Complications are rare when a forehead lift is performed by a surgeon trained in the technique. However, it is possible for the surgical process to damage the nerves that control eyebrow and forehead movements. Hair loss can also occur along the scar edges in the scalp when an incision is made through the hairline. Moreover, infection and bleeding are possible with any surgical procedure.

Patients who have Endotine implants in their foreheads risk moving their newly adjusted tissues with relatively small movements just after the operation and before complete healing takes place. While the implant absorbs into the body, the Endotine generally does not support the very thick forehead skin and heavy brows often seen in some overweight males [6, 7].

47.4Variations of Forehead and Brow Lift

If the patient requires upper eyelid blepharoplasty and eyebrow and forehead lift, this can be done simply through a combination of the transeyelid and scalp incisions above the hairline (Fig. 47.5). An endoscope and fixation may not always be required.

47.5Transpalpebral Corrugator Resection

This operation is done while the patient is under intravenous sedation. The area is infiltrated with lignocaine and adrenaline (1/100,000 concentration). The operation is done through the same upper blepharoplasty incision, with dissection to reach the orbital rim (Fig. 47.6) [8, 9].

47.6 Coronal Incision

This operation was the most commonly performed procedure some years ago; however, due to the advent of endoscopic forehead rejuvenation this procedure is less frequently seen now. The author recommends that every plastic or cosmetic surgeon should see this procedure performed to a patient, or to a cadaver, as it is extremely useful in demonstrating the anatomy of

a

b

the forehead. This procedure is done while the patient is under intravenous sedation; the incision is marked approximately 5 cm behind the hair line extending from one temple to the other, a few centimeters above the ear. Generally it is not necessary to shave the hair; however, techniques like braiding, elastic bands, and hair gel should be used. The area is infiltrated in its entirety with a modified tumescent solution, using lidocaine hydrochloride, 2%, and epinephrine, one in one thousand, as a local anesthetic. The incision is taken down to the subgaleal plane and laterally becomes superficial to the deep temporal fascia to avoid injury to the superficial branch of the facial nerve. The dissection is continued anteriorly and extended supraperiosteally to the superorbital rim. The arcus marginalis and the fibrous bands are released to allow the brow to be elevated. The supraorbital and supratrochlear nerves are carefully dissected and preserved. The corrugator muscle and the procerus are released and resected as extensively as possible to eliminate the frown lines. Fat grafting can be considered to fill the defect caused by surgery. Drains may minimize the postoperative bruising and swelling; however, the author does not tend to use them and results have been excellent. The incision is closed in two layers and normally surgical clips are used after surgery. Antibiotic ointment is placed on the incision. The patient will be allowed to wash their hair 3–4 days after the operation. Slight bruising is expected that can take up to 2–3 weeks to clear and normally instructions for pre and postoperative care are given [10, 11].

47.7 Fat Grafting

Fat grafting has seen renewed interest as research has shown that fat can survive if it is used in small droplets and placed near a good blood supply. In his practice, the author is able to achieve survival between 5 and 7 years. The use of autologous fat graft has been advocated since 1893, when Neuber [12] first published his paper. The success of this technique relies on obtaining the fat using a large bore syringe, thereby not macerating it. The author does not centrifuge the fat. Reinjection is done by using the pearl technique, which has been

Fig. 47.7 Fat ready for transfer

pioneered by Fischer [13] and yields extremely favorable results. The operation is normally combined with another procedure such as a face-lift, and so it can be done under sedation (Figs 47.7 and 47.8).

The donor site is infiltrated with small volumes of a saline solution that contains one in one thousand adrenaline and 20 units of lignocaine 1%. The fat reinjection site for the brow is usually just underneath the brow and this has an elevating effect and fullness especially in patients who loose fat due to atrophy or aging (Fig. 47.9). Slight absorption is always expected and the patients can have a touch-up on a yearly basis, in which case a fat-bank could be justifiable. In the author’s practice in England a fat-bank is not permitted; however, this is a very popular option in Japan, Argentina, and China, among others. It is also possible to inject the frown lines with autologous fat after performing subcision, in order to create a pocket for the insertion of the fat. The major warning is that one or two dramatic cases that resulted in death have been reported due to the fact that the fat was injected by mistake into a vein causing embolization. Patients must be informed about absorption, which can be irregular and which is a rare disadvantage of this operation. In addition, in thin patients it could be difficult to obtain enough graft.