03. Elastic lifting of the eyebrow by means of small incisions and minimal blunt dissection
KEYWORDS: lifting of the eyebrow, Elasticum®, elastic suture, two-tipped needle, Jano needle®.
This patient, who had already undergone eyebrow lifting with skin excision, wanted the outer corners of her eyebrows to be raised by another few millimetres. To achieve this, we used the two-tipped Jano needle® to implant a new elastic thread (Elasticum®, Korpo SRL) through two small, inconspicuous incisions. The preoperative design is first drawn and local anaesthesia carried out. The first incision is made at the hairline, above the temporal muscle, and the Jano needle® is inserted in the direction of the eyebrow. The anterior tip of the needle emerges from the skin just beyond the eyebrow. The needle is partially extracted and the elastic thread is pulled through. The depth-marks on the needle indicate the depth of the posterior tip. When the posterior tip of the needle is about 5 mm from the surface of the skin, it becomes anterior and the needle travels back towards the hairline, where it emerges from integral skin in a position lateral to the entry incision. The needle is extracted far enough for the elastic thread to be pulled through. When the posterior tip of the needle is at a depth of a few millimetres, the needle is rotated and changes direction. The tip passes through the temporal fascia, anchoring the thread to this robust anatomical structure. The needle is then withdrawn through the small incision where it entered and the elastic thread is knotted. The knot is then tucked into this small wound. A fragment of haemostatic collagen is used to keep the knot at the desired depth and away from the surface of the skin. The wound is sutured with a few stitches. A small medial incision is now made, again on the hairline. The operator then inserts the periosteal dissector into the incision and begins dissection, which extends downward beyond the orbital border in order to facilitate lifting of the eyebrow. The extent of dissection of the region is proportional to the degree to which the eyebrow is to be raised. In our patient, dissection involved a width of about 3 or 4 cm, enabling the eyebrow to be raised by a few millimetres. Dissection regularises the surface of the skin and contributes to achieving a long-lasting result.
The same procedure is now carried out on the other eyebrow.
A small incision is made at the hairline, above the temporal muscle. The elastic thread is anchored to the temporal fascia; it cannot be adequately anchored medially, where there is no muscle fascia. The Jano needle® is inserted into the small incision, travels across the forehead and emerges partially from the eyebrow. The thread is pulled through. The needle is extracted until only the last few millimetres of the posterior tip remain in the skin. This manoeuvre is facilitated by the depth-marks on the needle. The posterior tip of the needle now becomes anterior and travels back towards the hairline, emerging in a position lateral to the entry incision. The two-tipped needle is extracted far enough to allow the thread to be pulled through. It is now extracted further, though not completely. The depth-marks enable the operator to maintain 5 mm of the tip inside the tissues so that the needle can be rotated and made to penetrate into the muscle fascia in order to anchor the elastic thread. The needle emerges from the entry incision and the thread is knotted. A fragment of haemostatic collagen keeps the knot at the desired depth inside the small incision. A small medial incision is now made in order to perform subperiosteal dissection. Dissection does not involve any risks as it is carried out below the temporal branch of the facial nerve. On completion of the periosteal dissection, the second incision is sutured. The elasticity of the thread ensures that traction on the eyebrow is maintained and enables the periosteum to fix itself in a more elevated position, thus making the result stable.
The elastic thread is implanted before subperiosteal dissection and dissection of the deep temporal fascia. On completion of dissection, the eyebrow rises owing to the elasticity of the thread under tension.
Capurro S., Rava C. (2007): Elastic lifting of the eyebrow by means of small incisions and minimal blunt dissection. CRPUB Medical Video Journal. Elastic Plastic Surgery section. http://www.crpub.org
What sort of medication is required?
The patient wears an elasticated headband for a few days, which accelerates the disappearance of swelling.
Does the direction of traction always have to be vertical?
The elastic thread has to be fixed to the temporal muscle fascia. Traction may be almost vertical, as in this patient, or oblique, in accordance with the patient’s wishes. If the traction is very oblique, dissection is carried out immediately above the deep temporal fascia.
The procedure shown in video publication (3) has been replaced by elastic lifting of the eyebrows and temporal regions without dissection (21 and 30).
In our experience, dissection above or below the periosteum is of no use. In this procedure, the suspensive triangle has too acute an angle, which does not offer sufficient guarantee that the result will be maintained over time. As the cavity housing the knot has been created on the bone surface, the knot is palpable and may cause ulceration. The cavity housing the knot must always be deep and sufficiently broad: on the temporal fascia, in the soft tissues or muscle tissues, or at the bottom of bony fossae (30) – never on the bone surface.
The current procedure, which has replaced elastic lifting of the eyebrows by means of small incisions and minimal dissection (3), is carried out through an incision of a few millimeters; the incision is made at the hairline, in the upper part of the temporal fascia, and lifts not only the eyebrows but also the temporo-orbital region, thereby brightening the patient’s look. In this procedure, the lifting effect is exerted on the palpebral skin and not on the skin of the forehead.
If there is considerable distance between the eyebrows and the hairline, a second thread is implanted in order to distribute the excess skin. If the temporal fossa is conspicuous or presents irregularities, it is levelled by grafting adipose and stromal cells (Adipofilling). (30/07/15)