Naturally, brows should lie just above the upper edge of the orbit. Although all brows are different in shapes and sizes, the outer portion of the brow is generally higher than the inner portion.
Ageing, decreased skin laxity, effects of gravity and repetitive periorbital muscle contractions are contributing factors that will result to sagging brows, producing a droopy appearance over time. The loss of temporal support to the lateral brow, alongside volume loss in the upper eyelid, can also create the illusion of brow ptosis.
While there are still surgical options available, non-surgical treatment for brow lifts is on the rise. Brow lift treatments aim to reverse the effects of aging and gravity on your eye brow and will help reposition the forehead and eyebrows to achieve a natural, subtle youthful appearance, and can correct brow asymmetry.
In this article by Dr Victoria Manning and Dr Charlotte Woodward, we will review patient selection, techniques and complications & how to manage them when performing a non-surgical brow lift with combination of botulinum toxin and threads.
Aesthetic considerations of the brow
Subtle lifts on 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 a guide, Figure 1 illustrates the ideal positioning of the brow. This can be a guide for practitioners to help determine how the brow needs to be altered and decide if an elevation is needed.
The practitioner should be well informed of the anatomy in treatment area to avoid potential complications before the procedure. The scalp consists of five layers: the skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and periosteum (Figure 2).
Figure 2: The five layers of the scalp.
While understanding the flow of the blood supply and types of muscles on the eyebrow (Figure 3) is important, it is crucial for the practitioner to know the location of the sensory nerve supply as the insertion of threads has the potential to cause nerve damage if the anatomy is not correctly understood.
Figure 3: The supratrochlear (ST) nerve and artery lie 1.5- 1.7cm from the midline, and the supraorbital (SO) 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
As with all aesthetic procedures, it is paramount to assess patient suitability. Taking the patient’s medical, cosmetic and aesthetic history is mandatory. The practitioner is to identify contraindications like inflamed skin/tissue, haemophilia, pregnancy, IVF and unrealistic expectations.
Assess the skin quality, pre-existing asymmetry of the brows, tissue laxity and muscle activity with the patient seated upright, and with patient participation. This way they can view the process in a mirror, and decide on their desired shape of brow.
The number of threads used to lift the brow varies from one to two per side, depending on what lift is required.
Designed to rejuvenate the forehead, this minimally invasive non-surgical brow thread lift is performed under local anaesthetic. Using polydioxanone (PDO) thread with botulinum toxin provides the best results.
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.
To prepare for thread insertion, practitioners should clean the patient’s skin with a sterilising agent, and mark the desired lift and infiltrate entry and exit points in the brow. PDO barbed blunt cog is recommended for this procedure as it is safer due to the ‘danger areas’ of the supraorbital (SO) and supratrochlear (ST) arteries.
Always check with the patient to agree on the correct amount of lift that they desire to avoid over-tightening.
Patient are advised against rubbing or massaging the forehead for two weeks post treatment. Mild discomfort after the procedure is normal and it may last for up to two weeks. They are also advised to avoid impact exercise for two-weeks post procedure to allow the threads to embed within the tissue.
Patient will need to understand that there are potential bleeding risk, and are advised to not plan anything special for a few days 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: Although this is rare, when it occurs, rape up the brow as support, as the threads cannot anchor within fluid and will need additional support until haematoma resolves.
Nerve damage, sensory impairment, or hypersensitivity: To prevent these, when cutting the thread, pull the thread away from the skin so it will spring back beneath the dermis.
Results can last up to 18 months. Practitioners should note that this is an advanced procedure and adequate training must be taken before going ahead with treatment.
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