Brow Position Research Articles

Frontalis Linkage Without Intraoperative Eyelid Elevation for the Management of Myopathic Ptosis.

To report the effect of frontalis linkage without intraoperative eyelid elevation for the management of myopathic ptosis. Retrospective analysis of 21 (42 eyelids) myopathic patients with bilateral ptosis who were operated between 1999 and 2017. All patients had orbicularis weakness and poor or absent Bell's phenomenon. Surgery consisted of using an autogenous fascia sling to link the tarsal plate to the frontalis muscle without any degree of intraoperative eyelid elevation. The main outcome measures were margin reflex distance, brow height and degree of brow excursion and degree of lagophthalmos, and exposure keratitis. After surgery, there were significant changes (p <0.0001) in both margin reflex distance and brow position. Mean margin reflex distance increased to 1.4 mm ± 1.34 DP and with full frontalis contraction, it reached 3.0 mm ± 1.73 DP, while mean brow position decreased 1.6 mm ± 1.59 SD, p < 0.0001. Postoperative lagophthalmos was not detected in 31 (74%) eyes. In the remaining 11 eyes (26%), lagophthalmos ranged from 1.2 to 5.2 mm (mean = 1.7 mm ± 0.74 DP). Mild inferior superficial keratitis was detected in 14 eyes (33.3%) of 7 patients only 3 of which had lagophthalmos. One patient needed additional surgery to correct unilateral eyelid retraction. Overall, 81.81% of the patients were pleased with the procedure. Myopathic ptosis can be alleviated with a minimal amount of lagophthalmos by just linking the tarsal plate to the frontalis muscle without lifting the eyelid margin intraoperatively.

Eyebrow Elevation as a Prognostic Factor for Success of Frontalis Suspension in Severe Congenital Ptosis.

PurposeThe study aims at evaluating eyebrow elevation as a prognostic factor for frontalis sling procedure success in patients suffering from severe congenital ptosis with poor levator function.Patients and MethodsThis is a retrospective study that included 66 eyelids of 57 patients selected from a surgical log database between January 2016 and June 2019. All of them underwent frontalis suspension surgery for treating severe congenital myogenic ptosis with poor levator function. Based on the absence or presence of brow elevation, patients were divided into two groups: 1 and 2, respectively. The latter was further subdivided into subgroup A with unilateral brow elevation and subgroup B with bilateral brow elevation. All included cases completed 6 months of follow-up after surgery. Postoperative functional outcomes in the form of margin reflex distance (MRD1) and palpebral aperture (PA) were recorded and correlated to preoperative brow elevation status.ResultsBoth principal groups showed improvement of MRD1 and PA compared to the preoperative values. There was no statistically significant difference between both groups for the tested parameters in the 1st postoperative week. By the 6th postoperative month, MRD1 and PA showed statistically significant higher values in group 2 compared to group 1 (p<0.001). However, the difference between subgroups A and B was statistically insignificant for the same parameters.ConclusionEyebrow elevation is significantly associated with the success of frontalis suspension procedure. Hence, brow position evaluation should be included in the preoperative assessment of patients undergoing frontalis suspension for congenital ptosis.

Masseteric-zygomatic nerve transfer for the management of eye closure-smile excursion synkinesis.

The purpose of this study is to illustrate the efficacy of masseteric-to-zygomatic nerve transfer to address eye closure-smile excursion synkinesis after facial nerve paralysis. Synkinesis after facial nerve paralysis represents a wide range of facial movement disability. One manifestation is involuntary smiling with eye closure and a concomitant reduction of oral commissure movement with attempted smile ("frozen smile") - arising as a result of aberrant fibers populating the zygomatic branch-muscle complex. This is a particularly difficult area to treat with conservative management. We propose a single-stage procedure to sever the dysfunctional zygomatic nerve and perform a masseteric-zygomatic nerve coaptation to recover a voluntary smile. We present a case series of eight patients with eye closure/smile excursion synkinesis who underwent single-stage masseteric-zygomatic nerve transfer by a single surgeon. The surgical technique and indications for surgery were reviewed. Patients underwent facial movement analysis using Emotrics. We analyzed the pre- and post- surgical photographic images of 8 patients with synkinesis (7 female, 1 male). Masseteric-facial nerve transfer was performed from 18months to 22years after the initial facial paralysis. Eyelid and brow positioning were more symmetric after surgery, with discrepancy between affected and unaffected side decreasing from 2.1 to 1.0mm (p<.05) and 1.74 to 1.29mm (p<.05), respectively. Symmetry of smile excursion postoperatively was also improved with commissure excursion discrepancy decreasing from 8.8 to 3.78mm (p<.05). Discrepancy in the smile angle when comparing affected to unaffected side improved postoperatively from 10.3 to 5.2 degrees (p<.05). Improvement in oral commissure height was noted, but not statistically significant. The masseteric-zygomatic nerve transfer is a useful technique for the treatment of eye closure/smile excursion synkinesis after failure of chemodenervation and/or physical therapy.

Aesthetic Analysis of Alteration of Eyebrow Position After Double Eyelidplasty.

There is an anecdotal belief among some surgeons performing Asian eyelid surgery that double eyelid surgery itself decreases eyebrow position. However, the exact amount of descent and the specific changes in the proportion of facial aesthetics are unknown. The goal of this study is to determine whether there indeed is a change in brow position after double eyelidplasty and to quantify the proportional differences associated with the change. The three-point double eyelids surgery method was used so that the change in the brow position is solely attributed to the surgery itself and not to the excision of redundant skin. From January 2016 to December 2017, double eyelid surgery using the three-point technique was performed on 204 patients who did not require skin excision. Their pre- and postoperative photographs were standardized and analyzed. The ratio of the length between the upper edge of the eyebrow and the edge of the lower eyelid (A) and the length between the edge of the lower eyelid and the nasal base (B) as well as the subsequent change in the midfacial proportion was measured and analyzed. There was a statistically significant brow descent after double eyelidplasty. The average preoperative A/B was 0.71 and the average postoperative A/B was 0.67 (P < 0.001). Although the eyebrow distance did not change in 32.5% of patients, the remaining cohort showed average brow descent of 5.6%. And in this cohort that showed descent, linear regression showed that there was a correlation between the ratio of pre- and postoperative eyebrow distance CONCLUSION: Double eyelid surgery can lower the eyebrow in patients with foldless eyelids. This is in accordance with clinical observation in Asian blepharoplasty. In addition, there are associated changes in the proportion of midfacial aesthetics after the surgery. Such knowledge can be helpful in preoperative consulting with patients as well as in predicting postoperative results. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Brow Ptosis: Is Transblepharoplasty Internal Browpexy Suitable for Everyone?

Transcutaneous internal browpexy can provide patients with mild-to-moderate lateral brow ptosis, stabilization and modest lift of the lateral brow. Questions regarding effectiveness of this procedure and appropriate indications remain. The authors measured consecutive patients who underwent upper eyelid blepharoplasty with transblepharoplasty internal browpexy (TIB) September 2014 to December 2017. Pre- and postoperative brow elevation was assessed based on before and after photographs of each patient. Patient photographs were assessed for medial and lateral brow elevation, brow contouring and asymmetry. Optimal lateral brow elevation was classified as bilateral symmetrical and above the supraorbital rim for women, and symmetrical and at the supraorbital rim for men. A total of 239 patients underwent bilateral TIB and 39 underwent unilateral TIB (517 eyelids in total). Pre- and post-operative measurements were taken in 98 patients (41%), with an average elevation of the lateral brow position of 2.54 mm.Six patients had an underlying infection in the first postoperative week that resolved completely. Three patients underwent a second stage direct brow lift repair and 3 needed unrecognized ptosis repair as a second stage. Transblepharoplasty internal browpexy is an important tool that can be used in most patients with lateral and central brow ptosis, asymmetric brow ptosis and irregular contour of the brow. Additionally, browpexy adds to the success and longevity of upper blepharoplasty, while preventing early recurrence of lateral upper eyelid hooding. Patients with significant ptosis, heavy brows, medial greater than lateral ptosis, and post-facial palsy may not be good candidates for this procedure.

Self-denigration and the mixed messages of ‘ugly’ selfies in Instagram

Abstract This paper sets out a new, multimodal account (both visual and verbal analysis) of how self-denigration is conveyed through ‘ugly selfies’ as posted to the photo-sharing site Instagram. Drawing on 226 Instagram posts categorised by the poster themselves with the hashtag #uglyselfie, the visual analysis compared the persons and setting in the selfie, the person’s facial expression (eye brow position, mouth expression), eye gaze and camera angle. The verbal analysis included the self-denigration found in the image caption and the rapport enhancing or threatening responses found in the comments to the image posted by others. Ugly selfies are found to convey various types of self-denigration, including self-deprecation and self-mockery. The difference between self-deprecation and self-mockery are explained by the types of ‘mixed messages’ generated by the images. In self-deprecation, the mixed messages arise from a contrast between the visual image and the verbal caption. In self-mockery, the mixed messages arise from contrasts within the image itself, where visual exaggeration and incongruity lead to a jocular interpretation of the ugly selfie. Although the focus in this paper is on self-denigration and selfie-taking, the analysis of mixed messages can be used to analyse many different forms of politeness strategies and many kinds of images shared with increasing frequency and importance on social media sites.

Botulinum Toxin to Treat Horizontal Forehead Lines: A Refined Injection Pattern Accommodating the Lower Frontalis.

When treating horizontal forehead lines with botulinum toxin type A the traditional approach requires that injection points should stay 1.5 to 2 cm above the orbital rim to avoid brow ptosis. Failure to treat the lower frontalis may potentially cause worse rhytides in the lower forehead. The aim of this study was to present a refined injection pattern accommodating the lower frontalis and evaluate its clinical efficacy and safety. Patients were categorized into 4 types according to the patterns of their forehead wrinkles. Moderate and severe wrinkles in the upper forehead were treated by the "safe zone" technique. Mild wrinkles and rhytides in the lower forehead were treated by the Microbotox technique. Standard photographs and measurements were taken before and after treatment. The effect on wrinkle reduction and changes in brow heights were assessed. In total, 330 treatments were followed up in the clinic, and 246 treatments were followed up by telephone. Among the 330 treatments, 213 were evaluated in our clinic 2 to 4 weeks later, and the patients who received these treatments were recruited for effect evaluation and brow height measurements. The posttreatment severity of forehead wrinkles was significantly reduced (P < 0.05), and brow heights remained unchanged (P > 0.05). No severe adverse events were documented. Patient satisfaction was quite high. The refined injection pattern is an effective and safe technique to treat horizontal forehead lines. The Microbotox technique enables treatment of the lower frontalis without changes in brow position.

Periorbital Aesthetic Surgery: A Simple Algorithm for the Optimal Youthful Appearance.

Background:Blepharoplasty is one of the most common procedures performed. To achieve optimal results in periorbital rejuvenation, a systematic approach to patients that addresses all the problems in the periorbital region is important. The aim of this study is to analyze blepharoplasty patients according to preoperative deformities and postoperative results and to create a basic algorithm for periorbital aesthetic surgery.Methods:Patients who underwent periorbital aesthetic surgery were examined retrospectively. Patients’ medical records and preoperative and postoperative photographs were analyzed. Preoperative and postoperative photographs were analyzed for 6 main criteria: brow position, blepharoptosis, canthal tilt, excess skin or deficiencies, excess subcutaneous tissue or deficiencies, and periorbital skin rhytides. After the anatomical analyses, researchers rated the results as optimal or suboptimal.Results:In total, 176 patients’ medical records were analyzed. Among them, 154 were women and 22 were men. The mean age was 43.8 years. No comorbid situation was detected in 133 of these patients. The postoperative result was evaluated as suboptimal in 151 patients (86%) and optimal in 25 patients (14%). An algorithm was proposed for the systematic evaluation of periorbital surgery patients to achieve satisfactory results.Conclusions:A simple 6-step checklist is designed to define periorbital deformities and to achieve the optimal youthful appearance.

Exploring Brow Position Changes with Age in Koreans.

PurposeSeveral studies have described age-associated brow drooping in Westerners. However, there are few studies that address brow drooping in the Asian population, and especially in the Korean population. Therefore, we studied brow position changes with age in Korean individuals.MethodsA total of 300 adults older than 18 years were enrolled. The ImageJ program was used to analyze digital photos of the patients by measuring the following parameters: marginal reflex distance-1, brow-to-pupil distance, nasal ala-lateral brow distance, lateral brow plumb line, and the angle formed by the line from the mid pupil to the midline of the brow and a line from the midline of the brow to the lateral brow. We divided the patients into three groups (18 to 40, 41 to 60, older than 61) and compared them using the ANOVA test.ResultsGroup A included 100 patients between 18 and 40 years of age. Group B included 100 patients between 41 and 60 years of age. Group C included 100 patients older than 61 years. There were significant differences between groups A and C and between groups B and C with regard to marginal reflex distance-1, brow-to-pupil distance and the angle. Lateral brow plumb line showed significant difference only between groups A and B. Nasal ala-lateral brow distance was not significantly different across the three groups.ConclusionsWe sought to describe the physiologic facial changes that occur in Korean individuals. We also hoped to establish guidelines for ptosis corrective surgery. We used various parameters to characterize the aging process in Asians. Our data demonstrated that, like Westerners, Koreans experience lateral brow drooping with age; however, this change was only significant in the group aged >61 years.

Frontalis Muscle Contraction and the Role of Visual Deprivation and Eyelid Proprioception.

To determine if frontalis muscle contraction can be induced by manipulating visual and eyelid proprioceptive inputs through simulating visual deprivation and ptosis. Volunteers without prior eyelid or forehead pathologic study were recruited for this nonrandomized, prospective study. Baseline and study phase brow positions were documented. The first phase was to simulate visual deprivation and the second to simulate ptosis. The dominant eye was used for each phase. As a proxy to simulate visual field deprivation, a black contact lens was placed on the eye, which reduced vision to light perception. As a proxy to simulate ptosis, an external eyelid weight was placed on the upper eyelid. Brow position ratios were calculated at various points along the brow and statistical analysis was performed. Fifteen subjects participated. The average brow position ratio was 1.00 ± 0.08 for the visual deprivation group, which was not different from baseline (p = 0.86). The average brow position ratio for the external eyelid weight group was 1.13 ± 0.07, which was statistically significant compared with baseline and the visual deprivation group (p < 0.001). Inducing visual deprivation with a black contact lens does not lead to a change in brow position. However, placing an external eyelid weight does lead brow elevation, with an average increase of 13% from baseline. This suggests a likely role for proprioceptive or sensory inputs in frontalis muscle contraction in the setting of eyelid ptosis.

Reply re: "Frontalis Muscle Contraction and the Role of Visual Deprivation and Eyelid Proprioception".

PURPOSE To determine if frontalis muscle contraction can be induced by manipulating visual and eyelid proprioceptive inputs through simulating visual deprivation and ptosis. METHODS Volunteers without prior eyelid or forehead pathologic study were recruited for this nonrandomized, prospective study. Baseline and study phase brow positions were documented. The first phase was to simulate visual deprivation and the second to simulate ptosis. The dominant eye was used for each phase. As a proxy to simulate visual field deprivation, a black contact lens was placed on the eye, which reduced vision to light perception. As a proxy to simulate ptosis, an external eyelid weight was placed on the upper eyelid. Brow position ratios were calculated at various points along the brow and statistical analysis was performed. RESULTS Fifteen subjects participated. The average brow position ratio was 1.00 ± 0.08 for the visual deprivation group, which was not different from baseline (p = 0.86). The average brow position ratio for the external eyelid weight group was 1.13 ± 0.07, which was statistically significant compared with baseline and the visual deprivation group (p < 0.001). CONCLUSIONS Inducing visual deprivation with a black contact lens does not lead to a change in brow position. However, placing an external eyelid weight does lead brow elevation, with an average increase of 13% from baseline. This suggests a likely role for proprioceptive or sensory inputs in frontalis muscle contraction in the setting of eyelid ptosis.

A 3D Morphometrical Evaluation of Brow Position After Standardized Botulinum Toxin A Treatment of the Forehead and Glabella.

Botulinum toxin treatment for forehead wrinkles has been extensively studied and found to be a safe and reproducible procedure. However, the effect on the position of the eyebrows, which relies on the dynamic positioning of the treated muscles, has received less attention and has not been studied with 3-dimensional (3D) technology. The authors sought to evaluate the changes of eyebrow position after standardized botulinum toxin treatment of glabella or glabella and frontalis muscles with 3D imaging. In a prospective study, 2 groups of adult females were treated with botulinum toxin A at the glabella only (G) or at the glabella and the frontalis muscle (F/G). The brow position was measured at 5 positions with 3D photography before injection and 2 weeks, 3 months, and 6 months after injection. Results were statistically analyzed and related to patient age. In the F/G group, the brow descended significantly almost across the whole brow length after 2 weeks. The descent lessened after 3 months and moved medially. No clear trend was evident in the G group. There was no significant change attributed to patient age in both groups. Botulinum toxin treatment of the glabella and frontalis muscle impacts the position and configuration of the eyebrow. The degree of change is affected by the amount of frontalis weakening rather than by treatment of the glabella. While age in general is not a reliable predictor, individual factors play the major role in how pronounced a change of the brow can be expected.

Hering's Law in Congenital Ptosis: Evaluation of the Contralateral Response to Unilateral Congenital Ptosis Repair.

To determine the applicability and clinical relevance of Hering's law for the eyelids in cases of congenital ptosis. A retrospective chart review and digital photograph analysis of patients who underwent unilateral congenital ptosis repair at a tertiary, university-based, Oculoplastics clinic was conducted. Pre- and postoperative eyelid height (marginal reflex distance), upper eyelid symmetry, and brow position were determined using ImageJ analysis software. Changes in these values, and the relationship between the change in ipsi- and contralateral eyelid heights and brow positions, were determined. In 51 patients, the mean change in contralateral upper eyelid position (marginal reflex distance) following unilateral repair was -0.5 mm with 29% (n = 15) demonstrating a greater than 1 mm contralateral descent. The contralateral brow position remained stable with a mean change of +0.1 mm. No significant differences were seen between the 15 patients who demonstrated a contralateral upper eyelid descent greater than 1 mm and the remainder of the cohort in terms of amblyopia rate (p = 0.71), mean preoperative marginal reflex distance (p = 0.14), mean change in ipsilateral marginal reflex distance (p = 0.32), mean change in contralateral brow position (p = 0.44), or mean postoperative upper eyelid asymmetry (1.3 mm vs. 1.2 mm). Overall, the mean upper eyelid asymmetry improved from 2.6 mm preoperatively to 1.2 mm postoperatively. None of the 51 patients underwent subsequent contralateral ptosis repair. Hering's law for the eyelids applies to cases of congenital ptosis but has little clinical significance due to improved upper eyelid asymmetry following unilateral surgery.

Evaluation of the donor site after the median forehead flap.

BackgroundForehead flaps are useful for facial reconstruction. Studies of these flaps have mostly focused on the results of the reconstruction. However, due to the scarring and changes on the forehead caused by the median forehead flap (MFF), surgeons may be reluctant to perform this flap. Research into the donor site is needed for practical purposes.MethodsWe examined 42 patients who underwent an MFF at Pusan National University Hospital from 1996 to 2016. Based on a retrospective chart review, we examined the occurrence of complications. We also evaluated scars on the forehead using the Vancouver Scar Scale (VSS) and assessed changes in the eyebrow position of 22 patients.ResultsNo complications occurred in the 42 patients. The mean VSS score of the 22 patients was 2.8±0.79. The ratio of the height of the eyebrow on each side to the distance between the medial canthi increased postoperatively, meaning that both the left and right brows were elevated slightly (P=0.026 and P=0.014). However, the symmetry between the left and right sides did not change (P=0.979). The ratio of the interbrow distance to the distance between the medial canthi decreased slightly, meaning that the interbrow distance narrowed mildly (P<0.001). Moreover, there were no noticeable changes in the brow position as seen in a photo overlay.ConclusionsThere were no notable complications in the forehead. Forehead scarring was acceptable. No change in brow symmetry was observed via photographic measurements and a photo overlay. Therefore, we propose that the MFF is a useful choice for minimizing scarring or deformation of the donor site.

Volumization of the Brow at the Time of Blepharoplasty: Treating the Eyebrow Fat Pad as an Independent Unit

Loss of volume in the sub-brow fat pad with associated descent of the eyebrow is a common anatomical finding resulting in both functional and aesthetic consequences. A variety of techniques have been described to address brow position at the time of blepharoplasty. To our knowledge, none of these techniques treat the sub-brow fat pad as an isolated unit. Doing so enables the surgeon to stabilize and volumize the brow without resultant tension on the blepharoplasty wound. The authors describe a technique for addressing volume loss in the eyebrow with associated brow descent that treats the sub-brow fat pad as an isolated unit. A retrospective review of all patients undergoing brow ptosis repair by a single surgeon (J.W.S.) over an 11-month period was performed. Eighteen patients and 33 brows underwent the technique described. Patients were followed for an average of 11 weeks (range: 4 weeks to 20 weeks). All patients preoperatively displayed both visually significant dermatochalasis and brow descent below the orbital rim. Evaluation of pre- and postoperative photos demonstrates successful volumization of the brow with skin redraping without focal dimpling or undue tension on the eyelid wound. Performing a dissection that allows the sub-brow fat pad to be elevated in isolation from the overlying orbicularis and underlying periosteum allows for volumization and of the brow without compromising closure. This technique is a safe and effective means of volumizing the brow and treating secondary brow descent.

Minimally Invasive Approaches to Forehead Rejuvenation

Brow position is an established measure of both gender and youth. Patient goals can range from facial feminization to restoration of a more youthful form. Since its introduction in 1994, the endoscopic brow lift has become increasingly popular for elevation and stabilization of the brow, although numerous aesthetic surgeons still question its efficacy. The endoscopic brow lift demands a detailed understanding of specialized endoscopic instruments and regional anatomy. The dissection is tactile at times, but key portions require either direct or endoscopic visualization. Fixation options are numerous, each with their specific risks and benefits. Most importantly, well-planned surgical technique is key in avoiding the stigmata of brow surgery, such as a raised hairline, overcorrection with a surprised facade, and incisional alopecia. In this chapter, we review pertinent anatomy and an algorithm for brow ptosis evaluation. We discuss the specialized instruments necessary to perform this procedure and surgical techniques to maximize outcome while minimizing complications. In preparing patients for this procedure, we review the complication profile and key points of preoperative discussion. A well-done endoscopic brow lift can offer patients a sustainable, stable result with minimal surgical scars and should be included in the armamentarium of an aesthetic surgeon.

Effect of Orbicularis Muscle Resection during Blepharoplasty on the Position of the Eyebrow.

Dermatochalasis is a skin excess in the upper eyelid which may be associated with either an aesthetic and functional defect, blocking the peripheral vision. Upper blepharoplasty is the gold standard procedure for correction of dermatochalasis and to restore youthful contours to the periorbita. It is one of the most commonly performed procedures in aesthetic plastic surgery; however, there is still a lack of consensus about this procedure. The excess skin is sometimes removed alone or in conjunction with a strip of orbicularis oculi muscle. The rationale for both muscle and skin resection or skin alone preserving the muscle is uncertain. Some authors have studied the aging influence in brow position, and a few studies pointed out the influence of the upper blepharoplasty on brow height. The true effects, regarding the position of the eyebrow, of both techniques, with or without resection of the preseptal orbicularis oculi muscle, are unclear. The authors present a review of the literature to find the rationale for resecting or preserving the orbicularis oculi muscle in upper eyelid blepharoplasty and its relation to eyebrow position.

Manipulation of the Periorbital Musculature.

The resting and expressive states of the periorbital region contribute to perceived age, emotion, gender, race, and countenance. A thorough understanding of the periorbital musculature is essential for comprehensive facial rejuvenation. Surgical and nonsurgical manipulation of these muscles can lead to alterations in brow elevation, resting brow position, and dynamic periorbital rhytids. Both surgical and nonsurgical techniques can produce desired effects, and they are often used concomitantly to obtain optimal results.

Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and Brow Lift.

Upper eyelid dermatochalasis often triggers frontalis hyperactivity in an effort to elevate the upper lids away from the visual axis. Similarly, prior neuromodulator treatment of the brow depressors may cause false elevation of the brows, diminishing the extent of preoperative brow ptosis or dermatochalasis. Studies have quantified postoperative brow ptosis and recurrent dermatochalasis following upper blepharoplasty, but a methodology to predict the postoperative brow position remains to be elucidated. The authors present our comprehensive perioperative protocol utilizing neuromodulators to optimize results of upper blepharoplasty and brow lift. In patients presenting with upper lid dermatochalasis and frontalis hyperactivity, who request upper blepharoplasty, the authors apply a neuromodulator treatment protocol. Patients with prior neuromodulator treatment of brow depressors wait four months after the last treatment to allow for product attrition. Two weeks prior to surgery, the authors treat the frontalis with 15 to 20 units of Botox Cosmetic. From 2002 to 2016, the authors treated 521 patients (458 women, 63 men) with frontalis hyperactivity who presented for periorbital rejuvenation. This method has led to neither excessive resection of upper eyelid skin tissue nor lagophthalmos. Preoperatively, the authors have unveiled upper eyelid ptosis in 39 patients (31 women, 8 men) and brow ptosis in 131 patients (97 women, 34 men). Brow position and frontalis hyperactivity should be taken into consideration during preoperative evaluation for upper blepharoplasty and brow lift. Routine preoperative treatment of the hyperactive frontalis with neuromodulator, along with attrition of prior neuromodulator in the brow depressors, reveals the true anatomic brow position to optimize surgical planning.

Relationship between ocular dominance and brow position in patients with blepharoptosis

ABSTRACTPurpose: This study aims to determine if ocular dominance plays a role in predicting compensatory eyebrow elevation in cases of ptosis.Methods: This retrospective observational cohort study screened all individuals presenting to two tertiary oculoplastics practices with complaints of ptosis for entry. Primary position photographs were obtained. Ocular dominance was assessed via a modified Porta test. Ptosis was defined in bilateral cases as marginal reflex distance of <2.5 mm in both eyes and in unilateral cases as either an MRD1 < 2.5 mm or MRD1 of >1 mm lower on one side. Asymmetry in brow height was defined as a difference of >1 mm. Chi square and t-tests were performed.Results: Sixty-eight patients from the both tertiary practices met inclusion criteria (37 male, 31 female). Concordance between the higher brow and the dominant side was 50.0% (n = 22, p > 0.05). Mean brow height on the dominant side (15.5 mm) was not statistically different than brow height on the non-dominant side (15.3 mm, p > 0.05). The concordance between the higher brow and the lower MRD1 eyelid was not significant (45.5%, n = 20, p > 0.05). The difference in mean brow height between the lower and higher MRD1 eyes was not significantly different (−0.11 mm; p > 0.05). This also held true when restricted to unilateral cases (0.28; p > 0.05).Conclusions: Although asymmetric brow elevation can be noted in patients with ptosis, ocular dominance does not appear to be concordant with this asymmetry. Additionally, brow height does not appear to be concordant with MRD1 in cases of ptosis.