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