Small Incision Browplasty
length: 7:30
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Transcript
This video demonstrates a small incision browplasty with upper eyelid blepharoplasty. The dissection performed in this case is the same as that for an endoscopic browplasty, but without the endoscope. An incision is made along the blepharoplasty markings with a monopolar cautery, and a flap of skin and orbicularis muscle are removed. Medially the orbital septum is opened and the medial fat pad is identified and mobilized. This fat pad is then conservatively excised with the monopolar cautery on each side. Dissection is then carried out superiorly along the surface of the orbital septum to the superior orbital rim. This dissection is performed lateral to the level of the supraorbital neurovascular bundle. The superior orbital rim is then identified and the monopolar cautery is then used to make an incision through the periosteum along the length of the superior orbital rim lateral to the supraorbital neurovascular bundle. The periosteum is then elevated from the underlying bone medial to the temporal fusion line and the supraorbital neurovascular bundle can be identified and preserved. The same dissection is then performed on the other side along the surface of the orbital septum to the superior orbital rim. Again the periosteum of the superior orbital rim is incised and a subperiosteal dissection is developed superiorly. This is performed so that the supraorbital neurovascular bundle can be identified and preserved. Markings have been made above the hairline. Two vertical markings have been made 2 cm long approximately 1-2 cm above the hairline at the level of the peak of the brow. The 15 blade is then used to make an incision along the marking down to the underlying bone. A subperiosteal dissection is then developed with the freer and Padgett periosteal elevators. Dissection is performed inferiorly so that the previous dissection plane from the eyelid is identified. This is performed along surface of the bone and this is all done medial to the temporal fusion line. The same incision and dissection is performed on the other side. Elevation of the periosteum from the underlying bone is performed to mobilize the forehead completely medial to the temporal fusion line. The freer periosteal elevator is then used to complete the forehead mobilization. Addition incisions are then made temporally on the surface of the deep temporal fascia just lateral to the temporal fusion line. The deep temporal fascia is identified and dissection is carried out along the surface of the deep temporalis fascia with Metzenbaum scissors. The Metzenbaum scissors are then used to lyse the temporal fusion line by identifying the pocket medially that is subperioteal and laterally that is along the surface of the deep temporalis fascia. Lysing the temporal fusion line results in the forehead being completely mobile. The same incision is then made on the other side. Again, Metzenbaum scissors are used to identify the deep temporalis fascia and then dissection is carried out along the surface of the deep temporalis fascia inferiorly to the superior orbital rim. This dissection is lateral to the temporal fusion. And then the subperiosteal dissection medially is connected to the dissection along the surface of the deep temporalis fascia by lysing the temporal fusion line. In this case, an Endotine forehead device will be used for fixation. The manual Endotine drill is used to drill a hole in the bone. The Endotine forehead device is then popped into the hole. The tissue is released from the device and then the forehead is elevated and the tissue is engage with the barbs of the device. The same thing is performed on the other side with the use of the manual drill. The Endotine forehead device is then place and elevation of the forehead is performed, and the tissue is engaged with the device. The two temporal incisions are then closed by engaging the superficial temporalis fascia which results in a plication of the fascia to attain elevation temporally. This should result in an elevation of the scalp in this area. This is performed with a 3-0 Vicryl suture. This elevation will resolve in approximately 2-3 weeks. This is performed on the other side as well. Again, the suture is a 3-0 Vicryl suture with engagement of the superficial temporalis fascia on either side of the wound to get plication and elevation. The scalp incisions can then be closed with staples. The staples can be removed in approximately one week. The blepharoplasty incisions can then be closed with the monofilament suture of the surgeon's choice. In this case, a 6-0 prolene suture is placed in a running fashion. These sutures are removed at the one week visit. At the end of the case, there is usually about 2-3 mm of lagophthalmos which resolves with time. The hair is rinsed and washed and a head dressing is placed with Coban and Kerlex.
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