The upper face, including the eyebrows and periorbital regions, plays a dynamic role in the aging face. With the natural process of aging, the position of the brow relative to the supraorbital rim may become ptotic. Commonly, this presents as excessive hooding of the lateral eyelid but, in severe cases, may result in a visual field obstruction. Other less common causes of this phenomenon may be due to acquired facial paralysis or secondary to post-traumatic deformity. Various surgical options exist to reposition the brow, ranging from traditional open techniques to newer endoscopic approaches. Each of these techniques has their respective strengths and weaknesses, but no individual procedure has proven superiority in all clinical scenarios.
Recently, there have been trends in aesthetic surgery towards the utilization of the endoscopic browlift technique. Nevertheless, traditional open approaches remain a fundamental skill in the armamentarium of the facial surgeon as it provides the greatest degree of accuracy in relation to brow repositioning. Herein we outline the nuances of one of these open approaches, the direct brow lift, and focus on its role in rejuvenating the upper third of the face.
The upper third of the face exhibits many characteristic signs of aging, including:
Brow Lift Methods
As mentioned previously, multiple surgical approaches have been created to address the ptotic brow, including:
Pertinent Anatomic Structures
Ideal Brow Location and Shape
Indications for any type of brow lift surgery may include:
Clinical situations favoring a direct brow lift approach:
All in all, the direct brow lift is increasingly used as a reconstructive technique and less commonly performed in the cosmetic setting.
Contraindications to brow lift surgery include:
Contraindications to the direct brow lift approach:
The successful completion of the direct brow lift requires that the surgeon have excellent soft-tissue handling techniques and a thorough understanding of head and neck anatomy.
Routine steps are outlined below:
Although rare, complications may include:
Although a facial scar is inevitable, proper surgical technique promotes a high degree of satisfaction regarding scar appearance. Proper preoperatively counseling is paramount to optimize results and minimize complications.
The direct brow lift represents a successful and powerful tool in the armamentarium of the aesthetic and reconstructive facial surgeon. When confronted with the effects of facial paralysis or aging, this option provides precise results for repositioning an asymmetric or ptotic brow. The surgeon offering this technique should also be well versed in the other approaches in brow lifting in order to perform the most proper assessment and plan. In the hands of a knowledgeable and experienced surgeon, the outcomes can be very satisfactory.
It is paramount to identify the risk factors and perform a thorough assessment before performing a direct brow lift. The patient should have the following done:
An interprofessional team, including a facial surgeon, anesthesiologist, and operative nurse should perform the direct brow lift in order to obtain the best outcomes. Close follow-up should monitor the patient for potential complications such as brow asymmetry, facial paralysis, paresthesias, alopecia, overcorrection, hematoma formation, keloid formation, and eye dryness. Proper education should counsel the patient on appropriate wound care and activity level.
This interprofessional care is essential to achieving the best results when performing facial reconstructive surgeries such as the direct brow lift. [Level 5]
Recovery following direct brow lift surgery may vary due to the individual patient's functional and nutritional status. Judicious local wound care is important to ensure a healthy and clean surgical environment. Suction drains are rarely ever necessary. Blood thinners may be restarted the following day after surgery. The patient should be educated to avoid heavy lifting or straining until seen in follow up to allow for appropriate wound healing. When the proper sterile technique is employed, post-operative antibiotics are not necessary. Permanent sutures for skin closure, if utilized, should be removed within 5 to 7 days, depending on the amount of wound tension present. Following surgery, the patient is typically followed regularly until proper healing is ensured.
Close follow-up will help identify any acute postoperative complications. Swift identification and subsequent appropriate management will ensure optimal outcomes. The ancillary staff should assist in monitoring, education, and coordinating follow up.
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