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The ABC's of plastic surgery: Endoscopic surgery: a transformation of surgical care
By Dr. Mathew C. Mosher
In this column I'll discuss endoscopic surgery and how this technique helps me tailor cosmetic surgery to individual patient needs.
The original uses for endoscopic surgery were for procedures such as gall bladder removal, knee surgery and tubal ligation. Endoscopy in plastic surgery is more recent. As for most new technologies and techniques, ongoing evaluation and study is needed to determine the best applications and long-term effectiveness of these advances.
An endoscope is essentially two components: a hollow tube attached to an external camera and light source as well as a viewing screen to project images from the end of the tube. During the surgery, the surgeon watches the viewing screen while moving the endoscope and instruments in the surgical area. Advances in fiber optic light and precision instrument manufacturing have made all this possible.
Some of the advantages of endoscopic surgery include a decreased risk of incision pain and external scarring. Smaller surgical incisions are needed for access, while the camera and lighting create magnified images of the anatomy and facilitate the precise handling of tissues.
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.
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For more information about your cosmetic surgery options, click here to request a consultation with Dr. Mosher at YES Medspa and Cosmetic Surgery Centre. Or you can call our office at 604-888-9378 (Surgical Office) or 604-888-9397 (Medspa) and one of our helpful staff will assist you with scheduling an appointment.
