Forehead Lifting

Aging in the upper face becomes evident with a descent in the level of the eyebrow and the appearance of wrinkles and furrows, sometimes from an early age. These are a direct consequence of muscle dynamics, responsible for the multitude of expressions so characteristic of man, and also due to loss of skin tone. The use of botulinum toxoid has been a valuable adjunct to temporarily correct these lines of expression and has been widely indicated as a nonsurgical application, either by itself or as a complement to surgery.

Elements of the upper face that must be considered preoperatively for any procedure are the length of the forehead and the elasticity of the skin; muscle force and wrinkles; the position of the anterior hairline and the quality and quantity of hair.

An important decision to be made regarding a brow-lift is the placement of incisions. There are basically two classic approaches: the bicoronal incision and the limitedpre-pilose or juxta-pilose incision. The first allows for treatment of all elements that determine the aging forehead while hiding the final scar within the hairline. Certain situations, however, rule out this incision. Patients with a very long forehead or those that have already been submitted to previous surgery should not be considered for this incision, because they will have an excessively recessed hairline if the forehead is further pulled back. The final aspect will be displeasing, giving the patient a permanent look of surprise.

If the surgeon chooses to perform a bicoronal incision, a tri-plane approach is the preferred method:

Fig. 40.12. Positioning of the forehead flap is only done after the facial flaps have been rotated and "blocked." This avoids excessive elevation of the facial tissues, and alteration of the hairline

subgaleal down to the orbital rim, then subperiosteal, and subcutaneous over the glabella and all the way down to the nasal tip.

Having "blocked" the facial flaps at points A and B, as described before, we may pull the forehead in any direction, either straight backwards, or more laterally (Fig. 40.12). The amount of scalp flap to be resected is determined by the length of the forehead and the effect that traction causes on the level of the eyebrow. The midline is positioned, demarcated, incised and blocked with a temporary suture. Sometimes no traction is necessary and no scalp is removed in the midline. Two symmetrical flaps are created, and lat-

Forehead Lifting
Fig. 40.13. Correction of the level of the brow to a more elevated position may be done by the juxta-pilose incision, with a sub-periosteal blunt dissection

eral resection can now be performed allowing the eyebrow to be raised as necessary.

The second approach is the juxta-pilose incision, performed when the patient presents with ptosis of the lateral eyebrow and scant lines of expression of the forehead. The short distance required to reach the eyebrow region is easily performed by subperiosteal blunt dissection (Fig. 40.13).

Endoscopic instrumentation has permitted treatment of the brow through minimal access, and has proved useful in selected cases (Clinical Cases 40.4, 40.5).

Complications in rhytidoplasty are infrequent, yet can bring great distress to the patient and to the surgeon. It is essential to eliminate patients who continue to smoke, as the risk for skin slough is greatly increased. Smoking must be stopped completely at least 2 weeks in advance. In the immediate postoperative period, blood pressure must be constantly monitored

The Coronal Incision

Clinical Case 40.4. Forehead lifting by the coronal incision may still be indicated, in selected cases. This 56-year-old woman presented with marked furrows over the forehead. A face-lift was associated with an open brow-lift. Left: The patient is seen preoperatively. Right: The patient is seen at 2 years follow-up. Notice that the height of the forehead has not increased

Clinical Case 40.4. Forehead lifting by the coronal incision may still be indicated, in selected cases. This 56-year-old woman presented with marked furrows over the forehead. A face-lift was associated with an open brow-lift. Left: The patient is seen preoperatively. Right: The patient is seen at 2 years follow-up. Notice that the height of the forehead has not increased

Clinical Case 40.5. Correction of the aging face was done together with elevation of the lateral third of the eyebrow, through a juxta-pilose incision. This 65-year-old patient is seen before and 1 year following the surgical procedure. Left: Preoperative view. Right: Postop-eratively by the nursing staff, to prevent hypertension and consequently hematoma formation. If an expansive hematoma is diagnosed, the surgeon may initially attempt to drain the collection at the bedside. Early identification and treatment of large hematomas is essential to prevent sequelae. Nerve injuries, dehiscence and other complications are infrequent and should be treated conservatively.

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