® ENDOSCOPIC FOREHEAD LIFT Endoscopic Approach to Upper-Third Facial Rejuvenation Thomas ROMO III Kyle S. CHOE 2 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation Color Illustrations: Fairman Studios, LLC 681 Main Street, Suite 2-11 Waltham, Massachusetts 02451, U.S.A E-mail: jfairman@fairmanstudio Important notes: Endoscopic Forehead Lift – Endoscopic Approach to Medical knowledge is ever changing. As Upper-Third Facial Rejuvenation new research and clinical experience broaden Thomas Romo, III, M.D., F.A.C.S. our knowledge, changes in treat ment and therapy Kyle S. Choe, M.D. may be required. The authors and editors of the New York Eye and Ear Infirmary, New York, NY material herein have consulted sources believed to be reliable in their efforts to provide information that is complete and in accord with the standards accept ed Correspondence address of the author: at the time of publication. 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ISBN 978-3-89756-558-6 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 3 Table of Contents 1.0 Introduction . 4 2.0 Standard Aesthetic Proportions of the Upper Third of the Face . 5 3.0 Anatomy of the Forehead Muscles . 7 4.0 Traditional Approaches to Surgical Treatment of the Upper Third of the Face . 9 5.0 Patient Interview and Consultation . 12 6.0 Endoscopic Forehead Rejuvenation . 14 7.0 Temporary vs. Permanent Fixation . 16 8.0 Surgical Technique . 18 9.0 Clinical Cases (Eight Patients’ Pre and Postoperative Pictures) . 26 10.0 References. 34 11.0 Instruments for Endoscopic Forehead Lift . 35 4 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 1.0 Introduction The key qualities of a beautiful face are symmetry and balance. The challenge that the aging process most often poses to the facial plastic surgeon is gradual dissonance of the facial features. While the nose is the most prominent of these, sequelae from aging are most dramatically displayed in the upper third of the face: eyebrows begin to sag; wrinkles form on the forehead; and eyelids show signs of hooding. Bringing back equilibrium to this area has thus become a significant goal of facial rejuvenation surgery. The use of endoscopes has revolution ized how facial plastic surgeons approach rejuvenating the upper third of the face, i.e., the forehead between the hairline and the eyebrows. Within the past decade, endoscopic lifting of the face and brow has gained significant popularity and replaced many traditional surgical approaches. The primary advantage of endoscopic forehead rejuvenation, or endoscopic forehead lift, are the minimally invasive incisions used to expose the large anatomic unit of the forehead, temporal region and lateral orbit. Post-operational recovery is, in turn, shorter and less painful. Despite the many advantages of this new and exciting technology, endoscopic surgery is best suited for patients with mild to moderate ptotic brows. Endoscopic forehead rejuve- nation relies on four primary steps: (1) subperiosteal elevation dissection of the frontal, parietal and occipital scalp to the level of the superior and lateral orbital rims; (2) release of the superior and lateral orbital periosteum; (3) selective myotomies of the brow depressors; and (4) permanent fixation of the elevated brow. In this monograph, we review the traditional techniques of forehead rejuvenation and elaborate on the advantages of utilizing the endoscope. We then present our approach to endoscopic rejuvenation of the upper third of the face using KARL STORZ instruments. Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation 5 2.0 Standard Aesthetic Proportions of the Upper Third of the Face Cephalometrics of the upper third of the face are determining factors to the bal ance and symmetry that define facial beauty. Traditionally, the length of the face has been divided into three equally sized parts. Measurements are made from the midline of the face, from the trichion to the glabella, glabella to the subnasale and the subnasale to the menton. In surgical practice, the forehead, from the hairline to the eyebrows, comprises the upper third of the face. While defining the ideal eyebrow position is much less mathematical, the aesthetically favorable female eyebrow takes on a gracefully arching structure located slightly above the supraorbital rim. In males, the arch is flatter and rests at the level of the supraorbital rim. For both genders, the eyebrow begins at a vertical line from the alar-facial groove through the medial canthus and ends at the diagonal line from the alar-facial groove through the lateral canthus. The horizontal position of the eyebrow’s highest point is located at the vertical line tangential or just lateral to the lateral limbus. The medial and lateral ends of the eyebrow rests on a horizontal line. In terms of shape, the medial end of the female eyebrow is rounded and gradually tapers laterally. Trichion (Hairline) Glabella Subnasale Menton Fig. 1a Fig. 1b Standard aesthetic proportions of the upper third of the face. Ideal eyebrow position. 6 Endoscopic Forehead Lift – Endoscopic Approach to Upper-Third Facial Rejuvenation Aging Process of the Forehead Facial aging is a gradual process, which begins to manifest itself as horizontal wrinkles in the patient’s forehead region in their early 30s. By the time patients reach their 40s, the horizontal lines begin to deepen and vertical wrinkles be come more visible in the glabellar region. These changes are followed by drooping of the eyebrows below the supraorbital rims, folding of the infrabrow tissue over the thin eyelid skin and both medial and lateral “hooding” of the upper eyelid as the patient continues to age. Brow and glabellar ptosis alters what was once an aesthetically pleasing Y-shaped sweep between the eyebrow, medial orbit and lateral nose, to a T-shape. The overall result is a configuration that conveys age, sadness and anger. Fig. 2a Forehead anatomy, unlike other parts of the face, is more prone to rhytid and Patient in her early 30s. furrow formation because the eyelid, skin and muscles are intimately related. With little or no subcutaneous tissue between skin and muscle, such a close anatomic relationship leads to a direct transmission of muscle motion to the overlying skin, resulting in deep furrows and wrinkles.