Small incision browplasty with midface elevation
Richard C. Allen, MD, PhD, FACS
Additional Notes: Length 04:53
This is Richard Allen at the University of Iowa. This video demonstrates an endoscopic browplasty with cheek elevation through the temporal scalp incisions. A conservative blepharoplasty has been marked on each side. These markings are then incised with the needle tip cautery. A flap of skin and orbicularis muscle is removed. Attention is directed to the temporal orbicularis muscle which is generously excised to weaken the brow depressing effect of this muscle. The medial fat pad is mobilized on each side and excised with the needle tip cautery. Dissection is then carried out between the orbicularis muscle and the orbital septum to the superior orbital rim. The superior orbital rim is identified and incised with the needle tip cautery. The periosteum is then elevated from the underlying bone.
Incisions are then made in the scalp and the long-handle periosteal elevator is used to perform a subperiosteal dissection in the area medial to the conjoined tendons. This is carried out inferiorly along the nasal bone. Attention is then directed temporally where the dissection was carried out along the surface of the deep temporalis fascia. The conjoined tendon is lysed on each side with Metzenbaum scissors. This results in the forehead being completely mobile. The Metzenbaums are then used to dissect inferiorly along the surface of the deep temporalis fascia to the zygoma. The malar eminence has been marked on each side. A stab incision is then made with the 15 blade on the markings at the malar eminence. A 3–0 Vicryl suture is then placed through the stab incision and retrieved superiorly. This is performed in the exact same manner on each side. The suture is placed with front biting pediatric sinoscopy forceps from the temporal forehead incision. The suture is then pulled through the stab incision. The sinoscopy forceps are then placed through a different portion of the stab incision so that the tissue can be engaged. The suture is regrasped. This results in an area of engagement by the suture at the area of the incision. Pulling on the sutures results in elevation of the cheek. This is demonstrated on each side. This not does not result in a significant cheek lift but it does provide stabilization of the cheek.
The patient will also have a trans-blepharoplasty canthopexy performed. This is performed with a 4–0 Prolene suture which engages the lateral canthal angle followed by the superior temporal periosteum. This results in tightening of the lateral canthus as demonstrated here. Please refer to a separate video on the performance of the transblepharoplasty canthopexy. This is performed bilaterally. The forehead is then elevated with an Endotine forehead device. The cheek elevation sutures are then tied at a tension to give a slight dimple at the malar eminence. This is sutured to the deep temporalis fascia on each side. Stabilization of the cheek is demonstrated. The superficial temporalis fascia is then plicated and the incisions are then closed with staples. The blepharoplasty incisions are closed with a running 6–0 Prolene suture. At the conclusion of the case, erythromycin ophthalmic ointment is placed over the incisions. The stab incisions are closed with the 6–0 Prolene suture. A headband is placed, and the patient follows up in approximately 1 week for reevaluation.
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January 9, 2017