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Ramirez. Plast Aesthet Res 2020;7:25 Plastic and
DOI: 10.20517/2347-9264.2019.78 Aesthetic Research

Original Article Open Access

Endoscopic assisted facial rejuvenation: a 35 year

personal journey

Oscar M. Ramirez

Department Plastic Surgery Cleveland Clinic Florida, Adjunct Clinical Faculty, Cleveland Clinic, FL 33331, USA.

Correspondence to: Dr. Oscar M. Ramirez, Ramirez Plastic Surgery, 19495 Biscayne Blvd, Ste. 200, Aventura, FL 33180, USA.
E-mail: ramirezmdps@gmail.com

How to cite this article: Ramirez OM. Endoscopic assisted facial rejuvenation: a 35 year personal journey. Plast Aesthet Res
2020;7:25. http://dx.doi.org/10.20517/2347-9264.2019.78

Received: 26 Dec 2019 First Decision: 23 Mar 2020 Revised: 10 Apr 2020 Accepted: 7 May 2020 Published: 23 May 2020
Science Editor: Kai O. Kaye, John Yousif Copy Editor: Jing-Wen Zhang Production Editor: Jing Yu

Abstract
Aim: Traditional facelift techniques rely on pulling. They approach the superficial or intermediate layers where
the facial nerves and muscles are located, increasing the risk of facial nerve injury. They approach the central oval
from the periphery and produce unnatural vectors of pull and aesthetic results. Alternative techniques that work
on the subperiosteal plane using endoscopic techniques are described. Modern concepts of volume augmentation,
beautification and rejuvenation of the facial expression are an inherent part of such techniques, or can be easily
integrated.

Methods: The central oval is approached via four small scalp incisions and additional intraoral, upper gingivo-
buccal incisions. The interconnected frontal subperiosteal, temporal subfascial and midface subperiosteal areas
are lifted, imbricated and suspended sequentially. The brow/forehead is suspended to the skull using cortical
screws. The midface and lower periorbita are suspended to the fascia of the temporal muscle. The buccal
fat pad is used to enhance the ogee line of the midface. Other three-dimensional volumetric maneuvers can
easily be applied. In this setting, upper and lower lid blepharoplasties become more straightforward, skin only
procedures. Actinic or nicotine damaged skin can be treated with lasers, peels or fluidified fat grafting in the same
setting. The excess skin on the lower face and neck can be redrapped with standard cervicofacial techniques.
Deep subplatysmal cervicoplasty can be done concomitantly, or at another time to complete comprehensive
rejuvenation.

Results: The procedures described herein has been performed in 824 patients with excellent aesthetic results and
low complication rate. The average rate of rejuvenation was 18 years.

© The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made.

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