eMedicine Specialties > Plastic Surgery > Brow Lift
Brow Lift, Pretrichial Lift: Treatment
Updated: Mar 14, 2008
Treatment
Intraoperative Details
The operation is performed under monitored or general anesthesia. The hair is secured with rubber bands to expose the incision site; shaving is not necessary. A mixture of 1% Xylocaine and 1:100,000 adrenaline is injected along the incision site after appropriate cleaning and draping.
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. Injudicious cautery use for hemostasis damages hair follicles with risk of alopecia.
The incision is deepened to the subgaleal plane in the frontal region. Undermining at this level in this region is relatively avascular. In the temporal region, the incision is deepened to the level of the deep temporal fascia and undermining is performed at this subtemporoparietal fascia/supra deep temporal fascia level. At or around the region of the anterior temporal hairline, transition is affected between the subgaleal plane anteriorly and the supra deep temporal fascial plane laterally. This affords maximum protection to the frontal division of the temporal branches of the facial nerve.
Anteroinferiorly, the supraorbital rim is identified along with the supratrochlear and supraorbital nerves. The former nerve may be hidden by the corrugator supercilii muscles, but gentle vertical spreading dissection with scissors displays its presence. The corrugator supercilii and procerus muscles are transected using bipolar electrocautery.
Some authors advise weakening the frontalis muscle. Exercise caution, as trauma may occur to both the motor and sensory nerves. Lateral to the supraorbital nerves, the periosteum may be incised and the dissection carried subperiosteally to expose the orbital fat. The rim periosteum is freed in this region to the level of the zygomaticofrontal suture. This allows better placement of the lateral hooding of the upper eyelid.
The entire flap is advanced posterocephalically and the excess trimmed to close without tension. The lateral eyebrow position is initially set with a single staple on each side. In the absence of excessive bleeding, no drains are used.
The incision is closed with 4-0 Dexon to the galea. For scalp skin, 6-0 Prolene sutures are used in the frontal region, and staples are used in the hair-bearing region. A light pressure dressing is applied.
A more conservative approach has been described by Aldo.2
Postoperative Details
Oral acetaminophen may be used for pain, which is usually minimal.
Follow-up
The wound is examined on the first postoperative day. Sutures are removed on the fifth postoperative day. Staples may be removed on the 10th postoperative day.
For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Black Eye.
Complications
No surgeon or operation is devoid of complications. Encountered complications specific to the brow lift operation may be enumerated as follows:
Hematoma formation
Minor or major hematomas may occur, usually within 12 hours of operation. Expanding ecchymosis, edema, and pain provoke suspicion. Neglected hematomas may cause skin necrosis and scarring. Minor hematomas may be dealt with by aspiration with an 18-gauge needle, while major hematomas may require flap re-elevation and exposure of the bleeder for appropriate action.
Infection
Because of the excellent blood supply, infection is rare. Appropriate antibiotic coverage is indicated should infection occur.
Facial nerve impairment
The frontal division of the temporal branches of the facial nerve provides motor innervation to the forehead. Unilateral trauma causes brow asymmetry at rest and aggravation of this asymmetry on volition. Immediate facial nerve palsy may be related to the local anesthesia. Neurapraxia may last several months, and aesthetic relief during this time may be provided by botulinum injection on the contralateral side. If recovery fails, a contralateral neurectomy may be considered after 18 months.
Sensory nerve impairment
The supratrochlear and supraorbital nerves, which are divided at the site of incision by necessity, provide sensory innervation. This causes numbness cephaloposterior to the incision, which tends to resolve in 3-6 months. Be aware of avoiding permanent damage to these nerves, particularly around the orbital rim, during surgery.
Alopecia
Alopecia may be temporary or permanent. Avoiding injudicious cautery to the incision edges and thus damage to the skin follicles may reduce permanent alopecia. Excessive skin tension closure also may contribute to this complication.
Eye complications
Postoperative lagophthalmos predisposing to corneal ulceration is a disaster. Careful preoperative assessment is necessary, especially if a concomitant upper lid blepharoplasty is planned.3 It is advisable to do the "brow before bleph" to plan exactly how much eyelid skin to excise without risk of ectropion.
Unsightly scarring
Undue tension on the incision leads to an unsightly scar that may need aesthetic correction.
Contour irregularities
Contour irregularities may arise from overzealous resection of soft tissue, particularly the frontalis muscle. Filler substances may correct the problem.
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References
McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg. Spring 1991;15(2):141-7. [Medline].
Aldo Mottura A. Open frontal lift: a conservative approach. Aesthetic Plast Surg. Jul-Aug 2006;30(4):381-9. [Medline].
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. Nov-Dec 1996;20(6):453-62. [Medline].
Connell BF, Lambros VS, Neurohr GH. The forehead lift: techniques to avoid complications and produce optimal results. Aesthetic Plast Surg. Fall 1989;13(4):217-37. [Medline].
Ellenbogen R. Transcoronal eyebrow lift with concomitant upper blepharoplasty. Plast Reconstr Surg. Apr 1983;71(4):490-9. [Medline].
Kaye BL. The forehead lift: a useful adjunct to face lift and blepharoplasty. Plast Reconstr Surg. Aug 1977;60(2):161-71. [Medline].
Koch RJ, Troell RJ, Goode RL. Contemporary management of the aging brow and forehead. Laryngoscope. Jun 1997;107(6):710-5. [Medline].
Tower RN, Dailey RA. Endoscopic pretrichial brow lift: surgical indications, technique and outcomes. Ophthal Plast Reconstr Surg. Jul 2004;20(4):268-73. [Medline].
Further Reading
Keywords
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