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Approaches to rejuvenation of the upper face
Panel Discussion
Approaches to Rejuvenation of the Upper Face Editor’s note: My thanks to the moderator, Foad Nahai, MD (board-certified plastic surgeon and ASAPS member, Atlanta, GA), and to panelists Antonio Fuente del Campo, MD (ASAPS corresponding member, Mexico City, Mexico); Sam T. Hamra, MD (board-certified plastic surgeon and ASAPS member, Dallas, TX); and Nicanor G. Isse, MD (board-certified plastic surgeon and ASAPS member, Burbank, CA), for sharing their opinions and experiences.
Dr. Fuente del Campo: In using the transpalpebral
approach, I would make the incision through the orbicularis muscle, to the edge of the orbital roof. From there, I would resect a 1-cm strip of the orbicularis, weakening the lateral portion of the muscle, and then perform a frontal dissection of the occipitofrontalis muscle. This would give the muscle freedom to elevate the eyebrows. I would not do anything to the procerus and corrugator muscles.
Dr. Nahai: The first patient is a
Dr. Nahai: How would you
Hispanic male with a lateral receding hairline, a mild degree of ptosis of the brow, and severe pseudoptosis of the upper eyelid; there are no signs of blepharoptosis (Figure 1). Dr. Isse, how would you treat this patient’s upper lids and brow?
obtain fixation through this approach? Dr. Fuente del Campo: I would
Dr. Isse: I would perform a Foad Nahai, MD
blepharoplasty, with excision of the skin and muscle fibers of the orbicularis muscle, to improve the pseudoptosis. Because he appears to be compensating with his frontalis muscle, the brow might drop substantially after the blepharoplasty. Therefore, I would also perform an endoscopic forehead lift, with subgaleal dissection to the medial origin of Sam T. Hamra, MD the corrugator muscle. At this level, I would dissect supraperiosteally to treat the procerus and depressor muscles in the glabellar area. I would also treat the orbicularis, lateral to the supraorbital nerve, and perform a bitemporal suspension. I would not do anything with the frontalis muscle. Dr. Fuente del Campo: I am very much in agreement
Antonio Fuente del Campo, MD
perform fixation to the periosteum or to the bone through a cortical tunnel. A single suture in the lateral arch of the eyebrows would suffice, because the position of the eyebrows would be raised in the middle by the frontalis muscle by approximately 4 or 5 mm, providing a nice arch.
Dr. Hamra: I would perform a very standard and simple upper blepharoplasty. I would never perform a brow lift on a man of this age unless I was going to do a face lift as well. An elevated Nicanor G. Isse, MD forehead would, in my view, create a facial disharmony. His brow and cheek level are both compatible with his age. I would only perform an isolated brow lift if he really exhibited an extreme amount of brow ptosis, which I don’t see here. Dr. Nahai: Do you have any concerns that once the
excess skin of the upper lid has been removed, improving his field of vision, his brow would drop?
with Dr. Isse. After completing the eyelid surgery, I would elevate the eyebrows by liberating the origin of the occipital frontalis muscle, allowing the eyebrows to be positioned higher.
Dr. Hamra: I would not be overly concerned about this. Even if his eyebrows drop, it would be preferable to creating an abnormal look with excessively high brow elevation.
Dr. Nahai: Your approach is through the palpebral inci-
Dr. Nahai: Dr. Isse, would you agree that the endofore-
sion. What muscle modifications would you make?
head lift would elevate his hairline?
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not be raised if the specific structures are fixed. Dr. Fuente del Campo: This is
absolutely correct. Dr. Isse: Regarding the potential for deformity, I have performed this technique on bald patients, and after 2 to 3 months, the scar is not noticeable. Dr. Nahai: Dr. Hamra, how do you
manage someone who is balding or has the potential for a balding scalp? Dr. Hamra: If I were performing a
Figure 1. Front and side views of a man in his fifties with a lateral receding hairline, a mild degree of ptosis of the brow, and severe pseudoptosis of the upper eyelid.
Dr. Isse: I do not agree with Dr. Hamra on this. However, much depends on the technique used for the endoscopic forehead procedure. There are still many surgeons performing the paramedial fixation technique. When temporal fixation is used to elevate the lateral third of the brow, the hairline will remain in place posteriorly. There can actually be shortening of the distance between the hairline and the brow by raising the brow a bit more. By leaving out suspension stitches in the medial or paramedial areas, the forehead may be shortened by as much as 5 to 7 mm.
Dr. Fuente del Campo: You can
raise the hairline if you perform a wide dissection. But if the dissection is performed just below the hairline incision, there is no chance of raising the hairline. Dr. Hamra: If this patient continues
to show signs of male pattern baldness as he ages, he will in later years develop a deformity that will be irreversible. I disagree with Dr. Isse in that you cannot perform a brow lift without having the hairline go up. Dr. Isse: What Dr. Hamra says is
true if the elevation is performed by pulling the skin, but the hairline will
I would never perform a brow lift on a man of this age unless I was going to do a face lift as well. An elevated forehead would, in my view, create a facial disharmony. —Sam T. Hamra, MD
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facelift as well, I would do an open coronal forehead lift. I would need to alter my vectors slightly from the standard vectors, making the incision well behind the hairline—further back than with women because of the elasticity of the skin, particularly in this Hispanic patient. Dr. Nahai: Okay. Let’s move along
to the second case. Dr. Fuente del Campo, I’ll ask you to start. This woman is looking for full facial rejuvenation. In particular, she would like to look better around her eyes, and seeks improvement of the lines on her forehead (Figure 2). Dr. Fuente del Campo: This woman
has a high forehead and could benefit from a coronal approach to obtain both frontal correction and eyebrow elevation. But in my experience, by approaching the forehead endoscopically, I could get a very good correction by liberating the occipitofrontalis muscle and working with the fascia to reduce the wrinkles there, while raising up the eyebrows as well. This patient needs a blepharoplasty. She also has some fullness in the lateral third of the supraorbital rim; rasping the bone will improve the dimension of the orbit and the general look of the
Volume 20, Number 1
Panel Discussion
area. The bone work can be done through the eyelid incisions. She has very thick skin with thin lines and wrinkles. This is a perfect candidate for a full-face lift and peeling with laser treatment. Dr. Nahai: Would you modify the
frontalis in any way? Dr. Fuente del Campo: The proce-
dure I describe will liberate the frontalis from the bone to allow it to bring out the eyebrows without working on the frontalis muscle in any other way. I would also weaken the corrugators and the procerus for a better effect. Dr. Nahai: Would you perform this
procedure endoscopically? Dr. Fuente del Campo: My
approach would be endoscopic, through small coronal incisions. I rarely find a circumstance that requires an open lift with long coronal incisions. Dr. Nahai: Would you consider the
transpalpebral approach for this patient? Dr. Fuente del Campo: No, because
I would elevate the eyebrows considerably. In these cases, I make 2 small incisions—approximately 2 cm in length—along the hairline, with 1 incision above each orbit. I mark the eyelids for my anticipated skin removal, perform the endoforehead lift, and finally resect the eyelid skin with some orbicularis muscle. Dr. Nahai: Dr. Hamra, how would
you approach this patient? Dr. Hamra: She’s a prime candidate
for a coronal lift because of her low hairline. With a composite facelift, there is a strong superomedial advancement of the cheek. Therefore, I would perform a superomedial
Approaches to Rejuvenation of the Upper Face
Figure 2. Front and side views of a woman in her fifties desiring full facial rejuvenation. She particularly seeks improvement around her eyes and to the lines on her forehead.
advancement of the brow as well. This would rule out both the endoscopic technique and limited dissection through the blepharoplasty incision. Dr. Nahai: Would you modify her
frontalis? Dr. Hamra: I don’t touch the frontal-
is anymore. Instead, I take out the temporalis fascia to encourage more adherence, resulting in a longer-lasting brow lift. The galea is scored between the nerves rather than the frontalis. Years ago I would score the frontalis to create scarring on the
forehead, but this resulted in a rather bizarre expression, with the brow being over adherent and the muscles not moving correctly. Dr. Nahai: Dr. Hamra, most sur-
geons performing a brow lift on this patient would follow a pull vector from the oral commissure to the canthus, or from the alar base to the lateral canthus onto the forehead. How would you describe your pull vector? Dr. Hamra: The composite lift moves
the cheek superior and medial, not vertical and superolateral.
By approaching the forehead endoscopically, I could get a very good correction by liberating the occipitofrontalis muscle and working with the fascia to reduce the wrinkles there, while raising up the eyebrows as well. —Antonio Fuente del Campo, MD
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Figure 3. Front and side views of a woman in her forties with a high forehead, who feels that she looks sad and angry.
Therefore, I would use medial advancement of the coronal lift to prevent bunching on the side. This frequently requires the removal of a triangle of skin at the top of the head because the skin is removed superiorly rather than laterally. I have found this procedure to be important in that it preserves the sideburns and prevents lateral medial brow displacement, thus solving a problem I have seen in conventional forehead lifts for years.
Dr. Nahai: Dr. Isse, how would your
approach differ from the 2 approaches we’ve just heard discussed? Dr. Isse: With this patient, it
appears that at least 80% of her brow is penciled on, and is not actual brow hair. If this is in fact the case, I would do a blepharoplasty alone and tell her to paint the brow slightly higher. If this is not the case, my endoscopic brow-repositioning technique uses 3 incisions, with 1
If I decide to lower the hairline after my usual endoscopic lift, a hairline incision in the coronal area is made—largely avoiding the temporal area—and I work endoscopically right under the brow skin. —Nicanor G. Isse, MD
sagittal incision made a couple of hairs behind the center of the hairline. The temporal incisions are made approximately 1.5 cm into the hairline on the temporal crest and span 2 cm in length. Attempting to reproduce the medial vector as suggested by Dr. Hamra, by doing a bitemporal cable fixation suspension, I grasp the galea and a small portion of the dermis at the medial end of the temporal incision. I then reach under the tissue at the subperiosteal level to the other temporal incision and again grab the medial end of that temporal incision. Placing tension on this suture, by grabbing both ends of the temporal incision, brings it medially into place. I suspend it with a 3.0 nylon suture, which provides very nice vertical elevation of the tail of the brow. Dr. Nahai: How do you manage the
muscles? Dr. Isse: I focus on the glabellar
area, namely the procerus and the depressor. The corrugator muscle is left intact because it serves as an elevator for the hair of the brow rather than as a depressor. Removal of the corrugator muscle causes an excessively wide distance in the interbrow area. Laser resurfacing would be appropriate for this patient as a complementary treatment modality. Dr. Nahai: Thank you. The next case
is a woman who feels she looks sad and angry (Figure 3). Dr. Hamra: This woman presents the
classic challenge of working with a high forehead. She cannot afford to keep her hairline where it is and would therefore need to undergo an open-hairline brow lift to elevate the brows and narrow the forehead. Dr. Nahai: Would you separate the
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Volume 20, Number 1
Panel Discussion
skin from the muscle, or dissect deep to the muscle? Dr. Hamra: I would go subgaleal,
because sacrificing the nerves is a small price to pay to get the ultimate look. Dr. Nahai: She has a very nice arch to
her brow, as seen in the three-quarter view. Can we modify or create this look, or does the lateral border of the frontalis predetermine it? Dr. Hamra: I think it’s predeter-
mined. I’ve never believed the theory that you can locate or shape a brow to the patient’s desires. Dr. Nahai: Dr. Isse, how would you
approach this woman’s forehead and upper lid? Dr. Isse: I would not touch the
upper eyelid, which can be well improved by repositioning the brow with an endoscopic forehead lift. I would detach the orbicularis muscle approximately 270° from the glabellar area, superior, lateral, and inferior to the rim area. I would then elevate the entire orbicularis with the forehead to improve the upper eyelid. Dr. Nahai: Is the arch or the shape of
the hair-bearing brow determined by the lateral extent of the frontalis? Dr. Isse: No, it is not. The hair-bearing brow goes beyond the insertion of the frontalis muscle. I believe the lateral edge of the frontalis is at the level of the temporal crest. Approximately 1.5 cm of the tail of the brow is unaffected by the frontalis action. Dr. Nahai: Many women find an arched brow to be very attractive and ask that you create it for them. Can you take a brow that is actually flat and make an arched shape out of it?
Approaches to Rejuvenation of the Upper Face
A
B
Figure 4. A, Front view of a woman in her sixties. B, Front view after removal of a meningioma, resulting in atrophy of her right temporal fossa and paralysis of her right forehead. She seeks improvement and balance to her eyebrows.
Dr. Isse: It is possible to create a very smooth arch, but not with a break like this.
Dr. Nahai: Dr. Fuente del Campo,
Dr. Nahai: After describing this
ticular case, it is very important to reduce the vertical dimension of the forehead. I would use a coronal hairline incision to bring the skin flap downward, removing skin to reduce the dimension of the forehead. Through this incision, a medial dissection of the frontalis muscle could be done to elevate the eyebrows. I would also remove the depressor supercilii and the corrugators. The goal here is to create an aesthetically pleasing eyebrow arch, because the medial portion of the eyebrow is flat. To create an attractive eyebrow, I would raise the medial portion of the eyebrow by working with the occipitofrontalis muscle, but the lateral part must be pulled and fixed.
operation to the patient, she replies that her forehead is already high enough and asks whether performing a forehead lift will make her forehead appear even higher. You have told her that it will not. But can you actually lower her hairline? Dr. Isse: If I decide to lower the hairline after my usual endoscopic lift, a hairline incision in the coronal area is made—largely avoiding the temporal area—and I work endoscopically right under the brow skin. Next, I undermine posteriorly, bringing the scalp forward, and resect the amount of skin anteriorly to lower the hairline. Dr. Nahai: Why would you perform an endoscopic lift followed by a subcutaneous advancement? In my opinion, you’re doubling your work. Why not perform a subperiosteal brow lift? Dr. Isse: I want to limit my skin incisions to the central area and not include the temporal area.
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what would your approach be? Dr. Fuente del Campo: In this par-
Dr. Nahai: Let’s move on to the last
case. A neurosurgeon has sent this woman to you after removing a meningioma, which resulted in atrophy of her right temporal fossa, paralyzing her right forehead. She would like improvement and balance to her eyebrows (Figure 4).
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Panel Discussion
area, and bring it back again. A 3.0 nylon suture would then be tied anteriorly to produce the appropriate elevation for the fixation of the brow.
Dr. Isse, how would you approach this woman? Dr. Isse: I would first ask her which of her 2 brows she believes is better. If she prefers the one on the right side, I will use the endoscope to resect a good portion of the nerve at the upper edge of the zygomatic arch of the left frontalis muscle. I would then look for the lateral zygomatic temporal neurovascular bundle, which is located roughly 2 cm in front of the tragus, and very close to the superior edge of the zygomatic arch. On seeing the neurovascular bundle, I would open the fascia, where the temporal branch of the facial nerve is found; this can be confirmed with nerve stimulation. If she preferred that I raise the left side, I would perform a unilateral endoscopic elevation of the paralyzed brow. At the same time, I would place a 2-mm Gore-tex implant (W.L. Gore & Associates, Elkton, MD) in the temporal fossa to build up a thicker layer in the center, which would taper as I work inferiorly and medially. Then I would suspend the brow from the temporal and paramedial areas.
there are 2 problems here. One is obviously the lower eyebrow on the affected side. The other eyebrow is also a little too high. Patients sometimes do not realize how much their expression and function can be affected by later paralysis. Therefore, I think it’s better to elevate the lower eyebrow. I would raise the frontalis without cutting the muscle and weakening or resecting the corrugator and the depressor supercilii. I would also raise the medial part of the eyebrow, fixing it to the bone. If the patient preferred to have the left side paralyzed, I would use Botox (Allergan, Irvine, CA) to show her how it would look.
Dr. Nahai: How would you perform
Dr. Nahai: Do you routinely use
the paramedial fixation?
Botox with your brow procedures?
Dr. Isse: My sagittal paramedial incision would be approximately 5 cm from the midline. I would take the posterior end of that incision and make a subperiosteal tunnel extending to the occipital area. Once in the occipital area, I would make the smallest skin incision required in order to drive in a suture passer, grab the galea and occipital fascia in that
Dr. Fuente del Campo: No. I only
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Dr. Nahai: Do you think you can ele-
vate the medial brow to match the other side at rest? Dr. Isse: Yes. I would also detach
the corrugator muscle and release the medial part to get the maximum elevation possible. Dr. Fuente del Campo: I believe
use Botox in very specific cases, such as this one, to demonstrate what would happen if we cut the nerve. I rarely use Botox. Dr. Nahai: If you’re planning to do a
brow lift, do you see any need for preoperative Botox? Dr. Fuente del Campo: This is an
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ideal situation for the patient to decide if we should paralyze the left side or raise the right side. But, as I said before, to raise the right side to a medial position and then weaken the left side slightly might be the best approach for her. Dr. Nahai: Dr. Hamra, how would
you approach this woman’s asymmetry? Dr. Hamra: I think she has had a
blepharoplasty in the past, and perhaps even a facelift. I agree with Dr. Fuente del Campo in that I would start with Botox on the active side first. I would never perform a neurectomy until she could see what the results would look like. The brows appear at almost the same level when she is in repose. Only when she animates her forehead does the left side rise. Therefore, if I were to perform a unilateral forehead lift or an endoscopic forehead lift, I would achieve a high right side that could only be matched with animation. Asymmetry with animation is the most significant challenge the surgeon will confront with this type of patient. Bearing this in mind, I would lean towards the Botox treatments 2 to 3 times a year until she becomes comfortable with that look. Symmetry, rather than brow position, is my goal for this patient. I would perform a direct skin excision over the eyebrow rather than do a forehead lift. This small procedure under local anesthesia would be more effective for achieving symmetry. ■ Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/104973
Volume 20, Number 1
Approaches to Rejuvenation of the Upper Face Editor’s note: My thanks to the moderator, Foad Nahai, MD (board-certified plastic surgeon and ASAPS member, Atlanta, GA), and to panelists Antonio Fuente del Campo, MD (ASAPS corresponding member, Mexico City, Mexico); Sam T. Hamra, MD (board-certified plastic surgeon and ASAPS member, Dallas, TX); and Nicanor G. Isse, MD (board-certified plastic surgeon and ASAPS member, Burbank, CA), for sharing their opinions and experiences.
Dr. Fuente del Campo: In using the transpalpebral
approach, I would make the incision through the orbicularis muscle, to the edge of the orbital roof. From there, I would resect a 1-cm strip of the orbicularis, weakening the lateral portion of the muscle, and then perform a frontal dissection of the occipitofrontalis muscle. This would give the muscle freedom to elevate the eyebrows. I would not do anything to the procerus and corrugator muscles.
Dr. Nahai: The first patient is a
Dr. Nahai: How would you
Hispanic male with a lateral receding hairline, a mild degree of ptosis of the brow, and severe pseudoptosis of the upper eyelid; there are no signs of blepharoptosis (Figure 1). Dr. Isse, how would you treat this patient’s upper lids and brow?
obtain fixation through this approach? Dr. Fuente del Campo: I would
Dr. Isse: I would perform a Foad Nahai, MD
blepharoplasty, with excision of the skin and muscle fibers of the orbicularis muscle, to improve the pseudoptosis. Because he appears to be compensating with his frontalis muscle, the brow might drop substantially after the blepharoplasty. Therefore, I would also perform an endoscopic forehead lift, with subgaleal dissection to the medial origin of Sam T. Hamra, MD the corrugator muscle. At this level, I would dissect supraperiosteally to treat the procerus and depressor muscles in the glabellar area. I would also treat the orbicularis, lateral to the supraorbital nerve, and perform a bitemporal suspension. I would not do anything with the frontalis muscle. Dr. Fuente del Campo: I am very much in agreement
Antonio Fuente del Campo, MD
perform fixation to the periosteum or to the bone through a cortical tunnel. A single suture in the lateral arch of the eyebrows would suffice, because the position of the eyebrows would be raised in the middle by the frontalis muscle by approximately 4 or 5 mm, providing a nice arch.
Dr. Hamra: I would perform a very standard and simple upper blepharoplasty. I would never perform a brow lift on a man of this age unless I was going to do a face lift as well. An elevated Nicanor G. Isse, MD forehead would, in my view, create a facial disharmony. His brow and cheek level are both compatible with his age. I would only perform an isolated brow lift if he really exhibited an extreme amount of brow ptosis, which I don’t see here. Dr. Nahai: Do you have any concerns that once the
excess skin of the upper lid has been removed, improving his field of vision, his brow would drop?
with Dr. Isse. After completing the eyelid surgery, I would elevate the eyebrows by liberating the origin of the occipital frontalis muscle, allowing the eyebrows to be positioned higher.
Dr. Hamra: I would not be overly concerned about this. Even if his eyebrows drop, it would be preferable to creating an abnormal look with excessively high brow elevation.
Dr. Nahai: Your approach is through the palpebral inci-
Dr. Nahai: Dr. Isse, would you agree that the endofore-
sion. What muscle modifications would you make?
head lift would elevate his hairline?
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not be raised if the specific structures are fixed. Dr. Fuente del Campo: This is
absolutely correct. Dr. Isse: Regarding the potential for deformity, I have performed this technique on bald patients, and after 2 to 3 months, the scar is not noticeable. Dr. Nahai: Dr. Hamra, how do you
manage someone who is balding or has the potential for a balding scalp? Dr. Hamra: If I were performing a
Figure 1. Front and side views of a man in his fifties with a lateral receding hairline, a mild degree of ptosis of the brow, and severe pseudoptosis of the upper eyelid.
Dr. Isse: I do not agree with Dr. Hamra on this. However, much depends on the technique used for the endoscopic forehead procedure. There are still many surgeons performing the paramedial fixation technique. When temporal fixation is used to elevate the lateral third of the brow, the hairline will remain in place posteriorly. There can actually be shortening of the distance between the hairline and the brow by raising the brow a bit more. By leaving out suspension stitches in the medial or paramedial areas, the forehead may be shortened by as much as 5 to 7 mm.
Dr. Fuente del Campo: You can
raise the hairline if you perform a wide dissection. But if the dissection is performed just below the hairline incision, there is no chance of raising the hairline. Dr. Hamra: If this patient continues
to show signs of male pattern baldness as he ages, he will in later years develop a deformity that will be irreversible. I disagree with Dr. Isse in that you cannot perform a brow lift without having the hairline go up. Dr. Isse: What Dr. Hamra says is
true if the elevation is performed by pulling the skin, but the hairline will
I would never perform a brow lift on a man of this age unless I was going to do a face lift as well. An elevated forehead would, in my view, create a facial disharmony. —Sam T. Hamra, MD
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facelift as well, I would do an open coronal forehead lift. I would need to alter my vectors slightly from the standard vectors, making the incision well behind the hairline—further back than with women because of the elasticity of the skin, particularly in this Hispanic patient. Dr. Nahai: Okay. Let’s move along
to the second case. Dr. Fuente del Campo, I’ll ask you to start. This woman is looking for full facial rejuvenation. In particular, she would like to look better around her eyes, and seeks improvement of the lines on her forehead (Figure 2). Dr. Fuente del Campo: This woman
has a high forehead and could benefit from a coronal approach to obtain both frontal correction and eyebrow elevation. But in my experience, by approaching the forehead endoscopically, I could get a very good correction by liberating the occipitofrontalis muscle and working with the fascia to reduce the wrinkles there, while raising up the eyebrows as well. This patient needs a blepharoplasty. She also has some fullness in the lateral third of the supraorbital rim; rasping the bone will improve the dimension of the orbit and the general look of the
Volume 20, Number 1
Panel Discussion
area. The bone work can be done through the eyelid incisions. She has very thick skin with thin lines and wrinkles. This is a perfect candidate for a full-face lift and peeling with laser treatment. Dr. Nahai: Would you modify the
frontalis in any way? Dr. Fuente del Campo: The proce-
dure I describe will liberate the frontalis from the bone to allow it to bring out the eyebrows without working on the frontalis muscle in any other way. I would also weaken the corrugators and the procerus for a better effect. Dr. Nahai: Would you perform this
procedure endoscopically? Dr. Fuente del Campo: My
approach would be endoscopic, through small coronal incisions. I rarely find a circumstance that requires an open lift with long coronal incisions. Dr. Nahai: Would you consider the
transpalpebral approach for this patient? Dr. Fuente del Campo: No, because
I would elevate the eyebrows considerably. In these cases, I make 2 small incisions—approximately 2 cm in length—along the hairline, with 1 incision above each orbit. I mark the eyelids for my anticipated skin removal, perform the endoforehead lift, and finally resect the eyelid skin with some orbicularis muscle. Dr. Nahai: Dr. Hamra, how would
you approach this patient? Dr. Hamra: She’s a prime candidate
for a coronal lift because of her low hairline. With a composite facelift, there is a strong superomedial advancement of the cheek. Therefore, I would perform a superomedial
Approaches to Rejuvenation of the Upper Face
Figure 2. Front and side views of a woman in her fifties desiring full facial rejuvenation. She particularly seeks improvement around her eyes and to the lines on her forehead.
advancement of the brow as well. This would rule out both the endoscopic technique and limited dissection through the blepharoplasty incision. Dr. Nahai: Would you modify her
frontalis? Dr. Hamra: I don’t touch the frontal-
is anymore. Instead, I take out the temporalis fascia to encourage more adherence, resulting in a longer-lasting brow lift. The galea is scored between the nerves rather than the frontalis. Years ago I would score the frontalis to create scarring on the
forehead, but this resulted in a rather bizarre expression, with the brow being over adherent and the muscles not moving correctly. Dr. Nahai: Dr. Hamra, most sur-
geons performing a brow lift on this patient would follow a pull vector from the oral commissure to the canthus, or from the alar base to the lateral canthus onto the forehead. How would you describe your pull vector? Dr. Hamra: The composite lift moves
the cheek superior and medial, not vertical and superolateral.
By approaching the forehead endoscopically, I could get a very good correction by liberating the occipitofrontalis muscle and working with the fascia to reduce the wrinkles there, while raising up the eyebrows as well. —Antonio Fuente del Campo, MD
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Figure 3. Front and side views of a woman in her forties with a high forehead, who feels that she looks sad and angry.
Therefore, I would use medial advancement of the coronal lift to prevent bunching on the side. This frequently requires the removal of a triangle of skin at the top of the head because the skin is removed superiorly rather than laterally. I have found this procedure to be important in that it preserves the sideburns and prevents lateral medial brow displacement, thus solving a problem I have seen in conventional forehead lifts for years.
Dr. Nahai: Dr. Isse, how would your
approach differ from the 2 approaches we’ve just heard discussed? Dr. Isse: With this patient, it
appears that at least 80% of her brow is penciled on, and is not actual brow hair. If this is in fact the case, I would do a blepharoplasty alone and tell her to paint the brow slightly higher. If this is not the case, my endoscopic brow-repositioning technique uses 3 incisions, with 1
If I decide to lower the hairline after my usual endoscopic lift, a hairline incision in the coronal area is made—largely avoiding the temporal area—and I work endoscopically right under the brow skin. —Nicanor G. Isse, MD
sagittal incision made a couple of hairs behind the center of the hairline. The temporal incisions are made approximately 1.5 cm into the hairline on the temporal crest and span 2 cm in length. Attempting to reproduce the medial vector as suggested by Dr. Hamra, by doing a bitemporal cable fixation suspension, I grasp the galea and a small portion of the dermis at the medial end of the temporal incision. I then reach under the tissue at the subperiosteal level to the other temporal incision and again grab the medial end of that temporal incision. Placing tension on this suture, by grabbing both ends of the temporal incision, brings it medially into place. I suspend it with a 3.0 nylon suture, which provides very nice vertical elevation of the tail of the brow. Dr. Nahai: How do you manage the
muscles? Dr. Isse: I focus on the glabellar
area, namely the procerus and the depressor. The corrugator muscle is left intact because it serves as an elevator for the hair of the brow rather than as a depressor. Removal of the corrugator muscle causes an excessively wide distance in the interbrow area. Laser resurfacing would be appropriate for this patient as a complementary treatment modality. Dr. Nahai: Thank you. The next case
is a woman who feels she looks sad and angry (Figure 3). Dr. Hamra: This woman presents the
classic challenge of working with a high forehead. She cannot afford to keep her hairline where it is and would therefore need to undergo an open-hairline brow lift to elevate the brows and narrow the forehead. Dr. Nahai: Would you separate the
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skin from the muscle, or dissect deep to the muscle? Dr. Hamra: I would go subgaleal,
because sacrificing the nerves is a small price to pay to get the ultimate look. Dr. Nahai: She has a very nice arch to
her brow, as seen in the three-quarter view. Can we modify or create this look, or does the lateral border of the frontalis predetermine it? Dr. Hamra: I think it’s predeter-
mined. I’ve never believed the theory that you can locate or shape a brow to the patient’s desires. Dr. Nahai: Dr. Isse, how would you
approach this woman’s forehead and upper lid? Dr. Isse: I would not touch the
upper eyelid, which can be well improved by repositioning the brow with an endoscopic forehead lift. I would detach the orbicularis muscle approximately 270° from the glabellar area, superior, lateral, and inferior to the rim area. I would then elevate the entire orbicularis with the forehead to improve the upper eyelid. Dr. Nahai: Is the arch or the shape of
the hair-bearing brow determined by the lateral extent of the frontalis? Dr. Isse: No, it is not. The hair-bearing brow goes beyond the insertion of the frontalis muscle. I believe the lateral edge of the frontalis is at the level of the temporal crest. Approximately 1.5 cm of the tail of the brow is unaffected by the frontalis action. Dr. Nahai: Many women find an arched brow to be very attractive and ask that you create it for them. Can you take a brow that is actually flat and make an arched shape out of it?
Approaches to Rejuvenation of the Upper Face
A
B
Figure 4. A, Front view of a woman in her sixties. B, Front view after removal of a meningioma, resulting in atrophy of her right temporal fossa and paralysis of her right forehead. She seeks improvement and balance to her eyebrows.
Dr. Isse: It is possible to create a very smooth arch, but not with a break like this.
Dr. Nahai: Dr. Fuente del Campo,
Dr. Nahai: After describing this
ticular case, it is very important to reduce the vertical dimension of the forehead. I would use a coronal hairline incision to bring the skin flap downward, removing skin to reduce the dimension of the forehead. Through this incision, a medial dissection of the frontalis muscle could be done to elevate the eyebrows. I would also remove the depressor supercilii and the corrugators. The goal here is to create an aesthetically pleasing eyebrow arch, because the medial portion of the eyebrow is flat. To create an attractive eyebrow, I would raise the medial portion of the eyebrow by working with the occipitofrontalis muscle, but the lateral part must be pulled and fixed.
operation to the patient, she replies that her forehead is already high enough and asks whether performing a forehead lift will make her forehead appear even higher. You have told her that it will not. But can you actually lower her hairline? Dr. Isse: If I decide to lower the hairline after my usual endoscopic lift, a hairline incision in the coronal area is made—largely avoiding the temporal area—and I work endoscopically right under the brow skin. Next, I undermine posteriorly, bringing the scalp forward, and resect the amount of skin anteriorly to lower the hairline. Dr. Nahai: Why would you perform an endoscopic lift followed by a subcutaneous advancement? In my opinion, you’re doubling your work. Why not perform a subperiosteal brow lift? Dr. Isse: I want to limit my skin incisions to the central area and not include the temporal area.
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what would your approach be? Dr. Fuente del Campo: In this par-
Dr. Nahai: Let’s move on to the last
case. A neurosurgeon has sent this woman to you after removing a meningioma, which resulted in atrophy of her right temporal fossa, paralyzing her right forehead. She would like improvement and balance to her eyebrows (Figure 4).
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area, and bring it back again. A 3.0 nylon suture would then be tied anteriorly to produce the appropriate elevation for the fixation of the brow.
Dr. Isse, how would you approach this woman? Dr. Isse: I would first ask her which of her 2 brows she believes is better. If she prefers the one on the right side, I will use the endoscope to resect a good portion of the nerve at the upper edge of the zygomatic arch of the left frontalis muscle. I would then look for the lateral zygomatic temporal neurovascular bundle, which is located roughly 2 cm in front of the tragus, and very close to the superior edge of the zygomatic arch. On seeing the neurovascular bundle, I would open the fascia, where the temporal branch of the facial nerve is found; this can be confirmed with nerve stimulation. If she preferred that I raise the left side, I would perform a unilateral endoscopic elevation of the paralyzed brow. At the same time, I would place a 2-mm Gore-tex implant (W.L. Gore & Associates, Elkton, MD) in the temporal fossa to build up a thicker layer in the center, which would taper as I work inferiorly and medially. Then I would suspend the brow from the temporal and paramedial areas.
there are 2 problems here. One is obviously the lower eyebrow on the affected side. The other eyebrow is also a little too high. Patients sometimes do not realize how much their expression and function can be affected by later paralysis. Therefore, I think it’s better to elevate the lower eyebrow. I would raise the frontalis without cutting the muscle and weakening or resecting the corrugator and the depressor supercilii. I would also raise the medial part of the eyebrow, fixing it to the bone. If the patient preferred to have the left side paralyzed, I would use Botox (Allergan, Irvine, CA) to show her how it would look.
Dr. Nahai: How would you perform
Dr. Nahai: Do you routinely use
the paramedial fixation?
Botox with your brow procedures?
Dr. Isse: My sagittal paramedial incision would be approximately 5 cm from the midline. I would take the posterior end of that incision and make a subperiosteal tunnel extending to the occipital area. Once in the occipital area, I would make the smallest skin incision required in order to drive in a suture passer, grab the galea and occipital fascia in that
Dr. Fuente del Campo: No. I only
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Dr. Nahai: Do you think you can ele-
vate the medial brow to match the other side at rest? Dr. Isse: Yes. I would also detach
the corrugator muscle and release the medial part to get the maximum elevation possible. Dr. Fuente del Campo: I believe
use Botox in very specific cases, such as this one, to demonstrate what would happen if we cut the nerve. I rarely use Botox. Dr. Nahai: If you’re planning to do a
brow lift, do you see any need for preoperative Botox? Dr. Fuente del Campo: This is an
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ideal situation for the patient to decide if we should paralyze the left side or raise the right side. But, as I said before, to raise the right side to a medial position and then weaken the left side slightly might be the best approach for her. Dr. Nahai: Dr. Hamra, how would
you approach this woman’s asymmetry? Dr. Hamra: I think she has had a
blepharoplasty in the past, and perhaps even a facelift. I agree with Dr. Fuente del Campo in that I would start with Botox on the active side first. I would never perform a neurectomy until she could see what the results would look like. The brows appear at almost the same level when she is in repose. Only when she animates her forehead does the left side rise. Therefore, if I were to perform a unilateral forehead lift or an endoscopic forehead lift, I would achieve a high right side that could only be matched with animation. Asymmetry with animation is the most significant challenge the surgeon will confront with this type of patient. Bearing this in mind, I would lean towards the Botox treatments 2 to 3 times a year until she becomes comfortable with that look. Symmetry, rather than brow position, is my goal for this patient. I would perform a direct skin excision over the eyebrow rather than do a forehead lift. This small procedure under local anesthesia would be more effective for achieving symmetry. ■ Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/104973
Volume 20, Number 1