Brow reduction, reshaping and suspension by a 20-degree beveled brow incision technique

Revisiting the Direct Brow Lift in Patients With Facial Palsy: 4 Key Modifications

PURPOSE

The direct brow lift is a simple and popular technique, particularly in patients with brow ptosis secondary to facial palsy. It provides a high degree of control in determining the degree of brow elevation and shape achieved. However, it is arguably the least debated in terms of addressing some of its sequelae, namely the risks of a visible or indrawn scar and forehead paraesthesia. In this article, we report outcomes using four alternative principles to those outlined in current published literature.

METHODS

All patients undergoing a primary direct brow lift for brow ptosis secondary to facial palsy between January 2015 and December 2019 under a single surgeon (R.M.) were included in the study. The technical refinements of the procedure included a W-plasty type stealth skin incision, counter-bevelling of the upper and lower incision lines, skin excision in the subcutaneous plane only with minimal excision of fat and browpexy to the frontal periosteum through small linear puncture incisions in the frontalis.

RESULTS

A total of 23 patients undergoing 24 direct brow lifts were included in the study. The mean follow-up was 1.3 years (range 0.5-3 years). No patients reported postoperative forehead paraesthesia or brow alopecia. One patient required a further temporal browlift 15 months later. Brow height was rated excellent (0-1.5 mm difference) in 71% of brows and good (1.6-4.9 mm difference) in 14% of brows. The average Manchester scar scale was 8.6/28.

CONCLUSION

The technical modifications presented substantially reduce the rates of postoperative paraesthesia, whilst achieving satisfactory aesthetic outcomes.

[The early days of aesthetic surgery: facelift pioneers Eugen Holländer (1867-1932) and Erich Lexer (1967-1937)]

INTRODUCTION AND BACKGROUND

 The human desire to achieve an improved/better way of looking can be traced back through all times of human history and culminated in the realm of plastic surgery in the beginning of the early 20th century. In particular a main interest was hereby the so-called facelift surgery and the first two German pioneers in this field: Eugen Holländer and Erich Lexer.

AIM OF THE PAPER

 The surgeons Eugen Holländer and Erich Lexer contributed to a big part to the development of facelift techniques. The paper aims to highlight in which way both surgeons conducted their research work and the topic of facelift and which findings could be drawn out of their work.

METHOD

 On the basis of old specialist literature and congressional quotations the curriculua vitae of Eugen Holländer and Erich Lexer are portrayed, as well as their professional career and their ground breaking work for facelift surgery and its differences amongst each other.

CONCLUSION

 Both Eugen Holländer and Erich Lexer performed, independently from another, the first facelifts in Germany. Hereby, their operative approach was different. In contrast to Holländer who only performed skin resections for a better tightening of the face, Lexer undermined the skin in an area of multiple centimetres.Even in their suture technique the difference was visible. Lexer for instance conducted a special suture technique by including the fascia temporalis superficialis in his sutures for achieving lasting stability and tension relief. Due to this reason Lexer can be regarded without any doubt as the initial pioneer of modern facelift surgery.

Outcome of Beveled versus Vertical IncisionTechnique after Reconstructive or Aesthetic Facial Surgery

Background:

We suggest that the degree of scar improvement with a beveled incision technique with an angle of about 20 degrees to the skin can be translated for various reconstructions on the face and can be verified by a validated clinical assessment scale and histology.

Methods:

A total of 5 patients (2 men and 3 women) with a mean age of 68 years (range 54–84 years) undergoing elective surgeries on the face for tumor excision or cosmetic procedures were included. The beveled incision technique was compared with the conventional vertical incision (control group). Outcome measures were major and minor complications, pain and scar quality using the Patient and Observer Scar Assessment Scale, and histomorphologic scar assessment.

Results:

After a mean follow-up of 7.6 months (range 6–13 months), all patients healed uneventfully without pain, hypertrophic scars, or infection. We found a better overall Patient and Observer Scar Assessment Scale score in the beveled incision technique group (15 ± 3.4) compared with the conventional vertical incision group (18.4 ± 7.8, P = 0.7). Histomorphologic analyses showed after 6 months less scar zone, less inflammatory reaction, fewer macrophages, less foreign body reaction, and more hair follicles in the beveled incision technique group compared with the vertical incision group.

Conclusion:

We showed that the beveled incision technique using a 20-degree angle in elective surgeries on the face yields a cosmetic pleasant result for both the patient and the surgeon, which also goes in line with our histomorphologic analyses.

Beveled Incisions: What is the Evidence?

BACKGROUND

Although many aesthetic surgeons believe that beveling the angle of an incision improves the aesthetic outcome with regard to scaring, the literature remains scarce largely because few studies have been conducted.

OBJECTIVE

This systematic review therefore aims to identify whether using a beveled incision adds an aesthetic benefit, to determine whether there is a specific angle that yields a superior outcome, and for the first time, to present a complete discussion of this subject for practicing surgeons.

METHODS

A comprehensive literature search was performed using the PubMed database to search for primary articles. The main inclusion criteria were primary journal articles investigating the use of a beveled angle via a controlled study.

RESULTS

A total of fifty-four publications were reviewed, with only four publications including 124 patients suitable for use in this systematic review. All the studies concluded that the use of a beveled angle incision improved aesthetic outcomes, with the ideal angle ranging from 10° to 45°.

CONCLUSIONS

The use of a beveled angle incision can improve scar aesthetics and encourages the regrowth of hair follicles and shafts through the scars via multiple mechanisms. Nevertheless, the paucity of literature available to the practitioner compels further research assessing this important topic.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Flat Incision Technique for Reconstructive Brow Surgery: A Wound Healing Model and Clinical Evaluation

Background:

Skin incision is considered to be placed at 90° in reference to the skin to get perfect wound edge adaptation. The incision on hair-bearing tissues, as the scalp, is considered to be bevelled at 45° to promote hair growth through the scar. There is no consensus about the preferred incision angle on the brow. The aim of this article was to demonstrate the feasibility of the “flat incision technique” for brow repositioning, where brow deformation results after forehead reconstruction. A wound-healing model for the bevelled incision is presented.

Methods:

Brow incisions are bevelled with an angle of 20°. The lower incision is placed inside the brow so that the upper 2 rows of hair are included; the dermis is completely transected and dissection is continued into the subdermal plane. The procedure is presented in a patient who underwent resection of the forehead due to melanoma.

Results:

The bevelled incision increases the surface area of dermal layer by a factor of 2 compared with the standard vertical skin incision at 90°. Loss of the dermal tissue integrity and continuity due to trauma hinders the recovery of cell migration and function, resulting in a more prominent scar formation. It appears reasonable that with the increased surface area of the dermal layers in the wound edges, the scar quality improves. The case study demonstrates the feasibility of the procedure.

Conclusion:

The bevelled 20° incision for brow repositioning and reshaping showed to be a viable and predictable procedure.