1,4,5 Ϯ familiarity 7,8 have shown that 6 All of these may 1–3 2.7 mm medial to the Ϯ COSMETIC 1.0 mm; the most lateral origin point, 1,6,7 120: 1647, 2007.) Ϯ In a recent study, Walden et al. with normal corrugatorsions supercilii in muscle reference dimen- minimize to this fixed unpredictabilitymore bony systematic and landmarks approach can allowsupercilii muscle to myectomy. for In precise addition, a ahensive compre- corrugator understanding of the corrugator supercilii the amount of corrugatortion supercilii can muscle vary resec- with depending as on much as thegator one-third supercilii approach of muscle the head used, remaining transversepalpebral after corru- trans- attempts atAlthough complete the muscle seniorthis removal. author may largely (B.G.) be believes technique-related, that become exaggerated on animation. The cause of thisapproach, may specific be technical relatedthe to execution, the and/or surgeon’s surgical technique. experience with a particular tence of dynamic rhytides. 2.9 mm from the nasion or 7.6 Ϯ Plast. Reconstr. Surg. The dimensions of the corrugator supercilii muscle are more Complete corrugator supercilii muscle resection is important for Unequal www.PRSJournal.com 1647 Twenty-five fresh cadaver heads (50 corrugator supercilii muscles Relative to the nasion, the most medial origin of the corrugator 1–3 3.1 mm cephalad to the nasion–lateral orbital rim plane and 18.0 2.8 mm. The lateralmost insertion of the corrugator supercilii muscle Ϯ Ϯ 3.7 mm medial to the lateralnoted orbital rim. between There the were no rightConclusions: statistical differences and left sides. extensive than previously described andbony can landmarks. be These easily delineated dataplete, using may fixed prove and beneficial symmetric inrejuvenation corrugator performing and safe, for supercilii com- effective musclesupratrochlear decompression of resection the for supraorbitalheadaches. nerve forehead branches and in ( the surgical treatment of migraine lateral orbital rim. The most cephalic extent32.6 (apex) of the muscle was located 14.0 measured 43.3 Background: supercilii muscle was found at 2.9 the surgical treatment ofative migraine abnormalities headaches in surgical and forehead may rejuvenation. Specificysis help topographic of anal- prevent corrugator postoper- supercilii musclethe dimensions supraorbital and nerve its branching detailed patterns associationPart has with I not been of thoroughly this delineated. raphy two-part with study respect aims to toMethods: define external corrugator bony supercilii landmarks. muscleand 50 topog- supraorbital ) were dissected tomuscle isolate from the corrugator surrounding supercilii muscles.tor Standardized supercilii measurements muscle of dimensions corruga- lateral were orbital taken rim. with respectResults: to the nasion and

Jeffrey E. Janis, M.D. Jason E. Leedy, M.D. omplete resection of the corrugator super- cilii muscle hasforehead been rejuvenation advocated and in for the both surgical Ashkan Ghavami, M.D.

Bahman Guyuron, M.D. Joshua A. Lemmon, M.D. Dallas, Texas; and Cleveland, Ohio From the Department ofTexas Southwestern Plastic Medical Surgery, Center, The andPlastic the University and Department of of ReconstructiveUniversity Surgery, School Case of Western Medicine. Received for Reserve publication April 13,7, 2006; 2006. accepted September Gaspar W. AnastasiSociety Award presentation for at AestheticOrlando, the Plastic Florida, American April Surgery 23,Copyright Annual ©2007 2006. by the Meeting, American Society in of PlasticDOI: Surgeons 10.1097/01.prs.0000282725.61640.e1 corrugator supercilii muscle removalcomplete and/or corrugator in- supercilii muscleafter resection forehead rejuvenation canable lead sequelae to such undesir- as dimpling,residual depressions, corrugator and activity, with resultant persis-

treatment of migraine headaches. C

Part I. Corrugator Topography Anatomy of the Corrugator Supercilii Muscle:

Downloaded from http://journals.lww.com/plasreconsurg by SlonBoPBttLBlesWK19Dk2zjhqEF20t9hZgFb4/+nucVgezvuhWCN7eWJVnDJyyJ2HOJuX0FknxIrnIziRU2QFO8LXAcJprnl0EqdSCPJ9lhdCqBrdvVGtsD7qyoTO6/ on 06/02/2021 Downloaded from http://journals.lww.com/plasreconsurg by SlonBoPBttLBlesWK19Dk2zjhqEF20t9hZgFb4/+nucVgezvuhWCN7eWJVnDJyyJ2HOJuX0FknxIrnIziRU2QFO8LXAcJprnl0EqdSCPJ9lhdCqBrdvVGtsD7qyoTO6/ on 06/02/2021 Plastic and Reconstructive Surgery • November 2007 muscle dimensions may assist less experienced sur- while interdigitating with the orbicularis oculi geons in obtaining a successful outcome when per- muscle and frontalis muscles. The oblique head of forming any of the numerous surgical approaches the corrugator supercilii muscle is smaller, with its for forehead rejuvenation that have been de- fibers commonly running parallel to those of the scribed. depressor supercilii muscle after insertion into the Migraine headaches have been postulated to be medial brow. associated with peripheral nerve trigger points.9–14 Knize15 dissected 40 hemifacial cadaver heads The supraorbital/supratrochlear nerves have been to evaluate the detailed muscular anatomy of the implicated as one of four peripheral trigger sites forehead region. The origin of the corrugator su- that potentially account for migraine headache percilii muscle was found to be consistent and symptomatology.10 Improvement or complete located at the near the superomedial amelioration of migraine headaches has been orbital rim, anterior and slightly cephalad to the demonstrated after chemodenervation of the cor- trochlea of the extraocular superior oblique rugator supercilii muscle by botulinum toxin type muscle.15 The corrugator supercilii muscle fibers A,9,10 which is theorized to act by decompression of then pass superolaterally “through” the frontalis the and by and orbicularis oculi muscles before inserting into relaxation of the investing musculature.10,14 Long- the medial half of brow skin.15 The corrugator term success has been demonstrated in a vast ma- supercilii muscle also extends through the galeal jority of patients who have subsequently gone on to fat pad before giving off its dermal insertions.15 It have complete corrugator supercilii muscle is unclear from these and other descriptions myectomy.10 whether the corrugator supercilii muscle extends Based on extensive intraoperative observation, beyond the temporal fusion line, and exactly how the senior author (B.G.) postulates that the su- lateral the insertion point is.16,17 praorbital nerve branches demonstrate a more In a recent report that examined the efficacy significant investment pattern in relation to the of the transpalpebral, endoscopic, and open coro- corrugator supercilii muscle fibers, further sup- nal approaches to corrugator supercilii muscle re- porting the necessity for safe and complete re- section, the transverse head of the corrugator su- section of the corrugator supercilii muscle for percilii muscle was found to be incompletely supraorbital nerve decompression in migraine resected, mostly in the lateral region using the treatment. Although the investing topography of transpalpebral approach.6 The authors noted that other peripheral trigger points has been the transverse head of the corrugator muscle was described,9,11–13 the supraorbital nerve and its longer and thicker (average, 7.5 mm) than the close relationship to the corrugator supercilii oblique head (2.0 mm).6 More complete resection muscle fibers requires further anatomical inspec- of the corrugator, along with the depressor super- tion. A comprehensive understanding of corru- cilii and procerus muscles, was seen with the en- gator supercilii muscle dimensions and its rela- doscopic approach. In addition, the authors noted tionship with the supraorbital nerve branching the utility of visual cues such as muscle color to patterns may improve the safety and predictabil- differentiate between the various muscle fibers.6 ity of forehead rejuvenation and surgical treat- For example, the medial orbicularis oculi is su- ment for migraine headaches. In Part I of this perficial and a lighter pink than the vertically ori- study, the topographic dimensions of the corru- ented red depressor supercilii muscle fibers.6 Isse gator supercilii muscle with respect to fixed ex- and Elahi17 performed a smaller cadaver study and ternal bony landmarks are defined, whereas in found that in the lateral two-thirds of the brow, the Part II, the branching patterns of the supraor- corrugator supercilii muscle fibers pass through the bital nerve as they relate to the corrugator super- orbicularis oculi and frontalis muscles. This most cilii muscle fibers are described. lateral region of the corrugator supercilii muscle, although difficult to dissect, is important because RELEVANT ANATOMY it may largely account for lateral brow depressions The corrugator supercilii muscle is one of the seen postoperatively.17,18 three commonly described brow depressor muscle The motor nerve supply to the corrugator groups (including the medial orbicularis oculi supercilii muscle is from the frontal branch of and depressor supercilii) and is composed of two the temporal division of the , heads. The transverse head originates from the whereas the zygomatic branch seems to inner- superomedial aspect of the orbital rim to insert vate the oblique head.2 Postoperative observation into the dermis at the middle third of the brow of corrugator supercilii muscle reactivation after lat-

1648 Volume 120, Number 6 • Corrugator Supercilii Muscle eral resection provides evidence that motor nerve ing the arches. The frontalis and depres- fibers originating medially exist and are involved in sor supercilii muscles were dissected off of the reinnervation.1,2,15 This further supports the impor- corrugator supercilii muscle and elevated along tance of complete corrugator supercilii muscle resec- with the skin flaps. Once the full extent of the tion for supraorbital nerve/supratrochlear nerve de- transverse and oblique heads of the corrugator compression in the surgical treatment of migraine supercilii muscle were well delineated, the nasion headaches and for forehead rejuvenation, when in- and lateral orbital rim apex (most lateral bony dicated. point) were marked, and standardized measure- The association of the supratrochlear nerve ments of muscle dimensions were taken. with the corrugator supercilii muscle is well Because of the globe distortion and soft-tissue known, as it exits just lateral to the corrugator changes present in cadaver specimens, soft-tissue supercilii muscle origin, enters the muscle (where reference points were not used. In addition, use of it divides into three or four small branches), soft-tissue landmarks may result in great variability courses in a cephalad direction just deep to the in vivo. Therefore, fixed bony landmarks were anterior surface of the corrugator, and then pen- chosen as reference points. etrates the .2,19 However, the inti- Vertical muscle dimensions were measured in mate relationship of the supraorbital nerve with reference to a horizontal line created to transect the corrugator supercilii muscle has not been spe- the lateral orbital rim and nasion points of refer- cifically elucidated. ence. Horizontal muscle dimensions were mea- Based on previous reports,15,20 the supraorbital sured relative to a vertical line bisecting the na- nerve does not seem to run within the corrugator sion, anterior nasal spine, and menton. Results are muscle mass. However, in a study by Knize,15 cross- listed as mean values with standard deviations. sectional histology performed in two cadavers re- Mean values between the right and left sides were vealed the presence of muscle fiber staining deep compared using paired t test analysis. to the supraorbital nerve (likely corrugator super- cilii muscle fibers). This may suggest a more inti- RESULTS mate relationship between the supraorbital nerve There was no statistical difference seen be- and corrugator supercilii muscle fibers than pre- tween the right and left corrugator supercilii mus- viously thought. This intricacy is important and cle dimensions based on paired t test analysis (p Ͻ will be examined further in Part II of our study. 0.0001); therefore, right (n ϭ 25) and left (n ϭ 25) corrugator supercilii muscle measurements were MATERIALS AND METHODS added (total n ϭ 50) to improve the power of the Twenty-five fresh cadaver heads (50 corruga- study and are provided as mean values with cor- tor muscles and 50 supraorbital nerves) were dis- responding standard deviations. All measure- sected using a cross-shaped incision centered over ments were obtained using millimeters as the unit the radix, with the transverse component follow- of measurement (Figs. 1 and 2). Horizontal cor-

Fig. 1. Corrugator supercilii muscle (CSM) topography; cadaver dissection with average distances. Cadaver dissection of the corrugator supercilii mus- cle showing the major data points that delineate muscle dimensions with respect to the nasion (N) and lateral orbital rim (LOR).

1649 Plastic and Reconstructive Surgery • November 2007

Fig. 2. Comprehensive corrugator supercilii muscle dimensions. Artistic rendition (proportionate scale) of all the measured data points of the cor- rugator supercilii muscle in relation to the palpable bony anatomy [na- sion (N) and lateral orbital rim (LOR)]. Note reflection of muscular inter- digitation required to delineate the lateral extent of the corrugator supercilii muscle. rugator supercilii muscle dimensions were mea- Table 2. Topographic Dimensions of the Corrugator sured first. The vertical midline connecting the Supercilii Muscle Lateral Orbital Rim Reference nasion and anterior nasal spine was used as the Points (Mean Values) reference landmark for all horizontal muscle di- Right (mm) Left (mm) Overall (mm) mension points (Table 1). LOR to apex 17.9 Ϯ 3.3 18.0 Ϯ 2.5 18.0 Ϯ 3.7 The nasion to lateral orbital rim distance mea- LOR to lateral sured 50.8 Ϯ 2.9 mm (range, 46 to 59 mm). The extent 6.9 Ϯ 2.6 8.3 Ϯ 3.2 7.6 Ϯ 2.7 most lateral insertion point of the corrugator su- LOR, the most medial palpable point of the lateral orbital rim. percilii muscle measured 43.3 Ϯ 2.9 mm from the nasion, which corresponds to a value that is 85 percent of the distance to the lateral orbital rim. cle was located 32.9 Ϯ 2.6 mm lateral to the nasion This is equivalent to a distance of 7.6 Ϯ 2.7 mm or 18.0 Ϯ 3.7 mm medial to the lateral orbital rim. medial to the lateral orbital rim (Table 2). Vertical dimensions were measured in reference The medial origin of the corrugator muscle to a straight horizontal plane that passes through was located 2.9 Ϯ 1.0 mm from the nasion, the nasion and lateral orbital rim (Table 3). whereas the lateral origin point measured 14.0 Ϯ The apex (most cephalad point) of the muscle 2.8 mm from the nasion. This corresponds to an was located at a mean distance of 32.6 Ϯ 3.1 mm average origin width of 11.1 mm. The apex (most from the horizontal plane. The vertical height of cephalad point) of the corrugator supercilii mus-

Table 3. Topographic Dimensions of the Corrugator Table 1. Topographic Dimensions of the Corrugator Supercilii Muscle Vertical Reference Points (Mean Supercilii Muscle Nasion Reference Points (Mean Values) Values) Right (mm) Left (mm) Overall (mm) Right (mm) Left (mm) Overall (mm) Plane to Nasion to lateral medial-inferior* 9.8 Ϯ 2.1 9.3 Ϯ 2.0 9.8 Ϯ 2.2 orbital rim 50.9 Ϯ 2.9 50.8 Ϯ 2.8 50.8 Ϯ 2.9 Plane to Nasion to medial medial-superior 18.6 Ϯ 2.4 18.2 Ϯ 2.5 18.7 Ϯ 2.4 origin 2.7 Ϯ 0.9 3.0 Ϯ 1.0 2.9 Ϯ 1.0 Plane to Nasion to lateral lateral-inferior 22.3 Ϯ 3.2 21.1 Ϯ 3.7 21.9 Ϯ 3.3 origin 13.8 Ϯ 3.0 14.2 Ϯ 2.6 14 Ϯ 2.8 Plane to Nasion to lateral lateral-superior 28.9 Ϯ 2.8 26.8 Ϯ 3.5 28.8 Ϯ 3.5 extent 44 Ϯ 2.6 42.7 Ϯ 3.5 43.3 Ϯ 2.9 Plane to apex 32.8 Ϯ 3.1 31.6 Ϯ 2.5 32.6 Ϯ 3.1 Ϯ Ϯ Ϯ Nasion to apex* 33.0 2.8 32.5 2.0 32.9 2.6 *Plane represents a straight horizontal reference line that passes *The most cephalad extent of corrugator supercilii muscle fibers. through the nasion and lateral orbital rim points.

1650 Volume 120, Number 6 • Corrugator Supercilii Muscle the most medial-inferior muscle origin was 9.8 Ϯ section to where the corrugator supercilii muscle 2.2 mm and 18.7 Ϯ 2.42 mm medial-superior. passes into the frontalis/orbicularis muscles lat- Lateral heights are 21.9 Ϯ 3.3 mm lateral-inferior erally, to prevent possible reinnervation from and 28.8 Ϯ 3.5 mm lateral-superior. other motor branches, such as the frontal branch of the facial nerve or from medial nerve fibers. DISCUSSION Although the endoscopic approach is the more Complete resection of the corrugator super- commonly described approach for surgical treat- cilii muscle has been advocated for both forehead ment of migraine headaches,10 multiple surgical rejuvenation1–3 and for the surgical treatment of techniques have been described for brow depressor migraine headaches.6,9 However, incomplete muscle excision and forehead rejuvenation. These and/or unequal corrugator supercilii muscle re- mainly include the transpalpebral, endoscopic, and section with simple, imprecise debulking proce- coronal approaches. Accuracy in brow depressor dures can have deleterious consequences. These muscle (including corrugator supercilii muscle) re- include forehead/brow asymmetries, skin dim- section has been clearly shown to be influenced by pling (particularly with animation), and recur- the surgical approach.6 Through this study, specific 1,2,15 rence of glabellar furrows and lines. In data regarding the most lateral, medial, superior, addition, aberrant reinnervation of residual mus- and inferior borders of the corrugator supercilii 1,2,4 cle can result in awkward forehead animation. muscle are now available and may increase the ac- Irregular “lateral horns” of reinnervated muscle curacy of performing more precise corrugator su- mass can become evident as early as 3 to 4 months 4 percilii muscle resection regardless of the surgical postoperatively. approach. In addition, information regarding su- The variability and unpredictability of com- praorbital nerve branching patterns provided in Part plete corrugator supercilii muscle resection may II of the current study will further refine our knowl- also hinder successful surgical treatment of mi- edge regarding the intimate relationship between graine headaches, as complete peripheral nerve (su- the supraorbital nerve and corrugator supercilii praorbital nerve and supratrochlear nerve) de- muscle. compression is mandatory.9,10 In our current Based on extensive intraoperative observation, report, we set out to further refine our under- the senior author (B.G.) has noted that corrugator standing of the average dimensions of the corru- supercilii muscle dimensions are more extensive gator supercilii muscle with respect to easily iden- than previously reported. Knize2 describes the cor- tifiable, fixed bony landmarks. To our knowledge, this is the largest cadaver study looking at corru- rugator supercilii muscle origin as being constant, gator supercilii muscle anatomy. This detailed to- with both a transverse and oblique head, whereas pographic information can assist the surgeon in the remainder of the muscle mass is variable. In- more accurate preoperative planning and im- adequate removal of the lateral portion of the transverse head of the corrugator supercilii mus- proved perioperative confirmation of complete 6 corrugator supercilii muscle resection. cle noted by Walden et al. suggests that the dis- Clinically, incomplete corrugator supercilii section of the most lateral insertion point of the muscle resection of up to 50 percent has been corrugator supercilii muscle is most unpredict- Ϯ reported with some techniques.6,8 In a recent de- able. We found this point to measure 43.3 2.9 tailed anatomical study, Walden et al.6 have dem- mm from the nasion (located 85 percent of the Ϯ onstrated that up to one-third (most lateral as- distance to the lateral orbital rim), or 7.6 2.7 pect) of the transverse corrugator supercilii mm medial to the lateral orbital rim. This point muscle head remained after transpalpebral resec- was not easily identifiable and required meticu- tion that was otherwise thought to be complete. lous dissection (using 3.8ϫ loupe magnification) Guyuron7 offers three plausible causes for subop- off of the interdigitating orbicularis oculi muscles, timal corrugator supercilii muscle resection: (1) frontalis muscle, and eyebrow dermis (Fig. 2). In interdigitations with the frontalis and orbicularis addition, this most lateral portion of the corruga- muscles may inhibit thorough visual assessment of tor supercilii muscle is thinner and more super- the superior aspect of the transverse head; (2) fear ficial; therefore, care must be taken to avoid in- of damage to the supraorbital nerve; and (3) the advertent frontalis and full extent of the lateralmost portion of the cor- injury during resection. The improved under- rugator supercilii muscle is underestimated. standing of this ambiguous point of muscular in- Knize2 recommends complete avulsion of the cor- terdigitation allows for a more precise and tailored rugator supercilii muscle origin medially, and re- approach to corrugator supercilii muscle removal.

1651 Plastic and Reconstructive Surgery • November 2007

Fig. 3. Most clinically relevant dimensions. Patient photograph depicts the more clinically useful topographic data points. Horizontal data points: me- dialmost corrugator supercilii muscle origin (2.9 mm); lateralmost extension point (43.3 mm from the nasion and 7.6 mm from the lateral orbital rim); location of apex from lateral orbital rim (18 mm). Vertical data points (from nasion to lateral orbital rim plane): apex (32.6 mm) and lateralmost extent of corrugator supercilii muscle (28.8 mm).

We did not observe a clear delineation be- and symmetric between left and right sides. Al- tween the oblique and transverse head fibers, as though palpation of a contracted corrugator su- the fibers quickly paralleled each other within the percilii muscle on forehead animation may pro- mass of the corrugator supercilii muscle after the vide approximate muscle dimensions in the origin of the oblique head was no longer seen. clinical setting and should be a part of the pre- This may indicate that there is a singular corru- operative examination, objective topographic gator supercilii muscle mass, possibly with variable points based on fixed bony landmarks more ac- or accessory muscle fiber origins without well-de- curately define the extent of the corrugator su- fined and separate heads. percilii muscle mass to be resected. This infor- We found an average muscle origin width of mation can potentially be used to plan a more 11.1 mm, with the medialmost origin of the systematic approach to complete corrugator su- oblique head of the corrugator supercilii muscle percilii muscle removal by providing a “surgical located 2.9 Ϯ 1.0 mm from the nasion and 9.8 Ϯ roadmap” as to the anatomical limits required 2.2 mm cephalad to the horizontal plane and the for precise surgical excision of the corrugator lateralmost origin point located 14.0 Ϯ 2.8 mm supercilii muscle, regardless of the technique lateral to the nasion. The apex (most cephalad used (Fig. 3). point) of the corrugator supercilii muscle was lo- Although complete muscle resection is indi- cated 32.9 Ϯ 2.6 mm lateral to the nasion at a cated for migraine surgery, differential preserva- mean height of 32.6 Ϯ 3.1 mm from the horizontal tion of muscle and selective release of periosteum plane. This apex point is crucial for performing and brow retaining ligaments may be required for accurate and complete chemodenervation of the a more individualized approach to forehead corrugator supercilii muscle with botulinum rejuvenation.1,21–23 This should be based on the toxin. A comprehensive technical approach that surgeon’s preoperative evaluation of each pa- involves a more thorough chemodenervation of tient’s specific forehead morphology.1,21,23–25 all the corrugator supercilii muscle fibers is re- Knowledge of the corrugator supercilii muscle to- quired for both the diagnosis of frontal peripheral pography can further assist in selective retention trigger points and in the definitive surgical treat- of portions of the corrugator supercilii muscle ment of migraine headaches.10 If the most ceph- mass or retaining ligaments when indicated. alad extent of the corrugator supercilii muscle is Other glabellar muscles were not evaluated; how- not adequately treated, the successful treatment of ever, future studies using histologic analysis are migraine symptoms may suffer. needed to better define regional muscles such as The current report found the corrugator the medial portion of the orbicularis oculi muscle supercilii muscle dimensions to be consistent and depressor supercilii muscle.

1652 Volume 120, Number 6 • Corrugator Supercilii Muscle

CONCLUSIONS 5. Macdonald, M. R., Spiegal, J. H., Raven, R. B., Kabaker, S. S., and Mass, C. S. An anatomical approach to glabellar rhytids. The dimensions of the corrugator supercilii Arch. Otolaryngol. Head Neck Surg. 124: 1315, 1998. muscle were found to extend more lateral and 6. Walden, J. L., Brown, C. C., Klapper, A. J., Chia, C. T., and superior and displayed a greater width of origin Aston, S. J. An anatomical comparison of transpalpebral, than previously described. In addition, a clear dis- endoscopic, and coronal approaches to demonstrate expo- tinction between the oblique and transverse fibers sure and extent of brow depressor muscle resection. Plast. Reconstr. Surg. 116: 1479, 2005. was not seen. Complete corrugator supercilii re- 7. Guyuron, B. An anatomical comparison of transpalpebral, section for forehead rejuvenation (when indi- endoscopic, and coronal approaches to demonstrate expo- cated) and for supraorbital nerve (and su- sure and extent of brow depressor muscle resection (Dis- pratrochlear nerve) decompression in migraine cussion). Plast. Reconstr. Surg. 116: 1488, 2005. headache treatment can be safely and more pre- 8. Jelks, G. Transpalpebral corrugator/depressor resection. Presented at the Aesthetic Surgery of the Aging Face Symposium, cisely accomplished with the aid of external bony New York, N.Y., November 22, 2003. landmarks. By performing a more systematic ap- 9. Guyuron, B., Varghai, A., Michelow, B. J., Thomas, T., and proach to corrugator supercilii muscle resection, Davis, J. Corrugator supercilii muscle resection and migraine the risk of undesirable postoperative outcomes headaches. Plast. Reconstr. Surg. 106: 429, 2000. such as forehead irregularities, asymmetries, and 10. Guyuron, B., Kriegler, J. S., Davis, J., and Amini, S. B. Com- prehensive surgical treatment of migraine headaches. Plast. unequal muscle reactivation may decrease. In ad- Reconstr. Surg. 115: 1, 2005. dition, the learning curve for performing success- 11. Mosser, S. W., Guyuron, B., Janis, J. E., and Rohrich, R. J. The ful forehead rejuvenation and surgical treatment anatomy of the greater occipital nerve: Implications for the of migraine headaches by means of numerous sur- etiology of migraine headaches. Plast. Reconstr. Surg. 113: 693, gical approaches may be improved with more ac- 2004. 12. Dash, K. S., Janis, J. E., and Guyuron, B. The lesser occipital curate knowledge of the topographic information nerves and migraine headaches. Plast. Reconstr. Surg. 115: provided in this study. In Part II of this study, a 1752, 2005. more refined description of the supraorbital nerve 13. Totonchi, A., Pashmini, N., and Guyuron, B. The zygomat- branching patterns as they pertain to the corru- icotemporal branch of the trigeminal nerve: An anatomical gator supercilii muscle mass will be described. study. Plast. Reconstr. Surg. 115: 273, 2005. 14. Austad, E. D. Comprehensive surgical treatment of migraine Jeffrey E. Janis, M.D. headaches (Discussion). Plast. Reconstr. Surg. 115: 1759, 2005. Department of Plastic Surgery 15. Knize, D. M. An anatomically based study of the mechanism The University of Texas Southwestern Medical Center of eyebrow ptosis. Plast. Reconstr. Surg. 97: 1321, 1996. 1801 Inwood Road, WA4.240 16. Park, J. I., Hoagland, T. M., and Park, M. S. Anatomy of the Dallas, Texas 75390-9132 corrugator supercilii muscle. Arch. Facial Plast. Surg. 5: 412, [email protected] 2003. 17. Isse, N. G., and Elahi, M. M. The corrugator supercilii muscle revisited. Aesthetic Surg. J. 21: 209, 2001. ACKNOWLEDGMENT 18. Knize, D. M. The corrugator supercilii muscle revisited (Dis- The authors thank Rod J. Rohrich, M.D., for the cussion). Aesthetic Surg. J. 21: 214, 2001. generous donation of the cadaver specimens used in this 19. Williams, P. L., Warkwick, R., Dyson, M., and Bannister, L. H. study. (Eds.). Gray’s Anatomy, 37th Ed. London: Churchill Living- stone, 1989. P. 1100. 20. Knize, D. M. A study of the supraorbital nerve. Plast. Reconstr. DISCLOSURE Surg. 96: 564, 1995. None of the authors received financial benefits from 21. Sullivan, P. E., Salomon, J. A., Woo, A. S., and Freeman, M. B. The importance of the retaining ligamentous attachments of any commercial entity in support of this article. the forehead for selective eyebrow reshaping and forehead rejuvenation. Plast. Reconstr. Surg. 117: 95, 2006. REFERENCES 22. Moss, C. J., Mendelson, B. C., and Taylor, G. I. Surgical 1. Guyuron, B. Endoscopic forehead rejuvenation: Limitations, anatomy of the ligamentous attachments in the temple and flaws, and rewards. Plast. Reconstr. Surg. 117: 1121, 2006. periorbital regions. Plast. Reconstr. Surg. 105: 1475, 2000. 2. Knize, D. M. Transpalpebral approach to the corrugator 23. Abramo, C. A., and Dorta, A. A. Selective myotomy in fore- supercilii and procerus muscles. Plast. Reconstr. Surg. 95: 52, head endoscopy. Plast. Reconstr. Surg. 112: 873, 2003. 1995. 24. Freund, R. M., and Nolan, W. B., III. Correlation between 3. Guyuron, B., Michelow, B. J., and Thomas, T. Corrugator browlift outcomes and aesthetic ideals for eyebrow height supercilii muscle resection through blepharoplasty incision. and shape in females. Plast. Reconstr. Surg. 97: 1343, 1996. Plast. Reconstr. Surg. 95: 691, 1995. 25. Byrd, H. S., and Andochick, S. E. The deep temporal lift: A 4. Knize, D. M. Muscles that act on glabellar skin: A closer look. multiplanar, lateral brow, temporal, and upper face lift. Plast. Plast. Reconstr. Surg. 105: 350, 2000. Reconstr. Surg. 97: 928, 1996.

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