The Open Approach to Forehead Lifting

Key Points

•Open brow lifts have a long history of successful brow rejuvenation.

•There are two open approaches: trichophytic and coronal. The procedure selection depends on the patient’s preoperative assessment.

•The open approach allows the best exposure to all key anatomic structures.

•Morbidity associated with this procedure is greatly minimized with proper technique.

•Appropriate beveling of the incision and meticulous closure are vital to the success of the operation.

•The excision of skin, not tissue repositioning, secures an excellent long-term result.

•There is little to no concern of the surgical outcome fading with time.

the other has left many surgeons unsure of the appropriate approach to employ.

Historically all brow rejuvenation procedures were initially performed via an open approach. And while the open coronal/trichophytic procedures demonstrated excellent long-term results, patients and surgeons were often hesitant to undergo such an involved procedure with extensive incisions and recovery time. With the advent of the endoscopic techniques in the early 1990, surgical rejuvenation of the upper third of the face became increasingly more acceptable to patients [10–14]. This trend, paired with the advent of noninvasive neuroparalytic agents and volume replenishment, has brought brow lifting to the forefront of facial rejuvenation.

6.1Introduction

Surgical forehead rejuvenation began at the turn of the twentieth century [1]. Passot is recognized as an early pioneer in the field [2]. Several other surgeons described their work over the subsequent years [3–6]. The popularity of these operations faded as morbidity was found to outweigh the benefit gained from surgery. However, as with most plastic surgical procedures, interest was renewed in the latter half of the twentieth century, when new techniques evolved and results improved [7–9].

There is an ongoing controversy as to the “correct” technique to rejuvenate the brow, i.e., an open vs. an endoscopic approach. This controversy is now spilling over to rhytidectomy as well. The contention that one operation is superior to

M.R. Murphy (*)

Director, Palm Beach Facial Plastic Surgery, Palm Beach Gardens, FL, USA

e-mail: mrm9002@gmail.com

6.2Background

The upper third is perhaps the most important region of the face. This is the focal region of the face during communication with others. Patients are less aware of this region when compared to the neck and jowl as the brow can be elevated by the patient, thus “pseudo-rejuvenating” the area, whereas the corresponding areas on the lower third cannot. Consequently, the patient generally focuses more on the latter regions than the upper third. The patient must be educated on this salient point.

If middle and lower-facial rejuvenation is performed without the addressing the brow, the patient may be left with an overall disharmonious appearance [15]. This is a common omission because these regions, the jowl and neck, can be addressed with the same procedure, the rhytidectomy, whereas the brow lift requires a separate procedure.

The primary reason for brow rejuvenation is the patient’s feeling, or being told, that they look tired or angry, especially in the glabellar area. The goals of any brow lifting procedure are to eradicate the depressing effect of the musculature of the glabellar region and to raise the lateral aspects of the brow. A key benefit of the open approach is the excellent

exposure which allows for precise handling of these problems. There is no need for overcorrection with the open approach because results remain, as ptotic tissue is excised, not suspended. In addition, the coronal and trichophytic approaches allow for more control of the brow contour by way their differential scalp incision [16].

Though the emphasis in the last decade has been on endoscopic and less invasive nonsurgical brow lifting methods, such as Botox®, the author has found that the open brow lift provides excellent and lasting results with minimal side effects. The open forehead lift allows optimal removal of the corrugator muscles and direct excision of skin, which promotes stability to the surgical outcome [17]. The open brow lift is an excellent operation in patients with severe ptosis of the brows, deep glabellar or mid-forehead wrinkles, or in the patient with a preexisting high forehead when a trichophytic lift is selected. The results achieved with this forehead lift are predictable, natural appearing, long lasting, and aesthetically pleasing with minimal morbidity.

I feel the side effects of the open brow lift techniques have been unduly negative. In a recent, unpublished report on the significance of the side effects of the open brow techniques, the authors found an overwhelming percentage of patients recommend the procedure to a friend or relative (Murphy MR and Johnson CM; unpublished data). Recent reports have also shown that the difference in the rate of alopecia between the open and endoscopic techniques is small, that sensory loss is higher with the endoscopic procedure, and that patient satisfaction is higher with the open technique [18, 19].

The other issue of concern when discussing the open approach to forehead rejuvenation is the extent of the incision. This is predominantly a matter of proper patient education. When comparing the length of the open incision vs. the combined length of the endoscopic incisions, the difference is negligible, and the patient can be comfortably reassured. Certainly, if the patient feels they are going to be “scalped” they will not consent to the procedure [20].

The coronal incision can be completely camouflaged with the patient’s hair. In the case of the trichophytic incision, only the anterior aspect of the incision is exposed. Additionally, this segment of the incision can also be masked with hair when the patient wears their bangs forward. In both instances, the incision generally heals imperceptibly when proper beveling and meticulous technique are employed during incision and closure. The patient must be counseled as to the amount of time it requires for the wound to heal completely. If the patient does not wish to have an open procedure because of the incision, the endoscopic approach should be explored.

The open technique via the pretricheal route enables the surgeon to manipulate certain aesthetic variables in unique ways. For example, the trichophytic lift allows for shortening of an elongated forehead. A long forehead disrupts the

harmony of the face and adds to the perception of the patient’s age [21]. The forehead shortening capabilities of the trichophytic brow lift cannot be obtained with the endoscopic technique [22, 23]. Detractors argue that the incision in this location is prohibitive. However, with proper planning and execution this approach yields an excellent aesthetic result [22]. This is not to say that this procedure is appropriate in all patients with an elongated forehead. If the patient is overly conscious of any scar, or whose hairstyle requires the hair being placed posteriorly, the surgeon should avoid this approach. The decision as to which open incision to use (coronal vs. trichophytic) has been discussed extensively in the literature and will be further elaborated in this chapter [24].

The purpose of this chapter is not to argue over the superior brow lifting technique. That is an individual decision for the patient and surgeon. The open brow lift and endoscopic procedures should be familiar to all aesthetic surgeons who rejuvenate the upper third of the face, and should be discussed with all patients. What will be presented is a detailed review of the open brow lift procedure and its inherent risks and benefits.

6.3Anatomy

To appropriately rejuvenate the brow, the surgeon must be cognizant of its anatomy (see Chap. 2). The position and movement of the brow is determined by several factors. First among these are the paired frontalis muscles. The frontalis is the sole elevator of the brow. These paired muscles have a definitive midline separation [25]. Each of these muscles originates from the galea aponeurotica. The muscles are encased by fascia, and insert onto the orbicularis oculi muscles, which in turn insert to the dermis of the eyebrow. Only the lower 20% of the frontalis muscle is mobile [26].

The brow has four depressor muscles: the procerus, corrugator supercilli, depressor supercilli, and the orbital portion of the orbicularis oculi. The depressor supercilli is located on the medial arc of the orbicularis and is considered by some to be part of the orbicularis [27]. This muscle aids the corrugator in depressing the medial head of the brow. The corrugator muscles originate from the frontal bone near the superior-medial orbital rim, and insert into the dermis of the forehead skin behind and immediately superior to the middle third of the brow [25]. Contraction of the corrugator complex results in depression of the medial brow and the formation of deep vertical glabellar rhytids. The procerus originates from the nasal bone and inserts into the lower medial skin of the forehead. Its contraction leads to the most inferior horizontal rhytid over the radix of the nose [27]. The orbital fibers of the orbicularis oculi muscle arise from the medial canthal tendon, arch along the orbital rim, and meet laterally at the zygoma. The superior division of

the muscle acts as an accessory brow depressor. The galea is contiguous with the superficial temporalis fascia laterally. The periosteum of the frontal bone is contiguous with the deep temporalis fascia. These respective fascial layers converge just medial to the temporal fusion line of the skull.

The sensory innervation to the forehead and scalp is derived from two nerves, the supraorbital and supratrochlear, with the supraorbital nerve being the main contributor. The supraorbital nerve has two divisions, superficial (medial) and deep (lateral) [28]. The deep division courses in the subgaleal plane, over the periosteum towards the superior temporal line before turning superficially through the galea, on its way to the skin of the frontoparietal scalp. The superficial division courses from the orbital rim, through and over the frontalis muscle, and terminates on the anterior scalp [26], supplying this area and the forehead skin. The supratrochlear nerve accompanies the superficial branch of the supraorbital nerve over the surface of the frontalis muscle. Motor innervation of the forehead/eyebrow muscles is supplied by the frontal branch of the facial nerve. It runs within the superficial temporalis fascia on its way to innervate the frontalis, currugator, and the orbicularis muscle.

6.4Preoperative Assessment

There have been numerous studies on the ideal aesthetic of the female eyebrow [24, 29–34]. An individual’s ethnicity, age, sex, culture, and adjacent structures all influence the perceived beauty of the brow. Though opinions vary, there are certain characteristics that commonly recur: (1) the medial brow should lie at, or below, the level of the supraorbital rim,

(2) the brow should have an apex lateral slant, (3) the medial brow should begin in the vertical plane of the medial canthus and lateral extent of the ala, (4) the brow ends laterally in line with a tangent drawn from the lateral ala through the lateral canthus, (5) the apex of the brow should lie above either the lateral limbus or lateral canthus [24, 29–32, 35]. An additional feature of facial beauty is the relationship of the medial brow to the dorsal aesthetic lines of the nose (Fig. 6.1). The soft and uninterrupted shadow effect, as the medial brow transitions to the dorsal nasal aesthetic line, can add inherent attractiveness to the face [7, 29].

The decision of utilizing a trichophytic vs. coronal incision is discussed with the patient before surgery. This judgment is based on the position of the hairline (low vs. high) and the manner in which the patient wears his or her hair [36]. Of course, the personal preferences of the patient must also be taken into account.

The key to an accurate preoperative assessment is the relaxation, manual if necessary, of the brow. It is in repose that the patient must objectively view the resting position of the brow. The patient reflexively raises his or her brow when

Fig. 6.1 The continuous line from the brow to the dorsal line of the nose is a key anatomic feature

placed in front of a mirror or when a photo is taken. The surgeon can manually position the brow as it appears at rest with the patient’s eyes closed and then instruct them to open their eyes slowly.

6.5Technique

The sequence of procedures for facial rejuvenation usually begins with the forehead lift. Rarely is the brow lift the sole procedure performed. In the author’s practice, it is most often combined with an upper and lower lid blepharoplasty and deep plane facelift. The brow lift is performed first because it allows for a more conservative, and accurate, upper lid blepharoplasty. In selected cases, such as those with deep-set eyes, previous blepharoplasty or those with minimal excess upper lid skin, the brow lift is all that is needed for rejuvenation of the upper third of the face.

Marking and shaving of the hair can be performed prior to or after the administration of the anesthesia method of choice. The patient is often very anxious during this time and the marking and shaving of hair can magnify these feelings. When performed under anesthesia, anxiety is reduced. However, in an arena where cost management is a priority, this can be done prior to the anesthetic.

For a coronal approach, a fusiform segment of tissue is shaved and marked for excision (Fig. 6.2). The markings for the tissue excision should lay 5–6 cm posterior to the anterior hairline. The lateral extent of the incision should terminate

Fig. 6.3 The coronal markings mimic the anterior hairline and taper laterally

approximately 1–2 cm above the superior insertion of the auricle to the skull, in an attempt to incorporate the superficial temporal vessels within the flap. It is preferable to preserve this vasculature. However, if it is compromised, the blood supply to the flap is relatively robust. The surgeon should insure that an adequate amount of temporal hair is left behind, especially if this procedure is being performed in conjunction with a facelift where a portion of the sideburn is shaved as well (Fig. 6.3). The incision should parallel the anterior hairline tapering at the lateral aspects to a point. The surgeon can reliably gauge the amount of tissue to resect by assessing the mobility of the scalp and its associated effect on brow position prior to incision. One can also decide on the exact amount of skin to be excised after raising the flap. However, precise incising of the tissue, as is desired when trying to preserve as many hair follicles as possible, is very challenging when incising this thick tissue after it has been mobilized. With adequate experience, the surgeon will be proficient in anticipating the total skin excision prior to the initial incision. Generally speaking, the amount of skin lies

between 1 and 2 cm. If the surgeon discovers that he or she has miscalculated and resected too much tissue, a posterior scalp elevation can be performed to reduce tension and aid in the closure. Obviously, it is better to err on the side of caution and remove less skin if the surgeon is uncertain as to the exact amount to be removed.

The trichophytic incision is more difficult to plan and perform; however, this approach yields excellent results when the procedure is executed in a meticulous manner. The marking begins with scissor trimming of the first two to three rows of hair in the anterior aspect of the hairline. Laterally the hair is shaved as an elongated, curved triangle with its apex above the superior insertion of the auricle to the scalp (Fig. 6.4). This area is generally 4–5 cm in length and should not be placed too inferior so as to encroach on the temporal hairline. This termination point varies from patient to patient depending on the position of the hairline and the contour of the patient’s skull. Once the incision is created a flap must be mobilized to allow access to the glabellar musculature. This often requires folding the flap upon itself so an adequate rotation point must be chosen laterally. In the midline, the incision has gentle undulations closely following the hairline. This undulation allows for improved camouflage of the incision over a simple straight-cut. This posterior aspect of the incision should be placed in the transition zone between the thick posterior hair of the scalp and the fine hairs that constitute the anterior hairline (Fig. 6.4).

The hair is secured with rubber bands anteriorly and with a circumferential band of tape posteriorly. In the trichophytic incision the only hair that is secured with rubber bands is the lateral temporal hair. The hair is shaved. The surgeon should be mindful not to place the posterior tape too tightly around the circumference of the head as to create a “false” lift leading to an under-correction at the conclusion of the case.

Fig. 6.5 The incision is beveled with the hair follicles in the coronal approach

The incisions are remarked and injected with local anesthetic. I prefer a mixture of equal parts of 0.5% lidocaine with 1:100,000 epinephrine with 0.5% bupivacaine with 1:200,000 epinephrine. The injection should be in the galeal, where most of the vessels run their course, and the subgaleal planes. Bilateral supraorbital and supratrochlear nerve blocks are administered. Lastly, the corrugator and procerus muscles are directly injected to aid in pain management as well as hemostasis. The patient is then prepped and draped in the standard fashion. A sterile towel is gently stapled around the head in a parallel course to the previous hair taping, being mindful not to place the towel too tightly.

The incisions are performed with a ten blade. This blade is preferred for its increased surface area, which allows for less blunting (and changing) of blades. The forehead skin is thick and will quickly dull smaller blades, requiring numerous replacements, increased cost, and operating time. Proper beveling of both the pretricheal and coronal incisions is vital to attaining maximal hair regrowth and scar camouflage. In the coronal incision the bevel parallels the follicles throughout the length of the incision (Fig. 6.5). The entire amount of shaved hair is removed leaving a hair-to-hair closure and preventing a noticeable region of alopecia postoperatively. The incision traces further laterally than the pretricheal incision and the orientation of hair at the end point of the incision is almost perpendicular to the skin; the blade must mimic this orientation.

The pretricheal incision requires alternating beveling techniques, and the surgeon must be cognizant of three separate incision areas (Fig. 6.6). The first is the anterior, visible hairline (Fig. 6.7). In this area the beveling transects the follicles to allow them to grow through the incision as it heals over time. This hair generally grows anteriorly and the incision is almost perpendicular to the follicles. When the surgeon chooses this approach, he or she should assess the growth pattern of these vital hairs preoperatively. If they grow posteriorly, masking of the incision by wearing the

Fig.6.6 This graphic depicts the varying angles of the blade during the trichophytic incision

bangs forward may not be possible. This should be discussed with the patient.

The second aspect of the incision is the interface of the anterior region of the incision with the hair bearing areas laterally (Fig. 6.8). At this juncture the beveling must be altered from one transecting the follicles to one running almost parallel to them. This is a brief transition and should quickly evolve into the standard follicle sparing angle seen with the coronal lift (Fig. 6.9). It should be noted that the surgeon must utilize the same angle of incision for both the posterior and anterior portions of the incision to ensure the best possible closure. The importance of proper beveling technique cannot be overemphasized. When done improperly, alopecia and noticeable, unattractive scars result. Lack of attention to detail in this step of the surgery, with resultant loss of hair and scars, are what have substantiated the criticisms of these techniques.

For the entire coronal incision and the lateral aspects of the pretricheal incision, the blade is advanced with a pushing motion, instead of the classical method of pulling the knife towards oneself. This technique allows for better control of the knife through the thick skin of the forehead. It also enhances the surgeon’s ability to follow the hair follicles correctly as one can see where the knife is directed instead of being masked by the hand. This is vital when one considers the exacting manner in which the knife must be beveled for these procedures. The incision is carried down to the level of the subgaleal plane of dissection. After the incisions have been created, the excess skin is removed. This is done one side at a time, so that blood loss is kept to a minimum. As all surgeons who operate in this area know, the blood supply to the scalp is robust. By removing half of the excess skin and obtaining hemostasis, complications can be avoided and

Fig. 6.7 (a) The posterior aspect of the trichophytic incision is made through the first few anterior hairs. This incision transects the follicles so that they grow through, and thus mask the healing wound. (b) The

Fig. 6.8 The angle of the blade transitions as the incision moves laterally

surgery is better controlled. Frequently, the superficial temporal vessels are transected laterally and bleeding should be immediately controlled. Bipolar cautery should be used to reduce thermal damage to adjacent hair follicles. To further prevent hair loss, the surgeon should control bleeding superficial to the galea with cold compresses rather than electrocautery, as the region lacks any major blood vessels. A complete examination of the incision should be performed prior to placing a cool, moist compress on the posterior portion of the incision. Bleeding can persist in the lateral aspects of the incisions and go unnoticed by the surgeon for extended

trichophytic incision is completed. Please note the angle of the bevel must be identical to that of the posterior portion of the incision to optimize wound healing

Fig. 6.9 The lateral aspect of the trichophytic incision parallels the |coronal incision

periods of time as he or she is focused elsewhere. The surgeon must check both lateral aspects of the incision periodically throughout the case to insure adequate hemostasis. The contralateral skin is removed, hemostasis is obtained, and the anterior flap is then elevated.

A subgaleal dissection is performed using a ten blade and Anderson bear claw retractor. The dissection is carried down to the superior aspect of the orbital rim (Fig. 6.10).

Fig. 6.10 The subgaleal dissection is performed with the ten blade

Fig. 6.11 A non-penetrating retractor is employed when approaching neurovascular structures

This “sliding plane” is preferable compared to the subperiosteal plane due to the ease of dissection [18]. With the excision of tissue in the open technique, we do not need to relay upon the periosteum adhering to the cranium to ensure longevity. A non-penetrating retractor is used when approaching the supraorbital and supratrochlear nerves medially, and the frontal branch of facial nerve laterally (Fig. 6.11). The supraorbital and supratrochlear bundles are preserved at the orbital rim, or notch, depending on the patient’s anatomy. The frontal branch is preserved by dissecting directly on the superficial aspect of the deep temporalis fascia.

When approaching the zygomatic arch, I change dissecting instruments from a ten blade to fine sharp scissors and cotton tip applicator for blunt dissection (Fig. 6.12). The dissection is carried down to the zygomatic arches bilaterally. Monopolar cauterization is avoided in this area to prevent potential thermal injury to the facial nerve. Judicious bipolar cautery is advised if necessary.

With the flap completely mobilized, attention is directed to the glabellar musculature. The flap is raised to the radix.

Fig. 6.12 A sharp scissor and non-penetrating retractor is used in the lateral component of the dissection

Fig. 6.13 The corrugator excision is performed with the bipolar after transecting the muscle. This maneuver is aided by retraction in the vector of the muscle

Using an Adsen forceps and sharp, fine dissecting scissors, the corrugator muscles are mobilized. This dissection is greatly aided by the assistant using a non-penetrating retractor in the natural vector of the corrugator to help expose the muscle (Fig. 6.13). Care must be taken to avoid inadvertent trauma to the supratrochlear neurovascular bundle during this phase of the operation. There is often a large vein encountered in the region. The medial 2–3 cm of the muscle is dissected free from the galea and it is transected and cauterized at its medial attachment to the bone.

The excision of the corrugator muscles leads to a longterm benefit unattainable with other methods of muscle weakening such as Botox. The concern over muscle resection leading to a deficit of expression is exceedingly rare. Even with aggressive muscle resection the patient usually has adequate expression postoperatively.

With the flap elevated the procerus is scored horizontally with a monopolar cautery (Fig. 6.14). This is performed gently

through muscle only. If done too aggressively, the patient will be left with a soft tissue depression in the glabellar region. The scoring should center on the medial aspect of the muscle to insure the supratrochlear neurovascular bundles are left undisturbed. Occasionally, in the heavy brow, I will perform a vertical myotomy to allow for lateral spread of the glabella (Fig. 6.15).

In most cases, a galeotomy and midline myotomy of the frontalis at the level of the most prominent mid-forehead rhytid is performed with monopolar cautery (Fig. 6.16). By performing this maneuver in the midline only (up to the medial aspects of the orbital rims), the surgeon allows the patient to retain muscle function laterally with lateral brow elevation. This technique however, should be used judiciously to avoid creating a “surprised” appearance.

A suction drain is then placed above the superior orbital rims and the field is copiously irrigated with antibiotic solution. The drain is brought out through a puncture in the posterior, non-elevated flap. Care should be exercised not to traumatize the temporal vessels during placement of the drain. Both open techniques are closed in a two-layer fashion.

Fig. 6.18 The coronal closure is complete with staples at the skin level. Please note the hair-to-hair apposition, a frequently misunderstood concept with this technique

For the coronal incision, a galeal closure is performed with interrupted 2–0 Dexon suture (Fig. 6.17). This is followed by skin closure with wide staples (Fig. 6.18). The pretricheal lift closure is more detailed. The deep layer closure is with 4–0 Maxon suture (Fig. 6.19). These deep sutures