The name of US plastic surgeon Oscar Ramirez has been in the professional press since 1988. It was then that Ramirez did his first endoscopic surgery to rejuvenate the upper parts of the face. Before the advent of this technique, traditional surgical lifting was offered to deal with sagging facial contours. Oscar Ramirez proposed a fundamentally different technique.
Oscar Ramirez,
MD, American College of Plastic Surgery certified plastic surgeon; received international recognition for innovative techniques in reconstructive and cosmetic surgery, in particular endoscopic plastic surgery.
Technique endoscopic midface lift
Oscar Ramirez proposed not to remove "extra" skin, but to tighten the facial muscles themselves, penetrating them with the help of endoscopic equipment. In this case, the size of the cuts becomes minimal, and their number is reduced to two. Moreover, the operation, intended, in general, to lift the forehead and cheeks, showed a pleasant additional effect: in an incredible way, the operation corrects the corners of the mouth that have fallen from the weight of years and “opens” the eyes. The effect of such a lifting is preserved for a longer period of up to 10 years compared to a traditional operation, since the surgeon works with muscles and fascia, and not with the skin. At the same time, the surgeon attaches in a special way at three points those muscles that are responsible for the youthful appearance of the face. After such operations, there are no scars in the behind-the-ear region and on the neck. Incisions are made in the scalp and in the mouth. They heal in five days. With this surgical intervention, neither blood vessels nor nerve endings are injured. The swelling will completely disappear in two to three weeks, and then the bruises will disappear.
The described technique, with some modifications and emphases, has been used on more than 500 patients with excellent aesthetic results and minimal postoperative complications. Earlier, in the experience of endoscopic midface lift, we observed several cases of temporary dysfunction of the orbicular muscle of the mouth and the levator of the upper lip, which was associated with tension in the soft tissues of the midfacial zone. Since then, by modifying the instrumental technique and stretching the soft tissues less, this complication has been avoided.
For whom is the endoscopic rejuvenation method applicable
The subperiosteal endoscopic method of rejuvenation of the central oval of the face through small and hidden incisions, in my opinion, is an advanced technique that is close to ideal. This technique is applicable to all patients regardless of age, gender, degree of ptosis of the soft tissues of the face, the appearance of wrinkles or structural changes.
A clean endoscopic technique without mobilization and excision of the skin in the auricle area is applicable to patients with signs of early aging, usually under the age of 50 years. For patients older than this age, or for patients with excessively sagging skin in the lower jaw or on the neck, the same operation is performed on the central oval of the face, to which a modified cervicofacial lift is added. A modified standard cervicofacial lift is performed through an anterior incision limited by the root of the curl, with limited skin incision and no manipulation of the SMAS elements.
The submandibular region of the neck is operated on by any of the described standard methods. Patients with excellent skin elasticity, minimal excess skin on the neck, and unexpressed cheekbones can be operated on with this method. A patient with a severe skin lesion may receive carbon dioxide laser or chemical peel treatment even if they have had a double skin incision method.
If the endoscopic method was used in its purest form, the entire face can be processed in the “full” and with the required number of procedures, without fear for the blood supply of the skin flaps. This is possible because the full-thickness skin flaps preserved during the operation have an excellent blood supply. A patient undergoing a dual intervention method can receive full carbon dioxide laser treatment of the central oval of the face and with reduced power in the area of skin flap incisions. It is also safe, as the flaps cut with this method are less susceptible to ischemia compared to superficial and intermediate methods.
Peculiarities of the subperiosteal method
Interlayer surgeons criticize those who prefer the subperiosteal method because the periosteum does not stretch well and does not allow proper tension on the cut flap. This statement is partly true because the interlayer flap is more prominent and better stretched than with the periosteum. However, in the subperiosteal technique, this apparently negative feature is transformed into one of the most positive aspects of the operation: the mobilization of dissimilar tissues in a single block.
You can do this by crossing the periosteum at key points: along the upper edge of the orbit — for lifting the eyebrows and forehead, along the lower edge of the zygomatic arch and upper jaw — to stretch the cheek. Vertical mobilization in the block gives a more efficient lifting of the said structures. In addition, structures such as the inner brows and corners of the mouth can be tightened more efficiently.
The subperiosteal technique also allows these complex flaps to be placed at the desired distance from the incision site. The absence of skin tension during fixation of the block and the cross method of fixing the threads lead to volumetric facial rejuvenation, which cannot be achieved with other methods.
As mentioned, the tension of Bish's fatty layers not only eliminates swelling of the zygomatic areas (pseudo-hernia), but also provides volumetric rejuvenation of the middle zone of the face. There are other methods of volumetric rejuvenation of other obligatory elements of the central oval of the face: eyebrows, bridge of the nose, chin. Volumetric rejuvenation of the chin is provided by mentopexy or the introduction of a volumetric implant. Volumetric rejuvenation of the eyebrows is achieved by cross-tensioning of tissues, or by the introduction of fat. Volumetric rejuvenation of the bridge of the nose is carried out by fat grafting or a specially designed implant.
It is worth mentioning that while maintaining the integrity of the intermediate layer, especially in the midfacial area, it is possible to provide volumetric rejuvenation of this area of the face by introducing fat without fear of its further migration. The subperiosteal space also appears to be a convenient way to nicely increase or decrease the underlying skeletal support. In this case, you have a different kind of volumetric facelift.
The most significant feature of subperiosteal endoscopic rejuvenation compared to intermediate layer methods is the safety of the procedure. I have already mentioned that with this method it is possible to avoid an incision in the eyelid. The subperiosteal space is a safe highway that avoids contact with important branches of the facial nerve — temporal branch passing in the zygomatic arch, branches to the circular muscle of the eye, passing in the interval between the large zygomatic muscle and the circular muscle of the eye, the main zygomatic nerve and its branches are deep and superficial relative to the large zygomatic muscle, the marginal mandibular nerve under the subcutaneous muscle of the neck (platysma ), crossing the lower border of the lower jaw, etc.
For those who prefer the periosteal approach, there is a high chance of damage to the mimic muscles far from the site of insertion, as opposed to the subperiosteal technique, when lifting the base of the muscles is a non-traumatic procedure. In the periosteal and intermediate methods, the dissection of tissues below and at the level of the zygomatic muscle is also limited. This does not allow volumetric lifting of the midfacial area and vertical facelift.
Others have criticized the subperiosteal method over the open method for prolonged facial swelling. The same degree of facial swelling is seen in most intermediate facelift techniques. In the first generations of endoscopic methods, described in 1994, there was still swelling of the face, but much less than with open methods. With the introduction of the technique described here, the degree of facial edema has become minimal. In addition, sensitivity in the temporal and jaw regions is preserved. These two important features make the recovery period shorter. On average, patients return to work after 2 —3 weeks.
Thus, rejuvenation of the central oval of the face can be performed using the principles of subperiosteal endoscopic techniques. Important modifications to the original full endoscopic facelift described by the author provide not only the integrity and function of the lower part of the orbicularis oculi muscle, but also the ability to reconstruct the central oval and provide the patient with volumetric facial reconstruction. And this is one of the main features of a young face. All this is done through small and hidden incisions. It is especially important to preserve the neurovascular structures and, as a result, to minimize edema and areas of insensitivity on the face. All these factors contribute to a faster recovery time for the patient.
According to nso-seti.ru
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