History

The earliest description of coronal brow lifting in the literature was published by Passot in 1919. Since that time, multiple modifications have been made by many talented plastic surgeons including Noel, Lexer, McIndoe, Gonzalez-Ulloa, Vinas, Regnault, Connell, and Ortiz-Monasterio (Paul). Open browlift can be performed using carefully placed incisions within the hair-bearing scalp, anterior hairline, and forehead skin to excise excess skin. Manipulation of the underlying fascia and muscle were well described in the 1950s (Paul). These procedures included surgical fascia reimplantation, myotomies, muscle excision(s), and/or denervation (chemical/surgical). Today, division of the frontal branch of the facial nerve to permanently denervate the frontalis muscle is not recommended since significant brow ptosis has been demonstrated as an unfavorable side effect.

Brow ptosis begins as early as the fourth decade of life. It contributes to sagging of the upper eyelid and most often imparts an aged, sad, and tired appearance to the face. The main etiologic factors in brow ptosis are senescence and gravity. The aging face undergoes a loss of tone from a diminution in the amount of elastic fibers, glycosaminoglycans, and collagen in the skin. Loss of underlying fascial and muscle support occurs, and opposition to the forces of gravity is diminished. Because the lateral brow has fewer attachments to the periosteum and has no underlying frontalis muscle, it usually descends more than the medial brow. Patients typically present with concerns related to a facial appearance that is aged, tired, or sad. Functional sequelae of brow ptosis, such as deficits in the visual field, headaches, or ocular fatigue, are less common.

The open browlift technique allows for direct visualization of sensory nerves and muscles that may otherwise be prone to iatrogenic injury resulting in functional impairment. Proper patient selection can not be overly emphasized.

Physical evaluation

Anatomy

Understanding the temporal and forehead anatomy is critical to successful browlift surgery (Fig. 24.1). The scalp is composed of five layers (Skin, Connective tissue, galea Aponeurotica, Loose areolar connective tissue, and Periosteum). The blood supply to the forehead scalp is from the internal (supratrochlear, supraorbital) and external carotid (superficial temporal) arteries. Hair follicles are located in the subcutaneous layer. Injury to the follicles results in temporary or permanent alopecia. The frontal branch of the facial nerve is located in the superficial temporal fascia and innervates the muscles of the forehead (frontalis, corrugators, depressor supercilii, and procerus). The supratrochlear and supraorbital nerves provides sensation to the central and lateral forehead as well as portions of the anterior scalp.

Fig. 24.1 Temporal region.

From Stuzin, JM et al. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg 1989;83:265–271.

No single “ideal” brow position is applicable for all patients. It has been suggested that the ideal brow appearance in women and men are different. In women, the medial brow should be slightly above the supraorbital ridge with the apex of the arch lateral to the mid pupil (Westmore 1974). Men typically should have brows that lie at the level of the supraorbital rim and are less arched. Ethnic variations in desired brow position and shape also must be considered when planning surgery for brow ptosis.

Technical steps

Patients should be marked preoperatively in the sitting position. Vertical glabellar lines and transverse forehead lines are marked. Coronal incision is outlined in the scalp. From the midline, the incision is curved posteriorly to the ear apex and can be connected to a facelift incision if needed. The hair is parted along the planned incision without shaving the head. It is important to bevel the incisions parallel to hair follicles to prevent damage and resulting alopecia.

Hemostasis/anesthetic solution (0.5% lidocaine with epinephrine 1 : 200,000) is infiltrated along the planned incision and dissection areas across the supraorbital rim. After 8 to 10 minutes have elapsed, the incision is beveled in the direction of the hair follicles and the flap is elevated in the loose areolar tissue plane between the galea and periosteum.

As the supraorbital rims are approached, the supraorbital neurovascular bundle is identified. The supratrochlear nerves lie in the corrugator muscle and are not visualized until the corrugator muscle is divided. The dissection is carried to the supraorbital rims and subperiosteal dissection is recommended to release all superior attachments. After the nerves have been identified, the corrugator muscles can be resected to release the medial brow. To prevent possible depression in this area, complete corrugator muscle excision is not recommended.

Modification of the frontalis muscle is controversial. Since the frontalis muscles elevate the forehead, surgical procedures weakening can cause further brow ptosis. However, a modified frontalis resection can be performed for deep rhytids while preserving lateral brow elevation. Forehead/brow redraping is performed in a posterior direction overlapping the cut edge of the posterior scalp flap. Key fixation points are midline and lines extending from the lateral limbus of the eye. These fixation points are secured with permanent sutures and excess anterior scalp tissue is excised. The galeal is reapproximated with 3-0 PDS or 4-0 Vicryl sutures; the scalp is stapled. Drains are not used. The head is wrapped using ace or an elastic supportive dressing.

Fig. 24.2 A, Frontal close-up preoperative. B, Frontal close-up postoperative. C, Frontal preoperative. D, Frontal postoperative.

Fig. 24.3 A, Frontal close-up preoperative. B, Frontal close-up postoperative. C, Frontal preoperative. D, Frontal postoperative.

Postoperative care

Postoperative management after open browlift is straightforward. The head should be kept elevated in the immediate postoperative period. Mild analgesics are prescribed for postoperative pain. Any complaints of pain must be evaluated for hematoma which is less common than after facelift. A sterile dressing and ace wrap is reapplied over the incisions for several days until swelling has subsided. Patients may shower after 48 hours. Ice to the forehead and eyes helps to relieve discomfort and decrease bruising at the surgical sites. Staples and sutures are usually removed within the 7–10 days.

Complications

Complications after open browlift are similar to other aesthetic procedures. Early diagnosis helps to prevent further bruising. Described complications include alopecia, scar widening, sensory nerve deficit, frontal muscle paralysis, skin necrosis, scar pruritis, infection, hematoma and bleeding, asymmetrical eyebrows or eyelids, chronic pain, over correction, and abnormal soft-tissue contour. Minimal tension along properly planned intraoperative incisions helps to reduce scalp alopecia or scar widening. Hair bearing scalp incisions should be placed parallel to direction of hair follicles. Hemostasis with bipolar forceps is used when possible. Galeal reapproximation is important to release hair bearing scalp tension. Management of complications focuses on the etiology of the setback. Revisional surgery is recommended only after a minimum of six months has elapsed. Widened scars or alopecia may benefit from hair transplantation or surgical scar re-excision. Browlift reversal has been described by Yaremchuk (2007). Frontalis muscle paralysis is rare. Injury to the frontal branch of the facial nerve can occur if flap dissection at the lateral orbital rim is too superficial. In the lateral orbital area the frontal branches of the facial nerve on the deep surface of the frontalis muscle can be visualize on the deep surface of the frontalis muscle. If frontalis paralysis is noted, it is almost always temporary. Full return of function may take up to 12 months. Chronic pain may require neurology service evaluation for medical therapy or surgical neurolysis. Brow asymmetry may be corrected temporarily with judicious use of botulinum toxin.