Aesthetic considerations in the elevation of the eyebrow

In an increasingly diverse and multicultural society, it becomes increasing imperative to understand the aesthetics and proper analysis of the face, particularly as it applies to forehead lifting and elevation of the eyebrow. Most articles published to date have emphasized the surgical anatomy and/or surgical technique of forehead lifting and addressed the question of brow aesthetics in a uniform, generalized fashion. In addition, the emphasis on brow elevation as a means to brow/upper lid rejuvenation can further distract the surgeon from appreciating each person's unique brow aesthetics. This article examines current surgical concepts of brow/upper lid proportion and harmony and compares and contrasts them with cultural notions of the "pleasing brow" as represented by the makeup and fashion industries. There is great variation in what is considered to be a "beautiful brow," and the facial plastic surgeon must understand the nuanced elements of eyebrow configuration that contribute to the overall balance and harmony of the face.     

Endoscopic forehead lifting and contouring

The concept of endoscopic foreheadplasty is based upon a sub- or supraperiosteal dissection of the parietal, occipital and frontal scalp, incision and release of the superior and lateral orbital periosteum, selective myotomies of the brow depressor muscles, and brow elevation into a desired position with fixation and healing. A significant limitation of this procedure appears to be the ability to predict the long-term forehead and brow elevation. We review the anatomy relevant to forehead rejuvenation surgery and present our surgical technique for permanent fixation endoscopic forehead lifting. We discuss the scientific rationale for permanent fixation to ensure long-term forehead and brow position and draw our conclusions based upon the results of animal and clinical studies that have been completed.     

Surgical rejuvenation of the brow and forehead

The position and orientation of eyebrows plays an important part in the overall appearance of the face. Many incisions and approaches have been described to elevate a ptotic eyebrow. It is essential to understand the periorbital anatomy and the biomechanics of elevation and fixation of the brow and forehead soft tissues. If properly planned and executed, surgical brow lifts can restore a youthful appearance to eyelids and the orbit.     

A Simple Device for Incision Retraction and Protection in Endoscopic-Assisted Brow and Forehead Lifting

BACKGROUND: Endoscopic-assisted cosmetic surgery has revolutionized various procedures. Forehead and brow lifting performed with endoscopic technique has been shown to be predictable and has fewer complications than open techniques. Providing surgical access and protecting the hair follicles is paramount in endoscopically assisted brow and forehead lifting. OBJECTIVE: To describe a simple retraction device to assist in incision retraction and protect hair follicles. METHODS: A simple, inexpensive retraction device is described that has been used in 60 endoscopic brow incisions to effectively protect the hair follicles and retract incisions for operative techniques. In addition, other methods of follicular protection are discussed. RESULTS: Decreased incisional alopecia and improved surgical access are provided by the use of a simple retraction device and attention to follicular preservation. CONCLUSION: Endoscopic-assisted brow and forehead lifting is becoming the preferred method of upper facial rejuvenation. There is a steep learning curve and often the lack of attention to hair follicle protection results in localized incisional alopecia. In addition, improper surgical access complicates the procedure. A simple device is described to assist in retraction and follicular preservation.     

Subperiosteal transblepharoplasty forehead lift

Contemporary options for correction of the aging upper one-third of the face include open techniques with a coronal or anterior hairline incision, endoscopic access to the forehead including muscle transection, brow lift through direct forehead skin excision and various forms of brow-pexies. Realizing the common need for aesthetic improvement in the upper eyelids and desiring minimal incisions for forehead rejuvenation, an approach through the blepharoplasty incision has been developed which addresses all of the components of the aging upper third of the face: A combined subperiosteal approach for forehead elevation and transection of corrugator and procerus muscles through the blepharoplasty incision is presented. The postoperative improvements in the position of the brow as well as improvement in the glabellar area rivals other approaches and allows simultaneous improvement in upper eyelid aesthetics.Presented at the Annual Meeting of The American Society for Aesthetic Plastic Surgery, Inc., March 1995 and at the 13th International Congress of The International Society of Aesthetic Plastic Surgery, September 1995     

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.     

Management of the brow in facial paralysis

Management of the brow remains a challenging, important, and gratifying area in the care of facial paralysis patients. Aged facial paralysis patients generally require surgical management of brow ptosis. Young facial paralysis patients occasionally require surgical management of brow ptosis. Indications for surgical management, treatment options, and surgical approach are discussed. Consideration of factors such as age, forehead furrows, skin type, duration of paralysis, and degree of visual impairment are discussed in the context of treatment planning.     

Rejuvenation of the aging upper third of the face

Age-related changes to the upper third of the face manifest, typically, as brow ptosis and the development of deep skin furrows. Depression of the brow evolves as gravity and the action of the corrugator supercilli, procerus, and orbicularis draw on the progressively inelastic forehead skin. Facial mimetic muscle action reveals itself over time via the development of deep forehead rhytids. Facial plastic surgeons have at their disposal several effective surgical, and recently, medical interventions to address these changes. Each technique has merits and suitable applications. This review examines the history of rejuvenation of the upper face, details the pertinent treatment modalities, and evaluates the context in which each is applicable.     

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.     

Optimizing results in endoscopic forehead rejuvenation

Endoscopic forehead rejuvenation has several advantages over traditional open techniques. First, large incisional scars are avoided. Second, the chances of forehead elongation are less. However, the technique requires a significant learning curve for best results. Suboptimal results may occur and are typically due to underresection or uneven resection of the glabellar musculature, overdissection of the medial periosteum, and under or overcorrection when repositioning of the lateral brow. This article reviews the pertinent anatomy and techniques for endoscopic forehead rejuvenation, and describes the authors' technique for more consistent, predictable results.     

Forehead and brow lifts and their relationship to blepharoplasty.

The brows and forehead are important considerations in planning a blepharoplasty. Forehead wrinkles, ptotic brows, and frown lines can be corrected effectively and safely with minimal complications at the time of, and prior to, the blepharoplasty. Various approaches that we use are presented here. The surgical procedure selected should reflect the defect present and the surgeon's preference.     

Do forehead lifts lift or unfurl?

Forehead lifts are becoming increasingly more popular as an adjunct to facial rejuvenation. Considerable confusion exists as to how much the eyebrow should be elevated and how much scalp should be removed to achieve this goal. In an effort to evaluate this question, we have reviewed our recent forehead lift experience. These were done with forehead flap dissection down to glabella and supraorbital ridge, partial resection of corrugator supercilii, procerus, and frontalis muscles, and limited skin resection. We suggest that a natural-appearing, rejuvenating forehead lift should unfurl facial wrinkles without excessive eyebrow elevation. Technical maneuvers to obtain this goal are discussed.Presented in part at the Second Italian-American Congress of Plastic Surgery, Venice, Italy, September 1990     

Osteomas of the orbit.

Clinical and histologic features of osteomas are reviewed. Techniques are described for the evaluation of osteomas, including the use of coronal and axial plane computed tomography. A series of 14 patients evaluated at the Massachusetts Eye and Ear Infirmary over a five-year period is presented. Two of these patients are discussed in detail. Two surgical approaches to osteomas of the frontal sinuses are described. A brow incision is recommended for tumors primarily within the orbit. A coronal incision and osteoplastic operation is recommended for tumors primarily within the sinuses. In one patient, unusually rapid tumor growth is documented by x-rays taken over a three-year period.     

Transblepharoplasty brow suspension: an expanded role

Brow position and hyperfunction of the muscles of forehead facial expression contribute to the aging diathesis of the upper one third of the face. In many cases, the eyelids and brows are addressed together to achieve a satisfying rejuvenation effect. Many different approaches to the brow are used, including the long coronal or pretricheal incisions, direct incision of the suprabrow or forehead, and finally the use of smaller incisions with an endoscopic technique. Another technique, deserving of further consideration, is the transblepharoplasty brow lift (TBBL). Though generally reserved for occasional use, this technique is easy to perform, minimizes facial incisions and operative time, and can achieve results comparable to other, more extensive, approaches.     

额眉提紧联合眼睑整形术的临床研究

为了使求美者既能消除眼睑皱纹，又能增添眼部美观。作者对５９例行额眉提紧联合眼睑整形术，取得了较好的美容效果。本文重点从美学方面对联合手术的优点及单纯手术的不足进行了讨论。     

Evolution in techniques for endoscopic brow lift with deep temporal fixation only and lower blepharoplasty-transconjunctival fat repositioning

As we become more confident with our surgical skills following our fellowship training, some of our approaches and techniques will be modified or changed. My primary evolutionary change involves procedures of the upper third of the face, primarily the brow lift and treatment of lower eyelid fat techniques. Traditional methods of forehead and brow rejuvenation, such as coronal, pretrichal, and direct brow lifts, have provided facial plastic surgeons with effective brow elevation for many years. In the past decade, the endoscopic brow lift has rapidly become accepted as part of the surgical armamentarium and is frequently the technique of choice. In general, the temporal dissection, temporal fixation, forehead subperiosteal or subgaleal dissection with release, and treatment to the brow depressor musculature have been standardized. Methods of bony fixation remain a controversial topic as there are numerous methods. We advocate deep temporal fixation only without bone fixation to achieve effective, long-term brow elevation. Traditionally, lower eyelid herniated fat is removed, which may cause a sunken or hollow lid appearance, especially in patients with a tear trough deformity (nasojugal groove). Lower eyelid transconjunctival fat repositioning, defined as the subperiosteal repositioning of the medial and central lower eyelid herniated orbital fat into the nasojugal fold, may prevent the surgical, hollow lower eyelid appearance while treating the herniated fat. Fat repositioning may be combined with an endoscopic subperiosteal midface-lift, transcutaneous skin pinch, and transconjunctival orbicularis oculi excision. This technique offers a powerful tool in the surgical armamentarium of the facial plastic surgeon.     

Bitemporal flap reconstruction of forehead.

The bitemporal flap meets the increasing demand for esthetic reconstruction of forehead defects. The surgical technique, applied anatomy, and plastic surgery principles are reviewed. Illustrative case histories review the application of the bitemporal flap reconstruction technique.     

Totally laparoscopic abdominal aortic aneurysm repair.

Current experience with totally laparoscopic aortic aneurysm repair is reviewed with particular attention to the techniques of surgery. Vascular surgery has been slow to enter the field of minimally invasive surgery because of the unique difficulties of managing arterial anatomy with minimal access techniques. Laparoscopic instrumentation has undergone a stunning evolution, and surgeon experience with minimally invasive surgery has grown exponentially. This dramatic revolution has allowed several groups to perform laparoscopic aortic vascular surgery. The surgical approach that each group has taken has varied. The approaches have included both laparoscopically assisted and totally laparoscopic aortic surgery with both transperitoneal and retroperitoneal approaches to the aorta. A review of these varied techniques will be discussed and include our experience with totally laparoscopic aortic surgery. This experience includes both transperitoneal and retroperitoneal approaches to infrarenal aortic aneurysms. An extended discussion of our surgical technique for aneurysm bypass is included. Patient selection, patient positioning, and trocar placement are described. The pattern of surgery for both techniques is enumerated, and postoperative care is discussed. However, the world experience with minimally invasive vascular surgery remains small, therefore a wider acceptance will require a prospective, randomized trial that shows an equally as safe surgical approach as provided open vascular surgery. With its acceptance, minimally invasive vascular surgery should show the patient benefits that befall minimally invasive surgery patients.