Non-endoscopic limited incision browlift

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CHAPTER 23 Non-endoscopic limited incision browlift

Richard Warren

History

As an alternative to the open coronal browlift, several techniques have been devised to elevate the brow complex through short or hidden incisions. The simple removal of skin has been advocated in various locations: the anterior hairline, within forehead wrinkles, and adjacent to the eyebrows. Browpexy techniques have been utilized through a transblepharoplasty approach with soft tissue fixation to periosteum. In 1996, Vasconez and Isse independently presented the minimal incision endoscopic technique. Also in 1996, Knize published his limited incision forehead lift, using an incision in the temple with an orbital rim release and soft tissue fixation between the superficial and deep temporal fasciae.

Unfortunately, all these methods have their deficiencies. In particular, the coronal browlift is plagued with a long incision which is feared by patients. Chronic dysesthesia and some scar alopecia are common. Cutaneous approaches leave scars which can be acceptable, but often are not. Browpexy procedures have proven to be inconsistent especially in the presence of mobile skin. Similarly, Knize’s procedure seems successful in some cases but not in others – presumably because of a fixation vector which is directed fairly laterally (Fig. 23.1).

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Fig. 23.1 Knize procedure.

From a surgical perspective, endoscopic brow lifting is an attractive option. It promises minimal incisions, minimal sensory change and little or no hair loss. Numerous authors have demonstrated the success of endoscopic brow surgery by measuring the amount of eyebrow elevation achieved from fixed orbital points. While clearly effective between the medial canthus and the lateral canthus, results at the lateral tail of the eyebrow can be unreliable. The example in Figs 23.2–23.4 illustrates the problem.

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Fig. 23.2 Preoperative.

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Fig. 23.3 Postoperative after 2 weeks.

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Fig. 23.4 Postoperative after 3 months.

In cases such as this, the only real problem is lateral brow ptosis. Unfortunately, despite complete soft tissue release, two-point fixation, and excellent early brow position, lateral brow position has been lost over a relatively short period of time. This is a critical failing, because an attractive eyebrow tends to be low medially, and rise laterally, while with age, the lateral tail becomes ptotic.

The limited incision browlift technique presented in this chapter is called the “modified lateral browlift” and it was developed in response to problems encountered with all other techniques. It is a hybrid procedure done through a nerve sparing incision directly over the temporal crest line (like Knize, but higher). There is full release of the supraorbital and lateral orbital rim (as used in the end brow technique), fixation by limited scalp excision (like a coronal lift) and suturing of superficial temporal fascia to deep temporal fascia (like an endo brow). Frown muscle modification may be done from above using an endoscope, from below through a blepharoplasty approach, or with botulinum toxin alone.

Physical evaluation

The periorbital region is the most complicated aesthetic unit of the face. Multiple variables interrelate in ways which affect the apparent age and attractiveness of the orbital complex:

• Orbit: the size and shape of the orbit, the level of supra-orbital rim, and the relative prominence of the globe within the orbit.

• Hair: the thickness and color of hair and the level of the hairline.

• Forehead skin: the number and depth of the transverse forehead furrows and the depth of the frown lines.

• Eyebrows: the density and color of the eyebrow hairs, the level of the eyebrows in relation to the supraorbital rim and the upper lid sulcus, the relative height of the medial brow to the lateral brow, and the shape of the eyebrow arch.

• Upper eyelids: the level of the lids (normal, ptotic or retracted), the amount of soft tissue fullness above the upper lid sulcus, and the amount of visible eyelid between the eyelashes and the sulcus.

• Muscles: the strength and resting tone in the frontalis, the orbicularis oculi, and the frown muscle complex: the corrugator supercilii, the depressor supercilii, and the procerus.

• Symmetry: of orbital size shape and position, of eyebrow level, and of eyelid level.

A difficult question for many surgeons to answer is: “who needs a browlift?” In some cases this is obvious, but in many cases it is much less clear. Traditional thinking is that eyebrows should be above the orbital rim. True in most cases, this axiom is nevertheless overly simplistic.

Many different professionals, including cosmetologists, anatomists and plastic surgeons have attempted to define the ideal position and shape of the eyebrow complex. This was reviewed by Gunter who concluded that the aesthetic ideal must be considered in relation to gender, ethnicity, orbital shape, eye prominence and facial proportions. Conventional descriptions of the “ideal eyebrow” in the modern era typically include the following (Fig. 23.5):

1. The medial eyebrow should be at or below the level of the orbital rim.

2. The medial border of the eyebrow should be above the medial canthus.

3. The eyebrow should rise gently, with a gentle peak at least two thirds of the way to its lateral end, and with this peak usually above the lateral limbus.

4. The lateral tail of the brow should be higher than the medial end.

5. The male brow should be lower and less peaked.

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Fig. 23.5 The ideal female eyebrow.

Gunter also observed that the eyebrow and the nasojugular fold create an oval with the pupil at the center of the oval. If the distance from center of the pupil to the eyebrow is reduced, the brow looks low (Fig. 23.6).

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Fig. 23.6 Gunter’s oval.

The amount of visible eyelid from the lash line to the palpebral fold should be approximately one-third the distance from the lash line to the eyebrow, and not more than one-half (Fig. 23.7).

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Fig. 23.7 Ideal relationship of the female eyebrow and eyelid.

With aging, the most stable structure in this area is the supraorbital rim, around which numerous soft tissue changes occur. Fat is lost from above the upper lid sulcus causing older eyes to look “hollow”. Upper eyelid skin becomes loose and redundant. Forehead skin becomes corrugated transversely (frontalis effect) and vertically (corrugator effect). There is ptosis of the eyebrow complex, especially laterally. Occasionally, the picture is confused with the development of senile eyelid ptosis. Patients, in response, often overly elevate their eyebrow complex.

With surgery, we can tighten lax eyelid skin (blepharoplasty), add fullness above the upper lid sulcus (fat grafting), elevate the eyelid complex (browlift) or raise the eyelid level (ptosis repair). By utilizing one or all of these procedures, we have the capacity to alter the ratio of visible upper eyelid skin to eyebrow height, to change the shape of the periorbital oval, and to change the shape of the eyebrow itself. The actual height of the eyebrow is therefore only one of many important variables.

Anatomy

If a cutaneous approach to brow lifting is used, the underlying anatomy is of little consequence, because the surgery is truly only “skin deep”. If, however, brow soft tissues are to be mobilized along a deeper plane, accurate anatomical knowledge is extremely important.

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