Chapter 109: Brow Lift

The frontalis originates at the galea aponeurosis and inserts into the supraorbital dermis and orbicularis oculi to act as the main brow elevator. The galea is an aponeurotic layer that connects the frontalis and the occipitalis muscles over the top of the scalp. It splits into two sheaths around the frontalis, with the deeper layer extending to the periosteum at the supraorbital rim. This attachment needs to be released during a brow lift. When closing scalp wounds, such as following an open brow technique, repair of the galeal layer can help reduce skin tension across the wound. It is also a useful layer in general plastic surgery, as it can be resected to provide deep clearance in skin tumor excision or used in the reconstruction of scalp defects as a local flap. In order to enable the frontalis to have mobility to elevate the brow, there is a loose areolar plane beneath the deeper galeal layer and the periosteum. The corrugator supercilii has two heads (oblique and transverse, not vertical), which are innervated by the zygomatic and temporal (frontal) branches of the facial nerve, respectively. Therefore, division of the temporal branch will only denervate part of the muscle. Procerus, corrugator, and depressor supercilii muscles all contribute to oblique glabellar lines. The orbicularis oculi muscle has three parts: pretarsal, preseptal, and orbital. The orbital muscle is responsible for forced eye closure and it has a medial and a lateral component. Although the medial portion can cause medial brow depression, it is not a particularly significant contributor to glabellar rhytids. The lateral portion may give rise to crow’s feet lines, which are lateral orbital rhytids.1–5

The frontalis muscle is the primary brow elevator, and the remaining muscles of the brow and periorbital region are brow depressors. These include the corrugator, the depressor supercilii, the procerus, and the orbicularis oculi. Therefore, the frontalis is working against both gravity and the brow depressor muscles described. With increasing age, patients frequently activate frontalis to a greater extent to compensate for progressive brow ptosis. This must be checked carefully when considering upper lid blepharoplasty and brow lift. Laterally, because there is no frontalis present, the downward pull of the other muscles, combined with aging soft-tissue ptosis causes the lateral brow to fall more than it does medially. It is not because of the soft tissue or deep attachments. The brow can be manipulated to give the illusion of being higher or lower medially or laterally with neurotoxins and grooming. For example, many female patients will groom the eyebrows to give a more lifted appearance to the lateral brow. Therefore, it would be unlikely that grooming would be causing the lateral brow to be lower.1

3. Abramo AC. Anatomy of the forehead muscles: the basis for the videoendoscopic approach in forehead rhytidoplasty. Plast Reconstr Surg 1995;95(7):1170–1177

4. Warren RJ. Forehead rejuvenation. In: Neligan P, ed. Plastic Surgery. 3rd ed. London: Elsevier; 2013:93–107

5. Janis JE, Ghavami A, Lemmon JA, Leedy JE, Guyuron B. Anatomy of the corrugator supercilii muscle: part I. Corrugator topography. Plast Reconstr Surg 2007;120(6):1647–1653

woman, you notice she has very thin eyebrows that taper laterally and sit just above the supraorbital ridge. Her When assessing a patient’s brow during an aesthetic consultation, the brow position at rest and during activation should be assessed. The position of the hairline is also important to ascertain. Although the description of her eyebrow position is normal, women may have an artificially elevated brow position either from chemodenervation with neurotoxin treatment or from brow hair plucking. Either could be giving an appearance of a more elevated brow position. There is individual variation in female brow shape and position, but it should normally form a curve with the medial and lateral ends sitting at roughly the same vertical level. The arch should peak at the junction of the middle and lateral thirds. A high hairline in females is indicated either by a measured distance of greater than 5 cm from the brow to hairline or by an anterior hairline sited on the oblique part of the forehead. This is relevant to correctional surgery, particularly endoscopic brow lifting. This patient would be a fair candidate for an endoscopy-assisted brow lift given her hairline position. The difficulty with performing an endoscopic approach with a high hairline is achieving access to the supraorbital rim “around the corner” with relatively straight instrumentation and small access incisions.1–5

7. Warren RJ. Forehead rejuvenation. In: Neligan P, ed. Plastic Surgery. 3rd ed. London: Elsevier; 2013:93–107 SENSATION TO THE BROW 4. Damage to which one of the following nerves during a brow-lift procedure is responsible for the patient having paresthesia to the central forehead? There are a number of nerves, which are at risk during brow lift procedures and the risk is specific to the precise technique and approaches used. The supratrochlear nerve is a terminal branch of the ophthalmic division of the trigeminal nerve. It usually exits the orbit via the frontal notch and passes through or deep to the corrugator, exiting 15 mm superior to the orbital rim before piercing frontalis on its deep surface to supply the central forehead. This nerve is most at risk of damage during corrugator resection, but usually this is of little clinical significance, particularly if discussed with patients in advance.1,2 The supraorbital nerve is also a terminal branch of the ophthalmic division of the trigeminal nerve and exits the skull through the supraorbital foramen or notch lateral to supratrochlear nerve and divides into superficial and deep branches. The superficial branch pierces frontalis and runs superficial to the muscle supplying the forehead up to 2 cm beyond the anterior hairline. The deep branch runs laterally in the deep galeal plane and supplies the scalp beyond the hairline up to the vertex. Transection of the deep branch with coronal incisions and subgaleal dissection are believed to be responsible for postoperative scalp paresthesias.3,4 The frontal branch is a motor nerve arising from the facial nerve. It innervates the frontalis muscle and division of this nerve leads to brow ptosis. The zygomaticotemporal nerve is a branch of the maxillary division of the trigeminal nerve. It provides sensation to a small area of skin over the temple. It may be inadvertently damaged during an endoscopic brow lift while releasing the lateral orbital adhesions and is purposely avulsed in surgical treatment of migraines.5

treated? Management of rhytids is an important part of brow and periorbital rejuvenation. Rhytids may be classified as static or dynamic and superficial and deep. Static rhytids are present at rest and are due to sustained muscle hyperactivity. They may be partially improved with surgical or chemical muscle weakening but, if deep, as in this case, they will require surgical redraping of the soft tissues. Superficial static rhytids may be improved with fillers such as hyaluronic acid, or resurfacing techniques such as laser or chemical peels.1,2 Dynamic rhytids are present only during animation and are often amenable to botulinum toxin injections. They can also be improved more permanently with surgical weakening during brow-lift procedures. If considering this, it is prudent to trial chemical weakening first as this is temporary, and if the patient does not like the effects, there will be no long-term sequelae. This patient may also benefit from skin resurfacing with laser, chemical peels, and or skin care. Hairline 5-6 cm Midpupillary line 1 cm 12-16 mm 3-6 mm 12-14 mm 2.5 cm 28-30 mm Brow line Orbital rim Supratarsal line Lash line Upper lid vertical Lower lid horizontal palpebral fissure Midpupil line Fig. 109.4 Aesthetic measurements of the brow and periorbital region.

Surgery to the scalp can result in hair loss around the incision site, which can be distressing for patients and signposts the fact that patients have undergone treatment. There are a number of techniques that may minimize visible scalp hair loss. It is important to minimize use of electrocautery on the skin edges, as this will damage hair follicles. Raney clips are small U-shaped clips that are temporarily placed at the skin edge to gently compress vessel ends and minimize intraoperative bleeding. They are commonly used in neurosurgery and may be useful for coronal approaches to brow lift. Minimizing tension during closure is also important, as excessive tension results in scar stretch and risk of wound dehiscence, each of which result in a more obvious scar with alopecia. For this reason, skin resection should be conservatively performed and the galea should be closed to reduce tension across the skin edges. Staples are useful for scalp closure, as they minimize tissue ischemia. Buried dermal sutures may strangulate the hair follicles and should generally be avoided in the hair-bearing scalp. Thoughtful placement of the scar is important to help camouflage it, although it has no direct effect on the area of hair loss. When performing a traditional coronal approach to the brow, the skin incision is placed at least 3 cm behind the hairline in most cases. If there is a low hairline, this is particularly useful as it can lift the hairline at the same time. (Approximately 1 mm of eyebrow elevation may be expected for every 1.5 mm anterior hairline retrodisplacement.) In patients with a high hairline, it may be preferable to use a hairline incision to reduce the vertical height of the forehead, at the expense of a more visibly located scar. Beveling the skin incision to either avoid follicle damage or encourage hair growth through the scar should help disguise a scar. Use of a zigzag incision can have similar benefits.1,2

This patient has signs and symptoms of frontal nerve injury following his skin cancer excision. Because this is affecting his vision, more immediate surgical intervention is warranted. Given his age, previous scarring, and current symptoms, a direct brow lift would be the most suitable procedure for him. This technique has a reliable outcome, is quick and simple to perform, can be achieved under local anesthetic, and has minimal risk of complications. The incision can be placed just above the eyebrow such that the final scar is hidden at the junction of the eyebrow and adjacent skin, or it can be placed higher within one of the static residual brow rhytids. In this setting, the functional elements probably rate more highly with the patient anyway and this approach will give a good functional benefit.1,2

A key part of performing an endoscopic brow lift is to ensure that the periorbital septa and adhesions are adequately released. If this is not performed, then the brow cannot be fully elevated, as the soft-tissue attachments to the bone at the supraorbital rim will limit its upward movement. Common approaches to endoscopic brow lift involve three incisions placed behind the anterior hairline. A small central incision is combined with two lateral incisions placed in the temple region. Some surgeons prefer to use two additional paramedian incisions as well. These allow access for dissection and the camera port to be placed. Once the midline incision has been made down through galea, dissection can proceed centrally, either subperiosteally or subgaleally. Both of these approaches provide relatively avascular planes that are easily elevated, but choice of plane will differ according to surgeon’s preference. There remains debate as to which of the two planes will provide a more durable result.1,2 The subcutaneous plane should be avoided, as it is slow and tedious to dissect and is the wrong plane to achieve either adequate soft-tissue release or muscle resection. Where a subperiosteal dissection is used, initial dissection can be performed blindly using a periosteal elevator to within a few centimeters of the supraorbital rim. The temporal dissection is performed just above the deep temporal fascia (not below), as this safely preserves the frontal branch of the facial nerve. The central and temporal planes of dissection are then joined up, and the endoscope can be used to complete the dissection to the supraorbital rim with direct visualization of the supraorbital and supratrochlear sensory nerves. If required, the glabellar musculature can then be weakened by incising the periosteum and performing partial muscle resection/ denervation. There is no proven benefit of fixation with screws over other products and the fixation method of choice is often surgeon’s preference.3

An endoscopic brow lift is a very useful technique but should be avoided in patients with both a high hairline and a high forehead, particularly when the hairline is situated on the oblique part of the forehead in the lateral view. This is because it is technically difficult to advance the scope around the curvature of the forehead and achieve adequate reach to safely release the supraorbital attachments. The best candidates for endoscopic approaches to brow lift are patients with short, flat foreheads with nonreceding, thick hairlines and normal skin. Poor candidates are those with a high convex forehead, a high receding hairline with thin hair, thick skin, and deep rhytids with true excess skin on the forehead and brow.1 A direct brow lift may be favored in patients who want or need a local anesthetic procedure and are willing to accept a visible scar on the brow. The coronal brow lift has fallen out of favor but can be useful for elevating a low hairline with a concealed scar. The temporal brow lift can be used as an isolated procedure to elevate the lateral brow with hidden scars or combined with an endoscopic approach. A transpalpebral approach is useful where a hidden scar is desired, blepharoplasty is being performed and a less invasive overall procedure is preferred. In summary, there is no single best option for brow lift surgery, hence the number of different and varied approaches that are practiced. The surgeon should be able to offer a range of options for patients such that treatment can be individualized for each case.1–3

The elastic band principle has clinical relevance to brow-lift procedures, as it states that the further away the suspension point is from the brow, the lift will be less effective.1 Therefore, placement of the fixation point should, in theory, be kept as close to the brow as possible. For this reason, a transpalpebral approach may be ideal, as the fixation will be close to the brow. When performing an open coronal or endoscopic approach, fixation is usually just behind the hairline and is therefore quite distant from the brow. However, there is no consensus on the best site of fixation or best device for fixation in brow-lift procedures. Furthermore, some surgeons debate whether fixation is even required, given the rebalancing of soft tissues that occurs following the procedure. In practice, maintaining fixation as close to the brow as possible is probably beneficial, given the underlining biomechanical principles. Recurrence of brow ptosis can occur after brow lift and patients must be made aware of this preoperatively. The soft tissues of the brow do have elastic properties, but this is not described by the elastic band principle. Rigid fixation devices (not flexible) are used in brow lifts such as Endotine devices, screws, bone anchor devices, and sutures with or without cortical drill holes.

The forehead and scalp are supplied by the bilateral supraorbital nerves. These nerves divide into superficial and deep branches. The superficial branch enters the frontalis muscle 2 to 3 cm above the rim and then supplies the forehead. The deep branch supplies the scalp posterior to the hairline and runs laterally up to 0.5 to 1.5 cm medial to the temporal crest. Transection of the deep branch can result in postoperative scalp paresthesias. There is no specific division of the supratrochlear nerve into superficial or deep branches and this supplies sensation to the central forehead. The lesser occipital nerve supplies the lower part of the ear and is too distant from the brow to be involved.1,2