Mid Forehead Brow Lift Treatment & Management

No medical treatment is indicated for this condition.

When planning for surgical correction of brow ptosis, detailed history, clinical examination, psychological assessment in cosmetic cases, defined surgical plan, and detailed discussion of proposed surgery and possible outcomes and complications must be undertaken. ^{[12, 13]}

A study by Hamamoto et al indicated that three methods of brow design (Westmore, Lamas, and Anastasia) used in surgical brow lifts produce equally attractive results. The study utilized 10 synthetic female faces, with a group of 50 professional makeup artists ranking the images based on brow shapes created with each of the three methods (30 images total). Attractiveness scores did not significantly differ between the three design strategies, although the Anastasia and Lamas techniques resulted in a more lateral brow arch than did the Westmore method. ^[14]

Preoperative preparation

Forehead lifts in general and mid forehead lifts in particular are prone to produce extensive bruising. The intake of aspirin or aspirin-containing products and anti-inflammatory medications such as ibuprofen, vitamin E, and anticoagulants are stopped at least a week prior to surgery. The authors used to provide a list of all medications containing aspirin or aspirin-containing products, but this list has proliferated to such an extent that patients are now asked to read their medication bottles to ensure that they are not taking such products. When operating on women, ask them to remove all make-up the night before surgery and cleanse their faces and eyelids once again on the morning of the surgery.

Patient consultation

This constitutes an important part of the discussion of forehead lifts. Cosmetic patients must be interviewed and counseled somewhat differently from reconstructive patients. This is discussed elsewhere in this journal.

The authors generally explain the findings to the patient while standing in front of a large mirror in which the whole face may be seen and the patient can see the surgeon without looking away. The findings are presented first and particular emphasis is placed on showing the patient asymmetry that may be present. The optimal position of the eyebrows and eyelids is discussed and pointed out. The sites of the surgical incisions are demonstrated and the limitations of the procedure are discussed. In particular, the patient is allowed, once again, to express desires and hopes. After this, a series of before and after photographs are shown to the patient, and particular emphasis is placed on the appearance of the scars (in this case, the mid forehead scars). Complications and limitations of the procedure are discussed in detail.

The authors' policy is to interview each patient at least twice before scheduling surgery. This allows the patient sufficient time to express desires and concerns. Furthermore, and just as importantly, this allows the surgeon to get to know the patient. Especially in cosmetic surgery, certain patients are not suited to surgical intervention and this may become apparent on subsequent interviews.

Skin markings

See the list below:

• Select a deep horizontal furrow and mark it with a marking pen. This is the superior incision line.

• Usually, a transverse incision is made across the whole forehead, stopping at the temporal fusion line, although the incision may be carried further laterally. In some patients, breaking up the incision as shown is helpful to allow better camouflage of the scar. Some surgeons use different forehead rhytides to make the incisions, which means that the scars are at different levels on the forehead. See the image below.

  Mid forehead brow lift. Transverse forehead incisions may be broken as shown to improve the appearance of the final result. Courtesy of Bhupendra Patel, MD, FRCS.

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Anesthesia

See the list below:

• With intravenous sedation, inject 2% lidocaine and 1:100,000 epinephrine to give supraorbital nerve blocks. Give further injections along the incision line, over the brow and glabellar regions. Adequate vasoconstriction is achieved in 10-15 minutes.

• The authors generally prepare the patient and drape after the administration of the local anesthetic to allow appropriate time.

Incisions

See the list below:

• Use a No. 15 C-blade to make a skin incision, which is carried down to the galea aponeurotica.

• If the incision is carried temporally, it is vital not to take the incision deeper than the skin only.

Dissection

See the list below:

• With the help of rakes, perform a sharp and blunt dissection in the subcutaneous plane. Do not penetrate the galea. See the image below.

  Mid forehead brow lift. Dissection is performed in the subcutaneous plane. Courtesy of Bhupendra Patel, MD, FRCS.

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• Perform the dissection in the loose aponeurotic layer down to the superior orbital rims. Make a transverse galeal incision 3 cm above the nasal root. This allows entrance into the subgaleal plane. Laterally, this incision must not extend beyond the supraorbital nerves. See the image below.

  Mid forehead brow lift. Transverse incisions are made in the galea to access the corrugator and procerus muscles. These incisions are kept in the middle to prevent injury to the supraorbital nerve branches. Courtesy of Bhupendra Patel, MD, FRCS.

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• Hemostasis is vital. This allows broad visualization of the corrugator and procerus muscles. The supraorbital and supratrochlear nerves are defined adequately and muscle weakening is performed as desired.

• The authors perform a sharp excision with the use of bipolar cautery. Some surgeons advocate the use of the Shaw hemostatic scalpel. The authors separate the corrugator muscles from the bony origin, cross-clamp them, and excise them with the use of bipolar hemostasis. The aim is not to completely resect the procerus and corrugator muscles but to weaken them to the desired degree. The extent to which the procerus muscle is weakened depends upon the extent of horizontal nasal furrowing and on the desired degree of elevation of the nasal root skin. See the image below.

  Mid forehead brow lift. Once exposed, the corrugator and procerus muscles are attenuated. Courtesy of Bhupendra Patel, MD, FRCS.

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• Undermine the skin superior to the upper incision for approximately 1.5 cm, thereby allowing skin eversion during closure. Horizontal weakening of the frontalis muscle may be achieved with superficial horizontal cuts, allowing release of deep creases.

Closure

See the list below:

• Close the deep galeal transverse incision after excision of excess using 4-0 polydioxanone sutures. Then pull up the inferior flap and excise redundant skin created by the preferred degree of brow position. See the image below.

  Mid forehead brow lift. The galea is shortened as desired and sutures are placed. Courtesy of Bhupendra Patel, MD, FRCS.

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• Asymmetry in preoperative brow positions may be corrected by performing appropriate skin excision. See the image below.

  Mid forehead brow lift. Elevation of the cutaneous structures is obtained and appropriate trimming is performed. Courtesy of Bhupendra Patel, MD, FRCS.

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• Skin closure is achieved in two layers. Close the dermal layer with 5-0 polydioxanone to take up all the tension on the skin. Evert the skin edges during the deep closure. Close the skin with a running 6-0 polypropylene suture. See the image below.

  Mid forehead brow lift. Meticulous subcuticular closure is achieved with no tension on the skin edges. Courtesy of Bhupendra Patel, MD, FRCS.

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• At the end of the surgery, the authors apply antitension Steri-Strips and dress the forehead over a Telfa dressing. Recently, they have begun to use Velcro-based forehead dressings, which pass under the chin, allowing the application of a firm dressing on the forehead. This dressing may be removed and reapplied as desired.

Variations

In some patients, weakening the orbital portion of the orbicularis oculi muscle may be necessary. Furthermore, the muscle and the dermis of the brow may be suspended to the periosteum superolaterally with several 3-0 nylon sutures, especially in particularly heavy brows.

Li et al described an operative technique for preventing eyebrow ptosis from recurring following brow lift surgery, in which skin and the lateral part of the orbital orbicularis oculi muscle are resected and the lower margin of the orbital orbicularis oculi muscle is elevated, with suturing of the muscle to the orbital periosteum. Compared with a group of patients in whom excess skin was resected during brow lift surgery, those who underwent the newer technique had significantly greater brow height at 24-month follow-up (20.76 vs 24.74 mm, respectively). ^[15]

Remove the Telfa dressing on day 3 and remove the sutures on day 5 or 6. After skin removal, place further Steri-Strips for another 9 days.

The brow position may appear overcompensated in the early postoperative period; this is not unusual. Relaxation of the brow is expected, although to a lesser degree than is seen with coronal or endoscopic brow lifts.

The authors generally observe patients every 3 months after all the sutures have been removed and healing is complete.

A variety of complications may occur after a mid forehead lift.

Hematoma

A postoperative hematoma requires immediate drainage. As the lower forehead flap is a skin flap, necrosis may occur if the hematoma is not drained judiciously.

Facial nerve injury

If the incision is carried laterally and deep dissection is performed, the surgeon risks injuring the frontal branch of the facial nerve. Usually, the paresis is temporary and is a result of edema and tension. However, injudicious use of bipolar cautery can result in thermal nerve injury.

• Hypesthesia: Temporary hypesthesia in the distribution of the supraorbital nerves may occur but usually recovers within a few days. If the galea aponeurotica is entered in the dissection, a real risk of permanent forehead hypesthesia exists.

• Paresthesia: Paresthesia is not uncommon in the postoperative period and may last several weeks.

• Neuralgia: Injury to the supraorbital nerves can lead to neuralgia.

Incision pruritus

This is a common finding in the first few days following surgery.

Depressed or widened scar

Despite a meticulous closure, forehead scars are not entirely predictable. In patients with substantial solar elastosis, the scar may be hypopigmented; this is a particular problem in men. Thick sebaceous skin tends to scar and is best avoided in the mid forehead lift. Dermabrasion or carbon dioxide laser ablation at approximately 6-10 weeks helps with the final result. When different creases are used for the incisions on the right and left sides of the forehead, one scar may be more obvious than the other.

Brow asymmetry

This is an inherent complication in all types of brow lifts. When a substantial difference exists in the preoperative height of the two sides, frequently a recurrence of the asymmetry is observed, albeit to a lesser degree. The authors' policy is to tell all patients with asymmetric brows that perfect symmetry cannot be achieved in the long term.

Abnormal soft tissue contours

If overzealous resection of the corrugator and procerus muscles is performed, localized soft tissue contour deformities may result. Indeed, when an aggressive degree of resection of these muscles is performed, the authors frequently replace the resected tissue with fat or fascial grafts. Insufficient care to the edges of the incision across the forehead can also lead to soft tissue contour abnormalities along the incision.

Lagophthalmos

Most patients who undergo brow lifts also undergo some form of upper eyelid procedure. Postoperative lagophthalmos may occur in any of these patients, especially if the patient has lower eyelid laxity with or without retraction and inferior scleral show.

Whereas the mid forehead brow lift was performed relatively frequently in men in the past, advances in endoscopic techniques have allowed minimal incision surgical correction of these patients while avoiding obvious mid forehead scars. When the patient is chosen carefully, the outcome can be very gratifying. As the lift is closer to the brow than with an endoscopic lift or a coronal lift, the degree of brow elevation and correction of asymmetry is more reliable. In addition, less chance of regression is present.

Mid forehead brow lift. Preoperative. A 68-year-old man with markedly overactive corrugator and procerus muscles. Note the particularly heavy sebaceous forehead skin and evidence of long standing overactivity of the orbital orbicularis oculi muscles, all conspiring to create a particularly menacing appearance. Such a patient would not do well with an endoscopic forehead lift. Courtesy of Bhupendra Patel, MD, FRCS.

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Mid forehead brow lift. Postoperative. Note that even 5 months following the repair, some pinkness of the incision site is present. When a patient has a great degree of actinic keratosis and secondary telangiectatic vessels, such as in this man, such persistent pinkness in the incision site is not uncommon. However, a reasonable elevation of his brows and weakening of his uncommonly powerful corrugator and procerus muscles has been achieved. Courtesy of Bhupendra Patel, MD, FRCS.

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A prospective study by Wormer et al indicated that in patients who undergo a combined brow lift/blepharoplasty procedure, the risk of major complications is no greater than in those who undergo either procedure by itself. The investigators reported the rate of major complications in blepharoplasty, brow lift, and the combined surgery to be 0.4%, 0.7%, and 0.4%, respectively. ^[16]

Occasionally, when the brow needs to be supported, physicians have used an internal browpexy approach, which, in the authors' hands, has yielded less than ideal results that are often transient.