Scarless immediate Isovolumetric Cervico Facial Lifting and Rejuvenation by Chemical Myoplasty and myopexy ( Endopeel)

 

Alain.TENENBAUM,Mauro TIZIANI

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Abstract

The immediate non invasive true medical face lifts using muscular repositioning without volume augmentation by myoplasty, myopexy and myotension (called Endopeel techniques) is a new weapon for facial plastic surgeons as cosmetic dermatologists.Figure1
A true facelift is a technique leading to a skin excess which will be removed, to perform a good skin tension
without exaggeration (to avoid necrosis), and that without any volume augmentation.

Keywords

Endopeel techniques;Face lifts;Facial paralysis,chemical myoplasty,medical facelift

Introduction

The Endopeel techniques can lead if decided by the facial plastic surgeon or cosmetic dermatologist practising dermatosurgery to a pretragal skin excess, which can be removed, and that too without any volume augmentation. These techniques can be proposed to patients wishing to maintain the benefits of a surgical face lift, to patients which are not candidates for the surgery, to surgeons who want to complete their surgical operation acting on the forbidden areas for the surgery (terminal ramifications of the facial nerve) and/or the areas which are not reachable for an invasive surgery [1]. The advantages of these techniques are important for the patients: the immediate effect, the absence of scars, the absence of down time, the absence of social eviction, as the transitory complications which are limited only to short duration edema and ecchymosis which may be avoided with the use of some medications. Facial paralysis can benefit too of these techniques to decrease the bad social aspect of facial asymmetry.

Warning about so called “Medical facelifts”

• Facelifts with fillers do not exist , as fillers increase the mass and volume of the facial treated area instead of removing the excess of tissue
• Mesolift is not a good terminology as mesotherapy never leads to excess of tissue
• Botulinum toxin never leads too to any surgical tissue removal, as it atrophies the muscles and paralyzes them
• The threads are creating a suspension of tissues and in english suspension or lift ( towards up) can be used as lift . But on the surgical point, medical threads don t lead to any skin removal.
• Actually only surgery or the ,, endopeel,, techniques can lead to a skin removal which is in excess. Figure2

Benefits and advantages for the facial plastic surgeon and/or the cosmetic dermatologist

• To perform a scarless true facelift with an immediate result, without using volumetric medical devices or paralyzing drug.
• To perform an immediate facelift without undermining leading to a pretragal skin excess which can be removed easily or which can be hidden with specific not PDO threads which will help to make an appropriate repartition of the skin excess, socially acceptable.Figure3
• To give back the lost tension to muscles involved in a facial paralysis.

Techniques chosen

• Intramuscular trivectorial injections using the surgical logic of a facelift require a basic anatomico physiological knowledge to realize a nasal labial furrow lifting on one side and to lift the sadly baggy low jowls on another side as to make a recontouring of the mandible.
• A special protocol allows also getting a pre tragal skin excess which can be removed as a dog ear excision or with the not PDO threads scarless technique, with a certain amount of Endopeel carbolic acid. This interesting strategy allows a long duration of Endopeel effect keeping a mini invasive lifting technique using the criss cross technique with a multiholes 2.0 mm cannula.Figure3

Patients selection

• All patients who desire a surgical or a not surgical can be candidates, as those not being candidate for any kind of filler injected in the naso labial furrows Figure4 ( the fillers not only can give unaesthetic aspects called rolling bulges, but are too often sources of complications like granulomas, necrosis, migration, nodules etc.), just as those which have the first semiological signs leading to the right indications of face lifts [2].
• Patients with irreversible facial paralysis are good candidates for Endopeel techniques which will give them less asymmetry (static as dynamic) and restituting them almost their social appearance prior to the facial paralysis event.Figure5
• Our criteria of exclusion are: exaggerate alcoholic patients, heavy smokers, pregnant women, subjects under 18 years, patients known with allergy to peanuts and arachides,or those having antecedents mentioning a Quincke edema, All the patients without any exception when the outside temperature exceeds 40°C are also excluded, because edema can last for 1 week but regress under corticotherapy if this one is given right before beginning the procedure.
• The ideal candidate is not alcoholic nor smoker,not allergic to peanuts and arachides, in apparent good health, with an age range between 20 and 85 years, neither fat nor too thin, eager of immediate face lift without surgery and scars.Figure6

Benefits and advantages envisaged for the patients

• The face lift effect is immediate and is perfectly visible 30 minutes after the end of the treatment with a maximum result 3 days after the procedure.Figure7
• The face lift effect is early and will be relayed by the late peeling effect, specific to the techniques Endopeel.
• The treatment can be ineffective in 8% of the cases (bad technique).
• The effectiveness of this treatment increases with the number or the repetition of the procedures because the basic muscular tone will be thus increasingly high on the scale of the tension of this last.Figure8
• It is easy to prove objectively the effectiveness of this treatment by treating, for example, only one half face on the same patient and by making a comparison between the treated half face and the controlateral untreated one by pure visual inspection, or by photographic images, or by using cephalometric points of reference.

• These same parameters are taken again to evaluate the duration of the results objectively.

• In the field of safety, so far and since 18 years these techniques started to be used, no legal procedure against a physician using the techniques Endopeel was announced and/or indexed to our knowledge. The only complications met are only transitory, like edema ecchymosis which never exceeds 10 days in worst cases without medications.Allergy to arachides can occur 10 days to 14 days after the treatment with bruising, itching , redness and disappears under the association of antihistaminics coupled with corticoids for at least 3 consecutive days.Figure9

• The report/ratio benefit cost of the treatment is accepted in the large majority of the cases.
• Less asymmetry and none social eviction for patients affected with facial paralysis.

Techniques

• The selection of the patients has been described above.
• The material to be used is the following :

- The medical device like the patented oily carbolic acid completely different from phenol

- Syringes 1 ml luer lock or a multihole canula 2.0 mm.

- Flexible needles for the face 30 g.

- 1 needle 18 g to aspire the solution of the patented oily carbolic acid.

- A post, Endopeel, cold cream.

- Finally one not alcoholic disinfecting product, gloves and gauzes.

• The technique known as standard treats 7 areas: the malar area, the zygomatic area, the masseter area, the area of the lower 1/3 of the face, the mandible edge, the angle of the mandible, the cervical area being above the higher limit of the cricoid cartilage.
• The technique to lift the nasolabial furrow will involve particularly the 8 following muscles: major, and minor zygomatics, risorius, buccinators, depressor of the angle of the mouth, elevator of the angle of the mouth, elevator of the upper lip and of the nasal aisle.
• The technique for saddy low jowls improvements involves the following muscles: platysma, digastric, mylo hyoïdeus, buccinators, depressors of the angle of the mouth.Figure10

• These 2 last techniques are rather reserved to the specialists, because they are not only one complement of the traditional surgery of the face lift while working on the zone of the terminal ramifications of the facial nerve (danger zone for the surgery), but also allow maintenance of a surgical face lift while working on the facial muscles by myopexy and myoplasty.
• The basic technique consists in injecting perpendicular to the plan of the muscle 0.05 ml of patented oily carbolic acid each cm and same in the perpendicular plan to the precedent following the direction and the sense to obtain the wished deformation of the muscle using criss cross-technique.( We do consider muscular units like viscoelastic elastomers where we can apply any chosen deformation with vectors and tensors in 3D).Figure11

Errors

The most current errors are not the IM injections made in SC (subcutaneous) which will give the desired effect (because the patented oily product will diffuse from SC tissue to the muscle) will use more quantity of product and will be responsible of an important edema not appreciated by the patients, which can last between 3 and 8 days without medication. Another error consists in touching the periosteum with the injection needle, which will provoke ecchymosis which can be hidden thanks to a makeup and which will disappear from 3 to 8 days without discomfort for the patient. The intra vascular injection of Endopeel carbolic acid cannot be regarded as an error, considering the sclerosing effect of this substance. The injection into the motor plate or any nerve of carbolic acid is known for the treatment of the trigeminal neuralgias and may slow down the speed of nervous conduction for one short duration.

Side effects, complications and alternative treatments

The side effects or complications are only transitory and are summarized with an early edema and some ecchymosis easily treated and being able to be avoided. As for late edema occurring at the 10^th day after the procedure, it is related to an allergy to peanuts and is treated only with antihistaminic. 2% of the Asian population is allergic to peanuts.

Actually there is no alternative to the myotension, myopexy and myoplasty using other products and techniques than Endopeel. But the Endopeel techniques can be potentialized using chemical peelings as other existing treatments in medicine and cosmetic surgery (skin tightening effect with radio frequency 4 MHz).Some authors combine Endopeel techniques with PRP, threads,and rarely fillers or botulinum toxin.

Research and applications

A study on cadavers masseter made by the author, demonstrates that there is no mass and/or volume augmentation between the treated masseter and the untreated one.Figure12

 But all semiological rejuvenation effects could be seen immediately on the half face treated after few minutes. After dissection, the aspect of the treated masseter was similar to a young alive masseter with a nice color and with good tension compared to the untreated masseter looking atrophic, without vitality without any tension and with cadaveric color. Also some recent experimentation demonstrate that, Endopeel, works also on very thin muscles, even in absence of nervous signals.

Conclusion

Until now, the concept of facial rejuvenation was based only on volume augmentation concept (fillers) as myorelaxation with myoatrophy (botulinum toxin) ;from now and thanks to the Endopeel techniques one acts not only on the myotension by preserving the muscular mass and without affecting the muscular contraction but also on the myoplasty and the myopexy. With this fact the indications of the fillers become more restricted and will apply only to the depressions which remain after tissue tension of the selected areas. Finally chemical true face lifts are not due as much of manufacturers claim it with an increase in volume by fillers but rather with a handing-over in tension of tissues with tightening effect like the Endopeel techniques. The techniques of Endopeel are thus a new strategic weapon for the facial plastic surgeons and dermatologists enabling them to complete and/or maintain a face lift and to propose an alternative to the surgery.

References

1. Tenenbaum A (2009) La tecnicaEndopeel- La medicinaestetica-A.Redaelli, EEAFlorence.

1. Dewandre L,Tenenbaum A (2011) The Chemistry of Peels (2nd edn), Saunders Elsevier.

3. Tenenbaum A (2013) Medical Facelifts by Chemical Myoplasty, Myotension and Myopexy (Endopeel Techniques or Muscular SMAS Repositioning). Anaplastology 2: 116. doi: 10.4172/2161-1173.1000116

Figures

Figure1 : Medical Facelift using Endopeel Techniques.Isovolumetric method just repositioning the facial muscles. No Fillers. No Botulinum.

 

 

Figure2  Endopeel techniques applied to the face, especially on the medium third of the face , can be or medical or surgical.More than usual number of injections of the patented mixture using oily carbolic acid , will lead to an excess of tissue before the tragus, like here on the right side of the face of this old female patient.

Such skin excess can be removed surgically like a dog ear.This prooves that Endopeel is a true lifting.

 

 

 

Figure3  A pre tragal skin excess post endopeel ( maxi treatment) can be treated

• Surgically as dog ear removal with pre tragal or retro tragal incision, without any undermining
• Medically using the idea of Dr.Marlen Sulamanidze ( Inventor of Aptos threads and 1 st of the world to have used threads in cosmetic surgery and aesthetic medicine) with 2 different directions to create a smooth repartition of the skin excess and to avoid any excision, sutures and so on…

 

 

 

Figure4    Naso labial furrow are best treated with Endopeel than using fillers.Fillers mostly create an inaesthetic rolling bulge.

 

 

 

Figure5 Endopeel is useful to hide the facial asymetry improving it with 1 session for 6-9 months duration ( repeat the sessions for the maintenance and improving the results)in case of sequellae of facial paralysis.Endopeel is helping in this way such patients to go back to a normal social life.

 

 

 

Figure6 Ideal candidate for endopeel facelift

Easily can be seen the results as

-lifting of upper, medium and lower third of the face

-tightening effect

- projection of the zygoma( isovolumetric method)

-nasal tip lift and upper lip lift

- improvement of the naso labial furrow

 

 

 

 

Figure7  Immediate effect of Endopeel, not only static but also dynamic without paralyzing any muscles. Endopeel is isovolumetric.Such effect will last 6 months and the procedure needs to be repeated.

 

 

Figure8 This 70 years brazilian old female has been treated 7 times in 2 years.The medium third has been treated as she refused to treat other areas like forehead or pericoular area.She got as well a skin quality improvement ( late peeling effect).

 

 

 

Figure9 Late edema may occur if the patient is allergic to arachides ( peanut) especially amonthe asian population.This edema appears mainly 10 days after the procedure and can be treated using antihistaminics combined or not with corticoids. It is recommend to patients wishing an endopeel facelift not to eat arachides before and after the procedure and not to drink beer ( beer contains arachides).

 

 

 

Figure10 : Lower third left hemiface treated on a female patient.The saddy low jowl on left side of the patient is lifted, the left hemimandible looks higher and shorter and the hemileft neck is concave .

 

 

 

Figure11 Vectors and Tensors marking for the medium third of the face

 

 

 

Figure12 Experimental study on the masseters of the cadaver.The patented oily carbolic acid has been injected in the left masseter ( 0.05ml) and 30 minutes after the aspect of the cadaveric masseter treated by Endopeel appears normotrophic, with a good colour,with a new shape ( myoplasty) and a tension ( myotension). Both masseters left and right or treated and untreated have the same weight. This prooves the chemical isovolumetric myoplasty and leads to indications for hypotrophy of muscles, like sequellae of facial paralysis.