Myectomy for essential blepharospasm.

Essential blepharospasm is a progressive, bilateral, involuntary facial spasm. In this study, we conducted a prospective analysis of myectomy for the treatment of this condition in 21 patients. The procedure consisted of extirpation of the muscles that close the eyelids (protractors), which include the pretarsal, preseptal, and orbital components of the orbicularis oculi, as well as the procerus and corrugator supercilii muscles of the brow. In addition, the muscles that open the eyelids (retractors) were strengthened (by resection of the frontalis muscle and repair of disinsertion of the levator aponeuroses). The most common symptoms that necessitated myectomy were difficulty with driving (20 patients), watching television (17 patients), reading (15 patients), and eating (5 patients). Overall, the 21 patients had a 70% mean decrease in symptoms postoperatively. Five patients required an additional operation for management of residual blepharospasm.

Treatment of essential blepharospasm. I. Comparison of facial nerve avulsion and eyebrow-eyelid muscle stripping procedure.

Benign essential blepharospasm is an incurable disease for which many treatment modalities have been suggested. The two surgical procedures that have been used most commonly are avulsion of the facial nerve and stripping of the protractor muscles of the eyelid and brow. We compare two matched series of 22 patients; one group underwent facial nerve avulsion ("Reynold's" procedure), and the other underwent "muscle stripping" ("Anderson's" procedure). We noted the number of procedures required for the patient to obtain a functional visual result and the side effects produced. Additional surgical procedures required by patients undergoing facial nerve avulsion were additional facial nerve avulsion, repair of ectropion, and correction of dermatochalasis and brow droop. Additional procedures required in patients who had muscle stripping were excision of lower lid orbicular fibers or residual brow fibers. The Reynold group required 16 additional procedures (38 separate procedures) to obtain functional results, as opposed to the four additional procedures (26 separate procedures) required in the Anderson group. Two patients in the Reynold group who needed surgery have not yet undergone it at this writing. If they did, that would boost the total number of procedures to 40. Secondary procedures are needed 4.5 times more often with the Reynold procedure than with the Anderson procedure. The patient's subjective response to and acceptance of the procedure are much greater for the Anderson procedure.

Treatment of essential blepharospasm. II. A modification of exposure for the muscle stripping technique.

The refinement of a muscle excision technique for the correction of essential blepharospasm has been a major contribution to treatment. In this procedure, incisions are made directly above the eyebrow to excise the brow muscles, often resulting in adherent scars and poor brow position. The bicoronal scalp flap has been used by many other surgical subspecialities for exposure of the frontal bone area, eg, in neurosurgical procedures, sinus surgery, and cosmetic forehead lifts. The use of the coronal flap exposure for excision of the corrugator and procerus muscles has allowed them to be more easily excised and has avoided the problems associated with the direct brow incisions. The Anderson muscle stripping technique, combined with the coronal flap exposure for the brow muscles, provides the best correction for the spasms in patients who have essential blepharospasm. The frequency of complications is low, and patient acceptance is high.

Browplasty as an adjunct to rhinoplasty.

Brow modifications are discussed with respect to their role as aids in achieving certain aesthetic effects when rhinoplasty is being performed. If a deep nasofrontal angle should not be brought forward, reduction of the brow may be indicated. If the nasofrontal angle should not be retrodisplaced to deepen a shallow angle, brow augmentation may prove helpful in separating the nose from the forehead or in making the nose appear shorter in the vertical dimension. Augmentation and reduction browplastic techniques are discussed, and selected methods are illustrated. Some involve additional resection of frontal bone or procerus muscle at the time of nasal-hump removal. Others employ grafts of bone and/or cartilage removed from the nose at the time of septorhinoplasty. The versatile aesthetic surgeon should be capable of changing all structures adjacent to the nose. Certain difficult cosmetic problems are best treated by directing appropriate attention to these structures and to the nose rather than by concentrating on the nose alone. That the brow is one of these important abutting landmarks is demonstrated.

The application of hair-bearing flaps in head and neck surgery.

The history of hair-bearing flaps is presented. A study of the vascular supply of the scalp with a particular emphasis on the posterior branch of the superficial temporal artery revealed that it was possible to transpose the entire scalp or any hair-bearing flap on a long, highly mobile, narrow pedicle containing this vessel. Clinical application of this finding to postexcisional defects allowed the reconstruction of hairline, eyebrows, sideburns, and various shapes of beards and moustaches. The technique was used on 80 occasions to produce various cosmetic units and proved to be a safe procedure.

The coronal brow lift.

We use a coronal brow lift to correct brow ptosis and associated forehead wrinkling. This technique eliminates the disadvantages of the traditional direct brow elevation, including scarring above the brow and failure to correct forehead and glabellar ptosis and wrinkling. The entire upper face is elevated as a unit, preserving the natural anatomy as much as possible. The scars are covered by hair. Eyebrow elevation and the final cosmetic results were satisfactory in all 22 cases in which we used this technique. There were no serious complications.

Surgical approach to the medial retrobulbar space.

To expose the medial retrobulbar space, an incision is made across the entire brow from the level of the lateral canthal ligament into the medial canthal area. The periosteum is incised and separated from the roof and medial wall to the level of the posterior ethmoidal foramen. The orbital tissues may then be brought forward and downward, making the area more accessible. Damage to the trochlea and levator palpebrae superioris muscle may be avoided by separation of the periorbita and careful handling of the tissues. This approach permitted the removal of a cavernous hemangioma in a 69-year-old woman. The only postoperative complication was supraorbital nerve anesthesia.

Scalpel neodymium:YAG laser in oculoplastic surgery.

In a three-year study, the scalpel Nd:YAG laser was compared with conventional surgery in 18 patients who underwent oculoplastic surgery. The postoperative follow-up was at least eight months. The contact Nd:YAG laser had distinct advantages over conventional surgery in the treatment of vascular orbital tumors, including less perioperative bleeding and a shorter operating time. In other oculoplastic procedures, ten of the 18 patients underwent surgery with the scalpel Nd:YAG laser on one side and conventional surgery on the other side. There was less bleeding, a shorter operating time, and less pain on removal of orbital fat on the laser-treated side. The postoperative scarring was initially more noticeable on the Nd:YAG laser-treated side, but after three months there was no appreciable difference in scar formation between the two sides. The amount of postoperative edema and ecchymosis did not appear to be significantly different with the Nd:YAG laser compared with conventional surgery. Additionally, microscopic evaluation showed minimal charring of tissues with the Nd:YAG laser.

Mersilene mesh brow suspension: efficiency and complications.

The use of the Mersilene mesh sling brow suspension procedure for the correction of severe blepharoptosis in 76 lids of 54 patients is presented. After a median follow up of 20 months functional and cosmetic results and complications were evaluated. The method is considered to be an alternative for those cases not primarily suitable for autogenous fascia lata brow suspension.

Eyebrow incision for combined orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of the anterior circulation. Technical note.

A modification of the supraorbital keyhole approach, the eyebrow incision-minisupraorbital craniotomy with orbital osteotomy, is described. Unique to this approach is a one-piece supraorbital craniotomy, measuring 2.5 x 3.5 cm, that incorporates the orbital rim and roof and the frontal process of the zygomatic bone through an eyebrow incision. The orbital osteotomy facilitates view of the anterior and middle cranial fossa through the operating microscope, as well as the maneuverability of instruments through a small craniotomy. A pericranial flap is elevated with its base at the orbit and used for closure of the frontal sinus, if necessary. The approach was used successfully in elective surgery of 10 aneurysms of the anterior circulation. The mean aneurysm size was 5.9 mm, with a range of 4 to 10 mm. Advantages of this approach include minimal disruption and exposure of normal brain tissue, reduced frontal lobe retraction, and an excellent postoperative cosmetic result. The approach is performed quickly by virtue of a limited skin incision with minimal temporalis muscle dissection and a small bone flap. The neuroendoscope, although helpful at times, is not essential and no special instruments or intraoperative image guidance is required. Relative contraindications include the presence of a large frontal sinus, severe brain edema, and recent subarachnoid hemorrhage. In addition, this approach has not been used for the treatment of giant intracranial aneurysms.

Infrabrow lift.

The infrabrow lift is presented as a specific method to correct skin redundancy between the eyebrow and upper lid. Indications are outlined which differentiate this technique from the suprabrow surgical approach. The surgical technique is discussed. Esthetic results have proven most satisfactory.

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.

Correction of the drooping brow: analysis of approach.

The attainment of a more youthful appearance is one of the goals of cosmetic facial surgery. In the orbital area this is usually accomplished by performing a blepharoplasty. There are, however, a number of cases in which performance of a blepharoplasty of the upper or lower lids or both does not produce as much of an improvement as the patient or the surgeon would desire. Proper preoperative analysis enables one to determine that the blepharoplasty alone will not produce the desired result. In those instances in which the ptosis of the blow is a contributing factor to the aged appearance, an operative procedure to correct the brow would be undertaken prior to or in conjunction with the blepharoplasty procedure. The various operative procedures will be discussed and analyzed from their positive and negative aspects.

The versatile midforehead browlift.

Ptosis of the brow is a significant and often unrecognized portion of aging of the upper face. It contributes to both cosmetic and functional aging. Correction is often mandatory prior to blepharoplasty in that functional problems may be worsened without elevating the brow. Direct and coronal browlifts are the most common approach to the problem. Midforehead browlifts have been reserved for men with receding hairlines. We have, for the past three years, performed midforehead browlifts on all our patients needing ptotic brow correction. Our review of 72 patients treated in this way, including 52 women, shows excellent and long-lasting cosmetic and functional improvement. There have been few complications, and the resultant incisional scars have been very well accepted. Therefore, we feel that the midforehead browlift, performed as we describe, is the ideal surgical correction for the ptotic brow.

Comparison of subperiosteal vs subgaleal elevation techniques used in forehead lifts.

OBJECTIVES: To compare eyebrow and forehead elevation and tension among the following 3 surgical techniques: subperiosteal dissection to the supraorbital rim, subperiosteal dissection with release (elevation, incision, and spread) of periosteum at the supraorbital rim, and subgaleal dissection to the supraorbital rim, and to determine the optimal method of elevation in an aesthetically accepted range for the endoscopic forehead lift. DESIGN: A randomized, self-controlled study using an open approach to the forehead in cadaver heads. Each half of head was compared with the other in the following 2 study groups: subperiosteal dissection without release vs subperiosteal dissection with release of periosteum (group 1) and subperiosteal dissection with release of periosteum vs subgaleal dissection. SETTING: Anatomy laboratory at a university medical center. SUBJECTS: Eight cadaver heads fixed with ethylene glycol in each group. INTERVENTION: Predissection distances in millimeters from fixed anatomic landmarks were measured. The forehead flaps were elevated using a coronal incision and divided with a midline incision for side-to-side comparison. Cadaver heads and side of surgical intervention were selected randomly. The flap tensions associated with incremental flap advancement of 0.5 and 1.0 cm were measured. Traction of 2.2 kg was then applied to each flap, and distances between the fixed landmarks were measured. MAIN OUTCOME MEASURES: Mean predissection and postdissection distance of brow and forehead elevation for each dissection type and mean distance and median tension of brow and forehead elevation within each group. RESULTS: The mean postdissection brow measurements at rest were significantly greater than the mean predissection measurements at most landmarks in all dissections for both groups (P<.05). The mean postdissection brow and forehead measurements with 2.2 kg of traction were significantly greater than the mean predissection measurements at all landmarks in all dissections for both groups (P<.05). The mean increase in distance from predissection to postdissection (at rest and with 2.2 kg of traction) did not significantly differ between the different dissection types (P>.05). For group 1, the median flap tension for subperiosteal dissection without release was greater than that for subperiosteal dissection with release (P>.05). For group 2, subperiosteal dissection with release had greater median flap tension than subgaleal dissection (P>.05). CONCLUSIONS: All 3 methods of dissection significantly elevated the brow at rest for most landmarks. All 3 methods of dissection significantly elevated the brow and forehead when traction was applied to the flap. Brow and forehead elevation at rest and with 2.2 kg of traction did not significantly differ between the dissections. Subgaleal dissection was associated with less flap tension compared with the subperiosteal dissection with or without release. The data support the use of all 3 methods of forehead dissection for brow elevation and subgaleal forehead dissection as the optimal approach for the forehead lift, whether performed endoscopically or open.

Rejuvenation of the brow.

Aging of the upper face is a frequent complaint in patients seeking a more youth appearance. Sometimes muscle dynamics are excessively forceful and cause marked lines of expression relatively early in life. Regardless of chronologic age, it is imperative that the surgeon perform a problem-oriented, detailed analysis of the face and each subunit, so that imperfections can be individually assessed as they apply to the harmonic balance of the whole face. Various factors, such as degree of eyebrow ptosis, vertical dimension of the forehead, preexisting scars, and level of hairline, will determine the best approach to surgical correction of the aging brow. In the authors' opinion treatment of the forehead, when done together with a rhytidectomy, requires previous blocking of the cervicofacial flaps so as not to distort important anatomic landmarks when traction is applied to the frontal flap, respecting the patient's desire for a natural aesthetic result.

The biplanar endoscopically assisted forehead lift.

Our experience with endoscopic forehead lifting and the biplanar forehead lift has been very rewarding, and although the postoperative results are early, the persistent elevation of the brows is encouraging, given that we do not temporarily suspend the forehead to the scalp with external bolsters or to the calvarium with internal anchors to bone, as has been described. The diminution of glabellar wrinkles also is marked. Clearly, the innovation of endoscopy to plastic surgical practice has enhanced our understanding of the goals in forehead lifting; and given our experience and that of others, it is hoped that many more patients will benefit form this continually evolving technique.

The coronal incision in rhytidectomy--the brow lift.

Rhytidectomy is not a routine procedure applicalbe to all patients. Variations of technique must be chosen for each individual case. Integral correction of the face is important and brow-lifting must often be done. Our criteria for selecting the coronal incision for the brow-lift are discussed and the surgical techniques are described in detail. Results are analyzed and a simple method for evaluation is presented.

Endoscopic browlift.

We have presented the development and current status of endoscopic browlifting from its inception at UAB to the present techniques as they are now practiced by the authors. Endoscopic browlifting was based on sound preclinical research and included thorough training of all investigators in the use and application of endoscopic equipment. We believe that endoscopic browlifting represents clear advantages over the open technique in selected patients. These advantages included avoidance of the long transverse incision and its secondary sequelae. Improved magnification and visualization of small structures are also a secondary advantage. Complications are no greater than the open technique and tend to diminish with experience. We feel that endoscopic browlifting will continue to be refined and will find a permanent place among the armamentarium of all aesthetic plastic surgeons.

Endoscopic subperiosteal browlift and facelift.

The subperiosteal facelift is an excellent technique for remodeling particularly the central third of the face. The endoscope has allowed us to perform rejuvenation of the upper face or the total face without incisional scars. On the other hand, the introduction of the endoscopic techniques to the biplanar surgery allowed us to perform the deep dissection with more safety and accuracy and to eliminate or decrease some of the undesirable sequelae of the traditional approaches such as the numbness on the forehead beyond the hairline or scalp incisions. In the lower face, the endoscopic techniques allowed us to protect the marginal mandibular branch of the facial nerve, and, on the neck, these techniques allowed us to perform a very accurate subplatysma dissection. The endoscope has allowed us to create a new technique for facial rejuvenation that can be equal to and perhaps in some cases even more versatile than other traditional, nonendoscopic approaches. In this way, we can tailor the operative procedure to the patient's needs rather than to give one type of operation to every patient that walks in for an office consultation. It will become imperative to outline the indications, contraindications, and limitations of each variation and to determine the appropriate role of the endoscope in facial rejuvenation. Only then will we better serve our colleagues and our patients.