In a previous article for this publication, I spoke about facial rejuvenation surgery which, of course, is "anchored" by "Facelift", a procedure probably first undertaken intentionally to improve facial appearance some 75 or more years ago. While that procedure has undergone a variety of refinements over that period of time, especially over the last decade or so, the common denominator of all "Facelifts" remains the removal of excess facial and neck skin through a somewhat lengthy incision beginning in the temporal area of the scalp and continuing inferiorly (downward) along the ear and then posteriorly (backward) into the mastoid area of the scalp. Were that incision straightened, it would, in many individuals, translate to almost a foot in length. Because it is hidden for the most part by hair in the temporal and mastoid areas of the scalp and hugs the ear and usually proves to be very good to excellent in just about anyone who undergoes the procedure, the resulting scar, once "mature", proves difficult to identify even under adequate lighting by the most "critical" observer.

Advancements in recent years in facial rejuvenation surgery are not so much a result of an improvement in "Facelift" as they are a function of adjunctive surgical procedures which are "piggybacked" onto a "Facelift" and which address areas of the aging face which a "Facelift", regardless of the specific technique employed, cannot address. Perhaps the most significant improvement in facial rejuvenation surgery is a result of the recognition of the importance of brow position to overall facial appearance and the development of surgical procedures to address brow position.

As we age our skin loses elasticity (not unlike a used rubberband) and the resultant laxity or looseness of facial skin can impart a fatigued, worn appearance to our faces. Perhaps just as important (if not more important) to changes in our facial appearance is the action of muscles of facial expression (known as the "mimetic" muscles) upon facial skin. By virtue of their frequent contraction and relaxation, they exert pull on the facial skin which translates into lines of facial expression, specifically deep nasolabial folds (those folds running from the sides of the nose to the corresponding corners of the mouth and beyond); perioral wrinkling (often known as "smoker's lines"); glabellar frown lines, situated in the lower forehead just above the nasal bridge and between the medial (inner) ends of the eyebrows; and, of course, horizontal furrows of the forehead. I am amused by claims in the media of improvement in one's facial appearance secondary to exercise of facial muscles since exercise of such muscles translates into more - rather than less - prominent lines of facial expression.

The actions of these facial muscles often result in an angry appearance and, in the case of ptotic (droopy) eyebrows, a sinister appearance owing to hooding of the eyes. The most effective solution to ptotic eyebrows is a Forehead (Brow) Lift which begins with nothing more than a continuation of the bilateral "Facelift" incisions from temple to temple. Generally the Forehead Lift incision is positioned well posterior to or behind the frontal hairline so that the resulting scar (which, like the "Facelift" scar, generally proves to be an excellent scar) is well camouflaged by adjacent hair. High foreheads often call for a Forehead Lift incision at the frontal hairline. The procedure then continues inferiorly as the forehead skin is separated from underlying forehead muscles and lifted in order to unfold the furrows within that skin or the forehead skin is lifted in conjunction with the underlying forehead muscles to produce what some plastic surgeons feel is an even longer lasting result in terms of improvement of forehead furrows. Furthermore, those muscles which contribute to unpleasant glabellar frown lines (known as the corrugator muscles) can be removed, thereby eliminating the glabellar frown lines and preventing them from occurring again or at least from becoming as prominent they were. Keep in mind that, unlike most muscles, the muscles of facial expression are not essential to our physical well being and function and some muscles (again like the corrugator muscles) can be eliminated without harm.

Even though the Forehead Lift incision is less in length than is either one of the bilateral "Facelift" incisions, I find that many patients to whom I offer a Forehead Lift do not want to consider the procedure because I suspect they associate an incision involving the coronal scalp (or the "crown" of the head) with neurosurgery ("brain surgery") and assume that a Forehead Lift is a much more drastic undertaking than is a "Facelift". In my opinion, a Forehead Lift is even safer than is a "Facelift", owing to the excellent vascularity of scalp and forehead skin/muscle which in turn translates to excellent wound healing and owing to the relative absence of any structures within the forehead which, if injured, could produce disability.

A variation of the Forehead Lift which is gaining popularity and which I employ often is elevation of the eyebrows through upper eyelid incisions, usually undertaken in conjunction with Bilateral Upper Blepharoplasty or surgery of both upper eyelids. While such a procedure may not address forehead furrows, it does address ptotic eyebrows and is particularly suited to men, especially balding men who cannot accommodate a coronal scalp incision, or in men and women whose problem is primarily ptotic eyebrows and hooding of the eyes rather than furrowed forehead skin.

In most of us the forehead represents one-third (in some cases, more) of the entire face, so undertaking a "Facelift" (which ordinarily does not address forehead problems) alone in an individual in need of total facial rejuvenation ignores a significant contributor to his/her unpleasant facial appearance.


Dr. Richard T. Vagley, a Board Certified Plastic Surgeon, is Medical Director of The Pittsburgh Institute of Plastic Surgery and a Contributing Editor of Outpatient Surgery Magazine.

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