19 Brow lift
INDICATIONS
Desire to minimize the frown lines and prominent forehead creases to achieve a youthful look
Repositioning of brow ptosis
Reconstruction of significant facial paralysis involving brows and forehead
CONTRAINDICATIONS
Primary frontal alopecia
Patient’s objection to altering or elevating the hairline and loss of sensation
All other common surgical contraindications
Scalpels Mayfield horseshoe headrest Cat claw retractors or coronal brow lift retractor Ramey clips Periosteal elevator Multiple “peanuts” for dissection 21-gauge needle Methylene blue Preoperative IV antiobiotic consistent with Surgical Care Improvement Project (SCIP) guideline Sterile antiseptic skin preparation Local anesthetic with 1:100,000 epinephrine Additional options Endotine multipoint fixation device and drill burr D’Assumpcao marking clamp Skin stapler |
INTRODUCTION
The face is the most important visible part of an individual’s features. The first visible sign of aging as well as elements of facial expressions are communicated via the face. The brow lift procedure is usually performed to treat conditions of the face associated with aging and facial paralysis. It may be done separately or in conjunction with other procedures to achieve a harmonious facial appearance. There are varieties of brow lift procedures. The open coronal brow lift has for years been considered the gold standard to which many other procedures are compared. The endoscopic brow lift, which was developed within the last 20 years, is a viable but less invasive alternative.
The open coronal approach provides excellent exposure for brow mobilization, lysis of adhesions, and muscle excision to achieve the desired brow elevation and shape enhancement. However, the large incision and scalp excision increase the risk of sensory changes and occasionally produce an unsightly scar. The advent of the endoscopic brow lift has minimized the scarring and sensory loss while providing excellent exposure with fiberoptic magnification. Nevertheless, the endoscopic approach is limited with exposure, inadequate elevation, and complete muscle excision. Plastic surgeons should be well versed in both approaches (as well as other less invasive or long-lasting minor procedures, i.e., direct suprabrow excision) to apply the correct and appropriate technique to well-selected patients.
CORONAL BROW LIFT
Preoperative markings
Mark the anterior hairline, transverse furrows, glabellar frown lines, supratarsal crease, and nasal root rhytides with the patient in the upright position.
Identify and mark the supraorbital and supratrochlear nerves.
Mark the coronal incision 5 cm behind the receding line or at the hairline with a sawtooth incision.
If upper lid blepharoplasty will be performed, the lids should be marked with the brow in the anticipated final position.
Intraoperative details
The patient is taken to the operating room and placed in a supine position. The procedure can be performed under general anesthesia or monitor anesthesia care. The neurosurgical Mayfield horseshoe headrest or the “doughnut” is used to support the head.
Cleanse the hair and braid the hair to expose the proposed incisions.
Shave a path approximately 1 cm anterior to the proposed incision.
Infiltrate the brow area with local anesthetic plus 1:100,000 epinephrine.
The patient is prepped and draped in standard sterile surgical fashion.
Protect the corneas with corneal eye shields, wet towels, or disposable sterile eye protectors.
Incise the skin and subcutaneous tissue down to the pericranium.
Carry the incision laterally to the root of both ears to facilitate scalp and flap mobilization.
Achieve hemostasis with Ramey clips.
Elevate and dissect in the subgaleal plane to a point approximately 4 cm above the supraorbital ridge.
At this point, incise the periosteum from one lateral aspect of the ridge to the other.
The periosteum is raised to just beyond the ridge and onto the nose just beyond the radix using a periosteal elevator.
Identify the previously marked superficial deformities.
Flip the scalp back to its normal anatomic position.
Mark the rhytides and creases with a 21-gauge needle with methylene blue at the needle tip and correlate these lines to the underlying frontalis muscle.
Connect the dots.
Identify, mark, and preserve the supraorbital neurovascular bundle.
Remove three to four thin strips of galea and a portion of the frontalis muscle 1 cm above and below the blue line.
Beware that too much resection of frontalis muscle can leave unsightly depressions and postoperative deformities.
Leave 3 to 4 cm of intact frontalis muscle above the supraorbital rim to preserve its function.
The glabellar frown lines are also marked in the same manner with methylene blue.
Identify the origins of the corrugator muscles, which are found arising from the superomedial orbital rim.
Resect approximately 2 cm of corrugator muscles to prevent reattachment.
If the patient has significant nasal root wrinkles, the procerus muscle is disrupted in a similar fashion to the corrugator.
Remember not to over-resect either the corrugator muscles or the procerus muscle to avoid contour irregularities.
Achieve hemostasis.
Place the scalp back in its anatomic position.
Using two clamps, grasp the scalp edges; a line is drawn from the lateral limbus of the eye.
Overcorrect the desired brow position by 1 to 1.5 cm.
Use the D’Assumpcao clamp to mark the extent of resection bilaterally and in the midline.
Tailor tack scalp edges and excise the overlapping scalp edge.
In patients with a heavy brow or excess ptosis, an Endotine fixation device may be placed in the paramedian position as for an endoscopic brow lift to support the brow in the long term.
The galea is closed with interrupted 3-0 Vicryl® (Ethicon, Somerville, NJ) sutures.
The skin edges are closed with skin staples, running 4-0 Prolene® (Ethicon) or 4-0 nylon sutures with attention paid to everting the edges.
The wound is dressed with nonocclusive dressing, and topical antibiotics are applied to wound edges to preclude the dressing from sticking to the hair.
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