Page 265 - Read Online

Page 6 of 21 Ramirez. Plast Aesthet Res 2020;7:25 I http://dx.doi.org/10.20517/2347-9264.2019.78

Figure 5. The subperiosteal repositioning of the orbicularis oculi and the origin of the muscles inserted in the modiolus and the specific
suture applied to the area near the modiolus will lift the corner of the mouth. All of these will rejuvenate facial expression. SOOF: sub-
orbicularis oculi fat

Upper blepharoplasty
Endoforehead lifts the brow and eliminates a small amount of excess skin from the upper eyelid. Greater
skin excess will still require an additional blepharoplasty. However, the amount of skin resection was far
less than if this was done in isolation. Ptosis of the brow creates apparent or real excess skin in the upper
eyelid area area. The apparent excess is reversed with the endoforehead. This will make the need for upper
blepharoplasty less likely.

Lower blepharoplasty
When combined with endomidface, lower blepharoplasty becomes more straight forward procedure.
Lateral orbicularis is suspended using a 4-0 nylon suture to the temporal fascia, using a skin only resection.
This is done after endomidface fixation. Midface lift has the additional benefit of filling the tear trough,
and blending it better with the infraorbital fat. I do not remove any intraorbital fat except under unusual
indications, i.e., globular eyes, excessive and protruding lower eyelid fat pads.

Advanced objectives of facial rejuvenation
The steps of endoscopic central oval rejuvenation (endoforehead-endomidface) and blepharoplasty
described above were all performed in patients below 50 years of age. This was the cornerstone over
which other techniques were added to provide a more comprehensive rejuvenation in the older cohort of
patients. The techniques described above may by themselves attained some of the objectives outlined below.
However, other techniques are needed to obtain the following objectives:

Volume enhancement
Volume augmentation of the face was obtained using one of the following methods: (1) facial implants; (2)
imbrication techniques; (3) vascularized fat mobilization; and (4) fat grafting. A representative illustration
summarizes these methods [Figure 6].