Specialized instruments in addition to standard endoscopic forehead lift instruments used in this modification include (a) ultra-curved periosteal elevator with a bent angulated tip (patent pending), (b) D-knife, (c) 2 mm osteotome, and (d) Daniel endoforehead fenestrated camera sleeve cannula
Standard endoscopic forehead lift instruments: marking pen, endoscopic graspers (sharp and dull), double hooks, endoscopic sleeve, (regular and fenestrated), right angle, long narrow tonsil, 30-degree endoscope, endoscope warmer, Guyuron endoscopic access devices (EAD) ×5, elevators of various degrees of bend and width, Adson tissue forceps, comb, Metzenbaum or Littler scissors, and suction cautery (image a) that is bent at the tip. Blunt-tip hooks (image b) are used for insertion of the EAD ports to minimize trauma to the skin
Position and marking. The patient is positioned in the same manner as in the open approach. Both the face and hair are prepped for a 1 cm vertical incision in the midline. Five incisions are marked behind the hairline (one in the midline and two laterally on each side) (a). The lateral incisions are made roughly 7–10 cm from the midline and slightly behind the anterior hairline (b). ∗Site 5A (the crossing point of ATN and anterior branch of the temporal artery) can be addressed during the placement of lateral incisions with the aid of an intraoperative Doppler to identify the temporal artery. This can be done in combination with site 1 surgery. This incision is typically longer, and the EAD may need to be sutured in to prevent dislodging later. While not necessary, one may elect to shave the hair only around the incision to facilitate closure of skin
Subperiosteal dissection with a straight-to-gradually curved elevators provides adequate exposure to supraorbital rim and SON and STN. In cases of extreme frontal bossing or difficulty in accessing the rim, modified instrument can be used to continue subperiosteal elevation beyond the bossing and orbital rim with minimal difficulty
Subperiosteal dissection. A modified, ultra-curved elevator can be used in dissection to access the supraorbital rim in cases with significant frontal bossing, as can be seen in this image
Exposure. The SON (right) and STN (left) are exposed and skeletonized. The cage sleeve is visible and provides a correct moderate tension on the overlying skin for the introduction of instruments through stab incision in the brow
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