Deep Plane Brow lift: A Technical Note

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: 1. 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. 2. Marking: Bilateral semi-lunar incisions extending from the medial to lateral brow are marked. The incision is placed 2–3 mm behind the hairline. 3. Infiltration: Local anesthesia with lidocaine and epinephrine (1:100,000) is administered. 4. Incision: Beveled incisions behind the hairline prevent follicle damage and alopecia. Two subperiosteal stab incisions are made to facilitate dissection. 5. Dissection: Subcutaneous dissection proceeds to the mid-forehead, followed by subperiosteal elevation and arcus marginalis release. 6. Excess Skin Removal: A D’Assumpcao marker determines the excision extent. Frontalis muscle stabs are sutured before excising redundant skin to prevent diastasis. 7. 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