Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Functional Brow Lift Following Facial Nerve Paralysis In May of 2001, C.M., a 63-year-old man, presented to the Houston VA with recurrent squamous cell carcinoma metastatic to his neck. His history is summarized here; it is quite complicated. In September of 2000, he had a squamous cell carcinoma of his right temple that was excised by plastic surgeons at the VA, with positive deep margins at the patient’s temple. In October of that same year he went back to the operating room for a wide local excision and superficial parotidectomy with negative margins. He did, however, have a recurrence in April of the following year, presenting with a right preauricular lesion as well as a right neck mass. The preauricular lesion was excised with negative margins; however, just a biopsy was done of the neck mass and this revealed moderately differentiated squamous cell carcinoma. At this point he was referred to the Houston VA, again with this right neck mass that had been biopsied and with a new preauricular lesion. So, we biopsied this lesion in clinic and it also proved to be a squamous cell carcinoma. The patient was presented at Tumor Board and it was decided to take him to the operating room for a wide local excision, a radical parotidectomy with facial nerve sacrifice and sural nerve graft, a modified radial neck dissection and posterolateral neck dissection, reconstruction with trapezius flap, as well as a split-thickness skin graft, and placement of gold weight. All the margins were negative and all the lymph nodes were negative for disease at this time. Patient was supposed to undergo postoperative XRT but he had some postop complications of wound breakdown as well as a C. difficile colitis, for which he was hospitalized. So, he refused XRT at that time. A year later he recurred over the right cheek suture line. Again, this is poorly differentiated squamous cell carcinoma. Wide local excision at that time revealed negative margins, and this time he did undergo XRT which was completed in October of that year. In January of 2003, the patient returned to the Houston VA with no evidence of disease, but complained of decreased vision due to his right brow ptosis. On exam, he was graded as a House Brackmann V. He had some tone in the distribution of his lower branches. He did have hooding of his right upper eyelid. The right eye gold weight was in place with adequate eye closure. Visual field testing revealed decreased vision in the right superolateral field. Later that month, Dr. Donovan, Dr. Olson, and I took the patient to the operating room and did a direct brow lift and the patient returned with significant improvement of his hooding subjectively, as well as on visual field testing, and his vision was much improved. The focus of today's presentation is the functional brow lift following facial nerve paralysis. First, I will briefly review the etiologies of facial nerve paralysis, as well as the grading system and prognostic tests for facial nerve paralysis. Reconstructive options for facial reanimation will be outlined and then we will focus on the upper one-third of the face with a review of the anatomy of the forehead and the brow, as well as the various approaches to brow lift. The advantages and disadvantages of each approach will be evaluated and complications of brow lift will be presented. There are multiple causes of facial palsies that have been described in the literature. Most often facial nerve palsies are not permanent and only require supportive care. Long-term paralysis, however, as in the patient that I presented, has significant physical, as well as emotional consequences for the patient. In addition to the lack of facial movement, problems encountered include eye irritation from inadequate eye closure, corneal protection, epiphora from failure of the lacrimal pump, visual field defects from ptosis of the brow and soft tissues of the forehead, as in our patient, speech difficulties from lip incompetence resulting in difficulty pronouncing consonants like "p" and "b," drooling and difficulty eating and drinking, also, from lip incompetence and biting of the buccal mucosa, and nasal obstruction from the collapse of nasal alar rim from the flattened nasal labial fold. In the case of permanent paralysis, patients need early intervention and rehabilitation. Appropriate management is directed by several factors, including the time of injury, the integrity of the facial nerve, viability of distal facial nerve branches and motor endplates, the patient's underlying medical conditions, as well as the patient's preferences. There are multiple etiologies of facial nerve paralysis. A detailed history, review of systems, and physical exam is essential on the diagnosis. A full review of the differential diagnosis and work-up of facial nerve paralysis is beyond the scope of this lecture, but I have listed the most common causes. Idiopathic, or Bell's Palsy, is the most common cause of facial nerve paralysis, accounting for up to 75 percent of cases in one large series of patients written up in the New England Journal of Medicine. First described by Sir Charles Bell in 1821, Bell's Palsy is a unilateral facial weakness of sudden onset that resolves spontaneously, usually in 4 to 6 months, but always by 12 months. It is a diagnosis of exclusion and idiopathic by definition. However, current theories for its cause include ischemic neuritis, viral infection, and entrapment neuropathy. The second most common cause of facial nerve paralysis is traumatic injury, which can be iatrogenic, as in mastoid or middle ear surgery, or an oncologic resection, as in our patient. The trauma can also be non-iatrogenic, as in penetrating or blunt trauma to the head or face. Other etiologies include infections, Herpes Zoster being the most common, neoplasm, acoustic neuromas and parotid tumors being common, congenital paralysis, systemic or metabolic disease, like sarcoid or HIV, and neurologic disorders like Guillain-Barré disease. Documentation of clinical findings at the time of onset of facial nerve paralysis is essential for diagnostic and prognostic purposes. It is also important to establish the baseline facial nerve function for comparison following reconstruction or reanimation. House developed a six-point system that is in wide use today and assigns levels of gross facial movement as well as specific motion of the forehead, eye and mouth. Level I is normal function, and Level VI is absent function. Levels II through V span mild to severe dysfunction. Level IV is significant in that it is the level at which incomplete eye closure occurs. Level V marks the presence of asymmetry at rest, which is what our patient was graded. Prognostic tests are not always indicated in the event of facial nerve paralysis. In our patient, for example, his facial nerve was intentionally sacrificed during a total parotidectomy. There is no mystery here and no anticipated recovery without intervention. The rule for prognostic testing is an acute total facial palsy and for following the course of disease in the setting of persistent paralysis. We will review some of the more common tests. The nerve excitability test was first described in 1964 by Hilger. It compares the electrical current measure in milliamps needed to elicit minimal muscle contraction on the normal side of the face compared to the paralyzed side. A difference of 3.5 milliamps or more is significant and suggests a degeneration. The Maximum Stimulation Test includes a stimulus applied to the normal side of the face and it is increased until the maximum amount of muscle movement is noted without discomfort to the patient. This stimulus is then applied to the paralyzed side and the difference in facial movement is observed. This test is obviously difficult to quantitate and is subject to intersubject variation. Electroneurography, or ENOG, is similar to the principle of the maximum stimulation test, except there is an actual recording of the summation potential. Thus, it is possible to quantitate the muscle response to stimulation and to compare the two sides of the face. The degree of degeneration is directly proportional to the difference between the amplitudes of the measured potentials, and it is recommended that surgical decompression be performed if 90 percent degeneration has occurred. Finally, electromyography involves a needle electrode which measures the muscle activity directly, both at rest and under voluntary contraction. It can detect active motor units that would otherwise go undetected and is used to provide early evidence of nerve recovery. Several other tests exist that fall under the category of topodiagnostic testing. These test specific neuronal functions in an attempt to isolate the lesion; however, they usually have little correlation with the actual site of the lesion, and they are not accurate prognostic indicators. These tests include the lacrimation or Shirmer's test, the stapedial reflex, salivary flow testing, and electrogustometry. In planning facial reanimation, the initial approach depends on etiology. If the facial nerve has been injured or transected, as in our patient, early nerve grafting is the best treatment. If the etiology, however, is unknown, a period of 12 months is given to allow for spontaneous recovery. After 12 months, it is thought that spontaneous recovery is unlikely and reanimation procedures are entertained. In early reanimation, the aim is to reestablish neural integrity, either through anastomosis of native facial nerve or through the use of interpositional graphs, when a tension-free primary anastomosis is not possible. Direct nerve repair involves the anastomosis of the proximal and distal stumps of the native facial nerve. In simple terms, if these stumps will not reach, a nerve graft can be used to connect them. Interpositional nerve graft, which is what our patient had, can be obtained from the great auricular nerve, the cervical plexus, or the sural nerve, depending on how much length you need. When the proximal portion of the nerve is unavailable for primary repair, but an intact distal facial nerve is available, cross-facial nerve grafting is an option. This involves the anastomosis between the facial nerve branches on the unaffected side to the distal branches on the paralyzed side. This is similar to cross-over reinervation, which involves the anastomosis of a donor nerve and the distal stump of the facial nerve. Donor nerves that have been used and written about in the literature include the hypoglossal nerve and buccal branches of the contralateral facial nerve. All of these techniques require intact facial musculature. In situations of irreversible muscle atrophy, alternative techniques are necessary. These techniques fall under the category of "late reanimation". Again, this is limited by the absence of distal nerve fibers and viable motor endplates, which have had ample time to atrophy. Reinervation of existing facial muscles is no longer an option and utilization of alternative muscles for animation is necessary. Regional muscle transfers of the temporalis and masseter muscle have been well described. The origin of the muscle is left intact and the distal portion is transposed with insertion into the upper lip musculature. This provides suspension of the soft tissues of the face, particularly the upper lip and oral commissure. Movement of the lip requires clenching of the teeth and, with practice, many patients are able to produce a reasonable smile. The more complicated microvascular free tissue transfer involves a two-stage procedure in which first a cross-facial nerve graft is performed using sural nerve anastomosis to the buccal branch of the unaffected side. The second stage involves the free transfer of the gracilis or rectus muscle to the face with microvascular anastomosis to the facial or superficial temporal vessels, and at the neural repair to the distal end of the sural nerve graft. Static procedures can be used as adjuncts to dynamic reanimation and include fascial slings, gold weight or spring implantation in the upper eyelid, brow and forehead lift, as in our patient, as well as lower lip wedge resection or botulinum toxin injections in the case of hemifacial or blepharospasm. To discuss the various approaches to the brow lift, we must first review the anatomy of the forehead and brow. The anatomic boundaries of the forehead are the eyebrows and nasal root inferiorly, the zygomatic arch inferiolaterally, and the hairline or superior extent of the frontalis muscle superiorly. The forehead can then be divided into a central portion and then two lateral portions—that one is not visible—or temple regions. The temple is separated from the central forehead at the superior temporal line, right there. This line exists at the anterior-most border of the temporalis muscle and is significant because several soft tissue layers adhere to the underlying skull here. It represents an important transition zone in surgical planes, and it is going to come up later. The central forehead and scalp consist of five layers, easily remembered by the pneumonic SCALP: the Skin, subCutaneous tissue, galea Aponeurosis, Loose connective tissue, and Pericranium. The galea aponeurosis is continuous with the temporoparietal fascia, which is also called the superficial temporal fascia. It is continuous with this fascia at the superior temporal line, which we just previously described. The galea is a thin sheet of connective tissue that encircles the entire skull, and it splits to envelop the frontalis and procerus muscles in the forehead. The loose areolar tissue connects the galea with the pericranium, and with injection of lidocaine with epinephrine this plane becomes relatively avascular, which is helpful in surgical dissection. The pericranium or periosteum is a thickened layer of connective tissue that is densely adherent to the surface of the skull. The transition of this outer periosteum to the inner periorbita of the orbit is referred to as the arcus marginalis, which is densely adherent to the orbital rim. The muscles of the forehead include the midline procerus, right here, and then the paired muscles, the frontalis, and the corrugator supercilii, as well as the ocularis. These muscles combine to determine the position and orientation of the eyebrows, as well as producing a variety of furrows and rhytids, thereby having a large role in determining facial expressions, such as sadness, anger, and surprise. Each of these muscles is inervated by the temporal branch of the facial nerve. The frontalis muscle originates in the fascia of the orbicularis and inserts on the galea aponeurosis. It elevates the brow and produces transverse rhytids, right here. The procerus originates in the fascia of the nasal bones and the upper lateral cartilages, and it inserts in the skin of the medial lower forehead. It causes descent of the medial aspect of the lower forehead, of the eyebrow and forehead, and it produces horizontal glabellar rhytids. The corrugator supercilii are the deepest muscles of the brow and they originate from the superior medial orbital rim and insert on the fascia of the lower frontalis muscles and skin of the brow. It pulls the brow inferiorly and medially here, producing vertical glabellar rhytids. The orbicularis oculi, the orbital portion, has its origin in the medial orbital rim and the medial canthal tendon, and it inserts on the medial aspect of the bony orbit. It causes descent of the brow. The boundaries of the temporal fascia are the superior temporal lines superiorly, the frontal process of the zygomatic bone anteriorly, and the zygomatic arch inferiorly. The temporal fascia contains the temporalis muscle and its layered fascia, the superficial and deep temporal vessels, the temporal branch of the facial nerve, and the auricular temporal nerve. The fascial layers of the temporal fascia have been identified by many names, making the anatomy in this region especially difficult to grasp. The layers are a little different from the pneumonic scalp. Again, you have the skin and subcutaneous tissue, and then you have the temporoparietal fascia, also called the superficial temporal fascia. It is the most superficial fascial layer and it contains and is supplied by the superficial temporal artery and vein. It also contains the temporal branch of the facial nerve. Deep to this is the deep temporal fascia. This has also been called temporalis muscle fascia. It envelopes the temporalis muscle and then inferiorly it splits into the superficial and the deep layer right here. And that actually is going to ensheath the temporal fat pad, and it is just the deep portion of this facial layer that actually splits to encompass the temporalis muscle. Again, you have your loose areolar tissue and the temporalis muscle, which is a flat fan-shaped muscle that arises from the temporal fascia and the deep surface of the deep temporal fascia. Its fibers converge and pass deep to the zygomatic arch to insert on the corneii process and the ramus of the mandible. Sensory innervation of the forehead, scalp, and temporal fascia is supplied by branches of the ophthalmic and maxillary divisions of the trigeminal nerve. The frontal nerve, which is a branch of the ophthalmic nerve, gives off the supraorbital and supratrochlear nerves, which exit the orbit through the supraorbital notch and pierce the corrugator muscles. They provide sensation to the skin and conjunctiva of the upper eyelid and then travel on the superficial surface of the frontalis muscle, supplying the skin of the forehead and scalp, from the eyebrows to the vertex superiorly. So, this green area is supplied by the ophthalmic division of the trigeminal nerve in the form of supraorbital and supratrochlear nerves. The branches of the maxillary division of the trigeminal nerve supply sensation to the lateral upper eyelid and skin of the temporal region. So, it is the maxillary branch of the trigeminal, and that supplies this area that is shaded in blue. The temporal branch of the facial nerve provides motor to the muscles of the forehead and brow. Again, these are the frontalis, the corrugator, the procerus and the orbicularis oculi. After exiting the superior portion of the parotid gland, the temporal branch of the facial nerve crosses the zygomatic arch just superficial to the zygomatic bone. It then courses through the temporoparietal fascia, which we described as the most superficial fascial layer in the temporal fascia. And then it enters the forehead. It enters the forehead deep to the frontalis muscle and travels there to supply all the muscles of the brow and forehead. The brow lift is both an aesthetic and a functional procedure. From an aesthetic standpoint, the ptotic brow and its associated forehead and glabellar rhytids can create an angry or sad expression. Patients will present wanting this resolved. This usually results from the process of aging. A functional brow lift addresses the ptotic brow that causes visual field restriction. Either aging or facial nerve paralysis can cause this. In several articles patients with long-standing facial nerve paralysis, specifically the frontal branch, cited visual field defects as their chief complaint. So, just to review, these are the approaches that we will be discussing. The coronal brow lift: in this approach a coronal incision is made 4cm - 6cm behind the anterior hairline. The incision extends through the galea to the level of the periosteum, so we are in the level of the loose aerolar tissue. Care is taken to bevel the incision parallel to the hair follicles in order to minimize hair loss. In this subgaleal and supraperiosteal plane, the dissection is carried to the level of the supraorbital rim, taking care not to damage the supraorbital and supratrochlear neurovascular bundles. Laterally, the plane of dissection is on the superficial layer of the deep temporalis fascia, which is deep to the frontal branch of the facial nerve, which runs in the temporoparietal fascia. Now, in our patient who had facial nerve paralysis, this is not really relevant, because you do not need to protect a nerve that is not functioning. But, in an aesthetic or functional lift in the patient whose nerve is intact, it is important. The frontalis, corrugator, and procerus muscles are easily accessed using this technique and can be incised or scored to address forehead and glabellar rhytids. After subgaleal dissection, down to the orbital rim, the flap is then draped superior posteriorly and you are going to have a rim of skin and subcutaneous tissue that you then excise. It is usually a width of about 2cm -4cm, and then the flap is secured to the periosteum using permanent sutures. The advantage of the coronal brow lift is that if the person has hair, then there is no visible scar. There is great exposure of the frontalis, corrugator, and procerus muscles if you would like to address forehead rhytids as well. The disadvantage is that this is the most extensive dissection with the greatest risk of hematoma and nerve damage. Scalp hypesthesias result from the transection of the distal fibers of the supratrochlear and supraorbital nerves as they travel superficial to the galea. Another disadvantage is that this technique elevates the hairline and it gives you the least control over brow asymmetries and the exact contour of the brows as you are simply elevating the entire upper one-third of the face. In reference to our patient and post-parotidectomy patients like him, his paralysis is unilateral and such an extensive dissection is not necessarily indicated. The next technique, the high forehead lift, is similar to the coronal lift except that the incision is placed either just anterior to the hairline, which is called pretrichial or just within the hairline, which is called trichophytic. Again, the plane of dissection is subgaleal and laterally it is on the deep temporalis fascia. The flap, again, is draped superior posteriorly and the excess skin and subcutaneous tissue is excised. The flap is secured to the periosteum. The difference is between the high forehead lift and the coroneal lift is the need for meticulous wound closure is essential in these techniques because the scar is potentially visible. However, with careful technique, you can see that these scars really aren't that obvious. This is the pretrichial incision and this is the trichophyitic. Once the hair grows over this incision, it won't be very obvious. Advantages of this technique are similar to the advantages of the coronal lift in that there's excellent exposure. An additional advantage in this technique is that it will not change the height of the hairline so it's good for people with a high hairline or a long forehead. The disadvantage of this technique is that it also includes extensive surgical undermining similar to the coronal lift. This increases the risk of hematoma and nerve injury. The greatest disadvantage of the high forehead lift is, again, the potential for a visible scar. The next technique is the mid-forehead brow lift. It's based on an excision of a strip of skin and subcutaneous tissue from the middle forehead. The upper limb of the excision is placed in an existing mid-forehead rhytid. This will be the position of the resultant scar. The vertical height of the excision depends on the degree of elevation desired. This strip of skin and subcutaneous fat is excised leaving the frontalis muscle intact, so this dissection is carried out in a subcutaneous plane. The plane is continued inferiorly; the supraorbital and supratrochlear sensory nerve branches are deep to this plane so they're well-protected as they run in the frontalis muscle. The dissection is carried to the level of the suprarorbital rims. At this point, when you get to the supraorbital rims, the dissection is taken deeper in the medial one-third of the incision. It's taken down through the frontalis and the galea and this is medial to the supraorbital notch so still the neurovascular bundles of the supraorbital and supratrochlear nerves are preserved. But, it gives you access to the medial portion of the corrugators and the procerus muscle. Myoplasty can be performed to address glabellar rhytids. The upper margin of the orbicularis muscle is then tacked superiorly to the periosteum and the skin incision is closed. Advantages of the mid-forehead lift are that it's a less extensive procedure, there's less dissection and less risk of hematoma. It does not alter the hairline, which is good for male-pattern or receding hairline, thinning hair or high hairline. And it allows precise elevation and contouring of the brow. The main disadvantage is that there is a visible scar. The direct brow lift, which is what our patient had, is the oldest and simplest surgical approach to the ptotic brow. First described in 1930 by Passat, this procedure involves the excision of an appropriately-sized lip of skin and subcutaneous tissue from just above the eyebrow. The preoperative marking of the incision is essential and must be done with the patient sitting upright to take into account the effects of gravity. The upper incision line marks the position of the superior margin of the postop brow and can be contoured into the desired curve. This allows great control of the shape of the brow. The inferior incision is marked just within the superior margin of the brow hair and the vertical height of the excision depends on the degree of ptosis and lateral hooding. After appropriate marking, the inferior incision is beveled to avoid injury to the brow hair. The superior incision is beveled to match the inferior wound edge for better apposition during closure. The skin excision is in a plane just above the frontalis and orbicularis oculi muscles. The frontal branch of the facial nerve enters the frontalis muscle laterally and on its under surface. So, careful dissection in the lateral one-third of the excision is important with emphasis on not going too deep. Again, on a patient with facial nerve paralysis, this is less relevant. The upper margin of the orbicularis muscle is tacked superiorly to the frontal periosteum or fascia to minimize post-op scar widening and the recurrence of ptosis. This is just an example of how you can directly control the shape of the postop brow based on where you mark your incision, and this is again the example of the suturing of the orbicularis oculi to the periosteum. Advantages of the direct brow lift are that it's a short, simple procedure with minimal morbidity. It provides the greatest control of brow height and shape and is thus the preferred method for the correction of severely asymmetric brows. It gives the most precise positioning of the brow, versus the more distant coronal approaches, thus it's the preferred surgical approach for correcting unilateral brow ptosis secondary to facial nerve paralysis. It's very effective in correcting lateral ptosis, and thus is ideal for the person seeking predominantly the functional brow lift for lateral hooding and restricted fields of vision. The disadvantage is the potential scar, the loss of eyebrow hair at the incision site, and that you don't have access to the correction of forehead or glabellar ptosis and rhytids. The most recent approaches to the brow lift have followed the trend of minimally-invasive surgery. Originally described in 1984 by Santana, the endoscopic approach to brow lift has been practiced with increasing popularity in the United States for the past 10-12 years. There are anywhere from 3-6 small incisions, vertical incisions placed just posterior to the hairline. A periosteal elevator is inserted in these small incisions and used to establish a subperiosteal dissection plane. This dissection is carried anteriorly and inferiorly to the supraorbital rims. The plane of the lateral dissection is in the loose areolar tissue between the temporoparietal fascia and the deep temporal fascia. So, again there's this transition zone that occurs between the anterior subperiosteal plane and the lateral areolar plane that must be appreciated. This occurs at the superior temporal line and is called the conjoined fascia. It's a condensation of the periosteum and the deep temporal fascia at the anterior border of the temporalis muscle. It attaches to the temporal bone of the superior temporal line. This fascia must be sharply elevated from the temporal bone in order to transition from the deeper subperiosteal plane in the forehead to the more superficial fascial plane in the temporal fascia. Use of the endoscope facilitates this dissection and allows careful identification and preservation of the supraorbital and supratrochlear neurovascular bundles. Once the dissection is complete, long, curved instruments can be inserted in the incisions and used to complete myoplasty of the frontalis, corrugator, and procerus muscles. Fixation of the flap and the suspension of the brow can be achieved by several techniques. These include permanent plate or screw fixation, permanent sutures in the orbicularis muscle affixed to the screws or plates, galeal suture placement, cortical bone tunnels, fibron glue and absorbable screws. There is no skin excision and flat fixation is the most debated aspect of this approach. Everyone agrees that fixation is the most critical aspect to successful elevation, yet, there's no consensus on the best technique. The major advantage of the endoscopic approach is that it's minimally invasive and it can address both brow and muscle issues. The major disadvantage of the approach, however, is the lack of long-term results comparing this technique to traditional brow lifts. Specifically, this technique is still being modified, especially with respect to the means of fixation, which, again, is the most critical aspect of the procedure. This procedure also requires specialized endoscopic equipment and requires a certain expertise. The most recent development in minimally invasive brow surgery was presented in the March-April 2003 issue of the Archives of Facial Plastic Surgery. The authors describe a technique to address unilateral brow suspension in a group of patients with head and neck tumors and brow ptosis caused by facial nerve paralysis. Intra-operatively, three horizontal stab incisions are made within the hair-bearing portion of the eyebrow, medially, laterally, and centrally. Then there are incisions made in the scalp, just posterior to the hairline, so they're well hidden. The incisions in the brow are carried down to the level of the frontalis muscle. The incisions posterior to the brow are carried down through the periosteum. A Freer Elevator is used to develop this plane, subperiosteally, similar to the endoscopic approach. The surgeon, however, must constantly be palpating the supraorbital notch to avoid injury to the supraorbital and supratrochlear neurovascular bundles because you're not doing this under direct visualization with use of the endoscope. A hemostat is then introduced through the incision in the brow, to perforate the frontalis muscle and enter the subperiosteal plane. Once this is done, a suture can be placed through the orbicularis muscle and a Heusen suture retriever is inserted through the forehead incision and used to grab the suture, pulling it through this subperiosteal plane and out this posterior hairline incision. This is repeated for all three incisions, and then the sutures are tacked superiorly to the periosteum at the desired elevation and position. So, you can see how you have good control over the shape of your brow. The authors propose that the advantages of this procedure are that it's minimally invasive and avoids a visible post-op scar, but in contrast to the endoscopic approach, it doesn't require special equipment and is not technically as difficult as the endoscopic approach. In their group of 23 patients, they claim acceptable to outstanding results with respect to brow elevation and contour symmetry as compared to the contralateral unparalyzed side. Complications of brow lift are similar for each technique, although with varying frequencies, and they're listed here. They include hematoma, infection, asymmetry, nerve injury, alopecia, and recurrent brow ptosis. So, in summary, functional brow lift is a static procedure that benefits patients with brow ptosis and lateral hooding, following facial nerve paralysis. There are multiple approaches that have been well-studied, and surgical planning depends on many factors. The direct brow lift traditionally has been the method of choice in patients with unilateral ptosis secondary to facial nerve paralysis. As new equipment and advanced technology become available, however, minimally invasive approaches continue to develop and challenge these more traditional approaches. And finally, a thorough understanding of the anatomy is critical, and just to review, there are these various dissection planes and it's important to realize which plane you're in and which structures are most at risk in those planes. You have subcutaneous, subgaleal, supraperiosteal, and then the subperiosteal, and these are the techniques that we discussed. Voltaire was noted as saying that the art of medicine consists of amusing the patient while nature cures the disease. I'm happy to say that in our patient, we actually did do something in addition to just amusing him, and he was very happy with his results. Again, this is the site of the ptosis, and this is the site postoperatively. Case Presentation: C.M., a 63-year-old man, presented to the Houston VA in May 2001 with recurrent squamous cell carcinoma metastatic to his neck. Past medical history: In September 2000, squamous cell carcinoma of the right temple was excised with positive deep margins. In October 2000, he underwent a WLE and superficial parotidectomy with negative margins. In April 2001 he had a recurrence in the right pre-auricular area and a right neck mass. The pre-auricular lesion was excised with negative margins and a biopsy of the neck mass revealed moderately differentiated squamous cell carcinoma. In May 2001, the patient presented to the Houston VA with a right neck mass and a new pre-auricular lesion. Biopsy of lesion in clinic showed a recurrence of squamous cell carcinoma. In June 2001, a WLE, radical parotidectomy and facial nerve sacrifice with sural nerve graft, post-lat neck dissection, reconstruction with trapezius flap and STSG, and placement of gold weight were performed. All margins and lymph nodes were negative for disease. Patient did not undergo post-op chemotherapy secondary to patient preference after post-op complications of wound breakdown and C.difficile colitis. In June 2002 a recurrence over the right cheek suture line was positive for poorly differentiated squamous cell carcinoma. WLE with negative margins. The patient completed chemotherapy treatment in October 2002. Bibliography: Carruthers J. Brow lifting and blepharoplasty. Dermatol Clin 2001;19:531-533. Catalano PJ, Bergstein MJ, Biller HF. Comprehensive management of the eye in facial paralysis. 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