The orbicular muscle has a concentric disposition over the orbit and circumferential vectors; it is wide, flat, inserted in the nasal portion of the frontal bone and in the frontal process of the jawbone, previous to the middle canthal ligament. It presents two portions: the orbital and palpebral. The palpebral portion has two fibrous insertions in the eyelid; the orbital portion has bony insertions. Its function is to approximate the loosened edge of the eyelid and provoke the occlusion of the palpebral cleavage. Its joint action produces descent of the eyebrow position. It is innervated by the ramification of facial nerve [19, 21, 22, 25, 28] (Fig. 43.2).

The areolar lax tissue is the continuation of the subgaleal tissue. The supraorbital insertion of the orbicular muscle is a strong ligament, formed, as well, by lateral and middle orbital ligaments [19, 20, 29].

The supraorbital and supratrochlear nerves give the sensitive innervations of the skin and the innervation’s mechanism comes from the facial nerve [22, 24–27].

The Sentinel vein is an important repair point in the endoscopic surgery; to avoid injuring it, it must be identified. It is located at the superior and lateral tail of the eyebrow and in some cases can be duplicated; it is a structure of transition that perforates the band and it is deepened in company of the frontal facial nerve, toward the lateral superior zone [30] (Fig. 43.3).

The frontal skin is the continuity of the scalp. It presents five well-defined layers: skin, subcutaneous

Fig. 43.4 The layers in the dissection of the frontal region are observed. Skin (S), subcutaneous cell tissue (SC), muscle (M), periosteum (PE), frontal bone (FB)

cell tissue, galea aponeurotic, areolar lax tissue, and periosteum. The skin is thin, rich in sebaceous glands, and sudoriparous; it is anchored in a homogeneous layer of compact adipose tissue and dense fibrous tissue separate it from the muscles label, which generates major quantity of lines of expression. The muscular aponeurosis is the continuation, in double layer of the facial SMAS, [12] keeping the different forehead muscle and the periocular area that possess two types of action: passive by traction and active by contraction. By its passive action it maintains the muscular anchorage and the others structures, while, in contraction puts close together the insertion ends [28, 31] (Fig. 43.4).

Fig. 43.3 Sentinel vein (SV) and frontal branch of the facial nerve (FN). The shaded area shows the orbital rim (Photo courtesy Dr. Jaime Ramirez)

43.4The Eyebrow and Forehead as an Aesthetic Unit

In the surgery of the facial third superior; the forehead, eyebrow, and eyelid must be dynamically analyzed. The patients consult by the apparent excess of palpebral skin, without noticing that in occasions the drop of the eyebrow is one that generates an over dimensioning of redundancy of the eyelid’s skin. In the last one is located one of the main keys to establish in the ptotic forehead, when it really corresponds to the drop of the eyebrow, below the orbital bony ledge, whether it is due to looseness or excess in the

Fig. 43.5 Simulation of the final desired position of the eyebrow and marking in the superior eyelid for the resection of the redundant skin (Photo courtesy Dr. Jaime Ramirez)

skin of the eyelid. Bellow regarding, before carrying out a cosmetic blepharoplasty, to make the simulation of the ideal position of the eyebrow, having the patients sitting down or standing up, move the eyebrow with the finger to the new wanted position and visualize the amount of the skin of the eyelid that still looks redundant preventing the definition of superior palpebral furrow. This is done at this moment and not before (Fig. 43.5). It is expected that the doctor realize this presurgical maneuver of measurement and demarcation commenting to the patient his findings. Then the patient will agree with greater facility to the approval of the integral treatment of the suspension forehead lifting with blepharoplasty.

It is also important to do a previous analysis of the factors that influence the eyebrows and forehead aesthetic unit, which must be postsurgically controlled to extend the obtained results, which are: intrinsic factors such as lost elasticity of the tissue and the marked activity of the depressor muscle and the extrinsic factors such as the gravity, the photo exposure, and the tobacco addiction.

Fig. 43.6 The ideal position of the eyebrow in women is observed (Photo courtesy Dr. Jaime Ramirez)

43.5 Position of the Eyebrows

The beauty concept must consider the cultural differences and also manage a parameter for each one of the sexes. Aesthetically, the ideal position of the eyebrow in women is defined as a smooth arch, located above the orbital rim, with its higher point coinciding with an imaginary line traced between the lateral limbo and the lateral canthus. The eyebrow descends to the point where the imaginary line ends, drawn up between the facial alar furrow and the lateral canthus [32] (Fig. 43.6).

In men, the eyebrow takes a horizontal line shape to level the orbital rim. With this reference it is understood that the major efforts put in the repositioning of the feminine eyebrow must be directed toward the elevation of the lateral portion; in men the final elevation of the eyebrow must leave the middle portion and the lateral one approximately to the same height preventing in the patient feminine features.

43.6 General Indications

Traditionally, the main indications for forehead-lift include:

1.To elevate the ptotic eyebrows

2.To correct asymmetry of the eyebrows

3.To reduce

(a)The palpebral redundant skin

(b)The frontal furrows

(c)The glabella furrows

(d)The lines of the lateral canthus expression

4.To elevate the aesthetic unit of the forehead

5.To modify, when desired, the implantation line of the hair

6.To diminish the extension of the frontal skin, when it tends to be redundant

These indications can be presented singly or in conjunction, doing necessary to consider in each case, the best way of possible approach. Intervening a young patient with an asymmetry of the eyebrow without any mark of the glabellar furrows, and a male patient, an adult with scarce hair and frontal marked furrows is not the same.

In literature, the technique and approach terms are frequently distorted, which generates confusion. For the authors, the approach is used to indicate the place where the incision is realized and the used plane for the dissection, whereas the technique refers to the intervention of the repair points and the suspension mechanism that is used for the correction of the eyebrow ptosis and the reduction of the frontal furrows.

43.7.2 Depth of the Skin Furrows

In patients, especially old men with tendency to baldness and with pronounced frontal furrow, the incisions can be camouflaged in the furrow, allowing a direct approach of the frontal region to suspend.

43.7.3 Asymmetries

The direct approach allows a more precise correction of the asymmetric position of the eyebrow. It would not be an option in patients that do not require a treatment in other areas of forehead and accept a possible visible scar.

43.7.4 Frontal Redundant Skin

This implies the necessity of exeresis for which the open approach of pretrichal type or trichial allows edge to edge suspension.

The technique must be individualized for each patient. Sex, age, physical features, and expectation should be considered. In order to define the way to approach and the technique of frontal suspension the following must be analyzed: degree of ptosis, depth level of the furrows of the skin, eyebrows asymmetry, amount of redundant skin, and the implantation pattern of hair.

43.7.1 Frontal Ptosis Degree

The higher the ptosis degree, the more aggressive the suspension techniques must be, whether this is done through opened or closed approach.

This can also condition the selection of the approach for the eyebrow and forehead suspension. Once the objectives of the procedure are defined, which can be directed to attenuate the strong expression of the glabella muscle spasms or revert and to correct the asymmetry of the eyebrow position, the approach must be selected considering the line of the hair implantation that can commonly be influenced in men by genetic factors like the alopecia. On the other hand, the line of high implantation in women causes that the approach selected do not elevate the hairline even more and can even facilitate the manipulation to diminish the length of the frontal skin, standing out in this situation the pretrichial–trichial approach (Fig. 43.7).

Fig. 43.7 The implantation lines of the hair and the corresponding approach options are observed

a

Hair Approachment implantation

Normal or low

Coronal /endoscopic

b

Hair Approachment implantation

Raised (elevated

Pre-triquial

forehead)

c

Hair Approachment implantation

Opening,

severally

Direct

retracted and

mediofrontal/

/or baldness

Ciliary