The normal eyebrow moves independently of the upper lid. Extreme elevation of the eyebrow, as seen with severe upper lid ptosis, causes only slight elevation of the eyelid. The elevator of the eyebrow is the frontalis muscle (Figure 6-3), which extends from the brow over the forehead to merge with the broad fibrous tissue of the galea aponeurotica. Elevation of the frontalis muscle causes the horizontal furrows frequently seen in the forehead. Innervation of the frontalis, like that of other muscles of facial expression, comes from a branch of the facial nerve, the frontal branch. This single nerve provides innervation to the brow on the same side. The approximate position of the frontal nerve can be estimated by drawing a line from the tragus of the ear to 1 cm above the tail of the brow (see Figure 2-27).

Figure 6-3 The frontalis muscle. Note that the frontalis muscle ends lateral to the body of the brow. Note the presence of the corrugator superciliaris and procerus muscles.

Surgery in the path of the frontal branch of the facial nerve should be undertaken with caution to avoid damage to this nerve. Because this single nerve causes elevation of the brow, inadvertent injury to the brow may cause a prolonged paresis or permanent paralysis of the eyebrow.

Temporal brow droop

You will notice that the width of the frontalis muscle stops short of the tail of the brow. Consequently, elevation of the temporal brow often becomes deficient with aging, causing a temporal brow droop (Figure 6-4). As the brow droops, the upper lid skin fold is pushed down, accentuating the upper lid fold, often misinterpreted as redundant skin. Look for this problem in your older patients. It is so common that you may be ignoring it.

Figure 6-4 Temporal brow droop is one of the most common, yet unappreciated, causes of visual loss.

The glabellar folds

The protractors, or depressors, of the eyebrow are the orbital orbicularis, the procerus, and the corrugator muscles (Figure 6-5). Contraction of the orbicularis muscle closes the eye and pulls the eyebrow down. The vertical fibers of the procerus muscle at the head of the brow are responsible for the horizontal furrows in the glabella. The C-shaped corrugator muscle pulls the head of the eyebrow medially and downward, causing the vertical glabellar wrinkles. Wrinkles in the area of the glabella are a common cosmetic concern among women. In many cases, these wrinkles may give an anguished or angry look to the face (see Figure 2-16).

Figure 6-5 Muscles that close the eyes: the orbicularis muscle, pretarsal, preseptal, and orbital; corrugator muscle; and procerus muscle.

The muscles of the eyebrows are among the most important muscles of facial expression. They are strong indicators of mood and feeling. This is best demonstrated by a simple diagram of the familiar happy face (Figure 6-6). A downward slope to the medial aspect of the eyebrows with associated glabellar wrinkles tends to convey anger. A drooping of the temporal brow suggests melancholy. Arched normally contoured eyebrows indicate happiness. Elevation of the arched brow with associated forehead furrows tends to indicate surprise. You may have seen this diagram in other texts. It is a very useful concept.

Figure 6-6 Position of brows as an expression of mood. Left, Happy. Center, Angry, mean. Right, Sad, melancholic

(modified from Ellenbogen, 1983).

There are many operations that raise the eyebrows. Compare the extremes—a temporal direct brow lift and a coronal forehead lift—the former lifting the lateral part of the eyebrow and the latter lifting the eyebrows and entire forehead. You will see that the temporal lift uses a short incision placed at the lateral third of the brow hairs. It corrects the temporal sag and helps to clear the field of vision. It does nothing for the medial brow or the glabella. The coronal forehead lift is performed through an incision across the top of the head from “ear to ear.” The entire forehead and eyebrows are raised. In addition, the glabellar folds, forehead furrows, and the redundancy of the eyelid skin under the medial brow are all improved. The overall result of the coronal lift is more aesthetically pleasing. Most forehead lifts are done for the “cosmetic” improvement and are “self-pay” procedures. You can guess that the recovery time and operating time for the two procedures are much different. Despite a long scar in the hairline for a coronal lift, it is less visible than the shorter scar over the eyebrow. However, the top of the head is left with some degree of numbness. You will learn which procedure is the best choice for your patient. I have somewhat arbitrarily divided these procedures as “functional eyebrow lifting procedures” and “cosmetic forehead lifting procedures” and will discuss them in separate chapters.

Facial proportions

The proportions of the “normal” face are divided into thirds: the upper third from the hairline to the pupil; the middle third from the pupil to the alae of the nose (the ‘mid’ face), and the lower third from the nose to the chin. These thirds occur in roughly equal portions in a well-balanced face. Changes in the position of the eyebrows and the hairline may change the facial proportions. In a general sense, people with a higher forehead are thought to be somewhat more intellectual; hence the term “high brow.” Changes in the male forehead associated with aging and male pattern baldness affect the proportions of the face. In general, a high forehead is considered to less aesthetically pleasing. The length of the forehead is influenced by browplasty. Incisions placed between the eyebrow and the hairline tend to shorten the forehead, and incisions placed in the hair tend to elevate the hairline, increasing the length of the forehead. These factors may contribute to the choice of incision placement in the patient’s forehead. We will talk more about rejuvenation operations that lift the upper, lower and ‘mid’ face.

The upper eyelid

The skin fold, superior sulcus, and skin crease

The upper eyelid consists of three parts:

• The upper lid skin fold

• The upper lid sulcus

• The pretarsal eyelid

The skin and muscle between the eyebrow and the lid crease form the upper lid skin fold (see Figure 6-2). To have normal movement of the eyelid, there needs to be some redundancy in the eyelid tissues. This movement is provided by the skin fold. The skin fold is bounded by the eyebrow above and the skin crease below.

The upper lid skin crease is formed by attachments of the levator aponeurosis extending through the orbicularis into the skin. As the levator contracts, the skin crease is pulled upward, accentuating the superior sulcus. The upper lid skin crease is slightly higher in women than in men. A man’s skin crease is usually at 6–8 mm whereas a woman’s skin crease is usually between 8 and 10 mm above the lid margin. As the patient ages, the pretarsal skin sags somewhat, and the upper lid skin crease may change. The natural skin crease position can be estimated in a simple procedure performed before marking for blepharoplasty. Elevate the eyebrow and give the patient a target. As you elevate the target, you will see the upper eyelid skin tuck into place. This is the line of the original skin crease. In general, this position corresponds to the height of the upper eyelid tarsus.

A complex interaction of anatomic factors affects the fullness of the skin fold and the depth of the sulcus. Younger patients tend to have a minimal skin fold. The brow is well supported, and there is little prolapse of orbital fat (key factors for a young skin fold). The levator muscle pulls the pretarsal portion of the lid into the orbit. In children, the skin fold appears to be more a part of the eyebrow than of the eyelid. As the bony forehead develops in children and young adults, the fold lifts and remains tight against the brow, and a superior sulcus develops. With age, the brow descends and orbital fat prolapses, tending to fill in the sulcus and to increase the fullness of the skin fold of the older adult (Figure 6-7). You may want to reread this. It is an important concept if you want to attain any level of sophistication in performing blepharoplasty.

Figure 6-7 The typical superior sulcus by age. Note progression of brow ptosis crowding the sulcus. (A) Teenager: the brow is well supported and independent of the eyelid. (B) Middle-aged woman: mild generalized brow ptosis contributing to the fullness of the sulcus. (C) Older woman: note the prominent temporal brow ptosis.

Individual facial proportions and bony features greatly influence the size of the skin fold. Some patients with a high or prominent brow will always have a minimal skin fold with a deep superior sulcus. Other patients with a flat brow have a full skin fold and shallow sulcus even as children. It is important to recognize these anatomic features because browplasty and blepharoplasty will not give the same results for each patient.

The upper eyelid skin and the orbicularis muscle

The upper eyelid skin is the thinnest skin of the body, allowing free movement of the eyelid. You will notice that the eyelid skin is much thinner than the eyebrow skin above.

The muscle underlying the eyelid skin is the orbicularis muscle. You are familiar with the three portions of the orbicularis muscle: the orbital, the preseptal, and the pretarsal portions. The orbital orbicularis muscle interdigitates with the procerus, corrugator, and frontalis muscles at the glabellar region (see Figure 6-5).

Relaxation of the frontalis muscle causes the brow (and underlying orbital orbicularis muscle) to fall. Correction of brow ptosis repositions the brow and orbital orbicularis muscle at the rim. Upper lid blepharoplasty removes a portion of the preseptal orbicularis and tightens the pretarsal orbicularis and skin.

The wrinkle lines in the lateral canthus, or “crow’s feet,” arise from contraction of the orbital orbicularis muscle.

The orbital septum

The orbital septum lies directly beneath the orbicularis muscle. It is a fibrous layer arising from the periosteum of the orbital rims. The septum functions as an anatomic boundary of the lids, separating the eyelids from the orbit (Figure 6-8). Although this fibrous tissue is quite tough, it also allows for vertical movement of the eyelid. With aging, weakening of the orbital septum allows fat to prolapse in the eyelid. When no fat prolapse is present, the orbital septum is not opened during upper lid blepharoplasty. When orbital fat prolapse is present, the orbital septum may be opened and fat is excised or repositioned. Fat prolapse is the main indication for blepharoplasty in the lower eyelid. Because the septum is not elastic, it should never be sewn closed as this may contribute to lagophthalmos. With aging, the smooth transition from the lower eyelid to the cheek is lost. Fat prolapse and associated cheek descent transforms the single convex surface of the eyelid and cheek to the so-called “double convexity” that is part of the aging midface. We will learn about this more later.

Figure 6-8 The orbital septum.

The preaponeurotic fat

The upper eyelid preaponeurotic fat is divided into two compartments containing the preaponeurotic or central fat and the nasal or medial fat. The lacrimal gland fills in the temporal aspect of the preaponeurotic space in the upper lid (Figure 6-9). The lacrimal gland is distinguished from the fat by its whitish color and lobulated surface. A branch of the palpebral artery runs posterior to the nasal fat pad. You should be careful not to inadvertently cut this artery because brisk bleeding will occur. The nasal fat pad is whiter in color than the central fat pad.

Figure 6-9 The preaponeurotic fat. Note central and nasal fat pads. Lacrimal gland is temporal to the central fat pad.

The amount and position of the fat prolapse varies from patient to patient. No fat prolapse is seen in many patients. These patients may have dermatochalasis only and do well with only skin and muscle being removed during upper lid blepharoplasty. Nasal fat prolapse is especially common, but patients may have fat prolapse in any combination of locations (Figure 6-10).

Figure 6-10 Lower eyelid fat prolapse and prominent upper nasal fat prolapse. Brow ptosis, blepharoptosis, and punctal ectropion are also present—all examples of involutional changes.

The lower eyelid

The lower eyelid position and contour

The normal lower eyelid rests at the limbus. The lateral canthus is slightly higher than the medial canthus in most patients. The lowest point of the lower lid is inferior to the lateral limbus (see Figure 6-2).

The position of the lower eyelid is dependent on several factors including:

• The inferior rim bony prominence

• The horizontal tension of the lower eyelid

• The length of the anterior or posterior lamellae of the eyelid

We saw in our discussion of ectropion (see Chapter 3) that patients with less prominent inferior orbital rims (maxillary hypoplasia or “hemiproptosis”) are more susceptible to lid retraction and ectropion. Another way to evaluate this is to view the patient from the side and draw a line from the cornea to the inferior orbital rim. If the line slopes toward the cheek, the patient is said to have a negative vector (the same as what we have termed hemiproptosis). Shortening of the skin, muscle, or conjunctiva from sun, disease, trauma, or surgery can cause lower lid retraction. You will learn to respect the forces that hold the lower eyelid in position. It does not take much to alter the balance of these forces to cause lower lid retraction, the most common complication of lower lid blepharoplasty.