C H A P T E R S I X T Y- S E V E N

Forehead and Brow Procedures

Angelo Cuzalina, MD, DDS

Upper facial cosmetic surgery has enjoyed an unprecedented increase in popularity over the past decade. The yearning of baby boomers to look and feel rejuvenated has led to new endoscopic techniques aimed at creating a more youthful and natural appearance with shorter recovery periods than existed in past decades.13 The ultimate goal of improving a persons appearance remains unchanged. Society shapes our views of what looks attractive, and no mathematic formula can ever be used to determine an ideal eyebrow position (Figure 67-1). Each individual has his or her own unique perception of facial beauty. For most people the upper face and eyes impart more emotion than does any other part of the human body; it is clear that rejuvenation of this vital area can provide an esthetically pleasing result. Esthetic concerns of the forehead and brow regions of the face affect a wide range of age groups. Unlike the standard lower face and neck rhytidectomy, which more commonly affects patients after the age of 45 years, cosmetic concerns in the upper third of the face may be evident for patients in their twenties and thirties owing to genetic predisposition. The forehead and brow area must be entirely evaluated for a wide range of interlacing diagnoses. Matching the problem(s) to the ideal rejuvenation technique(s) is essential for maximum esthetic benefits. Thinning skin and laxity owing to age and gravity encompass only a portion of the forehead and brow dilemmas that must be addressed when planning rejuvenation procedures (Figure 67-2). The aging process typically leads to forehead and brow ptosis on almost every patient; however, it is important to distinguish whether the ptosis in the forehead and brow region is owing to problems with brow position, upper eyelid laxity, or a combination of the two (Figure 67-3). Other problems such as dynamic lines caused by muscle activity in the glabellar region, variable hairline patterns, bony abnormalities, and asymmetries,

as well as skin texture itself, also must be assessed in relation to each other. Achieving the patients desired expectation depends not only on sound surgical skill and judgment, it also depends critically on communication between the surgeon and patient. Truthful disclosure of what can reasonably be attained is prudent and helps to prevent patient dissatisfaction. Rejuvenation of the upper third of the face is one of the most rewarding and fulfilling procedures a surgeon can offer to select patients. Specific elevation and correction of lateral hooding can be appear natural and still impart a tremendous improvement in the patients overall beauty and youthful appearance (Figure 67-4). The goal of this chapter is to review the upper third of facial anatomy specific to forehead and brow

rejuvenation techniques and to discuss a variety of the most common techniques for rejuvenating the forehead and brow region.

Anatomic and Esthetic Considerations

It is generally accepted that a youthful forehead is roughly one-third of the overall facial height.49 Essentially, the distance from the hairline to the glabella is equal to the distance from the glabella to the point at the base of the columella or subnasale (Figure 67-5). A youthful-appearing eyebrow is different for men and women. The female eyebrow should be arched with the highest point of the brow on a sagittal line from the lateral canthus.10,11 The entire brow itself should be above the orbital rim. In general the medial brow of the female is located ideally 1 to 3 mm above the

FIGURE 67-1 Three different types of esthetically pleasing foreheads and eyebrow position. The tail of the eyebrow is located along the alar-canthal line. The greatest brow arch is seen in the lateral third between the lateral limbus and canthus of the eye. The outer half of the brow is ideally located 5 to 10 mm above the orbital rim in females.

Part 9: Facial Esthetic Surgery

Youthful brow Aging brow

Frontalis Galeal fat pad Frontal bone

Orbicularis oculi Fusion at orbital rim Preseptal fat pad Levator aponeurosis Orbital septum Preaponeurotic fat pad

A
A
FIGURE

B
B

67-2 A, The youthful brow is elevated proportionately and has densely adherent periorbital fascia and muscle. B, Brow descent owing to aging and the associated loss of fascial integrity, along with orbital fat prolapse.

orbital rim and the lateral third of the brow 5 to 10 mm above the rim.12 This is in contrast to a typical male eyebrow that should lie at or only slightly above the orbital rim in a more horizontal or uniform arch fashion (Figure 67-6). Elevating the lateral third of the male eyebrow disproportionately more than the remaining brow will create a feminine appearance. The detailed anatomy of individual areas has been well described in the literature and often relates to the specific procedure being performed.1325 Therefore, the following anatomic discussion is simplified by separating the specific regions into bony landmarks, muscle and fascial

anatomy, vessel and nerve anatomy, and specific endoscopic anatomy, and each anatomic region is addressed individually as it relates to specific surgical procedures.

Bony Landmarks
Bony landmarks of the forehead and brow region can be focused all around the frontal bone, which makes up the highest percentage of the upper third of the face. The connections (suture lines such as the nasofrontal, zygomaticofrontal, and coronal) are important landmarks because they can be clinically relevant for limits of dissection and can help surgeons determine their location
Frontalis Brow fat pad Orbicularis oculi

Periosteum Subgaleal areolar fascia Deep fascia Arcus marginalis Eyelid fat pad Levator palpebrae superioris Whitnall's ligament Orbitalis

Orbital septum Levator aponeurosis

during dissection. For instance, the zygomaticofrontal suture line is an ideal location to end most basic brow lift dissections (Figure 67-7). Additional dissection can be performed if midface lifting is also planned or if the patient desires more elevation at the lateral canthal region. Overaggressive dissection here in many patients can create an unnatural cats-eye appearance, particularly if too much tissue is elevated medially along the suture line and lateral canthus. Likewise, the nasofrontal suture line is a nice landmark to note during dissection for a few reasons. First, dissection usually needs to proceed only a few millimeters below this suture level onto the nasal bones for adequate release. Second, the paired procerus muscles can be identified here and transection performed if required. Third, depending on the level of horizontal transection in this area, the nasofrontal angle point of takeoff can be altered slightly if desired. Last, nasal tip rotation can be achieved if wanted, especially with significant dissection below the nasofrontal suture line. Another general bony landmark is the orbital rim, which limits inferior dissection but must be well visualized and free of periosteal attachments to lift the brow and brow fat pads for long-term results. Important muscle and fascial attachments are also located at the level of the orbital rim medially and laterally. The tenacious temporal fusion line (zone of fixation) that exists along the temporal ridge must be identified during dissection.26,27 It is also important to know its location preoperatively so that proper incision placement can be made to facilitate a clean dissection under this area that enhances visualization endoscopically (Figure 67-8). Bony thickness varies in different areas of the skull. In addition, venous lakes present on the inside surface of the skull tend to be more centralized around the sagittal suture line. If bone tunnels or screws are planned for fixation purposes, the midline should be avoided, if possible, because of the sagittal sinus as well as higherdensity venous lakes in this area (Figure 67-9). Thickness does increase posteriorly near the occiput, but screw or bone tunnel fixation here is more challenging and is not required. Caution must be taken also to avoid lateral placement because of thinness of the lateral skull and the middle meningeal arteries. Knowledge of average thickness for a given location and internal anatomy indicates that the safest location for bone tunnels or screws is located along a parasagittal line approximately at the midpupil or lateral limbus line and just anterior to the coronal suture (see Figure 67-9).

Muscle and Fascial Anatomy

67-2 C, Cross section of the brow near the mid pupillary position.
FIGURE

Paired muscles of the forehead and brow region are often thought of as elevators and depressors.

Forehead and Brow Procedures

FIGURE 67-3 A, Rejuvenation of the upper third of the face must address whether the problem is limited to brow ptosis, eyelid ptosis, or a combination of both, as seen in the patient on the left. Skin texture must also be evaluated. B, The photo was taken 1 month after a coronal brow lift, upper blepharoplasties, and full-face laser resurfacing.

Although several depressor muscles can pull the brow down or obliquely, the only true elevator of the forehead, the frontalis, moves upward to raise the brow. This movement, along with some static tone, maintains brow position but also can lead to horizontal creases over time. The frontalis originates from the deep galeal plane (galea aponeurotica that connects to the occipitalis posteriorly). It inserts into the orbital portion of the orbicularis oculi, which inserts into the dermis immediately below the eyebrow. Its lateral extension fuses into the dense collection of fascia almost 1 cm wide, called the zone of adherence, which extends along the superior temporal line and ends inferiorly just above the zygomaticofrontal suture. The fascial attachments, known as the orbital ligament (see Figure 67-7), are the inferior termination point of the zone of adherence near the orbital rim where connective tissue fibers of the temporoparietal fascia are fixated to the bone at the superolateral orbital rim (Figure 67-10). Lateral and posterior along a near horizontal line from the orbital ligament is the orbicularis-temporal ligament, which is the transverse fusion zone of fibers from the lateral orbicularis, the temporoparietal fascia, and the temporalis fascia. These are important clinical anatomic areas because freeing the zones of adherence is necessary to achieve long-term results with lift procedures. However, care is required in this region to avoid overzealous stretching and injury to the facial nerve. The acronym SCALP applies for the standard layers in the forehead: skin, subcutaneous tissue, aponeurosis (the thick galeal fascia), loose areolar (subgaleal) plane, and periosteum2830; however, the galeal fascia fuses into the frontalis muscle and its midline fascial attachments at this level. This allows a sliding movement over the scalp with contraction of the muscle. The frontalis and galea together can also be thought of as an extension of the temporoparietal fascia in the temporal region

as well as the superficial musculoaponeurotic system (SMAS) below the level of the zygomatic arch.3133 The temporoparietal fascia appears somewhat loose or spongy clinically and houses the temporal nerve within its undersurface. Many other paired forehead and brow muscles thought of as depressors are present along the brow to facilitate facial expression.3441 The two most well known are the procerus and the corrugator supercilii, which are present in the glabella (Figure 67-11). The procerus muscles are paired superiorly but fuse inferiorly into one muscle belly that originates from the nasal bones and cartilage. Superiorly procerus fibers insert into medial frontalis and the overlying dermis. The procerus is responsible for depression and

frowning in the midline, which often creates a horizontal crease (bunny lines) across the upper portion of the nose. The corrugator supercilii are depressors that act obliquely across the glabella and produce the classic vertical lines seen when squinting (Figure 67-12). The corrugator originates from the frontal bone just above the nasal bones and inserts in the dermis of the medial brow. The corrugator has two heads, the oblique and the transverse, which act to pull the medial brow in respective locations. Together the paired procerus muscles and corrugator are the main depressors of the medial brow and are the most common muscles treated with botulinum toxin type A to help alleviate frown lines in the glabella. These same two muscles are also most often transected during a brow or forehead lift to achieve a smoother and longer-lasting result (Figure 67-13). Another depressor muscle of importance is the depressor supercilii, which originates on the frontal process of the maxilla just below the corrugator supercilii and inserts in the medial frontalis fibers and dermis just above the medial brow. Because it lies superficial to the corrugator, it can be easily paralyzed inadvertently by botulinum toxin. It is also important to note because it lies behind the corrugator and can be transected by aggressive dissection through the corrugator during a brow lift. Although patients with a very low medial brow position may occasionally benefit from this maneuver, it often gives rise to over-elevation of the medial brow following surgery, which causes the patient to look some-

FIGURE 67-4 A, Preoperative view of patient with classic lateral hooding brow ptosis and only pseudo upper eyelid laxity or ptosis. B, One week following endoscopic forehead and brow lift only. (Slight overcorrection is noted in this early period.) C, Correction of lateral hooding with isolated brow lift after 1 month.

Part 9: Facial Esthetic Surgery

Vessel and Nerve Anatomy

Blood supply to the upper face and scalp is plentiful and comes from multiple sources. Several major vessels of the upper face originate from the external carotid artery including the superficial temporal artery and the facial artery. These give rise to the blood supply in the medial canthal region via the angular artery and in the lateral canthal region by way of the frontal or anterior branch of the superficial temporal artery. The internal carotid artery gives way to the middle meningeal artery, and the ophthalmic artery. The ophthalmic artery then gives rise to the supraorbital and supratrochlear arteries, which exit their respective foramina and supply the majority of the forehead and midscalp with blood. The terminal arterial branches of the upper face have major anastomoses with adjacent vessels. Venous drainage of the upper face follows the respective arterial supply but can be somewhat more variable. However, one particular vein, known as the sentinel vein (medial zygomaticotemporal vein), runs perpendicular through the temporalis fascia connecting the superficial and middle temporal veins (Figure 6717).45 The sentinel vein can most often be found approximately 1 cm laterally or posteriorly to the zygomaticofrontal suture line. It is clinically significant during endoscopic procedures because, if injured, it can result in impaired field visualization and significant bruising. Nerve supply parallels arterial supply to some degree. The supratrochlear and supraorbital nerves, which are responsible for the majority of sensation in the forehead, exit via the same foramina or general location as do the supraorbital and supratrochlear blood vessels. The sensory nerves originate from the first division of the trigeminal nerve. The supraorbital nerve has two divisions after exiting its foramen: the deep (or lateral) division supplies the more lateral and posterior portion of the forehead and scalp, and

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1/5 1/3 1/5 1/5

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FIGURE 67-5 A, Example of ideal facial proportions based on vertical facial thirds and horizontal proportions approximately the width of the eye or one-fifth of the facial width. B, Preoperative. C, Six weeks following endoscopic forehead and brow lift along with laser skin resurfacing.

what surprised (Figure 67-14). Superficial to the depressor supercilii is the orbital portion of the orbicularis oculi that inserts into portions of the adjacent depressors, the superficial surface of the inferior frontalis, as well as the dermis below the brow.42,43 The orbital portion of the orbicularis muscle originates in part from the medial canthal tendon and adjacent bone. Deep to all the depressors is the galeal fat pad, which lies immediately below the transverse head of the corrugator and helps in identification of muscular landmarks.44 The galeal fat is usually exposed clinically instantly after transection through the periosteum along the orbital rim (Figure 67-15). Finally, paired temporalis muscles are located in each temporal fossa, where they originate and then insert on the coronoid process of the mandible. The importance of these muscles during upper facial rejuvenation chiefly pertains to their overlying fascia, which can be used to delineate surgical planes and aid in fixation. The spongy temporoparietal fascia is superficial to the dense and shiny white temporalis fascia. The temporalis fascia adheres to the temporalis muscles below and splits into a superficial and deep layer in the lower half of the fossa. For consistency, the superficial layer of deep temporalis fascia (which really describes only that portion of deep temporalis fascia at the level of the split and below) is subsequently referred to simply as temporalis fascia. In essence, this term will be used to

describe any of this deep thick fascial layer that is seen clinically from the temporal crest down to the zygomatic arch (Figure 67-16). One method of fixation during brow lifting is the use of suture to fixate the temporoparietal fascia from below a skin incision to the dense and adherent temporalis fascia above the incision to elevate the lateral brow. Some surgeons advocate removing a window of temporalis fascia and exposing the underlying temporalis muscle in hopes of creating scarification in this region and improving fixation longevity.12

FIGURE 67-6 A, Female brow shown with a nicely accentuated arch in the lateral third well above the orbital rim. B, The average male brow position is level with the orbital rim with a symmetric arch form.

Forehead and Brow Procedures

Superior temporal fusion line

Zone of fixation

Orbital ligament

Corrugator supercilii Depressor supercilii

Zygomaticofrontal suture line

Procerus Medial canthal tendon attachment

Lateral canthal tendon, anterior attachment

FIGURE 67-7 Periosteal elevator shown at a more aggressive level of dissection to elevate the lateral canthus slightly, if desired. Fascial and muscle attachments are labeled. Elevation at this level detaches only the superficial layer of the lateral canthal tendon. (The deep portion of the lateral canthus is 5 mm within the orbital rim attached to Whitnalls tubercle.)

the superficial (or medial) division pierces the frontalis and runs superficially to the muscle, supplying sensation to the forehead along the midpupil line (Figure 67-18). The location of the supraorbital nerves exit is relatively consistent. The supraorbital foramen or notch is typically found within 1 mm of a line drawn in a sagittal plane tangential to the medial limbus (Figure 6719).46 The deep division has been known to exit as often as 10% from another foramen that can be as high as 1.5 cm above the orbital rim. The supratrochlear nerves exit from around the orbital rim at an average of 9 mm medial to the exit of the supraorbital nerve.46 The nerves supply sensation to the midforehead with some overlap from the supraorbital nerves. Infratrochlear nerves, also from division one of the trigeminal nerve, exit just below the supratrochlear nerves around the medial orbital rim to supply sensation to the upper nose and medial orbit. Zygomaticofrontal and zygomaticotemporal nerves are from the second division of the trigeminal nerve. They exit their respective small foramina and supply sensation to the lateral orbit and temporal regions of the face. The facial nerve supplies motor innervation to the forehead and glabella.4751 The frontal (or temporal) branch of the facial nerve supplies the frontalis muscle, the superior portion of the orbicularis oculi, the superior portion of the procerus, and the transverse head of the corrugator

supercilii. The zygomatic branch of the facial nerve supplies the medial head of the orbicularis oculi, the oblique head of the corrugator supercilii, the inferior portion of the procerus, and the depressor supercilii (Figure 67-20). The auriculotemporal nerve, from the third division of the trigeminal nerve, supplies sensation in front of the ear to the temporal skin above the zygomatic arch and along the course of the superficial artery. It may be confused clinically during a face-lift with the frontal branch of the

facial nerve. It can, however, be distinguished from the facial motor nerve because it runs within 1 cm anterior to the tragus of the ear and parallel to the superficial temporal artery. The much more significant frontal branch of the facial nerve runs an average of 2 cm anterior to the tragus when crossing the zygomatic arch. The temporal branch of the facial nerve crosses the arch at an oblique angle at an average of 2 cm post to the orbital rim. The depth of the temporal nerve is just below the SMAS at the arch and below the

Frontalis Superior temporal fusion line Temporalis Depressor supercilii Corrugator supercilii (oblique head) (transverse head) Orbicularis oculi Procerus
FIGURE 67-8 Cutaway portions of the frontalis muscles, procerus, and orbicularis oculi on one side demonstrate the relationship to the deeper depressors of the brow (corrugator supercilii and depressor supercilii). The zone of fixation (in blue) runs medial to the superior temporal fusion line.

Zone of fixation

Part 9: Facial Esthetic Surgery

Middle meningeal artery Placement location for bone tunnel or screw

Multiple midline venous lakes

Dangerously thin area of bone below the temporal ridge Average skull thickness 5 mm (range 1.78 mm)

Average skull thickness 7 mm (range 411 mm)

FIGURE 67-9 A, Inside view of the calvarium of the skull demonstrating the high density of venous lakes near the midline and associated structures. B, Illustration of the ideal location placement for bone screws or tunnels based on ideal vector of lift and anatomic limitations.

temporoparietal fascia immediately above the arch. The frontal (temporal) branch usually has divided into two rami at the level of the arch and has at least four branches by the time it reaches the level of the eyebrow.

Endoscopic Anatomy
Initial dissection must be performed to gain adequate space for the endoscopic equipment. This early dissection is performed in the posterior forehead and temporal regions; endoscopy-guided dissection is used for the last 2 cm above the orbital rim and zygomatic arch. Elevation of the deep tissues in this safe zone is essentially perNerve fibers from the deep (lateral) branch of the supraorbital nerve Temporoparietal fascia Temporalis Orbicularis-temporal ligament Nerve fibers from the superficial (medial) branch of the supraorbital nerve Temporal branch of the facial nerve

formed blindly through each of the small scalp incisions. Incisions and specific tissue release and fixation techniques are highly variable among surgeons.5259 I prefer to dissect within a completely subperiosteal plane medially to the temporal crest and in the plane immediately above the temporalis fascia below the temporal line on each side. Subperiosteal dissection in the lateral forehead helps to avoid injury to the deep or lateral division of the supraorbital nerve, which runs in the subgaleal plane near the zone of fixation. Some surgeons begin their dissection in a subgaleal plane in the posterior scalp.59,60 Regardless, a space is created in the safer posterior areas

Frontalis (galea) Periosteum Bone

FIGURE 67-10 Layers of fascia are seen on each side of the zone of fixation (in blue). The layers must be elevated and connected to a uniform sliding plane surgically to achieve pleasing and long-lasting brow lift results, while not damaging the associated motor and sensory nerves.

of the scalp to allow room for placement of an endoscope, which aids dissection in the more risky areas of the forehead. The first anatomic landmark the surgeon must consider is the zone of fixation along the superior temporal crest. Its inferior edge is found near the superior lateral orbital rim. A convergence of fibers from the periosteum, galea, temporalis, and temporoparietal fascia interlace and fuse to form the zone of adherence, much in the same way the layers of tissue planes come together at the level of the zygomatic arch. The zone of fixation can be elevated bluntly at the hairline level and a couple centimeters below, but as the surgeon approaches the lateral brow beginning approximately 2 cm above brow level, use of an endoscope aids dissection. At this point the ligament has branches of the temporal nerve within it, and care must be taken to remain against the bone and temporalis fascia below to avoid nerve injury. Another fibrous attachment, the orbicularis-temporal ligament, is also present here and contains motor nerve fibers (see Figure 67-17); it is the decussation of fibers from the temporoparietal fascia and of the temporal fascia that extends laterally from the orbital ligament. The zone of adherence becomes even more tenacious as the orbital ligament (see Figure 67-7) at the orbital rim level is approached. Slow meticulous dissection is required at this point to avoid nerve injury as well as injury to the sentinel vein that is located within the orbicularis-temporal ligament approximately 1 cm laterally to the zygomaticofrontal suture. Careful dissection exposes an intact sentinel vein that can be seen piercing through the temporal fascia at a perpendicular

Forehead and Brow Procedures

Depressor supercilii Oblique head of corrugator supercilii Depressor supercilii

FIGURE 67-11 The oblique and transverse heads of the corrugator supercilii are seen behind the stump of the depressor supercilii. Both heads of the corrugator muscles and the orbicularis oculi insert into the dermis below the brow.

trochlear nerve and depressor supercilii muscle may be seen and protected from injury. Medially, in the glabella, the procerus muscle, which is variable in thickness, is seen. Care should be taken to avoid overaggressive muscle resection in thin patients as this can result in an atrophic defect in the glabella. Deeper dissection toward the skin level under the brow will lead to the orbicularis oculi but is typically not necessary to gain the desired effect (except with regard to the lateral orbicularis, where limited transection may improve lateral brow elevation).62,63 Also, one or more incisions through the periosteum at higher levels under the frontalis muscle in the midline can be performed but is only required if deep horizontal lines are present.64 It is more important to gain complete release of the retaining lateral ligaments, transection of those muscles causing glabellar lines, and adequate separation of the periosteum along the orbital rim to get the elevation of brow and forehead tissues for the most pleasing and long-term esthetic result.6575

angle and entering the temporoparietal fascia above (see Figure 67-17). Dissection above the orbital rims in the subperiosteal plane should expose the entire superior orbital rim from each zygomaticofrontal suture. The curvature of the rims should be visualized so that transection through the periosteum can be made at the level of the rims. The nasofrontal suture may not always be seen but can be felt by the periosteal elevator used to lift tissue. When transecting through the periosteum across the entire orbital rim, subgaleal fat is often encountered initially, except when the transection is directly behind the supraorbital nerve at the rim level where the deep (or lateral) division

of the nerve is closely adherent to periosteum (see Figure 67-15). Preoperatively marking a point on the brow at a level tangential to the medial limbus iris helps the surgeon to easily identify the location of the supraorbital vessels and nerves.46 Dissection through the periosteum in this region should be performed slowly and superficially to avoid injury to these structures. The transverse head of the corrugator supercilii is seen at the orbital rim level behind the supraorbital vessels and nerves. The corrugator supercilii can be carefully transected or partially excised.61 Medially, the oblique head of the corrugator is encountered, and by a transection through this portion of muscle, the supra-

Preoperative Evaluation and Surgical Preparation

Determining whether a patient will benefit from a brow or forehead lift and which procedure will work best is critical to avoid disappointing the patient. Commonly the novice surgeon notices only horizontal forehead lines as an indication for a brow lift. Unfortunately, this is much less of a problem for most patients than is a low lateral brow position (hooding) or glabellar crease (see Figure 67-3). As discussed above, the ideal female brow position is above the orbital rim at a level that varies among individuals. An average distance of 5 to 10 mm of brow elevation above the rim in the lateral third generally looks most pleasing. Men require a straight-up elevation of the entire brow to avoid feminizing their appearance by overelevation of the lateral brow. In addition, men may benefit more from a standard upper blepharoplasty and local transpalpebral brow lift if the brow ptosis is minimal. As with any cosmetic surgery, a decision regarding the risks and benefits must be made and must conform to the patients desires. Patient education is required so that they know the risks as well as what can realistically be achieved (Figure 67-21). Even with fairly aggressive muscle resection and forehead elevation, patients often form new dynamic lines in the upper face following surgery. Lateral crows-feet owing to the action of the orbicularis oculi when smiling may appear improved following a brow lift since the muscle is unfolded. However, they are not completely eliminated by brow lifting alone, and the patient must understand that botulinum toxin therapy may be required to treat these particular lines on an ongoing basis.76

FIGURE 67-12 Frown lines of the glabella are produced by the actions of the corrugator supercilii to produce the classic vertical wrinkles, whereas the actions of the more vertically arranged fibers of the procerus muscle produce the horizontal wrinkles seen across the bridge of the nose.

Classic vertical (frown lines) formed by the corrugator supercilii

Horizontal (bunny lines) formed by the procerus

Part 9: Facial Esthetic Surgery A In addition to lines on the forehead, lines in the glabella, brow ptosis, and the condition of the patients skin must also be evaluated. Intrinsic skin and collagen damage from the effects of sun, age, and smoking are not treated by lifting alone. Topical skin care (eg, retinoic acid, microdermabrasion, pulsed-light therapy, sunblocks) along with possible surgical resurfacing must be considered.7779 In general the forehead can be treated safely with chemical peels or laser skin resurfacing into the dermal level simultaneously with brow-lifting procedures, provided the lifting is performed with a subgaleal or subperiosteal technique rather than a subcutaneous one. Finally, bony irregularities or hypertrophic bony orbital rims can be evaluated for treatment by means of a cephalometric radiograph or computed tomography (CT) scan as required. Bony contouring can be performed on a limited basis endoscopically, but a major reduction for significant bone hypertrophy such as a frontal boss is best treated with an open (coronal) approach. The amount of bone reduction is limited by the pneumatization of the frontal sinus, which is best evaluated by CT. Although treatment planning for placement of bone tunnels does not require a preoperative CT, a standard cephalometric radiograph may help to reassure the surgeon regarding the thickness of corticocancellous bone available. As with any surgical procedure, appropriate preoperative laboratory and other indicated tests must be performed. Written instruction are given to the patient regarding pre- and postoperative care, including instructions for shampooing hair with antibacterial soap or other antiseptic shampoo and avoidance of the use of hair spray or other hair products immediately prior to surgery. The patient should be thoroughly instructed on the critical need to avoid all medications that may cause platelet dysfunction 10 days prior to surgery (including aspirin and other nonsteroidal anti-inflammatory drugs, vitamin E, and many over-the-counter herbal supplements). Endoscopic techniques require a very dry operating field that necessitates strict avoidance of these medications as well as proper preoperative injection of vasoconstrictive agents. Prior to anesthesia photos are taken and the patient is marked while awake and sitting up. Following the introduction of general anesthesia or intravenous sedation, the patient is prepped and carefully injected with local anesthetic with epinephrine. I prefer to use a local anesthetic with 1:100,000 epinephrine along the entire orbital rim, and a tumescent anesthesia solution (250 cc of normal saline mixed with 1 cc of 1:1,000 epinephrine and 20 cc of 2% lidocaine) in the remaining upper forehead, temple, and posterior scalp. Careful injection in the desired tissue planes helps to avoid the formation of a

Procerus

Intact corrugator supercilii

Supratrochlear vessels and nerve

Supratrochlear vessels and nerve Transected corrugator supercilii

FIGURE 67-13 Endoscopic views of the right supraorbital structures. Location of the corrugator supercilii relative to the supraorbital nerve (A) immediately before it is transected with a needle-tip cautery (B). Following transection through the belly of the corrugator supercilii.

FIGURE 67-14 Before (A) and after (B) photos following endoscopic forehead and brow lifting demonstrating good elevation of the lateral hooding but over-resection of the medial depressors in the area indicated (arrow). This can result in a surprised look, especially when the patient elevates the brow, as shown.

Forehead and Brow Procedures

Deep division of supraorbital nerve Superficial division of supraorbital nerve Transverse head of corrugator supercilii Orbicularis oculi
A

Inferior margin of the galeae fat pad Edge of periosteum Supraorbital vein Superior orbital rim Edge of periosteum

Supratrochlear vein

FIGURE 67-15 A, Line drawing demonstrating right-sided forehead landmarks. B, Endoscopic view of the right supraorbital nerve and vessels. The first view is seen with a 27-gauge needle over the nerve trunk after it is placed through the skin of the brow level with the patients medial limbus (iris).

lasting and possibly more precise than open brow lifting techniques. Care must be taken with the coronal lift to avoid elevating the medial brow too much and creating a very high hairline. Roughly, to gain 1 cm of brow elevation, 1.5 to 2 cm of scalp must be excised with this technique. The amount of tissue excised is not a precise determinant of amount of brow elevation obtained. Scoring of the underlying fascia and muscle resection can cause the tissue to stretch oddly, making prediction of the exact brow elevation difficult. The benefits of the coronal lift include great exposure and relatively easy dissection. It can also be used to extend the procedure into a deep plane face-lift by dissection over the zygomatic arches and onto the zygoma and masseter. This much more aggressive lift gives excellent elevation of the midface but greatly increases postoperative edema and the potential for motor nerve damage. The extended technique should only be attempted by an experienced surgeon,8993 and careful consideration should be given to alternative treatments. Comparatively, the basic coronal lift is an easier procedure for the novice surgeon. When selecting this tried-and-true method, one should take into account the disadvantages, including the lengthy scar and possible hair loss, significant scalp anesthesia, and a significantly elevated hairline.

Trichophytic or Pretrichial Forehead and Brow Lift

Although trichophytic and pretrichial lifts are sometimes thought to be the same procedure, the pretrichial lift actually involves an incision in front of the hairline. With this procedure, hair does not grow anterior to the incision, leaving a visible scar in front of the hairline. In contrast, in the trichophytic lift, although still at the frontal hairline, the incision is placed just behind the hairline. This incision is beveled so that follicles in front of the initial skin incision survive and hair grows anterior to the incision to better camouflage the resulting scar. It should be noted that many surgeons use these terms interchangeably. Even better than the trichophytic lift is the irregular trichophytic hairline, which not only employs a beveled incision but creates a wavy pattern along the hairline for a more natural postoperative appearance compared with a straight-line scar. Regardless of the specific incision design, the ultimate advantages of the trichophytic forehead and brow lift include great exposure (similar to that with the coronal approach) and the ability to lower a high forehead. Unlike the classic coronal lift, bare forehead skin is excised from the hairline. Also, lateral incisions and dissection are usually limited with this technique unless required. Incision design can even improve hair thinning in the temporoparietal areas by excising the area

hematoma during the injection and allows for a nearly bloodless procedure. Minor shaving of hair along the marked incision lines is performed if desired immediately prior to the final preparation and draping of the area.

Coronal Forehead and Brow Lift

Still one of the most common approaches for forehead and brow lifting, the classic coronal lift involves an incision across the entire forehead from ear to ear, staying well behind the hairline.8088 Dissection is typically in the subgaleal or subperiosteal plane and then connects to the subtemporoparietal plane laterally. This gives great exposure of the entire orbital rims for bony osteoplasty, if required, and treatment of muscles that require resection including the depressors (corrugator and procerus) as well as the frontalis. Heavy horizontal forehead

creases can be addressed with this technique either by way of midline myotomies or minor midline thinning of the frontalis. Major resection of the frontalis should be avoided to prevent postoperative irregularities and strange facial expressions during frontalis movement. The lateral frontalis should be avoided to prevent nerve damage, ptosis, and other irregularities. Regrettably, the coronal lift also has the disadvantages of a long incision and a significant elevation of the hairline. Patients with a high hairline are not good candidates for this technique since a significant amount of scalp excision is required. Many surgeons believe this scalp excision is a reasonable trade-off because they feel that the technique gives a more lasting approach than do newer endoscopic techniques. If performed correctly, the endoscopic technique can be as long

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Part 9: Facial Esthetic Surgery scopic approach with a slight elevation in hairline rather than risk a visible hairline scar. Still, the patient with an extremely high hairline is often thrilled with the lower hairline obtainable only with the trichophytic approach. Attention to detail and gentle soft tissue management are essential to attaining a natural hairline and hidden scar with this popular technique.

Endoscopic Forehead and Brow Lift

Early attempts at endoscopic surgery began over a century ago with Nietzes description of a crude cystoscope. A few decades ago endoscopic surgery progressed through use in upper gastrointestinal examinations and then intraabdominal surgery. However, facial endoscopic cosmetic surgery did not blossom until the early 1990s. Over the past decade the endoscopic forehead and brow lift procedure has been considered by many to be the state-of-the-art technique for upper facial rejuvenation.9597 It is versatile and can be combined with many other procedures. The most noted benefits of the endoscopic technique are the smaller scars hidden in the hairline and selective brow elevation without the need for removal of any hair or skin (Figure 67-22). The technique involves several incisions placed strategically behind the hairline to gain access for early blunt dissection and insertion of the endoscope and tissue retractor. Other incisions can be used as ports for dissecting tools such as periosteal elevators, electrocautery, lasers, tissue graspers, and suction instruments. Among surgeons a variety of incision (port) designs are used. Fixation points are usually placed at these incision sites; therefore, I prefer five separate 2.5 cm long incisions placed for easy access but mostly for ideal fixation placement. Each of the five incisions begins approximately 1 cm posterior to the hairline. One is placed in the midline in the sagittal plane and two in the parasagittal plane tangential to the lateral third of the brow (where maximum lift is typically desired in

A
Temporoparietal fascia Subtemporoparietal areolar fascia Dissector Temporalis fascia Temporalis Periosteum Frontalis Subgaleal areolar fascia Scope Subperiosteal plane Skull Temporal fusion line

B
FIGURE

67-16 A and B, Endoscopic dissection must connect the tissue planes on each side of the temporal crest. Various approaches may be used as long as the anatomic planes seen above are sufficiently understood to allow proper tissue release, a clean endoscopic view, and protection of the facial nerve.

of hair loss and bringing forward areas of dense hairbearing scalp. The posterior scalp and hairline can be brought forward to lower a high forehead by almost any amount. The more lowering that is desired, the more posterior is the dissection and release. Limited or no posterior dissection can be performed if the hairline is to remain at the same level. The forward dissection is the technique that varies the most among surgeons. A totally subperiosteal technique versus a subgaleal technique is an option. A subcutaneous technique has recently become more popular, particularly when the depressors in the lower brow do not require treatment.94 Staying superficial to the frontalis breaks the dermal insertions that create deep horizontal rhytids. The subcutaneous lift is occasionally combined with deep dissection to treat glabellar lines as well as horizontal lines in the forehead. Overall, the trichophytic technique of forehead and brow lifting is an invaluable tool for any surgeon performing facial cosmetic surgery. When a patient presents with a high forehead and low brow position, the trichophytic approach is the procedure of choice to correct both problems.

The main disadvantage is the potential for a visible incision despite best efforts. All prospective patients considering this technique must be informed of the chance that there may be a visible scar at the hairline. Surprisingly, when presented with the potential problems and given the choice, many patients prefer to undergo an endo-

Orbicularis oculi Inner edge of the lateral orbital rim Incised edge of the orbicularistemporal vein Medial zygomaticotemporal vein

Septum orbitale

Outer edge of the lateral orbital rim

FIGURE 67-17

Deep temporal fascia

Dissection below the patients right temporal crest is shown with release of the orbicularis-temporal ligament. The medial zygomaticotemporal (sentinel) vein seen here pierces the temporalis fascia approximately 1 cm posterior to the zygomaticofrontal suture line.

Forehead and Brow Procedures females). This same incision can be moved slightly medially in male patients to give a more even brow elevation. The midline incision plus the two parasagittal incisions are aligned vertically to avoid unnecessary transection of sensory nerves originating from the supraorbital nerves below. The two parasagittal incisions are placed medial to the temporal crest to gain access to skull bone rather than the more lateral temporalis fascia. Bone is the strongest fixation tissue available and ideally should be used thus.98100 It is important to access the subperiosteal plane easily for a clean future endoscopic view. Accidental placement of the parasagittal incisions too far laterally over the zone of fixation or temporalis muscle makes pocket development difficult and obscures future endoscopic visualization. Moreover, the parasagittal incisions are located in a thick area of the frontal bone where there is a low density of venous lakes. Placing the incision here helps to prevent accidental intracranial injury during bone tunnel creation or placement of bone screws. Lastly, two temporal incisions are made, one on each side of the head, for direct access to the thick temporal fascia. These incisions are placed perpendicular to the desired elevation vector from the lateral canthal region. Coincidently, the temporal incision parallels the course of the temporal branch of the facial nerve that is located 2 to 3 cm inferior to this incision. It also parallels the superficial temporal artery and vein. Arranging the three medial incisions on a vertical axis and the two temporal incisions in an oblique position to parallel the nerve and blood supply in each area can reduce interference with sensation and vascular supply to the scalp. Dissection is performed through the above incisions down through periosteum medial to the temporal crest and down to temporalis fascia lateral to the crest. Some surgeons may elect to use a subgaleal rather than subperiosteal placement of the incision medially. Total subperiosteal dissection medial to the temporal lines rather than subgaleal dissection leads to better fixation and long-term stabilization (see Figure 67-22). Blunt and blind dissection can be carried out after reaching the subperiosteal and subtemporoparietal planes through the five incisions. Finger dissection and long curved endoscopic periosteal elevators are used to lift the tissue anteriorly to a point 2 cm above the orbital rims and zygomatic arch. Posteriorly blunt dissection should elevate the temporal tissues a few centimeters behind the ear, where the temporal fossa becomes self-limiting. The subperiosteal dissection above needs to elevate the scalp at least 10 cm posteriorly but can extend as far back as the lambdoid suture. Once these areas are freed, a connection can be made from the temporal

11

Frontalis Deep division of supraorbital nerve Superficial division of supraorbital nerve Galeal fat pad Orbicularis oculi

Deep division of supraorbital nerve Frontalis Superficial division of supraorbital nerve Corrugator supercilli Galeal fat pad Orbicularis oculi

A region to the subperiosteal dissection through the upper portion of the zone of fixation at the temporal crest by finger dissection (Figure 6723). Blind release of the more inferior portion of the temporal line where the facial nerve crosses should be avoided. Endoscope-guided dissection here helps to prevent nerve injury. Using finger dissection the upper zone of fixation is broken through proceeding from the temporal incision A

FIGURE 67-18 A and B, Distribution of the superficial (medial) and deep (lateral) divisions of the supraorbital nerve.

toward the medial scalp, rather than vice versa, to prevent creation of a false tunnel in the spongy or foamy temporoparietal fascia. False tunnels along the temporal crest create problems when the endoscope is inserted through the parasagittal port to visualize the lateral forehead; the tunnels force the placement of the endoscope in a more superficial plane within the temporoparietal fascia, which greatly increases the chance of nerve B

67-19 A, Preoperative photograph demonstrating the location of the supraorbital vessels by a line drawn vertically from the medial iris. B, One and a half years following an endoscopic forehead and brow lift. No blepharoplasty was ever performed.
FIGURE

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Part 9: Facial Esthetic Surgery then pressure should be applied externally over the rim until improved visualization allows for control of bleeding without nerve damage. Vertical rhytids in the glabella created by the corrugators can be improved greatly by transection through these muscles. Likewise, horizontal glabellar lines are treated by transection of the procerus muscle that creates these particular facial wrinkles. Some surgeons advocate more aggressive surgical avulsion of these muscles with endoscopic biopsy forceps. Aggressive muscle removal may lead to a more permanent treatment of glabellar lines compared with isolated transection only but should be avoided in most cases owing to an increased risk of significant postoperative irregularities and abnormal facial expression. As a rule, patients prefer a more natural appearance with some minor return of frown lines to risking a bizarre facial expression and glabellar depression. Once the periosteum is completely freed across the orbital rims and appropriate muscles have been treated, the cut periosteal edges are spread apart (periosteal elevators work well for this) by at least 1 cm to aid the release at the arcus marginalis. This allows significant and long-term brow elevation. Next the lateral orbital rim must be exposed in the subperiosteal plane after careful

Corrugator supercilii and procerus each receive innervation from both branches of the facial nerve shown

Temporal branches of the facial nerve

Zygomatic branches of the facial nerve

FIGURE 67-20 Motor nerve supply to the forehead depressor muscle comes from both the temporal and zygomatic branches of the facial nerve.

injury. Therefore, it is critical to stay firmly against the periosteum and the temporalis fascia when initially elevating the scalp and forehead. Following blunt elevation of the scalp from each incision for complete flap elevation, the endoscope is normally inserted through one of the three more medial incisions. Poor initial blunt dissection makes the initial endoscopic dissection feel very tight, and care must be taken not to perforate the skin by excessive retraction. Medial dissection over the nasofrontal suture and orbital rims is performed under direct endoscopic vision with a curved and smooth elevator to avoid inadvertent tearing of the periosteum. The periosteum may be thin in some patients, in whom a straighter elevator may be used to transect the periosteum at the level of the rim (arcus marginalis). However, the entire rolled edge of the orbital rim must be visualized before proceeding with periosteal incision (Figure 67-24). Typically the periosteum is more precisely incised with a needle-tip cautery or laser set at low power. The supraorbital nerves and vessels as described earlier are at a level tangential to the medial limbus and are immediately behind (superficial to) the periosteum from the internal endoscopic view.46,101 This necessitates meticulous cautery dissection here to avoid injury to these structures (see Figure 67-24). Suction placed by an assistant from another port is required to maintain a clear view when using cautery or laser. Temporal incisions work well for suction ports during dissection over the rims since the endoscope and cautery take up most of the room through any of the middle three incision sites. With clear and near bloodless dissection at this point, transection can be performed

through the corrugator supercilii and procerus. If unwanted bleeding is encountered and cannot be controlled easily with pinpoint accurate cautery,

FIGURE 67-21 A, Because of both brow ptosis and upper eyelid laxity, the patient shown required upper blepharoplasties as well as endoscopic forehead and brow lifting to achieve the results she desired. B, The patient is shown before and after only blepharoplasty and full-face laser skin resurfacing. She has multiple problems including asymmetry of the brows owing to a blepharospasm on the left side, eyelid asymmetry and severe laxity, pseudoelevation of the brows owing to frontalis compensation for severe eyelid ptosis, and severe actinic skin damage. She is not a good candidate for simultaneous brow lifting since a change in brow position will likely occur following the removal of the eyelid ptosis. She is a good candidate for botulinum toxin therapy on her left side.

Forehead and Brow Procedures A B C D E

13
F

Preoperative

6 days

14 days

2 months

1 year

3 years

FIGURE 67-22 A to F, Sequential appearance following endoscopic forehead and brow lifting (eyelid and skin resurfacing procedures were also performed). Slight overelevation of the brow is noted for 6 days after surgery, as expected. The brow position remains very stable from 2 weeks to 3 years after the surgery.

release below the zone of fixation and orbital ligament. Dissection along the anterior and inferior aspects of the temporal crest must be performed cautiously to avoid temporal nerve injury. Overzealous retraction of the dense tissue here that contains the nerve can result in nerve damage. Staying snuggly against periosteum and the temporalis fascia helps to prevent nerve damage and produces a much cleaner dissection. Slowly creating a distinct plane of dissection down to the zygomaticofrontal suture line and avoiding excess retraction helps to prevent unwanted bleeding from the sentinel vein (zygomaticotemporal vein), which needs not be sacrificed for a standard endoscopic forehead and brow lift. Dissection for a standard endoscopic brow lift should not proceed all the way to the zygomatic arch but should stop approximately 1 cm above this level. If an extended midface lift is planned and there is a desire to elevate tissue over the zygomatic arch itself, then dissection must go below the superficial layer of deep temporal fascia just above the arch. Abbreviated midface lifts performed simultaneously with endoscopic brow lifts may simply stay in the subperiosteal plane along the lateral orbital rim and avoid the more risky full-arch release. The beauty of the classic endoscopic brow lift is its versatility and the ease with which additional procedures can be combined simultaneously with this eloquent cosmetic surgery. For instance, the temporal incision of an endoscopic forehead lift can easily be extended inferiorly to meet up with the preauricular incision from a standard lower face-lift. Also, midface lifting (with intraoral dissection) can connect the intraoral subperiosteal dissection over the zygoma to the subperiosteal plane from the endoscopic brow lift through a tunnel near the lateral orbital rim (Figure 67-25). After all dissection is complete, appropriate elevation and fixation is required (Figure 67-26). Many techniques have been described such as tissue suture only, bone screws and plates, resorbable

screws, bone tunnels, local skin excision, temporalis muscle exposure for added scarification, tissue glue, and tight head wraps.102 Regardless of any specific fixation technique, the key to long-term fixation is adequate lower forehead tissue release during endoscopic dissection. Failure to adequately release internal tissue results in a relapse of brow ptosis, even with heavy fixation and the appearance of a nice lift during surgery. Once complete internal release of the forehead is obtained, the specific lifting vectors must be determined for the most pleasing esthetic

effect. The lateral third of the female brow is elevated to the greatest extent, which is up to 1 cm above the orbital rim. The medial brow should be only slightly above the rim level and definitely below the middle and lateral brow levels to avoid a surprised or bewildered expression (see Figure 67-14). Typically the glabellar region is elevated on its own without the need for midline fixation, which helps to avoid overelevation medially. The lateral third of the brow is lifted straight up and fixated at the level of the hairline. The galeal tissue is typically secured to bone at this point,

FIGURE 67-23 Blind finger dissection is performed initially, avoiding overzealous dissection inferiorly. Dissection proceeds from the subtemporoparietal plane laterally to the already elevated subperiosteal plane medially. The opposite direction of elevation (medial to lateral) may produce false tunnels in the temporoparietal tissue, which impair future endoscopic vision.

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Part 9: Facial Esthetic Surgery

Oblique head of corrugator supercilii Orbicularis oculi Septum orbitale Right supraorbital nerve Levator Transverse head of corrugator supercilii Depressor supercilii

FIGURE 67-24 A, This line drawing demonstrates the orbital rim and local depressor muscle as seen from a transblepharoplasty incision. B, Endoscopic photographs show the rolled border of orbital rim prior to periosteal release in the first view and the supraorbital nerve and vein in the next view after excising through the periosteum.

while the lateral brow is held at the desired height or 1 to 2 mm above the desired level.12 Very little relapse occurs with proper technique and averages only 1 to 2 mm after 2 weeks. Measurements can also be made with clear circular templates from the pupil to brow to help improve symmetry. The brow position remains very stable following this early recovery period (see Figure 6722). A question remains as to the time required

for complete fixation of the periosteum. Some animal studies suggest a full 12 weeks are required for what is termed full histologic periosteal refixation.103 However, there is clinical evidence suggesting adequate fixation occurs in as little as 7 days. An example is the common fixation technique used by many surgeons who place a single transcutaneous bone screw at each parasagittal incision, which is removed after only

FIGURE 67-25 Views before (A) and after (B) an endoscopic forehead, brow, and midface lift. Arrows represent vectors of lift. Fixation is performed at the level of the hairline through the temporal and parasagittal incisions shown.

1 week. The 1-week fixation technique has been used with success for many years. It has been suggested that longer bony fixation may provide longer-term retention and less early relapse that some have considered normal. The key to longterm fixation seems for now to be determined usually by proper tissue dissection and release. Although there are many fixation techniques, the use of bone tunnels at the parasagittal incisions appears to be one of the best methods for fixating the galea and periosteum near the hairline to a bone tunnel created posteriorly under the incision using a single heavy suture (see Figure 67-26). Fixation of the lateral tail of the brow is performed at each temporal incision, where an isolated heavy suture plicates the temporoparietal fascia in a posterior and superior vector to the thick temporalis fascia. Optional creation of a small window of exposed temporalis muscle in this area may aid in internal scar formation and fixation. The vector of lift at this outer tail of the brow follows a line drawn at an angle from the outer nasal ala that passes just beside the lateral canthus (see Figure 67-25). Final closure of the hair-bearing scalp incisions can be performed with skin staples only with excellent scar formation since no skin is excised and no pressure exists at the incision sites. Redundant tissue (forehead skin) created by an average of 1 cm of brow elevation is easily distributed evenly over the posterior 15 to 20 cm of elevated scalp, which essentially absorbs or redistributes this excess tissue with few to no signs of bunching. Because of this phenomenon, the endoscopic forehead and brow lift tends to elevate the hairline only a very small amount compared with the open skin excising coronal technique.

Forehead and Brow Procedures

15

Transpalpebral and Other Local Brow Procedures

There has been a significant increase in the movement toward minimally invasive techniques to perform cosmetic surgery. New techniques for forehead and brow rejuvenation fill the literature and offer potentially exciting methods to gain esthetic improvement with less risk than with current procedures. A few such procedures include lateral brow lifting with temporal incisions only, denervation techniques through small punctures around the brow, and direct approaches through an upper blepharoplasty incision. It should be noted that although procedures such as making small punctures to destroy medial portions of facial nerve innervating medial depressors may seem minimally invasive, they are certainly not without risk. Many of the minimally invasive procedures take advantage of the proximity of the local depressor muscle. For instance, the transpalpebral or transblepharoplasty approach for forehead rejuvenation gains access to the local depressors through an upper eyelid incision.108 Dissection through this incision involves a short distance to the corrugator supercilii, the procerus, and depressor supercilii of the glabella, which can each be selectively transected from this incision to reduced unwanted wrinkles and elevate the medial brow (see Figure 67-11). Likewise, the orbicularis can be incised and subperiosteal dissection

FIGURE

67-26 Example of bone tunnel fixation shown at the site of the right parasagittal incision. The anterior circle represents the position of suture placement through the galea, which elevates the lateral brow toward the bone tunnel.

Interestingly, in a survey performed in 1998 of American Society of Plastic Surgeons members, of the total 6,951 brow lifts performed by 570 members who returned the questionnaire, 3,534 involved a coronal technique and incision and 3,417 were performed endoscopically. The most noted difference was the higher risk of hair loss with the coronal technique; however, both techniques enjoyed very low overall complication rates.

izontal line already present in the forehead. Although this is probably the least used of all the techniques described, it may be a practical alternative for the elderly patient with thin eyebrows and deep horizontal rhytids who requires a short procedure under local anesthesia.

Direct Brow Lift

The direct brow lift involves excision of an ellipse of skin adjacent to and just above the eyebrow (Figure 67-27). A beveled incision is used to parallel the hair follicles of the brow or so that some follicles remain at the base of the bevel to grow later above the scar. The dissection remains in the subcutaneous plane to avoid muscle or nerve injury. Advantages of the direct brow lift are that it is a simple procedure (with an easy two-layer closure), it can be performed under local anesthesia, and it can treat brow position asymmetries. It remains a good alternative technique that may be an excellent option for an elderly patient who has severe brow ptosis and heavy wrinkles but cannot tolerate more extensive surgery and would benefit from a short procedure under local anesthesia. The main disadvantage is the potentially visible scar immediately above the brow.

5 5 3 2 1

Midforehead and Brow Lift

Incisions made in the middle or upper forehead regions have similar advantages and disadvantages to the direct brow lift.104107 The incisions are made on each side of the forehead in an elliptic fashion so that the resulting scar follows a hor-

FIGURE 67-27 Representative incisions for typical brow-lifting procedures: (1) direct brow lift, (2) midforehead lift, (3) trichophytic brow lift, (4) coronal brow lift, and (5) endoscopic brow lift.

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Part 9: Facial Esthetic Surgery excessive toxin treatment of horizontal lines close to the eyebrows (within 1 cm) should often be avoided owing to the risk of true ptosis of the forehead, brow, and upper eyelids. Botulinum toxin has also been recommended to aid long-term stability of the surgical forehead and brow lift. The theory involved is that control of the downward pull of the depressors (by temporarily paralyzing them chemically) gives the periosteum time to attach securely in an elevated position. The injection can be done during surgery but there is an increased risk of eyelid ptosis and an unwanted delay since botulinum toxin typically takes 3 to 5 days to take full effect. Therefore, ideally botulinum toxin is injected 1 to 2 weeks prior to surgery. Regardless of any benefit this may give to long-term surgical fixation, the resulting reduction in wrinkles of the forehead and glabella and in crows-feet is almost always popular with patients, even though the results last for only 3 to 6 months. problems if the patient desires a surgical brow lift later. Therefore, if a patient is seeking brow lifting in addition to the micropigmentation, it is advisable to perform the surgical brow lift prior to the permanent makeup if feasible.

performed above the orbital rim to elevate the lateral brow through this same local incision. Suture plication of the periosteum above the rim may further elevate the lateral brow. Another adjunctive technique in the upper third of the face is that of fat grafting in areas of age-related fat atrophy. Fat can essentially be grafted anywhere; however, caution is required in the glabellar region where occasional local necrosis can occur from fat infiltration. This also occurs occasionally after collagen injections in the same region.109 There are a great number of alternative techniques, and each must be evaluated for safety, efficacy, and longevity on an individual basis.

Postoperative Care
Following surgical forehead and brow lifting, a compression bandage is applied using a material such as Coban or Coflex. The pressure helps to limit edema and hematoma formation while possibly improving fixation. Typically a drain is not required if a very dry field has been maintained. The patient should be instructed to limit activity and to use cold compresses over the eyes and brows. Head elevation is also recommended for the first several days. Avoidance of antiplatelet drugs preoperatively, a careful surgical technique, and the immediate postoperative use of cold compresses, elevation, and limited strenuous activity significantly decrease postoperative healing time. The relatively snug postoperative dressing may be removed on postoperative day 1 to visually inspect the surgical site for any problems. A less constrictive Velcro-type head wrap can then be used to allow patient comfort and easy removal for showering. Patients are allowed to gently shampoo their hair after 24 hours but must be cautioned to avoid water pressure directly over any incision sites. Each incision is then cleaned twice a day with a dilute peroxide solution, and a thin layer of antibiotic ointment is applied for the first week. Staples are removed at the end of 1 week. Chemical treatments of hair such as perms should be delayed for at least 2 weeks to avoid possible hair loss as a reaction to the harsh chemicals. Hot curling irons or other similar devices must be used with caution since areas of scalp anesthesia may be present for months and can predispose a patient to an accidental self-inflicted burn.

Botulinum ToxinAssisted Brow Lift

Botulinum toxin has been used for nearly two decades to improve the esthetic appearance of the upper third of the face by reducing wrinkles of the forehead (horizontal lines), glabella (frown and bunny lines), and lateral orbital crows-feet (laugh lines).110 More recently it has been used specifically to elevate certain regions of the brow to obtain a chemical brow lift.111 The depressor muscles are paralyzed with botulinum toxin not only to reduce the wrinkles they create but also to allow the frontalis muscle to elevate the brow farther because of the decrease in muscular antagonism. By decreasing the tone and downward pull of the orbicularis immediately below the brow, the lateral third of the eyebrow elevates approximately 2 to 4 mm from the result of botulinum toxin placed in the upper crows-feet area. Such treatment of depressor muscles in the glabellar region can help elevate the medial brow. Of course, as with surgical brow lifting, overcorrection in the medial brow may result in an abnormal facial expression. Dosages used vary with individuals. Botox comes in a 100-unit vial to be mixed with 1 to 10 cc normal saline. The more dilute solutions (610 cc/100 units) begin to loose efficacy and can distort the tissue, whereas high concentration mixtures (12 cc/100 units) may be wasteful and imprecise. Regardless of dilution, it is the total dosage in units of botulinum toxin and its proper placement that determine the outcome. For most individuals 5 to 10 units is all that is required for each lateral crows-foot region. However, the larger muscles of the glabella (procerus and corrugators) require at least 15 units of the toxin and up to 50 units for maximum results. Appropriate dosage in the glabella is the most variable. Treatment of horizontal forehead lines typically requires between 15 and 25 units. It should be noted that simultaneous treatment of horizontal forehead lines from the frontalis may decrease or eliminate brow elevation that otherwise may have been created by botulinum toxin treatment of the depressor muscles. Moreover,

Adjunctive Procedures: Skin Care and Micropigmentation

A variety of procedures can be used for the superficial treatment of poor skin texture and are covered more completely in Chapter 69, Skin Rejuvenation Procedures. For complete rejuvenation of the upper third of the face, skin resurfacing techniques may be required to address aging problems, especially those related to sun exposure, that cannot be adequately treated with lifting methods alone. Prior to any resurfacing procedure such as laser skin resurfacing, chemical peels, or dermabrasion, the patient should be treated with topical skin medications to decrease the risk of scarring and pigment problems. Retinoic acidtype preparations used for ideally 6 weeks prior to resurfacing and 4% hydroquinone for patients with darker skin tones (Fitzpatrick 3 or higher) are two possibilities(see Chapter 69, Skin Rejuvenation Procedures). Simultaneous resurfacing procedures can be accomplished with brow lifting provided the surgical plane of dissection is subperiosteal or subgaleal and not subcutaneous. Another adjunctive procedure growing in popularity is medical micropigmentation. The use of new skin pigments that do not contain iron oxide has improved the appearance of tattoos placed to enhance a thin eyebrow or as permanently applied eyeliner. The ink is relatively permanent but often requires touch-ups owing to some fading over the first 3 to 5 years. Patients who have poor hand motor skills can greatly benefit from this procedure. A certified technician under a doctors supervision usually performs the micropigmentation. However, consultation with a surgeon prior to micropigmentation is important since placement of a permanent brow tattoo in a more elevated position may create

Complications
Fortunately, major complications are rare with properly performed forehead and brow rejuvenation procedures. Good patient selection, diligent preoperative planning, meticulous surgical technique, and thorough postoperative care are all required to help limit the chance for complications.112115 Minor complications can always occur despite a surgeons best efforts. No matter how minor the problem, the patient must be treated with concern and compassion. Typically patients who undergo cosmetic surgery are expecting to look better as soon as possible and are not always as tolerant of perioperative problems as are trauma patients. Extensive edema and ecchymoses are not normally considered complications but may warrant appropriate reassurance and even simple suggestions to hasten recovery when feasible. Suggestions regarding makeup from a well-trained

Forehead and Brow Procedures staff member may greatly improve a postoperative patients mood when shown how to better hide persistent erythema or ecchymosis. True complications include poor scar appearance, wound dehiscence, hematoma, skin sloughs or perforations, asymmetries, sensory disturbances, facial paralysis, eyelid ptosis, corneal abrasions, dry eye syndrome, hair loss (alopecia), infection, relapse, irregular facial expressions, and contour irregularities. Of all these potential problems, permanent facial paralysis and major tissue loss are the most devastating. Fortunately, these particular complications are rare (< 0.3%, which is less than that for a standard lower face-lift). Regardless, it is critical to know the precise anatomy and to avoid improper or excessive retraction, overzealous cautery, and overthinning of the flaps when transecting the depressors. In addition, hematomas must be diagnosed and treated without delay. Some problems such as corneal abrasions can be very concerning to the patient owing to the severe pain and can be nearly eliminated by proper technique and perioperative attention to detail. For instance, an eye lubricant should always be used. Also, thought should be given to the placement of temporary tape strips, such as Steri-Strips, over the eyelids or a tarsorrhaphy suture to help prevent inadvertent scratching of the cornea by gauze or tubing, for example, during the procedure (see Figure 67-16). All severe pain requires immediate evaluation, and suspected abrasion should be treated by appropriate ophthalmic drops for pain and patching of the affected eye for 12 to 24 hours. Appropriate ophthalmologic consultation is required for persistent or uncontrollable eye pain, persistent dryeye symptoms, or unusual changes in vision. Minor blurred vision for the first 12 hours is not unusual owing to chemosis and use of ophthalmic ointments. Alopecia and sensory disturbances can be bothersome to the patient and often are not permanent. The problem is the inability to predict whether the numbness a patient has will partially, fully, or not go away, and just how soon is might be alleviated. With proper technique, an endoscopic forehead and brow lift has a high rate of sensory nerve recovery, but full recovery may take several months and require patient reassurance. Although exact numbers are not known, empiric observation of the last 150 endoscopic brow lifts that I have performed suggests that sensory disturbances are an occasional early concern but an unusual complaint after 6 to 12 months. Alopecia, on the other hand, is a significant concern, especially if it persists longer than 6 to 12 months. Hair may return after an average 4to 8-month dormancy period of the hair follicle. However, excessive tension on the flaps, rough handling of wound margins, or excessive use of cautery near follicles may lead to permanent hair loss that requires treatment.116 Proper planning, technique, and postoperative care helps to reduce the incidence of complications. Immediate and appropriate treatment along with sincere concern for the patients wellbeing should help to reduce the chance of the situation worsening or patient being dissatisfied.

17

day, it is the surgeons responsibility to provide the patient with the best and safest options available to achieve realistic goals.

References
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Summary and Conclusions

An explosion in the number of rejuvenation techniques for the upper face in the past decade, lead by the use of endoscopes and botulinum toxin, has revolutionized the treatment of aging in this area. Cosmetic surgery treatment of the upper third of the face is frequently an essential component for complete facial rejuvenation. Procedures are highly variable and can offer improvement to both young and old. Matching the problems to the ideal rejuvenation techniques is essential for maximum esthetic benefits. Even the best surgical technique can result in inadequate or even poor results if improper patient selection or incorrect diagnoses are made; for this reason, the forehead and brow area must be evaluated critically for a wide range of interlacing diagnoses. Specific skin problems vary with a patients age and sex, but gravity remains consistent and nonselective; therefore, the only issues regarding the occurrence of brow ptosis are when it will occur and how severe it will be. Wrinkles are also inevitable but may be dynamic or static in nature. Thanks to botulinum toxin, the previously difficult treatment of dynamic upper facial lines can be effected at low risk with a simple injection. The common and consistent finding of brow ptosis, especially in the lateral third of the brow, may now be selectively treated endoscopically to achieve a more youthful appearance. Societys idea of beauty at any one moment in time will ultimately help to guide the patient and surgeon to choose where the brow should be placed as opposed to merely raising it higher. True rejuvenation is likely more complex and involves multiple modalities and even tissue replacement such as fat grafting. Only time and persistence will prove what best restores youth to the upper face. Facial cosmetic surgery continues to rise in popularity exponentially. The aging population wants to feel and look more youthful but nonetheless demands to remain natural looking. Todays discerning patient is often very knowledgeable on the subject of their cosmetic surgery options and may insist on a specific technique. The advice of a well-trained surgeon and diagnostician may make or break the ultimate result and prevent a cosmetic disaster. It is vital that the surgeon refuse to perform treatment that is not in the best interest of the patient. Cosmetic surgery is a luxury and is an optional procedure, no matter how much of an emergency it seems to the patient. At the end of the

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Part 9: Facial Esthetic Surgery

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61. 62. 63. 64. 65. 66. 67. 68. 69.

90.

34. 35. 36.

91.

92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103.

37. 38. 39. 40. 41. 42. 43. 44. 45. 46.

70. 71. 72.

73. 74.

75. 76. 77. 78. 79. 80. 81. 82. 83.

47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60.

104. 105. 106. 107. 108. 109. 110.

111. 112. 113. 114. 115. 116.

84.

85. 86. 87.