Loss of elastic tissues and facial volume, as well as involutional changes of the forehead skin, lead to drooping of the forehead and eyebrows. This condition is known as brow ptosis. Severe brow ptosis may also result from facial nerve palsy. Brow ptosis frequently accompanies dermatochalasis and must be recognized as a factor that contributes to the appearance of aging in the periorbital area. If severe, brow ptosis may impinge on the superior visual field (Fig 12-28). The patient often involuntarily compensates for this condition by using the frontalis muscle to elevate the eyebrows. Such chronic contracture of the frontalis muscle often leads to brow-ache, headache, and prominent transverse forehead rhytids.
In most individuals, the brow is located at the level of or above the superior orbital rim. Generally, the female brow is higher and more arched than the typical male brow. The brow is considered ptotic when it falls below the superior orbital rim.
Brow ptosis should be recognized and treated prior to or concomitant with the surgical repair of coexisting dermatochalasis of the eyelids. Because brow elevation reduces the amount of dermatochalasis present, it should be performed or simulated first when combined with upper blepharoplasty. Aggressive upper blepharoplasty alone in a patient with concomitant brow ptosis leads to further depression of the brow. Brow ptosis may be corrected with browpexy, direct brow elevation, or endoscopic or pretrichial brow- and forehead-lift.
Figure 12-28 Brow ptosis causing functional impairment in the patient’s peripheral visual field.
(Courtesy of Bobby S. Korn, MD, PhD.)
Browpexy is used for treatment of mild brow ptosis and is performed through an upper eyelid blepharoplasty incision. The sub-brow tissues are resuspended with sutures to the frontal bone periosteum above the orbital rim as part of a blepharoplasty. Although this procedure provides minimal improvement in brow position, it can help prevent the retro–orbicularis oculi fat from descending into the eyelid.
Figure 12-29 Endoscopic forehead-lift. A, Location of incisions. B, After periosteal release, the scalp is retracted posteriorly and fixated in the 2 paracentral incisions with a fixation screw, drilled bone tunnel, or absorbable implant.
(Illustration by Christine Gralapp.)
Direct brow elevation
The brows can be elevated with incisions placed at the upper edge of the brow hairs. This is an effective technique for treatment of brow ptosis and is particularly useful for men and women with lateral brow ptosis. When direct eyebrow elevation is used across the entire brow, it may result in an arch or displeasing scar. Sensory paresthesias may be an adverse effect of the direct brow procedure.
Endoscopic brow- and forehead-lift
Endoscopic techniques allow the surgeon to raise the brow and rejuvenate the forehead (foreheadplasty) through small incisions approximately 1 cm (though incisions may vary) behind the hairline (Fig 12-29). Dissection is accomplished with an endoscopic periosteal elevator and blunt dissectors. Key steps are the incisions, creation of an optical cavity, periosteal release at the orbital rim, and fixation of the elevated flap. The forehead can be fixated using a drilled bone tunnel through the calvarium, resorbable anchors, or fixation screws. The advantages of the endoscopic technique are smaller incisions hidden within the hair, elevation of a lower hairline (short forehead), customized lifting of specific segments of the brow, and faster recovery (relative to pretrichial brow-lift). The disadvantages include the need for endoscopic equipment, risk of damage to the facial nerve, the possibility of alopecia around scalp incisions, and skin changes related to the fixation technique used.
Pretrichial brow- and forehead-lift
The pretrichial approach is used in patients who have a high hairline. Access is gained through a pretrichial incision (Fig 12-30) instead of the small skin incisions used with the endoscopic approach. Dissection is performed in the subcutaneous layer. An appropriate amount of forehead skin is resected, and the underlying frontalis and galea are plicated with a subsequent layered closure. The advantages of the pretrichial technique are powerful lifting of the brow without elevation of the hairline and no need for endoscopic equipment. The disadvantages are a relatively high incidence of postoperative sensory paresthesias and visible pretrichial scar line.
Figure 12-30 Pretrichial incision for forehead and brow elevation. The plane of dissection is the subcutaneous layer.
(Courtesy of Bobby S. Korn, MD, PhD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.