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One-year sustainability of brow-lifting procedures

Open AccessPublished:December 19, 2022DOI:https://doi.org/10.1016/j.bjps.2022.12.008

      Summary

      Background

      Unlike blepharoplasty or facelifting procedures, there is little evidence of the sustainability of brow-lifting techniques.

      Objectives

      This study aimed to investigate the one-year sustainability of three brow-lifting techniques performed at our department.

      Methods

      Thirty-six patients received an upper blepharoplasty and simultaneously one of three brow-lifting procedures: the direct (excisional) browpexy, the transpalpebral brow lift, and the Endotine forehead fixation.
      analogue and digital measurements of 3 vertical distances, from fixed anatomical points at pupil, lateral canthal, and lateral orbital rim level, were performed preoperatively and 12 months postoperatively.
      Patients’ and surgeons’ satisfaction considering functional and aesthetic outcomes were investigated by carrying out paper–pencil surveys.

      Results

      Direct browpexy was performed in 8, transpalpebral eyebrow lift in 10, and the Endotine fixation in 18 of the cases. In the first year, direct browpexy showed a general descent of 1.2 mm at the pupil level, 2.1 mm at the lateral canthal, and 0.6 mm at the orbital rim level. In the transpalpebral eyebrow lift group, a descent of 0.7 mm at the pupil level and 0.3 mm at the lateral canthal level was found; the orbital rim level showed a slight but nonsignificant ascent of 0.7 mm. In the Endotine group, a descent of 1.1 mm at the pupil level, 1.2 mm at the lateral canthal level, and 0.7 mm at the orbital rim level was shown.
      Subjective surgeon opinions and overall patient satisfaction underline an aesthetic improvement despite objective results falsifying the hypothesis of a raised eyebrow position after one year.

      Conclusion

      Patients showed minor eyebrow decrement after 12 months postoperatively; therefore, sustainability is questioned and must be reevaluated.
      The extent of dissection, the downward pull of upper blepharoplasty resection, and the decrease in frontalis muscle activity are discussed as the possible causes.
      Level of Evidence IV

      Keywords

      Background

      The shape and position of the eyebrow play an essential role in facial appearance, expressing emotions, and conveying personality.
      • Griffin J.E.
      • Frey B.S.
      • Max D.P.
      • Epker B.N.
      Laser-assisted endoscopic forehead lift.
      Analogous observations were made by Mueller et al. in the context of careers of US soldiers: facial expression on yearbook portraits of the United States Military Academy West Point Class of 1950 was rated on a seven-point scale from “1″ = very submissive to “7″ = very dominant. Cadets rated on a scale of 7 had higher eyebrow positions than those with fewer points.
      • Mueller U.
      • Mazur A.
      Facial dominance of west point cadets as a predictor of later military rank.
      During ageing, periorbital soft tissue becomes flaccid, characterized by ptosis of the eyebrow and excess tissue in the upper, lateral eyelid area. In the medial part of the eyebrow, the frontalis muscle is firmly attached to the periosteum and cranially connected to the deep galea aponeurotica. Soft tissue lateral to the temporal line is not as reinforced as medial soft tissue, causing additional skin drop.
      • Knize D.M.
      An anatomically based study of the mechanism of eyebrow ptosis.
      A singular correction of the upper eyelid may lead to a shortening of the midpupil to eyebrow distance, which creates an unnaturally angry facial expression.
      • Georgescu D.
      • Anderson R.L.
      • McCann J.D.
      Brow ptosis correction: a comparison of five techniques.
      A study by Lee et al. supports the hypothesis of midpupil to eyebrow distance loss in patients undergoing blepharoplasty. This effect was found even more in patients undergoing levator grafting.
      • Lee J.M.
      • Lee T.E.
      • Lee H.
      • Park M.
      • Baek S.
      Change in brow position after upper blepharoplasty or levator advancement.
      Most patients undergoing blepharoplasty are unaware of the correlation between excess eyelid tissue and eyebrow weight.
      • Ellenbogen R.
      Transcoronal eyebrow lift with concomitant upper blepharoplasty.
      In contrast to a well-established gold standard technique for upper blepharoplasty, there is no uniformly recognized method for the correction of brow ptosis.
      • Mueller U.
      • Mazur A.
      Facial dominance of west point cadets as a predictor of later military rank.
      ,
      • Walden J.L.
      • Orseck M.J.
      • Aston S.J.
      Current methods for brow fixation: are they safe?.
      The aim of this study was to investigate the extent of brow elevation after combined blepharoplasty in a long-term comparison over the course of one year. The study was carried out as a before and after comparison of surgical techniques.

      Methods

      This is a prospective study of a series of 36 patients who underwent brow lift and upper blepharoplasty surgery simultaneously, including three surgical techniques for brow lifting commonly used at the Department for Plastic and Reconstructive Surgery at the Clinic Ottakring in Vienna. All procedures were planned for functional improvement and not for purely aesthetic reasons. Procedures were paid for by the national health insurance system and performed by five plastic surgeons, including the senior author, under local anaesthesia or i.v. sedation.
      Blepharoplasties were planned by marking the caudal incision line along the supratarsal crease, running laterally into an upward-directed wrinkle of the crow's feet not further than 1 cm lateral of the lateral canthus. Skin excess was determined by gently pinching the skin using two anatomical forceps. An upper incision line was marked according to the determined skin excess. The marking was thoroughly planned to not affect the eyebrow position by pulling downward or over-exercising upper eyelid skin. After applying local anaesthesia, the skin spindle was excised. A small muscle strip of the orbicularis oculi muscle was removed, and the orbital septum was fenestrated. Spontaneously prolapsing fat was conservatively removed from the central and medial fat pads. After haemostasis was achieved, a running suture was applied.

      Surgical techniques

      Browpexy with endotine

      The border where the periosteum, the temporal profound fascia, and the temporal parietal fascia fuse (“temporal fusion line”) is determined and marked (Figure 1a). The same is done for the lateral orbital margin at the level of the lateral canthus. A vertical incision is made posterior to the hairline at the level of the estimated lifting vector.
      Figure 1
      Figure 1(a) Browpexy with endotine.... Extent of dissection (yellow), and position of endotine... forehead implant (purple). Vertical incision above implant not marked. (b) Transpalpebral brow lift. Extent of dissection (yellow), and position of 1-2 sutures suspending orbicularis oculi muscle and the overlying brow to the periosteum of the frontal bone (purple). Upper bleph incision not marked. (c) Direct browpexy. Marking of incision (purple) and extent of skin resection (yellow).
      Dissection starts subperiosteally and changes to a subgaleal plane at the hairline, continuing toward the lateral brow. The upper eyelid incision is used as an access to detach the brow epiperiosteally. Afterward, a suitable hole is drilled into the cranial bone, following the insertion of triangular Endotine forehead implants (MicroAire, Charlottesville, VA, USA). Mobilized tissue layers are pulled over the Endotine device in an utmost elevated position.
      • Pascali M.
      • Gualdi A.
      • Bottini D.J.
      • Botti C.
      • Botti G.
      • Cervelli V.
      An original application of the Endotine Ribbon device for brow lift.
      Skin closure was performed using a 6-0 ProleneTM running suture for the blepharoplasty incision and a 3-0 MonocrylTM interrupted suture for the scalp incision, respectively (both Johnson&Johnson).

      Transpalpebral brow lift

      The upper blepharoplasty incision is used to perform an epiperiosteal dissection layer that mobilizes the eyebrow laterally of the supraorbital nerve and the forehead skin cranially of the eyebrow. The extent of dissection starts from the medial supraorbital nerve and goes to the medial zygomaticotemporal vein, which is found about 1.5 cm lateral to the orbital rim and about 2.5 cm above the supraorbital margin (Figure 1b). Using 4–0 PDS sutures, the musculus orbicularis oculi and the overlying brow are suspended against the periosteum of the frontal bone, lifting the loosened brow.
      • Patrocinio L.G.
      • Patrocinio T.G.
      • Patrocinio J.A.
      Transpalpebral eyebrow lift.

      Direct browpexy

      A semilunar incision in a W-plasty type is done at the upper border of the lateral brow (Figure 1c). The brow is not fixed to underlying structures, and the skin is closed in 2 layers. The height and form of the semilunar marking will determine the amount of brow lifting and the position of the maximum lifting vector.
      • Walden J.L.
      • Orseck M.J.
      • Aston S.J.
      Current methods for brow fixation: are they safe?.
      The assignment of the patients to these three surgical techniques was deliberately not randomized and chosen according to aesthetic-functional aspects:
      Direct browpexy was performed in patients with bushy eyebrows and dominant forehead wrinkles. Patients with a low hairline were rather selected for the Endotine method, while those with a high-projecting forehead were selected for the transpalpebral access. The direct browpexy is particularly suitable for patients with dense eyebrows or preexisting forehead wrinkles as the resulting postoperative scars are easier to hide.
      • Massry G.G.
      The external browpexy.
      Within the transpalpebral approach, the risk of nerve injury whether through anesthesiologic infiltrations, injections, or dissections is low. A decisive criterion for the realization of this method is the thickness of the skin as the transpalpebral approach has proven to be less effective in patients with particularly thick skin.
      • Patrocinio L.G.
      • Patrocinio T.G.
      • Patrocinio J.A.
      Transpalpebral eyebrow lift.

      Study design

      During each examination, the following measurements were performed:

      Manual measurements

      A thread-plumb bob with a weight of 27 g is positioned in front of three anatomical landmarks (Figure 2), freely hanging down. The distance of each landmark to the centre of the vertical eyebrow height is marked on the thread, the thread is removed, and the distance is measured.
      Figure 2
      Figure 2Landmarks for manual measurements of eyebrow height with a thread plumb.
      Landmark 1: the light reflex of the midpupil
      Landmark 2: the lateral canthus
      Landmark 3: the point of intersection of a horizontal line passing through the lateral canthus and a vertical line at the lateral orbital rim.

      Digital measurements

      A device was constructed to standardize the distance (74 cm) from the patient's face to the lens of a Nikon D40 SLR camera. Photoshop CS6 was used to digitally measure the abovementioned distances (Figure 3).
      Figure 3
      Figure 3Device for standardized digital measurements (patient...s face to camera lens = 74cm).

      Patients’ and surgeons’ questionnaire

      A surgeons’ questionnaire, including the before and after pictures of all 36 patients, was designed to evaluate the surgical improvement (11 grades from (0) = none to (10) = best possible improvement) regarding the following parameters:
      • functional improvement in the brow lift
      • aesthetic improvement in the brow lift
      • functional improvement in blepharoplasty
      • functional and aesthetic results of both procedures combined
      A patient questionnaire was designed to evaluate the following parameters:
      • Overall patient satisfaction (4 grades from “very satisfactory” to “unsatisfactory”)
      • Improvement in eyebrow position (5 grades from “significantly higher” to “significantly lower”)
      • Improvement in visual field (5 grades from “I see significantly more” to “I see significantly less”)
      • Postoperative pain during the first seven days (11 grades according to VAS from “0, no pain” to “10, worst imaginable pain”)
      At 12 months postoperatively, all patients were asked to complete the questionnaire.

      Results

      Thirty-six patients were operated on by 6 consultants of our department. Twenty-four patients were female and twelve were male, with ages ranging from 42 to 77 years, and the mean age was 57.3 years (SD 9.0). All procedures were performed in 2019 and 2020 at the Department for Plastic and Reconstructive Surgery at the Clinic Ottakring in Vienna, Austria. Four patients were lost to follow-up.
      Manual and digital measurements did not differ statistically and were subsumed.
      The following variance-analytical investigations are based on the 32 patients for whom a complete measurement protocol was prepared preoperatively and 12 months postoperatively. Thirty-six patients were included. Four of them attended the postoperative consultations until 3 months postoperatively but were not available for the follow-up 12 months postoperatively. Two-factorial (2 × 2) variance analyses with repeated measurements were carried out to examine the changes between the two survey points (T1= preoperative/T2= postoperative).

      Brow height changes

      Overall results are shown in Figure 4.
      Figure 4
      Figure 4Overall results showing preoperative (blue) and 12 months postoperative (orange) mean brow height at the three landmarks.

      Orbital rim

      The overall mean brow height at orbital rim level was 12.5 (±2,2) mm preoperatively and 12.2 (±2,0) mm 12 months postoperatively. The test value for the interaction of time was not significant.

      Lateral canthus

      The overall mean brow height at lateral canthal level was 18.9 (±2,7) mm preoperatively and 17.7 (±2,7) mm 12 months postoperatively. There was a trend toward a smaller distance, but it did not show statistical significance.

      Pupil

      The overall mean brow height at pupil level was 17.8 (±2,5) mm preoperatively and 16.8 (±2,7) mm 12 months postoperatively. Again, there was a trend toward a smaller distance, but no statistical significance could be shown.

      Brow height changes depending on the technique

      The results of measurement changes depending on the different surgical techniques are presented in Figure 5. The differences in measured values (T2 = 12 months postoperative -T1 = preoperative) were interpreted as follows: negative values indicate a decrease, positive values an increase in brow height. Testing was carried out using single-factor variance analyses, depending on the localization. The three-category surgical technique (transpalpebral, direct browpexy, and Endotine forehead) was considered an intermediate subject factor. As a test prerequisite, variance homogeneity was examined by applying the Levene test and could be assumed for all analyses with a non-significant result of p > .05.
      Figure 5
      Figure 5Changes in brow height depending on technique. Negative values indicate a decrease, positive values an increase in brow height.
      Within all three techniques, a positive height gain could be achieved only through the transpalpebral approach at the orbital level. At the lateral canthal and the pupil level, a slight descent in the brow height was shown, and no significant difference in achieved height between the three surgical techniques could be confirmed.

      Results of the surgeons’ questionnaire

      The assessment of the surgical outcome was obtained from all 6 consultants of our department performing the brow lifts. The questionnaire was completed at the same time, assessing all 36 results in one stage, including the surgeon's and the other surgeon's results.
      Two patient examples evaluated by the surgeons pre- and postoperatively are shown in Figure 6.
      Figure 6
      Figure 6Two patient examples evaluated by the surgeons pre- and postoperatively.
      The mean value and standard deviation were calculated to get an idea of the average opinion of the surgeons. These values, including the degree of variance and range, are shown in Table 1.
      Table 1Indices of averaged surgeons’ opinions (n = 6) to brow-lifting and blepharoplasty improvements.
      Rating 0–10 (n = 6 surgeons)Yes vs. no
      1 Functional2 Aesthetic3 Functional Bleph4 Combination
      M +/- SD4.0 +/- 1.514.09 +/−1.495.85 +/- 1.65.594 +/- 0.293
      Min - max1.83 – 7.501.50 – 7.172.67 – 9.00.20 – 1.00
      Md (IQR)3.7 (3.0–4.5)4.2 (2.7 – 5.0)6.0 (4.3 – 7.0).60 (0.40 - 0.80)
      In a further step, the consensus of all surveyed surgeons on the four mentioned categories was calculated using the intraclass coefficient (ICC). The ICC was calculated with a two-factorial mixed model regarding the absolute agreement as an average value of the opinions of six surgeons on 35 patient protocols. Results are shown in Table 2.
      Table 2Absolute agreement and average value of surgeons’ opinions (n = 6). ICC coefficients with 95% confidence interval with significance assessment, LL= lower limit; UL = upper limit.
      Rating 0–10 (n = 6 surgeons)95% CIF-Test
      CategorySurgeonsPatientsICCLLULValuedf1df2p
      Functional635.56.26.764.06734170<0.001
      Aesthetic635.51.22.713.21134170<0.001
      Functional + blepharoplasty634.67.43.824.53933165<0.001
      Combination535.54.24.742.16234136<0.001

      Results of patients’ questionnaire

      Patient satisfaction, eyebrow position, and visual field change

      At 12 months postoperatively, patients were asked to rate the results of the procedure according to the following criteria: the result of the procedure should be rated from (1) very satisfactory to (4) unsatisfactory; visual field changes should be evaluated from (1) I see significantly more to (5) I see significantly less, and the position of the eyebrow should be evaluated from (1) significantly higher to (5) significantly lower. The level of pain should be rated from (0) no pain to (10) maximum imaginable pain. Thirty-one patients answered this questionnaire. Results of the patients’ questionnaire are shown in Figure 7a-c.
      Figure 7
      Figure 7(a) Results of patients' questionnaire: Satisfaction with surgery outcome. (b) Results of patients' questionnaire: Perception of postoperative brow position. (c) Results of patients' questionnaire: Perception of change of visual field.

      Postoperative pain

      The level of pain during the postoperative regeneration phase based on an eleven-section scale ranged from 0 to 10 with 1.68 ± 0.65 (min 1, max 3; Md = 2) on average. As the most frequent rating, the value 2 (mode) was given in 48.4% (see Table 3), representing an overall expectation of low postoperative pain.
      Table 3Frequencies and proportional values of postoperative pain n = 31.
      Pain score (0–10)FrequencySharesAccumulated
      11341,9%41,9%
      21548,4%90,3%
      339,7%100,0%
      Patients had the opportunity to leave additional comments, which was done by two participants only. One person noted a temporary irritation of the eye because of postoperative dryness. The other patient expressed his dissatisfaction with the postoperative result, feeling that the amount of improvement in brow-lifting was not satisfying for him.

      Discussion

      This paper presents a prospective and monocentric study aimed at investigating the long-term sustainability of three different surgical brow-lifting techniques by measuring three distances starting from static anatomical points and reaching to the centre of the eyebrow. These distances were measured manually and digitally preoperatively and 12 months postoperatively.
      In all three techniques, a minor decrease at the pupil level (−0.7 ± 2.1 mm in the transpalpebral, −1.2 ± 2.3 mm in the direct, and −1.1 ± 2.4 mm in the Endotine group) as well as at the lateral canthal level (−0.3 ± 3.1 mm in the transpalpebral, −2.1 ± 2.5 mm in the direct, and −1.2 ± 2.2 mm in the Endotine group) was shown at 12 months postoperatively.
      At the orbital rim level, the direct and the Endotine group showed a stable brow height (−0.6 ± 2.1 mm and −0.7 ± 1.4 mm after one year); the transpalpebral group showed a minimal increase (0.7 ± 2.1 mm) after 12 months, which was of no statistical significance.
      There are several limitations to this study: a comparatively small sample size, the missing randomization, and the assignment of method because of certain patient characteristics that may cause a systematic error in the results.
      Based on our results, the hypothesis of an increase in brow height as a long-term result of brow-lifting techniques must be rejected.
      Our study joins a group of studies in which a sustainable improvement in the brow position height could not be shown.
      Tian L. et al. examined 273 patients who underwent brow-lift surgery by removing a part of the orbicularis oculi muscle or attaching it to the orbital periosteum. A brow height of 28.37 ± 3.02 mm in the first group and a height of 29.21 ± 2.97 mm in the second group could be achieved postoperatively, taking the pupillary light reflex as the first measuring point. These measurements were repeated 6, 12, and 24 months after the procedure. After 24 months, the measured distance shortened to 20.76 ± 2.22 mm for group 1 and 24.74 ± 3.10 mm for group 2. A significant drop in height could be observed after 12 months in both techniques.
      • Li T.
      • Zhang D.
      • Li B.
      • Shao Y.
      A technique for the prevention of recurrent eyebrow ptosis after brow lift surgery.
      Chowdhury et al.
      • Chowdhury S.
      • Malhotra R.
      • Smith R.
      • Arnstein P.
      Patient and surgeon experience with the endotine forehead device for brow and forehead lift.
      compared the endoscopic method with the Endotine implant in 31 patients after 4 and 22 months. On average, an elevation of 2.7 mm on the right side and 2.9 mm on the left side of the face was achieved.
      Some studies showed at least a partial improvement in brow position.
      McKinney and Sweis pointed out a height gain of 6 to 7 mm intraoperatively and a descent postoperatively of 2 to 3 mm during the follow-up phase of nine months in 24 randomly selected patients undergoing endoscopic brow lifting.
      • McKinney P.
      • Celetti S.
      • Sweis I.
      An accurate technique for fixation in endoscopic brow lift.
      —————
      The patients’ satisfaction was assessed with the help of questionnaires. Most of the patients considered the operation outcome as satisfactory (54.8%) and very satisfactory (35.5%); a decent improvement in the visual field was reported by 45.2% and a significant improvement by 35.5% of the patients. Postoperative eyebrow height was rated similarly positive: 41.9% considered the eyebrow to be slightly more elevated.
      The surgeons’ assessments of pre- and postoperative images are based on a holistic visual assessment, which means that facial changes were evaluated within the whole facial composition. Aesthetic aspects might have influenced their opinion, indicating that these results need to be interpreted with caution. This might be the reason for an intermediate degree of consensus between the different surgeons’ opinions. Functional results of the blepharoplasty procedure were assessed as clearly positive, adding a benefit to the combination of the two operations.
      Possible explanatory models for our long-term results:
      • 1.
        The frontalis muscle tone is increased preoperatively to enlarge restricted field of vision by constant brow elevation; this would lengthen the preoperative measurement distances. Patients tend to lift their brows because of a restricted field of vision. This long-standing habit is often maintained even three months postoperatively. During our long-term examination over the past 12 months, patients might have been reducing their frontalis muscle tone, explaining the lowering of the eyebrow. Further studies to evaluate the alteration of frontalis muscle tone over time (e.g., measurement of brow position with closed eyes) are planned.
      • 2.
        Patients may not have relaxed their foreheads completely while the picture was taken.
      • 3.
        The blepharoplasty procedure shortens the brow to midpupil distance by excising excess tissue. The excision of skin excess during blepharoplasty can be seen as a factor contributing to the descent of the eyebrow.
      • 4.
        The dissection area was limited in all three techniques, explaining the lack of long-term sustainability of these procedures. The limited dissection could be of greater impact in surgical techniques attaching the eyebrow fixating suture at a great distance above the eyebrow, such as the brow-lifting method with the Endotine Forehead Device, compared with a local fixation like in the direct method.

      Conclusion

      Limited dissection brow-lifting techniques can be understood as stabilizing additional procedures to the functional result of upper blepharoplasty by reducing lateral hooding.
      It could be hypothesized that treating our patients without any brow-lifting technique would have caused the brow to drop even more, but this study is lacking an adequate control group.
      Therefore, we do not recommend brow-lifting techniques in primary cases like ours. Probably, adding brow lifting as an adjunctive procedure to secondary upper blepharoplasties might be more useful to correct drooping eyebrows because of a shortened pupil to eyebrow distance from the first blepharoplasty. Long-lasting rejuvenation of the brow and forehead region needs a wider dissection.
      Compared with other aesthetic procedures, there is poor evidence in studies concerning brow-lifting techniques. It requires further studies to evaluate brow-lifting sustainability of the multiple existing techniques that differ in the amount of dissection, plane of dissection, vector of lifting, point of fixation, and combination with volumizing procedures such as lipofilling. The results of this study can be used as a basis for further work.

      Ethical declaration

      An ethical declaration of consent was obtained from the Vienna Municipal Department (processing number EK 18 091 0618).

      Human or animal participants

      This article does not contain any studies with human participants or animals performed by any of the authors.

      Informed consent

      Written consent to participate in this study was obtained from all participants in compliance with the guidelines of the Declaration of Helsinki. All participants whose photos are used in the article gave consent to publish.

      Funding

      The author(s) received no financial support for the research, authorship, and/or publication of this article.

      Conflicts of interest

      The authors declare that they have no conflicts of interest to disclose.

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