KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Brow lift.

Question 0

What are the muscles in the forehead region?

Answer 0

Frontalis
Corrugator supercilii (vertical & oblique glabellar lines)
Depressor supercilii (oblique lines)
Procerus (transverse lines)

Question 1

What are the bony landmarks separating the forehead and temporal fossa?

Answer 1

diagram pg 548
Temporal ridge consists of:
1. Inferior temporal fusion line - origin of temporalis and overlying deep temporal fascia.
2. Superior temporal fusion line.
3. Zone of fixation (6mm wide area just medial to temporal ridge) - where overlying soft tissue structures are firmly adherent to bone.

Question 2

What fasciae are involved in a brow lift?

Answer 2

1. Galea aponeurotica - must be released at supraorbital rim and zone of fixation.
2. Superficial temporal fascia
   - continuous with galea,
   - tethered to overlying skin,
   - can elevate lateral 1/3 of brow.

Can dissect between superficial and deep temporal fascia until an adhesion (orbicularis-temporal ligament aka inferior temporal septum) is reached, 2-3cm above zygomatic arch. Through this space are the frontal branches (VII) in parotid temporal fascia and zygomaticotemporal vessels and nerves.

Sentinel vein = medial zygomaticotemporal vein, close to frontal branches of VII.

Question 3

What sensory and motor nerves may be affected in a brow lift?

Answer 3

1. Supraorbital (notch)
2. Supratrochlear (medial to 1)
3. Frontal branch of VII

Question 4

How do you assess for brow lift?

Answer 4

Please refer to facelift section, plus

History

• frontal headaches (constant contraction of frontalis).
• looking ‘tired, angry, sad’.

Examination: Ellenbogen’s ideal brow position.

1. Medial canthus = alar base (vertical).
2. Alar base -> lateral canthus -lateral brow.
3. Medial = lateral brow (horizontal).
4. Brow apex = lateral limbus.
5. Female - just above supraorbital rim, male - at SOR.

diagram pg 551.

Question 5

What are the possible complications of brow lift?

Answer 5

Early

• scalp numbness.
• loss of fixation.
• haematoma.
• infection.
• injury to frontal branch.

Late

• alopecia (tension on hair-bearing scalp).
• scalp itching and tingling (sensory recovery).
• asymmetry.
• loss of brow stability.

Question 6

What techniques of brow lift are there?

Answer 6

1. Coronal
2. Endoscopic
3. Transpalpebral

Question 7

Describe the coronal technique of brow lift.

Answer 7

• Coronal incision 7-9cm posterior to hairline (or pretrichial of hairline is high).
• Dissect over frontal bone in subperiosteal plane.
• Dissect between superficial and deep temporal fascia over temporal fossa.
• Forehead flap is pulled under tension, overlapping skin excised and tension holding sutures in galea.

Question 8

Describe the Endobrow technique.

Answer 8

3 incisions: midline + lateral temporal x2.

Subperiosteal dissection over forehead.
Dissection between STF & DTF laterally.
Endoscope (what angle / type?) used to visualise the release of periosteum at zones of adherence at supraorbital rim and superior temporal fusion line.
Protect sensory nerves with assistant’s fingers over supraorbital rim.
(Can visualise glabellar muscles and divide at this point).

After release, forehead flap is elevated and fixed with:

1. Drill tunnel anchoring sutures.
2. Miteck bone anchors.
3. Absorbable screws & sutures.
4. Endotine devices.

Temporal area: mobile STF is sutured to immobile DTF to elevate lateral brow.

Question 9

Describe the transpalpebral technique.

Answer 9

• Upper blepharoplasty incision.
• Supraorbital galeal plane dissection. Lateral brow elevated with orbicularis.
• Suture / Endotine brow tissues to lateral brow periosteum.
• Only suitable for minor brow ptosis or balding men - Does not address forehead rhytids.