Fig. 42.3 (a) Patient developed a soft swelling a few days after modified face-lift. This was drained with a suction catheter. The wound drained 120 ml clear fluid daily. (b) Following removal of the vacuum reservoir there was no drainage after 1 min.

(c) Following biting of a wedge of lime, there was drainage starting at the end of the catheter within 5 s. The diagnosis of salivary fistula was confirmed

References

1.Niamtu III J. Expanding hematoma in face-lift surgery: literature review, case presentations, and caveats. Dermatol Surg. 2005;31(9 Part 1):1134–44.

2.LeRoy JL, Rees TD, Nolan III WB. Infections requiring hospital readmission following face lift surgery: incidence,

treatment, and sequelae. Plast Reconstr Surg. 1994;93(3): 533–6.

3.Rees TD, Liverett MD, Guy CL. The effect of cigarette smoking on skin-flap survival in face lift patient. Plast Reconstr Surg. 1984;73(6):911–5.

43.1 Introduction

The procedures of forehead lifting are those that tend to change the apparent descent or the other effects of the soft tissue aging located over the skeletal supraorbital ring, fixing the eyebrow descent and the appearance of wrinkles or furrows and in some cases removing the leftover frontal skin. When speaking of techniques of forehead lifting it is necessary to talk about the diverse ways to deal with the rejuvenation of a specific face area, as it is the superior third. Sometimes the completed procedure, even if is open or with minimum system invasion, does not obtain the expected results, which has generated multiple variations of the surgical approach applied and the suspension techniques.

There is a necessity to treat the superior face segment where the aging process is marked. As a consequence it brings the surgical approach and techniques applied for its adjustment that have been improved trying to diminish the poor result and the appearance of the undesired effects like alopecia, scars, or parasthesia [1, 2].

J. Ramirez ( )

Calle 105 A No. 14-92 Consultorio 107, Bogotá, Colombia e-mail: info@jaimeramirez.com

Y.S. Amado

Hospital Central de la Policia Ncional, Cra 11 90-07 cs 208, Bogotá, Colombia e-mail: steveamadog@hotmail.com

A.C. Navarro

Universidad Nacional de Colombia,

Cll 131 A No 55A – 26 Apto 504, Bogotá, Colombia e-mail: acnavarrona@unal.edu.co

The object of this chapter is to expose how and when to use a procedure and the advantages and disadvantages of each of the different approaches and techniques used for forehead lifting and also to discuss these based on the experience of the senior author who uses them according to the indications required for each particular case. The selection of the ideal surgical techniques for the patient, that is occasionally a reason of controversy, must be the result of the joint search between the doctor in charge and his patients.

It is understood that the endoscopic forehead lifting is nowadays the most used technique because of its versatility and benefits and this is widely recognized by the majority of authors in facial rejuvenation [3, 4].

The ideal approach for the forehead-lift must allow an efficient loosening and elimination of the adhesions that prevent the free displacement upward of the inelastic structures of the forehead and obtaining reversion of the frontal orbital ptosis generated by aging. This situation is more relevant when the forehead-lift takes part, along with blepharoplasty, as an integral treatment for the facial superior third.

In this chapter the coronal approach is excluded, in spite of being for several years the standard method for superior face rejuvenation. At the moment it has been in disuse for being an invasive technique that requires an ample and notorious incision generating problems of sensitivity and healing as well as greater morbidity.

43.2 Historical Review

The first literary mention referring to the elevation of the facial third superior was by Passot [5], who used elliptic excision in the forehead skin. Hunt in 1926 [6] described

his technique using incisions by the edge of the hairline in the implantation and in the forehead skin, this being the beginning of the pretrichial approach. In 1930, Passot [7] suggested using a direct incision by the superior edge of the eyebrow end and removing the superfluous skin, which constitutes the first description of the direct eyebrow-lift, as it is actually known. Fomon, in 1939 [8], was the first to indicate that anatomically, the frontal skin continue with the epicranium, and the importance of the muscular fascia implantation, which is important to understand the necessity to dry out the superfluous skin and the possibility to realize a frontal anchorage from the epicranium [9].

Motivated by the short duration of the results of the first forehead lifting the necessity to include the management of the frontal muscle was described; initially with chemical denervation using alcohol, no satisfactory results were obtained, which generate the necessity to evolve in the handling of the corresponding muscles of the frontal region. In 1962, Gonzalez Ulloa [10] described the utility of the frontal myotomies and in 1964 Marino and Gandolfo [11] reported on myotomies of the corrugators, which are still being used [12]. Vinas was the first to enumerate the repair points in the forehead-lift and in order to obtain elevation of the end of the eyebrow it is necessary to perform lateral traction that are elements still in force [1]. The repair points described by Vinas are the inelastic aponeurotic layer on the frontal muscle, which has importance in the vertical traction, necessary for the correction of eyebrow ptosis and the ledge of the orbital bony with its adhesions to the soft tissue that must be dried out to allow mobilization of the glabellar area. In addition Vinas was the first to classify wrinkles into two types: Transitory and persistent according to its relation with the movements of the facial expression [13]. These findings were integrated by Kaye in 1977 [14] who used a coronal approach for the frontal repairs and complementary rhytidectomy.

During the following decades few modifications to the repair points were made until the 1990s when revolutionary change was made to the approach of forehead lifting; Vasconez and Isse [15, 16] presented initial experiences using endoscopy in the correction of the eyebrow ptosis as did Chajchir [17, 18]. Chajchir postulated the bases for the use of surgical endoscopy in the accomplishment of forehead lifting, emphasizing that it is a functional dynamic process.

43.3 Anatomic Guidelines

In order to estimate the anatomy of the facial third superior, it is necessary to specify the anatomic limits of forehead: the superior edge is defined by the hairline implantation, the inferior edge in its medial portion by the frontonasal or glabella suture and laterally to the superior orbital margin. The bony structures are constituted by the frontal bone and its joints with the nasal bones and with the frontal process of the jawbone; laterally, with the frontal zygomatic bone union, and in the temporal cavity with the main wing of the sphenoid [19]. Hairline implantation can be influenced by several factors in its conformation such as age, sex, individual, familial or cultural characteristics, and conditioning of the handling of scars and attenuation of the same [19–22]. The eyebrow thickness, as well, can present similar individual variations too, and in addition to external alteration like shaved and the tattoo, the position and the contour of the same are important in the facial expression and aesthetic, defining gender characteristics, as well as, in men are thicker and more straight than women which are thinner and curved, given the lower implantation through the orbital rim, in man higher than women [22, 23].

The superior orbital margin is a palpable bony prominence or visible in individuals, especially in Latin people; besides, it can be even more notorious creating a fall in the skin over the eyebrow [22–24]. The lateral limit of the forehead corresponds to another bony repair point which is the temporal line that is easily palpable with the mastication movements. It is an important point to locate the temporal artery. To the lateral one, the frontomalar suture is found, located 10 mm from the external canthus. The frontal nerve is usually found at 5 mm previous to the tragus up to 15 mm to the end of the eyebrow, over the zygomatic arc, leading to the external canthal and area of 2.5 cm2 approximately as a secure area [24–26]. The supraorbital hole described, habitually in literature, in the superior edge of the ciliary arc corresponds properly to 49% foramen, 26% foramina, and present in just one side in 25% of the patients [27]; anatomical dissections realized by the senior author have shown that in some patients a proper orifice does not exist and the supraorbital nerve traverses a channel to the level of the orbital ceiling, to ascend by the frontal region after passing through a notch (Fig. 43.1).

Fig. 43.1 Corpse dissection with the supraorbital package (SOP) in relation to the notch (N), and the right supratrochlear nerve (SN). The frontal soft tissues have been rejected forward and downward (Photo courtesy Dr. Jaime Ramirez)

Anatomically, the frontal muscle has two ways of consideration: the first one, as an individual previous muscular unit and the second one, as a continuation of the digastric muscle that starts from an initial posterior belly, the occipital muscle. This is the primary elevator of the eyebrow; it has multiple insertions, the vertical fibers end up anchoring at the depressor muscle and the longitudinal ones have fibrous digitations along their run to a skin level giving as a result, the vector of contraction of the same going upward and vertically, producing the ascent of all the structures of the forehead and the formation of transverse lines on the skin to the contraction, as a consequence of their fibrous anchorages. This muscle is innervated by the frontal branch of the face [19, 21, 22, 28] (Fig. 43.2).

The corrugator muscle, measuring 2.5 cm/1 cm is thin, with fibers oriented in an oblique direction; it is located in the lateral region glabella, over the nasofrontal suture. Two types of fibers are inserted in the medial portion of the superciliary arc: The short fibers are directed upward up to the deep layer of the skin where the eyebrow begins, to be inserted. The long fibers, in oblique direction are inserted in the middle part and the end of the eyebrow, throughout the frontal muscle and the orbicular muscle. It is a forehead depressor; the simultaneous contraction of both types of fibers produce elevation of the beginning and the middle part of the eyebrow, acting in conjunction with the frontal muscle at the same time; with the orbicular of the eyelids, it produces a depression at the end of the eyebrow, which produces horizontal lines in the glabellar area. With the superciliary depressor it produces vertical lines in the skin. Its innervations take place

through the temporal ramification of the facial nerve [19, 21, 22, 24, 28] (Fig. 43.2).

The procerus or pyramidal muscles have their origin in the nasal back; they are two vertical muscular beams, which are inserted in the frontal muscle, from glabella to the lower middle part of the forehead. They are frontal depressors, and create interciliary horizontal lines due to their contraction of the inferior skin of the forehead descend. [19–22, 26, 28] (Fig. 43.2).

The superciliary depressor muscle is the most superficial one of the glabellar area; for some authors, it makes part of the orbicular muscle. It is located in the middle arc of the eyebrow and it is inserted in the nasal in the frontal bone, extending itself to get mixed with the procerus and frontal muscles. Its action elevates the beginning of the eyebrow and descends the middle portion and the skin of it and generates the vertical furrows of the beginning of the region and the middle portion of the eyebrow [22, 26, 28]. It is innervated by the ramification of the facial nerve (Fig. 43.2).

Fig. 43.2 The existing relation in the muscles of the frontal region is observed. Frontal muscle (FM), corrugator muscle (CM), procerus muscle (PM), orbicular muscle (OM) and its intimate relation with the superciliary depressing muscle (DM)