Forehead Plasty For Facial Rejuvenation

416 A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R / O C T O B E R 2 0 0 0
Operative Strategies is a fully illustrated guide to the

favorite techniques of aesthetic plastic surgeons based
on their signicant clinical experience. Authors are
Aesthetic Society members or other recognized experts.
B
row descent, forehead creases, glabellar wrinkles,
and furrows all produce a tired appearance that is
troubling to many patients. Complete rejuvenation
of the periorbital region requires consideration and man-
agement of brow ptosis. When combined with blepharo-
plasty, forehead plasty (brow lifting) completes the
rejuvenation of the upper third of the face. As with all
surgical procedures, variations in technique must be mas-
tered to accommodate each patients needs.
There are many individuals who are notable for their con-
tributions to forehead and periorbital rejuvenation.
Among those who have inuenced my technique the most
are Dr. Mario Gonzales Ulloa, who contributed greatly to
the introduction of forehead plasty into the United States;
Dr. Bernard Kaye, whose monographic atlas on aesthetic
surgery is a classic; and Dr. Larry Robbins, who also had
the foresight to use alternative approaches to forehead
rejuvenation with minimal incisions.
Mini-incision surgerieswith and without endoscopic
assisthave become commonplace in recent years. In my
opinion, the gold standard for forehead plasty remains
the open approach, which affords the surgeon the oppor-
tunity for direct visualization, palpation of anatomical
structures, adjustments, and appropriate excision without
the necessary use of cortical screws, bone tunnels, and
other devices to assure frontal ap xation. Unlike with
face lifts, a secondary forehead plasty is rarely necessary.
Although forehead plasty may be performed as an inde-
pendent procedure, it is more frequently performed in
combination with another procedure, such as blepharo-
plasty or face lift.
Most surgeons agree on the importance of interruption
of the muscular forces that contribute to forehead wrin-
kling. The variety of techniques described, however, is
evidence of the lack of a
consistent outcome. In my
hands, the combination of
brow ptosis, forehead wrin-
kling, corrugator furrows,
and loose skin at the root of
the nose is best corrected by
complete forehead plasty
through use of an open,
coronal approach (Figure 1).
If correction is for brow
ptosis alone, more limited
alternative methods are
available; these include direct brow lift by skin excision,
through a forehead crease or along the upper portion of
the eyebrow, and transpalpebral internal browpexy.
Patient Evaluation
The nal determination of the resting brow position and
the benets of brow elevation are demonstrated to the
patient in front of a mirror. Brow position is also demon-
strated while the patient is lying down, because the brow
assumes a natural position when the patient is supine
(Figure 2).
Surgical Technique for Forehead Plasty
The choice of incision for complete forehead plasty,
including muscle modication and brow elevation, is
individualized to accommodate the patients preferences
as well as the perceived deformity. For most patients, my
preference is a transcoronal incision 6 to 8 cm posterior
to the frontal hairline, although variations of this incision
(Figure 3) are often necessary, depending on the patients
forehead height, positioning of the frontal and temporal
hairline, and hair density.
The main advantage of the coronal incision is the
decreased visibility of the scar in patients with a normal
density of hair. The coronal incision is not a useful
option in bald patients, patients with high foreheads, or
patients with receding hairlines who do not want their
hairlines further elevated or exposed. The placement,
development, and closure of the coronal incision require
Stanley A. Klatsky, MD,
Baltimore, MD, is a board-
certied plastic surgeon and an
ASAPS member.
Forehead Plasty for Facial Rejuvenation
Op e ra t i v e St ra t e gi e s
A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R / O C T O B E R 2 0 0 0 417 Forehead Plasty for Facial Rejuvenation
Figure 1. A, Anatomy of the forehead and periorbital region. B, Contraction lines secondary to action of underlying muscles.
Frontalis muscle
Supratrochlear nerve
Supraorbital nerve
Corrugator muscle
Procerus muscle
Orbicularis oculi
muscle
Frontalis
contraction lines
Corrugator
contraction lines
Procerus
contraction lines
A B
Figure 2. A, Preoperative view of a 54-year-old woman being evaluated for coronal brow lift, upper- and lower-lid blepharoplasty, face lift, and
neck lift. Note descent of brow, forehead wrinkling, glabella frown lines, and horizontal lines from loose skin at the root of the nose. Glabella
frown lines and anterior border of the platysma have been marked with ink. B, Preoperative view of the same patient in supine position. Note
repositioning of the brow and facial tissues secondary to positional change only, no surgery having been performed.
A B
Illustrations by William M. Winn, Atlanta, GA.
418 A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R / O C T O B E R 2 0 0 0 Volume 20, Number 5
less meticulous attention than surgery in which an anteri-
or hairline incision is used.
Although the anterior hairline incision for forehead
plasty is not favored by many plastic surgeons, I find it
to be a desirable alternative to increased hairline eleva-
tion and possible hair loss at the site of the incision. I
select an anterior hairline incision if the frontal hairline
is high and the distance between the temporal hairline
and lateral eyebrow exceeds 3 to 4 cm of skin, the
equivalent of 2 finger breadths. Thinning scalp hair is
another indication for an anterior hairline incision,
Figure 3. The choice of incisions. Modied incision is at the hairline in the central frontal area and behind the hairline in the temporal area. This inci-
cision is used for patients with a high frontal hairline and a temporal hairline within 3 to 4 cm of the lateral eyebrow.
Coronal incision
Modied incision
Anterior
hairline incision
because posterior placement of the scar would damage
more hair follicles and thin, wispy, fine hair tends to
expose a coronal incision when it becomes wet or wind-
blown. The anterior hairline incision also offers some
mechanical advantage inasmuch as it is closer to the
supraorbital rim. The closer the incision to the deformi-
ty, the better the mechanical lifting advantage. The
anterior hairline incision also permits selective use of
the subcutaneous plane of dissection.
Disadvantages of the anterior hairline incision include
possible visibility of the scar, the added precision
required in the placement and angulation of the incision
to avoid disruption of the hair follicles, and the require-
ment of a tension-free, precisely layered closure.
An alternative approach is to combine the anterior and
posterior incisions. The anterior forehead incision is
placed just posterior and central to the hair follicles and
is hidden well back in the scalp in the temporal area hair-
line. This incision is used for patients who have a high
central forehead line and a temporal hairline that is less
than 3 to 4 cm from the lateral eyebrow.
Surgical Technique for Coronal Forehead Lift
Patients are asked to shampoo their hair preoperatively
and avoid the use of hair sprays. The vectors of elevation
are drawn on the patient with a skin marker, and the
patient is shown the direction of the anticipated brow
elevation in front of a mirror (Figure 4).
A 1- to 2-cm swath of hair is clipped for exposure dur-
ing the operation, and the hair is parted and smoothed
out of the incision area by an application of water-solu-
ble lubricant, such as KY Jelly (Johnson and Johnson),
which is easily removed with shampooing at the conclu-
sion of the surgery (Figure 5). Multiple small pieces of
aluminum foil are used to wrap the hair into small bun-
dles and keep it out of the way during surgery. The eyes
are protected with ophthalmic ointment or scleral
shields, and a moistened, ne-mesh gauze sponge is
placed over the eyelids so that exposure and irritation
can be avoided during surgery. The face and incisional
Figure 5. Hair is parted to show the site of a coronal incision, 6 cm
posterior to the hairline.
Figure 4 A, A 40-year-old woman being prepared for a coronal brow lift. B, Surgeon shows brow elevation to patient while she looks into a mirror.
A
B
areas are prepared with a colorless antiseptic solution,
such as TECHNICARE (Care-Tech Laboratories; St.
Louis, MO), and the patient is draped.
The operation may be performed with the patient under
general or local anesthesia with intravenous sedation.
The usual incision extends bilaterally from the root of the
helix across the scalp, 6 to 8 cm posterior to the hairline.
The incisional area is inltrated intradermally and subcu-
taneously to the pericranium with 0.5% lidocaine con-
taining 1:100,000 epinephrine and buffered with sodium
bicarbonate. The suprabrow region is similarly inltrated
across the forehead to the root of the ear on each side.
Supraperiosteal inltration across the orbital rim pro-
vides an effective regional block.
The incision is made 5 to 7 minutes after inltration; this
permits sufcient time for vasoconstriction. The scalpel is
beveled parallel to the shafts of hair to avoid damage to
the hair follicles. The incision extends to the pericranium,
and subgaleal dissection proceeds in a relatively avascular
areolar plane to the root of the nose and to the supraor-
bital rims. The dissection extends laterally over the tem-
poralis muscle fascia. Dissection over the supraorbital
rims and nasal dorsumwhen indicated to raise the nasal
tipis carried out with scissors to release the soft-tissue
attachments of the brow and nasal areas.
The corrugator supercilii and procerus muscles are then
identied. The thin procerus muscle is divided in multiple
areas to the subcutaneous fat through use of a Colorado
cautery (Colorado Biomedical, Inc., Evergreen, CO;
Figure 6). The corrugator muscles are identied and iso-
lated (Figure 7). They are divided, and a small muscle
segment is excised (Figure 8). Care is taken to identify
and preserve the neurovascular pedicles.
The supraorbital nerve pathways are then identied and
Figure 6. Subgaleal dissection shows regional anatomy and dissection of the procerus muscle with a Colorado needle.
Surgeons View Anatomy
Division of procerus
and corrugator muscles
using Colorado needle
Supratrochlear
nerves
Supraorbital
neurovascular
bundle
Galeal ap
Supratrochlear nerves
Supraorbital nerve
Corrugator muscle
deep to orbital
portion of orbicularis
oculi muscle
Frontalis muscle
Supraorbital
neurovascular
bundle
Pericranium
marked on their course through the frontalis muscle. The
site of frontalis weakening is located between the supraor-
bital nerves, 2 cm superior to the orbital rim and extending
to the anterior hairline. A thin sheet of frontalis muscle
and fascia is tangentially excised, care being taken to avoid
injury to the nerves and subcutaneous tissue (Figure 9).
Lateral segments of frontalis muscle are similarly weak-
ened, if necessary. The periosteum at the border of the
supraorbital rim is incised with a Colorado cautery and
dissected 1 cm distally with a Joseph elevator (Storz
Surgical Instruments, St. Louis, MO), the brow attach-
ments being released. Care is taken to stay close to the per-
icranium in the suprabrow area to avoid potential injury to
the frontal branch of the facial nerve.
The scalp ap is then retracted superiorly, and temporary
3-0 nylon pilot sutures are placed centrally and in the
temporal areas to adjust the tension and determine the
degree of elevation of the skin ap (Figure 10). The skin
ap is adjusted and the excess excised. Final suturing is
performed with a continuous 3-0 nylon suture (Figure
11). Cotton, saturated with mineral oil, is placed over the
suture line and held in place with a bulky head dressing
for 24 hours. Sutures are then removed 10 to 12 days
postoperatively.
Complications, which have been infrequent, have consist-
ed mainly of hair loss along the incision line, probably
caused by excessive tension or injudicious use of cautery
that injured the hair follicles. An occasional case of fore-
head irregularities, due to imprecise forehead muscle
resection, has also been observed. Typical results are
shown in Figures 12 and 13.
Anterior Hairline Approach
When an anterior hairline incision is chosen, it is made
precisely 2 mm posterior to the hairline. The scalpel is
beveled parallel to the hair follicles. This maneuver
avoids damage to the hair follicles and may allow
regrowth of hair through the scar. Dissection is per-
formed in the subcutaneous plane to preserve sensation
to the scalp, posterior to the incision.
Figure 7. Subgaleal dissection, with forehead scalp ap retracted
inferiorly to demonstrate isolation of the corrugator muscle.
Figure 8. Subgaleal ap shows corrugators and procerus muscles divided.
Figure 9. Subgaleal ap shows tangential resection of strips of frontal-
is muscle and fascia.
422 A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R / O C T O B E R 2 0 0 0
The subcutaneous plane must be precisely dissected
especially just anterior to the incisionto avoid an over-
ly thin ap and possible wound necrosis. The dissection
plane, just supercial to the frontalis muscle, continues
to the level of the supraorbital rims. I do not perform
frontalis muscle surgery when I use the subcutaneous
approach, because forehead wrinkling is reduced signi-
cantly by division of the brous septa, extending from
the muscle to the subdermal layer of the skin.
The corrugator and procerus muscles are resected or
avulsed, as in the subgaleal approach. Access to these
muscles is obtained by penetration of the frontalis-pro-
cerus aponeurosis in the region of the glabella (Figures 14
Figure 10. Forehead ap redraped with appropriate vectors of elevation. Pilot sutures and distribution of tension on the ap are demonstrated.
Second suture
First suture
Third suture
Volume 20, Number 5
and 15). A meticulous 2-layer wound closure is carried
out through use of 5-0 Monocryl sutures (ETHICON,
Inc., Somerville, NJ) subcutaneously and 6-0 nylon
sutures for the skin (Figure 16).
The advantages of the subcutaneous approach are the
direct division of the cutaneous brous insertions from
the underlying muscle, preservation of sensation to the
scalp, and the ease of establishing the same level of dis-
section when the procedure is combined with a face lift.
The increased difculty of dissection and the potential for
increased bleeding, resulting in hematomas, are the prin-
ciple disadvantages.
Figure 11. Scalp excess is excised, and the wound is closed with a continuous single layer of 3-0 nylon sutures.
I use this approach frequently, however, and nd it
extremely useful. When I use the Colorado cautery, I nd
the dissection to be precise and easily accomplished, with
minimal bleeding. When this procedure is used appropri-
ately in selected patients, there is a high level of patient
satisfaction (Figure 17).
Figure 12. A, Preoperative view of a 56-year-old woman. Note persistent elevation of the brows in an attempt to relieve upper-lid heaviness and visu-
al impairment. B, Postoperative view 6 months after coronal brow lift, upper- and lower-lid blepharoplasty, and face lift. Note eyebrows at normal rest-
ing position.
A B
Figure 13. A, Preoperative view of a 46-year-old woman. B, Postoperative view 1 year after coronal brow lift, upper- and lower-lid blepharoplasty, face
lift, and mentoplasty.
A B
Conclusion
The goals of forehead plasty are to eliminate or reduce
forehead wrinkles, brow ptosis, frown lines, and loose
skin at the root of the nose. The desired result is a patient
whose appearance is refreshed and alert, without the
look of surprise or astonishment. Conservative and
appropriate adjustment of the scalp and forehead skin is
the cornerstone of a natural result.
Care must be taken to preserve the function of the orbic-
ularis oculi and lateral frontalis muscles to provide ani-
mation of the brow and forehead. An expressionless,
porcelain forehead is unnatural and readily displays
the look of having been operated on. Conversely, mini-
mal or no movement of the procerus and corrugator
muscles is desired. Complete disruption of the function of
these muscles eliminates the frowning look and the deep
creases of the glabellar area.
Although aesthetic surgeons continually strive to expand
the available techniques, we should not abandon tried-
and-true procedures. Forehead plasty has been proven
safe, efcacious, and easily reproducible; it consistently
achieves a high level of patient satisfaction. I
Suggested Reading
1. Klatsky S. Browlift. In: Cohen M, ed. Mastery of Plastic and
Reconstructive Surgery. Boston: Little-Brown; 1994:1958-1967.
2. Kaye B. Facial rejuvenation surgery. Philadelphia: Lippincott; 1987.
3. Litton C. Forehead and eyebrow liftanatomical and clinical aspects.
In: Lewis, ed. The Art of Aesthetic Plastic Surgery. Boston, MA: Little-
Brown; 1991:2;691-695.
4. Ristow B. The forehead and eyebrows. In: Vistnes LM, ed. Procedures
in Plastic and Reconstructive Surgery: How They Do It. Boston: Little-
Brown; 1991:51-57.
5. Ellenbogen R. Transcoronal eyebrow lift with concomitant upper ble-
pharoplasty. Plast Reconstr Surg 1983;71:490.
Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO
63146-3318; phone (314) 453-4350; reprint no. 70/1/110281
doi:10.1067/maj.2000.110281
Figure 14. Subcutaneous forehead dissection. Anterior surface of
frontalis muscles and penetration of frontalis procerus aponeurosis are
shown.
Figure 15. Isolation of corrugator muscle when the subcutaneous fore-
head ap is raised.
Figure 16. Skin closure after excision of excessive skin.
Endoscopic brow lift has become the method of choice
for forehead and upper-orbital rejuvenation for many
surgeons because of its manifest advantages:
Short incisions
Low risk of dividing sensory nerves
Decreased hair loss
Precise muscle modication with the aid of magnication
Increased patient acceptance
The open, transcoronal brow lift is still preferred by some
surgeons, however, and Dr. Klatsky presents a persuasive
case for its routine use. His clear exposition makes the
open lift appear technically easy in comparison with the
endoscopic approach, which is relatively complex.
Having grown up with the open approach and switched
to the endoscopic approach 5 years ago, I am comfort-
able stating that the results are equivalent. The learning
curve for the endoscopic approach is steeper and more
difcult, but in my hands this approach has the rewards
of decreased morbidity and increased patient acceptance.
Despite my preference for the closed approach, I occa-
Figure 17. A, and C, Preoperative views of a 52-year-old woman. B and D, Postoperative views 2 months after a brow lift through use of anterior inci-
sion in central frontal area and posterior incisions in the temporal areas. Patient also had upper- and lower-lid blepharoplasty and face and neck lift.
Although these scars are only 2 months old, they are already inconspicuous, even with the hair pulled back.
A B
C D
Comme nt a ry
by Gerald H. Pitman, MD
Editor, Operative Strategies
sionally nd patients for whom the open approach is
more desirable or necessary:
Patients with very high hairlines in whom the increased
distance from access incisions to the superior orbital
rim over a curving cranial surface imposes extra techni-
cal difculties in visualization and treatment of struc-
tures at the superior orbit
Patients who have had a previous open lift and already
have a transverse scar in the hairline
Patients who are undergoing an endoscopic procedure
and require conversion to an open approach for any
reason.
It is advantageous to be familiar with a variety of
approaches, and the open technique is a time-tested
method of permanently elevating and rejuvenating the
forehead and upper-orbital area. A close reading of Dr.
Klatskys article will enhance the surgeons ability to per-
form this important and reliable procedure.

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416 A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R / O C T O B E R 2 0 0 0

Operative Strategies is a fully illustrated guide to the

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