Fig. 6.19 The trichophytic closure is begun with buried, absorbable sutures at the galeal level

Fig. 6.20 The skin closure is accomplished with vertical mattress sutures. We prefer nonabsorbable suture at the skin level to minimize the inflammatory response

will cause a dimpling of the tissue immediately inferior to the incision in the midline. The patient should be informed preoperatively that this will resolve when the sutures dissolve. The skin in the visible region of the incision is then closed with interrupted 5–0 Prolene suture in a vertical mattress fashion (Fig. 6.20). Skin eversion is vital and must be attained with these sutures. The vertical mattress suture line is further enhanced with the use of a running, locking 6–0 Nylon to maximize the wound approximation (Fig. 6.21). The hair bearing areas are closed with larger staples on the lateral components and smaller staples in the medial aspect of the incision (Fig. 6.22). Though time consuming, this elaborate closure greatly enhances the patient’s wound

Fig. 6.21 A running, locking 6–0 nonabsorbable suture is used to maximize wound closure and thus, the postoperative result

Fig. 6.22 The lateral portions of the trichophytic incision are closed with large staples laterally and smaller ones medially

healing. The wound is then coated with antibiotic ointment and a nonadhesive telfa is placed over the incision. A light compressive dressing is then applied.

6.6Postoperative Care

The drain is often removed in the recovery room on the evening of the procedure to decrease the headache and nausea that often accompanies drains in this area.

The dressing is removed on postoperative day 1 and no further dressing is necessary. The patient may immediately begin using hydrogen peroxide to keep the incision free of crusts. Showering with baby shampoo is allowed 48 h after the procedure. The sutures for the pretricheal lift are removed on postoperative day 3–5 depending on the nature of the

healing and logistics of removing sutures from other surgical procedures that may have been performed. The staples are removed at 1 week postoperatively. The pretricheal incision is immediately taped in the non-hair bearing area after application of adhesive. The tape is worn continuously for 1 week after the removal of the sutures. After this point, the tape is kept every night for approximately 1 month. The tape minimizes tension on the skin encouraging excellent camouflage of the wound. In the coronal approach, all staples are removed 1 week postoperatively.

The patient is advised that the edema in the forehead will be most significant 2–3 days after the procedure. This edema can be quite uncomfortable for the patient. The patients are advised that this will gradually resolve and they may commence strenuous activity 3–4 weeks after the procedure. They are also advised to avoid using a curling iron or a blow-dryer on a hot setting in the first 6 weeks of the procedure since they may have poor sensory perception during this period. This paresthesia is rarely an issue in the author’s practice.

6.7Complications

Despite the recent advances of endoscopic techniques, the open brow lifting method remains an excellent option for brow rejuvenation as it leads to excellent surgical outcomes and high patient acceptance. The complication profile for the open brow lift is excellent with a 0.4% incidence of hematoma formation, permanent alopecia, and “nerve damage” [37]. Others have found similar complication rates.

I have rarely encountered hematomas after surgery. They are treated as with hematomas elsewhere on the face with drainage, or rarely reexploration. The most common and troubling complication I see after open brow lifting is paresthesia. The patient must be aware, preoperatively, that the forehead and scalp will be numb for several months, and possibly permanently. When discussed extensively in the preoperative phase this issue is managed adequately and usually resolves in the appropriate time period. Scarring can occur after surgery but its incidence is greatly reduced with appropriate surgical technique. When it does occur it can be managed with steroid injections. Alopecia is directly related to incision technique, tension on wound closure, tissue trauma, and overzealous use of cautery. Its occurrence cannot be eliminated, but certainly reduced, with adhering to sound surgical principals. In my practice, as well as those of other highly experienced surgeons, alopecia, numbness, and scarring have been of limited impact [36, 38, 39].

A very troublesome complication from surgery is the creation of a “surprised look,” evidenced by a widened, elevated medial brow complex [1]. This is minimized by judicious removal of tissue and an appropriate resection of the glabellar musculature.

An occasional issue that arises postoperatively is pruritus along the incision line. If the patient aggressively scratches and rubs this area, focal alopecia may develop. This can be avoided with patient education. If the alopecia has already occurred, the patient is advised not to disturb the area further and the hair often returns.

6.8Conclusion

The open brow lift remains as the standard by which brow rejuvenation techniques are measured. All surgeons should be familiar with, and competent in utilizing these procedures as they may be the only option for certain patients. With adequate experience, the open brow lift approach can be performed with limited morbidity and high patient satisfaction.

References

1.Lexer E. Zur Geischsplastik. Arch Klin Chur. 1910;92:749.

2.Passot R. La Churugie Esthetique des Rides du Visage. Presse Méd. 1919;27:258.

3.Hunt HL. Plastic surgery of the head, face and neck. Philadelphia: Lea & Febiger; 1926.

4.Noel A. La Chirurgie Esthetique et son Role Socia. Paris: Masson; 1926.

5.Joseph J. Nasenplastik und Sonstige Gesichtplastik Nebst Einen Anhang Uber Mammaplastik. Leipzig: Kabitzch; 1931.

6.Paul M. The evolution of the brow lifting. Aesthetic plastic surgery. Plast Reconstr Surg. 2001;108:1409.

7.Brennan GH. The forehead lift. Otolaryngol Clin North Am. 1980;13:209.

8.Connell BF. Eyebrow, face and necklifts for males. Clin Plast Surg. 1978;5:15.

9.Kaye BL. The forehead lift: a useful adjunct to facelift and blepharoplasty. Plast Reconstr Surg. 1977;60:161.

10. Core GB, Vasconez LO, Askren C, et al. Coronal facelift with endoscopic techniques. Plast Surg Forum. 1992;15:227.

11.Liang M, Narayanan K. Endoscopic ablation of the frontalis and corrugator muscles: a clinical study. Plast Surg Forum. 1992;15:58.

12. Vasconez LO, Gore GB, Gamboa-Bodadilla M, et al. Endoscopic techniques in coronal brow lifting. Plast Reconstr Surg. 1994; 94:788.

13. Isse NG. Endoscopic facial rejuvenation. Endoforehead, the functional lift: case reports. Aesthet Plast Surg. 1994;18:21.

14. Ramirez OM. Endoscopic techniques in facial rejuvenation. An overview: part I. Aesthet Plast Surg. 1994;18:141.

15. Wojtanowski MH. Bicoronal forehead lift. Aesthet Plast Surg. 1994;18:33.

16. Yarenchuk MJ. Subperiosteal and full-thickness skin rhytidectomy. Plast Reconstr Surg. 2001;107:1045.

17. Hamra ST. A study of the long-term effect of malar fat repositioning in face lift surgery: short term success but long-term failure. Plast Reconstr Surg. 2002;110:940.

18. Elkwood A, Matarasso A, Rankin M, et al. National plastic surgery survey: brow lifting techniques and complications. Plast Reconstr Surg. 2001;108:2143.

19. Godek CP, Buckey LP, Whitaker LA. Endoscopic versus open coronal forehead surgery: surgeon preference and patient satisfaction. Plast Surg Forum. 1999;22:182.

20. Koch RJ. Endoscopic browlift is the preferred approach for rejuvenation of the upper third of the face. Arch Otolaryngol Head Neck Surg. 2001;127:87.

21. Guyuron B, Behmand RA, Green R. Shortening of the long forehead. Plast Reconstr Surg. 1999;103:218.

22. Marten TJ. Hairline lowering during foreheadplasty. Plast Reconstr Surg. 1999;103:224.

23. Michelow BJ, Guyuron B. Rejuvenation of the upper face: a logical gamut of surgical options. Clin Plast Surg. 1997;24:199.

24. McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthet Plast Surg. 1991;15:141.

25. Knize D. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg. 1996;97:1321.

26. Knize D. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg. 1996; 97:1334.

27. Romo III T, Jacono AA, Sclafani AP. Endoscopic forehead lifting and contouring. Facial Plast Surg. 2001;17:4.

28. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg. 1995;96:564.

29. Gunter J, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr Surg. 1997;99:1808.

30. Whitaker LA, Morales Jr L, Farkas LG. Aesthetic surgery of the supraorbital ridge and forehead structure. Plast Reconstr Surg. 1986;78:23.

31. Cook TA, Brownrigg AJ, Wang TD, et al. The versatile midforehead browlift. Arch Otolaryngol Head Neck Surg. 1989;115:163.

32. Matarasso A, Terino EO. Forehead-brow rhytidoplasty: reassessing the goals. Plast Reconstr Surg. 1994;93:1378.

33. Freund RM, Nolan III B. Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females. Plast Reconstr Surg. 1996;97:1343.

34. Ellenbogen R. Transcoronal eyebrow lift with concomitant upper blepharoplasty. Plast Reconstr Surg. 1983;71:490.

35. Roth JM, Metzinger SE. Quantifying the arch position of the female eyebrow. Arch Facial Plast Surg. 2003;5:235.

36. Adamson PA, Johnson CM, Anderson JR, Dupin CL. The forehead lift: a review. Arch Otolaryngol Head Neck Surg. 1985;111:325.

37. Vinas JC, Caviglia C, Cortinas JL. Forehead rhytidoplasty and brow lifting. Plast Reconstr Surg. 1976;57:445.

38. Adamson PA, Cormier R, McGraw BL. The coronal forehead lift: modifications and results. J Otolaryngol. 1992;21:1.

39. Kerth JD, Torimui DM. Management of the aging forehead. Arch Otolaryngol Head Neck Surg. 1990;116:1137.