Introduction

The plastic surgery armamentarium for forehead rejuvenation has expanded considerably during the past 15 years.^1–12 Whereas the focus of rejuvenation in the past was focused mainly on the face and neck, it has now become widely recognized that rejuvenation of the forehead is essential to produce a natural, well-balanced result. There is now greater emphasis on minimizing incisions and long-term side effects, such as numbness, while achieving a superior aesthetic outcome with improved patient satisfaction. Less invasive techniques have also emerged.

The senescent changes reflected in the forehead area may range from barely discernible glabellar lines to the full gamut of eyebrow ptosis, deep frown lines, elongation of the forehead, and deep horizontal lines. Not every patient who has been affected by gravity desires a complete forehead rejuvenation for a variety of reasons. The aesthetic surgeon must therefore be equipped with a gamut of techniques that will offer solutions to satisfy every patient’s needs.

This chapter reviews most of the techniques available for forehead rejuvenation.

Indications

Preoperative History and Considerations

Operative Approach

Relevant surgical anatomy

The forehead is a dynamic zone of the face, especially in expressive people. Frequent use of the muscle often results in lines and creases. For instance:

• contraction of the frontalis muscle may cause horizontal lines;

• contraction of the corrugator muscle may result in vertical lines;

• the depressor supercilii muscle is often responsible for the creation of oblique lines in the medial eyebrow area;

• creases at the root of the nose are a product of procerus muscle overactivity coupled with forehead ptosis.

The anatomic layers of the forehead are both continuous and analogous to the five layers of the scalp.¹⁶ There is a gradual decrease in sebaceous gland content of the skin in a cephalad direction.

As with the scalp, the forehead skin is firmly adherent to the underlying epicranial layer. The epicranial layer is formed by the vertical fibers of the frontalis muscle anteriorly (Fig. 7.1) and the occipitalis muscle posteriorly. The galea aponeurotica spans these muscles.

Fig. 7.1 Anatomy. Artistic illustration of muscles, nerves, and vessels of forehead.

Operative Technique

Complications

A distinct disadvantage of fat injection is its unpredictability, but multiple passes and injections in different planes may improve the predictability and reliability. Another disadvantage is its failure to eliminate the muscle function, thus its inability to avoid recurrence of lines.

Fat injection is generally an uncomplicated procedure, but over- or under-injection may occur.

One serious complication of fat injection, which is extremely rare, is blindness.^11,12 The loss of eyesight is probably related to embolization of the injected fat into the retinal artery. If this complication develops, immediate consultation with an ophthalmologist is necessary. Intentional overcorrection may result in longlasting glabellar fullness, which may ultimately resolve. This site is more privileged as a fat recipient site than most sites in terms of retention of the injected volume, and complete fat absorption is unlikely, which reduces the need for an overcorrection.

Postoperative Care

Advantages of fat injection are the ease of the technique and a lack of any incisional scars. Usually the patient recovers quickly and may be presentable the next day, provided there is no significant ecchymosis or edema. The results are commonly longlasting (Fig. 7.2A&B).

Fig. 7.2 Before and after fat injection. A, Before fat injection. B, 7 years after two injections of fat into frown lines.

(From Michelow B, Guyuron B. Rejuvenation of the upper face. A logical gamut of surgical options. Clin Plast Surg 1997; 24(2):199-212).

Operative Approach

Since its introduction by Neubeur in 1893, the use of an autologous fat graft has been consistently popular.¹⁸ The degree of fat graft take is:

After a large volume of fat is grafted, it undergoes distinct cytologic changes resulting in a peripheral zone of viable adipocytes, an intermediate zone of inflammation, and a central zone of necrosis. Therefore, the larger the volume of grafted tissue, the higher the percentage of the graft absorbed. In fact, if a large graft is used, one should expect a volume loss of 50% or more.

When a fat graft is thinner than 1 cm, a larger percentage of tissue will be revascularized and retained.

The amount of fat necessary to fill the glabellar frown lines is minimal, and this results in a high success rate.

Using fat grafts becomes a particularly useful adjunct to forehead rejuvenation when a concomitant procedure provides suitable donor tissue. A combination of facial rhytidectomy and fat graft to the frown lines is a notable example. The surgeon may use fat alone or dermis and fat in combination; however, when addition of a dermal component may increase the risk of cyst formation.

Complications

Fat graft may result in irregularities, infection, or accumulation of a small amount of blood around the graft, which may persist and cause the patient concern. These undesirable outcomes are unlikely.

Irregular absorption is an unlikely disadvantage of this technique because this type of graft seldom dissolves.

Postoperative Care

The advantages of fat grafting are its simplicity and avoidance of larger scars (Fig. 7.3A&B).

Fig. 7.3 Before and after fat graft. A, Before fat graft. B, After placement of fat graft in glabellar line.

(From Michelow B, Guyuron B. Rejuvenation of the upper face. A logical gamut of surgical options. Clin Plast Surg 1997; 24(2):199-212).

Operative Approach

A transpalpebral incision may be used to resect the corrugator which usually results in disappearance of the frown lines (Fig. 7.4A-D).^19,20 Transpalpebral corrugator resection may be performed concurrently with an endoscopic procedure to facilitate removal of the corrugator muscle. The advantages of this operation are its simplicity with direct and full exposure of nerves and muscles. The results are highly predictable and reproducible. When combined with a blepharoplasty, fat is readily available for replacement of the corrugator muscle.

Fig. 7.4 Before and after transpalpebral corrugator resection. A, In repose before transpalpebral corrugator resection. B, In repose approximately 1 year after transpalpebral resection of corrugator supercilii, C, Animated expression before transpalpebral corrugator resection. D, Animated expression approximately 1 year after transpalpebral resection of corrugator supercilii.

Operative technique

• Transpalpebral corrugator resection is performed with the patient under intravenous sedation using fentanyl, midazolam, or propofol.

• The upper eyelid and glabellar areas are generously infiltrated with lidocaine hydrochloride containing 1 : 100 000 epinephrine.

• If blepharoplasty is to be performed concurrently, eye shields are placed first, and the conventional upper blepharoplasty incision is used. Otherwise, the incision is confined to the medial half of the conventional blepharoplasty incision.

• After removal of the redundant skin if intended, the orbital septum is retracted caudally and the orbicularis muscle is pulled cephalically (Fig. 7.5).

• The easily identifiable plane between the orbital septum and orbicularis muscle is easily entered, and dissection is continued toward the superior orbital rim.

• While the orbicularis muscle is being retracted anteriorly, the depressor and corrugator supercilii muscles are exposed immediately cephalad to the orbital rim (Fig. 7.6). A few branches of the supratrochlear nerve may become visible at this point; if so, they should be retracted and protected.

• As much as possible of the depressor and corrugator supercilii muscles are exposed and removed. The supratrochlear and supraorbital nerves are identified and preserved. The muscles are removed using the coagulation power of the electrocautery (Fig. 7.7). Occasionally gentle traction with a pair of multi-tooth forceps may be sufficient to avulse the muscle.

Fig. 7.5 Transpalpebral corrugator resection 1. After incision and removal of excess skin, if intended, the orbicularis muscle is retracted cephalically, the orbital septum is pulled caudally and the dissection is directed toward orbital rim.

(From Michelow B, Guyuron B. Rejuvenation of the upper face. A logical gamut of surgical options. Clin Plast Surg 1997; 24(2):199-212).

Fig. 7.6 Transpalpebral corrugator resection 2. The corrugator muscle is exposed as widely as possible while orbicularis muscle is retracted anteriorly.

(From Michelow B, Guyuron B. Rejuvenation of the upper face. A logical gamut of surgical options. Clin Plast Surg 1997; 24(2):199-212).

Fig. 7.7 Transpalpebral corrugator resection 3. As much of the corrugator muscle as possible is removed using coagulation power of electrocautery, while protecting the supratrochlear and supraorbital nerves.

(From Michelow B, Guyuron B. Rejuvenation of the upper face. A logical gamut of surgical options. Clin Plast Surg 1997; 24(2):199-212).

Inadequate removal of the muscle will result in irregularities and flaws during the forehead rejuvenation.

• A pair of baby Metzenbaum scissors is used to separate the skin overlying the glabellar area from the underlying tissues and the procerus muscle fibers are removed if indicated.

Complete or almost complete removal of the procerus muscle can cause excessive elevation of the medial eyebrows.

• At this point pieces of fat that have been harvested from the medial portion of the upper eyelids are placed into the space created by the resection of the corrugator muscles (Fig. 7.8). Use of this fat offers several distinct advantages: it fills in the depression that may result from a thorough resection of the corrugator muscle; it shields residual corrugator fibers so even if the corrugator resection is not complete or if muscle fibers regenerate, they will be deprived of bony insertion and muscle that does not have bony fixation is not as potent; as part of the senescence, the glabellar area becomes flatter, so rejuvenation of the forehead should include replacement of the lost volume in this region. The fat graft is fixed to the underlying periosteum using 6-0 Vicryl or Monocryl to prevent postoperative dislodgement.

• The eyelid skin is repaired using 6-0 plain catgut.

• The incisions are treated with antibiotic ointment.

Fig. 7.8 Transpalpebral corrugator resection 4. A matching size fat graft is used to replace the resected corrugator muscle and, if necessary, to contour the glabellar area.

(From Michelow B, Guyuron B. Rejuvenation of the upper face. A logical gamut of surgical options. Clin Plast Surg 1997; 24(2):199-212).

Optimizing outcomes

• The depressor supercilii muscle is commonly mistaken for the corrugator muscle. The latter is darker, more pliable, located deeper and more medial to the former.

• Some patients with longstanding frown lines may require laser resurfacing to obtain optimal results.

Complications

The major disadvantage of transpalpebral corrugator resection is that it does not significantly correct eyebrow ptosis. Release of the corrugator and depressor supercilii muscles primarily results in elevation of the medial, and to a lesser degree, the lateral portions of the eyebrows. This procedure will not be sufficiently efficacious for patients who demonstrate more profound signs of forehead aging.

Transpalpebral resection of the corrugator may result in induration around the fat graft or asymmetric corrugator function and permanent numbness, though these complications are highly unlikely.

Eyelid incisional scar hypertrophy, specifically medially, or webbing that results in the development of epicanthus, are observed in rare situations. An injection of a small amount of triamcinolone 40 mg/ml will improve the scars.

Operative Approach

The endoscopic procedure has revolutionized forehead rejuvenation for many surgeons. It is performed almost exclusively on an outpatient basis.

The most significant advantage of endoscopic forehead rejuvenation is the avoidance of the large incisional scars that are inherent to the open techniques. Many patients who decline forehead rejuvenation because of concerns about the incisional scars are willing to proceed with an endoscopic procedure when they learn about the alternatives. Other advantages are the reduced chance of forehead elongation (which is commonly observed after a coronal incision) and a diminished chance of surgery-related alopecia, primarily because the incisions have been minimized. Even if some hair is lost around the incision, this is temporary and the hair follicles usually recover. The magnification is another positive aspect of endoscopic surgery.

Operative technique

• Intravenous sedation is preferred unless the procedure is conducted in conjunction with other procedures that necessitate induction of general anesthesia.

• Prior to sedation, the midline incision site is marked approximately 0.5 cm behind the hairline at the widow’s peak.

• Next, two incisions are marked in the temple area, the first approximately 7 cm and the second 10 cm from the midline and 1.5-2 cm behind the hairline. These radial incisions are 1.2-1.5 cm in length, depending on the thickness of the skin and subcutaneous tissue. A longer incision is used when the scalp is thick. The hair between these markings is braided by the assistants to avoid transfer of hair into the wounds (Fig. 7.9).

• The entire non-hairbearing forehead area is injected with lidocaine hydrochloride containing 1 : 100 000 epinephrine, and the hairbearing scalp up to approximately 7.5 cm behind the incision is injected with lidocaine containing 1 : 200 000 epinephrine to minimize the potential for any hair loss.

• The most lateral incision is made in the right temple area. This incision is taken through the superficial temporal fascia down to the deep temporal fascia. Using a pair of baby Metzenbaum scissors and spreading technique, the deep temporal fascia is exposed.

• Using the Obwegeser periosteal elevator, enough space is created above the deep and superficial temporal fascia to allow insertion of the Endoscopic Access Device (Fig. 7.10). To insert the EAD the inner shield is folded using a pair of large multi-tooth Adson forceps and while the skin hooks are separating the wound margins, the surgeon introduces the inner shield into the wound step-by-step (Fig. 7.11). Any resultant folds inside the lumen are easily eliminated by inserting the forceps into the central cannula and running them around the lumen.

• The periosteal elevator is passed into the first incision and advanced in different directions to dissect the tissues at the plane immediately superficial to the deep temporal fascia plane surrounding the second incision. Almost invariably the second incision falls over the periosteum rather than the temporalis fascia and near the temporal ridge. Skin hooks are now placed under the periosteum through the second incision, and the wound edges are retracted. The second EAD is then introduced.

• The dissection proceeds medially under the midline incision. At this point a third incision is made in the midline, and the EAD is again inserted. The procedure is then continued on the right side, starting laterally and advancing medially. The dissected areas are then connected with a periosteal elevator.

• At this point the surgeon’s attention returns to the right side. The Obwegeser periosteal elevator is used to dissect posterior to the incisions. This part of the procedure is done without the use of the endoscope.

• The dissection is repeated in the subperiosteal plane in the central forehead area, superficial to the deep temporalis fascia in the temple region. At this point, the 30 ° 4-mm scope is introduced through the EAD.

• The dissection is continued toward the supraorbital rim using the endoscope (Fig. 7.12). The arcus marginalis and the periorbita are released along the entire supraorbital rim using a longer periosteal elevator (Fig. 7.13).

• The fibrous bands are separated and elevated until the orbital septum, which has a glistening, grayish appearance, becomes visible. The periosteum along the lateral orbital rim is also released along the lateral orbital wall. A complete release of the periorbita and adequate removal of the muscles is far more important than fixation techniques. A sweep of the periosteal elevator across the temple area should not encounter any resistance.

• As the dissection is advanced medially, the supraorbital nerve and vessels are identified, as is the supratrochlear nerve. The supraorbital nerve is closer to the field of dissection and therefore more easily identified.

• The corrugator muscle lies superficial to a communicating vein between the supratrochlear and supraorbital veins. This vein is cauterized and the corrugator muscle is removed as radically as possible using the Daniel grasper or punch biopsy (Fig. 7.14). If necessary, the nerves are retracted with a nerve hook. The periosteum over the glabellar area is elevated but not transected in most patients, unless there is a significant medial eyebrow ptosis with skin folding over the radix.

• The dissection is repeated on the opposite side, and the corrugator supercilii muscle is removed.

• Hemostasis is secured step-by-step.

• The corrugator muscle site is then replaced with fat, which is often harvested from another site if an additional procedure is done in conjunction with the forehead rejuvenation. If no other procedure is being performed, fat is harvested from the area immediately under the deep temporal fascia above the zygomatic arch medially (Fig. 7.15).²⁵ The harvested fat is then delivered to the corrugator supercilii site with a periosteal elevator. If there is flattening or a depression in the middle of the glabellar area, it is augmented with fat grafts as well.

• In most patients, one fascia suspension suture on each side achieves the aesthetic goal.²⁶ At no point is a medial suspension performed. To achieve proper fixation, two single skin hooks are placed at the junction of the anterio-caudal one-third and the posteriocephalad two-thirds of the incision, and the wound edges are retracted. With the surgeon’s index finger of the nondominant hand everting the caudal portion of the incision, a 3-0 polydioxanone (PDS) suture is passed in and out, taking a substantial bite of the superficial temporal fascia, which is then passed out-in through the opposite side of the same incision (Fig. 7.16).

• Next, the skin hooks are placed at the cephalic or posterior one-third of the incision and are used to retract the scalp as far posteriorly as possible in the direction of the desired vector. This vector is predominantly directed laterally and slightly cephalad. The suture that has been passed through the anterior portion of the incision is then passed through the temporalis fascia (Fig. 7.17). This suture is tied incrementally as the surgeon watches the eyebrow being repositioned to the level deemed aesthetically pleasing.

• A similar suture is then passed through the caudal portion of the second incision only if additional fixation is considered necessary for further repositioning of the eyebrow or correction of eyebrow asymmetry. Cephaloposteriorly, this suture will be passed through a bone tunnel. To do this, the surgeon places the skin hooks in the cranial half of the incision and pulls the scalp laterally and cephalically along the intended vector. A malleable retractor is also placed at the posterior edge of the wound to protect the soft tissue. A 1.1 mm hole burr, with a safety guard providing maximum effective length of 5 mm, is then connected to a power tool such as an office dermabrader or a Zimmer-Hall drill. Two burr holes, opposing each other at a 45 ° angle and approximately 3-4 mm apart, are made to meet at a depth of 3-4 mm (Fig. 7.18). The bone is irrigated with saline containing antibiotic solution to avoid thermal damage during creation of the bone tunnel.

Fig. 7.9 Endoscopic forehead rejuvenation 1. Design of five radial incisions, and demonstration of control of the hair with braiding.

Fig. 7.10 Endoscopic forehead rejuvenation 2. Photograph of the endoscopic access device (EAD). This device has two shields – one smaller internal and one larger external – connected by an obliquely oriented cannula to properly guide the endoscopic instruments in the targeted field.

Fig. 7.11 Endoscopic forehead rejuvenation 3. Insertion of the endoscopic access device (EAD) is initiated by folding the inner shield and introducing it into the wound step-by-step using a pair of multi-tooth Adson forceps.

Fig. 7.12 Endoscopic forehead rejuvenation 4. The Obwegeser periosteal elevator is used to raise the periosteum and to dissect the plane superficial to deep temporal fascia.

Fig. 7.13 Endoscopic forehead rejuvenation 5. Release of arcus marginalis and fibrous attachment of eyebrow.

Fig. 7.14 Endoscopic forehead rejuvenation 6. Exposure and removal of the corrugator muscle using grasper.

Fig. 7.15 Endoscopic forehead rejuvenation 7. The fat graft can be harvested by making a small rent in the deep temporal fascia immediately cephalad to the most medial portion of the zygomatic arch.

Fig. 7.16 Endoscopic forehead rejuvenation 8. A 3-0 PDS suture is being passed through the anterocaudal portion of the most lateral incision.

Fig. 7.17 Endoscopic forehead rejuvenation 9. While the skin is pulled as far posterolaterally as possible, the suture that has been passed through the anterior portion of the incision is passed through the deep temporal fascia.

Fig. 7.18 Endoscopic forehead rejuvenation 10. Two burr holes are made approximately 3-4 mm apart at a 45 ° angle to each other to meet at a depth of 3-4 mm.

Pre-existing eyebrow asymmetry will persist and be a source of patient discontent postoperatively if not corrected with differential eyebrow elevation.

• The free end of the previously placed PDS suture is bent using a pair of fine hemostats, passed through the tunnel (Fig. 7.19) and tied incrementally, while closely watching the eyebrow. A similar suture is placed on the opposite side if necessary. The distance from the cranial border of the eyebrow to the eyelash is measured bilaterally while the eyes are closed. Generally, this distance should be about 25 mm.

• Screws or absorbable fixation devices such as the Endotine Forehead Device can be used for the fixation. If a screw is used the site for it is determined while the skin is being retracted, and the screw is placed in the skull and the incision is repaired. Alternatively, the screw is placed while the repaired incision is being pulled cephalically. These screws have a short effective length and will not likely penetrate the skull. The disadvantages of screw fixation are the need for extraction of the screw, cost of the screw, short fixation duration and potential for alopecia around the screw site.

• Following completion of fixation, a TLS suction drain is passed through the most lateral incision, into the adjacent incision, and continued step-by-step until it is delivered through the last incision, into the opposite temporal area and fixed in position using a 5-0 plain catgut suture.

• The periosteum and the galea are repaired with 5-0 Monocryl, and the skin is repaired using 5-0 plain catgut.

• After the soft tissue is repaired and while the skin is being draped posteriorly, the drain is connected to the vacuum tube.

• Before the patient is transferred to the recovery room, the forehead area, particularly the area of the supratrochlear and supraorbital nerves, is injected with generous amounts of bupivacaine or ropivacaine to minimize postoperative discomfort.

Fig. 7.19 Endoscopic forehead rejuvenation 11. The free end of the suture is bent to facilitate passing it through the tunnel.

Optimizing outcomes

• Preservation of the central portion of the periosteum and the fascia during the endoscopic forehead lift is crucial to reducing the medial eyebrow elevation.

Postoperative Care

The drain is removed in 2 days and the sutures usually dissolve in approximately 7-10 days. With proper care, most patients are very pleased with the results (Fig. 7.20A-D).

Fig. 7.20 Before and after endoscopic forehead rejuvenation. A, In repose before endoscopic forehead rejuvenation. B, In repose 1 year after endoscopic forehead rejuvenation. C, While frowning before endoscopic forehead rejuvenation. D, While frowning 1 year after endoscopic forehead rejuvenation.

Complications

Although the corrugator muscle can be resected more thoroughly, the deep horizontal lines on the forehead are not as effectively addressed with endoscopic forehead rejuvenation as they are with the open technique, particularly with the subcutaneous forehead lift. This deficiency can be overcome to some degree, however, by combining endoscopic forehead rejuvenation and laser resurfacing. The endoscope approach is not an optimal choice for those who have an elongated forehead.

An endoscopic forehead rejuvenation may result in inadequate or excessive elevation of the eyebrows, asymmetry, dimpling upon animation, undercorrection, overcorrection, or persistent paresthesia.²⁷ A suboptimal endoscopic forehead rejuvenation result is often the consequence of under, or uneven, resection of the muscle. Uneven resection of the muscle may also cause dimpling of the forehead skin. Over-elevation of the eyebrows, most often medially due to aggressive medial soft tissue release, is the consequence of zealous dissection and aggressive repositioning of the eyebrows.²⁷

Alopecia around the incision is unlikely and, if it occurs, is often transient. However, using screws for fixation, compared to bone tunneling, may result in a higher incidence of localized alopecia as a result of undue tension on the skin level.

Damage to the temporal branch of the facial nerve may result in paralysis of the frontalis muscle. If this occurs, it is often ephemeral; however, permanent injury to this nerve is also possible.

Persistent and intense itching of the forehead may be experienced after an endoscopic or coronal forehead lift. There is no universally accepted treatment for this complication, but use of antiserotonin-type compounds, such as cyproheptadine, may result in some relief. Use of antihistamines may have a beneficial effect.

Infection and hematoma are also complications of this surgery.

The disadvantages of endoscopic rejuvenation include the need for specialized instruments and a training process, which is absolutely vital. Performing an operation using an endoscope while watching a monitor, rather than directly inspecting the surgical site, is a different experience for many surgeons, and proper training and education are essential. The chance of sensory nerve damage is initially slightly higher because this dissection is conducted through a two-dimensional view, whereas a safe nerve dissection mandates three-dimensional observation.

Operative Approach

Because of the increasing popularity of endoscopic forehead rejuvenation, the coronal forehead lift has lost some of its popularity. Its advantages include speed of surgery and a bloodless plane of dissection.

Every student of aesthetic plastic surgery should be familiar with this technique and perhaps begin learning the forehead rejuvenation with an open technique provided the patient is willing to accept the incisional scar. This offers an opportunity for the novice surgeon to become more knowledgeable about the forehead anatomy and pathology.

Operative technique

• Before sedation, the coronal incision is marked approximately 5 cm behind the hairline, extending from one temple to the other, directly above the ear. Generally it is not necessary to shave the hair; however, some means of controlling the hair, such as the use of Surgilube, may prevent the hair from becoming a nuisance during surgery. A curvilinear incision is preferred to minimize the scar’s visibility. Braiding, especially anterior to the incision, is the best means of controlling the hair. Care must be taken to avoid tight braiding because it reduces the flexibility of the skin.

• Like the other forehead rejuvenation techniques, the coronal forehead rejuvenation is performed while the patient is under intravenous sedation.

• After infiltration of the non-hairbearing forehead with xylocaine containing 1 : 100 000, and the hairbearing scalp using lidocaine hydrochloride containing 1 : 200 000 epinephrine, an anteriorly beveled incision is made and taken down to the subgaleal plane4,28 (Fig. 7.21). Adding curves to this incision may reduce the scar visibly.

• Laterally the dissection is conducted superficial to the deep temporal fascia.

• Medial to the temporalis muscle, the dissection is extended supraperiosteally or above the periosteum to the supraorbital rims.

• The arcus marginalis and fibrous bands along the lateral supraorbital rim and the lateral orbital wall are released, allowing the eyebrows to be moved to the intended level.

• The dissection is continued medially until the corrugator muscles are exposed.

• The supraorbital and supratrochlear nerves are carefully dissected and preserved.

• The corrugator and the depressor supercilii muscles are removed as radically as possible (Fig. 7.22). If necessary, the procerus muscle is also released, but no attempt is made to remove the procerus muscle completely.

• The resected corrugator site is contoured using fat grafts, including the glabellar area if indicated (Fig. 7.23).

• The area is irrigated copiously and the skin is draped back.

• Centrally, removal of the skin should be conservative to produce a pleasing outcome (Fig. 7.24A&B). At no point should the forehead be pulled tightly centrally.

• Placement of a drain may minimize postoperative bruising and swelling.

• The incision should be repaired in two layers, approximating the galea in a separate layer using 5-0 Monocryl and the epidermal layer using 5-0 catgut.

Fig. 7.21 Coronal forehead lift 1. Marking of the incision for coronal forehead rejuvenation.

Fig. 7.22 Coronal forehead lift 2. The defect following removal of the corrugator and depressor supercilii muscle.

Fig. 7.23 Coronal forehead lift 3. Fat graft is placed in the corrugator sites.

Fig. 7.24 Before and after coronal forehead lift. A, Before coronal forehead lift. B, After coronal forehead lift.

Complications

The most serious complication of coronal forehead rejuvenation is hair loss. This type of alopecia is unlikely unless undue tension has been exerted on the scalp flap or the patient smokes cigarettes.

A coronal forehead lift may also produce suboptimal results such as undercorrection, or more commonly, overcorrection.

Patients may experience some paresthesia or permanent anesthesia in the forehead area after this operation. Infection and hematoma are also very rare.

Because of the need for further lateral dissection, the frontal branch of the facial nerves can be injured.²⁴ Other possible complications include wide or depressed scars, recurrent brow ptosis, poor brow elevation, and intense itching of the scalp.²⁹ The ear-to-ear coronal incision, which may result in alopecia, is the major drawback of this technique.³⁰ Connell et al.¹⁰ warn their patients that unusual scalp sensations and intense itching may occur 3-6 months after surgery. The symptoms usually disappear after 6-9 months. Occasionally the patient may feel forehead tightness persisting for 12-18 months; regenerating sensory nerves are probably the cause of this sensation.

Adamson et al.¹ noted that of the 40 patients who underwent coronal forehead lifts in his study, transient paresthesia (resolving within 6 months) occurred in 17%, a widened scar in 12%, transient frontal nerve paresis (lasting 3 weeks to 3 months) in 12%, and dysesthesia in 10%. Two patients experienced localized alopecia, and two sustained transient episodes of depression.

Postoperative Care

The sutures are allowed to dissolve. No particular postoperative care is necessary, except for application of antibiotic ointment directly on the incision and the drain site, which is continued for a period of 5-7 days. The drain is removed in 2 days and patients are allowed to wash their hair with shampoo and warm water on the third postoperative day.

Use of hair dryers and curling irons should be avoided for at least 2 weeks and with extreme care thereafter because the scalp may be hypoesthetic, and thermal damage could occur without patient discomfort. In addition, the patient should not color the hair for 2-3 weeks.

Operative Approach

Operative technique

• Pretrichial forehead rejuvenation is conducted under intravenous sedation.

• The incision design is critical and will determine the visibility of the scars in most patients. If the patient is endowed with an exaggerated widow’s peak, the incision will be started approximately 1 cm behind this anatomic landmark, continued along the hairline to the temple area, and taken behind the hairline toward the side-burns. The incision should be designed in a curvilinear fashion to further minimize its visibility (Fig. 7.25). Centrally, because the amount of skin removed is somewhat minimal, a portion of the widow’s peak could be preserved. The amount of skin to be removed laterally is significant; however, the hair in this area is sparse and fine, so what is removed is not often consequential. This type of incision often allows a portion of the incision to fall behind the hairline.

Straight pretrichial incision may result in scar visibility, reducing patient satisfaction.

• After completion of the marking, the hair is shaved anterior to and a few millimeters behind the incision.

• Next, the face is prepped and draped, and the forehead is infiltrated with lidocaine hydrochloride containing 1 : 100 000 epinephrine and a beveled incision is made (Fig. 7.27).

• In spite of vasoconstriction produced by injection of epinephrine, some bleeding will be encountered. The dissection is carefully conducted in a caudal direction at the interface between the subcutaneous plane and the frontalis muscle, or in the subperiosteal plane (Fig. 7.28). If there is no extensive wrinkling on the forehead area, the dissection could be conducted in the submuscular or subperiosteal level. The dissection in this plane is terminated caudal to the most caudal horizontal line in the central forehead area and down to the eyebrow level laterally. Every effort should be made to avoid raising a thin skin flap especially on patients who smoke or are previous smokers.

Fig. 7.27 Forehead rhytidectomy with pretrichial incision 3. The dissection will be conducted in the subperiosteal plane.

Fig. 7.28 Forehead rhytidectomy with pretrichial incision 4. The corrugator muscles are exposed by incising the periosteum.

Fig. 7.26 Forehead rhytidectomy with pretrichial incision 2. The incision is made in a beveled fissure to provide an opportunity for hair growth into the incisional scar.

• After the final caudal horizontal crease is released, the medial borders of the frontalis muscle are elevated and the submuscular dissection is continued medially until the corrugator and depressor supercilii muscles are exposed. These muscles are then removed with careful dissection and meticulous hemostasis.

• Fat graft is used to replace the resected corrugator muscle (see above for endoscopic forehead rejuvenation).

• The procerus muscles are removed conservatively.

• Laterally the skin flap is dissected down to the lateral orbital wall.

• As the skin is then re-draped, a great deal of excessive skin overlaps the incision (Fig. 7.29). The redundant skin is excised and repaired tension-free using 6-0 Monocryl and 6-0 fast absorbable catgut.

Fig. 7.29 Forehead rhytidectomy with pretrichial incision 5. The forehead flap is draped back and excess skin is excised without any tension.

The aesthetic goals are achieved predictably (Fig. 7.30).

Fig. 7.30 Before and after forehead rhytidectomy with pretrichial incision. A, Elongated and senescent forehead before surgery. B, After pretrichial subcutaneous forehead rejuvenation technique.

For patients who do not demonstrate deep horizontal lines or for those who smoke, dissection may be subperiosteal or submuscular without any subcutaneous component.

Dissection in the submuscular plane

• The skin incision is carried through the frontalis muscle and dissection is continued caudally in the plane between the muscle and the periosteum (this technique is similar to the coronal forehead rejuvenation, the only difference being that the incision site is at the hairline rather than 5 cm behind the hairline and is curvilinear rather than straight).

• The arcus marginalis is released.

• The dissection is continued laterally in the plane immediately above the deep temporal fascia and the periosteum is released above the orbital rim.

• The corrugator and depressor supercilii muscles are identified and resected and replaced with a fat graft.

• If indicated, the procerus muscle is removed conservatively.

• Excess skin is trimmed following the outline of the underlying incision sequentially (some tension is necessary when the dissection is conducted in a deeper plane compared with the subcutaneous approach).

• A suction drain is placed in position if submuscular dissection is being performed as an isolated procedure (if a subcutaneous forehead rejuvenation is combined with a facial rhytidectomy, there is no need for a drain because any drainage in the subcutaneous plane will flow to the facelift area).

• A combination of 6-0 Monocryl subcutaneous and 6-0 plain fast-absorbable catgut skin sutures are used meticulously for a precise repair of the incision.

• The incision line is treated with one pass of the CO₂ laser set at 60 watts. The laser treated area is then covered with the Laser-Seal dressing.

Optimizing outcomes

• The amount of skin that is excised medially during open forehead rejuvenation should be minimal to avoid excessive elevation of the medial eyebrow.

• Avoiding injection of a solution containing 1 : 100 000 epinephrine in hairbearing skin may reduce the incidence of alopecia after forehead rejuvenation, especially if the patient is a current or previous smoker.

Complications

If a subcutaneous dissection is used on a patient who currently smokes or smoked heavily in the past or if the skin is pulled too vigorously, skin necrosis may result. For this reason, the submuscular dissection is a safer choice for the patient who is a current or past smoker. Although permanent paresthesia of the scalp is an unlikely result of a subcutaneous forehead lift, it becomes more likely when the dissection has been submuscular. Asymmetry and damage to the facial nerve are specific complications of submuscular dissection.

In a study of 30 patients with anterior incision forehead rejuvenation¹³ only two patients (who were smokers) experienced small areas of necrosis requiring revisions.

In another study by Vogel and Hoopes³¹, complications of subcutaneous forehead rhytidectomy included one small hematoma, temporary or clinically unnoticeable hypesthesia (66%), altered scalp sensibility (33%), persistent forehead hypesthesia or paresthesia (33%), and temporary (12%) or permanent (12%) alopecia.

To determine whether beveled or perpendicular incisions should be used when areas containing hair follicles are incised during brow elevation or facial rejuvenation, Camirand and Doucet⁴ studied 30 patients. For each patient, one half of the incision was beveled and the opposite half was perpendicular. Neither the patients nor the examiners were aware of the type of incision used for each side. The resulting scars were examined for visibility, nonlinearity, absence of hypopigmentation, and presence of hair in and in front of the scar. In 95% of the patients the scar on the side that was incised in a beveled fashion was judged to be more desirable.

The disadvantages of forehead rhytidectomy with pretrichial incision are the additional time required for dissection and detailed repair, and the potential for a visible scar at the hair junction on the frontal area.¹³

Operative technique

Fig. 7.32 Shortening of the elongated forehead 2. One to three relaxing incisions are made in the galeal fascia, depending on the extent of necessary forehead advancement.

Fig. 7.33 Shortening of the elongated forehead 3. Galeal fascia is advanced and suspended using a bone tunneling technique.

Fig. 7.34 Shortening of the elongated forehead 4. The non-hairbearing skin of the scalp is excised incrementally to achieve shortening of the forehead.