| Brow ptosis below orbital rim causing visual obstruction |
| Heavy brows with thick brow cilia |
| Pre-existing supraciliary rhytids |
| Paralytic eyebrow ptosis (CN VII palsy) |
| Magnitude of brow ptosis |
| Age and gender of patient |
| Forehead rhytids |
| Frontalis function |
| Location of hairline |
| Quality and quantity of eyebrow cilia |
| Prior eyelid, facial surgery or trauma |
| Presence of concurrent upper dermatochalasis and/or eyelid ptosis |
Introduction
The normal eyebrow position rests at or above the superior orbital rim. Eyebrow configuration varies between men and women, with men having a more flat brow across the entire length and women having the lateral tail of the brow higher than the medial aspect of the brow ( Figure 20.1 ).
With aging, the eyebrows can descend below the superior orbital rim. This can cause a sensation of heaviness in the eyelids and objectively cause visual obstruction with worsening of dermatochalasis. Evaluation of visual obstruction should include an independent assessment of dermatochalasis in the natural state and also with manual elevation of the eyebrow to assess full impact of eyebrow ptosis. Browplasty should be performed before any upper eyelid surgery as this may affect the amount of upper eyelid tissue marked and subsequently removed.
The choice of direct browplasty as a procedure to elevate the brow depends on several factors. Direct browplasty has the advantage of giving a great amount of lift for the amount of skin excised. Patients with heavy brows with thicker eyelid cilia respond best to direct browplasty. If kept laterally, scarring can be minimal and inconspicuous. In the thicker skin of the eyebrow region wounds heal best with maximal wound eversion, as can be obtained with a horizontal mattress suture. The procedure is primarily a functional procedure to elevate a heavy brow causing visual obstruction. It can be performed in women but is best kept laterally as the medial brow tends to show the incision more visibly when healed.
Direct browplasty procedure also works well for patients with paralytic eyebrow ptosis from CN VII palsy. In these cases, fixation of the eyebrow to the deeper periosteum can provide more long-lasting elevation. Small incision direct browplasty has also been described and can also be used for suture fixation to the periosteum. Avoidance of the supraorbital nerve is critical with any deeper suture pass.
