Brow lift
All about Brow lift plastic surgery , Brow lift cost, Clinics, Brow Lift before and after photos and pictures, complications.
The term browlift is generally used to describe a family of procedures aimed at the rejuvenation of the upper third of the face. A number of different incisions, planes of elevation, vectors of pull and methods of anchoring may be employed, depending on the underlying anatomic pathophysiology at work in the individual
patient. Techniques continue to evolve and must be tailored to each patient taking into account the patient’s sex, age, facial features and expectations.
ANATOMY AND AESTHETICS
Traditionally, the ideal forehead is thought of as occupying one-third of the height of the face when viewed from the front. The aesthetically ideal brow is generally thought of as a graceful arc occupying the space just superior to the orbital rim, ending at a point along a line drawn from the lateral nasal ala and the lateral canthus of the eye. The zenith of the arc should lie above a point between the lateral limbus and lateral canthus in females, while in males, it may lie more directly above the pupil.
The soft tissues of the brow and forehead are basically comprised of five layers, often remembered with the aid of the mnemonic SCALP:
Skin, subcutaneous tissue, Aponeurosis, Loose areolar tissue and Periosteum. The skin of the forehead is quite thick with many fibrous connections to the underlying facial muscles. There is also a relative paucity of fat compared with other regions of the face. The strong connection of the skin to the dynamic muscles of facial expression, coupled with the lack of subcutaneous fat to act as a filler contribute to the vulnerability of this facial region to the stigmata of aging.
The arterial supply to the forehead derives from the supraorbital and supratrochlear arteries medially (tributaries of the internal carotid system) and the superficial temporal artery laterally (a terminal branch of the external carotid). This dual arterial system forms a rich and robust blood supply with many anastomotic connections.
Venous drainage, as with most of the skin of the face is supplied primarily by an extensive subdermal venous plexus rather than discrete named vessels. The region is innervated by all three divisions of the trigeminal nerve with the supratrochlear and supraorbital nerve branches of the first division supplying the brow medially, the zygomaticotemporal branch of the second division supplying the medial temple, and the auriculotemporal nerve supplying the lateral aspect of the temple.
The brow is home to several muscles of facial expression whose function can lead to the development of deep rhytides over time. The frontalis muscle serves to elevate the brow, while the actions of the orbicularis oculi, corrugators and procerus all depress the brow. The frontalis muscle is the anterior half of the epicranius muscle and is not attached to bone. Its action over time contributes to the formation of deep horizontal rhytides in the forehead. The orbicularis oculi close the eyes, but their action over time contributes to crow’s feet, brow ptosis and hooding, particularly laterally where their action is less well opposed by the more attenuated frontalis.
The corrugator supercilii muscles lie deep to the frontalis and orbicularis muscles.
They originate from the medial orbital rim and insert into the dermis overlying the supraorbital foramen, producing the vertically oriented glabellar frown line. The procerus muscle originates from the inferior portion of the nasal bones and inserts into the dermis above the glabella and creates a horizontal rhytid between the eyes.
In addition to the neurovascular supply and musculature of the brow and forehead, a knowledge of the fascial planes is critical to understanding the anatomy of this region. The superficial temporal fascia, also known as the temporoparietal fascia, lies immediately deep to the dermis and is contiguous with the galea aponeurotica above and the superficial musculoaponeurotic system (SMAS) below. The superficial temporal artery, vein, and temporal branch of the facial nerve all lay within the temporoparietal fascia. The temporal branch of the facial nerve can be found along Pitanguy’s line which runs from 0.5 cm inferior to the tragus to 1.5 cm above the lateral aspect of the eyebrow. Deep to the temporoparietal fascia lies the fascia of the
temporalis muscle, known as the deep temporal fascia, which is contiguous with the periosteum of the skull at the conjoint tendon. The deep temporal fascia splits into superficial and deep layers above the zygomatic arch to envelop the superficial temporal fat pad.
BROWLIFT PREOPERATIVE AND ANESTHETIC CONSIDERATIONS
Preoperative workup consists of standard screening for risks of anesthesia with laboratory and cardiac workup tailored to the age and comorbidities of the patient and the type of anesthesia planned. Aspirin, other blood thinning medications and herbal remedies are discontinued. Frontal, lateral and oblique photographs should be obtained in a standardized fashion. Most browlift techniques can easily be performed
under intravenous conscious sedation in conjunction with effective local anesthesia although some still favor general anesthesia. Local anesthesia should be infiltrated along all incision lines as well as performing blocks of the supraorbital and supratrochlear nerves.
OPERATIVE TECHNIQUE
CORONAL BROWLIFT
Although minimally invasive techniques are rapidly gaining popularity, the full coronal browlift is still employed by many and does offer some advantages. The technique offers full exposure of the frontalis, corrugator and procerus muscles with an incision that is concealed within the hair-bearing scalp. Care must be taken to
select patients whose hairlines will tolerate the inevitable elevation associated with this technique. The incision is performed such that the resultant scar will lie approximately 3 cm posterier to the hairline following the excision of excess scalp. The incision is scyved in alignment with hair follicles, and electrocautery is used judiciously to minimize the region of alopecia associated with the scar.
Dissection takes place within the relatively bloodless subgaleal plane. In the temporal region, dissection is carried out between the superficial temporal fascia and the superficial layer of the deep temporal fascia, protecting the temporal branch of the facial nerve. Medially, the trunks of the supratrochlear and supraobital nerves are identified and preserved. The corrugator supercilii and procerus are easily visualized and may be divided to address horizontal or vertical rhytides in the medial orbitital region, the so called “frown lines.” Finally, 1-2 cm of excess scalp is excised from the incisional edge of the flap and a layered closure is performed.
PRETRICHIAL BROW LIFT AND TRICHOPHYTIC BROW LIFT
These techniques seek to minimize or eliminate disturbance to the hairline. The pretrichial incision is carried out at or just anterior to the hairline while the trichophytic incision lies a few millimeters posterior to the hairline. Careful beveling of the incision and minimal use of electrocautery are critical to avoiding unsightly
incisional alopecia. The plane of dissection and remainder of operative technique are essentially those of the coronal browlift; however great care must be taken with closure as the scar is far more likely to be visible, especially if the patient’s hairline recedes with time.
TEMPORAL LIFT
A temporal approach can be of great benefit in patients with isolated lateral brow ptosis or hooding. The incision is performed in the temporal region, running anterosuperior to posteroinferior across the temporalis muscle, similar to the Gillies approach to zygomatic arch repair. Dissection is carried out in a similar fashion to
the coronal technique, in the plane between the temporoparietal fascia and the superficial layer of the deep temporal fascia, protecting the frontal division of the temporal branch of the facial nerve which courses through the superficial temporal fascia. Dissection continues inferomedially to the supraorbital rim and arcus
marginalis. The superficial temporal fascia is then anchored superolaterally to the deep temporal fascia achieving the desired degree of elevation. Excess skin is excised, and skin is closed in a layered fashion.
MIDFOREHEAD BROW LIFT
This technique places the incision directly in the middle of the forehead, concealed within an existing forehead crease. It is useful for the patient seeking correction of severe brow ptosis or asymmetry for whom the appearance of horizontal forehead rhytides is of secondary concern. Either a single incision extending the full length of the forehead or two fusiform incisions above each brow are performed centered on a prominent forehead crease. Asymmetric positioning of these incisions can assist in their camouflage as natural wrinkles. In contrast to the coronal, trichophytic and pretrichial techniques, the plane of dissection is subcutaneous, superficial to the frontalis muscle and is carried down until the orbicularis oculi are visualized. The galea may be incised 2-3 cm superior to the orbital rim and excess galea excised or redraped and anchored to underlying periosteum. Excess skin is excised and closed in a layered fashion.
DIRECT BROW LIFT
Direct browlift refers to a skin and subcutaneous tissue-only technique which directly addresses positioning of the brow. A fusiform incision is made superior to each brow. Dissection is carried out in the subcutaneous plane with preservation of underlying muscular and neurovascular structures. Long term fixation is achieved through placement of sutures anchoring the superior aspect of the incision to the periosteum.
Meticulous skin closure is essential as the scar is located in a very visible location.
ENDOSCOPIC BROW LIFT
Minimally invasive surgical techniques have revolutionized all aspects of surgical practice, and aesthetic plastic surgery is no exception. Endoscopic browlift techniques allow results comparable to traditional incision techniques without the risks of incisional anesthesia and alopecia associated with longer scars.
Although techniques are rapidly evolving, the typical approach utilizes one midline coronal incision located along the traditional coronal browlift course and two temporal incisions placed along the traditional temporal browlift incision line (along a line drawn from the lateral ala throught the lateral limbus).
The dissection is similar to the open coronal and temporal browlift techniques.
The central dissection may proceed in the traditional subgaleal plane or alternatively in the subperiosteal plane, which some find to provide a more bloodless dissection and a better optical cavity. The supraorbital notch serves as the landmark to identify and preserve the neurovascular bundles. The corrugators and procerus musculature may be disrupted as in the open technique. Methods include sharp or blunt transection, thermal injury through electrocautery, or laser ablation. A superolateral orbicularis myotomy may be performed to maximally release the brow for elevation.
Laterally the dissection through the temporal ports proceeds along the traditional plane between the superficial temporal fascia and the superficial leaf of the deep temporal fascia until one reaches the supraorbital rim and arcus marginalis. Proceeding superomedially, the two dissections are joined at the conjoint tendon where the lateral dissection is transitioned to the deeper subperiosteal plane of the
central dissection. Care is taken in this area to identify the so called “sentinel vein” which identifies the course of the temporal branch of the facial nerve that lies directly above the vein in the superficial temporal fascia.
Fixation of the soft tissues along vectors providing ideal superolateral elevation of brow structures is a matter of rapidly evolving debate. Techniques and materials include soft tissue suture fixation, permanent or absorbable cortical screws with suture or staple fixation, cortical bone tunnels and various tissue glues. Regardless of fixation method, proper mobilization of the soft tissues during dissection is critical, and the ideal fixation method is likely of secondary importance so long as it provides a reliable result and is easily accomplished through the limited incisions of the endoscopic technique.
BROW LIFT POSTOPERATIVE CARE
Most browlift procedures are well tolerated and can be performed as an outpatient with a responsible family member on visiting nurse to provide reliable observation in the first 24-48 hr postoperatively. Ice packs may be used judiciously to limit postoperative swelling. Patients typically do well with a few days of mild oral narcotic analgesia, transitioning to over the counter pain medications as tolerated. Sutures and staples should be removed one week after surgery. Patients may advance their activity as tolerated with most returning to normal daily activities within 3-5 days. Aerobic and other strenuous activities should be avoided for two weeks postoperatively.
BROW LIFT COMPLICATIONS
Swelling and bruising should be expected, although the incidence of both can be minimized through judicious use of electrocautery and careful adherence to relatively avascular tissue planes.
BROW LIFT SCARS
Scarring is present in every brow lift. Well-designed incisions closed without tension produce the best scars. Patients with a family or personal history of hypertrophic scarring or keloid formation or risk factors for excessive scarring after a facelift should be counseled preoperatively.
Hematomas may occur in the setting of inadequate hemostasis or in the failure to recognize a potential bleeder due to intraoperative
vasospasm or vasoconstriction from the use of local anesthetics containing epinephrine.
Patients should be warned of the risk of incisional alopecia and anesthesia.
Both can be minimized by limiting thermal injury associated with electrocautery and taking care to minimize tension along the suture line during closure. Standard perioperative antibiotics may be administered to limit the incidence of wound infection although the rich vascular supply of facial skin makes this a rare complication even in the absence of such prophylactic measures.
In addition to incisional anesthesia, risk of injury to major sensory or motor nerves must be related to the patient. Careful dissection along safe tissues planes and avoidance of excessive tissue traction minimize these risks. In the absence of complete transection, most nerve injury is transient, and patients may be reassured that partial or complete return of function is typical.
Finally, as in any elective aesthetic procedure, the patient should be counseled on the inherent unpredictability of the final outcome and the very real possibility of under-or overcorrection, asymmetry, hypertrophic scarring and other aesthetic considerations which are a function of the body’s inherent response to the surgery out of the control of the surgeon.
Pearls and Pitfalls
• The highest brow peak in women is between the lateral limbus and lateral canthus, whereas in men it is more directly above the pupil, less of a peak and roughly at the level of the orbital rim.
• Vertical glabellar wrinkles are due to the corrugators, whereas horizontal wrinkles are primarily due to the procerus.
• Excessive resection of the procerus, corrugator and frontalis muscles can result in visible depressions in the center of the forehead and glabellar regions.
• For patients who have a very high hairline preoperatively, the pretrichal approach will preserve the hairline without elevating it further.
• For patients with any lateral ptosis, insufficient release of the orbital retaining ligaments (dermal to periosteal adhesions) will result in under correction of the ptosis and a likely dissatisfied patient.
• If an upper blepharoplasty is planned along with the browlift, much of the dissection can be performed through the upper bleph approach. After dissection above the supraorbital rim and development of the subperiosteal plane, the periosteum can be released from the bone and the muscles readily divided under
direct vision.
HOW MUCH THE PRICES AND COSTS
COST OF A BROW LIFT:
The average price of brow lift is $4,000 to $15,000. the average cost also depends on the location of the clinic, the surgeon’s experience and the size of the procedure. In addition, prices include much more than just the surgeon’s fee, which typically costs about $ 4000 – $ 5000, even as the cost of installation fees, hospital fees, anesthesiologist fees, and more.
Average face lift prices according to technique are as follows:
Threadlift face lift: USD$1,900-$5000, average $38000
Standard face lift: $5,000-$14,000, average $7,000
Mini (weekend) face lift: $2,900-$5,500, average $4,000
Mid face lift: $3,800-$9,000, average $8,000
Lower face lift: $3,950-$9,600, average $6,000
BROWN LIFT BEFORE AND AFTER PHOTOS – PICTURES AND VIDEO
VIDEO CONSULTATION