How is a damaged aponeurosis of the superior forehead repaired?

Surgical Repair of Damaged Superior Forehead Aponeurosis

The repair of a damaged aponeurosis of the superior forehead requires surgical intervention through an aponeurotic approach, with the specific technique depending on the extent of damage and associated functional or cosmetic concerns.

Assessment of Damage

Before proceeding with repair, a thorough evaluation should include:

• Assessment of functional impact (visual field obstruction, eyebrow position)
• Evaluation of cosmetic concerns (asymmetry, wrinkles, ptosis)
• Determination of the extent of aponeurotic damage (dehiscence, disinsertion, or stretching)
• Measurement of levator function (should have at least 8mm of elevation from downward to upward gaze for aponeurotic repair)

Surgical Repair Techniques

Aponeurotic Approach for Ptosis Repair

For cases where the damage has resulted in blepharoptosis:

1. Incision placement: 7mm above the lash line through skin and pretarsal muscle 1
2. Dissection: Blunt dissection upward until the preaponeurotic fat pad is exposed
3. Aponeurosis repair:
   • Pick up the upper part of the aponeurosis under the fat pad
   • Suture to the lower part of the aponeurosis with 5-0 chromic gut 1

Posterior Approach White-Line Levator Advancement

For more severe cases requiring repair under general anesthesia:

1. Transconjunctival approach to expose the posterior surface of the levator aponeurosis
2. Advancement of the aponeurosis through tarsus onto its anterior surface or to skin 2
3. Suturing: Secure the advanced aponeurosis in position

Forehead Cutaneo-Musculo-Aponeurotic Unit Repair

For cases involving the broader forehead region:

1. Recognition of anatomical unit: Address the forehead as a cutaneo-musculo-aponeurotic unit (CMAU) composed of skin, galea, and frontalis muscle 3
2. Correction of galea relaxation: Tighten the galea aponeurotica to address recession of the forehead
3. Frontalis muscle reattachment: Ensure proper attachment to the galea for optimal forehead expression and eyelid support

Considerations for Optimal Outcomes

• Anesthesia choice: Local anesthesia is preferred when possible to allow for intraoperative adjustment of height and contour 1
• Phenylephrine test: A positive test is a good predictor of postoperative height and contour when general anesthesia is required 2
• Early postoperative adjustment: Enables revision with minimal additional surgical trauma 4

Potential Complications and Management

• Asymmetry: May require revision if greater than 2mm difference between sides
• Overcorrection or undercorrection: More common when surgery is performed under general anesthesia without intraoperative adjustment
• Contour abnormalities: May require additional sutures to reshape the aponeurosis

Special Considerations

• For combined frontal and glabellar wrinkles, consider vertical and horizontal cuts in the aponeurosis of the frontal region 5
• The frontalis muscle plays a fundamental role not only in forehead expression but also in supporting and elevating the eyelids 3

The success rate for aponeurotic repair approaches 95% when proper technique and patient selection are employed 2, making it an effective solution for damaged superior forehead aponeurosis.