Endoscopic-assisted midface lift utilizing retrograde dissection

Endoscopic facial surgery is gaining wide acceptance, as results are providing comparable if not superior to the standard, superficial musculoaponeurotic system rhytidectomy, with minimal scarring. Frontal branch facial nerve injury remains a troublesome complication. The purpose of our study was to determine if a subciliary retrograde dissection would decrease facial nerve injury and allow for more accurate midfacial suspension. Fresh cadaver dissections were performed using endoscopic equipment. Anterograde temporal incisions in the scalp and retrograde subciliary incisions were studied. The anterograde temporal dissection was developed deep to the superficial layer of the deep temporal fascia. Retrograde subciliary dissection was subperiosteal. Forty-nine endoscopic-assisted midface lifts were performed. Midfacial suspension was accomplished with nonabsorbable sutures placed in the suborbicularis oculi fascia, anchored to the deep temporal fascia. Two of three endoscopic-assisted procedures done in the anterograde fashion, without a subciliary incision, experienced transient frontal branch injury, which resolved within 6 weeks. The remaining forty-six patients, operated with a combined subciliary and temporal approach, experienced no frontal branch injuries. We have found that the retrograde dissection through a subciliary incision substantially reduced the incidence of facial nerve injury, provided direct visualization of the suborbicularis oculi fascial layer (allowing more accurate midfacial suspension), and reduced total operative time.