In the evaluation of patients with upper eyelid skin redundancy and hooding, it is important to note the upper brow position and check for eyebrow ptosis. The upper eyebrow normally rests above the superior orbital rim in females and at the level of the supraorbital rim in males. With aging, the brow may sag down to below the orbital rim. A ptotic brow can gravitate into the upper lid skin area, creating a secondary eyelid hooding, which is relieved when the eyebrow is repositioned to its normal location. Symptoms may include visual fatigue, visual field obstruction, and fatigue of the forehead muscles, as well as headaches. This process of brow ptosis also produces a narrowed spacing between the eyebrow hairs and the lashes, which can cause a frowning appearance in the patient. The presence of brow ptosis therefore needs to be addressed either before upper blepharoplasty or handled concurrently.
The following eyebrow procedures that are commonly used in conjunction with upper lid blepharoplasty are covered in detail in this chapter:
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Endoscopic-assisted eyebrow forehead lift (see Chapter 4 ) is used more commonly in females for the nasal two-thirds of the brow and glabellar area. (It is commonly supplemented with the internal browpexy.)
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Direct eyebrow lift (p. 62 ) is used, generally, in males. It involves direct skin incision over the area above the brow. It is also commonly supplemented with the internal browpexy, which corrects for lateral brow ptosis.
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Temporal forehead lift (p. 65 ) is used for the lateral third of the brow when there is severe skin laxity lateral to the brow, beyond the lateral orbital rim. Performed through a subgaleal approach, it is commonly used as a supplement to the cheeklift procedure.
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Internal browpexy (p. 68 ) is performed through the upper blepharoplasty incision for correction of laxity in the lateral third of the brow. It is commonly used by itself in conjunction with upper lid blepharoplasty or used as a supplement to the endoscopic eyebrow forehead lift or the direct eyebrow lift for elevation of the lateral third or tail of the brow.
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Browplasty (p. 70 ) is used to correct fullness due to abundance of retro-orbicularis oculi brow fat (ROOF).
Direct Browlift
A sagging eyebrow can be corrected by a direct brow lift . After the eyebrow area is locally anesthetized, an above-brow incision line is designed from the medial to the lateral extent of the upper eyebrow hair, in a gentle curve with a slight lateral flare upward. A segment of the ptotic forehead skin, usually between 8 and 10mm, is marked out parallel to this lower incision. A No. 15 blade is used to incise the upper and lower brow markings. The strip of ptotic forehead skin and subcutaneous tissue, down to the level of the frontalis muscle, is excised using cutting Bovie cautery with a needle tip. The deep frontalis muscles are reapproximated to those at the deep plane of the upper incisional edge, using multiple interrupted 4-0 Polydek sutures (ME-2 needle, Deknatel). The subcutaneous tissues are then closed using subcuticular placement of 5-0 Vicryl. The skin is closed with 4-0 nylon in an interlocking running stitch. The nylon stitches may be kept in place for 10–14 days. In Figure 6.12 , the long strand of the suture is locked under the loop of the “far–far” passage.
