23 Brow Rejuvenation
The goal is a stable, natural, and, ideally, long-lasting improvement and/or elevation when necessary.
Strict adherence to a single procedure, especially if arbitrary, cannot best serve all patients.
Before selecting a brow-improvement procedure, the correct diagnosis should be made.
Most patients requiring brow elevation nevertheless still require upper eyelid blepharoplasty.
All brow lifts fall over time.
In females, one goal is to raise the lateral brow above the orbit but allow the medial brow to remain at or slightly below the orbital rim (i.e., where it began).
According to a quote by Val Lambros: “[… ] brow lifts by whatever ilk have proved to be maddeningly inflexible, imprecise, and uncontrollable in the very patients who need the most care in the degree and location of elevation… good outcomes are usually from good preoperative configurations”
Most of the literature has historically focused on lifting the brows. Contemporary procedures will focus equally on issues like positioning, shaping, brow and infrabrow fullness, and tissue integrity.
The brow–lid complex is the key component in aesthetic facial appearance, and facial improvement must begin with this area in mind. As part of the periorbital region, the brows define the superior boundaries of the upper eyelid (the two function as a unit),1 touch both the temple and the glabella, and serve as part of the “frame” that defines the eye. Let us explore the (sometimes misunderstood) region of the brow and how, as surgeons, we can help our patients in its analysis and rejuvenation. We focus on the brow and periorbit but not on upper or lower eyelid issues, which are covered in the next three chapters.
Background: Basic Science of Procedure
Lying in the inferior forehead, forming the superiormost frame of the eye, brows are the central focus for facial expression. Even a minor change in brow position alters the expression and perceived emotions of a person′s face. Forehead height is typically one third of the face: longer foreheads connote aging and shorter ones connote youth.
Ideally, the periorbit resembles an oval with an open lateral end and a closed nasal line medially blending into a smooth and full glabella. The brow must either be above, at, or below the orbital rim, and in fact may do all three at once. An attractive and youthful brow–lid junction (“infrabrow”) is convex, full, and smooth ( Fig. 23.1 ).
Eyebrow shape is generally, but not always, considered more attractive if it takes a gentle arc, compared with a straight line. The shape of the brow is more important than the actual position of the brow and in part depends on the adjacent anatomy (balance) to look good. Additionally, brows that seem attractive on one face may not look good on another. Thus there is no one “perfect brow.”
What Is the Standard of Attractiveness?
One study asked participants to position brows where they liked them best. The preferred female brow began medially below the orbital rim and gently arched as it became lateral and above the orbital rim to a peak of 13 mm. For men, the preferred position was a lower, flatter brow just above or at the rim, with less of a tail. Both sexes peak the brow at the lateral canthus ( Figs. 23.2 and 23.3 ).2 Other studies support similar findings.3
In women, the peak of the ideal brow should be 0.5 to 1 cm above the supraorbital rim.4 Westmore described the ideal brow: (1) the medial brow begins at the plane of the lateral ala/inner canthus, (2) the lateral brow ends from the oblique ala to the lateral canthus, (3) the medial and lateral brows lie at about the same plane, and (4) the apex lies on the vertical at the lateral limbus ( Fig. 23.4 ).5
However, mathematical and linear measurements should serve as a guide and not as an absolute goal. Each patient′s anatomy is unique. Proper proportion and balance are more important. The “Golden Proportion,” for example, is considered both mathematically and aesthetically vital based on the ratio of 1:1.6 comparing the brow height to the eyelid aperture of females and males, respectively ( Fig. 23.5 ). In males, brows positioned above the rim give a feminizing appearance. Heavy, bushy brows are generally not considered a feminine attribute.
Culture, ethnic background, gender, and age, as well as current fashion trends, influence what is considered most attractive. African Americans, in general, have higher brows than Caucasians, according to one study.6 Note that the shape of the brows of fashion models is often more dramatic than what is seen in typical society.6
Why Are Some Brows Unattractive?
Although the diversity of facial features makes humans more interesting, certain characteristics are generally considered unattractive. Brows might just represent the ultimate in “body language.” Disharmony of the brows may convey an appearance or emotion discordant with how that person really feels (“I am told I look angry but I am not”).7
By shape and position, the brow can indicate a range of emotions. For example, if brows are angled with the medial portion lowered in a scowl (overactive corrugator combined with procerus activity), this can convey an angry or hostile demeanor. Brows that encroach upon the upper lid convey a tired appearance, whereas brows that are excessively low laterally with an elevated medial position signify a sad look or fatigue.
Higher brows convey more alertness to a degree, but if taken even higher, then a surprised or goosed or unintelligent appearance results. Asymmetries in elevated position create an inquisitive look. An elevated brow in the deep-set eye patient may unmask the orbit, creating an emaciated look. Ideally, brow aesthetic surgery creates a more youthful, peaceful, relaxed face. But it can inadvertently create a surprised or bizarre look, too. Thus brow position can either positively or negatively affect how others perceive us and react to us ( Fig. 23.6a–d ).
How do brows age ( Fig. 23.7 )? Often the lateral brows descend, and with soft tissue thinning, this produces a more angular superior brow edge. Forehead creases develop, and with medial brow movement, the thicker brow skin moves the thinner glabellar skin, shifting it more medially and producing a crease, which over time changes from a dynamic crease to a passive crease. Upper lid ptosis, independent of eyelid and brow changes, can also occur.
Why do brows descend? (1) Tissue lateral to the temporal fusion line has no frontalis muscle to pull superiorly, (2) active orbicularis oculi and corrugator supercilii muscles pull inferiorly, (3) the lateral orbital ligament inserts from the periosteum to the superficial temporal fascia but does not connect to the dermis, and (4) gravity ( Fig. 23.8 ). But movement is not always in the inferior position. Van den Bosch et al noted that the midbrow elevates with advancing age in large numbers of women and in some men ( Fig. 23.9 ).8 Lambros studied a series of women over several years (an average 25 year span), and using digital analysis concluded that brows descended in 29% of women, remained stable in 41%, but actually elevated in 28%.9
Other studies demonstrated an elevation of the brows in aging women as well.10 One compared two cohorts of women 20 to 30 years old with a second cohort age 50 to 60 years and measured three heights: medial brow, midbrow, and lateral brow positions. The 20- to 30-year-old group had average measurements as follows: medial 15.7 mm, middle 19.8 mm, and lateral 21.3 mm. The older 50- to 60-year-old group had average measurements as follows: medial 19.1 mm, middle 22.4 mm, and lateral 22.4 mm. All distances rose (medial 3.4, mid 2.6, lateral 1.1 mm) as aging progressed.
In patients whose brows elevate, what is the reason? Some postulate it is overactivity of the frontalis, which compensates for gradual levator weakness.11 One does see compensatory unilateral brow elevation when ptosis of the upper lid is present, and contracting the frontalis to lift the brows can improve vision. If, after blepharoplasty, the stimulus to elevate the brows is gone, the brows may indeed lower, in some cases diminishing the surgical results.12
But We Help Patients Look Better, Don′t We?
A study surveyed a group of plastic surgeons and aestheticians and asked them what shape and position of brows they believe most attractive. Reviewing photos from 16 frequently cited medical articles, they also evaluated 100 preop photos to compare with 100 postop photos. Patients were from three different ethnic groups and had undergone brow surgery. Not surprisingly, both surgeons and aestheticians preferred the medial brow at the orbital rim and with an apex lateral slant. However, the surgical results, as judged by photographs, did not seem to produce the desired result, with brows either placed too high or the shape changed from a lateral slant to a less desirable flat or medial slant. The article said, “We conclude that the brow lift procedure, as documented in the plastic surgical literature, does not reliably achieve the most desirable aesthetic results for eyebrow height and shape.”13
Other studies have opined that some popular surgical procedures create a result that is not attractive, including the tendency of some procedures to overelevate the brows, which created a surprised look in spite of our knowledge about what constitutes an attractive brow.14 The fact that some patients who have undergone forehead lift procedures seek surgical reversal of their results suggests that sometimes a given procedure can be anatomically “too successful.”15
Patients often consult with surgeons when they desire a fresher, more rested, attractive, and youthful look. It is important to ask them what they notice about their brows. Sometimes patients are not even aware of the role brows play, thinking the issue is only related to upper lid redundancy. For example, if a woman wears bangs, she may have little awareness of her forehead and brows. When describing their eyelids, patients may use their fingertips to actually elevate their lateral brow, thinking they are addressing the lids only (Flowers sign). When horizontal creases are evident in the forehead, the surgeon can assume that the frontalis muscle has been used to elevate the brows to (unconsciously) compensate for a low position. Vertical (frown) lines suggest overactivity of the corrugator muscles. An upper lateral lid skin fold that extends beyond the eyelid and into the lateral periorbital tissues, or even to the level of the lateral lower lid, defines forehead ptosis and suggests a brow procedure may be indicated (Connell′s sign).
Symmetry should be mentioned given that postprocedure the brow appearance will be scrutinized. But because human faces are inherently asymmetric, good proportion, balance, and brow shape are more important considerations. Prior to a procedure, pertinent questions include the following:
What does the patient request?
Is there a problem with brow descent?
Where were the brows during the twenties and thirties?
Is there adequate inflation (fullness) of the periorbital soft tissue?
Do the brows crowd the upper lid region?
Is there significant asymmetry?
Is there functional, including visual, disturbance?
Will the patient′s hair pattern or style influence where possible incisions are made?
What are the shape and height of the forehead?
Is upper lid blepharoplasty necessary and can it be performed simultaneously?
Technical Aspects of Procedures
The prepared facial plastic surgeon has several options to offer patients, and a combination of techniques will serve the surgeon and patient well Video 23.1. A description of procedures follows, and while subdivided, naturally there is some overlap of techniques. At times it is advantageous to combine parts of “separate procedures” for the benefit of one patient.16 Surgical procedures designed to improve brow aesthetics can be categorized as follows: (1) traditional versus nontraditional, (2) using general or sedation anesthesia versus local anesthesia, and (3) performed in a surgical suite versus an office setting.
• Traditional, general or sedation anesthesia, surgical suite
It has been said that “open foreheadplasty techniques remain the standard against which other procedures are measured.”17 Utilizing an incision posterior to the anterior hairline (coronal) or just at the hairline (trichophytic or pretrichial) and extending bilaterally toward the superior auricles, the open foreheadplasty has been the mainstay in brow elevation for many years ( Fig. 23.10 ). A large flap is created either in the subgaleal, subperiosteal, or subcutaneous plane. Once soft tissue release is accomplished in the superior orbital level, the entire forehead can be elevated and skin excised. Medial muscles can be divided or resected, and frontalis muscles may be partially scored under direct vision, if necessary.17–19
Dissection of the lateral scalp is taken deep to the temporoparietal fascia, just superficial to the deep temporal fascia, upon which dissection can be advanced inferiorly and medially. Subperiosteal dissection in the region of the superior lateral orbit requires that the ligaments and adhesions be adequately released to achieve lateral elevation. This includes the lateral brow thickening of the periorbital septum and temporal ligamentous adhesions and has been referred to as the orbital ligament (confluence of the anterior leaf of the deep galea and superficial temporalis fascia). Knize refers to the superior temporal septum (temporal crest, conjoint tendon) as the “zone of fixation.”20
When dissecting in the temporal region, careful attention is paid to the position of the frontal branch of the facial nerve, which is just deep to the temporoparietal fascia lateral to the brow. It has been described as running halfway between the tragus and the lateral canthus and in close proximity to the sentinel vein21 and 0.9 to 1.4 cm posterior to the lateral orbital rim.22 And surgeons should remember it is not one ramus but several rami that cross the zygomatic arch, approximately half of which may be covered with from two to four rami.23
Likewise, understanding the position of the supraorbital and supratrochlear nerves (2.7 and 1.7 cm from midline, respectively) is vital to avoid sensory deficits due to unnecessary trauma to these nerves.
Manipulating the medial muscles (corrugator and procerus) allows the medial brow to elevate if desired. At the skin incision, one may need to resect approximately twice the skin at open incision in relation to amount of brow actually elevated (2:1), and this will lengthen the forehead unless a trichophytic incision is used.24 Here the incision may be straight or irregularly shaped, beveling away from the hair follicles to encourage hair growth through the resultant scar. Here a subcutaneous or subgaleal or subperiosteal plane can be used ( Fig. 23.11 ).
The pretrichial approach does shorten the forehead but does not necessarily lower the hairline unless the posterior scalp is mobilized and advanced, which usually requires a galeotomy.25 Good candidates for hairline lowering include those with a high hairline, good scalp mobility, good hair, and no prior scalp surgery. Poorer candidates include those with a rigid scalp, thin or fragile hair, and previous transplants, as well as heavy smokers.
Pros: Works in an open access, and excessive skin is not just repositioned but removed. Results are believed by many to be longer lasting. The pretrichial scar can be camouflaged and is a good choice for heavily wrinkled forehead skin, which can be tightened well. When subcutaneous, there may be less postop itching and dysesthesias because the plane of dissection is superficial to the sensory nerves.
Cons: Produces a larger scar, and some hair loss (risky choice in males whose genetic hair pattern is still evolving). Sensory dysesthesias and paresthesias are frequent. Subcutaneous dissection requires meticulous attention to blood vessels and the position of the frontal branch of cranial nerve VII. Use caution in smokers.
Endoscopically Assisted Foreheadplasty
Traditional, general or sedation anesthesia, surgical suite
In recent years, the endoscopically assisted forehead lift has been popular ( Fig. 23.12 ). Via limited paramedian and lateral incisions (four or five), this procedure combines manual dissection with use of an endoscopic camera attached to a video monitor. Again, success in advancement of the forehead requires complete release of the arcus marginalis and temporal crest (conjoint tendon), as well as dissection caveats as previously discussed in the coronal approach section. The plane of dissection is typically subperiosteal or subgaleal,26 and some techniques sometimes add a limited subcutaneous portion.27
A variety of centrally placed techniques can be utilized for fixation and include the Endotine and Ultratine devices (Microaire, Charlottesville, VA),28 bone tunnel,29 subcutaneous suspension sutures,30 and external and internal screws, plates, and tacks (Mitek Quickanchor screw, DePuy Mitek, Norwood, MA).
Application of tissue adhesives has also been employed. Lateral fixation via deep temporal fascia sutures is usually adequate for suspension and fixation. This not only may involve fixation for the temporoparietal fascia to the deep temporal fascia with strong sutures but also can include a window of resected temporalis fascia to promote additional scar tissue stabilization.31 Laterally based suspension ribbons have also been employed.32
Note that when a drill is used in the anterior table of the skull, safety is paramount (i.e., avoidance of cerebrospinal fluid leak). Thickness is increased medially and posteriorly with thicker bone posterior to the coronal sutures. Drilling in the midline (sagittal sinus) and lateral to the temporal crest (thin temporal bone) is not recommended. In one study, cortical tunnels at 45 degrees never penetrated the inner table nor did Mitek screws, although one Endotine post did on one of 14 cadaver skulls.33
Although generally described as minimally invasive, there is considerable dissection involved, often subperiosteal. Only the incisions are minimally invasive. Of interest is a study by Chiu and Baker of 21 surgeons showing that the number of endoscopically assisted forehead procedures was dramatically reduced between 1997 and 2001, in part because several surgeons were not pleased with the results.34
Pros: Best for younger patients with low or low normal hairline with minimal wrinkles or muscle problems. Smaller incisions can lead to faster recovery, fewer sensory disturbances (usually), and less alopecia. There is no scalp resection.
Cons: Less useful in older patients, high hairlines, thin-skinned men, extremely thick sebaceous skin, and very heavy, low brows. Curved foreheads can be problematic (“double convexity”) because most equipment is straight. Resection of corrugators can be very time consuming. Specialized equipment and a fixation method are required. Some controversy about longevity exists, and Fig. 23.13a,b demonstrates a 1 year surgical result.