An approach can be chosen, according to Lazor and Cheney [33], considering the implantation line of the hair as it is observed in Fig. 43.7.

43.8What Fixing Approaches and Techniques Do We Use?

(a)Coronal

(b)Pretrichial/Trichial

(c)Medio-Frontal

(d)Direct Eyebrow Lift

(e)Endoscopic

A template designed by the surgeon to demarcate the incision form is used and in the cases where resection of skin is required, in the new edge the same template is used to make the ends coincide when joining (Fig. 43.9). Laterally, the incision can continue in linear shape to 1 cm. behind the hairline, this zone corresponding to the superior part on the temporal region (Fig. 43.10).

The dissection plane in the previous region is subgaleal that allows the loosening of the muscular cutaneous plane above the supraorbital rim, facilitating the exposure of the corrugator muscle and the superior portion of the procerus muscle, as well as the neurovascular supraorbital packages of each side, that must

43.8.1 Coronal

Nowadays a facial approach is rarely used. Dissection plan: Subgaleal

Advantages: An excellent exposure and direct access to the frontal myotomy.

Disadvantages: It is an invasive surgical approach; there is a risk of hematoma, elevation of the implantation line of the hair and alopecic scar. This can produce vertical enlargement of the forehead. It is not used for the scar and has limited uses in men.

43.8.2 Pretrichial/Trichial

Preparation: The definition of the incision is realized, immediately in front of the hairline, in a zigzag shape reaching to exceed each end of the scalp (Fig. 43.8).

Fig. 43.9 Pretriquial–triquial approach. The template for the demarcation of incision is observed. In case incision of the skin is required, the template is used again in the new incision to allow the edges to coincide (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.8 Demarcation of the incision for the pretrichial–trichial approach (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.10 Incision in a zigzag shape, reaching up to exceed in each end of the scalp for the Pretriquial–triquial approach (Photo courtesy Dr. Jaime Ramirez)

be respected (Fig. 43.11). Laterally the dissection is performed in the interfascial plane. In this procedure, fragments of the corrugator (Fig. 43.12) and procerus (Fig. 43.13) muscles and rectangular segments of the superior portion of the orbicular muscle of each side are sectioned and dried out. In addition, when needed, the skin is dried out. The suspension technique uses Ethibond 3–0 to suspend, in the previous region, from galea to galea and in the lateral portion, from superficial fascia to deep fascia (Fig. 43.14).

The advantages are: Excellent visualization of the operating field. It does not change the implantation line of the hair. It allows realizing exeresis of the skin, reducing the length of the forehead and the lax tissue or leftover. By diminishing the depth of furrows when tightening the skin, the scar can be camouflaged (Fig. 43.15).

Fig. 43.11 Plane of subgaleal dissection in the pretrichial approach. The Galena is marked with a G (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.13 Transverse cut of the procerus muscle (MP) with electric scalpel (EB) (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.14 Suspension technique. Anchorage point of the superficial to the deep fascia is observed. The arrow indicates the needle of the suture used for the anchorage (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.12 Image of the right corrugator muscle (CM) and supraorbital package (SOP) (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.15 Closing of the incision, without closing the implantation line of the hair and allowing camouflage of the scar (Photo courtesy Dr. Jaime Ramirez)

Disadvantages: It can generate temporal hypoesthesia of the scar and the frontal skin.

The scar can be occasionally visible. The surgical time is greater.

Ideal for patients with higher hairline, although with restriction in men.

43.8.3 “Half Frontal”

Preparation: the frontal furrows to be intervened must be selected on each side of the forehead, through which the approach will be realized. Later on, it is demarcated and an incision is made in the ellipse in the lateral or middle base according to the case, which increases the inferior flap when the surgical wound is sutured (Fig. 43.16). The incision point can be chosen: throughout the furrow line, centrally, throughout the forehead, or two fusiform excisions to each side (Fig. 43.17).

The initial dissection plane is subcutaneous, to preserve the sensorial innervation; once it is taken to the supraorbital level it affects the galea and the subgaleal plane is introduced (Fig. 43.18) that allows to the superciliary corrugator (Fig. 43.19) and procerus muscles (Fig. 43.20), which can be partially dried out.

The Suspension Techniques: anchorage is realized from the superior portion of the orbicular muscle to the superolateral frontal periosteum with Ethibond 3–0.

Fig. 43.16 Marking of the incisions in ellipse for the middle frontal approach and the orientation lines of orbicular muscle suspension are observed (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.17 Patient with middle frontal approach. The incisions of the skin in an ellipse and the subcutaneous plane are observed (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.18 Dissection and direct access to the supraorbital musculature in a half frontal approach (Photo courtesy Dr. Jaime Ramirez)

Each side, depending on the necessity to suspend different portions of the eyebrow, needs two or three sutures. One of the key factors in the final results of the scars camouflage is the meticulous closing by planes of the incisions (Figs. 43.21 and 43.22).

Advantages: It is possible to preserve the sensorial innervation.

Good camouflage of the scar in the deep furrows. A more precise reposition of the eyebrow.

Direct division of the corrugator muscle and the procerus muscle.

Disadvantage: Resultant scar line. It is ideal in male patients, adults with deep horizontal furrows with frontal baldness, with glabellar furrows, and ptosis of the eyebrows.

Fig. 43.19 Access to the corrugator muscle (CM), through the half frontal incision. Eyebrow (E), Adson Brown (AB), Bipolar (BP) (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.20 Access to the procerus muscle (PM), through the half frontal incision (Photo courtesy Dr. Jaime Ramirez)

43.8.4 Direct Eyebrow Lift

Its name makes reference to the simple way that allows fixing the position of the eyebrow, without including another forehead region.

Preparation: With the patient seated or standing up a marking of the incision is made, preferably more over the lateral region of the eyebrow (Fig. 43.23). The incision of the skin is made in the superior edge of the eyebrow, following the same direction of the hair, to prevent any injury of the follicles. Once the position of the eyebrow is set, the superior line of the ellipse, which is the one that defines the amount of the skin to dry out, the marking of the incision is made (Fig. 43.5).

In some cases when the planned incision is extended to the middle extreme of the eyebrow, there can be limited access to the glabellar musculature. The dissection plane is subcutaneous and is realized downward with scissors up to the frontal muscle. The technique allows to select molding of the eyebrow for modifications of the middle, central, or lateral components of the excision [34].

The Suspension Technique: Although the cutaneous excision can elevate the inferior flap, making the suspension dispensable, this one can be placed from orbicular muscle to the periosteum immediately above the eyebrow (Fig. 43.24). The option to anchor the orbicular to the lateral periosteum of the eyebrow can put in risk the frontal branch of the facial nerve (Figs. 43.25 and

Fig. 43.21 (a) Preoperative. (b) Two years postoperative following the forehead lifting half-frontal approach and blepharoplasty (Photo courtesy Dr. Jaime Ramirez)

Fig. 43.22 (a) Preoperative. (b) One year postoperative following the forehead lifting half-frontal approach and blepharoplasty (Photo courtesy Dr. Jaime Ramirez)

43.26). In the case of a preexisting scar, associated to asymmetry of the eyebrow the place of the scar for the approach can be used (Figs. 43.27 and 43.28).

Advantages: Excellent approach for the treatment of asymmetric ptotic eyebrow.

Less invasive surgical dissection.

Low cost, security, effectiveness, and simplicity [35]. Quick recovery.

Disadvantages: Scar sometimes visible. Limited access to the glabellar musculature. Not recommended in young patients.

Ideal in adult patients with thick eyebrows, average ptosis, and/or unilateral ptosis.

Fig. 43.23 Marking of the incisions in the lateral edge of the eyebrows for the direct approach of the eyebrow lifting (Photo courtesy Dr. Jaime Ramirez)