Trichophytic brow lifting is a popular method of repositioning the brows/upper lid complex. The procedure has traditionally been described in a subcutaneous plane of dissection. An equally effective, yet safer modification of the trichophytic brow lift, performed in the deeper, subgaleal plane, is described herein. This modification significantly improves the vascularity of the forehead flap.
One of the hallmarks of a youthful face is the appearance of an open and wide brow/upper lid complex. A lack of upper lid fullness or fat prolapse, along with the proper position of the brow in relation to the supraorbital rim, eludes the perception of a young and attractive face. There have been a number of surgical and non-surgical methods used to establish proper brow position. The coronal brow lift, initially described in the 1920s and later modified, is perhaps the oldest method known, while other methods such as the endoscopic forehead lift, trichophytic lift, and browpexy have become more popular in today’s aesthetic practice. There is no doubt that there are advantages and perceived disadvantages to each technique; however, it is a well-known fact the trichophytic brow lifting allows the flexibility to shorten a ‘long’ forehead while repositioning the brows at the same time. Traditionally, trichophytic brow lifting has been described as elevating the forehead in the subcutaneous plane. A modification of the trichophytic brow lift, which the author believes to be an effective, yet safer, technique in repositioning the brows and creating a youthful brow/upper lid complex, is described herein.
The procedure begins with the administration of a local anaesthetic with vasoconstrictor throughout the forehead. An incision is marked a few millimetres within the hairline (along the vellus hair) between the two temporal fusion lines. The incision is made with an exaggerated bevel in order to preserve hair follicles. The initial depth of the incision is through the subcutaneous tissue down to the subgaleal plane ( Fig. 1 ). The flap is then developed in the subgaleal plane all the way down to the brows until the forehead is passively elevated. If necessary, the temporal fusion line is transected in order to release laterally and inferiorly. Once proper elevation is achieved, the flap is mobilized in an almost composite fashion (skin, subcutaneous tissue, and galea aponeurotica), leaving the pericranium intact (Supplementary Material; video: note passive elevation of the forehead and brows prior to closure). Back-cuts are then made and the flap trimmed in a bevelled fashion in order to obtain a passive primary closure. If the hairline needs to be advanced forward, undermining of the hair-bearing scalp is performed, also in the subgaleal plane, prior to closure. Fibrin sealant is used within the wound prior to final closure. No drains are used. A pressure dressing is placed for 48 h.
Irrespective of the method employed, the objectives of a forehead lift procedure include elevation of the brows to an acceptable and aesthetic position, improving the brow/eyelid complex, as well as reduction of deep forehead rhytids. One of the surgical and anatomical advantages of operating in the head and neck region is the lush vascular supply. The forehead area is no different; the main blood supply to the forehead arises from the right and left supratrochlear and supraorbital arteries. Maintaining an adequate vascular perfusion to any flap during aesthetic surgery (face lift, brow lift, etc.) is paramount. Unlike performing a deep plane face lift, where one can easily elevate a robust skin/fat flap as well as a separate fascia/muscle flap (superficial musculoaponeurotic system, SMAS), elevation of a subcutaneous forehead flap can be tedious. Anatomically, there is not as much subcutaneous fat within the forehead as there is in the cheek areas of the face; therefore, elevation in a superficial plane can potentially injure the subdermal plexus and compromise the flap vascularity. Elevation of a subcutaneous flap in the forehead also relies solely on the supratrochlear artery; a deeper plane of dissection, such as the subgaleal elevation, takes advantage of the supratrochlear and supraorbital arteries. Advocates of the subcutaneous plane dissection tout its ease of elevation and quickness of the operation, as well as its efficacy in removing transverse rhytids of the forehead. It is the opinion of this author that deepening the dissection to the subgaleal plane is just as quick and easy, and it certainly does elevate the brows to the ideal position while addressing forehead rhytids. It also significantly reduces the possibility of a vascular compromise to the forehead since elevation down to the subgaleal plane creates a thicker flap.
In conclusion, while some authors advocate performing the trichophytic forehead flap in a subcutaneous plane, it is important to note that deepening the dissection to the subgaleal plane can significantly improve flap vascularity without compromising the final outcome ( Figs 2 and 3 ).