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Minimally Invasive Treatment of Dynamic Horizontal Forehead Lines

Citarella, Enzo Rivera, M.D.; Sterodimas, Aris, M.D., M.Sc.; Condé-Green, Alexandra, M.D.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 438e-439e
doi: 10.1097/PRS.0b013e3181bcf5a7

Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Institute, Rio de Janeiro, Brazil

Correspondence to Dr. Sterodimas, Department of Plastic Surgery, Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Institute, Av. Beira Mar 406, Rio de Janeiro, Brazil

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Facial mimetic muscle action reveals itself over time by means of the development of forehead rhytides. Plastic surgeons have at their disposal several effective medical and surgical interventions to address these changes.1,2 Each technique has merits and suitable applications. Since the introduction of endoscopic surgical techniques, an evolution from the standard coronal forehead lift to a minimally invasive one has occurred. The treatment of facial lines though, with botulinum toxin type A, has truly changed the concepts held by physicians regarding facial rejuvenation, mainly on the upper aspect of the face. It is one of the most common cosmetic procedures currently performed by physicians.2 We report a new surgical approach for the treatment of dynamic horizontal forehead lines.

A 57-year-old woman with dynamic forehead lines is shown in Figure 1. The expected path of the supraorbital and supratrochlear neurovascular bundles through preoperative marking of their meridians is respected. After infiltrating the forehead with lidocaine 0.5%, bupivacaine 0.125%, and epinephrine 1:240,000, subperiosteal dissection is performed without the use of an endoscope by means of a unique 1-cm median intracapillary incision 0.5 cm behind the hairline. The dissection is safe until 1.5 cm above the superior orbital rim and laterally until an imaginary line that crosses the lateral border of the pupil (Fig. 2). On completion of dissection, a knife with a no. 15 blade is inserted and multiple vertical myotomies are performed. Depending on the extent of the horizontal forehead lines, usually five to seven vertical and horizontal myotomies are performed. Postoperative Micropore taping of the forehead for 48 hours is recommended. No postoperative complications were noted apart from swelling, which lasts 5 to 7 days. The patient expressed her satisfaction regarding the final result. The postoperative view 1 year after treatment is shown in Figure 3.

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

Fig. 3.

Fig. 3.

The frontal myotomies performed under direct visualization during a coronal lift have been proven to be an effective treatment for the dynamic horizontal forehead lines.3 The endoscopic forehead treatment avoids many of the undesirable results of the coronal approach yet remains very efficacious for the treatment of forehead lines. However, it is expensive and has a significant learning curve. The use of injectable agents, specifically botulinum toxin type A, has risen dramatically over recent years for the treatment of forehead transverse lines, because of the increased demand for minimally invasive techniques. However, the cost of botulinum toxin type A remains one of the primary concerns for repeated application, and patients seek a more definitive treatment.4,5

This nonendoscopic, low-cost, easy-to-perform procedure has not been previously described and provides another option that can be used for the treatment of horizontal forehead lines. Further cases need to be performed to better define long-term results.

Enzo Rivera Citarella, M.D.

Aris Sterodimas, M.D., M.Sc.

Alexandra Condé-Green, M.D.

Department of Plastic Surgery

Pontifical Catholic University of Rio de Janeiro and the Carlos Chagas Post-Graduate Medical Institute

Rio de Janeiro, Brazil

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1. Rohrich RJ. Advances in facial rejuvenation: Botulinum toxin A. Hyaluronic acid dermal fillers, and combination therapies—Consensus recommendations. Editor's Foreword. Plast Reconstr Surg. 2008;121 (5 Suppl.):1S–2S.
2. Presti P, Yalamanchili H, Honrado CP. Rejuvenation of the aging upper third of the face. Facial Plast Surg. 2006;22:91–96.
3. Carruthers JD, Glogau RG, Blitzer A. Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: Botulinum toxin type A, hyaluronic acid dermal fillers, and combination therapies—Consensus recommendations. Plast Reconstr Surg. 2008;121 (5 Suppl.):5S–30S; quiz 31S–36S.
4. Flowers RS, Ceydeli A. The open coronal approach to forehead rejuvenation. Clin Plast Surg. 2008;35:331–351; discussion 329.
5. Lee H, Saladi RN, Fox JL. Cohort study on patient response to botulinum toxin cosmetic therapy. J Cosmet Dermatol. 2008;7:39–42.

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