FOREHEAD BROW LIFT

INDICATIONS

·  The primary indication is ptosis of the brows and lateral aspect of the upper lid.

·  In addition, the forehead brow lift will help correct:

i.   Transverse forehead lines

ii. Glabella creases

iii.   Transverse folds at the root to the nose

iv.   Upper nasal and medial eyelid fullness

·  In some patients, forehead or frown lines are the indication for forehead brow lift.

·  If, once the brow has been lifted, there is still upper lid redundancy, then, in addition, the patient needs an upper blepharoplasty.

·  patients in whom the distance from the midpupil to the top of the eyebrow was equal to or greater than 2.5 cm were not candidates to have their brow raised further. (McKinney)

IDEAL EYEBROW POSITION AND CONTOUR (Ellenbogen, 1983)

1. The medial extent of the eyebrow is to a vertical line drawn through the alar base

2. The lateral extent of the eyebrow is to an oblique line drawn from the alar base through the lateral canthus

3. The medial and lateral ends of the eyebrow lie at about the same horizontal level

4. The apex of the brow lies on a vertical line drawn through the lateral limbus

5. The brow arches above the supraorbital rim in women(1cm) and lies at the supraorbital rim in men

Measurements

·  Supratarsal crease to upper edge brow =16mm

·  Midpupil to bottom of brow at least 23mm

·  Upper brow to hairline 5cm.

ANATOMY (David Knize PRS 2000)

Muscles

·  Prolonged hyperactivity of facial muscles causes—

1.  Transverse forehead wrinkles - frontalis

2.  Brow ptosis- corrugator and orbicularis (lateral)

3.  Glabellar wrinkling- corrugator, orbicularis, depressor and procerus

·  Frontalis pulls the eyebrows up - inserts into supraorbital dermis, interdigitating with orbicularis

·  Eyebrow depressors:

  1. corrugator supercilli
  2. procerus
  3. medial head of the orbital portion of the orbicularis oculi
  4. depressor supercilli (most superficial)

·  Corrugator supercilli

·  Oblique head - originate from the superiormedial orbital rim, passing thru orbicularis and insert to the dermis at the medial end of the eyebrow, just above the insertion of depressor supercilli. Vertical creases from over-action. Supplied by zygomatic branch

·  Transverse head - originate from the superiormedial orbital rim (6mm from midline), passing thru orbicularis and insert to the dermis just superior to the middle third of the eyebrow (4cm from midline). Moves eyebrow medially – supplied by frontal branch

·  Procerus arises from the UL cartilages and the nasal bones and inserts into the skin of the glabella region. Contraction ® transverse creases. Supplied by zygomatic branch

·  Depressor supercilli - originate from the superiormedial orbital rim, superficial to corrugator and inserts into medial brow. Supplied by zygomatic branch

·  Medial head of the orbital portion of the orbicularis oculi – inserts into the medial end of brow. Contraction causes oblique lines. Supplied by zygomatic branch

Surgical anatomy. Each frontalis muscle originates from forehead galea aponeurotica and interdigitates with the orbicularis oculi muscle, which inserts into the eyebrow dermis. Superficial temporal fascia and temporalis fascia from the temporal fossa become confluent in the area of the zone of fixation (stippled) with galea aponeurotica and periosteum, respectively, from the forehead. The lateral frontalis muscle usually terminates or becomes markedly attenuated along the lateral margin of the zone of fixation, which extends to the temporal fusion line (TL) and the superior temporal line (STL) of the skull. A fibrous band (*) connects the orbital rim and the superficial temporal fascia deep to the lateral eyebrow. The corrugator supercilii (CSM) and procerus(PM) muscles may participate in the mechanism of eyebrow ptosis, with corrugator supercilii contributing to lateral eyebrow ptosis. Courses of the deep division of the supraorbital nerve and the frontal branch of the facial nerve (FB VII) are shown. The inferior temporal line(ITL) forms the margin of temporalis fascia as it inserts into bone.

Periorbital and temporal ligamentous attachments with major neurovascular relationships: lateral view. Temporal ligamentous adhesion (TLA), supraorbital ligamentous adhesion (SLA), superior temporal septum (STS), inferior temporal septum (ITS), periorbital septum (PS), lateral brow thickening of periorbital septum (LBT), lateral orbital thickening of periorbital septum (LOT), sentinel vessel (SV), temporal branches of facial nerve (TFN), zygomaticotemporal nerve (ZTN), zygomaticofacial nerve (ZFN).

Nerves

Supratrochlear nerve

·  in danger during dissection of the corrugator muscle in forehead lifting as it passes thru the muscle.

·  Average distance from the nasion to the frontal notch/foramen - 25 mm

·  bilateral supratrochlear(frontal) notch in 97%; however, 1% possess bilateral foramina, and 2% have a notch on one side and a foramen on the other

Supraorbital nerve

·  must be protected during an endoscopic subperiosteal forehead lift by not extending the blind dissection beyond 2 cm of the supraorbital margin.

·  25% foramen, 70% notch, 5% from multiple foramens

·  Average distance from the nasion to supraorbital notch/foramen 31 mm

·  2 branches (medial/superficial and lateral/deep)

·  Deep branch travels 0.5-1.5cm medial to superior temporal line between galea and periosteum - terminal branches of this deep supraorbital nerve branch pierce the galea near the coronal suture to supply scalp sensation

·  Superficial branch enters frontalis 2-3cm above supraorbital rim - supply the forehead and up to 3.5 cm of the frontal scalp

·  Also supplies upper lid and nasal root

Frontal branch of facial nerve

·  runs across the anterior temporal fossa within superficial temporal fascia before entering frontalis muscle

·  landmarks –

1.  runs in a line from 0.5 cm below the tragus to 1.5 cm above the outer upper part of the eyebrow (Pitanguy)

2.  2cm from the bony acoustic meatus (horizontal line)

3.  junction of central 1/3 and lateral 1/3 of zygomatic arch or at about 24 mm from the point where the superior border of the zygomatic arch meets the helix.

·  When approaching the region of the superior border of the arch, dissect deep to the superficial layer of the deep temporal fascia cephalad to the arch, proceeding subperiosteally to the caudal border of the arch.

·  This point cannot be overemphasized because the fascial layers fuse at the superior border of the zygomatic arch and the nerve therefore becomes most susceptible to injury at this location.

·  Supplies Frontalis, superior orbicularis, transverse head corrugator, superior end of procerus

The temporal and zygomatic branches of the facial nerve pass through the zygomatic arch: 1, temporal branch of the facial nerve; 2, zygomatic branch of the facial nerve; 3, parotid gland; 4, lower aspect of the zygomatic arch; 5, lateral border of the orbicularis oculi muscle; 6, tragus.

Sentinel vein (De la Plaza 1991)

·  5 mm lateral to the frontozygomatic suture line

·  a tributary of the supraorbital vein at the height of the superior orbital rim, draining the temporal region, passing from the subcutaneous layer through the temporoparietal fascia, then through a perforation or attenuation in the deep temporal fascia to the temporalis muscle - the internal maxillary vein

·  The temporal division of the facial nerve is usually found cephalad to the sentinel vein and, at the nearest point, they were a mean distance of 6.4 mm apart.

·  do not use monopolar electrocautery on the sentinel vein itself because of the risk of a conducted thermal injury to the nerve

·  Inadvertent transection of the sentinel vein adds to periorbital bruising, and ligation or occlusion of the vein seems to cause prominent temporal cutaneous veins postoperatively

Mechanism of Brow Ptosis (Knize PRS 1996)

·  mechanisms producing eyebrow ptosis has a relatively greater effect on the lateral eyebrow segment.

·  The lateral eyebrow has less support from deeper structures than the medial eyebrow, and the balance of forces acting on the eyebrow selectively depresses the lateral segment.

·  Three forces that act on the lateral eyebrow are

1.  frontalis muscle resting tone, which suspends that eyebrow segment medial to the temporal fusion line of the skull

2.  gravity, which causes the soft-tissue mass lateral to the temporal line (galeal fat pad) to slide over the temporalis fascia plane and push the lateral eyebrow segment downward

3.  corrugator supercilii muscle hyperactivity in conjunction with action of the lateral orbicularis oculi muscle, which can antagonize frontalis muscle activity and directly facilitate descent of the lateral eyebrow.

·  The axis point for these forces is the temporal fusion line of the skull near the superior orbital rim.

BROW LIFT

History

·  Passot 1919 - elliptical excisions to elevate the brows and diminish crow's feet

·  Passot 1930 - incision above the eyebrows with undermining and excision of excess tissue, with vertical excisions to relieve vertical rhytids

·  1926 Hunt – coronal incisions both within the hair-bearing scalp and at the anterior hairline and direct excisions within the forehead skin

·  1950s- measures to weaken frontalis (crosshatching, injecting alcohol in frontal branch)

·  1962 Gonzalez-Ulloa– complete circumferential forehead/face lifting

·  1964 Morel-Fatio – partial excision of frontalis

·  1965 Vinas made the following observations:

  1. The inelastic aponeurotic-muscle layer, formed by the frontalis and its extensions adheres to the skin and does not permit free movement of it. Traction on the frontotemporal region with a finger will show this fixation of the skin, as it does not cause the wrinkles to disappear.
  2. There are adhesions that prevent free movement of the soft tissues of the supraorbital regions over the bony orbital rims. Unless these adhesions are eliminated, traction from above will not give a permanent lift to the eyebrow

·  1993 Chajchir first described endoscopic browlifting

Surgical Technique

  1. Approach
  2. Plane of Dissection
  3. Type of fixation

Aims

Restoration of brow position, symmetry and shape
Avoid overcorrection and xs elevation of medial brow
Classification (Ramirez)

Type I: Open, Brow-Forehead Lift with Skin Excision

Type II: Full Endoscopic, Brow-Forehead Lift, No Skin Excision

Type III: Biplanar Brow-Forehead Lift

Approaches
Principle: the further the suspension point from the weight attached the less effective the lift
  1. Direct browlift - advantage of a direct one-to-one correction of brow ptosis, but the tradeoff is a visible scar. More suitable in men with thicker brow or bald

2.  Open browlift

  1. standard coronal incision
  2. modified anterior hairline incision – advantages: maintenance of forehead size, a mechanically efficient lift, a direct attack on wrinkles, and a low incidence of hair loss.
  3. Midbrow - Strip of mid-forehead skin excised at frontalis furrow

3.  Endoscopic

  1. Standard (4-5 port – depending on convexity of forehead)
  2. Subperiosteal dissection to the nasal bones and supraorbital rims, and subsuperficial temporal fascia dissection medially to end at the sentinel vein and inferiorly to the superior edge of the zygomatic arch

b.  Extended

  1. extended over the lateral orbital rim, supraperiosteal up to the midborder of the lateral orbital rim. Recommended when the primary goal was elevation of the tail of the brow, as well as the desire to correct crow’s feet and elevate the lateral raphe of the lateral canthus.

4.  Limited-incision

  1. Temporal incision (Knize)
  2. Transblepharoplasty - Attaching eyebrow flap to superiorly based periosteal flap (browpexy)
  3. Combination procedures

Plane

  1. Subcutaneous

·  direct, removes transverse wrinkles, preserves sensation posterior to incision

·  Decrease flap vascularity, alopecia, poor scars and forehead anaesthesia

·  For older pts with considerable transverse wrinkling, significant brow ptosis, 2nd or 3rd lift, option of shortening or lengthening forehead

  1. Subgaleal

·  Rapid, obvious plane, safe, facilitates muscle excision, bloodless

·  Doesn’t allow skin to stretch

·  Eyebrow movement occurs between leaves of galea at orbital rim

·  Dissection in this layer—greatest degree of translation of brow

·  Can start subgaleal and release orbicularis from periosteum or proceed subperiosteal 2cm above orbital rim

  1. Subperiosteal

·  Indirect lift

·  Arcus marginalis must be released for elevation (periosteum/septal junction)

·  Maintains natural gliding of forehead tissues by maintaining layer between periosteum and galea / frontalis

Ancillary procedures

·  Botulinum injection, fat injection, fat grafting, transpalpebral corrugator muscle resection, subcutaneous forehead rejuvenation, and endoscopic techniques for forehead rejuvenation.

·  Combination with laser used to resect muscles (potassiumtitanylphosphate laser) or CO2 for resurfacing

Open Approach (Pitanguy type)

·  Forehead wrinkles and frown lines are marked pre-op.

·  Standard coronal incision for patients with a normal or low hair line and normal to thick hair.

·  The coronal incision is placed 7-9 cm behind the anterior hairline so that after resection, at least 5 cm of hair-bearing scalp remains anterior to the incision.

·  Every 1mm of eyebrow elevation produces 1.5-2mm of retrodisplacement of hairline, 3mm when frontalis is removed.

·  The anterior hairline incision is used for patients with a high hairline(eyebrow to hairline distance >5cm) or thin hair. In the temporal region, it curves round to meet the top of the ear like the coronal incision.

·  The hair is parted in the line of the planned incision and held with elastics.

·  If a facelift is done concomitantly, the incision continues pre-auricularly. The facelift is usually done first.

·  Infiltration of local with vasoconstrictor.

·  Ocular protection with a corneal shield or contact lens.

·  Incision is parallel to the hair follicles and down to pericranium in one sweep.

·  Dissection is sub-galeal (supra-periosteal), preferably with a scalpel as blunt dissection can cause irregular stripping of the galea and pericranium (­ing post-op pain) and can avulse small sensory n branches resulting in anaesthesia and paraesthesia.

·  Laterally, the dissection is just above the deep temporal fascia.

·  STA and vein require ligation since they lie on the STF.

·  Supra-orbital and supra-trochlear vessels and nerves identified and preserved.

·  Using scissors, the dissection continues down the nose.

·  Corrugator is divided close to the bone (leave about half of the muscle attached to the skin to avoid a post-op depression in this area. The supra-trochlear nerve bundle normally lies in the corrugator so it must be searched for and protected at the time of corrugator division.

·  Laterally, the flap is dissected down to the lateral orbital rims (level of the zygomatic arches) and the pericranium is incised over the orbital rim to the lateral canthus, releasing the periorbita.