Subperiosteal endoscopic frontoplasty with temporal suture threads fixation
Frontoplastia endoscópica subperiostal com fixação temporal por fios de sutura

INTRODUCTION

The upper third of the face’s aging is characterized by eyebrow ptosis (eyebrows), glabellar and deep, transverse wrinkles in the frontal region¹.

The surgical treatment of aging in this area can be performed using the classic technique of open coronal frontoplasty (FCA), temporal frontoplasty with limited incisions (associated with the treatment of glabellar wrinkles through the upper blepharoplasty incision - described by Knize), and frontoplasty endoscopy (EF)^1,2.

EF was first described by Vasconez^3,4, in the early 1990s, for eyebrow repositioning (“brown lift”). At the same time, Isse⁵ described EF with a subperiosteal approach and myotomy of the musculature of the glabellar region; and, subsequently, Ramirez⁶ presented his series similar to that of Isse⁵ (subperiosteal access and myotomy of the corrugator muscle and the procerus muscle), thus providing a strong technical and scientific basis for EF.

Regarding the ways of fixing the elevated and suspended flap, they can be done through bone tunnels, absorbable screws and sutures of the flap in the deep temporal fascia and the temporal muscle^1,2,7. The flap suturing technique avoids possible bone erosion and infections with screws (foreign bodies)¹.

OBJECTIVE

This study aims to describe the subperiosteal EF technique with myotomy of the muscles of the glabellar region (corrugator muscle, depressor superciliary muscle and procerus muscle) and fixation of the flap in the deep temporal fascia, evaluating its applicability and effectiveness.

METHODS

We retrospectively evaluated 24 female patients who underwent EF associated with upper blepharoplasty, aged between 37 and 72 years, over 10 years (from January 2010 to December 2020), at Lincoln Graça Neto - Plastic Surgery, in Curitiba, PR. Patients with previous frontoplasty surgery were excluded from the study.

Measurements were performed through photographic analysis using the Mirror 6.0 digital imaging system (Canfield Imaging Systems, Fairfield, NJ), measuring the distance between the interpupillary line to the upper portion of the eyebrow in the medial, central and side on each side; preoperatively, and 6 months postoperatively (PO) (Figure 1).

Figure 1 - Example of measurements preoperatively (left) and 6 months postoperatively (right).

Figure 1 - Example of measurements preoperatively (left) and 6 months postoperatively (right).

This study was approved by the institutional review board of our institution and was carried out following the principles of the Declaration of Helsinki (1964).

Operative Technique

Patient in the supine position, administered 1 g of intravenous cefazolin, under local anesthesia (20 ml 2% lidocaine + 20 ml 1% ropivacaine + 160 ml of saline solution + 1:1000 adrenaline) and sedation. The entire frontal region was infiltrated, up to the eyebrows, glabellar region and temporal fossa, extending to the zygomatic arch and prominence of the malar bone.

Five incisions were made on the scalp, one of them in the midline (sagittal), two for sagittal (one on each side) with a length of 1 cm, and two temporal incisions of 3 cm (being these coronal and lateral to the temporal fusion line - LT) (Figure 2).

Figure 2 - Positioning the incisions.

Figure 2 - Positioning the incisions.

The dissection is subperiosteal with an inferior direction in the frontal region up to 2 cm above the orbital rim and laterally up to the TL; here, the periosteum is opened to gain access to the overlying anatomical structures. Laterally, in the temporal region, the dissection is performed below the posterior layer of the superficial temporal fascia and above the deep temporal fascia. The direction is also inferior until reaching the sentinel vein, the orbital ligament, the temporal zygomatic nerves (lateral and medial - sensory) and the lateral canthal ligament (here already in the supraperiosteal plane) (Figure 3).

Figure 3 - In the center the orbital ligament (LO), on the left the subperiosteal plane and on the right the plane below the temporal fascia.

Figure 3 - In the center the orbital ligament (LO), on the left the subperiosteal plane and on the right the plane below the temporal fascia.

The orbital ligament must be sectioned and released with long Metzenbaum scissors, as well as the entire TL, from lateral to medial until communicating the two dissection planes, the lateral one (in the temporal region and below the superficial temporal fascia) and the central one in the region frontal (subperiosteal). Once the periosteum has been incised, the supraorbital and supratrochlear nerves are dissected and preserved, the muscles of the glabellar region are approached, and a partial myectomy of the corrugator, superciliary depressor and procerus muscles is performed (Figure 4). Long curved Kelly forceps are used here.

Figure 4 - Muscles of the glabellar region: procerus (P), depressor superciliary (DS) and corrugator (C).

Figure 4 - Muscles of the glabellar region: procerus (P), depressor superciliary (DS) and corrugator (C).

The flap is fixed in the temporal region, fixing the flap in the deep temporal fascia, as described by Knize1, using nylon threads with 2 “X” stitches (Figure 5). The excess skin (redundant skin) of the flap pulled superiorly is excised; then, simple nylon 4.0 stitches are used for scalp synthesis, and a micropore dressing is applied to the entire area of skin that was dissected.

Figure 5 - Nylon 2.0 stitches in “X” in the temporal region.

Figure 5 - Nylon 2.0 stitches in “X” in the temporal region.

Upper blepharoplasty was always performed after EF to allow the removal of only the real excess skin, thus avoiding cases of difficult upper eyelid occlusion.

The statistical analysis described the variables considered the mean, median, minimum value, maximum value and standard deviation. To compare the two moments of evaluation of the results (preoperative and PO moments), the “Student” t-test for paired samples was considered. P values less than 0.05 indicated statistical significance.

RESULTS

Twenty-four patients underwent surgery over 10 years. The age ranged from 37 to 72 years (Table 1). There was statistical significance in all evaluated eyebrow areas (Lateral part (LP), medial portion (MP) and Central part (CP)), and the mean was 0.3 cm, showing that the result was effective, as there was statistical significance (p<0.05) (Tables 2, 3 and 4 and Figures 6, 7 and 8).

Figure 6 - The results obtained in the study can be visualized in the graph.

Figure 6 - The results obtained in the study can be visualized in the graph.

Figure 7 - The results obtained in the study can be visualized in the graph.

Figure 7 - The results obtained in the study can be visualized in the graph.

Figure 8 - The results obtained in the study can be visualized in the graph.

Figure 8 - The results obtained in the study can be visualized in the graph.

Table 1 - Descriptive statistics of the age of the cases considered in the study.

Table 2 - Descriptive statistics of the lateral portion of the eyebrow at the two evaluation moments and the difference in results (preoperative and postoperative).

Table 3 - Descriptive statistics of the central part of the eyebrow in the two evaluation moments and the difference in the results (preoperative and postoperative).

Table 4 - Descriptive statistics of the medial portion of the eyebrow at the two evaluation moments and the difference in results (preoperative and postoperative).

The null hypothesis of the same CP of the eyebrows was tested in the two evaluation moments versus the alternative hypothesis of different means.

The null hypothesis of an equal MP of the eyebrow in the two evaluation moments was tested versus the alternative hypothesis of different means.

Complications were:

Figure 9 - A. Front view of a 47-year-old patient in the preoperative period. B. Frontal view of a 47-year-old patient in the 6-month postoperative period.

Figure 9 - A. Front view of a 47-year-old patient in the preoperative period. B. Frontal view of a 47-year-old patient in the 6-month postoperative period.

Figure 10 - A. Preoperative front view of a 53-year-old patient. B. Frontal view of a 53-year-old patient in the 6-month postoperative period.

Figure 10 - A. Preoperative front view of a 53-year-old patient. B. Frontal view of a 53-year-old patient in the 6-month postoperative period.

Figure 11 - A. Preoperative front view of a 44-year-old patient. B. Frontal view of a 44-year-old patient in the 6-month postoperative period.

Figure 11 - A. Preoperative front view of a 44-year-old patient. B. Frontal view of a 44-year-old patient in the 6-month postoperative period.

Figure 12 - A. Preoperative front view of a 56-year-old patient. B. Frontal view of a 56-year-old patient in the 6-month postoperative period.

Figure 12 - A. Preoperative front view of a 56-year-old patient. B. Frontal view of a 56-year-old patient in the 6-month postoperative period.

Figure 13 - A. Front view of a 67-year-old patient in the preoperative period. B. Front view of a 67-year-old patient in the 6-month postoperative period.

Figure 13 - A. Front view of a 67-year-old patient in the preoperative period. B. Front view of a 67-year-old patient in the 6-month postoperative period.

Figure 14 - A. Front view of a 43-year-old patient in the preoperative. B. Frontal view of a 43-year-old patient in the 6-month postoperative

Figure 14 - A. Front view of a 43-year-old patient in the preoperative. B. Frontal view of a 43-year-old patient in the 6-month postoperative

DISCUSSION

There are several techniques for treating the frontal region. The most traditional is the ACF, which can be performed either in the subgaleal or subperiosteal plane, allowing the treatment of glabellar wrinkles and good positioning of the eyebrow. As for disadvantages, it determines long or definitive hypoesthesia of the portion posterior to the scar on the scalp, alopecia and extensive and more visible scars^1,2.

Taking these aspects into account, Knize^1,2,7 performed anatomical studies on the temporal fasciae and the positioning of the branches of the supraorbital nerve. From then on, he proposed the technique of temporal frontoplasty with limited incisions associated with the treatment of glabellar wrinkles through the upper blepharoplasty incision. This technique has in its favor the fact that it avoids sectioning the branches of the supraorbital nerve. As a disadvantage, it has the limitation for treating the eyebrow in the medial portion and always having to be associated with upper blepharoplasty to treat glabellar wrinkles.

EF, in turn, allows wide dissection of the flap, maximizing the image with easy identification of important anatomical structures, such as nerves and muscles, good eyebrow repositioning, avoiding scalp hypoesthesia and less chance of alopecia. As a disadvantage, it requires specific training and acquisition of videoendoscopy surgical material^7-9.

The subperiosteal dissection plane used in this study, already proposed in the 1990s by Isse⁵ and Ramirez⁶, presents less bleeding and is below the plane through which the supratrochlear and supraorbital nerve branches pass. That is, it is safer and has less morbidity^5-7. The subgaleal plane also has against it the fact that it has less adhesion and less chance of fixation^10,11.

The most used forms of fixation are the bone tunnel, absorbable screws and fixation of the flap with wires in the temporal region^1,12. Regardless of the form of fixation, the function would be to stabilize the flap until it heals and adhere and does not pull it superiorly in excess because fixation under tension causes recurrence. The bone tunnel technique is quite safe and effective, whereas absorbable screws are financially more expensive^8,9,11. The use of wires with “X” stitches in the temporal region, as described by Knize, has low cost, low morbidity, does not require special equipment for bone drilling, and is very fast and reproducible.

Going in the opposite direction, Troilius¹¹ demonstrated that there was no need for flap fixation due to periosteal adherence. In our country, Casagrande et al.¹³ described temporal fixation using a personalized needle as a successful treatment; and Graf et al.¹⁴ published, in 2005, their 8-year experience with videoendoscopy.

The eyebrow elevation measurement method used was the same proposed by Graf et al.⁸, being easy to perform and reproducible, analyzing and comparing preoperative and 6-month PO measurements. The average brow lift was 3 mm across its entire length - this value was observed in MP, CP and LP. This demonstrates uniformity in the treatment and the effectiveness of the surgical technique used. In the LP, the variation of measurements was from 1.3 to 3.0 mm, with a standard deviation of 0.4 and p<0.001. Regarding complications, there were a low number and no cases of serious complications such as injury to the temporal branch of the facial nerve.

The limitation of this study is that the results were not compared with other fixation techniques, such as the one using bone tunnels.

CONCLUSION

Subperiosteal EF with myotomy of the muscles of the glabellar region and fixation of the flap in the deep temporal fascia with stitches proved to be effective in treating aging of the upper third of the face, with statistically proven results, low morbidity and good aesthetic results.