Endoscopic Rhytidectomy

David N. Sayah

Endoscopic techniques represent a major advance in the practice of facial aesthetic surgery and a solution for today's patients who d ire facial rejuvenation with minimal scarring, reduced postoperative morbidity, and early re umption of careers and social obligations. Although some surgeons may think limited incisions mean limited options, this is not the case; the same range of standard rhytidectomy operations ordinarily performed as open procedures can now be performed endoscopically with even greater accuracy. A wider degree of dissection is possible with reater safety as even the smallest of blood vessels or nerves are visualized and addressed. The greatest advantage of endoscopic approaches to face-lift procedures is the shorter recovery time and greater safety, because circulation to the elevated skin flaps is maintained circumferentially.

Facial Aging

The face inevitably portrays the first visible signs of aging. Rev r. ing these changes remains one of the major challenges in aesthetic surgery. Over time the tissues of the face and body change in quality as collagen crosslinkages break down and the ratio of elastic type III collagen to type I collagen decreases progressively. Along with decreased tissue elasticity and tensile strength, gravity exert its prolonged effects. Our soft tissues become ptotic in the direction of gravitational pull. In the midface, the malar fat pad descends to accentuate the nasolabial folds. A tear trough deformity forms in some patients with descent of the malar fat pad as a soft tissue void develops between the suborbicularis oculi fat (SOOF) and the fat pad. The lower eyelid skin forms rhytids and may develop puffiness in thoes with blepharochalasis. Descent of the lower face leads to jowling and prominent labiomental folds.

Progressive atrophy with increasing age is yet another factor responsible for facial aging. With tissue atrophy and gravitational forces, the eyebrows become ptotic, leading to compensatory frontalis muscle contraction in an effort to elevate the brow. With increased severity of brow ptosis, the brow droops over the upp r eyelids and in extreme cases obstructs the field of vision. The constant contraction of the frontalis muscle leads to static forehead rhytids and a feeling of "forehead fatigue." Hyperactivity of the orbiculari oculi muscle with squinting or smiling is another factor contributing to brow ptosis and development of crow's-feet.

With a growing number of plastic surgery procedures being performed and frequent requests for secondary rhytidectomy, prior facial plastic surgery is anoth r variable that must be considered in the aging face. Preauricular scars, tragal obscurity, ear lobule deformities, prior frontal branch injuries, and other sequelae from the first operative intervention must be addressed at the time of secondary rhytidectomy or forehead lift by any technique.

But aging does not only occur at the subdermal layer. Environmental damage from sun and other variables, uch as smoking, leads to fine rhytids and pigment or vascular irregularities that also reveal the passage of time. Lipstick lines develop around the lips, crow's-feet at the lateral paracanthal regions, and multiple solar lentigos add to the aged look of the ptotic face. To address all of these issues a comprehensive rejuvenation process must be undertaken, including excell nt skin care, collagen or other soft tissue fillers, facial implants, fat injections or grafts, Botox injectIons, and laser treatments.

Although this chapter concentrates on the surgical aspects of facial rejuvenation, the other adjuncts to rejuvenation must also be considered when evaluating a patient. (See Adjunctive Procedures, p. 958.)

Evolution of Technique

Muscle excision to affect rhytids was first described by Miller in 1906. The first surgeon to describe brow lifting in the literature was Passot in 1919. He performed elliptical excisions to achieve a brow lift while impr ving crow's-feet. In 1926 Hunt published a report on coronal brow lifts and pretrichial inci ions to directly excise the forehead skin, thereby lifting the ptotic brow. These early techniques were modified and refined over many decades, including muscle resections, muscle modifications, neurotomies, and variations of scar placement in brow lifts.

Essentially no change in the general approach toward lifting the ptotic brow was published until 1994, when Isse first described an endoscopic forehead lift and reported a case of fuJI face lift performed with an endoscope. Is e I ter de 'ribed a modification of the technique using a sLlpraperiosteal di section. Since that time, minimally invasive face lifts or various types of mini-invasive face lifts have been presented in the literature, including superficial subciliary cheek lift, transblepharoplasty subp riosteal cheek lift, and subperiost al endoscopic laser forehead lift.

Advantages

The surgical plan with any rhytidectomy procedure is first to achieve wide undermining or dissection to create visual and technical access to the subcutaneou tissue while releasing the skin for redraping. The second goal is to exert tension on the skin and subcutaneous tissue by fixing the specific layer to an immobile structure to achieve a lift. The target layer to be lifted might include the SMAS, malar fat pad, S OF, or the periosteum. Finally, the surgeon aims to achieve tissue modifications to provide lasting results or greater tissue mobility. All of these goals can be accomplished endoscopically without the need for skin exci ion.

Endoscopic rhytidectomy's chief advantage i that there are fewer complications than are associated with standard open techniques. Avoidable complications with standard coronal forehead lifts and face lifts include significant blood loss and scalp and face anesthesia resulting from severing of the superficial sensory nerves during subcutaneous dissection and skin flap elevation. Injury to the frontal branch of the facial nerve is an additional concern, especially in subperiosteal rhytidectomy procedures. The scalp flap raised in the coronal approach is in essence a random flap with decreased vascularity. There is subsequently a high rate of alopecia secondary to decreased arterial inflow associated with elevating such large random flaps. Scalp innervations from branches of the supraorbital nerves are inevitably divided when making the coronal or anterior hairline incisions. Anesthesia or paresthesias are therefore common findings in such patients, causing many surgeons to abandon the techniques. The resulting scars are often depressed or hypertrophic as a result of excess tension in wound closure.

In endoscopic procedures, long incisions in visible regions of the face or forehead are avoided. The small incisions within the scalp heal well and become nearly indiscernible. In endoscopic rhytidectomies, the small subcutaneous sensory nerves and blood vessels are magnified with the endoscope and thus preserved, minimizing the risk of anesthesia or paresthesia in these patienrs. Smaller incisions preserve the arterial, venous, and lymphatic circulation through the skin and subcutaneous tissues, which leads to less edema and fewer ischemic complication. Maintaining the vascularity to the undermined skin in endoscopic techniques also avoids postoperative alopecia. An added advanrage is the ability to perform the procedure in bald or balding men. Because these patients are unable to cover the preauricular rhytidectomy scars with makeup or long hair, small incisions in the scalp offer distinct advantages.

Endoscopic facial rejuvenation procedures offer the 'ame surgical "power" with decreased morbidity. In fact no significant difference in results has been noted between endoscopic brow lifts and coronal or pretrichial forehead lifts. Using the optical avity, the same level of wide undermining or dissection as in open techniques is possible. The same SMAS plication or suspension procedures are also possible through minimal incisions to correct soft tissue ptosis. In most of our patients we no longer see a need for a preauricular incision to provide access to the subcutaneous tissues. The resulting preauricular scar and tragal obscurity with forward displacement of the tragus caused by excess traction on the skin flaps in the posterior direction is entir Iy avoidable. The next advantage of endoscopic rhytidectomy is the vector of pull on the ptotic skin and soft tissues. As the face ages, the soft tissues and skin sag downward and not anteriorly. To correct this ptosis, the kin and subcutaneous tissue have to be repositioned upward and not posteriorly. Any posterior tension on the skin flaps during a facial rhytidectomy procedur must be avoided to prevent the unnatural change in direction of skin creases and rhytids that would accompany this maneuver.

The philosophical difference between open and endoscopic techniqu cent rs on the approach to skin excision to achieve a lift. Standard techniques rely on skin excision, with or without a SMAS procedure, to correct facial soft tissue pto i . Endoscopic techniques rely on redraping and scar contracture of the skin and subcutaneous tissues ver us skin excision. We believe that as skin elasticity decrea e over time, we do not grow more skin but gather skin in dependent ar as on the face as a result of gravitational forces. With this in mind, we do not see a need for skin excision when performing endoscopic forehead or face lifts. The s in on the preauricular ar a is excised only if a severe dog-ear results aft r redraping and suspension of the skin.