Branch Plane
Branch Plane
Cosmetic, Plastic, Aesthetic and Reconstructive Surgery:- Brow Lift
Introduction
Facial rejuvination surgery has undergone significant changes. The need for an optimal long-term result with minimal downtime has led to a more critical appraisal of traditional surgical techniques. The integration of endoscopic, suture/threads and minimal access cranial suspension techniques into aesthetic surgery offer further alternatives and modifications to those more traditional procedures. Furthermore the use of non surgical techniques in facial rejuvination or the combination of non surgical and surgical techniques offers a more diverse range of treatments.
Anatomy of the forehead
Traditionally we have been taught that the scalp is composed of five layers, skin, connective tissue, aponeurosis, loose areolar tissue and periosteum. Moving from scalp to forehead, the galea aponeurotica becomes contiguous with the superficial temporal fascia, and the periosteum of the frontal bone becomes contiguous with the temporalis fascia. The confluence of these tissue planes occurs just medial to the temporal fusion line of the skull and its continuation as the superior temporal line. Near the junction between the temporal fusion line of the skull and the orbital rim is the orbital ligament, a fibrous band connecting superficial temporal fascia to the orbital rim. It limits cephalad superficial temporal fascial movement during forehead flap transposition by tethering the lateral eyebrow segment to the orbital rim.
The galea aponeurotica passes onto the forehead and envelopes the frontalis muscle with a thin layer above and a thicker layer below creating a superficial and a deep galeal layer.
Beneath the deep galeal layer lies a well-defined layer of loose areolar tissue called the subgaleal plane. The subgaleal plane however is fused to the periosteum in the lower 2cm of the forehead and in an area just medial to the temporal fusion line of the skull and its continuation as the superior temporal line. The deep galeal layer is further divided into two layers in the lower forehead one fused with periosteum and the other lining the deep surface of the muscle creating two spaces 1) the galeal fat pad and 2) the subgaleal fat pad glide space which lies deep to the galeal fat pad. The galeal fat pad extends from 2cm above the orbital rims and across the forehead deep to the lower frontalis muscles enclosed, in the main, in a fascial plane that is inserted in the lateral side more inferiorly. Laterally the preseptal fat pad can be found to extend upward over the lateral orbital rim under the descended galea fat pad.
The muscles of the forehead are present in three planes. The superficial (frontalis, procerus and orbicularis oculi) with close adherence to the skin throughout their course, intermediate (depressor supercilli muscle) and deep (corrugator muscle), both with definite bony origins and direct insertions into the skin.
The frontalis muscle originates from a split in the galea approximately 6-10 cm above the orbital rim and inserts into the forehead skin just above the eyebrow with no bony origin or insertion. Medially there is a confluence of the frontalis, orbicularis oculi and depressor supercilli with blending of the procerus. It does not insert laterally beyond the middle and lateral third of the eyebrow with the lateral border of the frontalis corresponding to the underlying superficial temporal crest. Depressor supercilli originates from the nasal process of the nasal portion of the frontal bone 1cm above the medial canthal ligament and inserts into the skin beneath the medial head of the eyebrow. It is considered to be distinct from the orbicularis oculi.
Mobility of frontalis muscle is essentially limited to its inferior 20 percent, under which exists the galeal fat pad enveloped by the deep galeal plane. The corrugator supercilii muscle passing through the galeal fat pad is incorporated into the roof of the subgaleal fat pad glide space, which then penetrates the frontalis and orbicularis muscles en route to its dermal insertion. Its smooth walls serve as glide plane surface allowing the corrugator and inferior 20 percent of the frontalis muscles to move the overlying soft tissues with less resistance. The subgaleal fat pad glide space provides the greatest movement between surfaces.
The deep division of the supraorbital nerve innervating the frontoparietal scalp runs from the orbital rim between the deep galeal plane and periosteum under the glide plane space floor toward the superior temporal line of the skull. It then runs parallel with the superior temporal line and is always found from 0.5 to 1.5 cm medial to the superior temporal line until the nerve turns medially to enter the scalp. The superficial division of the supraorbital nerve runs from the orbital rim over the frontalis muscle to terminate in the anterior scalp in most patients. The frontal branch of the facial nerve runs across the anterior temporal fossa within superficial temporal fascia before entering frontalis muscle.
Aging changes
A youthful eyebrow is one in which the medial brow is at or below the supraorbital rim and the lateral two thirds of the eyebrow is arched or elevated. Aging in the upper face becomes evident with a descent in the level of the eyebrow and the appearance of wrinkles and furrows, sometimes from an early age. One of the earliest signs of facial aging, starting is the descent or flattening of the lateral eyebrow.
Although partly attributable to the progressive laxity of scalp and forehead soft tissues with age many other structures promoting mobility and gravitational descent of the eyebrow have been shown to be causative. An understanding of these complex interactions is required in order to surgically or non surgically address these aging changes.
The lateral margin of the frontalis muscle almost always ends or abruptly attenuates along the temporal fusion line of the skull; therefore, the more medially the palpable temporal line intersects the eyebrow, the less lateral eyebrow support is available from the frontalis muscle. Any lateral eyebrow segment not suspended by frontalis muscle is pushed downward by the descending temporal fossa soft-tissue mass and the depressor forces affecting the lateral brow from the orbicularis oris. Unsupported soft tissues superficial to the plane of the temporalis fascia drift downward with aging. This explains, in part, why the lateral eyebrow segment almost always becomes more ptotic than the medial segment. The galeal fat pad over the superolateral orbital rim is relatively mobile and may act as a lubricating surface for lateral eyebrow descent, possibly complemented in this function by the lateral end of the preseptal fat pad when it extends over the orbital rim. The glide plane space, located between the galeal fat pad and the deepest layer of the multilayered deep galeal plane, also may facilitate lateral eyebrow ptosis through a glide plane effect from its smooth lining surfaces.
A dynamic equilibrium at the lateral eyebrow level exists between the force of descending temporal fossa soft tissue pushing the eyebrow down and the force of frontalis muscle action suspending it. Action of the corrugator and orbicularis oculi muscles may upset this equilibrium by promoting lateral eyebrow ptosis. The strength of orbicularis depression varies from patient to patient. Action of the procerus muscle, the medial orbicularis oculi muscle and the depressor supercilli may promote medial eyebrow segment ptosis. With aging attenuation of the facial muscles lead to increased wrinkles and furrows.
The goals of surgical rejuvenation of the forehead include reproducible and long lasting brow manipulation, attenuation of transverse forehead rhytids, and reduction of glabellar frown lines.
History of endoscopic brow lifting
For nearly a century, aesthetic improvements of the aging upper third of the face have remained a challenging problem. Since the earliest description of brow lifting by Passot in 1919, brow ptosis management has undergone evolutionary changes from the classic coronal open brow and anterior hairline techniques to the more recently described, less invasive techniques, such as minimal incision lateral brow and endoscopic brow lift.
The use of the endoscope in brow lifting was first introduced in 1992. Elevation in the subperiosteal plane was subsequently described. This early experience was further developed over the next two years. Isse and Chajchir detailed their method of performing a brow lift through small incisions behind the anterior hairline. Isse noted that a dynamic functional lift could be achieved by modifying or weakening the corrugator supercilii and thus addressing the balance of muscular activity between the frontalis and the corrugator supercilii muscle. He also identified the need to vary techniques on the basis of the configuration of the skull, bony architecture, and soft tissue thickness and tightness.
Other methods of forehead lifting
The main benefits of endoscopic brow lifting as compared to the classical bicoronal open lift are related to the limited access incision and the associated decreased incidence of alopecia resulting from the shortened scar. There is also the advantage of not dividing the deep branch of the supraorbital nerve producing a lower incidence of numbness and postoperative neuralgia after endoscopic techniques. From an aesthetic standpoint the long incision of the coronal brow lift has several disadvantages. It is situated distant to the eyebrow and thus long-term fixation is more difficult. A 2:1 ratio of scalp resection to eyebrow elevation is required via the coronal approach accounting for the significant hairline shift commonly associated with this procedure. The long-term fixation is also achieved by scalp excision only, which is less stable compared with the more rigid fixation of securing scalp to calvarium as seen in the endoscopic lifts. As the posterior scalp is a mobile structure there is a tendency for the posterior scalp to re-descend. Controlling brow shape is more difficult with long scar techniques with the tension of fixation distributed along the incision. It cannot address individual portions of the brow which need addressed. Endoscopic techniques allow access incision placement directly superior to the region that needs elevation.
Complications however of endoscopic brow lifting include alopecia, hairline position change, asymmetry, prolonged paraesthesia over the forehead/brow area, scalp dystaesthesia and frontal nerve paralysis. It would seem that the initial surge of enthusiasm for the endoscopic technique has since tailed off with a decrease in the number of procedures performed. Possible reasons include more stringent criteria for patient selection and the use of other equally or effective medical and surgical techniques. These include surgery through the upper eyelid, minimal incision brow lift/foreheadplasty, minimally invasive thread/mesh/suture suspension, botulinum toxin injections and laser resurfacing.
Consultation
When considering cosmetic rejuvination to the upper third of the face it is important to consult with a cosmetic surgeon with experience of all the surgical and non surgical techniques discussed above. Further information is available on www.garylross.com
(c) copyright 2009 garyross
About the Author
MrMr Gary Ross is a Consultant Plastic Surgeon at The Christie and BMI Alexandra with a practice specializing in head and neck and breast surgery. He is registered with the British Association of Plastic Surgeons and also the British Association of Aesthetic & Plastic Surgeons. Mr Ross has become a leading figure in the highly competitive field of Plastic Surgery. His private practice in Cheshire reflects his interest in head and neck and breast aesthetics. He has been appointed as an honorary senior lecturer at the University of Manchester and has published over 50 peer reviewed articles and a number of book chapters (including face lifts, brow lifts, blepharoplasty). He has presented worldwide over 200 times many as a key note lecturer and moderator. He has organized a number of international conferences and instructional courses and offers non surgical options including laser, botox, fillers and peels.
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