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Ramirez. Plast Aesthet Res 2020;7:25 I http://dx.doi.org/10.20517/2347-9264.2019.78 Page 15 of 21

Figure 17. Frontal view of a 48-year-old patient with prior standard facelift three years earlier. Still looks sad, the cheeks are sagging,
there is hyperactivity of the forehead, and eyelidptosis (left picture). The post-operative view on the right are two years later observe
the rejuvenation of “facial expression”

Figure 18. Tilted-down view of the same patient. Before and after views

trough. In that scenario lower eyelid surgery becomes a skin-only operation. Likewise, endoforehead makes
upper blepharoplasty unnecessary, or minimizes the amount of skin excision required [Figures 15 and 16].
The case examples [Figures 17-19] demonstrate the exquisite results that can be obtained. Creation of the
ogee, blending of lower eyelid-midface interface, natural contour and fullness of the lower eyelids and
rejuvenation of the facial expression are features that you do not see consistently with other techniques. The
reposition of the facial muscle mask explains changes in facial countenance [Figures 20-22]. Treatment of
the lower face and neck can be easily incorporated into the surgical plan. They can be done simultaneously,
or if time constraints exist a month later.

After pure endoscopic procedures patients can resume work after about 2-3 weeks. The addition of
standard facelift or deep subplatysmal cervicoplasty will increase the amount of swelling and extend the
recovery period to about 4-6 weeks. Subtle, subclinical swelling can take up to 6 months to subside. Despite
this, the degree of rejuvenation that can be obtained (many times as much as 25 years difference) makes
the procedure appealing to those patients that are willing to spend the time and resources for long lasting
results and paradoxical “very natural results” [Figures 23-29].

In conclusion, endoscopic techniques of the central oval of the face are the cornerstone of rejuvenation for
patients of any age. In my view, addressing the central oval of the face is what makes the major difference.