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Page 12 of 21 Ramirez. Plast Aesthet Res 2020;7:25 I http://dx.doi.org/10.20517/2347-9264.2019.78

RESULTS
I have performed 824 total facial rejuvenation procedures over a 35-year period. In a random sample of 100
of these cases, independent observers and patient’s rated the average number of years of rejuvenation to be
18 (range 11-25 years). This group had a minimum of two years follow-up. Patient satisfaction was excellent
in 80%, moderate in 18% and substandard in 2%.

Refinements in endoscopic techniques over time have resulted in globally low complication rates.
Temporary frontal neuropraxia in endoforehead cases was approximately four percent, with function
returning in all cases between one and three months. I have had one case of permanent unilateral frontal
nerve injury. This was a secondary case after a previous coronal approach. Likewise, neuropraxia of the
zygomatic or buccal nerve branches were uncommon, affecting less than two percent of patients. More
common were neuropraxia or musculopraxia of isolated muscles of the face, particularly the levator labii
superioris (4%). They were also temporary, recovering by two months on average. Mentopexy, chin and
mandibular implants, and deep cervicoplasty all had a combined rate of marginal mandibular neuropraxia
of less than three percent. All of these were temporary and likely related to edema or traction. Localized
alopecia at the site of scalp access was highly dependent on surgical technique. Silastic port protectors
decreased hair follicle damage. Occasionally, patients experienced telogen effluvium, with two cases of
near total scalp effluvium that completely resolved after several months. They were related to systemic and
localized stresses. Infection was also rare and occurred in less than one percent of cases.

To prevent infection due to bacterial contamination from saliva I use Chlorhexidine gluconate 0.12% oral
rinse twice a day pre-operatively. Intra-operatively I clean the intraoral mucosa with Betadine solution and
a diluted solution of Betadine was used in the dissection cavity, applied in neurosurgical sponge pads. I
also leave a 2 mm drain in the cavity with the drain brought out thru a ministab incision in the temporal
scalp. If an abscess occurs post-operatively drainage, irrigation and antibiotics are sufficient to manage this
complication. I lost some of the lifting effect following removal of the internal suspension sutures. None
required reoperations.

Bleeding complications were rare in this endoscopic cohort. One patient developed a moderate volume
post-operative hematoma that required drainage but did not require blood transfusion. A few other cases
developed minor localized hematomas that were treated by simple aspiration. The overall hematoma rate is
less than 1%.

DISCUSSION
In the last 30 years many advances have been made in the treatment of the aging face. Previously the
central oval of the face has been more elusive. The subperiosteal endoscopic approach works beautifully
for forehead and midface. The trans-blepharoplasty approach is associated with a high rate of eyelid
malposition, but using the endoscopic technique, avoiding eyelid incisions, is almost devoid of this
[23]
complication . Additionally, rates of neuropraxia are less common than those reported in the intermediate
layer techniques. The plane of work in sub-SMAS techniques is where the mimetic muscles and nerves are
located. Therefore, neuropraxia is common to all sub-SMAS techniques. The subperiosteal plane is deep
to these structures. Nevertheless, there are two areas that are still at particular risk: the frontal nerve as it
crosses the zygomatic arch and the zygomatic and buccal nerves as they cross over the masseter tendon.
The infraorbital nerves can also be injured by blind dissection or excessive traction. Proper technique can
significantly reduce these complications. My personal rate of nerve injury on the midface, forehead and
mandible is around 2%, highlighting that this procedure can be performed safely and consistently over
time.