Transblepharoplasty browlift

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CHAPTER 26 Transblepharoplasty browlift

John Siebert, Emily Ridgway

History

Since the initial description of the browlift by direct supraciliary forehead excision in 1964 by Castanares, several changes have allowed for its evolution: a more complete understanding of the role of the periorbital musculature and the advent of minimally invasive surgery and endoscopic techniques. The principal components of any surgical rejuvenation of the upper third of the face include orbital rim soft-tissue release, partial corrugator resection and frontalis modification, and lifting the brows to passively improve the upper eyelid aesthetics. These tenants have not changed but the approach to achieving them has evolved.

In 1982, Sokol and Sokol described the transpalpebral brow suspension through a blepharoplasty incision. They used interposing periosteal and orbicularis oculi flaps to elevate the brow without the need for a forehead incision. McCord and Doxanas also described a transpalpebral browpexy through a blepharoplasty incision in 1990. In 1996, Paul published his technique for the transblepharoplasty subperiosteal browlift. The periosteum of the superior orbital rim is incised lateral to the supraorbital neurovascular bundle extending to the subtemporalis fascial plane. The origin and insertion of the procerus are divided and the corrugator muscles are partially incised. In order to allow stabilization, a temporal incision is made for an oblique vector and lateral brow elevation and an anterior hairline incision made for vertical brow stabilization. Zarem et al. modified these techniques by elevating the undersurface of the orbicularis oculi and then securing it approximately one centimeter above the orbital rim. Niechajev again further modified this technique in 2002 by including orbicularis oculi muscle plication. These techniques were further advanced by the use of the endoscope. Ramirez described the similar approach with the addition of the endoscope.

It has been our practice since 1996 to perform fixation of the periosteum to the overlying orbicularis oculi. Since 1997, 281 cases have been performed in this manner. The indications initially included bald or high hairline patients but have since expanded to include patients with a thinning frontal/temporal hairline, with brow asymmetry, with mild to moderate non-central brow ptosis and as an adjunct to standard upper eyelid blepharoplasty. It can also be implemented in cases of concurrent or prior endoscopic browlifting to address recurrent trouble spots.

The advantages are the access through the upper blepharoplasty incision, technical ease, less bruising, and a shorter surgical time. In our opinion the results demonstrate an improvement in lateral brow or crow’s feet and the face to brow transition in cases combined with facelifting.

Physical evaluation

• In evaluation of the patient considering a transblepharoplasty browpexy, one performs a systematic assessment of the forehead and adjacent scalp and hairline, brow, upper eyelid and orbit.

• The patients should be examined with the frontalis muscle at rest.

• The central and lateral forehead and eyebrow and upper eyelid are evaluated separately.

• The brow is evaluated for prior incisions, symmetry, ptosis, and the relationship of the brow to the supraorbital rim.

• In women, the brow should arch above the supraorbital rim peaking above the lateral limbus. In men, the brow traverses the supraorbital rim in a more horizontal manner. Signs of brow ptosis include descent below the supraorbital rim, and lateral upper eyelid hooding.

• Kaye describes a method in assessing the need for a browlift with or without an upper eyelid blepharoplasty. The surgeon gently elevates the forehead and brows in order to visualize the effect on the eyelid ptosis.

• As patients age, they may present with ptosis of the forehead and eyebrows and laxity and excess of the upper eyelid skin. These patients may not achieve an optimal result with blepharoplasty or browlift alone and would be ideal candidates for a transblepharoplasty browpexy.

Anatomy

The transblepharoplasty browpexy focuses on the interface of two muscles: the orbicularis oculi and the frontalis. The orbicularis oculi is a sphincteric muscle involved in eyelid closure, both voluntary and blink. It has a concentric orientation of muscle fibers, which divide into the palpebral (pretarsal and preseptal) and orbital portions. The palpebral division is located just above the margin blending into the orbital portion of the orbicularis oculi, which in turn extends circumferentially to approximately 1.5 cm beyond the orbital rim.

The upper margin of the orbicularis oculi overlaps the frontalis muscle superiorly, the corrugator muscle, supratrochlear and supraorbital nerve medially and the anterior temporal fascia laterally.

Innervation to the forehead and supraorbital musculature is derived from the facial nerve (CN 7).

The frontalis muscle originates superiorly from the galea aponeurosis and attaches inferiorly onto the skin of the forehead. The temporal branch of the facial nerve innervates the frontalis muscle. The nerves travel in the areolar plane deep to the SMAS then cross the zygomatic arch and innervate the frontalis muscle via its inferior surface.

The temporal, zygomatic and buccal branches of the facial nerve innervate the orbicularis oculi on its deep surface. Sensibility to the forehead and brow is supplied by the ophthalmic division (V1) of the trigeminal nerve. The supratrochlear and supraorbital nerves arise from the trigeminal nerve and exit the skull via foramina or grooves at the supraorbital rim. After exiting the groove or foramen, the supraorbital nerve divides into the superficial and deep branches. The superficial supraorbital branches run over the surface of the frontalis muscle and supply sensibility to the lateral forehead, brow and anterior scalp with cross-over innervation from the zygomatic temporal branches which originate from the lateral forehead. The deep supraorbital division travels in a plane which is deep to the frontalis muscle to provide sensibility to the frontoparietal scalp.

The supratrochlear nerve branches pass through the corrugator supercilii muscle and supply sensibility to the central forehead.

Technical steps

1. Upper eyelid incision and blepharoplasty.

2. If the browpexy is performed as an isolated procedure, or if a skin-only blepharoplasty is performed, a transverse incision is made through the orbicularis oculi muscle.

3. Develop a plane deep to the orbicularis oculi muscle and dissect in the cephalad direction approximately 3–4 cm above the supraorbital rim and 1–2 cm beyond the eventual point of fixation.

4. Release the nasal brow and perform corrugator and/or procerus excision.

5. Browpexy absorbable suture placement beginning at central eyebrow moving laterally (three or more sutures are usually placed). Sutures are placed securing the inferior surface of the orbicularis oculi to the periosteum and frontalis muscle deep at the desired level. The suture placement is overcorrected and differential.

6. Examine result of suture placement for contour symmetry and achieved brow elevation.

7. Replacement of sutures should be done to correct asymmetry and to correct obvious dimpling of the brow with a smaller bite of the underside of the orbicularis oculi muscle.

8. Incision closure.

Postoperative care

Postoperative care of the transblepharoplasty browpexy patient includes acute management and delayed management:

• Acutely, the head is kept elevated and cool iced gauze is applied at the upper eyelids and brow region. Blood pressure is maintained within normal limits.

• The incision is managed with Steristrips, which are kept in place until suture removal at 3–4 days and then replaced.

• Long-term management includes gentle brow massage in cases of dimpling which resolves spontaneously and reassurance that forehead sensation will be restored.

Complications

The most frequent complications are transient contour abnormalities and dimpling at sites of suture placement and lower forehead, brow numbness. Both of these complications are transient. Less common complications include recurrent brow ptosis, asymmetry and hematoma.

Pearls & pitfalls

Pearls

• Dissect in the submuscular plane cephalad to the level of your intended suture placement. This will help smooth the contour of the brow and prevent notching above the brow.

• Place the sutures with a medial to lateral ascent.

• Obtain meticulous hemostasis and perform prudent dissection when possible with the Colorado tip electrocautery.

• Only elevate the middle to lateral third of the brow with suture placement. Elevation of the medial brow may be achieved by resecting the corrugator, procerus and medial orbicularis oculi muscle resection.

• Before wound closure, observe the patient for symmetry, contour abnormalities that could be remedied by suture replacement.

Pitfalls

• Do not elevate the middle or medial third of the brow as much as the lateral brow.

• Pay close attention to the location of the supraorbital and supratrochlear nerves.

• The goals of the surgery and eyebrow contour are different for a female or male patient.

• Do not use this procedure alone in cases of severe central brow ptosis.

• Permanent sutures are not recommended.

Summary of steps

1. Upper eyelid incision and blepharoplasty.

2. Incise orbicularis oculi muscle.

3. Dissect beyond the supra orbital rim and beyond the eventual point of fixation.

4. Corrugator or procerus excision.

5. Browpexy suture placement.

6. Examine for contour, symmetry and aesthetic goals.

7. Incision closure.

Fig. 26.C1 Case photographs: Anterior-posterior view.

Fig. 26.C2 Case photographs: Lateral photos of the patient with one- and three-year follow-up.

Further reading

Adamson PA, Johnson CM, Anderson JR, Dupin CL. The forehead lift: a review. Arch Otolaryngol. 1985;111:325.

Kaye BL. The forehead lift: a useful adjunct to the face-lift and blepharoplasty. Plast Reconstr Surg. 1977;60:161.

Knize DM. An anatomically based study of the mechanism of the eyebrow ptosis. Plast. Reconstr Surg. 1996;97:1321–1333.

Niechajev I. Transpalpebral browpexy. Plast Reconstr Surg. 2004;113:2172.

Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast Surg. 1996;20:129.

Paul MD. The surgical management of upper eyelid hooding. Aesthetic Plast Surg. 1989;13:183.

Ramirez OM. Transblepharoplasty forehead lift and upper face rejuvenation. Ann Plast Surg. 1996;37:577.

Riefkohl R, Kosanin R, Georgiade GS. Complications of the forehead-browlift. Aesthet Plast Surg. 1983;7:135.

Sokol AB, Sokol TP. Transblepharoplasty brow suspension. Plast Reconstr Surg. 1982;69:940.

Zarem HA, Resnick JL, Carr RM, Wootton DG. Browpexy: lateral orbicularis muscle fixation as an adjunct to upper blepharoplasty. Plast Reconstr Surg. 1997;100:1258.

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