Plastics

FFS

The patient was brought to the operating room after her surgical site was marked in the preoperative holding area, including trichial incision extending post-trichial in the temporal region, frontal bony prominences including the frontal and glabella bossings including the supralateral orbital ridges. We also marked the trajectory of her brow lift, particularly the lateral brow potion including peak of her eyebrow, including both her malar regions. She was transferred to the surgical table in a supine position. Sequential compression devices were placed on both lower extremities for mechanical DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis, and redosed appropriately during the case. A tranexamic acid infusion was given under the care of anesthesia under my supervision in order to minimize bleeding. In addition, she received 10 mg of IV decadron.

A formal anesthesia timeout was performed to identify and confirm correctly the patient, the procedure, and the surgical site. The patient was orally intubated by the anesthesia team and general anesthesia was induced. The endotracheal tube was secured by anesthesia with tape to the mandible. Appropriate padding was applied to all areas at risk of pressure point neuropathy and/or ulcers including bony prominences. A foley catheter was placed.

The pre-trichial incision mark was injected with a total of 20 cc of 2% lidocaine with 1:100,000 epinephrine.

The face including hair as well as the neck extending to the clavicle were prepped and draped in the normal sterile fashion. Ophthalmic laden plastic corneal protectors were applied to both eyes. I was present for the surgical timeout in which all necessary personnel including the anesthesia, surgical and nursing staff as well as the correct patient, the correct surgical site and procedure were identified. Tegaderm was then placed over the mouth.

We then first paid our attention to the hairline, particularly where we had previously marked our incision. A tricophytic trichial incision was made at the junction between the hair-bearing and non-hair bearing skin. This was transitioned bilaterally to a post-trichial incision at bilateral temporal regions to a more traditional coronal incision pattern ending posterior and cephalad to the helical root of either ear. We then raised our forehead flap in a subperiosteal plan dissecting medial to both temporal lines of fusion. Laterally to the temporal fusion line, we elevated all soft tissue superficial to the superficial layer of the deep temporal fascia preserving the frontal branch of the frontal branch of the facial nerve. We were able to observe the frontal branch underlying the fascia. We were able to encounter the intermediate temporal fat pad, leaving the fat pad down, intact and encased by superficial layer of the deep temporal fascia. We continued our dissection caudally. Both superior orbital rims were exposed completely including lateral orbital rim as inferiorly beyond the zygomaticofrontal (ZF) suture. The arcus marginalis as well as temporal fusion line were divided and spread aggressively to allow for effective elevation of the brow in the latter portion of the procedure. Medially, the dissection was completed inferior to the nasofrontal suture.

Care was taken to free the supraorbital neurovascular bundle as well as the medial supratrochlear neurovascular bundles with minimal damage. The right supraorbital neurovascular bundle was freed quite easily from its bony notch. A 2 mm osteotome was used to osteotomized and free the left supraorbital neurovascular bundle from its bony foramen.

We then examined the contour of the foreheads. There was a large horizontal frontal prominence approximately middle of the forehead. In addition, there was a very prominent glabellar prominence with moderate superolateral orbital ridges noted bilaterally.

We then proceeded with osteoplasty of the forehead in the following fashion. Transillumination was used to confirm the boundaries the frontal sinus. We then applied the custom KLS forehead cutting guide as planned preoperatively. We confirmed proper placement and seating prior to temporarily fixating it to the frontal bone with a total of four 5-mm screws. A reciprocating saw as well as sonopet were used to remove the anterior table of the frontal sinus in a full thickness fashion as outlined by the guide. This was delivered without any injury to the posterior table or nasal frontal outflow tracts. The bone was then contoured in the back table with a pineapple bur until the flattened appearance had been achieved. We also removed inner table septate with a rongeur. This bone was then preserved by placing in saline to be used for bone grafting. We also obtained additional bone grafting from the septate bone in the frontal sinus. Additional contouring of the frontal bandeau was performed with a pineapple bur under saline irrigation with particular attention to the right side given the asymmetric frontal sinus. Once appropriate contour had been adequately achieved, the frontal bone was copiously irrigated with normal saline.

We then proceeded with orbital rim osteoplasty. With a pineapple bur under saline irrigation, we contoured the lateral orbital rims to allow for a wider orbital aperture, increasing the superior orbital rim position by another 6 mm and laterally by and additional 3 mm. This was done with the assistance of the KLS patient specific implant guide to allow for precise osteoplasty.

We then removed the KLS cutting guides as well as its fixation screws. We then performed additional contouring of the forehead to smooth any minor osseous contour deformity.

Once the central portion of the frontal bone osteotomy had been contoured appropriately, we then placed the osteotomized anterior frontal sinus table to its new setback position using KLS specific positioning template, temporarily securing the template to the bone with two 5-0 mm screws. This setback was measured to be approximately 2.5 mm. Once the frontal bone setback along with the template was positioned appropriately within the frontal sinus cavity, the frontal bone graft was stabilized to the surrounding frontal bone with a total of eight 3.5 mm screws and two 0.4 mm four-hole linear plates. They were placed along the superolateral portion of the anterior frontal sinus table. We confirmed its stability and it did not require additional fixation.

There were some notable gaps between the intact frontal bone and the newly repositioned frontal bone. As such, decision was made to proceed with bone grafting the defect. We then prepared the bone graft previously harvested by dicing them using a small rongeur into as small pieces as possible. We then used this diced bone graft by packed the defects around the bone flap, filling the gaps between intact frontal bone and the newly repositioned anterior frontal sinus bone.

At that point we proceeded with the brow lift . The coronal flap was advanced superiorly at the lateral most extent of the lateral brow on the right. We confirmed an ideael adequate brow position which measured approximately 1.0 cm above the caudal edge of the supraorbital rims. We then confirmed adequate position and symmetry of both lateral brows, measuring approximately 1.0 cm above the caudal edge of the supraorbital rims.

We then proceeded with the forehead rhytidectomy, the coronal flap was advanced superiorly at the lateral most extent of the lateral brow and excess skin of approximately 1.5 cm was excised, at the temporal region as well as approximately 1.0 cm in the midline. This provided smooth contouring of the forehead without any noticeable rhytids. In addition, by excising this skin, we were able to achieved an additional 5 mm of adequate brow position which measured to be approximately 1.5 cm above the lateral orbital rim bilaterally with the anticipation of relapse from brow positioning.

We then re-approximated the scalp flap to the forehead flap in a tension-free manner, temporarily secured with staples. In order to achieve this, this required the the posterior scalp flap, and hence the hairline to be advanced anteriorly by approximately 1.0 cm. This was achieved by performing galeal scoring the posterior scalp.This was done in a meticulous fashion ensuring the subdermal plexus was not damaged. We confirmed adequate positioning the lateral brow. This local adjacent tissue transfer from the posterior scalp measured 1.5 cm x 20 cm, totaling 30 cm2.

We then directed our attention back to the forehead. We then elevated the posterior scalp flap in a subgaleal plane in order to allow the posterior scalp to be advanced anteriorly. This required galeal scoring of the posterior scalp. Once we were satisfied with both brow and hairline incisions, we then removed the staples. We irrigated both flaps as well as frontal bone with copious amount of irrigation. a #15 French Blake drain was placed in the subgaleal fashion in the posterior occipital region exiting the temporoparietal region posterior to the left ear. This was secured with 3-0 Nylon sutures. Bleeders were appropriately electro cauterized. The tissues were closed in a layered fashion with 3-0 Vicryl at the galeal layer, 4-0 Monocryl in the deep dermal layer. This was reinforced by running 4-0 chromic sutures in the temporal hair-bearing regions. In the hairline regions, we used 5-0 Prolene in a running fashion.

We then cleansed and dried the wound. Her hair was then shampooed and straightened as much as possible with a comb, removing as much of the blood clots and bone debris as reasonably possible. Bacitracin and xeroform gauze strips were then applied to the wound. A Kirlex head wrap was then applied after reinforcing the wound with gauze and abdominal absorbent pads.

Drain: Yes
Sutures:
Dressing:
Resident Notes:

Place foley, turn bead 180, and Oral Rae tube for intubation

FFS Augmentin x 7 days

Galea closed with 3-0 vicryl SH

Deep dermals with 3-0 monocryl

Skin is closed with 5-0 prolene along the center of incision, and 5-0 chromic in the hair bearing portion of incision

Bacitracin over incision, then wrap head with Kerlix like a mummy