Brow lift - Midforehead approach

Considerations

• • Indications

    • Brow asymmetry 

    • Deep horizontal forehead rhytids and androgenic baldness (receding anterior hairline) 

  • Advantages 

    • Precise brow positioning

    • Preserves hairline

  • Disadvantage

    • Visible scar

Preparation

• • Marking

    • Design an elliptical incision around the deep horizontal rhytid superior to the brow with two-thirds of the ellipse above the rhytid and one-third below

    • Over the contralateral brow, design a similar incision placed over a rhytid at a different vertical height (staggered) to avoid a continuous incision

    • Optional: Plan one continuous elliptical transverse incision stopping at the temporal fusion line laterally with irregularization (broken line) of the incision edges

  • Local anesthesia 

    • Infiltrate 1-2% lidocaine and 1:100,000 epinephrine at the planned incision, over the brow and glabellar regions, and to give supraorbital nerve blocks

  • Sterile preparation and drape

Procedure

• • Incise the skin with the 15 blade

    • Laterally, incise only skin

  • Excise the skin and subcutaneous tissue off the frontalis muscle

  • Dissect inferiorly in the subcutaneous plane to the orbicularis oculi at the superior orbital rim

  • Optional: Incise the galea plane transversely in the midline ~ 3 cm above the nasal root allowing entrance into the subgaleal plane

    • Laterally, this incision must not extend beyond the supraorbital nerves

    • Expose the corrugator and procerus muscles as well as the supraorbital and supratrochlear nerves

    • Complete muscle attenuation as desired

    • Optional: Separate the corrugator muscles from the bony origin, cross-clamp them, and excise them with the use of bipolar hemostasis

      • Do not completely resect the procerus and corrugator muscles but weaken them depending upon the extent of horizontal nasal furrowing and on the desired degree of elevation of the nasal root skin

  • Undermine the skin superior to the upper incision for approximately 1.5 cm, allowing skin eversion during closure

  • Optional: Horizontal attenuation of the frontalis muscle may be achieved with superficial horizontal cuts, allowing release of deep creases

  • 4-0 PDS horizontal mattress sutures inferiorly through the orbicularis oculi muscle to the periosteum superiorly 

  • Optional: Approximate the deep galeal transverse incision after excision of excess using 4-0 PDS

  • Optional: For particularly heavy brows, suspend the muscle an dermis of the brow to the periosteum superolaterally with several 3-0 nylon sutures

  • Excess redundant skin and address brow asymmetry 

  • Approximate the skin in 2 layers 

    • 5-0 Polysorb interrupted buried deep dermal sutures

    • 6-0 Prolene or Biosyn subcuticular running suture

  • Dressing

    • Anti-tension steri-strips

    • Telfa

    • Headwrap 

Sample operative report

Post-op

• • POD 3 - remove head wrap and Telfa dressing

  • POD 5-6 - remove skin sutures 

    • Replace anti-tension steri-strips for an additional 7-10 days

• Complications 

  • Facial nerve injury 

  • Hematoma

  • Brow asymmetry 

  • Abnormal soft tissue contour where muscle is excised or weakened 

  • Lagophthalmos 

  • Scar

Pearls & Pitfalls

High-Yield

Links

• eMedicine - Mid Forehead Brow Lift