Minimally Invasive Brow Lifting Techniques

Talmage Broadbent; Ali Mohktarzadeh; Andrew Harrison

Disclosures

Curr Opin Ophthalmol. 2017;28(5):539-543. 

In This Article

Abstract and Introduction

Abstract

Purpose of review: Aesthetic concerns about upper eyelid and brow position are very common in ophthalmic practice. Management of brow descent and devolumization requires an approach customized to each patient taking into consideration preoperative examination and patient desires. This article will review several minimally invasive techniques that can be used to address the needs of patients with mild-to-moderate brow ptosis.

Recent findings: Recent publications describe and analyse efficacy of several variations of browpexy techniques.

Summary: Browpexy techniques provide a minimally invasive way to provide stabilization and modest elevation of the lateral brow. They can enhance outcomes of upper eyelid surgery in patients with both functional and cosmetic brow ptosis, who desire to avoid the cost and morbidity of more formal brow lifting techniques.

Introduction

Patients with periorbital concerns, whether they are purely aesthetic or functional, should have an evaluation that includes both eyelids and eyebrows. These structures function together and changes in one can affect changes in the appearance and function of the other. Consequently, patients who present for evaluation of droopy eyelids may have dermatochalasis, ptosis, brow ptosis, and often some combination of all of these. A growing body of research is aimed at understanding the interplay between the eyelid and brow position and how intervention, be it surgical, with neurotoxin, or volumization, alters brow position and contour. Customizing management of brow position needs to take into consideration numerous factors, including brow position, contour, forehead rhytids, hairline, and most importantly patient desires.

Three articles have specifically addressed the question of whether brow position changes after ptosis surgery. Taken together these articles suggest that ptosis surgery, whether done by Muller's muscle conjunctival resection or by external levator advancement, leads to a decrease in brow height.[1,2,3] Though the amount of brow descent and how often it is clinically relevant is still debated.

The question of whether or not blepharoplasty alone results in a change in brow height is a question that has been examined several times with mixed results.[1,4,5,6,7,8–11] These studies vary significantly in their methodology and conclusions making it difficult to form a definitive opinion by appealing to the existing literature.

It is clear that the regulation of the position of the eyelids and brows is a complex one with interplay between muscles and connective tissue structures with neuronal pathways and interactions that are not fully understood. Taken together, the body of literature indicates that there is a subset of patients who will manifest latent brow ptosis after eyelid surgery. Each patient should be assessed as an individual with a customized treatment plan. In such complex situations, it can be difficult to generalize results from population-based studies to an individual.

It is our experience that unrecognized lateral brow ptosis prior to surgery or unmasking of latent brow ptosis following surgery both lead to patient dissatisfaction. Attempting to remedy this with additional skin excision can shorten the distance between the eyelid and the brow causing both aesthetic and functional concerns.[12,13] The most appropriate course is often to address the lateral brow position during eyelid surgery which allows for appropriate debulking of redundant upper eyelid tissues. Browpexy techniques are very effective in this role.

We do not opine that browpexy procedures should be considered in the same category as formal brow lifting procedures such as endoscopic, pretrichial, and cornonal brow lift. Browpexy procedures can provide patients with mild-to-moderate lateral brow ptosis with stabilization and modest lifting of the lateral brow, as well as create a subjectively more pleasing three-dimensional contour secondary to repositioning of the brow fat pad. Browpexy techniques are most often performed at the time of upper eyelid blepharoplasty and provide both an additional aesthetic and functional benefit to these cases, though they can be used successfully as isolated procedures for some patients. These procedures do not provide a significant amount of brow elevation and patients with severe brow ptosis or those desiring more than 2–3 mm of central or lateral brow lift will be better served with traditional brow lifting techniques. Traditional brow lifting procedures can provide powerful lift; they may be financially prohibitive, more invasive, and more significant potential complications than the procedures that will be discussed in this review. In addition, many patients desire to avoid the 'operated on look', which can be associated with the more traditional brow-lifting techniques. This article will review three browpexy techniques: internal browpexy, brassiere suture, and external browpexy.

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