5 Mini Open Brow Lift
The Transfollicular Subcutaneous Approach
Numerous techniques have been described to treat the aging brow and forehead.1–22 Chapter 6 on endoscopic brow and forehead lift (EBFL) will make it apparent how advanced technology provided a new procedure that has become very popular and probably represents the most common contemporary brow lift technique. Despite its popularity, there remain surgeons who do not favor EBFL. Some may be intimidated by the equipment and learning curve and prefer the same coronal brow lift they learned decades ago. Other surgeons don’t like EBFL because they simply aren’t proficient at it. They have the training, they have the instrumentation, they do the procedure, but the results or longevity are lacking; this is actually a common scenario. I have personally met competent surgeons all over the world who have given up their scope and switched back to a blade. “Endoscopic brow lift does not work” is a statement frequently heard at meetings and conferences, yet there are thousands of surgeons who attest that it does!
Who is right and who is wrong? I certainly believe EBFL works and still do the procedure, although I have had cases that relapsed more frequently with this technique. I also have patients who for various reasons are not suitable candidates for EBFL, and I need another option: Enter the transfollicular subcutaneous brow and forehead lift (TFSBFL), also referred to as the trichophytic approach. This chapter will discuss TFSBFL as an alternative to other brow lift techniques, including EBFL.
Terminology plays an important role in understanding (or misunderstanding) surgical procedures, so we will discuss it first. Incisions made in front of hair follicles are termed trichophylic (hair loving) because the follicles are not disturbed. Incisions that transect intact hair follicles (transfollicular) have been termed trichophytic,20,22–26 tricho meaning “hair” and phytic either from the Greek phynai, “to be born,” or phyein, “to produce.” Ask different surgeons the meaning of trichophylic and trichophytic, and you are likely to get a variety of answers. I prefer to use the term transfollicular to describe the incision used with the mini open brow lift.
Open brow techniques have been around for decades and were in fact the first brow lift techniques performed. The coronal brow lift is the granddaddy of all techniques but has fallen out of popularity owing to notable drawbacks such as hair loss, nerve damage, raising the hairline, and the sheer aggressiveness of the procedure. There are indications in which an open technique is desirable, and TFSBFL serves as an acceptable alternative to older coronal approaches.
When discussing the pluses and minuses of various brow lift procedures, TFSBFL comes up a winner in many categories (Table 5-1). It is the only commonly used brow and forehead lift procedure that does not elevate the anterior hairline—very important, especially in females. For patients with a low hairline, virtually any brow lift procedure is acceptable; a nominal hairline elevation is not critical. For patients with higher hairlines (longer foreheads), no extra increase in the anterior hairline is acceptable, so these patients are optimum candidates for TFSBFL (Figure 5-1). In fact, it can lower the hairline if the superior scalp is freed.
|Subcutaneous Mini Open Brow and Forehead Lift||Endoscopic Brow and Forehead Lift|
|No specialized instrumentation required||Significant specialized instrumentation required|
|Minor to moderate learning curve||Significant learning curve|
|Simple subcutaneous dissection||Requires extensive dissection of multiple tissue planes|
|No concern of frontal nerve injury||Frontal nerve injury more problematic|
|Direct-vision technique||Closed technique|
|Does not raise the hairline||Raises the hairline|
|Excellent improvement of forehead rhytids||Less dramatic improvement of forehead rhytids|
|Very low tension on brow suspension||Often extreme tension to fixate brow|
|Control of brow suspension over entire brow||Less precise control of brow suspension|
|Subcutaneous dissection, less edema, faster recovery||Subperiosteal dissection, extends recovery|
|Direct access to brow depressors||Indirect access to brow depressors|
|No need for osseous fixation||Usually requires osseous fixation|
|No need for overcorrection||Frequently overcorrected|
|Predictable longevity||Longevity varies among surgeons|
A high hairline is not the only reason to use TFSBFL. Another huge advantage is that it is a direct-vision procedure and allows direct vision from scalpel to suture. No complex instrumentation and digital equipment are required, making it simpler. The learning curve is less complex than EBFL, and it is very attuned to facelift surgery, which most cosmetic facial surgeons are familiar with. The TFSBFL is a skin-excision technique and is simply a facelift for the forehead and brow. Subcutaneous dissection, flap development, skin excision, and resuturing techniques are virtually identical to rhytidectomy. Being a subcutaneous procedure, there is less edema and ecchymosis compared to other brow lift techniques. Since this is a skin-excision technique, stability is excellent, and the result is immediately evident. As the skin is excised all across the horizontal width of the brow and the area resutured, the suspension is dispersed across the entire brow hairline (Figure 5-2, A). This is in extreme opposition to the EBFL, which only has several fixation points that are suspended with extreme tension in selected regions (see Figure 5-2, B).
FIGURE 5-2 A, Typical incision length of the transfollicular subcutaneous brow and forehead lift. B, Typical length of endoscopic brow lift incisions. In actuality, the TFSBFL has a shorter incision than the sum of the multiple endoscopic incisions.
An additional advantage is that TFSBFL, being a subcutaneous technique, will have an impressive effect on the effacement of horizontal forehead rhytids. This is possible because the skin is dissected from the underlying frontalis muscle and then tightened, which significantly improves horizontal wrinkles. Subperiosteal brow lifts are not nearly as effective at improving horizontal forehead wrinkles, because they cannot effectively be addressed from the subperiosteal plane. Direct access to the brow depressors is another advantage when compared to endoscopic access; the treatment of these muscles is easier under direct vision. There is no need for osseous fixation with the TFSBFL, which is an advantage for both the surgeon and the patient as many patients are adverse to having holes drilled in their skull. Finally, there is no need for overcorrection with the subcutaneous skin-excision technique and virtually no chance for frontal nerve injury.
There are few disadvantages to the TFSBFL technique. One relative disadvantage is that it is not reversible insofar as it is a skin-excision technique. An endoscopic brow and forehead lift that was overcorrected could be reversed in the first several weeks by removing the fixation and redissecting the pockets. There is no easy means of reversing TFSBFL after the skin has been removed. Another relative disadvantage is the public or collegial perception that open brow lifts are excessive or antiquated. This thinking is mostly a result of opinions concerning older coronal brow lifts. Endoscopic proponents claim that EBFL is a minimally invasive procedure. This is simply not true. Only the actual incisions are less invasive. In reality, EBFL is the most aggressive brow lift technique, traversing numerous tissue planes and necessitating cranial fixation. Comparatively, TFSBFL is a very conservative procedure. There is the stigma of a visible incision for several weeks, but when this procedure is performed correctly, the incision is rarely a concern. Multiple authors have described various subcutaneous approaches for brow and forehead lifting.10–14
The diagnosis for TFSBFL is the same as for endoscopic techniques. Once it is determined that a patient needs or wants a brow lift, a decision is made as to what technique to employ. When deciding which technique to use, I consider several factors. First and foremost is the position of the patient’s hairline. If the patient already has a naturally high hairline with a long forehead, I do TFSBFL by default; I have yet to meet a patient with a high hairline and long forehead who desires additional hairline elevation. Another scenario is a patient with a significantly rounded frontal bone or frontal bossing. Exaggerated curvature makes an endoscopic technique more difficult because the surgeon is “working over a ledge,” and the straight scope is tangential to the rounded frontal bone. Some patients will request TFSBFL when they find out that the endoscopic technique will require drilling into the skull.
Anticipated use of laser skin resurfacing also factors into which approach to choose. If aggressive, high-fluence, multipass carbon dioxide (CO2) laser resurfacing is contemplated, the endoscopic approach is favored; the thicker flap can tolerate aggressive laser without the risk of flap devitalization. On the contrary, TFSBFL is dependent upon a thin subcutaneous flap that can only be lightly lasered to maintain viability.
The patient is marked preoperatively in the holding area. The area of maximum brow elevation is decided with the patient looking in the mirror. This area generally corresponds to the lateral pupillary limbus but is personal preference (Figure 5-3). The proposed incision can also be marked preoperatively, which can assist the novice surgeon, but in reality it is just as easy to perform this in surgery. Although it is commonly discussed as the junction of the medial and lateral brow being the area of maximum elevation, I personally feel that this varies on every patient and I always seek input from the patient when deciding how and where to elevate the brows. In addition, the medial brow should not be over elevated as this leads to the unnatural or overdone appearance in patients.
FIGURE 5-3 The surgeon and patient decide the area of maximum brow elevation (A), which frequently corresponds to the lateral limbus of the pupil. This area is marked with an arrow for intraoperative reference. The irregular incision can also be marked about 5 mm into the hairline and extends in younger patients to just past the desired area of maximum elevation (B).
The instrumentation for TFSBFL is extremely simple and similar to facelift surgery. I prefer round scalpel handles, #11 scalpel blades, pickups, comb, marking pen, suction, retractors (lighted are preferable), a radiowave or electrosurgical unit, and 4-0 gut, 5-0 gut, and 6-0 nylon sutures. The TFSBFL can easily be performed with local or tumescent anesthesia, but I most often use intravenous (IV) sedation because I am usually performing numerous other procedures simultaneously.
As outlined in Chapter 6, Brow and Forehead Lifting, I perform simultaneous blepharoplasty on 99% of my brow patients (Figure 5-4). I do, however, temper the amount of skin removal and the incision outline of the upper blepharoplasty when performing concomitant brow lift, regardless of approach (Figures 5-5 and 5-6).
FIGURE 5-4 Image illustrates the relative importance of simultaneous blepharoplasty with browlift procedures. This patient underwent transfollicular subcutaneous brow and forehead lift as evidenced by her elevated brows in the postoperative image (B). Even with the elevated brows, she has redundant eyelid skin that could have been corrected with simultaneous blepharoplasty. She later opted for his procedure.
FIGURE 5-5 In conventional blepharoplasty, 20 mm of upper lid skin is left intact, and skin in excess of that can be removed (blue outline). When performing simultaneous brow lift, about one third of the normal amount of skin is removed so as not to cause lagophthalmos (red outline).
FIGURE 5-6 A, When performing conventional blepharoplasty, a lateral sweep of the incision is usually performed to address lateral hooding. B, When performing blepharoplasty with brow lift, there is no need to include the lateral sweep. The brow lift will address hooding, so a tapered incision is used. This image shows outlines used for conventional blepharoplasty. It must be kept in mind that only one third of this amount of skin would be removed with simultaneous brow lift.
The entire brow and forehead is injected with tumescent anesthesia, and the actual hair incision is injected with lidocaine 2%, 1 : 100,000 epinephrine (Figure 5-7). It is important to remember that this is a subcutaneous procedure, and the anesthesia must be injected subcutaneously. The eyelid surgery is performed first, which allows the local anesthesia and vasoconstrictor to take effect in the brow.
FIGURE 5-7 Before surgery, the brow and forehead are injected with tumescent anesthesia. A, The anesthetized area includes the entire forehead to about 3 cm into the hairline and inferiorly to the nasal radix and the superior orbital rims bilaterally. The lateral extension is to the temporal crests bilaterally. B, The actual intraoperative tumescent anesthesia injection.
There are few surgeries totally defined by a specific incision, but this is one of them. The technicality and quality of the transfollicular incision can make or break the aesthetic success of the mini open brow lift. The basic premise of this highly specific incision is to craft the incision to allow hair regrowth through the surgical scar, thus camouflaging it. Elevating the brow and forehead without raising the hairline is the other important aspect of this operation.
The transfollicular (trichophytic) incision does not happen by accident and requires some level of skill to perform properly. Most surgical skin incisions are made with the scalpel blade perpendicular to the skin surface, which produces a flat interface on both sides of the healing skin. The trichophytic incision is made using an extreme angle of bevel when incising. The scalpel is actually held at a 10- to 20-degree angle, which almost makes the scalpel appear perpendicular to the skin surface (Figure 5-8). It is of extreme importance to keep the scalpel at the same angle along the entire incision. Again, the angulation of the incision is the crux of this procedure.
The incision pattern is also very critical for a naturally appearing hairline scar. First and foremost, the incision should never be made anterior to the hairline. The trichophylic incision totally avoids any hair follicles. This may sound good in theory and will definitely be easier to incise and close, but the aesthetics are frequently unacceptable. In my opinion, it should never be attempted. I frequently hear surgeons advocate the prehairline incision but continually see patients in my office who were treated elsewhere and have unacceptably visible trichophylic incisions. There are few straight lines in nature. Also important is the fact that there is no such thing as a “natural hairline.” Only a toupee or a bad hair transplant produces a true “hairline” (Figure 5-9). Making a straight-line prefollicular incision on a patient’s forehead can make them an “incision cripple” for life, with a visible and often hypopigmented scar. A natural hairline is not a line at all but a gradual transition of follicular density from the very thin and sparse vellus anterior hairs to the area of more follicular density where the hairline thickens (Figure 5-10).
FIGURE 5-9 A, A linear prefollicular brow incision is not an acceptable option because it produces a very unnatural hairline that is a giveaway of poor surgical technique. B, An abrupt hairline is not seen in nature and is reminiscent of a toupee.
The transfollicular (trichophytic) incision is a totally different animal in design. First and foremost, the incision is designed to “cut across” existing hair follicles and is intentionally placed about 5 mm posterior to the anterior hairline. The optimum placement of this incision is at the region of the follicular density change from the thin, sparse anterior hairs to the denser follicles of the “actual” hairline which averages about 5 mm it the hairline (Figure 5-11, A). After the incision is made, excess skin trimmed, and the flap replaced, the transected follicles will lie under the newly placed flap, which is beveled (see Figure 5-11, B). As the wound matures (over several weeks), the hair bulbs of the transected follicles begin to grow through the thinly beveled flap (see Figure 5-11, C). When fully mature, most of the transected follicles will regrow through the flap and effectively camouflage the scar (see Figure 5-11, D).
FIGURE 5-11 A, The trichophytic incision is transfollicular and must be made posterior enough to intentionally transect several rows of intact hair follicles. It is important to cut across these follicles but leave hair bulbs intact in most of the transected hairs. These hairs will in turn grow through the incision scar. B, The transected follicles lying under the beveled skin flap. C, The transected follicles will regrow hair through the thinly beveled skin flap.D, When fully mature, many of the transected follicles will have repopulated and grown through the original scar, providing effective camouflage.
The first step to successful TFSBFL and an aesthetic scar is a firm understanding of this incision. The bevel of the incision is critical and must be the same angle on both flaps. The first incision is an extreme bevel, and the second incision on the excess skin must be cut at the same angle and bevel as the initial incision. There are several reasons for this. The beveled flap will transition from subcutaneous to dermal to epidermal. The thin dermal/epidermal interface allows a thin enough transition to allow the underlying follicles to perforate the flap. To illustrate this transition, Figure 5-12 shows a beveled incision on a lemon peel; the white region corresponds to the dermis, and the yellow region corresponds to the epidermis.
FIGURE 5-12 This representation of the extreme bevel scalp incision (A) shows the beveled incision on the scalp and the reversed bevel incision on the underside of the forehead flap. A representation is comparatively illustrated in B, in which this lemon has been sliced with an extreme beveled incision. D, Dermis; E, epidermis.
I stated earlier that linear prefollicular incisions produce unaesthetic scars. It is appropriate to mention at this point that even irregular geometric incisions are unfavorable when placed anterior to the hair follicles (Figure 5-13). Incision position is critical.
The TFSBFL incision is optimally placed about 5 mm posterior to the most anterior hairline, which corresponds to the change in follicular density from sparse to thick. To be effective, this incision must be placed posteriorly enough to transect several rows of hair follicles; otherwise there are no follicles to regrow through the scar (Figure 5-14).
Keeping with incision design, the next aspect to be addressed is incision geometry. Understanding that the incision is placed about 5 mm into the hairline, the configuration can be regular with large or small triangles or irregular with random undulating geometry. Different surgeons prefer one of these configurations over the others. Proponents of large triangular incisions say that the incision, skin excision, and reapproximation of the trimmed flap is less laborious. My experience with the larger triangular configured flaps has been poor; this intentional geometry is obvious after healing (Figure 5-15).
Some surgeons prefer much smaller triangular incisions. I have experienced acceptable results with this type of incision but have mixed feelings about using small triangles. The increased surface area makes for a much more complex incision, excision, and especially suturing (Figure 5-16). It heals with acceptable results but is simply more time intense. Additionally, as the triangles become smaller they become more like a straight line, which is unfavorable.
(Courtesy Todd Owsley, DDS, MD.)
After experimenting with all the common geometric incision patterns, I have settled on a random, irregular, undulating incision pattern (Figure 5-17). This incision is made by using the scalpel in a reciprocating manner much like filleting a fish. The pattern is basically irregular and reminiscent of ventricular fibrillation on an ECG. When I teach this technique to residents, I tell them to incise like they’ve had too much coffee. The incision pattern and the angle of the cut are both critical factors in the success of this technique. If a patient has a prominent widow’s peak, it is better to cut through the lower third of the apex instead of following the distinct V shape of the peak. Otherwise the angles are too conspicuous with the final scar.
FIGURE 5-17 In the author’s experience, an irregular, random, undulating incision has produced the best postoperative scar. The pattern of this incision resembles ventricular fibrillation on an ECG rhythm strip.
The extent of the incision is commensurate with the amount of aging changes specific to the patient. Younger patients without extreme lateral brow hooding can be treated with shorter incisions, because the amount of lateral dissection is less. In the younger patient, the incision and dissection only need to be made to a point just lateral to the maximum desired arch of the brow (Figure 5-18). In other words, as the dissection is made over the brow and it begins to be released, the dissection can stop just past the area of maximum arch. This usually corresponds the lateral limbus. When this area is released and the brow is significantly arched, there is no need to continue lateral dissection (Figure 5-19, A).
FIGURE 5-18 The area undermined on a younger patient without significant lateral brow ptosis is shown in yellow. The blue areas indicate the lateral extension of the incision used in older patients or those with more hooding and lateral brow ptosis.
In the older patient or those with significant lateral hooding, increased lateral dissection will be required, thus a wider incision and dissection (see Figure 5-19, B). With this technique, no incision is ever carried lateral to the temporal crest.
Once the incision is made, the next step is to “pretunnel” the subcutaneous flap (Figure 5-20). This step is not performed by all surgeons, but I truly feel it is worth the small amount of time required. It is absolutely critical to make the flap dissection in the subcutaneous plane. />