek rejuvenation.

&NA; Standard face‐lift techniques are excellent for the treatment of the jawline and neck. Treatment of the area between the lower eyelid and the corner of the mouth required the development of techniques in the intermediate lamella of the face. Alternative techniques of subperiosteal dissection by means of lower eyelid incisions were described with good aesthetic results but at the expense of increased morbidity and complications. All these techniques were also two‐dimensional manipulations of the soft tissues of the face. The author presents a different approach that he believes is close to the ideal in terms of safety, morbidity, and complications. Although midface rejuvenation may be performed alone, it is more commonly done as a component of total facial rejuvenation. The midface is approached by means of a combination of a temporal slit incision and an upper oral sulcus incision; no eyelid access is used. Fifty percent of the midface dissection is performed under direct visualization, and 50 percent is performed under endoscopic control. Dissection of the temporal area is done under the temporoparietal fascia down to the zygomatic arch. The anterior two‐thirds of the zygomatic arch periosteum is elevated along with a few millimeters of the intermediate temporal fascia and the fascia of the masseter muscle. The subperiosteal dissection of the zygoma and maxilla is completed with the medial extension of the dissection just medial to the infraorbital nerve. The orbital fat pads are released by means of intraoral route, and the lateral and middle fat pads are advanced over the orbital rim and fixed to the masseter tendon and the periosteum of the maxillary shelf at the intraoral incision. Three suspension points are typically used on the midface, each one with a different action. All are anchored to the temporal fascia proper. The vascularized Bichats fat pad is mobilized and fixed with 4‐0 polydioxanone sutures. This provides a volumetric cheek augmentation and improvement of the jowl. The inferior malar periosteum and fascia is used for malar imbrication with 4‐0 polydioxanone sutures. This provides an anterior projection of the cheek and elevates the corner of the mouth. The suborbicularis oculi fat is used for en bloc vertical suspension of the cheek. This also improves the infraorbital V deformity. This technique has been used in close to 200 patients over the last 5 years. The complications have been minimal: two cases of temporary paresis of the levator of the upper lip, one case of paresis of the orbicularis oris (unilateral), one case of buccinator muscle dysfunction, and two moderate infections that were treated with simple drainage. The degree of facial edema has been minimal compared with the open or the transblepharoplasty approach. Typically, patients can return to work 2 weeks after surgery. The three‐dimensional endoscopic midface enhancement provides a technique of midface remodeling that provides the missing dimension (volume) to the rejuvenation of the midface. This can be done with a minimal rate of complications, and the aesthetic results surpass by far the results of other midface techniques previously described by the author. (Plast. Reconstr. Surg. 109: 329, 2002.)

Why I prefer the endoscopic forehead lift.

The objectives of the forehead lift and the surgical principles of the open versus the endoscopic methods have been outlined. The advantages and disadvantages of each method have been described. Based on this, I state without any reservations my preference for the endoscopic forehead lift because the advantages significantly outweigh the disadvantages. Based on these and on the enthusiasm of surgeons and the high degree of patient satisfaction and acceptability, I predict that the endoscopic method with its many variations will replace the traditional open approach as a first alternative for forehead lift and upper face rejuvenation.

Postoperative care following carbon dioxide laser resurfacing : Avoiding pitfalls

&NA; Facial skin resurfacing using the carbon dioxide laser has become an increasingly popular procedure. Improvements in carbon dioxide laser technology have made the procedure simpler and more reliable. However, difficulties and problems in the postoperative period can lead to patient morbidity and physician anxiety. The authors have performed laser resurfacing in almost 2,000 patients in the last 4 years. Problems encountered and methods formulated to minimize postoperative complications are discussed.

Subperiosteal minimally invasive laser endoscopic rhytidectomy: the SMILE facelift.

Current concepts of total facial rejuvenation involve a comprehensive integrated approach to achieve a balanced youthful appearance. Recently introduced endoscopic-assisted techniques allow us to rejuvenate the face through small, remote incisions. Previously, we have considered only young patients with good skin turgor as candidates for minimally invasive procedures, but the advent of the resurfacing laser has allowed us to expand our indications for single stage minimal access rejuvenation. Full facial immediate laser resurfacing at the time of standard rhytidectomy has been avoided due to risk of flap necrosis. Subperiosteal minimally invasive endoscopic assisted techniques do not substantially interfere with facial blood supply. We can now perform endoscopic-assisted full facelifts combined with immediate laser resurfacing to reposition the tissues in a more youthful position and then tighten the skin envelope. Extended endoscopic-assisted subperiosteal forehead lift is performed through three to five scalp incisions; subperiosteal midface lift is performed through a crows foot or intraoral incision. Cervicoplasty, if needed, is performed through a small submental incision. Full face laser resurfacing is done using a Coherent Ultrapulse laser. To date we have performed eleven subperiosteal minimally invasive laser endoscopic (SMILE) rhytidectomies. There has been no evidence of flap necrosis with this technique. Postoperative recovery has been no different from patients treated only by full face resurfacing, except perhaps for the slight increase in early facial edema. We believe the SMILE facelift is a viable alternative to standard techniques. The limitations of this procedure still need to be elucidated.

Postoperative care following CO2 laser resurfacing: avoiding pitfalls.

Facial skin resurfacing using the carbon dioxide laser has become an increasingly popular procedure. Improvements in carbon dioxide laser technology have made the procedure simpler and more reliable. However, difficulties in the postoperative period can lead to patient morbidity and physician anxiety. Common problems such as prolonged erythema, hyperpigmentation, acne, milia, dermatitis, and infection can be controlled or avoided with proper postoperative care. Less common sequela such as hypertrophic scarring and prolonged healing are often a results of errors committed in the postoperative period. The authors have performed laser resurfacing in almost 2100 patients in the last 4 years. Changes in the postoperative regimen to include no pretreatment, use of semipermeable dressings, antiviral and antibacterial prophylaxis, and early treatment with sunscreens and bleaching agents have made for a smoother recovery with more predictable results.

Full face rejuvenation in three dimensions: a "face-lifting" for the new millennium.

Abstract. Traditional facial rejuvenation techniques address the face by lifting the soft tissues in one or two dimensions. The face is a tri-dimensional structure and aging occurs in three dimensions, therefore, facial rejuvenation should be done in three dimensions.Sagging of facial soft tissues occurs inferiorly and inferomedially. The ideal reorientation during rejuvenation is in the opposite direction: vertically and supero-laterally. Two other elements not routinely addressed by traditional rejuvenative operations are reduction of skeletal framework and atrophy of soft tissues, particularly subcutaneous fat layer. These are the third dimension of facial aging.By principle, any technique that unfolds, pulls, or lifts produces a flattening effect of the structure being treated. They may give a false impression of augmentation if these tissues are advanced over bony prominences. These stretched out tissues also have a tendency to recoil. For that reason, the author suggests use of structures or methods less susceptible to a stretch relaxation or recoil.A prerequisite to 3-D facial rejuvenation is to perform a 2-D-(bi-dimensional) lift. A third dimension is integrated into it. There are four methods to provide the third dimension: (1) augmentation of the skeletal framework; (2) augmentation of subcutaneous layer with fat injection; (3) imbrication of soft tissues; (4) mobilization and repositioning of fat pockets as pedicle flaps. These methods are not exclusive to each other. One, a few, or all methods could be integrated according to the patients needs and aesthetic goals.Tridimensional changes in facial rejuvenation can be assessed by a standard photographic comparison, using tools for in-vivo measurements or 3-D digital imaging.3-D facial rejuvenation is an advanced concept in our pursuit to provide superior results with the more aesthetic, natural, and harmonious youthful look to our patients.

Frontalis Muscle Advancement: A Dynamic Structure for the Treatment of Severe Congenital Eyelid Ptosis

Forty-two consecutive patients have had severe eyelid ptosis corrected by intraorbital frontalis flap advancement as a motor unit to substitute for the function of the levator muscle. This technique has avoided the need for the linking structure necessary in the standard frontalis sling approach and has improved the direction of pull to more closely mimic that of a normal levator. This simple technique includes elevation of the innervated frontalis muscle flap and the creation of a pulley near the insertion of the orbital septum at the superior orbital rim, which redirects the lid movement along the surface of the globe rather than lifting it from the globe’s surface toward the brow. This type of displacement is produced because the muscle is directed posteriorly by the pulley, so that it conforms to the plane of the levator aponeurosis all the way down to the tarsal plate. In addition, to improve the remaining function of the levator muscle (if any) and to facilitate voluntary positioning of the eyelid, the levator aponeurosis is shortened by plication. Symmetry is created by intervention on the contralateral eyelid to provide symmetrical supratarsal creases.

Anchor subperiosteal forehead lift: from open to endoscopic.

Anchor Subperiosteal Forehead Lift: From Open to Endoscopic Oscar Ramirez; Plastic and Reconstructive Surgery