eMedicine Specialties > Plastic Surgery > Brow Lift

Brow Lift, Direct Brow Lift

Daniel N Ronel, MD, FAAP, FACS, Clinical Assistant Professor, Department of Pediatrics, Division of Plastic Surgery, University of New Mexico School of Medicine; Consulting Staff, New Mexico Plastic Surgery, St Vincent Surgical Group
Martin I Newman, MD, FACS, Consulting Surgical Staff, Department of Plastic and Reconstructive Surgery, Associate Program Director and Educational Director of Plastic Surgery Resident Program, Department of Plastic Surgery, Cleveland Clinic Florida; Anthony Labruna, MD, Assistant Professor, Department of Otolaryngology, Department of Surgery and Plastic Surgery, Cornell University Medical Center; Mia Talmor, MD, Assistant Professor, Department of Surgery, Weill Medical College of Cornell University

Updated: Jul 23, 2009

Introduction

The appearance of the brow is invested with an emotional, expressive, and psychological significance that makes it one of the most prominent features of the face. As the brow naturally descends with aging, its position often imparts undesired characteristics to the face, such as fatigue, sadness, anger, ennui, or other qualities that do not represent the individual's state of mind.

Many techniques have been developed to address the ptotic brow, and they are thoroughly reviewed in the following articles:

Brow Lift, Endoscopic
Brow Lift, Mid Forehead
Brow Lift, Coronoplasty
Brow Lift, Periorbital Rejuvenation
Brow Lift, Pretrichial Lift
Browplasty
Direct Brow Lift
Endoscopic Forehead Lift

This article focuses on the plastic and reconstructive surgical considerations of the direct brow lift, which involves an incision (and the resulting scar) immediately over the eyebrows. The procedure has waned in popularity as a cosmetic technique, having been replaced by more aesthetically satisfying methods that raise the forehead and the brow. The direct brow lift remains useful in certain clinical situations for functional restoration of the overhanging brow, eg, in persons who are not candidates for more modern forehead-lifting techniques.

History of the Procedure

In 1919, Raymond Passot described excision of the skin and soft tissue above the eyebrows to eliminate wrinkles around the lateral eyes and above the brow. In the ensuing decades, the entire forehead became the focus of rhytidectomy, and various placements of incisions and degrees of undermining within the forehead and scalp were proposed. The early techniques did not produce long-lasting results until it was determined, in the 1950s, that incision of the frontalis muscle was required.¹ Modern bicoronal, endoscopic, and other techniques, in which incisions are placed in hidden areas, have eclipsed the direct brow excision in popularity.

Problem

Brow ptosis begins as early as the fourth decade of life. It contributes to sagging of the upper eyelid and most often imparts an aged, sad, and tired appearance to the face. Significant upper eyelid hooding may encroach upon the upper visual fields. Brow ptosis and resultant blepharoptosis generates compensatory activity of the frontalis muscle, which, over time, can create horizontal rhytides across the forehead and may contribute to ocular fatigue and headaches. The brow may descend to below the level of the supraorbital ridges.

No single ideal brow appearance is applicable for all patients. Women generally desire thin brows that lie slightly above the supraorbital ridge, with the apex of the arch lateral to the mid pupil. Men typically desire brows that lie at the level of the supraorbital rim and that are less arched. Ethnic variations in desired brow position and shape also must be considered when planning surgery for brow ptosis.²

Frequency

Members of the American Society of Plastic Surgeons performed 43,705 forehead lifts in 2003.³ This number increased to 112,933 in 2008.⁴ The number of direct brow lifts performed is unknown.

Etiology

The main etiologic factors in brow ptosis are senescence and gravity. The aging face undergoes a loss of tone from a diminution in the amount of elastic fibers, glycosaminoglycans, and collagen in the skin. Loss of underlying fascial and muscle support occurs, and opposition to the forces of gravity is diminished. Because the lateral brow has fewer attachments to the periosteum and has no underlying frontalis muscle, it usually descends more than the medial brow.⁵

Pathophysiology

See Etiology.

Presentation

Patients typically present with concerns related to a facial appearance that is aged, tired, or sad. Lateral support is reduced, and more ptosis develops in the lateral brow than in the medial area.

Functional sequelae of brow ptosis, such as deficits in the visual field, headaches, or ocular fatigue, are less common.

For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article BOTOX® Injections.

Indications

Major reasons for performing a direct brow lift include (1) improvement in a visual-field deficit caused by overhanging eyebrow skin, (2) relief of ocular fatigue caused by compensatory overactivity of the frontalis muscle, (3) improvement in cosmetic appearance, and (4) requirement for a simple, expedient procedure. The cosmetic indication is tempered by the creation of scars above the eyebrows. This may be a secondary consideration for patients with marked brow asymmetry after previous traumatic injury.

Direct brow excision is best used in middle-aged or older men with male-pattern baldness, thick eyebrows, and lateral hooding, as depicted in Image 1.⁶

Direct brow lift. Typical patient for direct brow excision (McKinney, 1991). Courtesy of Springer-Verlag. Used with permission.

Patients who use a thick brow pencil to create the brow also may be candidates because they can conceal the scar with makeup. Scarring may be more obvious in patients with fair-colored eyebrow hair.

Specific physical findings that can be better addressed by other methods of brow lifting include ptosis of the forehead and medial eyebrows, transverse forehead wrinkles, vertical glabellar frown lines, transverse wrinkles at the root of the nose that become exaggerated when the forehead is manually depressed, and a drooping nose.

Relevant Anatomy

The tissue layers of the forehead include the skin, subcutaneous tissue, superficial galea, frontalis muscle, deep galea, loose areolar tissue, and periosteum. The forehead component of the superficial musculoaponeurotic system is the frontalis muscle with its galeal sleeve. The direct brow lift is an open technique with dissection in a plane superficial to the frontalis and orbicularis muscles, whereas in the bicoronal, midforehead, and endoscopic techniques, the dissection is performed in a subcutaneous, subgaleal, or subperiosteal layer.^7,8,9,10

The primary elevators of the brow are the paired frontalis muscles. They are vertically oriented and originate from the epicranial galea at the level of the anterior hairline, cover most of the forehead, and insert into the dermis of the lower forehead skin. The main eyebrow depressors are the corrugator supercilii, procerus, and orbicularis oculi muscles.⁵

The 3 nerves on each side of the forehead that are preserved during a direct brow lift are the (1) supraorbital nerve, (2) supratrochlear nerve, and (3) temporal (frontal) branch of the facial nerve. The supratrochlear nerve traverses the most medial aspect of the supraorbital rim and innervates the ipsilateral corrugator muscle. The nerve travels through the corrugator and is easily cut when the muscle is sectioned to treat frown lines.

The supraorbital nerve travels somewhat more laterally over the medial supraorbital rim and divides into 2 branches. The deep branch travels laterally and then superiorly to reach the central frontoparietal scalp and vertex, coursing in a plane between the periosteum and the galea.¹¹ The superficial branch of the supraorbital nerve divides several times and innervates the central forehead and hairline, coursing through and across the anterior aspect of the frontalis. Both the supraorbital and supratrochlear nerves can be damaged when they leave their bony foramina, where they are more adherent and less easily moved or stretched.¹²

Direct brow lift. Innervation by the supraorbital and supratrochlear nerves (Seckel, 1994). Courtesy of Quality Medical Publishing. Used with permission.

The temporal (frontal) branches of the facial nerve enter the forehead within 2 cm of the lateral orbital rim, traveling just under the temporoparietal fascia to enter the frontalis muscle laterally; however, one cadaver study found the nerve to course as high as 4 cm above the lateral canthus.^13,14

The limited dissection of the direct brow lift avoids the supraorbital and supratrochlear nerves, although removing too much subcutaneous tissue laterally can injure the frontal branch of the facial nerve.

While the ideal brow position varies depending on sex and ethnicity, Ellenbogen and Westmore described general criteria for eyebrow position and contour that are helpful when planning and performing the brow lift.¹⁵ See Image 3, which corresponds to the following:

Direct brow lift. Ideal brow position.

The brow should begin medially at a vertical line extending from the ipsilateral alar base and medial canthus (line A-E).
The brow should end laterally at an oblique line extending through the ipsilateral alar base and lateral canthus (line B-E).
The medial and lateral ends of the eyebrow should lie at approximately the same horizontal level (line A-B).
The apex of the brow should lie directly above the lateral limbus of the eye (line C-D).
The brow should arch above the supraorbital rim in women and lie approximately at the level of the rim in men.

These criteria are easier to meet with the direct brow lift than with other procedures because the brow can be precisely positioned on the forehead.¹⁶

Contraindications

Patients who cannot tolerate a scar above the eyebrow are not candidates for the procedure. Inadequate upper eyelid skin is a contraindication to any brow lift; the dearth of eyelid skin is often the result of a previous resection for upper eyelid ptosis, without the realization that a brow lift was indicated.

Workup

Laboratory Studies

Although usually unnecessary, a complete blood cell count and coagulation profile may be obtained at the discretion of the involved surgeon and anesthesiologist, following generally accepted medical guidelines based on age and clinical conditions.

Imaging Studies

Preoperative photographs should be obtained as before any cosmetic procedure.

Other Tests

A general medical evaluation and clearance for local anesthesia with sedation should be performed, as in all patients undergoing elective facial aesthetic procedures. Medications that may inhibit coagulation or wound healing are stopped at the appropriate interval before surgery. Patients with significant visual impairment may warrant referral to an ophthalmologist.

Treatment

Medical Therapy

The only medical therapy currently available is the injection of botulinum toxin A (BOTOX®). Anticholinergic denervation with botulinum toxin A effects a temporary (3-6 mo) elevation of the medial or lateral eyebrow after selective injections into the forehead muscles.¹⁷

Surgical Therapy

The many surgical techniques available for brow lifts are reviewed elsewhere (see Introduction). The direct brow lift is the oldest, simplest, and most expedient of the surgical approaches. Its main advantages over the other techniques include better control of brow position and shape and a less invasive surgical dissection. The risks of hematoma, nerve injury, and hair loss may be lower. Disadvantages of the direct brow lift include a visible scar, even when placed directly above the eyebrow hairs, and poor correction of medial brow ptosis.^7,18,19,5,20

Preoperative Details

The extent of the planned resection is marked with the patient sitting upright and with the eyebrows relaxed and ptotic. The brows are elevated to a desired position by the surgeon, and the amount of necessary elevation (and the related width of skin excision) is noted. If excess upper lid skin is present even after manual elevation of the brow, optimal correction likely mandates a blepharoplasty in combination with the brow lift.

The medial and lateral extent of the incision depends on the degree of brow ptosis and the amount of sagging tissue in the lateral orbital area. Generally, the incision is made over the lateral two thirds of the brow. Scarring is more obvious in the glabellar area, and, if possible, avoid medial extension of the incision. The inferior marking follows the curve of the brow, and the superior marking, which forms the curve of the brow, is varied as needed, eg, to create a lateral arch.⁷

Marking for direct brow lift.

Direct brow lift. Preoperative marking for eyebrow ptosis after partial facial nerve resection.

Although the dissection should be performed superficial to the course of the supraorbital and supratrochlear nerves, visualizing the danger zone through which they pass is helpful. A circle with a radius of 1.5 cm drawn around the supraorbital foramen (above the mid pupil) encompasses the course of the nerves.¹²

Intraoperative Details

While some variations have been described, the overall surgical technique is relatively simple and rapid.^7,18,19,5 Lidocaine 1-2% with 1:200,000-400,000 epinephrine is infiltrated beneath the area to be excised, causing the subcutaneous tissue to lift away from the frontalis. This helps minimize the chance of injury to nerves or vessels during the dissection. After infiltration, the area may be massaged gently for 5 minutes, allowing enough time for vasoconstriction and anesthesia.

The marked area is excised, and the dissection is performed with scissors to the level of the frontalis muscle. The lower incision is beveled to preserve the fine brow hair. The upper incision can be beveled to match the lower incision to ensure a seamless closure.

Direct brow lift. Excision to the level of the frontalis.

Direct brow lift. Beveling the incision.

The skin dissection is in the subcutaneous plane, avoiding injury to underlying muscle and fine neurovascular structures. Careful excision of tissue from the lateral third of the brow helps avoid injury to the temporal (frontal) branch of the facial nerve coursing up towards the frontalis.

Direct brow lift. Injury to the temporal (frontal) branch of the facial nerve in a patient referred for treatment.

The lower skin margin is dissected off the underlying orbicularis oculi muscle for approximately 2 mm inferiorly to help evert the edge for wound closure. Some surgeons elevate the upper skin margin in a subcutaneous plane for approximately 1.5 cm; others do little or no undermining. Electrocautery is used for hemostasis. Respecting the locations of the supraorbital and supratrochlear nerves helps to avoid conducted thermal injury.

Fixation of the orbicularis oculi may prevent recurrence of the ptosis. The upper margin of the muscle is tacked superiorly to either the frontal periosteum or the frontalis fascia with several permanent sutures; fixation to the frontalis is exaggerated by 1-2 mm to compensate for postoperative settling.²¹

Direct brow lift. Fixation of brow and closure.

Some surgeons fix the eyebrow dermis rather than the orbicularis.²² Fixation should cause the wound edges to almost meet. The subcutaneous layer is usually closed with deep dermal absorbable sutures, and the skin is closed in a separate layer. Many surgeons use interrupted nylon vertical mattress sutures to ensure eversion of the wound edges.

Direct brow lift. Placement of deep dermal sutures.

Direct brow lift. Closed wound.

Postoperative Details

Antibiotic ointment is applied to the suture line, and the incisions are covered with sterile, nonadherent dressing. Cold compresses for the first 24-48 hours help reduce swelling around the incision. Sutures may be removed after 5 days. The healing scar may be camouflaged with cosmetic makeup 7-10 days after surgery. The scar typically matures and fades after 6-12 months.

Over the past several years, the movement to integrate traditional Western medical practice with complementary and alternative therapies from other perspectives has grown rapidly. Surveys conducted 10 years ago of cancer patients from 13 countries, including 5 patients from the United States, revealed that approximately 31% used these therapies. This number is undoubtedly higher today. The notion that patients can influence health with their minds is an appealing concept for many Americans. It affirms the power of the individual, a basic value of American culture. Some mind-body interventions have already moved into mainstream medicine, such as meditation, biofeedback, and yoga.^23,24

Therapies such as acupuncture, homeopathy, and guided imagery have exploded in popularity, especially among cancer patients. Many hospitals and universities have established presurgical programs to help patients achieve better surgical results and lessen emotional and psychological stress. Well-established benefits include reductions in anxiety, discomfort, and pain; reduced length of hospital stay; and improved coping skills. Similar programs can be established in smaller community settings, such as an outpatient plastic surgery practice.

Complications

The complication rate is generally low. Hematomas usually resolve spontaneously. Overcorrection of the brow position or loss of movement of the brow can result in the patient having a look of perpetual surprise, particularly if the brow has been fixed to the underlying periosteum. Undercorrection occurs when skin resection was insufficient or fixation of the underlying tissues was poor. Contour irregularities can be avoided by limited undermining of subcutaneous tissue. Hypesthesia, if it occurs, usually resolves in 6 months. Even less likely is numbness or painful dysesthesias of the forehead, scalp, upper eyelid, and nasal dorsum.^7,18,12,5 Injury to the temporal branch of the facial nerve is also possible.

Outcome and Prognosis

The incision usually fades into what appears to be a natural skin crease above the brow.

Future and Controversies

The direct brow lift is unlikely to undergo further development. It is the easiest and most rapid method of lifting the brow, at the expense of leaving a visible scar. It is an effective reconstructive technique, but its use as an aesthetic procedure should be eschewed. The other methods of brow lifting are constantly undergoing revision and improvement and are reviewed elsewhere (see Introduction).

Multimedia

Media file 1: Direct brow lift. Typical patient for direct brow excision (McKinney, 1991). Courtesy of Springer-Verlag. Used with permission.

Media file 2: Direct brow lift. Innervation by the supraorbital and supratrochlear nerves (Seckel, 1994). Courtesy of Quality Medical Publishing. Used with permission.

Media file 3: Direct brow lift. Ideal brow position.

Media file 4: Marking for direct brow lift.

Media file 5: Direct brow lift. Preoperative marking for eyebrow ptosis after partial facial nerve resection.

Media file 6: Direct brow lift. Excision to the level of the frontalis.

Media file 7: Direct brow lift. Beveling the incision.

Media file 8: Direct brow lift. Injury to the temporal (frontal) branch of the facial nerve in a patient referred for treatment.

Media file 9: Direct brow lift. Fixation of brow and closure.

Media file 10: Direct brow lift. Placement of deep dermal sutures.

Media file 11: Direct brow lift. Closed wound.

References

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Thorne CHM, Aston SJ. Forehead/brow lift. In: Aston SJ, Beasley RW, Thorne CHM, eds. Grabb and Smith's Plastic Surgery. Philadelphia, Pa: Lippincott Williams & Wilkins; 1997.
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Keywords

brow lift, direct brow lift, brow ptosis, forehead ptosis, ptotic brow, brow wrinkles, brow rhytid, brow rhytide, face lift, facelift, direct brow excision, blepharoplasty

Contributor Information and Disclosures

Author

Daniel N Ronel, MD, FAAP, FACS, Clinical Assistant Professor, Department of Pediatrics, Division of Plastic Surgery, University of New Mexico School of Medicine; Consulting Staff, New Mexico Plastic Surgery, St Vincent Surgical Group
Daniel N Ronel, MD, FAAP, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Martin I Newman, MD, FACS, Consulting Surgical Staff, Department of Plastic and Reconstructive Surgery, Associate Program Director and Educational Director of Plastic Surgery Resident Program, Department of Plastic Surgery, Cleveland Clinic Florida
Martin I Newman, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Florida Medical Association, Florida Society of Plastic Surgery, International Confederation for Plastic and Reconstructive Surgery, Southeastern Society of Plastic and Reconstructive Surgeons, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Anthony Labruna, MD, Assistant Professor, Department of Otolaryngology, Department of Surgery and Plastic Surgery, Cornell University Medical Center
Anthony Labruna, MD is a member of the following medical societies: American Medical Association and American Rhinologic Society
Disclosure: Nothing to disclose.

Mia Talmor, MD, Assistant Professor, Department of Surgery, Weill Medical College of Cornell University
Mia Talmor, MD is a member of the following medical societies: American College of Surgeons and American Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

R C A Weatherley-White, MD, Associate Clinical Professor of Surgery (Plastic), University of Colorado; Medical Director, Department of Plastic Surgery, Columbia Rose Medical Center
R C A Weatherley-White, MD is a member of the following medical societies: American Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society for Aesthetic Plastic Surgery, Colorado Medical Society, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center
Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Further Reading