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

Patient assessment

A proper forehead length and eyebrow position with a smooth and properly contoured forehead is an integral part of facial beauty (see Chapter 1). Any disturbance of this balance undoubtedly detracts from the pulchritude of the face.

Slight elongation of the forehead is a fairly constant component of the aging process for both men and women. Male pattern baldness resulting in receding frontal hair not only affects men, but may also alter the forehead length in women. The elongated forehead by itself denotes aging, and correcting it will yield a more rejuvenated appearance.

The main complaint of a patient with forehead aging is the frown lines. These wrinkles bestow a tired and perturbed appearance. Although these patients may not be truly angry or unhappy, they are commonly asked why they seem vexed.

Patients often incorrectly attribute the periorbital aging condition to excess eyelid skin rather than ptosis of the eyebrows, and demonstrate what they wish to achieve through surgery by manually raising their eyebrows. The surgeon should use this occasion to point out that it is the elevation of the eyebrows rather than the stretching out of redundant eyelid skin directly that is improving the eyelid appearance.

Patients with eyebrow and eyelid ptosis either consciously or subconsciously may recruit the frontalis muscle to aid in opening their eyelids.¹⁴ These two conditions should be differentiated in one of the following two ways:

• one of the most effective means for discerning between the two is to ask the patient to smile – as the patient smiles, frontalis compensation is often eliminated;

• the patient can also be asked to close the eyelids tightly and then gradually open the eyes until the patient can see the examiner. The eyebrows will assume an uncompensated position at this point. As soon as the patient is allowed to open the eyelids freely, the eyebrows will rise dramatically.

For a complete evaluation the eyebrow and eyelid imperfections are reviewed as a unit and the abnormal findings should be categorized and clearly explained to the patient. Flaws related to the forehead include:

• length disharmony or a receding hairline;

• frontal bossing;

• glabellar flattening;

• horizontal, oblique and vertical wrinkles;

• eyebrow ptosis;

• misshaped eyebrow arch.

It is important to inquire about and record the frequency, severity and duration of frontal and temporal migraine headaches in patients who are undergoing forehead rejuvenation. Many of these patients will enjoy the potential elimination or reduction of migraine headaches resultant from forehead injection of botulinum toxin A.

Patient information

The patients should be informed of the findings, the available techniques, the advantages and disadvantages of each technique, and the surgeon’s own opinion as to which treatments may provide the best results. Patients will then choose the technique that they feel is best suited to their aesthetic objectives. If a patient selects a procedure that will provide a suboptimal outcome, this should be adequately discussed with the patient, and the limitations of the procedure clearly reiterated. This explanation may reduce the potential for postoperative discontent.

Fat Injection

Loss of subcutaneous volume is a significant factor in the process of aging, and results in ptosis of the skin and the development of lines and folds. Any modality that restores the thickness of the skin and subcutaneous tissue invariably reduces the visibility of these lines.

Since the introduction of fat injection as the means to eliminate facial lines, there has been a longstanding debate about its efficacy and reliability. In 1911 Brunings ³ injected small cubes of autologous adipose tissue under the skin during rhinoplasty, but there was significant absorption of the injected fat.² Interest in fat injection for facial rejuvenation has recently re-emerged as a result of the refinement of techniques and more reliable outcomes.¹⁵

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

• Before injecting the recipient site, the target area is outlined and any furrows are precisely marked.

• The procedure is performed under local anesthesia with or without intravenous sedation. Lidocaine hydrochloride containing 1 : 100 000 epinephrine should be used for both the donor site and the recipient site. It is advisable to use 3 units/mL hyaluronidase to ensure faster diffusion of the anesthetic in the injected site and elimination of the injected volume. This allows for a more precise judgment about the necessary volume of fat to be injected.

• The ideal donor site is the lower quarter of the abdomen or gluteal region, which should first be infiltrated with a generous amount of the anesthetic solution. Fat is then aspirated using a 14-gauge cannula and a 1 cc syringe. Gentle rotation and advancement of the cannula, while simultaneously applying external pressure to the abdomen with the non-dominant hand, avulses fat tissue, and significantly facilitates the harvesting process.¹⁷

• Next, an 18-gauge needle is connected to a Coleman cannula, and the sharp, beveled end of the needle is inserted in the skin caudal to the target area. Advancing the needle to the injection site with a gentle side-to-side motion of the needle, the fibrous bands connecting the dermis to deeper tissue layers are released. This process is repeated until unencumbered movement of the needle is achieved in an area approximately 4-5 mm wide centered under the deep portion of the frown line.

• With multiple passes, the surgeon injects the fat into the subcutaneous layer.

Optimizing outcomes

• When injecting fat into the frown line, overcorrection should be minimal because the success rate is high in this site.

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).

Fat Graft

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:

• inversely influenced by the volume of transferred fat;

• directly affected by vascular integrity of the recipient sites.

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.

Operative technique

• Because fat grafting is seldom performed as an isolated operation, the patient will have received intravenous sedation for the concurrent procedures.

• The glabellar area is infiltrated with lidocaine hydrochloride containing 1 : 100 000 epinephrine with 3-units/mL of hyaluronidase.

• A stab incision is made in the most cephalic portion of the frown line.

• A pair of fine scissors is used to develop a pocket by undermining the furrows.

• The fat is fashioned proportionately into a single strip and introduced into the subcutaneous pocket.

• Overcorrection is unnecessary because the success rate is close to 100%.

• The small stab incision is closed using 6-0 plain, fast-absorbing catgut sutures.

• The graft may be gently molded after cutaneous repair.

• The wound usually heals well to leave an indiscernible scar.

Alternatively, the fat can be prepared in strips of 1-2-mm width and an 18-guage needle is used to release subcutaneous fibrous bands. The sharp end of the needle is then used to deliver the grafts into the pocket. Dermis fat is easier to insert into the target area using this technique.

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).

Transpalpebral Corrugator Resection

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.

Relevant surgical anatomy

Frontalis muscle

Deep to the frontalis muscle, the epicranial layer is separated from muscle by loose connective tissue, which allows the scalp to glide short distances over the underlying bony skull. Neither frontalis nor occipital muscle has bony origins. The frontalis:

• arises from the skin and subcutaneous tissue in the region of the eyebrows and root of the nose and inserts into the galea;

• medial fibers are continuous with the procerus muscle at the nasion;

• intermediate fibers blend with the corrugator supercilii muscle;

• lateral fibers blend with the orbicularis oculi muscle.

Deep to the frontalis muscle, a layer of loose connective tissue partitions the epicranium from the underlying bone, so allowing the scalp to glide short distances over the skull.

During animation, the frontalis muscle, which expresses attention, elevates the eyebrows and causes transverse wrinkling of the forehead.²¹ Its contraction provides a constant, cranially directed force vector on the eyebrows.

Orbicularis oculi muscle

The cranial vector of frontalis muscle contraction is counteracted by muscular and periosteal anchors. The orbicularis is one such muscle, and is divided into orbital and palpebral portions:

• the orbital portion spans the superciliary arch and acts to depress the eyebrow;

• the palpebral portion contains the preseptal segment (which is found between the inferior border of the eyebrow and upper margin of the tarsal plate) and the pretarsal segment (which covers the tarsus).

The medial and superior portions of the orbicularis overlie another muscle, the depressor supercilii, which is a forceful depressor of the head of the brow.

Temporal and zygomatic branches of the facial nerve²² innervate the cephalic portion of the orbicularis oculi.

Corrugator supercilii muscle

Corrugator supercilii muscle is a small, pyramidal muscle located at the medial end of the eyebrow, deep to the frontalis and orbicularis muscles. Its fibers:

• originate from the medial portion of the supraciliary arch;

• span superolaterally and pass between the fibers of the orbicularis muscle to insert into the deep surface of the forehead skin.²³

Corrugator supercilii is innervated primarily by temporal branches of the facial nerve (CN VII). It often extends to the junction of the lateral one-third and medial two-thirds of the supraorbital rim where it is innervated by the frontal and zygomatic branches of CN VII, though buccal branches of CN VII also make a contribution.

Removal of corrugator supercilii during forehead rejuvenation eliminates the inferomedially directed vector, allowing separation and elevation of the medial eyebrows.

Procerus muscle

Procerus is a pyramidal, fasciculate muscle with tendinous fibers originating at the inferior portion of the nasal bones and inserting into the dermis between the eyebrows. It is:

• innervated by the deep buccal branch of CN VII through the infra-orbital plexus;

• responsible for expressions of aggression and pulls the glabella caudally;

• attached to the periosteum of the nasal bones and this is a major factor stabilizing the eyebrow.

Dividing the periosteum laterally and freeing the arcus marginalis is necessary to free the lateral brow, enabling its elevation during endoscopic and/or open rejuvenation procedures.

Supraorbital and supratrochlear nerves

The supraorbital and supratrochlear nerves (see Fig. 7.1) are the terminal branches of the ophthalmic division of the trigeminal nerve (CN V) and provide sensory innervation to the forehead and scalp:

• the supraorbital nerve in the adult exits the supraorbital foramen or notch 2.7 cm from the midline;

• the supratrochlear nerve is located 1.7 cm from the midline and lies 0.8 cm anterior to the supraorbital nerve.²⁴

Injury to the supraorbital and supratrochlear nerves may result in intense forehead itching following surgical forehead rejuvenation technique.

The thickest portion of the corrugator supercilii muscle is interposed between these two sensory nerves.