Numerous options in brow lifting exist that can be broadly categorized as open and minimally invasive or endoscopic. Proper patient evaluation, procedural goals, and surgeon preference all play into procedure choice. There are common desirable traits of the esthetic brow. One must take into account gender differences when considering alteration of the brow. Multiple options exist for brow fixation. One must take into account 3 factors during brow lift: release of the brow, brow fixation after advancement, and depressor muscle release. A brow lift will affect the amount of excess upper lid skin and pretarsal lid show.
Key points
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Numerous options in brow lifting exist that can be broadly categorized as open and minimally invasive or endoscopic.
- •
Proper patient evaluation, procedural goals, and surgeon preference all play into procedure choice.
- •
There are common desirable traits of the esthetic brow. One must take into account sex differences when considering alteration of the brow.
- •
Multiple options exist for brow fixation.
- •
One must take into account 3 factors during brow lift: release of the brow, brow fixation after advancement, and depressor muscle release.
- •
A brow lift will affect the amount of excess upper lid skin and pretarsal lid show.
Introduction
Brow lifting is an integral part of facial rejuvenation, and in the past 20 years, the techniques used to achieve an aesthetic result have undergone a transformation based on 2 driving forces: (1) advances in technology available to perform the procedure and (2) a shift toward minimally invasive and minimal incision techniques.
Advances in surgical equipment (ie, scopes, cameras, and fixation devices) have allowed the surgery community to respond to the patient-driven interest in less-invasive procedures.
Goals of brow lift
The pleasing brow in a woman is at or slightly above the orbital rim prominence and generally arches upwards as it sweeps laterally or has a break at about the two-thirds point ( Fig. 1 ). The brows should be symmetric in shape and position. There is a natural and youthful fullness to the space between the lateral brow and the upper lid. This is the same space from which women pluck brow hair, because it is attractive and youthful to have this area without hair. There are limits, however, to brow height. Generally speaking, the medial aspect of the brow should be lower than the rest of the brow and the overall brow height should not exceed far beyond the orbital rim prominence. An elevated brow position in the presence of forehead rhytids (as seen with upper lid ptosis or dermatochalsis) is not esthetic and is an indicator of old age. The esthetic brow in a man is different: it should be flat and straight and at or slightly below the orbital rim. Brow configuration other than this in a man looks odd.
The distance between the brow and the hair bearing scalp must be taken into consideration during patient assessment and surgical planning. Typical youthful distances for forehead height are 4.5 to 5.5 cm, although balance with the middle third and lower third of the face must also be considered. A high hairline contributes to an aged appearance. Some brow procedures raise the hairline (endoscopic and coronal brow lifts); some lower the hairline (pretrichial hairline advancement with concomitant brow lift); and some have no affect (direct brow and transblepharoplasty techniques).
Access options
There are numerous options for access to brow lifting: full open coronal, pretrichial hairline, direct mid-forehead, directly above the brow, transblepharoplasty, temporal brow, and endoscopic ( Fig. 2 ). Each of the these options has its indications and its pros and cons in terms of access, resultant scar, potential for sensory changes, elevation of hairline, and degree of lift ( Table 1 ).
| Degree of Lift | Effect on Hairline | Favorable Scar | Potential for Sensory Changes | Access to Forehead Musculature | |
|---|---|---|---|---|---|
| Coronal brow lift | ✓ ✓ ✓ ✓ | Raises | ✓ ✓ | ✓ ✓ ✓ | ✓ ✓ ✓ ✓ |
| Endoscopic brow lift | ✓ ✓ ✓ | Raises | ✓ ✓ ✓ | ✓ | ✓ ✓ ✓ ✓ |
| Pretricheal | ✓ ✓ ✓ ✓ | Can raise or lower | ✓ ✓ ✓ ✓ | ✓ ✓ ✓ | ✓ ✓ ✓ ✓ |
| Direct forehead | ✓ ✓ ✓ | No effect | ✓ ✓ | ✓ | ✓ |
| Direct brow | ✓ ✓ | No effect | ✓ ✓ | ✓ | ✓ |
| Transblepharoplasty | ✓ | No effect | ✓ ✓ ✓ ✓ | ✓ | ✓ ✓ ✓ |
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