Beruflich Dokumente
Kultur Dokumente
27:58–62, 2003
DOI: 10.1007/s00266-002-0058-6
Abstract. Aging in the upper face becomes more evident as The aging process presents a pattern of change for
the eyebrow level descends. Sometimes this may begin at an the facial parameters that we have described in pre-
early age. The senior author has described a limited ap- vious articles and that we have studied by analyzing
proach for the treatment of this aesthetic alteration. In se- measurements taken from a sample of patients
lected cases, the juxtapilose incision, placed laterally at the [17,19]. Our work revealed that ‘‘round lifting’’ of the
margin of the anterior hairline, allows for the subperiosteal vector of traction, described by the senior author, is
undermining of the entire forehead and dissection of the the technique that best corrects the physical defor-
elements that cause the descent of the eyebrow. The pro- mation of facial tissues secondary to aging [17,19,21].
cedure is safe and expedient, and permits for a controlled In our experience, forehead lifting is indicated to
repositioning of the eyebrow. In this paper, the authors treat frontoglabellar wrinkles and frontal laxity and
describe the juxtapilose incision and the subperiosteal ap- can also promote the elevation and leveling of the
proach of the forehead as a practical ancillary procedure eyebrows in cases of unilateral or bilateral frontal
for correction of the aging face. paralysis. Eyebrow ptosis, especially in its lateral
segment, constitutes the best indication for forehead
Key words: Eyebrow ptosis—Frontoglabellar wrinkles— lifting. The use of the juxtapilose and bicoronal in-
Forehead lifting cisions present more natural results than direct eye-
brow lifting through a superciliary incision [2].
Frontal region flaccidity and eyebrow ptosis may
Facial aging is a biological phenomenon that brings produce the appearance of excess upper eyelid skin,
about undesirable changes, such as skin flaccidity and thus it requires a thorough evaluation [11,13,14,
marked lines of expression. As we age, skin properties 16,18,19,21]. Regarding the indication for this pro-
change and it loses its elasticity and tonicity. Gravity cedure, elements of the upper face should be carefully
and facial expressions contribute to the mechanical examined, including the length of the forehead, the
deformation of the face. In addition to the loss of elasticity of the skin, the level of the anterior hairline,
elasticity and tonicity of the skin, other structural and the quality and quantity of hair, as well as the
changes occur, such as the reduction of the volume of presence of pre-existing incisions. When ptosed eye-
the facial bones, absorption of the adipose tissue, and lids are observed without a considerable laxity of the
the creation of wrinkles on the lines of musculocu- tissues as a whole and, as is often the case, without
taneous insertion due to muscle dynamics [3]. Ptosis the presence of wrinkles or signs of muscular hyper-
of the eyebrow is a defining element of facial aging trophy in the frontal region, the limited juxtapilose
and may present at an early age [1]. By identifying incision with a subperiosteal approach is indicated
these changes and their corresponding distortional [2]. In cases of severe eyebrow ptosis with laxity of the
forces, we may be better able to reverse these signs of frontal area, especially in the older patient, the
aging. bicoronal approach is indicated, associated with the
‘‘blocking lifting’’ technique, which avoids alterations
in anatomical landmarks in the face [2,11,13,14,
16,18].
Correspondence to I. Pitanguy, The Ivo Pitanguy Clinic, In this paper, the authors describe the juxtapilose
Rua Dona Mariana, 65, Rio de Janeiro 22280-020, Brazil; incision performed on the hairline with a subperio-
email: pitanguy@visualnet.com.br steal approach, as a safe procedure that permits for a
I. Pitanguy and N.F. Gontijo de Amorim 59
Age group (Years) Number of cases Percent Procedures Number of cases Percentage
suffer variations, such as a transverse or oblique 16,18]. Our experience shows that the direction of
temporal component, according to each case [16]. traction presented in this article is the one that best
Nevertheless, basic surgical principles have stood the corrects the physical deformation of facial tissues
test of time and should always be remembered. The secondary to aging [17,19]. Certain situations, how-
surgeon must be knowledgeable in details of surgical ever, preclude the coronal incision, such as, patients
technique and its variations to attain the best result with a very long forehead or those who have had
for each individual case. previous surgery who will have an excessively re-
Currently, the subperiosteal approach through a cessed hairline if the forehead is further pulled back.
juxtapilose incision is more frequently performed In these cases, the final aspect will be displeasing and
than the bicoronal incision, since this limited incision give the patient a permanent look of surprise
technique does not present some of the undesirable [4,12,15,23].
results of the open approach, such as enlargement of Videoendoscopy has become an adjunct to proce-
the scars, sensorial disturbances, and alopecia in the dures such as the facelift. Endoscopic instrumenta-
postoperative period. tion has permitted the treatment of the brow through
The juxtapilose incision is executed on the hair minimal-access incisions and has proved useful in
implant line, and the undermining of the whole fore- selected cases. The subperiosteal dissection, com-
head area is subperiosteal, releasing the orbital liga- bined with the removal of the corrugator supercilii
ment and periosteal attachments along the orbital rim and the procerus muscles and the release of the
and the temporal line. After releasing the periosteal periosteum from the temporal line of fusion, allows
attachments, the traction of the periosteum becomes the surgeon to lift the brow to the desired degree.
more efficient to raise the eyebrows. By undermining This technique is safe and well accepted among the
the periosteum in its deeper surface and from the patients who are hesitant toward more extensive
upper tissues, the surgeon may apply more tension on surgery. However, its execution requires specific
his structure, therefore resecting less skin. The con- training. A mixed technique, open in the temporal
trolled resection of the skin and the suture placement areas and with the endoscope in the mid-frontal area,
in the galea and the periosteum will thus avoid the may also be used [8,22].
undesirable enlargement of the scar. The galeal por- There are other options for treatment depending
tion of the transposed flap (with periosteum on its on the patient’s needs, such as the open resection of
deep surface) adheres to the frontal bone to provide part of the corrugator muscle in some cases of muscle
flap stability, so the use of fibrin glue is not necessary. hypertrophy, resurfacing with a CO2 laser for treat-
In the cases of patients with severe ptosis of the ment of fine wrinkles, and dermabrasion (mechanical
eyebrow, especially in old people, the bicoronal in- peeling) for the treatment of wrinkles [11,13,14,
cision should be considered, since it allows for the 18,20]. Injection of botulinum toxin A is useful as
treatment of all of the elements of the aging forehead a complementary procedure in the postoperative
and it hides the final scar within the hairline. The period. The botulinum toxin causes temporary
bicoronal forehead lift is most commonly done to- paralysis of striated muscles that promote eyebrow
gether with a cervico-facial rhytidoplasty as a com- ptosis, such as corrugator supercilli and procerus
bined procedure (‘‘blocking lifting’’) [2,11,13,14, muscles [5].
62 Forehead Lifting