Brow Gliding: Elevating Eyes with Non-Surgical Precision
In the process of aging, the upper third of the face transforms, marked by the elongation of the forehead due to the descent of eyebrows and the development of horizontal and glabellar rhytids. The phenomenon of eyebrow ptosis is a common consequence of aging, necessitating interventions for eyebrow shape enhancement and repositioning to rejuvenate the upper facial region. Various surgical techniques have been documented for this purpose, each presenting its unique advantages and disadvantages.
These approaches are broadly classified into open techniques, involving direct visualization of anatomy, and endoscopic techniques, employing indirect visualization through endoscopy. Open methods encompass incisions along the anterior hairline or coronal region, with soft tissue detachment in subgaleal, subperiosteal, or subcutaneous planes. These techniques allow repositioning of the eyebrows, often involving excision of skin or scalp, resulting in effective elevation of the ptotic eyebrows. While open approaches demonstrate higher efficacy in achieving brow rejuvenation goals with fewer issues related to relapse and asymmetries, their adoption is limited due to associated complications such as scarring, alopecia, changes in sensitivity, and scalp necrosis.
Direct brow lift, involving skin resection above the eyebrow, is effective but may lead to visible and uncomfortable scars for the patient. Furthermore, limitations in elevating the brow's tail to the optimal position arise from the lateral scar at the tail of the brow.
The advent of endoscopic techniques in forehead and eyebrow rejuvenation initially held promise for reducing complications associated with open techniques. However, a prolonged learning curve and complications related to alopecia, sensory nerves, and relapse rates have led many professionals to discontinue the use of endoscopic methods.
Suspension threads, known for their technical simplicity, have been considered, but issues such as durability, high recurrence rates of eyebrow ptosis, and the associated cost have restricted their widespread use. An alternative approach to brow elevation is trans-palpebral browpexy, performed in the subperiosteal or subgaleal plane. Despite its potential, this technique has not gained widespread acceptance according to a survey by Elkwood.
In the pursuit of an effective and stable eyebrow lifting and reshaping technique with minimal incisions, capable of avoiding the considerable complications of existing methods, the development of gliding brow lifting (GBL) emerged. This innovative technique seeks to address the challenges associated with aging-related eyebrow changes.
In this blog, we will discuss the minimally invasive gliding brow technique to achieve almond upturned eyes with minimal scarring for patients.
Understanding GBL
The GBL procedure stands out as an ideal solution meeting specific criteria for brow-lifting interventions. These criteria include achieving an optimal brow position and shape, ensuring durability, minimizing expenses, reducing complications, and facilitating a swift recovery. GBL introduces a novel approach by combining two innovative concepts: subcutaneous frontal detachment with minimal incision access and temporary cutaneous fixation using a hemostatic net.
The subcutaneous plane of dissection, extensively described with various incision sites, is a well-established and efficient approach known for its low relapse rate. GBL, performed in this subcutaneous plane, introduces a modification to access through minimal incisions, enhancing the overall technique.
GBL's success in elevating and maintaining frontal skin and eyebrow position is contingent upon the utilization of the hemostatic Net. The subcutaneous detachment is a prerequisite for the Net's application, as it allows fixation of the skin and eyebrow to the underlying soft tissue. The technique would not be viable with subgaleal or subperiosteal detachment, where soft tissue beneath the elevated forehead and brow would be lacking.
The concept of percutaneous sutures for fixation and hemostasis, introduced by Pontes, laid the foundation for the hemostatic net. Developed by Auersvald and Auersvald, the hemostatic net prevents hematoma formation, reduces the need for electrocoagulation, and eliminates the use of drains and garments. The Net's application in facelifts has demonstrated success in preventing hematoma within the initial 48 hours, promoting cutaneous redraping and optimal healing.
Building upon this experience, GBL was conceived to simplify brow lifting, enhance predictability, and reduce complications associated with conventional open and endoscopic procedures. Postoperative recovery was observed to be faster, with less edema and bruising, attributed to the Net's role in preventing fluid accumulation.
The basic principles of the GBL technique involve wide undermining of the forehead and lateral orbital region at the subcutaneous level through minimal access incisions. The eyebrow is elevated and shaped by gliding the skin over the underlying muscles and fascia. Fixation of the eyebrow and skin to the underlying tissues is achieved with the Net. Patient satisfaction with GBL results after 2–3 years exceeds 70%, reflecting the technique's success in maintaining brow shape and position.
Advantages
GBL distinguishes itself through technical ease, low risk, precise control over eyebrow position and shape, and cost-effectiveness. GBL offers technical advantages over endoscopic brow lifting, including lower equipment costs, a shorter learning curve, and a specialized instrument kit developed by Viterbo. The GBL kit streamlines subcutaneous detachment, simplifying the procedure compared to the technical demands of endoscopic equipment. Furthermore, GBL eliminates the need for expensive absorbable devices used in some endoscopic techniques for fixation, which require additional instrumentation and expertise and may induce foreign body reactions.
The success of GBL lies in the extensive subcutaneous undermining for treatment. A larger area of detachment and fixation, particularly in the frontal and temporal regions, proved more efficient in preventing relapse. The technique's success is underscored by its durable subcutaneous detachment, facilitating eyebrow lift by maintaining continuity between the eyebrow and frontal cutaneous flap.
In contrast, endoscopic approaches rely on adhesion between repositioned periosteum and underlying bone, with laboratory studies showing inconsistent outcomes. GBL offers advantages over endoscopic brow lifts, including lower equipment costs and a shorter learning curve, as demonstrated by a specialized instrument kit. The absence of absorbable devices for fixation further distinguishes GBL, eliminating additional costs and expertise requirements.
GBL's unique ability to shape the eyebrow precisely is attributed to skin and eyebrow detachment, allowing for malleability and modeling of the desired shape. Preoperative evaluation, including reference photographs and patient input, guides surgeons during the procedure. Correction of asymmetries demands careful preoperative assessment and postoperative attention. Most patients experienced an improvement in horizontal frontal wrinkles due to the higher eyebrow position, reducing reflex mechanisms and excursion with strong attachment to the underlying frontalis muscle.
Procedure
Step 1: The procedure commences with the infiltration of tumescent anesthetic into the subcutaneous plane in the designated area for subcutaneous dissection. This encompasses the frontal region up to one centimeter below the eyebrows and the periorbital region extending laterally and inferiorly to the lower border of the zygomatic arch.
Access to the subcutaneous plane is achieved through bilateral 3-mm vertical incisions, strategically placed in the scalp at the anterior hairline and in the frontal-temporal area (A). In certain cases, elevation of all eyebrows and frontal areas is indicated (B), requiring dissection through additional incisions. In instances where central brow elevation is desired, a third incision in the central region facilitates dissection in longer foreheads (C). The dissection involves the frontal region to be elevated, extending medially to the desired point of brow elevation and up to 5 mm below the eyebrows, while also encompassing the periorbital region inferiorly to the lower border of the zygomatic arch. Select cases may necessitate elevation only in the middle area.
Step 2: Specific cylindrical and rhombic dissectors, including straight cylindrical, semi-curved, ‘‘L’’-shaped, and curved detachers, are sequentially introduced. These instruments, developed for this technique by Viterbo and manufactured by Faga Medical, are tailored to the procedure's intricacies.
The straight dissector is inserted into the subcutaneous plane with its tip moving in a superior to inferior direction, maintaining a trajectory toward the skin. Lateralization movements with the curved detacher follow the achievement of vertical tunnel detachment, ensuring complete release of the skin from the underlying frontalis muscle. The non-dominant hand facilitates uniform subcutaneous detachment, minimizing undulations or irregularities. The process concludes with the ‘‘L’’ detacher in the ‘‘pushing’’ mode and, if necessary, the ‘‘pulling’’ mode to address stronger fibrous fibers. Continuous vigilance is crucial to maintaining the subcutaneous dissection plane, reducing the risk of injury to the temporal frontal branch of the facial nerve and the supraorbital nerve.
Step 3: Post-detachment, the forehead skin is mobilized superiorly through a sliding movement, repositioning the eyebrow and periorbital skin to the desired position. Repositioning is achieved by utilizing one or two single hooks above the eyebrow, followed by fixation through one or two horizontal stitches. Overcorrection of 20% above the desired position is recommended.
Step 4: Upon placement of the fixation sutures, vertical continuous running sutures, known as the hemostatic net (Net), are applied at the maximum desirable elevation points. Symmetry is meticulously checked, with similar sutures applied in the lateral periorbital region. The skin is further moved superiorly, and fixation continues with the placement of sutures to create a long column of the Net. A single hook guides traction during Net placement, ensuring complete fixation with continuous running sutures using nylon 5-0 triangular, 26-mm needles, with 4-0 nylon used for thicker skin to ensure adequate fixation to the underlying frontalis muscle.
The dual function of the Net involves creating fixation with traction sutures to the underlying tissues and obliterating the subcutaneous space to prevent hematoma and seroma formation. Needle passage follows a uniform pattern, passing perpendicular to the skin, encompassing the skin and underlying muscle, and emerging 0.5–1.0 cm from the previous entry point. Traction sutures in the eyebrow and periorbital area are 25 mm in height above the brow. When elevating the entire eyebrow, additional traction columns are placed medially, with a 5 mm distance between loops. Above the traction sutures, a 10 mm distance between loops prevents hematoma and seroma formation.
Step 6: Additional columns are strategically placed over all detached areas to prevent hematoma formation and redistribute the skin. The superior traction of the skin results in a skin redundancy in the superior aspect of the forehead.
Potential Complications
The GBL procedure demonstrates a favorable risk profile relative to both open and endoscopic brow lifts, providing a predictably stable aesthetic outcome. Complications inherent in brow lifting techniques are contingent upon the incision site and the plane of dissection, with endoscopic approaches displaying a more extensive array of complications compared to open methods.
Common complications shared by both open and endoscopic techniques include alopecia, scarring, and sensory changes, with endoscopic procedures presenting additional challenges related to asymmetry, relapse, and motor nerve disturbances.
Alopecia (3–9%) and unacceptable scars (2.5–9%) are reported for both open and endoscopic approaches. The GBL, with its minimal 3-mm incision inside the anterior hairline, offers a significant advantage in avoiding alopecia and scarring issues associated with longer incisions.
Necrosis, reported in subcutaneous dissection planes, is mitigated in the GBL through meticulous preservation of arterial, venous, and lymphatic circulation. In this series, tissue necrosis was notably absent, even in elderly patients, although the safety of such extensive subcutaneous undermining in smokers remains undetermined.
Scarring risk in the GBL primarily pertains to the hemostatic net. To minimize risk of scarring, the Net is removed 48 hours postoperatively. Despite this short fixation period, it provides sufficient adherence of the skin to the frontalis muscle for desired positioning.
Motor function disturbances related to frontal branch injury were not observed as permanent in the GBL series. The longevity of a symmetrical brow position and optimal shape is crucial for procedure success. Recurrent asymmetry and loss of elevation, often reported for endoscopic techniques, occurred in only 5% of GBL patients, and reoperations successfully addressed these cases.
Monitoring skin color during Net application and the early postoperative period is crucial. Careful observation of traction sutures, applied at closer intervals, ensures timely response to any potential issues. While transient external suture marks were noted, their permanency was not observed in the series, emphasizing the importance of stitch tension, needle size, and suture diameter.
The choice of Net as a continuous suture minimizes the risk of suture marks by distributing tension uniformly within the continuous running suture. The recommended suture is nylon 5-0 with a cutting circle, 25 or 26 mm. Skin type may influence the risk of post-inflammatory hyperpigmentation, particularly in darker-skinned patients. However, in this series, no patients required treatment for hyperpigmentation, and resolution typically occurred between 3 and 5 months.
Past Research
Gliding Brow Lift (GBL): A New Concept
This study was conducted on 124 patients who underwent the GBL technique between November 2015 and April 2016. Outcome evaluation relied on the surgeon's subjective assessment of preoperative and postoperative photographs, and patient satisfaction was gauged through a straightforward questionnaire assessing their contentment level. The choice between general anesthesia and local anesthesia with sedation was tailored to individual patient preferences. Among the 124 identified GBL patients, 114 (92%) were female, and 10 (8%) were male, with an average age of 55.6 years (± 7.9), ranging from 35 to 76. The mean follow-up duration was 17 months, ranging from 3 to 35 months.
Postoperative recovery was uneventful for all patients, characterized by moderate edema and mild pain. Notably, there were no instances of skin flap necrosis, alopecia, or infection. The initial postoperative period was marked by reduced forehead movement due to detachment and swelling, without any permanent paralysis or asymmetrical movement observed in the patient cohort.
As anticipated with extensive cutaneous detachment, sensory innervation interruption led to transient paresthesia lasting approximately 30–90 days in the detached areas and the scalp. Brow elevation was consistently observed in all cases during the immediate postoperative period, as assessed through the surgeons' review of before-and-after photographs.
During the postoperative period, six patients (5%) exhibited early bilateral or unilateral recurrence, all of which occurred in the initial stages of the technique's development. It was determined that insufficient release inferiorly below the eyebrow and laterally along the lateral orbital attachments contributed to these relapses. Of the six patients with recurrence, four underwent successful correction through a repeat GBL procedure.
Patient satisfaction was appraised 1–3 years postoperatively using a straightforward questionnaire that queried their contentment with the brow elevation result, allowing responses ranging from very satisfied to very dissatisfied. Beyond brow elevation and reshaping, noteworthy observations included reduced excursion of the frontalis and corrugator muscles, resulting in a decrease in frontal and glabellar wrinkles.
Very Satisfied | Satisfied | Neutral | Dissatisfied | |
Number of patients | 20 | 50 | 24 | 7 |
Percentage | 20.8% | 49.5% | 23.7% | 6.9% |
Reference:
Gliding Brow Lift (GBL): A New Concept (2019)
Brow gliding: A new non-surgical concept for almond upturned eyes (2022)
The Gliding Brow Lift (2022)
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