cosmetic special topic the evolution of the brow lift in...

Cosmetic Special Topic

The Evolution of the Brow Lift in AestheticPlastic SurgeryMalcolm D. Paul, M.D.Irvine, Calif.

For nearly 100 years, aesthetic improvement of theaging face has included surgical elevation of the brow.Early attempts to correct brow ptosis were largely unsuc-cessful. Recognizing the need to modify the frown musclesheralded the achievement of results previously unobtain-able. Within the past decade, the minimal incision ap-proach to brow lifting afforded with the endoscope rad-ically changed surgical options in forehead rejuvenation.Further advances have added to these options and haveprovided a palette of alternatives in aesthetic correction ofthe upper one-third of the aging face. (Plast. Reconstr.Surg. 108: 1409, 2001.)

HISTORY OF THE BROW LIFT

The Coronal Brow Lift

The early approaches. The earliest descriptionof brow lifting in the literature was published byPassot1 in 1919. He used elliptical excisions toelevate the brows and diminish crow’s feet (Fig.1). Interestingly, Miller2 in 1906 recommendedmuscle excision. In 1926, Hunt3 published Plas-tic Surgery for the Head, Face, and Neck, in whichhe described his techniques, which includedcoronal incisions both within the hair-bearingscalp and at the anterior hairline and directexcisions within the forehead skin (Fig. 2). Pas-sot4 in 1930 proposed an incision above theeyebrows with undermining and excision of ex-cess tissue (Fig. 3). The attempts to relieve ver-tical rhytids by parietal excision3,5 were not ef-fective. Vertical glabellar excisions wereperformed as well (Fig. 2).3 Noel6 in 1926 andJoseph7 in 1931 published their techniques offorehead lifting that were routinely performedand produced “satisfactory” (for 1926) results.Lexer published his technique for face andforehead lifting in 1931, but is generally cred-ited with performing the first face lift in 19068

(Fig. 4). Claoue9 in 1931 illustrated a more ex-tensive rhytidectomy that included incisions

and rather aggressive (for its time) undermin-ing of the forehead as well as the face and theupper neck (Fig. 5). Fomon10 in 1939 under-mined the forehead skin and transected theepicranium. He also recommended fascia im-plantation, and in 195111 he suggested the useof dermafat grafts for this procedure. For theensuing 20 years, the literature is lacking inaddressing either the benefits or the shortcom-ings of these approaches, which did not include

From the Division of Plastic Surgery, University of California. Received for publication December 29, 2000; revised March 20, 2001.

FIG. 1. Elliptical excisions to elevate the brows and di-minish crow’s feet. From Passot, R. La chururgie esthetiquedes rides du visage. Presse Med. 27: 258, 1919. Used withpermission.

1409

muscle modifications including myotomies,muscle excision(s), and/or denervation (chem-ical or surgical). In the 1950s, the standard fore-head lift was mentioned only to be condemnedbecause it did not provide permanent or evenlong-lasting correction. It was recognized thatmodification of the frontalis muscle was neces-sary to impart long-lasting if not permanentimprovement in the aesthetics of the forehead.Transection of the frontal branch of the facialnerve was recommended12 to improve the tem-porary nature of improvement gained with theearlier techniques. However, profound browptosis occurred from this maneuver. The fron-tal branch was reportedly injected with 80%alcohol to cause a permanent chemical dener-vation, with unfavorable side effects.4 Cross-hatching of the muscle to diminish frontalisactivity (Bames13) and incision (Eitner14) weredescribed. Gonzalez-Ulloa15 in 1962 (Fig. 6) de-scribed a complete circumferential incision forforehead and face lifting procedures. Marinoand Gandolfo,16 in 1964, believed that their fail-ures were because of the action of the foreheadmuscles, which had not been modified by their

technique. They described modifying the fron-talis and corrugator muscles to improve the re-sults. [They credit this modification to McIndoe(no reference cited).] Morel-Fatio17 describedpartial excision of the frontalis muscle in 1964,and Uchida18 in 1965 described a technique to

FIG. 2. Coronal, anterior hairline, and direct incisions toelevate the brows. From Hunt, H. L. Plastic Surgery of theHead, Face, and Neck. Philadelphia: Lea & Febiger, 1926. Usedwith permission.

FIG. 3. Incision above the eyebrows. From Castanares,S. Forehead wrinkles, glabellar frown and ptosis of eye-brows. Plast. Reconstr. Surg. 34: 406, 1964. Used withpermission.

FIG. 4. Incisions for forehead lift and face lift. FromLexer, E. Die Gesamte Wiederherstellungs-Chirurgie, Vol. 1.Leipzig: Jahann Ambrosius Barth, 1931. P. 551. Used withpermission.

FIG. 5. Incisions for extensive rhytidectomy. FromClaoue, C. La ridectomie cervico-faciale par accrochage pa-rieto-temporo-occipital et resection cutanee. Bull. Acad. Med.(Paris) 109: 257, 1933. Used with permission.

1410 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2001

correct the hypermotility of the muscles of theforehead. Vinas in 196519 described a proce-dure for correcting the clinical findings in theaging forehead. What was described 35 yearsago is currently relevant in rejuvenating theforehead:

(1) An inelastic aponeurotic-muscle layer,formed by the frontalis and its extensions,occupies the frontal region and expands lat-erally toward both temporal regions. Thislayer adheres to the skin and does not per-mit free movement of it. Traction on thefrontotemporal region with a finger willshow this fixation of the skin, as it does notcause the wrinkles to disappear (Fig. 7)—incontrast to the results of a similar test in thelower faciocervical area, where the skinglides easily over the subjacent tissue.

(2) There are adhesions that prevent freemovement of the soft tissues of the supraor-bital regions over the bony orbital rims. Inour experience, unless these adhesions areeliminated, traction from above will not givea permanent lift to the eyebrows.Vinas presented his technique for forehead

rhytidectomy and brow lifting in 1969 at theAnnual Meeting of the American Society ofPlastic and Reconstructive Surgeons and pub-lished it in 1976.20 He recognized two types offorehead wrinkles, transitory and persistent:

Transitory wrinkles appear only with themovements of expression, and they disap-

pear when the action of the muscles is elim-inated and the skin is stretched.

Persistent wrinkles remain when the mus-cles are relaxed and can be “erased” only byadding a skin abrasion to the precedingtreatment.He realized that maximum elevation in the

lateral brow and crow’s feet area without ten-sion was necessary to obtain adequate correc-tion. He accomplished this by excising a stripof the deep aponeurotic-muscle layer in theupper portion of the forehead (Fig. 8), extend-ing the excision laterally to the temporal re-gions and by releasing the adhesions betweenthe soft tissues of the eyebrow and the orbitalrims. Interestingly, Vinas acknowledged theneed to change the location of the coronalincision on the basis of the height of the fore-head (Fig. 9). In 80 percent of the cases, theincision was placed behind the hairline,whereas only one in five had a forehead heightthat would commit one to an anterior hairline

FIG. 6. The complete circumferential incision for fore-head and face lifting. From Gonzales-Ulloa, M. Facial wrin-kles: Integral elimination. Plast. Reconstr. Surg. 29: 65, 1962.

FIG. 7. Traction on the frontotemporal region.

FIG. 8. Excision of a strip of the deep aponeurotic-musclelayer.

Vol. 108, No. 5 / BROW LIFT IN AESTHETIC PLASTIC SURGERY 1411

incision. Vinas effectively dealt with verticalfrown lines in the glabellar region by detachingthe frontal flap medially so as to expose andthen resect 1 cm from the medial corrugatormuscle mass.

The resection of an aponeurotic-musclelayer did allow some skin stretching and liftingof the brows. However, “badly drooped brows”could only be effectively corrected by “elimi-nating any adhesions between the eyebrowsand the orbital rims.”

To this end, the subfascial dissection must godown to reach the orbital cavities, and later-ally down to the level of the zygomatic archeswhere, if necessary, the fascia can be de-tached from the arches for an effective face lift.Of historical interest in light of current

trends in facial rejuvenation, an editorial com-ment to this article reads: “The reader willrecognize, of course, that many authorities donot agree with the necessity for, or the advis-ability of, this maneuver.”

Of interest, Vinas also described variations ofa “butterfly wing” technique that elevated lowbrows by excising various skin patterns directlyabove the brow (Fig. 10). (This technique car-ries the advantage of a direct one-to-one cor-rection of brow ptosis, but the tradeoff is a scarthat is visible and the method is advisable onlywhen the patient’s medical condition will notpermit more aggressive brow elevation tech-niques from a distance, a usable foreheadcrease is not available, and the patient is willingto accept the scars.) Vinas even recommendedusing this technique when the results of thelong flap technique did not effectively elevatethe brows or correct the crow’s feet.

Among the more frequent complicationswere paresthesias and pruritus “which, in ner-

vous people, may last up to 8 to 10 months.”(Note: were these patients “nervous” before orafter the pruritus developed?)

Regnault presented her approach to correct-ing the stigmata of the aging face by perform-ing a “double traction on crow’s feet” at theAnnual Meeting of the American Society forAesthetic Plastic Surgery in 1971 and publishedit in 1972.21 This was accomplished by a sub-galeal forehead dissection to the eyebrows andthe upper margin of the crow’s feet with galealrelaxing incisions for better traction, if neces-sary, and a subcutaneous face lift dissectionpreserving the neurovascular bridge in thetemporal area (Fig. 11). Again, historically theeditorial note is fascinating as we look at whatmany are now doing:

FIG. 9. Locations of the frontotemporal flap incision. (1)Coronal incision. (2) Anterior hairline incision.

FIG. 10. The “butterfly wing” incision. From Vinas, J. C.,Caviglia, C., and Cortinas, J. L. Forehead rhytidoplasty andbrow lifting. Plast. Reconstr. Surg. 57: 445, 1976.

FIG. 11. Schematic of the incisions and undermining.From Regnault, P. Complete face and forehead lifting, withdouble traction on “crow’s feet.” Plast. Reconstr. Surg. 49: 123,1972.


The reviewing editors felt the work pre-sented herein to be rather heroic, and ofinterest to readers. Two of them noted thatthey often add blepharoplasty, dermabra-sion, or submental lipectomy to a facelift—or all 3—but there is a point whereprudence becomes better than valor.

She lists numbness of the scalp as a compli-cation that usually lasts for a few months, “butin a few cases has been permanent.”

Kaye presented in 1976 and published in197722 his method of performing a foreheadlift derived from the methods of Vinas.20 Heelevated the forehead flap deep to the galeaand resected segments of the corrugator super-cilii muscles as well as a strip of frontalis andfascia. He would combine the coronal lift witha facial rhytidectomy, preserving the frontalbranch of the facial nerve in the mesotem-poralis while ligating the superficial temporalartery and vein to increase flap upward mobil-ity. Kaye made the following observations:

Older patients may present with ptosis ofthe forehead and eyebrows along with sag-ging upper lid skin. Under these circum-stances, it may be difficult to accomplish thedesired result by blepharoplasty alone.

Upper lid ptosis in younger patients is of-ten secondary to congenitally low position,or premature ptosis, of the upper third ofthe face. Often these patients can benefitfrom a forehead lift without an upper lidblepharoplasty. The surgeon can determinethis preoperatively by gently elevating theforehead and eyebrows, and seeing what thisdoes for the eyelid ptosis.

This is a widely practiced and extremely use-ful maneuver in assessing the need for a browlift with or without an upper eyelid blepharo-plasty. Kaye discussed the alternate use of ananterior hairline incision in patients with ahigh forehead. He felt, as this author does, thatpatients with a high forehead typically weartheir hair down to partially cover their fore-head and therefore their lifestyle would not bechanged by a slightly higher forehead. Kayefelt that the only absolute contraindication tothe coronal incision was lack of enough hair tocover the incision, as in male pattern baldness.(Note: A further posterior incision or the useof small access incisions such as those affordedby an endoscopic approach may lessen thisconcern.)

Pitanguy23 described the blocking techniquein face and forehead lifting. The importantelements of his technique are the following:

1. Wide exposure of the forehead flapthrough an open approach.

2. Weakening of the muscles that act in thisregion by making multiple incisions thatcut through the aponeurosis and free themuscle fibers.

3. Blocking the facial flaps with key stitchesso that once the forehead has been posi-tioned, no alterations in anatomy will oc-cur in the face.

He also described using the open approachas the route to the dermocartilaginous liga-ment of the nose.24 By sectioning this ligament,the nasal tip can be rotated to a slightly moresuperior position.

This approach to lifting the brows and pas-sively improving the upper eyelid aestheticsthrough orbital rim soft-tissue release, partialcorrugator resection, and frontalis modifica-tion has remained the mainstay of correctingthe stigmata of the upper one-third of the ag-ing face for about 35 years. This has remaineda popular procedure despite the sequelae andcomplications reported by Riefkohl et al.25

They reported the following:

Sequelae of the procedure• Numbness behind the coronal incision• Pain, swelling, and bruising• Temporary loss of expressive movements• Sensation of tightness in the forehead• Eyebrow position initially high• Absent nasoglabellar frown

Complications of the procedure• Sensory nerve deficit• Frontalis muscle paralysis• Skin necrosis• Alopecia• Infection• Hematoma and bleeding• Abnormal hair part and visible scar• Asymmetrical eyebrows or eyelids• Chronic pain• Permanent overcorrection• Abnormal soft-tissue contour

Interestingly, in discussing numbness be-hind the incision, Riefkohl26 observed: “It isextraordinary for a patient to be bothered bythis numbness. Apparently, among neurosurgi-cal patients, complaints of numbness behind a


coronal incision are practically unheard of.Obviously, the cosmetic surgery patient is lessforgiving.” (Note: as true, or more so today,than it was in 1983.)

The most common and the most trouble-some complication discussed by Riefkohl was asensory nerve deficit affecting the forehead.He felt that the supratrochlear and supraor-bital nerves should be identified and the su-praorbital nerve should be freed from the fron-tal bone to prevent a stretch injury.

Owsley27 stressed the importance of ade-quate release of the galea from its fascial at-tachments at the superior orbital rim. He mod-ifies frown muscles and excises a strip offrontalis muscle between the branches of thesupraorbital nerve. The flap is advanced,trimmed, and closed without tension. He fol-lowed patients for 5 years and reported excel-lent maintenance of aesthetic correction.

A review of the forehead lift by Adamson etal.28 in 1985 presented their experience in aforehead lift procedure closely following thatsuggested by Brennan.29 Ninety-two percent oftheir patients had the correction of eyebrowptosis as their major indication for foreheadlifting. Other indications were ablation of gla-bellar and forehead creases, and improvementin glabellar ptosis. Of interest were the follow-ing more common complications and theirpercentages: hair loss (33 percent temporary, 8percent permanent); scar widening (32 per-cent); scar itch (18 percent temporary, 10 per-cent bothersome or nonresolving); foreheadnumbness (16 percent temporary, 8 percentpermanent); and forehead neuritis (10 per-cent). Despite this reported complication rate,the authors found this procedure to be “ . . . auseful surgical procedure to reduce the signsof aging of the upper third of the face.”

The later approaches. Papillon et al.30 and Suet al.31 presented an anterior hairline incisionwith a subcutaneous dissection plane. In 1989,Wolfe and Baird32 published their limited ex-perience (27 patients) with the subcutaneousapproach to forehead lifting. They found nodifficulties with wound healing or alopecia andfelt that this procedure had the advantages ofmore effectively removing the vertical andtransverse wrinkles in the glabellar area, raisingthe brows, and preserving sensation posterior tothe incision.

Connell et al.33 published their experiencewith coronal brow lifting and presented theirconcept of improving the aesthetics in the up-

per one-fourth of the nose by modifying theprocerus and depressor supercilii muscles.They emphasized precision in diagnosis, pre-operative planning, technique, and postopera-tive care. A hallmark of their technique is min-imizing detection of the surgical incisions bydetailed planning of their location, meticuloushandling of soft tissue, and precision in clo-sure. Flowers34 stressed the value of correctingbrow ptosis as the major aesthetic finding inthe aging upper one-third of the face and notremoving excessive upper eyelid skin. He com-bined “anchor blepharoplasty” with the coro-nal brow lift for optimal aesthetic improve-ment while avoiding the deformities associatedwith excision of excessive amounts of uppereyelid skin. Periorbital soft-tissue and bony or-bital rim contouring were added as indicatedby the anatomy. Lateral canthoplasties werefrequently included to improve the aestheticsand stability of the lower eyelid.

Tirkanits and Daniel35 in 1990 combined thebest features of the subcutaneous, anteriorhairline dissection with the subgaleal coronaldissection to improve results in patients withhigh foreheads, severe static wrinkling, andasymmetric eyebrows. In their technique, thejunction between the subgaleal and subcutane-ous plane is divided at the temporal hairlinelevel.

The longest published postoperative fol-low-up at that time of the subcutaneous fore-head lift with an anterior hairline incision waspublished by Vogel and Hoopes36 in 1992. Themean follow-up was 7.5 years with a range of 1to 17 years. They found the benefits of thisapproach to be maintenance of forehead size,a mechanically efficient lift, a direct attack onwrinkles, and a low incidence of hair loss. Ac-cording to patient assessment, the benefits ofthe procedure were long-lasting. The addedprecision required in making the incision,time-consuming dissection, and closure werelisted as disadvantages. Mayer and Fleming37 in1992 described their method of further cam-ouflaging the anterior hairline incision by fol-lowing the irregular trichophytic hairline,which made the scar less conspicuous. To getthe hair to grow through the scar, the anterioredge of the flap was deepithelialized and theforehead skin sutured over this. De Benito38

described a “zigzag” incision when selectingthe anterior hairline incision to camouflagethe scar.


The periorbital approach. Paul39 presented histechnique for a transblepharoplasty brow liftthat used an upper eyelid incision to perform abrowpexy while simultaneously correcting thefindings in the hooded eyelid. This includedtrimming of hypertrophied orbital orbicularisoculi muscle and suborbicularis fat (the “roof”fat pad) with brow stabilization by soft tissuesuturing above the orbital rim (Fig. 12).

There were other periorbital and midfore-head approaches to brow lifting, and theseincluded a direct brow lift as mentioned previ-ously. Connell40 also described using existingtransverse forehead rhytids as a means of re-moving forehead soft tissue and thereby ob-taining lifting of the brow while nicely conceal-

ing the scar in selected individuals with fairskin whose main concern was brow ptosis.

McKinney et al.41 developed clinically usefulmeasurements to aid the surgeon in decidingwhen to perform a forehead lift and where toplace the incisions. They used four basic surgi-cal techniques: (1) direct brow lift, (2) mid-forehead crease incision, (3) prehairline inci-sion, and (4) posthairline incision. Anextremely useful measurement that McKinneyet al. presented indicated that patients inwhom the distance from the midpupil to thetop of the eyebrow was equal to or greater than2.5 cm were not candidates to have their browraised further.

An interesting assessment of the goals ofbrow lifting by Matarasso and Terino42 revealedthat the traditional goal of elevating low browswas no longer the most common indication.Previously considered minor goals such as fore-head rhytids, frown muscle imbalance, uppereyelid aesthetics, lateral temporal laxity, and anabnormal expression were actually found to bemore prevalent as the reason(s) for perform-ing a forehead rhytidoplasty.

The subperiosteal approach. The concept of el-evating the soft tissues of the face (the “masklift”) through a subperiosteal plane of dissec-tion was initiated by Tessier43 in 1979 and fur-ther described in 1989.44 Psillakis45 and San-tana46 followed Tessier with publications in1984. Krastinova-Lolov47 in 1989 presented histechnique as an application of craniofacial pro-cedures. Hinderer in 198548 and Hinderer et al.198749 published a combined approach with asubperiosteal dissection in the lower foreheadand a sub–superficial musculoaponeurotic sys-tem dissection in the middle third of the face.However, beginning in 1986, Hinderer limitedhis subperiosteal undermining to a small areaaround the supraorbital bundle to facilitate itsdissection.

Ortiz-Monasterio50 (Fig. 13) presented hisexperience with the subperiosteal dissectionplane for the forehead lift as well as skeletalremodeling by bony recontouring or augment-ing. In 1991, Tapia et al.51 published their sub-periosteal approach to the upper one-half ofthe face, which included dissecting the fronto-nasal orbital rim and zygomaticomalar areas toobtain complete mobilization.

The endoscopic approach to the forehead lift. Vas-conez52 and Isse53 presented their early experi-ence with the use of an endoscope in browlifting in 1992. The first publication on the use

FIG. 12. (Above) Trimming of hypertrophied orbicularisoculi muscle and suborbicularis oculi fat. (Below) Suspensionof orbital orbicularis oculi muscle to the orbital rim. FromPaul, M. Transblepharoplasty brow lift. In R. W. Bernard(Ed.), Surgical Restoration of the Aging Face. Newton, Mass.:Butterworth-Heinemann, 1996. Used with permission.


of the endoscope for brow lifting was by Chaj-chir in 1993.54 Appearing in the same year,1994, were two publications that presented thisnew high-tech method of elevating the fore-head soft tissues at the subperiosteal plane withthe use of an endoscope. Isse55 (Figs. 14 through16) and Chajchir56 detailed their method ofperforming a brow lift through small incisionsbehind the anterior hairline. In 1995, Isse57 up-dated his experience with the endoscopic ap-proach and made the following points:

The basic concept of this procedure is adynamic functional lift of the eyebrow ex-

erted by the frontalis muscles when the de-pressor of the eyebrows has been modifiedor weakened.

One should remember that when we weredoing the “open approach” we were relyingmainly on soft-tissue traction and soft-tissueresection with minimal soft-tissue modifica-tion. The only muscle mentioned as an eye-brow depressor was the corrugator superciliimuscle. No other muscles were mentioned

FIG. 13. The undermining of the facial musculature at the subperiosteal level. (Left) Shadedarea demonstrates maximum skin undermining on a conventional face lift. (Center) Diagramillustrating the facial musculature. (Right) Shaded area demonstrates the amount of underminingof the facial musculature as a unit by the subperiosteal approach. From Ortiz-Monasterio,F. Aesthetic surgery of the facial skeleton: The forehead. Clin. Plast. Surg. 18: 19, 1991. Usedwith permission.

FIG. 14. Skin incisions and muscle release. (1) Right para-medial incision. (2) Midline incision. (3) Left paramedialincision. (4) Temporal or lateral incision. (5) Myotomy ofprocerus muscles. (6) Myotomy or detachment corrugatormuscles. (7) Myotomy of depressor supercilii muscle.

FIG. 15. Level of dissections. (1) Subperiosteal. (2) Eithersubperiosteal or supraperiosteal. (3) Subsuperficial temporalfascia (temporoparietalis). (4) Subperiosteal.


as responsible for lowering of the eyebrowsand frown line formation (e.g., the procerusmuscle). Now we read that the depressorsupercilii muscle and the orbital portion ofthe orbicularis muscle are powerful addi-tional depressors of the eyebrows.Isse identified the need to vary his technique

on the basis of the configuration of the skull,bony architecture, and soft-tissue thickness andtightness. He suggested four techniques se-lected to accommodate patient variations anddegree of tissue dissection. The classificationswere the following:

1. Standard forehead lift: Five incisions with sub-periosteal dissection to the nasal bones andsupraorbital rims, and subsuperficial tempo-ral fascia dissection medially to end at thesentinel vein and inferiorly to the superioredge of the zygomatic arch

2. Extended forehead lift: Same as above withthe dissection extended over the lateral or-bital rim, supraperiosteal up to the midbor-der of the lateral orbital rim. This techniquewas recommended when the primary goal waselevation of the tail of the brow, as well as thedesire to correct crow’s feet and elevate thelateral raphe of the lateral canthus.

3. Lateral forehead/temporal lift: Incisionsplaced in the paramedian area and the tem-poral area to mainly effect elevation of the tailof the brow, modify the contour of the brow,improve the crow’s feet, and/or elevate thelateral canthal raphe.

4. Limited forehead lift:

a. Glabellar: Dissection either subperiostealor supraperiosteal with access from thefrontal hairline, palpebral, or nasal routes.Treatment of the brow depressors was ac-complished as the only goal of this tech-nique. (Note: Isse felt that this techniquewould narrow the brows, a point that hasbeen debated, as some postoperative en-doscopic results from various authors showa spreading of the brow with increasedinterbrow distance.)

b. Supraorbital rim: This technique uses atranspalpebral access at either the supra-or subperiosteal level followed by modifi-cation of the orbital portion of the orbic-ularis muscle. The technique is designedto elevate the tail of the brow, correct browcontour, improve crow’s feet, and elevatethe lateral canthal raphe. (Note: Isse feltthat one might not be able to obtain thesame elevation of the tail of the brow whenusing the transpalpebral route as that ob-tained through a temporal access. Thispoint is shared by this author (see theTransblepharoplasty Subperiosteal Brow Liftsection).

Other elements of the endoscopic brow liftare tissue modifications. These include perios-teal release (horizontal and/or vertical); retro-orbicularis fat pad release to improve the lat-eral brow; muscle modifications includingmyotomies, myectomies, and detachment; andneurotomies to denervate brow depressors(Note: Precise anatomic knowledge can guideone to the motor innervation of these muscles,but reliability is the key to successfuldenervation.)

Of considerable interest and ongoing debateare the various methods of flap fixation tomaintain the elevated brow position while thesoft tissues are readhering at a higher level. Anexcellent review of the controversies and therationale of various methods of fixation is pro-vided by Rohrich and Beran.58 The methodsused medial to the anterior temporal crest in-clude bolster fixation, mattress sutures, corticaltunnels, Kirschner wire, external screws, inter-nal screws both absorbable and nonabsorb-able, and fibrin glue. The temporal flap can bestabilized with the use of sutures between thesuperficial and the deep layers of the temporalfascia.

In reviewing his experience, Isse57 in 1995found a few cases of partial alopecia and par-

FIG. 16. Mechanism of forehead and brow elevation: mus-cles and periosteum release, pulling of fronto-galea-occipitalmuscles, sliding of the scalp posteriorly, and soft-tissue con-tracture. From Isse, N. G. Endoscopic facial rejuvenation:Endoforehead, the functional lift. Case reports. Aesthetic Plast.Surg. 18: 21, 1994. Used with permission.


esthesias, all of which were temporary. He did,however, recognize that recurrence may occurin men with supraorbital bossing. (Note: Re-currence of brow ptosis may also result frominadequate soft-tissue release including failureto transect the orbital ligament, inadequatemuscle modification, and/or inadequate flap

stabilization.) In 1995, Oslin et al.59 proposedthat fixation of the elevated forehead flapthrough an endoscope was not necessary andthat maintenance of brow position could beaccomplished by adequate release alone.

Daniel and Tirkanits60 felt that the illumina-tion and magnification brought by the endo-

FIG. 17. Schematic of the operative technique. (Above, left) Old incisions on the left, new incisions on the right. (Above, right)The planes of dissection. (Center, left) Subgaleal muscle resection is graded but may include the insertions of all four confluentmuscles. (Center, right) Periosteal release allows posterior advancement of the forehead. (Below, left) Bony fixation is accuratelydetermined using screws and staples. (Below, right) The lateral temporal advancement uses absorbable sutures to open the eyes.From Daniel, R. K., and Tirkanits, B. Endoscopic forehead lift: An operative technique. Plast. Reconstr. Surg. 98: 1148, 1996.


scope could be applied to the aesthetics, anal-ysis, goals, and techniques that formerlyguided the classic approach (coronal, sub-galeal). Techniques were developed to addressthe individual anatomic findings in the agingupper third of the face, discarding the oneoperation theme that was so easy to apply withan endoscope.

Ramirez61 in 1995 described an endoscopi-cally assisted biplanar forehead lift to be usedin all patients in whom the anterior hairline

incision is used. In his technique, the subcuta-neous dissection transforms to a subperiostealand subtemporoparietal fascial dissection

FIG. 18. (Above) Incisions are located to avoid the deepbranch of the supraorbital nerve, which lies between thedotted lines, 5 and 15 mm medial to the superior temporalline. (Center) The six galea aponeurosis plication sutures pullagainst gravity with only vertical vectors. (Below) Plicationsutures provide temporary fixation of the lifted brow untilscar tissue provides permanent fixation over the entire areaof flat elevation, as shown.

FIG. 19. (Above) The galea aponeurosis is freed com-pletely on the deep surface to mobilize the forehead and justalong the hairline on the superficial surface to allow short-ening by plication. (Below) This procedure raises the browand leaves a roll of excess skin at the hairline to shrink orredistribute. From Hamas, R. S. An endoscopic brow liftthat does not raise the hairline. Aesthetic Surg. J. 17: 127, 1997.Used with permission.

FIG. 20. Subperiosteal transblepharoplasty dissection.


about halfway down the forehead. He felt thatthis approach allowed preservation of sensa-tion behind the incision and endoscopicallycontrolled periorbital dissection and frownmuscle modification. Ramirez62 further modi-fied his technique to avoid some of the se-quelae of a coronal brow lift and incorporatedthem in endoscopically assisted brow lifts.Among others, the recommendations were in-cluding the pericranium in the flap, extensivesubperiosteal dissection, maintenance of theintegrity of the frontalis muscles, using a galeaperiosteal rim flap to anchor the frontal flap tothe posterior scalp flap, and detailed skin clo-sure without through-and-through sutures toprevent alopecia.

Daniel and Tirkanits63 reviewed 100 endo-scopic brow lifts and modified their techniqueto better address the frown muscles and pre-dictably control the position and the shape of

the elevated brow (Fig. 17). The essential com-ponents were the following:

l. A subgaleal resection of muscle insertionsrather than a subperiosteal approach tomuscle origins.

2. A complete periosteal release along thelateral orbital rim.

3. A vertical suspension using screws and sta-ples that are removed at 1 week.

4. A lateral temporal expansion using ab-sorbable sutures.

Certainly, the endoscope was used by othersto address isolated glabellar findings and per-mitted muscle modification(s) with an anteriorhairline short incision.64,65 Hamas66 also pub-lished a technique to avoid raising the anteriorhairline while using an endoscope. He de-scribed a galea aponeurosis plication tech-nique that entails several sutures placedthrough an anterior galeal flap dissected off ofthe forehead flap and anchored posteriorly.The brow is nicely elevated without raising thecentral hairline (Figs. 18 and 19).

Transblepharoplasty Subperiosteal Brow Lift

Paul67 in 1996 published his technique forthe subperiosteal brow lift using the upper eye-lid as the approach. The periosteum along thesuperior orbital rim is incised lateral to thesupraorbital neurovascular bundle and the lineof fusion is divided connecting the dissectionwith the subtemporalis fascial plane laterally.The corrugator muscles are partially excisedand the origin and insertion of the procerusmuscle are divided. A counterincision is madeat the projected peak of the brow behind theanterior hairline for vertical brow vector stabi-lization and a temporal incision is made toallow an oblique vector for lateral brow eleva-tion and spanning. All aspects of the hoodedupper eyelid can be addressed through thisapproach, and biologic fillers can be added aswell (Figs. 20 through 22). Ramirez68 publisheda similar approach with the added benefit oftranspalpebral use of the endoscope to assist inthe dissection. He identified the following cat-egories of patients who might benefit from thistechnique:

1. Patients with male pattern baldness2. Patients with a history of hair transplants3. Patients with excessively high foreheads4. Patients in which upper blepharoplasty is

planned simultaneously with the brow lift

FIG. 21. Transblepharoplasty corrugator muscle resection.

FIG. 22. Transblepharoplasty disinsertion of procerusmuscle.


5. Patients with spastic frontalis syndrome6. Patients needing periorbital orbicularis

muscle repositioning

Del Campo69 detailed the transpalpebral ap-proach to the forehead as part of the “endo-face lift,” which included the transpalpebral

approach to the midface and subperiostealmandibular dissection.

The Limited-Incision Forehead Lift

This technique, published by Knize70 in1996, advocates the following procedures. Us-ing a short temporal incision, the subtempora-lis fascial plane is dissected, a portion of thedeep temporal fascia is removed as a graft andto provide cicatrical flap fixation, medial sub-periosteal dissection is performed as indicated,the orbital ligament is divided to mobilize thelateral brow, and the flap is stabilized laterallyat the fascial level (Fig. 23). Through an uppereyelid incision, the corrugator muscles are par-tially excised, the procerus muscle is divided,and temporalis fascia is placed in the glabella.The hallmark of this technique is the preserva-tion of the deep division of the supraorbitalnerve. The importance of preserving this nerveis well described in the skillfully detailed ana-tomic work of Knize71 (Fig. 24).

Combining approaches and technology. Mich-elow and Guyuron72 sorted out the options inforehead rejuvenation and suggested a palate ofprocedures, both invasive and noninvasive, onthe basis of the individual goals and needs of thepatient. The armamentarium includes botuli-num injection, fat injection, fat grafting, trans-palpebral corrugator muscle resection, subcu-taneous forehead rejuvenation, and endo-

FIG. 23. (Left) Limited incision forehead lift: dissection. The orbital ligament (*) must be transected. Slanted lines, zone offixation. TL, temporal fusion line of the skull; STF, superficial temporal fascia. (Right) Forehead flap advancement. Thesuperficial temporal fascia is sutured to the deep surface of the superficial temporal fascia.

FIG. 24. Surgical anatomy. Stippled area, zone of fixation.Fibrous band (*) connecting the orbital rim and the super-ficial temporal fascia. PM, procerus muscle; TL, temporalfusion line; STL, superior temporal line of the skull; OO,medial fibers of orbicularis oculi muscle; CSM, corrugatorsupercilii muscle; FB VII, frontal branch of facial nerve; ITL,inferior temporal line. From Knize, D. M. Limited-incisionforehead lift for eyebrow elevation to enhance upper bleph-aroplasty. Plast. Reconstr. Surg. 97: 1334, 1996.


scopic techniques for forehead rejuvenation.Combining the endoscope with the potassium-titanyl-phosphate laser allowed Keller et al.73 toincise or excise the procerus, corrugator, andfrontalis muscles, with little or no bleeding, ata distance from a small incision immediatelybehind the hairline. Rosenberg74 combined anendoscopic brow lift with a flexible laser wave orrigid laser extensions to ablate the frown mus-cles. He did not use skin excision or fixationwith this technique. Roberts and Ellis75 com-pared coronal brow lifting, endoscopic browlifting with carbon dioxide laser resurfacing,and carbon dioxide laser resurfacing alone.The best result in wrinkle reduction was re-ported in those patients who underwent endo-scopic brow lifting with carbon dioxide laserresurfacing. (Note: Many proponents of the en-doscopic brow lift feel that adequate diminu-tion in static and dynamic rhytids occurs frombrow depressor muscle modification and, there-fore, resurfacing is not necessary.) Weinstein76

combined carbon dioxide laser resurfacing withendoscopic forehead lift, laser blepharoplastyand transblepharoplasty corrugator resection.

Nassif et al.77 compared three methods offorehead elevation to determine the most ef-fective dissection plane. They found that thesubperiosteal plane with or without release atthe superior orbital rim and the subgaleal dis-section plane significantly elevated the brow atrest and when traction was applied to the flap.However, subgaleal dissection was associatedwith less flap tension and therefore was con-cluded to be the optimal plane for the fore-head lift, whether performed with the aid of anendoscope or via the open approach.

Ellis and Bakala78 studied the motor inner-vation of the corrugator muscle in fresh-frozencadaver heads. As a result, a procedure wasdeveloped to perform a selective neurotomylateral to the corrugator muscle that affectedvertical glabellar creases without affecting theglabellar depressor muscles.

A fascinating study on muscle activity andassociated eyebrow displacement79 sheds lighton the frequent finding of preoperative andpersistent postoperative brow asymmetry de-spite the best attempt to correct the asymmetrywith a stronger pull on the lower side, allowingthe higher side to float rather than be fixed inposition.

As one travels back almost a century in look-ing at the upper one-third of the aging faceand how best to correct the signs of aging, the

position of the brow and how to change it, theeffect that raising the brow has on improvingthe upper eyelid appearance, and the aesthet-ics of the upper eyelid and how it impactssurgical decision making are paramount toproperly performing aesthetic restoration.Constant refinement of techniques with an eyealways focused on the goals and patient safetywill allow us to proceed with caution and, it ishoped, with improved, long-lasting, aestheti-cally desirable results.

Hunt in 19263 validated the goals of futuregenerations of aesthetic plastic surgeons:

Those who have held that their mission isto heal rather than beautify may find that thetwo practices are not dissimilar and that theyare equally effective in making life moreworth the living to the patient.

Malcolm D. Paul, M.D.1401 Avocado Ave.Suite 810Newport Beach, Calif. [email protected]

REFERENCES

1. Passot, R. La chururgie esthetique des rides du visage.Presse Med. 27: 258, 1919.

2. Miller, C. C. Cosmetic Surgery, 2nd Ed. (copyright 1906).Chicago: Oak Printing and Publishing Co., 1908.

3. Hunt, H. L. Plastic Surgery of the Head, Face, and Neck.Philadelphia: Lea & Febiger, 1926.

4. Passot, R. Chirurgie Esthetique Pure: Techniques et Resultats.Paris: Gaston Doin & Cie, 1930.

5. Miller, C. C. Cosmetic Surgery. Philadelphia: F. A. Davis,1924.

6. Noel, A. La Chirurgie Esthetique et son Role Social. Paris:Masson, 1926. Pp. 62–66.

7. Joseph, J. Nasenplastik und sonstige Gesichtplastik nebsteinen Anhang uber Mammaplastik. Leipzig: Kabitzch,1931. Pp. 507–509.

8. Lexer, E. Die Gesamte Wiederherstellungs-Chirurgie, Vols. 1and 2. Leipzig: Jahann Ambrosius Barth, 1931.

9. Claoue, C. La ridectomie cervico-faciale par accrochageparieto-temporo-occipital et resection cutanee. Bull.Acad. Med. (Paris) 109: 257, 1933.

10. Fomon, S. Surgery of Injury and Plastic Repair. Baltimore:Williams & Wilkins, 1939.

11. Fomon, S., Goldman, I. B., Neivert, H., and Schattner, A.Face-lift operation by rotation flaps. Arch. Otolaryngol.54: 478, 1951.

12. Castanares, S. Forehead wrinkles, glabellar frown andptosis of eyebrows. Plast. Reconstr. Surg. 34: 406, 1964.

13. Bames, H. O. Frown disfigurement and ptosis of eye-brows. Plast. Reconstr. Surg. 19: 337, 1957.

14. Eitner, E. Weitere Mitteilungen uber kosmetische Fal-tenoperationen im Gesicht. Wien. Med. Wochenschr. 85:244, 1935.

15. Gonzales-Ulloa, M. Facial wrinkles: Integral elimina-tion. Plast. Reconstr. Surg. 29: 658, 1962.

16. Marino, H., and Gandolfo, E. Treatment of foreheadwrinkles. Prensa Med. Argent. 51: 1368, 1964.


17. Morel-Fatio, O. Cosmetic surgery of the aging face. InT. Gibson (Ed.), Modern Trends in Plastic Surgery. Wash-ington, D.C.: Butterworths, 1964.

18. Uchida, J. I. A method of frontal rhytidectomy. Plast.Reconstr. Surg. 35: 218, 1965.

19. Vinas, J. C. Plan general de la ritidoplastia y zona tabu.In Transactions of the 4th Brasilian Congress on PlasticSurgery, Porto Alegre, October 5–8, 1965. P. 32

20. Vinas, J. C., Caviglia, C., and Cortinas, J. L. Foreheadrhytidoplasty and brow lifting. Plast. Reconstr. Surg. 57:445, 1976.

21. Regnault, P. Complete face and forehead lifting, withdouble traction on “crow’s feet.” Plast. Reconstr. Surg.49: 123, 1972.

22. Kaye, B. L. The forehead lift: A useful adjunct to facelift and blepharoplasty. Plast. Reconstr. Surg. 60: 161,1977.

23. Pitanguy, I. Section of the frontalis-procerus-corruga-tor aponeurosis in the correction of frontal and gla-bellar wrinkles. Ann. Plast. Surg. 2: 422, 1979.

24. Pitanguy, I. Surgical importance of a dermocartilagi-nous ligament in bulbous noses. Plast. Reconstr. Surg.36: 247, 1965.

25. Riefkohl, R., Kosanin, R., and Georgiade, G. S. Com-plications of the forehead-brow lift. Aesthetic Plast.Surg. 7: 135, 1983.

26. Wilkins, R. Personal communication (cited by Riefkohl,R., Kosanin, R., and Georgiade, G. S. Complicationsof the forehead-brow lift. Aesthetic Plast. Surg. 7: 135,1983).

27. Owsley, J. Q., Jr. Forehead lift (Letter). Plast. Reconstr.Surg. 69: 1025, 1982.

28. Adamson, P. A., Johnson, C. M., Jr., Anderson, J. R., andDupin, C. L. The forehead lift: A review. Arch. Oto-laryngol. 111: 325, 1985.

29. Brennan, H. G. The frontal lift. Arch. Otolaryngol. 104:26, 1978.

30. Papillon, J., Perras, C., and Tirkanits, B. A comparativeanalysis of forehead lift techniques. Presented at theAnnual Meeting of the American Society for AestheticPlastic Surgery, Boston, 1984.

31. Su, C. T., Morgan, R. F., Manson, P. N., et al. Techniquefor division and suspension of the orbicularis oculimuscle. Clin. Plast. Surg. 8: 673, 1981.

32. Wolfe, S. A., and Baird, W. L. The subcutaneous fore-head lift. Plast. Reconstr. Surg. 83: 251, 1989.

33. Connell, B. F., Lambros, V. S., and Neurohr, G. H. Theforehead lift: Techniques to avoid complications andproduce optimal results. Aesthetic Plast. Surg. 13: 217,1989.

34. Flowers, R. S. Periorbital aesthetic surgery for men: Eye-lids and related structures. Clin. Plast. Surg. 18: 689,1991.

35. Tirkanits, B., and Daniel, R. K. The “biplanar” foreheadlift. Aesthetic Plast. Surg. 14: 111, 1990.

36. Vogel, J. E., and Hoopes, J. E. The subcutaneous fore-head lift with an anterior hairline incision. Ann. Plast.Surg. 28: 257, 1992.

37. Mayer, T. G., and Fleming, R. W. Fleming-Mayer flap(modified after Juri) forehead lifting. In Aesthetic andReconstructive Surgery of the Scalp. St. Louis: Mosby, 1992.

38. Benito, J. Aesthetic incision in the subcutaneous fore-head lift. Aesthetic Plast. Surg. 17: 239, 1993.

39. Paul, M. D. The surgical management of upper eyelidhooding. Aesthetic Plast. Surg. 13: 183, 1989.

40. Connell, B. F. Eyebrow, face and neck lifts for males.Clin. Plast. Surg. 5: 15, 1978.

41. McKinney, P., Mossie., R. D., and Zukowski, M. L. Cri-teria for the forehead lift. Aesthetic Plast. Surg. 15: 141,1991.

42. Matarasso, A., and Terino, E. O. Forehead-brow rhyti-doplasty: Reassessing the goals. Plast. Reconstr. Surg. 93:1378, 1994.

43. Tessier, P. Face lifting and frontal rhytidectomy: In E. J.Fonseca (Ed.), Transactions of the International Congressof Plastic and Reconstructive Surgery, Rio de Janeiro, Cart-graf, May 26–27, 1979. P. 393.

44. Tessier, P. Le lifting facial sous-perioste. Ann. Chir.Plast. Esthet. 34: 193, 1989.

45. Psillakis, J. M. Empleo de tecnicas de cirugia craneofa-cial en las ritidectomias del tercio superior de la cara.Cir. Plast. Iberolatinoam. 10: 297, 1984.

46. Santana, P. S. M. Metodologia craneomaxilofacial enritidoplastias. Cir. Plast. Iberolatinoam. 10: 321, 1984.

47. Kristinova-Lolov, D. Le lifting facial sous-perioste. Ann.Chir. Plast. Esthet. 34: 199, 1989.

48. Hinderer, U. T. The blepharo-periorbitoplasty in rhyt-idectomy: Anatomical basis. In Transactions of the VIIIISAPS Congress, Madrid, September 15–19, 1985. P. 91.

49. Hinderer, U. T., Urriolagoitia, F., and Vildosola, R. Theblepharo-periorbitoplasty: Anatomical basis. Ann.Plast. Surg. 18: 437, 1987.

50. Ortiz-Monasterio, F. Aesthetic surgery of the facial skel-eton: The forehead. Clin. Plast. Surg. 18: 19, 1991.

51. Tapia, A., Ferreria, B., and Blanch, A. Subperiostic lift-ing. Aesthetic Plast. Surg. 15: 155, 1991.

52. Vasconez, L. O. The use of the endoscope in browlifting. A video presentation at the Annual Meeting ofthe American Society of Plastic and ReconstructiveSurgeons. Washington, D.C., 1992.

53. Isse, N. G. Endoscopic forehead lift. Presented at theAnnual Meeting of the Los Angeles County Society ofPlastic Surgeons, Los Angeles, September 12, 1992.

54. Chajchir, A. Endoscopia en Cirugia Plastica y Estetica.In L. J. Gonzalez Montaner, E. Huriado Hoyo, R.Altman, and R. Maino (Eds.), El Libro de Oro en Ho-menaje al Doctor Carlos Reussi. Buenos Aires: Ed. Asso-ciacion Medica Argentina, 1993. P. 74.

55. Isse, N. G. Endoscopic facial rejuvenation: Endofore-head, the functional lift. Case reports. Aesthetic Plast.Surg. 18: 21, 1994.

56. Chajchir, A. Endoscopic subperiosteal forehead lift.Aesthetic Plast. Surg. 18: 269, 1994.

57. Isse, N. G. Endoscopic forehead lift: Evolution and up-date. Clin. Plast. Surg. 22: 661, 1995.

58. Rohrich, R. J., and Beran, S. J. Evolving fixation meth-ods in endoscopically assisted forehead rejuvenation:Controversies and rationale. Plast. Reconstr. Surg. 100:1575, 1997.

59. Oslin, B., Core, G. B., and Vasconez, L. O. The biplanarendoscopically assisted forehead lift. Clin. Plast. Surg.22: 633, 1995.

60. Daniel, R. K., and Tirkanits, B. Endoscopic foreheadlift: Aesthetics and analysis. Clin. Plast. Surg. 22: 605,1995.

61. Ramirez, O. M. Endoscopically assisted biplanar fore-head lift. Plast. Reconstr. Surg. 96: 323, 1995.

62. Ramirez, O. M. The anchor subperiosteal forehead lift.Plast. Reconstr. Surg. 95: 993, 1995.

63. Daniel, R. K., and Tirkanits, B. Endoscopic forehead


lift: An operative technique. Plast. Reconstr. Surg. 98:1148, 1996.

64. Hamas, R. S. Reducing the subconscious frown by en-doscopic resection of the corrugator muscles. AestheticPlast. Surg. 19: 21, 1995.

65. Matarasso, A., and Matarasso, S. L. Endoscopic surgicalcorrection of glabellar creases. Dermatol. Surg. 21: 695,1995.

66. Hamas, R. S. An endoscopic brow lift that does not raisethe hairline. Aesthetic Surg. J. 17: 127, 1997.

67. Paul, M. D. Subperiosteal transblepharoplasty foreheadlift. Aesthetic Plast. Surg. 20: 129, 1996.

68. Ramirez, O. M. Transblepharoplasty forehead lift andupper face rejuvenation. Ann. Plast. Surg. 37: 577,1996.

69. Del Campo, A. F., Lucchesi, R., and Cedillo Ley, M. P.The endo-facelift: Basics and options. Clin. Plast. Surg.24: 309, 1997.

70. Knize, D. M. Limited-incision forehead lift for eyebrowelevation to enhance upper blepharoplasty. Plast. Re-constr. Surg. 97: 1334, 1996.

71. Knize, D. M. A study of the supraorbital nerve. Plast.Reconstr. Surg. 96: 564, 1995.

72. Michelow, B. J., and Guyuron, B. Rejuvenation of theupper face. Clin. Plast. Surg. 24: 199, 1997.

73. Keller, G. S., Razum, N. J., Elliott, S., and Parks, J. Small

incision laser lift for forehead creases and glabellarfurrows. Arch. Otolaryngol. Head Neck Surg. 119: 632,1993.

74. Rosenberg, G. J. The subperiosteal endoscopic laserforehead (SELF) lift. Plast. Reconstr. Surg. 102: 493,1998.

75. Roberts, T. L., III, and Ellis, L. B. In pursuit of optimalrejuvenation of the forehead: Endoscopic brow liftwith simultaneous carbon dioxide laser resurfacing.Plast. Reconstr. Surg. 101: 1075, 1998.

76. Weinstein, C. Carbon dioxide laser resurfacing com-bined with endoscopic forehead lift, laser blepharo-plasty, and transblepharoplasty corrugator muscle re-section. Dermatol. Surg. 24: 63, 1998.

77. Nassif, P. S., Kokoska, M. S., Homan, S., Cooper, M. H.,and Thomas, J. R. Comparison of subperiosteal vssubgaleal elevation techniques used in forehead lifts.Arch. Otolaryngol. Head Neck Surg. 124: 1209, 1998.

78. Ellis, D. A., and Bakala, C. D. Anatomy of the motorinnervation of the corrugator supercilii muscle: Clin-ical significance and development of a new surgicaltechnique for frowning. J. Otolaryngol. 27: 222, 1998.

79. Pennock, J. D., Johnson, P. C., Manders, E. K., and Van-Swearingen, J. M. Relationship between muscle ac-tivity of the frontalis and the associated brow displace-ment. Plast. Reconstr. Surg. 104: 1789, 1999.


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