eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Browplasty

J David Kriet, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Director of Facial Plastic and Reconstructive Surgery, University of Kansas School of Medicine
Paulino E Goco, MD, Consulting Staff, Division of Facial Plastic and Reconstructive Surgery, Middle Tennessee Ear, Nose and Throat

Updated: Nov 25, 2008

Introduction

Facial aging is a multifactorial process that is especially prominent in the upper third of the face. Techniques for brow rejuvenation have evolved over the years and must be individualized for each patient. A careful analysis of the patient's sex, age, physical attributes, and expectations must be taken into account when planning rejuvenation procedures. The trend toward minimizing incisions and reducing scars has led to the development of advanced procedures in brow rejuvenation surgery.

Problem

Descent of the soft tissues overlying the skeletal supraorbital rim leads to brow ptosis, rhytide formation, dermatochalasia, and a tired and aged appearance. Some patients primarily have cosmetic concerns, while others with more severe brow ptosis experience functional visual-field impairment.

Frequency

Brow ptosis is frequently observed in patients presenting for upper eyelid blepharoplasty. If overlooked, aesthetic and functional outcomes will be suboptimal.

Etiology

Many factors contribute to aging of the upper face and brow. Signs of upper facial aging clinically appear approximately at age 34-39 years. Intrinsic factors, such as skin elasticity and pigmentation or other hereditary conditions, influence the degree and rapidity of the aging process. Extrinsic factors, including gravity and other more controllable factors (eg, sun exposure, smoking), may greatly increase an individual's aging. Facial paralysis, whether idiopathic, traumatic, or iatrogenic, usually produces dramatic brow ptosis and may be unilateral or bilateral.

Pathophysiology

Brow elevator and depressor musculature is not in balance with the depressors, with the orbicularis oculi, corrugator supercilii, and procerus muscles predominating. These muscles exert their effect over the entire length of the brow. The sole brow elevator is the frontalis muscle, which is deficient laterally. This lack of lateral brow elevation in the continued presence of lateral brow depression (ie, orbicularis oculi) results in more pronounced descent of the lateral brow.

Presentation

Most patients begin to develop faint horizontal rhytides in the third decade of life. By the fourth decade, descent of the lateral brow is noticeable, and as time passes, further descent of the medial brow occurs. As the brow continues its inevitable descent, patients rely on the frontalis muscle to elevate the brow and associated upper eyelid skin out of the visual field. This leads to even deeper horizontal rhytides.

Frontalis hyperactivity must be noted prior to periorbital surgery. Further brow descent after performing upper eyelid blepharoplasty alone in the patient with unrecognized brow ptosis is not uncommon.

Indications

Each patient presenting for cosmetic or functional eyelid surgery should be evaluated for brow ptosis. Treatment of the brow should accomplish the following goals:

• Elevate ptotic eyebrows
• Reduce redundant upper eyelid skin
• Correct eyebrow asymmetry
• Reduce forehead rhytides
• Reduce glabellar rhytides
• Reduce lateral canthal smile lines or crow's feet
• Elevate the forehead aesthetic unit
• Modify the hairline (if desired)

Relevant Anatomy

Brow aesthetics

The ideally proportioned forehead occupies one third of the facial height as measured from the hairline to the glabella. The brow in women should have a gently arching shape and should lie just above the orbital rim. Some debate exists as to the ideal shape, but most surgeons agree that the highest point of the brow should lie between the lateral limbus and lateral canthus. The lateral aspect of the brow is higher than the medial aspect and parallels the free margin of the lateral upper eyelid. It should end along an oblique line connecting the lateral canthus and lateral nasal ala (see Image 1).

Anatomy

The brow and forehead are a single contiguous anatomical structure. The forehead and scalp have 5 layers, the terms for which can be remembered by the acronym SCALP, as follows:

• Skin
• Subcutaneous tissue
• Aponeurosis
• Loose areolar tissue
• Periosteum

The facial skin in the forehead is the thickest of the entire face and has very little subcutaneous adipose tissue. Many tenuous fibrous septa connect the underlying musculature to the forehead and brow skin. These strong attachments and the lack of subcutaneous adipose tissue account for the relative immobility of the brow and forehead skin and also contribute to early development of rhytides.

The blood supply to this area is provided by both the internal carotid and external carotid systems. The terminal branches of the external carotid (superficial temporal artery) supply the lateral aspect of the brow and forehead. The supraorbital and supratrochlear branches, fed by the internal carotid system, supply the medial forehead and scalp. The 2 vascular systems freely interconnect, providing robust blood supply to the region.

All 3 divisions of the trigeminal nerve contribute to brow and forehead sensory innervation. The first division gives rise to the supratrochlear and supraorbital nerves. Medial brow sensation is provided by the supratrochlear nerves (see Image 2). The lateral brow, to the vicinity of the temporal line and posteriorly to the vertex, is supplied by the supraorbital nerves. The second division of the trigeminal nerve supplies the anterior aspect of the temporal region via the zygomaticotemporal nerve. The posterior aspect of the temporal area receives its sensory innervation from the auriculotemporal nerve, a branch of the third division of the trigeminal nerve.

The musculature of this region can be grouped into brow depressors or elevators. Brow depressors predominate and include the orbicularis oculi, corrugators, and procerus. Brow elevation is accomplished only by the frontalis muscle. The orbicularis muscle is an oval-shaped muscle originating from the medial palpebral ligament, the frontal process of the maxilla, and the nasal process of the frontal bone. It inserts into the lateral palpebral raphe, the frontalis muscle, the corrugator muscle, and the superior and inferior tarsal plates. The muscle is supplied by the temporal and zygomatic branches of the facial nerve.

Contraction of the orbicularis muscles closes the eyes, and, over time, it causes prominent crow's feet, rhytides emanating from the lateral canthus. The orbicularis muscle action also contributes to lateral brow ptosis and hooding. Brow ptosis is usually more severe laterally because this region of the brow has no corresponding elevator. The corrugator supercilii muscle, which lies deep to the frontalis and orbicularis muscle, arises from the medial orbital rim and inserts into the dermis covering the supraorbital foramen or notch (see Image 3). Contraction of this muscle draws the brow inferomedially and produces the vertically oriented glabellar frown line.

The corrugators are innervated by the temporal and zygomatic nerves. The procerus muscle originates on the inferior portion of the nasal bones and inserts into the dermis above the glabella. Contraction of the procerus causes inferior descent of the medial brow and produces a horizontally oriented rhytide. The buccal branch of the facial nerve innervates the procerus.

The single elevator is the frontalis muscle. The frontalis muscle is the anterior portion of the epicranius muscle and is not attached to bone. The fibers originate from the superficial periorbital musculature (ie, corrugators, procerus, orbicularis oculi) and insert into the galea aponeurotica just anterior to the coronal suture. The frontalis muscle raises the brow and produces the horizontal wrinkles of the forehead. The muscle fibers are located laterally only to approximately the level of a vertical line drawn through the lateral canthus. The temporal branch of the facial nerve innervates this muscle.

A very important landmark of the region is the temporal fascia. The temporalis muscle is covered by a dense, tough fascia known as the deep temporal fascia. The deep temporal fascia is continuous with the periosteum of the skull at the temporal line known as the conjoint tendon. The deep temporal fascia splits into superficial and deep layers a few centimeters above the zygomatic arch. Between these 2 layers of fascia is the superficial temporal fat pad.

Superficial to the deep temporal fascia is another distinct fascial layer called the superficial temporal fascia or temporoparietal fascia (see Image 4). It lies immediately deep to the dermis and is continuous with the galea aponeurotica above and the superficial musculoaponeurotic system below. A distinct avascular plane containing fine, wispy fascial fibers separates the temporoparietal fascia from the deep temporal fascia. The superficial temporal artery, vein, and temporal branch of the facial nerve all lie within the temporoparietal fascia. The temporal branch of the facial nerve consistently courses along a line projected from a point 0.5 cm inferior to the tragus to a point 1.5 cm above the lateral aspect of the eyebrow.

Contraindications

Browplasty has few absolute contraindications. Care must be observed when the patient has had prior upper eyelid blepharoplasty. If excessive skin was excised during the blepharoplasty, subsequent elevation of the brow to the ideal location may result in lagophthalmos and corneal exposure. This further emphasizes the need to evaluate the entire brow and periorbital area preoperatively. Browplasty with conservative upper eyelid blepharoplasty generally produces more favorable outcomes than aggressive blepharoplasty alone.

Workup

Laboratory Studies

• In general, only studies indicated to evaluate underlying medical conditions and ensure safe anesthesia are necessary. Routine preoperative blood work is not obtained.

Other Tests

• Visual-field testing
  • Visual field testing may be helpful for documenting the severity of brow ptosis.
  • During testing, 2 sets of visual fields are obtained, one with the brow in the relaxed, ptotic state and one with the brow in the elevated (ie, taped) position.
  • Improvement in the visual field is then documented (see Images 5-7).
  • This test is generally reserved for patients with functional brow ptosis and is sometimes required by insurance carriers as part of the precertification process.

Treatment

Medical Therapy

Management of the aging and ptotic brow is primarily surgical. However, recent experience with botulinum toxin has shown that some elevation of the lateral brow is possible after treatment with the neuromuscular blocking agent. Botulinum toxin is also being evaluated as an adjunct to endoscopic browlift. Dyer and Yung reported their early experience injecting botulinum toxin into the brow depressors 2 weeks prior to surgical elevation.¹ Preoperative chemical paralysis of brow depressor function is thought to promote readherence of the brow periosteum in the elevated position.

Nonsurgical techniques

Studies have shown that dermal monopolar radiofrequency treatments using Thermage Thermacool (Hayward, Calif) can produce browlifting. The response to treatments can be variable with the current technology, but essentially no downtime or wound care is needed. Patients can expect a 5-20% improvement. Realistic expectations by the provider and patient are mandatory for a successful outcome. In a study by Nahm et al, at the end of 3 months an average of 4.3 mm of brow elevation was elicited.² Additional technologies, such as the Titan Procedure (Cutera, Brisbane, Calif) and Polaris RF (Syneron, Ontario, Canada), also use thermal energy to cause browlifting that does not require surgical intervention.

Minimally invasive techniques

•  Tissue volume loss around the periorbital area accounts for the development of brow ptosis. Various injectable materials, whether the patient's own fat or a hyaluronic acid material, such as Restylane (Medicis Aesthetics Inc, Scottsdale, Ariz), can effectively cause brow elevations. Sculptra (Sanofi-Adventis) has been approved as a treatment of lipoatrophy by the Food and Drug Administration (FDA). Sculptra is an injectable poly-L-lactic acid that is used to restore volume to facial soft tissue. Increases in dermal thickness using Sculptra have been shown to last for up to 2 years in clinical studies. The lateral brow is filled with the injectable material to produce the browlift. Different types of fillers can be used to achieve this effect as more become available. One must be cognizant of surrounding vascular structures to avoid blindness and tissue injury.
•  Suture suspension techniques, known as the thread lift, are very popular with patients. The promises of minimal anesthesia, less postoperative downtime, fewer serious risks, and lower cost compared with surgical procedures are very appealing to the lay person. Barbed polypropylene sutures are used to lift the brow tissue. In 2004, the FDA approved the Contour ThreadLift with patented Contour Threads suture, which was introduced by Dr. Gregory Ruff, M.D. The ideal candidate has a moderate amount of skin and brow laxity that moves easily with minimal manipulation. The procedure can be done with just local anesthesia. Again, patient selection and realistic expectations are requirements for a good outcome.

Surgical Therapy

Numerous surgical approaches to browplasty are available. As with any facial aesthetic procedure, an excellent outcome in browplasty begins with a careful analysis of the patient's face. The appropriate technique is then chosen and tailored to enhance the patient's natural features.

Preoperative Details

Standardized photographs of every patient are obtained prior to surgery. Full frontal and close-up periorbital views are essential, and oblique and lateral periorbital views are helpful.

The patient is seen in consultation shortly before surgery to answer any questions arising since the initial visit. At this visit, the planned procedure is discussed, including incision design, risks, benefits, alternatives, and expected postoperative course. Aspirin, nonsteroidal anti-inflammatory medication, vitamin E, and ginkgo cessation is confirmed. The patient is instructed to wear loose-fitting clothing and to have a responsible family member or friend available for transportation and observation during the first 24 hours.

Preoperative markings in the sitting position are made prior to the patient's arrival to the surgical suite. The photographs are again reviewed and any asymmetry is noted. Prophylactic antibiotics and dexamethasone are administered prior to the start of the procedure.

Intraoperative Details

Anesthesia

Most browlift procedures are easily performed with the patient under intravenous sedation supplemented with local anesthesia. General anesthesia is also an excellent alternative. Local anesthesia containing epinephrine (1% lidocaine with 1:100,000 epinephrine mixed with an equal volume of 0.25% bupivacaine) is infiltrated along all incision lines after performing supraorbital and supratrochlear nerve blocks. Injection is performed prior to sterile preparation to allow adequate time for vasoconstriction.

The various options for browplasty are highlighted below.

Although endoscopic browlift is currently the preferred technique of many surgeons, coronal browlift and its variations have long been considered the criterion standard forehead rejuvenation procedure (see Images 8-9). The procedure allows complete access to the frontalis, corrugator, and procerus musculature, and the incision is completely hidden within the hair. Because the incision is placed in the hair-bearing scalp, elevation of the hairline is an unavoidable consequence. For this reason, patients selected for this approach ideally should have a low hairline. In the properly selected patient, this elevation can improve facial proportion. The incision in this approach is also longer than in any other brow rejuvenation technique; therefore, postoperative hypoesthesia may be more pronounced.

• Incision placement: The incision is placed so that it will lie 2-4 cm behind the hairline following excision of excess scalp. The incision courses posteriorly in the temporal regions and extends inferiorly to the level of the superior auricle. The incision can easily be connected to preauricular facelift incisions when both procedures are performed concomitantly. Take care to bevel the incision with the hair follicles, and avoid excess cautery to prevent incisional alopecia.
• Dissection plane: Dissection proceeds easily within the relatively bloodless subgaleal plane. Temporally, take care to dissect close to the superficial layer of the deep temporal fascia and deep to the temporoparietal fascia. This helps prevent injury to the temporal branch of the facial nerve. Centrally, the supraorbital and supratrochlear neurovascular bundles are identified and preserved. The corrugator and procerus muscles are transected if desired.
• Fixation: Excess scalp tissue is excised (generally 1-2 cm), and layered closure is performed with dissolving suture and surgical staples.

Trichophytic Lift

The trichophytic lift is an alternative to the coronal lift and is useful in patients with high hairlines. This technique allows improved fine-tuning of brow asymmetry (see Image 10). It allows ready access to the corrugator and procerus musculature to treat glabellar furrowing. Although the resulting scar is generally barely perceptible, other techniques may be better suited for patients who wear their hair pulled back. Prolonged hypoesthesia of the scalp is possible just as with the coronal lift.

• Incision placement: The incision is placed in a curvilinear fashion within the fine hair of the frontal hairline. Irregularize the incision to aid in scar camouflage. Reverse beveling of the incision preserves hair follicles and promotes hair growth through the incision (see Image 11).
• Dissection plane: Rapid and relatively bloodless elevation of the flap is performed in the subgaleal plane and is no different from the coronal dissection (see Image 12).
• Fixation: Excess tissue is trimmed, taking care to match the beveled incision. Closure is performed in layered fashion with 4-0 polydioxanone interrupted dermal sutures and running 6-0 nylon or fast-absorbing gut. Meticulous attention to detail is essential to maximize the disappearance of this potentially visible scar (see Image 13).
• Pretrichial variant: The pretrichial incision is placed in the non–hair-bearing scalp just inferior to the hairline. This necessarily results in a visible scar. The authors do not routinely use this incision.

This technique is useful in the properly selected patient. It is effective in treating functional brow ptosis and unilateral forehead paralysis, especially in male patients with high hairlines (see Image 14). The ideal candidate has prominent forehead skin creases yet relatively thin nonsebaceous skin to optimize incision camouflage. The dissection is less extensive than in the procedures mentioned above and can be performed under straight local anesthesia if necessary (see Image 15).

Because the incisions are placed relatively close to the brow, asymmetry is relatively easily corrected, and with lateral extension of the incision, temporal hooding can be improved (see Images 16A-B). The course of the temporal branch of the facial nerve must always be respected laterally to avoid inadvertent injury. While brow position can be precisely adjusted, glabellar and horizontal forehead rhytides are not addressed well with this technique.

For further reading, see the eMedicine article Brow Lift, Mid Forehead

• Incision placement: Fusiform incisions are placed above the lateral brow and centered over a prominent horizontal crease. Positioning the incisions at 2 levels maximizes camouflage (see Image 16C).
• Dissection plane: This technique differs from the coronal and trichophytic lifts because dissection is performed in the subcutaneous plane superficial to the frontalis muscle. Dissection proceeds inferiorly to the level of the brow where the horizontal fibers of the orbital orbicularis muscle are readily identified (see Image 16D). Superior undermining is performed only to allow wound edge eversion.
• Fixation: Two or three 4-0 nylon or polydioxanone sutures are placed from the orbicularis muscle to the superolateral forehead periosteum. Take care to preserve a relatively horizontal brow shape in the male patient. Closure is performed in layers with multiple, buried, inverted 5-0 polydioxanone sutures and an everting running 6-0 nylon or fast-absorbing gut skin closure.

A direct browlift is accomplished by excising skin directly above the patient's brow bilaterally. For strictly functional lifting of the brow, this technique is very effective. However, if the incision is not meticulously closed in multiple layers, a noticeable scar may form.

For further reading, please see the eMedicine article Brow Lift, Direct Brow Lift

• Incision placement: A fusiform incision is made along the superior length of each brow. The amount of skin excised should reflect the desired amount of brow elevation. This technique is unique among the other techniques because there is a 1:1 removal of tissue-to-elevation of brow when determining the amount of tissue to excise. The incision is beveled carefully to preserve the fine brow hair.
• Dissection plane: Surgical excision of tissue is made in the subcutaneous plane, preserving the underlying musculature and neurovascular tissues.
• Fixation: Brow elevation is maintained over time by anchoring the superior suture into the lateral brow periosteum. The subcutaneous layer is closed with buried inverted sutures, and the dermis is closed with cutaneous interrupted vertical mattress sutures.

The transpalpebral browlift is a unique and effective procedure. The upper blepharoplasty incision is used to access the supraorbital structures and achieve brow elevation. This technique works very well in men with male-pattern baldness and in patients who require a minimal lift or fixing of the brow.

• Incision placement: As the name implies, the only incisions used are the upper blepharoplasty incisions.
• Dissection plane: After marking the planned upper blepharoplasty incisions while holding the brow in the proposed placement, the dissection is assisted by the infiltration of local anesthetic with hyaluronidase (Wydase) into the subgaleal plane. Within the subgaleal plane, the entire lateral brow is elevated with the orbicularis oculi muscle. The supraorbital neurovascular bundles are easily identified and preserved. The procerus, corrugators, and depressor supercilii are transected medially.
• Fixation: Anchoring sutures from the brow tissue to the lateral brow periosteum are placed. The overlying brow and orbicularis oculi are thereby fixed to the lateral brow periosteum in an elevated position. Endotine TransBelph 3.5 (Coapt, Palo Alto, Calif) is a bioabsorbable brow fixation device that is placed through the transpalpebral incision to fixate the brow tissue. The device negates placement of sutures and serves to distribute the pull on the tissues over a larger surface area.

The temporal lift is the procedure of choice for patients with isolated lateral brow descent. This technique is similar to the Gillies approach to the zygomatic arch. The temporal lift may be performed in conjunction with an endoscopic browlift or facelift.

• Incision placement: The incision is placed in the temporal area running in a superior to posterior-inferior direction over the temporalis muscle.
• Dissection plane: Dissection is performed deep to the temporoparietal fascia and superficial to the superficial layer of the deep temporal fascia. This dissection plane keeps the temporal branch of the facial nerve protected from injury during surgery. The dissection is carried inferiorly to the supraorbital rim and through the arcus marginalis to free the soft tissues and allow brow elevation.
• Fixation: Using a long-lasting absorbable suture or permanent suture, the temporoparietal fascia posterior to the course of the temporal branch of the facial nerve is sutured to the superficial and deep temporal fascia after desired brow elevation is achieved.

Minimal-incision endoscopic surgery has revolutionized approaches to all fields of medicine. The ability of the endoscopic browlift technique to achieve results similar to other traditional procedures has made more patients amenable to undergoing the elective cosmetic procedure. The scars hidden within the hairline and preservation of sensory nerves to the frontal and scalp region are characteristics very popular with patients (see Images 17-20).

For further reading, see the eMedicine article Endoscopic Forehead Lift

• Incision: Typically, 5 access incisions are used during an endoscopic browlift. Three are placed in the anterior hair-bearing scalp, and 2 are placed in the temporal area, similar to the temporal lift incisions. A central scalp incision is placed approximately 1.5 cm behind the hairline in a sagittal plane. The 2 paramedian incisions are placed 1.5 cm behind the hairline and situated where the surgeon desires maximal brow elevation. The paramedian incisions are usually placed along a line drawn from the lateral alar crease through the lateral limbus. The temporal incisions are placed approximately 1-2 cm posterior and parallel to the temporal hairline.
• Dissection
  • The central endoscopic browlift dissection has been described in both the subgaleal and subperiosteal planes. The subperiosteal plane proves to be less bloody and therefore provides a better optical cavity. This anterior dissection is performed blindly to within 1 cm above the supraorbital rim. The supraorbital notch is used as a landmark to identify the neurovascular bundles (see Image 21).
  • In the temporal area, the dissection is performed superficial to the deep temporal fascia. This dissection plane protects the temporal branch of the facial nerve, which lies superficially within the temporoparietal fascia. Surgical dissection is relatively easy through the wispy gossamer fibers separating the temporalis fascia from the temporoparietal fascia. Laterally, the dissection proceeds almost to the zygomatic arch.
  • The conjoint tendon is approached in a lateral-to-medial direction to join the subperiosteal dissection over the frontal area. The central dissection to the orbital rim becomes more adherent under the orbicularis oculi muscle. Meticulous dissection in the temporal area is mandatory to identify the sentinel vein. Either preservation or careful cauterization of the sentinel vein is performed to prevent injury to the temporal branch of the facial nerve that lies directly above the vein within the temporoparietal fascia.
  • The arcus marginalis is then released at the level of the supraorbital rim from lateral canthus to lateral canthus under direct endoscopic visualization. The supraorbital neurovascular bundle at the supraorbital notch or foramen must be carefully identified when releasing the arcus marginalis. Complete periosteal release is essential to proper brow elevation (see Image 22).
  • The corrugators, procerus, and depressor supercilii muscles can then be transected or removed. Various techniques for releasing the brow depressor musculature have been described and include sharp or blunt dissection, laser ablation, and electrocauterization. Additionally, orbicularis oculi myotomy at the lateral superior brow may be performed for maximal brow release and elevation.
• Fixation
  • The topic of endoscopic browlift fixation within the frontal area is broad. Techniques include soft tissue suturing, cortical screws with staple fixation, cortical screws and plates with suturing, absorbable screws, cortical bone tunnels with suturing, and tissue glue. The ideal fixation method allows pericranial readherence in the newly elevated position and is simple, quick, and inexpensive. Most authors believe that proper brow dissection and release are more important to the final result than the specific fixation technique.
  • In the temporal area, fixation of the overlying temporoparietal fascia (posterior to the course of the temporal branch of the facial nerve) to the deep temporal fascia is accomplished with absorbable sutures.

Postoperative Details

After all incisions are sutured, the hair is washed with warm sterile water. A light coating of antibiotic ointment is placed, and a nonstick dressing is secured with a bulky noncompressive dressing.

Follow-up

The dressing is removed the morning after surgery. All incisions are cleaned, the hair is washed, and postoperative instructions are reviewed again. Sutures are removed on postoperative day 5. Surgical clips are removed 10-12 days postoperatively.

The patient is cautioned against sun exposure, and sunscreen use is encouraged. Additional postoperative visits are at 1, 3, 6, and 12 months. Postoperative photographs are typically taken at the 3- and 12-month visits.

Complications

Complications are infrequent when browplasty is properly performed. However, as with any surgical procedure, complications can arise and should be treated appropriately. The following is a list of complications that can be observed following browplasty.

• Asymmetry: Most asymmetry in the postoperative period relates to preexisting facial asymmetry. A thorough evaluation of the patient's face preoperatively and photographic documentation of the preoperative state are essential. A candid discussion of facial and brow asymmetry should occur with the patient during the initial consultation.
• Hypoesthesia/numbness: Transient numbness in the supraorbital nerve distribution is not uncommon following browplasty. Patients sometimes describe the sensation as itching, as a feeling of wearing a hat, or as a feeling of wearing band around their head. Most of these sensations resolve completely but may be permanent. These symptoms are more common following coronal and trichophytic techniques than following endoscopic, midforehead, or direct browlift procedures.
• Scarring: Poor wound healing may result in widened, depressed, hypopigmented, or hypertrophic scars. Meticulous surgical technique should minimize noticeable scarring.
• Overcorrection/undercorrection: These untoward outcomes can be minimized by performing a detailed preoperative evaluation. Surgical planning and patient marking with the patient in the sitting position are extremely helpful.
• Facial nerve injury: Injury to the frontal branch of the facial nerve is rare. Surgical dissection in the temporal region must be subgaleal (just superficial to the deep temporal fascia and deep to the temporoparietal fascia) to minimize this serious complication. Take care with cauterization of blood vessels in the lateral brow and temporal regions.
• Alopecia: Atraumatic tissue handling and careful cautery protects hair follicles and minimizes this complication. It also may be seen at endoscopic browlift fixation sites.
• Flap necrosis: This is rarely observed given the excellent vascularity of the forehead. Use caution in patients who smoke or have diabetes. Ensure that the postoperative dressing is placed lightly.
• Hematoma: Hematoma is uncommon, especially when the dissection plane is subgaleal or subperiosteal. Dissection in a more superficial plane can lead to some blood accumulation. Expression of any blood or clots prior to dressing placement minimizes the risk of hematoma formation.
• Infection: This is rare. Always use sterile surgical techniques. Prompt recognition and treatment of any infection minimizes permanent sequelae.

Outcome and Prognosis

With proper patient selection and meticulous surgical technique, browplasty should yield a high degree of both patient and physician satisfaction.

Multimedia

Media file 1: Woman demonstrating ideal brow aesthetics. Note the gentle curving shape of the brows, which are positioned slightly above the orbital rims. The highest arching point should lie between the lateral limbus and lateral canthus. The tail of the brow lies on a line drawn between the lateral canthus and lateral nasal ala.

Media file 2: Cadaver dissection demonstrating supraorbital nerves (arrowheads); periosteum has been incised.

Media file 3: Cadaver dissection of corrugator musculature.

Media file 4: Cadaver specimen showing the temporoparietal fascia (held by a skin hook) dissected from the deep temporalis fascia; the temporalis muscle fibers are visible through the deep temporal fascia.

Media file 5: Preoperative photograph of 61-year-old man concerned with visual-field limitation in superior and lateral gaze. Note marked brow ptosis and dermatochalasis with hooding. This patient is a candidate for functional browplasty and blepharoplasty.

Media file 6: Visual-field test of the patient in Image 5. Note the dramatic improvement in visual fields when the brows and upper eyelid skin are elevated and taped (blue line, relaxed; red line, taped; green area, visual-field improvement).

Media file 7: Patient from Image 5, two months following endoscopic browlift and upper and lower blepharoplasties. The patient's visual-field complaints resolved with surgery.

Media file 8: Preoperative photo of a 59-year-old woman prior to an endoscopic browlift, lower lid transconjunctival blepharoplasty, rhytidectomy, and carbon dioxide laser resurfacing.

Media file 9: Patient from Image 8 seen 6 months postoperatively.

Media file 10: A: Brow and facial asymmetry resulting from left idiopathic facial nerve paralysis. B: Four-month postoperative view showing improved brow symmetry following trichophytic browplasty. Plication of the left facial superficial musculoaponeurotic system and placement of a facial sling were performed simultaneously.

Media file 11: Reverse beveling of the trichophytic incision encourages hair growth through the incision.

Media file 12: A: Trichophytic frontal incision. B: Subgaleal dissection of the flap is quick and relatively bloodless. Arrowheads denote supraorbital nerves that should be preserved.

Media file 13: Early postoperative view of trichophytic incision. Reverse beveling of the incision at the time of surgery promotes hair growth through the incision.

Media file 14: A 76-year-old man with left unilateral facial paresis. Note the marked brow ptosis, absence of horizontal forehead rhytides, and lower eyelid paralytic ectropion. This patient is an ideal candidate for midforehead browlift, gold weight placement, and ectropion repair.

Media file 15: A: Preoperative view of a 52-year-old woman who desires browplasty. The patient did not want sedation or general anesthesia. A midforehead browlift was performed with local anesthesia. The authors usually reserve the midforehead browlift for men with deep horizontal forehead rhytides. B: Three months status post midforehead browlift. Note the well-healed forehead incisions. Dermabrasion, although not used in this patient, may improve scar camouflage.

Media file 16: A: Elderly patient with paralytic brow ptosis on right (note hyperactive left frontalis muscle). B: Early postoperative result demonstrating improved brow symmetry. The left frontalis muscle is no longer overcompensating. C: Staggered fusiform incisions and proposed site of suspension sutures. D: orbicularis oculi fibers identified prior to brow suspension.

Media file 17: Preoperative frontal view of a patient with brow ptosis and dermatochalasis prior to endoscopic browlift and lower lid blepharoplasties.

Media file 18: Four-month postoperative view of patient in Image 17. Note mild elevation in hairline that is invariably observed following endoscopic and coronal browlift procedures. The patient was counseled about the hairline change preoperatively.

Media file 19: This is a 50-year-old woman prior to endoscopic browlift, carbon dioxide laser resurfacing, and botulinum toxin injection of periorbital rhytides (preoperatively).

Media file 20: Six-month postoperative view of woman in Image 19.

Media file 21: Endoscopic view of right supraorbital neurovascular bundle. Note the relatively bloodless subperiosteal dissection plane.

Media file 22: Endoscopic view of right supraorbital nerve following periosteal release.

Media file 23: Bulky dressing seen immediately upon completion of trichophytic browlift.

References

1. Dyer WK, Yung RT. Botulinum toxin-assisted brow lift. Facial Plast Surg. Aug 2000;8(3):343-54.

2. Nahm WK, Su TT, Rotunda AM, et al. Objective changes in brow position, superior palpebral crease, peak angle of the eyebrow, and jowl surface area after volumetric radiofrequency treatments to half of the face. Dermatol Surg. Jun 2004;30(6):922-8; discussion 928. [Medline].

3. Ahn MS, Catten M, Maas CS. Temporal brow lift using botulinum toxin A. Plast Reconstr Surg. Mar 2000;105(3):1129-35; discussion 1136-9. [Medline].

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Keywords

browplasty, forehead lift, browlift, brow lift, brow plasty, browpexy, brow plexy, direct browlift, temporal lift, endoscopic browlift, transpalpebral browlift, brow ptosis, midforehead browlift, mid forehead browlift, facial aging, cosmetic surgery, brow rejuvenation surgery, brow rejuvenation, forehead surgery, brow rhytid, brow rhytide, rhytids, rhytides, forehead wrinkles, brow wrinkles, facial aesthetic procedure, facial aesthetic surgery

Contributor Information and Disclosures

Author

J David Kriet, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Director of Facial Plastic and Reconstructive Surgery, University of Kansas School of Medicine
J David Kriet, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, AO Foundation, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Paulino E Goco, MD, Consulting Staff, Division of Facial Plastic and Reconstructive Surgery, Middle Tennessee Ear, Nose and Throat
Paulino E Goco, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Medical Editor

Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice
Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Allergan Honoraria Consulting

Pharmacy Editor

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

Managing Editor

Dominique Dorion, MD, MSc, FRCSC, Program Director and Division Chair, Professor of Surgery, Division of Otolaryngology, University of Sherbrooke, Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

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