Direct Brow Lift

Brow ptosis is the downward displacement of the brow which can lead to cosmetic and/or functional deficits. Brow ptosis may be due to excessive hooding of the lateral eyelid or the ptotic supraorbital rim, which may in turn be a result of unilateral facial paralysis, post-traumatic deformity, or natural aging. A direct brow lift is a surgical technique designed to reposition the brow and can also be performed for functional reasons i.e., to relieve a visual field obstruction or for cosmetic purposes

The indications for a direct brow lift are: visual field obstruction pseudo-blepharoptosis, brow ptosis, facial paralysis, brow asymmetry, deep forehead rhytids, or glabellar lines (Jawad, 2022). A direct brow lift may be particularly favorable to patients who have unilateral facial paralysis, a receding hairline, baldness, heavy eyebrows, prior eyebrow scarring, convex forehead craniofacial skeleton, or lack of forehead rhytids.

The contraindications for a direct brow lift are: body dysmorphia, a history of blepharoplasty, dry eye syndrome, or a history of decreased tear production (Jawad, 2022).

Key equipment:
Cornea shield
Skin marker
Scalpel
Bipolar cautery
Suture (5-0 monocryl)
Scissors

With the patient sitting upright, the brow areas are marked in the ptotic and elevation position to estimate the amount of brow ptosis that needs correction. Crescentic marks are drawn above the lateral brows for direct brow repair. Topical anesthetic drops are instilled in both eyes. Under the benefits of MAC anesthesia, local anesthetic consisting of 2% lidocaine with epinephrine 1:1000,000 mixed 1:1 with 0.75% Marcaine is administered bilaterally along the markings of the brows. The patient is prepped and draped in a normal sterile fashion for oculoplastic surgery. Cornea shields are placed.
The skin is incised along the markings with a #15 blade. A flap of skin and subcutaneous tissue is excised with Stevens scissors ensuring that there is fat remaining below the plane of excision.
Hemostasis is ensured with bipolar cautery. Next, Stevens scissors are used to sharply dissect along the inferior edge of the wound in the inferior direction to allow the brow and subbrow tissue to freely mobilize upward. Hemostasis is again ensured with bipolar cautery. These steps can then be repeated on the other side. Before closing the skin, both sides are inspected to ensure that closure of the wounds results in symmetric brow elevation. Next, the incision is approximated with buried interrupted 5-0 monocryl sutures. The skin incision is closed with a 5-0 fast gut horizontal mattress running suture. These steps are then repeated on the other side.

A thorough medical history and complete eye examination should be performed. Pertinent history should include a history of blepharoplasty, dry eye syndrome, and a history of decreased tear production, as pursuing this repair may result in exacerbation of symptoms secondary to exposure keratopathy.

Various other techniques for addressing brow ptosis include:
• Midforehead brow lift: A single incision at the midforehead allows for bilateral brow repositioning. It is ideal for men with receding hairlines and deep forehead rhytids (Jawad, 2022).
• Hairline brow lift: An incision within or immediately in front of the hairline enables bilateral periorbital soft tissue elevation, ideal for patients with elongated foreheads as this technique may lower the hairline.
• Coronal incision brow lift: An incision placed behind the hairline hides the scar within the hair. This technique may elongate the patient’s forehead and as a result, it is not ideal for patients with an already existing elongated forehead.
• Endoscopic brow lift: Small incisions within the hairlines permit endoscope insertion and the use surgical instruments. This technique is associated with decreased risk of facial nerve injury and quicker healing times, but requires fixation with absorbable materials and offers minimal elevation.

Potential post-operative complications include infection, hematoma, brow asymmetry, forehead paresthesias, injury to the facial nerve, scarring, alopecia of the eyebrow, ocular dryness, or overcorrection.
A brow lift can be done alone or in addition to other facial procedures such as blepharoplasty. Caution should be taken to avoid the facial nerve as the brow position is determined by the frontalis muscle, orbicularis oculi, corrugator supercilli, and procerus muscles, all of which are innervated by branches of the facial nerve.

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Jawad BA, Raggio BS. Direct Brow Lift. PubMed. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK559261/
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