notice the asymmetry postoperatively during focused attention on the surgical results.

Viñas [10] and Castañares [9] correct the eyebrow ptosis by resection of a roughly elliptical section of the forehead skin immediately above and lateral to the eyebrow. Through this approach the forehead is undermined to the hairline, severing all epicranial fibers, the corrugator supercilii, and the procerus [9]. Different from Viñas and Castañares, the authors’ resection is performed superficially, like Schwartzman’s maneuver in breast reduction surgery, without undermining underneath the epidermis level. In this manner, the authors believe that this approach reduces the prevalence of unaesthetic scar formation by avoiding injury to the dermis. Further, the maximal amount of skin is excised laterally, allowing a favorable elevation of the lateral portion of the eyebrow with respect to the medial part.

In this series, the most common complication was epidermal cyst (3.3%), suture dehiscence due to local trauma (2.2%), and reoperation of unsatisfied patients (2%). Reoperation was performed in nine patients with minimal recurrence of brow ptosis due to previous inadequate resection. Viñas et al. [10] revealed an extremely low complication rate (0.4%) of hematoma formation, permanent alopecia, and “nerve damage.” They also reported a 2.4% dissatisfaction rate, which is comparable with the numbers presented in this series and other studies in literature [2, 8, 10, 12–14, 16, 18, 19]. According to Viñas, the advantage of this approach is its simplicity, it is well tolerated as an outpatient procedure under local anesthesia and that most patients can resume their activities the following day [10]. The authors agree with Viñas on this advantage; another is that it carries a direct one-to-one correction of brow ptosis. The disadvantage of this procedure is the scars on the forehead, but to quote Viñas: “The scars usually become inconspicuous with time. Also because of their location, they can be easily disguised (if necessary) with a couple of strokes of an eyebrow pencil” [10]. If these factors are properly explained beforehand and with the visible improvement, these patients accept the temporary inconveniences with conformity and understanding.

46.6 Conclusions

The key to correction of eyebrow ptosis in patients undergoing cosmetic surgery is to first recognize it and include this component in each patient’s evaluation.

The “butterfly wing” incision provides a useful alternative in situations in which the surgeon may not be familiar with endoscopic techniques, does not have access to endoscopic equipment, or when frontalis modification is not required. Although this operation yields sustained improvements, it does not remove all underlying factors involved in brow aging. The effects of gravitational forces continue and may result in the need for future enhancements. The final results of this operation are consistently very gratifying to the patient and to the plastic surgeon alike.

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