Browpexy and direct brow lift

What it is

• Heavy upper lids are often partly caused by low brows. Eyelid surgery alone does not raise a low brow and can let it sag further (PMID 6824482).
• On average the brow sits slightly lower after upper eyelid surgery, by under a millimetre after a simple blepharoplasty; about one patient in three has a lower brow afterward, men more often than women (PMID 36890345, PMID 27308242).
• A browpexy is a small step added to eyelid surgery that steadies the outer brow and lifts it a little (PMID 25853507, PMID 31261340).
• A direct brow lift is a separate small operation: a strip of skin is removed along the top of the brow hairs, or in a forehead crease (a midforehead lift) (PMID 35710156, PMID 2914087).

Where it came from

• Brennan described forehead-crease incisions with browpexy and facelift in 1982 (PMID 7138368), and Sokol described brow suspension through the eyelid incision the same year (PMID 7079400).
• In 1991 McKinney set out when a forehead lift helps: a brow that sits less than about 2.5 cm above the pupil, or a previous facelift (PMID 2035363).
• In 1997 Zarem described fixing the outer orbicularis muscle to the bony rim as part of upper blepharoplasty (PMID 9326790, PMID 19336182).
• Recent changes focus on scars and on lifting the fat pad under the brow during a direct lift (PMID 42355613, PMID 41738837).

Who it suits

• Browpexy: mild to moderate droop of the outer brow in someone having upper eyelid surgery (PMID 31261340).
• Browpexy suits poorly: heavy brows, marked droop, an inner brow lower than the outer brow, or a past facial palsy (PMID 31261340).
• Direct brow lift: any degree of droop, most often in men, older women and people with facial nerve weakness (PMID 17182403). Bald men and men with a high hairline are common candidates, since the scar hides in the brow (PMID 27274124). In one large practice most men had a direct lift and most women an endoscopic lift (PMID 40016580).
• A man's brow normally sits flat along the rim (PMID 16052142). With age, brows can rise and women's brow shape can come to resemble men's, so lifting can make some faces look surprised (PMID 30819648).
• Lost vision in the outer upper field points to a brow procedure as well as eyelid surgery, and combined repair led to fewer revisions (PMID 42697227).

How it is done

• Internal browpexy: through the eyelid incision, the upper edge of the orbicularis muscle under the brow is stitched to the tissue along the bony rim with a few dissolving stitches (PMID 19336182). Placing the stitches at measured points keeps the two sides even (PMID 25853507).
• Variants trim part of the muscle or release the ligaments under the outer brow for more lift (PMID 27429226, PMID 37592144).
• External browpexy: the same suspension placed through a small incision at the brow (PMID 22410656).
• Direct brow lift: an ellipse of skin is removed within or just above the brow hairs. Surgeons angle the cut to spare the hair roots, free the skin edges, anchor the brow to the bone lining and close in layers to hide the scar (PMID 35710156, PMID 42355613).
• Direct lift variants: lifting the muscle with the skin (PMID 40064642), moving the fat pad under the brow higher (PMID 41738837), and an adjusted incision for facial palsy (PMID 32852375).
• Midforehead lift: skin is removed through an existing deep forehead crease (PMID 2035363, PMID 2914087).

Results and how long they last

• Browpexy lifts the outer brow by about 2 to 3 mm, and internal and external versions gave similar lift in most comparisons (PMID 28267396, PMID 32049161, PMID 31261340); one study found more lift with the external version (PMID 36847688).
• Its main effect is to stop the brow drop that follows eyelid surgery alone (PMID 25853507, PMID 32049161). A forehead lift with an implanted fixation device gave more height (PMID 25853507).
• In a randomized trial, browpexy added fullness to the outer brow and lid area as well as height (PMID 34166117).
• Direct brow lift raised the brow in nearly all men at 12 months, with a visible scar in about 1 in 25 (PMID 27274124). In facial palsy, most results were rated excellent or good, with no brow hair loss (PMID 32852375).
• How long: brows lifted through the eyelid gradually came down over five years, while endoscopic forehead lifts held (PMID 23190834). At one year, direct and through-the-eyelid lifts had both settled slightly, by up to about 2 mm (PMID 36669433).

Risks and how surgeons lower them

• Numbness of the forehead: the direct lift had the highest numbness rate of all brow lifts in a systematic review, about 1 in 18 (PMID 30534495). The forehead sensory nerve leaves the rim at a point that varies between people (PMID 23299811).
• Direct lift: a visible scar, lumps from braided dissolving stitches, and the brow dropping again; browpexy: less lift than hoped and dimpling from stitches (PMID 17182403).
• After internal browpexy a few patients needed a later direct lift, and a few had eyelid ptosis that had been missed and needed its own repair (PMID 31261340).
• Adding a brow lift to blepharoplasty did not raise the major complication rate, about 4 in 1,000 (PMID 29369102).

Recovery

• Numbness after a direct lift usually recovers within a few months, in one series by three to five months (PMID 17182403, PMID 40064642).
• For the scar, laser treatment after surgery and wrinkle-relaxing injections around the time of surgery improved its look; evidence for silicone gel is unclear (PMID 42355613).
• External browpexy patients were pleased at about six months (PMID 22410656).
• Removing skin just below the brow (subbrow blepharoplasty) is an alternative for mild droop; scarring was rare and no sensation was lost (PMID 41240177).

With a facelift

• A previous facelift is one reason to consider a forehead lift; a direct lift is kept for minimal droop, uneven brows or a patient who wants a small procedure (PMID 2035363).
• Midforehead incisions, browpexy and facelift were described together as parts of full-face rejuvenation (PMID 7138368).
• Safety data for combined surgery come from eyelid surgery: adding a brow lift did not raise major complications (PMID 29369102).

Questions to ask a surgeon

• Is my brow low, and is it part of my heavy eyelids? (PMID 6824482)
• Would a browpexy hold my brow during eyelid surgery? (PMID 25853507)
• Where would a direct lift scar sit, and how visible is it? (PMID 42355613)
• How long will the lift hold with this method? (PMID 23190834)
• How will you avoid numbness of my forehead? (PMID 23299811)

Open questions

• Internal or external browpexy: equal lift in two studies (PMID 28267396, PMID 32049161); more lift with external in one (PMID 36847688).
• Durability: measured descent at one year (PMID 36669433) and up to five years (PMID 23190834) after lifts through the eyelid.
• Volume: browpexy may add fullness to the outer brow as well as height (PMID 34166117).
• Visual field criteria for adding a brow procedure to eyelid surgery (PMID 42697227).

Terms

• Brow ptosis: a brow lower than its normal position, with cosmetic or visual effects (PMID 35738352).
• Dermatochalasis: excess upper eyelid skin (PMID 28975711).
• Internal browpexy: stitching the brow tissue to the bony rim through the eyelid incision (PMID 9326790).
• External browpexy: the same suspension placed through a small incision at the brow (PMID 22410656).
• Arcus marginalis: the thickened tissue along the orbital rim used as an anchor (PMID 19336182).
• Orbicularis oculi: the ring muscle around the eye; its upper edge is stitched in browpexy (PMID 19336182).
• ROOF: retro-orbicularis oculi fat, the fat pad under the brow (PMID 41738837).
• Direct brow lift: removal of skin just above the brow hairs (PMID 35710156).
• Midforehead lift: skin removal through a forehead crease (PMID 2914087).
• Supraorbital notch or foramen: where the forehead sensory nerve leaves the orbital rim (PMID 23299811).

Papers