Frontoplastia Bogota Cirugia de Frente Soacha Facatativa Girardot


Cirugia de frente | Lifting frontal


glabellar area; for some authors, it makes part of the orbicular muscle. It is located in the middle arc of the eyebrow and it is inserted in the nasal in the frontal bone, extending itself to get mixed with the procerus and frontal muscles. Its action elevates the beginning of the eyebrow and descends the middle portion and the skin of it and generates the vertical furrows of the beginning of the region and the middle portion of the eyebrow [22, 26, 28]. It is innervated by the ramification of the facial nerve (Fig. 43.2). Fig. 43.1 Corpse dissection with the supraorbital package (SOP) in relation to the notch (N), and the right supratrochlear nerve (SN). The frontal soft tissues have been rejected forward and downward (Photo courtesy Dr. Jaime Ramirez) Fig. 43.2 The existing relation in the muscles of the frontal region is observed. Frontal muscle (FM), corrugator muscle (CM), procerus muscle (PM), orbicular muscle (OM) and its intimate relation with the superciliary depressing muscle (DM) 478 J. Ramirez et al. The orbicular muscle has a concentric disposition over the orbit and circumferential vectors; it is wide, flat, inserted in the nasal portion of the frontal bone and in the frontal process of the jawbone, previous to the middle canthal ligament. It presents two portions: the orbital and palpebral. The palpebral portion has two fibrous insertions in the eyelid; the orbital portion has bony insertions. Its function is to approximate the loosened edge of the eyelid and provoke the occlusion of the palpebral cleavage. Its joint action produces descent of the eyebrow position. It is innervated by the ramification of facial nerve [19, 21, 22, 25, 28] (Fig. 43.2). The areolar lax tissue is the continuation of the subgaleal tissue. The supraorbital insertion of the orbicular muscle is a strong ligament, formed, as well, by lateral and middle orbital ligaments [19, 20, 29]. The supraorbital and supratrochlear nerves give the sensitive innervations of the skin and the innervation’s mechanism comes from the facial nerve [22, 24–27]. The Sentinel vein is an important repair point in the endoscopic surgery; to avoid injuring it, it must be identified. It is located at the superior and lateral tail of the eyebrow and in some cases can be duplicated; it is a structure of transition that perforates the band and it is deepened in company of the frontal facial nerve, toward the lateral superior zone [30] (Fig. 43.3). The frontal skin is the continuity of the scalp. It presents five well-defined layers: skin, subcutaneous cell tissue, galea aponeurotic, areolar lax tissue, and periosteum. The skin is thin, rich in sebaceous glands, and sudoriparous; it is anchored in a homogeneous layer of compact adipose tissue and dense fibrous tissue separate it from the muscles label, which generates major quantity of lines of expression. The muscular aponeurosis is the continuation, in double layer of the facial SMAS, [12] keeping the different forehead muscle and the periocular area that possess two types of action: passive by traction and active by contraction. By its passive action it maintains the muscular anchorage and the others structures, while, in contraction puts close together the insertion ends [28, 31] (Fig. 43.4). 43.4 The Eyebrow and Forehead as an Aesthetic Unit In the surgery of the facial third superior; the forehead, eyebrow, and eyelid must be dynamically analyzed. The patients consult by the apparent excess of palpebral skin, without noticing that in occasions the drop of the eyebrow is one that generates an over dimensioning of redundancy of the eyelid’s skin. In the last one is located one of the main keys to establish in the ptotic forehead, when it really corresponds to the drop of the eyebrow, below the orbital bony ledge, whether it is due to looseness or excess in the Fig. 43.3 Sentinel vein (SV) and frontal branch of the facial nerve (FN). The shaded area shows the orbital rim (Photo courtesy Dr. Jaime Ramirez) Fig. 43.4 The layers in the dissection of the frontal region are observed. Skin (S), subcutaneous cell tissue (SC), muscle (M), periosteum (PE), frontal bone (FB) 43 Forehead Lifting Approach and Techniques 479 skin of the eyelid. Bellow regarding, before carrying out a cosmetic blepharoplasty, to make the simulation of the ideal position of the eyebrow, having the patients sitting down or standing up, move the eyebrow with the finger to the new wanted position and visualize the amount of the skin of the eyelid that still looks redundant preventing the definition of superior palpebral furrow. This is done at this moment and not before (Fig. 43.5). It is expected that the doctor realize this presurgical maneuver of measurement and demarcation commenting to the patient his findings. Then the patient will agree with greater facility to the approval of the integral treatment of the suspension forehead lifting with blepharoplasty. It is also important to do a previous analysis of the factors that influence the eyebrows and forehead aesthetic unit, which must be postsurgically controlled to extend the obtained results, which are: intrinsic factors such as lost elasticity of the tissue and the marked activity of the depressor muscle and the extrinsic factors such as the gravity, the photo exposure, and the tobacco addiction. 43.5 Position of the Eyebrows The beauty concept must consider the cultural differences and also manage a parameter for each one of the sexes. Aesthetically, the ideal position of the eyebrow in women is defined as a smooth arch, located above the orbital rim, with its higher point coinciding with an imaginary line traced between the lateral limbo and the lateral canthus. The eyebrow descends to the

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