Aesthetic and Reconstructive Brow Lift - Current Techniques, Indications, and Applications

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Perspective
Aesthetic and Reconstructive Brow Lift: Current Techniques,
Indications, and Applications
Jugpal S. Arneja, M.D., F.R.C.S.(C.), David L. Larson, M.D., and Arun K. Gosain, M.D.
Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee.
Surgical manipulation of the forehead and brow is ofincreasing interest to the plastic and reconstructive
surgeon. In the last two decades, there have been numer-
ous reports of nonsurgical approaches, applied anatomi-
cal studies, and minimally invasive technological ad-
vances directed toward the forehead and brow. This
suggests that there has been no clear consensus on the
most appropriate method of managing the ptotic brow
and rejuvenating the upper third of the facial skeleton.
The goals of aesthetic brow rejuvenation differ from
those of treatment for senile or paralytic brow ptosis,
and, as such, current operative techniques and interven-
tions naturally will not be applicable to each patient. A
patient seeking aesthetic correction requires long-lasting
elevation of the brow, reduction of transverse forehead
rhytids, and elimination of vertical and oblique glabellar
lines. Patients with obstruction of the visual axis due to
mechanical or paralytic brow ptosis generally have little
concern for the aesthetics of the upper third of the face
but rather seek elevation of the resting brow position to
correct a functional problem.
Therefore, the plastic surgeon treating the reconstruc-
tive or aesthetic patient must be comfortable with several
methods of brow reconstruction and rejuvenation to
satisfy these respective patient populations. This report
will outline current aesthetic and reconstructive tech-
niques available to address the malpositioned brow and
the aging forehead and offer indications and applications
for their utility.
ANATOMY, PATHOPHYSIOLOGY, AND
IDEAL AESTHETICS
Brow position and forehead appearance are deter-
mined by several factors, including muscular tone, skin
quality, natural aging, and gravitational forces. Anatom-
ically, brow position is determined by opposing agonist-
antagonist muscular forces.1 Five groups of muscles
produce this biomechanical balance of eyebrow height
and shape in the frontal region.2–4 The frontalis muscle is
the primary elevator of the brow, whereas the brow
depressors include the procerus, depressor supercilii,
corrugator supercilii, and orbicularis oculi muscles.
These muscles are powered by the frontal branch of the
facial nerve, which courses through the temporal region
laterally toward the midline of the forehead. Sensation to
the forehead and scalp is provided by the supraorbital
and supratrochlear nerves, which traverse through the
forehead in the caudal to cephalic direction.
Knize5 described the mechanism of eyebrow ptosis,
based on a detailed account of the anatomy of the
forehead and brow. He concluded that the lateral brow
segment becomes ptotic earlier in life than the medial
segment. Factors contributing to earlier lateral descent
include (1) gravity, which results in the soft tissues of the
galeal and preseptal fat pads lateral to the temporal line
of fusion to slide over the temporalis fascia; (2) de-
creased resting tone in the frontalis muscle that suspends
the brow medial to the temporal fusion plane; and (3)
hyperactive corrugator supercilii and lateral orbicularis
oculi muscles, which antagonize the frontalis effect and
can augment the descent of the lateral soft tissue mass.5
Senile eyebrow ptosis is also thought to result from the
laxity and loss of elasticity of the forehead soft tissues.6
To compensate for the descent, hyperactivity of the
frontalis muscle follows, with subsequent muscular hy-
pertrophy resulting in permanent transverse forehead
creases.6 Two additional muscle groups contribute to the
development of glabellar creases: hyperactivity of the
corrugator supercilii muscle produces vertical and
oblique rhytids in the caudal central forehead region, and
a chronically hyperactive procerus muscle produces
transverse furrows at the nasal root.
The ideal eyebrow position has been described by
several authors7–11 (Westmore MG. Facial cosmetics in
conjunction with surgery. Course presented at the Aes-
thetic Plastic Surgery Society meeting, Vancouver, Brit-
ish Columbia, Canada, 1975). Briefly, the brow should
Accepted June 3, 2005.
Address correspondence and reprint requests to Dr. Arun K. Gosain,
Department of Plastic Surgery, Medical College of Wisconsin, 8700
Watertown Plank Road, Milwaukee, WI 53226. E-mail gosain@mcw.edu
DOI: 10.1097/01.iop.0000186128.61392.31
Ophthalmic Plastic and Reconstructive Surgery
Vol. 21, No. 6, pp 405–411
©2005 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
405
be medially positioned at a vertical line from the alar
base through the medial canthus; the lateral extent should
fall on an oblique line from the alar base through the
lateral canthus.8 Horizontally, the medial and lateral
points of the brow should lie in the same plane.9,10 In
addition, the brow should form an arch with its maxi-
mum elevation at the level of the lateral limbus.8 In men,
the brow should sit at the level of the supraorbital rim,
whereas in women, the brow should lie well above the
rim.11 Another description of ideal brow position noted
the top of the brow to lie 2.5 cm above the mid-pupillary
point, with the brow to hairline position to equal 5 cm in
women and 6 cm in men.7 These descriptions represent
traditional aesthetic conceptions of the ideal brow anat-
omy and position. However, this aesthetic ideal is often
difficult to recreate surgically, and further study should
be performed to determine the accuracy of these mea-
surements and their clinical significance.
When evaluating the upper third of the facial skeleton
in preparation for upper eyelid rejuvenation, it is essen-
tial to first elevate the brow to the projected correct
operative position, then subsequently mark the upper
eyelid for skin excision. A common mistake is to resect
an excessive amount of upper eyelid skin rather than
performing a brow lift in conjunction with the upper
eyelid blepharoplasty.12 This can result in the undesir-
able complication of lagophthalmos and the potential for
corneal exposure.12
CORONAL BROW LIFT AND ALTERNATIVE
INCISIONS
Hunt13 provided the first account of the coronal brow
lift in the literature in 1926. His techniques described a
coronal incision in the hair-bearing scalp and at the
anterior hairline. The modern coronal brow lift technique
was outlined by Gonzales-Ulloa in 1962.14 Other
thoughtful descriptions of the coronal technique have
been documented by Ortiz-Monasterio.15,16 The coronal
brow lift remains the standard against which all other
techniques must be compared. The primary advantage of
the coronal brow lift is direct visualization and attention
to all aspects of pathology in the brow and forehead
region. Disadvantages and potential complications of
coronal brow lift include poor scarring, alopecia, fore-
head paresthesias and pruritis, temporal region atrophy
and hollowing, injury to the frontal branch of cranial
nerve seven, brow relapse, loss of normal facial expres-
sion, and asymmetry.17
Many technical modifications have ensued since the
initial descriptions, with controversies commonly dis-
cussed in the literature including incision style, plane of
dissection, method of fixation, and the management of
forehead musculature. These will be individually ad-
dressed below.
Incision. Connell18 outlined and offered indications for
the various types of incisions possible for the coronal lift.
Today, most surgeons prefer a modified stealth inci-
sion19 to best conceal the scar and avoid alopecia asso-
ciated with the traditional coronal incision.
The anterior hairline incision, described by Hunt13 in
1926 and advocated by Vogel and Hoopes20 in 1992,
offers several advantages over the traditional coronal lift.
With an anterior hairline incision, the amount of fore-
head can be reduced, thereis greater visualization of the
forehead musculature, a more mechanically efficient lift
can be performed, and there is no risk of postoperative
alopecia.20 McKinney7 suggested an anterior hairline
approach in patients with a distance of more than 5 cm
from eyebrow to hairline to achieve forehead reduction
with brow elevation. Several authors have suggested
various techniques of beveling the incision18 and deepi-
thelializing the anterior flap21 to further camouflage the
anterior hairline incision. Also, patients who choose to
wear their hair forward can often conceal the anterior
hairline scar.
The midforehead incision offers similar advantages as
the anterior hairline incision at the expense of a visible
scar.22 The ideal patient would be a male with deep
forehead furrows and recession of the anterior hairline,
making the coronal incision less desirable.11
Dissection Plane. The plane of dissection can either be
subcutaneous, subgaleal, or subperiosteal. Wolfe23,24
prefers the subcutaneous plane for cases including a very
wrinkled forehead with lateral brow ptosis and secondary
or tertiary brow lift. He believes the principal advantage
is accurate placement of the brow where one prefers.23,24
Subcutaneous dissection is rarely performed today due to
decreased vascularity of the coronal flap and risk of
subsequent complications including, alopecia, wound de-
hiscence, skin slough, and forehead paresthesias.15 The
following discussion will focus on the subgaleal and
subperiosteal dissection planes. Advantages and disad-
vantages are of each plane are well documented by
Nassif et al.25 They performed a critical evaluation of
subperiosteal versus subgaleal dissection planes for brow
lift on 24 cadaver heads. They concluded that both
dissection planes significantly elevated the brow at rest
and against traction. However, these authors advocated
dissection in the subgaleal plane, finding that in this
plane there was less flap tension and easier release of the
central frown muscles at their insertion.
In contrast, Trolius26 and Ramirez27 commented that
the subperiosteal plane offers better traction for brow
elevation and longer-lasting maintenance of brow posi-
tion. Knize28 favors dissection in the subperiosteal plane,
based on his appraisal of 25 fresh cadaver dissections. He
concludes that subperiosteal dissection was advanta-
geous for two anatomic reasons. First, subperiosteal
406 J. S. ARNEJA ET AL.
Ophthal Plast Reconstr Surg, Vol. 21, No. 6, 2005
dissection preserves the subgaleal plane vascular supply,
resulting in optimal blood supply to the coronal flap and
a potential decreased risk of alopecia at the incision site.
Second, dissection in the subperiosteal plane preserves
sensation to the frontoparietal scalp by sparing injury to
the deep division of the supraorbital nerve.28
Forehead and Glabella Management. There is ongoing
debate regarding the management of transverse furrows
caused by the hypertrophic frontalis muscle. Surgical man-
agement has consisted of no excision,29 complete exci-
sion,30 limited strip excision,31 and horizontal scoring.32
Glabellar frown lines have been managed surgically with
direct excision33 or limited incision.34 Nonsurgical manage-
ment of forehead and glabellar creases has been proposed
with injectable filler materials (i.e., autologous fat, collagen,
Restylane) or botulinum toxin A.
Fixation Method. The traditional approach to maintaining
the elevated brow is with the excision of skin. Reported
ratios of skin excision to brow elevation have ranged from
2:135 to 5:1.29 The development of the endoscopic brow lift
with its absence of skin excision has resulted in the evolu-
tion of numerous fixation techniques to suspend the ele-
vated brow. These techniques have improved the long-term
maintenance of brow position and are applicable to the
coronal lift in conjunction with skin excision. Fixation
techniques will be discussed below.
ENDOSCOPIC BROW LIFT
Isse36 and Vasconez37 are credited with developing
the endoscopic brow lift technique during the early
1990s. The technique is well described by Vasconez,37
with the premise being that a shift in the dynamic muscle
balance produced by manipulation and weakening of the
depressor muscles of the forehead (orbicularis oculi,
depressor supercilii, procerus, and corrugator supercilii)
results in brow elevation by an unopposed frontalis
muscle. Access to these depressor muscles is through
three small incisions in the hair-bearing scalp, with
dissection in either a subgaleal or subperiosteal plane.
Subsequent myectomy or myotomy of the depressor
muscles is followed by fixation of the elevated brow by
various techniques; no significant scalp excision is per-
formed during an endoscopic lift.37
Many alloplastic and autogenous methods to fixate the
brow in an endoscopic forehead lift have been described.
Rohrich and Beran38 provide a detailed review of the
advantages and disadvantages of the various methods of
fixing the elevated brow. These methods include exterior
bolster fixation, deep suspension sutures, cortical bone
tunnels, K-wires, external screw fixation, internal plate
or screw fixation (resorbable or nonresorbable), Mitek
anchor system, and tissue adhesives.38 The authors con-
clude that brow fixation techniques must hold the brow
in position until sufficient healing has occurred to pre-
vent subluxation, usually for a period of 42 to 60 days.
Tension at the closure site predisposes patients to re-
lapse, poor scarring, and alopecia.38 Rohrich and Beran
espouse a variety of techniques as suitable for fixation,
with the optimal techniques being those able to stand the
test of time. Guyuron39 argues that fascial polydioxanone
sutures passed through cortical bone tunnels offer the
most control, are most economical, and pose the least
risk of complications.40
There have been several large, long-term outcome
studies reported in the literature suggesting the efficacy
of the endoscopic lift.41–43 Advantages of the endoscopic
technique include small incisions with decreased risk of
alopecia, short intraoperative course, low risk to the
frontal branch of the VIIth cranial nerve, low incidence
of postoperative scalp paresthesias, and rapid recovery.44
However, not all authors believe the endoscopic brow lift
is the most effective technique. Its limitations include
relapse of brow ptosis, overcorrection of the medial
brow, steep learning curve for the surgeon, expensive
instrumentation, and limited efficacy in cases of severe
brow ptosis.17 Chiu and Baker45 reviewed an institu-
tional series of 628 cases of endoscopic brow lift and
found a significant decline in the number of cases per-
formed over a 5-year period, with the number of open
brow lift procedures remaining constant. These authors
believed that the endoscopic lift is ineffective in the
majority of patients. They attributed the decline in the
number of cases of endoscopic lifting performed at their
institutions to limited indications for the ideal candidate,
with other techniques being equally or more effective.45
In a survey of brow-lifting techniques, Elkwood et al.46
reported that the respondents felt the coronal lift was
more efficacious than the endoscopic lift for the three
major goals of brow lifting: brow elevation, eradication
of transverse forehead lines, and reduction of glabellar
lines.
LIMITED INCISION BROW LIFT
TECHNIQUES
Knize extensively studied the anatomy of the forehead
and temporal regions and with this knowledge, devel-
oped the limited incision forehead lift in 1996.47 This
technique uses both a temporal incision and upper eyelid
blepharoplasty incision. Through a 4.5-cm temporal in-
cision, dissection is performed over the deep temporal
fascial plane with removal of a portion of the deep
temporal fascia. Dissection then proceeds in the subpe-
riosteal plane medially and inferiorly as needed such that
the orbital periosteal attachments are completely re-
leased. The orbital ligament is divided, resulting in a
fully mobilelateral brow, and the entire unit is fixed
laterally in the temporal region with a three-layered
closure.5 The advanced, redundant scalp is not excised
407PERSPECTIVE
Ophthal Plast Reconstr Surg, Vol. 21, No. 6, 2005
but is left to flatten over time, thereby avoiding tension at
the scalp closure site. Subsequently, through an upper
blepharoplasty incision, the procerus muscle is divided,
the corrugator supercilii muscles are partially excised,
and for cases with upper eyelid dermatochalasis, an
upper blepharoplasty is performed.5
Advantages of this technique are preservation of the
deep division of the supraorbital nerve, minimal scarring,
and minimal risk of alopecia. Disadvantages and poten-
tial complications of this technique include limited ex-
posure to modify the transverse forehead creases by
direct frontalis resection, transient palsy of the frontal
branch of cranial nerve VII, and transient sensory dis-
turbances in the supraorbital and supratrochlear nerve
distributions. The ideal patient for this procedure would
have isolated lateral brow ptosis and glabellar frown
lines. In addition, balding men with a retained temporal
hairline are well suited for this procedure.48 This proce-
dure directly addresses the pathophysiology of lateral
brow ptosis and should be recommended for this patient
population.
Paul49 described a minimally invasive subperiosteal
brow lift technique through an upper blepharoplasty
approach. The periosteum along the supraorbital rim is
released from the supraorbital foramen medially to the
subtemporalis fascial plane laterally. Disinsertion of the
procerus and excision of the corrugator supercilii mus-
cles are performed. Through small counter-incisions, two
fixation points are made at the peak of the brow and in
the temporal hairline. The indications for this procedure
include patients with male pattern baldness, previous hair
transplantation, recession of the anterior hairline, and
concurrent need for blepharoplasty.49 For isolated lateral
brow ptosis and upper eyelid hooding, Strauch and
Baum50 prefer a combined subgaleal and subperiosteal
approach through two transverse anterior hairline inci-
sions.
DIRECT BROW LIFT
The first description of the brow lift was by Passot51 in
1919, who used a direct technique for lifting the ptotic
brow. The direct brow lift has historically most often
been used for patients with senile brow ptosis, resulting
in obstruction of the visual axis and unilateral facial
palsy with brow asymmetry or for patients seeking aes-
thetic correction with contraindications to alternative
approaches who are willing to accept a visible scar. This
technique involves excision of an ellipse of tissue di-
rectly above the brow. The size of the ellipse is deter-
mined by the resting brow position, thereby estimating
the amount of tissue removed that is required to elevate
the brow to the ideal position. Dissection is carried
through the subcutaneous tissue to the level of the fron-
talis muscle, with caution medially to prevent injury to
the supraorbital nerve and vessels. Fixation of the ele-
vated brow with permanent sutures to the frontal bone
periosteum is an option during closure of the deep layer
to provide added stability to the elevation.52
The direct brow lift has several advantages over other
techniques, including a significant mechanical advantage
with greatest degree of lift per millimeter of tissue excised
and excellent control over brow position and contour.53
Flowers29 suggested that lifting the brow is subjected to an
elastic band principle: The farther away the suspension
point is from a weight attached to an elastic band, the poorer
the mechanical advantage and the less effective the lift.
Green et al.54 reported the scarring from a direct brow lift
to be acceptable; scarring can be minimized with a
two-layer closure and further camouflaged with makeup
and spectacle wear. In addition, this incision is preferred
in men, given the ability to hide the scar in the thicker
male eyebrow and the fact that other incisions are less
desirable in the balding male.
Patients who have unilateral facial palsy often have
lagophthalmos, paralytic ectropion, absent facial ani-
mation, and brow ptosis. Ptosis of the eyebrow results
in a narrow palpebral fissure with visual field obstruc-
tion. A functional and aesthetic improvement can be
made with a unilateral brow lift. Takushima et al.6
suggested that younger patients with less than 5 mm of
brow ptosis are best treated with an endoscopic lift,
whereas older patients with more than 5 mm of brow
ptosis should be treated with a direct brow lift. They
thought that the endoscopic lift was not effective for
more than 5 mm of lift and relatively ineffective in
patients older than age 50. Ueda et al.52 commented
that a direct brow lift should be the recommended
procedure for patients with facial palsy because the
paralytic frontalis muscle gives good long-term main-
tenance of brow elevation with minimal brow relapse
and rare scar widening or hypertrophy.
CHEMICAL BROW LIFT: BOTULINUM
TOXIN A
Given the success of the use of botulinum toxin A for
a wide variety of aesthetic procedures and with knowl-
edge of the balanced forces at work in the forehead as the
premise of the endoscopic lift, several authors have
reported on the use of botulinum toxin A for lifting the
ptotic brow.4,55,56 Forehead rejuvenation with the use of
botulinum toxin A has become a widely accepted addi-
tion to the armamentarium of the aesthetic surgeon. The
observation during the use of botulinum toxin A for
glabellar line correction that the medial brow became
elevated has resulted in further study as to its effects on
chemically lifting the ptotic brow.55 Intramuscular injec-
tion of the depressor muscles (orbicularis oculi, depres-
sor supercilii, procerus, and corrugator supercilii) of the
brow with botulinum toxin A produces temporary paral-
ysis of these muscles, resulting in increased activity of
408 J. S. ARNEJA ET AL.
Ophthal Plast Reconstr Surg, Vol. 21, No. 6, 2005
the primary brow elevator muscle (frontalis), thereby
elevating the brow.
Ahn et al.4 described their technique of a temporal
brow lift by using botulinum toxin A in 22 patients. Their
technique consisted of 16 to 20 units of botulinum toxin
A injected in the superolateral aspect of the orbicularis
oculi muscle,56 which produced an average of 4.83 mm
elevation in height of the lateral brow and 1.02 mm
elevation at the mid-pupil level. Huang et al.57 found that
they were able to elevate the nasal, central, and temporal
brow by using 10 units of botulinum toxin A injected
along the superior orbital rim, achieving the greatest
amount of elevation in the central brow.
The ideal application for botulinum toxin A use in
brow lift would be a young patient with isolated ptosis of
the lateral brow who desired nonsurgical treatment. For a
temporary solution, botulinum toxin A appears to be a
suitable choice. The primary advantage of this technique
is that it is an office-based outpatient procedure with
minimal patient morbidity. This method of brow lift does
not replace surgical intervention and has limitations
including temporary efficacy with the need for repetitive
treatments, painful injections, and unpredictable results.
Maas et al.56 noted that more efficacious results were
found in younger patients. As a consequence of injection
to depressor muscles in the glabellar region, the medial
brow becomes elevated due to unopposed action of the
frontalis muscle. However, excessive injection to the
depressor muscles can result in overelevation of the
brow, resulting in an unaesthetic, “surprised” look.58
Other complications with the use of botulinum toxin A
include bruising and eyelid ptosis.4
CONCLUSIONS
Aesthetic and reconstructive surgery of the brow has
seen significant advances in the past two decades. Given
the numerous surgical techniques currently available, an
accurate diagnosis of the anatomic location and severity
of brow pathology is essentialto correctly treat the
problem. No single technique is universally applicable to
treating the problems of brow ptosis and forehead aging.
The advantages, limitations, indications, and applications
for the various brow lifting techniques in current practice
are summarized in the Table.
The coronal brow lift remains the accepted standard by
which other brow lift techniques should be compared
because of its versatility in addressing most of the patho-
logic anatomy with direct vision. Knize28 advocates that
this technique should be performed in the subperiosteal
plane to avoid injury to the deep branch of the supraor-
bital nerve. Given the advances made with fixation
techniques in endoscopic lifting, extrapolation to the
coronal lift is applicable. The recommended incision for
a coronal lift should be a stealth-style incision to best
camouflage the scar. The incision may be placed at the
anterior hairline to allow forehead reduction in cases of
hairline recession in balding men or women who choose
to wear their hair forward. A midforehead incision can be
used in patients with hairline recession and deep fore-
head furrows. The main limitation of the coronal lift is
the coronal scar and the possibility of associated alope-
cia, forehead paresthesias, and pruritis. Coronal lifting is
suitable for the aesthetic or reconstructive brow, al-
though patients with unilateral facial palsy might be
better served by a direct brow lift.
Although there is a steep learning curve for endo-
scopic brow lifting, the literature suggests good long-
term results. Endoscopic lifting has been practiced long
enough to allow critical evaluation of its current place in
the management of the ptotic brow. As with most tech-
nical innovations, there is often much attention given to
the technique in the initial stages, with decreased interest
following mixed results. Patients with mild brow ptosis
and those seeking correction of forehead rhytids and
Advantages, Limitations, Indications, and Applications of the Aesthetic and Reconstructive Brow Lift
Technique Advantages Limitations Indications and Applications
Coronal Direct Visualization, Hidden
Scar, Direct Management
of Pathology
Large Scar, Paresthesias,
Alopecia
Severe Brow Ptosis, Forehead and
Glabellar Phytids
Anterior Hairline Mechanical Advantage,
Forehead Reduction
Visible Scar Hairline Recession
Midforehead Mechanical Advantage,
Forehead Reduction
Visible Scar Deep Forehead Creases, Hairline
Recession
Endoscopic Limited Scarring, Low Risk
Paresthesias
Learning Curve,
Instrumentation, Limited
Efficacy
Mild-Moderate Brow Ptosis, Phytids
Limited Incision Limited Scarring, Low Risk
Paresthesias
Difficult Management of
Forehead Rhytids and Medial
Brow Ptosis
Lateral Brow Ptosis, Glabellar
Rhytids
Direct Superior Suspension,
Mechanical Advantage
Visible Scar Unilateral Facial Palsy, Senile Ptosis,
Hairline Recession
Chemical No Surgery, Minimal
Morbidity
Temporary, Unpredictable
Results
Non-surgical Candidates, Younger
Patients, Lateral Brow Ptosis,
Rhytids
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Ophthal Plast Reconstr Surg, Vol. 21, No. 6, 2005
those with mild asymmetry associated with unilateral
facial palsy might benefit from endoscopic lifting. Many
surgeons do not have the large number of patients, nor
the patience, to arrive at such results, making the coronal
lift a more reproducible alternative. Endoscopic brow
lifting is not a panacea, and it should not be applied to
every patient presenting for brow reconstruction or reju-
venation. It demands expert technique, and some reports
suggest the effects are not as permanent as initially
thought. However, in trained hands, and given the right
indications, it remains a valid option for management of
the ptotic brow.
Patients with isolated lateral brow ptosis and forehead
rhytids seeking a permanent solution to their symptoms
are excellent candidates for the Knize limited incision
brow lift technique. This technique directly treats the
pathophysiology of brow ptosis and offers a rational
solution to the problem. If patients are not inclined to
surgical correction, the chemical brow lift using botuli-
num toxin A is an option. In younger patients, this
technique offers an excellent, temporary option for lift-
ing the lateral brow. If the patient presents with forehead
and glabellar rhytids, these too can be treated with
botulinum toxin A. One must be cautious of overcorrect-
ing the medial brow with botulinum toxin A, as this
produces the undesirable result of excess elevation and
gives the patient a “surprised” look. There appears to be
limited morbidity with this technique once the surgeon
becomes familiar with the functional anatomy of the
forehead region.
The direct brow lift offers the most mechanically
advantageous approach, at the expense to the patient of a
visible scar. It should be reserved for patients with facial
palsy, elderly patients seeking correction of visual axis
obstruction, and patients with male pattern baldness who
have thick eyebrows. Patients with severe senile ptosis
seeking a functional improvement probably will not
accept the increased complexity and potential complica-
tions associated with the coronal brow lift, and, as such,
a direct brow lift will often suffice.
Given the increased interest in aesthetic surgery in
North America, surgeons treating the brow and forehead
region must become increasingly critical of their tech-
niques and results. No single technique offers the ideal
method of treating the aging brow and hence the surgeon
must be capable of tailoring the technique to the patient’s
symptoms and signs. As seen in this review of current
literature, the brow lift is a dynamic technique and will
undoubtedly continue to evolve with further technolog-
ical change.
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411PERSPECTIVE
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