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Plastic Pointers How to Avoid Brow-lift ComplicationsCareful preop preparation and a meticulous wound closure are two of the keys to success.Kyle Balch,
MD Presented here are five kinds of approaches to eyebrow and forehead lifting: the suprabrow or direct approach, the mid-forehead, the pretrichial, the coronal and the endoscopic approach. Some complications pertain to all five techniques, while others are unique to specific ones. We’ll discuss them in order, highlighting the complications and how you can avoid them. Suprabrow/Direct The suprabrow, or direct, approach is one of the quicker and technically simpler eyebrow lifting procedures.  This technique entails removal of skin and subcutaneous
tissues immediately superior to the brow. This is typically done as a bilateral
procedure and includes an incision over each eyebrow. Follow-ing the removal of
the suprabrow tissue, each wound is closed in a layered fashion.
Though techniques such as those shown here can work well, they do carry a risk of complications ranging from contour abnormalities to loss of sensation. Contour abnormalities can result if you don’t have an eye toward the contour differences of the sexes. Men have a straighter contour to the eyebrow when compared to women, who typically have a central-lateral arch. In men, you can restore the ideal contour by removing a greater amount of tissue laterally. To avoid contour abnormalities, it’s important to identify your goals and any potential problems preop. By noting the areas of the greatest brow ptosis, and recognizing the desired contour, you can minimize abnormalities.
Noticeable suprabrow scars two weeks after a direct eyebrow lift (left). Note the improved appearance eight months later (right). Noticeable scars are inherent to the direct approach simply because of the incision location. You can minimize them by choosing patients properly. The best candidates for the direct approach are older men with deep forehead wrinkles. Just as important, meticulous closure of the wound will minimize scars. Some advocate a four-layer closure, but a meticulous two-layer closure is probably sufficient. This would include closure of the deep tissue with an absorbable suture (i.e., 5-0 vicryl) followed by skin closure with a non-absorbable suture (i.e., 6-0 prolene) that results in excellent eversion of the wound. Sensation problems occur due to injury or transection of the supraorbital and supratrochlear nerves or their branches. You can avoid significant sensation problems that result from injuring the large branches of the supratrochlear and supraorbital nerves by staying above the brow fat pad and frontalis muscle. Finally, a fixed or immobile brow can result from suturing the mobile superficial tissue to the immobile periostium. To avoid immobilizing the eyebrow, simply avoid a suture bite through the deep immobile tissues (i.e., periostium). Mid-forehead Incision This approach is essentially the removal of tissue between deep furrows or wrinkles in the forehead. This can be done either by removing a single strip that spans the width of the forehead or a strip of mid-forehead tissue above each brow.
You can avoid or minimize undesirable scarring by choosing patients with deep forehead wrinkles, by placing the inferior incision in the trough of one of the forehead wrinkles and by a meticulous closure. The last technique involves a meticulous two-layer closure. In this approach, again remember to stay superficial, above the frontalis muscle, which is just beneath the skin and subcutaneous tissue. Pretrichial, Coronal and Endoscopic Lifts These approaches to eyebrow lifting have the additional benefit of also “lifting” the forehead and the upper lateral facial tissues. It is for this reason that these techniques are performed for both cosmetic and functional reasons. As discussed below, these three techniques share many of the same complications, but the appropriate technique can significantly minimize them. The pretrichial eyebrow and forehead lift involves placing an incision across the entire length of the forehead just in front of the hairline. Typically, the incision is carried laterally, either as a continuation in front of the hairline or as a continuation of the previous incision that extends posterior to the hairline and then inferiorly to the top of the ear. The scalp incision is full-thickness, and is typically carried down to or through the periostium. The surgeon then undermines the forehead and eyebrow tissues and lifts them away. He releases deep attachments and advances the entire flap superiorly, then excises the redundant tissue. This is followed by a layered closure of the wound. The coronal incision is very similar to the pretrichial incision, except that the coronal incision is posterior to the hairline for its entire length. The surgeon performs the same undermining and releasing, as well as the superior advancement and excision of the redundant flap tissue. Because this approach, like the endoscopic lift, pulls the hairline superiorly, patients with “high” foreheads do better with the pretrichial approach. The endoscopic approach accomplishes the same goals of eyebrow and forehead lifting, but does so through a series of five or six very small incisions just posterior to the hairline. The surgeon passes an endoscope/camera through the incisions to visualize and aid in the dissection. Instead of excising a flap of tissue as is done in the other approaches, the permanence of the lift is accomplished by various fixation techniques whereby the forehead flap is lifted superiorly and secured to the skull, usually with screws.
A thorough knowledge of anatomy is mandatory before attempting these procedures. Knowledge of the path of the frontal branch of the facial nerve and avoidance of excessive dissection in its pathway minimizes the occurrence of this complication. The key is to develop and maintain a plane of dissection deep to the nerve. The most likely areas of damage are in the temporal regions where the facial nerve travels in the superficial temporal fat pad. By developing and maintaining a plane of dissection just superficial to the deep temporal fascia (deep to the nerve), one can minimize the risk of nerve damage. Hair loss is another potential complication of these approaches and occurs due to damage to the hair follicle. It primarily occurs with the open techniques, but can also occur focally with the endoscopic techniques. This is likely to occur when the incision traverses through the hair. Actual damage to the follicle is most likely to occur with cautery, or by placing excessive traction on the follicles during closure. The hair loss can be permanent, but it typically regrows within three to six months. The incidence of hair loss is greater with the coronal approach, simply due to the larger incision size. You can minimize hair loss with good surgical techniques and by limiting the use of cautery and wound traction. It’s important to identify patients with thin hair and discuss this potential complication with them. They may have better results if you use either the pretrichial or endoscopic approach. There may also be some degree of temporary sensation loss with each technique because the nerve’s branches are transected in the full-thickness procedures, and stretched or bruised during the endoscopic ones. You can minimize this by avoiding blunt and sharp trauma to the supraorbital and supratrochlear nerves. Remember that the supraorbital nerve may exit the orbit through a supraorbital notch, or less commonly through a foramen that’s up to 1 cm superior to the superior orbital rim. Therefore, lift the forehead flap under direct visualization with special attention to these areas. Postoperative-ly, instruct patients to be very careful with hot hair dryers and curling irons, since they could severely burn their scalps without feeling it. Widened scars may also occur, typically as a result of poor wound closure or excessive traction that occurs when too much tissue is removed. You can avoid widened scars by practicing meticulous wound closure with minimal traction. For patients who are dissatisfied, scar revision is the only option.
Both surgeons and patients have many options for lifts. By learning these approaches and selecting the right technique for each patient, you can be very successful with them.
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