History

As an alternative to the open coronal browlift, several techniques have been devised to elevate the brow complex through short or hidden incisions. The simple removal of skin has been advocated in various locations: the anterior hairline, within forehead wrinkles, and adjacent to the eyebrows. Browpexy techniques have been utilized through a transblepharoplasty approach with soft tissue fixation to periosteum. In 1996, Vasconez and Isse independently presented the minimal incision endoscopic technique. Also in 1996, Knize published his limited incision forehead lift, using an incision in the temple with an orbital rim release and soft tissue fixation between the superficial and deep temporal fasciae.

Unfortunately, all these methods have their deficiencies. In particular, the coronal browlift is plagued with a long incision which is feared by patients. Chronic dysesthesia and some scar alopecia are common. Cutaneous approaches leave scars which can be acceptable, but often are not. Browpexy procedures have proven to be inconsistent especially in the presence of mobile skin. Similarly, Knize’s procedure seems successful in some cases but not in others – presumably because of a fixation vector which is directed fairly laterally (Fig. 23.1).

Fig. 23.1 Knize procedure.

From a surgical perspective, endoscopic brow lifting is an attractive option. It promises minimal incisions, minimal sensory change and little or no hair loss. Numerous authors have demonstrated the success of endoscopic brow surgery by measuring the amount of eyebrow elevation achieved from fixed orbital points. While clearly effective between the medial canthus and the lateral canthus, results at the lateral tail of the eyebrow can be unreliable. The example in Figs 23.2–23.4 illustrates the problem.

Fig. 23.2 Preoperative.

Fig. 23.3 Postoperative after 2 weeks.

Fig. 23.4 Postoperative after 3 months.

In cases such as this, the only real problem is lateral brow ptosis. Unfortunately, despite complete soft tissue release, two-point fixation, and excellent early brow position, lateral brow position has been lost over a relatively short period of time. This is a critical failing, because an attractive eyebrow tends to be low medially, and rise laterally, while with age, the lateral tail becomes ptotic.

The limited incision browlift technique presented in this chapter is called the “modified lateral browlift” and it was developed in response to problems encountered with all other techniques. It is a hybrid procedure done through a nerve sparing incision directly over the temporal crest line (like Knize, but higher). There is full release of the supraorbital and lateral orbital rim (as used in the end brow technique), fixation by limited scalp excision (like a coronal lift) and suturing of superficial temporal fascia to deep temporal fascia (like an endo brow). Frown muscle modification may be done from above using an endoscope, from below through a blepharoplasty approach, or with botulinum toxin alone.

Physical evaluation

The periorbital region is the most complicated aesthetic unit of the face. Multiple variables interrelate in ways which affect the apparent age and attractiveness of the orbital complex:

A difficult question for many surgeons to answer is: “who needs a browlift?” In some cases this is obvious, but in many cases it is much less clear. Traditional thinking is that eyebrows should be above the orbital rim. True in most cases, this axiom is nevertheless overly simplistic.

Many different professionals, including cosmetologists, anatomists and plastic surgeons have attempted to define the ideal position and shape of the eyebrow complex. This was reviewed by Gunter who concluded that the aesthetic ideal must be considered in relation to gender, ethnicity, orbital shape, eye prominence and facial proportions. Conventional descriptions of the “ideal eyebrow” in the modern era typically include the following (Fig. 23.5):

Fig. 23.5 The ideal female eyebrow.

Gunter also observed that the eyebrow and the nasojugular fold create an oval with the pupil at the center of the oval. If the distance from center of the pupil to the eyebrow is reduced, the brow looks low (Fig. 23.6).

Fig. 23.6 Gunter’s oval.

The amount of visible eyelid from the lash line to the palpebral fold should be approximately one-third the distance from the lash line to the eyebrow, and not more than one-half (Fig. 23.7).

Fig. 23.7 Ideal relationship of the female eyebrow and eyelid.

With aging, the most stable structure in this area is the supraorbital rim, around which numerous soft tissue changes occur. Fat is lost from above the upper lid sulcus causing older eyes to look “hollow”. Upper eyelid skin becomes loose and redundant. Forehead skin becomes corrugated transversely (frontalis effect) and vertically (corrugator effect). There is ptosis of the eyebrow complex, especially laterally. Occasionally, the picture is confused with the development of senile eyelid ptosis. Patients, in response, often overly elevate their eyebrow complex.

With surgery, we can tighten lax eyelid skin (blepharoplasty), add fullness above the upper lid sulcus (fat grafting), elevate the eyelid complex (browlift) or raise the eyelid level (ptosis repair). By utilizing one or all of these procedures, we have the capacity to alter the ratio of visible upper eyelid skin to eyebrow height, to change the shape of the periorbital oval, and to change the shape of the eyebrow itself. The actual height of the eyebrow is therefore only one of many important variables.

Anatomy

If a cutaneous approach to brow lifting is used, the underlying anatomy is of little consequence, because the surgery is truly only “skin deep”. If, however, brow soft tissues are to be mobilized along a deeper plane, accurate anatomical knowledge is extremely important.

The temporal crest is a palpable line which separates the temporal fossa and the origin of the temporalis muscle from the forehead portion of the frontal bone. This is an area of transition where the deep temporal fascia covering the temporalis continues medially as the periosteum of the frontal bone. More superficially, the superficial temporal fascia continues medially across the forehead as the galea. These layers are all bound to bone along the temporal crest line in a zone of adhesion (Knize), also called the superior temporal septum (Moss et al.). Closer to the orbital rim, tethering fibers become stronger and more adherent, and the zone of adhesion widens to become the orbital ligament (Knize), also known as the temporal ligamentous adhesion (Moss et al.). Medially across the supraorbital rim there is further attachment of galea to bone (supraorbital ligamentous adhesion).

Also visible is the orbicularis retaining ligament which completely encircles the orbit, attaching the orbicularis oculi to the orbital rim. Laterally, this attachment broadens to become the lateral orbital thickening (Fig. 23.8).

Fig. 23.8 Periorbital facial attachments.

The galea aponeurotica splits into a superficial and deep portion, encompassing the frontalis muscle. As it approaches the orbital rim, the deep portion subdivides into three distinct layers: the first underlying the frontalis muscle and forming the roof of the galeal fat pad, a second forming the floor of the galeal fat pad, and a third layer tethered to bone (at the supraorbital ligamentous adhesion). Brow soft tissue (skin, orbicularis and galeal fat pad) move over a glide plane formed by the two deepest galeal layers (Fig. 23.9).

Fig. 23.9 Relationship of galea layers to surrounding structures. The white layers are the galea. The purple area (GPS), is the glide plane. The two large pink muscles are the frontalis (the superior one, FM) and the orbicularis oculi (OOM) and the small one (CSM-T), is the corrugator supercillii. GFP, galeal fat pad.

In fact, the most effective strategy for lateral brow lifting would be to reposition only the mobile soft tissue. Paradoxically, traditional surgical approaches deep to the galea or periosteum place the surgeon at a mechanical disadvantage by using relatively immobile structures to shift the overlying mobile soft tissue.

Laterally, where the frontalis dissipates, the galeal fat pad may or may not be separated from the preseptal fat (ROOF or retro-orbicularis fat), depending on the reflection of galea at the orbital rim. Knize has speculated that continuity of galeal fat and preseptal fat predisposes certain individuals to lateral brow ptosis (Fig. 23.10).

Fig. 23.10 Lateral orbital rim with deep galeal attachment and lateral orbital rim with no galeal attachment.

The level of the eyebrow is a result of the muscular and gravitational forces which depress the brow, balanced against the only force of elevation: frontalis.

Frontalis imparts its elevation effect primarily on the medial and central brow, less so above the lateral canthus, and not at all over the eyebrow tail. This, then, is a set-up for lateral brow ptosis (Fig. 23.11).

Fig. 23.11 Frontalis muscle action.

Medially, several muscular brow depressors take origin from bone and insert into soft tissue: corrugator supercilii, depressor supercilii, and the procerus (Fig. 23.12).

Fig. 23.12 Muscular depressors of the medial brow.

Laterally, the orbicularis oculi acts like a sphincter, pulling down the tail of the brow (Fig. 23.13).

Fig. 23.13 Lateral constricting action of orbicularis oculi.

Nerves in the periorbital region include the temporal branch of the facial nerve (VII) (Fig. 23.14) and multiple sensory nerves (Fig. 23.15).

Fig. 23.14 Facial nerve branches.

Fig. 23.15 Sensory nerves.

The supraorbital nerve leaves the orbit either through a notch in the rim or through a foramen above the rim. There is considerable anatomic variation, such that blind dissection can damage a nerve which exits through a supraorbital foramen. Because of this, some visualization of the supraorbital rim area is important during dissection of this area.

Deep branch of the supraorbital nerve

The supraorbital nerve divides into two branches. The superficial portion travels on the superficial surface of the frontalis innervating the central forehead. The rest of the scalp and top of the head is innervated by the deep branch which travels laterally and between the periosteum and the galea. Knize has described the anatomy of deep branch of the supraorbital nerve. It may be single, double or triple. In all instances, the deep branch runs in a 1 cm wide band which lies between 5 mm and 15 mm medial to the palpable temporal crest line (Fig. 23.16).

Fig. 23.16 Deep branch of the supraorbital nerve.

Technical steps

Preoperative planning will determine which surgical procedures are required. Old photographs of the patient are often helpful. Almost always, aging causes ptosis of the lateral brow. As well there may be some ptosis of the central brow or medial brow. There may be upper sulcus fat excess or fat deficiency. There may be a hollowing of the upper lid sulcus, or loose skin may obscure the upper sulcus. Brow level must be considered in relation to all these variables. Frown muscle effect should be assessed.

Preoperative markings are done with the patient in the upright position. The patient is asked to clench her teeth, making the temporalis muscle palpable. This helps delineate the temporal ridge which is marked. If visible, the sentinel vein (medial zygomatico-temporal vein) is marked (an X in the photo in Fig. 23.17). The expected course of the facial nerve, temporal branch is delineated, as it crosses the middle third of the zygomatic arch and courses superiomedially at the sentinel vein. The expected course of the supraorbital nerve, deep and superficial branches are then marked. The desired vectors of pull are marked. Although guidelines for these have been described, a customized approach is often more useful. With this method the planned vectors are usually more vertical than traditionally described.

Fig. 23.17 Preoperative marking.

Once the vectors are determined, the incision is marked. This is placed 1 cm behind the hairline, and is usually 6 cm in length. Patients with a widow’s peak require some modification of the incision site. Lastly, if frown muscle modification is planned (either transpalpebral or through an endoscope), the patient is asked to frown and the muscle action is marked.

The procedure is done under general anesthesia or local anesthesia with sedation. Local anesthetic containing epinephrine is injected into the planned incision, as well as around the orbital rim. A small strip of hair is shaved in a 1 cm strip immediately superior to the planned incision (Fig. 23.18). The incision is made parallel to hair follicles and a 1 cm wide strip of skin is raised from the underlying galea and superficial temporal fascia and is retracted posteriorly. This skin can be excised now or later.

Fig. 23.18 Planned incision site.

The lateral portion of the incision is then entered, spreading with scissors through the superficial temporal fascia down to the deep temporal fascia (Fig. 23.19). This dissection will be lateral to the expected course of the deep branch of the supraorbital nerve. The temporal pocket is then dissected under direct vision using a headlight or a lighted retractor. The sentinel vein is identified as the marker for the overlying branches of the facial nerve. If the dissection is kept deep on the surface of the deep temporal fascia, these nerve branches will be safe.

Fig. 23.19 Temporal pocket dissection.

The medial pocket is then developed by spreading through the frontalis and galea, and utilizing a periosteal elevator, through periosteum to enter the subperiosteal plane (Fig. 23.20). This dissection will be medial to the expected course of the supraorbital nerve’s deep branch.

Fig. 23.20 Subperiosteal pocket dissection.

At this point a bridge of tissue will remain between the lateral and medial portions of the incision (Fig. 23.21). This bridge contains the deep branches of the supraorbital nerve and terminal branches of the anterior temporal artery and vein. It is not necessary to individually dissect out these structures.

Fig. 23.21 Neurovascular bundle.

After both pockets have been developed, they are connected from lateral to medial using a periosteal elevator in a blind sweeping motion. This maneuver changes anatomic planes from the temple (superficial to the deep temporal fascia), to the forehead (subperiosteal) (Fig. 23.22).

Fig. 23.22 Joining two dissection pockets.

The zone of adhesion can now be completely divided down to the orbital rim.

Depending on operator preference, an endoscope can be inserted at this point to aid with orbital rim release. The author’s preference here is to use the endoscope, but with proper retraction and focused lighting, it is not absolutely necessary. A thorough release of the lateral orbital rim is completed down to the level of the zygomatic arch. The supraorbital rim is released medially past the supraorbital nerve. At this point some method of visualization is necessary to confirm safety of the supraorbital nerve trunk. The extent of medial release can be determined with traction placed on the flap. It is usually necessary to release 1 cm medial to the supraorbital nerve for satisfactory mobility of the lateral brow complex. Finally, the operator can insert a finger to confirm satisfactory mobility around the orbital rim (Fig. 23.23).

Fig. 23.23 Completed dissection.

The scalp flap is then drawn superiorly and fixed into place. This is done through the lateral portion of the incision with two sutures placed from the superficial to the deep temporal fascia (Fig. 23.24). These sutures can be permanent or a long lasting absorbable such as 3-0 Monocryl. If a peak to the lateral third of the brow is desired, working through the medial portion of the incision fixation to bone can be done utilizing any available technique. LactoSorb tacks are simple and effective.

Fig. 23.24 Suture fixation to deep temporal fascia.

Lastly, the cut edges of galea are drawn together under some tension (Fig. 23.25). If the flap has been well mobilized, sutures will bunch up the galea at this point. The redundant, hair-bearing scalp skin, is conservatively excised enabling a tension free closure. The neurovascular bundle simply telescopes up under the closed scalp. A bupivacaine block is injected into the supraorbital nerve. A drain is not normally used. A light dressing is then applied.

Fig. 23.25 Suturing of galea.

Postoperative care

Postoperative care is routine, with analgesic required as long as the nerve block is functional. As it wears off in 12 hours, some light analgesics are normally required to control headache. The head is kept elevated, and cold packs are applied to the eyes. The patient is seen in 24 to 48 hours for dressing removal and wound inspection. Scalp stitches and staples are removed at 7 days.

At 2 weeks postop, 10 units of botulinum toxin are injected into the lateral orbicularis oculi to help prevent relapse. This is normally repeated several months later, and is considered part of the original surgery.

Complications

Problems with this procedure are analogous to the endoscopic approach. Specifically, there is the potential for early hematoma, and for sensory or motor nerve injury. Because the incision is longer than with a pure endoscopic approach there is also the potential for minor alopecia formation. Should this develop, it can be watched for 6 months, and if persistent, can be corrected with simple excision (Fig. 23.26).

Fig. 23.26 Incision line alopecia.