Direct Brow Lift Procedures Treatment & Management

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]}   

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