Endoscopic operations (or keyhole surgery) are much less stressful for the patient and give a better cosmetic result than 'open' surgery. But on the other hand, it is very difficult for the surgeon to carry out keyhole surgery. This is due to the disruption of hand-eye coordination, as the surgeon has to operate via a 2D image on a monitor. Moreover, the video camera has to be operated by an assistant and the work must be done using long and rigid instruments that provide little freedom of movement. The existing robot systems that have been developed to solve the aforementioned problems are complex, expensive and do not provide the required (force) feedback to the surgeon.

Cosmetic surgeons have developed endoscopic or “keyhole” surgery, as it is sometimes referred to, in cosmetic plastic surgery. This technique allows the cosmetic surgeon to operate through tiny incisions and leave fewer and smaller scars.

An endoscope consists of two elements. A tiny camera with a light on the end of a long tube and a monitor, which displays a magnified image of what the camera visualizes. the cosmetic surgeon performs the procedure while manipulating the endoscope and watching the monitor.

Some surgeries that may be performed either partially or totally with endoscopy are:

• breast augmentation
• forehead or brow lift

The keyhole surgery technique is also used in some reconstructive procedures such as sinus surgery, reconstructive breast surgery and carpal tunnel surgery. Endoscopic or keyhole surgeries are less stressful for the patient and give a better cosmetic result as well. Advantages of the keyhole or endoscopic surgery technique include a quicker recovery time, reduced bleeding, bruising and swelling and the possibility of performing the surgery on an out-patient basis under local anesthesia.

Endoscopic surgery has been used for years in orthopedic surgery, urological surgery and gynecologic surgery. Now, improvements in technology have enabled cosmetic surgeons to employ endoscopy for cosmetic procedures.

Candidacy

A good candidate for endoscopic cosmetic surgery must be in good health, with no active disease or serious pre-existing medical conditions. After a consultation with your surgeon, a decision will be made if endoscopy is the best choice for you. This decision is based on your physical condition, the type of procedure being performed and what your expectations are for the results. It is important to have realistic goals and expectations for what the outcome will be. After surgery it is important you follow all your surgeon’s instructions as this will promote better healing and result in an improved new physical appearance.

Face-lift keyhole surgery

Face-lift keyhole is becoming more and more common. Cosmetic surgeons now use endoscopic or keyhole facelift surgery quite routinely to perform parts of the facelift, particularly the brow lift. Several tiny cuts are made into which an endoscope, a thin fiber optic tube with a camera at the end, is introduced. Tiny instruments are placed under the skin through other small entry holes. The surgeon performs the facelift surgery using images from the endoscopic camera on a large screen TV that relays the images from the endoscopic camera.

This type of operation is extremely skilled but it does produce only small cuts in the skin so the scarring after the surgery is much less than occurs with a full face lift, which involves quite large incisions from the temple, around the ear to the back of the scalp.

Some surgeons also use a technique called minimal access cranial suspension (MACS), in which shorter cuts are made in the temple and in front of the ears. Tissue is tightened from the edge of the face and sewn in place.

Forehead lift

The forehead lift is the commonest procedure carried out endoscopically. Three or more stab incisions are made just behind the hair line instead of the usual ear to ear incision. It allows the surgeon to reduce the transverse frown lines of the forehead and vertical glabella frown lines between the inner end of the eyebrows.

Sagging eyebrows can be lifted to a higher level. The procedure on its own can be carried out as a day case or with one night in hospital under general anaesthesia or local anaesthesia with intravenous sedation. There is usually swelling around the eyes after surgery which takes a few weeks to settle. Hair is sometimes lost around the scalp incisions and if this is the case it takes several months to re-grow.

Deep facelift

This is an extension of the forehead lift which is designed to tighten the skin of the upper half of the face, as opposed to the standard facelift which helps the lower half of the face. The deep facelift carried out endoscopically avoids the same ear to ear incision. It is usually carried out at a younger age than the standard facelift. It tightens the skin of the mid-face and freshens the eyes, opening and lifting the outer angle and reducing the wrinkles of the crow’s feet. There will be swelling around and below the eyes which gradually resolves in about a month. There will also be scars beneath the eyelashes of the lower eyelid and sometimes in the upper gum line. There is a slight risk of damage to the nerve which supplies the muscles of the forehead. This weakness is usually partial and temporary, on rare occasions it may be permanent.

Other procedures in the face

The traditional facelift is the best choice for patients with significant surplus skin, but there are a number of specific indications for endoscopic surgery to the mid-face and to the neck. Incisions are usually concealed under the lower eyelash margin, the upper gum line, behind the ears and under the chin.

Breast augmentation

A range of different types of breast implant which are safe and available. Endoscopy has a limited use in putting in saline filled implants through remote incisions. The commonest is the incision in the armpit when the implant is put under the pectoral muscles which have been released surgically from their origin from the sternum (breast bone). Similarly, these implants can be put in through incisions or existing scars in the abdomen.

Abdominoplasty endoscopy

Abdominoplasty endoscopy has been shown to be useful in a few selected patients who have lost abdominal muscle tone but do not have any surplus skin. The muscle can be tightened through a relatively short incision like a small caesarean section scar. This can be combined with liposuction.

Reconstructive surgery

Muscle flaps, and most commonly the latissimus dorsi, from the back can be raised through a small incision endoscopically. Tissue expanders can be placed through small incisions remotely and the carpal tunnel in the wrist can be decompressed to cure median nerve symptoms in the fingers.