10 Midforehead Browlift Technique
Abstract
Brow ptosis cannot be ignored when evaluating a patient for rejuvenation of the upper third of the face. There are several techniques to address brow ptosis, and midforehead browlift has been performed for decades. It is a technically straightforward procedure and, with graded resection, can be used to lift any part of the brow and address the medial brow depressors. This technique has special utility in the treatment of brow ptosis associated with facial paralysis.
10.1 Introduction
Brow ptosis progresses with age causing functional and aesthetic complaints. The combination of loss of tissue volume and elasticity, effects of gravity, and contraction of the brow depressors results in forehead or brow ptosis with a tired, aged appearance and visual obstruction if severe. Significant unilateral eyebrow ptosis can also result from seventh nerve palsy following trauma, Bell’s palsy, or other diseases. When evaluating options for rejuvenation of upper third of the face, brow ptosis is often found in conjunction with horizontal forehead rhytids and furrowing of glabella. Contraction of the frontalis muscle results in horizontal creases and the action of corrugator muscle results in vertical creases of the glabella. These creases deepen with age and become permanent.
There are several ways to perform a browlift depending on the amount of brow ptosis, tissue characteristics, hairline, forehead height, age, gender, and cosmetic expectations. Treatment options include nonsurgical treatments such as botulinum toxin denervation of the brow depressors, thread lifts and internal browpexy, direct browlift, midforehead browlift, pretrichial browlift, and coronal and endoscopic foreheadlift. 1
The midforehead browlift approach described by Brennan and Rafaty in the 1980s takes advantage of the deep horizontal forehead furrows. 2 It can be useful in patients with broad or recessed hairline where a coronal or pretrichial approach may leave an unacceptable scar at the hairline. In addition, the midforehead approach allows ready access to the brow depressor muscles that may be resected and weakened. This technique is excellent in patients with facial palsy who have a significant brow ptosis and lack rhytids on the paralytic side.
In this procedure, appropriate amounts of midforehead skin and subcutaneous fat are removed with an incision generally based on a deep midforehead crease. It is performed bilaterally or unilaterally as needed with excellent functional and cosmetic outcomes.
10.2 Goals of Intervention/Indications
Elevate medial, central, and/or lateral eyebrow as needed.
Camouflage scar in midforehead furrows.
No hair loss or disturbance of the hairline or eyebrow.
10.3 Risks of the Procedure
Bleeding.
Infection—rare.
Scarring.
Forehead sensory or motor deficit.
10.4 Benefits of the Procedure
Lift eyebrow bilaterally or unilaterally.
Easy access to brow depressors if needed.
Camouflage scar in forehead rhytids.
Special utility in facial paralysis as a more natural contour can be achieved with elevation of the head (medial) brow to an optimal contour.
10.5 Informed Consent
Include risks and benefits (as above).
Emphasize incision location and months required for incision to mature and resolve incisional erythema.
10.6 Contraindications
Very short forehead to hairline.
Patient unwilling to accept incision location or time to heal.
10.7 Preoperative Assessment
Preoperative assessment should be performed in an upright position with the face in repose.
Redundant eyelid skin that extends beyond the lateral canthus provides clues for temporal brow ptosis.
Relative position of brow to the orbital rim is noted.
A female brow typically rests above the orbital rim.
The male eyebrow generally rests at or near the orbital rim.
Forehead and medial brow rhytids are noted.
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