Forehead28

The Scar Solution Natural Scar Removal

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Dimitrije E. Panfilov

The upper third of the face is limited by the hairline above and the eyebrows below. The most powerful muscles, innervated by fronto-temporal branches of n. facialis, are m. frontalis and mm. corrugatores supercilii. The hyperaction of frontalis ingraves the horizontal "wrinkles of concentration" and corruga-tors produce vertical glabellar "wrinkles of anger" or "worry wrinkles".

The superficial wrinkles can be treated by peeling (mechanical dermabrasion, chemical abrasion, laser abrasion, or by radiofrequency treatment) through permanent or nonpermanent skin-fillers or by Botox, the huge popularity of which some 3-4 years ago has diminished for two reasons. First, its measurable effect lasts only 8 weeks; second, faces with a china surface have no mimetic expressions. Autologous fat transfer into the lower two thirds of the face is very successful but is less effective in the forehead, probably because of strong tension of the skin in this region.

In the last 10 years I only twice did a classic forehead lift with preferably ciliar incisions. The majority of foreheads were treated by endoscopic forehead lift.

If two or more forehead wrinkles are very deep, they can be excised, well adapted, and sutured in two layers very carefully. After a while, the scar will look like a single wrinkle.

Thanks to endoscopic technology, we are now able to lift the forehead through three to five incisions of 1-2 cm length. The light source and the microcamera have a diameter of 4 or even 2.7 mm and on monitor we see anatomical structures magnified 10 times.

Endofrontal lift is almost always associated with temporal lift, which can also be performed isolated. Temporal excision should be made in a prolonged line from the nostril to the lateral canthus.

The medial part of the forehead can be reached through a T-incision. Caudal preparation with a less or more curved rasparatorium follows in the sub-periostal layer, backwards on the scalp in the subga-leal layer. After weakening of frontal muscle, the occipital muscle produces more tension through the galea. Proceeding forward and caudal with the raspa-ratorium, we reach the level of the eyebrows. Here we need a horizontal complete uninterrupted section of the periosteum from the left end of left eyebrow to the right end of the right eyebrow. This is easy to perform with the rasparatorium turned opposite to the bone curvature.

Care should be taken of the nn. supratrochleares, which arise 17 mm lateral of the midline, and the nn. supraorbitales, which are 27 mm away from the mid-line, as Lopez from New York found after cadaveric studies. This distances are constant. Knowing this,

Rasparatorium Surgery
Fig. 28.1. Endoscopic forehead lift

Fig. 28.2. a Chemical peeling. b Laser peeling. c Botox we can do endo-forehead lift without an endoscope. We would not recommend this, unless the operating surgeon has done many endoscopic surgeries before. An endoscopic muscle-grasper is very useful for removing corrugator and procerus muscle fibres.

For fixation we use neither metal nor resorbable screws. From inside we apply fibrin glue, pull the skin manually, and keep this position for 3 min and close the V incision, temporal incisions, and eventually two more minimal incisions, if needed as an entrance for instruments, with stapled clamps.

The outside fixation starts with suture strips as paper stitching plaster to keep the eyebrows elevated, starting from the midline. Thereafter the adhesive bandages are applied in the same manner and should remain for 8 days. Removal should be done starting from the eyebrows and pulling backwards.

Bibliography

Please see the general bibliography at the end of this book.

Fig. 28.2. a Chemical peeling. b Laser peeling. c Botox

  1. 28.3. a Zigzag incision allows an inconspicuous suture line. b Exposed frontal bone and the m. procerus and mm. supercilii. c Suture line at the end of the surgery. The same patient d before and e 2 weeks after surgery corrugators
  2. 28.3. a Zigzag incision allows an inconspicuous suture line. b Exposed frontal bone and the m. procerus and mm. supercilii. c Suture line at the end of the surgery. The same patient d before and e 2 weeks after surgery corrugators
Fig. 28.5. a Endoscopic microcamera with a cold-light source. b Sitting above the head of the patient, looking at the procerus muscle fibres at the nasal root on the monitor. c Nonbleeding

surgery with minimal scaring and minimal complications. d Four or five well-chosen instruments will do the job

Fig. 28.6. a Superficial temporal fascia incised, prepared and tightened backwards to be sutured at the deep temporal fascia. b Semilunar area of hairy skin removed and sutured
  1. 28.7. a Dermographic markings of the nn. supratrochleares the midpart of the frontal skin should be pulled backwards, medial and nn. supraorbitales lateral (green vertical lines). the lower T wings cut off, and sutured in a V manner: T-V-Wrinkles are marked in blue. b T-incision: after preparation, plasty
  2. 28.7. a Dermographic markings of the nn. supratrochleares the midpart of the frontal skin should be pulled backwards, medial and nn. supraorbitales lateral (green vertical lines). the lower T wings cut off, and sutured in a V manner: T-V-Wrinkles are marked in blue. b T-incision: after preparation, plasty
Fig. 28.8. a Fibrin glue applied subperiostally. b Adhesive bandages pulled backwards and stapled parieto-occipitally. c Below the adhesive bandages, vertical pull of the eyebrows through suture strips

Fig. 28.9. a Vertical glabellar, horizontal wrinkles and deep eyebrow through elevation of the eyebrows - "nonscrewing method"

position.

Removing of wrinkles and opening of the eyes

Fig. 28.9. a Vertical glabellar, horizontal wrinkles and deep eyebrow through elevation of the eyebrows - "nonscrewing method"

position.

Removing of wrinkles and opening of the eyes

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