Endoscopy Assisted Plastic Surgery of the Face

by Dr. Dennis Nigro MD, FACS, FICS

Sir Harold Gillies, an English knight, who endeared himself to crown with a scalpel rather than a lance and shield observed, "Plastic surgery is the constant battle between beauty and blood supply." Profound? Almost Shakespearian. Not complete though. Maybe he should have added "... cursed by the tracks of our journey - the scar." The scar, the beast, is a necessary but distasteful evil.

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

The last two decades in particular, have seen remarkable and steady success. In facial surgery, the focus of this writing, the myopic simplistic notion of just pulling the skin tight, while marginally effective in some cases, left many patients with that "operated look" similar to a greyhound running through a plastic garbage bag. With much advancement, the interchange between reconstructive and aesthetic surgery brought the SMAS procedure (an acronym for Superficial Musculoaponeurotic System - meaning facial muscles), facial skeletal alterations and topical treatments of skin. A permutation of one of these notions was the lifting of the sagging muscles off the bones of the face and replacing them in a more youthful or appropriate position on those bones, called subperiosteal face lifts. While not ubiquitous in its application, this approach has added a new avenue that has been quite effective, albeit more invasive and requiring more skill and a greater understanding of the anatomy.

But the taxes, the scar, have not changed all that much and are still a significant factor, sometimes too significant. Even in the most capable and caring hands, the best laid plans of patient and surgeon have gone awry 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 cleverly conceived, dutifully performed surgical exercise. Expectations thus dashed, brows have furrowed, tears shed and hands wrung while dealing with this beast of the beauty. Dexterous sub-skin maneuvers have been diminished and denigrated by the presence of this antagonist. Patients, similarly, have elevated inadequate procedures to Olympian efforts because the scar was negligible.

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

The Endoscope is a tiny (4-10 millimeters in diameter) lighted camera that can be slipped into small incisions, allowing the operative field to be put on a television screen. The surgical procedure can thus be performed with special instruments through these small incisions while having 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 player from the roster.)

For example, the brow lift, an extraordinarily effective procedure in dealing with hooding of the eyes, and those nasty vertical lines between the eyes which produce the angry, tired or forlorn countenance utilizes a curvilinear incision which traditionally goes from ear-to-ear across the top of the head. Patients with high foreheads, thin or balding hair patterns have to think long and hard about the tradeoff.

The endoscope now allows this procedure to be done through several small "stab" incisions and offers this option to patients who otherwise might have declined because of a significant and noticeable scar. The instrument seems to be applicable to "the facelift," breast, and abdominal surgery as well.

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

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

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

Endoscopic surgery will not obviate all traditional surgery and its incisions either. It may he used in conjunction, it may only give a percentage of the result obtained with the open technique, or it may not be indicated at all. It should however, be an option. Ask your surgeon if the decision for your surgical plan has brought into consideration all of these options, and if your surgeon performs those procedures regularly and has been duly trained! A good credibility check will be verified if your surgeon has passed credentialing to perform those procedures at a local hospital. If not, beware! If so, this Endoscopically-assisted surgery might be just what the doctor ordered.