An anatomically based study of the mechanism of eyebrow ptosis

The development of eyebrow ptosis with aging is commonly attributed to progressive laxity of scalp and forehead soft tissues. If the change in eyebrow position with aging resulted entirely from this basic mechanism of tissue stretching, uniform lowering of the medial and lateral eyebrow segments should occur. Clinical observations show, however, that the lateral eyebrow segment usually becomes ptotic earlier than the medial segment, indicating that a more complex mechanism exists. To clarify this process, anatomic studies were done on 20 (40 half-head) fresh cadaver specimens. Histologic studies also were performed to complement the gross anatomic findings. These studies confirm that the mechanism producing eyebrow ptosis has a relatively greater effect on the lateral eyebrow segment. The lateral eyebrow has less support from deeper structures than the medial eyebrow, and the balance of forces acting on the eyebrow selectively depresses the lateral segment. Structures that may promote mobility and gravitational descent of the eyebrow, especially the lateral eyebrow segment, are (1) the galea fat pad, (2) the preseptal fat pad, and (3) the subgalea fat pad glide plane space. Three forces that act on the lateral eyebrow are (1) frontalis muscle resting tone, which suspends that eyebrow segment medial to the temporal fusion line of the skull, (2) gravity, which causes the soft-tissue mass lateral to the temporal line to slide over the temporalis fascia plane and push the lateral eyebrow segment downward, and (3) corrugator supercilii muscle hyperactivity in conjunction with action of the lateral orbicularis oculi muscle, which can antagonize frontalis muscle activity and directly facilitate descent of the lateral eyebrow. The axis point for these forces is the temporal fusion line of the skull near the superior orbital rim. The interaction of those structures and forces contributing to the mechanism producing eyebrow ptosis is discussed. Derived concepts are applied to the execution of the forehead lift procedure.

Aesthetic analysis of the eyebrows

Advances in surgical techniques and instrumentation have led to an increased popularity of brow-lifting procedures. However, because of patient variability and differing surgeon opinions, eyebrow aesthetics and thus surgical goals remain to be clearly defined. We performed an in-depth evaluation of current eyebrow aesthetics using two study groups. Popular fashion models were evaluated and compared with our own patient population. Important differences in eyebrow position and shape between these groups are delineated and the surgical implications defined. Criteria that contribute to the aesthetics of the eyebrow are reviewed, and guidelines to optimize surgical results and avoid potential complications are discussed.

Raising eyebrows with botulinum toxin

BACKGROUND

Brow elevation rejuvenates the facial appearance.

OBJECTIVE

To determine if a significant degree of brow elevation could be achieved through selective botulinum toxin treatment of brow depressors.

METHODS

Seven women aged 31-42 (mean 37) years old were treated. The distance from lowest eyebrow cilium of the eyebrow to the midpupillary point was measured before and 1 month posttreatment. Botulinum toxin was injected into the glabellar area (7-10U) and the supralateral eyebrow (0-2.5U each side), to a total dose of 10-14 U.

RESULTS

Five individuals (71%) showed brow elevation of 1-3 mm with a mean elevation of 1 mm. Two individuals showed no change. Concurrent weakening of the frown response was noted in all patients.

CONCLUSION

Botulinum toxin treatment of brow depressors produces a small degree of brow elevation in the majority of patients.

Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females

This study correlates brow lift outcomes published in the plastic surgical literature with aesthetic criteria for ideal female eyebrow height and shape. Aesthetic criteria were determined by testing the opinions of 11 cosmetic surgeons and 9 cosmetologists. Eyebrow height and shape were altered with computer graphics to isolate those changes as the only variables of appearance. Plastic surgeons and cosmetologists preferred (p = 0.01) medial eyebrows below or at the supraorbital rim and disliked the medial eyebrow above the rim. Both groups preferred (p = 0.01) eyebrow shape to have an apex lateral slant. One hundred preoperative and 100 postoperative photographs from 16 frequently referenced articles on brow lifts were evaluated. There was a significant (p = 0.0008) increase in the number of medial eyebrows elevated above the rim. The number of medial apex eyebrows increased, and the number of flat brows decreased (p = 0.01). There was no significant increase in the number of apex lateral eyebrows. Three conclusions are made about female eyebrows: (1) The medial eyebrow should be located at or below the supraorbital rim but not above it. (2) Eyebrow shape should have an apex lateral slant. (3) Standard open and endoscopic brow lift operations frequently result in unsatisfactory eyebrow height and shape, judged by these criteria.

Orbital roof craniotomy via an eyebrow incision: a simplified anterior skull base approach

Utilizing the conceptual combination of brain protective skull base surgery and minimalism, a conventional frontal craniotomy for tumors in the subfrontal and parasellar regions is modified to an orbital roof craniotomy. Through a 4 to 5 centimeter (cm) long eyebrow incision an orbital roof craniotomy (measuring 2 cm by 3 cm), including the supraorbital arch, is made as a single piece bone flap. The orbital roof is opened up to the supraorbital fissure and to the optic canal by additional removal of the bone in the orbital roof. This will expose the globe and the orbitofrontal dura mater. When the dural incision is made at the orbital portion of the dura mater, the orbital contents are retracted by tack-up sutures. The tumor is removed utilizing the orbital space rather than the intracranial space. Brain retractors are not necessary and are not used to execute the tumor resection. This technique has been used in three patients with craniopharyngiomas, seven patients with meningiomas, and one patient with a subfrontal teratoma. Gross total resection was achieved in three patients with craniopharyngiomas and in five patients with subfrontal or parasellar meningiomas. Subtotal resection of the tumor was achieved in two patients with recurrent meningiomas and in the patient with a subfrontal teratoma. The surgeon's operating space through this exposure was sufficiently ample to achieve the goals of the operation. The direct eyebrow incision provides an additional vital working space with a width of more than 1 cm at the skull base by eliminating the scalp flap which a coronal incision employs. The surgical technique is described with a report of 11 cases.

Transcoronal eyebrow lift with concomitant upper blepharoplasty

A technique for eyebrow lift is presented which employs the eyebrow arch used by makeup artists to add subjectively to the operation and prevent the aesthetically displeasing result of a too highly arched brow. The marking technique to achieve the proper life is outlined. A concomitant blepharoplasty technique and its indications are presented.

Browplasty and browpexy: an adjunct to blepharoplasty

Surgical approaches to the eyelids and eyebrows have been refined by application of their anatomy and appreciation of their pathophysiology. Sexual variations in eyebrow appearance can be attributed in part to the eyebrow fat pad. In females, the eyebrow is generally arched and above the level of the supraorbital rim. The male eyebrow is flatter and at the level of the supraorbital rim. The eyebrow fat pad is more prominent in the male, producing a fuller appearance in the lateral brow area. Many women are concerned about the flatter, full lateral brow, which assumes a masculine quality. The authors describe a surgical technique that permits identification of the brow fat pad and then the ability to debulk the eyebrow (browplasty). In addition, the brow can be elevated by internal plication suture to physically elevate the eyebrow (browpexy). This procedure is designed to utilize an eyelid crease incision, and it reduces the indications for more involved procedures to eliminate brow ptosis, such as midforehead or coronal approaches.

Limited-incision forehead lift for eyebrow elevation to enhance upper blepharoplasty

Treatment of eyebrow ptosis to enhance the cosmetic effect from blepharoplasty is commonly done with a forehead lift using a coronal incision approach. The coronal scalp incision is associated with the annoying sequelae of frontoparietal scalp numbness, itching, and paresthesias, all of which can be permanent. A forehead lift technique with temporal scalp incisions only 4.5 to 5.0 cm in length can produce a result comparable with that of the coronal incision approach when combined with transpalpebral resection of the corrugator supercilii muscles and transection of the procerus muscle. This eyebrow elevation technique, like the endoscopic approach, minimizes the risk of permanently injuring the supraorbital nerve branches that innervate the frontoparietal scalp. Unlike the approach using only endoscopy, however, this technique can effectively treat cases of advanced eyebrow ptosis. The appropriate area of eyelid skin for excision may be difficult to assess when a forehead lift and upper blepharoplasty are done concomitantly. The described forehead lift incorporates a method to determine this area. This forehead lift technique, combined with a technique for protecting against overresecting upper eyelid skin, is described as used effectively on 140 blepharoplasty cases followed for 3 months to 4 years.

Eyebrow incision for combined orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of the anterior circulation. Technical note

A modification of the supraorbital keyhole approach, the eyebrow incision-minisupraorbital craniotomy with orbital osteotomy, is described. Unique to this approach is a one-piece supraorbital craniotomy, measuring 2.5 x 3.5 cm, that incorporates the orbital rim and roof and the frontal process of the zygomatic bone through an eyebrow incision. The orbital osteotomy facilitates view of the anterior and middle cranial fossa through the operating microscope, as well as the maneuverability of instruments through a small craniotomy. A pericranial flap is elevated with its base at the orbit and used for closure of the frontal sinus, if necessary. The approach was used successfully in elective surgery of 10 aneurysms of the anterior circulation. The mean aneurysm size was 5.9 mm, with a range of 4 to 10 mm. Advantages of this approach include minimal disruption and exposure of normal brain tissue, reduced frontal lobe retraction, and an excellent postoperative cosmetic result. The approach is performed quickly by virtue of a limited skin incision with minimal temporalis muscle dissection and a small bone flap. The neuroendoscope, although helpful at times, is not essential and no special instruments or intraoperative image guidance is required. Relative contraindications include the presence of a large frontal sinus, severe brain edema, and recent subarachnoid hemorrhage. In addition, this approach has not been used for the treatment of giant intracranial aneurysms.

Eyebrow analysis after blepharoplasty in patients with brow ptosis

Fifteen patients and 28 eyes with measurable eyebrow ptosis underwent standard upper eyelid blepharoplasty with or without sub-brow fat excision. The patients were educated about the status of their eyebrow position and the effects of either direct or indirect methods of brow elevation. The patients either refused or chose not to undergo browpexy by any method. Eleven patients and 22 eyes showed an insignificant change in their eyebrow position after surgery. Two patients and three eyes had a mild to moderate descent of the eyebrow and two patients had what was felt to be significant worsening of their eyebrow ptosis in one or both eyes. However, all were pleased with their result. Information as such, after a careful review of the literature, has not previously been published.

The versatile midforehead browlift

Ptosis of the brow is a significant and often unrecognized portion of aging of the upper face. It contributes to both cosmetic and functional aging. Correction is often mandatory prior to blepharoplasty in that functional problems may be worsened without elevating the brow. Direct and coronal browlifts are the most common approach to the problem. Midforehead browlifts have been reserved for men with receding hairlines. We have, for the past three years, performed midforehead browlifts on all our patients needing ptotic brow correction. Our review of 72 patients treated in this way, including 52 women, shows excellent and long-lasting cosmetic and functional improvement. There have been few complications, and the resultant incisional scars have been very well accepted. Therefore, we feel that the midforehead browlift, performed as we describe, is the ideal surgical correction for the ptotic brow.

The evolution of the brow lift in aesthetic plastic surgery

For nearly 100 years, aesthetic improvement of the aging face has included surgical elevation of the brow. Early attempts to correct brow ptosis were largely unsuccessful. Recognizing the need to modify the frown muscles heralded the achievement of results previously unobtainable. Within the past decade, the minimal incision approach to brow lifting afforded with the endoscope radically changed surgical options in forehead rejuvenation. Further advances have added to these options and have provided a palette of alternatives in aesthetic correction of the upper one-third of the aging face.

Muscles that act on glabellar skin: a closer look

The coronal incision forehead lift became a component of the face-lift procedure 35 years ago and increased the cosmetic benefit for the facial aesthetic surgery patient. Later, this enhanced cosmetic effect achieved from eyebrow resuspension was complemented by treatment of the glabellar skin lines by modifying corrugator supercilii and procerus muscle function through the same coronal incision. In recent years, newer procedures for treating the corrugator supercilii and procerus muscles by using endoscopy or limited incision techniques have eliminated the need for the coronal incision. With these newer techniques has come a renewed interest in the surgical anatomy of the muscle complex that acts on glabellar skin. This study was designed to examine the current understanding of the anatomy of these muscles and to resolve misconceptions and controversy concerning them. Fresh cadaver dissections and simulated muscle action studies done on the glabellar musculature of four specimens were correlated with nerve blockade studies performed in 10 subjects on the temporal and zygomatic branches of the facial nerve. The presence of the depressor supercilii muscle as a distinct entity was confirmed. The little-appreciated oblique head of the corrugator supercilii muscle was identified. The conclusions from this study suggest that the transverse head of the corrugator supercilii muscle produces the vertical component of the glabellar skin line and also contributes to the formation of the oblique component of the glabellar skin line. The oblique head of the corrugator supercilii muscle, the depressor supercilii muscle, and the medial head of the orbital portion of the orbicularis oculi muscle all appear to depress the medial head of the eyebrow and contribute to the formation of the oblique glabellar skin line. The nerve block study provided evidence that the zygomatic branch of the facial nerve supplies the three medial eyebrow depressor muscles, which opens the possibility for future nerve ablation techniques to control the action of the medial eyebrow depressor muscle group. This nerve block study also supports the concept of "physiologic" elevation of the medial eyebrow as an effective component of foreheadplasty.

Contemporary management of the aging brow and forehead

Management of the aging brow and forehead has recently evolved based on available innovative technologies. Likewise, procedure-specific indications have changed based on collective surgical experiences. No longer is the approach based solely on hair pattern or degree of brow ptosis. Patients require varying combinations of brow elevation (prior to blepharoplasty), correction of brow asymmetries, and hairline-preserving forehead elevation. Some may only require excisional or paralytic procedures of the frontalis muscle (horizontal forehead creases), corrugator supercilii muscles (vertical glabellar furrows), and procerus muscle (horizontal glabellar furrows). We present a 3-year experience using a problem-specific approach. This incorporates endoscopic technology, botulinum toxin type A purified neurotoxin complex (Botox, Allergan, Irvine, CA) intramuscular injection, and traditional procedures such as the coronal, pretrichial, midforehead, and direct browlift. Current indications, patient selection, and results are also discussed.

Treatment of essential blepharospasm. I. Comparison of facial nerve avulsion and eyebrow-eyelid muscle stripping procedure

Benign essential blepharospasm is an incurable disease for which many treatment modalities have been suggested. The two surgical procedures that have been used most commonly are avulsion of the facial nerve and stripping of the protractor muscles of the eyelid and brow. We compare two matched series of 22 patients; one group underwent facial nerve avulsion ("Reynold's" procedure), and the other underwent "muscle stripping" ("Anderson's" procedure). We noted the number of procedures required for the patient to obtain a functional visual result and the side effects produced. Additional surgical procedures required by patients undergoing facial nerve avulsion were additional facial nerve avulsion, repair of ectropion, and correction of dermatochalasis and brow droop. Additional procedures required in patients who had muscle stripping were excision of lower lid orbicular fibers or residual brow fibers. The Reynold group required 16 additional procedures (38 separate procedures) to obtain functional results, as opposed to the four additional procedures (26 separate procedures) required in the Anderson group. Two patients in the Reynold group who needed surgery have not yet undergone it at this writing. If they did, that would boost the total number of procedures to 40. Secondary procedures are needed 4.5 times more often with the Reynold procedure than with the Anderson procedure. The patient's subjective response to and acceptance of the procedure are much greater for the Anderson procedure.

Replantation of amputated facial tissues with microvascular anastomosis

A challenge to the microsurgeon is perfecting the technique of replantation of small pieces of facial tissue, mainly because of the extremely small size of the arteries as well as a lack of suitable veins for drainage. In the past 4 years, we have had seven cases of facial amputations, which included one scalp, two nasal tips, two ears, one lower lip, and one eyebrow. All of these patients were replanted/revascularized by microvascular anastomosis. Only two of the cases had suitable veins for anastomosis. Alternative techniques used for improving venous outflow were arterio-venous fistula, chemical leeches, and pin pricks. Four of the cases were completely successful, two cases had partial loss of the replant, and one case failed due to absence of venous drainage. In facial amputation, an aggressive microsurgical attempt will result in more tissue surviving and a better cosmetic outcome than in any other reconstructive procedures.

Reconstruction of eyelids and eyebrows in burned patients

The records of 283 consecutive patients treated for facial burns were reviewed. Eighteen percent of these patients had significant deformities of the eyelids or adnexal structures and underwent surgical correction. Our experience in managing these patients is presented and discussed.

Brow suspension, a minimally invasive technique in facial rejuvenation

People tend to prefer noninvasive or minimally invasive methods of facial rejuvenation, especially when it involves their face, which is the hallmark of a person's identity and impossible to hide. It is widely known that brow ptosis gives the face a "tired look" and also accentuates deformities of the upper eyelid. Most people who are interested in facial rejuvenation may not accept even a minor surgery, such as an endoscopic surgery. The senior author has developed a minimally invasive method of suspending the brow at a higher position. In this technique, there is neither surgical dissection nor a surgical incision except for four stab incisions and suture insertion, which is why we refer to it as a nonsurgical brow suspension. It is done under local anesthesia, and the brows are fixed in the position that they assume when the patient is supine. In the past 6 years, we performed 387 brow suspensions on 324 female and 63 male patients. The youngest patient was 19 years old, and the oldest was 74 years old. A retrospective chart review was done. These 387 cases were reviewed by comparison of preoperative and postoperative photographs. This approach was not only used for patients who were not interested in surgical rejuvenation but was also combined with lipofilling, laser resurfacing, and/or upper blepharoplasty. This technique is useful for correcting postsurgical brow asymmetry. We present this technique as an adjunct to the established techniques of facial rejuvenation. Despite the high patient acceptance and technical ease, it is not a replacement for the established techniques of facial rejuvenation.

Immediate hair transplantation into a newly closed wound to conceal the final scar on the hair-bearing skin

A surgical incision after suturing usually leaves a visible scar on the hair-bearing skin, even after optimal wound conditions. The conspicuousness of such a scar results from its linear continuity and hairlessness. To prevent this effect, a row of micrografts or minigrafts was inserted between the wound edges immediately after wound closure. The hair grafts that were transplanted were dissected from the discharged skin in the same surgical procedure, if feasible. Otherwise, a mini donor strip was harvested from the mastoid scalp to dissect the hair grafts. The final linear scar was interrupted and concealed sufficiently with the growth of the transplanted hairs. Tension-free closure is required to obtain a satisfactory result with this technique.

Invasive keratoacanthoma of the eyelid and ocular adnexa

PURPOSE

To report three patients with superficially invasive crateriform squamous proliferations of periocular tissue.

METHODS

The authors identified three patients with superficially invasive periocular tumors that had clinical features of keratoacanthoma. Clinical histories, radiographs, and surgical pathologic specimens were reviewed.

RESULTS

All three tumors arose over several weeks, had a crateriform configuration, and exhibited superficial invasion of underlying tissues, including perineural invasion and infiltration into skeletal muscle. All three tumors were classified as invasive keratoacanthoma. One tumor exhibited late perineural extension into the cavernous sinus and convincing histologic features consistent with squamous cell carcinoma.

CONCLUSION

The clinical importance of recognizing invasive keratoacanthoma is that although the tumor has the potential for spontaneous involution, locally aggressive behavior with deep perineural invasion is possible. This tumor is considered to represent a variant of squamous cell carcinoma. The authors recommend complete surgical excision of crateriform squamous proliferations with frozen section control of margins of resection.

Reconstruction of the eyebrow in the pediatric burn patient

We have reviewed our experience with reconstruction of eyebrow alopecia secondary to thermal injury in the pediatric patient. Reconstruction was performed with free composite strip grafts or vascularized island pedicle flaps. The complication rates for eyebrows reconstructed with vascularized island pedicles with respect to loss of a significant portion of the flaps (30.8 percent) and malalignment of the grafts (23.1 percent) were significantly greater (p less than 0.001) than the significant tissue loss (10.6 percent) or graft malalignment (7.9 percent) observed for free composite grafts. Hair density was more predictably restored with the free composite graft technique (p = 0.0004). The patients reconstructed with composite grafts had 89.4 percent acceptable results in contrast to 38.5 percent acceptable results obtained with the island pedicle technique. Based on these findings, we reserve the use of the vascularized island pedicle technique for male patients with unilateral alopecia and heavy hair density in the remaining eyebrow and in cases where free composite grafts have failed. The remaining patients are initially treated with free composite grafts with acceptable results in the overwhelming majority of cases.

Congenital ptosis: results of surgical management

PURPOSE

To determine the visual and cosmetic outcome following the surgical correction of isolated congenital ptosis.

METHODS

A retrospective review of the outcome of isolated congenital ptosis corrected under the supervision of one surgeon at The Children's Hospital, Camperdown, between January 1983 and January 1993 was examined. Some 65 patients with 80 involved eyes were identified; 30 eyes underwent a levator resection procedure, 40 eyes underwent a brow suspension using donor stored fascia lata, and in 10 eyes a brow suspension was performed using mersilene mesh.

RESULTS

In 78 eyes of 63 patients, a good cosmetic result was achieved. In two patients (two eyes) a poor cosmetic result was achieved. These two patients refused further surgery following an undercorrection of their initial ptosis. The recurrence rates for the primary procedures were 16.7% for levator resection procedures, 35% for brow suspension procedures using donor fascia lata, and 30% for brow suspension surgery using mersilene mesh. Some 35.3% of eyes following mersilene slings required further surgery for granulomas and exposed mersilene mesh compared with 6% having similar complications with stored fascia lata. Nine patients (11.25%) had reduced visual acuity (one line or more on the Snellen chart or its equivalent with the other tests used) on the operated side. Only one patient was found to have significant astigmatism.

CONCLUSIONS

An acceptable cosmetic result was achieved with one operation in 75.3% of cases. In 20.8% of cases a second operation was required and in 3.9% of cases three or more operations were required. This series supports the view that where possible, levator resection is the preferred form of surgery to correct congenital ptosis. When the levator function is inadequate, brow suspension is performed. The use of donor fascia lata resulted in a good cosmetic appearance with a low occurrence of surgical side effects. Amblyopia, when strictly defined, occurred in 11.25% of eyes despite early surgery for severe cases and intensive amblyopia therapy. Management requires repeated follow up for early detection and introduction of occlusion therapy or surgical ptosis correction.

Biodegradable positive fixation for the endoscopic brow lift

Development of endoscopic techniques allows the separation and repositioning of the periosteum of the orbital rims and zygomaxilla for a brow lift without skin excision. Questions have been raised about the permanence of this repositioning without fixation. We have developed a technique using biodegradable polylactide pericranial pins that serve as fixation points to allow specific suspension of the periosteum with positive positioning until the third phase of wound healing is complete. Through two inconspicuous incisions near the midportion of the scalp, subperiosteal dissection is carried to the orbital rims and the zygomatic arch anteriorly and all the way to the base of the occiput posteriorly. This allows for contracture of the occipitalis muscle to contribute to the repositioning and lifting of the brow. Up to seven sutures are then placed through and through the pericranium of the periosteum and frontalis along the superior and lateral border of the orbital rim. These stitches of long-acting polylactide acid are secured to two pins placed in the outer table of the cranium to maintain positive fixation for more than 6 weeks. In this way precise, positive positioning is maintained until wound healing and reattachment of the structures are complete. We began these procedures in 1993; our results at 24 months are promising.

Mersilene mesh brow suspension: efficiency and complications

The use of the Mersilene mesh sling brow suspension procedure for the correction of severe blepharoptosis in 76 lids of 54 patients is presented. After a median follow up of 20 months functional and cosmetic results and complications were evaluated. The method is considered to be an alternative for those cases not primarily suitable for autogenous fascia lata brow suspension.