16 (1)

B ro w A n a t o m y an d
Aesthetics of the Upper

Face
James E. Zins, MD, FACSa,*, Jacob Grow, MDb, Cagri Cakmakoglu, MDc
KEYWORDS
Brow anatomy Brow esthetics Brow lift Forehead lift
KEY POINTS
An understanding of the three-dimensional anatomy of the forehead is critical to safe and effective
esthetic surgery of the upper face.
The complex anatomy of the forehead is three-dimensionally similar to the temporal region.
The deep branch of the supraorbital nerve is easily injured in brow surgery, and understanding the
anatomy will minimize this risk.
Improving or maintaining brow shape is perhaps more important than brow lifting.
INTRODUCTION resection, the gliding brow lift, and the chemical

lift. Finally, the anatomy of this area is complex.
Effective treatment of facial aging should use a To best serve our patients, to provide the best re-
global approach addressing the upper, mid, and sults, and to minimize complications, an in-depth
lower face as well as the neck. In this monograph, understanding of this anatomy is critical. Although
we focus on only one of these critical areas, the up- controversies exist regarding the most effective
per face. When patients consult the plastic surgeon methods for brow lift surgery, a thorough under-
regarding periorbital aging, the focus is often on the standing of the complex anatomy in this area is
eyelid area only in spite of the fact that the brow the foundation for both surgical and nonsurgical
represents a critical part of the aging problem. It correction of brow ptosis.
is therefore incumbent upon the plastic surgeon
to raise the issue of brow rejuvenation. Often with
aging, the patient loses the natural appearance of BROW ESTHETICS
the superior orbital rim. Brow surgery can restore
that loss of definition of the superior lateral orbit, At the lowest border of the forehead, the brow marks
whereas upper lid surgery alone cannot. a natural transition point from the upper to middle
The surgical correction of brow ptosis has horizontal third of the face. The ideal position of the
perhaps changed more than any other area of brow varies not only by gender but also between cul-
facial esthetics. We currently have both surgical tures. Iatrogenic manipulation of brow shape with
and nonsurgical options available which now go makeup, manual hair removal, and the more recent
far beyond what can be accomplished by the utilization of microblade tattooing are common.
classic coronal brow lift. This includes the endo- Just as trends exist in clothing fashion and hairstyle,
scopic approach, the isolated temporal lift, the what could be considered an attractive brow has
plasticsurgery.theclinics.com
direct brow lift, the transpalpebral corrugator also undergone evolution over time. While still appre-
ciating this variability, anatomic tenants of brow
a
Section of Cosmetic Surgery, Department of Plastic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland,
OH 44195, USA; b Southern Indiana Aesthetic and Plastic Surgery, 2450 NorthPark, Suite B, Columbus, Indiana
47203, USA; c Cleveland Clinic Department of Plastic Surgery, 9500 Eucllid Avenue, Cleveland Ohio 44195, USA
* Corresponding author:
E-mail address: [email protected]
Clin Plastic Surg 49 (2022) 339–348

https://doi.org/10.1016/j.cps.2022.03.001
0094-1298/22/Ó 2022 Elsevier Inc. All rights reserved.
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340 Zins et al
position exist that help to guide our surgical

decision-making when analyzing the brow for
rejuvenation.
The modern description of brow position was
described by Westmore in 1974.1 The medial
brow originates on the same vertical plane as the
lateral alar border and medial canthus. Here, it is
rounded in shape and has the greatest density of
hair follicles. In females, the brow continues later-
ally to form a gentle arch that peaks at the junction
between its lateral and middle third, aligning at the
lateral limbus. The space between the upper eyelid
crease and the brow should gradually increase
from medial to lateral.2 Debate exists in the litera-
ture regarding ideal vertical brow position in fe-
males, but at least 5 mm above the rim is the
esthetic ideal.3–5 From medial to lateral, brow
thickness decreases to a taper at the tail of the
brow, which is positioned along an oblique line
connecting the ipsilateral nasal ala and lateral
canthus. In females, the tail of the brow should
sit in a slightly higher vertical position than the
medial origin.6 The male brow tends to be flatter
with less of an arch, traveling at the level of the su-
perior orbital rim. Although it still tapers laterally,
hair density tends to be more uniform and fuller
throughout its length. It is suggested that the
Fig. 1. The medial brow originates on the same verti-
term brow lifting is inaccurate and a misnomer. A
cal plane as the lateral alar base. In the female, it
better description of brow rejuvenation would be forms a gentle superior arc from medial to lateral
“shaping” (Fig. 1). with the apex of the arc at the lateral limbus or junc-
tion of the middle and lateral third of the brow. In the
BROW AGING male, the ideal brow shape is flatter, lower, and
located at the superior orbital rim.
The brow’s contribution to periorbital aging is
often times underappreciated. Although upper
eyelid dermatochalasis, development of crow’s preseptal fat pad, and the subgaleal glide plane.
feet, and glabellar rhytids are important areas for The lack of the presence of the frontalis muscle
treatment, they rarely occur in isolation. Brow pto- laterally allows the lateral orbicularis oculi to act
sis is defined by a loss of vertical position of the relatively unimpeded. The medial brow on the
brow relative to the supraorbital rim, giving a heavy other hand remains more fixed and less mobile
and tired appearance to the eyes. Observational with strong glabellar muscle attachment with no
studies by Lambros have shown that the brow po- significant associated fat pads or gliding plane.
sition descends with age.7 In addition, the shape As a result, the lateral brow descends with age,
of the brow also undergoes significant change. often resulting in compensatory frontalis hyperac-
The gentle arch and peak are lost as the brow be- tivity (Fig. 2).
comes flatter.8 Importantly, the medial brow is Correction of this lateral descent is a primary
more fixed and less mobile than the lateral brow. goal of surgical and nonsurgical treatment and
Therefore, descent of the lateral brow below the also effects the longevity of surgical intervention.
level of the medial brow is a common feature of ag- Relapse following surgical correction most
ing. Work by Matros and colleagues9 demon- commonly occurs at the tail of the brow owing to
strated this phenomenon by showing little the depressor action of the lateral orbicularis oculi
change in medial brow position between youthful and the absence of frontalis antagonistic effect.11
and aged patient cohorts. Cadaver studies by Medial brow ptosis may also be addressed in
Knize illustrate the anatomic basis for higher sus- some patients, but rarely is medial correction
ceptibility of the lateral brow to descend with alone indicated. With descent, lateral hooding oc-
age.10 Specifically, greater mobility of the lateral curs and is commonly mistaken for excess upper
brow is afforded by the galeal fat pad, the eyelid skin. Performing a blepharoplasty alone in
Brow Anatomy 341
that is relatively avascular, and periosteum. The

galea in particularly has been well described by
Knize.13 It is composed of a superficial and deep
portion that encases the frontalis muscle begin-
ning at its origin. More inferiorly, the deep galea
splits into a superficial and deep layer enveloping
the galeal fat pad which continues below the level
of the brow. In the lowest portion of the forehead,
the deep galea splits once again, forming a gliding
plane coinciding with the transverse portion of the
corrugator muscle. This gliding plane affords the
brow its high degree of dynamic motion during
expression. The deepest layer then fuses with
periosteum just above the supraorbital rim (Fig. 3).
Anatomy of the temporal area is similarly com-
plex but mirrors the anatomy of the forehead just
described. Understanding this three-dimensional
anatomy is critical to avoid injury to the frontal
branch of the facial nerve. In the temple the super-
ficial temporal fascia, or temporoparietal fascia, lies
immediately superficial to the skin and subcutane-
ous tissue. Deep to the superficial temporal fascia
lies the deep temporal fascia which is a single layer
covering the temporalis muscle. Proceeding inferi-
orly, approximately at the level of the brow, the
deep temporal fascia splits to form the superficial
and deep layers of the deep temporal fascia. This
Fig. 2. Brow aging and loss of brow shape. The lateral
can be recognized because of a color change. Su-
brow descends to a greater degree than the medial
periorly the deep temporal fascia is red in color,
brow. When the lateral brow is lower than the medial
brow, the patient has a sad or tired appearance. reflecting the temporalis muscle. Inferiorly the su-
perficial and deep layers of the deep temporal fas-
these patients cannot correct lateral brow hood- cia invest the intermediate fat pad. This gives this
ing. Bruneau and colleagues12 have shown that area its characteristic yellow color14 (Fig. 4).
with aging, a lower brow position is associated In women, 6-7 cm is the esthetic ideal for verti-
with the presence of dermatochalasis, as well as cal forehead length measured from the trichion to
compensatory frontalis hyperactivity. In some the glabella. Deviation from these proportions
cases, brow ptosis may be severe enough to may classify the forehead as either long or short
cause a superior lateral visual field loss. In such and convex or flat. Brow shape and height play a
cases, ptosis visual field testing to document and decisive role in choosing the most appropriate
confirm a field deficit may lead to insurance technique for brow lift surgery.15 Rhytids are ori-
coverage. Finally, the heavy brow may lead to ented transversely, lying perpendicular to the fron-
pseudoptosis which may be corrected by brow talis muscle fibers. Variability in the hairline may
surgery alone. In addition, unrecognized upper exist. A midline peak or “widow’s peak” is congen-
eyelid ptosis may accompany brow ptosis and, if ital and should be noted when present. With age,
so, requires correction. Accurately distinguishing irregularities in the hairline tend to develop, with
between upper eyelid ptosis, upper eyelid derma- temporal recession common in most males but
tochalasis, and brow ptosis is critical as is recog- not infrequent in middle-aged females. In addition
nizing their concomitant occurrence. to the changes in hairline, an aged forehead may
be marked by deep, resting rhytids and diffuse
THE FOREHEAD actinic changes through accumulated sun expo-
sure.16 In men, the forehead is higher than in
The forehead comprises the upper third of an women, especially with recession of the anterior
esthetically balanced face and includes the eye- hairline. Males are classified as having “stronger”
brows. Its well-defined layers have an important foreheads, attributable primarily to bossing at the
impact on the various surgical planes of dissec- frontal sinus, giving the appearance of a heavy
tion. They include the skin, subcutaneous tissue, brow ridge. The superior lateral orbital rim tends
galeal frontalis muscle, loose areolar tissue plane to be more prominent than in the female.
342 Zins et al
Transverse rhytids are also characteristically

deeper and more pronounced, while the general
nature of the skin tends to be more sebaceous17
(Fig. 5).
BONY ANATOMY AND ZONES OF FIXATION

The frontal bone composes most of the forehead,
with the supraorbital rim acting as a constant bony
landmark to assess brow position and ptosis. At
the lateral margin of the frontal bone lies the supe-
rior temple fusion line or temporal crest. This
marks the transition point from the forehead medi-
ally to the temporal fossa laterally. The superior
temporal line can be identified by having the pa-
tient bight down. The line of fusion is just superior
to the contracting temporalis muscle (Fig. 6). The
line of fusion is approximately 5 mm in width
throughout the length of the ridge.13 It includes a
confluence of the galea aponeurotica and its
lateral continuation the superficial temporal fascia,
as well as the deep temporal fascia. Immediately
medial to this line of fusion, it is important to
dissect in the subperiosteal plane to avoid injury
Fig. 3. The frontalis muscle is invested on its deep and to the deep branch of the supraorbital nerve
superficial surface by the superficial and deep layers (Fig. 7). Approaching the orbital rim, the zone of
of the galea. Inferiorly the deep layer splits to invest adhesion becomes denser and expands to form
the galeal fat pad on its superficial and deep surfaces. the temporal ligamentous adhesion or orbital liga-
In the lowest portion, the deep galea splits once more ment. This dense fascial convergence connects
forming the gliding plane with the corrugator muscle.
the superficial temporal fascia to the orbital rim
Finally the deep layer fuses with the periosteum just
at the tail of the brow and is continuous with the
above the orbital rim.
lateral orbital thickening at the lateral orbital rim.
Surgical release of these areas where soft tissue
is adherent to bone represents a key principle in
Fig. 4. (A) Cadaver dissection demonstrating the deep temporal fascia (red) covering the temporalis muscle (ar-
row). Inferiorly the color changes to yellow as the deep temporal fascia splits to form the superficial and deep
layers of the deep temporal fascia investing the intermediate fat pad (asterisk). (B) Endoscopic view of the
same structures. Superiorly (three o’clock) the deep temporal fascia appears red, reflecting the underlying tem-
poralis muscle. Inferiorly the yellow color indicates that the deep temporal fascia has split into the superficial and
deep layers of the deep temporal fascia, investing the yellow intermediate fat pad.
Brow Anatomy 343
significantly less mobile than the lateral brow,

attributable to the more robust muscle attach-
ments comprising the galea and anchoring from
the supraorbital and supratrochlear neurovascular
bundles.10
MUSCLES
Brow animation plays a distinctive role in the
display of emotion. Medial depression with furrow-
ing signals anger or disagreement, exaggerated
elevation suggests surprise and excitement, and
lateral depression is associated with sadness. Uni-
lateral elevation is synonymous with skeptical cu-
riosity or intrigue in today’s popular culture.
Maintaining an ability to animate the brow after
surgery avoids the frozen and perpetually sur-
prised appearance that is often negatively associ-
Fig. 5. Ideal facial proportions in the frontal view. The ated with an overoperated result.18
face can be divided into thirds. Distance A (brow to
The muscles of facial expression that are
medial canthus) is roughly equal to the vertical dis-
responsible for brow movement represent dy-
tance of the upper lip (C). Distance B (midface) is
roughly equal to the distance from the alar base to namic and opposing forces. A variety of brow de-
the inferior border of the chin (D). pressors act across the lower forehead, whereas
the frontalis muscle stands as the sole brow
elevator. Manipulation of these forces through
effective brow lift surgery (see Fig. 7). As neuromodulation or surgical muscle excision can
mentioned previously, the medial eyebrow is generate desirable changes in brow position.
Fig. 6. (A) Cadaver dissection demonstrating the superior temporal fusion line marked in blue. If the fusion line is
followed caudally, it coalesces with the temporal ligamentous adhesion. This fascial fusion must be divided to
elevate the lateral brow. (B) Close up of (A) demonstrating the temporal ligamentous adhesion.
344 Zins et al
When present, decussation either occurred at

the level of the brow or continued to the mid fore-
head. They suggest that variability may exist
based on ethnicity and contribute to the general
shape differences of the periorbital region be-
tween cultures.19 Of clinical importance, identi-
fying the extent of frontalis muscle proper in the
midline helps to guide treatment with neuromodu-
lators to avoid residual dynamic rhytids, asymme-
try, and iatrogenic brow ptosis following
injection.20
Medial Brow Depression: The Glabella

A series of muscles act to pull the medial brow
medially and inferiorly. They originate from bone
and insert at various locations into dermis. Their
action causes the formation of distinct rhytids at
Fig. 7. Endoscopic view of the right temporal fusion the glabella which are a hallmark of facial aging.10
line identified and dissection then medially immedi- The procerus muscle forms at the superior aspect
ately taken subperiosteal to avoid injury to the deep of the nasal bones and runs vertically, producing
branch of the supraorbital nerve. transverse rhytids at the bridge of the nose. The
corrugator supercilia begins at the superomedial
orbital rim and travels primarily in a transverse
Specifically weakening of the depressor muscles orientation, forming the vertical or “eleven lines”
can allow the frontalis to act relatively unopposed at the glabella. Anatomically, evidence of a trans-
leading to brow elevation. Conversely, weakening verse and oblique head of the corrugator supercilia
of the frontalis especially in the lower forehead can have been described but are many times indistinct
inadvertently lead to eyebrow ptosis. Strong mus- from one another clinically21,22 (Fig. 8). The orbicu-
cle action produces distinct and predictable rhyti- laris oculi muscle is arranged as a sphincter sur-
des perpendicular to the muscle fibers which are rounding the orbit. Originating at the medial
accentuated with age. It is important to distinguish canthal tendon, the superomedial orbital portion
rhytides as either dynamic or static to determine is arranged obliquely, pulling the brow inferome-
the most effective treatment modality. Static rhyti- dially. This assists with voluntary eyelid closure.
des will not respond well to neuromodulation, In addition, the depressor supercilii muscle has
whereas dynamic rhytides will. been described in cadaver studies as a distinct
medial brow depressor from the corrugator super-
Brow Elevation cilii and orbicularis muscle, oriented obliquely but
more vertically relative to the orbicularis. Its origin
The frontalis muscle is a broad, thin muscle fan-
is relatively low, at the frontal process of the
ning across the forehead and terminating at the
maxilla approximately 1 cm above the medial can-
superior temporal septum. Originating at the galea
thal tendon. At this origin, the angular artery
superiorly at the approximate level of the hairline, it
passes within its fibers.23
inserts into the dermis at the eyebrow. Inferiorly, it
interdigitates with the opposing procerus and orbi-
cularis oculi muscles. Laterally, it fuses at the tem-
Lateral Brow Depression
poral crests.13 Therefore, because it is absent The lateral portion of the orbicularis oculi is solely
laterally, it provides no counteraction to the responsible for lateral brow depression. As it in-
depressor activity of the lateral orbicularis. When serts at the lateral orbital thickening, its fibers are
activated, the frontalis is responsible for trans- primarily vertical, forming the rhytids associated
verse forehead rhytids. Identifying the location of with “crow’s feet”10 (Fig. 9).
these forehead wrinkles also gives insight into
the decussation pattern of the muscle in the NEUROVASCULAR STRUCTURES
midline. According to anatomic cadaver studies
by Raveendran, it was most common for some de- The muscles of facial expression responsible for
gree of decussation to exist. However, approxi- brow movement receive innervation from specific
mately 1 in 4 specimens demonstrate complete branches of the facial nerve. The frontal branch
separation between the two muscle bellies. powers the frontalis muscle to elevate the brow
Brow Anatomy 345
Fig. 8. (A) Cadaver dissection of the corrugator muscle. The muscle is best approached subgaleally or subperios-
teally. Anatomically it has a transverse and oblique head. Within the muscle lie the suprtrochlear nerve branches.
(B) Endoscopic view of the left corrugator muscle partially excised in the center of the photograph. Distal cut end
of the muscle is marked with an arrow. Endoscopic grasper is visualized in the lower right.
and have been studied extensively. Pitanguy and have shown that the upper zygomatic branch of
Ramos originally described the trajectory of the the facial nerve to be found consistently deep to
frontal branch of the facial nerve along a line pro- the upper third of the zygomatic major muscle in
jected from a point 0.5 cm below the tragus to a the sub-superficial musculo aponeurotic system
point 1.5 cm above the tail of the brow.24 At the (SMAS) plane. It continues medially to innervate
zygomatic arch, this correlates to the middle third the medial brow depressors of the glabella.28
of the arch, approximately 4 cm from the lateral Sensory innervation to the forehead and brow
canthus. The frontal branch remains in a plane relies on the supraorbital and supratrochlear
deep to the parotidmasseteric fascia until crossing nerves, both branches from the ophthalmic divi-
the arch. Cadaver dissections by Agarwal and col- sion of the trigeminal nerve. The supratrochlear
leagues25 identify a fascial transition zone 1.5 to
3.0 cm above the arch and 0.9 to 1.4 cm posterior
to the lateral orbital rim where the frontal branch
then passes from the innominate fascia to run
within the superficial temporal fascia. For this
reason, staying deep or immediately on top of
the superficial layer of the deep temporal fascia
avoids injury to this nerve branch within the tem-
poral fossa. It should be noted that some terminal
branches of the frontal nerve do play a role in
innervating medial brow depressors, primarily the
transverse portion of the corrugator supercilii and
procerus. However, these contributions are both
minor and redundant. If an injury to the frontal
branch is sustained, iatrogenic brow ptosis and
asymmetry result.26 While a variety of muscles
act synergistically to depress the brow, all share
primary innervation by the zygomatic branch of
the facial nerve on their deep surface. Although
the buccal branch plays an important functional Fig. 9. Endoscopic subperiosteal dissection along the
component in innervating the palpebral portion of lateral orbital rim releases all soft tissue of the rim
the orbicularis oculi muscle, this action has no ef- except for the deep head of the lateral canthal
fect on brow position.27 Alghoul and colleagues tendon.
346 Zins et al
neurovascular bundle may be found approxi-

mately 1.5 cm on average from midline as it
emerges from a bony notch or foramen at the su-
praorbital rim.29 It runs through the medial aspect
of the corrugator muscle dividing into multiple
branches as it provides sensation to the inferior
medial forehead and glabella. Clinically, nerve
branches are skeletonized during corrugator
resection30 (see Fig. 8B). The supraorbital nerve
is found lateral to the supratrochlear nerve, origi-
nating approximately 2.5 cm from the midline as
it emerges from the supraorbital notch or fora-
men31 (Fig. 10). Often times, this is a distinct,
palpable bony landmark. In 90% of cases, a true
notch exists although a true bony foramen located
up to 1.5 cm cephalad to the supraorbital rim may
be present 10% of the time. The supraorbital nerve
then divides immediately into a deep and superfi-
cial branch. The superficial division travels supe-
rior medially, passing through the frontalis
muscle into the subcutaneous plane in the mid to
upper central forehead. The deep division runs su-
perior laterally, staying deep to the galea on top of
periosteum. Within 0.5 to 1.5 cm medial, it then re- Fig. 11. Cadaver dissection demonstrating the deep
mains parallel to the temporal crest (Fig. 11). Along branch of the supraorbital nerve coursing 0.5 to
this course, branches emerge that pierce the galea 1.5 cm medial to the superior temporal fusion line.
sequentially, providing sensation to the frontopar- The deep branch lies between periosteum and galea
ietal scalp.32 Because the nerve lies between and is easily injured in a subgaleal dissection.
galea and periosteum, it is readily injured during
a subgaleal dissection. This can lead to chronic supraorbital and supratrochlear neurovascular
and intractable pruritus of the scalp. bundles form from the ophthalmic artery of the in-
Vascular supply to the brow and forehead is ternal carotid. Laterally, the superficial temporal
robust and derived from both the internal and artery represents the terminal branch of the
external carotid systems. Centrally, the
Fig. 12. The sentinel vein is encountered inferior to

the inferior temporal septum. It lies 1.5 cm lateral
Fig. 10. Endoscopic view of the supraorbital vessels and 2 cm superior to the lateral orbital rim. The fron-
emanating from the supraorbital foramen 2.5 cm tal branch of the facial nerve is superior and lateral to
from the midline. the vein.
Brow Anatomy 347
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B ro w A n a t o m y an d

Aesthetics of the Upper

INTRODUCTION resection, the gliding brow lift, and the chemical

Clin Plastic Surg 49 (2022) 339–348

position exist that help to guide our surgical

that is relatively avascular, and periosteum. The

Transverse rhytids are also characteristically

BONY ANATOMY AND ZONES OF FIXATION

significantly less mobile than the lateral brow,

When present, decussation either occurred at

Medial Brow Depression: The Glabella

neurovascular bundle may be found approxi-

Fig. 12. The sentinel vein is encountered inferior to

external carotid, transmitting frontal branches to REFERENCES

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