Keywords

Introduction

Over the past decade, improved appreciation of facial aging changes has modified management considerations for facial rejuvenation. In the brow region, traditional changes of soft tissue descent due to loss of skin elasticity and gravitational effect have been updated to include soft tissue and bony volume loss (deflation) (Whitaker and Bartlett 1991; Pessa and Chen 2002). Thus, optimal management of age-related brow ptosis should address these changes.

Brow descent may be appropriately addressed using open (coronal, pretrichial, midforehead, direct) or endoscopic techniques, as well as less invasive transblepharoplasty techniques (transblepharoplasty internal browpexy, release of orbicularis retaining ligaments as well as weakening the brow depressors) (Kerth and Toriumi 1990; Holck et al. 1998; Burroughs et al. 2006; Muzaffar et al. 2002; McCord and Doxanas 1990). However, techniques describing aggressive resection of the retro-orbicularis oculus fat (ROOF) pads for aesthetic brow rejuvenation must be reconsidered (McCord and Doxanas 1990; May et al. 1990). Excess resection may only exacerbate the soft tissue deflation. Indeed, brow volume augmentation in conjunction with ROOF resuspension should be considered in lieu of soft tissue resection.

Several reports have described augmenting the temporal brow region utilizing soft tissue fillers and bony onlay implant techniques. (Ramirez 1998; Carruthers and Carruthers 2005) Soft tissue augmentation of this region is usually accomplished using temporary fillers (collagen and hyaluronic acids) as well as autologous fat injections. Bony volume augmentation may be facilitated through the use of a superior lateral orbital rim onlay implant to aid in the rejuvenation of the superotemporal orbital area (MEDPOR, Porex Surgical Inc., Newnan, GA). We describe using the patient’s own dermal/subcutaneous soft tissue obtained at the time of open or endoscopic brow elevation surgery to augment the temporal brow region to facilitate both brow elevation as well as to enhance the soft tissue volume in this area.

Procedure

At time of coronal or pretrichial browlifting, excised segments of scalp are taken (Fig. 102.1). In the endoscopic technique, a crescent-shaped segment of temporal hair-bearing scalp is excised to augment the temporal lift. These excised tissues are used for the brow volume augmentation. The optimal segments are trimmed to approximately 10 mm × 30 mm. A no. 10 blade scalpel is used to excise the epidermis from the dermis and subcutaneous tissue, leaving a 3- to 4-mm-thick remnant (Fig. 102.2). The subcutaneous tissue is placed along the temporal superior orbital rim. In an open technique, the graft may be sutured to underlying periosteum (Fig. 102.3). In the endoscopic technique, the graft may be fixed to the ROOF using a percutaneous suture. The graft material is placed below the inferior row of brow hair and above the inferior portion of the superior orbital rim. This allows the soft tissue graft to act as a support for the brow as well as augment soft tissue volume.

Fig. 102.1
figure 1

Scalp segments are excised in a pretrichial browlift. The segments are approximately 10 mm × 30 mm

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Fig. 102.2
figure 2

The epidermis (with care taken to remove all hair follicles) is removed, leaving the dermis and subcutaneous tissue

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Fig. 102.3
figure 3

The graft is sutured to the underlying periosteum along the superior orbital rim on the lateral two thirds of the rim. The supraorbital neurovascular bundle is visible just nasal to the graft

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The same material may also be used after extirpation of the corrugator muscles. In this setting, strips approximately 8 mm × 5 mm are sutured to the cut ends of the corrugator muscles (Fig. 102.4). This prevents the muscle edges from reapproximating, further weakening the corrugators. Additionally, the augmented volume prevents subcutaneous depressions and dimpling in the area of corrugator extirpation.

Fig. 102.4
figure 4

Graft segments of approximately 8 mm × 5 mm are sutured to the cut ends of the corrugator muscle to avoid soft tissue depression and prevent the cut ends from rejoining

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With follow-up approaching 1 year, the soft tissue augmentation appears to persist (Fig. 102.5). Indeed, magnetic resonance imaging at 9 months postoperatively demonstrates persistence of the graft.

Fig. 102.5
figure 5

Pre- and 6-month postoperative view demonstrating elevation of the temporal brow with soft tissue volume augmentation

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Conclusions

In the management of brow ptosis, elevation and volume augmentation may provide the optimal rejuvenation. Injectable fillers placed at the lateral two thirds of the brow in the subdermal plane have been shown to elevate and augment brow soft tissue volume (Carruthers and Carruthers 2005). However, these materials offer a temporary result. The technique described above provides long-lasting volume augmentation as well as maximizes the browlift. Managing both descent and deflation may provide the optimal rejuvenation of the brow region.