Overview of Pretrichial Brow Lift
People often visit doctors with issues of “droopy eyes”. This can mean a variety of things. A common problem is called upper eyelid dermatochalasis, which is essentially excess skin on the upper eyelid. There can also be fat or fluid buildup, or drooping of the tear gland referred to as pseudoherniated fat or lacrimal gland ptosis. As we get older, drooping eyelids, known as blepharoptosis, is common. However, patients may not realize that drooping eyebrows, or brow ptosis, can add to an appearance of aging and even interfere with vision. Therefore, when doctors examine the area around the eyes, they must carefully consider the best treatment for each patient. This could include a brow lift along with upper eyelid surgery, if needed.
The brow lift surgery has come a long way since the first one was performed by Passot in 1919. Over the years, doctors have developed many techniques to improve the outcomes of the surgery. The first modern approach was through a coronal incision, a cut made across the top of the head from ear to ear. This was followed by the trichophytic and pretrichial methods. Other techniques, such as direct, mid-forehead, and temporal approaches, as well as endoscopic and transblepharoplasty methods, were developed in the following years.
As progress has been made in facial plastic surgery and less invasive procedures have become more popular, the endoscopic and transblepharoplasty methods are now preferred. An endoscopic procedure involves using a small camera to guide the surgeon, while a transblepharoplasty approach involves making an incision, or cut, in the eyelid. However, the coronal incisions and their variants are still useful in some cases. The choice of technique largely depends on whether any adjustment to the hairline at the front of the head is needed. A traditional coronal approach will raise the hairline in proportion to the amount of scalp skin removed during the surgery. On the other hand, pretrichial/trichophytic approaches do not raise the hairline and can even be used to lower it, if required. The decision between the pretrichial and trichophytic methods is generally based on the surgeon’s and patient’s preference. The pretrichial approach places the incision just in front of the hairline, while the trichophytic approach hides the scar a few millimeters behind the hairline. In some cases, for adjustment of the hairline, the incision may run partially in front of the hairline and partially within it.
This article talks about the pretrichial brow lift approach, which places the incision just in front of the hairline, and explains its benefits and limitations.
Anatomy and Physiology of Pretrichial Brow Lift
The appearance of our eyebrows constantly changes, reflecting evolving beauty ideals and fashion trends. Usually, a man’s eyebrow is full and mostly straight, lining up with the bony ridge of the brow. On the other hand, a woman’s eyebrow is often slightly above or level with this ridge, being thicker towards the nose and thinner towards the sides. However, beauty standards are diverse, and many beautiful actresses and models wear thicker or flatter eyebrows, challenging convention.
To safely perform plastic surgery procedures, like a brow lift, it’s crucial to have a good knowledge of the face’s structure. For instance, there are several layers under the skin of your forehead down to your brow bone and temples. This understanding is vital so doctors can safely work on the right areas during surgery.
We all have a small tendon-like structure that separates the central and side compartments of our forehead – not a true tendon, but an area where different fascia (connective tissue) layers converge. To perform a brow lift, this structure must be cut to lift the forehead.
Moving on, we also have nerves that give the forehead sensation. The supratrochlear nerve, a branch of a bigger nerve called the trigeminal nerve, is responsible for feeling in the middle forehead. The supraorbital nerve, another offshoot of the trigeminal nerve, provides sensation to the side brow and forehead. Sometimes, this nerve passes through a tiny hole or notch in the skull, which might restrict some tissue movement. In these cases, doctors might need to perform an additional procedure to minimize the risk of injury and improve forehead mobility during a brow lift.
Then there’s the temporal branch of the facial nerve, which is at risk during some surgical procedures due to its location beneath certain facial layers. Surgeons use certain reference marks to identify the nerve’s general course, but irregularities often occur due to grooming practices or previous surgeries. Always, the area under the hairy part of the scalp is the safest for procedures.
The muscles in your face that help with expressions – such as those that lift your brows or contribute to wrinkles – play an important role in how your brow looks and moves when you make different expressions.
The arcus marginalis is another connective tissue structure running along your orbital (eye socket) rim that may need to be cut to lift and mobilize the skin and soft tissue during surgery.
Why do People Need Pretrichial Brow Lift
If someone experiences sagging eyebrows or difficulty seeing objects above their eye level due to droopy brows, they might need a procedure known as a pretrichial brow lift. Various methods are available for addressing these droopy brows. However, the pretrichial brow lift, specifically, is most suitable for individuals who are happy with their current hairline or those who are seeking to adjust, reshape, or lower a high hairline. This procedure is often used in facial feminization, which reshapes a male face to make it more typically female.
Like other similar techniques, the pretrichial brow lift gives the surgeon excellent access to various areas of the forehead, including the forehead bone (frontal calvarium), forehead skin (periosteum), forehead sinus (frontal sinus), and the area around the nose and eyes (naso-orbital-ethmoid region). This method also allows the surgeon to access and separate specific forehead muscles which cause vertical creases between the eyebrows. These creases often show up when we frown and are frequently called “frown lines” or “number elevens.”
Besides, the pretrichial brow lift procedure offers the advantage of a great view for the surgeon, which makes it a suitable choice for secondary “revision” procedures if the first one did not yield satisfactory results. But, it’s important to note that the amount of eyebrow lift achieved from this procedure is similar to that of a technique known as an endoscopic lift.
To sum up, the pretrichial brow lift is mostly used for the following reasons:
- When a minimally invasive surgery did not give the desired result and needs to be corrected.
- To move the front hairline forward while concurrently performing a brow lift for faces showing signs of aging.
- For creating a more feminine hairline while providing access for forehead shaping in facial feminization surgery for transgender females.
- For dealing with post-trauma reconstruction or removing a tumor that may require access to the forehead sinus, the front of the brain, or the area around the nose and eyes.
- For creating a flap of skin and tissue over the forehead bone, which might be required in certain surgery types.
When a Person Should Avoid Pretrichial Brow Lift
The pretrichial incision, which is a cut made along the hairline, is a method that can sometimes have an unwanted outcome. People who already have a receding hairline or are likely to in the future should not opt for this procedure. Similarly, if someone has previously not healed well, leaving noticeable scars, or if they care a lot about minimising any visible scars, they might want to consider other options. These could involve smaller cuts or placing the incisions in the hair-covered area of the head.
The coronal approach, another brow-lifting method, raises the forehead all at once. Thus, it can be hard to adjust the tension differently on one side compared to the other. As such, if you have noticeably uneven eyebrows, a method that can treat each eyebrow separately, like direct, temporal, or transblepharoplasty lifts, might give better results. Lastly, people with low hairlines may not be the best candidates for the pretrichial approach, because their hairline could move forward slightly during the procedure.
Equipment used for Pretrichial Brow Lift
If you’re scheduled for a pretrichial brow lift, here’s what you should know about the equipment your doctor will be using:
A syringe filled with a solution called 1% lidocaine with 1:100,000 epinephrine (this is a type of local anesthetic or numbing medication), fitted with small, sharp needles that measure 27 to 30 gauges. The #15 scalpel blade and the #3 Bard-Parker scalpel handle are types of sharp cutting tools used during surgery.
To help lift skin and tissues, they’ll use a tool called a Freer elevator, and for securing the skin during the procedure, they’ll have 10 mm Joseph double prong skin hooks on hand. The Daniel endoscopic forehead elevator, which is a specialized instrument with a 1/4 curved edge, is used to lift the skin of the forehead.
The Metzenbaum scissors and Adson-Brown forceps are for cutting and holding tissue, while a 3 mm straight, unguarded osteotome and mallet might be used if there is a requirement to manipulate bone (especially if there’s a supraorbital notch).
Electrocautery tools (both monopolar and bipolar) are used to control bleeding by mildly burning the blood vessels. A Raney gun with extra clips is used to halt bleeding quickly during the procedure.
Your doctor will use different types of sutures, which are medical threads, to sew your skin back together after the procedure. These sutures are usually classified by their thickness and the material they’re made from, namely 3-0 polyglactin, 4-0 poliglecaprone, and 5-0 gut sutures. Suture scissors will then be used to cut these threads.
After the procedure, an antibiotic ointment will be applied to prevent infection, and the area will be bandaged with a cotton gauze roll and a compressive wrap to keep the area clean and promote healing.
Who is needed to perform Pretrichial Brow Lift?
To carry out a procedure called a pretrichial brow lift, several medical personnel are needed. The team includes:
Firstly, there’s a surgeon who leads the team and does the operation. The surgeon is a specially trained doctor who knows how to do complex procedures like a brow lift.
Next, there’s a surgical assistant. This person offers a helping hand to the surgeon during the operation. They are also trained in surgery and know how to assist in these procedures.
Another key team member is the surgical scrub technician. This person helps by passing necessary instruments to the surgeon and keeping the operating area sterile, ensuring a clean and safe surgery.
The circulating nurse has an important role too. This nurse moves around the operating room, supervising, and making sure that everything is running smoothly. They’re also responsible for helping other team members and keeping conditions safe.
Last but not least, the anesthesia provider is the one who makes sure you’re asleep during the surgery so you won’t feel any pain. They’re in charge of giving anesthesia, or meds that make you sleep, and monitor your vital signs throughout the procedure.
This team will work together to make your pretrichial brow lift surgery as safe and successful as possible.
Preparing for Pretrichial Brow Lift
Before surgery, it’s very important for your doctor to discuss with you what to expect during and after the surgery, as well as any potential risks involved. This conversation helps you understand what the surgery results may look like, and reduces the chances of surprises or misunderstandings after surgery. This also helps to build a solid relationship between you and your doctor, which can be helpful if anything unexpected happens during surgery.
When the surgery involves lifting the brow or removing extra skin from the eyelids (blepharoplasty) for functional reasons, it’s important to document any issues with your field of vision. This is crucial in dealing with health insurance companies who may be covering the cost of the surgery. It’s also very important to take photos before the operation. At a minimum, these photos should show a full frontal view of your face relaxed and with your brow lifted. If removing extra skin from the eyelid is also part of the surgery, side views of the eyes looking straight ahead, closed, and looking up may be helpful. These photos are useful for planning the operation and also serve as a legal record when compared with photos taken after the surgery. Ideally, these photos should be displayed in the operating room during the surgery for easy reference.
How is Pretrichial Brow Lift performed
In this procedure, after making sure you understand and agree to the procedure (this is called giving consent), the doctor will prepare the area where they will be operating. They’ll inject a local anesthetic into the scalp to numb the area and reduce bleeding. They might also use a solution made to reduce swelling and bruising in place of the normal anesthetic. The anesthetic goes from the side of the forehead, across the width of the forehead, and a little into the hairline above the forehead.
Next, the doctor will carefully mark the area where they will make a cut. The cut starts just above the top of your ear, moves up into your hairline, and then turns to go horizontally across your forehead. The cut is zigzagged to match the natural contours of your hairline and to hide the scar better. The incision is made using a precise scalpel and any bleeding will be controlled.
The doctor will make sure to cut in the right place to avoid damaging hair follicles, which are like tiny roots that grow hair. They cut deep enough so that they can elevate the forehead later and take the stress off your eyes. If necessary, they will gently detach the skin from the underlying muscles and bone to have more room to work.
If the surgeon chooses to operate under the thin layer of your scalp (the galea), they will gently and very carefully break up the connection between the skin on your forehead and the underlying tissues. They use a precise metal instrument called a scalpel, and specialized scissors designed for this purpose. If they choose to operate deep under this layer down at your skull, they will do the same thing.
Afterward, the surgeon will make an incision on the side of your head across your hairline, exposing the muscle underneath. They will then gently and carefully separate the underlying muscle from the skin, continuing until they reach a strong, fibrous band of tissue. This band of tissue is carefully opened up from the side to the middle, allowing access to a deeper layer.
Then, the surgeon will reflect (or fold back) the lifted area gently toward your nose. If necessary, the surgeon’s assistant can help maintain this position using delicate instruments. Special care is taken to avoid any unnecessary trauma to the area. The surgeon will then reveal the area below your eyebrows and between your eyes. Certain bundles of nerves and surrounding tissues might be gently relieved from their positions around the eye sockets to make sure that the surgical area moves freely and doesn’t cause any nerve damage or impairment in sensation.
The surgeon will then continue to lift the tissues at the level of your eye socket and a little above it. This lifting will extend all the way to the left side of your face. If the lifting was done under your forehead muscle and a thin layer of tissue, also known as a “flap”, is planned to be lifted, the flap needs to be lifted at this stage. If the lifting was done under that layer down to the bone and a flap was planned to be lifted, the flap may be lifted from the underside of the forehead flap at any time during surgery.
After the eye socket is fully exposed, the surgeon will precisely separate a specific layer of connective tissue around your eyes and spread it proactively. This is done to make sure that your eyebrows are lifted up to the right position. Depending on the findings and requirements during surgery, additional procedures are also considered at this stage.
The surgeon will then reinstall the separated area and apply upward tension until the desired brow height is obtained. In some cases, the surgeon may use devices to secure the elevated position of your forehead before surgical closing. These devices ensure the eyebrow lift by maintaining tension on the forehead and can be strategically positioned to exert forward tension for hairline advancement if required.
The closing of the surgery involves securing the incision site with sutures or staples. This helps the surgeon assess any excess tissue that can be safely removed. Generally, in older females, this typically involves the removal of a long, elliptical piece of scalp. However, for those seeking changes in their hairline, the approach may be different and may include the removal of non-hair-bearing scalp.
Possible Complications of Pretrichial Brow Lift
Just like with any surgery involving the soft tissues, brow lift surgeries can lead to some side effects like pain, bleeding, infection, and even scarring that doesn’t look quite perfect. This particular procedure can possibly lead to other issues too like numbness affecting part or all of the forehead. This could happen if the supraorbital or supratrochlear nerves, which are located in the face, get injured. There’s also a risk of the eyebrows becoming weak or drooping, this can happen if the frontal branch of the facial nerve is harmed during this procedure.
There are a few more complications that could potentially arise as well, like hematoma or seroma (which are types of swelling due to blood or fluid build-up), eyebrows that are uneven, the eyebrows being lifted too much or not enough, irregularities in the hairline, and even hair loss at the scar line. It’s important for the patient to know that they could feel numbness in the scalp behind the incision after the surgery, and this feeling might not disappear completely over time. Giving these details to patients is very crucial to make sure they are fully informed and satisfied with their decision.
What Else Should I Know About Pretrichial Brow Lift?
Nowadays, there’s a focus on using less invasive methods for surgeries that improve the look of the face. That said, traditional operations such as pretrichial brow lifting are still useful choices for many people. This procedure is particularly helpful when you want to lift your eyebrows and adjust the position of your hairline at the same time. It’s often used for female transgender patients who want to lift the area where their brow hairs grow, reduce the prominent bone above the eye socket (supraorbital ridges), and reshape their hairline. These changes can all be made through an incision in the pretrichial area (which is where your hair starts on your forehead).
Pretrichial brow lifting is also a good option in situations where moving the hairline or brow position isn’t the main goal, like in cases of frontal sinus fractures, NOE fractures, and anterior skull base tumors. This approach might be better than a traditional coronal incision, especially for those with short hair who do not want a noticeable scar on the top of their head. Although brow lifting methods like the coronal-type approach might take more time and create a scar that’s easier to see than less invasive methods, they provide a similar level of lifting while giving surgeons a better view of the frontal skull. For this reason, pretrichial brow lifting is a vital and flexible tool for facial surgeons.
