The combination of lateral temporal subcutaneous brow lift (LTSBL) with upper blepharoplasty has emerged as a highly effective method for addressing lateral brow ptosis and upper eyelid ptosis14,15. Combining these two procedures enhances aesthetic outcomes and prevents common postoperative issues such as lateral brow descent, which frequently compromises the results of isolated upper blepharoplasty5,9,16. Our study demonstrates the significant advantages of performing both procedures simultaneously, as reflected in several studies in the literature that echo similar observations.
David B. Lyon’s study emphasizes the combination of upper blepharoplasty with brow lifting to enhance both functional and aesthetic outcomes in the upper periorbital region. He highlights the common issue of brow ptosis following isolated blepharoplasty and emphasizes the importance of preoperative evaluation to prevent this complication. Like our findings, Lyon supports the use of combination surgeries for comprehensive rejuvenation while also comparing the benefits and drawbacks of various brow-lifting techniques, ultimately favoring less invasive methods for better patient satisfaction and reduced complications5.
The importance of combination surgery
Several authors have noted that failing to address brow ptosis during upper blepharoplasty may result in further brow descent postoperatively. McCord, for instance, famously likened the interaction between the eyebrow and upper eyelid to a “curtain rod and curtain” mechanism, where removing excess skin from the eyelid (the curtain) without stabilizing the brow (the curtain rod) results in further brow descent14,15,17. David B. Lyon also emphasized in his review of upper blepharoplasty and brow lift techniques that combining surgery can significantly improve aesthetic and functional outcomes in the upper periorbital area5. Our findings reinforce these conclusions, as performing the LTSBL first allowed for more conservative upper eyelid skin resection, minimizing the risk of overcorrection while preventing postoperative lateral hooding.
Mehryar Ray Taban’s study focuses on a minimally invasive temporal subcutaneous brow lift under local anesthesia, primarily addressing lateral brow ptosis. Taban’s approach offers advantages such as less dissection, hidden scars, and quicker recovery, making it ideal for patients with lateral brow descent18. This technique demonstrates high patient satisfaction and minimal complications, including no nerve damage or visible scarring. Compared to our approach, while Taban’s technique is effective for lateral brow ptosis, our study’s combined method of lateral brow lift with upper blepharoplasty provides a more comprehensive solution for periorbital rejuvenation, simultaneously addressing both brow and eyelid concerns. Both techniques emphasize safety, cost-effectiveness, and patient satisfaction, though Taban’s method focuses more on lateral brow correction alone.
Regarding complications, our study observed minimal risks associated with the LTSBL approach, which aligns with the findings of Savetsky et al.17. In their extensive series of over 500 lateral temporal subcutaneous brow lifts, the authors reported high patient satisfaction with a low incidence of complications, including hematomas and transient hypesthesia, none of which resulted in mid-term morbidity. Similar results were found in our study, with only two cases of hematomas and no nerve injuries or cases of brow asymmetry, reinforcing the safety of the subcutaneous dissection plane. Our conservative approach in combining LTSBL and upper blepharoplasty also supported this safety profile, as it allowed for a balanced correction without over-resection.
Various brow-lifting techniques have been documented in the literature, ranging from coronal and endoscopic lifts to anterior hairline and temporal approaches19,20,21. The coronal brow lift, although effective, has fallen out of favor due to its association with longer scars, scalp numbness, and a risk of elevated hairlines, as reported by authors such as Lyon5. Endoscopic brow lifts, which gained popularity in the 1990 s, involve a deeper dissection and require specialized equipment, often resulting in longer recovery times and less predictable outcomes22,23,24.In contrast, Savetsky and Matarasso also advocate for the lateral temporal subcutaneous approach used in our study, which has been shown to provide consistent results with minimal scarring and a low complication rate17,25. The technique’s minimal invasiveness, combined with its simplicity, makes it an attractive option for patients with lateral brow ptosis, as supported by the outcomes of our study.
Westmore’s ideal eyebrow shape and positioning guidelines have long been the standard for evaluating eyebrow aesthetics. In our study, postoperative results reflected significant improvements in the A-C line (50% increase) and the D-E line (45% increase), closely aligning with Westmore’s recommendations for brow height and arch. Savetsky and Matarasso also achieved similar improvements in their patient cohort, noting that the lateral temporal subcutaneous brow lift effectively restored the ideal brow position in most cases17,25. This consistency across studies underscores the reliability of the technique in achieving natural-looking brow elevation. Additionally, our study’s maintenance of symmetry and avoidance of overcorrection underscore the importance of adhering to Westmore’s principles to guide surgical intervention.
Esin Yalçınkaya et al.‘s study highlights the aesthetic significance of the eyebrow and its variation across ages, genders, and cultures. They define an ideal brow using anatomical landmarks and emphasize the risks of overcorrection, which can result in an unnatural, surprised look. They focus on optimizing surgical results while avoiding common mistakes in brow lifting13.
In comparison, our study emphasizes the combination of lateral brow lift and upper blepharoplasty for comprehensive periorbital rejuvenation. While both highlight the importance of avoiding overcorrection, our study addresses brow ptosis prevention post-blepharoplasty, a topic not explored in depth by Yalçınkaya et al.13.
Patient satisfaction is a crucial indicator of the success of any cosmetic surgery. In our study, the combination of LTSBL and upper blepharoplasty led to universally positive patient outcomes, with 89% of patients expressing satisfaction and 11% reporting that they were highly satisfied. This is comparable to the findings by Savetsky and Matarasso, who reported a high degree of patient satisfaction across their cohort 17,25. In Lyon’s review, patient satisfaction was similarly high when combination surgeries were performed, further reinforcing the benefits of addressing both brow ptosis and upper eyelid excess in a single procedure5. Using our study’s visual analog scale (VAS) questionnaire also helped quantify these positive outcomes, showing a clear appreciation for the natural and rejuvenated appearance achieved by combination surgery.
The stability of subcutaneous temporal brow lift techniques is crucial for evaluating their mid-term efficacy. Overcorrection is an intentional strategy to counteract the anticipated descent of the brow during healing, with mid-term follow-up data crucial for evaluating durability.
In our study, with a follow-up range of 3–13 months (average 11 ± 2 months), early results (3–4 months) showed mild overcorrection, aligning with the technique’s goal to achieve stable mid-term outcomes. By the 1-year follow-up, most patients’ brow positions had stabilized within ideal aesthetic ranges defined by Westmore’s guidelines. These results’ durability is consistent with previous research emphasizing the importance of precise surgical technique and limited dissection to maintain outcomes while minimizing complications. Limiting dissection to the lateral pretrichial area reduced the risks of brow descent and preserved tissue integrity. While some variability in mid-term assessments arose from patients who did not return for follow-up after 3–4 months, 1-year postoperative photographs from a subset of patients support the stability and aesthetic success of the technique. Future studies with larger sample sizes and extended follow-ups would further validate these findings.
Our combined LTSBL and upper blepharoplasty provides a minimally invasive solution for lateral brow ptosis and upper eyelid ptosis, achieving significant improvements in brow positioning (A-C line: 50%, D-E line: 45%) with 89% patient satisfaction at 11 ± 2 months follow-up. In contrast, Pascali and Massarelli’s temporal subcutaneous brow lift (TSBL) with orbicularis oculi muscle (OOM) elastic flap targets broader periorbital and malar rejuvenation, preserving natural aesthetics in 298 patients, with 230 followed for 12 months. While both techniques report no significant complications and high reproducibility, TSBL with OOM enhances malar aesthetics but involves greater procedural complexity26. Our method prioritizes simplicity and shorter recovery while delivering reliable periorbital rejuvenation. These distinctions meet individual patient needs.
The field of periorbital rejuvenation has advanced significantly, with various techniques addressing brow ptosis and the signs of aging. Our combined lateral temporal subcutaneous brow lift (LTSBL) and upper blepharoplasty offer a minimally invasive solution for lateral and upper eyelid ptosis. By contrast, Pascali et al.‘s ‘Temporal MORE’ technique targets comprehensive periorbital and malar rejuvenation through extended dissection, including repositioning of the orbicularis muscle27. Key differences lie in scope and complexity. Our approach, with limited lateral pretrichial dissection, minimizes complications and shortens recovery. In Pascali et al.’s study of 212 patients, their FACE-Q© scores improved significantly from 34.3 ± 5.9 preoperatively to 80.1 ± 6.8 at 12 months.
In comparison, our study of 28 patients showed 89% patient satisfaction and 11% high satisfaction at 11 ± 2 months using the Visual Analog Scale (VAS). Both techniques demonstrate mid-term stability, with follow-ups of 12 months in Pascali et al.‘s study and 3–13 months in ours. While ‘Temporal MORE’ achieves broader rejuvenation, our method provides a more straightforward, effective solution for brow and upper eyelid concerns. These results underscore the value of tailoring surgical approaches to patient needs.
The Gliding Brow Lift (GBL) by Viterbo et al. and our lateral temporal subcutaneous brow lift (LTBL) differ significantly in complexity and recovery28. GBL involves extensive subcutaneous detachment and fixation with a hemostatic net, resulting in effective mid-term brow elevation (average follow-up time: 17 months). However, this procedure is associated with a longer recovery period, characterized by temporary paresthesia that typically lasts 30–90 days. In contrast, our LTBL employs limited lateral dissection, minimizing trauma and reducing recovery time while achieving significant patient satisfaction (89% satisfied, 11% highly satisfied) at an 11 ± 2-month follow-up. While GBL addresses broader forehead rejuvenation, our approach prioritizes simplicity, reproducibility, and minimally invasive techniques.
An in-depth understanding of periorbital anatomy is essential when evaluating the interplay between brow ptosis and upper eyelid concerns29,30,31. Brow ptosis is not merely a static descent of soft tissue but reflects a dynamic interplay involving the frontalis muscle, orbicularis oculi, and the levator palpebrae superioris complex32,33,34. Knize et al. and Miller et al.‘s studies have demonstrated compensatory frontalis hyperactivity in patients with lateral brow descent, which can mask underlying eyelid changes and alter clinical assessment2,3,6,7. In our series, all patients presented with lateral brow descent but preserved levator function, confirming the absence of true blepharoptosis. However, clinical signs of frontalis overuse—such as eyebrow elevation on attempted lid opening—were frequently noted preoperatively. Following the lateral temporal brow lift, intraoperative relaxation of the frontalis was often observed, indicating resolution of this compensatory effort. These findings support a tailored approach to periorbital rejuvenation, where combined brow lift and blepharoplasty address both structural and functional components of the upper face, particularly in patients with subtle neuromuscular compensation patterns35,36,37.
Numerous temporal lifting methods—including direct, endoscopic, and deep-plane variations—have been well-documented in the literature, as well as in foundational surgical texts and technique-focused Chaps38,39,40,41,42,43.. Our study contributes to this evolving body by evaluating a simplified, reproducible approach using the pretrichial subcutaneous technique, specifically in conjunction with blepharoplasty, with quantifiable outcomes and patient-reported satisfaction metrics.
