Facial mimics and the coronal brow lift

Postsurgical predictive theoretical thickness (PTT) of frontal sinus anterior wall as key point in surgical management of frontal bossing: proposal of a new analytic method

BACKGROUND

Frontal bossing is a malformation characterized by peculiar prominent forehead, and commonly it can be associated with cranial synostosis and endocrine disorder; however, nonsyndromic conditions are described as well.Literature controversies on proper frontal bossing surgical treatment showed evidence of 2 main surgical procedures: frontal bone reshaping and bone en bloc mobilization.A decision-making criterion between these 2 techniques has never been described in literature.

METHODS

In this paper, the authors introduce their brand-new analytic method for decision-making between bur shaping and en bloc mobilization in frontal bossing treatment, and describe a successful case of a nonsyndromic frontal bossing patient, treated with their unconventional surgical technique.

RESULTS

Our analytic method indicated that bur shaping was not indicated in this particular case: aggressive remodeling of excessive thin wall could lead to sinus perforation, which could turn into unsatisfied aesthetic and functional outcome.So we planned for a bilateral orbitofrontal en bloc reposition, followed by internal rigid fixation. No postoperative complications occurred. Postoperative CT scan revealed good bone repositioning and recovery.

CONCLUSIONS

The authors explained their analytic method based on careful presurgical CT-scan measurements for decision-making between bur shaping and en bloc mobilization.

Surgical correction of aesthetically deformed eyebrows using local transposition flaps

BACKGROUND

Eyebrow positions differ in many ways. They vary in shape, thickness, length, and distance between the eyebrows, making the face more or less harmonious. When a large distance exists between the eyebrows and the medial brow is slanting downward, the glabellar area is larger, giving the face an awkward appearance.

METHODS

To correct this deformity, the authors propose using two Z-plasties to allow transposition of flaps in the region of the medial brow. The Z-shaped flap is outlined at the medial third of the brow, in the glabellar region, with the eyebrow centered in the lower portion of the "Z" and the hairless skin in the upper portion. The flaps then are transposed and sutured.

RESULTS

Transposition of the flaps, lifting the brow flap to the glabellar region, results in horizontal positioning of the medial and central third of the eyebrow.

CONCLUSION

The proposed transpositioning of "Z" flaps in this region corrects this type of deformity of the medial and central portions of the eyebrows, with an aesthetically satisfactory result.

Attractiveness of eyebrow position and shape in females depends on the age of the beholder

BACKGROUND

Great diversity exists among individuals with respect to eyebrow position and shape, and the notion of an "ideal" eyebrow has changed quite significantly over the past several decades.

METHODS

This study compared three different variations of eyebrows. One variation was the arched eyebrow with the maximum height in the middle. The other two variations had their maximum height in the lateral third, but differed in their position (high vs low). For each of the seven female portraits presented, three variations were generated using morphing software. A total of 357 subjects 12 to 85 years of age compared these variations and ranked each woman individually with respect to perceived attractiveness.

RESULTS

The data show that the preference for a specific eyebrow shape depends on a person's age. Young subjects up to 30 years of age preferred eyebrows in a lower position, and ruled out arched eyebrows. Subjects older than 50 years stated exactly the opposite preference.

CONCLUSION

First, there is not one single beauty ideal for eyebrows, but at least three. The ideal a person prefers depends on his or her age. Second, because trends are generally introduced by young people and not by older individuals, and the young tend to prefer eyebrows in a lower position, it seems plausible to assume that the trend currently appears to be moving away from arched eyebrows toward lower positioned eyebrows with a maximum height in the lateral third.

The Importance of the Retaining Ligamentous Attachments of the Forehead for Selective Eyebrow Reshaping and Forehead Rejuvenation

BACKGROUND

Forehead rejuvenation procedures can lead to excessive elevation of the medial brow, resulting in the "surprised look." Differential treatment of the medial and lateral brow allows more precise positioning. The purpose of this study was to determine whether retaining structures exist in the forehead that would permit this differential elevation.

METHODS

Anatomical dissections were performed in the foreheads of 12 cadavers. Multiplanar dissections at the subperiosteal, subgaleal, and subcutaneous levels were performed on eight hemiforeheads. Clinical correlation for these findings was obtained during endoscopic and open brow-lift surgery.

RESULTS

Four retaining structures of the brow were identified: three medial and one lateral. The superomedial attachment begins 13 mm from the midline and 10.8 mm above the supraorbital rim. The superolateral attachment begins 23 mm from the midline and 10.3 mm above the supraorbital rim. The inferomedial attachment begins 12.6 mm from the midline at the level of the supraorbital rim, just medial to the supraorbital nerve. These three structures were found to control the position of the medial brow. Laterally, brow position was controlled by a broad ligamentous attachment extending across the lateral aspect of the supraorbital rim.

CONCLUSIONS

Medial retaining structures have been found to extend from the cranium into the forehead musculature. Release of the lateral broad ligamentous attachment was performed, followed by selective preservation of medial retaining structures. With this approach, we were able to gain control of the position of the medial brow and prevent overelevation and lateral spreading.

Classification of Crow???s Feet Patterns among Caucasian Women: The Key to Individualizing Treatment

One of the most common complaints of aging patients is the appearance of crow's feet lines in the lateral canthal region. Many different treatment methods, including chemical peels, surgical procedures, filler material injections, botulinum toxin injections, and laser resurfacing, have been used for effacement of these lines among aging patients and patients with sun damage. Despite the fact that many scientific articles have been written regarding the treatment of crow's feet lines, the actual patterns of these lines have not been adequately studied or classified. Several different patterns of animation in this area have been observed. These different patterns and their frequencies are described. All crow's feet patterns are not the same, and it follows that treatment of different patterns of crow's feet lines should be adapted to the particular patterns.

In pursuit of optimal rejuvenation of the forehead: endoscopic brow lift with simultaneous carbon dioxide laser resurfacing

Coronal foreheadplasty has long been the traditional method of improving the aesthetic appearance of the forehead, permitting not only repositioning of ptotic tissues but also direct access for modification of the "frown" muscles. However, it was only moderately successful in eliminating vertical corrugator lines or deeply etched transverse wrinkles. The recent advent of the endoscopic brow lift has permitted us to minimize the dysesthesias associated with the coronal approach by making the incisions shorter and radially oriented and by being more precise in the muscle resection. Nonetheless, endoscopic brow lift gives no further improvement in persistent deep vertical and transverse wrinkles. Carbon dioxide laser resurfacing can improve the existing wrinkles but does not eliminate the muscular cause of forehead wrinkles. It seemed reasonable that combining these techniques might yield better results than either procedure alone. To evaluate this possibility, 30 patients with simultaneous endoscopic brow lift and carbon dioxide resurfacing were compared with 24 patients having laser resurfacing only and with 26 patients who had traditional coronal foreheadplasty. Both foreheadplasty groups had corrugator resection. All patients were evaluated at least 4 to 6 months postoperatively. Ratings were based on the percent of wrinkles removed, both vertical and transverse. The ratings were performed with predetermined criteria by a surgeon not involved with the operative procedures nor after care. A rating of "excellent" (> or = 95 percent reduction in wrinkles) was obtained in 50 percent of coronal foreheadplasties; 41.7 percent of carbon dioxide resurfacing alone and 80 percent of endobrow lifts with carbon dioxide laser resurfacing. There was no vascular compromise from this latter combination of procedures, no hypertrophic scars, and no impairment of healing. We conclude that endoscopic brow lift with carbon dioxide laser resurfacing is a safe and perhaps more effective means of aesthetic rejuvenation of the forehead.

Criteria for the forehead lift

We have developed clinically useful measurements to assist the surgeon in deciding when to do the forehead lift and where to place the incision. Also, we have reviewed our experience over the past decade and discuss the four categories and applications of forehead lifts. We use three indications for forehead lift: ptosis, creases, and previous facelift (PCP). There are four basic surgical techniques applicable to the upper face: (1) direct browlift, (2) midforehead crease incision, (3) prehairline incision, and (4) posthairline incision. We determined more accurate guidelines from measurements taken on 50 volunteers, as well as patients seeking a facelift. The line of measurement in a vertical plane extends from the midpupil to the top of the eyebrow and up to the hairline. We have found that the normal distance from the midpupil to the upper edge of the eyebrow on average is 2.5 cm and that the distance from the upper edge of the eyebrow to the hairline is approximately 5 cm on average. If the distance from pupil to brow is less than 2.5 cm, then the patient may benefit from a forehead lift. If the distance from brow to hairline is less than 5 cm, then we use a posthairline incision in females. If this same distance is greater than 5 cm in females, we advise the prehairline incision. In male patients we strongly consider direct crease incision. The direct browlift is reserved for minimal ptosis, asymmetry, or patients who wish a minimal procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Esthetic evaluation and treatment of the upper one third of the face

Esthetic assessment and treatment planning for the upper one third of the face is reviewed. The importance of esthetic anatomy in evaluation of the face as a whole is stressed. Three basic approaches to the forehead and brow lift are discussed, with particular regard to patient selection, indications, and contraindications. Clinical cases are presented as examples.