Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pretrichial Brow Lift

  • Author: S Valentine Fernandes, MBBS, MCPS, FRCSEd, FRACS, FACS, LLB; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
 
Updated: Oct 17, 2014
 

Background

The brow lift operation aims to correct the loss of soft tissue elasticity in the upper third of the face, which may lead to ptosis of the brow and hypertonicity of the frontalis, corrugator supercilii, and procerus muscles with subsequent wrinkling of the forehead (see the image below). This confers a look often described as tired. Several techniques are available to correct this occurrence depending on the individual patient's needs and desires.

Preoperative view of forehead of an ideal patient. Preoperative view of forehead of an ideal patient.

The operative nomenclature describes the incision employed or the level of undermining necessary to achieve the result. Of course, it makes more sense to describe the operation using terms to define both the incision used and the level of undermining employed (eg, pretrichial subgaleal brow lift). For information on other brow lift techniques, see the Plastic Surgery Brow Lift section.

Pretrichial denotes an incision in front of the hairline. On a practical note, it is advisable to make the bevelled incision about 2 mm behind the hairline to induce hair growth through the scar and improve cosmesis. See the image below.

Diagram showing preoperative marking: The scalpel Diagram showing preoperative marking: The scalpel incision follows 2 mm behind the hairline in the frontal region and extends into the hair in the temporal region. The lateral extension joins the upper extent of the facelift incision, if a facelift is performed at the same time. The incision is beveled posteroanteriorly.

For expert viewpoints on skin procedures, see Medscape’s Aesthetic Medicine Resource Center.

Next

Problem

Aesthetically, the face is divisible into 3 equal parts, of which the forehead (from the top of the eyebrow to the anterior hairline) occupies the upper third. In males, this area averages 7 cm; in females, it averages 5 cm. In Caucasians, in the ideal situation, the medial extent of the eyebrow lies over a line extrapolated upward from the nasal ala to the medial canthus. The lateral extent of the eyebrow lies over a similar line extrapolated upward from the nasal ala to the lateral canthus. The male eyebrow is less arched than the female eyebrow. Maximum arching of the eyebrow occurs in a vertical line with the lateral limbus. The male eyebrow lies at the level of the supraorbital rim; the female eyebrow lies above the rim. The top of the eyebrow lies approximately 2.5 cm from the mid pupil.[1] A lesser distance denotes eyebrow ptosis. With aging, these parameters may shift.

Previous
Next

Pathophysiology

Loss of forehead skin elasticity from genetics, solar damage, and gravity causes eyebrow drooping, with resultant upper eyelid ptosis and visual embarrassment. This causes hypertonicity of the forehead elevator muscles. Aging causes depletion of the subcutaneous fat with resorption of the subjacent skull bone. This leads to forehead wrinkling, the direction of which depends upon the vector of action of the underlying muscle.

Previous
Next

Presentation

Clinical presentation

The patient may state that others describe him or her as having a tired, surprised, worried, or annoyed look. Younger patients may state that they are misconstrued as aged.

Clinical examination

The position of the hairline, eyebrow, and upper eyelids is carefully noted. The role of brow ptosis in causing pseudoblepharoptosis or in adding to blepharochalasis is examined. The examination is performed by manually locating the eyebrow to the ideal position and observing the effect on the upper eyelid. The presence of lagophthalmos is a contraindication to surgery. The sites of forehead wrinkles are recorded along with eyebrow asymmetry, which should be brought to the patient's attention. The patient is counseled on realistic results. If the patient questions the postoperative results, preoperative photodocumentation, apart from self-education, can help the physician demonstrate the results to the patient.

Previous
Next

Indications

The pretrichial incision is indicated in individuals with a forehead section that is aesthetically larger than acceptable. Allowances must be made for impending or foreseeable receding male hairlines, which often require another approach.

Previous
Next

Relevant Anatomy

Forehead region

The layers in the forehead and scalp region include the skin, subcutaneous fat layer, superficial musculoaponeurotic system (SMAS) equivalent termed the galea (which incorporates the paired frontalis muscles and continues laterally to become the temporoparietal fascia), a loose areolar layer, and the periosteum.

The frontalis muscle inserts at the medial supraorbital rim into the upper part of the orbicularis oculi muscle and overlying skin. The paired corrugator muscles, arising from the periosteum at the superomedial aspect of the orbital rim, lie deeper and insert with the frontalis and orbicularis oculi into the skin laterally. The supratrochlear nerves may penetrate the corrugator muscle to emerge on the deep surface of the frontalis muscle. Damage to the nerve may occur at this point during corrugator resection. The procerus muscle lies medial and ventral to the corrugator muscles, arising from the nasal bones and upper lateral cartilages and inserting into the skin between the eyebrows. The supraorbital nerve and vessels usually emerge from the supraorbital notch or canal and continue cephalad in the galea. Occasionally this neurovascular bundle may exit from a foramen cephalad to the orbital rim, demanding caution with blind subperiosteal dissection within 2 cm of the supraorbital rim.

Temporal region

The layers of the temporal region include the skin, subcutaneous fat, temporoparietal fascia (the equivalent of the SMAS layer), temporal fascia, and the temporalis muscle. See the image below.

The fascial planes of the forehead and temple. The The fascial planes of the forehead and temple. The temporal branch of the facial nerve runs within the superficial temporal fascia (ie, temporoparietal fascia).

The temporal fascia overlying the muscle splits into 2 layers that enclose the superficial fat pad before reuniting approximately 1 cm above the superior margin of the zygomatic arch and fusing with the parotidomasseteric fascia below. The deep fat pad is an extension of the masticatory fat pad of Bichat and lies deep to the deeper layer of temporal fascia. The frontal division of the temporal branches of the facial nerve lies in the temporoparietal fascia and is at risk during lateral undermining.

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

Previous
Next

Contraindications

Contraindications to surgery include general systemic instability and bleeding dyscrasias. The patient must discontinue use of aspirin and similar medications at least 2 weeks prior to surgery and for 2 weeks postoperatively. An absolute contraindication is the presence of lagophthalmos. Psychosocial deficiency is carefully assessed. Unrealistic expectations must be dealt with preoperatively.

Previous
 
 
Contributor Information and Disclosures
Author

S Valentine Fernandes, MBBS, MCPS, FRCSEd, FRACS, FACS, LLB Conjoint Senior Clinical Lecturer, Department of Otorhinolaryngology, Newcastle University; Senior Consultant Surgeon, Department of Otorhinolaryngology-Head and Neck Surgery, John Hunter, Warners Bay Private Hospitals, Australia

S Valentine Fernandes, MBBS, MCPS, FRCSEd, FRACS, FACS, LLB is a member of the following medical societies: American College of 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.

References
  1. McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg. 1991 Spring. 15(2):141-7. [Medline].

  2. Aldo Mottura A. Open frontal lift: a conservative approach. Aesthetic Plast Surg. 2006 Jul-Aug. 30(4):381-9. [Medline].

  3. Friedland JA, Jacobsen WM, TerKonda S. Safety and efficacy of combined upper blepharoplasties and open coronal browlift: a consecutive series of 600 patients. Aesthetic Plast Surg. 1996 Nov-Dec. 20(6):453-62. [Medline].

  4. Guyuron B, Gatherwright J, Totonchi A, et al. Cessation of hairline recession following open forehead rejuvenation. Plast Reconstr Surg. 2014 Jan. 133(1):1e-6e. [Medline].

  5. Connell BF, Lambros VS, Neurohr GH. The forehead lift: techniques to avoid complications and produce optimal results. Aesthetic Plast Surg. 1989 Fall. 13(4):217-37. [Medline].

  6. Ellenbogen R. Transcoronal eyebrow lift with concomitant upper blepharoplasty. Plast Reconstr Surg. 1983 Apr. 71(4):490-9. [Medline].

  7. Kaye BL. The forehead lift: a useful adjunct to face lift and blepharoplasty. Plast Reconstr Surg. 1977 Aug. 60(2):161-71. [Medline].

  8. Koch RJ, Troell RJ, Goode RL. Contemporary management of the aging brow and forehead. Laryngoscope. 1997 Jun. 107(6):710-5. [Medline].

  9. Tower RN, Dailey RA. Endoscopic pretrichial brow lift: surgical indications, technique and outcomes. Ophthal Plast Reconstr Surg. 2004 Jul. 20(4):268-73. [Medline].

 
Previous
Next
 
Schematic sagittal section through forehead in the frontal region.
Schematic dissection in the loose areolar tissue (subgaleal) plane in the frontal region. View from cephalic aspect.
The supratrochlear nerve branches penetrating through the corrugator muscle are shown. The orbicularis oculi muscle has been reflected downward, and the periosteum has been incised superiorly.
The superficial temporal artery and its subdivisions above the level of the zygoma lie in the superficial musculoaponeurotic system layer.
Schematic representation of the frontal division of the temporal branches of the facial nerve around the zygoma region. The deep layer of the temporal fascia separates the superficial fat pad from the deep fat pad.
Diagram showing preoperative marking: The scalpel incision follows 2 mm behind the hairline in the frontal region and extends into the hair in the temporal region. The lateral extension joins the upper extent of the facelift incision, if a facelift is performed at the same time. The incision is beveled posteroanteriorly.
Preoperative view of forehead of an ideal patient.
Postoperative view of same patient following pretrichial brow lift.
The fascial planes of the forehead and temple. The temporal branch of the facial nerve runs within the superficial temporal fascia (ie, temporoparietal fascia).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.