Brow and Forehead Lift: Form, Function, and Evaluation

The brow and forehead complex is a unique structure in that it not only conveys the aesthetics of youth and aging but is also essential in communication. The mimetic upper facial muscles and periorbital region convey diverse nonverbal communication. We frequently “talk” with our brows and forehead. Raising the brow can signal a question or surprise; contracting and depressing the brow and forehead can signal aggression or displeasure; raising a single brow can question sincerity, and so on. Changing the brow and forehead complex with surgery or neuromodulators can either enhance aesthetics or make a person look unnatural. I believe that fewer browlifts are being performed today because of the overcorrected “deer in the headlights” look seen with so many celebrities. A subtle brow and forehead lift can make a patient look younger and refreshed, while an overdone browlift can look hideous. Patients are aware of this, and many are reticent to undergo browlift because an overcorrected brow is one the worst cosmetic deformities.

The idea that all beautiful women have elevated brows is a fallacy. Look at any fashion or model magazine, and you will see beautiful women with elevated brows and low-sitting brows. Not every patient with low brows looks “better” with them elevated. The brow and forehead region thus must be carefully diagnosed in consultation.

To give the patient (and surgeon) a chairside prediction of the possible result, the brow can be simply elevated with the surgeon’s finger while the patient looks in the mirror. Using clear tape on the brow and forehead to lift the brow is another way to convey a result ( Fig. 4.1 ). Lying the patient horizontal in a reclining chair will usually serve to position the brows in the position very similar to a natural browlift and is a means of showing the patient an anticipated result ( Fig. 4.2 ). Digital imaging can also be used for prediction, but I rarely use it as patients may take the prediction as a guarantee.

Whatever method is used to show a patient a possible result, is not as important as the moment when the patient looks in the mirror. In my experience, patients will either say, “Oh my God, I look unnatural, “like a deer in the headlights,” or they will say, “Wow doc, that looks great; that is how I used to look, I love it!” The latter is the response that validates the proposed procedure. In consultation, I lift the patient’s brows, and I am honest with them if it looks natural or not. I also involve my staff in this opinion, and it is helpful to have the patient’s spouse or significant other present to view the prediction to add their input. Many patients do not have a good understanding of what a browlift does, and most conservative patients are not interested in a browlift. Educating the patient by lifting their brows with the surgeon’s finger and asking them if they like the look is important. If a patient is undecided about a browlift procedure, then I do not perform it. Most browlift techniques are not reversible, and this can make a patient very unhappy for a very long time. Browlifting can look great on the appropriate patient but is not a procedure for the undecided.

That said, a well-performed browlift on the appropriate patient is one of the most rejuvenating and longest-lasting cosmetic procedures being performed today. Most people who get a great browlift will never need another one again. They may need future filler or fat around the brows or an upper blepharoplasty, but rarely will they need to “re-elevate” the brow position. Because of the longevity of this procedure, the surgeon must do everything possible to get it right the first time. The biggest mistake of a surgeon that leads to the patient’s greatest fear is overelevation of the medial eyebrows resulting in the quintessential “surprised look” ( Fig. 4.3 ). Patients fears can often be averted during consult by demonstrating with your own eyebrow how gently lifting the outer brow is typically rejuvenating and normal looking while significant elevation of the inner brow looks bizarre and is avoided by all means necessary.

During a consultation, it can be impossible to get a female patient to relax her brows to a neutral position. Experienced surgeons know that if you hand a woman a mirror, 99% of them will automatically raise their brows. This is probably an involuntary learned posture that is gradually adapted with aging and related brow descent. As we age, the forehead, brows, and upper lids become ptotic, and it can affect form and function. People may raise their forehead to make their upper-lid complex look younger, or some may do it to improve their visual field. Chronic brow elevation will increase frontalis wrinkling as proof of this habit. On a side note, it is this type of patient who becomes very unhappy with neurotoxin treatment to their forehead, which inactivates the frontalis function. This can produce an inability to raise their brow, hence their upper lids have more redundancy, and patients can become very disturbed by this. Male patients who have this major subconscious forehead elevation resulting from severe upper eyelid laxity are usually best suited for upper blepharoplasty alone versus trying to do both a brow and eyelid surgery. The patient must be warned that while forehead wrinkles will improve after the extra eyelid skin is excised, the eyelids may still have some residual laxity despite major skin excision because the eyebrows will relax and lower to a more natural position ( Fig. 4.4 ).

I have performed many female browlifts but only a handful of male browlifts. I have colleagues who have done many male browlifts, but personally I feel that almost any browlift feminizes male patients, and frequently they look unnatural. Endoscopic techniques can be used on balding men with good results provided the lateral tail of the brow is not overelevated, which feminizes the male patient ( Fig. 4.5 ). The exception is transgender men who love the look of lateral brow elevation. In general, browlifting on the average masculine male patient must be done with great care to avoid hollowing, feminization, or a surprised look from overelevation. Also, and perhaps because of my own bald head, I am sensitive to scarring the scalp of male patients with unstable hairlines.

Brow and Forehead Anatomy

Male brows are usually less peaked and sit at the level of the orbital rim in youth and descend with age. The youthful female brow generally sits above the level of the superior orbital rim ( Fig. 4.6 ).

Fig. 4.6, The male brow (left) is more linear and sits at the level of the orbital rim. The youthful and attractive female brow (right) sits above the level of the orbital rim and is peaked and tapered.

The youthful female brow is a delicate structure that tapers from a thicker and squarer medial portion to a fine point laterally. Classical proportions dictate the tail of the brow tapers at the lateral orbital rim, the peak of the brow at the lateral limbus, and the medial brow at the medical canthus. Classical proportions show the region of the youthful female brow between the lash and the brow to be one-third the distance below the crease and two-thirds the distance above the crease ( Fig. 4.7 ).

Fig. 4.7, The youthful brow tapers to a fine point at the lateral orbital rim (C), peaks at the lateral limbus (B), and becomes thicker and terminates at the medial canthus (A). The space between the lash and brow is one-third the distance below the crease and two-thirds the distance above the crease in the youthful female brow.

Discussing a browlift procedure with patients is less straightforward. Many patients are browlift candidates, but they may still not look natural when the brow is elevated. Similarly, the patient may look very pleasing to the surgeon and staff when the brows are elevated, but the patient may not agree. The bottom line is that the beauty of the browlift is truly in the eye of the beholder. Having said this, it is extremely important and ethical to inform all patients who have ptotic brows that they are candidates for a browlift procedure, whether they desire the procedure or not. This is important because many patients who are browlift candidates undergo aggressive blepharoplasty without ever being counseled about the possibility of brow and forehead lift. Every year I see a number of patients who have ptotic brows and desire browlift, but unfortunately they have had several upper-lid blepharoplasties without being offered the option of browlift, and it is impossible as the patient would not be able to close their eyelids because of the previous aggressive removal of upper-eyelid skin ( Fig. 4.8 ). This not only robs the patient of contemporary rejuvenation but may be grounds for a lawsuit from previous misdiagnosis. The take home message here is that if a patient has ptotic eyelids or an aging forehead, they need to be offered the option of brow and forehead lift. If the diagnosing surgeon does not possess that skillset, then ethics dictate referring the patient to a surgeon proficient in brow and forehead lift.

Fig. 4.8, This patient had two previous blepharoplasties and was never informed by her previous surgeon that she was a browlift candidate (left) . She presented to my office with a request for browlift but did not have enough lid skin for normal eyelid closure because of her previous blepharoplastie (right) . This patient should have at least had a browlift discussion with her previous surgeon.

Numerous factors dissuade patients from brow and forehead lift. These include a misunderstanding of the procedure, failure of the surgeon to discuss the procedure, fear of an unnatural appearance, and finances. The optimum policy is to discuss browlift and blepharoplasty with all appropriate patients and document this information in the medical record.

In addition to actually elevating the brow, a brow and forehead lift may improve horizontal forehead rhytids (depending on the type of lift performed), open up the eye/orbit complex, giving a more alert and youthful appearance, improve lateral brow hooding that blepharoplasty does not address, and lift and thin glabellar ptosis and fullness seen with aging.

Types of Browlifts

Elevating the ptotic brow and forehead complex is an important part of cosmetic facial surgery, and a plethora of techniques has been described. As with many cosmetic procedures, there is no right and wrong technique, and the best procedure is the one that produces natural and long-lasting results with low complications and happy patients. Some patients are very pleased with a 2-mm brow elevation from neurotoxin and nonsurgical skin-tightening devices. My practice, on the other hand, is surgical, and my patients expect and demand more dramatic results. The happy patient with a 2-mm brow from the office next door may demand a refund for such a small result at my office. In my experience, the most common type of browlift performed today is endoscopic, with conservative open procedures running a close second. I know very few surgeons who still perform the classic coronal brow and forehead lift. The one exception is for transgender surgery that requires major bone reduction of frontal bossing. Many times, this male-to-female appearance request is best suited for a wide-open coronal browlifting for maximum exposure of the entire orbital rim that must be shaved down with a rotary bur. A trichophytic approach could work too, but many of these patients wear female wigs and prefer the incision further away from the hairline.

The coronal browlift is an aggressive open technique that utilizes a trauma-type incision from ear to ear across the scalp. Coronal browlifting was once the most popular technique but has fallen out of popularity as a result of drawbacks such as overelevated hairline, hair loss, nerve damage, and the sheer aggressiveness of the procedure. It is simply too aggressive, and the scar and related problems can be significant. Some of the more common approaches for coronal lift are shown in Fig. 4.9 .

Fig. 4.9, Common browlift approaches include coronal (blue) , transfollicular (green) , endoscopic (yellow) , pretrichial (red) , direct (white) , and trans-blepharoplasty (pink) approaches.

Conservative browlifts are described in all shapes and forms in the literature. They involve remote small incisions in the hairline and attempt to raise the brow with these tiny skin excisions and/or with suture suspension through the incision. Although these lifts come in and out of favor, they are not known for their efficacy or longevity.

Direct browlifts are performed by removing a horizontal ellipse of forehead skin at some position above the eyebrow. Basically, the surgeon is taking a pleat out of the forehead and sewing the edges back, which lifts the brow. Although moderately effective, they do not address the entire forehead and leave noticeable scars. Older patients with deep horizontal wrinkles may tolerate such a scar.

Trans-blepharoplasty browlift involves performing routine upper-lid blepharoplasty and attempting to suspend the eyebrow to the periosteum to raise it. Although this remains popular with some surgeons, it does not have a great track record for efficacy or longevity. More recently, this approach has been modified with resorbable plastic tine devices that are anchored in the skull and support the elevated brow. This, I feel, fails to address the entire brow and forehead.

Suture suspension browlifting has wafted in and out of popularity for almost 30 years. It is a technique that appeals to non-surgeons as it is simple to perform. It involves securing the brow with a suture and suspending it higher on the forehead or using barbed sutures to suspend the brows. In my experience, this procedure has disappointing results.

Injectable filler browlifts are performed by some doctors and can be effective for minimal improvement of brow aesthetics (see Chapter 10 ). Filler is injected in multiplanes beneath the eyebrow, and the effect is more of a projection than a lift. When done properly by an experienced injector, it can improve brow aesthetics, but it only produces a minor change.

Although the endoscopic brow and forehead lift (EBFL) is a high-tech procedure, there are numerous disadvantages to the technique. First of all, it requires a good deal of expensive and specialized equipment, including a camera, light source, and monitor, along with significant hand instrumentation. Second, there is a steep learning curve for competency. Just because something is new does not mean it is better. Many surgeons feel that EBFL is not a stable procedure and is more prone to relapse. I have personally seen more postoperative change with this technique than I have with my transfollicular technique. When any surgeon reviews, studies, analyzes, or criticizes someone else’s technique, it is very important to be open-minded. If a given surgeon is using a different technique with safe and repeatable, long-lasting outcomes and happy patients, then their technique can be validated, even if it may not be effective in the hands of other surgeons. I do still perform EBFL in my practice. Dr. Cuzalina, on the other hand, used EBFL as his mainstay procedure and has great longevity in his hands, as shown later in this chapter. As with many procedures, I may feel that a certain technique is better suited for a given patient, or a patient may request a given approach. In reality, there are numerous techniques that I use for multiple operations, and they all basically have the same safe and predictable outcome, or I would not use them. It is important for the reader to understand that when I endorse or downplay any procedure, it is based not only on my personal experience, but I also try to take into account the basic “gestalt” of the contemporary multispecialty cosmetic surgery community.

Transfollicular Subcutaneous Brow and Forehead Lift

Joe Niamtu, III

The transfollicular subcutaneous brow and forehead lift (TFSBFL) has become my “go-to” procedure and the biggest reason is simplicity. It only requires several instruments, does not necessitate cameras or scopes, is a direct vision technique, is more stable because skin is removed, and it DOES NOT raise the hairline. This section is devoted to the transfollicular TFSBFL, which I also refer to as the mini open browlift .

A discussion of terminology plays an important role in understanding (or misunderstanding) surgical procedures. Incisions made in front of hair follicles are termed trichophylic (hair-loving) or pretrichial (in front of the follicles) because the follicles are not disturbed. Incisions that transect intact hair follicles (transfollicular) have been termed trichophytic ( tricho meaning “hair” and phytic either from the Greek phynai , “to be born,” or phyein , “to produce”). I have seen these terms misquoted, misused, and used interchangeably in articles, textbooks, and lectures. This browlift uses an incision that transects the hair follicles and for accuracy will henceforth be referred to as the transfollicular approach . Because this lift is performed in the subcutaneous plane, the formal name is the transfollicular subcutaneous brow and forehead lift or TFSBFL.

An important factor to keep in mind when choosing a browlift technique is whether or not it elevates the patient’s hairline. A long forehead and high hairline are not considered aesthetic for females. Coronal and endoscopic browlift approaches will both elevate the anterior hairline along with the brows. The endoscopic approach separates the deep tissue planes and elevates the brow and forehead by lifting the redundant skin and repositioning it posteriorly ( Fig. 4.10 ). The TFSBFL does not raise the hairline when lifting the brow and forehead.

Fig. 4.10, During an endoscopic brow and forehead lift (top) , the excess skin that is shown in multiple folds will be positioned posteriorly and fixated to the skull. The mere existence of this level of redundancy explains why the hairline will be elevated. When using the transfollicular subcutaneous approach (bottom) , the redundant skin is excised just within the hairline, hence the hairline is not elevated.

Perhaps the biggest advantage of the TFSBFL is that does not elevate the anterior hairline, which is of tremendous importance. For patients with a low hairline, virtually any browlift procedure is acceptable, as nominal hairline elevation is not critical (see Fig. 4.10 ). For patients with higher hairlines (longer foreheads), no extra increase in the anterior hairline is acceptable, so patients with elevated hairlines are optimum candidates for TFSBFL. This approach does not raise the hairline (when properly performed) but with additional distal scalp undermining and release, a patient’s hairline can actually be lowered.

The learning curve is less complex than with EBFL, and this approach is very similar to facelift surgery in that it involves subcutaneous dissection and skin excision. The TFSBFL is simply a facelift for the forehead and brow. Subcutaneous dissection, flap development, skin excision, and resuturing techniques are virtually identical to hair-bearing regions encountered in rhytidectomy.

Being a subcutaneous procedure, there is less edema and ecchymosis compared with other browlift techniques. Because this is a skin excision technique, stability is excellent, and the result is immediately evident. As the skin is excised all across the horizontal hairline and the area resutured, the suspension is dispersed across the entire brow hairline ( Fig. 4.11 ). This is in opposition to the EBFL, which only has several fixation points that are suspended with extreme tension in selected regions (see Fig. 4.11 ).

Fig. 4.11, When performing a transfollicular subcutaneous brow and forehead lift (left), the suspension is evenly dispersed over the entire forehead. The main suspension for the endoscopic brow and forehead lift (right) is confined to tow points and under significant tension.

An additional advantage is that TFSBFL, being a subcutaneous technique, will have an impressive effect on the effacement of vertical and horizontal forehead rhytids. This is possible because the skin is dissected from the underlying frontalis muscle and then tightened, which significantly improves horizontal wrinkles. Subperiosteal browlifts are not nearly as effective at improving horizontal forehead wrinkles because they cannot effectively be addressed from the subperiosteal plane. Direct access to the brow depressors is another advantage compared with endoscopic access; the treatment of these muscles is easier under direct vision.

There is no need for osseous fixation with the TFSBFL, which is an advantage for both the surgeon and the patient, as many patients are averse to having holes and hardware in their skull. Finally, there is no need for overcorrection with the subcutaneous skin excision technique and much less chance of frontal nerve injury. Box 4.1 shows the relative advantages of TFSBFL compared with the endoscopic technique. Fig. 4.12 shows forehead and hairline variations that may determine the type of browlift technique utilized.

Box 4.1

Relative advantages of subcutaneous mini open brow and forehead technique compared with endoscopic brow and forehead lift.

Subcutaneous mini open brow and forehead lift (transfollicular subcutaneous brow and forehead lift)	Endoscopic brow and forehead lift
No specialized instrumentation required Minor to moderate learning curve Simple subcutaneous dissection Less concern of frontal nerve injury Direct vision technique Does not raise the hairline Excellent improvement of forehead rhytids Very low tension on brow suspension Control of brow suspension over entire brow Subcutaneous dissection, less edema, faster recovery Direct access to brow depressors No need for osseous fixation No need for overcorrection Predictable longevity	Significant specialized instrumentation required Significant learning curve Requires extensive dissection of tissue in multiple planes Frontal nerve injury more problematic Closed technique Raises the hairline Less dramatic improvement of forehead rhytids Often extreme tension to fixate brow Less precise control of brow suspension Subperiosteal dissection extends recovery Indirect access to brow depressors Usually requires osseous fixation Frequently overcorrected Longevity varies among surgeons

Subcutaneous mini open brow and forehead lift (transfollicular subcutaneous brow and forehead lift)

Endoscopic brow and forehead lift

No specialized instrumentation required
Minor to moderate learning curve
Simple subcutaneous dissection
Less concern of frontal nerve injury
Direct vision technique
Does not raise the hairline
Excellent improvement of forehead rhytids
Very low tension on brow suspension
Control of brow suspension over entire brow
Subcutaneous dissection, less edema, faster recovery
Direct access to brow depressors
No need for osseous fixation
No need for overcorrection
Predictable longevity

Significant specialized instrumentation required
Significant learning curve
Requires extensive dissection of tissue in multiple planes
Frontal nerve injury more problematic
Closed technique
Raises the hairline
Less dramatic improvement of forehead rhytids
Often extreme tension to fixate brow
Less precise control of brow suspension
Subperiosteal dissection extends recovery
Indirect access to brow depressors
Usually requires osseous fixation
Frequently overcorrected
Longevity varies among surgeons

Fig. 4.12, This patient with a lower hairline and shorter forehead (top) is an excellent candidate for endoscopic brow and forehead lift. Raising the hairline is not a problem, and the operator does not need to fight the curvature of the frontal bone with the rigid endoscope. This patient with a higher hairline and longer forehead (bottom) is a better candidate for a transfollicular subcutaneous brow and forehead lift. Using an endoscopic technique in this patient would further increase the height of the hairline and should be avoided. In addition, the degree of curvature and bossing of this type of forehead makes navigation of the rigid endoscope more difficult.

A relative disadvantage is that the TFSBFL is not reversible, insofar as it is a skin excision technique. An overcorrected EBFL could be reversed in the first several weeks by releasing the fixation and redissecting the pockets. Like a facelift, there is no easy means of reversing TFSBFL after the skin has been removed. Another relative disadvantage is the public or collegial perception that open browlifts are excessive or antiquated. Endoscopic proponents claim that the endoscopic technique is a minimally invasive procedure. Only the actual incisions are minimally invasive. In reality, the endoscopic technique is the most aggressive browlift technique, traversing numerous tissue planes on the majority of the skull and necessitating the use of cranial fixation ( Fig. 4.13 ). The EBFL is definitely more high-tech, and the small incisions are attractive to patients, especially when overtouted by surgeons who do not possess the skillset for the transfollicular subcutaneous technique. Comparatively, TFSBFL is a very conservative procedure. There is a visible incision for several weeks, but when this procedure is performed correctly, the incision is rarely a concern.

Fig. 4.13, The limited dissection of the transfollicular browlift is shown (left) . The extent of dissection necessary for endoscopic brow and forehead lift (center and right) is a much more aggressive procedure traversing numerous tissue planes.

Diagnosis

Although I am a proponent of the transfollicular technique, any browlift that has natural results, low complications, and happy patients is a good procedure. The diagnosis for TFSBFL is the same as for other browlift techniques. Once it is determined that a patient is a suitable candidate and desires a browlift, a decision is made as to which technique to employ. When deciding which technique to use, several factors should be considered. First, the position of the patient’s hairline: if the patient already has a naturally high hairline with a long forehead, the TFSBFL is preferable, as no patient with a high hairline wants it higher. Another scenario is a patient with a significantly rounded frontal bone or frontal bossing. This exaggerated frontal curvature makes an endoscopic technique more difficult because the surgeon is working tangential to the curved bone, making it difficult to position the tip of the scope. Also, the need for drilling into the skull and using some type of retention system is a negative for many patients. To ensure accurate informed consent, it is important to let patients know preoperatively if drill holes and/or hardware will be used.

Patients with permanently tattooed eyebrows can be problematic, especially if the tattoos are not symmetric or extremely peaked. When the skin is excised and the forehead retracted, an unnatural result can occur. Any patient with permanent tattooed brows should be closely evaluated for results when the brows are manually lifted, and the problem should be discussed while the patient looks in a mirror. Some patients have virtually no eyebrow hair and draw them on daily. This is not a problem, as they can be drawn at any height postoperatively by the patient. This type of patient is actually the best browlift candidate, as the operation improves their periorbital aging, and the brows can be drawn anywhere the patient desires.

Also germane with choosing a brow technique is the use of simultaneous laser resurfacing. The endoscopic technique is subperiosteal and can be aggressively lasered in the same manner as the rest of the face. The transfollicular subcutaneous technique is a much thinner flap and more prone to devitalization. When I laser an endoscopic forehead, I use the same settings as used for the face, but when I laser a transfollicular subcutaneous browlift, I reduce the power or the density of the laser in the same manner that I do with facelift flaps.

For novice surgeons, it is sometimes difficult to determine which patients are appropriate (or inappropriate) candidates for brow and forehead lift ( Box 4.2 ). The situation is generally pretty straightforward. First of all, someone needs to have ptotic brows that look better, yet natural when they are elevated. Also, a surgeon must ensure that the patient seeking a browlift is doing it for the correct reasons and understands the specifics of what it will and will not do. Finally, all novice surgeons must be on the lookout for patients with body dysmorphic disorder. With the browlift, this may be a patient who is too young or has normal brows but is still seeking a lifting procedure. Blepharoplasty is an extremely common procedure, but browlift is usually performed much less frequently. Surgeons and patients must understand when the procedure is appropriate and when it is not. Many times, it is the stability of someone’s hairline that may determine being a candidate or not. Although small incision techniques may be appropriate for balding patients and Dr. Cuzalina discuss this with endoscopic browlift later in the chapter, a transverse forehead scar on a balding patient in my opinion is contraindicated. Almost every male patient has some form of hairline compromise and some female patients do as well. If somebody has thinning hair and you’re going to put a scar across the front of their forehead that may be hidden now but visible in 10 years, it can be problematic. This procedure is designed for re population of hair follicles through the scar and these scars usually heal extremely well; however, with the lack of hair, any scar may be unacceptable. In addition, I have performed very few browlifts on male patients. There is no specific contraindication to browlifting on male patients other than it does tend to feminize the appearance of some men. In my experience most male patients opt for blepharoplasty and do not have a big interest in brow and forehead lift. I have other colleagues who do significant numbers of browlifts on male patients.

Box 4.2

Indications and contraindications for brow and forehead lift.

Indications	Contraindications
Ptotic brows that when manually elevated produce a desirable look in the patient’s and surgeon’s opinion Significant lateral brow hooding that will not be improved with simple upper-lid blepharoplasty Patients with ptotic periorbital tissues that make the eye complex appear small. Lifting the brow and forehead can “open up” the lid complex Patients with enough upper-eyelid skin to be able to fully close eyes when the brow is elevated Patients with frontalis and glabellar wrinkles (some brow techniques improve these more than others) Patients with obscured visual fields that blepharoplasty does not improve	Patients who are not sure about the clinical results when the brows are manually elevated Patients who are impulsive and “want a browlift,” without proper research on their part Patients with previous aggressive upper-lid blepharoplasty that may be subject to lagophthalmos after browlift Young patients who do not exhibit classic aging signs Patients with an unstable hairline who may have visible scars in the future Patients with significant orbital, eye, or brow asymmetries who want guaranteed equalization Patients with permanent tattooed eyebrows that may look unnatural when elevated

Indications

Contraindications

Ptotic brows that when manually elevated produce a desirable look in the patient’s and surgeon’s opinion
Significant lateral brow hooding that will not be improved with simple upper-lid blepharoplasty
Patients with ptotic periorbital tissues that make the eye complex appear small. Lifting the brow and forehead can “open up” the lid complex
Patients with enough upper-eyelid skin to be able to fully close eyes when the brow is elevated
Patients with frontalis and glabellar wrinkles (some brow techniques improve these more than others)
Patients with obscured visual fields that blepharoplasty does not improve

Patients who are not sure about the clinical results when the brows are manually elevated
Patients who are impulsive and “want a browlift,” without proper research on their part
Patients with previous aggressive upper-lid blepharoplasty that may be subject to lagophthalmos after browlift
Young patients who do not exhibit classic aging signs
Patients with an unstable hairline who may have visible scars in the future
Patients with significant orbital, eye, or brow asymmetries who want guaranteed equalization
Patients with permanent tattooed eyebrows that may look unnatural when elevated

Transfollicular Subcutaneous Brow and Forehead Lift: Surgical Technique

Patients are instructed to wash their hair on the night before surgery and the day of surgery with an antibacterial soap.

As with blepharoplasty, TFSBFL success revolves around proper preoperative incision markings, which must be precise and accurate. After photographs are taken, the patient is marked preoperatively. The area of maximum brow elevation is decided with the patient looking in the mirror. When in doubt, it is always better to be conservative. The area of maximum brow elevation is generally at the junction of the central and lateral thirds of the eyebrow, which usually coincides with an imaginary vertical line at the lateral limbus ( Fig. 4.14 ). This is a guideline and may differ in some patients, but it is generally accurate. Some older female patients literally have no eyebrow hairs and draw them in daily, which, as stated earlier, is a safe situation. Care must be exercised not to overelevate the medial brows, as this can produce an unnatural and quizzical appearance (see Fig. 4.3 ).

Fig. 4.14, Although it can differ from patient to patient, the average region of maximum elevation is at the junction of the central one-third and the lateral one-third of the brow.

It is not uncommon to see patients with brow asymmetry, and this must be addressed preoperatively ( Fig. 4.15 ). There are numerous reasons for one brow being higher or lower than the other. This can include developmental differences from one side to the other side. In some patients, the frontal bone may be larger or smaller, and the soft tissues may also differ in anatomy. In addition, some patients simply have animation differences in which their muscle movement is different from side to side. Whatever the reason, again, the surgeon must recognize it and discuss options with the patient. Although I am usually able to even the brows when faced with asymmetry, I never guarantee this to the patient. Their anatomy may simply prevent symmetry. If I even their brows, I am a hero; if I do not, they understand because of our presurgical discussions.

Fig. 4.15, A patient with a lower-left eyebrow is shown. All patients require detailed preoperative analysis and discussion about surgeon and patient expectations.

Additional markings commonly used include the supratrochlear nerves, which are located approximately 17 mm from the midline, and the supraorbital nerves, which are approximately 27 mm from the midline ( Fig. 4.16 ). Marking the neurovascular bundles allows the surgeon to be mindful of significant anatomy. Blepharoplasty markings are also performed if planned during the same procedure.

Fig. 4.16, The relationship of the supratrochlear and supraorbital nerves (left) along with the deep branch of the supraorbital nerve. In general, the supratrochlear nerve is 17 mm lateral to the glabellar midline, and the supraorbital nerve is 27 mm lateral to the glabellar midline. The intraoperative correlation with this anatomy is also shown (right) .

Preoperative markings are made immediately before surgery with the patient in the upright position before anesthesia is given ( Fig. 4.17 ). Markings include the proposed brow peak bilaterally and an irregular incision outline at least 5–7 mm posterior to the “true hairline.” By true hairline , I am referring to the region of the anterior hairline where the thin anterior hairs change to the true follicular density.

Fig. 4.17, The basic preoperative markings include the proposed brow peaks and the irregular incision pattern at least 5–7 mm posterior to the dense follicular hairline.

There are numerous reasons why this incision is crafted as described in this procedure. One common question is, “Can the incision be made several inches behind the hairline so no hair follicles are excised?” The answer to this question is that placing the incision more posteriorly will further raise the hairline.

Another common question is, “Can this procedure be performed with a subgaleal or subperiosteal approach instead of a subcutaneous approach?” The answer to this question is that using the subcutaneous approach allows skin wrinkle improvement when dissecting the skin from the underlying frontalis. The subcutaneous approach also allows protection of the sensory nerves. Making the incision across the entire brow and cutting deeper than the skin will transect deep branches of the supraorbital nerves. The final reason that one does not need incision and dissection deeper than the subcutaneous level is that there is no benefit in the final result, and involvement of additional tissue planes can produce more complications.

The TFSBFL can be performed with local or tumescent anesthesia, but it is most commonly performed in my office with general anesthesia because other simultaneous procedures are frequently performed.

Regardless of the browlift technique utilized, I personally do a simultaneous blepharoplasty in the majority of cases. I feel that most patients who are in need of a browlift are also in need of some upper-lid skin reduction. Obviously, eyelid closure must remain functional, so discretion is required. If the upper lids are not addressed, the patient may be left with a perfectly elevated brow but redundant upper-lid skin that detracts from the result ( Fig. 4.18 ). Also, in the event the brow is not elevated enough or minor relapse occurs, the combination of blepharoplasty and browlift provide a combined change that will usually satisfy the patient.

Fig. 4.18, The left image shows a preoperative photograph of a patient who underwent isolated browlift without blepharoplasty. Although her brows are well elevated, the redundant eyelid skin detracts from the aesthetics of the case. Performing conservative blepharoplasty at the same time as the browlift helps complete the upper face rejuvenation.

When performing simultaneous blepharoplasty with browlift, a much more conservative blepharoplasty procedure is invoked. Less skin is removed, and the outline of the blepharoplasty incision is different from conventional blepharoplasty. When performing conventional blepharoplasty, most surgeons use an upswept incision at the lateral portion of the eyelid. This is done to assist with lateral hooding. When performing browlift surgery, the lateral hooding is automatically corrected, so there is no need to perform the upswept lateral blepharoplasty incision. The “bleph with brow” incision is tapered on both ends ( Fig. 4.19 ). Whereas a traditional blepharoplasty may dictate a 10-mm skin excision, the blepharoplasty done with browlift requires only 3–4 mm of skin excision. When combining simultaneous blepharoplasty and browlift, novice surgeons should perform the browlift first, as the amount of eyelid skin excision is more easily determined. Experienced surgeons can perform the blepharoplasty first by taking 3–4 mm of skin at the beginning of the procedure. Regardless of the order performed, enough skin must remain to close the lids. Additionally, elevating the brow will reposition the eyelid tissues so significant muscle or fat removal is not generally necessary, and simple skin excision is usually sufficient for most cases. I have never experienced a lagophthalmos problem when combining these procedures. For novice surgeons, I recommend informing the patient that the browlift will be performed, and any redundant eyelid skin remaining can easily be touched up as a skin-only excision with local anesthesia at another time. I utilize the same type of conservative blepharoplasty with endoscopic browlift as well.

Fig. 4.19, A traditional outline for upper eyelid blepharoplasty is shown (left) . A much more conservative incision utilized with concomitant blepharoplasty and browlift is shown (right) .

When performing blepharoplasty before the browlift, the lid incisions are closed before scalp excision is performed. The surgeon can therefore decide how much excess forehead skin can be removed without producing significant lagophthalmos. Enough skin must remain to close the lids, and this is taken into account during excess scalp excision.

Crafting the Incision

There are few surgeries totally defined by a specific incision, but this is one of them. The technicality and quality of the transfollicular incision can make or break the aesthetic success of this browlift procedure. There are two basic principles of this lift. The first critical principle is to craft a precision incision to allow hair regrowth through the surgical scar, thus camouflaging it. The second principle is to elevate the brow and forehead without raising the hairline.

The incision pattern is also very critical for a naturally appearing hairline scar. First, the incision should never be made anterior to the hairline. To avoid old terminology confusion, we will refer to incisions anterior to the hairline simply as prefollicular hairline incisions. They are also referred to as trichophytic or pretrichial , and this incision totally avoids any hair follicles. This may sound good in theory and will definitely be easier to incise and close, but the aesthetics are frequently unacceptable and produce a straight line, often a hypopigmented scar ( Fig. 4.20 ).

Fig. 4.20, Incisions anterior to the hairline are contraindicated in natural-appearing open forehead procedures. Making any incision anterior to the hairline, especially straight-line incisions, are difficult to conceal and look very unnatural.

I frequently hear surgeons advocate the prefollicular hairline incision but continually see patients in my office who were operated on elsewhere and have unacceptably visible scars. Even geometric, random incisions performed anterior to the hairline can heal with a very unnatural appearance. In addition to avoiding prefollicular incisions, it is also important to avoid straight-line incisions. As there are very few straight lines in human anatomy, these prefollicular scars can look unnatural. Also important is the fact that there is no such thing as a “natural hairline.” Normal hairlines are not lines at all; they are very incidental and random patterns of follicles. Only a toupee or a poor hair transplant produces a true “hairline.” Making a straight-line prefollicular incision on a patient’s forehead can make them look unnatural, with a visible and often hypopigmented scar ( Fig. 4.21 ).

Fig. 4.21, Naturally occurring hairlines are incidental with sparse, fine vellus hairs anteriorly that change to a thicker follicular density posteriorly (left and center) . A “toupee-like” hairline (right) is a straight line and stands out as being very unnatural.

The transfollicular incision is unique in design. First, the incision is designed to transect the existing hair shafts and follicles with a steep bevel. This incision is intentionally placed about 5 mm posterior to the true hairline. The optimum placement of this incision is at the region of the follicular density change from the thin, sparse anterior hairs to the denser follicles of the “actual” hairline (see Fig. 4.17 ). The incision must be placed posteriorly enough to allow the scalpel to transect enough hair shafts and follicles to regrow through the thin scar edges.

The bevel of the incision is critical and must transect several rows of hair shafts and follicles at different heights. For this to occur, a scalpel with a No. 11 blade must be held about 10–20 degrees above the horizontal plane, as shown in ( Fig. 4.22 ). This angle and scalpel movement is similar to filleting a fish, except the blade is not totally horizontal. The reciprocal motion of filleting a fish is used when the incision is made in an unintentional and random pattern.

Fig. 4.22, The incision design and technique is critical for this procedure. A hyperbeveled incision is made about 15 degrees from horizontal.

This extreme bevel has numerous functions. First, it allows the angled transection of hair shafts and follicles, which encourages hair regrowth through the scar. Second, this extreme bevel produces a very thin skin incision edge. Whereas an incision made perpendicular to the skin surface will produce the thickest skin edges, the more angled the scalpel is held, the thinner the skin flap edges will be. This very thin epidermal/dermal interface contributes to the excellent aesthetics of this type of skin incision. This thin interface also makes it easier for the underlying hair follicles to grow through the thin flap. When the surgeon appreciates these characteristics and can predictably perform this incision, repeatable outcomes are accomplished with this approach.

Incision Geometry

Keeping with incision design, the next aspect to be addressed is incision geometry. Understanding that the incision is placed about 5–7 mm into the hairline, the configuration can be regular with large or small triangles or irregular with random undulating geometry. Different surgeons prefer one of these configurations over the others. Proponents of large triangular incisions say that the incision, skin excision, and reapproximation of the trimmed flap is less laborious. My experience with the larger triangular configured flaps has been that the larger regular triangles show more intentional geometry and visible scars. Other surgeons prefer very tiny triangles, and this is not only more labor-intensive to cut and sew, but the smaller the triangles, the more the final incision will resemble a straight line. After experimenting with all the common geometric incision patterns, experience has shown that a random, irregular, undulating incision pattern produces the best postoperative scar. The pattern is basically irregular and reminiscent of ventricular fibrillation on an electrocardiogram ( Fig. 4.23 ). The incision pattern and the angle of the cut are both critical factors in the success of this technique.

Fig. 4.23, I have had my best postsurgical scars when using a random, undulating pattern that I compare to ventricular fibrillation.

If a patient has a prominent widow’s peak, it is better to cut through the lower third of the apex instead of following the distinct V shape of the peak. Otherwise the angles are too conspicuous with the final scar.

Similar to blepharoplasty, correctly marking this browlift incision is critical. The incision marking does not need to be an exact template, but rather a guide to geometry.

Transfollicular Incision and Healing

The reason this incision heals so well when performed properly is that the transected hair follicles can regrow through the incision and camouflage the scar. For this to occur, the bevel of the incision must transect the hair shafts and follicles at various angles. The most anterior and usually fine vellus hairs may be totally excised and be lost. Generally, this small amount of hair loss is negligible and not noticeable in the final result. The next rows of follicles are transected close to the hair bulb, and these are the hairs that will regrow through the scar. The posterior-most hair shafts will be transected toward the top of the shaft, and these will also grow back ( Fig. 4.24 ).

Fig. 4.24, For this incision to be effective with hairs growing back through the scar, several rows of hair follicles must be transected.

Although some hair may be excised when trimming the flap, it should be negligible if the incision is made correctly. It may appear that more hair is lost when incising, but it is important to remember that some of the rows of follicles that appear to be cut will actually regrow through the scar; in effect, most of these hairs are cut but not lost.

For patients who have a distinct, straight hairline or have lateral hair recession, the incision must be modified to accommodate the follicular density as it curves around the hairline ( Fig. 4.25 ).

Fig. 4.25, The incision must follow the patient’s hairline. A horizontal incision in a patient with a straight hairline (top) and an incision that follows a more receding hairline (bottom) are shown.

After the initial hyperbeveled incision is made and dissection is completed, the excess forehead skin will be retracted toward the scalp and also trimmed with the same-angle bevel as used for the initial incision. The feather-edged forehead skin flap will then lie on the feather-edged scalp flap to create a very thin epidermal/dermal interface ( Fig. 4.26 ).

Fig. 4.26, After the soft tissue excision from the distal flap, the beveled flaps are reapproximated.

It is this thin skin interface, which lies over the transected hair shafts and follicles, that allows the hair to regrow through the skin and camouflage the scar ( Figs. 4.27 and 4.28 ).

Fig. 4.27, As the transected hair follicles repopulate, they grow back through the original incision and scar.

Fig. 4.28, The regrowth of new hair through the incision scar is testament to the effectiveness of the incision design.

When these incisions are properly performed, new hair regrowth can be seen in the first several weeks after the procedure ( Fig. 4.29 ).

Fig. 4.29, With experience and a moderate learning curve, the after results can be almost undetectable.

Step-by-Step Operative Technique

Surgical Instrumentation

The instrumentation for TFSBFL is minimal and similar to facelift surgery (see Fig. 4.30 ). Most commonly used instruments include the following:

Round scalpel handles
No. 11 scalpel blades
Fine pickups
Comb
Marking pen
Suction
Retractors (lighted are preferable)
Radiofrequency or electrosurgical unit for hemostasis
4-0 gut, 5-0 gut, and/or 6-0 nylon sutures

Fig. 4.30, Instrumentation for the transfollicular browlift is minimal and similar to facelift armamentarium.

Treating the patient with a neuromodulator preoperatively may assist healing as a result of decreased mobility. Some surgeons insist that all brow and forehead lift patients be treated with neuromodulators before surgery.

Simultaneous Blepharoplasty

I believe that almost any patient who needs a browlift also needs blepharoplasty. I perform simultaneous blepharoplasty with almost all browlifts (endoscopic and transfollicular). The only exceptions are patients who do not have dermatochalasis or those who have had previous aggressive upper-lid skin resection. To determine this, I manually elevate the brow to the desired position. If there is redundant lid skin (which is generally the case), then I will perform simultaneous blepharoplasty. Another means of estimating the need for blepharoplasty is to lie the patient back in the chair. This automatically places the brows in an elevated position. If there is still excess upper-lid skin in this position, a blepharoplasty may be warranted.

After the surgical preparation is completed, the incision marking is visualized, and several rows of hair are combed forward to expose the scalp where the incision will be made ( Fig. 4.31 ).

Fig. 4.31, To allow the incision to be beveled anteriorly and transect the forward follicles, 5–7 mm of the anterior hairline is prepped and combed forward.

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