Direct Brow Lift: An Aesthetic Approach

Key Points

•With aging, the lateral brow descends more than the medial brow.

•A direct eyebrow lift provides significant lift per millimeter of excised tissue.

•The limited lateral supraciliary eyebrow lift provides excellent functional improvement and a reasonable aesthetic outcome.

•In mid-forehead lifting, dividing the incision between rhytids of differing vertical levels on each side of the hemiface avoids a longer, less natural, more visible scar that traverses the width of the forehead.

•Visible scarring is the most significant drawback of both direct eyebrow and mid-forehead lifting.

•Silicone sheeting and intralesional corticosteroid injections are excellent treatment options available to manage early surgical scarring.

8.1Introduction

Eyebrow position intimately influences eyelid position and architecture. In particular, eyebrow position may affect the height of the upper eyelid. For example, some cases of apparent upper eyelid ptosis and dermatochalasis result from eyebrow ptosis. The eyebrows are also important to facial expression. Complex changes of expression are possible due

M.J. Lucarelli (*)

Professor, Director, Oculofacial and Orbital Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, WI, USA e-mail: mlucarel@wisc.edu

to a superficial eyebrow musculo-cutaneous plane that slides over bone and rigidly anchored periosteum.

The ideal aesthetic contour of the eyebrow has been debated and refined during the past 4 decades. In 1974, Westmore described the ideal eyebrow as having an arch where the brow apex rests above the lateral limbus, with the medial and lateral ends of the brow at the same horizontal level [1]. In general, the youthful eyebrow complex has easily appreciated three-dimensional fullness. Gender differences play an important role in our perception of ideal eyebrow position. For example, the male eyebrow tends to ride lower and flatter than the female brow. For either a man or woman, an eyebrow that has dropped partially or wholly below the supraorbital rim may be classified as ptotic.

Aging changes of the eyebrow region result from descent and deflation. Solar damage to this region is often less pronounced than in the remainder of the periorbita due to the relative thickness of the eyebrow skin and camouflaging effects of the eyebrow hairs. The supraorbital rim tends to become more prominent with aging due to a loss of eyebrow fullness [2]. Deflation of the eyebrow complex is likely due to fat atrophy [2]. Descent of facial tissues due to gravitational forces plays another important role in the aging brow. With aging, the lateral brow descends more than the medial brow owing to a number of anatomic factors. Lateral to the temporal fusion line, beyond the action of the frontalis muscle, there is no upward vector to counteract the gravitational forces on the temporal brow or the depressor action of the lateral orbicularis oculi muscle [3]. Also, dense fibrous attachments anchor the eyebrow to the supraorbital ridge on the medial one-third to one-half of the eyebrow. Finally, the lateral brow fat pad’s lack of this same degree of underlying support may facilitate its descent relative to the medial brow [4].

Several nonsurgical and surgical options are available to correct eyebrow ptosis. Selective chemical denervation of the eyebrow depressors with botulinum toxin may allow unopposed action of the frontalis muscle to lift the eyebrow position [5]. Volume augmentation of the brow with facial fillers or autologous fat has been advocated to address brow deflation [6, 7]. For many patients, surgical eyebrow lifting procedures remain the treatment of choice. Options include coronal or pretrichial brow lift, mid-forehead lift, temporal lift, endoscopic brow lift, trans-blepharoplasty browpexy, and direct supraciliary brow lift. In this chapter, we describe an aesthetic surgical approach to direct eyebrow and midforehead lifting.

8.2Direct Eyebrow Lift

A direct eyebrow lift provides significant lift per millimeter of excised tissue. Due to the proximity of the incision to the eyebrow, it also provides ability to control brow contour. Direct eyebrow lifting has traditionally been used in older men with heavy brows as an alternative to coronal or temporal eyebrow-lifting procedures. Direct brow lifting is especially considered in patients with a receding hairline where scars from other techniques may be more visibly noticeable. Other advantages include a brief operating time, technical ease, and a favorable complication profile along with reasonable long-term results.

The greatest drawback of direct brow lifting is visible scarring. Although meticulous wound closure technique may minimize scarring, patients must be willing to accept visible scarring as a potential outcome. Scarring is often most visible in the medial extent of the incision, while the lateral incision is more easily camouflaged into the eyebrow hairs and thinner brow skin. Our surgical technique has evolved to limit substantially the medial extent of our incision. For most patients with predominantly lateral eyebrow ptosis, this limited lateral supraciliary eyebrow lift usually provides excellent functional improvement and a reasonably aesthetic outcome. Also, this refined technique has allowed us to expand the pool of appropriate surgical candidates.

Other potential risks to direct eyebrow lifting include damage to the hairs of the upper eyebrow as well as the supraorbital nerve. Facial nerve injury to the temporal (frontal) branch during direct eyebrow-lifting is extremely rare. Injury is avoided by keeping the depth of the lateral portion of the incision relatively superficial [8].

In the properly selected and counseled patient, acceptance of direct eyebrow lifting is excellent. A recent retrospective review of patients undergoing direct brow lift for involutional brow ptosis or facial nerve palsy revealed excellent efficacy and patient satisfaction [9]. Fifty-four direct eyebrow

lift procedures were performed on 36 patients (M:F 17:19). With a mean follow-up period of 11 months (3–44), the most common documented complications were temporary paresthesias and numbness in 22 cases. Four patients were unhappy with their final scar appearance. In this study, the authors used a traditional direct eyebrow technique that included an incision that extended across the full width of the eyebrow.

8.3The Limited Lateral Supraciliary Eyebrow Lift Procedure

Preoperative markings are performed with the patient in an upright position. With the frontalis muscle fully relaxed, the eyebrow is manually elevated to the desired level while a marking pen is held over the skin at the superior edge of the eyebrow. Once the eyebrow is released and allowed to fall to its native position, a mark is made on the skin above the brow (Fig. 8.1). This mark on the skin will serve as a guide for the superior incision line. This is repeated in the lateral, central, and medial portions of the desired incision site. Natural rhytids should be used when possible. The keys to achieving aesthetically pleasing results with this operation are selecting patients with predominantly lateral brow ptosis and limiting the medial extent of the incision. The inferior portion of the incision marking may include a few eyebrow hairs, thus helping to conceal the postoperative scar (Fig. 8.2). Local infiltrative anesthesia is achieved with 2% lidocaine with 1:100,000 units epinephrine (American Regent, Inc.) mixed in equal parts of 0.5% bupivacaine (APP Pharmaceuticals, LLC).

Incision along the previously placed markings is performed with a No. 15 Bard-Parker blade. The incision adjacent to the brow should be beveled parallel to the direction of the eyebrow cilia in order to avoid hair follicle damage (Fig. 8.3). A similarly beveled incision should be made on the superior incision line to provide normal wound apposition during closure. A microdissection needle (Megadyne) on a monopolar unit (ConMed Corporation) may be used to remove the skin/brow fat flap. The frontalis muscle is left undisturbed (Fig. 8.4).

The wound is closed with deep, buried sutures of either 4–0 chromic or 4–0 polyglactin. At the medial aspect of the crescent, a few interrupted, vertical mattress sutures of 4–0 nylon or polypropylene are used to reapproximate the wound edges and provide excellent wound eversion. The lateral aspect of the wound may be closed with running 5–0 or 6–0 nylon or polypropylene (Fig. 8.5). Antibiotic ointment is placed at the end of the procedure and no dressings are necessary. The sutures should be removed at the first postoperative visit 5–7 days later (Fig. 8.6).

Fig. 8.3 The eyebrow incision is beveled in the direction of the upper brow hairs to minimize damage to the follicles

Fig. 8.5 Proper suturing technique is used to create wound eversion. In this example, a few vertical mattress sutures of 5–0 Nylon are placed medially and continued laterally in a running fashion