Web Log – March 2012 – NWSPS Meeting and HealthSmart Segments

Diamond Head Crater Summit View
Diamond Head Crater Summit View

I recently attended the Northwest Society of Plastic Surgeons meeting and picked up lots of good ideas.  Some were small points such as drain placement position and local anesthetic injection technique while others were larger concepts such as breast reduction and reconstruction approaches.  These all come under the setting of building a better mousetrap and are very satisfying to most plastic surgeons in our attempt to perform the perfect operation.  Really big ideas are usually seen at the major meetings like the American Society of Aesthetic of Plastic Surgeons in May.  I will tell you what I find out in the June blog.

Below are the questions and answers for the last few HealthSmart segments.  See the segments live every Tuesday Morning at 0735 on KTVB ch 28 or later on our Video and Media Web Page.


Brow Lifts

“What types of fixation are available for endoscopic brow lifts and what are the advantages and disadvantages of those fixation methods?”

This is a pretty advanced question.  First, we should discuss a few basics first.  When we age, the brow droops and makes us look tired and angry.  Our forehead muscle, or frontalis, elevates our brow to help keep our eyelids out of our eyes and caused forehead wrinkles.  People see aging in the upper third of their face and think eyelids are the problem, but often, a droopy brow makes up 50% or more of the  cause.
The question suggests that there is more than one way to lift a brow.
Yes, there are three main ways.  Common to all of them is cutting the corrugator muscles, the ones we paralyze with Botox.  Next, the brow is detatched from the superior orbital rim so that it is mobile and can be repositioned.  There are 3 incisions: coronal, anterior hairline, and endoscopic. The coronal incision is the long one across the top and is used when there is significant brow droop, when the brow is asymmetric, and when there is a low hairline.  It can cause numbness behind the incision line.  The anterior hairline incision is used for the same reasons, except when the hairline is higher.  I find in Boise, Idaho that this is the most common incision that I use.  It is reliable, shortens the senile forehead, and the incision hides really very well.
And that brings us to the  endoscopic lift and our question.
In an endoscopic lift, small incisions are and the operation is done via a video scope.  It’s nice that there is less scar and numbness, but it is not as powerful of a lift.  It is best used in younger or minimal lift patients, but is very popular in some markets.  In the open lifts, a strip of scalp is removed and the lift is maintained by the tension of the closure.  In the endoscopic, no skin it removed, so the lift is maintained by fixation.  Fixation may be with a suture tied to a bone tunnel, a suture tied to a temporarily placed titanium screw that sticks out of your head for a few weeks, or with an endotine device.  This is an absorbable plastic like device with is popped into a shallow hole drilled into the skull and holds the scalp up with multiple tines.  I like it because it is relatively quick and easy, but it is expensive.
Upper Lid Blephaproplasty

We previously discussed that a portion of upper face aging is due to brow droop.  Let’s talk about how the other part, drooping upper lids.

Depending on the patient, upper lids may make up a large or small part of looking old.  In most faces, upper lids are the feature which would benefit from surgery – or blepharoplasty – first.  Extra skin that you can pinch is removed, as well as extra fat and muscle. In some patients, the operation can even be done under local anesthetic only and recovery is usually minimal.  The scar hides nicely in the sulcus and usually is very hard to see.
It sounds simple, but we know by now, no operation ever is.  What sorts of things are there to worry about.
Upper lid blepharoplasty is one of the most straight forward operation on the face, but there is a lot to be careful about.  The upper lid is functional – it acts like a roll top desk to protect the eye.  If you remove too much skin, the eye can become uncomfortably dry and even threaten vision.  The levator muscle which acts like a window shade pulling up the lid can be damaged and potentially cause lid droop.  Over resection of extra fat around the eye can make the orbit look hollow.  Finally, bleeding caused behind the eye, while extremely rare, can cause vision loss.
So blepharoplasty while it seems simple, can be dangerous.  What specialties have formal training for this procedure?
Plastic surgeons, ENT’s who have had facial plastic surgery training, and ophthalmologists – in particular those with ophthalmic plastic surgery training most frequently perform blepharoplasty. Even the most straight forward seeming operation can have problems.  Some populations, such as asians and the elderly, can be especially challenging.
Does insurance ever cover upper lid blepharoplasty?

Overwhelmingly, most patient have aesthetic problems only, so it is a self pay procedure.  In a small number, however, there is so much extra lid skin that patients actually cannot see well and have what we call a visual field deficit.  If after exam by a surgeon, this is felt to be a possibility, the patient should be seen by an optometrist for visual field deficit testing.  If it is indeed positive, the case can be submitted for insurance review.

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