INTRODUCTION Brow ptosis results from sagging of forehead skin and loss of fascial support of the eyebrows to the frontal bone. It is a common deformity in the aging face and frequently accompanies laxity of other periorbital structures, such as eyelid skin and canthal tendons. A downward displacement of the eyebrows can accentuate the degree of redundancy in upper eyelid skin and result in significant loss of superior visual field. The ptosis may be general, involving the entire width of the brow, or more exaggerated medially, or more commonly, laterally. Often associated with brow ptosis is descent of the sub-brow fat pad producing a thickened upper eyelid. Failure to recognize brow ptosis as a contributing factor in upper eyelid surgery can lead to a disappointing result from ptosis repair and/or blepharoplasty alone.
CLINICAL CHARACTERISTICS In the normal face the brows typically lie at about the level of the orbital rim medially and above the rim centrally and laterally. The male brow has a flatter contour especially medially, whereas the female brow usually shows a greater arc. When brow ptosis is present part or all of the brow lies below the superior orbital rim. The sub-brow fat pad frequently descends into the upper eyelid and excess skin hangs down to simulate or exacerbate dermatochalasis. Laterally, excess skin may hang in cascading folds that cover the lateral can-thal angle and may extend onto the temple. With medial brow ptosis the glabellar skin forms horizontal folds over the bridge of the nose. Brow ptosis may result in a pseudoblepharoptosis which cannot be adequately repaired with standard aponeurotic advancement techniques.
TREATMENT Several procedures are available for the correction of brow ptosis. The choice depends upon a number of factors: (i) the sex of the patient and, therefore, the desired brow contour; (ii) the relative position of the brows; (iii) the density of the brow cilia; (iv) the presence of associated deformities such as "crow's feet" and prominent transverse glabellar folds; and (v) the height of the scalp hair line or presence of male-pattern baldness. Each procedure has its advantages and disadvantages, and selecting the most appropriate operation must be individualized for each patient. The brow pexy is the simplest technique where the deep fascia of the frontalis muscle is fixed to periosteum to prevent the action of gravity from pulling the brows downward. More recently the trans-blepharoplasty Endotine (Coapt) has made this procedure more effective. In the direct brow lift an ellipse of skin is removed from above the brow, leaving a fine scar just above the brow hairs. However, this tends to arch the brow contour more than in a normal male brow. When there is associated forehead ptosis a forehead elevation can be achieved through an endoscopic lift or via a coronal lift. In all cases of brow ptosis repair, the brows should be repo-sitioned before excision of residual dermatochalasis.
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