Ptosis

San Diego -- The subcutaneous forehead lift is not a new procedure but an evolving one. It's not a replacement for lifts approached via coronal or endoscopic means, direct excision or transblepharoplasty, but is an addition to the armamentarium. Furthermore, what constitutes an ideal patient is not a function of age but of eyebrow shape, according to Gerald G. Edds, M.D., facial plastic and cosmetic surgeon, Owensboro, Ky. Dr. Edds says the most beautiful position for the female eyebrow places the medial eyebrow at or below the supraorbital rim and the apex in the lateral third of the eyebrow.

"In some procedures, we tend to lift the entire brow complex, including the medial portion," he said at the American Academy of Cosmetic Surgery (AACS) annual meeting here. "The brows end up with a dome shape where the central one-third is the highest point. That can look unnatural and aesthetically unpleasing."

Advantages

Descriptions of the subcutaneous lift first appeared in medical literature about 25 years ago. Few surgeons adopted the procedure until Timothy A. Miller, M.D., presented a simplified approach in 2003. Dr. Edds began experimenting with the technique shortly thereafter and has performed approximately 50 subcutaneous lifts. He attributes the following advantages to the procedure:

* predictable elevation of the lateral brow without increase in vertical forehead height;

* improvement of deep forehead rhytids;

* correction of eyebrow asymmetry;

* minimal risk of permanent sensory changes to the forehead and scalp;

* optional sedation;

* fast (30 minute) procedure, requiring minimal instrumentation; and

* quick recovery with low complication rates.

In experimenting with the technique, Dr. Edds has devised two modifications.

"I bevel incisions to allow hair growth into the scars," he says. "I also use deep sutures for closure. They last at least six weeks and allow the scar to mature better."

More successful

The primary indication for a subcutaneous lift is lateral ptosis. Dr. Edds, who is also an assistant clinical professor of surgery at the University of Kentucky, points out that, while some people inherit this tendency, it more often presents as an early sign of aging. The result is a facial appearance often described as "sad" or "angry."

Addressing ptosis also improves other conditions: accumulations of excess skin in the upper eyelids and in the lateral crow's feet areas, plus deep forehead rhytids.

Dr. Edds notes, "Some periosteal and subgaleal techniques aren't as effective as more superficial ones in removing deep wrinkles."

The subcutaneous lift is not advisable for certain patients. People with significant furrowing in the glabella area, in addition to ptosis, require a surgical procedure that will address both conditions. Women who like to wear their hair pulled back and most men are contraindicated because a hairline scar will begin at mid-eye and extend 4 cm to 5 cm laterally.

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