Anatomic considerations

The eyebrow and its surrounding soft tissues represent a specialized anatomic region of the face and the superficial sliding muscle plane of the forehead. Cadaveric studies by Lemke and Stasior⁴ have helped to define the brow-eyelid anatomic unit and its importance in repair of brow ptosis and dermatochalasis.

A fat pad exists beneath the eyebrow, from which dense attachments secure the brow to the supraorbital ridge. This fat pad enhances eyebrow motility, especially laterally, where it is most pronounced (Fig. 12-2A). The brow fat pad often extends inferiorly into the suborbicularis fascia-preseptal plane in the upper eyelid and can be mistaken for orbital fat by the novice blepharoplasty surgeon (Fig. 12-2B).

Figure 12-2 A, Frontal illustration of a ptotic left brow. The brow and the sub-brow fat pad extend below the orbital rim (dotted line), and brow ptosis is more prominent temporally.

B, Midsagittal illustration of the ptotic brow with inferior extension of the sub-brow fat pad anterior to the orbital septum. Note the relation of the thick ptotic sub-brow fat pad anterior to the orbital septum and orbital fat.

Both the size and position of the brow fat pad contribute to the gender differences in eyebrow appearance, which the surgeon must take into consideration. In women, the brow is generally arched and above the level of the supraorbital rim; in men, it is flatter and positioned at the level of the supraorbital rim. The fat pad in men is more prominent, producing a fuller appearance in the lateral brow area. Surgical manipulation of the size and position of the fat pad should respect these variations in men and women so that a natural and aesthetically pleasing result is obtained.

Early ptosis of the brow occurs most commonly over the lateral brow. The firm attachments of the brow fat pad to the supraorbital rim periosteum extend only over the medial one half to two thirds of the orbit around the supraorbital ridge prominence. Laterally, the attachments are weaker.

In addition, the frontalis muscle of the forehead supports the medial two thirds of the eyebrow and interdigitates with the orbicularis muscle. However, because the frontalis muscle fibers do not extend as far laterally as the lateral brow, frontalis muscle contraction cannot effectively prevent lateral eyebrow ptosis.

The supraorbital artery and nerve emanate from the supraorbital notch and pass superiorly within the medial portion of the eyebrow fat pad. For this reason, fat pad debulking and internal eyebrow lifting should involve only tissue lateral to the supraorbital notch, so that damage to the sensory nerves of the forehead is avoided.

Indications

Dermatochalasis (excessive skin) can often be dramatically improved with simple upper blepharoplasty alone. When ptotic eyebrows accompany dermatochalasis, however, they often accentuate the upper eyelid abnormality and should be taken into consideration during surgery. Debulking of the sub-brow fat pad via the blepharoplasty incision is an effective way to reduce the excessive fullness occasionally present in the lateral brow and can produce a more aesthetic overall result. This browplasty procedure is particularly important in women, in whom a thickened sub-brow fat pad can create a masculine appearance.

In patients with mild to moderate brow ptosis, plication of the brow above the supraorbital rim through the blepharoplasty incision can reduce the brow component of the upper lid dermatochalasis. This is especially helpful in patients with unilateral brow ptosis with asymmetric eyelid creases and folds. (In these patients a traditional upper blepharoplasty will lead to persistence of the asymmetric upper eyelid creases and folds.) This restores the natural height and curvature of the brow, thus enhancing the result of blepharoplasty.

Although the coronal and endoscopic forehead lift procedures provide the most pronounced correction of forehead and glabella laxity, these techniques may be more extensive than the patient or surgeon desires. It should be emphasized that the internal browpexy procedure does not replace conventional brow lifts and should not be done in patients with severe brow ptosis (see Chapter 6).

The browpexy and browplasty procedures described later can be used together or separately as an adjunct to standard blepharoplasty in carefully selected patients. The browplasty technique can be used alone in selected patients with ‘fullness’ of the lateral brow in whom there is no significant element of brow ptosis. Many patients have mild to moderate brow ptosis or unilateral brow ptosis without a significant thickening of the sub-brow fat pad. Although the debulking aspect of the browplasty procedures is not necessary in these patients, occasionally some amount of sub-brow fat needs to be removed so that periosteum for browpexy can be exposed. (However, I have gained respect for the sub-brow fat providing an aesthetically pleasing appearance and therefore either leave it intact or do a minimal incision in most cases.)

I have also found the internal brow approach to be useful in lowering an abnormally high eyebrow that occurs from fixation of the brow to periosteum from trauma.⁵ In these cases the brow is sutured to the level of the superior orbital rim.

Surgical technique

The amount of brow lift desired is determined while the patient is seated on the operating table. The site of the blepharoplasty is marked in the upper lid crease, and the supraorbital notch is palpated and marked to localize the supraorbital nerve and vessels (Fig. 12-3). The patient can then be reclined, and the upper eyelid and brow infiltrated with 2 percent lidocaine with epinephrine.

Figure 12-3 The supraorbital notch is marked, and a line is made above the brow to indicate the location of the supraorbital nerve.

Browplasty

After the standard blepharoplasty excision of the skin and orbicularis muscle, the dissection is extended superiorly toward the brow in the submuscular plane in the postorbicularis fascia (Fig. 12-4A and B). Dissection should extend approximately 1–1.5 cm above the superior and lateral orbital rim. The brow fat pad can then be identified overlying the lateral orbital margin. As has been emphasized, excision of the fat pad should be confined to the lateral aspect of the brow to avoid injury to the medial supraorbital neurovascular complex. Only partial sub-brow fat is removed as some fat should be retained over the orbital bone to avoid a depression of skin in this area.

Figure 12-4 A, A frontal illustration of browplasty. A skin-muscle eyelid crease approach is used to expose the sub-brow fat pad. The plane of dissection is in the submuscular postorbicularis fascia.

B, Midsagittal illustration of browplasty.

Following identification and exposure of the brow fat pad, an elliptical section measuring 1–1.5 cm vertically and tapering nasally and temporally can be marked with methylene blue (Fig. 12-5A). The fat pad is then removed on bloc from the central third of the superior orbital margin and laterally as far as the frontozygomatic structure (Fig. 12-5B). The fat pad should be removed down to, but not including the periosteum but leaving a thin layer of fat over the periosteum. The periosteum and a superficial layer of fat should remain intact so that adhesions can be avoided in an area designed for motility. Also, some fullness in this area is aesthetically desirable. If brow fixation or elevation is not desired, the blepharoplasty can then be completed.

Figure 12-5 Illustrations of browplasty technique.

A, After an eyelid crease incision is made, the upper eyelid skin is retracted superiorly. The thick sub-brow fat pad is exposed and marked with methylene blue.

B, The surgeon uses a cutting-cautery unit to resect the superficial sub-brow fat pad, leaving the periosteum and a thin layer of sub-brow fat intact.

Browpexy

Fixation or plication of the brow to the supraorbital rim periosteum can provide elevation of the ptotic or lax brow. One to three 4-0 polypropylene (Prolene) sutures are passed transcutaneously from the lower edge of the brow hairs into the previously dissected sub-brow space approximately 1 cm apart (Fig. 12-6A). The transcutaneous introduction of the sutures allows the surgeon to mark the position of the brow hairs while working underneath the dissected flap.

Figure 12-6 Illustrations of internal browpexy technique.

A, A 4-0 polypropylene (Prolene) suture is passed transcutaneously from the lower edge of the brow hairs into the previously dissected sub-brow space.

B, The 4-0 polypropylene suture is sewn through the remaining sub-brow fat and periosteum above the orbital rim.

C, The suture is then passed again into the sub-brow muscular tissue at the level of the original transcutaneously passed marking suture. The transcutaneous suture is removed.

D, The surgeon ties the suture in a loop over a 4-0 silk knot releasing suture if adjustment is necessary. Care is taken to avoid overtightening the suture once adequate placement is achieved, which may immobilize the brow.

E, Midsagittal section of completed browpexy.

Each suture is then passed through periosteum approximately 1–1.5 cm above the supraorbital rim (Fig. 12-6B). At this stage of the procedure, the height and curvature of the brow can be adjusted according to the patient’s gender. Placing the more central suture slightly higher allows the characteristic arch of the female brow to be restored or preserved.

The sutures are then passed again into the sub-brow muscular tissue at the level of the original transcutaneously passed marking suture (Fig. 12-6C). It is important to engage firm subcutaneous tissue so that the polypropylene browpexy sutures have the desired effect. The surgeon must, however, avoid suturing into the very superficial sub-brow tissues. This can lead to a dimpling of the skin as well as erosions of superficial tissues over the sutures and exposure of the sutures.

The original transcutaneous suture end is then pulled through the skin under the flap. The sutures are tied carefully over a 2–3 inch piece of 4-0 silk knot releasing suture in an attempt to avoid overtightening the 4-0 polypropylene loop (Fig. 12-6D). The patient is sat up on the operating table and the brow position is studied. If the brow is too high or low or if the arch is unsatisfactory, then the 4-0 silk suture is pulled to release the Prolene tie and the suture is replaced until the desired brow position is achieved. Ideally, these subcutaneous sutures should provide a mild brow-lifting effect and still allow the brow a good range of mobility (Fig. 12-6E).

I perform the internal brow lift with the septum still covering the levator aponeurosis to avoid a high upper eyelid crease from forming by orbicularis muscle attaching to the levator. Once the brow is placed in the proper position, I penetrate the orbital septum and suborbicularis fascia and then excise herniated orbital fat. When I form a lid crease by suturing skin to levator aponeurosis, I also include the inferior edge of the orbital septum-suborbicularis fascia. This technique provides a layer between orbicularis muscle and levator aponeurosis and avoids the complications of a crease that is too high and an eyelid that will not elevate properly.

Once the brow is set in the proper position, the surgeon penetrates the orbital septum and suborbicularis fascia. This is achieved by pulling the upper lid downward with a 4-0 silk traction suture that has been placed through central skin, orbicularis and superficial tarsus. The orbital septum and suborbicularis fascia are picked up with toothed forceps and pulled upward and outward. The tented inferior aspect of the septum and suborbicularis fascia is penetrated with Westcott scissors until the subseptal space can be see (Fig. 12-7A). The area then is widened by spreading the scissors blades.

Figure 12-7 A, After the brow has been elevated through internal fixation sutures, the suborbicularis fascia-septal layer is entered at its inferior position and is severed temporally and nasally. This is facilitated by pulling the upper eyelid downward with traction suture while lifting the central orbicularis fascia-septal tissue upward and outward with a forceps.

B, Two toothed forceps grasp the inferior edge of the suborbicularis fascia-septal tissue after it has been severed from its inferior attachment slightly above the superior tarsal border.

C, The surgeon uses two toothed forceps to lift the suborbicularis fascia-septal layer upward and outward, thereby exposing the orbital fat and levator aponeurosis.

D, Orbital fat is occasionally excised, and the levator aponeurosis is attached to the superior edge of the tarsal orbicularis. Then 6-0 polyglactin (Vicryl) sutures pass through the inferior skin edge, levator aponeurosis, and inferior edge of the suborbicularis fascia-septal layer and exit through the superior skin edge. Three sutures are placed to add to formation of the crease and to ensure that the suborbicularis fascia-septal layer covers the levator aponeurosis.

E, Cross-section of eyelid and eyebrow, as depicted in Fig. 12-7D.

With the eyelid still kept in this position with traction suture and forceps, one blade of the Westcott scissors is used to penetrate the central opening in orbital septum-suborbicularis fascia and is slid across the temporal eyelid. Cutting with the Westcott scissors proceeds anteriorly, and the septum-suborbicularis fascia is cut at its inferior aspect (Fig. 12-7A).

The maneuver is repeated over the nasal half of the orbital septum-suborbicularis fascia. The maneuver creates a flap of septum-suborbicularis fascia that has an inferior edge close to the superior tarsal border (Figs 12-7B and C).

An eyelid crease is formed by attaching three 6-0 white polyester fiber (Mersilene) sutures from the orbicularis muscle of the lower skin flap to levator aponeurosis. Next, three 6-0 white polyglactin (Vicryl) sutures are sewn to connect skin to levator aponeurosis and to the inferior edge of the septum-suborbicularis fascia flap (Figs 12-7D and E). One of these sutures is placed centrally, and one is placed nasally and temporally. The skin is closed with a 6-0 black silk suture run continuously.

Complications

One complication of internal brow lifts is dimpling of the skin in the area of the sutures if they pass too close to the skin. Most of the time, this problem can be determined during the surgical procedure and replacement of the suture can avoid the complication. If dimpling is noted postoperatively, it will usually resolve in a few months, but if not, then massaging the area frequently resolves the problem.

In a few patients in whom I originally performed the internal brow lift, a high upper eyelid crease was created that made it difficult for the patients to look upward. The patients found this crease objectionable. One possible cause of this complication is that the orbital septum and the suborbicularis fascia slid upward with the brow elevation. This allowed the orbicularis oculi muscle to fuse to levator aponeurosis at a high level. To help prevent this complication, I perform the excision of skin and orbicularis and browpexy or browplasty without penetrating the orbital septum and suborbicularis fascia. Once this is accomplished, I penetrate orbital septum and suborbicularis fascia, excise herniated orbital fat, and perform eyelid crease reconstruction. I then incorporate the inferior edge of the orbital septum-suborbicularis fascia flap to the inferior edge of the levator aponeurosis and to each edge of the skin wound. This technique enhances the crease and forms a barrier between the orbicularis muscle and the levator aponeurosis. I believe that this modification decreases the potential complication of a high upper eyelid crease, which would cause the patient difficulty in looking upward.

Complications of the browpexy and browplasty procedures, as with routine blepharoplasty, are few but notable. During exposure and debulking of the sub-brow fat pad, the surgeon may notice a significant venous plexus lying below and within the fat pad. Approximate cautery may be necessary to obtain adequate hemostasis and prevent postoperative hematoma. In addition, removal or disruption of this venous network may contribute to prolonged postoperative eyelid edema. Although a small amount of brow asymmetry may be unavoidable and acceptable, occasionally the extent of asymmetry may be unacceptable. This complication may be due to unilateral failure of the browpexy secondary to ‘cheesewiring’ of the suture through subcutaneous tissue. It can usually be avoided if the subcutaneous suture is passed into the sub-brow muscular tissue.

If too much brow fat is removed, it can lead to a depression of brow skin. This can be avoided by leaving a thin layer of sub-brow fat.

As stated previously, the internal browpexy procedure works well for mild to moderate brow ptosis and as an adjunct to blepharoplasty in selected patients. This procedure in patients with severe brow laxity commonly yields unsatisfactorily results.

Results

I have used the browplasty and/or browpexy procedures over the past two decades in more than 100 selected patients undergoing upper blepharoplasty and have had good results (Figs 12-8 and 12-9).

Figure 12-8 A, Preoperative photo of patient with fullness of temporal sub-brow due to thickened sub-brow fat.

B, Same patient after excision of sub-brow fat (browplasty).

Figure 12-9 A, Preoperative photo of patient with unilateral brow ptosis leading to asymmetrical upper eyelid folds. B, Same patient after elevation of ptotic eyebrow that not only leads to more symmetric brows but also more symmetric upper eyelids folds.

The browplasty fat removal technique has been uniformly successful in predictably debulking the thick, full lateral brow fat pad in selected patients. Most patients tolerate the somewhat prolonged postoperative edema and the transient lateral brow numbness quite well.

Similarly, the internal browpexy procedure yields good results once the surgeon gains adequate experience with the technique. Single suture browpexy for correction of mild lateral brow ptosis has consistently yielded excellent results in our patients. Occasionally, brow asymmetry has been encountered in patients with more marked brow ptosis in whom the browpexy procedure required more than two fixation sutures. Recurrent brow ptosis does often occur, at least partially, within 12 months of the internal suture browpexy procedure.

Since I have added the above modifications to the internal brow lift, no patient undergoing this procedure has developed an undesirable upper eyelid crease or has experienced any difficulty in looking upward.