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BROW LIFT
Jerome H. Liu, MD, MSHS
Andrew P. Trussler, MD
Cosmetic
PLATINUM PARTNERS
facial aesthetics
SILVER PARTNER
Editor-in-Chief
Jeffrey M. Kenkel, MD
Editor Emeritus
F. E. Barton, Jr, MD
Reconstruction Topics
Contributing Editors
W. P. Adams, Jr, MD
S. M. Bidic, MD
G. Broughton II, MD, PhD
S. Brown, PhD
Breast Reconstruction
Cleft Lip and Palate
Craniofacial
Eyelid Reconstruction
J. L. Burns, MD
Facial Fractures
J. J. Cheng, MD
Hand: Congenital
A. A. Gosman, MD
J. R. Griffin, MD
K. A. Gutowski, MD
R. Y. Ha, MD
R. E. Hoxworth, MD
K. Itani, MD
J. E. Janis, MD
R. K. Khosla, MD
J. E. Leedy, MD
J. A. Lemmon, MD
A. H. Lipschitz, MD
J. H. Liu, MD
Nasal Reconstruction
Surgery of the Ear
Trunk Reconstruction
Vascular Anomalies
Wounds and Wound Healing
R. A. Meade, MD
J. K. Potter, MD, DDS
Cosmetic Topics
S. M. Rozen, MD
M. Saint-Cyr, MD
M. Schaverien, MRCS
J. F. Thornton, MD
A. P. Trussler, MD
R. I. S. Zbar, MD
Blepharoplasty
Body Contouring: Excisional Surgery
Body Contouring: Noninvasive, Liposuction, and Fat Grafts
Breast Augmentation
Breast Reduction and Mastopexy
Brow Lift
Face-lift
Dori Kelly
Corporate Sponsorship
Skin Care
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BROW LIFT
Jerome H. Liu, MD, MSHS
Andrew P. Trussler, MD
INTRODUCTION
The brow and periorbital region play a central role in
the expression of emotion, health, and aging.
Successful brow lifting is predicated on a fundamental
knowledge of the anatomy, a thorough understanding
of the aging process, an artistic grasp of brow
aesthetics, and a logical well-executed surgical plan.
The aesthetic goals of browplasty include the
correction of eyebrow ptosis, muscle imbalance or
activity, forehead rhytids, brow shape and lid
aesthetics, lateral brow laxity, and abnormal or
unattractive facial expressions.1,2
HISTORY
In 1919, Passot3 was the first to report brow lifting in
the literature. He used multiple elliptical skin excisions
to elevate the brow and to diminish crows feet.
Subsequently, Hunt4 described a variety of techniques
to address the brow, including the coronal incision in
the hair-bearing scalp, a hairline incision, and direct
forehead incision. During the ensuing 20 to 30 years,
the forehead lift lost favor because of its transient
longevity. During that time, attempts to improve the
durability of the operation included transection of the
temporal branch of the facial nerve or injection of
alcohol into the motor nerves.5,6 Those efforts were
unsuccessful and fraught with complications.1,7
During the 1960s, interest in brow lifting was
renewed. Failures of earlier brow lifts were attributed
Figure 9. Summary of supraorbital nerve branching pattern classification. Left, Type I supraorbital nerve branching pattern, most
common type. Right, Types II through IV. SON-S, superficial division of the supraorbital nerve; SON-DCSM, branch from the deep
division of the supraorbital nerve; SON-D, deep division of the supraorbital nerve; SON-SCSM, branch from the superficial
division of the supraorbital nerve. (Reprinted with permission from Janis et al.34)
the rim.
The lateral brow terminates at an oblique line
drawn through the ala of the nose and the
lateral canthus.
The medial and lateral ends lie at
approximately the same horizontal level (the
medial end has a club head configuration that
gradually tapers laterally).
The apex of the brow lies on a vertical line
directly above the lateral limbus.
Table 1
Candidates with Indications Categorized and Correlated with Goals of Surgery2
Candidates
Primary
Secondary
Indications
Goals
Forehead rhytids
SURGICAL GOALS
Matarasso and Hutchinson57 divided the goals of
forehead-brow rhytidoplasty into primary and
secondary indications. The primary indication for
surgery is ptosis of the forehead and eyebrows. The
secondary criteria include frown muscle imbalance,
transverse forehead rhytids, upper eyelid aesthetics,
lateral brow-temporal laxity, and abnormal and/or
unattractive expression. A retrospective review,
however, showed a relatively uniform distribution of
patients into each category (primary or secondary).2
The primary and secondary indications and their
corresponding surgical goals are shown in Table 1.2 An
algorithm for selecting the appropriate forehead brow
procedure based on the patients main concern is
shown in Table 2.57
The overall goals of surgery are the restoration of
brow position, shape, and symmetry. For a soft,
esthetically pleasing result, it is important to avoid
overcorrection of brow position and excessive
elevation of the medial brow. Over-elevation of the
brow and abnormal shape are associated with
perceived tiredness, sadness, anger, or surprise.55,58 In
addition, any secondary criteria also need to be
addressed. The selection of incisions, dissection, and
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Table 2
Algorithm for Selecting Appropriate Forehead-Brow Procedure Based on Patients
Main Concern and Any Proposed Concomitant Surgery57
Indications
Associated Procedures
Treatment
Forehead rhytids
None
None
None
Rhytidectomy
Brow ptosis
*In patients desiring botulinum toxin treatment in conjunction with browpexy, the botulinum toxin should not be
injected laterally (leaving a strip of frontalis muscle intact) if the depressor orbicularis oculi are treated. An array of soft-tissue
fillers and substitutes (e.g., collagen replacement procedures, fat injections, liquid injectable silicone) can also be used.
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Figure 15. Types of incision used in brow lift. A, hairline; B, gull wing; C, vertex; D, lambdoidal; E, W incision; F, lambdoidal
paddle; G, interlocking Ms. (Reprinted with permission from Connell and Marten.76)
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Figure 17. Technique of limited incision foreheadplasty through transpalpebral approach. n., nerve. (Reprinted with permission
from Knize.111)
Figure 18. Algorithm for treatment of forehead wrinkles. (Modified from Rohrich.112)
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OTHER ISSUES
Combined Procedures
Brow lifting commonly is performed in conjunction
with other procedures for balanced facial
rejuvenation.15,18 Although the combinations are
virtually endless, several common combinations
deserve special mention.
Brow lift often is performed in conjunction with
periorbital rejuvenation. It is critical to position the
brow in its anticipated postsurgical position for
accurate evaluation of the upper eyelid.15,18,54 Upper
blepharoplasty skin excision tends to be less aggressive
when performed with brow lift.
Stuzin67 described his approach to endoscopic
brow lift, upper and lower blepharoplasty, and
retinacular canthopexy. He reported using the
endoscope predominantly for dissection along the
temporal line of fusion between the frontal bone and
temporalis muscle to help protect the temporal branch
of the facial nerve. Corrugator resection and
subperiosteal forehead dissection are still performed
through the transpalpebral approach. The lower lid is
addressed with a skin flap and canthal repositioning
and/or tightening.
When performing an endoscopic brow lift, the
dissection can proceed carefully down into the midface
for combined upper and midface rejuvenation. After
mobilization of the brow, Byrd and Andochick91 and
Hunt and Byrd151 approached the midface through a
sub-SMAS approach, following the superficial layer of
the deep temporal fascia over the zygomatic arch and
into the midface. Fascial fixation and suspension
sutures and microscrews are used. Hobar and Flood152
performed a subperiosteal midface lift in conjunction
with an endoscopic brow lift. Combining the forehead
and the midface lift can have favorable effects on
lower eyelid aesthetics by decreasing the vertical
height of the lower eyelid, lessening infraorbital
hollowing, and improving dermatochalasis.153
Modification of the Upper Facial Skeleton
The bony characteristics of the forehead often
differentiate men from women.154 The male forehead
has extensive supraorbital bossing with a cephalad
flat area before the convex curvature of the upper
forehead. In contrast, the female has nearly
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RECOMMENDED READING
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