Goals

In addition to blepharoplasty and blepharoptosis repair, brow and forehead lifting are the staples of improving the form and function of the upper third of the face. Though brow lifting and forehead lifting can be differentiated and discussed as distinct entities, for the purposes of this text, they are considered part of the same procedure, and the term "brow lift" is used exclusively to describe the procedure.

Though brow ptosis may be a hereditary feature, it is mostly due to the aging process that is influenced by factors such as sun exposure, gravity, and genetics, which contribute to loss of skin and connective tissue elasticity and loss of adipose tissue volume. Facial nerve paralysis or paresis, due to a variety of etiologies, can also cause brow ptosis, usually unilaterally.

Broadly speaking there are 3 goals of brow and forehead lifting procedures:

• Improve a patient's visual function. More specifically, the functional goal of brow lift is to counteract the aging related descent of the lateral brow soft tissue and skin that leads to the "lateral hooding" of the upper eyelid skin over the patient's lashes, thus compromising the superior and lateral visual field.
• Rejuvenate the upper third of the face. The aesthetical goal of a brow lift is to improve the tired, sad, angry, or aged appearance of the eyes, eyebrows, and forehead, thus generating a younger, happier, and less tired appearance.
• Rehabilitation of facial nerve paralysis. Paralytic forehead/brow ptosis is associated with various lesions of the facial nerve, possibly congenital, but usually acquired, i.e., neoplasms or trauma.

Indications

• Ptotic eyebrows leading to compromised visual field as documented by formal visual field testing. This may be aging related or paralytic (facial nerve) in etiology.
• Lateral hooding and redundant upper eyelid skin
• Glabellar rhytids/furrows created by corrugators, procerus, and depressor supercilii muscle action
• Horizontal forehead rhytids/furrows created by frontalis muscle function
• Lateral orbital ("crow's feet") rhytids created by orbicularis oculi muscle function
• Correction of brow asymmetry, if any

Contraindications

• Relative
• Alopecia, either of scalp or eyebrow cilia
• Dry Eye symptoms
• Absolute
• Lagophthalmos
• Severe dry eye
• Psychological/psychiatric instability of patient
• Unrealistic patient expectations (i.e., objects to presence of any surgical scars)

History

Complete medical and surgical patient history with special attention to

• Patient concerns, complaints
• Cosmetic: Patient complains of looking tired, angry, or sad despite feeling otherwise.
• Functional
• Visual: impairment of superior or lateral visual field hampering activities of daily living such as driving.
• Sensory: headaches, brow fatigue/ache due to chronic frontalis contraction
• Motor: difficulty opening eyes due to heaviness of eyelid/eyebrow
• History of dry eye: Pre-existing dry eye may be a relative or absolute contraindication to surgery.
• Prior eyebrow, forehead, or eyelid surgery
• History of prior facial paralysis may limit the success of surgical correction, requiring revision surgery.

Examination

The upper third of the face, namely scalp, forehead, eyebrows, and upper lids including glabella and lateral canthi need to be assessed. When evaluating the brow, it is important to ensure that the patient is not subconsciously recruiting the frontalis muscle to elevate the brows. This can be facilitated by asking patient to close the eyes, and slowly open while the surgeon is holding down brow manually to discourage frontalis contracture.

Brow anatomic morphology

The following specific age-independent anatomic factors need to be evaluated.

• Scalp hairline at frontal and temporal regions
• Forehead height: distance from eyebrow hairs to scalp hairline (normally 5–6 cm)
• Eyebrow shape and position, symmetry, hair quality, and mobility
• Bony eyebrow prominence (supraorbital ridge) and frontal bone convexity
• Forehead/scalp mobility
• Skin quality, texture, sebaceous quality, and thickness

There are female/male differences in the brow, with male brows being generally straight across, forming a T with the nose, at the level of the superior orbital rim, whereas female brows are positioned above the rim, with the aforementioned arch at the lateral canthus.

It is important to assess the medial and lateral brow position. The medial brow should be slightly lower than the lateral brow and the arch of the brow should be at the level of the lateral canthus, according to current aesthetic ideals.

There are normal variations to brow position with some patients having a "low brow" due to a small orbit, leaving a short brow to eyelid distance, and some brows being higher over the orbital rim with a greater distance from eyebrow cilia to the eyelid margin.

Aging-related changes of the brow

The forehead and brow soft tissue becomes more elastic with age and descends with gravity and the underlying attachments of the scalp to the supraorbital ridge weaken and stretch.

The frontalis muscle does not extend temporally to the bony temporal line, and does not extend to the tail of the brow, often allowing lateral brow ptosis to develop with age.

Chronic contraction of the brow depressors (corrugator muscles, orbicularis oculi muscle, and depressor supercilii muscle) facilitates brow ptosis and formation of rhytids at the glabella and crow's feet.

Chronic contraction of the frontalis to counteract the depressor forces leads to formation of transverse forehead rhytids.

The following aging-related specific factors need to be assessed:

• Severity of rhytids at forehead, glabella and lateral canthi
• Lateral hooding at lateral canthus, and degree of true dermatochalasis
• Presence of facial scars indicating prior brow or eyelid surgery
• Presence of lagophthalmos
• Presence/absence of Bell's phenomenon
• Hair quality: degree of alopecia
• Upper eyelid superior sulcus deformity/hollowness

Photography and visual field testing

• Insurance providers require photography and visual field testing to confirm the visual significance of brow ptosis.
• With and without eyebrow elevation

The only alternative to a surgical brow lift is a so-called "chemical brow lift" using botulinum toxin. Selective injection of this toxin into the depressor muscles of the brow — namely orbicularis oculi, corrugators, depressor supercilii, and procerus muscles — cause the elevation of the brow due to the unopposed action of the main brow elevator, the frontalis muscle. The effect of this type of brow lift is usually a few millimeters.

Direct Brow Lift

Indications, advantages

• Visually significant brow ptosis with heavy lateral hooding; excellent lift of brow with degree of lift directly correlating to amount of skin excised.
• Males with thick brows hide incisions better.
• Older patients with deep rhytids for incision placement
• Quick procedure for patients that can't undergo lengthier surgeries or deep IV sedation or general anesthesia
• No change in hairline
• Increased versatility in addressing brow asymmetry, and lifting the medial, central, or lateral brow depending on placement of incision

Contraindications, disadvantages

• Visible scar — though in older patients with thinner skin the scar may be imperceptible
• Possible forehead hypoesthesia if incision too deep
• Avoid in females and patients with thin brows
• Cannot raise medial brow significantly
• Cannot address forehead or glabellar rhytids

Anesthesia

• Local anesthesia (1% Lidocaine with 1:100,000 epinephrine mixed 2:1 with Bupivicaine 0.75%)
• IV sedation is useful to minimize discomfort from anesthetic injection, if available.

Instrumentation

• Adson or Adson-Brown forceps
• Webster or Castroviejo needle driver
• 15 Bard-Parker blade
• Small tenotomy scissors
• Suture scissors
• Needle-tip monopolar cautery

Marking the incision

This author prefers the "lift and drop" technique, with the patient sitting upright.

• Initially, the lower arm of the elliptical incision is marked either just above the brow cilia, or if present in a rhytid, close to the brow cilia.
• The medial extent of the incision should not reach the head of the brow.
• If there is significant lateral hooding, the lateral extent of the incision can be taken laterally past the tail of the brow.
• A manual lift of the brow is then performed positioning the brow where it should sit ideally, and with the pen hovering at where the initial lower mark was made.
• The brow is then allowed to drop without moving the pen and the skin is marked with a dot where the tissue rests underneath the hovering pen. This marks the height of tissue to be excised.
• This same "lift and drop" maneuver is repeated at 3 or 4 positions along the width of the brow.
• The upper line of the ellipse is drawn by connecting the dots forming an ellipse with the medial and lateral portions of the upper line tapering to meet the lower line.
• Once the incision is marked, the anesthetic solution is injected subcutaneously (with or without IV sedation).
• The ellipse can be positioned more medially or laterally depending on the need for lifting the head or tail of the brow (usually the tail).

Incision

• After allowing 10 minutes for epinephrine vasoconstriction, the incision is made.
• If incising directly adjacent to brow hairs, some surgeons advocate a beveled incision with the hair follicles, but this author prefers a perpendicular incision, slightly more cephalic to avoid hair follicles, which achieves better eversion of wound closure.
• The incision is taken down to the level of the frontalis and the skin and subcutaneous tissue is excised with Bovie cautery or tenotomy scissors.
• Wound closure is done in 2 or 3 layers depending on skin thickness and brow mobility.
• With thicker skin and a looser, more mobile brow, a deeper closure at level of frontalis is performed with 4‑0 absorbable Monocryl. This gives an additional level of brow suspension independent of the skin excision.
• A second layer of closure of the more superficial subcutaneous tissue is then performed with the same absorbable suture.
• Meticulous closure of the dermis layer can produce a well-everted wound edge, and ensures a minimally widened, nondepressed scar.
• The skin closure is performed with a 5‑0 or 6‑0 Prolene or nylon in running-locking fashion.

Postoperative instructions

• Head elevation, antibiotic ointment or plain petroleum jelly, and ice application
• A brow pressure dressing in shape of a headband can be placed to minimize postoperative edema and ecchymosis.
• Sutures are removed at 5–7 days.
• Patients are informed that incisions will be red for a few weeks and the scar can take a few weeks to mature and become less visible.

Internal browpexy

Indications, advantages

• Mild to moderate brow ptosis, especially at lateral third of the brow, in a patient undergoing upper blepharoplasty
• Quick procedure for patients who cannot undergo lengthier surgeries or deep IV sedation or general anesthesia
• No additional incision/scar
• No change in hairline
• Can contour sub-brow fat in excessively full brows (i.e., thyroid eye disease)

Contraindications, disadvantages

• Ineffective in moderate to severe brow ptosis
• Does not address forehead or glabellar rhytids unless medial dissection is carried out through medial extent of blepharoplasty incision to excise corrugators and/or procerus with some risk to supratrochlear neurovascular bundle

Anesthesia

• Local anesthesia (1% Lidocaine with 1:100,000 epinephrine mixed 2:1 with Bupivicaine 0.75%)
• If available, IV sedation is useful to minimize discomfort from anesthetic injection.

Instrumentation

• Adson or Adson-Brown forceps
• Webster or Castroviejo needle driver
• 15 Bard-Parker blade
• Small tenotomy scissors
• Suture scissors
• Needle-tip monopolar cautery

Marking the incision

• A browpexy is recommended only as an adjunct to upper blepharoplasty.
• Though this can be achieved in a sitting position, this author prefers placing the patient in a supine position. This naturally places the brow in the proper anatomic position as the downward effects of gravity are neutralized.
• A conventional blepharoplasty skin excision marking is then made using a pinch technique, and the eyelid and brow is injected with anesthetic solution.
• Once the incision is marked, the anesthetic solution is injected subcutaneously (with or without IV sedation).

Incision

• After allowing 10 minutes for epinephrine vasoconstriction, the upper blepharoplasty is performed.
• Once upper eyelid skin incised, using needle-tip cautery or tenotomy scissors, a suborbicularis dissection is performed above septum in a plane extending towards the superior orbital rim, staying deep to the retro-orbicularis oculi fat, but superficial to the periosteum.
• Blunt dissection in this plane with a cotton tip applicator is quite effective, extending exposure of this plane medially, staying lateral to the supraorbital neurovascular bundle.
• The superior extent of this dissection should be 2–3 cm above the rim.
• The lateral extent should be just past the blepharoplasty incision. One should be aware of the zygomaticotemporal vessels laterally.
• Once the dissection is complete, a needle is passed full-thickness through skin of the midbrow cilia perpendicularly to exit on the undersurface of the elevated brow flap to indicate the placement level of the brow fixation sutures.
• Using a 4‑0 polypropylene suture, 2 or 3 horizontal mattress sutures are used to fix and suspend the soft tissue of the brow (ROOF and subcutaneous tissue) to the underlying brow periosteum about 1–1.5 cm above the rim.
• Subtle dimpling of the overlying skin is acceptable and will resolve with time.
• The blepharoplasty incision is then closed as per surgeon preference.

Postoperative instructions

• Head elevation, antibiotic ointment or plain petroleum jelly, and ice application (2–3 days)
• Eyelid sutures are removed at 4–7 days.
• Patients are informed that incisions will be red for a few weeks and the scar can take a few weeks to mature and become less visible.

Midforehead

Indications, advantages

• Older patients with deep horizontal rhytids for incision placement
• Does not elevate hairline; in fact, it can decrease forehead height in high hairline patients, depending on the extent of the horizontal incision.
• Increased versatility in addressing brow asymmetry and lifting the medial, central, or lateral brow depending on placement of incision, which can be staggered across right and left sides of the forehead
• Can improve forehead lines inferior to incision

Contraindications, disadvantages

• Visible scar — though in older patients with thinner skin the scar may be imperceptible
• Avoid in women unless there are severe forehead rhytids/creases
• Thicker, sebaceous skin not ideal for this technique
• Possible forehead hypoesthesia if incision too deep

Anesthesia

• Local anesthesia (1% Lidocaine with 1:100,000 epinephrine mixed 2:1 with Bupivicaine 0.75%)
• If available, IV sedation is useful to minimize discomfort from anesthetic injection.

Instrumentation

• Adson or Adson-Brown forceps
• Webster or Castroviejo needle driver
• 15 Bard-Parker blade
• Small tenotomy scissors
• Suture scissors
• Needle-tip monopolar cautery
• Wide skin hooks

Marking the incision

• The midforehead incision can be made in 2 different ways:
• Complete transverse incision along the width of the horizontal forehead crease with possible irregular marking in midline to camouflage the scar
• This gives excellent access to the midline glabellar muscles for debulking purposes, if needed.
• 2 separate horizontal incisions, staggered at different heights on the forehead, on the right and left sides; they may overlap slightly at the midline.
• This breaks up the scar more effectively, drawing less attention.
• However, the corrugators and procerus muscles cannot be accessed with this incision.

Incision

• After allowing 10 minutes for epinephrine vasoconstriction, the incision is made.
• The incision is taken down to the subcutaneous plane, without entering the galea.
• The subcutaneous skin flap is then elevated with sharp and blunt dissection with a blade and tenotomy scissors to the level of the brow and root of the nose.
• To access the glabellar muscles, a central transgaleal incision is made about 3 cm superior to the root of the nose.
• The supraorbital neurovascular notch should be identified and the incision should not be extended laterally to avoid damage.
• The subgaleal dissection is then performed through this medial incision, to access the corrugators and procerus muscles which can be cauterized and extirpated with Adson-Brown forceps.
• The supratrochlear nerves should be avoided at the medial third of the corrugator muscle.
• The galeal incision is then closed with an absorbable 4‑0 suture.
• The cephalic subcutaneous dissection of the upper edge of the incision is performed for about 1–2 cm to allow proper wound eversion on closure.
• The flap is then draped superiorly, and while pulling the flap upward, the amount of skin to be excised at the flap edge can be marked while determining the preferred level of brow elevation along the width of the flap.
• This allows for versatility to address brow asymmetry, by tailoring the amount of skin excision medially and laterally.
• The wound closure is then performed meticulously in 2 layers.
• Deep dermal closure with multiple, buried 4‑0 or 5‑0 PDS (depending on skin thickness) is performed along the width of the wound, eliminating any tension on the skin.
• The skin closure is performed with a 5‑0 or 6‑0 Prolene or nylon in running-locking fashion.
• A subcuticular suture is also possible, which minimizes risk of suture track marks, but wound eversion is slightly compromised.
• If decision is made to make staggered incisions for better scar camouflage, 2 separate forehead creases are marked at different heights on the forehead on the right and left side.
• Again, a subcutaneous incision is made to the level of the brow.
• In severe brow ptosis, the superior edge of the orbicularis can be suspended to the periosteum with two to three 3‑0 nylon sutures.
• This is especially helpful in cases of facial paralysis.
• This will also help with the excision of the excess skin, once the flap is draped superiorly.
• Closure is performed in the same meticulous fashion described above.

Postoperative instructions

• Head elevation, antibiotic ointment or plain petroleum jelly, and ice application
• A brow pressure dressing in shape of a headband can be placed to minimize postoperative edema and ecchymosis.
• Skin sutures are removed at 4–7 days.
• Patients are informed that incisions will be red for a few weeks and the scar can take a few weeks to mature and become less visible.
• The importance of sunblock and minimizing sun exposure is stressed to avoid possible hyperpigmentation of the inflamed scar.

Endoscopic

Indications, advantages

• Effective for addressing medial and lateral brow ptosis
• Improves glabellar and forehead wrinkling and furrows
• Minimally invasive (small incisions, all camouflaged behind the hairline)
• Minimal risk of scalp sensory dysfunction and alopecia
• Improved success in patients with thin skin, and mild/moderate brow ptosis
• Excellent, magnified visualization of anatomy with endoscopic visualization to release periorbital adhesions
• Can be used in patients with alopecia with minimal scarring.
• Ideal candidate: short/flat forehead, normal/thin skin, moderate rhytids, thick hairline

Contraindications, disadvantages

• Should not be used in patients with high hairlines (forehead length 7 cm or greater)
• Less effective in patients with severe brow ptosis, and heavier, less mobile foreheads
• Increases height of forehead
• Need for endoscopic equipment and fixation technique/equipment (increased cost of surgery)
• Risk to temporal branch of facial nerve if dissection in improper plane or if cautery applied to exit of sentinel vein into flap
• Question regarding longevity of lift without skin excision
• Poor candidate: high/convex forehead, receding/thin hairline, thick skin, deep rhytids

Anesthesia

• Local anesthesia (1% Lidocaine with 1:100,000 epinephrine mixed 2:1 with Bupivicaine 0.75%)
• Injection is performed at all sites of incision and along the entire forehead, and temporal dissections, especially at the arcus marginalis, supraorbital/supratrochlear neurovascular bundles, and glabellar muscles.
• General anesthesia, or deep IV sedation with propofol and midazolam/fentanyl, administered by anesthesia team is required.
• Airway protection is extremely important in deep sedation.

Instrumentation

• Adson or Adson-Brown forceps
• Webster needle driver
• 15 Bard-Parker blade
• Endoscope: 4‑ or 5‑mm 30‑degree-angle Hopkin rod with cannula or endo-rectractor
• Monitor and light source
• Camera
• Defogging solution
• Suture scissors
• 9 periosteal elevator
• Curved periosteal elevator
• Nerve dissector
• Suction cautery or insulated grasping cautery
• Endoscopic scissors
• Wide skin hook
• Fixation device:
• Bone tunnel bridge system with handheld or
• Electric drill or
• Endotine fixation device/drill

Marking the landmarks and incisions

• Useful landmarks to identify:
• Midline of the forehead
• Supraorbital neurovascular bundles about 2.7 cm on each side of midline, the temporal crest, or ridge, which is the site of adhesion of the galea medially to the temporoparietal fascia laterally
• Sentinel vein, if visible
• 5 total incisions are marked:
• 3 for the frontal optical cavity posterior to frontal hairline
• One vertical incision is marked at midline just posterior to hairline about 1 cm long for improved visualization of glabellar region with endoscope.
• Laterally, one each side, one vertical incision is made posterior to hairline at the level of the highest convexity of the arch of the brow. This will be the site of skull fixation on each side.
• 2 temporal incisions, 1 on each side for the temporalis optical cavity
• On each side, 3‑cm long incision parallel and posterior to the temporal hairline.
• Extending in a line from the ala through the lateral canthus and onward past the temporal hairline can help identify the region over the temporalis muscle.
• This should be lateral to the marking of the temporal crest.
• This incision can be placed about 2 cm behind the hairline to camouflage the incision within the temporal hair.

Incision

After allowing 10–15 minutes for epinephrine vasoconstriction, the procedure is initiated in the following sequence:

• Temporal incisions/dissection:
• This is essentially the same as a temporal brow lift incision.
• About 2 to 3 cm behind the hairline, the incision is made through scalp skin down to the level of the deep temporalis fascia (DTF).
• Once the incision is initialed, 2 wide muscle hooks applied to each side of the incision can help bluntly pull open the planes safely until the glistening white DTF is seen.
• Gliding the skin incision back and forth with the skin hooks can help identify the fibers of the superficial temporalis fascia that move over the DTS.
• A 9 periosteal elevator is used to slide through these fibers to enter the proper plane.
• If unsure whether you are in the proper plane, a small nick on the DTF will reveal the underlying muscle below.
• The incision is made 3 cm behind the temporal hairline and taken down through subcutaneous tissue and temporoparietal fascia to the level of the shiny deep temporalis fascia.
• The elevation of the flap is then initiated towards the lateral canthus in this plane with a blunt 9 periosteal elevator.
• As this dissection continues inferiorly, one should switch to endoscopic visualization.
• The superficial temporal fat pad on the deep surface will be encountered.
• Traversing this space between the flap above and the temporalis muscle below, the zyomatico-temporal vein ("sentinel vein") can be seen.
• This structure is important as the temporal branch of the facial nerve is usually slightly temporal to this structure within the raised flap, and care should be taken to avoid traumatizing this nerve by traction or cautery.
• Avoid cautery of this structure as other more superficial periorbital veins may become more visible postoperatively.
• The dissection should be taken to the frontozygomatic process at the lateral canthus.
• There are dense adhesions, "orbital ligaments," to the underlying bone at this location that need to be released for adequate elevation of the brow.
• This may be done with the periosteal elevator bluntly, but if not possible, the endoscopic scissors can be used.
• The "conjoint tendon," or the adhesions of the galea to the superficial temporalis fascia at the temporal ridge, is the medial extent of this dissection.
• Once the dissection to the orbital rim/lateral canthus is complete, the flap will then be pulled superolateral vector to see the movement of the tail of the brow.
• If the movement is unsatisfactory, further dissection of adhesions at the frontozygomatic suture, lateral arcus marginalis, and lateral canthus is required until mobility is achieved.
• Frontal incisions/dissection:
• The 3 incisions are then made with 15 blade all the way down through periosteum to the bone.
• Some surgeons have advocated a subgaleal dissection, believing that this achieves better draping of the flap and better long term results. Most surgeons, myself included, prefer a subperiosteal dissection.
• Once the incision is made through periosteum, a curved periosteal elevator is used to enter the subperiosteal space and blindly dissect inferiorly on the bone along the width of the forehead to about 1 cm of the orbital rim, at which time the endoscope is inserted with its sheath to safely visualize the neurovascular bundles and the corrugator muscles.
• With the curved elevator, the arcus marginalis is released around the neurovascular bundles, and the periosteum at the rim is incised with side to side action of the elevator, exposing brow fat.
• This is the most important aspect of the surgery ensuring proper release and elevation for a long lasting lift.
• A nerve dissector may be used to release the nerves from the periosteum.
• Release of medial brow depressors:
• If medial brow elevation or softening of the glabellar rhytids is required, the procerus, corrugators, and depressor supercilii muscles can be addressed once the periosteum has been released.
• Cautery with a circular suction device can minimize bleeding of the muscle prior to removal of the muscles.
• This can ideally be achieved with an endoscopic grasper. Care should be taken to avoid grasping and injuring the supraorbital and supratrochlear nerves.
• To avoid healing of the muscle fibers, one can place subcutaneous fat from edge of skin excisions in the space created between the fibers.
• Releasing the temporal line of fusion, temporal conjoint fascia:
• Once the temporal and central optical cavities have been created, the adhesion of the TPF and the galea at the temporal ridge needs to be released.
• This can be done with blunt dissection with a periosteal elevator or closed Metzenbaum scissors from temporal cavity to central cavity.
• The release is started superiorly and can be extended inferiorly by forcefully sliding the elevator towards the supraorbital rim.
• Further release of adhesions ("conjoint tendon") at this area needs to be performed to ensure adequate periosteal release and elevation of the lateral brow.
• Brow elevation and fixation:
• Though some surgeons have described elevation without fixation, the author prefers fixation to underlying bone.
• Subperiosteal dissection of the scalp posterior to the incisions needs to be performed for about 4–5 cm superiorly to allow for adequate superior draping of the forehead flap and to minimize bunching of skin at the incision sites.
• Using the paracentral forehead incisions at the level of the tail of the brow, cortical bone tunnels are created with the angled bone tunnel device or Endotine drill system.
• The placement of the hole is determined by draping the forehead flap superiorly as far as it can be moved and marking the bone at that level.
• Skin hooks can be used to facilitate the draping and exposure for drilling.
• Once the bone tunnel is made, 2‑0 Prolene suture is used to secure a thick bite of the periosteum of the elevated flap to the bone hole while your assistant pushes the forehead superiorly.
• Overcorrection is necessary as the brow will settle within a few weeks.
• It is very difficult, at least in this surgeon's hands, to overcorrect an endoscopic lift in a patient with a truly ptotic brow, as endoscopic brow lifts tend to settle with time.
• Skin closure of the 3 frontal vertical incisions is achieved with staples.
• The temporal flaps are then each draped superiorly, redundant temporal skin is excised, and the superficial temporalis fascia is suspended to the deep temporalis fascia with 2–3 sutures using 4‑0 PDS.
• Closure of incision is again performed in 2 layers, deep closure with 4‑0 PDS, and staples to close skin.
• Avoid unnecessary cautery to minimize risk of alopecia.

Dressing

• Telfa gauze with bacitracin ointment is placed over the incision sites
• Pressure dressing with Kerlix gauze and Coban wrap is placed to prevent hematoma formation and to minimize postoperative edema and ecchymosis.

Postoperative instructions

• Head elevation, antibiotic ointment or plain petroleum jelly, and ice application
• The head wrap can be removed at postoperative day 3.
• Staples are removed at 5–7 days.
• Patients should be informed that incisions will be red for a few weeks and the scar can take a few weeks to mature and become less visible.
• Full activities can be resumed at 3 weeks.

Temporal

Indications, advantages

• Effective for addressing ptosis at the tail of the brow (lateral one third of brow)
• Improves lateral hooding and temporal laxity/wrinkling
• Excellent scar camouflage if incision is made behind temporal hairline

Contraindications, disadvantages

• Visible scar if incision is placed at temporal hairline
• Increased length of temporal nonhair-bearing skin (raising of temporal tuft) if incision is made behind the temporal hairline
• Does not address the medial brow or the forehead rhytids
• Risk to temporal branch of facial nerve if dissection in improper plane

Anesthesia

Local anesthesia (1% Lidocaine with 1:100,000 epinephrine mixed 2:1 with Bupivicaine 0.75%). IV sedation is useful to minimize discomfort from anesthetic injection, if available.

Instrumentation

Adson or Adson-Brown forceps, Webster needle driver, 15 Bard-Parker blade, Metzenbaum scissors, suture scissors, No.9 periosteal elevator, bipolar bayonet tip cautery, wide skin hooks, headlight or fiberoptic skin retractor.

Marking the incision

There are 2 incision options:

• Posterior to temporal hairline:
• Mark a 3 cm incision parallel and posterior to the temporal hairline.
• This incision can be placed about 3 cm behind the hairline to camouflage the incision within the temporal hair.
• With redraping of the temporal flap superolaterally, the width of the nonhair-bearing skin will increase.
• At temporal hairline:
• 3 cm incision just anterior to the temporal hairline follicles
• Though leaving a visible scar, this has the benefit of not changing the width of the patch of nonhair-bearing skin between the tail of the brow and the temporal hairline.

Incision

After allowing 10 minutes for epinephrine vasoconstriction, again, 2 options exist for elevating the temporal flap:

• Subcutaneous plane:
• The skin incision is made with a 15 blade.
• The incision is taken down to the subcutaneous plane, just deep to the hair follicles, above the temporoparietal fascia.
• The flap is then slowly and meticulously elevated in this plane with the Metzenbaum scissors until the superotemporal edge of the orbicularis oculi is visualized.
• It is of paramount importance that this flap elevation is not mistakenly taken too deep, thus entering the temporoparietal fascia within which the temporal branch of the facial nerve travels.
• Once the flap is effectively elevated to the orbicularis oculi, it can be suspended to the deep temporalis fascia with 2–3 sutures using 4-0 PDS.
• The flap will then have some redundancy when it is redraped in the superotemporal vector.
• It can be excised and the closure can be done in 2 layers:
• Deep closure of subcutaneous tissue with 4-0 PDS
• Skin closure with 5-0 Prolene if incision is anterior to hairline.
• If incision is posterior to hairline, it can be closed with staples.
• Deep temporal fascia plane — this is the same dissection as performed for the lateral aspect of the endoscopic forehead lift
• The incision is made 3 cm behind the temporal hairline and taken down through subcutaneous tissue and temporoparietal fascia to the level of the shiny deep temporalis fascia.
• The elevation of the flap is then initiated towards the lateral canthus in this plane with a blunt 9 periosteal elevator.
• As this dissection continues inferiorly, one will visualize the superficial temporal fat pad on the deep surface.
• Traversing this space between the flap above and the temporalis muscle below, the zyomatico-temporal vein ("sentinel vein") can be seen.
• This structure is important as the temporal branch of the facial nerve is usually slightly temporal to this structure within the raised flap, and care should be taken to avoid traumatizing this nerve by traction or cautery.
• The dissection should be taken to the frontozygomatic process at the lateral canthus.
• There are dense adhesions, "orbital ligaments," to the underlying bone at this location that need to be released for adequate elevation of the brow.
• The "conjoint tendon" or the adhesions of the galea to the superficial temporalis fascia at the temporal ridge is the medial extent of this dissection, though some surgeons advocate releasing this attachment, as in endoscopic brow-lifting, to achieve a better mobilization of the lateral brow.
• Once the dissection to the orbital rim/lateral canthus is complete, the flap will then be pulled in a superolateral vector until the tail of the brow is in the desired position.
• The redundant skin is then excised and the superficial temporalis fascia is suspended to the deep temporalis fascia with 2–3 sutures using 4-0 PDS.
• Closure of incision is performed in 2 layers:
• Deep closure with 4-0 PDS
• Skin with staples
• Avoid undue cautery to avoid alopecia.

Postoperative instructions

• Head elevation, antibiotic ointment or plain petroleum jelly, and ice application
• A brow pressure dressing in shape of a head/forehead wrap (Kerlix gauze and Coban wrap) can be placed to minimize postoperative edema and ecchymosis.
• The head wrap can be removed at postoperative day 3.
• Skin sutures and/or staples are removed at 5–7 days.
• Patients should be informed that incisions will be red for a few weeks and the scar can take a few weeks to mature and become less visible.
• The importance of sunblock and minimizing sun exposure is stressed to avoid possible hyperpigmentation of the inflamed scar.

Pretrichial (Hairline)

This is the author's preferred cosmetic technique for patients with

• Normal to high hairlines
• Moderate to good hair density
• Moderate to severe brow ptosis

Indications, advantages

• Moderate to severe brow ptosis
• Excellent lift at both medial and lateral brow
• Increase longevity of lift due to removal of nonhair-bearing skin
• Improves lateral hooding and temporal laxity/wrinkling as well as ability to improve glabellar and midforehead rhytids
• Excellent technique in patients with high hairlines (can shorten height of forehead and possible lower hairline), convex forehead, and heavy skin
• Excellent exposure to release adhesions and periorbita, address forehead and brow muscles
• Good scar camouflage with inferiorly beveled incision sparing the hair at incision

Contraindications, disadvantages

• Visible scar if incision is incision is poorly executed.
• Scalp anesthesia behind hairline which may take a year or longer to improve
• Technically difficult procedure
• Not ideal for thin hairlines or male patients with receding hairlines as scar will be more visible

Anesthesia

• Local anesthesia (1% Lidocaine with 1:100,000 epinephrine mixed 2:1 with Bupivicaine 0.75%)
• Deep IV sedation or general anesthesia is required.

Instrumentation

• Adson or Adson-Brown forceps
• Webster needle driver
• 10 and 15 Bard-Parker blades
• Metzenbaum scissors
• Suture scissors
• 9 periosteal elevator
• Bipolar bayonet-tip cautery
• Wide skin rakes/hooks

Marking the incision

• The incision is marked 3 mm behind the frontal hairline along the width of the forehead, from crest to crest, in a sinusoidal pattern.
• This is done to minimize attention that a straight incision might generate.
• The incision is then taken into the temples in a curvilinear fashion posteriorly about 2–3 cm behind the temporal hairline and curved down to about 1–2 cm superior to the root of the helix.
• This can be continued to meet a facelift incision if performed.
• The hair along this incision mark is then shaved about 3 mm at frontal hairline and 1 cm in temples for ease of incision and closure.

Incision

• Local anesthetic is infiltrated in subgaleal plane along forehead and temples. The incision is also infiltrated subcutaneously.
• After allowing 10–15 minutes for vasoconstriction, the incision is initiated along the sinusoidal mark in a beveled fashion from superior to inferior so that the hair follicles are not elevated with the flap.
• This will avoid their excision along with the redundant skin as the flap is redraped later on in the procedure.
• The preservation of these hair follicles will allow for hair growth through the scar for better camouflage.
• The depth of the incision is to the subgaleal plane.
• The incisions are then taken laterally on each side to the hair bearing temple.
• This region of the incision is not beveled, but rather kept perpendicular with follicles.
• The depth of this incision is to the deep temporalis fascia.
• This is the shiny covering on the temporalis muscle that is not mobile as the skin overlying it is moved.
• A nick in the fascia will make the muscle visible and confirm that you are in the correct plane.
• Using a 9 periosteal elevator, the flap is elevated in the temples along this plane, keeping the frontal branch of the facial nerve safely above within the superficial temporalis fascia in the elevated flap.
• Along the frontal incision the subgaleal dissection is continued inferiorly with the help of a 10 blade, which is quite efficient.
• Along the temporal crests, the line of fusion of the galea to the temporoparietal fascia is released connecting the temporal dissections to the frontal dissection.
• The elevation of the temporal aspects of the flap is then initiated towards the lateral canthus in this plane with a blunt 9 periosteal elevator.
• As this dissection continues inferiorly, one will visualize the superficial temporal fat pad on the deep surface.
• Traversing this space between the flap above and the temporalis muscle below, the zyomatico-temporal vein ("sentinel vein") can be seen.
• This structure is important as the temporal branch of the facial nerve is usually slightly temporal to this structure within the raised flap, and care should be taken to avoid traumatizing this nerve by traction or cautery.
• The dissection should be taken to the frontozygomatic process at the lateral canthus.
• There are dense adhesions at this location, sometimes called "orbital ligaments," to the underlying bone which need to be released for adequate elevation of the brow.
• The "conjoint tendon," or the adhesions of the galea to the superficial temporalis fascia at the temporal ridge should be released all the way down to the rim of the orbit to achieve better mobilization of the lateral brow.
• The frontal subgaleal dissection is continued inferiorly until about 1 cm from the brow ridge at which point it is transitioned to a subperiosteal plane.
• The supraorbital and supratrochlear neurovascular bundles are the identified and dissected free from the periosteum.
• The entire arcus marginalis is then elevated from the orbital rim ensuring proper release of the brow attachments from lateral canthus to lateral canthus.
• With the flap reflected anteriorly over the patient's eyes/face, there is excellent visualization of the glabellar muscles.
• The corrugator muscles are then cauterized and excised along the medial third with special care to avoid damage to the neurovascular bundles.
• If there are deep horizontal lines in the glabellar region, the procerus muscle can be transected horizontally and stripped as well.
• An Adson-Brown forceps is excellent for the stripping of the glabellar muscle.
• Once a gap is generated within the corrugators muscle, this author likes to suture an autologous spacer graft in this space to prevent healing and reanimation of the corrugators muscle, which almost invariably happens with time.
• Fat is excellent to use as a spacer graft.
• Once can use fat from lower blepharoplasty if available, or from the redundant SMAS from a facelift, or even subcutaneous fat from the edge of the flap's redundant skin, when redraped.
• Temporalis fascia is also a possibility.
• This is sutured into place with a 4-0 or 5-0 absorbable suture.
• Once this is complete, the fully elevated flap with excellent release at the orbit and canthi can be redraped with a superior pull to determine the amount of brow elevation desired.
• Major fixation is performed at midline and at each lateral tail of the brow to support the elevated flap while minimizing wound tension.
• With the flap elevated to the desired height with an Adson forceps at skin edge, an 11 blade is used to make a stab incision at the location of fixation sutures, and the 11 blade is rotated and a back cut is made toward the skin edge.
• This will be the redundant skin that will be excised along the frontal incision.
• The scalp should be undermined in subgaleal plane posteriorly to allow for proper closure.
• Using a buried 2-0 PDS suture, the galea is redraped and fixated to the posterior flap.
• Once both lateral fixation sutures are placed, the redundant skin is excised along the frontal incision, again in a beveled fashion inferiorly to ensure proper alignment of the wound edges, and growth of hair through the incision scar.
• This can be technically challenging as the incision is sinusoidal and proper tension is required to make this beveled incision on the redundant flap skin.
• This is critical for proper scar camouflage.
• Once the excess nonhair-bearing skin has been removed, additional buried 2-0 sutures are used along the width of this incision to ensure minimal tension on the wound.
• Attention is then turned to the temporal extent of the incision, where with a superolateral vector of pull on the flap, until the tail of the brow is in the desired position, the redundant hair-bearing skin is excised.
• The superficial temporalis fascia is suspended to the deep temporalis fascia with 2–3 sutures using 4-0 PDS.
• Closure of incision is performed in two layers, deep closure with 4-0 PDS, and skin with staples.
• Avoid undue cautery to avoid alopecia.

Postoperative instructions

• Head elevation, antibiotic ointment or plain petroleum jelly, and ice application
• A brow pressure dressing in the form of a head/forehead wrap (Kerlix gauze and Coban wrap) should be placed to minimize postoperative edema and ecchymosis and possible hematoma.
• The head wrap can be removed at postoperative day 3.
• Skin sutures and/or staples are removed at 5–7 days. Patients should be informed that incisions will be red for a few weeks and the scar can take a few weeks to mature and become less visible.
• The importance of sunblock and minimizing sun exposure is stressed to avoid possible hyperpigmentation of the inflamed scar.

Coronal

First described by Hunt in 1926, coronal brow lifts where once considered the gold standard for brow lifting. Though the coronal brow lift gives excellent exposure and lift, its potential disadvantages are considerable:

• Poor scarring
• Alopecia
• Forehead paresthesia
• Scalp anesthesia
• Extensive elevation of frontal hairline by as much as 1–2 cm

With the advent of the endoscopic technique and pretrichial techniques, coronal brow lifting has essentially become an obsolete approach to brow lifting, which this author has never used in clinical practice.

The technique is essentially identical to the pretrichial approach detailed above, with the only exception being that the incision is made 4–6 cm behind the hairline in the scalp. The benefit of this approach is that the incision will be entirely hidden — as long as alopecia does not develop.

Combination Trichophytic and Endoscopic

This technique combines the 2 techniques to minimize scar length of the standard pretrichial brow lift while enabling the surgeon to remove excess forehead skin which the standard endoscopic brow lift cannot achieve. This ensures that the hairline is not raised and the forehead height is not elongated. The technique was first described by Tower and Dailey in 2004.

Postoperative instructions

See individual procedures above.

Strenuous activity and lifting objects greater than 20 lbs should be avoided for the first 2 weeks after surgery.

Wounds should be kept moist with ointment for first 10–14 days after surgery until complete epithelialization has taken place

Scar massage can be initiated starting 2 weeks after surgery using Vitamin E for 5–10 minutes a day for 6–8 weeks after surgery.

Medications prescribed

• Pain medication: Oxycodone or hydrocodone
• Lubrication: Bacitracin ointment or plain petroleum jelly

Other management considerations

If brow lifting is done in conjunction with upper eyelid blepharoplasty, the brow lift should be performed first so as to better assess the amount of eyelid skin removal.

If face lift procedure is done in conjunction with brow lift procedure, the upper extent of the preauricular incision of the face lift can be continuous with the temporal brow lift incision.

Initial "overcorrection" of brow ptosis with endoscopic technique will settle with time.

Overcorrection with trichophytic approach should not be performed because this approach settles minimally.

Botulinum toxin of glabellar muscles are thought to help during fixation period after endoscopic approach until periosteal healing is complete. Some find that permanent periosteal reattachment is completed within 2 weeks, whereas others that it can take 6 weeks or longer.

Common treatment responses, follow-up strategies

Trichophytic, coronal, direct, and midforehead lifts should impart a significant lift that should last 10–15 years or longer.

Endoscopic brow lift longevity is in the 7–10-year range depending on skin thickness.

Internal browpexy technique generally does not impart significant lift to the brow, but rather stabilizes the brow position.

Facial palsy patients have a significant shorter longevity of lift even with aggressive direct brow lifts, and repeat surgery is often required.

• Hematoma
• Confirm complete hemostasis at temporal incisions where the superficial temporal vessels may cause hematomas
• Drain hematoma with needle aspiration or opening of the wound if the hematoma is consolidated. After hematoma evacuation, compression dressing should be reapplied.
• Flap Necrosis
• Avoid undue wound tension
• Avoid overly tight compression dressing
• Infection
• Be aware of increasing erythema and pain at 3–4 days postoperatively.
• Cover for gram positive infection
• Alopecia
• Avoid aggressive cautery at incisions
• Facial nerve paresis
• Make sure plane of dissection is directly on top of deep temporalis fascia
• Avoid cautery of flap near "sentinel vein"
• Scalp hypesthesia/paresthesia
• Will improve with time, often longer than 1 year
• Neuralgia
• Corticosteroid injections may be helpful
• Incision pruritis
• Temporary (1–2 weeks) use of class 7 corticosteroid cream may be helpful.
• Widened or depressed scar
• Make sure deep sutures take tension off wound. Meticulous closure is necessary.
• Laser resurfacing or scar revision may be necessary
• Scar pigmentation
• Hyperpigmentation can be treated with hydroquinone and steroid creams
• Hypopigmentation needs to be covered with makeup
• Brow asymmetry
• Careful inspection during surgery can help minimize risk
• Facial paralysis may necessitate repeat surgery
• Elevated hairline
• Avoid coronal or endoscopic techniques in patients with high hairlines
• In severe cases, tissue expanders in the hair bearing scalp can provide tissue to lower brow.

• Progressive visual field/vision deficit
• Possible irritation of eyelid skin with lash irritation

Passot first described elliptical forehead excisions to lift brows in 1919.

Hunt described coronal brow lift in 1926.

Lexer described different forehead incisions for brow lifting in 1931.

Vinas presented techniques for forehead rhytidectomy and brow lifting in 1969. He is often credited as one of the innovators of the coronal brow lift.

Kay in 1976 described the modern coronal brow lift and the option of a hair line incision to preserve the height of the forehead.

Pitanguy suggested modification of the glabellar muscles to augment the lift and improve rhytids in 1979.

Mayer and Fleming described the beveled and irregular trichophytic approach in 1992.

Paul may have been the first to describe the internal browpexy approach in 1989.

Vasconez and Isse first described the use of endoscope for brow lifting in 1992.

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