Endoscopy Assisted Plastic Surgery of the Face

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Endoscopy Assisted Plastic Surgery of the Faceby Dr. Dennis Nigro MD, FACS, FICS
Sir Harold Gillies, an English knight, who endeared himself to crownwith a scalpel rather than a lance and shield observed, "Plasticsurgery is the constant battle between beauty and blood supply."Profound? Almost Shakespearian. Not complete though. Maybe he shouldhave added "... cursed by the tracks of our journey - the scar." Thescar, the beast, is a necessary but distasteful evil.

Over the decades the discipline and disciples of plastic surgery havelabored long and increasingly effectively to hide, improve, minimizeand camouflage this unwanted companion. Plastic surgeons haveresearched wound healing, studied scar formation and exchanged ideas ofhow to best diminish their calling card on their patients.

The last two decades in particular, have seen remarkable and steadysuccess. In facial surgery, the focus of this writing, the myopicsimplistic notion of just pulling the skin tight, while marginallyeffective in some cases, left many patients with that "operated look"similar to a greyhound running through a plastic garbage bag. With muchadvancement, the interchange between reconstructive and aestheticsurgery brought the SMAS procedure (an acronym for SuperficialMusculoaponeurotic System - meaning facial muscles), facial skeletalalterations and topical treatments of skin. A permutation of one ofthese notions was the lifting of the sagging muscles off the bones ofthe face and replacing them in a more youthful or appropriate positionon those bones, called subperiosteal face lifts. While not ubiquitousin its application, this approach has added a new avenue that has beenquite effective, albeit more invasive and requiring more skill and agreater understanding of the anatomy.

But the taxes, the scar, have not changed all that much and are still asignificant factor, sometimes too significant. Even in the most capableand caring hands, the best laid plans of patient and surgeon have goneawry without premonition ("... slings and arrows of outrageous fortune..."). The scar has thickened, discolored, produced hair loss, dimpled,tethered and generally put a flashing red light on a cleverlyconceived, dutifully performed surgical exercise. Expectations thusdashed, brows have furrowed, tears shed and hands wrung while dealingwith this beast of the beauty. Dexterous sub-skin maneuvers have beendiminished and denigrated by the presence of this antagonist. Patients,similarly, have elevated inadequate procedures to Olympian effortsbecause the scar was negligible.

Technology has recently provided a potential remedy for thisschizophrenic villain. Not a panacea, but potentially significant help.Its name - the Endoscope.

The Endoscope is a tiny (4-10 millimeters in diameter) lighted camerathat can be slipped into small incisions, allowing the operative fieldto be put on a television screen. The surgical procedure can thus beperformed with special instruments through these small incisions whilehaving the benefit of substantial magnification of the operative field.Thus, it allows great precision without the burden of a large incision.(I need not rant on about how wonderful it would be to drop that playerfrom the roster.)

For example, the brow lift, an extraordinarily effective procedure indealing with hooding of the eyes, and those nasty vertical linesbetween the eyes which produce the angry, tired or forlorn countenanceutilizes a curvilinear incision which traditionally goes fromear-to-ear across the top of the head. Patients with high foreheads,thin or balding hair patterns have to think long and hard about thetradeoff.

The endoscope now allows this procedure to be done through severalsmall "stab" incisions and offers this option to patients who otherwisemight have declined because of a significant and noticeable scar. Theinstrument seems to be applicable to "the facelift," breast, andabdominal surgery as well.

It is not very new. Orthopedic and general surgeons have long utilizedEndoscopic approaches effectively reducing "recovery time," i.e., scarformation, swelling, discomfort and pain.

Now, a word of caution. Do not embrace the technology per se. We allhave this annoying and potentially troubling habit of expecting themachine to be the "franchise player." Liposuction, electrocautery,synthetic bone, titanium screws, microsurgery and lasers have beenparaded by many in this fashion. This, of course, is heresy.

Although technology has helped the accomplished, trained flyer ordriver to go higher, turn better, see better and have greater control,it cannot make a prince from a toad. It cannot train, give experienceto, or confer the muse of judgment on a charlatan. In fact, it mightmake the fake more dangerous. You wouldn't want someone who can't fly akite flying that jet.

Endoscopic surgery will not obviate all traditional surgery and itsincisions either. It may he used in conjunction, it may only give apercentage of the result obtained with the open technique, or it maynot be indicated at all. It should however, be an option. Ask yoursurgeon if the decision for your surgical plan has brought intoconsideration all of these options, and if your surgeon performs thoseprocedures regularly and has been duly trained! A good credibilitycheck will be verified if your surgeon has passed credentialing toperform those procedures at a local hospital. If not, beware! If so,this Endoscopically-assisted surgery might be just what the doctorordered.

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