11 Open Coronal Pretrichial Browlift Surgery
Abstract
Brow lifting is an integral part of facial rejuvenation. Forehead rejuvenation is able to restore a more youthful and aesthetically pleasing brow position and facial harmony. Currently, there are many well-described approaches available for forehead rejuvenation. Here, we describe the coronal pretrichial lift to elevate the eyebrow and enhance the upper face by addressing forehead rhytids and improving the brow to trichion distance.
11.1 Introduction
The coronal open pretrichial browlift treats a descended brow line and addresses the aging forehead in a long-lasting way. It can be approached through either a pre- or posttrichial coronal incision. 1 ID#b3a237a676_2 – ID#b3a237a676_3 ID#b3a237a676_4 ID#b3a237a676_5 ID#b3a237a676_6 ID#b3a237a676_7 ID#b3a237a676_8 ID#b3a237a676_9 10 Patients with a significant component of medial eyebrow ptosis, mechanical ptosis, vertical and horizontal glabellar rhytids, a high hairline, and a pronounced dorsal nasal root are well treated with this open technique because access and visualization for glabellar manipulation are excellent. 1 ID#b3a237a676_2 – ID#b3a237a676_3 ID#b3a237a676_4 ID#b3a237a676_5 6 Coronal brow lifting incisions are less useful in male patients with male-pattern baldness due to a noticeable scar. Patients less concerned with forehead rhytids or cosmesis and who desire a procedure solely to expand their visual field may not require an open browlift.
11.2 Unique Anatomical Considerations in Coronal Brow Lifting
Age and genetics contribute to periorbital soft tissue descent and deflation. The subbrow fibrofatty soft tissue (the retro-orbicularis oculus fat pad or ROOF) descends over the orbital rim and into the eyelid, and may aggravate dermatochalasis and upper eyelid herniated orbital fat. These changes may alter the face and may emote a fatigued, angry, depressed, or sad appearance, as well as affect the superior field of vision. Altering the upper face through an open brow lifting approach requires a thorough understanding of brow anatomy to improve the facial aesthetic and to avoid complications.
The Eyebrow
Characteristics of the ideal brow have been described. The ideal height and contour vary by age and gender.
11.2.1 Eyebrow Position
The medial eyebrow should begin in the same vertical plane as the nasal ala and medial canthus. The temporal brow should end along the oblique line extending from the nasal ala through the lateral canthus. The eyebrow apex should lie directly over the lateral limbus. 11 For women, the brow begins at or slightly above the orbital rim prominence, arches upward as it sweeps laterally, and is at its maximal height at the two-thirds point. In men, the aesthetically pleasing brow should be flatter, straighter, and at or slightly below the orbital rim. 2
Eyebrow Hair Orientation
The medial aspect of the brow has hairs that direct upward, the body of the brow has hairs that direct more horizontally, and the tail of the brow has hairs that may orient slightly downward. The tail of the brow often does not overlie the frontalis muscle because this muscle does not extend past the conjoint fascia separating the temporalis muscle laterally from the frontalis muscle centrally. This exacerbates temporal brow ptosis with age.
11.2.2 The Anatomic Layers
The scalp is composed of five layers: skin, subcutaneous tissue, aponeurosis, loose areolar tissue, and periosteum. The skin of the brow and forehead is thick and laden with sebaceous glands. The supraorbital ridge separates the midface from the forehead, and the hairline separates the forehead from the scalp. The galea aponeurosis connects anteriorly to the frontalis muscle, which serves as the primary brow elevator and posteriorly to the occipital muscle. The loose areolar tissue allows a safe, reliable dissection plane for the open browlift. It also allows easy access to the glabella with its corrugator and procerus muscles. The subcutaneous dissection also allows another dissection plane. Caution is necessary in the subcutaneous plane to avoid excess skin tension, which may cause overlying ischemia and necrosis.
11.2.3 The Muscles of Elevation and Depression
The muscles responsible for brow depression include the paired corrugator supercilii, procerus, and the orbicularis oculi muscles. 1 , 4 The temporoparietal fascia (TPF) is deep to the skin and subcutaneous tissue in the temporal region. It is contiguous with the superficial muscular aponeurotic system inferiorly and galea superiorly. Deep to the TPF is the deep temporal fascia. The deep temporal fascia divides at the supraorbital ridge into intermediate temporal fascia and deep temporal fascia, with an intermediate fat pad between the two layers. The dissection plane between the superficial and deep temporalis fascial plane is loose and often may be dissected digitally. The deep temporal fat pad lies below the deep temporal fascia. Traumatizing the deep temporal fat pad may cause atrophy and temporal wasting. 4
11.2.4 The Sensory Supply
The sensory supply to the forehead and scalp includes the supratrochlear and supraorbital branches of the ophthalmic division of the trigeminal nerve. These may be easily identified in the subgaleal approach and preserved during dissection. 4 The supraorbital nerve can be seen exiting the supraorbital notch, or in 10% of cases from the supraorbital foramen. 5 There are multiple trunks to the supraorbital nerve as it exits the supraorbital notch or foramen. The zygomaticotemporal and auriculotemporal nerves, branches of the maxillary nerve and mandibular branches of the trigeminal nerve, supply the temple. The scalp is supplied by extensions of these nerves and also by branches of the dorsal rami of cervical spinal nerves and the cervical plexus. 1
11.2.5 The Facial Nerve
The course of the temporal branch of the facial nerve must be appreciated during brow lifting. The temporal branch of the facial nerve emerges from the parotid gland approximately 2.5 cm anterior to the tragus and runs obliquely. It passes 1.5 cm lateral to the lateral orbital rim to innervate the frontalis muscle from its deep surface. 6 It is just superficial to the periosteum at the zygoma, and then it travels anterior to the superficial layers of the deep temporal fascia superiorly to ultimately reach the brow musculature from the undersurface. Fibers enter the underbelly of the frontalis muscle approximately 1 cm above the supraorbital rim. It is imperative to carefully dissect deep to the temporal fascia, staying anterior to the deep temporalis fascia to avoid functional and cosmetic complications from nerve injury (see “Upper Facial Danger Zones” in Chapter 2). 1
11.2.6 The Vascular Supply
The vascular supply to this region is from branches of both the internal and external carotid arteries. 1 , 4 The supraorbital and supratrochlear arteries originate from the internal carotid system via the ophthalmic artery and supply the central anterior forehead and scalp. These arteries pierce the frontalis muscle a centimeter above the brow and lie more superficial. The remainder of the blood supply comes via the branches of the superficial temporal, zygomaticotemporal, posterior auricular, and occipital arteries, which all are branches of the external carotid.
11.3 Patient Evaluation
Preoperative evaluation of the browlift patient is a critical step. It is here that forehead length and contour, eyebrow shape and contour, forehead rhytids, and nasal root aging changes are addressed.
11.3.1 Forehead Length and Contour
The distance between the brow and hairline must always be considered in brow lifting. The typical youthful distances for forehead height are 4.5 to 5.5 cm. 3 The distance must be balanced with the upper and lower thirds of the face. Higher hairlines contribute to an aged face. A high hairline is better suited to the pretrichial open browlift incision to avoid unnaturally lengthening of the forehead. Hairline contour should also be taken under consideration when planning the incision. The incision should be made in parallel to the shape of the hairline. Patients with a widow’s peak should have the incision marked to avoid altering the central contour of the hairline.
11.3.2 Eyebrow Shape and Contour
Patients with nasal brow ptosis, mechanical ptosis from eyebrow descent, and lateral brow ptosis are ideal candidates for the pretrichial open-sky approach.
11.3.3 Forehead Rhytids
Prominent forehead rhytids are treated by elevation of the entire frontalis muscle, skin, and subcutaneous tissue as a unit. Scoring the underside of the frontalis muscle perpendicular to the frontalis muscle orientation can easily be performed with the open-sky approach and will weaken the horizontal lines.
11.3.4 Nasal Root
A prominent nasal root can be released through an open browlift. As needed for deep vertical and horizontal glabellar lines, release of the corrugator and procerus muscles, respectively, can offer long-lasting desirable reduction of these lines. Caution must be exercised to avoid overaggressive resection of the corrugator muscles to prevent splaying of the medial head of the brow as well as dimpling of the glabella postoperatively. An increased risk of hypesthesia may also be seen. The authors occasionally place soft tissue fillers in the area around the resected corrugator muscles to avoid these complications.
11.4 Goals of Intervention/Indications
The main goal of the open browlift is to meet the patient’s desires. The primary goal is to correct functionally limiting or aesthetically displeasing brow ptosis with associated forehead wrinkling by elevating the entire brow as a unit. 1
Improvement in the superior field of vision (functional brow ptosis with resultant mechanical upper eyelid ptosis).
Improved eyebrow height.
Improved eyebrow contour.
Reduction of glabellar folds and the skin redundancy at the nasal root.
Improved aesthetic treatment of forehead rhytids.
Relief from nonsurgical applications to improve the eyebrow height and contour, specifically neurotoxins into the brow depressors and fillers to volumize.
11.5 Risks of the Procedure
Bleeding (subflap hematoma formation).
Infection (uncommon).
Wound dehiscence (uncommon).
Asymmetric brow position.
Asymmetric hairline position.
Overcorrection (aesthetically displeasing overelevation).
Undercorrection.
Damage to frontal (temporal) branch of the facial nerve, inducing brow ptosis.
Sensory nerve deficit (prolonged anesthesia, paresthesia, and dysesthesia of the scalp and forehead). 9 , 10
Lagophthalmos from elevation of the eyebrow in conjunction with upper blepharoplasty.
Skin necrosis.
Prominent or irregular scar.
Temporary or permanent eyebrow alopecia.
Abnormal hair part (with posttrichial open browlift).
Abnormal soft tissue contour.
11.6 Benefits of the Procedure
Improvement of superior field of vision and mechanical ptosis.
Aesthetic enhancement of the upper face, including the forehead, eyebrow, and upper eyelids.
Improvement of glabella and nasal root.
Improved eyebrow contour.
Avoidance of nonsurgical preparations to create the desired brow height and contour (neuromodulation and filler volumization).
Incision camouflage in posttrichial coronal browlift and relative incision camouflage in pretrichial coronal browlift.
Low rate of serious complications.
11.7 Contraindications
Lagophthalmos due to a deficiency of upper eyelid skin from prior blepharoplasty, other surgery, or trauma.
Poor corneal protective mechanisms.
A high hairline or male-pattern baldness is a relative contraindication to coronal incision brow lifting because the incision will be visible.
11.8 Informed Consent
Include risks, benefits, and contraindications.
Have the patients demonstrate their desired eyebrow position and contour with a mirror.
Understand and convey what is a functional and what is an aesthetic outcome.
Discuss the possible need for additional surgery to address upper eyelid ptosis, dermatochalasis and herniated orbital fat, crease reformation, and/or lacrimal gland prolapse, if present.
Preoperative discussion of postoperative pain, swelling, and bruising that may persist for several weeks following surgery.
Discuss temporary or prolonged numbness, paresthesias, and dysesthesias as possible sequelae of surgery: postoperative sensory disturbance such as itching or numbness can persist for months.
Injury to the facial nerve is rare, but the consent should cover damage to the temporal branch of the facial nerve.
Discuss possible early postoperative seroma or hematoma formation, which would require drainage (uncommon).
11.9 The Procedure
The procedure described can be done in an outpatient (ambulatory) surgery center, hospital, or in a well-equipped office-based setting. If cooperative ptosis surgery is planned, it should be performed prior to brow rejuvenation, which requires heavier anesthesia.
11.9.1 Instruments Needed
Sterile surgical marking pen.
Ruler.
Local (2% lidocaine with 1:100,000 U epinephrine mixed 1:1 ratio with 0.75% bupivacaine to inject incisions) and tumescent local anesthesia (mix 90 mL of normal saline, 60 mL of 1% lidocaine with 1:100,000 epinephrine, and 40 mL of 0.25% bupivacaine; 30–40 mL on 1.5-inch spinal needle).
Adson (large-toothed) forceps.
Facelift scissors.
Bishop Harmon forceps.
Bipolar cautery.
Hemostat.
Scalpel blades, #10 and #11.
The 4 × 4 gauze and lap sponges.
Freer periosteal elevator.
Large two-prong skin hooks (two).
Hemostat clamp.
Monopolar (optional).
Bipolar cautery.
Westcott scissors.
0.5 or Bishop Harmon forceps.
Headlight.
Suction.
Illuminated retractor.
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