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 Dr. Cuzalina |
"We do it (browlifts) all the time now, and we are getting more consistent results with fewer problems," says Dr. Cuzalina, who is in private practice at Tulsa Surgical Arts, Tulsa, Okla. As a general principle, surgeons need to look at proportions in the face to determine if a browlift is indicated, he says.
"We are usually doing it for two reasons, which is typically addressing the glabellar lines on the forehead and hooding over the lateral third (of the brow)," Dr. Cuzalina says. "Raise the lateral brow up. If the patient likes the appearance of that better, then the patient is likely a good candidate for a browlift."
A trichophytic browlift is appropriate for an individual who has a high hairline, Dr. Cuzalina says. "You need to be careful and very precise with the incision, so that the hair grows up and in front of the resulting scar. It is a simple procedure with much less dissection than an endoscopic browlift."One of the pitfalls of the trichophytic browlift, however, is that it can leave a visible scar, he says.
ENDOSCOPIC, CORONAL LIFTS The endoscopic browlift is advantageous because it usually results in a short recovery time. It also provides good access to the muscles and requires less surgery time than other types of browlifts, Dr. Cuzalina says.
The endoscopic browlift should be used cautiously in someone with a very high hairline, because it can raise the hairline even more. "It is more challenging with a man who has a high hairline or is bald, because you are using a straight scope for a curved skull," he says.
Dr. Cuzalina says he reserves use of the coronal browlift for cases in which the male patient presents with severe frontal bossing, or an overgrowth of bone, that needs to be shaved down.
ADDING BLEPHAROPLASTY Individuals can present with a combination of problems, warranting both a blepharoplasty and a browlift, according to Dr. Cuzalina.
"The brow might be ptotic and their eyelids sag as well," Dr. Cuzalina says. "A lot of it depends on what the patient wants, and we want to give them a natural look. If you do them in combination, you should do the browlift first.
"Typically, you will be removing less skin from the upper eyelid," he says. "If you remove just as much skin from one or the other, then you will have a problem where the person would not be able to close their eyes."
More permanent results with a browlift are likely when a surgeon relies on the frontalis muscle to elevate the brow. "You don't want to do a frontalis myotomy," Dr. Cuzalina says. "Cutting the depressor muscles and leaving the frontalis alone will give you long-term stability."
GENDER GUIDELINES It's key that gender be a consideration when performing a browlift, Dr. Cuzalina says. In females, the target in a browlift is to have the outer third of the brow lie, on average, 5 to 10 cm above the bony rim. By contrast, males should have the outer third of the brow lie along the orbital rim.
"Male brows run parallel with the orbital rim," he says. "If you lift the male brows on the outer third of the brow as you would the female brow, it will create a feminine look. The male brows should be lifted straight up and not very much. Females look better with the outer third of their eyebrow elevated. You don't want to give males the same arch."
Browlifts can be performed under general anesthesia or can be performed under local anesthetic with intravenous sedation, Dr. Cuzalina says.
"It is a personal preference," he says. "The trichophytic browlift is a small procedure, for it covers a small area of the scalp. You could use local anesthetic if you wanted to, to anesthetize that area. That is perhaps one advantage of the trichophytic (browlift). The other advantage is that it is done subcutaneously."
The trichophytic browlift is the best choice of browlift to smooth out deep, horizontal, forehead furls, Dr. Cuzalina says.
An alternative to a browlift is the administration of onabotulinumtoxinA (Botox, Allergan), which can be injected in the crow's feet area. "It can give you outer brow elevation, and it can smooth out forehead wrinkles," Dr. Cuzalina says.
DISCLOSURES:
Dr. Cuzalina reports no relevant financial interests.
