David M. Knize

An anatomically based study of the mechanism of eyebrow ptosis.

&NA; The development of eyebrow ptosis with aging is commonly attributed to progressive laxity of scalp and forehead soft tissues. If the change in eyebrow position with aging resulted entirely from this basic mechanism of tissue stretching, uniform lowering of the medial and lateral eyebrow segments should occur. Clinical observations show, however, that the lateral eyebrow segment usually becomes ptotic earlier than the medial segment, indicating that a more complex mechanism exists. To clarify this process, anatomic studies were done on 20 (40 half‐head) fresh cadaver specimens. Histologic studies also were performed to complement the gross anatomic findings. These studies confirm that the mechanism producing eyebrow ptosis has a relatively greater effect on the lateral eyebrow segment. The lateral eyebrow has less support from deeper structures than the medial eyebrow, and the balance of forces acting on the eyebrow selectively depresses the lateral segment. Structures that may promote mobility and gravitational descent of the eyebrow, especially the lateral eyebrow segment, are (1) the galea fat pad, (2) the preseptal fat pad, and (3) the subgalea fat pad glide plane space. Three forces that act on the lateral eyebrow are (1) frontalis muscle resting tone, which suspends that eyebrow segment medial to the temporal fusion line of the skull, (2) gravity, which causes the softtissue mass lateral to the temporal line to slide over the temporalis fascia plane and push the lateral eyebrow segment downward, and (3) corrugator supercilii muscle hyperactivity in conjunction with action of the lateral orbicularis oculi muscle, which can antagonize frontalis muscle activity and directly facilitate descent of the lateral eyebrow. The axis point for these forces is the temporal fusion line of the skull near the superior orbital rim. The interaction of those structures and forces contributing to the mechanism producing eyebrow ptosis is discussed. Derived concepts are applied to the execution of the forehead lift procedure. (Plast. Reconstr. Surg. 97: 1321, 1996.)

A study of the supraorbital nerve

A detailed description of the anatomical relationships of the supraorbital nerve as it courses across the forehead and under the scalp cannot be found in most anatomy textbooks, and illustrations of the nerve beyond the superior orbital rim frequently misrepresent its course. Because the supraorbital nerve is a structure at risk in many plastic surgical techniques, the plastic surgeon would benefit from a clearer understanding of its anatomy and function. The supraorbital nerve was studied anatomically in 12 (24 half-head) fresh cadaver specimens, and its sensory distribution was studied in 30 living subjects using selective nerve blocks. Beyond the orbital rim, the supraorbital nerve has two consistently present divisions: (1) a superficial (medial) division that passes over the frontalis muscle, providing sensory supply to the forehead skin and only to the anterior margin of the scalp in 90 percent of the study subjects; and (2) a deep (lateral) division that runs cephalad across the lateral forehead between the galea aponeurotica and the pericranium as the sensory nerve to the frontoparietal scalp. When a forehead lift is performed, injury to this deep division causes most of the distressful sequelae of scalp numbness and paresthesia. Unlike the superficial division, the course of the deep division in all cadaver specimens and its sensory distribution in all living volunteer subjects was consistent. This study has application for any procedure requiring scalp or forehead incisions, such as the forehead lift and the endoscopic facial techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

Limited incision forehead lift for eyebrow elevation to enhance upper blepharoplasty.

&NA; Treatment of eyebrow ptosis to enhance the cosmetic effect from blepharoplasty is commonly done with a forehead lift using a coronal incision approach. The coronal scalp incision is associated with the annoying sequelae of frontoparietal scalp numbness, itching, and paresthesias, all of which can be permanent. A forehead lift technique with temporal scalp incisions only 4.5 to 5.0 cm in length can produce a result comparable with that of the coronal incision approach when combined with transpalpebral resection of the corrugator supercilii muscles and transection of the procerus muscle. This eyebrow elevation technique, like the endoscopic approach, minimizes the risk of permanently injuring the supraorbital nerve branches that innervate the frontoparietal scalp. Unlike the approach using only endoscopy, however, this technique can effectively treat cases of advanced eyebrow ptosis. The appropriate area of eyelid skin for excision may be difficult to assess when a forehead lift and upper blepharoplasty are done concomitantly. The described forehead lift incorporates a method to determine this area. This forehead lift technique, combined with a technique for protecting against overresecting upper eyelid skin, is described as used effectively on 140 blepharoplasty cases followed for 3 months to 4 years. (Plast. Reconstr. Surg. 97: 1334, 1996.)

Transpalpebral approach to the corrugator supercilii and procerus muscles

The most effective method for treating glabellar area skin contour irregularities produced by hyperactive corrugator supercilii and/or procerus muscles is resection of the former and at least transection of the latter. The usual surgical approach is a coronal incision, which produces recognized sequelae of scalp or prefrontal hairline scarring and scalp dysesthesia; potential complications include injury to the frontal branch of the facial nerve, postoperative alopecia, and excessive recession of the frontal hairline. Hyperactive corrugator supercilii muscles may be excised and procerus muscles transected without a coronal incision. These muscles can be treated through an upper blepharoplasty incision without compromise to the blepharoplasty procedure. A transpalpebral technique as performed on 40 patients followed 6 to 24 months is described, and the cadaver and nerve block studies upon which this technique is based are discussed. The postoperative cosmetic improvement of the glabellar area is comparable in appearance with that achieved from a coronal incision approach.

Anatomic concepts for brow lift procedures.

Background: Brow lifting became a component of the facialplasty procedure 45 years ago, and the original brow-lifting technique incorporating a coronal incision approach is still practiced by many surgeons today. Over the past 15 years, however, the endoscope-assisted procedure and the limited incision, nonendoscopic techniques have evolved as alternate procedures for brow lifting. The level of artistry in performing any brow lift technique is raised when the surgeon acquires knowledge of upper facial anatomy and integrates that knowledge into a working concept of the aging process of the upper face. Methods: This article presents one surgeon’s concepts of the process that culminate in the typical appearance of the aged upper face. The same understanding of upper facial anatomy that can be called upon to explain the steps in this aging process can also be applied to the technical steps of any foreheadplasty procedure. Those anatomic structures that play a role in this process are examined here. Results: The typical appearance of the aged upper face is the product of muscle action and gravitational forces acting on the unique anatomy of the human face. Interestingly, the appearance of the typical aged upper face exhibits much the same characteristics as one might observe in the face of an individual experiencing the emotions of sadness or grief. It is an inappropriate facial expression of sadness or grief that most often motivates the patient to schedule a consultation with the plastic surgeon. Conclusion: Any of the brow lift procedures used in current clinical practice can provide a successful cosmetic result in selected patients if the procedure incorporates technical steps based on sound anatomic principles.

Endoscopic Brow Lift: A Personal Review of 538 Patients and Comparison of Fixation Techniques

The senior author performed 538 consecutive endoscopic foreheadplasty operations, which were examined retrospectively. Every patient underwent the same procedure, except that two different forehead flap suspension techniques were used. The authors state, “Our study compared two essentially identical groups of patients undergoing the same operation performed by the same surgeon, with the only variable being the method of brow fixation.” The authors did address the effect of a possible learning curve over the course of 538 cases and 6 years. In the first 189 of the 538 patients who underwent the endoscopic brow lift procedure, fibrin glue was used to stabilize forehead flap position. These patients became group 1. In the last 349 patients who underwent the endoscopic brow lift procedure, sutures fixed to bone tunnels were used to stabilize forehead flap position. These patients became group 2. The authors conclude that suture fixation of the forehead flap to bone provided more stable long-term eyebrow position than fixation of the forehead flap with fibrin glue. This is not a surprising conclusion, but we should examine the authors’ basis for reaching it. Because the authors based their conclusions on statistical analysis of eyebrow level measurements made preoperatively and postoperatively, we should give critical attention to the details of that process. While the title suggests that 538 patients were studied, apparently only data on 324 patients were available for analysis. In group 1, there were 104 patients with complete records, and in group 2, there were 220 patients (as shown in the authors’ Table IV). The follow-up time for group 1 was 9.1 months (range, 3 to 60 months), and for group 2 it was 9.7 months (range, 3 to 23 months). The preoperative measurement on each studied patient was compared with a measurement taken at least 3 months postoperatively, but that specific point in time was not stated. The method for determining eyebrow position in this study was to measure the distance from the level of the midpupil in forward gaze to the superior edges of the hairs at the apex of the eyebrow. As shown in the authors’ Figure 1, all of the measurements were made with a caliper by the operating surgeon. I must question whether accuracy of this measuring technique was adequate for determining the relatively small differences between the preoperative and postoperative eyebrow levels reported in this study. The differences between the mean preoperative and postoperative eyebrow levels in these cases were 3.79 and 6.16 mm for group 1 and group 2, respectively. A measurement error that altered this difference only 1 mm could change the data by 16 to 28 percent. For example, consider the potential variables introduced by subtle differences in globe position or in the positions of the eyebrow hairs between the preoperative and postoperative measurements. Instead of a “blinded” examiner, the operating surgeon performed all of the measurements, which introduces the question of bias; however, this actually may have provided consistency for the measurements in this particular study. While the measurement method may well be acceptable for this application, I believe that these issues should be brought to the readers’ attention. I cannot comment on the method used for the statistical analysis of the data, because I am not a biostatistician. Apparently,

Avoiding Hematoma in Cervicofacial Rhytidectomy: A Personal 8-Year Quest. Reviewing 910 Patients

Jones and Grover challenge a basic practice in plastic surgery: the preoperative infiltration of adrenaline into a surgical site to limit perioperative bleeding. They believe their study supports the hypothesis that adrenaline injected along with the anesthetic solution into the tissues of patients before undergoing a face lift procedure can result in an increased incidence of postoperative hematoma, and, therefore, should be abandoned. The first part of the article describes the senior author’s earlier attempts to control postoperative hematoma formation in face lift patients. He studied 678 patients whose face lift procedures were performed with intravenous propofol and fentanyl anesthesia, with endotracheal intubation administered by one member of a three-person team of anesthetists, each using the same anesthesia protocol. Techniques that potentially could reduce the incidence of postoperative hematoma formation— tumescent infiltration, fibrin glue, dressings, and drains—were used on subsets of patients in this study group. Despite these measures, the overall hematoma rate was 4.4 percent (range of 4.2 to 4.8 percent for the various measures used). More recently, two additional face lift patient groups of the senior author were studied for the incidence of hematoma formation. In one group of 229 patients (group A), adrenaline was added to the injected tumescent anesthetic solution; in the other group of 232 patients (group B), it was not. The postoperative hematoma rate for group A was 4.8 percent, essentially the same as that seen in his earlier experience. In striking contrast, group B developed only one minor hematoma that did not require evacuation. This difference is remarkable, but we should examine the information that the authors have provided to evaluate their interpretation of this result. A single surgeon in the same dedicated plastic surgical unit performed all of the procedures, and one member of the three-person anesthetist team used the same anesthetic technique for both group A and group B. The ratio of male to female patients and primary to secondary face lift cases was approximately the same for each group. The authors reported that group A and group B underwent “essentially similar” face lift procedures. They acknowledged, however, that the type and frequency of face lift techniques did differ between the two groups of patients. One question we must ask is whether this difference in the mix of techniques used for each of the two groups and listed in Table III affected the results of the study. This is important to consider because, in my experience, hematomas requiring evacuation usually occur at the subcutaneous level and most often in the neck. They rarely present at the sub–superficial musculoaponeurotic system (SMAS) level. In this regard, there are two notable dissimilarities between the two study groups. One is the use of the extended supraplatysmal plane technique in group A (29 percent) and its absence in group B. This technique involves wider subcutaneous undermining than the other techniques they used. The second difference is that in 79 percent of the cases in group B (compared with 28 percent in group A), the SMASectomy technique was used; this tech-