Knize D M
Department of Surgery, University of Colorado Health Sciences Center, Denver 80110, USA.
Plast Reconstr Surg. 1998 Aug;102(2):478-89; discussion 490-2. doi: 10.1097/00006534-199808000-00032.
Thirty years ago, the aging upper face was generally ignored by surgeons performing facial rejuvenation surgery. Ultimately, the coronal incision forehead lift technique became an accepted procedure, with most surgeons raising the forehead flap at the subgaleal plane. These surgeons found the subgaleal plane to be the "natural" or most accessible dissection plane to use, and it continues to be the most commonly used dissection plane for foreheadplasty today. However, some surgeons have begun to advocate using the subperiosteal plane, and controversy surrounds the question of which dissection plane is more surgically sound for raising a forehead flap. On the basis of 25 fresh cadaver dissections and more than 20 years of clinical experience with foreheadplasty, the author concludes that dissection done at the subperiosteal rather than the subgaleal plane provides greater benefit to the patient. Although both subgaleal and subperiosteal planes can provide relative ease of dissection, elevation of the forehead flap at the subperiosteal plane can maximally preserve blood supply for the forehead flap and predictably preserve long-term frontoparietal scalp sensation. The deep division of the supraorbital nerve, which provides sensation to the frontoparietal scalp, is placed at risk for transection with subgaleal elevation of the forehead flap. The skin incision approach chosen for the forehead flap can also affect postoperative frontoparietal scalp sensation. The deep division of the supraorbital nerve will always be transected by a coronal incision approach for forehead flap elevation, with dissection done at either the subgaleal or the subperiosteal level. Only limited scalp incisions placed to avoid the course of the deep division of the supraorbital nerve can avoid transecting this nerve, and only subperiosteal dissection of the forehead flap can predictably preserve this nerve while elevating the forehead flap.
30年前，进行面部年轻化手术的外科医生普遍忽视了衰老的上半面部。最终，冠状切口前额提升技术成为一种被认可的手术方法，大多数外科医生在帽状腱膜下平面掀起前额皮瓣。这些外科医生发现帽状腱膜下平面是“自然的”或最容易操作的解剖平面，并且它至今仍是前额整形术中最常用的解剖平面。然而，一些外科医生已开始主张使用骨膜下平面，围绕掀起前额皮瓣哪个解剖平面在手术操作上更合理的问题存在争议。基于25例新鲜尸体解剖以及20多年前额整形术的临床经验，作者得出结论：在骨膜下而非帽状腱膜下平面进行解剖对患者更有益。虽然帽状腱膜下平面和骨膜下平面都能相对容易地进行解剖，但在骨膜下平面掀起前额皮瓣能最大程度地保留前额皮瓣的血供，并可预期地保留额顶头皮的长期感觉。为额顶头皮提供感觉的眶上神经深支，在帽状腱膜下掀起前额皮瓣时存在被横断的风险。为前额皮瓣选择的皮肤切口入路也会影响术后额顶头皮的感觉。采用冠状切口入路掀起前额皮瓣时，无论在帽状腱膜下还是骨膜下平面进行解剖，眶上神经深支总会被横断。只有放置有限的头皮切口以避开眶上神经深支的走行才能避免横断该神经，并且只有在掀起前额皮瓣时进行骨膜下解剖才能在可预期地保留该神经的同时掀起前额皮瓣。
