Rejuvenation of the Aging Upper Third

of the Face
Paul Presti, M.D.,
1
Haresh Yalamanchili, M.D.,
1
and Carlo P. Honrado, M.D.
2
ABSTRACT
Age-related changes to the upper third of the face manifest, typically, as brow
ptosis and the development of deep skin furrows. Depression of the brow evolves as gravity
and the action of the corrugator supercilli, procerus, and orbicularis draw on the
progressively inelastic forehead skin. Facial mimetic muscle action reveals itself over
time via the development of deep forehead rhytids. Facial plastic surgeons have at their
disposal several effective surgical, and recently, medical interventions to address these
changes. Each technique has merits and suitable applications. This review examines the
history of rejuvenation of the upper face, details the pertinent treatment modalities, and
evaluates the context in which each is applicable.
KEYWORDS: Facial rejuvenation, browlift, forehead lift, endoscopic
An individuals visage undergoes dramatic mor-
phological changes with time. These changes bear the
unfortunate consequence of aesthetically detracting fa-
cial rhytids and ptosis of the skin. Such manifestations of
age are particularly noticeable on the forehead and brow.
The facial plastic surgeon has within his or her arma-
mentarium a multitude of surgical and, more recently,
medical interventions to address the concerns pertinent
to the upper third of the face. This article serves to
review the options for treating the aging forehead and
dene, in greater detail, the more prominent techniques
utilized at present.
Two distinct deformities relate to the aging fore-
head: brow ptosis and rhytids (furrows). Both are a
consequence of time-related elastolysis and collagen
rearrangement. Aged skin has a notable loss of ground
substance with subsequent thinning of the dermis. The
culmination of these changes makes skin less elastic and
more prone to wrinkling. The cumulative effects of
gravity on this less elastic skin and decreased subcuta-
neous tissue evolve into brow ptosis. The development of
deep forehead furrows arises from the repeated action of
facial mimetic muscles on the overlying skin.
1
Horizontal forehead furrows relate to the con-
traction of the underlying frontalis muscle during eye-
brow elevation. The procerus muscle is a continuation of
the frontalis muscle as it insinuates into the interbrow
space. Contraction of this pyramidal-shaped muscle
creates horizontal rhytids overlying the radix. Similarly,
the action of the corrugator supercilli muscle causes
inferomedial contraction of the interspace between the
brows and results in deep glabellar vertical furrows.
2
The
corrugator and procerus, along with the orbicularis
muscle, serve to depress the brow. Critical to the
management of the aging forehead is the interplay
between the antagonistic action of these brow depressors
and the sole brow elevator, the frontalis muscle.
To attempt rejuvenation of the aging brow,
one must have a fundamental understanding of the
ideal brow position. In men, typically the brow over-
lies the orbital rim without a pronounced arch. In
women, classical descriptions of the peak of the brow
1
Department of OtolaryngologyHead and Neck Surgery, New York
Eye and Ear Inrmary, New York, New York;
2
Department of
OtolaryngologyHead and Neck Surgery, New York Medical Col-
lege, Valhalla, New York.
Address for correspondence and reprint requests: Carlo P. Hon-
rado, M.D., ENT Faculty Practice, LLP, 1058 Saw Mill River Road,
Ardsley, NY 10502.
Modern Surgery of the Aging Face; Guest Editors, Adam T. Ross,
M.D., Jeffrey B. Wise, M.D.
Facial Plast Surg 2006;22:9196. Copyright # 2006 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI 10.1055/s-2006-947714. ISSN 0736-6825.
91
demonstrate that it is situated in a line drawn verti-
cally and tangent to the lateral limbus of the eye.
Recently, however, brow positioning with its peak
lying above the lateral canthus has become quite
popular. The medial brow takes on a club shape that
incrementally tapers as it extends laterally to a point
on the same horizontal plane as its medial position.
The lateral brow approximates a line drawn from the
alar groove through the lateral canthus, and the
medial brow approximates a vertical line perpendicular
to the nasal ala. In a series of 596 patients, brow
position was evaluated, demonstrating the mean posi-
tion of the male brow to be 20.8 mm (range
11 to 27 mm) from midpupil to brow, and in women
to be 21.4 mm (range 11 to 32 mm).
3
Similarly,
McKinney et al reported that the normal distance
from the midpupil to the upper limit of the brow is
2.5 cm in adults.
4
The relationship of the brow,
medial orbital rim, and nasal bone in women should
conform to create a Y-shaped conguration, whereas
men tend toward a T-shaped conguration of these
structures.
5
Certainly, the described classical aesthetics
of the upper forehead are recommendations that have
both opponents and proponent. Ultimately the pa-
tients sentiment will be an overriding consideration
when determining brow position, as such features and
aesthetic ideals differ among races and cultures.
In addition to the aesthetic considerations, one
must also be cognizant of the relevant neurovascular
anatomy of the forehead. The supraorbital and supra-
trochlear nerves, both branches of the rst (ophthalmic)
division of the trigeminal nerve, provide sensation to the
forehead. The supraorbital nerve exits via the palpable
supraorbital notch, or foramen, situated 2.7 cm from
the midline. Approximately 1.7 cm from the midline,
medial to the supraorbital nerve, exits the supratrochlear
nerve. Interposed between the two neurovascular bun-
dles lies the bulk of the corrugator supercilii muscle.
6
Motor innervation of the frontalis and corrugator
muscles is derived from the temporal branch of the facial
nerve, which traverses through multiple fascial planes
depending on the area of the face. Below the zygoma, the
temporal nerve passes through the lateral lobe of the
parotid gland and runs in the sub-supercial musculoa-
poneurotic system plane. Superior to the zygoma the
nerve courses within the supercial temporal fascia.
Therefore, the plane of dissection utilized in forehead
lifting is on the deep temporal fascia, remaining deep to
and avoiding the temporal branch of the facial nerve.
7
Distally, the nerve then pierces the frontalis muscle from
its undersurface 1.5 cm medial to the lateral canthus.
8
HISTORY OF FOREHEAD REJUVENATION
The concept of forehead and brow rejuvenation is not
novel, although techniques have evolved throughout the
century with the advent of endoscopic tools and inject-
able llers. In 1906, a forehead lift was performed by
Lexer, who later went on to describe the procedure in
1931.
9
Hunt
10
contemporaneously published his de-
scription of the coronal incision for brow lifting in
1926 in his text Plastic Surgery of the Head, Face,
and Neck (Philadelphia, 1926). Both techniques de-
scribed skin resection at the level of the hairline. Pang-
man and Wallace, thereafter, described a similar
dissection but with a posthairline incision.
11
Alternative
methods of treating forehead furrows at the time in-
cluded temporal neuronectomy via alcohol injections or
incision. The coronal incision became the mainstay for
surgical rejuvenation of the forehead until the advent of
endoscopic instrumentation. In 1991, Keller and col-
leagues introduced the minimally invasive technique of
endoscopic brow lifting.
12
This advantageous and effec-
tive technique has become the preferred approach for
many current practitioners.
PATIENT EVALUATION
To adequately address the upper third of the face, one
must consider the surrounding salient features. This
includes the location and density of the hairline, the
color and thickness of the forehead skin, and, of specic
importance, the degree of brow ptosis.
Evaluation should entail relaxation of the fore-
head musculature with the patients eyes closed. This
maneuver mitigates any possible habitual brow elevation,
revealing the underlying extent of true brow ptosis.
Measurement of the brow should be obtained with the
forehead relaxed and the eyes closed.
13
Recommended
photographic preoperative and postoperative documen-
tation includes a frontal full face view, right and left
lateral views, right and left oblique views, frontal view
with the brow in repose, forehead view with the brow
raised, and a frontal view with the brow raised.
13
With the patient in the seated position, the fore-
head and brow is manually raised to the desired position,
thereby revealing the presence or absence of underlying
blepharoptosis or blepharochalalasis. Recognition of lid
ptosis or lagophthalmos warrants further investigation.
A concomitant blepharoplasty can address un-
sightly redundant upper lid skin; however, this should
be performed after the brow is raised. With the brow
elevated, one can appropriately assess the degree of upper
lid skin excess.
Prior to surgery, patients should undergo a com-
prehensive ophthalmic exam to dene visual eld de-
fects, a potential result of signicant brow ptosis.
Preoperative evaluation should also include a detailed
history, including cigarette smoking, use of anticoagu-
lant or antiplatelet therapy, and the use of monoamine
oxidase (MAO) inhibitors. Cigarette smoking should be
discontinued well in advance of expected surgery. The
92 FACIAL PLASTICS SURGERY/VOLUME 22, NUMBER 2 2006
use of aspirin or similar medication is typically discon-
tinued 2 weeks prior to surgery and the knowledge of
MAO inhibitor use will avoid potential pharmaceutical
interactions during the perioperative period.
14
TECHNIQUES
Coronal
The coronal browlift is a useful and time-tested techni-
que. It has the advantage of simultaneously addressing
brow ptosis and deep forehead furrows. Wide exposure
allows for clear identication and incision of the over-
lying frontalis, corrugator, and procerus muscles. More-
over, the incision is well concealed within the depth of
the hairline. Although advantageous to the patient with
a low hairline, the procedure is not recommended for
men or women with high hairlines. Moreover, men with
male pattern baldness are at risk for poor scar conceal-
ment if their hairline recedes. Scalp anesthesia posterior
to the incision site and potential peri-incisional alopecia
are additional noteworthy disadvantages.
The procedure begins with a bicoronal incision
placed 5 to 7 cm behind the hairline from a point 2 cm
above the superior attachment of the ear to the same
point on the contralateral side. The incision is beveled
from posterior to anterior and carried down to the
subgaleal plane. Beveling the incision, taking care not
to damage the underlying follicles on the leading edge as
one proceeds from posterior to anterior, ultimately allows
for hair ingrowth through the scar. Within the avascular,
subgaleal plane the dissection is advanced over the supra-
orbital rim and laterally to the zygoma. Along the lateral
scalp, the plane of dissection is directly above the deep
temporalis fasciaavoiding the facial nerve running
along the underside of the supercial temporal fascia.
Identication and lysis of the procerus and
corrugator supercilii follow exposure of the supraorbi-
tal and supratrochlear neurovascular bundles. Once
free from the underlying pericranium, the long ap is
pulled taught to elevate the brow to the predetermined
position. The excess scalp, typically 1 to 2 mm in
length, is excised, and a closed suction drain is left in
place. The wound is closed in layers, approximating the
galeal layer with absorbable suture rst, followed by
closure of the skin edges with nonabsorbable suture or
staples.
15
Modication of this procedure with a tricho-
phytic or pretrichial incision obviates the elevation of
the hairline. Nonhair-bearing skin of the forehead is
excised, maintaining, if not lowering, the hairline.
Therefore, this technique may be of utility for female
patients with high hairlines. Yet the same disadvantages
persist: scalp anesthesia and the presence of a potentially
unacceptable scar if meticulous closure is not per-
formed.
5,16
The incision is often irregular to mimic the
hairline, or alternatively, a W-plastywith 5.5-mm
limbs at 55-degree angles from each othermay be
performed to camouage the scar.
15
Midbrow
The midbrow approach, while effective at addressing
both brow ptosis and forehead rhytids, has limited utility
secondary to risk of unsightly scaring. Its use has been
relegated to those patients (typically male) with deep,
prominent forehead furrows and high hairlines. The
incision lies within a furrow, providing direct access to
the brow musculature and allowing for the placement of
suspension sutures. Excisions here may be tailored to
remove more midline tissue for more central ptosis or
more lateral tissue for temporal ptosis. Asymmetric
amounts of skin may be excised with comparatively
dissimilar amounts of ptosis.
Advantages of the procedure include direct and
precise placement of the brow, as well as maintenance of
the natural hairline.
15
The plane of dissectionin con-
trast to the coronal liftis within the subcutaneous
tissue (supercial to the frontalis) to prevent anesthesia
of the skin superior to the incision.
5
Direct Brow
Like the midbrow approach, the incision of the direct
brow approach is similarly camouaged within a deep
forehead furrow, although located adjacent to the lateral
brow. Direct access allows for precise placement of the
brow with suspension sutures, although forehead rhytids
cannot be treated via this approach. The plane of dis-
section is within the subcutaneous tissue for the same
reason as described for the midbrow approach. This
technique is best suited for elderly patients who require
functional elevation of the brow or possess unilateral
brow ptosis.
5
Endoscopic Forehead Lift
Endoscopic forehead lifting provides the dramatic re-
nement of rhytids and elevates the brow to a more
youthful position without affecting the hairline or creat-
ing postoperative scalp anesthesia. Thus, its application
is much wider than any of the aforementioned ap-
proaches. The necessary incisions are small and easily
camouaged within the hair, yet the access to the facial
mimetic musculature and the ability to suspend the
forehead is on par with the coronal approach. There is,
however, a greater degree of technical skill demanded of
the surgeon performing the procedure. There are many
modications and preferences espoused by facial plastic
surgeons for the endoscopic browlift technique. The
technique outlined herein was described by Romo and
Yalamanchili and serves as an example.
7
REJUVENATION OF THE AGING UPPER THIRD OF THE FACE/PRESTI ET AL 93
A total of six 1.5-cm vertical incisions are made
within the hair-bearing scalp (5 mm posterior to the
hairline). There are two medial paramedian incisions
(2 cm from midline), two lateral paramedian incisions (in
line with the lateral canthus), and two temporal incisions
(2 cm posterior to the temporal hairline). The incision is
carried down through the periosteum as the dissection is
performed within the subperiosteal plane. At the ante-
rior position of the vertical incisions, holes are drilled
into the diploic space of the calvarium using a 1.7-mm
drill bit. The length of desired brow elevation deter-
mined preoperatively is then measured out on the
calvarium posterior to these drill holes. Fixation holes
are then created at these sites.
Dissection is then undertaken within the subper-
iosteal plane anteriorly to the supraorbital ridgereleas-
ing the arcus marginalisand then several centimeters
posterior to the incision sites (Fig. 1). Through the
temporal incision, dissection is performed directly over
the deep temporal fascia avoiding the temporal branch of
the facial nerve. A sentinel vein, delineating the relative
location of this nerve, typically is encountered as one
approaches the zygomaticofrontal suture. The temporal
pocket is then made continuous with medial pocket.
Under direct endoscopic visualization, myotomies of the
procerus and corrugator muscles are performed after
identication and preservation of the supraorbital neuro-
vascular bundle.
7
Fixation of the now-released and elevated fore-
head ap may be performed with either titanium screw
anchors or simple cortical bone tunnels. Of note, the
literature describes a multitude of both permanent and
temporary xation schemes, making the choice of x-
ation seemingly surgeon-dependent. There is, however,
data within the literature that support the durability of
brow elevation when permanent xation devices are
implemented versus temporary techniques.
17,18
Endoscopic browplasty is particularly applicable
to patients with thin, fair, nonsebaceous skin as scarring
would be an overriding concern. Moreover, the low
morbidity and apparent success associated with this
technique have made it a favored approach in recent
times.
Alternative Therapies
BOTULINUM TOXIN
As an adjunct to or in place of surgical rejuvenation of
the forehead, Botox (Botulinum toxin A) injections have
become a useful and exciting addition to the facial plastic
surgeons armamentarium of tools. Clostridium botulinum
toxin exerts its paralytic effect by inhibiting the presy-
naptic release of acetylcholine. Prior success in treating
muscle dystonia and blepharospasm provided a segue for
its use in facial rejuvenation. Currently, the use of
botulinum toxin is approved by the U.S. Food and
Drug Administration for use in the glabellar area only,
although it has been used extensively in most areas of the
face and neck. The goal of attenuating facial wrinkles
and furrows can be achieved with temporary paralysis of
the underlying facial mimetic musculature vis-a`-vis sur-
gical resection or debulking (Figs. 2, 3).
Work by Blitzer and Keen et al have demon-
strated the effect of paralysis to persist up to 6 months
with a 3- to 4-day delay in onset.
19,20
The quantity
injected per facial subunit varies on the order of 5 to
20 IU of toxin. The LD
50
in humans is estimated as
2730 IU.
19
Clearly the quantity normally utilized for
cosmetic use is well within the range of safety.
Repeated use of botulinum toxin for the treat-
ment of blepharospasm, requiring larger quantities than
described for facial rejuvenation, have demonstrated no
untoward or deleterious effects.
21
However, there are
contraindications to it use: namely, patients with neuro-
muscular disorders such as amyotrophic lateral sclerosis,
myasthenia gravis, and Eaton Lambert syndrome and
patients with known hypersensitivity to the toxin. Minor
Figure 1 Conjoint tendon. Endoscopic view showing dissec-
tion of the conjoint tendon. Dissection over this area is very
important to allow for proper release of the brow complex.
Figure 2 Pre-Botox. A patient with vertical glabellar lines with
contraction.
94 FACIAL PLASTICS SURGERY/VOLUME 22, NUMBER 2 2006
drawbacks to botulinum toxin treatment include pain
and temporary ecchymosis at the injection site.
SUBDERMAL SUSPENSION THREADS
The concept of subdermal tread suspension of ptotic skin
was born out of the demand for less invasive yet effective
options for treating the aging face. Sulamanidze pa-
tented the Aptos threads and the featherlift techni-
que suspending facial skin. Aptos Threads (Nutec
International, Arizona) are bidirectional barbed mono-
laments of polypropylene, which are available in #30
and #20 gauges. More recently, unidirectional barbed
sutures (ContourThreads
TM
) have become quite popular
and rely on stabilization of the suture material to fascia
and contouring the skin and subcutaneous tissue over
these threads (Fig. 4).
ContourThreads
TM
are placed in the subcutane-
ous tissue after stab incisions are made in the hair-
bearing skin corresponding to marks that would allow
for elevation of the brow. The needle is passed in a
sinusoidal fashion toward a predetermined point on the
brow and allowed to exit, leaving the barbed portion of
the suture in the underlying subcutaneous tissue. This
straight needle is then cut, leaving a small amount of
suture material emanating from the skin. The other end
of the suture has a needle that is passed through the
periosteum where the incision was made in the hairline.
Usually two sutures are placed in the brow, and the two
superior ends of the suture are tied to each other and
trimmed. The part of the suture that emanates from the
brow is then held with one hand while the brow and
forehead are pushed in a superior direction (contoured)
with the other hand for brow elevation. Slight over-
correction is warranted. Transient swelling, mild ecchy-
mosis, limited overlying erythema, and asymmetry have
been reported. Preliminary results have been positive and
promising.
22
Lycka et al reported their experience using
Aptos threads: of 350 patients, 198 had very good to
excellent results. Additionally, 117 of the 350 patients
maintained 70% of their original results over a 12- to
24-month follow-up.
22
Although the concept and reported results are
exciting and noteworthy, more experience will be re-
quired before this technique is incorporated into the
mainstream of treatment modalities.
CONCLUSION
The facial plastic surgeon has several well-established
techniques to achieve forehead and brow rejuvenation.
Each of these techniques has specic merit and is
applicable, given the appropriate situation. Hence, the
facial plastic surgeon must consider several factors,
specically the patients concern, the inherent character-
istics of the patients face, and what the patient is willing
to accept with regards to scarring and hairline placement.
Moreover, the surgeon must be facile with each techni-
que and possess a fundamental knowledge of its appro-
priate application.
The advent of Botox and alternate options to
rejuvenate the upper third of the face has provided an
effective, yet ephemeral, option for patients. This may be
best suited for those patients deemed as poor surgical
candidates, or simply for patients not yet ready to accept
the process of more invasive surgery. Treatment of the
aging face is not limited to one modality. Rather, the
combination of both injectable and surgical procedures
has proven successful in providing harmonious forehead
rejuvenation.
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Figure 3 Post-Botox. The same patient 1 month after Botox
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Figure 4 Contour thread. A picture showing the unidirectional
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