Transblepharoplasty endoscopic subperiosteal midface lift.

The use of endoscopy in the transblepharoplasty midface lift is essential for preventing the complications of facial nerve injury and bleeding. Complete observation allows precise dissection and release of all structures in the composite flap. This technique fully preserves the zygo-orbicular nerve plexus and prevents denervation of the orbicularis oculi and zygomaticus muscles. Blind dissection has a significant probability of denervation of the entire zygo-orbital muscle complex, and avulsion of the zygomaticofacial vessels, with associated postoperative bleeding complications. The modification involving suturing of the "vest" of the combined lateral orbital periosteal and superficial layers of the deep temporal fascia over the elevated "pants" of the orbicularis periosteal flap provides very secure fixation for suspension of the lower eyelid and midface. The use of slowly absorbable polydioxanone sutures for this technique prevents the problems caused by permanent sutures beneath the very thin skin of the lateral canthal area. Careful trimming of the prominent roll of the orbicularis muscle that often develops with suspension eliminates the uneven contour and yields a smooth lower lid appearance. The details and modifications described should decrease the complications and morbidity that can occur with this procedure and provide for a more precise and reliable procedure for rejuvenation of the lower eyelid and midface.