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 zygomati- cofrontal suture line is an ideal location to end most basic brow lift dissections (Figure 67-7). Additional dissection can be performed if mid- face 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 medial- ly along the suture line and lateral canthus. Like- Frontal bone wise, the nasofrontal suture line is a nice land- mark 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 anato- my 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 super- cilii 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 some- what more variable. However, one particular vein, known as the sentinel vein (medial zygo- maticotemporal 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 sig- nificant 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 mus- cle attachments are labeled. Elevation at this level detaches only the superficial layer of the lateral canthal tendon. (The deep portion of the later- al 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 mus- cles 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 appear- ance by overelevation of the lateral brow. In addi- tion, 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 elim- inated 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 signif- icant 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 cephalo- metric 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 sham- poo 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 injec- tion 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 epi- nephrine. 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 epi- nephrine 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 medi- al 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 hid- den 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.