A simplified approach to  Midface Lift: the Endotine fixation device    
Costas Papageorgiou MD, London September 2014

Elevation of the midface is an important component of facial rejuvenation as fullness of the cheek represents a key feature of youthfulness. In the process of ageing, descent or atrophy of the midface fat compartments, bone resorption and muscle re-adaptation can lead to a tired or sad appearance. Another anatomical change that occurs with ageing in the mid-face area is weakening of the ligaments around the orbital rim contributing to the “orbital hollowness”. The malar fat pad which in youth is at the level of the orbital rim falls downward and medially accentuating this hollowness. In addition weakening of the muscular structures, with their associated ligaments accentuates the drooping of the corner of the mouth and further deepens the nasolabial fold.

Although volumetric augmentation with high viscosity dermal fillers or malar implants can improve contours, they cannot entirely address midface descent over the fixed ligaments of the nasolabial fold. Beyond volume augmentation, adequate release and fixation is critical for a natural and aesthetically pleasing outcome.

The Endotine ST midface approach is a new fixation technology for midface lifting that uses a spiked suspension and fixation device for safe and reliable midface elevation. The device is entirely biodegradable, as it is made of a polymer of polylactic and polyglycolic acids and has FDA approval. The technique relies on an endoscopic camera to visualise and release the deep tissues of the cheek area and offers the advantage of using two small hidden incisions within the hairline. As a result the procedure can be performed in less than an hour under sedation (Monitored Care Anaesthesia) with an expedited recovery period similar to other minimally invasive procedures.

Guided by the endoscopic camera and through a small incision within the scalp, Dr Papageorgiou uses short sweeping motions to release attachments and create a deep sliding plane over the zygomatic arch and maxilla. The dissection cavity over the bony structures is avascular as it lies underneath the bony coating (periosteum) and avoids the pathway of critical nerves and vessels in the region.

Following adequate release, the Endotine device is introduced through the scalp incision and deployed to the soft tissues of the cheek. Once the cheek tissue is engaged, upward tension is applied on the tail of the device to elevate the midface in the desired position and followed by fixation of the device at the temple area. The size of the Endotine is amenable to placement through the small incision but long enough to distribute tension over a wide area, thus maximising fixation strength and holding power.

Adjustability and repositioning are major advantages of using this device, compared to traditional suturing techniques.  Adequate engagement of the Endotine platform in the proper location and fixation across the correct vector as well as surgeons experience are critical in optimising outcomes.

The endoscopic assisted midface lift with the Endotine ST device is appropriate for patients with midface descent and mild nasolabial folds. Most of the aesthetic benefit from the procedure is volume redistribution with increased projection of the zygoma and a more youthful appearance. In patients who have undergone previous facelifts and necklifts, the procedure can provide a secondary vector to correct tissue descent lateral to the mouth in the lower cheek.

The ability of the device to maintain mechanical fixation until biological fixation occurs optimises outcomes. Implant palpability is minimal and reabsorption starts at 6 months.  This is an improvement over non-absorbable sutures, which remain permanently implanted long after they are no longer needed for fixation. Temporary tenderness over the malar area can be expected during the early post-operative period.