Treating the Brow

By Dr Charlotte Woodward and Dr Victoria Manning / 18 Aug 2017

Dr Victoria Manning and Dr Charlotte Woodward present their techniques for performing a non-surgical brow lift using threads for medial elevation

When a person is young, their brow should lie just above the upper edge of the orbit. The outer portion of the young brow is higher than the inner portion as it slopes gently upwards, before dropping slightly at its tail. 

Factors such as ageing, decreasing skin elasticity, the effects of gravity and repetitive periorbital muscle contractions will inevitability result in sagging brows, especially laterally, producing a flat, droopy appearance over time. As well as this, the loss of temporal support to the lateral brow, alongside volume loss in the upper eyelid, can create the illusion of brow ptosis.

A brow-lift will help reposition the forehead and eyebrows to achieve a natural, subtle youthful appearance, and can correct brow asymmetry. If a patient is against surgery, a combined non-surgical approach can often deliver great results.1,2 There are multiple options for lifting the brow, such as dermal fillers, botulinum toxin and now threads, and they can all be used in combination.

In this article, we will discuss treating the brow with a combination of botulinum toxin and threads for medial corrections and we will explore anatomy, patient selection, techniques, complications and how to best manage them.

Aesthetic considerations of the brow

Subtle elevation of the medial, central, and/or lateral portions of the brow can be achieved with a variety of advanced brow-lifting techniques. It is critical when balancing the face to know whether the brow should be elevated, as well as which parts of the brow should be lifted and why. 

As a guide, Figure 1 illustrates the ideal positioning of the brow. Practitioners can use this to help determine how the brow needs to be altered and decide if an elevation is needed.

Figure 1: The positioning of the ideal brow12,13

Anatomy

Before conducting any aesthetic procedure, the practitioner should be well informed of the anatomy in the treatment area to avoid potential complications. The scalp consists of five layers: the skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and periosteum (Figure 2). The galea is tendinous connective tissue that connects the frontalis muscle with the occipitalis muscle. 

The frontalis muscle originates from the galea and inserts into the forehead skin. Superiorly, the galea becomes tightly attached to the periosteum. Laterally, the galea continues as the temporoparietal fascia, which is continuous with the superficial musculo-aponeurotic system (SMAS) layer of the face and the platysmal layer of the neck.9

Sensory nerve supply

The insertion of threads has the potential to cause nerve damage if the anatomy is not correctly understood. The nerve supply to the brow and anterior scalp is the ophthalmic division of the trigeminal nerve. 

The ophthalmic division divides into the lacrimal nerve and the frontal nerve, which further divides into the supraorbital and supratrochlear nerves. The supratrochlear innervates the conjunctiva, upper eyelids, and inferomedial part of the forehead, whereas the supraorbital nerve innervates the upper lid, forehead, and anterior scalp. For marking out purposes, the supratrochlear nerve lies 1.5-1.7cm from the midline, and the supraorbital nerve lies 1cm lateral to the supratrochlear nerve (Figure 3).4 The temporal part of the facial nerve supplies the muscles of the forehead and the orbicularis oculi muscle.4

Blood supply

The internal and external carotid arteries supply the forehead. The internal carotid artery, via the ophthalmic artery, divides to form the frontal, supraorbital, and supratrochlear arteries. The external carotid artery system supplies the largest area of the scalp via the superficial temporal artery.4

Muscles

There are four muscles in the eyebrow: frontalis, procerus, corrugator supercilii and orbicularis oculi. The frontalis is a divaricated, subcutaneous muscle that inserts into the skin of the eyebrow. The frontalis muscle has no bony insertions, and its sole action is brow elevation. 

Horizontal forehead lines are due to continual frontalis activity. Infero-nasally, the frontalis muscle extends to form the procerus muscle.4 The procerus inserts onto the medial belly of the frontalis muscle and the dermis between the eyebrows. The action of the procerus muscle produces inferior brow movement and creates the horizontal glabellar lines.4

Figure 2: The five layers of the scalp9


Non-surgical brow lift procedure

The minimally invasive non-surgical brow thread lift is performed under local anaesthetic and is designed to rejuvenate the forehead. It takes around 60 minutes, involves minimal discomfort and the recovery time is generally five to seven days. However, due to the potential bleeding risk, we always advise patients not to plan anything special for a few days post treatment. The results can last up to 18 months.14

Patient selection

As with all aesthetic procedures, it is paramount to assess patient suitability. Taking the patient’s medical, cosmetic and aesthetic history is mandatory. Identify the following contraindications: inflamed skin/tissue, history of keloid scarring, autoimmune diseases (such as scleroderma, sarcoidosis, amyloidosis due to unpredictable results), anticoagulant medication, haemophilia, pregnancy, IVF, malignancy, history of bacterial endocarditis (existing systemic infection), body dysmorphia and unrealistic expectations.17

Assessment

Assess the skin quality, pre-existing asymmetry of the brows, tissue laxity and muscle activity. With the patient seated upright, and with patient participation so they can view the process in a mirror, decide on desired shape of brow. 

It is important to note that although this article focuses on the medial lift, you may also require a lateral lift, or both. The number of threads used to lift the brow varies from one to two per side, depending on what lift is required.

Figure 3: The supratrochlear nerve and artery lie 1.5- 1.7cm from the midline, and the supraorbital nerve and artery lie 1cm lateral to the supratrochlear nerve. The vessels and nerves lie in the medial aspect of the brow so caution is required whenever treating this area so as not to damage these structures and cause excessive bruising.

Medial lift procedure

There are multiple protocols for brow lifting for different types of threads, which act as a scaffold for the ptotic skin and mechanically lift it while stimulating collagen. We use polydioxanone (PDO) barbed blunt cog for medial elevation, as we find it safer due to the ‘danger areas’ medially of the supra-orbital and supratrochlear arteries.

We find that using threads in conjunction with botulinum toxin gives the best results. Pre-treat the orbicularis with botulinum toxin two weeks prior to the thread lift procedure as hyperactivity of the lateral orbicularis oculi muscle can pull down on the lateral aspect of the brow.16 The orbicularis oculi muscle pulls down on the tail of the brow and opposes the lifting action of the frontalis muscle.5,6 

To prepare for thread insertion, practitioners should clean the patient with chlorohexidine or other skin sterilising agent, mark the desired lift and infiltrate entry and exit points in the brow and along the suture track with local anaesthetic mixed with adrenaline. This helps separate the tissues to allow for easier suture insertion. Allow time for maximal vasoconstriction and await blanching, this may take up to 10 minutes. 

Create a sterile field and drape the patient. Remember to consider the danger zones of the supraorbital and supratrochlear vessels. Firstly, puncture the skin at the apex of the inverse V technique using 18G needle with a blunt cannula using 60mm 3D barbed threads. The inverse V technique involves a single entry hole at the apex, which widens at the anchor points in the brow, which is the wider part of the V. 

Then, insert the suture, advancing towards the brow. The suture is placed in the subdermal plane, avoiding deep placement through the aponeurosis. Exit in the hairline for good anchorage. 

Once the suture has been inserted, slight compression is made to the tissue overlying the suture to reshape the brow. The non-inserted ends of the suture are cut off. Once in place, anchor the suture and tighten it to get the desired lift. 

Avoid overtightening – always check with the patient to agree on the correct amount of lift. 

Ensure the thread springs back beneath the dermis to limit thread migration and finish by applying antibiotic ointment to the entry points.

Aftercare 

Advise patients not to rub or massage the forehead for two weeks post treatment. In our experience, mild discomfort after the procedure is normal and it may last for up to two weeks, so reassure the patient of this. If the patient feels pain, advise them to take paracetamol 500mg, one to two tablets every six hours as required. 

It is also important to advise against anti-inflammatory medication such as ibuprofen, as inflammation is necessary to initiate the new collagen stimulation18 and increases bruising. 

Tell them to avoid impact exercise for two-weeks post procedure to allow the threads to embed within the tissue. It is also strongly recommended that patients avoid radiofrequency or any heat-producing treatments of the thread-treated areas for 12 weeks, as we have found that it can affect how the threads settle. The patient should be reviewed two weeks later with photography at three months’ post treatment.

Figure 4: Patient before and after treatment. Image demonstrates correction of asymmetry using a unilateral ‘inverse V technique’ with PDO threads.

Avoidance of risks and complications

Asymmetry: Always involve the patient at the tightening stage to ensure desired effect.

Bleeding/haematoma: This is rare, but if it occurs, tape up the brow as support, as the threads cannot anchor within fluid and will need additional support until haematoma resolves.7

Puckering: If overtightened, the skin will bunch up over the thread and cause visible puckering. Sometimes slight unevenness can be caused by oedema and the local anaesthetic along the tract, causing the tissues to swell.

Infection: In our experience, infection post-thread procedures is extremely rare. All threads should be placed using an aseptic technique to reduce the risk of infection and in our practice antibiotic ointment is applied to entry points post treatment.

Granuloma: These arise from threads being placed too superficially in the dermis.7,15

Thread breakage: Typically, this occurs during tightening of the PDO cogs.

Thread migration or loss: It is paramount to ensure that when the thread is cut, the end will spring back into the skin – migration of a thread through the skin is an infection and granuloma risk. If the end of a thread is left in a superficial plane, then there is increased likelihood of granuloma formation.10

Nerve damage,7 sensory impairment,8 chronic pain8 and hypersensitivity:8 To prevent these, when cutting the thread, pull the thread away from the skin so it will spring back beneath the dermis.

Palpable visible threads: These usually settle after several days but may need intervention using hydrodissection to lift the overlying skin off the thread. If placed too superficially, the threads may need removing as they can cause hyperstimulation of the dermis and eyebrows.

Conclusion

Treating the brow in the correctly selected patient can enable excellent satisfaction and results that can last 18 months, or even longer. Practitioners should note that this is an advanced procedure and adequate training must be taken before going ahead with treatment. 

References
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  8. Della Torre, F., Della Torre, E. & Di Berardino, F, ‘Side effects from polydioxanone’, Eur. Ann. Allergy Clin. Immunol, 37, 47–8 (2005).
  9. Weinberger MS, Becker DG, Toriumi DM. Rhytidectomy. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds, ‘Otolaryngology Head and Neck Surgery’, 3rd ed. St. Louis: Mosby; 1998:649.
  10. Paul MD. Complications of barbed sutures. Aesthet Plast Surg. 2008;32:149
  11. Manavpreet Kaur, Rakesh K Garg, Sanjeev Singla, ‘Analysis of facial soft tissue changes with aging and their effects on facial morphology: A forensic perspective’, Egyptian Journal of Forensic Sciences, V5, 2015, pp.46-56 <http://www.sciencedirect.com/science/article/pii/ S2090536X14000501>
  12. Esin Yalcınkaya, Cemal Cingi, Hakan Soken et al., ‘Aesthetic analysis of the ideal eyebrow shape and position,’ Eur Arch Otorhinolaryngol, 2014, <https://www.researchgate.net/publication/267742996_ Aesthetic_analysis_of_the_ideal_eyebrow_shape_and_position>
  13. Romm S, ‘Art, love, and facial beauty’, Clin Plast Surg, 1987, 14(4):579–583
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  17. Yuki Shimizu, Kanae Terase, ‘Thread lift with absorbable monofilament threads’, Journal of Japan Society of Aesthetic Plastic Surgery (JSAPS), 2013 Vol.35 No. 2.
  18. Pountos I, Georgouli T, Blokhuis TJ, Pape HC, Giannoudis PV, ‘Pharmacological agents 

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