Surgical Technique
Small-Incision Frontalis Muscle Transposition Flap for Lateral Eyebrow Ptosis Repair Bryan R. Costin, M.D. and Julian D. Perry, M.D. Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.
Purpose: To describe a novel technique to correct lateral eyebrow ptosis using a frontalis muscle transposition flap. Methods: The charts of all patients undergoing eyebrow ptosis repair using a frontalis muscle transposition flap from December 2013 through April 2014 were reviewed to describe the surgical technique. Results: Sixteen patients underwent eyebrow ptosis repair using a frontalis muscle pedicle flap during the study period. Briefly, after local infiltration, a lateral forehead rhytid was marked and incised for approximately 1.5 cm. Blunt dissection exposed the frontalis-orbicularis angle, the frontalis-orbicularis insertion, and the lateral extent of the frontalis muscle. A pedicle flap of lateral frontalis muscle was created, trimmed, and transposed laterally in graded fashion to achieve the optimal eyebrow height and contour. The incision was closed with 5-0 polypropylene suture. All patients reported improvement in eyebrow position. Conclusions: This novel technique provides frontalis muscle elevatory force to the lateral eyebrow through a small incision to improve eyebrow ptosis. Further study, including objective measures of long-term results, is required. (Ophthal Plast Reconstr Surg 2015;31:63–65)
A
s the only muscle capable of elevating the eyebrow, the frontalis muscle opposes 4 eyebrow depressors (the procerus, corrugator, depressor supercilii, and orbicularis oculi) and the forces of gravity.1–3 The orbicularis muscle extends further laterally than the frontalis muscle, where it produces an unopposed depressor action on the lateral eyebrow.4,5 This absence of lateral frontalis muscle has been implicated in eyebrow ptosis and “lateral hooding.”4 The authors recently described lateral frontalis muscle landmarks and morphologic variability in senescent Caucasian fresh frozen human cadavers that may illuminate additional anatomic underpinnings of lateral eyebrow ptosis.6 The frontalis-orbicularis interdigitation (FOI) represents the lateral confluence point of the frontalis and orbicularis oculi muscles (Fig. 1A). At the FOI, the frontalis-orbicularis angle is formed. Both of these entities vary between cadaveric specimens and within the same specimen with respect to laterality.6 The authors postulate that the position of the FOI and the degree of the frontalis-orbicularis angle determine the vector forces responsible for lateral brow elevation and position. Senescent changes may rarify the lateral frontalis muscle to Accepted for publication August 28, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Julian D. Perry, M.D., Cole Eye Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000333
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
produce a more medially displaced FOI, and a more acute frontalis-orbicularis angle (Fig. 1B). Transposing a flap of frontalis muscle laterally should provide a force to elevate the lateral eyebrow (Fig. 1C). A small incision within a lateral forehead rhytid should allow for easy access to these landmarks with minimal scar visibility.
METHODS The charts of all patients undergoing eyebrow ptosis repair using a frontalis muscle pedicle flap at the Cole Eye Institute between December 2013 and April 2014 were studied. Charts were reviewed for patient demographic data and operative reports were studied to describe the surgical technique. This study was approved by the Cleveland Clinic Institutional Review Board and adhered to the tenets of the Declaration of Helsinki.
RESULTS All surgeries were performed in a similar fashion by one surgeon (J.D.P.). The incision site was chosen preoperatively with the patients’ approval and understanding of the likelihood of a small visible scar. The incision site fell within a forehead rhytid or along the superior-most brow cilia at a fulcrum point where digital elevation provided optimal brow contour. This site was described in the chart preoperatively for reference at the time of surgery. The lateral forehead was infiltrated in this region with approximately 2 cc of 1% lidocaine solution containing 1:100,000 epinephrine. The rhytid was marked for incision (Fig. 2A) and the incision was created with a Bard-Parker #15 blade Caledonia, MI). In some cases an ellipse was created between 2 and 4 mm in height to aid in subcutaneous dissection and visualization. Stevens tenotomy scissors were used to bluntly dissect through the subcutaneous tissues, and blunt dissection with a cotton-tipped applicator exposed the frontalis-orbicularis angle (Fig. 2B). The Stevens tenotomy scissors were directed superiorly to dissect in the plane just anterior to the frontalis muscle for approximately 2 cm (Fig. 2C). The pedicle flap was created using monopolar cautery or scissors, and measured approximately 2 cm vertically by 1 cm horizontally (Fig. 2D). The flap was transposed laterally to the region along the orbicularis muscle that provided for optimal brow position and contour (Fig. 2E). The distal flap was resected to the level where apposition with 0.5 mm Castroviejo forceps provided the desired eyebrow height (Fig. 2F). The transposition flap was then sutured to the orbicularis muscle with one interrupted 4-0 polyglactin 910 suture at its medial and its lateral extent (Fig. 2G). The incision was closed with a running 5-0 polypropylene suture (Fig. 2H) and dressed with antibiotic ointment. Eyebrow ptosis repair using this technique was performed on 27 eyebrows of 16 patients (6 males, 10 female) during the study period. Eleven patients underwent bilateral eyebrow ptosis repair, 3 patients underwent left eyebrow ptosis repair, and 2 patients underwent right eyebrow ptosis repair. Each patient reported improvement in eyebrow position and improved cosmesis (Fig. 3). All patients reported acceptable scar appearance and no patient asked for scar revision or other scar treatment.
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Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
B. R. Costin and J. D. Perry
DISCUSSION
FIG. 1. A, A laterally based frontalis-orbicularis interdigitation, where the frontalis muscle interdigitates with the orbicularis muscle to produce a relatively obtuse frontalis-orbicularis angle, may produce a higher and more dynamic lateral brow position. B, A more medially based frontalis-orbicularis interdigitation, where the frontalis muscle also interdigitates more acutely with the orbicularis muscle, allows for unopposed orbicularis action on the lateral brow and may contribute to lateral eyebrow hooding. C, Transposing the frontalis muscle laterally restores lateral eyebrow elevation.
64
This frontalis muscle transposition flap technique introduces an elevatory force to the lateral eyebrow through a small incision that hides within a preexisting rhytid or the superior eyebrow cilia. Constant muscle opposition between the frontalis muscle and the orbicularis oculi laterally, where the interdigitation between the 2 muscles is nearly parallel (and thus less stable), may result in separation of the lateral FOI laterally to produce a more medial FOI with age. This loss of dynamic elevatory force laterally may contribute to lateral eyebrow ptosis. Further cadaver studies or noninvasive techniques could substantiate this theory. In any case, the transposition flap certainly redirects frontalis muscle elevation to the lateral eyebrow. By resecting the distal frontalis muscle flap, this surgery allows for a graded correction of eyebrow ptosis in a manner similar to levator resection for repair of blepharoptosis. While the lidocaine solution could paralyze the frontalis muscle and confound efforts to grade muscle resection, the authors’ early findings suggest that neither intraoperative undercorrection nor overcorrection is required. The authors chose a flap width of 1 cm to allow for easy manipulation within a small incision, but the flap width can be increased, or even divided in 2, to provide a wider fulcrum for more diffuse brow elevation. In some cases without a significant lateral forehead rhytid, an incision was made along the superior-most brow cilia. The authors’ previous work suggests that this incision falls beneath superior extent of the orbicularis oculi muscle in most cases.6 Thus, these eyebrow incisions required more superior dissection in order to expose approximately 2 cm of frontalis muscle superior to the FOI. The authors have gravitated toward incisions 1.5–2 cm above the orbital rim even in cases without a significant forehead rhytid to allow for more straightforward dissection and flap advancement to the superior edge of orbicularis muscle. The frontalis muscle flap was created in each case, regardless of incision site, with its inferior aspect at least 1.5–2 cm above the orbital rim to avoid the temporal branch of the facial nerve, which courses in this region deep to the frontalis muscle. While the authors identified no cases of facial nerve injury, considering the course of its frontal branch, the potential risk of facial nerve injury must be kept in mind. While this technique involves suspending the eyelid protractor muscle to a dynamic elevatory structure, it does not seem to increase the risk of lagophthalmos beyond those imposed by other brow lifting techniques. Interestingly, in this population of patients with significant lateral eyebrow ptosis, the authors noted a commonly occurring lateral forehead rhytid that may be produced by the vector forces produced by the medially displaced FOI. During surgery, this common lateral eyebrow furrow was found to end at the FOI in many cases. This furrow, when present, allowed for an incision site providing easy access to the lateral extent of the frontalis muscle with good exposure of the lateral orbicularis muscle for the final positioning of the transposed flap. The standard incision coursed approximately from a perpendicular line though the lateral canthus laterally to a line perpendicular to the lateral limbus medially. The exact incision site varied according to the fulcrum point that resulted in optimal brow contour and the location of any concealing rhytid. The subcutaneous dissection extended for at least 2 cm superior to the incision to prevent buckling of the overlying skin due to advancement of the deeper tissues. Small cutaneous redundancies produced from tightening the underlying tissues inevitably resolved within several weeks after surgery. While some cases were performed with the excision of a small ellipse of skin, no more than 4 mm of skin was removed
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Frontalis Transposition Flap for Eyebrow Ptosis Repair
FIG. 2. Intraoperative photographs demonstrate eyebrow ptosis repair using a frontalis muscle transposition flap through a small incision. A, A predetermined lateral forehead rhytid is used for the incision site. B, Blunt dissection readily exposes the frontalis-orbicularis angle. C, Stevens scissors are used to dissect superiorly. D, The frontalis muscle transposition flap is created. E, The flap is transposed laterally with forceps to determine the flap position and amount of resection that will result in the desired eyebrow height and contour. F, The distal aspect of the flap is resected. G, The flap is sutured to orbicularis muscle medially and laterally. H, The wound is closed with 5-0 polypropylene suture.
brow ptosis, contracture of the opposing orbicularis and frontalis muscles in this region may rarify this surgical attachment over time. The long-term elevatory effects of this transposition flap remain to be determined. In addition to the lack of long-term data, this descriptive study suffers from weaknesses that include its retrospective nature, the small number of patients, and a lack of quantitative data to assess lateral brow elevation. This novel frontalis muscle transposition flap technique is based upon new anatomic findings in senescent cadavers. It may correct aging changes associated with lateral eyebrow ptosis, and it provides an elevatory force to the lateral eyebrow through a small, relatively concealed incision. Further study regarding nuances of the technique, longer term results, objective outcome measures, and complications is required.
REFERENCES FIG. 3. External photographs before and 3 months following right frontalis muscle transposition flap lateral eyebrow lift. A, Preoperative. B, Postoperative.
in any case. Excising a small amount of skin vertically aided in bluntly dissecting the flap and likely did not produce significant eyebrow elevation on its own. The resultant scar from all surgeries was nearly invisible by 6 weeks postoperatively and no patient complained of a visible or untoward scar. The transposition places frontalis muscle fibers nearly parallel to the vertically oriented lateral orbicularis fibers. Similar to the mechanism that the authors postulate may contribute to lateral
1. Paul MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg 2001;108:1409–24. 2. Presti P, Yalamanchili H, Honrado CP. Rejuvenation of the aging upper third of the face. Facial Plast Surg 2006;22:91–6. 3. Hetzler L, Sykes J. The brow and forehead periocular rejuvenation. Facial Plast Surg Clin N Am 2010;18:375–84. 4. Lemke BN, Stasior OG. The anatomy of eyebrow ptosis. Arch Ophthalmol 1982;100:981–6. 5. Costin BR, Sakolsatayadorn N, McNutt SA, et al. Dimensions and anatomic variations of the orbicularis oculi muscle in nonpreserved, fresh-frozen human cadavers. Ophthal Plast Reconstr Surg 2014;30:198–200. 6. Costin BR, Plesec TP, Sakolsatayadorn N, et al. Anatomy and histology of the frontalis muscle. Ophthal Plast Reconstr Surg 2015;31:66–72.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
65
Small-Incision Frontalis Muscle Transposition Flap for Lateral Eyebrow Ptosis Repair Bryan R. Costin, M.D. and Julian D. Perry, M.D. Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A.
Purpose: To describe a novel technique to correct lateral eyebrow ptosis using a frontalis muscle transposition flap. Methods: The charts of all patients undergoing eyebrow ptosis repair using a frontalis muscle transposition flap from December 2013 through April 2014 were reviewed to describe the surgical technique. Results: Sixteen patients underwent eyebrow ptosis repair using a frontalis muscle pedicle flap during the study period. Briefly, after local infiltration, a lateral forehead rhytid was marked and incised for approximately 1.5 cm. Blunt dissection exposed the frontalis-orbicularis angle, the frontalis-orbicularis insertion, and the lateral extent of the frontalis muscle. A pedicle flap of lateral frontalis muscle was created, trimmed, and transposed laterally in graded fashion to achieve the optimal eyebrow height and contour. The incision was closed with 5-0 polypropylene suture. All patients reported improvement in eyebrow position. Conclusions: This novel technique provides frontalis muscle elevatory force to the lateral eyebrow through a small incision to improve eyebrow ptosis. Further study, including objective measures of long-term results, is required. (Ophthal Plast Reconstr Surg 2015;31:63–65)
A
s the only muscle capable of elevating the eyebrow, the frontalis muscle opposes 4 eyebrow depressors (the procerus, corrugator, depressor supercilii, and orbicularis oculi) and the forces of gravity.1–3 The orbicularis muscle extends further laterally than the frontalis muscle, where it produces an unopposed depressor action on the lateral eyebrow.4,5 This absence of lateral frontalis muscle has been implicated in eyebrow ptosis and “lateral hooding.”4 The authors recently described lateral frontalis muscle landmarks and morphologic variability in senescent Caucasian fresh frozen human cadavers that may illuminate additional anatomic underpinnings of lateral eyebrow ptosis.6 The frontalis-orbicularis interdigitation (FOI) represents the lateral confluence point of the frontalis and orbicularis oculi muscles (Fig. 1A). At the FOI, the frontalis-orbicularis angle is formed. Both of these entities vary between cadaveric specimens and within the same specimen with respect to laterality.6 The authors postulate that the position of the FOI and the degree of the frontalis-orbicularis angle determine the vector forces responsible for lateral brow elevation and position. Senescent changes may rarify the lateral frontalis muscle to Accepted for publication August 28, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Julian D. Perry, M.D., Cole Eye Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000333
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
produce a more medially displaced FOI, and a more acute frontalis-orbicularis angle (Fig. 1B). Transposing a flap of frontalis muscle laterally should provide a force to elevate the lateral eyebrow (Fig. 1C). A small incision within a lateral forehead rhytid should allow for easy access to these landmarks with minimal scar visibility.
METHODS The charts of all patients undergoing eyebrow ptosis repair using a frontalis muscle pedicle flap at the Cole Eye Institute between December 2013 and April 2014 were studied. Charts were reviewed for patient demographic data and operative reports were studied to describe the surgical technique. This study was approved by the Cleveland Clinic Institutional Review Board and adhered to the tenets of the Declaration of Helsinki.
RESULTS All surgeries were performed in a similar fashion by one surgeon (J.D.P.). The incision site was chosen preoperatively with the patients’ approval and understanding of the likelihood of a small visible scar. The incision site fell within a forehead rhytid or along the superior-most brow cilia at a fulcrum point where digital elevation provided optimal brow contour. This site was described in the chart preoperatively for reference at the time of surgery. The lateral forehead was infiltrated in this region with approximately 2 cc of 1% lidocaine solution containing 1:100,000 epinephrine. The rhytid was marked for incision (Fig. 2A) and the incision was created with a Bard-Parker #15 blade Caledonia, MI). In some cases an ellipse was created between 2 and 4 mm in height to aid in subcutaneous dissection and visualization. Stevens tenotomy scissors were used to bluntly dissect through the subcutaneous tissues, and blunt dissection with a cotton-tipped applicator exposed the frontalis-orbicularis angle (Fig. 2B). The Stevens tenotomy scissors were directed superiorly to dissect in the plane just anterior to the frontalis muscle for approximately 2 cm (Fig. 2C). The pedicle flap was created using monopolar cautery or scissors, and measured approximately 2 cm vertically by 1 cm horizontally (Fig. 2D). The flap was transposed laterally to the region along the orbicularis muscle that provided for optimal brow position and contour (Fig. 2E). The distal flap was resected to the level where apposition with 0.5 mm Castroviejo forceps provided the desired eyebrow height (Fig. 2F). The transposition flap was then sutured to the orbicularis muscle with one interrupted 4-0 polyglactin 910 suture at its medial and its lateral extent (Fig. 2G). The incision was closed with a running 5-0 polypropylene suture (Fig. 2H) and dressed with antibiotic ointment. Eyebrow ptosis repair using this technique was performed on 27 eyebrows of 16 patients (6 males, 10 female) during the study period. Eleven patients underwent bilateral eyebrow ptosis repair, 3 patients underwent left eyebrow ptosis repair, and 2 patients underwent right eyebrow ptosis repair. Each patient reported improvement in eyebrow position and improved cosmesis (Fig. 3). All patients reported acceptable scar appearance and no patient asked for scar revision or other scar treatment.
63
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
B. R. Costin and J. D. Perry
DISCUSSION
FIG. 1. A, A laterally based frontalis-orbicularis interdigitation, where the frontalis muscle interdigitates with the orbicularis muscle to produce a relatively obtuse frontalis-orbicularis angle, may produce a higher and more dynamic lateral brow position. B, A more medially based frontalis-orbicularis interdigitation, where the frontalis muscle also interdigitates more acutely with the orbicularis muscle, allows for unopposed orbicularis action on the lateral brow and may contribute to lateral eyebrow hooding. C, Transposing the frontalis muscle laterally restores lateral eyebrow elevation.
64
This frontalis muscle transposition flap technique introduces an elevatory force to the lateral eyebrow through a small incision that hides within a preexisting rhytid or the superior eyebrow cilia. Constant muscle opposition between the frontalis muscle and the orbicularis oculi laterally, where the interdigitation between the 2 muscles is nearly parallel (and thus less stable), may result in separation of the lateral FOI laterally to produce a more medial FOI with age. This loss of dynamic elevatory force laterally may contribute to lateral eyebrow ptosis. Further cadaver studies or noninvasive techniques could substantiate this theory. In any case, the transposition flap certainly redirects frontalis muscle elevation to the lateral eyebrow. By resecting the distal frontalis muscle flap, this surgery allows for a graded correction of eyebrow ptosis in a manner similar to levator resection for repair of blepharoptosis. While the lidocaine solution could paralyze the frontalis muscle and confound efforts to grade muscle resection, the authors’ early findings suggest that neither intraoperative undercorrection nor overcorrection is required. The authors chose a flap width of 1 cm to allow for easy manipulation within a small incision, but the flap width can be increased, or even divided in 2, to provide a wider fulcrum for more diffuse brow elevation. In some cases without a significant lateral forehead rhytid, an incision was made along the superior-most brow cilia. The authors’ previous work suggests that this incision falls beneath superior extent of the orbicularis oculi muscle in most cases.6 Thus, these eyebrow incisions required more superior dissection in order to expose approximately 2 cm of frontalis muscle superior to the FOI. The authors have gravitated toward incisions 1.5–2 cm above the orbital rim even in cases without a significant forehead rhytid to allow for more straightforward dissection and flap advancement to the superior edge of orbicularis muscle. The frontalis muscle flap was created in each case, regardless of incision site, with its inferior aspect at least 1.5–2 cm above the orbital rim to avoid the temporal branch of the facial nerve, which courses in this region deep to the frontalis muscle. While the authors identified no cases of facial nerve injury, considering the course of its frontal branch, the potential risk of facial nerve injury must be kept in mind. While this technique involves suspending the eyelid protractor muscle to a dynamic elevatory structure, it does not seem to increase the risk of lagophthalmos beyond those imposed by other brow lifting techniques. Interestingly, in this population of patients with significant lateral eyebrow ptosis, the authors noted a commonly occurring lateral forehead rhytid that may be produced by the vector forces produced by the medially displaced FOI. During surgery, this common lateral eyebrow furrow was found to end at the FOI in many cases. This furrow, when present, allowed for an incision site providing easy access to the lateral extent of the frontalis muscle with good exposure of the lateral orbicularis muscle for the final positioning of the transposed flap. The standard incision coursed approximately from a perpendicular line though the lateral canthus laterally to a line perpendicular to the lateral limbus medially. The exact incision site varied according to the fulcrum point that resulted in optimal brow contour and the location of any concealing rhytid. The subcutaneous dissection extended for at least 2 cm superior to the incision to prevent buckling of the overlying skin due to advancement of the deeper tissues. Small cutaneous redundancies produced from tightening the underlying tissues inevitably resolved within several weeks after surgery. While some cases were performed with the excision of a small ellipse of skin, no more than 4 mm of skin was removed
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Frontalis Transposition Flap for Eyebrow Ptosis Repair
FIG. 2. Intraoperative photographs demonstrate eyebrow ptosis repair using a frontalis muscle transposition flap through a small incision. A, A predetermined lateral forehead rhytid is used for the incision site. B, Blunt dissection readily exposes the frontalis-orbicularis angle. C, Stevens scissors are used to dissect superiorly. D, The frontalis muscle transposition flap is created. E, The flap is transposed laterally with forceps to determine the flap position and amount of resection that will result in the desired eyebrow height and contour. F, The distal aspect of the flap is resected. G, The flap is sutured to orbicularis muscle medially and laterally. H, The wound is closed with 5-0 polypropylene suture.
brow ptosis, contracture of the opposing orbicularis and frontalis muscles in this region may rarify this surgical attachment over time. The long-term elevatory effects of this transposition flap remain to be determined. In addition to the lack of long-term data, this descriptive study suffers from weaknesses that include its retrospective nature, the small number of patients, and a lack of quantitative data to assess lateral brow elevation. This novel frontalis muscle transposition flap technique is based upon new anatomic findings in senescent cadavers. It may correct aging changes associated with lateral eyebrow ptosis, and it provides an elevatory force to the lateral eyebrow through a small, relatively concealed incision. Further study regarding nuances of the technique, longer term results, objective outcome measures, and complications is required.
REFERENCES FIG. 3. External photographs before and 3 months following right frontalis muscle transposition flap lateral eyebrow lift. A, Preoperative. B, Postoperative.
in any case. Excising a small amount of skin vertically aided in bluntly dissecting the flap and likely did not produce significant eyebrow elevation on its own. The resultant scar from all surgeries was nearly invisible by 6 weeks postoperatively and no patient complained of a visible or untoward scar. The transposition places frontalis muscle fibers nearly parallel to the vertically oriented lateral orbicularis fibers. Similar to the mechanism that the authors postulate may contribute to lateral
1. Paul MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg 2001;108:1409–24. 2. Presti P, Yalamanchili H, Honrado CP. Rejuvenation of the aging upper third of the face. Facial Plast Surg 2006;22:91–6. 3. Hetzler L, Sykes J. The brow and forehead periocular rejuvenation. Facial Plast Surg Clin N Am 2010;18:375–84. 4. Lemke BN, Stasior OG. The anatomy of eyebrow ptosis. Arch Ophthalmol 1982;100:981–6. 5. Costin BR, Sakolsatayadorn N, McNutt SA, et al. Dimensions and anatomic variations of the orbicularis oculi muscle in nonpreserved, fresh-frozen human cadavers. Ophthal Plast Reconstr Surg 2014;30:198–200. 6. Costin BR, Plesec TP, Sakolsatayadorn N, et al. Anatomy and histology of the frontalis muscle. Ophthal Plast Reconstr Surg 2015;31:66–72.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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