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Endoscopic Midforehead Techniques: Improved Outcomes with Decreased Operative Time and Cost

Asa D. Morton

The design and implementation of any surgical procedure should first optimize outcome. Secondarily, procedural steps can be refined to maximize efficiency and minimize cost. Novel techniques for hair confinement and flap xation adhering to these constructs are presented.

Optimum hair confinement provides for improved wound visualization and shorter operative times. A 4-cm open-ended cylinder is fashioned from the barrel of a 3 cc plastic syringe. A series of small dental rubber bands are double wrapped onto the barrel and rest parallel to each other. The hair is wet, combed, and parted to expose the incision sites. Alongside of each incision the hair is twisted into a tightly wrapped tuft. A small straight hemostat is then placed through the modified syringe barrel lumen and used to grasp the hair tuft 4 cm from the scalp. The hemostat is withdrawn pulling the hair tuft through the barrel. The hair tuft is pulled taut and the syringe barrel is held firmly against the scalp. The most proximal band is advanced off the barrel, capturing the hair tuft near the scalp. The procedure is repeated until all the incision sites are exposed. A small scissor can be used to snip the band free at case conclusion.

Numerous central flap xation techniques have been described. Periosteal suture fixation bites placed anterior to the hairline may provide for better brow elevation while minimizing posterior shift of the hairline. The semicircular needle of the selected fixation suture is modified into the shape of a lazy “S” (author’s preference 3-0 Mersilene with FS-1 needle) (Figure 71.1). The needle is loaded into a Webster needle driver with the tip directed back toward the surgeons hand and parallel to the instrument. The suture end of the needle is directed 180° from this position, running away from the surgeon’s hand and parallel to the instrument tip. The loaded needle driver is inserted into the parasagital incision and directed down toward the brow (Figure 71.2A). The needle tip is palpated and directed to enter the periosteum approximately 2 cm inferior to the hairline. As the needle driver is withdrawn, a large slip of

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Chapter 71 Endoscopic Midforehead Techniques 225

periosteum is captured and the needle directed to exit near the anterior apex of the incision and deep to the periosteum (Figure 71.2B).

For bone fixation a simple 1 4 mm titanium screw is used. It is placed near the posterior extent of the parasagital incision with the screw head left slightly elevated (Figure 71.3A). A #12 Frazier suction tip, just large enough to fit over the screw head, is essential to completing the fixation through a small 10mm incision. The Frazier suction tip is placed over the screw head and angled approximately 30° anterior to a vector perpendicular to the cranium. While the assistant holds the suction tip in this position, the surgeon ties the previously placed fixation suture around it (Figure 71.3B). The knot is rotated into the wound. The suction tip is angled posteriorly and gently twisted on the screw head. This encourages the suture loop to slip off and anchor on the exposed screw head. The rotational arc of the suction tip acts as a lever arm, adding a small amount of additional suture tension to suspend the ap (Figure 71.4).

Hair confinement improves wound exposure while minimizing the amount of hair that is dragged in to the wound. This confinement technique is quick and does not require special instrumentation. Rubber band removal at case completion is easily completed with scissors.

The central flap xation technique allows for anterior and inferior placement of the periosteal fixation sutures. This translates to a more direct pull on the brow and better lift. Additionally, it may minimize posterior shift of the hairline.

Using simple titanium screws and the lever arm suture capture technique decreases cost, operative time, and wound size. Titanium screws are readily available and easy to place. Securing a suture over the small screw head can be difficult. The addition of a Frazier suction tip to guide the suture loop on to the screw head allows for a small incision and decreased operative time.

Figure 71.1. S-shaped bend in needle(left), then loaded into needle holder (right).

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Fifteen Principles of Enhanced

Success in Endoscopic Browlift

Guy G. Massry

The endoscopic browlift can be a powerful surgical procedure. As surgery is performed within a closed space and with specialized instrumentation, attention to detail, knowledge of anatomy, and surgical experience is critical to attain successful results. Educate yourself with knowledge and practice.

With these basic principles in mind, I have found that that there are a number of caveats which both simplify the surgery and enhance surgical outcome:

1.In the majority of patients it is the tail of the brow that has become lax and ptotic. Elevating the body and head of the brow out of proportion to the tail yields unnatural results and unhappy patients. To accomplish this elevation, mark the temporal posthairline incision parallel to the tail of the brow. The marking should be an inch and one-half long and the same distance behind the temporal hairline.

2.I rarely perform paracentral boney fixation with screws or other means, as it has risks and is unnecessary with appropriate release.

If you choose paracentral boney fixation, the fi xation point (and incision) should be somewhere between the lateral limbus and lateral canthus. The exact point will vary with individual anatomy.

3.Precise incisional markings are not necessary in our experience. We routinely use three incisions (one midline, two temporal). The anteroposterior midline incision is approximately 2 cm posterior to the hairline and 1 cm in length. Temporal incisions are 3 cm long 2 cm posterior to the hairline. The temporal incision is parallel to the tail of the brow, with its medial extent at the temporal conjoint fascia. It is not necessary to mark the incision before surgery.

4.Use high-volume, low-concentration local anesthetics. To avoid excess bleeding that will obscure the surgical view, inject 15–20 cc of 1% xylocaine with 1 :100,000 epinephrine where bleeding will occur, to the incision sites, supraorbital rims, lateral canthus, and medial zygomatic arch. Inject 30–40 cc of 0.25% xylocaine with 1 :800,000 epinephrine diffusely to the same areas and sites in between. This high-volume injection aids greatly in attaining appropriate hemostasis.

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