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Volume 11 Issue C1
BROW LIFT
Jerome H. Liu, MD, MSHS
Andrew P. Trussler, MD
Cosmetic
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Reconstruction Topics
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G. Broughton II, MD, PhD
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Breast Reconstruction
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J. L. Burns, MD
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J. J. Cheng, MD
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A. A. Gosman, MD
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J. R. Griffin, MD
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K. A. Gutowski, MD
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R. Y. Ha, MD
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R. E. Hoxworth, MD
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K. Itani, MD
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J. E. Janis, MD
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R. K. Khosla, MD
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J. E. Leedy, MD
J. A. Lemmon, MD
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J. H. Liu, MD
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Surgery of the Ear
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J. K. Potter, MD, DDS
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J. F. Thornton, MD
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Blepharoplasty
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BROW LIFT
Jerome H. Liu, MD, MSHS
Andrew P. Trussler, MD
Department of Plastic Surgery,
University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
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 crow’s 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
to the persistent activity of the forehead muscles. The
McIndoe-Beare techniques8 for modifying the frontalis
and corrugators were updated by Marino and
Gandolfo.9 Vinas10 also made some very astute
observations that remain relevant even today:
“1. An inelastic aponeurotic-muscle layer, formed
by the frontalis and its extensions, occupies the
frontal region and expands laterally toward both
temporal regions. This layer adheres to the skin
and does not permit free movement of it.
Traction on the frontotemporal region with a
finger will show this fixation of the skin, as it
does not cause the wrinkles to disappear¾in
contrast to the results of a similar test in the
lower faciocervical area, where the skin glides
easily over the subjacent tissue.
2. There are adhesions that prevent free
movement of the soft tissues of the supraorbital
regions over the bony orbital rims. In our
experience, unless these adhesions are
eliminated, traction from above will not give a
permanent lift to the eyebrows.”
Subsequently, surgeons investigated different
approaches and planes of dissection. However, the
brow received little attention relative to other aspects of
facial rejuvenation. The advent of endoscopic brow
rejuvenation in the early 1990s11,12 stimulated increasing
attention to browplasty. A recent review13 discussed 262
articles that were published between 1966 and 2008 on
SRPS Volume 11, Issue 1C, 2009
the topic of brow lift. One hundred forty-two (54%) of
the articles were published during the last 10 years.
ANATOMY
In this section, we present summaries of the anatomy
related to brow lifting. For more in-depth study, we
refer the reader to descriptive textbooks and atlases by
Baker et al.,14 Barton,15 Knize,16 Mathes,17 Nahai,18 and
Zide and Jelks.19,20
Muscles
The frontalis muscles are paired extensions of the galea
aponeurotica and insert into the supraorbital dermis
by interdigitating with the orbicularis oculi muscle.
The superficial and deep galea layers continue to the
upper palpebral margin as the anterior and posterior
sheaths of the frontalis and orbicularis muscles. A fat
pad develops within a split in the posterior muscle
sheath at the brow. The galea is continuous with the
superficial temporal fascia laterally, which is
continuous with the superficial musculoaponeurotic
system (SMAS) inferiorly.21,22 The fixation of the brow
has been examined by Knize,23 who emphasized the
importance of the fusion plane between the galea,
temporalis, and periosteum at the temporal crest.
The depressors of the brow are the procerus,
corrugator supercilii, depressor supercilii, and
orbicularis oculi muscles.24,25 All except the sphincter
pass within the fat pad deep to the frontalis.23 The
procerus muscles originate from the upper lateral
cartilages and nasal bones and insert into glabellar
skin at the medial edges of the frontalis. Contraction
produces transverse wrinkling at the radix of the nose.
The corrugator muscle has both a transverse and
an oblique head. The procerus, depressor supercilii,
and oblique head of the corrugator muscle originate
from the superior-medial orbital rim and share a
parallel course before inserting into the dermis under
the medial eyebrow. 25 The transverse head of the
corrugator supercilii muscle originates from the medial
superior orbital rim and inserts into the dermis just
superior to the middle third of the eyebrow. The
transverse head of the muscle moves the entire
eyebrow medially, producing both vertical and oblique
glabellar skin creases. The procerus, depressor
supercilii muscle, and oblique head of the corrugator
2
supercilii muscle produce oblique glabellar skin lines.25
In a recent study of cadaveric dissections, Janis et
26
al. described the topography of the corrugator muscle
in great detail and noted that the corrugator supercilii
are much larger than previously described (Fig. 1). At
its medial origin, the corrugator begins 2.9 mm from
the nasion and extends laterally to a point 43 mm from
the nasion or 7.6 mm medial to the lateral orbital rim.
The most cephalic extent (apex) of the muscle is 32.6
mm superior to the nasion-lateral orbital rim plane. At
its medial origin, the most caudal muscle fibers are
approximately 1 cm cephalad to the nasion-lateral
orbital rim plane.
Figure 1. Comprehensive corrugator supercilii muscle
dimensions. Artistic rendition (proportionate scale) of all
measured data points of corrugator supercilii muscle in
relation to palpable bony anatomy. Note reflection of
muscular interdigitation required to delineate lateral extent
of corrugator supercilii muscle. (Reprinted with permission
from Janis et al.26)
The orbicularis oculi muscle is the sphincter of the
eyelid. This broad, thin, oval muscle is adherent to the
overlying skin and consists of three parts: a peripheral
orbital portion spreading over the forehead and cheek;
a palpebral portion that constitutes the voluntary
muscle of the eyelids; and a small lacrimal portion
associated with the medial palpebral ligament. The
orbital portion attaches to the medial canthal tendon,
the nasal part of the frontal bone, along the
inferomedial orbital margin, and interdigitates with
the corrugators medially. Laterally, the orbital portion
of the orbicularis continues around the orbit without
interruption at the lateral canthus into the zygomatic
area.14 Contraction of the orbicularis results in
downward displacement of the lateral brow.
SRPS Volume 11, Issue 1C, 2009
Contraction of the medial head of the orbital portion
depresses the level of the medial eyebrow but does not
uniformly contribute to the formation of oblique
glabellar skin lines. The palpebral portion of
orbicularis oculi spreads concentrically in the
subcutaneous tissue of the upper and lower eyelids.
The palpebral orbicularis oculi has pretarsal and
preseptal segments.
Ligaments and Attachments
The orbicularis oculi is anchored by well-defined
ligamentous attachments. Muzaffar et al.27 provided a
detailed description of the attachments. Medially, the
orbicularis has a direct attachment to the inferior
orbital rim from the region of the anterior lacrimal
crest to approximately the level of the medial limbus.
Laterally, the attachment is indirect and provided by
the orbital retaining ligament (ORL) (Fig. 2). The
anatomy of the ORL and its relationship to the orbital
septum were clarified in cadaver studies by Ghavami
et al.28 The authors found the ORL to be circumferential
in nature and consistent in every specimen. Although
the ORL and orbital septum merge at the orbital rim
into a thickening called the arcus marginalis, the two are
always noted to be distinct structures (Fig. 3).
The ORL extends from the periosteum just outside
the orbital rim to the fascia on the undersurface of the
orbicularis oculi. At its lateral extent (and in the region
Figure 2. Anatomy of inferior periorbital space. Medially,
orbicularis oculi originates directly from orbital rim above
origin of levator labii superioris. More centrally, orbicularis
attaches indirectly to orbital rim by means of orbicularis
retaining ligament, which courses directly on orbital side of
zygomaticofacial nerve. Laterally, ligament merges into
lateral orbital thickening. (Reprinted with permission from
Muzaffar et al.27)
of the lateral canthus), the ORL merges with the
“lateral orbital thickening” (LOT). The ORL is more lax
and greater in length laterally compared with medially,
where it is more taut and shorter (Fig. 4).28 The LOT
represents a triangular condensation of the superficial
and deep orbicularis that extends across the frontal
process of the zygoma onto the deep temporalis fascia.
In a study conducted by Muzaffar et al.,27 the
dimensions of the LOT varied greatly with age (Fig. 5).
The ORL is predictably continuous with the LOT
below the lateral canthal tendon. Specifically, the ORL,
LOT, and lateral palpebral raphe form a single
anatomic unit in that region (Fig. 6). Release of the
ORL and LOT, therefore, allows untethered redraping
of all the structures.
Figure 3. Schematic drawing shows relationship of orbital
septum and orbicularis retaining ligament (ORL). Orbicularis
retaining ligament arises from orbital rim several centimeters
above inferior edge. Arcus marginalis is fused area of orbital
septum, orbicularis ligament, and periosteum and lies
between the orbital septum and orbicularis retaining
ligament. OOM, orbicularis oculi muscle. (Reprinted with
permission from Ghavami et al.28)
3
SRPS Volume 11, Issue 1C, 2009
Figure 4. Schematic shows view from the lateral orbital rim
toward nasal bones with orbicularis oculi muscle (OOM)
suspended by hooks to show length and size differential
between lateral and medial orbicularis retaining ligaments
(ORL). Lateral orbicularis retaining ligament is longer than
medial orbicularis retaining ligament in both superior and
inferior orbits. Note relationships among orbicularis
retaining ligament, corrugator supercilii muscle (CSM), and
lateral orbital thickening (LOT). (Reprinted with permission
from Ghavami et al.28)
Figure 5. Dimensions of orbicularis retaining ligament and
lateral orbital thickening vary with age. Larger triangle
represents lateral orbital thickening in youngest specimen.
Smaller triangle within defines lateral orbital thickening in
older specimens. Numbers indicate millimeters. (Reprinted
with permission from Muzaffar et al.27)
Moss et al.29 conducted a detailed anatomic study
of the temporal and periorbital regions and provided a
taxonomy for the various supporting structures. The
authors divided structures into ligaments (deep fascia
or periosteum to dermis), septi (fibrous wall between
fascial layers), and adhesions (fibrous or fibro-fatty
4
Figure 6. Orbicularis retaining ligament (ORL), lateral orbital
thickening (LOT), and lateral palpebral raphe form a single
unit lateral to the lateral canthal tendon (LCT). TPF, temporal
parietal fascia; TP, tarsal plates. (Reprinted with permission
from Muzaffar et al.27)
adhesion between deep and superficial fascia). They
identified six global temporal and periorbital
structures relevant to brow lifting: temporal
ligamentous adhesion, supraorbital ligamentous
adhesion, superior temporal septum, inferior temporal
septum, lateral brow thickening, and LOT. The
temporal ligamentous adhesion measures
approximately 20 mm high and 15 mm wide at its base
and begins 10 mm cephalad to the superior orbital rim.
Moss et al. also delineated the relationships to adjacent
relevant neurovascular structures: sentinel vessel,
temporal branch of facial nerve, zygomaticotemporal
nerve, and zygomaticofacial nerve. Their findings are
illustrated in Figures 7 and 8. Sullivan et al.30 identified
four specific retaining ligaments: three medial and one
lateral. Selective release of the ligaments allows for
eyebrow reshaping.
Sensory Nerves
The sensory nerves of the forehead are the supraorbital
and supratrochlear nerves. The supratrochlear nerve
emerges from the supraorbital rim 1.4 to 1.7 cm lateral
to the midline of the nasal radix, and the supraorbital
nerve courses 2.4 cm lateral to the midline.31 Beer et
al.32 investigated more than 1000 orbits and found wide
variation between the exit patterns of the supraorbital
nerve, with asymmetric findings between left and right
in 74% of the specimens. Additionally, the largest
distance the supraorbital nerve exited from the
supraorbital rim was 19 mm. In a different study,
SRPS Volume 11, Issue 1C, 2009
Figure 7. Lateral view shows periorbital and temporal
ligamentous attachments with major neurovascular
relationships. TLA, temporal ligamentous adhesion; SLA,
supraorbital ligamentous adhesion; STS, superior temporal
septum; ITS, inferior temporal septum; PS, periorbital
septum; LBT, lateral brow thickening of periorbital septum;
LOT, lateral orbital thickening of periorbital septum; SV,
sentinel vessel; TFN, temporal branches of facial nerve; ZTN,
zygomaticotemporal nerve; ZFN, zygomaticofacial nerve.
(Reprinted with permission from Moss et al.29)
Webster et al.33 found that approximately 50% of skulls
had bilateral supraorbital notches, 25% had bilateral
supraorbital foramina, and 25% had one notch and one
foramen. Bilateral supratrochlear notches were present
in 97% of specimens.
The supraorbital nerve divides into a deep branch
and a superficial branch. Janis34 describes four distinct
branching patterns of the supraorbital nerve relative to
the corrugator supercilii (Fig. 9). With pattern I (40%),
the deep division sends branches that course along the
undersurface of the muscle. With pattern II (34%), both
the superficial and deep divisions have branches
adjacent to the corrugator. Pattern III (4%) has only
branching contributions from the superficial division,
and with pattern IV, all branching of the supraorbital
nerve occur cephalad to the bulk of the corrugator
muscle. The authors found the supraorbital nerve to be
more intimately related to the corrugator muscle than
previously thought. However, the supraorbital nerve
Figure 8. Anterior view shows periorbital and temporal
ligamentous attachments with major neurovascular
relationships. TLA, temporal ligamentous adhesion; SLA,
supraorbital ligamentous adhesion; STS, superior temporal
septum; ITS, inferior temporal septum; PS, periorbital
septum; LBT, lateral brow thickening of periorbital septum;
LOT, lateral orbital thickening of periorbital septum; SV,
sentinel vessel; TFN, temporal branches of facial nerve; ZTN,
zygomaticotemporal nerve; ZFN, zygomaticofacial nerve.
(Reprinted with permission from Moss et al.29)
was not observed to perforate through the muscle in
any of the cadaver specimens.34 The superficial
(medial) division enters the frontalis 2 to 3 cm above
the supraorbital rim and provides sensation to the
forehead skin and 1 to 3 cm of the anterior scalp.35 The
deep (lateral) division runs between the galea and
periosteum and proceeds laterally until the
midforehead, where it takes a course 0.5 to 1.5 cm
5
SRPS Volume 11, Issue 1C, 2009
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)
medial to the temporal fusion line.35 The deep division
provides sensation to the frontoparietal scalp, and
Knize23 suggested that arrangement is responsible for
the itching and numbness patients feel after open
coronal brow lift procedures. The supratrochlear nerve
exits the orbit medially and enters the substance of the
corrugator and then the frontalis.35
Motor Nerves
The motor nerve of the forehead is the temporal
branch of the facial nerve, which lies on the
undersurface of the temporal fascia. The temporal
6
branch of the facial nerve supplies the frontalis muscle,
superior orbicularis muscle, transverse head of the
corrugator supercilii muscle, and superior end of the
procerus muscle (Fig. 10).25 Pitanguy and Ramos36
traced the temporal branch of the facial nerve from 0.5
cm below the tragus to 1.5 cm superior to the lateral
brow. The temporal branch usually runs just below the
frontal branch of the temporal artery.37 Stuzin et al.38
delineated the multiple layers in the temporal region,
described the course of the nerve in a threedimensional fashion relative to the fascial planes, and
suggested a safe dissection route. The concept of the
SRPS Volume 11, Issue 1C, 2009
Figure 10. Periorbital motor nerves and the muscles they
activate. TB, temporal branch of the facial nerve; ZB,
zygomatic branch of the facial nerve; FM, frontalis muscle;
CSM, corrugator supercilii muscle; DSM, depressor supercilii
muscle; PM, procerus muscle; ZM, zygomaticus major
muscle. (Reprinted with permission from Knize.25)
frontal temporal nerve triangle39 can assist in locating
motor and sensory nerves in the upper face.
The zygomatic branch of the facial nerve supplies
the inferior orbicularis oculi muscle, inferior end of the
procerus muscle, depressor supercilii muscle, oblique
head of the corrugator supercilii muscle, and medial
head of the orbicularis oculi muscle.25
Calvaria
The skull thickness varies based on location. Walden et
al.40 showed that the thickness increases medially and
posteriorly. Knize16 measured the thickness of the skull
in various locations, with averages ranging from 5.1
mm laterally to 7.7 mm medially. The temporal bone
was found to be as thin as 1.7 mm. The skull is also
thin just superficial to the middle meningeal artery,
measuring as little as 2.1 mm.16
PATHOPHYSIOLOGY
Prolonged hyperactivity of the upper facial
musculature produces three kinds of deformities of the
forehead and brow complex: transverse forehead
wrinkling (frontalis muscles), brow ptosis (corrugator
and orbicularis muscles), and glabellar wrinkling
(corrugator, orbicularis, and procerus muscles).
Flowers et al.41 reviewed the dynamics of frontalis
function as related to brow lift.
Knize23 discussed the mechanism of eyebrow
ptosis in an anatomic study that identifies the balance
of forces acting on the eyebrow and specific glide
planes and supporting structures. He postulated that
the lateral eyebrow segment becomes ptotic earlier
than the medial segment because the lateral eyebrow
has less support from deeper structures and the
balance of forces acting on the eyebrow selectively
depresses the lateral segment (Fig. 11). The author
identified three forces acting on the lateral eyebrow:
“1) frontalis muscle resting tone, which suspends
that eyebrow segment medial to the temporal
fusion line of the skull;
2) gravity, which causes the soft-tissue mass
lateral to the temporal line to slide over the
temporalis fascia plane and push the lateral
eyebrow segment downward; and
3) corrugator supercilii muscle hyperactivity in
conjunction with action of the lateral orbicularis
oculi muscle, which can antagonize frontalis
muscle activity and directly facilitate descent of
the lateral eyebrow.”
AESTHETICS
One cannot discuss brow aesthetics without
simultaneously discussing periorbital and eyelid
aesthetics. Clearly defined goals of brow and orbital
aesthetics are the basis of successful results in surgical
rejuvenation of the upper face. The goals vary
significantly with sex, age, race, culture, and personal
preference. The globe by itself is entirely
expressionless and depends on the surrounding softtissue complex to convey the myriad human
emotions. Many of these aesthetic goals intertwine the
forehead, brow, eyelid, and pupil into the brow and
temporal region. Often, the “ideal” measurements
refer back to the golden proportion, reminding us that
the relative positions and distances might be more
important than the absolute.15,42
Farkas and Kolar,43 Flowers,44 and Wolfort et al.45
reviewed the aesthetic goals of blepharoplasty. Certain
7
SRPS Volume 11, Issue 1C, 2009
Figure 11. Forces contributing to lateral eyebrow ptosis.
Unsupported eyebrow lateral to the temporal fusion line of
the skull (TL) is pushed down by the gravity-driven descent
of the temporal fossa soft tissues. Lateral-most limit of the
frontalis muscle resting tone suspension of the eyebrow
extends just over the zone of fixation (slanted lines) along the
temporal fusion line of the skull. Hyperactive corrugator
supercilii muscle and lateral orbicularis oculi muscle action
can antagonize frontalis muscle action and actively facilitate
the descent of the superficial temporal fossa soft tissues.
(Reprinted with permission from Knize.23)
numerical guidelines are helpful in planning the
surgery. At the midpupillary line, the anterior hairline
to brow distance should measure 5 to 6 cm. The
distance from brow to orbital rim, brow to supratarsal
crease, and brow to mid pupil should be 1 cm, 1.6 cm,
and 2.5 cm, respectively.2 Canthal tilt averages 4.1 mm
(+4 degrees) in women and 2.1 mm (+3 degrees) in
men.46 Visible pretarsal skin should measure 3 to 6
mm47 and lash line to lid fold ranges from 8 to 10 mm.48
The upper lid should cover 2 to 3 mm of the iris, and
the lower lid forms a “lazy-S” and should just meet its
inferior aspect. The intercanthal distance is ideally onefifth of the facial width at eye level and represents one
eye width.49
McKinney et al.50 analyzed 15 normal healthy
volunteers with esthetically pleasing faces and
observed that the average distance from the mid pupil
to the upper edge of the eyebrow was 2.5 cm and the
distance from the upper edge of the eyebrow to the
hairline was approximately 5 cm (Fig. 12). Connell et
al.51 added that the distance between the upper eyelid
8
Figure 12. Distance from midpupil to top of brow should be
at least 2.5 cm. If shorter, brow ptosis exists. Forehead height
averages 5 cm in women and 6 cm in men. (Modified from
McKinney et al.50)
crease and the upper edge of the brow is
approximately 15 mm in esthetically pleasing faces.
Because of naturally occurring variations in the
sizes and shapes of human structures, a discussion of
relationships between parts is more relevant than
absolute numbers. The medial edge of the eyebrow, the
medial canthus, and the lateral border of the nasal ala
should all fall on the same vertical plane. The eyebrow
should form a gentle arch whose peak lies at the
junction of the medial two-thirds and the lateral onethird.52 The peak should ideally lie midway between
the lateral aspect of the iris and the lateral canthus.
Some have suggested that the peak of the brow arch
should be more lateral than the classic description.53
The brow should overlie the orbital rim in men and be
several millimeters above the rim in women. The edge
of the lateral eyebrow should lie slightly above the
medial brow. A line drawn between the lateral
eyebrow and the nasal ala should intersect the lateral
canthus.52,54 Ellenbogen54 illustrated the aesthetic
relationships of the brow to other facial features (Fig.
13), as originally described by Westmore52:
• In women, the eyebrow begins medially at a
vertical line drawn perpendicularly through
the ala of the nose.
• In women, the brow should arch to above the
supraorbital rim; in men, it should arch along
SRPS Volume 11, Issue 1C, 2009
•
•
•
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.
•
•
•
•
The medial brow should be lower than the
lateral peak.
The eyelids should remain aesthetic with the
brow elevated, otherwise surgical alteration of
the eyelids might be indicated.
The periorbital area should have its own
balance. It should resemble an oval consisting
of the eyebrow superiorly, the nasal dorsal
line medially, the nasojugal groove inferiorly.
The eye should be in the center of the oval,
and the oval should balance with the rest of
the face (Fig. 14).
Aesthetics of the male brow differ. The male
brow tends to be less arched and usually flat
or nearly horizontal. The lateral brow is
usually more prominent in men.
Figure 14. Periorbital oval. (Reprinted with permission from
Gunter and Antrobus.55)
Figure 13. Spatial relationships of ideal eyebrow. B, medial
brow; E, brow apex; C, lateral brow. (Reprinted with permission
from Ellenbogen.54)
Gunter and Antrobus55 provided further criteria
that contribute to an aesthetic brow:
•
•
•
The medial brow should be a continuation of
the aesthetic dorsal line of the nose.
The medial brow should start approximately
above the medial canthus.
The vertical distance from the supraorbital
arch to the peak of the brow will differ.
However, the peak should rarely be more than
10 mm above the most caudal portion of the
medial brow. It should be higher in women
than in men.
Final brow position and shape should be
determined during preoperative discussions with the
patient in the context of facial aesthetics, individual
preferences, and facial shape. A recent study by Baker
et al.56 showed that brow aesthetics should take facial
shape into consideration. Using computer imaging
software, the authors morphed a model’s face into
different shapes (round, square, oval, and long) and
applied the classic description presented by
Westmore52 versus the recommendations of a
professional makeup artist. No significant difference
was noted between the classic and modified eyebrow
for oval or round facial shapes. However, the brow
modified by the professional makeup artist was found
to be more attractive with square and long facial
shapes. Specifically, square faces favored a softer curve
with the arch lateral to the lateral limbus and long
faces were more attractive with a straighter brow,
avoiding a high arch that may add length to the face.
9
SRPS Volume 11, Issue 1C, 2009
Table 1
Candidates with Indications Categorized and Correlated with Goals of Surgery2
Candidates
Primary
Secondary
Indications
Goals
Eyebrow malposition (ptosis)
Senile
Congenital
Elevate forehead and eyebrows
Balance, position, symmetry
Frown muscle imbalance
Minimize corrugator-procerus activity and
central frown folds
Forehead rhytids
Decrease frontalis muscle hyperactivity and
transverse rhytids
Enhancing medial and/or lateral eyelid
incision (aesthetics)
Confine the eyelid incision within the
tarsal crease
Lateral brow laxity (temporal lift)
Restore temporal, lateral brow, and
canthal regions
Abnormal and/or unattractive expression Adjust brow position to normalize expression
(e.g., sad, tired, angry)
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 patient’s 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
10
adjunctive procedures needs to be tailored to specific
patient desires.
TECHNIQUE
With the aesthetic goals clearly in mind, the approach,
plane of dissection, and means of fixation are chosen.
Incisions
Direct
Flowers et al.41 suggested that the brow is subject to the
elastic band principle: the farther away the suspension
point is from a weight attached to an elastic band, the
less effective the lift will be. The direct or superciliary
excision of an ellipse of skin and subcutaneous fat was
first described by Passot in 1919.3 In 1964, Castanares59
presented his results, which attested to predictable,
controlled elevation of the brow. Vinas et al.10 described
two techniques for brow lift, one of which was a
butterfly-wing pattern of excision, emphasizing
resection from the lateral brow.
The direct excision approach is most often taken in
men because of the opportunity to hide the scar above
the thicker male eyebrow and because other
approaches cannot be hidden if the patient is balding.
The most appropriate candidates for the direct brow
SRPS Volume 11, Issue 1C, 2009
Table 2
Algorithm for Selecting Appropriate Forehead-Brow Procedure Based on Patient’s
Main Concern and Any Proposed Concomitant Surgery57
Indications
Associated Procedures
Treatment
Forehead rhytids
None
Botulinum toxin ± laser resurfacing*
Glabellar creases (corrugator
muscle hypertrophy)
None
Endoscopic corrugator muscle excision
or botulinum toxin ± laser resurfacing*
Upper eyelid surgery
Corrugator muscle excision through
upper lid ± laser resurfacing
None
Limited procedure (i.e., endoscopic,
temporal lifts), upper lid browpexy
Rhytidectomy
Lateral brow lift through temporal aspect
of facelift incision
With or without rhytidectomy
Coronal brow lift, endoscopic brow lift,
anterior hairline brow lift for high
(>5–6 cm) forehead
Lateral brow laxity
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.
lift are male patients older than 50 years with eyebrow
ptosis and lateral hooding, well developed crow’s feet,
long dense eyebrows, and low transverse forehead
wrinkles.60 The biggest disadvantage of a direct
technique is the potential for a perceptible scar at a
visible portion of the face.61 Some authors have found
that the scar is hardly noticeable after 6 to 9 months.60
Midbrow
Excision of a strip of midforehead skin is advocated for
patients who have deep forehead rhytids, to conceal
the scar, and in those who have male pattern baldness,
in whom a coronal lift is impossible. This approach,
originally described by Gurdin and Carlin62 in 1972,
has the additional advantage of advancing the hairline
forward. Advocates53 of the midbrow lift tout its
advantages: 1) moderate undermining above the
frontalis muscle, 2) no hairline distortion, 3) precise
sculpting of the entire brow, and 4) access to the
superior orbital rim. Its primary disadvantage is the
position of the scar.53
Transblepharoplasty
Sokol and Sokol63 described a transblepharoplasty
brow suspension that involved tacking a soft-tissue
eyebrow flap to a superiorly based orbital rim
periosteal flap. McCord and Doxanas64 reported a
method of resecting the brow fat pad and suspending
the brow from the periosteum above the brow to the
preseptal orbicularis.
Others have performed more extensive forehead
dissections through the blepharoplasty incision.
Leopizzi65 reported performing wide supraperiosteal
dissection of the lateral orbicularis through an upper
blepharoplasty incision, transecting the “zone of
fixation” where the superior temporal line joins the
superior orbital rim. The lateral orbicularis oculi
muscle is raised with one non-absorbable suspension
stitch in the deep temporal fascia. Paul66 described a
transblepharoplasty subperiosteal brow lift with
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SRPS Volume 11, Issue 1C, 2009
corrugator and procerus resection. Stuzin67 also
reported performing a large portion of the brow
dissection through a blepharoplasty incision, although
he used an endoscope to complete the dissection
through the zone of fixation. Langsdon et al.68 reported
widely undermining in the subgaleal plane through an
upper eyelid incision medial to the temporal line.
Suspension sutures and absorbable anchors are used to
support the brow. Cintra and Basile69 described a
combined approach that included transblepharoplasty
and temporal incisions.
Knize70 and Guyuron et al.71 described a transblepharoplasty approach to the corrugator supercilii and
procerus muscles for the treatment of glabellar
wrinkles. Brow contouring and shaping can also be
accomplished through an upper blepharoplasty
incision. Resection of the retro-orbicularis fat can
soften and flatten the heaviness and bulkiness in the
upper periorbital and brow region.72,73 The fat pad
overlies the lateral orbital rim and extends outward
toward the end of the brow. Zarem et al.74 described
performing browpexy through an upper lid incision to
prevent the brow from dropping below the superior
orbital rim.
Coronal
In 1962, Gonzalez-Ulloa75 combined a coronal incision
for forehead lifting with traditional rhytidectomy for
the lower face. Interest in the technique remained
sporadic until Vinas et al.10 reported 250 cases of
frontotemporal “rhytidoplasty.” Connell and Marten76
indicated that every 1 mm of eyebrow elevation
produces 1.5 mm of retro-displacement of the anterior
hairline. The incision, therefore, should be performed
in patients who have low hairlines or in whom the
predicted shift is esthetically acceptable. Flowers and
Ceydeli77 reported adhering to a “five-to-one” rule
with which each 5 mm of scalp excision results in 1
mm of long-term brow elevation. In bald or balding
men, Connell and Marten used a vertex incision
further posterior, where it is not visible in conventional
photographs. Other patterns are shown in Figure 15.
Flowers and Ceydeli recommended having at least 4
cm of hair remaining after scalp resection; Barton15
recommended 5 cm.
Excellent descriptions of the classic coronal brow
lift can be found in articles by Ellenbogen,54 Flowers
and Ceydeli,77 Kaye,1 Ortiz-Monasterio et al.,78 and
Pitanguy.79 Aldo Mottura80 presented an alternative of
galeal plication after limited incision dissection in the
subgaleal plane. With that method, skin is excised and
the galeal is plicated through a coronal incision. The
coronal open brow lift usually provides the most
effective lift and is best suited for heavy tissues or
prominent eyebrow ptosis.81,82
Hairline
Hunt,4 in 1926, placed an incision along the anterior
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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SRPS Volume 11, Issue 1C, 2009
hairline in an attempt to reduce forehead wrinkling.
McKinney et al.50 recommended the anterior hairline
incision for patients with an eyebrow-to-hairline
distance greater than 5 cm. Debate continues regarding
whether to bevel the incision parallel or perpendicular
to the hair follicles to produce the best cosmetic result.
Camirand83 and Camirand and Doucet84 compared the
two beveling techniques and found that the incisions
that were oriented perpendicular to the hair follicles
were superior based on invisibility of the scar,
nonlinearity of the scar, absence of hypopigmentation,
and presence of hair in front of the scar. The hair
follicles of the anterior temporal hairline grow
anteriorly and inferiorly at an angle of 7 to 27 degrees
(mean, 16 degrees) to the epidermis.85 Pollock and
Pollock86 reported performing a hairline subcutaneous
brow lift that results in acceptable scars by beveling
the incision perpendicular to the hair follicles.
Guyuron and Rowe87 described the use of a hairline
incision combined with posterior scalp advancement
to shorten a long forehead during brow lift.
Temporal
Temporal brow lifting is one of the oldest known
methods for repositioning the brow, dating to Passot in
1919.3 Gleason88 performed brow lift by extensive
subcutaneous undermining in the temporal and lateral
orbital areas up to the anterior branch of the temporal
artery, at which point the dissection deepened to a
subgaleal plane. The incisions were not connected
across the midline. Ten of 102 patients developed
transient temporal alopecia, and one patient
experienced temporary frontal paresis. Dingman89
described another modification of the temporal lift that
involved initial dissection in a subgaleal plane.
Byrd90 and Byrd and Andochick91 described a
temporal approach that involves dissection in the
subgaleal plane with extensive soft-tissue release at the
superior and lateral orbital rim. Further dissection over
the zygomatic arch below the superficial layer of the
deep temporal fascia allows elevation of the malar fat
pad and avoids the temporal branch of the facial nerve.
Several authors92,93 have reported using a biplanar
temporal lift to improve lateral brow elevation.
Marshak et al.92 described a temporal incision and then
creation of an SMAS-galeal flap to increase the amount
of lift. Fogli93 described beginning his dissection in the
subgaleal plane and then transitioning to the
subcutaneous plane just anterior to the hairline.
Endoscopic
The endoscopic approach allows access to the forehead
for release of the retaining structures of the upper face
and for muscle resection through very small incisions
in the scalp. Use of the endoscope in forehead surgery
was first presented by Isse11 and by Vasconez12 in 1992
and by Hamas94 in 1993. Steinsapir et al.95 reviewed the
anatomy and surgical technique of endoscopic
forehead lift. Excellent descriptions of that technique
can be found in articles and chapters by Aiache,96
Daniel and Tirkanits,97 DeCordier et al.,98 Guyuron,99
Rowe and Guyuron,100 Isse,24 and Nahai.18
Vasconez et al.101 presented the results of a series of
brow lifts performed in 32 patients. A subperiosteal
approach was used, with subgaleal dissection down to
the orbital rims, corrugator and procerus resection, and
frontalis scoring. Fixation was by bone-soft tissue
anchors or by sutures connecting the galea to the
temporalis fascia. The authors reported moderate
lifting of the brow in most cases. Complications
included perforation and burning of the forehead,
temporary palsy of the temporal nerve, and three cases
of glabellar hematoma.
Sozer and Biggs102 reviewed 128 endoscopic
forehead lifts performed in a subperiosteal plane. Their
operative time was 15 to 30 min. A common
complication was local alopecia, which decreased in
frequency when the authors began using fixation with
titanium microscrews. Two patients had asymmetrical
brow position. The lift effect persisted for the 5 years
of follow-up.
Hamas103 reported limiting his technique to
resection of the corrugator and procerus muscles to
reduce prominent glabellar frown lines. In his series of
35 patients, approximately 50% of glabellar wrinkles on
maximal effort were reduced. Complications included a
noticeable depression in the glabellar region in the first
few patients and one patient with a skin burn.
Hamas and Rohrich104 presented a technique
whereby the galea aponeurosis is plicated after
separating it from the forehead skin above and below
the scalp incision. The modification effectively raises
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SRPS Volume 11, Issue 1C, 2009
the central brow without elevating the central hairline.
Other contributions to endoscopic foreheadplasty
have been made by Isse,24 Aiache,96 Ramirez,105 and
Chajchir.106 Since those authors presented their reports
in 1994, long-term follow-up results have been
presented by multiple authors.98,99,107,108 The results have
been long lasting and stable.
Limited Incision
Several authors have reported using endoscopic brow
lift-type incisions in the hairline to raise the lateral
eyebrow through a limited incision. Kikkawa et al.109
reported using small scalp and upper eyelid
blepharoplasty incisions to dissect the lateral brow in a
subperiosteal plane and to resect the corrugator and
procerus muscles.
Knize110,111 described limited-incision
foreheadplasty, with lateral dissection of the lateral
brow in a subperiosteal plane. The author emphasized
that the dissection must include release of the
periosteal attachments along the superior orbital rim
and transection of the ligamentous band that he calls
the orbital ligament (Fig. 16). A transpalpebral approach
is taken to the procerus and corrugator musculature
(Fig. 17).110,111 In a discussion of the articles presented by
Knize, Rohrich112 offered an algorithm for correction of
Figure 16. Eyebrow elevation through small incision in scalp.
Subperiosteal forehead flap is raised and orbital ligament (*)
transected for maximum upward movement of superficial
temporal fascia. STF, superficial temporal fascia; TL,
temporal fusion line of the skull; div., division; n., nerve.
(Reprinted with permission from Knize.110)
14
the aging forehead and periorbital area (Fig. 18).
Limited incision non-endoscopic techniques have
gained popularity. Their biggest advantage over the
endoscopic approach is the avoidance of cumbersome
and expensive equipment.113 A non-endoscopic limited
approach can be safely performed with mastery of the
regional anatomy.114 Medial brow elevation can be
minimized or avoided with a limited incision
technique. A transpalpebral route can be used in
conjunction with a limited incision technique for
corrugator resection.
Plane of Dissection
Subcutaneous
A subcutaneous brow lift has the advantages of a
direct approach to removing transverse wrinkles of the
forehead and for elevating the brow while preserving
sensation to the scalp posterior to the incision. The
disadvantage of the technique is a significant decrease
in flap vascularity, which was responsible for high
rates of complications in several series.78,115,116 Rees and
Wood-Smith115 and Ortiz-Monasterio et al.78 listed
potential problems with the subcutaneous brow lift,
such as alopecia, wound dehiscence, skin slough, poor
scars, anesthesia of the forehead, and compromised
circulation. Guyuron116 also reported a higher
complication rate with the subcutaneous brow lift than
with other methods of rejuvenating the forehead.
In contrast, Wolfe and Baird117 presented their
experience with subcutaneous brow lift in 27 women
and reported no significant loss of tissue or hair. The
authors recommended the procedure for older patients
who have considerable transverse and vertical
wrinkling or pronounced brow ptosis. Not long ago,
Wolfe118 reviewed his indications for subcutaneous
forehead lift, as follows:
• very wrinkled forehead with pronounced
brow ptosis, particularly laterally
• secondary or tertiary forehead lift
• very short forehead that needs heightening
• high forehead that needs shortening by
advancing a scalp flap
The author’s routine forehead lift is still a subgaleal
dissection through a coronal incision. Complications
occurring in several dozen patients included a small
SRPS Volume 11, Issue 1C, 2009
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)
15
SRPS Volume 11, Issue 1C, 2009
subcutaneous ecchymosis and one case of cutaneous
hypersensitivity of the lateral brow and temporal area
that persisted for more than a year.
Guyuron116 asserted that a subcutaneous plane is
more effective than other methods for eliminating
forehead wrinkles and crow’s feet. With that approach,
the surgeon has the option of shortening or
lengthening the forehead or leaving the length
unchanged. Vogel and Hoopes119 presented a report of
50 patients who underwent subcutaneous brow lift
with few complications. The main disadvantage of that
technique is the precision required for the incision and
closure and the time-consuming dissection.
Miller et al.120 reviewed the pros and cons of
subcutaneous brow lift and interbrow muscle resection
through an incision in the lateral temporal hairline. An
additional benefit of that approach is the ability to
excise some of the non-hair-bearing skin, thereby
decreasing temporal baldness. The authors reported
minimal complications in 65 patients.
Pollock and Pollock86 reported that the
subcutaneous lift provides the most direct approach to
elevation of the ptotic bow, which is a skin appendage.
The ratio of advancement to lift is 1:1. Corrugator
resection is performed by incising the galea
transversely in the glabellar region. Flap advancement
is secured by using progressive tension sutures to hold
the brow in position. In their series of 80 patients, only
one patient had transient epidermolysis in the
temporal scalp resulting in a small area of alopecia.
Subgaleal
Rudolph and Miller121 reported that the subgaleal
dissection is rapid, considering the plane is obvious
and safe, and that it facilitates direct resection of
muscle without nerve damage. Connell and Marten76
stated that they use that plane because it is relatively
bloodless, is easy to identify and dissect, and offers
excellent access to hypertrophied muscles. Ramirez122
reported that by elevating the rigid pericranium, the
skin is not allowed to stretch in cases of severe fixed
forehead wrinkles. Connell and Marten,76 Vinas et al.,10
and Ortiz-Monasterio et al.78 all reported series in
which a subgaleal flap was effectively used, and De La
Plaza et al.123 suggested that the galea adheres more
rapidly to periosteum than does periosteum to bone,
16
resulting in surer fixation of the tissues.
Knize23 stated that the majority of eyebrow
movement occurs between the leaves of the galea at
the orbital rim. Dissection in that plane is likely to
result in the greatest degree of translation of the brow.
Byrd and Andochick91 reported performing their
temporal lift in the subgaleal plane, freeing the
attachments of the orbicularis to the periosteum.
Dissection can initially begin in the subgaleal plane
and transition to the subperiosteal plane 2 cm above
the orbital rim.
Troilius124 compared the surgical outcome of
subgaleal and subperiosteal brow lifts in 120 patients.
Measurements were obtained from preoperative
photographs and compared with postoperative
measurements at 1 year. The data were analyzed by
means of a digitalized analyzing tool. Patients who
had undergone subgaleal brow lift showed no
significant elevation of the brow after 1 year, whereas
patients who had undergone subperiosteal brow lift
showed a mean increase in vertical brow height of 7
mm. In a discussion of the article by Troilius, Stuzin
and Rohrich125 attributed the lack of persistent
improvement in the subgaleal series to many factors,
such as method of fixation (Troilius did not use anchor
fixation), incision position (mostly coronal rather than
hairline), skin versus galea excess (a subcutaneous
technique might be indicated for older patients with
brow skin laxity), and the dynamic forces of orbicularis
oculi contraction on a daily basis (which should be
counteracted with botulinum toxin injections).
Subperiosteal
Ramirez122 reported that lifting the inelastic
pericranium produces more effective traction over the
brows. The theory is that a more natural gliding of the
forehead tissues can be obtained by preserving the
subgaleal fascia in the interface between the frontalis
muscle and the pericranium. McKinney126 noted that
advocates of this plane of dissection think a more
solid elevation is attained when the periosteum sticks
to the bone. This, therefore, has been the preferred
plane of dissection of most practitioners of endoscopic
brow lift. The arcus marginalis must be released for
effective elevation.122 de la Paza and de la Cruz127
cautioned that the periosteum is the sole nutrient
SRPS Volume 11, Issue 1C, 2009
source of membranous bones and that its removal
could hasten the resorption of the facial skeleton that
occurs with age.
Combined Subcutaneous and Subperiosteal
The main advantage of the subcutaneous approach is
that it preserves sensation posterior to the incision
line. The subperiosteal approach, on the other hand,
allows better periorbital remodeling. Ramirez122
combined the two approaches in a biplanar dissection
through the endoscope that maximizes the
advantages and minimizes the disadvantages of either
method alone (Fig. 19).
Figure 19. Biplanar dissection in foreheadplasty with
endoscope. (Reprinted with permission from Ramirez.162)
Hamas and Rohrich104 stated that the combined
subcutaneous and subperiosteal approach allows brow
lifting without elevation of the central forehead.
Subgaleal versus Subperiosteal
Thomas et al.128 compared the strength of subgaleal
versus subperiosteal flap adherence in a rabbit model.
They found that the subgaleal flap strength exceeded
that of the subperiosteal flap at all time points.
Additionally, the subgaleal flap regained preoperative
strength at 2 weeks, compared with the subperiosteal
flap at 8 weeks. Early and rapid readherence is noted
in the subgaleal plane compared with the
subperiosteal plane in a rabbit. Microscopic analysis at
4 weeks showed less intervening space and greater
connective tissue proliferation in the subgaleal flap.
Although this suggests that subgaleal dissection
might provide some advantages over the subperiosteal
approach, the exact clinical implications require further
investigation. Boutros et al.129 examined the temporal
sequence of periosteal readherence in guinea pigs.
They found that meaningful strength was regained by
30 days. The rate of healing and the accumulation of
wound strength approximated that of other types of
wounds. The two studies might have implications
regarding the type and duration of stable fixation
required during the postoperative period.
Method of Fixation
Traditionally, brow elevation has been maintained by
excising skin. Ortiz-Monasterio130 proposed guidelines
for the removal of skin during brow lift. The author
recommended a 2:1 ratio of skin resection to brow
elevation and 3:1 when frontalis muscle is removed.
Flowers et al.41 and Flowers and Ceydeli,77 on the other
hand, stated that a ratio of 4:1 or 5:1 is required to
produce a long-lasting effect. Aggressive skin excision
however, can cause many secondary wound problems,
particularly when the frontalis has been resected.
Rohrich and Beran131 reviewed methods of
endoscopic fixation for brow lift procedures (Fig. 20).
Skin excision has been adapted to the endoscopic
technique by the Emory group with their V-to-Y
closure.132 Other methods have relied on compressive
dressings while the surgical planes “bond.”101
Microscrew fixation has been used by Daniel and
Tirkanits.97 Fiala and Owsley133 used Mitek anchors.
Guyuron99 used a combination of fascial sutures and
bone tunnels for suture fixation. Swift et al.,134 Walden
et al.,40 and McKinney and Sweis135 used cortical
tunnels. Isse24 suspended the temporalis fascia to the
deep temporal fascia and between the periosteum and
the bone by tunneling or applying microscrews. Jones
and Grover136 achieved significantly more stable results
with polydioxanone suture than with fibrin glue.
Kobienia and Van Beek137 burred an upside-down Ushaped trough in the outer calvaria around which the
suspension suture is hooked. Others have presented
different variations of fixation involving soft-tissue
imbrication138 and suspension sutures acting as cables
all the way to the brow dermis.139 Troilius140 stated that
no fixation is needed when the goal of brow elevation
is 4 mm or less.
17
SRPS Volume 11, Issue 1C, 2009
Figure 20. Methods of endoscopic fixation for brow lift
procedures. Lower left, cortical tunnel fixation; upper left,
internal screw fixation with Goretex tab; upper center, internal
screw fixation, no tab; upper right, Mitek anchor fixation;
lower right, external screw fixation. (Reprinted with permission
from Rohrich and Beran.131)
Significant interest has been shown in the use of
bioabsorbable screws and multipoint fixation devices.
Both Eppley141 and Morello142 reported achieving
adequate fixation with bioabsorbable screws. Coapt
Systems (Palo Alto, CA) has developed bioabsorbable
multipoint fixation devices (Endotine and Ultratine)
for use with endoscopic brow lift.143–146
Walden et al.40 investigated the safety of different
methods of invasive brow fixation. The authors
compared techniques that used Mitek anchors, cortical
tunnels, Endotine fixation devices, and miniscrews. All
techniques were performed on fresh cadavers as
described in the literature or per manufacturer
recommendations. No instance of inner table
penetration was seen with cortical tunnels or with
Mitek anchors. One Endotine post penetrated the inner
table, and three miniscrews penetrated the inner table.
Relative contraindications to invasive brow fixation
include any pathological condition of bone, including
severe osteoporosis, cystic changes of hyperparathyroidism, Paget disease, osteopenia or osteomalacia,
osteonecrosis, previous fracture, or previous surgery.
Endoscopic versus Coronal versus Transpalpebral
Techniques
The literature abounds with opinions regarding the
18
various surgical approaches, but very little objective
data are available for comparison. Dayan et al.147
retrospectively evaluated the results of different
techniques to determine whether endoscopically
assisted procedures achieve the same degree of
correction as do coronal techniques. The authors
studied the effects of concurrent blepharoplasty on
brow elevation and assessed the long-term outcomes
after coronal lifts (but not endoscopically assisted lifts).
The authors concluded that in their study group, both
methods achieved similar brow elevation at 1 year,
concomitant blepharoplasty had no significant effect
on brow elevation, and coronal lifts were associated
with a gradual drop in brow elevation over 5 years.
In a recent study, Walden et al.148 compared the
efficacy of corrugator resection between
transpalpebral and endoscopic techniques in 24
anatomic dissections. The authors found that the
endoscopic approach facilitated visualization, and
thus more complete resection, than did the
transpalpebral technique, which failed to remove up
to one-third of the transverse head of the corrugator
muscle. Guyuron,149 however, countered with his
experience in achieving complete corrugator resection
when using his transpalpebral technique.
Chiu and Baker150 examined the usefulness of
endoscopic brow lift over a 5-year period. The authors
found a 70% decline in the number of endoscopic brow
lifts performed at their hospital. A survey queried the
plastic surgeons at that hospital about the decline and
showed that 48% thought the selection criteria for
endoscopic brow lift candidates were more limited, 35%
thought other techniques were equally or more
effective, and 35% thought that endoscopic brow lift
does not work in the majority of patients. Although 70%
of patients were satisfied with their results, only half of
plastic surgeons were happy with the long-term results.
Elkwood et al.82 conducted a national survey to
assess trends in brow lifting techniques. Approximately
equal numbers of coronal brow lifts and endoscopic
brow lifts were performed. Plastic surgeons generally
found the open approach to be more effective for brow
elevation, forehead wrinkle elimination, and eradication
of glabellar frown lines. Younger practitioners were
more likely to use newer technologies.
SRPS Volume 11, Issue 1C, 2009
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
nonexistent supraorbital bossing with a continuous
mild curvature. Departures from these
anthropometric norms can affect forehead and brow
aesthetics. Others have noted excessive down
slanting of the supraorbital ridges as contributing to
a “sad look.”155,156
Access to the forehead and periorbital area is
achieved through a coronal scalp incision.130 For
limited contouring isolated to the supraorbital rim,
an upper lid approach can be used.155 Ousterhout154
divided patients into three groups: group 1 can be
treated through bony contouring alone, group 2
requires bony contouring in conjunction with methyl
methacrylate cranioplasty. and group 3 requires
extensive modification with osteotomies.
Recontouring the frontal bone and supraorbital
ridge is best achieved with a burr, obtaining a
controlled graduated resection.130 The orbital rim can
be contoured with a burr130 or an osteotome.155
Augmentation can be achieved with bone grafts,
synthetic materials, or pericranial or other soft tissue
flaps.156 Pitfalls include entering the frontal sinus and
other complications inherent to craniofacial surgery
or periorbital aesthetic surgery.
Forehead Wrinkling
The issue of which management approach includes the
most modification of forehead wrinkles remains
controversial. Flowers et al.,41 Ramirez,122 and
McKinney126 do not favor resection of the frontalis
muscle, reasoning that frontalis hypertrophy from
brow ptosis causes the rhytids and that elevating the
brow will decrease frontalis activity.
Numerous authors have emphasized the
importance of surgical manipulation of the frontalis
muscle to decrease muscle hypertrophy. Marino157
stated that he prefers horizontal incision of the
frontalis without muscle excision to decrease the
tendency of the subcutaneous tissue to adhere to the
galea at the site of muscle resection. Pitanguy79
advocated vertical and horizontal incisions of the
aponeurosis.
Vinas et al.10 and Kaye1 recommended excision of
a strip of frontalis across the midforehead (beneath
the area of maximum transverse wrinkling) while
maintaining intact frontalis in the suprabrow area to
19
SRPS Volume 11, Issue 1C, 2009
preserve normal upper facial expression. LeRoux and
Jones158 reported excision of the entire frontalis muscle
in 71 patients. Botulinum toxin type A (Botox) has
also been used in the treatment of dynamic rhytids in
the forehead.159
Glabellar Wrinkling
Vertical rhytids of the glabella area are caused by
corrugator activity. Transverse rhytids at the nasal root
are caused by the procerus muscle. Selective surgical
interruption of the nerves to the muscles has been
suggested by Castanares59 and by Bames,160 whereas
other authors1,10,78 have advocated muscle division or
segmental resection through either an endoscopic24,161,162
or a transpalpebral70,71 approach.
Guyuron and Rose163 used a fat graft harvested
from the infratemporal fossa to pad the glabellar space
during forehead and/or brow rejuvenation. According
to the authors, the fat graft prevents contour
deformities after muscle resection, restores a more
“rejuvenated contour,” and helps prevent recurrence
from reattachment of the residual muscle to itself or to
the underlying bone. The authors reported no adverse
consequences associated with the maneuver performed
in 74 patients.
Glabellar wrinkles can also be temporarily
corrected by intramuscular injection of botulinum
toxin. Keen et al.164 showed the efficacy of botulinum
toxin in 11 patients. Electromyographic tracings were
used to pinpoint the site of injection. The onset of
action was 3 to 5 days, and the duration of action was
approximately 6 months. Botulinum toxin injection is
now well established as an adjunct to brow lift surgery
for the treatment of glabellar furrows and lateral
crow’s feet.164–167 Patient satisfaction with Botox
treatment is consistently high, and patient-reported
outcomes have indicated significant improvement in
recent years.168,169
Chemical and Liquid Brow Lift
Botox can also be used to perform a “chemical brow
lift” through selective muscle weakening, which is
known as chemodenervation.165–167,170,171 The chemical brow
lift can be used to target the medial brow, lateral brow,
or both. Although the lifting effect is temporary,
20
improved cosmesis has been reported.
Frankel and Kamer165 reported performing
chemical brow lift by injection of 20 units of Botox into
the procerus and corrugator supercilii in 29 patients, 18
(62%) of whom showed higher medial brows after
treatment. Fifty-nine percent of patients also showed
an increase in interbrow distance. Huang et al.167
reported accomplishing temporary brow lift with
botulinum toxin in 11 women. The authors injected 5
units into the glabella and 10 units along the lateral
orbital rim. The largest mean elevations
(approximately 2.5 mm) were noted in the central
brow area.
Ahn et al.166 injected 7 to 10 units of Botox directly
into the lateral orbicularis oculi to elevate the lateral
brow a mean 4.83 mm (Fig. 21). The elevation persisted
for 3 to 4 months in all 22 patients. Mild bruising was
reported in five patients and minimal transient eyelid
ptosis in two. Guyuron172 noted that 7 to 10 units might
be insufficient for achieving a lasting result. The author
subsequently noted an age-dependent response, with
younger patients having more elevation than older
patients. The technique presented by Guyuron was
further modified by Maas and Kim,173 with smaller
target doses being administered in the frontalis (12–16
units) and increased doses in the superolateral brow
area (16–20 units).
Figure 21. Botox injection sites (x) into lateral portion of
orbicularis oculi muscle. Subsequent unopposed frontalis
muscle activity results in lateral brow elevation. (Reprinted
with permission from Ahn et al.166)
Carruthers and Carruthers171 were able to obtain
lateral brow elevation with only a glabellar injection
SRPS Volume 11, Issue 1C, 2009
of Botox. Lateral brow elevation was almost
immediate, and then central and medial brow
elevation peaked at 12 weeks after treatment. The
authors postulated that the diffusion of Botox to the
medial frontalis caused an increased resting tone in
the remainder of the muscle. They also noted that the
minimal amount needed in the glabellar region to
obtain lifting of the brow was 20 units.
New trends indicate a combination of Botox with
fillers to further sculpt the brow. The combination of
volume restoration and alteration of muscle balance can
enhance the results. Kane174 and the Facial Aesthetics
Consensus Group Faculty159 used this technique.
Ciuci and Obagi175 used autologous fat transfer for
rejuvenation of the periorbital complex. With that
method, fat is injected to provide for volume
restoration, achieving a full upper brow, decreased
skin laxity, and camouflaged supraorbital and
infraorbital rim.
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We thank the
Aesthetic Surgery Journal
and
Plastic and Reconstructive Surgery
for their support.
Aesthetic Surgery Journal
Official Journal of the American Society
for Aesthetic Plastic Surgery
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Aesthetic Surgery Journal is a peer-reviewed international
journal focusing on scientific developments and clinical
techniques in aesthetic surgery that recently became indexed
in Medline/Pubmed. An official publication of the 2400member American Society for Aesthetic Plastic Surgery
(ASAPS), ASJ is also the official English-language journal
of eleven major international societies of plastic, aesthetic
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Central America, Europe, Asia, and the Middle East, as well
as the official journal of The Rhinoplasty Society.
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