The Open Browlift

History

The brow has historically been overlooked in the rejuvenation of the aging face. The focal procedure of facial rejuvenation has always been the rhytidectomy. Surgical forehead rejuvenation began at the turn of the 20th century . Passot has been generally recognized as a pioneer in the field. Several other surgeons described their work over the subsequent years . The interest in these procedures waned, as the effects were often found to be transitory. However, as with most plastic surgery procedures, interest in brow rejuvenation was renewed in the latter half of the 20th century, when new techniques evolved and results improved .

There has been, and continues to be, significant controversy as to the “correct” technique to rejuvenate the brow; for example, whether to use an open versus an endoscopic approach, and currently, in some quarters, whether the brow can be adequately elevated with nonsurgical techniques such as Botox and fillers. The contention that one operation is superior to the other has left many surgeons unsure of the appropriate approach. This confusion has contributed to the subjugation of the browlift to the less controversial rhytidectomy and blepharoplasty procedures, and thus avoidance of addressing the aging brow in lieu of correcting the aging face and periorbital regions.

Historically all brow rejuvenation procedures were performed via the open technique. Although this procedure has excellent long-term results, patients and surgeons were often hesitant to undergo such an involved procedure with extensive incisions and recovery time. With the advent of the endoscopic techniques in the early 1990s, surgical rejuvenation of the upper third of the face became increasingly popular . This trend, coupled with the advent of noninvasive paralytic agents, brought brow rejuvenation to the forefront of facial rejuvenation.

Personal Philosophy

Comprehensive facial rejuvenation merits an appraisal of all components of the face. This is especially pertinent for the upper third of the face. This is the focal region of the face during communication with others. The importance of the periorbital area is seen in everyday life. Indeed, it is so common in our observations of others that it is often overlooked. When speaking to or meeting someone for the first time, attention is immediately brought to the periorbital area, much more so than the jowls or the neck that so bother the aging patient. Patients with brow ptosis subconsciously raise their brows when viewing themselves in the mirror. This cannot be done on the ptotic, sagging tissue of the middle and lower thirds of the face. Thus the patient masks an issue that others see at all times. Although simple, this is an often-overlooked point that must be discussed with the patient.

The importance of brow rejuvenation is vital to facial rejuvenation. In our practice, this procedure is often seen as the primary operation to rejuvenate the face. In addition, if middle- and lower-third rejuvenation is performed without addressing the brow, the patient may be left with an overall disharmonious appearance .

The primary reason for brow rejuvenation in our practice is to address the patient's concern about looking heavy, tired, or angry, especially in the glabellar area. The goals of any browlifting procedure are to eradicate the depressing effect of the musculature of the glabellar region and to raise the lateral aspects of the brow. A key benefit of the open approach is the excellent exposure, which allows for precise handling of these problems. There is no need for overcorrection with the open approach because the surgeon can be confident that the results will be long lasting. This is owing to excision, rather than suspension, of the ptotic tissues.

There have been concerns over the side effect profile of open browlift techniques. Likewise, endoscopic techniques are being questioned as to the quality and longevity of the results. Despite the variety of methods to surgically, or nonsurgically, address this area, it often remains neglected.

The endoscopic techniques have done a tremendous amount to reinvigorate interest in the aging upper third of the face. Surgeons have noted the advantages of smaller incisions: less downtime; reduced scarring, numbness, and alopecia; and minimizing the loss of blood . However, endoscopic techniques do have selected disadvantages. For example, there is still no method of fixation that is clearly superior to others . The technique has a limited ability to correct severe eyebrow ptosis and must be utilized only in certain patients . In addition, the endoscopic record is not yet defined . Reports in the literature have confirmed many surgeons' trepidations about this technique. Only 50% of plastic surgeons surveyed felt that their results were satisfactory more than 2 years after the operation .

In addition to the longevity concerns regarding endoscopic browlifts, there have also been questions regarding its impact on the contour of the brow . It has been found that the greatest impact of the endoscopic browlift is medially not laterally, thus contributing to the dreaded “surprised look” and not affecting the lateral brow where the lift is generally desired . This highlights another advantage of the open browlift technique. The open approach allows for more control of the brow contour by way of its differential scalp incision . Although emphasis has been on endoscopic and less invasive methods such as the use of botulinum toxin A and various fillers, the open browlift has a proven record of providing excellent, lasting results with minimal side effects. The open browlift maximizes the optimal removal of the corrugators and excess skin that accumulates with time . In addition to the traditional coronal and tricophytic approaches, the temporal, or lateral, browlift is a modification of the open approach by focusing the incision placement in a vector that optimizes the aesthetic ideal of lateral brow elevation with no raising of the medial aspect of the brow . This approach is also quite useful when coupling the procedure with a vertical facelift in that it allows for removal of the troubling redundancy of tissue incurred at the superior, anterior aspect of the facelift incision.

In our opinion, the main role for the endoscopic approach is in young patients with a minimal amount of ptosis. In our practice, however, we often suggest deferring the procedure in younger patients until the concerns have truly manifested themselves, at which point we perform what we believe to be the procedure of choice, the open browlift. We feel the open browlift is the optimal operation in patients with severe ptosis of the brows, deep glabellar or midforehead wrinkles, or a preexisting high forehead, when a trichophytic lift is selected. The results achieved with this forehead lift are predictable, natural appearing, long lasting, and aesthetically pleasing with minimal morbidity .

Other surgeons have also reported that the open technique is more effective in achieving the three main goals of brow surgery: brow elevation, reduction of transverse lines, and reduction of glabellar lines . We would add to this the enhanced ability to contour an asymmetric brow and the aforementioned elimination of excess tissue in the temple region that is often found after a vertical facelift. Even those who favor the endoscopic technique state that some patients will benefit from the open approach .

The negative side effects of open browlift techniques seem to have been unduly emphasized in the literature. In an unpublished report on the significance of the side effects of the open browlift techniques, the authors found an overwhelming percentage of patients who would recommend the procedure to a friend or relative. Studies have also thrown light on various vague detractions of the open technique. The difference in the rate of alopecia between the two techniques is small, and sensory loss has been noted to be higher with endoscopic techniques . In summary, the open browlift technique has a similar complication rate, a comparable rate of sensory loss, and a higher patient satisfaction rate compared with endoscopic techniques .

The other issue commonly mentioned when discussing the open approach to forehead rejuvenation is the extent of the incision. We feel that this is predominantly a matter of proper patient education and surgical technique. In our practices it is rare for patients to opt out of this approach after a thorough conversation on the benefits of the procedure. Certainly, if patients feel that they are going to be “scalped,” they will not consent to the procedure .

The coronal incision can be completely camouflaged with the patient's hair. In the case of the trichophytic incision, only the anterior aspect is exposed, and this component of the incision can also be masked with hair when the patient wears her bangs combed forward. In both instances the incision generally heals imperceptibly when proper beveling is employed during the incision and meticulous technique is applied during the closure. The patient must be counseled as to the amount of time it requires for the wound to heal completely. If the patient does not wish to have an open procedure because of the incision, the endoscopic approach should be explored with the patient.

The open technique via the pretrichial route enables the surgeon to manipulate certain situations in unique ways. For example, the pretrichial lift allows for shortening of an elongated forehead. A long forehead disrupts the harmony of the face and adds to the patient's age . The forehead-shortening capabilities of the trichophytic browlift are unobtainable with the endoscopic technique . Detractors argue that the incision placement prohibits the use of this technique, but many feel that with proper planning, technique, and execution this approach yields an excellent aesthetic result . This is not to say that this procedure may be used in all patients with an elongated forehead. If the patient is overly self-conscious of scarring or has a hairstyle that positions the hair posteriorly, the surgeon would be wise to avoid this technique.

The decision-making process for the coronal versus the pretrichial approach has been reported in the literature . We generally agree with these parameters but do make exceptions in certain cases to the 5-cm rule.

The purpose of this chapter is not to determine which technique is superior. That is a decision to be made during the consultation. The open browlift technique should be familiar to all plastic surgeons rejuvenating the upper third of the face. Endoscopic and open techniques should be discussed with all patients. Finally, endoscopic and open browlift techniques do not address volume changes that occur in the brow and temple regions because of bony remodeling and fat atrophy. Volume loss has to be addressed with fillers or autologous fat grafting and will be discussed elsewhere in this book.