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Other names for brow lift :-eyebrow lift, forehead lift, coronal lift, endoscopic brow lift, direct brow lift, temporal lift, midforehead lift, internal brow lift, browplasty, browpexy, upper face lift.

Ideally, a woman's eyebrows should arch on or slightly above the upper orbital rims. Laughing, smiling, crying and squinting are all everyday facial movements that gradually cause your forehead to develop unwanted furrows, wrinkles and lines. This, coupled with the inevitable effects of aging can create forehead lines that lead to a tired, worn look

Brow lift surgery improves the face dramatically by creating a brighter, softer, fresher appearance. It lifts heavy eyebrows away from the eyes and smoothes out vertical lines between the eyebrows and transverse lines across the forehead.

Understanding the muscle anatomy of the eyebrow

The forehead and eyebrow regions are composed of 5 major muscles: the occipitofrontalis, orbicularis oculi, depressor superciliaris, corrugator supercilii, and procerus. The occipitofrontalis has 4 bellies, 2 occipital and 2 frontal, connected by the epicranial aponeurosis, also termed the galea aponeurotica. The occipital bellies arise from the highest nuchal line on the occipital bone and pass forward to insert on the galea. The frontal portion has no bony insertion but arises from the skin and superficial fascia of the eyebrow, passes through the orbital orbicularis oculi muscle, and inserts on the galea approximately midway between the coronal suture and the brow.

The orbicularis oculi muscle has 3 parts, the orbital, preseptal, and pretarsal orbicularis oculi muscle. The orbital portion overlies the orbital rim and arises from the anterior limb of the medial canthal tendon and the surrounding periosteum. The fibers sweep superiorly and inferiorly around the eye and meet laterally over the zygoma. The preseptal portion of the orbicularis oculi has superficial heads from the medial canthal tendon and deep heads from the posterior lacrimal crest. The fibers that sweep laterally form the lateral palpebral raphe.

The pretarsal fibers arise from the medial canthal tendon and Horner muscle. These fibers pass laterally to unite at the lateral canthal tendon. The orbicularis oculi muscle closes the eyelids, thereby pulling the skin of the forehead, temple, and cheek toward the eyes. The superior orbital portion of the orbicularis oculi muscle is a particularly powerful depressor of the brow, as is evident in patients with blepharospasm.

The corrugator supercilii muscles originate from the nasal process of the frontal bone at the superomedial orbital rim. The muscle inserts into the medial cutaneous portion of the eyebrow, interdigitating with the frontalis muscle. The corrugator muscles produce vertical glabellar furrows.

The procerus muscle appears as a continuation of the inferior medial end of the frontalis muscle. It arises from the lower part of the nasal bone, and its action pulls down the medial end of the eyebrow and produces horizontal wrinkles of the skin.

The muscle plane of the eyebrow is secured to the frontal bone periosteum by a firm attachment on the underside of the fat pad, often known as the deep galeal insertion, particularly over the medial two thirds of the orbit.

Points to consider

Careful assessment by the surgeon is critical to ensure a satisfactory cosmetic result.

• Frequently, droopy eyebrows and excess eyelid skin are a combined problem. If this is the case, simply removing some eyelid skin will not correct the problem. In fact, it may worsen it by creating a shortage of skin in the upper lid causing the brow to be pulled down further.

• If both a brow lift and blepharoplasty are found to be necessary, it is important to place the eyebrow in its correct position by performing the brow lift surgery first. In this way, less upper eyelid skin is removed during the blepharoplasty, thus preventing any problems with eyelid closure.

• Brow lift surgery for forehead wrinkles is particularly effective in correcting droopy eyebrows as well. If, however, droopy eyebrows are not the problem, other options may be considered, including laser resurfacing, collagen implants or muscle relaxants such as Botox.

• A "sinking" nose and excess nasal skin can be corrected with a brow lift, as an alternative to a rhinoplasty (nose job). Asymmetrical eyebrows, where one side sits higher than the other, may be improved by lifting the brow on the droopy side.

What is involved in a brow lift?

Many surgical approaches to the ptotic brow are available, including the direct brow lift, mid forehead lift, pretrichial lift, temporal lift, coronal lift, and endoscopic lift. This article discusses the assessment and planning of brow lifts in general and the coronal technique in particular. Three surgical techniques are used, each having distinct advantages and disadvantages:

• The coronal technique is an incision made either in the scalp or at the junction of the scalp hair and forehead.

• The mid-forehead technique involves an incision made within the natural creases of the mid-forehead.

• The direct technique locates the incision just within the hairline of the upper part of the eyebrow.

The coronal technique is the most popular because the incision is hidden by the hair. By partially removing some of the muscle as well as the redundant skin, furrows and wrinkles on the forehead can be smoothed out as the same time the brows are lifted. The most up-to-date method of performing the coronal technique utilizes a laser and an endoscope. An endoscope is a small round tube or cannula through which a light, a microscope and the fiber optics of the laser are passed. With conventional scalpel surgery the incision is made from ear to ear across the top of the forehead just within the hair line. The incision is much smaller with the laser and endoscopic technique; 1 to 2 centimeter if reduction of the forehead and glabellar (between the eyebrows) wrinkles is the goal and a bit longer if a brow lift is also being performed. An improved visual field is possible because the laser seals off the blood vessels. The endoscope allows the surgeon to work under the skin without having to pull the entire skin flap away from the forehead.

The mid-forehead technique reduces wrinkling on the forehead and lifts droopy eyebrows, however, the disadvantage is that the scar is visible on the forehead.

The direct method does not reduce the wrinkles on the forehead, it is strictly a technique for lifting the brows. The surgeon can more accurately position the brow with this method, a particularly important consideration when the brows are asymmetrical.

How long does brow lift surgery take and does it hurt?

The length of surgery varies with the technique being used and the extent of the correction.

The actual surgery is painless because a local anesthetic is used to numb the area prior to the procedure. After the freezing wears off, some discomfort may be felt along the incision. A temporary headache and tightness of the forehead and scalp may also be experienced. Oral painkillers are all that is needed to relieve this discomfort, but no acetylsalicylic acid (aspirin) products should be used.

When can normal activities be resumed?

With conventional surgery swelling and bruising will last approximately 7 to 10 days, whereas with the laser and endoscopic method, the recovery period is only 3 to 4 days. Most people do not feel presentable in public until the initial stages of swelling and bruising have passed. Elevation of the head is recommended until the swelling has subsided. When this occurs any normal activity which does not precipitate discomfort is allowed.

How will surgery affect the face?

A conventional coronal brow lift will raise the hairline and a hairstyle change may be recommended if the change is quite dramatic. This is not as significant a problem when the laser and endoscopic technique is used.

A softer, brighter, more alert and youthful look will be noticed after the procedure. The appearance of the upper eyelids is also improved and the eyes will look wider. It is not uncommon to receive compliments on a well-rested happy look after brow lift surgery.

How long does the result last?

Brow lift surgery does not prevent aging. Lines of expression over the forehead and between the eyebrows will still be present, although to a much lesser extent. With time, they become more pronounced but the youthful effect created by the surgery remains for a prolonged period of time.

What are the possible complications of a brow lift?

• Prolonged Redness of the Scar:
  This is unusual and of significance only in cases where the incision has been made in the forehead. The scar may also be tender and lumpy. Eventually this subsides but it may take 1 to 2 years. The vascular lasers (pulsed dye or variable pulse width) can be used to remove the redness. Injections of cortisone and resurfacing with the carbon dioxide laser can smooth out raised and uneven scar tissue. Medications and ointments are not effective in speeding up the healing process. Makeup can be used to camouflage a scar until it has healed.
  
  

• Balding:
  Women, with male-pattern hair loss or a strong family history of balding are cautioned about scarring. As balding progresses, a scalp scar will become more and more apparent because it is no longer hidden within the hair. A scalp incision often accelerates hair loss because of the tension of the scar and the subsequent interruption of the blood supply to the scalp. Other causes of hair loss in the region of the scar are infection and hematoma, both of which are rare. This is much less of a problem with the laser and endoscopic technique.
  
  

• Loss of Sensation:
  Often, a transient loss of sensation over the forehead and scalp to the crown of the head is felt. Feeling returns to the forehead within 4 to 6 weeks and to the scalp after 6 to 9 months. The smaller incisions used with the laser and endoscopic technique significantly reduce the occurrence of this complication.
  
  

• Overcorrection:
  If too much skin is removed, the face may look surprised or startled. With time, gravity's effect will improve this result. Overcorrection by too much tension at the scalp incision. This may cause poor healing, a wide scar, and hair loss.
  
  

• Itching:
  This may be troublesome, especially in the scalp area behind the incision. Fortunately this eventually subsides as the incision heals.
  
  

• Muscle Weakness:
  Muscle weakness is usually a temporary condition which gradually disappears. A positive aspect of this is that the forehead furrows markedly diminish with relaxed muscles.

What are the alternatives to brow lift surgery?

Collagen implants or muscle relaxants are alternatives to brow lift surgery for deep furrows on the forehead. Droopy eyebrows, however, require some form of surgery. Laser resurfacing of the forehead may tighten the skin above the brow enough to give droopy eyebrows a bit of a lift. If the eyebrows are really heavy then a brow lift is the only option available.

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