8.1 Introduction

Although there are many options for surgically elevating a droopy eyebrow, the aptly named “direct brow” technique addresses this sequela of the aging face or motor paralysis by directly excising and shortening the tissue immediately superior to the ptotic brow. ¹ The incision may span the entire brow, such as in cases of seventh nerve paralysis, or simply the temporal portion in patients with isolated temporal brow ptosis, temporal hooding, and an irregular brow contour. This technique effectively and durably elevates the eyebrow to its natural resting position over the superior orbital rim. One of the main risks of this procedure is visible scarring; therefore, patient selection, preoperative counseling, and technically sound surgical technique are of the utmost importance to achieve a cosmetically acceptable outcome. Wound construction and meticulous closure are paramount. However, even with flawless surgical technique, the scar at the incision site is often still visible, especially when the medial brow is included, where the skin is thicker with more sebaceous units. Damage to the sensory branches of the supraorbital and supratrochlear neurovascular bundles is also a risk but can be avoided with a sound knowledge of the local anatomy and dissection in a more superficial plane when approaching that medial area.

8.2 Relevant Anatomy

The eyebrow is defined by the visible eyebrow hairs and their relationship to the nose, forehead, eyelids, and temples. The medial and central hair follicles are oriented in an obliquely superior plane, whereas the hair follicles in the temporal third of the brow are oriented more perpendicular to the skin edge ^{2 ,​ 3} (Fig. 8.1). Biologically, the eyebrow and brow hairs serve to protect the eyes from moisture, dust, and dander, which helps to maintain a clear visual axis. ⁴ The eyebrow is also a vital part of facial expression and can be voluntarily raised, lowered, or furrowed to convey a wide spectrum of emotions. ⁵ A ptotic brow can interfere with an individual’s visual axis and unintentionally convey a sense of tiredness or sleepiness (Fig. 8.2 a, Fig. 8.3 a). Additionally, ptosis of the medial head of the brow can convey anger, while ptosis of the lateral head of the brow may suggest sadness. ⁶

The brow may be defined anatomically by several distinct changes from the nearby eyelids. ⁷ Dermatologically, there is a transition from the thin eyelid skin without subcutaneous fat to the thicker and more sebaceous brow skin that is contiguous with the skin of the forehead. There is an increasingly thick layer of subcutaneous fat separating the skin from the underlying muscular layer, which transitions from the circumferentially oriented orbicularis oculi, a brow depressor, to the vertically oriented frontalis muscle, a brow elevator. Above the arcus marginalis at the superior orbital rim but beneath the muscular layer, there is an additional fat pad overlying the periosteum labeled the brow fat pad or the retro-orbicularis oculi fat pad. This fat pad gives volume to the temporal aspect of the brow and is of particular aesthetic importance in women. ⁵

The normal resting position of the youthful eyebrow is at or slightly above the superior orbital rim. The head, or most medial portion, of the eyebrow is also typically the thickest portion and begins at a line drawn vertically upward from the lateral nasal ala. The body, or central portion, of the brow continues laterally until arching and descending downward into the tail, the most lateral portion. The tail of the brow typically ends at an oblique line drawn from the lateral nasal ala intersecting with the lateral canthus. ⁸ The contour of a normal brow differs between men and women. Whereas the male brow is typically flatter with a small or absent peak (Fig. 8.4 a), the female brow arches upward over the lateral canthus to accent the underlying brow fat pad ⁹ (Fig. 8.4 b).