Many medical conditions rely upon strict numerical definitions to provide a diagnosis; diabetes mellitus and hyperlipidemia are two examples. In the case of brow ptosis, diagnosis is determined predominantly by the judgment and experience of the examining physician. Brow ptosis exists when inferior malposition of the brow interferes with aesthetics or function. The brow level deemed low in one person may be perfectly acceptable or "normal" in another.
With the brow being a mobile structure and prone to the secondary effects of age, solar elastosis, muscle action, trauma, and gravity, some degree of brow descent will eventually occur in everyone. Ideal brow position is regarded differently in different genders, races, ages, and even generations. In some communities, the concept of changing the brow's position or shape is considered anathema; in many Western societies, however, it is considered routine.
The classic teaching describes the ideal female brow position as above the level of the bony supraorbital rim, with an upward arch such that the peak of the brow lies between the lateral limbus and the lateral canthus. In men, the eyebrows normally sit at or just above the superior orbital rim, with a flatter contour. Age, cultural influences, occupations, and environmental effects all influence not only brow position and shape but also perceptions of what is aesthetically pleasing. A weather-worn farmer, for example, may have an inferiorly-positioned brow that provides some protection from light, dust, and wind. On the other hand, a model may require a higher brow position in order to appear more youthful or attractive, regardless of gender. Subtle changes in brow shape are also indicators of emotional state: low lateral eyebrows denote sadness or concern, low medial brows indicate anger, flat or low brows may display fatigue, and excessively elevated brows appear surprised. Similarly, temporal hooding and upper eyelid dermatochalasis may indicate tiredness, but when combined with frontalis overactivation because of the heavy upper eyelids, the impression of fatigue is multiplied. Finding the precise balance to portray happiness and vitality can be challenging. If upper blepharoplasty and blepharoptosis repair take place without addressing brow ptosis, the brows will appear lower after surgery because the frontalis tone is diminished once the visual fields are improved, thus also exacerbating a fatigued appearance. When brow ptosis is present, it is rarely completely symmetrical, because of myriad factors, including differences between the right and left sides of the face (hemifacial microsomia or facial paralysis), differential exposure to the elements (particularly for those who drive with a lowered window), the preferred side a patient may sleep on, and many others all affect brow position.
Common Causes of Brow Ptosis
Aging
Facial palsy
Trauma
Tumors
Clinical Presentation
Cosmetic complaints
Visual obstruction caused by secondary dermatochalasis and pseudoptosis
Asymmetric brow position
Irritation caused by secondary eyelash ptosis
In the absence of trauma, paralysis, or disease, brow ptosis occurs slowly, and most patients will not be aware of the brow ptosis until it is noted during a clinical examination or remarked upon by an acquaintance. Almost everyone over the age of 40 years, male or female, will have some degree of brow ptosis, and most of these patients will not require surgical correction.
Surgical Treatment Options
Direct brow lift
Mid-forehead brow lift
Pretrichial brow lift
Temporal brow lift
Coronal brow lift
Endoscopic brow lift
Internal (transblepharoplasty) brow lift
This article reviews the assessment and planning of brow lifts, in general, and indications and techniques for the mid-forehead lift, in particular.
Procedure History
Many surgical procedures, such as cranial trephination, nasal reconstruction, and skin grafting, have been performed for hundreds of years, and some, like cataract surgery, thousands of years. Surprisingly, brow lift surgery was only reported in the 20th century when Lexer first discussed and presented the forehead lift in 1910. Subsequently, an early coronal brow lift was described by Hunt, who did not undermine any of the tissues, thus limiting results. Joseph, in 1931, presented a detailed description of the pretrichial brow lift as well as incisions made lower on the forehead to augment the brow elevation. Many surgeons continued the practice of simple tissue resection until Passot reported selective neurotomy of the frontal branch of the facial nerve in 1933. This method diminished forehead wrinkles; however, the resting tone of the frontalis muscle was lost, and this was clearly counterproductive for brow ptosis. For reasons not entirely clear, surgeons continued to explore the idea of forehead motor denervation. Edwards reported isolated temporal neurectomy as recently as 1957. A more anatomical approach was advanced by Bames that same year when he described a direct eyebrow lift. Through this approach, he weakened the corrugator muscles and undermined the forehead up to the hairline while crosshatching the frontalis muscle. Modern hairline and coronal approaches to the forehead lift and brow lift were ushered in by Pangman and Wallace in 1961. Further refinement occurred in 1962 when Gonzalez-Ulloa incorporated the forehead lift into his facelift procedure.
Despite the initial enthusiasm for coronal lifting, reports in the 1960s and 1970s suggested that results of coronal forehead lifts were short-lived, which led to the procedure losing favor. It remained unrecognized that the results were bound to be temporary without undermining after excision of excess soft tissue. Until the early 1970s, most surgical procedures consisted of resection and repair without undermining or manipulating the forehead muscles; the anatomy and physiology of the forehead had not yet been adequately appreciated.
A significant advance occurred in the mid-1970s when several surgeons (Skoog, Vinas, Hinderer, Griffiths, Marino, and others) began to manipulate the frontalis muscle, usually by excising a strip to eliminate dynamic transverse lines on the forehead. This technique also allowed better stretching of the superficial tissues. Washio was one of the first to carry out cadaver studies when he noted in 1975 that removal of a transverse section of the frontalis muscle resulted in a significant elevation of the forehead. More dramatic approaches by Tessier, LeRoux, and Jones advocated the complete removal of the frontalis muscle. Not surprisingly, this aggressively destructive approach did not endure.
In the 1980s and 1990s, the coronal brow lift became the established method of brow lifting; this was partly because of the advances made by Tessier and his group in the exposure of the skull via subperiosteal approaches. It was said, not entirely in jest, that the coronal brow lift, with its associated loss of hair and sensation, and the overly tight appearing forehead and brow was "a surgical procedure designed by men for use on women."
In the 1990s, endoscopic approaches to brow lifts were developed. After the evolution of fixation techniques, it became apparent that in "brow lifting," brow shaping was at least as important, if not more so. Repositioning of the brows and forehead could be controlled with release of the periosteum from the lateral canthus to the lateral canthus across the superior orbital rims and the nasal bridge, combined with manipulation of the depressor and elevator muscles of the brows. Anatomical details were studied in order to design safe approaches that could be performed using minimal incision techniques. Understanding the sensory and motor innervation of the forehead and periorbital area allowed more accurate manipulation and modification of the tissues and permitted less invasive but also more effective techniques, such as the pretrichial and temporal brow lifts.
After some debate about the longevity and effectiveness of endoscopic brow lifts compared to coronal brow lifts, there are now two schools: one school still largely performs coronal brow lifts. However, more and more surgeons are becoming experts at performing endoscopic brow lifts. When patients are chosen correctly, these endoscopic brow lifts provide reliable and long-lasting results. Coronal brow lifts, pretrichial brow lifts, mid-forehead brow lifts, direct brow lifts, and temporal brow lifts are now more often performed for specific indications. The so-called internal brow lift, or transblepharoplasty browpexy, should perhaps be called a "supporting procedure" rather than a proper "brow lift." No long-term studies show effective brow lifting, and the design of the procedure does not address the complete arch of the brow nor the forehead.
Similar to many others, the mid-forehead lift procedure has specific indications, advantages, and limitations. This approach is most useful in males with heavy brows, overactive frontalis muscles, and deep, transverse forehead wrinkles that may hide a surgical scar.
Development of Brow Ptosis
Common refrains encountered in plastic surgery are "I am becoming my mother" and "I look like my dad." The patient is saying that family characteristics, both physical structure and response to aging, are becoming apparent. Everyone has an "aging clock," which is genetically determined, but skin and deeper tissues are also affected by environmental factors such as smoking, exposure to ultraviolet light, health, and diet, among others. It can help to examine photographs of the patients when they were younger and photographs of their parents to provide patients with some context for these changes. Aging affects nearly every structure in the face, and it is certainly the most common cause of brow ptosis.
Patients routinely exposed to the elements will show marked overaction of the corrugator, procerus, and frontalis muscles, especially if they have not protected their eyes from sunlight and other harsh environmental factors. The "weathered face" seen in sailors and farmers show these changes well, not just in the region of the forehead and the brows but also in the lower face and neck. These patients develop horizontal rhytides at the root of the nose, caused by procerus muscle contraction and marked corrugator lines, which are the vertical "number elevens;" the eyebrow heads may also appear closer together because of hypertonicity of the corrugator muscles. In these cases, surgeons may make an effort to elevate and separate the brow heads - an action that would often be avoided otherwise because of the operated appearance it can produce. When brow ptosis is moderate to severe, deep horizontal forehead lines may also appear due to frontalis muscle overuse. Some patients with notable glabellar muscle hyperactivity may develop a "fat nose syndrome" caused by the downward slide of the procerus muscle and the inward movement of the corrugator muscles. This results, especially in females, in a widened root of the nose. These patients benefit significantly from disruption of the procerus and corrugator muscles during brow lifting.
It may be helpful to compare current pictures of the patient with photographs taken when the patient was younger to assess the degree to which the brow position and contour have changed. Sometimes patients are surprised to see that their brows have changed very little since their teenage years. Regardless, while young patients may look attractive with brows in either a high or a low position because many visual cues exude youth, older patients typically look better with somewhat higher brows.
Besides the glabellar impact of aging, lateral brow droop almost always progresses over time because of a lack of support from the frontalis muscle. The angle of insertion between the frontalis and the orbicularis oculi muscles becomes more acute with age, thereby leading to further loss of support laterally; this results in temporal hooding, lash ptosis, temporal brow droop, and crow's feet wrinkles.
Clinical Presentation
Presentation of brow ptosis ranges from cosmetic complaints of forehead lines and secondary heaviness, or hooding, of the upper eyelids to unattractive frown lines and problems with vision. Cosmetic patients will primarily focus on upper eyelid heaviness and fullness; other complaints may include "looking tired, angry or unhappy" either from the patient or family members and colleagues. Patients will only rarely complain that their brows are heavy or droopy in the absence of other concerns and will usually need to have brow malposition demonstrated to them in the mirror.
History
A thorough preoperative assessment is vital. Past illnesses, medications, allergies, and any history of hypertrophic or keloid scarring are noted. Specific emphasis is placed upon any history of thyroid disease, diabetes, cigarette smoking, anticoagulation use, prior eyelid or brow surgery, and any tendency to develop unusual edema. Patients with thyroid disease may have deeper frown lines and may suffer from madarosis (loss) of the brow hairs. These patients also tend to develop prolonged edema after facial surgery. Thyroid disease must be controlled and stable, ideally for at least six months, prior to scheduling surgery.
Examination of the Face
Regardless of the nature of the chief complaint, if it pertains to facial aging, a complete facial examination is critical. Patients will often present with vague concerns that relate to the appearance of aging, fatigue, or poor mood; many will ask, "what do you think?" or "what can you do for me, Doctor?" The ability to pinpoint specific problem areas and identify corresponding surgical targets is crucial; counseling patients after completing a thorough physical examination will be immensely informative for them and facilitate the development of realistic goals and expectations. As a general rule, the face should be assessed for asymmetry between the left and right sides, as hemifacial microsomia can have a profound impact on surgical outcomes, and then the proportions of the upper, middle and lower thirds of the face should be examined. Lastly, the skin color and quality of every potential cosmetic patient should be evaluated as well. This algorithmic approach to facial analysis will help prevent overlooking any major abnormalities and focus the surgeon's and patient's attention on the available treatment options, which may or may not relate directly to the chief complaint, or the patient's original self-perception.
Examination of the Brows
Assess the hairline and forehead height relative to gender and ethnic norms.
Assess the density and distribution of scalp hair centrally and temporally.
Measure the height of the forehead: the distance between the corneal reflex and the anterior hairline or the distance between the central brow and the anterior hairline.
Measure brow position: the brow can be measured relative to the superior orbital rim or measured from the lid margin to the brow or from the corneal reflex to the brow centrally and from the medial and lateral limbi to the medial and lateral brow. Others use the medial and lateral canthi as reference points and compare the left and right brow positions.
Assess brow shape and symmetry
Assess eyebrow hair distribution: evidence of plucking, loss, tattooing, etc.
Assess eyebrow mobility.
Measure the degree of true dermatochalasis, as opposed to secondary dermatochalasis caused by brow ptosis - manually lift the brow into the desired position to do this.
Assess the medial and central superior orbital fat pads and any lacrimal gland prolapse.
Assess the distribution and depth of the forehead and glabellar rhytides.
Assess corrugator and procerus lines.
Assess crow's feet.
Evaluate for blepharoptosis.
Assess skin thickness and quality, noting how sebaceous the glabellar skin appears.
A basic lower eyelid assessment should be performed when considering brow or upper eyelid surgery.
When documenting brow ptosis, one reproducible measurement is the distance between the inferior limbus and the center of the brow. In most patients, this distance will be more than 22 mm. Although a measurement of less than 22 mm suggests brow ptosis, the formal diagnosis will depend upon the many other factors discussed above: age, gender, occupation, and societal expectations, among others. Ideal brow position is best determined on an individual basis by the surgeon and patient, taking into account the surgeon's experience, the patient's current and previous youthful appearance, and the specific aesthetic goals.
Measurement of Brow Ptosis
Measuring with a ruler on an upright patient, the brow is elevated medially, centrally, and laterally to assess the degree of brow ptosis. The difference between the desired brow position and the relaxed brow position indicates the degree of brow ptosis. It is critical for patients to relax the frontalis muscle before taking measurements; this may be accomplished by first having the patient close their eyes, then gently massaging the brow and forehead downward into their natural positions. From there, the patient can gently open their eyes, taking care not to engage the frontalis muscle. Occasionally, multiple attempts are required, and even with this method, reliably reproducible results can be elusive. Measurements will often reveal brow position asymmetry, and this should be indicated to the patient preoperatively using a mirror to forestall postoperative suggestions that any asymmetry is iatrogenic.
Although discussions concentrate on the brow and the brow height and contour, surgeons must not forget that the characteristics of the forehead are equally important; the severity of glabellar, corrugator, and frontalis lines, as well as skin quality should all be documented. The distance between the brow and the anterior hairline should be measured because, in some patients, hairline advancement may be desirable, which will inform the choice of brow lift approach.
Upper and lower eyelid assessment is important even for patients focused on brow lifting. The forehead, brow, and periorbital region are contiguous, and procedures performed on the brow will inevitably affect the upper eyelids, which will, in turn, influence the appearance of the lower eyelids. While some procedures directly involve both the upper and lower lids, such as canthoplasty, in many cases, the rejuvenation of the brows and upper eyelids in the absence of lower blepharoplasty will leave the inferior periorbital area looking more aged simply by contrast.
Assessment of the upper eyelids may include the following:
Corneal reflex to lid margin distance
Presence and position of the upper eyelid supratarsal skin crease
Amount of tarsal platform show
Degree of dermatochalasis: primary and secondary
Upper eyelid fat herniation, medial and central
Presence and degree of lacrimal gland prominence
Upper eyelid skin quality: solar elastosis, vertical wrinkles, visible blood vessels, etc
Bell's phenomenon
Blink completeness
Assessment of the lower eyelids may include the following:
Medial canthus: position, laxity, dystopia, scarring, webbing
Lateral canthus: position, dystopia, laxity, scarring, webbing
Lower eyelid distraction test
Lower eyelid snapback test
Inferior scleral show
The prominence of medial, central, and lateral fat pads
Nasojugal and malar groove depth
Malar angle
Tear film integrity and tear breakup time
Corneal sensation and health
Hertel measurement of the globe to assess for proptosis or enophthalmos
Copyright © 2024, StatPearls Publishing LLC.