FPSAM - Roundtable 2022 - 3

changed everything. In fact, there was an interesting
article that came out that showed that people
are, in general, more attractive with a mask on the
lower part of their face than without, which demonstrates,
interestingly that we see more beauty is
in the eye area, and detractors from beauty in the
lower face suspect personally that it relates to light,
in that I think of the forehead as a bit of a visor and
flat cheeks as a lack of reflectors.
And when you have a fuller cheek anteriorly, I
believe that reflects light up toward the eyes. Then
you are doing two things to brighten the eyes area,
which is a very feminine characteristic. However,
after forehead surgery, my second most powerful
procedure is a lip lift because, again, light reflections.
I have seen people who have only done a lip lift and
suddenly look very feminine because this very short
upper lip with a lot of bright teeth showing is not a
distinctly masculine feature. Let us go anatomically,
and let us talk about the forehead. Dr. Schechter,
what are hairline considerations in Chicago with
relating to forehead surgery, incisions, approaches?
Dr. Schechter: Yeah, thanks, Jeff. Let me step back for
one second, and just play a little bit of devil's advocate.
I certainly agree, upper third, forehead, and eyes, but let
me also just speak of nonsurgical, really nonmedical,
interventions: hair-and that may be in the form of a
wig-makeup, teeth, dental, cosmetic are also incredibly
important. If you look at Eddie Redmayne in The
Danish Girl, and you just look at the effects: hair, makeup,
teeth, etc., it is quite dramatic.
In terms of hairline incisions, we're generally anterior
hairline incision with the goal of advancing the
forehead. We do not do much in the way of hair
transplant, but the anterior hairline incision, and then
manipulating the brow and orbital rim as needed.
Dr. Spiegel: What is the plane of dissection you all
are using in approaching the forehead?
Dr. Schechter: Typically, that would be subperiosteal
if we are going to do concomitant forehead work.
Dr. Spiegel: Dr. Knott, how about in San Francisco?
Hairline considerations? What is your approach?
What are you doing?
Dr. Knott: We do very similar approaches to what you
do and showed us. We do subperiosteal centrally between
the temporal lines. Within the temples, I still stay
above the temporalis fascia. I just find it is a very easy
bloodless plane to dissection. Dr. Seth stays below the
fascia, right on top of the muscle, then we extraordinarily
aggressively release over the brows and laterally
to get the tails to come up and try to restore or reshape
the brows into the feminine aesthetic.
ยช 2022 American Academy of Facial Plastic and Reconstructive Surgery, Inc.
We are just about to publish an article of trying to
measure the amount of brow elevation, hairline reduction,
and hairline advancement that we can achieve
with the techniques. I know you have done some
publishing on this as well. We tried to use photographs
and iris width to do some of our measurements and
things. It is amazing how much change you can get.
Once you set that bone back, it really allows you to get
much more brow elevation than you otherwise would
get in your typical trichophytic brow lift patients.
Dr. Spiegel: I think that is true. I think that we are a
little spoiled with the brow lifting because when you
reduce the volume of the glabella, you have some
skin that can redistribute a little easier. You get
away with not being in a more superficial plane.
Is anybody doing almost relaxing incisions of that
periosteum? Dr. Garcia?
Dr. Garcia: That is what I started doing a couple of
years ago, where I had a couple of patients who had the
stiffest eyebrows. I was trained to do galeotomies to
stretch the scalp, so I just applied that knowledge to the
forehead to stretch the skin more and allow a better lift.
I do relaxing incisions right above the orbital rim, and
right above the neurovascular bundles. I have made
probably about four or five on each side. I reassess after
a couple of ones to see how much the lift is, if no more
are needed I stop. This is variable between patients. I do
have to anticipate more significant edema around the
eyelids that can be quite dramatic.
Dr. Spiegel: Yes, that's what we have been doing,
too. Releasing the arcus marginalis and fascia laterally
can be important as we are subperiosteal.
Dr. Alperovich, anything different? Then after
that, what are you using for fixation, if anything?
Dr. Alperovich: I will do some cross-hatching to kind
of release it, just to get a little bit more give. I have
tried everything for the lifts. I have tried drilling holes.
I have tried mini plates and sutures. I have now kind of
just converted almost exclusively to Endotines. I find
that it distributes the force better, less relapse. I just
have to get their OK that they are going to feel this
there for a few months. I have found that has, for me at
least, been the most reproducible and long lasting.
Dr. Spiegel: Are you putting it to support the brow
or to support the scalp or both?
Dr. Alperovich: I use both. I support the brow, then I
invert them 180, and then for the scalp advancement
to reduce stretching at the trichophytic incision, I'll
also support it from the back.
Dr. Spiegel: Well, it's a good, quick survey question.
What's everybody else doing? Dr. Rodman?

FPSAM - Roundtable 2022

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