AN INSTITUTIONAL REVIEW OF THE MID FOREHEAD BROWLIFT PROCEDURERizwan Siwani, MBBS, Ahmed Younes, MBBCh, Oren Friedman, MD

Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN

ABSTRACTBrow ptosis gives the face a sad, heavy look and often disturbs the visual field. In this retrospective case series we looked atpatients who underwent a mid forehead browlift to assess the efficacy of this technique in correcting this functional and aesthetic disfigurement. We identified 16 patients with greater than six months of postoperative photographic documentation. Information was collected concerning patient demographics, etiology and severity of brow ptosis, and outcome of surgery.Four independent evaluators were recruited to compare pre operative with post operative photographs for the following aspects: brow symmetry, elevation, incision scar, and overall appearance. The mid forehead browlift was found to offer excellent aesthetic results in all patients.

INTRODUCTIONThe first known documentation of the mid forehead lift describing pretrichial and lower forehead incisions was provided by Joseph in 1931. In 1930 Passot described the direct brow lift, involving excision of an ellipse of tissue immediately above the brow. This technique was subsequently modified to utilize a mid forehead incision that has gained increasing popularity.

The primary disadvantage of this procedure is the positioning ofthe incisional scar in the visible portion of the forehead. However, it is argued that the disadvantage is only theoretical and that, in fact, the scar resulting from this procedure is less objectionable than those resulting from other approaches to elevate the brow. Thorough preoperative planning and careful placement of the incision in a natural skin crease would result in a less prominent scar. In this report we reviewed our experience with this procedure in the light of ongoing concerns regarding scar formation. We aimed to establish whether the mid forehead brow lift still has a place and, if so, which patients are most suited to this technique.

© 2009 Mayo Foundation for Medical Education and Research

METHODSWe performed a retrospective review of all mid forehead brow lifts performed by one facial plastic surgeon (OF) over the last five years with a minimum follow up of 6 months. Information gained from clinical notes concerned demographics, etiology and severity of brow ptosis, and outcome of surgery. Two sets of photographs of the patient were taken: pre operatively, and at least 6 months post operatively. These were evaluated for cosmesis by a panel of four independent evaluators. The panel included two surgeons with experience in facial plastic surgery and two lay persons. The panel was asked to grade cosmesis from 1 – 4 (poor, unsatisfactory, satisfactory, very good) for each of the following aspects of forehead appearance: symmetry, brow elevation, incision scar and overall appearance.

Fig 1. Before (top row) and after (bottom row) photographs of patients who underwent this procedure. Left: 90 year old woman at 8 months post op. Center: 61 year old man at 7 months post op. Right: 57 year old man at 31 months post op.

SURGICAL TECHNIQUE(1) Bilateral, asymmetric, incision lines are marked centered around preexisting mid forehead wrinkles.1% lidocaine with 1:100,000 epinephrine is utilized for local anesthesia. (2) Elliptical skin excisions areperformed followed by (3) subcutaneous dissection along the frontalis muscle down to the orbicularis ocullimuscle. (4) Separate interrupted sutures using 4-0 PDS are used to secure the orbicularis oculli muscle tothe periosteum at the superior aspect of the skin excision site. (5) A 2 layer closure of the skin is achievedusing 5-0 PDS and 5-0 monocryl for the subcutaneous tissue and (6) 6-0 fast absorbing gut suturefor skin closure.

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RESULTSIn all 16 patients with at least six months of follow up were identified who had undergone a mid forehead browlift using the technique described. This group of patients consisted of 14 men and 2 women with an average age of 69 (range 52-90). The etiology of the brow ptosis was seventh cranial nerve palsy in 1 patient and involutional in 15. Dermatochalasis was found in addition to brow ptosis in 4 of the 16 cases, for which all underwent subsequent blepharoplasty. Visual field obstruction was the most common complaint, present in all patients. The surgical scar became scarcely noticeable over time (6-9 mos), with one exception where hyperemia was still present at the incision site after 12 months. Subjective functional relief with respect to vision field and the feeling of heaviness and satisfaction with the aesthetic result were reported by all patients. The bar charts (Fig 2.) above show high ratings (3-4) for overall appearance and incision scar almost uniformly for all sixteen patients by surgeons and lay persons alike. Evaluators rated brow elevation and brow symmetry in a similar fashion with all results being no less than satisfactory.

CONCLUSIONThe mid forehead browlift is a simple, quick, and effective procedure that is easy to perform, has minimal morbidity, and allows the surgeon good control of both the degree of brow elevation and postoperative shaping of the brow. Thorough preoperative planning and careful placement of the incision in a natural skin crease resulted in a less prominent scar with excellent aesthetic results.

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Overall appearance rated by two lay persons

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Fig 2: 1: Poor, 2: Unsatisfactory, 3: Satisfactory, 4: Very good.