F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am 15 (2007) 255–264

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Comprehensive PeriorbitalRejuvenation with ResorbableEndotine Implants for Trans-lidBrow and Midface ElevationAnthony P. Sclafani, MD, FACSa,b,*

- Transblepharoplasty browpexywith Endotine fixation

Indications and contraindicationsTechniqueAnesthesiaIncision and elevationFixationClosure and dressing

- Transblepharoplasty midface liftwith Endotine fixation

Indications

TechniqueAnesthesiaIncision, exposure, elevation, and releaseFixationLid support, skin resection, and closure

- ResultsTransblepharoplasty Endotine browpexyTransblepharoplasty midface lift

with Endotine fixation- Summary- References

The position of the eyebrows can significantly af-fect a person’s appearance and perceived de-meanor. Differences of a few millimeters can havea dramatic effect on periorbital aesthetics, and pa-tients who seek upper blepharoplasty often havean element of brow ptosis that, even if mild, canlimit the benefits of a blepharoplasty. Most interestin aesthetic brow surgery over the past 10 to 20years has focused on major open or endoscopicprocedures, and although the benefits of concur-rent forehead and upper eyelid surgery are undeni-able, many patients are reluctant to commit to an

1064-7406/07/$ – see front matter ª 2007 Published by Elsevierfacialplastic.theclinics.com

additional procedure, which compromises the finalaesthetic appearance. Several limited incision pro-cedures have been described for correction ofmild brow ptosis but have never achieved wide-spread use, chiefly because of concerns aboutlong-term fixation and stability of elevation. Simi-larly, lower lid blepharoplasty does not addressall lower periorbital contour deformities. Simpleorbital fat excision may remove some lower lid full-ness but can accentuate suborbital hollowing frommalar soft tissue atrophy and ptosis. Lower lid fattransposition can partially camouflage this

Video techniques for Transblepharoplasty Midface Lift with Endotine Fixation and TransblepharoplastyBrowpexy with Endotine Fixation can be viewed online at http://www.theclinics.com/.a Division of Facial Plastic Surgery, Department of Otolaryngology- Head & Neck Surgery, 310 East 14thStreet, 6th Floor North Building, The New York Eye & Ear Infirmary, New York, NY 10003, USAb New York Medical College, 310 East 14th Street, 6th Floor North Building, The New York Eye & Ear Infir-mary, New York, NY 10003, USA* Division of Facial Plastic Surgery, Department of Otolaryngology- Head & Neck Surgery, 310 East 14th Street,6th Floor North Building, The New York Eye & Ear Infirmary, New York, NY 10003.E-mail address: asclafani@nyee.edu

Inc. doi:10.1016/j.fsc.2007.01.011

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appearance but does not address the central prob-lem of the midface. Midface lifting has enjoyeda relative renaissance with the popularization ofthe extended endoscopic midface lift, but it re-quires an extensive forehead and temporal dissec-tion. This article describes two periorbitaltechniques, easily combined with upper and lowerlid blepharoplasty, that can strikingly enhance theperiorbital appearance.

Transblepharoplasty browpexywith Endotine fixation

Modern aesthetic forehead surgery was first de-scribed by Hunt [1] in 1926, who advocated a coro-nal incision for forehead elevation. Subsequentearly work on forehead surgery concentrated on ex-cising and elevating the skin of the forehead and thebrows. In 1976, Vinas and colleagues [2] publishedtheir approach, which consisted of a coronal inci-sion, corrugator resection, and release at the supra-orbital rims. Forehead lifting gained in popularitywith the addition of forehead myoplasties, whichimproved results in treating transverse foreheadand oblique glabellar lines. Issues with scar length,scar alopecia, forehead hypesthesia, and prolongedpostoperative recovery limited patient acceptance,however, especially in cases of mild brow ptosis.

Patients with mild (particularly lateral) brow ptosisoften are unaware of their brow malposition andpresent for consultation requesting upper blepharo-plasty only. This lateral upper lid ‘‘hooding’’ byptotic infrabrow skin is not appropriately treatedby blepharoplasty, and failure to address this condi-tion concurrently can limit the benefit of an upperlid blepharoplasty (Fig. 1).

Alternative traditional approaches to the brow(midforehead or direct browlift) may not be appro-priate or acceptable to a patient because of the vis-ible scars. Several authors have advocated limitedincision approaches to the brow to avoid visible in-cisions [3–6]. The procedures range from subfascialtemporal approaches to subperiosteal transblephar-oplasty approaches, and our understanding of browdynamics has been significantly advanced by thework of Knize [7,8]. Each of these approaches re-quires incision, elevation/release, and fixation.Transtemporal procedures rely on fascia-to-fasciasutures and fibrosis, whereas transblepharoplastyapproaches incorporate soft tissue to periosteumsutures, periosteal readherence to bone for fixation,and (often) myoplasties to reduce the downwarddisplacement forces. Unfortunately, suture fixationto periosteum may fail because of the thin and wispycharacter of the forehead periosteum more thana few millimeters above the orbital rim, and the

Fig. 1. Preoperative views (A, B) show redundant upper lid skin prolapsing over eyelashes. After upper blepha-roplasty, the improvement can be seen on oblique view (C). On frontal view (D), the effect is less dramaticbecause the patient refused an endoscopic browlift to treat the mild lateral brow ptosis.

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elevation in these cases may be lost in the earlypostoperative period. Alternatively, the transtempo-ral and transeyelid approaches can be combined,and fixation can be established with lateral temporalfascia-to-fascia adherence and central periostealsutures. The long-term permanence of the eyebrowelevation through these limited approaches con-tinues to be a major concern, however.

Recently, a device designed to maintain brow ele-vation during the period of early readherence was in-troduced. The Endotine Transbleph Implant (CoaptSystems, Inc., Palo Alto, California) is a co-polymerof 82/18 L–lactide/glycolide and is designed to de-grade by hydrolysis over a 6- to 12-month period.The device is two-sided. (1) The deep surface hasa central post with a small flange designed to fitsnugly into a 3-mm monocortical hole in the frontalbone. (2) The superficial surface has three 3- or 3.5-mm tines extending upward at roughly 45� froma thin platform that sits flush against the bone. Thetines are designed to be impaled into the brow softtissue and suspend the brow more superiorly. Thelow profile of the implant allows placement throughan upper blepharoplasty incision.

Although the manufacturer advertises the use ofthe implant as a brow lift, it is more appropriatelycalled a browpexy, because there is no soft tissue(including muscle) incision or modification, butrather subperiosteal elevation followed by semi-permanent fixation of the brow at a higher position.Because there is no dissection over the temple,change of the position of the tail of the brow occursto a lesser degree—and only passively. Becausethere are no modifications of periorbital musclesand dissection medial to the supraorbital neurovas-cular bundle is limited, significant change to medialbrow position or glabellar contour should not beexpected. This technique is best suited for subtlyrecontouring the arch of the lateral brow whilesecondarily elevating the brow 1 to 4 mm. Thetransblepharoplasty Endotine browpexy can becombined with other brow modifications for addi-tional brow changes. In particular, this techniquecan be combined with myoplasties of the corruga-tor supercilii and procerus muscles for a more com-plete contouring of the brow when significantmedial brow aging is present.

Indications and contraindications

The transblepharoplasty Endotine browpexy is indi-cated for recontouring the mildly ptotic brow. Theuse of the Transbleph implant is contraindicated incases in which there is a suspicion that the skullbone may be thin. Relative contraindications forthis technique are severe brow ptosis, moderate tosevere glabellar furrows and medial brow ptosis (un-less performed in conjunction with medial brow

myoplasties), and prior orbital or forehead trauma.As with any periorbital surgery, patients should beassessed for dry eye syndrome before surgery toavoid unmasking or exacerbating a case of border-line xerophthalmia. Primary ptosis also should beruled out, because brow suspension and fixationmay limit a patient’s pre-existing mechanism forcompensation of the ptosis. This procedure can beperformed in patients with prior blepharoplasty, al-though special attention is required during dissec-tion to ensure the correct surgical plane.

Technique

As with any brow repositioning procedure, assess-ment of the degree of brow ptosis present at restis essential. The patient is placed in a seated uprightposition, and marks with water-soluble ink areplaced at the upper edge of the brows above the me-dial end of the brow, the midpupillary line, and thedesired brow beak (either lateral limbus or lateralcanthus). The brow is then manually raised to itsideal height by the surgeon and confirmed by hav-ing the patient evaluate the brow position in a mir-ror. It is important to insist that the patient focus onbrow shape and position, not the upper eyelidcrease contour at this stage. Once the desiredbrow position is confirmed, a pen point is placedover each of the suprabrow marks, manually hold-ing the brow in its elevated position. Without mov-ing the pen, the brow is released and allowed to fallto its natural resting position. Another ink mark isplaced on the forehead skin directly under thepen point. This procedure is done for each mark,and the distances between each superior and infe-rior mark are measured to the nearest millimeterand recorded. Use of this technique in patentswho desire medial brow elevation more than 2 to3 mm or midpupillary line or lateral elevationmore than 5 mm is not recommended, because re-sults may be disappointing. The procedure is idealfor patients who require less than 2 mm of medialbrow elevation and 3 to 4 mm of lateral elevation.Immediately before surgery, this process is repeatedfor confirmation, and with the brow held at its de-sired position, the required upper eyelid skin exci-sion is planned and marked.

Anesthesia

This procedure can be performed with local anes-thesia only or supplemented with intravenous seda-tion or general anesthesia. For analgesia andhemostasis, 1% xylocaine with 1:100,000 epineph-rine is infiltrated into the upper eyelid skin and forbilateral supratrochlear and supraorbital nerveblockade. To ensure adequate block of the deepbranch of the supraorbital nerve, a small amountof anesthesia is infiltrated along the superior orbital

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rim lateral to the supraorbital notch. Small aliquotsof anesthesia are also injected subperiosteally overthe forehead, which typically provides excellent an-esthesia over the forehead up to the crown. Thedense attachments of fascia and periosteum at the‘‘zone of fixation’’ around the temporal crests aredifficult to completely anesthetize, however, andpatients may experience some mild discomfort atthese lateral limits of dissection (Fig. 2) [7].

Incision and elevation

A standard upper blepharoplasty supratarsal creaseincision is used. It is advisable that initially sur-geons defer upper lid skin excision until afterbrow repositioning, but once comfortable withthe procedure, the upper lid elliptical skin excisioncan be performed immediately. The orbicularis oc-uli muscle is penetrated and the septum orbitaleis identified. If preaponeurotic fat excision isneeded, it is best deferred until the end of the pro-cedure. The orbicularis muscle is then gently ele-vated with a cotton tip applicator off the septumuntil the superior orbital rim is exposed (Fig. 3).The supraorbital notch is palpated and the soft tis-sues over the orbital rim are incised with a cauteryapproximately 4 mm above the inferior aspect ofthe orbital rim, carefully staying lateral to the notch.

Fig. 2. Preoperative marks include the position of thesupratrochlear nerves (blue lines, asterisks), supraor-bital nerves (blue lines, 1), temporal crests (black dot-ted line, ˆ), and planned areas of dissection (reddotted lines).

Using a Freer elevator, the periosteum is elevated su-periorly to the frontal hairline and laterally to thetemporal crests (Fig. 4). Medially, dissection is lim-ited by the supraorbital nerve. With the surgeon’snondominant thumb over the notch, the elevatoris swept as medially as possible (see Movie 1).Once the dissection is performed bilaterally andthe dissection pockets are connected, the foreheadperiosteum is elevated in between the temporalcrests from the orbital rim to the hairline, exceptfor a small triangle based along the orbital rim be-tween the supraorbital notches.

Fixation

Fixation of the forehead flap is performed using theCoapt Endotine Transbleph implant. Except in pa-tients with thin skin, the 3.5-mm tine implant is pre-ferred. In a vertical plane above the desired browpeak, a monocortical hole is drilled into the calvar-ium with the supplied drill bit. Typically, this hole is

Fig. 3. The transblepharoplasty browpexy begins withan upper lid supratarsal crease incision followed bya preseptal, suborbicularis dissection to the orbitalrim. Ptotic galeal fat is seen above the arcusmarginalis.

Fig. 4. The forehead is undermined subperiosteallythrough the upper lid incision after the periosteumis incised.

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placed at a distance above the cut edge of the perios-teum 2 mm more than the desired amount of eleva-tion (Fig. 5). The transblepharoplasty bone post isthen placed into the drill hole until engaged, andthe introducer is detached. The forehead flap isthen set on the tines. Under direct vision, the tinesare impaled into the flap under the cut edge of theperiosteum, which is suspended on the tines(Fig. 6). The brow position is then assessed; if theamount of elevation is not correct, the flap can be el-evated off the tines and easily repositioned. The pro-cedure chiefly elevates the lateral two thirds of thebrow; however, the preseptal plane can be followedmedially and the corrugator and procerus musclesdivided if significant glabellar rhytides are presentor a greater degree of medial brow elevation isdesired.

Closure and dressing

If any upper lid skin resection is planned, it shouldbe done at this point. It is essential to gently redrapethe upper lid skin and avoid any bunching of skinin the infrabrow area. Although the planned upperlid skin resection was marked preoperatively, thesurgeon must not overresect skin so as to avoidpostoperative lagophthalmos. The wound is closedwith a running subcuticular 6-0 Polene suture. Alightly compressive tape dressing is applied to theforehead for 24 hours, and the patient is told to ap-ply cold compresses to the forehead and eyes for thefollowing 24 hours. Patients are generally able to re-sume normal activities in 3 to 5 days (depending onecchymosis). The forehead anesthesia and edemagenerally resolve in 1 to 2 weeks, although mildedema of the infrabrow skin may persist for severalweeks.

Fig. 5. Once the elevation is complete, a 3.5-mm holeis drilled into the frontal bone approximately 2 mmabove the desired brow peak.

Transblepharoplasty midface liftwith Endotine fixation

Currently, the most common approach to midfacelifting is through an endoscopic temporal ap-proach. This approach, however, may not allowfor the optimal vector of elevation. Translid proce-dures have been described, but the risk of postoper-ative lid malposition has plagued these techniques[9]. This technique addresses this valid and majorconcern through the application of secure cheekflap fixation.

Indications

Two similar fixation devices are produced to elevatethe midface. The Endotine Midface ST (soft tissue)and B (bone) devices are designed to elevate andfixate midfacial soft tissues via a transtemporal ortranslid approach, respectively. These devices ele-vate the ptotic midface differently and should bechosen based on patient needs. For patients witha significant medially angled ptosis, the MidfaceST device is more appropriate; however, when themidface has descended in a primarily inferior vec-tor, the Midface B device may be more useful,especially when there is significant infraorbital hol-lowing and tear trough deformity.

The translid midface lift can be performedthrough either a subciliary or transconjunctivalapproach. A canthal tightening procedure is recom-mended with both procedures, and canthotomy andcantholysis are generally necessary to adequately ex-pose the superior maxilla for implant placementand fixation if the transconjunctival approach isused. Some skin excision is generally required inthese procedures, although usually much less thanmight be expected. If significant skin excision is re-quired, a pinch excision (with a transconjunctival

Fig. 6. The Transbleph implant is positioned in thefrontal bone, and the superior cut edge of the perios-teum is suspended on the tines of the implant.

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approach) or strip excision (with a subciliary ap-proach) may be performed. Judicious skin resectionis the rule.

Technique

The most critical aesthetic judgment is the determi-nation of the appropriate vector of elevation. Withthe patient seated and the head and gaze in a neutralposition, the surgeon identifies the bulk of theptotic midfacial fat and subcutaneous tissue. Thisfat and tissue are then manually elevated (at first)superiorly and the effect noted. This elevation isshifted medially and then laterally, and the effectsare noted. The direction that yields the most naturaland aesthetically pleasing appearance is noted.

Anesthesia

Although this procedure can be performed underintravenous sedation or general anesthesia, with ap-propriate care it also can be performed with localanesthesia only. Bilateral infraorbital nerve blockswith 1% xylocaine with 1:100,000 epinephrine areperformed first, followed by blockade of the zygo-maticofacial nerves. After these injections begin toanesthetize the cheeks, the local anesthesia is infil-trated into the lower eyelids as for a lowerblepharoplasty.

Incision, exposure, elevation, and release

If a subciliary incision is used, a skin-muscle flap isdeveloped and a preseptal dissection is performeddown to the orbital rim (Fig. 7). As with the uppereyelid in the transblepharoplasty browpexy, re-moval of pseudoherniated fat is deferred until afterthe midface procedure.

Once the infraorbital rim is exposed (with eitherapproach), the periosteum is incised from medial

Fig. 7. The transblepharoplasty midface lift can beperformed either through a subciliary incision (shownhere) or a transconjunctival approach. The preseptaldissection is carried inferiorly to expose the infraorbi-tal rim.

to lateral, carefully preserving a cuff of periosteumalong the entire anterior lip of the orbital rim. Asubperiosteal plane is then developed over the en-tire maxilla, carefully isolating while protectingthe infraorbital nerve (Fig. 8). Laterally, the dissec-tion extends to the bony origins of the massetermuscle. Medially it extends to the ascending processof the maxilla and fibers of the levator labii superio-ris alaque nasi. Inferiorly it extends to the gingivo-buccal sulcus (which is not incised) (see Movie2). During the dissection, the zygomaticofacialnerve is often encountered near the junction ofthe malar eminence and inferolateral orbital rim.Care should be taken to preserve this nerve andavoid any stretching injury, because anesthesia orneuralgia over the superolateral cheek may occurpostoperatively.

The periosteum inferiorly is then released bysharp incision and blunt inferior-to-superiorly di-rected stripping with a Freer elevator. This proce-dure should be done until the cheek flap can beelevated easily without any inferior tethering. Theflap should be freely mobile from the nose (medi-ally) to the masseter (laterally) and from the gingi-vobuccal sulcus (inferiorly) to the orbital rim(superiorly), except for the infraorbital neurovascu-lar bundle. It is essential that the flap be easily ad-vanced superiorly without any restriction orinferior traction on the lower eyelid.

Fixation

The Midface B implant is composed of a distal‘‘rake,’’ which has five 4.5-mm tines that can engagethe periosteum and cheek soft tissue. The proximalportion is essentially a ‘‘leash’’ by which the im-plant can be advanced superiorly and fixed to theinfraorbital rim. The primary vector of elevation(superolaterally, superiorly, or superomedially)can be tailored to the patient’s needs by small

Fig. 8. After incising the periosteum on the anteriorlip of the infraorbital rim, the midface is elevated ina subperiosteal plane.

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adjustments in the sites of periosteal engagementand bony fixation. Once introduced, the positionof the tines and vector of elevation are assessedfor maximal benefit, and the periosteum is impaledon the tines (Figs. 9–11). A 3.5-mm hole is drilledand tapped in the lower portion of the infraorbitalrim once the device has engaged periosteum inferi-orly and the appropriate vector of elevation is cho-sen. A bioabsorbable screw is placed through thefixation device ‘‘leash’’ and into the bone hole.Once this screw is secured, additional sutures canbe placed on low tension between the orbital rimand flap periosteum, which is particularly helpfulin elevating soft tissue to correct tear trough defor-mities. Typically, one to three sutures are placed oneither side of the Endotine bony fixation. Caremust be taken to avoid any more tension on eitherthe flap or orbital rim periosteum in placing su-tures to gently drape the soft tissue over the rim.

Before the introduction of the Endotine MidfaceB device, I fixate the cheek flap to the periosteumalong the infraorbital rim and a few millimeters lat-eral to the lateral canthus with 3-0 polydiaxanoneor polygalactin 910 sutures. The periosteal cuff atthe infraorbital rim is often flimsy and tolerates ten-sion poorly, however, which makes reliance on thislayer of tissue for secure fixation somewhat dubi-ous. It can be difficult to place sutures to gently

Fig. 9. Once the midface is elevated and released byincising the periosteum inferiorly, the Midface B im-plant is placed through the lid incision. (Courtesy ofCoapt Systems, Inc., Palo Alto, CA; with permission.)

drape soft tissue into a tear trough. The additionof the Endotine Midface B implant allows transferof the significant flap tension to the device andthe orbital rim, which protects the lower eyelidfrom any significant inferior pull.

Lid support, skin resection, and closure

At this point, the orbital septum can be opened andpseudoherniated fat resected, if present. The lowereyelid support is re-established, most commonlywith a lateral tarsal strip canthoplasty, althougha lateral canthopexy may be substituted in therare patient with excellent lower eyelid tone andsupport. If a transconjunctival approach with can-tholysis and canthotomy is used, the canthal repairis performed and the conjunctival incision real-igned and allowed to heal spontaneously. Redun-dant skin can be removed with a subciliary pinchtechnique at this time, theoretically avoiding dis-ruption of the middle lamella of the lid. If a subcili-ary approach is used, the canthus is repaired ortightened and the appropriate amount of skin exci-sion determined with the patient’s gaze directed su-periorly and the mouth opened. The skin is resectedand the wound closed with interrupted 6-0 chromicsutures. With either approach, conservative skin ex-cision is the rule. I inform patients that to avoid

Fig. 10. The proper vector of elevation is determinedby engaging the periosteum and malar fat with theimplant tines and assessing for optimal improvementwith different directions of pull. (Courtesy of CoaptSystems, Inc., Palo Alto, CA; with permission.)

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postoperative lid malposition from excessive skinresection, there may seem to be some minimalskin redundancy for the first few weeks. If this ex-cess skin persists, it can be removed easily 3 to 4weeks postoperatively under local anesthesia.

Results

Transblepharoplasty Endotine browpexy

The transblepharoplasty browpexy has been well re-ceived by patients and provides a simple and rela-tively quick method to treat mild central andlateral brow ptosis (Fig. 12). It is particularly usefulin patients undergoing concurrent upper lid bleph-aroplasty who would benefit from a modest lateralbrow elevation. Most patients note smoothing offorehead rhytides, similar to an endoscopic brow-lift, which persists even after resolution of postoper-ative edema.

Moderate postoperative edema is the rule, but aswith endobrow procedures, forehead edema gener-ally resolves in 2 to 3 days. Persistent infrabrowswelling is common and may last 4 to 6 weeks. Al-though this swelling is generally subtle, it may ob-scure some of the benefit of the lateral browelevation and upper blepharoplasty, and it is

Fig. 11. Oncethepropervectorofpull isdetermined, thetines are further manually impaled on the implant tines.A monocortical hole is drilled on the infraorbital rim,and the Midface B implant is fixed at the drill holewith a biodegradable screw. (Courtesy of Coapt Systems,Inc., Palo Alto, CA; with permission.)

important to counsel patients about this possibilitypreoperatively. Forehead hypesthesia typically lasts2 to 4 weeks, and if the deep branch of the supraor-bital nerve is affected, it may extend from the level ofthe brows to the vertex. Rarely, in my experience,postoperative neuralgia can occur and typically is re-lated to the lateral dissection and presumed injuryto the deep branch of the supraorbital nerve. Pa-tients generally can palpate a mild fullness deep tothe lateral brows as early as 3 weeks as swelling sub-sides, but the profile of the implant is generally notvisible in all but patients with thin skin and browsoft tissue atrophy. The Transbleph Endotine im-plants are available with either 3- or 3.5-mm tines,and although most patients tolerate the longer tineswell, patients with thin skin and brow soft tissue at-rophy should be treated with the 3-mm tines andconsidered for injectable soft tissue augmentation.

Transblepharoplasty midface liftwith Endotine fixation

Results with this technique have been excellent.Complications are uncommon if proper precau-tions and a conservative approach are taken. Thereis usually significant chemosis postoperatively,which generally resolves in 2 to 3 days. If it persistslonger, topical steroid eye drops (if not contraindi-cated) can be used for 4 to 5 days to hasten resolu-tion of the chemosis. Significant lid retractionshould be treated aggressively, and early reopera-tion should be considered if fixation was deemedinadequate. Patients may note facial hypesthesiain the distribution of the infraorbital nerve for 2to 3 weeks, but it sometimes can persist for a longerperiod of time. Patients should be followed fordecreasing density and area of distribution of thehypesthesia until complete recovery can be docu-mented. Patients occasionally may complain ofpain over the malar eminence, probably caused bystretching of the zygomaticofacial nerve, which gen-erally resolves in 3 to 4 weeks. Most patients noticesome mild trismus for 3 to 7 days if a complete sub-periosteal dissection up to the masseter muscle in-sertion was performed. No patient to date hascomplained about implant palpability. In general,patients have been pleased with the results of thisprocedure, typically returning to normal activitiesin 5 to 7 days and work in 7 to 14 days.

Summary

As with any new technology or device, the science ofthe material and the wound-healing processes in-volved should be considered when examiningclaims of longevity. The manufacturer claims thatthe material is fully resorbed by 12 months througha process of hydrolysis but loses significant strength

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Fig. 12. Preoperative (A, C) and postoperative (B, D) views of a patient who underwent transblepharoplastybrowpexy and transblepharoplasty midface lift under local anesthesia. Note the improved brow position andcontour. In the midface, there is a shortened lower lid length, elimination of the double contour of the lowerlid and cheek mound, and effacement of the tear trough. The shape of the face is less ‘‘square’’ postoperatively,with an increased bizygomatic width.

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by 20 weeks. Because these implants are fully re-sorbed over time, the longevity of the results de-pends on the fixation of the elevated tissues to thedeep structures that develops before the loss of de-vice strength and integrity and any modification ofinferiorly directed forces. Myoplasty is not intrinsicto either of these procedures, so it is reasonable toassume that longevity of elevation is caused by heal-ing of the periosteum to bone at the new, elevatedposition, counterbalanced by differential ptosis ofthe more superficial tissues. Sclafani and colleagues[10] previously showed that the bone-periosteumbond is well established by 6 weeks in an animalmodel, whereas others have described faster timecourses [11,12]. In light of this report, late loss of el-evation presumably would be caused by resorptionof tines that are engaging tissue above the perios-teum (eg, retro-orbicularis oculi fat or galeal fat[brow], suborbicularis oculi fat or malar fat [mid-face]). During my 18 months of experience withthe Transbleph device, I have not seen a late (>6weeks) loss of elevation; my follow-up with theMidface B device is less (approximately 6 months),but again no late loss of elevation has been noted.Over the long-term, facial aging will continuewith ptosis of supraperiosteal tissues, but it wouldseem unlikely that the benefit gained by these pro-cedures would be lost.

The introduction of the Endotine Transbleph andMidface B implants has allowed a more accurateand secure elevation of brow and midfacial tissues, re-spectively, with only minor modifications of previ-ously described techniques. These implants havebeen consistent is their ease of use, and results havebeen reproducible. These implants have allowed theexpansion of existing techniques in a way that allowsbetter and more specific treatment of patients whootherwise might not have achieved optimal results.

References

[1] Hunt HL. Plastic surgery of the head, face andneck. Philadelphia: Lea and Febiger; 1926.

[2] Vinas JC, Caviglia L, Cortinas JL. Forehead rhyti-doplasty and browlifting. Plast Reconstr Surg1976;57:445–51.

[3] Tardy ME, Thomas JR, Brown RJ. Temporal lift.Fascial Aesthetic Surgery 1995. p. 196–206.

[4] McCord CD, Doxanas MT. Browplasty and brow-pexy: an adjunct to blepharoplasty. Plast Re-constr Surg 1990;86:248–54.

[5] Paul MD. Subperiosteal transblepharoplasty fore-head lift. Aesthetic Plast Surg 1996;20:129–34.

[6] Ramirez OM. Transblepharoplasty forehead liftand upper face rejuvenation. Ann Plast Surg1996;37:577–84.

[7] Knize DM. Anatomy of a frown: basis for a lim-ited incision approach to treatment of eyebrowptosis and glabellar lines: perspectives. PlastSurg 1996;10:1–37.

[8] Knize DM. Muscles that act on glabellar skin:a closer look. Plast Reconstr Surg 2000;105:350–61.

[9] Hester TR, Codner MA, McCord CD, et al. Evolu-tion of technique of the direct transblepharo-plasty approach for the correction of lower lidand midfacial aging: maximizing results andminimizing complications in a 5-year experi-ence. Plast Reconstr Surg 2000;105:393–406.

[10] Sclafani AP, Fozo MS, Romo T, et al. Strength andhistological characteristics of periosteal fixationto bone after elevation. Arch Facial Plast Surg2003;5:63–6.

[11] Kriet JD, Yang CY, Wang TD, et al. Evaluation ofpericranial skull adherence during healing in therabbit model. Arch Facial Plast Surg 2003;5:67–9.

[12] Kim JC, Downs C, Azuola ME, et al. Time scalefor periosteal readhesion after brow lift. Laryn-goscope 2004;114:50–5.