Upper Facial Diagnosis

Understanding upper facial aging requires insight and experience, and some seasoned practitioners fail to understand the intricacies between the forehead, brow, and eyelids. I feel that in contemporary cosmetic facial surgery, failure to properly diagnose and treat the ptotic brow and forehead is one of the most overlooked and underappreciated situations.

Upper facial aging oftentimes occurs earlier than lower facial aging and represents a complex relationship of changes involving many different tissues. Our hairline recedes, the skull shrinks, the forehead wrinkles, the forehead and eyelid tissues become ptotic and produce hooding and dermatochalasis, the periorbital fat protrudes, and the skin undergoes actinic and aging changes. Collectively, these tissues and their respective changes produce a tired and aged appearance in the upper face. A general rule is that the youthful female brow should lie above the superior orbital rim, and the youthful male brow should lie at the level of the rim. Most cosmetic facial surgeons agree that an aesthetic lateral brow lies about 5 to 10 mm above the lateral orbital rim.

Numerous surgical approaches for brow and forehead lifting have been described over the last 50 years (Figure 6-1). Although many of these approaches have fallen in and out of favor over the years, no brow and forehead lift has received more contemporary attention than the endoscopic technique.¹^–¹⁴

FIGURE 6-1 Some of the more popular brow and forehead lift surgical approaches. A illustrates (from superior to inferior) the coronal approach, the trichophytic approach, and the pretrichal approach. B shows (from superior to inferior) the endoscopic approach, the midforehead approach, and the direct approach. The latter two surgical approaches are not frequently performed by most surgeons.

One problem that exists, even among some very well-known surgeons, is failure to diagnose ptotic changes in the forehead and brow. I have seen patients who had blepharoplasty done by competent surgeons from every specialty when in fact they needed a browlift. Many of these patients are shocked to find out that a brow and forehead lift (BFL) option existed and are disappointed when they realize that after having eyelid skin removed numerous times, they are no longer candidates for BFL (Figure 6-2). In essence, these patients have been crippled by previous excess lid skin removal and cannot have the required or desired procedure for fear of permanent lagophthalmos. I am familiar with at least one case of litigation for misdiagnosis and treatment of a patient who clearly should have been offered a BFL option but was repeatedly treated with aggressive blepharoplasty. Offering patients contemporary options is critical to competent practice, even if the treating surgeon does not perform that particular operation.

FIGURE 6-2 Misdiagnosis of brow and forehead ptosis and excessive upper eyelid skin removal can rule out future options for patients. A, Patient who requested BFL but previously had overaggressive blepharoplasty by another surgeon. B, When the brow is elevated in consultation, there is inadequate upper lid skin for closure, limiting surgical options for this patient.

The average adult in their mid-40s has some component of brow and forehead ptosis. It is informative to examine youthful pictures of prospective patients to determine if they in fact ever had arched or higher-positioned brows. Many patients have ptotic brows in adulthood, but some may not have had elevated brows in youth (Figure 6-3).

FIGURE 6-3 The author is shown 40 years after (left) the youthful picture (right). Note that although there is significant eyelid skin excess, his brow position has not largely changed.

Surgeons utilize various measurements and in some cases complicated devices to attempt to quantify brow ptosis and show where the brow should be. During cosmetic evaluation, I take a more practical approach and perform a systematic, orderly evaluation and diagnosis of the entire head and neck. Beginning from the top and working down to the mid- and lower face has worked well for me. Many patients present for consultation thinking they need blepharoplasty when in reality they are BFL patients. They may find the suggestion of BFL unusual or foreign and meet it with resistance. “Oh no, I didn’t come here for anything that drastic, I just want some skin clipped off” is a common patient response at the mere mention of BFL. Such responses merit patient education on the complex relationship between upper facial aging and treatment options.

Sophisticated options are available to show patients a surgical prediction of BFL, but I have found them to be time misspent. Simply handing a patient a mirror and manually elevating their brow into a proposed position gives a pretty accurate idea of what a postsurgical result may resemble, and a patient can tell you in 2 seconds if they like or dislike the look. “That is exactly how I used to look, and I miss that” would be an appropriate response from a patient who appreciates the proposed change. “I don’t like this, it looks unnatural or surprised” is a common response from patients who find the anticipated change objectionable. Today’s patients are sophisticated and keyed into tabloid print and TV and we have all seen well-known celebrities that were overtreated with BFL. This is a significant concern for many patients that are BFL candidates, and readily so, as few procedures look as unnatural as an over-elevated BFL.

Another means of predictive illustration for BFL is to recline the patient to a supine position. In this position, gravity elevates the brows and is a surprisingly accurate predictor of a postsurgical result.

When the brow is manually elevated, numerous things occur. First, the brow is superiorly repositioned, improving appearance and producing a fresh, youthful, and alert appearance. Second, the upper eyelid complex is improved in numerous ways. The elevated brow improves hooding and dermatochalasis because it stretches the excess skin, providing a more youthful eye. Lifting the brow repositions the protruding periorbital fat and improves fat protrusion. The elevated brow also produces a more distinct shelf between the ciliary margin and the upper lid crease. The posed elevation will also stretch the ptotic frontal skin and improve its appearance. Finally, elevating the midforehead will decrease the redundant tissue in the glabellar region, giving a more youthful appearance. The sum of all of these lifting changes is a more youthful upper-facial appearance (Figure 6-4).

FIGURE 6-4 Manually elevating an aging brow can show the patient how the brow and forehead aesthetics can be improved. It is important to point out to the patient that in the manual simulation, the brows become more youthfully arched, the upper eyelid dermatochalasis is improved, and the aging glabella, which becomes wider and redundant, is more youthfully narrowed.

Another method to demonstrate predictive brow changes is simply taping the brow to an elevated position on one or both sides. This is helpful for some patients, because they can observe the new look over several hours at home (Figure 6-5). A photograph with the patient’s brow and forehead relaxed is easily morphed to an elevated position with digital imaging software, which can also be used for prediction and patient education. If the surgeon does not have imaging software, he or she can take a picture with the assistant elevating the patient’s brow (or brows), then crop the assistant’s fingers from the picture to mimic the surgical repositioning (Figure 6-6).

FIGURE 6-5 Taping the patient’s brow in an elevated position can help the patient decide whether they like the proposed result.

FIGURE 6-6 A, A simple means of “morphing” a ptotic brow to an elevated position is to have an assistant use the fingers to manually elevate the brow. B, The picture is then cropped to “remove” the assistant’s visible fingers, leaving a predictive picture.

One caveat for the novice brow-lift surgeon (appreciated by all experienced surgeons) is the fact that it is sometimes impossible to get a female patient to relax their brows. Many females spend their awake hours in a state of subconscious brow elevation to the point where they don’t realize their brow is elevated. The surgeon asks them to relax their brow and they say it is relaxed, even though their frontalis is wrinkled. Even while looking in a mirror, some females cannot relax their brow. This can be frustrating for the surgeon and can also make diagnosis and treatment less accurate.

Patients Either Like the Look of Elevated Brows or They Don’t

It sounds painfully simple but is actually a complex factor in diagnosis and patient acceptance of brow and forehead lifting: a patient either likes the look of elevated brows or they don’t. Instead of employing standard classical measurements to determine brow position, I elevate the patient’s brow with my fingers to the proposed position and ask if they like it. They can usually answer in seconds. If they don’t like the result or are not sure, I don’t consider them “psychological candidates” for brow and forehead lift. Occasionally a patient will like the result but only want “half” the amount of brow lift you showed them. I also take this as a caveat. There is nothing wrong with a conservative brow lift, but it is impractical to perform a 2-mm brow lift. I explain to the patient that either they need a brow lift or they don’t. Since it is difficult to precisely control the amount of elevation in millimeter increments, the surgeon is better off not treating a patient who wants “half a brow lift.” This type of patient is likely to feel they are overcorrected with the normal amount of lift or feel they had no benefit from the surgery if a small lift is achieved. The lesson is that if a patient dislikes the look of brows elevated by finger traction, they may be unhappy with any result. Having said that, it is reasonable to perform conservative lifts in some patients (especially those who may be subject to postsurgical lagophthalmos) and more aggressive lifts in others.

In the consultation process, the patient must be made aware of possible complications and sequelae, including overcorrection, undercorrection, the need for revision surgery, probable temporary sensory nerve deficit or dysesthesia, temporary or permanent alopecia at the incision lines, elevation of the hairline, the possible need for cranial fixation depending on the type of lift, and surgical relapse.

All surgeons approach diagnosis and treatment differently, but one thing that became apparent to me in my early years of performing brow lift surgery was that virtually all brow-lift patients also needed blepharoplasty. This would exclude younger patients or those brow-lift patients whom have had previous significant upper-lid skin removed. In 99% of my BFL surgeries, I am also performing simultaneous upper lid blepharoplasty, and that fee is included as part of the brow lift. The reasons for this are multifactorial. Many older patients will still have upper lid skin excess after surgical brow elevation, so some conservative removal is advantageous for an aesthetic result. Experienced surgeons may feel they have done a very successful brow lift—the brow position was improved, the forehead elevated, the glabella narrowed—but the patient focuses on the small amount of upper lid skin redundancy that was not addressed. By performing conservative blepharoplasty with most BFLs, there is a symbiotic relationship: the brow lift makes the lid look better, and the conservative blepharoplasty makes the brow look better. In conjunction, they are a winning combo. Caution must be exercised so as not to perform aggressive blepharoplasty; only 50% or less skin is removed when performing the BFL with simultaneous upper blepharoplasty. In a typical case where I might normally remove 10 to 12 mm of upper eyelid skin if blepharoplasty were the sole procedure, I will remove 3 to 4 mm of upper eyelid skin when performing concomitant BFL (Figure 6-7). When performing upper blepharoplasty with simultaneous BFL, I do not generally remove upper lid fat unless it is very excessive. The small skin (and or orbicularis oculi) excision simply serves to make a more defined brow/lid complex. When performing blepharoplasty as a sole procedure, some lateral expansion of the upper blepharoplasty incision is made to account for lateral upper lid skin. I call this outline a “bird’s beak” configuration (Figure 6-8, A). Since the excess lateral upper lid skin is automatically addressed by lateral brow elevation when performing BFL in conjunction with upper blepharoplasty, no lateral incision modification is required. For upper blepharoplasty in conjunction with BFL, I use a “Napoleon’s hat” configuration (see Figure 6-8, B).

FIGURE 6-7 In the normal patient without BFL, 20 mm of skin is required to close the lid; skin in excess of that can be removed. When performing simultaneous blepharoplasty and browlift, much less skin is excised. When performing blepharoplasty without brow lift, 10 to 12 mm of excess upper lid skin is often excised (blue outline), but when performing simultaneous BFL, about one third to one fourth of that normal amount is excised so as not to cause lagophthalmos.

FIGURE 6-8 A, Normal incision outline when performing isolated blepharoplasty, which employs an upsweep of the lateral incision that somewhat addresses skin hooding. There is no need for this upsweep when performing browlift with blepharoplasty; the brow lift addresses hooding. B, The incision geometry when performing browlift and simultaneous blepharoplasty.

Other important preoperative details must also be considered. If the patient currently has a high hairline, they must be made aware that endoscopic brow and forehead lift (EBFL) will further elevate their hairline. If they are uncomfortable with this, a trichophytic brow lift (described later in this chapter) is preferred because it does not elevate the hairline. General hair issues are always a concern. For example, almost all adult males have some component of hairline recession. Although many surgeons treat male patients with EBFL, it has been a rarity in my practice. I know surgeons who say they routinely perform EBFLs on males with pattern baldness, but I have chosen not to. Perhaps being follicularly challenged heightens my sensitivity to defacing someone’s scalp with incisions that will be forever visible. If there is any hint of an unstable hairline, I shy away from brow lift in males or females unless they are considering a hairpiece.

Higher hairlines with frontal bossing or a very convex forehead also complicate endoscopic technique insofar as the straight endoscope is tangent to the arc of the frontal bone, and it can be difficult to navigate the scope and instruments in this situation. In these cases, I would be more apt to pursue a trichophytic approach.

Endoscopic Brow and Forehead Surgical Procedure

The evolution of endoscopically assisted brow and forehead lift is well detailed, and numerous changes have been employed since its inception.¹^–¹⁴

Instrumentation

When I wrote this type of chapter 12 years ago, I needed to be very precise in terms of what equipment was required and available. At that time, EBFL was in its infancy, and most practicing surgeons had not received residency training in the technique. It was therefore necessary to be extremely specific about equipment. Now that EBFL has become a frontline technique, the available cameras, scopes, light sources, and surgical instruments are refined and readily available. Realizing this, I will not spend significant time in this chapter discussing armamentaria. I will say that for the recent graduate with limited funds, discounted or free used endoscopic equipment may be available from their local hospital. Many specialties utilize cameras, scopes, and light sources, and some hospitals and factory reps have older but well-functioning equipment they are happy to part with. A 15-cm, 30-degree endoscope is preferred for EBFL. A decent camera, scope, and light source are mandatory for a clear image and precise surgical technique. Figure 6-9 shows an endoscope and two popular types of sheaths with terminal retractors to keep the soft tissue from obscuring the endoscopic field.

FIGURE 6-9 A, A common 15-cm, 30-degree endoscope. B, A camera sheath with a soft-tissue retractor on the end designed to keep the superior tissues from obscuring the lens. C, A right-angle sheath that also allows more efficient soft-tissue retraction. The pistol-grip sheath can be useful in retracting the soft tissues as well as for camera stabilization by the surgeon or assistant.

Although a vast array of instruments are available for EBFL, in reality, very few are necessary. A simple Molt Number 9 periosteal elevator can be used for about 80% of the subperiosteal dissection (Figure 6-10). Numerous other instruments facilitate subperiosteal dissection, especially around nerve trunks and orbital rims (see Figure 6-10). Multiple instruments are also available for incising periosteum and brow-depressor musculature (Figure 6-11).

FIGURE 6-10 Although hundreds of endoscopic brow and forehead lift instruments are available, most are not necessary. The dissectors shown are routinely used by the author. 1, Molt #9 periosteal elevator; 2, sharp dissector for frontozygomatic region; 3, Batwing dissector for areas of broad subperiosteal dissection such as the vertex; 4-5, smaller spoon dissectors for subperiosteal dissection around smaller structures and areas; 6, fine dissector with down-curved tip to elevate arcus marginalis from superior orbital rim; 7, optional surgical knife to incise supraorbital periosteum.

FIGURE 6-11 Endoscopic brow and forehead lift requires the ability to precisely incise periosteum and brow-depressor musculature, frequently in close proximity to neurovascular structures. Instruments used to do this include CO₂ laser waveguides (not pictured), endoscopic knife (A), Ellman radiowave long, curved microtipped electrode (B), and proprietary long, bendable electrosurgery knife/suction devices (C).

Over the past 5 years, widescreen plasma and LCD television monitors have become very affordable. These monitors have been welcome additions to the cosmetic surgery office for numerous reasons, including patient entertainment while waiting, patient education and marketing, monitoring vital signs during anesthesia, and endoscopic surgery (Figure 6-12).

FIGURE 6-12 Widescreen television monitors are very useful in the operating suite for monitoring vital signs, displaying “time out” patient information, and for endoscopic surgery. A, Endoscope in place. B, Widescreen TV monitor, which facilitates vision for everyone in the room.

Surgical Procedure

All EBFL patients are placed on preoperative antibiotics beginning 24 to 48 hours preop and are given instructions to wash the body and hair with antibacterial soap the night before and morning of surgery. A preoperative series of pictures is taken, with care to have the patient in neutral brow position. The hair is combed back into a ponytail and parted at the temporal tuft region for the temporal incisions.

Various surgeons utilize different markings and incisions. I prefer to make three frontal incisions, one central at the midline (Figure 6-13, 1) and two lateral incisions that correspond to the approximate area of maximum desired brow elevation. This most frequently corresponds to an imaginary line tangent to the lateral limbus (see Figure 6-13, 2) and also to the junction of the central and lateral third of the brow. Two temporal incisions are also made. These incisions are about 3-4 cm long and perpendicular to an imaginary line drawn through the ala and canthus (see Figure 6-13, 3). It is also helpful to draw the approximate position of the supraorbital and supratrochlear nerves on the soft tissue over their hard-tissue landmarks (Figure 6-14). The supratrochlear nerve is located approximately 17 mm lateral to the glabellar midline and the supraorbital nerve is located approximately 27 mm lateral to the glabellar midline. Although all of these incisions are relatively standard in text descriptions, it is important for the surgeon to keep in mind that each patient presents a different situation, and the lateral frontal incisions should be in the anticipated region of maximum brow elevation. Similarly, the temporal incisions should be placed in a direction that will maximally elevate the lateral brow when placed under tension.