The central oval of the face: tridimensional endoscopic rejuvenation.

The central oval of the face is a distinct anatomic and aesthetic unit. Early signs of aging and advanced features of aging are manifested primarily in this unit. Standard face lift techniques are ineffective in treating this area. Intermediate layer (sub-SMAS, [superior musculo-aponeurotic system], intermuscular, etc.) and deep layer (subperiosteal) techniques were developed to treat this rather difficult part of the face. All variations of the intermediate layer technique have negative features, primarily safety issues related to potential nerve-muscle injury and protracted facial edema. Early described subperiosteal techniques (open, first generation endoscopic) were also associated with these types of complications. The author has outlined 14 principles of the ideal technique for the rejuvenation of the central oval. The advances and modifications to the first and second generation endoscopic central oval rejuvenation method comply with these principles. There are several principles that distinctly separate it from all other techniques: (1) direct approach to the central oval; (2) interconnected subperiosteal plane of dissection to the upper and midface; (3) use of small hidden slit incisions; (4) absence of eyelid incisions; (5) use of endoscopic techniques; and (6) absence of traction on skin or SMAS from the peripheral hemicircle. Another important advance made in this approach is the manipulation of soft tissues in the brow, glabella, cheek, and chin to provide a tridimensional rejuvenation. This was lacking in all previously described procedures. This method has been used with several modifications in over 500 patients. Aesthetic results have been excellent, with minimal sequela and a low complication rate. The subset of patients in whom this third generation endoscopic subperiosteal approach has been used have also had a three-dimensional remodeling and enhancement. The aesthetic results and safety factors surpass all other previously described techniques done at the intermediate or deep layers of the face.