Scalp incision details for a small incision browplasty
This is Richard Allen at the University of Iowa. This video demonstrates the details of the scalp incisions in a patient undergoing a small incision or endoscopic browplasty. A 15 blade is used to make an incision through the skin and subcutaneous fat down to the periosteum and bone. This is performed on the vertical incision. A Freer periosteal elevator is then used to elevate the periosteum from the underlying bone. A gold handled long periosteal elevator is then use to widen the subperiosteal dissection. This is performed laterally to the area of the conjoint tendon. Inferiorly, this is performed down to the superior orbital rim as well as the root of the nose.
Attention is then directed to the temporal horizontal incision that straddles the conjoint tendon. A 15 blade is used to make an incision through the skin and subcutaneous fat. Lateral to the conjoined tendon, Metzenbaum scissors are used to sharply and bluntly dissect through the superficial temporalis fascia to the deep temporalis fascia. Dissection is then carried out along the surface of the deep temporalis fascia. This can be performed bluntly lateral to the conjoint tendon. This can be performed down to the eyelid incision. Medial to the conjoint tendon, a Freer periosteal elevator is then used to expose the subperiosteal pocket. The conjoint tendon can then be lysed between these 2 dissection planes with the Metzenbaum scissors. As is shown here, each pocket is demonstrated with the scissor tips and then the blades are opened to lyse the tendon between the two.
In this patient, an Endotine forehead device will be used for the fixation. The Endotine manual drill is used to drill a hole into the bone. The fixation device is then introduced into the incision and popped into the hole. A Freer periosteal elevator is then used to make sure that the scalp is not yet engaged with the device. A skin hook is then used to raise the scalp as much as possible and then the surgeon's thumb is used to engage the scalp with the device.
Along the temporal incision, a 3–0 Vicryl suture is used to engage the superficial temporalis fascia inferiorly. This results in a SMAS lift. The same tissue plane is then engaged superiorly. Some surgeons will engaged deep temporalis fascia; however, I just engage the superficial temporalis fascia on either side of the incision. Tying this suture results in elevation of the skin at the incision which is desired. This is demonstrated here. The scalp incisions can then be closed with staples. I think that staples give very good closure. No deep sutures are needed. The patient will return in approximately 1 week and have the staples removed.
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