With this technique, less cutting of the skin and
underlying muscles is needed to see below these layers.
Less cutting usually means less pain, shorter hospital
stays and a faster return to our busy lifestyles.
For many procedures, endoscopic surgery has literally
transformed surgical care.
In plastic surgery, the many uses of endoscopy continue
to evolve. Some cosmetic surgical procedures assisted by
this technique include browlift, breast augmentation,
abdominoplasty and facelift. I will briefly discuss
these procedures and my own experience with them.
“Less cutting
usually means less pain, shorter hospital
stays and a faster return to our busy lifestyles.”
Browlift/forehead lift
This is likely the most common application for
endoscopy in plastic surgery. A browlift rejuvenates the
upper one-third of the face by improving the shape and
position of the brow as well as reducing the appearance
of forehead creases and frown lines. Traditionally, this
was done with an incision extending over the top of the
head, roughly from ear to ear.
When performed correctly, a so-called “open” browlift
achieves the above goals in a predictable fashion. With
an open browlift, the forehead is lifted and the excess
skin and scalp is removed. When the anterior hairline is
receding, the incision can be placed along the front of
the hairline. This prevents the hairline from moving
higher when the excess is removed. The main concern with
this “open” approach is the long surgical incision. The
incision may leave a visible scar, altered sensation
above the scar and thinning or loss of hair in front of
the scar. Significant and lasting problems such as these
are rare.
An endoscopic browlift or “endobrow” is performed with
four or five incisions, each about two to three
centimeters long. This reduces the total length of the
surgical scar by as much as 75 per cent. More
importantly, incision placements can be customized to
patients’ hair patterns to further minimize the risk of
visible scarring, loss of hair and permanent sensory
loss.
The unique disadvantages of an endobrow include the
unavoidable elevation of the anterior hairline, less
ability to modify some brow muscles and a higher relapse
rate of the brow position. Most plastic surgeons feel it
is essential during an endobrow to anchor the brow to
the skull using a permanent or disposable device drilled
into the bone. Without this, the brow can fall down at
an unacceptable rate. These differences and limitations
of an endobrow have caused some surgeons to revert back
to the traditional open approach. I feel that endoscopic
browlift is the preferred approach for most patients,
but the technique used must be decided upon only after a
thorough discussion of the risks and benefits.
Breast augmentation
An endoscope can assist surgeons to position and
place breast implants. The advantage is perceived to be
the freedom to place the incision in a more discreet
location rather than near the nipple or under the
breast. The most common application is with an incision
in the axilla or armpit. This is known as trans-axillary
breast augmentation and is very popular with some
surgeons. Less widely utilized is the trans-umbilical
breast augmentation (TUBA). Endoscopy was seen as a real
advance for some surgeons who were dissatisfied with the
visibility of scars on or under the breast.
However, despite our initial enthusiasm for this new
technique, most plastic surgeons now feel the potential
benefits of endoscopic breast surgery are unjustified
for the majority of patients. There are a few unique
situations where this approach may be favored. You must
have a consultation to discuss all of your options and
what will work best for you. I personally prefer an
incision within the more pigmented areolar skin or
within the breast crease. These scars are discreet and
allow for more options when using the newer pre-filled
silicone gel implants. Scars within a bathing suit line
also are the most versatile for revisional breast
augmentation surgery which must be considered in all
patients considering breast augmentation.
Abdominoplasty (tummy tuck)
Endoscopy is used in some patients to assist
tightening the loose fascia (connective tissue) around
the abdominal muscles. Most patients requesting tummy
tuck surgery also have some looseness of the abdominal
skin and fat. These problems are only corrected with
removal of the excess achieved with an incision of
variable length across the lower abdomen. When this
longer incision is needed, there is no advantage to
using an endoscope. Consequently, the endoscope is used
rarely for this area of the body.
Facelift
Just like in browlift surgery, endoscopy can be
useful in selected facelift patients. In the rare
situation when sagging occurs in the absence of loose
skin, an endoscopic approach may be helpful. This is the
most recent application of this technology in cosmetic
surgery.
A traditional facelift remains the best choice for most
patients, especially if there is loose skin. The
customary incision placed in front and behind the ear
can be shortened or eliminated when the tissues are
approached with an endoscope. One of the best
applications appears to be in the younger patient with
good skin tone but sagging cheek tissues. In this
situation I prefer an endoscopic mid-facelift. This is
often done in conjunction with an endobrow.
This is just a short list of cosmetic surgical
procedures in which your plastic surgeon may consider
using an endoscope. While not all surgeons have been
trained in these new techniques and therefore may not
offer them, endoscopy has become very useful in surgery
and is here to stay. I recommend you have a thorough
discussion on all of your options before you determine
the best plastic surgeon and approach for you.
