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Chapter 20 Indications and Techniques for Coronal Brow Lifting

■■ A patient may be a candidate to have the entire brow com- plex lifted or more commonly to have only part of the eye- brow raised, thus improving eyebrow shape. Occasionally, in a patient who chronically looks angry, this may involve raising the medial brow only, but most commonly, it is the lateral third to one-half of the eyebrow that requires reposi- tioning with little or no lift of the medial portion. ■■ Weakening or eliminating the glabellar frown musculature is a useful parallel objective. ■■ If brow lifting is contemplated, the effect on the upper eyelid complex must be considered. Previous upper lid blepharo- plasty may have left a patient tissue deficient, so that brow lifting could impair eyelid closure. Also, brow lifting may reveal the previously unappreciated hollowing of the upper lid sulcus. NONOPERATIVE MANAGEMENT ■■ Numerous nonoperative strategies are available to change eyebrow shape and/or position. ■■ Nonmedical: eyebrow plucking, cosmetic makeup, tattooing ■■ Medical, nonsurgical: botulinum toxin injection, synthetic filler injection, thread lifting ■■ Surgical, non-brow lift: transpalpebral frown muscle ablation SURGICAL MANAGEMENT Preoperative Planning ■■ There are many surgical techniques available to elevate or to reshape the eyebrow. The coronal approach is a traditional method with a long track record of proven results. 11,12 ■■ The preoperative discussion is an excellent time for the sur- geon to teach the patient about periorbital aging. To achieve the patient’s objectives, some concepts that are new to the patient may be introduced. A patient requesting brow reju- venation surgery may also be a candidate for blepharoplasty, upper sulcus fat grafting, or eyelid ptosis repair. ■■ This procedure provides maximum visibility and flexibility. Therefore, during the planning process, the surgeon should develop a mental image of what portion of the eyebrows are to be lifted, how much lift is required, and if there is any brow asymmetry to be corrected. ■■ With the patient awake and in the upright position, with the forehead in repose, the desired amount and direction of eyebrow elevation are assessed by manually elevating the brow complex ( FIG 3 ). Specific vectors have been described, but more artistic decision-making is preferred.

■■ Other lines in the forehead are caused by the glabellar frown muscles. Vertical lines are caused by the transversely oriented corrugator, horizontal lines are caused the verti- cally running procerus, and oblique lines are caused by the depressor supercilii and orbicularis. ■■ Age-related brow ptosis is not universal. Up to 40% of peo- ple have relatively stable eyebrow position throughout life and are generally not candidates for brow lift surgery. 8 ■■ Frontalis is the only lifting force to counter balance the various muscles and gravity that depress the brow level. The lateral portion of the eyebrow is particularly sensitive to this inter- play because frontalis action is attenuated laterally and also because the security of lateral brow fixation to bone is incon- sistent. 9,10 Poor soft tissue attachment with no muscular lift will inevitably lead to ptosis of the lateral third of the eyebrow. PATIENT HISTORY AND PHYSICAL FINDINGS ■■ Most patients will not be aware of the many factors involved in periorbital aging, and they may not want the multiple pro- cedures required to treat all of these components. For that reason, identifying the main component of every patient’s periorbital aging is important. Old photographs are very helpful in helping the surgeon determine which age-related changes predominate. ■■ Assessment is done with the patient awake and upright in the sitting or standing position. The following issues are evalu- ated: visual acuity, eyebrow and orbital symmetry, position of anterior hairline, thickness of scalp hair, transverse fore- head lines, glabellar frown lines, thickness of eyebrow hair, eyebrow height, axis of the eyebrow (downward or upward lateral tilt), shape of the eyebrow (flat or peaked), passive and active eyebrow mobility, and the presence of old scars or tattoos. The upper eyelids should also be assessed for soft tissue redundancy, for upper sulcus hollowing, and for eyelid level (ptosis or lid retraction). ■■ To identify patients with chronic frontalis contraction, examination should be done with eyes open and eyes closed. When the eyes are closed, the frontalis can be made to relax, revealing the true position and shape of the eyebrows. If the eyebrows are forcibly held in this position when the patient opens their eyes, the eyebrow-eyelid relationship without frontalis effect will be revealed. FIG 2  • The attractive eye exhibits a modest amount of visible upper lid (“tarsal show”); this dimension is about one-third of the distance from the lash line to the lower border of the eyebrow. The brow itself starts medially over the supraorbital rim and vertically in line with the medial canthus. It angles gently upward, peaking about two-thirds of the way along the brow toward its lateral extent. In females, this peak is at or lateral to the lateral limbus of the eye. In men, this peak is minimal or absent. Laterally, the “tail” of the brow should end at a higher point than the medial end of the brow.

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FIG 3  • With the frontalis muscle in repose, the desired amount and direction of eyebrow elevation are estimated by manually elevating the brow complex. The desired vector of lift can also be determined using this method.

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