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Transpalpebral Brow Lifting
Transpalpebral Brow Lif ting Henrique P.L. Cintra, MDa,b,*, FilipeV. Basile, MDb KEYWORDS
New technologies have created a trend for lessinvasive procedures in all surgical specialties. Over the past 2 decades, great advances have been made in the fields of minimal-incision and endoscopic surgeries. The endoscope, with its accompanying instrumentation, has been the key development supporting this trend. The endoscopic brow lift was the first procedures to gain widespread acceptance among plastic surgeons. The subperiosteal dissection approach as applied to the forehead arose from the development of craniofacial techniques. Using this plane, the application of an endoscope to visualize and dissect the periorbita was described in 1994.1,2 In the mid-1990s a better understanding of the relevant anatomy and the evolving therapeutic modalities (including both open and closed techniques) have helped clinicians reach a renewed refinement in the aesthetic surgery of the forehead and brow area. Endoscopic-assisted views of the anatomic landmarks and planes helped surgeons better understand the dynamics of brow ptosis. However, some investigators realized that the endoscope was only necessary because of the long distance between the temporal port and the periorbita, making its dissection hazardous. Still in the mid-1990s, some investigators described forehead and brow limited-incision techniques that achieved reliable results without endoscopic support.3–5 Despite the good results, much criticism arose concerning the safety of the procedure because there was no direct view of the anatomic landmarks as one elevates the flap further than 5 cm
from the scalp incision. This blind dissection increases the risk of damaging the temporal branch of the facial nerve and branches of the trigeminal nerve division, the supraorbital and supratrochlear nerve, as each leaves its respective foramen at the junction of the middle and medial one third of the orbital rim. Bleeding is also a major concern for two main reasons: first, because bleeding from vessels that cannot be directly visualized is impossible to stop and, second, because of the close relationship that such vessels as the sentinel vein and the frontal branch of the superficial temporal artery and vein have with nerves.6,7 To enable better visualization and address these problems, an upper blepharoplasty incision can be made for access to the inferior region of the forehead. More patients present for eyelid surgery than for brow lift, and even those requesting a brow lift and those requesting upper facial rejuvenation also require upper blepharoplasty. Thus, it is natural to think of the upper eyelid incision as an alternative port because of its proximity to periorbital anatomic structures. Through this incision, direct visualization of the anatomic landmark in the orbital rim and inferior forehead is obtained and dissection proceeds upwards joining the downwards dissection done through a short temporal scalp incision. The combined-access foreheadplasty allows direct visualization of all the anatomic structures that are not directly visualized through the temporal incision. Because this technique dispenses with endoscopic instrumentation, it is less expensive and simpler than the endoscopic-assisted approach. With dissection through the upper blepharoplasty incision, the
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Department of Plastic and Reconstructive Surgery, Pontifical Catholic University of Rio de Janeiro, Brazil Brazilian Plastic Surgery Society, Sa˜o Paulo, Brazil * Corresponding author. Avenida Lineu de Paula Machado 1000 apto. 401 bloco 01 – Jardim Botaˆnico- Rio de Janeiro –RJ- Brazil 22470-040. E-mail address: [email protected] (H.P.L. Cintra).
b
Clin Plastic Surg 35 (2008) 381–392 doi:10.1016/j.cps.2008.02.001 0094-1298/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
Transpalpebral Transblepharoplasty Brow lifting Subperiosteal Limited incisions
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Cintra & Basile distance is short to the corrugator supercilii muscle, the procerus muscle, and the depressor supercilii muscle, each of which can be selectively transected through this incision to reduce unwanted wrinkles and elevate the medial brow. Likewise, the orbicularis can be incised and subperiosteal dissection performed above the orbital rim to elevate the lateral brow through this same local incision. The result has been a decrease in morbidity as well as a decrease in surgical and recovery times.8,9 From the endoscopic experience, it is now known that the failure of an endoscopic brow lift may be related to inadequate dissection and release, inadequate fixation, or both.10 This article describes a limited-incision foreheadplasty technique with combined transpalpebral, subperiosteal, and transtemporal access to provide a safe and reliable brow elevation and glabellar furrow reduction by releasing inferior tethering and weakening the brow depressor muscles with direct visualization of these anatomic structures. The technique produces aesthetic results comparable to that allowed by the endoscopic-assisted technique.
HISTORICAL BACKGROUND For nearly a century, many techniques for rejuvenation of the upper third of the face and brow have been described.11 The earliest description of brow lifting in the literature was published by Passot12 in 1919. Castanares13 described local access through an incision just over the brow to treat the oblique portion of the corrugator muscle, remove excessive forehead skin, and elevate the ptotic brow. It could be suggested that Franco and Rebello14 in the 1970s made the first attempt to use the blepharoplasty incision to address the corrugator muscle. Connell15 described the use of existing transverse forehead rhytids as a means of removing forehead soft tissue and thereby lifting the brow while nicely concealing the scar in selected individuals with fair skin whose main concern was brow ptosis. Pitanguy16 popularized a subgaleal approach for the temporal region. More recently, Flowers17 stressed the value of correcting brow ptosis as the major aesthetic finding in the aging upper one-third of the face and not removing excessive upper eyelid skin. In more recent years, rejuvenation of the aging upper third of the face has undergone evolutionary transformations from the classic open coronal or anterior hairline brow lift to scar-reduction techniques, such as the endoscopic brow lift in the early 1990s, the limited temporal incision brow lift, and the transpalpebral access to the brow depressor muscles.
Vasconez and Isse in 1992 presented early experience with endoscopic brow lift. However, the first publication on the use of the endoscope for brow lifting was by Chajchir2 in 1993. Since then, enormous advances in the field of endoscopic surgery have produced a significant paradigm shift in surgical management of brow and forehead aging. A survey of the membership of the American Society of Plastic Surgeons in 2000, representing 6951 brow lifts, revealed that approximately 50% were performed endoscopically.18 Unlike the open techniques that rely on a combination of skin excision and soft tissue traction, endoscopic techniques rely solely on soft tissue repositioning. Since the initial presentation by Vasconez19 and Isse,20 many other investigators have made important contributions to this field. Knize3 first reported on the limited-incision technique in 1996. He advocated using a short temporal incision to create a subtemporalis fascial plane and a medial subperiosteal plane, division of the orbital ligament, and mobilization of the lateral brow. Through an upper eyelid incision, the corrugator supercilli muscle is partially excised, the procerus muscle is divided, and a graft of temporalis fascia is placed in the glabella as filler. This technique has become more popular over the past few years, producing similar results to the endoscopic approach. Paul4 was the first to describe a systematic approach using both temporal and palpebral incisions for a brow lift, while simultaneously correcting the findings in the hooded eyelid. This included trimming of orbital orbicularis oculi muscle and suborbicularis fat with brow stabilization by soft tissue suturing above the orbital rim. All aspects of the hooded upper eyelid can be addressed through this approach.21
APPLIED SURGICAL ANATOMY Only in recent years has a better understanding of the relevant anatomy and the evolving therapeutic modalities (including both open and closed techniques) contributed to a renewed refinement in the aesthetic surgery of the forehead and brow area. Detailed knowledge of this particular anatomy is paramount for anyone planning to perform adequate forehead rejuvenation.22–26 The forehead is divided into three main aesthetical (and surgical) unities: (1) the brow and temporal region lateral to the temporal line, including the potential space that separates the superficial temporal fascia to the deep temporal fascia; (2) the central forehead to 5 cm above the orbital rim, including the potential subperiostal space contained between the two temporal lines; and (3) the central brow, which is more mobile, overlies the muscle
Transpalpebral Brow Lifting
Fig. 3. Image of cadaver dissection used as basis for Fig. 2. Fig. 1. Surgical unities of the forehead and brow. (A) Medial brow. (B) Lateral brow and temporal area. (C) Central forehead.
and nerve bundles, and should be addressed separately (Fig. 1). Each of these potential spaces has different layers with complex relationships to several anatomic landmarks and attachments structures that fix the brow in position. The superficial layers of the forehead and temporal region are retained by a complex system of attachments that arise from the underlying deep fascia or periosteum. An understanding of the dynamics of these
Fig. 2. Anatomic landmarks from cadaver dissection shown in Fig. 3. Note that the scissors are beneath the temporal fusion line adhesion (TLA) to the frontal bone. DTF, deep temporal fascia; FN, facial nerve; OM, orbicularis oculi muscle; P, periosteum; STF, superficial temporal fascia; SV, sentinel vein.
attachments and their relationships to each other and to the anatomic landmarks of the temporal region is essential. There are a few structures or attachments that avoid the brow to be elevated and should be released during any forehead rejuvenation procedure. Some controversy has arisen regarding the appropriate terminology for the retaining structures of the face. Although the term ligament has conventionally referred only to connective tissue between bones, Furnas24 introduced the concept of cutaneous retaining ligaments as those elements in the face and forehead that run from deep and fixed structures to the overlying dermis. Knize10 has described the orbital ligament that tethers the lateral orbital rim to the superficial temporal fascia and dermis. This article uses the coherent and pragmatic terminology recently proposed by Mendelson.22 The superior temporal septum (STS), which separates the frontal periosteum medially from the deep temporal fascia, laterally continues inferior forming the temporal ligamentous adhesion (TLA) in the confluence of the periorbit, the forehead, and the temporal area. The confluence of the superficial temporal fascia with galea aponeurotica and periosteum from the forehead forms the TLA. The overlying tissues are bonded to periosteum and fixed to bone. The lateral frontalis muscle usually terminates along the STS and TLA. Along with the STS and TLA, the supraorbital ligamentous adhesion restrains the brow elevation and therefore should also be properly released. All these attachments rest less than 3 cm from the edge of the orbit and, because of that, can be easily addressed through a blepharoplasty incision. Mendelson’s extensive work shows that the potential space between the inferior temporal
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Fig. 4. (A and C) A 60-year-old patient before surgery. (B and D) The same patient 3 years after surgery. Note that the frontalis muscle in this patient is narrow with a more medial insertion of its fibers, not extending to the lateral brow and causing it to be more severely ptotic.
septum and the STS does not contain major branches of the facial nerve and, therefore, could be dissected without direct visualization. The inferior temporal septum has been shown to be an oblique, weak attachment line extending from the lateral corner of the temporal ligament toward the external acoustic meatus. The deep temporal fascia divides itself into superficial and deep temporal fascia above the level of the inferior temporal septum. The inferior temporal septum forms the superior border of a triangular compartment between the superficial temporal fascia and the underlying deep temporal fascia and is known to contain some emerging branches of the zygomaticotemporal nerve, the sentinel vein, and the temporal branches of the facial nerve within the fatty layer (Figs. 2 and 3). As stated by Zide,27 if not for the temporal branches of the facial nerves, most of this periorbital surgery would be simple because surgeons for years gave little thought to the sensory nerves around the orbit. The general course of the temporal branch nerve has been well
documented. It branches from the main trunk caudal to the zygomatic arch approximately 1.5 cm in front of the tragus, crossing the arch approximately 2.5 cm in front of the anterior border of the external auditory meatus. Hinderer and colleagues28 have described the midpoint of the line between the helix and the lateral canthus as being the external landmark where the temporal branch crosses the zygomatic arch. The traditional and more common method, however, for representing the course of the temporal division is to draw a line from just below the tragus to a point 1.5 cm above the lateral part of the eyebrow as described by Ramos and Pitanguy.29 De la Plaza and colleagues described perforating vessels (sentinel vein) in the temporal region passing through the temporoparietal fascia, the deep temporal fascia, and temporalis muscle. This vein is about 5 mm lateral to the frontozygomatic suture line. Attempts to describe more precisely the position of the sentinel vein were made.7 Some cadaver studies have shown that, contrary to common understanding, the nerve
Transpalpebral Brow Lifting
Fig. 5. (A and C) A 49-year-old patient before surgery. (B and D) The same patient 3 years after surgery. Note the severe temporal brow ptosis with normal medial brow position.
course is not always consistently caudal to the vein. After many attempts to correctly predict the anatomic position of the temporal branches of the facial nerve, experience has shown that the best way to avoid an injury is to avoid the nerve’s plane, rather than its topography. Thus, the more caudal the dissection progresses, the greater the chance of reaching the point where the branches of the facial nerve could be deep to the superficial temporal fascia and therefore in the same plane of dissection.22 Looking into the central brow and its structures, access to the medial anterior surface of the superior orbital rim can be gained through two different dissection planes. One is between the orbicularis muscle and the septum orbitale and the other is through the deep surface of the septum orbitale. Dissection shows and releases the wall of deep galea enveloping the galea fat pad to expose the transverse head of the corrugator supercilii muscle. Caudal to the muscles, one can palpate the supraorbital foramen. When these orbital rim
landmarks cannot be palpated, anatomic data can be used to map out the most likely location of the origin of the nerve bundles on the rim. Previous anatomic studies variably describe the location of the origins as 16 to 22 mm from midline for the supratrochlear bundle and 24 to 32 mm from midline for the supraorbital bundle. The supratrochlear nerve branches pass through the anterior surface of the medial third of the corrugators supercilii and some of its branches (two to four) may enter the corrugators supercilii muscle and be difficult to separate from its body. The deep branch of the supraorbital nerve usually exits at the supraorbital notch in the orbital rim, but it can also exit bone from a foramen located up to approximately 1.5 cm superior to the rim. Knize30 first showed that the superficial branch of the nerve runs in the subgaleal plane, piercing the frontal muscle, whereas the deep branch or branches—there may be more than one—are running just superficial to the periosteum approximately 5 to 15 mm medial to the line formed by
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Fig. 6. Schematic view of the surgical dissection using the blepharoplasty incision. DTF, deep temporal fascia; FN, facial nerve; P, periosteum; SON, supraorbital nerve; SV, sentinel vein.
the temporal septum. The deep branch or branches must be avoided.
DYNAMICS Eyebrow ptosis is essentially a result of gravity. Laxity of the forehead, eyebrows, and eyelids develop with time, resulting in inferior migration of the eyebrow. With the downward movement of the eyebrows, the frontalis muscle attempts to
Fig. 8. Operative sequence. (Zone 1) Subperiostal undermining between lateral temporal adhesion and neurovascular bundle. (Zone 2) Subsuperficial temporal fascia undermining dissection plane, releasing lateral temporal adhesion and connecting both subperiosteal and subfascial plane until 5 cm above the orbital rim. (Zone 3) Through the temporal incision, upper portion of the STS is released until zones 1, 2 and 3 are connected. (Zone 4) Lateral subperiosteal release of the STS until all four zones are connected. Diverging arrows above zone 3 indicate the scalp incision placement. Diverging arrows connected by dotted line indicate the periosteum incision placement. Dotted line bordering zones 2 and 3 indicates the lateral limits of the subsuperficial temporal fascia plane.
elevate the eyebrows, resulting in horizontal lines. Unlike the medial two thirds of the eyebrow, the lateral third does not have deep structural attachments to the periosteum, making it especially susceptible to temporal brow ptosis. In addition, the
Fig. 7. Visualization of the sentinel vein through an upper blepharoplasty incision after releasing the TLA. DTF, deep temporal fascia; SV, sentinel vein.
Fig. 9. Visualization of the supraorbitary foramen and nerve through an upper blepharoplasty incision.
Transpalpebral Brow Lifting
Fig. 10. A 2-0 nylon is placed through the posterior galea 3 cm above the superior margin of the incision after a Reverdin needle is used to perform a temporal flap suture that enters and leaves the anterior skin through the same point (usually at the temporal hairline) but also brings together a consistent amount of anterior galea. Arrows indicate directions in which needle is pulled or pushed.
frontalis muscle fibers do not extend to the lateral brow, further contributing to the lack of lateral support because the contraction of the frontalis muscle is the primary force that elevates the lateral brow. This lateral attenuation is variable and one can see that the more medial the insertion of the frontalis muscle fiber ends, the more severe the temporal descent and brow ptosis (Fig. 4). Standard upper blepharoplasty may even aggravate brow ptosis because the frontalis muscle spasm will be relieved after the upper eyelid weight and mass reduction. Just performing an upper lid blepharoplasty without any method of brow stabilization shortens the distance from the
Fig. 11. After the temporal flap is released and suspended, a periosteal gap exposes the frontal bone above the orbital rim.
eyebrow to the lid margin if the frontalis muscle was necessarily contributing to the lid opening. It is useful to separate the discussion of brow ptosis into lateral and medial components. The forces that cause descent of the lateral eyebrow include the action of the orbicularis and the transverse portion of the corrugator muscle, and the mass effect of the eyelid, brow fat pad, and the soft tissues of the temporal forehead. Ptosis of the medial two-thirds of the brow is related to the action of the depressor supercilli muscle, the procerus, and the medial portion of the orbicularis muscle. As a result of these underlying anatomic arrangements, severe temporal brow ptosis with secondary dermatochalasis causing hooding of the upper eyelid skin without any great medial brow ptosis is not uncommon (Fig. 5). There is a great morphologic diversity the shape of eyebrows. Even young individuals may have naturally low-set brows. Others may show significant signs of facial aging but have little or no brow ptosis. One should be cautious in addressing a highly arched ptotic brow, correcting only the temple soft-tissues’ descent and avoiding an excessive brow elevation. On another hand, if the eyebrow tail is low-set without any signs of aging and the patient requests a change in its shape, a more aggressive approach and even a direct brow elevation would be necessary. So one may elevate the eyebrows that are congenitally low or low from changes due to aging, removing excess skin and fullness from the upper eyelid. One may also improve symmetry or change the shape of
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Fig. 13. Lateral view of the traction vectors (arrows).
Fig. 12. Lateral view of the three suspending sutures.
the eyebrows, and the decrease muscle function in the brow and glabellar regions that cause dynamic wrinkling. However, just because a brow can be elevated does not mean it should be elevated, especially in the male gender. A precise diagnosis of the position and shape of the eyebrows as well as their dynamic changes is essential for the appropriate surgical indication.
SURGICAL TECHNIQUE Upward Forehead Flap Elevation The surgical principles of the transpalpebral subperiosteal approach are the same as those for an endoscopic brow lift. The only difference is that the surgeon approaches these structures from below and, because the surgeon is closer to the periorbital anatomic structures, those structures are addressed first. Initially determine and outline the area of redundant upper eyelid skin, as done routinely in preparation for an upper blepharoplasty procedure. This should be done after slightly elevating the lateral brow and marking the elevation vectors that will be used during advancement of the forehead flap. When the lateral brow is elevated by advancing the forehead flap, eyebrow skin that had
descended onto the orbit is resuspended and spared from resection. This maneuver prevents any overresection of skin in the upper eyelid.3 After skin is excised, the orbicularis oculi muscle is identified and a 6-cm incision parallel to the skin incision is made to expose the surface of the septum orbitale. Using double hooks, the orbicularis oculi muscle is retracted and blunt dissection over the anterior surface of the septum is performed in a cephalic direction. The periosteum is incised 3 mm above the edge of the superior orbital rim from the upper and lateral limit of the orbit to the exit of the supraorbital neurovascular bundle. Careful dissection reveals a band of connective tissue between the orbital rim and the overlying superficial temporal fascial plane near the point where the temporal fusion line meets the superolateral orbital rim. In a departure from other limited-incision techniques, transection of the lateral temporal adhesion, lateral brow thickening of the periorbital septum, and lateral orbital thickening of the periorbital septum is performed under direct view (Fig. 6). The lateral aspect of the dissection enables dissection under direct visualization of the most delicate area of the flap—the lower temporal compartment as defined by Mendelson. This compartment contains the sentinel vein, the temporal branch of the facial nerve, and the zygomatic nerves. This elevation can be gently performed with gauze, leaving these
Transpalpebral Brow Lifting
Fig. 14. A 40-year-old patient before surgery.
structures above the plane of dissection until the inferior temporal line is reached and carefully elevated from its attachments to the bone. With this blunt dissection beyond the lateral limit of the orbit and above the lateral canthus level, the deep temporal fascia is exposed and, as the superior and lateral dissection progresses, the sentinel vein is seen and may be preserved (Fig. 7). At this level, we know that the frontal branches of the facial nerve should be in the superficial temporal fascia flap and we can now safely release the lateral temporal adhesion connecting the subsuperficial temporal fascia plane with the subperiosteal plane under direct vision. The medial aspect of the flap elevation is easier. A periosteal elevator is required to free the zone of firmly fixed soft tissues from bone near the orbital rim. Again, under direct visualization, all the periosteal attachments above the brow are released. Keeping the subperiosteal plane and stopping its dissection at the supraorbital notch, we avoid any injury to the supraorbital neurovascular bundle, even if it is not visualized. The flap elevation performed until this moment should stop approximately 5 cm above the brow (after releasing of the inferior temporal line and the temporal ligamentous adhesion). Further elevation is performed through the two scalp temporal incisions performed next.
Scalp Temporal Incision Access Two scalp incisions are performed behind the frontal hairline, almost as high as the lateral segment of
Fig.15. The same patient as in Fig.14, but as a 50-yearold 10 years after a blepharoplasty, returning for a face-lift.
a classic coronal incision, and perpendicular to the selected suspension vector line. The incisions should not be placed more medially than the temporal line to avoid injury to the deep branch of the supraorbital nerve, postoperative scalp numbness, and dysesthesia. The scalp incisions go through superficial temporal fascia down to the temporalis fascia. There is a clear plane between the temporalis fascia and superficial temporal fascia. After elevating the superficial temporal fascia through the scalp incision, the periosteum is incised at the superior temporal line and elevated in the forehead. Because the inferior region of the forehead has already been released from its deep attachments, the periosteal elevation should proceeds downwards. At this point, the elevation in the frontal region meets the prior elevation done through the blepharoplasty incisions (Fig. 8).
The Transpalpebral Miectomy of the Corrugator Muscle At this point, all the dissection of the corrugator supercilii muscle is already done. The lateral end of the muscle is transected just as the muscle passes into the plane of the frontalis and orbicularis oculi muscles. While elevating the lateral end of the transected corrugator supercilii muscle away from the trunk of the supraorbital nerve, resect the lateral part of the muscle. The supraorbital
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Fig. 16. Transpalpebral and transtemporal subperiostial foreheadplasty and face-lift, 1-year postoperative view.
nerve trunk, before dividing into superficial (medial) divisions, containing three or four small branches, and deep (lateral) divisions, is safely deep to the plane of the corrugator supercilii muscle when the soft tissues are retracted away from the orbital rim (Fig. 9). However the supratrochlear nerve branches pass through the anterior surface of the medial third of the muscle and can have four to eight branches. Because of that, it is recommended to leave a muscle stump protected by interlaced supratrochlear nerve branches. This small muscle stump left interlaced has no effect on glabellar skin. The remaining muscle located medially to the nerve branches is also elevated and resected after careful dissection. This prevents later recurrence of glabellar action and asymmetry. The medial head of the orbital portion of the orbicularis oculi muscle and the depressor supercilii are also resected if oblique glabellar skin creases are present. They can be easily identified overlying the origin of the corrugator muscle.
Fixation There are many techniques to fix the brow or forehead once it has been elevated off the calvarium in brow-elevation procedures. These include fixing the brow to bone by drilling holes in the calvarium and securing it with sutures and using temporary
Fig.17. Patient before transpalpebral and transtemporal subperiostial foreheadplasty and face-lift.
screws to the bone or semipermanent absorbable screws to the bone. The advantages and disadvantages of all these methods are reviewed by Rohrich and colleagues.31 This article does not extensively discuss the methods of fixation. The authors believe that each surgeon can choose his or her preferred method of fixation. However, in the authors’ experience, fixation has been accomplished with nylon 2-0 sutures passed through the superficial temporal fascia plane within the margin of the advanced flap and sutured to the deep surface of the temporal fascia of the posterior scalp. An extensive subgaleal and subperiosteal plane is the healing interface, maintaining the elevation of the temple and the forehead. To enhance the flap adhesion to the deep plane in the temporal area, a window measuring 2 cm by 2 cm is open in the deep temporal fascia. The inner surface of the superficial temporal fascia will strongly adhere to the exposed temporal muscle and stabilize the temporal flap at a higher position. By placing a through-and-through suture in the flap along the temporal line, the forehead and its previously released temporal adhesion is lifted, transmitting the pull to the lateral two thirds of the eyebrow (Fig. 10). After this fixation, a gap above the orbital periosteum incision exposing the bone surface is often seen through the eyelid incision (Fig. 11). Two more sutures are placed at the temporal hairline 1 in apart and tied to the posterior leaf of the
Transpalpebral Brow Lifting REFERENCES
Fig. 18. The same patient in Fig. 17, 1 year after transpalpebral and transtemporal subperiostial foreheadplasty and face-lift.
aponeurotic galea, applying enough tension to elevate the temple soft tissues (Figs. 12 and 13). This suspension of the temporal flap results in excessive scalp around the temporal incision that should not be removed, as it will flatten in 2 or 3 months without a noticeable scar.
SUMMARY Forehead rejuvenation goals are to raise the eyebrows, attenuate forehead wrinkles, and decrease glabellar frown lines. The best way to accomplish this has been subject of passionate discussion. The original article by Knize describing a fully nonendoscopic procedure with minimal incision has shed some light on this issue. The combinedaccess brow lift described in this article is a limited-incision technique that can provide a cosmetic effect comparable to that produced by the coronal incision technique (Figs. 14–18). It also allows safe direct visualization of anatomic structures comparable to that allowed by the endoscopic-assisted technique but dispenses with tedious endoscopic instrumentation, is less expensive, and takes less time to learn. The only essential requirement is thorough knowledge of the relevant anatomy.
1. Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional lift. Case reports. Aesthetic Plast Surg 1994;18(1):21–9. 2. Chajchir A. Endoscopia en Cirugia Plastica y Estetica. In: Gonzalez Montaner LJ, Huriado Hoyo E, Altman R, Maino R, editors. El Libro de Oro en Homenaje al Doctor Carlos Reussi. Buenos Aires: Ed. Associacion Medica Argentina, 1993. 3. Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 1996;97:1334–42. 4. Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast Surg 1996;20:129. 5. Ramirez OM. Transblepharoplasty forehead lift and upper face rejuvenation. Ann Plast Surg 1996;37: 577–84. 6. Campiglio GL, Candiani P. Anatomical study on the temporal fascial layers and their relationships with the facial nerve. Aesthetic Plast Surg 1997;21:69. 7. Trinei FA, Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg 1998;101(1):27–32. 8. Knize DM. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty. Plast Reconstr Surg 1998;102:478–89. 9. Knize DM. Muscles that act on glabellar skin: a closer look. Plast Reconstr Surg 2000;105(1): 350–61. 10. Knize DM. The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and forehead rejuvenation. Plast Reconstr Surg 2007;119(3):1119–20. 11. Paul M. Evolution of the brow lift. Plast Reconstr Surg 2001;108(5):1409–24. 12. Passot R. La chirurgie esthetique des rides du visage. Presse Med 1919;27:258. 13. Castanares S. Forehead wrinkles, glabellar frown and ptosis of eyebrows. Plast Reconstr Surg 1964; 34:406. 14. Franco T, Rebello C. Cirurgia este´tica. Sa˜o Paulo: Editora Ateneu; 1977. p. 98–9. 15. Connell BF. Eyebrow, face, and neck lifts for males. Clin Plast Surg 1978;5(1):15–28. 16. Pitanguy I. Section of the frontalis-proceruscorrugator aponeurosis in the correction of frontal and glabellar wrinkles. Ann Plast Surg 1979;2: 422–7. 17. Flowers RS. Periorbital aesthetic surgery for men: eyelids and related structures. Clin Plast Surg 1991;18:689–729. 18. Elkwood A, Matarasso A, Rankin M, et al. National plastic surgery survey: brow lifting techniques and complications. Plast Reconstr Surg 2001;108(7): 2143–50 [discussion: 2151–2].
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forehead rejuvenation. Plast Reconstr Surg 2006; 117(1):95–104. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg 1989;83(2):265–71. Zide BM. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions by Christopher [letter]. Plast Reconstr Surg 2000; 105(4):1495–6. Hinderer UT, Urriolagoitia F, Vildosola R. The blepharo-periorbitoplasty: anatomical basis. Ann Plast Surg 1987;18(5):437–53. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting surgery. Plast Reconstr Surg 1966;38(4):352–6. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg 1995;96:564–9. Rohrich RJ, Beran SJ. Evolving fixation methods in endoscopically assisted forehead rejuvenation: controversies and rationale. Plast Reconstr Surg 1997; 100(6):1575–82.
New technologies have created a trend for lessinvasive procedures in all surgical specialties. Over the past 2 decades, great advances have been made in the fields of minimal-incision and endoscopic surgeries. The endoscope, with its accompanying instrumentation, has been the key development supporting this trend. The endoscopic brow lift was the first procedures to gain widespread acceptance among plastic surgeons. The subperiosteal dissection approach as applied to the forehead arose from the development of craniofacial techniques. Using this plane, the application of an endoscope to visualize and dissect the periorbita was described in 1994.1,2 In the mid-1990s a better understanding of the relevant anatomy and the evolving therapeutic modalities (including both open and closed techniques) have helped clinicians reach a renewed refinement in the aesthetic surgery of the forehead and brow area. Endoscopic-assisted views of the anatomic landmarks and planes helped surgeons better understand the dynamics of brow ptosis. However, some investigators realized that the endoscope was only necessary because of the long distance between the temporal port and the periorbita, making its dissection hazardous. Still in the mid-1990s, some investigators described forehead and brow limited-incision techniques that achieved reliable results without endoscopic support.3–5 Despite the good results, much criticism arose concerning the safety of the procedure because there was no direct view of the anatomic landmarks as one elevates the flap further than 5 cm
from the scalp incision. This blind dissection increases the risk of damaging the temporal branch of the facial nerve and branches of the trigeminal nerve division, the supraorbital and supratrochlear nerve, as each leaves its respective foramen at the junction of the middle and medial one third of the orbital rim. Bleeding is also a major concern for two main reasons: first, because bleeding from vessels that cannot be directly visualized is impossible to stop and, second, because of the close relationship that such vessels as the sentinel vein and the frontal branch of the superficial temporal artery and vein have with nerves.6,7 To enable better visualization and address these problems, an upper blepharoplasty incision can be made for access to the inferior region of the forehead. More patients present for eyelid surgery than for brow lift, and even those requesting a brow lift and those requesting upper facial rejuvenation also require upper blepharoplasty. Thus, it is natural to think of the upper eyelid incision as an alternative port because of its proximity to periorbital anatomic structures. Through this incision, direct visualization of the anatomic landmark in the orbital rim and inferior forehead is obtained and dissection proceeds upwards joining the downwards dissection done through a short temporal scalp incision. The combined-access foreheadplasty allows direct visualization of all the anatomic structures that are not directly visualized through the temporal incision. Because this technique dispenses with endoscopic instrumentation, it is less expensive and simpler than the endoscopic-assisted approach. With dissection through the upper blepharoplasty incision, the
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Department of Plastic and Reconstructive Surgery, Pontifical Catholic University of Rio de Janeiro, Brazil Brazilian Plastic Surgery Society, Sa˜o Paulo, Brazil * Corresponding author. Avenida Lineu de Paula Machado 1000 apto. 401 bloco 01 – Jardim Botaˆnico- Rio de Janeiro –RJ- Brazil 22470-040. E-mail address: [email protected] (H.P.L. Cintra).
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Clin Plastic Surg 35 (2008) 381–392 doi:10.1016/j.cps.2008.02.001 0094-1298/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
Transpalpebral Transblepharoplasty Brow lifting Subperiosteal Limited incisions
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Cintra & Basile distance is short to the corrugator supercilii muscle, the procerus muscle, and the depressor supercilii muscle, each of which can be selectively transected through this incision to reduce unwanted wrinkles and elevate the medial brow. Likewise, the orbicularis can be incised and subperiosteal dissection performed above the orbital rim to elevate the lateral brow through this same local incision. The result has been a decrease in morbidity as well as a decrease in surgical and recovery times.8,9 From the endoscopic experience, it is now known that the failure of an endoscopic brow lift may be related to inadequate dissection and release, inadequate fixation, or both.10 This article describes a limited-incision foreheadplasty technique with combined transpalpebral, subperiosteal, and transtemporal access to provide a safe and reliable brow elevation and glabellar furrow reduction by releasing inferior tethering and weakening the brow depressor muscles with direct visualization of these anatomic structures. The technique produces aesthetic results comparable to that allowed by the endoscopic-assisted technique.
HISTORICAL BACKGROUND For nearly a century, many techniques for rejuvenation of the upper third of the face and brow have been described.11 The earliest description of brow lifting in the literature was published by Passot12 in 1919. Castanares13 described local access through an incision just over the brow to treat the oblique portion of the corrugator muscle, remove excessive forehead skin, and elevate the ptotic brow. It could be suggested that Franco and Rebello14 in the 1970s made the first attempt to use the blepharoplasty incision to address the corrugator muscle. Connell15 described the use of existing transverse forehead rhytids as a means of removing forehead soft tissue and thereby lifting the brow while nicely concealing the scar in selected individuals with fair skin whose main concern was brow ptosis. Pitanguy16 popularized a subgaleal approach for the temporal region. More recently, Flowers17 stressed the value of correcting brow ptosis as the major aesthetic finding in the aging upper one-third of the face and not removing excessive upper eyelid skin. In more recent years, rejuvenation of the aging upper third of the face has undergone evolutionary transformations from the classic open coronal or anterior hairline brow lift to scar-reduction techniques, such as the endoscopic brow lift in the early 1990s, the limited temporal incision brow lift, and the transpalpebral access to the brow depressor muscles.
Vasconez and Isse in 1992 presented early experience with endoscopic brow lift. However, the first publication on the use of the endoscope for brow lifting was by Chajchir2 in 1993. Since then, enormous advances in the field of endoscopic surgery have produced a significant paradigm shift in surgical management of brow and forehead aging. A survey of the membership of the American Society of Plastic Surgeons in 2000, representing 6951 brow lifts, revealed that approximately 50% were performed endoscopically.18 Unlike the open techniques that rely on a combination of skin excision and soft tissue traction, endoscopic techniques rely solely on soft tissue repositioning. Since the initial presentation by Vasconez19 and Isse,20 many other investigators have made important contributions to this field. Knize3 first reported on the limited-incision technique in 1996. He advocated using a short temporal incision to create a subtemporalis fascial plane and a medial subperiosteal plane, division of the orbital ligament, and mobilization of the lateral brow. Through an upper eyelid incision, the corrugator supercilli muscle is partially excised, the procerus muscle is divided, and a graft of temporalis fascia is placed in the glabella as filler. This technique has become more popular over the past few years, producing similar results to the endoscopic approach. Paul4 was the first to describe a systematic approach using both temporal and palpebral incisions for a brow lift, while simultaneously correcting the findings in the hooded eyelid. This included trimming of orbital orbicularis oculi muscle and suborbicularis fat with brow stabilization by soft tissue suturing above the orbital rim. All aspects of the hooded upper eyelid can be addressed through this approach.21
APPLIED SURGICAL ANATOMY Only in recent years has a better understanding of the relevant anatomy and the evolving therapeutic modalities (including both open and closed techniques) contributed to a renewed refinement in the aesthetic surgery of the forehead and brow area. Detailed knowledge of this particular anatomy is paramount for anyone planning to perform adequate forehead rejuvenation.22–26 The forehead is divided into three main aesthetical (and surgical) unities: (1) the brow and temporal region lateral to the temporal line, including the potential space that separates the superficial temporal fascia to the deep temporal fascia; (2) the central forehead to 5 cm above the orbital rim, including the potential subperiostal space contained between the two temporal lines; and (3) the central brow, which is more mobile, overlies the muscle
Transpalpebral Brow Lifting
Fig. 3. Image of cadaver dissection used as basis for Fig. 2. Fig. 1. Surgical unities of the forehead and brow. (A) Medial brow. (B) Lateral brow and temporal area. (C) Central forehead.
and nerve bundles, and should be addressed separately (Fig. 1). Each of these potential spaces has different layers with complex relationships to several anatomic landmarks and attachments structures that fix the brow in position. The superficial layers of the forehead and temporal region are retained by a complex system of attachments that arise from the underlying deep fascia or periosteum. An understanding of the dynamics of these
Fig. 2. Anatomic landmarks from cadaver dissection shown in Fig. 3. Note that the scissors are beneath the temporal fusion line adhesion (TLA) to the frontal bone. DTF, deep temporal fascia; FN, facial nerve; OM, orbicularis oculi muscle; P, periosteum; STF, superficial temporal fascia; SV, sentinel vein.
attachments and their relationships to each other and to the anatomic landmarks of the temporal region is essential. There are a few structures or attachments that avoid the brow to be elevated and should be released during any forehead rejuvenation procedure. Some controversy has arisen regarding the appropriate terminology for the retaining structures of the face. Although the term ligament has conventionally referred only to connective tissue between bones, Furnas24 introduced the concept of cutaneous retaining ligaments as those elements in the face and forehead that run from deep and fixed structures to the overlying dermis. Knize10 has described the orbital ligament that tethers the lateral orbital rim to the superficial temporal fascia and dermis. This article uses the coherent and pragmatic terminology recently proposed by Mendelson.22 The superior temporal septum (STS), which separates the frontal periosteum medially from the deep temporal fascia, laterally continues inferior forming the temporal ligamentous adhesion (TLA) in the confluence of the periorbit, the forehead, and the temporal area. The confluence of the superficial temporal fascia with galea aponeurotica and periosteum from the forehead forms the TLA. The overlying tissues are bonded to periosteum and fixed to bone. The lateral frontalis muscle usually terminates along the STS and TLA. Along with the STS and TLA, the supraorbital ligamentous adhesion restrains the brow elevation and therefore should also be properly released. All these attachments rest less than 3 cm from the edge of the orbit and, because of that, can be easily addressed through a blepharoplasty incision. Mendelson’s extensive work shows that the potential space between the inferior temporal
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Fig. 4. (A and C) A 60-year-old patient before surgery. (B and D) The same patient 3 years after surgery. Note that the frontalis muscle in this patient is narrow with a more medial insertion of its fibers, not extending to the lateral brow and causing it to be more severely ptotic.
septum and the STS does not contain major branches of the facial nerve and, therefore, could be dissected without direct visualization. The inferior temporal septum has been shown to be an oblique, weak attachment line extending from the lateral corner of the temporal ligament toward the external acoustic meatus. The deep temporal fascia divides itself into superficial and deep temporal fascia above the level of the inferior temporal septum. The inferior temporal septum forms the superior border of a triangular compartment between the superficial temporal fascia and the underlying deep temporal fascia and is known to contain some emerging branches of the zygomaticotemporal nerve, the sentinel vein, and the temporal branches of the facial nerve within the fatty layer (Figs. 2 and 3). As stated by Zide,27 if not for the temporal branches of the facial nerves, most of this periorbital surgery would be simple because surgeons for years gave little thought to the sensory nerves around the orbit. The general course of the temporal branch nerve has been well
documented. It branches from the main trunk caudal to the zygomatic arch approximately 1.5 cm in front of the tragus, crossing the arch approximately 2.5 cm in front of the anterior border of the external auditory meatus. Hinderer and colleagues28 have described the midpoint of the line between the helix and the lateral canthus as being the external landmark where the temporal branch crosses the zygomatic arch. The traditional and more common method, however, for representing the course of the temporal division is to draw a line from just below the tragus to a point 1.5 cm above the lateral part of the eyebrow as described by Ramos and Pitanguy.29 De la Plaza and colleagues described perforating vessels (sentinel vein) in the temporal region passing through the temporoparietal fascia, the deep temporal fascia, and temporalis muscle. This vein is about 5 mm lateral to the frontozygomatic suture line. Attempts to describe more precisely the position of the sentinel vein were made.7 Some cadaver studies have shown that, contrary to common understanding, the nerve
Transpalpebral Brow Lifting
Fig. 5. (A and C) A 49-year-old patient before surgery. (B and D) The same patient 3 years after surgery. Note the severe temporal brow ptosis with normal medial brow position.
course is not always consistently caudal to the vein. After many attempts to correctly predict the anatomic position of the temporal branches of the facial nerve, experience has shown that the best way to avoid an injury is to avoid the nerve’s plane, rather than its topography. Thus, the more caudal the dissection progresses, the greater the chance of reaching the point where the branches of the facial nerve could be deep to the superficial temporal fascia and therefore in the same plane of dissection.22 Looking into the central brow and its structures, access to the medial anterior surface of the superior orbital rim can be gained through two different dissection planes. One is between the orbicularis muscle and the septum orbitale and the other is through the deep surface of the septum orbitale. Dissection shows and releases the wall of deep galea enveloping the galea fat pad to expose the transverse head of the corrugator supercilii muscle. Caudal to the muscles, one can palpate the supraorbital foramen. When these orbital rim
landmarks cannot be palpated, anatomic data can be used to map out the most likely location of the origin of the nerve bundles on the rim. Previous anatomic studies variably describe the location of the origins as 16 to 22 mm from midline for the supratrochlear bundle and 24 to 32 mm from midline for the supraorbital bundle. The supratrochlear nerve branches pass through the anterior surface of the medial third of the corrugators supercilii and some of its branches (two to four) may enter the corrugators supercilii muscle and be difficult to separate from its body. The deep branch of the supraorbital nerve usually exits at the supraorbital notch in the orbital rim, but it can also exit bone from a foramen located up to approximately 1.5 cm superior to the rim. Knize30 first showed that the superficial branch of the nerve runs in the subgaleal plane, piercing the frontal muscle, whereas the deep branch or branches—there may be more than one—are running just superficial to the periosteum approximately 5 to 15 mm medial to the line formed by
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Fig. 6. Schematic view of the surgical dissection using the blepharoplasty incision. DTF, deep temporal fascia; FN, facial nerve; P, periosteum; SON, supraorbital nerve; SV, sentinel vein.
the temporal septum. The deep branch or branches must be avoided.
DYNAMICS Eyebrow ptosis is essentially a result of gravity. Laxity of the forehead, eyebrows, and eyelids develop with time, resulting in inferior migration of the eyebrow. With the downward movement of the eyebrows, the frontalis muscle attempts to
Fig. 8. Operative sequence. (Zone 1) Subperiostal undermining between lateral temporal adhesion and neurovascular bundle. (Zone 2) Subsuperficial temporal fascia undermining dissection plane, releasing lateral temporal adhesion and connecting both subperiosteal and subfascial plane until 5 cm above the orbital rim. (Zone 3) Through the temporal incision, upper portion of the STS is released until zones 1, 2 and 3 are connected. (Zone 4) Lateral subperiosteal release of the STS until all four zones are connected. Diverging arrows above zone 3 indicate the scalp incision placement. Diverging arrows connected by dotted line indicate the periosteum incision placement. Dotted line bordering zones 2 and 3 indicates the lateral limits of the subsuperficial temporal fascia plane.
elevate the eyebrows, resulting in horizontal lines. Unlike the medial two thirds of the eyebrow, the lateral third does not have deep structural attachments to the periosteum, making it especially susceptible to temporal brow ptosis. In addition, the
Fig. 7. Visualization of the sentinel vein through an upper blepharoplasty incision after releasing the TLA. DTF, deep temporal fascia; SV, sentinel vein.
Fig. 9. Visualization of the supraorbitary foramen and nerve through an upper blepharoplasty incision.
Transpalpebral Brow Lifting
Fig. 10. A 2-0 nylon is placed through the posterior galea 3 cm above the superior margin of the incision after a Reverdin needle is used to perform a temporal flap suture that enters and leaves the anterior skin through the same point (usually at the temporal hairline) but also brings together a consistent amount of anterior galea. Arrows indicate directions in which needle is pulled or pushed.
frontalis muscle fibers do not extend to the lateral brow, further contributing to the lack of lateral support because the contraction of the frontalis muscle is the primary force that elevates the lateral brow. This lateral attenuation is variable and one can see that the more medial the insertion of the frontalis muscle fiber ends, the more severe the temporal descent and brow ptosis (Fig. 4). Standard upper blepharoplasty may even aggravate brow ptosis because the frontalis muscle spasm will be relieved after the upper eyelid weight and mass reduction. Just performing an upper lid blepharoplasty without any method of brow stabilization shortens the distance from the
Fig. 11. After the temporal flap is released and suspended, a periosteal gap exposes the frontal bone above the orbital rim.
eyebrow to the lid margin if the frontalis muscle was necessarily contributing to the lid opening. It is useful to separate the discussion of brow ptosis into lateral and medial components. The forces that cause descent of the lateral eyebrow include the action of the orbicularis and the transverse portion of the corrugator muscle, and the mass effect of the eyelid, brow fat pad, and the soft tissues of the temporal forehead. Ptosis of the medial two-thirds of the brow is related to the action of the depressor supercilli muscle, the procerus, and the medial portion of the orbicularis muscle. As a result of these underlying anatomic arrangements, severe temporal brow ptosis with secondary dermatochalasis causing hooding of the upper eyelid skin without any great medial brow ptosis is not uncommon (Fig. 5). There is a great morphologic diversity the shape of eyebrows. Even young individuals may have naturally low-set brows. Others may show significant signs of facial aging but have little or no brow ptosis. One should be cautious in addressing a highly arched ptotic brow, correcting only the temple soft-tissues’ descent and avoiding an excessive brow elevation. On another hand, if the eyebrow tail is low-set without any signs of aging and the patient requests a change in its shape, a more aggressive approach and even a direct brow elevation would be necessary. So one may elevate the eyebrows that are congenitally low or low from changes due to aging, removing excess skin and fullness from the upper eyelid. One may also improve symmetry or change the shape of
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Fig. 13. Lateral view of the traction vectors (arrows).
Fig. 12. Lateral view of the three suspending sutures.
the eyebrows, and the decrease muscle function in the brow and glabellar regions that cause dynamic wrinkling. However, just because a brow can be elevated does not mean it should be elevated, especially in the male gender. A precise diagnosis of the position and shape of the eyebrows as well as their dynamic changes is essential for the appropriate surgical indication.
SURGICAL TECHNIQUE Upward Forehead Flap Elevation The surgical principles of the transpalpebral subperiosteal approach are the same as those for an endoscopic brow lift. The only difference is that the surgeon approaches these structures from below and, because the surgeon is closer to the periorbital anatomic structures, those structures are addressed first. Initially determine and outline the area of redundant upper eyelid skin, as done routinely in preparation for an upper blepharoplasty procedure. This should be done after slightly elevating the lateral brow and marking the elevation vectors that will be used during advancement of the forehead flap. When the lateral brow is elevated by advancing the forehead flap, eyebrow skin that had
descended onto the orbit is resuspended and spared from resection. This maneuver prevents any overresection of skin in the upper eyelid.3 After skin is excised, the orbicularis oculi muscle is identified and a 6-cm incision parallel to the skin incision is made to expose the surface of the septum orbitale. Using double hooks, the orbicularis oculi muscle is retracted and blunt dissection over the anterior surface of the septum is performed in a cephalic direction. The periosteum is incised 3 mm above the edge of the superior orbital rim from the upper and lateral limit of the orbit to the exit of the supraorbital neurovascular bundle. Careful dissection reveals a band of connective tissue between the orbital rim and the overlying superficial temporal fascial plane near the point where the temporal fusion line meets the superolateral orbital rim. In a departure from other limited-incision techniques, transection of the lateral temporal adhesion, lateral brow thickening of the periorbital septum, and lateral orbital thickening of the periorbital septum is performed under direct view (Fig. 6). The lateral aspect of the dissection enables dissection under direct visualization of the most delicate area of the flap—the lower temporal compartment as defined by Mendelson. This compartment contains the sentinel vein, the temporal branch of the facial nerve, and the zygomatic nerves. This elevation can be gently performed with gauze, leaving these
Transpalpebral Brow Lifting
Fig. 14. A 40-year-old patient before surgery.
structures above the plane of dissection until the inferior temporal line is reached and carefully elevated from its attachments to the bone. With this blunt dissection beyond the lateral limit of the orbit and above the lateral canthus level, the deep temporal fascia is exposed and, as the superior and lateral dissection progresses, the sentinel vein is seen and may be preserved (Fig. 7). At this level, we know that the frontal branches of the facial nerve should be in the superficial temporal fascia flap and we can now safely release the lateral temporal adhesion connecting the subsuperficial temporal fascia plane with the subperiosteal plane under direct vision. The medial aspect of the flap elevation is easier. A periosteal elevator is required to free the zone of firmly fixed soft tissues from bone near the orbital rim. Again, under direct visualization, all the periosteal attachments above the brow are released. Keeping the subperiosteal plane and stopping its dissection at the supraorbital notch, we avoid any injury to the supraorbital neurovascular bundle, even if it is not visualized. The flap elevation performed until this moment should stop approximately 5 cm above the brow (after releasing of the inferior temporal line and the temporal ligamentous adhesion). Further elevation is performed through the two scalp temporal incisions performed next.
Scalp Temporal Incision Access Two scalp incisions are performed behind the frontal hairline, almost as high as the lateral segment of
Fig.15. The same patient as in Fig.14, but as a 50-yearold 10 years after a blepharoplasty, returning for a face-lift.
a classic coronal incision, and perpendicular to the selected suspension vector line. The incisions should not be placed more medially than the temporal line to avoid injury to the deep branch of the supraorbital nerve, postoperative scalp numbness, and dysesthesia. The scalp incisions go through superficial temporal fascia down to the temporalis fascia. There is a clear plane between the temporalis fascia and superficial temporal fascia. After elevating the superficial temporal fascia through the scalp incision, the periosteum is incised at the superior temporal line and elevated in the forehead. Because the inferior region of the forehead has already been released from its deep attachments, the periosteal elevation should proceeds downwards. At this point, the elevation in the frontal region meets the prior elevation done through the blepharoplasty incisions (Fig. 8).
The Transpalpebral Miectomy of the Corrugator Muscle At this point, all the dissection of the corrugator supercilii muscle is already done. The lateral end of the muscle is transected just as the muscle passes into the plane of the frontalis and orbicularis oculi muscles. While elevating the lateral end of the transected corrugator supercilii muscle away from the trunk of the supraorbital nerve, resect the lateral part of the muscle. The supraorbital
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Fig. 16. Transpalpebral and transtemporal subperiostial foreheadplasty and face-lift, 1-year postoperative view.
nerve trunk, before dividing into superficial (medial) divisions, containing three or four small branches, and deep (lateral) divisions, is safely deep to the plane of the corrugator supercilii muscle when the soft tissues are retracted away from the orbital rim (Fig. 9). However the supratrochlear nerve branches pass through the anterior surface of the medial third of the muscle and can have four to eight branches. Because of that, it is recommended to leave a muscle stump protected by interlaced supratrochlear nerve branches. This small muscle stump left interlaced has no effect on glabellar skin. The remaining muscle located medially to the nerve branches is also elevated and resected after careful dissection. This prevents later recurrence of glabellar action and asymmetry. The medial head of the orbital portion of the orbicularis oculi muscle and the depressor supercilii are also resected if oblique glabellar skin creases are present. They can be easily identified overlying the origin of the corrugator muscle.
Fixation There are many techniques to fix the brow or forehead once it has been elevated off the calvarium in brow-elevation procedures. These include fixing the brow to bone by drilling holes in the calvarium and securing it with sutures and using temporary
Fig.17. Patient before transpalpebral and transtemporal subperiostial foreheadplasty and face-lift.
screws to the bone or semipermanent absorbable screws to the bone. The advantages and disadvantages of all these methods are reviewed by Rohrich and colleagues.31 This article does not extensively discuss the methods of fixation. The authors believe that each surgeon can choose his or her preferred method of fixation. However, in the authors’ experience, fixation has been accomplished with nylon 2-0 sutures passed through the superficial temporal fascia plane within the margin of the advanced flap and sutured to the deep surface of the temporal fascia of the posterior scalp. An extensive subgaleal and subperiosteal plane is the healing interface, maintaining the elevation of the temple and the forehead. To enhance the flap adhesion to the deep plane in the temporal area, a window measuring 2 cm by 2 cm is open in the deep temporal fascia. The inner surface of the superficial temporal fascia will strongly adhere to the exposed temporal muscle and stabilize the temporal flap at a higher position. By placing a through-and-through suture in the flap along the temporal line, the forehead and its previously released temporal adhesion is lifted, transmitting the pull to the lateral two thirds of the eyebrow (Fig. 10). After this fixation, a gap above the orbital periosteum incision exposing the bone surface is often seen through the eyelid incision (Fig. 11). Two more sutures are placed at the temporal hairline 1 in apart and tied to the posterior leaf of the
Transpalpebral Brow Lifting REFERENCES
Fig. 18. The same patient in Fig. 17, 1 year after transpalpebral and transtemporal subperiostial foreheadplasty and face-lift.
aponeurotic galea, applying enough tension to elevate the temple soft tissues (Figs. 12 and 13). This suspension of the temporal flap results in excessive scalp around the temporal incision that should not be removed, as it will flatten in 2 or 3 months without a noticeable scar.
SUMMARY Forehead rejuvenation goals are to raise the eyebrows, attenuate forehead wrinkles, and decrease glabellar frown lines. The best way to accomplish this has been subject of passionate discussion. The original article by Knize describing a fully nonendoscopic procedure with minimal incision has shed some light on this issue. The combinedaccess brow lift described in this article is a limited-incision technique that can provide a cosmetic effect comparable to that produced by the coronal incision technique (Figs. 14–18). It also allows safe direct visualization of anatomic structures comparable to that allowed by the endoscopic-assisted technique but dispenses with tedious endoscopic instrumentation, is less expensive, and takes less time to learn. The only essential requirement is thorough knowledge of the relevant anatomy.
1. Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional lift. Case reports. Aesthetic Plast Surg 1994;18(1):21–9. 2. Chajchir A. Endoscopia en Cirugia Plastica y Estetica. In: Gonzalez Montaner LJ, Huriado Hoyo E, Altman R, Maino R, editors. El Libro de Oro en Homenaje al Doctor Carlos Reussi. Buenos Aires: Ed. Associacion Medica Argentina, 1993. 3. Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 1996;97:1334–42. 4. Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast Surg 1996;20:129. 5. Ramirez OM. Transblepharoplasty forehead lift and upper face rejuvenation. Ann Plast Surg 1996;37: 577–84. 6. Campiglio GL, Candiani P. Anatomical study on the temporal fascial layers and their relationships with the facial nerve. Aesthetic Plast Surg 1997;21:69. 7. Trinei FA, Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg 1998;101(1):27–32. 8. Knize DM. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty. Plast Reconstr Surg 1998;102:478–89. 9. Knize DM. Muscles that act on glabellar skin: a closer look. Plast Reconstr Surg 2000;105(1): 350–61. 10. Knize DM. The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and forehead rejuvenation. Plast Reconstr Surg 2007;119(3):1119–20. 11. Paul M. Evolution of the brow lift. Plast Reconstr Surg 2001;108(5):1409–24. 12. Passot R. La chirurgie esthetique des rides du visage. Presse Med 1919;27:258. 13. Castanares S. Forehead wrinkles, glabellar frown and ptosis of eyebrows. Plast Reconstr Surg 1964; 34:406. 14. Franco T, Rebello C. Cirurgia este´tica. Sa˜o Paulo: Editora Ateneu; 1977. p. 98–9. 15. Connell BF. Eyebrow, face, and neck lifts for males. Clin Plast Surg 1978;5(1):15–28. 16. Pitanguy I. Section of the frontalis-proceruscorrugator aponeurosis in the correction of frontal and glabellar wrinkles. Ann Plast Surg 1979;2: 422–7. 17. Flowers RS. Periorbital aesthetic surgery for men: eyelids and related structures. Clin Plast Surg 1991;18:689–729. 18. Elkwood A, Matarasso A, Rankin M, et al. National plastic surgery survey: brow lifting techniques and complications. Plast Reconstr Surg 2001;108(7): 2143–50 [discussion: 2151–2].
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Cintra & Basile 19. Vasconez LO. The use of the endoscope in brow lifting. A video presentation at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons. Washington, DC, 1992. 20. Isse NG. Endoscopic forehead lift. Presented at the Annual Meeting of the Los Angeles County Society of Plastic Surgeons. Los Angeles, CA, September 12, 1992. 21. Paul MD. The surgical management of upper eyelid hooding. Aesthetic Plast Surg 1989;13:183. 22. Moss CJ, Mendelson BC. Surgical anatomy of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg 2000;105(4): 1475–90. 23. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg 1996;97(7):1321–33. 24. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989;83(1):11–6. 25. Sullivan PK, Salomon JA, Woo AS, et al. The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and
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