Achieving Permanent Forehead Rejuvenating Effects by Purposeful Transection of the Frontal Nerves and Periosteal Scoring.

Abstract

For over 100 years, forehead lift surgery has undergone a significant evolution in technique—from the traditional coronal approach, to the minimally invasive endoscopic forehead lift, to the combining procedures of endoscopic and temporal brow lift.1,2 Botulinum toxin injections and thread-lift sutures have been effective additions to techniques available to plastic surgeons for forehead lift, but only give temporary aesthetic improvements.2,3 Long-lasting forehead rejuvenation is a common pursuit for both surgeons and patients. Is it possible to have a kind of forehead-lift technique that provides permanent rejuvenating effects? And what is the tradeoff of the procedure? In the article published previously by the senior author (S.C.L.), “Surgical Treatment of Facial Siliconoma Involving the Temporal Area,”4 the then–43-year-old woman developed forehead siliconoma following liquid silicone injections for cosmetic purposes. Excision of the foreign bodies resulted in depression deformities in the central forehead and glabella areas. These conspicuous nodular indurations of the face caused embarrassment, anxiety, and phobic avoidance of her social life. She was nicknamed “sunset lady”––because she was too afraid to go out during the daytime and reveal the marks on the face. To solve her problems, radical resection of the siliconoma and forehead and temporal lifts were simultaneously performed to remove the redundant scalp skin by bicoronal zigzag incisions. Having obtained the patient’s informed consent for the procedure, we transected the bilateral frontal nerves embedded in the hard textured siliconoma purposefully during surgery. Postoperatively, she was pleased with the aesthetic results and returned to normal daily activities soon after surgery. Twenty-nine years later, she showed up at my outpatient office, asking for bilateral upper and lower blepharoplasty. Physical examination revealed tight adhesions between the forehead flap and underlying frontal bone without downward drooping of the eyebrows and forehead skin (Fig. 1). The tight forehead skin was unable to be pinched up between the thumb and index finger. [See Video (online), which shows that the glossy forehead skin was unable to be pinched up, 29 years after forehead lift combined with purposeful transection of the frontal nerves and periosteal scoring.] Vertical distances between the medial canthus, midpupil, and lateral canthus and the frontal hairline of the right and left eyes measured 9.8, 8.5, and 7.6 cm and 9.6, 8.4, and 7.4 cm, respectively. Sensory functions including touch, temperature, and pain remained intact. Transection of the frontal nerves and radical periosteal scoring have brought to light maintaining long-lasting forehead rejuvenation. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video shows that the glossy forehead skin was unable to be pinched up, 29 years after forehead lift combined with purposeful transection of the frontal nerves and periosteal scoring.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_b0t416s7"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: The patient demonstrated tight adhesions between the forehead flap and underlying frontal bone without downward drooping of the eyebrows and forehead skin.Radical periosteal scoring provided a space for tight adhesions between the frontal muscles and underlying frontal bone; and transection of the frontal nerves caused paralysis of the muscles, thereby strengthening the adhesions. Simultaneous temporal brow lift with release of the temporal fusion line further tightened the adjacent tissues. Application of the procedures can be beneficial to patients with irreversible unilateral frontal nerve injury caused by trauma, tumor resection, or foreign body removal in the forehead and temporal regions; patients with floppy eyelid syndrome with extreme forehead skin redundancy5; or patients who refuse periodic injections of botulinum toxin for forehead lift. PATIENT CONSENT The patient provided written consent for the use of her images. DISCLOSURE The authors have no relevant financial interest in this article.