Changes in Eyebrow Position and Shape with Aging and Brow Lifting
I congratulate Matros, Garcia, and Yaremchuk on their timely article on changes in eyebrow position and shape with aging.1 This study was long overdue. It has long been known to some people that endoscopic brow lifting can create an unnaturally high medial brow and an unaesthetic, operated appearance to the brow.
I studied facial photographs of 141 female Caucasian subjects aged 25 to 85 years.2 Photographs were normalized in terms of size, and measurements were obtained using proprietary software to determine the height of the medial, apex, and lateral brow above the interpupillary line in both frontal and oblique views. The notable feature was that brow heights showed a wide variation across all ages with, if anything, only a very minor trend toward brow height elevation with age (Fig. 1). The lateral brow slope angle showed a trend toward increasing with age, consistent with Knize's description of brow ptosis beginning with the lateral brow,3 but again, the major feature was the wide scatter in variability of brow slopes across all age groups (Fig. 2). Brow surgery is an aesthetic decision that needs to be individualized to the patient's desires. Patients require examination in front of a mirror to determine their preferences.
My brow-lifting technique with permanent suspension sutures is one that I have modified from that which I learned from Dr. Des Fernandes. This technique has been presented2 and is described briefly below. The procedure is performed under local anesthesia and is quick and simple. One-centimeter incisions are made in the lateral hairline. A space is dissected down to the eyebrow deep to the galea-frontalis by spreading with a pair of Metzenbaum scissors. Elevation and shaping of the brow is performed with permanent 4-0 Prolene sutures (Ethicon, Inc., Somerville, N.J.) placed by a retrograde needle technique. A 27-gauge, 9-cm-long spinal needle is passed from the brow up into the dissected cavity to exit through the incision. A 4-0 Prolene suture is passed down the needle from the tip to exit at the hub. The suture is trapped at the hub with a finger, the needle is withdrawn so that the deep dermis can be grasped with the needle point (the needle must not exit the skin, and the suture must not be left too superficial), whereupon the needle is again advanced up the dissected cavity to exit through the incision. A loop of suture thus runs from the deep dermis of the brow to exit at the incision. The cranial end of the suture is secured to the periosteum. Four to six sutures are used on average to shape and suspend the brow.
The advantage of this technique is that the brow can be shaped, supported, and suspended. An apex lateral brow can be created. Patients still retain their natural ability to elevate the brow and express emotion. Glabellar frown lines can be effaced to a degree. Some slight brow descent may occur early postoperatively, but thereafter, in a small series of patients, the brow remains stable.