Board Certifications: American Board of Facial Plastic and
Reconstructive Surgery American Board of Otolaryngology - ABO

Procedures :: Surgical


Very often the facial and eyebrow regions are the first areas where marked aging becomes apparent. These are undoubtedly the most expressive part of the face and the eyelid/eyebrow is one of the areas in which subtle improvements may provide excellent aesthetic results, this region is also one of the areas where minor imperfections are easily recognizable and, therefore, aesthetically unacceptable. The facial region, eyes and eyebrows should be assessed individually and as a unit, seeing that their interrelationship should be subjected to a detailed examination prior to the commencement of treatment.

Various factors, such as damage caused by solar rays, gravitational forces and genetic predisposition, contribute toward the loss of skin elasticity, which can result in sagging of the eyebrow. The loss of volume in the superior region of the may also be important. Therefore, a patient’s upper eyelid /eyebrow may exhibit an appearance that does not correspond with the patient’s subjective feelings of good health and vitality.

Apart from the cosmetic issue, there may be functional deterioration of the superior visual field. Furthermore, brow ptosis may have gone unnoticed by the patient. Very often, they complain of excessive overhanging of the skin of the eyelid without realizing that the position of the eyebrow can be an important factor contributing to the appearance of the this “hood” of skin on the upper eyelid. In fact, superior belapharoplasty performed separately may further reduce the eyebrow. It is important that the plastic surgeon informs the patient and emphasises of the importance of the position of the eyebrow in upper eyelid skin redundancy, since, occasionally, only a lift of the eyebrows will resolve the problem.

In this chapter we will describe the aesthetics of the facial region, anatomy, surgical techniques (including the ideal candidates for these procedures), the authors’ preferred procedure and the “treasures” associated with the various techniques.


The scalp consists of the skin, subcutaneous tissue, galea aponeuratica, areola loose tissue and the periosteum. The galea that connects the frontalis muscle to the occipital muscle constitutes the galea aponeuratica. The galea is not only attached to the superficial musculo-apneurotic system (SMAS), but, is also an extension of it. The frontalis muscle originates from the galea (which divides to form a layer enclosing the muscle) and attaches to the skin of the frontal region. It is the main muscle responsible for raising the eyebrow. It actively raises the medial thirds of the eyebrow and passively, the lateral third of this structure. The main depressors of the eyebrow are the corrugator muscles of the eyebrow and the orbicular muscle of the eye and the procerus muscle. The orbicular muscle depresses the entire brow while the procerus and corrugators muscles merely depress the medial segment of the eyebrow. In addition, the corrugator also medializes the eyebrow.

The periosteum above the frontal bone fuses to form the zygomatic arch of the supraorbital notch, which becomes continuous with the periosteum. The temporoparietal fascia (the superficial deep temporal layer) is fused with the periosteum along the temporal line. The deep temporal fascia is found immediately below the temporoparietal fascia, in the temporal region. The deep temporal fascia is attached to the periosteum along the superficial temporal line.

It is at this point that the superficial temporal fascia joins the galea. The point at which the fascia joins is known as the combined fascia or combined tendon and should be separated in an effective manner by means of blunt or sharp dissection when performing a lift along the subperiosteal plane. These planes are distinct from the adipose panicle and located, respectively, above the intermediate adipose panicle and below the temporal adipose panicle.

The motor nerve of the frontalis is the temporal /frontal branch of the facial nerve. This nerve runs exactly below the temporoparietal fascia and is located on the

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