Direct Brow Lift

Brow ptosis is a common condition in the later part of life. It should be considered in the evaluation of all patients who are interested in a blepharoplasty. Often, the pseudoptosis observed in patients with dermatochalasis can be partially or completely corrected with a brow lift; therefore, consideration of a brow lift as a primary or adjunctive procedure should always be kept in mind.[1]

Most patients do not appreciate the extent to which brow malposition contributes to the overall appearance of the aging periorbital area. This needs to be pointed out specifically to help the patient understand why a blepharoplasty alone often does not fully correct the problem. If a manual lift of the brow to the desired position significantly improves the patient's appearance, a browplasty, either alone or combined with blepharoplasty, should be considered. If a blepharoplasty is performed without recognizing any associated brow ptosis, the lateral eyebrow can appear pulled down, which produces an undesirable sad appearance. When both surgical procedures are performed together, eyelid surgery should follow brow correction in order to avoid removing too much skin.

See the image below.

Brow ptosis may be asymmetric, the brows being unequal or uneven. Sexual variations in brow appearance and configuration should be considered. Females generally have brows that are more arched and above the level of the supraorbital rim. Brow fat pads may be more prominent in men and in both sexes may become diffusely or segmentally ptotic.

Frequency

Brow ptosis is very common in the general population, increasing steadily in prevalence for those older than 50 years. It is even more common in the population of patients interested in blepharoplasty or having dermatochalasis.

Gravity and age, as well as genetic inclination and physiognomy, all play a part in the etiology of brow ptosis. Aging changes in the eyelids and face are related to loss of tone in the various layers underlying the skin. Changes that occur in the upper eyelid skin are usually due to passive stretching, loss of support, or redundancy of skin secondary to lowering of the brows. The adhesion of the fascial planes decreases with age, and with the effect of gravity, the soft tissue of the forehead slips down the frontal bone.

Usually, brow ptosis is noted when the patient becomes concerned about cosmesis with increasing age. It may also be discussed with patients with symptoms of ocular fatigue secondary to the continuous action of the frontalis muscle or with symptoms of limitation in superior visual field due to overhanging skin.[2]

Indications include (1) cosmesis, (2) relief of ocular fatigue secondary to the continuous action of the frontalis muscle, and (3) improving restricted superior visual field due to overhanging skin.

A thorough understanding of forehead anatomy is essential to evaluate brow ptosis. The layers in the mid forehead are skin, dermis, superficial galea, frontalis muscle, deep galea, and periosteum. The forehead skin is much thicker than the eyelid skin. The dermis and subcutaneous fat are connected to the underlying frontalis muscle by multiple fibrous septae. The paired frontalis muscles originate just anterior to the coronal suture line. A smooth fibrous sheath, the galeal aponeurotica, envelops the frontalis to form both superficial and deep galeal layers. The periosteum lies beneath the deep galeal layer.

Laterally, the frontalis muscle ends or becomes markedly attenuated along the temporal fusion line of the skull. Here, the superficial galea, the superficial temporalis fascia, and the periosteum of the frontal bone fuse. The confluence of these tissue planes is called the zone of fixation. Near the junction between the temporal fusion line of the skull and the orbital rim, a fibrous band called the orbital ligament connects the superficial temporal fascia to the orbital rim. This structure effectively tethers the lateral brow to the orbital rim.

The eyebrow fat pad (ie, subgaleal fad pad) is a transverse band of fibroadipose tissue 2-2.5 cm above the orbital rim. It lies within the subgaleal space between the deep galeal layer and the periosteum and is firmly attached to the frontal bone at the superior orbital rim. It allows movement of the frontalis muscle in the lower forehead. The eyebrow fat pad is continuous inferiorly with the suborbicularis space in the eyelid.

Two additional muscles in the forehead can cause furrows in the glabellar region. The procerus muscle is continuous with the medial portion of the frontalis muscle and inserts into the nasal bone glabellar subcutaneous tissue. It causes horizontal wrinkles of the glabella. The corrugator supercilii muscle is obliquely oriented, passing from the subcutaneous brow to the frontal bone medially. It causes vertical glabellar furrows.

Several important neurovascular structures occur in the forehead. The frontal branch of the facial nerve lies within the superficial temporal fascia before entering the frontalis muscle. The deep division of the supraorbital nerve that innervates the frontoparietal scalp passes from the orbital rim between the deep galeal layer and the periosteum toward the superior temporal line of the skull. The superficial division of the supraorbital nerve passes from the orbital rim beneath and within the frontalis muscle to terminate in the anterior scalp. The supratrochlear nerve pierces the corrugator.

Several factors contribute to the appearance of the aging forehead and brow. These include changes in the quality of the skin, loss of tissue support, and forehead and glabellar furrows related to action of the underlying facial muscles. The lateral eyebrow segment usually becomes ptotic before the medial segment does because less structural support exists in this area. The absence of the frontalis muscle lateral to the temporal fusion line allows the brow and preseptal fat pads to slide over the temporalis fascial plane and push the lateral eyebrow segment downward. With an increasingly medial temporal line, less lateral eyebrow support is available from the frontalis muscle. The final brow position depends on the dynamics between the frontalis muscle pulling the brow up and the descending temporal soft tissue dragging it down.

See Surgical therapy.

Photography

Preoperative and postoperative photographs are very important if not absolutely necessary in all cosmetic and reconstructive procedures.

Numerous surgical approaches exist for correction of brow ptosis, each having advantages and disadvantages. The surgical approaches include internal browpexy and browplasty, direct brow elevation, mid forehead brow lift, coronal forehead lift, and endoscopic forehead lift.[3, 4, 5]

Internal browpexy and browplasty is discussed in Browplasty. The procedure is only useful for mild cases of brow ptosis and is best used as an adjunct to blepharoplasty surgery.

Direct brow elevation is best used for patients with localized small-to-moderate amounts of eyebrow ptosis who preferably have thick eyebrows. Scarring can be marked and is obvious in patients with light brows, especially in redheads. Currently, it is primarily indicated for elderly patients with predominantly lateral brow ptosis and functional hooding with visual field deficits.

Mid forehead brow lift is best used for patients with preexisting deep forehead furrows with significant brow ptosis. It is now primarily indicated in men with extensive male pattern baldness or very high frontal hairlines, deep forehead creases, and significant brow ptosis.

Coronal forehead lift is best used for patients with any amount of eyebrow ptosis who also have generalized forehead ptosis. It is the procedure of choice for patients who have concomitant essential blepharospasm and are having a combined myectomy.

Endoscopic forehead lift is discussed in Endoscopic Forehead Lift. It is today's cosmetic procedure of choice. In capable hands, it is as effective as the coronal lift and far less invasive.

The amount of brow correction is determined preoperatively by considering the variations in brow position, brow configuration, fat pad prominence, and sex. Preoperative planning is important because the brows change position when the patient is supine on the operating table.

Direct brow lift

The direct brow lift is the oldest and simplest surgical approach. Its advantages include a less invasive surgical dissection with less risk of damage to the facial nerve and minimal risk of hematoma. It is ideally suited for patients with bushy brows and mild brow ptosis. It can also be used in patients who have unilateral brow ptosis, which most commonly occurs following peripheral facial nerve palsy. Direct brow lift does not correct medial brow ptosis and results in a visible scar even when placed directly above the eyebrow hairs. The resultant surgical scar above the eyebrow leaves an unnaturally sharp border because of loss of the fine upper brow hairs. In patients who have large bushy brows, the incision tends to be less apparent than in those with thin wispy brows. One modification includes a more temporal skin excision to correct isolated temporal brow ptosis. Another modification is combining the direct brow lift with suspension of the orbicularis oculi muscle, which the authors believe causes significantly improved scarring.[6]

The vertical extent of the incision is measured with a ruler held in front of the brow with the patient sitting. The brow is then elevated to the desired position, and the amount of necessary elevation is recorded. Such measurements are made along the entire width of the brow because areas of uneven ptosis may exist. Preoperative sketches and measurements are useful guides intraoperatively. The brow often has less support laterally (because of unequal attachments of the undersurface of the brow fat pad in this area) and develops more ptosis in this area with age.

Mid forehead brow lift

The midfrontal approach provides less brow lift effect than does the bicoronal but more than the direct brow lift approach. Advantages include less risk of nerve damage. The corrugator supercilii and procerus muscles may be resected directly through this approach, which is ideally suited for patients who have deep horizontal furrows in the forehead (usually men), especially when frontal baldness prevents the use of a bicoronal incision. Incisions can be made along a furrow line the entire length of the forehead or along a furrow line staggered centrally, or 2 separate fusiform excisions can be made, each extending from the medial to lateral end of the brow.

The major disadvantage of this technique is the resultant scar line, which can be visible, particularly if it cannot be camouflaged within a deep horizontal furrow. Excisions here may be tailored to remove more midline tissue for more central ptosis or more lateral tissue for temporal ptosis. Asymmetric amounts of excision may be effected with comparatively dissimilar amounts of ptosis. Mid forehead lifts can be used to correct glabellar furrows as well as brow ptosis in individuals with male pattern baldness, thinning hairlines, and high hairlines. As a result of this and the need for deep furrows, the procedure is most commonly used in males. Conveniently, almost all of these lifts can be performed by removing the tissue between the second and third frontalis wrinkle lines above the brows. This usually corresponds to 1 cm of tissue.

As for the direct brow lift, markings are made and preoperative sketches, measurements, and photographs are used.

Bicoronal forehead lift

The bicoronal forehead lift allows the maximal effect of brow elevation with a well-camouflaged incision site. It is ideally suited for patients with significant brow ptosis, without frontal baldness, and with a normal-to-low hairline. The incision is hidden posterior to the hairline (posttrichion). Alternatively, in patients who have a high forehead, the incision can be placed at the hairline (pretrichion) to avoid further elevating the hairline. Two major choices for the surgical dissection plane exist, subcutaneous and subgaleal.

Factors that influence the choice of dissection plane include the quality and elasticity of the skin, the amount of skin wrinkling, and the depth of the furrows, but surgeon preference is likely to be the most significant factor. A combined coronal brow lift and blepharoplasty can be used in patients with excessive eyelid fat and brow ptosis but little or no dermatochalasis. The major disadvantages of the bicoronal technique include its invasive surgical approach, which can be intimidating to the patient, and the increased risk of hematoma and nerve injury.

For all the procedures, caution is required when performing deep dissection around the supraorbital notch because of the wide variation in anatomy seen with respect to the position of the supraorbital foramen.[7]

Direct brow lift

Lidocaine (2%) with epinephrine is infiltrated beneath the area to be excised, and the area is gently massaged for 3-5 minutes. Excessive amounts of anesthetic distort the lines of incision and should be avoided; however, because the brow is very vascular, ensure enough time to allow for the action of the vasoconstrictors.

The skin is incised with a number 15 Bard-Parker blade beveled along the direction of the hairs. Dissection with scissors is carried down until the fibers of the frontalis muscle are found. The area under the marks is then excised en bloc. Electrocautery for hemostasis is then performed.

To prevent scarring, layer-by-layer reconstruction of the wound is advised. For the deep layers, 4-0 nylon interrupted sutures are used, making sure not to engage the periosteum in the bites, and 5-0 or 6-0 Vicryl interrupted sutures with knots tied down are used for the superficial subcutaneous layer, bringing the skin edges together without gaping. The skin is closed with 6-0 nylon interrupted sutures for vertical alignment only.

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.[8]

A study by Butler et al indicated that certain modifications to the direct brow lift procedure can reduce the chance of complications. In these modifications, a W-plasty–type stealth skin incision is used; the upper and lower incision lines are counterbeveled; skin is excised only in the subcutaneous plane, with minimal fat excision; and browpexy is performed “to the frontal periosteum through small linear puncture incisions in the frontalis.” Of 23 patients in the study (24 direct brow lifts), all of whom had facial palsy–associated brow ptosis, the investigators found, at mean 1.3-year follow-up, no postoperative forehead paresthesia or brow alopecia, with height rated good or excellent in 14% and 71% of brows, respectively.[9]

Mid forehead brow lift

The skin is incised over the markings as per the direct brow lift followed by en bloc excision and cautery, and the same layered closure with the same suture types is used.

Coronal brow lift

The midline is marked, and a symmetrical incision is outlined with a marking pen. Laterally, the incision should be carried to the anterior and superior reflection of the ear. Be prepared to extend the incision down to the root of the ear if turning down the flap enough to expose the superior orbital rim is difficult. Initially, stop the incision at the top of the ear. The incision is made while providing digital pressure to the margins for hemostasis. The skin and galea are incised. The incision is beveled and aligned with the hair follicles to minimize postoperative alopecia. Laterally, do not incise the temporalis fascia so as to avoid the muscle bleeding. Take great care to identify and spare the superficial temporalis vessels.

The galea must be incised completely and retracted to expose the underlying pericranium before hemostatic clamps are applied. Placing the clips is difficult if the galea has not been completely transected. Raney neurosurgical clips can be used on both skin edges.

Once hemostasis has been obtained, the coronal flap is developed with a combination of sharp and blunt (finger) dissection. Care must be taken to avoid the terminal branches of the seventh nerve superiorly and laterally above the orbital rims.

As the flap is turned down, the dissection proceeds in the subgaleal avascular plane. Laterally, the surgeon must develop the plane on the fascia of the temporalis muscle. Take extreme care here to avoid damaging the frontal branch of the facial nerve and causing postoperative brow paralysis.

As the superior orbital rim is approached, the supraorbital neovascular bundles are encountered. A peanut dissector is used to expose them. Turn the flap down to completely expose the complete supraorbital rim, the periosteum over the zygomatic process of the frontal bone laterally, and the superior aspects of the nasal bone in the glabellar region medially. The procerus, corrugator supercilii, and orbital orbicularis muscles are elevated with the forehead skin and frontalis muscle. The corrugator/procerus complex may also be removed, as most surgeons do today; they can also be removed in the mid forehead lift by going subgaleal at the level of the glabella.

At this point, if a myectomy for essential blepharospasm has been planned, these muscles may be excised. If a cosmetic procedure is all that is necessary, simply remove the hemostatic clamps at this point and pull the scalp superiorly to overlap the posterior skin edge. The amount of skin and hair to be resected is estimated and rarely exceeds 3 cm. Vertical skin incisions are made anteriorly in the coronal flap corresponding to the amount of skin to be excised with a scalpel.

The apex of each incision is sutured to the posterior skin edge with a 6-0 Prolene suture. The excess skin and galea are excised with a scalpel. The skin and galea are closed in layers. Stapling the skin and ignoring the galea is possible, but this introduces excessive tension on the wound. The galea is closed with 2-0 Dexon or 3-0 Nurolon on an atraumatic taper needle. The skin is then stapled or sutured in a normal fashion. Drainage is usually unnecessary, but if needed a Penrose drain can be used exiting through a separate lateral stab incision.

Direct brow lift

Antibiotic ointment is applied to the suture line and the incisions covered with Telfa dressings.

Mid forehead brow lift

Postoperative care is the same as for the direct brow lift.

Bicoronal forehead brow lift

A loose turban dressing is placed without undue pressure, leaving the orbits visible. The head of the bed is elevated 45 degrees to reduce swelling, and ice compresses are applied to the lids for 10 minutes every hour. Drains can be removed the first postoperative day.

For the direct brow lift and mid forehead brow lift, skin sutures are removed after 5-7 days, and Steri-Strips are used for the next week. For the coronal lift, staples or sutures may be removed in 7 days if galeal sutures were used or in 2 weeks if skin closure only was used.

Complications of browplasty depend on the technique used. Two major groups of complications exist: those related to the incision site and those related to the extent of dissection. Complications related to the incision site are visible scar and alopecia. Infectious abscesses are very rare.

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.[10]

Excessive cutaneous scar and alopecia

Forehead skin is thicker and less vascular than eyelid skin, so incisions in the forehead often heal with a visible scar. Meticulous closure with adequate subdermal tension-bearing sutures and careful approximation of wound edges is important. Placement of the incision is the main determinant of scar visibility, however. Locating the incision site at or above the hairline is generally preferable. A randomized, double-blind clinical trial by Cadet et al reported that silicone gel was no more successful in the treatment of direct brow lift scars than was placebo.[11]

Alopecia is believed to be related to the closure of hair-bearing skin under tension, to ischemia along the opposing wound edges, or to undermining too close to the hair follicles, with resultant follicle damage.

Granuloma Formation

Granuloma formation can occur with the use of braided absorbable sutures rather than monofilament sutures.[12]

Hypesthesia and hematoma

Related to the extent of dissection are the potential associated nerve injuries that can result in frontal paresis, numbness, and an increased risk of hematoma formation. Temporary hypesthesia following browplasty is very common but usually resolves within 6 months. A literature review by Cho et al of complications in various brow lift techniques found that among the open procedures, direct brow lift was associated with the highest rate of numbness (5.5%).[13]

Hematomas are a common complication of the subcutaneous bicoronal brow lift but are rare with the subgaleal approach. Hematomas are more significant following a more superficial subcutaneous dissection because an enlarging hematoma can compromise the skin flap. Small hematomas often spontaneously resolve, but larger ones should be immediately evacuated to avoid flap necrosis, especially with a subcutaneous dissection.

Overcorrection and undercorrection

Overcorrection of brow position or loss of movement of the brow can result in an expression of perpetual surprise, particularly if the brow has been fixed to the underlying periosteum in an overzealous direct brow lift. Undercorrection occurs when insufficient elevation is achieved; it is more common with the endoscopic technique and with posterior fixation of the brow through a blepharoplasty incision.

Revision and asymmetry

In the above-mentioned study by Cho et al, direct brow lift had the second highest revision rate (3.6%) among the open surgeries, following hairline brow lift (7.4%), and the second highest open-procedure asymmetry rate (0.9%), following temporal/lateral brow lift (1.5%).[13]

Following brow elevation procedures, the patient should experience an improvement in appearance and a restoration of the superior visual field. In order to achieve these results, the brow repair may have to be combined with a blepharoplasty.

Booth et al reviewed their experience with direct brow lift to establish its efficacy and complication rate.[14] The direct brow lift operation was found to give a predictable outcome, with high levels of patient satisfaction. With careful wound closure, postoperative scars were rarely cosmetically unacceptable to the patient. Paraesthesia were common but well-tolerated sequelae. The direct brow lift was found to be a reliable method for treating brow ptosis arising through involutional change or facial nerve palsy in both men and women. The postoperative scars may be more evident in younger patients, so the authors reserve this technique for rehabilitative rather than cosmetic brow lifts in patients of middle age and beyond.

See Endoscopic Forehead Lift.