Transtemporal Endoscopic Deep Plane Face Lift: A Vertical Vector Approach to Midface Rejuvenation
- Admin
- Jun 30
- 6 min read
Updated: Jul 4
The ongoing refinement of deep plane facelift techniques has led to the emergence of vertical vector approaches that better align with the true direction of facial aging. Among these, the Transtemporal Endoscopic Deep Plane Face Lift (TEDPF), as described by Kul, Eryilmaz, and Özer (2025), stands out as a transformative method—offering midface and periorbital rejuvenation through a scar-minimizing, anatomically driven technique.
By eliminating the need for preauricular incisions and targeting the soft tissue descent via a superior vertical lifting vector, TEDPF directly addresses the limitations of traditional lateral facelifts. Its appeal lies in its precision, its ability to preserve tissue integrity, and its compatibility with patients who desire natural, long-lasting results without extensive scarring.
Understanding the Anatomical Basis
The Aging Vector and the Midface
Facial aging is a result of skeletal remodeling, descent of deep fat compartments, laxity of the superficial musculoaponeurotic system (SMAS), and skin redundancy. The descent of midface soft tissues, particularly the malar fat pad, follows an inferomedial vector. To effectively counteract this gravitational trajectory, the ideal lifting vector must be vertical and superior—exactly what TEDPF is designed to achieve.
Forehead and Temporal Considerations
The transtemporal approach offers a critical advantage: safer, more direct access to the midface without violating the preauricular area. Understanding the anatomy of the superficial temporal fascia, temporal septa, and frontal branch of the facial nerve is essential. The nerve crosses the zygomatic arch to enter the frontalis muscle through the temporal fat pad—making it vulnerable during conventional lateral dissections. TEDPF avoids this risk by using defined endoscopic corridors under direct vision.
Surgical Technique
TEDPF is a deep-plane, endoscopically guided procedure that vertically repositions the facial soft tissue layers as a composite unit. Below is a detailed breakdown of the surgical steps:
1. Preoperative Marking
With the patient upright, mark:
Arcus zygomaticus
Inferior and superior temporal septa (ITS, STS)
Orbicularis retaining ligament (ORL)
Lateral orbital thickening (LOT)
Infraorbital rim and zygomatic cutaneous ligaments (ZCL)
Zygomaticus major (ZMa) origin
Tear trough ligament (TTL)
Mapping the predicted course of the frontal branch of the facial nerve is crucial to avoid injury.
2. Anesthesia and Tumescent Infiltration
Under general anesthesia, a tumescent solution of 0.5% bupivacaine with 1:200,000 epinephrine is injected into the temporal, supraorbital, and midface regions to facilitate dissection and reduce bleeding.
3. Incision and Endoscopic Access
A 3-cm temporal scalp incision is made approximately 2 cm posterior to the hairline. Dissection proceeds:
Under the superficial temporal fascia
Through the STS into the subperiosteal plane
Along the supraorbital rim, releasing ligamentous adhesions and periosteum to enable brow elevation
Dissection continues inferiorly into the inferior temporal compartment, identifying key landmarks such as the sentinel vein, zygomaticotemporal nerve, and LOT.
4. Orbicularis Retaining Ligament (ORL) Management
The ORL is exposed and temporarily suspended. After release along the infraorbital rim, including the tear trough ligament, a defined plane is created between:
Superior: OOm and SOOF
Inferior: ZCLs
Floor: Preperiosteal fat
This maneuver elevates the OOm and softens the lid-cheek junction, effectively simulating a canthopexy without additional procedures.
5. Midface Dissection
Dissection proceeds:
Above the ZMa to avoid disrupting mimetic function
Releasing ZCLs and upper masseteric ligaments
Elevating the malar fat pad en bloc with the SMAS
The middle premasseteric space is then entered to expose the buccal fat pad and buccal branches of the facial nerve. Intracapsular fat reduction may be performed when necessary.
6. Lower Face Extension
Using a Trepsat dissector or blunt scissors, the lower premasseteric space is accessed. Careful dissection avoids injury to the marginal mandibular and buccal branches.
7. Vertical Fixation and SMAS Suspension
Five vertical suture fixation points anchor the lifted SMAS to the deep temporal fascia:
Platysma
Septum between middle and lower premasseteric spaces
Roof of the middle premasseteric space
Main zygomatic ligament
Lateral aspect of the ORL
This creates a vertical vector suspension, restoring midface volume and cheek projection.
8. Ancillary Procedures
Pinch blepharoplasty addresses minor lower eyelid redundancy
Temporal lift via posterior redraping corrects lateral hooding
Postauricular incisions are used for neck lift when indicated
Submental access allows for digastric and subplatysmal contouring
No drains are needed due to minimal dead space and intact skin-SMAS continuity.
Patient Selection
Ideal candidates:
Age 30–70 with mild to moderate laxity
Positive orbital vector and well-defined malar eminence
Concerned about visible scars or keloid risk
Early facial aging or revision cases
Relative contraindications:
Severe skin redundancy requiring extensive excision
Negative vector or flat malar projection (unless modified)
Clinical Outcomes
In a study of 140 patients:
Lower eyelid length decreased by 22.45%, indicating effective periorbital support
Complications were minimal:
5 cases of temporary frontal neuropraxia, all resolved
6 minor revision surgeries (e.g., malar dimpling, excess temporal skin)
Ancillary blepharoplasty and neck lifts were easily incorporated
Advantages of the Transtemporal Endoscopic Deep Plane Face Lift (TEDPF)
TEDPF distinguishes itself by aligning surgical technique with the anatomical direction of facial aging, delivering rejuvenation that is both comprehensive and elegant. Its scarless approach, precise vector of lift, and deep anatomical dissection provide a host of benefits that enhance both aesthetic outcomes and procedural safety.
1. Vertical Vector Lift Aligned with True Aging Direction
Unlike traditional lateral or oblique lifts, TEDPF employs a vertical vector that directly opposes the natural inferomedial descent of the midface. This leads to:
Restoration of youthful cheek projection
Elevation of the malar fat pad in its anatomical axis
More natural transitions at the lid-cheek and nasolabial areas
2. Scar Minimization: No Preauricular Incision
TEDPF eliminates the need for a preauricular scar in most patients, thanks to its transtemporal access:
Incision is hidden within the hairline
Ideal for younger patients, males, or keloid-prone individuals
Reduces patient anxiety associated with visible surgical signs
3. True Deep Plane Rejuvenation Without Skin Undermining
The technique lifts the skin, fat pads, and SMAS as a single composite flap:
Avoids wide skin undermining, reducing trauma and dead space
Preserves vascularity for faster healing and lower necrosis risk
Creates natural-looking, long-lasting facial contours
4. Periorbital Enhancement Without Canthopexy
By releasing and suspending the ORL and elevating the OOm:
Improves lower eyelid support and reduces its apparent length
Enhances canthal tilt without needing lateral canthopexy
Achieves smoother transition between the eyelid and cheek
5. Preservation of Facial Nerve Function
Endoscopic access allows careful navigation around critical neurovascular structures:
Reduces risk of injury to the frontal branch
Protects the zygomatic, buccal, and marginal mandibular branches
Minimal cases of transient neuropraxia (5 of 140), all resolved
6. Effective Midface and Jawline Contouring
Release of ZCLs and masseteric ligaments allows:
True elevation of the malar and buccal fat pads
Restoration of youthful midface volume
Reduction of jowls and nasolabial folds
7. Faster Recovery and No Drains
Minimal skin undermining means:
Reduced bruising and swelling
No need for surgical drains
Shorter recovery times and faster return to social activity
8. Highly Compatible with Ancillary Procedures
TEDPF integrates easily with:
Pinch blepharoplasty
Temporal lift
Neck lift (via postauricular incision)
Submental access for lower face sculpting
9. Ideal for Secondary and Selective Cases
TEDPF works well in:
Revision facelifts where preauricular tissue is already scarred
Targeted midface-only rejuvenation without extensive dissection
10. Durability Through Deep Fixation and Tissue Remodeling
SMAS is anchored to the deep temporal fascia, and long-term positioning is supported by:
Fibrotic adherence at fixation points
Results rivaling traditional deep plane lifts in longevity
Comparison with Traditional Deep Plane Techniques
Feature | Traditional Deep Plane Lift | TEDPF |
Incision | Preauricular | Transtemporal (scarless) |
Lift Vector | Oblique/Superolateral | Vertical (gravity-opposing) |
Skin Undermining | Extensive | Minimal |
Nerve Injury Risk | Moderate | Lower (endoscopic control) |
Midface Correction | Indirect | Direct, anatomical repositioning |
Lower Eyelid Support | Often needs canthopexy | Achieved via ORL/OOm repositioning |
Visible Scarring | Yes | No (in most cases) |
Conclusion
The Transtemporal Endoscopic Deep Plane Face Lift is a meticulously structured, anatomically grounded procedure that delivers effective vertical elevation of facial tissues with minimal scarring and high patient satisfaction. It respects facial anatomy, restores youthful contours, and offers versatility in both primary and revision settings. For surgeons seeking a powerful, modern alternative to traditional techniques, TEDPF is a compelling and evidence-backed addition to the facial rejuvenation armamentarium.
Reference:
Kul, Zekeriya & Eryilmaz, Erhan & Özer, Emre. (2025). Transtemporal Endoscopic Deep Plane Face Lift. Plastic and Reconstructive Surgery - Global Open. 13. e6461. 10.1097/GOX.0000000000006461.
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