20.1 Goals

The direct brow lift is one of many options available to surgically correct ptotic eyebrows. It may be performed under local anesthesia or with sedation and may be combined with other procedures, such as blepharoplasty. In particular, a direct browplasty is useful for correcting temporal brow ptosis in patients who have preexisting rhytides and present mainly with functional rather than cosmetic complaints.

20.2 Advantages

A main advantage of the direct browplasty is that it does not require special equipment, such as endoscopes, screws, or tacks, and can be performed with readily available sutures. The surgical skills required to perform this procedure are basic and it does not require endoscopic surgical competence. In addition, it is not a time-consuming procedure and can be performed under local anesthesia or with minimal sedation in an office or operative setting. The surgical results are very predictable, as it is possible to carefully control the amount of brow elevation, even in cases of significant brow asymmetry, because the lift is a direct result of tissue excision. Furthermore, the surgical results are lasting, and are not expected to diminish over time. This is in contrast to other methods such as endoscopic brow lifting where the brow is suspended and at risk of falling as suspension materials stretch or give way.

20.3 Expectations

Surgical expectations should be discussed with patients to ensure that they are appropriate candidates for the procedure. Patients should be forewarned that they almost certainly will have a visible scar postoperatively and that they will have numbness surrounding the incisions, which will improve over time. They should know that the vertical distance of the forehead between the brows and the hairline will decrease in size. This may be desirable in those with a high hairline, but may be a concern in those with a short distance between hairline and brow. Men, in particular, should know that the procedure will elevate and often arch the brow, which may have an undesirable feminizing effect. Efforts should be made to minimize this arched configuration in male patients through careful incision design. Patients should be warned that in rare instances, damage to the temporal branch of the frontal nerve may occur, leading to paralysis of the frontalis muscle; also, in rare instances, damage may occur to the supraorbital nerve, leading to permanent numbness of the ipsilateral forehead and part of the scalp. The surgeon should stress that the purpose of a direct browplasty is to improve the functional rather than the cosmetic aspects of brow ptosis, and that if a patient is more concerned with cosmetic outcomes, an alternative brow-lifting procedure may be more appropriate, where the incision is created at or behind the hairline.

20.4 Key Principles

A key principle in successfully performing a direct browplasty is to carefully select appropriate surgical candidates, who will be happy with the functional improvements in vision and will not be bothered by a potential scar. The surgeon should remember to avoid branches of the frontal and supraorbital nerves to minimize the risks of numbness and paralysis. In addition, the surgeon should be attentive to where preoperative surgical marks are placed and how much tissue will be removed in order to create a pleasantly arched eyebrow in women and avoid feminizing effects in men.

20.5 Indications

A direct browplasty is an excellent option in patients who do not want general anesthesia, in older men and women with skin of lighter pigmentation who do not mind a faint scar postoperatively, in patients with significant temporal brow ptosis, in patients with a long forehead who could benefit in moving the brows closer to the hairline, and in patients who do not mind an arched eyebrow or a smoothed contour of the upper eyebrow hairs. Patients with scarring of the tissue in or around the brow may benefit more from this powerful procedure than one involving a more remote incision placement. This procedure is also highly effective in patients with facial nerve paralysis resulting in a nonmobile brow.

20.6 Contraindications

This procedure should not be performed in younger individuals or in patients who insist upon an excellent cosmetic outcome without a scar. It should also be avoided in patients who form keloids or hypertrophic scars, and patients with darker skin who may have depigmented scars for a prolonged time period. Caution should be exercised in patients who have underlying dry eye or lagophthalmos, as overaggressive brow elevation can result in lagophthalmos. The procedure should not be performed in patients with a vertically short forehead, as removal of additional skin between the eyebrows and hairline will only worsen this feature. Men who do not want to risk a feminizing effect, either from arching of the eyebrow or from loss of the rough, feathered appearance of eyebrow hairs at the superior border of the brow should be advised not to undergo this procedure.

20.7 Preoperative Preparation

Preoperatively the patient should refrain from taking anticoagulant medications for an appropriate time prior to surgery, as determined by consensus of the surgeon and the prescribing physician. The surgeon and patient should discuss whether the direct browplasty will be performed in isolation or will be combined with a blepharoplasty or other procedure, such as ptosis repair or mid-face lift. If a blepharoplasty will be performed in conjunction, the direct browplasty should be performed first as it may alter the amount of skin that will be removed during the blepharoplasty. In addition, the surgeon should decide whether the browplasty will involve only the temporal portion of the brow or a more extensive segment.

The necessary preoperative materials should be obtained, including a signed informed consent and appropriate patient identification, a ruler, marking pen, 5% povidone iodine, topical anesthetic drops, local anesthetic (typically a 1:1 mixture of 2% lidocaine with 0.75% marcaine and 1:100,000 epinephrine), a #15 blade, forceps, Stevens scissors, cautery, 4–0 or 5–0 polyglactin 910 or poliglecaprone 25 sutures for deep closure and 5–0 polypropylene or nylon for cutaneous closure.