Direct Brow Lift Procedures

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. Direct brow lift has become the most common approach to address the ptotic brow in Asian patients. However, although direct brow lift remains an excellent option for functional improvement, its popularity as a cosmetic technique has waned in the United States, having been replaced by more aesthetically satisfying methods that raise the forehead and the brow. A retrospective review performed by Rohrich et al that included 159 patients who underwent brow rejuvenation procedure found that direct brow lift was performed in only 1.9% of the patients; the endoscopic approach was the most common procedure, being carried out in 44.7% of patients.[1, 2]

As indicated above, the direct brow lift remains useful in certain clinical situations for functional restoration of the overhanging brow; this is the case, for example, in persons who are not candidates for more modern forehead-lifting techniques, who have thick eyebrows, who demonstrate asymmetries, and who are bald or have a high anterior hairline.[3]  A study by Pascali et al of 50 consecutive male patients who underwent direct brow lift (along with upper blepharoplasty) found at 12-month follow-up that 98% of patients demonstrated statistically significant brow elevation. The investigators concluded that direct brow lift provides beneficial, long-lasting outcomes in bald men, in patients with a high anterior hairline, and in those in whom an asymmetry needs correction. The report states that the procedure is safe and replicable, with a short recovery period. Moreover, because this method requires no width dissection, it is less traumatic and can be rapidly performed, offering an advantage for elderly patients.[4, 3]

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.[5] Modern bicoronal, endoscopic, and other techniques, in which incisions are placed in hidden areas, have eclipsed the direct brow excision in popularity.

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.[6]

Frequency

According to the American Society of Plastic Surgeons, board-certified specialists performed an estimated 88,675 forehead lifts in 2020. This represented a 27% decrease compared with the 120,971 forehead lifts performed in 2000.[7]  We hypothesize that the decline in brow surgery may be due to the rise in popularity of neurotoxin treatments. 

The main etiologic factors in brow ptosis are aging of the skin and gravity. As an individual grows older, the skin of the face loses tone, owing to a diminution in the amount of elastic fibers, glycosaminoglycans, and collagen. Loss of underlying fascial and muscle support also 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.[8]

See Etiology.

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, see eMedicineHealth's patient education article BOTOX® Injections.

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 or acquired facial paralysis.

Direct brow excision is best used in middle-aged or older men with male-pattern baldness, thick eyebrows, and lateral hooding, as depicted in the image below.[9]

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.

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.[10, 11, 12, 13]

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.[8]

The three 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 (approximately 1.5 cm from midline) 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.[14]

The supraorbital nerve travels somewhat more laterally over the medial supraorbital rim (approximately 2.5 cm from midline) and divides into two 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. 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.[15, 16, 14] See the image below.

 

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.[17, 18]

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.[19] See the image below, which corresponds to the following:

See the list below:

• The brow should begin medially at a vertical line extending from the ipsilateral alar base and medial canthus (line A-B).

• The brow should end laterally at an oblique line extending through the ipsilateral alar base and lateral canthus (line A-C).

• The medial and lateral ends of the eyebrow should lie at approximately the same horizontal level (line B-C).

• The apex of the brow should lie directly above the lateral limbus of the eye (line E).

• 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.[20]

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

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. As with any periocular surgery a history of “dry eye” should be elicited, for surgery has the potential to cause or exacerbate this condition.

 

The focus of the clinical exam is as follows[3] :

• Brow position and stability
• The distance between the top of the brow and the pupil
• Forehead length
• The presence of baldness or a thinning anterior hairline
• The presence of ‘widow’s peaks’ and other irregularities of the hairline’s contour
• Forehead skin quality and rhytid depth and prominence
• Heaviness of the tissue around the brow and thickness of the brow hair

All patients must undergo eye examination. The focus of the ophthalmic history and physical examination is the presence or absence of lagophthalmos, lid position at rest, and ocular surface disorders, such as dry eye disorder.

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.

Preoperative photographs should be obtained as before any cosmetic procedure.

A general medical evaluation and clearance for local anesthesia with sedation should be performed, as in all patients undergoing elective facial aesthetic procedures. For 2 weeks prior to the surgery, medications that may inhibit coagulation or wound healing such as aspirin, nonsteroidal anti-inflammatory drugs, and other coagulopathic agents and supplements are avoided. Patients with significant visual impairment may warrant referral to an ophthalmologist. Visual field testing can prove useful in a select patients group of patients.[14]

Currently available nonsurgical therapies include the injection of neurotoxin, fat injection, and the use of radiofrequency devices. Denervation with neurotoxins effects a temporary (3-6 mo) elevation of the medial or lateral eyebrow after selective injections into the forehead muscles. A brow lift by neurotoxin can result in long-lasting and predictable results, and it has become increasingly popular (with a 459% increase in the procedures since the beginning of the 21st century). The most common complications in neurotoxin injection are bruising (1.7%), flulike symptoms/persistent wrinkles/trace ptosis (0.7%), and eyelid ptosis/excessive retraction (0.3%).[21]  Regarding fat injection, infection (0.4%) has been documented, while the literature is sparse with respect to complications for radiofrequency brow lift. The recurrence and revision rates for these procedures are unknown.[7, 22, 21, 1]

The many surgical techniques available for brow lifts are reviewed elsewhere (see Introduction). When rejuvenating the brow, the goals of treatment include restoring eyebrow position, symmetry, stability, and volume. 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.[8, 10, 23, 24, 25, 26, 14]

Patient counseling should be provided with regard to the risks and benefits of the procedure and its alternatives. Improper brow position, incomplete eye closure, eye dryness, disfiguring facial scar, need for revisions, alopecia, paresthesia and facial nerve injury are complications pertinent to this procedure. Pain, bleeding, infection, and scarring are additional common complications associated with the surgery.[4]

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.[10] See the images below.

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.[16]

While some variations have been described, the overall surgical technique is relatively simple and rapid.[10, 23, 24, 8] 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 to 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. See the images below.

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. See the image below.

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 and can be performed at the discretion of the operating surgeon. The upper margin of the muscle can be tacked superiorly to either the frontal periosteum or the frontalis fascia with several permanent sutures; fixation to the frontalis can be exaggerated by 1-2 mm to compensate for postoperative settling.23 See the image below.

Some surgeons fix the eyebrow dermis rather than the orbicularis.[27] 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. See the images below.

A study by Stacey et al indicated that a high incidence of undetected blood splatter occurs during oculofacial plastic surgery, particularly during certain procedures, including direct brow lifts. The investigators suggested, therefore, that when operating on patients with known blood-borne diseases or in cases in which blood splatter is likely, oculofacial plastic surgeons should consider wearing eye protection. In the study, in which surgeons and their assistants wore eye shields during 131 surgeries, it was determined that these study participants were aware intraoperatively of only 2% of blood splatters, with another 98% of the splatters detected postoperatively when the shields were examined with a luminol blood detection system. According to the study, splatters were especially likely during direct brow lifting, orbitotomy with bony window, full-thickness eyelid procedures, and orbital fracture repairs.[28]

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.

A randomized, double-blind trial by Cadet et al of 12 patients who underwent bilateral direct brow lift (24 scars) found that compared with placebo, topical application of silicone gel did not significantly improve scarring by 6-month follow-up.[29]

Care should be taken to avoid postoperative hypertension and sodium intake to minimize bruising and swelling. For 2 weeks following surgery, medications that may inhibit coagulation or wound healing such as aspirin, nonsteroidal anti-inflammatory drugs, and other coagulopathic medications and supplements are avoided.[14]

The complication rate is generally low. Hematomas usually resolve spontaneously but may have to be drained. Infection and alopecia of the eyebrow are uncommon. 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. Hypoesthesia, if it occurs, often resolves in 6 months. Even less likely is numbness or painful dysesthesias of the forehead, scalp, upper eyelid, and nasal dorsum.[8, 10, 16, 23] {ref37-INVALID REFERENCE}  

However, a literature review by Cho et al looking at complication rates associated with various types of brow lift procedures reported numbness to occur most frequently (5.5%) in direct brow lifts. Additionally, the rates of asymmetry and revisional surgery in direct brow lift were 0.9% and 3.6%, with, by comparison, the temporal approach having the highest asymmetry rate (1.5%), and the hairline approach having the highest revisional surgery rate (7.4%). Other brow lift techniques reviewed in this study included coronal, lateral, and transblepharoplasty lifts, as well as endoscopic and nonsurgical procedures.[21]

Injury to the temporal branch of the facial nerve is also possible in direct brow lift. Preservation of this nerve is essential to prevent frontalis muscle palsy, which produces a devastating deformity.[30]  

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

The direct brow lift is unlikely to undergo much 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).

However, Butler et al did report on a series of modifications to direct brow lift surgery that, according to the investigators, substantially lower the postoperative paresthesia rate, with satisfactory aesthetic outcomes obtained as well. The modifications include the following[31] :

• Stealth skin incision of the W-plasty type is performed
• Skin excision is carried out in the subcutaneous plane only with minimal excision of fat
• Small linear puncture incisions in the frontalis are used for browpexy to the frontal periosteum