Brow Lift, Endoscopic

Brow Lift, Endoscopic

Introduction

Technology has created a trend for less invasive procedures in all surgical specialties. The endoscope, with its accompanying instrumentation, has been the key development supporting this trend. It has helped surgeons in nearly every surgical specialty, including plastic surgery, develop less invasive techniques. With new technology comes patient demand and expectation for less invasive procedures, or at least for procedures perceived as such. The endoscope now is used in a variety of reconstructive and cosmetic plastic surgical applications, with the endoscopic brow lift the first procedure to gain widespread acceptance.

History of the Procedure

Over the last 3 decades, more surgical specialties have incorporated fiberoptic and endoscopic technology. Endoscopes have been widely used by gynecologists since the 1970s for diagnostic and therapeutic procedures. By the end of that decade, the same technology was gaining acceptance in the orthopedic community for diagnostic procedures. As instrumentation improved, less invasive therapeutic procedures became common.

Endoscopic procedures were introduced into general surgery in 1986, and laparoscopic (endoscopic) cholecystectomies became standard by 1990, with increasingly complex surgeries gradually transitioning to less invasive approaches. In the early 1990s, the first endoscopic brow lift procedures were described.¹ Shortly thereafter the endoscope was incorporated into plastic surgery of the mid and lower face, breast, abdomen, hand (in carpal tunnel surgery), and trunk.^2,3

The advent of the endoscopic approach to the face and, in particular, the brow was brought about in large part by the ability to create a sufficient optical cavity. Specialized dissection instruments and understanding of principles of brow suspension were also significant contributing factors. For information on other brow lift procedures, see the Brow Lift section of eMedicine’s Plastic Surgery journal.

Problem

Surgeons should examine the face as a whole to better determine which procedures will help achieve the goal of a balanced natural appearance.⁴ When evaluating the face for rejuvenation or other cosmetic improvement, surgeons classically divided the face into 3 sections: face and/or neck, brow, and eyes. As techniques and technology advanced, analysis of the face became more complex, changing relationships between these classifications. The face and neck now are analyzed as mid face, lower face, and neck. For information and CME activities on aesthetic procedures of the face, visit Medscape’s Aesthetic Medicine Resource Center.

Evaluation of the eyelids now includes examination of the mid face. Brow examination must include evaluation of lids and the general orbital area. Specifically, patients with upper lid ptosis or even blepharochalasia must be evaluated regarding dynamic rhytides of the forehead. These patients often require surgical correction of the eyelids in conjunction with the brow lift. The location of the hairline or width of the brow must be noted also.⁵ Very high foreheads or very deep rhytides may require skin excision in addition to endoscopy to allow relaxation of the forehead.

Although most facial soft tissue structures tend to descend under constant forces of gravity and time (eg, cheeks, neck), the brow is often an exception. Some individuals naturally have a low-set brow. Others may show significant signs of facial aging but have little or no brow ptosis. Just because a brow can be elevated does not mean it should be elevated.

Perform the endoscopic brow lift for the following reasons:

• Elevate the eyebrows: Brows may be congenitally low or low from changes associated with aging. Elevating the brow may remove excess skin and/or fullness from the upper eyelid.
• Improve symmetry of the eyebrows
• Change the shape of the eyebrows
• Decrease the transverse static wrinkles of the brow
• Decrease function of muscles in the brow and glabellar region that cause dynamic wrinkling

Pathophysiology

Poor brow position can be an inherited condition or an acquired condition associated with aging. As with other soft tissue structures of the face, the brow may become ptotic with increasing age; however, note that in the youthful face the brow is often quite low yet still attractive. As the face ages, fat is lost from the orbital rim between the brow and eyelid, creating an aged or ptotic appearance.

Repetitive or hyperactive use of corrugator muscles can depress the medial head of the eyebrow over time.^6,7 Similarly, overuse of frontalis muscles, especially on one side, can create noticeable asymmetry in eyebrow height. In addition, patients who have significant upper lid ptosis may attempt to compensate by overusing the frontalis muscle to lift the brows and, subsequently, the lids out of the field of vision.

Presentation

Good candidates for endoscopic brow lift present in several ways. The patient may note that the brow is ptotic or low. These patients commonly report that their eyes have a tired or heavy appearance. Often they note that they "have always had this" or that it "runs in the family." Frequently, the patient has practiced achieving the desired look by pulling the lateral brow up with his or her hands while looking in the mirror.

Patients often present with excess upper eyelid skin. Carefully evaluate the brow in any patient evaluated for cosmetic eyelid surgery, because the brow may be involved in 50% of patients.

Patients often present with a chief complaint of deep glabellar rhytides caused by excessive corrugator activity. They often are frustrated that they look angry, upset, or tired when they do not feel this way. They have a frequent subconscious tendency to frown. Additionally, patients may be concerned with horizontal forehead creases caused by excessive frontalis activity.

Indications

In the normal brow (see the image below), the medial eyebrow extends to the medial canthus of the eye, and the lateral eyebrow extends to the intersection of an imaginary line drawn from the nasal ala through the lateral canthus of the eye.⁸ Head of the medial eyebrow can begin below or at the medial orbital rim. Tail of the lateral brow is positioned above the bony orbital rim, often dropping to the same horizontal level as the medial head of the eyebrow. Tail of the brow normally may be found above the horizontal line of the medial brow. Apex of the brow arch lies immediately above the lateral edge of the iris. In fashion models, the apex tends to be at the point dividing the medial and lateral third of the brow, or sometimes even more laterally, creating a stylized or more exotic appearance. In the average patient the apex of the brow often is located more centrally, but this still can produce an attractive brow.

In evaluating the orbit, note several essential things, including depth of the orbit or eye socket and shape of the overall orbit. In a patient with deep-set eyes, an overly elevated brow appears more abnormal, whereas a patient with a shallower orbit can tolerate over-elevation of the brow and still appear within normal limits.

As the face ages, the orbital shape changes from an oval or egg shape to a circular shape, caused most often by ptosis of the mid face. In patients with significant nasojugal crease from midface ptosis, avoid elevating the brow as an isolated procedure, since this accentuates the circular shape of the orbit and increases the aged appearance. Consider performing a facelift or mid facelift in conjunction with brow lift. A mid facelift also can be performed in conjunction with a lower eyelid procedure.

Check for asymmetry, which often goes unnoticed by the patient. Noticeable asymmetry of eyebrows is present in approximately one third of patients. Often the distance from orbit to brow is the same bilaterally even though the brows appear uneven. In this situation, the entire orbit on one side of the face is usually lower. Decide which approach provides a more symmetric look—raising the brow the same degree bilaterally, which maintains the asymmetry of the brow, or raising the eyebrows asymmetrically, which equalizes the eyebrows but may introduce a new asymmetry in distances between brows and eyes. Computer imaging helps determine the more suitable approach.

Although any brow can be elevated, evaluate the amount of redundant skin in the lateral canthal region.⁹ Significant overhanging skin near the "crow's feet" is difficult, if not impossible, to remove with eyelid surgery alone. Elevating the lateral brow may be necessary. This is one helpful indication in addressing the need for brow elevation, especially in the patient presenting with heavy upper eyelids.

Relevant Anatomy

Scalp

Scalp layers include skin, subcutaneous tissue and fat, the galeal aponeurosis, and periosteum. As the scalp joins the forehead, an additional layer of muscle (frontalis muscle) is found between the subcutaneous and galeal layers.

Vascular anatomy

Supraorbital vessels exiting supraorbital foramina above each orbit supply the forehead. These vessels coalesce with superficial temporal arteries and occipital vessels in the posterior scalp to provide a redundant blood supply to the scalp. The entire scalp can survive on one major arterial vessel. Additional blood to the central forehead is supplied by supratrochlear vessels exiting the orbits superomedially and extending in a cephalad direction. In the temporal region, the sentinal vein should be avoided.¹⁰

Neurologic anatomy

Sensory nerves to the forehead (supraorbital and supratrochlear nerves) exit the orbits in neurovascular bundles with supraorbital arteries and supratrochlear arteries. These nerves may be large singular nerves or smaller bundles. Usually a dominant single nerve is present. Supraorbital nerves exit approximately 2.7 cm from the mid line. Nerves easily are seen and preserved.¹¹

Motor nerves

The facial nerve's temporal branch (VII) provides innervation to the frontalis muscle. Its course follows a line drawn from the tragus through a point 1-1.5 cm lateral to the eyebrow's lateral tail. The nerve is found in a fatty layer between the temporoparietal fascia and superficial layer of the deep temporal fascia (see the first image below). During dissection, one can identify the general location of this motor nerve by locating a predictable vein (see the second image below), referred to as the "sentinel vein." Injury to this nerve can cause temporary or permanent frontalis muscle paralysis.

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Cross section illustrating anatomy of temporal region and close relationship between sentinel vein and temporal branch of the facial nerve (VII).

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Diagram showing surface anatomy relationship between sentinel vein and temporal branch of facial nerve. Caution zone 10 mm in diameter is drawn at intersection of 2 lines: one extending from the mental foramen to lateral edge of the orbit, and another from the superior edge of the orbit to the junction of the ear helix and zygomatic arch. Perform dissection in this area under endoscopic vision (Trinei, 1998).

Muscle anatomy

The frontalis muscle is a broad flat bilateral muscle of facial expression spanning the forehead that raises the eyebrows. Corrugator muscles are small fan-shaped muscles that lie nearly under the eyebrows. They also are muscles of facial expression that cause frowning in the glabellar region. The procerus muscle extends from the upper nose to the lower forehead, and its action wrinkles the upper nose.

Contraindications

As with eyelid procedures, question patients regarding a history of dry eyes. Excessive brow elevation, especially in conjunction with upper eyelid surgery, can exacerbate a previous condition. Confirm adequate eye tearing or lubrication with a Schirmer test if necessary.

Patients with an excessively high hairline may not be good candidates for this procedure. Contrary to common belief, an endoscopic brow lift raises the hairline at least the distance the brow is elevated, if not more, depending on elasticity of skin and brow. Advise patients with high hairlines that the hairline may appear higher and offer them an anterior hairline approach, which can elevate the brow while shortening the forehead. Disadvantages of the anterior hairline approach are more visible scarring, temporary or permanent scalp paraesthesia, and longer operative time.

Evaluate all cosmetic surgery patients for psychological instability or unrealistic expectations.

Brow Lift, Coronoplasty

Brow Lift, Coronoplasty

Introduction

History of the Procedure

The forehead lift or brow lift is a common facial rejuvenation procedure, performed as an isolated technique or in combination with total facial rejuvenation, including facelift and blepharoplasty. Most recent clinical data and paradigm shifts have reoriented the term brow lift as a misnomer. The terms browplasty or brow reshaping focus on the overall contour rather than the absolute height of the brow.^1,2

Problem

Periorbital changes are often recognized as the earliest signs of aging. Common changes include upper eyelid skin folds extending beyond the upper eyelid into the temple, frown lines or glabellar transverse forehead creases, thickening or bunching of the corrugator muscles at the medial eyebrow, and descent (ptosis) of the eyebrows.

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Left - Preoperative view, brow lift Right - Postoperative view at 2 years

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Left - Preoperative view, brow lift Right - Postoperative view at 2 years

These changes potentially are reversed with an appropriately performed brow lift or forehead lifting procedure.

In this discussion, the terms brow lift and forehead lift are used interchangeably. The actual incision used to perform a brow lift can vary from the coronal line, the prehairline, and just above the eyebrow. This topic focuses on the indications, techniques, and results of the coronal approach. For information on other brow lift procedures, see the Brow Lift section of eMedicine’s Plastic Surgery journal.

Frequency

Aging varies in each individual. Forehead changes are based on environmental factors (sun damage), genetic makeup, and skin type. The extent of aging can vary greatly.

Beginning in the fourth decade, early changes of brow position, influenced by gravity, become apparent. This eventually occurs in all individuals, although the degree of brow ptosis and constellation of findings such as glabellar frown lines and transverse forehead creases vary. By the fifth decade, most individuals have undesirable changes of the forehead and upper periorbital region that would benefit from rejuvenative forehead procedures.

Etiology

The etiology of the aging upper face involves loss of elasticity, soft tissue ptosis, genetic predisposition, and repetitive facial motion (eg, squinting, constant corrugation of eyebrow muscles).

Individuals with active facial animation, especially those who are exposed to sun, may exhibit more advanced signs of upper forehead aging.

Pathophysiology

Constant motion of the frontalis muscle creates the transverse rhytides of the forehead. Patients with advanced brow ptosis activate the frontalis muscles on a regular and involuntary basis to maintain elevation of their brows, thereby preventing the visual field obstruction that occurs from brow ptosis. As forehead soft tissues continue their descent over time, compensatory frontalis muscle tone creates progressively deepening lines to offset the effect on visual field obstruction.

In such cases, the well-intentioned removal of upper eyelid skin can create further brow ptosis through a relaxation in frontalis tone, which is now no longer required to maintain the visual field. The removal of upper lid skin in such cases can make later brow elevation more complicated, with poorer aesthetic results due to the limitations created by a paucity of upper lid skin. To overcome this deficiency, skin grafts or flaps from the lower lid may be considered. Remarkable aesthetic improvements can be achieved with techniques that diminish frontalis tone and weaken the centralizing and depressing muscular action while elevating the brow to an appropriate position.

Presentation

Patients may be told by family, friends, or colleagues that they appear angry, sad, or anxious when this appearance does not match their emotional state. This misinterpretation can be quite concerning for some and may result in a visit to a plastic surgeon for treatment. Elevating the brow while diminishing corrugator and procerus function can reduce forehead rhytides. This goal is accomplished through a skillfully performed brow lift.

Indications

A brow lift may be indicated in anyone who approaches the fourth decade of life and exhibits changes such as brow ptosis and excess corrugator action with glabellar creases between the eyebrows and transverse forehead wrinkling. Many of these patients are motivated to change the unacceptable appearances of anger, annoyance, or fatigue that commonly are associated with changes in the forehead.

In the female patient, elevation of the lateral eyebrow and weakening of the centralizing and depressor muscles provides a more aesthetically pleasing upper periorbita, consistent with youthful femininity.

In men, eyebrow position also may be excessively low, and elevation may be indicated; however, excessive elevation can be feminizing. Vertical glabellar frown lines may suggest anger or anxiousness and are typically undesirable. Concerns over the appearance of these unwanted lines often prompts a visit to a plastic surgeon.

Relevant Anatomy

A thorough knowledge of the layers of the scalp and forehead is paramount. The layers encountered in brow lift surgery are the skin, subcutaneous tissue, galea or aponeurosis, loose areolar tissue plane, and periosteum. Progressing inferiorly from the coronal or hairline incision, the deep and superficial layers of the temporal fascia are encountered laterally; an understanding of these layers and how they relate to the frontal branch of the facial nerve as it traverses the galea and superficial musculoaponeurotic system (SMAS) layer is critical.³

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Cross-section of the temporal region showing fascial relationships to the zygomatic arch.

A brow lift may be performed via a subcutaneous, subgaleal, or subperiosteal layer. Most brow lifts are performed through an open technique in a subgaleal fashion, with release of soft tissue attachments at the supraorbital rim to make transmission of lift to the lateral eyebrow possible.

Anatomic understanding of the supraorbital and supratrochlear nerve branches that traverse the medial eyebrow region also is important. Supratrochlear nerves are invested within the corrugator muscle. They are visualized in dissection and removal of the corrugator muscle and must be preserved. The supraorbital nerve exits more lateral than the supratrochlear nerves and provides sensation to the hemi-forehead, extending superiorly above the hairline. Preserving these nerves minimizes sensory deficiencies.

The frontal branch of the facial nerve is carried in the forehead flap when the procedure is performed through the subgaleal or subaponeurotic dissection. Tension or traction on the forehead flap at the level of the lateral orbital rim must be gentle to avoid neurapraxia or permanent injury to the nerve.

An intimate knowledge of the insertion and origin of the corrugator muscles, procerus muscle, and frontalis muscle is essential to performing a comprehensive brow lift procedure that reverses the signs of aging.

Contraindications

The most significant contraindication to a forehead lift is deficiency of upper eyelid skin. This often occurs when previous upper eyelid surgery has been performed, lagophthalmus has occurred, and adequate lid closure is a concern. Elevation of the brow to its proper level may be impossible if adequate upper eyelid skin is not present. This demonstrates the importance of proper diagnosis in the aging face so that excess upper eyelid skin is not removed simply because this is the "easier way out."

In most patients, a properly performed brow lift is the cornerstone of upper facial rejuvenation. Only after placing the brow in the proper position can one assess excess upper eyelid skin. This is especially true in women, in whom eyebrow position and shape is quite important in establishing the aesthetics of the periorbital region. A properly arched and elevated lateral brow is a key element to a rejuvenated female face.

A relative contraindication to a coronal forehead lift is a preexisting high anterior hairline. When excessively high, a coronal brow lift exacerbates this aesthetic problem. Further, following a coronal brow lift, performing subsequent hairline brow lifts to correct the problem is difficult without jeopardizing the vascularity to the intervening scalp segment that contains the anterior hairline. The endoscopic and prehairline brow lifts do not significantly alter hairline position and, therefore, are more appropriate choices for patients who have high anterior hairlines. However, recent studies suggest limited and often incomplete excursion of the lateral brow via the endoscopic approach.² The direct lateral brow lift has thus gained significant favor owing to its technical ease and reliability.⁴

Nasal Implants

Nasal Implants

Introduction

The nose is critically involved in appearance, both to oneself and to others, and it is significantly involved in the perception of beauty both publicly and privately. Because of its central location on the face, plane of projection, and relatively weak chondrocutaneous support structure, the nose is susceptible to injury, and deformities are readily apparent.

Whatever the circumstances that led to the nasal deformity, the complex tasks of assessing the patient's nasal anatomy, pathologic defect, aesthetic qualities, baseline perception, planning the reconstruction, and preparing the patient for the possible positive and negative outcomes can be daunting. In planning for nasal reconstruction requiring an implant, careful decisions need to be made regarding the types of materials to substitute for support. Final soft-tissue coverage of the planned reconstruction is of paramount importance in the preparation.

History of the Procedure

In northern India, during the 6th century BC, Susruta focused on soft-tissue augmentation for amputation injuries and nasal reconstruction.¹

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Reproduction of plate from Susruta showing style of nasal reconstruction. Note that support for the nasal bridge is absent. The intrinsic rigidity of the dermis was relied upon for structural support. (Susruta, An English Translation of the Susrita Samhita, based on original Sanskrit text. Edited and published by Kaniraj Kunjabal Blushagratna. Calcutta: Bose, 1916).

In the 16th and 17th centuries, Tagliocozzi used a tubed pedicle flap and Carpue, an Englishman, reinstituted the forehead flap.^2,3

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Reproduction of plate from Tagliocozzi as depicted by Gnudi and Webster. Skin of the inner upper arm has minimal intrinsic rigidity and always requires internal structural support.

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Reproduction of plate from Carpue manuscript. Note refinements in flap design.

Various nonautogenous materials have been employed over the centuries to improve reconstruction of the nose by providing bridge support. Early attempts at finding the ideal or most suitable nasal implant for bridge construction included trials of materials such as paraffin, gold, silver, aluminum, ivory, cork, stones from the Black Sea, polyethylene, rubber, silicone, lead, and a toothbrush handle.

Currently, general categories of available materials include autografts, homografts, and allografts. This article covers the variety of materials commonly employed. The pros and cons of various materials are detailed and illustrated.

Problem

The choice of nasal implants to be placed in reconstructive surgery of the nose is a difficult but important component in the patient's care. The degree of loss noted in tip support, bridge contour, or nasal valve collapse may mandate implant use in nasal reconstruction. Each of the various materials has benefits and pitfalls, which must be balanced against the surgeon's familiarity with each material. Because of the nose's central location, minor defects of reconstruction may be particularly noticeable to any casual observer but may play a much larger role psychologically in the patient's perception of self. Based on the authors' review of the literature and clinical experience, autogenous cartilage and/or bone are recommended as the primary choices for nasal implants.

Indications

Although the major underlying cause of nasal reconstruction is trauma, a number of pathologic entities traditionally have required surgical nasal reconstruction (eg, congenital malformations, malignant destruction, septal perforations, granulomatous disease, congenital syphilis, leishmaniasis, leprosy). Whatever the cause of the defect, nasal reconstruction with or without various implant materials allows restoration of function along with restoration of an aesthetically critical component of the face.

Relevant Anatomy

A prerequisite to nasal reconstruction is familiarity with nasal anatomy and proportions. The nose is generally divided by anatomic units into thirds. The upper third of the nose, or bony vault, is represented by the paired nasal bones that overlie the nasal spine of the frontal bone. The cartilaginous vault represents the lower two thirds of the nose, with the middle third being the region of the upper lateral cartilages, and the lower third involving the nasal tip, septum, and lower lateral (alar) cartilages. The general function of the nose is to warm and humidify incoming air. To achieve both form and function, the nasal vestibule should comprise approximately one half to two thirds of the nasal lobule as viewed from the basal projection. Attention should be dedicated to reconstructing the columella, tip, and ala to form an adequate nostril internally while incorporating aesthetics externally.

Contraindications

Ongoing infection or conditions requiring further therapy (eg, serial débridements) are examples of contraindications to reconstruction. Address patient stabilization and optimization, including nutritional status when possible, prior to surgical intervention. Therapies such as radiation or chemotherapy should be completed prior to reconstruction.