The evolution of the brow lift in aesthetic plastic surgery

For nearly 100 years, aesthetic improvement of the aging face has included surgical elevation of the brow. Early attempts to correct brow ptosis were largely unsuccessful. Recognizing the need to modify the frown muscles heralded the achievement of results previously unobtainable. Within the past decade, the minimal incision approach to brow lifting afforded with the endoscope radically changed surgical options in forehead rejuvenation. Further advances have added to these options and have provided a palette of alternatives in aesthetic correction of the upper one-third of the aging face.     

Endoscopic forehead lift: review of technique,cases, and complications

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.     

A new resorbable tack fixation technique for endoscopic brow lifts

The endoscopic brow lift is now widely accepted in aesthetic plastic surgery, and various fixation techniques have been described in the literature. New developments and technology have expanded the use of resorbable devices in different surgical specialties, including plastic surgery. The authors present a technique that offers simple, fast, and reliable forehead fixation for endoscopic brow lifts using resorbable tacks. Successful facial rejuvenation was obtained in the majority of the patients without complications, need for follow-up visits to tighten the flap fixation system, or secondary procedures to extract the fixation system.     

A minimally invasive approach for correction of chin ptosis

Although ptosis of the tip of the chin is common and can be seen in persons of any age, it is frequently seen in older patients seeking facial rejuvenation. A variety of techniques have been described to correct ptosis of the chin. The authors describe a minimally invasive method that can be used correct chin ptosis. This technique uses a small intraoral incision to place a U-shaped Prolene suture that gathers the soft tissue of the chin and elevates it above the lower border of the mandibular symphysis. A retrospective review of 314 cases performed in conjunction with face lifts between January of 1994 and January of 2000 was performed to evaluate this technique. There were no significant complications, and long-term results have been very satisfactory and lasting.     

Transpalpebral browpexy

Transpalpebral browpexy could be performed as an adjuvant procedure to the upper blepharoplasty or as a separate procedure. It is done by separating interdigitalizing connections between the orbicularis and frontalis muscles, moving the orbicular part of the orbicularis muscle with overlying brow to the more cephalad position and again uniting both of these muscles with nonresorbable sutures in a new higher position. During the years 1990 to 1999, 55 patients (47 women and eight men) were operated on with this technique, which was partially developed by the author. Additional time required to achieve transpalpebral brow stabilization during standard blepharoplasty was approximately 30 minutes. Forty-three patients were followed, 38 of them for longer than 4 years. The elevation effect gradually decreased but persisted, with wide variations, between 1.5 and 7 more years. At the last follow-up examination, 36 of 43 patients had maintained lateral brows in the same position as before operation and sometimes even higher, which was appreciated by the patients. Complications were very few and they were correctable. Transpalpebral browpexy proved to be a useful addition to blepharoplasty and can be used for the minor adjustments after an open coronal or endoscopic brow lift. Particular indications included patients with lateral brow ptosis and discrete forehead wrinkles and balding men.     

Advanced rejuvenative upper blepharoplasty: enhancing aesthetics of the upper periorbita

The surgical approach to rejuvenation of the periorbita continues to evolve with the application of procedures that are safe and effective with a greater sensitivity of aesthetics. Most of the topics in the recent literature discuss improvements with techniques relating to the lower eyelid and midface. Improved surgical techniques of the upper periorbita have been mostly limited to advances in brow lifting. The most common and traditional approach to upper blepharoplasty has remained essentially unchanged and has not considered, to the same degree as in the lower periorbita, the actual changes that occur with age or more accurate surgical approaches toward rejuvenation. The author presents an overview of his personal view of the concepts relating to the aging upper periorbita and discusses his experiences with this procedure.     

Volumetric perceptions in midfacial aging with altered priorities for rejuvenation

The history of facial rejuvenation surgery has largely involved the manipulation of facial soft tissues under tension within the two-dimensional confinements of a facial plane. However, the youthful human face is not planar; it presents as a complex geometric solid with a curvilinear profile on the oblique view that forms an architectural ogee. Restoration of this shape by sculptural manipulation of the facial soft tissues is deemed the highest priority in midfacial rejuvenation, whereas improvement of the periorbital and perioral environments is deemed second. Effacement of the nasolabial fold is relegated to a third level of importance in this philosophy of altered priorities for midfacial rejuvenation. The importance of early patient photographs is stressed in operative planning to direct facial changes toward a past intrinsic facial personality. Postoperative results are presented of patients who have undergone facial rejuvenation by a new midfacial technique that targets these reordered goals. Comparisons with photographs taken earlier in life and traditional preoperative photographs can then be made.     

Endoscopic brow lift: a personal review of 538 patients and comparison of fixation techniques

Since the introduction of endoscopic brow lifting in the mid-1990s, it has become widely accepted as a method for rejuvenation of the upper third of the face. Despite the multitude of brow fixation techniques, there are few long-term studies providing accurate analysis of outcome. The aims of this investigation were to evaluate the long-term objective results of endoscopic brow lifting and to establish whether the technique of fixation altered the longevity of aesthetic outcome. The outcome of endoscopic brow lifts carried out on 538 consecutive patients over a 6-year period was assessed. For each patient, midpupil-to-brow distance was measured preoperatively and at intervals postoperatively. Two different fixation methods were compared: fibrin glue (n = 189, group 1; 104 records available) and polydioxanone sutures tied through bone tunnels (n = 349, group 2; 220 records available). In 214 patients, an upper lid blepharoplasty was performed simultaneously (85 in group 1 and 129 in group 2). At 1 month postoperatively, each fixation technique had produced a significant change in mean pupil to brow height (5.93 mm in group 1 and 6.21 mm in group 2, with no significant difference between the two methods; p = 0.17). However, when measurements were compared more than 3 months postoperatively (mean, 9.4 months), there was a significant difference, with some relapse in the patients treated with fibrin glue (p < 0.01). However, in group 2 (tunnel fixation), measurements remained stable, with 6.21 mm at 1 month compared with 6.16 mm long term (no significant difference, p = 0.34). In contrast, in group 1 (fibrin glue), measurements showed significant reduction, with a 1-month result of 5.93 mm and a long-term outcome of 3.79 mm (p < 0.01). Upper lid blepharoplasty had no effect on the long-term outcome of either group (p > 0.3 in group 1, p > 0.4 in group 2). Complications were few in both groups. In group 1, there was one infection, two instances of significant alopecia (both temporary), and one reoperation for relapse. In group 2, four patients required minor surgical revision of a lateral port scar and three minor areas of temporal alopecia, which recovered in less than 3 months. One patient had a paresis of the frontal branch that had recovered after 4 months. The endoscopic brow lift is therefore a safe and effective technique for increasing mean pupil to brow height. Fixation with polydioxanone sutures tied through bone tunnels produces a significantly more stable result than fibrin glue, without greater risk. This lends weight to experimental evidence that periosteal fixation must be maintained for at least 6 weeks to be secure.     

Endoscopic brow lift: a retrospective review of 628 consecutive cases over 5 years

Since its introduction in 1992, endoscopic brow lift has gained tremendous recognition because it has been promoted as a novel technique to correct brow ptosis as well as glabella rhytids in a minimally invasive manner with fewer complications than the classic coronal brow lift method. In this retrospective study, 628 endoscopic brow lift procedures performed over a 5-year period (1997-2001) at Manhattan Eye Ear and Throat Hospital were reviewed. The number of endoscopic brow lift procedures performed at this institution has declined 70 percent. The purpose of this study was to elucidate the causes of this striking trend by soliciting the opinions of 21 New York plastic surgeons on their current brow ptosis management. The response rate was 84 percent (21 of 25 surgeons contacted). Currently, 25 percent of the interviewed plastic surgeons perform endoscopic brow lift regularly, 50 percent of the plastic surgeons perform endoscopic brow lift occasionally, and 25 percent of the participants no longer perform endoscopic brow lift. While most patients (70 percent) were satisfied with their results, only 50 percent of the plastic surgeons were pleased with the long-term results (after more than 2 years of follow-up). Observed postsurgical complications of endoscopic brow lift included alopecia, hairline changes, infected hardware, brow asymmetry requiring surgical revision, prolonged forehead/brow paresthesia, frontal branch nerve paralysis, and scalp dysesthesia. These complications were similar to those resulting from open brow lifts. Seventy-one percent of the surveyed New York plastic surgeons routinely administered botulinum toxin type A (Botox) within 6 months of the endoscopic brow lift procedure. Possible explanations for the decline in the overall number of endoscopic brow lift procedures include the following: (1) the selection criteria for the ideal endoscopic brow lift patients are currently more limited; (2) other techniques equal or surpass endoscopic brow lift in effectiveness and predictability; and (3) endoscopic brow lift is ineffective in the majority of patients. There is no single superior surgical procedure for brow ptosis management available at this time.     

Aesthetic eyelid ptosis correction: a review of technique and cases

Upper eyelid ptosis can present both functional and aesthetic problems. Because proper correction of ptosis can be difficult to achieve, numerous surgical procedures have been developed. Plication of levator aponeurosis can be combined with aesthetic blepharoplasty and facial rejuvenation procedures to successfully address ptosis. The authors assessed the effectiveness of levator aponeurosis plication for correction of acquired upper eyelid ptosis in patients presenting for concomitant cosmetic facial procedures. The medical records of 74 consecutive patients (68 women and six men) who had upper eyelid ptosis correction in conjunction with cosmetic facial procedures from January of 1994 to January of 2000 were reviewed. During this period, 400 endoscopic forehead lifts and 479 face lifts were performed. The correction was performed through an external upper blepharoplasty approach removing an ellipse of skin and orbicularis muscle. Once the orbital septum was opened, a plication of the levator aponeurosis was accomplished by one or more horizontal mattress sutures of 6-0 clear nylon (with the first bite placed at or just medial to the vertical level of the pupil). The average follow-up period was 14 months. Long-term correction of the ptosis was excellent. The complications were minor, with the most common occurrence being asymmetry. Revisions were performed on only four patients. Correction of ptosis can be performed safely and effectively in conjunction with periorbital and facial rejuvenation. The technique described is simple, reliable, and reproducible.     

Three-dimensional rejuvenation of the midface: volumetric resculpture by malar imbrication

The rejuvenation technique of malar imbrication, which avoids dissection in the plane of the seventh cranial nerve, is presented to address the author's altered priorities in midfacial rejuvenation. These priorities target volumetric over tension-based goals in a manner that is simpler, safer, and more sculpturally effective than existing techniques. Volumetric manipulations in the subperiosteal and subcutaneous planes also bring substantial rejuvenation to the periorbital and perioral regions, without lip or lower lid incisions. Fourteen of the 172 patients (8 percent) who underwent consecutive procedures for primary facial rejuvenation suffered temporary upper lip paresis. Other complications were infrequent and limited. One patient underwent reoperation for asymmetry. Increased postoperative swelling and recovery are a necessary consequence of the subperiosteal component, just as increased operative time attends the wide undermining of the subcutaneous component. Despite these liabilities, the author recommends adding volumetric resculpture to the existing conventional tools of soft-tissue displacement under tension and topical resurfacing in pursuit of safer, more effective, and more natural rejuvenation of the aging face.     

Cosmetic medicine: facial resurfacing and injectables

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the most common options available for minimally invasive facial rejuvenation. 2. Identify key elements essential to each treatment option. 3. Know how to avoid and manage complications for these procedures. SUMMARY: Minimally invasive cosmetic procedures continue to increase in popularity. This article is intended to provide a broad and practical overview of common minimally invasive cosmetic techniques available to the plastic surgeon.     

Subperiosteal brow lifts without fixation

Most surgeons today advocate an endoscopic subperiosteal brow lift for surgical correction of the upper third of the face. At the author's clinic, this operation has been performed since 1994 and the subgaleal bicoronal brow lift is no longer used. In earlier investigations, the author showed that the subperiosteal approach (n = 60) gives a better result than the subgaleal method (n = 60) when compared 1 year after surgery. In the literature, however, there are no published data regarding the long-term results of subperiosteal brow lifts. The author took material from his earlier investigations and looked at the same patients 5 years postoperatively. He compared the subperiosteal approach (n = 30) with the subgaleal brow lift (n = 15) and found that after 5 years the brows of the subgaleal patients were on the same level as they were before surgery, but in the group of subperiosteal brow lifts, almost all of the brows were higher 5 years after surgery than they were 1 year after surgery, with a mean increase in height of 2.5 mm. These findings led the author to the question whether scalp fixation was necessary at all when performing a subperiosteal brow lift. He performed 20 subperiosteal endoscopic brow lifts where scalp fixation was not used at all, relying only on changing the balance of muscle vectors around the eyebrows. Using a computerized instrument, measurements were made of the distance between the medial canthus and the top of the eyebrow, the midpupil and the top of the eyebrow, and the lateral canthus and the top of the eyebrow. All patients were measured before and 1 year after surgery. The author found an increase of the vertical height from the midpupil to the top of the brow, with an average increase of 3.9 mm. There were no differences between patients who had only a brow lift and those who had a brow lift and an upper blepharoplasty at the same time. The author concludes that for most cases where an increased vertical height of the brows of more than 4 mm is not needed, it is not necessary to use scalp fixation to achieve a natural result.     

The brow slide: a technique for the aesthetic treatment of eyebrow tumors.

Skin neoplasms involving the eyebrow are not an uncommon problem. Standard surgical resections that depend on elliptical excision and closure tend to either remove an excessive amount of brow or place scars in an unfavorable position. We present a simple technique that allows for maximal brow preservation, alignment of remaining brow, and a minimal amount of exposed scars.     

Combined erbium:YAG laser resurfacing and face lifting

Facial aging occurs secondary to gravity-induced tissue ptosis and photoaging. Combined face lifting and carbon dioxide laser resurfacing provides a comprehensive one-stage approach to facial rejuvenation but is condemned by many plastic surgeons due to the nonspecific thermal effects of the laser and risk of skin necrosis. Newer high-energy erbium:YAG lasers allow precise tissue ablation with minimal thermal effect. In this study, various facial rejuvenation techniques were combined with simultaneous erbium:YAG laser resurfacing to assess results and complications. A total of 257 patients from Florida, Melbourne, Australia, and Tel Aviv, Israel, underwent combined erbium:YAG laser resurfacing and surgical facial rejuvenation. Various face-lift methods were used, including endoscopic, deep plane, and subcutaneous. Simultaneous, full-facial laser resurfacing was performed using a variety of erbium:YAG lasers. It was found that combined laser resurfacing and face lifting was successful in greater than 95 percent of patients with minimal morbidity. Two patients (1 percent) (both heavy smokers) developed small areas of skin necrosis that healed with minor pigment changes. Five patients (2 percent) developed synechia that was treated with no residual effect. Two additional patients (1 percent) developed temporary ectropion. There were no other cases of scarring, infection, or cosmetically obvious hypopigmentation. Although larger studies are necessary, it seems that the lack of thermal injury from the erbium:YAG laser makes it possible to safely perform laser resurfacing with surgical facial rejuvenation in nonsmokers. However, the authors caution that familiarity with the nuances of erbium:YAG laser resurfacing be obtained before performing combined laser resurfacing and face lifting.     

Restoring facial shape in face lifting: the role of skeletal support in facial analysis and midface soft-tissue repositioning

Aesthetic analysis in facial rejuvenation has traditionally been subordinate to technical solutions. While concerns regarding correction of facial laxity, a reduction in the depth of the nasolabial fold, and improvement of both the jowl and the jawline are worthy goals in rhytidectomy, the aesthetic concept of restoring facial shape to a more youthful appearance is equally important. Restoring facial shape in face lifting requires an understanding of how the face ages and then the formulation of a treatment plan that is individualized for the patient. Re-establishment of facial contour is significantly influenced by the re-elevation of descended facial fat through superficial musculoaponeurotic system manipulation; it can be approached through a variety of technical solutions. Underlying skeletal support affects not only the appearance of the face in youth but also how the face ages and influences the operative plan in terms of the requirements for fat repositioning. Formulating a treatment plan that is patient specific and based on the artistic goals as influenced by skeletal support is the key element for consistency in restoring facial shape in face lifting.     

Biometric evidence that sexual selection has shaped the hominin face

We consider sex differences in human facial morphology in the context of developmental change. We show that at puberty, the height of the upper face, between the lip and the brow, develops differently in males and females, and that these differences are not explicable in terms of sex differences in body size. We find the same dimorphism in the faces of human ancestors. We propose that the relative shortening in men and lengthening in women of the anterior upper face at puberty is the mechanistic consequence of extreme maxillary rotation during ontogeny. A link between this developmental model and sexual dimorphism is made for the first time, and provides a new set of morphological criteria to sex human crania. This finding has important implications for the role of sexual selection in the evolution of anthropoid faces and for theories of human facial attractiveness.     

The extended subperiosteal face lift: a definitive soft-tissue remodeling for facial rejuvenation.

The subperiosteal face lift described by Psillakis has been criticized for not showing a more dramatic improvement over conventional brow/face lift procedures. His approach also has a significantly high incidence of nerve injury. This study reports our anatomic findings and surgical modifications, which have permitted a significant improvement in the safety of execution and clinical results using the subperiosteal face lift concept. Pertinent points of applied local anatomy and dissection techniques are as follows: First, we use extensive interconnected subperiosteal dissection that includes the entire zygomatic arch. This allows better repositioning of the deep soft tissues of the entire upper face, most of the midface, and indirectly, key structures of the lower face. Second, the upward pull of the muscles of the cheek and mouth will produce an elevation of the corner of the mouth, affecting positively the smiling mechanism, the oral frowning, and the jowls. Third, the dissection deep to both layers of the temporal fascia decreases the risk of injury to the frontalis nerve. Fourth, the temporal fascia is used as a lifter and anchoring element of the entire cheek-perioral soft tissues as opposed to the periorbital fibrofatty tissues. This will decrease the risk of injuring the frontal and zygomatic branches of the facial nerve. These modifications have been used in 28 patients. Our rate of patient satisfaction has been high, and no complications with regard to nerve injury have been observed. This compares favorably with our initial 60 patients, in whom the Psillakis or Tessier approach was used. In these patients, there was an 11 and 20 percent rate of nerve injury, respectively.     

Expression of matrix metalloproteinase-1 (MMP-1) in Wistar rat's intervertebral disc after experimentally induced scoliotic deformity

Minimally invasive spine surgery is becoming more common in the treatment of adult lumbar degenerative disorders. Minimally invasive techniques have been utilized for multilevel pathology, including adult lumbar degenerative scoliosis. The next logical step is to apply minimally invasive surgical techniques to the treatment of adolescent idiopathic scoliosis (AIS). However, there are significant technical challenges of performing minimally invasive surgery on this patient population. For more than two years, we have been utilizing minimally invasive spine surgery techniques in patients with adolescent idiopathic scoliosis. We have developed the present technique to allow for utilization of all standard reduction maneuvers through three small midline skin incisions. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, and allows adequate facet osteotomy to enable fusion. There are multiple potential advantages of this technique, including: less blood loss, shorter hospital stay, earlier mobilization, and relatively less pain and need for pain medication. The operative time needed to complete this surgery is longer. We feel that a minimally invasive approach, although technically challenging, is a feasible option in patients with adolescent idiopathic scoliosis. Although there are multiple perceived benefits, long term data is needed before it can be recommended for routine use.