16.1 Introduction

Understanding brow aesthetics and physiologic changes that occur to the brow with aging is key to determining appropriate surgical or nonsurgical management for any patient. There has been a significant evolution in brow aesthetic preferences as seen across cultures and fashion, suggesting that there is no single ideal brow shape and contour. Many studies ¹ ID#b393a000_2 ^– ID#b393a000_3 ID#b393a000_4 ⁵ have attempted to find unifying principals for an objective brow aesthetic; however, no consensus has been reached. Ideal brow contour is an ever-evolving concept.

Nonetheless, a universally youthful upper lid–brow–temple complex is full with natural convexities. The aging process is associated with lipoatrophy and volume loss that contribute to lateral brow deflation and descent. ^{6 ,​ 7} The recognition of volume loss in facial aging has found well-established treatments with autologous fat transfer and fillers, especially in the lower lid and cheek. ^{8 ,​ 9} Until recently, however, the classic understanding of brow ptosis focused on gravitational descent, especially of the tail of the brow, with management mainly directed at surgical lifting.

Studies have revealed that there may be less brow descent with aging than previously thought. ¹⁰ In some cases, it has been shown that there is a paradoxical elevation of the medial brow with age associated with frontalis muscle tone compensating for blepharoptosis. The paradoxical elevation of the medial brow and the soft tissue deflation around the lateral brow together create a greater impression of lateral brow ptosis than may actually occur. Surgical brow lifting, which focuses solely on countering the gravitational forces that cause skin laxity and soft tissue descent, does not address the oftentimes more profound impact of volume loss. Volume loss with aging makes the bony orbit more visible and the lateral brow less visible as it dives posteriorly. A hollow between the bony orbit and the temporal fossa creates shadows and hides the tail of the brow, which is normally prominent in a youthful face. Surgical elevation alone may lead to further skeletonization of the orbital rim and an overelevated, unnatural appearing brow. ¹¹ Lambros ^{10 ,​ 12 ,​ 13} and others ^{14 ,​ 15} ID#b393a000_16 ^– ID#b393a000_17 ID#b393a000_18 ID#b393a000_19 ²⁰ have discussed the important role of volume replacement in the upper lid and below the brow for periorbital rejuvenation. With this knowledge, the treatment paradigm for the aging brow is shifting toward volumization with hyaluronic acid fillers and autologous fat transfer.

Autologous fat is an abundant, biocompatible material that is relatively easy to harvest and long-lasting. ^{6 ,​ 7 ,​ 21 ,​ 22} Patients already undergoing upper blepharoplasty are ideal candidates for intraoperative fat grafting to the brow and temporal fossa to provide an added rejuvenated effect. In our practice, autologous fat transfer has a noticeable synergistic effect with upper blepharoplasty to restore the natural convexities of the brow–temple complex (Fig. 16.1, Fig. 16.2). It is a safe, rapid, and reliable procedure. It has the benefits of giving a natural restorative appearance, with fat biocompatibility potentially leading to greater longevity than alternative treatments. We have found this to be a useful enhancement for blepharoplasty patients who do not wish to undergo a browlift procedure or where a browlift would lead to an unnatural brow appearance. Here, we describe our experience with autologous fat transfer to the brow as a useful adjunct to the standard upper blepharoplasty.