9 Internal Eyebrow Lift
Abstract
The internal eyebrow lift has gained popularity since its first description in 1982. It allows brow stabilization and some elevation through an upper blepharoplasty incision. The procedure also minimizes temporal eyebrow descent that may occur due to eyelid skin and soft tissue removal after upper blepharoplasty. The procedure is safe, quick, and long-lasting and it does not require expensive equipment or additional incisions.
9.1 Introduction
Aesthetic and functional assessment of the upper face requires a careful understanding of the upper face–eyebrow–eyelid continuum. The ideal eyebrow shape has been the subject of debate. 1 To optimize surgical lifting outcomes, each patient should be evaluated individually, taking into account the overall facial profile, age, gender, and ethnicity. 2 ID#b1a509a452_3 – 4 While patients may present with isolated eyelid or eyebrow complaints, a thorough upper facial rejuvenation requires assessment of both structures. The correction of dermatochalasis or eyelid ptosis in the presence of significant brow ptosis can reduce the compensatory frontalis contraction and aggravate brow descent if not concurrently addressed (Fig. 9.1). 5
Addressing brow ptosis with the internal browlift provides the advantages of a hidden scar, placed within a standard upper blepharoplasty incision, no additional incisions, no extended forehead dissection, and limited increased operative and recovery time. 6 ID#b1a509a452_7 – ID#b1a509a452_8 ID#b1a509a452_9 ID#b1a509a452_10 ID#b1a509a452_11 12 The technique prevents lateral brow descent and may even achieve a mild-to-moderate eyebrow elevation (Fig. 9.2). Medial brow lifting may also be attained through the same incision by weakening the eyebrow muscle depressors, allowing unopposed frontalis action. 9 , 10 Further benefits include minimal equipment cost, a shorter learning curve, and a lower risk of neurovascular damage because the procedure is performed under direct visualization. 7 , 8 , 13 The procedure may provide a cosmetic effect comparable to that produced by more aggressive techniques while minimizing complications. 8 ID#b1a509a452_9 – ID#b1a509a452_10 ID#b1a509a452_11 12
Internal browlift disadvantages include a limited amount of lift that can be achieved and questionable long-term results compared with brow lifting through direct, midforehead, coronal, and endoscopic approaches. 14 , 15 Damage to the neurovascular bundles (supraorbital and supratrochlear) remains a concern if the medial portion of the brow is accessed. 10 Here, we discuss our approach to internal eyebrow lifting.
9.2 Anatomic Considerations of the Upper Facial Continuum
The eyebrow and upper eyelid should be seen as a continuum. 1 In a patient presenting for upper blepharoplasty, the eyebrow position and shape should always be evaluated because its descent may be an important cause of postoperative eyelid skin redundancy and patient dissatisfaction. 16 It is important to recognize if brow ptosis has a lateral and/or medial component, as the causal forces and resultant corrective procedures are distinct. Further, it is important to maintain awareness of contemporary beauty ideals: the female eyebrow is arched laterally and positioned a few millimeters above the orbital rim, 3 while the male brow lies at the level of the orbital rim and is flat. 4 Brow volume should also be noted, in particular, the retro-orbicularis oculi fat (ROOF) pad position and volume. If a browlift is indicated and not performed, the possibility of postblepharoplasty brow ptosis from reduced compensatory frontalis contraction should be discussed with the patient. Older patient photographs assessing brow position in youth are a helpful guide on where to set the eyebrow position.
9.3 Goals of Intervention
Brow stabilization.
Treatment of mild-to-moderate temporal brow ptosis in patients who are undergoing upper blepharoplasty.
9.4 Risks
Over- or undercorrection.
Asymmetry.
Brow ptosis recurrence.
Bleeding.
Infection.
Transient edema.
Eyelid, forehead, and scalp numbness.
Temporary lagophthalmos.
Eyebrow contour deformities.
Skin dimpling.
Prolonged forehead sensory loss from damage to the supraorbital and supratrochlear nerves.
Consecutive eyebrow droop from damage to temporal branch of facial nerve.
9.5 Benefits
Same incision as a standard upper blepharoplasty procedure.
Limited tissue dissection.
Quick procedure.
Recovery time is the same as in upper blepharoplasty.
Lower complication rate when compared to temporal or coronal lifts.
The procedure may be used in thin-haired or bald patients.
Minimal additional cost.
9.6 Informed Consent
The impact of browlift complications on the patient and the surgeon may be profound. It is easier to manage a dissatisfied patient when there has been a thorough preoperative discussion about the procedure, risks, benefits, and alternative approaches to manage the problem. The patient should be made aware of the possibility of additional surgery and financial responsibility.
9.7 Indications
9.8 Contraindications
Severe brow ptosis requiring large eyebrow elevation. 10 , 14 , 18
Patient desire to address prominent horizontal wrinkles or redundant forehead skin. 18
Very thick-skinned patients where this minimally invasive technique is less effective.
Very thin skin and ROOF, where the risk for dimpling is higher.
9.9 Patient Assessment
A good preoperative patient evaluation is essential to an excellent postoperative outcome. We focus on a patient’s medical history, ophthalmic history, and external examination.
9.9.1 Medical History
Systemic conditions such as hypertension, diabetes, thyroid dysfunction, allergies, and autoimmune and hematologic disorders should be noted and managed preoperatively.
Thyroid eye disease should be inactive for a period of at least 6 months.
Antiplatelet drugs (such as aspirin, clopidogrel, and nonsteroidal anti-inflammatory agents), anticoagulants (heparin and warfarin), and supplemental medications should be recorded and withheld prior to surgery.
9.9.2 Ophthalmic History
A thorough ophthalmic history is important to avoid postoperative landmines in brow lifting surgery.
History of previous facial surgical and nonsurgical treatments, with particular attention toward the use of neuromodulators and fillers.
A 3- to 6-month waiting period should be used in patients receiving these treatments to assess baseline eyebrow and eyelid positions.
Previous refractive surgery or dry eye symptoms should be elicited because dry eye can complicate postoperative comfort and patient satisfaction.
9.9.3 Ophthalmic Examination
A complete ophthalmologic examination, including visual acuity, ocular motility, slit lamp examination, and tear film status, should be performed before every eyebrow and eyelid lift. Proceed with caution in patients with ocular surface staining, poor Bell’s phenomenon, lagophthalmos, or decreased tear production.
9.9.4 Anatomic Evaluation: The Eyelid and Eyebrow Subunits
In assessing the upper facial continuum, careful attention must be given to each subunit separately.
The Eyelid
Preoperative evaluation should include the upper margin–pupillary reflex distance (MRD1), margin crease distance, and margin fold distance with the brow in a neutral position to identify concurrent upper eyelid ptosis or any preexisting margin crease or fold asymmetries, respectively.
The degree of eyelid hooding over the eyelid margin with and without digital brow suspension should be assessed.
The prominence of the medial and central preaponeurotic fat pads should be noted.
The presence of lacrimal gland prolapse should be identified.
The presence of periorbital asymmetries should be documented.
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