DOI: 10.1097/01.prs.0000215332.53084.c0

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Issn Print: 0032-1052

Publication Date: 2006/04/01


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Discussion

Jack A. Friedland

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Dr. Guyuron has long been an advocate of the endoscopic approach for forehead rejuvenation. He has written two articles in which he evaluates the approach in both the short and long term, and has provided a detailed discussion of problems seen after endoscopic procedures that contribute to flawed outcomes. In addition, he has presented his methods and techniques for avoidance and correction of those problems. These include worthwhile tips regarding the necessity for sufficient dissection of the forehead and lateral periorbital soft tissues and the placement of harvested fat where muscles of facial expression have been removed to prevent depressions and/or reattachment of residual fibers of the muscles. He uses fascial suspension sutures for the soft tissues and, when necessary, bone fixation, especially in the midportion of the forehead. The periosteum is left intact medially to prevent an excessive rise of the medial brows.
I do not disagree with any of the precepts or concepts outlined in these articles, but I do disagree with Dr. Guyuron's feeling that the most disturbing and inevitable consequence of open forehead rejuvenation is elongation of the forehead. The height of the frontal hairline may be slightly greater in the open approach because the whole forehead as a unit is elevated from the brows to the hairline. The distance from the brows to the frontal hairline does not increase.
In 1996, I published a retrospective review of 600 patients who underwent an open approach for forehead rejuvenation.1 That study compared data similar to those in the present study. Preoperative and postoperative photographs were analyzed by the patients themselves, and by me and an additional surgeon. Comparing the results of the studies in the open approach analysis, patient satisfaction was slightly higher in terms of appearance of the resulting scar, facial appearance, length of convalescence, and durability of results. A more significant difference was that in Dr. Guyuron's study: 50 percent of the patients had some neurosensory problems (the most prevalent being persisting paresthesias) and several were found to have dynamic imperfections and irregularities of the forehead. None of the patients in the open approach study had significant nerve injuries or late problems.
In 2001, Matarasso et al. published the results of a national plastic surgery survey on brow-lifting techniques and complications in this Journal.2 The authors of that study had anticipated a trend toward the endoscopic approach for its alleged advantages, but they found comparable effectiveness and a markedly lower rate of complications with the open procedure (such as hair and sensory loss). Alopecia was noted to be slightly higher with the open approach, but permanent sensory loss was lower. They concluded that “if not for potential scarring, the endoscopic approach would or should have been popularized—especially since the open procedure is believed to be more efficacious.” They went on to further state that “the only reason to perform the closed procedure is concern over scarring.”
I am extremely impressed with Dr. Guyuron's analysis and presentation of his concepts. The results are unquestionably excellent, and I am sure that his patients are pleased with their rapid healing and minimal scarring. However, it remains for the individual plastic surgeon to determine which method he or she will select for forehead rejuvenation. Complications are rare with either approach, and each method has proven to be reliable. Although I still consider the open approach to be the standard, Dr. Guyuron has demonstrated that the endoscopic approach is just as safe, effective, and economical, and with practice can be easily mastered for rejuvenation of the forehead and upper face.
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