Ankara Eğt. Arş. Hast. Derg.

, 2022 ; 55(3) : 224-228

Özgün Çalışma / Or g nal Art cle DOI: 10.20492/aeahtd.1117202

The Evolution Of Subcutaneous Brow Lift: A Comparative Analysis Of Outcomes And Complications

Subkütan Kaş Kaldırma Cerrah s n n Evr m : Sonuçların Ve Kompl kasyonların Karşılaştırmalı Anal z

Arda KÜÇÜKGÜVEN¹

ABSTRACT ÖZET
AIM: This study aims to analyze and compare the results of three different AMAÇ: Bu çalışma, üç farklı subkütan kaş kaldırma tekn ğ n n sonuçlarını
subcutaneous brow lift techniques: Fogli temporal lift, pretrichial brow lift, and anal z ederek karşılaştırmayı amaçlamaktadır: Fogl temporal germe, saç önü
gliding brow lift. (pretrichial) kaş kaldırma ve gl d ng kaş kaldırma.

MATERIAL AND METHOD : Thirty-three female patients underwent brow lift GEREÇ VE YÖNTEM: Otuz üç kadın hastaya kaş kaldırma amel yatı
surgery between July 2022 and September 2021. Initially, eighteen gerçekleşt r ld . Başlangıçta ardışık on sek z hastaya alın uzunluklarına göre ya
consecutive patients were operated with either the temporal lift technique or temporal germe ya da saç önü kaş kaldırma amel yatı yapıldı. Ardından, alın
pretrichial brow lift technique based on their forehead length. Then, fifteen uzunluğuna bakılmaksızın ardışık on beş hastaya gl d ng kaş kaldırma amel yatı
consecutive patients underwent the gliding brow lift surgery regardless of their gerçekleşt r ld . Kaş kaldırma tekn ğ n n türüne göre skalpte parestez ,
forehead length. Age, type of anesthesia, other accompanying surgical ns zyonel y leşme sorunları, bel rg n ns zyon skarı, ns zyon dışı y leşme
procedures, and postoperative complications including presthesia in the sorunları, h pop gmentasyon, h perp gmentasyon, frontal dal nöropraks s ,
scalp, incisional postoperative healing problems, unfavorable incisional nüks ve hematom retrospekt f olarak ncelend .
scarring, non-incisional h e aling proble ms, h ypopigme ntation,
hyperpigmentation, neuropraxia of the frontal branch, recurrence, and BULGULAR: Ortalama tak p süres 13,6 ay (9-21 ay) d . Gl d ng kaş kaldırmada
hematoma were analyzed based on the type of the brow lift technique en sık görülen kompl kasyonlar skalpte geç c parestez (%47), ns zyon dışı
retrospectively. y leşme sorunları (%27) ve alında küçük h pop gmentasyon alanları (%20) d .
Temporal germen n en sık görülen kompl kasyonları skalpte bel rg n ns zyonel
RESULTS: The average follow-up period was 13.6 months (range, 9-21 skar (%85) ve geç c (%77) ya da kalıcı (%31) parestez d . Saç önü subkütan
months). In the gliding brow lift, the most common complications were kaş kaldırmada ns zyonda küçük y leşme sorunları (%80) ve bel rg n skar
transient scalp paresthesia (47%), non-incisional healing problems (27%), and (%60) oranı yüksekt . H çb r hasta rev zyon cerrah s geç rmed . H çb r hastada
small areas of hypopigmentation in the forehead skin (20%). The most kalıcı frontal dal hasarı görülmed .
common complications of the temporal lift were the unfavorable incisional
scarring (85%) and transient (77%) or permanent (31%) paresthesia in the SONUÇ: Per orb tal gençleşt rmede m n mal nvaz v tekn klere doğru b r eğ l m
scalp. The rate of postoperative small incisional problems (80%) and scarring olmaktadır. İdeal tekn k m n mal morb d teye sah p olmalı ve uzun sürel etk ler
(60%) were high in the pretrichial subcutaneous brow lift. None of the patients sağlamalıdır. Bu çalışma, gl d ng kaş kaldırma tekn ğ n n, kaş gençleşt rmede
required a revision surgery or had a permanent frontal branch injury. m n mal nvaz v n tel kte ve memnun yet ver c sonuçlarıyla umut vadeden b r
tekn k olduğunu göstermekted r.
CONCLUSION: There has been a trend toward the minimally invasive
techniques in periorbital rejuvenation. The ideal technique should have Anahtar kel meler: c lt altı, Fogl , kaş kaldırma, per orb tal, saç ç zg s ,
minimal morbidity and provide long-lasting effects. This study demonstrates temporal germe
that the gliding brow lift technique is a promising and minimally invasive
technique with pleasing outcomes in brow rejuvenation.

Keywords: Browlift, Fogli, hairline, periorbital, pretrichial, temporal lift

1
Sağlık Bakanlığı Ankara Eğ t m ve Araştırma Hastanes . Plast k, Rekonstrükt f ve Estet k Cerrah Kl n ğ , Ankara, Türk ye

Makale Gel ş Tar h / Subm tted: Mayıs 2022 / May 2022 Makale Kabul Tar h / Accepted: Ağustos 2022 / August 2022
Sorumlu Yazar / Correspond ng Author: Yazar B lg ler /Author Informat on:
Arda KÜÇÜKGÜVEN
Adres: Sağlık Bakanlığı Ankara Eğ t m ve Araştırma Hastanes . Plast k, Rekonstrükt f ve
Estet k Cerrah Kl n ğ . Hacettepe Mh. Ulucanlar Cd. No:89 06230,
Altındağ, Ankara, Türk ye Telefon: +90 537 603 96 40
E-posta: ardakucukguven@gma l.com
ORCID: 0000-0002-1345-3549

224
INTRODUCTION by the author
The knowledge of aging-related changes in the periorbital region and
interventions for periorbital rejuvenation is of great importance in plastic
surgery. Various brow lift technique have been debated for decades by plastic
surgeons, and the best technique is yet to be determined.1-8 Each technique
has its own advantages and disadvantages.

Recently, a shift towards less invasive techniques has begun in brow lift
surgery. Transcoronal brow lift,2 Fogli temporal lift,3 pretrichial brow lift,6
internal browpexy,9 direct brow lift,10 endoscopic brow lift,11 gliding brow lift
(GBL),4 chemical brow lift,12 and thread lift13 are popular techniques in brow
elevation. The plastic surgeon is responsible for establishing a balance
between patients' expectations and surgical techniques. Durability of the
brow elevation, postoperative scarring, paresthesia in the scalp, hairline
distortion, frontal branch injury, and hematoma are important parameters in
deciding the right technique.

Chemical brow lift and thread lift are associated with short-term brow
elevation,12,13 Transcoronal brow lift is an invasive approach and only
performed in selected cases due to its long scar and postoperative
paresthesia.2,5 Direct brow lift is reserved for a selected patient group who will
not complain about the scar over the brow.10 However, in most cosmetic
cases, patients desire a well-concealed scar. Internal browpexy is a good F g u r e 1B. l u n t d s s e c t o
u rsse d n
th e g l d n g b r o w l f t s u r g e r y .
adjunct in upper blepharoplasty, however it has a moderate effect with
restricted brow elevation and causes irregularities over the brow.14
Endoscopic brow lift is a popular technique due to its less invasive nature. It Figure 1
has a long learning curve and necessitates endoscope. It is not suitable for
patients with high hairline, and it suffers from high recurrence rates.15 which are very similar to the ones designed by Viterbo but have small
modifications.4 A 5-mm hairline incision is made to allow entry of the
Subcutaneous techniques have been used with high satisfaction rates.4,6,16 dissectors. After tumescent infiltration into the subcutaneous plane, the skin is
The Fogli temporal lift, pretrichial brow lift, and GBL are different subcutaneous elevated bluntly in the subcutaneous plane, and the brow is elevated. Gliding
brow lift techniques.3,4,6 The GBL is a novel technique with a 5-mm incision, motion of the brow and lateral forehead skin over the underlying soft tissue is
and involves the hemostatic net application.17 This study aims to analyze and seen while the skin is pulled upwards with two skin hooks. The hemostatic net
compare the results of three different subcutaneous brow lift techniques: is applied for four reasons: (1) to elevate the brow, (2) to cause adhesions
Modified Fogli temporal lift, pretrichial brow lift, and GBL. between the skin flap and underlying tissue, (3) skin adaptation and
redistribution in the upper half of the forehead, and (4) hemostasis. No drains
MATERIAL AND METHOD are used.

Thirty-three patients underwent brow lift surgery between July 2020 and The two sutures placed around the brow were removed 5 days after surgery in
September 2021. Patients were operated with three different subcutaneous all GBL patients. Remaining sutures were removed no later than 48 hours (in
brow lift techniques: GBL, modified Fogli temporal lift, and pretrichial brow lift. average, 36 hours after surgery) in the last 10 cases. At the beginning, the
Initially, eighteen consecutive patients were operated with either the temporal hemostatic net sutures of the forehead were removed 3 days after surgery in
lift technique or pretrichial brow lift technique based on their forehead length. the first 5 consecutive GBL patients.
The pretrichial brow lift was performed in patients with long forehead length,
on the other hand, temporal lift was performed in patients who has short to RESULTS
normal forehead length. Then, fifteen consecutive patients underwent the The average follow-up period was 13.6 months (range, 9-21 months). All
gliding brow lift surgery regardless of their forehead length. Age, type of patients had some degree of brow ptosis preoperatively. All patients were
anesthesia, smoking status, other accompanying surgical procedures, and female. The number of patients operated with the GBL, temporal lift, and
postoperative complications including paresthesia in the scalp, incisional pretrichial brow lift was 15, 13, and 5, respectively. The average age of the
postoperative healing problems, unfavorable incisional scarring, non- patients was 42.8 years (range, 28-58 years). 94% of all cases were
incisional healing problems, hypopigmentation, hyperpigmentation, performed in combination with other procedures. 18% were operated under
neuropraxia of the frontal branch, recurrence, and hematoma were analyzed local anesthesia. Patients' characteristics and intraoperative findings are
based on the type of the brow lift technique retrospectively. Written informed shown in
consent was obtained from all patients for the procedures performed and for
the use of their images. The study protocol was approved by the Institutional
Review Board of Hacettepe University Faculty of Medicine (approval date and
no: 04 Jan 2022, GO: 22/33). This study adhered to the principles of the
Declaration of Helsinki.
Surgical techniques

The pretrichial brow lift surgery is performed in the subcutaneous plane. A

hairline incision parallel to the hair shafts is employed. Excess skin is removed
following surgical brow elevation. Special care is taken to close the incision
with minimal tension. No drains are used.

The modified Fogli temporal lift incision is placed 3 cm posterior to the hairline
to conceal the postoperative scar. Incision is placed in a most appropriate
position to give the lateral brow a desired shape. Dissection begins over the
deep temporal fascia and periosteum in the subgaleal plane not to injure hair
follicules. Then, the dissection plane changes to the subcutaneous plane just
anterior to hairline. Excess scalp tissue can be removed after brow elevation, if
desired. No drains are used.

The GBL procedure is performed using two special blunt dissectors designed

225
Table 1. Patients' characteristics and intraoperative data of the three brow lift None of the GBL patients had hematoma. In the first 5 GBL patients, forehead
techniques. sutures were removed 3 days after surgery. However, this resulted in suture-
related ischemic problems leading to non-incisional healing problems in three
Gl d ng Temporal Pretr ch al
patients, and hypopigmentation in two patients. Therefore, the forehead
Brow L ft L ft Brow L ft Total hemostatic net sutures were removed around 36 hours after surgery to
(n=15) (n=13) (n=5) (n=33) decrease the rate of non-incisional healing problems in the remaining 10
Age (yrs) 41.2 43.8 45.2 42.8 patients. Among these, only 1 patient experienced a hemostatic net related
Anesthes a ischemic problem leading to hypopigmentation in a small area. These small
General 11 12 4 82% hypopigmentations are well tolerated by patients. The two sutures placed
around the brow did not cause any ischemic problems even though they were
Local 4 1 1 18%
removed 5 days after surgery to increase the adherence. All irregularities
Smok ng 8 7 3 55%
caused by the hemostatic net were disappeared until 1 month after surgery.
Comb nat on
None 1 1 - 6% The most common complication of the Fogli temporal lift was the unfavorable
Facel ft 4 3 - 21% incisional scarring (85%). Although the incision is placed in the hair-bearing-
Neckl ft 3 2 - 15% scalp, they tend to widen over time
M dface l ft 1 - - 3%
L pof ll ng 4 2 2 24%
Upper 11 8 3 67%
blepharoplasty

Lower 4 6 2 36%
blepharoplasty

Rh noplasty - 2 - 6%
Lateral 13 10 2 76%
canthopexy
226
Ch n mplant 2 - - 6%

Comparison of the techniques

In the GBL technique, the most common complications were transient scalp
paresthesia (47%), non-incisional healing problems (27%), and small areas of
hypopigmentation in the forehead skin (20%). The blunt dissection resulted in F gure 3. Preoperat ve (a) and 14 months postoper at ve (b ) obl que mages of a 31 -year -old female
minimal to no bleeding, therefore the electrocautery was not used. The
pat ent who underwent the mod f ed Fogl temporal l ft. Note the non- nc s onal heal ng problem
hemostatic net was utilized to prevent hematoma or seroma accumulation
result ng n a small area of hypop gmentat on ( b, black arrow). The w dened scar of the temporal l ft s
postoperatively. The hemostatic net was also used to increase skin adaptation
and adherence to the underlying soft tissue, and to elevate the brow seen postoperat vely (b , red arrow).

Figure 3

None of these patients underwent a scar revision surgery. Transient (77%) or

permanent (31%) paresthesia in the scalp was also another common
complication of this technique because the incision reaches the deep
temporal fascia and transects all neurovascular structures located in the
subcutaneous level.

It should be noted that the subcutaneous brow lift techniques can also
eliminate or decrease forehead wrinkles, which can be considered as a
secondary beneficial effect of these techniques

F gure 4. Preoperat ve (a) and 12 months postoperat ve (b) mages of a 52 -year-old female pat ent who
underwent facel ft, l pof ll ng, canthopexy, upper and lower blepharoplasty. The subcutaneous brow l ft
F gure 2. Preoperat ve (a), ntraoperat ve (b), and 11 months postoperat ve (c) mages of a 40 -year -old
techn ques can el m nate or decrease forehead wr nkles .
female pat ent who underwent the GBL, cant hopexy, and lower p nch blepharoplasty.

Figure 4
Figure 2

226
 DISCUSSION
Brow lift procedures have evolved from the most invasive technique, such as a
transcoronal brow lift, to a minimally invasive approach, such as a GBL, over
the past century.2,4 Currently, there is no consensus on which brow lift
technique is the most durable and safe. As we learn more about the anatomy,
and see long-term results of each technique, we can refine our techniques to
reach the best outcome. In this study, evolution of the author's brow lift
technique has been demonstrated by comparing the results of the three
different techniques.

It is of utmost importance to understand the ideal brow shape. There are two
important principles in female brow rejuvenation: (1) The lateral end of the
brow should be located slightly higher than the medial end, and (2) The brow
peak should be located between medial two-thirds and lateral one-third.18,19
On the other hand, to reach these goals, we need to use the best technique
that has long-lasting results, and causes minimal scars, zero to minimal
paresthesia, and minimal postoperative complications.

The idea of subcutaneous brow lift has been embraced by plastic surgeons as
it results in long-lasting results due to the strong attachments caused by
fibrosis between the skin flap and underlying soft tissue.4 Although there was
no recurrence in this study, the average follow-up period was 13.6 months
(range, 9-21 months). This means some of the patients did not have a long-
term follow-up. Another minimally invasive technique is the endoscopic brow
lift. This procedure relies on the adhesion between the underlying bone and
the repositioned periosteum. However, there are controversial results on the
strength of the periosteal readhesion in different experimental studies.20,21
There is still an ongoing debate on the high recurrence rates of the endoscopic
brow lift.5,15 Another feature of the endoscopic brow lift is the elongation of
the forehead as the hairline is pulled backwards.

As the frontal branch of the facial nerve runs under the frontalis muscle and
superficial temporal fascia, the subcutaneous brow lift procedures are safe in
terms of nerve injury.22 None of the patients had a permanent frontal branch
injury in this study. Furthermore, blunt subcutaneous dissection is an
atraumatic technique which minimizes bleeding and obviates the use of
electrocautery in the GBL surgery.
Figure 5. Preoperative (a), two weeks postoperative (b), and 16 months
postoperative (c) images of a 46-year-old female patient who has a long Considering the postoperative complications of the three techniques, the
forehead length underwent the pretrichial brow lift, lower pinch Fogli temporal lift has a high risk of postoperative paresthesia and incisional
blepharoplasty, and lipofilling. Bilateral incisional healing problems are seen scarring. Despite the incisional closure with minimal tension, this scar tends to
two weeks after the surgery (b). Although care was taken to minimize tension widen over time which might be visible although it is located in the hair-
on the incision, the rate of postoperative small incisional problems (80%) and bearing-scalp. In the temporal lift, it is safer to place the incision lateral to the
scarring (60%) were high in the pretrichial subcutaneous brow lift temporal crest not to injure the deep branch of supraorbital nerve to prevent
scalp paresthesia. However, the location of the incision is determined by the
Subcutaneous sharp dissection causes bleeding which necessitates the use desired postoperative brow shape and patient's anatomy. Some patients'
of electrocautery in the pretrichial brow lift and temporal lift cases. This peak of brow is located medial to the crest which requires medial placement of
increases the risk of non-incisional healing problems and neuropraxia of the the incision to give the brow a better shape. Those patients have a high risk of
frontal branch. There were no permanent frontal branch injury cases in this postoperative paresthesia if operated with the Fogli temporal lift technique.
study. One patient operated with the temporal lift technique underwent
hematoma drainage under local anesthesia. Details of the postoperative The pretrichial brow lift is a relatively easy procedure. Elliptical skin excision is
complications are listed in performed. Patients with a short forehead length are not ideal candidates for
Table 2. Postoperative complications. this technique as it shortens the forehead. Additionally, patients with indistinct
and sparse hair should not undergo this technique as the hairline scar will be
Gl d ng Temporal Pretr ch al
apparent. In the present study, incisional small healing problems were
Compl cat ons
Brow L ft L ft Brow L ft
encountered in patients operated with the pretrichial brow lift technique as the
(n=15) (n=13) (n=5)
skin flap in thin, and it is impossible to close the incision with no tension.
Paresthes a
Trans ent (mos) 7 10 2
The GBL is a novel approach in brow rejuvenation. It can be performed under
Permanent - 4 - local anesthesia unless it is combined with other procedures. On the other
Inc s onal postoperat ve 1 3 4 hand, endoscopic brow lift is performed under general anesthesia. In the GBL
heal ng problems surgery, only a 5-mm incision is made for the entry of the blunt dissectors on
Unfavorable nc s onal 1 11 3 each side. The rate of incisional healing problems is low (7%) as there is only a
scarr ng
small incision in the GBL technique. In other subcutaneous techniques, 4-5
Non- nc s onal heal ng 4 2 1 cm incisions are used which increases the risk of incisional healing problems
problems
and scarring. Moreover, non-incisional healing problems can be seen in these
Hypop gmentat on 3 1 2
techniques due to sharp dissection and use of electrocautery. In this study, 3
Hyperp gmentat on 1 - -
out of 18 patients operated with the Fogli temporal lift and pretrichial brow lift
Frontal branch - 1 -
techniques had non-incisional healing problems. These problems can lead to
neuroprax a
hypopigmentation of the skin in the long-term. Blunt dissection is relatively
Recurrence - - -
easy to perform with the blunt dissectors. It is performed rapidly; however,
Hematoma - 1 -
additional time is necessary to apply the hemostatic net for brow elevation and
skin adaptation. Theoretically, this technique cannot cause a permanent

227
paresthesia as the deep branch of the supraorbital artery runs in the subgaleal Jun 2009;11(3):178-83. do :10.1001/archfac al.2009.10
plane at this region.23 Blunt dissection minimizes the risk of other 14.Tyers AG. Brow l ft v a the d rect and trans-blepharoplasty approaches.
neurovascular injury. This technique has no risk of alopecia or forehead Orb t. Dec 2006;25(4):261-5. do :10.1080/01676830600977384
lengthening as the hair-bearing skin remains intact. In selected cases, a few 15.Ch u ES, Baker DC. Endoscop c brow l ft: a retrospect ve rev ew of 628
entries with the blunt dissector having a straight tip can be performed to consecut ve cases over 5 years. Plast Reconstr Surg. Aug 2003;112(2):628-
distribute the skin if the skin buckling is excessive at the hairline. But, it is not 33; d scuss on 634-5. do :10.1097/01.PRS.0000071042.11435.2E
necessary in almost 90% of the cases as the skin can be adapted easily by the 16.Verpaele AM, Tonnard PL, Hamd M. Long-term use of the Fogl temporal l ft
net sutures as described by Viterbo et al.4 The present study showed that the techn que. Plast Reconstr Surg. Feb 2015;135(2):282e-290e.
ischemic non-incisional healing problems can be seen if the sutures are do :10.1097/PRS.0000000000001070
removed 3 days after surgery. Although, these small ischemic regions heal 17.Auersvald A, Auersvald LA. Hemostat c net n rhyt doplasty: an effic ent and
well with minimal hypo- or hyper- pigmentations and are well tolerated by safe method for prevent ng hematoma n 405 consecut ve pat ents. Aesthet c
patients, removal of the sutures around 36 hours after surgery results in similar Plast Surg. Feb 2014;38(1):1-9. do :10.1007/s00266-013-0202-5
outcomes with a lower risk of non-incisional healing and pigmentation 18.Pham S, W lhelm B, Mowlav A. Eyebrow peak pos t on redefined. Aesthet
problems. Surg J. May-Jun 2010;30(3):297-300. do :10.1177/1090820X10369918
19.D ng A. The Ideal Eyebrow: Lessons Learnt From the L terature. Aesthet c
There are several limitations of the present study. First, the study had a limited Plast Surg. Apr 2021;45(2):536-543. do :10.1007/s00266-020-01920-x
number of patients. Therefore, statistical analysis of the results could not be 20.Brodner DC, Downs JC, Graham HD, 3rd. Per osteal readhes on after brow-
performed. Second, this was a retrospective study based on the experience of l ft n New Zealand wh te rabb ts. Arch Fac al Plast Surg. Oct-Dec
a single surgeon. Further clinical prospective studies including the procedures 2002;4(4):248-51. do :10.1001/archfac .4.4.248
other than the subcutaneous techniques should be designed to better 21.K m JC, Crawford Downs J, Azuola ME, Devon Graham H, 3rd. T me scale
analyze the efficacy of the brow lift techniques. for per osteal readhes on after brow l ft. Laryngoscope. Jan 2004;114(1):50-5.
do :10.1097/00005537-200401000-00008
CONCLUSION 22.Kucukguven A, Ulk r M, B lg c Kucukguven M, Dem ryurek MD, Vargel I.
There has been a trend toward the minimally invasive techniques in periorbital Defin ng a Preaur cular Safe Zone: A Cadaver c Study of the Frontotemporal
rejuvenation. The ideal technique should have a minimal morbidity and long- Branch of the Fac al Nerve. Aesthet Surg J. Mar 12 2021;41(4):398-407.
lasting effects. This study demonstrates that the GBL technique is a promising do :10.1093/asj/sjaa232
and minimally invasive technique with pleasing outcomes. 23.Kn ze DM. A study of the supraorb tal nerve. Plast Reconstr Surg. Sep
1995;96(3):564-9. do :10.1097/00006534-199509000-00007
Acknowledgements
The author declares that there is no conflict of interest. No financial support
was received from any institution or person for the study.

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