22.1 Goals

Anatomically and functionally, there is an intimate relationship between the forehead, the brow, and the upper eyelids. Understanding this relationship is key to avoiding pitfalls of upper eyelid surgery in which the eyelids are raised without considering descent of the forehead and brow. ¹ Many different procedures exist to address the brow region, from foreheadplasty surgeries such as the coronal or endoscopic forehead lift to more direct procedures addressing the brow region via a direct or transblepharoplasty approach. ² The purpose of the current chapter is to discuss the pretrichial brow-lift procedure.

The goal of the procedure is to accomplish elevation of the brow in patients in which brow ptosis is contributing to the aesthetic appearance of looking “tired” or the functional consequence of interference with the visual field. Descent of the brow can exacerbate limitation of the superior visual field in patients with preexisting dermatochalasis. This is especially pronounced laterally, and indeed the main goal of the procedure in the modern era is to accomplish lateral elevation and reshaping of the brow. During the advent and growth period of endoscopic brow elevation in the mid-1990s, many advocates of this procedure had focused on medial and lateral brow elevation as an important goal of the procedure. ³ But as long-term results have been evaluated, this is an area that—if raised significantly relative to the lateral elevation—can induce a facial expression of surprise that can be aesthetically displeasing. In addition, extirpation of the corrugator or procerus muscles can increase the risk of intraoperative and postoperative bleeding as well as dysesthesia. The goal of any brow procedure in the modern era is lateral more than medial elevation, especially in the female population where the arch of the brow is more pronounced. ⁴ In select patients with an elongated forehead, however, the goal may be intentional forehead shortening, best accomplished with a pretrichial or coronal lift over other techniques. ⁵

It is important to understand the anatomy of the frontalis muscle and its relationship to the orbicularis oculi and brow depressors (Fig. 22‑1). The lateral portion of the upper eyelid orbicularis extends past the insertion of the frontalis muscle into the temple region, and the contraction of the orbicularis unopposed can lead to lateral brow ptosis. During patient evaluation, it is also helpful to consider the concept of “facial thirds” (Fig. 22‑2), and the pretrichial lift is the most direct option to restore the upper third of the face that can elongate with aging (Fig. 22‑3). ⁶

22.2 Advantages

The advantage of the pretrichial brow lift over other techniques is the significant amount of mechanical elevation and skin excision that can be safely accomplished, as well as the open surgical exposure compared to the endoscopic approach. In patients who style their hair with bangs or have sufficient follicles at the anterior hairline, the incision from this approach can be concealed. In addition, patients with an elongated forehead may be able to achieve better symmetry between the upper, middle, and lower thirds of the face with a forehead shortening procedure via this approach. ⁵ The other practical advantage of the pretrichial brow lift is that it does not require any special instrumentation in contrast to the endoscopic approach. Lastly, although many different procedures have been proposed to address the ptotic brow, the coronal and pretrichial approaches have stood the test of time as reliable procedures to raise the brow, despite the larger incision. ⁷