Eyebrow position, symmetry and contour are of paramount importance in the evaluation of the eyelids and midface. The eyebrows dramatically influence overall facial appearance and convey the physical and emotional state of patients.
Surgeons have sought to improve eyebrow appearance through various means for decades. Coronal forehead lifts and, more recently, endoscopic elevations have received the bulk of the cosmetic attention. These techniques allow the surgeon to address the brow height and contour as well as weaken the medial brow depressors. However, these procedures have drawbacks in many situations. Coronal incisions may leave conspicuous scars, cause hair loss, elevate the hairline, and create significant scalp paresthesia. While endoscopic forehead and brow elevation causes less scarring, they may cause alopecia and paresthesia as well as elevate the hairline.
Neither of these techniques are options in patients with receding hairlines. In addition, the ability of the endoscopic approach to provide the longevity desired or a reliably "natural" postoperative appearance has been called into question by many. The authors present a technique to improve the eyebrow appearance and position in conjunction with upper eyelid blepharoplasty while avoiding many of the commonly associated complications of brow surgery. We refer to this technique as the internal brow elevation. No additional incisions beyond the upper blepharoplasty are required. Therefore, there is no forehead scarring, no elevation of the hairline and no alopecia. The procedure saves time and money and reduces morbidity while producing a natural elevation of the brow.
The anatomy and function of the brow region is an important consideration in cosmetic eyelid surgery. Several forces act segmentally on the eyebrows to create a dynamic equilibrium that determines brow position. The motility of the brow fat pad is important in determining how to best manipulate eyebrow position. Lemke and Stasior describe the mobile plane within the brow created by a division within the deep galea aponeurotica. The divisions of the deep galea, the anterior and posterior leaf, envelop the brow fat pad. The frontalis muscle and the orbicularis muscle have strong attachments to the frontal bone medially but less so laterally. This dearth of lateral support of the eyebrow and the mobility of the brow fat pad account for the prevalence of involutional lateral brow ptosis.
1) Intraoperative photo of the confluence of the orbital ligament and the anterior leaf of the deep galea. Note the attachment at the lateral orbital rim.
It is best to divide the discussion of brow ptosis into its lateral and medial components. The forces that cause descent of the lateral eyebrow include the weight of the eyelid and brow fat pad and the soft tissues of the temporal forehead above it. In addition, the confluence of the anterior leaf of the deep galea and the "orbital ligament"(formed by the superficial temporal fascia) and their attachment to the superolateral orbital rim tether the eyebrow and restrict it from full superior mobility. We believe this ligament is a check ligament preventing overaction of the frontalis muscle. The primary force that elevates the lateral eyebrow is contraction of the frontalis muscle. However, this is limited by the attenuation of the frontalis muscle lateral to the temporal fusion line of the skull. In addition, the brow fat pad's attachments to the lateral aspect of the supraorbital rim support the brow position in younger patients but weakens in older patients. The brow fat pad falls and puts more tension on the "orbital ligament" and anterior leaf of the galea.
We address the lateral eyebrows by sculpting and debulking the brow fat pad as well as releasing its attachment to the lateral orbital rim. The release of the inferior aspect of the "orbital ligament" and the anterior leaf of the deep galea aponeurotica maximizes the effect of the frontalis on the lateral eyebrow. The overall effect is a decrease in the bulkiness and weight of the brow fat pads and a subtle and natural elevation of the lateral brow. Of course, patients with severe brow ptosis or facial paralysis may require augmentation of their brow sculpting with browpexy, direct brow or small incision elevation techniques. However, the vast majority of patients in our practice are pleased with the natural appearance of brow sculpting and release associated with this technique. This occurs because of a decreased effect of gravity on the heavy tissues as well as unrestricted frontalis action.
2) Intraoperative photo of Stevens scissors opening the anterior leaf of the deep galea and releasing its tethering effect on the lateral brow. Note the underlying brow fat pad.