The surgical management of upper eyelid hooding

A technique is described that aesthetically corrects brow ptosis and upper eyelid hooding in selected patients. This procedure is performed through a standard upper eyelid blepharoplasty incision and addresses the common findings of soft tissue fullness below the brow due to excessive suborbicularis fat and hypertrophied orbicularis oculi muscle.Presented at IXth Congress of the International Society of Aesthetic Plastic Surgery, New York New York October 1987Presented at 20th annual meeting of The American Society of Aesthetic Plastic Surgery, Los Angeles, California, March 1987     

Criteria for the forehead lift

We have developed clinically useful measurements to assist the surgeon in deciding when to do the forehead lift and where to place the incision. Also, we have reviewed our experience over the past decade and discuss the four categories and applications of forehead lifts. We use three indications for forehead lift: ptosis, creases, and previous facelift (PCP). There are four basic surgical techniques applicable to the upper face: (1) direct browlift, (2) midforehead crease incision, (3) prehairline incision, and (4) posthairline incision. We determined more accurate guidelines from measurements taken on 50 volunteers, as well as patients seeking a facelift. The line of measurement in a vertical plane extends from the midpupil to the top of the eyebrow and up to the hairline. We have found that the normal distance from the midpupil to the upper edge of the eyebrow on average is 2.5 cm and that the distance from the upper edge of the eyebrow to the hairline is approximately 5 cm on average. If the distance from pupil to brow is less than 2.5 cm, then the patient may benefit from a forehead lift. If the distance from brow to hairline is less than 5 cm, then we use a posthairline incision in females. If this same distance is greater than 5 cm in females, we advise the prehairline incision. In male patients we strongly consider direct crease incision. The direct browlift is reserved for minimal ptosis, asymmetry, or patients who wish a minimal procedure. We have found these criteria for the forehead lift to be simple, reliable, and clinically useful.Presented at the 22nd Annual Meeting of the American Society for Aesthetic Plastic Surgery, Orlando, FL, April 1989, and at the Xth Biennial Congress of the International Society of Aesthetic Plastic Surgery, Zurich, September 1989     

Present status and future prospects for aesthetic plastic surgery

The recent developments and changes in surgical procedures such as rhytidectomy, blepharoplasty, nasoplasty, otoplasty, mammoplasty, mammary reconstruction, and abdominoplasty are briefly reviewed in this article, which is substantially reduced in its overall length from the guest lecture given by the author at the Seventh International Congress of Plastic and Reconstructive Surgery held in Rio de Janeiro in May 1979, in his role as president of the International Society of Aesthetic Plastic Surgery (ISAPS).     

A new technique for the treatment of lacrimal gland prolapse in blepharoplasty

The lateral temporal fullness of the upper eyelid in patients presenting for a blepharoplasty is sometimes due to a prolapse of the lacrimal gland. The operative procedures that attempt to reposition the migrated lacrimal gland have been either dangerous in that they cause a dry-eye syndrome or unsatisfactory in that they have a high rate of recurrence or other complications. A new and different operative approach to a herniated or prolapsed lacrimal gland deals with an extraglandular concept of repositioning the gland that corresponds to the general principles of hernial surgery.Presented at the 29th Annual Meeting of the Austrian Society of Plastic, Aesthetic and Reconstructive Surgery, Graz, Austria, October 1991Presented at the Annual Meeting of the Swiss Society of Plastic Surgery, Arlesheim, Basel, May 1992     

Arcus Marginalis Release II Via Endoscopic Midface-Lift

Tear troughs in combination with midfacial ptosis may be early and synergistic signs of aging. Premaxillary and suborbicularis oculi fat (SOOF) descent decreases soft tissue volume covering the orbital rim, while prolapsing retroseptal fat actually underscores the resulting tear trough shadow. This volume change precedes skin redundancy. Thus, volume redistribution avoiding external skin incisions is the adequate treatment. De la Plaza’s transconjunctival lower lid blepharoplasty is a reliable tool for arcus marginalis release. For patients also requiring an endoscopic midface-lift, even the transconjunctival incision for intraorbital fat compartment realignment can be avoided by performing the release of the lower orbita septum via the buccal mucosa incision. Presented in part at the XXth anniversary meeting of the Mediterranean Society of Plastic Aesthetic Surgery, Nice France, 13–15 April 2007     

Endoscopic facial rejuvenation: Endoforehead,the functional lift. Case reports

Endoscopic techniques have only very recently been applied to aesthetic plastic surgery procedures, especially in carpal tunnel release, in forehead plasties, and in breast augmentation operations. The author briefly outlines his experiences with endoscopic forehead lifts, first reported at surgical conferences in Los Angeles and Buenos Aires in 1992, and now totaling 61 cases performed in the 11 months just prior to the submission of this article. This endoscopic approach to forehead lifting has provided similar and comparable results to conventional coronal forehead lift operations, by means of small incisions made in the scalp area with minimal and fewer complications.Presented at the XIlth Congress of the International Society of Aesthetic Plastic Surgery (ISAPS), Paris, France, September 7, 1993     

The Forehead Lift: Endoscopic Versus Coronal Approaches

Rejuvenation surgery of the upper one-third of the face can be accomplished by a number of well-known techniques and approaches. The objectives of this study were to: (1) determine if endoscopic-assisted forehead lifts achieve the same degree of correction as the coronal/pretrichial forehead lifts, (2) to assess the effect of concurrent blepharoplasty on brow elevation, and (3) to evaluate long-term results of coronal/pretrichial forehead lifts. The study was a retrospective blinded comparison of pre- and postoperative photographs of patients who underwent forehead lifts. In order to control for the differences in photographs, ratios of distances were measured utilizing standard anthropometric sites of the brow, medial canthus, and subnasale. All reviewed cases were operated on by the same surgeon (S.W. Perkins, M.D.). A total of 140 patients having undergone forehead lift procedures and with 12-month postoperative photographic documentation were included in the study. Of these 121 patients had coronal forehead lifts and 19 had endoscopic-assisted forehead lifts. Results revealed that at 1 year follow-up both methods achieved brow elevation without a significant difference in the approach. Concomitant blepharoplasty had no statistical effect on brow position. Additionally, long-term follow-up on the coronal/pretrichial lifts revealed a gradual drop in brow position over 5 years. We conclude that both endoscopic and coronal/pretrichial forehead lifts provide for comparable elevation at 1-year follow-up. Concomitant blepharoplasty has minimal to no significant effect on brow position. Brow elevation in coronal/pretrichial forehead lifts may be temporary.     

Secondary endoscopic forehead lift in patients with previous coronal brow lifts

INTRODUCTION: The development of endoscopic surgical techniques has allowed an evolution from the standard coronal forehead lift to a minimally invasive one. Endoscopy avoids many of the undesirable results of the coronal approach while it remains very efficacious. The purpose of this study is to evaluate the effectiveness and safety of endoscopic forehead lift in patients who have previously undergone coronal brow lift. MATERIALS AND METHODS: A retrospective review was performed on the medical records of 726 consecutive patients who had undergone endoscopic forehead lift between 1994 and 2004. Sixty-three patients were identified who had undergone prior coronal incision brow lift and then required subsequent elevation of the forehead using endoscopy. Those who had persistent low eyebrows and forehead wrinkles underwent the standard minimal incision endoscopic approach. Patients with severe brow ptosis and excessive height of the forehead underwent a biplanar endoscopic forehead lift. RESULTS: Of the 63 endoscopic forehead lifts performed, 49 used the minimal access technique, while 14 employed the biplanar approach. The subject population consisted of 58 female and 5 male patients whose average age was 57 years (range of 42 to 80 years). Eighty-seven percent of these brow lifts also had concomitant rhytidectomy, and 4% had blepharoplasty. Average follow-up was 21 months (range 1 to 7 years). Following the endoscopic procedure, none of the patients had frontal nerve injury, alopecia, or persistent glabellar wrinkle lines. Complications included 1 forehead dysesthesia, 1 forehead irregularity, 1 eyebrow malposition, 1 persistent horizontal forehead wrinkling, and 2 hematomas. Operative management was not required for any of these complications. CONCLUSION: The secondary endoscopic forehead lift is effective in rejuvenating the upper face in the patient who has had a previous coronal forehead lift. It elevates the eyebrows and reduces both transverse and vertical wrinkles while avoiding further displacement of the hairline. The low rate of complications is comparable to that of primary endoscopic forehead lifts. Finally, serial follow-up indicates that the results are effective at correcting brow ptosis and are long lasting.     

The Round-Ear Incision in Full Face-Lifting

Several techniques for face-lifting have been described, all aimed at achieving a youthful appearance with a hidden scar. The authors are concerned about the conspicuous horizontal scar that travels all the way through the hairless skin behind the ears, which they consider very unpleasant and totally unnecessary. They are able to achieve a normal-appearing face with a safer technique that minimizes the visible scars such as the postauricular one, yet still has good and lasting results. In the past 9 years, 202 patients, men and women ages 38 to 86 years, have undergone surgery using the round-ear face-lifting technique, most of them with local anesthesia and sedation. The authors were able to achieve good and lasting results with a minimum of complications and to change the unaesthetic postauricular scar to a retroauricular one (with contouring of the concha) using a new design of marking the skin incisions. A new face-lifting incision is described. The procedure is suitable and safer for all patients requiring facial rejuvenation. The main advantage of this technique is the absence of visible postauricular scars. Paper presented at the 17th Congress of the International Society of Aesthetic Plastic Surgery (ISAPS), Houston, USA, 2004, and at the 18th Congress of the International Society of Aesthetic Plastic Surgery (ISAPS), Rio de Janeiro, Brazil, 2006.     

Das „upper face-lift“

The “upper face lift” is a modified treatment of the cranial two thirds of the face (forehead, brow, temporal, cheeks) which can be tailored to the patient’s individual requirements and extent of aging. It is essential in the treatment of ptosis of the forehead, brow and temporal region (including pseudoblepharochalasis of the eyelid, “crow’s feet”, frowning, horizontal folds and wrinkles) which is sometimes accompanied by sagging of the cheek (deeper nasolabial fold, hamster cheek). Together, these changes reinforce the impression of a negative, sad and/or tired or resigned expression. The method of choice for the correction and improvement of this loss of youthful appearance is, in our opinion and according to our experience, the subcutaneous forehead/brow lift with an individually formed hairline incision and cranialisation and dynamisation of the sagged superficial musculoaponeurotic system (SMAS) in the cheek area. Only the combination of forehead/brow lift with dynamisation of the cheek area achieve the desired and optimal result with a refreshed, naturally youthful appearance and restored attractiveness, thus ensuring full patient satisfaction and durability with minimal morbidity.     

Endoscopically assisted forehead-brow rhytidoplasty: Theory and practice

Forehead-brow rhytidoplasty has evolved from a procedure primarily advocated for brow ptosis, to one in which a group of deformities are routinely addressed. It has also become evident that the surgical results stem from wide undermining with release of the periosteum and the concomitant alteration of the forehead muscles and not necessarily from skin lifting using elevation/excision ratios. Therefore, with the introduction of endoscopically assisted techniques to plastic surgery, the indications for a long forehead incision and its untoward sequelae have to be reconsidered. The anatomic basis for minimally invasive forehead-brow rhytidoplasty and three types of procedures are discussed. These include Type I—complete, endoscopically assisted forehead-brow rhytidoplasty; Type II—segmental, in conjunction with facelift surgery; and Type III—isolated, frown-muscle modification. The role of fixation (external support, internal suspension, or excision techniques) is described. Results suggest that these options provide a worthwhile alternative to traditional open techniques in certain circumstances, although some relevant questions remain unresolved.Presented in part at the XXXXIIth Post-Graduate Instructional Course sponsored by the Educational Foundation at the Biennial Meeting of the XIIth International Congress of the International Society of Aesthetic Plastic Surgery, Paris, France, September 1993     

Neurosensory Preservation in Endoscopic Forehead Plasty

The recent introduction of endoscopic techniques and instrumentation in aesthetic surgery was caused in part by the desire to minimize surgical scars as well as to decrease the possibility of sensory changes secondary to extended incisions, such as the execution of a coronal incision in performing a forehead plasty. Although endoscopic surgical techniques provide field magnification together with excellent illumination, localization and preservation of the forehead neurovascular bundles via the endoscope can be time consuming and tedious. A new method is introduced where percutaneous localization of the supraorbital and supratrochlear nerves enables the surgeon to perform an endoscopic forehead plasty in an expeditious manner with preservation of sensation of the forehead and scalp.Presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery, Dallas, Texas, USA 1994     

Plastic Surgery: Personal Recollections,Contributions, and Some Thoughts: The Ohmori Lecture: 18th I.S.A.P.S. Congress,Rio de Janeiro–2006

Professor Ivo Pitanguy is Head Professor of the Plastic Surgery Departments of the Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Institute of Postgraduate Medical Studies. He also is a member of the Brazilian Society of Plastic Surgery, the National Academy of Medicine, and the Brazilian Academy of Letters, as well as Visiting Professor of the International Society of Aesthetic Plastic Surgery (ISAPS). He is a Fellow of the American and the International College of Surgeons (FICS, FACS). He also is the Honorary President of the Alumni Association of Professor Ivo Pitanguy, and has recently been declared the Patron of Plastic Surgery in Brazil through a unanimous vote by the Brazilian Society of Plastic Surgery.     

The “Biplanar” forehead lift

A new technique of forehead rhytidectomy is presented that combines the best features of the coronal incision with those of the anterior hairline incision. The plane of dissection is formed by an anterior subcutaneous plane dissecting a lateral subgaleal plane. This approach is particularly valuable in patients with high foreheads, severe static wrinkling, and asymmetrical eyebrows.Presented in part at the Annual Meeting of the American Society of Aesthetic Plastic Surgeons, Boston, MA, 1984     

The use of Silastic in face lifting

Pieces of Silastic are described which are placed in the nasolabial fold and in chin regions for the purpose of filling in depressions that may exist since youth and which may, in latter life, give the face a look of age, a look that is not completely improved with face lifting alone.Paper presented at the IV International Congress of the International Society of Aesthetic Plastic Surgery, Mexico City, Mexico, April 1977.     

Central (third) fat pad of the upper eyelid

A clinical study on the surgical anatomy of the upper-eyelid fat pads was performed on 55 consecutive patients who underwent a blepharoplasty. It was confirmed that the periorbital fat is encapsulated in compartments and that the number of fat pads varies. In 56% of the cases there were two fat pads and in the 44% three fat pads in the upper eyelid. The third fat pad is anatomically and histologically an accessory medial extension of the lateral fat pad. However, for the sake of clarity, the term central fat pad of the upper eyelid is proposed as a denominator of this structure. The purpose of this article is to make the less experienced surgeons aware of variations in the configuration of the periorbital fat and to remind them that after two fat pads are removed from the upper eyelid there might still be a third.Presented at the 10th Congress of the International Society of Aesthetic Plastic Surgery, Zürich, Switzerland, September 11, 1989     

Augmentation rhinoplasty

Augmentation rhinoplasty using a silicone implant is the most popular operation in Japan, but is not without several complications such as exposure of the implant and its deviation. We obtained good results in preventing these complications by a fixation at the hollow which is made by chiseling the frontal bone and by fibrous tissue which grows through the small holes of the implant tail.This paper was presented at the 36th Congress of the Japan Society of Aesthetic Plastic Surgery, Yokohama, Japan, May 16, 1987, and at the 9th Congress of the International Society of Aesthetic Plastic Surgery, New York, October 11–14, 1987     

小切口额眉提紧术联合重睑术治疗中重度上睑皮肤松垂症

目的探讨小切口额眉提紧术联合重睑术治疗中重度上睑皮肤松垂症的方法及疗效。方法采用小切口额部提紧术联合重睑术治疗中重度眼睑皮肤松垂症25例,通过发迹内或发迹缘小切口行帽状腱膜下剥离,眉毛及发迹缘行埋没导引缝合悬吊额眉部软组织,额眉组织提升后再行重睑成形术。结果本组切口平均0.9(0.8～1.0)cm,术后5～10d消肿,术后1月眼部形态恢复,额眉眼比例恢复。无一例大血肿、皮肤坏死等并发症。术后平均随访32个月(3个月～6年),所有患者上眼睑皮肤提紧,手术疤痕不明显。结论小切口额眉提紧术联合重睑术治疗中重度上睑皮肤松垂症简单、有效,不需特殊设备,在解除眼部症状的同时,又能达到良好的美容效果。     

Reduction malar plasty

Among Caucasians, augmentation malar plasty is occasionally performed, but, most often Orientals complain of the prominent zygoma and want an oval face. The procedure of the reduction malar plasty is not reported here. Instead, this article discusses the authors' method of reduction malar plasty and presents several cases.This paper was presented at the 6th Congress of the International Society of Aesthetic Plastic Surgery, Tokyo, September 29, 1981     

Concurrent brow lift and blepharoplasty with a resorbable fixation device

Background

Ageing changes on the forehead and the periocular area are of much concern to the patient not only from an aesthetic but a functional point of view as well. Many techniques exist for correction of upper periorbital ageing changes. We hereby present our technique of doing a brow lift and upper lid blepharoplasty as a combined procedure using a resorbable fixation device.

Methods

We carried out the study over a period of 36 months from July 2008 to July 2011. Only the patients requiring both brow lift and blepharoplasty were included in the study. Brow lift was performed through the upper lid blepharoplasty incision, and elevation was maintained by the resorbable fixation device screwed into the frontal bone. Following this, excess upper lid skin and muscle was excised to complete the upper lid blepharoplasty.

Results

A total of 25 cases including 17 females and 8 males were operated. The age ranged from 39 to 74 years, and the mean age was 54 years. Seven patients required both upper as well as lower lid blepharoplasty along with a brow lift, whereas 18 patients underwent only upper lid blepharoplasty along with a brow lift. In two of the patients who had a predominantly medial brow ptosis, we placed the Endotine device over the medial eyebrow. All patients were satisfied with the final result, and the device became impalpable over a period of 1 year.

Conclusions

The technique described is simple, reproducible and quick for addressing the upper lid and brow in one surgical sitting. A thorough preoperative discussion and demonstration of achievable result to the patient along with thorough understanding of the anatomy is the key to success.

Level of Evidence:

Level IV, therapeutic study.