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Page 2 of 21 Ramirez. Plast Aesthet Res 2020;7:25 I http://dx.doi.org/10.20517/2347-9264.2019.78

Conclusion: These combination techniques are called Biplanar Endoscopic Assisted Mask and Triplanar
Endoscopic Assisted Mask facial rejuvenation. They are advanced techniques of facial rejuvenation that provide
comprehensive, natural, long lasting results.

Keywords: Endoscopic face lift, videoendoscopy, facial rejuvenation, high definition face, picograft, ogee face,
midface

INTRODUCTION
The procedures, concepts and principles described in this article were developed over a 35 year period,
beginning during my Plastic Surgery residency at the University of Pittsburgh. The driving force behind the
innovations described in this article were the unnatural, in vogue facelift results of that era.

Traditionally, the aging face was approached using techniques that pulled and stretched the facial soft
tissues. The face was approached in a superficial plane, tightening the skin and SMAS (superficial muscular
[1-3]
aponeurotic system) only . Over time, face lift techniques beneath the SMAS evolved, including the
[4,5]
deep plane facelift or composite facelift . Initially, some surgeons considered this technique unsafe, and
[6]
were hesitant to go deep to SMAS due to the proximity of facial nerve branches . Moreover, the degree
of facial edema was considered more marked using intermediate layer techniques. Around the same time,
Paul Tessier described and popularized the subperiosteal approach [7-12] . I first described my five experience
into the subperiosteal technique at the 1989 Biannual Congress of the International Society for Aesthetic
Plastic Surgery in Zurich, Switzerland, and the 1990 American Society for Aesthetic Plastic Surgery Annual
Congress in Chicago Illinois . Another paradigm shift that influenced my thinking was the endoscopic
[13]
[14]
approach to the forehead pioneered by Luis Vasconez . This was first presented at the 1992 annual meeting
of the American Society of Plastic and Reconstructive Surgeons, in Washington DC. I quickly adopted
[14]
and modified Vasconez’s forehead rejuvenation technique . Noticing the advantages of the endoforehead
compared to the traditional coronal approach I extended the application of the endoscopic approach to
total facial rejuvenation [15-18] . It became clear that the subperiosteal plane was better suited to endoscopic
techniques including secondary rhytidectomies . It also made it safer and easier to add supplementary
[19]
techniques. Those are described below [20-24] [Figure 1]. Along the way Adrien Aiache and I discovered the
[25]
suborbicularis fat that I coined SOOF (sub-orbicularis oculi fat) . It was an excellent structure for filling
the tear trough and to lift and imbricate the cheek. More recent research regarding the innervation of the
lower eyelid orbicularis has also been relevant to the endo-midface, and the preservation of function of
[26]
this muscle was another added benefit of this approach . The most important side effects of introducing
these new techniques were that surgeons were compelled to compare these with the older techniques.
In the process we started to focus more critically on the anatomy and aesthetics of the face [27,28] . We
began thinking more about the benefits of volume preservation and restoration in contrast to the pulling
maneuvers of traditional methods [21-24,28,29] . This also created a new landscape for developing new minimally
invasive techniques and non-invasive techniques, including the use of fillers and neuromodulators as
temporary alternatives to surgical approaches [30,31] .

Following the realization that loss of volume was an important component of the aging process many
[32]
surgeons and dermatologists started over filling faces creating an unnatural aesthetic . In my opinion

we need to swing the pendulum back and treat all features of facial aging in a more balanced approach.
Moreover, a comprehensive approach addressing all thirds of the face gives a more natural result than
when surgery is performed in a segmental fashion. An endoscopic approach to the face can address the
three thirds of the face in a balanced fashion. If the endoscopic approach is insufficient to address all of the
components of the aging face, other main or ancillary procedures can be easily integrated without burning
any bridges.