12 Pretrichial Temporal Browlift
Abstract
In many patients with aging, there can be a loss of volume in the lateral brow. This will cause the brow to descend, resulting in excess skin with hooding in the lateral portion of the upper lid. Failure to address a low brow position when doing an upper eyelid surgery can result in a heavy, undercorrected appearance postoperatively. There have been many procedures described for the elevation of the temporal brow. Many of them use an incision either at or behind the hairline in the lateral forehead. Dissection proceeds inferiorly to the orbital rim. The technique in this chapter uses an incision of an ellipse of skin and subcutaneous tissue in front of the temporal hairline. In contrast to other techniques previously reported, there is no dissection or undermining around the ellipse. Instead, the tissue is closed directly with deep and superficial sutures or staples. The procedure is quick with minimal bruising and swelling while consistently elevating the lateral eyebrow several millimeters.
12.1 Introduction
When considering aesthetic surgery of the upper eyelid, it is important that the position of the eyebrow also be evaluated. In many patients with aging, there can be a loss of volume in the lateral brow causing brow descent and resulting in excess skin hooding in the lateral portion of the upper eyelid. Failure to address a low brow position when doing an upper eyelid surgery can result in a heavy, undercorrected appearance postoperatively.
There have been conflicting reports regarding the actual descent of the brow after upper eyelid surgery. 1 ID#b149a310_2 – ID#b149a310_3 4 From personal experience, I have found several cases of brow descent after upper eyelid surgery. As the lateral brow is the area of major descent for most patients with secondary dermatochalasis, many surgeries have been described to elevate just this area. 5 ID#b149a310_6 – ID#b149a310_7 ID#b149a310_8 ID#b149a310_9 10 While all of these surgical techniques demonstrated elevation of the lateral brow, they all incorporate dissection down to the orbital rim in either a subcutaneous plane or on top of the deep temporalis fascia. This dissection increases operative time, increases the risk of postoperative bruising and swelling, and can damage the temporal branch of the facial nerve. I describe an alternative approach here, which uses a pretrichial elliptical incision in the temporal forehead, removing skin and subcutaneous tissue with no inferior incision undermining.
12.2 Goals of Intervention/Indications
Improvement of superotemporal visual field.
Elevation of ptotic brow to its proper anatomic position.
Decreasing upper eyelid hooding and dermatochalasis.
Decreasing need for neurotoxin to elevate brow.
12.3 Risks of Procedure
Bleeding.
Infection.
Visible scar.
Suture granuloma.
Asymmetry of brows.
Overcorrection.
Undercorrection.
Damage to temporal branch of facial nerve.
12.4 Benefits of Procedure
Improvement of superolateral visual field.
Elevation of the ptotic lateral eyebrow.
Decreasing upper eyelid hooding and dermatochalasis.
Decreasing the need for neurotoxins to elevate the lateral eyebrow.
12.5 Contraindications
Low temporal hairline.
Bald or severe recession of temporal hairline.
12.6 Informed Consent
Include risks, benefits, and contraindications.
Revision may be necessary if there is postoperative asymmetry.
12.7 Preoperative Evaluation
For any patient interested in upper eyelid surgery, either blepharoplasty or ptosis, the eyelid will be evaluated for excess skin.
The brow should be elevated manually to determine the amount of laxity and the glide in the eyebrow tissues.
If the brow is below the orbital rim, it will need to be elevated to prevent persistent lateral hooding postoperatively.
It is helpful to demonstrate to the patient the different cosmetic appearance that will be obtained if the brow is elevated at the same time as upper eyelid surgery.
A pretrichial temporal browlift can be done in any patient who has a good temporal hair tuft.
If a patient has an extremely low temporal hairline, this surgery may not be appropriate because it can move the brow too close to the hairline.
Consider avoiding the pretrichial temporal browlift in patients with short hair or in patients who wear their hair away from their face hair as this does not provide the ability to conceal the small possibility of a visible scar.
Preoperative full-face photographs are important.
Primary and lateral oblique views are important for pre- and postoperative comparisons.
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