Title: an Alternative Approach to Browlift Fixation

Alternative Approach to Browlift Fixation: Temporoparietalis fascia, Galeal and Periostal Imbrication.

Fernando Tuccillo, MD; Gabriel Repetti, MD; Patricio Jacovella, MD, PhD; Oscar Zimman, MD, PhD

Objectives and Purpose: Brow elevation is one of the goals of surgical rejuvenating procedures. An extended dissection of the frontotemporal flap, the release of links between galea-periosteum and the orbital rim, and changes in the functional balance between the frontal and depressor muscles by means of myotomies or myectomies are the required steps to attain this goal1. These maneuvers may be done through an open, endoscopic or combined surgical approach. However the flap fixation method is a key factor to achieve a lasting result2. We evaluate the results of a temporal suspension-fixation technique by means of TPF-galeal -periostal flaps imbrication through an open or endoscopically assisted approach.

Methods and Materials: Between October 1997 – October 2002, a total of 32 female patients ages between 44 and 72 years were operated under local anesthesia and sedation. The follow-up was 8 to 24 months, average of 15 months. In 23 cases, the frontotemporal lift was associated with a cervicofacial lift through separate incisions, in 19 with an upper-lower blepharoplasty done at the same time or subsequently. The open approach was used in 26 and a combined approach with endoscopic assistance and reduced temporal incisions was done in 6 cases.

Technique: bitemporal 3-4cm incisions were placed 2 cm behind and parallel to the hairline. Additional paramedian short incisions, perpendicular and 1cm behind the hairline were also planned if there was a need to lift the medial brow, and for ease of subperiostal dissection. Once divided and dissected off the scalp the lateral TPF and the medial galea-periosteum, the frontotemporal flap was dissected through a combined subperiostal and sub TPF plane, dividing the fusion line, releasing and dividing the orbital rim periosteum lateral to the supraorbital notch and the orbital ligament3. A superior orbicularis myotomy was done at the same time4. Once obtained a free of tension flap, suspension - fixation was done by means of TPF- Galeal- Periostal flaps imbrication (figs.1 and 2), advanced according the desired elevation and fixed to the deep temporal fascia with irresorbable mattress sutures. Very conservative resections of scalp rolls were done avoiding any tension, based on the anterior flap.

Results: Pre and postoperative measures were taken between the lower hairline of the eyebrow and the medial and lateral canthal angles (fig.4) Lateral brow elevation ranged from 3 to 7mm, average 5mm. A lasting result was observed during the follow-up period(fig.3), with partial relapse in 5 cases. Complications consisted of 2 transient frontal paresias, remarkable periorbital bruising in 4 cases, transient decrease in temporal hair density in 6 (6 to 8 months). No permanent alopecia was observed.

Conclusions : Brow elevation is an essential feature for a pleasing esthetic result in the periorbital region. The best results are those in association with a blepharoplasty. We consider this suspension –fixation technique as predictable, low cost because does not need the use of hardware devices and feasible when an endoscope is not readily available. The results are lasting, and the incidence of sequelae and complications acceptable.

Fig.1.(Left) Operative technique: bite on TPF-G-P posterior flap. (Right) Operative technique: bite on DTF.

Fig.2. (Left) Operative technique: needle takes the anterior TPF-G-P_ flap released from the scalp from its undersurface, and then DTF and posterior TPF-G-P flap. (Right) Operative technique: tightening the mattress suture, anterior TPF-G-P flap advances over posterior TPF-G-P flap tacking both to DTF. The knot remains between the two layers of TPF-G-P. No tension is exerted on scalp.

Fig.3.(Left) Age 62, preoperative oblique view. (Right) One year postoperative view, after browlift with TPF-G-P imbrication and upper and lower blepharoplasty.

Fig.4.(Left) Same patient, close up preoperative view with measurements in reference to canthal angles. (Right) close up, one year postoperative view.

References

1.Rohrich, R.J, Beran, S.J., : Evolving fixation methods in endoscopically assisted forehead rejuvenation: controversies and rationale. Plast Reconstr Surg, 100(6):1575-1582, 1997.

2. Guyuron, B., Michelow, B., : Refinements in endoscopic forehead rejuvenation. Plast Reconstr Surg, 100(1): 154-160, 1997.

3. Knize, D. M., : Limited incision forehead lift for eyebrow elevation to enhance upper blepharoplasty. Plast Reconstr Surg 97:1334, 1996.

4. Isse, N.G., : Endoscopic forehead lift: Evolution and update. Clin Plast Surg 22: 661, 1995.