Operative Technique in Plastic Surgery – Kevin C.Chung

■ A 5-0 Vicryl or similar suture can be used to pexy the orbicularis to a higher
point on the frontalis muscle, using two or three sutures for this purpose.
Others have described progressive tension sutures from the underside of the
flap down to the frontalis muscle.15
■ The subcutaneous scalp flap is then advanced superiorly over cut edge of the
original scalp incision. This is done with minimal tension but still with
enough tension to cause the undermined flap to advance superiorly over cut
edge of the scalp incision.
■ The degree of overlap is marked, and excess forehead skin is removed from
the inferior (undermined) side of the incision.
■ Repair of the scalp incision is meticulously done with 5-0 nylon sutures.
■ A bupivacaine block is done across the supraorbital rim, targeting the
supratrochlear and supraorbital nerves.
■ A light forehead dressing can be applied, or alternatively the incision is open
with ointment applied along the suture line.
■ Brow Lowering Procedure (Subgaleal Plane)
■ The high hairline in conjunction with a long forehead can be a congenital
condition, or it may be acquired through hair loss in the frontal hairline.
■ The high hairline can be lowered and the long forehead shorted by
advancing the hair-baring scalp and excising a portion of the upper forehead
skin.16
■ Preoperative markings delineate an incision at the anterior hairline and then
coursing laterally into the temple and then into the temple (see FIG 4 above).
■ Anterior hairline incisions create less visible scars if the incision is wavy, not
linear (TECH FIG 2A). Also, when very thin hair is present at the hairline, it
is preferable to place the incision a few millimeters behind, into the zone of
denser hair to hide the ultimate scar.
■ The incision is made with a scalpel beveled in such a way as to transect
some hair follicles, causing new hairs to grow through the resulting scar.
■ Like the open coronal, the incision is carried down full thickness through
scalp down to periosteum.
■ Using blunt dissection or with a scalpel beveled away from the periosteum, a
posterior dissection is done, raising the scalp flap as far posteriorly as the
occiput.

■ In order to advance the scalp flap anteriorly, shallow transverse releasing
incisions are made into the galea, taking great care to not cut further into the
flap. Clinical experience is that for every galeal releasing incision, expect
about 1 mm of additional scalp advancement (TECH FIG 2B).
■ Once the flap has been mobilized, gentle traction is applied for several
minutes to allow for soft tissue creep.
■ The anterior forehead flap is raised far enough to allow for the advancement
of the posterior flap.
■ After anterior advancement of the posterior scalp flap, it is fixed to bone,
using 3-0 PDS (or equivalent) to some form of bony fixation such as
LactoSorb bone tacks (TECH FIG 2C).
■ The excess portion of the anterior forehead flap is excised (TECH FIG 2D).
■ The incision is closed with absorbing sutures in the galea/frontalis plane (3-0
Vicryl) and fine sutures in the skin (running 5-0 nylon).
■ Occasionally a patient may present with a high hairline in conjunction with
low eyebrows. In such a case, through the anterior hairline incision, two
procedures can be done at once: posterior scalp advancement (to lower the
hairline) and an open brow lift (to raise and reshape the eyebrows).
TECH FIG 2 • A. A slightly wavy line is used for the
anterior hairline incision. It is placed a few hairs

behind the hairline, and hair follicles are transected to
encourage new hair growth through the scar. B. The
scalp has been raised posteriorly to the occiput, and
to improve its anterior mobility, multiple transverse
releasing incisions have been made in the galea. C.
To hold the advancing flap as far forward as possible,
two points of bony fixation are used on either side of
the midline at the leading edge of the flap. In this
case, a dissolving bone tack is being used and is
placed just posterior to the anticipated new location of
the new hairline in order that the device will be hidden
under hair-bearing scalp. D. After the scalp flap has
been advanced anteriorly and fixed to bone, the
excess forehead skin is excised.
PEARLS AND PITFALLS
Diagnosis
■ A preoperative aesthetic diagnosis is a vital step embarking on brow
lift surgery. Variables that affect aesthetic decision-making include
eyelid ptosis, excess upper lid soft tissue, or, conversely, deficient
upper sulcus fat.
Eyebrow
shape and
height
■ Many patients have stable brow position throughout their lives and
never develop brow ptosis. In patients whose brows become ptotic, it is
lateral brow ptosis that usually predominates.
Technique
■ The elevated forehead through the coronal approach provides
maximum visibility. Frown muscle ablation is easily accomplished,
and the results of brow elevation are relatively predictable.
■ Sensory nerve transection during the coronal approach is inevitable.
Patients should be warned of this in advance.
Closure
■ Excess suture tension on the scalp skin along the incision line can
cause scar alopecia. Tension should be taken by the galeal sutures.
■ In most cases lateral brow elevation should exceed medial brow
elevation.

POSTOPERATIVE CARE
■ Cold packs are applied to the upper third of the face, as required for comfort.
■ The patient is encouraged to keep the head elevated for the first week to
decrease swelling.
■ A light dressing consisting of a head wrap is put in place.
■ Sutures are removed at 1 week postop.
OUTCOMES
■ An open coronal brow lift is relatively predictable. Complete relapse is
uncommon, and the surgical result is long lasting.
■ This procedure affords unparalleled access for modification of frown
musculature.
■ Unavoidable side effects are a long scar in the scalp, sensory nerve transection,
and a posterior shift of the anterior hairline that lengthens the height of the
forehead.
■ Unaesthetic overlifting of the central brow has historically been a problem, but
with improved knowledge of forehead anatomy and the physiology of aging,
this issue can be avoided.
■ In the end, after assessment at 18 to 24 months, patient satisfaction is reported
as being very high.11
COMPLICATIONS
■ Unsatisfactory scar formation with scar alopecia can occur due to suture
tension along the incision line. A systematic review identified this problem in
3.6% of cases.17 Scar revision is usually successful.
■ Sensory nerve damage routinely occurs leading to dense scalp numbness
initially. This recovers over time, but on testing, there is almost always some
permanent paresthesia to part of the scalp. This is generally not a concern to
patients after 18 to 24 months have passed.12
■ Hematoma is an uncommon complication at 0.5%.
■ Infection is uncommon at 0.2%
■ Motor nerve damage (temporal branch of the facial nerve) has rarely been
reported with subgaleal coronal dissections.
■ The anterior hairline subcutaneous approach, when done in smokers, has led to
a small incidence of partial skin necrosis in the forehead flap.18
REFERENCES

1. Knoll BI, Attkiss KJ, Persing JA. The influence of forehead, brow, and
periorbital aesthetics of perceived expression in the youthful face. Plast
Reconstr Surg. 2008;121:1793-1802.
2. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis.
Plast Reconstr Surg. 1996;97(7):1321-1333.
3. Warren RJ. The modified lateral brow lift. Aesthet Surg J. 2009;29(2):158-
166.
4. O’Brien JX, Ashton MW, Rozen WM, et al. New perspectives on the surgical
anatomy and nomenclature of the temporal region: literature review and
dissection study. Plast Reconstr Surg. 2013;131(3):510-522.
5. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg.
1995;96:564.
6. Agarwa CA, Mendenhall MS, Foreman KB, et al. The course of the frontal
branch of the facial nerve in relation to fascial planes: an anatomic study. Plast
Reconstr Surg. 2010;125:532.
7. Gunter J, Antrobus S. Aesthetic analysis of the eyebrows. Plast Reconstr
Surg. 1997;99:1808-1816.
8. Lambros V. Observations on periorbital and midface aging. Plast Reconstr
Surg. 2007;120:1367-1376.
9. Lemke BN, Stasior OG. The anatomy of eyebrow optosis. Arch Ophthalmol.
1982;100:981.
10. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg.
2009;124(6):2118-2126.
11. Friedland JA, Jacobsen WM, TerKonda S. Safety and efficacy of combined
upper blepharoplasties and open coronal browlift: a consecutive series of 600
patients. Aesthetic Plast Surg. 1996;20(6):453-462.
12. Cilento BW, Johnson CM Jr. The case for open forehead rejuvenation: a
review of 1004 procedures. Arch Facial Plast Surg. 2009;11:13-17.
13. Ullmann Y, Levy Y. In favor of the subcutaneous forehead lift using the
anterior hairline incision. Aestheict Plast Surg. 1998;22(5):332-337.
14. Camirand A, Doucet J. A comparison between parallel hairline incisions and
perpendicular incisions when performing a face lift. Plast Reconstr Surg.
1997;99(1):10-15.
15. Pollock H, Pollock TA. Subcutaneous brow lift with precise suture fixation
and advancement. Aesthet Surg J. 2007;27(4):388-395.
16. Guyuron B, Behmand RA, Green R. Shortening of the long forehead. Plast
Reconstr Surg. 1999;103:218.

17. Byun S, Mukovozzov I, Farrokhyar F, Thoma A. Complications of browlift
techniques: a systematic review. Aesthet Surg J. 2013;33(2):189-200.
18. Guyuron B, Davies B. Subcutaneous anterior hairline forehead rhytidectomy.
Aesthetic Plast Surg. 1988;12:77-83.

21
CHAPTER
Indications and Technique
for Endoscopic Brow Lifting
Navid Pourtaheri, Ali Totonchi, and Bahman Guyuron
DEFINITION
■ Age-related changes of the forehead include elongation of the forehead from a
receding hairline and eyebrow ptosis, static and dynamic rhytides or frown
lines, frontal bossing, glabellar flattening, and a misshapen eyebrow arch.
■ An elongated forehead is defined as having an upper third of the face, hairline
down to the glabella that is greater than approximately one-third of the vertical
height of the face.
ANATOMY
■ The forehead is the continuation of the scalp from the hairline to the eyebrows.
■ The glabella, frontal sinuses, and frontal bone give the forehead its underlying
contour.
■ Overlying the bone, the soft tissue layers of the forehead, from deep to
superficial, include the pericranium, loose areolar tissue, muscular layer (ie,
frontalis muscle and galea aponeurosis), subcutaneous connective tissue and
fat, dermis, and epidermis.
■ Sensory nerves are supplied from supratrochlear and supraorbital nerves,
emerging from the supraorbital rim at 1.7 and 2.5 cm from the midline,
respectively, via a foramen or notch along with associated arteries.
■ The paired frontalis muscles are brow elevators with vertically oriented fibers,
and their attachments with the dermis give rise to horizontal rhytides of the
forehead.
■ Medial, intermediate, and lateral fibers of the frontalis are continuous with the
procerus muscle, corrugator supercilii, and orbicularis oculi muscles,
respectively.

■ The procerus muscle is a brow depressor vertically oriented, originates from
the periosteum over the nasal bones, and inserts into the frontalis muscle and
the glabellar dermis which is responsible for rhytides at the root of the nose.
■ The corrugator supercilii muscles are brow depressors obliquely oriented
originating from the medial superciliary arch and passing through the
orbicularis oculi muscle superolaterally inserting into the dermis of the brow
and are responsible for vertical frown lines in the glabella.
■ The paired depressor supercilii muscles are brow depressors originating from
the medial orbital rim and inserting into the glabellar dermis and are
responsible for oblique rhytides in the medial eyebrow area.
■ The orbital portion of the orbicularis oculi muscle is a brow depressor (FIG 1).
PATHOGENESIS
■ Recession of the upper hairline and temporal hairline increases the length and
width of the forehead, respectively.
■ Eyebrow ptosis occurs with age secondary to involutional changes of the facial
soft tissues from thinning fat and dermis, collagen laxity, and aging. It is
usually first seen in the lateral forehead and eyebrows because the frontalis
muscle may compensate by elevating the medial two-thirds of the eyebrows.
Brow ptosis may also occur due to blepharospasm from hyperactivity of the
orbicularis oculi muscle or weakness of the facial nerve and frontalis muscle.
■ Frontal bossing is typically due to hyperaeration of the frontal sinuses and less
commonly due to soft tissue excess.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A comprehensive analysis is recommended of the face, hairline, brow position
and arch, forehead length, width, contour, soft tissue quality, and rhytides. A
significantly elongated forehead is best rejuvenated with an open approach via
a pretrichial incision to remove excess skin (discussed in another chapter). A
useful method to analyze the brow position is to eliminate the compensation
from the frontalis muscle by asking the patient to smile or close their eyes
tightly and then open them just enough to see the examiner. The
uncompensated position of the eyebrows is at the supraorbital rim in males or
slightly above in females, with its apex at the lateral limbus of the eye.
■ Then, rhytide evaluation is recommended in repose, smiling, and frowning.
Deep static forehead rhytides are best treated with a subcutaneous approach
rather than the endoscopic approach, whereas the fine rhytides are treated with

laser resurfacing after endoscopic brow lift.
IMAGING
■ Imaging is only warranted if there are contour abnormalities due to a soft
tissue mass or underlying bony defect that must be evaluated and addressed
prior to forehead rejuvenation.
NONOPERATIVE MANAGEMENT
■ A combination of botulinum toxin injection, fillers, and fat grafting may be
used to perform forehead rejuvenation nonoperatively.
FIG 1 • Forehead anatomy. (Reprinted from Guyuron B.

Forehead rejuvenation. In: Guyuron B, Eriksson E,
Persing J, eds. Plastic Surgery: Indications and
Practice. Philadelphia, PA: Saunders Elsevier,
2009:1409-1426, with permission from Elsevier.)
SURGICAL MANAGEMENT
■ Endoscopic brow lift is indicated in patients with eyebrow ptosis and
hyperactive forehead muscles without static deep horizontal forehead wrinkles
or excess forehead length. This is done on an outpatient basis under
intravenous sedation or general anesthesia. Compared to open technique, there
is a smaller chance of hair loss or forehead elongation (commonly observed
after a coronal incision), as well as improved visualization with magnification.
■ Disadvantages of endoscopic rejuvenation include the need for specialized
instruments and a learning curve due to operating while looking at a monitor
with a two-dimensional view.
Preoperative Planning
■ An AP photograph of the patient’s forehead in repose and while furrowing the
brow in a standardized fashion is recommended for analysis and postoperative
comparison; any eyebrow asymmetry needs to be noted and addressed using
differential eyebrow suspension during surgery.
■ General medical conditions including hypertension and hyperglycemia, as well
as smoking cessation, are best addressed prior to surgery to minimize wound-
healing complications.
Positioning
■ Surgery is done in supine position. After anesthesia/sedation and prepping and
draping the patient, the marking is started by marking a 1.2- to 1.5-cm incision
on the midline from the hairline going posteriorly, followed by pairs of lateral
incisions in the temple approximately 7 and 10 cm from the midline and 1.5 to
2 cm behind the hairline on either side. Each marking should be made
vertically approximately 1.2 cm in length or 1.5 cm if the scalp is thick (FIG
2).
Approach
■ This chapter explains the endoscopic approach of the brow lift. Open

approaches are discussed in another chapter.
FIG 2 • Markings and hair braiding for endoscopic brow
lift. (Reprinted from Guyuron B. Forehead rejuvenation.
In: Guyuron B, Eriksson E, Persing J, eds. Plastic
Surgery: Indications and Practice. Philadelphia, PA:
Saunders Elsevier, 2009:1409-1426, with permission
from Elsevier.)
T E C H N I Q U E S
■ Endoscopic Brow Dissection
■ Following the positioning of the patient, the hair next to the incision line is
either braided or clamped to prevent it from entering the incision.
■ The non–hair-bearing forehead is injected with approximately 10 cc of 1%
lidocaine with 1:100 000 units of epinephrine using a 27-gauge needle, and
the hair-bearing scalp is injected caudally up to 7.5 cm behind the incision
with approximately 10 cc of 1% lidocaine with only 1:200 000 units of
epinephrine to minimize hair loss due to vasoconstriction.
■ Five minutes after the injection, incisions are made using a no. 15 blade
scalpel on the most lateral marking and then using a pair of baby
Metzenbaum scissors, and the tissue is spread bluntly down to the deep
temporal fascia.

■ At this point, Obwegeser periosteal elevator is used to make a pocket above
the deep and superficial temporal fascia to insert an endoscopic access
device. To insert the access device, the inner shield is folded using a pair of
large multitooth Adson forceps and with an assistant separating the wound
margins using skin hooks, introducing the inner shield into the incision
(TECH FIG 1A).
■ A periosteal elevator is passed through the most lateral incision and
advanced toward the adjacent temporal incision to dissect the tissues at the
plane immediately superficial to the deep temporal fascia and frontal
periosteum.
■ Endoscopic access devices are inserted in the same fashion described before.
■ Using a periosteal elevator, subperiosteal dissection is performed posterior to
the incision in the hair-bearing area and lateral to the incision over the deep
temporal fascia. Unlike posterior and lateral dissection that is performed
blindly, the anterior dissection is performed with the assistance of an
endoscope.
■ A 30-degree 4-mm endoscope is used through the second access device on
the right side, whereas the most lateral access device is used to control the
dissector.
■ Under endoscopic visualization, a periosteal elevator is introduced through
the lateral temporal access device on the right, and dissection is continued
inferiorly toward the supraorbital rim (TECH FIG 1B).
■ To preserve the temporal branch of the facial nerve, it is important not to
leave the plane of dissection from deep temporal fascia to more superficial
layers. One practical point is to ensure that all fat cells over the deep
temporal fascia are dissected off the deep temporal fascia and elevated with
skin, subcutaneous, and deep layer of the deep temporal fascia until
dissection reaches the zygomatic arch.
■ At this point, using a longer periosteal elevator, soft tissue is separated from
lateral orbital rim and zygomatic arch at subperiosteal plane (TECH FIG
1C).
■ Medial to the zone of adhesion of the temporal muscle, dissection is carried
subperiosteally to the supraorbital rim where the supraorbital and
supratrochlear nerves and vessels are identified after making a cut over the
periosteum of the supraorbital rim.
■ The corrugator supercilii muscle is grasped and carefully avulsed using

Daniel grasper or punch biopsy forceps.
■ Muscles need to be removed as thoroughly as possible to minimize the
dynamic asymmetry and deformity of the area postoperatively. The
corrugator muscle lies superficial to a communicating vein between the
supratrochlear and supraorbital veins—this vein is cauterized using suction
Bovie cautery. Bovie nerve hooks can be used to retract and prevent injury
to the supraorbital and supratrochlear nerves during corrugator myectomy.
The depressor supercilii can be mistaken for the corrugator supercilii—it
can be distinguished as the darker, more pliable muscle that lies deeper and
more medial in its location (TECH FIG 1D).
TECH FIG 1 • A. Endoscopic access device insertion
into the temple. B. Endoscopic dissection is performed
using a periosteal elevator in a plane superficial to the
deep temporalis fascia in the temple and
subperiosteal over the medial forehead. C. Release of
the arcus marginalis and fibrous attachments of the
eyebrow using a periosteal elevator. D. Resection of
the corrugator supercilii using a grasper. E. A fat graft
is harvested to replace the volume of the removed
corrugator supercilii by making a small opening in the
deep temporal fascia cephalad to the medial zygoma
and then harvesting fat with biopsy forceps.

(Reprinted from Guyuron B. Forehead rejuvenation.
In: Guyuron B, Eriksson E, Persing J, eds. Plastic
Surgery: Indications and Practice. Philadelphia, PA:
Saunders Elsevier, 2009:1409-1426, with permission
from Elsevier).
■ Elevation of the periosteum over the glabella and the central portion of the
periosteum will cause the undesirable medial eyebrow elevation.
Uncommonly, there may be significant medial eyebrow ptosis with skin
folding over the radix. If so, dissection of the medial part is necessary. At this
point, the process is repeated on the other side, and hemostasis is achieved
with suction Bovie cautery.
■ To prevent contour deformity, the removed corrugator muscle pieces are
eyeballed to harvest and replace the similar-sized piece of fat at the
corrugator site.
■ Fat is usually harvested from deep temporal fat pad deep to the deep
temporal fascia just above the zygomatic arch using the sharp end of the
curved endoscopic periosteal elevator and grasper.
■ If there is a second procedure to be performed in which there is access to
fat for harvest, this alternate site may be used.
■ Using a curved iris scissors, the harvested fat graft is trimmed to the size of
the removed corrugator muscle. Then, using a periosteal elevator, the graft
is delivered to the corrugator supercilii removal site (TECH FIG 1E).
■ Brow Resuspension
■ Fascial suspension of the forehead is performed next. Usually, one lateral
fascial suspension suture per side is sufficient.
■ Medial suspensions are avoided to prevent the elevation of the medial site.
■ Suspension is usually performed in the most lateral incision after removing
the endoscopic access device, after placement of two single skin hooks at
the junction of the caudal one-third and the cephalad two-thirds of the
incision. While an assistant retracts the wound edges, a 3-0 polydioxanone
suspension (PDS) suture is passed through the galea on two sides of the
incision, and the forehead is suspended from deep temporal fascia after
applying necessary tension. This is done while watching the eyebrow, and

the suture is tied down incrementally until the desired eyebrow position is
reached (TECH FIG 2A,B).
■ If additional fixation is needed to reposition the eyebrow or to correct
asymmetry, a second suspension suture may be placed on the second port
site.
■ A 3-0 PDS suspension suture is passed through the galea on two side of the
incision, and the suture is pulled along the desired vector to confirm the
position where it will be suspended cephalically from the frontal bone after
making a bone tunnel.
■ Skin hooks are placed in the cranial half of the incision by retracting the
scalp laterally and cephalically along the intended vector.
■ A narrow malleable retractor is placed at the posterior edge of the wound to
protect the soft tissue.
■ A 1.1-mm drill bur with a safety guard length of 5 mm is connected to an
office dermabrader.
TECH FIG 2 • A. A 3-0 PDS suture being passed
through the anterocaudal third of the lateral-most
incision. B. The suspension suture passed through the

anterior superficial temporal fascia of the incision is
passed through the deep temporal fascia and then
tied down incrementally to achieve the proper
eyebrow position. C. A bone tunnel is made for
suspension suture anchoring by drilling two 1.1-mm
bur holes 3 to 4 mm apart opposing one another
drilled at 45 degrees to the bone to meet at a depth of
3 to 4 mm. D. The suspension suture is bent to
facilitate its passing through the bone tunnel.
(Reprinted from Guyuron B. Forehead rejuvenation.
In: Guyuron B, Eriksson E, Persing J, eds. Plastic
Surgery: Indications and Practice. Philadelphia, PA:
Saunders Elsevier, 2009:1409-1426, with permission
from Elsevier).
■ A Zimmer-Hall drill may be used to bur two opposing holes. Each hole
should be drilled in at a 45-degree angle to the bone approximately 3 to 4
mm apart to meet at a depth of 3 to 4 mm (TECH FIG 2C).
■ During drilling, the bone is irrigated with saline to minimize thermal
damage. The free end of the PDS needle is bent using a pair of fine
hemostat clamps. The needle is passed through the bony tunnel (TECH
FIG 2D). The suture is tied down incrementally while watching the
eyebrow to achieve the desired eyebrow position. The distance from the
cranial border of the eyebrow to the eyelashes is measured while the eyes
are closed—this distance should be approximately 2.5 cm. These steps are
repeated for suspension on the contralateral side using one or two
suspension sutures, beginning with the lateral most temporal incision.
■ Screws or absorbable fixation devices such as the Endotine Forehead device
can be used for fixation. Disadvantages of screw fixation over the proposed
technique include the short length of the screws limiting penetration into the
skull, the need for extraction of the screw, cost, short duration of fixation, and
potential alopecia around the screw site.
■ Drains are usually not necessary in this procedure. Skin closure is done by
repairing the galea at each incision with buried 5-0 Monocryl suture and skin
with simple interrupted 5-0 plain catgut sutures.

PEARLS AND PITFALLS
Periorbital release and
corrugator resection
■ Complete release of the periorbita and adequate
removal of the corrugator muscles is the most
important factor in guaranteeing a smooth lift and
aesthetically pleasing result.
Preserving the
periosteum and fascia
of the central glabella
■ Transection of the central glabellar attachments can
result in excessive medial eyebrow elevation and a
displeasing eyebrow curvature.
Pre-existing eyebrow
asymmetry requires
differential eyebrow
elevation
■ Pre-existing eyebrow asymmetry will persist
postoperatively and be a source of patient discontent.
■ This can be addressed by intraoperative differential
eyebrow elevation with one to two suspension sutures
per side.
■ Medial forehead suspension sutures are not
recommended.
Hemostasis
■ Meticulous hemostasis with a suction Bovie is
performed while the patient is at baseline preoperative
blood pressure to prevent postoperative bleeding.
POSTOPERATIVE CARE
■ Patients are typically allowed to shower on postoperative day 1 but instructed
not to scrub their forehead or anterior hair-bearing scalp or submerge their head
under water for 2 weeks.
■ Patients are instructed to avoid strenuous activity and manage their blood
pressure at home.
OUTCOMES
■ With proper postoperative care, patients are usually pleased with the results of
their forehead rejuvenation.
■ Pre- and postoperative photographs of the patient’s forehead in repose and
while furrowing their brow can be used to highlight the outcomes of surgery to
the patient at their postoperative visit.

COMPLICATIONS
■ Inadequate, excessive, or asymmetric elevation of the eyebrows (may require
corrective procedures)
■ Dimpling upon animation
■ Alopecia around the incision sites (usually temporary)
■ Persistent paresthesia or temporary weakness due to injury to the temporal
branch of the facial nerve (usually temporary)
■ Persistent and intense itching of the forehead
■ No universally accepted treatment; antihistamines or antiserotonin-type
compounds such as cyproheptadine, may provide some relief
■ Infection
■ Hematoma

22
CHAPTER
Indications and Techniques
for Subcutaneous Lateral
Brow Lifting
Richard J. Warren
DEFINITION
■ Lateral brow ptosis describes an abnormally low position of the lateral third to
one-half of the eyebrow complex.
■ Brow position and shape convey an impression of emotion. When the lateral
portion of the brow turns down, the patient appears sad or melancholy. It is
also associated with aging.1
■ Ptosis of the lateral eyebrow encroaches on the upper lid sulcus, changing the
dynamics of the upper lid/brow junction. Thus, lateral brow ptosis will affect
the assessment of patients who present for blepharoplasty, periorbital fat
grafting, or senile eyelid ptosis repair.
ANATOMY
■ Please refer to the anatomy section of the coronal brow lift chapter.
■ The position of the lateral brow depends on two main issues: muscle anatomy
and the firmness of soft tissue attachment.
■ The level of the lateral eyebrow is the result of a balancing act between the
muscular forces that elevate the brow and the muscular forces that depress the
brow, along with the universal depressor, gravity (FIG 1).
■ The frontalis is the only elevator of the eyebrow. It originates from the galea
aponeurotica superiorly and interdigitates inferiorly with the upper orbicularis.
Contraction raises this muscle mass and the overlying eyebrow, which is a
cutaneous structure. The muscle is deficient laterally and nonexistent lateral to
the temporal crest line, so its primary lifting effect is exerted on the medial and
central portions of the eyebrow.

FIG 1 • The frontalis is the only muscle which lifts the
eyebrow complex. On contraction, most of the
movement occurs in the lower third of the muscle, and
this action is strongest in the medial and central
eyebrow. Laterally, frontalis action is weaker and is
completely absent lateral to the temporal crest line. The
orbicularis oculi acts like a sphincter surrounding the
orbit. Laterally, it pulls the tail of the brow inferiorly.
■ The primary muscular depressor of the lateral eyebrow is the orbicularis that
encircles the orbit acting like a sphincter. Its action on the lateral brow can be
temporarily reversed with botulinum toxin.
Sensory Nerves
■ Innervation to the lateral brow and forehead is supplied by the supraorbital
nerve that divides into two segments after it exits the orbit: the superficial and
the deep branches.
■ The superficial branches of the supraorbital nerve run on the superficial
surface of the frontalis muscle and are visible when a subcutaneous flap is
raised. These nerves innervate the forehead and the first 2 cm of the hair-

bearing scalp. The rest of the scalp, back to the vertex, is innervated by the
deep branch that courses laterally and is deep to the frontalis muscle.
Motor Nerves
■ The temporal branch of the facial nerve crosses the middle third of the
zygomatic arch as two or three branches. These branches are entirely deep to
the frontalis muscle and are on the underside of the superficial temporal fascia.
Therefore, they are completely safe during the raising of a subcutaneous
forehead skin flap.
Vessels
■ The anterior branch of the temporal artery and accompanying veins coursing
superficial to the frontalis muscle and the superficial temporal fascia. These
may require cauterization during the raising of a subcutaneous forehead flap.
PATHOGENESIS
■ Please refer to the pathogenesis of eyebrow ptosis in the coronal brow chapter.
■ The desired eyebrow shape and position vary with ethnicity, gender, and the
era in which we live. In this era, the elevated lateral eyebrow is the preferred
configuration with the lateral end of the eyebrow ideally being higher than the
medial end.
■ As mentioned, the lateral portion of the eyebrow has two causes for inferior
displacement (lateral orbicularis contraction and gravity) balanced against the
only force that can lift: the frontalis. Despite this apparent imbalance, many
patients (40% in one study) do not develop lateral brow ptosis over time.2 The
likely explanation for their brow stability is the strength of the underlying soft
tissue attachments.
■ Soft tissue fixation to bone is inconsistent in the lateral eyebrow. Laterally
along the supraorbital rim, the galeal fat pad is separated from the preseptal fat
(ROOF, retro orbicularis oculi fat) by one of the layers of galea. However, in
the lateral brow, this galeal layer is thought to be variable, with some
individuals having limited soft tissue attachment to bone. As a result, the galeal
fat pad is contiguous with the preseptal fat (ROOF), and the lateral brow is
relatively free to descend over time.3
■ Many patients who develop lateral brow ptosis do so as a relatively early sign
of facial aging.
PATIENT HISTORY AND PHYSICAL FINDINGS

■ Please refer to the patient history and physical examination in the coronal
brow chapter (Chapter 20).
■ Patients with lateral brow ptosis may present with a request for upper eyelid
blepharoplasty, or they may request a facelift procedure, hoping it will improve
their brow position. Both scenarios provide the surgeon with an opportunity to
teach the patient about the dynamics of eyebrow aging.
■ The laxity of the lateral forehead skin is assessed by manually manipulating
the tail of the brow. Patients best suited for a subcutaneous lateral brow lift are
those with loose skin and a relatively lax attachment between their lateral
forehead skin and the underlying frontalis and superficial temporal fascia.
■ The eyebrow itself is a cutaneous structure, and shifting the deep plane tissues
with a deeper procedure may not translate well to the overlying skin if that skin
is loose. Conversely, a successful procedure to shift the skin will directly shift
the eyebrow.
■ The ptotic lateral eyebrow is a common physical finding in the patient
demographic who seek facial rejuvenation surgery. Consequently, a
subcutaneous lateral brow lift can be an excellent adjunctive procedure for the
patient who is a candidate for a facelift or blepharoplasty (FIG 2).
FIG 2 • This 56-year-old woman presents for
blepharoplasty and facelift surgery. She has
downturned lateral eyebrows that were not present in
youth. The position of her medial and central brow is
well maintained. In conjunction with the procedures she
is requesting, a repositioning of the lateral eyebrows will
be a useful adjunctive procedure.

■ An examination of the temporal hairline will often demonstrate a triangular
widow’s peak where the hair is thin; this can be an ideal area to extend a
hairline incision into the peak laterally.
NONOPERATIVE MANAGEMENT
■ Nonoperative strategies to elevate the lateral eyebrow include the following:
■ Nonmedical: eyebrow plucking, cosmetic makeup, tattooing
■ Medical: botulinum toxin injection to the lateral orbicularis and the medial
brow depressors, thread lifting
SURGICAL MANAGEMENT
Preoperative Planning
■ The planned repositioning and degree of eyebrow elevation are reviewed with
the patient who may have specific requests regarding eyebrow position and
shape.
■ The location of the hairline will affect the incision planning. The normal
hairline will lend itself to an incision along the anterior hairline in the widow’s
peak area. Patients with a low hairline may benefit from an incision behind the
hairline, which will shift the anterior hairline posteriorly. Patients in whom the
temple hairline is positioned above (superior to) the lateral eyebrow may
benefit from an incision placed in the temple hair.
■ The presence of transverse forehead lines and the quality of forehead skin is
assessed. The patient with thick corrugated skin may benefit from an incision
made in a transverse forehead crease. This is often the case with middle age or
older men.
■ With the patient awake in the upright position and the forehead in repose, the
desired amount and direction of lateral eyebrow elevation are assessed by
manually elevating the lateral eyebrow. A mark is made on the skin, and the
eyebrow is allowed to drop, thus determining the degree of elevation required.
■ The most effective vector for eyebrow advancement is determined when the
examiner manually repositions the brow. Most commonly, the desired vector
runs along the axis of the temporal crest line.
Positioning
■ The patient is placed on the operating table in the supine position with the
head on a small pillow or soft donut.

■ The head of the bead is raised slightly to help reduce venous engorgement.
Approach
■ As described for preoperative planning, possible locations for subcutaneous
lateral brow lifting are
■ At the hairline
■ Just behind the hairline
■ Lateral extension of a transverse forehead line
■ Directly adjacent to the eyebrow (FIG 3)
■ All of these approaches are “skin deep” with varying degrees of subcutaneous
dissection. For the first three incisions (hairline, behind the hairline, transverse
forehead line), the dissection plane is subcutaneous, immediately superficial to
the frontalis muscle. In the fourth option (adjacent to eyebrow), there is no skin
undermining.
FIG 3 • Incision options for subcutaneous brow lifting

are shown. An incision posterior to the hairline involves
the removal of hair-bearing skin posterior to the
incision. An incision at the hairline involves the removal
of forehead skin inferior to the incision. The transverse
crease incision involves subcutaneous dissection on the
eyebrow side of the incision, with skin excision on the
inferior side of the crease. The direct brow incision does
not involve undermining. The ideal vector for lateral
eyebrow lifting is shown. This will be slightly different in
every case but typically will follow the temporal crest
line.
■ The farther away from the eyebrow the incision is made, the less effective a
subcutaneous lift will be.
■ In planning the skin resection, the author’s clinical experience has determined
a “rule of thumb”: at the time of surgery, an incision directly adjacent to the
eyebrow will initially raise the eyebrow in a 1:1 ratio to the width of skin
excised. An incision in the mid forehead will raise it in a 1:2 ratio, and an
incision at the hairline will raise the eyebrow in a 1:3 ratio, or even 1:4,
depending on the height of the forehead and the elasticity of the skin. In
addition, over the first few months, there is always some relapse of lateral brow
height that in some cases approaches 50% of the lift achieved at the time of
surgery. Firm, thick forehead skin provides a more durable result than thin aged
skin.
■ Incisions posterior to the hairline are potentially the least visible but introduce
the possibility of damaging hair follicles. Also, they will result in a slightly
raised hairline.
■ Incisions at the hairline are potentially visible but will not shift the hairline.
■ Incisions in deep forehead lines provide a powerful lift and are potentially very
well hidden, depending on the depth of the existing fold.
■ Incisions adjacent to the eyebrow provide the most powerful lift of the various
subcutaneous options. The scar can be well hidden when eyebrows are full or
when there is an adjacent transverse fold in which to hide the scar.

T E C H N I Q U E S
■ Anterior Hairline Approach
Markings and Anesthesia
■ The preoperative markings are done prior to surgery with the patient awake
and in the upright position.
■ The essential preoperative markings include the planned incisions and the
desired vector for flap movement (TECH FIG 1).
■ The incision length is determined by the length of the eyebrow and the
amount of eyebrow to be lifted. This maybe just the tail or, possibly, the
entire lateral half of the brow.
■ Because of variability in desired lifting vectors as well as hairline variability,
there is variability in the incision location. Every case is customized.
Normally, the incision starts medially at the mid pupillary line and extends
laterally from there over a distance of 3 to 6 cm in length, entering the
temporal scalp. If a widow’s peak is present, the incision follows the hairline
into the peak.
■ The procedure is done under local anesthetic with or without sedation.
■ The head and neck area is prepped and draped with exposure of the entire
face.
■ A local anesthetic mixture composed of 1% lidocaine with 1:100 000
epinephrine and 0.25% bupivacaine with 1:200 000 epinephrine is infiltrated
into the superior incision line, along the supralateral orbital rim and in a
hydrodissection manner, into the subcutaneous space between these two
zones.

TECH FIG 1 • A. Preoperative marking is done with
the patient upright and with the frontalis in repose. The
planned incision is marked. In this case, the incision
location is the anterior hairline, with a planned skin
ellipse inferior to that. The vector for the lateral brow
lift is marked. As in this case, the preferred vector is
often along the temporal crest line. B. The planned
incisions and skin removal as seen from above.
Incision and Dissection
■ After waiting for the epinephrine effect, the incision is made a few hairs
posterior to the hairline. The scalpel is beveled in such a way that the hair
follicles will be partially transected, utilizing the Camirand principle.4
■ The incision stops when the frontalis is visualized. Dissection then turns
inferiorly, following the superficial surface of the frontalis (TECH FIG 2A).
■ Initially, dissection is sharp, using fine scissors, but after 1 to 2 cm,
Metzenbaum scissors can be used with a gentle spreading motion, with tips
up toward the skin (TECH FIG 2B). Blunt finger dissection deeper in the
dissection pocket is a useful adjunct (TECH FIG 2C).
■ Care is taken to identify and protect the superficial branches of the
supraorbital nerve that will be running on the superficial surface of the
frontalis muscle.
■ Subcutaneous veins may require cauterization, and the anterior branch of the
temporal artery may be protected or, if necessary, cauterized.
■ Laterally, dissection is taken down the upper third of the lateral orbital rim.
Suturing and Completion
■ The transverse running fibers of the orbicularis oculi will normally be
visualized. A 5-0 or 4-0 Vicryl or similar suture is then used to pexy the
orbicularis to a higher point on the frontalis muscle, using two or three
sutures (TECH FIG 3).
■ Another option is to place similar sutures from the underside of the skin flap
to the frontalis muscle, shifting the skin flap superiorly with progressive
tension sutures.5
■ Once internal suturing is done, the undermined flap is advanced superiorly

over the cut edge of the scalp incision.
■ The degree of overlap is marked and excess skin is removed from the
inferior (undermined) side of the incision. Normally, the width of skin
excision is in the range of 1.5 to 2.5 cm, depending on the age of the patient
and the laxity of their skin.
■ Repair of the scalp incision is done with 5-0 nylon sutures.
■ A bupivacaine block is done across the supraorbital rim, targeting the
supratrochlear and supraorbital nerves.
■ The incision is left open with ointment applied along the suture line.
■ In vascular cases, a light pressure dressing can be placed over the forehead,
and an elastic head wrap can be put in place for 1 hour.
TECH FIG 2 • A. After carefully beginning the
dissection, branches of the supraorbital nerve will be
seen lying on the surface of the frontalis muscle.
Dissection continues inferiorly as far as the eyebrow.
B. Metzenbaum scissor dissection. C. Finger
dissection.

TECH FIG 3 • The placement of internal pexy sutures
is an optional maneuver, especially in those cases
where the eyebrow is very mobile. Two sutures (5-0
Vicryl, 4-0 Vicryl or equivalent) are placed from the
transverse running fibers of the orbicularis to a higher
level on the frontalis. Similar sutures can be used from
the underside of the skin flap in a progressive tension
fashion.
■ Posterior to the Hairline Approach
Incisions and Dissection
■ This procedure is identical to the hairline approach, except that the incision
is placed in hair-bearing scalp, 1 cm posterior to the anterior hairline.
■ Consequently, the incision will follow the hairline and will usually be a
gentle S-shaped incision following the hairline (TECH FIG 4).
■ This incision is well suited for the patient with a hairline close to the tail of
the eyebrow, where a modest shift of the hairline is not a problem and where
a scar within the hair will be less visible than one at the leading edge of a low

hairline.
■ This incision is also helpful when the natural nap of hair lies in such a way
that the anterior hairline incision scar would not be well hidden by the hair.
■ The incision is made with the scalpel blade kept parallel to the hair follicles
in order to preserve the hairs in the flap.
■ Flap dissection toward the eyebrow is done on the superficial surface of the
frontalis (or if the incision is lateral, on the superficial temporal fascia).
TECH FIG 4 • Markings designate an incision within
the hairs of the temple behind the hairline. Following
the hairline down into the temple, the inferior
dissection will be done deep to the hair follicles and
will then proceed subcutaneously the short distance to
the eyebrow. After flap advancement along the
planned vector, hair-bearing skin will be removed
posterior to the planned incision. This marking
designates the desired vector of lift and the planned
incision. In this case, the incision is being placed
within the fine hairs of the temple and skin excision
will be done posterior to the incision.
■ For the first 1 cm of dissection, care is taken to stay deep, directly on the
frontalis and/or superficial fascia, to protect the hair follicles. Dissection is
done with a scalpel or fine dissecting scissors
■ After the first 1 cm, the hair follicles are no longer at risk, and dissection can

continue inferiorly in the subcutaneous plane, in the same fashion as with the
anterior hairline approach.
Suturing and Completion
■ As with the anterior hairline approach, deep sutures may be placed to help
with flap advancement superiorly.
■ At the incision line, the overlapping flap is placed against the scalp, and the
amount of overlap is marked.
■ Excess scalp skin is then removed from the posterior (cranial) side of the
incision.
■ Scalp resection is done with the blade beveled to partially transect hair
follicles. On closing the incision, the anterior hairline will be preserved but
will be shifted slightly posteriorly.
■ Occasionally, because of variations in a patient’s hairline, this incision can
be broken up into two separate incisions behind different parts of the hairline.
■ This provides excellent exposure and two different lifting vectors for the
lateral brow (TECH FIG 5).
TECH FIG 5 • In this case, due to the shape of the
hairline, two shorter incisions placed behind the
hairline, each 2.5 cm in length, have been used for
access. The subcutaneous flap has been raised, and
the skin will be advanced superiorly and obliquely
along two different vectors. Skin excision will be
superior to the incision.

■ Transverse Forehead Line Approach
■ Preoperative surgical markings are done in the upright position (TECH FIG
6).
■ The procedure is done under local anesthetic with or without sedation.
■ The head and neck area is prepped and draped with exposure of the entire
face.
■ A local anesthetic mixture composed of 1% lidocaine with 1:100 000
epinephrine and 0.25% bupivacaine with 1:200 000 epinephrine is infiltrated
into the planned incision site and 1 to 2 cm inferior to that.
■ After waiting for the epinephrine effect, the initial incision is made and the
planned ellipse of skin is removed.
TECH FIG 6 • This 68-year-old man has deep
transverse forehead lines. Preoperative markings
designate three locations for transverse crease
incisions with elliptical skin excisions inferior to the
crease incisions.
■ The inferior skin is then undermined for several millimeters, using a scalpel
in the subcutaneous plane, freeing it from its attachment to the underlying
frontalis.
■ This incision is closed meticulously, using interrupted 6-0 or 5-0 permanent
sutures.
■ The incision is left open with ointment applied along the suture line.

■ Direct Eyebrow Incision
■ Preoperative surgical markings are done.
■ There are two possible incision locations for a direct eyebrow lift.
■ Directly adjacent to the eyebrow, cutting parallel to the hairs, and excising
an ellipse of skin above (superior) to that
■ Within the lowest transverse fold which is near the eyebrow, excising an
ellipse of skin below (inferior) to that
■ The procedure is done under local anesthetic with or without sedation.
■ The head and neck area is prepped and draped.
■ A local anesthetic mixture composed of 1% lidocaine with 1:100 000
epinephrine and 0.25% bupivacaine with 1:200 000 epinephrine is infiltrated
into the planned incision site.
■ After waiting for the epinephrine effect, the inferior incision is made directly
adjacent to eyebrow hair follicles, taking care to bevel the blade accurately
along the axis of these hairs.
■ No flap undermining is done.
■ The planned ellipse of full-thickness skin is excised.
■ The incision is closed meticulously, using 5-0 Vicryl (or similar) in the deep
dermal layer and a fine suture in the skin, either a running subcuticular 5-0
nylon or interrupted 6-0 Prolene sutures.
■ The incision is left open with ointment applied along the suture line.
PEARLS AND PITFALLS
Incision
choice
■ Choose the anterior hairline approach when the forehead skin is
mobile and the anterior hairline is high.
■ Choose an incision behind the hairline when the hairline is low and
the patient is averse to a potentially visible scar.
■ Choose the transverse fold incision when forehead skin is thick and
deep transverse folds are present.
■ Choose the direct brow lift when there is a bushy eyebrow or when
there is a deep nearby fold in which to hide the scar.
Suturing
■ All these procedures require very careful suture closure to

minimize the chance of a visible scar.
Tension
■ For an incision in the vicinity of the anterior hairline, excess
tension can create a widened scar and can lead to skin necrosis,
especially in smokers.
Predictability
■ The longevity of a subcutaneous brow lift is somewhat
unpredictable due to the inherent elasticity of skin.
POSTOPERATIVE CARE
■ The patient is encouraged to keep the head elevated for the first week to
decrease swelling.
■ Sutures are removed 5 to 6 days postoperatively.
■ At 7 to 10 days postoperatively, botulinum toxin can be injected into the lateral
orbicularis to reduce the brow depressing effect of the lateral orbicularis during
the healing phase.
OUTCOMES
■ These subcutaneous procedures are all relatively simple. The operative time is
short, and they can be done under local anesthetic in the day surgery setting. In
appropriately selected cases, they accomplish the same objective as much more
involved procedures such as open brow lifts or endoscopic brow lifts.
■ Overall patient satisfaction is very high, and serious complications are rare.6–10
■ Clinical experience does demonstrate a degree of unpredictability with respect
to the magnitude of brow lift achieved and longevity of the surgical result.
However, this issue is common to all brow elevation procedures.
COMPLICATIONS
■ Subcutaneous procedures are truly “skin deep, and therefore they avoid
potential damage to deeper anatomic structures. The biggest concern with
subcutaneous brow lift procedures is the potential of visible scarring, but
multiple series have demonstrated that this is not a problem reported by
patients.6,7
■ A recent series of subcutaneous lateral brow lifts report no cases with seromas,
hematomas, infection, or nerve damage, either sensory or motor.5
■ Accurately predicting the amount of relapse is a problem with subcutaneous
brow lifting as it is with all brow lift procedures. Relapse is more likely to
occur in patients with lax tissues and when the incision is relatively far
removed from the eyebrow.

■ Scar alopecia can occur along the incision line when sutures are placed in hair-
bearing skin with excessive tightness.
REFERENCES
1. Knoll BI, Attkiss KJ, Persing JA. The influence of forehead, brow, and
periorbital aesthetics of perceived expression in the youthful face. Plast
Reconstr Surg. 2008;121:1793-1802.
2. Lambros V. Observations on periorbital and midface aging. Plast Reconstr
Surg. 2007;120:1367-1376.
3. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis.
Plast Reconstr Surg. 1996;97(7):1321-1333.
4. Camirand A, Doucet J. A comparison between parallel hairline incisions and
perpendicular incisions when performing a face lift. Plast Reconstr Surg.
1997;99(1):10-15.
5. Pollock H, Pollock TA. Subcutaneous brow lift with precise suture fixation
and advancement. Aesthet Surg J. 2007;27(4):388-395.
6. Bidros RS, Salazar-Reyes H, Friedman JD. Subcutaneous temporal browlift
under local anesthesia: a useful technique for periorbital rejuvenation. Aesthet
Surg J. 2010;30(6):783-788.
7. Miller TA, Rudkin G, Honig M, et al. Lateral subcutaneous brow lift and
interbrow muscle resection: clinical experience and anatomic studies. Plast
Reconstr Surg. 2000;105(3):1120-1127.
8. Miller TA. Lateral subcutaneous brow lift. Aesthet Surg J. 2003; 23(3):205-
210.
9. Mahmood U, Baker JL. Lateral subcutaneous brow lift: updated technique.
Aesthet Surg J. 2015;35(5):621-624.
10. Bernard RW, Greenwald JA, Beran SJ, Morello DC. Enhancing upper lid
aesthetics with the lateral subcutaneous brow lift. Aesthet Surg J.
2006;26(1):19-23.

23
CHAPTER
Lowering the Overelevated
Brow
Michael J. Yaremchuk, Erez Dayan, and Dev Vibhakar
DEFINITION
■ Brow lift procedures can create brows with positions much higher and
configurations much different than those seen in youth. This results in an older
appearance, with hollowed upper lids and a raised hairline (FIG 1).1,2
■ Brow lifts that preferentially elevate the medial brow and increase the distance
between the medial brows create an unnatural, surprised, and unintelligent
look.1–3
ANATOMY
■ The ideal youthful eyebrow in women has been described as an arch where the
brow apex terminates above the lateral limbus of the iris. The medial and
lateral ends of the brow should be at the same horizontal, located at or below
the supraorbital rim, not above it.
■ Men have a flatter-shaped, lower-placed brow.4
■ With aging, the gravitational descent of the medial two-thirds of the brow is
often camouflaged by the reflexive action of the frontalis muscle to counteract
upper lid descent. This lid descent results from the senile dehiscence of the
levator muscle. Because the lateral aspect of the brow extends beyond the
frontalis territory, it descends. As a result, brows often elevate with aging. As
described by Garcia and Matros, brow shape may change from an apex lateral
slant to an apex neutral position1 (FIG 2).
PATHOGENESIS
■ Brow lift procedures can raise the brow to positions higher than they existed in
youth. Because the medial brow often elevates with aging, exaggerated brow

lifts often have an aging effect due to this brow position.1,2
FIG 1 • Patient after brow lift with overelevated,
flattened, and widened brow. Also, note elevated
hairline and hollow upper lids.
■ Over elevation of the brows also tends to decrease upper lid redundancy by
exaggerating the hollow eyes of senility and accentuating lid ptosis.2
■ Removal of the corrugator muscles in an attempt to eliminate glabellar frown
lines allows the medial brows to separate and elevate.
■ Overelevation of the brows may result in an unacceptably high hairline. This
may disrupt the proportional balance of the horizontal zones of the face.
Hairline elevation can also reflect senility.1,2
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Physical examination should focus on the forehead and periorbital area and its
relation to the balance of the face. Analysis should document the height of the
forehead, shape and position of the brows, depth of the upper lid sulcus, upper
lid position, and levator function.
■ History should focus on elements related to the periorbital area, including
method and date of the brow lift surgery; periorbital surgeries or procedures
including neurotoxins, fillers, and fat injections; and ocular health.
IMAGING
■ Photographs documenting pre–brow lift appearance should be obtained.
SURGICAL MANAGEMENT

Preoperative Planning
■ Informed consent should include intrinsic risks related to brow and hairline
repositioning. These include infection, asymmetry, alopecia, and motor/sensory
nerve injury.
■ Preoperatively, with the patient both in the upright and supine position, the
distance of the medial brow and the central hairline is measured in relation to
the intercanthal line. The distance change to accomplish the desired locations is
recorded.
■ The authors’ preference is to use general endotracheal or nasotracheal
anesthesia. This allows optimal preparation of the operative site and control of
the airway.2
Positioning
■ Patients are placed supine on the operating room table at a 90-degree
perpendicular position relative to the anesthesiologist for maximal exposure.
FIG 2 • A. In young patients, the medial brow is the
lowest point or apex lateral slant. B. In older patients,
the medial brow elevates, creating an apex neutral
brow. This levels the brow in older patients, generating
a flat appearance compared to the peaked brow of
younger patients.
T E C H N I Q U E S
■ Preparation
■ Prior to antiseptic preparation and draping, a dilute solution of lidocaine and

epinephrine (1:200 000) is infiltrated into the operative site for postoperative
pain control and intraoperative hemostasis.
■ Intravenous cephalosporin or ciprofloxacin antibiotic prophylaxis is
administered approximately 30 minutes preoperatively.
■ Incisions
■ Bicoronal incisions are used for both previously performed open or closed
(endoscopic) brow lift procedures. The incision is made to re-elevate the
anterior scalp flap in a subperiosteal plane down to the supraorbital rim and
just beyond the nasofrontal suture.
■ If in the preoperative evaluation it was determined that the frontal hairline
was high prior to the brow lift, a hairline incision may be used.
■ After scalp incision and before flap elevation, the skull is scored with a drill
directly beneath the scalp incision. The position of the anterior hairline is
similarly marked. These marks serve as reference points during hairline and
scalp repositioning (TECH FIG 1).

TECH FIG 1 • Coronal incision with register for hairline
and Mitek anchors for medial brow positioning.
■ Brow Repositioning
■ The anterior scalp flap is freed by subperiosteal dissection well onto the
nasal root medially and the supraorbital rims laterally.
■ The brow is repositioned relative to the medial canthus with Mitek anchoring
system.
■ The Mitek anchor is secured in the frontal bone at the desired distance
(usually 15–18 mm) directly above each medial canthus. This places the
anchors near the level of the nasofrontal suture. The inevitable penetration of
the frontal sinus by this anchor is of no clinical significance.
■ The nasofrontal suture is easily palpable through the skin and clearly visible
when the scalp flap is reflected, and it is a useful reference when positioning
the Mitek anchor.

■ A 19-gauge needle is positioned at the most inferomedial aspect of the brow
and passed through the scalp flap. This marks the area for Mitek anchor
suture purchase (TECH FIG 2).
■ The sutures are then tied, securing the posterior aspect of the flap and, hence,
the medial aspect of the brow on its anterior surface to the desired position.
■ Depending on the plan, this technique repositions the medial brow 3 to 8 mm
inferiorly and 1 to 3 mm medially.
TECH FIG 2 • Anchoring the medial brow using
transcutaneous needle (A) and Mitek anchor (B).
■ The midbrow and lateral brows are repositioned as determined by patient
preference. Most often, an “apex lateral slant” appearance is created through
manipulation of the lateral aspect of the scalp flap. This position is secured
by suturing the galea beneath the hair-bearing skin over the tail of the brow to
the deep temporal fascia.
■ With the incision and hairline registration marks placed earlier as a
reference, the anterior hairline is repositioned. This position is secured with
Mitek anchor scalp fixation to the skull positioned just off the midline to
avoid possible sagittal sinus penetration. Cortical tunnels are an alternative to
anchors in providing a stable fixation point for suturing to the skull.
■ Posterior Scalp Flap Advancement
■ Brow and hairline lowering inevitably leaves a gap between the anterior and
posterior scalp flaps.

■ In patients who have had their brow lift surgery performed endoscopically,
no scalp is removed and the gap reflects tissue repositioned posteriorly.
■ Sufficient tissue can be recruited from the posterior flap by widely
undermining it back to the occiput and advancing it anteriorly.
■ In patients who have had their brow lift surgery performed through an open
approach, the gap reflects scalp that has been excised. Filling this defect
requires serial scoring of the galea to expand the scalp surface area, as well as
wide undermining and posterior scalp advancement.
■ It is sometimes necessary to elevate the posterior scalp flap beyond the
occiput to obtain sufficient posterior scalp flap length and forward
movement.
■ Closure
■ Prior to closure, a thin suction drain is placed immediately above the
supraorbital rim.
■ Closure is achieved in two layers with inverted dermal sutures and nylon
skin sutures.
■ Using the nasal dorsum as a point of fixation, the medial brow is taped in the
desired position prior to initiating the suction apparatus. These measures are
intended to control scalp flap adherence and, hence, desired brow position.
PEARLS AND PITFALLS
Apex lateral
vs apex
neutral slant
■ Younger patients have a medial brow that is low with the apex of
the brow positioned lateral (at the lateral limbus). Older patients
have an elevated medial and middle brow, which contributes to a
flattened or apex neutral appearance.
Hairline
repositioning
■ Scoring the calvarium at the scalp incision and hairline provides
useful landmarks for subsequent hairline repositioning.
Medial brow
positioning
■ The nasofrontal suture is a useful landmark for medial brow
repositioning.
Brow and
■ Mitek anchoring sutures and cortical tunnels are valuable fixation

scalp
fixation
methods to maintain the desired reposition of the scalp flap.
FIG 3 • A,B. Brow lift reversal was performed using a
hairline incision in this patient who preoperatively had a
high forehead. The patient also underwent infraorbital
rim augmentation, subperiosteal midface lift, and lateral
canthopexy. C,D. This patient underwent brow lift
reversal and subperiosteal midface lift. E,F. This patient
underwent brow lift reversal.
POSTOPERATIVE CARE
■ The drain is removed the morning after surgery.
■ Oral antibiotics are prescribed for 3 to 5 days after surgery.
■ Patients are instructed to refrain from strenuous exercise for 2 to 3 weeks
postoperatively.
■ Sutures are removed at 7 to 10 days after surgery.
OUTCOMES
■ In the senior author’s experience of reversing brow lifts, the medial brow is
typically lowered 4 to 10 mm (average 5 mm) relative to the intercanthal line
and the anterior hairline is lowered 5 to 18 mm (average 10 mm).
Repositioning of the brow has remained clinically stable during follow-up, and
no revisional surgery to reposition the brow or hairline has been requested
(FIG 3).
COMPLICATIONS
■ Postoperative complications are rare following lowering of the over elevated

brow and tend to involve concerns over asymmetry and temporary sensory
nerve dysfunction.
■ Areas of temporary and rarely permanent alopecia in the posterior scalp flap
after galeal scoring are a potential complication after using this technique.
Rogaine may be helpful in stimulating regrowth in these instances.
■ Soft tissue redundancy may develop in the glabellar area after flap lowering,
particularly in those patients who have had extensive corrugator resection
during their brow lift surgery.
■ Brow asymmetry may result with animation when corrugator resection was
uneven during the initial brow lift surgery.
REFERENCES
1. Matros E, Jesus G, Yaremchuk MJ. Changes in eyebrow position and shape
with aging. Plast Reconstr Surg. 2009;124:1296-1301.
2. Yaremchuk MJ, O’Sullivan N, Benslimane F. Reversing brow lifts. Aesthet
Surg J. 2007;27:367-375.
3. Gunter JP, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr
Surg. 1997;99:1808-1816.
4. Freund RM, Nolan WB III. Correlation between brow lift outcomes and
aesthetic ideals for eyebrow height and shape in females. Plast Reconstr Surg.
1996;97:1343-1348.

24
CHAPTER
Indications and Techniques
for Transpalpebral
Corrugator Resection
Ximena A. Pinell-White and Foad Nahai
DEFINITION
■ Horizontal glabellar frown lines result from contraction and hypertrophy of the
corrugator supercilii and transverse lines from procerus muscle activity.
Commonly, these central glabellar changes are also associated with lateral
brow ptosis.
ANATOMY
■ The paired corrugator supercilii muscles originate from the superomedial
brow, traverse the galeal fat pad, and insert on the skin of the central brow. The
corrugator muscles lie deep to the procerus and frontalis muscles. Contraction
depresses the central brow, creating vertical and oblique glabellar rhytids (FIG
1).
■ The procerus muscle takes its origin in the lower nasal bone and inserts into
the skin overlying the nasal root. Contraction depresses the central brow and
creates a transverse line at the nasal bridge.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The procerus and corrugator muscles can be identified by asking the patient to
frown.
■ It is important to distinguish between dynamic lines, which are evident only on
animation, and static rhytids, which are uniformly present and are more
challenging to correct. The Glogau classification of photoaging describes the
severity of actinic changes based on the degree of skin wrinkling.
■ Dynamic lines represent early to moderate photoaging (Glogau class II) and

generally respond to less invasive procedures such as injection of neurotoxins.
■ Static wrinkles, on the other hand, indicate more advanced photodamage
(Glogau class III) that will often require surgery.
NONOPERATIVE MANAGEMENT
■ Injection of neurotoxins is most effective in relaxing the muscles to
temporarily eliminate glabellar rhytids. Etched or deep lines may also be
improved with resurfacing or injections of fillers.
SURGICAL MANAGEMENT
■ Glabellar frown lines can be addressed through an upper eyelid blepharoplasty
incision in patients with little or no medial brow ptosis and no excess skin
above the nasal radix. In patients with significant lateral brow ptosis, the
procedure can be paired with a lateral temporal brow lift.
FIG 1 • Anatomy of the glabellar muscles.
Preoperative Planning

■ The patient is marked preoperatively for an upper lid blepharoplasty. He or she
is asked to frown to identify and mark the glabellar muscles. Note is made if
the procerus should be divided.
Positioning
■ The patient is positioned supine with slight elevation of the head.
Approach
■ A transpalpebral approach to the glabellar muscles is employed at the time of
upper lid blepharoplasty.
T E C H N I Q U E S
■ Transblepharoplasty Excision of Corrugator and
Procerus Muscles
Incision and Dissection
■ Upper lid blepharoplasty incisions are made, and the upper eyelid skin and,
when indicated, muscle are excised.
■ Any planned fat removal is deferred until after the glabellar muscles are
excised so as to facilitate dissection of the orbicularis off of the orbital
septum.
■ The dissection is then continued superiorly, deep to the orbicularis muscle.
■ The depressor supercilii portion of the orbicularis is divided to expose the
diagonal and more deeply colored fibers of the corrugator muscle at the
superior orbital rim (TECH FIG 1A).
■ Our preference is to dissect with the cutting current of a Colorado tip needle.
■ The supraorbital and supratrochlear nerves are visualized at this stage
(TECH FIG 1B). The supraorbital nerve is more lateral and tends to be
singular, larger, and in front of the muscle, whereas the supratrochlear nerve
arborizes early and interdigitates with the fibers of the corrugator medially.
Muscle and Fat Excision
■ After the nerves are identified and protected, a mosquito clamp is passed
around the corrugator muscle to elevate it centrally (TECH FIG 2A).

■ A portion of the muscle is resected using electrocautery so as to leave a
central gap. More muscle is taken from the lateral cut edge when the
corrugators are particularly hypertrophied (TECH FIG 2B).
■ There are often veins coursing with the nerves that should be avoided but
when necessary can be cauterized with bipolar forceps. The trochlea of the
superior oblique muscle tendon can theoretically be injured during
dissection in the superomedial corner of the orbit, but this is rare and can be
avoided by limiting dissection behind the origin of the corrugator.
■ Patients with transverse dorsal nasal lines benefit from division of the
procerus muscle.
■ This is accomplished by elevating the orbicularis muscle medially,
directing a pair of scissors toward the nasal radix, and cutting the procerus
muscle fibers just beneath the skin (TECH FIG 3).
■ This is a blind procedure and is often accompanied by some bleeding,
which can easily be controlled with pressure.
■ Fat removal from the upper lid can be performed if desired at this point, and
the incision closed.
■ On occasion, I may place a small 5×5 mm piece of fat, harvested from the
nasal fat pocket, in between the remaining edges of the corrugator. This
would be to avoid a depression following removal of sections of the
muscle.
TECH FIG 1 • A. Identification of the corrugator
supercilii muscle. B. Location of the supraorbital and
supratrochlear nerves.

TECH FIG 2 • A. Division of the corrugator muscle. B.
Appearance of corrugator after resection of central
segment.
TECH FIG 3 • Division of the procerus muscle.
PEARLS AND PITFALLS
Incomplete
■ It is important that full-thickness portions of the muscle are removed.