Chapter 89 – Cosmetic Blepharoplasty and Browplasty

FRANÇOIS CODÈRE

NANCY TUCKER

DEFINITION

• Surgery of age-induced alterations in the eyelids and forehead area manifested by redundancy and displacement of tissues.

KEY FEATURES

• Brow position plays a key role in the appearance of the upper eyelid.

• Excessive skin removal is to be avoided in upper and lower eyelid surgery.

• Position of the fat pad determines the position of the lid crease.

• In the lower eyelid, repositioning the lid should precede any removal of skin.

• Eventual forehead surgery is considered when planning upper blepharoplasty.

INTRODUCTION

Aging changes in the eyelids and the face are related to loss of tone in the various layers underlying the skin. Changes that occur in the upper eyelid skin are usually due to passive stretching, loss of support, or redundancy of skin secondary to lowering of the brows.

Most patients do not appreciate the extent to which brow malposition contributes to the overall appearance of the aging periorbital area. This needs to be pointed out specifically to help the patient understand why a blepharoplasty alone often will not fully correct the problem. If a manual lift of the brow to the desired position significantly improves the patient’s appearance, a browplasty, either alone or combined with blepharoplasty, should be considered. If a blepharoplasty is performed without recognizing any associated brow ptosis, the lateral eyebrow can appear pulled down, which produces an undesirable, sad appearance.

ANATOMICAL CONSIDERATIONS

Eyelids

Key anatomical features that cause excess upper eyelid skin include brow ptosis from the loss of forehead deep tissue support, loss of the deep invagination of the eyelid skin in the principal lid crease as a result of anterior displacement of the suborbicularis fat pads, and stretching of attachments between the levator aponeurosis and the skin. To understand the anatomy, the lid may be arbitrarily divided into two distinct portions ( Fig. 89-1 ).

UPPER EYELID.

In the upper eyelid the first segment spans the zone between the lid margin and the lid crease. From anterior to posterior, it consists of skin, orbicularis muscle, levator aponeurosis, tarsus or Müller’s muscle higher up, and, finally, conjunctiva (see Chapter 82 ). These layers are held tightly together by

Figure 89-1 The orbital septum inserts into the levator aponeurosis (arrows). The preaponeurotic fat pads are located posterior to the septum. In downgaze the lid crease becomes attenuated (weakened), and in a normal young eyelid the fold is absent. (Adapted with permission from Zide BM, Jelks GW. Surgical anatomy of the orbit, Ch 4. New York: Raven Press; 1985:23.)

fibers of the levator aponeurosis that cross the orbicularis and insert into the dermis.[1] The second segment of the lid begins at the crease and extends to the superior orbital rim. Its layers consist of skin and orbicularis muscle, the orbital septum, the preaponeurotic fat pads, the levator aponeurosis, Müller’s muscle, and conjunctiva. The eyelid crease is formed by upper limit of septal

Figure 89-2 The invagination of the normal eyelid crease is created by the posterior pull on the septal insertion by the elevating levator aponeurosis. The preaponeurotic fat is also retracted by the septum. The flat portion of the lid under the crease slips inside the upper preseptal portion. (Adapted with permission from Zide BM, Jelks GW. Surgical anatomy of the orbit, Ch 4. New York: Raven Press; 1985:23.)

fibers from the aponeurosis inserting onto the orbicularis intermuscular septa and the skin. It marks the position where the septum inserts into the aponeurosis, which is also the lowest extent of the preaponeurotic fat pads.[2] If the fat recedes, the crease appears higher. When the levator aponeurosis becomes stretched or disinserted from the tarsus, it retracts upward, pulling up the septal insertion. In Asiatic eyelids, the crease (if present) is lower because of the low insertion of the septum into the aponeurosis and thus the lower extension of fat. [3]

When the eyelid opens, the lid crease skin is pulled upward and backward by the aponeurosis as it retracts under the fat pad (see Fig. 89-2 ).[4] The portion of the lid above the crease bulges slightly as this fat pushes the skin forward. During downgaze, tension in the aponeurosis becomes lax, resulting in a weakened or absent lid crease. These anatomical relations are also influenced by the size and position of the eye within the orbit.[5]

LOWER EYELID.

The lower eyelid has a similar, but simpler, anatomy. The capsulopalpebral fascia, equivalent to the levator aponeurosis, fuses with the orbital septum at or only a few millimeters below the lower border of the tarsus. Integrity of the medial and lateral canthal tendons (see Chapter 82 ) is very important to maintain a proper lid position with aging, but the bony configuration of the midface also plays a key role. Movement of the lower lid is of small amplitude. The crease, if present, is faint and lies close to the lid border.

Brows

A thorough understanding of the forehead anatomy is essential to evaluate brow ptosis ( Fig. 89-3 ). The layers in the midforehead are skin, dermis, superficial galea, frontalis muscle, deep galea, and periosteum. The forehead skin is much thicker than

Figure 89-3 Surgical anatomy of the forehead muscles and fascia.

the eyelid skin. The dermis and subcutaneous fat are connected to the underlying frontalis muscle by multiple fibrous septa. The paired frontalis muscles originate just anterior to the coronal suture line. A smooth fibrous sheath, the galea aponeurotica, envelops the frontalis to form both superficial and deep galeal layers. The periosteum lies beneath the deep galeal layer.

Laterally, the frontalis muscle ends or becomes markedly attenuated along the temporal fusion line of the skull. Here, the superficial galea, the superficial temporalis fascia, and the periosteum of the frontal bone fuse. The confluence of these tissue planes is called the “zone of fixation.” The eyebrow fat pad (subgaleal fad pad) is a transverse band of fibroadipose tissue 2–2.5?cm above the orbital rim. It allows movement of the frontalis muscle in the lower forehead. The eyebrow fat pad is continuous inferiorly with the suborbicularis space in the eyelid.

Centrally, the procerus muscle is continuous with the medial portion of the frontalis muscle and inserts into the nasal bone glabellar subcutaneous tissue. It causes horizontal wrinkles of the glabella. The corrugator supercilii muscle is obliquely oriented, passing from the subcutaneous brow to the frontal bone medially. It causes vertical glabellar furrows.[6] [7]

Several important neurovascular structures occur in the forehead. The frontal branch of the facial nerve lies within the superficial temporal fascia before entering the frontalis muscle. At the superior rim there are the lacrimal nerve laterally, the supraorbital nerve with its deep and superficial division, and the supratrochlear nerve more nasally.

Several factors contribute to the appearance of the aging forehead and brow. These include changes in the quality of the skin, loss of tissue support, and forehead and glabellar furrows related to action of the underlying facial muscles. [8] [9] [10] The lateral eyebrow segment is more prone to become ptotic because of less

structural support in this area. The final brow position depends on the dynamics between the frontalis muscle pulling the brow up and the descending temporal soft tissue dragging it down.[7]

BLEPHAROPLASTY

Preoperative Evaluation and Diagnostic Approach

HISTORY AND PSYCHOLOGICAL EVALUATION.

When evaluating patients who seek cosmetic improvement of the periorbital area, the surgeon should understand the patients’ motives for undergoing surgery and the decision-making process they have undertaken. Asking patients what changes they hope the surgery will make for them can sometimes reveal unexpected motives or unrealistic expectations. The psychological screening should include a past medical and surgical history with specific questions about previous cosmetic surgery. Outcomes of previous surgeries might give a clue to unrealistic expectations, especially if the objective results of these previous surgeries are not in harmony with the patient’s perception. A history of numerous cosmetic procedures is often an indication of inner conflicts. Previous mental illness should alert the surgeon—a psychiatric consultation is sometimes useful. Mental illnesses are not necessarily a contraindication to cosmetic surgery but can be in some instances. [11]

In assessing expectations, the surgeon can help by carefully discussing the surgery and explaining the improvements to be expected. It is important to detail the cosmetic defects that cannot be changed by surgery and establish a realistic plan for facial rejuvenation.

The patient is asked to consider carefully the decision to undergo surgery and, if one is sought, should be encouraged to obtain a second opinion. Establishing a relationship of trust is of paramount importance. If in any doubt, even for unclear objective reasons, a conservative attitude is recommended.

PHYSICAL EXAMINATION.

The position and shape of the different periorbital structures are evaluated along with the quality of the skin. In the forehead area, the level and shape of the hairline, the quality of skin of the forehead, and the position and shape of the brows are evaluated with specific attention to detecting brow asymmetry. The muscular layer is judged by looking at the frown lines in the forehead and glabellar area and by asking the patient to relax the forehead. Concomitant treatment with paralyzing injection (Botox) can distort this assessment. The bony orbit is then evaluated, especially laterally at the orbital rim, where some prominence can mimic lacrimal gland prolapse. This is a good time to evaluate the position of the globe in relation to the bony orbit, as this is an important determinant of the type of lid fold to aim for. A fuller orbit with a large eye leads to a convex upper eyelid above the crease, whereas a large orbit with a small eye results in a more concave upper lid abovethe crease.[12] A prominent globe with recessed zygoma often leads to lower lid malposition.

The inferior periorbital area is evaluated in a similar fashion. The quality of the skin is important, and cicatricial changes from dermatologic conditions can make the lid more susceptible to malposition after surgery. The cheek is examined for the presence of festoons, noting whether they consist of only skin and orbicularis or also of suborbicularis fascia and/or orbital fat.[13] [14] Precise measurements of the eyelid aperture should be recorded, noting the high point of the upper lid and the general shape of the palpebral fissure. The position of the lid crease and fold should be documented. The amount of fat to be removed in all fat pad areas, both superiorly and inferiorly, is estimated. The position of the lacrimal glands is also noted. The amount of excess skin should be evaluated after the surrounding structures have been corrected mentally. If a brow lift is also planned, the excess of lid skin will be less. In the lower lids the fat pads are also carefully assessed. Laxityof the canthal tendons is noted and manually tightened with the finger before considering removal of any skin. The nasojugal area should be examined to detect tear trough deformities, which may need correction instead of fat pad removal.[15]

The use of a flow sheet to outline systematically the physical findings is an excellent way to plan present and future surgery ( Fig. 89-4 ).[16] Surgery planning must take into account the patient’s desires, what he or she is willing to undergo, and what the

Figure 89-4 A sample worksheet to document the physical findings and surgical plan. (Adapted with permission from Flowers RS, Flowers SS. Precision planning in blepharoplasty. Clin Plast Surg. 1993;20:303–10.)

surgeon thinks is reasonable and safe. Figure 89-4 gives an overview of the evaluation of the patient consulting for blepharoplasty and brow malposition. A good set of photographs should carefully document the changes noted and be kept as part of the patient’s chart.

Anesthesia

Local infiltrative anesthesia containing epinephrine for hemostasis is adequate for all blepharoplasty procedures.

General Techniques

The patient should avoid using makeup on the day of surgery. Draping should be done carefully to avoid distortion of the brow and lateral canthi[17] and to allow the patient to sit up, if necessary, during the operation. The amount of skin to be removed is marked before infiltration. In the upper eyelid, excessive removal of thin lid skin and dragging down of thick brow skin are a nonesthetic shortcut and should not be substituted for adequate repositioning of the brows. In the lower lids the same principle applies: the lid should be repositioned and the scleral show corrected before any skin is removed. The ideal brow position is determined with the patient supine. Then, by letting the brow drop to its natural state, the amount of brow elevation required can be determined.

Specific Techniques

UPPER LID BLEPHAROPLASTY.

The lid crease is first marked at 8–10?mm above the lash line, taking into account the racial background of the patient. The crease marking usually goes from a point above the superior punctum to, but not beyond, the lateral orbital rim. Skin excess should be evaluated so that in downgaze the crease is attenuated without lid retraction, and a gentle fold reforms over it in primary position. Proper crease reformation and adequate excision of prolapsed fat allow the skin fold to be pulled into the orbit in upgaze. In general, 20–24?mm of skin should be left between the brows and the lid margin.[18] Even if associated brow ptosis is not to be corrected at the same time, excessive skin removal should be avoided. The long-taught rule that the eyes should not close on the operating table has certainly become obsolete. Excessive skin removal medially may result in hood formation. If disproportionate tissue is still present in this region after surgery, a glabellar lift should be considered.An optional small triangular flap of skin can be added to the usual skin pattern medially to minimize folding of the skin at the time of closure in patients with an unusual excess of skin medially ( Fig. 89-5 ).

The lid is placed under traction. A Bard-Parker No. 15 blade is used to incise the skin to the level of the dermis. The skin flap is then removed with a blade or scissors, leaving the orbicularis intact at this stage.

Gentle pressure on the globe prolapses the orbital fat and helps identify the orbital septum. The fat is exposed by making a small buttonhole centrally through the orbicularis and the septum above its insertion on the aponeurosis. The septum is opened laterally and medially from this buttonhole ( Fig. 89-6 ). Each fat pad capsule is opened. The fat is gently prolapsed and sectioned. The section line can be cauterized with a bipolar cautery ( Fig. 89-6 ). The paler nasal fat pad should be specifically exposed and resected to ensure a clean medial canthal area.

The orbicularis muscle is thinned down. The aponeurosis is bared of orbicularis just above the tarsal border to encourage the formation of a good adherence between the aponeurosis and the skin where the lid crease is to be formed. Invagination of the skin by fixing the skin edge to the aponeurosis at the time of closure ensures a good position of the crease in fuller lids but is not always necessary. The orbicularis can be tacked down to the aponeurosis immediately under the upper skin edge using two or three 6-0 plain sutures. This defines the position of the eyelid crease and controls the position of the fat pad in the lid ( Fig. 89-7 ). These techniques minimize the risks of ptosis and allow better attenuation of the lid crease in downgaze than firmer skin fixation.

The lid is closed with 6-0 nylon. The area beyond the lateral canthal angle is closed with interrupted sutures to obtain an edge-to-edge closure without folds. The rest of the lid is usually closed with a simple nonlocking continuous running suture ( Fig. 89-8 ).

LOWER LID BLEPHAROPLASTY.

Two specific techniques are popular for lower lid blepharoplasty. The skin approach allows modification of the interaction between the muscle and the skin planes and makes lid tightening or canthal repositioning easier. When only fat prolapse is present, the transconjunctival approach allows surgical access without visible scar and avoids the risk of lid malposition.

Skin Approach.

In the skin approach, the skin is marked 3?mm below the lash line from the inferior punctum to the lateral canthal angle. If excess skin is to be removed or if the orbicularis muscle is to be tightened, the incision is extended laterally and downward toward the earlobe for a short distance. Local anesthetic can be injected through the conjunctiva.

The skin is incised with a no. 15 blade and scissor dissection exposes the suborbicularis plane and the anterior surface of the orbital septum. The septum is easily identified by pushing gently on the globe to prolapse the fat and opened with scissors. The temporal and central fat pads are one continuous pad separated by a vertical band of fascial connections between the capsulopalpebral fascia and the orbital septum.[3] The capsule of each of the fat pads is opened. Care is taken to tease the fat out of the respective pockets without undue traction in order to avoid deep bleeding in the orbit. In the medial lid the fat capsule is opened separately, and care must be taken to protect the inferior oblique at the time of excision. The fat is carefully examined for bleeders before it is allowed to retract into the orbit

A canthopexy can be used to lift a sagging lateral angle by placing a suture through the lateral canthus and attaching it to periosteum.[19] If horizontal lid laxity is present, a tarsal strip procedure can be performed (see Chapter 88 ). A small triangle of skin and orbicularis muscle may be excised laterally. Closure of the orbicularis as a sliding flap often helps to rejuvenate an older lid. Hemostasis is attained carefully before the skin is closed with a continuous suture of 6-0 nylon.

Transconjunctival Approach.

With the transconjunctival approach, the lid is everted over a medium-size Desmarres retractor. The lateral fat pad is often the most difficult to expose—a buttonhole through the conjunctiva laterally about 4?mm from

Figure 89-5 Typical skin incision line used for upper eyelid blepharoplasty. A small additional medial flap is added (shaded area) if a dog-ear or fold develops because of excessive skin nasally.

Figure 89-6 Exposure and cauterization of fat pads. Preaponeurotic fat pads are a key landmark just anterior to the aponeurosis. The orbital septum is opened to expose the fat, and each pad is carefully cauterized along its base before being cut with scissors.

Figure 89-7 The eyelid fold or crease is reformed by passing several sutures from the orbicularis muscle to the aponeurosis at the appropriate height.

the inferior tarsal border can be helpful. The Desmarres retractor is used to pull the lid toward the cheek to expose the lateral fat pad. The fat is cauterized at the base and carefully cut with fine scissors. This approach allows early identification of the lateral fat pad before any bleeding occurs. The incision can then be extended medially to expose the central and medial pads, which are removed in the same way. Closure of the conjunctiva is completed with a few 6-0 plain catgut sutures.

Other Surgical Techniques

Use of the CO2 laser to minimize bleeding and help in tissue dissection is becoming popular but still requires proper understanding of lid anatomy and the general surgical principles of blepharoplasty. Resurfacing of the skin with the ultrapulse CO2 laser or chemical peeling solutions offers new opportunities

Figure 89-8 The skin is closed with two to three interrupted sutures laterally, where the skin is thicker, and with a running suture along the remainder of the wound.

to correct persistent wrinkles and lax skin that remain after blepharoplasty.[20] [21]

Specific techniques should be used when operating on Asian eyelids—the goals determine the technique to be used. In general, the skin incision is made lower toward the lid margin, depending upon the desired position of the resulting crease. Some preaponeurotic fat should be left to act as a barrier between the levator and the skin if the Asian-type lid is to be preserved.

Postoperative Care

A medium-pressure bandage is applied to the lids with an appropriate antibiotic ointment. The patient can remove the patches rapidly after surgery and start applying cold packs to the surgical site for 10 minutes each hour during the first evening and then four or five times the next day. Light analgesia for

blepharoplasty is usually sufficient. Severe pain is not expected and warrants immediate examination to rule out orbital hemorrhage or corneal abrasion. The sutures on the skin can be removed 5–7 days postoperatively if nylon 6-0 is used.

Complications

Complications of blepharoplasty are of two orders. One group of complications can occur from events unrelated to the technique used; a second group can occur following improper surgery for a particular deformation. For example, infection, despite the best surgical techniques, will occur in a small number of patients; the same is true of milia formation along a scar line. Lower lid ectropion or canthal angle rounding in the lower eyelid is usually the result of improper surgical planning or techniques. In the first group, careful follow-up and good patient teaching prevent most major problems. In the latter group, prevention is always better than secondary correction.

ORBITAL HEMORRHAGE AND BLINDNESS.

Orbital hemorrhage following blepharoplasty is an emergency. It has been associated with permanent loss of vision in some cases, especially if the lower eyelid is involved.[18] [22] Prevention involves careful preoperative screening for use of anticoagulants, including aspirin. Meticulous hemostasis, gentle manipulation of fat during surgery, and good control of blood pressure postoperatively are important. Early removal of patches and application of cold packs minimize swelling. Strenuous activities should be avoided for the first 3–4 days. Anticoagulants should not be administered for at least 5–6 days after surgery. The surgeon and medical staff should be alerted by unusual pain, swelling under tension, or double or blurred vision. If in doubt, the patient must be seen immediately for an assessment of visual acuity and pupillary response. In the presence of a deep hematoma the patient should be admitted for close monitoring of optic nerve function. If optic nerve dysfunctionappears, the wounds are opened and the blood is evacuated. The use of concomitant hyperosmotic agents (e.g., mannitol) has been advocated.[18] A lateral cantholysis helps decompress the soft tissues of the orbit, but with a deep hemorrhage an orbital exploration may be required. If all else fails, an orbital decompression, as done for compressive neuropathy in Graves’ disease, may become necessary (see Chapter 96 ).

INFECTIONS.

Fortunately, the eyelids are well vascularized so that infections after blepharoplasty are rare. Patients should be aware that an increase in swelling with redness and pain may be the first sign of infection. If it is confirmed by examination, appropriate cultures and sensitivities should be obtained and the patient started immediately on wide-spectrum systemic antibiotics. Close follow-up to rule out abscess formation in the orbit is necessary in severe cases and proper orbital imaging should be obtained. Blindness is a rare complication of infection, but it has occurred following blepharoplasty.[23]

TELANGIECTASIAS, CHEMOSIS, MILIA, AND SUTURE TRACTS.

Telangiectasias can form or previously present rosacea can become more evident in the lids after surgery, especially in the zone between the lid border and the incision in the upper eyelid. With time, these usually fade. Minimal dissection in this area prevents this annoying complication. In some cases, ecchymoses may stain the skin for up to a year. Careful suturing and early removal of sutures minimize the risks of inclusion cysts, milia, and suture tracts.

PTOSIS.

Ptosis may be present but unrecognized on initial preoperative examination in patients with severe skin excess. Palpebral fissures should be evaluated along with the levator action as if all patients were consulting for ptosis (see Chapter 86 ). If present, ptosis should be corrected by advancing the levator aponeurosis on the tarsal surface. Otherwise, at the time of blepharoplasty care should be taken not to damage the aponeurosis. If impending ptosis is present and the lid crease is reconstructed by supratarsal fixation, a slight tightening of the aponeurosis may be wise. When ptosis appears after surgery, conservative observation for 6 months is recommended. If it persists, surgical correction may be necessary.

LAGOPHTHALMOS, LOWER LID RETRACTION, ECTROPION, AND LATERAL CANTHAL DEFORMITIES.

If excessive skin has been removed in the upper lid, resulting in lagophthalmos, time is often of help; the brows continue their downward drift and the lagophthalmos often progressively decreases. Massage and ocular lubricants in the first few months after surgery may bring the patient out of this difficult phase. But if keratitis ensues and threatens the integrity of the eye, surgical correction should be done. In the lower lid, gravity works against spontaneous improvement. Frank ectropion might resolve with massage but almost invariably leaves lower scleral show. Using the transconjunctival approach when minimal or no skin excess is present, tightening the lateral canthal tendon if necessary, and avoiding excessive skin removal are the best ways to prevent this complication.[24] [25] Revision using a lateral tarsal strip procedure combined with a disinsertion of the lower eyelid retractors can give satisfactory results in mild cases. A midfacial lift or a skin graft may becomenecessary with more severe deformities. [26] [27] [28]

OTHER COMPLICATIONS.

Tearing after blepharoplasty can be a complex problem, especially if lagophthalmos is present. Investigation of this complication should include a full lacrimal work-up with assessment of the reflex component if keratitis is present. The integrity of the canaliculi and the position of the lid margin and puncta are all evaluated before planning correction (see Chapter 98 ). Injury to the extraocular muscles can occur, especially in the lower lid, where the inferior oblique and inferior rectus are prone to damage with exploration of the medial fat pad.[29] The superior oblique tendon can also be damaged in upper lid surgery.[30] In these instances, a follow-up of at least 6 months is necessary prior to considering surgical interventions, as spontaneous resolution is fortunately the rule.

Outcome

Most patients who seek cosmetic eyelid or brow surgery expect some improvement in their appearance and in their self-image and are usually happy with the result. Some, in whom the anatomical deformity interferes with visual function, as in severe overhanging dermatochalasis, can also notice improvement in their visual field. The patients who enter into surgery with unrealistic goals, either physical or social, are more at risk of not being satisfied with the results.

BROW MALPOSITION

Preoperative Evaluation and Diagnostic Approach

The ideal brow position and shape are subjective, but in general the brow is straighter and at the superior orbital rim in a man and more curved and slightly above the rim in a woman. An evaluation of the most cosmetically pleasing brows in women suggests that the medial eyebrow should be positioned at or below the supraorbital rim, with the eyebrow shape having an apex lateral slant.[31] [32]

The clinical evaluation should include brow position (estimated by the difference between the actual resting brow position and the desired position), the amount of excess forehead skin and degree of furrowing, the hairline position, and the length of the forehead. The length of the forehead can be determined by passing imaginary horizontal lines through the hairline, the upper border of the eyebrows, and directly below the nose. These lines divide the balanced face into three equal portions. An increase or reduction of the upper segment is an important factor when selecting the incision site using the coronal approach.[33] The extent to which the procerus and corrugator muscles contribute to furrowing of the forehead should be determined. A family history of male pattern baldness should be sought. It is important to determine how extensive a surgery the patient is willing to undergo to achieve the best results; often the

Figure 89-9 Surgical incision sites for correction of brow ptosis.

final surgical choice is a compromise between the most effective technique and the least invasive procedure.

Anesthesia

Anesthesia is provided by supraorbital and supratrochlear regional blocks along with direct local infiltration, depending on the extent of anesthesia desired for each of the various techniques. In selected patients, general anesthesia may be considered. Gentle but constant pressure minimizes the formation of hematomas that can distort anatomy.

General Techniques

Surgical approaches to the correction of brow ptosis include direct, midfrontal, and bicoronal brow lifts (see Fig. 89-9 ). More recently, endoscopic and small incision browplasties have been described. Minimal brow elevation can also be approached through an eyelid crease incision at the time of blepharoplasty.[34] The choice of technique depends on the amount of correction required and on the patient’s expectations.

Specific Techniques

THE BICORONAL FOREHEAD LIFT.

The bicoronal forehead lift allows the maximal effect of brow elevation with a well-camouflaged incision site.[35] It is ideally suited for patients with significant brow ptosis, without frontal baldness, and with a normal to low hairline.

The incision is hidden posterior to the hairline (post-trichion). Alternatively, in patients who have a high forehead, the incision can be placed at the hairline (pretrichion) to avoid further elevating the hairline. There are two major choices for the surgical dissection plane: subcutaneous and subgaleal.[33] Factors that influence the choice of dissection plane include the quality and elasticity of the skin, the amount of skin wrinkling, and the depth of the furrows, but surgeon preference is likely to be the most significant factor.[8] [33] A combined coronal brow lift and blepharoplasty can be used in patients with excessive eyelid fat and brow ptosis but little or no dermatochalasis.[36] The major disadvantages of the bicoronal technique include its invasive surgical approach, which can be intimidating to the patient, and the increased risk of hematoma and nerve injury.

THE MIDFRONTAL BROW LIFT.

The midfrontal approach provides less brow lift effect than does the bicoronal but more than the direct brow lift approach. Advantages include less risk of hematoma (because only moderate undermining is required and it is performed above the frontalis muscle) and less risk of nerve damage. The corrugator supercilii and procerus may be resected directly through this approach. It is ideally suited for patients who have deep horizontal furrows in the forehead (usually men), especially when frontal baldness prevents the use of a bicoronal incision. Some surgeons use this as their procedure of choice for brow ptosis in men and women.[32] There are various types of incisions that can be used for the following:

• Along a furrow line the entire length of the forehead.

• Along a furrow line staggered centrally.

• Two separate fusiform excisions, each extending from the medial to lateral end of the brow.

The major disadvantage of this technique is the resultant scar line.

THE DIRECT BROW LIFT.

The direct brow lift is the oldest and simplest surgical approach. Its advantages include a less invasive surgical dissection with less risk of damage to the facial nerve and minimal risk of hematoma. It is ideally suited for patients with bushy brows and mild brow ptosis. It can also be used in patients who have unilateral brow ptosis, which most commonly occurs following peripheral facial nerve palsy. It does not fully correct the medial brow ptosis, and it results in a visible scar even when placed directly above the eyebrow with often an unnaturally sharp border due to loss of the fine upper brow hairs. In patients who have large bushy brows, the incision tends to be less apparent. Modifications include a more temporal skin excision to correct isolated temporal brow ptosis.

ENDOSCOPIC BROW LIFT.

Recently, less invasive techniques have emerged in an attempt to reduce complications and achieve faster recovery. These techniques include endoscopic procedures, which involve small incisions placed temporally and/or centrally on the scalp, posterior to the hairline. A subperiosteal or subgaleal dissection is carried down to the level of the brow. The procerus and corrugator muscles are usually cut and excised, and the periosteum is transected at the superior orbital rim. The forehead is pulled upward and the periosteum fixed into position.

TRANSBLEPHAROPLASTY BROW FIXATION.

For minimal brow ptosis, the brow can be elevated through a blepharoplasty incision by suturing the sub-brow dermis higher on to the frontalis muscle. This approach can help correct mild brow ptosis or small asymmetries.[34]

Complications

Complications of browplasty depend on the technique used. There are two major groups of complications, those related to the incision site and those related to the extent of dissection. Complications related to the incision site are visible scar and alopecia.

EXCESSIVE CUTANEOUS SCAR AND ALOPECIA.

The forehead skin is thicker and less vascular than the eyelid skin, so incisions in the forehead often heal with a visible scar. Meticulous closure with adequate subdermal tension-bearing sutures and careful approximation of the wound edges is important. However, placement of the incision is the main determinant of scar visibility. It is generally preferable to locate the incision site at or above the hairline. Alopecia can be secondary to tension of wound, ischemia, or superficial dissection.

PARESTHESIA AND HEMATOMA.

Related to the extent of dissection are the potential associated nerve injuries, which can result in frontal paresis, numbness, and an increased risk of hematoma formation. Temporary paresthesia following browplasty is common but usually resolves within 6 months. Hematomas can occur

after bicoronal brow lift. They can be prevented at the end of surgery by placement of suction drains under the flaps. Small hematomas often resolve spontaneously, but larger ones should be evacuated to avoid flap necrosis, especially with a subcutaneous dissection where necrosis is more likely.

OVERCORRECTION AND UNDERCORRECTION.

Overcorrection of brow position or loss of movement of the brow can result in a “look of perpetual surprise,” particularly if the brow has been fixed to the underlying periosteum in an overzealous direct brow lift. Undercorrection occurs when insufficient elevation is achieved; it is more common with the endoscopic technique and with posterior fixation of the brow through a blepharoplasty incision.

Outcome

Following brow elevation procedures, the patient should experience an improvement in appearance and a restoration of superior visual field. In order to achieve these results, the brow repair may have to be combined with a blepharoplasty.

REFERENCES

1. Anderson RL, Beard C. The levator aponeurosis. Attachments and their clinical significance. Arch Ophthalmol. 1977;95:1437–41.

2. Flowers RS. Upper blepharoplasty by eyelid invagination. Clin Plast Surg. 1993;20:193–207.

3. Doxanas MT, Anderson RL. Eyebrows, eyelids and anterior orbit, Ch 4. In: Doxanas MT, Anderson RL, eds. Clinical orbital anatomy. Baltimore: Williams & Wilkins; 1984:57–88.

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