Abstract
Purpose
The presence of male pattern baldness poses a significant challenge when attempting to optimize treatment of the upper third of the face. The purpose of this study is to demonstrate and discuss results of the endoscopic forehead lift in patients with male pattern baldness.
Materials and methods
This was a retrospective case series done in an academic medical center. Eleven patients with male pattern baldness (Norwood class IV–VII) underwent endoscopic forehead lift for forehead creases and brow ptosis.
Results
All patients achieved smoothing of the forehead and elevation of the brow with no scalp anesthesia at 1 month postoperatively. All patients were pleased with the healing of their incisions in midline, paramedian, and temporal regions. Alloplastic fixation devices used were visible postoperatively in 2 patients initially.
Conclusions
The endoscopic forehead lift is a suitable approach for treating the upper third of the face in the presence of male pattern baldness. The use of alloplastic fixation devices may be used in this patient population, but other fixation methods should be considered.
1
Introduction
Cosmetic facial rejuvenation surgery among male patients appears to be gaining popularity. Increased experience with this patient population oftentimes reveals considerable differences in the ultimate goals desired from treatment. More natural, more conservative, and less “stylized” looks preserving natural masculinity seem to be the rule for male cosmetic patients. These goals, however, may be difficult to articulate by patients and even more difficult to understand by surgeons during preoperative evaluations.
Optimal treatment of the upper third of the face continues to be a challenge. Rejuvenation of this area typically involves treatment of brow position and forehead creases . Commonly used approaches include direct, midforehead, pretrichial, trichophytic, bicoronal, and endoscopic techniques, each of which has its own advantages, disadvantages, and indications . Since its introduction, the endoscopic technique, specifically, has gained popularity because of its ability to lift the brow and smooth frontalis creases in a minimally invasive fashion while decreasing postoperative morbidity from scarring and scalp anesthesia .
Male pattern baldness poses a unique challenge for upper third techniques. In addition to the stylistic challenges noted above, no perfect procedure exists to lift the brow and smooth forehead creases while minimizing obvious scars in non–hair-bearing areas. For this reason, some surgeons are reluctant to perform browlifts in men, particularly men with male pattern baldness. The popular saying “when many solutions attempt to solve a problem, it is typically the case that no one solution is perfect” seems to apply to this situation. Traditionally, balding males with deep forehead creases have undergone midforehead browlifts, whereas endoscopic techniques have been considered less than ideal with only anecdotal experiences and 1 case series noted in the literature . The purpose of this study is to demonstrate and discuss results of the endoscopic forehead lift performed in a case series of patients with male pattern baldness.
2
Methods
A retrospective database search using Mirror imaging software (Canfield Imaging Systems, Fairfield, NJ) was performed and noted over 200+ browlifts performed between 2005 and 2010. Of these, 18 were male patients, 11 of which presented with significant male pattern baldness (ie, Norwood class IV–VII). These 11 patients underwent endoscopic forehead lift procedures for brow ptosis and frontalis creases. Preoperative and postoperative photos were obtained for each patient. This study was approved by the institutional review board of Johns Hopkins University School of Medicine number NA_00035679.
2.1
Surgical technique
In brief, endoscopic forehead lifts were performed using the use of 5 incisions: 1 midline, 2 paramedian, and 2 temporal incisions. These incisions can be oriented either vertically (classic description) or horizontally (if desired to hide within existing creases). Subperiosteal dissection was performed, and the arcus marginalis was freed at the superior orbital rim. Laterally, dissection was performed deep to the temporoparietal fascia just superficial to the deep temporal fascia. This temporal plane was connected with the midline subperiosteal plane by incising the conjoined tendon at the superior temporal line.
Fixation methods used the use of the Endotine fixation device (Coaptsystems, Palo Alto, CA) via the 2 paramedian incisions suspending the soft tissues subperiosteally. Skin edges were outwardly beveled to promote eversion upon closing. Two-layered closure was performed using 4-0 Vicryl (Ethicon Inc, Somerville, NJ) suture for the deep layers and 5-0 Prolene (Ethicon Inc) suture in a vertical mattress fashion to close the skin layer of all 5 incisions.
Sutures were removed at 7 days postoperatively. No postoperative scar revisions were performed. Patients were followed up at 1 week, 1 month, and 1 year postoperatively.
2
Methods
A retrospective database search using Mirror imaging software (Canfield Imaging Systems, Fairfield, NJ) was performed and noted over 200+ browlifts performed between 2005 and 2010. Of these, 18 were male patients, 11 of which presented with significant male pattern baldness (ie, Norwood class IV–VII). These 11 patients underwent endoscopic forehead lift procedures for brow ptosis and frontalis creases. Preoperative and postoperative photos were obtained for each patient. This study was approved by the institutional review board of Johns Hopkins University School of Medicine number NA_00035679.
2.1
Surgical technique
In brief, endoscopic forehead lifts were performed using the use of 5 incisions: 1 midline, 2 paramedian, and 2 temporal incisions. These incisions can be oriented either vertically (classic description) or horizontally (if desired to hide within existing creases). Subperiosteal dissection was performed, and the arcus marginalis was freed at the superior orbital rim. Laterally, dissection was performed deep to the temporoparietal fascia just superficial to the deep temporal fascia. This temporal plane was connected with the midline subperiosteal plane by incising the conjoined tendon at the superior temporal line.
Fixation methods used the use of the Endotine fixation device (Coaptsystems, Palo Alto, CA) via the 2 paramedian incisions suspending the soft tissues subperiosteally. Skin edges were outwardly beveled to promote eversion upon closing. Two-layered closure was performed using 4-0 Vicryl (Ethicon Inc, Somerville, NJ) suture for the deep layers and 5-0 Prolene (Ethicon Inc) suture in a vertical mattress fashion to close the skin layer of all 5 incisions.
Sutures were removed at 7 days postoperatively. No postoperative scar revisions were performed. Patients were followed up at 1 week, 1 month, and 1 year postoperatively.
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