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FA C I A L P L A S T I C S U R G E R Y C L I N I C S O F N O R T H A M E R I C A
Trichophytic Endoscopic Forehead-Lifting in High Hairline Patients
Stephen W. Perkins, MD*, Rami K. Batniji, MD
- Surgical technique
- Discussion
- Summary
- Acknowledgments
- References
Since Hunt’s description of the coronal brow-lift
in 1926, many techniques for surgical rejuvenation
of the upper third of the face have been described in
the literature [1]. Although the coronal forehead-lift
has been the standard with which all other techniques
have been compared, most surgeons and
patients prefer the endoscopic approach to forehead-lifting. The disadvantages of the coronal approach
include the potential for poor scarring
with a noticeable scar in the temporal recession,
alopecia, forehead paresthesia, hypoesthesia or
numbness of the scalp which may be persistent
on occasion, pruritus at the incision site, and elevation
of the frontal hairline [2]. Additionally, most
patients are reluctant to accept the larger coronal
incision and prefer the less invasive endoscopic approach
to surgical rejuvenation of the upper third of
the face. One noticeable effect of the endoscopic approach
is an elevation of the hairline. Although this
is an acceptable result for most patients, persons
who have high hairlines (greater than 5 to 6 cm)
may not wish to move the hairline more posterior.
Patients with high hairlines and a curved sloping
(‘‘double convexity’’) forehead pose a technical
challenge to the surgeon because the endoscopic
equipment is relatively short and straight, making
treatment of the depressor musculature with myotomy
or myectomy a difficult endeavor. In 2004,
Tower and Dailey [3] described their approach to
rejuvenation of the upper third of the face in patients
with high hairlines through a long pretrichial
incision. Since 2000, the senior author (SWP) has
performed a technique combining a short 3- to 4-cm pretrichial incision with endoscopic equipment
to lift the forehead in patients who present with
brow ptosis and high hairlines. This technique also
offers the esthetic advantage of lowering the high
hairline. The following is a description of the operative
technique.
Surgical technique
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| Fig. 1. The pretrichial incision is approximately 4 cm in
length and is made at the midline following the natural
irregular contour of the hairline. Laterally on
each side a 3- to 4-cm incision is made 2 cm posterior
to the temporal hairline recession at a location demarcated
by the lateral canthus and temporal line. |
Pretrichial endoscopic forehead-lifting is performed
with the patient under monitored anesthesia care or
general anesthesia. Although intraoperative antibiotics
are not typically given to the patient, a 5-day
course of cephalexin is started the day before surgery.
In the preoperative holding area, the surgical
markings are made, and the patient’s hair is twirled.
The pretrichial incision marking is approximately 4
cm in length and is made at the midline following
the natural irregular frontal hairline contour in a scalloped fashion. Laterally on each side, a 3- to 4-cm vertical mark is made 2 cm posterior to the temporal
hairline recession at a location demarcated by
the lateral canthus and temporal line (Fig. 1).
Once an appropriate level of anesthesia is
achieved, the incision sites are infiltrated with 1%
lidocaine with epinephrine (1:50,000), and the
forehead is infiltrated with 0.5% lidocaine with epinephrine (1:100,000). Subsequently, 15 U of
botulinum toxin A is injected in the corrugator
supercilii and procerus muscles. The combination
of chemical ablation of the depressor muscles with
botulinum toxin A and myotomy of the depressor
muscles during the pretrichial endoscopic forehead-
lift acts synergistically to not only maintain
the elevated forehead position but also treat nasoglabellar
furrows. The senior author believes the addition
of botulinum toxin A results in less chance of
return of depressor muscle function when compared
with myotomy or myectomy alone.
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| Fig. 2. (A) The pretrichial incision is made in a beveled (anterior to posterior) manner. (B) The incision is extended
through galea but not periosteum. |
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| Fig. 3. (A) The Ramirez EndoForehead Parietal Elevator is used to elevate the forehead and temporal skin in
a subgaleal plane. (B) The elevation is continued approximately 5 cm posterior to the incision sites. |
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| Fig. 4. (A) A custom-made curved elevator is positioned into the temporal region through the lateral incision to
divide the conjoint tendon. (B) Dissection of this temporal region is performed down to an area slightly superior
to the zygomatic arch and lateral canthus. |
Using a No. 15 scalpel, the lateral incisions are made through galea but not periosteum. The midline
pretrichial incision is then performed in a beveled
(anterior to posterior) fashion. This incision is
also made through galea but not periosteum
(Fig. 2). Hemostasis is achieved with bipolar
cautery.
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| Fig. 5. The Daniel EndoForehead Elevator is used to
elevate the brow in a subperiosteal plane down to
a level 2 cm above the supraorbital rim. |
The Ramirez EndoForehead Parietal Elevator
(Snowden Pencer, Tucker, Georgia) is used to elevate
the forehead and temporal skin in a subgaleal
plane (Fig. 3). The elevation is performed approximately
5 cm posterior to the incision sites; the
posterior elevation not only minimizes the development
of scalp rolls but also mobilizes the posterior flap, allowing for closure of the pretrichial
incision without elevating the hairline.
Next, the temporal region is elevated in a plane
between the temporoparietal fascia and the superficial
layer of the deep temporal fascia. A curved
elevator (custom-made) is positioned into the temporal
region through the lateral incision. Using this
elevator, the conjoint tendon is divided (Fig. 4).
Dissection of this temporal region is performed
down to an area slightly superior to the zygomatic
arch and lateral canthus. The frontal branch of the
facial nerve is protected because the plane of dissection
is between the temporoparietal fascia and the
superficial layer of the deep temporal fascia.
The Daniel EndoForehead Elevator (Snowden
Pencer) is used to elevate the brow in a subperiosteal
plane down to a level 2 cm above the supraorbital
rim (Fig. 5). The Ramirez EndoForehead A/M
Dissector (Snowden Pencer) is then used to elevate
the arcus marginalis at the level of the supraorbital
rim. The elevation is performed with the nondominant
hand functioning as a guide to the level of the
supraorbital rim and the location of the supraorbital
foramina (Fig. 6). This elevation is performed
in the region of the glabella down to the nasion.
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| Fig. 6. (A) The Ramirez EndoForehead A/M Dissector is used to elevate the arcus marginalis at the level of the
supraorbital rim. (B–D) The elevation is performed with the nondominant hand functioning as a guide to the
level of the supraorbital rim and the location of the supraorbital foramina. |
Using the 30-degree EndoPlastic Scope (Snowden
Pencer) to provide visualization, the conjoint
tendon is further divided with curved endoscopic
scissors (Accurate Surgical & Scientific Instruments
Corp., Westbury, New York) down to the level of
the sentinel vein (Fig. 7). The Isse elevator (Karl
Storz, Culver City, California) is then used to complete
the subperiosteal elevation to the level of the
supraorbital rim and nasion. Care is used to identify
and preserve the supraorbital neurovascular
bundle (Fig. 8). With a custom-made reusable electrode
knife tip, the periosteum is incised in a horizontal
direction at the level of the supraorbital
rim (Fig. 9). Myotomy of the corrugator supercilii
and procerus muscles is performed with the electrode
knife tip. The supraorbital and supratrochlear
nerves are identified and preserved during the procedure.
Because the motor nerve to the corrugator
supercilii muscle runs within the substance of the
lateral orbicularis oculi muscle, the senior author
performs a lateral myotomy of the orbicularis oculi
muscle to not only weaken the orbicularis oculi
muscle but also interrupt the innervation to the corrugator
supercilii muscle. Following this, the electrode
knife tip is used to weaken the frontalis
muscle with scoring of the periosteum and frontalis
muscle at the level of deep horizontal forehead
creases.
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| Fig. 7. The conjoint tendon is divided with curved
endoscopic scissors. This aspect of the procedure is
performed under visualization with the use of a 30-
degree endoscope, which is placed through the lateral
incision. |
In an effort to camouflage the pretrichial incision,
the senior author not only bevels the incision
but also de-epithelializes the posterior flap. A 2- to
3-mm strip of epidermis from the posterior flap is
excised (Fig. 10). The anterior flap of the pretrichial
incision is lifted up, and vertical incisions
are made through the anterior flap. Staples are
placed at these positions to approximate the anterior
and posterior flaps. The excess skin and soft
tissue from the anterior flap are then excised in
a beveled manner; the bevel is directed from posterior
to anterior (Fig. 11). The staples are then removed,
and hemostasis is achieved with bipolar
cautery.
Fixation with sutures via bone tunnels of the
outer cortex of the skull is performed. The bone
tunnels are made with the Browlift Bone Bridge system
and drill bit with a 2-mm diameter and 25-mm
guard (Medtronic Xomed Surgical Products, Jacksonville,
Florida). Two bone tunnels are created at
the pretrichial incision site in a horizontal direction,
whereas bone tunnels are created in the vertical
direction at the lateral incisions (Fig. 12). Using
the drill bit with a 25-mm guard, there have been
no instances of cerebrospinal fluid leaks or other intracranial
complications. If significant bleeding is encountered from the bone tunnel site, hemostasis is achieved with Bone Wax (Ethicon, Somerville,
New Jersey), and new bone tunnels are created. A
2-0 polyglactin suture (Vicryl) is used for fixation
from the bone tunnel to the galea and subcutaneous
tissue of the anterior flap to achieve lifting of
the medial forehead at the pretrichial incision site.
The lateral forehead is lifted with the suture from
the bone tunnel to the galea and subcutaneous tissue
at the most anterior aspect of the lateral incision
on both sides (Fig. 13). This suture not only lifts the
lateral forehead but also reapproximates the edges
of the lateral incision. The lateral incision is closed
with staples.
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| Fig. 8. (A) The subperiosteal elevation is completed at the level of the supraorbital rim with the use of the Isse
elevator. (B) The pretrichial incision provides easy access to the level of the supraorbital rim despite the high anterior
hairline and double convexity of the forehead. |
The pretrichial incision is closed in a layered fashion
using 3-0 polyglactin and 4-0 polydioxanone
(PDS) sutures in an interrupted buried fashion to
obtain deep tissue reapproximation. During this
closure, the posterior flap is mobilized anteriorly
by the assistant to allow closure of the wound without
moving the hairline posterior. In fact, this maneuver
affords the esthetic benefit of bringing the
hairline more anterior at times. Meticulous skin closure
with proper eversion of the skin edges without
tension is achieved with a 5-0 blue polypropylene
(Prolene) suture in a running locked manner
(Fig. 14).
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| Fig. 9. A custom-made, reusable electrode knife tip
(inset demonstrates tip of instrument) is used to incise
the periosteum at the level of the supraorbital
rim and perform myotomy of the procerus, corrugator
supercilii, and orbicularis oculi muscles. |
Upon completion of the surgery, a pressure dressing
is placed. No drains are used. The dressing is removed
the following morning. The incision and
staple sites are cleansed with baby shampoo. The
sutures and staples are removed on postoperative
day 7.
Discussion
In 2001, the senior author performed a retrospective
review comparing his results of the forehead-lift via
an endoscopic versus coronal approach [4]. Since
then, his practice has shifted in favor of the less invasive,
less morbid, endoscopic approach to rejuvenation
of the upper third of the face. Although the
endoscopic approach is appealing to many patients,
patients who have high hairlines have been discouraged by the associated elevation of the hairline
following endoscopic forehead-lifting. Patients
who have high hairlines and a curved sloping (double
convexity) forehead pose a technical challenge
to the surgeon because the endoscopic equipment
is relatively short and straight, making treatment
of the depressor musculature with myotomy or
myectomy a difficult endeavor. In an effort to offer
patients with high hairlines an alternative to the
coronal approach for forehead-lifting, the senior
author developed a pretrichial endoscopic approach
and has been performing this procedure in
selected patients since 2000.
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Fig. 10. A 2- to 3-mm strip of epidermis from the posterior flap is excised. (A) A scalpel is used to make the incision
through the epidermis. (B) A sharp curved scissor is then used to complete the excision of the strip of epidermis.
(C) Photograph demonstrates the intact dermis, subcutaneous tissue, and hair follicles after removal of
the epidermal layer. |
|
While a retrospective review of the results is currently
underway, a few observations can be made.
First, beveling the incision and de-epithelialization
of the posterior flap allow for hair growth through
the pretrichial incision, camouflaging the incision
site (Fig. 15). Second, weakening of the frontalis
muscle has been a source of controversy in forehead-lifting surgery. Relapse of brow position has
been attributed to weakening of the frontalis muscle
[5]. In the senior author’s experience, weakening
of the frontalis muscle is an integral part of eradicating
deep horizontal creases of the forehead; therefore,
scoring of the periosteum and frontalis
muscle in the medial forehead is routinely performed
in patients with deep horizontal creases
(Fig. 16). The senior author has not observed a correlation
between relapse of forehead position and weakening of the frontalis muscle. An ongoing retrospective
study will further evaluate the effects of
weakening of the frontalis muscle on postoperative
forehead position.
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| Fig. 11. Sequential resection of the anterior flap is performed. (A) Vertical incisions are made into the anterior
flap, and (B) staples are placed to approximate the anterior and posterior flaps. (C) The excess skin and soft tissue
from the anterior flap is then excised in a beveled (posterior to anterior) manner. (D) The result following
this excision. |
Third, there has been much discussion regarding
the optimal plane of dissection. Nassif and coworkers
[6] critically evaluated the results of the
subperiosteal versus subgaleal dissection planes
for the forehead-lift and concluded that the subgaleal
plane provided less tension. In contrast, Troilius
[7] commented that the subperiosteal plane
offers better traction for forehead elevation and
longer-lasting maintenance of forehead position.
The senior author performs a subgaleal elevation
at the incision sites to minimize tension in these regions.
A subperiosteal elevation is then performed
down to the arcus marginalis. This plane of
dissection provides broad fixation and traction as
the periosteum re-adheres to the skull. The subperiosteal
plane of dissection also provides a safe reliable
means of approaching the depressor muscles
for myotomy.
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| Fig. 12. The Browlift Bone Bridge system and drill bit with a 2-mm diameter and a 25-mm guard is used to make
a vertically oriented bone tunnel at the lateral incision (A) and two horizontally oriented bone tunnels at the
pretrichial incision (B). |
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| Fig. 13. (A) A 2-0 polyglactin (Vicryl) suture is used for fixation from the bone tunnel to the anterior flap of the
pretrichial incision. (B, C) At the lateral incision, fixation is achieved with suture from the bone tunnel to the
most anterior aspect of the lateral incision on both sides. (D) This suture not only lifts the lateral forehead
but also reapproximates the edges of the lateral incision. The suture is passed through galea to achieve proper
tissue strength for elevation and fixation. |
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| Fig. 14. (A, B) Meticulous closure of the pretrichial incision is performed with a 3-0 polyglactin suture in an interrupted
buried fashion to obtain deep tissue reapproximation. (C) The assistant mobilizes the posterior flap to
allow closure of the wound without moving the hairline more posterior. Further subcutaneous reapproximation
is achieved with 4-0 polydioxanone. (D) Following this, skin closure with proper eversion of the skin edges is
achieved with a 5-0 blue polypropylene (Prolene) suture in a running locked manner. |
 |
|
Fig. 15. Postoperative photograph demonstrating esthetic
result of the pretrichial incision at 11 months.
The design of the flap allows hair growth through
the pretrichial incision site and subsequent camouflage
of the incision. Meticulous closure is paramount
to the outcome of the pretrichial incision. |
There has been great debate regarding the need
for fixation and the type of fixation used to maintain
forehead position. Central to this debate of
fixation is the length of time required for periosteum
to re-adhere to the skull following forehead-lifting. Animal studies have suggested that 1
to 12 weeks are required for periosteal reattachment
[8], whereas other research has demonstrated
that at least 6 weeks of fixation may be necessary to
allow the periosteum adequate time to re-adhere
to its new location on the frontal bone cortex
[9]. As a result, many fixation techniques have
been described in the literature [10]. Recently, Holzapfel
and Mangat [11] have reported safe, effective, and reliable results with a bioabsorbable
fixation device that uses multiple points of fixation
(Endotine Forehead device; Coapt Systems, Palo
Alto, California). Sidle and coworkers [12] reported
maintenance of forehead elevation at 12
months following forehead-lifting and fixation
with a tissue adhesive (BioGlue Surgical Adhesive;
CryoLife, Kennesaw, Georgia). Fixation with suture
suspension via cortical bone tunnels is performed
in a timely manner with no significant financial expense
and low morbidity; therefore, it is the fixation
method of choice for the senior author.
Summary
Pretrichial endoscopic forehead-lifting is a viable alternative
for patients who have high hairlines and
who seek rejuvenation of the upper third of the
face. Results have been gratifying for the patient
and the senior author, with long lasting correction
of glabellar ptosis, significant reduction of forehead
creases and glabellar furrows caused by muscular
hyperactivity, and improved esthetics of the anterior
hairline. Although clinical experience suggests
this approach is safe and effective, further research
is required.
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| Fig. 16. Preoperative (A) and 1 year postoperative (B) photographs following pretrichial endoscopic foreheadlifting
Release of the periosteum at the nasion and myotomy of the procerus and corrugator supercilii muscles
result in effacement of furrows and creases in the nasoglabellar region, particularly the transverse creases at the
nasion. Effacement of the horizontal forehead creases is achieved after scoring of the periosteum and frontalis
muscle during pretrichial endoscopic forehead-lifting. Note the more youthful brow position. |
Acknowledgments
The authors would like to acknowledge Nancy
A. Rothrock for her assistance in the preparation
of the digital images used in this article.
References
[1] Hunt HL. Plastic surgery of the head, face, and
neck. Philadelphia: Lea & Febiger; 1926.
[2] Paul M. The evolution of the brow lift in aesthetic
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7(6):393–7. |
