Forehead and Brow Procedures

C H A P T E R S I X T Y- S E V E NForehead and Brow ProceduresAngelo Cuzalina, MD, DDSUpper facial cosmetic surgery has enjoyed an as well as skin texture itself, also must be assessed rejuvenation techniques and to discuss a varietyunprecedented increase in popularity over the in relation to each other. Achieving the patient’s of the most common techniques for rejuvenatingpast decade. The yearning of baby boomers to desired expectation depends not only on sound the forehead and brow region.look and feel rejuvenated has led to new endo- surgical skill and judgment, it also depends criti-scopic techniques aimed at creating a more cally on communication between the surgeon Anatomic and Esthetic Considerationsyouthful and natural appearance with shorter and patient. Truthful disclosure of what can rea- It is generally accepted that a youthful forehead isrecovery periods than existed in past decades.1–3 sonably be attained is prudent and helps to pre- roughly one-third of the overall facial height.4–9The ultimate goal of improving a person’s vent patient dissatisfaction. Essentially, the distance from the hairline to theappearance remains unchanged. Society shapes Rejuvenation of the upper third of the face is glabella is equal to the distance from the glabellaour views of what looks attractive, and no math- one of the most rewarding and fulfilling proce- to the point at the base of the columella or sub-ematic formula can ever be used to determine an dures a surgeon can offer to select patients. Spe- nasale (Figure 67-5). A youthful-appearing eye-ideal eyebrow position (Figure 67-1). Each indi- cific elevation and correction of lateral hooding brow is different for men and women. The femalevidual has his or her own unique perception of can be appear natural and still impart a tremen- eyebrow should be arched with the highest pointfacial beauty. For most people the upper face and dous improvement in the patient’s overall beauty of the brow on a sagittal line from the lateral can-eyes impart more emotion than does any other and youthful appearance (Figure 67-4). The goal thus.10,11 The entire brow itself should be abovepart of the human body; it is clear that rejuvena- of this chapter is to review the upper third of the orbital rim. In general the medial brow of thetion of this vital area can provide an esthetically facial anatomy specific to forehead and brow female is located ideally 1 to 3 mm above thepleasing result. Esthetic concerns of the forehead and browregions of the face affect a wide range of agegroups. Unlike the standard lower face and neckrhytidectomy, which more commonly affectspatients after the age of 45 years, cosmetic con-cerns in the upper third of the face may be evi-dent for patients in their twenties and thirtiesowing to genetic predisposition. The foreheadand brow area must be entirely evaluated for awide range of interlacing diagnoses. Matchingthe problem(s) to the ideal rejuvenation tech-nique(s) is essential for maximum esthetic bene-fits. Thinning skin and laxity owing to age andgravity encompass only a portion of the foreheadand brow dilemmas that must be addressed whenplanning rejuvenation procedures (Figure 67-2). The aging process typically leads to foreheadand brow ptosis on almost every patient; howev-er, it is important to distinguish whether the pto-sis in the forehead and brow region is owing toproblems with brow position, upper eyelid laxity,or a combination of the two (Figure 67-3). Otherproblems such as dynamic lines caused by muscle FIGURE 67-1 Three different types of esthetically pleasing foreheads and eyebrow position. The tail of the eyebrow isactivity in the glabellar region, variable hairline located along the alar-canthal line. The greatest brow arch is seen in the lateral third between the lateral limbus andpatterns, bony abnormalities, and asymmetries, canthus of the eye. The outer half of the brow is “ideally” located 5 to 10 mm above the orbital rim in females.

2 Part 9: Facial Esthetic Surgery Youthful brow Aging brow 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 Frontalis can create an unnatural cat’s-eye appearance, Galeal fat pad particularly if too much tissue is elevated medially along the suture line and lateral canthus. Like- Frontal bone wise, the nasofrontal suture line is a nice landmark to note during dissection for a few reasons. Orbicularis oculi First, dissection usually needs to proceed only a few millimeters below this suture level onto the Fusion at orbital Levator nasal bones for adequate release. Second, the rim aponeurosis paired procerus muscles can be identified here and transection performed if required. Third, Preseptal fat pad Orbital septum depending on the level of horizontal transection Preaponeurotic in this area, the nasofrontal angle point of takeoff fat pad can be altered slightly if desired. Last, nasal tip A B rotation can be achieved if wanted, especially A B with significant dissection below the nasofrontalFIGURE 67-2 A, The youthful brow is elevated proportionately and has densely adherent periorbital fascia and mus- suture line.cle. B, Brow descent owing to aging and the associated loss of fascial integrity, along with orbital fat prolapse. Another general bony landmark is the orbital rim, which limits inferior dissection but must be well visualized and free of periostealorbital rim and the lateral third of the brow 5 to anatomy, vessel and nerve anatomy, and specific attachments to lift the brow and brow fat pads for10 mm above the rim.12 This is in contrast to a endoscopic anatomy, and each anatomic region is long-term results. Important muscle and fascialtypical male eyebrow that should lie at or only addressed individually as it relates to specific sur- attachments are also located at the level of theslightly above the orbital rim in a more horizon- gical procedures. orbital rim medially and laterally. The tenacioustal or uniform arch fashion (Figure 67-6). Elevat- temporal fusion line (zone of fixation) that existsing the lateral third of the male eyebrow dispro- Bony Landmarks along the temporal ridge must be identified dur-portionately more than the remaining brow will Bony landmarks of the forehead and brow region ing dissection.26,27 It is also important to know itscreate a feminine appearance. can be focused all around the frontal bone, which location preoperatively so that proper incision The detailed anatomy of individual areas has makes up the highest percentage of the upper placement can be made to facilitate a clean dis-been well described in the literature and often third of the face. The connections (suture lines section under this area that enhances visualiza-relates to the specific procedure being per- such as the nasofrontal, zygomaticofrontal, and tion endoscopically (Figure 67-8).formed.13–25 Therefore, the following anatomic coronal) are important landmarks because they Bony thickness varies in different areas of thediscussion is simplified by separating the specific can be clinically relevant for limits of dissection skull. In addition, venous lakes present on theregions into bony landmarks, muscle and fascial and can help surgeons determine their location inside surface of the skull tend to be more cen- tralized around the sagittal suture line. If bone tunnels or screws are planned for fixation pur- Frontalis poses, the midline should be avoided, if possible, Periosteum because of the sagittal sinus as well as higher- Subgaleal areolar fascia density venous lakes in this area (Figure 67-9). Brow fat pad Thickness does increase posteriorly near the Deep fascia Orbicularis oculi occiput, but screw or bone tunnel fixation here is Arcus marginalis more challenging and is not required. Caution must be taken also to avoid lateral placement Eyelid fat pad because of thinness of the lateral skull and the Orbital septum middle meningeal arteries. Knowledge of average Levator palpebrae superioris Levator aponeurosis thickness for a given location and internal anatomy indicates that the safest location for bone tun- Whitnalls ligament nels or screws is located along a parasagittal line Orbitalis approximately at the midpupil or lateral limbus line and just anterior to the coronal suture (see Figure 67-9). Muscle and Fascial AnatomyFIGURE 67-2 C, Cross section of the Paired muscles of the forehead and brow regionbrow near the mid pupillary position. C are often thought of as elevators and depressors.

Forehead and Brow Procedures 3 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 theA B main depressors of the medial brow and are theFIGURE 67-3 A, Rejuvenation of the upper third of the face must address whether the problem is limited to brow pto- most common muscles treated with botulinumsis, eyelid ptosis, or a combination of both, as seen in the patient on the left. Skin texture must also be evaluated. B, The toxin type A to help alleviate frown lines in thephoto was taken 1 month after a coronal brow lift, upper blepharoplasties, and full-face laser resurfacing. glabella. These same two muscles are also most often transected during a brow or forehead lift to achieve a smoother and longer-lasting resultAlthough several depressor muscles can pull the as well as the superficial musculoaponeurotic sys- (Figure 67-13).brow down or obliquely, the only true elevator of tem (SMAS) below the level of the zygomatic Another depressor muscle of importance isthe forehead, the frontalis, moves upward to raise arch.31–33 The temporoparietal fascia appears the depressor supercilii, which originates on thethe brow. This movement, along with some static somewhat loose or spongy clinically and houses frontal process of the maxilla just below the cor-tone, maintains brow position but also can lead the temporal nerve within its undersurface. rugator supercilii and inserts in the medialto horizontal creases over time. The frontalis Many other paired forehead and brow mus- frontalis fibers and dermis just above the medialoriginates from the deep galeal plane (galea cles thought of as depressors are present along brow. Because it lies superficial to the corrugator,aponeurotica that connects to the occipitalis pos- the brow to facilitate facial expression.34–41 The it can be easily paralyzed inadvertently by botu-teriorly). It inserts into the orbital portion of the two most well known are the procerus and the linum toxin. It is also important to note becauseorbicularis oculi, which inserts into the dermis corrugator supercilii, which are present in the it lies behind the corrugator and can be transect-immediately below the eyebrow. Its lateral exten- glabella (Figure 67-11). The procerus muscles are ed by aggressive dissection through the corruga-sion fuses into the dense collection of fascia paired superiorly but fuse inferiorly into one tor during a brow lift. Although patients with aalmost 1 cm wide, called the zone of adherence, muscle belly that originates from the nasal bones very low medial brow position may occasionallywhich extends along the superior temporal line and cartilage. Superiorly procerus fibers insert benefit from this maneuver, it often gives rise toand ends inferiorly just above the zygomati- into medial frontalis and the overlying dermis. over-elevation of the medial brow followingcofrontal suture. The procerus is responsible for depression and surgery, which causes the patient to look some- The fascial attachments, known as theorbital ligament (see Figure 67-7), are the inferi-or termination point of the zone of adherence A B Cnear the orbital rim where connective tissuefibers of the temporoparietal fascia are fixated tothe bone at the superolateral orbital rim (Figure67-10). Lateral and posterior along a near hori-zontal line from the orbital ligament is the orbic-ularis-temporal ligament, which is the transversefusion zone of fibers from the lateral orbicularis,the temporoparietal fascia, and the temporalisfascia. These are important clinical anatomicareas because freeing the zones of adherence isnecessary to achieve long-term results with liftprocedures. However, care is required in thisregion to avoid overzealous stretching and injuryto the facial nerve. The acronym SCALP applies for the standardlayers in the forehead: skin, subcutaneous tissue,aponeurosis (the thick galeal fascia), loose areolar(subgaleal) plane, and periosteum28–30; however,the galeal fascia fuses into the frontalis muscle andits midline fascial attachments at this level. Thisallows a sliding movement over the scalp withcontraction of the muscle. The frontalis and galea FIGURE 67-4 A, Preoperative view of patient with classic lateral hooding brow ptosis and only “pseudo” upper eyelidtogether can also be thought of as an extension of laxity or ptosis. B, One week following endoscopic forehead and brow lift only. (Slight overcorrection is noted in thisthe temporoparietal fascia in the temporal region early period.) C, Correction of lateral hooding with isolated brow lift after 1 month.

4 Part 9: Facial Esthetic Surgery Vessel and Nerve Anatomy Blood supply to the upper face and scalp is plen- tiful and comes from multiple sources. Several major vessels of the upper face originate from the external carotid artery including the superficial 1/3 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 1/5 branch of the superficial temporal artery. The internal carotid artery gives way to the middle meningeal artery, and the ophthalmic artery. The 1/3 1/5 B ophthalmic artery then gives rise to the supraor- 1/5 bital and supratrochlear arteries, which exit their respective foramina and supply the majority of the forehead and midscalp with blood. The ter- minal arterial branches of the upper face have major anastomoses with adjacent vessels. 1/3 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 A C superficial and middle temporal veins (Figure 67- 17).45 The sentinel vein can most often be foundFIGURE 67-5 A, Example of ideal facial proportions based on vertical facial thirds and horizontal proportions approx- approximately 1 cm laterally or posteriorly to theimately the width of the eye or one-fifth of the facial width. B, Preoperative. C, Six weeks following endoscopic foreheadand brow lift along with laser skin resurfacing. zygomaticofrontal suture line. It is clinically significant during endoscopic procedures because, if injured, it can result in impaired field visualiza-what surprised (Figure 67-14). Superficial to the describe any of this deep thick fascial layer that is tion and significant bruising.depressor supercilii is the orbital portion of the seen clinically from the temporal crest down to Nerve supply parallels arterial supply toorbicularis oculi that inserts into portions of the the zygomatic arch (Figure 67-16). some degree. The supratrochlear and supraor-adjacent depressors, the superficial surface of the One method of fixation during brow lifting bital nerves, which are responsible for the major-inferior frontalis, as well as the dermis below the is the use of suture to fixate the temporoparietal ity of sensation in the forehead, exit via the samebrow.42,43 The orbital portion of the orbicularis fascia from below a skin incision to the dense and foramina or general location as do the supraor-muscle originates in part from the medial canthal adherent temporalis fascia above the incision to bital and supratrochlear blood vessels. The senso-tendon and adjacent bone. Deep to all the depres- elevate the lateral brow. Some surgeons advocate ry nerves originate from the first division of thesors is the galeal fat pad, which lies immediately removing a window of temporalis fascia and trigeminal nerve. The supraorbital nerve has twobelow the transverse head of the corrugator and exposing the underlying temporalis muscle in divisions after exiting its foramen: the deep (orhelps in identification of muscular landmarks.44 hopes of creating scarification in this region and lateral) division supplies the more lateral andThe galeal fat is usually exposed clinically instant- improving fixation longevity.12 posterior portion of the forehead and scalp, andly after transection through the periosteum alongthe orbital rim (Figure 67-15). Finally, paired temporalis muscles are locat- A Bed in each temporal fossa, where they originateand then insert on the coronoid process of themandible. The importance of these muscles dur-ing upper facial rejuvenation chiefly pertains totheir overlying fascia, which can be used to delin- FIGURE 67-6 A, Female broweate surgical planes and aid in fixation. The shown with a nicely accentuat-spongy temporoparietal fascia is superficial to the ed arch in the lateral third welldense and shiny white temporalis fascia. The above the orbital rim. B, Thetemporalis fascia adheres to the temporalis mus- average male brow position is level with the orbital rim with acles below and splits into a superficial and deep symmetric arch form.layer in the lower half of the fossa. For consisten-cy, the superficial layer of deep temporalis fascia(which really describes only that portion of deeptemporalis fascia at the level of the split andbelow) is subsequently referred to simply as tem-poralis fascia. In essence, this term will be used to

Forehead and Brow Procedures 5 Superior temporal Zone of fixation fusion line Orbital ligament Corrugator supercilii Depressor supercilii Zygomaticofrontal Procerus suture line 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 Whitnall’s tubercle.)the superficial (or medial) division pierces the supercilii. The zygomatic branch of the facial facial nerve. It can, however, be distinguishedfrontalis and runs superficially to the muscle, nerve supplies the medial head of the orbicularis from the facial motor nerve because it runs with-supplying sensation to the forehead along the oculi, the oblique head of the corrugator super- in 1 cm anterior to the tragus of the ear and par-midpupil line (Figure 67-18). The location of the cilii, the inferior portion of the procerus, and the allel to the superficial temporal artery. The muchsupraorbital nerve’s exit is relatively consistent. depressor supercilii (Figure 67-20). more significant frontal branch of the facial nerveThe supraorbital foramen or notch is typically The auriculotemporal nerve, from the third runs an average of 2 cm anterior to the tragusfound within 1 mm of a line drawn in a sagittal division of the trigeminal nerve, supplies sensa- when crossing the zygomatic arch. The temporalplane tangential to the medial limbus (Figure 67- tion in front of the ear to the temporal skin above branch of the facial nerve crosses the arch at an19).46 The deep division has been known to exit the zygomatic arch and along the course of the oblique angle at an average of 2 cm post to theas often as 10% from another foramen that can superficial artery. It may be confused clinically orbital rim. The depth of the temporal nerve isbe as high as 1.5 cm above the orbital rim. during a face-lift with the frontal branch of the just below the SMAS at the arch and below the The supratrochlear nerves exit from aroundthe orbital rim at an average of 9 mm medial tothe exit of the supraorbital nerve.46 The nervessupply sensation to the midforehead with someoverlap from the supraorbital nerves. FrontalisInfratrochlear nerves, also from division one of Superior temporal Zone of fixationthe trigeminal nerve, exit just below the supra- fusion linetrochlear nerves around the medial orbital rim tosupply sensation to the upper nose and medial Temporalisorbit. Zygomaticofrontal and zygomaticotempo- Depressor superciliiral nerves are from the second division of the Corrugator superciliitrigeminal nerve. They exit their respective small (oblique head)foramina and supply sensation to the lateral orbit (transverse head)and temporal regions of the face. Orbicularis oculi The facial nerve supplies motor innervation Procerusto the forehead and glabella.47–51 The frontal (ortemporal) branch of the facial nerve supplies thefrontalis muscle, the superior portion of the FIGURE 67-8 Cutaway portions of the frontalis muscles, procerus, and orbicularis oculi on one side demonstrate theorbicularis oculi, the superior portion of the pro- relationship to the deeper depressors of the brow (corrugator supercilii and depressor supercilii). The zone of fixationcerus, and the transverse head of the corrugator (in blue) runs medial to the superior temporal fusion line.

6 Part 9: Facial Esthetic Surgery Middle meningeal artery Placement location for bone tunnel or screw Dangerously thin area of bone below the temporal ridge Multiple midline venous lakes Average skull thickness 5 mm (range 1.7–8 mm) Average skull thickness 7 mm (range 4–11 mm) A B 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 formed blindly through each of the small scalp of the scalp to allow room for placement of anarch. The frontal (temporal) branch usually has incisions. Incisions and specific tissue release and endoscope, which aids dissection in the moredivided into two rami at the level of the arch and fixation techniques are highly variable among risky areas of the forehead.has at least four branches by the time it reaches surgeons.52–59 I prefer to dissect within a com- The first anatomic landmark the surgeonthe level of the eyebrow. pletely subperiosteal plane medially to the tem- must consider is the zone of fixation along the poral crest and in the plane immediately above superior temporal crest. Its inferior edge is foundEndoscopic Anatomy the temporalis fascia below the temporal line on near the superior lateral orbital rim. A conver-Initial dissection must be performed to gain ade- each side. Subperiosteal dissection in the lateral gence of fibers from the periosteum, galea, tem-quate space for the endoscopic equipment. This forehead helps to avoid injury to the deep or lat- poralis, and temporoparietal fascia interlace andearly dissection is performed in the posterior eral division of the supraorbital nerve, which fuse to form the zone of adherence, much in theforehead and temporal regions; endoscopy-guid- runs in the subgaleal plane near the zone of fixa- same way the layers of tissue planes come togeth-ed dissection is used for the last 2 cm above the tion. Some surgeons begin their dissection in a er at the level of the zygomatic arch. The zone oforbital rim and zygomatic arch. Elevation of the subgaleal plane in the posterior scalp.59,60 Regard- fixation can be elevated bluntly at the hairlinedeep tissues in this “safe zone” is essentially per- less, a space is created in the safer posterior areas level and a couple centimeters below, but as the surgeon approaches the lateral brow beginning approximately 2 cm above brow level, use of an Nerve fibers from Frontalis (galea) endoscope aids dissection. At this point the liga- the deep (lateral) ment has branches of the temporal nerve within branch of the Periosteum it, and care must be taken to remain against the supraorbital nerve Bone bone and temporalis fascia below to avoid nerve Temporoparietal injury. Another fibrous attachment, the orbicu- fascia laris-temporal ligament, is also present here and Temporalis contains motor nerve fibers (see Figure 67-17); it Orbicularis-temporal is the decussation of fibers from the tem- ligament poroparietal fascia and of the temporal fascia that Nerve fibers from extends laterally from the orbital ligament. The the superficial zone of adherence becomes even more tenacious (medial) branch of the supraorbital as the orbital ligament (see Figure 67-7) at the nerve orbital rim level is approached. Slow meticulous Temporal branch dissection is required at this point to avoid nerve of the facial injury as well as injury to the sentinel vein that is nerve located within the orbicularis-temporal ligament approximately 1 cm laterally to the zygomati-FIGURE 67-10 Layers of fascia are seen on each side of the zone of fixation (in blue). The layers must be elevated and cofrontal suture. Careful dissection exposes anconnected to a uniform sliding plane surgically to achieve pleasing and long-lasting brow lift results, while not damag- intact sentinel vein that can be seen piercinging the associated motor and sensory nerves. through the temporal fascia at a perpendicular

Forehead and Brow Procedures 7 trochlear nerve and depressor supercilii muscle may be seen and protected from injury. Medial- ly, 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 Depressor supercilii orbicularis oculi but is typically not necessary to gain the desired effect (except with regard to the lateral orbicularis, where limited transection Oblique head of may improve lateral brow elevation).62,63 Also, corrugator supercilii 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 Depressor supercilii deep horizontal lines are present.64 It is more important to gain complete release of the retain- ing lateral ligaments, transection of those muscles causing glabellar lines, and adequate separa- tion of the periosteum along the orbital rim to get the elevation of brow and forehead tissuesFIGURE 67-11 The oblique and transverse heads of the corrugator supercilii are seen behind the stump of the depres- for the most pleasing and long-term estheticsor supercilii. Both heads of the corrugator muscles and the orbicularis oculi insert into the dermis below the brow. result.65–75 Preoperative Evaluation andangle and entering the temporoparietal fascia of the nerve is closely adherent to periosteum Surgical Preparationabove (see Figure 67-17). (see Figure 67-15). Preoperatively marking a Determining whether a patient will benefit from Dissection above the orbital rims in the sub- point on the brow at a level tangential to the a brow or forehead lift and which procedure willperiosteal plane should expose the entire superi- medial limbus iris helps the surgeon to easily work best is critical to avoid disappointing theor orbital rim from each zygomaticofrontal identify the location of the supraorbital vessels patient. Commonly the novice surgeon noticessuture. The curvature of the rims should be visu- and nerves.46 Dissection through the periosteum only horizontal forehead lines as an indicationalized so that transection through the perios- in this region should be performed slowly and for a brow lift. Unfortunately, this is much less ofteum can be made at the level of the rims. The superficially to avoid injury to these structures. a problem for most patients than is a low lateralnasofrontal suture may not always be seen but The transverse head of the corrugator supercilii brow position (hooding) or glabellar crease (seecan be felt by the periosteal elevator used to lift is seen at the orbital rim level behind the supra- Figure 67-3). As discussed above, the ideal femaletissue. When transecting through the periosteum orbital vessels and nerves. The corrugator super- brow position is above the orbital rim at a levelacross the entire orbital rim, subgaleal fat is often cilii can be carefully transected or partially that varies among individuals. An average dis-encountered initially, except when the transec- excised.61 Medially, the oblique head of the cor- tance of 5 to 10 mm of brow elevation above thetion is directly behind the supraorbital nerve at rugator is encountered, and by a transection rim in the lateral third generally looks mostthe rim level where the deep (or lateral) division through this portion of muscle, the supra- 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 Classic vertical (frown lines) any cosmetic surgery, a decision regarding the formed by the corrugator risks and benefits must be made and must con-FIGURE 67-12 Frown lines of the supercilii form to the patient’s desires. Patient education isglabella are produced by the required so that they know the risks as well asactions of the corrugator supercilii what can realistically be achieved (Figure 67-21).to produce the classic vertical Even with fairly aggressive muscle resection andwrinkles, whereas the actions of forehead elevation, patients often form newthe more vertically arranged fibers dynamic lines in the upper face followingof the procerus muscle produce the surgery. Lateral crow’s-feet owing to the action ofhorizontal wrinkles seen across the orbicularis oculi when smiling may appearthe bridge of the nose. 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 Horizontal (bunny lines) formed required to treat these particular lines on an by the procerus ongoing basis.76

8 Part 9: Facial Esthetic Surgery A In addition to lines on the forehead, lines in the glabella, brow ptosis, and the condition of the patient’s skin must also be evaluated. Intrin- sic skin and collagen damage from the effects of sun, age, and smoking are not treated by lifting Procerus alone. Topical skin care (eg, retinoic acid, micro- dermabrasion, pulsed-light therapy, sunblocks) along with possible surgical resurfacing must be Intact corrugator considered.77–79 In general the forehead can be supercilii treated safely with chemical peels or laser skin resurfacing into the dermal level simultaneously Supratrochlear with brow-lifting procedures, provided the lift-vessels and nerve ing is performed with a subgaleal or subpe- B riosteal 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 com- puted 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 Supratrochlear best treated with an open (coronal) approach.vessels and nerve The amount of bone reduction is limited by the pneumatization of the frontal sinus, which is best evaluated by CT. Although treatment plan- Transected corrugator ning for placement of bone tunnels does not supercilii require a preoperative CT, a standard cephalometric radiograph may help to reassure the sur- FIGURE 67-13 Endoscopic views of the right supraorbital structures. Location of the corruga- geon regarding the thickness of corticocancel- tor supercilii relative to the supraorbital nerve (A) immediately before it is transected with a lous bone available. needle-tip cautery (B). Following transection through the belly of the corrugator supercilii. As with any surgical procedure, appropriate preoperative laboratory and other indicated tests must be performed. Written instruction are given A B 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). Endo- scopic 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. Fol- lowing 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 FIGURE 67-14 Before (A) and after (B) photos following endoscopic forehead and brow remaining upper forehead, temple, and posterior 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 scalp. Careful injection in the desired tissue when the patient elevates the brow, as shown. planes helps to avoid the formation of a

Forehead and Brow Procedures 9 lasting and possibly more precise than open brow Deep division of Inferior margin of lifting techniques. Care must be taken with the supraorbital nerve the galeae fat pad coronal lift to avoid elevating the medial brow too much and creating a very high hairline. Roughly, Superficial division of Edge of periosteum to gain 1 cm of brow elevation, 1.5 to 2 cm of supraorbital nerve scalp must be excised with this technique. The amount of tissue excised is not a precise determi- Transverse head of nant of amount of brow elevation obtained. Scor- corrugator supercilii Supraorbital vein ing of the underlying fascia and muscle resection can cause the tissue to stretch oddly, making pre- Superior orbital Orbicularis oculi rim diction of the exact brow elevation difficult. The benefits of the coronal lift include great Edge of periosteum exposure and relatively easy dissection. It can alsoA Supratrochlear vein 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 attempt- ed by an experienced surgeon,89–93 and careful consideration should be given to alternative treatments. Comparatively, the basic coronal lift is an easier procedure for the novice surgeon.FIGURE 67-15 A, Line drawing demon- When selecting this tried-and-true method, onestrating right-sided forehead landmarks. should take into account the disadvantages,B, Endoscopic view of the right supraor- including the lengthy scar and possible hair loss,bital nerve and vessels. The first view is significant scalp anesthesia, and a significantlyseen with a 27-gauge needle over the elevated hairline.nerve trunk after it is placed through theskin of the brow level with the patient’s Trichophytic or Pretrichial Foreheadmedial limbus (iris). 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 B 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 cam-hematoma during the injection and allows for a creases can be addressed with this technique either ouflage the resulting scar. It should be noted thatnearly bloodless procedure. Minor shaving of by way of midline myotomies or minor midline many surgeons use these terms interchangeably.hair along the marked incision lines is performed thinning of the frontalis. Major resection of the Even better than the trichophytic lift is the irreg-if desired immediately prior to the final prepara- frontalis should be avoided to prevent postopera- ular trichophytic hairline, which not onlytion and draping of the area. tive irregularities and strange facial expressions employs a beveled incision but creates a wavy during frontalis movement. The lateral frontalis pattern along the hairline for a more naturalCoronal Forehead and Brow Lift should be avoided to prevent nerve damage, ptosis, postoperative appearance compared with aStill one of the most common approaches for fore- and other irregularities. straight-line scar.head and brow lifting, the classic coronal lift Regrettably, the coronal lift also has the dis- Regardless of the specific incision design, theinvolves an incision across the entire forehead from advantages of a long incision and a significant ele- ultimate advantages of the trichophytic foreheadear to ear, staying well behind the hairline.80–88 Dis- vation of the hairline. Patients with a high hairline and brow lift include great exposure (similar tosection is typically in the subgaleal or subperiosteal are not good candidates for this technique since a that with the coronal approach) and the ability toplane and then connects to the subtemporoparietal significant amount of scalp excision is required. lower a high forehead. Unlike the classic coronalplane laterally. This gives great exposure of the Many surgeons believe this scalp excision is a lift, bare forehead skin is excised from the hair-entire orbital rims for bony osteoplasty, if required, reasonable trade-off because they feel that the line. Also, lateral incisions and dissection are usu-and treatment of muscles that require resection technique gives a more lasting approach than do ally limited with this technique unless required.including the depressors (corrugator and procerus) newer endoscopic techniques. If performed cor- Incision design can even improve hair thinningas well as the frontalis. Heavy horizontal forehead rectly, the endoscopic technique can be as long in the temporoparietal areas by excising the area

10 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 Nietze’s description of a crude cystoscope. A few decades ago endoscopic surgery progressed through use in upper gas- trointestinal examinations and then intra- abdominal surgery. However, facial endoscopic cosmetic surgery did not blossom until the early 1990s. Over the past decade the endoscopic fore-A head and brow lift procedure has been considered by many to be the state-of-the-art technique for upper facial rejuvenation.95–97 It is versatile and Temporoparietal fascia Periosteum can be combined with many other procedures. The most noted benefits of the endoscopic tech- Subtemporoparietal areolar fascia nique are the smaller scars hidden in the hairline Frontalis and selective brow elevation without the need for Dissector Subgaleal areolar fascia removal of any hair or skin (Figure 67-22). Temporalis fascia Scope The technique involves several incisions Temporalis Subperiosteal plane placed strategically behind the hairline to gain Skull access for early blunt dissection and insertion of the endoscope and tissue retractor. Other inci- B Temporal fusion line sions can be used as ports for dissecting tools such as periosteal elevators, electrocautery, lasers,FIGURE 67-16 A and B, Endoscopic dissection must connect the tissue planes on each side of the temporal crest. Vari- tissue graspers, and suction instruments. Amongous approaches may be used as long as the anatomic planes seen above are sufficiently understood to allow proper tis- surgeons a variety of incision (port) designs aresue release, a clean endoscopic view, and protection of the facial nerve. used. Fixation points are usually placed at these incision sites; therefore, I prefer five separate 2.5of hair loss and bringing forward areas of dense The main disadvantage is the potential for a visi- cm long incisions placed for easy access buthair–bearing scalp. The posterior scalp and hair- ble incision despite best efforts. All prospective mostly for ideal fixation placement. Each of theline can be brought forward to lower a high fore- patients considering this technique must be five incisions begins approximately 1 cm posteri-head by almost any amount. The more lowering informed of the chance that there may be a visi- or to the hairline. One is placed in the midline inthat is desired, the more posterior is the dissec- ble scar at the hairline. Surprisingly, when pre- the sagittal plane and two in the parasagittaltion and release. Limited or no posterior dissec- sented with the potential problems and given the plane tangential to the lateral third of the browtion can be performed if the hairline is to remain choice, many patients prefer to undergo an endo- (where maximum lift is typically desired inat the same level. The forward dissection is the technique thatvaries the most among surgeons. A totally subpe-riosteal technique versus a subgaleal technique is Orbicularis oculian option. A subcutaneous technique has recent-ly become more popular, particularly when the Inner edge of the Incised edge of lateral orbital rim the orbicularis-depressors in the lower brow do not require treat- temporal veinment.94 Staying superficial to the frontalis breaksthe dermal insertions that create deep horizontal Septum orbitale Medial zygomatico-rhytids. The subcutaneous lift is occasionally temporal veincombined with deep dissection to treat glabellarlines as well as horizontal lines in the forehead. Overall, the trichophytic technique of fore- Outer edge of the Deep temporalhead and brow lifting is an invaluable tool for any lateral orbital rim fasciasurgeon performing facial cosmetic surgery.When a patient presents with a high forehead and FIGURE 67-17 Dissection below the patient’s right temporal crest is shown with release of the orbicularis-temporal lig-low brow position, the trichophytic approach is ament. The medial zygomaticotemporal (sentinel) vein seen here pierces the temporalis fascia approximately 1 cm pos-the procedure of choice to correct both problems. terior to the zygomaticofrontal suture line.

Forehead and Brow Procedures 11females). This same incision can be moved slight- Frontalis Deep division ofly medially in male patients to give a more even supraorbital nervebrow elevation. The midline incision plus the two Deep division of Frontalisparasagittal incisions are aligned vertically to supraorbital nerve Superficial division ofavoid unnecessary transection of sensory nerves supraorbital nerveoriginating from the supraorbital nerves below. CorrugatorThe two parasagittal incisions are placed medial Superficial division supercilli of supraorbitalto the temporal crest to gain access to skull bone nerve Galeal fat padrather than the more lateral temporalis fascia.Bone is the strongest fixation tissue available and Galeal fat pad Orbicularis oculiideally should be used thus.98–100 Orbicularis oculi It is important to access the subperiostealplane easily for a clean future endoscopic view.Accidental placement of the parasagittal incisionstoo far laterally over the zone of fixation or tem- B FIGURE 67-18 A and B, Distribu-poralis muscle makes pocket development diffi- tion of the superficial (medial) andcult and obscures future endoscopic visualiza- deep (lateral) divisions of the supra-tion. Moreover, the parasagittal incisions are A orbital nerve.located in a thick area of the frontal bone wherethere is a low density of venous lakes. Placing theincision here helps to prevent accidental intracra- region to the subperiosteal dissection through toward the medial scalp, rather than vice versa, tonial injury during bone tunnel creation or place- the upper portion of the zone of fixation at the prevent creation of a false tunnel in the spongy orment of bone screws. temporal crest by finger dissection (Figure 67- foamy temporoparietal fascia. False tunnels along Lastly, two temporal incisions are made, one 23). Blind release of the more inferior portion of the temporal crest create problems when theon each side of the head, for direct access to the the temporal line where the facial nerve crosses endoscope is inserted through the parasagittalthick temporal fascia. These incisions are placed should be avoided. Endoscope-guided dissection port to visualize the lateral forehead; the tunnelsperpendicular to the desired elevation vector here helps to prevent nerve injury. Using finger force the placement of the endoscope in a morefrom the lateral canthal region. Coincidently, the dissection the upper zone of fixation is broken superficial plane within the temporoparietal fas-temporal incision parallels the course of the tem- through proceeding from the temporal incision cia, which greatly increases the chance of nerveporal branch of the facial nerve that is located 2to 3 cm inferior to this incision. It also parallelsthe superficial temporal artery and vein. Arrang- A Bing the three medial incisions on a vertical axisand the two temporal incisions in an obliqueposition to parallel the nerve and blood supply ineach area can reduce interference with sensationand vascular supply to the scalp. Dissection is performed through the aboveincisions down through periosteum medial tothe temporal crest and down to temporalis fas-cia lateral to the crest. Some surgeons may electto use a subgaleal rather than subperiostealplacement of the incision medially. Total sub-periosteal dissection medial to the temporallines rather than subgaleal dissection leads tobetter fixation and long-term stabilization (seeFigure 67-22). Blunt and blind dissection can be carried outafter reaching the subperiosteal and subtem-poroparietal planes through the five incisions.Finger dissection and long curved endoscopicperiosteal elevators are used to lift the tissue ante-riorly to a point 2 cm above the orbital rims andzygomatic arch. Posteriorly blunt dissectionshould elevate the temporal tissues a few cen-timeters behind the ear, where the temporal fossabecomes self-limiting. The subperiosteal dissec-tion above needs to elevate the scalp at least 10cm posteriorly but can extend as far back as the FIGURE 67-19 A, Preoperative photograph demonstrating the location of the supraorbital vessels by a line drawn ver-lambdoid suture. Once these areas are freed, a tically from the medial iris. B, One and a half years following an endoscopic forehead and brow lift. No blepharoplas-connection can be made from the temporal ty was ever performed.

12 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. Corrugator supercilii and Vertical rhytids in the glabella created by the procerus each receive innervation from both corrugators can be improved greatly by transec- branches of the facial tion through these muscles. Likewise, horizontal nerve shown 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 Temporal branches lead to a more permanent treatment of glabellar of the facial nerve lines compared with isolated transection only but should be avoided in most cases owing to an Zygomatic branches increased risk of significant postoperative irregu- of the facial nerve larities 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 musclesFIGURE 67-20 Motor nerve supply to the forehead depressor muscle comes from both the temporal and zygomatic have been treated, the cut periosteal edges arebranches of the facial nerve. spread apart (periosteal elevators work well for this) by at least 1 cm to aid the release at the arcusinjury. Therefore, it is critical to stay firmly through the corrugator supercilii and procerus. If marginalis. This allows significant and long-termagainst the periosteum and the temporalis fascia unwanted bleeding is encountered and cannot be brow elevation. Next the lateral orbital rim mustwhen initially elevating the scalp and forehead. controlled easily with pinpoint accurate cautery, be exposed in the subperiosteal plane after careful Following blunt elevation of the scalp fromeach incision for complete flap elevation, theendoscope is normally inserted through one of A Bthe three more medial incisions. Poor initialblunt dissection makes the initial endoscopic dis-section feel very tight, and care must be taken notto perforate the skin by excessive retraction.Medial dissection over the nasofrontal suture andorbital rims is performed under direct endoscop-ic vision with a curved and smooth elevator toavoid inadvertent tearing of the periosteum. Theperiosteum may be thin in some patients, inwhom a straighter elevator may be used to tran-sect the periosteum at the level of the rim (arcusmarginalis). However, the entire rolled edge ofthe orbital rim must be visualized before pro-ceeding with periosteal incision (Figure 67-24).Typically the periosteum is more precisely incisedwith a needle-tip cautery or laser set at lowpower. The supraorbital nerves and vessels asdescribed earlier are at a level tangential to themedial limbus and are immediately behind(superficial to) the periosteum from the internalendoscopic view.46,101 This necessitates meticu-lous cautery dissection here to avoid injury tothese structures (see Figure 67-24). Suctionplaced by an assistant from another port isrequired to maintain a clear view when using FIGURE 67-21 A, Because of both brow ptosis and upper eyelid laxity, the patient shown required upper blepharo-cautery or laser. Temporal incisions work well for plasties as well as endoscopic forehead and brow lifting to achieve the results she desired. B, The patient is shown beforesuction ports during dissection over the rims and after only blepharoplasty and full-face laser skin resurfacing. She has multiple problems including asymmetry ofsince the endoscope and cautery take up most of the brows owing to a blepharospasm on the left side, eyelid asymmetry and severe laxity, pseudoelevation of the browsthe room through any of the middle three inci- owing to frontalis compensation for severe eyelid ptosis, and severe actinic skin damage. She is not a good candidate forsion sites. With clear and near bloodless dissec- simultaneous brow lifting since a change in brow position will likely occur following the removal of the eyelid ptosis.tion at this point, transection can be performed She is a good candidate for botulinum toxin therapy on her left side.

Forehead and Brow Procedures 13 A B C D E F Preoperative 6 days 14 days 2 months 1 year 3 yearsFIGURE 67-22 A to F, Sequential appearance following endoscopic forehead and brow lifting (eyelid and skin resurfacing procedures were also performed). Slight overelevation ofthe 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 lig- screws, bone tunnels, local skin excision, tempo- effect. The lateral third of the female brow is ele-ament. Dissection along the anterior and inferior ralis muscle exposure for added scarification, tis- vated to the greatest extent, which is up to 1 cmaspects of the temporal crest must be performed sue glue, and tight head wraps.102 Regardless of any above the orbital rim. The medial brow should becautiously to avoid temporal nerve injury. specific fixation technique, the key to long-term only slightly above the rim level and definitelyOverzealous retraction of the dense tissue here fixation is adequate lower forehead tissue release below the middle and lateral brow levels to avoidthat contains the nerve can result in nerve dam- during endoscopic dissection. Failure to adequate- a surprised or bewildered expression (see Figureage. Staying snuggly against periosteum and the ly release internal tissue results in a relapse of brow 67-14). Typically the glabellar region is elevatedtemporalis fascia helps to prevent nerve damage ptosis, even with heavy fixation and the appear- on its own without the need for midline fixation,and produces a much cleaner dissection. Slowly ance of a “nice” lift during surgery. which helps to avoid overelevation medially. Thecreating a distinct plane of dissection down to the Once complete internal release of the fore- lateral third of the brow is lifted straight up andzygomaticofrontal suture line and avoiding excess head is obtained, the specific lifting vectors must fixated at the level of the hairline. The galeal tis-retraction helps to prevent unwanted bleeding be determined for the most pleasing esthetic sue is typically secured to bone at this point,from the sentinel vein (zygomaticotemporalvein), which needs not be sacrificed for a standardendoscopic forehead and brow lift. Dissection for a standard endoscopic browlift should not proceed all the way to the zygo-matic arch but should stop approximately 1 cmabove this level. If an extended midface lift isplanned and there is a desire to elevate tissue overthe zygomatic arch itself, then dissection must gobelow the superficial layer of deep temporal fas-cia just above the arch. Abbreviated midface liftsperformed simultaneously with endoscopic browlifts may simply stay in the subperiosteal planealong the lateral orbital rim and avoid the morerisky full-arch release. The beauty of the classicendoscopic brow lift is its versatility and the easewith which additional procedures can be com-bined simultaneously with this eloquent cosmet-ic surgery. For instance, the temporal incision ofan endoscopic forehead lift can easily be extend-ed inferiorly to meet up with the preauricularincision from a standard lower face-lift. Also,midface lifting (with intraoral dissection) canconnect the intraoral subperiosteal dissectionover the zygoma to the subperiosteal plane fromthe endoscopic brow lift through a tunnel nearthe lateral orbital rim (Figure 67-25). After all dissection is complete, appropriate FIGURE 67-23 Blind finger dissection is performed initially, avoiding overzealous dissection inferiorly. Dissection pro-elevation and fixation is required (Figure 67-26). ceeds from the subtemporoparietal plane laterally to the already elevated subperiosteal plane medially. The oppositeMany techniques have been described such as tis- direction of elevation (medial to lateral) may produce false tunnels in the temporoparietal tissue, which impair futuresue suture only, bone screws and plates, resorbable endoscopic vision.

14 Part 9: Facial Esthetic Surgery Oblique head of corrugator supercilii Orbicularis oculi Transverse head of Septum orbitale corrugator supercilii Right supraorbital nerve Levator Depressor supercilii A B FIGURE 67-24 A, This line drawing demonstrates the orbital rim and local depressor muscle as seen from a transblepharoplasty incision. B, Endoscop- ic 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 for complete fixation of the periosteum. Some 1 week. The 1-week fixation technique has beenor 1 to 2 mm above the desired level.12 Very little animal studies suggest a full 12 weeks are used with success for many years. It has been sug-relapse occurs with proper technique and aver- required for what is termed full histologic gested that longer bony fixation may provideages only 1 to 2 mm after 2 weeks. Measurements periosteal refixation.103 However, there is clinical longer-term retention and less early relapse thatcan also be made with clear circular templates evidence suggesting adequate fixation occurs in some have considered normal. The key to long-from the pupil to brow to help improve symme- as little as 7 days. An example is the common fix- term fixation seems for now to be determinedtry. The brow position remains very stable fol- ation technique used by many surgeons who usually by proper tissue dissection and release.lowing this early recovery period (see Figure 67- place a single transcutaneous bone screw at each Although there are many fixation tech-22). A question remains as to the time required parasagittal incision, which is removed after only niques, the use of bone tunnels at the parasagittal incisions appears to be one of the best methods for fixating the galea and periosteum near theA B 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. Redun- dant 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 hairlineFIGURE 67-25 Views before (A) and after (B) an endoscopic forehead, brow, and midface lift. Arrows represent vec- only a very small amount compared with the opentors of lift. Fixation is performed at the level of the hairline through the temporal and parasagittal incisions shown. 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 cer- tainly not without risk. Many of the “minimally invasive” procedures take advantage of the proximity of the local depressor muscle. For instance, the transpalpebralFIGURE 67-26 Example of bone tunnel fixation shown at the site of the right parasagittal incision. The anterior circlerepresents the position of suture placement through the galea, which elevates the lateral brow toward the bone tunnel. 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 Interestingly, in a survey performed in 1998 of izontal line already present in the forehead. the corrugator supercilii, the procerus, andAmerican Society of Plastic Surgeons members, of Although this is probably the least used of all the depressor supercilii of the glabella, which can eachthe total 6,951 brow lifts performed by 570 mem- techniques described, it may be a practical alter- be selectively transected from this incision tobers who returned the questionnaire, 3,534 native for the elderly patient with thin eyebrows reduced unwanted wrinkles and elevate the medi-involved a coronal technique and incision and and deep horizontal rhytids who requires a short al brow (see Figure 67-11). Likewise, the orbicu-3,417 were performed endoscopically. The most procedure under local anesthesia. laris can be incised and subperiosteal dissectionnoted difference was the higher risk of hair losswith the coronal technique; however, both tech-niques enjoyed very low overall complication rates.Direct Brow Lift 5 4The direct brow lift involves excision of an ellipse 5 3of skin adjacent to and just above the eyebrow(Figure 67-27). A beveled incision is used to paral- 2 5lel the hair follicles of the brow or so that some fol-licles remain at the base of the bevel to grow laterabove the scar. The dissection remains in the sub- 1cutaneous plane to avoid muscle or nerve injury. Advantages of the direct brow lift are that itis a simple procedure (with an easy two-layer clo-sure), it can be performed under local anesthesia,and it can treat brow position asymmetries. Itremains a good alternative technique that may bean excellent option for an elderly patient who hassevere brow ptosis and heavy wrinkles but cannottolerate more extensive surgery and would bene-fit from a short procedure under local anesthesia.The main disadvantage is the potentially visiblescar immediately above the brow.Midforehead and Brow LiftIncisions made in the middle or upper foreheadregions have similar advantages and disadvan-tages to the direct brow lift.104–107 The incisionsare made on each side of the forehead in an ellip- FIGURE 67-27 Representative incisions for typical brow-lifting procedures: (1) direct brow lift, (2) midforehead lift,tic fashion so that the resulting scar follows a hor- (3) trichophytic brow lift, (4) coronal brow lift, and (5) endoscopic brow lift.

16 Part 9: Facial Esthetic Surgeryperformed above the orbital rim to elevate the lat- excessive toxin treatment of horizontal lines close problems if the patient desires a surgical brow lifteral brow through this same local incision. Suture to the eyebrows (within 1 cm) should often be later. Therefore, if a patient is seeking brow liftingplication of the periosteum above the rim may avoided owing to the risk of true ptosis of the in addition to the micropigmentation, it is advis-further elevate the lateral brow. forehead, brow, and upper eyelids. able to perform the surgical brow lift prior to the Another adjunctive technique in the upper Botulinum toxin has also been recommend- permanent makeup if feasible.third of the face is that of fat grafting in areas of ed to aid long-term stability of the surgical fore-age-related fat atrophy. Fat can essentially be head and brow lift. The theory involved is that Postoperative Caregrafted anywhere; however, caution is required in control of the downward pull of the depressors Following surgical forehead and brow lifting, athe glabellar region where occasional local necro- (by temporarily paralyzing them chemically) compression bandage is applied using a materialsis can occur from fat infiltration. This also gives the periosteum time to attach securely in an such as Coban™ or Coflex™. The pressure helps tooccurs occasionally after collagen injections in elevated position. The injection can be done dur- limit edema and hematoma formation while pos-the same region.109 There are a great number of ing surgery but there is an increased risk of eyelid sibly improving fixation. Typically a drain is notalternative techniques, and each must be evaluat- ptosis and an unwanted delay since botulinum required if a very dry field has been maintained.ed for safety, efficacy, and longevity on an indi- toxin typically takes 3 to 5 days to take full effect. The patient should be instructed to limit activityvidual basis. Therefore, ideally botulinum toxin is injected 1 to and to use cold compresses over the eyes and 2 weeks prior to surgery. Regardless of any bene- brows. Head elevation is also recommended forBotulinum Toxin–Assisted Brow Lift fit this may give to long-term surgical fixation, the first several days. Avoidance of antiplateletBotulinum toxin has been used for nearly two the resulting reduction in wrinkles of the fore- drugs preoperatively, a careful surgical technique,decades to improve the esthetic appearance of the head and glabella and in crow’s-feet is almost and the immediate postoperative use of cold com-upper third of the face by reducing wrinkles of always popular with patients, even though the presses, elevation, and limited strenuous activitythe forehead (horizontal lines), glabella (frown results last for only 3 to 6 months. significantly decrease postoperative healing time.and bunny lines), and lateral orbital crow’s-feet The relatively snug postoperative dressing(laugh lines).110 More recently it has been used Adjunctive Procedures: Skin Care and may be removed on postoperative day 1 to visu-specifically to elevate certain regions of the brow Micropigmentation ally inspect the surgical site for any problems. Ato obtain a “chemical brow lift.”111 The depressor A variety of procedures can be used for the super- less constrictive Velcro-type head wrap can thenmuscles are paralyzed with botulinum toxin not ficial treatment of poor skin texture and are cov- be used to allow patient comfort and easyonly to reduce the wrinkles they create but also to ered more completely in Chapter 69, “Skin Reju- removal for showering. Patients are allowed toallow the frontalis muscle to elevate the brow far- venation Procedures.” For complete rejuvenation gently shampoo their hair after 24 hours butther because of the decrease in muscular antago- of the upper third of the face, skin resurfacing must be cautioned to avoid water pressure direct-nism. By decreasing the tone and downward pull techniques may be required to address aging ly over any incision sites. Each incision is thenof the orbicularis immediately below the brow, problems, especially those related to sun expo- cleaned twice a day with a dilute peroxide solu-the lateral third of the eyebrow elevates approxi- sure, that cannot be adequately treated with lift- tion, and a thin layer of antibiotic ointment ismately 2 to 4 mm from the result of botulinum ing methods alone. applied for the first week. Staples are removed attoxin placed in the upper crow’s-feet area. Such Prior to any resurfacing procedure such as the end of 1 week. Chemical treatments of hairtreatment of depressor muscles in the glabellar laser skin resurfacing, chemical peels, or der- such as “perms” should be delayed for at leastregion can help elevate the medial brow. Of mabrasion, the patient should be treated with 2 weeks to avoid possible hair loss as a reaction tocourse, as with surgical brow lifting, overcorrec- topical skin medications to decrease the risk of the harsh chemicals. Hot curling irons or othertion in the medial brow may result in an abnor- scarring and pigment problems. Retinoic acid–- similar devices must be used with caution sincemal facial expression. type preparations used for ideally 6 weeks prior areas of scalp anesthesia may be present for Dosages used vary with individuals. Botox to resurfacing and 4% hydroquinone for patients months and can predispose a patient to an acci-comes in a 100-unit vial to be mixed with 1 to 10 with darker skin tones (Fitzpatrick 3 or higher) dental self-inflicted burn.cc normal saline. The more dilute solutions (6–10 are two possibilities(see Chapter 69, “Skin Reju-cc/100 units) begin to loose efficacy and can dis- venation Procedures”). Simultaneous resurfacing Complicationstort the tissue, whereas high concentration mix- procedures can be accomplished with brow lift- Fortunately, major complications are rare withtures (1–2 cc/100 units) may be wasteful and ing provided the surgical plane of dissection is properly performed forehead and brow rejuvena-imprecise. Regardless of dilution, it is the total subperiosteal or subgaleal and not subcutaneous. tion procedures. Good patient selection, diligentdosage in units of botulinum toxin and its prop- Another adjunctive procedure growing in preoperative planning, meticulous surgical tech-er placement that determine the outcome. For popularity is medical micropigmentation. The nique, and thorough postoperative care are allmost individuals 5 to 10 units is all that is use of new skin pigments that do not contain required to help limit the chance for complica-required for each lateral crow’s-foot region. How- iron oxide has improved the appearance of tat- tions.112–115 Minor complications can always occurever, the larger muscles of the glabella (procerus toos placed to enhance a thin eyebrow or as per- despite a surgeon’s best efforts. No matter howand corrugators) require at least 15 units of the manently applied eyeliner. The ink is relatively minor the problem, the patient must be treatedtoxin and up to 50 units for maximum results. permanent but often requires touch-ups owing to with concern and compassion. Typically patientsAppropriate dosage in the glabella is the most some fading over the first 3 to 5 years. Patients who undergo cosmetic surgery are expecting tovariable. Treatment of horizontal forehead lines who have poor hand motor skills can greatly ben- look better as soon as possible and are not alwaystypically requires between 15 and 25 units. It efit from this procedure. A certified technician as tolerant of perioperative problems as are trau-should be noted that simultaneous treatment of under a doctor’s supervision usually performs ma patients. Extensive edema and ecchymoses arehorizontal forehead lines from the frontalis may the micropigmentation. However, consultation not normally considered complications but maydecrease or eliminate brow elevation that other- with a surgeon prior to micropigmentation is warrant appropriate reassurance and even simplewise may have been created by botulinum toxin important since placement of a permanent brow suggestions to hasten recovery when feasible. Sug-treatment of the depressor muscles. Moreover, tattoo in a more elevated position may create gestions regarding makeup from a well-trained

Forehead and Brow Procedures 17staff member may greatly improve a postoperative cautery near follicles may lead to permanent hair day, it is the surgeon’s responsibility to provide thepatient’s mood when shown how to better hide loss that requires treatment.116 patient with the best and safest options available topersistent erythema or ecchymosis. Proper planning, technique, and postopera- achieve realistic goals. True complications include poor scar tive care helps to reduce the incidence of compli-appearance, wound dehiscence, hematoma, skin cations. Immediate and appropriate treatment Referencessloughs or perforations, asymmetries, sensory along with sincere concern for the patient’s well- 1. Ramirez OM. Endoscopic techniques in facial rejuvenation. An overview. Part 1. Aesthetic Plast Surgdisturbances, facial paralysis, eyelid ptosis, being should help to reduce the chance of the sit- 1994;8:141.corneal abrasions, dry eye syndrome, hair loss uation worsening or patient being dissatisfied. 2. Isse NG. Endoscopic facial rejuvenation. Endoforehead,(alopecia), infection, relapse, irregular facial the functional lift. Case reports. Aesthetic Plast Surg Summary and Conclusions 1994;18:21–9.expressions, and contour irregularities. Of all 3. Tessier P. Ridectomie frontale. [Lifting frontale.] Gazthese potential problems, permanent facial paral- An explosion in the number of rejuvenation tech- Méd Fr 1968;75:55–65.ysis and major tissue loss are the most devastat- niques for the upper face in the past decade, lead 4. Becker FF, Johnson CM. Surgical treatment of the upper third of the aging face. In: Cummings CW, Fredrick-ing. Fortunately, these particular complications by the use of endoscopes and botulinum toxin, son JM, Harker LA, editors. Otolaryngology-headare rare (< 0.3%, which is less than that for a has revolutionized the treatment of aging in this and neck surgery. St. Louis: Mosby; 1986. p. 475.standard lower face-lift). Regardless, it is critical area. Cosmetic surgery treatment of the upper 5. Zide BM, Jelks GW. Surgical anatomy of the orbit. New York: Raven Press; 1985.to know the precise anatomy and to avoid third of the face is frequently an essential compo- 6. Fagien S. Eyebrow analysis after blepharoplasty inimproper or excessive retraction, overzealous nent for complete facial rejuvenation. Procedures patients with brow ptosis. Ophthal Plast Reconstrcautery, and overthinning of the flaps when tran- are highly variable and can offer improvement to Surg 1992;8:210. 7. Ellis DAF, Ward D. The aging face. J Otolaryngol 1986;secting the depressors. In addition, hematomas both young and old. Matching the problems to 15:217–23.must be diagnosed and treated without delay. the ideal rejuvenation techniques is essential for 8. Johnson JD, Hadley RC. The aging face. In: Converse Some problems such as corneal abrasions maximum esthetic benefits. Even the best surgical JM, editor. Reconstructive plastic surgery. Philadel- phia: WB Sanders; 1964. p. 1306–42.can be very concerning to the patient owing to technique can result in inadequate or even poor 9. Powell H, Humphrieys B. Proportions of the aestheticthe severe pain and can be nearly eliminated by results if improper patient selection or incorrect face. New York: Thieme-Stratton; 1984.proper technique and perioperative attention to diagnoses are made; for this reason, the forehead 10. Huntley HE. The divine proportion. New York: Dover; 1970.detail. For instance, an eye lubricant should and brow area must be evaluated critically for a 11. Rickets RM. Divine proportion of facial aesthetics. Clinalways be used. Also, thought should be given to wide range of interlacing diagnoses. Plast Surg 1982;9:401.the placement of temporary tape strips, such as Specific skin problems vary with a patient’s 12. Evans TW. Browlift. Atlas of the oral and maxillofacial surgery clinics of North America. Aesthetic surgerySteri-Strips, over the eyelids or a tarsorrhaphy age and sex, but gravity remains consistent and for the aging face. Vol 6. Number 2. 1998. p. 111–33.suture to help prevent inadvertent scratching of nonselective; therefore, the only issues regarding 13. Ellis DAF, Bakala CD. Anatomy of the motor innervation of the corrugator supercilii muscle: clinical sig-the cornea by gauze or tubing, for example, dur- the occurrence of brow ptosis are when it will nificance and development of a new surgical tech-ing the procedure (see Figure 67-16). All severe occur and how severe it will be. Wrinkles are also nique for frowning. J Otolaryngol 1998;27:222–7.pain requires immediate evaluation, and suspect- inevitable but may be dynamic or static in nature. 14. Larrabee WF, Mahielski KH. Surgical anatomy of the face. New York: Raven Press; 1993.ed abrasion should be treated by appropriate Thanks to botulinum toxin, the previously diffi- 15. Gonzalez-Ulloa M. Facial wrinkles, integral elimination.ophthalmic drops for pain and patching of the cult treatment of dynamic upper facial lines can Plast Reconstr Surg 1962;29:658.affected eye for 12 to 24 hours. Appropriate oph- be effected at low risk with a simple injection. 16. Bostwick J, Eaves F, Nahai F. Endoscopic plastic surgery. St. Louis: Quality Medical Publishers; 1995.thalmologic consultation is required for persis- The common and consistent finding of brow pto- 17. Hiatt JL, Gartner LP. In: Gardner J, editor. Textbook oftent or uncontrollable eye pain, persistent dry- sis, especially in the lateral third of the brow, may head and neck anatomy. 2nd ed. Baltimore:eye symptoms, or unusual changes in vision. now be selectively treated endoscopically to Williams and Wilkins; 1987. p. 373–45. 18. Hamas RS. Reducing the subconscious frown by endo-Minor blurred vision for the first 12 hours is not achieve a more youthful appearance. Society’s scopic resection of the corrugator muscles. Aesthet-unusual owing to chemosis and use of oph- idea of beauty at any one moment in time will ic Plast Surg 1995;19:21–5.thalmic ointments. ultimately help to guide the patient and surgeon 19. Salasche SJ, Bernstein G, Senkank. Surgical anatomy of the skin. Appleton & Lange; 1988. Alopecia and sensory disturbances can be to choose where the brow should be placed as 20. Edwards BF. Bilateral neurotomy for the frontalis hyper-bothersome to the patient and often are not per- opposed to merely raising it higher. True rejuve- motility. Plast Reconstr Surg 1957;19:341–4.manent. The problem is the inability to predict nation is likely more complex and involves mul- 21. Ellis DAF, Masri H. The effect of facial animation on the aging upper half of the face. Arch Otolaryngol Headwhether the numbness a patient has will partial- tiple modalities and even tissue replacement such Neck Surg 1989;115:710–2.ly, fully, or not go away, and just how soon is as fat grafting. Only time and persistence will 22. Brennan HG. The forehead lift. Otolaryngol Clin Northmight be alleviated. With proper technique, an prove what best restores youth to the upper face. Am 1980;13:209. 23. Rafaty FM, Brennan HG. Current concepts in brow pexy.endoscopic forehead and brow lift has a high rate Facial cosmetic surgery continues to rise in Arch Otolaryngol Head Neck Surg 1983;109:152.of sensory nerve recovery, but full recovery may popularity exponentially. The aging population 24. Rafaty FM, Goode RL. The browlift operation in a man.take several months and require patient reassur- wants to feel and look more youthful but nonethe- Arch Otolaryngol Head Neck Surg 1978;104:69. 25. Rafaty FM, Goode RL, Fee WE. The browlift operation.ance. Although exact numbers are not known, less demands to remain natural looking. Today’s Arch Otolaryngol Head Neck Surg 1975;101:467.empiric observation of the last 150 endoscopic discerning patient is often very knowledgeable on 26. Knize DM. Reassessment of the coronal incision andbrow lifts that I have performed suggests that the subject of their cosmetic surgery options and subgaleal dissection for foreheadplasty. Plast Recon- str Surg 1998;102:478.sensory disturbances are an occasional early con- may insist on a specific technique. The advice of a 27. Grant JCB, editor. Grant’s atlas of anatomy. 6th ed. Bal-cern but an unusual complaint after 6 to 12 well-trained surgeon and diagnostician may make timore: Williams & Wilkins, 1972.months. Alopecia, on the other hand, is a signifi- or break the ultimate result and prevent a cosmetic 28. Tolhurst DE, Carstens MH, Greco RJ, et al. The surgical anatomy of the scalp. Plast Reconstr Surg 1991;87:603.cant concern, especially if it persists longer than 6 disaster. It is vital that the surgeon refuse to per- 29. Tremolada C, Candiani P, Signorini M, et al. The surgi-to 12 months. Hair may return after an average 4- form treatment that is not in the best interest of the cal anatomy of the subcutaneous fascial system ofto 8-month dormancy period of the hair follicle. patient. Cosmetic surgery is a luxury and is an the scalp. Ann Plast Surg 1994;32:8. 30. Carstens MH, Greco RJ, Hurwitz DJ, et al. Clinical appli-However, excessive tension on the flaps, rough optional procedure, no matter how much of an cations of the subgaleal fascia. Plast Reconstr Surghandling of wound margins, or excessive use of emergency it seems to the patient. At the end of the 1991;87:615.

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