Brow Ptosis Repair
Leon Rafailov, MD
DISEASE DESCRIPTION
Eyebrow ptosis is an eyebrow that rests below the superior orbital rim. The resting eyebrow position is determined by a balance of the elevating frontalis muscle opposing the depressing forces of gravity and the orbicularis oculi, corrugator, and procerus muscles. Eyebrow ptosis may have neurogenic, mechanical, traumatic, or involutional causes.
PREOPERATIVE CONSIDERATIONS
Consider any factors that may contribute to lagophthalmos or exposure keratopathy, such as paralytic orbicularis weakness.
Determine the amount of available upper eyelid skin, especially if brow ptosis repair will be combined with a blepharoplasty or if the patient has had a blepharoplasty in the past.
Consider forehead height, frontal convexity, and frontal rhytides, which impact surgical technique.
Assess the overall health of the patient, paying attention to vasculopathic risk factors such as smoking or poorly controlled hypertension or diabetes, which may compromise healing in the postoperative period.
PREOPERATIVE EVALUATION
Determine the patient’s complaints and goals. Establish to what extent concerns are due to brow ptosis versus dermatochalasis. Confirm that the patient has realistic expectations regarding the level of correction that may be achieved with each technique.
Examine the patient, making sure to palpate the position of the brows relative to the orbital rim. Women typically have brows that are above the orbital rim, with a more acutely angled lateral arch. Men tend to have flatter and thicker eyebrows and more prominent orbital rims. Inspect the forehead for any deep furrows, which may be a good place to create a surgical incision.
Consider whether the patient may benefit from blepharoplasty in addition to brow ptosis repair, because dermatochalasis and brow ptosis often coexist. These two
surgeries may be performed together. If the patient has had prior blepharoplasty, be sure there is enough remaining anterior lamella for brow ptosis repair. Lifting the brow in patients who have had prior aggressive blepharoplasty may contribute to lagophthalmos and exposure keratopathy.
FIGURE 8.1. Surgical approaches to brow ptosis repair. Direct supraciliary (pink), transblepharoplasty (dotted white), mid-forehead (solid white), trichophytic (red, green), endoscopic (yellow), coronal (blue).
Decide with the patient which brow ptosis repair would be most appropriate (Figure 8.1)
Direct supraciliary
An incision is placed along the superior aspect of the brow. This technique may be used to elevate the whole brow, but concerns about scar appearance may limit the medial extent of the repair. Scar may be visible directly above the eyebrow hairs. Suitable for patients with thick or long brow hairs and predominantly lateral brow ptosis
Transblepharoplasty or internal browpexy
The brow soft tissues are fixed to the periosteum of the superior orbital rim. This technique can be performed via the blepharoplasty incision, sparing the patient additional scarring. Provides brow tissue support to the orbital rim, with limited elevation; it is particularly useful in patients with mild temporal brow ptosis.
Mid-forehead
An incision is placed along a prominent frontal rhytide. This technique is excellent for lifting the whole brow without creating the aggressive arch seen in direct supraciliary browlifts. Hypoesthesia, usually transient, may result from supraorbital and supratrochlear nerve injury. The patient must be comfortable with scars across the forehead; generally suitable for men with thicker skin and deep rhytides.
Trichophytic
An incision is placed along the frontal hairline, beveled so that surviving hair follicles may allow hairs to regrow through the incision. The forehead is shortened and the hairline may be lowered. Dissection may smooth forehead rhytides.
Endoscopic
Multiple smaller incisions are hidden behind the hairline. This technique is particularly useful in patients with vertically short foreheads. Required tacking/suspension devices may be palpable. Likely the longest and most technically challenging of the brow ptosis repairs but often yields good results
Coronal
An incision is placed well behind the hairline, with a small risk of incisional alopecia. This technique requires extensive dissection but can lift the entire forehead, reduce frontal rhytides, and is suitable for patients with vertically short foreheads.
Pay close attention to the hairline in patients. Men who have a receding hairline may unveil their incision sites years down the line.
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