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SUBCUTANEOUS FOREHEAD LIFT
R ATIONALE FOR USE AS R EOPERATIVE PROCEDURE
Subcutaneous forehead lifts appeal to me for the following reasons:
1. The sensory nerves are not divided.
2. The multiple attachments of the occipitofrontalis muscle to the overlying
skin are divided, therefore effectively diminishing, if not eliminating, most of
the creases.
3. The arterial network remains intact.
4. The corrugator muscle attachments to the overlying skin are effectively in-
terrupted, thereby eliminating the need for total excisions, divisions, or par-
tial excisions of the corrugator muscles.
I have observed that results of subcutaneous forehead lifts are long-lasting and that
the mild reattachment of the occipitofrontalis and corrugator muscles to the over-
lying skin does not cause objectionable deep creases.The lines that do reappear are
mild and faint and give the forehead a serene, normal appearance.
The main contraindication to subcutaneous forehead lifts in my experience is
smoking. On occasion, I have operated on smokers, as always using my gentlest
technique. One patient lost the few very important temporal hairs I leave in front
of the temporal aspect of the incision. Although after 4 months the hair returned,
it was not of the same quality. Twice daily application of minoxidil is of value in
these instances.12 The second patient had two areas of skin compromise that healed
uneventfully but small scars remained.Therefore I avoid performing subcutaneous
forehead lifts on smokers, believing the risk to be excessive.
Some of the ill effects of smoking can be countered by the use of 100% oxygen and
iso urane intraoperatively in a closed anesthesia system and the supplemental use of
oxygen postoperatively for the rst night.The mechanism of displacement of car-
bon monoxide from the hemoglobin molecule is purely by competition between
the molecules of oxygen and carbon monoxide. All of our facial rejuvenation pa-
tients who smoke receive this extra treatment13 (see Chapter 10).

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In the forehead the occipitofrontalis muscle is in intimate contact with the overly-
ing skin;there is no subcutaneous fat or tissue.In this respect the orbicularis oris and
the orbicularis oculi muscles are identical in their relation to the overlying skin.
To effect the delicate dissection between the dermis and occipitofrontalis muscle,
I suggest that a larger amount of anesthetic solution with diluted epinephrine be
placed at the skin/muscle interface.
TECHNIQUE
The incision is placed just within the hair follicles with a No. 15 Personna Plus
blade angled anteriorly independent of the hair shaft inclination. The objective is
to leave some viable hair follicles just below the thin caudad ap. These few hairs
will thus emerge through the scar.

As dissection proceeds caudally, the skin becomes progressively thicker. Indeed, at
the glabellar region the skin is almost 0.5 cm thick.14 Hemostasis is delicately ob-
tained using a ne-pointed titanium jewelers’forceps. All efforts are made to min-
imize the handling of the ap.
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Since hair growth continues during the immediate postoperative period, these hairs
will make their emergence quite early through the incision line. In blonde patients
the scar is even less visible.
Even in brunettes, in whom the hair color contrasts with the light-colored scar, the
incision line is dif cult to detect.

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When the ap is redraped, two key sutures are placed, one on the right and one on
the left, each approximately 2 inches from the midline. To ensure that the ap is
correctly positioned at the midline, a temporary suture is placed in the center of the
ap and tied to the center of the scalp. However, the central ap overlies the cen-
ter scalp at this point; the ultimate adjustment of the hairline will be done only
once the lateral xed points (left and right) have been secured with the proper ten-
sion. Only then is the excess caudad central ap tissue trimmed, and even then it
must overlap the cephalad ap by 2 mm.
A thin Jackson-Pratt drain is used transversely under the ap, exiting eccentrically
in the scalp.
POSTOPERATIVE CARE
Before the patient awakens in the operating room, a sterile water shampoo is per-
formed, and all incisions are subsequently covered with a layer of bacitracin oint-
ment.The same care to keep sutures free of blood and covered with antibiotic oint-
ment is continued in the recovery room. Patients are allowed to shampoo their hair
the day following surgery.They are instructed to continue to apply bacitracin oint-
ment over the suture lines for the ensuing 5 days if possible. The application of
topical antibiotics exerts a positive in uence on scar lines, keeping them moist and
free of bacteria.
CAVEATS FOR REOPERATIVE FOREHEAD LIFTS
The following principles must be respected and adhered to in reoperative forehead
lifts:
Know the arterial status of the patient.
Do not execute “new” incisions that would leave segments of hair-bearing
scalp devoid of blood supply in a patient who had a previous coronal incision
(for example, a coronal incision more inferior than the previous coronal in-
cision, a full-depth hairline incision).
Study the position and the course of the frontal branch of the seventh cranial
nerve carefully. Rely on true anatomic dissections to appreciate its variances
rather than on conceptualized drawings found in textbooks.
Master the feel of tension on aps. Tension-demarcating clamps are treach-
erous to the inexperienced! However, they are the best tool in the hands of
those who have mastered their nuances.
Be gentle with all dissections. Release and reapply all sutures that seem too
tight.
Be conscious of and respect hair follicle inclination.
Do not use interlocking, deeply encompassing sutures. They close off the
blood supply to the healing edges.The wound may heal, but the hair will be
lost.
Do not “compress” scalp on closure in an effort to save hair follicles. This is
as big a reason for hair loss as is tension.

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UNSOLVED PROBLEMS
Overly resected corrugator muscles, resection of the procerus muscle, overly ele-
vated eyebrows giving a startled look, hairline severely displaced upward, and
widened scars because of excessive tension on closure sadly remain unsolved prob-
lems. Skillful tattooing with skin-colored pigment offers some help in disguising
visible scars.
References—With Key Annotated References
1. Ristow B. Forehead lifts. In Cohen M, ed. Mastery of Surgery—Plastic and Reconstructive
Surgery. Boston: Little Brown, 1992.
A classic text presenting surgical techniques practiced and perfected by the most respected plastic sur-
geons in the eld.
2. von Ristow A, Bonamigo T, Buriham E, et al. Doencas da Aorta e Seus Ramos: Diagnostico e
Tratamento. Sao Paulo: Gra ca e Editorial, 1991.
3. Pitanguy I. Aesthetic Plastic Surgery of Head and Body. Berlin: Springer-Verlag, 1981.
4. Connell BE. The forehead lift: Techniques to avoid complications and produce optimal re-
sults. Aesthetic Plast Surg 13:217-237, 1989.
This discussion of forehead lifting, based on modi cations of Vinas, Caviglia, and Cortinas, shares the
authors’methods of patient evaluation, diagnostic details, architectural planning, and surgical concepts
for forehead rhytidectomy along with correction of malpositioned and ptotic eyebrows as well as glabel-
lar frown problems.
5. Ristow B.The forehead and the eyebrows. In Vistnes LM, ed. Procedures in Plastic and Recon-
structive Surgery—How They Do It. Boston: Little Brown, 1991.
6. Ristow B. Aesthetic plastic surgery of the upper face. In Braverman MH, ed. Surgical Technol-
ogy International. London: Century Press, 1991.
7. Connell BE. Personal communication, 1990.
8. Stille-Ristow Facelift Scissor Article No. 101-8454-1.
9. D’Assumpçao EA. A new instrument for rhytidoplasty. Br J Plast Surg 23:301, 1970.
10. Connell BF. Personal communications, 1992 and 2005.
11. Marten TJ. Hairline lowering foreheadplasty. Plast Reconstr Surg 103:224-236, 1999.
Scienti c article on technique for lowering hairline during forehead lift procedure.
12. Hoef in SM. Instructional course for the American Society for Aesthetic Plastic Surgery, Los
Angeles, April 1992.
13. Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 8th ed. New York: Perg-
amon Press, 1990.
14. Papillon J. Closed circuit surgical demonstration. ISS-Face Congress, Marseille, May 1990.

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1. In open foreheadplasty, it is important to:
a. Close the galea layer tightly so that the follicles have plenty of blood supply
b. Close the galea on key points only, sometimes just two sutures
c. Preserve hair, compress the hair tightly on the closure
d. Not close the galea at all, just the scalp
2. In open foreheadplasty:
a. Corrugators can be removed without later postoperative lateral migra-
tion of eyebrows
b. The ablation of corrugators never leaves any postoperative depressions
c. It’s a good idea to place a galeal graft between the neurovascular bundles
(to prevent depressions and migrations)
d. None of the above
3. Subcutaneous forehead lifts are appealing because:
a. No major sensory nerves are divided
b. Muscular connections to overlying skin (creases) are divided
c. The arterial network essentially remains intact
d. All of the above
e. a and c only
4. A careful surgical technique was employed but a frontal branch is injured. The
best is:
a. Be con dent that it could not have been cut
b. Do nothing; movement of the affected side almost always recuperates
completely
c. May use some Botox on the normal side
d. All of the above
e. None of the above
5. The position of the super cial temporal artery in relation to the frontal branch is:
a. Always posterior to the branch
b. Always anterior to the branch
c. Varies considerably from patient to patient
d. Right above the frontal branch
e. Immediately below the frontal branch
6. In incising the scalp, leaving a cuff of galea will:
a. Make it easy to stop bleeding because you see the vessels
b. Make it less likely to thermically injure follicles
c. Provide a “cuff over pants,” fascia over fascia healing
d. Effectively avoid scalp depressions
e. All of the above
R EVIEW QUESTIONS

(Trang không có chữ)

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Use of Endoscopy in
Reoperative Brow-Lifting
Jorge I. de la Torre and Luis O.Vásconez
C ha pter 13
Reoperative Problems
Elevated hairline
Recurrent brow ptosis
Persistent transverse wrinkles
Alopecia
Asymmetry
Depressed scar
In the forehead and the eye,
the lecture of the mind doth lie.
French proverb
The current era of forehead rejuvenation has seen the evolution of technical ap-
proaches from traditional coronal brow lifts (see Chapter 12) to endoscopic tech-
niques.1 Although the coronal (open) technique is effective in elevating the brow,
it can result in visible scars, retrodisplacement of the hairline, and alopecia.2 The en-
doscopic forehead lift helps to prevent lengthy scars, alopecia, posterior displace-
ment of the hairline, and postoperative paresthesia of the forehead. In addition, the
length of the procedure and time required for recovery are both shorter.3,4 Advan-
tages of the endoscopic approach to reoperative forehead surgery include provid-
ing a safe approach to secondary rejuvenation of the forehead, and improving the
stigmata of prior traditional coronal brow lift procedures.5

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ANATOMIC CONSIDERATIONS
The anatomic layers of the scalp are of particular importance in the endoscopic
approach to reoperative forehead surgery. These layers include the skin, subcuta-
neous tissue, galea, loose areolar tissue, and pericranium. In the frontal area, the
galea envelops the frontalis muscle, forming the super cial and deep galea planes.
The super cial galea also overlies the procerus and orbicularis oculi muscles. The
super cial and deep galea layers fuse with the periosteum inferiorly, approximately
1 cm above the supraorbital rim.6
In the temporal region, the super cial temporal fascia is continuous with the galea
aponeurotica, frontalis, and the super cial musculoaponeurotic system (SMAS).7
The periosteum continues as temporal fascia, which divides into super cial and
deep layers above the level of supraorbital rim.8 The super cial temporal fat pad is
separated from the buccal fat pad by the deep layer of the temporal fascia.9 The
deep temporal fat pad is the extension of the buccal fat pad that lies beneath and
traverses the zygomatic arch.10 The super cial layer of temporal fascia ends at the
zygomatic arch periosteum, whereas the deep layer blends with the parotidomasse-
teric fascia.
The super cial temporal, occipital, and supratrochlear vessels form a network super-
cial to the galea, and send branches to the deeper layers where they anastomose
with the branches of the middle meningeal artery.11,12
The facial nerve and its branches, including the frontotemporal branch, run deep to
the SMAS. This branch runs obliquely under the super cial temporal fascia be-
tween the tragus and the lateral canthus, 3 to 5 cm from the lateral orbital margin,
as shown above.13,14 This nerve is separated from the arch by the deep layer of the
deep temporal fascia and can easily be injured during dissection;care must be taken
when releasing the lateral aspect of the periosteum to avoid injury to the frontalis
branch. The supratrochlear nerve is 1.7 cm lateral to midline and the supraorbital
nerve is 2.7 cm lateral to midline.These nerves provide the sensory innervation of

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Use of Endoscopy in Reoperative Brow-Lifting
the forehead and the scalp region up to the vertex. Ramirez and Robertson15 noted
accessory branches of the supraorbital nerve in 10% of cases.
Originating from the galea, the frontalis muscle (green arrow) inserts into the brow
skin.This muscle has multiple attachments to the skin;its contraction causes trans-
verse forehead creases. The procerus (yellow arrow) lies in the midline, within the
same surgical plane as the frontalis muscle.This muscle originates from the junction
of the nasal bones and the upper lateral cartilages, and inserts into the skin. Lateral
to the procerus is the corrugator supercilii (blue arrow).This muscle originates from
the medial end of the orbit, enters the galea fat pad, runs superiorly and laterally
along the deep galea plane, and then inserts into the skin of the supraorbital region
above the middle third of the eyebrow.16 The depressor supercilii muscle originates
from the superomedial orbital rim, overlying the origin of the corrugator, and in-
serts into the dermis of the medial eyebrow.The orbicularis oculi muscle (red arrow)
encircles the eye. The medial head of the orbital portion of this muscle originates
from the medial canthus.
The orbicularis oculi, corrugator, depressor supercilii, and procerus muscles are de-
pressors. The medial head of the orbital orbicularis oculi originates from the me-
dial canthus and pulls the medial eyebrow downward, creating vertical frown lines.
The transverse head of the corrugator produces vertical frown lines and contributes
to oblique lines, whereas the oblique head of the corrugator, depressor supercilii,
and medial head of the orbital portion of the orbicularis oculi muscle depress the
medial eyebrow and contribute to glabellar oblique lines.
SURGICAL TECHNIQUE
Whether it is performed as a primary or reoperative procedure, successful forehead
elevation depends on three basic principles. First, there must be adequate release of
the periosteum at the supraorbital rim. Second, ablation of the depressor muscles of
the brow must be performed. Last, the suspension technique used should be effec-
tive, but simple and safe.17

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STANDARD ENDOSCOPIC TECHNIQUE
Subperiosteal undermining is performed between the hairline and supraorbital rims
using three small prehairline incisions. Elevation is extended laterally in both direc-
tions to the transition zone between the frontal periosteum and the deep tempo-
ral fascia. No undermining is performed posterior to the hairline.The endoscopic
approach allows adequate visualization within the optical cavity as a result of ele-
vation in the subperiosteal plane.The blunt dissector can be used to free the infe-
rior aspect of the periosteum.
Using a 30-degree wide-angled endoscope for visualization, the periosteum is re-
leased at the level of the supraorbital rims, from lateral to the supraorbital nerves to
the level of the lateral orbital rim. Release of the lateral periosteum can be per-
formed easily using an endoscopic carpal tunnel scalpel. The right-angle blade al-
lows controlled release to avoid injury to the frontal branch of the facial nerve.

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An endoscopic biopsy forceps can then be used to resect the corrugator and pro-
cerus muscles between the supraorbital nerves.
Postoperative forehead suspension is maintained using temporary suture suspen-
sion. A staple is placed in each of the closed incision sites and a second staple is
placed approximately 5 cm posterior to the hairline over each incision. A 3-0 ny-
lon suture is threaded between each pair of staples and is used to apply tension.
The sutures are left in place for 3 to 5 days and then the suture and staples are re-
moved.

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BIPLANAR TECHNIQUE
The biplanar technique uses a limited prehairline incision and subcutaneous under-
mining of 2 to 4 cm. A beveled incision is placed within the hairline at the border
of the denser hair between both temporal regions (left). A hemostat is spread bluntly
in the subcutaneous plane for 3 to 4 cm anterior to the hairline incision, leaving the
frontalis muscle intact. Three small incisions are made in the frontalis muscle to
permit elevation within the subperiosteal plane (right).
After resection of the depressors, the three access ports are closed (left) and the
frontalis muscle is plicated at 1 to 1.5 cm intervals (right). The frontalis plication
results in extra skin at the hairline that can be resected, allowing the forehead ap
to be closed without any tension. No drains or suspension is required with this
technique.

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SUBPERIOSTEAL DISSECTION
The subperiosteal plane elevation offers safe and reproducible mobilization of the
forehead in the patient who has previously undergone either a coronal approach or
an endoscopic forehead lift.This technique preserves a robust blood supply to the
forehead, regardless of the prior plane of dissection. Plane elevation is straightfor-
ward and the re ective properties of the bone periosteum increase the light to en-
hance visualization with the endoscope.18 Direct visualization of the nerves helps to
preserve sensory innervation of the forehead and maximize access to the inferior
depressor muscles. For these reasons, subperiosteal dissection is safer than dissec-
tion along the subgaleal plane.
Once the frontal periosteum is released and the brow depressor muscles are ab-
lated, the elevated forehead should be maintained in position until the periosteum
adheres to the frontal bone.The time frame for this process varies in the literature
from a few days to several weeks, depending on the author.The objective of the x-
ation technique is to hold the eyebrow in position, but not pull or distract it. In pa-
tients who have had a previous coronal incision, we have not observed a compro-
mise to the scalp between the hairline and the more posterior coronal incision.
ANATOMIC RATIONALE
After operative correction, recurrent signs of aging can appear in the forehead.
Wrinkles return and the brow drops, giving the patient a tired and/or angry appear-
ance. In addition, prior operative management may result in undesirable sequelae.
Secondary correction has three primary objectives: (1) improvement of the verti-
cal and transverse wrinkles, (2) reelevation of the eyebrows, and (3) reduction of
signs of prior surgery. The risk of complications is not increased when the endo-
scopic technique is used as a secondary procedure.
W RINKLES
The forehead exhibits horizontal wrinkles as well as vertical wrinkles at the glabel-
lar region, and a transverse crease at the root of the nose.The mimetic muscle ac-
tivity of the upper face results in two types of facial wrinkles—static and dynamic—
that may recur after a coronal brow lift.
The at muscles of the face have no enveloping fascia and can contract portions of
the dermis, giving rise to the expressive quality of mimetic musculature.This mus-
cle contraction results in dynamic wrinkles that are no longer present when the
muscles relax. With age, progressive loss of elasticity in the dermis and repeated
mimetic activity result in permanent alterations or creases in the dermis, the static
wrinkles.

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The coronal incision approach involves lifting the forehead skin, thus tightening the
dermis and ablating the static wrinkles. Elevation of the entire forehead counters
the action of the depressor muscle group and reduces dynamic wrinkles. However,
this technique does not offer a lasting result because, with time, laxity in the fore-
head skin and gravity permit the forehead to become ptotic again.The imbalance
in function between the frontalis and depressor muscles recurs, thus both the dy-
namic and static wrinkles return. Similarly, in patients with upper lid ptosis correc-
tion surgery will not only improve the periorbital appearance but will decrease the
activity of the frontalis muscle, reducing transverse forehead wrinkling.
Ablation of the brow depressor muscles should be an integral part of the reopera-
tive endoscopic forehead lift. Resection of the depressor muscles needs to be con-
servative enough to avoid a noticeable depression; however, ablation of the muscle
mass between the supratrochlear and supraorbital nerves can be more aggressive.
This maneuver improves the wrinkles in the glabellar area, and elevates and sepa-
rates the medial brow, which is particularly important for older patients who often
present with inferomedial drooping of the medial brows.
This 74-year-old patient underwent a coronal brow lift 10 years before undergo-
ing an endoscopic forehead lift with midface elevation. The patient is shown 8
months postoperatively.

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Ablating the corrugator muscle is also important because it eliminates the force
that counteracts the frontalis muscle over the lateral eyebrow.The resting tension of
the frontalis muscle allows elevation of the lateral brow. Despite aggressive ablation
of the muscles between the supratrochlear and supraorbital nerves, animation is
preserved to ensure a rejuvenated yet natural appearance.19 This 66-year-old woman
underwent a coronal brow lift and face lift 7 years before undergoing an endo-
scopic forehead lift, midface lift, platysmal plication, and nasoplasty. She is shown
before and 10 months after surgery.
BROW PTOSIS
Although ablation of the muscles is important in correcting dynamic forehead
rhytids, forehead elevation addresses static rhytids and brow ptosis.The skin of the
inferior half of the forehead is more mobile than that of the superior half. This
change in forehead skin mobility is a manifestation of the transition of the deep
galea plane from a single-layered to a multilayered plane. When the supraorbital
skin is mobilized superiorly, it slides together with its frontalis muscle over the most
super cial layers of the deep galea plane. The movement of the skin over the up-
per forehead is limited because there is tight adherence between the one-layered
deep galea plane deep to the frontalis muscle and the periosteum.Therefore at the
deep galea transition zone, the inferior, more mobile forehead skin moves in a cra-
nial direction against the upper forehead skin, which is quite adherent to the perios-
teum. On the surface, this movement can manifest as transverse skin creases, partic-
ularly in the cephalad part of the forehead.20

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The frontalis muscle is tethered to the frontal bone over a 2 cm supraorbital band.
The deep galea plane of the upper forehead transitions into the rmly xed deep
galea plane of the lower forehead. Because it is tethered, the mobile lower frontalis
muscle requires a higher resting tone to produce animated eyebrow elevation. Mul-
tiple brous septa connecting the frontalis muscle to the dermis results in trans-
verse creases on the forehead skin.Transecting the periosteum and deep galea of the
lower forehead frees the frontalis muscle, allowing enhanced brow elevation with a
lower resting tone, thus reducing dynamic rhytids. A concomitant ablation of the
eyebrow depressor muscles will further reduce the counteracting forces to the
frontalis muscle.
Effectively restoring the balance between the depressor and elevator muscles will,
however, provide physiologic suspension of the brow. This suspension is the result
of the resting tone of the frontalis muscle.
HAIRLINE
Overelevation using the coronal brow approach can result in posterior displace-
ment of the hairline, thus creating a very long forehead.The use of the standard en-
doscopic technique will allow correction of recurrent ptosis without exacerbating
the high hairline, but it will not offer signi cant correction of the problem. How-
ever, using the biplanar forehead lift will allow the excess forehead height to be
decreased. In addition, this technique can provide signi cant improvement for pa-
tients with extremely deep recurrent or residual transverse forehead wrinkles. Free-
ing the forehead skin over the upper half severs the brous septa between the mus-
cle and the dermis, reducing the transverse creases.
This technique requires making a prehairline incision that results in acceptable re-
sults for many patients. In addition, plication of the frontalis muscle allows the skin
to be redraped and inset without tension, which improves the scar quality, partic-
ularly in patients older than 55 years of age.This 64-year-old patient underwent a
previous brow elevation and a subsequent endoscopic-assisted biplanar brow lift.
Preoperative, postoperative, and long-term follow-up photos are shown.The post-
operative photo was taken at 6 months, and the long-term photo was taken more
than 1 year after the endoscopic forehead lift was performed.

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BROW ASYMMETRY AND IRREGULARITY
A great deal of attention is focused on accurate repositioning and reshaping of the
eyebrows, particularly when prior surgery results in asymmetry of the eyebrow lo-
cation. Mild to moderate cases of asymmetry can be treated using the endoscopic
approach.The biplanar technique allows greater control to correction of asymme-
try. Plicating the frontalis muscle allows a more accurate correction of the posi-
tion, shape, and asymmetry of the eyebrows’shape and location.
This patient underwent an endoscopic brow lift and face lift 8 years before presen-
tation. A secondary endoscopic forehead lift and midface elevation were performed.
She is shown 7 months postoperatively.
Irregularity of the brow and glabellar region usually results from inconsistent or
overaggressive resection of the muscles. Improvement can be achieved with careful
and conservative resection. Overresection requires lling the soft tissue defect.This
can be performed using various materials. If an SMAS resection and facelift are
performed concomitantly, the resected SMAS can be contoured and inserted
through the endoscopy port and positioned with a through-and-through suture of
fast-absorbing plain gut.
ALOPECIA
Alopecia is rare when prehairline incisions and the staple xation technique are
used. Screws that are removed require scarring at the time of both placement and
removal. Absorbable screws often result in sterile abscess formation and drainage.
Avoiding the use of screw xation and the need to undermine the posterior scalp
will also reduce alopecia. In rare cases, however, the micrograft technique can be
used for hair transplantation. If desired, this technique can be performed either at
the time of the reoperative endoscopic procedure or later.

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CONCLUSION
As the use of endoscopy has expanded, so have the number of technical variations.
However, the key elements to successful forehead rejuvenation for all variations in-
clude (1) adequate release of the periosteum, (2) ablation of the depressor muscles
of the brow, and (3) a simple and reliable suspension technique. The endoscopic
forehead lift consistently attenuates transverse forehead wrinkles, reduces the glabel-
lar frown lines, and raises the eyebrows in patients who have had prior aesthetic
surgery of the brow, either endoscopically or by a coronal approach. In addition, this
technique creates a more open and pleasing expression to the eyes so that the pa-
tient looks less tired or angry, avoiding a surprised appearance. Understanding the
limitations of standard minimal-access endoscopy is as essential as executing it prop-
erly. The use of the biplanar approach expands the indications for endoscopy of
the forehead and, with proper patient selection, can yield improved results. This
approach is offered to patients with very ptotic eyebrows, deep transverse wrin-
kles, or a high forehead. Long-term follow-up demonstrates that using endoscopy
for reoperative rejuvenation of the upper third of the face yields lasting and pre-
dictable results.21
References—With Key Annotated References
1. Vásconez LO, Core GB, Gamboa-Bobadilla M, et al. Endoscopic techniques in coronal brow
lifting. Plast Reconstr Surg 94:788-793, 1994.
This is one of the seminal descriptions of endoscopy for forehead rejuvenation. Using fresh cadaver
heads to demonstrate the feasibility of endoscopic techniques and the clinical experience in 32 patients,
the endoscopic approach was established as an effective technique.
2. Gonzáles-Ulloa M. Facial wrinkles-integral elimination. Plast Reconstr Surg 29:659, 1962.
3. Vásconez LO, Core GB, Gamboa-Bobadilla M, et al. Endoscopic techniques in coronal brow
lifting. Plast Reconstr Surg 94:788, 1994.
4. Guyuron B. Endoscopic forehead rejuvenation. I. Limitations, aws, and rewards. Plast Recon-
str Surg 117:1121-1133; discussion 1134-1136, 2006.
The purpose of this article is to discuss the common features and reasons for suboptimal endoscopic
forehead rejuvenation outcomes, and how to avoidance these aws based on the author’s experience
with 372 procedures.
5. de la Torre JI, Paulsen SM, Decordier B, et al. Ann Plast Surg 54:251-255, 2005.
The secondary endoscopic forehead lift is effective in rejuvenating the upper face in the patient who
has had a previous coronal forehead lift. It elevates the eyebrows and reduces both transverse and ver-
tical wrinkle, avoiding further displacement of the hairline. It is reliable and safe in this patient pop-
ulation.
6. Knize D. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty. Plast
Reconstr Surg 102:478-489, 1998.
7. Mitz V, Peyronie M. The super cial musculo-aponeurotic system (SMAS) in the parotid and
cheek area. Plast Reconstr Surg 58:80-88, 1976.
8. Heinrichs HL, Kaidi A. Subperiosteal face lift: A 200-case, 4-year review. Plast Reconstr Surg
102:843-855, 1998.
9. Guyuron B, Michelow BJ. Re nements in endoscopic forehead rejuvenation. Plast Reconstr
Surg 100:154, 1997.

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Use of Endoscopy in Reoperative Brow-Lifting
10. Stuzin JM, Wagstrom L, Kawamato H, Wolfe SA. Anatomy of the frontal branch of the facial
nerve:The signi cance of the temporal fat pad. Plast Reconstr Surg 83:265-271, 1989.
11. Cutting CB, McCarthy JG, Berenstein A. Blood supply of the upper craniofacial skeleton:The
search for composite calvarial bone aps. Plast Reconstr Surg 74:603-610, 1984.
12. Casanova R, Cavalcante D, Grotting JC,Vásconez LO, Psillakis JM. Anatomic basis for vascu-
larized outer-table calvarial bone aps. Plast Reconstr Surg 78:300-308, 1986.
13. Pitanguy I, Ramos AS.The frontal branch of the facial nerve:The importance of its variations
in face lifting. Plast Reconstr Surg 38:352-356, 1966.
14. Ishikawa Y. An anatomical study on the distribution of the temporal branch of the facial nerve.
J Craniomaxillofac Surg 18:287-292, 1990.
15. Ramirez OM, Robertson KM. Update in endoscopic rejuvenation. Facial Plast Surg Clin
North Am 10:37-51, 2002.
16. Knize D. Muscles that act on glabellar skin: A closer look. Plast Reconstr Surg 105: 350-361,
2000.
17. De Cordier B, de la Torre JI, Al-Hakeem MS, et al. Endoscopic forehead lift: Review of tech-
nique, cases, and complications. Plast Reconstr Surg 110:1558-1568, 2002.
A large clinical experience demonstrates the signi cant improvement in the surgical rejuvenation of the
upper face using the endoscopic forehead lift.To successfully elevate the eyebrows, it is essential to re-
lease the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the
glabella.
19. Hamas RS. Endoscopic management of glabellar frown lines. Clin Plast Surg 22:675, 1995.
20. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr
Surg 98:1148, 1996.
21. Behmand RA, Guyuron B. Endoscopic forehead rejuvenation. II. Long-term results. Plast Re-
constr Surg 117:1137-1143, 2006.
This study objectively demonstrates the long-term ef cacy of the endoscopic forehead lift. Preoperative
and postoperative photographs of 100 patients who underwent endoscopic forehead rejuvenation were
evaluated with a mean follow-up of 44 months. Brow position relative to the orbital rim, brow arch
form, vertical frown lines, and horizontal frown lines of the forehead were analyzed, with stable re-
sults many years after surgery.

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1. The temporal branch of the facial nerve found between which anatomic layers?
a. Galea and periosteum
b. Temporalis muscle and super cial layer of the deep temporal fascia
c. Temporalis muscle and deep layer of the deep temporal fascia
d. Temporoparietal fascia and super cial layer of the deep temporal fascia
e. Temporoparietal fascia and subcutaneous tissue
2. Which of the following are considered adequate methods of postoperative x-
ation after endoscopic forehead lift?
a. Suture suspension from absorbable screws
b. Suture suspension to deep soft tissue or fascia
c. Temporary external xation
d. No xation
e. All of the above
3. Advantages of the subperiosteal dissection do not include:
a. Safety
b. Creation of optical cavity
c. Preservation of the forehead blood supply
d. Avoidance of the supratrochlear and supraorbital nerves
e. All of the above
4. Which of the following is considered to be a disadvantage of the endoscopic
brow lift approach versus the coronal (open) approach?
a. Decreased operative length
b. Decreased scalp paresthesia
c. Need for special equipment
d. Decreased incision length
e. Increased patient acceptance of procedure
5. Indications for secondary forehead lift do not include:
a. Persistent wrinkles
b. Recurrent brow ptosis
c. Brow asymmetry
d. Upper lid ptosis
e. Patient’s desire for further aesthetic improvement
R EVIEW QUESTIONS

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Adjunctive Surgical Procedures to
Improve the Face-Lift Result
G. Mabel Gamboa-Bobadilla, Omer Re k Ozerdem,
and Luis O.Vásconez
C ha pter 14
We are built to solve problems, to achieve goals,
and we nd no real satisfaction or happiness in life without
obstacles to conquer and goals to achieve.
Maxwell Maltz
Primary face-lift procedures seek to correct the major signs of aging exhibited in
the face and neck. Most approaches provide a rested, more youthful appearance by
smoothing facial wrinkles, excising and tightening the skin, removing excess fat
and skin, and lifting or restoring key anatomic landmarks. Face-lift patients com-
monly request correction of facial wrinkling, double chin, jowls, drooping eyelids
and eyebrows, and horizontal forehead and vertical glabellar wrinkles.1 In addition
to these obvious common complaints, there are other defects associated with aging
that often are not addressed during the primary face lift, such as thinning of the up-
Reoperative Problems
Thinning lips
Ptotic chin
Earlobe deformities
“Sad pleats” deformity
Aging nose
Prominent brow furrows
Malar fat pad descent
Prominent ears

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per lip and mouth, ptotic chin, prominent labiomental folds, thickening of the nasal
tip, a hanging columella, and earlobe deformities. Over the years we have found that
minor surgical corrections of such problems improve the overall primary result.
More recently we have begun to incorporate these re nements or nishing touches
as a part of the primary face-lift procedure to having to address these problems sec-
ondarily and enhance patient satisfaction.
THINNING AND ELONGATION OF THE
UPPER LIP
A harmonious facial appearance is determined by a balanced relationship among all
the facial features.Thinning of the lips and formation of perioral wrinkles are part
of the normal degenerative process; the upper lip lengthens with age, becoming
at and curtainlike as a result of the loss of delineation of the philtral columns and
vermilion pout.These signs of aging are often unacceptable to the patient who de-
sires a more youthful appearance.2-5 When analyzing the aging mouth, the aesthetic
surgeon encounters three types of abnormalities that are amenable to surgical cor-
rection: (1) elongation of the upper lip, resulting in loss of symmetry and convex-
ity, (2) thinning of the vermilion, with loss of shape and commissural drooping,
and (3) formation of radial lines from the vermilion extending onto the upper and
lower lips.These lines are the result of constant stress imposed on the perioral der-
mis by continuous intrinsic muscular activity, and they become more pronounced
once skin elasticity has been lost.
Two major techniques have been described for the correction of the aging lip:
local surgery and chemical peel or mechanical dermabrasion (see Chapter 15).
FLEUR-DE-LIS EXCISION AT THE NASAL BASE
Excision of the nasal base has limited applications because it leaves a scar at the
base of the nose. We restrict its use to patients over 55 years of age in whom the
scarring process is less active and who are thus less likely to have scarring prob-
lems. In these patients we suggest shortening the upper lip by removing an ellipse
of skin at the base of the nose.
The skin next to the base of the nose is
meticulously and symmetrically marked
in the form of a fleur-de-lis, breaking
the line at the base of each nostril to
maintain the natural lip-nose intersec-
tion. If necessary, the line of excision
may extend to the alar bases. The aver-
age width of the excision is about
5 mm.

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Following removal of the skin, the underlying orbicularis oris muscle is exposed
and tightened form philtrum to philtrum with one or two horizontal mattress su-
tures of ne nylon. If necessary, the orbicularis oris muscle is reattached to the nasal
spine above. This produces a tightening of the muscle at the nasal base and causes
the red portion of the lip to pout.
A dog-ear is resected at the center of the lip vertically. In very long lips the hori-
zontal excision is combined with a vertically oriented elliptical excision of 2 to
3 mm along the philtral crests. This additional excision both compensates for the
dog-ear resulting from the orbicularis oris plication and restores the natural convex-
ity of the philtral columns.
The result is shown 3 months postoper-
atively.

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Preoperative and postoperative photos are shown of the patient above, who un-
derwent eur-de-lis excision of the nose base and excision of the nasolabial folds
and the marionette lines.
NARROW ING THE NOSTRILS
Millard’s alar cinch stitch technique could be used to narrow the wide alar bases.6
This also enhances the length of the columella slightly and changes the direction of
the nostrils from transverse to oblique or vertical. In this technique, bilateral alar
aps are elevated at the nostril sills, denuded, and sutured to each other and to the
nasal spine through a tunnel at the base of the caudal septum. Ship’s alar base resec-
tion modi cation technique is another method available to narrow the alar sills.7 In
this method, rectangular tissues are removed at the alar bases bilaterally and the alar
base aps are advanced to close the defect, narrowing the aring nostrils.

EXCISION OF THE VERMILION BORDER
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Thin, inexpressive,“sad” lips can be corrected by direct excision at the vermilion
border. For the upper lip the vermilion is meticulously and symmetrically marked,
with two junction points at the philtral crests. The midline of the lip and vermil-
ion border is marked.The new height and form of the lip are designed symmetri-
cally. Between each philtral crest and the midline we recommend that the line of
excision be an acute angle.This angle should be marked in a slightly overcorrected
position resembling the top point of an M.The midline point marks an acute an-
gle in the midline and touches the vermilion. Positioning the midpoint in this way
gives the lip an extra pout and natural contour. Excision along the other acute an-
gles of the M gives a natural, protruding mucocutaneous border, and subsequent
scarring will contract the overlying skin without erasing the contour of the lip,
thereby preserving a smooth expression that gives a very pleasing result.The lateral
lines of excision are curved slightly toward the commissures but do not touch the
commissures.The lower line of excision is marked along the white line of the ver-
milion border.The border of the vermilion is preserved at the midline of the lip to
maintain the eversion of the midlobule of the lip.
Markings for the lower lip follow the shape of the lip and de ne the excision that
will be necessary. As with the upper excision, to prevent circumferential scar con-
tracture, the lower excision should not meet the commissures.The skin between the
actual and future vermilion borders is completely excised. In this patient a 2 mm
skin resection was performed.

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The wound must be closed in a meticulous fashion with half-buried horizontal
mattress sutures that pass through the dermis of the upper margin vertically and
are tied horizontally over the vermilion to prevent cutaneous stitch marks.The su-
tures are removed on the third postoperative day.
The patient is shown 2 weeks postoperatively.

This patient had a very thin upper lip.Three months after upper lip enhancement
by direct excision, the appearance of the upper lip is much improved.
This procedure is seldom indicated at present since it produces a visible and palpa-
ble scar. Besides, good results could be obtained with autogenous (for example, fat)
or exogenous (for example, Restylane) lling materials.
VERMILION THINNING
For patients in whom the vermilion has thinned as a result of aging and younger
patients with congenitally thin vermilion borders, treatment includes VY advance-
ment lip augmentation combined with orbicularis muscle tightening or fat/colla-
gen injection.
VY ADVANCEMENT LIP AUGMENTATION
VY advancement lip augmentation was first suggested by Dr. Aldo Piccolo of
Rome, Italy.8 This technique involves two isolated VY advancements of the mucosa
of the upper lip. The apex of each V is marked at the approximate midpoint be-
tween the philtral column and the commissure. The limbs extend at an approxi-
mately 45-degree angle from the buccal sulcus to the wet-dry line of the lip. The
incision is deepened through the mucosa to expose the orbicularis oris muscle on
each side.The philtral columns are left uninvolved. If necessary, the orbicularis mus-
cle may be tightened with a horizontal mattress suture, which is then tacked to the
nasal spine. Only 5 to 7 mm of advancement is necessary to obtain a satisfactory re-
sult.The central portion of the lip is left undisturbed, thus avoiding the creation of
an abnormal pout.
The effectiveness of this procedure is based on the clinical observation that any in-
cision along the mucosal border of the lip heals by hypertrophy. Johnson9 advo-
cated applying this clinical prolonged swelling and discomfort as well as the poten-
tial of asymmetry if the advancements are unequal.
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LABIOMENTAL FOLDS OR “SAD PLEATS”
DEFORMITY
“Sad pleats” are furrows that arise from the oral commissure and turn downward,
giving the patient a stern or sad look.10 Even with extensive undermining during
the face-lift procedure, these furrows in the skin are not always corrected. Several
corrective approaches have been suggested, including selective resection of the le-
vator alae nasi muscle and elevation of the malar fat pad.
SELECTIVE R ESECTION OF THE LEVATOR ALAE NASI MUSCLE
The levator alae nasi muscle is a paired thin muscle that lies deep to the orbicularis
oculi muscle superiorly, originates from the maxilla, and inserts into the lateral alae
and orbicularis oris muscles.The angular artery and vein coarse medial and super-
cial to the levator alae nasi muscle, and the infraorbital nerve lies lateral to the le-
vator alae nasi muscle and beneath the levator labii superioris alaeque nasi muscle.
Action of the levator alae nasi muscle elevates the alar base, creating a sneer ex-
pression. As the alar base is elevated, the nasolabial angle becomes acute and the me-
dial nasolabial fold becomes accentuated. Pessa11 and Pessa and Brown12 stated that
levator labii superioris alaeque nasi creates the medial nasolabial fold, whereas the
levator labii superioris creates the middle part of the fold. They also reported that
the zygomaticus major muscle has little effect on the lateral part of the fold, but
does affect the corner of the mouth.
Dissection is performed through a subciliary incision, and the skin-muscle ap is el-
evated.The orbicularis oculi muscle is dissected inferiorly to free it from the orbital
rim.The dissection proceeds medially to the groove between the maxilla and nasal
bone where the levator alae nasi muscle is located and identi ed. A 0.5 to 1 cm seg-
ment of this muscle is resected. The transconjunctival method, as described by
Goldberg,13 is preferred; the origin of the muscle could be found and resected follow-
ing dissection behind the orbicularis oculi muscle and then at the infraorbital area
subperiosteally.
This procedure is seldom performed at present, because the same effect can be ob-
tained temporarily with Botox.
MALAR FAT SUSPENSION ADJUVANT TO R HYTIDECTOMY
As part of the aging process, the malar fat pad descends and causes deepening of the
nasolabial fold. As the malar fat descends, a hollowing effect at the lower portion of
the lower lid along the infraorbital rim occurs, forming the so-called nasojugal crease.
Descent of this midface fat also contributes to the formation of marionette lines
and visible lowering of the corners of the mouth.

Surgeons have attempted to reposition this fat using a variety of methods. Our pre-
ferred technique is to reposition the malar fat pad by means of suspension sutures.
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The area is approached through the prehairline incisions.14 The malar fat pad is
covered by the SMAS layer, which forms a continuous sheath through the midface.
A subcutaneous dissection over the SMAS allows access to the malar fat pad.
Suture purchases edge
of orbicularis oculi muscle
Suspensory sutures
in SMAS
Orbicularis oculi
muscle

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As shown in the illustration on p. 355 and the cadaver dissections above, two sus-
pension sutures are placed in the SMAS medially and in the malar fat pad laterally;
a third suture is placed at the lateral aspect of the orbicularis oculi muscle.The su-
tures are then anchored above to the zygomatic arch. This maneuver restores the
youthful appearance of the face with fullness in the infraorbital area and marked im-
provement in the nasolabial folds. Elevation of the corners of the mouth and some
attening of the perioral folds are also achieved.

This 43-year-old woman requested improvement of deep nasolabial folds and a ptotic
central face. Malar fat elevation was performed as an adjunct to rhytidectomy.The
correction was maintained at 1 year postoperatively.
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Preoperative and postoperative pictures are shown of this patient who had a previ-
ous face lift and underwent malar fat elevation and allograft insertion to the dor-
sum of the nose secondarily.
This intraoperative photo shows malar
fat pad lifting that has been employed
on the right side. Please note the malar
fullness on the right side.

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PTOTIC CHIN
The tip of the chin tends to droop with age.This sagging is exaggerated as the soft
tissues droop in edentulous patients, resulting in a lack of anterior support to the
midline musculature. Following rhytidectomy and suction-assisted lipectomy with
platysma plication, the ptotic chin becomes more obvious. Correction of the jaw
line with standard techniques of rhytidectomy may accentuate even a mildly ptotic
chin.15
A great number of procedures have been advocated for the correction of the ptotic
chin. Most of these techniques attempt to elevate the soft tissues as well as the mus-
cular insertions on the bone through resection of skin and fat. In addition, chin
implants inserted at a higher level may be used to camou age the ptosis and to
take up the excess skin. Our preferred method is to elevate the soft tissues or the
hanging part of the chin upward over the mandible, thereby enabling the skin to re-
drape over the elevated tissues.The procedure is performed in conjunction with the
face lift without signi cantly increasing the operative time. Successful results are
achieved in patients with mild, moderate, and severe degrees of chin ptosis.
TECHNIQUE
After the face lift has been performed, usually in conjunction with submental lipec-
tomy and platysma plication through an added submental incision, we elevate the
skin and muscle above the horizontal lateral rami of the mandible and the sub-
mental crease and over the symphysis close to the mental crease.
The oral cavity is irrigated with a dilute mixture of povidone-iodine (Betadine),
and a puncture wound is made in the mucosa appropriately 1 cm anterior to the
labial sulcus.
A 3-0 Prolene suture is placed through the intraoral stab wound to exit at the ptotic
side on the chin; the surgeon must be careful to include the xation point on the
mandibular periosteum.

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The needle is then introduced through the same side on the skin and directed back
toward the intraoral stab wound.The second limb of the suture loop is placed in a
slightly different plane from the rst.The suture is then tied with moderate tension
under direct vision in order to control the degree of correction.
POINTED CHIN TYPE

The technique may be modi ed, depending on the type of the chin to be cor-
rected. In patients with pointed chins, the U stitch is reinserted exactly at the cu-
taneous exit point. In patients with square ptotic chins, the suture is redirected in-
traorally 3 to 4 mm horizontally in the intradermal plane.
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SQUARE CHIN TYPE

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Immediate postoperative correction of the ptotic chin is performed concomitantly
with the rhytidectomy.
The mucosal insertion is then closed with 4-0 chromic catgut. As the Prolene su-
ture is tied intraorally, a dimple is created in the submental area. Although this fea-
ture usually lasts for several months, it has not been a problem in our experience.
Many patients notice this dimple, and some consider it an added bene t. Having
followed up a good number of these patients over the years, we believe that this
technique produces a lasting correction. Only rarely have we had to repeat this
maneuver in the same patient.

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This 60-year-old woman is shown 1 year after correction of the ptotic chin as an
adjunctive procedure to a face lift.The percutaneous chin stitch is barely noticeable.
This percutaneous mentopexy restores facial balance and can be used successfully
in both rhytidectomy patients and patients who have an underdeveloped mandible
and refuse a chin implant at the time of rhinoplasty.

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AESTHETIC RHINOPLASTY IN THE
AGING PATIENT
Certain changes in the skin and soft tissue of the nose occur with aging including
involution of the sebaceous glands and thinning of the skin. The skin over the tip
of the nose in particular can become thinner, thus making the alar cartilages more
prominent. The nose lengthens with age, and the tip of the nose tends to droop.
The membranous septum may become redundant, requiring correction.
Patients requesting face-lift procedures are usually unaware of these changes. Since
the results of tip rhinoplasties and small adjunctive techniques in the nose are so
gratifying to patients, we will sometimes suggest these procedures. Reassurance is
given that the facial appearance will not be dramatically changed nor will the patient
have the stigmata of a “nose job.” Subtle adjustments speci cally to the tip of the
nose bring the facial features into harmony. It is important that the surgeon t the
nose to the face rather than trying to make the nose t an ideal mold. A classic
rhinoplasty should not be performed on these patients because this procedure
would dramatically change their appearance, potentially requiring a long period of
psychological adjustment.
After analyzing our cases, we have found that in most the correction involved a
bulbous tip, drooping nasal tip, or minimal nasal hump, which is amenable to rasp-
ing without osteotomy. Lifting the nasal tip and re ning the nasal lines without
changing the basic facial characteristics add much to facial rejuvenation, and when
combined with face lift, patients are almost universally pleased with the results.
The surgical technique for thinning the bulbous tip of the nose is cephalic resec-
tion of the alar cartilage and insertion of a crushed cartilaginous tip graft, since the
nasal tip droops following alar cartilage resection.

This patient underwent face and neck lifting, blepharoplasty and nasoplasty with tip
elevation. Her preoperative and postoperative photos are shown.
CORRECTION OF THE HANGING COLUMELLA
The hanging columella, which may have been acceptable in youth, becomes much
more prominent as the patient ages. Our approach is to resect a suf cient part of the
membranous septum to correct the hanging portion. A minimal 2 to 3 mm seg-
ment is also resected from the caudal end of the septum, excising a bit more mu-
cosa than cartilage, and the remaining caudal septum is then wedged between the
leaves of the membranous septum using horizontal mattress sutures of ne nylon.
In addition, a tip graft is often added to maintain elevation of the nasal tip.
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On occasion, the orbicularis oris muscle may be tightened by grasping it on both
sides of the anterior nasal spine through the incision in the membranous septum
and by reattaching it above the nasal spine.
This patient’s primary concern was her aging face. However, the hanging columella
and ptotic nasal tip contributed to her elderly appearance. Rhytidectomy, minimal
resection of the caudal end of the septum to correct the hanging columella, and
repositioning of the ptotic chin were performed (see p. 363).
PROMINENT EARS
As patients age, the prominence of the external ear may become accentuated, and
conchae of the ear may become deeper. To set the ears back, making them less
prominent, requires only a simple maneuver during the face-lift procedure. As the
postauricular incision is closed, the skin overlying the conchae is undermined, the
mastoid fascia is exposed posteriorly, and one or two conchae-mastoid sutures of
4-0 clear nylon are placed that, when tightened, effectively set the ears back, thereby
enhancing the overall result of the face lift. If the concha is quite deep, we do not
hesitate to resect an ellipse of conchae posteriorly.
On rare occasions we may perform a complete otoplasty with cre-
ation of an antihelix. This simple maneuver has not been discussed
elsewhere to our knowledge; we recommend it highly.

Preoperative and postoperative photos are shown of the patient who underwent
cervicofacial lifting and otoplasty.
The ear descends with age.This could be improved during the midface lift proce-
dure.We continue the temporal prehairline incision posteriorly at the upper part of
the ear and then advance anteriorly to carry on the preauricular incision, creating
a triangular peninsula. Excision of this part followed by suturing the upper and
lower wound edges during the face-lift procedure elevates the ear.
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This illustration shows tissue excised and vertical traction applied, elevating the ear.
EARLOBE DEFORMITIES
The earlobe is an almost universal attribute of beauty throughout the world, exem-
pli ed by its decoration with earrings and coloring in countless cultures.With ag-
ing the earlobe becomes longer and wrinkled and earlobe ptosis or pseudoptosis
may occur.16,17 As it enlarges, it attens and takes on a rounded con guration, which
seems to hang down from the face. Reduction of the earlobe is recommended in
patients who show moderate to marked enlargement of the earlobe and is per-
formed in conjunction with the face-lift procedure.

We prefer a rectangular excision of the redundant earlobe.The edges are approxi-
mated in an anteroposterior layer of ne nylon sutures. We do not advocate the
use of a triangular resection, since this design creates a pointed earlobe, which is less
attractive.This procedure is simple and effective and ameliorates some of the wrin-
kles. The earlobe regains its natural shape and size. For patients with pierced ears,
the ear is repierced and a 1-0 Prolene suture is loosely tied to maintain the open-
ing. Following the earlobe reduction, the incision heals so well that it is hardly no-
ticeable.
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This patient underwent eur-de-lis excision of the nose base and an earlobe reduc-
tion.

An alternative method to reduce the earlobes consists of a rounded tangential ex-
cision outlined at the caudal end of the earlobe that follows the normal curvature.
We resect the anteroposterior thickness with a No. 11 blade, and the wound edges
are sutured with 6-0 nylon sutures. Once the wound heals, the scar is hardly notice-
able.
The pixie-ear deformity, which results from the adherence of the earlobe to the
skin of the cheek, can be avoided during the face-lift procedure.The postauricular
ap is suspended with one suture superiorly and one suture at the concha-mastoid
sulcus, leaving the tip of the earlobe free of any sutures. The maximal tension and
xation are thus above the earlobe.The surgeon should avoid hanging the postau-
ricular ap on the earlobe because the earlobe becomes elongated in a tethered
position with gravity and wound contraction.
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If the pixie-ear deformity occurs, it can be corrected by the following procedure.
The attached portion of the earlobe is released up to its normal level of attach-
ment. The neck skin is then rotated into the postauricular area, trimmed, and su-
tured in the postauricular crease. It is best to leave the edge of the released earlobe
unsutured, allowing the earlobe to heal with a completely normal shape and virtu-
ally without a scar.
Edge left unsutured
Skin of lateral neck
sutured behind ear

REDUCING FULLNESS OF THE CHEEK
The buccal fat pad is located in the masticatory space and separates the masticatory
muscles, so that gliding surfaces of these muscles do not affect each other during
mastication.18 In the round face this tissue can be removed partially. Either an ex-
ternal or an intraoral approach may be used as described by Stuzin et al18 and
Adamson and Tokso.19 In an external approach, after subcutaneous dissection dur-
ing the face-lifting procedure, SMAS-masseteric fascia is dissected gently with a
hemostat so as not to injure the facial nerve branches, exposing the underlying
buccal fat pad in front of the masseter. In an intraoral approach, an incision is made
in the upper buccal sulcus, 5 mm above the attached gingiva at the level of the sec-
ond molar and extended 2 cm posteriorly.Then the fascia of the fat pad is incised
and the desired amount of fat is removed. Stuzin et al18 stated that 1 to 2 g of tissue
in many cases and 4 to 5 g in severe cases are adequate amounts to be removed.
CONCLUSION
The procedures described in this chapter, although simple, require a certain amount
of daring, an artistic eye, and an appreciation of the contribution of subtle adjust-
ments to the overall final result. These refinements address deformities not im-
proved by rhytidectomy; such problems call for a direct surgical approach. Poten-
tial difficulties can be obviated by the careful selection of patients and the
performance of appropriate surgical techniques.
References—With Key Annotated References
1. Barton FE.The SMAS and the nasolabial fold. Plast Reconstr Surg 89:1054-1057, 1992.
2. Baker TJ, Gordon HL. Chemical peeling as a practical method for removing rhytides of the up-
per lip. Ann Plast Surg 2:209-212, 1979.
3. Cardoso AD, Sperli AE. Rhytidoplasty of the upper lip. In Transactions of the Fifth Interna-
tional Congress of Plastic and Reconstructive Surgery. Melbourne, AU:Butterworth, 1971, pp
1127-1129.
4. Gonzáles-Ulloa M.The aging lip. In Transactions of the Sixth International Congress of Plas-
tic and Reconstructive Surgery. Paris: Masson, 1975, pp 443-446.
5. Pitanguy I, Muller P, Piccolo N, et al. Esthetic surgery of the aging lip. Compendium 8:460-
463; 465, 1987.
6. Millard DR Jr.The alar cinch in the at, aring nose. Plast Reconstr Surg 65:669-672, 1980.
7. Ship AG. Alar base resection for wide aring nostrils. Br J Plast Reconstr Surg 28:77-79, 1975.
8. Piccolo A. Personal communication, LO Vásconez, 1990.
9. Johnson HA. A simple method for the repair of minor post-operative cleft lip “whistling” de-
formity. Br J Plast Surg 25:152-154, 1972.
10. Borges AF. Sad pleats. Ann Plast Surg 22:74-75, 1989.
11. Pessa JE. Improving the acute nasolabial angle and medial nasolabial fold by levator alae mus-
cle resection. Ann Plast Surg 29:23-30, 1992.
373
Chapter 14
Adjunctive Surgical Procedures to Improve the Face-Lift Result

374
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
12. Pessa JE, Brown F. Independent effect of various facial mimetic muscles on the nasolabial fold.
Aesth Plast Surg 16:167-171, 1992.
The independent effect of the contraction of various facial mimetic muscles on the nasolabial fold was
de ned through study of cadaver dissections.The four major lip elevator muscles were identi ed, and
the effect of traction of these muscles on the nasolabial fold was studied.This study identi ed the le-
vator alae muscle (levator labii superioris alaeque nasi) as the primary facial muscle responsible for cre-
ating the medial nasolabial fold.The levator labii superioris muscle was found to de ne the middle na-
solabial fold.These two facial muscles may be signi cant in the etiology of the prominent nasolabial
fold that occurs with aging.
13. Goldberg RA.Transconjunctival orbital fat repositioning:Transposition of orbital fat pedicles
into a subperiosteal pocket. Plast Reconstr Surg 105:743-748, 2000.
14. Collawn SS,Vásconez LO, Gamboa M, et al. Subcutaneous approach for elevation of the malar
fat pad through a prehairline incision. Plast Reconstr Surg 97:836-841, 1996.
Vertical suspension of the malar fat pad has been a safe procedure that results in the creation of a more
youthful cheek and a lessening of the prominence of the nasolabial folds.
15. de la Torre JI, Martin SA, Al-Hakeem MS, et al. A minimally invasive approach for correction
of chin ptosis. Plast Reconstr Surg 113:404-409, 2004.
Although ptosis of the tip of the chin is common and can be seen in persons of any age, it is frequently
seen in older patients who seek facial rejuvenation.The authors describe a minimally invasive method
that can be used to correct chin ptosis.This technique uses a small intraoral incision to place a U-shaped
Prolene suture that gathers the soft tissue of the chin and elevates it above the lower border of the
mandibular symphysis.A retrospective review of 314 cases performed in conjunction with face lifts be-
tween January 1994 and January 2000 was performed to evaluate this technique.
16. Mowlavi A, Meldrum DG,Wilhelmi BJ, et al. Effect of face lift on earlobe ptosis and pseudo-
ptosis. Plast Reconstr Surg 114:988-991, 2004.
In this study, the authors evaluated the effects of standard face-lift surgery on earlobe ptosis and
pseudoptosis by comparing the preoperative and postoperative earlobe height measurements from life-
size photographs of 44 patients who underwent rhytidectomy performed by the senior author. Earlobe
height changes can result from either age-related lobule ptosis (increase in free caudal segment), as pre-
viously described, or in patients undergoing rhytidectomy (increase in attached cephalic segment).
Therefore ideal lobule distances, along with the effects of aging and rhytidectomy surgery on the lob-
ule, should be discussed with patients seeking a more youthful facial appearance, so that the aging ear
may be addressed concurrently with the aging face.
17. Mowlavi A, Meldrum DG,Wilhelmi BJ, et al. Incidence of earlobe ptosis and pseudoptosis in
patients seeking facial rejuvenation surgery and effects of aging. Plast Reconstr Surg 113:712-
717, 2004.
18. Stuzin JM, Wagstrom L, Kawamoto HK, et al. The anatomy and clinical applications of the
buccal fat pad. Plast Reconstr Surg 85:29-37, 1990.
The buccal fat pad is an anatomically complex structure that has great importance in facial contour.
In properly selected individuals, judicious harvesting of buccal fat can produce dramatic changes in fa-
cial appearance by reducing the fullness of the cheek and highlighting the malar eminences. Using fresh
cadaver dissection, the anatomy of the buccal fat pad is delineated, and its relationship to the masti-
catory space, facial nerve, and parotid duct is de ned.An intraoral approach for buccal fat harvesting
is described based on these anatomic ndings. Clinical experience manipulating the buccal fat pad for
aesthetic modi cation of facial contour is illustrated.
19. Adamson JE, Tokso AE. Progress in rhytidectomy by platysma-SMAS rotation and elevation.
Plast Reconstr Surg 68:23, 1981.