Aesth. Plast. Surg.

27:159–165, 2003
DOI: 10.1007/s00266-003-0062-5

Temporal Lift by Galeapexy: A Review of 270 Cases

Alain L. Fogli
Marseille, France

Abstract. The purpose of this technique is to correct the
ptotic tail of the brow and crow’s feet as well as to redrape
the premalar skin to allow us to make a greater skin re-
section in the lower lid. The purpose of this presentation is
to expose the advantages, the inconveniences, and the
complications of this technique.
We reviewed the charts of 270 patients who were oper-
ated on between June 1996 and January 2002. The average
age of the patients was 45 years old. Temporal lifts were
performed during a frontotemporal lift in 92 cases, and
during a three-stage lift (frontal, facial, and cervical) in 170
cases. In eight cases, an isolated temporal lift was per-
formed. An upper blepharoplasty was performed in 252
cases and transconjunctival fat pad excision was performed
in 188 cases. Finally, a lower lid skin resection was done
following a galeapexy in 241 cases.
The surgical approach consists of a temporal incision,
followed by a subgaleal dissection, and then a subcutaneous
dissection that allows the cephalic galea, previously incised,
to be anchored to the temporal aponeurosis. This allows
good cutaneous redraping that raises the brow tail and a
detachment of the orbicularis fibers. The suturing of the
scalp is done without tension and without eliminating hair.
The results of the technique with a follow-up period of
more than five years for the earlier cases and six months for
the last cases, were evaluated with three criteria: (1) the
distance between the brow and the eyelashes, (2) the re-
duction of crow’s feet, (3) the reduction of wrinkles at the
level of the lower lid and the malar region. Overall satis-
faction was also rated. Of 270 patients, 225 had ratings of
very good to good, 13 had average results, and 13 had
unsatisfactory results. As far as complications, five had
Presented at the Congress of the European Association of
Plastic Surgeons in Madrid, Spain, in May of 1999 and at
the ISAPS Postgraduate Course in Beirut, Lebanon, May
2001.
Correspondence to A.L. Fogli, Plastic Surgical Center, 281,
Corniche Kennedy, 13007 Marseille, France. email: alain.
fogli@wanadoo.fr
unilateral hematoma requiring an evacuation, four patients
had temporary alopecia, and eight patients had temporary
frontal muscle weakness that resolved within one to three
months.
This technique, performed under local anesthesia, is very
efficient, reproducible, and simple. The incidence of com-
plications can be reduced when one is meticulous during
dissection.
Key words: Temporal lift—Galea—Brow ptosis—Crow’s
feet
Full face-lifts often do not provide sufficient im-
provement in the temporal and malar regions. These
regions are a transition zone between forehead and
face. The purpose of this article is to describe a
technique with an intracapillary temporal approach
that elevates the tail of the brow and improves crow’s
feet and the malar area. We will also discuss an as-
sociated skin resection of the lower lid. We accom-
plish a temporal lift by suturing the galea to the
temporal fascia.
We studied 270 cases that were operated on be-
tween June 1996 and January 2002. The average pa-
tient age was 45 years. A total of 92 patients did
benefit from this temporal lift when a frontotemporal
lift was performed. A total of 170 patients did benefit
from a full face-lift (frontal, facial, and cervical).
Finally, eight patients benefited from an isolated
temporal lift. An associated upper blepharoplasty
was performed in 252 cases and lower-eyelid herni-
ated fat pads were removed via a transconjunctival
approach in 188 cases. Finally, a lower-eyelid skin
resection was performed in 241 cases of galeapexy.
The clinical signs of temporal aging are the fol-
lowing (Fig. 1): (1) lowering of the tail of the brow,
(2) crow’s feet, (3) temporal and malar wrinkling, and
(4) wrinkling of the lower lid.
160 Temporal Lift by Galeapexy

Fig. 1. Different goals of the temporal

lift by galeapexy.

Fig. 2. Limits of the surgical area.

Fig. 3. (A) The dotted line marks the

temporal crest. The continuous line
represents the scalp incision perpen-
dicular to the temporal crest and
parallel to the hairline. (B) Detach-
ments: (1) subperiosteal undermining,
(2) subgaleal undermining, (3) subcu-
taneous undermining.

(In this study we will omit discussing blepharo- landmarks (Fig. 2): (1) the temporal crest above, (2)
chelasis and lower-lid herniated fat pads.) the hairline posteriorly, (3) the zygomatic arch and
The surgical area does not correspond to the area the malar bone below, and (4) the orbital rim ante-
described by anatomists. It is limited by the following riorly.
A.L. Fogli
Methods
Anatomical Considerations
The temporoparietal fascia represents the lateral ex-
tension of the galea. In the interest of convenience,
the lateral extension of the galea will be called the
galea in this paper. But, anatomically speaking, we
must keep in mind that the galea ends at the level of
the temporal crest and that what we are calling the
galea is the temporoparietal fascia.
The galea is adjacent to the superficial temporal
fascia and the periosteum of the frontal bone. These
three structures are confluent in a band 5–6 mm lo-
cated in the medial part of the temporal bone crest
and are adherent to the periosteum and the bone.
Depending on the obliquity of the temporal crest, the
tail of the brow will measure from one-third to one-
quarter of the total length of the brow. The brow tail
is not created by the frontal muscle, which is an ele-
vator. Its ptosis is more influenced by the depressors,
such as the orbicularis and the brow depressor. The
temporal branch of the facial nerve is located between
1 and 1.5 cm below the horizontal projection of the
brow and there is a deep branch of the supraorbital
nerve that innervates the frontotemporal scalp, as
described by Kinze [5]. This branch is located be-
tween the deep layer of the galea and the periosteum
and runs between the orbital rim and the inferior part
of the temporal crest.
Different planes of dissection
The planes of dissection are listed and discussed be-
low (Fig. 3B).
1. Thesubperiostealplane: this is to allow different mus-
culoaponeurotic attachments to be freed from the
temporal crest without any risk of nerve damage.
This will enhance the lift of the tail of the brow.
2. The subgaleal plane: this easy dissection will not
risk any damage to hair follicles and can be carried
out up to 1 cm in front of the hairline. The incision
of the galea under visual control will allow us to
grab and raise the flap and also to easily change
planes if one want to pursue further the subcuta-
neous dissection.
3. The subcutaneous dissection plane: a soft and me-
ticulous dissection will protect us from damaging
the temporal branches of the facial nerve and al-
low us to separate the orbital fibres of the orbi-
cularis muscle from the skin.
Markings
As we palpate, we draw the temporal crest. Within
the hairline, we draw a straight line of 3–4 cm, per-
161
pendicular to the temporal crest. This line is located
3–4 cm behind the hairline, depending on the hair
density (Fig. 3A).
A second line (also 3–4 cm) is drawn 1 cm in front
of the hairline, parallel to it and to the line described
earlier (Fig. 3B). This is the level of the future galeal
incision determining the extent of the subgaleal dis-
section. The subcutaneous dissection could extend as
far as the orbital rim, the zygomatic arch, the malar
bone, and the inferior palpebral area.
Operative Procedure
The intracapillary incision is made with a number 15
blade and the subperiosteal detachment, following a
1-cm periosteal incision is carried out at the level of
the temporal crest as far as the orbital rim. Then, the
subgaleal dissection is easily carried out until the
second line described earlier. The tines of the scissors
are underneath the skin. The galea is opened 4 cm at
the level of the second designed line (Fig. 4). He-
mostasis is achieved using the electric scalpel and a
cold light retractor under direct vision.
With traction on the freed galea, the mobilization of
the brow’s tail is evaluated. Then, with traction on the
temporal teguments, mobilization of the skin of the
malar area and on the lower lid are also evaluated.
This maneuver is repeated at three different levels
on the galea where the stitches will eventually be lo-
cated, depending what is needed. The subcutaneous
dissection can be extended as hemostasis is maintained
and one must be aware of the facial nerve located on
this plane. Once the galea is in the desired position, it
is fixed with a braided U-type stitch on the temporal
fascia. Then, two more stitches are made (Fig. 5).
Before suturing, one can dissect the superior sub-
galeal space as much as is required to avoid dis-
graceful pleating that would require two to three
months to disappear.
At the end, the excess skin from the lower lid is
assessed and can be excised directly with the scissors
(Fig. 6).
Sutures
Suturing the scalp is done without tension and
without resection (Fig. 7). We use deep, resorbable 3
· 0 monocryl. Staples are used on the skin and are
removed six to eight days later. For the lower lid, we
use a number 1 intradermis flexocrin that is removed
three days later along with those of the potential
upper blepharoplasty. No drains are used.
Dressing
We always apply ice to the temporal area for a few
hours. This ice is maintained with a dressing that is
removed in the evening to reduce edema and bruising.
162
Edema and bruising will be more obvious in the lower
lid and, in cases of extensive subcutaneous dissection
(done in 15% of cases), in the malar area.
Results
The results of this technique over 5.5 years of follow-
up (six months for the last patients) are evaluated
according to three criteria:
1. The distance between the eyelashes and the tail of
the brow
2. The improvement of crow’s feet, rated on a scale
from to 1 to 3
Temporal Lift by Galeapexy
Fig. 4. Illustration showing the galea incision,
which is made in front of the hairline and
parallel to it. This incision is performed with
blunt-tipped, curved scissors.
Fig. 5. (A) Illustration demonstrating the
fixation of the lifted cephalic galea to the
temporal aponeurosis. Note the distance
between the cephalic and caudal edges of the
galea. (B) Operative view showing the fixation
of the cephalic galea to the temporal aponeu-
rosis with a braided U-type stitch. Notice that
the direction of the suture is parallel to the
scalp incision in order to prevent its tearing.
3. The improvement of wrinkles on the lower lid and
the malar lid, rated on a scale of 1 to 3
Of 270 patients, 225 had a good to very good re-
sults, 13 had average results, and 13 had unsatisfac-
tory results because of improper correction of the tail
of the brow. We have improved our results by using
subperiosteal detachment of the temporal crest.
Complications
We reported five unilateral hematomas drained under
local anesthesia. These five cases are from the first 30
cases from this series. All of these hematomas
A.L. Fogli 163

Fig. 6. The excess skin can be directly excised. Fig. 7. Postoperative aspect of the scalp suture, which is
without tension.

Fig. 8. (Left top and bottom) Frontal and three-quarter preoperative views of a 32-year-old woman who presents a lateral
brow ptosis without excess lid skin. (Right top and bottom) Frontal and three-quarter postoperative views, six months after
galeapexy.

resulted from blood diffusion and no precise hemos-
tasis was required following these five cases. We now
apply ice for many hours and we have not seen a
hematoma since. Four cases of temporary alopecia
were seen when galeatomy was performed under the
scalp. From the twentieth case on, the galeal incision
was made at least 1 cm or more in front of the
hairline and no alopecia has been reported since.
Although no permanent paralysis of the temporal
branch of the facial nerve was seen, eight patients
experienced weakness that lasted from three weeks to
two months. Unlike other complications, these were
seen in recent cases and were certainly caused by
more rapid dissection and excessive stretching.
Discussion
This technique can be done under local anaesthesia
alone and most of the time it is performed with an
upper and a lower blepharoplasty. It can also be done
with a face-lift and a forehead lift.
164 Temporal Lift by Galeapexy

Fig. 9. (Left top and bottom) Preoperative frontal and three-quarter views of a 52-year-old woman who presents a moderate
brow ptosis, shortened distance between brows and eyelashes, and round eyes. (Right top and bottom) Nine months post-
operative views following galeapexy with upper and lower blepharoplasties. The scar of the upper lid does not extend too far
laterally, thanks to the temporal lift.

Fig. 10. (Left top and bottom) Preoperative frontal and three-quarter views of a 53-year-old woman. She presents marked
stigma of periorbital aging and noticeable excess skin at the level of the lower lid, located equidistant between the lower ciliary
border and the orbital rim. (Right top and bottom) Fourteen months postoperative views following a temporal and facial lift
with upper blepharoplasty and skin resection from the lower lid. The incision is located 8 mm from the ciliary border.
A.L. Fogli
This technique does not require canthopexy or
canthoplasty, except in cases where they are precisely
indicated. It does not constitute any treatment of
lagophthalmos or ectropion. The concept of this
technique is fundamentally different than that of
subperiosteal techniques that lift all the tissues to-
gether [3,10]. The logic of this technique is based on
the fact that the ptosis of the brow tail is cutaneous
(Fig. 8). This technique is guided by three aspects:
skin redraping, solid anchoring, and respect of hair.
In our hands, it appears to be more efficient than
the galeal plication as described by Hamas [2]. As we
perform a galeatomy, we always notice a spreading of
the two flaps, the relatively fixed caudal flap and the
cephalic flap, which can easily be brought up. A wide,
4-cm anchoring to a solid structure, such as the
temporal facia, will guarantee its persistence. More-
over, there is no backward displacement of the hair-
line, as mentioned by Hamas [2]. The scalp sustains a
true wave-like movement that will keep it in place
(Fig. 5B) as the subjacent tissues are brought up.
By using endoscopy [1,4,9,11], we were able to
avoid the long scar of the coronal lift, the temporal
branches of the facelift, and, most of all, excessive
scalp resections. The cleverest temporal lift will in-
evitably result in scars [10,11], even if there is no
alopecia. We prefer the 4-cm incision that allows us
to use the cold light, although we could manage
without it. It is a timesaving procedure and there is
no hair loss and no tension that could cause alopecia,
provided the galeatomy is done in front of the hair-
line. The different planes of dissection allow an an-
atomic approach and logical management of the
temporomalar ptosis, including the malar bags. The
few unsatisfactory results were observed, with an in-
adequate lift of the tail of the brow.
On the other hand, the improvement is spectacular
at the temporomalar region, where the fine tissues
will exhibit fine wrinkles, and also at the lower lid,
where one can resect with impunity a strip of wrin-
kled skin (Figs. 9 and 10). It is an excellent method to
prevent, and sometimes to correct, a round eye and
there is no need for peeling or laser resurfacing.
This technique can perfectly complement frontal
and facial lifts (Fig. 10). It prevents the illogical lift of
the facial skin toward the temporal region. The im-
proved draping guarantees more natural results. The
temporal region seems to be an entity of its own, re-
quiring a specific technique. This is why it can be used
alone in a younger patient (Fig. 8), with or without
periorbital aging, without significant nasolabial folds,
and without significant jowls. Of course, we do not feel
that subperiosteal dissection is indicated for a cuta-
neous improvement. Other techniques have precari-
ous anchoring or move the hairline too far backward.
165
Conclusions
This temporal lift technique that exploits galeapexy
can be used alone or in combination with extensive
lifts and will accomplish the following:
1. Management of cutaneous ptosis (the lowering of
the brow tail, temporal, malar, and inferior lid
wrinkling)
2. The solid anchoring that relies on the galea
3. Prevention of hair loss
4. Prevention of backward displacement of the
hairline
This technique can be performed under local an-
aesthesia. It is efficient, reproducible, and relatively
easy, with a low incidence of complications if metic-
ulously executed.
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