The focus of this article is treatments of the brow and upper lid, in the context of appreciating their relationship to the forehead and periorbital complex to best evaluate and treat. This material is focused on treatments designed to stimulate collagen synthesis, as well as improve fine lines, wrinkles, and overall appearance of the skin, by mechanical dermabrasion, application of chemical peels, laser surgery, and treatment with energy devices including radiofrequency and focused ultrasound.
Key points
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Evaluation and treatment of the eyebrow and upper eyelid must include thorough appreciation of their relationship to the forehead and periorbital complex.
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The upper third of the face consists of the forehead, temples, glabella, eyebrows, and upper eyelids, with varying skin textures, and many important skeletal landmarks and interconnecting muscle groups.
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A thorough past medical and surgical history as well as review of all topical and oral medications and allergies is imperative when evaluating a patient for potential rejuvenative treatment.
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Dermabrasion, chemical peels, laser, light, and energy devices, as well as neuromodulation and fillers, are used to varying degrees as first-line resurfacing and rejuvenation techniques for the eyebrow and upper eyelid.
Introduction
The focus of this article is treatments of the brow and upper lid; yet, one cannot evaluate and treat these target areas without appreciating their relationship to the forehead and periorbital complex.
With age, there is a loss of the supporting framework of collagen, elastin, and hyaluronic acid, as well as losses of bone and fat. Increased skin laxity results, with redundancy, accentuated skin folds, and uneven texture. Nature’s course can be further expedited by exogenous factors, such as chronic sun exposure, cigarette smoking, and other insults to the skin and underlying structures, resulting in further wrinkling and dyspigmentation.
Resurfacing of the skin of the brow and upper lid may be achieved by mechanical dermabrasion, application of chemical peels, laser surgery, and treatment with energy devices, including radiofrequency and focused ultrasound. We focus on treatments designed to stimulate collagen synthesis, as well as improve fine lines, wrinkles, and overall appearance of the skin.
Introduction
The focus of this article is treatments of the brow and upper lid; yet, one cannot evaluate and treat these target areas without appreciating their relationship to the forehead and periorbital complex.
With age, there is a loss of the supporting framework of collagen, elastin, and hyaluronic acid, as well as losses of bone and fat. Increased skin laxity results, with redundancy, accentuated skin folds, and uneven texture. Nature’s course can be further expedited by exogenous factors, such as chronic sun exposure, cigarette smoking, and other insults to the skin and underlying structures, resulting in further wrinkling and dyspigmentation.
Resurfacing of the skin of the brow and upper lid may be achieved by mechanical dermabrasion, application of chemical peels, laser surgery, and treatment with energy devices, including radiofrequency and focused ultrasound. We focus on treatments designed to stimulate collagen synthesis, as well as improve fine lines, wrinkles, and overall appearance of the skin.
Anatomy of the upper eyelid, eyebrow, and forehead
The upper third of the face consists of the forehead, temples, glabella, eyebrows, and upper eyelids. We focus on the skeletal landmarks, muscles, and skin and subcutaneous tissue of the upper lid, brow, glabella and forehead for our purposes here.
Skeletal Landmarks
Bony landmarks of this anatomic location include the following :
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lateral, supra, and infraorbital margins
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supra and infraorbital and zygomaticofacial foramina
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superciliary and zygomatic arches
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superior and inferior temporal lines
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frontal and malar eminences
The supraorbital margin is composed of the frontal bone with the often palpable supraorbital notch, or foramen, located approximately 2.5 cm (ranging from 1.5 to 3.8 cm) from the facial midline. This is where the supraorbital nerve exits the orbit to join the supraorbital artery and vein and innervate the forehead, scalp, and upper eyelid.
The superciliary arch lies above and parallel to the supraorbital margin, underneath the eyebrow and above the frontal sinus. This arch may be absent in women. Above this arch, the frontal eminence of the anterior scalp and forehead may be palpable.
The infraorbital margin is composed medially of the maxillary bone and laterally by the zygomatic bone.
Approximately 2.5 cm from the facial midline and 1.0 cm inferior to the infraorbital rim is the infraorbital foramen, where additional vessels and nerve are located.
Laterally, the frontal process of the zygomatic bone forms the orbital margin.
Along the supralateral rim, across the temple and parietal scalp, it is possible to palpate the superior attachment of the temporalis muscle. It is at this point of attachment that the inferior and superior temporal lines on the frontal and parietal bones may be noted.
Although the supraorbital and infraorbital and lateral orbital margins are distinctly defined by bony structures, the medial orbital margin is less so, being formed by the frontal bone superiorly and maxilla inferiorly.
The cheekbone, or malar eminence, is formed by the zygomatic bone, with its fullness attributed to the overlying buccal fat pad.
The widest part of the cheek, and face, is the zygomatic arch, formed by the temporal process of the zygomatic bone and the zygomatic process of the temporal bone. It is located between the malar eminence and superior border of the external auditory meatus.
Muscles
The muscles of the eye, including the upper eyelid, consist of the following :
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orbicularis oculi
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procerus
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corrugators supercilii
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levator palpebrae superioris
The orbicularis oculi muscle complex is one of the superficial muscles of facial expression, lying beneath and acting on the eyelid and periorbital skin. The voluntary and involuntary palpebral portion of the muscle overlies the tarsal plate and orbital septum, and may act independently of or together with the purely voluntary orbital portion. This latter portion originates superiorly on the anterior part of the supraorbital rim, medial to the supraorbital foramen, and connects with other superficial muscles of facial expression. These include the frontalis, procerus, and corrugators supercilii superiorly; the superficial temporalis fascia laterally; and the muscles of the quadratus labii superioris and the zygomaticus complex inferiorly. The upper pretarsal and preseptal muscles depress the upper lid, whereas the levator palpebrae superioris muscle contributes to the raising of the upper eyelid. It is the fibrous elements of this muscle aponeurosis that create the smooth, taut appearance of the eyelid margin skin.
The glabellar complex consists of the corrugator supercilii and procerus muscles. The corrugator supercilii is small and deep, originating from and located directly on the frontal bone of the medial superior orbit. The repeated activity of this muscle is responsible for the vertical furrows, or “11 lines,” located at the root of the nose. This muscle inserts into eyebrow skin and interdigitates with the frontalis and orbicularis oculi. In fact, a part of this muscle is derived from fibers of the orbital portion of the orbicularis. As a brow depressor, contraction draws the eyebrow downward and medially, resulting in a “scowl.” The procerus muscle originates at the lower nasal bone and nasal cartilage, attaching to the skin at the nasal root. Its fibers similarly are interwoven with the frontalis, orbicularis oculi, and corrugator supercilii. Contraction of this muscle results in inferior movement of the forehead and eyebrows. This muscle is responsible for the transverse wrinkles at the root of the nose and the “bunny lines.”
Eyebrows are elevated and held in position by the main forehead muscle, the frontalis. This muscle originates in the galea aponeurotica just at the anterior hairline, with insertions into the skin of the forehead and eyebrows, as well as with the orbicularis oculi and glabellar complex. Contraction raises the eyebrows, responsible for the horizontal creases of the forehead, as well as aids in widened opening of the eye. Loss of function or paralysis results in a flat forehead and drooping eyebrow.
Skin and Subcutaneous Tissue
Eyelid skin is the thinnest on the body, with minimal subcutaneous tissue underlying the preseptal and pretarsal skin, the upper lid with greater redundancy than the lower. In undamaged, youthful skin, there should be a seamless transition from this thin eyelid skin to the thicker skin of the eyebrow. The subcutaneous tissue consists of loose connective tissue with a notable absence of fat in the skin overlying the tarsal plate. Eyelashes serve a protective and sensory function, and the upper eyelid has more than 100 follicles arranged in multiple rows. Unlike other terminal hair follicles, they are not associated with arrector pili muscle. Additionally, eyelashes have a shorter anagen and greater telogen phase, and are not sensitive to androgens.
The dense fibrous tissue of the tarsal plate provides eyelid support, with the posterior margins adjoining conjunctivae. The orbital fat overlying the intraocular muscles is held in place by the multilayered orbital septum, a connective tissue structure that extends from the aponeurosis to the tarsal plate. The upper eyelid fat pad is located between this septum and aponeurosis, divided into the central and medial compartments. The retro-orbicularis fat is directly above, under the orbital portion of orbicularis oculi.
The forehead encompasses the thicker skin from the hairline to eyebrows and laterally at the temporal ridges, just medially to the lateral eyebrow.
Evaluation
Functional and Esthetic
Aging of the upper third of the face results in functional changes in addition to the cosmetic concerns. As individuals age, the location of the eyebrow lowers from its original position at or above the supraorbital rim. This can result in ptosis, and becomes even more of a concern when an individual also develops redundancy of upper eyelid skin. Functionally, this may affect upward gaze and superior field of vision. In compensating for this, often the frontalis muscle is overused, and more prominent transverse forehead creases result. In youth, the forehead is free of deep horizontal wrinkles that come with age and prolonged use. Ptosis of the glabella deepens the vertical and horizontal frown lines associated with the corrugator supercilii and procerus muscles. Additionally, as we age, fat is redistributed, and along with gradual weakness of the underlying connective tissue, results in increased prominence of transitions between the cosmetic units of periorbital and surrounding skin.
To effectively evaluate the upper eyelid and brow, it is imperative to note the positioning of the two relative to one another as well as the forehead. Esthetically, the upper eyelid should be full, with greater density laterally. The lengthwise upper eyelid skin crease, located between the medial canthus and the lateral orbital rim, should be well demarcated, dividing the eyelid with a more prominent superior component that seamlessly flows laterally into the temporal region. The visible distance between the upper eyelid margin and the superior palpebral sulcus should be 3 to 6 mm. Regarding the aperture, the upper eyelid margin should cover 1 to 2 mm of the iris.
In addition to shape, location, and symmetry of the eyebrows, differences in gender and in the shape and size of one’s face and eyes dictate what is considered to be a culturally acceptable and esthetically pleasing brow. In men, the brow appears heavier and should be located at the supraorbital rim with less of an arch when compared with women. In women, the eyebrow should be located above the supraorbital rim. There are considered to be 5 basic shapes of eyebrow: curved, sharp angled, soft angled, rounded, and flat. The ideal eyebrow is defined by the following landmarks ( Fig. 1 ):
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A vertical plane containing the edge of medial eyebrow, medial canthus, and the alar base
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A horizontal plane containing the medial and lateral eyebrow edges
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An oblique plane containing the lateral edge of eyebrow and the lateral canthus
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A vertical plane containing the peak of the eyebrow and lateral limbus
