Continuing Medical Education Examination—Facial Aesthetic Surgery: Lateral Subcutaneous Brow Lift

Abstract

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to:

1. Describe the signs of aging that affect the lateral aspect of the brow.

2. List the advantages of the lateral subcutaneous brow lift.

3. Recommend ways to avoid bruising.

Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 211.

The author performs a subcutaneous plane brow lift to lift the lateral brow in patients with an otherwise normal brow position. He contends that his technique is simple, yields an efficient lift, may improve the hairline in some, and may also be used to improve wrinkling in the medial forehead.

It is generally agreed that plastic surgeons are seeing younger patients desiring face- and brow-lift surgery. One of the earliest signs of aging, and one of the most common concerns of patients, is descent of the lateral aspect of the brow. Even small amounts of relaxation in this area can result in loss of the attractive prominence of the superior orbital rim and redundant skin in the upper eyelid and in the lateral crow's-feet area. When the lateral portion of the brow is lower than the medial, the slant often conveys an undesirable appearance of fatigue or even sadness (Figure 1).

Alternatives for Lifting the Lateral Brow

In the past, I frequently performed a coronal brow lift at the same time as a face lift. Although the coronal approach is generally effective, I found considerable variation in the results, and in some patients, results were unsatisfactory. In patients with high foreheads, or in those with a normal medial brow position, at or above the supraorbital rim, I found it occasionally difficult to achieve the pleasing elevation of the lateral third of the brow that was desired. Furthermore, the increase in vertical forehead height that resulted from this procedure was less than desirable. Although I have heard some surgeons say that the coronal or endoscopic brow procedure does not increase the height of the forehead, I must disagree.

Moreover, I struggled with the closure and resulting scar, a humbling experience after practicing for more than a few years. No matter how I closed the wound — and my efforts included layered closure, varying suture materials, and other methods — some patients had wider scars than I had predicted or found acceptable. Unfortunately, patients shared my views. Even worse, a small but significant number complained of numbness posterior to the incision or a feeling of “tightness” around the head. In 3 patients, whose faces are forever imprinted on my memory, there was the complaint of chronic itching. In one, ulceration from scratching occurred. On the basis of this experience, I explored alternative methods of lifting the lateral brow in patients with otherwise normal brow position.

At first I made the incision through the scalp and forehead, down to the periosteum. I resected a full-thickness ellipse of the forehead or scalp. I attempted suture suspension. The results were unsatisfactory for several reasons. I found the galea relatively unyielding, and because branches of the supraorbital nerve lay directly in the region of the incision, the incidence of numbness was significant.

Then I explored a brow lift in the subcutaneous plane, above the frontalis muscle and sensory nerves, described by Connell and others.^1–10 The advantages were immediately clear. First and foremost, the procedure is very simple. The dissection is easy, and the branches of the supraorbital nerve can be avoided with no change in sensation in the posterior scalp. The lift of the lateral brow after dissection in the subcutaneous plane is extraordinarily efficient. In addition, on blunt dissection, the wrinkling in the more medial forehead skin can be improved by separating the plane between subcutaneous fat and muscle. Moreover, in many patients with very fine hair or balding, commonly seen in the lateral temporal forehead-scalp region, the hairline can actually be improved (see Figure 6). Finally, I have consistently found that the scar not only heals very well but also, in most patients, is difficult to identify after 3 to 4 months.

Technique

The incision is made along the junction of hair-bearing and non-hair-bearing skin of the lateral forehead (Figure 2). In many patients, a line can be identified demarcating the area in which thicker hair gives way and below, in a semitriangular area, very fine, sparse hair is found. If the incision is made in this area, much of the thin hair can be excised at the time of closure. The medial part of the incision is begun on a line directly above the pupil and extended laterally into the hair-bearing scalp for 4 to 5 cm. It is essential to infiltrate the area with epinephrine (1:100,000) to allow identification of the plane of dissection above the frontalis muscle and supraorbital nerve. To reduce bruising, perform multiple percutaneous injections as opposed to moving the needle through the forehead and scalp.

As soon as you see subcutaneous fat, after incising the skin, perform the deeper dissection very carefully (Figure 3). Pressure with a gauze sponge helps delineate the plane between the skin flap and muscle. Beneath the thin subcutaneous fat, the red-brown color of the muscle will be apparent. After sharp dissection in the plane above the frontalis muscle, the branches of the supraorbital nerve will be evident (Figure 4).

After dissecting 1 cm inferiorly, you can easily and rapidly complete the dissection with your index finger extended in the direction of the supraorbital rim but stopping 1 cm above it (Figure 5). The brow medial to the incision can also be undermined. Usually there is no bleeding.

The skin flap is then lifted superiorly and the effect on the lateral brow evaluated (Figure 6). In most cases, the desired result is achieved when the lateral brow is approximately 0.5 to 0.7 cm higher than the medial brow. In fact, unless there is some overcorrection, the brow will descend in the first few weeks because of forward migration of the scalp.

Excise an ellipse of skin and some fine hair; this may vary from 1.5 to 2 cm at its widest portion. In many patients, this improves the hairline. Do not use buried sutures in the closure; use metal staples alternating with 4-0 plain catgut sutures (Figure 7).

Dress the forehead immediately with 4x4 gauze over the dissected area and wrap it with a 2-inch elastic bandage. Place the wrap very snugly at first and then loosen it 1 hour after completing the procedure (Figure 8). It is rare to see bruising in patients after the procedure, which, after some experience, can be performed in less than 30 minutes.

On the third postoperative day, remove all but 2 staples. Remove the remainder on the fifth day. The absorbable sutures will dissolve within 10 days or can be removed. Instruct the patient to wear the elastic dressing for at least 1 week.

Advise the patient that the initial appearance of the brow does not represent the final result. If slight overcorrection has been accomplished, the brow will, within the first 1 to 3 weeks, assume a straight or slightly raised position, depending on the surgeon's aesthetic judgment.

References

Continuing Medical Education Examination—Facial Aesthetic Surgery: Lateral Subcutaneous Brow Lift

Instructions for Category I CME Credit

ASAPS CME Program No. ASJ-CME-FAS16. The American Society for Aesthetic Plastic Surgery is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The American Society for Aesthetic Plastic Surgery designates this educational activity for a maximum of 1 hour in Category 1 credit toward the American Medical Association Physician's Recognition Award for correctly answering 14 questions to earn a minimum score of 70%. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

Please return the examination (photocopy or tear out) with your full name and address, your ASAPS or ASPS identification number, and a self-addressed, stamped return envelope to the following address:

ASJ CME

c/o ASAPS Central Office

11081 Winners Circle

Los Alamitos, CA 90720-2813

If you are not a member of either ASAPS or ASPS, please note this on your examination. The deadline for receipt of examinations for Category 1 CME credit based on this activity is January 15, 2004.

Multiple Choice

1. Early signs of aging can include all the following except:

   • Deepening of the nasolabial fold

   • Slight anterior nasal septal curvature

   • Increased prominence of intraorbital fat

   • Lateral brow ptosis

2. All but which of the following may occur after a coronal brow lift?

   • Increase in the vertical height of the forehead

   • Increased hair growth

   • Decrease in sensation in the posterior scalp

   • Itching in the posterior scalp

3. In performing a lateral subcutaneous brow lift, after the initial incision the best way to determine the plane of dissection is:

   • Continued scalp dissection with the No. 15 blade

   • Blunt scissors dissection

   • Gauze-sponge dissection

   • Index-finger dissection

4. Which of the following does not reduce bruising?

   • Elastic dressing

   • Multiple percutaneous injections of local anesthesia and epinephrine

   • Exclusive use of sharp dissection

   • Identification of the subcutaneous plane

5. During the performance of a lateral subcutaneous brow lift, which of the following will not be visualized?

   • Subcutaneous fat

   • Frontalis muscle

   • Supraorbital nerve

   • Auriculotemporal nerve

6. When blunt undermining is complete, a desirable result is achieved when the lateral brow elevation is:

   • 0.5 to 0.7 cm higher than the medial brow

   • 0.5 to 0.7 mm higher than the medial brow

   • 1.5 to 2 cm higher than the supraorbital ridge .1.5 to 2 mm higher than the supraorbital ridge

7. Some postoperative descent occurs after surgery within the forehead-brow:

   • Never

   • Seldom

   • Often

   • Always

8. Advantages of a brow lift in the subcutaneous plane include all the following except:

   • Easy dissection

   • Avoidance of the branches of the supraorbital nerve

   • Efficient lift of the lateral brow

   • Improved hairline in patients with very thick hair

9. In closure, which of the following is used?

   • Only buried sutures

   • Metal staples alternating with 4-0 plain-catgut sutures

   • Metal staples alternating with buried sutures

   • Only 4-0 plain-catgut sutures

10. After the skin is incised, deeper dissection is performed after:

    • Subcutaneous fat is seen

    • Branching of the supraorbital nerve is evident

    • Lifting of the skin flap

    • None of the above

True or False

• 11. At the level of the hairline, the supraorbital nerve is always deep to the frontalis muscle.

  T   F

• 12. There are well-recognized methods for avoiding nerve damage in the coronal brow lift.

  T   F

• 13. The head dressing should be kept in place without being changed for 10 days after a lateral subcutaneous brow lift.

  T   F

• 14. The auriculotemporal nerve is rarely damaged in the superficial temporal brow lift.

  T   F

• 15. Blunt dissection in the subcutaneous plane of the forehead is usually associated with considerable bleeding.

  T   F

• 16. When the lateral subcutaneous brow lift is complete, the position of the brow should not be elevated above the supraorbital rim.

  T   F

• 17. Infiltration of epinephrine is not essential for identification of the plane of dissection above the frontalis muscle and supraorbital nerve.

  T   F

• 18. An incision along the junction of the hair and non–hair-bearing skin of the lateral forehead facilitates excision of much of the thin hair at the time of closure.

  T   F

• 19. The coronal brow lift sometimes results in scarring that is unacceptable to patients.

  T   F

• 20. Numbness may occur if incisions are made directly in the region of the branches of the supraorbital nerve.

  T   F

Evaluation

1. Overall, did the activity provide an adequate overview of the subject matter? Yes___ No ___

2. Was the subject matter of the activity: Too basic___ Too advanced___ Just right ___

3. Do you feel that the length of the activity was: Too short___ Too long ___ Just right ___

4. This activity increased my awareness and understanding of the surgical procedures described in the article.

   Strongly agree ___ Agree ___ Neutral ___ Disagree ___ Strongly disagree___

5. I would again participate in an Aesthetic Surgery Journal CME activity. Yes ___ No ___

6. Would you recommend an Aesthetic Surgery Journal CME activity to a colleague? Yes ___ No ___

7. What other topics (including instructor names, if possible) would you like to see covered in future issues of Aesthetic Surgery Journal?

Name: _____

Address:_____

City/State/Zip:_____

ASAPS/ASPS ID no.:_____

Author notes