Lateral pretrichial subcutaneous brow lift with upper eyelid blepharoplasty

Abstract

This study evaluates the combined approach of lateral temporal subcutaneous brow lift (LTSBL) and upper blepharoplasty to improve both brow and eyelid aesthetics. An analysis was conducted on 28 female patients (mean age: 47 ± 6.3 years) who underwent the combined procedure between January 2023 and September 2024. Preoperative and postoperative photographs were analyzed using Westmore’s ideal eyebrow measurements. Satisfaction was assessed with a visual analog scale (VAS) questionnaire. The combined surgery demonstrated significant improvement in brow positioning. Follow-up was conducted at an average of 11 ± 2 months (range: 3–13 months) to assess the mid-term stability of brow position. The A-C line (lateral brow) showed a 50% improvement, increasing from 46 mm (SD ± 4.6) to 71 mm (SD ± 5.1) (p = 0.02). The D-E line (brow apex) improved by 45%, from 35 mm (SD ± 5.6) to 50.75 mm (SD ± 4.5) (p = 0.04). Horizontal alignment (B-C) improved by 25%, contributing to overall brow symmetry. Patient satisfaction was high, with 89% expressing satisfaction and 11% reporting high satisfaction. Combining LTSBL with upper blepharoplasty provides comprehensive periorbital rejuvenation, addressing lateral brow ptosis and upper eyelid excess. This technique offers high aesthetic satisfaction with minimal complications, making it an effective option for patients seeking enhanced upper facial harmony.

Introduction

Patients with low lateral eyebrows and drooping upper eyelids often find that upper blepharoplasty alone does not fully address their aesthetic concerns^1,2. This is due to the fact that eyebrow position plays a critical role in the overall appearance of the periorbital region^2,3. In response to this challenge, combining upper eyelid blepharoplasty with a lateral pretrichial brow lift has emerged as a more comprehensive approach for achieving optimal outcomes^4,5.

The lateral brow lift is a valuable addition to upper blepharoplasty, as it enhances the aesthetic result by lifting the lateral brow, which can dramatically improve the appearance of the upper face^6,7. Numerous techniques have been developed for brow lifting, including coronal, endoscopic, direct, pretrichial, and mid-forehead lifts, each tailored to specific patient needs and anatomical considerations^8–10.

Achieving aesthetic harmony in the upper face requires careful assessment of both the brow and upper eyelid as they function dynamically. Eyebrow ptosis can exacerbate the appearance of excess upper eyelid skin, leading to dissatisfaction with upper blepharoplasty alone. By addressing both structures simultaneously, this combination approach ensures more stable and satisfactory patient results^5,11.

This study aims to present my experience with a combined approach using the lateral temporal subcutaneous brow lift (LTSBL) along with upper blepharoplasty. The combined procedure enables the elevation of the lateral brow and the correction of excess upper eyelid skin, resulting in a more youthful and balanced periorbital contour.

Materials and methods

Ethical approval

Ethical approval

for this study was obtained from Istanbul Aydın University (Approval No: 2023/15, dated 29.11.2023). The study adhered to the guidelines outlined in the Declaration of Helsinki, and informed consent was obtained from all patients before their inclusion in the study.

Patient selection

This retrospective study included 28 patients who underwent combined lateral temporal subcutaneous brow lift (LTSBL) and upper blepharoplasty. Patients were collected from Istanbul Aydın University VM Medical Park Florya between January 2023 and September 2024. Inclusion criteria required patients to have mild to moderate lateral eyebrow ptosis and redundant upper eyelid skin. Exclusion criteria included significant medial brow ptosis, active infections, smoking, or poor healing tendencies.

Preoperative evaluation

Patients underwent a comprehensive evaluation focusing on the periorbital region. The position of the eyebrows relative to the bony supraorbital rim was measured, with the ideal position for female patients being 1 cm above the rim and for male patients, at or just above the rim. Manual brow elevation was demonstrated to the patient, and preferences were noted to tailor the surgical approach accordingly. The degree of brow ptosis was assessed using Westmore’s ideal eyebrow measurements, widely recognized for evaluating eyebrow aesthetics and positioning. Key anatomical landmarks were used, including the A-B, A-C, B-C, and D-E lines, as described by Westmore^12,13. These measurements were analyzed to determine the degree of ptosis preoperatively and to evaluate postoperative improvement. This approach ensures consistency and reliability in assessing brow ptosis. Additional references include Martin et al.⁴ and Yalçınkaya et al.¹³, who have utilized similar methodologies in aesthetic brow evaluation.

Statistical analysis

Data were analyzed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY). Continuous variables were expressed as mean ± standard deviation (SD). The Shapiro–Wilk test was used to assess the normality of the data. For normally distributed paired measurements, preoperative and postoperative comparisons were performed using the paired sample t-test. Non-parametric data were evaluated using the Wilcoxon signed-rank test.To quantify the magnitude of the surgical effect, Cohen’s d was calculated for key measurements, with values greater than 0.8 interpreted as indicating large effect sizes. Changes in eyebrow position were further visualized with patient-level line plots and violin plots to assess distributional shifts and individual variability. A significance threshold of p < 0.05 was considered statistically significant.

Surgical technique

Lateral temporal subcutaneous brow lift (LTSBL)

The procedure begins with marking a 4–5 cm incision along the hairline, typically extending laterally from above the mid-pupillary line to the temporal scalp. Local anesthesia with epinephrine is infiltrated to minimize bleeding and facilitate dissection. The procedure begins with marking a 4–5 cm incision along the hairline. The incision begins approximately 1 cm posterior to the hairline, located lateral to the mid-pupillary vertical line, and extends toward the temporal scalp. The mid-pupillary line serves as a reference to align the incision with the central axis of the eyebrow, ensuring precise lifting of the lateral brow. During the procedure, this alignment facilitates symmetry between the lateral and medial brow regions. Additional illustrative references are provided in Figs. 1 and 2. Once the incision is made, dissection is carried through the subcutaneous plane, just above the frontalis muscle. In detail, after marking the incision site, a 4–5 cm incision is made along the pretrichial temporal hairline. Subcutaneous dissection is performed in the lateral portion of the pretrichial area, limited to the region extending to the lateral canthus and the lateral end of the brow. Care is taken to avoid extending the dissection medially or inferiorly beyond these boundaries, thereby minimizing unnecessary undermining and preserving surrounding structures. This focused approach ensures precise lateral brow elevation while maintaining tissue stability and reducing the risk of complications. The skin flap is elevated superiorly, and the lateral brow is repositioned (Figs. 1 and 2).

Fig. 1.

Sequential Surgical Steps of Lateral Temporal Brow Lift (LTBL) and Upper Blepharoplasty (Patient 1). Preoperative Planning (Anterior View): Anterior view of the patient’s eyes, eyelids, and eyebrows preoperatively. Symmetry and anatomical landmarks are marked, ensuring alignment with the patient’s aesthetic goals and surgical plan. Preoperative Planning (Lateral View): The right lateral view shows detailed upper eyelid and lateral brow markings. The planned incision lines and lifting zones are drawn based on patient-specific anatomy and desired elevation. Post-Lateral Brow Lift (Anterior View): Anterior view after completing the lateral brow lift but before performing the upper blepharoplasty. This step highlights the immediate effect of brow elevation. Skin Excision and Elevation (Lateral View): Lateral view showing the precise area of skin excision (shaded zone) for upper blepharoplasty. The blue arrows indicate the direction of subcutaneous elevation achieved during the lateral brow lift. Immediate Postoperative Outcome (Anterior View): Anterior view immediately following the combined lateral brow lift and upper blepharoplasty. The symmetry and alignment of the brows and eyelids demonstrate the surgical result. Immediate Postoperative Outcome (Lateral View): Lateral view of the right side after the procedure. The black arrows indicate the elevated position of the brow, showcasing the improved contour and symmetry.

Fig. 2.

Sequential Steps of Lateral Temporal Brow Lift (LTBL) (Patient 2): Left Lateral View Demonstrating Skin Excision, Subcutaneous Elevation, and Immediate Pre- and Postoperative Results Prior to Blepharoplasty. Pretrichial Incision and Skin Removal: The pretrichial incision is marked and made along the planned surgical site. Excess skin is excised, demonstrating the removal area essential for brow elevation. Skin Removed, Subcutaneous Plane Exposed: The subcutaneous plane is exposed post-excision, highlighting the layer targeted for elevation and repositioning to achieve optimal lateral brow lifting. Subcutaneous Skin Elevation : The surgical instrument is inserted along the subcutaneous plane, as indicated by black dotted lines. Elevation progresses toward the lateral canthus, ensuring controlled and precise dissection. Subcutaneous Skin Elevation : Further subcutaneous elevation along the same plane, visualizing the extended reach of dissection to achieve the desired lift. Black dotted lines trace the path of the surgical instrument under the skin. Immediate Preoperative View: The lateral brow is shown preoperatively, highlighting the position of the eyebrow and surrounding anatomy before the procedure. Immediate Postoperative View: Immediate postoperative results demonstrating the elevated lateral brow. The black arrow marks the improved eyebrow position, emphasizing the surgical outcomes of LTBL.

The brow position is adjusted based on intraoperative assessment. After determining the ideal elevation, an elliptical portion of excess skin is excised. The subcutaneous tissue is sutured using deep 4 − 0 PDO sutures to secure the flap in its new position. The incision is then closed with 5 − 0 nylon sutures. Slight overcorrection is applied to compensate for expected postoperative brow descent. The area is dressed with light gauze, and the patient wears an elastic bandage for 24 h postoperatively.

Upper blepharoplasty

Following the brow lift, an upper blepharoplasty is performed. An elliptical incision is made along the marked upper eyelid crease. The incision is extended through the skin and orbicularis oculi muscle to expose the orbital septum. In cases of significant fat prolapse, excess fat pads are carefully excised. The redundant skin and muscles are then removed to tighten the upper lid.

The incision is closed using 6 − 0 nylon sutures, ensuring the eyelid maintains a natural contour. Postoperative instructions include applying cold compresses and limiting eye movement to reduce swelling and promote proper healing.

Data collection and analysis

Preoperative and postoperative photographs were obtained and analyzed. Postoperative assessments were conducted at an average of 11 ± 2 months (range: 3–13 months) to evaluate the stability of brow position over time. Before and after surgery, brow position was measured using Westmore’s ideal eyebrow measurements. According to Westmore’s ideal eyebrow shape and positioning guidelines, the eyebrow is evaluated using key anatomical landmarks to achieve a balanced and harmonious appearance. This approach is often employed to achieve consistent results in aesthetic and reconstructive surgeries^12,13.

• Medial Brow Position (A-B Line):

• The medial part of the eyebrow should align with a vertical line from the outer edge of the nostril to the inner canthus. This distance (A-B) typically measures 25–30 mm, ensuring the eyebrow begins at an anatomically correct point for facial symmetry.

• Lateral Brow Position (A-C Line):

• The lateral brow should end along an oblique line drawn from the outer nostril through the lateral canthus. This measurement (A-C) generally falls between 50 and 60 mm, forming the outer boundary of the brow and contributing to its horizontal balance.

• Horizontal Alignment (B-C Line):

• Both the medial and lateral ends of the brow should approximately align horizontally, with the distance between these points typically ranging from 45 to 55 mm, ensuring symmetry across the brow.

• The apex of the Brow (D-E Line):

• The highest point of the brow, or its apex, should be directly above the lateral limbus (outer edge of the iris), along a vertical line through the pupil. This line (D-E) typically measures 35–45 mm, positioning the brow’s arch to enhance facial aesthetics.

Patient satisfaction

At the 11 ± 2 months (3–13 months) follow-up visit, patients were shown their preoperative photographs and asked to complete a visual analog scale (VAS) questionnaire to assess their satisfaction with the surgical results (Figs. 3 and 4).

Fig. 3.

Postoperative (Top) and Preoperative (Bottom) Results of Lateral Temporal Brow Lift (Patient 1): Yellow arrows and dotted lines highlight lateral brow elevation, and white arrows demonstrate overall improvement in brow positioning.

Fig. 4.

Postoperative (Top) and Preoperative (Bottom) Results of Lateral Temporal Brow Lift (Patient 2). Yellow arrows and dotted lines emphasize brow contour elevation, and white arrows indicate improvements in brow height and symmetry.

Results

Twenty-eight female patients, with a mean age of 47 years (SD ± 6.3; range 35–61), underwent lateral temporal subcutaneous brow lift (LTSBL) combined with upper blepharoplasty. Each patient was evaluated preoperatively and postoperatively with follow-up using Westmore’s ideal eyebrow measurements to assess changes in brow positioning.

Surgical outcomes

The surgical results demonstrated significant improvements in key eyebrow measurements (Table 1) :

Table 1.

Eyebrow position changes and effect Sizes.

Measurement	Preoperative Mean ± SD (mm)	Postoperative Mean ± SD (mm)	Change Percentage (%)	P-Value	Effect Size (Cohen’s d)
A-B (Medial Brow Position)	30.0 ± 3.5	30.0 ± 3.5	0	N/A	N/A
A-C (Lateral Brow Position)	46.0 ± 4.6	71.0 ± 5.1	50	0.02	5.31
B-C (Horizontal Alignment)	50.0 ± 3.6	62.5 ± 4.5	25	0.04	3.09
D-E (Apex of Brow)	35.0 ± 5.6	50.75 ± 4.5	45	0.04	3.47

• A-B Line (Medial Brow Position): The A-B line, which remained stable postoperatively, showed no significant change, with both preoperative and postoperative values at 30 mm (SD ± 3.5) (p-value = N/A).

• A-C Line (Lateral Brow Position): The A-C line, which measures lateral brow position, demonstrated a 50% improvement, increasing from 46 mm (SD ± 4.6) preoperatively to 71 mm (SD ± 5.1) postoperatively (p = 0.02). This increase was statistically significant, indicating effective lateral brow lifting.

• B-C Line (Horizontal Alignment): The horizontal alignment of the brow showed a 25% improvement, increasing from 50 mm (SD ± 3.6) to 62.5 mm (SD ± 4.5) (p = 0.04). The change was statistically significant, contributing to the overall symmetry of the brow.

• D-E Line (Apex of the Brow): The D-E line, representing the apex of the brow, demonstrated a 45% improvement, increasing from 35 mm (SD ± 5.6) to 50.75 mm (SD ± 4.5) (p = 0.04). This change was also statistically significant, reflecting an effective elevation of the brow arch.

No cases of brow asymmetry were reported following surgery. Two patients developed minor hematomas; one was evacuated intraoperatively immediately, and the other was successfully treated postoperatively in the office the next day. The mean total operative time for the combined procedure was 65 ± 20 min. No major complications were observed. Postoperative recovery was limited to transient edema and ecchymosis, which resolved within 7–10 days. Mild discomfort related to dressing pressure and slight pain were reported on the first postoperative day, which was effectively managed with paracetamol and ibuprofen.

Patient satisfaction (VAS Scores)

Patient satisfaction was assessed at an average follow-up of 11 ± 2 months (3–13 months) using a visual analog scale (VAS) questionnaire. All patients reported satisfaction with their results. Patients were shown their preoperative photographs and asked to rate their satisfaction. All patients reported satisfaction with their results. Specifically, 89% of patients expressed satisfaction with the outcomes, and 11% reported being highly satisfied with their postoperative appearance (Figs. 3 and 4).

As visualized in Fig. 5, both group-level and patient-level analyses revealed statistically significant improvements in lateral brow position (A–C line) and apex elevation (D–E line) following the combined procedure. The A–C line increased from a mean of 46.0 ± 4.6 mm preoperatively to 71.0 ± 5.1 mm postoperatively (p = 0.02, Cohen’s d = 5.31), while the D–E line improved from 35.0 ± 5.6 mm to 50.75 ± 4.5 mm (p = 0.04, Cohen’s d = 3.47). The line plots (b, c) demonstrate a consistent upward trajectory across nearly all individual patients, and the violin plots (d, e) show a narrower and higher distribution postoperatively, indicating more clustered and improved aesthetic outcomes. The bar chart (a) highlights these collective gains, particularly in lateral and apex measurements, affirming the reliability and aesthetic impact of this combined lateral temporal brow lift and upper blepharoplasty approach.

Fig. 5.

Advanced Statistical Visualization of Eyebrow Positioning Outcomes. (a) Pre- vs. Postoperative Eyebrow Measurements (Group Mean). (b) Patient-Level Change: A-C Line (Lateral Brow Position). (c) Patient-Level Change: D-E Line (Brow Apex Position). (d) Violin Plot: A-C Line (Lateral Brow Position). (e) Violin Plot: D-E Line (Brow Apex Position).

Discussion

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 ptosis^14,15. 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 blepharoplasty^5,9,16. 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 descent^14,15,17. 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 approaches^19–21. 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 outcomes​^22,23,24.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 rate^17,25. 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 cases^17,25. 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 concerns^29–31. 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 complex^32–34. 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 assessment^2,3,6,7. 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 patterns^35–37.

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 Chaps^38–43.. 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.

Strengths, limitations, and future directions

The primary strength of our approach lies in its ability to deliver effective and anatomically targeted periorbital rejuvenation through a minimally invasive technique with reduced operative time and accelerated recovery. Building on foundational work by Lyon and Savetsky, the lateral temporal subcutaneous brow lift has proven to be a simple yet powerful strategy for correcting lateral brow ptosis in selected patients^5,17,25. Our technique is particularly beneficial for individuals with mild to moderate brow descent, offering reproducible aesthetic improvements with low complication rates. Notably, the concurrent performance of upper blepharoplasty enhances both functional and cosmetic outcomes by harmonizing the brow position and upper eyelid contour. However, this method may not be optimal for patients with severe brow ptosis or significant frontalis compensation, where more extensive surgical techniques may be warranted. Another limitation is the follow-up period, which ranged from 3 to 13 months (mean: 11 ± 2 months). While consistent with standard mid-term evaluation parameters for soft tissue lifting procedures, this duration may not fully capture mid-term changes in brow position, skin elasticity, or scar evolution. Ongoing longitudinal follow-up is underway to assess the durability and potential recurrence patterns over an extended timeline.

Future studies should incorporate larger patient cohorts, objective grading systems, and patient-reported outcome measures (PROMs) to enhance the understanding of the disease. Additionally, exploring adjunctive treatments such as neuromodulators or fat grafting may further refine outcomes and individualize care. The integration of artificial intelligence–assisted facial analysis could also enhance preoperative planning and postoperative evaluation in future protocols.

Conclusion

The combination of lateral temporal subcutaneous brow lift (LTSBL) and upper blepharoplasty offers a highly effective and minimally invasive solution for addressing lateral and upper eyelid ptosis. This approach enhances aesthetic outcomes and ensures long-lasting patient satisfaction with minimal complications. By treating the brow and eyelid as a dynamic functional unit, this technique provides a more comprehensive and harmonious rejuvenation of the upper face.

Ethical approval

Ethical approval for this study was obtained from Istanbul Aydın University (Approval No: 2023/15, dated 29.11.2023). The study adhered to the guidelines outlined in the Declaration of Helsinki, and informed consent was obtained from all patients prior to their inclusion in the study.

Author contributions

Conception: ES, AA; Design: ES, AA; Supervision: ES, AA; Fundings: None; Materials: ES, AA; Data Collection and/or Processing: ES, AA; Analysis and/or Interpretation: AA; Literature: ES, AA; Review: ES, AA; Writing: AA, ES; Critical Review: ES, AA.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.