Deep Plane Brow lift: A Technical Note

Abstract

In recent years, plastic surgeons worldwide have strived to enhance surgical techniques in order to improve short- and long-term outcomes. While numerous approaches to brow lift surgery have been discussed in the literature, a definitive choice for all facial plastic surgeons remains elusive. This article presents the deep plane brow lift, a refined surgical technique for eyebrow elevation. The procedure emphasizes minimal invasiveness with a focus on rapid recovery and reduced complications. The authors highlight the advantages of this approach over traditional methods, such as endoscopic techniques, by emphasizing its simplicity, predictability, and reduced risk of complications like hair loss and numbness.

Introduction:

Brow lift surgery has evolved significantly over the past two decades due to advancements in surgical techniques and increasing patient preference for minimally invasive procedures. However, no single technique has demonstrated universal superiority.¹ This article introduces the deep plane brow lift, refined through a decade of surgical experience, offering an effective, reproducible, and uncomplicated approach.

Materials and Methods:

Preoperative Setup.

The procedure may be performed under local or general anesthesia. General anesthesia is preferred for combined procedures. The required surgical instruments are depicted in Figure 1.

FIG. 1.

Key instruments for the deep plane browlift. (A) Marking pen, (B) Mayo scissors, (C) Metzenbaum scissors, (D) Needle holder, (E) Freer elevator, (F) Army-Navy retractor, (G) Curved iris scissors, (H) No. 15 blade, (I) Double hook, (J) Adson forceps with teeth, (K) Straight iris scissors, (L) Jeweler bipolar cautery, (M) Yankauer suction tip.

Surgical Technique:

Prepping and Draping: The forehead is sterilized with Betadine, and ophthalmical solutions are used for corneal protection. Draping leaves a 5 mm posterior hairline margin exposed.

Marking: Bilateral semi-lunar incisions extending from the medial to lateral brow are marked. The incision is placed 2–3 mm behind the hairline.

Infiltration: Local anesthesia with lidocaine and epinephrine (1:100,000) is administered.

Incision: Beveled incisions behind the hairline prevent follicle damage and alopecia. Two subperiosteal stab incisions are made to facilitate dissection.

Dissection: Subcutaneous dissection proceeds to the mid-forehead, followed by subperiosteal elevation and arcus marginalis release.

Excess Skin Removal: A D’Assumpcao marker determines the excision extent. Frontalis muscle stabs are sutured before excising redundant skin to prevent diastasis.

Closure: Deep interrupted Monocryl sutures minimize tension, followed by running nylon sutures for skin approximation. Bacitracin ointment is applied postoperatively.

Discussion:

Brow lifting procedures encompass various techniques, each with its own advantages and disadvantages.² Table 1 provides an overview of frequently employed procedures. Endoscopic techniques have gained prominence initially but have experienced a decline in recent years. A single-institution study reported a 7% decrease in the number of endoscopic brow lift procedures, attributing this decline to the availability of equally or more effective and predictable alternative medical and surgical techniques.³ The deep plane brow lift technique incorporates the favorable aspects of these procedures while minimizing potential drawbacks. The senior author aimed to develop a brow lifting procedure characterized by an easy learning curve, technical simplicity, and long-lasting results. The technique addresses concerns such as visible scars, permanent scalp numbness, alopecia, hairline recession, and reversible outcomes. The incision hidden in the hairline with an acute-angled bevel addresses the issues of visible scars and alopecia. The vertical stab incisions in the frontalis muscle mitigate neurovascular bundle injury, preventing permanent scalp numbness. Subperiosteal elevation and release of the arcus marginalis, achieved through subcutaneous and subperiosteal dissection and elevation, provide enduring lift and permanent results. Skin excision at the conclusion of the procedure reinforces the lift and caters to individuals with a high hairline seeking brow lifts. Patient responses and satisfaction with the overall experience have been overwhelmingly positive.

Table 1.

Advantages and disadvantages of the different eyebrow lift techniques

Technique	Purpose	Contraindications	Pros	Cons
Botulinum toxin injections	Paralyze orbicularis oculi muscle causing therefore brow elevation	Hypersensitivity to Botulinum toxin injections	Not an invasive procedure	Temporary effect, costly on the long run
Direct browlift	Skin excision immediately above the brows	If medial eyebrow elevation is sought	Great elevation of the lateral brow	Permanent scar above the brow
Internal browpexy	Anchoring the brow tissue to the periosteum of the frontal bone	No blepharoplasty indicated	Great procedure for brow anchoring	No true browlift
Coronal forehead lift	Large incision behind the hairline and extensive tissue excision and lift	High hairline	Permanent lift, easily reproducible, long lasting	Extensive incision, persistent hair loss and numbness
Endoscopic forehead lift	5 small incisions in the scalp with subperiosteal elevation and brow tissue anchoring sutures	High hairline	No visible incisions	Requires high technical abilities and equipment, Risk of persistent hair loss and numbness
Mid forehead lift	Skin excision along a central forehead crease	No rhytids on forehead	Easily reproducible, local anesthesia, lowers hairline	Prominent scar on forehead, less effective for lateral brow ptosis
Trichophytic browlift	Incision in front of the hairline with skin excision and lift	Short forehead	Easily reproducible, local anesthesia, lowers hairline	Chance of scarring, no long term results because of skin only excision

Conclusion:

The deep plane brow lift exemplifies the balance of simplicity, efficacy, and patient satisfaction, positioning itself as the preferred technique for contemporary brow rejuvenation.

Authorship Confirmation Statement:

Dr. C.M. conceptualized and designed the study, drafted the article, and supervised the work. Dr. P.B. contributed to data collection, analysis, and critical article revisions. Both authors have reviewed and approved the final article for submission.

Conflict of Interest Statement:

The authors declare no conflicts of interest related to this article.

Declaration of AI and AI-Assisted Technologies in the Writing Process:

During the preparation of this work, the authors used AI-assisted tools for grammar and readability improvement. The authors reviewed and edited the content to ensure accuracy and take full responsibility for the final version.