Background: Aging of the face affects all structures but none are more noticeable, both early and late in the process, than that of what occurs around the eyes. One of those changes is a sag or lowering of the eyebrows. Due to frequent motion of the muscles which often pulls them down and the long-term effects of gravity, the eyebrows can lower from their original position on the brow bones. A lower than normal eyebrow position not only affects how we look but can make redundancy of upper eyelid worse.
The treatment of brow ptosis (brow sagging) can be done by a variety of techniques, most of which are based on some type of superior scalp incisional approach. The traditional full coronal incision of yesterday has been largely replaced by a much more limited endoscopic technique. With smaller incisions and a quicker recovery, the endoscopic browlift can be applied even to younger patients with smaller amounts of brow sagging.
But the endoscopic browlift is not perfect and the benefits of the smaller incisions are offset by the limits of what the procedure can do. Besides restrictions on how much of the forehead muscles can be manipulated, its lifting effect is based on an epicranial shift concept. Because no tissue is removed, the browlift effect is created because the scalp is moved backwards. As the scalp tissues a removed back, the forehead is pulled upward with the brows at the lower end being pulled with it. While the brows may be lifted, the forehead also lengthens. This may be aesthetically disadvantageous for the patient who already has a long forehead.
An intermediate browlift technique between a coronal and endoscopic method is the pretrichial or hairline method. This less frequently used browlifting method has many of the advantages of other browlift techniques with the only disadvantage of how well the hairline scar appears.
Case Study: This 62 year-old female was undergoing a variety of facial rejuvenation procedures. One of them was her desire to give her eyes a less tired look. She already received Botox injections in the glabellar region and felt that if her brows were lifted, particularly the middle and outer areas (which Botox did not lift very much) then she would have a less tired and worn appearance.
Under general anesthesia, a beveled frontal hairline incision was made which went behind the hairline as it was extended into the high temporal area. The forehead tissues were elevated off the bone and the brow ridge periosteum separated and lifted, exposing the supraorbital neurovascular bundles on each side. Portions of the corrugator and procerus muscles were removed centrally and around the nerves. Horizontal strips of frontalis muscle were also removed in two separate rows. The forehead skin was lifted to create the desired browlifting effect as well as temporal scalp skin out laterally. The overlapping forehead skin and scalp tissues were trimmed, the deeper tissues secured to the galea and deep temporal fascia and the incisions closed.
Recovery from a pretrichial browlift is about whatever bruising and swelling occurs around the eyelids. That will be significantly influenced by whether any blepharoplasty surgery is done at the same time. When done without accompanying blepharoplasties, one can look pretty good in one week after surgery. When done with blepharoplasties, that recovery of acceptable appearance will be extended to 10 to 14 days.
The pretrichial browlift does carry two distinct disadvantages, one of which is obvious and the other not visibly apparent. There will be a fine line scar along the frontal hairline which usually heals very well. In patients with more pigment in their skin, a mild line of hypopigmentation may result. The unseen disadvantage is the transection of the sensory nerve branches as they cross into the scalp. This will cause some temporary numbness of the frontal scalp which patients often described as a ‘dead woody’ feeling in that area for few months after surgery. That numbness feeling is usually more profound than the more traditional coronal incision because it cuts across the nerves closer to their origin.
Case Highlights:
1) Brow lifts can be done by a variety of techniques of which the hairline or pretrichial approach offers a balance between a relatively hidden scar and a powerful brow lifting effect.
2) The amount of skin removed along the frontal hairline correlates closely with the amount that the brows are actually elevated.
3) The scar along the frontal hairline can have some hair that grows through it with a small amount of hypopigmentation.
Dr. Barry Eppley
Indianapolis, Indiana