Multiple invasive techniques have been described for fixation of the scalp and upper face; however, these methods do not allow the direct positioning of the brow like in the suture method, described by thy author. Within the past decade, the demand for minimal invasive surgery, fast recovery and immediate beautification result have revised large surgeries and radically changed surgery in face forehead beautification and rejuvenation. Even minimal incision approach to brow lifting and endoscopic methods has become undesired options for beautification in younger patients. Further advances have provided a palette of suture and thread alternatives in aesthetic correction of the position of the eyebrow. Improved understanding of eyebrow anatomy, pathophysiology of the aging face, and advances in small- and non-incision surgery, has contributed to a new approach in correction of the eyebrow position in beautification of the face. A suture method with needle skin perforations between the eyebrow hairs only was introduced by the author since 1994. Like in all other authors suture methods, the idea is to catch movable but stable tissue (in this case - subdermal skin) and to attach it to hard nonmovable tissue (bone periosteum) using special polyamide threads No0 that are elastic, absorbable, antimicrobial, braided; and special curved, elastic needles. The aim is to lift the brow without visible scars, to save the mimic & movement of the brow, and to preserve the naturale look. The results are immediate with a very high longevity and patient acceptance.
Early experiments to correct eyebrow ptosis were widely unsuccessful and unaesthtetic. The evolution in aesthetic cosmetic surgery has proved that aesthetic improvement of the aging face includes surgical elevation of the brow. Despite improvements in surgical techniques, the surgical outcome deviates from the eyebrow ideal in young and midaged patients. Both the surgical management and objectives of eyebrow surgery continue to evolve1.
Rhytidectomies or face-lifts were designed as operations to remove facial wrinkles2. A lot of surgical procedures were proposed to obtain a brow lift as a part of the face lift surgery for facial ptosis and ageing – such as transcoronal eyebrow lift (subperiosteal or subgaleal), extended subperiosteal face lift, third generation subperiosteal rhitidectomy, the anchor subperiosteal forehead lift, midforehead lift, lift by flap transposition in the glabrous brow area, direct eyebrow lift, deep temporal lift, subperiosteal lateral temporal browlift, transblepharoplasty forehead lift, endoscopically assisted biplanar forehead lift, endoscopic extended browlift, small incision forehead and brow lift, browlifting with threads, botox injections etc. The face lift alone is seldom adequate treatment for the aging face3. Other procedures must be considered for treatment of specific areas of the face to enhance the effect of the face lift itself. Rhytidectomy is not a routine procedure applicalbe to all patients with brow lift ptosis. Variations of technique must be chosen for each individual case4. Ptosis of the brow with or without vertical and horizontal wrinkling accompanies aging in other areas of the face. This abnormality may be noted in some younger patients who may have no other signs of aging and, in fact, may render it more noticeable5. Facial rejuvenation and beautification includes several operations to correct proportions, volumes and angles. The brow lift surgery is no more connected only with rejuvenation of the aging face. The recent surge of interest in aesthetic procedures has prompted more patients to inquire for and undergo different aesthetic corrections of the face. There are four basic incisions applicable to the upper face and brow: (1) direct browlift, (2) midforehead crease incision, (3) prehairline incision, and (4) posthairline incision. All of them are not applicable in young patients requiring cosmetic surgery. Brow lift without scars as a part of the beautification in young patients is becoming more and more the modern goal in cosmetic surgery nowadays.
The author describes a useful technique for local brow-lift operation by sutures with skin punctures inside of the eyebrow hairs that exclude postoperative scarring. The eyebrow lift employs the eyebrow arch used by makeup artists. The operation may be performed in conjunction with other cosmetic surgery.
ANATOMY AND FASHION
Knowledge of the anatomy of the region is important for doing brow lift surgery in order to avoid injuring the neurovascular bundles passing through some notches and foramina. The frontalis branch of the facial nerve is located in the superficial musculoaponeurotic system layer of superficial fascia above the level of the temporalis fascia6, 7. Dissections revealed that the supratrochlear nerve was never closer than 1.6 cm to the midline at the level of the supraorbital ridge6, 7.
The decrease in facial bone bulk and increased soft-tissue expansion associated with aging produce effects of brow and facial laxity and ptosis8. Crow’s feet are one of the characteristic signs of the eyebrow ptosis and aging face. The orbital fibers of the orbicularis oculi muscle play a fundamental role in the pathogenesis of wrinkles. The dynamic action of the zygomatic muscles contributes to exaggerate these wrinkles. Statically, ptosis of the lateral brow and the aging skin contributes to skin droping over the eye lateral canthus9. During the past decade, surgeons have increasingly recognized that brow ptosis is an important contributor to dermatochalasis and ptosis of the upper eyelid10. Patients with ptosis of the tail and overhanging skin fold over the upper lid or over the eyelashes and the lateral canthus of the eyes can profit from a brow lift before to undergo upper lid blepharoplasty. The eye-eyebrow region is the most influential in determining facial expressions. There is only a narrow range of positions of the eyebrows in which they are perceived as attractive11. Surgical elevation of the ptotic brow improves eyelid esthetics. Artistical position of the eyebrow is a guide line for eyebrow positioning12. It is useful to have measurements to assist the surgeon in deciding when to do the brow lift and where to place the suture. We have reviewed the young position of the eye brow in models and the artistic experience and aesthetic criteria for ideal female eyebrow height and shape in international fashion models and movie stars. The line of measurement in a vertical plane extends from the upper orbital rim to the top of the eyebrow and the eyebrow tail in the lateral canthus line. The normal distance from the upper orbital rim to the upper edge of the eyebrow and the eyebrow tail on average is 1 cm. Eyebrow shape should have an apex lateral slant13. In male patients we have to consider less rising of the eyebrow tail. The importance of esthetic anatomy, àåsthetic assessment and treatment planning in evaluation of the face is with regard to patient selection, indications, and contraindications14.
It is also important to preserve the brow and facial function in a clinically meaningful way. We wanted to develop a scarless suture method whereby anatomic motion15 of the eyebrow as well as its nonanatomic motion15 in botulinum toxin treated or paralyzed face could be preserved.
Anatomic landmarks for our method are 1. The unnamed vertical rim between the frontal muscle and temporal muscle (Fig. 1.); and 2. The crosspoint of the lateral canthus line and the eyebrow.
Fig. 1. Anatomy of the eyebrow region: 1- m. Corrugator supercilii, 2 - m. Procerus, 3 - m. Depressor supercilii, 4 - rim between frontal and temporal muscle, 5 - lateral canthus line
A) B) C)
Fig. 2. A. ptotic eye brow tail positioned at, or below the upper orbital rim with dropping lateral canthus; B. Lifted eyebrow and lateral canthus of the eye. Eyebrow tail position designed for man and elderly ladies. C. Lifted eyebrow and lateral canthus of the eye. Design for young ladies models. The direction of the needle when biting in the periosteum defines the eybrow design.
Our aim with this method is to obtain beautification in patients of any age, and rejuvenation in elderly, using minimally invasive cosmetic surgery procedure. It is done ambulatory, under local anesthesia with i.v. sedation, with immediate result and close to 0% complications, preventing facial expression and gesture without any scaring.
METHODS AND MATERIALS
The brow lift suture is done by needle punctures only between the eyebrow hairs to prevent scaring. It presents a stable fixation of the subdermal skin layer to the periosteum of the above described unnamned rim (Fig. 1) and the insertions of the frontal mucle. The direction of the needle bites in the periosteum between points A and B defines the eybrow design (Fig. 2). An important instrument that facilitates performing this technique is the curved, semielastic, semiblunt mini needle of 50 or 60 mm lenght with a hole at the tip that can be turned down and up in order to enter through the skin, to catch periosteum and exit through another skin perforation point (Fig. 3). Most important is that we have at our disposal the 0 polycaproamide threads with marked elasticity that are longterm biodegradable (in 2-3 years), antimicrobial and braided (Fig. 4). The semielastic, braided, No0 threads permit movements of face and muscles, fixation under elastic tension, and do not trauma or cut the sutured tissue. The long term resorbtion quality gives time for a stable fibrosis formation and do not leave foreign bodies in the tissue after the fibrotic fixation is finished.
Fig. 3. Curved, elastic, semiblunt, mini needle
Fig. 4. Semielastic, absorbable, braided, antimicrobial, polyamide-silk threads No 0
METHOD FOR SCARLESS BROW LIFT BY SUTURE
To perform and accomplish the brow lift suture, the author uses 2 perforation points between the hairs of the brow, done by the needle itself or previously done, using the tip of a scalpel blade 11. The perforation points are located both sides of the crosspoint of the lateral canthus line and the eyebrow (Fig. 5). To position the eyebrow for fixation we pull the forehead skin with a finger placed 1 cm higher than the eyebrow at the lateral canthus line (Fig. 5a). The optimum pull positiones the brow tail at the desired level of 1 cm over the upper orbital rim without exeptions. (NB. Do not pull the eyebrow alone, which is looser and more movable. It will result in a wrong brow tail position). The needle, tip down, enters through the lateral skin perforation point A, slides down on the rough surface of the rim taking periosteum and frontal muscle insertions and becomes fixed (Fig. 5b). (NB. If the needle is not fixed and can be moved lateraly, it is wrong located in a superficial tissue and its position should be changed deeper to periosteum (Fig. 5c)). Turning the tip up, the needle passes through the frontal muscle and exits through the medial skin perforation point B. After threading the needle tip hole, the thread is introduced and positioned through the first needle pass. The second needle pass is done through the lower dermis layer between the points A and B. Advancing the needle through the lower dermis is very hard and is performed by turning the needle left - right (NB. Pushing can result in tissue perforation in an undesired direction). After exiting through point B and re-threading the needle, the second end of the thread is pulled out through the second needle pass, and the knot of the suture is done under medium elastic tension. Slight pressure is used to flatten the brow over the suture and to stop any bleeding. Still using pressure, perforation points A and B are pulled out away from the suture with a “mosquito” branch to remove any dimpling. (Fig. 5b-i) No bandages are necessary. A skin color tape is placed on the upper eyelid that stays overnight to reduce swelling (Fig. 6b). Additionally, through a 3-mm medial brow incision, the interbrow musculature can be excised to improve vertical glabellar wrinkles.
A) B) C) D)
E) F) G) H)
Fig. 5a-i. Surgical method. A. Finger located 1 cm over the eye brow tail in the lateral canthus line lifts the forehead skin with the brow tail, B. The needle is fixed in the periosteum in a stable good position, C. Wrong superficial position of the needle – the needle is not fixed and drops with the tissue downwards, D. A correct first needle pass is done and the needle is threaded, E. The thread is introduced through the first needle pass, F. Second superficial needle pass through the lower dermal tissue is done. G. The second thread end is placed in the needle hole, H. The thread is positioned in the second needle pass, I. The knot of the suture is made and the eye brow is lifted. Possible dimpling is eliminated using a “mosquito” branch.
Fig. 6a., b. Before and after brow lift by suture. A skin color tape is placed on the upper lid to reduce swelling.
Post op care: Next day, the tape is removed from the upper lid. Face wash is obligatory to remove residual blood. Swelling in the suture area and the upper lid is nearly unvisible for observers. In 99%, no bruising appears. Patients can return to social life. Wound disinfection should be done several times in the next 2-3 days.
Fig. 7. A. Before, B. Intraop: right eyebrow is lifted without visible scars. Visible lift of the lateral cantus of the right eye, C. Both eyebrows are lifted at the end of the operation
We perform browlift by suture in cases of ptosis, asymmetry, or in patients who wish a nonscaring and non-invasive procedure. Indications are beautification, rejuvenation, correction of proportions and angles.
During the period from 1994 to 2001, brow elevations using sutures were carried out in 773 patients. The follow up period varies from one month to 7 years. 764 patients achieved excellent results, while eight experienced good results. 73 % of the patients were followed during the first 3 years after surgery with very good satisfaction. Only one 59 years old patient experienced aesthetic lack of satisfaction, due to different understanding of aesthetic proportions and angles in her age. Complications were minimal – only 2 cases of infection in the lateral skin punctures threated by wound cleaning and disinfection for 2-3 days.
There were no instances of scarring, skin problems, or hair loss. The post op period is characterized by small percentage of swelling, no bleeding, no nerve injury, no scars, near to zero complications, possible social activities next day, immediate return to social life, mimic preservation.
In the patients with more than one year of follow up we have abserved stable results and no ptosis was discovered with the years during follow up.
Fig. 8a., b. Before and after brow lift by suture. Visible lift of the eyebrow and lateral eye cantus. A tape stays over night
Fig. 9. A and B. Before and 5 days after Brow lift + Teemporal SMAS lift by suture
Fig. 10. Beautification is mostly obtained by a combination of multiple operations – in this case: Brow lift + Chin enhancement + Chin dimple – all done by suture + Lip augmentation + Secondary rhinoplasty – immediate result
Fig. 11. Beautification in a 22 years young female obtained by a combination of operations: Brow lift + Tip and allar base narrowing by suture + Chin enhancement + Medial SMAS – all done by sutures + Hump removal. Result 4 days after surgery.
Fig. 12. Beautification and rejuvenation obtained by a combination of operations: Brow + Temporal + Lower SMAS lifts by sutures + Rhinoplasty – Immediate result.
Fig. 13. Beautification is a young male: Brow lift + Chin enhancement by sutures + Rhinoplasty.
In no patient was nerve damage to the supraorbital nerve noted.
Two complications, infection in the lateral perforation point, 2 and 3 weeks after surgery, were treated by wound cleaning and disinfection, and healed in 2 to 3 days. We have no case of thread removal.
The purpose of this paper is to present new trends in brow lifting philosophy, and techniques.
A discussion comparing one procedure to other brow lift procedures is important, outlining respective advantages and disadvantages In the literature, there are a lot of procedures for brow lift that can have some negative effects for patients in modern society life: scars on the face that are only partially acceptable or non acceptable, increased tension across the healing wound, tension-related trophic skin changes, alopecia, loss or change of mimic and expression, paresis, ptosis, chemosis etc.16, 17, 18. We can devide the proposed methods in invasive and minimal invasive surgeries. When using invasive methods, drooping of the central part of the eyebrow requires a frontal or coronal lift or an eyebrow lift19. Some authors prefer the coronal brow lift to correct brow ptosis with the presumption that scars are covered by hair and the technique eliminates the disadvantages of the traditional direct brow elevation, including scarring above the brow, but the transcoronal eyebrow lift is related with some effects on wound healing, scar formation, tension-related trophic skin changes, depending on the place of the incision: direct browlift, midforehead crease incision, prehairline incision, or posthairline incision20, 21, 22, 23, 24, 25. Other authors mention that the forehead-brow lift corrects ptosis of the eyebrows and redundancy of the upper eyelids very little or for only a brief time26. 3 surgical techniques: subperiosteal dissection to the supraorbital rim, subperiosteal dissection with release (elevation, incision, and spread) of periosteum at the supraorbital rim, and subgaleal dissection to the supraorbital rim are performed endoscopically or open as forehead dissection for brow elevation27, 28. Extended surgeries are proposed to correct ptosis of the face: a subperiosteal browlift could be performed in combination with midface lift as a total mobilization of composite full-thickness soft tissues from the bony skeleton with superior suspension29. Complication rates reported are at large with previous complication rates. Lagophthalmos may appear during a brow lift procedure if a patient has had a prior upper lid blepharoplasty30, 31. When performing a transcoronal brow lift, one should decide if it is better to incise parallel or perpendicular (at an angle) to hair follicles to reduce visibility, linearity, and hypopigmentation32. Trichophytic incisions, since they avoid anterior hairline elevation and maintain preoperative temporal tuft position, are especially valuable in revision procedures in which the hairline has previously been elevated to, or beyond an acceptable anatomical position33. Midforehead brow lift is also described in cases of pattern hairline, thinning hair, or a high hairline that may contraindicate coronal forehead lift34. The direct browlift with proper symmetrical excision is reserved for minimal ptosis, asymmetry, or patients who wish a minimal procedure20, 35. 36, but this may produce adverse scarring37. The temple brow lift may be employed to draw the lateral part of the eyebrow upward and laterally. In the temporal lift it is possible to perform an easy subaponeurotic and subperiosteal dissection of the soft tissues of the temporal area through an incision behind the hairline. The brow ptosis is corrected without noticeable scars and with inconspicuous damage to scalp follicles of the temporal region38, 39, 40. 41. A brow lift via blepharoplasty incisions is also described. The dissection is done with the aid of the endoscope introduced42. The endoscopic brow lift has become an increasingly popular method, due to its less invasive nature, minimal scars and without the associated nerve damage of the open approach. There is a discussion if the endoscopic subperiosteal brow lift has a better long-term result than the bicoronal subgaleal brow lift and there is no significant difference shown30, 43, 44. Questions have been raised about the biodegradability of pericranial pins that maintain positive calvarial fixation for more than 6 weeks and about the stability of fibrosis after 6 weeks in such technique45, 46, 47. The endoscopic extended browlift adds to the armamentarium against aging48. Small or minimal incisions nonendoscopic browlifts with or without screw placement, or without undermining are other techniques that minimise scars and provide a useful alternative to the endoscopic approach49, 50, 51. Brow elevation can occur as a result of paralysis of brow depressors after botulinum toxin A injection52 into selected brow depressor muscle (lateral orbicularis oculi) bilaterally. The procedure may be considered an alternative to surgical brow elevation. This article aims to describe a new innovation in scarless brow lifting without any incision, without undermining, but suturing on place the brow subdermal fibrous tissue higher to stable periosteum using special needles and skin punctures only between the hairs of the brow. The method was started 1994, with protocol describtion and was presented around the world as a part of our fashion art face beautification in young patients and for correction of ptotic eye brow and rejuvenation as well53-54. It has the following advantages compared to incision and excision metods: short intervention time about 5 minutes each side, no visible scars, minimal trauma, and immediate result, short and easy postop period and immediate return to social life. Thread is long term absorbable – in 2-3 years, so that it stays until the fibrosis is finally completed in 6 to 12 month after surgery and desapears later. Result is longlasting and pleasing.
The brow lift by suture without scars is an effective and safe technique for beautification of the eye region and rejuvenation of the upper face, producing a natural result with minimal complications and hi level of longivity. It is a beautification method, ambulatory, under local anesthesia with i.v. sedation, with immediate result and less than 0,00038% complications. It is done without visible scars, saves the mimic and the expression, the movement of the brow, and preserves the natural look. All facial cosmetic surgical procedures are done on an outpatient basis. A combination of local anesthesia and intravenous sedation provides excellent patient tolerance and comfort both intraoperatively and postoperatively. Postoperative recovery is uneventful. Complications are very, very rarely encountered. The eye-eyebrow region is the center for facial expression. The position of the eyebrows expresses emotion, and even a minor change in brow position can be important for the understanding and contact between individuals. Lifting the eyebrows can change the expression into a more pleasant, young and natural one. We believe that this technique provided us with a more permanent and stable result. This brow lift method can be one of the most beneficial surgical procedures in cosmetic surgery. This very simple procedure requires about ten to twenty minutes both sides and allowes lifting in any degree and elevation of any brow point. It supports the upper lid with lateral face improvement. It may be utilized for eyebrow ptosis alone, or for fashion beauty, whether unilateral or bilateral; in conjunction with other suture techniques for equalizing asymmetrical eyebrows, and for further support of markedly ptotic upper lids. It has been used by the author in instances of partial and complete facial paralysis in conjunction with other procedures in the face to accomplish better symmetry. The stable duration of results with this procedure depends on the tissue quality and healing, the non-traumatic surgical technique, care given the area during healing by the patient, amount of frowning and vigorous facial muscle use by the patient, and aging. It is a useful adjunct, especially when used with temporal SMAS lift, other author’s suture methods on the face, beautification rhinoplasty etc. to adjust proportions, volumes and angles for beautification and rejuvenation of the individual’s face.
Our experience indicates that this specific method of scarless brow lift by suture adds a great deal to appearance and satisfaction. The operating time is short with immediate aesthetic result, and there is a very high patient acceptance. The procedure has taken its place as an integral part of facial beautification and rejuvenation in our practice.
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Address for correspondence:
Nikolay P. Serdev, MD, PhD
Medical Center "Aesthetic Surgery and Aesthetic Medicine"
11, "20th April" St., 1606 Sofia, BULGARIA
Phone (mobile) +359 888 802004
Fax +359 2 9515668
The Bulgarian Society of Aesthetic Surgery and Aesthetic Medicine
Send for publication: 27 08 2001