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.

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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.

Walrath & McCord118





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.

Walrath & McCord120





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.

Walrath & McCord122





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

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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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The Open Brow Lift