THE FOREHEAD
Multivariate in size and shape, the forehead comprises a significant proportion of our frontal facial appearance. Our foreheads can help us to express such emotions as concern, anger, surprise, and even a quizzical look. Moreover, our foreheads can betray us by having “frown lines” which can be misinterpreted as angry scowl.
The most common reason for performing cosmetic surgery on the forehead relates to aging changes. Concerns about low eyebrow position, excessive wrinkling, or a hairline that is too low or too high are the common reasons for consultation. Sometimes, when a person desires treatment regarding excessive upper eyelid skin, the real problem is that the eyebrows have descended with age. Occasionally, a patient is concerned about the bony contour of the forehead.
The most commonly performed cosmetic surgery of the forehead is a browlift, or forehead lift. This procedure can improve several, often concomitant, problems. It can raise and shape the eyebrows, improve the appearance of the upper eyelids, smooth transverse forehead lines, and smooth vertical interglabellar lines. The surgical approach is most often via three to five small incisions behind the hairline. An endoscope is usually used to visualize the dissection. A single long incision behind the hairline can also be used. It is important to dissect beneath the superficial tissues of the forehead. Although the usual plane of dissection is subperiosteal, the subgaleal or subcutaneous planes are used at times. This dissection extends over the supraorbital rims, where the periosteum is carefully incised or freed, taking care to avoid the supraorbital nerves. Dissection is carried beyond the adherence of the periosteum to the temporal line and onto deep temporal fascia, while avoiding traction or irritation of the frontal branches of the facial nerve. A “sentinel” vein crosses the anterior portion of this adhesion. Commonly, the muscles that cause vertical interbrow frown lines (corrugator supercilii, etc.) are at least partially removed. Care is taken to avoid damage to the supratrochlear nerve branches, which run through these muscles. The frontalis muscles, which elevate the brows while causing transverse forehead wrinkles, can also be modified in some (unusual) cases. The lateral ends of the brows usually need to be elevated more than the medial ends. If the left and right brows are at unequal levels prior to surgery, the lower brow must be significantly overcorrected, and perfect symmetry cannot be guaranteed. To a limited degree, the bone of the supraorbital rims or brow can be shaped. It is also possible to place an implant to contour part of the forehead.
At times, a primary concern is that the forehead is too high, meaning excessive distance from the brows to the hairline. In this case, the incision is placed along the hairline from temple to temple, the browlift is performed, and excess skin can be excised. Great care is taken to disguise the resulting scar, as it will lie along the hairline. Creating some hairline irregularity, and beveling the edge of the skin so that hair can grow through this bevel to disguise the scar, can be helpful. For men, it is assumed that the hairline will recede with age, causing a scar to become visible, even years later. In some cases it is helpful to make a long browlift incision that follows the hairline back to the balding crown of the head so that excess skin excision reduces the surface area of bald scalp. This also creates access to raise the hair-bearing scalp, allowing even more removal of bald scalp. (This is called a scalp reduction.)
Several methods are available to stabilize the forehead in its new position. I currently place small absorbable screws into the calvarium. Long-lasting absorbable sutures (3-0 PDS) secure the repositioned forehead. The forehead tissue (between skin and bone) is about 8mm thick (much thicker than most people would guess). Excess hair-bearing scalp “bunches up” behind the area of fixation. We used to excise this large lump, but the lump does flatten spontaneously over several months, and allowing nature to shrink this excess scalp results in less hair loss and less scarring.
Although any surgery is painful, there is generally less pain after forehead surgery than one would expect, but a headache is common. Swelling and bruising drift downward to the periorbital areas, where the skin is looser (causing “black eyes”). Paresthesia or anesthesia of the forehead and scalp are common, but this is usually temporary. The ability to raise one or both eyebrows may be lost as a result of irritation of the frontal branch of the facial nerve, but fortunately normal movement usually returns after a few weeks or months. Although some over-elevation is sometimes done to counteract relapse, if the brow stays too high the patient may have a “surprised look”. This appearance is even less acceptable in men. Yet if the brow does not seem adequately elevated, the patient may feel that the surgery was for naught. Naturally, perfection is the goal.
Fortunately, there are alternatives to forehead surgery. If the primary concern is vertical “frown lines” between the eyebrows, BotoxR is an easy and low-risk solution. Many patients can break their habit if frowning with the aid of BotoxR, so that it does not have to be repeated every three or four months. If the eyebrows are naturally rather high, and if there are unwanted transverse forehead creases, BotoxR is again a good alternative. However, more often the transverse forehead creases result from a habit of raising eyebrows that would otherwise be too low. In this situation, BotoxR causes the brows to drop, crowding the upper eyelids. There is now an alternative botulinum toxin to BotoxR, called MyoblocR. MyoblocR lasts much longer on the shelf, but the duration of its clinical effect on muscle movement is less.
As an aside, I should mention that I see a number of patients who have eyebrows that are only slightly low, and excess wrinkled skin on the upper eyelids. The ideal aesthetic solution would be a forehead lift and upper eyelid surgery. But many people would prefer only upper eyelid surgery, as I usually perform this under local anesthesia. This causes minimal discomfort, less risks, the recovery is rapid, and it saves the patient money.
So, we can use our foreheads to add to our expressiveness, or we can choose to not to have this vehicle of expression. We can use pharmaceutical or surgical means to alter our foreheads, and these means can be used to modify our habitual expressions. It is interesting that we can do so well with a smooth and less mobile forehead, if that is our informed choice.