Temporal and lateral brow lift

What it is

The outer brow ages first. The forehead muscle holds up the brow only as far out as a ridge on the side of the skull, the temporal fusion line; beyond that ridge the soft tissue of the outer brow has little support and slides down over the firm fascia of the temple (PMID 8643714). The outer third of the brow drops earliest and most, and it sets the shape of the whole brow (PMID 19371849). Measured in women, the brow as a whole sits higher with age, which is why surgeons favor lifting the outer brow selectively rather than the entire brow (PMID 19935315, PMID 30819648).

A temporal lift works on that outer segment. Through an incision in the temple hair, the surgeon frees the outer brow and the skin of the temple and moves them up and back (PMID 31624658). The risks follow from the anatomy of the temple: the frontal branch of the facial nerve, which moves the forehead, crosses it in a predictable layer (PMID 5926990, PMID 20124839), and ligaments hold the brow and eye-area tissue to bone (PMID 10744245).

Where it came from

• In 1966 Pitanguy and Ramos mapped the path of the frontal nerve branch across the temple for facelift surgeons (PMID 5926990).
• In 1996 Knize showed why the outer brow drops first (PMID 8643714), and Byrd described the deep temporal lift, which frees the outer eye muscle from the rim and lifts the outer brow, temple and upper face in several layers (PMID 8618995).
• In 2000 Moss mapped the ligaments of the temple and around the eye (PMID 10744245).
• In 2003 Fogli published the galeapexy, which anchors the scalp tissue of the temple to the temporal fascia and closes the scalp without tension (PMID 14534826). Verpaele and Tonnard used it for years alongside the MACS facelift and reported results at 5 years and more (PMID 25502857).
• In 2019 Viterbo, Auersvald and O'Daniel described the gliding brow lift, which frees the skin of the forehead and temple through tiny incisions and holds the new brow with a net of temporary skin stitches (PMID 31511923, PMID 38806160).
• Among American plastic surgeons, coronal lifts became less common between 2000 and 2020, and temporal and hairline lifts more common (PMID 37409963).

Who it suits

• A low brow tail and hooding at the outer upper lid, the classic pattern of brow aging (PMID 8643714, PMID 31624658).
• Upper eyelid surgery patients whose outer hooding comes from the brow; the lift is often done with the eyelid surgery (PMID 31624658, PMID 40820029).
• Facelift patients, especially with a short-scar MACS lift (PMID 25502857, PMID 40906287).
• People who want a small operation. A skin-level temporal lift can be done under local anesthesia in the office (PMID 21131449).
• People who want the whole brow reshaped may be better served by a gliding lift, which can raise the inner, middle and outer brow (PMID 42535924).

How it is done

• Skin-level (subcutaneous) lift. The surgeon frees the skin of the temple and outer brow just under the skin and removes a strip of skin at the incision (PMID 35710152, PMID 21131449). One practice has used this approach in hundreds of patients over 20 years (PMID 42224034), and it can be combined with an upper eyelid lift through a hairline incision (PMID 40820029).
• Deep lift on the temporal fascia. The surgeon works just above the deep temporal fascia, joins that space to the space under the bone lining at the rim, releases the ligaments around the eye, divides the frowning muscle through the eyelid incision and advances the scalp tissue with stitches (PMID 31624658, PMID 8618995).
• Fixation. Stitches at several points hold the outer brow and eye muscle to the scalp tissue (PMID 26430629); the galeapexy anchors the temple scalp to the temporal fascia (PMID 14534826). Working in two layers released more skin than one (PMID 18330618).
• Endoscopic temporal lift. A camera adds the endoscopic approach to the temporal incision (PMID 31764641).
• Eye muscle repositioning. Moving the outer eye muscle during a temporal lift also softened crow's feet, an effect that held for 2 years (PMID 39288448, PMID 42202561).
• Gliding lift. Through one or two small incisions, blunt instruments free the skin from the muscle beneath; the brow is pushed up and held by the surgical net while it heals (PMID 35710153, PMID 31511923). An extended version adds a deeper release in the scalp (PMID 41217905).

Results and how long they last

• The temporal lift lasts. In Verpaele and Tonnard's patients followed 5 years or more, hooding and brow position stayed improved in more than 9 in 10, and fewer than 1 in 10 relapsed (PMID 25502857). A multi-point stitch technique gave a satisfactory lift of the outer brow in most patients (PMID 26430629).
• Hooding goes away. A limited-incision lateral lift resolved outer hooding in every patient of one surgeon's series (PMID 31624658).
• The gliding lift is modest and holds. It raised the brow tail by about 3 mm at 12 months (PMID 39487802, PMID 41217905). A whole-brow version lifted the outer brow by about 7 mm and lost only a fraction of a millimeter over 8 months (PMID 42535924). About 1 in 20 patients in the first series had the brow drop again, and most were redone within a month (PMID 31511923).
• Gliding lift against mesh. An endoscope-assisted mesh lift and the gliding lift gave similar results, with more late loss of height after the gliding lift (PMID 37315493). The gliding lift evidence is still mostly retrospective (PMID 39150844).
• With eyelid surgery. In a randomized trial of women having upper eyelid surgery, an internal browpexy through the eyelid raised the outer brow at 6 months and a temporal lift did not change it (PMID 28975711).
• Endoscopic temporal lift. A small average lift at the outer eye corner with few complications (PMID 31764641).

Risks and how surgeons lower them

• Forehead weakness. Temporary weakness on one side of the forehead from stretching of the frontal nerve branch is the main nerve risk: about 1 in 34 after galeapexy, resolving in 1 to 3 months (PMID 14534826), and about 1 in 18 after a temporal facelift, resolving in about 3 months on average (PMID 39641911). Large series reported no permanent injury (PMID 31624658, PMID 42224034). Surgeons protect the nerve by staying in the right layer: over the cheekbone arch it runs in a fascia beneath the SMAS and rises into the superficial temporal fascia above it (PMID 20124839, PMID 20335873).
• Uneven brows. Temporal and lateral lifts had the highest asymmetry rate of any brow lift type in a systematic review, about 1 in 70 (PMID 30534495).
• Bleeding. Hematomas needing drainage followed about 1 in 50 galeapexies (PMID 14534826). Across facelifts, brow lifts and neck lifts done with a surgical net, hematoma was very rare (PMID 41936137).
• Hair loss at the incision, temporary and limited, in small numbers (PMID 14534826, PMID 26430629).
• Relapse and revision. Revision followed about 1 in 14 limited-incision lateral lifts (PMID 31624658) and about 1 in 40 temporal facelifts (PMID 39641911).
• Net stitches. Red marks from the net are common, about 1 in 8, and fade within 2 to 3 months (PMID 41936137). In cadavers, the net's skin stitches lay closer to the frontal branch than the deep stitches of a suture lift; nerve injuries reported in patients so far were temporary (PMID 41286172).
• Slow healing at the temple incision in about 1 in 33 (PMID 31624658).

Recovery

• A skin-level temporal lift can be done under local anesthesia in the office (PMID 21131449); most limited-incision lifts in one series were done under sedation, a third of them in the office (PMID 31624658).
• After a temporal facelift, aftercare included taping, lymphatic massage, botulinum toxin for uneven brow movement and steroid injections for swelling of the midface; skin dimples resolved by 5 months (PMID 39641911).
• After temporal eye-muscle repositioning, the authors report a fast recovery (PMID 39288448).
• Net stitch marks fade in 2 to 3 months without lasting pigment (PMID 41936137).

With a facelift

• Fogli did most of his temporal lifts as part of a lift of the forehead, face and neck (PMID 14534826), and Verpaele and Tonnard combined most of theirs with a MACS facelift (PMID 25502857). A brow lift was added to most MACS facelifts in another series, without major complications (PMID 40906287).
• The deep temporal lift was designed to lift the outer brow, temple and upper face together and also benefits the outer eye corner, lower lid and cheek (PMID 8618995).
• In high-SMAS facelifts, a separate fascia over the cheekbone arch shields the frontal branch (PMID 20335873).
• Temple hair follicles grow at a shallow angle, so a bevelled hairline incision allows hair to grow through the scar (PMID 17440370); incisions cut across the follicles scarred better than incisions parallel to them in a split-face comparison (PMID 8982181).
• In a gliding lift series, the one return to the operating room for bleeding came from the facelift done at the same time, not the brow (PMID 39487802).
• No single method of treating crow's feet during a facelift or temporal lift has been shown best (PMID 38170976).

Questions to ask a surgeon

• Is my hooding from the brow, the eyelid or both? (PMID 31624658)
• Will you lift only the outer brow, or the whole brow? (PMID 19935315)
• Which layer will you work in, and how do you protect the forehead nerve? (PMID 20124839)
• Where will the incision sit in my hairline, and how will you keep hair growing through it? (PMID 17440370)
• How long do your temporal lifts hold, and how often do you revise one? (PMID 25502857)
• Would a browpexy through my eyelid incision do as well? (PMID 28975711)

Open questions

• Gliding lift: early reviews found low-level evidence (PMID 39150844); newer series add measurements (PMID 39487802, PMID 42535924).
• Gliding lift durability against mesh suspension (PMID 37315493).
• Nerve safety of the net's skin stitches (PMID 41286172).
• Temporal lift or internal browpexy for the outer brow at eyelid surgery (PMID 28975711).
• Eye-muscle release and repositioning for crow's feet during temporal lifts (PMID 42202561, PMID 38170976).

Terms

• Lateral hooding: skin overhanging the outer upper eyelid from a low outer brow (PMID 31624658).
• Temporal fusion line: ridge on the side of the skull; beyond it the forehead muscle does not hold the brow (PMID 8643714).
• Deep temporal fascia: firm layer over the temple muscle used as the dissection plane and as an anchor (PMID 31624658, PMID 18330618).
• Galeapexy: anchoring the cut galea of the temple to the temporal fascia (Fogli) (PMID 14534826).
• Frontal branch: facial nerve branch to the forehead muscle; temporary injury shows as forehead weakness (PMID 14534826, PMID 20124839).
• Parotid-temporal (innominate) fascia: layer deep to the SMAS that carries the frontal branch over the cheekbone arch (PMID 20335873, PMID 20124839).
• Retaining ligaments: fibrous attachments that tether skin and soft tissue to bone in the temple and around the eye (PMID 10744245).
• Gliding brow lift: skin-level release through small incisions, with the brow held by a surgical net (PMID 31511923).
• Hemostatic (surgical) net: rows of temporary stitches through the skin that hold the lifted skin in place (PMID 38806160).
• MACS lift: minimal access cranial suspension facelift (PMID 25502857).

Papers