The Open Brow Lift Joseph D. Walrath, MD*, Clinton D. McCord, MD INTRODUCTION Open brow lifting has been performed for nearly a century 1,2 and is a wi dely perf ormed cosmet ic pr o- cedure today. Open brow lifting encompasses a range of techniques including coronal hair-bearing approaches, frontal pretrichial approaches with or withou t tempo ral hair -bear ing inci sions , tempo ral hair-bearing approaches for la ter al brow ptos is, mid-forehead approaches, and direct brow supra- ciliary approaches. Combined with small-incisional endos copic brow eleva tion , trans palpe bral brow elevation, and various forms of browpexy, a palette of opti on s must be co nsidered join tl y by the surg eon and pat ient in determination of the app rop ria te procedure for each individual patient. There is an ebb and flow in the approach to treatment of various surgical problems, cosmetic or otherwise. This trend is certainly present in ocu- loplastics, where today there are, for example, re- gional diff eren ces in the pref erred surgi cal treat ment of blepharoptosis. In the strongly consumer-driven markets of cosme tic sur ger y, the se fluctuations can be massive. Some of this fluctuation is media driven, some patient driven, some surgeon driven, and some technology driven. Attaching words like end osc opi c or las er- ass ist ed to an y pro ced ure generally makes that procedure appealing to pa- tients, as it implies that the procedure is somehow less invasive, less risky, or has less down time. It also implies th at the surge on is cur ren t in his or her skills and is at the forefront of the field, whether or not there is any merit to this assumption. How els e can one ex pla in las er-ass ist ed ble pha rop las ty? Thi s phe nomen on lik ely con tri but ed to the wid e adoption of endoscopic small-incision brow li fting procedures in the 1990s. Vasconez 3 and Isse 4 first presented the small-incision endoscopic approach to brow lifting in 1992. Initial indications for endo- scopic brow lifting were essentially the same as for open techniques, and the requisite small incisions were eas ily accept ed by pat ien ts. Af ter an in iti al up - swel l in en doscop ic br ow li ft in g, th e tec hn ique is not per for medas oft en tod ay,alth oug h cle arl y in thepro- per pat ien t with the pro per techn iqu e, theresult s can be excellent. The reasons for the shift back to open techniques relate to dura bilit y, preve ntion of hair line elevation (or designed lowering of the hairline), and a desire for less dependence on technology. Paces Plastic Surgery, 3200 Downwood Circle, Suite 640, Atlanta, GA 30327, USA * Corresponding author . E-mail address: [email protected]KEYWORDS Plastic surgery Brow lift Aging face Surgical techniques Facial rejuvenation KEY POINTS The vast array of open brow lift techniq ues provide s a durable correction to brow ptosis. Some open techniques are more powerful than others, with incisions closer to the brow (direct brow lift) offering a greater correction in brow height. The pr et richial open brow li ft is the pr ocedur e of choi ce for br ow elevation and tr eatmen t of forehead rhytids in patients with a high hairline or long forehead. With meticulous wound closure and proper patient selection, there is high postprocedure patient acceptance of the incisional scar after pretrichial open brow lift, mid-forehead brow lift, and direct brow lift. Direct brow lifting rarely results in sensory disturbances, provided that the depth of the excision remains above the frontalis medially. Clin Plastic Surg 40 (2013) 117–124 http://dx.doi.org/10.1016/j.cps.2012.06.002 0094-1298/13/$ – see front matter 2013 Elsevier Inc. All rights reserved. p l a s t i c s u r g e r y . t h e c l i n i c s . c o m
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century1,2 and is a widely performed cosmetic pro-
cedure today. Open brow lifting encompasses arange of techniques including coronal hair-bearing
approaches, frontal pretrichial approaches with or
without temporal hair-bearing incisions, temporal
hair-bearing approaches for lateral brow ptosis,
mid-forehead approaches, and direct brow supra-
ciliary approaches. Combined with small-incisional
endoscopic brow elevation, transpalpebral brow
elevation, and various forms of browpexy, a palette
of options must be considered jointly by the surgeon
and patient in determination of the appropriate
procedure for each individual patient.
There is an ebb and flow in the approach to
treatment of various surgical problems, cosmetic
or otherwise. This trend is certainly present in ocu-
loplastics, where today there are, for example, re-
gional differences in the preferredsurgical treatment
of blepharoptosis. In the strongly consumer-driven
markets of cosmetic surgery, these fluctuations
can be massive. Some of this fluctuation is media
driven, some patient driven, some surgeon driven,
and some technology driven. Attaching words like
endoscopic or laser-assisted to any procedure
generally makes that procedure appealing to pa-
tients, as it implies that the procedure is somehow
less invasive, less risky, or has less down time. Italso implies that the surgeon is current in his or
her skills and is at the forefront of the field, whether
or not there is any merit to this assumption. How
else can one explain laser-assisted blepharoplasty?
This phenomenon likely contributed to the wide
adoption of endoscopic small-incision brow lifting
procedures in the 1990s. Vasconez3 and Isse4 first
presented the small-incision endoscopic approach
to brow lifting in 1992. Initial indications for endo-
scopic brow lifting were essentially the same as for
open techniques, and the requisite small incisionswere easily accepted by patients. After an initial up-
swell in endoscopic brow lifting, the technique is not
performedas often today,although clearly in thepro-
per patient with the proper technique, theresults can
be excellent. The reasons for the shift back to open
techniques relate to durability, prevention of hairline
elevation (or designed lowering of the hairline), and
a desire for less dependence on technology.
Paces Plastic Surgery, 3200 Downwood Circle, Suite 640, Atlanta, GA 30327, USA* Corresponding author.E-mail address: [email protected]
KEYWORDS
Plastic surgery Brow lift Aging face Surgical techniques Facial rejuvenation
KEY POINTS
The vast array of open brow lift techniques provides a durable correction to brow ptosis.
Some open techniques are more powerful than others, with incisions closer to the brow (direct brow
lift) offering a greater correction in brow height.
The pretrichial open brow lift is the procedure of choice for brow elevation and treatment of forehead
rhytids in patients with a high hairline or long forehead.
With meticulous wound closure and proper patient selection, there is high postprocedure patient
acceptance of the incisional scar after pretrichial open brow lift, mid-forehead brow lift, and direct
brow lift.
Direct brow lifting rarely results in sensory disturbances, provided that the depth of the excision
remains above the frontalis medially.
Clin Plastic Surg 40 (2013) 117–124http://dx.doi.org/10.1016/j.cps.2012.06.0020094-1298/13/$ – see front matter 2013 Elsevier Inc. All rights reserved. p
l a s t i c s u r g e r y . t h e c l i n i c s . c
SURGICAL TECHNIQUE FOR OPEN BROW LIFTPretrichial Coronal Forehead Lift withHair-Bearing Temporal Lift
Preparation
Lidocaine 2% with epinephrine is injected
about the proposed incision line, and along
the corrugators and superior orbital rim: the“vascular tourniquet.”
Lidocaine 0.25% with epinephrine is in-
jected throughout the forehead at the level
of the periosteum to provide hemostasis
and to provide some hydrodissection.
Thehair is rinsedwitha chlorhexidine solution.
If incisions are to be performed in the tem-
poral hair-bearing region, the hair in this
region is parted and stapled out of the way
of the proposed incision site.
If a temporal lift is to be performed, that portion is
performed first.
An approximately 5- to 6-cm incision is
marked 2 to 3 cm posterior to the hairline
temporally ( Fig. 5 ), beveled so as to remain
parallel to hair follicles.
Fig. 3. ( A) Preoperative photo of a patient before undergoing open pretrichial brow elevation. ( B) Postopera-tively, she has a faint pretrichial scar. The brows are elevated by 0.5 cm bilaterally, and the forehead is reducedin length by approximately 16%. The hairline contour is improved.
Fig. 4. Long-term follow-up after pretrichial frontalincision for a forehead-lowering procedure.
Fig. 5. A typical incision used for open hair-bearingtemporal brow lifting.
Fig. 6. ( A) A typical pretrichial incision spanning both lines of temporal fusion. (B) A subgaleal blunt dissection isperformed with a peanut. (C ) Blunt dissection is carried down toward the root of the nose blindly. (D) Pilot cuts
are useful in determining the amount of skin to excise. (E ) Deep closure is performed in layers: the galea issecured with 2-0 polydioxanone suture and the subcutaneous aspect is secured with multiple 5-0 Vicryl horizontalmattress sutures. (F ) Meticulous skin closure is critical.