Redução da região frontal com incisão pré-capilar : relato de experiência e indicações Forehead reduction using precapillary incision : experience report and indications

Background: A long forehead can give a less attractive and disproportionate appearance. It may also indicate aging. The objective of this study is to show the experience of the authors in forehead reduction using precapillary incision and to support the indications for this procedure. Methods: Patients who underwent precapillary incision for forehead reduction between 2005 and 2011 were retrospectively analyzed. The indications for an anterior hairline incision were eyebrow ptosis in patients with thin and sparse frontal hair, congenital long forehead, or extensive forehead wrinkles. Results: Precapillary incision was performed in 31 patients, who were followed up for an average of 1.5 years. No problems related to flap vascularization were detected. All patients reported temporary paresthesia, from which they recovered within 1 year. Three patients presented seromas during the postoperative period and were treated using puncturing. All patients reported that the benefits of altering the hairline were greater than the disadvantages of a possibly more visible scar. Conclusions: Frontal rhytidectomy using precapillary incision is recommended in patients who wish to correct thin and sparse frontal hair, extensive forehead wrinkles, or congenital/ senile long forehead.


INTRODUCTION
In 1926, Hunt 1 reported an anterior hairline incision with skin removal to correct forehead wrinkles.In 1961, Pangman & Wallace 2 used the same approach for the correction of forehead wrinkles and eyebrow ptosis.In 1965, Uchida 3 described an anterior hairline approach, with galeal and subcutaneous isolation of the frontal muscle.In this method, the upper portion of the skin was removed and the lower portion of the frontal muscle was sutured to the skin flap.In 1973, Rees & Wood-Smith 4 reported the possibility of cir culatory impairment and hair loss associated with subcutaneous dissection when a coronal approach was used.In 1982, Connell et al. 5 recommended the anterior broken-hairline incision, with subgaleal dissection.The authors also em phasized the necessity of meticulous closure of the layers to obtain satisfactory results.
The normal proportions and the main units of the face have already been defined and are used to evaluate the size of the forehead, which is the segment extending from the glabella to the frontal hairline [6][7][8] (Figures 1 and 2).A long forehead can give a less attractive and disproportionate appearance.Moreover, it may indicate aging.
The aim of this study is to report our experiences in forehead reduction using precapillary incision and to support the indications for this procedure.

METHOD
This is a descriptive retrospective study, which was performed by analyzing the medical records of patients who un derwent facial rhytidectomy with forehead reduction using precapillary incision between 2005 and 2011.
Patients complaining of eyebrow ptosis and long foreheads were divided into 3 groups according to the length of their foreheads as follows: (1) patients with eyebrow ptosis and slight forehead elongation; (2) patients with moderate forehead elongation; and (3) patients with severe forehead elon gation, who were candidates for forehead reduction using precapillary incision.
The primary indications for anterior hairline incision are eyebrow ptosis for patients with thin and sparse frontal hair, congenital long forehead, or extensive forehead wrinkles.Another indication is a clear interest shown by the patient for the procedure.Otherwise, a coronal approach is commonly used to obtain upper facial rejuvenation.

Procedure
To determine the severity of eyebrows ptosis and to plan the extent of forehead reduction desired, patients we re examined in the orthostatic position.Surgeries were performed under general anesthesia and were performed along with other cosmetic procedures.A broken-line incision was mar ked in the anterior hairline, immediately behind the junc tion of the hair with the forehead (Figure 3).
Local infiltration with 0.9% saline solution and epinephrine in a 1:200,000 proportion was applied to the incision site and the area to be dissected.As soon as the effect of Reproduced from Marten 17 .

Figure 2 -Facial disproportion and aging.
In A, the young face is divided into 3 equal parts.In B, the aged face, the superior one-third of the face (forehead) is generally larger than the medial and lower segments.Reproduced from Marten 17 .
A B epinephrine set in, a subgaleal incision was performed along the skin marks and the distribution of the hair follicles 19 (Figure 4).Precise dissection with scissors was performed to separate the skin from the septa that strongly adheres to the fron tal muscle (Figure 5).Then, after gaining access, the subga leal plane could easily by was easily dissected.Atraumatic tissue handling was important to prevent vascular impairment.The dissection was extended up to the supraorbital bilateral rim, and if necessary, to the nasal dorsum.The scalp was dissected up to the parieto-occipital region to ensure easy advancement of the flap.At this point, an easy access to the frontal, procerus, and corrugator muscles rendered easy dissection possible, when necessary (Figure 6).The supratrochlear nerve and veins are located in this region; therefore, the surgeon should act cautiously to avoid inadvertent injury.Homeostasis was achieved, the region was irrigated, and the flap was subsequently repositio ned.The excess skin was marked and gradually removed to avoid excessive tension on the scar (Figure 7).Suturing was performed in planes using 4.0 and 5.0 monofilament nylon threads.
The quantity of skin incised in the brow-lift varied.No drains were used; however, a pressure-dressing pad was applied.Because applying hot water or ice could cause injury to the dormant tissue, specific guidelines were provided to the patients to prevent possible complications.Stitches were removed 7 to 10 days after surgery.

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Forehead reduction using precapillary incision: experience report and indications

RESULTS
Precapillary incision was performed in 31 patients, 30 women and 1 man, who were followed up for a period ranging from 3 months to 5 years, with an average follow-up of 1.5 years.
One patient complaining of a long forehead underwent a secondary rhytidectomy procedure, which was performed 3 years after treatment of the middle and lower one-third part of his forehead.
No patient in this study presented with flap vascularization complications.Hematomas, hypertrophic scars, facial nerve lesions, alopecia, or infections were not observed.
All patients reported temporary paresthesia, but 87% of them showed sensory recovery within 6 months and the rest within 1 year.Three patients (9.67%) presented with postoperative seromas, which were treated using puncturing.All patients reported that the benefits of forehead reduction were greater than the disadvantages of a possibly more visible scar (Figures 8 and 9).

DISCUSSION
Basic forehead-lift procedures have been reported since 1926.These procedures are similar to a mini facelift or early rhytidectomy, in which small ellipses of skin are resected, with minor or no morbidity.Currently, there is a better understanding of the periorbital aesthetic unit as well as the functional anatomy of the muscular groups in this region, which with the passage of time, results in the accumulation of muscular actions, thereby generating dynamic and static wrinkles.Dynamic wrinkles are efficiently treated and can be smoothened using botulinum toxin.However, there is a general consensus that treatment of static wrinkles requires the use of other techniques such as fillers and surgical procedures, which can be endoscopic or can involve conventional open surgery.
To optimize the results of surgery, an individualized approach becomes necessary.Therefore, the endoscopic procedure or bicoronal incision provides better cosmetic results in patients with standard normal hair and a low anterior hairline.In contrast, precapillary incision is the best indication in patients with a high anterior hairline insertion (long forehead), extensive wrinkling, or very thin skin 6,9-18 .In our experience, we have performed extensive subgaleal detachment, advancing the flaps from the forehead and scalp, without detecting cases of alopecia or flap necrosis.Moreover, we did not require to perform galeatomy or rigid fixation of the flap (with screws), as described by other authors 15,17 .The patients should be asked to stop smoking 30 days before the procedure and during the postoperative period.The results obtained with the endoscopic procedure in the first 10 years of experience were satisfactory, although published studies suggested the existence of a learning curve and early recurrence of ptosis, which discouraged many surgeons 9 .However, recent advances in fixation techniques have led to longer lasting results and better acceptance of the procedure.Therefore, the endoscopic procedure is currently seen by many surgeons as the best option for forehead reduction, eyebrow ptosis correction, and periorbital and frontal muscle treatment, as it allows good visualization and minimal morbidity [10][11][12] .
Rodrigues Neto JN et al.
In many institutions, the endoscopic technique has be co me the most commonly performed procedure, whereas the conventional open technique has assumed a lesser role, creating certain stereotypes that cannot replace the knowledge and pre-existing experience associated with open surgery.
Several difficulties associated with open procedures, which account for poor acceptance by the patient and high morbidity, are frequently described in the literature.However, during conventional open procedures, many experienced surgeons have reported patient satisfaction and a complication rate comparable to or lower than endoscopic techniques 7,18 .
Experienced surgeons require little special equipment to provide long lasting results with open procedures.For many patients, the benefits of forehead reduction, with hairline lowering, exceed the disadvantages of an anterior hairline position and the possibility of a more visible scar.

CONCLUSIONS
Frontal rhytidectomy using precapillary incision is commonly indicated in patients who wish to correct thin and sparse frontal hair, extensive forehead wrinkles, or a congenital/senile long forehead.In these cases, a frontal facelift is recommended.
The technique of forehead reduction using precapillary incision is safe and enables an easy brow-lift, with ten sionfree closure and acceptable scars.Moreover, it provides good access to treat the underlying muscles.The success rate that we have experienced with this approach has led us to recommend this procedure to selected patients.

Figure 1 -
Figure 1 -For a proportional face, the height of the forehead should correspond to one-third of the total facial height.Reproduced from Marten 17 .

Figure 3 -
Figure 3 -In A, precapillary broken-line mark.In B, forehead size measurement.In C, advancement of the flap.

Figure 4 -
Figure 4 -Effect of hair follicle orientation in a visible scar with beveled incision.Figure extracted from Mowlavi et al.19 .

Figure 7 -
Figure 7 -In A, folded frontal flap and subgaleal parieto-occipital dissection.In B, excess skin mark after advancement of the flap.

Figure 8 -Figure 9 -
Figure 8 -In A and D, right and left preoperative profile, respectively.In B and E, right and left postoperative profile, respectively, 6 months after surgery.In C and F, precapillary aesthetic scar, easily concealed by hairs.