The Open Brow Lift
Transcript of The Open Brow Lift
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T h e O p e n B r o w L i f t
Joseph D. Walrath, MD*, Clinton D. McCord, MD
INTRODUCTION
Open brow lifting has been performed for nearly a
century1,2 and is a widely performed cosmetic pro-
cedure today. Open brow lifting encompasses arange of techniques including coronal hair-bearing
approaches, frontal pretrichial approaches with or
without temporal hair-bearing incisions, temporal
hair-bearing approaches for lateral brow ptosis,
mid-forehead approaches, and direct brow supra-
ciliary approaches. Combined with small-incisional
endoscopic brow elevation, transpalpebral brow
elevation, and various forms of browpexy, a palette
of options must be considered jointly by the surgeon
and patient in determination of the appropriate
procedure for each individual patient.
There is an ebb and flow in the approach to
treatment of various surgical problems, cosmetic
or otherwise. This trend is certainly present in ocu-
loplastics, where today there are, for example, re-
gional differences in the preferredsurgical treatment
of blepharoptosis. In the strongly consumer-driven
markets of cosmetic surgery, these fluctuations
can be massive. Some of this fluctuation is media
driven, some patient driven, some surgeon driven,
and some technology driven. Attaching words like
endoscopic or laser-assisted to any procedure
generally makes that procedure appealing to pa-
tients, as it implies that the procedure is somehow
less invasive, less risky, or has less down time. Italso implies that the surgeon is current in his or
her skills and is at the forefront of the field, whether
or not there is any merit to this assumption. How
else can one explain laser-assisted blepharoplasty?
This phenomenon likely contributed to the wide
adoption of endoscopic small-incision brow lifting
procedures in the 1990s. Vasconez3 and Isse4 first
presented the small-incision endoscopic approach
to brow lifting in 1992. Initial indications for endo-
scopic brow lifting were essentially the same as for
open techniques, and the requisite small incisionswere easily accepted by patients. After an initial up-
swell in endoscopic brow lifting, the technique is not
performedas often today,although clearly in thepro-
per patient with the proper technique, theresults can
be excellent. The reasons for the shift back to open
techniques relate to durability, prevention of hairline
elevation (or designed lowering of the hairline), and
a desire for less dependence on technology.
Paces Plastic Surgery, 3200 Downwood Circle, Suite 640, Atlanta, GA 30327, USA* Corresponding author.E-mail address: [email protected]
KEYWORDS
Plastic surgery Brow lift Aging face Surgical techniques Facial rejuvenation
KEY POINTS
The vast array of open brow lift techniques provides a durable correction to brow ptosis.
Some open techniques are more powerful than others, with incisions closer to the brow (direct brow
lift) offering a greater correction in brow height.
The pretrichial open brow lift is the procedure of choice for brow elevation and treatment of forehead
rhytids in patients with a high hairline or long forehead.
With meticulous wound closure and proper patient selection, there is high postprocedure patient
acceptance of the incisional scar after pretrichial open brow lift, mid-forehead brow lift, and direct
brow lift.
Direct brow lifting rarely results in sensory disturbances, provided that the depth of the excision
remains above the frontalis medially.
Clin Plastic Surg 40 (2013) 117–124http://dx.doi.org/10.1016/j.cps.2012.06.0020094-1298/13/$ – see front matter 2013 Elsevier Inc. All rights reserved. p
l a s t i c s u r g e r y . t h e c l i n i c s . c
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PATIENT EVALUATION FOR BROW LIFT
The first branch point in the brow lift decision-
making process is determined by the patient’s
goals. In the oculoplastic practice, where many pa-
tients are referred from general ophthalmologists,
often the primary goal of treating brow ptosis anddermatochalasis is to improve vision, with the
secondary goal being minimal out-of-pocket ex-
pense. In these patients, extended dissection in
the region of the frontal branch of the facial nerve
makes little sense, so the direct supraciliary brow
lift and mid-forehead lift are the only surgeries
offered. It is important in this functional population
to assess eyelid position while the brow is at rest;
it is not uncommon for true blepharoptosis to ac-
company dermatochalasis and brow ptosis. After
performing a brow lift, the central drive to elevate
tissue out of the visual axis is reduced, and a trueblepharoptosis is unmasked ( Fig. 1 ).
Once the patient has indicated that cosmetic
considerations predominate, the evaluation
focuses on determining the most effective tech-
nique for brow lifting and forehead rhytidectomy
that is consistent with the most acceptable risk
profile for that particular individual. The clinical
examination ( Table 1 ) focuses on the position
and stability of the brow, the distance from the
top of the brow to the pupil, the length of the fore-
head, the presence of baldness or anterior hairlinethinning, the presence of “widow’s peaks” and
other contour irregularities of the hairline, the
quality of the forehead skin and depth and promi-
nence of rhytids, heaviness of the tissue about the
brow, and the thickness of the brow cilia.
As a rough guide, it has been suggested that
a brow-to-pupil distance of 2.5 cm (measured
from the top of the brow cilia; Fig. 2 ) indicates
that no further brow lifting be considered. A fore-
head height of approximately 5 cm (measured at
the midline, the distance from the line connecting
the top of the brow cilia to the frontal hairline) isconsidered average,5 and a forehead length of
greater than approximately 6 cm6 has been used
as a criterion in the decision to perform pretrichial
open brow procedures instead of endoscopic or
coronal procedures. For some surgeons, including
the senior author, the pretrichial and coronal hair-
bearing open approaches are the procedures of
choice, with the pretrichial procedures far out-
weighing the coronal procedures in frequency.
Occasionally a combined pretrichial and hair-
bearing approach is indicated to reduce hairline
contour abnormalities. In these instances, thepath of the incision can span hair-bearing and pre-
trichial scalp to even out hairline irregularities such
as the widow’s peak.
The brow configuration is a central consider-
ation. In younger patients, early lateral hooding
can be addressed with an isolated hair-bearing
temporal lift. In these patients, it may not even
be necessary to disrupt the temporal fusion line
with this procedure. The temporal brow and lateral
canthal region also need to be considered in the
context of the other procedures that the surgeon
is going to perform. For example, if a midface lift
is part of the operative prescription, a temporal
lift is often required to redistribute the excess
tissue that normally would accumulate at the
superolateral leading edge of the midface lift.
The ophthalmic history and physical examination
focuses on the presence or absence of lagophthal-
mos, lid position at rest, and ocular surface dis-
orders including dry-eye disorder. A history of
refractive procedures, some of which can lead to
temporary denervation of portions of cornea, is
noted. If warranted, a slit-lamp examination of theocular surface is performed. As noted earlier, sub-
conscious brow elevation is often part of a compen-
satory mechanism for blepharoptosis. Therefore,
eyelid position with the brow at rest must be docu-
mented, and an appropriate ptosis repair procedure
may need to be included in the operative plan.
SURGICAL ANATOMY
The anatomy relevant to forehead lifting has been
well described,7 particularly with respect to the
facial nerve and supraorbital bundle. The mostfeared complication of brow lifting remains palsy
of the temporal branch of the facial nerve. Above
the zygomatic arch, the branch lies along the
deep aspect of superficial temporal fascia (super-
ficial to the deep temporal fascia). As dissection
Fig. 1. ( A) A patient with severe brow ptosis preoperatively. ( B) Postoperatively, after direct brow elevation, trueblepharoptosis is appreciated.
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elaborate forehead wraps applied, and the pa-
tients return for suture removal at 1 week.
SURGICAL TECHNIQUE FOR OPEN BROW LIFTPretrichial Coronal Forehead Lift withHair-Bearing Temporal Lift
Preparation
Lidocaine 2% with epinephrine is injected
about the proposed incision line, and along
the corrugators and superior orbital rim: the“vascular tourniquet.”
Lidocaine 0.25% with epinephrine is in-
jected throughout the forehead at the level
of the periosteum to provide hemostasis
and to provide some hydrodissection.
Thehair is rinsedwitha chlorhexidine solution.
If incisions are to be performed in the tem-
poral hair-bearing region, the hair in this
region is parted and stapled out of the way
of the proposed incision site.
If a temporal lift is to be performed, that portion is
performed first.
An approximately 5- to 6-cm incision is
marked 2 to 3 cm posterior to the hairline
temporally ( Fig. 5 ), beveled so as to remain
parallel to hair follicles.
Fig. 3. ( A) Preoperative photo of a patient before undergoing open pretrichial brow elevation. ( B) Postopera-tively, she has a faint pretrichial scar. The brows are elevated by 0.5 cm bilaterally, and the forehead is reducedin length by approximately 16%. The hairline contour is improved.
Fig. 4. Long-term follow-up after pretrichial frontalincision for a forehead-lowering procedure.
Fig. 5. A typical incision used for open hair-bearingtemporal brow lifting.
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Fig. 6. ( A) A typical pretrichial incision spanning both lines of temporal fusion. (B) A subgaleal blunt dissection isperformed with a peanut. (C ) Blunt dissection is carried down toward the root of the nose blindly. (D) Pilot cuts
are useful in determining the amount of skin to excise. (E ) Deep closure is performed in layers: the galea issecured with 2-0 polydioxanone suture and the subcutaneous aspect is secured with multiple 5-0 Vicryl horizontalmattress sutures. (F ) Meticulous skin closure is critical.
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SUMMARY
Open brow lifting techniques are durable and well
tolerated procedures that can address brow ptosis
and forehead rhytids, while maintaining appro-
priate forehead heights and pleasing aesthetic
appearances. Pretrichial forehead lifting (oftenthe authors’ procedure of choice) is appropriate
in most women and many men. Mid-forehead
and direct supraciliary brow lifting are essential
components of the operative plan in men with
deep rhytids or very heavy brows.
REFERENCES
1. Hunt HL. Plastic surgery of the head, face, and neck.
Philadelphia: Lea & Febiger; 1926.2. Paul MD. The evolution of the brow lift in aesthetic
plastic surgery. Plast Reconstr Surg 2001;108:1409.
3. Vasconez LO. The use of the endoscope in brow lift-
ing. A video presentation at the Annual Meeting of the
American Society of Plastic and Reconstructive
Surgeons. Washington, DC, September 25, 1992.
4. Isse NG. Endoscopic forehead lift. Presented at the
Annual Meeting of the Los Angeles County Society of
Plastic Surgeons.Los Angeles (CA), September12, 1992.
5. McKinney P, Mossie RD, Zukowski ML. Criteria for
forehead lift. Aesthetic Plast Surg 1991;15:141–7.
6. Mottura AA. Open frontal l ift: a conservative
approach. Aesthetic Plast Surg 2006;30:381–9.
7. Knize DM. Galea aponeurotica and temporal fascias.
In: Knize DM, editor. Forehead and temporal fossa:
anatomy and technique. Philadelphia: Lippincott Wil-
liams & Wilkins; 2001. p. 45.
8. Knize DM. Anatomic concepts for brow lift proce-
dures. Plast Reconstr Surg 2009;124:2118.
9. Trinei F, Januskiewicz J, Nahai F. The sentinel vein: animportant reference point for surgery in the temporal
region. Plast Reconstr Surg 1998;101(1):27–32.
Fig. 9. ( A) Preoperative brow ptosis in a patient who had direct incisional brow lift. ( B) Closure does not incor-porate the periosteum.
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