48. The Drooping Brow and Browlift
1. It is said that the eyes are the window to our mind and a pair of smiling eyes is a sight to behold (Fig. 1 and 2).
2. In fact the eyebrows can even perform a dance (Fig. 3). However as age advances and the frontalis muscle that suspends the eyebrow as well as lifts it loses its tone with age and the eyebrow descends to give the eye a hooded appearance. As the elastic fibres of the skin undergo senile fragmentation the forehead may show coarse or fine creases (Fig. 4).
3. The eye can also be marred by weakness of the orbital septum which allows peri-orbital fat to protrude under the orbicularis oculi leading to a ‘puffed up’ appearance both in the upper and lower eyelids (Fig. 5-6). Also with aging the skin gets wrinkled and forms folds in the area of the supra-tarsal region of the eyelid. Before surgery for drooping eyebrows is performed abnormal herniation of fat in the eyelids and the wrinkling of the skin needs to be noted if present. In such a situation only an eyebrow lift will not help but a blepharoplasty will have to be done as well to improve the appearance (please see next chapter).
4. The normal eyebrow (!) (if such a thing exists) is said to begin at a point perpendicular to the ala of the nose on the medial side, rises to its height about the level of the lateral limbus and starts tapering off at the level of the lateral canthal ligament (Fig. 7). The female eyebrow is usually slightly above the supra-orbital ridge as compared to the male eyebrow. This description is subject to a wide variation (Fig. 8-9).
5. In the modern world the eyebrows are probably worked upon by a variety of means for them to appear attractive. This includes threading, painting and even shaving (Fig. 10-11). However they can never really be lifted because of these maneuvers. The eyebrow lift therefore must be preceded by a close estimation of where the original eyebrow would have been if not treated by these cosmetic procedures.
6. The frontalis muscle which suspends and also lifts the eyebrow is disposed slightly obliquely from lateral to medial side in relation to the trichion (which is the highest point of the forehead in the midline) and is inserted into the medial two thirds of the skin of the eyebrow. In the process it traverses through the orbicularis oculi muscle. The lateral border of the frontalis muscle on the either side merges with the temporal fascial zone but the two areas are quite distinct with an intervening vertical strip of fascia which is fixed to the periosteum. This fascial zone condenses into what is called the orbital ligament inferiorly and is attached to the structures below and deep to the lateral most part of the eyebrow. For any surgery to succeed, which attempts to modify the action of an attenuated frontalis muscle, in order to statically raise the eyebrow, it must cut this ligament and release the fixed fascial zone lateral to the frontalis margin (Fig. 12-14). The frontalis muscle is closely aligned to the deep fascia of the forehead, which is in fact the galea continuing from the vault and the rest of the skull. Below the galea is the loose aereolar tissue and the periosteum. The superficial fascia under the skin, also sometimes called the superficial galeal fascia, is tightly applied to the skin. It is between this fascia and the galea that the fibres of the frontalis are located. In the lower half of the forehead the main deep galeal fascia splits, the muscle having become much thinner now and one layer remains closely attached to the muscle. The other deeper layer gets attached to the periosteum just above the supra-orbital ridge of the frontal bone, enclosing a space with some fat within. This is called the gliding space over which the frontalis pulls the eyebrows upwards because it is inserted into the skin of the eyebrow under its medial two third. It is for this reason the drooping appears first in the lateral third of the eyebrow. If the frontalis is the elevator of the eyebrow, the orbicularis oculi is its chief depressor. The other three smaller depressors are, procerus (PR), depressor ciliaris superficialis (DS), corrugator superficialis (CS) (Fig. 12-14).
7. In the recent past (since Browlift is a comparatively new operation) the condition was treated by an elliptical excision just above the eyebrow which included skin subcutaneous tissue and the galea together with the frontalis muscle (Fig. 15). The procedure as expected had a problem that of formation of a scar just above the eyebrow which was not always inconspicuous. The other alternative method was to make a long horizontal incision on the vault of the skull as far as possible within the hairline and then excise the skin together with the frontalis muscle (and the galea) and pull the whole thing up, sort of ‘en masse’, excise the excess and suture it to each other. This lifted the eyebrows from a very distant point without cutting the periosteal attachment of the galea to the supraorbital ridge and was therefore not very effective (Fig. 16).
8. Both the above procedures are hardly ever done now. Instead through small incisions in the midline and/or on the temporal side (Fig. 17), dissection is carried out endoscopically either sub-periosteally or below the galea till the emergence of the supra-orbital nerves (see later para). After protecting the supra-orbital neurovascular bundle the dissection is carried out so to detach the periosteal attachment of the frontalis galea complex. Then through the vault it is possible to lift the frontalis galeal complex very easily which then is excised as per requirement and sutured to its posterior part (for details see text below fig. 18-19).
While taking the temporal approach the axis is first achieved superficial to the fixed zone then the endoscope crosses the fixed zone, to enter either the sub-galeal or the sub-periosteal plane depending upon the surgeon’s choice. This maneuver requires skill but once you reach beyond the fixed zone the dissection becomes easier because the slightly oblique axis of the endoscope allows good dissection up to the midline from either side and during this dissection it is convenient to detach the frontalis from the fixed fascial zone between the temporalis and the frontalis muscles. After the supraorbital nerves are located and saved the three depressors (Fig. 20-21) are avulsed to free the eyebrow.
9. The nerve supply to the frontalis muscle comes from the lateral side and the branches of the facial nerve which supply it are in a fairly superficial zone as they enter it at about the level of the fixed zone between the frontalis muscle and the temporlis fascia. The sensory supply of the forehead however requires to be discussed in some detail because the supraorbital nerve which emerges from the supraorbital foramen lies on the periosteum for at least one or two centimeters before it gets superficial and is responsible for supplying the whole of the forehead except a very small part near the root of the nose and above which is supplied by the supra-trochlear nerve which is superficial even at the level of the supraorbital ridge. All operations done for a frontalis lift by the sub-galeal or the sub-periosteal approach must take into account the depth at which the supraorbital nerve courses through the forehead in order to avoid injury to it (Fig. 22-23). As the dissection progresses downwards from the vault of the skull about one and a half to two centimeters above the supra-orbital ridge, the supra-orbital nerve can be seen distinctly through an endoscope and the dissection must skirt around the nerve to save it.
10. Surgery irrespective of whether it is done under local or general anaesthesia will need moderate amounts of infiltration of an adrenaline solution because the area is vascular. The local anaesthetic also can have a certain percentage of adrenaline in some proprietary preparations. If the proper sub-galeal and sub-periosteal planes are entered the dissection will become smooth till you reach the supra-orbital neurovascular bundle nearer the mid-line or the sentinel vein which emerges above the orbital ligament (*near the orbital ligament, Fig. 21 left, Fig. 22 right). Both structures need to be protected. Occasionally the sentinel vein might be clamped and cauterized.
11. This operation initially is static in that the eyebrows are lifted up to a point to fix them in their normal positions which can be seen quite easily on the table itself, that location having been planned prior to surgery. The active motion of the frontalis takes some time to reappear. Below are reproduced figures of three representative cases. In case there is disparity between the level of the two eyebrows post-operatively, the position of the abnormal eyebrow can be corrected by a re-operation by either lengthening or shortening the frontalis.
12. As mentioned earlier surgery for a browlift and for the effects of ageing on eyelids are frequently performed together. There is a method by which a browlift can be achieved through the same incision which is used for a blepharoplasty. This subject will be covered in the next chapter on blepharoplasty.
13. The following pictures are included in this chapter because the brow is at a very high position. In the words of the contributor of this case which in fact is a craniofacial cleft manifestation (please see Craniofacial Clefts, Bangalore classification on this blog). Dr. Sekhar of Bangalore has treated this condition by releasing the eyebrow by creating a defect superior to it and then, fashioned a subcutaneous vascular supply skin flap below the abnormal eyebrow. The flap with the eyebrow is then shifted as a ‘bucket handle’ to be placed at its normal position while the subcutaneous vascular skin flap is lifted above under the transverse bi-pedicle flap, containing the eyebrow and is placed in the defect created originally (see Fig. 27-29).