Forehead and Brow Procedures

Upper facial cosmetic surgery has enjoyed anunprecedented increase in popularity over thepast decade. The yearning of baby boomers tolook and feel rejuvenated has led to new endo-scopic techniques aimed at creating a moreyouthful and natural appearance with shorterrecovery periods than existed in past decades.1–3

The ultimate goal of improving a person’sappearance remains unchanged. Society shapesour views of what looks attractive, and no math-ematic formula can ever be used to determine anideal eyebrow position (Figure 67-1). Each indi-vidual has his or her own unique perception offacial beauty. For most people the upper face andeyes impart more emotion than does any otherpart of the human body; it is clear that rejuvena-tion of this vital area can provide an estheticallypleasing result.

Esthetic concerns of the forehead and browregions of the face affect a wide range of agegroups. Unlike the standard lower face and neckrhytidectomy, which more commonly affectspatients after the age of 45 years, cosmetic con-cerns in the upper third of the face may be evi-dent for patients in their twenties and thirtiesowing to genetic predisposition. The foreheadand brow area must be entirely evaluated for awide range of interlacing diagnoses. Matchingthe problem(s) to the ideal rejuvenation tech-nique(s) is essential for maximum esthetic bene-fits. Thinning skin and laxity owing to age andgravity encompass only a portion of the foreheadand brow dilemmas that must be addressed whenplanning rejuvenation procedures (Figure 67-2).

The aging process typically leads to foreheadand brow ptosis on almost every patient; howev-er, it is important to distinguish whether the pto-sis in the forehead and brow region is owing toproblems with brow position, upper eyelid laxity,or a combination of the two (Figure 67-3). Otherproblems such as dynamic lines caused by muscleactivity in the glabellar region, variable hairlinepatterns, bony abnormalities, and asymmetries,

as well as skin texture itself, also must be assessedin relation to each other. Achieving the patient’sdesired expectation depends not only on soundsurgical skill and judgment, it also depends criti-cally on communication between the surgeonand patient. Truthful disclosure of what can rea-sonably be attained is prudent and helps to pre-vent patient dissatisfaction.

Rejuvenation of the upper third of the face isone of the most rewarding and fulfilling proce-dures a surgeon can offer to select patients. Spe-cific elevation and correction of lateral hoodingcan be appear natural and still impart a tremen-dous improvement in the patient’s overall beautyand youthful appearance (Figure 67-4). The goalof this chapter is to review the upper third offacial anatomy specific to forehead and brow

rejuvenation techniques and to discuss a varietyof the most common techniques for rejuvenatingthe forehead and brow region.

Anatomic and Esthetic ConsiderationsIt is generally accepted that a youthful forehead isroughly one-third of the overall facial height.4–9

Essentially, the distance from the hairline to theglabella is equal to the distance from the glabellato the point at the base of the columella or sub-nasale (Figure 67-5). A youthful-appearing eye-brow is different for men and women. The femaleeyebrow should be arched with the highest pointof the brow on a sagittal line from the lateral can-thus.10,11 The entire brow itself should be abovethe orbital rim. In general the medial brow of thefemale is located ideally 1 to 3 mm above the

C H A P T E R S I X T Y- S E V E N

Forehead and Brow Procedures

Angelo Cuzalina, MD, DDS

FIGURE 67-1 Three different types of esthetically pleasing foreheads and eyebrow position. The tail of the eyebrow islocated along the alar-canthal line. The greatest brow arch is seen in the lateral third between the lateral limbus andcanthus of the eye. The outer half of the brow is “ideally” located 5 to 10 mm above the orbital rim in females.

2 Part 9: Facial Esthetic Surgery

orbital rim and the lateral third of the brow 5 to10 mm above the rim.12 This is in contrast to atypical male eyebrow that should lie at or onlyslightly above the orbital rim in a more horizon-tal or uniform arch fashion (Figure 67-6). Elevat-ing the lateral third of the male eyebrow dispro-portionately more than the remaining brow willcreate a feminine appearance.

The detailed anatomy of individual areas hasbeen well described in the literature and oftenrelates to the specific procedure being per-formed.13–25 Therefore, the following anatomicdiscussion is simplified by separating the specificregions into bony landmarks, muscle and fascial

anatomy, vessel and nerve anatomy, and specificendoscopic anatomy, and each anatomic region isaddressed individually as it relates to specific sur-gical procedures.

Bony LandmarksBony landmarks of the forehead and brow regioncan be focused all around the frontal bone, whichmakes up the highest percentage of the upperthird of the face. The connections (suture linessuch as the nasofrontal, zygomaticofrontal, andcoronal) are important landmarks because theycan be clinically relevant for limits of dissectionand can help surgeons determine their location

during dissection. For instance, the zygomati-cofrontal suture line is an ideal location to endmost basic brow lift dissections (Figure 67-7).Additional dissection can be performed if mid-face lifting is also planned or if the patient desiresmore elevation at the lateral canthal region.Overaggressive dissection here in many patientscan create an unnatural cat’s-eye appearance,particularly if too much tissue is elevated medial-ly along the suture line and lateral canthus. Like-wise, the nasofrontal suture line is a nice land-mark to note during dissection for a few reasons.First, dissection usually needs to proceed only afew millimeters below this suture level onto thenasal bones for adequate release. Second, thepaired procerus muscles can be identified hereand transection performed if required. Third,depending on the level of horizontal transectionin this area, the nasofrontal angle point of takeoffcan be altered slightly if desired. Last, nasal tiprotation can be achieved if wanted, especiallywith significant dissection below the nasofrontalsuture line.

Another general bony landmark is theorbital rim, which limits inferior dissection butmust be well visualized and free of periostealattachments to lift the brow and brow fat pads forlong-term results. Important muscle and fascialattachments are also located at the level of theorbital rim medially and laterally. The tenacioustemporal fusion line (zone of fixation) that existsalong the temporal ridge must be identified dur-ing dissection.26,27 It is also important to know itslocation preoperatively so that proper incisionplacement can be made to facilitate a clean dis-section under this area that enhances visualiza-tion endoscopically (Figure 67-8).

Bony thickness varies in different areas of theskull. In addition, venous lakes present on theinside surface of the skull tend to be more cen-tralized around the sagittal suture line. If bonetunnels or screws are planned for fixation pur-poses, the midline should be avoided, if possible,because of the sagittal sinus as well as higher-density venous lakes in this area (Figure 67-9).Thickness does increase posteriorly near theocciput, but screw or bone tunnel fixation here ismore challenging and is not required. Cautionmust be taken also to avoid lateral placementbecause of thinness of the lateral skull and themiddle meningeal arteries. Knowledge of averagethickness for a given location and internal anato-my indicates that the safest location for bone tun-nels or screws is located along a parasagittal lineapproximately at the midpupil or lateral limbusline and just anterior to the coronal suture (seeFigure 67-9).

Muscle and Fascial AnatomyPaired muscles of the forehead and brow regionare often thought of as elevators and depressors.

Fusion at orbitalrim

Galeal fat pad

Preseptal fat pad

Orbicularis oculi

Levatoraponeurosis

Frontalis

Orbital septum

Frontal bone

Preaponeuroticfat pad

A B

Youthful brow Aging brow

FIGURE 67-2 A, The youthful brow is elevated proportionately and has densely adherent periorbital fascia and mus-cle. B, Brow descent owing to aging and the associated loss of fascial integrity, along with orbital fat prolapse.

A B

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FIGURE 67-2 C, Cross section of thebrow near the mid pupillary position. C

Forehead and Brow Procedures 3

Although several depressor muscles can pull thebrow down or obliquely, the only true elevator ofthe forehead, the frontalis, moves upward to raisethe brow. This movement, along with some statictone, maintains brow position but also can leadto horizontal creases over time. The frontalisoriginates from the deep galeal plane (galeaaponeurotica that connects to the occipitalis pos-teriorly). It inserts into the orbital portion of theorbicularis oculi, which inserts into the dermisimmediately below the eyebrow. Its lateral exten-sion fuses into the dense collection of fasciaalmost 1 cm wide, called the zone of adherence,which extends along the superior temporal lineand ends inferiorly just above the zygomati-cofrontal suture.

The fascial attachments, known as theorbital ligament (see Figure 67-7), are the inferi-or termination point of the zone of adherencenear the orbital rim where connective tissuefibers of the temporoparietal fascia are fixated tothe bone at the superolateral orbital rim (Figure67-10). Lateral and posterior along a near hori-zontal line from the orbital ligament is the orbic-ularis-temporal ligament, which is the transversefusion zone of fibers from the lateral orbicularis,the temporoparietal fascia, and the temporalisfascia. These are important clinical anatomicareas because freeing the zones of adherence isnecessary to achieve long-term results with liftprocedures. However, care is required in thisregion to avoid overzealous stretching and injuryto the facial nerve.

The acronym SCALP applies for the standardlayers in the forehead: skin, subcutaneous tissue,aponeurosis (the thick galeal fascia), loose areolar(subgaleal) plane, and periosteum28–30; however,the galeal fascia fuses into the frontalis muscle andits midline fascial attachments at this level. Thisallows a sliding movement over the scalp withcontraction of the muscle. The frontalis and galeatogether can also be thought of as an extension ofthe temporoparietal fascia in the temporal region

as well as the superficial musculoaponeurotic sys-tem (SMAS) below the level of the zygomaticarch.31–33 The temporoparietal fascia appearssomewhat loose or spongy clinically and housesthe temporal nerve within its undersurface.

Many other paired forehead and brow mus-cles thought of as depressors are present alongthe brow to facilitate facial expression.34–41 Thetwo most well known are the procerus and thecorrugator supercilii, which are present in theglabella (Figure 67-11). The procerus muscles arepaired superiorly but fuse inferiorly into onemuscle belly that originates from the nasal bonesand cartilage. Superiorly procerus fibers insertinto medial frontalis and the overlying dermis.The procerus is responsible for depression and

frowning in the midline, which often creates ahorizontal crease (“bunny lines”) across theupper portion of the nose. The corrugator super-cilii are depressors that act obliquely across theglabella and produce the classic vertical lines seenwhen squinting (Figure 67-12). The corrugatororiginates from the frontal bone just above thenasal bones and inserts in the dermis of themedial brow. The corrugator has two heads, theoblique and the transverse, which act to pull themedial brow in respective locations. Together thepaired procerus muscles and corrugator are themain depressors of the medial brow and are themost common muscles treated with botulinumtoxin type A to help alleviate frown lines in theglabella. These same two muscles are also mostoften transected during a brow or forehead lift toachieve a smoother and longer-lasting result(Figure 67-13).

Another depressor muscle of importance isthe depressor supercilii, which originates on thefrontal process of the maxilla just below the cor-rugator supercilii and inserts in the medialfrontalis fibers and dermis just above the medialbrow. Because it lies superficial to the corrugator,it can be easily paralyzed inadvertently by botu-linum toxin. It is also important to note becauseit lies behind the corrugator and can be transect-ed by aggressive dissection through the corruga-tor during a brow lift. Although patients with avery low medial brow position may occasionallybenefit from this maneuver, it often gives rise toover-elevation of the medial brow followingsurgery, which causes the patient to look some-

FIGURE 67-3 A, Rejuvenation of the upper third of the face must address whether the problem is limited to brow pto-sis, eyelid ptosis, or a combination of both, as seen in the patient on the left. Skin texture must also be evaluated. B, Thephoto was taken 1 month after a coronal brow lift, upper blepharoplasties, and full-face laser resurfacing.

A B

FIGURE 67-4 A, Preoperative view of patient with classic lateral hooding brow ptosis and only “pseudo” upper eyelidlaxity or ptosis. B, One week following endoscopic forehead and brow lift only. (Slight overcorrection is noted in thisearly period.) C, Correction of lateral hooding with isolated brow lift after 1 month.

A B C


what surprised (Figure 67-14). Superficial to thedepressor supercilii is the orbital portion of theorbicularis oculi that inserts into portions of theadjacent depressors, the superficial surface of theinferior frontalis, as well as the dermis below thebrow.42,43 The orbital portion of the orbicularismuscle originates in part from the medial canthaltendon and adjacent bone. Deep to all the depres-sors is the galeal fat pad, which lies immediatelybelow the transverse head of the corrugator andhelps in identification of muscular landmarks.44

The galeal fat is usually exposed clinically instant-ly after transection through the periosteum alongthe orbital rim (Figure 67-15).

Finally, paired temporalis muscles are locat-ed in each temporal fossa, where they originateand then insert on the coronoid process of themandible. The importance of these muscles dur-ing upper facial rejuvenation chiefly pertains totheir overlying fascia, which can be used to delin-eate surgical planes and aid in fixation. Thespongy temporoparietal fascia is superficial to thedense and shiny white temporalis fascia. Thetemporalis fascia adheres to the temporalis mus-cles below and splits into a superficial and deeplayer in the lower half of the fossa. For consisten-cy, the superficial layer of deep temporalis fascia(which really describes only that portion of deeptemporalis fascia at the level of the split andbelow) is subsequently referred to simply as tem-poralis fascia. In essence, this term will be used to

describe any of this deep thick fascial layer that isseen clinically from the temporal crest down tothe zygomatic arch (Figure 67-16).

One method of fixation during brow liftingis the use of suture to fixate the temporoparietalfascia from below a skin incision to the dense andadherent temporalis fascia above the incision toelevate the lateral brow. Some surgeons advocateremoving a window of temporalis fascia andexposing the underlying temporalis muscle inhopes of creating scarification in this region andimproving fixation longevity.12

Vessel and Nerve AnatomyBlood supply to the upper face and scalp is plen-tiful and comes from multiple sources. Severalmajor vessels of the upper face originate from theexternal carotid artery including the superficialtemporal artery and the facial artery. These giverise to the blood supply in the medial canthalregion via the angular artery and in the lateralcanthal region by way of the frontal or anteriorbranch of the superficial temporal artery. Theinternal carotid artery gives way to the middlemeningeal artery, and the ophthalmic artery. Theophthalmic artery then gives rise to the supraor-bital and supratrochlear arteries, which exit theirrespective foramina and supply the majority ofthe forehead and midscalp with blood. The ter-minal arterial branches of the upper face havemajor anastomoses with adjacent vessels.

Venous drainage of the upper face followsthe respective arterial supply but can be some-what more variable. However, one particularvein, known as the sentinel vein (medial zygo-maticotemporal vein), runs perpendicularthrough the temporalis fascia connecting thesuperficial and middle temporal veins (Figure 67-17).45 The sentinel vein can most often be foundapproximately 1 cm laterally or posteriorly to thezygomaticofrontal suture line. It is clinically sig-nificant during endoscopic procedures because, ifinjured, it can result in impaired field visualiza-tion and significant bruising.

Nerve supply parallels arterial supply tosome degree. The supratrochlear and supraor-bital nerves, which are responsible for the major-ity of sensation in the forehead, exit via the sameforamina or general location as do the supraor-bital and supratrochlear blood vessels. The senso-ry nerves originate from the first division of thetrigeminal nerve. The supraorbital nerve has twodivisions after exiting its foramen: the deep (orlateral) division supplies the more lateral andposterior portion of the forehead and scalp, and

FIGURE 67-5 A, Example of ideal facial proportions based on vertical facial thirds and horizontal proportions approx-imately the width of the eye or one-fifth of the facial width. B, Preoperative. C, Six weeks following endoscopic foreheadand brow lift along with laser skin resurfacing.

1/3

1/3

1/3

1/5

1/5

1/5

A

A B

C

B

FIGURE 67-6 A, Female browshown with a nicely accentuat-ed arch in the lateral third wellabove the orbital rim. B, Theaverage male brow position islevel with the orbital rim with asymmetric arch form.


the superficial (or medial) division pierces thefrontalis and runs superficially to the muscle,supplying sensation to the forehead along themidpupil line (Figure 67-18). The location of thesupraorbital nerve’s exit is relatively consistent.The supraorbital foramen or notch is typicallyfound within 1 mm of a line drawn in a sagittalplane tangential to the medial limbus (Figure 67-19).46 The deep division has been known to exitas often as 10% from another foramen that canbe as high as 1.5 cm above the orbital rim.

The supratrochlear nerves exit from aroundthe orbital rim at an average of 9 mm medial tothe exit of the supraorbital nerve.46 The nervessupply sensation to the midforehead with someoverlap from the supraorbital nerves.Infratrochlear nerves, also from division one ofthe trigeminal nerve, exit just below the supra-trochlear nerves around the medial orbital rim tosupply sensation to the upper nose and medialorbit. Zygomaticofrontal and zygomaticotempo-ral nerves are from the second division of thetrigeminal nerve. They exit their respective smallforamina and supply sensation to the lateral orbitand temporal regions of the face.

The facial nerve supplies motor innervationto the forehead and glabella.47–51 The frontal (ortemporal) branch of the facial nerve supplies thefrontalis muscle, the superior portion of theorbicularis oculi, the superior portion of the pro-cerus, and the transverse head of the corrugator

supercilii. The zygomatic branch of the facialnerve supplies the medial head of the orbicularisoculi, the oblique head of the corrugator super-cilii, the inferior portion of the procerus, and thedepressor supercilii (Figure 67-20).

The auriculotemporal nerve, from the thirddivision of the trigeminal nerve, supplies sensa-tion in front of the ear to the temporal skin abovethe zygomatic arch and along the course of thesuperficial artery. It may be confused clinicallyduring a face-lift with the frontal branch of the

facial nerve. It can, however, be distinguishedfrom the facial motor nerve because it runs with-in 1 cm anterior to the tragus of the ear and par-allel to the superficial temporal artery. The muchmore significant frontal branch of the facial nerveruns an average of 2 cm anterior to the traguswhen crossing the zygomatic arch. The temporalbranch of the facial nerve crosses the arch at anoblique angle at an average of 2 cm post to theorbital rim. The depth of the temporal nerve isjust below the SMAS at the arch and below the

FIGURE 67-7 Periosteal elevator shown at a more aggressive level of dissection to elevate the lateral canthus slightly, if desired. Fascial and mus-cle attachments are labeled. Elevation at this level detaches only the superficial layer of the lateral canthal tendon. (The deep portion of the later-al canthus is 5 mm within the orbital rim attached to Whitnall’s tubercle.)

Corrugator supercilii

Depressor supercilii

Procerus

Medial canthal tendon attachment

Superiortemporal

fusion line

Zygomaticofrontalsuture line

Lateralcanthal tendon,

anterior attachment

Zone of fixation

Orbital ligament

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FIGURE 67-8 Cutaway portions of the frontalis muscles, procerus, and orbicularis oculi on one side demonstrate therelationship to the deeper depressors of the brow (corrugator supercilii and depressor supercilii). The zone of fixation(in blue) runs medial to the superior temporal fusion line.


temporoparietal fascia immediately above thearch. The frontal (temporal) branch usually hasdivided into two rami at the level of the arch andhas at least four branches by the time it reachesthe level of the eyebrow.

Endoscopic AnatomyInitial dissection must be performed to gain ade-quate space for the endoscopic equipment. Thisearly dissection is performed in the posteriorforehead and temporal regions; endoscopy-guid-ed dissection is used for the last 2 cm above theorbital rim and zygomatic arch. Elevation of thedeep tissues in this “safe zone” is essentially per-

formed blindly through each of the small scalpincisions. Incisions and specific tissue release andfixation techniques are highly variable amongsurgeons.52–59 I prefer to dissect within a com-pletely subperiosteal plane medially to the tem-poral crest and in the plane immediately abovethe temporalis fascia below the temporal line oneach side. Subperiosteal dissection in the lateralforehead helps to avoid injury to the deep or lat-eral division of the supraorbital nerve, whichruns in the subgaleal plane near the zone of fixa-tion. Some surgeons begin their dissection in asubgaleal plane in the posterior scalp.59,60 Regard-less, a space is created in the safer posterior areas

of the scalp to allow room for placement of anendoscope, which aids dissection in the morerisky areas of the forehead.

The first anatomic landmark the surgeonmust consider is the zone of fixation along thesuperior temporal crest. Its inferior edge is foundnear the superior lateral orbital rim. A conver-gence of fibers from the periosteum, galea, tem-poralis, and temporoparietal fascia interlace andfuse to form the zone of adherence, much in thesame way the layers of tissue planes come togeth-er at the level of the zygomatic arch. The zone offixation can be elevated bluntly at the hairlinelevel and a couple centimeters below, but as thesurgeon approaches the lateral brow beginningapproximately 2 cm above brow level, use of anendoscope aids dissection. At this point the liga-ment has branches of the temporal nerve withinit, and care must be taken to remain against thebone and temporalis fascia below to avoid nerveinjury. Another fibrous attachment, the orbicu-laris-temporal ligament, is also present here andcontains motor nerve fibers (see Figure 67-17); itis the decussation of fibers from the tem-poroparietal fascia and of the temporal fascia thatextends laterally from the orbital ligament. Thezone of adherence becomes even more tenaciousas the orbital ligament (see Figure 67-7) at theorbital rim level is approached. Slow meticulousdissection is required at this point to avoid nerveinjury as well as injury to the sentinel vein that islocated within the orbicularis-temporal ligamentapproximately 1 cm laterally to the zygomati-cofrontal suture. Careful dissection exposes anintact sentinel vein that can be seen piercingthrough the temporal fascia at a perpendicular

FIGURE 67-9 A, Inside view of the calvarium of the skull demonstrating the high density of venous lakes near the midline and associated structures.B, Illustration of the ideal location placement for bone screws or tunnels based on ideal vector of lift and anatomic limitations.

Dangerously thin area of bone belowthe temporal ridge

Average skull thickness 5 mm(range 1.7–8 mm)

Middle meningealartery

Placement location for bone tunnel or screw

Multiple midline venous lakes

Average skull thickness 7 mm(range 4–11 mm)

A B

Temporal branchof the facial

nerve

Temporalis

Nerve fibers fromthe superficial

(medial) branch ofthe supraorbital

nerve

Nerve fibers fromthe deep (lateral)

branch of the supraorbital nerve

Orbicularis-temporalligament

Temporoparietalfascia

Bone

Frontalis (galea)

Periosteum

FIGURE 67-10 Layers of fascia are seen on each side of the zone of fixation (in blue). The layers must be elevated andconnected to a uniform sliding plane surgically to achieve pleasing and long-lasting brow lift results, while not damag-ing the associated motor and sensory nerves.


angle and entering the temporoparietal fasciaabove (see Figure 67-17).

Dissection above the orbital rims in the sub-periosteal plane should expose the entire superi-or orbital rim from each zygomaticofrontalsuture. The curvature of the rims should be visu-alized so that transection through the perios-teum can be made at the level of the rims. Thenasofrontal suture may not always be seen butcan be felt by the periosteal elevator used to lifttissue. When transecting through the periosteumacross the entire orbital rim, subgaleal fat is oftenencountered initially, except when the transec-tion is directly behind the supraorbital nerve atthe rim level where the deep (or lateral) division

of the nerve is closely adherent to periosteum(see Figure 67-15). Preoperatively marking apoint on the brow at a level tangential to themedial limbus iris helps the surgeon to easilyidentify the location of the supraorbital vesselsand nerves.46 Dissection through the periosteumin this region should be performed slowly andsuperficially to avoid injury to these structures.The transverse head of the corrugator superciliiis seen at the orbital rim level behind the supra-orbital vessels and nerves. The corrugator super-cilii can be carefully transected or partiallyexcised.61 Medially, the oblique head of the cor-rugator is encountered, and by a transectionthrough this portion of muscle, the supra-

trochlear nerve and depressor supercilii musclemay be seen and protected from injury. Medial-ly, in the glabella, the procerus muscle, which isvariable in thickness, is seen. Care should betaken to avoid overaggressive muscle resection inthin patients as this can result in an atrophicdefect in the glabella. Deeper dissection towardthe skin level under the brow will lead to theorbicularis oculi but is typically not necessary togain the desired effect (except with regard to thelateral orbicularis, where limited transectionmay improve lateral brow elevation).62,63 Also,one or more incisions through the periosteumat higher levels under the frontalis muscle in themidline can be performed but is only required ifdeep horizontal lines are present.64 It is moreimportant to gain complete release of the retain-ing lateral ligaments, transection of those mus-cles causing glabellar lines, and adequate separa-tion of the periosteum along the orbital rim toget the elevation of brow and forehead tissuesfor the most pleasing and long-term estheticresult.65–75

Preoperative Evaluation and Surgical PreparationDetermining whether a patient will benefit froma brow or forehead lift and which procedure willwork best is critical to avoid disappointing thepatient. Commonly the novice surgeon noticesonly horizontal forehead lines as an indicationfor a brow lift. Unfortunately, this is much less ofa problem for most patients than is a low lateralbrow position (hooding) or glabellar crease (seeFigure 67-3). As discussed above, the ideal femalebrow position is above the orbital rim at a levelthat varies among individuals. An average dis-tance of 5 to 10 mm of brow elevation above therim in the lateral third generally looks mostpleasing. Men require a straight-up elevation ofthe entire brow to avoid feminizing their appear-ance by overelevation of the lateral brow. In addi-tion, men may benefit more from a standardupper blepharoplasty and local transpalpebralbrow lift if the brow ptosis is minimal. As withany cosmetic surgery, a decision regarding therisks and benefits must be made and must con-form to the patient’s desires. Patient education isrequired so that they know the risks as well aswhat can realistically be achieved (Figure 67-21).Even with fairly aggressive muscle resection andforehead elevation, patients often form newdynamic lines in the upper face followingsurgery. Lateral crow’s-feet owing to the action ofthe orbicularis oculi when smiling may appearimproved following a brow lift since the muscle isunfolded. However, they are not completely elim-inated by brow lifting alone, and the patient mustunderstand that botulinum toxin therapy may berequired to treat these particular lines on anongoing basis.76

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FIGURE 67-11 The oblique and transverse heads of the corrugator supercilii are seen behind the stump of the depres-sor supercilii. Both heads of the corrugator muscles and the orbicularis oculi insert into the dermis below the brow.

FIGURE 67-12 Frown lines of theglabella are produced by theactions of the corrugator superciliito produce the classic verticalwrinkles, whereas the actions ofthe more vertically arranged fibersof the procerus muscle produce thehorizontal wrinkles seen acrossthe bridge of the nose.

Classic vertical (frown lines)formed by the corrugatorsupercilii

Horizontal (bunny lines) formed by the procerus


In addition to lines on the forehead, lines inthe glabella, brow ptosis, and the condition ofthe patient’s skin must also be evaluated. Intrin-sic skin and collagen damage from the effects ofsun, age, and smoking are not treated by liftingalone. Topical skin care (eg, retinoic acid, micro-dermabrasion, pulsed-light therapy, sunblocks)along with possible surgical resurfacing must beconsidered.77–79 In general the forehead can betreated safely with chemical peels or laser skinresurfacing into the dermal level simultaneouslywith brow-lifting procedures, provided the lift-ing is performed with a subgaleal or subpe-riosteal technique rather than a subcutaneousone. Finally, bony irregularities or hypertrophicbony orbital rims can be evaluated for treatmentby means of a cephalometric radiograph or com-puted tomography (CT) scan as required. Bonycontouring can be performed on a limited basisendoscopically, but a major reduction for signif-icant bone hypertrophy such as a frontal boss isbest treated with an open (coronal) approach.The amount of bone reduction is limited by thepneumatization of the frontal sinus, which isbest evaluated by CT. Although treatment plan-ning for placement of bone tunnels does notrequire a preoperative CT, a standard cephalo-metric radiograph may help to reassure the sur-geon regarding the thickness of corticocancel-lous bone available.

As with any surgical procedure, appropriatepreoperative laboratory and other indicated testsmust be performed. Written instruction are givento the patient regarding pre- and postoperativecare, including instructions for shampooing hairwith antibacterial soap or other antiseptic sham-poo and avoidance of the use of hair spray orother hair products immediately prior to surgery.The patient should be thoroughly instructed onthe critical need to avoid all medications that maycause platelet dysfunction 10 days prior tosurgery (including aspirin and other nonsteroidalanti-inflammatory drugs, vitamin E, and manyover-the-counter herbal supplements). Endo-scopic techniques require a very dry operatingfield that necessitates strict avoidance of thesemedications as well as proper preoperative injec-tion of vasoconstrictive agents.

Prior to anesthesia photos are taken and thepatient is marked while awake and sitting up. Fol-lowing the introduction of general anesthesia orintravenous sedation, the patient is prepped andcarefully injected with local anesthetic with epi-nephrine. I prefer to use a local anesthetic with1:100,000 epinephrine along the entire orbitalrim, and a tumescent anesthesia solution (250 ccof normal saline mixed with 1 cc of 1:1,000 epi-nephrine and 20 cc of 2% lidocaine) in theremaining upper forehead, temple, and posteriorscalp. Careful injection in the desired tissueplanes helps to avoid the formation of a

Procerus

Supratrochlearvessels and nerve

Intact corrugatorsupercilii

Supratrochlearvessels and nerve

Transected corrugator

supercilii

FIGURE 67-13 Endoscopic views of the right supraorbital structures. Location of the corruga-tor supercilii relative to the supraorbital nerve (A) immediately before it is transected with aneedle-tip cautery (B). Following transection through the belly of the corrugator supercilii.

A

B

FIGURE 67-14 Before (A) and after (B) photos following endoscopic forehead and browlifting demonstrating good elevation of the lateral hooding but over-resection of the medi-al depressors in the area indicated (arrow). This can result in a surprised look, especiallywhen the patient elevates the brow, as shown.

A B


hematoma during the injection and allows for anearly bloodless procedure. Minor shaving ofhair along the marked incision lines is performedif desired immediately prior to the final prepara-tion and draping of the area.

Coronal Forehead and Brow LiftStill one of the most common approaches for fore-head and brow lifting, the classic coronal liftinvolves an incision across the entire forehead fromear to ear, staying well behind the hairline.80–88 Dis-section is typically in the subgaleal or subperiostealplane and then connects to the subtemporoparietalplane laterally. This gives great exposure of theentire orbital rims for bony osteoplasty, if required,and treatment of muscles that require resectionincluding the depressors (corrugator and procerus)as well as the frontalis. Heavy horizontal forehead

creases can be addressed with this technique eitherby way of midline myotomies or minor midlinethinning of the frontalis. Major resection of thefrontalis should be avoided to prevent postopera-tive irregularities and strange facial expressionsduring frontalis movement. The lateral frontalisshould be avoided to prevent nerve damage, ptosis,and other irregularities.

Regrettably, the coronal lift also has the dis-advantages of a long incision and a significant ele-vation of the hairline. Patients with a high hairlineare not good candidates for this technique since asignificant amount of scalp excision is required.Many surgeons believe this scalp excision is a reasonable trade-off because they feel that thetechnique gives a more lasting approach than donewer endoscopic techniques. If performed cor-rectly, the endoscopic technique can be as long

lasting and possibly more precise than open browlifting techniques. Care must be taken with thecoronal lift to avoid elevating the medial brow toomuch and creating a very high hairline. Roughly,to gain 1 cm of brow elevation, 1.5 to 2 cm ofscalp must be excised with this technique. Theamount of tissue excised is not a precise determi-nant of amount of brow elevation obtained. Scor-ing of the underlying fascia and muscle resectioncan cause the tissue to stretch oddly, making pre-diction of the exact brow elevation difficult.

The benefits of the coronal lift include greatexposure and relatively easy dissection. It can alsobe used to extend the procedure into a deep planeface-lift by dissection over the zygomatic archesand onto the zygoma and masseter. This muchmore aggressive lift gives excellent elevation ofthe midface but greatly increases postoperativeedema and the potential for motor nerve damage.The extended technique should only be attempt-ed by an experienced surgeon,89–93 and carefulconsideration should be given to alternativetreatments. Comparatively, the basic coronal liftis an easier procedure for the novice surgeon.When selecting this tried-and-true method, oneshould take into account the disadvantages,including the lengthy scar and possible hair loss,significant scalp anesthesia, and a significantlyelevated hairline.

Trichophytic or Pretrichial Foreheadand Brow LiftAlthough trichophytic and pretrichial lifts aresometimes thought to be the same procedure, thepretrichial lift actually involves an incision infront of the hairline. With this procedure, hairdoes not grow anterior to the incision, leaving avisible scar in front of the hairline. In contrast, inthe trichophytic lift, although still at the frontalhairline, the incision is placed just behind thehairline. This incision is beveled so that folliclesin front of the initial skin incision survive andhair grows anterior to the incision to better cam-ouflage the resulting scar. It should be noted thatmany surgeons use these terms interchangeably.Even better than the trichophytic lift is the irreg-ular trichophytic hairline, which not onlyemploys a beveled incision but creates a wavypattern along the hairline for a more naturalpostoperative appearance compared with astraight-line scar.

Regardless of the specific incision design, theultimate advantages of the trichophytic foreheadand brow lift include great exposure (similar tothat with the coronal approach) and the ability tolower a high forehead. Unlike the classic coronallift, bare forehead skin is excised from the hair-line. Also, lateral incisions and dissection are usu-ally limited with this technique unless required.Incision design can even improve hair thinningin the temporoparietal areas by excising the area

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FIGURE 67-15 A, Line drawing demon-strating right-sided forehead landmarks.B, Endoscopic view of the right supraor-bital nerve and vessels. The first view isseen with a 27-gauge needle over thenerve trunk after it is placed through theskin of the brow level with the patient’smedial limbus (iris).

A

B


of hair loss and bringing forward areas of densehair–bearing scalp. The posterior scalp and hair-line can be brought forward to lower a high fore-head by almost any amount. The more loweringthat is desired, the more posterior is the dissec-tion and release. Limited or no posterior dissec-tion can be performed if the hairline is to remainat the same level.

The forward dissection is the technique thatvaries the most among surgeons. A totally subpe-riosteal technique versus a subgaleal technique isan option. A subcutaneous technique has recent-ly become more popular, particularly when thedepressors in the lower brow do not require treat-ment.94 Staying superficial to the frontalis breaksthe dermal insertions that create deep horizontalrhytids. The subcutaneous lift is occasionallycombined with deep dissection to treat glabellarlines as well as horizontal lines in the forehead.

Overall, the trichophytic technique of fore-head and brow lifting is an invaluable tool for anysurgeon performing facial cosmetic surgery.When a patient presents with a high forehead andlow brow position, the trichophytic approach isthe procedure of choice to correct both problems.

The main disadvantage is the potential for a visi-ble incision despite best efforts. All prospectivepatients considering this technique must beinformed of the chance that there may be a visi-ble scar at the hairline. Surprisingly, when pre-sented with the potential problems and given thechoice, many patients prefer to undergo an endo-

scopic approach with a slight elevation in hairlinerather than risk a visible hairline scar. Still, thepatient with an extremely high hairline is oftenthrilled with the lower hairline obtainable onlywith the trichophytic approach. Attention todetail and gentle soft tissue management areessential to attaining a natural hairline and hid-den scar with this popular technique.

Endoscopic Forehead and Brow LiftEarly attempts at endoscopic surgery began overa century ago with Nietze’s description of a crudecystoscope. A few decades ago endoscopicsurgery progressed through use in upper gas-trointestinal examinations and then intra-abdominal surgery. However, facial endoscopiccosmetic surgery did not blossom until the early1990s. Over the past decade the endoscopic fore-head and brow lift procedure has been consideredby many to be the state-of-the-art technique forupper facial rejuvenation.95–97 It is versatile andcan be combined with many other procedures.The most noted benefits of the endoscopic tech-nique are the smaller scars hidden in the hairlineand selective brow elevation without the need forremoval of any hair or skin (Figure 67-22).

The technique involves several incisionsplaced strategically behind the hairline to gainaccess for early blunt dissection and insertion ofthe endoscope and tissue retractor. Other inci-sions can be used as ports for dissecting toolssuch as periosteal elevators, electrocautery, lasers,tissue graspers, and suction instruments. Amongsurgeons a variety of incision (port) designs areused. Fixation points are usually placed at theseincision sites; therefore, I prefer five separate 2.5cm long incisions placed for easy access butmostly for ideal fixation placement. Each of thefive incisions begins approximately 1 cm posteri-or to the hairline. One is placed in the midline inthe sagittal plane and two in the parasagittalplane tangential to the lateral third of the brow(where maximum lift is typically desired in

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FIGURE 67-16 A and B, Endoscopic dissection must connect the tissue planes on each side of the temporal crest. Vari-ous approaches may be used as long as the anatomic planes seen above are sufficiently understood to allow proper tis-sue release, a clean endoscopic view, and protection of the facial nerve.

A

B

Orbicularis oculi

Inner edge of thelateral orbital rim

Septum orbitale

Outer edge of thelateral orbital rim

Incised edge ofthe orbicularis-temporal vein

Medial zygomatico-temporal vein

Deep temporalfascia

FIGURE 67-17 Dissection below the patient’s right temporal crest is shown with release of the orbicularis-temporal lig-ament. The medial zygomaticotemporal (sentinel) vein seen here pierces the temporalis fascia approximately 1 cm pos-terior to the zygomaticofrontal suture line.


females). This same incision can be moved slight-ly medially in male patients to give a more evenbrow elevation. The midline incision plus the twoparasagittal incisions are aligned vertically toavoid unnecessary transection of sensory nervesoriginating from the supraorbital nerves below.The two parasagittal incisions are placed medialto the temporal crest to gain access to skull bonerather than the more lateral temporalis fascia.Bone is the strongest fixation tissue available andideally should be used thus.98–100

It is important to access the subperiostealplane easily for a clean future endoscopic view.Accidental placement of the parasagittal incisionstoo far laterally over the zone of fixation or tem-poralis muscle makes pocket development diffi-cult and obscures future endoscopic visualiza-tion. Moreover, the parasagittal incisions arelocated in a thick area of the frontal bone wherethere is a low density of venous lakes. Placing theincision here helps to prevent accidental intracra-nial injury during bone tunnel creation or place-ment of bone screws.

Lastly, two temporal incisions are made, oneon each side of the head, for direct access to thethick temporal fascia. These incisions are placedperpendicular to the desired elevation vectorfrom the lateral canthal region. Coincidently, thetemporal incision parallels the course of the tem-poral branch of the facial nerve that is located 2to 3 cm inferior to this incision. It also parallelsthe superficial temporal artery and vein. Arrang-ing the three medial incisions on a vertical axisand the two temporal incisions in an obliqueposition to parallel the nerve and blood supply ineach area can reduce interference with sensationand vascular supply to the scalp.

Dissection is performed through the aboveincisions down through periosteum medial tothe temporal crest and down to temporalis fas-cia lateral to the crest. Some surgeons may electto use a subgaleal rather than subperiostealplacement of the incision medially. Total sub-periosteal dissection medial to the temporallines rather than subgaleal dissection leads tobetter fixation and long-term stabilization (seeFigure 67-22).

Blunt and blind dissection can be carried outafter reaching the subperiosteal and subtem-poroparietal planes through the five incisions.Finger dissection and long curved endoscopicperiosteal elevators are used to lift the tissue ante-riorly to a point 2 cm above the orbital rims andzygomatic arch. Posteriorly blunt dissectionshould elevate the temporal tissues a few cen-timeters behind the ear, where the temporal fossabecomes self-limiting. The subperiosteal dissec-tion above needs to elevate the scalp at least 10cm posteriorly but can extend as far back as thelambdoid suture. Once these areas are freed, aconnection can be made from the temporal

region to the subperiosteal dissection throughthe upper portion of the zone of fixation at thetemporal crest by finger dissection (Figure 67-23). Blind release of the more inferior portion ofthe temporal line where the facial nerve crossesshould be avoided. Endoscope-guided dissectionhere helps to prevent nerve injury. Using fingerdissection the upper zone of fixation is brokenthrough proceeding from the temporal incision

toward the medial scalp, rather than vice versa, toprevent creation of a false tunnel in the spongy orfoamy temporoparietal fascia. False tunnels alongthe temporal crest create problems when theendoscope is inserted through the parasagittalport to visualize the lateral forehead; the tunnelsforce the placement of the endoscope in a moresuperficial plane within the temporoparietal fas-cia, which greatly increases the chance of nerve

FIGURE 67-19 A, Preoperative photograph demonstrating the location of the supraorbital vessels by a line drawn ver-tically from the medial iris. B, One and a half years following an endoscopic forehead and brow lift. No blepharoplas-ty was ever performed.

A B

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FIGURE 67-18 A and B, Distribu-tion of the superficial (medial) anddeep (lateral) divisions of the supra-orbital nerve.A

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injury. Therefore, it is critical to stay firmlyagainst the periosteum and the temporalis fasciawhen initially elevating the scalp and forehead.

Following blunt elevation of the scalp fromeach incision for complete flap elevation, theendoscope is normally inserted through one ofthe three more medial incisions. Poor initialblunt dissection makes the initial endoscopic dis-section feel very tight, and care must be taken notto perforate the skin by excessive retraction.Medial dissection over the nasofrontal suture andorbital rims is performed under direct endoscop-ic vision with a curved and smooth elevator toavoid inadvertent tearing of the periosteum. Theperiosteum may be thin in some patients, inwhom a straighter elevator may be used to tran-sect the periosteum at the level of the rim (arcusmarginalis). However, the entire rolled edge ofthe orbital rim must be visualized before pro-ceeding with periosteal incision (Figure 67-24).Typically the periosteum is more precisely incisedwith a needle-tip cautery or laser set at lowpower. The supraorbital nerves and vessels asdescribed earlier are at a level tangential to themedial limbus and are immediately behind(superficial to) the periosteum from the internalendoscopic view.46,101 This necessitates meticu-lous cautery dissection here to avoid injury tothese structures (see Figure 67-24). Suctionplaced by an assistant from another port isrequired to maintain a clear view when usingcautery or laser. Temporal incisions work well forsuction ports during dissection over the rimssince the endoscope and cautery take up most ofthe room through any of the middle three inci-sion sites. With clear and near bloodless dissec-tion at this point, transection can be performed

through the corrugator supercilii and procerus. Ifunwanted bleeding is encountered and cannot becontrolled easily with pinpoint accurate cautery,

then pressure should be applied externally overthe rim until improved visualization allows forcontrol of bleeding without nerve damage.

Vertical rhytids in the glabella created by thecorrugators can be improved greatly by transec-tion through these muscles. Likewise, horizontalglabellar lines are treated by transection of theprocerus muscle that creates these particular facialwrinkles. Some surgeons advocate more aggressivesurgical avulsion of these muscles with endoscop-ic biopsy forceps. Aggressive muscle removal maylead to a more permanent treatment of glabellarlines compared with isolated transection only butshould be avoided in most cases owing to anincreased risk of significant postoperative irregu-larities and abnormal facial expression. As a rule,patients prefer a more natural appearance withsome minor return of frown lines to risking abizarre facial expression and glabellar depression.

Once the periosteum is completely freedacross the orbital rims and appropriate muscleshave been treated, the cut periosteal edges arespread apart (periosteal elevators work well forthis) by at least 1 cm to aid the release at the arcusmarginalis. This allows significant and long-termbrow elevation. Next the lateral orbital rim mustbe exposed in the subperiosteal plane after careful

FIGURE 67-21 A, Because of both brow ptosis and upper eyelid laxity, the patient shown required upper blepharo-plasties as well as endoscopic forehead and brow lifting to achieve the results she desired. B, The patient is shown beforeand after only blepharoplasty and full-face laser skin resurfacing. She has multiple problems including asymmetry ofthe brows owing to a blepharospasm on the left side, eyelid asymmetry and severe laxity, pseudoelevation of the browsowing to frontalis compensation for severe eyelid ptosis, and severe actinic skin damage. She is not a good candidate forsimultaneous brow lifting since a change in brow position will likely occur following the removal of the eyelid ptosis.She is a good candidate for botulinum toxin therapy on her left side.

A B

Zygomatic branchesof the facial nerve

Temporal branchesof the facial nerve

Corrugator supercilii andprocerus each receiveinnervation from bothbranches of the facialnerve shown

FIGURE 67-20 Motor nerve supply to the forehead depressor muscle comes from both the temporal and zygomaticbranches of the facial nerve.


release below the zone of fixation and orbital lig-ament. Dissection along the anterior and inferioraspects of the temporal crest must be performedcautiously to avoid temporal nerve injury.Overzealous retraction of the dense tissue herethat contains the nerve can result in nerve dam-age. Staying snuggly against periosteum and thetemporalis fascia helps to prevent nerve damageand produces a much cleaner dissection. Slowlycreating a distinct plane of dissection down to thezygomaticofrontal suture line and avoiding excessretraction helps to prevent unwanted bleedingfrom the sentinel vein (zygomaticotemporalvein), which needs not be sacrificed for a standardendoscopic forehead and brow lift.

Dissection for a standard endoscopic browlift should not proceed all the way to the zygo-matic arch but should stop approximately 1 cmabove this level. If an extended midface lift isplanned and there is a desire to elevate tissue overthe zygomatic arch itself, then dissection must gobelow the superficial layer of deep temporal fas-cia just above the arch. Abbreviated midface liftsperformed simultaneously with endoscopic browlifts may simply stay in the subperiosteal planealong the lateral orbital rim and avoid the morerisky full-arch release. The beauty of the classicendoscopic brow lift is its versatility and the easewith which additional procedures can be com-bined simultaneously with this eloquent cosmet-ic surgery. For instance, the temporal incision ofan endoscopic forehead lift can easily be extend-ed inferiorly to meet up with the preauricularincision from a standard lower face-lift. Also,midface lifting (with intraoral dissection) canconnect the intraoral subperiosteal dissectionover the zygoma to the subperiosteal plane fromthe endoscopic brow lift through a tunnel nearthe lateral orbital rim (Figure 67-25).

After all dissection is complete, appropriateelevation and fixation is required (Figure 67-26).Many techniques have been described such as tis-sue suture only, bone screws and plates, resorbable

screws, bone tunnels, local skin excision, tempo-ralis muscle exposure for added scarification, tis-sue glue, and tight head wraps.102 Regardless of anyspecific fixation technique, the key to long-termfixation is adequate lower forehead tissue releaseduring endoscopic dissection. Failure to adequate-ly release internal tissue results in a relapse of browptosis, even with heavy fixation and the appear-ance of a “nice” lift during surgery.

Once complete internal release of the fore-head is obtained, the specific lifting vectors mustbe determined for the most pleasing esthetic

effect. The lateral third of the female brow is ele-vated to the greatest extent, which is up to 1 cmabove the orbital rim. The medial brow should beonly slightly above the rim level and definitelybelow the middle and lateral brow levels to avoida surprised or bewildered expression (see Figure67-14). Typically the glabellar region is elevatedon its own without the need for midline fixation,which helps to avoid overelevation medially. Thelateral third of the brow is lifted straight up andfixated at the level of the hairline. The galeal tis-sue is typically secured to bone at this point,

FIGURE 67-22 A to F, Sequential appearance following endoscopic forehead and brow lifting (eyelid and skin resurfacing procedures were also performed). Slight overelevation ofthe brow is noted for 6 days after surgery, as expected. The brow position remains very stable from 2 weeks to 3 years after the surgery.

A B C D E F

Preoperative 6 days 14 days 2 months 1 year 3 years

FIGURE 67-23 Blind finger dissection is performed initially, avoiding overzealous dissection inferiorly. Dissection pro-ceeds from the subtemporoparietal plane laterally to the already elevated subperiosteal plane medially. The oppositedirection of elevation (medial to lateral) may produce false tunnels in the temporoparietal tissue, which impair futureendoscopic vision.


while the lateral brow is held at the desired heightor 1 to 2 mm above the desired level.12 Very littlerelapse occurs with proper technique and aver-ages only 1 to 2 mm after 2 weeks. Measurementscan also be made with clear circular templatesfrom the pupil to brow to help improve symme-try. The brow position remains very stable fol-lowing this early recovery period (see Figure 67-22). A question remains as to the time required

for complete fixation of the periosteum. Someanimal studies suggest a full 12 weeks arerequired for what is termed full histologicperiosteal refixation.103 However, there is clinicalevidence suggesting adequate fixation occurs inas little as 7 days. An example is the common fix-ation technique used by many surgeons whoplace a single transcutaneous bone screw at eachparasagittal incision, which is removed after only

1 week. The 1-week fixation technique has beenused with success for many years. It has been sug-gested that longer bony fixation may providelonger-term retention and less early relapse thatsome have considered normal. The key to long-term fixation seems for now to be determinedusually by proper tissue dissection and release.

Although there are many fixation tech-niques, the use of bone tunnels at the parasagittalincisions appears to be one of the best methodsfor fixating the galea and periosteum near thehairline to a bone tunnel created posteriorlyunder the incision using a single heavy suture(see Figure 67-26). Fixation of the lateral tail ofthe brow is performed at each temporal incision,where an isolated heavy suture plicates the tem-poroparietal fascia in a posterior and superiorvector to the thick temporalis fascia. Optionalcreation of a small window of exposed temporalismuscle in this area may aid in internal scar for-mation and fixation. The vector of lift at thisouter tail of the brow follows a line drawn at anangle from the outer nasal ala that passes justbeside the lateral canthus (see Figure 67-25).

Final closure of the hair-bearing scalp inci-sions can be performed with skin staples only withexcellent scar formation since no skin is excisedand no pressure exists at the incision sites. Redun-dant tissue (forehead skin) created by an averageof 1 cm of brow elevation is easily distributedevenly over the posterior 15 to 20 cm of elevatedscalp, which essentially absorbs or redistributesthis excess tissue with few to no signs of bunching.Because of this phenomenon, the endoscopic fore-head and brow lift tends to elevate the hairlineonly a very small amount compared with the openskin excising coronal technique.

FIGURE 67-25 Views before (A) and after (B) an endoscopic forehead, brow, and midface lift. Arrows represent vec-tors of lift. Fixation is performed at the level of the hairline through the temporal and parasagittal incisions shown.

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FIGURE 67-24 A, This line drawing demonstrates the orbital rim and local depressor muscle as seen from a transblepharoplasty incision. B, Endoscop-ic photographs show the rolled border of orbital rim prior to periosteal release in the first view and the supraorbital nerve and vein in the next view afterexcising through the periosteum.

A B


Interestingly, in a survey performed in 1998 ofAmerican Society of Plastic Surgeons members, ofthe total 6,951 brow lifts performed by 570 mem-bers who returned the questionnaire, 3,534involved a coronal technique and incision and3,417 were performed endoscopically. The mostnoted difference was the higher risk of hair losswith the coronal technique; however, both tech-niques enjoyed very low overall complication rates.

Direct Brow LiftThe direct brow lift involves excision of an ellipseof skin adjacent to and just above the eyebrow(Figure 67-27). A beveled incision is used to paral-lel the hair follicles of the brow or so that some fol-licles remain at the base of the bevel to grow laterabove the scar. The dissection remains in the sub-cutaneous plane to avoid muscle or nerve injury.

Advantages of the direct brow lift are that itis a simple procedure (with an easy two-layer clo-sure), it can be performed under local anesthesia,and it can treat brow position asymmetries. Itremains a good alternative technique that may bean excellent option for an elderly patient who hassevere brow ptosis and heavy wrinkles but cannottolerate more extensive surgery and would bene-fit from a short procedure under local anesthesia.The main disadvantage is the potentially visiblescar immediately above the brow.

Midforehead and Brow LiftIncisions made in the middle or upper foreheadregions have similar advantages and disadvan-tages to the direct brow lift.104–107 The incisionsare made on each side of the forehead in an ellip-tic fashion so that the resulting scar follows a hor-

izontal line already present in the forehead.Although this is probably the least used of all thetechniques described, it may be a practical alter-native for the elderly patient with thin eyebrowsand deep horizontal rhytids who requires a shortprocedure under local anesthesia.

Transpalpebral and Other Local Brow ProceduresThere has been a significant increase in the move-ment toward minimally invasive techniques toperform cosmetic surgery. New techniques forforehead and brow rejuvenation fill the literatureand offer potentially exciting methods to gainesthetic improvement with less risk than withcurrent procedures. A few such proceduresinclude lateral brow lifting with temporal inci-sions only, denervation techniques through smallpunctures around the brow, and direct approach-es through an upper blepharoplasty incision. Itshould be noted that although procedures such asmaking small punctures to destroy medial por-tions of facial nerve innervating medial depres-sors may seem minimally invasive, they are cer-tainly not without risk.

Many of the “minimally invasive” procedurestake advantage of the proximity of the localdepressor muscle. For instance, the transpalpebralor transblepharoplasty approach for foreheadrejuvenation gains access to the local depressorsthrough an upper eyelid incision.108 Dissectionthrough this incision involves a short distance tothe corrugator supercilii, the procerus, anddepressor supercilii of the glabella, which can eachbe selectively transected from this incision toreduced unwanted wrinkles and elevate the medi-al brow (see Figure 67-11). Likewise, the orbicu-laris can be incised and subperiosteal dissection

FIGURE 67-26 Example of bone tunnel fixation shown at the site of the right parasagittal incision. The anterior circlerepresents the position of suture placement through the galea, which elevates the lateral brow toward the bone tunnel.

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FIGURE 67-27 Representative incisions for typical brow-lifting procedures: (1) direct brow lift, (2) midforehead lift,(3) trichophytic brow lift, (4) coronal brow lift, and (5) endoscopic brow lift.


performed above the orbital rim to elevate the lat-eral brow through this same local incision. Sutureplication of the periosteum above the rim mayfurther elevate the lateral brow.

Another adjunctive technique in the upperthird of the face is that of fat grafting in areas ofage-related fat atrophy. Fat can essentially begrafted anywhere; however, caution is required inthe glabellar region where occasional local necro-sis can occur from fat infiltration. This alsooccurs occasionally after collagen injections inthe same region.109 There are a great number ofalternative techniques, and each must be evaluat-ed for safety, efficacy, and longevity on an indi-vidual basis.

Botulinum Toxin–Assisted Brow LiftBotulinum toxin has been used for nearly twodecades to improve the esthetic appearance of theupper third of the face by reducing wrinkles ofthe forehead (horizontal lines), glabella (frownand bunny lines), and lateral orbital crow’s-feet(laugh lines).110 More recently it has been usedspecifically to elevate certain regions of the browto obtain a “chemical brow lift.”111 The depressormuscles are paralyzed with botulinum toxin notonly to reduce the wrinkles they create but also toallow the frontalis muscle to elevate the brow far-ther because of the decrease in muscular antago-nism. By decreasing the tone and downward pullof the orbicularis immediately below the brow,the lateral third of the eyebrow elevates approxi-mately 2 to 4 mm from the result of botulinumtoxin placed in the upper crow’s-feet area. Suchtreatment of depressor muscles in the glabellarregion can help elevate the medial brow. Ofcourse, as with surgical brow lifting, overcorrec-tion in the medial brow may result in an abnor-mal facial expression.

Dosages used vary with individuals. Botoxcomes in a 100-unit vial to be mixed with 1 to 10cc normal saline. The more dilute solutions (6–10cc/100 units) begin to loose efficacy and can dis-tort the tissue, whereas high concentration mix-tures (1–2 cc/100 units) may be wasteful andimprecise. Regardless of dilution, it is the totaldosage in units of botulinum toxin and its prop-er placement that determine the outcome. Formost individuals 5 to 10 units is all that isrequired for each lateral crow’s-foot region. How-ever, the larger muscles of the glabella (procerusand corrugators) require at least 15 units of thetoxin and up to 50 units for maximum results.Appropriate dosage in the glabella is the mostvariable. Treatment of horizontal forehead linestypically requires between 15 and 25 units. Itshould be noted that simultaneous treatment ofhorizontal forehead lines from the frontalis maydecrease or eliminate brow elevation that other-wise may have been created by botulinum toxintreatment of the depressor muscles. Moreover,

excessive toxin treatment of horizontal lines closeto the eyebrows (within 1 cm) should often beavoided owing to the risk of true ptosis of theforehead, brow, and upper eyelids.

Botulinum toxin has also been recommend-ed to aid long-term stability of the surgical fore-head and brow lift. The theory involved is thatcontrol of the downward pull of the depressors(by temporarily paralyzing them chemically)gives the periosteum time to attach securely in anelevated position. The injection can be done dur-ing surgery but there is an increased risk of eyelidptosis and an unwanted delay since botulinumtoxin typically takes 3 to 5 days to take full effect.Therefore, ideally botulinum toxin is injected 1 to2 weeks prior to surgery. Regardless of any bene-fit this may give to long-term surgical fixation,the resulting reduction in wrinkles of the fore-head and glabella and in crow’s-feet is almostalways popular with patients, even though theresults last for only 3 to 6 months.

Adjunctive Procedures: Skin Care andMicropigmentationA variety of procedures can be used for the super-ficial treatment of poor skin texture and are cov-ered more completely in Chapter 69, “Skin Reju-venation Procedures.” For complete rejuvenationof the upper third of the face, skin resurfacingtechniques may be required to address agingproblems, especially those related to sun expo-sure, that cannot be adequately treated with lift-ing methods alone.

Prior to any resurfacing procedure such aslaser skin resurfacing, chemical peels, or der-mabrasion, the patient should be treated withtopical skin medications to decrease the risk ofscarring and pigment problems. Retinoic acid–-type preparations used for ideally 6 weeks priorto resurfacing and 4% hydroquinone for patientswith darker skin tones (Fitzpatrick 3 or higher)are two possibilities(see Chapter 69, “Skin Reju-venation Procedures”). Simultaneous resurfacingprocedures can be accomplished with brow lift-ing provided the surgical plane of dissection issubperiosteal or subgaleal and not subcutaneous.

Another adjunctive procedure growing inpopularity is medical micropigmentation. Theuse of new skin pigments that do not containiron oxide has improved the appearance of tat-toos placed to enhance a thin eyebrow or as per-manently applied eyeliner. The ink is relativelypermanent but often requires touch-ups owing tosome fading over the first 3 to 5 years. Patientswho have poor hand motor skills can greatly ben-efit from this procedure. A certified technicianunder a doctor’s supervision usually performsthe micropigmentation. However, consultationwith a surgeon prior to micropigmentation isimportant since placement of a permanent browtattoo in a more elevated position may create

problems if the patient desires a surgical brow liftlater. Therefore, if a patient is seeking brow liftingin addition to the micropigmentation, it is advis-able to perform the surgical brow lift prior to thepermanent makeup if feasible.

Postoperative CareFollowing surgical forehead and brow lifting, acompression bandage is applied using a materialsuch as Coban™ or Coflex™. The pressure helps tolimit edema and hematoma formation while pos-sibly improving fixation. Typically a drain is notrequired if a very dry field has been maintained.The patient should be instructed to limit activityand to use cold compresses over the eyes andbrows. Head elevation is also recommended forthe first several days. Avoidance of antiplateletdrugs preoperatively, a careful surgical technique,and the immediate postoperative use of cold com-presses, elevation, and limited strenuous activitysignificantly decrease postoperative healing time.

The relatively snug postoperative dressingmay be removed on postoperative day 1 to visu-ally inspect the surgical site for any problems. Aless constrictive Velcro-type head wrap can thenbe used to allow patient comfort and easyremoval for showering. Patients are allowed togently shampoo their hair after 24 hours butmust be cautioned to avoid water pressure direct-ly over any incision sites. Each incision is thencleaned twice a day with a dilute peroxide solu-tion, and a thin layer of antibiotic ointment isapplied for the first week. Staples are removed atthe end of 1 week. Chemical treatments of hairsuch as “perms” should be delayed for at least 2 weeks to avoid possible hair loss as a reaction tothe harsh chemicals. Hot curling irons or othersimilar devices must be used with caution sinceareas of scalp anesthesia may be present formonths and can predispose a patient to an acci-dental self-inflicted burn.

ComplicationsFortunately, major complications are rare withproperly performed forehead and brow rejuvena-tion procedures. Good patient selection, diligentpreoperative planning, meticulous surgical tech-nique, and thorough postoperative care are allrequired to help limit the chance for complica-tions.112–115 Minor complications can always occurdespite a surgeon’s best efforts. No matter howminor the problem, the patient must be treatedwith concern and compassion. Typically patientswho undergo cosmetic surgery are expecting tolook better as soon as possible and are not alwaysas tolerant of perioperative problems as are trau-ma patients. Extensive edema and ecchymoses arenot normally considered complications but maywarrant appropriate reassurance and even simplesuggestions to hasten recovery when feasible. Sug-gestions regarding makeup from a well-trained


staff member may greatly improve a postoperativepatient’s mood when shown how to better hidepersistent erythema or ecchymosis.

True complications include poor scarappearance, wound dehiscence, hematoma, skinsloughs or perforations, asymmetries, sensorydisturbances, facial paralysis, eyelid ptosis,corneal abrasions, dry eye syndrome, hair loss(alopecia), infection, relapse, irregular facialexpressions, and contour irregularities. Of allthese potential problems, permanent facial paral-ysis and major tissue loss are the most devastat-ing. Fortunately, these particular complicationsare rare (< 0.3%, which is less than that for astandard lower face-lift). Regardless, it is criticalto know the precise anatomy and to avoidimproper or excessive retraction, overzealouscautery, and overthinning of the flaps when tran-secting the depressors. In addition, hematomasmust be diagnosed and treated without delay.

Some problems such as corneal abrasionscan be very concerning to the patient owing tothe severe pain and can be nearly eliminated byproper technique and perioperative attention todetail. For instance, an eye lubricant shouldalways be used. Also, thought should be given tothe placement of temporary tape strips, such asSteri-Strips, over the eyelids or a tarsorrhaphysuture to help prevent inadvertent scratching ofthe cornea by gauze or tubing, for example, dur-ing the procedure (see Figure 67-16). All severepain requires immediate evaluation, and suspect-ed abrasion should be treated by appropriateophthalmic drops for pain and patching of theaffected eye for 12 to 24 hours. Appropriate oph-thalmologic consultation is required for persis-tent or uncontrollable eye pain, persistent dry-eye symptoms, or unusual changes in vision.Minor blurred vision for the first 12 hours is notunusual owing to chemosis and use of oph-thalmic ointments.

Alopecia and sensory disturbances can bebothersome to the patient and often are not per-manent. The problem is the inability to predictwhether the numbness a patient has will partial-ly, fully, or not go away, and just how soon ismight be alleviated. With proper technique, anendoscopic forehead and brow lift has a high rateof sensory nerve recovery, but full recovery maytake several months and require patient reassur-ance. Although exact numbers are not known,empiric observation of the last 150 endoscopicbrow lifts that I have performed suggests thatsensory disturbances are an occasional early con-cern but an unusual complaint after 6 to 12months. Alopecia, on the other hand, is a signifi-cant concern, especially if it persists longer than 6to 12 months. Hair may return after an average 4-to 8-month dormancy period of the hair follicle.However, excessive tension on the flaps, roughhandling of wound margins, or excessive use of

cautery near follicles may lead to permanent hairloss that requires treatment.116

Proper planning, technique, and postopera-tive care helps to reduce the incidence of compli-cations. Immediate and appropriate treatmentalong with sincere concern for the patient’s well-being should help to reduce the chance of the sit-uation worsening or patient being dissatisfied.

Summary and ConclusionsAn explosion in the number of rejuvenation tech-niques for the upper face in the past decade, leadby the use of endoscopes and botulinum toxin,has revolutionized the treatment of aging in thisarea. Cosmetic surgery treatment of the upperthird of the face is frequently an essential compo-nent for complete facial rejuvenation. Proceduresare highly variable and can offer improvement toboth young and old. Matching the problems tothe ideal rejuvenation techniques is essential formaximum esthetic benefits. Even the best surgicaltechnique can result in inadequate or even poorresults if improper patient selection or incorrectdiagnoses are made; for this reason, the foreheadand brow area must be evaluated critically for awide range of interlacing diagnoses.

Specific skin problems vary with a patient’sage and sex, but gravity remains consistent andnonselective; therefore, the only issues regardingthe occurrence of brow ptosis are when it willoccur and how severe it will be. Wrinkles are alsoinevitable but may be dynamic or static in nature.Thanks to botulinum toxin, the previously diffi-cult treatment of dynamic upper facial lines canbe effected at low risk with a simple injection.The common and consistent finding of brow pto-sis, especially in the lateral third of the brow, maynow be selectively treated endoscopically toachieve a more youthful appearance. Society’sidea of beauty at any one moment in time willultimately help to guide the patient and surgeonto choose where the brow should be placed asopposed to merely raising it higher. True rejuve-nation is likely more complex and involves mul-tiple modalities and even tissue replacement suchas fat grafting. Only time and persistence willprove what best restores youth to the upper face.

Facial cosmetic surgery continues to rise inpopularity exponentially. The aging populationwants to feel and look more youthful but nonethe-less demands to remain natural looking. Today’sdiscerning patient is often very knowledgeable onthe subject of their cosmetic surgery options andmay insist on a specific technique. The advice of awell-trained surgeon and diagnostician may makeor break the ultimate result and prevent a cosmeticdisaster. It is vital that the surgeon refuse to per-form treatment that is not in the best interest of thepatient. Cosmetic surgery is a luxury and is anoptional procedure, no matter how much of anemergency it seems to the patient. At the end of the

day, it is the surgeon’s responsibility to provide thepatient with the best and safest options available toachieve realistic goals.

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Forehead and Brow Procedures