Transblepharoplasty browlift

Published on 22/05/2015 by admin

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Last modified 22/05/2015

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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

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