Kasr El Aini Journal of Surgery VOL., 7, NO 3 September 2006 7 ENDOSCOPIC FOREHEAD LIFT A NEW EASY TECHNIQUE Dr. Hisham M. El-Minawi, M.D. The Department of Surgery, Faculty of Medicine, Cairo University ABSTRACT The key qualities of a beautiful face are symmetry and balance. The challenge that the aging process most often poses to the facial plastic surgeon is gradual dissonance of the facial features. Sequelea from aging are most dramatically displayed in the upper third of the face: eyebrows begin to sag ; wrinkles form on the forehead ;and eyelids show signs of hooding. Bringing back equilibrium to this area has thus become a significant goal of facial rejuvenation surgery. Without the need for all the equipment and space needed in the traditional endoscopic forehead lift, the study was performed on 12 patients using the portable hysteroscope which is hand held with a built in light source and the usefulness, reliability of the scope was assessed. The use of the portable hand held scope was found to be useful giving good results without complications, saving time of surgery by nearly 40% and saving space and less expensive than ordinary endoscopic procedures. Key words: forhead lift, endoscope, minimally invasive, office surgery. INTRODUCTION As one of the earliest pioneers of endoscopic fore head rejuvenation, Keller, in 1991, described foreheadplasty using endoscopic visualization to incise the procerus, corrugator and depressor musculature and perform a temple lift.( 1 ) Isse in 1994 described an endoscopic forehead lift and reported a case of full face lift with an endoscope ( 2 ). Keller, Isse, Ramirez soon advanced the technique by varying it on the basis of the configuration of the skull, bony architecture and soft tissue thickness and tightness. A move toward smaller incisions also ensued.( 1,2,3 ) Since then, numerous authors have reported their personal experiences and further added to the endoscopic forehead rejuvenation technique. Despite these revisions, the basic concept of endoscopic forehead rejuvenation remains unchanged:(1)a sub-or supra-periosteal dissection of the scalp to the level of the superior and lateral orbital rims and zygomatic arch;(ii)incision and release of the orbital periosteum and ;(iii)selective myotomies of the brow depressors.( 4 ) The current trend has focused on less invasive incisions, wider undermining and a permanent fixation technique. Endoscopic foreheadplasty has proven to be as reliable as the traditional open approaches, but with significantly less surgical morbidity and postoperative discomfort. It has therefore become an excellent alternative in aesthetic rejuvenation of the upper third of the aging face.( 5 ) Endoscopic forehead lift procedures entitles the use of expensive equipment, an endoscope, camera, monitor, light source, irrigator and aspirator machine together with the endoscopic surgical instruments and a mobile tower to hold up the equipment.( 4 ) The use of a portable hand held all in one endoscope was the target of this study to show the benefits of having all the equipment in one machine, using the same principles of endoscopic fore head lift by utilizing an endoscope used by gynecologists. The endoscope has a built in light source that runs with r14 size alkaline batteries and small Co2 canisters for insufflations. The endoscope could be connected with the camera to a 6in LCD viewer and could be connected to laptops.
Kasr El Aini Journal of Surgery VOL., 7, NO 3 September 2006 8 PATIENTS & METHODS The study was carried on from October 2004 till November 2005 on twelve patients, eleven females and one male patient with the mean of age of 54 years. All had minor to moderate brow ptosis that needed forehead lifts. All twelve patients were operated upon under general anesthesia. All patients were given a prophylactic dose of antibiotics before the operation and continued on the antibiotic four days after surgery. All patients were operated upon with the operating table flexed to put the patients in a semi-sitting position. The patients face and hair were sterilized with betadine and drapes were placed. All incision sites were infiltrated with adrenaline 1/200,000. The all- in- One endoscope: A portable handy hysteroscope By Wolf company (Panoview) was used with a built in light source was used with its 2.7mm scope in its rigid sheath.the light source runs with 2 R14 sized batteries. The camera was connected to 6 inch LCD screen via a digital cable connecter. (Figures 1, 2, 3).The camera could also be connected to a laptop for recording operations. The outer sheath could allow continuous flow of saline when needed. A double sided periosteal elevator was used which was custom bent during the procedure to fit the curves of the forehead.(figure 3b). A grasping forceps was used to disrupt the muscles. Forehead lift steps: Five incisions are used most commonly. A single 1.5-cm midline incision is set 1 cm behind the hairline. The lateral incisions are placed midway between lateral limbus of the pupil and lateral canthus but at a 30-degree angle laterally and extend 1.5 cm in length. The goal is to accentuate the lateral pull on the glabellar lines and the arch of the eyebrows. The temporal incisions are 2 cm in length and perpendicular to the alar-lateral canthus tangent line. They are placed higher with two-thirds superior and one-third inferior to the tangent line. The incision has a 1-cm inverted-t component to facilitate subsequent insertion of the temporal advancement suture. The central three incisions are made down to periosteum, while the temporal incisions extend down to deep temporal fascia Reference marks are made on the skull beneath the anterior end of the lateral incisions by means of the drill. Reference marks are made beneath the temporal incision with a no. 15 blade. Visualization of the underlying temporal muscle confirms the correct dissection plane on top of deep fascia. The initial dissection consists of three components: scalp, temporal area, and upper forehead. The upper half of the forehead is dissected in the sub-periosteal plane with the curved elevator. The temporal dissection extends down to the level of the supra-orbital rim on top of deep temporal fascia. Then all three pockets are connected, which requires a lateral to central release of the fascial fixation at the temporal crest line. Once the release is complete, the endoscope can be inserted. With the endoscope in the lateral incision and the elevator in the temporal incision, the periosteum over the lateral forehead is elevated down to the orbital rim. The corrugator muscles are stripped upward and disrupted. The corrugator and depressor supercilii are removed in three portions: between the two nerves and medial to and behind the supratrochlear nerve branches Using the endoscopic scissors, the periosteum is divided along the supraorbital rim from lateral to medial, stopping before the supraorbital nerve. Repeated stretching in a vertical direction separates the periosteum and also the underlying galea, eventually resulting in exposure of the brow fat pad. The supraorbital nerve is identified, and then the periosteum is divided in a vertical direction. After release of the brow through multiple scalp ports, and determination of brow position, direct suturing is used to hold the brow in position. T to V advancement is performed. This involves the incision of a T-shaped pattern of the endoscopy port site with the vertical limb perpendicular to the frontalis and anterior to the horizontal limb. The vertical limb of 1.5 to 2.0
Kasr El Aini Journal of Surgery VOL., 7, NO 3 September 2006 9 cm is advanced posteriorly, sutured to the galea or periosteum, and closed to form a V. The excess skin triangles are excised and discarded. A B Figure(1) (A)performing the endo forehead while looking through the scope,(b) performing the procedure while looking at the portable LCD screen A B Figure (2):(A) showing the Hysteroscope with the battery operated light source,(b) showing the 2.7 mm 25 degree scopes and the rigid sheath A B Figure (3) : (A) showing the hysteroscopy bag with all it s accessories, (B) showing the periosteal elevator
Kasr El Aini Journal of Surgery VOL., 7, NO 3 September 2006 10 RESULTS The endoscopic forehead lift was done for all twelve patients using the all in one scope which showed a mean of 50 minutes operating time. The degree of patient satisfaction was between good and excellent results based on a patient survey. The time for the setup of the endoscopy equipment for the procedure was of a mean of 4 min (range 3-8). There were no complications other than 2 cases showing slight asymmetry between the levels of the two eye brows. One patient presented with a huge haematoma on the night of surgery, for which only follow up and conservative treatment was done. The staff of the operating theater needed less time to set up the room and less time to remove the equipment than the traditional endoscopic forehead lift. Case number (1): pre and 3 months after endoforehead Case number (2):showing pre and 6 months post Endo forehead lift with the Hysteroscope
Kasr El Aini Journal of Surgery VOL., 7, NO 3 September 2006 11 DISCUSSION The use of the portable Hysteroscope made the chance of performing an endoscopic forehead lift in this series higher as there was no need to look for major hospital equipment and it made it more easier to move around with the hysteroscope in its bag which is in the size of a regular samsonite bag easier. The video endoscopic imaging system recommended by Romo III and Choe,2004,consist of the camera, the monitor, the light fountain, the fiber optic light cable, the DVCAM video recorder,the coagulation generator with it s cord together with the mobile video cart and the power box. ( 4 ) The handy equipment needs no towers or space to build up the set up for the procedure. The hysteroscope with its built battery operated light source cancelled any need to use any separate external light source equipment with connecting electricity cables. The use of the endoscopes camera with its digital connecting cable to the 6 inch LCD screen made it easier to let the assistant outside the field to move around the screen where ever the surgeon wishes and makes it a great option to even have screen in front of the surgeon and only inches away. The camera could even be connected to any laptop for larger views and for recording of the operation. The double sided periosteal elevator which was custom bent to follow the forehead contours replaced the traditional expensive periosteal elevators. Nahai points to the cost of endoscopic procedures as one of the drawbacks stating that although most major hospitals house endoscopic towers for general, gynecologic, or urologic surgery procedures, they may not have endoscopic surgery designed to overcome the challenges of particular anatomic obstacles in the face. Smaller surgery centers and private operating rooms that do not own such endoscopic towers will face a greater startup expense.( 6 ) He also pointed that other potential disadvantages of endoscopic procedures are the reliance on specialized instruments and video equipment to the degree that if one of the devices malfunctions, the surgery will become exponentially more difficult in the best case scenario. Out-of- order towers will translate into postponed procedures, although rare because of his use of highly reliable devices that are currently available.( 6 ) The working time including in it the set up of the instruments took a mean time of 50 minutes which was much less than the normal time taken in the classic fore head lift by the same operator by 15 minutes because of the time needed to set up the equipment and test the connections. Hernandez-Zendejas et al in 2004 described a novel Universal Serial Bus Endoscope which they described to allow a smooth running procedure rarely lasting longer than 45 min. When the operation started, the operative field was crowded with instruments and cables. These technical details frequently caused the traditional endoscopic forehead lift to be timeconsuming, typically requiring more than 1 h to complete( 7 ) When the operative field remains clear of instruments and cables, this eliminates an occasional source of distraction for the surgeon and allowed greater focus on the anatomical and technical aspects of the procedure( 7,8,9 ) Certainly, a typical fiber optic light source provides a more powerful and clear source of light. Notwithstanding, the additional fiber optic cable attached to the endoscope still is cumbersome in the surgical field. ( 7 ) The use of the portable 6 inch LCD screen made it easier for the operator to view the field from any angle with out the need to fix the view only on the monitor on the trolley in classic endoscopic forehead lifts. Hernandez-Zendejas used the laptop screen as their monitor but stated that the images from the Universal Serial Bus Endoscope (USBE) were not as large crisp, and clear as those obtained with the traditional video-endoscope system, but they were clear enough for performing a safe and reliable endoscopic forehead Lift. ( 7 ) The self adjustable double sided elevator helped in dissection and alleviated the need to use different shapes and curves of elevators. The price of the procedure was less as the price of rental of the endoscopic equipment was not included in the procedures. The number of personnel in the operating field was reduced than in classic procedures as a
Kasr El Aini Journal of Surgery VOL., 7, NO 3 September 2006 12 technical assistant to operate the machines and fix the connections was not needed in any of the operations. The need to operate in big expensive hospitals with fully equipped endoscopic sets was also not a must in any of the procedures as the endoscopy bag was easily set in any hospital and needed no big operating theaters for the set up The ability to connect the system through the camera cable to a lap top would make it helpful to store procedures on laptops, edit material and even use the laptop screen as a monitor. CONCLUSION The use of portable all in one endoscope is a way by which surgeons in areas in the world that can not have the benefit of having endoscopic trolleys with expensive sets present in all hospitals, perform endoscopic surgery in a less expensive, easy way.the need for fully equipped hospitals, the rent of sets and the use of special technicians to operate the equipment will not be a problem with the use of such equipment. Surgery could be done in any operating room and could be a solution in countries that allow office based surgery. REFERENCES 1. Keller,G.S.: Small incision frontal Rytidectomy with KTP Laser. American Academy of Cosmetic Surgery, World Congress. October 1991 2. Isse NG: Endoscopic facial rejuvenation: Endo forehead, the functional lift: Case reports. Aesth Plast Surg.; 1994, 18:21 29. 3. Ramirez OM: Endoscopic full facelift. Aesth. Plast. Surg.; 1994, 18:363 371. 4. Romo III,T.and Choe,K.S.: Endoscopic Forehead lift; endoscopic approach to upper Third Facial Rejuvenation Karl Storz, 2004. 5. RomoIII, T., Jacono, A.A. and Scalafani, A.P.: Endoscopic Forehead lifting and Contouring. Facial Plastic Surgery.; 2001, 17:3-10. 6. Nahai F.: The art of aesthetic surgery, principles and techniques. Vol.3.chapter 27 endoscopic Rytidectomy; 2005, p 931. 7. Hernandez-Zendejas G, M.D.,1 Marek K. Dobke, M.D., Ph.D.,1 and Jose Guerrerosantos, M.D: The Universal Serial Bus Endoscope: Design and Initial Clinical Experience Aesth. Plast. Surg.; 2004, 28:181 184. 8. Daniel RK, Tirkanits B: Endoscopic forehead lift: An operative technique. Plast Reconstr Surg.; 1996, 98:1148 1157. 9. Hernandez-Zendejas G, Guerrerosantos J: Closed forehead lift combined with percutaneous selective radio-frequency neuroablation. Worldplast; 1996, 1:225 229.