Small incision browplasty in a male patient
Richard C. Allen, MD, PhD, FACS
Additional Notes: Length 05:22
This video demonstrates a small incision browplasty in a male. This is a browplasty using similar dissections in which surgeons would use an endoscope. No endoscope is used for this procedure. A blepharoplasty has been marked and is incised with the 15 blade. A flap of skin and orbicularis muscle is removed with the needle tip cautery. Temporal orbicularis is removed with the needle tip cautery to help in brow elevation. The same procedure is performed on the opposite side. The medial fat pad is identified by dissecting through the orbital septum medially. The fat pad is mobilized and conservatively excised with the needle tip cautery.
Dissection is then carried out superiorly between the orbicularis muscle and the orbital septum to the superior orbital rim. The periosteum of the superior orbital rim is identified and incised with the needle tip cautery. A Freer periosteal elevator is then used to elevate periosteum from the underlying bone. What you notice in males is the periosteum seems to be much more adherent to the bone. The same procedure is performed on the opposite side. Again, note the more adherent periosteum in this male.
Attention is then directed to the scalp incisions were a 15 blade is used to make an incision to the periosteum. The periosteum is incised and then a subperiosteal dissection is performed with the Freer periosteal elevator. Again, be prepared for the periosteum to be more adherent than what you would be used to in females. A gold handle elevator is then introduced into the incision and the subperiosteal dissection is carried out medial to the superior orbital neurovascular bundles. Again note how adherent the periosteum is to the underlying bone. Dissection is carried out to the root of the nose. This is safely away from the supraorbital neurovascular bundle. The periosteal elevator is then used to perform additional dissection superior to the supraorbital neurovascular bundle. Attention is then directed to the scalp incision on the opposite side where the same dissection is performed.
A temporal incision is then made to straddle the conjoint tendon. This incision is made down to the deep temporalis fascia and dissection is carried out along the surface of the deep temporalis fascia lateral to the conjoined tendon. Medial to the conjoint tendon, a subperiosteal dissection plane is identified and then the conjoint tendon can be lysed between these 2 dissection planes. This is demonstrated on the opposite side as well. In general, endoscopic browplasties are performed less frequently in males for number of reasons. One is due to the fact that you need to ensure that the male has a relatively low hairline otherwise raising the hairline maybe disadvantageous. In this procedure, Endotine forehead devices are used for fixation. The Endotine drill is used to drill into the bone followed by introduction of the device and engagement of the scalp with the device. This is performed in the exact same manner on each side to get adequate brow elevation. Brow elevation in males I think in general is pretty conservative due to the weight of the scalp. Along the lateral incisions, the superficial temporalis fascia is plicated. This is performed with a 3–0 Vicryl suture. The scalp incisions are then closed with staples. The eyelid incisions will be closed with interrupted and running 6–0 Prolene sutures. At the conclusion of the case, erythromycin ointment is placed over the incisions and a headband is placed. The patient will return approximately one week for suture and staple removal.
