THE ANCHOR SUBPERIOSTEAL FOREHEAD LIFT

The coronal incision used for brow lift procedure has a high rate of l ocalized alopecia, widening, and depression of the scar at the suture line. Other sequelae of the standard coronal brow lift incision proced ure are ''stretchback'' with a recurrent brow ptosis, poor brow elevat ion, and numbness beyond the incision line. Factors causing alopecia a re tension, use of a monopolar cautery, use of key sutures with undue tension, one-layer closure, and sutures left too long. Recurrent brow ptosis may be due to anterior displacement of the posterior scalp flap , stretching of the anterior frontal skin flap, or insufficient power of the weakened frontalis muscle. Poor brow elevation may be due to un satisfactory dissection on the glabella and orbital rims. Numbness and itching beyond the incision line are due to a low coronal incision. T o avoid these problems, the following principles were followed: (1) If not contraindicated, the incision is made high on the vertex of the h ead, posterior to a biauricular line. (2) The pericranium is included in the frontal flap starting at the incision lines. (3) The subperiost eal dissection is continued down to the orbital rims and nasal bones. (4) The release of the periosteum at the arcus marginalis or just abov e allows repositioning of the brow structures. (5) The inelastic peric ranium maintains the position of the elevated structures and avoids st retching of the frontal skin. (6) The integrity of the frontalis muscl e is maintained completely. (7) Two large triangles of scalp resected in the posterior flaps allow fixing the position of the posterior scal p and match better the length of the anterior flap. (8) The galea peri osteal rim flap allows anchoring of the frontal flap to the undersurfa ce of the posterior scalp flap. This stabilizes the closure with minim al tension on the hair-bearing portion of the scalp. The wide surface of contact avoids depression and widening at the suture line. (9) Clos ure with Skin staples avoids constriction of the hair follicles. (10) Hemostasis is done with a bipolar cautery. (11) No through-and-through key sutures are used. Some of these principles were introduced to the endoscopic subperiosteal forehead lift. The modifications mentioned a bove have been used in 92 open brow/face lift procedures with excellen t aesthetic and functional results and minimal complications.