A. Aldo Mottura
Even though the endoscopic frontal lift appeared to replace the traditional open techniques, the initial enthusiasm has been decreasing in the last few years. According to recent papers, in the USA half of the plastic surgeons still prefer the open techniques [2-5].
There are two standard open frontal lifts: the in-tracapillary or coronal lift and the precapillary one . In both, surgeons transect the galea and revert the frontal flap to treat the frontal, corrugator and proc-erous muscles [6-8]. As a disadvantage, these techniques require the incision to be long enough and the galea to be transacted all along the skin incision to turn over the flap. As a consequence of that, long scars should be expected as well as an alteration of the sensitivity of the scalp which is often observed as a result of the section of the sensitive nerves of the scalp. Besides, when the arteries and veins of the scalp are sectioned, there is a diminution of the blood supply of the scalp that in the course of years produces a decrease in the hair population of the scalp.
In accordance with Knize's concept  of the lateral subgaleal dissection of the forehead, I began to try another way of doing an open frontal lift without undesirable side effects.
In my routine, I use the endoscopic procedures in young patients or in minor or moderate brow ptosis. But when I am confronted with a marked ptosis and a resection of skin or scalp is necessary, the open techniques are selected. If the forehead is a narrow one, so that the hairline can be moved 1-2 cm backward, I use the intracapillary or coronal technique, but if there is a receding hairline that cannot be moved backward, in that case or when the patient would like to have a narrower forehead, I select the precapillary technique. When the patient has a 6-7-cm-wide forehead but with a coronal technique this should be
moved 2 cm backward, this precapillary technique should also be considered (Figs. 29.1, 29.2).
With the patient in a standing or sitting position, I pencil on the skin or on the scalp the amount of skin I will remove. I consider a ratio of brow elevation to skin removal of 1:1 for the precapillary technique and 1:2 for the intracapillary one.
I infiltrate under the incision lines and in the area to be dissected a solution composed of 10 ml lidocaine, 10 ml bupivacaine, 0.5 ml 1:1,000 adrenaline and 150-200 ml saline solution. Then I do the incision on the skin all along the marks and the skin is easily stripped off the galea.
With the intracapillary technique, a small incision is performed in the middle of the galea from where I
introduce a dissector that separates the galea from the periosteum. One additional 5 mm small incision 1 cm posterior to the hairline is made for the introduction of a pair of scissors to have direct access to the orbital rim. The scissors progress in the subgaleal plane and an opening is made perpendicularly to the frontal bone to separate the attachment of the galea from the periosteum and at the orbital rim. In case the incisions extend to the temporal regions, complementary small incisions at the galea facilitate the lateral subga-leal dissection. Once the forehead is completely mobile, the folding of the galea is performed with a 3/0 Vicryl running suture taking big bites at the galea at both sides of the cutaneous wedges. After three to five bites, the thread is pulled strongly and the galea is automatically folded, and this is repeated to the other end of the incision. This way the skin contacts without any tension and can be stapled (Figs. 29.3-29.8).
In the precapillary technique, the skin incisions are marked following the irregularities of the hairline or in a W pattern. The subgaleal dissection and galea folding are conducted in the same way, but the skin sutures are performed using 6/0 mononylon separate sutures.
The treatment of the corrugator or the procerous muscles can be performed through an upper-lid incision or using the assistance of the endoscope trough the galea when, as in most cases, concomitant superior blepharoplasty is performed.
No compression bandage is used and for some hours gauze soaked in cold chamomile tea is applied over the forehead
I have experience of 34 cases using the coronal approach, and of 30 cases using the precapillary one. I had to touch up a small part of the scar in three cases with the precapillary approach and in one case with the coronal one. I had to review the whole procedure in one case of unsatisfactory brow elevation when I used the coronal technique [11, 12]. Transitory hair loss around the scar was observed in one case of the coronal approach, with the total amount of the hair population being recovered in the fifth month. When the precapillary approach was used, transitory pares-thesia of the scalp recovered total sensation before the sixth month. When the precapillary technique was
used, in no case did the patient complain about the scar. There was no case of diminution of the hair population posterior to the scar. Stable results can be observed 3-4 years after surgery (Figs. 29.9-29.12).
The first complete technique concerning the open frontal lift has to be accredited to the Argentinian José Viñas , who described in 1967 the coronal and precapillary approaches, transecting the galea and everting the frontal flap. Since then this technique has been carried out with slight variations. According to De la Plaza's ideas  of subgaleal dissection, the mobile part of the scalp, I would add that by folding the galea, this tissue is tensed and still remains mobile, thus preserving an important part of the expression. A mobile galea as opposed to a fixed galea obtained after its fixation to the bone. Moreover, resecting a strip of skin contributes to stretching the skin and to smoothing the wrinkled forehead.
Without transecting the galea, the plane where arteries, veins and nerves run, the blood supply of the forehead and scalp is preserved, which is especially important in elderly persons.
At the orbital rim region, opening the scissors in a transverse way and only dissecting and separating the planes do not damage the vessels and nerves [9, 10] (Figs. 29.13, 29.14). The dissection should be gentle, especially at the lateral site where the fine nerves of the frontal branch run.
After some precapillary procedures, some months of paresthesia can be observed, posteriorly to the scar. This can be the consequence of the compression of the galea suturing, but absorbable threads release the possible nerve compression after 3-4 weeks.
Folding the galea with a running suture is a fast, simple and uniform procedure that can also be done with separate stitches, but is more demanding and time-consuming. The whole coronal procedure takes
Fig. 29.12. a Intracapillary approach. b Two-year follow-up with the sclera corrected
around 20 min to perform, while the precapillary procedure takes about 40 min.
Some difficulties in the dissection can be observed in secondary cases when the galea is fixed to the deep temporal facia or to the bone. The W incisions as proposed by Camirand  at the hairline with the scalpel beveled 30°, reduce the skin tension at the scars and allow the hair to grow into and anteriorly to the scars; thus, inconspicuous scars are obtained
With this conservative way of doing an open frontal lift, two of the three drawback of the standard open technique are avoided, i.e., preserving the blood supply of the scalp and the integrity of the nerves. The length of the scars can also be reduced according to each case because there is no need to make large incisions from one earlobe to the other, because the frontal flap is not everted. Comparing some cases of endo-scopic frontal lift when three to five incisions are made, we find that in some cases they reach 12 cm, while with the open procedures, the incisions are 1418 cm long, so the difference is not significant.
Some hours of postoperative pain relief can be obtained with the use of bupivacaine in the anaesthetic solution.
By using this conservative open frontal lift, the brows can be elevated with a simple and fast technique, leaving acceptable scars, with a minimal rate of allopecias and without the drawbacks of the classic open techniques. It is an excellent alternative for those surgeons who still perform the classic open frontal lift.
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