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Coronoplasty Brow Lift

  • Author: Frank S Ciminello, MD; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
 
Updated: Apr 08, 2016
 

History of the Procedure

The forehead lift or brow lift is a common facial rejuvenation procedure, performed as an isolated technique or in combination with total facial rejuvenation, including facelift and blepharoplasty.[1] Most recent clinical data and paradigm shifts have reoriented the term brow lift as a misnomer. The terms browplasty or brow reshaping focus on the overall contour rather than the absolute height of the brow.[2, 3]

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Problem

Periorbital changes are often recognized as the earliest signs of aging. Common changes include upper eyelid skin folds extending beyond the upper eyelid into the temple, frown lines or glabellar transverse forehead creases, thickening or bunching of the corrugator muscles at the medial eyebrow, and descent (ptosis) of the eyebrows. See the images below.

Left - Preoperative view, brow lift Right - Postop Left - Preoperative view, brow lift Right - Postoperative view at 2 years
Left - Preoperative view, brow lift Right - Postop Left - Preoperative view, brow lift Right - Postoperative view at 2 years

These changes potentially are reversed with an appropriately performed brow lift or forehead lifting procedure.

In this discussion, the terms brow lift and forehead lift are used interchangeably. The actual incision used to perform a brow lift can vary from the coronal line, the prehairline, and just above the eyebrow. This topic focuses on the indications, techniques, and results of the coronal approach. For information on other brow lift procedures, see the Brow Lift section of Medscape’s Plastic Surgery journal.

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Epidemiology

Frequency

Aging varies in each individual. Forehead changes are based on environmental factors (sun damage), genetic makeup, and skin type. The extent of aging can vary greatly.

Beginning in the fourth decade, early changes of brow position, influenced by gravity, become apparent. This eventually occurs in all individuals, although the degree of brow ptosis and constellation of findings such as glabellar frown lines and transverse forehead creases vary. By the fifth decade, most individuals have undesirable changes of the forehead and upper periorbital region that would benefit from rejuvenative forehead procedures.

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Etiology

The etiology of the aging upper face involves loss of elasticity, soft tissue ptosis, genetic predisposition, and repetitive facial motion (eg, squinting, constant corrugation of eyebrow muscles).

Individuals with active facial animation, especially those who are exposed to sun, may exhibit more advanced signs of upper forehead aging.

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Pathophysiology

Constant motion of the frontalis muscle creates the transverse rhytides of the forehead. Patients with advanced brow ptosis activate the frontalis muscles on a regular and involuntary basis to maintain elevation of their brows, thereby preventing the visual field obstruction that occurs from brow ptosis. As forehead soft tissues continue their descent over time, compensatory frontalis muscle tone creates progressively deepening lines to offset the effect on visual field obstruction.

In such cases, the well-intentioned removal of upper eyelid skin can create further brow ptosis through a relaxation in frontalis tone, which is now no longer required to maintain the visual field. The removal of upper lid skin in such cases can make later brow elevation more complicated, with poorer aesthetic results due to the limitations created by a paucity of upper lid skin. To overcome this deficiency, skin grafts or flaps from the lower lid may be considered. Remarkable aesthetic improvements can be achieved with techniques that diminish frontalis tone and weaken the centralizing and depressing muscular action while elevating the brow to an appropriate position.

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Presentation

Patients may be told by family, friends, or colleagues that they appear angry, sad, or anxious when this appearance does not match their emotional state. This misinterpretation can be quite concerning for some and may result in a visit to a plastic surgeon for treatment. Elevating the brow while diminishing corrugator and procerus function can reduce forehead rhytides. This goal is accomplished through a skillfully performed brow lift.

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Indications

A brow lift may be indicated in anyone who approaches the fourth decade of life and exhibits changes such as brow ptosis and excess corrugator action with glabellar creases between the eyebrows and transverse forehead wrinkling. Many of these patients are motivated to change the unacceptable appearances of anger, annoyance, or fatigue that commonly are associated with changes in the forehead.

In the female patient, elevation of the lateral eyebrow and weakening of the centralizing and depressor muscles provides a more aesthetically pleasing upper periorbita, consistent with youthful femininity.

In men, eyebrow position also may be excessively low, and elevation may be indicated; however, excessive elevation can be feminizing. Vertical glabellar frown lines may suggest anger or anxiousness and are typically undesirable. Concerns over the appearance of these unwanted lines often prompts a visit to a plastic surgeon.

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Relevant Anatomy

A thorough knowledge of the layers of the scalp and forehead is paramount. The layers encountered in brow lift surgery are the skin, subcutaneous tissue, galea or aponeurosis, loose areolar tissue plane, and periosteum. Progressing inferiorly from the coronal or hairline incision, the deep and superficial layers of the temporal fascia are encountered laterally; an understanding of these layers and how they relate to the frontal branch of the facial nerve as it traverses the galea and superficial musculoaponeurotic system (SMAS) layer is critical.[4] See the image below.

Cross-section of the temporal region showing fasci Cross-section of the temporal region showing fascial relationships to the zygomatic arch.

A brow lift may be performed via a subcutaneous, subgaleal, or subperiosteal layer. Most brow lifts are performed through an open technique in a subgaleal fashion, with release of soft tissue attachments at the supraorbital rim to make transmission of lift to the lateral eyebrow possible.

Anatomic understanding of the supraorbital and supratrochlear nerve branches that traverse the medial eyebrow region also is important. Supratrochlear nerves are invested within the corrugator muscle. They are visualized in dissection and removal of the corrugator muscle and must be preserved. The supraorbital nerve exits more lateral than the supratrochlear nerves and provides sensation to the hemi-forehead, extending superiorly above the hairline. Preserving these nerves minimizes sensory deficiencies.

The frontal branch of the facial nerve is carried in the forehead flap when the procedure is performed through the subgaleal or subaponeurotic dissection. Tension or traction on the forehead flap at the level of the lateral orbital rim must be gentle to avoid neurapraxia or permanent injury to the nerve.

An intimate knowledge of the insertion and origin of the corrugator muscles, procerus muscle, and frontalis muscle is essential to performing a comprehensive brow lift procedure that reverses the signs of aging.

For more information about the relevant anatomy, see Forehead Anatomy.

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Contraindications

The most significant contraindication to a forehead lift is deficiency of upper eyelid skin. This often occurs when previous upper eyelid surgery has been performed, lagophthalmus has occurred, and adequate lid closure is a concern. Elevation of the brow to its proper level may be impossible if adequate upper eyelid skin is not present. This demonstrates the importance of proper diagnosis in the aging face so that excess upper eyelid skin is not removed simply because this is the "easier way out."

In most patients, a properly performed brow lift is the cornerstone of upper facial rejuvenation. Only after placing the brow in the proper position can one assess excess upper eyelid skin. This is especially true in women, in whom eyebrow position and shape is quite important in establishing the aesthetics of the periorbital region. A properly arched and elevated lateral brow is a key element to a rejuvenated female face.

A relative contraindication to a coronal forehead lift is a preexisting high anterior hairline. When excessively high, a coronal brow lift exacerbates this aesthetic problem. Further, following a coronal brow lift, performing subsequent hairline brow lifts to correct the problem is difficult without jeopardizing the vascularity to the intervening scalp segment that contains the anterior hairline. The endoscopic and prehairline brow lifts do not significantly alter hairline position and, therefore, are more appropriate choices for patients who have high anterior hairlines. However, recent studies suggest limited and often incomplete excursion of the lateral brow via the endoscopic approach.[3] The direct lateral brow lift has thus gained significant favor owing to its technical ease and reliability.[5]

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Contributor Information and Disclosures
Author

Frank S Ciminello, MD Director of Craniofacial Surgery, University Hospital, New Jersey Medical School

Frank S Ciminello, MD is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Chief Editor

Zubin J Panthaki, MD, CM, FACS, FRCSC Professor of Clinical Surgery, Department of Surgery, Division of Plastic Surgery, Associate Professor Clinical Orthopedics, Department of Orthopedics, University of Miami, Leonard M Miller School of Medicine; Chief of Hand Surgery, University of Miami Hospital; Chief of Hand Surgery, Chief of Plastic Surgery, Miami Veterans Affairs Hospital

Zubin J Panthaki, MD, CM, FACS, FRCSC is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, Miami Society of Plastic Surgeons, Medical Council of Canada, Canadian Military Engineers Association

Disclosure: Nothing to disclose.

Additional Contributors

R C A Weatherley-White, MD MA (Cantab), FACS, FAAP, FRSM, Associate Clinical Professor in Surgery (Plastic), University of Colorado School of Medicine; Medical Director, Cleft Palate/Craniofacial Center, Rose Medical Center

R C A Weatherley-White, MD is a member of the following medical societies: American Society of Plastic Surgeons, American Cleft Palate-Craniofacial Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, Colorado Medical Society, Royal Society of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Matthew J Trovato, MD Fellow, Division of Plastic Surgery, Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

References
  1. Lyon DB. Upper blepharoplasty and brow lift: state of the art. Mo Med. 2010 Nov-Dec. 107(6):383-90. [Medline].

  2. Matros E, Garcia J, Yaremchuck. Changes in eyebrow position and shape with aging. Plast Reconstr Surgery. 2009. 124:1296-1301.

  3. Trovato MJ, Ciminello FS, Rauscher GE. Redefining the brow-lift: A quantitative topographic assessment of age-related changes and operative techniques. Presented at the American Society of Aesthetic Plastic Surgery, May 3, 2009;

  4. Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989 Feb. 83(2):265-71. [Medline].

  5. Communication with John Q. Owsley, M.D. 2008.

  6. Graham DW, Heller J, Kurkjian TJ, Schaub TS, Rohrich RJ. Brow lift in facial rejuvenation: a systematic literature review of open versus endoscopic techniques. Plast Reconstr Surg. 2011 Oct. 128(4):335e-341e. [Medline].

  7. Guillot JM, Rousso DE, Replogle W. Forehead and scalp sensation after brow-lift: a comparison between open and endoscopic techniques. Arch Facial Plast Surg. 2011 Mar-Apr. 13(2):109-16. [Medline].

  8. Camirand A. Improvement of the Scars of Temporal and Frontal Face Lifts. McKinney P. Yearbook of Plastic Surgery. St. Louis: Mosby; 1993.

  9. Byun S, Mukovozov I, Farrokhyar F, Thoma A. Complications of browlift techniques: a systematic review. Aesthet Surg J. 2013 Feb. 33 (2):189-200. [Medline].

  10. Powell B, Younes A, Friedman O. Evaluation of the midforehead brow-lift operation. Arch Facial Plast Surg. 2011 Sep-Oct. 13(5):337-42. [Medline].

  11. Hamamoto AA, Liu TW, Wong BJ. Identifying ideal brow vector position: empirical analysis of three brow archetypes. Facial Plast Surg. 2013 Feb. 29(1):76-82. [Medline].

 
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Cross-section of the temporal region showing fascial relationships to the zygomatic arch.
Method for quantitative topographic assessment of age related brow changes and operative technique.
Left - Preoperative view, brow lift Right - Postoperative view at 2 years
Left - Preoperative view, brow lift Right - Postoperative view at 2 years
Left - Preoperative view, brow lift Right - Postoperative view at 2 years
Left - Preoperative view, brow lift Right - Postoperative view at 2 years
 
 
 
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