the upper third of the face , of which the eyelid - brow complex is of primary importance , is integral to both facial expression and beauty . with age , gravity and loss of elastic tissue support
can lead to progressive descent of the brows and lateral hooding of the upper lids . as the ptotic brow drops below the supraorbital rim
, it can exacerbate dermatochalasis by pushing the adjacent skin of the upper lid further down .
not only does this result in a tired or angry appearance , but it may also produce functional visual impairment . when a patient has excess tissue and heaviness in the upper eyelids , a problem - specific approach is imperative to selecting the most appropriate therapeutic modality .
failure to recognise brow ptosis as a contributing factor prior to blepharoplasty can lead to worsening of the brow ptosis and/or over - resection of skin in the lateral half of the upper eyelid . over - resection of this lateral eyelid skin
, a brow lift procedure can be used to restore proper brow position , allowing for re - suspension of the upper lid complex and a more conservative removal of upper eyelid skin during blepharoplasty . while upper lid blepharoplasty technique is fairly standard ,
several brow - lift techniques exist : coronal , endoscopic , mid - forehead , direct , trans - blepharoplasty , and pretrichial brow lifts .
while each technique has its advantages and disadvantages , no single technique or combination is clearly superior . in patients seeking functional improvement of vision secondary to dermatochalasis and mild to moderate brow ptosis , selecting a targeted approach that is technically easy and quick , yet cosmetically acceptable
the authors present a series of such patients that were treated with a modified pretrichial brow lift combined with upper lid blepharoplasty .
the purpose of this study was to evaluate the outcomes associated with the aforementioned technique .
in this retrospective case series , surgical logs were reviewed for all patients who underwent combined bilateral upper lid blepharoplasty and modified pretrichial brow lift at the senior authors ' practice between january 2008 and december 2011 .
inclusion criteria included all patients with both pre - operative and 3-month post - operative photos .
charts were reviewed for patient demographics and the following outcome variables : measurements of brow lift at 3 months , complications , patient satisfaction and surgeon satisfaction .
brow measurements were retrospectively analyzed by comparing non - standardised photos taken in office with a canon eos 30d digital camera . to allow for comparison
, images were standardised for measurements using adobe photoshop imaging software . by scaling the horizontal corneal diameter to 11 mm ,
all patients ' horizontal corneal diameters were clearly visible thus allowing for scaling to be performed on all patients .
brow height was measured from a horizontal line through the centre of the pupil to the top of the eyebrow at four set points : medial limbus , centre of the pupil , lateral limbus , and the lateral canthus [ see figure 1 ] . in order to minimise inter - observer variability ,
the same grader ( mm ) scaled all patient photographs and measured pre- and post - brow height measurements .
given that this was not a comparative study , the grader was not blinded to the procedure when taking measurements .
pre- and post - operative brow positions were compared with a paired t - test ( 2-tail ) .
brow height was measured from a horizontal line through the centre of the pupil to the top of the eyebrow at four set points : medial limbus ( ml ) , middle of the pupil ( mp ) , lateral limbus ( ll ) , and the lateral canthus ( lc ) .
pupil resized and standardised at 11 mm charts were retrospectively reviewed for mention of potential complications which included but were not limited to alopecia , scar visibility , asymmetry , dimpling , paraesthesia , haematoma , skin necrosis , posterior displacement of hairline , shortened forehead , suture migration , blepharospasms , lagophthalmos and need for surgical revision . subjective patient and doctor satisfaction were also evaluated by grading the chart on a scale from one to four ( 1 = very dissatisfied , 2 = somewhat dissatisfied , 3 = satisfied , 4 = very satisfied ) .
the face is prepped and draped in the usual sterile fashion for eye plastic surgery under monitored sedation .
the upper eyelid skin to be excised is outlined with a skin marker , and the area to be excised is infiltrated with a local anaesthetic solution of 2% lidocaine with epinephrine 1:100,000 .
next , ellipses of skin , typically measuring 3 cm  1 cm are outlined bilaterally in the pretrichial skin of the temporal forehead [ see figure 2 ] .
local anaesthetic consisting of 2% lidocaine with 1 : 100,000 epinephrine mixed equally with 0.5% marcaine anaesthetic is injected beneath the markings .
the ellipses of pretrichial skin are then excised with a # 15 blade , extending into the subcutaneous fat .
haemostasis is ensured . the skin and subcutaneous tissues inferior to the excised skin are undermined with tenotomy scissors down to the superior orbital rim .
this dissection is carried out in a subcutaneous plane , taking care to avoid neurovascular bundles .
a 4 - 0 pds suture is used to suspend the lower , undermined flap to the periosteum immediately deep to the upper edge of the elliptical excision .
this is repeated with three to four interrupted stitches , to provide an effective  lift  of the brow .
the subcutaneous tissue is closed with 5 - 0 monocryl suture . the skin is then closed with a running 5 - 0 prolene suture .
following the brow lift , the blepharoplasty was performed . when performing the upper eyelid blepharoplasty ,
the tissue removal was performed so that greater than 2.0 cm of upper eyelid skin was left in each patient 's upper eyelid postoperatively .
a small strip of orbicularis oculi muscle was removed just above the lid crease . no pre - tarsal or sub - brow orbicularis muscle was removed . with this limited resection of upper eyelid muscle , it was felt to be unlikely to contribute to any elevation of the brow .
the face is prepped and draped in the usual sterile fashion for eye plastic surgery under monitored sedation .
the upper eyelid skin to be excised is outlined with a skin marker , and the area to be excised is infiltrated with a local anaesthetic solution of 2% lidocaine with epinephrine 1:100,000 .
next , ellipses of skin , typically measuring 3 cm  1 cm are outlined bilaterally in the pretrichial skin of the temporal forehead [ see figure 2 ] . local anaesthetic consisting of 2% lidocaine with 1 : 100,000 epinephrine mixed equally with 0.5% marcaine anaesthetic is injected beneath the markings .
the ellipses of pretrichial skin are then excised with a # 15 blade , extending into the subcutaneous fat .
the skin and subcutaneous tissues inferior to the excised skin are undermined with tenotomy scissors down to the superior orbital rim .
this dissection is carried out in a subcutaneous plane , taking care to avoid neurovascular bundles .
a 4 - 0 pds suture is used to suspend the lower , undermined flap to the periosteum immediately deep to the upper edge of the elliptical excision .
this is repeated with three to four interrupted stitches , to provide an effective  lift  of the brow .
the subcutaneous tissue is closed with 5 - 0 monocryl suture . the skin is then closed with a running 5 - 0 prolene suture .
following the brow lift , the blepharoplasty was performed . when performing the upper eyelid blepharoplasty ,
the tissue removal was performed so that greater than 2.0 cm of upper eyelid skin was left in each patient 's upper eyelid postoperatively .
no pre - tarsal or sub - brow orbicularis muscle was removed . with this limited resection of upper eyelid muscle , it was felt to be unlikely to contribute to any elevation of the brow .
all 46 patients were white women with a mean age of 64 years old ( range 51 - 84 ) .
the mean brow lift at the four selected points was 1.85  2.22 mm at the lateral canthus , 1.54  2.19 mm at the lateral limbus , 1.31  2.02 mm at the mid - pupil , and 1.07  1.83 mm at the medial limbus .
brow lift at the lateral canthus was significantly more elevated than at the medial limbus ( 1.85 mm vs 1.07 mm respectively , p < 0.001 ) .
brow lift at the lateral limbus was also significantly more elevated than at the mid - pupil ( 1.54 mm vs 1.31 mm , respectively , p = 0.005 ) .
( a ) pre - operative photo ( b ) 7 months post - operative photos following bilateral modified pretrichial brow lift and blepharoplasty post - operative complications were seen in seven of the 46 study patients .
these included a case of transient forehead paraesthesia , three cases of infection of the incision that healed with a short course of oral antibiotics , and three cases of incision opening requiring a minor procedure performed in the office to reclose .
mean patient satisfaction score was 3.20 , while the mean surgeon satisfaction score was 3.24 .
in this study , we found that the modified pretrichial brow lift was a useful adjunct to an upper lid blepharoplasty .
the 1.85 mm of lateral lift safely complemented the blepharoplasty in correcting the visual field obstruction without increasing the potential for lagophthalmos .
moreover , the targeted lateral lift allows for the correction of the  angry  appearance of the eyelid - brow complex .
our results were in agreement with the approximately 2-mm brow elevation reported by mcguire and gladstone in their description of a novel pretrichial brow lift . while there are conflicting reports on whether or not upper lid blepharoplasty lowers the brow , our technique demonstrated an ability to significantly elevate the brow despite being combined with a blepharoplasty .
additionally , this technique was met with a high degree of patient and surgeon satisfaction , and had a minimal complication profile .
compared to the coronal or full pretrichial lift that has long contiguous incisions extending the width of the scalp , this modified pretrichial technique offers smaller and less invasive incisions . by utilising two temporal incisions immediately anterior to the hairline , there is less risk of alopecia and it leaves two smaller scars more ammendable to camouflaging with hairstyling than seen with a direct brow lift . these features in combination with the low complication rate offer advantages similar to an endoscopic approach .
furthermore , the modified pretrichial brow lift does not suffer from the disadvantages of an endoscope such as less direct surgical exposure , need for retraining , or the expense of additional equipment .
another approach that offers similar appeal in this patient population is the trans - blepharoplasty brow lifts ; however , much of the literature either only describes the technique or focuses on subjective patient / doctor satisfaction outcomes without focus on anthropometric measurements . in short ,
this type of modified pretrichial brow lift offers a minimally invasive , open technique that is both safe and effective while providing a good cosmetic result in the appropriately selected patient . a major contributing factor to the patient and surgeon satisfaction with the modified pretrichial brow lift was the careful selection of our patient population .
given our patients roughly experienced 1.0 to 1.85 mm of lift to the overall brow , this technique should be reserved for patients with mild to moderate brow ptosis .
what is more , discussion of a patient 's cosmetic expectations remains an important component of the pre - operative exam .
men may not find the preferential lateral lift to be cosmetically acceptable , as most men prefer the more masculine flat brow configuration . on the other hand , the ideal female brow aesthetic features a brow that peaks between the lateral limbus and lateral canthus . with regards to concealing post - operative scars
, bitemporal incisions may become conspicuous in men with receding hairlines . by selecting older women with deep forehead rhytids and a definitive or thick anterior hairline
first , we can not comment on the longevity of the brow lift , as our study had limited follow - up and brow measurements were only measured once at the 3-month follow - up visit .
this was likely because patients were both highly satisfied and free of complications , and did not require return office visits .
also , despite standardisation of photos by scaling the iris to 11 mm , this method inherently introduces error into measuring differences between pre - operative and post - operative photos .
in closing , the pretrichial brow lift is a safe , effective and technically easy procedure to accompany upper lid blepharoplasty in the appropriate patient .
furthermore , the use of anthropometric measurements should be routinely incorporated into future brow lift studies .
 background : as the ptotic brow drops below the supraorbital rim , it can exacerbate dermatochalasis by pushing the adjacent skin of the upper lid further down.aim:the purpose of this study was to evaluate the outcomes associated with a combined pretrichial brow lift and upper lid blepharoplasty in patients with dermatochalasis and mild to moderate brow ptosis.materials and methods : a retrospective case series of 46 patients with dermatochalasis and mild to moderate brow ptosis treated with a combined , bilateral pretrichial brow lift and upper lid blepharoplasty from january 2008 to december 2011 . 
 main outcome measures included measurements of brow lift at 3 months post - operatively , complications encountered , patient satisfaction and surgeon satisfaction.results:outcomes from 46 patients were evaluated . 
 the mean brow lift was 1.85 mm at the lateral canthus , 1.54 mm at the lateral limbus , 1.31 mm at the mid - pupil , and 1.07 mm at the medial limbus . 
 brow lift at the lateral canthus was significantly more elevated than at the medial limbus ( p < 0.001 ) . 
 minor complications were encountered in seven of 46 patients ( 15.2% ) . 
 mean patient satisfaction score was 3.20 and surgeon satisfaction 3.24 ( max = 4 , very satisfied).conclusions : the modified pretrichial brow lift offered effective lateral lift that complements an upper lid blepharoplasty . 
 this technique was met with a high degree of patient and surgeon satisfaction , and had a minimal complication profile . 
INTRODUCTION
MATERIALS AND METHODS
Surgical technique
RESULTS
DISCUSSION
CONCLUSIONS
Financial support and sponsorship
Conflicts of interest