WP Chung O T in Plastic Surgery

C H A P T E R 20

Section VII: Brow Lifting

Indications and Techniques for Coronal Brow Lifting

Richard J. Warren

DEFINITION

■■ The surgical significance of the temporal crest line is that overlying fascial layers are tethered to bone in a band imme- diately medial to the palpable ridge. This has been called the zone of fixation or the zone of adhesion. 2,3 Inferiorly, where the ridge approaches the orbital rim, the fixation becomes broader and denser, forming the orbital ligament, also known as the temporal ligamentous adhesion. Regardless of the surgical technique used, when a full-thickness forehead flap is mobilized, all fascial attachments to bone must be released, including the zone of adhesion and the orbital liga- ment, plus attachments to the supraorbital rim and lateral orbital rim. 4 ■■ The temporal crest also marks a change in nomenclature as tissue planes transition from lateral to medial. The deep temporal fascia covers the temporalis muscle and is attached to bone along the temporal crest. It then continues medially as the periosteum of the frontal bone. Similarly, the super- ficial temporal fascia (also known as the temporal-parietal fascia) continues medially as the galea aponeurotica. ■■ The galea aponeurotica splits into a superficial and a deep layer to encompass the frontalis muscle. Inferiorly, the deep galea layer separates further into three separate layers: two layers encompass the galeal fat pad, and a third layer is adherent to periosteum. 2 Superficial to the deepest galeal

■■ Brow ptosis describes an abnormally low position of the eyebrow complex, either in whole or in part. ■■ Low lying or malpositioned eyebrows may be congenital or acquired through aging. ■■ Brow position and shape convey an impression of emotion. When the entire brow is low, the patient looks tired. When only the medial brow is low, the patient appears to be angry, and when only the lateral brow is low, the patient appears to be sad. 1 ■■ Brow ptosis encroaches on the upper lid sulcus, changing the dynamics of the upper lid/brow junction. Thus, brow ptosis will affect the assessment of patients presenting for blepharoplasty, periorbital fat grafting, or senile eyelid pto- sis repair. ANATOMY ■■ Underlying the forehead is the frontal bone. Laterally, the frontal bone is crossed by a curved ridge called the temporal crest (temporal ridge or temporal fusion line). This palpable landmark separates the forehead from the temporal fossa laterally ( FIG 1 ). The temporalis muscle takes its origin from the temporal fossa.

Temporal crest line (superior temporal septum) Temporal ligamentous adhesion (orbital ligament)

Sentinel vein

Supraorbital ligamentous adhesion

Inferior temporal septum

Adhesions Copyright © 2019 Wolters Kluwer, Inc. Unauthorized reproduction of the cont nt is prohibited.

Temporal branches of the facial nerve

FIG 1  • Galeal attachments must be completely released to allow a forehead flap to move superiorly. The firmest attachment is at the temporal ligamen- tous adhesion (orbital ligament) but is also present along the supraorbital rim (supraorbital ligamentous adhesion), down the lateral orbital rim (lateral orbital thickening) and along the temporal crest line. In rais- ing the flap, the temporal branches of the facial nerve will be in the roof of the dissection immediately above the medial zygomatic vein (sentinel vein).

Lateral orbital thickening of periorbital septum

Orbicularis retaining ligament

Chung1e9781496339508-V1P1-c020.indd 69

1/29/2019 3:03:18 PM