The Open Brow Li ft

Joseph D. Walrath, MD*, Clinton D. McCord, MD

INTRODUCTION
Open brow lifting has been performed for nearly a
century
1,2
and is a widely performed cosmetic pro-
cedure today. Open brow lifting encompasses a
range of techniques including coronal hair-bearing
approaches, frontal pretrichial approaches with or
without temporal hair-bearing incisions, temporal
hair-bearing approaches for lateral brow ptosis,
mid-forehead approaches, and direct brow supra-
ciliary approaches. Combined with small-incisional
endoscopic brow elevation, transpalpebral brow
elevation, and various forms of browpexy, a palette
of options must be considered jointly by the surgeon
and patient in determination of the appropriate
procedure for each individual patient.
There is an ebb and flow in the approach to
treatment of various surgical problems, cosmetic
or otherwise. This trend is certainly present in ocu-
loplastics, where today there are, for example, re-
gional differences inthepreferredsurgical treatment
of blepharoptosis. In the strongly consumer-driven
markets of cosmetic surgery, these fluctuations
can be massive. Some of this fluctuation is media
driven, some patient driven, some surgeon driven,
and some technology driven. Attaching words like
endoscopic or laser-assisted to any procedure
generally makes that procedure appealing to pa-
tients, as it implies that the procedure is somehow
less invasive, less risky, or has less down time. It
also implies that the surgeon is current in his or
her skills and is at the forefront of the field, whether
or not there is any merit to this assumption. How
else can one explain laser-assisted blepharoplasty?
This phenomenon likely contributed to the wide
adoption of endoscopic small-incision brow lifting
procedures in the 1990s. Vasconez
3
and Isse
4
first
presented the small-incision endoscopic approach
to brow lifting in 1992. Initial indications for endo-
scopic brow lifting were essentially the same as for
open techniques, and the requisite small incisions
were easily accepted by patients. After an initial up-
swell in endoscopic browlifting, the technique is not
performedasoftentoday, althoughclearlyinthepro-
per patient withtheproper technique, theresults can
be excellent. The reasons for the shift back to open
techniques relate to durability, prevention of hairline
elevation (or designed lowering of the hairline), and
a desire for less dependence on technology.
Paces Plastic Surgery, 3200 Downwood Circle, Suite 640, Atlanta, GA 30327, USA
* Corresponding author.
E-mail address: jdwalrath@gmail.com
KEYWORDS

Plastic surgery

Brow lift

Aging face

Surgical techniques

Facial rejuvenation
KEY POINTS
The vast array of open brow lift techniques provides a durable correction to brow ptosis.
Some open techniques are more powerful than others, with incisions closer to the brow (direct brow
lift) offering a greater correction in brow height.
The pretrichial open browlift is the procedure of choice for browelevation and treatment of forehead
rhytids in patients with a high hairline or long forehead.
With meticulous wound closure and proper patient selection, there is high postprocedure patient
acceptance of the incisional scar after pretrichial open brow lift, mid-forehead brow lift, and direct
brow lift.
Direct brow lifting rarely results in sensory disturbances, provided that the depth of the excision
remains above the frontalis medially.
Clin Plastic Surg 40 (2013) 117124
http://dx.doi.org/10.1016/j.cps.2012.06.002
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PATIENT EVALUATION FOR BROW LIFT
The first branch point in the brow lift decision-
making process is determined by the patients
goals. In the oculoplastic practice, where many pa-
tients are referred from general ophthalmologists,
often the primary goal of treating brow ptosis and
dermatochalasis is to improve vision, with the
secondary goal being minimal out-of-pocket ex-
pense. In these patients, extended dissection in
the region of the frontal branch of the facial nerve
makes little sense, so the direct supraciliary brow
lift and mid-forehead lift are the only surgeries
offered. It is important in this functional population
to assess eyelid position while the brow is at rest;
it is not uncommon for true blepharoptosis to ac-
company dermatochalasis and brow ptosis. After
performing a brow lift, the central drive to elevate
tissue out of the visual axis is reduced, and a true
blepharoptosis is unmasked (Fig. 1).
Once the patient has indicated that cosmetic
considerations predominate, the evaluation
focuses on determining the most effective tech-
nique for brow lifting and forehead rhytidectomy
that is consistent with the most acceptable risk
profile for that particular individual. The clinical
examination (Table 1) focuses on the position
and stability of the brow, the distance from the
top of the brow to the pupil, the length of the fore-
head, the presence of baldness or anterior hairline
thinning, the presence of widows peaks and
other contour irregularities of the hairline, the
quality of the forehead skin and depth and promi-
nence of rhytids, heaviness of the tissue about the
brow, and the thickness of the brow cilia.
As a rough guide, it has been suggested that
a brow-to-pupil distance of 2.5 cm (measured
from the top of the brow cilia; Fig. 2) indicates
that no further brow lifting be considered. A fore-
head height of approximately 5 cm (measured at
the midline, the distance from the line connecting
the top of the brow cilia to the frontal hairline) is
considered average,
5
and a forehead length of
greater than approximately 6 cm
6
has been used
as a criterion in the decision to perform pretrichial
open brow procedures instead of endoscopic or
coronal procedures. For some surgeons, including
the senior author, the pretrichial and coronal hair-
bearing open approaches are the procedures of
choice, with the pretrichial procedures far out-
weighing the coronal procedures in frequency.
Occasionally a combined pretrichial and hair-
bearing approach is indicated to reduce hairline
contour abnormalities. In these instances, the
path of the incision can span hair-bearing and pre-
trichial scalp to even out hairline irregularities such
as the widows peak.
The brow configuration is a central consider-
ation. In younger patients, early lateral hooding
can be addressed with an isolated hair-bearing
temporal lift. In these patients, it may not even
be necessary to disrupt the temporal fusion line
with this procedure. The temporal brow and lateral
canthal region also need to be considered in the
context of the other procedures that the surgeon
is going to perform. For example, if a midface lift
is part of the operative prescription, a temporal
lift is often required to redistribute the excess
tissue that normally would accumulate at the
superolateral leading edge of the midface lift.
The ophthalmic history and physical examination
focuses on the presence or absence of lagophthal-
mos, lid position at rest, and ocular surface dis-
orders including dry-eye disorder. A history of
refractive procedures, some of which can lead to
temporary denervation of portions of cornea, is
noted. If warranted, a slit-lamp examination of the
ocular surface is performed. As noted earlier, sub-
conscious browelevation is often part of a compen-
satory mechanism for blepharoptosis. Therefore,
eyelid position with the brow at rest must be docu-
mented, and an appropriate ptosis repair procedure
may need to be included in the operative plan.
SURGICAL ANATOMY
The anatomy relevant to forehead lifting has been
well described,
7
particularly with respect to the
facial nerve and supraorbital bundle. The most
feared complication of brow lifting remains palsy
of the temporal branch of the facial nerve. Above
the zygomatic arch, the branch lies along the
deep aspect of superficial temporal fascia (super-
ficial to the deep temporal fascia). As dissection
Fig. 1. (A) A patient with severe brow ptosis preoperatively. (B) Postoperatively, after direct brow elevation, true
blepharoptosis is appreciated.
Walrath & McCord 118
moves inferiorly, deep temporal fascia proper
splits into two layers:
1. Intermediate temporal fascia, inserting on the
anterior aspect of the arch
2. Deep temporal fascia, inserting on the posterior
aspect of the arch
Dissection remains along the intermediate deep
temporal fascia to avoid injury to the overlying
temporal branch. As is widely appreciated, the
temporal branch runs in a supermedial direction
approximately 1 fingerbreadth above the lateral
aspect of the brow.
8
Thesentinel vein, whereit perforatesthetempora-
lis fascia, is incloseproximity tothe temporal branch
of the facial nerve. It passes fromthe subcutaneous
plane through superficial temporalis fascia and then
through the deep temporalis fascia, at the outer
aspect of the superolateral orbital rim, near the tail
of the nonptotic brow.
9
Exercising the standard
cautions during dissection in this region is prudent:
1. Remain along the deep temporal fascia proper.
2. Avoidaggressive flapelevation near thetail of the
browto avoid tractional injury to the facial nerve.
3. Penetrate the temporal line of fusion fromlateral
tomedial toavoidinadvertentlychoosingaplane
that is too superficial, placing the nerve at risk.
PATIENT PERSPECTIVE
Large incisional surgery is occasionally met with
some resistance from patients at the outset.
However, most patients also recognize and have
distaste for the high forehead that can result
from using a small-incision endoscopic technique
in the wrong patient, or the high forehead that
exists naturally or in association with hairline
recession (Fig. 3). Review of postoperative photos
frompatients who have undergone pretrichial fore-
head lifting can help to reassure the patients
about the minimal impact on the incisional scar
on their appearance (Fig. 4). Patients are coun-
seled that they may not be able to wear their hair
in certain styles at least temporarily, or possibly
permanently, because of scar visibility although,
in general, problems related to the incision have
not been the experience of the authors.
PREOPERATIVE AND POSTOPERATIVE
ROUTINE
In addition to the usual suspension of antiplatelet
and anticoagulant agents, the patients are in-
structed to perform Hibiclens scrubs and sham-
pooing for several days before the procedure.
The usual postoperative precautions on activity,
care of the incision, and icing apply. There are no
Fig. 2. A rough guide to average measurements of
forehead and brow height. Line segment A averages
about 5 cminlength; if line segment Bis approximately
equal to 2.5 cm, lifting the central brow is not
appropriate. (Adapted from McKinney P, Mossie RD,
Zukowski ML. Criteria for forehead lift. Aesth Plast
Surg 1991;15:1417; with permission.)
Table 1
Targeted elements of the examination that help to determine the technique chosen for brow lifting
Hairline Brow/Forehead Periocular
Presence of thinning or male
pattern baldness
Presence of widows peak or
other contour irregularities
Height of forehead from
superior brow border to
anterior hairline
Quality of forehead skin: thick
and sebaceous?
Severity of forehead rhytids
Thickness of brow cilia
Height of brow from superior
cilia to center of the pupil
Medial versus lateral brow
ptosis
Blepharoptosis?
Lagophthalmos?
Ocular surface disease?
The Open Brow Lift 119
elaborate forehead wraps applied, and the pa-
tients return for suture removal at 1 week.
SURGICAL TECHNIQUE FOR OPEN BROW LIFT
Pretrichial Coronal Forehead Lift with
Hair-Bearing Temporal Lift
Preparation
Lidocaine 2% with epinephrine is injected
about the proposed incision line, and along
the corrugators and superior orbital rim: the
vascular tourniquet.
Lidocaine 0.25% with epinephrine is in-
jected throughout the forehead at the level
of the periosteum to provide hemostasis
and to provide some hydrodissection.
Thehair is rinsedwithachlorhexidinesolution.
If incisions are to be performed in the tem-
poral hair-bearing region, the hair in this
region is parted and stapled out of the way
of the proposed incision site.
If a temporal lift is to be performed, that portion is
performed first.
An approximately 5- to 6-cm incision is
marked 2 to 3 cm posterior to the hairline
temporally (Fig. 5), beveled so as to remain
parallel to hair follicles.
Fig. 3. (A) Preoperative photo of a patient before undergoing open pretrichial brow elevation. (B) Postopera-
tively, she has a faint pretrichial scar. The brows are elevated by 0.5 cm bilaterally, and the forehead is reduced
in length by approximately 16%. The hairline contour is improved.
Fig. 4. Long-term follow-up after pretrichial frontal
incision for a forehead-lowering procedure.
Fig. 5. A typical incision used for open hair-bearing
temporal brow lifting.
Walrath & McCord 120
Dissection is carried down to the deep tem-
poral fascia with monopolar cautery. It is
helpful to staple a 4 4 sponge to the pos-
terior aspect of the incision to keep hair out
of the field.
Blunt dissection is then performed down to
the level of the superolateral orbital rim.
Dissection is performed blindly until ap-
proaching within approximately 2 cm of
the rim. At this point, a lighted Aufrecht
retractor or endoscope can be used to aid
in the identification and preservation of the
sentinel vein.
SURGICAL PEARL: Care is taken to avoid
aggressive elevation of the overlying tissue
at this point so as to avoid tractional injury
to the temporal branch of the facial nerve.
The central forehead pretrichial incision is
made with a 15 blade, is not beveled, and
generally spans the arc from temporal
fusion line to temporal fusion line (Fig. 6A).
The subgaleal plane is entered with sharp
iris scissors.
A subgaleal blunt dissection using a peanut
is performed (Fig. 6B); this often naturally
becomes subperiosteal as the dissection
continues inferiorly.
The dissection is extended down to the root
of the nose without direct visualization
(Fig. 6C), but in the region of the medial
brow, it stops short of the supraorbital
notch by approximately 2 cm.
At this point, a lighted Aufrecht retractor
or endoscope can be used to assist
in the dissection around the supraorbital
bundle.
The periosteumalong the rimis releasedwith
a combination of blunt and sharp dissection,
and the corrugators are disrupted.
At this point, the temporal pocket can be
connected up with the central pocket by
releasing the temporal fusion line from the
lateral direction.
Closure of the pretrichial incision
With the central forehead flap on traction
with Alice (or similar) clamps, a central pilot
cut is made to aid in the determination of
the amount of tissue to remove.
When making this assessment, the assis-
tant pushes the tissue along the superior
aspect of the incision inferiorly, and the
amount of tissue overlap is noted.
The ellipse of tissue is then marked for the
excision; it typically ranges between 1 and
2 cm of tissue. Additional pilot cuts laterally
are useful in developing the elliptical exci-
sion (Fig. 6D).
The deep aspect (galea) is then closed with
2-0 polydioxanone (PDS) buried sutures
(Fig. 6E).
Subcutaneous closure is performed with
many 5-0 Vicryl horizontal mattress sutures.
The skin is closedmeticulously with 6-0 nylon
running locking vertical mattress sutures
(Fig. 6F).
Closure for hair-bearing temporal incision
Closure of the deep aspect of the temporal
incision is layered, with the deep aspect of
the temporal flap secured to the deep
temporal fascia with 2-0 PDS.
The number of buried 5-0 Vicryl horizontal
mattress sutures placed in the subcutaneous
layer is limited, so as to prevent alopecia.
Skin staples are used for the skin closure.
Aftercare
No head wrapping is performed. A 5-day course of
oral antibiotics and rest is prescribed. Follow-up is
in 1 week.
Mid-Forehead Lift
Men with deep rhytids, heavy brows, and thick
sebaceous skin often require an open lift that is
more proximal to the brows. Central forehead rhy-
tids can be used for access, if they are prominent.
The excision can span 2 prominent rhytids, or
alternatively the excision can be constructed as
an ellipse centered on the most prominent rhytid
(Fig. 7). The technique is relatively simple and
involves a full-thickness excision centrally,
tapering to skin-only temporally. Corrugator and
procerus muscles can be addressed. Sensory
loss is generally more of a problem with this
approach. Scarring can be minimized by a meticu-
lous layered closure (Fig. 8).
Direct Incisional Brow Lift
The incision in direct brow lifting is placed above
the brow cilia for the full extent of the brow.
An elliptical incision is marked about with
the peak over the central brow, or just
lateral to this, depending on the brow
configuration.
Beveling the incision does not seem partic-
ularly helpful in this region, as it may
compromise the ability to achieve the
The Open Brow Lift 121
Fig. 6. (A) A typical pretrichial incision spanning both lines of temporal fusion. (B) A subgaleal blunt dissection is
performed with a peanut. (C) Blunt dissection is carried down toward the root of the nose blindly. (D) Pilot cuts
are useful in determining the amount of skin to excise. (E) Deep closure is performed in layers: the galea is
secured with 2-0 polydioxanone suture and the subcutaneous aspect is secured with multiple 5-0 Vicryl horizontal
mattress sutures. (F) Meticulous skin closure is critical.
Walrath & McCord 122
most accurate wound closure and scar
minimization.
Medially and laterally, the incision depth is
through skin only, to protect the supraorbital
nerves and the temporal branch, respectively.
Closure does not incorporate the perios-
teum, unless extra support is clinically indi-
cated, as in facial palsy (Fig. 9).
Coronal Brow Lift
Although the open brow lift is considered the gold
standard in brow lifting and longevity of the lift, it
has fallen out of favor because of its long scalp inci-
sion, somewhat overdone appearance, and
tendency to elongate the forehead. In clinical situa-
tions where the forehead is short and the brow
needs significant repositioning, an incision can be
made several centimeters behind the hairline from
just above one ear to the other ear. Straight inci-
sions are easier to see, so a trick to better conceal
the scalp incision is to corrugate the incision so that
when the hair lays down it is more difficult to see.
The dissection is done deep to galea and
superficial or deep to the periosteum, de-
pending on surgeon preference.
Once the brow is mobilized the scalp
flap is advanced back, the redundant
portion is resected, and a 2-layer closure
is performed, being sure to include the
galea.
Occasionally the periosteum or galea asso-
ciated with the medial brow can be left
intact to avoid an overdone appearance or
overly elevated medial brow.
COMPLICATIONS IN BROW LIFT
The unique feature of pretrichial, mid-forehead, or
direct brow lifting is the requirement for an inci-
sion in a nonhair-bearing location. The presence
of this scar needs to be discussed with the
patient. This discussion emphasizes that the
scar will be prominent initially, but that it will
fade and not remain problematic. Meticulous
layered closure of the incisions is critical. Perfor-
mance of a precise closure has led to very high
patient satisfaction; to date, the senior author
has never had to revise a pretrichial scar. Other
than the incision, the risk profile is similar to other
brow lifting procedures.
Fig. 7. (A) Preoperative brow ptosis and blepharoptosis in a patient with a complaint of decreased peripheral
vision laterally. Note the very heavy brows and the deep central rhytid. (B) Postoperative photo at 1 week demon-
strating segmental mid-forehead open brow lift and lateral temporal direct brow lift.
Fig. 8. (A) Subcutaneous closure approximating wound edges after mid-forehead excision. (B) Meticulous closure
to minimize scarring after open mid-forehead lift.
The Open Brow Lift 123
SUMMARY
Open brow lifting techniques are durable and well
tolerated procedures that can address browptosis
and forehead rhytids, while maintaining appro-
priate forehead heights and pleasing aesthetic
appearances. Pretrichial forehead lifting (often
the authors procedure of choice) is appropriate
in most women and many men. Mid-forehead
and direct supraciliary brow lifting are essential
components of the operative plan in men with
deep rhytids or very heavy brows.
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8. Knize DM. Anatomic concepts for brow lift proce-
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Fig. 9. (A) Preoperative brow ptosis in a patient who had direct incisional brow lift. (B) Closure does not incor-
porate the periosteum.
Walrath & McCord 124