Fig. 10.5 Intraoperative photograph showing the elevation of the orbicularis oculi muscle from its deep ligamentous attachments at the lateral orbital rim using a vertical spreading technique with Stevens scissors. The orbitomalar and zygomaticomalar ligaments are released, creating a large myocutaneous flap all the way from the brow to the cheek

oculi muscle is elevated from its deep ligamentous attachments using a vertical spreading technique with Stevens scissors (Fig. 10.5). Dissection proceeds downward below the suborbicularis oculi fat (SOOF), releasing the orbitomalar and the zygomaticomalar ligaments. The lateral canthal tendon is not detached from Whitnall’s tubercle. The brow fat pad is then suspended to the periosteum 1–2 cm above the lateral orbital rim with one or two interrupted 4.0 PDS or 4–0 polyglactin sutures. Care must be taken to avoid dimpling the skin. A canthopexy and a midface lift can be performed at the same setting via the upper eyelid incision using the same suture type as for the browpexy.

10.4Glabellar Myectomy

Based on the anatomy of brow elevation, the current belief is that procedures that elevate the brow from below, through a blepharoplasty incision, are not as effective as those that elevate the brow from above [3–6]. While overlooked by many surgeons, the depressor supercilii muscle is the strongest depressor of the medial brow [21]. In our experience the medial brow is maximally and most permanently elevated by removal of the brow depressor muscles, which can be effectively performed via a blepharoplasty incision [3, 10]. Elevating the brow from above without releasing the depressor muscles will not achieve the same result on the medial aspect of the brow. We have also found that corrugator and depressor supercilii muscle extirpation is an excellent treatment for migraine and tension-type headaches originating in the glabellar region [22]. This surgery has improved more than 90% of headaches refractory to other forms of treatment. Finally, from a cosmetic standpoint, the trans-blepharoplasty glabellar myectomy effaces the vertical furrows between the brows in a reliable and reproducible manner.

Fig. 10.6 Intraoperative photograph showing the en block resection of the corrugators superciliaris muscle with Stevens scissors via an upper eyelid blepharoplasty incision. The orbicularis oculi muscle is retracted superiorly with two lacrimal rakes

The main complication of corrugator muscle removal is damage to the supratrochlear nerves and the superficial branches of the supraorbital nerve, which travel through and above this muscle. This results in transient anesthesia to the central forehead that usually resolves over a period of several months [10]. Patients should be informed of this expected complication in their preoperative evaluation.

10.4.1 Surgical Technique

The corrugator and depressor supercilii muscles are excised while the procerus is undermined and stretched. This procedure can be performed in isolation, or in conjunction with upper lid blepharoplasty, using the same upper eyelid incision. The anterior leaf of the deep galea is released across the superior orbital rim to the medial canthus while the orbicularis oculi muscle is elevated with two lacrimal rakes (Fig. 10.4d). Dissection proceeds superior to the orbital rim and the corrugator muscle fascia is sharply incised with Stevens scissors to expose the muscle belly. A number of sensory nerve branches are usually seen overlying this fascia. The muscle is grasped with a heavy forceps and elevated anteriorly and superiorly over the supraorbital notch, to avoid damage to the supraorbital neurovascular bundle. The corrugator muscle is then excised en bloc to its medial attachments on the frontal bone (Fig. 10.6). The depressor supercilii muscle is then pulled from underneath the orbicularis oculi muscle at the medial canthus and excised sharply with scissors (Fig. 10.7). This results in immediate release and elevation of the medial brow (Fig. 10.8). Scissors dissection is used to further elevate the medial brow by undermining the procerus muscle and releasing its deep attachments to the bone