Key Indications of Transtemporal Endoscopic Deep Plane Facelift (TEDPF)

Transtemporal Endoscopic Deep Plane Facelift (TEDPF) The transtemporal endoscopic deep plane facelift (TEDPF) is designed to achieve true vertical lifting by approaching the deep plane through the temporal region rather than a traditional preauricular incision. Using endoscopic assistance, the same dissection planes and retaining ligament releases as a conventional deep plane facelift are safely performed. Vertical SMAS elevation avoids excess preauricular skin redundancy, eliminating the need for a preauricular incision—an advantage particularly for younger and middle-aged patients concerned about visible scarring.

TEDPF also allows creation of a surgical plane between fat pads and mimetic muscles in the midface, addressing the primary mechanism of midfacial aging described by Hamra: inferomedial ptosis of superficial fat pads over the lip elevator muscles. Vertical lifting of these fat pads in the suborbicular plane directly corrects this descent. Mendelson’s anatomical space principles are applied to ensure safe, bloodless dissection.

Contemporary Concepts of Facial Aging Facial aging is not a surface phenomenon. Long-term studies and anatomical dissections have demonstrated that aging involves: Skeletal remodeling and volume loss

• Inferior migration of superficial and deep fat pads

• Attenuation and descent of the SMAS

• Secondary skin redundancy

Importantly, these structures descend as a composite unit, rather than independently. The implication for facelift surgery is clear: durable rejuvenation requires mobilization and repositioning of the SMAS and associated fat pads, not simply skin excision.

Figure 1. Illustration demonstrates the process of midface aging. As the malar fat pad descends, the nasolabial fold is accentuated. The orbital rim is left covered only by thin eyelid skin, and the tear-trough deformity becomes apparent.  Vector Analysis: Why Vertical Lift Matters

Facial ptosis occurs predominantly along a vertical vector, extending from the temporal region toward the lower face. However, many traditional facelift techniques rely on oblique or lateral vectors dictated by preauricular access and skin closure requirements. These vectors may improve jowling but often inadequately address midface descent and can produce an unnatural lateral sweep. An ideal facelift vector should:

• Counteract inferior facial descent

• Restore midfacial volume position

• Preserve natural facial proportions

A superiorly directed vertical vector best fulfills these criteria. Achieving this vector consistently, however, is challenging through a preauricular incision alone—prompting the rationale for a transtemporal approach.

Transtemporal Approach

The transtemporal route offers direct access to the deep facial planes required for vertical lifting while avoiding a preauricular incision. By approaching the SMAS and midface from above, surgeons can: Elevate the SMAS vertically without creating preauricular skin redundancy

• Conceal incisions within the temporal hair-bearing scalp

• Preserve the natural preauricular contour

• Minimize visible scarring, particularly in younger and middle-aged patients
  

Because the dissection planes and retaining ligaments addressed are identical to those in a conventional deep plane facelift, endoscopic visualization is essential to ensure safety and precision. Anatomical Foundations of TEDPF The TEDPF is grounded in well-established anatomical principles, including those described by Mendelson’s facial spaces concept. Key anatomical considerations include:

• Temporal compartments and the superficial temporal fascia

• The superior temporal septum and subperiosteal plane

• The prezygomatic space

• Retaining ligaments of the midface

• The course of the frontal branch of the facial nerve

Of particular importance is the region medial to the zygomaticus major muscle, where the SMAS becomes attenuated and a true dissection plane is absent. The transtemporal deep plane approach allows the surgeon to create a controlled surgical plane between the superficial fat pads and the underlying mimetic muscles, enabling effective vertical repositioning of the midface.

Figure 2. The SMAS cheek flap was then redraped. The arrow in the upper part of the figure shows the pull parallel to the vector of the long axis of the zygomaticus major. The lower arrow shows the direction of the vector of the SMAS flap as it is pulled in. The superior advancement of the anterior superior SMAS flap reflects the direction of the pull. 

Endoscopic Visualization in Transtemporal Endoscopic Deep Plane Facelift (TEDPF)

Purpose of Endoscopic Assistance Endoscopic guidance allows surgeons to:

• Identify critical neurovascular structures, including the frontal branch of the facial nerve.

• Map the retaining ligaments that tether the SMAS and fat pads.

• Visualize anatomical boundaries, such as the prezygomatic space and zygomaticus major borders.

• Create and maintain bloodless planes along natural anatomical separations.

Safety Advantages The frontal branch of the facial nerve and temporal vessels are at risk in any deep plane dissection. Endoscopy:

• Provides magnified, high-resolution imaging of the SMAS–fat interface.

• Allows precise ligament release without blind traction, minimizing nerve injury.

• Enables subtle midface mobilization without aggressive tissue handling, which reduces postoperative bruising and edema.

Technical Role in Plane Development TEDPF involves two primary planes:

Subperiosteal Plane (temporal and zygomatic regions)

• Endoscopy helps identify the superior temporal septum, temporal compartments, and underlying periosteum.
  

• Ensures safe entry into the subperiosteal space without disrupting the overlying superficial temporal fascia.
  

Advantages Over Traditional Visualization

• Endoscopic visualization facilitates safe separation of fat pads from mimetic muscles.

• Enables vertical lifting of the superficial and deep fat pads, restoring midface volume and projection.

• Assists in ligament release (e.g., zygomatic cutaneous, masseteric) that allows tension-free mobilization of the SMAS.

Advantages Over Traditional Visualization

Feature	Traditional Deep Plane	Endoscopic (TEDPF)
Incision	Preauricular (larger)	Temporal (small, concealed)
Visualization	Limited, sometimes blind	Magnified, high-resolution
Nerve Protection	Relies on landmarks	Direct visualization
Fat Pad Mobilization	Partial or indirect	Precise, vertical repositioning
Skin Redundancy	Requires excision	Minimized due to vector control

Practical Considerations

• Requires familiarity with endoscopic equipment and hand-eye coordination.

• Surgeons must recognize anatomical cues on video that differ from direct visualization.

• Endoscopy facilitates controlled, stepwise dissection that maintains the integrity of the facial layers, allowing a vertical lift without skin overpulling.

Aesthetic Outcomes and Advantages

Figure 3. Preoperative and postoperative results of a patient undergoing the TEDPF, highlighting aesthetic improvements from different angles. a, Preoperative picture of a female patient in oblique view. B, Postoperative result in oblique view. When properly indicated and executed, TEDPF offers several aesthetic advantages:

• Restoration of midfacial fullness and projection

• Softening of the nasolabial fold through vertical fat repositioning

• Preservation of the natural facial vector and expression

• Absence of preauricular scars

• Avoidance of the “over-pulled” lateral facelift appearance

Limitations and Considerations

Despite its advantages, TEDPF is not without limitations:

• Technically demanding with a learning curve

• Requires proficiency in endoscopic facial surgery

• Not a universal replacement for traditional facelift techniques

• Dependent on meticulous anatomical knowledge

Acknowledging these limitations is essential when incorporating TEDPF into a broader facial rejuvenation practice.

Conclusion The Transtemporal Endoscopic Deep Plane Facelift represents a thoughtful evolution in facial rejuvenation surgery—one that aligns surgical technique with the true anatomical vectors of facial aging. By enabling vertical SMAS and midface elevation through a scar-concealed approach, TEDPF offers a powerful option for selected patients seeking natural, durable rejuvenation without visible preauricular scarring.

As our understanding of facial anatomy and aging continues to advance, techniques such as TEDPF underscore the importance of anatomy-driven, vector-appropriate facial surgery in achieving optimal aesthetic outcomes.

Reference:

1. Kul, Z., Eryilmaz, E., & Özer, E. (2025). Transtemporal endoscopic deep plane face lift. Plastic and Reconstructive Surgery – Global Open, 13(1), e6461.
   

2.  Heffelfinger, R. N., Blackwell, K. E., Rawnsley, J., & Keller, G. S. (2007). A simplified approach to midface aging. Archives of Facial Plastic Surgery, 9(1), 48–55. https://doi.org/10.1001/archfaci.9.1.48
   

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