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