Internal Brow Elevation at Blepharoplasty

The internal brow elevation at blepharoplasty is a reproducibly safe and effective technique to improve eyebrow appearance without fixation.

See Original Article for photos and methods: Internal BrowElevation at Blepharoplasty John R Burroughs, Richard L Anderson et al

Eyebrow position, symmetry, and contour are paramount in the evaluation of the eyelids and face, as the eyebrows dramatically influence facial appearance and convey the physical and emotional state. For decades surgeons have sought to improve eyebrow appearance through various approaches. Most transblepharoplasty techniques recommend periosteal fixation, which limits brow elevation and increases the rate of complications. Coronal forehead-lifts and, more recently, endoscopic elevations have received the bulk of the cosmetic attention. These techniques address brow height and contour and attempt to weaken the medial brow depressor muscles. However, these procedures have several drawbacks. Coronal incisions are time consuming, leave conspicuous scars, cause hair loss, elevate the hairline, and may create significant scalp paresthesia. While endoscopic forehead elevation causes less scarring, it can cause alopecia, paresthesia, and hairline elevation and requires expensive instrumentation. Longevity and achievement of a reliably natural postoperative appearance has been debated.  Neither of these techniques are good options in patients with receding hairlines or “tall” foreheads. While these techniques may improve forehead rhytids, botulinum A toxin has become the best treatment for forehead rhytids in patients with adequate brow position.

More patients present for eyelid surgery than for brow-lift, and even those who request brow-lift and those requesting upper facial rejuvenation also require upper blepharoplasty. Most patients who present for eyelid surgery reject an upper facelift if suggested. Standard upper blepharoplasty and/or ptosis repair frequently aggravates brow ptosis by tightening tissues below and raising the upper eyelid margin. We present a technique, the internal brow elevation, to improve eyebrow appearance and position in conjunction with upper blepharoplasty. Suture fixation is not required, and we advise against brow fixation to allow enhanced natural brow elevation rather than restriction of movement. Most other transblepharoplasty techniques recommend periosteal fixation of the brow, which restricts movement of the brow and may create scarring to deep tissues and contour irregularities.

There has been a high level of patient acceptance of internal brow elevation, and it avoids many of the commonly associated complications of brow surgery. No additional incisions beyond the upper blepharoplasty are required. Release of the anterior leaf of the posterior galea and orbital ligament laterally, with removal of the corrugator and depressor superciliaris muscles medially, is performed. Sculpting of heavy brow fat pads enhances the elevation. There is no forehead scarring, no elevation of the hairline, and no alopecia. We have not encountered overcorrection or patients complaining of a postoperative “surprised” appearance. Temporary forehead hypesthesia is a predictable adverse effect. Internal brow elevation has high patient acceptance, saves time and cost, and reduces morbidity, while producing enhanced natural elevation of the brow rather than reduced motility from fixation.


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We retrospectively reviewed results of internal brow elevation on 1000 patients performed over the last 9 years in one of our practices (R.L.A.). All procedures were performed on patients presenting for blepharoplasty. Many patients also had associated ptosis repair. Long-term follow-up ranged from 6 months to 9 years. Patients presenting for internal brow elevation and corrugator muscle removal with myectomy for blepharospasm or for headache were excluded from this study. Patient selection and preoperative discussion is paramount because internal brow elevation is not adequate for all cosmetic patients. However, we have been pleased with the high level of patient acceptance and satisfaction in our oculoplastic surgery practice. Many patients who rejected a recommended forehead or direct brow-lift accepted the internal brow-lift and were satisfied. Some patients failed to achieve the degree of brow elevation they had expected, but only 5 opted for a secondary forehead-lift. Postoperative swelling, bruising, and wound discharge are often slightly more pronounced compared with standard blepharoplasty. None of our patients experienced overcorrection or longterm complications from the internal brow elevation with the exception of forehead hypesthesia. Some immediate forehead and brow hypesthesia is present in all patients because the superficial-most branches of the supratrochlear, supraorbital, and lacrimal nerves are invariably transected. Hypesthesia usually resolves in weeks to months and should be discussed preoperatively.Permanenthypesthesia is rare, and bothersome forehead hypesthesia lasting longer than 2 years has been a complaint in only 2 patients.