Phẫu Thuật Tạo Hình (Tập 2): Phẫu Thuật Thẩm Mỹ – Neligan (Ấn bản 4)

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CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
superficial fat to disguise any irregularities that may arise
from these procedures. In addition, if isolated surgery on the
neck was performed as the primary procedure, pseudo-ptotic
jowl fat and fat lying along the mandibular border has usually
been erroneously excised. This can result in harsh or irregular
contours when the SMAS is subsequently elevated, and defat­
ted areas are unavoidably advanced superiorly onto the face
(Fig. 6.10.32). In these situations, care must be taken in any
secondary procedure to preserve as much fat as possible and
to carefully contour fat at the interface between face and neck.
It should be the aim of every surgeon who endeavors to
rejuvenate the face to create an attractive neck and not one
simply devoid of fat. Excessive fat excision does not produce
attractive or youthful contours, and often exposes and accen­
tuates other neck problems. These problems include platysma
bands, prominent submandibular glands, and large digastric
muscles. Each of these neck problems generally requires that
wide cervical skin undermining be performed if appropriate
correction is to be made. This is often difficult when little fat
is present. Any such dissection must be carried out with great
care to avoid any injury to residual subdermal fat, the pla­
tysma, and regional motor nerves. Excessive fat excision can
also result in troublesome dermomuscular adhesions. These
frequently result in tethering and abnormal appearances in
animation and generally require careful division if an open
dissection of the neck is planned. If no modification of the
platysma or other deep layer structures is needed, dermomus­
cular adhesions can be treated transcutaneously with a “V”
tipped needle dissector and carefully placed fat injections.
Although judicious excision of cervical fat is often neces­
sary as part of rejuvenation of the aging neck, the excision of
facial fat will usually produce an aged and haggard look,
inconsistent with the intended goal of producing an improved
appearance. This haggard appearance is evident in many
patients presenting for secondary surgery who have under­
gone “minilifts”, “weekend facelifts”, “microliposculpture”,
practiced, anchoring the lobule to auricular cartilage or adja­
cent deep tissue with buried sutures will not be effective if
enough skin is not present to allow closure to be made under
minimal skin tension. Over time, the lobule will migrate
inferiorly.
In all but the unusual case, there will not be enough skin
present to correct “loving cup” earlobes by undermining and
elevating the cheek skin. It will also be an artistic error to
simply place the lobule back in an inappropriate position. In
such instances, it may be best to move the lobule into a normal
position and carefully close the defect into which it was origi­
nally inset using meticulous technique. The resulting scar will
go unnoticed because the eye will not be drawn to the area as
it once was by the abnormal appearing lobule. In addition,
the scar itself will often heal well following this maneuver, as
the incision can be closed under minimal tension under these
circumstances. A small amount of make-up or a cosmetic
tattoo is often usually sufficient to conceal it. If the healed scar
is raised or irregular and is incompletely concealed with
make-up, dermabrasion can be performed as a subsequent
step. For most patients, a scar on the cheek will be less notice­
able than a displaced lobule, and is an acceptable trade-off for
obtaining proper lobular position.
Over-excision of subcutaneous fat
The introduction of liposuction, along with ill-conceived
procedures in which subcutaneous fat of the face and neck is
aggressively curetted, excised, or even subjected to laser and
ultrasound treatment, has resulted in a group of patients with
excessively defatted necks and concomitant deformities
(Fig. 6.10.31).
These patients with “cadaver necks” have little fat between
their cervical skin and the underlying platysma and present
a difficult problem when they request secondary procedures.
Often, they require platysma surgery, although they have little
Fig. 6.10.31  Over-excision of
subcutaneous fat. (A) The patient has
undergone a “weekend facelift” in which
aggressive liposuction was performed and
too much fat was removed. The neck and
submental region are irregular and
unattractive. (B) A different patient who has
had a previous facelift. Submental
“microliposculpture” was performed as part
of the procedure. Inappropriate over-
resection of fat has resulted in harsh and
unnatural contours. Note the contrast with
the soft contours of the cheek and neck.
(Procedures performed by unknown
surgeons.)
A
B

257
Identification and analysis of secondary surgical deformities
more evident when the neck is flexed somewhat or when the
patient swallows.
Correction of the dug-out neck deformity is best made
using fat injections if it is the only problem present. If large
digastric muscles and/or large submandibular glands are
present, reducing these as part of the procedure may be suf­
ficient to hide the deformity. If secondary surgery is planned
and adequate platysma is present, an anterior invagination
(rather than excision) of the redundant portion of the medial
platysma borders can also produce some improvement.
Over-excision of buccal fat
Although the judicious excision of buccal fat will occasionally
benefit certain patients seeking primary or secondary facelift,
and other procedures in which facial liposuction is often
performed. In these cases, remaining fat must be carefully
tailored to produce the best contours possible. These patients
will also often benefit from facial fat injections.
Over-excision of subplatysmal fat
Although not all surgeons routinely explore the subplatysmal
space and excise subplatysmal fat, patients with an unappeal­
ing “dug-out neck” deformity are increasingly presenting
for secondary procedures. The dug-out neck deformity is
a term used by some to describe situations in which subpla­
tysmal and/or deep cervical fat has been erroneously over-
excised resulting in an objectionable depression in the
submental region (Fig. 6.10.33). Typically, this depression is
Fig. 6.10.32  Erroneous excision of submental and
pseudo-ptotic jowl fat. (A) Aggressive liposuction is
performed as a primary procedure over the neck and jowl
(shaded area) in a misguided attempt to rejuvenate the
face. (B) When the patient returns for formal facelift and
ptotic deep layer tissues are properly repositioned,
denuded areas are advanced up onto visible areas of the
face. This can result in harsh and irregular contours.
A
B
Fig. 6.10.33  (A,B) The “dug-out neck”
deformity. The “dug-out neck” deformity is a
term used to describe situations in which
subplatysmal and/or deep cervical fat has
been erroneously over-excised resulting in
an objectionable depression in the
submental region. (Procedures performed by
unknown surgeons.)
A
B

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CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
it will usually result in an ill or haggard look inconsistent with
the intended goal of producing an improved appearance (Fig.
6.10.34A). This is evident in many patients presenting for
secondary surgery who have undergone “minilifts”, “weekend
facelifts”, and limited-incision procedures in which buccal fat
excision is often performed. In these patients, SMAS advance­
ment or midfacelifts can exacerbate this situation by elevating
the over-reduced buccal pad. These patients will often benefit
from less aggressive SMAS surgery and avoidance of
midfacelifting.
Correction of the over-resection of buccal fat is most easily
made using fat injections, and these can generally be per­
formed as part of the secondary facelift procedure (Fig.
6.10.34B). Injections should be made meticulously in small
amounts and in multiple passes in multiple planes with a
small blunt infiltration cannula. In general, 3–7 cc of centri­
fuged fat is needed for each cheek. Alternatively, free fat
grafts, or dermis fat grafts can be used. Facial fat injections
can also be performed as a separate procedure after secondary
facelift is performed. This allows the patient and surgeon to
Fig. 6.10.34  (A) Inappropriate excision of buccal fat. Excision of buccal fat as part of a “mini” facelift has resulted in an ill or haggard look. This problem is most easily
corrected by fat injections, and these can generally be performed as part of the secondary facelift procedure. (Procedure performed by unknown surgeon.) (B,C) Correction
of the over-resected buccal fat pad. (B) Secondary facelift patient who had buccal fat removed as part of her primary procedure. An unattractive, ill appearance has resulted.
(Procedure performed by unknown surgeon.) (C) Same patient after secondary facelift that included fat injections. The lower face has been filled, and lost buccal volume
restored. A healthy, youthful, and attractive appearance results. (Procedure performed by Timothy J. Marten, MD, FACS.)
A
B
C
Fig. 6.10.35  (A,B) Prominent submandibular glands. Prominent submandibular glands are commonly seen in patients presenting for secondary facelifts. They are typically
evident as objectionable residual bulges in the lateral triangle of the lateral submental region. Prominent glands often go unnoticed at the primary procedure because they
are obscured by neck fat and lax platysma muscle. (Procedures performed by unknown surgeons.)
A
B
examine what was accomplished during the secondary pro­
cedure, and adjust the fat injection procedure accordingly.
Prominent submandibular glands
As experience is gained in evaluation of patients presenting
for secondary surgery, prominent submandibular glands will
increasingly be recognized as a frequent part of the secondary
neck deformity and the underlying cause of objectionable
residual bulges in the lateral triangle of the lateral submental
region (Fig. 6.10.35). Often, these bulges go unnoticed at the
time of the primary procedure owing to the fact that they
are obscured by neck fat and lax platysma muscle. In most
instances, the secondary facelift will provide an opportu­
nity for proper diagnosis and appropriate treatment, when
present.
If a large or ptotic submandibular gland is present, it can
usually be seen and/or palpated lateral to the ipsilateral
anterior belly of the digastric muscle within its respective
submandibular triangle.

259
Identification and analysis of secondary surgical deformities
This corresponds to a plane tangent with the ipsilateral
inferior mandibular border and anterior belly of the digastric
muscle. Intraglandular vessels are often encountered and
these must be carefully divided and immediately cauterized
in a controlled fashion. Any bleeding points on the raw surface
of the gland are then further cauterized once the redundant
portion has been excised. Platysmaplasty (suturing the medial
borders of the right and left platysma muscles together in the
midline) and platysmamyotomy (transverse division of the
platysma at the level of the cricoid cartilage) are then per­
formed as indicated. A 10F closed suction drain is placed in
both the preplatysmal and subplatysmal spaces when sub­
mandibular gland reduction is performed. It is not necessary
to remove the entire gland to create an attractive cervical
contour. Complete submandibular gland excision risks injury
to the marginal mandibular branch of the facial nerve and is
likely result in a depression or other contour abnormality.
Subtotal submandibular gland excision to date has resulted in
no cases of nerve injury, hematoma, seroma formation, sali­
vary fistula, or gustatory sweating.
Large digastric muscles
As experience is gained in evaluation of patients presenting
for secondary surgery, large, low-lying anterior bellies of the
digastric muscles will increasingly be recognized as a frequent
part of the secondary neck deformity and the underlying
cause of objectionable linear, paramedian fullness in the
submental region. These bulges often go unnoticed at the
primary procedure because they are often obscured by neck
fat and lax platysma muscle. In most cases, the secondary
facelift will provide an opportunity for proper diagnosis and
appropriate treatment (Fig. 6.10.37).
Prominent anterior bellies of the digastric muscles can be
treated by superficial subtotal myectomy. Superficial, subtotal
anterior digastric myectomy is performed under direct vision,
Large glands can be incrementally resected through the
submental incision after raising the ipsilateral platysma but
before submental platysmaplasty is performed, if indicated.
Submandibular glands are usually firm and have a distinctive
lobulated appearance. Reduction is begun by incising the
glandular capsule inferomedially and grasping the inferior-
most portion of the gland. The gland can then easily be sepa­
rated from its capsule and adjacent tissue using a combination
of gentle blunt and sharp scissors technique. Care should be
taken when mobilizing the superior–lateral portion of the
gland, as both the retromandibular vein and the marginal
mandibular branch of the facial nerve are in proximity in this
area.
An examination of the dissected submandibular gland will
show it to be large, and not “ptotic”, and careful consideration
of this fact will reveal that attempts to reposition it more
superiorly with sutures or by tightening the platysma are
misguided and will ultimately be fruitless. This observation
forms the basis of the recommendation that partial resection
be performed in these patients.
After the protruding portion of the gland has been exposed
and freed from adjacent tissue, the redundant portion of the
submandibular gland is excised using a long-tipped cautery
and a long pair of shielded forceps. Adequate exposure is
necessary, as is good light, an attentive assistant, and a good
source of suction. It should be noted that all vital structures
are situated lateral to the dissection and lie outside the glan­
dular capsule. Excision is begun by grasping the inferior
portion of the gland and gently pulling it inferiorly and medi­
ally out of its fossa and away from adjacent structures. The
redundant portion is subsequently incised incrementally
along the planned line of resection (Fig. 6.10.36).
Fig. 6.10.36  Overview of the technique for reduction of prominent submandibular
gland. A submental incision has been made approximately 1 cm posterior to the
submental crease and the neck subcutaneously undermined. The right platysma
muscle has been elevated and is retracted with a double-pronged skin hook and a
malleable retractor. The gland will be seen as a distinct bulge just lateral to the
ipsilateral anterior belly of the digastric (scissors tips rest on digastric). The
capsule has been incised inferiorly and medially and the submandibular gland
isolated using blunt dissection. The gland, once isolated, is gently pulled inferiorly
(forceps). The protruding portion is then excised incrementally with electrocautery.
(Courtesy of Timothy J. Marten, MD, FACS.)
Fig. 6.10.37  Prominent anterior belly of the digastric muscle. The patient has had
prior face and necklift. The anterior belly of the digastric muscle can be seen as
objectionable linear paramedian fullness in the submental region that spoils and
otherwise good result. Prominent digastric muscles often go unnoticed at the time
of the primary procedure due to the fact that they are frequently hidden by cervical
fat and lax platysma muscle. (Procedure performed by unknown surgeon.)

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CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
a good result in a younger patient with modest deep layer
problems, more often it accomplishes little more than expos­
ing underlying platysma bands, resulting in an objectionable
and elderly appearance.
Primary and secondary platysma bands are best treated by
transverse platysma myotomy (transverse division of the pla­
tysma at the level of the cricoid cartilage), as the underlying
problem is one of platysma hyperfunction, not horizontal
platysmal laxity. Dividing the muscle defunctionalizes the
muscle similar to the way in which the gastrocnemius muscle
is defunctionalized when the Achilles tendon is ruptured.
Platysmaplasty alone (suturing the right and left platysma
muscles together in the midline) is usually insufficient as it
does not address the underlying cause of the problem.
Transverse platysma myotomy generally requires complete
subcutaneous undermining of the neck because myotomy
must be preformed at or near the level of the cricoid cartilage
where the platysma muscle is thin if visible irregularities are
to be avoided. Bleeding will also be minimal when myotomy
is performed at this location, and there is minimal chance that
lower lip dysfunction will be produced. If platysma transec­
tion is performed higher where the muscle is thicker, bleeding
from cut muscle edges is more common, and contour irregu­
larities are likely to be evident once swelling is gone and
healing is complete. A high division of the platysma can also
precipitate lower lip dysfunction. If wedge resection of the
platysma is made near the hyoid, as is often traditionally
taught, muscle and low lip dysfunction is common and an
unattractive overly sharp cervicomental angle is likely to
result.
Anterior bands require transection of the platysma to a
point lateral to the band to the midpoint of the muscle (Fig.
6.10.40). If lateral bands are present, transection is extended
further laterally to a more lateral point in the muscle to include
them as well (Fig. 6.10.41).
Platysma bands are the result of platysma muscle hyper­
function they are not logically or effectively treated in most
cases by suspension sutures or direct excision. Suspension
Fig. 6.10.38  Isolation of the protruding portion of the anterior digastric muscle.
The tips of curved hemostatic forceps are bluntly pushed through the mid-body of
the muscle belly. (View from patient’s right of right digastric muscle through
submental incision. Patient’s chin is on the left and neck on right.)
Fig. 6.10.39  Excision of protruding portion of anterior digastric muscle. The
muscle has been isolated on a hemostat. The isolated muscle segment is then
divided near the hyoid and mandible using electrocautery. (Courtesy of Timothy J.
Marten, MD, FACS.)
working through the submental incision after the subplatys­
mal space has been opened and the medial platysma muscle
borders mobilized. Partial digastric myectomy is usually best
performed after subplatysmal fat excision and submandibular
gland reduction have been performed, if indicated, as it is
easiest to assess the muscles at that time. Two basic techniques
can be used: incremental tangential shave excision and
muscle-splitting myectomy. In the former, the protruding
portion of the muscle is shaved tangentially in an incremental
fashion using a DeBakey forceps and medium Metzenbaum
scissors until appropriate contour is obtained. The neck is
re-examined and the maneuver repeated until an improved
contour is obtained. Usually this entails the excision of 25–50%
of the superficial-most part of the anterior muscle belly, but
occasionally, 50–90% of the muscle must be removed. In the
muscle-splitting partial myectomy technique, the protruding
portion of the muscle is isolated on a tonsil forceps, or similar
instrument, by pushing the instruments tips transversely
through the muscle belly (Fig. 6.10.38). The isolated segment
is then excised with scissors or electrocautery by dividing the
muscle near the mandible and the hyoid (Fig. 6.10.39). Con­
tours are checked and the maneuver repeated as indicated.
Platysmaplasty (suturing the medial borders of the right and
left platysma muscles together in the midline) and platysma­
myotomy (transverse division of the platysma at the level of
the cricoid cartilage) are then performed as indicated.
A 10F closed suction drain is usually placed in the subpla­
tysmal space when digastric myectomy is performed, and
almost always if subplatysmal fat excision or submandibular
gland reduction is concomitantly carried out. Digastric
myotomy has not resulted in dysphagia, dysphonia, or other
functional problem.
Residual platysma bands
The introduction of liposuction has resulted in many surgeons
adopting a closed plan of treatment for the neck, consisting
of suction excision of preplatysmal fat with and without
postauricular skin excision. Although this occasionally yields

261
Identification and analysis of secondary surgical deformities
uncorrected or undercorrected midface, evident as infraorbital
hollowing, malar flattening, and nasolabial fold formation.
These changes often appear more obvious and more objec­
tionable after the patient’s primary procedure as they typically
stand in contrast to an overly tight jawline and against a
background of aggressive rejuvenation of other adjacent
areas.
Treatment of midface problems remains controversial and
a consensus of opinion as to the best way to correct them has
yet to arise. A major shortcoming of “skin lifts” and the typical
“low” SMAS flap elevated below the zygomatic arch is that
neither is able to produce significant improvement in the
midface area. Skin lifts fail because skin provides little in the
way of support of the malar fat pad. “Low” SMAS flaps are
ineffective, as they are unable, by design, to exert a significant
vector of pull over the midface and infraorbital region.
Incising and elevating the SMAS flap “higher”, along the
mid-body of the zygomatic arch, and extending the dissection
medially to release and mobilize midface tissue, however,
sutures and straps, especially those extending from mastoid
to mastoid, often result in an overly rigid noose that is dis­
turbing and uncomfortable to patients, especially when they
look down. Sutures extending partially across the neck are
better tolerated and may be helpful for minor muscular
irregularities. Neither, however, addresses directly the ana­
tomical basis of the problem.
Excision of platysma bands, although recommended and
practiced for some time, can result in nerve injury and muscle
dysfunction, and typically results in visible irregularity, and
recurrent deformity. Excision does not address the anatomic
basis of the problem and often results in new bands on each
side of the excised muscle.
Uncorrected and undercorrected
midface deformities
A careful examination of the typical patient presenting
for secondary surgery is commonly remarkable for an
Fig. 6.10.40  Treatment of residual anterior platysma
bands. (A) Schematic showing anterior band and plan for
platysma myotomy. (B) After myotomy and SMAS flap
advancement.
A
B
Fig. 6.10.41  Treatment of residual anterior and lateral
platysma bands. (A) Schematic showing anterior and
lateral bands and plan for platysma myotomy. (B) After
myotomy and SMAS flap advancement.
A
B

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CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
plan also precludes dimpling and irregular contours over the
upper cheek when the patient smiles (“smile block”) due to
impingement of the cheek pad at suture sites and tethering of
tissue there. This can occur, however, if attempts are made to
suspend midface or malar pad over the superior aspect of the
zygoma or to the periosteum along the infraorbital rim.
It should be recognized that the nasolabial fold and crease
are a product of the patient’s individual anatomical make-up
and in many cases are a specific familial trait. In such cases,
elevation of the midface as described should not be expected
to eliminate or obliterate these features. Indeed, in such cases,
there is little artistic imperative to do so.
Most midfacelifts are generally conceptually flawed and of
limited utility in the secondary facelift patient in that they
erroneously assume the problem seen in the anterior upper
cheek is solely one of tissue sagging. Failure to acknowledge
the fact that atrophy is present to a significant degree in most
cases has led to general disappointment following many
enables problems in these areas to be addressed (Figs. 6.10.42
& 6.10.43). This high SMAS plan, as such, provides a means
for both elevating ptotic infraorbital and malar tissue, and
increasing lower lid support.
It is common at the time of secondary facelift surgery to
find that the SMAS has been dissected timidly at the primary
procedure and that the high, extended dissection described
above can easily be performed in a virgin plane. Fortunately,
a secondary SMAS dissection is also still possible after a more
extensive primary SMAS procedure, and the subSMAS plane
usually offers little in terms of scar, adhesions, or other
encumbrances.
Advancing the cheek SMAS flap superiorly and suspend­
ing it without excising its superior margin or folding its
superior edge upon itself at the primary procedure, provides
the ideal setting for secondary SMAS surgery. The overlap­
ping tissue segments are easily dissected at some future date
and minimal subSMAS cicatrix is produced. A high SMAS
Fig. 6.10.42  “Low” SMAS flap. The traditional “low” plan
for the cheek SMAS flap is by design only able to apply a
vector to the lower cheek and jowl, but not the midface.
(A) Plan for low SMAS flap. (B) Low SMAS flap after
advancement and fixation. Arrow indicates that flap
elevation results in improvement in the lower cheek and
jowl only.
A
B
Fig. 6.10.43  “High” SMAS flap. The “high” plan for the
cheek SMAS flap allows a vector to be applied to not only
the lower cheek and jowl, but the midface and infraorbital
region as well. (A) Plan for high SMAS flap. (B) High
SMAS flap after advancement and fixation. Arrow indicates
that flap elevation results in not only improvement in the
lower cheek and jowl, but in the midface and infraorbital
region as well (compare with Fig. 6.10.42A,B).
A
B

263
Identification and analysis of secondary surgical deformities
elevation, judicious fat excision, and geniomandibular groove
fat grafting may be indicated.
Distortion and abnormal appearances
due to inappropriate skin shifts
Many patients presenting for secondary facelift will have
abnormal appearances due to inappropriate shifts of skin
flaps. This problem is particularly common in the older patient
with deep rhytides and poor skin elasticity, and will typically
be evident as superiorly over-shifted cervicofacial rhytides in
the lower lateral cheek, perilobular area, and upper lateral
neck, sometimes referred to as a “wrinkle shift deformity”
(Fig. 6.10.45).
Superior over-shifting of cervicofacial rhytides is com­
monly seen in skin-only facelifts, composite-type procedures,
and in minimal access cranial suspension (MACS) lifts and
other “short-scar” procedures in which a short postauricular
incision is used and skin is obligatorily shifted along a supe­
riorly directed vector. This deformity is commonly accompa­
nied by temporal hairline displacement, unless an incision
along the temporal hairline has been used. The fundamental
problem with these procedures is that they fail to address the
fact that skin and SMAS age at different rates and along dif­
ferent vectors. In general, skin needs to be advanced along a vector
perpendicular to the nasolabial fold, whereas the SMAS and deep
layer tissue needs to be advanced along a more superiorly directed
vector roughly parallel to the long axis of the zygomaticus major
Fig. 6.10.44  Residual jowl and jawline laxity. Incomplete elevation of the jowl is
commonly seen in patients presenting for secondary facelifts and represents
incomplete or under-utilization of the cheek SMAS. Although liposuction and direct
excision of jowl fat may straighten mandibular contours, this fat more appropriately
belongs higher on the face and should not be arbitrarily sacrificed. (Procedure
performed by unknown surgeon.)
Fig. 6.10.45  Abnormal appearance due to inappropriate skin shifts. Wrinkles
originally present on the neck have been moved up over the jawline and in front of
the lobule. This occurs in “skin lift” procedures when the skin is advanced along a
superiorly directed vector in a mistaken attempt to improve neck contour. It can
also occur in Skoog and “composite” procedures as skin and SMAS must
obligatorily be advanced in the same direction. (Procedure performed by unknown
surgeon.)
procedures for both patients and surgeons, and has resulted
in the addition of dermis fat grafts, orbital fat transposition,
and “septal resets” to “midfacelift” procedures. It is question­
able and remains to be answered, however, whether these
procedures can produce a restoration of lost volume as simply,
naturally, and effectively as can be obtained with fat injec­
tions. The current trend seems to strongly favor a “filling”
rather than a “lifting” approach.
Residual jowl
Incomplete elevation of the jowl, or recurrent jowl ptosis, is a
common problem seen in patients presenting for secondary
facelifts that in all but the unusual case, represents incomplete
mobilization, improper shift, inadequate fixation, or other
improper or under-utilization of the cheek SMAS (Fig. 6.10.44).
In most patients, the secondary facelift will provide an oppor­
tunity to reposition sagging jowl tissues and to restore attrac­
tive mandibular contour. Although liposuction and direct
excision of jowl fat can be used to improve mandibular con­
tours in some instances, this fat more appropriately belongs
higher on the face and should not be arbitrarily sacrificed (see
Fig. 6.10.33). In addition, in most instances liposuction and/
or direct jowl fat excision was performed aggressively at the
primary procedure, and little residual superficial fat is typi­
cally present in secondary cases. Almost all patients with
residual jowls presenting for secondary surgery will be better
served by formal SMAS dissection and suspension, than by
fat excision. Occasionally, patients with very heavy jowls will
require the combination of repositioning of jowl fat via SMAS
elevation and conservative jowl fat removal via direct excision
or liposuction. In a minority of instances, however, residual
large jowls present after a primary facelift represent a combi­
nation of residual excess fat, jowl tissue ptosis, and atrophy
at the geniomandibular groove, and a combination of SMAS

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CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
improvement in the midface, cheek, jowl, and infraorbital
areas, it will also inevitably produce compression of the
temporal face and lateral orbital region if tissue shifts have
been meaningful and temple lift or foreheadplasty is not
performed. This compression and wrinkling not only contrib­
ute to a “young face–old forehead” deformity, but also will be
worse after a secondary facelift if temple and lateral upper
facial tissue are not correspondingly repositioned.
Patients are often aware that a problem exists in the temple
area after their primary facelift but often mistakenly assume
it to be a problem of skin wrinkling and residual “crow’s feet”.
Many rightly observe that tissue compression is worse upon
smiling. These patients will benefit from repositioning of
temporal tissues or formal foreheadplasty if not performed as
part of the primary procedure.
Skin deficiencies and “tight look”
Whenever prospective patients and the lay public discuss
facelift surgery, they inevitably express the most concern and
dismay over the tight faces of various celebrities and their
friends and acquaintances who have undergone the proce­
dure. Many unhesitatingly demonstrate what they see to be
the problem by pulling forcefully on their cheeks, eyes, and
eyebrows asking either not to look that way after their surgery,
or stating they will never undergo surgery for fear of ending
up with a similar appearance. This concern is reinforced by
the numerous jokes and references in the popular press to
“masks”, “wind tunnels”, and “faces so tight they will crack”
if their wearer smiles. Despite these expressed concerns and
the frequent popular ridicule of the typical outcome of mul­
tiple skin-only facelifts, procedures based predominantly on
skin excision that produce a tight look continue to be widely
performed.
The fundamental problem with a “skin-only” facelift,
especially if multiple such procedures are performed, is that
skin is meant to serve a covering function and not a support­
ing one. Most of the changes seen in the aging face, however,
muscle. In skin-only lifts, skin is typically over-shifted along a
superiorly directed vector in a misguided attempt to correct
problems of deep layer origin seen in the lower face and along
the jowl. In deep plane and composite procedures, skin is
obligatorily advanced as a composite with underlying SMAS,
and skin must be over-shifted superiorly to obtain the best
SMAS effect. The “wrinkle shift deformity” is most problem­
atic in MACS lifts and short scar procedures, and any similar
procedure in which an attempt is made to shorten or eliminate
the postauricular scar. These procedures, by design, require
that cervicofacial skin flaps be shifted along a purely vertical
vector, and do not provide a means for wrinkled cervical skin
to be partially excised, shifted more posteriorly, and kept on
the cervical area.
Separating the skin and SMAS from one another into sepa­
rate lamella and advancing each along independent vectors
allows each layer to be treated most appropriately and as
indicated. When this is done, wrinkled cervical skin can be
shifted posteriorly and partially excised, and kept off the face.
This minimizes cervical wrinkle shift onto the face and other
secondary irregularities resulting from improper skin shifts.
This treatment of the skin and SMAS as separate layers is
referred to as a “lamellar” or “bidirectional” facelift.
Neck-to-face wrinkle shift is difficult to correct, especially
in the patient with little residual skin redundancy. Although
skin flap elevation and re-advancement along a more poste­
riorly directed vector can produce some improvement, the
degree to which the flap can be shifted back into a normal
position will be limited by the severity of the previous skin
over-shifting, the previous cut-out made for the lobule at the
primary procedure, and the amount of recurrent redundant
skin present at the time that secondary surgery is requested
(Fig. 6.10.46).
Compression of the temporal face
Although advancement of the SMAS along a mostly superi­
orly directed vector will produce the most comprehensive
Fig. 6.10.46  Improvement of inappropriate
skin shifts. (A) Wrinkles originally present
on the neck have been moved up over the
jawline and in front of the lobule at the
patient’s primary procedure. (Procedure
performed by unknown surgeon.) (B) After
secondary facelift. Contour has been
created using the SMAS and platysma and
cheek skin has been shifted inferiorly to the
extent possible. (Procedure performed by
Timothy J. Marten, MD, FACS.)
A
B

265
Identification and analysis of secondary surgical deformities
The patient presenting for secondary facelift who had skin
excision only at their primary procedure is the quintessential
patient in need of deep layer support. Additional skin exci­
sion will result in an accentuation of their deformities, and
little improvement in facial contour.
Skin slough
The continued popularity of procedures in which the skin of
the face and neck is extensively undermined and then sus­
pended under abnormal tension in an attempt to create
youthful contour has resulted in the continued occurrence of
potentially avoidable secondary deformities resulting from
skin slough. Skin slough is also frequently the result of inap­
propriately aggressive surgery on smokers and arguably risky
procedures in which a facelift is performed concomitantly
with aggressive laser resurfacing of undermined skin.
Small areas of scarring resulting from skin slough in
patients presenting for secondary surgery can sometimes be
corrected at the time of the secondary procedure by direct
excision after adequate mobilization of surrounding tissue
or by incorporation of the scarred area into a more compre­
hensive incision plan. Larger areas of skin loss resulting from
excessive flap undermining, excessive flap tension, rough
tissue handling, or overly tight facial bandages are usually
much more difficult to correct, especially if skin excision
was aggressive at the primary procedure and little residual
redundancy is present. Regrettably, this is all too frequently
the case. In such situations, the patient and surgeon must
accept that complete correction is not possible at the time of
the secondary procedure, no matter how much they wish it
were so.
It is a common error to assume that scarred areas can
simply be excised and that the skin needed for closure can be
are the result of an attenuation of support and subsequent
descent of deep layer facial tissues, and not sagging of skin.
Any attempt to lift significant sagging of deep facial tissue
with skin will be short-lived, destined to produce an overly
tight appearance, and doomed to result in secondary
deformities.
As the elastic limits of skin are exceeded in a skin-only
facelift, a tight or pulled appearance develops and facial
contour is flattened. Tightness and flattening will be most
pronounced in the preauricular region, where tension is
highest and the threshold of elasticity exceeded the most.
More inferiorly, in the jowl and perioral region, skin will be
under less tension and below its threshold of inelasticity. Less
tightness will thus be present in these areas, where it is needed
most. Further tightening of the skin usually results in more
preauricular flattening but little improvement in jowl and
perioral contour. Over time, “tight lines” (Fig. 6.10.47) will
appear across the lower cheek and upper lateral neck upon
neck flexion and “drapery lines” (Fig. 6.10.48), or “lateral
sweep” will develop over the lower cheek and jowl. Drapery
lines and lateral sweep develop because skin is fixed and
tethered in the preauricular and peristomal regions, but has
no support in-between where deep layer tissue sagging is
greatest. Wrinkling and tightness extending from the lobule
to the jowl and submental area when the patient looks down
(“tight lines”) also occurs after well-intended attempts to
contour the face by skin excision because the elastic limits of
cheek skin is exceeded when the neck is flexed and its normal
covering function is corrupted (see Fig. 6.10.47). This telltale
deformity is typically evident when the patient is looking
down and the neck is markedly flexed (e.g., when looking at
a menu, book, or theater program).
Fig. 6.10.47  “Tight lines”. Wrinkling and tightness extending from the lobule to
the jowl and submental area when the patient looks down (“tight lines”) occurs
after well-intended attempts to contour the face by skin excision because the elastic
limits of cheek skin is exceeded and its normal covering function is corrupted.
(Note other tension artifacts including retracted lobule and wide, cross-hatched
perilobular scar.) (Procedure performed by unknown surgeon.)
Fig. 6.10.48  “Drapery lines” and “lateral sweep”. “Drapery lines” and “lateral
sweep” are common problems following a “skin-only” facelift. In these procedures,
skin tightness is most pronounced in the preauricular region where it is least
needed. More inferiorly, in the jowl and perioral region, skin will be under less
tension where it is needed most. “Drapery lines” develop because skin is fixed and
tethered in the preauricular and peristomal regions, but has little no support in
between, where deep layer tissue sagging is greatest. (Procedure performed by
unknown surgeon.)

266
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
Distortion and abnormal appearances due to
inappropriate SMAS shifts or SMAS injury
Many patients presenting for secondary facelift will have had
skin-only, non-SMAS procedures and, as such, will be poten­
tially free from deformities related to inappropriate SMAS
maneuvers. SMAS injury during non-SMAS surgery can,
however, result in distortion and irregularities of SMAS
origin, even though no actual SMAS surgery was performed.
The typical SMAS injury resulting in secondary deformity
occurs when the SMAS is knowingly or unknowingly “but­
tonholed”. This will result in asymmetries and contour irregu­
larities, especially when the patient is in animation or clenches
their teeth (Fig. 6.10.49). Identification and repair of these
SMAS defects at secondary surgery will eliminate many of
these types of problems. Larger rents or defects in the SMAS,
resulting from larger areas of SMAS injury, SMAS excisions,
and failed plications present a bigger challenge and can be
difficult to fully correct.
Patients who have had prior SMAS lifts may have other
secondary SMAS deformities that must be recognized and
addressed as well. These deformities include ridges from
SMAS plication or SMAS excision, irregularities from an
uneven or overly tight SMAS suspension, and distortion and
unnatural appearances from advancement of the SMAS along
an improper vector.
Ridges and irregularities from prior plication or SMAS
excision may limit the potential for improvement in second­
ary procedures, and secondary correction techniques must be
individualized according to the specific problems present.
recruited by wide undermining of adjacent cheek or neck
tissue. Even the surgeon who knows better will often set good
judgment aside when subjected to the persistent pleading of
a patient desperate for some kind of improvement. Experi­
ence has shown, however, that simple scar excision and
adjacent tissue undermining in these patients will result in
inadequate skin for a tension-free repair and a forced, exces­
sively tight closure. This tight closure, in turn, will inevitably
result in wound dehiscence, scar widening, and associated
tension-related deformities including scar hypertrophy, cross-
hatched suture marks, facial distortion, tragal irregularities,
and lobular malposition. In these patients, it is best to accept
partial correction of the problem, rather than creating a new
one or injuring remaining normal tissue. Make-up, camou­
flage tattooing, or restyling of hair are better alternatives to
conceal the residual scars in these circumstances.
If make-up is ineffective in concealing scars due to ridges
and step-offs where they abut normal tissue, dermabrasion
may be helpful in reducing the discrepancy in tissue height
and smoothing the transition between the two areas. Even if
discrepancies in tissue height can be reduced in this manner,
there is usually a marked difference in tissue texture that
prevents the scar from being completely concealed. Patients
wishing further improvement may benefit from scar excision
and full-thickness skin grafting, as this technique can provide
cover with more natural-appearing skin texture. Several
follow-up dermabrasion procedures may be necessary to
smooth the interface between the skin and skin grafts and
these patients are likely to benefit from the use of a silastic gel
sheet and/or facial compression garments during the healing
process. In some circumstances, it may be better to excise
some normal skin along with scarred areas and graft a large
anatomical subunit, rather than creating a patch quilt of
smaller grafts. In extreme situations, consideration may have
to be given to cheek or neck skin expansion.
Skin slough can be minimized or avoided by exercising
caution, using common sense, and adhering to basic plastic
surgery principles. All patients who smoke or have a history
of smoking should be identified and their surgery planned in
a way that recognizes their increased risk for compromised
healing and skin necrosis. Consideration should be given to
not performing a facelift on heavy smokers with a long history
of tobacco use, or employing a facelift technique that does not
involve wide skin flap undermining and skin flap tension.
Many of these patients will be satisfied with a combination of
limited lower-risk procedures including closed forehead­
plasty, eyelid surgery, conservative submental liposuction, fat
injections, and laser resurfacing. Smokers should always be
approached with caution, however, and every surgeon should
recognize these patients have a higher risk of experiencing
healing problems after surgery.
Flap necrosis is dependent upon a variety of factors under
the surgeon’s control and can be minimized by procedure
design. These factors include tissue trauma, the extent of skin
undermining, and skin tension. Because deep layer techniques
limit skin undermining, preserve important cheek perfora­
tors, and avoid excessive tension on cervicofacial skin flaps,
a careful surgeon employing a gentle, atraumatic, technique
in carefully selected patients should infrequently encounter
skin slough. And when the procedure is performed in this
manner, skin slough, should it occur, should be limited and
easily managed.
Fig. 6.10.49  Contour irregularity (arrow) due to prior SMAS injury. A common
type of SMAS injury resulting in secondary deformity occurs when the SMAS is
knowingly or unknowingly “buttonholed” at the primary procedure. This can result
in bulges or contour irregularities when the patient animates or clenches her teeth.
(Note the bulge in the lower cheek in this patient when clenching her teeth.)
(Procedure performed by unknown surgeon.)

267
Identification and analysis of secondary surgical deformities
cheek and midface using a high SMAS flap (see Fig. 6.10.43),
or by employing a subperiosteal midfacelift technique. Tech­
niques that require suture fixation of more superficially situ­
ated tissue, or “low” fixation on the face, should be avoided.
Smile block can also often be corrected percutaneously by
release of tethered areas with a small “V” tipped lipo-
infiltration needle and concomitant fat injection.
Unaesthetic facial implants
It is not uncommon to find patients presenting for secondary
facelift who have inappropriate or unaesthetic facial implants
that detract from their appearance and limit the potential for
improvement at any secondary procedure. Frequently, these
implants were placed in an attempt to offset the deficiencies
and shortcomings of a “minilift”, “laser facelift”, “infomercial
lift”, “franchise facelift”, or “weekend” procedure, or were
placed in an isolated procedure in a patient who would have
arguably been better served by formal facelift surgery. These
can include under- and oversized malar implants, submalar
implants, chin implants, and mandibular angle implants.
Often even more troublesome are PTFE (polytetrafluoroethyl­
ene, Gore-Tex) strips and similar implants placed in the lips
and nasolabial folds. These can be seen to result in visible
surface irregularities and buckle and fold upon facial
animation.
Although facial implants collectively comprise a significant
advance in aesthetic surgery and have helped many patients,
they were devised primarily to be used in individuals with
skeletal deficiencies. Patients troubled by age-associated soft
tissue ptosis are more logically, appropriately, and effectively
treated by procedures that reposition and redistribute ptotic
tissue, rather than those designed to augment the facial skel­
eton. Patients troubled predominantly by soft-tissue atrophy
are likewise more appropriately treated by fat injections than
with facial implants.
Many patients with unaesthetic facial implants are aware
that all is not right with their appearance and are more than
willing to consent to implant exchange or removal. These
patients are typically seen to have small button-like chin or
cheek implants, oversized malar implants, or submalar
implants placed in a failed attempt to improve their nasolabial
folds.
A more difficult situation exists when the patient does not
see the problem and is unwilling to consider implant exchange
or removal. In these patients, one must decide whether it is
possible to work around this, or if it is preferable to let the
patient enlist the services of another surgeon.
In general, the removal or exchange of facial implants at
the time of secondary facelift is not difficult and results in a
few untoward occurrences. If implants were originally placed
subcutaneously, a more natural appearance can usually be
obtained when they are moved to a subperiosteal position.
Submalar implants often can be removed at secondary proce­
dures, as cheek and midface repositioning will often result in
abnormal appearances if these are left in place. Alternatively,
they can be left in place and removed in a subsequent proce­
dure, if necessary, if the patient desires.
PTFE (Gore-Tex) implants placed in the lips and nasolabial
folds present a particular problem in that they can be exceed­
ingly difficult to remove. In addition, removal can often result
in troublesome and difficult-to-correct secondary deformities.
Fig. 6.10.50  “Smile block”. If the SMAS is suspended too low, too far medially
over the zygoma, or too rigidly directly to the periosteum, tissue tethering can result
in dimpling and other irregularities when the patient smiles (arrow). This problem
can also be seen when attempts are made to directly suspend the malar pad or
when the malar midface or other mobile area of the face is suspended to the
infraorbital rim or other part of the bony skeleton. (Procedure performed by
unknown surgeon.)
Some correction is usually possible if tissues are carefully
examined and the origins of the problem can be ascertained.
SMAS advancement along an improper vector can result in
distortions in animation and at rest. These typically occur
when the cheek SMAS flap has been erroneously advanced
and suspended under tension along a predominantly posterior,
rather than mostly superior vector and are typically evident
as a “clown mouth” or “pulled mouth” appearance and
bizarre and unusual facial movements in animation.
The proper vector of advancement of the SMAS is along a vector
parallel to the long axis of the zygomaticus major muscle. If the
SMAS is advanced along another vector, the zygomaticus
major muscle will be bowed off its axis of normal function
and its action corrupted. Posterior traction also exaggerates
risorius action and results in an objectionable change in the
resting posture of perioral tissues. Secondary deformities
related to an improper advancement of the SMAS flap are
often markedly improved during secondary surgery when the
SMAS is re-elevated and re-advanced along a proper vector.
“Smile block”
Attempts to directly suspend the midface or malar fat pad
with sutures, or low rigid suspension of the SMAS to the facial
skeleton, will prevent natural gliding of cheek and midface
tissue during animation. This will be clinically apparent
postoperatively when the patient emotes as dimpling and
contour irregularities, often referred to as “smile block” (Fig.
6.10.50).
Smile block can usually be improved at a secondary
procedure by a thorough release of the tethered area and
re-suspension of ptotic tissues using a technique that allows
unrestrained and natural gliding of malar pad and midface.
This is usually best accomplished by high suspension of the

268
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
Because a patient’s hairstyle can conceal important signs of
forehead aging, and compensatory frontalis spasm can give
the false impression that the eyebrows are in an appropriate
position, it is imperative that the face of the patient presenting for
secondary facelift be examined with the patient’s hair pushed well
back off their forehead. In addition, because patients who wear
forehead concealing hairstyles often do not see the full extent
of these problems, it is helpful, as it is during the rest of their
evaluation, for the patient to hold a hand mirror during this
part of the examination. They can then be shown these impor­
tant findings and counseled as to how they are actually the
product of forehead ptosis.
The erroneous assumption that forehead ptosis is not
present because the eyebrow appears to be in a normal posi­
tion is the single biggest stumbling block in evaluating the
forehead for patients and surgeons alike. Patients are accus­
tomed to optimizing the appearance of their face when looking
at their reflection by unconsciously raising their eyebrows.
This is often further compounded by the fact that many
women aggressively pluck the inferior–lateral portion of their
eyebrow to give the allusion that it is higher and more arched.
In many cases, the entire outer third of the eyebrow will be
seen to be missing and has been drawn on in a higher position
with an eyebrow pencil. The all too commonly observed cir­
cumstance is one in which the patient with a marked frontalis
spasm and marked transverse forehead wrinkling holds a
hand mirror during his or her consultation and sees only that
his or her eyebrows appear in a normal position.
Because many patients presenting for secondary facelift
will have unrejuvenated foreheads, foreheadplasty will
usually be an important component of the planned facelift
procedure. (Forehead rejuvenation is discussed in Chapter 7.)
Unrejuvenated perioral region
Although advanced perioral aging is usually appreciated at
the time of primary facelift, more subtle deformities often go
Fig. 6.10.51  The “young face–old
forehead” deformity. (A) Patient seen after
facelift, necklift, genioplasty, and eyelid
surgery performed elsewhere. Her forehead
appears older than the rest of her face, and
her overall appearance is disharmonious
and unnatural. (Procedure performed by
unknown surgeon.) (B) Same patient seen
after hairline lowering foreheadplasty. No
eyelid surgery or other procedures have
been performed. Her face appears more
natural, harmonious, and balanced, and all
areas appear to be the same age.
(Procedure performed by Timothy J. Marten,
MD, FACS.)
A
B
It is often best to encourage the patient to return to the surgeon
who originally placed these implants before secondary
surgery is performed if he or she wishes them to be removed.
This allows problems associated with implant removal to be
clearly defined prior to the secondary surgery, and an appro­
priate plan for correction to be made. If implant removal is
made as part of the secondary facelift, problems may be
erroneously attributed to that procedure or the technique
used.
The unrejuvenated forehead
Rarely does isolated aging occur in the cheek and neck.
Nonetheless, most attempts to rejuvenate the face are targeted
at these areas and many patients presenting for secondary
facelift will have a distinct and telltale “young face–old fore­
head” deformity. This results from a failure to recognize and
treat forehead aging at the primary procedure (Fig. 6.10.51).
A careful consideration of the typical patient presenting for
secondary facelift frequently reveals that isolated tightening
of the neck and cheeks is often an artistically inappropriate
undertaking. This is due, at least in part, to the fact that
changes in the forehead are more likely to be mistakenly
assigned emotional significance than those in the lower face
and neck, and as such, play a greater role in how we interact
with and are regarded by others. In addition, rejuvenating
the lower face and neck only will typically result in facial
disharmony and an unnatural, unbalanced, and “surgical”
appearance.
Recognizing the “young face–old forehead” deformity is
necessary for it to be corrected and a prerequisite to com­
municating the need for forehead surgery to the patient. To
appreciate the “problem”, the surgeon must examine the
patient’s face in its entirety and consider the way in which his
or her appearance might make others feel. This is often best
accomplished by viewing the patient’s face at a distance and
momentarily deferring to one’s intuition.

269
Identification and analysis of secondary surgical deformities
dibular grooves, chin, and jawline lend themselves to concur­
rent treatment, when indicated.
Eyelid skin deficiencies and
eyelid malposition
Many patients presenting for secondary facelift have under­
gone aggressive excision of eyelid skin at their primary pro­
cedure and are secondarily troubled functionally by nocturnal
lagophthalmos, lid retraction, canthal laxity, scleral show, and
dry eye problems; and aesthetically by orbital hollowing,
change in eye shape, and unnatural ocular appearance. (These
problems and deformities and their treatment are discussed
in Chapter 9.)
Over-reliance on laser resurfacing
Motivated by largely unscientific claims of laser manufactur­
ers and enticing, but deceptive, early postoperative photo­
graphs of patients shown at meetings and included in
commercial advertisements, many plastic surgeons and phy­
sicians in other specialties embraced laser resurfacing as a
substitute for traditional surgical maneuvers in which ptotic
deep layer tissue was repositioned and redundant tissue
excised. Indeed, laser resurfacing was often referred to as a
“laser facelift” and numerous claims were made regarding the
lasers ability to incite skin contraction and “tighten” the facial
skin. Although laser resurfacing has proven to have clinical
utility, experience has shown that it does not produce the skin
tightening once hoped for. In addition, “wrinkle relapse” is
common once patients are fully healed and all traces of swell­
ing are gone.
Many patients who have undergone laser resurfacing are
now presenting for formal facelifts, disappointed in the lack
of “lift” gained from their “laser facelift” and concerned over
associated secondary deformities including hypopigmenta­
tion, skin sensitivity, abnormal skin texture, lower lid
malposition, and an unnatural “smooth face–wrinkled neck”
appearance. Radiofrequency and ultrasound-based technolo­
gies suffer the additional drawback that they often result in a
loss of subcutaneous facial fat.
Artistically, the fundamental problem with laser resurfac­
ing is that its primary effect is to smooth skin, and that it does
little, if anything, to reposition ptotic tissue, to reduce skin
redundancy, or to correct facial atrophy. Its misapplication to
the patient with ptotic deep layer tissue and redundant skin
typically produces an unnatural, incongruent “smooth skin–
sagging face” appearance. Because this combination appears
rarely in nature, the patient is left with a telltale “surgical”
appearance, often easily recognized, by even the untrained
eye, at a considerable distance.
In all but the unusual instance, facial contour takes artistic
precedent over smooth skin. Indeed, a few surface wrinkles will
be overlooked by the eye if youthful facial contour is success­
fully re-established. A more balanced, harmonious, and
natural appearance will result, and a less “surgical look” will
be present.
If the patient presenting for secondary facelift has had good
repositioning of ptotic tissue at the primary procedure, and
little recurrent ptosis is present, skin resurfacing may be
worthwhile and appropriate if residual surface textural wrin­
kling is present. It must be kept in mind, however, that skin
unnoticed, especially when viewed against a background of
advanced aging elsewhere on the face. As a result, perioral
deformities often go untreated at the primary procedure and
usually appear more apparent after rejuvenation of adjacent
areas is done. This can result in a telltale “young face–old
mouth” deformity.
Recognizing the “young face–old mouth” deformity is
necessary if improvement is to be made and a prerequisite to
communicating the need for the procedure to the patient.
Because many patients presenting for secondary facelift will
have an unrejuvenated perioral area, perioral rejuvenation
will often be an important component of the planned second­
ary “facelift” procedure. This will usually require some form
of skin resurfacing to improve skin quality and reduce skin
wrinkling, and fat or filler injections to counteract perioral
atrophy. Other treatments such as upper liplifts and corner
lifts of the mouth are also very useful in secondary facelift
patients.
Facial atrophy
Traditionally, the aging face has been thought of and defined
in terms of tissue relaxation and surface wrinkling, but
more recently surgeons have come to appreciate atrophy
and lipodystrophy as integral parts of the aging process.
A careful examination of patients presenting for secondary
facelift will reinforce this assertion and reveal that simply
smoothing wrinkles and lifting sagging tissues will fall short of
truly rejuvenating the face in most cases. This is particularly
true if the patient is thin, buccal fat was removed as part of
the primary procedure, or facial liposuction was performed
(Fig. 6.10.52).
Atrophy is usually most profound and most easily observed
around the orbits, upper midface, and infraorbital and peri­
oral areas, but can be seen on close inspection of many patients
in the forehead, brow, temple, cheek, jawline, chin, and neck.
Atrophy is not corrected by traditional “facelift” procedures,
and is usually incompletely or poorly corrected by tradition­
ally used facial implants. These procedures may even exacer­
bate the problem, and result in an arguably more unnatural,
hard, and objectionable appearance.
Correction of facial atrophy requires the addition of volume
to the face, not a subtraction, lifting, or tightening, and a
rethinking of the traditionally taught approach to rejuvena­
tion of the face. Unlike problems corrected by a “lift” of the
face, correction of atrophy requires the surgeon to employ
techniques that “fill” and “sculpt” the face, and to think in
three, instead of just two, dimensions (see Fig. 6.10.52).
Currently, the most effective and natural correction of facial
atrophy is best achieved through the use of fat injections. Fat
injections, when properly performed, produce soft and natural
contours and afford one the opportunity to correct problems
traditional surgery cannot (see Fig. 6.10.53).
Fig. 6.10.53 appears online only.
As a practical matter, fat injections are most effectively
performed in areas where tissue planes have not been opened.
As a result, they are less applicable and less commonly per­
formed concurrently with a facelift in some areas. These areas
include the preauricular cheek and the neck. Other areas,
however, including the temples, forehead, brows, glabella,
radix, orbits, cheeks, midface, “tear troughs”, buccal recess,
lips, nasolabial folds, nasal base, stomal angles, genioman­

270
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
disguise forehead wrinkles by inciting swelling, it is no sub­
stitute for formal foreheadplasty.
Patients who have undergone prior skin resurfacing can
present a number of technical problems at the time of second­
ary facelift as well. The most vexing of these is the inevitable
shift of the line of demarcation between resurfaced and
un-resurfaced areas below the jawline onto the lower face.
resurfacing will do little to permanently reduce wrinkles that are
the product of muscle hyperactivity. These include glabellar
frown lines, transverse forehead wrinkles, and lateral perior­
bital lines. Correction of these “expression lines” will require
reduction or resection of hyperactive muscles, repositioning
of ptotic tissue, or removal of excess tissue stimulating muscle
contraction. Although skin resurfacing will temporarily
Fig. 6.10.52  Facelift and fat injection example. (A–C) Before-surgery view of a woman, aged 75, who has had multiple prior facelifts and related procedures, including
laser resurfacing, performed by unknown plastic surgeons. Note marked, uncorrected pan-facial atrophy and, despite her multiple traditional lifts, a frail, ill, and elderly
appearance. (D–F) Same patient, 1 year 4 months after secondary facelift, necklift, foreheadlift, upper and lower blepharoplasties, canthopexy, and aggressive fat transfer to
the forehead, temples, cheeks, upper and lower orbits, lips, perioral area, buccal recess, chin, and jawline. A total of 90 cc of fat was injected. No skin resurfacing, facial
implants, or ancillary procedures were performed. Note that the patient has soft, natural facial contours and absence of a tight or pulled appearance. Atrophy in all treated
areas has been markedly improved with fat injections to create a softer, more youthful, fit, healthy, athletic, and energetic appearance. Such an improvement cannot be
obtained with traditional lifting and tightening. It can only be achieved by volume replacement. As was the case in this patient, for many secondary facelift patients, volume
replacement is more important than the facelift itself.
A
B
C
D
E
F

271
Technical considerations in secondary facelift
correcting deep layer problems and secondary deformities,
depending upon the skill of the surgeon performing the
primary procedure and the type of technique used. This is
because the focus of most primary procedures is usually on
skin resection and this is more easily and quickly performed
than deep layer maneuvers. In addition, skin resection and
skin tightening are the underlying cause of many secondary
problems. Very often, the skin elevated and recruited by deep
layer maneuvers at the secondary or tertiary procedure is
needed to correct these problems and will not be excised.
It should also be recognized that secondary facelifts are
often time consuming and technically demanding when
compared with primary procedures and are likely to test the
patience and composure of most surgeons. It is highly recom­
mended that additional operating room time be allotted for
the procedure and that the services of an anesthesiologist or
competent nurse anesthetist be enlisted. This is particularly
true if the procedure is being performed on a patient who is
overly apprehensive or has a history of anesthetic difficulties,
hypertension, or other medical problems.
Although less bleeding is often encountered in elevation of
the skin flap in secondary surgery, skin flap undermining is
often more taxing because of subcutaneous scar and adhe­
sions resulting from the previous dissection. Scissors-pushing
techniques should not be used and it is wise that dissection
be made carefully, under direct vision, in good light, with an
experienced assistant.
Patients undergoing secondary procedures have at least
some areas of their face or neck that have been aggressively
stripped of fat and these areas must be carefully dissected
when skin flaps are elevated. Not uncommonly, dermomus­
cular adhesions are present in the upper lateral neck over the
superficial-most portion of the great auricular nerve. Similar
caution must be taken when subcutaneous dissection is made
secondarily in the temple. It is also very common for the
anterior neck and submental regions to have been aggres­
sively defatted at the primary procedure by aggressive small-
cannula liposuction, ultrasonic lipectomy, excessive direct
excision, or by other means. In such patients, it is very easy
to perforate, get under the platysma, or damage it while
attempting to re-elevate the cervicosubmental skin. Entry
under the platysma can result in nerve injury and platysma
dysfunction, and can render the SMAS or platysma useless in
the planned repair. For these reasons, all skin flap dissection
must be made with great care in secondary procedures and it
is not advisable to use aggressively patterned “super-sharp”
or serrated scissors for flap elevation. These scissors tend to
pick up and cut delicate structures and are more likely to
result in the inadvertent fenestration of the platysma, or
unintended excision of subdermal fat.
Subcutaneous fat is generally precious in the secondary
facelift patient and as much of it as possible should be pre­
served until the surgeon is certain that its sacrifice is artisti­
cally appropriate and of benefit to the patient. Care must be
taken, however, not to injure the SMAS and platysma, while
elevating skin flaps, as these will serve as the workhorse
tissue layers in restoring more youthful facial contours. The
margin for error is thus very small, and often critically so. The
careful infiltration of dilute local anesthetic solutions is often
helpful in these situations in pre-establishing the proper plane
by hydrodissection. This beneficial effect will be lost if infiltra­
tion is made carelessly or in the wrong plane.
This “demarcation line shift” usually requires that a second
resurfacing procedure be performed to lower this line back
into the shadow of the submental area.
Although many surgeons now assert concomitant facelift
and laser skin resurfacing to be safe (and cheek skin has
arguably been “delayed” at the primary procedure), this
combination of procedures still carries significant risk in any
case in which skin has been undermined. For this reason, it is
preferable to defer resurfacing until 3 months or more after
the facelift procedure, at which time the face can be safely,
comprehensively, and aggressively treated, if necessary.
The patient who has had a previous combined facelift and
skin resurfacing procedure is often an excellent candidate for
secondary facelift. This is because the previous surgeon,
fearing complications might result from aggressive surgical
undermining or relying heavily on resurfacing to make up for
shortcomings of the chosen surgical procedure, has been
conservative in his or her surgical approach and timid during
dissection. Indeed, examination usually shows that these
patients have residual uncorrected or undercorrected deep
layer ptosis and residual forehead deformities.
A new generation of “skin shrinking” technologies has now
been introduced that have been widely embraced and said by
some to eventually supplant the traditional facelift. In its
current form, this certainly is not the case, and for the time
being at least, facelifts and secondary facelifts offer improve­
ments unobtainable by other means.
Patient considerations
Many patients requesting secondary or tertiary facelifts are
chronologically elderly, but deceptively young in appearance.
A careful medical history must be taken because they often
have concomitant medical problems consistent for their age
group that were not present at the time of their primary
procedure. It is also wise to obtain independent medical clear­
ance prior to surgery, as this group of patients will commonly
minimize existing problems and deny important symptoms
of age-related illness.
A careful documentation of all existing secondary problems
and deformities must also be made in patients undergoing
secondary facelift procedures, including, but not limited to,
facial muscle weakness, dyskinesias, numbness, paresthesias,
eye dryness, visual disturbances, and chronic pain. These
problems do not show up in a photograph and are not always
recognized or volunteered by the patient. If not documented
preoperatively, they will inevitably be attributed to be the
result of the secondary procedure.
Technical considerations in
secondary facelift
The secondary or tertiary facelift will present technical prob­
lems and certain risks not seen in primary procedures. In
addition, the general approach to secondary procedures is
somewhat different depending upon the type of secondary
deformities present.
The secondary or tertiary facelift will generally require a com­
paratively small resection of skin and an increased focus on

272
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
patient are worth careful consideration, even for the surgeon
who performs only the occasional secondary procedure, as
they exist as compelling reminders of mistakes to avoid in the
planning and performance of any primary procedure.
A satisfactory and uncomplicated SMAS dissection can
usually be performed in most secondary procedures, particu­
larly if the primary surgeon previously elevated the SMAS in
a skilled manner. Occasionally, the SMAS will be found to
have been damaged or thinned, however, or compromised by
previous plication or suture lifts, making elevation difficult
and putting facial nerve branches at risk. Use of a nerve
stimulator or raising the flap with cautery on a low setting
can be helpful in such instances to differentiate retaining liga­
ments from nerve branches. Ultimately, however, no amount
of aesthetic improvement is worth a facial nerve injury, and
dissection should not be continued if overly difficult and
motor nerve branches are put at unacceptable risk. In such
cases, a formal SMAS elevation may have to be abandoned
and replaced by an arguably safer alternative treatment such
as SMAS plication.
Not all deformities resulting from the primary procedure
can necessarily be corrected, and the patient needs to have
their expectations set in this regard. In addition, the secondary
facelift patient will often need ancillary procedures in addi­
tion to secondary facelift surgery if maximum improvement
is to be obtained (see Figs. 6.10.53–6.10.56).
Figs 6.10.53–6.10.56 appear online only.
Conclusion
The increased number of patients seeking early facelifts at a
younger age, coupled with the continued good health of an
older group of patients who have already undergone one or
more procedures, has resulted in an increase in requests for
secondary facelift procedures. Although many aspects of
planning and performing secondary surgery are similar to
those of the primary procedure, additional considerations
must be taken into account in the evaluation and treatment of
the patient presenting for secondary facelift as one must
identify and treat not only new problems that are the product
of age, but those that have resulted from the prior procedure
as well. Often, it is these secondary deformities that present
the biggest challenge to the surgeon in terms of creativity,
planning, preparation, and technique. The secondary facelift
patient is also usually short on skin and will typically present
with problems of deep layer origin. Additional excision of
large amounts of skin is likely to be counterproductive, result
in unnatural appearances, and compound existing deformi­
ties. Many of the problems seen in the secondary facelift
Bonus content for this chapter can be found online at

Case study 6.10.1 Secondary cervicofacial rejuvenation: 57-year-old woman
Case study 6.10.2 Secondary cervicofacial rejuvenation: 62-year-old woman
Case study 6.10.3 Tertiary cervicofacial rejuvenation: 64-year-old woman
Case study 6.10.4 Secondary cervicofacial rejuvenation: 68-year-old woman
Fig. 6.10.53 Multiple views of a 57-year-old woman before and 12 months after
secondary cervicofacial rejuvenation.
Fig. 6.10.54 Multiple views of a 62-year-old woman seen before and 12 months
after secondary facelift and related procedures.
Fig. 6.10.55 Multiple views of a 64-year-old woman before and 13 months after
tertiary cervicofacial rejuvenation.
Fig. 6.10.56 Secondary cervicofacial rejuvenation. Multiple views of a 68-year-
old woman seen before, and 1 year and 8 months after secondary facelift and
related procedures.
Further Reading
Connell BF, Marten TJ. Deep layer techniques in cervico-facial
rejuvenation. In: Psillakis J, ed. Deep Face-Lifting Techniques. New
York, NY: Thieme Medical; 1994.
Connell BF, Marten TJ. Facelift. In: Cohen M, ed. Mastery of Plastic and
Reconstructive Surgery. Boston, MA: Little Brown; 1994:1873–1902.
Connell BF, Marten TJ. Orbicularis oculi myoplasty: surgical treatment
of the crow’s feet deformity. In: Jurkiewicz MJ, Culbertson JH, eds.
Operative Techniques in Plastic and Reconstructive Surgery.
Philadelphia, PA: WB Saunders; 1995.
Guyuron B, Eriksson E, Persing JA, et al., eds. Facelift in Plastic Surgery:
Indications and Practice. Philadelphia, PA: Saunders; 2009.
Marten TJ. Facelift: planning and technique. Clin Plast Surg. 1997;24:
269–308.
Marten TJ, ed. Facelift – State of the Art. Seminars in Plastic Surgery. New
York, NY: Thieme Medical; 2002.
Marten TJ, ed. Maintenance facelift: early facelift for younger patients.
In: Facelift: State of the Art. Seminars in Plastic Surgery. New York,
NY: Thieme Medical; 2002.
Marten TJ. High SMAS facelift: combined single flap lifting of the jaw
line, cheek, and midface. Clin Plast Surg. 2008;35:569–603.
Marten TJ. Lamellar high SMAS face and midfacelift: a comprehensive
technique for natural-appearing rejuvenation of the face. In: Nahai
F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed.
St Louis, MO: Quality Medical Publishing; 2010:1525.

272.e1
Conclusion
Case study 6.10.1  Secondary cervicofacial rejuvenation: 57-year-old woman
Multiple views of a 57-year-old woman before and 12
months after secondary cervicofacial rejuvenation (Fig.
6.10.53). The primary facelift was performed by an
unknown surgeon using conventional techniques and
included aggressive upper and lower blepharoplasty but
no forehead surgery. The secondary procedure consisted
of a high cheek SMAS advancement with postauricular
transposition flaps, preplatysmal and subplatysmal cervical
lipectomy, anterior platysmaplasty, and platysma myotomy.
Incisions along the hairline were used in the temporal and
occipital areas and the preauricular incision was moved
from a pretragal position to the margin of the tragus.
Foreheadplasty, lower blepharocanthoplasty, bilateral ptosis
correction, and perioral dermabrasion were also performed.
Full-thickness skin grafts taken from the postauricular areas
were applied to the upper lids to allow foreheadplasty to
be performed and the eyebrows elevated to an appropriate
position. No resurfacing or other ancillary procedures were
performed.
(A) Patient, several years after primary conventional
facelift, necklift, and upper and lower blepharoplasty
were performed elsewhere. Note residual and secondary
deformities including unrejuvenated forehead, bilateral
senile ptosis, midface ptosis, and residual jowl laxity. (B)
Same patient, 12 months after secondary facial rejuvenation.
Note improvement in forehead, cheeks, periorbital area,
and along jawline that has been achieved without a tight
or pulled appearance. (C) Patient, several years after
conventional facelift was performed elsewhere. Note residual
and secondary deformities including obvious preauricular
scar. (D) Same patient, 12 months after a secondary facial
rejuvenation. (Secondary facelift and related procedures
performed by Timothy J. Marten, MD, FACS.) (E) Patient,
several years after conventional facelift was performed by an
unknown surgeon. Note residual and secondary deformities
midface ptosis, malar flattening, residual jowl, residual
cervical obliquity and “witch’s chin” deformity. (F) Same
patient, 12 months after a secondary facial rejuvenation.
Cheek and midface tissue has been elevated, the pretragal
scar has been moved to the margin of the tragus, and cervical
contour improved. The witch’s chin deformity has also
been corrected. (G) Patient, several years after conventional
facelift and upper and lower blepharoplasty was performed
elsewhere. Note severe, untreated residual brow ptosis.
When the patient’s eyebrows were held up in an appropriate
position, she was unable to close her eyelids. (H) Same
patient, 12 months after a secondary facial rejuvenation. Full-
thickness postauricular skin grafts were applied to the upper
eyelids so that foreheadplasty could be performed without
compromising lid function. Canthopexy and bilateral ptosis
correction was also performed. (I,J) Improved periorbital
appearance is evident.

272.e2
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
A
B
C
D
Fig. 6.10.53  Multiple views of a 57-year-old woman before and 12 months after secondary cervicofacial rejuvenation (A–J).

272.e3
Conclusion
E
F
G
H
I
J
Fig. 6.10.53, cont’d

272.e4
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
Case study 6.10.2  Secondary cervicofacial rejuvenation: 62-year-old woman
Multiple views of a 62-year-old woman seen before and
12 months after secondary facelift and related procedures
(Fig. 6.10.54). The primary procedure was performed by an
unknown surgeon.
The secondary procedure consisted of a high SMAS
facelift, necklift, small incision forehead lift, facial fat
injections, trichloroacetic acid (TCA) lower eyelid peel, scar
revisions, and earlobe repair. The neck procedures included
excision of residual subplatysmal fat, submandibular gland
reduction, superficial digastric myectomy, and anterior
platysmaplasty with postauricular transposition flaps. No
subcutaneous cervical fat was removed. Fat injections were
performed in the temples, upper and lower orbits, the radix
and upper nasal dorsum, the cheeks, midface, nasolabial,
stomal angle, perioral, lips, chin, geniomandibular groove,
and jawline areas. A total of 70 cc of fat was placed.
(A) Preoperative anteroposterior (AP) view. The patient
can be seen to have suboptimal eyebrow position and
configuration with over-elevation of the medial brow,
residual cheek and jowl ptosis, and poor posture of the
perioral tissues. The periocular appearance suggests
aggressive upper and lower blephaorplasty had been
previously performed. A mild ptosis is present on the right.
Marked atrophy can be seen in the temples, orbits, cheeks,
oral and perioral, and perimental areas. Marked facial
asymmetry can also seen to be present. Overall the face has
a tired, and aged appearance. (B) Postoperative AP view.
The patient has a soft, natural non-surgical appearance. The
lateral portion of each eyebrow has been raised, and eyebrow
position and configuration have been improved creating a
more alert and engaged appearance (the uncorrected right
ptosis still triggers right frontalis spasm that results in mild
asymmetry). The cheek mass and jowls have been raised
and the posture of tissues around the mouth improved. The
temples and the upper and lower orbits have been filled
using fat injections. Atrophy present in the oral, perioral,
chin, geniomandibular groove, and jawline areas has been
nicely improved using fat injections as well. The lips have
been subtly filled with fat and the lip border enhanced.
Overall improved facial symmetry can also be seen.
(C) Preoperative smiling view. Smiling reveals mandibular
asymmetry and a poor transition from the lower eyelid
to the cheek. (D) Postoperative smiling view. The patient
appears natural when smiling. The temples and upper and
lower orbital areas are distinctly fuller and more healthy and
youthful appearing, and the transition from the lower eyelid
to the cheek is improved.
(E) Preoperative oblique view. The patient has a sad,
forlorn appearance and the orbital area looks sunken and
hollow. The lower face lacks strength and aesthetic appeal
and appears elderly. Suboptimal eyebrow position and
configuration is evident and residual cheek and jowl ptosis
can be seen. Atrophy can be seen in the temples, orbits, upper
cheek, oral and perioral, and perimental areas. The chin is
poorly integrated with the jawline. The posterior jawline
is weak. The lips are thin and have an elderly, retruded
appearance. The lower lip appears smaller than the upper
lip. (F) Postoperative oblique view. Overall the patient has
a soft, natural, non-surgical look and a youthful, athletic,
aesthetic, and healthy appearance. The lateral eyebrow has
been raised and the eyebrow position and configuration
have been improved. The cheek mass and jowls have been
repositioned and the temples and the upper and lower orbits
have been filled. An improved transition from the lower
eyelids to the cheeks is present. Atrophy present in the oral,
perioral, and geniomandibular groove areas has been nicely
improved and the posterior jawline has been strengthened
with fat injections. This has resulted in a more aesthetic and
youthful-appearing chin that is integrated with a stronger,
more photogenic jawline. The lips have been subtly filled and
the lip border enhanced, and the entire perioral area can be
seen to have been filled and strengthened. A better overall
aesthetic balance between facial features is present and the
patient has a more attractive and feminine appearance.
(G) Preoperative lateral view. The patient can be seen to
have a poor transition from the lower eyelid to the cheek,
cheek and jowl ptosis, residual cervicosubmental fullness
and suboptimal jawline contour. Marked atrophy can
also be seen in the upper and lower orbits, cheeks, oral
and perioral, and perimental (geniomandibular) areas.
(H) Postoperative lateral view. Overall the patient has a
soft, natural, non-surgical look. Improved balance between
facial features can be seen and the patient has an attractive,
photogenic appearance. Scars are well concealed and the
“loving cup” earlobe have been corrected. The cheek mass
and jowl have been raised, resulting in improvement in
“drool lines” and nasolabial folds. Atrophy present in the
oral and perioral areas has been improved with fat injections
and the lips have been subtly filled and the lip border
enhanced creating a more youthful and attractive mouth. The
geniomandibular groove (“prejowl sulcus”) has been filled
integrating the chin and the jowl into a strong, aesthetically
desirable, continuous line. The posterior jawline has also
been strengthened with fat injections adding to the effect.
The protruding portion of the enlarged submandibular gland
has been reduced, the cervicomental angle improved, and
platysma bands corrected. The improved cervicosubmental
configuration provides a youthful, fit, decisive, and attractive
appearance.
(I) Preoperative lateral flexed view. The patient can be
seen to have cheek and jowl ptosis, residual cervicosubmental
fullness, an indistinct jawline, and a “double chin”. Residual
poor neck contour results in an overweight and indecisive
appearance. The lips are flat and the perioral area is retruded,
resulting in an elderly appearance. An earlobe irregularity
is present. (J) Postoperative lateral flexed view. The patient
now has a fit, athletic look and an attractive, photogenic
appearance. A strong mandibular contour is present with
the chin and the jowl integrated into a distinct, aesthetically
desirable, continuous line. Residual subplatysmal fat and
protruding portions of the submandibular glands have
been removed, and plasysma laxity corrected. The posterior
jawline has also been strengthened with fat injections adding
to the effect. The double chin deformity has been eliminated
by dissecting subcutaneously in a retrograde fashion onto
the chin to release the submental retaining ligaments, and
blending the fat of the chin and submental regions. The
lips and perioral are projected to produce a more aesthetic
and youthful appearance. The earlobe irregularity has been
corrected.

272.e5
Conclusion
A
B
C
D
Fig. 6.10.54  Multiple views of a 62-year-old woman seen before and 12 months after secondary facelift and related procedures (A–J).

272.e6
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
E
F
G
H
Fig. 6.10.54, cont’d

272.e7
Conclusion
I
J
Fig. 6.10.54, cont’d

272.e8
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
A
B
Case study 6.10.3  Tertiary cervicofacial rejuvenation: 64-year-old woman
Multiple views of a 64-year-old woman before and 13 months
after tertiary cervicofacial rejuvenation (Fig. 6.10.55). The
primary facelift and secondary necklift were performed by
an unknown surgeon using conventional techniques. The
secondary procedure consisted of trifurcated cheek SMAS
advancement with temporal and postauricular transposition
flaps, preplatysmal and subplatysmal cervical lipectomy,
anterior platysmaplasty, platysma myotomy, and correction
of “loving cup” ear. Incisions along the hairline were used in
the temporal and occipital areas and the preauricular incision
was moved from a pretragal position to the margin of the
tragus. Foreheadplasty, lower blepharoplasty, bilateral ptosis
correction and crow’s feet reduction were also performed. No
resurfacing or other ancillary procedures were performed.
(A) Patient, aged 64, 8 years after primary conventional
facelift was performed by an unknown surgeon. A secondary
necklift had also been performed by the same surgeon at a
later date. Note residual and secondary deformities including
unrejuvenated forehead, bilateral senile ptosis, midface
ptosis, and residual jowl laxity. (B) Same patient aged 65, 13
months after tertiary facial rejuvenation. Note improvement
in forehead, cheeks, periorbital area, and along jawline that
has been achieved without a tight or pulled appearance. Note
also residual aging in perioral area (“young face–old mouth”
deformity). Regrettably, the patient declined recommended
perioral rejuvenation.
(C) Patient age 64, 8 years after primary conventional
facelift was performed elsewhere. A secondary necklift had
been performed by the same surgeon at a later date as well.
(D) Same patient, 13 months after tertiary facial rejuvenation.
Note that SMAS and platysma surgery has not resulted in
abnormalities during expression.
(E) Patient aged 64, 8 years after conventional facelift
was performed by an unknown surgeon. Note residual
and secondary deformities. (F) Same patient, 13 months
after tertiary facial rejuvenation. Note improvement in jowl
contour has achieved made without the creation of skin
tightness or flattening of facial contour.
(G) Patient aged 64, 8 years after conventional facelift
was performed elsewhere. Note residual and secondary
deformities midface ptosis, malar flattening, shift of cervical
wrinkles onto lower face, “loving cup” ear, residual jowl,
and residual cervical obliquity. (H) Same patient, 13 months
after tertiary facial rejuvenation. Cheek and midface tissue
has been elevated, the pretragal scar has been moved to the
margin of the tragus, the lobular–facial junction has been
improved, over-shifted wrinkles have been partially moved
back onto neck, and cervical contour improved.
(I) Patient aged 64, 8 years after conventional facelift
was performed by an unknown surgeon. Note shift of
cervical wrinkles onto lower face, “loving cup” ear, and
residual cervical obliquity. (J) 13 months after a tertiary
facial rejuvenation. The pretragal scar has been moved to
the margin of the tragus, the lobular–facial junction has been
improved, over-shifted wrinkles have been partially moved
back onto neck, and cervical contour improved.
Fig. 6.10.55  Multiple views of a 64-year-old woman before and 13 months after tertiary cervicofacial rejuvenation (A–J).

272.e9
Conclusion
C
D
E
F
Fig. 6.10.55, cont’d

272.e10
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
G
H
I
J
Fig. 6.10.55, cont’d

272.e11
Conclusion
Case study 6.10.4  Secondary cervicofacial rejuvenation: 68-year-old woman
Secondary cervicofacial rejuvenation. Multiple views of a
68-year-old woman seen before, and 1 year and 8 months
after secondary facelift and related procedures (Fig. 6.10.56).
The primary procedure was performed by an unknown
surgeon. The secondary procedure consisted of a high SMAS
facelift, necklift, small incision closed forehead lift, upper
and lower blepharoplasties with reinsertion of the levator
aponeurosis and canthopexy, facial fat injections, perioral
dermabrasion, scalp scar revisions, and nevus excision. The
neck procedures included excision of residual subplatysmal
fat, submandibular gland reduction, superficial digastric
myectomy, anterior platysmaplasty with postauricular
transposition flaps, and full-width platysmamyotomy.
No subcutaneous cervical fat was removed. Fat injections
were performed in the temples, upper and lower orbits,
the upper nasal dorsum, the cheeks, midface, piriform,
nasolabial, stomal angle, perioral, lips, chin, geniomandibular
groove, and jawline areas. No resurfacing or other ancillary
procedures were performed.
(A) Preoperative AP view. The patient can be seen to
have suboptimal eyebrow position and configuration with
over-elevation of the medial brow, residual cheek and
jowl ptosis, and poor posture of the perioral tissues. The
periocular appearance suggests aggressive upper and lower
blepharoplasty had been previously performed. Marked
atrophy can be seen in the temples, orbits, cheeks, oral and
perioral, and perimental areas. Marked facial asymmetry,
mild perioral wrinkling, and bilateral senile ptosis, worse on
the left, are also present. Overall, the face has an ill, tired, and
aged appearance. (B) Postoperative AP view. The patient has
a soft, natural non-surgical appearance. The lateral portion
of each eyebrow has been raised and eyebrow position and
configuration have been improved, creating a more alert and
engaged appearance. The cheek mass and jowls have been
raised and the posture of tissues around the mouth improved.
The temples and the upper and lower orbits have been filled
using fat injections. A slight undercorrection of upper orbital
atrophy on the left can be seen. Atrophy present in the oral,
perioral, chin, geniomandibular groove, and upper nasal
dorsum areas has been nicely improved using fat injections
as well. The lips have been subtly filled with fat and the lip
border enhanced without a “stung by a bee” or “filler lip”
appearance. The combination of fat injections and perioral
dermabrasion has produced natural-appearing correction of
perioral wrinkling. Overall improved facial symmetry can
also be seen. The patient’s ptosis has been improved.
(C) Preoperative smiling view. Smiling reveals mandibular
asymmetry and a poor transition from the lower eyelid to the
cheek. (D) Postoperative smiling view. The patient appears
natural when smiling. The transition from the lower eyelid to
the cheek is improved. The chin is integrated with the jawline
and the two together form one continuous and desirable
aesthetic line. The lips are fuller but the shape of the mouth is
unchanged.
(E) Preoperative oblique view. The patient has a sad,
forlorn appearance and the orbital area looks sunken and
hollow. The lower face lacks strength and aesthetic appeal
and appears elderly. Suboptimal eyebrow position and
configuration is evident and residual cheek and jowl ptosis
can be seen. Atrophy can be seen in the temples, orbits, upper
cheek, oral and perioral, and perimental areas. The chin is
frail and narrow-appearing and is poorly integrated with
the jawline. The posterior jawline is weak and the mandible
has a diminutive appearance. The lips are thin and have an
elderly retruded appearance. (F) Postoperative oblique view.
Overall, the patient has a soft, natural, non-surgical look and
a youthful, athletic, aesthetic, and healthy appearance. The
lateral eyebrow has been raised and the eyebrow position and
configuration have been improved. The cheek mass and jowls
have been repositioned and the temples and the upper and
lower orbits have been filled. An improved transition from
the lower eyelids to the cheeks is present. Atrophy present
in the oral, perioral, chin, and geniomandibular groove areas
has been nicely improved and the posterior jawline has
been strengthened with fat injections. This has resulted in
a broader more aesthetic and youthful-appearing chin that
is integrated with a stronger, more photogenic jawline. The
lips have been subtly filled and the lip border enhanced, and
the entire perioral area can be seen to have been filled and
strengthened. Fat injections to the upper nasal dorsum have
also resulted in a more aesthetic and attractive nasal line.
A better overall aesthetic balance between facial features is
present and the patient has a more attractive and feminine
appearance.
(G) Preoperative lateral view. The patient can be seen to
have a poor transition from the lower eyelid to the cheek,
cheek and jowl ptosis, residual cervicosubmental fullness
and platysmal bands, a large submandibular gland,
suboptimal jawline contour, a retracted tragus, and a mild
“loving cup” earlobe. Marked atrophy can also be seen in
the upper and lower orbits, cheeks, oral and perioral, and
perimental (geniomandibular) areas. (H) Postoperative lateral
view. Overall, the patient has a soft, natural, non-surgical
look. Improved balance between facial features can be seen
and the patient has an attractive, photogenic appearance.
Scars are well concealed and the retracted tragus and “loving
cup” earlobe have been corrected. The cheek mass and jowl
have been raised, resulting in improvement in “drool lines”
and nasolabial folds. Atrophy present in the oral and perioral
areas has been improved with fat injections and the lips have
been subtly filled and the lip border enhanced, creating a
more youthful and attractive mouth. The geniomandibular
groove (“prejowl sulcus”) has been filled, integrating the chin
and the jowl into a strong, aesthetically desirable, continuous
line. The posterior jawline has also been strengthened with
fat injections, adding to the effect. The protruding portion
of the enlarged submandibular gland has been reduced,
the cervicomental angle improved, and platysma bands
corrected. The improved cervicosubmental configuration
provides a youthful, fit, decisive, and attractive appearance.
(I) Preoperative lateral flexed view. The patient can be
seen to have a poor transition from the lower eyelid to the
cheek, cheek and jowl ptosis, residual cervicosubmental
fullness, an indistinct jawline, and a “double chin”. Residual
poor neck contour results in an overweight, indecisive, and
unattractive appearance. The lips are flat and the perioral
area is retruded, resulting in an elderly appearance. (J)
Postoperative lateral flexed view. The patient now has a

272.e12
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
A
B
Fig. 6.10.56  Secondary cervicofacial rejuvenation. Multiple views of a 68-year-old woman seen before, and 1 year and 8 months after secondary facelift and related
procedures (A–J).
Case study 6.10.4  Secondary cervicofacial rejuvenation: 68-year-old woman—cont’d
fit, athletic look and an attractive, photogenic appearance.
A strong mandibular contour is present with the chin and
the jowl integrated into a distinct, aesthetically desirable,
continuous line. Residual subplatysmal fat and protruding
portions of the submandibular glands have been removed,
and platysma laxity corrected. The posterior jawline has also
been strengthened with fat injections adding to the effect.
The double chin deformity has been eliminated by dissecting
subcutaneously in a retrograde fashion onto the chin to
release the submental retaining ligaments, and blending the
fat of the chin and submental regions. The orbits have been
filled using fat injections, and the lips and perioral are project
to produce a more aesthetic and youthful appearance.

272.e13
Conclusion
C
D
E
F
Fig. 6.10.56, cont’d

272.e14
SECTION I
CHAPTER 6.10 • Facelift: Secondary deformities and the secondary facelift
G
H
I
J
Fig. 6.10.56, cont’d

SECTION I • Aesthetic Surgery of the Face
7 
Forehead rejuvenation
Richard J. Warren
SYNOPSIS
■ Detailed knowledge of forehead anatomy is the basis for rejuvenation
strategies of the forehead region.
■ Eyebrow position is the net result of forces that depress the brow,
forces that raise the brow, and the structures that tether the eyebrow
in place.
■ Brow depression is caused by glabellar frown muscles, the orbicularis,
and gravity. Frontalis is the only effective brow elevator.
■ Attractiveness of the periorbital region is intimately related to eyebrow
shape and eyebrow position as it relates to the upper eyelid and the
upper lid sulcus.
■ Aging causes enlargement of the orbital aperture as well as changes in
eyebrow shape. In a subset of individuals, there is ptosis of the entire
forehead complex.
■ Key elements of forehead rejuvenation are the attenuation of frown
muscle action and the repositioning of ptotic eyebrow elements. The
lateral eyebrow is often the only portion requiring elevation.
■ Forehead rejuvenation can be accomplished using a combination of
surgical and non-surgical techniques.
■ If surgical elevation of the brow complex fails early, it is usually due to
lack of soft-tissue release. If it fails late, is usually due to failure of
fixation.
■ Many methods of soft-tissue fixation and bony fixation have been
proven effective in maintaining the position of the surgically elevated
brow.
Access the Historical Perspective section online at

Introduction
The periorbital region is the most expressive part of the
human face. The eyes are central, framed above by the eye­
brows, and below by the cheek. Alteration in components of
the orbital frame, as well as the eyelids themselves, will
profoundly affect facial appearance. The aesthetic balance
created by surgery can project strong human emotions,
ranging from joy to sadness and from restfulness to fatigue.
In the younger individual, aesthetic alteration of the fore­
head is generally limited to the non-surgical alleviation of
glabellar frown lines and lateral orbital wrinkles. These issues
are discussed in Chapters 4 and 5. Occasionally, surgery is
indicated to change the basic shape of a youthful eyebrow. In
the older individual, the forehead typically becomes ptotic
laterally, while in the orbit, there is a relative loss of orbital fat
together with an accumulation of loose eyelid skin. Under­
standing the interplay between these complex anatomical
changes is critical in choosing an appropriate surgical strategy
to rejuvenate the upper third of the face.
Anatomy
The frontal bone is crossed laterally by a curved ridge called
the temporal crest (also called the temporal ridge or the
superior temporal fusion line of the skull). This is a palpable
landmark that separates the temporal fossa and the origin of
the temporalis muscle from the forehead portion of the frontal
bone (Fig. 7.1). It also marks a change in nomenclature as
tissue planes transition from lateral to medial. The deep
temporal fascia covering the temporalis muscle attaches along
the temporal ridge and continues medially as the periosteum
that covers the frontal bone. Similarly, the superficial temporal
fascia (also known as the temporal parietal fascia) continues
medially as the galea aponeurotica that encompasses the
frontalis muscle.
The surgical significance of the temporal crest line is that
all fascial layers are tethered to bone in a band approximately
5 mm wide immediately medial to the palpable ridge. This
has been called the zone of fixation.22,23 Where this zone
approaches the orbital rim at its inferior end, the fascial
attachment widens and becomes more dense, forming the
orbital ligament (Fig. 7.2). All fascial attachments in this
  Access video lecture content for this chapter online at expertconsult.com

273.e1
Historical perspective
Historical perspective
The history of aesthetic brow surgery was thoroughly
reviewed by Paul in 2001.1
The first description of brow elevation surgery was a
publication by the French surgeon Passot in 1919.2 His tech­
nique involved the removal of multiple small skin ellipses,
positioning scars in the forehead crease lines and at the frontal
hairline. In 1926, Hunt described what appears to have been
a full anterior hairline incision for brow lifting access.3 In
1931, Lexer published a combined forehead and open brow
lift with a hairline incision,4 and in 1933, Claoue published
a similar extensive approach.5 Interestingly, forehead lifting
then fell into disfavor for several decades until 1962 when
Gonzalez-Ulloa published in the English literature an open
coronal brow lift combined with facelift.6 Shortly thereafter,
in Brazil, Vinas presented (1965)7 and subsequently described
(1976)8 his advanced concepts of brow elevation. He suggested
making a concerted effort to elevate the lateral portion of
the brow. He also described a local method of direct brow
lifting for certain patients. In 1984, Papillon and colleagues
presented a subcutaneous dissection plane from the anterior
hairline approach.9 In 1989, Paul described a transblepharo­
plasty approach.10
The original description of endoscopic brow lifting is
attributed to two surgeons, Isse and Vasconez, both of whom
presented their method at different venues in 1992.11,12 The
first publication of this method was by Chajchir in 1993.13
In 1996, Knize published his “limited incision forehead
lift”,14 using a short temple incision without endoscopic assist.
By 2003, a reduction in the number of endoscopic brow lifts
being done was documented due to uncertainty over the
stability of endoscopic brow lifting.15 In the first part of the
21st century, other methods appeared to deal with lateral
brow relapse.16 Numerous reports demonstrated the success
of endoscopic brow lifting using measurements from the
brow to the pupil.17–21

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SECTION I
CHAPTER 7 • Forehead rejuvenation
describe the crisscrossing white fibers that loosely attach the
superficial to the deep temporal fascia.
The inferior temporal septum is a useful landmark during
endoscopic dissection from above, because it separates the
safe upper zone containing no vital structures from the lower
zone where facial nerve branches travel in the cavity’s roof.
The medial zygomatic temporal vein (sentinel vein) is also
present in this lower zone, adjacent to the lateral orbital rim.
The temporal branches pass immediately superior to this vein
(Figs. 7.3 & 7.4).
Galea
Knize has described galeal anatomy in detail.26 In the fore­
head, the galea aponeurotica splits into a superficial and deep
region must be released from bone when a full-thickness
forehead flap is being repositioned.
Some fascial structures in this area have been named by
different authors, generating some confusion. The superior
temporal septum24 and the zone of adhesion16 are alternative
terms used to describe the zone of fixation. The temporal
ligamentous adhesion24 describes the lower portion of the
zone of fixation and the orbital ligament. The inferior tem­
poral septum24 and the orbicularis-temporal ligament25 both
Fig. 7.1  Bony anatomy of the forehead and temporal fossa. The palpable temporal
ridge separates the temporal fossa from the forehead. The zone of fixation (also
called zone of adhesion, superior temporal septum) is a 5-mm wide band along the
temporal ridge where all layers are bound down to periosteum.
Superior temporal
fusion line
Zone of fixation
(zone of adhesion)
Temporal ridge
(temporal crest)
Fig. 7.2  Fascial attachments around the orbital rim. The inferior end of the zone of
fixation is the orbital ligament. The lateral orbital thickening is a lateral extension of
the septum that extends across the lateral orbital rim onto deep temporal fascia.
Lateral orbital thickening
of periorbital septum
Orbital ligament
Periorbital septal
attachment
Temporal branches
of the facial nerve
Inferior temporal
septum
Sentinel vein
Superior temporal septum
Zone of fixation
(zone of adhesion)
Fig. 7.3  Endoscopic view of the inferior temporal septum, right side.
Fig. 7.4  Endoscopic view of the medial zygomaticotemporal vein (sentinel vein),
right side.

275
Anatomy
thought to be variable, with some individuals having a con­
tinuous layer of fat from galeal fat pad to the preseptal fat
(Fig. 7.6).26
Muscle
Eyebrow level is the result of a balance between the muscular
forces that elevate the brow, the muscular forces that depress
the brow, and the universal depressor: gravity (Fig. 7.7).
Brow depressors in the glabella originate from bone medi­
ally, inserting into soft tissue. The procerus runs vertically,
the depressor supercilii and orbicularis run obliquely, and
the corrugator mostly runs transversely. The transverse
corrugator supercilii is the largest and most powerful of
these muscles. It originates from the orbital rim at its most
layer encompassing the frontalis muscle (Fig. 7.5). Inferiorly,
the deep galea layer separates further into three separate
layers: one layer immediately deep to the frontalis forming
the roof of the galeal fat pad, a second layer forming the
floor of the galeal fat pad but not adherent to bone, and a
third layer adherent to periosteum. The two deepest layers
define the glide plane space between the galeal fat pad and
the skull. Inferiorly, the septum orbitale divides orbital fat
from preseptal fat (also known as retro-orbicularis oculi
fat; ROOF).
When the eyebrow is raised by frontalis contraction, the
soft tissue slides over the glide plane space. The galeal fat pad
extends across the entire width of the lower 2 cm of the
forehead; medially it surrounds the supraorbital and supra­
trochlear nerves as well as portions of the frown musculature.
The galeal fat pad is separated from the preseptal fat (ROOF)
by a reflected layer of galea. Laterally, this separation is
Fig. 7.5  Relationship of galea to surrounding tissue as it splits to encompass the
frontalis muscle, the galeal fat pad, and the glide plane space. The corrugator
supercilii traverses through the galeal fat pad as it courses from its deep bony
origin to its superficial insertion in the orbicularis and dermis.
Galeal aponeurosis
Subgaleal space
Periosteum
Periosteum
Preseptal fat (ROOF)
Orbital septum
Obicularis oculi muscle
Suborbital fascia
Superficial galea
Deep galea
Fontalis muscle
Galeal fat pad
Glide plane space
Corrugator supercilii muscle
Orbital rim
Fig. 7.6  Lateral orbital rim variation. (A) Galeal attachment tethers the overlying
brow. (B) The galeal fat pad is contiguous with retro-orbicularis oculi fat, potentially
making the lateral brow prone to ptosis.
A
B
Preseptal fat
Lateral orbital rim with
deep galeal attachment
Lateral orbital rim with
no galeal attachment
Orbital septum
Obicularis
oculi muscle
Fontalis
muscle
Galeal
fat pad
Galeal
attachment
Fig. 7.7  Glabellar frown muscles.
Depressor supercilii
Corrugator supercilii
Procerus
Orbicularis oculi

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SECTION I
CHAPTER 7 • Forehead rejuvenation
Sensory nerves
Innervation to the upper periorbita is supplied by the supra­
orbital and supratrochlear nerves, as well as two lesser nerves,
the infratrochlear, and zygomaticotemporal (Fig. 7.10).
The infratrochlear nerve exits the orbit medially, supplying
sensation to the nasal dorsum and medial orbital rim. It is
seldom damaged and rarely a cause of postoperative concern.
The zygomaticotemporal nerve exits posterior to the lateral
orbital rim, piercing the deep temporal fascia just inferior to
the sentinel vein. In brow lifting, with complete release of the
lateral orbital rim, it is often avulsed. Consequences of this
are minimal and temporary.
The supratrochlear nerve usually exits the orbit superome­
dially, although this is variable, and it occasionally will exit
near the supraorbital nerve. It immediately divides into 4–6
branches, which can pass superficial (anterior) to the corruga­
tor, or more frequently, directly through the substance of the
corrugator. These branches then become more superficial,
innervating the central forehead.
The supraorbital nerve exits the superior orbit either
through a notch in the rim, or through a foramen superior to
the rim. Much variation occurs, with foramina present about
20% of the time.28 The location of the notch or foramen is
between 16 and 42 mm from the midline, with a mean of
25 mm. A useful landmark for this is a palpable notch, or
failing that, the mid-papillary line. When a foramen is present,
it has been found as far as 19 mm above the rim. Because of
such variation, blind dissection from above should be discon­
tinued at least 2 cm above the orbital rim.
superomedial corner, with the large transverse head later
passing through galeal fat, becoming progressively more
superficial until it interdigitates with the orbicularis and
frontalis at a skin dimple, which is visible when the patient
frowns.27
The orbicularis encircles the orbit acting like a sphincter.
Medially and laterally, the orbicularis fibers run vertically and
act to depress brow level. Laterally, orbicularis is the only
muscle that depresses brow position (Figs. 7.8 & 7.9).
Frontalis is the only elevator of the brow. It originates from
the galea aponeurotica superiorly and interdigitates inferiorly
with the orbicularis. Contraction raises this muscle mass, and
in so doing, lifts the overlying skin which contains the
eyebrow. Due to its deficiency laterally, the primary effect of
frontalis contraction is on the medial and central portions of
the eyebrow.
Fig. 7.8  Lateral orbicularis acts like a sphincter, depressing the lateral brow.
Fig. 7.9  Frontalis acts to raise the eyebrow complex. On contraction, most
movement occurs in the lower third of the muscle, and action is strongest on the
medial and central eyebrow.
Orbicularis occuli
muscle
Frontalis muscle
Temporal crest line
Fig. 7.10  Sensory nerves.
Superficial branch of
supraorbital nerve
Supratrochlear nerve
Infratrochlear nerve
Infraorbital nerve
Deep branch of
supraorbital nerve
Zygomatico-
temporal nerve
Zygomatico-
facial nerve

277
Anatomy
3. Parallel and adjacent to the inferior temporal septum
4. Immediately superior to the sentinel vein (medial
zygomaticotemporal vein).
In all forehead lift procedures, dissection planes are designed
to protect the temporal branches. This can be done by staying
deep to them, which requires dissecting directly on deep
temporal fascia in the temple and in the subgaleal or subperi­
osteal planes over the frontal bone. Alternatively, dissection
The supraorbital nerve immediately divides into two dis­
tinct segments: superficial and deep. The superficial branch
pierces orbicularis and frontalis, dividing into several smaller
branches, which travel on the superficial surface of the fron­
talis to innervate the central forehead as far posteriorly as the
first 2 cm of hair. The rest of the scalp, as far back as the vertex,
is innervated by the deep branch. The deep branch courses
superiorly in a more lateral location, remaining between the
periosteum and the deepest layer of galea. As it travels supe­
riorly, it becomes more superficial, piercing frontalis to
innervate the skin.
It is a double branch approximately 60% of the time.29 An
important fact during endoscopic brow lifting is that the deep
branch runs in a 1-cm wide band, which is between 5 mm and
15 mm medial to the palpable temporal ridge (Fig. 7.11).
Motor nerves
The temporal branch of the facial nerve is the only motor
nerve of concern in this area. Loss of this branch would result
in a brow ptosis and asymmetry due to impaired frontalis
action (Fig. 7.12). The anatomy of this nerve has been well
described.30–33
The temporal branch enters the temporal fossa as multiple
(2–4) fine branches that lie on the periosteum of the middle
third of the zygomatic arch. Between 1.5 cm and 3.0 cm above
the arch, these branches become more superficial, entering the
superficial temporal fascia (temporoparietal fascia), traveling
on to innervate the frontalis, superior orbicularis, and glabel­
lar muscles.34
A number of different landmarks are commonly used to
predict the course of the temporal branches. These include:
1. The middle third of the palpable zygomatic arch
2. 1.5 cm lateral to the tail of the eyebrow
Fig. 7.11  The deep branch of the supraorbital nerve
travels in a 1-cm wide band between 5 and 15 mm medial
to the temporal ridge.
Supraorbital
nerve,
deep branch
Supraorbital
nerve,
superficial
branches
Fig. 7.12  Facial nerve branches in the periorbital region. Note the corrugator has
dual innervation from the temporal branch and the zygomatic branch. The temporal
branch crosses the middle third of the zygomatic arch as 2–4 branches.
Facial nerve, zygomatic branch
Facial nerve, temporal branch

278
SECTION I
CHAPTER 7 • Forehead rejuvenation
are not so clear. Some studies actually suggest that eyebrows
may sometimes rise with age, at least in the medial and central
portions (Figs. 7.15).35–37
Logically, the medial and central eyebrows could rise over
time through the action of frontalis. This may be caused by a
subconscious reaction to excess upper lid skin or to early
eyelid ptosis caused by senile levator disinsertion. Both phe­
nomena will stimulate frontalis contraction to open the line
of sight. Also at play is personal habit, exhibited by the brow
elevation seen when most individuals are confronted with a
mirror, or on facing a camera. Closing the eyes will usually,
but not always, relax the frontalis, causing the eyebrows to
drop. Frontalis paralysis due to facial nerve injury or botuli­
num toxin will always drop the level of the eyebrow, indicat­
ing that some resting tone is normal.
A final factor is the shape of the orbital aperture, which
appears to enlarge with age, the superomedial brow rising,
and the inferolateral orbital rim dropping and receeding.38,39
This could contribute to a rising medial brow, because of
soft-tissue attachment and the soft-tissue support provided by
the trunk of the supraorbital nerve (Fig. 7.16).
As described earlier, the level and shape of the eyebrow is
the result of a balancing act between the many forces of brow
depression and the only elevator, which is the frontalis muscle.
The lateral portion of the brow is particularly sensitive to this
interplay because frontalis action is attenuated laterally.40
Against the unrelenting force of gravity and the lateral orbi­
cularis oculi, the principle resistance to lateral brow decent is
soft-tissue attachment. This attachment is variable and may
be absent, leaving the lateral brow free to move.41 The result
is often a gradual ptosis of the lateral third of the brow, rela­
tive to the medial brow. This effect will be accentuated if a
patient also chronically raises the medial brow. The resulting
downturned lateral brow imparts a look of sadness, tiredness,
and age.
can be kept superficial to the frontalis, the orbicularis, and the
superficial temporal fascia.
Patient presentation
Forehead aging
Historically, the visible signs of forehead aging have been
described in two ways. First, and most obvious, are the
furrows caused by the repetitive action of underlying muscles:
transverse lines are due to the eyebrow-lifting action of the
frontalis, while glabellar frown lines are due to the corruga­
tor, depressor supercilii, and the procerus. The corrugator,
being the most transverse of these muscles, causes vertical
frown lines, the depressor supercilii, being oblique, causes
oblique folds which cut across the orbital rim, and the verti­
cally running procerus causes transverse lines at the radix
(Figs. 7.13 & 7.14).
Second, it has been assumed that the forehead/eyebrow
complex becomes ptotic with age, encroaching on the orbit,
causing a pseudo-excess of upper eyelid skin. While consistent
with the age-related ptosis of most other body parts, the facts
Fig. 7.13  Patient frowning. The paired vertical folds are caused by the corrugator
supercilii and the transverse lines at the nasal radix are caused by the procerus. The
paired oblique lines are caused by the depressor supercilii and the medial
orbicularis oculi. Laterally, the “crow’s feet” lines are caused by the vertically
running fibers of the orbicularis oculi.
Fig. 7.14  Patient raising eyebrows. The transverse forehead lines are caused by the
frontalis.
Fig. 7.15  From age 25 (A) to 50 (B), photographs demonstrate a 3–4 mm rise in
the medial and central brows. One possible cause is chronic tone in the frontalis
muscle.
A
B

279
Patient presentation
Fig. 7.16  Orbital changes with age: orbital volume
expands, most marked superomedial and
inferolateral. (With permission from Kahn DM,
Shaw RB. Aging of the bony orbit. A three-
dimensional computed tomographic study. Aesthet
Surg J. 2008;28:258–264.)
A
B
Fig. 7.17  An oval formed by the eyebrow above, and the nasojugal fold below,
should have the pupil at its equator. (Adapted from: Gunter J, Antrobus S. Aesthetic
analysis of the eyebrows. Plast Reconstr Surg. 1997;99:1808–1816.)
Fig. 7.18  On oval analysis of this case, the pupil lies above the natural equator of
the oval. This confirms a low lying eyebrow plus or minus a low lying nasojugal
fold.
Another effect of a dropping lateral brow is a bunching up
or a pseudo-excess of lateral upper eyelid skin. In response to
this, Flowers and Duval have described the phenomenon of
compensated brow ptosis where patients subconsciously
contract the frontalis to open their line of sight.42 This further
exacerbates the appearance of a downturned lateral brow.
Many patients recognize these changes and treat them­
selves with make-up, eyebrow plucking, or tattooing in order
to make the lateral brow appear higher. Alternatively, they
may seek blepharoplasty to deal with lateral soft-tissue
hooding, unaware that the ptotic lateral brow is the most
significant factor. The unsuspecting surgeon who performs
blepharoplasty in this circumstance will see the frontalis relax,
unmasking the compensated brow ptosis, causing the medial
and central brow to fall.
Aesthetics
Traditional teaching has been that the correct eyebrow posi­
tion is at or above the supraorbital rim. While usually true,
this axiom is overly simplistic, because eyebrow height is only
one of many variables. Young patients may have congenitally
low, or laterally downturned eyebrows (see Fig. 7.32). With
age, in many individuals, the lateral brow becomes more
ptotic than the medial, thus altering eyebrow shape. Studies
have demonstrated that our impression of people can be
affected by altering the shape of their eyebrows, implying that
the shape of the brow is more important than its absolute
height.43,44 Furthermore, age-related changes in eyebrow
shape and position do not occur in isolation. The junction of
the upper eyelid and brow is aesthetically complex, involving
an interplay between eyebrow shape and position, the full­
ness or hollowness of the upper sulcus, the presence or
absence of eyelid ptosis, and the shape of the orbit itself. With
age, the upper lid sulcus may become more hollow as fat is
lost and the orbit enlarges, upper lid skin will become more
redundant, and senile eyelid ptosis may cause reflex brow
raising, especially medially (see Fig. 7.15B).
Gunter observed that the eyebrow and nasojugal fold
create an oval shape, and that in an attractive eye, the pupil
will lie at the equator of that oval (Fig. 7.17).45 Applying this
analysis is a useful exercise to determine if brow position is
an issue (Fig. 7.18).

280
SECTION I
CHAPTER 7 • Forehead rejuvenation
Patient selection
Most patients are not aware of the many variables involved
in periorbital rejuvenation, and they may not want the mul­
tiple procedures required to treat all of these components. For
that reason, identifying the main component of every patient’s
periorbital aging is important. Old photographs are very
helpful in determining which aging changes predominate.
Such a review will also help to focus patients’ perspectives on
exactly how they have aged and what, if any, rejuvenation
they would prefer.
Assessment of the patient should be done with the patient’s
head in the vertical position; the patient will be sitting or
standing. The following issues are evaluated: visual acuity;
eyebrow and orbital symmetry; position of anterior hairline;
thickness of scalp hair; transverse forehead lines; glabellar
frown lines; thickness of eyebrow hair; eyebrow height; axis
of the eyebrow (downward or upward lateral tilt); shape of
the eyebrow (flat or peaked); passive and active eyebrow
mobility; and the presence of old scars or tattoos. The upper
eyelids should be assessed for soft-tissue redundancy, for
hollowness, and for lid level (ptosis versus lid retraction). The
patient should be examined with eyes open and eyes closed.
With the eyes closed, the frontalis can usually be made to
relax, revealing the true position and shape of the eyebrows.
If the brow is held in this position when the patient opens
their eyes, the eyebrow/eyelid relationship without frontalis
effect will be revealed. The surgeon can then manually reposi­
tion the eyebrows, experimenting with various positions and
different vectors of mobilization.
A patient may be a candidate to have their entire brow
complex lifted, or more commonly to have only part of the
eyebrow raised, thus improving eyebrow shape. Occasionally,
this may involve raising the medial brow only, but most typi­
cally it involves raising the lateral third to half of the brow,
with little or no lift of the medial portion. Weakening or
eliminating the glabellar frown muscles is a useful parallel
objective. Numerous methods are available, ranging from
botulinum toxin, to surgical techniques that may weaken, or
completely eliminate the glabellar frown muscles.
Surgical techniques
Surgical rejuvenation of the forehead has changed dramati­
cally from the one-size-fits-all approach of an earlier era. As
our understanding of anatomy and aging has improved, our
available surgical techniques have also evolved. Alongside
this evolution, the introduction of botulinum toxin for aes­
thetic indications has changed many of our fundamental
concepts, and for many patients has supplanted any interest
in aesthetic brow surgery.
Open coronal approach
The coronal approach was long considered the “gold stan­
dard” against which other techniques must be measured and
it is still a very effective way to modify the forehead. The
principal advantage of this approach is the unparalleled sur­
gical exposure, which facilitates release and mobilization of
brow soft tissues, as well as the modification of glabellar
Ovals that are vertically wide look aged, while vertically
narrow ovals look youthful.
There is an intimate relationship between eyebrow position
and the eyelid. The ratio of the visible eyelid from the lashes
to the palpebral fold should be one-third, and at most one-
half, the distance from the lashes to the lower border of the
eyebrow (Fig. 7.19).45 A number of different factors may
change this ratio:
■ Changing eyebrow height
■ Lid ptosis or lid retraction
■ Redundant upper eyelid soft tissue
■ Loss of upper sulcus fat.
Any one of these issues can be treated independently or in
conjunction with a brow lift. Brow repositioning is a powerful
tool but it must be considered in the context of other possibili­
ties such as ptosis repair, blepharoplasty, and fat grafting to
the upper lid sulcus.
Individualization is a key component to any periorbital
rejuvenation. Gender, ethnicity, eye prominence, and overall
facial proportions must be considered. For example, Oriental
faces look attractive with higher eyebrows than would seem
appropriate for the Caucasian face. Complicating matters, the
“ideal” eyebrow has also changed over time. Renaissance
painters tended to portray their subjects with normal eye­
brows and relatively hollow upper sulci, while in the 1950s,
eyebrows became very high and arched.44 Individual varia­
tion aside, there are certain themes that define “the ideal
eyebrow” (see Fig. 7.19) in the era when this text is being
written:
1. The medial eyebrow level should lie over the medial
orbital rim
2. The medial border of the eyebrow should be vertically
in line with the medial canthus
3. The eyebrow should rise gently, peaking slightly at least
two-thirds of the way to its lateral end; typically this
peak lies vertically above the lateral limbus
4. The lateral tail of the brow should be higher than the
medial end
5. The male brow should be lower and less peaked.
Fig. 7.19  The modern ideal brow/upper eyelid complex.
Peak
2/3
1/3

281
Surgical techniques
access to the muscles (see Fig. 7.21). The frown muscles, cor­
rugator, depressor supercilii, and procerus can be removed or
weakened as necessary (see Fig. 7.22). Typically, resection of
the corrugator requires dissection of the supratrochlear nerve
branches that course through the substance of this muscle. It
is often advantageous to leave some galeal attachment medi­
ally to prevent over-elevation of the medial scalp. Otherwise,
for proper brow elevation, there must be a thorough release
of the galeal attachments along the central and lateral orbital
rims. The zone of fixation will be released as dissection pro­
gresses laterally over the deep temporal fascia. The trunk of
the supraorbital nerve is identified and preserved. To reposi­
tion the brows, the flap is drawn superolaterally, and a full-
thickness strip of scalp is excised. Laterally, scalp excision will
range from 1 to 3 cm, but centrally, little or no scalp is excised.
The scalp is closed directly, approximating galea and skin.
Although deeper fixation can be added, the classic open
coronal lift relies on scalp excision alone to maintain brow
position.
Disadvantages of the open coronal approach include scalp
numbness, which may be permanent, a long scar, disruption
of hair follicles, and scalp dysesthesia. Inevitably, the anterior
hairline will be raised and some hair-bearing scalp will be
sacrificed. This technique should be used cautiously or not at
all in patients with a high anterior hairline, with thin hair, or
in patients who may eventually lose their hair.
Anterior hairline approach
This incision is usually placed along the anterior hairline,
until it reaches the hairline laterally, where it transitions into
the hair-bearing temporal scalp. Alternatively, it can follow
the hairline over its entire extent (see Fig. 7.20). Certain techni­
cal details help minimize scar visibility. These include placing
the incision within or just posterior to the fine hair of the
anterior hairline and beveling the incision parallel to the hair
follicles. Alternatively, the principle of cutting across the hair
follicles may be used in order to promote growth of hairs
through the resulting scar.46 The incision, when made as a
slightly wavy line, tends to create a less visible scar. Skin
tension is minimized by approximating the galea and doing
a meticulous skin closure.
From the anterior hairline incision, dissection of the
forehead flap can be done in one of three different planes:
muscles under direct vision. Surgical results are stable and
relatively long lasting.
The technique involves an incision over the top of the head,
classically about 6–8 cm behind the anterior hairline, although
this incision can be placed almost anywhere in the hair-bearing
scalp (Fig. 7.20). An incision at the vertex will be at the water­
shed between posterior and anterior running sensory nerves,
thus reducing scalp numbness. However, a more anterior
incision involves less scalp dissection, better visibility, and a
closer point of traction on the eyebrows (Figs. 7.20–7.22).
The incision is made full-thickness down to periosteum,
and the anterior flap can then be raised in either the subperi­
osteal, or more commonly, the subgaleal plane. Under direct
vision, the flap is elevated anteriorly down to the orbital rim.
If glabellar muscles are to be exposed, the galea must be
breached on its deep surface, entering the galeal fat pad for
Fig. 7.20  Coronal and anterior hairline approaches.
Fig. 7.21  Open coronal flap dissection shown in the subgaleal plane.
Fig. 7.22  Coronal approach showing corrugator muscles.

282
SECTION I
CHAPTER 7 • Forehead rejuvenation
bony fixation is done at the supraorbital rim (see Figs. 7.24 &
7.25).48–50
The main disadvantage of the anterior hairline incision is
the presence of a permanent scar along the anterior hairline.
In addition, if the scalp incision is full-thickness, the resulting
scalp denervation will be worse than with the coronal
approach because the posterior running sensory nerves are
transected closer to their origin. Lastly, a full dissection of
forehead skin may compromise cutaneous blood flow leading
to partial skin necrosis.
Endoscopic approach
The endoscopic brow lift involves the same amount of dissec­
tion and soft-tissue release as the open coronal approach, but
with much smaller access incisions and with visibility pro­
vided by an endoscope. More than any other innovation, the
introduction of endoscopy to facial aesthetic surgery stimu­
lated the quest for better understanding of forehead and
temple anatomy. Basic anatomic principles are integral to the
theory of endoscopic brow lifting. Laterally, brow lifting is
accomplished by releasing all periorbital galeal attachments
and relying on mechanical fixation, not scalp excision, to
maintain the scalp in a higher position. Medially, brow lifting
happens passively by removing muscular depressors and
allowing the frontalis to lift unopposed.
The principle advantages of the endoscopic approach are a
very good surgical exposure, magnification of the surgeon’s
view, and short, undetectable incisions. In addition, the scalp
denervation associated with the open coronal approach is
largely avoided (Fig. 7.26).
Access for the procedure is through three to five small
(1–2 cm) incisions placed within the hair-bearing scalp. Medial
to the zone of fixation, the dissection plane can be subgaleal,
or the more popular subperiosteal approach. Flap dissection
can be done blindly at first but is completed under endoscopic
control when approaching the orbital rim in order to avoid
damaging the supraorbital nerve. Lateral to the zone of fixa­
tion, dissection is done against the deep temporal fascia, with
the inferior temporal septum and the sentinel vein used as
landmarks for the position of the overlying temporal nerve
branches. Dissection is kept on the deep temporal fascia in
subperiosteal, subgaleal, and subcutaneous. Regardless of the
plane being used, the anterior hairline approach offers the
same advantage as the coronal approach, namely excellent
surgical exposure, without the disadvantage of moving the
anterior hairline posteriorly. In addition, there are two unique
advantages.
Because there is no undermining of hair follicles, the
surgeon has the option of a subcutaneous dissection plane,
which is done on the superficial surface of the frontalis muscle.
This allows brow elevation without the need to divide any
sensory nerves and also provides a potential effacement of
deep transverse forehead lines. A popular modification of this
method is a short incision in the widow’s peak, which is used
to target only the lateral brow (Fig. 7.23).47
The anterior hairline approach can also be used to lower
an excessively high anterior hairline or to lower overly high
eyebrows. These problems may be congenital but often are
the result of previous brow lift surgery. Hairline lowering
involves a posterior dissection past the vertex of the skull, in
order to extensively mobilize the scalp. Releasing incisions are
made in the galea, and the scalp is advanced, utilizing bony
fixation to maintain the new hairline position (Figs. 7.24 &
7.25). If the anterior approach is used to lower the eyebrows,
Fig. 7.23  Limited hairline subcutaneous approach.
Fibers of frontalis muscle
Fig. 7.24  Anterior hairline incision to lower the anterior hairline.
Fig. 7.25  Hairline lowering.

283
Surgical techniques
done with sutures between the superficial and deep temporal
fascia. If surgical modification of glabellar frown muscle
modification is desired, a transpalpebral approach can be
used.
Disadvantages of this method include limited visibility of
the central and medial supraorbital rim, an oblique vector
applied to the lateral brow (see Fig. 7.27).
Transpalpebral approach – muscle
modification
Using the upper lid blepharoplasty approach, the glabellar
frown muscles can be approached directly.54,55 This is an excel­
lent method to attenuate glabellar frown lines in patients who
do not require a forehead lift. It can also be used as an adjunct
to the patient undergoing an isolated elevation of the lateral
third of the brow. The advantage of this method is a hidden
incision, which may be used for two purposes, blepharoplasty
and frown muscle ablation.
Through an upper blepharoplasty incision, dissection
proceeds superiorly deep to the orbicularis oculi, but superfi­
cial to the orbital septum. Over the supraorbital rim, the
transverse running fibers of the corrugator supercilii will be
found. The muscle becomes more superficial as it courses
laterally through the galeal fat pad, eventually combining
with the orbicularis oculi and the lower frontalis. The muscle
can be removed, although care must be taken to protect
supratrochlear nerve branches which travel through the
substance of the muscle or around its inferior border. Medially
in the wound, the depressor supercilii can be seen coursing
almost vertically, and the orbicularis oculi courses obliquely.
Portions of these muscles are removed. The procerus can be
transected by dissecting across the root of the nose.
The main disadvantages of this approach include potential
damage to sensory nerves (supraorbital and supratrochlear),
Fig. 7.26  Five-port endoscopic approach.
Frontal pocket – subperiosteal
Temporal pocket – against deep temporal fascia
Fig. 7.27  Temple approach.
order to avoid these branches. The medial and lateral dissec­
tion pockets are then joined by going from lateral to medial.
Soft-tissue attachments along the lateral orbital rim and the
supraorbital rim are visualized and released. Dissection down
the lateral orbital rim may be preperiosteal or subperiosteal,
but must be done at least as far as the lateral canthus in order
to allow lateral brow elevation. The supraorbital nerve is
visualized during orbital rim release. If glabellar musculature
is to be removed or avulsed with biting forceps, the supra­
trochlear nerves are visualized as they pass through the
substance of the corrugator supercilii. Care is taken to avoid
excessive release of the flap medially to prevent over-elevation
medially and to avoid separation of the eyebrows. Once dis­
sected, the forehead flap is drawn superiorly and somewhat
laterally. Specific vectors have been described in this regard,51
but the surgeon can make an artistic decision during preop­
erative planning, with appropriate vectors customized for
each individual patient. While some authors have suggested
that no fixation is necessary,17 two methods of fixation are
normally employed: suture fixation in the lateral dissection
pocket from the superficial to the deep temporal fascia and
bony fixation in the medial dissection pocket. In an attempt
to make the operation more predictable, a wide variety of
fixation methods, devices, and techniques have been described,
all designed to attach the elevated flap to the skull.52
The main disadvantages of endoscopic brow lifting are the
technical demands of using endoscopic equipment, the poten­
tial of overly elevating or separating the medial eyebrows,
and some uncertainty about maintaining adequate fixation.15
Temple approach
A temple approach or “temple lift” involves a full-thickness
scalp incision in the temple, lateral to the temporal crest line.53
Knize improved and popularized this approach with dissec­
tion on the deep temporal fascia, releasing of the lateral orbital
rim, the supraorbital rim, and the zone of fixation with using
an endoscope (Fig. 7.27).14 After flap mobilization, fixation is

284
SECTION I
CHAPTER 7 • Forehead rejuvenation
The modified lateral brow lift is a hybrid procedure
utilizing a 5–6 cm incision in the scalp, approximately 1 cm
behind the hairline.16 Because the desired vector is directly
along the course of the deep branch of the supraorbital nerve,
this procedure is designed to be nerve sparing. Orbital rim
release can be done with or without an endoscope. A full-
thickness excision of scalp is done (like an open coronal lift),
but nerve branches are preserved as a neurovascular bundle.
Fixation is accomplished with deep temporal sutures and by
direct galeal closure; bony fixation can also be added. The
main advantages of this method are those of the endoscopic
approach, plus the same strength of fixation provided by
a coronal lift. The main disadvantage, compared with the
pure endoscopic approach, is a slightly longer incision
(Fig. 7.30).
Direct suprabrow approach
Because the eyebrow is a cutaneous structure, the most effec­
tive method to lift it would theoretically be a subcutaneous
approach done adjacent to the eyebrow itself. This simple
technique was described almost a century ago. An excision of
full-thickness skin is done along the upper margin of the
eyebrow, or alternatively within a deep forehead crease. On
closure, there is initially a 1 : 1 relationship between the
amount of skin removed and brow elevation, but the surgeon
should plan for a 50% relapse in the first few months follow­
ing the procedure. The closer the incision is to the eyebrow,
the less will be the relapse. The advantages of this technique
are: the surgery is easy; it is well tolerated by the patient; there
is no scalp denervation; there is no risk to motor nerves; and
the result is relatively predictable
The principle disadvantages of this method are the visible
scar it creates and that fact that over time, brow depressing
forces will once again stretch out the skin, causing a recur­
rence of brow ptosis. Certain individuals, especially older
men with deep forehead creases or thick eyebrows may be
good candidates for this procedure, which can easily be
repeated if necessary (Fig. 7.31).
and increased bruising and edema compared to an isolated
upper lid blepharoplasty (Fig. 7.28).
Lateral brow approach
The lateral brow approach utilizes a more medial incision
than the temple approach. Its location is based on the observa­
tion that the most effective vector for elevating the lateral half
of the eyebrow is directly along the temporal crest line (Fig.
7.29). A variety of fixation methods can be utilized.56 Propo­
nents of this approach feel it is directed at the most ptotic
portion of the aging brow or congenitally downturned brow.16
Fig. 7.29  Preoperative marking for modified lateral brow lift. The planned vector of
pull is marked. Laterally, the purple dashed lines mark the expected course of the
facial nerve temporal branches. The purple dot represents the sentinel vein. The
curved purple line marks the temporal crest line, which is accentuated when the
patient clenches her teeth, contracting the temporalis. Medial to the crest line, the
black cross-hatched band is the expected course of the deep branch of the
supraorbital nerve, in purple. The corrugator supercilii, depressor supercilii, and
procerus are marked in black.
Fig. 7.30  The neurovascular bundle of the deep branch of the supraorbital nerve.
The subperiosteal pocket has been developed medially, and the temporal pocket
against the deep temporal fascia has been developed laterally. The two pockets are
joined along the temporal crest line. When the lateral brow is raised, the
neurovascular bundle will telescope up under the scalp closure.
Fig. 7.28  Transpalpebral exposure of the frown musculature.
Septum
orbitale
Corrugator
supercilii
Depressor
supercilii
Supratrochlear
nerve branches
Supraorbital
nerve branches

285
Outcomes
Postoperative care
Postoperative care for minor brow procedures is limited
to head elevation, cold packs, ointment application, and
analgesics.
More extensive procedures (e.g., open coronal lift, endo­
scopic lift) will require dressings and the possibility of drains
for 24 h. Use of bupivacaine to block the supraorbital and
supratrochlear nerves is very helpful in decreasing the inci­
dence of postoperative headache. Patients can shower after
48 h, with scalp suture removal in 7–10 days.
After initial healing, measures can be adopted to prevent
relapse of lateral brow ptosis. The use of botulinum toxin in
the lateral orbicularis is helpful, as is the use of sunglasses
and sun avoidance to prevent squinting in the first postopera­
tive month.
Outcomes
The surgical result of forehead rejuvenation depends on the
type of deformity, the procedure done, and the quality of its
execution.
Lesser procedures generally produce lesser results, but for
the individual patient with appropriate expectations, this may
be adequate.
More involved procedures afford the opportunity for
greater anatomic intervention, more dramatic results, and
potentially greater longevity. However, as our understanding
of the aging brow has progressed, it is clear that ptosis of the
entire brow is not as significant a factor as was once thought.
As discussed earlier, brow shape is aesthetically more impor­
tant than the actual height of the eyebrow. Therefore, the
aesthetic outcome of surgery will depend on what portion of
the brow is being raised (Fig. 7.32). Unfortunately, an overly
elevated medial brow will create a chronically surprised look,
while an overly elevated lateral brow will create an angry look
– both of which are difficult situations to correct.
As discussed earlier, the aesthetics of the upper lid–brow
junction encompasses many variables other than eyebrow
shape and height. The patient who is a candidate for brow lift
surgery may also benefit from simultaneous procedures such
as blepharoplasty, periorbital fat grafting, or eyelid ptosis
repair (Fig. 7.33). The key step in determining the correct
constellation of surgical procedures is to make the correct
aesthetic diagnosis at the outset.
Fig. 7.33 appears online only.
Lastly, every surgeon will have greater comfort with some
procedures compared with others. It is incumbent on surgeons
to critically analyze their own results in order to give patients
a realistic idea of what can be expected.
Complications
In addition to the aesthetic issues mentioned above, surgical
complications of brow rejuvenation include scar alopecia,
hematomas, infections, contour deformities, and nerve
damage.
Localized alopecia is caused when hair follicles are
damaged by surgical incisions, electrocautery, or wound
tension. Hair loss may be temporary, but if permanent, can be
treated with simple scar excision or hair grafting (Fig. 7.34).
Transpalpebral browpexy
During upper lid blepharoplasty, the ptotic lateral brow can
be addressed through the same upper lid incision.57,58 The
lateral portion of the superior orbital rim is easily exposed,
and dissection proceeds superiorly over the frontal bone,
superficial to the periosteum. Dissection should continue for
2–4 cm above the orbital rim, or at least 1 cm above the level
of planned fixation. Several sutures are then used to tether the
mobilized brow in a more superior position, fixating the
underside of the orbicularis to the periosteum. Alternative
methods of fixation to bone can also be used. Overly tight
sutures must be avoided because of suture dimpling in the
eyebrow. A more modest pexy is achieved if the cut edge of
orbicularis oculi is simply sutured to the orbital rim, with no
superior dissection at all.59 Advantages of transpalpebral
browpexy are the ease of the procedure and a hidden scar. The
principle disadvantage is the limited effect achieved and
questionable longevity.
Suture suspension browpexy
A number of methods have been developed to elevate the
brow only using sutures, with no dissection at all. Methods
include barbed sutures or suture loops that are placed blindly
through subcutaneous tunnels. The obvious advantage of
these methods is extreme simplicity and relative safety, while
the principle drawback is a concern about the degree and
longevity of their effect. Nevertheless, proponents feel that the
results, while modest, are justifiable because of the minimal
surgical invasion required.60,61
Fig. 7.31  A 74-year-old man shown (A) before and (B) 8 months following a
direct brow lift with excision of full-thickness skin in a transverse brow crease. In
addition, the upper orbicularis had been sutured onto the frontalis muscle in a more
superior position.
A
B

285.e1
Outcomes
Fig. 7.33  A middle-aged woman who has unilateral brow ptosis, vertical orbital
dystocia, and fat atrophy in the upper lid sulcus. She is shown (A) before and (B)
12 months after a right-sided endoscopic brow lift, bilateral upper sulcus fat
grafting, and excisional upper eyelid blepharoplasty.
A
B

286
SECTION I
CHAPTER 7 • Forehead rejuvenation
Fig. 7.34  Scar alopecia after coronal brow lift.
Fig. 7.35  Temporary neurapraxia of left temporal branch after coronal brow lift.
Fig. 7.32  Young woman with congenitally downturned lateral eyebrows. She is
shown (A) before and (B) 6 months after a modified lateral brow lift.
A
B
Hematomas are uncommon and will resolve if they are
small; however, a significant hematoma should be treated
with surgical drainage. Infections are rare, consistently
reported at less than 1%, and treated with wound care and
appropriate antibiotics.18 Contour deformities can occur in
areas of muscle excision; these problems are ideally prevented
by the intraoperative utilization of filling material such as fat
or temporal fascia. If identified late, similar tissue can be
added at a separate procedure.
Sensory nerve damage is a common problem and is uni­
versal with some types of procedures. With coronal incisions,
all posterior-running sensory nerves are routinely transected.
Initially, the resulting scalp denervation is profound and will
extend to the vertex, but will gradually recover, often continu­
ing to improve over many years. With limited incisions, such
as endoscopic ports or lateral brow lifts, sensory change is less
of an issue, but sensory nerves may still be traumatized due
to traction, cautery, or instrumentation. The expectation is that
normal sensation will likely return over time. With frown
muscle ablation, temporary neurapraxia is normal, with
sensory return typically appearing by 2–3 weeks. Similarly,
temporary neurapraxia of the supraorbital nerve is very
common after a deep surgical release of the supraorbital rim.
The only motor nerve of concern in the forehead is the
temporal branch of the facial nerve, and damage to this nerve
is the most worrisome local complication in brow lift surgery.
Temporary neurapraxias are relatively common; fortunately,
permanent damage to the temporal branch is rare. Should a
neurapraxia develop, watchful waiting is a must (Fig. 7.35).
Possible interventions are described below.
Secondary procedures
The most common reason for revision surgery after brow
surgery is to correct aesthetic deformities. One common
version of this problem is the loss of the aesthetic effect that
is initially seen after brow lift surgery. This situation can often
be resolved to the patient’s satisfaction with a conservative
upper lid blepharoplasty. However, if the loss of effect is
significant, a repeat brow lift procedure may be necessary,
preferably using a different technique with a different dissec­
tion plane and a different method of fixation.
When overly aggressive brow lift surgery has been done,
the most frequent result is over-elevation of the medial brow
(Fig. 7.36). If it is minimal, botulinum toxin injection in the
central frontalis will help attenuate the problem. Alternatively,

287
Secondary procedures
if the condition is pronounced, the medial brow can be surgi­
cally lowered. This requires a full release of the scalp’s attach­
ment to the underlying skull, lowering of the medial brow,
and bone anchoring to the orbital rim.50 Successful reversal of
an overdone brow lift is typically more difficult to achieve
than the original brow lift itself.
Another common variation of unfavorable brow shape
occurs when the medial brow has been appropriately elevated,
Fig. 7.36  Over-elevated medial brow after endoscopic brow lift.
Bonus images for this chapter can be found online at

Fig. 7.33 A middle-aged woman who has unilateral brow ptosis, vertical orbital
dystocia, and fat atrophy in the upper lid sulcus. She is shown (A) before and
(B) 12 months after a right-sided endoscopic brow lift, bilateral upper sulcus
fat grafting, and excisional upper eyelid blepharoplasty.
but the lateral brow remains unelevated, causing a laterally
downturned appearance. Such a scenario can be treated with
an isolated lateral brow lift.
Fortunately, true complications are uncommon and minor
issues, such as scar alopecia and contour deformities in the
glabella, are treatable with simple procedures.
In the case of a temporal branch palsy that does not improve
with time, treatment options include the use of botulinum
toxin to the frontalis on the normal side, or alternatively, a
repeat brow lift on the affected side.
Lastly, like any surgery for age-related change, the surgical
effects of a brow lift may become attenuated over time. In
order to maintain a longstanding effect, revision surgery may
be necessary.
1. Paul MD. The evolution of the brow lift in aesthetic plastic surgery.
Plast Reconstr Surg. 2001;108:1409–1424. In this paper, the author
thoroughly reviews the published history of brow lift surgery, from 1919
to 2001.
14. Knize DM. Limited incision foreheadplasty. Plast Reconstr Surg.
1999;103:271–284.
16. Warren RJ. The modified lateral brow lift. Aesthet Surg J. 2009;29:
158–166.
20. Guyuron B, Kopal C, Michelow BJ. Stability after endoscopic
forehead surgery using single-point fascia fixation. Plast Reconstr
Surg. 2005;116:1988–1994.
22. Knize DM. An anatomically based study of the mechanism of
eyebrow ptosis. Plast Reconstr Surg. 1996;97:1321–1333. In this paper,
the author presents the results of careful anatomic dissections to delineate
the fascial structures that govern eyebrow stability. Surgical implications
are described in the second paper in the same journal.
24. Moss CJ, Mendelson BC, Taylor I. Surgical anatomy of the
ligamentous attachments in the temple and periorbital regions. Plast
Reconstr Surg. 2000;105:1475–1490. The authors describe a different way
of describing fascial structures surrounding the orbit and creating
structural layers in the temple. A number of anatomic terms are
introduced for the first time.
26. Knize DM. Galea aponeurotica and temporal fascias. In: Knize DM,
ed. Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia
PA: Lippincott Williams & Wilkins; 2001:45. This text thoroughly
presents the anatomy of the temporal fossa, the forehead and the soft
tissues that relate to the eyebrows. Knize combines several anatomical
studies to summarize this anatomy, while several additional authors
contribute to the technique portions of the book.
36. Matros E, Garcia JA, Yaremchuk MJ. Changes in eyebrow shape
and position with aging. Plast Reconstr Surg. 2009;124:1296–1301.
41. Knize DM. Muscles that act on glabellar skin: a closer look. Plast
Reconstr Surg. 2000;105:350–361.
45. Gunter J, Antrobus S. Aesthetic analysis of the eyebrows. Plast
Reconstr Surg. 1997;99:1808–1816. The authors analyze the features of
periorbital attractiveness. They conclude that eyebrow aesthetics must be
considered in concert with the entire periorbital area, including the
eyelids. They describe novel ways to analyze eyes for attractiveness and
identify eight features of attractive eyes.
Access the complete reference list online at

287.e1
References
References
1. Paul MD. The evolution of the brow lift in aesthetic plastic surgery.
Plast Reconstr Surg. 2001;108:1409–1424. In this paper, the author
thoroughly reviews the published history of brow lift surgery, from 1919
to 2001.
2. Passot R. La chururgie esthetique dew rides du visage. Presse Med.
1919;27:258–260.
3. Hunt HL. Plastic Surgery of the Head, Face, and Neck. Philadelphia,
PA: Lea & Febiger; 1926.
4. Lexer E. Die Gesamte Wiederherstellungs-Chirurgie. Vols. 1 and 2.
Leipzig: Jahann Ambrosius Barth; 1931.
5. Claoue C. La ridectomie cervico-faciale par accrochage parieto-
temporo-occipital et resection cutanee. Bull Acad Med (Paris).
1933;109:257–265.
6. Gonzalez-Ulloa M. Facial wrinkles: integral elimination. Plast
Reconstr Surg. 1962;29:658–673.
7. Vinas JC. Plan general de la ritidoplastia y zona tabu. Transactions of the
4th Brazilian Congress on Plastic Surgery, Porto Alegre, October 5–8,
1965:32.
8. Vinas JC, Caviglia C, Cortinas JL. Forehead rhytidoplasty and brow
lifting. Plast Reconstr Surg. 1976;57:445–454.
9. Papillon J, Perras C, Tirkanits B. A comparative analysis of forehead lift
techniques. Presented at the Annual Meeting of the American Society
for Aesthetic Plastic Surgery, Boston, 1984.
10. Paul MD. The surgical management of upper eyelid hooding.
Aesthetic Plast Surg. 1989;13:183–187.
11. Isse NG. Endoscopic forehead lift. Presented at the Annual Meeting of
the Los Angeles County Society of Plastic Surgeons, Los Angeles,
September 12, 1992.
12. Vasconez LO. The use of the endoscope in brow lifting. A video
presentation at the Annual Meeting of the American Society of
Plastic and Reconstructive Surgeons, Washington, DC, 1992.
13. Chajchir A. Endoscopia en cirugia plastica y estetica. In: Gonzalez
Montaner LJ, Huriado Hoyo E, Altman R, et al., eds. El Libro de Oro
en Homenaje al Doctor Carlos Reussi. Buenos Aires: Associacion
Medica Argentina; 1993:74.
14. Knize DM. Limited incision foreheadplasty. Plast Reconstr Surg.
1999;103:271–284.
15. Chiu ES, Baker DC. Endoscopic brow lift: a retrospective review of
628 consecutive cases over 5 years. Plast Reconstr Surg.
2003;112:628–633.
16. Warren RJ. The modified lateral brow lift. Aesthet Surg J.
2009;29:158–166.
17. Troilius C. Subperiosteal brow lifts without fixation. Plast Reconstr
Surg. 2004;114:1595–1603.
18. Jones BM, Grover R. Endoscopic brow lift: a personal review of 538
patients and comparison of fixation techniques. Plast Reconstr Surg.
2004;113:1242–1250.
19. Swift RW, Nolan WB, Aston SJ, et al. Endoscopic brow lift: objective
results after 1 year. Aesthet Surg J. 1999;19:287–292.
20. Guyuron B, Kopal C, Michelow BJ. Stability after endoscopic
forehead surgery using single-point fascia fixation. Plast Reconstr
Surg. 2005;116:1988–1994.
21. Graf RM, Tolazzi ARD, Mansur AEC, et al. Endoscopic periosteal
brow lift: evaluation and follow-up of eyebrow height. Plast
Reconstr Surg. 2008;121:609–616.
22. Knize DM. An anatomically based study of the mechanism of
eyebrow ptosis. Plast Reconstr Surg. 1996;97:1321–1333. In this paper,
the author presents the results of careful anatomic dissections to delineate
the fascial structures that govern eyebrow stability. Surgical implications
are described in the second paper in the same journal.
23. Knize DM. Limited-incision forehead lift for eyebrow elevation to
enhance upper blepharoplasty. Plast Reconstr Surg.
1996;97:1334–1342.
24. Moss CJ, Mendelson BC, Taylor I. Surgical anatomy of the
ligamentous attachments in the temple and periorbital regions. Plast
Reconstr Surg. 2000;105:1475–1490. The authors describe a different way
of describing fascial structures surrounding the orbit and creating
structural layers in the temple. A number of anatomic terms are
introduced for the first time.
25. Isse N. Endoscopic anatomy of the forehead and temporal fossa. In:
Knize DM, ed. Forehead and Temporal Fossa: Anatomy and Technique.
Philadelphia, PA: Lippincott Williams & Wilkins; 2001:73.
26. Knize DM. Galea aponeurotica and temporal fascias. In: Knize DM,
ed. Forehead and Temporal Fossa: Anatomy and Technique. Philadelphia
PA: Lippincott Williams & Wilkins; 2001:45. This text thoroughly
presents the anatomy of the temporal fossa, the forehead and the soft
tissues that relate to the eyebrows. Knize combines several anatomical
studies to summarize this anatomy, while several additional authors
contribute to the technique portions of the book.
27. Janis JE, Ghavami A, Lemmon JA, et al. Anatomy of the corrugator
supercilii muscle: part I. Corrugator topography. Plast Reconstr Surg.
2007;120:1647–1653.
28. Beer GM, Putz R, Mager K, et al. Variations of the frontal exit of the
supraorbital nerve: an anatomic study. Plast Reconstr Surg.
1998;102:334–341.
29. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg.
1995;96:564–569.
30. Furnas DW. Landmarks for the trunk and the temporofacial
division of the facial nerve. Br J Surg. 1965;52:694–696.
31. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the
importance of its variation in face lifting. Plast Reconstr Surg.
1966;38:352–356.
32. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy of the
frontal branch of the facial nerve: the significance of the temporal
fat pad. Plast Reconstr Surg. 1989;83:265–271.
33. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of the facial
nerve: how reliably can we predict its path? Plast Reconstr Surg.
1997;99:1224–1233.
34. Agarwal CA, Mendenhall MS, Foreman KB, et al. The course of the
frontal branch of the facial nerve in relation to fascial planes: an
anatomic study. Plast Reconstr Surg. 2010;125:532–537.
35. Van Den Bosch W, Leenders I, Mukler P. Topographic anatomy of
the eyelids and the effects of sex and age. Br J Ophthamol.
1999;83:348–352.
36. Matros E, Garcia JA, Yaremchuk MJ. Changes in eyebrow shape
and position with aging. Plast Reconstr Surg. 2009;124:1296–1301.
37. Lambros V. Observations on periorbital and midface aging. Plast
Reconstr Surg. 2007;120:1367–1376.
38. Pessa JE, Chen Y. Curve analysis of the aging orbital aperture. Plast
Reconstr Surg. 2002;109:751–755.
39. Kahn DM, Shaw RB. Aging of the bony orbit: a three-dimensional
computed tomographic study. Aesthet Surg J. 2008;28:258–264.
40. Lemke BN, Stasior OG. The anatomy of eyebrow optosis. Arch
Ophthalmol. 1982;100:981–986.
41. Knize DM. Muscles that act on glabellar skin: a closer look. Plast
Reconstr Surg. 2000;105:350–361.
42. Flowers RS, Duval C. Blepharoplasty and periorbital aesthetic
surgery. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb and Smith’s
Plastic Surgery. 5th ed. Philadelphia, PA: Lippincott-Raven; 1997:612.
43. Knoll BI, Attkiss KJ, Persing JA. The influence of forehead, brow,
and periorbital aesthetics of perceived expression in the youthful
face. Plast Reconstr Surg. 2008;121:1793–1802.
44. Warren RJ. Endoscopic brow lift: five-portal approach. In: Nahai F,
Saltz R, eds. Endoscopic Plastic Surgery. 2nd ed. St Louis, MO:
Quality Medical Publishing; 2008:212.
45. Gunter J, Antrobus S. Aesthetic analysis of the eyebrows. Plast
Reconstr Surg. 1997;99:1808–1816. The authors analyze the features of
periorbital attractiveness. They conclude that eyebrow aesthetics must be
considered in concert with the entire periorbital area, including the
eyelids. They describe novel ways to analyze eyes for attractiveness and
identify eight features of attractive eyes.
46. Camirand A, Doucet J. A comparison between parallel hairline
incisions and perpendicular incisions when performing a face lift.
Plast Reconstr Surg. 1997;99:10–15.
47. Miller TA, Rudkin G, Honig J, et al. Lateral subcutaneous brow lift
and interbrow muscle resection: clinical experience and anatomic
studies. Plast Reconstr Surg. 2000;105:1120–1127.