Methods/Technique:
A retrospective chart review was conducted of 183 patients who underwent endoscopic midface surgery. Patients treated from 1998 to 2003 received direct needle fixation (n = 95). Those treated later underwent fixation with the Endotine device (n = 88).A retrospective chart review was conducted of 183 patients treated consecutively between [month] 1998 and [month] 2012. All patients underwent an endoscopic midface lift. Patients treated in the first 6 years of the study period (n = 95) received direct needle fixation. Those treated more recently (n = 88) underwent fixation with an Endotine mid- face device (Microaire, Charlottesville, Virginia). Institutional review board approval was not obtained for this study.
Inclusion criteria. Appropriate candidates for the endoscopic midface lift were those who presented with accentuation of the nasolabial groove, ptosis at the corner of the mouth, ptosis at the lateral corner of the eyelid, sliding of the orbital rim, loss of projection (flattening) of the malar area, accentuated nasojugal groove(s), and/or ptosis of the tail of the brow (without excess skin).
Surgical Technique
Incisions. Temporal incisions were made approximately 2 cm behind the hairline, in the coronal direction, corresponding to a line of the lateral wing of the nose, passing through the lateral canthus, and reaching the hairbearing scalp. Paramedian incisions were made at the mid-pupil line of the hair-bearing scalp (Figure 3).
Dissection. Open dissection was performed superficial to the deep temporal fascia (white glistening tissue). In the event of uncertainty about the correct plane, a small incision was placed on the fascia to visualize the temporal muscle.
Blunt dissection continued downward to the point of resistance, at the level of the supraorbital rim. The endo- scope was introduced in the cavity to allow better visualization, safer dissection, and adequate hemostasis. Medially, the dissection continued through the areolar tissue, connecting the deep temporal fascia with the sub- periosteal plane. Dissection continued along the areolar plane until reaching the supraorbital rim and the superior border of the zygomatic arch. (This plane is below the superficial temporal fascia and above the deep temporal fascia. The temporal branch of the facial nerve is superficial to this plane of dissection.) At this point, the sentinel veins were identified and left intact if possible. Release of the fusion line (junction of periosteum and deep temporal fascia) and the supraorbital rim periosteum allowed entry into zone 3 of the midface. supraorbital rim was identified. The lateral dissection above the deep temporal fascia extended down along the lateral orbital rim into the malar region in a subperiosteal plane, inferiorly and medially to the infraorbital region. The infraorbital nerve was visualized medially and preserved.
The masseter fibers attached to the malar bone were identified and divided. This facilitated suspension and prevented early relapse. The inferior border of dissection, located superior to the gingival sulcus, was the point at which complete release of the periosteum was achieved. In this location, the nasolabial folds were treated by undermining fat injection and/or suspension.
Fixation: It did not begin until complete undermining had been achieved. From 1998 to 2003, fixa- tion for midface lifting was achieved using the direct needle technique. Since 2003, the Endotine device has been used for fixation. By sliding an introducera deployment system that protected the Endotine implant during insertion elevation of soft tissues was achieved with a simple trigger release to engage the tines to the soft tissue. (The tines were engaged by digital pressure on the soft tissue.) The insertion tool was then removed, and the sheath of the device was fixed to the deep temporal fascia with permanent sutures;
Results/Complications:
Most (90%) of the patient population was female, and the average age at the time of surgery was 46 years (range, 39-54 years). Needle fixation was used in 95 patients and Endotine fixation in 88. The average follow-up period was 7 years. The authors have observed many improvements in outcomes since the introduction of the Endotine device into their practice. These include reduced swelling and bruising, more symmetric elevation of the malar fat pad, mild improvement of tear trough deformity, softening of the nasolabial folds, and, in some cases, decreased “jowling.” The asymmetry often associated with direct needle fixation has decreased, and no skin dimpling has occurred. Through their experience, the authors’ preferred technique has become the temporal-only approach with Endotine fixation.
Conclusion: The Endotine midface suspension device enhances soft-tissue fixation, provides simple adjustability for optimal elevation and projection, and maintains mechanical fixation until biologic fixation becomes adequate. The 5 tines provide multiple points of contact for secure soft-tissue fixation. Elevation forces are evenly distributed over a wide area, which eliminates skin irregularities. Insertion and deployment are accomplished easily through temporal incision.