Browplasty Treatment & Management

Updated: Nov 02, 2018
  • Author: J David Kriet, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
  • Print
Treatment

Medical Therapy

Management of the aging and ptotic brow is primarily surgical. However, recent experience with botulinum toxin has shown that some elevation of the lateral brow is possible after treatment with the neuromuscular blocking agent. Botulinum toxin is also being evaluated as an adjunct to endoscopic browlift. Dyer and Yung reported their early experience injecting botulinum toxin into the brow depressors 2 weeks prior to surgical elevation. [2] Preoperative chemical paralysis of brow depressor function is thought to promote readherence of the brow periosteum in the elevated position.

A retrospective study by Steinsapir et al reported good results from the use of a microdroplet technique for administering botulinum toxin along the eyebrow, crow’s-feet, and glabellar region, with the average brow height increasing from 24.6 mm before treatment to 25 mm posttreatment. The study involved 227 patients (563 microdroplet treatments). [3]

Nonsurgical techniques

Studies have shown that dermal monopolar radiofrequency treatments using Thermage Thermacool (Hayward, Calif) can produce browlifting. The response to treatments can be variable with the current technology, but essentially no downtime or wound care is needed. Patients can expect a 5-20% improvement. Realistic expectations by the provider and patient are mandatory for a successful outcome. In a study by Nahm et al, at the end of 3 months an average of 4.3 mm of brow elevation was elicited. [4] Additional technologies, such as the Titan Procedure (Cutera, Brisbane, Calif) and Polaris RF (Syneron, Ontario, Canada), also use thermal energy to cause browlifting that does not require surgical intervention.

Minimally invasive techniques

Tissue volume loss around the periorbital area accounts for the development of brow ptosis. Various injectable materials, whether the patient's own fat or a hyaluronic acid material, such as Restylane (Medicis Aesthetics Inc, Scottsdale, Ariz), can effectively cause brow elevations. Sculptra (Sanofi-Adventis) has been approved as a treatment of lipoatrophy by the Food and Drug Administration (FDA). Sculptra is an injectable poly-L-lactic acid that is used to restore volume to facial soft tissue. Increases in dermal thickness using Sculptra have been shown to last for up to 2 years in clinical studies. The lateral brow is filled with the injectable material to produce the browlift. Different types of fillers can be used to achieve this effect as more become available. One must be cognizant of surrounding vascular structures to avoid blindness and tissue injury.

Suture suspension techniques, known as the thread lift, are very popular with patients. The promises of minimal anesthesia, less postoperative downtime, fewer serious risks, and lower cost compared with surgical procedures are very appealing to the lay person. Barbed polypropylene sutures are used to lift the brow tissue. In 2004, the FDA approved the Contour ThreadLift with patented Contour Threads suture, which was introduced by Dr. Gregory Ruff, M.D. The ideal candidate has a moderate amount of skin and brow laxity that moves easily with minimal manipulation. The procedure can be done with just local anesthesia. Again, patient selection and realistic expectations are requirements for a good outcome.

Next:

Surgical Therapy

Numerous surgical approaches to browplasty are available. As with any facial aesthetic procedure, an excellent outcome in browplasty begins with a careful analysis of the patient's face. The appropriate technique is then chosen and tailored to enhance the patient's natural features.

Previous
Next:

Preoperative Details

Standardized photographs of every patient are obtained prior to surgery. Full frontal and close-up periorbital views are essential, and oblique and lateral periorbital views are helpful.

The patient is seen in consultation shortly before surgery to answer any questions arising since the initial visit. At this visit, the planned procedure is discussed, including incision design, risks, benefits, alternatives, and expected postoperative course. Aspirin, nonsteroidal anti-inflammatory medication, vitamin E, and ginkgo cessation is confirmed. The patient is instructed to wear loose-fitting clothing and to have a responsible family member or friend available for transportation and observation during the first 24 hours.

Preoperative markings in the sitting position are made prior to the patient's arrival to the surgical suite. The photographs are again reviewed and any asymmetry is noted. Prophylactic antibiotics and dexamethasone are administered prior to the start of the procedure.

Previous
Next:

Intraoperative Details

Anesthesia

Most browlift procedures are easily performed with the patient under intravenous sedation supplemented with local anesthesia. General anesthesia is also an excellent alternative. Local anesthesia containing epinephrine (1% lidocaine with 1:100,000 epinephrine mixed with an equal volume of 0.25% bupivacaine) is infiltrated along all incision lines after performing supraorbital and supratrochlear nerve blocks. Injection is performed prior to sterile preparation to allow adequate time for vasoconstriction.

The various options for browplasty are highlighted below.

Coronal Browlift

Although endoscopic browlift is currently the preferred technique of many surgeons, coronal browlift and its variations have long been considered the criterion standard forehead rejuvenation procedure, as depicted in the images below. [5] The procedure allows complete access to the frontalis, corrugator, and procerus musculature, and the incision is completely hidden within the hair. Because the incision is placed in the hair-bearing scalp, elevation of the hairline is an unavoidable consequence. For this reason, patients selected for this approach ideally should have a low hairline. In the properly selected patient, this elevation can improve facial proportion. The incision in this approach is also longer than in any other brow rejuvenation technique; therefore, postoperative hypoesthesia may be more pronounced.

Preoperative photo of a 59-year-old woman prior to Preoperative photo of a 59-year-old woman prior to an endoscopic browlift, lower lid transconjunctival blepharoplasty, rhytidectomy, and carbon dioxide laser resurfacing.
Postoperative photo of a 59-year-old woman six mon Postoperative photo of a 59-year-old woman six months after an endoscopic browlift, lower lid transconjunctival blepharoplasty, rhytidectomy, and carbon dioxide laser resurfacing.

See the list below:

  • Incision placement: The incision is placed so that it will lie 2-4 cm behind the hairline following excision of excess scalp. The incision courses posteriorly in the temporal regions and extends inferiorly to the level of the superior auricle. The incision can easily be connected to preauricular facelift incisions when both procedures are performed concomitantly. Take care to bevel the incision with the hair follicles, and avoid excess cautery to prevent incisional alopecia.

  • Dissection plane: Dissection proceeds easily within the relatively bloodless subgaleal plane. Temporally, take care to dissect close to the superficial layer of the deep temporal fascia and deep to the temporoparietal fascia. This helps prevent injury to the temporal branch of the facial nerve. Centrally, the supraorbital and supratrochlear neurovascular bundles are identified and preserved. The corrugator and procerus muscles are transected if desired.

  • Fixation: Excess scalp tissue is excised (generally 1-2 cm), and layered closure is performed with dissolving suture and surgical staples.

Trichophytic Lift

The trichophytic lift is an alternative to the coronal lift and is useful in patients with high hairlines. This technique allows improved fine-tuning of brow asymmetry, as depicted in the image below. It allows ready access to the corrugator and procerus musculature to treat glabellar furrowing. Although the resulting scar is generally barely perceptible, other techniques may be better suited for patients who wear their hair pulled back. Prolonged hypoesthesia of the scalp is possible just as with the coronal lift.

A: Brow and facial asymmetry resulting from left i A: Brow and facial asymmetry resulting from left idiopathic facial nerve paralysis. B: Four-month postoperative view showing improved brow symmetry following trichophytic browplasty. Plication of the left facial superficial musculoaponeurotic system and placement of a facial sling were performed simultaneously.

See the list below:

  • Incision placement: The incision is placed in a curvilinear fashion within the fine hair of the frontal hairline. Irregularize the incision to aid in scar camouflage. Reverse beveling of the incision preserves hair follicles and promotes hair growth through the incision, as depicted in the image below.

    Reverse beveling of the trichophytic incision enco Reverse beveling of the trichophytic incision encourages hair growth through the incision.
  • Dissection plane: Rapid and relatively bloodless elevation of the flap is performed in the subgaleal plane and is no different from the coronal dissection, as depicted in the image below.

    A: Trichophytic frontal incision. B: Subgaleal dis A: Trichophytic frontal incision. B: Subgaleal dissection of the flap is quick and relatively bloodless. Arrowheads denote supraorbital nerves that should be preserved.
  • Fixation: Excess tissue is trimmed, taking care to match the beveled incision. Closure is performed in layered fashion with 4-0 polydioxanone interrupted dermal sutures and running 6-0 nylon or fast-absorbing gut. Meticulous attention to detail is essential to maximize the disappearance of this potentially visible scar, as depicted in the image below.

    Early postoperative view of trichophytic incision. Early postoperative view of trichophytic incision. Reverse beveling of the incision at the time of surgery promotes hair growth through the incision.
  • Pretrichial variant: The pretrichial incision is placed in the non–hair-bearing scalp just inferior to the hairline. This necessarily results in a visible scar. The authors do not routinely use this incision.

Midforehead Browlift

This technique is useful in the properly selected patient. It is effective in treating functional brow ptosis and unilateral forehead paralysis, especially in male patients with high hairlines, as depicted in the 1st image below. The ideal candidate has prominent forehead skin creases yet relatively thin nonsebaceous skin to optimize incision camouflage. The dissection is less extensive than in the procedures mentioned above and can be performed under straight local anesthesia if necessary, as depicted in the 2nd image below. [6]

A 76-year-old man with left unilateral facial pare A 76-year-old man with left unilateral facial paresis. Note the marked brow ptosis, absence of horizontal forehead rhytides, and lower eyelid paralytic ectropion. This patient is an ideal candidate for midforehead browlift, gold weight placement, and ectropion repair.
A: Preoperative view of a 52-year-old woman who de A: Preoperative view of a 52-year-old woman who desires browplasty. The patient did not want sedation or general anesthesia. A midforehead browlift was performed with local anesthesia. The authors usually reserve the midforehead browlift for men with deep horizontal forehead rhytides. B: Three months status post midforehead browlift. Note the well-healed forehead incisions. Dermabrasion, although not used in this patient, may improve scar camouflage.

Because the incisions are placed relatively close to the brow, asymmetry is relatively easily corrected, and with lateral extension of the incision, temporal hooding can be improved, as depicted in the images A & B below. The course of the temporal branch of the facial nerve must always be respected laterally to avoid inadvertent injury. While brow position can be precisely adjusted, glabellar and horizontal forehead rhytides are not addressed well with this technique.

A: Elderly patient with paralytic brow ptosis on r A: Elderly patient with paralytic brow ptosis on right (note hyperactive left frontalis muscle). B: Early postoperative result demonstrating improved brow symmetry. The left frontalis muscle is no longer overcompensating. C: Staggered fusiform incisions and proposed site of suspension sutures. D: orbicularis oculi fibers identified prior to brow suspension.

For further reading, see the Medscape Reference article Mid Forehead Brow Lift.

  • Incision placement: Fusiform incisions are placed above the lateral brow and centered over a prominent horizontal crease. Positioning the incisions at 2 levels maximizes camouflage, as depicted in mage C above.

  • Dissection plane: This technique differs from the coronal and trichophytic lifts because dissection is performed in the subcutaneous plane superficial to the frontalis muscle. Dissection proceeds inferiorly to the level of the brow where the horizontal fibers of the orbital orbicularis muscle are readily identified, as depicted in mage D above. Superior undermining is performed only to allow wound edge eversion.

  • Fixation: Two or three 4-0 nylon or polydioxanone sutures are placed from the orbicularis muscle to the superolateral forehead periosteum. Take care to preserve a relatively horizontal brow shape in the male patient. Closure is performed in layers with multiple, buried, inverted 5-0 polydioxanone sutures and an everting running 6-0 nylon or fast-absorbing gut skin closure.

Direct Browlift

A direct browlift is accomplished by excising skin directly above the patient's brow bilaterally. For strictly functional lifting of the brow, this technique is very effective. However, if the incision is not meticulously closed in multiple layers, a noticeable scar may form.

For further reading, please see the Medscape Reference article Direct Brow Lift Procedures.

  • Incision placement: A fusiform incision is made along the superior length of each brow. The amount of skin excised should reflect the desired amount of brow elevation. This technique is unique among the other techniques because there is a 1:1 removal of tissue-to-elevation of brow when determining the amount of tissue to excise. The incision is beveled carefully to preserve the fine brow hair.

  • Dissection plane: Surgical excision of tissue is made in the subcutaneous plane, preserving the underlying musculature and neurovascular tissues.

  • Fixation: Brow elevation is maintained over time by anchoring the superior suture into the lateral brow periosteum. The subcutaneous layer is closed with buried inverted sutures, and the dermis is closed with cutaneous interrupted vertical mattress sutures.

Transpalpebral Browlift

The transpalpebral browlift is a unique and effective procedure. The upper blepharoplasty incision is used to access the supraorbital structures and achieve brow elevation. This technique works very well in men with male-pattern baldness and in patients who require a minimal lift or fixing of the brow.

  • Incision placement: As the name implies, the only incisions used are the upper blepharoplasty incisions.

  • Dissection plane: After marking the planned upper blepharoplasty incisions while holding the brow in the proposed placement, the dissection is assisted by the infiltration of local anesthetic with hyaluronidase (Wydase) into the subgaleal plane. Within the subgaleal plane, the entire lateral brow is elevated with the orbicularis oculi muscle. The supraorbital neurovascular bundles are easily identified and preserved. The procerus, corrugators, and depressor supercilii are transected medially.

  • Fixation: Anchoring sutures from the brow tissue to the lateral brow periosteum are placed. The overlying brow and orbicularis oculi are thereby fixed to the lateral brow periosteum in an elevated position. Endotine TransBelph 3.5 (Coapt, Palo Alto, Calif) is a bioabsorbable brow fixation device that is placed through the transpalpebral incision to fixate the brow tissue. The device negates placement of sutures and serves to distribute the pull on the tissues over a larger surface area.

Temporal Lift

The temporal lift is the procedure of choice for patients with isolated lateral brow descent. This technique is similar to the Gillies approach to the zygomatic arch. The temporal lift may be performed in conjunction with an endoscopic browlift or facelift.

Incision placement

The incision is placed in the temporal area running in a superior to posterior-inferior direction over the temporalis muscle.

Dissection plane

Dissection is performed deep to the temporoparietal fascia and superficial to the superficial layer of the deep temporal fascia. This dissection plane keeps the temporal branch of the facial nerve protected from injury during surgery. The dissection is carried inferiorly to the supraorbital rim and through the arcus marginalis to free the soft tissues and allow brow elevation.

Fixation

Using a long-lasting absorbable suture or permanent suture, the temporoparietal fascia posterior to the course of the temporal branch of the facial nerve is sutured to the superficial and deep temporal fascia after desired brow elevation is achieved.

In a study of 45 temporal browlift patients, Pascali et al suggested that of three different temporal browlift fixation methods—using Endotine Ribbon, Mersilene mesh, and Prolene suture—the mesh procedure provided the best long-lasting stability at 1-year follow-up. [7]

Endoscopic Browlift

Minimal-incision endoscopic surgery has revolutionized approaches to all fields of medicine. The ability of the endoscopic browlift technique to achieve results similar to other traditional procedures has made more patients amenable to undergoing the elective cosmetic procedure. [8, 9, 10] The scars hidden within the hairline and preservation of sensory nerves to the frontal and scalp region are characteristics very popular with patients, as depicted in the images below.

Preoperative frontal view of a patient with brow p Preoperative frontal view of a patient with brow ptosis and dermatochalasis prior to endoscopic browlift and lower lid blepharoplasties.
Four-month postoperative view of a patient with br Four-month postoperative view of a patient with brow ptosis and dermatochalasis prior to endoscopic browlift and lower lid blepharoplasties. Note mild elevation in hairline that is invariably observed following endoscopic and coronal browlift procedures. The patient was counseled about the hairline change preoperatively.
This is a 50-year-old woman prior to endoscopic br This is a 50-year-old woman prior to endoscopic browlift, carbon dioxide laser resurfacing, and botulinum toxin injection of periorbital rhytides (preoperatively).
Six-month postoperative view of a 50-year-old woma Six-month postoperative view of a 50-year-old woman after endoscopic browlift, carbon dioxide laser resurfacing, and botulinum toxin injection of periorbital rhytides.

For further reading, see the Medscape Reference article Endoscopic Forehead Lift.

  • Incision: Typically, 5 access incisions are used during an endoscopic browlift. Three are placed in the anterior hair-bearing scalp, and 2 are placed in the temporal area, similar to the temporal lift incisions. A central scalp incision is placed approximately 1.5 cm behind the hairline in a sagittal plane. The 2 paramedian incisions are placed 1.5 cm behind the hairline and situated where the surgeon desires maximal brow elevation. The paramedian incisions are usually placed along a line drawn from the lateral alar crease through the lateral limbus. The temporal incisions are placed approximately 1-2 cm posterior and parallel to the temporal hairline.

  • Dissection

    • The central endoscopic browlift dissection has been described in both the subgaleal and subperiosteal planes. The subperiosteal plane proves to be less bloody and therefore provides a better optical cavity. This anterior dissection is performed blindly to within 1 cm above the supraorbital rim. The supraorbital notch is used as a landmark to identify the neurovascular bundles, as depicted in the image below.

      Endoscopic view of right supraorbital neurovascula Endoscopic view of right supraorbital neurovascular bundle. Note the relatively bloodless subperiosteal dissection plane.
    • In the temporal area, the dissection is performed superficial to the deep temporal fascia. This dissection plane protects the temporal branch of the facial nerve, which lies superficially within the temporoparietal fascia. Surgical dissection is relatively easy through the wispy gossamer fibers separating the temporalis fascia from the temporoparietal fascia. Laterally, the dissection proceeds almost to the zygomatic arch.

    • The conjoint tendon is approached in a lateral-to-medial direction to join the subperiosteal dissection over the frontal area. The central dissection to the orbital rim becomes more adherent under the orbicularis oculi muscle. Meticulous dissection in the temporal area is mandatory to identify the sentinel vein. Either preservation or careful cauterization of the sentinel vein is performed to prevent injury to the temporal branch of the facial nerve that lies directly above the vein within the temporoparietal fascia.

    • The arcus marginalis is then released at the level of the supraorbital rim from lateral canthus to lateral canthus under direct endoscopic visualization. The supraorbital neurovascular bundle at the supraorbital notch or foramen must be carefully identified when releasing the arcus marginalis. Complete periosteal release is essential to proper brow elevation, as depicted in the image below.

      Endoscopic view of right supraorbital nerve follow Endoscopic view of right supraorbital nerve following periosteal release.
    • The corrugators, procerus, and depressor supercilii muscles can then be transected or removed. Various techniques for releasing the brow depressor musculature have been described and include sharp or blunt dissection, laser ablation, and electrocauterization. Additionally, orbicularis oculi myotomy at the lateral superior brow may be performed for maximal brow release and elevation.

  • Fixation

    • The topic of endoscopic browlift fixation within the frontal area is broad. Techniques include soft tissue suturing, cortical screws with staple fixation, cortical screws and plates with suturing, absorbable screws, cortical bone tunnels with suturing, and tissue glue. The ideal fixation method allows pericranial readherence in the newly elevated position and is simple, quick, and inexpensive. Most authors believe that proper brow dissection and release are more important to the final result than the specific fixation technique.

    • In the temporal area, fixation of the overlying temporoparietal fascia (posterior to the course of the temporal branch of the facial nerve) to the deep temporal fascia is accomplished with absorbable sutures.

Previous
Next:

Postoperative Details

After all incisions are sutured, the hair is washed with warm sterile water. A light coating of antibiotic ointment is placed, and a nonstick dressing is secured with a bulky noncompressive dressing.

Previous
Next:

Follow-up

The dressing is removed the morning after surgery. All incisions are cleaned, the hair is washed, and postoperative instructions are reviewed again. Sutures are removed on postoperative day 5. Surgical clips are removed 10-12 days postoperatively.

The patient is cautioned against sun exposure, and sunscreen use is encouraged. Additional postoperative visits are at 1, 3, 6, and 12 months. Postoperative photographs are typically taken at the 3- and 12-month visits.

Previous
Next:

Complications

Complications are infrequent when browplasty is properly performed. However, as with any surgical procedure, complications can arise and should be treated appropriately. The following is a list of complications that can be observed following browplasty.

  • Asymmetry: Most asymmetry in the postoperative period relates to preexisting facial asymmetry. A thorough evaluation of the patient's face preoperatively and photographic documentation of the preoperative state are essential. A candid discussion of facial and brow asymmetry should occur with the patient during the initial consultation.

  • Hypoesthesia/numbness: Transient numbness in the supraorbital nerve distribution is not uncommon following browplasty. [11] Patients sometimes describe the sensation as itching, as a feeling of wearing a hat, or as a feeling of wearing band around their head. Most of these sensations resolve completely but may be permanent. These symptoms are more common following coronal and trichophytic techniques than following endoscopic, midforehead, or direct browlift procedures.

  • Scarring: Poor wound healing may result in widened, depressed, hypopigmented, or hypertrophic scars. Meticulous surgical technique should minimize noticeable scarring.

  • Overcorrection/undercorrection: These untoward outcomes can be minimized by performing a detailed preoperative evaluation. Surgical planning and patient marking with the patient in the sitting position are extremely helpful.

  • Facial nerve injury: Injury to the frontal branch of the facial nerve is rare. Surgical dissection in the temporal region must be subgaleal (just superficial to the deep temporal fascia and deep to the temporoparietal fascia) to minimize this serious complication. Take care with cauterization of blood vessels in the lateral brow and temporal regions.

  • Alopecia: Atraumatic tissue handling and careful cautery protects hair follicles and minimizes this complication. It also may be seen at endoscopic browlift fixation sites.

  • Flap necrosis: This is rarely observed given the excellent vascularity of the forehead. Use caution in patients who smoke or have diabetes. Ensure that the postoperative dressing is placed lightly.

  • Hematoma: Hematoma is uncommon, especially when the dissection plane is subgaleal or subperiosteal. Dissection in a more superficial plane can lead to some blood accumulation. Expression of any blood or clots prior to dressing placement minimizes the risk of hematoma formation.

  • Infection: This is rare. Always use sterile surgical techniques. Prompt recognition and treatment of any infection minimizes permanent sequelae.

Previous
Next:

Outcome and Prognosis

With proper patient selection and meticulous surgical technique, browplasty should yield a high degree of both patient and physician satisfaction.

Previous