F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am 14 (2006) 247–251

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Combining Techniques to OptimizeUpper Facial RejuvenationPaul J. Carniol, MDa,*, Sterling Baker, MDb

- Evaluation- Skin rejuvenation- Brow rejuvenation- Transblepharoplasty brow-lift

- Eyelid rejuvenation- Summary- References

To optimize the results of upper facial rejuvena-tion, one should plan to correct all of the tissues af-fected by the aging process. This process starts witha comprehensive evaluation including all of the tis-sue-affected layers, that is, the epidermal, dermal,subcutaneous, musculoskeletal, and associatedlayers. Once this is completed, the options for opti-mal upper facial rejuvenation can be considered.The goal of facial rejuvenation should be a moreyouthful refreshed appearance, not a tighter agedface. Often, more than one procedure is necessaryto achieve this goal. Depending on the procedures,it may be possible to perform them simultaneously,or it may be necessary to perform themsequentially.

Evaluation

The evaluation should start with the facial skin. Arethere signs of photoaging, keratotic changes, pig-mentary problems, dyschromia, or lentigines? Arethere dermal changes, rhytids, telangiectasias, orscars? Is there skin and soft tissue laxity? Is there de-scent of the malar tissues or the brow? Is there lossof soft tissue volume in the periorbital region orbrow region? Is there upper eyelid blepharochala-sis? Is there any brow descent contributing to theappearance of blepharochalasis? Is there any

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underlying upper eyelid ptosis, herniation of thelower eyelid fat, or lower eyelid laxity? Is thereany proptosis? Are there any muscle-induced linesor rhytids? Is there loss or descent of periorbital softtissue contributing to the appearance of lower eye-lid fat pad herniation?

Once these and other questions have been an-swered, the surgeon can begin to select the proce-dures that will best address these issues.

Skin rejuvenation

Currently, multiple techniques are available to im-prove the appearance of the skin and to treatphotoaging changes. These techniques include re-surfacing and nonablative modalities.

In the first author’s (PJC) experience, resurfacingprocedures are the most predictable for treatingphotoaging changes. Most commonly, an erbiumlaser is used. These lasers are manufactured by morethan one company (Friendly Light, Tarrytown, NewYork; Contour, Sciton, Palo Alto, California.). Thelasers can be used to treat mild-to-moderate photo-damage [1]. The erbium:YAG laser has a wavelengthof 2940 nm. It can be used to ablate the photoagedepidermis and, as needed, the papillary dermis. Thislaser has a high absorption coefficient by its chro-mophore, water. With this high absorption

a Department of Surgery, Section of Otolaryngology, The New Jersey Medical School-UMDNJ, Newark, NJ, USAb Department of Ophthalmology, College of Medicine, The University of Oklahoma, Oklahoma City, OK, USA* Corresponding author. 33 Overlook Road, Suite 401, Summit, NJ 07901.E-mail address: pjclaser@aol.com (P. J. Carniol).

s reserved. doi:10.1016/j.fsc.2006.05.001

Carniol & Baker248

coefficient, there is only a small amount of adjacentthermal injury. Furthermore, the laser wavelength isclose to collagen’s peak absorption, 3030 nm.

The significantly higher absorption by water re-sults in a quicker recovery than after resurfacingwith a carbon dioxide laser. Typically, after resurfac-ing with an erbium laser, patients have re-epithelial-ized skin within a week. Usually, the pinknessresolves in 10 days or less [2]; however, dependingon the depth of resurfacing and the patient’shealing, it can persist for 2 to 4 weeks [1]. Whenmore superficial resurfacing is performed, patientscan often resume their activities within a few days.Furthermore, this type of resurfacing can beperformed using only topical anesthesia. Skin con-traction and the formation of new collagen andelastic fibers have been demonstrated with erbiumresurfacing [3].

Although, the erbium laser is the authors’ pre-ferred tool for resurfacing, when deeper skin pa-thology is present, a carbon dioxide laser ora deep chemical peel will be necessary to optimizethe possibility of eliminating the pathology. Bothof these modalities can have a significantly longerrecovery time than erbium laser resurfacing.Furthermore, there is a risk of residual hypo-pigmentation.

Nonablative lasers can also be used to improvethe appearance of the skin. Rather than alter theepidermal layer, these lasers heat the dermal layerto stimulate the production of dermal collagenand elastic fibers. They can be used to treat rhytids,traumatic scars, or acne scars. Several lasers can beused for this purpose, including those with wave-lengths of 532 [4],1064 [5,6], 1320 [7,8], 1450[9,10], and 1540 nm [11]. The main chromophorefor the 532 nm laser is oxyhemoglobin, whereasthe main chromophore for the 1320 and 1450nm lasers is water. The 532 nm laser heats the oxy-hemoglobin molecule, which stimulates cytokinerelease. The lasers that have water as their chromo-phore are used to stimulate the dermis with heat.This heat creates a thermal injury that, with healing,results in neocollagen production. Epidermal cool-ing technology is used to minimize the effects onthe epidermis.

In one recent study, acne scars were treated witha series of four treatments. These treatments werefollowed by two chemical peels using 30% tri-chloroacetic acid (TCA). Analysis of the results re-vealed that there was an improvement in the scarsafter the four treatments with the 1450 nm laser.There was a further improvement after the addi-tional TCA treatments. Response to the treatmentsvaried depending on the type of acne scars. Prior in-vestigators made a similar recommendation for the1320 nm nonablative laser [7,8].

Photoaging changes of the skin can include lenti-gines, dyschromias, and keratoses. These changescan involve all parts of the face, including the upperface. Besides resurfacing lasers and chemical peels,these changes can be treated with a combinationof aminolevulinic acid and blue light therapy. Theapplication time for the aminolevulinic acid beforeblue light therapy varies, and there can be some dis-comfort associated with the treatment. Typically,post treatment, there is some redness of the skinthat can take a few days to resolve. One group of in-vestigators has reported clearance of 90% of actinickeratoses after one treatment [12]. The clearancethat is obtained can vary depending on the regimenused. Some physicians have used intense pulsedlight or a vascular laser in combination with theaminolevulinic acid as an alternative to a blue light.

Although the procedures for skin rejuvenationcan give dramatic results, they typically are not suf-ficient to truly rejuvenate the appearance of the up-per face. Often, the aging changes extend beyondthe skin surface and can only be treated by usinga combination of procedures.

Brow rejuvenation

Besides the skin, it is important to rejuvenate therest of the upper face. This treatment starts withan evaluation of the brow region and brow posi-tion. The critical question in this region is whetherthe brow has descended significantly. Once browdescent has been identified, it can be addressedwith several modalities. These methods includebrow-lift surgery, brow soft tissue augmentation,or Botox injection. The first author frequently com-bines brow procedures with blepharoplasty or skinrejuvenation procedures.

Brow-lift can be performed using three differentapproaches—the more traditional coronal ap-proach and its variations, the endoscopic approach,and the upper eyelid transblepharoplasty approach.Recently, the endoscopic approach has become lesspopular as some surgeons have returned to themore traditional open procedures [13].

The resurgence of the traditional approach relatesto the potential issue of delayed brow descent afterendoscopic approaches. Because of this concern,the controversy over the optimal fixation techniquefor endoscopic and transblepharoplasty brow-lifthas become more significant. Multiple techniquesof fixation have been used for these procedures, in-cluding adhesive, fixation screws, bone tunnels,sutures, and the Endotine device (Coapt Systems,Palo Alto, California). The best comparative analy-sis of fixation efficacy would probably require a ran-domized split face study.

Optimizing Upper Facial Rejuvenation 249

Transblepharoplasty brow-lift

The upper eyelid transblepharoplasty brow-lift isappealing because it can be performed simulta-neously with an upper eyelid blepharoplasty with-out additional incisions and the associatedpotential for incision and upper forehead dissec-tion-related complications. Suture fixation has beenused for this procedure as well as a new transble-pharoplasty Endotine fixation device.

The procedure is performed through the uppereyelid blepharoplasty incision. Dissection is per-formed superiorly in the preseptal suborbicularisplane until the level of the orbital rim. At that level,the dissection is continued subperiosteally to allowadequate brow mobilization for repositioning.A hole is drilled into the bone using a bit providedby Coapt Systems, and the device is placed. Thebrow tissues are then secured on the device (Fig. 1).

In a recent 3-month follow-up review of 65 con-secutive patients who had a transblepharoplasty

Fig. 1. (A–B) Top photograph shows a 56-year-oldwoman who had brow ptosis, upper eyelid blepharo-chalasis, and herniation of her lower eyelid fat pads.She underwent bilateral upper eyelid blepharoplastyand transblepharoplasty brow-lift using Endotines.Bottom photograph shows the result 6 months aftersurgery. Staged laser skin rejuvenation procedurescould further enhance her appearance.

brow-lift with Endotine fixation, 61 of the patientswere pleased with the results. Four patients hada second revision surgery for recurrent brow ptosisor other issues. Six patients had transient neuralgia[14]. Initially after surgery, the Endotine device ispalpable. Because it is composed of a lactic acidand glycolic acid mixture, it absorbs over severalweeks and is no longer palpable. Further follow-upwill be necessary to compare the longer term re-sults with those of transblepharoplasty brow-liftwith suture fixation and alternative brow-lifttechniques.

In some patients, a temporary brow-lift can beachieved by using a combination of hyaluronic acidgel injection to support the brow and Botox. Thehyaluronic acid gel injection is an off-label useand should be performed with careful attention totechnique. The gel is injected deep to the brow toprovide elevation and support (Fig. 2). To maintainthis result, the injection needs to be performedevery 4 to 6 months. This procedure can be usedfor the group of patients who want a noticeable im-provement and do not want surgery. This soft tissuefilling for brow elevation can also be achieved withliposculpture techniques.

Fig. 2. (A–B) Top photograph shows a 60-year-oldwoman who had hyaluronic gel injection in her browregion and Botox in her forehead and lateral canthalregion. Some brow asymmetry has also been cor-rected. Bottom photograph was taken 1 month afterthe injections.

Carniol & Baker250

Eyelid rejuvenation

When the upper face is evaluated, the periorbitalarea should be carefully examined. As part of thisevaluation, multiple questions must be answered.Owing to their intimate relationship, the browregion and the upper eyelids must be consideredtogether. If a significant brow ptosis is present,upper eyelid correction alone may not adequatelyimprove the esthetic appearance. In some patients,if brow correction alone is performed, there may

Fig. 3. (A–B) Top photograph shows a 46-year-oldwoman who had brow and midface descent as wellas blepharochalasis. Treatment included an endo-scopic brow-lift and midface lift with Endotine fixa-tion and a bilateral upper eyelid blepharoplasty. Themidface lift corrected her loss of midfacial volume.Bottom photograph was taken 6 months after surgery.

be a significant improvement in the appearance ofthe upper eyelids without eyelid surgery.

When evaluating the lower eyelids, all related is-sues must be considered. The eyelids should beevaluated for potential or actual laxity. If this is pres-ent, a lateral canthoplasty should be performed atthe same time as the lower eyelid blepharoplastyprocedure.

Another issue that should be considered iswhether there are truly herniating lower eyelid fatpads, volume loss around the lower eyelid fat padsgiving the appearance of herniation, or a combina-tion of both. Volume loss around the lower eyelid

Fig. 4. (A–B) Top photograph shows a patient whohad brow and midface descent. She also had blephar-ochalasis. Treatment included an endoscopic brow-lift, upper eyelid blepharoplasty, and midface lift.Bottom photograph was taken 6 months after thesurgery was performed.

Optimizing Upper Facial Rejuvenation 251

should be treated with liposculpture, fillers, ora midfacial rejuvenation technique (Figs. 3 and 4)rather than with fat removal. In some patients,a lower eyelid fat transfer procedure should beconsidered.

Summary

When evaluating a patient for upper facial rejuvena-tion, one must consider all of the issues that are af-fecting the patient’s appearance. The patient’s upperfacial rejuvenation will often be optimized by com-bining procedures. The combination that is selecteddepends on the patient’s issues and priorities.

References

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[10] Carniol PJ, Vynatheya J, Carniol E. Evaluation ofthe efficacy of acne scar treatment with the 1450nm wavelength laser and trichloroacetic acidchemical peels. Arch Facial Plast Surg 2005;7:251–5.

[11] Lupton JR, Williams CM, Alster TS. Nonablativelaser skin resurfacing using a 1540 nm erbiumglass laser: a clinical and histologic analysis. Der-matol Surg 2002;28:833–5.

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[13] Elkwood A, Matarasso A, Rnakin M, et al. Na-tional plastic surgery survey: browlifting tech-niques and complications. Plast Reconstr Surg2001;108:2143.

[14] Mack PM, Rose JF Jr, Lucarelli MJ, et al. Brow lift-ing using the transbleph Endotine fixation sys-tem. Presented at the Annual Meeting of theASOPRS. Chicago, October 2005.