There are two well delimited anatomical areas at face and neck in connection with aging and rejuvenation surgery, which have to be addressed separately; the midline or central structures, formed by eyelids, nose, lips and chin; all these indeed do age and deserve specific surgical attention with techniques designed and developed to their anatomical features; and then the peripheral unit made of three thirds of head and neck, being the upper third formed by the forehead, eyebrows, temple and periorbital area, the middle third by cheekbones, cheeks, nasolabial folds and perioral area, and the lower third integrated by the parotid area, the lower area at the jawline and finally the jowls extended into the neck region; these peripheral three thirds can be treated subdivided into two groups; the surgeon may treat the upper two thirds, by means of a short temporal incisions supraperiosteal extended lift of the upper two thirds of the face, or treat the lower two thirds with a deep plane SMAS platysma face and neck lift.
The temple area provides two excellent, firm and resistant fibrous layers, mainly made of very strong collagen alike the tendons, which are optimal for the anchoring maneuver in this technique; the most superficial one is called temporoparietalis fascia or superficial temporalis fascia, and the underlying one is named as temporalis muscle fascia or deep temporalis fascia; between them courses a layer of lax millefeuille areolar tissue which contains in the middle of its thickness the frontal branch of the facial nerve; to avoid this branch the dissection has to be at the deepest part the interfascial plane leaving all the areolar tissue attached to the superficial temporalis fascia and the surgical action take place in intimate contact with the deep temporal fascia; by doing so no permanent damage is produced to the nerve; other nerve branches to avoid are the first trigeminal branches arising from the orbital rim and entering the forehead to provide sensation to the scalp, mainly the supraorbital and supratrochlear nerves, which are avoided by accurate preoperative anatomical references and intraoperative palpation of their foramen.
This fronto orbital rejuvenation technique allows incisions very well limited to the temporal fossa and far from the hairline, present or future, even in male pattern baldness since they stay within the pilous areas at the sides of the head; through them we carry ahead the undermining of the temple, forehead, eyebrow, frontal rim and part of the scalp in the supraperiosteal plane (giving name to the technique), releasing all the attachments of the facial structures to the bone; eventually and due to the normal skull curvature a high interparietal mini counter incision is necessary to join the dissection between both sides.
Once the forehead and the eyebrows are released the undermining progresses into the upper face region, dissecting the side and the lower orbital rim, where attention has to be paid again not to damage the second trigeminal infraorbital sensitive nerve. Here the surgeon may stay short or carry ahead the extended version to treat as well the middle third of the face; if planned so and only in very well trained hands the dissection continues under the SMAS (superficial muscular aponeurotic system) or facial fascia which is the continuation of the superficial temporal fascia into the middle face to undermine the whole cheekbones, cheek, nasolabial folds and down to the corner of the mouth where is set the anatomical limit of the technique.
Once the dissection is completed the grade of elevation, angulation and lift of face, orbit, temple, eyebrows and forehead is assessed and decided, proceeding next to secure it by means of very powerful sutures to anchor both superficial and deep temporal fascial tendon layers to each other, which is the key for a very long lasting effect. No skin or scalp is removed, at all, since the anti gravitational traction vector is achieved with the internal tendinous fascias and not with skin removal or closure under tension.
Finally, scalp closure is done under in a smooth way, preventing thus baldness and scar widening typically caused when poor technical excellence procedures are attempted to raise the forehead.
Advantages of this technique are its safety, the low nerve damage risk involved, the short length of scars and their perfectly hidden placement, the superb and undetectable aesthetic features of the scars, the adjustable and natural looking results, very long lasting effects, comprehensive rejuvenation of the entire upper third of the face and orbit, no hairline distortions or setbacks, no aging after effects due to baldness progression that might expose the scars in the future and, should the extended version performed by experienced hands, an awesome scar free deep plane lift of the face is added on top, plus the inherent forehead and eyebrows lift, making this procedure a perfect choice for young or middle aged patients as much as for aged ones. Additionally it has a smooth postoperative recovery, literally painless or a very slight tensional headache, swift recovery and early return to daily activities.
Quite often this procedure is associated to eyelid surgery in middle aged patients or to lower face, jowls and neck lift, especially in elder patients.
Dr. Alejandro Nogueira is one of the few surgeons trained in this technique; his skills and expertise throughout the years make him master this amazing surgical rejuvenation procedure.