Direct Brow Lift

Article Author:
Basit Jawad
Article Editor:
Blake Raggio
Updated:
6/12/2020 8:06:27 PM
PubMed Link:
Direct Brow Lift

Introduction

The upper face, including the eyebrows and periorbital regions, plays a dynamic role in the aging face.[1] With the natural process of aging, the position of the brow relative to the supraorbital rim may become ptotic. Commonly, this presents as excessive hooding of the lateral eyelid but, in severe cases, may result in a visual field obstruction.[2] Other less common causes of this phenomenon may be due to acquired facial paralysis or secondary to post-traumatic deformity. Various surgical options exist to reposition the brow, ranging from traditional open techniques to newer endoscopic approaches. Each of these techniques has their respective strengths and weaknesses, but no individual procedure has proven superiority in all clinical scenarios.[3] 

Recently, there have been trends in aesthetic surgery towards the utilization of the endoscopic browlift technique.[4] Nevertheless, traditional open approaches remain a fundamental skill in the armamentarium of the facial surgeon as it provides the greatest degree of accuracy in relation to brow repositioning. Herein we outline the nuances of one of these open approaches, the direct brow lift, and focus on its role in rejuvenating the upper third of the face.

Anatomy and Physiology

The upper third of the face exhibits many characteristic signs of aging, including:[5]

  • Horizontal midforehead lines secondary to the vertical action of the frontalis muscle.
  • A fullness of the upper lateral eyelid caused by downward migration of the upper facial soft tissues resulting in brow ptosis. 
  • The vertical and oblique glabellar lines secondary to the action of the corrugator supercilii and the depressor supercilii (i.e., superomedial orbicularis oculi muscle). 
  • Horizontal lower midforehead lines secondary to the action of the procerus muscle. 

Brow Lift Methods

As mentioned previously, multiple surgical approaches have been created to address the ptotic brow, including:[1]

  • Direct Brow Lift: superior brow incision used to camouflage at the level of the eyebrow hair follicles.
    • Allows for the most precise repositioning of the brow 
    • Best suited in cases of unilateral facial paralysis.
  • Midforehead Brow Lift: Incision planned at the level of the midforehead, ideally within the confines of a preexisting horizontal rhytid.[6]
    • Allows for bilateral brow repositioning with a single incision
    • Best suited for men with a receding hairline and deep forehead rhytids.
    • May consolidate multiple rhytids into one transverse rhytid. 
  • Hairline Brow Lift: Incision planned either within (trichophytic) or just in front (pretrichial) of the hairline.[7]
    • Allows for the bilateral elevation of the periorbital soft tissues
    • Useful in patients with elongated foreheads as this may lower the patient's hairline
    • May be combined with a hairline advancement if warranted.
  • Coronal Incision Brow Lift: Incision made several centimeters behind the hairline.
    • The incision is completely hidden within the substance of the hair.
    • Avoid in patients with elongated foreheads, as this will elevate the patient's existing hairline.
    • Avoid in patients who are bald, as this may leave an unsightly scar.
  • Endoscopic Brow Lift: Multiple small incisions made within the frontal and temporal hairlines to allow for the insertion of the endoscope and surgical instruments.[4][8]
    • Minimally invasive approach with a theoretically decreased risk of injury to neurovascular structures and quicker healing times
    • Not well-suited for patients with receding hairlines or convex forehead structure which may restrict endoscopic visualization 
    • Requires fixation, typically with absorbable materials (e.g., sutureless bioabsorbable implants, sutures), to reposition and stabilize the forehead soft tissues 
    • A technical learning curve exists.
    • Only provides moderate brow elevation (several millimeters)

Pertinent Anatomic Structures[9]

  • Supraorbital Nerve (SON): Exits a notch or foramen roughly 2.7 cm lateral to the midline forehead (may be approximated to the level of the medial limbus). The SON further divides into deep and superficial branches that provide sensory innervation to the frontoparietal and upper eyelid skin, respectively.[10]
  • Supratrocheal Nerve: Usually identified 1 cm medial to the exit point of the supraorbital nerve. This provides sensory innervation to the medial upper eyelid, glabella, and a small portion of the conjunctiva.[10]
  • The Temporal Branch of Cranial Nerve VII (Facial Nerve): Provides motor innervation the forehead (frontalis) and upper orbicularis oculi. The path of this nerve may be approximated by Pitanguy’s line, which is a line drawn from 0.5 cm inferior to the tragus to a spot 1.5 cm superolateral to the lateral brow).[11]

Ideal Brow Location and Shape

  • For women, the ideal brow position takes the shape of an arch with its peak roughly at the level of the lateral limbus.
  • In men, the ideal brow remains relatively flat and positioned at the level of the supraorbital rim. 

Indications

Indications for any type of brow lift surgery may include:[12]

  • Visual field obstruction
  • Psuedo-blepharoptosis (eyelid appears to be lowered but no pathology of the eyelid musculature or levator aponeurosis is present)
  • Brow ptosis
  • Facial paralysis
  • Facial (brow) asymmetry
  • Deep forehead rhytids
  • Glabellar lines
  • Concerns regarding the perceived resting facial aesthetic (e.g., an "angry" or "tired" look)

Clinical situations favoring a direct brow lift approach:[13]

  • Lack of forehead rhytids
  • Unilateral facial paralysis
  • Convex forehead craniofacial skeleton (limits endoscopic approach)
  • Receding hairline
  • Baldness
  • Heavy eyebrows
  • Prior eyebrow scar
  • Patient preference

All in all, the direct brow lift is increasingly used as a reconstructive technique and less commonly performed in the cosmetic setting.[14]

Contraindications

Contraindications to brow lift surgery include:[15]

  • Body dysmorphic syndrome
  • Prior history of blepharoplasty (relative contraindication)
  • Dry eye syndrome or history of decreased tear production

Contraindications to the direct brow lift approach:

  • Unwillingness to accept a potentially visible facial incision
  • Thin eyebrows
  • Patient anatomy and/or expectation better suited for another surgical approach

Equipment

Preoperatively

  • Surgical marker
  • Local injectable anesthetic
  • Surgical cleansing solution
  • Eye protection in the form of a corneal shield or eye taping

Intraoperatively

  • Scalpel
  • Facial plastic or related soft tissue surgical instrument set
  • Electrocautery device
  • Suture, per surgeon preference (e.g., 4-0 monocryl for deep layers, 6-0 prolene for skin)

Postoperatively

  • Antibiotic ointment
  • External wound dressing, per surgeon preference

Personnel

  • Surgeon
  • Surgical scrub technician
  • Operating room nurse (circulator)
  • An anesthesiologist and/or nurse anesthetist (NOTE: The procedure may be performed under local anesthesia per surgeon and patient preferences.)

Preparation

  • The patient should be evaluated preoperatively by a medical professional who may risk-stratify and optimize the patient for general anesthesia if warranted.
  • A thorough preoperative exam should be performed with the patient in an upright position with no facial animation.
    • Includes the assessment of brow position, gross visual field evaluation, presence of existing rhytids and/or scars, and facial nerve function.
  • Preoperative photographic documentation should be obtained. 
  • The patient should be appropriately counseled regarding the risks, benefits, and alternatives to the procedure.
    • Pertinent to this procedure, it is important to mention improper brow position, incomplete eye closure, eye dryness, a disfiguring facial scar, need for revisions, alopecia, paresthesias, and facial nerve injury. Other common risks associated with surgery include pain, bleeding, infection, scarring, etc. 
    • The patient's expectations should be discussed, and realistic goals must be set.
  • Patients who may require additional simultaneous rejuvenating procedures such a blepharoplasty, fat transfer, and laser resurfacing should be identified and counseled. 
  • Important landmarks are identified:
    • The supraorbital rim, supraorbital/supratrochlear neurovascular bundles, temporal line, sentinel vein, corrugator supercilii, procerus muscles, the expected trajectory of the temporal branch of the facial nerve (Pintanguy's line), the position of the hairline, and the anticipated eyebrow shape.[1]
  • General anesthesia is recommended, but not necessary.
    • Muscle paralytics are usually avoided to allow for intraoperative facial nerve monitoring if desired. 
  • A single dose of intravenous antibiotics covering skin flora may be given preoperatively.
  • The supine surgical position is preferable. 
  • Skin marking
    • Starts with a fusiform beveled incision just within the most superior row of eyebrow hair. The upper incision is marked such that the height of the skin excised replicates the amount of brow repositioning desired. The bulk of the elevation occurs laterally and allows the restoration of the natural brow position.

Technique

The successful completion of the direct brow lift requires that the surgeon have excellent soft-tissue handling techniques and a thorough understanding of head and neck anatomy.

Routine steps are outlined below:

  • Once the proper preoperative checklist has been completed, the patient is prepared for the surgical procedure. 
  • The patient is positioned and draped in a standard sterile fashion. A safety checklist is performed, followed by a surgical time out. 
  • The planned amount of skin to be resected is verified and compared to the preoperative marking. Local anesthesia (1% lidocaine with 1:100,000 epinephrine with a maximum of 7 mg/kg of lidocaine) is injected into the planned surgical site.
  • A 15 blade scalpel is used to create a slightly beveled incision such that the final closure will naturally evert the skin edges. Near the eyebrow, one should bevel the blade in the direction of the hair follicle to preserve the brow hairline.
  • The skin and underlying soft tissue are resected while avoiding injury to underlying neurovascular structures and muscle (frontal and orbicularis oculi). 
  • The ptotic frontalis and orbicularis oculi muscles may be suspended to a more youthful position by superiorly anchoring them to the forehead periosteum. If prominent rhytids of the glabellar and procerus muscle need to be addressed, medial dissection may allow for sectioning of these muscles. 
  • Hemostasis is achieved using pressure and limited electrocautery. 
  • The deep layer of the wound is closed using absorbable suture (e.g., vicryl or monocryl). The skin may be closed in a subcuticular or superficial fashion per the surgeon's preference.
  • A dressing is placed per the surgeon's preference. 

Complications

Although rare, complications may include:[16]

  • Wound infections
  • Hematoma
  • Brow asymmetry
  • Forehead paresthesias
  • Injury to the temporal branch of the facial nerve 
  • Disfiguring scar formation
  • Alopecia of the eyebrow
  • Need for revision
  • Overcorrection
  • Eye dryness

Although a facial scar is inevitable, proper surgical technique promotes a high degree of satisfaction regarding scar appearance. Proper preoperatively counseling is paramount to optimize results and minimize complications. 

Clinical Significance

The direct brow lift represents a successful and powerful tool in the armamentarium of the aesthetic and reconstructive facial surgeon. When confronted with the effects of facial paralysis or aging, this option provides precise results for repositioning an asymmetric or ptotic brow.[17] The surgeon offering this technique should also be well versed in the other approaches in brow lifting in order to perform the most proper assessment and plan. In the hands of a knowledgeable and experienced surgeon, the outcomes can be very satisfactory. 

Enhancing Healthcare Team Outcomes

It is paramount to identify the risk factors and perform a thorough assessment before performing a direct brow lift. The patient should have the following done:

  • Evaluation by a surgeon experienced in facial aesthetic and reconstructive surgery
  • Medical optimization prior to proceeding with general anesthesia
  • Evaluation by an opthalmologist or optometrist to assist in the management of visual field obstruction, dry eye, ptosis, and/or lagophthalmos.
  • A preoperative, operative and postoperative specialty nurse trained in the monitoring of patients undergoing facial surgery is necessary. This individual will assist with the coordination of care and education. 

An interprofessional team, including a facial surgeon, anesthesiologist, and operative nurse should perform the direct brow lift in order to obtain the best outcomes. Close follow-up should monitor the patient for potential complications such as brow asymmetry, facial paralysis, paresthesias, alopecia, overcorrection, hematoma formation, keloid formation, and eye dryness. Proper education should counsel the patient on appropriate wound care and activity level. 

This interprofessional care is essential to achieving the best results when performing facial reconstructive surgeries such as the direct brow lift. [Level 5]

Nursing, Allied Health, and Interprofessional Team Interventions

Recovery following direct brow lift surgery may vary due to the individual patient's functional and nutritional status. Judicious local wound care is important to ensure a healthy and clean surgical environment. Suction drains are rarely ever necessary. Blood thinners may be restarted the following day after surgery. The patient should be educated to avoid heavy lifting or straining until seen in follow up to allow for appropriate wound healing. When the proper sterile technique is employed, post-operative antibiotics are not necessary. Permanent sutures for skin closure, if utilized, should be removed within 5 to 7 days, depending on the amount of wound tension present. Following surgery, the patient is typically followed regularly until proper healing is ensured. 

Nursing, Allied Health, and Interprofessional Team Monitoring

Close follow-up will help identify any acute postoperative complications. Swift identification and subsequent appropriate management will ensure optimal outcomes. The ancillary staff should assist in monitoring, education, and coordinating follow up.


References

[1] Karimi N,Kashkouli MB,Sianati H,Khademi B, Techniques of Eyebrow Lifting: A Narrative Review. Journal of ophthalmic     [PubMed PMID: 32308957]
[2] Balado AS,Stevens HP, Lateral Hooding of the Brow Revisited: Reverse Brow Lifting Versus the ROOF Lift. Aesthetic plastic surgery. 2020 Apr;     [PubMed PMID: 32020281]
[3] Graham DW,Heller J,Kurkjian TJ,Schaub TS,Rohrich RJ, Brow lift in facial rejuvenation: a systematic literature review of open versus endoscopic techniques. Plastic and reconstructive surgery. 2011 Oct;     [PubMed PMID: 21921747]
[4] Rohrich RJ,Cho MJ, Endoscopic Temporal Brow Lift: Surgical Indications, Technique, and 10-Year Outcome Analysis. Plastic and reconstructive surgery. 2019 Dec;     [PubMed PMID: 31764641]
[5] Hwang K, Periorbital and Perioral Regions in Relation to Aging. The Journal of craniofacial surgery. 2020 May 8;     [PubMed PMID: 32398622]
[6] Patel BC,Malhotra R, Mid Forehead Brow Lift 2020 Jan;     [PubMed PMID: 30571073]
[7] Spiegel JH, Scalp Advancement and the Pretrichial Brow Lift. Facial plastic surgery : FPS. 2018 Apr;     [PubMed PMID: 29631283]
[8] Raggio BS,Winters R, Endoscopic Brow Lift . 2020 Jan     [PubMed PMID: 31424804]
[9] Chi JJ, Periorbital Surgery: Forehead, Brow, and Midface. Facial plastic surgery clinics of North America. 2016 May;     [PubMed PMID: 27105796]
[10] Kikuta S,Yalcin B,Iwanaga J,Watanabe K,Kusukawa J,Tubbs RS, The supraorbital and supratrochlear nerves for ipsilateral corneal neurotization: anatomical study. Anatomy     [PubMed PMID: 32274242]
[11] Green Sanderson K,Conti A,Colussi M,Connolly C, A Simple Clinical Application for Locating the Frontotemporal Branch of the Facial Nerve Using the Zygomatic Arch and the Tragus. Aesthetic surgery journal. 2020 Apr 14;     [PubMed PMID: 31254463]
[12] Angelos PC,Stallworth CL,Wang TD, Forehead lifting: state of the art. Facial plastic surgery : FPS. 2011 Feb;     [PubMed PMID: 21246456]
[13] Pascali M,Bocchini I,Avantaggiato A,Carinci F,Cervelli V,Orlandi F,Quarato D, Direct brow lifting: Specific indications for a simplified approach to eyebrow ptosis. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India. 2016 Jan-Apr;     [PubMed PMID: 27274124]
[14] Walrath JD,McCord CD, The open brow lift. Clinics in plastic surgery. 2013 Jan     [PubMed PMID: 23186761]
[15] Pascali M,Carinci F,Bocchini I,Avantaggiato A,Cervelli V, Brows Asymmetry Correction With the Direct Approach: Myth or Reality? The Journal of craniofacial surgery. 2016 Mar;     [PubMed PMID: 26967074]
[16] Neves JC,Medel Jiménez R,Arancibia Tagle D,Vásquez LM, Postoperative Care of the Facial Plastic Surgery Patient-Forehead and Blepharoplasty. Facial plastic surgery : FPS. 2018 Dec;     [PubMed PMID: 30593072]
[17] Jansma J,Schepers RH,Vissink A, [Lifting procedures in cosmetic facial surgery]. Nederlands tijdschrift voor tandheelkunde. 2014 Oct     [PubMed PMID: 26185994]