CHAPTER 45 FOREHEAD AND BROW REJUVENATION
BENJAMIN Z. PHILLIPS, ERIK A. HOY, JOHNNY T. CHANG, JHONNY A. SALOMON, AND PATRICK K. SULLIVAN
The upper third of the face, specifically the forehead, can be an area of major concern for individuals as aging occurs. Culturally, great emphasis is placed on the eyes and surrounding soft tissues as they relate to interpersonal interactions. This focus on the forehead can lead individuals to feel uncomfortable or self-conscious about skin redundancy and creases. For the majority of individuals, the hair-bearing brow is the most conspicuous region of the forehead. For this reason, procedures such as forehead lifts and forehead plasties have been referred to as “brow lifts.”1 For nearly a century, the aesthetic improvement of the aging forehead has been a challenge to the surgeon. Since its first description in the literature by Passot in 1919, the brow lift procedure has undergone evolutionary changes from the coronal open brow and anterior hairline techniques, to modern, less invasive techniques, such as the minimal incision lateral brow lift and endoscopic brow lift.2 Procedures aimed at correcting forehead and brow ptosis are among the most commonly performed in plastic surgery. In 2010, surgeon members of the American Society of Plastic Surgeons performed over 42,000 brow lift procedures, 5.3 million botulinum treatments, and 1.7 million soft-tissue filler procedures.3 All these procedures, in addition to repositioning the brow, are directed at combating the three types of hyperkinetic lines of the aging forehead: vertical glabellar furrows, horizontal glabellar furrows, and horizontal forehead rhytids.
Muscle and Effect on Aging
There are two types of paired muscles in the forehead and brow, elevators and depressors. Brow elevation is due to the paired frontalis muscles that are composed of two distinct parts, a static component and a mobile component. The frontalis muscle does not originate from or insert into the bone. The superior half of the frontalis is relatively static secondary to its close adherence to the galea aponeurotica, which serves as its origin. The inferior half of the frontalis hangs freely and inserts into the orbital portion of the orbicularis oculi. This mobile component provides the entire range of motion for the muscle resulting in eyebrow elevation. When the frontalis muscle contracts superiorly directed forces are translated across the orbicularis oculi and the lower brow skin adherent to it. The mobile soft tissue of the lower brow is pulled up into the fixed superior forehead skin and soft tissue, resulting in deep transverse lines in the planes created by the deep dermal insertions between the skin and frontalis muscle. Laterally, the frontalis muscle fuses into a dense network of fascia referred to as the zone of adherence. This region lies along the palpable superior temporal line and ends inferiorly at the zygomatico-frontal suture at a convergence of fascia known as the orbital ligament.4
Several paired muscles are found along the brow and antagonize the action of the frontalis. Collectively, these muscles are referred to as forehead depressors. These include the corrugator supercilii, the orbicularis oculi, the procerus, and the depressor supercilii muscles. The corrugator supercilii originate from the frontal bone just superior to the nasal bones and insert into the dermis of the medial brow. The corrugator is composed of two heads, the oblique and the transverse. The coordinated actions of the two heads pull the brow down and medial across the glabella, resulting in vertical glabellar lines. Thus, hyperactivity may lead to the classic “angry” appearance. The orbicularis oculi muscles are oriented at right angles to the inferior border of the frontalis muscle for much of the brow’s length. Their strong sphincter function exerts a downward pull on the frontalis, creating periorbital wrinkles or “crows’ feet.” The procerus muscles originate on the nasal bones and cartilages as a single muscle belly. Superiorly, the muscles are paired and insert into the medial aspect of the frontalis muscle and the overlying dermis. Contraction of the procerus results in depression of the medial brow and the creation of transverse skin lines along the root of the nose. The depressor supercilii is found superficial to the corrugator muscle and its origin is on the frontal process of the maxilla, inferior to the origin of the corrugators. It inserts obliquely onto the medial fibers of the frontalis muscle, superior to the medial brow. The superficial position of the depressor supercilii is important to be aware of because inadvertent transection may result in over-elevation of the medial brow and a “shocked” appearance. In unison with the oblique head of the corrugators and the medial aspect of the orbicularis oculi, the depressor supercilii opposes the action of the frontalis causing depression of the medial brow and oblique glabellar skin creases.
The facial nerve (cranial VII) supplies the motor innervation to the mimetic muscles of the forehead and brow. The frontal (temporal) branch of the facial nerve supplies the frontalis, the superior portion of the orbicularis oculi, the superior aspect of the procerus, and the transverse head of the corrugator supercilii muscles. The zygomatic branch supplies the medial orbicularis oculi, the oblique head of the corrugator supercilii, the inferior aspect of the procerus, and the depressor supercilii muscles. The frontal branches course from a point 5 mm below the tragus to a point 15 mm above the lateral brow. Over the zygomatic arch, they are found about 2.5 cm lateral to the lateral canthus, placing them halfway between the lateral canthus and the inferior helix.5
Sensory innervation to the brow is by means of branches of the ophthalmic division of the trigeminal nerve (cranial nerve V). The paired supraorbital and supratrochlear nerves supply the central and medial forehead, respectively. The supraorbital nerves exit from the supraorbital foramen an average distance from midline of 2.42 ± 0.04 cm in females and 2.56 ± 0.05 in males.6 They then split into superficial (or medial) and deep (or lateral) branches to supply the forehead and scalp. The deep division supplies the frontoparietal region and can be injured along its course from the main nerve trunk, where it runs superiorly between the galea and periosteum. It pierces the galea 2 to 2.5 cm above the orbital rim and continues superiorly within 1 to 2 cm of the temporal fusion plane. If this nerve branch is injured, it is often secondary to traction injury with the dissector or to transection by the coronal incision and results in paresthesia over the temporoparietal scalp. The superficial branch is shorter, more medial, and less often injured in browlifts. The superficial branch pierces the frontalis muscle early in its course, running superficial to the muscle belly. It supplies the area of the lower/mid-forehead along the mid-pupil line. The lateral forehead is supplied by the auriculotemporal branch of the mandibular division (V3) of the trigeminal nerve (cranial nerve V).
The blood supply to the forehead and brow is robust. Several major blood vessels to the upper face and brow, including the superficial temporal artery and facial artery, are branches of the external carotid artery. These vessels supply the medial canthal region via the angular artery and lateral canthal region via the frontal or anterior branch of the superficial temporal artery. The majority of the forehead and mid-scalp is supplied by branches of the internal carotid artery, specifically the supraorbital and supratrochlear arteries.
The venous drainage mirrors the arterial supply with some variation. One specific vein is relatively consistent and is referred to as the sentinel vein (medial zygomatico-temporal vein). The sentinel vein travels perpendicular through the temporalis fascia approximately 2 cm lateral to above the lateral canthus.4 Because of the consistent nature of its location, the sentinel vein must be identified and care must be taken not to accidentally tear the vessel during lateral dissection. This approach will avoid post-op ecchymosis and impaired visualization of the surgical field.
Multiple authors have defined the aesthetic brow, including Westmore,7 Cook et al.,8 Connell et al.,9 Matarasso and Terino,10 McKinney et al.,11 and Gunter and Antrobus.12 Most authors acknowledge that the aesthetic ideal has changed over time. Westmore proposed that the aesthetic brow had the following attributes: a medial brow that began at the same vertical intercept as the medial canthus and ending laterally along an axis connecting the nasal ala with the lateral canthus, medial and lateral end points along the same horizontal axis with a peak directly above the lateral limbus.7 However, it is more aesthetically pleasing to most patients and surgeons to achieve a final brow orientation with a more elevated lateral third relative to the medial and middle thirds of the brow.
A trend has emerged away from qualitative descriptors of the aesthetic brow toward a more quantitative definition. The brow should begin medially directly at the caudal aspect of the superior orbital rim. The superior portion of the brow should be 1 cm superior to the orbital rim and 5 to 6 cm inferior to the hairline. Additionally, the brow should be 1.6 to 2.5 cm above the eyelid crease.13 The superior peak of the brow should lie at the juncture of the middle and lateral thirds, lateral to the location described by Westmore.
More recently, Gunter and Antrobus reviewed pre- and postoperative photos of a patient cohort and compared their brow position versus that of a number of fashion models in print magazines.12 They found that the patients tended to have flatter brows that started medial to, peaked more lateral to, and ended more inferolaterally than those of the models studied. They therefore refined the ideal brow to include the periorbital structures, since intuitively more attractive periorbital anatomy either enhanced an attractive brow or helped to compensate for the less attractive one. By their specifications, the brow should lie along a slightly inclining axis when viewed from medial to lateral.
A cautionary note should be mentioned here: these “ideal” brow descriptions are for the female patient. The male eyebrow has been less studied and has several key differences.14 First of all, the male brow should lie at the level of the superior orbital rim and is less arching than the female brow. Still, the peak should lie at the junction of the two lateral thirds.
Unlike other areas of the face, bony changes contribute minimally to the aging process of the forehead and brow. Barton describes a spectrum of orbital rim anatomy seen in the aging face.1 The superior orbital rim may take the form of a gradual transition from orbital roof to inferior brow, with its details masked by profuse orbital and periorbital fat. Alternatively, some patients may have a more severe appearance of their superior orbital rim, relatively devoid of upper lid and periorbital fat to disguise the bony anatomy. Whatever the configuration, in terms of bony anatomy, what one sees is what one gets: Rarely is bony anatomy changed in forehead rejuvenation, though volume restoration in the form of autologous tissue transfers such as fat grafting has been used to good effect by the senior author.
Increasing laxity and ptosis of the soft tissues of the brow are responsible for the stigmata of aging in this area. Since the descent of the brow is a soft-tissue process, attempts at rejuvenation involve release, redraping, and resuspension of these tissues, with occasional resection of excess skin. Difficulty in obtaining precise control of the medial, middle, and lateral thirds of the brow spurred further studies into the anatomy of this area.
The senior authors conducted a cadaveric dissection study of 12 hemi-foreheads, with close attention to the ligamentous attachments of the brow.15 Notable findings included an area 1 cm above the superior orbital rim where two attachments were identified: (1) a superomedial ligamentous attachment was found to originate on average 10.8 mm above the supraorbital rim and 13 mm from the midline and (2) a superior lateral ligamentous attachment originating an average of 10.3 mm above the supraorbital rim, and 23 mm from the midline (Figure 45.1). A third retaining structure was identified at the orbital rim. This inferomedial ligamentous attachment was identified below the aforementioned attachments and originated 12.6 mm from the midline (Figure 45.2). Though these attachments appeared to serve a similar purpose to those of the midface, the ligamentous thickenings of the forehead are broad-based. They continued from the bone, pierced the periosteum, and inserted into the frontalis muscle and the tightly adherent overlying skin. Also identified was a long and broad ligamentous structure that extended from the lateral aspect of the supraorbital rim and extended laterally to the superior aspect of the lateral orbital rim (Figure 45.3). This structure inserted to the superficial temporal fascia, as described by Knize.16,17 Without release of this structure in its entirety, the lateral brow cannot be optimally elevated. The short and stout fibers of the retinaculum cutis help secure the skin tightly to the frontalis muscle, and in dissection, no definite ligamentous attachments were encountered.
The interrelations between development of brow ptosis and changes in the upper eyelid are notoriously misunderstood by patients presenting for rejuvenation of the upper third of the face. In addition to a thorough medical history and physical exam, a series of photos and an exam in front of a large mirror are vital in evaluating prospective patients to set expectations. Documenting patient’s facial asymmetries preoperatively is extremely important. Most patients are unaware of their unique facial abnormalities; however, postoperatively patients may perseverate on these preexisting findings as they scrutinize their face after surgery. Preoperative photographs should include the standard anterior–posterior, oblique, and lateral views, as well as close-up views of the periorbital area in repose with eyes open and closed, smiling, with eyes tightly closed, and with full corrugator/procerus and frontalis muscle contractions. These views along with a dynamic exam in front of a large mirror should help educate the patient and surgeon about what features of aging are present, and which procedures are indicated. These images should be printed and readily available during the surgical procedure for easy reference, as the facial anatomy is easily distorted in the supine position. As always, the patient is examined again on the day of surgery, in the preoperative area, and after observing the brow in motion and at rest, the transverse brow and glabellar creases are marked. Preoperative markings are also placed if a blepharoplasty is planned. Typically, limited-length or endoscopic access incisions are marked in the preoperative setting.
FIGURE 45.1. (Above and center) Superomedial and superolateral ligamentous attachments are defined in the subperiosteal space. The superomedial structure averages 10.8 mm above the supraorbital rim and 13 mm from the midline. The superolateral structure averages 10.3 mm above the supraorbital rim and 23 mm from the midline (A). (B,C). Appearance of ligamentous attachments in cadaver dissection. NVB, neurovascular bundle.
FIGURE 45.2. The inferomedial ligamentous attachment is at the level of the orbital rim and averages 2.6 mm from the midline just medial to the supraorbital nerve (A). (B). Fresh cadaver dissection. NVB, neurovascular bundle.
FIGURE 45.3. The broad ligamentous attachment extending across the lateral aspect of the supraorbital rim at the subgaleal level.
As with much of aesthetic surgery, the aims in rejuvenative procedures for the brow are straight forward, the difficulty lies in their implementation. The main goal is to restore a more youthful appearance to the brow region, without brow spreading and over-elevation conveying the perpetually surprised unnatural appearance. As Barton states in his book, the depressed brow is unaesthetic but it is natural. The elevated brow is a postsurgical look.1 The goal is to elevate the elements of the brow smoothly and to the correct extent. As discussed above, the lateral brow in a female always needs to be lifted more than the remainder of the brow. In most patients, the medial brow needs little, if any, elevation. Elevation of the medial and central brow is usually what conveys that “surprised look.”18 In lifting and redraping the brow, transverse forehead lines and glabellar creases should soften. If necessary, autologous or off-the-shelf fillers can be employed to fill deeper creases. Neurotoxins are also helpful to address glabellar frown lines and forehead creases. Hair follicle concentration and thickness should be preserved, as well as scalp sensation and the hairline location should be either preserved or lifted to a minor extent. If indicated, an upper blepharoplasty can be performed to excise excess upper eyelid skin prior to redraping of the brow. Whenever possible, the tenets detailed above for the aesthetic brow should be the goal. The appearance of the brow and upper lids can vary greatly between individuals and should be tailored to best suit the patient.
Gonzalez-Ulloa first described the coronal approach in an isolated procedure for elevation of the forehead and brows. Ortiz-Montasterio then incorporated this as an element of his rhytidectomy technique in 1978 (Table 45.1). Two variations on this long coronal incision have become commonplace, the standard coronal incision with curvilinear deviations such that the incision is always 7 to 9 cm posterior to the frontal hairline and a modified anterior hairline incision. This modified anterior hairline incision is located anterior to the frontal hairline and allows for excision of forehead skin to correct a long forehead. This is the senior author’s preferred incision in those patients with a relatively high hairline or anteriorly thinning hair. However, either approach results in a rather long scar, across the whole of the temporoparietal scalp.
In 1994, Vasconez and Isse reported their experience with elevating the forehead soft tissue at the subperiosteal plane utilizing an endoscopic approach. Knize further refined these approaches with a limited scar technique for brow, temporal, and upper eyelid rejuvenation. These minimally invasive techniques are in most cases, as potent in terms of brow elevation as the coronal approach, with a reduced incidence of scalp paresthesias or alopecia. Though fewer surgeons are relying on the coronal approach, it is still the technique used by some plastic surgeons despite these shortcomings. We have not used it in over 10 years.
SENIOR AUTHOR’S TECHNIQUE
The senior author prefers not to use a coronal incision as part of his operative technique. A hairline incision with or without scalp advancement may be employed in certain patients with a high forehead. An endoscopic approach is most often the surgical approach utilized by the senior author. The technique involves two vertically oriented incisions that are made 1 to 2 cm posterior to the hairline; (depending on the thickness of the hair) dissection is performed posteriorly in the subperiosteal plane to release the attachments of the posterior scalp. Attention is then given to the lower forehead area where an endoscope is employed to develop a supraperiosteal dissection plane from lateral to medial (Figure 45.4). Special care is taken to preserve the medial brow retaining structures and perform a selective release of retaining ligaments as needed to achieve the aesthetic goals. Of course, special emphasis is made laterally to avoid the sentinel vein. The lateral retinacular ligament is released lateral to the supraorbital nerve, avoiding any traction on the nerve. Adequate exposure for resection of the medial corrugators and procerus muscles is obtained by dissecting a central tunnel between the two superomedial retaining structures. Preserving these medial retaining structures allows the surgeon to control the position of the lateral brow while helping to prevent over-elevation or lateral spreading of the medial brow. This is one element that prevents the “surprised look” patients (Figures 45.5 and 45.6).
Once the dissection is completed, the process of brow elevation and suspension can begin. Characteristically four unicortical tunnels (two per side) are created using a drill with an 8 mm stop. The anterior tunnel is made by entering the bone at a 45° angle and sweeping the drill from 5 to 7 o’clock. The posterior tunnel starts approximately 2.5 mm posteriorly from the anterior tunnel. Three individual holes are created in a row, and by moving the drill superiorly and inferiorly the three holes are connected and produce the completed inferior tunnel. Once this is completed, a suture needle is passed into the anterior tunnel and out the posterior tunnel. This cleat provides a strong anchor point to suspend the forehead flap. The suspensory sutures consist of permanent (3-0) nylon sutures in the deep dermal plane. Three passes of the suture are made through the deep dermis, aponeurotic tissues, and galea for each point of fixation. Using a rocking motion (in a vertical plane), the first tie is placed so that there is NO slack and the suture is completely tight. Then subsequent throws are placed. The skin edges of the scalp incisions are everted and closed with sutures or skin staples. This manner of closure has the advantages of easy postoperative removal.
FIGURE 45.4. Endoscope dissection of the forehead.
FIGURE 45.5. Preoperative (A–C) and postoperative (D–F) photographs of a patient who underwent endoscopic forehead rejuvenation. The medial retaining ligamentous attachments were left intact to control the position of the medial brow.
Postoperative care of the patient begins on the operating table at the conclusion of the procedure. First, emergence from sedation should be smooth, with good communication between the surgeon and the anesthesiologist, and without hypertension, coughing, or retching. About 99% of the time we use intravenous sedation without intubation or paralysis. With the combination of meticulous intraoperative hemostasis and strict adherence to postoperative activity restriction, the incidence of hematoma should be rare. As with rhytidectomy, patients should be instructed to sleep with their head elevated, and their neck extended slightly. The senior author also instructs his patients to place a wedge beneath the head when sleeping. NSAIDs (nonsteroidal anti-inflammatory drugs) and anticoagulants should be held for a number of days before and after brow rejuvenation. Finally, ensuring good communication between the surgeon and the patient throughout the process increases cooperation and helps achieve better outcomes.
FIGURE 45.6. Preoperative (A–D) and postoperative photographs (E–H) of a patient who underwent endoscopic forehead rejuvenation. The medial retaining ligamentous attachments were left intact to control the position of the medial brow.
Paralysis of the frontalis muscle is possible secondary to traction injury to the temporal branch of the facial nerve. Fortunately, this is usually not permanent; however, recovery may take upward of 3 to 6 weeks. Permanent paralysis is rare and we have not seen it, but it is a real complication that should be discussed with the patient prior to surgery. Scalp sensation may be altered and is also usually temporary and a limited complication.
Alopecia is associated more with the coronal technique when the hair-bearing scalp is closed under tension. This risk may be reduced if closure takes place at the deeper galeal/superficial temporal fascia level, allowing for a tension-free closure at the surface of the scalp.
Hematoma formation is a risk of any technique. Achieving excellent hemostasis throughout the procedure is required. If a hematoma is encountered prompt evacuation is necessary with possible operative exploration if brisk bleeding is encountered.
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