1
บทความที่
2
(14 หน้า – 4 รู ปภาพ)
ส่ วนที่ 1
ข้อมูลผูล้ งทะเบียนส่ งบทความ
คานาหน้า :
นาย
ชื่อ-สกุล :
ปรเมศร์ พิทกั ษ์อรรณพ
คานาหน้า :
Mr. (M.)
ชื่อ-สกุล :
Poramate PITAK-ARNNOP
ที่อยูท่ ี่ติดต่อได้ : 34 Rue de Lübeck (porte 27)
รหัสไปรษณี ย ์ : 75116
เมือง : Paris
ประเทศ :
France
หมายเลขโทร. : 06 31 22 91 38
E-mail:
dormigum@hotmail.com
สาขาที่ศึกษา : วิทยาศาสตร์
ระดับการศึกษา: 3ème cycle – Hors programme communautaire (chirurgie maxillo-faciale)
ชื่อสถาบัน : Service de Chirurgie maxillo-faciale, CHU Pitié-Salpêtrière, Faculté de Médicine,
Université Pierre & Marie Curie (Paris VI), Paris, France
ส่ วนที่ 2
ข้อมูลงานวิจยั /บทความ
ชื่อบทความ :
Endoscopic excision of forehead lipomas: a technical note
(การผ่าตัดเนื้ องอกไลโพมาบริ เวณหน้าผากด้วยกล้องส่ อง-เทคนิควิธีการ)
สาขาที่เกี่ยวข้อง:
Clinical medical science (plastic and maxillofacial surgery)
วิทยาศาสตร์ การแพทย์คลินิก (ศัลยศาสตร์ ตกแต่งและแม็กซิ ลโลเฟเชียล)
ระดับการวิจยั : 3ème cycle – Docteur en médicine (chirurgie maxillo-faciale)
คาหลัก :
endoscopic surgery, lipoma, forehead, head and neck tumour
รายละเอียด :
รอการพิจารณาเพื่อตีพิมพ์ในในวารสาร International Journal of Oral and Maxillofacial Surgery
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-
Meningaud J-P, Pitak-Arnnop P, Rigolet A, Bertrand J-Ch. Endoscopic excision of
forehead lipomas. Int J Oral Maxillofac Surg 2005 (submitted)
การประยุกต์ :
1.สามารถใช้บาบัดผูป้ ่ วยไทยในรายที่มีขอ้ บ่งชี้
เพื่อหลีกเลี่ยงผลไม่พึงประสงค์จากการผ่าตัดโดยเฉพาะการเกิดแผลเป็ น
2.สามารถประยุกต์เพื่อการวิจยั ศัลยกรรมบาบัดรอยโรคเนื้อเยื่ออ่อนลักษณะอื่นต่อไป
3.สะท้อนแนวคิดในการแก้ไขปั ญหาในการปฏิบตั ิงาน เพื่อให้เกิดผลการทางานที่มีประสิ ทธิ ภาพต่อไป
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Endoscopic excision of forehead lipomas: a technical note
Jean-Paul MENINGAUD, Poramate PITAK-ARNNOP*,
Arnaud Rigolet, Jacques-Charles BERTRAND
Department of Maxillofacial Surgery, Teaching Pitié-Salpêtrière Hospital,
Faculty of Medicine, University of Pierre & Marie Curie (Paris VI), 47 bd de l’hôpital, 75651 Paris, France
*E-mail address: dormigum@hotmail.com
Abstract
Endoscopic surgery has largely taken the place of various procedures in
craniomaxillofacial surgery. Our experiences in this technique we will present have proven
useful in the resection of forehead lipomas. It magnification allows the better identification
of lesions, or even small nerves, and vessels. The tumours were extracted without
additional incisions. The result is at least equivalent with a greatly decreased incidence of
scarring, and neurovascular injury of forehead. This technique has a steep learning curve.
To our knowledge and experience, we believe that well-trained surgeons using the proper
instruments can perform this manoeuvre with minimal trauma and few complications.
Key words
endoscopic surgery, lipoma, forehead, head and neck tumour
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Introduction
Clinically, lipoma presents as a soft, asymptomatic mass. Conservative excision is
considered as the treatment of choice for this tumour, and recurrence is quite rare.[5]
Simple direct approach to masses on the forehead always leaves obvious scars.[2] In an
attempt to minimize the scarring, it has been more than 10 years since the endoscopic
technique was first used in facial plastic and reconstructive surgery. At this time, the
meaningful advantage offered by the endoscope has been a number of procedures, for
instance, face lift, forehead lift, frontal sinus surgery, rhinoplasty, mandibular
osteotomy.[1,2,4,6] Endocopic approach of forehead lipoma has been established as a safe,
and effective procedure in two series with a total of 12 patients; [2,6] this technique,
however, has not become a routine procedure in maxillofacial surgery. The purpose of this
article is to advocate the application of endoscopic removal of forehead lipomas.
Case report
A 28-year-old French white woman presented with two painless masses in the
forehead. Except for iodine allergy, her medical history was unremarkable. The patient
denied any trauma to the site or any familial occurrence of skin lesions. Physical
examination revealed soft, mobile, and nontender masses located on the right side of her
forehead measuring 1 X 1, and 1.5 X 2 cm, respectively. None of them were painful and no
discolouration of skin surface. Clinically, these findings were consistent with lipomas. She
wished to have these masses removed; nevertheless, she was concerned with facial scarring
which could be prominent because of her smooth, noncorrugated forehead. (Fig. 1)
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Prior to surgery, the patient was informed about detail of procedure and possibility
of conversion to an open technique. A video system (Karl Storz GmbH & Co. KG,
Tuttlingen, Germany) consisting of endoscopic camera (Telecam DX® PAL Video Camera
System), flexible and high-intensity light source with cool nature (175-watt Xenon lamp),
television monitor, and video recorder was used. A good view was provided by the 4 mm
30° endoscope (18 cm in length) with combined rod lens and light source. The video
camera connected to the endoscope eyepiece captured the image that is then projected on a
video monitor. During the procedure, the surgical field was seen by viewing a monitor.
Magnification aided delineating the subcutaneous structures very well. Several endoscopic
instruments, retractors, and periosteal elevators were also used to perform surgical
procedure.
Even it is possible using local anaesthesia on an outpatient basis, preference should
be given to general anaesthesia. Owning to vascularized lushness of facial soft tissues, we
advocate an adrenaline infiltration at surgical site in an attempt to reduce intra-operative
haemorrhage and allow a hydrodissection effect that is helpful for dissection. To minimize
risk of postoperative alopecia, the two 15-mm scalp incisions were created parallel to the
long axis of hair follicles. The first one was located in the midline and posterior to the
anterior hairline; whereas the other, more laterally, was placed 1 cm behind to the temporal
hairline. The incisions were carried down through the galea aponeurotica, and the pockets
were linked together in the subaponeurotic space. The first incision was used for the
insertion of endoscope and the retractor on which it was mounted. Through the other
incision, elevators, forceps, scissors, and curettes were introduced. With an elevator, the
subgaleal dissection was performed under endoscopic visualization. At first, masses were
not visualized in the dissecting plane because of their location in overlying muscular or
subcutaneous layers. The localisation of the masses was estimated by manipulation of the
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skin externally using the non-dominant hand. Once reaching the tumour location, a
dissection of surrounding tissues to free the masses was done with gently digital pressure
to the overlying skin for pushing masses downward. (Fig. 2) Complete excision with
forceps and long haemostat to remove them piece by piece was relatively easy without
additional incisions. (Fig. 3) The resected masses were sent to Department of Pathology
for definite diagnosis.
Before primary closure with 2 staples at each incision, the cavity was irrigated
repeatedly with physiological saline, and the haemostasis was verified. Any drain was
unnecessary. The operating time was 30 minutes. A firm dressing with an elastic bandage
in a rolling manner from the orbital rim to the incisions was applied for a few days
postoperatively. She was discharged from hospitalization at the day of procedure. The
patient quickly resumed her daily routine with normal postoperative healing and
satisfactory outcome. (Fig. 4) Tumours extracted revealed the result of benign lipomas.
There is no evidence of recurrence appeared over the follow-up period to date.
Discussion
Lipomas are very common lesions which can occur anywhere on the body. Usually,
they grow slowly and are expansible before diagnosis.[5] Patients with a lipoma on their
face are often disturbed by its appearance and frequently request the surgical removal
without scars, particularly in young people and women. Unfortunately, the standard
treatment is direct excision, which often leads to conspicuous and unacceptable scars for
various reasons: patients with a smooth forehead without many wrinkles, a large mass
necessitating a large incision, poor wound healing, predisposition to skin discolouration,
and an uneventful healing with hypertrophic scarring, or much more badly, keloid
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formation, including patients extremely anxious and conscious of any residual forehead
scar.[2]
Recently, the use of endoscope in craniomaxillofacial surgery has limited the use of
wide incisions for exposure. It has been used to visualize the upper face and brow in
aesthetic facial surgery.[1,4] A case report by Pozner and their colleagues [8] was the first
in which the success of endoscopic application in the treatment of lipoma along the angle
of mandible. Since then well other reports has demonstrated the effectiveness of this
endoscopically assisted lipoma removal.[2,6,7,9] Its magnification allows the better
identification of lesions, or even small nerves, and vessels, [2,6] then it is excellent for the
excision of forehead lipomas without conspicuous scarring; this technique minimizes the
scalp scarring and blood loss, avoids numbness of forehead, provides a comfortable
postoperative recovery, and may shortens length of hospitalization.[2] In contrast with
lipomas, dermoid and epidermoid cysts which may be seen in the area of forehead are
more fragile (in risk of rupture) and more superficial, as well as neccessitate removing the
cutaneous pore. When they rupture, the inflammatory reaction is usually seen. Thus it is
more time-consuming and technically demanding in such cases.[2,6] To our opinion, it is
so advisable that the preoperative evaluation and differential diagnosis necessitate for both
treatment plan and patient inform. The differential diagnosis of forehead masses includes
lipoma, osteoma, dermoid cyst, epidermoid cyst, haemangioma, and a number of
malignancies. Lipoma is usually soft, and mobile; the procedure can be converted to a
direct approach without difficulty in cases of the extensive lesions or suspicion of
malignancy. In addition, incision can be enlarged to accommodate pulling masses out.[2]
Projection from the television monitor can be recordable for medical students’ and
trainees’ study in surgical anatomy. By our experience, we use 4.0 mm-diameter rigid
endoscopes because of its capability of tissue retraction providing the better operative field,
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compared with the flexible ones often used in exploratory surgery via the natural openings,
such as antral osteum, rectum or ductal orifice. We, moreover, find we can be more
precious when the high intensity light with cool nature from the Xenon lamp is introduced
to use in our procedures adjunctive to the endoscope instead of the old fashion; this brings
us the better quality of light.
Regarding the dissection plane for approaching the forehead masses, subgaleal
plane which is superficial to the deep temporal fascia is preferred. This dissection will
offer a wider operative field, a nearly direct approach to masses, as well as prevent injury
of the temporal branch of facial nerve.[6]
Nonetheless, endoscopic surgery possess several limitations, such as the training
and learning curve necessary to achieve optimal results, the initial increased operation time,
the use of new instrumentation, as well as the overall investment in the endoscopic
instruments. The endoscopic approach to forehead masses carries the same risk of damage
to frontal branch of facial nerve and/or supraorbital nerve due to requirement of dissection
in the frontotemporal area. However, the incidence of frontal nerve weakness and
persistent dysaesthesias in endoscopic forehead rejuvenation has been reported
approximately 1.8, and 2.3 per cents, respectively. This may be due to good illumination
and magnification; nerve fibres are clearly identified and preserved.[2,4,6] A simple
landmark for identification of supraorbital and supratrochlear nerves was explained by
Cuzalina and Holmes.[3] It was found that all nerves coursed 2 mm or less from a vertical
line constructed tangential to medial limbus at the supraorbital rim. Greater care should be
taken when dissection in this area will be performed. On concern in a learning curve, it is
steep after the first five or ten procedures, and general laparoscopic equipments can be
adapted in this kind of surgery.[2] Besides, as the endoscopic surgery becomes
increasingly available, its drawbacks will be solved.
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Now, during the peak of interest in minimally invasive surgery with limited scars
using endoscope is the time to highlight this time-sparing, safe, and effective approach.
The endoscope is a useful adjunct not only for diagnosis but also for resection of forehead
lesions. Application of endoscope provides advantages over the conventional direct
excision and avoids a handful of undesirable sequelae, especially a more aesthetically
pleasing result. Careful examination should be carried out to exclude the malignant lesions
and we recommend careful selection based on the indications described.
References
1. CHIU ES, BAKER DC. Endoscopic brow lift: a retrospective review of 628
consecutive cases over 5 years. Plast Reconstr Surg 2003; 112: 628-633.
2. CRONIN ED, RUIZ-RAZURA A, LIVINGSTONE CK, TIMOTHY KATZEN J.
Endoscopic approach for the resection of forehead masses. Plast Reconstr Surg
2000; 105: 2459-2463.
3. CUZALINA AL, HOLMES JD. A simple and reliable landmark for identification
of the supraorbital nerve in surgery of the forehead: an in vivo anatomical study. J
Oral Maxillfac Surg 2005; 63: 25-27.
4. DE CORDIER BC, DE LA TORRE JI, AL-HAKEEM MS, ROSENBERG LZ,
GARDNER PM, COSTA-FERREIRA A, et al. Endoscopic forehead lift: review of
technique, cases, and complications. Plast Reconstr Surg 2002; 110: 1558-1568.
5. DANIELSON PA. Soft Tissue Cysts and Benign Neoplasms. In: FONSECA RJ,
ed.: Oral and Maxillofacial Surgery. Vol. 5. Surgical Pathology. Philadelphia: W.B.
Saunders, 2000: 137-138.
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6. LIN SD, LEE SS, CHANG KP, LIN TM, LU DK, TSAI CC. Endoscopic excision
of benign tumors in the forehead and brow. Ann Plast Surg 2001; 46: 1-4.
7. PAIGE KT, EAVES EF III, WOOD RJ. Endoscopically assisted plastic surgical
procedures in the pediatric patient. J Craniofac Surg 1997; 8: 164-167.
8. POZNER JN, CANICK MI, RAMIREZ OM. Endoscopically assisted lipoma
removal. Plast Reconstr Surg 1996; 98: 376-377.
9. SAKAI Y, OKAZAKI M, KOBAYASHI S, OHMORI K. Endoscopic excision of
large capsulated lipomas. Br J Plast Surg 1996; 49: 228-232.
Captions to illustrations
Fig.1:
Preoperative photograph showing two forehead lipomas.
Fig.2:
Endocopic view during freeing masses. R: retractor, L: lipoma, S: scissors.
Fig.3:
Endocopic view during removing masses. R: retractor, L: lipoma, F: forceps.
Fig.4:
Postoperative photograph at 1-month follow-up.
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Fig.1
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Fig. 2
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Fig. 3
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Fig. 4