Internal browplasty

Table 21.1

Indications for surgery

Minimal eyebrow ptosis below orbital rim

Prevention of eyebrow descent in conjunction with upper blepharoplasty

Stabilization of eyebrow position

Table 21.2

Preoperative evaluation

Position of eyebrow

Age and gender of patient

Magnitude of eyebrow ptosis

Quality and quantity of eyebrow cilia

Prior eyelid, facial surgery or trauma

Introduction

Eyebrow position is dynamically controlled through the interplay between the eyebrow depressors (orbicularis oculi, corrugator supercilii, procerus and depressor supercilii) and the eyebrow elevator (frontalis). Elevation of the eyebrows can occur through the use of selective targeting of brow depressors by neurotoxins or by surgical elevation. The surgeon should be cognizant of the differences in eyebrow shape and contour between the genders ( Chapter 20 ).

Different techniques exist to surgically elevate the eyebrow. The selection of operation depends on the goals of the surgery, the magnitude of the eyebrow ptosis, and the age and gender of the patient. To best conceal the incision, the upper eyelid crease incision and either behind or within the hairline are the most inconspicuous. The internal brow ptosis repair (or internal brow pexy) is performed through an upper eyelid crease incision and allows for simultaneous upper blepharoplasty with the ability to perform corrugator and procerus myectomy through the medial aspect of the incision if desired.

Internal browplasty will not elevate a severely ptotic brow and, in general, this operation should be considered when minimal brow ptosis is present or if stabilization and prevention of descent of the eyebrow is desired. The dissection occurs deep to the orbicularis oculi in the plane of the ROOF (retro-orbicularis oculi fat) just superficial to the periosteum. Fixation to the periosteum of the frontal bone at least 1 cm above the superior orbital rim lateral to the supraorbital nerve allows for modest elevation. It is important to avoid injury to the supraorbital nerve to avoid numbness or hyperesthesia. After placing the periosteal pass of the suture, it is best to target the thicker portion of the ROOF to avoid superficial dimpling of the skin. Typically, 1–2 sutures are placed.