28
Thanks to endoscopic technology, we are now able to lift the forehead through three to five incisions of 1–2 cm length. The light source and the microcamera have a diameter of 4 or even 2.7 mm and on monitor we see anatomical structures magnified 10 times.
Endofrontal lift is almost always associated with temporal lift, which can also be performed isolated.
Temporal excision should be made in a prolonged line from the nostril to the lateral canthus.
The medial part of the forehead can be reached through a T-incision. Caudal preparation with a less or more curved rasparatorium follows in the sub- periostal layer, backwards on the scalp in the subga- leal layer. After weakening of frontal muscle, the oc- cipital muscle produces more tension through the galea. Proceeding forward and caudal with the raspa- ratorium, we reach the level of the eyebrows. Here we need a horizontal complete uninterrupted section of the periosteum from the left end of left eyebrow to the right end of the right eyebrow. This is easy to perform with the rasparatorium turned opposite to the bone curvature.
Care should be taken of the nn. supratrochleares, which arise 17 mm lateral of the midline, and the nn.
supraorbitales, which are 27 mm away from the mid- line, as Lopez from New York found after cadaveric studies. This distances are constant. Knowing this, The upper third of the face is limited by the hairline
above and the eyebrows below. The most powerful muscles, innervated by fronto-temporal branches of n. facialis, are m. frontalis and mm. corrugatores supercilii. The hyperaction of frontalis ingraves the horizontal “wrinkles of concentration” and corruga- tors produce vertical glabellar “wrinkles of anger” or
“worry wrinkles”.
The superficial wrinkles can be treated by peeling (mechanical dermabrasion, chemical abrasion, laser abrasion, or by radiofrequency treatment) through permanent or nonpermanent skin-fillers or by Botox, the huge popularity of which some 3–4 years ago has diminished for two reasons. First, its measurable ef- fect lasts only 8 weeks; second, faces with a china sur- face have no mimetic expressions. Autologous fat transfer into the lower two thirds of the face is very successful but is less effective in the forehead, proba- bly because of strong tension of the skin in this re- gion.
In the last 10 years I only twice did a classic fore- head lift with preferably ciliar incisions. The majority of foreheads were treated by endoscopic forehead lift.
If two or more forehead wrinkles are very deep, they can be excised, well adapted, and sutured in two layers very carefully. After a while, the scar will look like a single wrinkle.
Forehead
Dimitrije E. Panfilov
Fig. 28.1. Endoscopic forehead lift
per stitching plaster to keep the eyebrows elevated, starting from the midline. Thereafter the adhesive bandages are applied in the same manner and should remain for 8 days. Removal should be done starting from the eyebrows and pulling backwards.
Bibliography
Please see the general bibliography at the end of this book.
Fig. 28.2. a Chemical peeling. b Laser peeling. c Botox
Fig. 28.3. a Zigzag incision allows an inconspicuous suture line. b Exposed frontal bone and the m. procerus and mm. corrugators supercilii. c Suture line at the end of the surgery. The same patient d before and e 2 weeks after surgery
Fig. 28.4. a Two deep horizontal wrinkles. b Excision with radiofrequency treatment without any bleeding. c Ten days postoperatively; the scar will soon look like a single wrinkle
Fig. 28.5. a Endoscopic microcamera with a cold-light source.
b Sitting above the head of the patient, looking at the procerus muscle fibres at the nasal root on the monitor. c Nonbleeding
surgery with minimal scaring and minimal complications.
d Four or five well-chosen instruments will do the job
Fig. 28.6. a Superficial temporal fascia incised, prepared and tightened backwards to be sutured at the deep temporal fascia.
b Semilunar area of hairy skin removed and sutured
Fig. 28.7. a Dermographic markings of the nn. supratrochleares medial and nn. supraorbitales lateral (green vertical lines).
Wrinkles are marked in blue. b T-incision: after preparation,
the midpart of the frontal skin should be pulled backwards, the lower T wings cut off, and sutured in a V manner: T-V- plasty
Fig. 28.9. a Vertical glabellar, horizontal wrinkles and deep eyebrow position. b Removing of wrinkles and opening of the eyes through elevation of the eyebrows – “nonscrewing method”
Fig. 28.8. a Fibrin glue applied subperiostally. b Adhesive bandages pulled backwards and stapled parieto-occipitally.
c Below the adhesive bandages, vertical pull of the eyebrows through suture strips
