blepharoplasty guide

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Chapter 16 - 1

Eyebrow Lift

Other names: Brow lift, forehead lift, coronal lift, endoscopic brow lift, direct brow lift, temporal lift, midforehead lift, internal brow lift, browplasty, browpexy, upper face lift

Primary goal: Elevation of drooping eyebrows

Secondary goals: Softening of forehead wrinkling and glabellar (the area between the brows) frown lines

Special anatomy: Be sure to review the illustration of the muscles of the eyelids, brow, forehead, and glabellar region (the area between the two brows).

Anesthesia: The more extensive the surgical approach, the deeper the level of required anesthesia. General anesthesia or deep intravenous sedation is advisable for coronal forehead lifts.

Operative technique: Because so many very different operations exist, presenting the specifics of each is beyond the scope of this summary. Depending upon the operation, the actual lift may be achieved by a combination of skin and muscle removal, tucking of underlying muscle, or loosening of forehead and scalp periosteum with resuspension at a higher level. Incisions may be closed by using simple sutures, staples, bone screws, or sutures placed through bone tunnels.

Variations: The number of different surgical approaches to brow elevation is large and include:

Coronal forehead lift, in which the scalp is incised from ear to ear over the top of the head

Endoscopic forehead lift, in which the forehead is loosened and elevated through small incisions in the scalp using of instrument called an "endoscope"

Temporal lift, in which the incision is made over the temple and only the outer portion of the brow is lifted

Midforehead lift, in which the incision is placed within a deep wrinkle on the middle of the forehead

Direct brow lift, in which an incision is made just above the eyebrow hair, after which a strip of skin and muscle excised. The deeper tissues are then supported as in browpexy. Although this operation can yield a vigorous lift, its main disadvantage is the creation of a noticeable external scar that is slow to fade, and so it is seldom used.

Internal brow lift, in which the brow is stabilized through the upper blepharoplasty incision by releasing its check ligament and muscular depressors, thus allowing it to elevate naturally under its own power or be elevated with sutures (browpexy). The sub-brow fat pad (ROOF) is sometimes thinned slightly (browplasty).

Non-incisional RF heating, in which radiofrequency energy applied to the skin of the forehead and temple supposedly tighten the deeper tissues

Cable brow lift, in which thick suture placed deep below the skin mechanically connects the eyebrow to tissues below the scalp to create a suspension

Botox brow lift is covered here.

Limitations: For endoscopic brow lifting, the ideal candidate is a woman with thick hair, a low hairline, normal or thin skin, and slight brow droop; patients with thicker skin or more advanced drooping are generally better served with a full coronal forehead lift. Radiofrequency and cable brow lifts are relatively new and associated with high failure rates. Severe brow descent is difficult to address successfully with any procedure other than a direct brow lift.

Contrary to the proclamations of some enthusiatic surgeons, brow or forehead lift (in reality, an upper face lift) does not substitute for an eyelid lift, and vice versa. Each operation is directed at a different problem and achieves a different effect. When indicated by the patient's condition, the two procedures may sometimes be performed simultaneously. Unless there is clear evidence that the forehead has actually drooped, however, conservatism is wise.

Care and recovery: Bruising, swelling, and pain are more pronounced than with blepharoplasty, especially with the more invasive variations of the operation. Recovery is usually rapid, especially with endoscopic-assisted surgery skillfully performed.

Risks and complications: Aside from aesthetic concerns, the most common complication is objectionable scarring. When surgery is performed from within the hairline, the scars are hidden but may still become depressed or be associated with hair loss. When the incisions are made in visible skin, the scars are noticeable, slow to fade, and not always well hidden by natural creases. Only the internal brow lift (browplasty, browpexy) creates no additional scar (but is, unfortunately, a weak procedure that works only over the lateral brow and doesn't hold up well with time).

Other less common complications include nerve damage, hematoma (large blood clot), asymmetry, excessive bruising and swelling, numbness, and scalp itching. If combined with upper eyelid blepharoplasty, the risk of lagophthalmos (inability to close eyes fully) is increased.

Contrary to popular opinion, a recent survey conducted by the American Society of Plastic Surgeons found that the complication rates of the open coronal method and closed endoscopic method were comparable, while the coronal lift method was generally believed to be more efficacious and long-lasting.

Next: Considering Browlift?
Proceed With Caution


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