Brow Lift

Facial Plastic and Reconstructive Surgery

Module Summary

There are many different options for brow and forehead rejuvenation. Surgeons must be able to assess the brow and forehead, accommodate specific patient requests, and develop a customized treatment plan. The most important attributes for preoperative evaluation are brow position and shape, asymmetry, hairline, and scar tolerance.

Module Learning Objectives

Describe the anatomy of the brow complex
Summarize the components of brow aesthetics
Describe the proper planes of dissection in brow lift techniques
Cite important facets of patient selection for lift procedures

Anatomy and Aging Process

Layers of the Scalp and Brow

Corrugator supercilia – paired muscle
- Originates superomedial orbit and inserts into medial brow skin
- Contraction leads to medial and inferior displacement of the medial brow
Procerus – single muscle
- Originates from upper nasal bones and inserts into glabellar dermis
- Leads to inferior displacement of the medial brow
Frontalis – usually a single muscle, but can be bifid
- Extension of galea aponeurosis
- Inserts into dermis of upper brow
- Leads to elevation of the brow
Oribicularis Oculi – paired muscle
- Inserts into dermis of brow
- Leads to inferior displacement of the brow

Layers of the Anterior Temple Region

Skin
Subcutaneous Tissue
Temporoparietal Fascia
- Frontal nerve lies on this layer’s undersurface
Deep Temporal Fascia
- Fascia divides into Superficial Layer and Deep Layer as they relate to the superficial temporal fat pad
Temporalis Muscle

Neurovascular Contributions

Sentinel Vein – lateral frontal vein that lies within 1cm of the frontal nerve
Supratrochlear artery – intimately adjacent to the corrugator, from internal carotid system
Supraorbital artery – from internal carotid system
- Deep branches of the supratrochlear and supraorbital arteries vascularlize the pericranium
Superficial Temporal Artery – responsible for temporoparietal fascial flap, anterior branch may need to be addressed during surgery
Supraorbital nerve (V1) supplying forehead
Zygomaticotemporal nerve and Auricotemporal nerve of V2 supplying the temple region

Brow aesthetics

Brow aesthetics have significantly evolved in the last 20 years
Lateral brow terminates along an oblique line drawn through the nasal ala and the lateral canthus
- Medial and lateral brow lie at approximately same height
Men:
- Apex of brow directly above pupil
- Brow lies along orbital rim
Women:
- Apex of brow lies on vertical line above lateral canthus or lateral limbus
- Brow lies above orbital rim
- Due to the globalization of beauty and particularly due to Hispanic influence, the flat, heavy female brow has been featured more as a sign of beauty

The Aging Process in the Brow

Medial Brow
- The corrugator supercilii muscles cause vertical rhytids at the glabella
- The procerus causes horizontal rhytids at the radix
Lateral Brow
- The frontalis muscle extends along the brow approximately to the lateral canthus
- The orbicularis oculi acts to pull down the brow along the entire brow
- The tail of the brow is therefore only affected by the orbicularis oculi, leading to a downward pull. This may cause superolateral visual field impairment
- Lateral brow descent may lead to redundant tissue, lateral to the canthus, exacerbating crow’s feet
Forehead
- Alopecia involving the anterior hairline can increase the relative size of the forehead
  - Androgenic alopecia
  - Frontal fibrosing alopecia
  - Traction alopecia (“corn rows” or tight ponytails)
- Frontalis muscle leads to horizontal rhytids
- Oblique lines may be caused by sleeping positions, solar damage, etc.
- Loss in skin elacity leads to progressive sagging
Upper Eyelid
- Upper eyelid blepharocholasis and dermatoblepharon must be differentiated from brow ptosis
- Upper blepharoplasty will not elevate the brow, underlining the importance of managing patient expectations

References

Langsdon P, Petersen D: Management of the aging forehead and brow. Facial Plast Surg 2014 Aug;30(4):422-30.
Ridgway, JM, Larrabee WF. Anatomy for blepharoplasty and brow-lift. Facial Plastic Surg 2010 Aug;26(3):177-85.
Nassif PS, Thomas JR. Management of the aging brow and forehead. In: Cummings CW, Flint PW, eds. Otolaryngology Head & Neck Surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005: 750-763.

Technique

Types of Lifts

Coronal
- Indication
  - low or normal hairlines,
  - without alopecia in the crown
- Advantages
  - Hidden scar line
- Disadvantages
  - Numbness posterior to the incision
  - Limited use in men
  - Unable to adjust asymmetries
- Procedure
  - Curvilinear incision made 7cm behind the anterior hairline
  - Incision made parallel to hair follicles
  - Plane of dissection:
    - Subgaleal/supraperiosteal over parietal scalp
    - Supraperiosteal over frontal bone
    - Superficial to superficial layer of deep temporal fascia
  - Periosteum (pericranium) can be raised as separate vascularised flap for craniofacial reconstruction
  - Corrugators and procerus partial resection

Trichophytic/Pretrichial
- Indication
  - Normal or high hairlines who do not want a hairline elevation,
  - Without frontal alopecia
  - Can be combined with hairline advancement to potentially lower the hairline
- Advantages
  - Preserves hairline
- Disadvantages
  - Visible thin scar
  - Prolonged hypesthesia
- Procedure
  - Irregular incision in front of the hairline (pretrichial)
  - Irregular incision 3-4mm behind hairline (trichophytic)
  - Bevelled incision to allow hair to grow through scar
  - Dissection continues as coronal lift
    - Some advocate for a subcutaneous forehead dissection, which carries higher risk of flap necrosis and possible decreased longevity

Endoscopic
- Indication
  - Short forehead
  - Balding patients
- Advantages
  - Small incisions
  - Decreased incidence of postop anesthesia
  - Preserves hairline
- Disadvantages
  - Additional required equipment
  - Significant learning curve
  - Discomfort associated with fixation devices
- Procedure
  - Midline transverse incision 3-5cm behind hairline
  - Two paired vertical incisions 4-5 cm from midline behind hairline
  - Two paired incisions in temporal hair
  - Lateral dissection performed first to develop proper plane to protect Frontal nerve on deep temporal fascia
  - Medial dissection performed next in subperiosteal, joined to the lateral dissection
  - Corrugators and procerus partial resection
  - Fixation of periosteum using screws, plates, other fixation devices

Mid-forehead
- Indication
  - Deep forehead rhytids
  - Asymmetric brows or unilateral frontal paresis/paralysis
- Advantages
  - Excellent for unilateral issues
  - Fine-tuning of brow possible
- Disadvantages
  - Scar located in visible forehead
- Procedure
  - Single fusiform excision vs two fusiform excisions in prominent rhytid
  - Plane of dissection is subcutaneous, superficial to the frontalis

Direct
- Indication
  - Brow ptosis with desire for brow reshaping
  - Lateral ptosis/hooding
- Advantages
  - Each brow independently assessed/treated
  - Ability to customize excision for brow reshaping
  - Preserves forehead/scalp sensation
- Disadvantages
  - Visible scar above eyebrow(s)
- Procedure
  - Fusiform excision made directly above the brow
  - Dissection in subcutaneous plane
  - Fixation suture used from skin, through muscle, to periosteum

Indirect Browlift/Brow-pexy
- Indication
  - Lateral ptosis/hooding
- Advantages
  - Each brow independently assessed/treated
- Disadvantages
  - Need for over-correction
  - Lack of longevity
  - Prolonged eyelid edema
- Procedure
  - Incision made through an upper blepharoplasty incision
  - Dissection through subbrow muscular space
  - Suture placed through subbrow tissue to periosteum,
  - Or:
    - Temporal incision made to the deep temporal fascia
    - Dissection performed from temporal incision anteroinferiorly, into subperiosteal dissection to the brow incision
    - A suture is passed from the deep lateral brow and then secured to the deep temporal fascia

Neuromodulator
- Indication
  - Desire for non-surgical management
- Procedure
  - Injection of botulinum toxin into desired muscle groups
    - Corrugator and procerus for glabella rhytids
    - Lateral orbicularis oculi for lateral brow elevation
    - Frontalis for transverse forehead rhytids
- Advantages
  - Quick
  - Non-surgical, non-invasive
- Disadvantages
  - Spread of toxin to cause ptosis
  - Frozen appearance to brow
  - Sagging of brow
  - Mephisto Sign aka the “Spock” brow
  - Effects of injections dissipate in 3-6 months

References

Langsdon P, Petersen D: Management of the aging forehead and brow. Facial Plast Surg 2014 Aug;30(4):422-30.
Murphy MR, Johnson CM. The Open Browlift. In: Azizzadeh B, Murphy M, Johnson C, Massry G, Fitzgerald R Master Techniques in Facial Rejuvenation. Philadelphia: Elsevier; 2017. p. 80.
Nassif PS, Thomas JR. Management of the aging brow and forehead. In: Cummings CW, Flint PW, eds. Otolaryngology Head & Neck Surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005: p. 750-763

Case Studies

A 79-year-old male underwent Mohs resection of a temple cutaneous squamous cell carcinoma. 1 year after surgery, he has had a persistent left frontal paralysis with brow ptosis. To address this patient’s brow asymmetry, his surgical options include:

Midforehead lift
Direct Brow lift
Indirect brow lift

A 68-year-old female presents to the office 10 days after her neuromodulator treatment. She is very happy overall but her right eyebrow seems higher than her left. Options for treating this asymmetry include:

Watchful waiting (The neuromodulator will wear off in 3-4 months)
Treatment of right lateral frontalis with 1-2 Botox unit equivalents
Treatment of the left orbicularis occuli with 1-2 Botox unit equivalents

Review Questions

A 54-year-old woman complains that over the past 20 years, her eyebrows seem to have dropped. She has received Botox for many years but the results have been unsatisfactory. She states that her forehead appears longer because of this. She does not want a visible facial scar and does not want her forehead to appear bigger. Which of the following is the best option for her forehead rejuvenation?

Endoscopic forehead lift
Direct Browlift
Trichophytic forehead lift
Indirect forehead lift

A 60-year-old female undergoes an endoscopic forehead lift. The procedure was relatively uneventful except in the left medial temple there was a small bleeding vessel. It was carefully cauterized. However, she is noted to have left frontal paresis in the recovery room. The vessel encountered was likely:

Anterior branch of the superficial temporal artery
Supraorbital vein
Supratrochlear Artery
Bridging Vein

Brow Lift

Brow Lift

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