|Year : 2018 | Volume
| Issue : 2 | Page : 70-75
Direct brow lift versus transblepharoplasty browpexy for correction of brow ptosis
Mahmoud M.M Genaidy, Ahmed M.K Elshafei, Raafat M.A Abdallah, Mahmoud M Shetawy
Department of Ophthalmology, Minia University, Minia, Egypt
|Date of Submission||20-Dec-2017|
|Date of Acceptance||20-Dec-2017|
|Date of Web Publication||30-Aug-2018|
Mahmoud M.M Genaidy
Department of Ophthalmology, Minia University, Minia
Source of Support: None, Conflict of Interest: None
Purpose The aim of this study was to compare direct brow lift and transblepharoplasty browpexy for the management of brow ptosis in terms of cosmetic results, complications, and patient satisfaction.
Patients and methods It is a surgical intervention prospective comparative study, 40 brows of 24 patients with brow ptosis were divided into two groups. Group A included 20 brows that were subjected to direct brow lift and group B included 20 brows that were subjected to transblepharoplasty browpexy. Preoperative evaluation included assessment of general and ophthalmological history, brow evaluation, any associated dermatochalasis, ocular examination, cranial nerve examination, visual field assessment, and photographic documentation.
Results Bilateral brow ptosis was present in 16 patients, whereas eight patients had unilateral brow ptosis. There were 16 female patients and eight male patients. Their age ranged between 53 and 75 years. The cosmetic complaint of an undesirable appearance was the presenting symptom in 18 patients, whereas functional issues with heaviness and temporal visual field defects were the presenting symptoms in four patients. In group A (direct brow lift), 16 brows were corrected with the brow level at or slightly above the superior orbital margin, whereas four brows were undercorrected. In group B (transblepharoplasty browpexy), 12 brows were fully corrected, whereas eight brows were undercorrected.
Conclusion Both direct brow lift and transblepharoplasty browpexy are effective and safe techniques for the correction of brow ptosis. Each procedure has its own advantages.
Keywords: brow, browbexy, ptosis, transblepharoplasty
|How to cite this article:|
Genaidy MM, Elshafei AM, Abdallah RM, Shetawy MM. Direct brow lift versus transblepharoplasty browpexy for correction of brow ptosis. J Egypt Ophthalmol Soc 2018;111:70-5
|How to cite this URL:|
Genaidy MM, Elshafei AM, Abdallah RM, Shetawy MM. Direct brow lift versus transblepharoplasty browpexy for correction of brow ptosis. J Egypt Ophthalmol Soc [serial online] 2018 [cited 2018 Sep 21];111:70-5. Available from: http://www.jeos.eg.net/text.asp?2018/111/2/70/240126
| Introduction|| |
Although the ideal brow position is subjective, the medial and lateral ends of the brow should be approximately on the same horizontal level, with an arch that peaks over the lateral limbus. In males, the brow typically rests at the level of the superior orbital rim, whereas in females, the brow should rest above the orbital rim. Brow ptosis represents an aging process because of thinning and descent of the tissue of the forehead. It may be associated with dermatochalasis and upper eyelid ptosis. Occasionally, brow ptosis may be caused by facial palsy, a tumor, or trauma . There are many techniques for correction of brow ptosis. Direct brow lift is suitable for any degree and pattern of brow ptosis . Less invasive limited-incision techniques (with or without an endoscope) have started to replace more aggressive open approaches, such as those performed through a coronal or an anterior hairline incision ,. The browpexy technique anchors the underlying brow soft tissue to the bone allowing for stabilization. This procedure can be performed concomitantly with an upper eyelid blepharoplasty through the same incision . An absorbable endotine transblepharoplasty fixation device can improve postoperative results, with higher patient satisfaction . Endoscopic brow lift has gained more popularity. However, this procedure has several drawbacks. It may cause alopecia, paresthesia, and hairline elevation, and requires expensive instrumentation . In this study, a comparison between direct brow lift and transblepharoplasty browpexy was performed in terms of cosmetic results, complications, and patient satisfaction.
| Patients and methods|| |
This is a surgical intervention prospective comparative study that was carried out in the Ophthalmology Department of Minia University Hospital between November 2013 and April 2015. The study included 40 brows of 24 patients with brow ptosis (16 bilateral and eight unilateral) with age range between 53 and 75 years, 16 women and eight men. The 40 brows were divided into two groups. Group A included 20 brows that were subjected to direct brow lift and group B included 20 brows that were subjected to transblepharoplasty browpexy.
Patients with either cosmetic or functional problems (field defect) were included in the study. Patients with previous surgical intervention for brow ptosis, patients with facial nerve palsy, and patients with bleeding tendency were excluded from the study.
All patients were subjected to the following preoperative evaluations:
- General medical history of systemic disorders and/or medication.
- Ophthalmological history of ocular trauma, surgery, chronic ocular diseases, and a history of facial nerve weakness or paralysis.
- Ophthalmological examination:
- Eyebrow evaluation while the patient was seated and looking forward with relaxed frontalis muscle, with documentation of the relation between the brow and the superior orbital rim.
- Examination for scars of old surgery or trauma.
- Cranial nerve examination including facial nerve function.
- Evaluation of any associated dermatochalasis.
- Slit-lamp examination of the anterior segment.
- Pupillary reaction examination.
- Visual acuity measurement.
- Intraocular pressure measurement.
- Extraocular motility assessment.
- Visual field assessment using a Humphrey visual field analyzer (Zeiss, Germany).
- Photographic documentation including study of old patient photographs and discussion of the changes in the brow position and the surgical goals with the patient.
Preoperative and postoperative photographs for the documentation and evaluation of the results
Patients with bilateral brow ptosis were subjected to the same operative procedure on both sides to achieve symmetrical results. Brows with isolated brow ptosis were allocated to group A (direct brow lift), whereas those associated with dermatochalasis were distributed in the two groups.
Direct brow lift
Skin marking was performed while the patient was sitting, looking straight ahead. With the brow in the ptotic position, the full length of the upper border was marked, then the brow was pulled up to its intended position, aiming at a slight overcorrection, and the marker pen was held just above the skin at this level. A 3–5 ml of a mixture of 2% of lidocaine with epinephrine 1 : 200 000 and 0.5% marcaine was infiltrated subcutaneously. The skin of the forehead was prepared with a 10% povidone iodine solution. An incision was made along the mark. Then, the incision was deepened to the level of the frontalis muscle ([Figure 1]a). A dissection was performed to excise the desired ellipse of skin ([Figure 1]b). Hemostasis was performed using bipolar diathermy ([Figure 1]c). The wound was closed in one layer with a nonabsorbable 4/0 sutures suture ([Figure 1]d).
|Figure 1 Operative procedure of direct brow lift: (a) skin incision along the marking, (b) dissection and tissue excision, (c) hemostasis, (d) skin closure.|
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Skin marking included blepharoplasty incision and browpexy marking, where the optimum position for the brow was determined by lifting the brow manually and marking the point of the fixation of the subcutaneous tissue for the sutures to be inserted later to lift the brow. Subcutaneous infiltration anesthesia of the lid and the brow was administered using the same mixture and skin preparation was performed similar to a direct brow lift. The blepharoplasty incision was made and the amount of redundant skin was removed. Dissection was performed superiorly, immediately deep to the orbicularis muscle, until the brow fat was exposed with continued dissection in the same submuscular plane to expose about 1–2 cm of the frontal periosteum ([Figure 2]). The dissection was extended a short way laterally to expose the deep temporal fascia. The brow was fixed to the periosteum about 1–2 cm superior to the orbital rim with two or three 4/0 nonabsorbable sutures. The needle was passed through the periosteum 1–2 cm superior to the orbital rim and then passed through the subcutaneous tissue of the brow at the point of marking ([Figure 2]b and c).
|Figure 2 Operative procedure of transblepharoplasty browpexy: (a) submuscular dissection, (b, c) a needle is passed through the underlying periosteum and subcutaneous tissue, (d) skin closure.|
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Skin incision was closed by prolene 6/0 ([Figure 2]d).
At the end of surgery, a combination of topical antibiotic and steroid skin cream was applied. The patient was instructed to place ice packs for the first few hours. The sutures were removed within 7–10 days postoperatively.
The patients were examined within a few hours after the procedure, 1 week, 4 weeks, 2 months, and 6 months after surgery. Patients were evaluated for eyebrow level, symmetry, final scar, patient satisfaction, and postoperative complications. A postoperative field examination was performed at the 6-month postoperative follow-up period. A simple patient questionnaire was used to evaluate the patients’ satisfaction.
This study was approved by the Local Ethical Committee of the Faculty of Medicine of Minia University and adhered to the tenets of the Declaration of Helsinki. An informed consent was obtained from each patient after an explanation of the procedure, the possible risks, and complications of the surgery was provided. The consent included agreement on the surgical procedure and photography including the possibility to use the photos for academic purposes including publications.
| Results|| |
This study included 40 brows of 24 patients with brow ptosis. Bilateral brow ptosis was present in 16 patients, whereas eight patients had unilateral brow ptosis.
There were 16 female patients and eight male patients. Their age ranged between 53 and 75 years. The cosmetic complaint of an undesirable appearance was the presenting symptom in 18 patients, whereas functional issues with heaviness and temporal visual field defects were the presenting symptoms in four patients. In group A (direct brow lift), 16 brows were corrected with the brow level at or slightly above the superior orbital margin ([Figure 3]), whereas four brows were undercorrected. In group B (transblepharoplasty browpexy), 12 brows were fully corrected ([Figure 4]), whereas eight brows were undercorrected.
In terms of the scar appearance in group A, eight of 12 patients were satisfied with the scar appearance, whereas in group B, 10 of 12 patients were satisfied with the scar appearance. In terms of the satisfaction with the degree of correction, in group A, eight patients were satisfied and four patients were unsatisfied. In group B, eight patients were unsatisfied, whereas four patients were satisfied. In terms of the symmetry between the two eyes, 10 patients were satisfied in group A and four patients were satisfied in group B.
Mild-to-moderate early postoperative lid edema and ecchymosis were present in all cases and resolved completely by the fourth-week follow-up visit. No wound dehiscence, infection, or granuloma developed throughout the study. In group A, one patient developed a prominent unsightly scar with upper eyelid retraction. In group B, one patient developed shin dimpling in one brow and wooding odd appearance in the other one.
| Discussion|| |
Many studies have been carried out to assess the eyebrow relation to the eyelid and determine whether the blepharoplasty could affect the eyebrow appearance. If blepharoplasty is performed alone, this will aggravate the brow ptosis, and if brow ptosis was to be corrected alone, the patient would not be satisfied with either cosmetic or functional outcomes because of the presence of dermatochalasis ,,.
Fagein , in his study, found that a very small percentage of patients had significant worsening of their eyebrow ptosis in one or both eyes after blepharoplasty. However, all were satisfied with the results.
In the current study, 80% of the patients who underwent direct brow lift were fully corrected during the early and late postoperative period, and 20% of patients were undercorrected. The degree of correction was maintained throughout the 6-month postoperative follow-up period.
Unacceptable scar appearance was present in 60% of brows during the early postoperative period, whereas 40% had an acceptable scar appearance. An improvement in the scar appearance was observed during the last postoperative (3–6 months) period to be 60% with acceptable scar appearance.
A bilateral symmetrical eyebrow level was noted in 83.33% of patients, whereas 16.67% had some asymmetry.
In terms of patient satisfaction, 66.6% of the patients were satisfied with the degree of correction and with the scar appearance and 83.33% were satisfied with the symmetry between both the eyes.
These results are in agreement with Booth and colleagues, who reported almost the same results in terms of the degree of correction and scar appearance, but symmetry was not observed in this study. Booth and colleagues found that the direct brow lift yielded a predictable outcome, with high levels of patient satisfaction and with careful wound closure, postoperative scars were rarely cosmetically unacceptable to the patient. Paresthesia was a common but well-tolerated sequel that was found in the study by Booth and colleagues but we did not encounter this sequel and it was not one of our parameters.
Also, these results are not in agreement with Tyers, who compared both techniques and encountered granuloma formation in patients who underwent direct brow lift; this was because of the use of braided absorbable sutures rather than monofilament sutures. Also, that study reported that the brow descended again. This difference may be because of our aim to slightly overcorrect the eyebrow and this is in agreement with Booth and colleagues. Our study is in partial agreement with Lewis , who reported that the direct brow lift could be utilized for eyebrow ptosis alone, whether unilateral or bilateral, to equalize asymmetrical eyebrows. It had been used by the author in instances of partial and complete facial paralysis in conjunction with other procedures of the face to achieve better symmetry. The duration of the results with this procedure varied with tissue quality and healing, surgical technique, care of the area during healing by the patient, amount of frowning and vigorous facial muscle use by the patient, and aging. This was a useful adjunct, especially when used for moderate or subtle brow lifts. Our results are in agreement with that study in terms of the symmetry and not in agreement with the degree of eyebrow ptosis that could be corrected using direct brow lift .
Overall, 40% of eyes that were subjected to transblepharoplasty browpexy were fully corrected in the early postoperative period, whereas 60% were undercorrected, and the degree of correction was maintained throughout the 6-month follow-up period. In all, 20% of eyes had an undesirable scar appearance, whereas 80% had an acceptable scar appearance. Bilateral symmetry was achieved in 33.33% of patients, while 66.67% were asymmetrical.
In terms of patient satisfaction, 83.33% of our patients were satisfied with their postoperative scar appearance and 66.67 were unsatisfied with the undercorrection or asymmetry.
These results are in agreement with those of Tyers  in terms of postoperative eyebrow level, scar appearance, and symmetry. He reported that the transblepharoplasty brow lift was associated with less lift than desired, and sutures causing dimpling of the skin that was encountered in our study but was not a major sequel .
Our study is not in agreement with Cohen et al.  who retrospectively reviewed the charts of 21 patients who were treated with browpexy through the upper lid. The age range of the 21 patients in this study was 54–70 years. Twelve patients were men; nine patients were women. There were no major immediate or long-term complications (including loss of suspension, frontal nerve injury, hematoma, infection, or wound dehiscence). No patients required reoperation for recurrent brow ptosis or upper lid deformity. That study reported that all the pateints were uniformly happy with their postoperative esthetic results, but this study did not consider symmetry to be one of the parameters, and also did not determine the degree of brow ptosis that could be suitable for that technique .
In conclusion, both direct brow lift and transblepharoplasty browpexy are effective and safe techniques for the correction of brow ptosis. Each procedure has its own advantages.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]