FPSAM - Roundtable 2022 - 4

EXPERT PANEL DISCUSSION
Dr. Rodman: I drill bone tunnels in the forehead for the
brow lift. Then if I'm doing a hairline advancement at
the same time, I try to drill a little bone tunnel to support
the scalp as well. Mostly I use a 1.5-mm drill bit. I do it
myself, I freehand it because at this point I am comfortable
with the drill, and then I just do a 2-0 PDS
suture. For me, it's a lot about cost because I'm cash
based, mostly. I'm out-of-network insurance and mostly
cash pay. All those plates and screws and stuff add up.
I try to do anything I can do more cost-effectively.
Dr. Spiegel: That makes good sense. How about
you, Dr. Knott, what are you doing, and Dr.
Schechter?
Dr. Knott: I tend to use Endotines, like Michael does.
The 3.0s are kind of nice. I was disappointed with how
much support I got when I would advance a scalp with
it. I don't think it helped that much. I use sutures laterally
to the arc, the highest arch of the brow. I will
suture that to the temporalis fascia laterally, and I will
use Endotines anteriorly if I think it's going to help.
Probably half the time I don't use anything. I just use
the skin excision and the sutures.
Dr. Schechter: Similar to others, and a combination of
either and/or cortical tunnels, depending on how heavy
the brow is, and I think the Endotines are great. Expensive
is, for self-pay individuals.
Dr. Spiegel: OK, good. I will say that I have tried all
these things. I use the tunnels, too. I have tried both
the little chucks to drill them with, which I find
harder to use than freehanding it. I think the chucks
leave a thin piece of bone that's not enough support.
But lately, I have been using either nothing or a
product called SonicWeld, from KLS Martin, which
is like an Endotine, except instead of a palpable hook
it has an absorbable plug that goes into the bone.
I have been using a 2-0 silk suture underneath,which
then provides a lot of long-lasting lift. I'm not sure
you get quite as much lift as you would with an
Endotine, and then again, you don't feel it.
All right, the big one: Bone modification methods.
Dr. Rodman, what are you doing for glabellar
bone? Let's talk about imaging, how you approach
the sinus, how you are fixating it if you need to,
when you do that, how you choose what procedure
and technique to use, what's your go to?
Dr. Rodman:Mygo to is whatever I'mfeeling that day.
I do get CT scans on everybody. The way that I do it is I
basically just make the osteotomyimmediately. I like the
CT scan, to make sure that they have an aerated sinus, to
map this imagery. I usually draw a fewmeasurements on
thescantoknow do Ineedtogo2cm or 4 cm, etc.
4
I do not do a whole virtual-surgical planning with
models, but I do my own little planning in the office
then, in the OR I expose everything, and then like I
said, I usually do the orbital rims, burr down first. Then
I make the sinus osteotomy, I draw out what I had
measured before, and I do it at a very beveled cut. Even
if I'm not exactly right, according to the measurements
the bevel gives me a buffer. It's almost like a splitcalvarial
bone graft. I'm doing it almost parallel to the
bone and then I take that off. Then I do a little modification
of that. The benefit of having that really beveled
angle is that I can burr that down a little bit and
that recesses.
There is still bony overlap, then I'll also do a little bit
of a hinge by just burring out the area of the glabella, so
that it caves in a little bit. So I do that, then I usually
fixate it. I go back and forth between two companies
right now. I use a four-hole tiny plate, either an eighthole
plate that I cut in halfand I usually use three screws
on each side or Zimmer Biomet now has these really,
really ultralow profile plates that are like 0.3mm. I just
use two of those. I usually try to save all that bone dust
when I'm burring stuff and I mix that with a little blood
clot, and put that around the edges as a little bone paste.
Dr. Spiegel: All right. Dr. Alperovich, what are you
doing in New Haven?
Dr. Alperovich: For me, it's similar. I generally get a
CT scan. I have tried transillumination with just the
lighted and I also like cut guides. I work at a training
program and I think sometimes it's easier for them to
have a marked-out area. I use a wire-passing drill bit
just to make sure that I'm losing resistance along my
planned osteotomies. I have switched to, for my actual
osteotomy, an ultrasonic saw. I would use the Sonopet
system, typically it's piezo. I find that it is less traumatic,
a little bit more fine control, and a smaller diameter,
of smaller width of the saw blade. And I use
that to remove the anterior.
Dr. Spiegel: Are you using that for the entire procedure?
Or do you use a cutting or diamond burr
any time as well?
Dr. Alperovich: Idouseaburraswell. I'll switch toa
burr for feathering, but I find that if they have a wide
frontal sinus, and I'm worried that it's going to potentially
interfere with the brow contouring, I'll be a little
bit more gentle. For patients who actually have a more
medialized frontal sinus, I'll use that Sonopet saw to
actually make the brow osteotomy as well, just to speed
things up. Then I'll feather and contour with the burr.
I find that speeds it up a little bit and then it also ensures
that I have symmetry bilaterally. Then, in terms of the
feathering, in addition to just focusing here, I'll really
work on also rounding out that upper third of the
ª 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.
FPSAM - Roundtable 2022

Table of Contents for the Digital Edition of FPSAM - Roundtable 2022
