Treatment of the upper face is vital to addressing the appearance of aging. The brow lift has evolved dramatically over the last century from Dr. Passot’s original description of the brow lift in 1919 utilizing elliptical excisions on the forehead,5 to Dr. Vinas’ bicoronal incisions presented in 1969,6 to Dr. Vasconez and Dr. Isse’s descriptions of the endoscopic brow lift in 1992,7,8 and to Dr. Knize’s limited incision forehead lift published in 1996.9 Each new technique has benefited substantially from the successes and pitfalls of its predecessors and has led to progressively smaller incisions for maximal benefit.10 The senior author’s (T.A.M.) technique presented in this article builds upon and attempts to simplify the technique described by Dr. Knize.
Resuspension of the brow and forehead can be an essential component of upper face rejuvenation. Patients presenting for consultation often interpret lateral hooding as an upper eyelid problem rather than a brow ptosis problem and initially may not appreciate the importance of the brow lift to the overall result. Often, they need to be educated on the importance of restoring the youthful brow position, redraping the forehead, and correction of lateral hooding to rejuvenate the upper face in harmony with any concurrent blepharoplasty and rhytidectomy procedures. However, there may be hurdles to patients accepting the inclusion of a foreheadplasty into the operative plan. These include extra cost, added operative time, possible need for general anesthesia or formal operating room setting, and perceived added complexity. Endoscopic techniques and open brow techniques justify some of these concerns given their requirement for equipment, hardware, and anesthesia.
The lateral brow lift as described above can be performed relatively quickly, without need for an assistant and without need for specialized instruments. No drains are required, which aids in patient acceptance of the procedure as conceptually an extension of an upper blepharoplasty to correct lateral hooding rather than an additional significant procedure. When these advantages of the modified lateral brow lift are discussed in consultation, the senior author has found markedly increased acceptance rate when offered to patients seeking upper face rejuvenation as the blepharoplasty and brow lift essentially become a truly combined procedure.
Discussion to this point has focused primarily on the lateral brow, but it should be noted that the medial brow also has an impact on the overall appearance of the upper face. There is rarely ptosis of the medial brow, but if present, the culprit is usually the procerus muscle. This can be verified by the presence of deep transverse dorsal nasal lines.2 Although in many cases resection of a portion of the procerus and corrugator muscles will alleviate glabellar frown lines, and result in subtle elevation of the medial brow, the primary focus of the brow lift should be elevation of the lateral aspect of the brow. In the presented technique, the upper blepharoplasty incision is useful as it provides access to these muscles and safe dissection around the nerves of the upper face.
One of the important distinctions of the lateral browlift approach is the low rate of temporary or permanent nerve dysfunction. There have been no permanent nerve deficits in our case series and the 2 frontal branch neuropraxias we have encountered resolved uneventfully with no need for intervention, for an overall temporary motor nerve paralysis rate of 1.33%, and a permanent paralysis rate of 0%. These compare favorably to the rates of 0.0%–6.4% reported in the literature11 and the 7% motor branch injury rate reported by Dr. Knize in the follow-up to his original description.12 Our 0% rate of paresthesias/dysesthesias rate is also lower than the reported overall (0.3%–5.4%) incidence rate of paresthesia/dysesthesia.11 The safety of the procedure hinges on the subperiosteal dissection initiated from the temporal and blepharoplasty access points, with the frontal branch of the facial nerve and the supraorbital nerves always superficial to the plane of dissection. Dissection around the supraorbital nerve is also performed with direct visualization in our technique, leading to greater safety and likely a higher level of comfort for the less-experienced surgeon.
Moreover, there is no bony anchoring and no special equipment required, so the modified lateral brow lift can be reliably performed with basic instruments in an office setting under conscious sedation and local anesthesia, unlike the previously described techniques. Some of the alternative fixation strategies employ bony anchors, resorbable fixation devices such as Endotine (MicroAire Surgical Instruments, Charlottesville, VA), and suture fixation without skin excision. Endotine fixation is a valuable tool in the aesthetic surgeon’s arsenal but carries with it an additional cost for the device itself and the extra materials and time to drill for bony fixation. Moreover, the device itself can be palpable and associated with numbness as shown in a recent series.13 We feel that achieving similar or better results without needing extra instrumentation and time, while also avoiding bony manipulation, is a more patient-friendly approach. A key to adequacy of fixation is complete release of the attachments in the region of the lateral orbital rim inferiorly to the level of the lateral canthus and lateral to the orbital rim. We have found that PDS sutures are adequate, and medial fixation is unnecessary.
This technique allows the surgeon to apply tension most effectively to the lateral component of the eyebrow by virtue of where the temporal incision is placed, but certain patients present with medial eyebrow hooding that can also be addressed with a slight modification. For these cases, the senior author prefers a posttrichial skin excision in the medial portion of the anterior scalp to provide the needed amount of medial eyebrow elevation. This incision allows excellent access to connect the subperiosteal planes of dissection across the midline and elevate the entire forehead in one continuous, avascular plane.
The limitations of the study include retrospective nature and discontinuous time frame, which was imposed because of limitations of access to patient charts for the 2010–2014 period. Patient satisfaction and surgical success were measured subjectively at the follow-up visits by interviewing patients regarding the change in their appearance and assessing the degree of lateral hooding correction. Measurements were not routinely taken, as an overall aesthetically congruent brow elevation was the goal, with no specific minimal elevation targeted.
The senior author’s technique as described above is a modification of Dr. Knize’s approach that allows it to be performed in the office under light oral sedation using only benzodiazepines combined with local anesthesia and achieve a much lower neuropraxia rate than Dr. Knize’s series. We also show a multiyear case series with long-term follow-up to demonstrate that the modified lateral brow lift can be performed safely, quickly, and reliably, thus addressing the patient’s concerns and leading to a higher acceptance rate when the brow lift is offered as part of an upper face rejuvenation package. The role of the lateral browlift in the senior author’s practice is to address the lateral hooding and it is explained as such to the patients, with no expectation of dramatic brow position changes. The shape of the brow and limitations of the technique in terms of brow elevation and shaping, thus, do not come into play as these are not the primary goals of the lateral browlift approach as described here.
For patients desiring comprehensive correction of lateral brow hooding, the modified limited incision lateral brow lift provides a safe, cost-effective, and reliable option. The senior author has found that the reliability of this procedure in producing natural-appearing results has led to very high acceptance rates of the combined lateral brow and blepharoplasty procedure.
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