Direct Brow Lift Procedures Treatment & Management

Updated: May 11, 2017
  • Author: Daniel N Ronel, MD, FAAP, FACS; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
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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. [18]

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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. [8, 19, 20, 6, 21, 22]

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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. [8] See the images below.

Marking for direct brow lift. Marking for direct brow lift.
Direct brow lift. Preoperative marking for eyebrow 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. [13]

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Intraoperative Details

While some variations have been described, the overall surgical technique is relatively simple and rapid. [8, 19, 20, 6] 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. See the images below.

Direct brow lift. Excision to the level of the fro Direct brow lift. Excision to the level of the frontalis.
Direct brow lift. Beveling the incision. 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. See the image below.

Direct brow lift. Injury to the temporal (frontal) 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. [23] See the image below.

Direct brow lift. Fixation of brow and closure. Direct brow lift. Fixation of brow and closure.

Some surgeons fix the eyebrow dermis rather than the orbicularis. [24] 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.

Direct brow lift. Placement of deep dermal sutures Direct brow lift. Placement of deep dermal sutures.
Direct brow lift. Closed wound. Direct brow lift. Closed wound.

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. [25]

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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. [26, 27]

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.

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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. [8, 19, 13, 6] Injury to the temporal branch of the facial nerve is also possible.

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Outcome and Prognosis

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

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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).

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