Fig. 10.2 Superior orbital rim anatomy (artist’s rendition of a sagittal section at the level of the pupil). GA galea aponeurotica; DGA deep galea aponeurotica; SGA superficial galea aponeurotica; FM frontalis muscle; P periosteum; SF subcutaneous fat; BFP brow fat pad; AM arcus marginalis; PSFP preseptal fat pad; OOM orbicularis oculi muscle

10.2Anatomical Considerations and Preoperative Evaluation

The brow is a complex structure composed of a muscular layer sandwiched between two layers of fat [2, 7–9]. Most superficially, under the thick forehead skin, the subcutaneous fat lies on top of an interdigitation of the frontalis and the orbicularis oculi muscles. The muscle layer is covered anteriorly by the superficial galea and posteriorly by the anterior leaf of the deep galea (Fig. 10.2). Laterally, beneath the muscular layer, above the orbital rim, and between the leafs of the deep galea sits the brow fat pad which continues inferiorly, below the rim, as the retro-orbicularis oculi fat (ROOF) [2, 7– 9]. The ROOF is situated above and anterior to the orbital septum and should not be confused with the preaponeurotic fat pad of the eyelid which is situated behind the orbital septum. Medially, the anterior leaf of the deep galea gives rise to the fascia that covers the corrugator muscle.

Fig. 10.3 Intraoperative photograph showing the release of the orbital ligament at the supero-lateral orbital rim with Stevens scissors to enter the plane between the posterior leaf of the deep galea and periosteum. Release of the orbital ligament allows the brow to elevate under the action of the frontalis muscle

Laterally, the anterior leaf of the deep galea has a dense attachment to the orbital ligament, which is fused to the lateral orbital rim periosteum and the lateral canthal tendon. It is the orbital ligament and the anterior leaf of the deep galea that must be released to allow the brow to move upward under the action of the frontalis muscle (Fig. 10.3).

In addition to brow height, two other issues need to be addressed in the preoperative evaluation of the patient with brow ptosis: brow symmetry and brow contour. The brow height is apparent to the patient and addressed with the elevation inherent to surgery. However, many patients with asymmetrical brows may not be aware of it. It is important to point out brow and facial asymmetry and give patients reasonable expectations of what improvements can be made. In general, eyebrow and forehead surgery can be expected to reduce but not completely correct asymmetry. Brow contour, on the other hand, is not something patients usually complain of, as opposed to height or symmetry. However, the contour is an important variable of brow aesthetics. Most women prefer a higher lateral than medial brow position. This is particularly important in patients who have downward slanting brows preoperatively. Once the patient’s expectations have been determined, a treatment plan can be carefully formulated and presented.

10.3Internal Brow Fat Sculpting and Elevation

This procedure was initially described by McCord et al. who recommended internal brow sculpting followed by reattachment of the brow to a higher position [6]. Attaching the brow to the periosteum above the orbital rim is now commonly

performed by many surgeons [3, 4, 6, 14]. This can be very useful in the treatment of involutional brow ptosis, brow asymmetry, and even facial palsy, when there is significant concern with postoperative scarring. However, for patients with an intact facial nerve it can actually prevent the action of the frontalis muscle and limit the natural elevation and animation of the brow. In addition, it can result in skin dimpling and an irregular brow contour, if sutures are placed too superficially. These problems usually resolve when the anchoring sutures dissolve. However, if nonresorbable sutures are used, these complications can be longer lasting and unsightly.

Our group has reported on 15 years of experience of a modified internal brow elevation technique that achieves excellent results with minimal side effects and no restriction in voluntary brow elevation [3, 10]. Our standard technique avoids fixating the frontalis muscle to periosteum and instead releases the brow retaining ligaments, the anterior leaf of the deep galea, and the orbital ligament that tether the brow down laterally. If the brow has an excessive fat pad, some of the fat is sculpted to decrease brow heaviness [17]. However, care is taken to leave enough fat over the lateral orbital rim to prevent the skin from adhering to the bone. Also it is the brow fat pad, and not the frontalis muscle, which is secured to periosteum in order to avoid the complications mentioned above.

In our technique, the orbicularis oculi muscle is removed together with the skin at the time of blepharoplasty. Excision of the lateral orbicularis oculi muscle helps raise the temporal brow, much like the effect obtained with neurotoxin injection into this site. This not only weakens this brow depressor but also thins and lightens the eyelid tissue. Interestingly, we have found that, in moderate brow ptosis with good frontalis muscle function, the lateral brow is equally elevated after internal brow sculpting regardless of whether suture fixation is performed or not [10]. However, in patients with severe brow ptosis, marked brow asymmetry, or facial palsy, fixation sutures are essential to outcome. In patients in whom the brow fat pad is not in excess, it is not sculpted, but only resuspended superiorly with sutures.

In selected cases, a lateral canthal resuspension and a midface elevation can also be performed via the same upper blepharoplasty incision to further reduce inferior traction on the brow and aid in elevation. The brow, the lateral canthus, and the midface should be regarded as one functional and aesthetic unit, and should be treated at the same setting.

10.3.1 Surgical Technique

This procedure is performed following an upper skin-muscle blepharoplasty. After the orbicularis oculi muscle is retracted superiorly, Stevens scissors are used to incise the brow retaining ligaments (Fig. 10.4a, b). This results in immediate release of the lateral and central brow (Fig. 10.4c). The anterior leaf of

Fig. 10.4 Intraoperative photographs showing the internal brow fat sculpting and release procedure. (a) Upward traction with a lacrimal rake shows the anterior leaf of the deep galea (arrow-tight band) and the orbital ligament tethering the brow down to the lateral orbital rim. (b) The brow retaining ligaments are sharply incised with Stevens scissors, starting laterally. (c) The lateral and central part of the right brow move to a higher position immediately after the brow retaining ligaments are released on the right side. (d) The anterior leaf of the deep galea is sharply incised with Stevens scissors to expose the brow fat pad laterally and the depressors medially

the deep galea and the orbital ligament are grasped with toothed forceps at the lateral orbital rim and incised across the superior orbital rim to expose the brow fat pad laterally and the depressor muscles medially (Fig. 10.4d). To further mobilize the brow, dissection is continued for 2 cm above the superior orbital rim, between the posterior leaf of the deep galea and the periosteum, using a vertical spreading technique. The excess brow fat pad is sculpted and cauterized conservatively to avoid hollowing, as brow fullness is a sign of youthfulness. In cases where midface suspension is added, dissection proceeds inferiorly at the lateral canthus, undermining the orbicularis oculi muscle in the preperiosteal plane. The orbicularis