Endoscopic Forehead Lift. Technique and Case Presentations

J Oral Maxhfac Surg 54569.577, 1996

Endoscopic Forehead Lift: Technique and Case Presentations

CLARK 0. TAYLOR, MD, DDS,* JAMES G. GREEN, MD, DDS,t AND DAVID P. WISE, MD, DDS*

Purpose: The advent of the endoscopic forehead lift has provided an alternative to the conventional open approach. This article describes the basic technique, with some modifications, and reports three clinical cases.

Results: The subperiosteal forehead technique rejuvenates the upper third of the face with no scalp resection, minimal risks of hypesthesia, limited risk of alopecia, reduced tissue trauma, small camouflaged scars, less bleeding and edema, improved postoperative comfort, and faster recovery compared with the standard open techniques.

Conc/usions: The endoscopic subperiosteal forehead lift is a useful technique for providing rejuvenation of the upper third of the face. It reduces or eliminates forehead rhytids by eliminating the reflex contracture of the frontalis and contributes to softening of the vertical glabellar rhytids. Longitudinal studies will be required to assess the effectiveness of this technique compared with open techniques.

The introduction of endoscopic surgical procedures has provided an alternative to traditional approaches for performing facial cosmetic surgery. The endoscopic technique allows controlled, precise surgery through small incisions placed in inconspicuous loca- tions. The development of endoscopic equipment de- signed for esthetic surgery now permits rejuvenation of the upper third of the face with no excision of hair- bearing scalp, elimination or reduction of visible scarring, and decreased risk of alopecia, anesthesia, or hypesthesia. The basic techniques for the endoscopic forehead lift, with some modifications and clinical cases, are presented.

Indications and Preoperative Evaluation

The rationale for performing a forehead lift is to reestablish the esthetic balance between the upper and

* Associate Professor, University of Nebraska Medical Center, Director of Institute of Facial Surgery, Bismarck, ND.

t Senior Oral and Maxillofacial Surgery Resident, Department of Oral and Maxillofacial Surgery, University of Nebraska Medical Center, Omaha, NE.

$ Senior Oral and Maxillofacial Surgery Resident, Department of Oral and Maxillofacial Surgery, University of Nebraska Medical Center, Omaha, NE.

Address correspondence and reprint requests to Dr Taylor: Insti- tute of Facial Surgery, 416 N 6th St, Bismarck, ND 58501.

0 1996 American Association of Oral and Maxillofacial Surgeons

0278-2391/96/5405-0006$3.00/O

middle thirds of the face that have been lost because of the aging process. The position of the brow represents. a key anatomic structure in rejuvenation of the upper third of the face. Elimination or reduction of transverse and vertical rhytids of the forehead and nasal region represents the second important component of the forehead lift. Critical evaluation of postoperative results shows that perhaps the most important effect of forehead rejuvenation is not the magnitude of brow elevation or the precision of brow position, but the elimination of the “tense’ ’ forehead. This is the result of proper depressor muscle resection and forehead tissue elevation and fixation.

The indications for a forehead lift are represented by the anatomic changes of the aging upper face. These include brow ptosis; lateral hooding; hypertrophic or hyperactive corrugator, frontalis, and procerus muscles, creating a “tense” forehead; disruption of the smooth sweep of the brow into the nose; brow skin descending over the orbit (pseudoblepharochalasis); brow asymmetry; and reduction of the distance from the upper eyelid tarsal crease to the eyebrow.] Some of these changes may interfere with the patient’s vision and necessitate surgical correction. Another common indication for forehead rejuvenation is a history of pre- vious cervicofacial rhytidectomy.’ Many patients who undergo a facelift operation do not have a simultaneous forehead lift performed. Postsurgical results often ac-

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centuate the difference between the rejuvenated lower two thirds and the untreated upper one third of the face.

The aging upper face develops as gravity pulls the forehead tissues down over the supraorbital rims and eyelids, creating the appearance that the patient is tired, angry, or sad. Decent of brow skin over the upper eyelid can lead to inappropriate or excessive upper blepharoplasty if normal brow position is not reestab- lished first. The upper eyelid skinfold may extend beyond the lateral canthus onto the lateral periorbital region (lateral hooding) and represents a hallmark of brow ptosis. The forehead musculature becomes re- flexively hyperactive in an effort to reposition the eye- brows to a normal position.” The constant counter- action between the brow elevators (frontalis and corrugator muscles) and the depressors (orbicularis, procerus, corrugator, and depressor supercilii muscles) leads to the development of characteristic transverse and vertical rhytids and the classic clinically “tense” forehead. The tense forehead may result in the brow being held in the normal position at rest. The chronic contraction of the forehead muscles is an often over- looked cause of frontal headaches. Eventually, the vertical distance between the brows and the hairline in- creases, disrupting the balance between the upper and middle thirds of the face. The distance between the upper eyelid crease and eyebrow is also noted to decrease.lT4

Evaluation of the patient for a forehead lift requires an understanding of the variations between female and male esthetics. In women, the highest point of the arched brow should be at the lateral limbus or canthus of the eye. The relationship of the brow with the medial orbital rim should create a smooth Y-shaped curvature. The brow should be positioned slightly above the supraorbital rim, and the forehead should have few or no horizontal or transverse rhytids. Men normally have the brow positioned at the supraorbital rim, and the brow creates a T-shaped configuration with the medial orbital rim. The brow appears horizontal or mildly arched, and variable amounts of vertical and horizontal rhytids are acceptable. In both men and women, the medial and lateral brow margins should be at the same height to avoid a surprised, sad, tired, annoyed, or angry appearance.5

Sex, age, skin quality, hair quantity and quality, hair pattern, hairline, eyebrow position and shape, presence of forehead, glabellar, and nasal rhytids, motor function of the forehead musculature, and bony architecture must be systematically evaluated.6 Thorough evaluation leads to identification of specific anatomic problems, selection of the proper surgical approach, and improved treatment results. Although the literature contains specific numbers for the diagnosis of brow ptosis (less than 2.5 cm from the midpupil to the upper

edge of the brow), deficient brow-to-hairline measure- ment (less than 5 cm from the top of the brow to the hairline), and deficient upper eyelid crease-to-brow distance (less than 1.5 cm), the patient’s input before surgery and the surgeon’s assessment at the time of surgery remain critical factors.* However, these mea- surements can assist the surgeon in determining which areas require treatment and which surgical approach should be used.

The indications for an endoscopic forehead lift are the same as those for the traditional approaches. The best candidates are 30 to 50 years of age, with limited skin excess, who show the early or classic signs of brow ptosis. The endoscopic procedure is also suitable for older individuals with excess skin but who are unwilling to accept the undesirable sequelae of traditional open approaches. The endoscopic technique of- fers the following advantages: no scalp resection, minimal risk of hypesthesialanesthesia, limited risk of alopecia, less tissue trauma, small camouflaged scars, less bleeding and edema, improved postoperative comfort, and faster recovery.‘-”

Endoscopic Technique

The patient is initially positioned in the semisupine position, and intravenous sedation is induced. Before beginning the forehead dissection, 2% lidocaine with epinephrine 1: 100,000 is infiltrated in all proposed incision marks and in the region of the supratrochlear and supraorbital nerves. A small volume of anesthetic solution (approximately 30 mL) is infiltrated in the subgaleal plane to facilitate the dissection and for additional anesthesia. Further discussion regarding the tumescent technique can be found in the article by Schoen et al.‘”

Three sagittal incisions, through periosteum to bone, are initially made approximately 1 to 3 cm posterior to the hairline. In addition, two horizontal incisions down to the deep layer of the superficial temporalis fascia are made in the temporal hair-bearing region of the scalp over the temporalis muscle (Fig 1). The proper layer is identified by manipulating both edges of the surgical wound and observing the scalp tissues sliding directly over the deep layer of the temporalis fascia. The incisions are made approximately 1 to 1.5 cm in length to allow introduction of the endoscopic telescope and instrumentation.

The pericranium is elevated with periosteal dissectors using a blind technique, taking care to avoid tearing the periosteal layer during elevation of the flap. The entire forehead region is elevated down to ,a point approximately 3 cm above the bony orbital rim. Poste- riorly, the entire scalp is elevated blindly in a subperiosteal plane to the attachment of the occipitalis muscles and laterally into the suprahelical areas. The endoscope

TAYLOR, GREEN, AND WISE

FIGURE 1. Artist rendition of the five incisions needed for the endoscopic brow technique. Incisions 1 and 3 are parasagittal incisions, incision 2 is a midsagittal incision, and incisions 4 and 5 are temporal incisions (fifth incision is not shown).

is then inserted through one of the three sagittal access ports to allow completion of the forehead dissection under direct visualization in a color monitor (Fig 2). The dissection is accomplished throughout the re- maining extent of the forehead and in the area of the supratrochlear and supraorbital neurovascular bundles (See Fig 3 for overlying anatomy). Visualization is optimized with saline irrigation, and suction is provided by a Frazier tip inserted into one of the open sagittal incisions. Using soft tissue dissectors, the neurovascular bundles are identified (Fig 4). Once the neurovascular bundles are identified, the corrugator and procerus muscles are directly visualized through the endoscope, and they are either avulsed with a biting instrument or their dermal attachments are transected while taking care to avoid the neurovascular structures in the area (Fig 5). Care is taken during this portion of the procedure to avoid damage to the subcutaneous or dermal tissues.

The temporal dissector is now inserted through the temporal incision into the plane just superficial to the deep layer of the superficial temporalis fascia. Under direct visualization, the temporal dissector is used to transect the temporalis fascial attachments along the

I3

FIGURE 2. A, Intraoperative view of endoscope and dissector in place. B, Artist rendition of endoscope in the subperiosteal tissue plane.


FIGURE 3. Artist rendition of the pertinent overlying anatomy in the region where the endoscopic brow lift procedure is performed (not shown are the corresponding arterial and venous counterparts and the frontal branch of the facial nerve).

FIGURE 5. View through the endoscope showing the endoscopic biting forceps resecting the corrugator supercilii muscle.

temporal crest and thus release the scalp flap from the temporal crest region (Fig 6). Maintaining a proper tissue plane is extremely important during this portion of the procedure to avoid damage to the frontal branch of the seventh cranial nerve. The temporalis fascial attachments are released posteriorly until the entire temporal and frontal flaps are mobile. Reference points are marked on the bony skull at the anterior extent of the coronal sagittal incisions and at the planned posterior movement position using rotary air-driven instrumentation. The average posterior positioning in the midsagittal region is 8 to 10 mm, whereas in the parasagittal region this movement is 10 to 12 mm. Using skin hooks, the scalp is advanced posteriorly, and screw holes are placed at the posterior reference mark. Care is taken to recognize penetration through the outer cortex to avoid perforation into the dural sinus or into the brain. Luhr (Howmedia Inc, Rutherford, NJ) pan- fixation screws are then inserted through the anterior extent of the scalp flap into the prepared posterior hole to anchor the scalp in a posterior position while simul-

taneously observing the brows for ideal orientation. Traction is then placed in the temporal region to elimi- nate any lateral hooding and to allow a smooth transi- tion between the temporal and facial regions. This ad- vancement in the temporal region is secured by anchoring the anterior extent of the incision to the temporalis fascia using a Maxon or .PDS (D & G Monofil Inc, Manati, Puerto Rico) suture.

Should bleeding be encountered during any segment of the procedure, it is easily controlled with electrocau- tery. The sagittal and temporal incisions are then closed with either staples or 4-O nylon sutures. A light pres- sure dressing is placed for 48 hours. The patient is given preoperative antibiotics and is maintained on postoperative antibiotic therapy for 7 days. The cutaneous sutures are removed at 7 days, and the percutane- ous cranial screws are removed at 12 to 14 days. After the initial 48 hours, and for an additional 2 weeks after

FIGURE 4. View through the endoscope showing the supraorbital neurovascular bundle and the endoscopic dissector.

FIGURE 6. View through the endoscope showing the temporal dissector perforating through the junction of the temporalis fascial attachments along the temporal crest region (lower right) to release the scalp flap.

TAYLOR, GREEN, AND WISE 573

removal of screws, an elastic forehead dressing, such as a tennis headband, is worn at night until full adher- ence of the periosteum to the cranium is noted.

Report of Cases

Case 1

A 35-year-old white woman had features of an aging face, including brow ptosis, herniated lower eyelid fat pads, and lateral eyelid laxity, along with a indistinct mentocervical angle (Fig 7). She underwent the following procedures: endoscopic forehead lift with corrugator resection, transcon- junctival preexcision lower lid blepharoplasty, and sub- mental liposuction. Her preoperative and postoperative photographs demonstrate substantial improvement in her facial appearance. Note the significant decrease in the vertical glabellar rhytids and lack of reflex contraction of the frontalis muscle.

Case 2

A 67-year-old white woman presented 10 years after a direct browlift with severe glabellar rhytids and medial brow ptosis (Fig 8). She underwent an endoscopic forehead/brow rejuvenation technique with procerus and corrugator supercilii muscle resection. Note the lack of significant forehead rhytids in the postoperative photographs, which were present preoperatively.

Case 3

A 45-year-old woman presented with brow ptosis and corrugator hyperactivity (Fig 9). She underwent an endoscopic forehead/brow rejuvenation technique with brow elevation and corrugator resection.

Discussion

The endoscopic forehead technique is in its infancy, and a number of different approaches and techniques have been used with modifications being incorporated on a trial-and-error basis. Incision design, tissue plane approach, necessity for disruption of the frontalis muscle, and tissue stabilization methods represent current areas of controversy. With continued experience and further research, the endoscopic approach will continue to evolve and become more standardized.

The endoscopic forehead lift can be adequately performed through the five incisions described. T-shaped, chevron, and straight sagittal incision designs also have been described. We favor the straight sagittal and parasagittal incisions over the T-shaped and chevron designs because they can be closed with minimal diffi- culty, are more esthetic, do not require scalp excision with forehead repositioning, and carry a lower risk of alopecia.

Although both subperiosteal and subgaleal approaches can be performed with the endoscopic technique, the subperiosteal plane has several advantages.

It is safe, quick, and can be done in a blind fashion over a large percentage of the forehead. The lymphatic and vascular channels are not disrupted, thereby pro- ducing less edema and hemorrhage. Maintenance of the lymphatics also permits early resolution of the surgical edema. The subperiosteal approach allows for creation of a nearly bloodless optical chamber, which improves visualization of critical anatomic structures (supratrochlear and supraorbital nerves, a small branch of the superficial temporal artery associated with the fat pad containing the frontal branches of the facial nerve and the corrugator and procerus muscles). The periosteum can also be elevated down to or slightly beyond the supraorbital rim. Additionally, the periosteum is inelastic, and the released periosteum allows effective traction for forehead and brow repositioning. Readaptation to the cranium appears to be faster, giv- ing earlier stability to the elevated tissues, and the subperiosteal approach is less likely to suffer from stress relaxation. The normal gliding mechanism of the occipitalis-frontalis muscle is preserved, maintaining a dynamic and stable brow position.’

Access to the procerus and corrugator muscles is excellent with either the subperiosteal or subgaleal approach. Resection can be accomplished easily after the supratrochlear and supraorbital nerves have been identified and isolated. Partial or complete resection of these muscles results in elimination or improvement of the vertical glabellar and transverse nasal rhytids. The muscle-dermis junction is easily identified, and care should be used to avoid damage to the dermal and cutaneous layers. External cutaneous depressions have not been a problem, and fat grafts to replace the resected muscle have not been necessary. Redraping of the forehead tissue without depressor muscle resection is not advocated because the hyperactive muscle activity is not eliminated and may reappear with adher- ence of the periosteum to the cranium or the subgaleal tissues to the pericranium.‘”

Treatment of the frontalis muscle is controversial, and some surgeons do not believe that sectioning or scoring of the frontalis muscle is required or advisable. The frontalis muscle is the primary elevator of the brow, and diminishing its effect is not advantageous. Proper brow and forehead repositioning appear to reduce frontalis hyperactivity and provide gradual improvement in the forehead rhytids and elimination of the clinically “tense” forehead. In addition, elimination of the antagonistic effect of the forehead depressor muscles further diminishes frontalis activity.”

Posterior dissection of the parietal and occipital por- tions of the scalp can be performed in either the subperiosteal or the subgaleal plane. Release in either plane allows posterior sliding of the scalp and soft tissue contracture. Hemorrhage, hypesthesia, and alopecia are of minimal concern with either method.

HEAD LIFT

FIGURE 7. Case 1. Patient with an aging face showing brow ptosis, herniated lower eyelid fat pads and lateral eyelid laxity with an indistinct mentocervical angle. A, Preoperative relaxed view. B, Preoperative frown. C, 6-month postoperative relaxed view. D, Postoperative frown.


FIGURE 8. Case 2. Sixty-seven-year-old woman who had a direct browlift performed approximately 10 years earlier. Note her recurrent glabellar rhytids and medial brow ptosis. A, Preoperative relaxed view. B, Preoperative frown. C, h-month postoperative relaxed view. 0, Postoperative frown.


FIGURE 9. Case 3. Patient with brow ptosis and corrugator hyperactivity. A, Preoperative relaxed view. B, Preoperative frown. C, 6-month postoperative relaxed view. D, Postoperative frown.


Techniques for forehead and scalp fixation have used sutures, miniscrews, or a combination of both. Our technique precisely fixes the tissue directly to the cranium with 1.7~mm diameter vitallium miniscrews at the midsagittal and parasagittal incisions. Mini- screws can be selected by length to match the level of the scalp so as to reduce visibility and avoid interfer- ence with daily hair hygiene. The concomitant use of suspension sutures is eliminated, and the concern about suture slippage or breakage is negated. The scalp tissue does not react adversely to the vitallium miniscrews, and removal can be accomplished without local anesthesia. When combined with the sagittal incisions, scalp excision is not required, the risk of alopecia is minimal, and wound closure is simple and esthetic. The risk of entering the cranial vault or sagittal sinus is minimal if the appropriate equipment and technique are used. Suspension sutures are used to reposition the lateral orbital and temporal tissues at the appropriate level by attachment to the temporalis fascia.

The use of the endoscopic technique can be limited by a number of predisposing factors. Significant fronto-orbital bony irregularities that require extensive recontouring and the need for excision of skin preclude the use of the procedure. The presence of an exces- sively high hairline (>6.0 to 6.5 cm from the brow) also precludes any technique that will further lengthen the forehead. The thick or tight skin and prominent frontal and periorbital attachments in Asians, Ameri- can Indians, and Latinos make elevation difficult, even with open techniques. Other limiting factors include the learning curve required to achieve optimal results, use of new instrumentation, staff training, and the associated overall investment.’

Endoscopic and open forehead lift procedures are not without possible complications and postoperative problems. However, certain postoperative problems may be less frequent or totally avoidable with the endoscopic technique. Anesthesia or hypesthesia associated with coronal or trichophilic incisions are minimal or nonexis- tent because the incisions are placed parallel to the sen-

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sory nerves and dissection is subperiosteal. Alopecia is also avoidable because there is minimal damage to hair follicles, skin excision is not required, and there is less tension on the scalp, reducing ischemia. Scarring is min- imized because the incisions are hidden in the scalp, small, and easily closed with simple techniques. Infec- tion, hematoma, unsatisfactory contours, suboptimal correction, skin slough, xerophthahnia, and cranial nerve V (supratrochlear and supraorbital nerves) and cranial nerve VII (frontal branch) injuries are possible complications related not to a specific surgical approach, but rather to improper operative technique and surgeon error. Currently, no long-term studies exist to document the potential for, and rate of, relapse of brow ptosis with the endoscopic technique.

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Endoscopic Forehead Lift. Technique and Case Presentations

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