Brow Lift, Coronoplasty

History of the Procedure

The forehead lift or brow lift is a common facial rejuvenation procedure, performed as an isolated technique or in combination with total facial rejuvenation, including facelift and blepharoplasty.

Problem

Periorbital changes often are recognized as the earliest signs of aging. Common changes include upper eyelid skin folds that extend beyond the upper eyelid into the temple, frown lines or glabellar transverse forehead creases, thickening or bunching of the corrugator muscles at the medial eyebrow, and descent (ptosis) of the eyebrows.

These changes potentially are reversed with an appropriately performed brow lift or forehead lifting procedure.

In this discussion, the terms "brow lift" and "forehead lift" are used interchangeably. The actual incision used to perform a brow lift can vary. Access incisions include the coronal line, the prehairline, and just above the eyebrow.

Frequency

Aging varies in each individual. Forehead changes are based on environmental factors (sun damage), genetic makeup, and skin type. The extent of aging can vary greatly.

Beginning in the fourth decade, early changes of brow position, influenced by gravity, become apparent. This eventually occurs in all individuals, although the degree of brow ptosis and constellation of findings such as glabellar frown lines and transverse forehead creases vary. By the fifth decade, most individuals have undesirable changes of the forehead and upper periorbital region that would benefit from rejuvenative forehead procedures.

Etiology

The etiology of the aging upper face involves loss of elasticity, soft tissue ptosis, genetic predisposition, and repetitive facial motion (eg, squinting, constant corrugation of eyebrow muscles).

Individuals with active facial animation, especially those who are exposed to sun, may exhibit more advanced signs of upper forehead aging.

Pathophysiology

Constant motion of the frontalis muscle creates the transverse rhytides of the forehead. Patients with advanced brow ptosis activate the frontalis muscles on a regular and involuntary basis to maintain elevation of their brows, thereby preventing the visual field obstruction that occurs from brow ptosis. As forehead soft tissues continue their descent over time, maintained frontalis muscle tone creates progressively deepening lines to offset the effect on visual field obstruction.

In such cases, the well-intentioned removal of upper eyelid skin can create further brow ptosis through a relaxation in frontalis tone, which is now no longer required to maintain the visual field. The removal of upper lid skin in such cases can make later brow elevation more complicated, with poorer aesthetic results due to the limitations created by a paucity of upper lid skin. To overcome this deficiency, skin grafts or flaps from the lower lid may be considered. Remarkable aesthetic improvements can be achieved with techniques that diminish frontalis tone and weaken the centralizing and depressing muscular action while elevating the brow to an appropriate position.

Clinical

Patients may be told by family, friends, or colleagues that they appear angry, sad, or anxious when this appearance does not match their emotional state. This misinterpretation can be quite concerning for some and may result in a visit to a plastic surgeon for treatment. Elevating the brow while diminishing corrugator and procerus function can reduce forehead rhytides. This goal is accomplished through a skillfully performed brow lift.