Endoscopic Rhytidectomy

David N. Sayah
Nicanor G. Isse

Disadvantages

A learning curve is certainly associated with endos opic procedure', as with any other novel procedure. We anticipate, however, that with a growing number of gen ral surgery residents well trained to perform laparoscopic procedures, endoscopic plastic surgery techniques will be mastered with gr ater ease.

The most challenging technical skill that a plastic surgeon must master to perform endoscopic procedures involves developing hand-eye coordination while visualizing a three-dimensional space on a two-dim nsional video monitor. Learning the terminology and instrumentation associated with endoscopic surgery is another challenge that can be asily met.

Cost is the last drawback associated with endoscopic procedures. Although most major hospitals house endoscopic towers for general, gynecologic, or urologic surgery procedures, they may not have endoscopi plastic surgery instruments 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.

Other potential disadvantages of endoscopic procedures are the reliance on the 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 in our experience such occasions are extremely rare because of the highly reliable devices that re currently available.

Indlcations and Contraindications

The indications for an endoscopic brow and face lift are broader than those for an anterior hairline brow lift or a coronal brow lift because of the limited scars produced by an endoscopic procedure. The risk-benefit ratio is arguably weighted toward benefits if the risks are decreased. We feel many of the procedures that would otherwise not be undertaken in high-risk patients are possible with endoscopic approaches because of the decreased risks associated with these minimally invasive techniques.

The Primary Aging Face

Candidates are those with varying degre s of brow ptosis, with or without muscle hyperactivity in the forehead or brow area. Eyebrow ptosis can result from tissue laxity (solar elastosis) or muscle actions. An endoscopic midface lift is indicated to elevate the inferior and lateral periorbital soft tissues by repositioning the malar and nasojugal fat pads. Another indication for this procedure is prominent deep nasolabial folds and laxity of the orbicularis oculi producing scleral show. Endoscopic rhytidectomy procedures are ideal in smokers who present a relative contraindication for standard open techniques.

Brow Ptosis

Functional endoscopic brow lifts are performed for visual field correction in severe brow ptosis in conjunction with a blepharoplasty. Standard field-of-vision test need to be performed to confirm the indications for such procedures.

The Secondary Aging Face

Recurrence of the effects of aging after a primary open rhytidectomy or brow lift provides the perfect situation for an endoscopic procedure. Incisions along prior rhytidectomy scars are tempting but lead to a prolonged recovery among such patients. Unless the scars associated with the primary rhytidectomy need revision, we prefer endoscopic procedures in this patient group.

Nerve Exploration

For patients with a history of a prior nerve injury after an op n brow lift, endoscopic techniques are invaluable in nerve explorations during secondary brow lifts. The nerve under suspicion, which is typically a branch of the supraorbital nerve, can be identified during dissection under magnification and the nerve photographed for medicolegal documentation at the point of prior injury. Endoscopic supraorbital nerve and frontal branch of facial nerve neurolysis, neurectomy, and neurorrhaphy are also p ssible with endoscopic techniques.

Facial Paralysis

Endoscopic brow lifts are also indicated for ptosis of the brow caused by facial paralysis. The degree of brow lift can be cu tomized to each ide of the face based on th examined asymmetry.

Myotomies for Migraines

"Soft indications' for endoscopic brow lift with myotomies include migraine headaches. Elimination or improvement of migraines has been associated with corrugator upercilii muscle resection during endoscopic, transpalpebral, or open forehead rej uvena tion procedures.

Bony Deformities

Posttraumatic or congenital bony deformities on the forehead can b shaved or cut with an osteotome through smaJl port incisions under endoscopic visualization. Endoscopic burrs are now available to shave down abnormal bony ridges under great control through minimal incisions. Even small deformitie would be treatable with minimally invasive approaches made possible by endoscopic techniques.

Insertion of Grafting Material

Facial implants or synthetic bone fillers can be inserted through tandard forehead port incisions under endoscopic visualization. This can be performed in conjunction with an endoscopic forehead lift or endoscopic face lift.

As in open procedures, age does not present a contraindication to endoscopi rhytid ctomy. The youngest patient to undergo the procedure in our experience was in her late twenties, while the oldest was 85 years old.

Special caution must b e, ercised in patients with prior head trauma. In such cases, a preoperative CT scan may be helpful in identifying areas of calvarial defect, which may lead to dural tear during the subperiosteal dissection. Based on our anecdotal experience, Native Americans, Asians, Hispanics, and blacks who have thicker tissues may require a greater degree of tissue modification (myotomies, myectomies, and neurotomi s) to ensure longevity of the results. A greater number of fixation points may also be required in this group including dir ct brow susp nsion or midbrow as w II as lateral brow suspension. As in standard open coronal lifts, brow elevation appears to be limited in patients with hollow eyes and senile orbit.