The direct brow lift: efficacy, complications, and patient satisfaction

Dual-plane lift-and-hold technique for brow ptosis in young patients with facial paralysis

BACKGROUND

Direct browlift is useful but leaves a scar above the brow. We proposed a dual-plane browlift to avoid facial scarring while effectively resolving brow ptosis in young and young adult patients.

METHODS

Seven patients with facial palsy underwent dual-plane browlift between July 2018 and June 2022. The mean postoperative follow-up period was 31.9 months. Skin resection at the hairline was combined with subcutaneous dissection down to the inferior margin of the brow to "lift" the brow. Fascia lata strips were fixed to the dermis just inferior to the eyebrow to "hold" the brow, and the strips were suspended upward through the subperiosteal tunnel and fixed to the periosteum. Brow height was compared before and after the procedure and with the contralateral side.

RESULTS

The reported complications included slight hematoma at the recipient site, temporary difficulty in closing the eye, and seroma at the fascia donor site. The paralyzed side showed significant differences between the preoperative period and postoperative months (POM) 3, 6, and 12, but differences were not shown in the intervals between POM 3 and 6, 6 and 12, or 3 and 12. The difference in eyebrow height between the paralyzed and nonparalyzed sides was significant preoperatively but not at POM 3, 6, or 12. All scars matured well, and the fascia silhouette was not visible in the forehead region.

CONCLUSIONS

Dual-plane browlift enables rigid suspension using the fascia lata and excises flaccid skin without leaving facial scars, yielding excellent cosmetic quality and stable long-term outcomes.

Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

How Brow Rotation Affects Emotional Expression Utilizing Artificial Intelligence

BACKGROUND

It is well known that brow position affects emotional expression. However, there is little literature on how and to what degree this change in emotional expression happens. Previous studies on this topic have utilized manual rating; this method of study remains small and labor intensive. Our objective is to correlate manual brow rotations with emotional outcomes using artificial intelligence to objectively determine how specific brow manipulations affected human expression.

METHODS

We included 53 brow-lift patients in this study. Pre-operative patients' brows were rotated to - 20, - 10, +10, and +20 degrees in respect to the central axis of their existing brow using PIXLR, a cloud-based set of image editing tools and utilities. These images were analyzed using FaceReader, a validated software package that uses computer vision technology for facial expression recognition. The primary facial emotion and intensity of facial action units (0 = no action unit detected to 4 = most intense action unit detected) generated by the software were recorded.

RESULTS

265 total images [5 images (pre-operative, - 20 degree brow rotation, - 10, +10, and +20) per patient] were analyzed using FaceReader. The primary emotion detected in the majority of images was neutral. The percentage of disgust in patients' expressions, as detected by FaceReader, increased with increased positive brow rotation (1.76% disgust detected at - 20 degrees, 2.09% at - 10 degrees, 2.65% at neutral, 2.61% at +10 degrees, and 2.95% at +20 degrees). In contrast, the percentage of sadness in patients' expressions decreased with increased positive brow rotation (29.92% sadness detected at - 20 degrees, 21.5% at - 10 degrees, 11.42% at neutral, 15.75% at +10 degrees, and 12.86% at +20 degrees). Our facial action unit analysis corresponded with primary emotion analysis. The intensity of the inner brow raiser decreased with increased positive brow rotation 8.54% at - 20 degrees, 4.21% at - 10 degrees, 1.48% at neutral, 0.84% at +10 degrees, and 0.76% at +20 degrees). The intensity of the outer brow raiser increased with increased positive brow rotation (0.97% at - 20 degrees, 0.45% at - 10 degrees, 1.12% at neutral, 5.45% at +10 degrees, and 11.19% at +20 degrees).

CONCLUSION

We demonstrated that increasing the degree of brow rotation correlated positively with the percentage of disgust and inversely with the percentage of sadness detected by FaceReader. This study demonstrated how different manipulated brow positions affected emotional outcomes using artificial intelligence. Physicians can use these findings to better understand how brow-lifts can affect the perceived emotion of their patients.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Occurrence and treatment of peripheral nerve injuries after cosmetic surgeries

Although non-invasive and minimally invasive aesthetic procedures increasingly dominate the cosmetic market, traditional plastic surgery remains the most effective improvement method. One of the most common complications in plastic surgery, peripheral nerve injuries, though has a low incidence but intrigued plastic surgeons globally. In this article, a narrative review was conducted using several databases (PubMed, EMBASE, Scopus, and Web of Science) to identify peripheral nerve injuries following cosmetic surgeries such as blepharoplasty, rhinoplasty, rhytidectomy, breast surgeries, and abdominoplasty. Surgery-related nerve injuries were discussed, respectively. Despite the low incidence, cosmetic plastic surgeries can cause iatrogenic peripheral nerve injuries that require special attention. The postoperative algorithm approaches can be effective, but the waiting and treatment processes can be long and painful. Preventive measures are undoubtedly more effective than postoperative remedies. The best means of preventing disease is having a good understanding of anatomy and conducting a careful dissection.

Objective Comparison of Eyebrow Position after Internal and External Browpexy

BACKGROUND

Several brow-lift techniques have been used to prevent brow ptosis after blepharoplasty. For example, both internal and external browpexies have been adopted worldwide. However, few studies have compared these two methods. The authors compared postoperative eyebrow position changes between upper eyelid skin excision, internal browpexy, and external browpexy.

METHODS

The authors retrospectively reviewed the cases of 87 patients who underwent upper blepharoplasty performed by a single clinician at their institute between April of 2018 and June of 2020. Patients with routine outpatient photographs taken before and after surgery were enrolled in the study. ImageJ was used to measure brow height at eight points in each eye. Brow height changes were compared among the three groups.

RESULTS

Routine photographs were available for 68 patients (133 eyes). Thirty-nine patients underwent internal browpexy (78 eyes), nine underwent external browpexy (17 eyes), and 20 underwent upper eyelid skin excisions (38 eyes). Three months after surgery, significant elevation was noted on the lateral side of the brow in the internal browpexy group and across the whole brow in the external browpexy group. In the upper eyelid skin excision group, whole brow ptosis was observed. Brow-lift outcomes were better in the external than in the internal browpexy group, whereas both browpexy groups showed better outcomes than the upper eyelid skin excision group.

CONCLUSIONS

Within 3 months of surgery, both internal and external browpexy provided significant brow-lift effects, preventing brow ptosis caused by blepharoplasty with skin excision. External browpexy had better brow-lift outcomes than did internal browpexy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Topography of the frontal branch of the facial nerve and its clinical implication for temporal direct browplasty

Due to anatomic proximity to the surgical site, iatrogenic trauma to the frontal branch of the facial nerve (FbFN) with resultant brow paralysis is a recognized major complication of temporal direct browplasty. This study was aimed to elucidate the course of the FbFN in the area superolateral to the brow in order to facilitate safer temporal direct browplasty by preventing facial nerve injury. Forty-five hemifaces from 32 embalmed Korean cadavers were dissected. A horizontal line connecting the tragion to lateral canthus was established. Then, an oblique line passing through the lateral canthus and 45° to the horizontal line was used as reference line. The mean distance from the lateral canthus to the points where the FbFN cross the reference line was measured. The angle between the FbFN and reference line at the crossing points were also recorded. After crossing the zygomatic arch, FbFN continues in an anteriorly inclining curve across the temporal region, passing near the lateral end of the brow as it heads toward frontalis muscles. During the course, the FbFN laying in the innominate fascial layer was divided into 3 branches. The anterior and posterior branch of FbFN crossed the reference line superiorly and laterally at 3 and 4 cm from the lateral canthus, respectively. In conclusion, the oculofacial surgeon must bring the dissection plane of the forehead tissue more superficially around the 3 cm superolaterally to the lateral canthus in the direction of 45° from the horizontal line in order to avoid nerve injury.

Evaluating the results of eyebrow lift by combining methods of subcutaneous flap and thread support in patients with droopy eyebrows

BACKGROUND

Brow lift also known as eyebrow lift was first described in 1919, and since then, many changes have been made in the methods of doing it, although there is still no agreed method of absolute superiority for eyebrow lift. Most previous studies have reported the results generally qualitatively and based on patient or surgeon satisfaction. In this study, by combining two less complicated methods of eyebrow lift, we have evaluated the quantitative results.

METHOD

Before the surgery, a standard photograph of the face was taken. The vertical distance between the tail of the eyebrow and interpupillary line was determined.

RESULTS

This study was performed on 15 females with a mean age of 38.27 ± 6.82 years. The mean distance between the eyebrow and interpupillary line by photographic measurement before surgery, 3 weeks, and 6 months after surgery was, respectively, 10.45 ± 1.74, 15.72 ± 1.77, and 13.53 ± 1.69 mm using the tail of the eyebrow and 18.47 ± 1.67, 23.33 ± 1.57, and 21.55 ± 1.66 mm using the crown of the eyebrow. In the clinical measurement, the eyebrow tail was 11.98 ± 1.75, 19.22 ± 1.73, 17.35 ± 1.68 and 15.13 ± 1.76 mm away from the pupil line, and the crown of eyebrow was 20.45 ± 1.90, 27.12 ± 1.58, 25.00 ± 1.80, and 23.35±1.78 mm. There is a significant difference between the distance of the tail of the eyebrow and the crown of the eyebrow in both measurement methods (photographic and clinical) at different times (p-value <0.001).

CONCLUSION

Performing eyebrow lift with the Pretrichial method has many comparative advantages to other methods. Additionally, eyebrow lift with the thread support is a less invasive method.

Brow and Eyelid Rejuvenation: Trends from the 100 Most Cited Articles over 30 Years

Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989-April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms "lower blepharoplasty", "upper blepharoplasty", "browlift", "browplasty", "endobrow lift", "endoscopic brow", "Foreheadplasty", "lower eyelid anatomy", "upper eyelid anatomy", "forehead lift", "eyelid rejuvenation", "canthopexy", "canthoplasty", "eyelid fat pad", "orbital fat pad", "tear trough", and "eyelid bags" were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author's primary specialty, the focus of the article, the corresponding author's country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989-1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.

Brow gliding: A new non-surgical concept for almond upturned eyes

BACKGROUND

The eyes are one of the most prominent features of the face. To date, a vast majority of procedures have been described for periorbital rejuvenation. Among them, non-surgical threading is an alternative and minimally invasive technique.

OBJECTIVE

We developed a new non-surgical threading technique to achieve long-lasting almond-shaped upturned eyes with brow lifting that we call "brow gliding". We developed a new non-surgical threading technique to achieve long-lasting almond-shaped upturned eyes with brow lifting that we call "brow gliding". Here, we present details of our procedure and the clinical experience of our patients who have at least a 6-month follow-up period.

METHODS AND MATERIALS

We used polydioxanone cog threads in combination with knots to lift the lateral sides of the brows and eyes. By burying these knots in the subcutaneous tissue and extending the threads to the scalp fascia, we were able to spread the load of the threads over multiple stable structures in order to achieve an effective lifting impact.

RESULTS

According to the subjective assessment scale, all patients described the improvements as very good or beyond expectations after the procedure. During the follow-up period, 4 of 34 (11.8%) patients stated it was very good and 19 of 34 (55.9%) patients stated that it was still beyond expectations.

CONCLUSION

The Brow Gliding technique is a promising office-based cosmetic procedure for periorbital aesthetics with a prominent outcome and minimally invasive fashion.

Comparison of Postoperative Scarring in Asian Women After Supra-brow and Sub-brow Blepharoplasty: A Retrospective Study

BACKGROUND

Supra-brow and sub-brow blepharoplasty are two types of upper eyelid blepharoplasties that are commonly performed in middle-aged Asian women to correct skin laxity of the upper eyelid; the postoperative scar formation of the two procedures may be different. Therefore, we designed this retrospective study to explore the differences in postoperative scarring between patients receiving supra- or sub-brow blepharoplasty.

METHODS

We identified 52 patients who underwent supra-brow blepharoplasty and 54 patients who underwent sub-brow blepharoplasty. For each patient, the scar quality was assessed using photographs, the Observer Scar Assessment Scale (OSAS), and the Patient Scar Assessment Scale (PSAS) 1 year following surgery.

RESULTS

For OSAS, higher scores for pigmentation, thickness, relief, pliability, surface, and overall opinion were observed in patients who underwent supra-brow blepharoplasty (p < 0.05) except for the "vascular score" (p = 0.148). The average overall opinion scores of the supra- and sub-brow blepharoplasty were 3.90 ± 0.41 and 2.33 ± 0.48, respectively, indicating that acceptance of postoperative scars in patients who underwent supra-brow blepharoplasty was worse than that in patients who underwent sub-brow blepharoplasty. Significantly higher scores were observed in all items of PSAS items for patients with supra-brow blepharoplasty (p < 0.05).

CONCLUSIONS

The postoperative scars in patients who underwent supra-brow blepharoplasty were more obvious than those in sub-brow blepharoplasty. From the perspective of postoperative scar formation, sub-brow blepharoplasty may be a more suitable choice for patients.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

An Algorithm for Correction of the Aging Upper Face

As the approach to the upper face has evolved in recent years, so has the focus of aesthetic brow procedures. Brow position was the primary focus early in the late twentieth century, with the coronal brow lift the primary means of surgical correction. In more recent years, improving or maintaining brow shape has taken on greater importance and has increasingly been addressed by contemporary techniques. These include the endoscopic, temporal, direct, gliding approaches as well as nonsurgical brow lifts. As each patient has individual facial characteristics and expectations, every technique comes with a unique set of indications.

Functional brow lifting

Brow ptosis is an abnormal descent of the eyebrow resulting in a displeased appearance and/or functional deficit. While most cases of brow ptosis do not result in a functional impairment, functional brow surgery is generally reserved for individuals with severe brow asymmetry or visual field deficit related to excess soft tissue pushing downwards on the eyelid. A combination of both intrinsic and extrinsic anatomic factors contributes to an unfavorable brow shape, contour, and position. Proper management of brow ptosis requires an understanding of both surgical and non-surgical modalities. Traditionally, individuals with functional brow ptosis are treated by browpexy via blepharoplasty approach, direct browlift, mid-forehead browlift, or less commonly endoscopic browlift.

An overview of surgical techniques and non-surgical treatments in lifting the eyebrow including current treatments available

The eyebrow is a complex structure of the human face, which has both functional (communication) and aesthetic aspects and contributes to a persons’ individual appearance. Ptosis of the eyebrow is a common condition, especially among the elderly and smokers. Facial appearance is disrupted by eyebrow ptosis, and in many cases, correction and treatment are needed. No specific type of browlift has been shown to be superior to another, and since there is a wide variation in treatment preference between patients, it requires an individual approach to each specific patient. This review provides an overview of the history of the browlift, non-surgical treatment and current surgical techniques available.

Level of evidence: Not ratable.

Effects of Modified Osteoplastic Pterional Craniotomy on Temporal Muscle Volume and Frontal Muscle Nerve Function

Introduction  Pterional craniotomy is a surgical approach frequently used in aneurysm and skull base surgery. Pterional craniotomy may lead to cosmetic and functional problems, such as eyebrow drop due to facial nerve frontal branch damage, temporal muscle atrophy, and temporomandibular joint pain. The aim was to compare the postoperative effects of our modified osteoplastic craniotomy with classical pterional craniotomy in terms of any change in volume of temporal muscle and in the degree of frontal muscle nerve damage. Materials and Methods  Aneurysm cases were operated with either modified osteoplastic pterional craniotomy or free bone flap pterional craniotomy according to the surgeon's preference. Outcomes were compared in terms of temporal muscle volume and frontal muscle nerve function 6 months postoperatively. Results  Preoperative temporal muscle volume in the modified osteoplastic pterional and free bone flap pterional craniotomy groups were not different ( p  > 0.05). However, significantly less atrophy was observed in the postoperative temporal muscle volume of the osteoplastic group compared with the classical craniotomy group ( p  < 0.001). In addition, when comparing frontal muscle nerve function there was less nerve damage in the modified osteoplastic pterional craniotomy group compared with the classical craniotomy group, although this did not reach significance ( p  > 0.05). Conclusion  Modified osteoplastic pterional craniotomy significantly reduced atrophy of temporal muscle and caused proportionally less frontal muscle nerve damage compared with pterional craniotomy, although this latter outcome was not significant. These findings suggest that osteoplastic craniotomy may be a more advantageous intervention in cosmetic and functional terms compared with classical pterional craniotomy.

Cephalometric analysis following combined Sub-SMAS hyaluronic acid injection and subdermal and supraperiosteal poly-L-lactic acid injections in Asian women

Background

The aging face is characterized by skin laxity and volume loss. Attenuation of facial retaining ligaments significantly contributes to skin sagginess and soft tissue volume loss.

Aims

We designed a prospective cohort study to quantitatively assess the efficacy of hyaluronic acid (HA) with adjunct poly‐L‐lactic acid (PLLA) injections in strengthening the retaining ligaments.

Patients/Methods

A total of 12 Asian women were treated with HA injections to the orbital, zygomatic, buccal‐maxillary, and mandibular retaining ligaments with adjunct supraperiosteal and subdermal PLLA injections to the temporal region, midface, and lower face. Cephalometric measurements were done before treatment and 2, 4, 12, and 24 weeks post‐procedurally.

Results

Eyebrow peak and tail angles increased 20.0° ± 3.8° to 21.0° ± 3.8° (p < 0.05) and −2.9° ± 4.2° to −1.3° ± 3.3° (p < 0.001) at week 12. Eyebrow‐to‐orbital‐rim distance increased 1.9 ± 2.0 mm to 3.9 ± 1.5 mm (p < 0.001) at week 12. Eyebrow‐to‐upper‐eyelid distance increased 11.6 ± 3.0 mm to 12.7 ± 3.2 mm (p < 0.001) at week 24. Eyebrow‐peak‐to‐lateral‐limbus distance decreased 6.1 ± 3.1 mm to 5.3 ± 2.4 mm (p < 0.05) at week 4. Tragus‐oral‐commissure length and lower‐facial‐contouring length decreased 281 ± 11 mm to 275 ± 10 mm (p < 0.01) and 297 ± 14 to 292 ± 11 mm (p < 0.05) at week 12, respectively.

Conclusion

Hyaluronic acid injection for strengthening of facial retaining ligaments with adjunct PLLA is viable, safe, and effective in facial rejuvenation as supported by quantitative data.

Infraeyebrow Blepharoplasty Using Dynamic Suspension Technique Between Dermis-Fascia Flap and Frontalis in Upper Eyelid Lifting and Eyebrow Augmentation

OBJECTIVE

Upper eyelid laxity affects facial aesthetics and the eyebrow arch in the East Asian population is generally low. The authors developed infraeyebrow blepharoplasty using a dynamic suspension technique between the dermis-fascia flap and frontalis for upper eyelid lifting and eyebrow augmentation.

METHODS

A retrospective study was performed on 43 female patients with upper eyelid laxity from August 2015 to October 2019. The epidermis and superficial dermis of the infraeyebrow was removed from the surgical marking area with the deep dermis and fascia preserved. The eyebrow skin flap was separated from the frontalis surface which fully exposed the area around eyebrow arch. The preserved dermis-fascia flap was folded and suspended to frontalis in the superior margin of eyebrow arch.

RESULTS

Forty-three patients (median age 54 years [range, 38-70]) underwent this operation. Mean follow-up was 25 months (range, 8-42) was assessed. All incisions healed well and were almost invisible. The eyebrow area improved with upper eyelid skin lift and eyebrow augmentation; 40 cases were "very satisfied" with their appearance. Three cases were "not very satisfied," including 1 case with numbness in surgical area. 2 cases had slight bilateral asymmetry of the upper eyelids.

CONCLUSIONS

The dynamic suspension technique is worthy of clinical application because it can correct upper eyelid laxity, augment the low eyebrow arch, and obtain an invisible scar by reducing the incision tension.

Direct Brow Lift and Skin Contraction in Facial Nerve Palsy: A Switch Technique

The authors present a case series of 4 patients with facial nerve palsy who underwent a direct brow lift to correct brow ptosis, using the excised brow skin as a full-thickness skin graft to correct lower eyelid skin contracture, ectropion, and retraction. Functional outcomes were measured using the validated cornea, static asymmetry, dynamic function, synkinesis (CADS) grading system and by photographic assessment of lower eyelid height via margin reflex distance. Aesthetic outcomes were measured using a published grading scale specific to eyelid skin grafts.

Revisiting the Direct Brow Lift in Patients With Facial Palsy: 4 Key Modifications

PURPOSE

The direct brow lift is a simple and popular technique, particularly in patients with brow ptosis secondary to facial palsy. It provides a high degree of control in determining the degree of brow elevation and shape achieved. However, it is arguably the least debated in terms of addressing some of its sequelae, namely the risks of a visible or indrawn scar and forehead paraesthesia. In this article, we report outcomes using four alternative principles to those outlined in current published literature.

METHODS

All patients undergoing a primary direct brow lift for brow ptosis secondary to facial palsy between January 2015 and December 2019 under a single surgeon (R.M.) were included in the study. The technical refinements of the procedure included a W-plasty type stealth skin incision, counter-bevelling of the upper and lower incision lines, skin excision in the subcutaneous plane only with minimal excision of fat and browpexy to the frontal periosteum through small linear puncture incisions in the frontalis.

RESULTS

A total of 23 patients undergoing 24 direct brow lifts were included in the study. The mean follow-up was 1.3 years (range 0.5-3 years). No patients reported postoperative forehead paraesthesia or brow alopecia. One patient required a further temporal browlift 15 months later. Brow height was rated excellent (0-1.5 mm difference) in 71% of brows and good (1.6-4.9 mm difference) in 14% of brows. The average Manchester scar scale was 8.6/28.

CONCLUSION

The technical modifications presented substantially reduce the rates of postoperative paraesthesia, whilst achieving satisfactory aesthetic outcomes.

Techniques of Eyebrow Lifting: A Narrative Review

None of brow lift techniques are completely satisfactory because of their limited effectiveness, lack of longevity, and potential complications. The aim of this study was to provide a comprehensive review of the literature on the pros and cons of the most popular techniques in brow and forehead lift. Relevant original articles in the PubMed database (English language) were sought using the search terms “eyebrow lift", “forehead lift", "periorbital rejuvenation", "eyebrow ptosis", "blepharoplasty and eyebrow change", "surgical eyebrow lift", and "non-surgical eyebrow lift", No date limitation was considered. Titles and abstracts were scanned to include the most pertinent articles. Subsequently, full texts of included articles (111 articles) were skimmed and finally 56 references were selected for the review. A narrative synthesis of data was finally undertaken with particular attention to the indications, techniques, and common complications of the eyebrow lift procedures. Ten popular techniques including two non-surgical methods (Botulinum toxin A and soft tissue fillers) were reviewed in this article. In general, non-surgical methods of forehead/brow lift are temporary, need less experience and correction would be easier should any complication occur. Surgical methods are divided into three categories: trans-blepharoplasty eyebrow lift, direct eyebrow lift, and trans-forehead eyebrow/forehead lift. Currently, the most popular method is the endoscopic forehead lift approach even though its longevity is limited. Direct brow-lift is particularly useful in patients with facial palsy and those who are more likely to be accepting of the scar (male gender, high forehead hair line).

Dynamic Brow Restoration Using a Soft Tissue Expander in Adult Patients With Arteriovenous Malformation

BACKGROUND

Impaired brow function in adult patients with arteriovenous malformation is a serious disability that can even influence the field of vision. Brow reanimation techniques are used to recover a more natural appearance and brow function. Many static procedures have been set to augment brow elevation, but only dynamic procedures can lead to better functional results. In this study, the experience of a single surgeon addressing the challenge of brow restoration with dynamic procedures is presented.

METHODS

A retrospective review was performed using the records of 4 adult patients who underwent dynamic procedures using a soft tissue expander for brow restoration after arteriovenous malformation excision in the unilateral site of the forehead with the expander on the contralateral side. Movement and electrodiagnostic examinations were performed postoperatively at 2 months.

RESULTS

The patients included 3 males and 1 female (mean age, 20.5 ± 4.04 years). Brow improvement was noted in all patients. The results of the electrodiagnostic examination showed synchronous and spontaneous motor unit potentials and compound muscle action potentials with the contralateral forehead.

CONCLUSIONS

Dynamic procedures using a soft tissue expander can provide both static and dynamic functional brow elevation of the contralateral frontalis and skin.

Corneal re-innervation following refractive surgery treatments

Laser refractive surgery is one of the most performed surgical procedures in the world. Although regarded safe and efficient, it has side effects. All of the laser based refractive surgical procedures invoke corneal nerve injury to some degree. The impact of this denervation can range from mild discomfort to neurotrophic corneas. Currently, three techniques are widely used for laser vision correction: small incision lenticule extraction, laser-assisted keratomileusis in situ and photorefractive keratotomy. Each of these techniques affects corneal innervation differently and has a different pattern of nerve regeneration. The purpose of this review is to summarize the different underlying mechanisms for corneal nerve injury and compare the different patterns of corneal reinnervation.

Controversies in periocular reconstruction for facial nerve palsy

PURPOSE OF REVIEW

Periocular rehabilitation of the patient with a facial nerve palsy has evolved over time. Although protection of the ocular surface is paramount, application of disfiguring tarsorrhaphies should be utilized only in special situations. The purpose of this review is to discuss current surgical and medical strategies in treatment of the periocular area in patients with facial nerve palsy to give maximal functional and cosmetic results.

RECENT FINDINGS

Upper lid lagophthalmos is preferentially treated with upper eyelid weights. Platinum has distinct advantages over gold. A supratarsal position of the upper lid weight is preferred over a pretarsal location. Lower lid malposition should be treated as a retraction, rather than an ectropion. Recalcitrant ocular surface disease can be effectively managed with a scleral lens. Tearing in the patient with a facial nerve palsy is often multifactorial; small lumen Jones tubes and botulinum toxin injection to the lacrimal gland should be considered to treat epiphora in these patients.

SUMMARY

A facial nerve palsy can be devastating for patients from both a functional and cosmetic perspective. Although seismic shifts in treatment of the periocular subunit have not occurred, there are a number of small, yet significant, changes in treatment that should be adopted in taking care of these patients.

A Technique for the Prevention of Recurrent Eyebrow Ptosis After Brow Lift Surgery

BACKGROUND

Preventing the recurrence of eyebrow ptosis after brow lift surgery is challenging. We developed a novel technique to maintain elevation of the eyebrow after brow lift surgery.

METHODS

A consecutive sample of patients who underwent brow lift surgery between June 2014 and June 2016 was divided into 2 groups. Group A underwent resection of excess skin during brow lift surgery; group B underwent the new eyebrow lift technique, which involved resecting skin and the lateral part of the orbital orbicularis oculi muscle, elevating the lower margin of the orbital orbicularis oculi muscle, and suturing it to the orbital periosteum. Eyebrow height and patient satisfaction were measured preoperatively and after surgery.

RESULTS

This study included 273 patients. Mean follow-up time was 24.8 months (range, 6-52 months). Brow height was similar in groups A and B immediately postoperatively (group A: 28.37 ± 3.02 mm vs group B: 29.21 ± 2.97 mm) and at 6 months after operation (group A: 26.65 ± 2.53 mm vs group B: 27.45 ± 2.77 mm). At 12 months (group A: 22.73 ± 2.31 mm vs group B: 25.61 ± 2.62 mm) and 24 months (group A: 20.76 ± 2.22 mm vs group B: 24.74 ± 3.10 mm) after operation, the amount of brow elevation was significantly greater in group B. Two patients in group B experienced supraorbital neuralgia after surgery, which resolved by the 6-month follow-up. At 12 and 24 months after operation, patients in group B were significantly more satisfied with their surgery than patients in group A.

CONCLUSION

Our novel technique is simple and effective for preventing recurrent eyebrow ptosis after brow lift surgery.

Three-Dimensional Topography of the Supratrochlear Nerve With Reference to the Lacrimal Caruncle, and Its Danger Zone in Asians

BACKGROUND

The supratrochlear nerve (STN) is relatively superficial and therefore vulnerable to iatrogenic injury.

OBJECTIVE

To elucidate the course of STN with reference to the lacrimal caruncle, with the aim of preventing nerve injury during surgery in the forehead region.

MATERIALS AND METHODS

Thirty-four hemifaces from 18 Korean cadavers were dissected. The vertical line through the apex of lacrimal caruncle and the horizontal line through the supraorbital margin were used as horizontal and vertical reference lines, respectively. The course of STN in the frontal view and the point at which it pierced the overlaying musculature were examined.

RESULTS

After exiting the corrugator muscle cushion, the STN enters the subcutaneous plane by piercing the frontalis muscle. These piercing points occurred at mean horizontal and vertical distances relative to the medial branch of the STN of 9.2 and 9.6 mm, respectively; the corresponding distances for the lateral branch of the STN were 1.1 and 15.3 mm, respectively.

CONCLUSION

When performing surgery in the medial forehead region, the surgeon must ensure that the dissection plane of forehead tissue is more superficial: superiorly within 1.5 cm from the supraorbital margin and medially within 1.0 cm from the vertical line through the apex of lacrimal caruncle.

Botulinum Toxin for Eyebrow Shaping: A Systematic Review

BACKGROUND

Currently, there is no standardized approach for eyebrow shaping with botulinum toxin, and controversies still exist regarding this subject.

OBJECTIVE

The objective of this systematic review is to summarize and compare all the published data regarding eyebrow shaping with botulinum toxin.

METHODS

On March 10, 2017, an online search of published articles in the Medline, Embase, and Cochrane databases were conducted. All articles that used objective measurements to quantify the eyebrow changes after botulinum toxin injection were included in this review.

RESULTS

Eleven studies were selected for inclusion with a total of 585 patients. All the included studies used onabotulinumtoxin A. Seven studies injected both the lateral and the medial eyebrow depressors, 2 studies injected the lateral depressors alone, and 2 studies injected the medial depressors alone. The highest elevation was observed in the lateral brow (0.4-4.8 mm). Bruising and headache were the most frequently reported complications, and only 5 cases of eyelid ptosis were noted.

CONCLUSION

Botulinum toxin injection for eyebrow shaping is a noninvasive, safe, and reproducible procedure. Eyebrow reshaping can be achieved by targeting different muscle groups. However, further randomized controlled trials are warranted.

Transcutaneous Brow Shaping: A Straightforward and Precise Method to Lift and Shape the Eyebrows

BACKGROUND

The height of the eyebrow is less crucial aesthetically than is the relationship between the lateral and medial portions of the brow. Although various surgical procedures are effective in raising the brow, the authors maintain that transcutaneous brow shaping (TBS) is the only technique that enables precise shaping of the brow and correction of minor asymmetries.

OBJECTIVES

The authors described their experiences with direct TBS alone or in conjunction with blepharoplasty and facelift.

METHODS

A total of 212 patients underwent TBS performed by the senior author (M.P.C). All patients were evaluated clinically and by means of pre- and postoperative photographs. Patients completed questionnaires indicating scar quality and satisfaction with the results.

RESULTS

There were no major complications. Scar visibility was low, and patients expressed a high level of satisfaction with the aesthetic results of TBS.

CONCLUSIONS

A misconception of transcutaneous browlift procedures is that they yield visible scars. TBS requires accurate planning, preservation of subcutaneous volume, limited undermining, preoperative application of botulinum toxin, and perioperative administration of local vasodilators. When these requirements are fulfilled, the authors have found that TBS does not yield a visible scar and is the easiest, most precise, and most reliable procedure for brow shaping.

LEVEL OF EVIDENCE

4.

The cosmetic outcome of external dacryocystorhinostomy scar and factors affecting it

Purpose:

To study the cosmetic outcome of external dacryocystorhinostomy (Ex-DCR) and to detect the factors affecting it.

Patients and Methods:

Prospective randomized interventional study included forty patients who were treated by 40 Ex-DCRs. In twenty patients, medial canthal vertical incision was used and in the other twenty cases, subciliary incision was used. The skin was closed using vicryl 6-0 or prolene 6-0 interrupted sutures, and each one was randomly used in twenty patients (10 patients of each incision type). Cosmetic outcome was evaluated 6 months postoperative by the patients and by an oculoplastic surgeon on a four grades scale. Cosmetic results and its correlation to patients’ age, sex, skin complexion, type of incision, and type of skin sutures were studied.

Results:

The mean scar grading was 0.98 ± 1.0 and 1.3 ± 1.0 in patients’ and examiner's assessment. About 27.5% described their scars as cosmetically significant. The cosmetic outcome was significantly affected by the type of incision with only 5% significant scars in subciliary incision group. Prolene 6-0 suture was associated with better cosmetic results with 15% significant scars. 50% of dark-skinned patients showed cosmetically significant scars. Although no correlation was found between patients’ age and cosmetic outcome, pediatric patients showed higher tendency to scar visibility with mean scar grade 1.2 ± 1.0 and 1.5 ± 0.9 in patients’ and examiner's assessment.

Conclusion:

Dark skinned and pediatric patients are more prone to visible Ex-DCR scar. The use of subciliary approach and prolene 6-0 skin sutures is associated with more favorable cosmetic outcome.

Free dermal fat graft reconstruction of the head and neck: An alternate reconstructive option

OBJECTIVES

Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects.

STUDY DESIGN

Non-randomized retrospective analysis.

METHODS

The medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction.

RESULTS

Sixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site.

CONCLUSIONS

From our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.

Quantitative efficacy of external and internal browpexy performed in conjunction with blepharoplasty

Browpexy surgery is a minimally invasive surgical adjunct to upper blepharoplasty. The traditional internal (IB) approach is well documented, while the newer external (EB) variant has only recently been described. To date, there is little quantitative data to evaluate the efficacy of either procedure, and no data to compare results between the two. We determine the efficacy of, and compare surgical results between, internal and external browpexy surgery in lifting the central and lateral brow. A 3.5-year retrospective review of patients undergoing internal and external browpexy surgery to assess the amount of central and lateral lift to the brow was performed. Patients undergoing blepharoplasty without brow lift were used as a control group. The Massachusetts Eye and Ear Infirmary FACE-gram program was used to quantify surgical outcome. Ninety-eight patients are included for review, with an average follow-up of 4-5 months. The average elevation in lateral/central brow position was 2.29 mm and 1.47 mm in the IB group, and 2.97 mm and 1.90 mm in the EB group. These were not statistically significant (p = 0.164, and p = 0.507, respectively). There was a statistically significant elevation in central and lateral brow height for both browpexy techniques and the control group (p < 0.001). External and internal browpexy surgery afford a similar, and non-statistically different, elevation of the central and lateral brow at 4-5 months. When compared to standalone blepharoplasty (control) the amount of lift for both procedures is statistically significant.

A Review of Complications and Their Treatments in Facial Aesthetic Surgery

Aesthetic surgery has become increasingly popular in the last several decades, with facial aesthetic surgery accounting for a large percentage of the procedures performed. With this surge in popularity and the increase in the number of cosmetic surgeries and procedures completed, comes an inevitable increase in the number of complications encountered. This review elucidates common complications and effective management of frequently performed cosmetic facial surgeries. This article represents a general overview of the topic. For a more exhaustive review, the reader is encouraged to turn their attention to the facial plastics and additional surgical subspecialty literature. Aesthetic procedures discussed in this article include rhinoplasty, rhytidectomy, facial augmentation, otoplasty, brow lift, blepharoplasty, skin resurfacing and chemical peels, and facial injections.

Topography of the supraorbital nerve with reference to the lacrimal caruncle: danger zone for direct browplasty

PURPOSE

To elucidate the course of the supraorbital nerve (SON) with reference to the lacrimal caruncle in order to facilitate safer direct browplasty by preventing nerve injury.

METHODS

Thirty-four hemifaces from 18 embalmed Korean cadavers were dissected. A vertical line through the upmost point of the lacrimal caruncle and a horizontal line through the supraorbital margin were used as the horizontal and vertical reference positions, respectively. The course of the SON in the frontal view and the point at which it pierced the overlaying musculature were examined.

RESULTS

The SON divides into a superficial branch and a deep branch just after exiting the orbit. In all cases, the deep SON remains in the subgaleal plane deep to the corrugator and frontalis muscles. The superficial SON travels under the corrugator muscle dividing into three branches (medial, intermediate and lateral) and pierced the frontalis muscle at 19-32 mm above the supraorbital margin. However, in 11 cases (32%) the medial branch of the superficial SON pierced the lower portion of the corrugator muscle at 3.6 mm above the supraorbital margin and ran in front of the muscle along with the vertical line through the upmost point of the lacrimal caruncle.

CONCLUSIONS

One-third of the medial branch of the superficial SON without corrugator muscle protection is vulnerable to iatrogenic injury during direct browplasty. Therefore, the oculofacial surgeon must bring the dissection plane of the forehead tissue more superficially around the vertical line through the upmost point of the lacrimal caruncle in order to avoid nerve injury.

Split face evaluation of long-pulsed non-ablative 1,064 nm Nd:YAG laser for treatment of direct browplasty scars

PURPOSE

To investigate 1,064 nm long-pulse Nd:YAG laser for postoperative treatment of direct browplasty scars.

METHODS

Nine patients who underwent direct browplasty were enrolled in this prospective study. Subjects were randomized to unilateral laser treatment at 2-week intervals for six total treatments, with the contralateral scar used as a control. Prior to each treatment, subjects rated treated and control scars on overall cosmesis. Post-treatment, subjects rated each for erythema, swelling, discomfort, and perceived hair loss. Finally, examiners masked to treatment side were asked to judge side-by-side photographs of first and final visits for improvement and side effects.

RESULTS

Subjects rated the overall appearance of the treated scar significantly higher at the time of treatment number 5 (mean score 5.13 ± 2.03, P = 0.008) and treatment number 6 (6.25 ± 1.98, P = 0.005) compared to treatment 1 (3.75 ± 2.12); by contrast, they failed to rate the control scar more highly. On masked examination of photographs, the treated scar was selected as most improved 50.0 ± 12.5% of the time. Both subjects and graders reported side effects as transient and mild to moderate (mean score 1-4), with no reports of hair loss from either subjects or observers.

CONCLUSIONS

The 1,064 nm Nd:YAG laser provided significant improvement in scar cosmesis after direct browplasty, as rated by subject self-report, but not by masked observers, and appears to be a useful tool for increasing satisfaction among those dissatisfied with direct browplasty scars. Side effects-including erythema, edema, and discomfort-were transient and universally rated as mild to moderate. Lasers Surg. Med. 48:742-747, 2016. © 2016 Wiley Periodicals, Inc.

A Novel Supra-Brow Combined with Infra-Brow Lift Approach for Asian Women

BACKGROUND

Direct brow lift surgery remains popular among Asian women despite its disadvantages. The traditional direct brow lift by a supra-brow incision is not suitable for Asian women because of their unique facial features, such as higher eyebrows, wider upper eyelids, and more orbital fat. Therefore, we designed a novel brow lift technique via a supra-brow combined with an infra-brow approach for Asian women.

METHODS

An area of skin above and below the eyebrow was measured, demarcated, and surgically removed. The redundant orbicularis oculi muscle (OOM) was excised while keeping the frontalis muscle intact. The OOM in the inferior flap was elevated and sutured to the frontalis muscle. In cases of puffy eyelids, orbital fat was partially removed through an infra-brow incision. Finally, a series of modifications were performed to reduce post-operative scarring.

RESULTS

A total of 496 patients underwent this surgery from July 2009 to December 2013 and 432 patients were followed up for at least 6 months after surgery. Post-operative scars, in most patients (428/432), were inconspicuous. There were no facial nerve injuries documented and eight patients reported transient forehead numbness. The height of the palpebral fissure was increased but there was no marked increase observed of the distance between the upper eyelid edge and the eyebrow. In follow-up visits, 409 out of 432 patients (94.7 %) were satisfied with their surgical results.

CONCLUSIONS

This new brow lift technique via a supra-brow combined with an infra-brow approach provided a simple and safe surgical repair of lateral brow ptosis, upper eyelids hooding, and crows' feet in Asian women. The surgical outcomes were predictable and the scars were inconspicuous.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Subcutaneous lateral brow lift ("Z-lift")

Surgical eyebrow lift has been described by using many different open and endoscopic methods. Difficult techniques and only short time benefits oft lead to patients’ complaints. We present a safe and simple temporal Z-incision technique for eyebrow lift in 37 patients. Besides simplicity and safety, our technique shows long lasting aesthetic results with hidden scars and a high rate of patient satisfaction.

Brow Ptosis after Upper Blepharoplasty: Findings in 70 Patients

BACKGROUND

Brow ptosis is a potential complication after upper eyelid blepharoplasty. The aim of this study was to analyze the effect of upper blepharoplasty on eyebrow position.

METHODS

In this Between April 2011 and March 2013, eighty three patients (166 eyes with mean age of 49.7 years) underwent upper eyelid blepharoplasty. The patients were assessed using pre- and post-operatively digital photographs, in the primary position of the eye while the distance between the upper lid margin and the brow were measured before surgery. The postoperative degree of brow ptosis was evaluated as being mild (<2 mm), moderate (2-4 mm), and marked (>4 mm).

RESULTS

The postoperative brow position was unchanged in 46 cases (65.8%), and brow depression was noted in 24 cases ( 34.2%), including 7 males (58.3%) , and 17 females (29.3%).

CONCLUSION

Our study shows that postoperative brow position should be explained to patients before surgery, particularly in male and senile patients as concomitant brow lift or internal brow fixation through the blepharoplasty incision can help to stabilize the eyebrow in the proper position and to prevent this complication.

Safety and Effectiveness of a Small Incision Lateral Eyebrow Ptosis Repair Technique Using a Frontalis Muscle Transposition Flap

PURPOSE

To evaluate the safety and effectiveness of a frontalis muscle transposition flap for treatment of lateral eyebrow ptosis.

METHODS

The charts of all patients undergoing frontalis muscle transposition flap eyebrow ptosis repair from December 2013 to September 2014 were reviewed. Charts with inadequate photographs were excluded. Charts were reviewed for demographics, preoperative and postoperative photographs, surgical technique, and complications. The following parameters were assessed on preoperative and postoperative photographs: corneal diameter, central brow height, and lateral brow height. Measurements were normalized to a standard corneal diameter of 11.5 mm. Statistical analysis was performed in conjunction with the Cleveland Health Institute Biostatistics Department.

RESULTS

Forty-six total patients underwent frontalis muscle transposition flap eyebrow ptosis repair and the charts of 31 patients (53 cases) were reviewed. There were 20 female and 11 male patients. Average age was 69.1 ± 7.7 years (range: 50 - 86 years). There were 9 unilateral and 22 bilateral cases. Concomitant surgeries included upper blepharoplasty (33 cases), conjunctival-Mullerectomy blepharoptosis repair (3 cases), and intralesional tetracycline injection for festoons (3 cases). Average follow-up interval between surgery and the final postoperative photograph was 10.2 weeks (range: 6-26 weeks). Overall, lateral brow height increased postoperatively by 1.78 mm (p < 0.05). In patients that underwent frontalis muscle transposition flap alone, lateral brow height increased by 2.86 mm (p < 0.05). Scalp hypesthesia was documented in 10/31 patients, and resolved in 8/10 patients at last follow up.

CONCLUSIONS

A frontalis muscle transposition flap effectively addresses lateral eyebrow ptosis repair through a small, relatively concealed incision. It produces temporary scalp hypesthesia in a significant number of patients, and long-term results remain unknown.

Survey of Common Aesthetic Practices Among Oculofacial Surgeons in Parts of the Asia-Pacific

PURPOSE

An anonymous Web-based survey was performed to assess the current practices, preferences, and complications of aesthetic procedures encountered by oculofacial surgeons in the Asia-Pacific. Results were compared with a similar study carried out in 2007 among members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS).

DESIGN

This was a cross-sectional survey study.

METHODS

The study survey was sent out via e-mail to 131 oculofacial surgeons in 14 countries in the Asia-Pacific. Survey questions included the demographics of survey respondents, practices, preferences, and complications of aesthetic procedures encountered by the surgeons.

RESULTS

Seventy-four respondents (56.5%) attempted the survey between May and December 2012. Only completed surveys (43 surveys) were included in our analysis. Eighty-six percent of respondents performed aesthetic procedures in their practice. The top 3 most common nonsurgical procedures reported were injection of botulinum toxin (94.1% of respondents), tissue fillers (61.8%), and skin resurfacing (11.8%), whereas the top 3 most common surgical procedures reported were blepharoplasty (100% of respondents), brow lift (94.6%), and midface lift (29.7%).

CONCLUSIONS

The majority of our study respondents performed aesthetic procedures in their practice. The percentage of practices that comprised aesthetics services was lower than that seen in the ASOPRS study. The percentage of respondents who performed injection of botulinum toxin, tissue fillers, brow lifts, and thread lifts were similar to those in the ASOPRS study; however, the percentage of respondents who performed ablative skin resurfacing was much lower.

Comparison among three different fixation techniques in temporal brow lift surgery

INTRODUCTION

The eyebrow lifting with temporal approach is an increasing widespread technique. Many surgical procedures are described, but the long-term stability is dependent on the effectiveness in the fixation of elevated tissues. The authors compared 3 different fixation techniques in temporal brow lift.

METHODS

Forty-five consecutive patients aged between 33 and 70 underwent brow lift surgery with temporal approach. Patients were divided into 3 groups; in group 1, anchorage was performed with Endotine Ribbon, group 2 with a Mersilene mesh, and group 3 with a Prolene suture. The amount of brow elevation was assessed comparing the distance between interpupillar line and superior eyebrow hairline, measured at the midpupil and at the lateral and medial canthal angle. The follow-up was 1 year.

RESULTS

All patients had a pleasant improvement in brow shape. The average initial brow position was 19.84 mm near the head of the eyebrow area, 20.74 mm at the body, and 19.57 mm in the region of the tail. A progressive recovery and a partial relapse regarding the eyebrow body (23.88 mm at 6 months and 23.02 mm at 1 year) occurred, but overall for the lateral region, it passed from 27.53 mm at 6 months to 25.80 mm after a 12-month follow-up. Final brow position was dependent upon surgical technique used in fixation.

DISCUSSION

Different options in brow elevation and stabilization affect the final shape and position of the brows. From the statistical analysis, mesh suspension provided the best results in terms of long-lasting stability.

LEVEL OF EVIDENCE

Therapeutic III.

A simple, reliable, and validated method for measuring brow position

PURPOSE

To establish outcome of brow suspension techniques, a reliable and clinically suitable measurement tool is required. Most of the published methods lack statistical validation, and in none of the reviewed studies, the standardized photograph protocols were validated.

METHODS AND TECHNIQUES

Fifteen subjects were independently photographed by 2 different professional medical photographers. Adobe Photoshop CS5 software (San Jose, Calif) was used to perform the measurements based on interpupillary distance and medial, midpupil, and lateral reference points on the brow. To establish intrarater reliability, the photos of both photographers of the same subject were analyzed by the same researcher. To establish interrater reliability, the photos of 1 photographer were analyzed by 1 researcher, whereas the photos of the second photographer were analyzed by a second researcher. Reliability was assessed using the intraclass correlation coefficients (ICCs) and the smallest detectable differences.

RESULTS

The ICCs indicated good to excellent interrater and intrarater reliability. The ICCs of the interrater reliability were lower compared with those of the intrarater reliability, although they could still be categorized as good to excellent. We found that the lateral measurements had the highest reliability, and the medial measurements, the lowest reliability.

CONCLUSIONS

The current study supports that the "en face" photographs in our database are truly standardized. The good to excellent interrater and intrarater reliability of the present method makes it a valid measuring tool.

Aesthetic analysis of the ideal eyebrow shape and position

The aesthetic importance of the eyebrow has been highlighted for centuries. In this paper, we investigated ideal eyebrow. Eyebrows and eyelids, varies among different races, ages and genders. It is considered to be of primary importance in facial expression and beauty. We present one form of the ideal eyebrow aesthetic and discuss methods of optimising surgical results. For the modern acceptable concept of the ideal brow, the medial brow should begin on the same vertical plane as the lateral extent of the ala and the inner canthus and end laterally at an oblique line drawn from the most lateral point of the ala through the lateral canthus. The medial and lateral ends of the brow lie approximately at the same horizontal level. The apex lies on a vertical line directly above the lateral limbus. Individual perceptions and expectations also differ from person to person. The brow should over lie the orbital rim in males and be several millimetres above the rim in female. Male tend to have a heavier, thicker brow with a little arch present. There are some pitfalls in brow aesthetics. Overelevation creates an unnatural, surprised and unintelligent look which is the most common surgical mistake in brow lifting. Medial placement of the brow peak would create an undesired 'surprised' appearance. Moreover, a low medial brow with a high lateral peak induces an angry look. Overresection of the medial brow depressors may lead to widening and elevation of the medial brow, which creates an insensitive look and can also lead to glabellar contour defects. It is impossible to define an ideal eyebrow that is suitable for every face. However, one must consider previously described criteria and other periorbital structures when performing a brow surgery.

Direct brow lift combined with suspension of the orbicularis oculi muscle

BACKGROUND

Although the conventional direct brow lift operation provides a simple means of managing lateral brow ptosis, the scars produced have been unacceptable. However, using the modifications proposed here, scarring showed remarkable improvement. This article reviews our experiences with the presented technique, mainly with respect to postoperative scarring.

METHODS

Measured amounts of supra-eyebrow skin and subcutaneous fat were excised en bloc in the conventional manner under 'hyper-hydrated' local infiltration anesthesia. The lower flap and the edge of the upper flap were undermined above the muscular plane, and the orbicularis oculi muscle was directly suture-plicated and suspended upward to the distal frontalis muscle. Skin closure was performed in a basic plastic surgical manner.

RESULTS

From April 2007 to April 2012, a consecutive series of 60 patients underwent surgery using the above method. The average width of the excised skin was 8 mm (range, 5-15 mm) at the apex of the eyebrow. Preoperative complaints were resolved without occurrence of significant complications. The surgical scars showed remarkable improvement and were negligible in the majority of the cases.

CONCLUSIONS

The direct brow lift operation combined with plication/suspension of the superior and lateral portion of the orbicularis oculi muscle provides a simple, safe, and predictable means of correcting lateral brow ptosis. The scars were acceptable to all of the patients. For proper management of the frontalis tone, upper blepharoplasty and/or repair of eyelid levator function must be considered in addition to brow lift procedures.