TITLE: Browlift
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE: January 26, 2010
RESIDENT PHYSICIAN: Michael Briscoe, Jr., MD
FACULTY PHYSICIAN: Raghu Athre, MD
SERIES EDITORS: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Qui=
nn,
MS(ICS)
"This material was prepared by resident physicians in
partial fulfillment of educational requirements established for the
Postgraduate Training Program of the UTMB Department of Otolaryngology/Head=
and
Neck Surgery and was not intended for clinical use in its present form. It =
was
prepared for the purpose of stimulating group discussion in a conference
setting. No warranties, either express or implied, are made with respect to=
its
accuracy, completeness, or timeliness. The material does not necessarily
reflect the current or past opinions of members of the UTMB faculty and sho=
uld
not be used for purposes of diagnosis or treatment without consulting
appropriate literature sources and informed professional opinion."
INTRODUCTION
Facial rejuvenation has become an integral part = of today’s society because both sexes are constantly bombarded with imag= es that are considered beautiful. Facial rejuvenation can be accomplished by surgical and non-surgical means. Products such has faci= al rejuvenation creams, vitamins, supplements, herbal remedies, facials, dermabrasion, botox, injectable fillers, and non-ablative laser resurfacing have been marketed for reducing rhytids.&n= bsp; But for those with deep rhytids, only surgical procedures can adequa= tely improve their wrinkles. When performing surgical procedures, the face must be divided into brow and forehead, the midface, and the lower face.= The brow and forehead may have prominent ptosis with resultant deep rhytids and crow’s feet. This may communicate the emotions of sadness, tiredness, or anger even when these are not the true emotion. In addition with significant brow ptosis and lateral hooding, there can be vis= ual field defects. The first surg= eries to address the forehead and brow were described in 1919 by Passot, and there have been many modifications and new techniques developed over the past 90 years. Now there are multiple procedures that can be performed in a variety of patients with minimal morbidity.
ANATOMY
There are five layers of tissue in the forehead =
before
reaching the calvarium. They =
are
easily remembered by the mnemonic “scalp”. The skin is most
superficial, followed by the subcutaneous tissue, epicranial aponeurosis (g=
alea
and frontalis), loose areolar tissue, and then pericranium. The musculature includes one eleva=
tor,
and three depressors. The fro=
ntalis
muscle elevates the brow, it originates at the galea aponeurotica, and inse=
rts
into the supraorbital dermis. It
interdigitates with the obicularis oculi laterally, the procerus medially, =
and
the corrugators in its intermediate portion. The obicularis oculi closes the ey=
e, and
depresses the brow. The corru=
gators
supercilii arises from the supraorbital ridge of the frontal bone, deep to =
the
frontalis muscle, and it pulls the brow medially and inferiorly. The procerus inserts on the lateral
nasal bone, nasal cartilage, and skin between the eyebrows. It depresses the medial brow, and
elevates the root of the nose. The
vascular supply is from both the internal and external carotids. The supratrochlear and supraorbital
arteries originate from the ophthalmic branch of the internal carotid and t=
hey
supply the mid-portion of the forehead.&nb=
sp;
While the superficial temporal and zygomaticotemporal, branch of the
superficial temporal, arteries arise from the external carotid and supply t=
he
lateral forehead. Sensory
innervation is provided from all three branches of the trigeminal nerve.
PATHOPHYSIOLOGY
With aging, predictable changes in the skin occur. There is decreased col= lagen synthesis by fibrocytes in the dermal layer resulting in thinning of the papillary dermis. The amount = and quality of elastin in the skin decreases resulting in increased laxity of t= he skin. Sun exposure contribute= s to photoaging which results in dermal atrophy, subdermal fat loss, loss of ela= stic fibers, and homogenization of collagen fibers. The effects of gravity and the dec= reased elasticity of the skin cause ptosis of the brow and upper eyelid skin. The repeated contraction of brow m= uscles to counteract these forces, leads to the formation of rhytids, dermatochala= sis, and lateral hooding. The fron= talis muscle contributes to the deep, prominent horizontal wrinkles of the forehead. The obicularis oculi contributes to the lateral rhytids (crow’s feet). The corrugator supercilii contribu= tes to the vertical and oblique glabellar wrinkles. The procerus gives rise to the transverse nasal rhytids.
INDICATIONS, PATIENT SELECTION, AND PREOPERATIVE ASSESSMENT
Indications
The brow lift is appropriate for anyone with deep rhytids that desires facial rejuvenation.&= nbsp; There are also some people who have such severe lateral hooding, that they develop visual field defects. Brow lift in the temporal region can improve this problem. Brow asymmetry resulting from nerve paralysis or trauma can also be addressed with brow lift.
Patient Selection
As with any cosmetic procedure, patient expectat= ions and motivation for surgery need to be assessed prior to performing surgery. These surgeries will= make the patient look younger, but aging continues. They need to know the specific complications for each procedure, the preoperative, operative, and postoperative course, and there comfort level with the resultant scars for = the procedure they choose. The id= eal candidate is in good mental and physical health without systemic disease existing in an uncontrolled state. Preoperative assessment is not complete until a full history and physical exam has been performed, as well as, adequate facial analysis with photographs.
Facial analysis
It is important to assess the patient while seat= ed and in facial repose (relaxation) in the Frankfurt horizontal plane. The face should be analyzed in ter= ms of width and length. The width s= hould be five equal parts that are equal to the width of one eye. The nasal base width should be equ= al to the intercanthal distance. The facial length should be divided into thirds. The hairline (trichion) to the gla= bella represents the upper third, glabella to nasal tip is the middle third, and = from the nasal tip to the menton represents the lower third. With aging, there are predictable changes to each third of the face.
Assessment of the upper third begins with determ= ining its relationship to the middle and lower third. After that, the position of the hairline, the quality and thickness the hair, and presence of alopecia are = all important for choice of surgical procedure. The presence and severity of rhyti= ds, as well as their position are important because this will determine the extent= of dissection necessary to achieve a good surgical outcome.
Brow aesthetics includes the shape, symmetry, po=
sition
and mobility. The ideal shape=
for
men and women varies. For men=
, the
brow should be position at or near the supraorbital rim, while women need a
brow superior to the supraorbital rim, with a higher arch. The brow should be club shaped, and
begin at a line drawn from the alar facial crease to the medial canthus.
In addition to brow aesthetics, dermatochalasis = and temporal hooding should be assessed to determine if blepharoplasty will be = performed concurrently. Any ocular prob= lems such as lagopthalmus, or dry eye should be ascertained prior to surgery, but are not contraindications to surgery. These patients may require eye drops, or taping of the eye at night during the immediate postoperative period.= The patient’s skin type is important for wound healing, and sc= ar camouflage. Fair and thin-ski= nned patients usually heal with more ideal scars, and those with skin laxity usu= ally have finer scars than those who do not.
Photo documentation is very important, and most = Facial Plastic Surgeons have a photography suite in their office. This allows them to show photograp= hs of other patients that have undergone the proposed procedure. Also, they may use computer softwa= re that allows them to show the patient the expected postoperative result. This also helps with preoperative planning so the surgeon has an idea of the appropriate amount of lift that = can be provided.
Surgical Goals
The surgeon and the patient need to have the same surgical goals. Each procedur= e has its advantages and shortcomings. Information regarding this should be relayed to the patient so they = can make an informed decision on which procedure they want to undergo. Most of the procedures address the horizontal rhytids to some degree. In addition to the prominent horizontal wrinkles, surgery should ele= vate the ptotic brow, reduce the amount of lateral hooding, elevate the lateral canthus if necessary, reduce nasoglabellar rhytids, reduce crow’s fee= t, and correct brow asymmetry. If there is significant dermatochalasis, then blepharoplasty may be performed after performing brow lift.
PROCEDURES
Coronal Lift
This procedure offers great exposure and can add= ress most problematic areas of the upper face.&= nbsp; The forehead muscles are very well exposed and myotomies can be performed precisely and with ease. It is very useful in patients with low or normal hairline, which have extensive brow ptosis and prominent rhytids. The procedure can be performed und= er local anesthesia with intravenous sedation, or with a general anesthetic.
After appropriate infiltration of local anesthet= ic, a curvilinear incision that is 4-6 cm posterior to the anterior hairline is marked. The incision is bevel= ed following the hair shafts down through the galea. Dissection is carried out in a subgaleal, supraperiosteal plane down to about 1 cm superior to the supraorbital rim. Laterally, = the dissection is immediately on the deep temporalis fascia down to the level of the zygoma to avoid damage to the temporal branch of the facial nerve. The supraorbital and supraorbital neurovascular bundles are preserved, and the corrugators are dissected away from them. The procerus muscl= e may be incised or completely excised, while the frontalis and galea may be inci= sed to release prominent rhytids. Care should be taken to not excise the frontalis lateral to the lateral canthus because the temporal branch of the facial nerve may be injured. The flap is then pulled superiorly= and posteriorly in the midline, and superior and laterally in the temporal portion. Approximately 2 to 4= cm of redundant skin and soft tissue may be excised. There should be a minimal amount of overcorrection, which will resolve over a three week period. A suction drain should be placed, followed by meticulous closure of the galea, and staple closure of the skin. Antibiotic ointment and= a light dressing are placed. If= there is any lagopthalmos, then ophthalmic drops and ointment may need to be prescribed to avoid corneal injury. The suction drain and dressing is removed on postoperative day one, while the staples are removed on day seven and nine.
Advantages of this procedure include no visible = scar, it can precisely address different muscle groups, and there is excellent exposure. Disadvantages inclu= de scalp hypesthesia, it will elevate the hairline, and it is an extensive procedure with the potential for more blood loss than other procedures.
High Forehead Lifts
These are modifications to the coronal lift, and=
they
place the incision either a few millimeters anterior to the hairline
(pretrichial), or a few millimeters posterior to the hairline
(trichophytic). They are usef=
ul for
women with a high hairline, or increased vertical length to the forehead.
Advantages of this procedure include excellent exposure, as it can precisely address different muscle groups, and it does = not alter the hairline. Disadvant= ages include potentially visible scar requiring camouflage (make-up, wearing hair forward in women, hair transplantation in men), and permanent scalp hypesthesia.
Midforehead Lift
Yet another modification to the coronal lift, th= is technique involves making an incision in a prominent, central midforehead crease. Appropriate for males= with prominent horizontal rhytids, and alopecia or receding hairline. Dissection is in a subcutaneous ra= ther than subgaleal plane to preserve sensation to the scalp. As dissection approaches the orbit, subgaleal dissection is carried out medially to address the medial portion = of the frontalis muscle, corrugators, and procerus muscles. Redundant skin is excised, and the= flap is secured with a superior vector of pull.
Advantages of this procedure include precise brow elevation, less extensive dissection, scalp sensation remains intact, and it does not alter the hairline. Disadvantages include a visible scar, and it is difficult to achieve lateral elevation.
Direct Brow Lift
This is rarely used, but good for elderly with co morbidities that preclude longer duration procedures and for those with brow asymmetry. It is relatively contraindicated in those with light colored eyebrows and patients with hist= ory of poor scarring. The inferior incision is made in the superior brow line with care not to extend medial to the medial portion of the brow. Laterally, the incision can be extended in a gentle curve lateral to= the lateral eyebrow. The superior incision arcs, with the superior extent between the lateral limbus and late= ral canthus. The skin is removed,= while the superior edge of the obicularis is freed and sutured to the periosteum above the supraorbital rim.
Advantages include a short, simple procedure with minimal blood loss, and good control of brow position and shape. Disadvantages include visible scar= , and inability to manipulate the lateral rhytids.
Browpexy
This procedure is performed via an upper blepharoplasty incision and can treat mild brow ptosis. Elevation is performed in a submus= cular, post obicularis fascial plane towards the brow. Elevation is continued 1-1.5 cm ab= ove the supraorbital rim. One to = three permanent sutures are placed transcutaneously through the lower brow hairs. The suture is then tac= ked to the periosteum, and passed through the sub-brow muscular tissue at the posi= tion of the original transcutaneous suture.&nbs= p; The suture is pulled through the skin, and the suture is tied, lifti= ng the brow.
The advantage of this procedure is that it uses a pre-existing incision. Disadvantages include prolonged eyelid edema, possible brow asymmetr= y, and possible unsatisfactory appearance.
Endoscopic Brow Lift
This procedure was first described in 1992 by Co= re, and since that time, the equipment and number of surgeons performing this procedure have increased significantly.&nb= sp; This is a minimally invasive way of performing brow lift, with long-standing results similar to the open procedures.
Local is infiltrated at the proposed incision si= tes, for supratrochlear/supraorbital nerve blocks, and direct injection into the procerus and corrugators supercilii. There is one midline incision 2 cm posterior to the hairline and 1 c= m in length. There are 2 temporal incisions, which are 2 cm posterior to the temporal hairline and 3 cm in length. If a fixation system = is to be used, then two paramedian incisions may also be required.
The initial dissection is performed without the = use of the endoscope. Midline dissec= tion begins in the subperiosteal plane down to approximately 1 cm above the brow. Temporal dissection is = performed on the deep temporalis fascia with a blunt elevator to avoid injury to the facial nerve. Dissection cont= inues to the sentinel vein then the endoscope is used for the remaining dissection.
Facelift scissors are used to severe the temporal conjoint fascia, connecting the midline dissection with the temporal dissection. Dissection proceeds inferiorly toward the orbital rim under endoscopic visualization. The conjoint tendon (supraorbital rim fascial thickening) is sharply incised, releasing the brow. Temporal dissection proceeds in an inferomedial plane from the sentinel vein. Periosteum over the malar eminence= and superolateral orbital rim are released.&nb= sp; This continues medially with care to preserve the supraorbital neurovascular bundle. The brow depressors are then incised or removed.&nb= sp; Brow fixation is achieved by securing the superficial temporal fascia medially, to the deep temporal fascia in a superolateral vector. Various screws, biological glue, a= nd suture techniques have been used for fixation. There should be overcorrection, wh= ich generally corrects itself after three weeks. A small drain may be placed for 24 hours, and the surgical incisions are closed with staples.
Advantages include minimal blood loss, and this = is less invasive than traditional open procedures. Disadvantages are the highly speci= alized equipment necessary to perform the procedure, the high learning curve, and problems with fixation. In ad= dition to this, the degree of elevation of the brow and lateral brow may not be as much as with open procedures.
POSTOPERATIVE CARE AND COMPLICATIONS
Postoperative Care
For most of the procedures, the postoperative ca= re is the same. The incisions are d= ressed with antibiotic ointment, and possibly a light, cotton dressing. A small drain may be left in place= for the open procedures, and the endoscopic brow lift. Patients may experience headaches,= and a minimal amount of pain at the incision sites. They can begin gentle shampooing a= fter 48 hours, with hair being blow-dried on the cool setting. They should sleep in an upright or semi-upright position for four days postoperatively. Staples are removed after days sev= en and nine. They may return to norm= al activity after three weeks.
Complications
Complications in brow lifts are rare, with many = of these being only temporary. D= uring the preoperative appointment, it is imperative that the patient is educated= on the likely complications for their chosen procedure. Hematomas develop if hemostasis is= not achieved. Large hematomas can= develop and jeopardize vascular supply to the flap causing flap necrosis. If a scalp hematoma forms and continues to expand, the wound must be opened and the bleeding vessel cauterized.
Alopecia can occur in the endoscopic, coronal, a= nd high forehead lift procedures. Tension along incisions lines or around screw fixation, or overzealo= us cautery near the hair follicles are the cause for this complication. In most cases, this is temporary, = but there can be permanent alopecia if dissection occurs in the wrong plane.
Scarring can occur in the high forehead lifts, t=
he
midbrow lift, and the direct brow lift.&nb=
sp;
Depressed scars occur when there is poor wound closure and lack of
eversion of the wound edges. =
These
scars can be addressed as early as 6 to 8 weeks postoperatively with
dermabrasion.
Nerve injury can be either sensory or motor. Sensory injuries usually are tempo= rary, and are more common in the open techniques, or when subcutaneous dissection= is performed. Injury to the faci= al nerve can be from stretching, transection, or thermal injury. Knowledge of the course of the tem= poral branch of the facial nerve is important to avoid injuries.
CONCLUSION
Aesthetic surgery of the face involves addressin= g the aging process in the upper third, middle third and lower third of the face. Addressing the middle t= hird can help with the tired, sad, or angry look, which may not be the person’s true personality. Choosing the correct surgery for each patient requires thorough knowledge of the advantages and disadvantages of each procedure. This allows the surgeon and patien= t to choose the correct procedure that will address all of the patient’s problem areas. To avoid pitfa= lls during surgery, knowledge of the course of the arteries and nerves in the forehead and brow are crucial. Brow lifting techniques address the deep rhytids of the forehead, the transverse= and vertical nasoglabellar wrinkles, and can elevate lateral hooding to allevia= te visual field defects.
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