14.1 Introduction

Scientific study supports the central role of the eyes in aesthetic facial rejuvenation. In a study by Nguyen et al, an eye-tracking system was used to show that age and fatigue judgments are based on preferred attention toward the eye region, and as a consequence, addressing the aesthetic of this area could be one of the most effective interventions to improve the appearance of an individual’s face. ¹ In a recent study of female aesthetic patients, the large majority (75%) reported the first signs of notable aging occurred around the eyes, and a similar majority described this region as the most desirable for rejuvenation. ²

Attention to periocular signs of age is not a new phenomenon. Classic painters recognized and presented the signs of aging through the periocular area. In “The Old Man with a Gold Chain,” Rembrandt (Art Museum, Chicago) was able to represent old age by focusing on the features of the periocular region in a subject with a hat and beard hiding much of his face (Fig. 14.1). In the upper facial subunit, we notice forehead and brow descent (especially laterally), deepening of the upper sulcus, and dermatochalasis with lateral hooding. In 1645, Rembrandt similarly was able to represent the youthful upper periocular signs of beauty in a Dutch woman (Fig. 14.2). The forehead shows no wrinkles, the brows are full, high, and arched, the sulcus is full, and the margin fold distance is low.

Surgeons dedicated to the periocular region should look at aging as being much wider and complicated than just the eyelids. Age-related changes of the eyelids are directly related to aging adjacent soft tissue. Schematically, we define the upper periocular aesthetic unit as being formed by: the superior complex (SC), including the forehead, the brow, and the upper eyelid; the lateral complex (LC), formed by the temple, the malar mound, and the lateral canthus; and the inferior complex composed of the lower eyelid and cheek (Fig. 14.3). In the SC, descent plays a large role secondary to gravity forces and the continuous effect of the strong, synergistically acting depressor muscles: corrugator, depressor supercilii, procerus, and orbicularis oculi. Volume loss plays a relevant role, especially at the level of the brow fat, where it causes thinning of the brow, deepening of the sulcus, and loss of eyelid support with dermatochalasis. At the level of the LC, the temporalis fossa, located between the temporalis crest superiorly and the zygomatic arch inferiorly, has no room to descend, and its aging is determined exclusively by volume loss. To achieve the most natural rejuvenation of the upper face, we aim to restore the position of the descended tissues and volume to the deflated tissue. ³ Here, we discuss the endoscopic browlift portion of our minimal invasive vertical endoscopic lift (MIVEL) technique for rejuvenation of the face. Specifically, we believe in tissue release, repositioning, and volume restoration ⁴ ID#b410a292_5 ^– ID#b410a292_6 ⁷ (Fig. 14.4).

14.2 Goals of Intervention

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  Natural-appearing rejuvenation of the upper facial aesthetic unit, most importantly the periocular region.

  
  
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  Achieve three-dimensional rejuvenation with volume restoration (see Chapter 16 for fat grafting details).

  
  
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  Maintain dynamic facial animation.

  
  
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  Avoid traditional facelift approach of pulling skin along a horizontal plane in favor of vertical elevation.

  
  
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  Avoid noticeable scars.

14.3 Risks

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  Scalp paresthesia.

  
  
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  Alopecia along incision site.

  
  
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  Frontal branch facial nerve damage.

  
  
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  Hematoma.

  
  
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  Undercorrection.

14.4 Informed Consent

All patients should be aware of the high likelihood for transient forehead and scalp paresthesias after surgery. Patients should be made aware of nonsurgical alternatives such as neurotoxin and injectable fat or hyaluronic acid filler and the possible need for adjuvant filler or neurotoxin to maintain results. Although rare, the risk of alopecia and frontal nerve damage should be listed in the consent and understood by the patient.

14.5 Indications

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  Age-related changes, including descent and deflation of the upper face.

14.6 Contraindications

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  Unrealistic patient expectations.

  
  
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  Overvolumization or overelevation from previous surgery.

  
  
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  Thinning hair with preoperative alopecia.

  
  
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  Significant hairline recession with preoperative forehead elongation.

14.7 The Procedure

The procedure is most commonly performed in an outpatient surgery center under general or intravenous monitored sedation.

14.7.2 Instruments Needed (Fig. 14.5)

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  A 30° fiberoptic scope with endoscopic elevator that allows the surgeon to elevate tissue while viewing with one hand.

  
  
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  Notable dedicated endoscopic instruments from left to right.

  
  
  
  
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    Long and regular periosteal elevators (Karl Storz #58210 FGA and UKA).

    
    
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    Midface dissector (Karl Storz, Model #50205 ZL).

    
    
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    Fine dissectors (Anthony Products Inc #67–20–53E).

    
    
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    Farabeuf retractors (Hayden Medical Inc #105–112).

    
    
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    Reverdin needle (seen centrally just to the right of the large hemostats, an instrument similar to a Wright needle, only longer, straighter, and finer, typically used by orthopedic surgery) (KLS Martin #20–721–19–07).

    
    
    
    
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      A Wright needle can be used as an alternative to the Reverdin needle (FCI Ophthalmics #WF-1000u).

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