AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

History of the Procedure

The forehead lift or brow lift is a common facial rejuvenation procedure, performed as an isolated technique or in combination with total facial rejuvenation, including facelift and blepharoplasty.

Problem

Periorbital changes often are recognized as the earliest signs of aging. Common changes include upper eyelid skin folds that extend beyond the upper eyelid into the temple, frown lines or glabellar transverse forehead creases, thickening or bunching of the corrugator muscles at the medial eyebrow, and descent (ptosis) of the eyebrows.

These changes potentially are reversed with an appropriately performed brow lift or forehead lifting procedure.

In this discussion, the terms "brow lift" and "forehead lift" are used interchangeably. The actual incision used to perform a brow lift can vary. Access incisions include the coronal line, the prehairline, and just above the eyebrow.

Frequency

Aging varies in each individual. Forehead changes are based on environmental factors (sun damage), genetic makeup, and skin type. The extent of aging can vary greatly.

Beginning in the fourth decade, early changes of brow position, influenced by gravity, become apparent. This eventually occurs in all individuals, although the degree of brow ptosis and constellation of findings such as glabellar frown lines and transverse forehead creases vary. By the fifth decade, most individuals have undesirable changes of the forehead and upper periorbital region that would benefit from rejuvenative forehead procedures.

Etiology

The etiology of the aging upper face involves loss of elasticity, soft tissue ptosis, genetic predisposition, and repetitive facial motion (eg, squinting, constant corrugation of eyebrow muscles).

Individuals with active facial animation, especially those who are exposed to sun, may exhibit more advanced signs of upper forehead aging.

Pathophysiology

Constant motion of the frontalis muscle creates the transverse rhytides of the forehead. Patients with advanced brow ptosis activate the frontalis muscles on a regular and involuntary basis to maintain elevation of their brows, thereby preventing the visual field obstruction that occurs from brow ptosis. As forehead soft tissues continue their descent over time, maintained frontalis muscle tone creates progressively deepening lines to offset the effect on visual field obstruction.

In such cases, the well-intentioned removal of upper eyelid skin can create further brow ptosis through a relaxation in frontalis tone, which is now no longer required to maintain the visual field. The removal of upper lid skin in such cases can make later brow elevation more complicated, with poorer aesthetic results due to the limitations created by a paucity of upper lid skin. To overcome this deficiency, skin grafts or flaps from the lower lid may be considered. Remarkable aesthetic improvements can be achieved with techniques that diminish frontalis tone and weaken the centralizing and depressing muscular action while elevating the brow to an appropriate position.

Clinical

Patients may be told by family, friends, or colleagues that they appear angry, sad, or anxious when this appearance does not match their emotional state. This misinterpretation can be quite concerning for some and may result in a visit to a plastic surgeon for treatment. Elevating the brow while diminishing corrugator and procerus function can reduce forehead rhytides. This goal is accomplished through a skillfully performed brow lift.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

A brow lift may be indicated in anyone who approaches the fourth decade of life and exhibits changes such as brow ptosis and excess corrugator action with glabellar creases between the eyebrows and transverse forehead wrinkling. Many of these patients are motivated to change the unacceptable appearances of anger, annoyance, or fatigue that commonly are associated with changes in the forehead.

In the female patient, elevation of the lateral eyebrow and weakening of the centralizing and depressor muscles provides a more aesthetically pleasing upper periorbita, consistent with youthful femininity.

In men, eyebrow position also may be excessively low, and elevation may be indicated; however, excessive elevation can be feminizing. Vertical glabellar frown lines may suggest anger or anxiousness and are typically undesirable. Concerns over the appearance of these unwanted lines often prompts a visit to a plastic surgeon.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

A thorough knowledge of the layers of the scalp and forehead is essential to surgeons performing a brow lift. The layers encountered in brow lift surgery are the skin, subcutaneous tissue, galea or aponeurosis, loose areolar tissue plane, and periosteum. Progressing inferiorly from the coronal or hairline incision, the deep and superficial layers of the temporal fascia are encountered laterally; an understanding of these layers and how they relate to the frontal branch of the facial nerve as it traverses the galea and superficial musculoaponeurotic system (SMAS) layer is essential to complication-free surgery.

A brow lift may be performed in a subcutaneous layer, subgaleal layer, or subperiosteal layer. Most brow lifts are performed through an open technique in a subgaleal fashion, with release of soft tissue attachments at the supraorbital rim to make transmission of lift to the lateral eyebrow possible.

Anatomic understanding of the supraorbital and supratrochlear nerve branches that traverse the medial eyebrow region also is important. Supratrochlear nerves are associated intimately with the corrugator muscle. They are visualized in dissection and removal of the corrugator muscle and must be preserved. The supraorbital nerve exits more lateral than the supratrochlear nerves and provides sensation to the hemi-forehead, extending superiorly above the hairline. Preserving these nerves minimizes sensory deficiencies.

The frontal branch of the facial nerve is carried in the forehead flap when the procedure is performed through the subgaleal or subaponeurotic dissection. Tension or traction on the forehead flap at the level of the lateral orbital rim must be gentle to avoid neurapraxia or permanent injury to the nerve.

An intimate knowledge of the insertion and origin of the corrugator muscles, procerus muscle, and frontalis muscle is essential to performing a comprehensive brow lift procedure that reverses the signs of aging.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The most significant contraindication to a forehead lift is deficiency of upper eyelid skin. This often occurs when previous upper eyelid surgery has been performed, lagophthalmus has occurred, and adequate lid closure is a concern. Elevation of the brow to its proper level may be impossible if adequate upper eyelid skin is not present. This demonstrates the importance of proper diagnosis in the aging face so that excess upper eyelid skin is not removed simply because this is the "easier way out."

In most patients, a properly performed brow lift is the cornerstone of the beginning of upper facial rejuvenation. Only after placing the brow in the proper position can one assess excess upper eyelid skin. This is especially true in women, in whom eyebrow position is quite important in establishing the aesthetics of the periorbital region. A properly arched and elevated lateral eyebrow is a key element to rejuvenating the aging female face.

A relative contraindication to a coronal forehead lift is a preexisting high anterior hairline. When excessively high, a coronal brow lift exacerbates this aesthetic problem. Further, following a coronal brow lift, performing subsequent hairline brow lifts to correct the problem is difficult without jeopardizing the vascularity to the intervening scalp segment that contains the anterior hairline. The endoscopic and prehairline brow lifts do not significantly alter hairline position and, therefore, are more appropriate choices for patients who have high anterior hairlines.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• A general medical evaluation and clearance for local anesthesia with sedation are required for all patients undergoing elective facial aesthetic procedures.
• Perform CBC and electrolyte studies at the discretion of the surgeon and anesthesiologist, following generally accepted medical guidelines based on age and clinical conditions.

Other Tests

• Some patients have significant visual field obstruction secondary to brow ptosis and upper eyelid skin excess. A referral for visual field studies is indicated in patients desiring possible insurance coverage for brow or forehead lift procedures. Visual field defects are often graded as to severity, and coverage is often based on individual third-party payer criteria. A referral to an ophthalmologist who performs visual field studies on a regular basis is recommended.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical Therapy

Currently, the only medical therapy available is botulinum toxin (BOTOX®) injections to the corrugator muscles, lateral periorbital orbicularis muscle, and frontalis muscle. Chemical denervation with BOTOX® effects a temporary improvement, with changes in the forehead and elimination of vertical glabellar frown creases with corrugator muscle paralysis, improvement of transverse forehead rhytides with chemical denervation of the frontalis muscle, and elevation of the lateral eyebrow with selective injection of BOTOX® into the lateral orbicularis muscle.

This specific chemical denervation with BOTOX® injection can interrupt the imbalance of forehead muscle action, therefore eliminating rhytides that occur from contraction of these muscles. If dermal changes or deeper rhytides exist, full correction with chemical denervation is not likely. Additionally, the result lasts only 4-5 months, and subsequent treatment is necessary to maintain improvement. (See BOTOX® Injections for more information on BOTOX® therapy.)

Surgical Therapy

This article describes the surgical treatment (brow lift/forehead lift) of aging of the upper two thirds of the face. This includes brow ptosis, corrugator hyperactivity, frontalis hyperactivity, and the associated rhytides created by this hyperactivity.

Brow lift options include an open (traditional) brow lift with incisions just above the eyebrows, in the mid forehead region, or in the hairline or coronal area. Furthermore, the approaches can be subperiosteal, subgaleal, or subcutaneous. Generally, the most common brow lift technique is a subgaleal approach through a hairline or coronal incision.

Although some surgeons remain committed to a more limited incision in the mid forehead through an existing rhytid or just above the eyebrows, these procedures are not considered the most aesthetically pleasing or effective methods of improving brow ptosis. Additionally, they do not afford the patient the benefits of complete corrugator and frontalis modification.

Recently, endoscopic techniques for brow lifts have gained popularity. While these methods are effective in reducing corrugator activity, frontalis activity is difficult to alter reliably using this technique. Brow elevation can be achieved to a predictable degree, but fixation remains a concern with the endoscopic lift. Multiple techniques have been proposed for endoscopic brow fixation, with several alternatives proving successful.

This includes suture suspension, screw fixation (absorbable or removable screws), and K wire fixation. Endoscopic techniques limit the incisions, proving desirable to many patients as a "minimally invasive procedure." The endoscopic lift does not allow for modification of the hairline in patients with a high forehead.

Preoperative Details

• The first step in rejuvenation of the upper third of the face or brow region includes a thorough consultation with the patient. Give the patient a mirror so that the brow position, corrugator-glabellar area, and forehead-frontalis region can be examined. Attention to the level of the hairline also is important. Improvement can be simulated by elevation of the brow to obtain a reaction from the patient regarding desirability. Proper elevation of the eyebrow requires feedback from the patient regarding the desired look.
• The point of reference for determining the new brow position is the supraorbital rim. A marking pen can be used to identify the orbital rim. Elevate the brow to the appropriate level and mark the skin overlying the orbital rim again. This measurement of brow elevation then can be used to determine the amount of skin to be excised at various points, depending on the incision selected.
• Guidelines include the following: approximately 1 mm of brow elevation requires removal of approximately 1.5 mm of tissue if the incision is at the coronal site; at the hairline incision, the ratio of brow elevation to tissue removed is approximately 1:1.
• Assess modification of the corrugator and frontalis muscle; corrugator modification is planned in most patients with significant upper face aging. This eliminates the heaviness in the corrugator region in female patients and eliminates the glabellar frown lines that are created from contraction of these muscles.
• Assess frontalis hyperactivity clinically. Determine this by the amount of rhytides that are static and dynamic in the forehead. Plan thinning of the frontalis muscle based on its relative hyperactivity. Maintaining frontalis muscle activity is important, thus carefully control thinning.
• Plan the incision. In patients with a high forehead, a hairline incision almost always is preferable to elevating the hairline. Unfortunately, once a coronal or posterior hairline incision is made, subsequent procedures to lower the hairline are not possible. Therefore, proper planning is critical.
• A coronal incision is well hidden in patients with a low hairline. In patients with male pattern baldness, a more posterior incision along the vertex can be made, with expectations that the resulting incision will be hardly detectable. When the incision is precisely approximated, the scalp in this region heals nicely in almost all patients.

Intraoperative Details

• Treat patients under local anesthesia with intravenous (IV) sedation or under general anesthesia according to the preferences of the surgeon, patient, and anesthesia specialist.
• Typically, administer preoperative antibiotics and prepare the head in the usual fashion.
• Never shave hair, as this is unnecessary and often undesirable to the patient. Hair can be managed by simply towel drying and combing the hair or by placing the hair in an elastic band.
• Depending on the desired location, mark the incision along the anterior hairline and extend it back into the hair and along the temporal scalp, or mark it along the coronal position and then along the temporal scalp.
• Typically, inject local anesthetic with 1:400,000 epinephrine along the galea in the skin prior to the incision and wait the appropriate 4-5 minutes for the epinephrine to take effect before proceeding.
• Most procedures are performed in a subgaleal plane. Bevel the incision along the hair follicles throughout the length of the incision until the subgaleal plane is identified. Elevate the flap in the subgaleal plane with sharp or blunt dissection. The subgaleal plane includes the loose areolar tissue of the scalp and is dissected easily down to the orbital rims, where the attachments become more dense.
• Use hemoclips or judicious cautery along the galeal or incisional area to protect the hair bulbs and prevent injury that may create alopecia.
• Perform the dissection along the lateral orbital rim and temporal region bluntly with a sponge or a digital dissection, taking care not to use sharp instruments or retractors that may injure the frontal branch of the facial nerve in this region. Continue the dissection down to the orbital rim, where release of the lateral orbital rim is essential to allow for brow mobilization.
• Identify the supraorbital and supratrochlear nerves more medially, with the corrugator muscles covering most of the supratrochlear nerves.
• Perform the corrugator muscle modification under direct vision with the open brow lift. Release the corrugator muscle from its insertion into the medial-glabellar periosteum and follow it into the soft tissue of the flap more laterally. Contour it along the soft tissue to avoid leaving a lateral bulge that will be seen as a contour abnormality. Constantly replace the flap and check for symmetry.
• After contouring the corrugator muscles and preserving as much of the trochlear nerves as possible, further identify and protect the supraorbital nerve while carrying the release toward the lateral brow. The release often is carried into the orbital region to allow for full release.
• In some patients, the procerus muscle is modified by transverse incision to allow for a more pleasing radix, depending on the existing appearance of the nasal root. This release of the procerus muscle can allow for further elevation of the medial brow if necessary. This is a powerful movement and may be unnecessary in some patients. Assess the aesthetics of the nasal root and the existing position of the medial eyebrow prior to procerus muscle transection. Simply bevel the edges of the cut muscle; no segment of procerus muscle is removed.
• Thin the frontalis muscle appropriately based on the preoperative assessment of hyperactivity to the frontalis muscle. Thin it in a transverse direction using Metzenbaum or Mayo scissors to allow for reduction of the muscle fibers but retention of muscle function.
• Take care to avoid the supraorbital nerves that run in the flap near the area of thinning.
• Examine the area for hemostasis.
• Place a small silastic drain and bring it out through the temporalis fascia. Place the drain just into the radix region to drain fluid in this region for the first 24 hours. This diminishes bruising.
• Elevate the scalp and trim appropriately after marking 3 points of tension at the paramedian positions and the mid line.
• Suture these 3 tension points after elevating the flap and double checking the position of the brow. The preoperative assessment of brow elevation remains critical, since intraoperative appearance can be deceptive because of swelling and the recumbent position.
• Perform 1:1 removal of skin to account for brow elevation at the hairline, while 1.5-mm excision of scalp tissue at the coronal position allows for approximately a 1-mm elevation of brow position. In the vertex incision, the excision of tissue may approach 2:1 to allow for a proper amount of elevation.
• Following placement of tension at these 3 points (paramedian points, midline points), trim the flap between the points with no tension.
• Some surgeons prefer to close the galea in an interrupted fashion; others simply close with a full-thickness suture through the skin subcutaneous tissue and galea. A running skin suture is not recommended, because the ischemic nature of the suture and the resultant ischemia to the hair follicles can result in what appears to be a wide scar (but in reality is peri-incisional alopecia). Staples are appropriate for closure of most scalp wounds, especially with a tension-free closure.
• Recheck the 3 points of tension when closure is complete to ensure that tension is not excessive. Replace these sutures if tension appears excessive.
• Use a light Kerlix wrap for dressing. No other dressings are necessary. Place an ice pack over the brow while the patient is in recovery.

Postoperative Details

• Usually, the patient is discharged home on the day of surgery with instructions to empty the drain and apply ice packs to the forehead for comfort and decreased swelling.
• Typically, remove the drain on the day after surgery; the patient should shower and shampoo his or her hair within 24-48 hours.
• Most patients require mild narcotic analgesia or over-the-counter pain relievers. Some swelling in the lower eyelids is expected in some individuals.
• Check the sutures when the drain is removed to confirm that the swelling has not created areas of excessive tension along the sutures. If this has occurred, remove the sutures to release tension.
• Completely remove staples and sutures 7-9 days postsurgery.
• Most patients return to normal work activities within 3-5 days. Normal sports activities and aerobic exercise are begun 2 weeks postsurgery.

Follow-up

Most patients complain of some sensory deficit in the area posterior to the incision (forehead or coronal incision). This sensory deficit can be annoying to some patients, but in most patients it resolves in several months. Some residual swelling of the forehead may occur for several weeks but generally is not socially unacceptable. Forehead and brow mobility also is reduced for several weeks until swelling resolves and healing occurs.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

While brow lift and foreheadplasty procedures are safe and predictable, complications are documented.

• Swelling and bruising may be observed following surgery, although this can be diminished by drains, which are removed in the first 24 hours.
• More significant concerns include hematomas, which are associated with residual bleeding from the flap incision site. This is best avoided using hemostatic sutures to close the incision, including the scalp and galea.
• Alopecia often is observed with endoscopic or open techniques when the trauma to the incisional site is excessive, resulting in hair follicle injury. Tension at the suture line can create ischemia that results in hair follicle death, with resulting alopecia along the incisional site. In the subgaleal brow lift, with proper tension applied at the appropriate sites, alopecia should not be a concern. Avoid tight dressings. Additionally, beveling the incision along instead of across the hair shafts appears to preserve hair follicles. Avoid electrocautery along the base of the hair follicles.
• Infection is a rare complication of brow lift procedures. The vascular supply to the scalp is abundant, and, even with surgical manipulation of the hair along the incision, infection is rare. Perioperative antibiotics are administered routinely.
• Sensory nerve injury to the supratrochlear and supraorbital vessels is a concern. A careful understanding of the anatomic relationships of the corrugator muscles and the anatomic course of the sensory nerves is essential to avoid complications. Sensory loss posterior to the coronal or forehead incision is expected and transient. Advise patients of these issues.
• Injury to the frontal branch of the facial nerve is a more serious concern; however, if the procedure is performed in a subperiosteal or subgaleal plane, these injuries can be avoided by careful dissection along the lateral orbital rim using a blunt technique. Additionally, avoid excessive traction on the flap or neurapraxia may occur. Weakness of the frontal branch is a transient complication of traction on the flap. This usually resolves within 10-14 days, with return of normal frontalis function.
• Undesirable scars along the coronal or hairline incision often are a simple matter of poor technique and failure to attend to the details of closure with appropriate tension. Hypertrophic scars and keloid scars are not observed in these locations. The "widened scar" is more likely the result of peri-incisional alopecia. Hair follicle injury results in what appears to be a widened scar, when in reality hair follicles are injured.
• Contour irregularities and asymmetries are unlikely if careful contouring of corrugator muscles, procerus muscle, and frontalis muscle tissue is performed.
• Hairline distortion is a more significant concern, even in the hands of skilled surgeons. The coronal incision increases the length of the forehead in all patients. In patients with a high forehead (ie, hairline begins high), a hairline incision is much more acceptable so that the hairline actually can be lowered and the forehead length is diminished to make it more aesthetically pleasing. Precisely perform closure of the hairline portion of the incision. In many patients, hair shafts grow through the scar, making the incision almost undetectable and allowing patients to wear a desired hairstyle rather than hiding the high forehead with bangs. This is a critical judgment decision when visiting with the patient preoperatively; explain it carefully to the patient.
• Unfortunately, inadequate correction of brow ptosis occurs frequently. This usually results from failure to release the attachments at the lateral orbital rim, allowing for freedom of brow motion. Excessive elevation of the brow is possible and can be avoided by appropriate preoperative measurement of the amount of brow ptosis and by estimating the amount of tissue to be removed to accomplish this elevation.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Brow lift or forehead lift procedures provide gratifying results. The rejuvenating effect of a well-executed brow lift can be the most beneficial change in an aging face, especially with early aging. Inappropriate expressions of anger or sadness can be eliminated by contouring the corrugator muscles; a tired, concerned look can be changed by elevating the brow and opening up the lateral orbital area so that an awake, alert, and refreshed appearance is evident. While most female patients appreciate a more feminine appearance to the periorbital area and upper third of the nose, many men can benefit from a more relaxed and rejuvenated appearance without the excessive brow elevation desirable in the female eyebrow.

Current techniques have reduced complications and allow patients to return to normal work and social activities within several days. Excellent results are expected with brow lifts using current state-of-the art endoscopic techniques, further diminishing recovery time but possessing limited efficacy for advanced aging.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Continued modification of laser techniques and chemical denervation (BOTOX®) are exciting developments that will change the treatment of the aging forehead in the future. At present, these are adjunctive measures that can assist in temporarily reversing the effects of aging. Currently, an open forehead or coronal brow lift or endoscopic forehead lift is the most reliable and predictable method of reversing aging in the upper third of the face.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Left - Preoperative view, brow lift Right - Postoperative view at 2 years
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Media file 2:  Left - Preoperative view, brow lift Right - Postoperative view at 2 years
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Media file 3:  Left - Preoperative view, brow lift Right - Postoperative view at 2 years
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Media file 4:  Left - Preoperative view, brow lift Right - Postoperative view at 2 years
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REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

• Connell BF, Lambros VS, Neurohr GH. The forehead lift: techniques to avoid complications and produce optimal results. Aesthetic Plast Surg. Fall 1989;13(4):217-37. [Medline].
• Connell BF, Marten TJ. The male foreheadplasty. Recognizing and treating aging in the upper face. Clin Plast Surg. Oct 1991;18(4):653-87. [Medline].
• Guyuron B. Subcutaneous approach to forehead, brow, and modified temple incision. Clin Plast Surg. Apr 1992;19(2):461-76. [Medline].
• Hamra ST. Composite Rhytidectomy. St Louis: Quality Medical Publishing;1993.
• Hamra ST. Composite rhytidectomy. Finesse and refinements in technique. Clin Plast Surg. Apr 1997;24(2):337-46. [Medline].
• Isse NG. Endoscopic facial rejuvenation. Clin Plast Surg. Apr 1997;24(2):213-31. [Medline].

Article Last Updated: Oct 3, 2006