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Lifting the brow

This is Part 2 of an eight-part series on cosmetic surgery.
He arrived for surgery in a straw coolie hat. Now, minutes before the operation, he sits in his gown and paper cap, cracking jokes and answering a litany of questions from the anesthesiologist.“How’s your stomach?”“It’s too big.”“How’s your heart?”“It’s been broken a couple of times.”Anthony Jarrell is about as nonchalant as anyone facing surgery can get. After all, he’s been through this before. Many times before.“I started with rhinoplasty. I had large flaring nostrils. They took a tab of skin out of each nostril and pulled the sides of the nose in. I had a bump from when I was hit in the nose with an apple. They shaved off the bump.”Let’s see. He’s also had an upper eyelid lift, silicone cheek implants, an endoscopic brow lift, three liposuctions, Botox, a laser treatment on his face and a Cary Grant cleft carved into his chin.There’s more to come, of course.“You know that Extreme Makeover show on television? Well, I’d rather have constant makeovers rather than the extreme,” he says. “Having minor touchups should be like brushing your teeth and flossing and going to the dentist. If you don’t do those things, your teeth will rot.“I don’t know anyone who wants to accept this aging thing. I’m a single man with no children. I work out regularly to keep fit. I work in the beauty industry, so I try hard to maintain my looks as part of my job.”On this mid-February afternoon, the 43-year-old hairdresser will have his brow lifted. His high, furrowed forehead disturbs him. The earlier endoscopic procedure using tiny instruments and a TV camera didn’t produce the desired results.Now he’s trying a traditional coronal forehead lift that requires a large incision across his scalp. “They’re going to peel my forehead back like a Fruit Roll-Up,” he explains matter of factly.
A visit from the surgeon precedes the operation. Dr. Ted Jackson asks Jarrell to decide where he wants his eyebrows. “Take this mirror and lift your brows up to where you want them,” he says. Using a ruler, Jackson measures the lift at 13 millimeters. With ruler in hand, he marks Jarrell’s face with several black dots. “I’m planning the incision,” he explains. Finally in the operating room, the crew monitors the progress of Jarrell’s anesthesia. Instead of a general anesthetic, the operation will be performed under twilight anesthesia, a combination of local anesthetics with sedatives that will relax him and erase any memories of the surgery.“It’s a balancing act with sedation,” Jackson says. “Too much and they won’t breathe. Too little and they’ll be uncomfortable. We like to err on side of breathing.”After numbing Jarrell’s scalp, Jackson makes the incision across the top of Jarrell’s head. He uses a zigzag or beveled technique that will allow hair to grow through the scar and disguise it.Then, shoving needles under the separated skin, he injects Xylocaine with a mechanical pump. “That’s how we can do this operation without putting them to sleep. I already did some nerve blocks and blocked the incision site with a stronger local anesthetic.”Several times during the procedure, Jarrell stirs and murmurs. “They come to every now and then,” Jackson says. “It’s like at night when you sleep.”
A first assistant nurse uses a fork-like instrument to hold the scalp back as Jackson clips tissue layers away from the bone, a painstaking process. “These lifts would be easy if I didn’t have to preserve nerve function,” Jackson says. The failure rate is about 3 percent.“See that reddish purplish layer? That’s the muscle that wrinkles the forehead. We have to be careful at the brow line. If I damage that muscle, that eyebrow doesn’t work.”Gradually revealing more and more of the skull, Jackson dabs constantly at the oozing blood. It’s gruesome. He agrees. “Plastic surgery is not for everybody. Would I let somebody scalp me?”
With the implement, the nurse lifts the facial skin back as if she were lifting up a pliable Halloween mask.“Now we’re getting down to brass tacks,” Jackson says. “I just cut the periostium, the non-bone outer layer of the bone. I need to get down under that so I don’t hurt any vessels and nerves coming out from his eyes.It looks like the membrane under the shell of a hard-boiled egg. “It’s a very thick, hard layer,” he says. “It’s going to help us later when we stitch him back up because we’re able to put stitches in there and he will heal nicely.”Scar tissue from Jarrell’s previous endoscopic procedure makes it harder to separate the layers, Jackson says. “Scarring obliterates the sliding tissue that helps you separate more easily. Usually, it’s more elegant, like peeling skin off a chicken.”With the facial skin fully separated to the brow line and flipped, underside up, over Jarrell’s nose and cheeks, Jackson uses an electric cutting and coagulating instrument to burn a row of long stripes.“That’s the muscle that wrinkles the brow. I’m cutting off the nerve supply to it. The impulse won’t travel across the burned areas, so the forehead won’t be animated and the wrinkles will disappear. I don’t want to keep hearing about them.”Jarrell’s forehead will still move, however, and he still will be able to furrow his brow. “I’ve done all I can do safely,” Jackson says. “If it works, it works. If it doesn’t, it doesn’t.”Finally, he pulls the facial skin back up to the incision site, tugging on it to gauge how much skin he must cut to tighten the forehead. A brow lift can be performed by cutting a strip of skin below or above the hairline, he explains. “Cutting at the hairline would have been a better idea, but Anthony wanted the scar in his hair, so we had to scalp him.”Measuring with a ruler, he starts slicing off a horizontal strip of skin from Jarrell’s forehead. When the altered skin is stretched and stitched to the scalp, it will lift Jarrell’s brows to the height he chose.With the endoscopic procedure, surgeons perform surgery by remote control. Through small incisions, they insert a tiny camera and instruments that allow them to see and work under the skin without having to slice across the head and peel back the skin.Then, instead of pulling up the skin, stretching it tight and slicing off the excess, they simply shift it up and back and fasten it into its new position with screws that are removed or absorbed.It’s less drastic, but also less effective. Because excess skin hasn’t been clipped, the forehead may eventually droop.“Facelifts and other procedures all involve something like we just did,” Jackson says.Careful suturing consumes the rest of Jarrell’s time in the operating room. Jackson inserts a long tube with a bulb on one end into the scalp. Blood will drain from the tube into the bulb. He will remove the drain two days later.“He’s going to swell real bad. He will have black eyes, and the bleeding will turn into bruises. Tomorrow and the next day will be the worst.”Within minutes of the final stitch, Jarrell is sitting on the side of the operating table mumbling about a trip to the bathroom. With the nurse’s help, he shuffles to the toilet.Mission accomplished, he adjourns to an adjacent room for recovery. There isn’t much of that. He’s already cracking jokes and asking all sorts of questions. It’s time to dress and go home.He went to sleep that night with an icebag on his head and a vial of pain pills beside his bed if he needed them.He spent a full day in bed, had the stitches removed the following morning and returned to work. Hairdressers have little choice, he said. Clients want their standing appointments come hell, high water or plastic surgery.“I had black eyes and used ice packs,” he said, “but I felt great. Who started this idea of getting cosmetic surgery and hiding in the house for a month? When I had my upper eyelids done, I was at work the next day.”He’s happy with the results. “My forehead is wrinkle free and my brows are back up to where they were when I was a kid. And I can see better. I never thought about that as a by-product of beautification.”Friends say they don’t see a shocking difference. “That’s the thing about plastic surgery,” he said. “Too many people expect it to be like, Wow! It’s not a ‘Wow!’ thing.”Like a woman who has just had a baby, he’s not eager to repeat the process. “I don’t change tires on my car until I need to,” he said. “The next time, it will be something I need, not just something I want. But I’m not anxious to get under the knife again anytime soon. It kind of set me back.”To contact staff writer Sandy Wells, use e-mail or call 348-5173.Tuesday in the Gazette: The tummy tuck.
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