Transcalvarial suture fixation for endoscopic brow and forehead lifts

Dual cortical tunneling method for endoscopic forehead lift

Background Endoscopic forehead lift with cortical tunneling is an effective option for rejuvenation of the upper third of the face. Although it has been considered safe and reliable, with relatively consistent long-term results, relapse and weakening of adhesion have been common problems.Methods We suggest the dual-tunneling method for overcoming these limitations. A total of 100 patients aged 17 to 65 years underwent forehead lifting with cortical tunneling by the senior author from August 2016 to December 2017. The single-tunnel method was applied in one half of the patients and the dual-tunnel method in the other half. Bilateral brow positions were measured immediately following surgery and 6 months later.Results For all cases, cortical tunneling was done at the central incision and both paramedian incisions; therefore, three tunnels were used in the control group and six tunnels in the experimental group. In the single-tunnel group, relapse distances were 2.39±0.83 mm for the medial brow and 3.26±0.91 mm for the lateral brow (6 months postoperatively; n=100). The dual-tunnel group showed significantly smaller (P<0.001) relapse distances, with values of 1.69±0.46 mm and 2.17±0.59 mm for the medial and lateral brow, respectively (6 months postoperatively; n=100). The experimental group did not show an increase in complications.Conclusions The dual-tunneling method, designed to minimize the cheese-wiring effect, uses a triangular plane to avoid a focal fixation. The fixation also includes the periosteum to hold the forehead tissue in place, inducing stronger adhesion.

[Endoscopic forehead lifting: surgical anatomy and technique]

Endoscopic forehead lifting is a widely accepted treatment for brow ptosis. The procedure safely and effectively corrects horizontal forehead rhytids, brow ptosis, upper eyelid dermatochalasis and periorbital crow's feet. The result is a refreshed and more open facial expression. A thorough understanding of basic facial anatomy is the key to successful cosmetic surgery. The procedure is based on a subperiostal and preperiosteal mobilisation of the temporal and frontal soft tissues and a detachment of the periosteum of the orbital rim. An upper eyelid blepharoplasty and selective incomplete or complete myotomies of the corrugator and procerus muscles may be incorporated in the operation. Most surgeons prefer to fixate the elevated soft tissue planes to the calvarium by sutures, titanium or resorbabale polyglactid anchors. While initial enthusiasm for this procedure seems to be declining in several countries, few ENT-surgeons are familiar with this technique in Europe. This article reviews the surgical anatomy of the forehead and temporoparietal region by means of cadaver dissection and describes the surgical procedure for German speaking readers.

Endoscopic brow lifts uber alles

Innumerable approaches to the ptotic brow and forehead have been described in the past. Over the last twenty-five years, we have used all these techniques in cosmetic and reconstructive patients. We have used the endoscopic brow lift technique since 1995. While no one technique is applicable to all patients, the endoscopic brow lift, with appropriate modifications for individual patients, can be used effectively for most patients with brow ptosis. We present the nuances of this technique and show several different fixation methods we have found useful.

Stability after endoscopic forehead surgery using single-point fascia fixation

BACKGROUND

With endoscopic forehead rejuvenation, most surgeons use at least two points of fixation for each eyebrow, often including some type of bone fixation, to achieve the aesthetic goal of lasting repositioning of the eyebrows and elimination of frown lines. In this prospective study, short-term and 1-year postoperative changes in the position of the eyebrows following extensive release of eyebrow-retaining ligaments and use of single-point fascial suture (without bone fixation) were objectively evaluated.

METHODS

Front-view, life-size photographs of 48 patients undergoing endoscopic forehead surgery for treatment of migraine headaches were analyzed preoperatively and 1 and 12 months postoperatively. The distance of the caudal portion of each eyebrow from a horizontal line passing through the medial canthi was measured at three levels: (1) the lateral canthus, (2) midpupil on a straight gaze, and (3) medial canthus.

RESULTS

Statistical analysis revealed a significant elevation of the eyebrows at each of these three reference points when preoperative and 1-month postoperative data were compared (p = 0.001). Twelve months postoperatively, the eyebrows remained significantly elevated at each of the three reference points on both the left (p = 0.001) and right (p = 0.001) sides. Comparison of data at 1 and 12 months postoperatively did not show any statistically significant difference (p = 0.1 to 0.9 at the three levels), indicating that the eyebrow elevation was maintained.

CONCLUSIONS

The authors conclude that wide release of the eyebrow-retaining ligaments with single-point fascial fixation is an effective method for elevation of the eyebrows, and that bone fixation should be used when an alteration of eyebrow arch form or correction of eyebrow asymmetry is indicated.

Use of BioGlue Surgical Adhesive for Brow Fixation in Endoscopic Browplasty

OBJECTIVE

To determine the efficacy, longevity, and safety of BioGlue Surgical Adhesive for periosteal fixation in endoscopic browlifts.

METHODS

Retrospective review of 80 patients who underwent endoscopic browlift using BioGlue as the primary means of periosteal fixation. Visits were categorized as preoperative, 1 to 2 months, 3 to 6 months, and 7 to 12 months, and photographs of the first 15 patients were evaluated for change in brow position at each of these visits. Brow position was measured at the lowest brow hairs at the midpupillary and lateral canthus positions. Follow-up was 3 months to 3 years.

RESULTS

All of the first 15 patients were included in the 1- to 2-month postoperative grouping, 13 in the 3- to 6-month grouping, and 10 in the 7- to 12-month grouping. At all postoperative visits, brow elevation was significantly maintained during 12-month follow-up. Revision has been required in only 1 of 80 patients to date.

CONCLUSIONS

BioGlue is an effective and safe method of maintaining brow position in endoscopic browplasty. Brow elevation achieved using BioGlue was significantly maintained during the 7- to 12-month postoperative period. Tissue adhesives such as BioGlue have the potential to become significant adjuncts in facial plastic surgery and warrant more critical evaluation.

Time Scale for Periosteal Readhesion After Brow Lift

OBJECTIVES/HYPOTHESIS

The objective was to determine the time interval after brow lift required to achieve periosteal readhesion to the skull with preoperative strength [corrected].

STUDY DESIGN

Randomized prospective analysis of variance with repeated measures.

METHODS

Twenty-one New Zealand white rabbits, each serving as its own control, underwent subperiosteal elevation on one side of the skull. The elevated periosteum was lifted and fixed to a resorbable screw, and the contralateral periosteum was left untouched. Adhesion characteristics were subsequently examined at postoperative days 5, 6, 7, 8, 10, 12, and 17. Seven subjects were assessed histologically to determine attachment of periosteum to underlying bone. Fourteen subjects underwent biomechanical analysis of the bone-periosteum interface using the following three measures of periosteal readhesion strength: ultimate shear strength, shear stiffness, and shear energy [corrected].

RESULTS

Blinded histological analysis showed a qualitative increase in the number of markers of periosteal healing on days 8 to 12 for the operated sides. Analysis of ultimate shear strength and shear stiffness demonstrated a significant relationship to postoperative day (P <.001). The ultimate shear strength and shear stiffness of the operated side approached that of the nonoperated side by postoperative days 12 and 8, respectively. Shear energy was significantly lower for all time points on the operated side as compared with the control (P <.02).

CONCLUSION

Periosteal readhesion after surgical elevation approaches preoperative strength by the twelfth postoperative day.

A new resorbable tack fixation technique for endoscopic brow lifts

The endoscopic brow lift is now widely accepted in aesthetic plastic surgery, and various fixation techniques have been described in the literature. New developments and technology have expanded the use of resorbable devices in different surgical specialties, including plastic surgery. The authors present a technique that offers simple, fast, and reliable forehead fixation for endoscopic brow lifts using resorbable tacks. Successful facial rejuvenation was obtained in the majority of the patients without complications, need for follow-up visits to tighten the flap fixation system, or secondary procedures to extract the fixation system.

A retrospective comparison of open and endoscopic brow-lifts

OBJECTIVES

To measure and compare surgical brow elevation with open and endoscopic techniques; to compare patients who did and did not undergo an eyelid procedure in the same setting as the brow-lift; and to determine whether a learning curve exists for a successful endoscopic brow-lift procedure.

DESIGN

A retrospective review of patients who underwent coronal, trichophytic, and endoscopic brow-lift surgery from January 1, 1993, to December 31, 1997 (performed by K.A.L.). We analyzed preoperative and postoperative photographs obtained from 10 to 56 months after surgery while masked to the surgical technique used. Measurements included a horizontal baseline drawn through the midpoint of the right and left medial canthi, and extended laterally across the face; the distance from the baseline to the superior border of the medial eyebrow on the right and left sides; and the distance from the baseline to the highest point of the brow on the right and left sides. A second, nonbiased observer analyzed a random sampling of patient photographs to determine the degree of interobserver variation.

SETTING

Private facial plastic and reconstructive surgery practice. All procedures were performed in an ambulatory surgery setting.

PARTICIPANTS

We identified 125 patients (average age, 54 years) with greater than 10 months of postoperative photographic documentation. We excluded 41 patients owing to several inconsistencies between their preoperative and postoperative photographs and included 84. These patients were divided into 3 groups: those undergoing coronal, trichophytic, and endoscopic procedures. Of the patients undergoing concomitant eyelid procedures, 12 underwent upper lid blepharoplasties; 15, lower lid blepharoplasties; 16, bilateral upper and lower lid blepharoplasties; 6, periorbital laser resurfacing or chemical peel; 1, canthoplasty; and 1, ptosis repair. The endoscopic brow-lift procedure was not performed in this facial plastic surgery practice until 1995. To determine whether better results were obtained in the later half of the study, when the surgeon had more experience, this group was divided between the 14 patients who underwent the procedure from January 1, 1995, to June 30, 1996, and the 20 who did from July 1, 1996, to December 31,1997.

MAIN OUTCOME MEASURE

Comparison of preoperative photographs with postoperative 10- to 32-month follow-up photographs and with final 35- to 56-month follow-up photographs.

RESULTS

We found no statistically significant difference in: the distance of the medial brow (P =.89) or highest elevated point of the brow (P =.93) between the coronal, trichophytic, and endoscopic groups; the distance that the medial brow (P =.15) or the highest point of the brow (P =.11) was raised for those patients undergoing concomitant eyelid procedures; and the distance that the medial brow (P =.80) or highest point of the brow (P =.79) was raised between the 2 endoscopic brow-lift groups. Interobserver variation in brow measurements was 0.1 cm or less in more than 90% of cases.

CONCLUSIONS

Both open and endoscopic brow-lift techniques described herein elevate the entire brow successfully. We found no statistical difference in patients undergoing concomitant eyelid procedures, and there was no identification of a "learning curve" for a successful endoscopic brow-lift with the surgical technique described.

Periosteal readhesion after brow-lift in New Zealand white rabbits

OBJECTIVES

To define the postoperative time interval required for elevated periosteum to readhere to the skull and regain its preoperative strength, and to evaluate whether fixation of the periosteum affects this interval or the strength of postoperative readhesion.

DESIGN

Prospective analysis of variance and covariance with repeated measures.

SUBJECTS

Thirty-six New Zealand white rabbits, each serving as its own control.

INTERVENTIONS

Subperiosteal elevation was performed on one side of the skull, leaving the contralateral periosteum untouched. The periosteum in half of the subjects was lifted and fixed to a resorbable screw, with the comparison group undergoing subperiosteal elevation only, without lifting and fixation. Several adhesion characteristics were subsequently examined at postoperative weeks 1, 3, 5, 7, 8, 9, 10, 11, and 12. Half of the subjects were assessed histologically to determine attachment of periosteum onto underlying bone. The other half underwent analysis of periosteal readhesion strength.

RESULTS

The 3 independent measures of periosteal adherence to the skull all lacked significant differences between sides after the first postoperative week. Blinded histologic analysis showed no evidence of ongoing periosteal healing and demonstrated no difference between operated-on and nonoperated-on sides. Analysis of periosteal stiffness (P =.76) and energy density (P =.74) also demonstrated no significant differences between sides.

CONCLUSIONS

Periosteal readhesion after surgical elevation is virtually complete by the seventh postoperative day. In addition, tension secondary to periosteal elevation with suspension has no influence on postoperative healing. These findings will contribute to the debate regarding the most appropriate brow-lift fixation technique.

The subgaleal endoscopic browlift

Most endoscopic browlifts are performed in a subperiosteal plane with or without fixation posterior to the hairline at the incision site. The extent and longevity of browlifting are variable and somewhat unpredictable. We reviewed the literature on endoscopic browlifting techniques and describe herein our technique for the subgaleal endoscopic browlift procedure. It differs from the published reports of subperiosteal endoscopic techniques in the plane of dissection, circumvention of a periosteal release, and suture fixation at the brow level. We have used this technique for browlifting in male and female patients alike, as well as in patients with preoperative brow asymmetries, with consistent results.

Endoscopic foreheadplasty: a histologic comparison of periosteal refixation after endoscopic versus bicoronal lift

Endoscopic brow lift techniques using temporary fixation rely on rapid readherence of the periosteum to calvarial bone. Little is known about the histologic events that occur during the early postoperative period after these procedures. An animal study was designed to compare and contrast periosteal fixation to bone and unelevated periosteum, with endoscopic and bicoronal brow lift techniques. One method of temporary fixation is the use of absorbable (polylactic/polyglycolic acid copolymer) LactoSorb screws; a histologic analysis of implanted LactoSorb screws was also performed. Sixteen rabbits underwent brow lifts; eight underwent endoscopic brow lift and fixation with LactoSorb screws without skin excision, and another eight underwent traditional bicoronal brow lift with skin excision and closure under tension. Animals were killed 1, 2, 6, and 12 weeks after the procedures were performed to evaluate the interaction of periosteum and bone and the normal, unelevated periosteum/calvarium interface at a site distant from the operative area. Histologic specimens were examined for the degree of apposition of periosteum to bone and for any fibrous or bony reaction at this interface. Histologic analysis showed various degrees of periosteal fibrosis and fixation to calvarial bone. After an initial phase of minimal periosteal adherence and moderate inflammation, the periosteum became progressively more adherent to bone in both groups, with no significant differences between treatment groups in rates of fixation. Fixation required at least 6 weeks. LactoSorb screws were surrounded by an area of mild inflammation and were progressively hydrolyzed and digested. Periosteal fixation increases over time for bicoronal and endoscopic brow lifts with minimal differences between the two techniques. With this animal model, periosteal adherence to calvarium requires at least 6 weeks with complete adherence by 12 weeks. In addition, the use of absorbable fixation screws seems to be both effective and well tolerated. The histologic changes associated with periosteal healing observed in this study suggest that permanent or semipermanent fixation may improve the accuracy and early postoperative maintenance of forehead advancement.

The endoscopic browlift for forehead rejuvenation

Since its initial description by Vasconez et al in 1992, the endoscopic browlift has evolved into a popular method for addressing brow ptosis and forehead rejuvenation. The advantages of fewer incisions, less postoperative swelling, alopecia and prolonged scalp anesthesia, and more rapid rehabilitation have provided greater patient acceptance than the traditional coronal approach. Unlike the coronal browlift where the amount of elevation is determined by the amount of skin excised, the elevation in the endoscopic browlift is determined by periosteal release at the arcus marginalis and forehead flap fixation. Though equipment costs are greater and a learning curve exists, the endoscopic browlift offers the oculoplastic surgeon additional beneficial options in the management of brow ptosis.

Contemporary management of the aging brow and forehead

Management of the aging brow and forehead has recently evolved based on available innovative technologies. Likewise, procedure-specific indications have changed based on collective surgical experiences. No longer is the approach based solely on hair pattern or degree of brow ptosis. Patients require varying combinations of brow elevation (prior to blepharoplasty), correction of brow asymmetries, and hairline-preserving forehead elevation. Some may only require excisional or paralytic procedures of the frontalis muscle (horizontal forehead creases), corrugator supercilii muscles (vertical glabellar furrows), and procerus muscle (horizontal glabellar furrows). We present a 3-year experience using a problem-specific approach. This incorporates endoscopic technology, botulinum toxin type A purified neurotoxin complex (Botox, Allergan, Irvine, CA) intramuscular injection, and traditional procedures such as the coronal, pretrichial, midforehead, and direct browlift. Current indications, patient selection, and results are also discussed.