Direct brow lift: a cosmetic and reconstructive (but mostly reconstructive) procedure

By Joseph Walrath, MD | Nov 25, 2018 | Brow lifting, Cosmetic, Reconstruction

Advantages and disadvantages of direct brow lifting

Direct brow lifting has many advantages over other forms of brow lifting, and one major disadvantage.  I’ll start with the disadvantage:  there is a scar above the eyebrow.  That is not to be trivialized, and for patients who are concerned, there are pretty good odds that they will do something about the scar, e.g. feathering, filler, dermabrasion, tattooing.  There are people in which the scar heals to invisibility or near-invisibility, but that would never be something that I could assure patients about preoperatively.

Despite the scar, however, there are significant advantages to the procedure that should also not be trivialized:

1. There is exquisite control over brow shape, height, and contour.

2. It is possible to achieve minor adjustments in brow height and contour.

3. The procedure can be performed with or without sedation, and without the equipment or other facility expenses related to endoscopic brow lifting.

4. The procedure can be performed in the multi-operated patient who has other other attempts at brow-lifting that have not been satisfactory.

5. Revisions of direct brow lifting can be performed without sedation.


Who is direct brow lifting appropriate for?

1. The male cosmetic patient who has a heavy brow with thick eyebrows.  This patient could easily camouflage the incisional scar.  

2. The male cosmetic patient who has a receding hairline or very thin hairline.  These patients could not tolerate a large scalp incision (coronal brow lift), nor could they tolerate a 5-10% vertical elongation of the forehead, which could happen with endoscopic brow lifting or a “behind the hairline” open coronal incision.

3. The cosmetic patient who values brow height and shape over all other considerations and is planning to mask incisions with makeup, tattooing, featuring, or other treatments.

4. The multi-operated brow patient who has not had success with other forms of brow lifting.

5. The medical patient, who simply wants to see better due to severe brow droop.


Other thoughts:

Direct brow lifting sounds like such a simple procedure, and in many instances, it can be.  However, it is not without subtlety.  I find that direct brow lifting is significantly more challenging than upper blepharoplasty, in terms of my own preoperative assessment.  I harken back to a conversation that I had with a plastic surgeon a few years ago who scheduled a patient for that procedure and didn’t think too hard about it preoperatively, assuming that it would going to be a simple little excision.  He remarked to me with some surprise afterwards how difficult it was.  I was not surprised.

Like most surgeries, the technical aspects of performing a direct brow lift are not daunting.  (Similarly, the technical aspects of ptosis repair are straightforward.  It’s the decision-making and the observation that happen beforehand, in the office, that decide the success or failure of the surgical plan.) Similarly, the most difficult part of this procedure happens before entering the operating room: the decision-making that happens in the office, the preoperative planning, and most importantly, the preoperative marking.  The cardinal points of the excision are marked preoperatively, with the patient seated in the upright position, while manipulating the brow into the desired position manually.  This is where height and contour are defined.  I then complete the marking of the excision with a fine tip marker and calipers once we move to the operating room and the patient is in the supine position.

One of the most important innovations that I have incorporated into direct brow lifting is a medial M-plasty.  The M-plasty is a sideways “M”-shaped excision that allows greater lift on the inside portion of the brow, without extending the incision length.  This is critical when correcting brow shape.  A surgeon CANNOT get rid of the “angry brow” expression using direct brow lift without incorporating a medial M-plasty.  Any other attempts will either lead to a scar between the brows, or a quizzical look.  The only exception to this would be if there is a deep wrinkle all the way across the mid-forehead, which could be used to achieve the direct medial lift.


The illustrated steps of the direct brow lift:

1. The first case demonstrates the construction of incisions to correct brow asymmetry.  This is the preoperative appearance “on the table”.  Preoperative marking of the cardinal points of the excision was performed in the preoperative holding area, with the patient seated in the upright position.  The fine details of the excision are drawn with the patient in the supine position.


The correction of brow asymmetry can be seen in the asymmetric construction of the incisions.


2. The incision often, but not always, incorporates the “M-plasty”.  This can look dramatic intraoperatively.  The intraoperative appearance, with tissue removed, is seen below:


This patient had a significant excision, since this was a medical case, and the brow tissue was impacting his ability to see.  His one week postoperative appearance, after suture removal, is depicted below:



3. The intraoperative effect of the lift on height and contour can be easily appreciated:


This patient had a medial M plasty performed.  You can see the marking of the M plasty on the side that has not been operated on yet.  Without that M-plasty, this patient would have had a quizzical “Spock” look, since the inner corner of the brow would have been too low. Note that direct excision flares over the position of the “peak” of the brow, and the pleasing arched appearance of the postoperative brow can immediately be seen on her left side.


4. This patient demonstrates a postoperative week#1 appearance, with sutures still in.  The medial M-plasties can be seen.  The indication for the surgery was to reduce an “angry” or “uninviting” appearance of the brows.


There was some other surgery performed below the brows, which is irrelevant for the purposes of this discussion, but which is also very interesting in and of itself!


5. Finally, a long-term preoperative and postoperative result, demonstrating the effect of a direct brow lift to reduce the angry appearance of a male patient with a thick brow.  There were several other procedures performed.  This patient, naturally, had a medial M plasty as part of his procedure.