46.1 Introduction

Fascination with beauty as well as with the orbits and their surrounding tissues dates back to early human civilization. The lid–eyebrow complex is perhaps the most expressive part of the face; one can express anger, worry, surprise, and other emotions by his or her brows [1, 2]. A high eyebrow positioned above the orbital rim and small eyebrows with the eyebrow arch positioned in the middle were preferred for many decades [1–3].

Gravity and senescence are the main causes of aging of the entire periorbital region and brow; however, numerous etiologies for eyebrow ptosis exist, including those that were congenital, posttraumatic, iatrogenic, facial paralysis related, and functional (usually age related) [4–7]. One of earliest signs of facial aging, starting in the third decade, is descent or flattening of the lateral eyebrow [4, 6, 7]. Eyebrow ptosis gives the eyes a heavy, tired, and sad look, and enhances aesthetic deformities of the upper eyelid. The resultant brow ptosis manifests in lateral hooding of the eyelid and has implications for functional visual field obstruction [4–7].

There is a great diversity among individuals with respect to eyebrow position and shape and, the notion of an “ideal” eyebrow has changed quite significantly over the past several decades [1].

G.A.P. Viana ( )

Member of Brazilian Plastic Surgery, Department of Ophthalmology, Vision Institute,

Federal University of São Paulo, São Paulo, SP, Brazil e-mail: info@cliniplast.com

G.P. Viana

Alameda Jauaperi 732, São Paulo, SP 04523-013, Brazil e-mail: info@cliniplast.com

Many brow lift surgical procedures have been described over the last 100 years, including direct eyebrow lift, midforehead lift, coronal brow lift, transpalpebral brow lift, and endoscopic brow lift [1, 6, 8–16]. More recently, nonendoscopic, limited-incision approaches to correct the descent of the lateral eyebrow alone have been reported by several authors [4, 7, 9, 17–19]. A nonsurgical option for brow lift using botulinum toxin A injections has been described for temporary paralysis of the depressor muscles of the brow [20].

46.2 Patient Marking

After identification of eyebrow ptosis, one must determine the patient’s optimal eyebrow position. The “butterfly wing” incision was proposed initially by Viñas and popularized by Castañares [9, 10].

The amount of skin resection depends on the elevation desired and the amount calculated ahead of time to be excessive. Viñas has suggested a simple but accurate method to determine the amount of skin resection: by pinching the skin with thumb and index finger above the lateral end of the brow with the patient in the erect position and watching for the desired effect. The widest part of the drawing is marked above the tail of the brow, and the lateral extension is then carried out to complete it beyond the tail of the brow in an upward and lateral direction (Fig. 46.1) [10]. It is important to place the lower margin of the incision along the superior border of the brow abutting the hair follicles.

Another way to draw the “butterfly wing” incision would be with the patient in a supine position, doing the same maneuver described by Viñas with forceps, but the disadvantage would be no gravity acting on the tissues (Fig. 46.2).

Fig. 46.2 Drawing the “butterfly wing” incision with the patient in a supine position. Arrow: The superior limit of surgical scar often fell within or parallel to a preexisting crease of the crow’s feet

46.3 Surgical Procedure

The patient is placed in a supine position, the face and brows are cleaned with antiseptic solutions and draped. Under intravenous sedation, local anesthesia along the incision lines and into the “butterfly wing” incision is administered (Fig. 46.3). An incision is made and it is beveled to parallel the hair follicles, preventing damage to the brow hair follicles, then the authors undermine superficially (epidermis dissection), like Schwartzman’s maneuver in breast reduction surgery (Fig. 46.4). There is no undermining underneath this level. Thereafter, the epidermis is removed, following meticulous hemostasis of the wound (Fig. 46.5) and, the closure is carried out in the conventional manner (Fig. 46.6). A pressure dressing is applied to the incision for 5 days. The stitches are usually removed between 7 and 10 days postoperatively.

46.4 Complications

The overall rate of complications was low. The most common complication was epidermal cyst (3.3%) and suture dehiscence due to local trauma (2.2%). Reoperation was performed in the unsatisfied patients (2%).

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Fig. 46.4 Undermining superficially (a, b)

Fig. 46.5 Meticulous hemostasis

The surgical scar became scarcely noticeable over time, and often fell within or parallel to a preexisting crease of the crow’s feet. There were no hypertrophic or keloid scars, no infection, no lagophthalmos, and no postoperative hematoma. Neither brow hair loss nor scar widening was noticed.

46.5 Discussion

Since 1996 the authors had done 910 eyebrow elevations in 455 consecutive patients whose ages ranged from 35 to 85 years. Almost 94% of the patients were female. Over 90% of the cases were performed simultaneously with rhytidectomy and blepharoplasty, 16.9% were performed in association with blepharoplasty and eyebrow lift alone represented 4% of the cases. The procedure was completed on average in 30 min (20–45 min). The follow-up in this series was from 10 months to 12 years. Good brow elevation that lasted through the period of follow-up was uniformly demonstrated (Figs. 46.7–46.12).

Brow positioning is considered a “cornerstone” with respect to the appearance of the periorbital region, and ptosis of the eyebrow is considered a characteristic feature of the aging face [4]. Even a minor change in brow position can alter the expression of an individual’s face. With the correction of lateral drooping of the brow, the facial expressions of sadness and fatigue caused by brow ptosis can be improved to achieve a more tranquil facial aesthetic [4].

The modern concept of “ideal” brow position was described by Westmore in 1974 [1]. Optimal eyebrow position is both objective and subjective and, ideal

criteria vary from surgeon to surgeon and continue to be debated [1, 5, 21]. According to Feser et al. there is not one single beauty ideal for eyebrows, but at least three, this being determined by the patient’s age and trends. For instance, trends are generally introduced by young people and not by older individuals and the young tend to prefer eyebrows in a lower position. This way, it seems plausible to assume that the trend currently appears to be moving away from arched eyebrows toward lower-positioned eyebrows with maximum height in the lateral third [1].

Knize discussed several mechanisms contributing to brow ptosis, including depression of the medial eyebrow from overaction of the brow depressors and descent of the lateral eyebrow from unopposed lateral orbicularis oculi contraction [22].

To recreate the aesthetically pleasing brow, several surgical procedures have been published over the past century [2, 6–13, 15–19]. Many different surgical corrective procedures and types of incisions for raising the eyebrow have been characterized including direct eyebrow lift, midforehead lift,

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Fig. 46.12 (a) Preoperative 51-year-old female. (b) One month postoperative

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coronal brow lift, transpalpebral brow lift, endoscopic brow lift, and the use of botulinum toxin [1, 6, 8–16]. More recently, nonendoscopic, limitedincision approaches to correct the descent of the lateral eyebrow alone have been reported by several authors [2, 7, 9, 17–19]. Sometimes a combination with brow-lift and blepharoplasty is necessary to achieve the desired results [16, 23]. Performing upper blepharoplasty in conjunction with brow lift is not a problem if care is given to proper preoperative analysis, quantification, and marking [16].

The authors have presented their experience with “butterfly wing” incision based on Viñas’ study [10].

Indication for surgery is more dependent on the aging signs than on the patient’s chronological age. The authors use this approach to correct the lateral end of the brow (tail), mostly in patients with hairless eyebrow or in patients wearing makeup to disguise the brow ptosis. Nevertheless, this approach would be carried out in all patients because they have been warned ahead of time of the scar extension. It is important to stress to the patient that the scar would be visible for a period of time but it may be concealed temporarily with cosmetics. Another important fact is to identify and discuss any preoperative eyebrow asymmetry with the patient, because he or she will be more likely to