Dr Patrick Treacy shares some of his most challenging cases. This month he talks about brow elevation post frontotemporal craniotomy

1. 68 Aesthetic Medicine • September 2014
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T H R E A D S
CASE FILES
Dr Patrick Treacy shares some of his most challenging
cases. This month he talks about brow elevation post
frontotemporal craniotomy
Dr Treacy’s
CASEBOOK
DR PATRICK TREACY
is chairman of the Irish
Association of Cosmetic
Doctors and Irish regional
representative of the British
College of Aesthetic Medicine
(BCAM). He is European medical
advisor to Network Lipolysis
and Consulting Rooms and
holds higher qualifications in
dermatology, laser technology
and skin resurfacing. In 2012
and 2013 he won awards for
‘Best Innovative Techniques’
for his contributions to
facial aesthetics and hair
transplants. Dr Treacy also
sits on the editorial boards
of three international
journals and features regularly
on international television and
radio programmes. He was a
faculty member at IMCAS
Paris 2013, AMWC Monaco
2013, EAMWC Moscow 2013
and a keynote speaker for
the American Academy of
Anti-Ageing Medicine in
Mexico City this year.
>>
A
53 year-old Irish female presented with a left lateral brow ptosis
following a minifrontal craniotomy for an aneurysm repair. This
procedure had resulted in a frontotemporal defect and the patient
complained that the sagging of the upper eyelid caused her to have an
aged, sad, and tired appearance to her face. She denied any functional
sequelae of her brow ptosis, such as headaches or ocular fatigue, although she did
describe a small deficit in her visual field. Her visual acuity, pupillary examination
and extra ocular motility were normal. There was no loss of sensation in the area of
the resultant scar as the supratrochlear and supraorbital sensory nerves innervate
the central and lateral forehead as well as portions of the anterior scalp.
On examination it was obvious that the resultant damage to part of her
facial nerve had caused marked descent of the periorbital soft tissues of the
brow with a moderate degree of upper eyelid dermatochalasis. Her cranial
examination including facial nerve function showed inability to elevate her left
eye brow and the absence of Bell’s phenomenon. It was evident she had post
procedure damage to the frontal branch of the facial nerve causing inability to
control the frontalis muscle.
DISCUSSION
Each patient with facial paralysis requires a detailed analysis of the individual’s
particular concerns and physical deformities. The position of the eyebrows exerts
great influence over the upper eyelids, both in terms of skin excess as well as in the
overall aesthetics of the lid/orbit region. Multiple surgical techniques have been
Before

2. describedandadvocatedforfacialreanimationafterfacial
nerve paralysis. It was decided here to use some contour
threads as the procedure is quite simple to perform under
a local anaesthetic. Ideal candidates for thread
lifts include people with minimal signs of
ageingwhoneedjustasmalllift.Usually,
these are women between 35 and 45.
The threads are indicated because
these patients have begun to see
more prominence of the jaw, a
relaxed (or minimally sagging)
mid-facial appearance or
slight bags under the eyes or
on the neck. 1
Since the invention of the
first barbed (short) suture by
Sulamanidze in the late 1990s,
different techniques have been
described including Woffles
(long) thread lifting, Waptos
suture lifting, Isse unidirectional
barbed-threads lifting, and silhouette
lifting. However, essentially, there are
two types of barbed threads which are
available. These are:
A. Bi-directional threads, with no anchoring points,
insertedwithinahollowneedleandplacedinsuchamanner
that the thread cannot move either way because of the
two-way direction of barbs fixing it nicely. Examples are
the APTOS® threads
B. Uni-directional barbed threads, which are
anchored at a higher level fixation point. Examples are the
Contour® and Silhouette® threads2
Barbs along the thread act as cogs to grasp lift and
suspend a relaxed facial area. The barbs
open like an umbrella to form a support
structure that lifts the sagging tissue.
This creates tension in the thread,
and the tension lifts the skin
tissue. Collagen formation
occurs around the threads and
their cogs or barbs, producing
an increasing effect
ANATOMY
Understanding the temporal
and forehead anatomy is
important to any successful
browlift surgery. The frontal
branch of the facial nerve is
locatedinthesuperficialtemporal
fascia and innervates the muscles of
the forehead (frontalis, corrugators,
depressor supercilii, and procerus).
The blood supply to the forehead scalp is from
the internal (supra-trochlear, supraorbital) and external
carotid (superficial temporal) arteries. Hair follicles are
located in the subcutaneous layer. Injury to the follicles
results in temporary or permanent alopecia. The scalp
is composed of five layers (skin, connective tissue, galea
aponeurotica, loose areolar connective tissue, and
periosteum). >
69
CASE FILES
Aesthetic Medicine • September 2014
T H R E A D S
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On examination it was
obvious that the resultant
damage to part of her facial nerve
had cause marked descent of the
periorbital soft tissues of the brow
with a moderate degree of upper
eyelid dermatochalasis
The procedure

3. 70 Aesthetic Medicine • September 2014
S U R G I C A L
CASE FILES SPONSORED BY
METHOD
The procedure was performed
with the patient under
local anaesthesia and no
sedation was required. The
patient’s face was marked
preoperatively to determine
the appropriate vector of the
thread and its end fixation
points. The presence of
prominent dynamic and static
rythides in the patient’s forehead
was noted and influenced incision
placement. The location of the hairline
was noted. The superior border of the
thread was placed above the hairline
and exited at the level of the lateral brow. The sutures
were trimmed, and the proximal ends were secured on
the deep temporal fascia and reinforced with Vicryl
interrupted sutures.
PHYSICAL EVALUATION
A thorough past medical and facial surgical history was
obtained. The patient’s visual acuity, hairline position and
brow symmetry were noted. We also noted skin quality and
rhytiddepthinthemedialandlateralforehead.Theresidual
motor function was noted prior to the procedure.
REFERENCES
1. DeLorenziC.Barbedsutures:Rationaleandtechnique.AesthetSurgJ.
2006;26:223–9.
2. WuWT.Barbedsuturesinfacialrejuvenation.AesthetSurgJ.2004;24:582–7]
3. PaulMD.Complicationsofbarbedsutures.AesthetPlastSurg.2008;32:149
4. AestheticPlastSurg.2014Feb;38(1):69-74.Facialrejuvenationwithfine-
barbedthreads:thesimpleMizlift.ParkTH1,SeoSW,WhangKW.
5 TranspalpebralOrbitofrontalCraniotomy:AMinimallyInvasiveApproachto
AnteriorCranialVaultLesionsKofiD.OwusuBoahene,M.D.,MichaelLim,
M.D.,EugeneChu,M.D.andAlfredoQuinones-Hinojosa,M.D
www.aestheticmed.co.uk
CONCLUSION
Despite improvements in microsurgical techniques and
intraoperativefacialnervemonitoring,itisoftenimpossible
to preserve normal facial nerve function during craniotomy,
especially when performing emergency intracranial
surgeryorremovingtumourswithfacialnerveinvolvement.
Although the facial nerve is anatomically preserved in most
cases,functionmaybepartiallyorcompletelylost,resulting
in some level of paralysis4
. In these circumstances, full
facial paralysis is often physiologically and psychologically
devastating to the patient. Associated problems include
painful corneal irritation, visual loss, difficulties in eating
and speaking and in the worse circumstance, self-imposed
social isolation 5
. AM
ADDENDUM ON BROW PTOSIS
The main etiologic factors in brow ptosis
are gravity and age. The ageing face
undergoes a loss of tone from a
diminution in the amount of elastin
and collagen in the skin. Because
the lateral brow has fewer
attachments to the periosteum
and has no underlying frontalis
muscle, it usually descends
more than the medial brow. Brow
ptosis can happen secondary to
paralysis of the frontalis muscle as
in this case, but also because of Bell’s
palsy, acoustic neuroma or even birth
trauma. Medical causes include conditions
such as myasthenia gravis, myotonic and
oculopharyngeal dystrophy
After treatment
Despite improvements in
microsurgical techniques
and intraoperative facial
nerve monitoring, it is often
impossible to preserve normal
facial nerve function during
craniotomy,involvement