Aesth Plast Surg

https://doi.org/10.1007/s00266-019-01486-3

I N N OV A T I V E T E C H N I QU E S FACIAL SURGERY

Gliding Brow Lift (GBL): A New Concept

Fausto Viterbo1 • André Auersvald2 • T. Gerald O’Daniel3

Received: 25 April 2019 / Accepted: 8 August 2019

Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2019

Abstract Results The average follow-up period was 17 months.

Background Creating the ideal aesthetic eyebrow shape Adequate brow repositioning and/or reshaping was
and position is an important goal in facial rejuvenation. achieved in 118 patients. Six patients had bilateral or
One challenge of an eyebrow lift is to find a pre- unilateral recurrence of ptosis. Of these patients with
dictable procedure that balances the advantages and dis- recurrence, four patients had the same procedure re-per-
advantages of the available strategies. The gliding brow formed within 1 month postoperatively with successful
lifting (GBL) is a technique that provides minimal inci- repositioning and/or reshaping of their brow. There was no
sions, an effective and stable eyebrow lift, and offers the incidence of hematoma, seroma, infection, permanent
advantage of precise reshaping of the eyebrow. sensory changes, motor dysfunction, skin flap necrosis or
Methods In a retrospective review, 124 patients, who alopecia.
underwent GBL technique from November 2015 through Conclusion The ‘‘gliding brow lifting’’ (GBL), which
April 2016, were evaluated. With minimal incisions and combines subcutaneous frontal undermining with minimal
tumescent infiltration, the subcutaneous plane of the fore- incisions, elevation and reshaping of eyebrow and use of a
head, eyebrows and temporal face is undermined releasing temporary cutaneous fixation with hemostatic net (Net),
the skin from the underlying frontalis muscle, orbicularis allows effective, long-lasting results with low rates of
oculi muscle, corrugator muscle and temporal parietal complications and satisfactory results.
fascia. Fixation of the repositioned and reshaped eyebrow Level of Evidence IV This journal requires that authors
is achieved with the use of a hemostatic net for temporary assign a level of evidence to each article. For a full
cutaneous fixation. description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Electronic supplementary material The online version of this
article (https://doi.org/10.1007/s00266-019-01486-3) contains sup-
plementary material, which is available to authorized users. Keywords Frontal rejuvenation
Brow lifting

Hemostatic net
Video endoscopy
Skin undermining

& Fausto Viterbo
faustoviterbo@hotmail.com
Hemostatic net
André Auersvald
direto123@gmail.com
Introduction
T. Gerald O’Daniel
jerry.odaniel@gmail.com
With aging, there is loss of the aesthetic ideal of the upper
1
Plastic Surgery Division, São Paulo State University Júlio de third of the face with elongation of the forehead due to
Mesquita Filho, UNESP, Botucatu, Brazil descent of the eyebrows, development of horizontal and
2
Brazilian Society for Plastic Surgery, Curitiba, Brazil glabellar rhytids. It is suggested that aging determines
3
Department of Plastic Surgery, University of Louisville, eyebrow ptosis in most situations [1].
Louisville, KY, USA

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Numerous surgical techniques have been described for Method

improvement in eyebrow shape and correction of position
in order to rejuvenate the upper third of the face. Each In a retrospective review, the records of 124 patients who
technique has its own set of advantages and disadvantages. underwent GBL technique from November 2015 through
These procedures have been classified as open (directly April 2016 were evaluated. Evaluation of the outcomes was
visualized anatomy) or endoscopic (indirect visualization based on the surgeon’s assessment of the preoperative and
of anatomy by endoscopy) techniques. postoperative photographs. Patients’ satisfaction was
The open approaches include an anterior hairline or evaluated with a simple questionnaire asking each patient
coronal incision, with detachment of the forehead soft their level of satisfaction.
tissue in the subgaleal [2, 3], subperiosteal [4, 5] or sub- General anesthesia or local anesthesia with sedation was
cutaneous [6] planes allowing repositioning with excision used based on the patient’s request.
of skin or scalp, effectively elevating the ptotic eyebrow. The procedure begins with tumescent anesthetic infil-
The open approach has been associated with a higher tration into the subcutaneous plane in the area where sub-
efficacy in achieving the goals of brow rejuvenation with cutaneous dissection is to be carried out. This includes the
fewer issues related to relapse and asymmetries [7]. But the frontal region up to one centimeter below the eyebrows and
indications for this approach have been greatly restricted periorbital region from the temporal region laterally and
due to the scarring, alopecia, changes in sensitivity and inferiorly to the lower border of the zygomatic arch.
even necrosis of the scalp [8]. Access to the subcutaneous plane is achieved via two
Direct brow lift with skin resection at some position 3-mm vertical incisions, made bilaterally in the scalp at the
above the eyebrow is effective [9, 10], but the scars are anterior hairline and in the frontal–temporal area (Fig. 1a).
often visible and uncomfortable for the patient [11]. In In some cases is indicated the elevation of all eyebrows and
addition, it is difficult to elevate the tail of the brow into the all the frontal areas which are dissected (Fig. 1b). In longer
optimal position due to limits of the lateral scar at the tail foreheads when central brow elevation is desired, a third
of the brow. incision in the central region is performed to allow easier
The emergence of the endoscopic technique for forehead dissection. The detachment should include the frontal
and eyebrow rejuvenation brought great hope that there region that is to be elevated, extending as medially to the
would be a reduction in the complications experienced with desire point of brow elevation and up to 5 mm below the
the open techniques [12–14]. However, the learning curve eyebrows, continuing laterally to include the periorbital
is considerably long, and complications related to alopecia, region inferiorly to lower border of the zygomatic arch. In
sensorial nerves [8] and the relapses rate [15] have caused rare cases, the patients need elevation only in the middle
many professionals to abandon this technique. area (Fig. 1c).
Suspension threads have been suggested because of its Cylindrical and rhombic dissectors are introduced
technical simplicity. But durability issues with high rates of sequentially, initially using the straight cylindrical dissec-
recurrence of eyebrow ptosis and high costs of the threads tor, followed by the semi-curved dissector and then ‘‘L’’-
have limited its wide use [16–18]. shaped dissector. In the very convex forehead, the curved
Another option to brow elevation is the trans-palpebral detacher is used. These instruments were developed for this
browpexy [19–21]. This approach is performed in the technique by Viterbo (Fig. 2) and are manufactured by
subperiosteal or subgaleal plane. It has not been widely Faga Medical (São Paulo, Brazil).
accepted based on a survey by Elkwood [7]. The straight dissector is introduced into the subcuta-
Searching for a technique that could provide effective neous plane (Fig. 3) with the tip of the instrument moving
and stable eyebrow lifting and eyebrow reshaping, with in a superior to inferior direction, always pointing toward
minimal incisions that avoided the considerable compli- the skin. Once the vertical tunnel detachment has been
cations of the current techniques, led us to develop the achieved, lateralization movements are made with the
gliding brow lifting (GBL), previously published in a short curve detacher, until the skin is completely released from
introductory communication [22]. the underlying frontalis muscle (Video 1). The non-domi-
nant hand is extended over the skin so that the detachment
is made in the subcutaneous plane with the same depth,
Objective avoiding undulations or irregularities (Fig. 4). It ends with
the ‘‘L’’ detacher in the ‘‘pushing’’ mode releasing any
The objective of this publication is to introduce in detail a remaining fibrous bands. This detacher eventually may be
new technique to elevate and reshape the eyebrow. used in the ‘‘pulling’’ mode to release stronger fibrous
fibers.

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Fig. 1 Subcutaneous dissection includes the frontal region up to one 3-mm vertical incisions, made bilaterally in the scalp at the anterior
centimeter below the eyebrows, and the periorbital region from the hairline, in the frontal–temporal area (a). In some cases when
temporal region laterally and inferiorly to the lower border of the indicated, the entire eyebrow and all the frontal areas are elevated (b).
zygomatic arch. Access to the subcutaneous plane is achieved via two In rare cases, a patient may need elevation of the mid-forehead (c)

fixed using one or two horizontal single horizontal stitches

(Fig. 6). The elevation should include a 20% of overcor-
rection above the desired position.
After placement of the two horizontal fixation sutures,
two vertical continuous running sutures described as
hemostatic net (Net) are applied at both maximum desir-
able elevation points. After exhaustive checking for sym-
metry, two similar sutures are applied in the lateral
periorbital region. The skin is moved superiorly, and fix-
ation is achieved with continued placement of sutures
creating a long column of the Net. Similarly, a single hook
is used to guide the traction while placing the Net (Fig. 7).
Complete fixation is achieved using a continuous run-
ning suture described as hemostatic net (Net). The Net is
applied in vertical columns with nylon 5-0 triangular,
26-mm needle (15). A 4-0 nylon is used for thicker skin to
assure adequate fixation of the skin to the underlying
frontalis muscle (Fig. 8 and video 2).
The Net has two functions: first to create fixation with
traction sutures to the underling tissues and second to
obliterate the subcutaneous space to prevent hematoma and
seroma formation. The needle passage follows a uniform
pattern, passing perpendicular to the skin, encompassing
skin and underlying muscle, and emerging 0.5–1.0 cm
from the previous entry point. The traction sutures are used
Fig. 2 Viterbo’s dissectors in the eyebrow and in the periorbital area and are 25 mm in
height above the brow. When we want to elevate the entire
Care must be taken to assure that a subcutaneous dis- eyebrow, we detach entire eyebrow and central forehead
section plane always maintained. This subcutaneous and put one more traction column medially. The traction
detachment with blunt detachers will reduce the risk of sutures will have the distance between loops at 5 mm.
injury to the temporal frontal branch of the facial nerve and Above the traction sutures, we increase the distance
the supraorbital nerve. between loops to 10 mm to prevent hematoma and seroma
Once the detachment is completed, it is possible to formation.
mobilize the skin of the forehead superiorly, in sliding Additional columns are placed over all the detached
movement, bringing with it the eyebrow and periorbital areas to prevent hematoma formation and redistribute the
skin to its desired position. The skin is repositioned by skin.
placing one or two single hooks in the skin above the The superior traction of the skin will result in a skin
eyebrow (Fig. 5). The new eyebrow shape and position is redundancy in the superior aspect of the forehead.

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Fig. 3 Paired 3-mm-long

incisions are made in the
frontotemporal scalp (a).
Dissector is introduced into the
subcutaneous plane (b)

Fig. 4 Dissector is introduced

into the subcutaneous plane and
with back and forth movements,
and then with lateralization
movements, releases the skin
from the undermining tissues
(b). Non-dominant hand is
placed over the skin so that the
detachment is made in the
subcutaneous plane at a
consistent depth to avoid
undulations and irregularities
(a)

Fig. 5 One or two small hooks

are placed on the skin
(a) superiorly pulling upward
the eyebrow to its new position
(b)

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Fig. 6 New eyebrow shape and position is fixed using one or two
horizontal single horizontal stitches

Fig. 8 In addition to the vertical columns used to reposition and

Accommodation of this redundant skin is achieved by reshape the eyebrow, next vertical columns of hemostatic net were
undermining the hair bearing scalp above the galea and applied in the periorbital region to elevate and redrape the skin
placement of the Net with 4-0 nylon to assure fixation
through this thicker tissue. Results
Elevation and the symmetry are evaluated with a ruler
passed at the peak of both eyebrows in the supine and Of the 124 patients identified to have undergone the GBL,
sitting position with the head flexed. In addition, eyebrow 114 (92%) were women and 10 (8%) were men. The
position is confirmed with intra-operative photographs. average age was 55.6 years old, ± 7.9, ranging from 35 to
Separate 2 or 3 sutures are applied just below the eye- 76. The average follow-up was 17 months, with a range of
brow to block and prevent edema from descending to the 3–35 months.
upper lids (Fig. 9a). Postoperative recovery was uneventful in all cases, with
There were no dressings or drains used in the postop- all patients experiencing moderate edema and mild pain.
erative period. There was no incidence of necrosis of the skin flap,
Patients can be discharged the same day, though eval- alopecia or infection. During the initial postoperative per-
uation of the skin for adequate perfusion should be per- iod, there was diminished movement of the forehead due to
formed prior to discharge to assure these is not excess on the detachment and swelling.
the Net sutures. There were no incidences of permanent paralysis or
After 48 h, Net sutures are removed (Fig. 9b) and entry asymmetrical movement observed in this series.
site incision sutures are removed after 8 days. Extensive cutaneous detachment, as expected, leads to
an interruption of sensory innervation, causing transient
paresthesia for approximately 30–90 days in the detached
areas and the scalp.

Fig. 7 Skin is fixed in the new

position using a running suture
described as the hemostatic net
(a). Suture is passed through the
skin, capturing the deep tissues
before exiting the skin (b)

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Fig. 9 a Net after 24 h. Some

horizontal single stitches are
placed under the brow in the
orbital roof to block the descent
of edema. b After Net removal
after 48 h of the surgery. Patient
was submitted to GBL and
cervico-facial lifting

The brow elevation was evident in all cases in the Discussion

immediate postoperative period as evaluated by the oper-
ating surgeons’ review of before and after photographs. The criteria of the ideal brow lifting procedure are one that
After the initial visit in the postoperative period, six achieves an ideal brow position and shape, that is long
patients (5%) had early bilateral or unilateral recurrence. lasting and that can be achieved with less expense and less
All of these relapses occurred early in our experience as we complications and with a short recovery time. The GBL is
developed the technique, and it was determined that inad- a novel technique that meets these criteria by combining
equate release inferiorly below the eyebrow and laterally two innovative concepts: subcutaneous frontal detachment
along the lateral orbital attachments was responsible for the with minimal incision access and temporary cutaneous
relapse. Of the 6 patients with recurrence, four patients fixation with a hemostatic net.
were successfully corrected by performing a repeat GBL. The plane of dissection is subcutaneous, and this
The patient satisfaction was evaluated by a simple approach has been described extensively utilizing a variety
questionnaire 1–3 years postoperatively, asking the patient of incision sites including anterior hairline [23], temporal
about the brow elevation result. The simple questionnaire hairline [12], mid-forehead [24] direct brow lift [8] and
asked if the patient was very satisfied, satisfied, neither endoscopic [25]. The efficiency and ease of this plane of
satisfied or dissatisfied, dissatisfied or very dissatisfied dissection with low relapse rate are widely accepted. The
(Table 1). GBL is performed in this plane for these reasons. The
Figures 10, 11, 12, 13 and 14 show various patients modification of the access to minimal incisions is one of
having undergone the GBL procedure in the preoperative, the GBL’s novel additions to the open subcutaneous
early postoperative and late postoperative periods with approach.
successful eyebrow elevation and brow reshaping. The successful elevation and maintenance of the frontal
In addition to brow elevation and reshaping, we have skin and eyebrow position with the GBL are only possible
observed diminished excursion of the frontalis and corru- with the use of Net. This corresponds with our large
gator muscles and consequently decrease in frontal and experience previously acquired with the Net in other areas
glabellar wrinkles (Fig. 13). of the face by the authors. The Net can only be utilized if
the detachment is subcutaneous, allowing the skin and
eyebrow to be fixated to the underlying soft tissue with the
application of the Net. If the detachment was at the sub-
galeal or subperiosteal level, the technique would not be
possible because there won’t be soft tissue beneath the
Table 1 Chart showing patient satisfaction elevated forehead and brow tissue to allow application of
VS S NSDS DS VDS the Net.
The concept of percutaneous suture for fixation and
Number of patients 20 50 24 7 0 hemostasis was first introduced by Pontes [26] utilizing a
Percentage% 20.8 49.5 23.7 6.9 0 few individual sutures placed in the cervical region to
VS very satisfied, S satisfied, NSND not satisfied neither dissatisfied, effectively fixate skin to the deep tissues in the desired
D dissatisfied, VD very dissatisfied position.
Q square test p \ 0.001 The hemostatic net, introduced by Auersvald and
Auersvald [27], expanded on this concept of percutaneous

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Fig. 10 a and b Same patient

from Fig. 8 at the 5th post-op
day

Fig. 11 48 years old shown preoperatively and 2 years and 7 months

post-GBL, lower blepharoplasty and cervico-facial lifting. The brow
has been elevated and reshaped. a and c pre-op, b and d post-op
Fig. 12 55 years old shown preoperatively. b 2 years and 4 months
suture fixation of the skin to prevent hematoma formation, post-GBL, lower blepharoplasty and cervico-facial lifting. The brow
while reducing the need for electrocoagulation and elimi- has been elevated and reshaped. a and c pre-op, b and d post-op
nation of the use of drains and garments for pressure
dressings. The hemostatic net has been used by the authors facilitates cutaneous redraping and healing in the desired
[28] in over 1400 facelifts patients with no hematoma position. It has been observed that the redundant cervical
formation within the first 48 h. In addition, the Net

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Fig. 14 a 36 years old. b Post-op 3 years and 4 months

the lower border of the zygomatic arch at the subcutaneous

level through minimal access 3-mm incision; (2) the ele-
vation and shaping of the eyebrow by gliding the eyebrow
and forehead skin over the underlying frontalis muscle,
orbicularis muscle and temporoparietal fascia; (3) fixation
of the eyebrow, forehead skin and lateral orbital skin with
the Net to the underlying tissues at the desired position.
The GBL is differentiated from other described brow
lifting techniques due to the combination of technical ease,
low risk, the ability to precisely control the eyebrow pos-
tion and shape and low cost.
More than 70% of the patients were very satisfied or
satisfied with the GBL result after 2–3 years. This probably
is due to the maintenance of the brow shape and position
obtained in this technique.
Fig. 13 a–c 55 years old with ptosis of the entire brow, including the The GBL offers specific technical advantages in relation
medial aspect of the brow and hooding of the upper eyelids (pre-op). to endoscopic brow lifting surgery. There are significantly
d–f Same patient 19 months post-GBL and lower blepharoplasty less equipment costs with the GBL, and the learning curve
without botulinum toxin injections. There is marked improvement in is lower. The endoscopic brow lift depends on the sur-
brow position and shape with resolution of medial brow ptosis and
reduction in horizontal forehead lines. Improvement in the horizontal geons’ access to sophisticated cameras, lights sources and
frontal wrinkles is observed in many cases and is felt to be secondary specifically designed instruments, all of which come at a
to brow elevation and fixation significant expense. To facilitate the GBL, Viterbo has
developed a specific GBL kit with three instruments—
skin can be successfully repositioned to allow optimal cylindrical straight, curved and L tip dissectors, which
redistribution even in cases of no skin excision. facilitates efficiency and precision of the subcutaneous
Based on this experience utilizing the hemostatic net, detachment. The design of these instruments was inspired
the gliding brow lifting was conceived in an effort to by Luz [29] who developed cylindrical straight dissectors,
simplify brow lifting, improve the predictability of position for progressive tunneling, with 12 different diameters for
and shape and mitigate complications associated with cervico-facial lifting. The instruments make the perfor-
conventional open and endoscopic procedures. In addition, mance of the GBL skin detachment significantly simpler
the postoperative recovery was generally faster, with less with a minimal incision, particularly when compared to the
edema and bruising, probably related to the obliteration of technical expertise demanded for mastering the use of the
the area detached by the Net, not allowing the accumula- endoscopic camera and equipment.
tion of fluid behind the flap. Another advantage over the endoscopic brow lift is the
The basic principles of the GBL technique are: (1) wide absence of need for the use of absorbable devices to be
undermining of the forehead and lateral orbital region to used the achieve fixation as described by some authors

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[30]. These devices are expensive, require addition distribution of the tension within the continuous running
instrumentation and expertise to deploy and can create suture. The most appropriate suture is nylon 5-0 with cut-
foreign body reaction. ting ‘ circle, 25 or 26 mm. The skin type may also
The GBL is a procedure with acceptable risk when increase the possibility of hyperpigmentation. Darker-
compared to open and endoscopic brow lifts that pre- skinned patients will have a higher risk to develop post-
dictably produces a stable aesthetic outcome. Complica- inflammatory hyperpigmentation in the treated areas during
tions for all brow lifting techniques vary according to the the early postoperative period.
incision site and plane of dissection. Though it is excepted This post-inflammatory hyperpigmentation usually
that all brow lifting techniques have complications, the resolves between 3 and 5 months. No patients in this series
endoscopic approaches appear to have a larger number and required bleaching agents or treatment for hyperpigmen-
variety of complications when compared to the open tation. The use of bleaching creams or laser would be
approach [8]. useful in the quicker resolution of this process if one
Both the open and endoscopic techniques have in experiences post-inflammatory hyperpigmentation.
common complications that include alopecia, scarring and Disturbances in motor function from injury to the frontal
sensory changes, with endoscopic approach having in branch of the facial nerve have been reported to be highest
addition to complications related to asymmetry, relapse with coronal incision in the subperiosteal plane (6.4%) [8].
and motor nerve disturbances [31]. Alopecia (3–9%) There were instances of asymmetrical eyebrow movement
[8, 30] and unacceptable scars (2.5–9%) [8] have been in the early postoperative period that resolved within
reported for both the open and endoscopic approaches. weeks. There were no permanent motor nerve injuries in
With the GBL, the incision is 3 mm in length just inside our series.
the anterior hairline, through which all the subcutaneous Longevity of the ideal symmetrical brow position and
detachments take place. This fact makes this surgery optimal shape is an important criterion to determine the
extremely advantageous to avoid alopecia and unaccept- success of any procedure. The reoperation rate for recurrent
able scars in relation to other techniques with longer inci- asymmetry and loss of elevation has been reported most
sions. The patients in this series did not experience any often for endoscopic techniques [30]. Patients undergoing
incidences of alopecia or unacceptable scarring. GBL in this series exhibited a stable eyebrow position in
Necrosis has been reported with subcutaneous dissection 95% of the patients with the longest at 35 months. In our
plane [8]. In the GBL, an important factor is the preser- series of GBL, there were 6 patients (5%) who experienced
vation of arterial, venous and lymphatic circulation, which loss of elevation and/or asymmetries in the early postop-
consequently lowers the risk of necrosis. In the present erative period. Four of these 6 patients underwent repeat
series, there was no tissue necrosis, even in elder patients. operation in the early postoperative period. All re-opera-
We have not established the safety of doing this extensive tions were successful in elevating and shaping the brow.
subcutaneous undermining in a patient who smokes. All 6 relapses occurred early in the development of the
The biggest risk of scarring in the GBL procedure is technique, and the relapses were felt to be related to
related to the hemostatic net. To minimize this risk of inadequate periorbital subcutaneous detachment. Based on
scarring, the Net is removed 48 h postoperatively. Despite the early failures, it is to be emphasized that the success of
this relatively short period of fixation, there is sufficient this technique lies in the degree of skin surface to be
adherence of the skin to the frontalis muscle to hold the flap undermined for treatment. The frontal and temporal area
and the eyebrow in the desired position. should be completely detached, since a larger area of
It is important to observe the skin color during the detachment and fixation is more efficient than a small area
application of the Net as well as in the early postoperative of detachment, which may prevent relapse. In our series,
period. It is especially important to monitor the traction we experienced that the greater the area of mobilization,
sutures, which are applied at much closer intervals. If the especially in the periorbital region, the better the efficiency
skin is white after 1 h, we recommend cut but not removal of the result. Patients may experience transient improve-
the traction sutures, and wait for the normal color to return. ment in crow’s feet when the dissection is taken into the
External sutures will result in marks that are typically lateral lower eyelid.
transient, but in some situations, these marks could be The main factor that we feel is responsible for the
potentially permanent. There were no patients in our series success of this procedure is the subcutaneous detachment
that experienced permanent suture marks. It must be tends to be more durable. The eyebrow is in continuity with
emphasized that the stitch tension, needle size and suture the frontal cutaneous flap, and this facilitates eyebrow lift.
diameter contribute to the formation of these markings. The weight of the undermined flap is less than when
The use of Net as a continuous suture reduces the possi- undermining at the subgaleal or subperiosteal level where
bility of these marks from occurring because there is a the flap is thicker and heavier and causes greater tension at

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the distant fixation points and which may contribute to the Conclusion
eventual recurrence of ptosis. In the subcutaneous plane,
there is destruction of the gliding plane, described by Knize Gliding brow lifting (GBL) combines subcutaneous frontal
[3], between the lateral forehead skin and tail of the brow and periorbital detachment with minimal incisions, and
and the underlying temporoparietal fascia, where the elevation and fixation of eyebrows with temporary cuta-
resultant healing of the surgical plane creates a tight neous fixation with the hemostatic net. This technique
adhesion of eyebrow in its new position. offers effective, stable results with low rate of
In contrast, the endoscopic approach relies on an adhe- complications.
sion between the repositioned periosteum and the under-
lying bone. In laboratory experiments, adhesions of Compliance with Ethical Standards
repositioned periosteum have been studied with positive Conflict of interest The authors declare that Dr. Fausto Viterbo
[32] or negative [33] effect; even if the operation is per- receives royalties from Faga Medical, the company that produces the
formed properly, the adhesion of the surgical plane will not dissectors used to perform this technique. The other authors, Dr.
prevent the skin descent and consequently recurrence of the André Auersvald and Dr. T. Gerald O’Daniel have no conflict of
interest.
eyebrow ptosis.
The direct brow lift has an advantage of optimal brow Ethical Approval All procedures performed in studies involving
shaping but is not widely performed due to the visibility of human participants were in accordance with the ethical standards of
scars. Fausto Viterbo Plastic Surgery Clinic and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
We have found that eyebrow reshaping obtained with
the GBL allows the eyebrow to be shaped precisely to a Informed Consent Informed consent was obtained from all indi-
predetermined desired curvature due to the skin and eye- vidual participants included in the study.
brow detachment. Once there has been adequate release
from the underlying frontalis and orbicularis oculi mus-
culature, there is malleability of the eyebrow that facilitates References
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