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Facial plastic surgery FPS 2006 Presti.pdf

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Rejuvenation of the Aging Upper Third of the Face Paul Presti, M.D., 1 Haresh Yalamanchili, M.D., 1 and Carlo P. Honrado, M.D. 2 ABSTRACT Age-related changes to the upper third of the face manifest, typically, as brow ptosis and the development of deep skin furrows. Depression of the brow evolves as gravity and the action of the corrugator supercilli, procerus, and orbicularis draw on the progressively inelastic forehead skin. Facial mimetic muscl
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  Rejuvenation of the Aging Upper Thirdof the Face Paul Presti, M.D., 1 Haresh Yalamanchili, M.D., 1 and Carlo P. Honrado, M.D. 2 ABSTRACT Age-related changes to the upper third of the face manifest, typically, as brow ptosis and the development of deep skin furrows. Depression of the brow evolves as gravity and the action of the corrugator supercilli, procerus, and orbicularis draw on theprogressively inelastic forehead skin. Facial mimetic muscle action reveals itself overtime via the development of deep forehead rhytids. Facial plastic surgeons have at theirdisposal several effective surgical, and recently, medical interventions to address thesechanges. Each technique has merits and suitable applications. This review examines thehistory of rejuvenation of the upper face, details the pertinent treatment modalities, andevaluates the context in which each is applicable. KEYWORDS:  Facial rejuvenation, browlift, forehead lift, endoscopic A n individual’s visage undergoes dramatic mor-phological changes with time. These changes bear theunfortunate consequence of aesthetically detracting fa-cial rhytids and ptosis of the skin. Such manifestations of age are particularly noticeable on the forehead and brow. The facial plastic surgeon has within his or her arma-mentarium a multitude of surgical and, more recently,medical interventions to address the concerns pertinentto the upper third of the face. This article serves toreview the options for treating the aging forehead anddefine, in greater detail, the more prominent techniquesutilized at present. Two distinct deformities relate to the aging fore-head: brow ptosis and rhytids (furrows). Both are aconsequence of time-related elastolysis and collagenrearrangement. Aged skin has a notable loss of groundsubstance with subsequent thinning of the dermis. Theculmination of these changes makes skin less elastic andmore prone to wrinkling. The cumulative effects of gravity on this less elastic skin and decreased subcuta-neous tissue evolve into brow ptosis. The development of deep forehead furrows arises from the repeated action of facial mimetic muscles on the overlying skin. 1 Horizontal forehead furrows relate to the con-traction of the underlying frontalis muscle during eye-brow elevation. The procerus muscle is a continuation of the frontalis muscle as it insinuates into the interbrow space. Contraction of this pyramidal-shaped musclecreates horizontal rhytids overlying the radix. Similarly,the action of the corrugator supercilli muscle causesinferomedial contraction of the interspace between thebrows and results in deep glabellar vertical furrows. 2  Thecorrugator and procerus, along with the orbicularismuscle, serve to depress the brow. Critical to themanagement of the aging forehead is the interplay between the antagonistic action of these brow depressorsand the sole brow elevator, the frontalis muscle. To attempt rejuvenation of the aging brow,one must have a fundamental understanding of theideal brow position. In men, typically the brow over-lies the orbital rim without a pronounced arch. In women, classical descriptions of the peak of the brow  1 Department of Otolaryngology—Head and Neck Surgery, New York Eye and Ear Infirmary, New York, New York;  2 Department of Otolaryngology—Head and Neck Surgery, New York Medical Col-lege, Valhalla, New York.Address for correspondence and reprint requests: Carlo P. Hon-rado, M.D., ENT Faculty Practice, LLP, 1058 Saw Mill River Road,Ardsley, NY 10502.Modern Surgery of the Aging Face; Guest Editors, Adam T. Ross,M.D., Jeffrey B. Wise, M.D.Facial Plast Surg 2006;22:91–96. Copyright # 2006 by ThiemeMedical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,USA. Tel:+1(212) 584-4662.DOI 10.1055/s-2006-947714. ISSN 0736-6825. 91  demonstrate that it is situated in a line drawn verti-cally and tangent to the lateral limbus of the eye.Recently, however, brow positioning with its peak lying above the lateral canthus has become quitepopular. The medial brow takes on a club shape thatincrementally tapers as it extends laterally to a pointon the same horizontal plane as its medial position. The lateral brow approximates a line drawn from thealar groove through the lateral canthus, and themedial brow approximates a vertical line perpendicularto the nasal ala. In a series of 596 patients, brow position was evaluated, demonstrating the mean posi-tion of the male brow to be 20.8 mm (range11 to 27 mm) from midpupil to brow, and in womento be 21.4 mm (range 11 to 32 mm). 3 Similarly,McKinney et al reported that the normal distancefrom the midpupil to the upper limit of the brow is  2.5 cm in adults. 4  The relationship of the brow,medial orbital rim, and nasal bone in women shouldconform to create a Y-shaped configuration, whereasmen tend toward a T-shaped configuration of thesestructures. 5 Certainly, the described classical aestheticsof the upper forehead are recommendations that haveboth opponents and proponent. Ultimately the pa-tient’s sentiment will be an overriding consideration when determining brow position, as such features andaesthetic ideals differ among races and cultures.In addition to the aesthetic considerations, onemust also be cognizant of the relevant neurovascularanatomy of the forehead. The supraorbital and supra-trochlear nerves, both branches of the first (ophthalmic)division of the trigeminal nerve, provide sensation to theforehead. The supraorbital nerve exits via the palpablesupraorbital notch, or foramen, situated   2.7 cm fromthe midline. Approximately 1.7 cm from the midline,medial to the supraorbital nerve, exits the supratrochlearnerve. Interposed between the two neurovascular bun-dles lies the bulk of the corrugator supercilii muscle. 6 Motor innervation of the frontalis and corrugatormuscles is derived from the temporal branch of the facialnerve, which traverses through multiple fascial planesdepending on the area of the face. Below the zygoma, thetemporal nerve passes through the lateral lobe of theparotid gland and runs in the sub-superficial musculoa-poneurotic system plane. Superior to the zygoma thenerve courses within the superficial temporal fascia. Therefore, the plane of dissection utilized in foreheadlifting is on the deep temporal fascia, remaining deep toand avoiding the temporal branch of the facial nerve. 7 Distally, the nerve then pierces the frontalis muscle fromits undersurface  1.5 cm medial to the lateral canthus. 8 HISTORY OF FOREHEAD REJUVENATION  The concept of forehead and brow rejuvenation is notnovel, although techniques have evolved throughout thecentury with the advent of endoscopic tools and inject-able fillers. In 1906, a forehead lift was performed by Lexer, who later went on to describe the procedure in1931. 9 Hunt 10 contemporaneously published his de-scription of the coronal incision for brow lifting in1926 in his text ‘‘Plastic Surgery of the Head, Face,and Neck’’ (Philadelphia, 1926). Both techniques de-scribed skin resection at the level of the hairline. Pang-man and Wallace, thereafter, described a similardissection but with a posthairline incision. 11 Alternativemethods of treating forehead furrows at the time in-cluded temporal neuronectomy via alcohol injections orincision. The coronal incision became the mainstay forsurgical rejuvenation of the forehead until the advent of endoscopic instrumentation. In 1991, Keller and col-leagues introduced the minimally invasive technique of endoscopic brow lifting. 12  This advantageous and effec-tive technique has become the preferred approach formany current practitioners. PATIENT EVALUATION  To adequately address the upper third of the face, onemust consider the surrounding salient features. Thisincludes the location and density of the hairline, thecolor and thickness of the forehead skin, and, of specificimportance, the degree of brow ptosis.Evaluation should entail relaxation of the fore-head musculature with the patient’s eyes closed. Thismaneuver mitigates any possible habitual brow elevation,revealing the underlying extent of true brow ptosis.Measurement of the brow should be obtained with theforehead relaxed and the eyes closed. 13 Recommendedphotographic preoperative and postoperative documen-tation includes a frontal full face view, right and leftlateral views, right and left oblique views, frontal view  with the brow in repose, forehead view with the brow raised, and a frontal view with the brow raised. 13  With the patient in the seated position, the fore-head and brow is manually raised to the desired position,thereby revealing the presence or absence of underlyingblepharoptosis or blepharochalalasis. Recognition of lidptosis or lagophthalmos warrants further investigation.A concomitant blepharoplasty can address un-sightly redundant upper lid skin; however, this shouldbe performed after the brow is raised. With the brow elevated, one can appropriately assess the degree of upperlid skin excess.Prior to surgery, patients should undergo a com-prehensive ophthalmic exam to define visual field de-fects, a potential result of significant brow ptosis.Preoperative evaluation should also include a detailedhistory, including cigarette smoking, use of anticoagu-lant or antiplatelet therapy, and the use of monoamineoxidase (MAO) inhibitors. Cigarette smoking should bediscontinued well in advance of expected surgery. The 92  FACIAL PLASTICS SURGERY/VOLUME 22, NUMBER 2 2006  use of aspirin or similar medication is typically discon-tinued 2 weeks prior to surgery and the knowledge of MAO inhibitor use will avoid potential pharmaceuticalinteractions during the perioperative period. 14 TECHNIQUES Coronal  The coronal browlift is a useful and time-tested techni-que. It has the advantage of simultaneously addressingbrow ptosis and deep forehead furrows. Wide exposureallows for clear identification and incision of the over-lying frontalis, corrugator, and procerus muscles. More-over, the incision is well concealed within the depth of the hairline. Although advantageous to the patient witha low hairline, the procedure is not recommended formen or women with high hairlines. Moreover, men withmale pattern baldness are at risk for poor scar conceal-ment if their hairline recedes. Scalp anesthesia posteriorto the incision site and potential peri-incisional alopeciaare additional noteworthy disadvantages. The procedure begins with a bicoronal incisionplaced 5 to 7 cm behind the hairline from a point  2 cmabove the superior attachment of the ear to the samepoint on the contralateral side. The incision is beveledfrom posterior to anterior and carried down to thesubgaleal plane. Beveling the incision, taking care notto damage the underlying follicles on the leading edge asone proceeds from posterior to anterior, ultimately allowsfor hair ingrowth through the scar. Within the avascular,subgaleal plane the dissection is advanced over the supra-orbital rim and laterally to the zygoma. Along the lateralscalp, the plane of dissection is directly above the deeptemporalis fascia—avoiding the facial nerve runningalong the underside of the superficial temporal fascia.Identification and lysis of the procerus andcorrugator supercilii follow exposure of the supraorbi-tal and supratrochlear neurovascular bundles. Oncefree from the underlying pericranium, the long flap ispulled taught to elevate the brow to the predeterminedposition. The excess scalp, typically 1 to 2 mm inlength, is excised, and a closed suction drain is left inplace. The wound is closed in layers, approximating thegaleal layer with absorbable suture first, followed by closure of the skin edges with nonabsorbable suture orstaples. 15 Modification of this procedure with a tricho-phytic or pretrichial incision obviates the elevation of the hairline. Non–hair-bearing skin of the forehead isexcised, maintaining, if not lowering, the hairline. Therefore, this technique may be of utility for femalepatients with high hairlines. Yet the same disadvantagespersist: scalp anesthesia and the presence of a potentially unacceptable scar if meticulous closure is not per-formed. 5,16  The incision is often irregular to mimic thehairline, or alternatively, a W-plasty—with 5.5-mmlimbs at 55-degree angles from each other—may beperformed to camouflage the scar. 15 Midbrow  The midbrow approach, while effective at addressingboth brow ptosis and forehead rhytids, has limited utility secondary to risk of unsightly scaring. Its use has beenrelegated to those patients (typically male) with deep,prominent forehead furrows and high hairlines. Theincision lies within a furrow, providing direct access tothe brow musculature and allowing for the placement of suspension sutures. Excisions here may be tailored toremove more midline tissue for more central ptosis ormore lateral tissue for temporal ptosis. Asymmetricamounts of skin may be excised with comparatively dissimilar amounts of ptosis.Advantages of the procedure include direct andprecise placement of the brow, as well as maintenance of the natural hairline. 15  The plane of dissection—in con-trast to the coronal lift—is within the subcutaneoustissue (superficial to the frontalis) to prevent anesthesiaof the skin superior to the incision. 5 Direct Brow Like the midbrow approach, the incision of the directbrow approach is similarly camouflaged within a deepforehead furrow, although located adjacent to the lateralbrow. Direct access allows for precise placement of thebrow with suspension sutures, although forehead rhytidscannot be treated via this approach. The plane of dis-section is within the subcutaneous tissue for the samereason as described for the midbrow approach. Thistechnique is best suited for elderly patients who requirefunctional elevation of the brow or possess unilateralbrow ptosis. 5 Endoscopic Forehead Lift Endoscopic forehead lifting provides the dramatic re-finement of rhytids and elevates the brow to a more youthful position without affecting the hairline or creat-ing postoperative scalp anesthesia. Thus, its applicationis much wider than any of the aforementioned ap-proaches. The necessary incisions are small and easily camouflaged within the hair, yet the access to the facialmimetic musculature and the ability to suspend theforehead is on par with the coronal approach. There is,however, a greater degree of technical skill demanded of the surgeon performing the procedure. There are many modifications and preferences espoused by facial plasticsurgeons for the endoscopic browlift technique. Thetechnique outlined herein was described by Romo and Yalamanchili and serves as an example. 7 REJUVENATION OF THE AGING UPPER THIRD OF THE FACE / PRESTI ET AL  93  A total of six 1.5-cm vertical incisions are made within the hair-bearing scalp (  5 mm posterior to thehairline). There are two medial paramedian incisions(2 cm from midline), two lateral paramedian incisions (inline with the lateral canthus), and two temporal incisions(2 cm posterior to the temporal hairline). The incision iscarried down through the periosteum as the dissection isperformed within the subperiosteal plane. At the ante-rior position of the vertical incisions, holes are drilledinto the diploic space of the calvarium using a 1.7-mmdrill bit. The length of desired brow elevation deter-mined preoperatively is then measured out on thecalvarium posterior to these drill holes. Fixation holesare then created at these sites.Dissection is then undertaken within the subper-iosteal plane anteriorly to the supraorbital ridge—releas-ing the arcus marginalis—and then several centimetersposterior to the incision sites (Fig. 1). Through thetemporal incision, dissection is performed directly overthe deep temporal fascia avoiding the temporal branch of the facial nerve. A sentinel vein, delineating the relativelocation of this nerve, typically is encountered as oneapproaches the zygomaticofrontal suture. The temporalpocket is then made continuous with medial pocket.Under direct endoscopic visualization, myotomies of theprocerus and corrugator muscles are performed afteridentification and preservation of the supraorbital neuro- vascular bundle. 7 Fixation of the now-released and elevated fore-head flap may be performed with either titanium screw anchors or simple cortical bone tunnels. Of note, theliterature describes a multitude of both permanent andtemporary fixation schemes, making the choice of fix-ation seemingly surgeon-dependent. There is, however,data within the literature that support the durability of brow elevation when permanent fixation devices areimplemented versus temporary techniques. 17,18 Endoscopic browplasty is particularly applicableto patients with thin, fair, nonsebaceous skin as scarring would be an overriding concern. Moreover, the low morbidity and apparent success associated with thistechnique have made it a favored approach in recenttimes. Alternative Therapies BOTULINUM TOXIN As an adjunct to or in place of surgical rejuvenation of the forehead, Botox (Botulinum toxin A) injections havebecome a useful and exciting addition to the facial plasticsurgeons armamentarium of tools.  Clostridium botulinum toxin exerts its paralytic effect by inhibiting the presy-naptic release of acetylcholine. Prior success in treatingmuscle dystonia and blepharospasm provided a segue forits use in facial rejuvenation. Currently, the use of botulinum toxin is approved by the U.S. Food andDrug Administration for use in the glabellar area only,although it has been used extensively in most areas of theface and neck. The goal of attenuating facial wrinklesand furrows can be achieved with temporary paralysis of the underlying facial mimetic musculature vis-a`-vis sur-gical resection or debulking (Figs. 2, 3). Work by Blitzer and Keen et al have demon-strated the effect of paralysis to persist up to 6 months with a 3- to 4-day delay in onset. 19,20  The quantity injected per facial subunit varies on the order of 5 to20 IU of toxin. The LD 50  in humans is estimated as2730 IU. 19 Clearly the quantity normally utilized forcosmetic use is well within the range of safety.Repeated use of botulinum toxin for the treat-ment of blepharospasm, requiring larger quantities thandescribed for facial rejuvenation, have demonstrated nountoward or deleterious effects. 21 However, there arecontraindications to it use: namely, patients with neuro-muscular disorders such as amyotrophic lateral sclerosis,myasthenia gravis, and Eaton Lambert syndrome andpatients with known hypersensitivity to the toxin. Minor Figure 1  Conjoint tendon. Endoscopic view showing dissec-tion of the conjoint tendon. Dissection over this area is veryimportant to allow for proper release of the brow complex. Figure 2  Pre-Botox. A patient with vertical glabellar lines withcontraction. 94  FACIAL PLASTICS SURGERY/VOLUME 22, NUMBER 2 2006
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