Frontoplastia Barranquilla lipolisis Soledad Malambo Sabanalarga


Cirugia de frente | Lifting frontal


point where the imaginary line ends, drawn up between the facial alar furrow and the lateral canthus [32] (Fig. 43.6). In men, the eyebrow takes a horizontal line shape to level the orbital rim. With this reference it is understood that the major efforts put in the repositioning of the feminine eyebrow must be directed toward the elevation of the lateral portion; in men the final elevation of the eyebrow must leave the middle portion and the lateral one approximately to the same height preventing in the patient feminine features. 43.6 General Indications Traditionally, the main indications for forehead-lift include: 1. To elevate the ptotic eyebrows 2. To correct asymmetry of the eyebrows Fig. 43.5 Simulation of the final desired position of the eyebrow and marking in the superior eyelid for the resection of the redundant skin (Photo courtesy Dr. Jaime Ramirez) Fig. 43.6 The ideal position of the eyebrow in women is observed (Photo courtesy Dr. Jaime Ramirez) 480 J. Ramirez et al. 3. To reduce (a) The palpebral redundant skin (b) The frontal furrows (c) The glabella furrows (d) The lines of the lateral canthus expression 4. To elevate the aesthetic unit of the forehead 5. To modify, when desired, the implantation line of the hair 6. To diminish the extension of the frontal skin, when it tends to be redundant These indications can be presented singly or in conjunction, doing necessary to consider in each case, the best way of possible approach. Intervening a young patient with an asymmetry of the eyebrow without any mark of the glabellar furrows, and a male patient, an adult with scarce hair and frontal marked furrows is not the same. In literature, the technique and approach terms are frequently distorted, which generates confusion. For the authors, the approach is used to indicate the place where the incision is realized and the used plane for the dissection, whereas the technique refers to the intervention of the repair points and the suspension mechanism that is used for the correction of the eyebrow ptosis and the reduction of the frontal furrows. 43.7 How to Choose the Approach and the Technique? The technique must be individualized for each patient. Sex, age, physical features, and expectation should be considered. In order to define the way to approach and the technique of frontal suspension the following must be analyzed: degree of ptosis, depth level of the furrows of the skin, eyebrows asymmetry, amount of redundant skin, and the implantation pattern of hair. 43.7.1 Frontal Ptosis Degree The higher the ptosis degree, the more aggressive the suspension techniques must be, whether this is done through opened or closed approach. 43.7.2 Depth of the Skin Furrows In patients, especially old men with tendency to baldness and with pronounced frontal furrow, the incisions can be camouflaged in the furrow, allowing a direct approach of the frontal region to suspend. 43.7.3 Asymmetries The direct approach allows a more precise correction of the asymmetric position of the eyebrow. It would not be an option in patients that do not require a treatment in other areas of forehead and accept a possible visible scar. 43.7.4 Frontal Redundant Skin This implies the necessity of exeresis for which the open approach of pretrichal type or trichial allows edge to edge suspension. 43.7.5 Implantation Pattern of the Hairline This can also condition the selection of the approach for the eyebrow and forehead suspension. Once the objectives of the procedure are defined, which can be directed to attenuate the strong expression of the glabella muscle spasms or revert and to correct the asymmetry of the eyebrow position, the approach must be selected considering the line of the hair implantation that can commonly be influenced in men by genetic factors like the alopecia. On the other hand, the line of high implantation in women causes that the approach selected do not elevate the hairline even more and can even facilitate the manipulation to diminish the length of the frontal skin, standing out in this situation the pretrichial–trichial approach (Fig. 43.7). 43 Forehead Lifting Approach and Techniques 481 a b c Hair implantation Normal or low Coronal /endoscopic Approachment Hair Approachment implantation Raised (elevated forehead) Pre-triquial Hair implantation Approachment Opening, severally retracted and /or baldness Direct mediofrontal/ Ciliary Fig. 43.7 The implantation lines of the hair and the corresponding approach options are observed 482 J. Ramirez et al. An approach can be chosen, according to Lazor and Cheney [33], considering the implantation line of the hair as it is observed in Fig. 43.7. 43.8 What Fixing Approaches and Techniques Do We Use? (a) Coronal (b) Pretrichial/Trichial (c) Medio-Frontal (d) Direct Eyebrow Lift (e) Endoscopic 43.8.1 Coronal Nowadays a facial approach is rarely used. Dissection plan: Subgaleal Advantages: An excellent exposure and direct access to the frontal myotomy. Disadvantages: It is an invasive surgical approach; there is a risk of hematoma, elevation of the implantation line of the hair and alopecic scar. This can produce vertical enlargement of the forehead. It is not used for the scar and has limited uses in men. 43.8.2 Pretrichial/Trichial

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