Part III Periorbital Rejuvenation

Thomas A. Mustoe and Sammy Sinno

Abstract

Treatment of the brow is necessary to correct lateral hooding. By lifting the brow in a superior and lateral direction, a tired and aged brow can be rejuvenated. When combined with an upper blepharoplasty, the following technique is very effective and can be performed under local anesthesia.

Brow lift – lateral hooding – blepharoplasty – lateral temporal incision – orbital retaining ligament – temporal septum

36 Brow and Forehead: Lateral Brow Lift

Key Points

The width of the area of lateral temporal tissue excision is based on the degree of brow ptosis, approximately a 4:1 ratio (width of tissue excision to expected lateral brow lift) is used.
Medially, the dissection is in the subperiosteal plane, protecting the supraorbital nerve.
Laterally, the dissection is deep to the superficial layer of deep temporal fascia (exposing the temporal fat pad), protecting the facial nerve.

36.1 Preoperative Steps

The procedure is performed via a 4 to 5 cm temporal incision parallel to the brow and 2 to 3 cm posterior to the temporal hairline.
The width of the scalp excision is planned to effect brow elevation in a 4:1 ratio. Based on this, standard upper blepharoplasty markings are made (Fig. 36.1).
Scalp incisions allow access to the zones of adhesion.
The upper eyelid approach allows access to the medial brow depressors, lateral temporal area, orbital retaining ligament, and periosteal/galeal attachments.
Medially, the dissection is in the subperiosteal plane, which protects the supraorbital nerve.
Laterally, the dissection is deep to the superficial layer of deep temporal fascia (exposing the temporal fat pad) which protects the frontal branch of the facial nerve (Fig. 36.2 and Fig. 36.3).

**Fig. 36.1** Simplified lateral brow lift markings.

**Fig. 36.2** Pitanguy’s line is the classic reference line for the general path of the frontal branch within the temporal regions. This landmark is a line from the base of the tragus to 1.5 cm above the eyebrow.

**Fig. 36.3** A cadaver dissection demonstrating the frontal branch within the temporal region (*arrow*). The superficial fascia (superficial musculoaponeurotic system [SMAS]) invests the superficial temporal artery, while deep to the SMAS (in the plane between superficial and deep fascia) is the loose areolar layer, termed subaponeurotic fascia, which contains sub-SMAS fat. The frontal nerve branches are situated in the subaponeurotic plane invested in the sub-SMAS fat.

36.2 Operative Steps

See Video 36.1.

36.2.1 Upper Blepharoplasty Access

Local anesthesia is infiltrated in all areas of planned dissection.
The upper blepharoplasty incision is made.
Medially, the corrugator and procerus are exposed. The corrugator is found deep to the orbicularis oculi.
A Ragnell retractor can be used to protect the supraorbital artery and nerve.
The corrugator muscle is divided with fine bipolar cautery.