Carl A. Troilius
Most surgeons today practicing aesthetic surgery advocate an endoscopic subperiosteal technique for elevation of the brow and elimination of the glabella furrows and wrinkles [1-10]. The reason for this is of course the ability to avoid the bicoronal scar with possible hair loss [7, 11], the avoidance of transection of the supraorbital nerves and the subsequent numbness of the scalp behind the scar. The transection of the supraorbital nerves at the incision is also believed to be the cause of a prolonged period of itching of the scalp. The bicoronal subgaleal browlift also gives the patient a markedly raised hairline, usually in the ratio of 2-3 times the distance the eyebrows are elevated .
It is true that also the subperiosteal browlift raises the hairline, but not more than the distance that the brows are raised .
The operative time of the two procedures is about the same in the hands of a trained surgeon. It has also been proven that the long-term result of a subgaleal approach is less reliable and stable compared with that of the subperiosteal approach .
The stability and well-proven efficacy of the sub-periosteal method are independent of whether the procedure is done openly or with the aid of an endoscope. The two factors that matter for the result are the plane of dissection and the altering of the muscle balance in the brow [9, 10, 15] (Oscar Ramirez, personal communication, May 1996).
If the brow is raised with applied tension and some kind of fixation is used, the tension is applied to the periosteum - a strong and inelastic structure. The height-altered periosteum will stick to the bone within a few days, after which fixation is really not needed.
If, however, you try to correct the height of the brows by cutting and shortening the galea, you are relying on a totally elastic structure, which over a few months will elongate and the brow will resume its earlier position.
By following our patients over the last 10 years, we have recently concluded that in most cases where only a minor to moderate raising of the brow is indicated, we really do not need a fixation at all. We rely only on changing the balance of muscle vectors around eyebrows, the release of the forehead and raising of the brows as well as the excision of parts of the corrugator supercilii, dpressor supercilii and the procerus muscles. Scoring and damage to the frontalis muscle should be avoided. The habit of scoring the frontalis muscle comes from a misunderstanding of the cause and nature of the wrinkles in the forehead. The frontalis muscle should be regarded as our friend as it is the only muscle that actually lifts the eyebrows [12, 16-18].
A natural eyebrow lift is achieved by interrupting the restrictive forces of the corrugator supercilii and procerus muscles, against the upward action of the occipitofrontalis muscle .
Use of a subperiostal, endoscopic method can have some disadvantages. The fact is that the method is so effective and the skin can be pulled so tightly that the eyebrows end up unnaturally high. This can occur through a primary factor of applying too much pull between the periosteum and the fixation in the bone, if such is used. The other possible reason for exaggerated results is a later development. It is the slow raising of the forehead and eyebrows owing to the changed muscle balance in the glabella area. This development is also support for the conclusion that fixation is not necessary at all for forehead lifts where the desired result is a moderate lift of the eyebrows, less than 4 mm  (Fig. 31.1).
Long-term studies spanning 5 years indicate that if you measure the height of a patient's eyebrows from the center of the pupil to the top edge of the eyebrow before surgery and then again 1 year after, there is often a harmonic, natural rise of about 4-7 mm net. If the same patient is measured digitally 4 years later, their eyebrows are now a further 1-2 mm higher (Figs. 31.2, 31.3). This is a statistically significant result that can only be explained by the change in muscle balance occurring around the eyebrows when the negative, downward-pulling vectors through the musculus procerus, depressor supercilii and corruga-tor supercilii are eliminated or greatly weakened to the benefit of the upward-pulling vector through the
musculus frontalis, which intact over time can slowly affect the eyebrows and forehead, causing them to rise. A natural conclusion is that fixation is not necessary or perhaps even not desirable for small or moderate eyebrow lifts or often when the indication for surgery is a desire for a change in eyebrow shape, that is to say a lift of either the lateral or the medial ends, perhaps in combination with elimination of vertical wrinkles in the glabella or general horizontal wrinkles in the forehead.
A forehead lift is an extremely special operation. Very few of the patients that sit in our consultation chair ask specifically for a forehead lift. It is more common for them to ask about eyelid surgery, mentioning that they have a tired appearance. As surgeons, we can often identify the problem as a combination of excess skin at the upper eyelid with eyebrows that sit low or that have lateral ends that lie lower than the medial ends. This contributes to a tired appearance. If you do not first adjust the eyebrows to a normal level and reshape them, upper-eyelid surgery has little chance of success and there is little chance that the patient will be satisfied afterward. It is also a well-known fact that if you solely perform upper-eyelid surgery on a patient, the eyebrows will be lowered 3-4 mm  (Fig. 31.4). This is because prior to the surgery, the patient felt the weight of the extra skin on the upper eyelid and tried to compensate for such over many years by raising the forehead with the help of the musculus frontalis. After upper-eyelid surgery, this stimulus to the musculus frontalis disappears and the muscle begins to relax, causing the eyebrows to lower. This is not always a negative development, but it is something the surgeon must take into consideration during the consultation.
Other patients that sit in our consultation chair may have been told by others that they look angry or sad. There has been no case where the patient saw a clear connection between this appearance and their eyebrows, so patients in this situation do not tend to ask about a forehead lift. That is why it is up to us as experts in the field to help the patient understand the connection between his/her appearance and the procession and shape of the eyebrows, perhaps in combination with deep vertical wrinkles in the glabella area. An alternative treatment of the latter condition can be a Botox injection in the area. If done well, this can imitate the effects of a forehead lift with muscle resection. The effects, however, are only temporary.
We should, however, under no circumstances contribute to an indiscriminate raising of the eyebrows,
which often results in an unnatural appearance. We should instead analyze the shape of the eyebrows and their position in relation to the eyelids. If we as surgeons honestly examine our results with different types of forehead lifts and compare them with the appearance of a young, beautiful model (Fig. 31.5), we will unfortunately find that our surgical browlifts often have an unnaturally high position. For this reason, I now only use fixation in any form in about half of all my forehead lifts.
You start by examining the patient from the front while he/she is in a sitting position. You then mark the
shape and position of the eyebrows. It is important to examine which part of the eyebrow needs to be raised the most and which needs to be raised the least. The point in the eyebrow that is to be raised the most is transferred vertically up to the hairline.
First you make an incision at the front edge of the hairline along the midline, followed by two vertical incisions on each side, which correspond to the marked point of each eyebrow (Fig. 31.6). If the patient has an abnormally high or receding hairline, these incisions can be made in non-hair-bearing skin provided that intradermal sutures are used upon completion. Hereafter, you begin dissection from the central incision and release the periosteum blindly but without destroying it. Use slow, steady movements with the elevator. From the central incision, it is important to lift the periosteum on each side of the two lateral incisions in order to keep the periosteum as intact as possible in these two lateral incisions if you wish to apply a fixation suture here. There is no dissection rearward behind the incisions over the scalp. An important factor in how easy the dissection is, how little blood there is and whether the periosteum can be lifted in a piece that is as whole as possible is the infiltration anesthesia administered prior to surgery. By applying the needle with the beveled side down, slightly tangential to the skin, you can with hydrodissection facilitate the later release of the periosteum. The endoscope is then introduced from the center incision and an elevator is introduced in one of the lateral holes, depending on at which side you begin (Fig. 31.7). Dissection occurs under the eye all the way down to the orbital rim. Dissection releases the periosteum all the way out to the lateral orbital rim, where the sentinel vein is often hit and bleeding must be stopped. You then dissect along the temporalis muscle so that the dissected pocket is well outside of the lateral edge of the eyebrow. Exercise care around the supraorbital nerve, which runs approximately 2 cm laterally of the midline. As you know, the nerve can lie in a channel a bit up the bone, which is why you may come across it before coming to the orbital rim. This is the case about 15% of the time. Perform dissection in the glabella area as far as the instruments allow.
The next instrument is an elevator that is curved downward and makes it possible to release the periosteum around the orbital rim. When the pocket is completely open from one lateral end to the other, a scalpel, honed elevator or laser is used to cut the periosteum from one lateral orbital rim across to the other. Try to make this incision as low as possible while watching for nerves and blood vessels in the supraorbital area. The next step is to use an upward-bent elevator to lift the periosteum and spread it, to make it possible to see the underlying nerves and muscles. The most important part of the entire operation comes next: muscle resectioning in the glabella area. At this stage, it is good to have a long instrument that is insulated and can be used to coagulate bleeds. The best is a long, insulated, curved suctioning device that can suction smoke and blood while you coagulate a source that is being suctioned. We use graspers as we not only cut the muscles but also resect so much of them that it is not possible for the ends to rejoin. Unless the patient has deep, vertical wrinkles in the gla-bella area, it is not necessary to completely resect all muscles. At this stage, you do not need to worry that
there will be a depression after muscle resectioning in the glabella area as experience tells us that this does not occur. The resected area is filled out rather quickly with fibrous tissue. After ensuring that all bleeding has stopped and inspecting the area, we remove the endoscope. If fixation is to be used, now is the time. We never use external fixation with staples as this undoubtedly leads to unnecessary hair loss and is uncomfortable for the patient. We use one of two internal fixations. The first possibility is a 4 mm titanium screw that is drilled into the bone at a drill speed of ten revolutions per second with cooling, where the drill has a stop at 3 mm.
A suture is then placed through both sides of the periosteum in front of the incision and is then pulled back to be tied around the screw before it is screwed as flat into the skull as possible (Fig. 31.8). As stated earlier, we avoid pulling this fixation suture too hard as you can expect a few more millimeters of lift in the future in addition to the immediate results of the eyebrow lift directly after surgery. Choice of suture is irrelevant as the periosteum fastens within 72 h. The second possibility for fixation is a so-called Endotine device (Coapt Systems, Palo Alto, CA, USA), which is a small bioabsorbable plate that is fastened in a pre-drilled hole in the skull. The plate has several small, 2-mm-long upward-pointing tines in which you fasten the periosteum. This method works wonderfully, but is quite costly.
The incisions are then closed with staples if they lie behind the hairline or with intradermal sutures if they lie in front of the hairline. We do not use drains or dressings. The hair is washed with water on the operating table and then washed thoroughly with shampoo the next morning. We recommend to our patients that they allow 1-2 weeks for convalescence
Bleeding and infection are two possible complications, but luckily they are very rare. We have experienced one instance of bleeding in 1,000 operations and have yet to experience any infection. This is likely due to the extremely good vascularization in the area. The patient commonly experiences a temporal lack of sensation in the area of the forehead and backwards. This usually returns within a few months.
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