Forehead Rejuvenation

Published on 22/05/2015 by admin

Filed under Plastic Reconstructive Surgery

Last modified 22/05/2015

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Chapter 7 Forehead Rejuvenation

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.

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:

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:

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.

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 Brunings3 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 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.

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:

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.

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.

Relevant surgical anatomy