teum. Often an endoscopic forehead lift is performed simultaneously,
so the entire arcus marginalis is exposed and released through a cen-
tral brow incision. However, if only the temporal lift is being per-
formed, it is still necessary to release the periosteal attachments
along the arcus marginalis medially to the area of the supraorbital
neurovascular bundle.
A fingertip inserted into the field is the best instrument for
strumming and identifying the remaining attachments. Most often I
find residual attachments at the inferolateral orbit and the zygomatic
arch; if these attachments are not released, the flap cannot elevate
and the surgery will have accomplished very little.
Once the flap is completely mobilized, the surgeon can grasp the
deep temporoparietal fascia with toothed forceps and elevate the en-
tire flap so the cheek rises. It is important to recognize that we can
always grasp the skin and elevate the flap; but only if the deep layer
lifts the flap without resistance is the flap adequately mobilized to
allow the surgery to be successful.
Once the flap is adequately mobilized, it is fixated in an elevated
position. This is done by placing a suture through the superficial tem-
poroparietal fascia (SMAS) 1 cm inferior to the cut skin edge and su-
turing the flap to the deep temporalis fascia in an elevated position.
The suture in the SMAS can dimple the skin, so it is best placed un-
derneath hair-bearing skin; moreover, an effort can be made to place
the suture bite in such a way that it minimizes skin dimpling. I do
not believe that a permanent suture offers any more success than a
long-lasting absorbable suture; hence I use an absorbing suture such
as 3-0 Vicryl to make the attachments. Two sutures can be placed. If
the assistant manually elevates the flap to relieve tension, it is eas-
ier for the surgeon to tighten the knot. Recognize, however, that it is
useless to try to lift the flap under extreme tension. We all know that
a surgical wound under tension does not heal. The flap must be ad-
equately released so fixation can be accomplished under normal sur-
gical tension and the surgery can be successful.
Sometimes a cable lift is performed simultaneously. When it is,
the cables are placed and fastened to the deep temporal fascia before
fixating the temporoparietal SMAS flap.
The short temporal incision can be closed with surgical staples. If
the incision was performed above the eyebrow, it is closed in layers
in standard fashion, with care taken to evert the wound to decrease
the chance of a depressed scar. The hair is washed with warm water
and baby shampoo, and no dressings are applied postoperatively.
Surgical Technique 61