Contemporary Concepts and Techniques for Scar Minimization in Direct Brow Lift: A Literature Review

Background: Despite the rise of endoscopic approaches, the direct brow lift remains one of the most effective procedures for correcting brow ptosis for both functional and cosmetic indications. It continues to offer superior control when correcting brow shape, height, and asymmetry. However, visible scarring remains a concern. This systematic review was conducted to synthesize recent evidence on strategies that minimize visible scarring in direct brow lift surgery. Methods: A systematic literature search was performed to retrieve English-language publications from the past decade, discussing scar-minimization strategies in direct brow lift. A total of 124 records were identified through database searches in Ovid MEDLINE and Embase. Records were screened manually according to predetermined criteria, and those not in English, not addressing scarring, or not focused on direct brow lift were excluded. After this process, ten publications were included in the final qualitative synthesis. Results: The qualitative synthesis of all included publications (together comprising data on approximately 900 patients) revealed several strategies for scar minimization. (1) Incision beveling: A shallow cranially directed bevel between 20° and 45° preserves brow hair follicles and allows hair regrowth through the scar, providing natural camouflage. (2) Undermining: Gentle subcutaneous undermining in a limited 1-2 cm field, while preserving subcutaneous fat, allows tension-free advancement and maintains brow volume. (3) Periosteal suspension: Anchoring the mobilized brow flap to the frontal periosteum redistributes tension away from the dermal closure, maintaining elevation and improving scar quality. (4) Layered closure: Two- or three-layered wound closure with deep dermal anchoring and fine everting skin sutures minimizes dermal traction and scar widening. (5) Adjunctive measures: Evidence for topical silicone gel was inconclusive, whereas postoperative laser therapy and perioperative neuromodulator use demonstrated improved scar appearance. Across studies, outcomes were consistent, with high patient satisfaction, inconspicuous scars in over 85% of cases, and low complication or revision rates. Conclusions: Direct brow lift has historically been criticized for conspicuous scarring, contributing to the popularity of endoscopic techniques. Nevertheless, the traditional direct brow lift remains a fundamental skill in the oculofacial plastic surgeon's armamentarium, offering unmatched accuracy in brow repositioning, reliability, and symmetry. Contemporary evidence demonstrates refinements that can markedly minimize scar visibility. This systematic review and qualitative synthesis allow us to continue to refine and improve our techniques to minimize scarring in direct brow lift to the benefit of our patients.