The Forehead Lift Some Hints to Secure Better Results

Transcription

1 Aesthetic Plastic Surgery 1: , 1977 by Springer-Verlag New York Inc. The Forehead Lift Some Hints to Secure Better Results Hector Marino M. D. Buenos Aires, Argentina ABSTRACT / The operation for the forehead lift is reviewed considering the experience acquired in recent years in order to facilitate its safe execution. Particular attention is given to the removal of factors limiting the free upward movement of the frontal flap, such as preparation of the meso temporalis. The treatment of the muscular layer is updated and a number of safety measures are proposed to prevent any undue damage to the blood and nervous supply of the region. The forehead lift, as a way to remove frontal wrinkles, raising a drooping brow and favorably influencing the expression of the subject, is a procedure accepted by many surgeons. But such was not the situation in the past, and we remember hearing some experienced specialists deprecating its results. On the other hand, even today we receive patients in whom a poor or mistaken execution of the operation amply justifies such criticisms. Since presenting our film on this topic in the International Congress of Plastic Surgery of Washington (1963), we have dealt with the forehead lift a few times (5,6) and we propose to :report briefly some details and observations suggested by our experience. We will point out difficulties that may be encountered in executing the operation and the way to overcome them. First, let us state the importance of fully discussing with the prospective patient the implications of such an undertaking and its effect not only on the forehead wrinkles but particularly on the expression of the face, so as to avoid any future complaints. The upward lift of the eyebrows must be measured to achieve a pleasing effect without falling in an exaggerated displacement ending in a fixed or unbecoming stare. The easiest way to prevent this is to perform a trial lift in front of a mirror by pushing the teguments upward so that the subject can visualize beforehand the approximate effect of the operation and approve or reject it. Once this important point is reached, the next step is to make an accurate diagnosis of the deformity so as to be able to apply the necessary measures to achieve a permanent correction. Anatomically we agree with Vifias et al. (8) that there are two types of wrinkles: transitory, which appear only when the frontalis muscle contracts voluntarily, and Address reprinf requests to: H~ctor Marino, M. D., Luis Agote 2332, 1425 Buenos Aires, Argentina

2 252 H. Marino Fig, 1, Tracing of the coronal incision. The shaved area of the scalp is partially or totally removed at the end of the operation Fig. 2. The knife severs the lower periosteal attachments of the frontalis muscle Fig. 3, The meso temporalis has been prepared. Scissors show its upper limit and the space leading to the zygomatic arch permanent or familiar (as they seem to appear even in young people as a family trait), which are independent of the movements of the skin. From a practical viewpoint, we find that both types are readily erased by a correctly performed operation; therefore, we can not agree with Vifias et al. on the necessity of abrading the skin to remove the permanent wrinkles. Once the surgical treatment is decided, it will be found that obtaining the desired effect may be fraught with difficulties arising during the operation proper.

3 The Forehead Lift 253 Fig. 4, "Tracing the limits of the wrinkled area Fig. 5. Reporting them to the deep aspect of the flap by means of a tinted needle Fig. 6. The muscle fibers are transected by two or three parallel incisions First, as the forehead flap is prepared, its upward translation will be hindered by the tethering effect of the periosteal attachments of the frontalis fascia to the supraorbital ridge, ]by the short pedicles of the supraorbital vessels and nerves, and by the lateral subcutaneous tissue covering the temporalis fascia. Second, removal of the frontalis muscle fibers--as taught to us by Mclndoe and shown in our first reports (5)--could give rise to an area of adhesions that will result in a quiescent zone surrounded by hyperactive muscle producing at best an unfamiliar aspect of the region. Third, correction of the frown lines by resection of the corrugator and procerus muscle fibers could be complicated by the many arterial and venous branches intermingled with

4 254 H. Marino them, particularly when the main trunks are divided before surfacing from the supraorbital foramen. Hemostatic measures could easily mean an injury to the neighboring nervous elements. Fourth, any injury to the facialis nerve supplying the frontalis muscle during the operation can cause its paralysis with a consequent reduction of the normal tension of the galea followed by a loss of the normal lifting effect on the brows; this is particularly unsightly when the lesion is unilateral (7). In order to prevent the above-listed difficulties, we have developed over the years a precise technique that, so far, has secured rewarding results. To develop the forehead flap properly, one must strive to free it from such attachments that tend to limit its easy movement without endangering its blood supply and its innerva- tion. Failure to do this accounted for the lack of success of former surgeons. To achieve such a requisite necessitates a large coronal approach, so as to be able to reach the lower part of the flap easily. A significant decision has to be made regarding the position of the incision according to the width of the forehead: a normal or narrow width with abundant hair allows for the incision being made 4 to 5 cm behind the hairline, whereas a wide forehead or a receding hairline justifies making the incision just on the border of the hairy area. (Fig. 1). The plane of areolar tissue between the galea and the periosteum is readily undermined with a few strokes of the knife. We do not like to do it by plain stripping as this can produce rents in the periosteal layer that cause unwanted adhe- sions. Once the supraorbital attachments are reached, they must be carefully severed with the knife down to the bone taking care not to injure the supraorbital vessels and nerves (Fig. 2). Here the skin and muscular layers can be gently stripped down to the upper eyelid, even continuing the undermining on the dorsum of the nose if a moderate lifting effect on its tip is desired (3). This stripping maneuvre also helps to mobilize as much as possible the short neurovascular pedicles arising from the supraorbital foramen, a limiting element which we are not allowed to stretch unduly or otherwise injure for obvious reasons. When this step is performed, the flap is still laterally retained by the areolar layer of tissues covering the parietal fascia. Failing to solve this problem will not only severely reduce the ascent of the flap but, more importantly, will prevent using this ascent to take care of the excess of skin when combining this operation with the regular lateral rhytidec- tomy. To remove this obstacle we have been developing since 1963 what we call the "meso temporalis," a triangular layer of areolar tissue whose upper limit is given by the frontal branch of the temporalis superficialis artery, the lower limit being its attachment to the zygomatic arch and its medial limit its expansion over the galea. It is important to remember that inside this layer run the frontal branches of the facialis to the frontalis muscle. To avoid injuring them we have found it expedient to separate the hair-bearing part of the flap by gently stripping it from the outer aspect of the meso temporalis, completing the undermining with dissecting scissors. In this way no unnecessary harm can come to the hair follicles and the vascular net beneath them.

5 The Forehead Lift 255 Fig. 7. The corrugator fibers are selectively coagulated. Fig. 8. A measured strip of scalp is resected. The deep aspect of the meso temporalis can also be easily separated from the fascia temporalis by blunt dissection opening a space whose lower limit is given by the zygomatic arch (Fig. 3). We must agree with McDowell that dissecting and severing the attachments to the zygomatic arch, as stated by Vifias et al. (8), in order to obtain "an effective face lift" could easily endanger the nerve branches running over the arch. Notwithstanding such limitations, it will be readily observed that on applying traction on the frontal flap, the meso temporalis can be deployed in a fan-like effect allowing for the required upward movement. To further assist in the removal of any retaining obstacle, we like to detach the medial expansions of the meso from the orbital ridge, completing this crucial step of the procedure. The meso then acts as a hinge of sorts for the flap, with the added advantage that, as long as the anterior branch of the artery coursing along its upper limit is not broken, one can be assured that the thin ramifications of the facialis will be spared any undue stretching.

6 256 H. Marino Fig. 9. Cases: preoperative views (A, C, E, and G) and postoperative results (B, D, F, and H).

7 The Forehead Lift 257

8 258 H. Marino Since our report to the International Congress of Plastic Surgery at Melboume was pub- lished (6), we have changed our way of treating the hyperactive frontalis muscle: we always report the tracing of the wrinkled area (Fig. 4) to the undersurface of the flap by piercing its perimeter with tinted needles (Fig. 5), but then, instead of resecting any part of the muscular layer--as still proposed recently (8)--we make two or at most three horizontal, parallel incisions through it (F!g. 6). In this way unwanted adhesions are prevented and the muscle remains active while losing some of its strength by two mechanisms: (a) interruption of its vertical fibers by the horizontal cuts interposes thin bands of scar tissue, and (b) section of its lower attachments to the orbital margin reduces the length of its excursion. The immediate effect of the procedure is also quite remarkable: as the slightest traction is applied on the flap the wrinkles fade away and the desired fiat surface is obtained. We have already signaled the difficulties that may be found in paralyzing the corrugator and procerus muscles in order to erase the frown lines. Forcefully disrupting them--as proposed by some authors (1, 2)--is not satisfactory either technically or functionally as the results could be at best erratic. Instead, we have found it most convenient to perform selective coagulation of the muscular fibers, effectively eliminating them without any injury to the neighboring vessels and nerves (Fig. 7). Proceeding along these lines, it is easy to maintain the integrity of the fine branches of the facialis nerve keeping the amount of activity of the frontalis muscle needed for a natural expression. The operation ends with precise hemostasis, measured excision of a strip of scalp and galea (Fig. 8), and approximation of the wound borders by suturing with interlocking running stitches if the incision is behind the hairline. If the cut follows this line, aesthetic reasons demand a more careful treatment: good aproximation of the deep plane by separate stitches and an accurate intradermal suture of the skin. We seldom drain, but a pressure dressing temporarily includes the eyes to prevent any undesirable bruising of the eyelids. Figure 9A to H shows resuks of the operation illustrated here. References 1. Bames, H. O.: Frown disfigurement and ptosis. Plast. Reconstr. Surg. 19:337, Castafiares, S.: Forehead wrinkles, glabellar frown and ptosis of the eybrows. Plast. Reconstr. Surg. 34:406, Gonzalez-Ulloa, M.: Facial wrinkles. Integral elimination. Plast. Reconstr. Surg. 29:658, Joseph, J.: Nasenplastik u. Sonstige Gesichtsplastik. C. Kabitzch, Leipzig, Marino, H.: Ritidectomia frontal. Bol. Tr. Soc. Cirugia Buenos Aires 47:93, Marino, H.: The surgery of facial expression. Transactions of the Fifth Congress of Plastic and Reconstructive Surgery, Melbourne, Australia. Butterworths, London, 1971, p Pitanguy, I., and Silveira Ramos, A.: The frontal branch of the facial nerve. The importance of its variations in face lifting. Plast. Reconstr. Surg. 38:352, Vifias, J., Caviglia, C., and Cortifias, J. L.: Forehead rhytidoplasty and brow lifting. Plast. Reconstr. Surg. 57:445, 1976.