Trichophytic Endoscopic Forehead-Lifting in High Hairline Patients
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA
Stephen W. Perkins, MD*, Rami K. Batniji, MD
- Surgical technique
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 . 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 . 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  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.
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.
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.
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.
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.
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.
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.
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.
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).
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.
In 2001, the senior author performed a retrospective review comparing his results of the forehead-lift via an endoscopic versus coronal approach . 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.
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 . 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.
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  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  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.
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).
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.
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 , 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 . As a result, many fixation techniques have been described in the literature . Recently, Holzapfel and Mangat  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  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.
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.
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.
The authors would like to acknowledge Nancy A. Rothrock for her assistance in the preparation of the digital images used in this article.
 Hunt HL. Plastic surgery of the head, face, and neck. Philadelphia: Lea & Febiger; 1926.
 Paul M. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg 2001; 108:1409–24.
 Tower RN, Dailey RA. Endoscopic pretrichial brow lift: surgical indications, technique and outcomes. Ophthal Plast Reconstr Surg 2004;20(4):268–73.
 Dayan SH, Perkins SW, Vartanian AJ, et al. The forehead lift: endoscopic versus coronal approaches. Aesthetic Plast Surg 2001;25:35–9.
 Ramirez OM. Subperiosteal brow lifts without fixation, discussion. Plast Reconstr Surg 2004; 114:1604–5.
 Nassif PS, Kokoska MS, Homan S, et al. Comparison of subperiosteal vs subgaleal elevation techniques used in forehead lifts. Arch Otolaryngol Head Neck Surg 1998;124:1209–15.
 Troilius C. A comparison between subgaleal and subperiosteal brow lifts. Plast Reconstr Surg 1999;104:1079–90.
 Kim JC, Crawford DJ, Azuola ME, et al. Time scale for periosteal readhesion after brow lift. Laryngoscope 2004;114:50–5.
 Boutros S, Bernard RW, Galiano RD, et al. The temporal sequence of periosteal attachment after elevation. Plast Reconstr Surg 2003;111:1942–7.
 Vasconez LO, Core GB, Gamboa-Bobadilla M. Endoscopic techniques in coronal brow-lift. Plast Reconstr Surg 1994;94:788–93.
 Holzapfel AM, Mangat DS. Endoscopic foreheadlift using a bioabsorbable fixation device. Arch Facial Plast Surg 2004;6:389–93.
 Sidle DM, Loos BM, Ramirez AL, et al. Use of bioglue surgical adhesive for brow fixation in endoscopic browplasty. Arch Facial Plast Surg 2005; 7(6):393–7.