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Dr. Barry Eppley

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Posts Tagged ‘pretrichial browlift’

Case Study – Pretrichial Browlift Long-Term Results

Sunday, September 20th, 2015


Background: Like the rest of the face the brows and forehead tissues do fall or go south with age. Besides the horizontal forehead lines and vertical glabellar wrinkles, the lowering of the brows is the most noticeable feature of aging of the upper third of the face. Sagging of the brows, as defined by where they are compared to the underlying brow bones, becomes relevant when the brows hang over the brow bones. This causes a frowning or scowling appearance and pushes upper eyelid skin downward.

Browlift surgery is a well known cosmetic procedure to lift sagging brows and partially deanimate some of the hyperactive forehead muscles. There are several types of browlift techniques which fundamentally differ by incision location and size and whether forehead/scalp tissues are removed or repositioned. The corona browlift is the historic procedure and the endoscopic technique is the more modern technique.

An intermediary browlift technique between the coronal and the endoscopic methods is that of the pretrichial approach. This browlift techniquesdoes use a scalp incision but it is located right at the hairline. This allows excess forehead skin to be removed to do an excisional browlift but does increase the vertical length of the forehead or create a scar back in the hairline that may cause some hair loss. It also allows a shorter open access to modification of the frontalis and glabellar muscles.

Case Study: This 56 year old female wanted a forehead rejuvenation to lift her sagging brows and open up her upper eyelids. She wanted her brows back up over the brow bones and to reduce some of her forehead wrinkle lines.

Under general anesthesia, she has a pretrichial browlift using an irregular hairline incision. Some of the glabellar muscles were excised and strips of frontalis muscle were removed. A total vertical length of 12 mms of upper forehead skin was removed along the hairline tapering it into the temporal area.

Ten Year Pretriochial Browlift result front view Dr Barry Eppley IndianapolisTen Year Pretrichial Browlift result oblique view Dr Barry Eppley IndianapolisPretrichial Browlift Scar result long-term Dr Barry Eppley IndianapolisWhen seen at ten years after the original procedure it could be appreciated that her brows were still up higher than they were just before the original browlift surgery. Her forehead wrinkles were not much worse and her hairline scar was nearly imperceptible.

No anti-aging facial surgery is a permanent procedure. Aging of the face continues unabated and it is just a question of time until the results of the surgery is overcome. While each patient is different, it is a general statement that many facelifting procedures will last about ten years. This patient’s browlift shows that she is just about back to where she started a decade ago.


1) Browlift surgery is not meant to have a permanent result and does degrade over time.

2) An excisonal technique, like a pretrichial browlift, should have fairly long-term results over other non-excisional techniques.

3) This is an example of a ten year pretrichial browlift result which still shows some persistence of improvement over her initial preoperative result.

Dr. Barry Eppley

Indianapolis, Indiana

Long-Term Hairline Stability in Pretrichial Browlifts

Saturday, January 11th, 2014


When it comes to forehead rejuvenation a variety of browlifting strategies exist. Three of the browlifting methods use a superior or scalp incisional access to do the procedure. The most popular of these is the endoscopic technique which uses a few small scalp incisions and an epicranial tissue shift to create its brow elevation effect. It is popular because of a lack of significant incisional lengths even though it does also result in some forehead lengthening.

Pretrichial Open Browlift Scar Dr Barry Eppley IndianapolisA very effective but less popular browlift method is the pretrichial or hairline technique. Making an irregular incision along the frontal hairline, the brows are lifted but without elongating the forehead. While this does place a scar along the frontal hairline, in the properly selected patient with good frontal hairline density, the scar can heal remarkably well and has rarely been a concern in my experience. There is always the understandable concern, however, if whether this incision negatively affects hair growth after healing and in the long-term. (does hair loss occur along the incision)

In the January 2013 issue of Plastic and Reconstructive Surgery, an article was printed entitled ‘Cessation of Hairline Recession following Open Forehead Rejuvenation’. Over a 15 year period, 31 patients had browlifts done using either the endoscopic (17) or open pretrichial incision (14) approaches. Measured photographs of eyebrow to hairline distances were done at 1 and greater than 8 years after surgery and compared to other cosmetic surgery patients who did not have forehead rejuvenation. Their results showed that over the long-term only the pretrichial group had a stable or improved hairline position without any signs of recession. No separation was seen between the scar and the hairline in the pretrichial incision patients.

This study is very relevant to not only pretrichial browlifts but other procedures that use incisions along the hairline such as a hairline lowering/advancement surgery for forehead reduction. Whether it is a woman or a man (but particularly in men), there is always the concern that hair loss may occur along the incision from surgical trauma or that long-term hairline recession may occur. These findings in this paper allay those concerns and suggest that the incision may have some protective effect in the long-term for follicular preservation…and intriguing but as of yet unexplainable biologic effect.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: The Hairline Browlift in Women

Wednesday, November 17th, 2010

Background:  Aging of the upper face primarily involves that which appears in the forehead. Falling of the eyebrows onto or off of the brow bone and the appearance of horizontal and vertical wrinkles are the classic, and quite frankly, only aging signs that can appear. The amount, if any, of brow sagging is the key to whether one considers having a browlift. If one isn’t concerned about the position of the brows, then the non-surgical approach of Botox injections is a good treatment for wrinkle reduction.

In considering browlift surgery, there are numerous options based on the location and type of incision and how much muscle work can be done or is needed. The older traditional approach of a coronal or scalp incision browlift is today quite uncommonly done. The trade-off of a long scalp incision for higher brows is appealing to just a minority of patients. Browlift options in women, other than the scalp incision approach, is using a limited incision endoscopic technique or changing the scalp incision to the hairline. (pretrichial incision)

Case: This 58 year-old woman was tired of ‘looking tired’ and felt that her forehead was a major reason for this appearance. Her brows were positioned at the level of the supraorbital rim and became lower with forehead muscle action, particularly with frowning. She had numerous levels of horizontal forehead wrinkles and an inverted Y wrinkle pattern between the eyebrows. (glabella) Her forehead was fairly long and measured 6.5 cms in length between the central eyebrow arch and her frontal hairline. She needed a browlift technique that lifted her brows but did not make her forehead any longer.

While she underwent other simultaneous facial rejuvenation procedures, a browlift was planned for the upper part of her ‘facelift’. The browlift was approached through a hairline incision to prevent the forehead from becoming longer. Preoperative markings were done delineating the forehead wrinkles and an irregular hairline incision was diagrammed at the very edge of the frontal hairline.

During surgery, the forehead skin was folded down along the bone from the hairline incision. The dissection was carried down to expose and preserve the supraorbital nerves. In the glabellar region, muscle was removed  between the two exiting nerves in the inner brow area. In the forehead, the frontalis muscle was removed in strips between the horizontal skin wrinkle marks. The brows were then lifted and the excess skin along the edge of the frontal hairline was then removed and the incision closed. To prevent the frontal hairline scar from possibly widening later, the deeper tissues underneath the incisional closure  were secured down to the bone with sutures for stability and to relieve wound tension.

All browlifts cause no bruising and minimal swelling…in the forehead. It is all driven down to the eyelids where swelling and bruising of the lower eyelids and upper cheeks will take several weeks to completely go away. The brows were nicely elevated, but not overly so, and the forehead remained perfectly smooth for months. Eventually some muscle action and wrinkles do return but generally about 50% less than what one started with prior to surgery

While having a scar along the hairline seems worrisome, those scars heal remarkably well and have never proven to be a bothersome issue to patients.

Case Highlights: 

1    The single most important factor in determining what type of browlift is best for a woman is the length of the forehead between the hairline and the brows. The density of the frontal hairline and the amount and depth of forehead and glabellar wrinkles are also important considerations.


2)      The hairline browlift offers the advantages of not lengthening one’s forehead while allowing optimal forehead and glabellar muscle removal. The frontal hairline can also be brought forward during closure to shorten the length of the forehead as well if the patient desires. The healing of the hairline scar is excellent and rarely needs any scar revision work.

3)      The hairline browlift is also readily combined with other upper facial procedures such as forehead reshaping  and midface lifts due to the good access and exposure provided.


Dr. Barry Eppley

Indianapolis Indiana

Advantages of the Hairline (Pretrichial) Browlift

Tuesday, September 1st, 2009

The best, and often only, option for upper facial rejuvenation is the browlift. Some may consider an upper blepharoplasty (eyelid) part of the upper face, and I would not disagree, but we will exclude that procedure for this discussion. The browlift rejuvenates by elevating the position of the brows (sometimes changing the shape of the brow arch) and reducing the amount of forehead wrinkling.

Browlifts can be done through four specific surgical techniques, largely differing in the incisional approach. Three of these four browlift types are based on using scalp incisions. One of these scalp browlift options is the pretrichial approach where the incision is made just at the edge of the frontal hairline.

The pretrichial browlift, a close cousin to the traditional coronal or scalp browlift (incision significantly behind the frontal hairline), offers one very specific advantage over all other forms of browlifting. Since the incision is at the hairline, any amount of upper forehead movement (brow elevation) will not move one’s frontal hairline back or make the forehead longer. This is a real significant issue for some potential browlift patients who already have a long forehead. It is the one single physical finding that can solely determine the type of browlift chosen.

The endoscopic browlift, while dramatically shortening the length of incisions used, produces brow elevation at the expense of a longer forehead. This is the same issue as in the coronal browlift which lifts the forehead with a trade-off of a strip of scalp hair being removed…and moving the frontal hairline back.

The hairline browlift also allows forehead wrinkling to be reduced through muscle removal of the forehead and between the eyebrows. Because the distance between the incision and the various muscle regions is the shortest of all the upper approaches, I find that the muscle is a little easier to remove and a more thorough job of that can potentially be done. Any form of open browlift, however, removes muscles of facial expression.

Despite leaving a scar that may be the most ‘visible’, the healing of the hairline scar can be quite good. In my Indianapolis plastic surgery practice, I have even performed it in women who comb their hair back or to the sides without a postoperative  problem. In theory, the density and quality of hair and its orientation of growth in relation to the forehead should be very important to the most inconspicuous scar. However, I have done hairline browlifts in women who have fine thin red hair to dark, coarse and curly hair with equally good scars. 

Dr. Barry Eppley
Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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