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Brow positioning in blepharoplasties key to keeping lid on deformities

Article-Brow positioning in blepharoplasties key to keeping lid on deformities

Dr. Flowers
National report — More than three decades ago, Robert S. Flowers, M.D., had a patient tell him that the blepharoplasty he'd done on her had changed the shape of her eye.

"I resisted at first, but I mustered the courage to listen and look," he recalls. "She was right; it was the operation that was wrong!"

Over the next few months, his philosophy on eyelid surgery "underwent a 180 degree change in direction and emphasis," Dr. Flowers, director, Flowers Clinic, Honolulu, tells Cosmetic Surgery Times.

"Instead of looking brighter, fresher and more youthful, my patient — like so many people having blepharoplasty — looked older, more tired and angry," he says. "I wondered what had gone wrong."

What had gone wrong, Dr. Flowers relates, is that the blepharoplasty had been designed on a static model, without any attention paid to the dynamic relationships between the muscles and skin around the eyes. When it comes to blepharoplasty, he adds, the upper eyelids are of special concern.

"Here's the problem as far as upper eyelids go," Dr. Flowers observes. "Most people constantly raise their eyebrows to have comfortable, unobstructed vision, which means constant frontalis muscle contraction from the time we wake up until we go to sleep. For convenience, we labeled this overtime working of that muscle 'compensated brow ptosis.'"

Assess brows, upper lids together

Dr. Flowers says that typically, when the ptotic brow remains uncorrected, upper blepharoplasty — by removal or invagination of upper-lid tissues — reduces visual obstruction along with the requirement for elevating the eyebrows.

This, in turn, allows the overworked frontalis muscle to relax, and this relaxation continues to drop the brow until the lid and juxta-brow tissues barely clear the upper lid margin (and the path of vision). This dumps more tissue on the eyelid, making it appear as if there is more excess eyelid skin. As more tissue is removed in subsequent procedures, there is yet further frontalis relaxation and brow drop, until either the brow bottoms out at its resting position or arrives at the lowest eye-open level where there is comfortable, unobstructed vision.

"After most upper-lid blepharoplasties, there is a significant drop in brow posture, which usually makes the patient look older and tired," Dr. Flowers explains. "In addition, the frontalis relaxation leaves its antagonist corrugator supercilli muscles unopposed, releasing frontalis pull on glabellar skin.

"Both of these accentuate corrugator frown activity between the brows, making the patient look more angry," he adds. "The constant frontalis muscle contraction demanded by ptotic eyebrows — which I refer to as 'compensated' brow ptosis — often raises the medial brow more than the lateral part."

Dr. Flowers says this is because the common limited medial insertion of the muscle makes it difficult to clear lateral brow overhang, so that marked medial elevation is needed in order to adequately clear vision obstruction laterally. He says this distorted medial brow over-elevation, caused by limited medial brow muscle insertion, self-corrects with frontalis relaxation induced by lateral brow lifting or elevation.

"In my opinion, the solution is that, before any eyelid operation, it's essential to determine the relaxed resting position of each eyebrow and properly assess the amount of compensated brow ptosis," Dr. Flowers says. "A brow-elevating procedure must precede or accompany any upper-lid blepharoplasty on a person with compensated brow ptosis, with very few exceptions."

This, he says, is the only way to avert the brow-drop frown accentuation deformity and to prevent over-excision of upper-lid skin and muscle, which causes dry eyes and makes subsequent brow lifting dangerous, if not impossible.

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