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Wednesday, January 04, 2006

The browlift procedure can be a tough sell. Patients might shy away om having the necessary hardware implanted and the hardware fixation devices that are available can add hundreds of dollars to the final tab.

Gregory Chernoff, M.D., a facial plastic surgeon in practice in Indianapolis, Ind. and Santa Rosa, Calif., has found a way to get around having to use hardware fixation in the browlift, without sacrificing outcome quality or longevity.

Dr. Chernoff, an assistant clinical professor at Indiana University, Indianapolis, has been performing browlift procedures without hardware fixation devices for seven years.

"You can substitute hardware with permanent stitches on anyone wanting the results of a browlift," says Dr. Chernoff. "It is quicker, there is no hardware required and, for the patient's benefit, there is an average $500 savings."

Patients not comfortable

Dr. Chernoff consulted for many endoscopic and hardware companies when the endoscopic browlift first became mainstream. He says despite the many hardware choices, including absorbable options, patients would hesitate when it got to the hardware part of the surgery, and the extra hardware expense would add salt to the wound.

But in developing a browlift procedure using sutures rather than hardware, Dr. Chernoff was concerned with the longevity of results.

For the sake of research, 20 patients allowed Dr. Chernoff to use conventional hardware fixation techniques on one side of their faces and the suture technique he describes on the other. He did not tell the patients which side was which, to avoid bias.

Dr. Chernoff has found, after nearly six years of follow-up, that uniformly--within a millimeter--there was no differences in procedure outcomes or longevity.

"The suture alternative is a much easier procedure to teach because the hardware, placed endoscopically, requires hand-eye coordination. This aspect of the surgery can be hard for doctors who are not comfortable using the endoscope to grasp," he says.

Suture browlift: step by step

Dr. Chernoff does a subperiosteal elevation through either a combination of a 2.5 cm or an inch-long single horizontal central incision.

"When you evaluate a patient, the patient either has ptosis at the head of the eyebrows, which gives the person an angry look, or ptosis of the lateral brow, which gives the patient a sad or tired look," Dr. Chernoff explains. "If the arch of the patient's brow is fine and the patient just needs elevation of the head of the brow, then I just make a single, central incision horizontally, a few millimeters into the hairline."

The facial plastic surgeon enters subperiosteally, as he or she would in the traditional endoscopic browlift, and identifies the supraorbital bundle to preserve it. He or she then uses a suction cautery or laser to divide the corrugator and procerus muscles.

The connection around the tail of the brow is divided, between the frontalis muscle and periorbititis muscle. This loosens up the entire brow complex, as it does in the traditional procedure.

"This is the point then that you would typically put in whatever hardware you were going to use to fixate," he says. "What we do instead, is we have elevated the periosteum anteriorly and now can take advantage of the fact that the rest of the patient's periosteum is still attached. We can now sew the area of elevation."

If elevating 1 cm of the head of the brow, he does a posterior cutout of some of the posterior scalp, as the back part of the incision, and cuts out whatever portion he needs.

"This gives you the amount of elevation that you will get" he says.

Dr. Chernoff then sews the periosteum together with a permanent stitch, using a 3-0 Proline. If he is using one horizontal incision in the central region, he usually would put in four to five permanent stitches.

"That is what gives you the elevation and permanent fixation" Dr. Chernoff says."Those stitches are nonabsorbable and buried, so they do not go anywhere."

Lateral brows

For patients who have ptosis of their lateral brows, Dr. Chernoff would make three incisions horizontally--one in the midline and one on either side--probably along the vector of the lateral corner of the eye.

The technique is the same, according to Dr. Chernoff, except that he would do three cutouts of scalp as opposed to the one.

Different take on old procedure

Cosmetic surgeons can use the suture alternative on any patient who wants a browlift, according to Dr. Chernoff.

Doctors have written previously in the literature about browlift procedures that have involved sewing periosteum to periosteum, and most procedures now are using some form of hardware, according to Dr. Chernoff.

"Other doctors who have sewn tissue, have drilled little holes into the bone and sewn those stitches into the bone," he says. "This procedure allows you to do the browlift without entering the bone at all."

Words of advice

Surgeons should remember not to make their bites too close to the actual epidermis when putting in the permanent stitches.

"The bites of the needle must be in the dermis and not make contact with the epidermis; otherwise, the Proline stitch could extrude," Dr. Chernoff says. "I have seen a 1 percent to 2 percent incidence of that, where at two to three months, a patient will come in with a visible stitch. I inject it with a local anesthetic in the office and cut out the one stitch. There are still four or so others holding things in place."

Added benefit

An added benefit of using the suture versus the traditional hardware browlift approach is that surgeons can simultaneously lower receding hairlines.

"We make the incision along the existing hairline, elevate the tissue and instead of excising the hair-bearing tissue posteriorly, I cut out the balding scalp," Dr. Chernoff says. "I just took the bandage off this morning of a gentleman on which I did this procedure yesterday, and when he looked in the mirror he said the nicest thing I did for him was to lower his hairline."

Disclosure: Dr. Chernoff reports no conflicts of interest related to products/companies named this article.

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