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c00028 The Aesthetic Brow 28 and Forehead Paul Nassif | Garrett Griffin

Key Points p0010 ■ The modern female brow peak should lie closer to the lateral canthus than to the lateral limbus. u0015 ■ In many patients the medial brow does not descend and may actually elevate with age. u0020 ■ The shape of the upper lid crease in comparison to the superior orbital rim and the distance between these curves are important components of a person’s apparent age. u0025 ■ Volumetric restoration of the temple and brow can achieve significant upper facial rejuvenation. u0030 ■ During surgical brow rejuvenation, it is best to avoid excess cautery, scalp excision, and subcutaneous sutures if possible. u0035 ■ Periosteal release is a given, but temporal orbicularis release is essential. u0040 ■ Bony fixation is usually not necessary in most cases, if an extensive release is performed. Deep temporal fixation with absorbable sutures is all that is needed to maintain brow height in many patients. u0045 ■ Avoid excess glabellar muscle manipulation. u0050 ■ Overcorrect brow height. u0055 ■ Botox is an excellent adjunct in the preoperative and postoperative period. u0060 ■ Be aware of neurologic deficit, do not be afraid of it; permanent motor damage is rare, and sensory deficit is common and is usually temporary. u0065 ■ Postoperative dressings can increase periorbital swelling and ecchymosis. Drains can decrease edema and bruising and provide a painless way to deliver bupivacaine after surgery in patients with excess pain.

p0075 Facial rejuvenation surgery requires an appreciation for aes- eyebrow. Over the past 15 years, aesthetic surgeons have thetic facial proportions. The face has traditionally been divided adopted a much more three-dimensional view of facial aesthet- into vertical thirds, with the upper third extending from the ics. The youthful brow region is full and convex with smooth glabella to the trichion. In patients with a receding hairline, skin and no creases. It is “luminous,” with no shadows. On the uppermost point of action of the frontalis muscle can be three-quarter view, the convex brow gently transitions into the used instead. The glabella can be defined as the point of concave lateral orbital wall to form the upper facial ogee. On maximal anterior projection on lateral view. An attractive frontal view, the temple is full and prevents visualization of the female forehead produces a smooth and gentle convexity on zygomatic arch or temporal line (Fig. 28-3). Recent studies have profile. Other shapes include sloping, flat, and protruding. The created a new terminology and emphasize the relationship of eyebrows generally follow a smooth, gently curving arc that the brow and upper eyelid. Goldberg and colleagues4,5 coined extends from the lateral eyebrow around the nasion and down the terms brow fat span (BFS) and tarsal platform show (TPS) to the lateral nasal sidewall (Fig. 28-1, A). In women, the eyebrow represent the distance between the upper eyebrow and upper should lie slightly above the supraorbital rim and follow a lid crease and lid crease and upper eyelid margin, respectively; gently curving arc (Fig. 28-2). The eyebrow begins at a line they went on to identify a youthful TPS : BFS ratio of 1 : 1.5 drawn from the alar-facial groove through the medial canthus medially and 1 : 3 laterally (Fig. 28-4). and ends at a line drawn from the alar-facial groove through the lateral canthus.1 Classically, the highest point of the eyebrow s0010 in women was said to lie above the lateral limbus, although ANATOMY recent studies suggest that the modern ideal female brow has The relatively thick forehead and brow skin abuts the very thin p0085 a peak above the lateral canthus.2,3 The medial and lateral ends upper eyelid skin at the inferior edge of the eyebrow. The of the eyebrow should lie in a horizontal line, and the medial forehead and periorbital muscles are a key driver of upper end should have a clublike configuration that gradually tapers facial aging. The orbicularis oculi muscle is superficial to the laterally. In men, the brow usually lies at the level of the supra- frontalis and acts as a middle and lateral brow depressor. The orbital rim and is less arched (see Fig. 28-1, B). medial brow depressors comprise the paired procerus muscles, p0080 In the past, the brow was primarily analyzed in only two dimen- which are flanked laterally by the depressor supercilli and sions and focused on the height and shape of the hair-bearing corrugator supercillii muscles. The corrugator muscle is the 28-1

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28-2 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

A B f0010 FIGURE 28-1. A, Smooth, gently curving line extending from eyebrow to nose. B, Sharp angle between eyebrow and nose. (Modified from Nassif PS, Kokoska MS. Aesthetic facial analysis. Facial Plast Surg Clin North Am 1999;7:1. Copyright 2008 by Johns Hopkins University, Art as Applied to Medicine.)

Westmore’s traditional More contemporary ideal female brow ideal female brow (brow peak) (brow peak)

Lateral limbus Lateral canthus

A B f0015 FIGURE 28-2. A, Westmore’s traditional ideal female eyebrow with the peak at the lateral limbus. B, A more contemporary ideal female eyebrow with the peak at the lateral canthus.

A B f0020 FIGURE 28-3. A, On frontal view, the youthful forehead skin has no creases. The temples are convex, and the superior edge of the zygomatic arch is well disguised. The full width of the eyebrow is visible. B, On three-quarter view, a full and convex brow gently transitions into the concave orbital rim and then into the full convex cheek. This creates the upper facial “ogee.” (From Matros E, Garcia JA, Yaremchuk M. Change in eyebrow position and shape with aging. Plast 6 Reconstr Surg 2009;123:1296-1301.)

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28 | THE AESTHETIC BROW AND FOREHEAD 28-3

1:3 1:1.5 BFS 1:2 TPS 1:1

A B f0025 FIGURE 28-4. A, The tarsal plate show (TPS) is the distance from the lash line to the upper lid crease. The brow fat span (BFS) is the distance between the lid crease and inferior edge of the brow. The youthful TPS to BFS ratio is 1 : 1.5 medially and 1 : 3 laterally. B, With age, bone and soft tissue loss around the eye increases the amount of TPS and decreases the BFS. In some patients, this can give the illusion of brow ptosis, when in fact the actual distance of the brow from the lash line is the same or even increased.

strongest brow depressor, has a transverse and oblique head, the levator and create a contour irregularity. The ORL extends and causes the formation of deep vertical glabellar creases. It over the zygoma as the lateral orbital thickening. It should also originates over the medial supraorbital ridge and inserts on the be emphasized that the ORL “seal” at the boundary between underside of the frontalis muscle. This deep location must be the forehead and upper lid is incomplete around neurovascu- kept in mind when performing botulinum toxin injections. The lar structures. This is one possible mechanism whereby botuli- procerus is largely responsible for the formation of transverse num toxin injections can reach the levator and cause ptosis. glabellar creases, also called “bunny lines.” p0090 The frontalis muscle is the primary brow elevator. In most patients, the medial edges of the left and right frontalis muscle bellies do not meet. Using cadaver dissections, Knize6 noted that the lateral margin of the frontalis muscle almost always Galea ends along or just lateral to the temporal fusion line. However, in these dissections, the temporal line was found to range from Superficial galea mid brow to just lateral to the lateral edge of the eyebrow. The more medial the intersection, the less frontalis muscle there is Deep galea to support the lateral brow; these individuals may be more prone to lateral brow ptosis. Frontalis muscle p0095 1 Knize has beautifully described the fascial layers of the brow region, which are critical to understand prior to performing surgery or volume augmentation in this area (Fig. 28-5). These layers are similar, but not identical, to the layers in the temple. The galea aponeurotica splits to envelop the frontalis muscle Galea fat pad and thus forms superficial and deep galea planes. The deep (brow fat) galea plane splits again to envelop the galea fat pad, also sometimes called brow fat. The corrugator muscle actually travels within the galea fat pad. The deep galea plane splits a third Corrugator muscle time to form the glide plane space deep to the corrugator, which contains only areolar tissue. The deepest layer of the deep Gliding plane space galeal fascia is adherent to the underlying periosteum. The various layers of the deep galeal fascia typically rejoin and fuse Superior orbital rim at the orbital rim to form the suborbicularis fascia and orbital septum, which divide the preseptal and preaponeurotic fat in Area of galea layer fusing 2 the upper lid. Knize7,8 did identify individuals in whom the at superior orbital rim deep glabellar fascial layers did not rejoin at the orbital rim. In these individuals, the glabellar fat pad is not as well encapsu- lated or fixed—another anatomic factor that could contribute to early brow ptosis. p0100 The aforementioned fascial layers travel parallel to the underlying bone, but the periorbital region is also rich in true and false facial retaining ligaments that pass perpendicularly f0030 and affix the skin to the underlying bone and deep fascia, FIGURE 28-5. The fascial layers in the brow are somewhat analogous to respectively.9 The orbicularis retaining ligament (ORL) is a the layers in the temple, where there is a deep and superficial fascia, and the membrane that extends from the suborbicular fascia to the deep fascia splits to envelop a fat pad. In the forehead and brow, the galea periosteum, thereby stabilizing the orbicularis oculi muscle. divides to envelop the frontalis, creating a superficial galea and deep galea. At the level of the brow, the deep galea divides to envelop the galeal fat pad, The ORL inserts 2 to 3 mm above the inferior edge of the also known as the brow fat. This space also contains the corrugator muscle. supraorbital rim and divides the forehead from the upper The deepest galeal layer splits again to create the glide plane space, which is eyelid. This is a critical anatomic point; materials injected above an area deep to the corrugator that contains areolar tissue only and allows this point will augment the brow, whereas injections inferior to the corrugator to medialize the brow. Typically, all of these layers re-fuse at this point will enter the upper eyelid proper, which can damage the superior orbital rim.

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28-4 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

Frontalis muscle

Supraorbital nerve Deep galea Frontal Galea fat pad periosteum (brow fat)

Corrugator muscle

f0035 FIGURE 28-6. The deep division of the supraorbital nerve runs in the floor of the glide plane space just superficial to the frontal periosteum. During a brow lift, if elevation of the forehead is errantly performed just superficial to the periosteum, this nerve can be injured. Injury to this nerve often causes parietal hypesthesia for 2 to 3 months followed by intense pruritus that can drive patients to literally scratch their hair out.

p0105 The supraorbital and supratrochlear branches of the oph- remain in place or elevate with age. Van den Bosch and col- thalmic division of the trigeminal nerve provide the primary leagues2 analyzed brow position in men and women through- sensory innervation to the forehead, upper lid, and brow. The out life, noting a higher lid crease (more TPS) and higher deep branch of the supraorbital nerve exits its foramen/notch eyebrow position. Goldberg and Lew4 have similarly shown that and turns posterolaterally to innervate the parietal scalp (Fig. the TPS increases medially and laterally with age. Matros and 28-6). It travels just superficial to the periosteum and is at risk colleagues3 compared brow position in young women (ages 20 during brow-lifting procedures, if the subgaleal or subperios- to 30 years) and older women (ages 50 to 60 years) and found teal layers of dissection are not respected. Injury to this nerve that the lateral brow remains stable, whereas the middle and can cause intense pruritus that can cause patients to literally medial brow rise. Lambros12 compared photographs of the same scratch their hair out. The zygomaticotemporal nerve (maxil- patients throughout their lives and found that the brow lary division of the trigeminal nerve) contributes to temporal descended in 29%, remained stable in 30%, and was elevated and lateral forehead sensation. in 41%. One possible confounding variable in some of these p0110 The facial nerve provides motor innervation to all of the studies is that upper lid dermatochalasis and involutional forehead and periorbital musculature. The frontal branch of the blepharptosis are more common in older individuals, and both facial nerve innervates the frontalis muscle. Above the zygomatic are known to cause eyebrow pseudoelevation. arch and lateral to the frontalis, this nerve travels just deep to Contemporary theories about upper facial aging emphasize p0125 the temporoparietal fascia and is at risk during endoscopic and that volume loss is as important as descent. The brow and deep open brow-lifting procedures (Fig. 28-7). The orbicularis oculi, temporal fat pads atrophy, and the normally thick brow skin corrugator, procerus, and depressor supercilii are innervated by becomes thinner and less elastic. The once full and convex temporal and buccal branches that travel inferior to the eye. brow skin lies flat against the underlying bone and creates p0115 The brow and forehead receive their blood supply primarily shadows between the eyebrow and the upper eyelid crease. The from the supraorbital and supratrochlear branches of the oph- temple becomes concave, exposes the zygomatic arch, and thalmic artery, which are part of the internal carotid system. causes shadows around the tail of the brow, which produces The frontal branch of the superficial temporal artery contrib- skeletonization and the impression of age. Forehead aging is utes to lateral forehead blood supply. Unilateral and even bilat- dominated by the formation of deep creases from the cumula- eral blindness caused by forceful injection of fat and filler into tive effect of periorbital muscle firing in combination with the the face and nose has been reported many times, presumably loss of collagen and elastin from the skin.13 because of retrograde flow of particles that cause central retinal Thus each patient’s brow and forehead aging will manifest p0130 artery occlusion.10,11 The location of these blood vessels must as a unique combination of ptosis, skin changes, and volume be kept in mind at all times when performing injections in this loss. As in all fields of medicine, the success of brow and fore- region. Blunt cannula techniques and small syringes may head rejuvenation depends on making the correct diagnosis. reduce the risk of injecting particles intravascularly.

s0015 AGING BROW AND FOREHEAD PATIENT SELECTION s0020 p0120 Traditional conceptions of brow aging focused on ptosis, so Psychological Considerations s0025 brow rejuvenation has historically revolved around brow-lifting As with any facial plastic surgery procedure, careful patient p0135 techniques. Interestingly, several studies show that the eyebrows selection is paramount. Realistic expectations and proper

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28 | THE AESTHETIC BROW AND FOREHEAD 28-5

Frontalis muscle 1.5 cm or more above the arch and 1 cm or more from lateral orbital rim

Zygomatic arch

Lateral orbital rim

Frontal branch of facial nerve

f0040 FIGURE 28-7. The frontal branch of the facial nerve is quite deep over the zygomatic arch but transitions to a more superficial location just deep to the temporoparietal fascia above the arch. Recent anatomic studies suggest that the nerve enters this more superficial plane 1.5 cm or more above the arch and 1 cm or more from the lateral orbital rim. During endoscopic brow lift, the nerve is encountered in this more superficial “danger area.” Thus the nerve is best protected by elevating right on the temporalis muscle fascia. In doing so, the frontal branch will be safely elevated with the temporoparietal fascia.

motivations of the patient are extremely important in achieving and in facial repose. Manually elevating the brow reveals the a successful outcome, a satisfied patient, and a pleased facial favorable effect of brow elevation. Individuals with ptotic eye- plastic surgeon. Despite a visually pleasing surgical result, if the brows often involuntarily attempt to elevate the brow with fron- surgeon has not performed proper patient screening, patient talis muscle contraction. To eliminate pseudoelevation of the dissatisfaction may still be encountered. Educating patients brow, patients should close their eyes and then slowly open about the different surgical procedures and goals requires them after allowing the frontalis muscle to relax. In some excellent physician-patient communication and guidance. patients, the surgeon will need to stabilize the brows as the eyes Computer imaging of the proposed brow elevation may enhance are opened to prevent the patient from unconsciously elevating the communication of surgical goals, because few patients are them. The true position of the eyebrow can then be evaluated aware that brow ptosis is responsible for their orbital changes. in repose by the surgeon. Additionally, the eyebrow position Often, patients think and are told that droopy eyelid skin in can be examined with the patient’s eyes closed. The following the presence of a ptotic brow is the cause of their “saddened” are anatomic and physiologic factors to evaluate when consider- look. If upper blepharoplasty is performed in this situation, the ing a patient for aging forehead rejuvenative surgery: eyebrow-lid margin is potentially narrowed, which obliterates • Location of frontal and temporal hairline u0070 adequate delineation of the supratarsal anatomy by sacrificing • Quality of hair: alopecia, thinning, or abundant u0075 excessive upper eyelid skin.14 Following the education process, • Forehead height relative to facial proportions u0080 candidates for aging brow surgery must give informed consent • Severity of forehead, temporal, and lateral canthal (crow’s u0085 after possible adverse outcomes, complications, and risks of the feet) rhytids selected surgical procedure are discussed. • Eyebrow aesthetics: shape, symmetry, quality, texture, posi- u0090 tion, and mobility s0030 Patient Evaluation • Presence of prominent supraorbital ridge or hollow orbit u0095 p0140 Analysis of the upper third of the face, from the eyebrows to • Degree of dermatochalasis: excess skin, tone, lateral u0100 the hairline, should begin with the assessment of interpersonal canthal hooding, and presence of medial fat pad factors; these may significantly affect the patient’s interpreta- • Previous eyelid or eyebrow surgery and scars u0105 tion of successful surgical intervention and, as such, these must • Presence of lagophthalmos (inability to close the upper u0110 be carefully examined. Age, gender, race, body habitus, and eyelid completely) personality are the main interpersonal components that must • Scalp mobility u0115 be considered when assessing the eyebrow complex.15 • Lateral canthus position u0120 p0145 When determining which brow-lifting procedure to use, spe- • Skin elasticity and texture u0125 cific anatomic criteria should be evaluated when examining the • History of ocular disease u0130 patient. The patient should be examined in a sitting position • Previous LASIK surgery or dry eyes u0135

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28-6 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

t0010 TABLE 28-1. Indications and Contraindications for Individual Forehead- and Brow-Lifting Procedures Procedure Indications and Advantages Contraindications and Disadvantages u0175 Coronal Treats all aspects of aging forehead and brow Limited use in men u0180 forehead lift Elevates hairline u0185 Vertically lengthens upper third of face u0190 Elongated scar u0195 Possible prolonged hypesthesia of the scalp u0200 Less fine-tuning of brow position u0205 u0210 Pretrichal High hairline Possible visible (exposed) scar u0230 u0215 forehead lift No vertical forehead lengthening Possible prolonged hypesthesia of scalp u0235 u0220 Preserves hairline u0225 Treats all aspects of aging forehead and brow u0240 Midforehead lift Prominent horizontal forehead creases Possible visible (exposed) scar u0260 u0245 Preserves hairline Avoid in oily, thick skin u0265 u0250 Improved fine-tuning of brow position u0255 Corrects brow asymmetry u0270 Direct brow lift Accurate brow elevation Possible visible (exposed) scar u0295 u0275 Preserves forehead/scalp sensation Treats brows only u0300 u0280 Patients with abundant or thick brow hair preferred u0285 Immediate scar camouflage (with hair) u0290 Corrects brow asymmetry u0305 Temporal lift Ideal and immediate scar camouflage (with hair) Not useful for midforehead glabellar creases u0315 u0310 Improves lateral hooding No effect on medial aspect of brow u0320 u0325 Browpexy Performed through upper blepharoplasty or small Possible prolonged eyelid edema u0335 superior edge of eyebrow incision Possible brow asymmetry u0340 u0330 Indicated for mild brow ptosis Possible unsatisfactory results u0345 u0350 Endoscopic Less invasive with small incisions Less fine-tuning of brow position u0380 u0355 brow lift Excellent scar camouflage Possible contour irregularities in scalp u0385 u0360 High hairline because of paramedian bony fixation u0365 No vertical forehead lengthening u0370 Preserves hairline u0375 Treats most aspects of aging forehead and brow Modified from Tardy ME, Thomas JR, Brown R, eds. Facial aesthetic surgery, St Louis: Mosby; 1995:163.

choice.17-19 In the past decade, a better appreciation for volume s0035 SURGICAL GOALS loss and the advent of injectable neurotoxins and soft tissue p0220 The goals associated with rejuvenation surgery of the brow and fillers have reduced the need for surgical rejuvenation of the upper third of the face include the following15,16: upper face. The indications and contraindications for each u0140 • Elevation of ptotic eyebrows open forehead and brow-lifting procedure are described in u0145 • Revolumization of the brow, temple, and periorbital Table 28-1. regions u0150 • Reduction of lateral hooding and redundant upper eyelid Coronal Forehead Lift s0045 skin For total forehead and brow elevation with excellent longevity, p0490 u0155 • Elevation of lateral canthus (if needed) the coronal lift should be considered. The coronal incision is u0160 • Reduction of glabellar and corrugator rhytids posterior to the frontal and temporal hairline and generally u0165 • Reduction of lateral canthal (crow’s feet) rhytids follows the shape of the hairline; it extends from the superior 3 u0170 • Correction of eyebrow asymmetry helical of one ear to that of the other ear. The subgaleal plane p0260 In general, the selected brow elevation procedure should be is used for the dissection. Redundant and excess skin and galea performed before upper blepharoplasty, so the facial plastic are excised, and the wound is closed in layers. Typically, 4-0 surgeon can judge the precise amount of upper eyelid skin to absorbable sutures are used in the galeal layer, and the skin is be removed. This helps prevent excessive elevation of the brow- closed with skin staples. Most aspects of the aging forehead and lid complex with the potential for causing lagophthalmos. In brow, including rhytids and ptosis, are effectively treated with some cases, the need for upper blepharoplasty may be elimi- this approach. nated after brow-lifting procedures. p0265 Overall, selection of the specific brow procedure will be Pretrichal Forehead Lift s0050 determined by integrating the psychological and anatomic con- In patients with an elongated forehead and high hairline, the p0495 siderations together with the proposed surgical goals. pretrichal forehead lift may be used. The pretrichal incision, created in an irregular pattern, is located at the junction of the cephalic aspect of the forehead and hairline, or it is placed just s0040 SURGICAL TECHNIQUES within the hairline to further camouflage the scar. A beveled p0270 Traditional methods of forehead and brow rejuvenation—such incision is used to allow hair follicle growth through the scar as coronal, pretrichal, and direct brow lifts—have provided to add additional camouflage. The temporal component of the facial plastic surgeons with effective brow elevation for many incision is connected to the pretrichal incision and is posterior years. In the late twentieth century, the endoscopic forehead to the temporal hairline, similar to a coronal lift. Excess skin and brow lift rapidly became accepted as part of the surgical and galea are resected from the anterior flap. Closure is beveled armamentarium and became the surgical technique of to accommodate hair follicle growth through the scar. The

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28 | THE AESTHETIC BROW AND FOREHEAD 28-7

galeal and dermal layers are closed with 4-0 absorbable suture, blepharoplasty through the same incision. Essentially, the brow and the skin is closed with 6-0 minimally reactive suture, which fat and orbicularis muscle are elevated and secured to the peri- is removed in 1 week. osteum more superiorly. Some authors have found this to be p0500 The advantage of the pretrichal incision is that the forehead somewhat unreliable and unpredictable. Multiple modifica- is not elevated, and the frontal hairline is preserved. The pre- tions that have intended to improve this technique have been trichal forehead lift treats all aspects of the aging forehead and described. We prefer Massry’s21 external browpexy, which relies brow. on an 8-mm incision along the central superior edge of the eyebrow. Through this small cutaneous access, a 2.5-cm wide s0055 Midforehead Lift tranverse cut is made through the orbicularis muscle and brow p0505 The midforehead lift is rarely performed. The typical patient fat down to the periosteum. A 4-0 permanent suture is passed must have prominent forehead creases because the incision through the periosteum at the desired brow height in a hori- and ultimate scar is placed in an elongated, central transverse zontal mattress fashion; the suture is then passed through the rhytid that crosses the midline. The subcutaneous plane is used orbicularis and brow fat at the inferior extent of the dissection, for the dissection. also in a horizontal mattress fashion. The suture is tied, and the incision is closed in two layers. After external browpexy, the s0060 Midforehead Brow Lift brow should resist inferior displacement (Fig. 28-8). Upper p0510 The midforehead brow lift is similar to the midforehead lift blepharoplasty can then be completed as necessary. except that the forehead incisions are bilateral and do not cross the midline, nor do they interconnect. Forehead and glabellar Endoscopic Brow Lift s0075 rhytids are not treated with this brow-lifting procedure. The Endoscopic brow-lifting techniques have been progressively p0525 procedure may be unilateral, as in cases of hemifacial paralysis refined through experience and improvements in equipment. with brow ptosis on one side. In general, the temporal dissection and temporal fixation have been standardized; however, different options for forehead dis- s0065 Direct Brow Lift section are available. Subperiosteal dissection with release— p0515 In certain situations, the direct brow lift may be used. The inci- elevation, incision, and spread—of periosteum or subgaleal sion follows the eyebrow and is placed within and parallel to dissection and release of brow depressor musculature to the the uppermost hair follicles of the brow. Even in the best of supraorbital rim are both effective techniques used in endo- meticulous closures, the fine scar may be visible. We have found scopic brow lifts. Methods of bony fixation remain a controver- this technique to work quite well in older males with bushy sial topic in that numerous methods are possible. Some of these eyebrows. This procedure may also be useful in the facial paral- methods include absorbable and nonabsorbable screws, bone ysis patient. tunnels with sutures, fixation to soft tissue using absorbable attachment devices such as Endotine or Ultratine (MicroAire, s0070 Browpexy Charlottesville, VA), and fibrin glue.22,23 For patients with more p0520 Browpexy is a term for a procedure that seeks to elevate or stabi- isolated lateral brow ptosis, we advocate deep temporal fixation lize the brow via a more direct and minimally invasive approach. only without any bone fixation.24 In patients with asymmetric In 1990, McCord and Doxanas20 described the internal brow- brows, ptotic medial brows, heavy brows, or a severely ptotic pexy as brow suspension performed in conjunction with upper brow, we use bone fixation with the Ultratine device.

Periosteum

Orbicularis muscle 8-mm incision

A B f0045 FIGURE 28-8. The external browpexy is a minimally invasive way to elevate the brow. It can also be used to stabilize the brow during aggressive or revision upper blepharoplasty. A, An 8-mm incision is made in the upper border of the eyebrow. The initial position of the eyebrow (dashed line) and lift (arrows) are shown. B, Sagittal view of the path of 4-0 Prolene sutures between the periosteum at the desired new height and through brow fat and orbicularis muscle at the inferior edge of the incision.

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28-8 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

Frontalis muscle

Depressor Procerus muscle supercilii muscle

Corrugator Transverse head supercilii muscle of corrugator supercilii muscle Temporalis muscle Medial head of orbicularis Orbicularis oculi muscle oculi muscle

f0050 FIGURE 28-9. Muscles relevant to rejuvenation of the brow and forehead. Brow elevators: frontalis muscle. Brow depressors: orbicularis oculi muscle, corrugator supercilii muscle (with transverse and oblique heads), depressor supercilii muscle, and procerus muscle. Other relevant muscles include the temporalis muscle.

p0530 The technique that achieves excellent brow elevation is in length. The key to obtaining a natural-looking brow is to release of the periosteum from one inferolateral orbit to the create a temporal incision parallel to the tail of the brow with other and release of the brow depressor musculature (corruga- its medial extent close to the temporal hairline (Fig. 28-10). tor, procerus, depressor supercilii, and supraorbital orbicularis The temporal incision orientation helps elevate the lateral half oculi; Fig. 28-9). Following the brow lift, all depressor vector of the brow in a superomedial vector. forces should be eliminated to promote the maintenance of the newly elevated brow position, because periosteal reattachment LOCAL ANESTHESIA s0095 to bone takes approximately 6 to 12 weeks.25 The local anesthesia consists of 10 mL of 1% lidocaine with p0550 s0080 Temporal Lift 1 : 100,000 epinephrine injected into the corrugator, procerus, p0535 In patients with adequate medial brow position and ptotic and depressor supercilii muscles; the proposed incision sites; lateral brow and lateral canthal hooding, an endoscopic tem- and for supraorbital and supratrochlear nerve blocks. The rest poral (temple) lift may be performed. A temporal lift is per- of the central forehead, parietal scalp, and temporal region are formed with the same principles and technique as the infiltrated with approximately 50 to 75 mL of a tumescent solu- endoscopic brow lift (surgical technique is described in subse- tion that consists of 500 mL of normal saline mixed with 0.5 mL quent paragraphs), except that the medial border of the periosteal and brow depressor musculature release is the supraorbital neurovascular complex. The supraorbital orbicularis oculi muscle is the only brow depressor treated. The medial brow and glabellar region are not dissected, which results in elevation of the lateral two thirds of the brow–lateral canthal complex.

s0085 SURGICAL TECHNIQUE p0540 Following photo documentation of the patient’s forehead and brows, the patient is brought into the operating suite. In most situations, an anesthesiologist administers general anesthesia with a laryngeal mask.

s0090 INCISIONS

p0545 The incisions are then marked: one midline and two temporal, f0055 although two paramedian incisions are made if bone fixation FIGURE 28-10. Standard endoscopic brow-lift incisions. The central inci- is planned. The anteroposterior midline incision is approxi- sion is made vertically by many surgeons, not horizontally as shown. If the mately 2 cm posterior to the hairline and 1 cm in length, just paramedian incisions are going to be used to help lift the brow, they should large enough to allow the introduction of periosteal elevators be placed directly superior to the desired point of elevation. If only lateral into the subperiosteal space; the temporal incisions are 3 cm brow elevation is desired, the paramedian incisions are omitted.

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28 | THE AESTHETIC BROW AND FOREHEAD 28-9

of 1 : 1000 epinephrine, 5 mL of sodium bicarbonate, and 25 mL of 2% lidocaine without epinephrine. The high volume of the solution acts as a vascular tourniquet and is primarily used in the temporal region. The patient is prepped and draped in the usual sterile fashion, and approximately 15 minutes is allowed for anesthesia and hemostasis to be established.

s0100 FRONTAL AND PARIETAL BONE DISSECTION p0555 The midline vertical incision is made and is extended through the periosteum. Without the use of the endoscope, a periosteal elevator is used to create a subperiosteal pocket posteriorly over the parietal forehead and anteriorly over the central forehead to approximately 1 cm above the brow, with care taken not to injure the supraorbital and supratrochlear neurovascular bundles. f0065 FIGURE 28-12. The temporal incision is taken down to the deep temporal s0105 TEMPORAL DISSECTION AND fascia. RELEASE OF THE PERIOSTEUM AND LATERAL SUPRAORBITAL ORBICULARIS OCULI MUSCLE to the dissection on the undersurface of the temporoparietal fascia.26 Usually, the sentinel vein is preserved, and the dissec- p0560 The temporal incisions are made and are extended to the deep tion is performed circumferentially around the vein. If the vein temporal fascia (Fig. 28-11 and 28-12). A blunt elevator dissects is cauterized, bipolar forceps are placed at the base of the sen- over the deep temporal fascia inferiorly, until a branch of the tinel vein to help prevent a thermal neuropraxic injury to the zygomaticotemporal vein, called the sentinel vein, is encoun- frontal branch of the facial nerve. If the sentinel vein is cauter- tered (Fig. 28-13). This is the inferior limit of the dissection ized, it may increase the prominence of temporal and lower lid without the use of the endoscope. A facelift scissors is used to veins, which is aesthetically displeasing. connect the temporal incision to the central forehead incision Dissection stops at the level of the lateral canthus. To prevent p0570 by severing the conjoint tendon, which is released with a peri- elevation of the lateral canthus, an assistant places a finger in osteal elevator in a superior to inferior direction to the level of the interior aspect of the lateral rim at the lateral canthus; in the supraorbital rim. Near the supraorbital rim, a thickening the rare instance that the surgical plan calls for lateral canthal 4 of periosteum is encountered, which Moss and colleagues9 angle elevation, the lateral canthus is released. The periosteal termed the “ligamentous adhesion.” Release continues inferi- release—elevation, incision, and spreading—begins superior to orly through the ORL and its more robust expansion near the the lateral canthus and extends medially to the supraorbital lateral canthus, called the lateral orbital thickening. Adequate neurovascular complex; care is taken not to injure the nerve. release of the conjoint tendon, ligamentous adhesion, and Following the periosteal release, the lateral supraorbital orbi- ORL are essential to obtaining an effective lift. cularis oculi muscle is meticulously released from the infero- p0565 The endoscope is placed in the temporal dissection along medial orbit to the supraorbital nerve, exposing the yellow with the elevator to visualize the sentinel vein, a reliable marker brow fat. This same procedure is performed on the contralat- for the frontal branch of the facial nerve, which lies superficial eral temporal region.

f0070 FIGURE 28-13. Dissection right on the deep temporalis fascia will reveal f0060 the sentinel vein piercing the temporalis fascia near the lateral brow. In this FIGURE 28-11. Marking of the temporal incision (large arrow) parallel to image, the frontal nerve will be lifted with the superficial flap. If the sentinel the tail of the brow with its medial extent just posterior to the temporal line vein is traumatized and bleeds, it should be cauterized near its base (near (small arrow). the deep temporal fascia) to help protect the frontal branch.

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28-10 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

BROW ELEVATION AND FIXATION s0115 We place a drain through the temporal hairline into the sub- p0580 periosteal space, which passes across the forehead to the con- tralateral temporal region. This decreases swelling and bruising and makes it easy to instill bupivacaine into the wound postoperatively, if patients have severe pain. If a complete release of all periosteum and brow depressor musculature is performed, the entire brow complex will elevate to an unnaturally high position without any tension (Figs. 28-15 and 28-16). Brow fixation is achieved by securing the superficial temporal fascia to the deep temporal fascia in a superomedial vector with two 2-0 polydioxanone (PDS) horizontal mattress 5 sutures, while the brow is lifted superiorly and overcorrected. If bone fixation is indicated, two paramedian 2-cm vertical incisions are made parallel to the lateral two thirds of the brow. The absorbable Endotine or Ultratine device is inserted into a hole drilled in the cranium. The periosteum/galea f0075 complex is lifted posterior to (over) the device. When the FIGURE 28-14. After periosteal and brow depressor muscle release, the brow is slightly overcorrected, the tissue is impaled onto the supraorbital neurovascular complex is visualized without obstruction from hooks of the device, thus fixating the brow to its new height overlying muscle fibers. (Fig. 28-17). The current Endotine absorbs in approximately 9 months, and the Ultratine absorbs slightly faster. A recent s0110 RELEASE OF THE BROW study suggested a higher failure rate and a greater incidence DEPRESSOR MUSCLES of cyst formation, with possible retention, with the Ultratine compared with the Endotine device.27 Occasionally, patients p0575 For the temporal lift, this portion of the procedure is elimi- may palpate the device or complain of sensitivity in the sur- nated. The endoscope remains placed through the temporal rounding region. incision, and the periosteal elevator is placed through the central incision. The dissection is carried to the central supraorbital region and radix of the nose, releasing the periosteum and s0120 avoiding injury to the supraorbital and supratrochlear nerves. POSTOPERATIVE CARE Thorough corrugator, procerus, and depressor supercilii myot- Incisions are dressed with antibiotic ointment without a head p0585 omies are performed. To ensure that complete myotomies have dressing, and patients may experience headaches and minimal been performed, each nerve of the supratrochlear and supraor- pain initially. Shampooing with gentle cleaning of the hair bital neurovascular complexes (Fig. 28-14) should be easily occurs at 48 hours, when the hair may be blown dry using a visualized without obstruction from overlying muscle fibers. cool drier setting. Patients are instructed to maintain a semiu- These muscles tend to regain activity even after an aggressive pright position when sleeping or resting for at least the first 4 release, and some authors place temporalis fascia or alloderm at days. The staples are removed at 7 days, and full activity may the myotomy site to limit regeneration; this is much less neces- resume in 3 weeks. Figures 28-18 through 28-20 are examples sary in the age of botulinum toxin. of results.

A C f0080 FIGURE 28-15. Patient before (A) and 1 week after (B) endoscopic brow lift with deep temporal fixation only. C, Intraoperative image of the patient’s elevated brow complex to an unnaturally high position after a complete release of all periosteum and brow depressor musculature before fixation.

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28 | THE AESTHETIC BROW AND FOREHEAD 28-11

f0085 f0090 FIGURE 28-16. Intraoperative image of a patient’s elevated left brow FIGURE 28-17. The Endotine and Ultratine devices are one way to suspend complex after a unilateral complete release of all periosteum and brow the forehead soft tissues after release and elevation. This image shows depressor musculature before fixation. Cotton swabs are positioned at the the Ultratine device in place before impaling the elevated soft tissue flap for inferior border of the supraorbital rim. suspension. The Ultratine is reported to absorb 2 to 3 months sooner, although it may be associated with a higher risk of retention and pseudocyst formation.

A f0095

FIGURE 28-18. Preoperative and 1-year postoperative views of a 32-year-old woman who had severe brow ptosis and blepharochalasis. Deep temporal fixation-only endoscopic brow lift and bilateral upper blepharoplasty were performed. A, Frontal before and after views. B, Right oblique before and after views. The oblique view documents significant improvement in the temporal hooding, lateral canthal, and eyelid regions.

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28-12 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

A B f0100 FIGURE 28-19. Right oblique before (A) and after (B) views of a 43-year-old man who underwent upper blepharoplasty 4 years earlier, now complaining of a “tired look.” The brow, especially in the temporal region, descends below the supraorbital rim and causes temporal hooding, and the supratarsal crease is covered by overhanging ptotic upper eyelid skin. After a deep temporal fixation–only brow lift, the patient’s brow ptosis is moderately improved.

s0125 COMPLICATIONS TREATMENT OF THE DEPRESSOR s0130 p0590 Few complications result from brow lifting, and it has been our MUSCLES WITH BOTULINUM TOXIN experience that fewer complications occur with the endoscopic brow lift than with the coronal lift. Hematoma, seroma, hypes- Botulinum toxin may be used alone or synergistically with the p0595 thesia, tingling, pruritus, a “bandlike” forehead sensation, surgical brow depressor musculature release in an effort to paresis of the temporary frontal branch of the facial nerve, weaken the inferior vector forces and promote the maintenance temporary or permanent alopecia, infection, stitch abscess, of the newly elevated brow. Botulinum toxin is used to block brow asymmetry, relapse of brow ptosis, paramedian incision the depressor function of the corrugator, procerus, depressor depressions with screw fixation, and hypertrophic scars have all supercilii, and lateral supraorbital orbicularis oculi muscles. been reported.15,24 We have removed an unabsorbed Ultratine Two weeks before or after surgery, patients are injected with implant at 9 months, and the region healed without further botulinum toxin; a 1% risk of upper lid ptosis attends glabellar sequelae. botox injections.28 Patients who experience this may then cancel

B f0105 FIGURE 28-20. Frontal before and after views (A) and left oblique before and after views (B) of a 41-year-old patient with brow ptosis and fat herniation of the lower eyelids. Following deep temporal fixation–only endoscopic brow lift, notice the significant medial brow elevation. The patient also underwent transconjunctival lower lid blepharoplasty.

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28 | THE AESTHETIC BROW AND FOREHEAD 28-13

sometimes lateral bony orbital rim will provide a nice result. The biostimulatory fillers poly-L-lactic acid (PLLA) and calcium hydroxyapatite (CaHA) cannot be reversed and are not recom- mended inferior to the eyebrow because of the risk of contour irregularity. However, preperiosteal injections immediately deep or superior to the eyebrow can produce a natural, long- lasting result. Fat is typically injected with a 0.9 mm Tulip microcannula. Fat grafting has a higher risk of contour irregularities and should be performed in a suborbicularis or preperiosteal plane to help prevent this complication. Some of the injected fat will be lost, so slight overcorrection is recom- mended. Volumetric brow enhancement can be completed at the same time as brow rejuvenation surgery as long as the planes of injection are undisturbed.29 Fat or filler can be injected with platelet-rich plasma (PRP) with the goal of improving the longevity of the result. Figures 28-22 and 28-23 f0110 are examples of brow rejuvenation with injectable fillers. FIGURE 28-21. Botulinum toxin injections can paralyze the brow depres- Volume loss in the temple exposes the inferior zygomatic p0605 sors during the healing process, which should improve the efficacy and lon- arch and temporal line, contributing to a skeletal and aged gevity of the brow lift. These injections also help augment the aesthetic result appearance. This loss of volume can contribute to lateral brow by improving or eliminating glabellar creases and “crow’s feet.” In the ptosis and can obscure visualization of the tail of the eyebrow on diagram, each red mark represents 4 units of Botox (roughly 10 units of Dysport). Each green or black mark represents 2 units of Botox (roughly 5 frontal view. Volume augmentation in the temple can be achieved units of Dysport). The green marks signify injections meant to weaken the with PLLA, hyaluronic acid (HA), CaHA, or fat. The practitioner portion of the orbicularis oculi that depresses the lateral brow. should be careful to avoid traumatizing the numerous superficial veins throughout the temple, which will cause significant bruising. HA or CaHA is injected in small aliquots with a blunt their planned surgery, which is why many surgeons wait until cannula into the plane between the temporoparietal and tem- after surgery to perform these injections. The corrugator, pro- poralis fascia, and it is massaged for even distribution. Lambros cerus, and depressor supercilii muscles (medial brow depres- and others have reported more even dispersal after diluting the sors) are typically injected with a total of 20 units of botulinum filler with lidocaine or saline.30 Our current formula is to mix toxin, and the lateral supraorbital orbicularis oculi muscles HA or CaHA with an equal volume of 1% lidocaine without (lateral brow depressors) are injected with 4 to 6 units of botu- epinephrine for more even distribution. PLLA can be injected linum toxin on each side (Fig. 28-21). Generally, no botulinum in the preperiosteal plane, within or deep to the temporalis toxin is injected into the frontalis muscle following a brow lift muscle, using needles and taking care to draw back on the because the frontalis acts as the only brow elevator. syringe to prevent intravascular injection. Fat is injected using 0.9-mm microcannulas in between the temporoparietal fascia s0135 VOLUME AUGMENTATION OF and temporalis fascia (the same plane as with HA). The aesthetic THE BROW AND TEMPLE goal of temple volume augmentation is a convex contour on frontal view that disguises the zygomatic arch and temporal line p0600 Injectable fillers and autologous fat grafting can achieve signifi- and allows the entire eyebrow to be seen on frontal view. In our cant brow and temple rejuvenation alone or in combination experience, fat grafted to the temples has poor survivability. with surgery. In the brow, volume augmentation has the ability to recreate a luminous, convex skin contour; eliminate shadows s0140 beneath the brow; and even “pick up” skin folds of the upper CONCLUSION lid—essentially, it approximates a nonsurgical upper blepharo- Each patient must be carefully evaluated for skin changes, p0610 plasty. Saline or local anesthetic can be injected first to show volume loss, or ptosis that could be contributing to their brow patients the expected result. We inject filler in a subcutane and forehead aging. These findings must be combined with the ous or supraperiosteal plane using a microthreading tech goals of the patient to generate an upper facial rejuvenation nique with a 25-gauge blunt microcannula. Typically, 0.5 to plan. Injectable neurotoxins and fillers have provided a power- 1 mL of hyaluronic acid carefully placed over the superior and ful new tool for upper facial rejuvenation that makes surgical

A B f0115 FIGURE 28-22. A, Before injection, this patient exhibits pseudoptosis of the brows because of upper lid hollowing and an increased tarsal platform show. She also exhibits early signs of the “A-frame” deformity, with deepening of the medial upper lid sulcus and superior elevation of the bony orbital rim (arrow). B, After 0.5 mL of hyaluronic acid injected on each side to the medial brows and along the superior orbital rim, the result is quite impressive. The patient appears much younger, with more attractive, apparently elongated eyes. The brow is fuller, more luminous, and appears to have been elevated. Volumizing the brow does cause some minimal true elevation, but much of the effect is due to decreasing the tarsal platform show and increasing the brow fat span, which creates the illusion of a very natural brow lift. (Courtesy Rebecca Fitzgerald, MD.)

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28-14 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

A B f0120 FIGURE 28-23. A, Before injection, this patient exhibits profound temporal volume loss that exposes the zygomatic arch and “clips off” the lateral eyebrow on frontal view. B, After poly-L–lactic acid is injected into and deep to the temporalis muscle, and diluted hyaluronic acid is injected into the temporoparietal fascial layer, the zygoma is much better disguised. The entire lateral brow is visible, and the brow is more luminous, which gives the illusion of a subtle brow lift. This patient has significant “A-frame” deformity and would benefit from medial superior orbital rim volume augmentation aswell. (Courtesy Rebecca Fitzgerald, MD.)

brow lifts less necessary than in the past. When mutual goals Isse NG: Endoscopic facial rejuvenation: endoforehead, the functional are safely and carefully addressed, the patient and surgeon will lift. Case reports. Aesthetic Plast Surg 18(1):21–29, 1994. both be happy. Richard MJ, Morris C, Deen BF, et al: Analysis of the anatomic changes of the aging facial skeleton using computer-assisted tomography. Ophthal Plast Reconstr Surg 25:382–386, 2009. p0615 For a complete list of references, see expertconsult.com. Rohrich RJ, Pessa JE: The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compart- ments. Plast Reconstr Surg 121:1904–1909, 2008. SUGGESTED READINGS Shaw RB, Katzel EB, Koltz PF, et al: Aging of the facial skeleton: aes- Fitzgerald R, Vleggaar D: Facial volume restoration of the aging face thetic implications and rejuvenation strategies. Plast Reconstr Surg with poly-l-lactic acid. Dermatol Ther 24:2–27, 2011. 127:374–383, 2011.

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28 | THE AESTHETIC BROW AND FOREHEAD 28-14.e1

17. Isse NG: Endoscopic facial rejuvenation: endoforehead, the func- REFERENCES tional lift: case reports. Aesthetic Plast Surg 18:21–29, 1994. 1. Rafaty FM, Brennan HG: Current concepts of browpexy. Arch Oto- 18. Ramirez OM: Endoscopic subperiosteal browlift and facelift. Clin laryngol 109:152, 1983. Plast Surg 22:639–660, 1995. 2. Van den Bosch WA, Leenders I, Mulder P: Topographic anatomy 19. Vasconez LO, Core GB, Gamboa-Bobadilla M, et al: Endoscopic of the eyelids, and the effects of sex and age. Br J Ophthalmol 83: techniques in coronal brow lifting. Plast Reconstr Surg 94:788–793, 347–352, 1999. 1994. 3. Matros E, Garcia JA, Yaremchuk M: Change in eyebrow position 20. McCord CD, Doxanas MT: Browplasty and browpexy: an adjunct and shape with aging. Plast Reconstr Surg 123:1296–1301, 2009. to blepharoplasty. Plast Reconstr Surg 86:248–254, 1990. 4. Goldberg RA, Lew H: Cosmetic outcome of posterior approach 21. Massry GG: The external browpexy. Ophthal Plast Surg 28:90–95, ptosis surgery (an American Ophthalmologic Society thesis). Trans 2012. Am Ophthalmol Soci 109:157–167, 2011. 22. Cousin JN, Ellis DA: Fibrin glue as the sole fixator in endoscopic forehead 5. Morley AM, Taban M, Malhotra R, et al: Use of hyaluronic gel for lift, presented at the Canadian Society of Otolaryngology—Head & Neck upper eyelid filling and contouring. Ophthalm Plast Reconstr Surg Surgery annual meeting, Toronto, Ontario, May 30, 2000. 25:440–444, 2009. 23. Marchac D, Ascherman J, Arnaud E: Fibrin glue fixation in fore- 6. Knize D: An anatomically based study of the mechanism of eyebrow head endoscopy: evaluation of our experience with 206 cases. Plast ptosis. Plast Reconstr Surg 97(7):1321–1333, 1996. Reconstr Surg 100:704, 1997. 7. Knize D: The importance of the retaining ligamentous attachments 24. Nassif PS, Kokoska MS, Cooper P, et al: Comparison of subperios- of the forehead for selective eyebrow shaping and forehead reju- teal vs subgaleal elevation techniques used in forehead lifts. Arch venation. Plast Reconstr Surg 119(3):1119–1120, 2007. Otolaryngol Head Neck Surg 124(11):1209–1215, 1998. 8. Knize D: The forehead and temporal fossa: anatomy and technique, 25. Sclafani AP, Fozo MS, Romo T, et al: Strength and histological Philadelphia, 2001, Williams & Wilkings, pp 46. characteristics of periosteal fixation to bone after elevation. Arch 9. Moss CJ, Mendelson BC, Taylor GI: Surgical anatomy of the liga- Facial Plast Surg 5:63, 2003. mentous attachments in the temple and periorbital regions. Plast 26. Agarwal CA, Mendenhall SD, Foreman KB, et al: The course of the Reconstr Surg 105:1475–1490, 2000. frontal branch of the facial nerve in relation to fascial planes: an 10. Lazzeri D, Agostini T, Figus M, et al: Blindness following cosmetic anatomic study. Plast Reconstr Surg 125:532–537, 2010. injections of the face. Plast Reconstr Surg 129:995–1012, 2012. 27. Servat JJ, Black EH: A comparison of surgical outcomes with the 11. Kim YJ, Choi KS: Bilateral blindness after filler injections. Plast use of 2 different biodegradable multipoint fixation devices for Reconstr Surg 131: 298e–299e, 2013. endoscopic forehead elevation. Ophthal Plast Reconstr Surg 28:401– 12. Lambros V: Observations on periorbital and midface aging. Plast 404, 2012. Reconstr Surg 120:1367–1376, 2007. 28. Carruthers JD, Lower NJ, Menter MA, et al: Double-blind, placebo- 13. Fitzgerald R: Contemporary concepts in brow and eyelid aging. controlled study of the safety and efficacy of botulinum toxin type Clin Plast Surg 40:21–42, 2013. A for patients with glabellar lines. Plast Reconstr Surg 112:1089– 14. Castanares S: Forehead wrinkles, glabellar frown and ptosis of the 1098, 2003. eyebrows. Plast Reconstr Surg 34:406, 1964. 29. Collar RM, Boahene KD, Byrne PJ: Adjunctive fat grafting to the 15. Tardy ME, Thomas JR, Brown R: Facial Aesthetic Surgery, ed 1, upper lid and brow. Clin Plast Surg 40:191–199, 2013. St Louis, 1995, Mosby. 30. Lambros V: A technique for filling the temples with highly diluted 16. Nassif PS, Kokoska MS: Aesthetic facial analysis. Facial Plast Surg hyaluronic acid: the “dilution solution.” Aesthet Surg J 31:89–94, Clin North Am 7(1):1, 1999. 2011.

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