Small Temporal Scalp Incision Browplasty with Internal Suture Browpexy Reinforcement
Transcript
There are multiple techniques that can be employed in brow elevation, and the procedure should be tailored to the individual patient. For primarily temporal brow ptosis, the use of small temporal scalp incisions is adequate for mild to moderate brow ptosis. Lately, I have been including a browpexy with this procedure. This video shows the employment of both temporal scalp incision and additional brow stabilization with an internal suture browpexy.
This is Richard Allen at oculosurg.com. This video demonstrates a small scalp incision temporal browplasty with the addition of a browpexy. I believe that this is a useful procedure for patients with moderate brow ptosis who are also undergoing an upper blepharoplasty. The needle tip cautery is used to make an incision along the previously marked blepharoplasty marking. A flap of skin and orbicularis is removed; this could be skin only if the patient has a component of dry eye. The medial fat pad is mobilized and resected. The needle tip cautery is then used to dissect along the surface of the orbital septum to the superior orbital rim. The orbital rim is identified and the brow fat is dissected from the periosteum of the superior orbital rim. A freer periosteal elevator is used to dissect in a preperiosteal plan along the length of the superior orbital rim from the area just lateral to the supraorbital neurovascular bundle to the lateral orbital rim. This is performed superiorly approximately 2 cm superior to the superior orbital rim. The needle tip cautery is then used to make an incision through the periosteum extending from the superior orbital rim medially, just lateral to the level of the supraorbital neurovascular bundle, extending superiorly and then lateral to the level of the conjoint tendon. The freer periosteal elevator is then used to elevate the periosteum superior to the incision.
Attention is then directed to the contralateral side where the procedure is performed similarly. Dissection is carried out along the anterior surface of the orbital septum to the superior orbital rim, preserving the brow fat. The freer periosteal elevator is then used to dissect along the surface of the periosteum superiorly along the superior orbital rim. Care is taken medially to not compromise the supraorbital neurovascular bundle. The needle tip cautery is then used to incise the periosteum 2 cm superior to the superior orbital rim, and then descending to the superior orbital rim just lateral to the supraorbital neurovascular bundle. The freer periosteal elevator is then used to elevate the periosteum superior to the incision, staying medial to the conjoint tendon. The supraorbital nerve can be exposed medially. Additional dissection is carried out superiorly. This subperiosteal dissection can be extended medially along the bridge of the nose.
Attention is then directed to the temporal scalp incision. The incision straddles the conjoint tendon and a 15 blade is used to make an incision through the skin and subcutaneous fat. Metzenbaum scissors are then used to bluntly dissect to the deep temporalis fascia. Dissection is then carried out inferiorly along the surface of the temporalis fascia. This dissection is lateral to the conjoint tendon and is continued inferiorly to the upper blepharoplasty incision. A freer periosteal elevator is then used to dissect to the bone medial to the conjoint tendon. The freer is use to complete the subperiosteal dissection medial to the conjoint tendon. Metzenbaum scissors are then reintroduced through the incision to transect the conjoint tendon. The scissors are placed medially in the subperiosteal plane, and then laterally in the plane on the anterior surface of the deep temporalis fascial. Each blade of the scissors is placed in each of these planes and then the conjoint tendon is incised. This is performed to the level of the blepharoplasty incision, resulting in complete mobilization of the forehead.
Attention is then directed to the left side where the same procedure is performed. The Metzenbaum scissors dissect to the deep temporalis fascia lateral to the conjoint tendon and dissection is carried out inferiorly to the blepharoplasty incision along the anterior surface of the deep temporalis fascia. The freer periosteal elevator is then used to expose the subperiosteal plane medial to the conjoint tendon. The Metzenbaum scissors are then used to transect the conjoint tendon between the medial subperiosteal dissection and the lateral plane on the anterior surface of the deep temporalis fascia. Additional dissection is performed laterally to the lateral orbital rim. This results in the forehead being freely mobile.
A 3-0 Vicryl suture then engages the inferior extent of the superficial temporalis fascia. The suture then engages the superficial temporalis fascia superior to the incision. This is essentially a SMAS lift. Sometimes the deep temporalis fascia is engaged to provide additional fixation. Tightening and tying the suture results in elevation of the temporal brow. The same procedure is performed on the other side. This results in an elevated area at the incision which will flatten out with time. The scalp incisions are then closed with staples. These will be removed at the one week follow up.
Extra stabilization is performed through the blepharoplasty incision with a quantitated internal suture browpexy. A 4-0 Monocryl suture is placed through the periosteum approximately 12 mm superior to the superior orbital rim. This suture then engages the soft tissue 12 mm superior to the incision. Tying the suture helps in stabilization of the brow. An additional suture is placed medially in the same fashion. The same procedure is performed on the contralateral side. The upper eyelid incisions are then close with a combination of running and interrupted 5-0 fast absorbing sutures. At the conclusion of the case, antibiotic ointment will be placed over the incisions and into the eyes. The patient will follow up in approximately one week.
