Comprehensive management of eyebrow and forehead ptosis.

The forehead and eyebrows are under the constant influence of downward forces of gravity and the periorbital protractor muscles (orbicularis oculi, procerus, corrugator, and depressor supercilii). These downward forces are opposed by the elevating action of the frontalis muscle. In time, this constant ‘‘tug of war’’ between the downward and upward forces leads to a series of wrinkles in the forehead and downward displacement of the eyebrows and eyelids (Fig. 1). The inferior displacement of the eyebrows results in apparent redundancy of the upper eyelid skin and hooding in the multicontoured areas of the medial and lateral canthal regions. Patients often present to the aesthetic surgeon complaining of dermatochalasis and request blepharoplasty. When the eyebrows are raised to their normal position, however, there is often less redundant upper eyelid skin than anticipated and blepharoplasty may not be necessary or appropriate [1,2]. Correction of the redundancy in the periorbital multicontoured regions represents a great challenge to the aesthetic surgeon. It is imperative that the surgeon and patient understand that excision of the upper eyelid and lateral canthal skin without elevating or fixating the eyebrow pulls the eyebrow down. This results in further ptosis of the eyebrows and canthal webbing [3,4]. This can give the eyebrows an appearance of being sutured to the eyelids (Fig. 2). The re-establishment of the structural integrity of the eyebrow is fundamental to achieving an aesthetically acceptable surgical result for cosmetic and functional periocular surgery [5]. For these reasons, an increasing percentage of blepharoplasties are performed in conjunction with eyebrow lifts [6].