BROW LIFT - Universiti Sains Malaysiapustaka.kk.usm.my/pustaka2/inhouse/e-journal/SRPS/11-C1...2 SRPS Volume 11, Issue 1C, 2009 the topic of brow lift. One hundred forty-two (54%)

Volume 11 Issue C1

Cosmetic

BROW LIFTJerome H. Liu, MD, MSHSAndrew P. Trussler, MD

OUR EDUCATIONAL PARTNERS Selected Readings in Plastic Surgery appreciates the generous

support provided by our educational partners.

PLATINUM PARTNERS

SILVER PARTNER

facial aesthetics

Dori Kelly

W. P. Adams, Jr, MD

S. M. Bidic, MD

G. Broughton II, MD, PhD

S. Brown, PhD

J. L. Burns, MD

J. J. Cheng, MD

A. A. Gosman, MD

J. R. Griffin, MD

K. A. Gutowski, MD

R. Y. Ha, MD

R. E. Hoxworth, MD

K. Itani, MD

J. E. Janis, MD

R. K. Khosla, MD

J. E. Leedy, MD

J. A. Lemmon, MD

A. H. Lipschitz, MD

J. H. Liu, MD

R. A. Meade, MD

J. K. Potter, MD, DDS

S. M. Rozen, MD

M. Saint-Cyr, MD

M. Schaverien, MRCS

J. F. Thornton, MD

A. P. Trussler, MD

R. I. S. Zbar, MD

Senior Manuscript Editor

Contributing Editors

Editor Emeritus

Editor-in-Chief

Business Managers

Corporate Sponsorship

Reconstruction Topics

Breast Reconstruction

Cleft Lip and Palate

Craniofacial

Eyelid Reconstruction

Facial Fractures

Hand: Congenital

Hand: Extensor Tendons

Hand: Flexor Tendons

Hand: Peripheral Nerves

Hand: Soft Tissue

Hand: Wrist, Joints, Rheumatoid Arthritis

Head and Neck Reconstruction

Lip, Cheek, Scalp, and Hair Restoration

Lower Extremity Reconstruction

Nasal Reconstruction

Surgery of the Ear

Trunk Reconstruction

Vascular Anomalies

Wounds and Wound Healing

Cosmetic Topics

Blepharoplasty

Body Contouring: Excisional Surgery

Body Contouring: Noninvasive, Liposuction, and Fat Grafts

Breast Augmentation

Breast Reduction and Mastopexy

Brow Lift

Face-lift

Injectable Agents and Dermal Fillers

Lasers and Light Therapy

Rhinoplasty

Skin Care

Selected Readings in Plastic Surgery (ISSN 0739-5523) is published approximately 5 times per year by Selected Readings in Plastic Surgery, Inc. A volume consists of 30 issues distributed over 6 years. Please visit us at www.SRPS.org for more information.

Printed on recycled paper using soy-based ink; 100% recyclable.

Jeffrey M. Kenkel, MD

F. E. Barton, Jr, MD

BROW LIFT

Jerome H. Liu, MD, MSHSAndrew P. Trussler, MD

Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

INTRODUCTIONThe brow and periorbital region play a central role inthe expression of emotion, health, and aging.Successful brow lifting is predicated on a fundamentalknowledge of the anatomy, a thorough understandingof the aging process, an artistic grasp of browaesthetics, and a logical well-executed surgical plan.The aesthetic goals of browplasty include thecorrection of eyebrow ptosis, muscle imbalance oractivity, forehead rhytids, brow shape and lidaesthetics, lateral brow laxity, and abnormal orunattractive facial expressions.1,2

HISTORYIn 1919, Passot3 was the first to report brow lifting inthe literature. He used multiple elliptical skin excisionsto elevate the brow and to diminish crow’s feet.Subsequently, Hunt4 described a variety of techniquesto address the brow, including the coronal incision inthe hair-bearing scalp, a hairline incision, and directforehead incision. During the ensuing 20 to 30 years,the forehead lift lost favor because of its transientlongevity. During that time, attempts to improve thedurability of the operation included transection of thetemporal branch of the facial nerve or injection ofalcohol into the motor nerves.5,6 Those efforts wereunsuccessful and fraught with complications.1,7

During the 1960s, interest in brow lifting wasrenewed. Failures of earlier brow lifts were attributed

to the persistent activity of the forehead muscles. TheMcIndoe-Beare techniques8 for modifying the frontalisand corrugators were updated by Marino andGandolfo.9 Vinas10 also made some very astuteobservations that remain relevant even today:

“1. An inelastic aponeurotic-muscle layer, formedby the frontalis and its extensions, occupies thefrontal region and expands laterally toward bothtemporal regions. This layer adheres to the skinand does not permit free movement of it.Traction on the frontotemporal region with afinger will show this fixation of the skin, as itdoes not cause the wrinkles to disappear¾incontrast to the results of a similar test in thelower faciocervical area, where the skin glideseasily over the subjacent tissue.2. There are adhesions that prevent freemovement of the soft tissues of the supraorbitalregions over the bony orbital rims. In ourexperience, unless these adhesions areeliminated, traction from above will not give apermanent lift to the eyebrows.”

Subsequently, surgeons investigated differentapproaches and planes of dissection. However, thebrow received little attention relative to other aspects offacial rejuvenation. The advent of endoscopic browrejuvenation in the early 1990s11,12 stimulated increasingattention to browplasty. A recent review13 discussed 262articles that were published between 1966 and 2008 on

2

SRPS Volume 11, Issue 1C, 2009

the topic of brow lift. One hundred forty-two (54%) ofthe articles were published during the last 10 years.

ANATOMYIn this section, we present summaries of the anatomyrelated to brow lifting. For more in-depth study, werefer the reader to descriptive textbooks and atlases byBaker et al.,14 Barton,15 Knize,16 Mathes,17 Nahai,18 andZide and Jelks.19,20

MusclesThe frontalis muscles are paired extensions of the galeaaponeurotica and insert into the supraorbital dermisby interdigitating with the orbicularis oculi muscle.The superficial and deep galea layers continue to theupper palpebral margin as the anterior and posteriorsheaths of the frontalis and orbicularis muscles. A fatpad develops within a split in the posterior musclesheath at the brow. The galea is continuous with thesuperficial temporal fascia laterally, which iscontinuous with the superficial musculoaponeuroticsystem (SMAS) inferiorly.21,22 The fixation of the browhas been examined by Knize,23 who emphasized theimportance of the fusion plane between the galea,temporalis, and periosteum at the temporal crest.

The depressors of the brow are the procerus,corrugator supercilii, depressor supercilii, andorbicularis oculi muscles.24,25 All except the sphincterpass within the fat pad deep to the frontalis.23 Theprocerus muscles originate from the upper lateralcartilages and nasal bones and insert into glabellarskin at the medial edges of the frontalis. Contractionproduces transverse wrinkling at the radix of the nose.

The corrugator muscle has both a transverse andan oblique head. The procerus, depressor supercilii,and oblique head of the corrugator muscle originatefrom the superior-medial orbital rim and share aparallel course before inserting into the dermis underthe medial eyebrow. 25 The transverse head of thecorrugator supercilii muscle originates from the medialsuperior orbital rim and inserts into the dermis justsuperior to the middle third of the eyebrow. Thetransverse head of the muscle moves the entireeyebrow medially, producing both vertical and obliqueglabellar skin creases. The procerus, depressorsupercilii muscle, and oblique head of the corrugator

supercilii muscle produce oblique glabellar skin lines.25

In a recent study of cadaveric dissections, Janis etal.26 described the topography of the corrugator musclein great detail and noted that the corrugator superciliiare much larger than previously described (Fig. 1). Atits medial origin, the corrugator begins 2.9 mm fromthe nasion and extends laterally to a point 43 mm fromthe nasion or 7.6 mm medial to the lateral orbital rim.The most cephalic extent (apex) of the muscle is 32.6mm superior to the nasion-lateral orbital rim plane. Atits medial origin, the most caudal muscle fibers areapproximately 1 cm cephalad to the nasion-lateralorbital rim plane.

The orbicularis oculi muscle is the sphincter of theeyelid. This broad, thin, oval muscle is adherent to theoverlying skin and consists of three parts: a peripheralorbital portion spreading over the forehead and cheek;a palpebral portion that constitutes the voluntarymuscle of the eyelids; and a small lacrimal portionassociated with the medial palpebral ligament. Theorbital portion attaches to the medial canthal tendon,the nasal part of the frontal bone, along theinferomedial orbital margin, and interdigitates withthe corrugators medially. Laterally, the orbital portionof the orbicularis continues around the orbit withoutinterruption at the lateral canthus into the zygomaticarea.14 Contraction of the orbicularis results indownward displacement of the lateral brow.

Figure 1. Comprehensive corrugator supercilii muscledimensions. Artistic rendition (proportionate scale) of allmeasured data points of corrugator supercilii muscle inrelation to palpable bony anatomy. Note reflection ofmuscular interdigitation required to delineate lateral extentof corrugator supercilii muscle. (Reprinted with permissionfrom Janis et al.26)

3


Contraction of the medial head of the orbital portiondepresses the level of the medial eyebrow but does notuniformly contribute to the formation of obliqueglabellar skin lines. The palpebral portion oforbicularis oculi spreads concentrically in thesubcutaneous tissue of the upper and lower eyelids.The palpebral orbicularis oculi has pretarsal andpreseptal segments.

Ligaments and AttachmentsThe orbicularis oculi is anchored by well-definedligamentous attachments. Muzaffar et al.27 provided adetailed description of the attachments. Medially, theorbicularis has a direct attachment to the inferiororbital rim from the region of the anterior lacrimalcrest to approximately the level of the medial limbus.Laterally, the attachment is indirect and provided bythe orbital retaining ligament (ORL) (Fig. 2). Theanatomy of the ORL and its relationship to the orbitalseptum were clarified in cadaver studies by Ghavamiet al.28 The authors found the ORL to be circumferentialin nature and consistent in every specimen. Althoughthe ORL and orbital septum merge at the orbital riminto a thickening called the arcus marginalis, the two arealways noted to be distinct structures (Fig. 3).

The ORL extends from the periosteum just outsidethe orbital rim to the fascia on the undersurface of theorbicularis oculi. At its lateral extent (and in the region

of the lateral canthus), the ORL merges with the“lateral orbital thickening” (LOT). The ORL is more laxand greater in length laterally compared with medially,where it is more taut and shorter (Fig. 4).28 The LOTrepresents a triangular condensation of the superficialand deep orbicularis that extends across the frontalprocess of the zygoma onto the deep temporalis fascia.In a study conducted by Muzaffar et al.,27 thedimensions of the LOT varied greatly with age (Fig. 5).The ORL is predictably continuous with the LOTbelow the lateral canthal tendon. Specifically, the ORL,LOT, and lateral palpebral raphe form a singleanatomic unit in that region (Fig. 6). Release of theORL and LOT, therefore, allows untethered redrapingof all the structures.

Figure 2. Anatomy of inferior periorbital space. Medially,orbicularis oculi originates directly from orbital rim aboveorigin of levator labii superioris. More centrally, orbicularisattaches indirectly to orbital rim by means of orbicularisretaining ligament, which courses directly on orbital side ofzygomaticofacial nerve. Laterally, ligament merges intolateral orbital thickening. (Reprinted with permission fromMuzaffar et al.27)

Figure 3. Schematic drawing shows relationship of orbitalseptum and orbicularis retaining ligament (ORL). Orbicularisretaining ligament arises from orbital rim several centimetersabove inferior edge. Arcus marginalis is fused area of orbitalseptum, orbicularis ligament, and periosteum and liesbetween the orbital septum and orbicularis retainingligament. OOM, orbicularis oculi muscle. (Reprinted withpermission from Ghavami et al.28)

4


Moss et al.29 conducted a detailed anatomic studyof the temporal and periorbital regions and provided ataxonomy for the various supporting structures. Theauthors divided structures into ligaments (deep fasciaor periosteum to dermis), septi (fibrous wall betweenfascial layers), and adhesions (fibrous or fibro-fatty

adhesion between deep and superficial fascia). Theyidentified six global temporal and periorbitalstructures relevant to brow lifting: temporalligamentous adhesion, supraorbital ligamentousadhesion, superior temporal septum, inferior temporalseptum, lateral brow thickening, and LOT. Thetemporal ligamentous adhesion measuresapproximately 20 mm high and 15 mm wide at its baseand begins 10 mm cephalad to the superior orbital rim.Moss et al. also delineated the relationships to adjacentrelevant neurovascular structures: sentinel vessel,temporal branch of facial nerve, zygomaticotemporalnerve, and zygomaticofacial nerve. Their findings areillustrated in Figures 7 and 8. Sullivan et al.30 identifiedfour specific retaining ligaments: three medial and onelateral. Selective release of the ligaments allows foreyebrow reshaping.

Sensory NervesThe sensory nerves of the forehead are the supraorbitaland supratrochlear nerves. The supratrochlear nerveemerges from the supraorbital rim 1.4 to 1.7 cm lateralto the midline of the nasal radix, and the supraorbitalnerve courses 2.4 cm lateral to the midline.31 Beer etal.32 investigated more than 1000 orbits and found widevariation between the exit patterns of the supraorbitalnerve, with asymmetric findings between left and rightin 74% of the specimens. Additionally, the largestdistance the supraorbital nerve exited from thesupraorbital rim was 19 mm. In a different study,

Figure 4. Schematic shows view from the lateral orbital rimtoward nasal bones with orbicularis oculi muscle (OOM)suspended by hooks to show length and size differentialbetween lateral and medial orbicularis retaining ligaments(ORL). Lateral orbicularis retaining ligament is longer thanmedial orbicularis retaining ligament in both superior andinferior orbits. Note relationships among orbicularisretaining ligament, corrugator supercilii muscle (CSM), andlateral orbital thickening (LOT). (Reprinted with permissionfrom Ghavami et al.28)

Figure 5. Dimensions of orbicularis retaining ligament andlateral orbital thickening vary with age. Larger trianglerepresents lateral orbital thickening in youngest specimen.Smaller triangle within defines lateral orbital thickening inolder specimens. Numbers indicate millimeters. (Reprintedwith permission from Muzaffar et al.27)

Figure 6. Orbicularis retaining ligament (ORL), lateral orbitalthickening (LOT), and lateral palpebral raphe form a singleunit lateral to the lateral canthal tendon (LCT). TPF, temporalparietal fascia; TP, tarsal plates. (Reprinted with permissionfrom Muzaffar et al.27)

5


Webster et al.33 found that approximately 50% of skullshad bilateral supraorbital notches, 25% had bilateralsupraorbital foramina, and 25% had one notch and oneforamen. Bilateral supratrochlear notches were presentin 97% of specimens.

The supraorbital nerve divides into a deep branchand a superficial branch. Janis34 describes four distinctbranching patterns of the supraorbital nerve relative tothe corrugator supercilii (Fig. 9). With pattern I (40%),the deep division sends branches that course along theundersurface of the muscle. With pattern II (34%), boththe superficial and deep divisions have branchesadjacent to the corrugator. Pattern III (4%) has onlybranching contributions from the superficial division,and with pattern IV, all branching of the supraorbitalnerve occur cephalad to the bulk of the corrugatormuscle. The authors found the supraorbital nerve to bemore intimately related to the corrugator muscle thanpreviously thought. However, the supraorbital nerve

was not observed to perforate through the muscle inany of the cadaver specimens.34 The superficial(medial) division enters the frontalis 2 to 3 cm abovethe supraorbital rim and provides sensation to theforehead skin and 1 to 3 cm of the anterior scalp.35 Thedeep (lateral) division runs between the galea andperiosteum and proceeds laterally until themidforehead, where it takes a course 0.5 to 1.5 cm

Figure 7. Lateral view shows periorbital and temporalligamentous attachments with major neurovascularrelationships. TLA, temporal ligamentous adhesion; SLA,supraorbital ligamentous adhesion; STS, superior temporalseptum; ITS, inferior temporal septum; PS, periorbitalseptum; LBT, lateral brow thickening of periorbital septum;LOT, lateral orbital thickening of periorbital septum; SV,sentinel vessel; TFN, temporal branches of facial nerve; ZTN,zygomaticotemporal nerve; ZFN, zygomaticofacial nerve.(Reprinted with permission from Moss et al.29)

Figure 8. Anterior view shows periorbital and temporalligamentous attachments with major neurovascularrelationships. TLA, temporal ligamentous adhesion; SLA,supraorbital ligamentous adhesion; STS, superior temporalseptum; ITS, inferior temporal septum; PS, periorbitalseptum; LBT, lateral brow thickening of periorbital septum;LOT, lateral orbital thickening of periorbital septum; SV,sentinel vessel; TFN, temporal branches of facial nerve; ZTN,zygomaticotemporal nerve; ZFN, zygomaticofacial nerve.(Reprinted with permission from Moss et al.29)

6


medial to the temporal fusion line.35 The deep divisionprovides sensation to the frontoparietal scalp, andKnize23 suggested that arrangement is responsible forthe itching and numbness patients feel after opencoronal brow lift procedures. The supratrochlear nerveexits the orbit medially and enters the substance of thecorrugator and then the frontalis.35

Motor NervesThe motor nerve of the forehead is the temporalbranch of the facial nerve, which lies on theundersurface of the temporal fascia. The temporal

branch of the facial nerve supplies the frontalis muscle,superior orbicularis muscle, transverse head of thecorrugator supercilii muscle, and superior end of theprocerus muscle (Fig. 10).25 Pitanguy and Ramos36

traced the temporal branch of the facial nerve from 0.5cm below the tragus to 1.5 cm superior to the lateralbrow. The temporal branch usually runs just below thefrontal branch of the temporal artery.37 Stuzin et al.38

delineated the multiple layers in the temporal region,described the course of the nerve in a three-dimensional fashion relative to the fascial planes, andsuggested a safe dissection route. The concept of the

Figure 9. Summary of supraorbital nerve branching pattern classification. Left, Type I supraorbital nerve branching pattern, mostcommon type. Right, Types II through IV. SON-S, superficial division of the supraorbital nerve; SON-DCSM, branch from the deepdivision of the supraorbital nerve; SON-D, deep division of the supraorbital nerve; SON-SCSM, branch from the superficialdivision of the supraorbital nerve. (Reprinted with permission from Janis et al.34)

7


frontal temporal nerve triangle39 can assist in locatingmotor and sensory nerves in the upper face.

The zygomatic branch of the facial nerve suppliesthe inferior orbicularis oculi muscle, inferior end of theprocerus muscle, depressor supercilii muscle, obliquehead of the corrugator supercilii muscle, and medialhead of the orbicularis oculi muscle.25

CalvariaThe skull thickness varies based on location. Walden etal.40 showed that the thickness increases medially andposteriorly. Knize16 measured the thickness of the skullin various locations, with averages ranging from 5.1mm laterally to 7.7 mm medially. The temporal bonewas found to be as thin as 1.7 mm. The skull is alsothin just superficial to the middle meningeal artery,measuring as little as 2.1 mm.16

PATHOPHYSIOLOGYProlonged hyperactivity of the upper facialmusculature produces three kinds of deformities of theforehead and brow complex: transverse forehead

wrinkling (frontalis muscles), brow ptosis (corrugatorand orbicularis muscles), and glabellar wrinkling(corrugator, orbicularis, and procerus muscles).Flowers et al.41 reviewed the dynamics of frontalisfunction as related to brow lift.

Knize23 discussed the mechanism of eyebrowptosis in an anatomic study that identifies the balanceof forces acting on the eyebrow and specific glideplanes and supporting structures. He postulated thatthe lateral eyebrow segment becomes ptotic earlierthan the medial segment because the lateral eyebrowhas less support from deeper structures and thebalance of forces acting on the eyebrow selectivelydepresses the lateral segment (Fig. 11). The authoridentified three forces acting on the lateral eyebrow:

“1) frontalis muscle resting tone, which suspendsthat eyebrow segment medial to the temporalfusion line of the skull;2) gravity, which causes the soft-tissue masslateral to the temporal line to slide over thetemporalis fascia plane and push the lateraleyebrow segment downward; and3) corrugator supercilii muscle hyperactivity inconjunction with action of the lateral orbicularisoculi muscle, which can antagonize frontalismuscle activity and directly facilitate descent ofthe lateral eyebrow.”

AESTHETICSOne cannot discuss brow aesthetics withoutsimultaneously discussing periorbital and eyelidaesthetics. Clearly defined goals of brow and orbitalaesthetics are the basis of successful results in surgicalrejuvenation of the upper face. The goals varysignificantly with sex, age, race, culture, and personalpreference. The globe by itself is entirelyexpressionless and depends on the surrounding soft-tissue complex to convey the myriad humanemotions. Many of these aesthetic goals intertwine theforehead, brow, eyelid, and pupil into the brow andtemporal region. Often, the “ideal” measurementsrefer back to the golden proportion, reminding us thatthe relative positions and distances might be moreimportant than the absolute.15,42

Farkas and Kolar,43 Flowers,44 and Wolfort et al.45

reviewed the aesthetic goals of blepharoplasty. Certain

Figure 10. Periorbital motor nerves and the muscles theyactivate. TB, temporal branch of the facial nerve; ZB,zygomatic branch of the facial nerve; FM, frontalis muscle;CSM, corrugator supercilii muscle; DSM, depressor superciliimuscle; PM, procerus muscle; ZM, zygomaticus majormuscle. (Reprinted with permission from Knize.25)

8


numerical guidelines are helpful in planning thesurgery. At the midpupillary line, the anterior hairlineto brow distance should measure 5 to 6 cm. Thedistance from brow to orbital rim, brow to supratarsalcrease, and brow to mid pupil should be 1 cm, 1.6 cm,and 2.5 cm, respectively.2 Canthal tilt averages 4.1 mm(+4 degrees) in women and 2.1 mm (+3 degrees) inmen.46 Visible pretarsal skin should measure 3 to 6mm47 and lash line to lid fold ranges from 8 to 10 mm.48

The upper lid should cover 2 to 3 mm of the iris, andthe lower lid forms a “lazy-S” and should just meet itsinferior aspect. The intercanthal distance is ideally one-fifth of the facial width at eye level and represents oneeye width.49

McKinney et al.50 analyzed 15 normal healthyvolunteers with esthetically pleasing faces andobserved that the average distance from the mid pupilto the upper edge of the eyebrow was 2.5 cm and thedistance from the upper edge of the eyebrow to thehairline was approximately 5 cm (Fig. 12). Connell etal.51 added that the distance between the upper eyelid

crease and the upper edge of the brow isapproximately 15 mm in esthetically pleasing faces.

Because of naturally occurring variations in thesizes and shapes of human structures, a discussion ofrelationships between parts is more relevant thanabsolute numbers. The medial edge of the eyebrow, themedial canthus, and the lateral border of the nasal alashould all fall on the same vertical plane. The eyebrowshould form a gentle arch whose peak lies at thejunction of the medial two-thirds and the lateral one-third.52 The peak should ideally lie midway betweenthe lateral aspect of the iris and the lateral canthus.Some have suggested that the peak of the brow archshould be more lateral than the classic description.53

The brow should overlie the orbital rim in men and beseveral millimeters above the rim in women. The edgeof the lateral eyebrow should lie slightly above themedial brow. A line drawn between the lateraleyebrow and the nasal ala should intersect the lateralcanthus.52,54 Ellenbogen54 illustrated the aestheticrelationships of the brow to other facial features (Fig.13), as originally described by Westmore52:

• In women, the eyebrow begins medially at avertical line drawn perpendicularly throughthe ala of the nose.

• In women, the brow should arch to above thesupraorbital rim; in men, it should arch along

Figure 11. Forces contributing to lateral eyebrow ptosis.Unsupported eyebrow lateral to the temporal fusion line ofthe skull (TL) is pushed down by the gravity-driven descentof the temporal fossa soft tissues. Lateral-most limit of thefrontalis muscle resting tone suspension of the eyebrowextends just over the zone of fixation (slanted lines) along thetemporal fusion line of the skull. Hyperactive corrugatorsupercilii muscle and lateral orbicularis oculi muscle actioncan antagonize frontalis muscle action and actively facilitatethe descent of the superficial temporal fossa soft tissues.(Reprinted with permission from Knize.23)

Figure 12. Distance from midpupil to top of brow should beat least 2.5 cm. If shorter, brow ptosis exists. Forehead heightaverages 5 cm in women and 6 cm in men. (Modified fromMcKinney et al.50)

9


the rim. • The lateral brow terminates at an oblique line

drawn through the ala of the nose and thelateral canthus.

• The medial and lateral ends lie atapproximately the same horizontal level (themedial end has a club head configuration thatgradually tapers laterally).

• The apex of the brow lies on a vertical linedirectly above the lateral limbus.

Gunter and Antrobus55 provided further criteriathat contribute to an aesthetic brow:

• The medial brow should be a continuation ofthe aesthetic dorsal line of the nose.

• The medial brow should start approximatelyabove the medial canthus.

• The vertical distance from the supraorbitalarch to the peak of the brow will differ.However, the peak should rarely be more than10 mm above the most caudal portion of themedial brow. It should be higher in womenthan in men.

• The medial brow should be lower than thelateral peak.

• The eyelids should remain aesthetic with thebrow elevated, otherwise surgical alteration ofthe eyelids might be indicated.

• The periorbital area should have its ownbalance. It should resemble an oval consistingof the eyebrow superiorly, the nasal dorsalline medially, the nasojugal groove inferiorly.The eye should be in the center of the oval,and the oval should balance with the rest ofthe face (Fig. 14).

• Aesthetics of the male brow differ. The malebrow tends to be less arched and usually flator nearly horizontal. The lateral brow isusually more prominent in men.

Final brow position and shape should bedetermined during preoperative discussions with thepatient in the context of facial aesthetics, individualpreferences, and facial shape. A recent study by Bakeret al.56 showed that brow aesthetics should take facialshape into consideration. Using computer imagingsoftware, the authors morphed a model’s face intodifferent shapes (round, square, oval, and long) andapplied the classic description presented byWestmore52 versus the recommendations of aprofessional makeup artist. No significant differencewas noted between the classic and modified eyebrowfor oval or round facial shapes. However, the browmodified by the professional makeup artist was foundto be more attractive with square and long facialshapes. Specifically, square faces favored a softer curvewith the arch lateral to the lateral limbus and longfaces were more attractive with a straighter brow,avoiding a high arch that may add length to the face.

Figure 13. Spatial relationships of ideal eyebrow. B, medialbrow; E, brow apex; C, lateral brow. (Reprinted with permissionfrom Ellenbogen.54)

Figure 14. Periorbital oval. (Reprinted with permission fromGunter and Antrobus.55)

10


SURGICAL GOALSMatarasso and Hutchinson57 divided the goals offorehead-brow rhytidoplasty into primary andsecondary indications. The primary indication forsurgery is ptosis of the forehead and eyebrows. Thesecondary criteria include frown muscle imbalance,transverse forehead rhytids, upper eyelid aesthetics,lateral brow-temporal laxity, and abnormal and/orunattractive expression. A retrospective review,however, showed a relatively uniform distribution ofpatients into each category (primary or secondary).2

The primary and secondary indications and theircorresponding surgical goals are shown in Table 1.2 Analgorithm for selecting the appropriate forehead browprocedure based on the patient’s main concern isshown in Table 2.57

The overall goals of surgery are the restoration ofbrow position, shape, and symmetry. For a soft,esthetically pleasing result, it is important to avoidovercorrection of brow position and excessiveelevation of the medial brow. Over-elevation of thebrow and abnormal shape are associated withperceived tiredness, sadness, anger, or surprise.55,58 Inaddition, any secondary criteria also need to beaddressed. The selection of incisions, dissection, and

adjunctive procedures needs to be tailored to specificpatient desires.

TECHNIQUEWith the aesthetic goals clearly in mind, the approach,plane of dissection, and means of fixation are chosen.

IncisionsDirectFlowers et al.41 suggested that the brow is subject to theelastic band principle: the farther away the suspensionpoint is from a weight attached to an elastic band, theless effective the lift will be. The direct or superciliaryexcision of an ellipse of skin and subcutaneous fat wasfirst described by Passot in 1919.3 In 1964, Castanares59

presented his results, which attested to predictable,controlled elevation of the brow. Vinas et al.10 describedtwo techniques for brow lift, one of which was abutterfly-wing pattern of excision, emphasizingresection from the lateral brow.

The direct excision approach is most often taken inmen because of the opportunity to hide the scar abovethe thicker male eyebrow and because otherapproaches cannot be hidden if the patient is balding.The most appropriate candidates for the direct brow

Table 1Candidates with Indications Categorized and Correlated with Goals of Surgery2

Candidates Indications Goals

Primary Eyebrow malposition (ptosis) Senile Congenital

Elevate forehead and eyebrowsBalance, position, symmetry

Secondary Frown muscle imbalance Minimize corrugator-procerus activity andcentral frown folds

Forehead rhytids Decrease frontalis muscle hyperactivity and transverse rhytids

Enhancing medial and/or lateral eyelid incision (aesthetics)

Confi ne the eyelid incision within the tarsal crease

Lateral brow laxity (temporal lift) Restore temporal, lateral brow, and canthal regions

Abnormal and/or unattractive expression (e.g., sad, tired, angry)

Adjust brow position to normalize expression

11


lift are male patients older than 50 years with eyebrowptosis and lateral hooding, well developed crow’s feet,long dense eyebrows, and low transverse foreheadwrinkles.60 The biggest disadvantage of a directtechnique is the potential for a perceptible scar at avisible portion of the face.61 Some authors have foundthat the scar is hardly noticeable after 6 to 9 months.60

MidbrowExcision of a strip of midforehead skin is advocated forpatients who have deep forehead rhytids, to concealthe scar, and in those who have male pattern baldness,in whom a coronal lift is impossible. This approach,originally described by Gurdin and Carlin62 in 1972,has the additional advantage of advancing the hairlineforward. Advocates53 of the midbrow lift tout itsadvantages: 1) moderate undermining above thefrontalis muscle, 2) no hairline distortion, 3) precisesculpting of the entire brow, and 4) access to thesuperior orbital rim. Its primary disadvantage is the

position of the scar.53

TransblepharoplastySokol and Sokol63 described a transblepharoplastybrow suspension that involved tacking a soft-tissueeyebrow flap to a superiorly based orbital rimperiosteal flap. McCord and Doxanas64 reported amethod of resecting the brow fat pad and suspendingthe brow from the periosteum above the brow to thepreseptal orbicularis.

Others have performed more extensive foreheaddissections through the blepharoplasty incision.Leopizzi65 reported performing wide supraperiostealdissection of the lateral orbicularis through an upperblepharoplasty incision, transecting the “zone offixation” where the superior temporal line joins thesuperior orbital rim. The lateral orbicularis oculimuscle is raised with one non-absorbable suspensionstitch in the deep temporal fascia. Paul66 described atransblepharoplasty subperiosteal brow lift with

Table 2Algorithm for Selecting Appropriate Forehead-Brow Procedure Based on Patient’s

Main Concern and Any Proposed Concomitant Surgery57

Indications Associated Procedures Treatment

Forehead rhytids None Botulinum toxin ± laser resurfacing*

Glabellar creases (corrugator muscle hypertrophy)

None Endoscopic corrugator muscle excision or botulinum toxin ± laser resurfacing*

Upper eyelid surgery Corrugator muscle excision throughupper lid ± laser resurfacing

Lateral brow laxity None Limited procedure (i.e., endoscopic,temporal lifts), upper lid browpexy

Rhytidectomy Lateral brow lift through temporal aspect of facelift incision

Brow ptosis With or without rhytidectomy Coronal brow lift, endoscopic brow lift, anterior hairline brow lift for high (>5–6 cm) forehead

*In patients desiring botulinum toxin treatment in conjunction with browpexy, the botulinum toxin should not beinjected laterally (leaving a strip of frontalis muscle intact) if the depressor orbicularis oculi are treated. An array of soft-tissuefillers and substitutes (e.g., collagen replacement procedures, fat injections, liquid injectable silicone) can also be used.

12


corrugator and procerus resection. Stuzin67 alsoreported performing a large portion of the browdissection through a blepharoplasty incision, althoughhe used an endoscope to complete the dissectionthrough the zone of fixation. Langsdon et al.68 reportedwidely undermining in the subgaleal plane through anupper eyelid incision medial to the temporal line.Suspension sutures and absorbable anchors are used tosupport the brow. Cintra and Basile69 described acombined approach that included transblepharoplastyand temporal incisions.

Knize70 and Guyuron et al.71 described a transble-pharoplasty approach to the corrugator supercilii andprocerus muscles for the treatment of glabellarwrinkles. Brow contouring and shaping can also beaccomplished through an upper blepharoplastyincision. Resection of the retro-orbicularis fat cansoften and flatten the heaviness and bulkiness in theupper periorbital and brow region.72,73 The fat padoverlies the lateral orbital rim and extends outwardtoward the end of the brow. Zarem et al.74 describedperforming browpexy through an upper lid incision toprevent the brow from dropping below the superiororbital rim.

CoronalIn 1962, Gonzalez-Ulloa75 combined a coronal incisionfor forehead lifting with traditional rhytidectomy forthe lower face. Interest in the technique remained

sporadic until Vinas et al.10 reported 250 cases offrontotemporal “rhytidoplasty.” Connell and Marten76

indicated that every 1 mm of eyebrow elevationproduces 1.5 mm of retro-displacement of the anteriorhairline. The incision, therefore, should be performedin patients who have low hairlines or in whom thepredicted shift is esthetically acceptable. Flowers andCeydeli77 reported adhering to a “five-to-one” rulewith which each 5 mm of scalp excision results in 1mm of long-term brow elevation. In bald or baldingmen, Connell and Marten used a vertex incisionfurther posterior, where it is not visible in conventionalphotographs. Other patterns are shown in Figure 15.Flowers and Ceydeli recommended having at least 4cm of hair remaining after scalp resection; Barton15

recommended 5 cm.Excellent descriptions of the classic coronal brow

lift can be found in articles by Ellenbogen,54 Flowersand Ceydeli,77 Kaye,1 Ortiz-Monasterio et al.,78 andPitanguy.79 Aldo Mottura80 presented an alternative ofgaleal plication after limited incision dissection in thesubgaleal plane. With that method, skin is excised andthe galeal is plicated through a coronal incision. Thecoronal open brow lift usually provides the mosteffective lift and is best suited for heavy tissues orprominent eyebrow ptosis.81,82

HairlineHunt,4 in 1926, placed an incision along the anterior

Figure 15. Types of incision used in brow lift. A, hairline; B, gull wing; C, vertex; D, lambdoidal; E, W incision; F, lambdoidalpaddle; G, interlocking Ms. (Reprinted with permission from Connell and Marten.76)

13


hairline in an attempt to reduce forehead wrinkling.McKinney et al.50 recommended the anterior hairlineincision for patients with an eyebrow-to-hairlinedistance greater than 5 cm. Debate continues regardingwhether to bevel the incision parallel or perpendicularto the hair follicles to produce the best cosmetic result.Camirand83 and Camirand and Doucet84 compared thetwo beveling techniques and found that the incisionsthat were oriented perpendicular to the hair follicleswere superior based on invisibility of the scar,nonlinearity of the scar, absence of hypopigmentation,and presence of hair in front of the scar. The hairfollicles of the anterior temporal hairline growanteriorly and inferiorly at an angle of 7 to 27 degrees(mean, 16 degrees) to the epidermis.85 Pollock andPollock86 reported performing a hairline subcutaneousbrow lift that results in acceptable scars by bevelingthe incision perpendicular to the hair follicles.Guyuron and Rowe87 described the use of a hairlineincision combined with posterior scalp advancementto shorten a long forehead during brow lift.

TemporalTemporal brow lifting is one of the oldest knownmethods for repositioning the brow, dating to Passot in1919.3 Gleason88 performed brow lift by extensivesubcutaneous undermining in the temporal and lateralorbital areas up to the anterior branch of the temporalartery, at which point the dissection deepened to asubgaleal plane. The incisions were not connectedacross the midline. Ten of 102 patients developedtransient temporal alopecia, and one patientexperienced temporary frontal paresis. Dingman89

described another modification of the temporal lift thatinvolved initial dissection in a subgaleal plane.

Byrd90 and Byrd and Andochick91 described atemporal approach that involves dissection in thesubgaleal plane with extensive soft-tissue release at thesuperior and lateral orbital rim. Further dissection overthe zygomatic arch below the superficial layer of thedeep temporal fascia allows elevation of the malar fatpad and avoids the temporal branch of the facial nerve.

Several authors92,93 have reported using a biplanartemporal lift to improve lateral brow elevation.Marshak et al.92 described a temporal incision and thencreation of an SMAS-galeal flap to increase the amount

of lift. Fogli93 described beginning his dissection in thesubgaleal plane and then transitioning to thesubcutaneous plane just anterior to the hairline.

EndoscopicThe endoscopic approach allows access to the foreheadfor release of the retaining structures of the upper faceand for muscle resection through very small incisionsin the scalp. Use of the endoscope in forehead surgerywas first presented by Isse11 and by Vasconez12 in 1992and by Hamas94 in 1993. Steinsapir et al.95 reviewed theanatomy and surgical technique of endoscopicforehead lift. Excellent descriptions of that techniquecan be found in articles and chapters by Aiache,96

Daniel and Tirkanits,97 DeCordier et al.,98 Guyuron,99

Rowe and Guyuron,100 Isse,24 and Nahai.18

Vasconez et al.101 presented the results of a series ofbrow lifts performed in 32 patients. A subperiostealapproach was used, with subgaleal dissection down tothe orbital rims, corrugator and procerus resection, andfrontalis scoring. Fixation was by bone-soft tissueanchors or by sutures connecting the galea to thetemporalis fascia. The authors reported moderatelifting of the brow in most cases. Complicationsincluded perforation and burning of the forehead,temporary palsy of the temporal nerve, and three casesof glabellar hematoma.

Sozer and Biggs102 reviewed 128 endoscopicforehead lifts performed in a subperiosteal plane. Theiroperative time was 15 to 30 min. A commoncomplication was local alopecia, which decreased infrequency when the authors began using fixation withtitanium microscrews. Two patients had asymmetricalbrow position. The lift effect persisted for the 5 yearsof follow-up.

Hamas103 reported limiting his technique toresection of the corrugator and procerus muscles toreduce prominent glabellar frown lines. In his series of35 patients, approximately 50% of glabellar wrinkles onmaximal effort were reduced. Complications included anoticeable depression in the glabellar region in the firstfew patients and one patient with a skin burn.

Hamas and Rohrich104 presented a techniquewhereby the galea aponeurosis is plicated afterseparating it from the forehead skin above and belowthe scalp incision. The modification effectively raises

14


the central brow without elevating the central hairline.Other contributions to endoscopic foreheadplasty

have been made by Isse,24 Aiache,96 Ramirez,105 andChajchir.106 Since those authors presented their reportsin 1994, long-term follow-up results have beenpresented by multiple authors.98,99,107,108 The results havebeen long lasting and stable.

Limited IncisionSeveral authors have reported using endoscopic browlift-type incisions in the hairline to raise the lateraleyebrow through a limited incision. Kikkawa et al.109

reported using small scalp and upper eyelidblepharoplasty incisions to dissect the lateral brow in asubperiosteal plane and to resect the corrugator andprocerus muscles.

Knize110,111 described limited-incisionforeheadplasty, with lateral dissection of the lateralbrow in a subperiosteal plane. The author emphasizedthat the dissection must include release of theperiosteal attachments along the superior orbital rimand transection of the ligamentous band that he callsthe orbital ligament (Fig. 16). A transpalpebral approachis taken to the procerus and corrugator musculature(Fig. 17).110,111 In a discussion of the articles presented byKnize, Rohrich112 offered an algorithm for correction of

the aging forehead and periorbital area (Fig. 18).Limited incision non-endoscopic techniques have

gained popularity. Their biggest advantage over theendoscopic approach is the avoidance of cumbersomeand expensive equipment.113 A non-endoscopic limitedapproach can be safely performed with mastery of theregional anatomy.114 Medial brow elevation can beminimized or avoided with a limited incisiontechnique. A transpalpebral route can be used inconjunction with a limited incision technique forcorrugator resection.

Plane of DissectionSubcutaneousA subcutaneous brow lift has the advantages of adirect approach to removing transverse wrinkles of theforehead and for elevating the brow while preservingsensation to the scalp posterior to the incision. Thedisadvantage of the technique is a significant decreasein flap vascularity, which was responsible for highrates of complications in several series.78,115,116 Rees andWood-Smith115 and Ortiz-Monasterio et al.78 listedpotential problems with the subcutaneous brow lift,such as alopecia, wound dehiscence, skin slough, poorscars, anesthesia of the forehead, and compromisedcirculation. Guyuron116 also reported a highercomplication rate with the subcutaneous brow lift thanwith other methods of rejuvenating the forehead.

In contrast, Wolfe and Baird117 presented theirexperience with subcutaneous brow lift in 27 womenand reported no significant loss of tissue or hair. Theauthors recommended the procedure for older patientswho have considerable transverse and verticalwrinkling or pronounced brow ptosis. Not long ago,Wolfe118 reviewed his indications for subcutaneousforehead lift, as follows:

• very wrinkled forehead with pronouncedbrow ptosis, particularly laterally

• secondary or tertiary forehead lift• very short forehead that needs heightening• high forehead that needs shortening by

advancing a scalp flap

The author’s routine forehead lift is still a subgalealdissection through a coronal incision. Complicationsoccurring in several dozen patients included a small

Figure 16. Eyebrow elevation through small incision in scalp.Subperiosteal forehead flap is raised and orbital ligament (*)transected for maximum upward movement of superficialtemporal fascia. STF, superficial temporal fascia; TL,temporal fusion line of the skull; div., division; n., nerve.(Reprinted with permission from Knize.110)

15


Figure 17. Technique of limited incision foreheadplasty through transpalpebral approach. n., nerve. (Reprinted with permissionfrom Knize.111)

Figure 18. Algorithm for treatment of forehead wrinkles. (Modified from Rohrich.112)

16


subcutaneous ecchymosis and one case of cutaneoushypersensitivity of the lateral brow and temporal areathat persisted for more than a year.

Guyuron116 asserted that a subcutaneous plane ismore effective than other methods for eliminatingforehead wrinkles and crow’s feet. With that approach,the surgeon has the option of shortening orlengthening the forehead or leaving the lengthunchanged. Vogel and Hoopes119 presented a report of50 patients who underwent subcutaneous brow liftwith few complications. The main disadvantage of thattechnique is the precision required for the incision andclosure and the time-consuming dissection.

Miller et al.120 reviewed the pros and cons ofsubcutaneous brow lift and interbrow muscle resectionthrough an incision in the lateral temporal hairline. Anadditional benefit of that approach is the ability toexcise some of the non-hair-bearing skin, therebydecreasing temporal baldness. The authors reportedminimal complications in 65 patients.

Pollock and Pollock86 reported that thesubcutaneous lift provides the most direct approach toelevation of the ptotic bow, which is a skin appendage.The ratio of advancement to lift is 1:1. Corrugatorresection is performed by incising the galeatransversely in the glabellar region. Flap advancementis secured by using progressive tension sutures to holdthe brow in position. In their series of 80 patients, onlyone patient had transient epidermolysis in thetemporal scalp resulting in a small area of alopecia.

SubgalealRudolph and Miller121 reported that the subgalealdissection is rapid, considering the plane is obviousand safe, and that it facilitates direct resection ofmuscle without nerve damage. Connell and Marten76

stated that they use that plane because it is relativelybloodless, is easy to identify and dissect, and offersexcellent access to hypertrophied muscles. Ramirez122

reported that by elevating the rigid pericranium, theskin is not allowed to stretch in cases of severe fixedforehead wrinkles. Connell and Marten,76 Vinas et al.,10

and Ortiz-Monasterio et al.78 all reported series inwhich a subgaleal flap was effectively used, and De LaPlaza et al.123 suggested that the galea adheres morerapidly to periosteum than does periosteum to bone,

resulting in surer fixation of the tissues.Knize23 stated that the majority of eyebrow

movement occurs between the leaves of the galea atthe orbital rim. Dissection in that plane is likely toresult in the greatest degree of translation of the brow.Byrd and Andochick91 reported performing theirtemporal lift in the subgaleal plane, freeing theattachments of the orbicularis to the periosteum.Dissection can initially begin in the subgaleal planeand transition to the subperiosteal plane 2 cm abovethe orbital rim.

Troilius124 compared the surgical outcome ofsubgaleal and subperiosteal brow lifts in 120 patients.Measurements were obtained from preoperativephotographs and compared with postoperativemeasurements at 1 year. The data were analyzed bymeans of a digitalized analyzing tool. Patients whohad undergone subgaleal brow lift showed nosignificant elevation of the brow after 1 year, whereaspatients who had undergone subperiosteal brow liftshowed a mean increase in vertical brow height of 7mm. In a discussion of the article by Troilius, Stuzinand Rohrich125 attributed the lack of persistentimprovement in the subgaleal series to many factors,such as method of fixation (Troilius did not use anchorfixation), incision position (mostly coronal rather thanhairline), skin versus galea excess (a subcutaneoustechnique might be indicated for older patients withbrow skin laxity), and the dynamic forces of orbicularisoculi contraction on a daily basis (which should becounteracted with botulinum toxin injections).

SubperiostealRamirez122 reported that lifting the inelasticpericranium produces more effective traction over thebrows. The theory is that a more natural gliding of theforehead tissues can be obtained by preserving thesubgaleal fascia in the interface between the frontalismuscle and the pericranium. McKinney126 noted thatadvocates of this plane of dissection think a moresolid elevation is attained when the periosteum sticksto the bone. This, therefore, has been the preferredplane of dissection of most practitioners of endoscopicbrow lift. The arcus marginalis must be released foreffective elevation.122 de la Paza and de la Cruz127

cautioned that the periosteum is the sole nutrient

17


source of membranous bones and that its removalcould hasten the resorption of the facial skeleton thatoccurs with age.

Combined Subcutaneous and SubperiostealThe main advantage of the subcutaneous approach isthat it preserves sensation posterior to the incisionline. The subperiosteal approach, on the other hand,allows better periorbital remodeling. Ramirez122

combined the two approaches in a biplanar dissectionthrough the endoscope that maximizes theadvantages and minimizes the disadvantages of eithermethod alone (Fig. 19).

Hamas and Rohrich104 stated that the combinedsubcutaneous and subperiosteal approach allows browlifting without elevation of the central forehead.

Subgaleal versus SubperiostealThomas et al.128 compared the strength of subgalealversus subperiosteal flap adherence in a rabbit model.They found that the subgaleal flap strength exceededthat of the subperiosteal flap at all time points.Additionally, the subgaleal flap regained preoperativestrength at 2 weeks, compared with the subperiostealflap at 8 weeks. Early and rapid readherence is notedin the subgaleal plane compared with thesubperiosteal plane in a rabbit. Microscopic analysis at4 weeks showed less intervening space and greaterconnective tissue proliferation in the subgaleal flap.

Although this suggests that subgaleal dissection

might provide some advantages over the subperiostealapproach, the exact clinical implications require furtherinvestigation. Boutros et al.129 examined the temporalsequence of periosteal readherence in guinea pigs.They found that meaningful strength was regained by30 days. The rate of healing and the accumulation ofwound strength approximated that of other types ofwounds. The two studies might have implicationsregarding the type and duration of stable fixationrequired during the postoperative period.

Method of FixationTraditionally, brow elevation has been maintained byexcising skin. Ortiz-Monasterio130 proposed guidelinesfor the removal of skin during brow lift. The authorrecommended a 2:1 ratio of skin resection to browelevation and 3:1 when frontalis muscle is removed.Flowers et al.41 and Flowers and Ceydeli,77 on the otherhand, stated that a ratio of 4:1 or 5:1 is required toproduce a long-lasting effect. Aggressive skin excisionhowever, can cause many secondary wound problems,particularly when the frontalis has been resected.

Rohrich and Beran131 reviewed methods ofendoscopic fixation for brow lift procedures (Fig. 20).Skin excision has been adapted to the endoscopictechnique by the Emory group with their V-to-Yclosure.132 Other methods have relied on compressivedressings while the surgical planes “bond.”101

Microscrew fixation has been used by Daniel andTirkanits.97 Fiala and Owsley133 used Mitek anchors.Guyuron99 used a combination of fascial sutures andbone tunnels for suture fixation. Swift et al.,134 Waldenet al.,40 and McKinney and Sweis135 used corticaltunnels. Isse24 suspended the temporalis fascia to thedeep temporal fascia and between the periosteum andthe bone by tunneling or applying microscrews. Jonesand Grover136 achieved significantly more stable resultswith polydioxanone suture than with fibrin glue.Kobienia and Van Beek137 burred an upside-down U-shaped trough in the outer calvaria around which thesuspension suture is hooked. Others have presenteddifferent variations of fixation involving soft-tissueimbrication138 and suspension sutures acting as cablesall the way to the brow dermis.139 Troilius140 stated thatno fixation is needed when the goal of brow elevationis 4 mm or less.

Figure 19. Biplanar dissection in foreheadplasty withendoscope. (Reprinted with permission from Ramirez.162)

18


Significant interest has been shown in the use ofbioabsorbable screws and multipoint fixation devices.Both Eppley141 and Morello142 reported achievingadequate fixation with bioabsorbable screws. CoaptSystems (Palo Alto, CA) has developed bioabsorbablemultipoint fixation devices (Endotine and Ultratine)for use with endoscopic brow lift.143–146

Walden et al.40 investigated the safety of differentmethods of invasive brow fixation. The authorscompared techniques that used Mitek anchors, corticaltunnels, Endotine fixation devices, and miniscrews. Alltechniques were performed on fresh cadavers asdescribed in the literature or per manufacturerrecommendations. No instance of inner tablepenetration was seen with cortical tunnels or withMitek anchors. One Endotine post penetrated the innertable, and three miniscrews penetrated the inner table.Relative contraindications to invasive brow fixationinclude any pathological condition of bone, includingsevere osteoporosis, cystic changes of hyperparathy-roidism, Paget disease, osteopenia or osteomalacia,osteonecrosis, previous fracture, or previous surgery.

Endoscopic versus Coronal versus TranspalpebralTechniquesThe literature abounds with opinions regarding the

various surgical approaches, but very little objectivedata are available for comparison. Dayan et al.147

retrospectively evaluated the results of differenttechniques to determine whether endoscopicallyassisted procedures achieve the same degree ofcorrection as do coronal techniques. The authorsstudied the effects of concurrent blepharoplasty onbrow elevation and assessed the long-term outcomesafter coronal lifts (but not endoscopically assisted lifts).The authors concluded that in their study group, bothmethods achieved similar brow elevation at 1 year,concomitant blepharoplasty had no significant effecton brow elevation, and coronal lifts were associatedwith a gradual drop in brow elevation over 5 years.

In a recent study, Walden et al.148 compared theefficacy of corrugator resection betweentranspalpebral and endoscopic techniques in 24anatomic dissections. The authors found that theendoscopic approach facilitated visualization, andthus more complete resection, than did thetranspalpebral technique, which failed to remove upto one-third of the transverse head of the corrugatormuscle. Guyuron,149 however, countered with hisexperience in achieving complete corrugator resectionwhen using his transpalpebral technique.

Chiu and Baker150 examined the usefulness ofendoscopic brow lift over a 5-year period. The authorsfound a 70% decline in the number of endoscopic browlifts performed at their hospital. A survey queried theplastic surgeons at that hospital about the decline andshowed that 48% thought the selection criteria forendoscopic brow lift candidates were more limited, 35%thought other techniques were equally or moreeffective, and 35% thought that endoscopic brow liftdoes not work in the majority of patients. Although 70%of patients were satisfied with their results, only half ofplastic surgeons were happy with the long-term results.

Elkwood et al.82 conducted a national survey toassess trends in brow lifting techniques. Approximatelyequal numbers of coronal brow lifts and endoscopicbrow lifts were performed. Plastic surgeons generallyfound the open approach to be more effective for browelevation, forehead wrinkle elimination, and eradicationof glabellar frown lines. Younger practitioners weremore likely to use newer technologies.

Figure 20. Methods of endoscopic fixation for brow liftprocedures. Lower left, cortical tunnel fixation; upper left,internal screw fixation with Goretex tab; upper center, internalscrew fixation, no tab; upper right, Mitek anchor fixation;lower right, external screw fixation. (Reprinted with permissionfrom Rohrich and Beran.131)

19


OTHER ISSUESCombined ProceduresBrow lifting commonly is performed in conjunctionwith other procedures for balanced facialrejuvenation.15,18 Although the combinations arevirtually endless, several common combinationsdeserve special mention.

Brow lift often is performed in conjunction withperiorbital rejuvenation. It is critical to position thebrow in its anticipated postsurgical position foraccurate evaluation of the upper eyelid.15,18,54 Upperblepharoplasty skin excision tends to be less aggressivewhen performed with brow lift.

Stuzin67 described his approach to endoscopicbrow lift, upper and lower blepharoplasty, andretinacular canthopexy. He reported using theendoscope predominantly for dissection along thetemporal line of fusion between the frontal bone andtemporalis muscle to help protect the temporal branchof the facial nerve. Corrugator resection andsubperiosteal forehead dissection are still performedthrough the transpalpebral approach. The lower lid isaddressed with a skin flap and canthal repositioningand/or tightening.

When performing an endoscopic brow lift, thedissection can proceed carefully down into the midfacefor combined upper and midface rejuvenation. Aftermobilization of the brow, Byrd and Andochick91 andHunt and Byrd151 approached the midface through asub-SMAS approach, following the superficial layer ofthe deep temporal fascia over the zygomatic arch andinto the midface. Fascial fixation and suspensionsutures and microscrews are used. Hobar and Flood152

performed a subperiosteal midface lift in conjunctionwith an endoscopic brow lift. Combining the foreheadand the midface lift can have favorable effects onlower eyelid aesthetics by decreasing the verticalheight of the lower eyelid, lessening infraorbitalhollowing, and improving dermatochalasis.153

Modification of the Upper Facial SkeletonThe bony characteristics of the forehead oftendifferentiate men from women.154 The male foreheadhas extensive supraorbital bossing with a cephaladflat area before the convex curvature of the upperforehead. In contrast, the female has nearly

nonexistent supraorbital bossing with a continuousmild curvature. Departures from theseanthropometric norms can affect forehead and browaesthetics. Others have noted excessive downslanting of the supraorbital ridges as contributing toa “sad look.”155,156

Access to the forehead and periorbital area isachieved through a coronal scalp incision.130 Forlimited contouring isolated to the supraorbital rim,an upper lid approach can be used.155 Ousterhout154

divided patients into three groups: group 1 can betreated through bony contouring alone, group 2requires bony contouring in conjunction with methylmethacrylate cranioplasty. and group 3 requiresextensive modification with osteotomies.

Recontouring the frontal bone and supraorbitalridge is best achieved with a burr, obtaining acontrolled graduated resection.130 The orbital rim canbe contoured with a burr130 or an osteotome.155

Augmentation can be achieved with bone grafts,synthetic materials, or pericranial or other soft tissueflaps.156 Pitfalls include entering the frontal sinus andother complications inherent to craniofacial surgeryor periorbital aesthetic surgery.

Forehead WrinklingThe issue of which management approach includes themost modification of forehead wrinkles remainscontroversial. Flowers et al.,41 Ramirez,122 andMcKinney126 do not favor resection of the frontalismuscle, reasoning that frontalis hypertrophy frombrow ptosis causes the rhytids and that elevating thebrow will decrease frontalis activity.

Numerous authors have emphasized theimportance of surgical manipulation of the frontalismuscle to decrease muscle hypertrophy. Marino157

stated that he prefers horizontal incision of thefrontalis without muscle excision to decrease thetendency of the subcutaneous tissue to adhere to thegalea at the site of muscle resection. Pitanguy79

advocated vertical and horizontal incisions of theaponeurosis.

Vinas et al.10 and Kaye1 recommended excision ofa strip of frontalis across the midforehead (beneaththe area of maximum transverse wrinkling) whilemaintaining intact frontalis in the suprabrow area to

20


preserve normal upper facial expression. LeRoux andJones158 reported excision of the entire frontalis musclein 71 patients. Botulinum toxin type A (Botox) hasalso been used in the treatment of dynamic rhytids inthe forehead.159

Glabellar WrinklingVertical rhytids of the glabella area are caused bycorrugator activity. Transverse rhytids at the nasal rootare caused by the procerus muscle. Selective surgicalinterruption of the nerves to the muscles has beensuggested by Castanares59 and by Bames,160 whereasother authors1,10,78 have advocated muscle division orsegmental resection through either an endoscopic24,161,162

or a transpalpebral70,71 approach.Guyuron and Rose163 used a fat graft harvested

from the infratemporal fossa to pad the glabellar spaceduring forehead and/or brow rejuvenation. Accordingto the authors, the fat graft prevents contourdeformities after muscle resection, restores a more“rejuvenated contour,” and helps prevent recurrencefrom reattachment of the residual muscle to itself or tothe underlying bone. The authors reported no adverseconsequences associated with the maneuver performedin 74 patients.

Glabellar wrinkles can also be temporarilycorrected by intramuscular injection of botulinumtoxin. Keen et al.164 showed the efficacy of botulinumtoxin in 11 patients. Electromyographic tracings wereused to pinpoint the site of injection. The onset ofaction was 3 to 5 days, and the duration of action wasapproximately 6 months. Botulinum toxin injection isnow well established as an adjunct to brow lift surgeryfor the treatment of glabellar furrows and lateralcrow’s feet.164–167 Patient satisfaction with Botoxtreatment is consistently high, and patient-reportedoutcomes have indicated significant improvement inrecent years.168,169

Chemical and Liquid Brow LiftBotox can also be used to perform a “chemical browlift” through selective muscle weakening, which isknown as chemodenervation.165–167,170,171 The chemical browlift can be used to target the medial brow, lateral brow,or both. Although the lifting effect is temporary,

improved cosmesis has been reported.Frankel and Kamer165 reported performing

chemical brow lift by injection of 20 units of Botox intothe procerus and corrugator supercilii in 29 patients, 18(62%) of whom showed higher medial brows aftertreatment. Fifty-nine percent of patients also showedan increase in interbrow distance. Huang et al.167

reported accomplishing temporary brow lift withbotulinum toxin in 11 women. The authors injected 5units into the glabella and 10 units along the lateralorbital rim. The largest mean elevations(approximately 2.5 mm) were noted in the centralbrow area.

Ahn et al.166 injected 7 to 10 units of Botox directlyinto the lateral orbicularis oculi to elevate the lateralbrow a mean 4.83 mm (Fig. 21). The elevation persistedfor 3 to 4 months in all 22 patients. Mild bruising wasreported in five patients and minimal transient eyelidptosis in two. Guyuron172 noted that 7 to 10 units mightbe insufficient for achieving a lasting result. The authorsubsequently noted an age-dependent response, withyounger patients having more elevation than olderpatients. The technique presented by Guyuron wasfurther modified by Maas and Kim,173 with smallertarget doses being administered in the frontalis (12–16units) and increased doses in the superolateral browarea (16–20 units).

Carruthers and Carruthers171 were able to obtainlateral brow elevation with only a glabellar injection

Figure 21. Botox injection sites (x) into lateral portion oforbicularis oculi muscle. Subsequent unopposed frontalismuscle activity results in lateral brow elevation. (Reprintedwith permission from Ahn et al.166)

21


of Botox. Lateral brow elevation was almostimmediate, and then central and medial browelevation peaked at 12 weeks after treatment. Theauthors postulated that the diffusion of Botox to themedial frontalis caused an increased resting tone inthe remainder of the muscle. They also noted that theminimal amount needed in the glabellar region toobtain lifting of the brow was 20 units.

New trends indicate a combination of Botox withfillers to further sculpt the brow. The combination of

volume restoration and alteration of muscle balance canenhance the results. Kane174 and the Facial AestheticsConsensus Group Faculty159 used this technique.

Ciuci and Obagi175 used autologous fat transfer forrejuvenation of the periorbital complex. With thatmethod, fat is injected to provide for volumerestoration, achieving a full upper brow, decreasedskin laxity, and camouflaged supraorbital andinfraorbital rim.

REFERENCES1. Kaye BL. The forehead lift: A useful adjunct to

face lift and blepharoplasty. Plast Reconstr Surg1977;60:161–171.

2. Matarasso A, Terino EO. Forehead-browrhytidoplasty: Reassessing the goals. PlastReconstr Surg 1994;93:1378–1389.

3. Passot R. La chirurgie esthetique des rides duvisage [in French]. Presse Med 1919;27:258.

4. Hunt HL. Plastic Surgery of the Head, Face, andNeck. Philadelphia: Lea & Febiger; 1926.

5. Passot R. Chirurgie Esthetique Pure: Techniques etRésultats. Paris: Gaston Doin et Cie; 1931.

6. Edwards BF. Bilateral temporal neurotomy forfrontalis hypermotility: Case report. PlastReconstr Surg (1946) 1957;19:341–345.

7. Paul MD. The evolution of the brow lift inaesthetic plastic surgery. Plast Reconstr Surg2001;108:1409–1424.

8. Beare R. Surgical treatment of senile changes inthe eyelids: The McIndoe-Beare technique. In,Smith B, Converse JM (ed): Proceedings of theSecond International Symposium of Plastic andReconstructive Surgery of the Eye and Adnexa. St.Louis: Mosby; 1967.

9. Marino H, Gandolfo E. Treatment of foreheadwrinkles [in Spanish]. Prensa Med Argent1964;51:1368–1371.

10. Vinas JC, Caviglia C, Cortinas JL. Foreheadrhytidoplasty and brow lifting. Plast ReconstrSurg 1976;57:445–454.

11. Isse NG. Endoscopic forehead lift. Presented atthe Annual Meeting of the Los Angeles CountySociety of Plastic Surgeons, Los Angeles,November 1992.

12. Vasconez LO. The use of the endoscope in browlifting. Presented at the Annual Meeting of theAmerican Society of Plastic and ReconstructiveSurgeons, Washington, DC, September 1992.

13. Patrocinio LG, Patrocinio JA. Forehead-lift: A 10-year review. Arch Facial Plast Surg2008;10:391–394.

14. Baker TJ, Gordon HL, Stuzin JM. SurgicalRejuvenation of the Face. 2nd ed. St Louis: C.V.Mosby; 1996.

15. Barton FE. Facial Rejuvenation. St. Louis: QualityMedical Publishing, Inc.; 2008.

16. Knize DM. The Forehead and Temporal Fossa:Anatomy and Technique. Philadelphia: LippincottWilliams & Wilkins; 2001.

17. Mathes SJ, Hentz VR. Plastic Surgery. 2nd ed.Philadelphia: Saunders Elsevier; 2006.

18. Nahai F. The Art of Aesthetic Surgery: Principlesand Techniques. St. Louis: Quality MedicalPublishing, Inc.; 2005.

19. Zide BM, Jelks GW. Surgical Anatomy of the Orbit.New York: Raven Press; 1985.

20. Zide BM, Jelks GW. Surgical Anatomy around theOrbit: The System of Zones. Philadelphia:Lippincott Williams & Wilkins; 2005.

21. Abul-Hassan HS, von Drasek Ascher G, AclandRD. Surgical anatomy and blood supply of thefascial layers of the temporal region. PlastReconstr Surg 1986;77:17–28.

22. Tolhurst DE, Carstens MH, Greco RJ, HurwitzDJ. The surgical anatomy of the scalp. PlastReconstr Surg 1991;87:603–612.

23. Knize DM. An anatomically based study of themechanism of eyebrow ptosis. Plast Reconstr Surg1996;97:1321–1333.

22


24. Isse NG. Endoscopic facial rejuvenation:Endoforehead, the functional lift: Case reports.Aesthetic Plast Surg 1994;18:21–29.

25. Knize DM. Muscles that act on glabellar skin: Acloser look. Plast Reconstr Surg 2000;105:350–361.

26. Janis JE, Ghavami A, Lemmon JA, Leedy JE,Guyuron B. Anatomy of the corrugator superciliimuscle: Part I. Corrugator topography. PlastReconstr Surg 2007;120:1647–1653.

27. Muzaffar AR, Mendelson BC, Adams WP Jr.Surgical anatomy of the ligamentous attachmentsof the lower lid and lateral canthus. Plast ReconstrSurg 2002;110:873–884.

28. Ghavami A, Pessa JE, Janis J, Khosla R, ReeseEM, Rohrich RJ. The orbicularis retainingligament of the medial orbit: Closing the circle.Plast Reconstr Surg 2008;121:994–1001.

29. Moss CJ, Mendelson BC, Taylor GI. Surgicalanatomy of the ligamentous attachments in thetemple and periorbital regions. Plast ReconstrSurg 2000;105:1475–1490.

30. Sullivan PK, Salomon JA, Woo AS, Freeman MB.The importance of the retaining ligamentousattachments of the forehead for selective eyebrowreshaping and forehead rejuvenation. PlastReconstr Surg 2006;117:95–104.

31. Lorenc ZP, Ivy E, Aston SJ. Neurosensorypreservation in endoscopic forehead plasty.Aesthetic Plast Surg 1995;19:411–413.

32. Beer GM, Putz R, Mager K, Schumacher M, KeilW. Variations of the frontal exit of thesupraorbital nerve: An anatomic study. PlastReconstr Surg 1998;102:334–341.

33. Webster RC, Gaunt JM, Hamdan US, FuleihanNS, Giandello PR, Smith RC. Supraorbital andsupratrochlear notches and foramina: Anatomicalvariations and surgical relevance. Laryngoscope1986;96:311–315.

34. Janis JE, Ghavami A, Lemmon JA, Leedy JE,Guyuron B. The anatomy of the corrugatorsupercilii muscle: Part II. Supraorbital nervebranching patterns. Plast Reconstr Surg2008;121:233–240.

35. Knize DM. A study of the supraorbital nerve.Plast Reconstr Surg 1995;96:564–569.

36. Pitanguy I, Ramos AS. The frontal branch of the

facial nerve: The importance of its variations inface lifting. Plast Reconstr Surg 1966;38:352–356.

37. Correia Pde C, Zani R. Surgical anatomy of thefacial nerve, as related to ancillary operations inrhytidoplasty. Plast Reconstr Surg1973;52:549–552.

38. Stuzin JM, Wagstrom L, Kawamoto HK, WolfeSA. Anatomy of the frontal branch of the facialnerve: The significance of the temporal fat pad.Plast Reconstr Surg 1989;83:265–271.

39. Lei T Gao JH, Xu DC, Zhong SZ, Li XJ, Chen B,Yang DY, Wang XH. The frontal-temporal nervetriangle: A new concept of locating the motor andsensory nerves in upper third of the facerhytidectomy. Plast Reconstr Surg2006;117:385–394.

40. Walden JL, Orseck MJ, Aston SJ. Currentmethods for brow fixation: Are they safe?Aesthetic Plast Surg 2006;30:541–548.

41. Flowers RS, Caputy GG, Flowers SS. Thebiomechanics of brow and frontalis function andits effect on blepharoplasty. Clin Plast Surg1993;20:255–268.

42. Seghers MJ, Longacre JJ, Destefano GA. Thegolden proportion and beauty. Plast Reconstr Surg1964;34:382–386.

43. Farkas LG, Kolar JC. Anthropometrics and art inthe aesthetics of women’s faces. Clin Plast Surg1987;14:599–616.

44. Flowers RS. The art of eyelid and orbitalaesthetics: Multiracial surgical considerations.Clin Plast Surg 1987;14:703–721.

45. Wolfort FG, Baker T, Kanter WR. Aesthetic goalsin blepharoplasty. In, Wolfort FG, Kanter WR(ed): Aesthetic Blepharoplasty. Boston: LittleBrown; 1995:17–34.

46. Bartlett SP, Wornom I III, Whitaker LA.Evaluation of facial skeletal aesthetics andsurgical planning. Clin Plast Surg 1991;18:1–9.

47. Flowers RS. Upper blepharoplasty by eyelidinvagination: Anchor blepharoplasty. Clin PlastSurg 1993;20:193–207.

48. Baker TJ, Gordon HL, Mosienko P. Upper lidblepharoplasty. Plast Reconstr Surg1977;60:692–698.

49. Tolleth H. Concepts for the plastic surgeon from

23


art and sculpture. Clin Plast Surg 1987;14:585–598.50. McKinney P, Mossie RD, Zukowsky ML. Criteria

for the forehead lift. Aesthetic Plast Surg1991;15:141–147.

51. Connell BF, Lambros VS, Neurohr GH. Theforehead lift: Techniques to avoid complicationsand produce optimal results. Aesthetic Plast Surg1989;13:217–237.

52. Westmore MG. Facial cosmetics in conjunctionwith surgery. Presented at the Aesthetic PlasticSurgical Society Meeting, Vancouver, BritishColumbia, May 1975.

53. Cook TA, Brownrigg PJ, Wang TD, Quatela VC.The versatile midforehead browlift. ArchOtolaryngol Head Neck Surg 1989;115:163–168.

54. Ellenbogen R. Transcoronal eyebrow lift withconcomitant upper blepharoplasty. Plast ReconstrSurg 1983;71:490–499.

55. Gunter JP, Antrobus SD. Aesthetic analysis of theeyebrows. Plast Reconstr Surg 1997;99:1808–1816.

56. Baker SB, Dayan JH, Crane A, Kim S. Theinfluence of brow shape on the perception offacial form and brow aesthetics. Plast ReconstrSurg 2007;119:2240–2247.

57. Matarasso A, Hutchinson OH. Evaluatingrejuvenation of the forehead and brow: Analgorithm for selecting the appropriatetechnique. Plast Reconstr Surg 2000;106:687–694.

58. Knoll BI, Attkiss KJ, Persing JA. The influence offorehead, brow, and periorbital aesthetics onperceived expression in the youthful face. PlastReconstr Surg 2008;121:1793–1802.

59. Castanares S. Forehead wrinkles, glabellar frown,and ptosis of the eyebrows. Plast Reconstr Surg1964;34:406.

60. Har-Shai Y, Gil T, Metanes I, Scheflan M. Browlift for the correction of visual field impairment.Aesthet Surg J 2008;28:512–517.

61. Tyers AG. Brow lift via the direct and trans-blepharoplasty approaches. Orbit2006;25:261–265.

62. Gurdin MD, Carlin GA. Aging defects in themale: A regional approach to treatment. In,Masters FW, Lewis JR (ed): Symposium onAesthetic Surgery of the Face, Eyelid, and Breast. St.Louis: Mosby; 1972:52–57.

63. Sokol AB, Sokol TP. Transblepharoplasty browsuspension. Plast Reconstr Surg 1982;69:940–944.

64. McCord CD, Doxanas MT. Browplasty andbrowpexy: An adjunct to blepharoplasty. PlastReconstr Surg 1990;86:248–254.

65. Leopizzi G. A transpalpebral approach totreatment of eyebrow ptosis. Aesthetic Plast Surg1999;23:125–130.

66. Paul MD. Subperiosteal transblepharoplastyforehead lift. Aesthetic Plast Surg 1996;20:129–134.

67. Stuzin JM. Endoscopic brow lift, upper andlower blepharoplasty, retinacular canthopexy:Personal approach. Plast Reconstr Surg2007;120:1697–1698.

68. Langsdon PR, Metzinger SE, Glickstein JS,Armstrong DL. Transblepharoplasty browsuspension: An expanded role. Ann Plast Surg2008;60:2–5.

69. Cintra HP, Basile FV. Transpalpebral brow lifting.Clin Plast Surg 2008;35:381–392.

70. Knize DM. Transpalpebral approach to thecorrugator supercilii and procerus muscles. PlastReconstr Surg 1995;95:52–60.

71. Guyuron B, Michelow BJ, Thomas T. Corrugatorsupercilii muscle resection throughblepharoplasty incision. Plast Reconstr Surg1995;95:691–696.

72. Owsley JQ Jr. Resection of the prominent lateralfat pad during upper lid blepharoplasty. PlastReconstr Surg 1980;65:4–9.

73. May JW Jr, Fearon J, Zingarelli P. Retro-orbicularis oculus fat (ROOF) resection inaesthetic blepharoplasty: A 6-year study in 63patients. Plast Reconstr Surg 1990;86:682–689.

74. Zarem HA, Resnick JI, Carr RM, Wootton DG.Browpexy: Lateral orbicularis muscle fixation asan adjunct to upper blepharoplasty. Plast ReconstrSurg 1997;100:1258–1261.

75. Gonzalez-Ulloa M. Facial wrinkles: Integralelimination. Plast Reconstr Surg Transplant Bull1962;29:658–673.

76. Connell BF, Marten TJ. The male foreheadplasty:Recognizing and treating aging in the upper face.Clin Plast Surg 1991;18:653–687.

77. Flowers RS, Ceydeli A. The open coronalapproach to forehead rejuvenation. Clin Plast

24


Surg 2008;35:331–351.78. Ortiz-Monasterio F, Barrera G, Olmedo A. The

coronal incision in rhytidectomy: The brow lift.Clin Plast Surg 1978:5:167–179.

79. Pitanguy I. Indications for and treatment offrontal and glabellar wrinkles in an analysis of3,404 consecutive cases of rhytidectomy. PlastReconstr Surg 1981;67:157–168.

80. Aldo Mottura A. Open frontal lift: A conservativeapproach. Aesthetic Plast Surg 2006;30:381–389.

81. Eaves FF, Barton FE, Knize DM, Paul MD,Rohrich RJ. Comparative methods for brow lift.Aesthet Surg J 1997;17:397–403.

82. Elkwood A, Matarasso A, Rankin M, Elkowitz M,Godek CP. National plastic surgery survey: Browlifting techniques and complications. PlastReconstr Surg 2001;108:2143–2150.

83. Camirand A. Facelifts and browlifts:Amelioration of scars. Can J Plast Surg1999;7:27–33.

84. Camirand A, Doucet J. A comparison betweenparallel hairline incisions and perpendicularincisions when performing a face lift. PlastReconstr Surg 1997;99:10–15.

85. Mowlavi A, Majzoub RK, Cooney DS, WilhelmiBJ, Guyuron B. Follicular anatomy of the anteriortemporal hairline and implications forrhytidectomy. Plast Reconstr Surg2007;119:1891–1895.

86. Pollock H, Pollock TA. Subcutaneous brow liftwith precise suture fixation and advancement.Aesthet Surg J 2007;27:388–395.

87. Guyuron B, Rowe DJ. How to make a longforehead more aesthetic. Aesthet Surg J2008;28:46–50.

88. Gleason MC. Brow lifting through a temporalscalp approach. Plast Reconstr Surg1973;52:141–144.

89. Dingman DC. Lateral temporal transitionbrowlift. Presented at the Annual Meeting of theAmerican Society for Aesthetic Plastic Surgery,Los Angeles, April 1983.

90. Byrd HS. The extended browlift. Clin Plast Surg1997;24:233–246.

91. Byrd HS, Andochick SE. The deep temporal lift:A multiplanar, lateral brow, temporal, and upper

face lift. Plast Reconstr Surg 1996;97:928–937.92. Marshak H, Morrow AA, Morrow DM. Biplanar

temple lift for lateral brow ptosis: Comparisonwith uniplanar dissection technique. AestheticPlast Surg 2008;32:517–522.

93. Fogli AL. Temporal lift by galeapexy: A review of270 cases. Aesthetic Plast Surg 2003;27:159–165.

94. Hamas RS. Endoscopic corrugator procerusmuscle resection through the subgaleal hairlineapproach. Presented at the Annual Meeting ofthe American Society of Aesthetic Plastic Surgery,Boston, May 1993.

95. Steinsapir KD, Shorr N, Hoenig J, Goldberg RA,Baylis HI, Morrow D. The endoscopic foreheadlift. Ophthal Plast Reconstr Surg 1998;14:107–118.

96. Aiache AE. Endoscopic facelift. Aesthetic PlastSurg 1994;18:275–278.

97. Daniel RK, Tirkanits B. Endoscopic forehead lift:An operative technique. Plast Reconstr Surg1996;98:1148–1157.

98. De Cordier BC, de la Torre JI, Al-Hakeem MS,Rosenberg LZ, Gardner PM, Costa-Ferreira A, FixRJ, Vasconez LO. Endoscopic forehead lift:Review of technique, cases, and complications.Plast Reconstr Surg 2002;110:1558–1568.

99. Guyuron B. Endoscopic forehead rejuvenation: I.Limitations, flaws, and rewards. Plast ReconstrSurg 2006;117:1121–1133.

100. Rowe DJ, Guyuron B. Optimizing results inendoscopic forehead rejuvenation. Clin Plast Surg2008;35:355–360.

101. Vasconez LO, Core GB, Gamboa-Bobadilla M,Guzman G, Askren C, Yamamoto Y. Endoscopictechniques in coronal brow lifting. Plast ReconstrSurg 1994;94:788–793.

102. Sozer O, Biggs TM. Our experience withendoscopic brow lifts. Aesthetic Plast Surg2000;24:90–96.

103. Hamas RS. Reducing the subconscious frown byendoscopic resection of the corrugator muscles.Aesthetic Plast Surg 1995;19:21–25.

104. Hamas RS, Rohrich RJ. Preventing hairlineelevation in endoscopic browlifts. Plast ReconstrSurg 1997;99:1018–1022.

105. Ramirez OM. Endoscopic techniques in facialrejuvenation: An overview. Part I. Aesthetic Plast

25


Surg 1994;18:141–147.106. Chajchir A. Endoscopic subperiosteal forehead

lift. Aesthetic Plast Surg 1994;18:269–274.107. Behmand RA, Guyuron B. Endoscopic forehead

rejuvenation: II. Long-term results. Plast ReconstrSurg 2006;117:1137–1143.

108. Graf RM, Tolazzi AR, Mansur AE, Teixeira V.Endoscopic periosteal brow lift: Evaluation andfollow-up of eyebrow height. Plast Reconstr Surg2008;121:609–616.

109. Kikkawa DO, Miller SR, Batra MK, Lee AC.Small incision nonendoscopic browlift. OphthalPlast Reconstr Surg 2000;16:28–33.

110. Knize DM. Limited-incision forehead lift foreyebrow elevation to enhance upperblepharoplasty. Plast Reconstr Surg1996;97:1334–1342.

111. Knize DM. Limited incision foreheadplasty. PlastReconstr Surg 1999;103:271–284.

112. Rohrich RJ. Discussion of “Limited incisionforeheadplasty” by D. M. Knize. Plast ReconstrSurg 1999;103:285.

113. Tabatabai N, Spinelli HM. Limited incisionnonendoscopic brow lift. Plast Reconstr Surg2007;119:1563–1570.

114. Marten TJ. Closed, nonendoscopic, small-incisionforehead lift. Clin Plast Surg 2008;35:363–378.

115. Rees TD, Wood-Smith D. Cosmetic Facial Surgery.Philadelphia: Saunders; 1973.

116. Guyuron B. Subcutaneous approach to forehead,brow, and modified temple incision. Clin PlastSurg 1992;19:461–476.

117. Wolfe SA, Baird WL. The subcutaneous foreheadlift. Plast Reconstr Surg 1989;83:251–256.

118. Wolfe SA. The subcutaneous forehead lift,revisited. Plast Reconstr Surg 2000;105:449–450.

119. Vogel JE, Hoopes JE. The subcutaneous foreheadlift with an anterior hairline incision. Ann PlastSurg 1992;28:257–265.

120. Miller TA, Rudkin G, Honig M, Elahi M, AdamsJ. Lateral subcutaneous brow lift and interbrowmuscle resection: Clinical experience andanatomic studies. Plast Reconstr Surg2000;105:1120–1127.

121. Rudolph R, Miller SH. Do forehead lifts lift orunfurl? Aesthetic Plast Surg 1992;16:1–9.

122. Ramirez OM. The anchor subperiosteal foreheadlift. Plast Reconstr Surg 1995;95:993–1003.

123. De La Plaza R, Valiente E, Arroyo JM.Supraperiosteal lifting of the upper two-thirds ofthe face. Br J Plast Surg 1991;44:325–332.

124. Troilius C. A comparison between subgaleal andsubperiosteal brow lifts. Plast Reconstr Surg1999;104:1079–1090.

125. Stuzin JM, Rohrich RJ. Discussion of “Acomparison between subgaleal and subperiostealbrow lifts” by C. Troilius. Plast Reconstr Surg1999;104:1091–1092.

126. McKinney P. Discussion of “The anchorsubperiosteal forehead lift” by O. M. Ramirez.Plast Reconstr Surg 1995;95:1004.

127. de la Paza R, de la Cruz L. Can some facialrejuvenation techniques cause iatrogenia?Aesthetic Plast Surg 1994;18:205–209.

128. Thomas JR, Lee AS, Patel AB. Brow-lift:Subgaleal vs subperiosteal flap adherence in therabbit model. Arch Facial Plast Surg2007;9:101–105.

129. Boutros S, Bernard RW, Galiano RD, Addona T,Stokes B, McCarthy JG. The temporal sequence ofperiosteal attachment after elevation. PlastReconstr Surg 2003;111:1942–1947.

130. Ortiz Monasterio F. Aesthetic surgery of the facialskeleton: The forehead. Clin Plast Surg1991;18:19–27.

131. Rohrich RJ, Beran SJ. Evolving fixation methodsin endoscopically assisted forehead rejuvenation:Controversies and rationale. Plast Reconstr Surg1997;100:1575–1582.

132. Eaves FF, Price CI, Bostwick J Nahai F, Jones G,Carlson GW, Culbertson J. Subcutaneousendoscopic plastic surgery using a retractor-mounted endoscopic system. Perspect Plast Surg1993;71–22.

133. Fiala TG, Owsley JQ. Use of the Mitek fixationdevice in endoscopic browlifting. Plast ReconstrSurg 1998;101:1700–1703.

134. Swift RW, Nolan WB, Aston SJ, Basner AL.Endoscopic brow-lift: Objective results after 1year. Aesthet Surg J 1999;19:287–292.

135. McKinney P, Sweis I. An accurate technique forfixation in endoscopic brow lift: A 5-year follow-

26


up. Plast Reconstr Surg 2001;108:1808–1810.136. Jones BM, Grover R. Endoscopic brow lift: A

personal review of 538 patients and comparisonof fixation techniques. Plast Reconstr Surg2004;113:1242–1250.

137. Kobienia BJ, Van Beek A. Calvarial fixationduring endoscopic brow lift. Plast Reconstr Surg1998;102:238–240.

138. Tuccillo F, Jacovella P, Zimman O, Repetti G. Analternative approach to brow lift fixation:Temporoparietalis fascia, galeal, and periostealimbrication. Plast Reconstr Surg 2007;119:692–702.

139. Foustanos A, Zavrides H. An alternative fixationtechnique for the endoscopic brow lift. Ann PlastSurg 2006;56:599–604.

140. Troilius C. Subperiosteal brow lifts withoutfixation. Plast Reconstr Surg 2004;114:1595–1603.

141. Eppley BL, Coleman JJ III, Sood R, Ha RY,Sadove AM. Resorbable screw fixation techniquefor endoscopic brow and midfacial lifts. PlastReconstr Surg 1998;102:241–243.

142. Morello DC. Fixation in endoscopic foreheadplasty. Aesthet Surg J 2001;21:181–184.

143. Berkowitz RL, Jacobs DI, Gorman PJ. Browfixation with the Endotine Forehead device inendoscopic brow lift. Plast Reconstr Surg2005;116:1761–1767.

144. Byrne PJ. Efficacy and safety of endotine fixationdevice in endoscopic brow-lift. Arch Facial PlastSurg 2007;9:212–214.

145. Chowdhury S, Malhotra R, Smith R, Arnstein P.Patient and surgeon experience with the endotineforehead device for brow and forehead lift.Ophthal Plast Reconstr Surg 2007;23:358–362.

146. Berkowitz RL, Apfelberg DB. Preliminaryevaluation of a fast-absorbing multipoint fixationdevice. Aesthet Surg J 2008;28:584–588.

147. Dayan SH, Perkins SW, Vartanian AJ, WiesmanIM. The forehead lift: Endoscopic versus coronalapproaches. Aesthetic Plast Surg 2001;25:35–39.

148. Walden JL, Brown CC, Klapper AJ, Chia CT,Aston SJ. An anatomical comparison oftranspalpebral, endoscopic, and coronalapproaches to demonstrate exposure and extentof brow depressor muscle resection. PlastReconstr Surg 2005;116:1479–1487.

149. Guyuron B. Discussion of “An anatomicalcomparison of transpalpebral, endoscopic, andcoronal approaches to demonstrate exposure andextent of brow depressor muscle resection,” by J.L. Walden et al. Plast Reconstr Surg 2005;116:1488.

150. Chiu ES, Baker DC. Endoscopic brow lift: Aretrospective review of 628 consecutive casesover 5 years. Plast Reconstr Surg 2003;112:628–633.

151. Hunt JA, Byrd HS. The deep temporal lift: Amultiplanar lateral brow, temporal, and upperface lift. Plast Reconstr Surg 2002;110:1793–1796.

152. Hobar PC, Flood J. Subperiosteal rejuvenation ofthe midface and periorbital area: A simplifiedapproach. Plast Reconstr Surg 1999;104:842–851.

153. Marotta JC, Quatela VC. Lower eyelid aestheticsafter endoscopic forehead midface-lift. Arch FacialPlast Surg 2008;10:267–272.

154. Ousterhout DK. Feminization of the forehead:Contour changing to improve female aesthetics.Plast Reconstr Surg 1987;79:701–713.

155. Lassus C. Ostectomy of superior orbital rim incosmetic blepharoplasty. Plast Reconstr Surg1979;63:481–484.

156. Whitaker LA, Morales L Jr, Farkas LG. Aestheticsurgery of the supraorbital ridge and foreheadstructures. Plast Reconstr Surg 1986;78:23–32.

157. Marino H. The forehead lift: Some hints to securebetter results. Aesthetic Plast Surg 1977;1:251.

158. Le Roux P, Jones SH. Total permanent removal ofwrinkles from the forehead. Br J Plast Surg1974;27:359–362.

159. Carruthers JD, Glogau RG, Blitzer A, FacialAesthetics Consensus Group Faculty. Advancesin facial rejuvenation: Botulinum toxin type A,hyaluronic acid dermal fillers, and combinationtherapies: Consensus recommendations. PlastReconstr Surg 2008;121[suppl 5]:5S–30S.

160. Bames HO. Frown disfigurement and ptosis ofeyebrows. Plast Reconstr Surg (1946)1957;19:337–340.

161. Keller GS, Razum NJ, Elliott S, Parks J. Smallincision laser lift for forehead creases andglabellar furrows. Arch Otolaryngol Head NeckSurg 1993;119:632–635.

162. Ramirez OM. Endoscopically assisted biplanarforehead lift. Plast Reconstr Surg 1995;96:323–333.

27


163. Guyuron B, Rose K. Harvesting fat from theinfratemporal fossa. Plast Reconstr Surg2004;114:245–249.

164. Keen M, Blitzer A, Aviv J, Binder W, PrystowskyJ, Smith H, Brin M. Botulinum toxin A forhyperkinetic facial lines: Results of a double-blind, placebo-controlled study. Plast ReconstrSurg 1994;94:94–99.

165. Frankel AS, Kamer FM. Chemical browlift. ArchOtolaryngol Head Neck Surg 1998;124:321–323.

166. Ahn MS, Catten M, Maas CS. Temporal brow liftusing botulinum toxin A. Plast Reconstr Surg2000;105:1129–1135.

167. Huang W, Rogachefsky AS, Foster JA. Browliftwith botulinum toxin. Dermatol Surg2000;26:55–60.

168. Stotland MA, Kowalski JW, Jay BB. Patient-reported benefit and satisfaction with botulinumtoxin type A treatment of moderate to severeglabellar rhytides: Results from a prospectiveopen-label study. Plast Reconstr Surg2007;120:1386–1393.

169. Fagien S, Carruthers JD. A comprehensive review

of patient-reported satisfaction with botulinumtoxin type A for aesthetic procedures. PlastReconstr Surg 2008;122:1915–1925.

170. Lee CJ, Kim SG, Han JY. The results of periorbitalrejuvenation with botulinum toxin A using twodifferent protocols. Aesthetic Plast Surg2006;30:65–70.

171. Carruthers A, Carruthers J. Eyebrow height afterbotulinum toxin type A to the glabella. DermatolSurg 2007;33[suppl 1]:S26–S31.

172. Guyuron B. Discussion of “Temporal brow liftusing botulinum toxin A,” by M. S. Ahn et al.Plast Reconstr Surg 2000;105:1139.

173. Maas CS, Kim EJ. Temporal brow lift usingbotulinum toxin A: An update. Plast ReconstrSurg 2003;112[suppl 5]:109S–112S.

174. Kane M. Live filler demonstration. Presented atAdvances in Aesthetic Plastic Surgery: TheCutting Edge VII, New York, November 2008.

175. Ciuci PM, Obagi S. Rejuvenation of theperiorbital complex with autologous fat transfer:Current therapy. J Oral Maxillofac Surg2008;66:1686–1693.

RECOMMENDED READING

Ahn MS, Catten M, Maas CS. Temporal brow lift usingbotulinum toxin A. Plast Reconstr Surg2000;105:1129–1135.

Barton FE. Facial Rejuvenation. St. Louis: QualityMedical Publishing, Inc.; 2008.

Castanares S. Forehead wrinkles, glabellar frown, andptosis of the eyebrows. Plast Reconstr Surg 1964;34:406.

Elkwood A, Matarasso A, Rankin M, Elkowitz M,Godek CP. National plastic surgery survey: Browlifting techniques and complications. Plast ReconstrSurg 2001;108:2143–2150.

Ellenbogen R. Transcoronal eyebrow lift withconcomitant upper blepharoplasty. Plast Reconstr Surg1983;71:490–499.

Gunter JP, Antrobus SD. Aesthetic analysis of the

eyebrows. Plast Reconstr Surg 1997;99:1808–1816.

Guyuron B. Endoscopic forehead rejuvenation: I.Limitations, flaws, and rewards. Plast Reconstr Surg2006;117:1121–1133.

Guyuron B, Michelow BJ, Thomas T. Corrugatorsupercilii muscle resection through blepharoplastyincision. Plast Reconstr Surg 1995;95:691–696.

Isse NG. Endoscopic facial rejuvenation:Endoforehead, the functional lift: Case reports.Aesthetic Plast Surg 1994;18:21–29.

Kaye BL. The forehead lift: A useful adjunct to face liftand blepharoplasty. Plast Reconstr Surg1977;60:161–171.

Knize DM. An anatomically based study of themechanism of eyebrow ptosis. Plast Reconstr Surg1996;97:1321–1333.

28


Knize DM. Muscles that act on glabellar skin: A closerlook. Plast Reconstr Surg 2000;105:350–361.

Matarasso A, Hutchinson OH. Evaluating rejuvenationof the forehead and brow: An algorithm for selectingthe appropriate technique. Plast Reconstr Surg2000;106:687–694.

Moss CJ, Mendelson BC, Taylor GI. Surgical anatomyof the ligamentous attachments in the temple andperiorbital regions. Plast Reconstr Surg2000;105:1475–1490.

Muzaffar AR, Mendelson BC, Adams WP Jr. Surgicalanatomy of the ligamentous attachments of the lowerlid and lateral canthus. Plast Reconstr Surg2002;110:873–884.

Nahai F. The Art of Aesthetic Surgery: Principles andTechniques. St. Louis: Quality Medical Publishing, Inc.;2005.

Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA.Anatomy of the frontal branch of the facial nerve: Thesignificance of the temporal fat pad. Plast Reconstr Surg1989;83:265–271.

Vinas JC, Caviglia C, Cortinas JL. Foreheadrhytidoplasty and brow lifting. Plast Reconstr Surg1976;57:445–454.

Zide BM, Jelks GW. Surgical Anatomy of the Orbit. NewYork: Raven Press; 1985.

Aesthetic Surgery Journal

Offi cial Journal of the American Society for Aesthetic Plastic Surgery

Aesthetic Surgery Journal is a peer-reviewed international journal focusing on scientifi c developments and clinical techniques in aesthetic surgery that recently became indexed in Medline/Pubmed. An offi cial publication of the 2400-member American Society for Aesthetic Plastic Surgery (ASAPS), ASJ is also the offi cial English-language journal of eleven major international societies of plastic, aesthetic and reconstructive surgery representing South America, Central America, Europe, Asia, and the Middle East, as well as the offi cial journal of The Rhinoplasty Society.

Visit www.aestheticsurgeryjournal.com for more information or to submit a manuscript.

Two Easy Ways to Order:

Phone: +1 800 654 2452 (US & Canada)

+1 314 453 7041 (Other Countries)

Web: www.us.elsevierhealth.com

We thank theAesthetic Surgery Journal

andPlastic and Reconstructive Surgery

for their support.

Whether you’re performing a routinecosmetic procedure or a difficultburn repair, having the right tool forunexpected complications is critical.

The intuitive, all-new, next-generation electronic journalsplatform from LippincottWilliams &Wilkins comes loadedwith personalized options for its journal subscribers, includingcustomizable state-of-the-art capabilities, self-serviceoptions tailored to your information preferences, rich mediacontent, improved search options, better article readabilityin HTML and better tools to help you manage content that’svital to your practice and patient care.

Register online at prsjournal.comNot a subscriber? Visit prsjournal.com to subscribe andfind out more

This is your website.The new Plastic and ReconstructiveSurgery Online

This is your life.

Documents

BROW LIFT - Universiti Sains Malaysiapustaka.kk.usm.my/pustaka2/inhouse/e-journal/SRPS/11-C1...2 SRPS Volume 11, Issue 1C, 2009 the topic of brow lift. One hundred forty-two (54%)