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intraoperative time are notable benefits of hairline lowering surgery, and
many patients opt for this procedure with this in mind [3, 33].
Women often pursue this procedure to create a rounder hairline, reduce
hair loss with aging, or correct the appearance of a larger forehead. Hairline
lowering surgery continues to become more popular with male patients of
varying ages who wish to reduce the appearance of pattern hair loss [20].
Facial feminization surgery is frequently pursued by male-to-female
transgender individuals and often incorporates hairline lowering into
contour augmentation procedures [34].
2.2.1 Preoperative Patient Assessment
Good surgical candidates for HLS have a sufficiently mobile scalp,
allowing for adequate displacement, and a stable frontal hairline. This
procedure is rarely recommended for men under 40, as progressive hair loss
can expose the resultant scar. Patients who prefer to wear their hair down
(or in a similar style) and brushed forward are the ideal candidates [5].
The overall facial aesthetics should be considered before the forehead
size is altered. Proportionally the face can be divided into thirds, the most
superior of which contains the forehead (glabella). The ideal forehead size
depends on the individual shape/proportion of the hairline and surrounding
facial features, with the overall desired average estimated at 5–6 cm [20,
35].
A focused physical examination and medical history should be obtained
before patients are considered for surgery. As with nonsurgical hairline
rejuvenation, the hairline appearance should be noted, in addition to the
presence of pattern hair loss or thinning [cite our book]. If a widow’s peak
is present, the provider should establish whether or not the patient would
like to incorporate the peak into the newly reconstructed hairline. The scalp
laxity should additionally be determined (as discussed above with FUT), as
it limits the degree of forward advancement. A scalp expansion or twostage procedure may be required if the scalp does not have sufficient
flexibility [36] (Fig. 7).
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Fig. 7 (Left) Incisional planning for maintenance of a patient’s widow’s peak is shown in the left
figure [27]
Patients should be informed of the potential complications, as well as
resultant visible scarring or unnatural-appearing hairline. Subsequent
procedures for follicular unit transplantation may be indicated to improve
the transition between the forehead and the hairline [36].
2.2.2 Surgical Procedure
Patients undergoing HLS are placed under twilight sedation and given local
anesthesia with supplemental nerve blocks prior to surgery. The existing
hairline is marked, and another line is drawn to represent where the new
hairline will be advanced. Irregular trichophytic incision patterns are used
to create a natural appearance. Once the thinning hair along the temporal
hairline is reached, the incision should gradually taper upwards into the
thicker hair [33].
Surgeons then make an incision extending across the marked hairline
just posterior to the first rows of hair. Hair growth is maintained using a
superficial angled cut through the epidermis and dermis, and the periosteum
is preserved by keeping the scalpel to a vertical angle through the deeper
galea [37]. The avascular tissues in the subgaleal plane are bluntly dissected
around the perimeter of the incision into the hairline. Scissors and/or sharp
dissection with a scalpel are utilized to continue the dissection anteriorly
along the frontal bone within this plane [36].
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To prepare the frontal scalp, two 60-secondcycles of upward traction
are applied using towel clips. Surgeons perform a galeotomy to optimize
advancement of the scalp during the procedure, making a shallow coronal
incision along the inside of the dissected skin flap to the dermis. A single
galeotomy is often sufficient to achieve necessary advancement; additional
incisions may increase the patient’s risk for shock hair loss. After
galeotomy is complete, a final cycle of traction is applied to the frontal
scalp [36] (Fig. 8).
Fig. 8 The dissected flap is lifted from the underlying osseous tissues, as shown in the left image,
and scored as necessary (galeotomy) to allow for increased tissue advancement [38]
Once the forehead has been adequately prepared with traction and
galeotomy, surgeons can remove any excess skin. The incisional pattern to
remove this skin should match the pattern made at the hairline, to allow for
smooth reattachment. The frontal scalp may then be secured to the
periosteum using dissolving clips (Endotine), which are anchored to the
cranium 2 cm laterally from the midline. Trained surgeons may avoid the
resultant transient contour irregularities from clips by creating two
parasagittal bone tunnels. To fixate the scalp, 2.0 polydioxanone sutures are
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placed through the galea and fixated in these bone tunnels. Some patients
may choose to take additional measures at this point (such as a brow lift)
requiring additional inferior dissection of muscles and surrounding tissues
[39].
Once the procedure is complete and the frontal scalp has been
adequately secured, the excess forehead skin can be excised. Surgeons close
the wound using a two-layer technique, first suturing the galea/avascular
forehead tissue to the frontalis muscle and then closing the skin edges [36].
Pain medication is prescribed for the first postoperative night, as this
tends to be the most painful point of recovery for patients. Some providers
will give nerve blocks (supratrochlear, periorbital) with 0.5% bupivacaine
in the postanesthesia care unit if the pain is unmanageable. The incision site
is wrapped with cling gauze and padded using fluffed cotton and should be
wrapped loosely to allow for optimal healing [36].
2.2.3 Complications and Outcomes
This procedure has been refined throughout the years, and the current risk
of postoperative complications in general can be estimated at 1% or less.
Individuals may experience temporary alopecia as a result of postsurgical
shock, often attributed to surgical trauma with galeatomy. Other reported
adverse effects include persistent paresthesia (lasting over 1year) and
hematoma formation. As discussed above, the resultant scar may be
unacceptably visible in certain patients, due to increased tension at the
wound closure site or self-limiting individual factors [40].
Other complications related to the procedure involve suture tunneling
(through the frontal bone) or pain at the site of dissolving clip placement,
although a review of the literature does not indicate changes to
complication rate with either technique. These documented adversities are
quite rare, with less than 10 cases noted overall upon review [35, 39, 41,
42].
A review of the literature indicates an average forehead reduction of 1.6
cm with hairline lowering surgery. Aesthetic augmentation is immediately
achieved after surgery, which can be contrasted with follicular unit
transplantation and nonsurgical techniques. Many patients are highly
satisfied with the results, and this procedure is known for the very high
rates of success. Since there are clear expectations and few surprises with
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hairline lowering surgery, most patients will see results similar to the
preoperative predicted outcome [39, 40] (Fig. 9).
Fig. 9 The 2-year postoperative results of a pretrichial forehead reduction are shown in the female
patient in the left image (lower image), with the preoperative appearance for comparison (upper
image) [43]
3 Blepharoplasty
The eyes are one of the major focal points of the face, playing a major role
in facial expression and physical appearance. Maintenance of eye contact is
an important part of social interaction, and any irregularity or asymmetry of
the surrounding skin can be obvious to an observer [44]. Blepharoplasty
(eyelid surgery) aims to adhere the upper eyelid skin to nearby muscles,
creating an upper crease when the eye opens.
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This procedure can reduce sagging and give patients a more youthful
appearance. Mongoloid eyes are commonly seen in Asian (and some
Caucasian) individuals, characterized by shorter upper eyelids and narrow
palpebral fissure (opening between the upper/lower eyelids). Examples are
shown in Fig. 10. Blepharoplasty widens the palpebral fissure in these
individuals, which helps to open the eyes and create a more optimal
aesthetic appearance [45].
Fig. 10 Different variations of Mongoloid-appearing eyelids [46]
3.1 Review of Relevant Anatomy
The eyelids play a crucial role in the protection of the eyes from pathogens,
debris, and physical damage, as well as maintenance of hydration. It is
important to understand the underlying bilamellar anatomy of the eyelid
and adjacent structures to avoid complications and provide patients with
optimal aesthetic outcomes [47].
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The anterior lamella contains cutaneous outer tissue and orbicularis
oculi muscle. The orbital septum and preaponeurotic fat make up the
middle lamella (just inside the anterior lamella). The posterior lamella
contains the tarsal plate, conjunctiva, levator palpebrae superioris, and
Müller’s muscles. These muscles lift the upper eyelid at their attachment to
the tarsal plate each time the eye is opened [44, 48] (Fig. 11).
Fig. 11 Detailed anatomical overview of the anterior and posterior lamellae from a lateral view [49]
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The projection of tissues in the periorbital area, as well as the ratio
between the upper eyelid fold and pretarsal space, contribute greatly to the
aesthetic appearance of the eyes and eyelids [50, 51]. An optimal aesthetic
appearance is achieved when the periorbital tissues project anteriorly to the
globe of the eye (lateral view) [50]. With blepharoplasty, the lateral junction
between the eyebrow and cheek should receive special consideration. A
smooth transition with minimal concavity at this junction contributes to a
more youthful and attractive appearance [47].
Across the width of the palpebral fissure, the upper eyelid fold contains
tissue from the eyebrow to the upper eyelid crease, and the continuation of
skin from crease to lash line is defined as the pretarsal space. Assessment of
the ideal medial and lateral eyelid fold:pretarsal space ratios in Caucasian
women shows an average of 1.87 medially and 2.98 laterally. This
highlights the importance of lateral brow height and minimal drooping of
the upper fold skin [47, 51]. On the contrary, Caucasian males tend to have
a more even preferred ratio across the palpebral fissure [52].
The lower eyelid is made up of the pretarsal space from lash line to
crease and surrounded inferiorly by the preseptal area, which contains the
orbital septum and surrounding fat. Directly beneath this region, a darker
depression identifies the eyelid-cheek junction, otherwise referred to as the
tear trough. Volume depletion with aging or existing lack of volume due to
genetic variation can result in triangular concavity above the cheekbones,
lending to the appearance of sunken, tired eyes [53].
3.2 Preoperative Patient Assessment
Generally, the relative contraindications for most aesthetic surgeries can be
applied to blepharoplasty, including poorly controlled hypertension, blood
disorders, chronic use of blood-thinning medication (NSAIDS, Warfarin,
etc.), and the presence of autoimmune pathology. Individuals with
pathology of the orbit, periorbital structures, or eyelids (whether congenital
or secondary to pathology or trauma) are not good candidates for
blepharoplasty in most cases [54].
Upper blepharoplasty is indicated with unaesthetic skin laxity of the
upper eyelid, ptosis, asymmetry, and impaired peripheral vision secondary
to obstructive excess skin draping. Lower blepharoplasty can be utilized for
correction of lower eyelid malposition, orbital fat pad herniation or excess
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fat, and increased skin/fascial/muscle laxity, in addition to recontouring of
the nasojugal and lid-cheek junction [54] (Fig. 12).
Fig. 12 This patient demonstrates blepharoptosis and lower lid laxity, emphasized by the physical
exam maneuver in the lower pane [55]
Prior to surgery, a comprehensive assessment of past medical history
should be obtained, with a special focus on prior ophthalmologic surgery or
previously diagnosed conditions. A detailed physical examination should be
performed to assess the periorbital area (upper and lower eyelids) and
eyebrows.
Focused ophthalmologic history [56]:
Prior/current dry eyes, glaucoma, blepharitis
– Presence of dry eyes indicates autoimmune testing and additional
evaluation (ophthalmologic, rheumatologic) to rule out comorbid
conditions
Diseases of the thyroid
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– Graves’ disease
Surgical history
– Vision correction surgery (LASIK, laser-assisted in situ
keratomileusis, photorefractive keratectomy)
Prior traumatic injury to the orbit or periorbital area.
Visual examination of the eyebrow and eyelid placement is essential in
the assessment of blepharoplasty candidates, and the surgeon should assess
for brow ptosis, eyelid ptosis, and bilateral symmetry of the orbit and
periorbital structures. In some cases, a browlift would be more beneficial,
whereas others would require both blepharoplasty and browlift to achieve
their postoperative aesthetic goals [57].
The corneal light reflex test is performed, in which the surgeon will
shine a light at the patient’s eyes and examine the point of reflection.
Measurement of the distance between the corneal light reflex and the upper
lid margin with forward relaxed gaze is referred to as MRD-1 (Margin
Reflex Distance-1) and is normally greater than 2.5 mm. If the patient’s
upper eyelid covers more than 2 mm of the superior iris and/or measured
MRD-1 is less than 2.5mm, blepharoptosis is assumed [57].
Involvement of the levator aponeurosis is determined through a lid
excursion test, in which the patient looks as far superiorly/inferiorly as
possible while the surgeon immobilizes the eyebrow. The distance of
vertical movement from downgaze to upgaze should be greater than/equal
to 12 mm. Blepharoptosis presenting with normal lid excursion implies
levator aponeurosis dehiscence/rupture [57].
Underlying brow ptosis may present as blepharoptosis, and this
relationship should be investigated at the preoperative consult. Hering’s law
of equal innervation implies that the obstructed vision with eyebrow/eyelid
ptosis induces increased muscle tone in adjacent muscles (frontalis) as a
corrective mechanism. With the eyelid opened manually by the observer,
relaxation of the frontalis muscles indicates blepharoptosis (localized to the
eyelid) [58, 59].
3.3 Surgical Procedure
3.3.1 Upper Blepharoplasty
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