8.4Mid-forehead Lift

Mid-forehead lifting is most effective for patients with combined brow and glabellar ptosis with sufficiently tall foreheads and prominent horizontal brow rhytids. This technique has traditionally been used in men with heavy brows, deep horizontal rhytids, and high frontal hairlines. It may also be considered in select elderly female patients with prominent forehead rhytids. As with direct eyebrow lifting, visible scarring is a significant potential drawback. Although some authors have described the incision as traversing the entire width of the forehead, we routinely divide the incision between rhytids of differing vertical levels on each side of the hemiface, respecting the midline (Fig. 8.7) [8, 10]. This avoids a longer, less natural, more visible scar that traverses the width of the forehead (Figs. 8.8 and 8.9). Careful wound eversion techniques should again be employed to help minimize visible scarring.

8.4.1The Mid-forehead Lift Procedure

Preoperative marking are made bilaterally with the use of natural forehead rhytids. The bilateral markings do not cross the midline or do so with minimal overlap. Local infiltrative anesthesia is achieved with 2% lidocaine with 1:100,000 units epinephrine (American Regent, Inc.) mixed in equal parts of 0.5% bupivacaine (APP Pharmaceuticals, LLC).

Incision along the previously placed markings is performed with a No. 15 Bard-Parker blade. A microdissection needle (Megadyne) on a monopolar unit (ConMed Corporation) may be used to remove the skin/brow fat flap. The frontalis muscle is left undisturbed. Laterally, the dissection may be taken down to just above the superficial temporalis fascia. Meticulous hemostasis is achieved with monopolor cautery and when necessary, gelatin foam soaked in thrombin. The wound is closed with deep, buried sutures

Fig. 8.7 Mid-forehead lift markings divide the incision between differing rhytids on each side of the hemiface, respecting the midline

of either 4–0 chromic or 4–0 polyglycan. Multiple interrupted, vertical mattress sutures of 4–0 nylon or polypropylene are used to reapproximate the wound edges. Alternatively, the lateral aspect of the wound may be closed with running 5–0 or 6–0 nylon or polypropylene suture. The sutures should be removed at the first postoperative visit 5–7 days later.

8.5Scar Management

Visible scarring is the most significant drawback of both direct eyebrow and mid-forehead lifting. Even normal mature scars which are flat and not hyperpigmented may be noticeable. More concerning, though, are erythematous, hyperpigmented or hypertrophic scars. In our experience, hypertrophic scarring with these procedures has been exceedingly rare. These scars result from excessive wound tension, infection, or delays in healing.

Both surgical and nonsurgical treatments are available to manage surgical scarring. A wide range of nonsurgical treatments has been evaluated. These are summarized in

Fig. 8.8 (a) Preoperative photo of an excellent candidate for mid-forehead lift and upper eyelid blepharoplasty. Note the severe brow and glabellar ptosis, deep horizontal rhytids, and tall forehead. (b) Erythema still present in the wounds 12 weeks after mid-forehead

Fig. 8.9 (a) Preoperative photo of a patient undergoing a lateral midforehead lift and upper eyelid blepharoplasty. Note the severity of the lateral brow ptosis. (b) Postoperative photo 6 months after surgery.

Table 8.1 Summary of nonsurgical therapies currently used for the management of scarring

Partially adapted from Occelston et al. [11]

lift. Note that the incisions are staggered at different vertical levels. The brow ptosis and the horizontal rhytids are markedly improved. The overall shape and contour of the eyebrow remain similar to the preoperative state

Some medial and central brow ptosis remains as expected, but the severe lateral ptosis has been substantially improved

Table 8.1 [11]. We often manage eyebrow or forehead wounds beginning at 3 weeks postoperatively with commercially available silicone sheeting, which has been demonstrated to be safe and effective [12, 13]. Intralesional corticosteroid injections (triamcinolone 10 mg/mL; BristolSquibb Company) are employed at approximately 6 weeks postoperatively when needed, although they do carry a small risk of skin atrophy, depigmentation, and telangiectasia [14]. Finally, scar revision techniques such as dermabrasion, excision, or laser may be necessary subsequently in rare cases.

8.6Conclusion

In conclusion, direct eyebrow and mid-forehead lifting are effective long-lasting management options in the treatment of brow ptosis of carefully selected and well-counseled patients.

Modifications in technique, such as the limited lateral supraciliary eyebrow lift as well as a staggered approach to the placement of mid-forehead lift incisions, allow for both satisfactory aesthetic and functional outcomes.

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