The Role of the “C-Line” in Obtaining a Permanent Brow Elevation

My Practice To Yours

The Role of the “C-line” in Obtaining a Permanent Brow Elevation

any different aspects of the techniques used for tion the lateral portion of brow lifting have been explored. I have not been the eyebrow but will often fully satisﬁed, however, by the long-term results lift the medial brow to give

M Downloaded from https://academic.oup.com/asj/article/19/2/148/227917 by guest on 23 September 2021 obtained by the forehead lift through either the open the “surprised look” technique or the endoscopic technique as it has been pre- because of inadequate eleva- viously described. After reviewing the functional anato- tion of the lateral brow. my of the area and the effectiveness of the successful surgical maneuvers,1-5 I have reached several conclusions. The temporal crest is the site of convergence of the super- A brief review of the anatomy reveals the location of the ficial temporal fascia and Adrien E. Aiache, MD, Beverly 6-10 Hills, CA, is a board-certified retaining structures in the lateral eyebrow region. the deep temporal fascia or plastic surgeon and an ASAPS These structures prevent the full elevation of the lateral temporal fascia proper. member. aspect of the brow whereas the medial brow elevation is These fasciae enclose the satisfactory. The localized and limited technique temporalis muscle with the periosteum below it. Medially described as “forehead lift” does not take into considera- the fascial elements enclosing the frontalis muscle are the fascia superiorly and the frontal muscle fascia and the periosteum inferiorly. These convergences create the so- called “line of fusion.” Its release and elevation are necessary to obtain a proper lifting. At its lower position this line of fusion proceeds to the so-called “orbital ligament” situated on the outer upper part of the brow, attached to the superficial temporal fascia at the level of the zygo- matico-frontal suture. Release of this line of fusion is performed usually from lateral to medial, thus avoiding a loss of proper plane of elevation because the periosteum and the posterior temporal fascia inserts on the temporal crest and the release at this level will continue to proceed under the periosteum and posterior fascia of the frontalis muscle. However, it can often be released from superior to inferior as I have done without any difficulties in hug- ging the temporal crest. This elevates the deeper levels of periosteum on both sides in a maneuver similar to the elevation of the periosteum over the zygomatic arch, which is done from medial to lateral and from lateral to medial in a maneuver designed to prevent any injury to the temporal branch.

The “C-line” release is performed as follows: Release of the orbital ligaments is performed at the lateral border of the brow. Over the temple and laterally the superﬁcial

Figure 1. Schematic illustration of the C-line and the incisions for face temporal fascia is distinct and needs to be elevated from lifting. A, The circular dotted line indicates the undermining necessary the deep temporal fascia by blunt dissection. The “sen- for elevation. B, The temporal hooked shaped line indicates the incision. tinel vein” and two sensory nerves mark the crossing of C, The C-line is the heavy dotted line crossing the temporal branch of the facial nerve (N). the frontal branch of the facial nerve. The superﬁcial

148 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 1999 My Practice To Yours Downloaded from https://academic.oup.com/asj/article/19/2/148/227917 by guest on 23 September 2021

1 Figure 2. A, Preoperative view of a 43-year-old woman. B, Postoperative view at 3 ⁄2 years after lower face liposuction with endoscopic temporal lift through endoscopic incisions and revision of bilateral lower lid blepharoplasty.

1 Figure 3. A, Preoperative view of a 41-year-old woman. B, Postoperative view at 3 ⁄2 years after complete face lifting procedure with elevation of the superficial musculoaponeurotic system and plication, and elevation of the corner of the brow through the incision described in Figure 1. temporal fascia is elevated from the deep temporal fascia, A lateral temporal approach will lead to the space whereas the elevator hugs and stays close to the interme- between the superficial temporal fascia above and the diate temporal fascia, which is the superficial layer of the deep temporal fascia below, thus reaching the zygomatic deep temporal fascia, to avoid injury to the frontal arch anterior to the temporomandibular joint. Starting in branch of the facial nerve. This is performed after the front of the temporomandibular and incising the perios- sentinel vein has been coagulated on the deep side to teum, continuation of the “C-line” elevation is performed avoid injury to the nerve. Further dissection over the by cautious elevation of the periosteum staying close to malar periosteum can be performed by use of a soft the bone and in this way going forward joining anteriorly periosteal elevator (Figure 1). the zone that has been freed from the anterior approach.

The Role of the “C-Line” in Obtaining a A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 1999 149 Permanent Brow Elevation My Practice To Yours

With a soft periosteal elevator used, these tissues are then References

elevated at the level below the zygomatic arch and imme- 1. Abramo AC. Full face lift through an endoscopic approach. Aesthetic diately on top of the masseter muscle for approximately Plast Surg 1996;20:59-64. 3 to 5 cm below the arch. This last surgical step is essen- 2. Aiache AE, Ramirez OH. The suborbicularis oculi fat pads: an anatomic tial because it allows the en bloc elevation of the tissues and clinical study. Plast Reconstr Surg 1995;95:37-42. over the zygomatic bone and the fascia of the masseter 3. Aiache AE. Endoscopic face lift. Aesthetic Plast Surg 1994;18:275-8. muscle. Without this last step at the lower part of the C- 4. Aiache AE. Transblepharoplasty brow lift. Can J Plast 1997;5:166-70. line, the temporal elevation of the corner of the brow is 5. Core GB, Vasconez LO, Askren C, Yamamoto M, Gamboa M. Coronal face-lift with endoscopic techniques. Plast Surg Forum 1992;XV:227-8. often impossible. As mentioned by Heinrichs,11 this 6. Giampapa V, DiBernardo B. Suture suspension techniques and liposuc- Downloaded from https://academic.oup.com/asj/article/19/2/148/227917 by guest on 23 September 2021 allows the soft tissue to ﬂoat freely over the zygomatic tion of the neck: an alternative to the early rhytidectomy candidate. arch area. Presented at the 26th annual meeting of The American Society for Aesthetic Plastic Surgery; Boston, MA; April 1993. Fixation is performed by suturing the superﬁcial tempo- 7. Hamas R. Reducing the subconscious frown by endoscopic resection of ral fascia at a higher level onto the deep temporal fascia. the corrugator muscles. Aesthetic Plast Surg 1995;19:21-5. Two strong sutures are applied. The skin is then excised 8. Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional at the level of the incision, ensuring the completion of the lift: case reports. Aesthetic Plast Surg 1994;18:21-9. en bloc elevation resulting from en bloc removal of skin, 9. Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 1996;97:1334-42. galea, and periosteum. This last step has not resulted in 10. Ramirez OM. Endoscopic techniques in facial rejuvenation: an any noticeable alopecia. overview—part I. Aesthetic Plast Surg 1994;18:141-7. The complete liberation of the tissues from the lateral 11. Heinrichs HL. A paradigm analysis. Presented at Horizons in Cosmetic Plastic Surgery Symposium; January 1999; Carlsbad, CA. orbital rim in the medial portion of the C-line is an extremely important step allowing the elevation of the Reprint orders: Mosby, Inc., 11830 Westline Industrial Drive, St. Louis, MO commissure tissues, the eyelid tissue, and the orbicularis 63146-3318; phone (314) 453-4350; reprint no. 70/1/96917 along with the lateral portion of the eyebrow.

This technique has given better long-term results than any of the other previous techniques I have used (Figures 2 and 3). ■

150 A ESTHETIC S URGERY J OURNAL ~ MARCH/APRIL 1999 Volume 19, Number 2