Biplanar Forehead Reduction and “Gliding” or Endoscopic Browplasty with Temporary Percutaneous Fixation for Supraorbital Nerve Preservation and Optimal Scar Healing

Goals/Purpose: Optimizing forehead and brow aesthetics in patients with upper facial third (forehead) disproportion, posterior hairline displacement, and lateral brow ptosis present a unique challenge as suboptimal forehead reduction, risk of scalp sensory loss, tension alopecia and poor scar healing can preclude an excellent result. In this study, we present a novel method of “biplanar” coronal forehead reduction by subperiosteal dissection and “accordion periosteal scoring” with cranial scalp flap fixation and concomitant “gliding” or endoscopic subcutaneous browplasty with temporary percutaneous fixation in 28 consecutive patients towards four primary aesthetic goals: (1) reduction of vertical forehead height by anterior hairline lowering, (2) lateral brow elevation, (3) preservation of supraorbital nerves (SON), and (4) scar healing optimization by “pilot incision/tailor tacking method of Manson” for tensionless incision closure.

Methods/Technique: Surgical Technique (Figure 1, 2)

A series of 28 patients who underwent biplanar forehead reduction and browplasty were retrospectively reviewed and outcomes analyzed with at least 6 months of follow in whom the following surgical technique was performed:

• Coronal pretrichial incision, anteriorly beveled, with “micro zig-zag” pattern around individual hair follicles
• To preserve the SON, “points of Knize” were marked at the intersection of a saggital plane with the hairline at 2.0 cm medial to the temporal crest
• The interval between points of Knize delimited the medial incision which is taken through the periosteum with wide cranial and posterior undermining to the occiput
• Maximal “accordion” scalp flap expansion is achieved by sharp horizontal scoring of periosteum, the scalp flap rotated anteriorly and suture fixation of periosteum to the outer table via 3 converging unicortical tunnels
• Preservation of the superficial and deep branches of supraorbital nerves by endoscopic approach lateral subcutaneous dissection to supraorbital rim and browplasty with temporary percutaneous suture fixation removed at 48 hours (also known as “gliding brow lift”)
• “Pilot incision/tailor tacking method of Manson” for precise skin resection and tensionless closure.

Data Generation (Figure 3):

Measurements were made by two methods, “direct” (on patient, in millimeters) and “digital” (on photographs, in pixels). Photographs were taken at 3 feet in studio lighting with a digital SLR camera, patient in primary gaze, level Frankfort horizontal. Pre- and post-operative distances were measured to determine relative hairline and brow movement as follows:

• Vertical Midline Forehead Height (VMFH): from cephalic medial brow to hairline at the midline
• Vertical Lateral Forehead Height (VLFH): from left/right lateral brow peak (LBP, defined as 2/3 the distance from the medial brow) to left/right hairline
• Vertical Brow Peak Height (VBPH): from left/right lash line at mid-pupil to left/right LBP

Analysis:

Absolute forehead reduction and brow elevation in millimeters were reported, and data were normalized to determine the “relative change” and reported as the percent of pre-operative distance, as follows:

• Vertical Midline Forehead Reduction (percent) = [(Pre-op VMFH - Pre-op VMFH)/Pre-op VMFH]*100
• Vertical Lateral Forehead Reduction (percent) = [(Pre-op VLFH - Pre-op VLFH)/Pre-op VMLH]*100
• Vertical Brow Peak Elevation (percent) = [(Pre-op VBPH - Pre-op VBPH)/Pre-op VBPH]*100

Results/Complications

:

• There were no complications.
• Mean reduction in vertical midline forehead height (VMFH) was -31.8 +/- 3.8 mm representing a relative change of -19.6% +/- 4.6%.
• Mean reduction in right vertical lateral forehead height (right VLFH) was -27.8 +/-1.3 mm representing a relative change of -18.8% +/- 4.2%.
• Mean reduction in left vertical lateral forehead height (left VLFH) was -28.2 +/-0.9 mm representing a relative change of -20.4% +/- 1.5%.
• Mean elevation in right vertical brow peak height (right VBPH) was +3.2 mm +/0.8 mm representing a relative change of +9.1% +/- 2.7%.
• Mean elevation in left vertical brow peak height (left VBPH) was +3.1 mm +/0.9 mm representing a relative change of +9.9% +/- 4.5%.

Case Series

Figure 5: 48 year old woman underwent biplanar forehead reduction and subcutaneous browplasty with results at 12 months. Concomitant deep plane face and neck lift and closed rhinoplasty were also performed. (Patient of ANR)

Figure 6: Pretrichial scar healing 12 months post-operatively is optimal due to tensionless closure using “pilot incision/tailor tacking method of Manson”.

Conclusion: Biplanar forehead reduction and “gliding” or endoscopic approach browplasty with temporary percutaneous fixation achieves up to 20.4% reduction in forehead height, and up to 9.9% lateral brow elevation. This novel technique is safe and effective to improve aesthetic proportion of the upper facial third with SON preservation and optimal scar healing.

Key Points:

• Biplanar forehead reduction and browplasty is effective to optimize forehead and brow aesthetics.
• Preservation of the deep and superficial branches of the SON is facilitated by biplanar (medial subperiosteal and lateral subcutaneous) dissection relative to the point of Knize.
• The surgeon is given total control of incisional tension by cranial fixation of scalp flap and Manson’s method of tailor tacking of excess forehead skin.