The endoscope is now introduced through the temporal incision
above the deep temporalis fascia. A blunt elevator is used in a di-
rection toward the ear, remaining 1 cm posterior to the facial nerve
marking, and the tissue is carefully elevated. The temporal and cen-
tral pockets are connected blindly, laterally to medially, detaching
the temporal crescent ligament, which is the fusion of the galea
aponeurotica to the crest. Most surgeons prefer to dissect in the sub-
periosteal plane, especially if the forehead is high (Fig. 2-3). The sub-
galeal plane of dissection results in increasing the distance from the
brow to the hairline. The dissection posteriorly is done behind the in-
cision line. Some surgeons choose to extend this farther back toward
the vertex. Continuing in the temporal pocket, dissection is carried
out down toward the lateral canthal angle with direct endoscopic vi-
sualization. It is important to stay on the deep temporalis fascia while
elevating upward gently. At this point the orbicularis-temporal liga-
ment is identified, which is a tough ligament joining the lateral or-
bicularis to the deep temporalis fascia. Carefully dissecting beyond
this point discloses the zygomaticotemporal (sentinal) vein. It is typ-
ically 5 mm temporal to the zygomaticofrontal suture line and is an
important landmark. It is here that branches of the facial nerve are
located, so the dissection should be minimal.
The lateral canthal ligament can be detached with endoscopic vi-
sualization. The arcus marginalis is then released along the supra-
orbital rim, extending medially toward the supraorbital nerve by in-
cising the periosteum. Once the supraorbital nerve is located, a
supraperiosteal pocket is formed above the bridge of the nose to ad-
dress the depressor muscles (procerus, corrugator, depressor super-
cilii, orbicularis). Using blunt dissection, the tissues are moved side
to side to separate the muscles for better visualization. At this point
the tough corrugators can be seen with their insertion and origin on
both sides. The corrugators can be avulsed, rather than cut, to pre-
vent injury to the supratrochlear nerve. This can be accomplished
with endoscopic scissors or laser. Branches of the supratrochlear
nerve are sometimes seen within the corrugator and should be
avoided. The procerus can be addressed in a similar fashion, with
avulsion. The depressor supercilii should also be avulsed and not cut
because of vessels within it. The orbicularis muscle can be visualized
within this area and can be cut vertically. To eliminate the glabellar
lines, vertical incisions can be made in the periosteum centrally, up
to the dermis. At this point, some surgeons choose to perform multi-
ple vertical interfascicular neurotomies to the superficial branches of
32 Endoscopic Foreheadplasty