The aesthetics of the periorbital region are significantly influenced by the position of the eyebrows, forehead wrinkles, and upper eyelid ptosis, with aging-related eyebrow ptosis playing a major role. Brow lift surgery has seen a marked increase in popularity, driven by a variety of techniques tailored to individual patient needs. The ‘gliding brow lift’ technique, which employs a minimally invasive subcutaneous approach using a hemostatic net, represents a recent advancement in eyebrow rejuvenation. This article outlines our three-year experience and adaptation with this technique, which is divided into three sequential steps: (1) subcutaneous dissection; (2) internal eyebrow fixation; (3) skin redraping. Our modified gliding brow lift technique combines simplicity, minimal equipment requirements, conservative principles that limit scarring and avoid skin resection, and long-lasting results with few complications, making it an attractive option for brow rejuvenation.

L’esthétique de la région périorbitaire est significativement influencée par la position des sourcils, les rides du front et la ptose de la paupière supérieure, la ptose des sourcils liée au vieillissement jouant un rôle majeur. La chirurgie de lifting des sourcils a connu une augmentation marquée de popularité, poussée par une variété de techniques adaptées aux besoins individuels des patients. La technique du ‘gliding brow lift’, qui utilise une approche sous-cutanée peu invasive avec un filet hémostatique, représente une avancée récente dans le rajeunissement des sourcils. Cet article présente notre expérience de trois ans et notre adaptation de cette technique, qui est divisée en trois étapes successives : (1) dissection sous-cutanée ; (2) fixation interne des sourcils ; (3) redrapage de la peau. Notre technique modifiée du gliding brow lift combine simplicité, besoins en équipements minimaux, principes conservateurs limitant les cicatrices et évitant la résection de la peau, et des résultats durables avec peu de complications, en faisant une option attrayante pour le rajeunissement des sourcils.

# Introduction

The periorbital region is one of the most expressive areas of the human face, where aesthetics are significantly influenced by the shape and position of the eyebrow, forehead wrinkles, and upper eyelid ptosis. Eyebrow ptosis, a mechanism related to aging, results from the loosening of the skin and soft tissues of the frontal region, the balance of action of the elevator (frontalis) and depressor (orbicularis oculi, corrugator, procerus) muscles, gravity [1], modification of the bony orbital frame [2,3]. The lateral part of the eyebrow is often the first affected due to the absence of frontalis muscle insertion [4].

Brow lift surgery has gained significant popularity, with a 60.1% increase in the number of interventions worldwide between 2018 and 2022 [5]. Therapeutic approaches for the surgical treatment of eyebrow ptosis are diverse and depend on the individual patient's needs and surgeon's preference. The techniques employed use various methods of access, such as open pre-capillary or coronal, lateral, direct supra-brow or in the forehead wrinkles, transpalpebral or endoscopic approaches. Several dissection planes have been described, such as the subcutaneous, supra-periosteal or subgaleal, and subperiosteal planes [6]. Complementary procedures can also be associated, such as resection of the corrugator or frontal muscles [7,8], fixations [9], or plications [10]. Each of these techniques has its advantages and disadvantages, with no single technique being universally accepted [11].

Recently, the emergence of the “gliding brow lift” technique has significantly changed our therapeutic approach to the eyebrow region. This technique uses a reduced approach at the hair level, a subcutaneous dissection plane, and the use of a hemostatic net [12,13]. In this article, we will share our experience and adaptations of this innovative technique that we have been using in our department for the past 3 years.

# Indications and contraindications

Brow lift surgery may be considered for patients in the context of facial rejuvenation with eyebrow ptosis, whether lateral or global. In this context, it is often performed in association with blepharoplasty to obtain optimal periorbital aesthetic results. Additionally, the presence of deep forehead wrinkles can also be improved through surgery.

Brow lift surgery may be indicated to modify the gaze especially in younger patients, or as an integral component of facial feminization in gender reassignment surgery. In these cases, the gliding brow lift as an isolated procedure may be the most appropriate technique.

Furthermore, brow lift procedures are also involved in more controversial surgical approaches known as ‘fox eye’ or ‘cat eye’ techniques [14].

However, a highly curved forehead or alopecia may be relative contraindications to surgery.

# Preoperative markings

To enhance surgical outcomes, botulinum toxin can be administered to the forehead and orbicularis muscle, focusing on the lateral and superior regions, at least two weeks prior to surgery. The preoperative markings are made before the intervention, with the patient seated or standing, and then verified in a supine position. The frontal-temporal dissection is marked with the inferior limit being the zygomatic arch laterally and 5mm below the eyebrow medially. The lateral and superior limits correspond to the hairline, while the medial limit extends 5mm beyond the desired effect on the eyebrow, potentially reaching the midline if the effect concerns the entire frontal region (Fig. 1a and b). The incision is made behind the hairline and measures 1cm in length, centered on the area to be dissected. The length of the skin incision will allow for better access to create and place the deep suspension sutures for the brow. In cases where upper blepharoplasty is also planned, markings are made for the supratarsal fold and the corresponding crow's feet wrinkles. The upper incision line for blepharoplasty is strategically placed by pulling upward on the temporal skin to simulate the effect of a brow lift (Fig. 1c), allowing for precise adjustment of the resection. Following classical guidelines, the lower incision is positioned at least 8mm above the pupil and 6mm from the outer canthus, while the upper incision is typically set at least 10mm below the eyebrow. This upper incision line is intentionally reduced by 1–2mm to anticipate the correction of upper eyelid skin redundancy by the brow lift (Fig. 1c), benefiting from the partial correction of eyelid skin excess achieved during the procedure. Simultaneously, correction of internal fat herniation or palpable eyelid ptosis can be performed. Post-brow lift, the upper resection edge is refined to ensure optimal aesthetic outcomes.

# The three-step procedure

The procedure can be performed under general anesthesia, local anesthesia with or without sedation depending on the patient's preferences.

## Step 1: subcutaneous dissection

A tumescent infiltration is performed at least 10minutes before the procedure with 30 to 60 cc of 1:1000 adrenaline serum per side, or with 1% xylocaine with adrenaline diluted 1:1 in saline solution in case of local anesthesia. The infiltration is performed strictly in the subcutaneous plane in the area of dissection and incision. Tumescent infiltration enables hydrodissection of the subcutaneous tissue, facilitating its separation and promoting uniformity (Fig. 2
                        ).

The incision is made along the marked line using a scalpel (Fig. 3
                        ). Subcutaneous dissection can commence with either an Joseph rugine or Metzenbaum scissors under visual guidance for the initial 1cm, followed by blind dissection along the entire planned dissection area (Fig. 4a–c). Alternatively, blunt dissectors typically used in implant expansion surgeries or those specifically designed by Viterbo for this technique [12] can be employed for subcutaneous undermining.

Techniques utilizing a subgaleal dissection plane, which corresponds to layer 4 and is composed of soft tissue spaces and retaining ligaments that function more as a dissection plane than a true fascial layer, or a subperiosteal dissection plane, located under layer 5 of the face and considered an anatomical dissection plane [15], carry a high risk of recurrence due to their location within a natural sliding plane. In contrast, strict subcutaneous undermining, which occurs in layer 2 and not in a natural dissection plane, is recommended because of its unique histological organization, specifically the tela subcutanea [16,17]. The subcutaneous tissue comprises numerous vertical fibrous septa, known as retinacula cutis 
                        [17], which firmly anchor the dermis to the underlying frontal muscle [18]. These septa are all the more vertical with respect to the retaining ligaments, which are: the superior temporal septum, the inferior temporal septum, the temporal ligamentous adhesion, the lateral orbital thickening, and the zygomatic ligaments [15]. This fibrous architecture is implicated in sagging, as decreased density and elasticity with aging are associated with the appearance of deep wrinkles [19,20]. Utilizing this dissection plane enables the reorganization of the histological structure of wrinkles, limits recurrence due to the absence of a natural sliding plane, and stimulates the creation of fibrous tissue through the healing process. Additionally, releasing the dermal insertions of the retaining ligaments in the previously mentioned regions allows for improved mobilization of the brow lift, leading to a more favorable result. Consequently, this procedure smoothes out wrinkles and significantly reduces the risk of recurrence.

Consistent subcutaneous dissection at a uniform depth, avoiding irregularities, and extending extensively to the lower edge of the zygomatic arch, facilitates tension-free mobilization of the subcutaneous brow lift flap, thereby further diminishing the risk of recurrence.

This dissection plane ensures safety concerning the danger zones of the frontotemporal region: the superficial temporal artery, zygomaticotemporal sensory nerves, supraorbital nerve, supratrochlear nerve, and the temporal and zygomatic branches of the facial nerve [21]. Only the superficial venous network might be affected, such as the sentinel vein, whose bleeding is never a significant issue due to the subsequent application of the hemostatic net.

## Step 2: internal fixation

A lateral fixation of the eyebrow is performed internally within the eyebrow fat compartment using a slow-resorbing, colorless 2/0 polydioxanone monofilament suture (PDS II, Ethicon). A 40mm and 21G green trocar is inserted percutaneously from the outside to the inside, reaching the previously dissected area at the desired brow suspension zone. The tip of the trocar is visualized through the scalp incision, with the slit oriented upwards. The distal end of the suture is passed through the trocar, extending at least once the length of the trocar. The trocar is then withdrawn with one hand while the index finger of the other hand is placed on the entry point to ensure the tip does not exit the skin. Once the tip is palpated under the index finger, the trocar changes direction within the soft tissues and exits at the dissection plane, allowing the needle tip to be re-visualized through the scalp incision. The suture is then retrieved, and the trocar is removed, creating a solid deep anchor point at the brow. Multiple suspension points can be created in this manner to enhance the brow's shape as needed (Fig. 5
                        ). This technique was recently published by another team for the indication of lower blepharoplasty with fat pad transposition [22].

In cases involving concurrent upper blepharoplasty, the procedure benefits from an initial palpebral incision, which is reduced by 1 to 2mm, and is performed prior to the forehead lift. This is followed by a subcutaneous dissection and opening of the orbicularis muscle, enabling precise visualization of the fixation area. The sub-orbicularis dissection connects with the frontotemporal dissection to facilitate internal eyebrow fixation (Fig. 6
                        ). Care is taken to avoid injuring the frontal branch of the facial nerve, which innervates the corrugator muscle. Additionally, resecting a lateral strip of the orbicularis muscle can reinforce the uplifting action. This approach allows for the placement of two to three suspension sutures in the eyebrow.

The deep anchor point aligns with the incision, and the knot is manually tied to allow tension adjustment as necessary. The deep fixation is secured to the deep temporal fascia (Fig. 7
                        ), which has demonstrated reliability [23], with the traction vector oriented obliquely based on the desired effect. The traction is intentionally over-corrected to prevent the slight, yet inevitable descent of the brow position in the postoperative period, which was fixed intraoperatively.

This stage enables precise adjustment of the eyebrow's shape and position by applying direct tension as close as possible to the eyebrow, thereby minimizing the impact of surrounding tissue elasticity. The use of a slow-absorbing suture, such as polydioxanone, which maintains sufficient strength for at least six weeks, is essential [24]. Analogous to subperiosteal brow lifting, the healing process benefits from long-lasting sutures that promote strong adherence between the dissection plane surfaces within this period [25]. This approach helps maintain the position of the eyebrow during scar maturation, resulting in long-lasting outcomes.

The preliminary internal brow fixation also allows for the elimination of the need to maintain traction on the cutaneous flap, as required in the original description of the gliding brow lift. This permits more precise positioning of the eyebrow, frees up an assisting surgeon, and simplifies the next step.

## Step 3: redraping of skin excess

The technique for skin redraping involves using either a hemostatic net, which is quicker, or separate stitches, which allow for more precise adjustments and are preferred by less experienced surgeons. The preferred suture is a 5-0 triangular needle crafted from polypropylene and polyethylene (Optilene 5-0; B. Braun Surgical). The application of the hemostatic net typically starts near the eyebrow, with suture passes running parallel to the eyebrow's axis, while the running sutures or separate stitches form an inferior to superior axis perpendicular to this line.

The needle is inserted into the skin at a 90° angle and anchored to the deep galeal plane before exiting the skin approximately 1.5cm from the entry point. Tension control on the suture may reduce this distance to 1cm. Each suture pass is spaced 0.8 to 1cm apart along the entire skin dissection, ensuring effective redraping while safeguarding vascular integrity of the skin flap [13,26]. This redraping facilitates the absorption of excess skin resulting from the repositioning of the eyebrow throughout the entire dissection height without altering the hairline or necessitating skin resection (Fig. 8
                        ).

Additionally, the hemostatic net aids in reducing skin tension caused by brow suspension points, thereby closing dead space and limiting the accumulation of postoperative fluids. This dual function helps mitigate inflammation and minimize shear movements, both of which can contribute to postoperative swelling.

The incision is closed with 3 or 4 skin staples (Fig. 9
                        ).

The blepharoplasty will be closed in a classic manner with 4 or 5 non-resorbable monofilament 6/0 sutures externally and an intradermal running suture with 5/0 internally.

The dressing is then performed after thorough washing to remove as much coagulated blood as possible at the level of the passage of the sutures. The dressing may be applied with the surgical site exposed to air or by utilizing petroleum or vitamin A ointments, or a petroleum interface, accompanied by compresses and bandages, contingent upon the patient's comfort with the hemostatic net technique's appearance. We refrain from using adhesive dressings to prevent potential disruption of the healing process from the superficial to the deep plane and to minimize discomfort during removal.

Afterward, care will consist of daily or multiple daily washing with water and gentle soap, along with the voluntary removal of scabs using hydrogen peroxide. This routine aims to prevent scabbing at the suture entry points, promoting epithelialization along the sutures and thereby minimizing the visibility of marks left by the hemostatic net after its removal.

## Postoperative care

Postoperative care of the surgical site will involve daily or multiple daily washing with water and gentle soap. Additionally, scabs will be voluntarily removed using hydrogen peroxide to prevent scabbing at the suture entry points. This routine facilitates epithelialization along the sutures, thus minimizing the visibility of marks left by the hemostatic net after its removal.

The usual analgesics of levels I and II are sufficient to manage postoperative pain.

The sutures of the hemostatic net will be removed on days 3 to 4 by cutting them in sections with scissors every two passes, leaving a safety length for subsequent suture removal with forceps. The staples can be removed after one week.

Follow-up consultations are scheduled for the patient at 3–4 days for the removal of the hemostatic net, 3 weeks to monitor wound healing, with the option of administering a botulinum toxin injection if not performed prior to surgery, 3 months to assess symmetry upon resolution of swelling, and one year postoperatively to evaluate the final outcome.

# Results

This minimally invasive subcutaneous brow lift technique delivers long-lasting results without visible scars or skin resection. The following case examples illustrate the effectiveness of this approach.

## Case 1

A patient underwent a brow lift alone. Preoperative views and immediate postoperative views with a hemostatic net, showing the immediate effect of the brow lift, are presented (Fig. 10a–d).

## Case 2

A patient underwent a brow lift using the described technique. Preoperative views show the initial condition (Fig. 11a and b). At 45 days postoperative, views display early results and healing progress, with no visible marks from the hemostatic net (Fig. 11c). Six months postoperative views demonstrate sustained benefits and stability of the procedure (Fig. 11d and e).

## Cases 3, 4, and 5

Patients underwent a brow lift using the described technique. Preoperative images show the frontal view of each patient's initial condition. One-year postoperative images display the frontal view, demonstrating significant and sustained improvements for each patient (Fig. 12a and b; Fig. 13a and b; Fig. 14a and b).

# Discomfort and complications

Infections are rare in this procedure.

The risk of bleeding and hematoma is minimal to nonexistent due to the presence of the hemostatic net [27].

Alopecia is uncommon owing to the small size of the incision and the atraumatic dissection with “cold” instruments. However, we observed in one patient some ischemia at the distal edge of the brow lift flap during combined blepharoplasty and brow lift procedures. To avoid such complications, it is advisable to adhere to the use of 5/0 monofilament with a large needle, as the threading and tension rules have proven safe in terms of skin vascularization.

Patients may experience swelling and discomfort in the frontal area, which are significantly relieved by tier I and II analgesics. The addition of ropivacaine to the tumescent infiltration fluid in the early postoperative hours can further alleviate these symptoms.

Temporary hypoesthesia or anesthesia of the forehead/scalp may occur and usually resolve over several weeks to months.

Net marks are visible in the initial weeks but typically disappear within three months; however, if they persist, application of a corticosteroid ointment can expedite their fading. Prevention involves the use of fine 5/0 monofilament, tension respecting skin vascularization, and early removal of the hemostatic mesh by day 3–4 at the latest.

As the edema subsides, irregularities in skin redraping may become noticeable. These irregularities are caused by the initial dissection performed in different planes (Fig. 15a). To address this issue, we recommend regular massages of the affected areas. If there is no improvement, a microfat grafting procedure may be performed (Fig. 15b).

In cases of inadequate results or asymmetry, corrective surgery can easily be performed using the same procedure under general or local anesthesia.

# Ancillary procedures

Ancillary procedures such as superior and inferior blepharoplasty, canthoplasty, temporal fat injection, and frontoplasty complement the gliding brow lift for comprehensive periorbital rejuvenation. They address specific concerns such as upper and lower eyelid aging, eye region refinement, temporal volume restoration, and upper facial feminization, enhancing overall aesthetic outcomes.

# Conclusion

Our modified gliding brow lift technique combines simplicity, minimal equipment requirements, conservative principles limiting scarring and avoiding skin resection, and enduring results with few complications, making it an attractive option for brow rejuvenation.

# Disclosure of interest

The authors declare that they have no competing interest.