Transpalpebral Corrugator Resection

Ji H. Son

Ali Totonchi

Bahman Guyuron

ANATOMY

Frontalis muscle: elevates the eyebrows and causes transverse wrinkling of the forehead. Its contraction provides a constant, cranially directed force vector on the eyebrows.
Orbicularis oculi muscle: depresses the eyebrows. The two main portions of this muscle are orbital and palpebral.
Corrugator supercilii muscle: thin, long, hexagon-shaped muscle located at the medial end of the eyebrow, deep to frontalis and orbicularis oculi muscles. Corrugators pass between the orbicularis oculi and insert into the deep surface of the forehead skin.
Depressor supercilii: a thin muscle that extends from the medial canthus area to the subcutaneous plane above the eyebrows.
Procerus muscle: pulls the glabella area skin caudally. The procerus originates from the caudal portion of the nasal bones and inserts into the dermis between the eyebrows, which makes it a major stabilizer of the eyebrows. Hyperactivity of this muscle causes transverse lines in the glabellar area and the nasal root.
Supraorbital nerve: exits the supraorbital notch or foramen 2.7 cm from the midline and runs with an associated artery.
Supratrochlear nerve: located 1.7 cm from the midline and 0.8 cm anterior to the supraorbital nerve and runs with associated artery.

PATHOGENESIS

Glabellar frown lines (vertical or oblique) develop due to the contraction/hyperactivity of the corrugator and depressor supercilii muscles and the thinning of the overlying skin.
The overactive procerus muscle can result in horizontal lines in the radix area.

HISTORY

Corrugator supercilii muscle resection is traditionally done using open or endoscopic forehead lift approaches. The senior author first introduced the transpalpebral approach in 1993.¹
This chapter will focus on the transpalpebral resection only. Other techniques are discussed in different chapters in this textbook.

PATIENT HISTORY AND PHYSICAL FINDINGS

A comprehensive analysis of the face, hairline position, brow position and arch, forehead length, width, contour, soft tissue quality, and rhytids will aid in selection of the procedure that will best serve the patient.
The upper face length is approximately one-third of the entire face.
- Frontalis compensation is extremely common, and it is crucial to eliminate it for a more accurate judgment about the eyebrow position by asking the patient to smile or close the eyes tightly and then open them just enough to see the examiner, making every effort to avoid upward motion of the eyebrows.
- The uncompensated position of the eyebrows is at the supraorbital rim in males and slightly above it in females, with its apex at the lateral limbus of the eye.
- The evaluation of the forehead rhytids is recommended in repose, smiling, and frowning.
The best candidates for transpalpebral corrugator resection are:
- Patients who have proper lateral eyebrow position with hyperactive corrugator muscles²^,³^,⁴
- Patients who are undergoing endoscopic forehead rejuvenation and blepharoplasty concomitantly
- Patients with male pattern baldness, on whom incisions must be limited further laterally to avoid visible scars in the forehead area
- Patients with long foreheads, who would not wish to have a forehead shortening procedure
- Patients with proptosis and overactive glabellar muscle where elevation of the eyebrows needs to be avoided, which would otherwise expose the proptosis more and have an adverse effect on the patient’s face
- Similarly, patients with eyelid ptosis who decline eyelid ptosis correction whereby elevation of the eyebrows would enhance the ill effects of existing ptosis on the periorbital congruity³^,⁴
- Patients with documented frontal migraine headaches without the temporal component⁵

IMAGING

Imaging is not indicated for transpalpebral corrugator resection, unless there is a clear reason such as mass or lesion in the area or frontal migraine headaches with the retrobulbar component.

NONOPERATIVE MANAGEMENT

Botulinum toxin A or fillers injection: These would be appropriate for temporary reduction of corrugator hyperactivity or contour deformity for those who are not ready to undergo surgery.⁶
Fat injection: Limited indication for the patient with permanent and static wrinkles, where the results are long lasting but less predictable than injectable fillers. Fat injection is indicated on patients who are not ready to undergo more invasive procedures.

SURGICAL MANAGEMENT