The operation is performed with the patient in supine positioning, either with intravenous sedation or general anesthesia. Prior to local infiltration, five radial port incisions are marked perpendicular to the hairline (Fig. 25.1). The midline incision is marked approximately 0.5 cm behind the hairline. The next set of incisions are marked as the vector of eyebrow elevation. These markings are 6.5 cm to 7 cm lateral to the midline marking and approximately 1.5 cm to 2 cm behind the hairline. The final pair of markings are approximately 3 cm lateral to the “vector” markings. All of the incisions are typically 1.2 to 1.5 cm in length, but may be slightly extended in males or in patients with thicker skin. Following marking, the non-hair-bearing forehead region is infiltrated with lidocaine 1% with 1 : 100,000 epinephrine, paying particular attention to the supraorbital ridge, glabella, and lateral temporal regions. The hair-bearing scalp is then infiltrated with lidocaine 1% with 1 : 200,000 epinephrine to minimize the possibility of postoperative alopecia.

Fig. 25.1 Location of the five radial port incisions. The midline incision is marked 0.5 cm behind the hairline, whereas the lateral incisions are 1.5 to 2 cm behind the hairline. Lateral ports are 6.5 cm to 7 cm lateral to the midline marking and 3 cm lateral to the “vector” markings. All of the incisions are typically 1.2 to 1.5 cm in length.

The lateral temporal ports are incised first and carefully dissected to the level of the deep temporal fascia. If the deep temporal fascia is not visualized and instead the dissection is performed in the superficial or intermediate temporal fascia, there will be inadequate visualization laterally, thus increasing the risk of injury to the temporal branch of the facial nerve. The remainder of the port incisions are made and carried to the subperiosteal level. Endoscopic assist devices (Applied Medical Technology, Cleveland OH) are inserted into the port sites in order to facilitate a clean insertion of the endoscopic camera and to keep hair out of the port sites (Fig. 25.2).

Fig. 25.2 Endoscopic assist device. The smaller silicone shield is inserted into the port incision. The larger external shield is connected to the internal shield by an obliquely oriented tube, facilitating entry of the endoscopic instruments.

Endoscopic dissection initially proceeds rapidly in the subperiosteal plane to the level of the supraorbital rim. Dissection is then extended laterally to the level of the lateral orbital rim and subsequently to the zygomatic arch (Fig. 25.3). Lateral dissection in the temporal region is performed in a blunt sweeping fashion in order to separate the superficial and deep temporal fascias. Careful dissection in the temporal region reveals both the sentinel vein and the zygomaticotemporal branch of the trigeminal nerve. The sentinel vein may be dissected from its investing fascia and cauterized if necessary, being mindful of the proximity of the temporal branch of the facial nerve. Once the lateral supraorbital rim is exposed, the periosteum and the arcus marginalis are released from lateral to medial. The periosteum is preserved in the glabellar region unless preoperatively it was discerned that the medial brow is positioned low. Preservation of the medial periosteum will help prevent excessive elevation of the medial brow. Care is taken when releasing the periosteum at the level of the supraorbital nerve, as excessive traction on the nerve is unwarranted and may lead to postoperative pain or excessive neuropraxia.

Fig. 25.3 Release of the periosteum at the lateral orbital rim using a periosteal elevator.

The glabellar musculature (corrugator supercilli, depressor supercilli, and procerus) are then resected. The senior author’s technique includes total removal of the musculature as completely as possible. During dissection of the corrugators, the supraorbital and supratrochlear nerves are identified and preserved, leaving the nerves in a “skeletonized” fashion (Fig. 25.4). Often, there is a communicating vein located deep to the corrugator and between the supraorbital and supratrochlear veins. This may be cauterized as necessary. Once the muscles have been adequately resected, the subcutaneous fat is visualized. The total resection of the glabellar musculature ensures that the vertical and transverse rhytids of the glabella will be eliminated with minimal chance of resultant muscular hypertrophy. Other described techniques describe subtotal muscular resection, thus weakening but not eliminating muscular activity.

Fig. 25.4 Resection of the corrugator supercilli. Note the skeletonized appearance of the supraorbital nerve.

Following muscular resection, a small incision in the deep temporal fascia above the medial zygomatic arch is made using a sharp curved periosteal elevator (Snowden Pencer, Tucker, GA). A small piece of temporal fat is harvested through this incision. If other procedures (i.e. rhytidectomy, abdominoplasty, liposuction) are being performed, fat from other sites may be utilized. The fat is then tailored to size and placed in the glabellar space. This eliminates the depression in the overlying skin due to complete resection of the musculature.

Once complete mobilization of the brow has been performed and the glabellar musculature resected, the endoscopic assist devices are removed and fixation of the brow is performed. Fixation in most instances is performed via suture fascial suspension (Fig. 25.5). At the lateral incision, a 3-0 polydioxanone suture is passed from the caudal end of the incision at the level of the superficial temporal fascia to the cephalic deep temporal fascia. This, in effect, attaches the superficial temporal fascia to the deep temporal fascia, allowing for traction of the brow without tension on the skin or superficial layers. In instances that brow arch position needs to be significantly altered, brow fixation using bone tunneling through the intermediate lateral incision may be employed. Bone tunneling is accomplished using a 1.1 mm hole burr with a safety guard at a maximum length of 4 mm. Two 45 degrees opposing burr holes are made approximately 3–4 mm apart. A 3-0 polydioxanone suture is used for the anchoring. Following fixation, a DTLS-Surgical Drainage System closed suction drain (Porex Surgical Inc., College Park, Georgia) is inserted into the lateral incision and passed across the length of the forehead. The galea and periosteum are repaired with 5-0 Monocryl and the skin is repaired with 5-0 catgut.