Browpexy and direct brow lift

What it treats

• Excess upper eyelid skin is often partly caused by low brows; blepharoplasty alone does not correct this and can make the brow sag further (PMID 6824482).
• Meta-analysis, 17 studies: brow height fell after upper eyelid surgery (mean difference 1.45 mm); simple blepharoplasty lowered the brow 0.67 mm; skin removal itself did not change brow height (PMID 36890345).
• 30 patients having blepharoplasty alone: brows fell a mean 1.7 mm (PMID 25853507).
• 70 patients after upper blepharoplasty: brow position unchanged in 65.8% and lower in 34.2%, including 58.3% of men and 29.3% of women (PMID 27308242).
• Functional brow surgery is reserved for severe asymmetry or visual field loss; the usual options are browpexy through a blepharoplasty, direct brow lift and midforehead lift (PMID 35738352).

Brow ptosis assessment

• McKinney 1991: normal distance from midpupil to the top of the brow about 2.5 cm; less than that suggests a forehead lift may help (PMID 2035363).
• 222 men: the male brow sits along the orbital rim with a flat contour; brow ptosis in 7.4%; mean brow position did not change with age; deep-set eyes had lower brows (PMID 16052142).
• 244 people: with age the brow moves up and women's brow shape comes to resemble men's; lifting can then look surprised or older (PMID 30819648).
• 171 patients with visual field testing: missed points in the mid-temporal field predicted selection for combined eyelid and brow surgery (odds ratio 1.38 per point); combined repair had lower odds of revision (0.31) (PMID 42697227).
• Patients with heavy brows, marked ptosis, medial more than lateral ptosis, or prior facial palsy may be poor candidates for internal browpexy (PMID 31261340).

How it is done

Internal (transblepharoplasty) browpexy

• Sokol and Sokol reported transblepharoplasty brow suspension in 1982 (PMID 7079400).
• Zarem technique: the upper cut edge of the orbicularis muscle is sutured to the arcus marginalis at the orbital rim with 2 to 4 absorbable 4-0 sutures (PMID 19336182); 208 patients (PMID 9326790).
• Quantitated internal suture browpexy places the suture at measured points for consistent, symmetric results (PMID 25853507).
• Partial orbicularis resection added ("tuck and rise"), 22 patients: brow tail up 2.42 mm (PMID 27429226).
• Periosteal pexy, orbicularis fixed to the arcus marginalis, lateral orbicularis removal and retaining ligament release, 50 patients in a phase 2 trial: brow tail up 3.45 mm at 1 month and 3.33 mm at 3 months (PMID 37592144).

External browpexy

• Transcutaneous variant through a small incision at the brow, 28 patients (18 men); 1 patient noted a subtle scar (PMID 22410656).

Direct brow lift

• An ellipse of skin and fat is removed within or just above the brow hairs; it can be limited to the lateral brow, or placed in the midforehead or eyelid crease (PMID 35710156).
• Scar methods from 10 publications (about 900 patients): 20-45 degree bevel that spares brow follicles, 1-2 cm undermining, suspension to the periosteum, and layered closure (PMID 42355613).
• Deep plane direct lift with orbicularis transection and suspension, 45 patients (PMID 40064642).
• Repositioning the retro-orbicularis oculi fat (ROOF) during a direct lift, 9 men: brow-to-corneal-reflex distance 5.17 mm before and 11.76 mm after (PMID 41738837).
• Facial palsy modification, 23 patients (24 lifts): W-plasty style incision, counter-beveled edges, skin removed in the subcutaneous plane with minimal fat removal, browpexy to the periosteum (PMID 32852375).

Midforehead lift

• Skin removed through a forehead crease incision (PMID 2035363); one series used it for all brow ptosis, 72 patients, 52 of them women (PMID 2914087).
• 21 patients: mean rating 3.60 of 4 from surgeons and laypersons (PMID 21931089).

Results and evidence

Browpexy

• 98 patients at 4-5 months: internal browpexy raised the lateral/central brow 2.29/1.47 mm, external 2.97/1.90 mm; no significant difference (PMID 28267396).
• 70 eyelids at 24 months: internal 2.10 mm central and 3.19 mm lateral; external 2.66 and 3.03 mm; blepharoplasty alone 0.48 and 0.55 mm (PMID 32049161).
• 68 patients at 3 months: external browpexy lifted more than internal; skin excision alone lowered the whole brow (PMID 36847688).
• 278 patients (517 eyelids): mean lateral elevation 2.54 mm in the 98 measured (PMID 31261340).
• Quantitated suture browpexy prevented descent and raised the lateral brow 1.3 mm (right) and 0.9 mm (left); Endotine forehead lift gave 4.0 and 3.5 mm (PMID 25853507).
• Randomized trial, 62 women: browpexy increased lateral brow-eyelid volume 0.85 mL against 0.19 mL with blepharoplasty alone (PMID 34166117).
• Randomized trial, 32 women: internal browpexy raised the lateral brow from 15.09 to 17.43 mm at 6 months; temporal brow lift did not change it (PMID 28975711).
• 97 transpalpebral browpexies: 95 had optimal elevation; 2 revisions (PMID 29098368).

Durability

• Up to 5 years: brows fell after transpalpebral browpexy (29 patients) and stayed up after endoscopic forehead lift (56) (PMID 23190834).
• 1 year, 36 patients with blepharoplasty: direct (excisional) browpexy lost 1.2 mm at the pupil and 2.1 mm at the lateral canthus; transpalpebral lift lost 0.7 mm at the pupil (PMID 36669433).

Direct brow lift

• 50 men with blepharoplasty: significant elevation in 98% at 12 months; visible scar in 2 (PMID 27274124).
• Facial palsy, 24 lifts: brow height rated excellent in 71% and good in 14%; no forehead paresthesia or brow hair loss (PMID 32852375).
• Deep plane direct lift: symmetric brows in 97.8% (PMID 40064642).
• 1,060 patients of one surgeon: women mostly had endoscopic lifts (83.8%), then direct lifts (9.3%); men mostly had direct lifts (63.1%), then endoscopic lifts (16.5%) (PMID 40016580).

Risks and complications

• Systematic review, 76 studies: direct brow lifts had the highest numbness rate of all brow lift types, 5.5% (PMID 30534495).
• Forehead numbness after brow lift has been reported as high as 40.7%; in 66 orbits the supraorbital notch or foramen lay 17.62 to 32.35 mm from the midline, with a foramen in 33% (PMID 23299811).
• Direct lift: a visible scar, granulomas from braided absorbable sutures, and the brow dropping again; transblepharoplasty lift: less lift than desired and skin dimpling from sutures (PMID 17182403).
• 278 patients with internal browpexy: 6 early infections, all resolved; 3 later direct brow lifts; 3 later repairs of unrecognized eyelid ptosis (PMID 31261340).
• CosmetAssure database, 6,126 patients: brow lift with blepharoplasty had a major complication rate of 0.4%, the same as blepharoplasty alone; hematoma was the most common (PMID 29369102).

Recovery

• Sensory changes after a deep plane direct lift were temporary and resolved in 3 to 5 months (PMID 40064642).
• Patches of reduced forehead sensation after a direct lift normally recover within a few months (PMID 17182403).
• Direct lift scars: postoperative laser and perioperative neuromodulator improved appearance; evidence for silicone gel was inconclusive (PMID 42355613).
• External browpexy: all 28 patients pleased at a mean 6 months (PMID 22410656).
• Skin excision below the brow (subbrow blepharoplasty) as an alternative, 33 patients: scarring rare at 6 months, no sensory loss (PMID 41240177).

Combined procedures

• McKinney 1991 lists a previous facelift among three indications for forehead lift and reserves the direct brow lift for minimal ptosis, asymmetry, or patients who want a minimal procedure (PMID 2035363).
• Brennan 1982 analyzed midforehead glabellaplasty, browpexy and facelift together as parts of full-face rejuvenation (PMID 7138368).
• A PubMed search on 2026-09-30 for browpexy or direct brow lift with facelift terms in title or abstract returned 5 records, none a combined-procedure outcome series; two are the criteria and technique papers above (PMID 2035363, PMID 7138368).
• Combined-procedure safety data come from blepharoplasty: adding a brow lift did not raise major complications (PMID 29369102).

Current questions

• Internal against external browpexy: equal lift in two studies (PMID 28267396, PMID 32049161); more lift with external in one (PMID 36847688).
• Durability: measured descent at 1 year (PMID 36669433) and up to 5 years (PMID 23190834) after transpalpebral techniques.
• Volume: browpexy may add fullness to the lateral brow and eyelid rather than height alone (PMID 34166117).
• Direct lift refinements 2025-2026: scar-minimizing closure (PMID 42355613), ROOF repositioning (PMID 41738837), deep plane lift (PMID 40064642).
• Visual field criteria for adding a brow procedure to eyelid surgery (PMID 42697227).
• Sex-based technique choice (PMID 40016580).
• Search string used: (browpexy[tiab] OR direct brow lift[tiab] OR direct browlift[tiab] OR direct browplasty[tiab] OR direct brow-lift[tiab]) AND (facelift[tiab] OR face lift[tiab] OR rhytidectomy[tiab] OR face-lift[tiab]) (https://pubmed.ncbi.nlm.nih.gov/).

Terms

• Brow ptosis: a brow lower than its normal position, with cosmetic or visual effects (PMID 35738352).
• Dermatochalasis: excess upper eyelid skin (PMID 28975711).
• Internal browpexy: suturing the brow tissue to the bone or rim through the eyelid incision (PMID 9326790).
• External browpexy: the same suspension placed through a small incision at the brow (PMID 22410656).
• Arcus marginalis: the thickened tissue along the orbital rim used as an anchor (PMID 19336182).
• Orbicularis oculi: the ring muscle around the eye; its upper edge is sutured in browpexy (PMID 19336182).
• ROOF: retro-orbicularis oculi fat, the fat pad under the brow (PMID 41738837).
• Direct brow lift: removal of skin just above the brow hairs (PMID 35710156).
• Midforehead lift: skin removal through a forehead crease (PMID 2914087).
• Supraorbital notch or foramen: exit point of the forehead sensory nerve on the orbital rim (PMID 23299811).

Papers