The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and forehead rejuvenation.
BACKGROUND: Forehead rejuvenation procedures can lead to excessive elevation of the medial brow, resulting in the "surprised look." Differential treatment of the medial and lateral brow allows more precise positioning. The purpose of this study was to determine whether retaining structures exist in the forehead that would permit this differential elevation. METHODS: Anatomical dissections were performed in the foreheads of 12 cadavers. Multiplanar dissections at the subperiosteal, subgaleal, and subcutaneous levels were performed on eight hemiforeheads. Clinical correlation for these findings was obtained during endoscopic and open brow-lift surgery. RESULTS: Four retaining structures of the brow were identified: three medial and one lateral. The superomedial attachment begins 13 mm from the midline and 10.8 mm above the supraorbital rim. The superolateral attachment begins 23 mm from the midline and 10.3 mm above the supraorbital rim. The inferomedial attachment begins 12.6 mm from the midline at the level of the supraorbital rim, just medial to the supraorbital nerve. These three structures were found to control the position of the medial brow. Laterally, brow position was controlled by a broad ligamentous attachment extending across the lateral aspect of the supraorbital rim. CONCLUSIONS: Medial retaining structures have been found to extend from the cranium into the forehead musculature. Release of the lateral broad ligamentous attachment was performed, followed by selective preservation of medial retaining structures. With this approach, we were able to gain control of the position of the medial brow and prevent overelevation and lateral spreading.