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Page 2 of 6 Pignata et al. Plast Aesthet Res 2018;5:23 I http://dx.doi.org/10.20517/2347-9264.2018.28

The ageing process that occurs in this age group affects the centre of the face, represented by the periocular
region and the mouth. Therefore, surgeons dedicated to the periocular region should look beyond the eye-
[3]
lids. In a previous publication, Bernardini et al. defined the periocular aesthetic unit as being formed by
the superior complex (SC), which includes the forehead, brow and upper eyelid, the inferior complex (IC),
which includes the lower eyelid and the cheek, and the lateral complex (LC) which includes the temple, the
malar mound and the lateral canthus. If we expand our focus to the peri-oral unit we can assess the whole
centre of the face.

In the past, aesthetic surgeons dedicated their efforts to the rejuvenation of the contour of the face, offering
variably satisfying results at the cost of long scar lines, extensive dissection and strong horizontal traction
with unnatural effects. Vertically repositioning the descended tissue seems to be the correct way to assess
the gravitational ageing vector. This is especially true in the SC and in a lesser proportion in the IC. Minimal
incision vertical endoscopic lifting (MIVEL) can obtain such results with invisible scars and fast postopera-
tive recovery. However, as much as we lift tissue, there is no natural, three-dimensional way to achieve re-
juvenation without volume restoration to the deflated areas. Superficial enhanced fluid fat injection (SEFFI)
is a novel technique, which not only provides the volume restoration of autologous fat, but also aids in skin
regeneration.

The authors attempt to review the literature on this two novel procedures as well as present their individual
techniques and results.

MIVEL
There are a few specific surgical instruments, but the single most important one is the endoscopic elevator
which slides on the fiberoptic and allows the surgeon to elevate the tissue while viewing with one hand.

Blind dissection
After a Klein-type of local anesthesia and with the patient under intravenous sedation the intervention
requires initial dissection in preparation for the endoscopic view. Three vertical 1.5-cm long incisions are
placed in the scalp, right behind the hairline: the central one in the midline and two paramedian incisions,
one on each side, 5 cm from the midline, to give access to the frontal area up to the temporal crest. Two 3-cm
long incisions are performed in the temporal region, one on each side, to provide access to the temporal,
malar, and zygomatic regions. In the frontal area, blind dissection is performed under the periosteum upto a
2-cm safety line above the superior orbital rim. Special care needs to be taken in order not to elevate the con-
joint tendon at this time. The lateral extension will be up to the temporal crest laterally and 2-3 cm posterior
to the hair line. In the temporalis area an optical pocket is created blindly and the dissection plane lies above
the superficial plane of the deep temporal fascia. From the temporal dissection the conjoint tendon can be
safely elevated, joining both pockets.

Endoscopic dissection
After the blind dissection is completed and a single optical pocket formed in the frontal and temporal ar-
eas, it is then time to enter with the endoscope. In the temporal region, the dissection is carried out on the
surface of the temporal fascia past the sentinel vein to expose the zygomatic temporal and zygomatic facial
bundles laterally and the lateral retinaclum and lateral canthal tendon medially. In the forehead region, sub-
periostal direction is carried up to the superior orbital rim. At this level, periosteum will be elevated from
lateral to medial, around the supraorbital nerve, and past it towards the glabellar region, elevating the cor-
rugator and procures muscles.

Fixation
Fixation was achieved with Endotine devices in more than 300 cases, encountering device related complica-