Transpalpebral Brow Lift During Blephaplasty

Question

(Female/47) Two years ago, I had a mid-face and neck lift along with excision of xanthalasma, around the inner upper/lower orbital area, with good results except alopecia began above my ears as the scars widened. (I wear my hair in a short wedge with bangs. I have a high forehead.) I'm now perimenopausal (low prog and test) taking BIO hormones. Thoughts on a upper bleph and transpalpebral brow vs endo lift given my now hooded eyes and hair loss concerns? Lateral brow is above orbital bone.

Richard H. Tholen, MD, FACS · Answer

I understand your concerns regarding hairline and scar alopecia, but compromising on the best operative approach to avoid the scar may end up giving an inadequate lift that often does not last (if it even makes a visible difference in the first place). Previous scar alopecia may be related to surgical technique and/or suture material choice rather than "your" innate scar healing (stretching).

	You may also find that a proper bicoronal or trichophytic (hairline) incision forehead lift will lift the brows into the "proper" aesthetic position, reducing the pseudodermatochalasis (pseudo-excess upper eyelid skin) and eliminating the need for upper lid blepharoplasty (or as much skin resection as previously thought). The hairline incision can actually lower your hairline, improving your "high forehead" at the same time as lifting your brows!

	While I have performed transpalpebral brow lifts in selected patients, I find that the results often do not live up to my patients' expectations, or my own standards, so this is an operation I rarely recommend. And although I have taken several endoscopic forehead lift courses over the years, and respect those surgeons who can achieve good results with this technique, I find that in my hands a bicoronal or hairline lift (with proper and precise suture closure technique) leaves a better and more long-lasting result, and a longer but much less visible scar (usually without alopecia or scar widening) than multiple endoscopic "puncture" incisions that actually end up being more visible and unsatisfactory than the scars they purportedly are designed to improve upon! You can also have the upper eyelid results "messed up" with the additional manipulations needed to perform the browlift through these incisions.

	Consider consultation with several ABPS-certified plastic surgeons before making your decision. Best wishes!

Sam Naficy, MD, FACS · Answer

If you have a high forehead your best and longest-lasting bet is a trichophytic hairline brow lift - even with thin hair the incision typically heals very nicely.

Kenneth D. Steinsapir, MD · Answer

This procedure is primarily used at the time of functional blepharoplasty in an attempt to provide inexpensive browlifting. Attempt being the operative word here. If you need brow lifting, the endoscopic brow lift is the answer. I would recommend this approach and then consider having hair grafting to improve your focal hair loss.

Robert L. Kraft, MD, FACS · Answer

I frequenly include this in my upper lid blepharoplasties because I think it does make a difference.  It avoids the hairline and scarring concerns and can improve the surgical outcome.  Great question.  Clearly, there is more than one option in facial rejuvenation surgery and you are wise to research various options to enable you to discuss them with your plastic surgeon.

Robert Schwarcz, MD · Answer

I have tried these transpalpebral browlifts and am always underwhelmed by them. They use the premise of pushing and resting the brow and with time and gravity they tend not to hold up well. The endoscopic brow lift works well and like other successful browlift methods they tend to pull and not push the brow upwards and allow for a more thorough dissection of th etissue with release of the tissue that is preventing it from coming up.

Edward Szachowicz, MD, PhD · Answer

It sounds to me that you are in the "less is more" approach to cosmetic surgery. I have experience with the Endotine Direct Browlift, in which the brow is raised from an upper eyelid incision. Thebrowlift results are improved by the use of an implant made from a carbohydrate which eventually resorbs, but does hold the eyebrow against gravity until the healing is complete. I find it important to use Botox before and during the healing to minimize the downward pull of the muscles around the eyebrow. Although some other approaches are more dramatic, you can get the 'most with the least' with this technique, esp., if you are younger and with good skin tone.

Barry L. Eppley, MD, DMD · Answer

While a transpalpebral browlift avoids any hairline scars, the 'price' to be paid for that decision is that it does a relatively poor job of lifting the brow. At best, it can only make a minor elevation of the tail of the eyebrow. It illustrates a basic principle that you can't really lift much when all you are doing is pushing up from below. With your already high forehead, I would strongly consider a hairline or trichophytic browlift technique. That would achieve the dual effect of lifting the brows and shortening the vertical length of the forehead at the same time. Provided you have a good frontal hairline density, the resultant fine scar at the edge of the hairline is one that is usually not associated with any significant scar widening.

Kamran Khoobehi, MD · Answer

I offer my patients the option of combined hair line reduction/advancement and endo forehead lift to reduce the Forehead.please send pictures.

Francis R. Palmer, III, MD (retired) · Answer

Photos of your eyes and eyebrows would be helpful in your evaluation. Transpalpebral brow lifts are far less effective than proper Brow Lifts and you might want to have several consultations to discuss your particular case.

Richard W. Fleming, MD (retired) · Answer

If you have brow ptosis with a high hairline I suggest you have a Irregular Trichophytic Hairline Brow Lift, a technique we described many years ago. With this approach, we make an incision at the hairline which enables us to lower your hairline when elevating your brows. We bevel the hairline incision so hair will grow through and in front of the resulting scar so it will not be seen.

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