What Are the Surgical Options for Brow Lifting?
Which do you prefer? Is an endoscopic brow lift always the best option? Is there ever a role for direct brow lifting?
Eyebrow ptosis is an important and frequent functional as well as cosmetic diagnosis in oculoplastic surgery. Gravity and aging works at least as much on the brows and forehead as it does on the eyelids. It is common for a patient to have brow ptosis, dermatochalasis, and eyelid ptosis simultaneously (Figure 46-1). When a patient has excess tissue and heaviness in the upper eyelids, it is imperative that the therapeutic modality chosen takes into consideration all of the factors involved. Blepharoplasty and eyelid ptosis repair performed alone in the presence of significant brow ptosis can result in further lowering of brow position with negative functional and cosmetic consequences. Diagnosing and treating brow ptosis and brow asymmetry is essential for achieving the optimal result.
Figure 46-1. Clinical photograph of a 55-year-old man with brow ptosis and dermatochalasis resulting in a tired facial appearance.
Historically, the brow lift procedures have been grouped into less invasive (internal brow, direct brow, mid-forehead, and endoscopic forehead lift) and more invasive (coronal forehead lifts and the pretrichial brow lift), based on the extent of surgery and recovery involved.
The internal brow lift involves internal brow sculpting with concomitant reattachment of the brow in a higher position (brow pexy) carried out through a blepharoplasty incision. Attaching the brow to the periosteum above the orbital rim is commonly performed by many surgeons today. In some patients the brow fat is not in excess but has simply prolapsed inferiorly. In these cases the brow fat is suspended superiorly with sutures. Removing the brow depressors at the same setting allows the frontalis muscle to more effectively elevate the medial and central brow (Figure 46-2).
Figure 46-2. Pre- and postoperative clinical photographs of patient who underwent internal brow sculpting with removal of the corrugator and depressor supercilii muscles. (A) Preoperative photograph showing marked dermatochalasis and brow ptosis. (B) Postoperative photograph showing higher medial, central, and lateral brow position.
The direct, mid-forehead and pretrichial brow lift have limited application because they tend to heal with visible scars. These are appropriate procedures in some elderly non-aesthetically motivated male patients and in patients with facial palsy who have marked asymmetry requiring substantial lateral brow elevation. Direct and mid-forehead lifting techniques are covered in some detail in Question 18.
The endoscopic forehead lift is an elegant way to lift the brows while simultaneously performing a lift of the upper third of the face. In most cases this is my preferred technique. The endoscopic forehead lift elevates the brow to a more youthful position with minimal forehead lengthening, postoperative incision line scarring, or scalp anesthesia (Figure 46-3). In my experience, endoscopic forehead lifting is the most effective technique for elevating the central and lateral brow. In addition to brow elevation, it provides a dramatic reduction in forehead furrow lines, elevates the midface, and improves the crow’s feet.
Figure 46-3. Pre- and postoperative clinical photographs of patient who underwent an endoscopic brow lift. (A) Preoperative photograph showing marked dermatochalasis and brow ptosis. (B) Postoperative photograph showing uniformly higher brow position and significant improvement of dermatochalasis.
In summary, excess eyelid skin, droopy upper eyelids, and droopy eyebrows all tend to occur in the same patient. It is not possible to achieve a good cosmetic and functional result unless all 3 components are addressed. The techniques of correcting eyebrow ptosis which leave the least scarring and give the best cosmetic result include: endoscopic forehead lift, internal brow elevation, and corrugators resection. Internal brow elevation and corrugators resection can be performed in the office procedure room as part of an upper blepharoplasty, thus decreasing cost and increasing patient acceptance. Endoscopic forehead lift often gives the best result but must be performed in a surgery center, which increases cost and decreases patient acceptance. These modern techniques are typically not covered by insurance companies so proper patient counseling is paramount so that patient expectations can be met.
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