The human face is a canvas of expression, emotion, and identity. As we age, the subtle changes in facial features can significantly impact our overall appearance and how we are perceived by others. Among these changes, the aging of the eyebrows plays a pivotal role in defining the youthful aesthetic of the face. The position, shape, and fullness of the eyebrows are integral to conveying expressions and framing the eyes, which are often referred to as the windows to the soul. In the field of plastic surgery, understanding and addressing the aging brow has become a cornerstone of facial rejuvenation surgery procedures aimed at restoring a more youthful and harmonious facial appearance. This chapter delves into the intricate nuances of eyebrow rejuvenation, exploring the anatomical changes associated with aging brows, non-surgical and surgical techniques and elucidating the significance of this area in achieving a rejuvenated and naturally youthful visage. However the ideal brow shape is influenced by many factors as age, sex, ethnicity, culture and current fashion trends. Additionally the surrounding periorbital features are important determinants of eyebrow shape and appearance. Therefore there is a great variance on shape, size and position of eyebrows that are aesthetically pleasing on different face shapes.   

As described in the introduction the eye region serves as the emotional and expressive focal point of the human face. Beyond the color, shape, and positioning of the eyes, other factors such as shape, color, and length of the lashes, quality and quantity of the skin and also height and shape of the eyebrows, are also significant aspects that influence the overall appearance of the face. For numerous decades, a preference existed for a high eyebrow situated above the orbital rim, and smaller eyebrows with the arch positioned in the middle. The optimal position of the eyebrow arch has been extensively deliberated in the literature.

Ideal eyebrow shape according to current literature:

1. Medial brow should begin on the same vertical plane as the lateral rim of the ala and the inner canthus (A-B)
2. The brow ends laterally (C) at an oblique line drawn from the most lateral point of the ala (A) through the lateral canthus
3. The lateral brow should be slightly higher than the medial (B,C)
4. The apex lies on a vertical line (D-E) directly above the lateral limbus
5. In male patients the brow should be straight at the level of the orbital rim


However it must be noted that the choice of a specific eyebrow type is influenced by the age of the individual being interviewed. It has been conclusively demonstrated that individuals older than 50 years tend to prefer an arched eyebrow type with the maximum height in the middle, a style that was fashionable until the 1970s. Perceptions differ significantly for younger subjects, specifically those up to 29 years of age. They consider arched eyebrows as unattractive and express a preference for eyebrows positioned lower, with the maximum height in the lateral third. The distinct preferences observed in younger versus older individuals lead to the conclusions that it is inaccurate to assert that there is only a singular beauty ideal regarding eyebrow position, and recommendations for plastic surgical interventions should not solely rely on this presumed ideal.


It is important to consider the audience to whom the patient seeks to appeal. Especially before any surgical intervention, the physician should be cognizant of how significantly the preferred eyebrow shape, and consequently the perception of attractiveness, is influenced by the individual's age.

Changes of the aging eyebrow: As shown by Matros et al. [11] the apex of the brow was is significantly higher in young females than in older patients. Therefore aging leads to a leveling out of the brow and consequently depression of the apex and the lateral brow. Additional leads a volume loss of the soft tissue and bone to a further ptosis of the brow. 

Hyperactivity of the musculus orbicularis oculi can result in ptosis of the lateral brow. Vertically and obliquely oriented fibers of muscle, when activated or with baseline resting muscle tension, pull down on the position of the tail of the brow and oppose the lifting action of the frontalis muscle.

Furthermore, leads a hyperactivity of the muculus proceurs, depressor supercilii and corrugator supercilii in the glabella region to a medial depression of the brow. 

• Musculus orbicularis oculi muscle is a strong brow depressor. In most patients, the superolateral orbicularis oculi is positioned at or just inferior to the level of the lateral eyebrow hairs.

• Injection has to be superior to the orbital rim to prevent lid ptosis and brow ptosis• Injection point on musculus depressor supercilii should be evaluated while patient clinches eyes. The more later a wrinkle formation superior to the eyebrow can be seen, the more superficial the injection has to be• simultaneous therapy of the frontalis muscle and the eyebrow region with neurotoxin should be always carefully considered. Heavy paralysis of the frontalis muscle can lead to further brow ptosis

• Male brows are commonly straight without a lateral peak, this should always be considered while injecting in this are to prevent alteration of the brow shape

• Injection in the area of the crows’feet can lead to further relaxation of the musculus orbicularis oculi and consequently a lateral eyebrow lift

The best effect occurs when the noninjecting hand is used to elevate the brow and injections are kept approximately 1 cm above the orbital rim. Topical anesthesia may be used but is not necessary in most cases. Injection sites and IU are shown in the following images. 

• Effect of a neurotoxin brow lift is only limited and not suitable for patients with heavy-very heave eyebrows

• Effect lasts 2-4 months

• Incorrect injection depth, quantity of neurotoxin and localization can lead to an even heavier brow ptosis 

• Lateral brow lift: depending on muscle anatomy and width of orbicularis oculi muscle, injection pattern should be adapted: a strong and wide orbicularis oculi muscle might need two parallel rows of injection to achieve a sufficient brow lift

• Medial brow lift: anatomy and depth of musculus depressor supercilii should be considered: depressor supercilii muscle lies in between the deep corrugator supercilii and superficial the musculus procerus. However, the lateral extent of the muscle lies superior to the orbicularis oculi and on the frontalis muscle. Its lateral extent reaches to the pupil. To address this muscle completely, injection depth has to be considered along the full extent. Median injection depth has to be deep, lateral very superficial. This is crucial to prevent eyelid ptosis due to deep injections on the lateral aspect of the muscle. 

Filler usage in cases of brow ptosis has emerged as a non-surgical option for addressing age-related changes in the brow region. Volume loss of bone, subcutaneous fat and soft tissue can lead to brow ptosis. Hyaluronic acid fillers can be strategically injected to lift and support the brows. By carefully placing fillers along the brow bone and temple area, a subtle yet impactful elevation of the brows can be achieved.

This approach offers patients an alternative to surgery, providing natural-looking results with minimal downtime and reduced risk compared to traditional brow lift surgeries. 

Suitable patients for a hyaluronic acid brow support and consequently brow lift should be selected carefully. Only minimal to little brow ptosis can be corrected by supporting the surrounding tissue. I cases of moderate to heavy brow ptosis surgery will be necessary. 

- HAG filler is applied via a 30 gauge needle in the retro-orbicularis oculi fat pad (ROOF) in the tissue plane deep to the orbicularis oculi muscle

- HA filler is distributed in a feathering technique with multiple passes to create a “haystack” configuration [12]

- The orbital septum should not be distorted and no filler should be injected into the orbital fatpad 

- Additional brow lift can be achieved by injecting HA filler around the crista frontalis between the superficial and deep temporalis fascia

• prolonged edema formation

• blue-gray dyschromia

• excessive eyebrow puffiness and heaviness due to filler migration through the orbital septum

Lipofilling, also known as fat grafting or fat transfer, has gained prominence as a versatile and natural approach to facial rejuvenation. When applied to the eyebrow region, lipofilling offers a unique method for restoring volume, contour, and youthful fullness to the aging brow. By harnessing the regenerative properties of autologous fat, lipofilling of the eyebrows can effectively enhance facial harmony and provide long-lasting rejuvenation and leads to improvement of skin quality. In particular, preparation according to the CELT protocol enables an end product with a very high number of fat precursor cells and a high proportion of extracellular matrix structures to be obtained. The viscosity properties are similar to a hyaluronic acid filler. Healing is excellent and it is a natural filler without tissue reaction.

Suitable patients for CELT Lipotransfer for brow rejuvenation have minimal-mild brow ptosis and overall volume loss of the periorbital region. However only mild to minimal brow ptosis can be corrected by supporting the surrounding tissue. In cases of moderate to heavy brow ptosis surgery will be necessary. Injection technique is analogous to HA filler injection pattern.

Selection of the appropriate technique (non-surgical and surgical) depends on the level of the hairline, thickness of the forehead skin, severity of the rhytids, and whether the brow ptosis is medial or lateral. The techniques for consideration are as follows Table 1: Surgical techniques: Values range from + mild to ++++ highest effect 

• often combined with upper lid blepharoplasty and is performed through the same incision

• suitable for relatively small degrees of brow ptosis affecting mainly the lateral two-thirds of the eyebrow

1. Determine the optimum position for pexie sutures of the eyebrow by manually lifting the brow in the area of the lateral third.
2. blepharoplasty incision and point of is marked and the localization of the desired point of brow lift is marked in upright patient position (lateral 1/3 of the eyebrow)

3. dissect is made superiorly in the area of the blepharoplasty incision and, immediately deep to the orbicularis muscle, until the brow fat (ROOF) is exposed. Leave the fat in situ and continue dissection in the same (submuscular) plane to expose about 1-2 cm of frontal periosteum. Extend the dissection a short way laterally to expose the deep temporal fascia.

4. The brow fat may be debulked laterally at this stage if desired to correct excessive lateral brow fullness.

5. Brow fixation to the periosteum about 1-2 cm superior to the orbital rim with one or two PDO 4/0 resorbable sutures. The skin immediately superior to the brow hairs will be sutured subcutaneously to the periosteum 1-2 cm superior to the orbital rim. 

6. Check positioning of the brow pexie before closing the knot! It is recommended to so one brow after the other. Correction of the more ptotic brow should be first due to only limited achievable raising of the brow with this technique

7. Wound closure is performed as a standard intracutaneous running non-resorbable suture with Prolene 5-0 suture 

• Relaps of brow ptosis 

• Loss of sensation due to trigeminal nerve irritation

• Irritation of the R. frontalis N. facialis

• Dimpling of skin in the area of pexie 

• Lack of forehead rhytids

• Unilateral facial paralysis

• Convex forehead craniofacial skeleton (limits endoscopic approach)

• Receding hairline (scar visibility)

• Baldness

• Heavy eyebrows

• Prior eyebrow scar

• Patient preference

• Unwillingness to accept a potentially visible facial incision

• Thin eyebrows

• Patient anatomy and/or expectation better suited for another surgical approach

• Patient without wrinkles with thin, flat forehead

1. 15C blade scalpel is used to create a slightly beveled incision such that the final closure will naturally evert the skin edges. Near the eyebrow, one should bevel the blade in the direction of the hair follicle to preserve the brow hairline.

2. Hemostasis is achieved using pressure and limited electrocautery.

3. Preoperative markings are done on an upright sitting patient pre surgery before local anesthesia infiltration

4. Surgery can be performed under local anesthesia

5. The planned amount of skin to be resected is verified and compared to the preoperative marking. Local anesthesia (1% lidocaine with 1 to 100,000 epinephrine with a maximum of 7 mg/kg of lidocaine) is injected into the planned surgical site subcutaneously 

6. The skin and underlying subcutaneous tissue is dissected from the frontal fascia and resected while avoiding injury to underlying neurovascular structures and muscle (frontal and orbicularis oculi).

7. The ptotic frontalis and orbicularis oculi muscles may be suspended to a more youthful position by superiorly anchoring them to the forehead periosteum with a PDO 4-0 suture. If prominent rhytids of the glabellar and procerus muscle need to be addressed, medial dissection may allow for dissection of these muscles. Special attention must be given to the neurovascular bundle.

8. The deep layer of the wound is closed using absorbable sutures (e.g., Vicryl or Monocryl). The skin may be closed in a subcuticular or superficial fashion with Prolene 5-0 running suture

- wound infections

- Hematoma

- Brow asymmetry

- Forehead paresthesias

- Injury to the temporal branch of the facial nerve

- unfavorable scar formation

- Alopecia of the eyebrow in the area oft he scar and due to necrosis of hair follicles due to cauterization 

- Overcorrection

- Eye dryness

Although a facial scar is inevitable, proper surgical technique promotes a high degree of satisfaction regarding scar appearance. Proper preoperatively counseling is paramount to optimize results and minimize complications. 

• heavy forehead rhytids

• Convex forehead craniofacial skeleton (limits endoscopic approach)

• Receding hairline (scar visibility)

• Baldness

• Heavy eyebrows

• Patient preference

• Surgery can be performed under local anesthesia

• Unwillingness to accept a potentially visible facial incision

• Patient anatomy and/or expectation better suited for another surgical approach

1. Preoperative markings are done on an upright sitting patient before local anesthesia infiltration. Eyebrow position can be anticipated with manual repositioning and preoperative markings can be made. Vertical guidelines median, medial brow and lateral brow are essential. Localization of Incision is placed in a deep rhytid of the forehead. If the rhytid is not continuous over the forehead a different rhytid can be used for the contralateral eyebrow

2. Local anesthesia (1% lidocaine with 1 to 100,000 epinephrine with a maximum of 7 mg/kg of lidocaine) is injected into the planned surgical site subcutaneously.

3. 15C blade scalpel is used to create a incision down to the galea aponeurotica

4. Plane of dissection is made subcutaneously supragaleal and superior to the musculus frontalis. Elevating the inferior flap with rakes and performing a combination of sharp dissection and blunt separation with scissors is the most common approach.

5. Hemostasis is achieved using pressure and limited electrocautery.

6. The corrugator and procerus muscles can be accessed if necessary, by incising the galea horizontally about 3 cm above the nasal root and carrying the dissection deeply. Care is taken not to injure the supraorbital nerves laterally. Muscle dissection can be performed with electrocautery or sharp

7. The degree to which the corrugator and procerus muscles need to be weakened is based on preoperative assessment. In some patients, partial removal of the muscles with clamping and cauterization is performed. In others, surgeons aim for minimal weakening. For more aggressive weakening, the muscles can be disinserted from their bony origins while protecting the neurovascular bundles.

8. Dissection is made to the orbital rim with caution on the neurovascular bundle

9. Before skin resection, dissection of the contralateral side should be performed to achieve a symmetrical result

10. In cases of heavy brow´s a direct brow pexie grabbing subcutaneous tissue to periosteum of the orbital rim with PDO 3-0 thread can be made in 1-3 areas (medial, median and lateral brow)

11. Brow position is now symmetrical repositioned and skin excess marked

12. Excess skin should be resected sharp with a 15c blade

13. The deep layer of the wound is closed using absorbable sutures (e.g., Vicryl or Monocryl). The skin may be closed in a subcuticular or superficial fashion with Prolene 5-0 running suture

14. Hemostatic NET can be added in patients with higher risk of postoperative bleeding 

15. Steristrips and a soft pad are applied. An additional pressure dressing can help minimize bruising and swelling, but care should be taken to ensure that it is neither too tight nor that it applies downward tension on the brows

The minimal invasive suture suspension brow lift is an ideal surgical approach in patients with mild-moderate brow ptosis. Technical limitations are a very high hairline. Surgery can be performed under local anesthesia. The brow can be refashioned medial, central and laterally which makes the minimal invasive technique a favorable approach. 

1. Preoperative markings are done on an upright sitting patient pre surgery before local anesthesia infiltration. Optimum position for lift is determined by manually lifting the brow. Vector guidelines are then been drawn onto the forehead vertical to the hairline

2. Incisions are planned at a vertical line from the medial aspect of the brow in the hairline and laterally at the vertical line of the lateral tail of the brow. If necessary in a global brow ptosis a additional incision can be planned in between the first two incisions

3. Local anesthesia (1% lidocaine with 1 to 100,000 epinephrine with a maximum of 7 mg/kg of lidocaine) is injected into the planned surgical site beginning at the point of lift at the eyebrow towards the hairline in a strict subcutaneous layer. In the area of incision in the hairline is a infiltration of local anesthesia subgalea additionally necessary

4. Incisions are made vertically with a 15 C blade scalpel with a beveled blade in in the direction of the hair follicle to preserve the brow hairline, the galea is left intact

5. Incision site is held open with a medial and a lateral skin retractor. Minimal undermining of the cutis is made with Metzenbaum’s scissors. 

6. A 20 Gauge cannula (with a length of 90mm or 70 mm) is inserted subcutaneously into the area of the desired brow elevation at the superior border of the hairy eyebrow (Transition from eyebrow to skin) and then advanced subcutaneously to the incision

7. Tip of the cannula is then being expose in the area of the incision in the hairline

8. A non-absorbable suture (fiber wire 3-0 (Arthrex) with a periosteal semicircular point needle with special cut) is then threaded into the tip of the cannula up to the caudal opening of the cannula and pulled for a minimum of 10 cm out of the cannula

9. The suture in the cannula is now tunneled subcutaneously through the forehead and exposed and fixed both in the area of the incision and in the area of the cannula head

10. The needle is now withdrawn caudally until the tip of the needle can be felt in the area of the eyebrow approx. 3 mm cranial to the puncture.

11. Now the needle tip is moved subcutaneous approx. 2 mm laterally and then tunneled again in a "new" subcutaneous channel cranially up to the incision. This creates an imaginary U with the suture in the area of the brow and both ends of the suture are now in the area of the incision

12. With the needle holding end of the suture is now a pexie into the galea performed and suture is then pulled as much as necessary under control to achieve the wanted brow lift on the brow

13. 4-6 Pexie threads are inserted according to the procedure described above

14. Wound closure will be performed after irrigation with staples to prevent ischemia in the hair follicles due to thread suture and consequently hair loss. Additionally, Dermabond glue can be applied to waterproof scars 

15. Staples are being removed 10 days post surgery 

- Periosteal diamond point needle, semicircular with special cut- High strength, soft suture with abrasion resistance

- Low friction coefficient 

- Eliminates suture breakage during knot tying

- Asymmetrie- Suture loosening and recurrence of ptosis

- Suture may be palpable subcutaneously by the patient

- the suture may be palpable subcutaneously by the patient  

• Our innovative method is simple, effective, and can be learned easily.

• Moreover, this minimally invasive technique is associated with a short recovery time, inconspicuous scarring, stable long-term results,

• and offers the possibility of simple later corrections if required.

- Brow ptosis mild-moderate

- Possibility to redefine the entire brow shape

- Slightly excess forehead/temporal skin

- Frontal skin shrinks approx. 10-15 %

- Surgery can be performed under local anesthesia or general anesthesia

1. Braid hair into plaits (taking the incision into account)

2. Draw vertical auxiliary lines in upright seated patient pre surgery: median forehead, medial eyebrow, lateral eyebrow

3. Local anesthesia (1% lidocaine with 1 to 100,000 epinephrine with a maximum of 7 mg/kg of lidocaine) is injected into the planned surgical site beginning at the point of lift at the eyebrow towards the hairline in a strict subcutaneous layer. In the area of incision in the hairline is an infiltration of local anesthesia subgalea additionally necessary (infiltration needs to be done periorbital up to 1 cm caudal to the eyebrows, laterally up to 1 cm inferior to the os zygomaticum)

4. Symmetrical incision in the area of the hairline via 3 mm vertical incisions with 15 blade beveled scalpel bilaterally: frontotemporal and frontal. Frontal incision: if mobilization of the entire brow and not just laterally is desired

5. Patients with a high forehead might need an additional paramedian incision to simplify preparation

6. Viterbo´s dissector is inserted into the frontal incision and subcutaneous dissection up to 1 cm caudally of the eyebrow is performed. Temporal dissection has to be strict subcutaneously and epifascial to prevent nerve damage of the frontal branch of the facial nerve

7. Areal of dissection: median: 5mm caudal of the inferior end of the eyebrow up to orbital rim, lateral: temporo-parietal fascia, periorbital region, inferior: Inferior border os zygomaticum

8. Selection of dissectors: Cranial preparation: rhomboid or cylindrical (straight) dissector. Caudal and lateral preparation: semi-curved dissector and L-shaped dissector. Strongly convex forehead/ high forehead: curved dissector

9. Handling of the dissector: movement: superior-inferior direction. Tip of the dissector directed towards the skin-> strictly subcutaneous preparation. CAVE: perforation of the skin. Non-dominant hand controls dissector (analogous to liposuction to avoid irregularities). L-dissector can also be used under caudally directed pressure to dissect fibrous bands 

10. After skin is dissected wound irrigation should be made

11. Eyebrow position fixed with a nylon 4-0 suture superior of the eyebrow to the periosteum of the orbital rim. Amount of sutures depends on wished positioning of the skin. Special attention must be given to the neurovascular bundle supraorbitally. 

12. In case of excess skin a skin redraping using and Hemostatic Net (NET-Auersvald) should be performed: 20% overcorrection necessary: Suture with nylon 5-0, nylon 4-0 for very thick skinFixation of the repositioned and reshaped brow by pexia of the skin to underlying periosteum

13. Hemostatic NET: transcutaneous horizontal continuous suture with Nylon 4-0 or 5-0. Symmetry of brow position should always be checked

14. Removal of the NET after 2-3 days. 2 hours postoperative blood circulation has to be checked, if skin perfusion is compromised opening of individual sutures necessary

- Repositioning/redraping of skin

- fixation of brows

- prevention of seroma/hematoma formation

- 20% overcorrection necessary

- Suture with nylon 5-0, nylon 4-0 - Hemostatic NET: transcutaneous horizontal continuous suture. Symmetry of brow position should always be checked

- Removal of the NET after 2-3 days. 2 hours postoperative blood circulation has to be checked, if skin perfusion is compromised opening of individual sutures necessary

Brow lifting procedures, under the category of open techniques, have been conducted for nearly a century and remain prevalent in contemporary cosmetic practices. [23] This chapter presents coronal forehead lift and the pretrichial modification of it.

Coronal forehead lift: This method is appropriate for individuals with a typical to lower hairline. Limitations of the coronal approach include a raised hairline in women and the occurrence of male pattern baldness. [2]

Pretrichal modification: The pretrichial modification of the coronal approach is recommended for women with an elevated hairline and an elongated vertical forehead or those with thick hair often styled forward. It is also recommended for men who have undergone hair transplantation in the past. [2]

1. The patient is positioned in a supine position on the operating room table

2. The facial and air areas are disinfected with a chlorhexidine solution, and the patient is draped in a sterile manner

3. Skin incision, positioned 4 to 10 cm behind the hairline, spanning the width of the scalp, approximately from one ear to the other

4. The dissection is extended anteriorly and inferiorly in a subgaleal (or subperiosteal) plane towards the supraorbital and lateral orbital regions. This is performed with direct visualization, facilitating the relatively straightforward preservation of the supratrochlear and supraorbital nerves.

5. The removal of brow depressor muscles, specifically the corrugator and procerus muscles, is performed during the undermining of the brow.

6. The extent of eyebrow elevation targeted is contingent on the width of the removed scalp tissue. (Typically, a scalp excision of 2.5 cm leads to a 1 cm elevation of the brow) The galeal layer is brought back together using absorbable sutures, and the skin closure is achieved through either continuous sutures or staples.

1. The patient is positioned in a supine position on the operating room table

2. The skin incision is marked along the front hairline, positioned behind the fine vellus hairs. Laterally, the skin cut is prolonged in a way that the bottom part of the incision concludes in the temporal hair, positioned above and in front of the base of the helix. While making the incision, the blade is angled in a way that the hair follicles are severed at an approximately perpendicular angle to their direction.

3. The dissection layer can be situated above the periosteum, reaching forward up to 2 cm from the supraorbital torus. At this juncture, the dissection layer should transition to being subperiosteal to safeguard the supraorbital nerves.

4. The periosteal connection of the arcus marginalis to the supraorbital rim is elevated.

5. The temporoparietal fascia should be incised, revealing the fascia of the temporalis muscle. Subsequently, the temporoparietal fascia should be lifted away from the temporalis fascia, progressing from the outer side to the inner side until the common tendon is reached.

6. After locating the common tendon, it should be pierced with a Freer elevator, moving from the outer side to the inner side, approximately 2 to 3 cm above the zygomaticofrontal suture.

7. The supraorbital neurovascular bundles should be freed from their notches to enable the full retraction of the flap. (In cases where foramina are present instead of notches, the lower edges of the foramina can be carefully osteotomized using a 3-mm osteotome. This facilitates the release of the neurovascular bundles and prevents neuropraxia.)

8. The periosteum needs to be raised precisely at the level of the supraorbital rim (and extending approximately 1 cm laterally from it)

9. The forehead flap is then pulled upwards until the intended brow height is achieved. It is possible to stabilize the flap in its elevated position before closure, e. g. with resorbable polymer anchors.

10. The closure process begins by securing the incision with sutures or staples, and an assessment is made to determine the amount of surplus tissue that can be removed.

11. Once the tissue has been excised, the remaining closure is carried out, ensuring proper hemostasis. The closure is done in layers, including the galea aponeurotica / temporoparietal fascia, subdermis, and the skin surface.

Standard complications associated with any soft tissue surgical procedure (including pain, bleeding, infection, and unsatisfactory scarring).

Specific complications after coronal / pretrichial brow lift:

• Numbness in part or the entirety of the forehead (from injury to the supraorbital and/or supratrochlear nerves)

• Weakened brow elevation or brow ptosis (due to frontal branch injury of the facial nerve) 

• Brow asymmetry

• Inadequate brow elevation or excessive brow elevation

• Hairline irregularities and alopecia at the scar line.

Prior to 1991, the coronal brow lift was considered the gold standard for addressing brow ptosis. However, the procedure was not without postoperative complications and undesirable consequences, such as prolonged numbness, itching, scalp alopecia, and scarring deformities. [24] The small-incision endoscopic approach to brow lifting was initially introduced by Vasconez and Isse in 1992. [23] [10]

The endoscopic brow lift achieves its impact through a mechanism distinct from that of the open coronal lift. The effectiveness of the coronal brow lift is attributed to a mechanical process. In contrast, the endoscopic brow lift relies on the dynamic interaction between the elevators and depressor muscles of the forehead. Weakening the depressors allows the elevators to function with less opposition. Nevertheless, it has become evident that the success of brow lifting should not solely rely on brow elevation. Instead, the emphasis should be on preserving or enhancing the shape of the brow. The brow lift is aimed at restoring the loss of definition that accompanies the aging process. [24]

• Browptosis (Due to aging, trauma, congenital deformity)

• Pseudo blepharoptosis (Secondary to brow ptosis)

• Brow height and shape asymmetry

• Redundant forehead skin with deep rhytids and furrows in the glabella/nasal radix, and the horizontal plane of the forehead

Absolute contraindication: Lagophthalmos: incompetent lid seal at rest.

Relative contraindications for endoscopic brow lift are

• High forehead/elongated upper facial third

• History of symptomatic dry eyes accompanied by incompetent lid seal with simulated brow lift

• Need for bony supra orbital rim recontouring 

The patient is marked while seated in an upright position, maintaining a neutral facial expression. It is advised not to shave the areas designated for incisions.[18]

First, Markings are made for the supraorbital foramen and the intended highest point of the brow arch. Typically, three incisions are mapped out along the frontal hairline: one in the median position and two paramedian. These incisions are generally positioned 5 to 10 mm posterior to the hairline and measure 2 cm in length. The paramedian incisions are marked vertically, slightly above and medial to the planned highest point of the brow arch. [18]

Afterwards, two incisions on the temporal region are delineated, running parallel to and situated behind the temporal hairline. These temporal incisions are generally 3 cm long and are aligned along a vector line drawn from the ala through the lateral canthus and extended into the hairline. [18]

While it is possible to perform the endoscopic brow-lift procedure using only local and tumescent anesthesia, it is recommended, for the comfort of the patient, to contemplate the utilization of general anesthesia or intravenous (IV) sedation. Corneal shields are favored over lubrication and taping for eye protection. [18]

Technique

1. The patient is positioned in a supine position on the operating room table

2. The facial and air areas are disinfected with a chlorhexidine solution, and the patient is draped in a sterile manner, exposing from the vertex to the chin

3. The median and paramedian incisions are extended to the bone using a No. 15 blade. Subsequently, a No. 9 periosteal elevator initiates the subperiosteal dissection, and a curved endoscopic periosteal elevator is employed to lift the skin and soft tissue envelope subperiosteally, ranging from 2 cm above the supraorbital rim to the vertex. Laterally, this dissection extends to the point of insertion of the superficial temporoparietal fascia in the superior temporal line

4. A 4-mm endoscopic periosteal elevator is employed for a minor frontal subperiosteal dissection, extending along the lateral orbital rim down to the level of the infraorbital rim. 

5. With the aid of a 30° endoscope for visualization, the frontal dissection is extended down to the supraorbital rim and the supraorbital nerve is preserved. The periosteum is incised along and parallel to the supraorbital rim. The superior aspect of the incised periosteum is stretched 1 cm from the inferior edge to prevent relapse. 

6. The temporal incisions are then extended to reach the temporoparietal fascia. If the superficial temporal vessels are identified, they are ligated. Following the incision through the temporoparietal fascia, the dissection is continued bluntly down to the deep temporal fascia. A beaver-tail elevator proves useful in bluntly opening the superficial temporal space from 1 cm above the zygomatic arch to the superior temporal line. The dissection is advanced anteriorly towards the lateral orbital rim, being cautious to elevate only until encountering a "soft stop." This stop indicates the confluence of deep and superficial temporal fascia, and further dissection poses a risk to the frontal branch of the facial nerve. The elevation of the superficial temporal space should also extend posteriorly to the temporal incision until the entire space is open. This opening facilitates the passive redraping of the temporal skin in a posterior-superior direction without the need to excise hair-bearing scalp.

7. An endoscope is inserted through the temporal incision to visualize the zygomaticotemporal bundle, which may be ligated if necessary.

8. A beaver-tail elevator releases the temporoparietal fascia from the superior temporal line, ensuring continuous and freely movable forehead and temporal flaps.

9. For muscle hyperactivity, myotomies can be performed through the corrugator and procerus muscles muscles using electrocautery. Similar myotomies may be carried out through the lateral orbicularis oculi (crow’s feet lines) and horizontally through the frontalis (forehead lines). It is generally not recommended to physically remove the muscle bellies.

10. The temporal flap is anchored in a posterior-superior direction. The medial flap is fastened through the temporoparietal fascia and secured with a hand tie to the deep temporal fascia. It is beneficial to have an assistant apply force to forcefully position the temporal flap in the intended direction for maximal tightening. A second suture, running from the inferior-medial temporoparietal fascia to the superior-lateral deep temporal fascia, is subsequently placed to reinforce the lift.

11. The frontal flap is then lifted and anchored at the paramedian incision level. Resorbable Endotine devices can be used to secure the inferior flap periosteum to the underlying bone. Holes are drilled in the skull through the paramedian incisions for the bilateral placement of Endotine devices. Subsequently, the inferior flap is raised off the bone and repositioned superiorly with the assistance of an aide, with the Endotine prongs maintaining the periosteum in place.

12. To address brow height asymmetries, the surgeon elevates the more dependent brow higher than its counterpart, allowing time for soft tissue creep. If laxity is observed, the periosteum is resecured under tension. The distance from the inferior brow to the supraorbital rim is measured, anticipating a vertical relapse of 4 to 6 mm.

13. The incisions are then closed with staples. No dressings or drains are required. Finally local anesthesia is infiltrated along the supraorbital rim and laterally to the level of the superior helix for patient comfort.

The recovery process is generally smooth, with noticeable discomfort peaking within the initial 24 to 48 hours.

Early complications

• Hematoma

• Failure of brow stabilization or insufficient brow lifting• Weakness or paralysis in the frontal branch of the facial nerve

• Diminished sensation in the forehead or scalp

Late complications

• Unpleasant or abnormal sensations, numbness, or lack of sensation in the forehead and scalp

• Recurrence or return of symptoms

• Overly elevated inner part of the brow

• Excessive distance between the eyebrows

• Irregularities in contour and muscle movement following myotomy

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