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    artigo anatomia da face

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    18 views13 pages

    Mid Forehead Brow Lift 2022

    Uploaded by

    ana clara scopel
    artigo anatomia da face

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 13
    Mid Forehead Brow Lift Patel BC, MalbotraR Continuing Education Activity Many medial conditions ely upon set numerical definitions to provides disgnosis: diabetes melita and hyperlipidemia, for example. In the ease oF bow plo, diagnosis it datrnedpredominanly by the judgment and experince ofthe examining physician. Brow plosis exists when inferior rnalposition ofthe brow interferes with aesthetics o uncon; therefore, the brow level deemed low inane person may be perfectly ascepable or normal” in another Wit the brow Being 2 mobile srueture and prone to the Secondary ees of age, solar elastoss, muscle ation, aura, end ravi, some degre of brow descent will eventually occur in everyone, dea brow poston is regarded ditferemy in diferent genders, races, age, and even generations. In some communities, the concep of changing the brows position or shape considered anthems: in many Western socotis, however, its considered routine. This atvity describes he pathophysiology of baw plsis its presentation, en the role of mi-oreheed brow it revere loss Objectives: “+ Desert the causes of bow ptosis “+ Review the indications for brow iting ‘+ Summarize the complications of the mid-forehead brow i procedure ‘+ Outline he importance of enhancing care coordination among interprossional eam members to improve outcomes fr patients who candergo midforhead row titi, Access fse mip choice questions on this tos Introduction Many medical conditions rely upon sit numerical definitions to provide a diggosis; diabetes melitus and hypelpidemia arc two examples Inthe ase of brow poss, diagnosis is determined prdominartly by the jugment and experience ofthe examining physician, Brow ptosis exists ‘when inferior malposion ofthe brow interferes wih esthetis ot faneton. The brow level deemed low in one person may be perfectly accepable or somal in anotber With he brow being a mobile structure and prone to the secondary ef of ae, solar clasoss, muscle ation, trauma, and gravity, some degree of brow descent wil ventally occur in everyone. Leal brow position i regarded ire in dillernt genders, races, ages and even generations In some communities, th concept of changing the brows position or shape i considered anathema a many Wester societies, however, iis considered routine. “Thecus caching describes the ideal female brow poison a above the level ofthe bony supraorit im, with an upward atch sch thatthe peak ofthe row ius betwoun the letra Hifbus andthe Tater ears. fn en, the eyebrows normaly sit at or just ove the suparir orbital si, with a ‘ane contour] Age cultural influences, occupations and environmental effets alia fueace not only bzow poston and shape but ls perceptions ‘of what is aesthetically pleasing. A weatht-worn farmer, for example, may have an infer positioned brow that provides some prteetin fiom light, dst, nd wind, On the other hand, a mode! may require higher brow position inorder to appetr more yout or atractve, regardless of igsader. Sole changes in brow shape are also nats of emotions stat: lw lteral eyebrows denote sadnes or conser, low medial brows indice anger, ator low brows may display aque, and excessively elevated brows spper surprised. Simi, temporal hoodng nd upper eyelid ermatoclass may indicate redness, but when combined with onal overatvation because ofthe heavy upper eels, the impression of Fatigue ‘smulpied. Finding the precise balance to pray happiness and vitality can be challenging I upper blepharoplasty and Bepharoposs repair take Place without adavessing ow ptosis, the brows wil appear lower ae surgery because the foals tone i diminished once the visual fields ae improved, thus so exacerbating a fatigued appearance. When bow pei is preset, it is rarely completely symmetrical, hecaus of mytid factors, including diferences beeen the right and lef sides ofthe face (Remifcial microsomiao ficial paralysis) differential exposure to the elements (anicularly for those who drive witha lowered window), the prefered side a patient may sleep on, and many others all affect brow poston, ‘Common Causes of Brow Ptots + Asing + Fasa palsy + Trauma + Tumors (Clinical Presentation + Cosmetic complains + Asymmetie brow positon ‘+ ation caused by secondary eyelash poss In the absence of wauma, paralysis, o disease, ow poss occurs slowly, and most patients wll not be aware ofthe now ptosis until tis ated during incl examination or rmarked upon by an acqusiiance, Almost everyone over the age of 40 year, male or female, wll have some degree ‘of brow poss, and most of thse patets will not require surgical conection. Surgical Treatment Options + irs row i} 1 Midforehead brow tit 1 Prtishil brow if{3] 4+ Temporal brow tit + Coronal brow it + Endoscopic brow lif) 4+ Intemal(ransbepharoplasty) brow lit ‘This antle reviews the assessment and planning of bow lifts, in genera, and indications and techniques for he mid-frehead i, in paieult Procedure History 5 Many sual procedures, such as cranial ephinain, nal reconsireton, and skin grafting, have been performed for hundred of ear, and some, ike eatract sugey, thousands of years, Surpssingly, bow Ht surgery as only reported in the 200 century when Lexer fist discussed and presented the forehead itn 1910, Subsequety, an etl coronal brow i was described by Hunt, who did not undersine any ofthe tau, ts limiting ess, Soseph in 1931, presented a detailed description ofthe preichil brow if aswell as incisions made lower on the Forehead to ‘augment the bow elevation. Many surgeons continued the practice of simple tissue eseston until Passot reported seestive neurotomy ofthe frontal ‘ranch ofthe ficial nerve in 1983, This method diminished forsbead wrinkles; however, the resting toe ofthe ental misc wa los, i this was clearly counerpodetive fr brow poss ar reasons not entre ler, surgeons continued lo explore the ea of forehead motor denervation, wards reported isolated temporal nearectomy a8 reenly as 1987. A more anatomical pprasch was advanced hy Bares thal same year when he describe a isc eyetnow lif. Through tis prose, he weakened the comugstor muscles and undermined the frehetd upto the bse while and bow lif wee ushered in by Pangman and Wal in 1961 Further refinement occured in 1962 when Gonzalez-Ulloa incorporated the forchead Tinos acelin procedure. csosshatching the fonalis muscle. Modern hain and coronal approaches tothe free Despite the inital enthusiasm fo coronal ling, repr in the 1960s and 1970s suggested that results of eoronalfrchead ifs were short-lived, which led to the procedure losing favor: It emained unecognizd thatthe results were bound tobe temporary without undermining afer excision of excess soft sue. Uni the ely 1970, mot surgical posodures consisted of resestin and repair without undermining or manipulating the forehead ‘muscles; the anatomy and physiology ofthe forehead had not yet ben adequately appreciated, A signiican vance occured inthe mid-1970s when several surgeons (Skoog, Vina, Hinder, Grits, Marin, and others) bogan to manipulate ‘the omalis muscle, usually by excising a strp to climate dynamic wansverse ines on the forehead, This technique aso allowed botrsucching of ‘the supericial issues. Watio was one ofthe fst cay ot eadaver studies when he noted in 1975 thatremoval ofa ransverse section ofthe ‘onais muscle reed in sigiicant elevation ofthe foreheg, More dramatic approaches by Teer, LeRowx, and Jones advosite the complete removal ofthe fons muscle, Not suprisingly, this aggressively destructive approach did nt endure, Inthe 1980s and 19%, the coronal brow lift bosamethe established method of row lifting: this was pay because f the advances made by Tessier and bis group inthe exposure ofthe skll via subperiosteal proaches. It ws std, not entizly i jest, hat the coronal brow lif, with ts associated. loss of ir and senston, nd he overly ight appearing frcheod und row was" surgical procedure designed hy men for ws on women" In the 1990s, endoscopic approaches to brow lite were developed] Af the evolution of fixation techniques, it became apparent tat a “brow lining brow shaping was a est as important, if aot moreso. Repositioning ofthe brows and forehead could be controlled with cas of the esosteum from the ltr canes tothe ater caus across he superior orbital ins andthe nasal bridge, combined with manipulation ofthe Aspressor and elevator males ofthe brows. Anatomical dts were said inorder to design safe approaches that could be performed using ‘minimal incision techniques. Understanding the sensory and motor imervation of he forehead and periorbital area allowed more accurate ‘manipulation and modiction ofthe ins. ot and permite les invasive utah moe effective techies, sucha the pretichil and temporal ow ‘After some debate about the longevity and effectiveness of endoscopic brow ifs compared to coronal brow lifts, thee are now two school: one schoo! sil args performs coronal brow ifs However, more and more surgeons are becoming experts al performing endoscopic brow lifts, When patents are chosen corel these endoscopic bow lifts provide reliable and lonlsting resus 7} Coronal raw lis, peti brow il, mide farehead brow ifs, direct brow lifts, nd tempol brow ifs ate now more often performed fr specific indications. The socalled internal brow i, sow UAL" No longer studios show effective brow ing, and the design ofthe procedure docs nt adress the complete arch ofthe brow or the oread ‘or tansblephaoplastybrowpery, shuld perhaps be called "supporting procedure” rather than a proper” Silat to many oes, the mid- forehead Lik procedure has specifi indications vantages, ad imitans. This approach is mos useful in males ‘with heavy bows, overactive fontalis muscles, 5d deep, transverse forehead wrinkles tht may hide a uric sear Development of Brow Piosit ‘Common reins encountered in plastic surgery are "Lam becoming my moter” and look like my dad" The patient is saying that family shractersties, bth psi! sractre and response aging, are becoming apparent. Everyone his an "aging clock," which sentially determined, but skin and deeper sues ae aio aected by environmental actors suchas smoking, exposure to lravilet light, heath, and diet, among others an help to examine photographs of he patients when they were younger and photographs of het paces to provie patients with some coment for ‘hese changes. Aging aects nearly every structure in the fice, and itis cevsaly the most common cause of Wow poss Patients ously exposed to the elements wil show marked overton ofthe corugatr, proces, apd rns muscles, especialy they have not protected their eyes rom sunlight and other harsh environmental factors. The “weatheed face" seen in sls and farmers show these changes well, ot just inthe egion ofthe orchead and the brows bu loin the lower face ad nck. These paints develop horizontal hydra the rot of he ose, caused by procers muscle contraction and marked comugstor Lins, which ae the vertical “umber eleventh eyebrow heads may also appear closer together because of hypertonicity ofthe cormgator muscles. n these cases, surgeons may make an effort to elevate ad separate the bow heads -an action that would often be avoided oserwise because ofthe operated appearance it can produce, When brow ptosis is moderate to severe, deep horizontal frebead ies may ao spear duc to frosts muscle overuse, Some pat velop specially in females, in a widened rot ofthe nose. These patients benefit igi ‘row titing. nts with notable label mail hypertvty may "at note sydome” caused bythe downwae slide ofthe process muscle andthe inward movernent ofthe comagaor muscles. Thi els, ly om dsrption of the procers and eormegator muscles ding may be helpfil to compare curren pictures ofthe patient with photographs taken when the patie! was younge a ates the degree to which the ‘wow postion and contour have changed. Sometimes paint ate suprised to se that ther rows have changed voy lil since ther eonage yess Regardless, while young patcats may lok active with brows in che high or alow position because many visuel cues exude yout, older patents ypcally look Better with somewhat higher brows ‘Besides she plabellar impact of aging, lateral row drop almost always progresses over me because of lack of suppor fom the fons muscle “The angle ofinseron botween the fonts and the obiculais cali muscles becomes more acute with age, hesby leading to furhe los of support Intealy this ess ia temporal booing, lash is temporal brow droop, nd cow's eet wrinkles. Cincal Presentation Prevention of brow poss ranges from cosmetic complains of fareead lines and secondary hevines, or hooding, ofthe upper eylids 'o unatraetive own lines and problems wih vision Cosmtic patients wil primarily focus on upper eyelid heavinets and falls other complains ray include “ooking tied, angry or unhappy” either fom the patient or fanity members and colleagues, Paints wil only rely complain ta heir ‘rows are heavy o droopy in the absence of ether concer and will usally ced to have brow malpostion droasatdto them ia the siox History _A thorough preoperative mssessment is vital, Past ilnesss, medications, allege, and any history of hypertrophic or keloid saving are noted, Specific emphasis pled upon any history of thyroid disease, diabetes, cattle smoking, anticoagulation use, prior eyelid or brow surgery, snd any tendency to develop unusual edems atiens with thyroid disease may have deeper ow lines and may sifer fom madaross (loss) of the bow ‘mrs. These paints lo tend develop prolonged edema afer facial surgery. Thyroid disease must be conlled and tbl, ideally for at least six months, pir to scheduling surgery. Examination of the Face Regarless ofthe nature ofthe chie complain i it pertains to ficial ging,» complet ficial examination is xia. Patints wil fen present with ‘vague concerns that relate othe sppesance of ing, fatigue, of poor mood; many wil atk, “what d you think? or what en you do form, Doctor? The ably to pinpoint specific problem areas adie eomrespondingsugial ages is eri counsling patients aller completing = ‘horough physical examination will be immensely informative for them and facia the development of rsisic goals and expectations, AS 2 general rule, he face shouldbe asessed for asymmetry betwee the left nd sight sides, hemifacial microsomia can have profound impact on sutical ‘ulcomes, and thea the proporons ofthe upp, mide and lower hed ofthe (ace shouldbe examined. Lastly, he skin color and quality of every potential cosmetic pation shouldbe evaluated a wel. Thi algorithmic aproach to facial apalyss wil ep prevent overlooking any major sionormaliis and focus the sugsons end patient atenson on the avilable treatment options, which may or may no relate dtetyt the cist comp or the patients ginal sel-percepton, Examination of ‘+ Assos the haine and forehead height relative to gender and ete noms. “Assos the densiy and distribution of ealp baie cently and txaporally ‘+ Measure the height ofthe forehead: the distance between the corneal reflex and the anterior hatine othe distance between the cena bow nd the enter bane + Measure brow poston: the brow en be measured relative to the superior abil rior measure from the lid magn othe brow or fom ‘he comeal reflex tothe brow cently a from te medi and ater! Kinbi to the mei and neal bow: Others we the mei and ater ati a reference points and eompare the lft and eight brow positions, 1+ Assess brow shape and symmetry “Assos eyebrow bai distribution: evidence of picking, lst, tong 1+ Assess eyebrow mobility. "+ Measure the degre of tue dermatochalasis, as opposed to secondary dematchalsis caused by brow ptosis - manually i the brow int the ested position odo tis + Assess the medial and ental superior bill fat pads and ny aerial pan prope + Asses the distuton and depth ofthe forehead and glabellar yids. 1+ Assess conrugtor and procers ne. 1 Assos row’ eet. + yalute for bephsroptoss ‘+ Ascoss sin thickness und quality, noting how sebaceous the plbelar skin appear + A basi lower eyelid assessment should be performed when considering brow or upper eyelid surgery. ‘When documenting Wow ptosis, one reproducible measurement isthe distance between the inferior Hinbus and he center of the brown most pation upon the many othe factors discussed above: age, gender, octupatio, and societal expectations among hes cal brow position s best determined this distance wil be mors than 22 mm, Alkhough 2 measurement oes than 22 mm suggests brow plosi, the Formal dngnois wil depend ‘om an individual basis by the surgeon ad paint aking into account the surgeon's experene, the patients erent ad previous yout appearance, and the specific aesthetic goal Measurement of Brow Pots Measuring with ale onan upright patient, the brow is elevated medially, cently, and lterally to asess the degre of brow poss. The difference ‘between the desired brow position and the relaxed brow postion indicates the degre of brow ptosis. Its critical fr patients to relax the fotalis muscle before taking measurements; this may be atcomplised by fist having the patent close ther eyes, then gently massaging the brow and forchead downed ito thee nataral positions. From thee, he plint can gel ape theres, aking eae not Lo engage the Fonais muscle, ‘Occasional, uit tenps ar equite, and even with this method, reliably reproducible results can be elusive. Measurements will fen reveal ‘row positon stymmety, and this shouldbe indicated tothe patient preoperatively using «minor to frestal postoperative suggestions that any asymmetry is iatogens Although discussions concentrate onthe brow and the brow height and contour, sgeons must not forget thatthe characteristics of the frend ae cqully important; the severity of glabella, corugatt, and fowls ines, aswell as skin quality should all be documented, The distance between the ‘brow and the anterior hasine shouldbe measured Because, in some putin, hain advancement may be deiable, which wil inform the choice of ‘brow tit approach Upper and lower eyelid assetment is important even for patents focused on brow lifting. The forehead, brow, and peril region ae contiguous, and procedures performed on the brow wil inevitably fest the upper eyelids, which wil, intr, in uence the appesrance ofthe Tower eyelids Wile sme procedures dirty involve both the upper and low lids, such a canthoplaey many cates, the revenaton ofthe brows ad upper «elds the absence of lower bleparopiaty wil leave the inferior peril are ooking more aged simply by cont Assessment ofthe uper eyelids may inchde the following “+ Comeal reflex id margin dance ‘+ Presence and postion ofthe upper eyelid spratasl skin crease ‘+ Amount oftaral platform show 1+ Degree of dermatocalasis: primary and secondary + Upper eyelid fat hemiation, medial an cen + Presence and depre of erinal land prominence + Upper eyelid skin quai: slar lasts, vertical wrinkles, visible Blood vessels, ete + Bells phenomenon 1+ Blink completeness Assessment ofthe lower eyelids may include the following + Metal cams: postion, last, dystopia scarring, webbing + Lateral cath: position, dyson, lacy, scarring, webbing + Lower eyelid dsvaction test. + Lower ejlidsnapback test “Inferior scleral show ‘+The prominence of medial, ema, and lteral fat pads ‘+ Nasojugal and malar groove depth + Malar angle + Tear il interity and tear breakup time + Comeat sensation and heath ‘+ Herel measurement ofthe globe to assess fr proposs or enopthalmos Anatomy and Physiology Surface Anatomy Surgery ofthe bows demands thorough understanding of surface anatomy, brow position, and brow conto Although theres vasiaton in ‘row potiton and shape among diferent etbicitis, the over diference between males and females apply to most situation 9] Generally, male ‘owe ae fat, while female brows ate moe arched The frale bow arch eats highest between thelr Himbus and thelr cans. ‘oth genders, the medal brow ideally sis about 1 cm cbove the superior exit rim. Over ime, it descends moe ia men Sealp and Forehead he five layers ofthe selp ae: a fascia, which i adherent othe undersurface of the skin + Gales sponeuroties, whichis contiguous with he fascia ofthe oesptlit and fomais mascles + Arcola sue, which butwoon the priostum and the musclelgalea layer and contains emissary vei and sal arteries + Perioseum Masten “The eyshroweforchead complex i composed ofthe followsng major muscles all innervate hy the facial nerve: Gcciptofontais|10} ceiptofrontalis i composed of ewo poster bellies, the ociptali, and tw anterior belie, te fonais. The gale aponeuatica a praia sponcurosis comets hese muscles. The superior nuchal ine the octal bone gives origin to the ocepital muscle belie. The frntals muscle i sachet the skin and fascia ofthe eyebrows, passing through the esbiclais ocali muscle anteriorly, posteily, it ecomes the galea aponewotca ‘and thon joins with the occipital. The bled supply tthe oosptalis comes fom the ocital artery, branch ofthe extra carotid ator. The supraotbital and supratroclear arteries, branches ofthe internal caro vio the opti artery, supply the frontals. The frontal muscle insets into the eyebrow and ako intedigitates wat the comagatorwupersii males, Orbicaaris Ocal (21) ‘The otbicuaisocli muscle is composed of bit! and palpebral porns, withthe palpebral postion Fare divided ino preseptal and ptr segments. The presepal muscle frms the lateral plpeval raph ltrally, andthe petarsal muscle Sibers unit laterally atthe lateral cath tenon, “The ombicuaris oul isa constrictor, casing closure ofthe eyelids, but it aso draws in she brows, the lower part of the Forehead, andthe temple ‘regons, mostly vats orbital component The bit obiclaris au the only depressor ofthe brow; and sometimes portion oft is ken a he "depressor supers” Ijetions of botulinum toxin into thes ater obi orbiculars bers can pradce a "chemi brow fil" but hi technique rms be pecformed very carefully de othe risk of bepharoptonit the toxin contacts the levator palpbrae superiors. ‘orrugator Super 12) “Thos are responsible for producing the vertical iowa ines, the “number eleven” These muscles originate from the frontal bone a the superomedil ‘orbital vim (nasal process and inser laterally into the medial and cer chi ofthe brow, nterdigitsng withthe fronts muscle. Te aera extent, ofthe corgator mses varies among indivi patients, Sometimes, extends all the way to the lateral hid ofthe brow bat is fen mich shorter snd may only reach hlfay, Assessment of eomrgalor aeons important when reatng paints wih botlinum toxin fr cosmetic reasons or when planning surtcal myomectomy a ae of a Brow Hi Procerus Muscle ‘This muscle arses from the masal bones and merges into the inferior ar ofthe fontais muscle, which ies dept it. The procers pulls down the ‘medial eyebrows, resulting in horizons nasal root wrinkles. Overtime, te resulting crease can become quite deep asthe cent fronalis muscle descends; only by ting he fontais deste hriztl groove improve. Tiss the ft nose syndrome” caused by a combination of meal movement ofthe brows becuse ofthe eormgatr super, inferior movement eased bythe proces, anda vertical descent ofthe fonais muscle, resulting in widening ofthe sof sssues atthe nasal rt, ‘The Retro-Orbicularis Ocul Ft Pad (ROOF) Deep tothe interdigaton ofthe orbiculars oul andthe fons scles, there ea ibrofty layer of tsue which has Bea called the "brow ft ad” or the reto-sbiculais oul ft (ROOF) pad. Tis fibrofaty layer was described in 1909 by M. Charpy, although he mistook ito bea lateral ft pocket in some countries, its refered to as "Charpy at pa” Is distinct rom te preaponeurtc ft, which lies behind te orbital septum, while he ROOF sis onthe periosteum ofthe ori im and anal bone, in front ofthe abil septum, and allows the brow to lie wp and down esl. In some cates atthe mei bow the at extends frtherinfronly below the abil rm and into the eel vena fara the inferior septal atachment tothe levator aponeursi. This ft provide the youthful fuss of the brow sen before the aging proces gins and skeletonizes the now as the fat stro. In general, resocion of his fat shouldbe avoided o prevent lng-trm cosmic isstisfaction, Motor Nerves Facial Nerve 13] ‘The motor innervation tothe forehead, ow and perocuar muscles comes ftom the facil neve, which exits the skal via the tylomastoi frames, coer the deep posterior spot of the part gland and then raves within the gland, superficial to the reromandibulr vein and external arti anery Its spcally divided int ive terminal branches frontal or emporl zygomatic, buccal, marginal manbulr, and ceric Frontal Branch ofthe Facial Nerve ‘Tis nerve is the mos superior brane; exits the superior art ofthe parotid land and supplies the anterior and superior ureular muses, the ‘tomas muse, the obicalais oul muscle, and the corugaorsupercili muscle. + "The courve ofthe frontal branch is approximated by Ptanguy's line, which tant 0.5 em below the tag and extends to point 1S em stove the lateral brow and 2 em lateral tthe lateral orbital rin] “+ ‘The nerve travels inthe musculogponeurtic layer, and superior to the zygoma, trans ou the undersurface ofthe temporoprital faci, ‘+ The anterior branch ofthe spericial temporal artery and vein are lateral tothe otal branch + Although portrayed as single nev, the neve divides into several branches ove the zygomatic ach 1+ Most ofthe nerves branches wil eros he zygomatic ach roughly 1/3 ofthe way from the auricle tothe lateral orbital rim, but he Aistbuton along he zygomatic arch an be broad and varied (5} 16) ‘+The medial comugatr and poceros muscles are innervated by the zygomatic and buccal branches ofthe facil neve, which loop meal nd superiorly. They also supply the medial canta repom of the medal upper and lower id 17) Sensory Nerves ‘The tine primary sensory nerves ofthe forehead and lzow ae the supraobital ere, the supratochlear neve, an the ifatoeear neve “The supraorital nerve ithe anges and ost aera branch ofthe frontal neve, which ie tself he largest branch of the ophthalmic nerve (V1). The supaotital neve ext the obit iter through a notch onthe superior fit im or ough a foramen jst above therm, deep to the coragator supe muscle, The neve then divides into a medal (superticial)branc, which passes over the ftomalis muscle and provides sensation tothe forehead skin and the anterior 3.5 em ofthe scalp. A doep (aera) branch runs between the guleaaponcurtica andthe peistcum towards the coronal suture It supplies sensation to he upper eyelid, the forehead andthe scalp afar ashe laiboidal suture. This lateral division is cormmonly injredinaoperatvely, resulting in paresthesia and scalp numbness ‘+A recent tuy on Sei Lankan sls found that 73.8 18) of suproobital nerves exited trough a notch, withthe rest passing through a foramen. ‘© 36.3% had a notch on ne side and foramen on he aher side, ‘© $5.1%had bilateral supraorbital notches. eal supraobial foramina ‘+ Accessory branches ofthe supraorital nerve may be preset in up 2 20% of eas, sully exiting the sl tra to the aot or foramen. ‘+The supraorbial nerve notch or foramen i fypically encountered approximately 4 mm from the midine, approximately 8 mm medial to ‘he temporal crest ofthe frontal bone, and approximately 29 mm fom the fontozygomati ure, + When foramen ie presse itis located approximately 2mm above the supraocital margin a males sod approximatcly 3 mm in females + In 80% oF eases, the suport foramen oe notch few millimeters medial tothe infant foramen, contrary tothe pope hat both Hein he same sgital plane. “The supratochlee nerve may en through foramen, although it offen exits through notch or depression athe bons The nerve exis tral othe corugitor supers masses bony origin. Itthen enters the murcle and divides into thre four branches. Aer penetrating the frontal muse, the nerves run vertically p the sal. The supearchlea nerve supplies sensation to Vere sep roughly I cm wide inthe cena frehesd, “The infatochleat nerve ia branch ofthe nascar nerve, whic ie a branch ofthe optim division ofthe trigeminal nev, Tis nerve rane slong the upper border ofthe mei reas mss and wl fen anasomose with the supratochleae neve, Several ranches ofthe infarochlear nerve ave othe medal cantas ofthe ey, supplying sensation to the mel upper and lowe evel skin the side ofthe nose, the conjunctiva, the lacimal sa, and the carole ‘The suprotitl nerve i typically losted 27 em rom the midline and the supratochlar nerve 1.7 em. Thee is, however, notable variably in these measurements among indivi Fascia “The temporoparctal faci is an extension ofthe superficial auscul sponeuroi system (SMAS), which extends across the zygomatic arch an, together withthe ls, he Sonali, and he oosptlie forme continuous fsil plane in the face. The tmmporoperisal asia also known ae he ssperfcal temporal ici, The frontal branch ofthe facia ere ies deep within or onthe dep surfice ofthe trporoparieta fascia, ‘The deep temporal fhscia has superticial and deep subdivisions. Te superticialtemporl fs cpaated fom the dcp temporal fascia by lease areolar tissu, which allows easy dssecton when pecfoming a temporal dissection. This plane lo called the subsponeuroic plane, is avascular and ows quick, bant separation ‘The deep temporal sci, or empoals muscle fascia, ie thick and overlies the temporal muscle before spliting ino two layers. Below the level of ‘the superior abit rm, the deep temporal fascia splits ito a superficial anda deep par, separated by Vasari fat pad alo known a the roperfcial temporal ft pu (or intermediate temporal ft pa, depending on prefered nomenclature, which exends fom dowa tothe zygomatic arch “The buccal fa pad and the deep temporal fs pad overlying the inferior pat of the emporalis muscle and tendon ae continuous under the zygomatic ach Indications Brow lings ep for tients wit siniicant brow ptosis, which an cme visual fed constriction and secondary dematochalss fn some patents, the brow droop may be mite othe til ofthe brow; resulting in temporal hoong an eyelash poss, Cosmatialy, brows ate powerfl indicators of mood, ad some pains will benefit fom changing the shape nd curve ofthe brow to make he face look les ted ary 88 oF ‘uizziea, Paints with facial ploy may have denser bow pls, which abo itrfres with Vision, Finally, some patients have undergone upp id surgery wit ptosis epi or blepharoplasty but sill ave underlying bow plosi, which may be exposed or exacerbated bythe iting ofthe eyes Wile mid- forehead brow iting ot commonly performed, deep forehea lines commonly encountered in men ae particu att forthe placement of incisions comparatively closet the brows, which inctenses the mechanical advantage ofthe midoehead brow li compared to endoscopic or coronal approaches In some patients, the fonal hain ca be lowered aprosaby using a midSorshead incision and appropite ‘ck levaton. Adina, patients with high hatines or baldness may nt be good candies for coronal prtichil,or endoscopic brow is ‘cate ofthe ensuing scars in hes case, pains may prefer a sarin a forhead crease to scars above the brows from dct bow iting. Mery ‘tens, particularly men, may not be bothered by the iden ofa rasverse forchead sca, provided i i welhden, bt ica be challenging to avoid track marks from sutures or widening ofthe sar postoperatively, Having a plan for postoperative skin resurfacing und Sear management may provide the patient some assurance preoperatively. Contraindications Mid-orebead brow lifts are cried out via incisions located in the center f the forchead, ven with the best closure, some degse of visible searing is inevitable; patients who will not be able o tolerate this shouldbe provided alterative options, Absolute Conran ‘+ Lack of frcheod furrows: in these cass, even mil scars will be apport ‘+ Absolutely resale havea wsble sear on the forehead Relative Contraindications + Low antesir biting “+ Female gendr: threat usually beter ways to adress the fochsad andthe brow position, such as endoscopic or pretichil approaches “+ Young age in male patients, due o lack of ransvere forehead hides oe ily of aksratve approaches thas ikely to susooed with reded + Facial poralysis: signitiantasyrmmetry in brow postion may be beter addressed wth det brow ling or suture suspension techniques duc 1o the mechaniesl advange they offer by poling direc onthe brow Equipment Equipment required for mid-forehead bow ling may inlude the following + skin marker + Local anesthetic, sch 8 1% ioesine wih 190,00 epinephrine + Bard-Parkor i seal handle and #15 blade + Tissue forceps, such as Adson-Brows “+ Skin nooks, sucha Joseph or Senn rakes + Dissecting scisors, uch as Kaye blepharoplasty scissors 1+ Suture sisson, such as irs seissors + Needle holder, such as Haley andlor Casroviejo + lecrocatry ther monopolar or bipolar + Absorbableand nonabsorbable suture in $0 and 6-0 sizes Personnel “The mid-forehead brow lit can be performed under either lea or genet] anesthesia, with general anesthesia more commonly used when addons] procedures, such a fou id lephaoplsty, lative LASER resurfacing or vytdectomy, is undertaken concurrently I addition ta surgeon, a nurse nua sugicaltchuologist ae necessary. In the operating room, an anesthesia provider and a surgical fst assistant are usually evable swell Preparation When performing brow lifting of any king, tis ruil obtain a detailed history, ncoding determining the duration ofthe problem and wht exactly bother the patient, esis the clinical examination, the srgsam should et a sens ofthe patient's paychlogil sss o avoid pasiens who are likely to become deprested, combat proposed surgery, addressing the atcipated outcomes and potential eompliaios or angresively dissatisfied postoperatively The surgeon and patent should have a detailed disussion ofthe Patient Consltation ‘When assessing bows for height and shape, te patient shouldbe siting upright. Ifa patient kes how their brows, forehead, and eysids used to look, it ean be informative forthe surgeon o view photograph of the patient at that gs. However, care mast alwys be taken when viewing photographs with patients or when using photograph manipulation software because doing so may led to unreasonable expectations despite appropeae ‘preoperative counseling, Duin the consulaton i mporant fo the sugeon nolo impos thet own aeahei emibilies upon the patent bu rather provide uidance based upon experience, While the patie is holding ¢ mito, the surgoon should ithe bow medially ental and laterally to determine the est poston and atch, Dong his can alo tse how scondary dermatochalasis of the upp eyelid ie reduced and how crow's ‘oot wrinkles ar improved. Doing this also Bes the surgeon extitate how mich upper eyelid surgery may ned o be performed alongwith he brow wi, is important to discuss suc incisions, edvanages, disadvantages, limitations, and likely searing expected with diferent approaches othe ‘operation, efore-and-afer photographs of previous patients re uf in showing brow lit candidates he srt of results that are achievable and also to encourage thers o ask questions based upon what they soe. Photographs af cars should be shown to prospective patents as wel, Standardizod photographs shouldbe taken for properave planing, intraoperative decision-making and ostoperstive counseling, The laters parila wef ithe event that the patient notices an imperfection ater surgery - ue to increased vigilance in the itor -and the surgeon eed fo assure the patent that he problem was preexisting and nota result of surgery: Informed consent for a midforchead brow shou nce the folowing pins ‘+The brow height and contour wil nt be absolutely symmstriel, xno person has perl symmetrical brows ‘+ Over the it few weoks, it is normal forthe brow to sete, and sherefore, the ntl bro height wil not be the final brow positon, ‘+ The aim isto create a natural-looking brow height and shape. + Some degree of numbness always occurs, and in the majority of patie, it desreases over weeks but sometimes takes mont + The brows wil oop spain with age and with ine “+ The most significant rik s the isk of dissatstaction with the esl, bt oer sks include pain, bleding, nunbacs, casting, inti, snd ned for further surgery. Cini photographs ae obtained fom the following viewpoints: + Full ce, onal + Pull ace, 45 degrees right Full ce, 48 degrees lett 4+ Full hes, 90 degrees ight 1+ Full fice, 90 degrees Tet ‘+ Closeup of bth eyes, forehead, brows, and upper and lower lid at sina angles For standaniaton purposes, patients should be siting uptight, with the head oriented inthe Frankfort horizontal plane Preoperative Preparation Forehead surgery, in general, and mi-forchead surgery, paricular, wil cause impressive bruising, Therefore, aspirin and aspirn-ontining procs and non-steroidal an-nflammatory medications are stopped one wesk before surgery, including most vitamins and herbal supplements, Arnica montana, however, ty help mitigate the ecchymosis Patents mut remove all makeup the night before and come in without fale eyelashes. The kins cleansed by the patient the night before and again, the morning of surgery to ensure the removal fall makeup produ, Scheduling at east wo consultations before surgery allows the patient slice time to expres desires and concems. Funhermore, and just 2s important allow the srgsom ost to know the patient wel, Cerin patents ae not sitet surge interventon and this may become paren during subsequent isis While oth she patent andthe surgeon must agree to proceed with an operation, ether party may decide 0 abort the pln tay tine before induction of anesthesia, Technique Please se the atached composi ilestation fran explanation of he following tecaigoe. Skin Markings ‘+ Based upon the degree of asymmetry ofthe brows andthe configuration of the forehead furrows, the decision is made whether to uses ovizonta incsion across she entre foehsad orto make separate incisions foreach side Inthe later ease, the ncsions ae placed in iret eytdes on each side. Whenever an incision snot made al the way across tbe forebead, offset the incisions to avoid a visually obvious, Anesthe + Suprotitl and sapravochlear nerve blocks ate administered using 2% lidocaine and epinepivine mined wth sodium bicarbonate (90 1, sespesively. “+ Further injections are administered along the ines ofthe incision and also unde the brow, and inthe labellar epi, The iniaochlear ere is blocked, Adequate vasoconstiston occur in 100 1S minutes, and coo compresses are applied a this stage and continued ‘hroughout the procedure to minimize echymesis and edema ‘+ The local anesthetic injections ae administered before the preparation ad draping of the patient, allowing ime for anesthesia and Incisions ‘+ ANo. 1S blades used:o make skin incsion down tothe gales aponeustia, ‘+ Incsions cared laterally to the temporal ine of fasion must be skin dep only. Dissection +The plane of dissection is subeutanous, similar a direct brow li andthe galealtontalis muscle ot violated, Elevating the inferior fap wth rakes and performing combination of sharp dissection and blunt separation with seisor i the mot common approach, + Ther ita loot sbeutanenus aponeuotic layer; dttction is performed in this ayer all he way tthe superie abil rms. ‘+ The conrugatar and procerus muscles ate accessed by incising the gale horizontally about 3 em above the nasal rot and caving the issction deeply. Cares taken not 0 ijure the supraobital nerves lateral “+The degros to which the sorrugitor an procsrus muscles eed tobe weaken is based on preoperative assesment, In some pins, paral removal ofthe muscles with clamping and cauterization i perfommed In otbers,srgcons am for minimal weakening For more agrssive ‘weakening, the mises canbe disiserted fom their bay origins wile protecting the neurovascular bundles + Some surgeons ante fa from the eyelid or elbewhere i the fice tothe azea where the procera and corgatr muses are removed for ‘yo reasons: (1) il any hollows that may form and (2) fil he preoperative glabellar hides. “+ ecause the orbital rbiclais ocala depressor ofthe brow, in some patents, sugcons weaken the depressor supecili muscle ‘+ The forehead shove she incision is undermined for approximately I em to felt tensiontee closure and wound edge everson. Should ‘he aitine require advancement, additional undermining wil be necessary. Deep forehead sbytides equtepatial-shickness horizontal incisions of he fonalis mscle for effective rewvenaton. + The skin inferior tthe ncn it erctd superiorly until the rows ut past it del poston andthe redundant skins wxcseds some degre of overcarreton i equred a account for erly seing ofthe brow, though na enough to create a suprising appearance. The subdermal layers thon closed with 4-0 poydoxanane sus “+ Some surgeons run horizontal and vera mates sutures fom the point ofthe incision tthe obi porn of the obiculrsoeul, ‘which provides honalis tightening an support and reduces the tension placed on the skin closure. This approach is especially effective in smaes with significant ptosis ofthe brows ‘+The dermis sutured wit 5.0 polyioxanone, and skin closures achieved witha 6-0 polypropylene sure + Steitrps and sft pare applied An ational resi desing can help minimize bring and swelling, but ate shouldbe taken to censure that its either oo ight nor ha it applies downward tension onthe rows, Postoperative “The dressing is removed the day ater suger, and wound closure strips and sutures are emoved afer seven days. More wound closure sips or skin le can be placed if needed Overcorection of the brows tobe expected forthe fist ew wecks The forehead andthe brows always Ste by at least 25%, However, since the incision i closer othe brow than wih the coronal or endoscopic brow lis early brow descent after surgery is es raat with mid-forehend ifing, Surgeons sould obain clinical photographs two months and six months after surgery and observe patents for upto ayer Complications Hematoma Like the rest ofthe fae, the forehead hasan excellent blood supply, which conabuts to apd healing nd low rates of infection. The corollary is hat id-freheed brow ling ends o be relatively bloody. Meticulous hema is rua during an afte the dissection. Aematoms encountered postoperatively roquies immediate drainage because of te risk of skin lap necrosis an seching of the freee skin, whic can negate the effect ofthe brow i Facial Nerve Injury “The Sonal branch ofthe facial nerve is at isk ifthe lateral end ofthe incision is extended and cried deeper than he skin {19} Local edema and tension can pve rs to paresis, which wil ecovee Electocautery should also be applied very sparingly fatal, inthe area ofthe nerve; hemostasis ‘with pressure andr a thrombin produc is preferable, Sensory Nerve Injury ‘+ Hypesthesiaparestesas most pt is sully recovers ina ns experience temporary bypsthesie because ofthe rising ofthe skin fap: ew weeks, the sepactital andor supratrchler nerves ae inured, long-erm or peminent numbness can ers, + Neuralyis: injury tothe supraobial nerves can eause neuralgia in ae eases Incision Prarits “Theis common forthe at one o two weeks afer surgery. Unsighaly Sear not “The Gna appearance ofthe orcad sea | even when the incision it eloted with tention lo everson and minimiza very iil to pred tension, Paints wth sig most woublesome outcome. Shin esrfacig o he uc of silicone gel can improve the appetance ofthe postoperative ser substantially, some rant un damage ar darker skin are likely to sue bypo- or ypespigmentation, but a widening of te eri typically the surgeons will addess Scars with aggressive prophylaxis; however, planning lasr resurfacing as Soon asthe sutures are removed and insisting hat atons avoid sunlight exposure fran entire year afer surgery. Numerous later optons are avilable E¥AG and CO? for reefing, PDL and [Nd:YAG for telangiectasia, and Eres for depressed sas Brow Asymmetry Brows are, by thei very nate alt ays Somewhat aaymmetie, Postoperative asymmetry should ideally ot be more than that seen preoperatively, Most bystanders will nat notice a baw asymmetry of es than 3m [20] Abnormal Soft Tissue Contours Contour deformities ee not sncommon ater receton of the eomrgutor and poceres muscles, Conservative myomestomy rater than the exis ‘of tne muscles leads to fewer contour deformities at grafting t fill any volume deficits atthe conclusion of surgery can be very bell for inmpeoving patient saisfaton Lagophttalmos Brow lif are on combined with uper eyelid surgery. Temporary lagophhslsis very common but should only las frs few days. Patients noted to have xerophthalmi,lgophthalmos, ra poor Bells phenomenon properatively may require a more conservative surgery or staging Between a ‘brow lit and upper blepharoplasty. n most cases, the brow it should be performed frst so that she surgeon can asess how much dermatochalsis ‘remains before excising the uppe eyelid skin. While some surgeons do succesfully perform the blepharoplasty before tbe brow li heres the ise that an aresive brow Kt performed afer the Blepharoplasty wil rvult in sipnificantlaophtiakmos Clinical Significance Mid-orebead brow hits were more popular before smal inion procedure, and endoscope procedures were developed and bey ave Become today's gold standard. However, there are specifi patents fr whotn the mid-forehead brow lif iea: typically men with thinning or abtent hae, sep forehead sties, and sparse eyelzow hat. When patient are chosen wih ca, the outcomes ar satsyng and cosmetically very accepabe “The main advantage ofthe mid-orcead brow li greater mechanical advantage than with coronal and endoscopic lis duc to he proximity ofthe

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