ENDOSCOPIC FOREHEAD LIFT Endoscopic Approach to Upper-Third Facial Rejuvenation

Thomas ROMO III Kyle S. CHOE

2 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Color Illustrations: Fairman Studios, LLC 681 Main Street, Suite 2-11 Waltham, Massachusetts 02451, U.S.A E-mail: jfairman@fairmanstudio

Important notes: Endoscopic Forehead Lift – Endoscopic Approach to Medical knowledge is ever changing. As Upper-Third Facial Rejuvenation new research and clinical experience broaden Thomas Romo, III, M.D., F.A.C.S. our knowledge, changes in treatment and therapy Kyle S. Choe, M.D. may be required. The authors and editors of the New York Eye and Ear Infirmary, New York, NY material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accept ed Correspondence address of the author: at the time of publication. However, in view of the Thomas Romo III, MD FACS possibili ty of human error by the authors, editors, or publisher, or changes in medical knowledge, neither Kyle S. Choe, M.D. th the authors, editors, publisher, nor any other party who 135 East 74 Street, has been involved in the preparation of this booklet, New York, NY 10021 warrants that the information contained herein is in New York City, NY 10021 every respect accurate or complete, and they are Phone: 001 212-288-1500 not responsible for any errors or omissions or for the Fax: 001 212-288-3746 results obtained from use of such information. The E-mail: [email protected] information contained within this booklet is intended for www.drthomasromo.com/home/ use by doctors and other health care professionals. This material is not intended for use as a basis for treatment decisions, and is not a substitute for professional All rights reserved. consultation and/or use of peer-reviewed medical 1st edition 2004 literature. © 2015 ® GmbH Some of the product names, patents, and re gistered P.O. Box, 78503 Tuttlingen, Germany designs referred to in this booklet are in fact registered Phone: +49 (0) 74 61/1 45 90 trademarks or proprietary names even though speciﬁ c Fax: +49 (0) 74 61/708-529 reference to this fact is not always made in the E-mail: [email protected] text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a No part of this publication may be translated, reprinted or reproduced, trans- representation by the publisher that it is in the public mitted in any form or by any means, electronic or mechanical, now known or domain. hereafter invent ed, including photocopying and recording, or utilized in any The use of this booklet as well as any implementation of information storage or retrieval system without the prior written permission of the information contained within explicitly takes place the copyright holder. at the reader’s own risk. No liability shall be accepted and no guarantee is given for the work neither from Editions in languages other than English and German are in preparation. For up- the publisher or the editor nor from the author or any ® other party who has been involved in the preparation to-date information, please contact GmbH at the address shown of this work. This particularly applies to the content, the above. timeliness, the correctness, the completeness as well as to the quality. Printing errors and omissions cannot Design and Composing: ® be completely excluded. The publisher as well as the GmbH, Germany author or other copyright holders of this work disclaim any liability, particularly for any damages arising out of Printing and Binding: or associated with the use of the medical procedures Straub Druck + Medien AG mentioned within this booklet. Max-Planck-Straße 17, 78713 Schramberg, Germany Any legal claims or claims for damages are excluded. In case any references are made in this booklet to 05.15-0.3 any 3rd party publication(s) or links to any 3rd party websites are mentioned, it is made clear that neither the publisher nor the author or other copyright holders of this booklet endorse in any way the content of said publication(s) and/or web sites referred to or linked from this booklet and do not assume any form of liability for any factual inaccuracies or breaches of law which may occur therein. Thus, no liability shall be accepted for content within the 3rd party publication(s) or 3rd party websites and no guarantee is given for any other work or any other websites at all. ISBN 978-3-89756-558-6 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 3

Table of Contents

1.0 Introduction ...... 4 2.0 Standard Aesthetic Proportions of the Upper Third of the Face ...... 5 3.0 Anatomy of the Forehead Muscles ...... 7 4.0 Traditional Approaches to Surgical Treatment of the Upper Third of the Face ...... 9 5.0 Patient Interview and Consultation ...... 12 6.0 Endoscopic Forehead Rejuvenation ...... 14 7.0 Temporary vs. Permanent Fixation ...... 16 8.0 Surgical Technique ...... 18 9.0 Clinical Cases (Eight Patients’ Pre and Postoperative Pictures) ...... 26 10.0 References...... 34 11.0 Instruments for Endoscopic Forehead Lift ...... 35 4 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

1.0 Introduction The key qualities of a beautiful face are symmetry and balance. The challenge that the aging process most often poses to the facial plastic surgeon is gradual dissonance of the facial features. While the nose is the most prominent of these, sequelae from aging are most dramatically displayed in the upper third of the face: eyebrows begin to sag; wrinkles form on the forehead; and eyelids show signs of hooding. Bringing back equilibrium to this area has thus become a significant goal of facial rejuvenation surgery. The use of endoscopes has revolutionized how facial plastic surgeons approach rejuvenating the upper third of the face, i.e., the forehead between the hairline and the eyebrows. Within the past decade, endoscopic lifting of the face and brow has gained significant popularity and replaced many traditional surgical approaches. The primary advantage of endoscopic forehead rejuvenation, or endoscopic forehead lift, are the minimally invasive incisions used to expose the large anatomic unit of the forehead, temporal region and lateral orbit. Post-operational recovery is, in turn, shorter and less painful. Despite the many advantages of this new and exciting technology, endoscopic surgery is best suited for patients with mild to moderate ptotic brows. Endoscopic forehead rejuvenation relies on four primary steps: (1) subperiosteal elevation dissection of the frontal, parietal and occipital scalp to the level of the superior and lateral orbital rims; (2) release of the superior and lateral orbital periosteum; (3) selective myotomies of the brow depressors; and (4) permanent fixation of the elevated brow. In this monograph, we review the traditional techniques of forehead rejuvenation and elaborate on the advantages of utilizing the endoscope. We then present our approach to endoscopic rejuvenation of the upper third of the face using KARL STORZ instruments. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 5

2.0 Standard Aesthetic Proportions of the Upper Third of the Face Cephalometrics of the upper third of the face are determining factors to the bal ance and symmetry that define facial beauty. Traditionally, the length of the face has been divided into three equally sized parts. Measurements are made from the midline of the face, from the trichion to the glabella, glabella to the subnasale and the subnasale to the menton. In surgical practice, the forehead, from the hairline to the eyebrows, comprises the upper third of the face. While defining the ideal eyebrow position is much less mathematical, the aesthetically favorable female eyebrow takes on a gracefully arching structure located slightly above the supraorbital rim. In males, the arch is flatter and rests at the level of the supraorbital rim. For both genders, the eyebrow begins at a vertical line from the alar-facial groove through the medial canthus and ends at the diagonal line from the alar-facial groove through the lateral canthus. The horizontal position of the eyebrow’s highest point is located at the vertical line tangential or just lateral to the lateral limbus. The medial and lateral ends of the eyebrow rests on a horizontal line. In terms of shape, the medial end of the female eyebrow is rounded and gradually tapers laterally.

Trichion (Hairline)

Glabella

Subnasale

Menton

Fig. 1a Fig. 1b Standard aesthetic proportions of the upper third of the face. Ideal eyebrow position. 6 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Aging Process of the Forehead Facial aging is a gradual process, which begins to manifest itself as horizontal wrinkles in the patient’s forehead region in their early 30s. By the time patients reach their 40s, the horizontal lines begin to deepen and vertical wrinkles be come more visible in the glabellar region. These changes are followed by drooping of the eyebrows below the supraorbital rims, folding of the infrabrow tissue over the thin eyelid skin and both medial and lateral “hooding” of the upper eyelid as the patient continues to age. Brow and glabellar ptosis alters what was once an aesthetically pleasing Y-shaped sweep between the eyebrow, medial orbit and lateral nose, to a T-shape. The overall result is a configuration that conveys age, sadness and anger.

Fig. 2a Forehead anatomy, unlike other parts of the face, is more prone to rhytid and Patient in her early 30s. furrow formation because the eyelid, skin and muscles are intimately related. With little or no subcutaneous tissue between skin and muscle, such a close anatomic relationship leads to a direct transmission of muscle motion to the overlying skin, resulting in deep furrows and wrinkles.

Fig. 2b Patient in her 40s.

Fig. 2c Patient in her 50s.

Fig. 2a – d Aging process of the forehead. Note the gradual changes to the forehead and eye brows as patient ages. Fig. 2d Patient in her 60s. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 7

3.0 Anatomy of the Forehead Muscles Frontalis m Successful cosmetic surgery starts with a thorough understanding of basic facial anatomy. The upper third of the face is composed of very active subcutaneous fascia and the occipitofrontalis, corrugator supercilii and procerus muscles. Knowing the location and actions of these muscles provides insight for correcting horizontal wrinkles on the forehead, horizontal lines on the root of the nose and vertical glabellar frown lines. Understanding the course of various sensory and motor nerves can help prevent accidents and pitfalls.

Forehead Group The occipitofrontalis muscle is a fibrous sheet consisting of thin and wide muscle bellies joined through an intermediate aponeurosis. The fibrous portion, or aponeurotic galea, caps the skull. It extends from the medial supraorbital ridge to the medial two-thirds of the superior nuchal line and is laterally attached with the superficial temporal fascia. The aponeurosis gives origin to the frontal bellies at the coronal suture. At its posterolateral borders, it is in continuity with the occipital bellies. The frontal bellies frequently appear in a quadrilateral shape and can be identified as a slim sheet that is contiguous with the procerus and corrugator supercilii muscles. The lateral fibers are blended with the pars orbitalis of the Fig. 3a orbicularis oculi muscle. The medial fibers are contiguous Forehead group. with the muscle fibers of the procerus and the intermediate fibers are mixed with those of the corrugator supercilii. Actions: Working as a whole, the usual action of the occipitofrontalis muscle is to raise the eyebrows and to crease the forehead horizonatally. The occipital belly pulls the aponeurotic galea that sustains the frontal belly Procerus m to execute its upward movement. Alternate action of the frontal and occipital bellies moves the scalp forward and backward. The frontal bellies, acting separately, only raise the eye brows. The frontal movement is antagonistic to those of the orbicularis oculi, procerus and corrugator supercilii muscles.

Nasal Group The procerus is a small pyramidal fasciculate muscle aris ing from the tendinous fibers that cover the inferior portion of the nasal bone and upper lateral nasal cartilage to be inserted into the skin between the eyebrows. Its fibers become continuous above the nose with the medial fibers of the frontal belly of the occipito-frontalis. Actions: The procerus muscle pulls the glabella downward, creating a small transverse crease at the root of the nose.

Fig. 3b Nasal group. 8 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Orbital Group The corrugator supercilii is defined by two different features. It can be found as a short, narrow pyramidal muscle located at Corrugator the medial end of the supraorbital ridge, or as a long, narrow, supercilii m straight muscle along the medial half of the supraorbital ridge. Orbicularis Both forms arise from a portion of the upper medial deeper oculi m fibers of the pars orbitalis of the orbicularis oculi muscle at the upper nasal process from the maxilla. The muscle fibers lie beneath the frontal belly. Actions: The corrugator supercilii is the principal muscle that causes vertical glabellar frowns between the eye brows. These lines are caused by the action of the paired corrugator supercilii muscles in drawing the eyebrows downward and medially.

Nerve Supply The facial nerve supplies the forehead, nasal and orbital muscles to execute voluntary movements. The occipital branch, the largest branch of the posterior auricular nerve, innervates the occipital belly of the occipitofrontalis muscle. The temporal branch crosses the zygomatic arch at its lateral half toward the frontal belly of the occipitofrontalis, corrugator supercilii and orbicularis oculi. The zygomatic branch supplies the corrugator supercilii and orbicularis Fig. 3c oculi. The deep buccal branch innervates the procerus Orbital group. muscle.

Galea aponeurotica

Frontalis m

Superficial temporal fascia

Orbital portion Orbicularis T oculi m Palbral portion Occipitalis m

Posterior Z auricular n

Facial n B

Fig. 4 Nerve supply. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 9

4.0 Traditional Approaches to Surgical Treatment of the Upper Third of the Face Several different approaches to forehead rejuvenation have been widely employed to correct the aging upper third of the face. The three classic approaches include: the coronal forehead lift; the high forehead lift; and the midforehead lift. Although certain patients may still benefit from one of these classic approaches, each procedure carries more disadvantages as compared to the endoscopic method without necessarily adding to forehead aesthetics.

Coronal forehead lift The coronal forehead lift involves the development of a scalp forehead flap in a subgaleal plane over the glabellar and Fig. 5a supraorbital rims. The forehead muscles are incised to relax Coronal forehead lift incision outline. the overlying rhytids. A coronal strip of hair- bearing scalp is removed, the size ranging from 1–2 cm x 25–30 cm. The scalp defect is then closed, elevating the brow-glabella complex. Galea aponeurotica Pericranium Disadvantages: Skin and 1. Excision of a strip of hair-bearing scalp subcutaneous fat 2. Alopecia, which may be substantial for patients with decreased hair density 3. Difficulty raising the brow-glabella complex from a distant area, leading to unreliable brow elevation 4. Elevation of anterior hairline 5. Potential for excess blood loss 6. Stretch back of scalp and forehead skin with excessive elevation

Fig. 5b Coronal forehead lift with a strip of scalp removed. 10 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

High forehead lift A modified pretrichial lift is used when a patient has a high forehead and involves a geometric incision just anterior to the hairline (Fig. 6a). The level of dissection and elevation of the brow-glabella complex is identical to the coronal forehead lift technique (Fig. 6b). A strip of nonhair-bearing skin is excised anterior to the hairline. Closure elevates the brow-glabella complex (Fig. 6c).

Disadvantages: 1. Visibility of anterior hairline incision and scar formation 2. Denervation and numbness of the scalp posterior to the incision line 3. Cannot be used in patients with a low anterior hairline or a smooth forehead Fig. 6a High forehead lift incision outline.

Galea aponeurotica Skin and Pericranium subcutaneous fat

Fig. 6b High forehead lift with a strip of skin removed.

Fig. 6c High forehead lift closure. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 11

Midforehead Lift The midforehead lift involves an incision in a natural horizontal crease followed by removal of a strip of forehead skin. Dissection in the subcutaneous plane extends in feriorly to the supraorbital rims. Access to the corrugator and procerus muscles is achieved through a subgaleal dissection centrally and inferiorly. Myoplasty can be done if indicated and the frontalis muscle can be divided between the supraorbital nerves. The skin is closed in a running fashion.

Disadvantages: 1. Only useful for patients with deep forehead creases and rhytids 2. Mild forehead scar

3. Possible transection of all sensory nerves to the Fig. 7a forehead during inferior flap elevation Midforehead lift incision outline. 4. Loss of forehead skin with subcutaneous flap elevation Skin and subcutaneous fat Frontalis m

Fig. 7b Midforehead lift with a strip of skin removed.

Fig. 7c Midforehead lift closure. 12 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

5.0 Patient Interview and Consultation Patient selection and evaluation are a critical part of preoperative planning, necessitating careful consideration of factors that determine the clinical appear ance of the upper third of the face. An array of factors including age, genetics, environmental exposure history and overall health contribute to the relaxation of the forehead and descent of the brow. More importantly, however, are the various facial features such as position of frontal hairline/eyebrows, fore head/glabellar rhytids and skin quality/redundancy. The “frame height” and “brow glide” also help determine which patients will best benefit from an endoscopic approach to facial rejuvenation. In evaluating patients for upper third face rejuvenation, one of the most important assessments is the position of the frontal hairline. The position of the frontal hairline will often determine the type of forehead rejuvenation technique to be employed. A high forehead with an elevated hairline is a relative contraindication to the endoscopic approach. However, because there are no visible scars with the endoscopic approach, certain patients can tolerate a higher than “normal” forehead height without appearing unnatural. Patients with male-pattern baldness who understand the possibility of minimally visible scaring are acceptable candidates for an endoscopic procedure. However, a history of hypertrophic scaring and skin pigmentary changes as a result of previous surgeries should be noted. If visible scaring is to be expected, patients with thin, non sebaceous and less pigmented skin are more ideal candidates. An accurate assessment of the position of the brow is also critical in the upper third facial analysis. Due to the dynamic forces of various upper facial muscles, the brow becomes ptotic over time. The visual effect of brow ptosis often results in a tired, sad or angry look. The clinical appearance of patients with brow ptosis can often be categorized as “brow elevator” or “squinter and frowner.” “Brow elevators” will elevate the brow artificially when they open their eyes to increase their visual field. This action results in repetitive frontalis muscle contraction leaving visible horizontal forehead wrinkling. The appearance of these horizontal lines can usually be diminished with brow elevating surgery. However, the postoperative position of the eyebrows will be minimally changed unless the surgeon accounts for the artificial brow elevation. This is easily accomplished by having an “eyes closed” preoperative view during which the patient is not elevating the brow. Patients who elevate their brows during facial expression should also be evaluated for eyelid ptosis. Patients with eyelid ptosis use brow elevation as a compensatory mechanism; therefore, any forehead rejuvenation surgery will make the appearance of eyelid ptosis worse. “Frowners and squinters” with their prominent vertical glabellar creases manifest earlier signs of upper face aging. These patients often demonstrate hypertrophy of the procerus, corrugator and depressor supercilii and require more meticulous attention. The patient’s skin surface quality and mobility should be also evaluated. Ramirez suggests that Asians and American Indians have tighter or thicker skin in the forehead and significant bony attachments of the frontal/orbital soft tissue compared to Caucasians. In these isolated groups, the endoscopic approach may not work effectively unless extended release and more reliable fixation of the soft tissue is made. However, more recent experiences have disputed such claims with reportedly successful results using the endoscopic method in Asian patients. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 13

The patient’s skin redundancy should also be examined carefully. It is not uncommon for aging patients to have redundant tissues develop in the eyelid complex. This cannot be addressed with a forehead lift alone. Such patients with redundant tissue and/or “puffy” eyelids often require blepharoplasty and repositioning or conservative removal of the orbital fats in conjunction with a forehead rejuvenation procedure. As part of the preoperative assessment, “frame height” and “brow glide” measurements should be taken. Frame height is the distance from the mid-pupil to the top of the central brow. Brow ptosis is defined to be present if this distance is less than 2.5 cm. “Brow glide” is measured by lifting the brow and recording maximal excursion of the medial, central and lateral portions of the brow from the neutral position. The average measurement is 1–2 cm. Ethnicity affects brow glide and patients of Asian, African-American and Mediterranean descent may have reduced measurements. Patients who demonstrate high glide indices will not have comparable results to patients who have lower indices. For the best aesthetic result, patients with mild to moderate brow ptosis or those re quiring less than 1.5 cm elevation of the midbrow are considered the best candidates for the endoscopic technique. Those requiring greater elevation should be treated with a skin resection forehead/browlift procedure.

Fig. 8 14 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

6.0 Endoscopic Forehead Rejuvenation For nearly 100 years, aesthetic rejuvenation of the aging face has focused on the surgical elevation of the brow and improving the appearance of the forehead. In the past decade, the application of endoscopic forehead lifting has revolutionized how aesthetic surgeons approach mild to moderate ptotic brow and forehead rhytids. As one of the earliest pioneers of endoscopic forehead rejuvenation, Keller, in 1991, described foreheadplasty using endoscopic visualization to incise the procerus, corrugator and depressor musculature and perform a temple lift. Keller, Isse and Ramirez soon advanced the technique by varying it on the basis of the configuration of the skull, bony architecture and soft tissue thickness and tightness. A move toward smaller incisions also ensued. Since then, numerous authors have reported their personal experiences and further added to the endoscopic forehead rejuvenation technique. Despite these revisions, the basic concept of endoscopic forehead rejuvenation remains unchanged: (i) a sub- or supraperiosteal dissection of the scalp to the level of the superior and lateral orbital rims and zygomatic arch; (ii) incision and release of the orbital peri- osteium and; (iii) selective myotomies of the brow depressors. The current trend has focused on less invasive incisions, wider undermining and a permanent fixation technique. Endoscopic foreheadplasty has proven to be as reliable as the traditional open approaches, but with significantly less surgical morbidity and postoperative discomfort. It has therefore become an excellent alternative in aesthetic rejuvenation of the upper third of the aging face.

Frontalis m Skin and subcutaneous fat

Galea aponeurotica

Supraorbital n

Superficial temporal fascia Supratrochlear n

Deep temporal fascia Corrugator supercilii m

Temporalis m Procerus m

Orbicularis oculli m Nasalis m

Temporal branches

Zygomatic branches Buccal branches

Facial n Marginal mandibular branch

Cervical branch Fig. 9 Facial anatomy. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 15

Indications It is imperative for the aesthetic facial surgeon to understand the appropriate indications for the endoscopic approach to forehead rejuvenation. Not every pa tient with an aging forehead will maximally benefit from endoscopic rejuvenation. Patients with one or more of the following indications would most benefit from the endoscopic approach:

1. Glabellar ptosis 2. Vertical glabellar rhytids 3. Forehead rhytids and frontalis hyperactivity 4. Mild to moderate ptosis of the eyebrow (less than 1.5 cm elevation of the midbrow) 5. Pseudoptosis eyelids

Relative contraindications No absolute contraindications exist for the endoscopic approach to rejuvenation of the upper third face as long as suitable modifications are made. Nonetheless, several relative contraindications do exist, and both surgeons and patients should understand that these contraindications would likely result in a less than ideal outcome. These are listed below:

1. High hairline 2. Asian and American Indian patients 3. Significant fronto-orbital irregularities

Advantages The endoscopic approach to forehead rejuvenation offers many advantages over traditional approaches. The main advantages are listed below:

1. Accurate resection or manipulation of the brow depressor muscles 2. Preservation of the scalp sensory nerves 3. Minimal rate of alopecia 4. Less recurrent brow ptosis 5. More control of brow position 6. Minimal elevation of the hairline 7. Can be used in thin hair or bald patients 8. Quicker recovery time 9. Less postsurgical numbness 10. Less postsurgical edema 16 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

7.0 Temporary vs. Permanent Fixation One of the controversies of the endoscopic forehead technique is the inexact predictability of the postoperative brow position. Some surgeons have reported a loss of forehead elevation in the early postoperative period, and many advocate routine overcorrection to compensate for this loss. The basis for this is unclear. However, as demonstrated in an animal model, significant adherence of periosteum to bone took at least 6–12 weeks (Histology 1–3). In the process of re-adherence, fibrous ingrowth into bony microfissures in the outer cortex of the calvarium, bony remodeling, and thickening of the periosteum were noted. While disruption of the brow depressor musculature and sectioning of the brow periosteum allow for immediate brow elevation, correct brow positioning is ultimately dependent on the stability from periosteal adherence to the calvarium formed during the first several weeks of the postoperative period. Various temporary fixation techniques with timing ranging from 3 days to 2 weeks have been used to achieve a stable and predictive brow position. However, based on animal studies and clinical experience, it is now clear that any type of temporary fixation technique is suboptimal. A permanent fixation technique, including cortical bone tunneling (Fig. 10) or any type of long-term fixation screws, which allows for a stable periosteal adherence to the calvarium, will offer the most precise and efficacious brow position.

Fig. 10 Bone tunneling method works equally effective for permanent fixation without the need for screws. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 17

Histology 1 Postoperative 1-week. A focal fibroblastic response and inflammation with sites of focal hemorrhage and bony remodeling are noted. The periosteum is thickened, Fig. 11a but there is no adherence to bone. The preoperative brow position reflects a balance between the brow elevator (fronto-occipitalis: red arrows) and brow depressors (corrugator and procerus: blue arrows; orbicularis muscles: purple arrows).

Histology 2 Postoperative 6-weeks. The periosteum is thinner than at week 1, with approximately 70 percent of the surface examined showing adherent periosteum. More bony remodeling is noted, with minimal to no inflammatory response.

Fig. 11b Immediately after subperiosteal elevation and depressor muscle sectioning, the brow position rises (blue arrows) due to the unopposed tonic contraction of fronto-occipitalis.

Histology 3 Postoperative 12-weeks. No acute inflammatory cells are seen. Thinner periosteum with complete adherence to bone and bony remodeling are noted.

Fig. 11c With time, the involuntary frontalis contraction relaxes. If this occurs prior to periosteal refixation to the calvarium at the elevated position, the brow will “relax” and settle at a lower, “dropped” position, compromising results. 18 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

8.0 Surgical Technique

Marking All patients are marked preoperatively in an upright position in the presurgical waiting area. These markings include the anticipated course of the temporal branch of the facial nerve, placement of the temporal and parietal incisions, and the desired brow elevation (5–8 mm medially and 8–10 mm laterally). The desired amount of brow elevation is marked in the following way. The position of the ptotic brow is marked (using a fine-tip marker pen) at its medial head, above the lateral limbus and the lateral canthus. Next, using accepted aesthetic norms, the brow is elevated manually to the desired position. The brow is then released, and the corresponding area of the frontal skin is marked. The distance between the pairs of marks is measured. Palpation and marking of the supraorbital notch is a useful landmark when later aggressive endoscopic dissection is performed (Figs. 12a – c). The course of the temporal branch of the facial nerve is marked by connecting the following points: one on the facial skin 1 cm anterior to the inferior ear lobule, another 3 cm anterior to the superior external auditory canal and the last, 1.5 cm lateral to the lateral brow (Fig. 13a). Six incisions are marked: two medial paramedian incisions each 2 cm lateral to the midline, 1.5 cm long and 5 mm behind the anterior hairline; two lateral paramedian incisions, centered on the lateral canthus, 1.5 cm in vertical length, just behind

12a 12b 12c Figs. 12a – c The desired amount of brow elevation is marked preoperatively with the patient in an upright position.

13b 13c

Fig. 13a Figs. 13b, c The temporal branch of the facial nerve Note the placement of scalp incision sites for patients with and without significant and the temporal incision markings: male-pattern baldness. The anticipated course of the temporal branch of the facial nerve is marked by connecting the following points: one on the facial skin 1 cm anterior to the inferior lobule, another 3 cm anterior to the superior external auditory canal and 1.5 cm lateral to the lateral brow. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 19

the anterior hairline; and two temporal Figs. 14a – d incisions 2 cm long and approximately 2 After general endotracheal anesthesia or monitored intravenous anesthesia has cm behind and parallel to the temporal been administered, supplemental local hairline. If greater access is needed to anesthetics are used in the soft tissues. the forehead in the patient with a high 1% lidocain with 1:100,000 epinephrine is injected into the region of supraorbital curved forehead, additional paramedian and supratrochlear nerves, the parietal vertical incisions can also marked scalp incision site, the parietal, frontal, behind the anterior hairline. One should and glabellar tissues, and the temporal not forget to modify the incisions in incision site. patients with male pattern baldness 14a to effectively hide them. However, even in bald patients the incision scars are minimal and the endofore- head lift can be effectively used for forehead rejuvenation (Figs. 13b, c).

Dissection General endotracheal anesthesia may be used, but we prefer monitored intravenous anesthesia in conjunction with supplemental local anesthetics; 1% lidocaine with 1:100,000 epinephrine is our standard local anesthetic. We inject 14b 14c in the following order: first into the region of the supraorbital and supratrochlear nerves to provide a regional nerve blockade; then the marked parietal scalp incision sites, the sur rounding parietal, frontal, and glabellar soft tissues in a periosteal plane; and last the temporal incisions and surrounding soft tissue in a subcutaneous plane. Care is taken to prevent injury to the superficial temporal artery and vein (Figs. 14a – d). Prior to making the anterior scalp incisions, the superior forehead and 14d brow are manually depressed into their natural ptotic position with the Fig. 15 Lateral paramedian incision is carried surgeon’s free hand. down to and through the underlying The four parietal scalp incisions are periosteum. made with a #15 scalpel blade and are carried down to and through the underlying periosteum (Fig. 15). Control holes are drilled into the calvarium at the anterior extent of each vertical incision with a hand drill fitted with a 1.7 mm diameter drill bit and a 4 mm stop (Figs. 16a, b).

16a 16b

Figs. 16a, b Four control holes (two medial and two lateral paramedian) are drilled with a 1.7 mm diameter drill bit with a 4 mm stop into the calvarium at the anterior extent of each vertical incision. 20 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Using a millimeter caliper, the premeasured desired distance for brow elevation is marked on the calvarium posterior to the four control holes (Figs. 17a, b). Fixation holes are then drilled into the calvarium at these points (Figs. 18a, b). Next, a wide subperiosteal undermining of the parietal scalp is accomp lished with a lateral dissection to each tempo- 17a 17b ral crest (Figs. 19a, b). Posterior dissection is completed with a large curved Figs. 17a, b Using a caliper, the premeasured desired distance for brow elevation is marked on the elevator to the superior and mid occipital calvarium posterior to the control holes. scalp (Fig. 20). Anterior dissection is carried over the forehead with a sharp down-turned elevator staying 2 cm above the superior orbital rims. In the area of the glabella a sharp large curved elevator is used to elevate the soft tissue down to the superior nasal bones (Fig. 21). The temporal incisions are made (Fig. 22) and a plane of dissection deep to the superficial temporal fascia is deve- loped with a broad periosteal dis sector. 18a 18b A front-to-back sweeping motion Figs. 18a, b exposes the deep temporal fascia, Fixation holes are seen at the premeasured sites posterior to the control holes in both which is not penetrated (Figs. 23a, b). medial and lateral paramedian sites. A superior and medial sweeping motion with the elevator allows for incision of the tightly adherent temporal fascia and perios teum at the temporal crest. (Fig. 24) This maneuver connects the temporal pocket to the parietal pocket. Continuing the dissection in an anterior- inferior directed motion carries the flap elevation down to the lateral orbital rim. Multiple small vessels including the sentinel vein may be encountered at 19a 19b this point of the dissection and are cau- Figs. 19a, b, 20 terized medially to the elevated flap with A wide subperiosteal undermining of the parietal and occipital soft tissue is performed. a bipolar cautery forceps (Figs. 25a, b).

20 Fig. 21 Fig. 22 A sharp curved elevator is used in the The temporal incisions are made and glabella region to elevate the soft tissue carried down to the level of the deep down to the superior nasal bone. temporal fascia. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 21

Caution is particularly important at this point. The dissection must stay lateral to the canthal tendon in order to not detach this important anatomic structure (Fig. 26). Inferior dissection continues in an anterior to posterior direction, staying just along the superior edge of the zygomatic arch. Dissecting inferior to the zygoma may result in injury to the temporal branch of the facial nerve. The soft tissues are elevated back to and in front of the anterior helix and then carried above and behind the auricle into the mastoid region. Care must be noted here as well. Do not proceed too posterior, or the mastoid vein may be injured resulting in severe bleed ing. With endoscopic visualization through a lateral paramedian incision, the curved sharp dissector is inserted through the temporal incision on the same side of the head, and a lateral-to-medial dissection of the periosteum from the supraorbital rim is performed (Fig. 27). The supraorbital and supratrochlear neurovascular bundles are identified and preserved (Fig. 28).

23a 23b Figs. 23a, b Fig. 24 Deep temporal fascia is exposed but not penetrated. A superior and medial sweeping motion allows for incision of the periosteum at the temporal crest.

25a 25b Figs. 25a, b Fig. 26 Multiple small vessels including the sentinel vein are encountered. These vessels are Performing dissection lateral to the carefully cauterized using a bipolar cautery forceps. can thal tendon and along the superior lateral orbital rim.

Fig. 27 Fig. 28 Periosteal attachments of the lateral half The supraorbital and supratrochlear of the superior and lateral orbital rim are neuro vascular bundles are seen through incised. the endoscope and preserved. 22 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

An upturned periosteal spreader is used along the supraorbital rim in a lateral- to-medial direction (Fig. 29). This dissection provides for further periosteal release that exposes the underlying retroorbicularis oculi fat pad and produces limited myotomies in the overlying orbicularis oculi muscle. Next, a thin nerve dissector is introduced to further incise the medial supraorbital periosteum. The neurovascular bundles Fig. 29 Fig. 30 An upturn periosteal spreader is used along The endoscope is inserted into the medial and depressor supercilii muscle, corru - the supraorbital rim to further release the paramedian site to view the glabellar area to gator supercilii muscle, and procerus periosteum. perform the myotomies. muscle are identified with this dissection. The endoscope is then inserted

Fig. 31 A #10 Fr. fluted drain is placed across the supraorbital brow and brought out through the right superior postauricular scalp.

32a Figs. 32a, b Medial and central brow fixations are performed using a 2 mm diameter titanium anchor in each of the four fixation holes.

32b Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 23

through the medial paramedian incision down to level of the (Fig. 30). A curved endoscopic forehead punch or grasping forceps is inserted through a paramedian incision and then utilized to perform myotomies of the procerus, corrugator, and depressor supercilii muscles. Myotomy of the corrugator muscle is performed both medial and lateral to the supratrochlear bundle. Hemostasis is controlled with bipolar 33a 33b electrocautery applied to insulated Figs. 33a – c forceps. A 10 Fr. fluted drain is routinely These screws are fitted with 2-0 ETHIBOND® (ETHICON) sutures. placed across the supraorbital brow and brought out through the right superior posterior scalp (Fig. 31). The release of the brow and forehead soft tissues allows intrinsic elevation of the brow with posterior pull of the occi pital-galea-frontalis complex.

Permanent Fixation Medial and central brow fixation is performed by placement of a 2 mm diameter (3.5 mm length) titanium anchor in each of the four holes (Figs. 32a, b). 33c These small screws are fitted with a Fig. 34 2-0 ETHIBOND® (ETHICON) suture The free end of the suture is threaded (Figs. 33a – c). The free end of the through the eyelet of a free needle. suture is threaded through the eyelet of a free needle (Fig. 34). Next, the needle is passed through the periosteal/galeal soft tissue at the anterior extent of each incision and brought out of the incision (Figs. 35a – c).

35a 35b

Figs. 35a – c The needle is then passed through the anterior extent of the soft tissue (periosteal/galeal) and brought out of the 35c incision. 24 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Fig. 36 Overview of the medial and central permanent fixation suture technique. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 25

The sutures are tied down under direct vision so the anterior extent of the incision lies over the titanium anchor (Fig. 36). This provides exact elevation and fixation at the desired brow height. The parietal incisions are closed with 3-0 Prolene® in a vertical mattress manner and supplemented with stainless steel staples (Figs. 37a, b).

Using the desired amount of brow 37a 37b elevation for the lateral canthus and Figs. 37a, b temporal region, a fixation point is The incisions are closed using a 3-0 Prolene® suture and stapled. identified superior and posterior to the inferior edge of the temporal incisions. Two 2-0 polygalactin sutures are placed in the deep temporal fascia at this point and are then passed through the dermis and temporoparietal fascia of the edge of the inferior temporal flap (Fig. 38). Manual advancement of the inferior temporal flap by an assistant is performed as the two polygalactin sutures are tied down and secured (Fig. 39). This provides elevation of the lateral brow. The edges of the temporal Fig. 38 Fig. 39 Two 2-0 polygalactin sutures are placed in Manual advancement of the inferior incisions are approximated with a 3-0 the deep temporal fascia and passed through temporal flap by an assistant while the Prolene® suture in a vertical mattress the dermis and temporoparietal fascia of the sutures are tied down for lateral brow fashion and then closed with stainless edge of the inferior temporal flap. eleva tion. steel staples (Figs. 40a, b). A soft, mildly compressive circumferential head dressing is placed and removed along with the drain on the first or second postoperative day (Fig. 41). The patient is instructed to place antibiotic ointment on the scalp suture lines two or three times per day. On the fifth postoperative day gentle hair washing is allowed. The sutures and staples are removed during the 40a 40b second postoperative week. Figs. 40a, b The edges of the temporal incisions are approximated with a 3-0 Prolene® suture in a vertical mattress fashion and then closed with stainless steel staples. Note the position of the drain.

Fig. 41 A soft, mildly compressive circumferential head dressing is placed. 26 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Preoperative Postoperative 9.0 Clinical Cases

Figs. 1a – 3b Patient’s brow ptosis, horizontal forehead rhytids and lateral crow’s feet are subtle and minimal, but real (Figs. 1a, 2a, 3a). Postoperatively, patient appears youthful and rejuvenated (Figs. 1b, 2b, 3b).

Fig. 1a Fig. 1b

Fig. 2a Fig. 2b

Fig. 3a Fig. 3b Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 27

Preoperative Postoperative

Figs. 4a – 6b A significant unilateral right brow ptosis conveys anger and age. A deviated nose also adds to the unbalanced appearance of the face (Figs. 4a, 5a, 6a). After endoscopic forehead lift and rhinoplasty, patient appears younger and more attractive. Note the symmetric brow posi tion (Figs. 4b, 5b, 6b).

Fig. 4a Fig. 4b

Fig. 5a Fig. 5b

Fig. 6a Fig. 6b 28 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Preoperative Postoperative

Figs. 7a – 9b Patient’s brow ptosis, crow’s feet, facial rhytids and pigmentary changes contribute to a fatigued and aged look. (Figs. 7a, 8a, 9a). Patient underwent endo scopic forehead lift, face lift and laser resurfacing (Figs. 7b, 8b, 9b).

Fig. 7a Fig. 7b

Fig. 8a Fig. 8b

Fig. 9a Fig. 9b Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 29

Preoperative Postoperative

Figs. 10a – 11b Ptotic medial portion of the brow and glabellar rhytids express anger in this patient (Figs. 10a, 11a). A significant improvement is achieved with the endo scopic fore head lift (Figs. 10b, 11b).

Fig. 10a Fig. 10b

Fig. 11a Fig. 11b 30 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Preoperative Postoperative

Figs. 12a – 13b Patient’s mild brow ptosis and horizontal forehead rhytids convey early aging (Figs. 12a, 13a). Patient appears more refreshed after the endoscopic forehead lift (Figs. 12b, 13b).

Fig. 12a Fig. 12b

Fig. 13a Fig. 13b Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 31

Preoperative Postoperative

Figs. 14a – 15b Patient’s mild brow ptosis and significant forehead and glabellar rhytids have been addressed by the endoscopic forehead lift (Figs. 14a, 15a). Postoperatively, patient appears much younger (Figs. 14b, 15b).

Fig. 14a Fig. 14b

Fig. 15a Fig. 15b 32 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Preoperative Postoperative

Figs. 16a – 17b Patient’s stern look suggests seriousness and mild anger (Figs. 16a, 17a). Patient’s appearance has now been softened and rejuvenated. Note the change in brow position (Figs. 16b, 17b).

Fig. 16a Fig. 16b

Fig. 17a Fig. 17b Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 33

Preoperative Postoperative

Figs. 18a – 19b The ptotic brows convey fatigue (Figs. 18a, 19a). Postoperatively, patient appears younger and eyes seem to “open-up” (Figs. 18b, 19b).

Fig. 18a Fig. 18b

Fig. 19a Fig. 19b 34 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

10.0 References 1. ABRAMO, A.C.: Anatomy of the forehead muscles: 8. RAMIREZ, O.M.: Endoscopic techniques in facial the basis for the videoendoscopic approach in forehead rejuvenation: an overview. rhytidoplasty. Part I. Aesthetic Plastic Surgery. 18: 141 – 147, 1994. Plastic & Reconstructive Surgery. 95: 1170 – 1177, 1995. 9. RAMIREZ, O.M.: Why I prefer the endoscopic forehead 2. ISSE, N.G.: Endoscopic facial rejuvenation: lift. Plastic & Reconstructive Surgery. 100: 1033 – 1039, endofore head, the functional lift. Case reports. 1997. Aesthetic Plastic Surgery. 18: 21 – 29, 1994. 10. ROMO, T., SCLAFANI, A.P., & YUNG, R.T.: Endoscopic 3. KELLER, G.S.: Small incision frontal rhytidectomy with foreheadplasty: temporary vs. permanent fixation. the KTP laser. American Academy of Cosmetic Aesthetic Plastic Surgery. 23: 388 – 394, 1999. Sur gery, World Congress. October 1991, Scotsdale, AZ 11. ROMO, T., & MILLMAN, A.L.: Aesthetic Facial Plastic 4. KIM, I.G., KEUN, J., BAEK, D.H.: Personal experiences Surgery. New York: Thieme Medical Publishers, Inc., and algorithm of endoscopically assisted 2000. subperiost eal face lift in Orientals for 5 years. 12. ROMO, T., SCLAFANI, A.P.,YUNG, R.T. & et al.: Plastic & Reconstructive Surgery. 108: 1768 –1779, 2001. Endoscopic foreheadplasty: a histologic comparison of 5. KRAUSE, C.J., PASTOREK, N., & MANGAT, D.S.: periosteal refixation after endoscopic versus bicoronal Aesthetic Facial Surgery. Philadelphia: lift. J.P Lippincott, Co, 1991. Plastic & Reconstructive Surgery.105: 1111–1117, 2000. 6. MALONEY, B.P:. Forehead rejuvenation techniques. 13. ROMO, T., JACONO, A.A., & SCLAFANI, A.P.: Facial Plastic Surgery Clinics of North America. Endoscopic forehead lifting and contouring. 8: 329 – 333, 2000. Facial Plastic Surgery. 17: 3 – 10, 2001. 7. PAPEL, I.D. & NACHLAS, N.E.: Facial Plastic & Recon- structive Surgery. St. Louis: Mosby Year Book, Inc., 1992. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 35

11.0 Instruments for Endoscopic Forehead Lift Recommended Set according to Dr. Thomas Romo III, FACS

50230 BWA 1 HOPKINS® Wide Angle Forward-Oblique 50232 GW 1 CLICKLINE Dissecting and Grasping Forceps, Telescope 30°, enlarged view, diameter 4 mm, heavy, dismantling, jaws horizontal opening, length 18 cm, autoclavable, curved sheath, size 3 mm, working length 18 cm, fiber optic light transmission incorporated, including: color code: red Metal Handle, insulated or: Outer Tube, with working insert 50230 BA 1 ® HOPKINS Forward-Oblique Telescope 30°, 50245 GW 1 CLICKLINE Scissors, dismantling, curved jaws, enlarged view, diameter 4 mm, length 18 cm, horizontal opening, curved sheath, size 5 mm, autoclavable, working length 18 cm, fiber optic light transmission incorporated, color code: red including: 50200 ES 1 Optical Dissector, with distal spatula, Metal Handle, insulated fenestrated, large, sharp, for use with Outer Tube, with working insert ® HOPKINS telescopes 50230 BA/BWA 496400 3 MASING Surgical Handle, length 14 cm, 58210 AGA Elevator, sharp, width 9 mm, curved, for use with blades 208010–15, 208210–15 working length 15 cm 499205 2 Double Hook, sharp, 5 mm wide, length 15 cm 58210 CA Elevator, sharp, spatula 12 x 12 mm, straight, 506400 1 AUFRICHT length 16.5 cm working length 15 cm Nasal Retractor, 58210 CGA Elevator, sharp, spatula 12 x 12 mm, curved, 512211 1 Scissors, tungsten carbide inserts, sharp/sharp, working length 15 cm straight, length 11 cm 58210 FGA Elevator, sharp, spoon-shaped spatula, 512411 1 Scissors, tungsten carbide inserts, blunt/blunt, width 12 mm, slightly curved, curved, straight, length 11 cm working length 15 cm 516013 2 Needle Holder, tungsten carbide inserts, 58210 GGA Elevator, sharp, bow-shaped spatula, length 13 cm width 9 mm, curved, working length 15 cm 516412 2 OLSEN-HEGAR Needle Holder-Scissors, 58210 LGA Elevator, sharp, for lifting and dissection of the tungsten carbide inserts, delicate, length 12 cm orbita rim periosteum, distal end of spatula 90° 525500 1 Rule, stainless steel, flexible, length 20 cm curved upwards, width 9 mm, upper part sharp, curved, working length 15 cm 525510 1 CASTROVIEJO Caliper, measuring range 0–15 mm, length 8 cm 58210 MGA Elevator, sharp, curved, curved upwards, upper part sharp, width 9 mm, length 15 cm 533112 2 ADSON Tissue Forceps, 1 x 2 teeth, length 12 cm 58210 WGA Elevator, sharp, triangular-shaped, 533212 2 ADSON-BROWN Tissue Forceps, width 4 mm, curved, working length 15 cm atraumatic, fine side grasping teeth, length 12 cm 58210 TKA Elevator, sharp, spatula slightly curved, 752500 1 GOOD Scissors, length 19.5 cm width 8 mm, straight, working length 6 cm 796011 3 BACKHAUS Towel Forceps, length 11 cm 58210 UKA Elevator, sharp, straight, width 8 mm, length 6 cm 810802 1 Cup Medicine, stainless steel, 25 cc, 50232 GG 1 CLICKLINE Dissecting and Grasping Forceps, height 28 mm, diameter 60 mm heavy, dismantling, curved sheath, size 3 mm, working length 18 cm, 810806 1 Cup Medicine, stainless steel, 60 cc, including: height 33 mm, diameter 70 mm Metal Handle, insulated 841219 2 Bipolar Coagulating Forceps, insulated, straight, Outer Tube, with working insert blunt, tip 1 mm wide, length 19 cm

It is recommended to check the suitability of the product for the intended procedure prior to use. 36 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Videoendoscopic Imaging Systems and Accessories:

TH 100 1 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head, 26004 M 1 Unipolar High Frequency Cord, IMAGE1 S compatible, max. resolution 1920 x 1080 with 4 mm plug for HF unit, models Berchtold pixels, progressive scan, soakable, and Martin, length 300 cm gas- and plasma-sterilizable, with integrated Parfocal 26005 M 1 Unipolar High Frequency Cord, Zoom Lens, focal length f = 15 – 31 mm (2x), with 5 mm plug for HF unit, models KARL STORZ 2 freely programmable camera head buttons, for use AUTOCON® system (50, 200, 350), AUTOCON® II 400 with IMAGE1 S and IMAGE 1 HUB™ HD/HD SCB® (111, 115) and Erbe type ICC, length 300 cm TC 200EN 1 connect module, for use with IMAGE1 CONNECT, 847000 M 1 Bipolar High Frequency Cord, up to 3 link modules, resolution 1920 x 1080 pixels, for Martin and Berchtold coagulators, length 300 cm with integrated KARL STORZ-SCB and digital Image Processing Module, power supply 847000 E 1 Bipolar High Frequency Cord, 100 – 120 VAC/200 – 240 VAC, 50/60 Hz to KARL STORZ Coagulator 26021 B/C/D, including: 860021 B/C/D, 27810 B/C/D, 28810 B/C/D, AUTOCON® system (50, 200, 350), AUTOCON® II 400 Mains Cord, length 300 cm system SCB (111, 113, 115) and Erbe-Coagulator, DVI-D Connecting Cable, length 300 cm T- and ICC-row, length 300 cm SCB Connecting Cable, length 100 cm UG 220 USB Flash Drive, 32 GB Equipment Cart wide, high, rides on 4 antistatic dual wheels equipped with locking brakes 3 shelves, mains switch on Please note: top cover, central beam with integrated electrical For detailed information on the KARL STORZ Endovision video subdistributors with 12 sockets, holder for power systems and additional accessories see the latest edition of broch ure supplies, potential earth connectors and cable TELEPRESENCE – IMAGING SYSTEMS, DOCUMENTATION, winding on the outside, ILLUMINATION. Dimensions: Equipment cart: 830 x 1474 x 730 mm (w x h x d), 9826 NB 1 26" FULL-HD Monitor, wall-mounted with VESA 100 shelf: 630 x 510 mm (w x d), adaption, color systems PAL/NTSC, max. screen caster diameter: 150 mm resolution 1920 x 1080, image fomat 16:9, inluding: power supply 100 – 240 VAC, 50/60 Hz Base module equipment cart, wide including: Cover equipment, equipment cart wide External 24 VDC Power Supply Beam package equipment, equipment cart high Mains Cord 3x Shelf, wide ® 201340 01 1 Cold Light Fountain XENON NOVA 300, Drawer unit with lock, wide lamp type: 300 W XENON lamp, power supply: 2x Equipment rail, long 100–125 VAC / 220–240 VAC; 50/60 Hz, including mains cord Camera holder 20 1330 28 1 XENON Spare Lamp, 300 watt, 15 volt, for XENON NOVA® 300 495 NA 1 Fiber Optic Light Cable, diameter 3.5 mm, length 230 cm 20 5205 01 1 AUTOCON® 50, High Frequency Surgery Unit, power supply: 100/120/230/240 VAC, 50/60 Hz, including: Mains Cord Adaptor, unipolar HF-output, 4 mm/5 mm

Please note: Additional accessories for AUTOCON® 50 (high frequency cords, neutral electrodes, handles, surgery set, etc.) see catalogue PLASTIC SURGERY. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 37

HOPKINS® Telescopes – Optical Dissector

50230 BA/BWA

50230 BWA HOPKINS® Wide Angle Forward-Oblique Telescope 30º, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: red or: 50230 BA HOPKINS® Forward-Oblique Telescope 30º, enlarged view, diameter 4 mm, length 18 cm, autoclavable, fiber optic light transmission incorporated, color code: red

50200 ES

50200 ES Optical Dissector, with distal spatula, fenestrated, large, sharp, for use with HOPKINS® telescopes 50230 BA/BWA 38 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Elevators, sharp – Nerve Hooks working length 6 cm / 15 cm

58210 AGA

58210 AGA Elevator, sharp, width 9 mm, curved, working length 15 cm

58210 BA Raspatory, straight, width 6 mm, working length 15 cm

58210 CA Elevator, sharp, spatula 12 x 12 mm, straight, working length 15 cm

58210 CGA Elevator, sharp, spatula 12 x 12 mm curved, working length 15 cm

58210 FGA Elevator, sharp, spoon-shaped spatula, width 12 mm, slightly curved, curved, working length 15 cm

58210 GGA Elevator, sharp, bow-shaped spatula, width 9 mm, curved, working length 15 cm

58210 LGA Elevator, sharp, for lifting and dissection of the orbita rim periosteum, distal end of spatula 90° curved upwards, width 9 mm, upper part sharp, curved, working length 15 cm

58210 MGA Elevator sharp, curved, curved upwards, upper part sharp, width 9 mm, length 15 cm

58210 WGA Elevator, sharp, triangular-shaped, width 4 mm, curved, working length 15 cm

58210 TKA Elevator, sharp, spatula slightly curved, width 8 mm, straight, working length 6 cm

58210 UKA Elevator sharp, straight, width 8 mm, length 6 cm

58210 ZA Raspatory, straight, strongly curved, pointed, width 3 mm, working length 15 cm Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 39

Dissecting and Grasping Forceps, Punch and Scissors curved sheath, CLICKLINE, dismantling – non-rotating

50232 GG

50232 GG CLICKLINE Dissecting and Grasping Forceps, heavy, dismantling, curved sheath, size 3 mm, working length 18 cm, including: Metal Handle, insulated Outer Tube, with working insert

50232 GW CLICKLINE Dissecting and Grasping Forceps, heavy, dismantling, jaws horizontal opening, curved sheath, size 3 mm, working length 18 cm, including: Metal Handle, insulated Outer Tube, with working insert

50245 GW CLICKLINE Scissors, dismantling, curved jaws, jaws horizontal opening, curved sheath, size 5 mm, working length 18 cm, including: Metal Handle, insulated Outer Tube, with working insert 40 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Surgical Handle and Blades, Nasal Retractor, Scissors, Needle Holders

208010 208015 208210 208215

208011 208211

496400 506400 512211 512411 516013

496400 MASING Surgical Handle, length 14 cm, for use with blades 208010–15, non-sterile, 208210–15, sterile 499205 JOSEPH Double Hook, sharp, 499205 width 5 mm, length 15 cm 506400 AUFRICHT Nasal Retractor, length 16.5 cm 512211 Scissors, tungsten carbide inserts, sharp/sharp, straight, length 11 cm 512411 Scissors, tungsten carbide inserts, blunt/blunt, straight, length 11 cm 516412 516013 Needle Holder, tungsten carbide inserts, length 13 cm 516412 OLSEN-HEGAR Needle Holder-Scissors, tungsten carbide inserts, delicate, length 12 cm

499205 516412 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 41

Rule and Caliper, Tissue Forceps, Scissors, Towel Forceps, Bipolar Coagulating Forceps and Cups

533112

533212

525500 525510 533112 752500 796011 841219

525500 Rule, stainless steel, flexible, length 20 cm 525510 CASTROVIEJO Caliper, measuring range 0–15 mm, length 8 cm 533112 ADSON Tissue Forceps, 1 x 2 teeth, length 12 cm 533212 ADSON-BROWN Tissue Forceps, atraumatic, fine side-grasping teeth, length 12 cm 752500 GOOD Scissors, length 19.5 cm 796011 BACKHAUS Towel Forceps, length 11 cm 810802 810802 Cup Medicine, 25 ccm, diameter 60 mm, height 28 mm 810806 Cup Medicine, 60 ccm, diameter 70 mm, height 33 mm 841219 Bipolar Coagulating Forceps, insulated, straight, blunt, tip 1 mm wide, length 19 cm

810806 42 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

IMAGE1 S Camera System n

Economical and future-proof ## Modular concept for flexible, rigid and ## Sustainable investment 3D endoscopy as well as new technologies ## Compatible with all light sources ## Forward and backward compatibility with video endoscopes and FULL HD camera heads

Innovative Design ## Dashboard: Complete overview with intuitive ## Automatic light source control menu guidance ## Side-by-side view: Parallel display of standard ## Live menu: User-friendly and customizable image and the Visualization mode ## Intelligent icons: Graphic representation changes ## Multiple source control: IMAGE1 S allows when settings of connected devices or the entire the simultaneous display, processing and system are adjusted documentation of image information from two connected image sources, e.g., for hybrid operations

Dashboard Live menu

Intelligent icons Side-by-side view: Parallel display of standard image and Visualization mode Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 43

IMAGE1 S Camera System n

Brillant Imaging ## Clear and razor-sharp endoscopic images in ## Reflection is minimized FULL HD ## Multiple IMAGE1 S technologies for homogeneous ## Natural color rendition illumination, contrast enhancement and color shifting

FULL HD image CLARA

FULL HD image CHROMA

FULL HD image SPECTRA A *

FULL HD image SPECTRA B **

* SPECTRA A : Not for sale in the U.S. ** SPECTRA B : Not for sale in the U.S. 44 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

IMAGE1 S Camera System n

TC 200EN

TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to 3 link modules, resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB and digital Image Processing Module, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz including: Mains Cord, length 300 cm DVI-D Connecting Cable, length 300 cm SCB Connecting Cable, length 100 cm USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US * Available in the following languages: DE, ES, FR, IT, PT, RU

Specifications: HD video outputs - 2x DVI-D Power supply 100 – 120 VAC/200 – 240 VAC - 1x 3G-SDI Power frequency 50/60 Hz Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm USB interface 4x USB, (2x front, 2x rear) Weight 2.1 kg SCB interface 2x 6-pin mini-DIN

For use with IMAGE1 S IMAGE1 S CONNECT Module TC 200EN

TC 300

TC 300 IMAGE1 S H3-LINK, link module, for use with IMAGE1 FULL HD three-chip camera heads, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz, for use with IMAGE1 S CONNECT TC 200EN including: Mains Cord, length 300 cm Link Cable, length 20 cm

Specifications: Camera System TC 300 (H3-Link) Supported camera heads/video endoscopes TH 100, TH 101, TH 102, TH 103, TH 104, TH 106 (fully compatible with IMAGE1 S) 22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3, 22 2200 54-3, 22 2200 85-3 (compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*) LINK video outputs 1x Power supply 100 – 120 VAC/200 – 240 VAC Power frequency 50/60 Hz Protection class I, CF-Defib Dimensions w x h x d 305 x 54 x 320 mm Weight 1.86 kg

* SPECTRA A : Not for sale in the U.S. ** SPECTRA B : Not for sale in the U.S. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 45

IMAGE1 S Camera Heads n

For use with IMAGE1 S Camera System IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300 and with all IMAGE 1 HUB™ HD Camera Control Units

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera head buttons, TH 100 for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications: IMAGE1 FULL HD Camera Heads IMAGE1 S H3-Z Product no. TH 100

Image sensor 3x 1/3" CCD chip Dimensions w x h x d 39 x 49 x 114 mm Weight 270 g Optical interface integrated Parfocal Zoom Lens, f = 15 – 31 mm (2x) Min. sensitivity F 1.4/1.17 Lux Grip mechanism standard eyepiece adaptor Cable non-detachable Cable length 300 cm

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, autoclavable, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera head TH 104 buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications: IMAGE1 FULL HD Camera Heads IMAGE1 S H3-ZA Product no. TH 104

Image sensor 3x 1/3" CCD chip Dimensions w x h x d 39 x 49 x 100 mm Weight 299 g Optical interface integrated Parfocal Zoom Lens, f = 15 – 31 mm (2x) Min. sensitivity F 1.4/1.17 Lux Grip mechanism standard eyepiece adaptor Cable non-detachable Cable length 300 cm 46 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Monitors

9619 NB 19" HD Monitor, color systems PAL/NTSC, max. screen resolution 1280 x 1024, image format 4:3, power supply 100 – 240 VAC, 50/60 Hz, wall-mounted with VESA 100 adaption, including: External 24 VDC Power Supply Mains Cord 9619 NB

9826 NB 26" FULL HD Monitor, wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1920 x 1080, image fomat 16:9, power supply 100 – 240 VAC, 50/60 Hz including: External 24 VDC Power Supply Mains Cord

9826 NB Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 47

Monitors

KARL STORZ HD and FULL HD Monitors 19" 26" Wall-mounted with VESA 100 adaption 9619 NB 9826 NB Inputs: DVI-D l l Fibre Optic – – 3G-SDI – l RGBS (VGA) l l S-Video l l Composite/FBAS l l Outputs: DVI-D l l S-Video l – Composite/FBAS l l RGBS (VGA) l – 3G-SDI – l Signal Format Display: 4:3 l l 5:4 l l 16:9 l l Picture-in-Picture l l PAL/NTSC compatible l l

Optional accessories: 9826 SF Pedestal, for monitor 9826 NB 9626 SF Pedestal, for monitor 9619 NB

Specifications: KARL STORZ HD and FULL HD Monitors 19" 26" Desktop with pedestal optional optional Product no. 9619 NB 9826 NB Brightness 200 cd/m2 (typ) 500 cd/m2 (typ) Max. viewing angle 178° vertical 178° vertical Pixel distance 0.29 mm 0.3 mm Reaction time 5 ms 8 ms Contrast ratio 700:1 1400:1 Mount 100 mm VESA 100 mm VESA Weight 7.6 kg 7.7 kg Rated power 28 W 72 W Operating conditions 0 – 40°C 5 – 35°C Storage -20 – 60°C -20 – 60°C Rel. humidity max. 85% max. 85% Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm Power supply 100 – 240 VAC 100 – 240 VAC Certified to EN 60601-1, EN 60601-1, UL 60601-1, protection class IPX0 MDD93/42/EEC, protection class IPX2 48 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

AUTOCON® II 400 SCB High Frequency Surgery Unit – Recommended System Configuration

20 5352 20-11x

20 535 20x-12x AUTOCON® II 400 with KARL STORZ SCB power supply 220 - 240 VAC, 50/60 Hz including: Mains Cord

AUTOCON® II 400 AUTOCON® II 400 Socket Position SCB, Set SCB 1 2 3 4 Standard Unipolar 3-pin Neutral Electr. Bipolar Bipolar and Erbe 6.3 mm jack 20 5352 01-111 20 5352 20-111

Bipolar Bipolar Unipolar 3-pin Neutral Electr. US-2-pin US-2-pin and Bovie 2-pin 20 5352 01-112 20 5352 20-112

Bipolar Bipolar Bipolar Bipolar Blind Socket Multifunction 20 5352 01-113 20 5352 20-113

Bipolar Bipolar Bipolar Blind Socket US-2-pin US-2-pin Multifunction 20 5352 01-114 20 5352 20-114

High-End Bipolar Unipolar 3-pin Neutral Electr. Bipolar Multifunction and Erbe 6.3 mm jack 20 5352 01-115 20 5352 20-115

Bipolar Bipolar Unipolar 3-pin Neutral Electr. US-2-pol. Multifunction and Bovie 2-pin 20 5352 01-116 20 5352 20-116 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 49

High Frequency Cords for unipolar and bipolar coagulation

KARL STORZ High Frequency Instrument Electrosurgical Generator

unipolar 26004 M Unipolar High Frequency Cord, with 4 mm plug for HF unit, models Berchtold and Martin, length 300 cm 26005 M Unipolar High Frequency Cord, with 5 mm plug for HF unit, models KARL STORZ AUTOCON® system (50, 200, 350), AUTOCON® II 400 SCB (111, 115) and Erbe type ICC, length 300 cm

bipolar 847000 M Bipolar High Frequency Cord, for Martin and Berchtold coagulators, length 300 cm 847000 E Bipolar High Frequency Cord, to KARL STORZ Coagulator 26021 B/C/D, 860021 B/C/D, 27810 B/C/D, 28810 B/C/D, AUTOCON® system (50, 200, 350), AUTOCON® II 400 system SCB (111, 113, 115) and Erbe-Coagulator, T- and ICC-row, length 300 cm

Cold Light Fountain XENON NOVA® 300

201340 01 Cold Light Fountain XENON NOVA® 300 lamp type: 300 W XENON lamp, power supply: 100–125VAC/220–240VAC, 50/60 Hz, including: Mains Cord 20133028 XENON Spare Lamp, only, 300 watt, 15 volt

Fiber Optic Light Cable

495 NL Fiber Optic Light Cable, straight connector, diameter 3.5 mm, length 180 cm 495 NA Same, length 230 cm 50 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Equipment Cart

UG 220 Equipment Cart wide, high, rides on 4 antistatic dual wheels equipped with locking brakes 3 shelves, mains switch on top cover, central beam with integrated electrical subdistributors with 12 sockets, holder for power supplies, potential earth connectors and cable winding on the outside, Dimensions: Equipment cart: 830 x 1474 x 730 mm (w x h x d), shelf: 630 x 510 mm (w x d), caster diameter: 150 mm inluding: Base module equipment cart, wide Cover equipment, equipment cart wide Beam package equipment, equipment cart high 3x Shelf, wide Drawer unit with lock, wide 2x Equipment rail, long Camera holder UG 220

UG 540 Monitor Swifel Arm, height and side adjustable, can be turned to the left or the right side, swivel range 180°, overhang 780 mm, overhang from centre 1170 mm, load capacity max. 15 kg, with monitor fixation VESA 5/100, for usage with equipment carts UG xxx

UG 540 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 51

Recommended Accessories for Equipment Cart

UG 310 Isolation Transformer, 200 V – 240 V; 2000 VA with 3 special mains socket, expulsion fuses, 3 grounding plugs, dimensions: 330 x 90 x 495 mm (w x h x d), for usage with equipment carts UG xxx

UG 310

UG 410 Earth Leakage Monitor, 200 V – 240 V, for mounting at equipment cart, control panel dimensions: 44 x 80 x 29 mm (w x h x d), for usage with isolation transformer UG 310

UG 410

UG 510 Monitor Holding Arm, height adjustable, inclinable, mountable on left or right, turning radius approx. 320°, overhang 530 mm, load capacity max. 15 kg, monitor fixation VESA 75/100, for usage with equipment carts UG xxx

UG 510 52 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation

Notes:

with the compliments of KARL STORZ — ENDOSKOPE