INTRODUCTION
The position of the eyebrow is important both from an esthetic and functional point
of view, varying in shape according to race, age and gender. A well-positioned eyebrow
is a sign of youth and beauty, with its position being classified in the literature1.
Besides an esthetic aspect, eyebrow ptosis contributes to excess skin on the eyelid
which in extreme cases can impair the visual field2.
The execution of blepharoplasty alone without a diagnosis of eyebrow ptosis can lead
to its deterioration3.
There are cultural and temporal influences in the perception of what is considered
an esthetically desirable eyebrow. Currently, the concept of the ideal eyebrow is
that the medial portion begins in the same vertical plane of a line passing through
the nasal wing and medial canthus and ending laterally in an oblique line drawn between
the most lateral part of the nasal wing passing by the lateral canthus. The medial
and lateral part of the eyebrow should be at the same height as in a horizontal line.
The highest part of the eyebrow is in a vertical line passing through the corneal
limbus and should be 2.5 cm from the pupillary midpoint4,5.
In men, the eyebrow should be at the height of the orbital edge, being thicker and
presenting a slight arc. In women, it should be a few millimeters above the orbit
and present a more pronounced arc. Some deviations from this standard may cause unnatural
results. An exaggerated lift of the entire eyebrow or medial part can cause a surprised
look. A marked lift of the side with the lower medial portion might result in a look
of annoyance6.
When performing the repositioning of the eyebrow, the particularities of the face
of each patient must be taken into account and not only established standards7.
An accentuated drop of the lateral part of the eyebrow occurs over time. This is due
to less frontal muscle support, decreasing tone in the lateral part of the temporal
fusion line, and the depressing action of the orbicularis muscles. To compensate this
decline, a contraction of the frontalis muscle occurs creating wrinkles in the area5,8..
Due to the importance of the eyebrow, several surgical and non-surgical procedures
have been developed aiming at their lift. The non-surgical procedures include the
use of botulinum toxin injections, fillers, lasers and peelings. Some of the most
common surgical procedures are a direct lift of the eyebrow, open rhytidoplasty and
laparoscopic surgery, and the elevations via temporalis9,10.
The aim of this report was to describe the surgical and non-surgical procedures for
eyebrow lift obtained through a review of the medical literature, and to present a
decision flowchart for the approach of eyebrow ptosis, taking into account the specific
characteristics of each patient.
METHODS
A search was performed within Medline and Lilacs databases, up to 31 May 2019, using
the MeSH descriptor [eyebrows (MeSH term)] and the DeCS descriptor "eyebrow," without
language restrictions.
Inclusion and exclusion criteria
Two authors independently assessed titles and abstracts according to the eligibility
criteria. Disagreements between authors were resolved by consensus between both.
Articles that contained surgical and non-surgical procedures for eyebrow lift were
included in the study.
Articles involving experiments on animals, eyebrow lift in reconstructive surgeries,
reviews, letters and responses to articles were excluded.
The flowchart of surgical decision was drawn based on the literature and on the experience
of the authors.
Consents were obtained and stored for publication of patient photographs in this study,
which adhered to the ethical principles of the Declaration of Helsinki.
RESULTS
A total of 1,695 studies were identified following the search strategy. After assessing
the titles and/or abstracts, 1,491 articles were excluded following the eligibility
criteria. After assessment of the full-texts of 204 articles, 67 articles were included
in the study (Figure 1).
Figure 1 - Inclusion and exclusion process of studies for the systematic review.
Figure 1 - Inclusion and exclusion process of studies for the systematic review.
The bibliographic survey resulted in the description of several surgical and non-surgical
approaches of eyebrow lift. The most commonly used procedures are described below.
Surgical procedures:
Open Rhytidoplasty: This technique uses a pretrichial incision for people with a long
forehead, medium-trichial for men with pronounced frontal wrinkles, or coronal for
people with a short forehead (Figure 2). Regardless of the incision, all techniques have the advantage of elevating the
entire eyebrow, treating the frontals and glabellar wrinkles. Open rhytidoplasties
are not appropriate for people with baldness. The complications include loss of motor
function and sensitivity, skin necrosis, alopecia, and asymmetry or overcorrection
of the eyebrows. There is no evidence in the literature that favors one surgical approach
at the expense of another11-17.
Figure 2 - Pre- and 1 year postoperative aspect of open rhytidoplasty with pretrichial incision
(upper left), coronal incision (upper right), endoscopic (lower left) and direct elevation
of the eyebrow (bottom right).
Figure 2 - Pre- and 1 year postoperative aspect of open rhytidoplasty with pretrichial incision
(upper left), coronal incision (upper right), endoscopic (lower left) and direct elevation
of the eyebrow (bottom right).
Dissection approaches may be subcutaneous, subgaleal, or subperiosteal. The subcutaneous
plane can be used in patients with very pronounced frontal wrinkles with lateral eyebrow
drop, and in reoperation cases. Although there is a higher accuracy of eyebrow positioning,
there is also a higher risk of flap necrosis, alopecia, and dehiscence. The subgaleal
plane is an avascular plane that also raises the eyebrow without tension and with
a lower risk of flap necrosis. The subperiosteal plane has the advantage of preserving
the irrigation of the galea, leaving the flap more robust and with a lower chance
of necrosis, besides preserving the frontoparietal innervation, but with more tension
for elevation5,18-20. The flap can be fixed through resection of the skin and suture or by fixing the
flap in the periosteum using mesh or screws. The relationship between skin excision
and eyebrow lift may range from 2:1 to 5:15,21.
Endoscopic Rhytidoplasty: This was introduced by Vasconez and Isse, 1992, and since
then, it has been an alternative to open rhytidoplasty in select cases. The best patients
for this technique are those with normal or low brow, since this surgery can increase
the size of the forehead (Figure 2). The repositioning of the forehead is achieved through a repositioning and fixation
of the scalp, unlike the open method that depends on its resection and suture 22,23.
This procedure has the same success rates as open rhytidoplasties, but with the advantages
of smaller scars, faster recovery, lower incidence of necrosis, and paresthesia of
the scalp. In this process, both the corrugator and the procerus can be weakened through
a partial resection. The shortcoming includes a lower exposure of the anatomy, expensive
specific equipment and higher learning curve24-27.
Fixation by endoscopy can be achieved through sutures in the cortical tunnels, Kirschner
wires, fixation with plate and internal screw, and through Endotine (polylactic acid).
The plates and screws can be made of absorbable or non-absorbable material. Regardless
of the method, the fixation must remain in place for 40 to 60 days until the healing
secures the flap in position5,22,28-32.
The ideal patient for this surgery includes those with thin skin, moderate ptosis
and slight skin flaccidity. Relative contraindications include bald people or with
high hairline and those with thick skin33.
Elevation of the eyebrows via temporal fascia: This technique uses an incision in the temporal region that can be pretrichial or
in the scalp. It resects a portion of skin to raise the lateral part of the eyebrow,
and it can be combined with other surgical procedures such as blepharoplasty. The
lift is obtained through the resection of the skin in the temporal region and suture29,34.
Direct eyebrow lift (Castanãres surgery): This consists of a skin incision above the eyebrow allowing for a greater control
and predictability in its lift and contour (Figure 2). It is indicated for the correction of unilateral ptosis of the eyebrows due to
nerve lesions. The disadvantage includes an apparent scar and supraorbital nerve injury
with paresthesia35.
Elevation of the eyebrow via the transpalpebral approach: Described by Paul and Ramirez, in 199636,37, it entails the subperiosteal lift of the eyebrow via the blepharoplasty incision.
An incision is performed in the periosteum through this access, just above the edge
of the orbit, myomectomy or myotomy of the corrugator and procerus. The advantage
of this technique is in correcting dermatochalasis as it yields results similar to
endoscopic rhytidoplasty without the need for specific equipment22,36.
Internal fixation of the eyebrows: Entails the internal lift of the lateral eyebrow through a blepharoplasty incision
(Figure 3). The dermis and fat on the side of the eyebrow are fixed in the periosteum of the
frontal bone through a suture. The disadvantage includes limited lifting of the eyebrow6,36,37.
Figure 3 - Pre- and 3 months postoperative aspect of upper blepharoplasty with internal fixation
of the eyebrow (top photo), elevation of the eyebrows with sustentation threads (middle
photo) and elevation of eyebrow with botulinum toxin (bottom photo).
Figure 3 - Pre- and 3 months postoperative aspect of upper blepharoplasty with internal fixation
of the eyebrow (top photo), elevation of the eyebrows with sustentation threads (middle
photo) and elevation of eyebrow with botulinum toxin (bottom photo).
Fixation Threads: This technique uses polylactic acid, nylon or polydioxanone (PDS) thread to raise
the eyebrows. Through a subcutaneous or subgaleal tunnel, the thread is fixed to the
dermis of the eyebrow, and the dermis of the scalp at the hairline in the temporal
region. After traction, the eyebrow is raised. The durability of the result is lower
when compared to other surgical procedures (Figure 3)29,38.
Non-surgical procedures
Botulinum toxin: The application of botulinum toxin in the depressor muscles (procerus, orbicularis
oculi, and corrugator supercilli muscles) produces a temporary paralysis of these
muscles, enabling a lift without opposition from the frontalis muscle, and raising
of the eyebrow (Figure 3). There is a possible complication of eyelid ptosis5,39.
Fillers: Filling in the upper region of the orbits results in mild lift of the tail of the
eyebrow, without repercussion in the medial and central region. It can be accomplished
with hyaluronic acid or fat graft, always in depth, above the periosteum40.
Given all these techniques and the experience of the authors, a decision flowchart
was elaborated to approach eyebrow ptosis (Figure 4).
Figure 4 - Decision flowchart to approach eyebrow ptosis.
Figure 4 - Decision flowchart to approach eyebrow ptosis.
DISCUSSION
Several surgical and non-surgical approaches for eyebrow lift were found in this literature
review, highlighting the evolution and incorporation of technology over the years.
Several articles presented slight variations of the same surgical approach, making
it difficult to describe each one in this study. It is to be assumed that there is
no gold standard approach to eyebrow lift that suits all patients, with each approach
presenting advantages and disadvantages (Tables 1 and 2).
To choose the best approach for the correction of eyebrow ptosis, it is important
to evaluate some of their characteristics, such as the degree and extent of ptosis,
the thickness of the eyebrow, presence of dermatochalasis, presence of glabellar and
frontal wrinkles and the height of the hairline (Figure 4).
The only classification of eyebrow positioning validated in the literature was used
in the elaboration of the flowchart1. Mild eyebrow ptosis was classified as 1 and 2, moderate ptosis as 3 and severe as
4.
Classification of eyebrow positioning (Carruthers et al., 20081):
- Youthful, refreshed look and high-arch eyebrow;
- Medium-arch eyebrow;
- Slight arch of the eyebrow;
- Flat arch of the eyebrow, visibility of folds, and tired appearance;
- Flat eyebrow with barely any arch, marked visibility of folds, and very tired appearance.
In general terms, the non-surgical procedures correct the mild forms of eyebrow ptosis,
while the surgical procedures correct the moderate and severe forms.
Although there are reports in the literature related to the choice of the best approach
of eyebrow ptosis, none included non-esthetic procedures that take into account other
factors than the severity of the ptosis.
The success of the surgical procedure to correct eyebrow ptosis depends greatly on
the surgeon's familiarity with the procedure. The decision of the best approach should
also take into account the surgeon's experience. Surgical approaches reserved for
severe ptosis of the eyebrow can be used in moderate ptosis, if the surgeon has no
experience with other options.
On the other hand, more complex surgical approaches can be left aside in the face
of simpler treatments. For example, to privilege direct lift of the eyebrows for moderate
ptosis and use botulinum toxin to treat frontal wrinkles, instead of, performing an
endoscopic rhytidoplasty. In summary, the best surgical approach is the one that provides
the surgeon with better results.
The drafting of the flowchart for the choice of the best approach for each eyebrow
and patient considered the experience of the authors and the services for which they
work. More than a rigid guideline, the objective of the flowchart is to demonstrate
that treatments must be customized and that there is a reason for the choice of any
procedure.
CONCLUSIONS
There is an abundance of articles describing various surgical and non-surgical approaches
for eyebrow lift, showing that there is no gold standard treatment, and that new technologies
have been incorporated throughout the years.
The decision flowchart for the best approach for eyebrow lift intends to show the
surgeon the need to customize the treatment and to highlight the reasoning behind
each approach.
COLLABORATIONS
REM
|
Analysis and/or data interpretation, Conception and design study, Data Curation, Final
manuscript approval, Formal Analysis, Investigation, Methodology, Project Administration,
Validation, Visualization, Writing - Original Draft Preparation, Writing - Review
& Editing
|
SM
|
Final manuscript approval, Supervision, Writing - Original Draft Preparation, Writing
- Review & Editing
|
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1. Universidade de São Paulo, São Paulo, SP, Brazil.
Corresponding author: Ricardo Eustachio de Miranda Rua Bandeira Paulista, 530, Sala 43, Itaim Bibi, São Paulo, SP, Brazil. Zip code:
04532-001. E-mail: ricardomiranda@hotmail.com
Article received: June 2, 2019.
Article accepted: July 8, 2019.
Conflicts of interest: none.