Brow Lift

The Clinical Problem ( Fig. 4.1 )

Introduction

Any patients requesting upper blepharoplasty must have an accurate assessment of the brow, and each portion must be treated according to its merits. Over-resection of the upper eyelid to compensate for brow ptosis will lead to a suboptimal result. The brow position must be checked for mobility; brow asymmetry might be a sign of upper eyelid ptosis on that side.

In a female, the lateral brow should be slightly higher than the medial brow, with the arch at the junction of the lateral third and the medial two-thirds in line with the lateral edge of the iris. Elevation of the brow position above the orbital rim looks unaesthetic. In a male patient, the brow should be straight at the level of the orbital rim. In our opinion, 70% of the problem will be improved by upper blepharoplasty and 30% by a brow lift, either simultaneously or at a later stage. Some patients are resistant to having a brow lift at the time of upper blepharoplasty.

There are excellent articles on anatomy, but the key to surgery involves adequate release of the lateral brow-retaining ligament and care to avoid the frontal branch of the facial nerve as well as the sentinel vein. A nonsurgical approach may also be considered.

Selection of the appropriate technique depends on the level of the hairline, thickness of the forehead skin, severity of the rhytids, and whether the brow ptosis is medial or lateral. The techniques for consideration are as follows ( Table 4.1 ; Fig. 4.2 ):

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Transblepharoplasty brow lift
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Direct brow lift
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Midforehead lift
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Endoscopic brow lift
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Pretrichial brow lift
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Coronal brow lift
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Temporal brow lift

Table 4.1

Varied options in brow lifting ^a

Option	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	✓✓✓✓	✓	✓✓✓

From Nahai, F.R., 2013. The varied options in brow lifting. Clin. Plast. Surg. 40, 101–104.

a Values range from ✓least favorable to ✓✓✓✓ most favorable.

Patient Selection ( Table 4.2 )

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A transblepharoplasty brow lift is suitable for the younger patient who only requires a moderate amount of lateral brow elevation.
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A direct brow lift is reserved for older male patients with a very heavy ptotic, brow-receding hairline and can be done under local anesthetic for those who are at risk for general anesthesia.
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A midforehead lift is suitable for an older male patient who has very deep central creases and is not too concerned about scarring.
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An endoscopic brow lift reserved for younger patients with mild brow ptosis and a heavy procerus muscle.
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A pretrichial brow lift is used for patients who tend to have a fringe and very high forehead.
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A coronal brow lift is for female patients with a normal, slightly elevated hairline and that allows for the brow hairline to be lowered.
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A temporal brow lift allows for more lateral brow elevation with less trauma and hairline distortion. It may be requested by the patient.

Table 4.2

Choosing the right approach ^a

Approach	Coronal brow lift	Endo brow lift	Pretricheal	Direct forehead	Direct brow	Transblepharoplasty
Hairline
High			✓	✓	✓	✓
Normal	✓	✓	✓	✓	✓	✓
Low	✓	✓	✓	✓
Degree of Brow Ptosis
Mild		✓	✓	✓	✓	✓
Moderate	✓	✓	✓	✓	✓
Severe	✓	✓	✓
Skin Rhytids
Mild	✓	✓	✓			✓
Moderate	✓	✓	✓		✓	✓
Severe	✓	✓	✓	✓	✓	✓