Temporal scalp incision browplasty
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This is Richard Allen at the University of Iowa.
This video demonstrates a small temporal scalp incision browplasty with upper blepharoplasty.
The patient has bilateral upper dermatochalasis as well as mild to moderate temporal brow ptosis. The purpose of this browplasty is really to release the temporal fusion line or conjoint tendon. An incision is made along the blepharoplasty markings and the monopolar cautery is used to excise a flap of skin and orbicularis. The temporal orbicularis is excised as this has a tendency to pull down the temporal brow. In patients that have any brow ptosis procedure, attention should be directed to the lateral orbicularis muscle to weaken it. The same is performed on the opposite side. The medial fat pad is then mobilized and conservatively excised with the monopolar cautery. This is performed bilaterally. Dissection will then be carried out between the orbicularis muscle and the orbital septum to the superior orbital rim, temporally. Dissection should be carried out along the surface of the orbital septum superiorly, beneath the brow fat. The periosteum is then incised. The freer periosteal elevator is then used to elevate the periosteum superior to the superior orbital rim to provide release in this area. This is performed medial to the conjoint tendon with the periosteal elevator. The same dissection is then carried out on the opposite side between the orbicularis muscle and the orbital septum to the superior orbital rim, staying beneath the brow fat. The superior orbital rim is then identified and the needle tip cautery is used to make an incision through the periosteum. The freer periosteal elevator is then used to elevate the periosteum superior to the superior orbital rim, medial to the conjoint tendon. This dissection can be taken medially if preferred.
An incision will now be made posterior to the hairline in the area that straddles the conjoint tendon. Dissection is carried out with Metzenbaum scissors to the deep temporalis fascia. Dissection is carried out medial to the conjoint tendon to enter the subperiosteal space. The Metzenbaum scissors are then use to dissect along the surface of the deep temporalis fascia inferiorly toward the superior orbital rim. The conjoint tendon can then be lysed between these two dissection planes staying beneath the branches of the facial nerve. The lift from this brow procedure some believe is just due to transection of the conjoint tendon, as well as the periosteal attachments of the brow. The same dissection is then performed on the opposite side. The incision is made with the 15 blade, and then dissection is carried out with Metzenbaum scissors bluntly to the deep temporalis fascia. Dissection is then carried out medial to the conjoint tendon to reach the subperiosteal space. The Metzenbaum scissors are then used to dissect along the surface of the deep temporalis fascia. The scissors are then used to lyse the tendon using feel or direct visualization. This provides release of the conjoint tendon as well as the attachments of the brow to the superior orbital rim.
A 3-0 Vicryl suture is then used to engage the superficial temporalis fascia inferiorly. This then engages the deep temporalis fascia superiorly. Tying this suture results in elevation of the brow. The same is performed on the other side. In tying the suture, you should get a bump of scalp at the incision. The scalp incision can then be closed with staples or sutures. Staple are used here which I believe heals very well. The blepharoplasty incisions can then be closed with a combination of interrupted and running prolene sutures. At the conclusion of the case the brows appear to be in good position. Antibiotic ointment is placed over the incisions three times per day. A head band is placed for 24 to 48 hours. The patient returns in one week for suture and staple removal.