5.2.7 Tips and Tricks

movements of the middle and lateral parts of the corrugator.

■When targeting the medial parts of the mm. corrugatores, small arterial vessels might be accidentally injured. Usually preand postinjection cooling helps to reduce

unwanted hematoma.

5.3Brow lift

Mauricio de Maio

5.3.1 Introduction

In the upper third of the face, the aging process causes gradual descent of the forehead and brow, especially its lateral third. Eyebrow mal-position- ing may lead to upper eyelid fullness that may be targeted insufficiently by blepharoplasty alone.

brow lifting, so that it is probably the most commonly used procedure of all.

5.3.2 Anatomy

The facial upper third extends from the hairline to the top of the eyebrows. In men with receding hairlines, the upper part of the forehead equals the superior aspect of the frontalis muscle. Its normal resting tension is responsible for the normal position of the eyebrows. The epicranial aponeurosis or galea aponeurotica covers the skull, just beneath the fat. The m. frontalis is the anterior part of the occipitofrontalis muscle. In front of the coronal suture, the aponeurosis gives origin to and is partly hidden by the frontalis bellies, which descend without any bony attachment to blend with the m. orbicularis oculi. The medial fibers of the m. frontalis blend with the m. procerus fibers and become contiguous at the nasal level. The m. frontalis has two halves and in

the superior aspect of the midline forehead there is no muscle, but a fascial band.

The usual action of the m. frontalis is to raise the eyebrows in the expression of surprise and even higher with fright, and to furrow the forehead with transverse lines with thought. The eyebrows have one elevator and three opponents as depressors: the m. corrugator, the m. procerus

5 and the m. orbicularis oculi. The m. frontalis interdigitates with the orbital m. orbicularis oculi at the nasal level. It also blends with the obliquely oriented fibers of the m. corrugator supercilli.

The corrugator is a small narrow muscle that arises from the inner extremity of the superior ciliary ridge and inserts into the deep surfaces of the skin above and between the orbital rims. It lies beneath the m. frontalis and m. orbicularis oculi. The corrugator draws the eyebrows downward and inward, producing the vertical wrinkles in the glabella. It is used to squint and protect the eyes. The m. procerus originates from the nasal bone and inserts into the skin of the forehead between the eyebrows. It pulls down the medial aspect of the eyebrow and produces

the horizontal line at this level. The m. orbicularis oculi when contracted pulls the complete eyebrow downwards. (Table 5.3)

5.3.3 Aim of Treatment

The aim of the treatment is to lift the lateral eyebrow. The medial aspect can also be lifted in selected cases. With brow lifting, patients may improve the tired or sad look as well as decrease the upper eyelid hooding.

5.3.4 Patient Selection

Patients should be analyzed both in the static and dynamic positions. In the static analysis, the patients that will benefit from eyebrow lifting with botulinum toxin are those with a weak frontalis and strong depressors. Independent of age, the eyebrow has a low position; especially its lateral aspect, and fullness in the upper eyelid can also be observed. There may be static lines, depend-