The Coronal Incisi m.in Rhytidectomy

The Coronal Incisi m.in
Rhytidectomy- The Brow Lift
From the Plastic Surgery Unit, Hospital General de Mexico, and the Graduate
Division, School 01 Medicine, Universidad Nacional Autonoma de Mexico, Mexico,
City, Mexico
FERNANDO ORTIZ-MONASTERIO,
GUSTAVO BARRERA, M.D.
ALVARO OLMEDO, M.D.
Aging of the face is not an isolated skin
phenomenon.
It is part of a general process
affecting the whole soft tissue coverage of the
head and neck. The skin of the face is affected
by age in three different ways: 1. Changes in
the quality of the skin itself are manifested
rnainly by decreased activity of the sebaceous
glands and the appearance of numerous superficial creases running in man y directions not
always dearly related to tension or expression
lines. These changes are more noticeable in
persons of light complexion after years of exposure to the sun and wind.
2. Loss of elasticity is due to deterioration
of the colla gen framework. The flaccid skin,
poorly supported by hypotonic facial musdes,
produces sagging of the face that is dearly
manifested in the cheeks, the nasolabial fold,
the jaw line, and the neck, in addition to the
eyelids, the nose, and the forehead.
3. Excessive
demarcation
of the skin
creases relates to normal facial movements.
These
expression
lines are particularly
marked in areas where the facial musdes are
attached to the skin. The "crow's feet", the
horizontallines
in the forehead and the vertical frown are the main affected areas.
Aging is very seldom a localized process affecting only one area, but certain parts of the
face may show more deterioration than others
and this varies with each persono Any operation aiming to produce a rejuvenating effect
must, therefore, be planned and performed in
a different way for each individual patient.
Clinics in Plastic Surgery-Vol.
5, No. 1,]anuary 1978
M.D.
Most of the face lifting techniques currently
described in the literature emphasize the correction of the neck, the cheeks, and the temporal area. Relatively little attention is given to
the forehead and even less to the ptosis of the
eyebrows.
The purpose of this artide is to present our
experience
with the coronal incision used
primarily as a brow lift and secondarily to correct forehead wrinkles.
HISTORICAL BACKGROUND
Forehead lifting'is not a new procedure. For
over half a century plastic surgeons have designed many ingenious operations-to correct
forehead and frown lines. In 1926 Hunt" advocated a complete coronal incision following
the hairline with forehead skin resection for
the correction of forehead wrinkles. He combined this procedure with a vertical skin excision for the frown. A more modest resection
located behind the hairline was recommended
by Mme. Noel.!' Removal of the skin at the
hairline was also reported by ] oseph io and
Lexer.P A limited frontal incision not extending into the temporal area was recommended
by these pioneers.
In 1931 Passot" also
suggested the removal of skin behind the hairline to correct forehead wrinkles. He later
complemented
this operation with denervation ofthe temporal branch ofthe facial nerve.
167
168
, Fernando
Ortiz-Monasterio,
Gustavo Barrera, Alvaro Olmedo
A case ofbilateral
temporal neurotomy
to correct frontal "hyperrnotility"
was reported
by
Edward
in 1957.4 Bame '<in the same
eáf
combined temporal neurotomy
with excision
of superciliary
skin.
In 1961 Pangman
returned
to the full coronal incision and skin removal at the hairline
to correct forehead wrinkles and to elevate the
brows. He also recommended
a more posterior incisiori.P A complete coronal incision to
improve
forehead
wrinkles was later advocated by Conzalez-Ulloa"
in combination
with
an extensive
face-lift. Castañares"
in 1964
popularized
the resection of superciliary
skin
to correct the pto i of the eyebrows. This approach to brow-lifting
was also foIlowed by
Johnson. 9 Section and reinsertion of the frontalis muscle through
a hairline incision was
done by Uchida'" in 1965. Picaud " analyzed
the indications
for coronal incision in 1967
and Marino P published
his results with cervicofacial face-lift in continuity
with coronal
incision
and removal
of frontal
muscle.
Rees19•20 described
the coronal incision with
disection superficial
to the frontalis muscle
and discusses the circulatory problems arising
in the frontal
flap with this procedure.
Gleason" suggested a bilateral temporal incision not reaching the midline emphasizing
the
two le veis of dissection for the forehead and
the temporal are a to preserve the integrity of
the facial nerve. Brow-lifting
was again discussed by Hinderer?
in 1975 who combined,
frontal or superciliary
incisions with elevation
of the skeletal insertion of the lateral canthal
ligament. The rationale and results of frontal
rhytidectomy
were analyzed by Viñas'" and by
Wa hi023 in 1976.
Several trends are clearly defined in the literature on forehead
rhytidectomy.
Denervation of the frontalis
muscle produces
very
smooth foreheads.
Loss of expression
and
sub equent ptosis of the eyebrows resulting
from this operation
are highly undesirable
and the procedure
is not generally accepted
except under very special circumstances.
Most
authors remove forehead skin at the hairline
or in the scalp to correct horizontal forehead
wrinkles. The frontal muscle is left untouched
and the wrinkles return soon after the postoperative
edema subsides. Excessive tension
on the suture against the convex frontal bone
is followed by circulatory
impairment
of the
flap and subsequent
alopecia or skin necrosis.
Undermining
the flaps from the frontalis
muscle can easily compromise
the circulation
and several authors report catastrophic
results. Coronal incision and forehead
lifting
were generally condemned
as a consequence
of inadequate
understanding
of its indications, its limitations, and its technical points.
Brow-Iifting a the main objective of the operation, associated or not with forehead wrinkles correction,
was disregarded
by rnost writers. Supraciliary
kin excision, sornetimes extended into the temple area, seemed a logical
answer and improvement
of the crow's feet
carne as an extra bonus.
FOREHEAD PTOSIS
A very large percentage
of the patients requesting
rhytidectomy
have ptosis of the
eyebrows.
Many of them camouflage
this
problem
by depilation.
The brow is then
. drawn in a higher position in an effort to exchange the expression
of fatigue for one of
alertness.
After a conventional
rhytidectomy
extending partially into the temporal area, patients
find the results of surgery very pleasing but
many comment that "there is asad look" in the
forehead that doesn't fit with the rejuvenated
part of the face.
When the brow is located below the supraorbital rirn, it produces bulging and drooping of the upper eyelid. Irnrnediate improvement of the eyelid is observed
when the
examiner pulls the eyebrow to a higher position. The amount of skin to be resected frorn
the upper
lid decreases
considerably
and
sometimes the superior blepharoplasty
is not
necessary.
FOREHEAD WRINKLES
Three groups of muscles give expression to
the forehead."
The frontalis
elevates
the
brows and is responsible
for the horizontal
creases. The two ,corrugators pull the head of
the brows towardsthe
midline, resulting in a
vertical frown, and ~e 'procer~s eleva~es t~e
root of the nose producing horizontal lines m
the frontonasal
groove.
Most patients are not very concerned about
, the horizontal
forehead
wrinkles. However,
when the motion of the frontalis
is exaggerated and the creases are very deep, it is
convenient
to do a partial resection of the
muscle.
Resection
of the hypertrophied
corrugators
eliminate~the
vertical frown and
softens facial expression.
Partial excision of
the procerus improves the horizontal wrinkl s
in the glabellar area.
The Coronal Incision in Rhytidectomy-The
INDICATIONS
FOR THE CORONAL
INCISION
Correction of the forehead ptosis and elevation of the eyebrows are, in our opinion, the
main indications for the forehead lift. Due to
its firm attachment to the fascia and muscle,
the forehead ski n has very limited elasticity ..
This anatomic characteristic is used to advantage to produce a brow-lift.
In the facial and cervical rhytidectomy the
skin is easily separated from the muscle layer
and then stretched to elimina te the wrinkles.
The same effect can not be obtained in the
frontal area because dissection ofthe forehead
skin from the frontalis and the galea is difficult
and even when performed with extreme care,
the circulation ofthe skin flap can be seriously
impaired.
For this reason the undermining
of the
frontal flap is done under the fascia and
stretching of the skin is not obtained. The
operation, therefore, does not improve at all
the horizontal creases. Partial resection of the
frontalis in the upper half of the forehead is
indicated when the forehead is very mobile
producing deep permanent creases.
The corona! approach gives excellent access
to the corrugators and procerus muscles. The
insertions are easily dissected and the muscle
o
Figure 1. A, Cephalic and B, lateral views showing the
hair arrangement for a coronal incision. No shaving is
necessary.
BTOW
Lift
169
fibers can be totally removed. We find the coronal incision indicated in most patients requesting rhytidectomy
when the eyebrows
have descended below the süpraorbital rldge.
It is also indicated
in combination
with
blepharoplasty
without face lifting. The typical patient will face the surgeon elevating the
tail of the brows with her index fingers and
say: "Doctor, 1want my eyelids done." In this
case, resection of skin from the upper lid, even
when extremely redundant,
pulls the brow
down. A forehead lift will raise the brows,
producing the desired result.
A coronal incision behind the hairline is not
indicated in patients with a high forehead or
when the hair is scarce. Here the brow-lift may
be done by a hairline incision or by superciliary skin resection. We are not very enthusiastic about the latter beca use of the visible
scar above the brow that always requires
cosmetic camouflage.
SURGICAL
TECHNIQUES
The Brow-Lift
The patient is instructed to wash the háif tfie
day before surgery. Before going to the
170
Fernando
Ortiz-Monasterio,
Gustavo Barrera, Alvaro Olmedo
Figure 2.
Downward
traction of the flap makes the
diss ction easier and allow good exposure of t.he glabel!ar
area.
Figure 3. The shaded area represents the Iirnits of the
dissection of the frontal flap.
otice the undermining
be101'1 the supraorbital
rirn and al the lateral orbital wall
and the glabel!a.
o
Figure 4. A needle is introduced
through the skin lO
mark the lower limit for the resecrío-, of the frontalis
musele. The amount of muele to be resected is marked
with blue dye.
The Coronal Incision in Rhytidectomy-The Brow Lift
171
Figure 5. A strip of frontalis muscle from the upper
pan of the forehead is carefully elevated. Creat care is
taken to protect the blood vessels running through the fat
tissue irnmediately under the muscle.
operating room a line is drawn on the scalp
parallel and 5 to 8 cm behind the hairline,
extending to the middle of the vertex of the
ear on each .side. All.the hair posterior to this
line is combed backwards. The hair situated in
front of this line is set in curls firml y fixed with
rubber bands (Fig. 1). Shaving is not necessary.
Routine skin preparation
and draping are
done inTlíe operatingroorn.
Local anesthesia
is obtained
by infiltration
of 1 per cent
Xylocaine
solution
with
epinephrine
1: 100,000. Intravenous sedation is routinely
used.
The incision on the scalp is made following
the previously marked line extending to the
apex of the ear on each side and then curving
forward and downwards within 1 cm of the
hairline. The incision includes skin, muscle,
and fascia. The dissection is carried out with a
knife between the fascia and the periosteum in
a well defined c1eavage plane and is greatly
facilitated by downwards traetion on the scalp
flap. Laterally the disseetion proceeds in the
direction of the zygoma between the fascia of
the temporalis and the frontalis muscle. The
supraorbital and supratrochlear
nerves are 10eated and isolated. The underminin'g
is eontinued at least half a centimeter below the orbital rim (Figs. 3 and 4).
Hemostasis is achieved by coagulation of a
few vessels at the skin edges and in the superciliary area.
o special care is necessary to
preserve the temporal branch of the facial
nerve because the dissection is done on a
deeper planeo
The flap is then returned to its original position exerting moderate backwards tension. To
facilita te the su ture a small "T" incision is
made at the midline on the forehead flap. The
vertical portion of the "T" is perpendicular to
the edge of the flap and the horizontalleg is
located at the level where the flap can meet the
posterior edge of the wound with moderate
tension (see Fig. 8). A fixation suture is then
placed and the maneuver is repeated on each
side, dividing the wound in four segments (see
Fig. 9). The extra skin is resected at this time
and closure is completed in one layer with 2-0
silk interrupted
sutures. Drainage is seldom
necessary. The width of the resected strip of
scalp may vary from 1.5 to 4.0 cm, the average
being 2.2.
Muscle-Resection
When the dissection {and hemostasis are
completed one may proceed to reseet a section
of the frontalis. The purpose of this maneu ver
is to limit (not to eliminate) the motion of the
frontalis. It is extremely important in our
opinion to preserve some mobility of the eyebrows. For this reason the resection should be
made in the upper forehead area leaving the
frontalis intact in the lower parto
The lower level of the lrontalis resection is
172
Fernando Ortiz-Mtmasterio,
Gustavo Barrera, Alvaro Olmedo
Figure 6.
identified
The muscle bellies of the corrugators
and isolated on each side.
are
Figure 7. The insertions of the corrugator to the
periosteum and to the orbicularis muscle are cornpletely
separated to eliminate the frown. The rest of the muscl . _
is then excised.
found midway between the hairline and brows
and marked on the skin with the flap in its
normal position. At this point a hypodermic
needle is passed perpendicularly
through the
skin as a way to determine the lower limit of
the frontalis resectionon the deep side of the
flap (see Fig. 4).
{:.
A l O to 30 mm strip of muscle is resected
horizontally, depending of the height of the
forehead and the activity of the frontalis. The
resection is extended laterally the whole width '
of the forehead and must be meticulously carried out to preserve the small veins and arteries located immediately under the muscle (Fig.
5). The distensibility of the frontal flap is increased after the musele and fascia are re-
moved, requiring a wider than average resection of scalp.
For the correction of the vertical frown, the
flap is turned down exerting traction with skin
hooks on the interciliary area. After dissecting
the belly of the corrugators, its periosteal and
orbicularis insertions are located and seetioned (Fig. 6). The whole muscle is then removed (Fig. 7).
Simultaneous
Brow-Lift and Face-Lift
We prefer to do the complete operation in
one stage and the corona] incision is always the
first step of the procedure. In patients with low
hairline and abundant hair in front ofthe ear,
The Coronallncision in Rhytidectomy-The Brow Lift
173
Figure 8. "T" incisions are made at the midline and on
each side to mark the extent of skin resection. The frontal
flap is pulled backwards with moderate tension to determine the position of the horizontal branch of the "T."
Figure 9. Detail of the "T." The vertical branch is
perpendicular
to the skin edge.lt is cut exerting backward
traction on the flap. The horizontal branch is loéated
where it can be joined with the posterior edge of the
wound under moderate tension. Traction on the two flaps
formed by the "T" facilitates the first suture. Once the
three pilot sutures are made, the excess scalp is safely
removed (indicated by broken line).
..,.,
the facial rhytidectomy can be done in continuity with the coronal incision extending
into the temporal area (Figs. 10 and 15). Care
must be taken to prevent injury to the temporal branch of the facial nerve by following
two different planes of dissection. The frontal
flap is elevated from a deep plane under the
galea. The dissection of the cheek proceeds
upwards on a more superficial plane, especially at the temple where the motor branch
enters the frontalis, usually 2 cm above the
brow. At this point the two planes of dissection
are overlapped, leaving a bridge of intact tissue surrounding
the temporal branch 'of the
facial nerve (Fig. 11). The lifting of the facial
and temporal skin in a backwards and upwards direction produces a receding hairline.
This may be critical in the preauricular area in
patients with a high hairline and in those who
had a previous rhytidectomy. In order to preserve the normal implantation of the hair at
the sideburns in front of the ear we prefer to
do two separate incisions (Figs. 12, 14, and 16).
The coronal incision stops in front of the apex
of the ear and the lower incision follows the
contour of the ear until it reaches the lower
'.Jeve! of the sideburn where it turns forward on
a 9.0° angle following the con tour of the hairlini' for 2 or 3 cm. A detailed version of the
preauricular incision can be seen in Figures 12
and 13. A small triangular flap is fitted between the root of the helix and the tragus to
break the continuity of the line and obtain a
less noticeable scar.
When the coronal incision is in continuity
with the preauricular
incision, the suture of
the scalp is completed to the leve! of the ternperal before starting the facial part of the pro-
174
Figure 10.
in continuity.
Fernando
Diagram
Location
Ortiz-Monasterio,
Gustavo Barrera, Alvaro Olmedo
demonstrating
the design ofthe skin resection when the coronal and facial incisions are done
of the scar and changes of the hairline are illustrated on the right.
Figure 11. The two-plane dissection is shown in the
photograph.
The frontal flap has been undermined
on a
deeper plane and is aIread y partially sutured. The two
planes overlap at the level of the crossing of the motor
branch for the frorualis muscle.
Figure 12. Diagram illustrating the
skin resection when the coronal and facial incisions are separated by a portion
of hair-bearing
skin. The position of the
scar is shown at the right.
'-:-.
{: .
cedure. Final adjustments are made at the end
of the operation and the temporal suture is
then completed. When the two incisions are
separated, the coronal suture is completed be~ore starting the face.
RESULTS
During the last 5 years, we have performed
a brow-lift by means of a coronal incision in
285 patients. It was done in combination with
The Coronal Incision in Rhytidectorny-The Brow Lift
175
Figure 13. Detail ofthe preauricular incision and skin
resection. A small triangular flap is inserted between the
tragus and the root of the helix. The incision follows the
hairline for 2 01' 3 cm. The hair-bearing skin is preserved.
Figure 14. A and B, Preoperative views of
patient with moderate sagging of the face and
neck, and ptosis of the eyebrows adding fullness to upper eyelid. Horizontal and vertical
creases are not very marked on the forehead.
e and D, Photographs taken 18 months after
simultaneous
coronal
and
cervicofacial
rhytidectomy.
The facial and coronal incisions were separated by .a segment of hairbearing preauricularskin.
Frontalis and corrugators were not removed. Blepharoplasty
was done at the same time.
blepharoplasty
in 39 patients; the rest had a
sirnultaneous
rhytidectorny
and blepharoplasty. In 28 cases the coronal incision extended
in continuity 'f!th the preauricular rhytidectorny incision. In the rernaining 218, the two
incisions were separated, preserving an intact
hairline at the sideburns in front of the ear.
Practically all of the patients complained of
a constricting sensation around the head, as if
they were tightly bandaged. This lasted 7 to 10
176
Fernando Ortiz-Monasterio,
Gustavo Barrera, Alvaro Olmedo
Figure 15. A and B, Preoperative views of
patient with moderauy flaccid face and neck,
deeply marked frown and horizontal creases on
forehead. The ptosis of the brows is comouflaged by depilation and painting on a higher
position. She has abundant hair and a very low
hairline.
e and D, Six months after coronal and cervicofacial rhytidectomy done in continuity because of low hairline, which permitted good
elevation of the temporal skin while preserving
agood amountofhair in frontofthe ear. A strip
of frontalis muscle was removed from the
upper half of the forehead. The two corrugators were entirely excised with a section of
the procerus.
o skin was removed from the
upper lid.
days and was relieved by mild analgesics. Severe pain requiring
special treatment
occurred in 12 patients.
The pain diminished rapidly, leaving an
anesthesia lasting several months to ayear. Itching and numbness in the forehead area during
the first 2 to 3 months were reported by 58
patients.
No important
hair loss occurred in our
series. One or more circular are as of alopecia
about 10 mm in diarneter were found in 37
patients at the sites of the three fixation sutures. This obviously resulted from excessive
suture tension. Secondary correction was required only on one occasion.
The coronal scars were consistently good
and remained well covered by the hair.
The elevation of the eyebrows obtained by
this procedure has been satisfactory to both
patient and surgeon (Figs. 14-16).
The upper eyelid is gready improved by the
brow-lift. In 20 per cent of the patien ts no skin
excision from the upper eyelid was necessary.
EVALUATION OF RESULTS
Assessment of postoperative results in aesthetic surgery is always diffij;ult. Clinical impressions are prejudiced and subjective, almost impossible to tabulate.
In order to obtain comparable
pre and
postoperative measurements
we have used a
method derived from physical anthropology
techniques: the patient is asked to stand erect
with the back against the wall. The head is
fixed by a cephalostat. A frame crossed by vertical and horizontal lines forming squares of
exactly 1 cm is placed directly in front of the
face. Two double lines, one vertical and one
horizontal, cross the center of the frame. The
vertical double line is situated directly in front
of the midline of the face (Fig. 17). The horizontal double line is located at the level of the
lateral canthus of the eyelids (Fig. 19). A photograph is taken from a distance of 3 meters
with an 85 to 90 mm lens to prevent distortion.
It is convenient to use a powerful flash corno
o
The Coronal Incision in Rhytidectomy-The Brow Lift
177
Figure 16. A and B, Preoperative viewsof patient who had a conventional rhytidectomy extending into the temporal
area 6 years before. e and D, Postoperative aspect after simultaneous cervicofacial rhytidectomy and coronal incision
separated by the hair-bearing preauricular skin. The frontalis muscle was left intact and the corrugators were removed.
No skin was removed from the upper eyelid.
178
Fernando
Ortiz-Monasterio,
Gustavo Barrera, Alvaro Olmedo
Figure 17. Diagram showing fixation of the head with
conventional cephalostat to obtain comparable preoperative and postoperative photographs,
bined with small lens aperture to increase
depth of focus in order to have the facial features on the same plane with the screen (Fig.
18).
This simple method can be repeated to
compare the position of faciallandmarks such .
as the eyebrows, angles ofthe mouth, hairline,
etc. as many times as necessary. Changes of
position of the different structures are easily
detected and accurately measured.
This method has been used to evaluate the
brow-lift in our series. A ratio of 2 to 1 has
been found between skin resection and elevation of the brows; that is, for every centimeter
of scalp resected, the brows are lifted half a
centimeter.
When a section of frontalis muscle is removed, the ratio changes to 3 to l. This is
interpreted as an increase in skin distensibility.
Although there are many individual variations, the elevation of the brow changes very
little during the first 2 years. After that time
the descent is comparable to the changes observed in the face and neck after a rhytidectomy.
SUMMARY
Rhytidectomy is not a routine procedure
applicable to all patients. Variations of tech-
•
Figure 18. Diagram illustrating the arrangment for photographic cephalometry. The
patient stands against the wall with the head
fixed by the cephalostat. A 1 cm grid is placed
directly in front of the face while the photograph is taken with an 80 to 90 mm lens from a
distance of 3 meters lO prevent distortion.
The Coronallncision in Rhytidectomy-The Brow Lift
179
Figure 19. Example of photographic anthropometric
study. The l cm grid permits accurate recording of the
position of the eyebrows and other facial structurs.
nique must be chosen for each individual case.
Integral correction of the face is important
and brow-lifting must often be done. Our
criteria for selecting the coronal incision for
the brow-lift are discussed and the surgical
techniques are described in detail. Results are
analyzed and _asimple method for evaluation
is presented.
.
REFERENCES
1. Bames, H. o.: Frown disfigurement
and ptosis of
eyebrows. Plast. Reconstr. Surg., 19:337, 1957.
2. Castañares, S.: Forehead wrinkles, glabellar frown
and ptosis of the eyebrows. Plast. Reconstr. Surg.,
34 :406, 1964.
3. Castro-Correa,
P., and Zani, R.: Glabellar frown
lines-Anatomical
study of m. corrugator supercilis.
Trans. 6th Internat. Congo of Plast. Reconstr. Surg.
Paris, Masson et Cie, 1976, p. 434.
4. Edwards, B. I.: Bilateral temporal
neurotorny
for
frontalis hyperrnotility.
Case report. Plast. Reconstr.
Surg., 19:341,1957.
5. Gleason, M. C.: Brow lifting through a temporal scalp
approach. Plast. Reconstr. Surg.,52:141,
1973.
6. Gonzalez-Ulloa,
M.: Facial wrinkles-integral
elirnination. Plast. Reconstr. Surg., 29:659, 1962.
7. Hinderer, U. T.: Blepharocanthoplasty
with eyebrow
lift. Plast. Reconstr. Surg., 56 :402, 1972.
8. Hunt, H. L.: Plastic Surgery of the Head, Face and
eck. Philadelphia,
Lea & Febiger, 1926.
9. johnson,j.
B., and Hadley, R. C.: The aging face.In
Converse, j. M. (ed.): Reconstructive Plastiq Surgery,
Philadelphia,
W. B. Saunders Co., 1964, pp. 13051345.
10. joseph, j.: Gesichtsplastik.
Leipzig, C. Kapitzsch,
1931.
11. Le Roux, P., and jones, S. H.: Total permanent removal of wrinkles from the forehead: Br. j. Plast.
Surg., 27:359, 1974.
12. Lexer, E.: Die Gesamte Wiederentstellung.
Leipzig,
Chirurgie, 1931.
13. Marino, H.: Surgery of facial expression. Trans. of
the 5th I nternat. Congo of Plast. Reconstr. Surg. Melbourne, Butterworths,
1971, p. 1102.
14. Noel, A.: La chirurgie esthetique et sa role ociale.
Paris, Masson et Cie, 1926.
15. Pangman,
W. j., and Wallace, R. M.: Cosmetic
surgery of the face. Plast. Reconstr. Surg., 27:544,
1961.
16. Passot, R.: Chirurgie esthetique pure (technique et
Resultats). Paris, Doin et Cie, 1931.
17. Passot, R.: Quelques generalities sur I'operation correctif des rides du visage: Rev. Chir. Plast., 3 :23,
1933.
18. Picaud, A. j.: Different forms of incisions and techniques in face-lifting. Trans. 4th Internat.
Congo
Plast. Reconstr. Su~. Amsterdam, Excerpta Medica,
1967, p. 1114.
19. Rees, T. D.: Technical considerations
in blepharoplasty and rhytidectomy. Trans. 5th Internat. Congo
Plast. Reconstr.
Surg. Melbourne,
Butterworths,
1971, pp. 1075-1077.
20. Rees, T. D., and Wood-Smith, D.: Cosmetic Facial
Surgery. Philadelphia, W. B. Saunders Co., 1973, p.
177.
21. Uchida., j.: A method of frontal rhytidectorny. Plast.
Reconstr. Surg., 35:218, 1965.
22. Viñas, j.
Caviglia, C., and Cortiñis, j. L.: Forehead rhytidéctorny and brow lifting. Plast. Reconstr.
Surg., 57:445, 1976.
23. Washio, H.: Rhytidoplasty
of the forehead-an
anatomical approach. Trans. 6th Internat.
Congo
Plast. Reconstr. Surg. Paris, Masson et Cie, 1976, p.
430.
c.,
Durango 33 8
Mexico 7, DF Mexico