forHEALTHYlife

Suborbital maxillary volume/ malar suborbital deflciences

for healthy life — Wed, 13 Jan 2010 09:35:48 +0000

A medial sulcus just lateral to the nasal pyramid, which extends distally for 2.5 cm obliquely towards the angle of the mandible, has been termed a ‘nasojugal’ sulcus or ‘tear trough.’⁷‘⁸ However, either by heredity or mainly with aging changes, this suborbital depression continues beneath the entire lower eyelid. This volume deficiency is not at the level of the inferior orbital rim as originally thought by plastic surgeons. Instead, it occurs consistently at a measured distance of 8 to 10 mm below the orbital rim. This observation was made by me early in the 1980s, when postoperative blepharoplasty patients began complaining about their more tired, ‘hollow’ look.

The etiology of why such a depression in this area appears as early as the third decade of life and certainly by the late 40s and early 50s has been unclear. Recently, however, largely through the photographic and computer studies of Lambros,⁴ it is now agreed upon that a true atrophy or involution of fat occurs in the upper two-thirds of the face and largely in the periorbital region. This disappearance of fat correlates with the increased appearance of a suborbital hollowness, which creates a tired, haggard appearance.

When indeed, as in many instances, weakening of the orbicularis oculi muscle and orbital septum occurs, permitting the intraorbital fat to protrude forward into what has been commonly called ‘fat bags,’ the suborbital hollow sulcus is accentuated even further. Ambient light creates a highlight on the top of the fat bag ‘mountains’ while a shadow is created in the suborbital ‘valley.’ The juxtaposition of the positive and negative contours enhances the tired ‘ring’ appearance at the lid-cheek junction.

This suborbital sulcus is further accentuated by relative and absolute anatomic skeletal bony deficiencies of the inferior orbital malar zygomatic complex.

The treatment of the suborbital sulcus has been evolving for at least 25 years. In 1983, prompted by complaints of patients about the increased hollowness of their orbital region from traditional blepharoplasty I began transplanting autogenous tissues such as fat, temporalis fascia, temporalis muscle, and galea into the suborbital region below the orbital rim behind the orbicularis oculi muscle and over the SOOF tissues⁹ (Fig. 20-6). This area has now become recognized as the true area of deficiency, which produces a tired appearance from the fat atrophy, which accompanies aging.

These transplanted tissues were successful because they improved most people while in others that they left something to be desired.

Overall, this experience proved to the author that there was a true need for a more permanent augmentation of this region.

Recognizing the limitations of autologous techniques (resorption and shrinkage) I felt that an implant could be designed to fit the suborbital region to improve contours from either aging or heredity, which gave an unattractive appearance.

My tissue transfer technique when a lower blepharoplasty was performed for ‘fat bags,’ the fat was excised tangentially from lateral to medial canthus, leaving a medial vascular pedicle. A small instrument such as a curved hemostat was introduced beneath the orbicularis muscle to tunnel from lateral to medial, grasping the fat pedicle and pulling it into the suborbital sulcus. When upper eyelid surgery was performed simultaneously, the strip of orbicularis muscle routinely removed, was also placed into the suborbital sulcus in a similar

fashion. When combined with rhytidectomy, the author often used segments of temporalis fascia including muscle or even large amounts of galea and on occasion ear cartilage (Fig. 20-7). These procedures were performed in 150 to 200 patients at that time.

Although these transplantation methods could be demonstrated in the long-term (see photographs at six months to one year, Figs 20-8 & 20-9) the results were elevated the orbicularis in the cheek above or below the periosteum and fat could be transposed over the orbital rim and sutured into the SOOF.’² A further refinement was the release and reset of the orbital septum.¹‘

Elimination of the ‘tired look’ is very adequately-accomplished with upper midface suspension because it provides the advantage of elevating the lower, thicker tissues of the cheek up over the thin suborbital sulcus adding additional thickness to the transposed fat thus providing a most consistent and excellent blending of the lid-cheek junction (Figs 20-10 & 20-11). A suborbital tear trough malar implant with transverse dimensions of 6 cm, a vertical dimension of 3.2 cm and a thickness of 3 or 4 mm will also blend the lid-cheek junction well without the need for an extensive midface submalar and lateral orbital temple brow dissection required for an upper and mid face ‘lifting’ procedure.

The upper eyelid crease and fold

for healthy life — Tue, 05 Jan 2010 14:17:54 +0000

What has been less understood, are the actual changes that occur to the upper eyelid crease and fold. Often the position of the eyelid crease is obscured by the appearance of redundant upper eyelid skin and fold displacement. A careful analysis of the crease in most individuals shows varied change from youth. The changes may also be asymmetric in any one individual (Fig. 8-8). This includes an elevated crease that may manifest in one or both upper eyelids. The solution has been, in most cases, to raise the eyelid crease of the affected upper eyelid with the excision of ‘excess’ soft tissue with or without brow lift. This maneuver, however, is routinely and repeatedly performed without respect for the presenescent appearance or understanding of the actual age-related changes of the upper periorbita (Figs 8-2, 8-3, 8-6).

The routine applications of traditional concepts in incision placement and soft tissue excision have also plagued some other technical aspects in upper blepharoplasty. The usual design of the upper eyelid crease commonly involves the use of 10 mm or greater (height) eyelid crease incision with excision of skin, orbicularis oculi muscle, and preaponeurotic fat.⁷‘⁸ This is customary whether or not upper blepharoplasty is performed with or without a brow lift. In part, the basis of this approach has been an attempt to elevate the upper eyelid crease, in essence, to expose a greater amount of the pretarsal surface and to ‘debulk’ the upper eyelid fullness by en-bloc or separate resection of skin and muscle.⁸ This approach, however, facilitated additional steps in upper blepharoplasty that are also aesthetically detrimental, including better access to the prcaponeurotic fat (resulting in further soft tissue reduction and volume depletion) and the levator aponeurosis for supratarsal fixation. Concerns with a lower placed incision included possible visibility of the upper eyelid incision scar, inability to achieve adequate final pretarsal exposure, and risk to the levator aponeurosis insertion to the pretarsal surface, especially when utilizing a full thickness skin muscle excision whether removed in separate ‘layers’ or ‘en-bloc’ The long-term consequences of the traditional approach, however, can be suboptimal. Deep or ‘hollow’ upper eyelid sulci are common effects, presumably from over-resection of soft tissue (Fig. 8-3), especially fat. In some, the upper eyelid crease scar becomes hypopig-mented (Fig. 8-9) and usually more visible with time, usually at a much higher level (15—20 mm). This is especially true in the patient with a prominent globe, negative upper periorbital vector, or in those who habitually elevate their eyebrows for a variety of reasons. The color transition can also at times become quite obvious, as the upper edge of the incision is placed in the darker and thicker sub-brow skin. The pretarsal skin also becomes progressively less taut (more ‘crepey’ in appearance) due to the sliding effect as most original points of fixation have been compromised by over-dissection.

Eyebrow position and volume

for healthy life — Mon, 04 Jan 2010 14:17:44 +0000

The term brow ptosis suggests a descent of the eyebrow position from its ‘normal’ state. Obviously some younger individuals with ‘low’ brows may request a ‘change’ or improvement of their brow position much as one would desire otoplasty or rhinoplasty (Fig. 8-5). Additionally, many patients will present wishing for surgical correction to accomplish more pretarsal ’show’ for reasons that include creating more area to apply cosmetics, a mistaken memory of what their upper eyelid looked like in youth, or simply their desired outcome. A review of old photographs is most often revealing, yet the ultimate determination must rest on the choice of each individual patient. Careful analysis including the use of morphing techniques as shown by Lambros¹¹ and others,^1- repeatedly and consistently has shown that the deflationary effects from facial volume loss with age can yield the apparent and illu-sionary effects of facial soft tissue ptosis. These misper-ceptions include an illusion of brow ptosis in some individuals that is due to soft tissue volume depletion, particularly in the temporal and lateral infrabrow regions, which may have prompted a brow lift when replacement of soft tissue volume has been shown to enhance aesthetics (Fig. 8-7)^u (see Chapter 23). There are also some individuals who would have compromised aesthetic results by not undergoing the necessary brow lift. Which individuals then, benefit from which procedures?

What Are the Symptoms of Kidney Moving

health — Sat, 02 Jan 2010 23:22:51 +0000

Kidney Stones in the kidneys of calcium and other small mineral fragments collected in the bladder through the ureter is created by large ones too. The main symptoms of kidney stone formation, and severe local pain and intense sweating are also related disease.

The most common symptom of kidney stone formation in the abdominal region of human sudden and debilitating pain which is sudden. Who have had kidney stones in the lower back pain on one side will result in your area. If this pain in the lower abdomen or groin ureter in advanced can. Permanent and continuous pain and the doctor is unable to move without the intervention of no longer moving means can not be resolved.

Fever and other symptoms of kidney stones among the chills, tingling sensation of the skin may also feel sticky, skin is cold or hot. Kidney stone moving fire in general, and kidney and excretory system could not adversely affect your work means. In such cases, kidney stones and antibiotic therapy should also be reduced. In addition, kidney stones, fatigue, nausea, constipation and diarrhea also may cause.Your doctor with these symptoms and blood or urine test, with the help of ultrasound or X-ray diagnosis is put. In kidney stones from taking plenty of fluids, anesthesia, surgery ranging from a minor under the various treatment methods are applied.

Upper Blepharoplasty: Volume Enhancement via Skin Approach: Lowering the Upper

for healthy life — Sat, 02 Jan 2010 14:20:58 +0000

Lid Crease
Steven Faeien
Over the years, success of a particular surgical procedure, even aesthetic, has been measured mostly by perceived outcome and to some degree by the frequency of complications. Since the overwhelming majority of aesthetic periorbital ‘complications’ have occurred with lower blepharoplasty, most of the attention on newer and improved techniques has focused on the lower periorbita’”6 (see Chapters 14-19, Lower blepharoplasty).
As functional misadventures are a much less encountered occurrence after upper blepharoplasty, complacency with existing methods and perpetuation of ill-perceived solutions to rejuvenation of the upper periorbita prevail.7,8
With rare exception, the approach to upper blepharoplasty has not been particularly physiologic or individualized and the universal application of traditional remedies for upper periorbital rejuvenation has translated to mediocrity.7″”9 The prevailing perception has been that the appearance of the aged upper eyelid is primarily due to excessive skin, muscle, and fat often in conjunction with brow descent. Additionally, there is the confounding erroneous memory in many individuals of what their upper periorbita looked like in youth. Finally, there is the influence of the ‘famous and beautiful’ people on what patients may request for their eventual appearance despite their configuration in earlier years (Fig. 8-1) that may explain some of the historical aesthetic desires as well as changes in ideas and what is currently expected after surgery.
Steven Fagien
The consultation
As with all surgical approaches to rejuvenation, we must take into account what are the actual changes that occur in the upper periorbita and whether the existing methods consider these occurrences for a wide variety of indi¬vidual presentations (Fig. 8-2). Do these techniques result in a rejuvenative appearance or simply achieve a ’cause and effect’ outcome whereby an altered appearance replaces youth? (Fig. 8-3). And, ultimately, what surgical procedures are some patients willing to undergo and what do they expect from surgery?

Postoperative care

for healthy life — Sat, 12 Dec 2009 07:33:41 +0000

No dressings are used after surgery. The patient is instructed to apply ice cold compresses on the eyelids. Pads 4 by 4 inches, soaked in a buckle of saline and ice are applied with slight general pressure to the lids. When the pads become warm, they arc dipped again into the saline and ice and reapplied. This process is repeated for 24 hours. The application should be fairly constant for the few postoperative hours. After that the compresses are applied for about 15 minutes with a 15-minute rest period in between until bedtime. The applications are resumed on awakening.

To reduce edema postoperatively the patient lies in bed with the head approximately 45° higher than the rest of the body. Nurses should check for bleeding associated with proptosis, pain, or loss of vision every 15 minutes for the first two to three hours postoperatively or until the patient leaves the surgical facility. Every hour thereafter until bedtime, the family or patient should monitor the patient’s ability to count

fingers and should check for residual proptosis and pain. If the patient cannot count fingers or has marked proptosis or pain, the family should take him or her to the emergency room. If loss of vision occurs secondary to retrobulbar hemorrhage, it could easily be detected by opening the incision involved.’ Garamycin ointment is applied to the eyes twice a day for the first two weeks.

Complications

Several patients in whom I performed the transconjunctival approach had postoperative residual derma-tochalasis, which needed to be removed through an external approach or a laser skin resurfacing. Better patient selection or combined initial procedure with skin flap excision or orbicularis muscle plication could have prevented this problem.

Although this procedure has not caused any motility problems, in several patients in whom this procedure was combined with a tarsal strip procedure, ocular

Surgical technique

for healthy life — Sat, 12 Dec 2009 07:31:45 +0000

The transconjunctival procedure is performed with the patient under local anesthesia. Two percent lidocaine (Xylocaine) with 1:100,000 epinephrine is injected subcutaneously at the center of the lower eyelid just beneath the lashes. An additional anesthetic agent is injected into each fat pad. To inject the anesthetic into the nasal, central, and temporal fat pad, the surgeon inserts a 25-gauge, 0.8-cm needle just above the inferior orbital rim and directs it downward slightly until it penetrates its entire length (0.8 cm). The barrel of the syringe is withdrawn to make sure that no blood has been entered, and approximately 0.5 ml of the agent is injected into each of the three fat pads.

A 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superficial tarsus at the center of the eyelid. The surgeon pulls the eyelid downward with a traction suture as the assistant everts the lower eyelid over a small Desmarres retractor to expose the inferior palpebral conjunctiva. Additional anesthetic is injected subconjunctival^ over the inferior palpebral conjunctiva across the eyelid. Topical tetracaine is instilled over the eye, and a scleral lens is placed over the eye to protect it. Two percent lidocaine with epinephrine is also injected subcutaneously over the center of the upper eyelid, and a 4-0 black silk traction suture is placed through skin, orbicularis muscle, and superficial tarsus to pull the upper eyelid upward.

A Colorado needle or disposable cautery (Solan Accu-Temp, Xomed Surgical Products, Jacksonville, FL) is applied to the inferior palpebral conjunctiva. The Colorado needle or cautery are used to cut conjunctiva from the medial to temporal end of the eyelid halfway between the inferior palpebral fornix and the inferior tarsal border (Fig. 14-1). The surgeon grasps the inferior edge of the severed palpebral conjunctiva while the assistant grasps the adjacent, more superior edge with forceps and the assistant pulls the Desmarres retractor downward (Fig. 14-2). The two forceps are pulled apart. Further dissection with the Colorado needle or disposable cautery is carried out through Miiller’s muscle and capsulopalpebral fascia until fat is seen.

A 4-0 black silk double arm suture is passed through the inferior edge of conjunctiva, Miiller’s muscle, and capsulopalpebral fascia and the suture arms are pulled upward and clamped to the drape (Fig. 14-3).

A small Desmarres retractor is placed over the lower eyelid and is pulled downward and outward to expose the orbital fat. With the use of cotton-tipped applicators, disposable cautery, and Westcott scissors, blunt dissection is carried out to isolate the three orbital fat pads. The central and nasal fat pads are divided by the inferior oblique muscle, which can be easily seen through the internal approach and should be identified to avoid injury to the structure. Also, the nasal and central fat pads are found in a slightly more temporal position than when they are isolated through an external approach.

The temporal herniated orbital fat is isolated, and the fat that prolapses with gentle pressure on the eye is clamped with a hemostat and cut along the hemostat blade with a No. 15 Bard—Parker blade. Then cotton-tipped applicators arc placed underneath the hemostat as a Bovie cautery is applied over the fat stump. The surgeon grasps the fat with a forceps before it is allowed to slide back into the orbit to make sure that there is no residual bleeding that might cause a second retrobulbar hemorrhage.¹

After the first temporal fat pad is removed, the surgeon applies additional pressure to the eye to determine whether there is a second temporal fat pad.² If a second temporal fat pad is found, it is also removed. The central and nasal fat pads are then removed in a similar manner (Fig. 14-4).

The 4-0 silk suture that attaches conjunctiva, Miiller’s muscle, and capsulopalpebral fascia to the superior drape is then removed. Conjunctiva is reap-proximated with three 6-0 plain catgut buried sutures (Fig. 14-5). Gcntamicin (Garamycin) is applied over the eye.

Lower Eyelid Herniated Orbital Fat

for healthy life — Sat, 12 Dec 2009 07:29:54 +0000

Transconjunctival Approach to Resection of Lower Eyelid Herniated Orbital Fat

The transconjunctival approach to removal of herniated orbital fat is the preferred method of treatment in patients who have only herniated orbital fat with minimal or no evidence of dermatochalasis (excess skin) and no hypertrophic orbicularis oculi muscle. This technique is also especially advantageous for:

Younger patients with large amounts of herniated orbital fat.
- Patients who have had previous blepharoplasties in whom an external approach might lead .to eyelid retraction or ectropion.
- Patients with lower eyelid retraction secondary to thyroid disease in whom hard-palate grafts are required (Chapter 18).
- Patients with wrinkled or minimally excessive lower eyelid skin in whom plication of the lateral canthi or laser resurfacing of lower eyelid skin is useful (see Chapter 15).

If there is horizontal lower eyelid laxity, this procedure can be easily combined with a horizontal eyelid tightening through a tarsal strip procedure (see Chapter 1).

Many patients want this approach done because it eliminates external scarring and produces less ecchymosis; however, it has been my experience that many patients develop conjunctival chemosis and slight redundancy and wrinkling of skin compared with those who were treated with the external approach. Therefore, I find that more frequently I am combining this approach with a lower eyelid skin flap dissection and excision with orbicularis tightening.

A contraindication to this procedure is with patients with minimal lower eyelid fat, inferior orbital rim or nasojugal hollowing and depression. In these patients, fat repositioning or cheek-midface lifting are indicated

Postoperative care

for healthy life — Wed, 09 Dec 2009 22:52:42 +0000

In the immediate postoperative period attention is given to minimization of edema and protection of the eyes. The head of the bed is maintained in an elevated position and ice therapy is placed on the operative site. The authors prefer Swiss Eye Therapy (Invotech International Inc., Jacksonville, FL) gel eye masks to provide therapeutic cooling to the tissues of the periorbital region where edema is most problematic. The packs should be replaced every 30 minutes and continued for the first 24 hours. If ice packs are used they should be wrapped in a moist cloth to prevent hypothermic injury to the tissues.

If brow lifting is performed in conjunction with blepharoplasty, lagophthalmos may be present postoperatively. In this situation the surgeon must provide means to prevent desiccation of the cornea. Artificial tears are used and administered by the patient as needed during the day. At bedtime a small portion of lacrilube or ophthalmic ointment is placed in the inferior fornix to maintain a moist environment during sleep.

Suture lines are cleansed with dilute hydrogen peroxide two to three times daily and the incision line dressed with antibiotic ointment. After three to four days, the wound has reepithelializcd and the ointment is therefore discontinued to prevent skin sensitivity from developing.

Endoscopic brow lift

for healthy life — Tue, 08 Dec 2009 22:51:30 +0000

Endoscopic brow techniques were developed to provide the ability to lift the brow while minimizing the complications characteristic to open techniques such as long scars, hair loss, and scalp parasthesias. Endoscopic surgery can be technically demanding and requires both access to and familiarity with the equipment. The most significant difference between endoscopic techniques and open techniques is that endoscopic techniques provide for repositioning of redundant/ptotic skin whereas open techniques allow excision of redundant skin. Although no studies have demonstrated a clear-cut superiority of one technique versus another, the authors feel that repositioning

tissues does not provide as long lasting a result as excisional techniques.

Essential components of the endoscopic brow lift include the creation of an optical cavity within the soft tissue planes of the forehead; release of the lateral periosteal attachments of the lateral brow; and transection of the medially located brow depressors to allow superior repositioning of the brow by the frontalis musculature. Failure to accomplish these goals will compromise the end result.

Advantages:

1. Small incisions.

2. Potential for preservation of scalp sensation.

3. Direct visualization of muscle resection.

Disadvantages:

Technical learning curve.

2. Need for fixation of scalp.

Equipment

Detailed discussion of available endoscopic equipment is beyond the scope of this text. There are a multitude of different camera and instrument systems available and in general are selected based upon surgeon preference. For endoscopic facial plastic surgery 4 mm endoscopes are optimal as they are able to provide the lighting and imaging necessary while being small enough for the limited spacial relationships encountered in the facial region. For brow techniques the authors find that use of a 30 degree camera equipped with a retractor hood provides the best opportunity to visualize the areas of interest and to account for the convex curvature of the forehead. Silicone skin protectors are also available to help prevent traction or thermal injury to the port-site skin which may lead to alopecia.

Technique

Incisions are located in the hair-bearing scalp and usually consist of a central, lateral and temporal incision. Incisions are vertically oriented, 2 cm in length, and at least 1—2 cm into the hairline. The central incision is located in the midline; the lateral incision should be located above the medial one-third of the brow; the temporal incision should be just medial to a line passing through the lateral ala and lateral brow. Incision locations are injected with 1% lidocaine with 1:100,000 epinephrine. The periorbital soft tissues along the superior and lateral orbital rims are infiltrated similarly. The incisions are performed with a #10 blade. The central and lateral incisions are carried through periosteum. A large periosteal elevator is used to elevate the forehead tissues in the subperiosteal plane stopping 2 cm superior to the superior orbital rim to prevent avulsing the supraorbital neurovascular structures. The endoscope may be utilized to perform this release under direct visualization. Blunt dissection is performed through the temporal incision to the level of the deep temporal fascia. Keeping the periosteal elevator against the deep temporal fascia, blunt dissection proceeds inferomedially to release the zone of fixation. At this point the temporal dissection transitions from a subgaleal plane to a subperiosteal plane. Maintenance of the subperiosteal plane of dissection medial to the zone of fixation is important to protect the deep division of the supraorbital nerve. Blunt dissection under direct vision proceeds to release the periosteal attachments along the superior orbital rim and to release the soft tissues surrounding the supraorbital nerve. The supraorbital nerve may be represented by a single bundle or may consist of 2—3 branches exiting the orbit separately. All branches are preserved. Dissection proceeds laterally to release the arcus margina-lis along the lateral rim to allow for superior repositioning of the lateral brow. The medial dissection divides the corrugator and procerus if indicated. The corrugator muscle will be visualized adjacent to the supraorbital nerve with fibers oriented inferomedially. Transection of the corrugator is accomplished by grasping the muscle fibers near their insertion on the overlying skin and avulsing them with care to avoid

Table 6-2 Summary lifts and endoscopic	of reported complications after open brow brow lifts
Complication	Open *(n =* 3534) (%)	Endoscopic (n = 3417)(%)
Alopecia	4.0	2.9
Dissatisfaction	0.8	1.8

<0.1

0.8

Scarring

Asymmetry	0.8	1.2
Sensory loss	0.1	0.6
Infection	<0.1	<0.1
Lagophthalamus	<0.1	<0.1
Motor deficiency	<0.1	<0.1
Abnormal contour	<0.1	<0.1
Hematoma	<0.1	<0.1

Reproduced with permission from Elkwood A, Matarasso A, Rankin M, et al: National plastic surgery survey: Brow lifting techniques and complications. Plast Reconstr Surg 2001; 108(7):2143-2150.

the neurovascular bundles. Complete release of the corrugator is confirmed with identification of the brow fat pad that lies superficial to the corrugator. The procerus is divided similarly centrally in the glabellar region. The cavity is then irrigated and meticulous hemostasis is accomplished.

The brow is then elevated to its desired position. Typically the lateral brow requires preferential elevation. This may be accomplished by rcdraping the lateral brow tissues in a superiomedial vector. Brow fixation may be accomplished in a wide variety of ways,¹⁰ but is typically accomplished with either a fixation screw or creation of a cortical tunnel for suture fixation. Animal studies have demonstrated that periosteal readherence requires at least 6 weeks, with complete adherence by 12 weeks.¹¹ Therefore suture selection should be directed towards the use of a material that provides secure brow position for 6-12 weeks. The authors’ preferred method is to perform a cortical tunnel in the frontal bone over the midportion of the brow along the desired vector using a 4 mm long 2.0 mm drill. Two separate, opposing drill holes are made through the superficial cortex that communicates in the diploic cancellous space. A 2-0 PDS suture is then passed through the tunnel and used to secure a strong bite of galea in the inferior edge of the incision. The brow is then redraped and manually held in position while the suture is tied. The procedure is repeated on the contralateral side. The incisions are closed with staples.

Other methods of acceptable fixation include Lacto-sorb (Walter Lorenz) resorbable endobrow screws, and titanium screws. The Lactosorb polymer has been shown to resorb over the course of 12 months and therefore will maintain brow position long enough for adhesion to develop. The screw may be palpable initially, but the patient can be reassured it is temporary. Titanium screws offer permanent fixation, but may require removal if palpability is objectionable to the patient. Endotine Forehead 3.5 (Coapt Systems, Paola Alta, CA) is a resorbable device for rapid fixation of the brow tissues. The device consists of five 3.5-mm prongs that are set into the skull with a single drill hole. The device has been reported to be palpable up to 24 weeks. Due to issues with palpability, the device is recommended for patients with scalps 5-6 mm thick.¹²