Arcus Marginalis Research Articles

The Endoscopic Browlift for Forehead Rejuvenation

Since its initial description by Vasconez et al in 1992, the endoscopic browlift has evolved into a popular method for addressing brow ptosis and forehead rejuvenation. The advantages of fewer incisions, less postoperative swelling, alopecia and prolonged scalp anesthesia, and more rapid rehabilitation have provided greater patient acceptance than the traditional coronal approach. Unlike the coronal browlift where the amount of elevation is determined by the amount of skin excised, the elevation in the endoscopic browlift is determined by periosteal release at the arcus marginalis and forehead flap fixation. Though equipment costs are greater and a learning curve exists, the endoscopic browlift offers the oculoplastic surgeon additional beneficial options in the management of brow ptosis.

Refinements in endoscopic forehead rejuvenation.

Endoscopic forehead technique provides an effective method for rejuvenation of the upper face. Distinct advantages of this technique over classic methods of forehead rejuvenation such as coronal or subcutaneous approaches include significant reduction of incisional scars. Described here are three refinements related to (1) control of hair, (2) differential release of the periosteum, and (3) advanced fixation methods. Control of hair can be achieved simply by braiding and the use of an Endoscopic Access Device. Extensive release of the periosteum and arcus marginalis is recommended laterally, while elevating the medial periosteum either intact or with conservative release. Different and technologically more advanced fixation methods are described to provide better control of elevated forehead. Incorporation of these refinements strives to optimize aesthetic results while minimizing operative morbidity. These refinements have been implemented during the care of 29 patients and have proven to be of major value in achieving greater patient satisfaction and technical advancement.

Importance of fat conservation in lower blepharoplasty.

The authors describes her experience in over 200 cases operated on from 1993 to 1996 with the lower blepharoplasty with arcus marginalis release and fat conservation as described by Hamra [Plast Reconstr Surg 96:354, 1995; Clin plast Surg 23:17, 1996]. The overall satisfaction with the somewhat modified technique led the author to abandon completely the conventional type of fat resection. The technique has been used in different clinical situations. The anatomical basis, the technique, and the complications are discussed.

The Anchor Subperiosteal Forehead Lift

The coronal incision used for brow lift procedure has a high rate of localized alopecia, widening, and depression of the scar at the suture line. Other sequelae of the standard coronal brow lift incision procedure are “stretchback” with a recurrent brow ptosis, poor brow elevation, and numbness beyond the incision line. Factors causing alopecia are tension, use of a monopolar cautery, use of key sutures with undue tension, one-layer closure, and sutures left too long. Recurrent brow ptosis may be due to anterior displacement of the posterior scalp flap, stretching of the anterior frontal skin flap, or insufficient power of the weakened frontalis muscle. Poor brow elevation may be due to unsatisfactory dissection on the glabella and orbital rims. Numbness and itching beyond the incision line are due to a low coronal incision. To avoid these problems, the following principles were followed: (1) If not contraindicated, the incision is made high on the vertex of the head, posterior to a biauricular line. (2) The pericranium is included in the frontal flap starting at the incision lines. (3) The subperiosteal dissection is continued down to the orbital rims and nasal bones. (4) The release of the periosteum at the arcus marginalis or just above allows repositioning of the brow structures. (5) The inelastic pericranium maintains the position of the elevated structures and avoids stretching of the frontal skin. (6) The integrity of the frontalis muscle is maintained completely. (7) Two large triangles of scalp resected in the posterior flaps allow fixing the position of the posterior scalp and match better the length of the anterior flap. (8) The galea periosteal rim flap allows anchoring of the frontal flap to the undersurface of the posterior scalp flap. This stabilizes the closure with minimal tension on the hair-bearing portion of the scalp. The wide surface of contact avoids depression and widening at the suture line. (9) Closure with skin staples avoids constriction of the hair follicles. (10) Hemostasis is done with a bipolar cautery. (11) No through-and-through key sutures are used. Some of these principles were introduced to the endoscopic subperiosteal forehead lift. The modifications mentioned above have been used in 92 open brow/face lift procedures with excellent aesthetic and functional results and minimal complications. (Plast. Reconstr. Surg. 95: 993, 1995.)

Arcus marginalis effacement and support of the lower lid by malar skin-fat flap blepharoplasty.

Various methods have been proposed for correction of the arcus marginalis (the externally visible rim sulcus or dark circle) along the lower orbital rim. For correction of lagophthalmos and scleral show of the lower lid, the standard technique has been lateral tarsal suspension. Instead, this method of lower blepharoplasty employs (1) extramuscular undermining and advancement of the skin and malar fat pad overlying the lateral orbicularis and zygomaticus, and (2) direct undermining of the arcus marginalis at the surface of the orbicularis, but without preseptal lid skin undermining and with reduced orbital fat pad excision. This technique evolved over a period of 6 years and, since, has been employed successfully in 85 primary and secondary cases over 5 years. It offers effacement of the arcus marginalis and improved support of the lid margin without the need for tarsal suspension, even in secondary blepharoplasty and in patients with a positive snap test for lower lid marginal laxity. Reoperation has consisted of skin adjustment in 3 patients and an additional orbital fat pad resection in 2 patients. No patient has required secondary tarsal suspension.

Endoscopically assisted biplanar forehead lift.

The standard subgaleal coronal incision used for brow lifting is limited to patients with low foreheads. The subcutaneous hairline brow lift used for patients with high foreheads has a high rate of vascular complications. However, the main advantage of the subcutaneous approach is preservation of sensation posterior to the incision line. The subperiosteal approach, on the other hand, allows a better periorbital remodeling. I have combined the subperiosteal and the subcutaneous approach to take advantage of and minimize the disadvantages of each individual approach. The advent of the endoscopic technique has allowed more accurate and controlled periorbital dissection and brow depressor muscle modification. The operation is indicated in every patient in whom the anterior hairline incision is indicated. It is a good method for decreasing the height of the forehead. The dissection is done initially in the subcutaneous plane, and about halfway on the forehead slit incisions through the galea-periosteal layer and through the temporoparietal fascia are made to continue the dissection in the deep plane. The periosteal dissection and release at the arcus marginalis is done under endoscopic control. Likewise, the brow depressor muscle modification is done under endoscopic magnification. Deep anchoring sutures fix the brow in the elevated position. Trimming and closure of the cutaneous layer are done with minimal tension. The biplanar subperiosteal-subcutaneous forehead lift has been used in 24 patients with very satisfactory results. Complications have been of a minor nature. Patients have maintained sensation posterior to the hairline incision. The height of the forehead has been decreased in every case. Frontalis muscle function has been preserved.

Arcus marginalis release and orbital fat preservation in midface rejuvenation.

With aging, the periorbital area reveals progressive exposure of underlying skeletal anatomy as compared with the lower areas of the face, whose thicker soft tissues continue to cover underlying bony landmarks. With recent techniques in cheek fat repositioning and orbicularis muscle repositioning, rejuvenation results of the midface have been markedly improved. Conventional lower blepharoplasty techniques that remove lower eyelid fat can create a concave contour deformity of the lower eyelids that causes the "operated" appearance. This paper describes a new technique to preserve the lower eyelid fat and to advance it beyond the infraorbital rim. An arcus marginalis release is accomplished, and the subseptal fat is advanced and sutured beyond the entire infraorbital rim and under the repositioned orbicularis muscle. By camouflaging the lower orbital rim anatomy, rejuvenation of the midface is more complete. A total of 152 cases have been done over a 3-year period with impressive results and minimal complications. This procedure is done in all composite rhytidectomies and in isolated blepharoplasty patients without advanced facial aging. It is particularly indicated in secondary procedures correcting overresection of orbital fat or deformities resulting from malar augmentation.

The Anchor Subperiosteal Forehead Lift

The coronal incision used for brow lift procedure has a high rate of localized alopecia, widening, and depression of the scar at the suture line. Other sequelae of the standard coronal brow lift incision procedure are "stretch-back" with a recurrent brow ptosis, poor brow elevation, and numbness beyond the incision line. Factors causing alopecia are tension, use of a monopolar cautery, use of key sutures with undue tension, one-layer closure, and sutures left too long. Recurrent brow ptosis may be due to anterior displacement of the posterior scalp flap, stretching of the anterior frontal skin flap, or insufficient power of the weakened frontalis muscle. Poor brow elevation may be due to unsatisfactory dissection on the glabella and orbital rims. Numbness and itching beyond the incision line are due to a low coronal incision. To avoid these problems, the following principles were followed: (1) If not contraindicated, the incision is made high on the vertex of the head, posterior to a biauricular line. (2) The pericranium is included in the frontal flap starting at the incision lines. (3) The subperiosteal dissection is continued down to the orbital rims and nasal bones. (4) The release of the periosteum at the arcus marginalis or just above allows repositioning of the brow structures. (5) The inelastic pericranium maintains the position of the elevated structures and avoids stretching of the frontal skin. (6) The integrity of the frontalis muscle is maintained completely. (7) Two large triangles of scalp resected in the posterior flaps allow fixing the position of the posterior scalp and match better the length of the anterior flap. (8) The galea periosteal rim flap allows anchoring of the frontal flap to the undersurface of the posterior scalp flap. This stabilizes the closure with minimal tension on the hair-bearing portion of the scalp. The wide surface of contact avoids depression and widening at the suture line. (9) Closure with skin staples avoids constriction of the hair follicles. (10) Hemostasis is done with a bipolar cautery. (11) No through-and-through key sutures are used. Some of these principles were introduced to the endoscopic subperiosteal forehead lift. The modifications mentioned above have been used in 92 open brow/face lift procedures with excellent aesthetic and functional results and minimal complications.

Naso-Jugal Groove Leveling With Fat Tissue

One of the causes of a depressed naso-jugal groove is the fixation of the septum orbitale at the level of the inferior-medial portion of the arcus marginalis. To permit the leveling of the groove, it is necessary to liberate the subjacent orbital septum from its fixation to the arcus marginalis. To avoid recurrence of the depression, some fat tissue is properly placed in the undermined space subjacent to the groove. This can be done by free fat grafting or fat pad sliding.

Transconjunctival Frontalis Suspension (TCFS)

We have devised a frontalis suspension technique originally described in an article entitled, "Transconjunctival frontalis suspension for blepharoptosis" (Trans Am Acad Ophthal Otolaryngol 83:684-92), by Swan and Tongue in 1977. This modified transconjunctival frontalis suspension (TCFS) procedure is described. It has been used at the Oregon Health Sciences University in its original or modified form since 1970. To better understand how this procedure successfully corrects blepharoptosis in patients with poor levator function, a study was undertaken to discern the anatomic relationship of the suspension material to important ocular adnexal structures. The findings are based on gross anatomic dissection and histologic examination of a cadaver eyelid after postmortem transconjunctival fascia lata frontalis suspension. The distal, horizontal limb of the fascia suspends the central portion of the levator aponeurosis in a hammock-type fashion. The two vertical limbs pierce the aponeurosis at the level of Whitnall's ligament and incorporate this ligament. The fascia then exits the orbit through the orbital septum near the arcus marginalis and is incorporated into the frontalis muscle near the junction of the medial one-third and lateral two-thirds of the brow, temporal to the supraorbital neurovascular bundle. This anatomic location is not only relatively easily and safely attained, but also maximizes the principles of more traditional frontalis suspensions while minimizing the effort and surgical manipulation.

Variation in Technique for Frontalis Suspension-Reply

In Reply. —We thank Dr Silver for his comments, and he is correct in suggesting that it is safer to pass the needle from inferior to superior while placing an eyelid plate between the lid and globe. However, while these maneuvers may be safer for some surgeons, we have noted the following difficulties in obtaining the desired effect when using these procedures: We place fascia in a base-down triangle fashion in the eyelids. Maneuvering the needle superiorly would involve its passage with fascia in the eyelet. This is a very difficult and traumatic pass that sometimes results in a tear in the fascia. It is virtually impossible to make the near right-angle turn necessary to change the direction of a needle that is behind the orbital septum at the arcus marginalis to a position anterior to the supraorbital rim and behind the frontalis muscle when passing from inferior

Levator transposition and frontalis sling procedure in severe unilateral ptosis and the paradoxically innervated levator.

Symmetry in severe unilateral ptosis, the jaw-winking syndrome, and ptosis with aberrant third-nerve regeneration is best achieved with bilateral frontalis suspension. However, the levator function needs to be removed in the normal side with unilateral ptosis and bilaterally with the paradoxically innervated levator. Levator transposition to the arcus marginalis is a reversible methods of establishing a complete ptosis. the reversibility of the procedure is demonstrated in the rhesus monkey. The procedure, when combined with frontalis suspension in humans, demonstrates the needed elimination of levator function.