CC
A 61-year-old female presents to your office for evaluation of her “droopy and sad-looking eyes.”
HPI
This patient presents for cosmetic consultation because for about the past 10 years, she has been receiving injected neuromodulators in her forehead and dermal fillers in her face, but she has noticed that her upper eyelids are beginning to droop around the sides and are giving her somewhat of a tired appearance that she would like corrected.
PMHX/PSHX/medications/allergies/SH/FH
The patient’s current medical status is only significant for mild hypertension and hyperlipidemia, which are currently treated with lisinopril and simvastatin, respectively. Past surgeries include two cesarean sections, a hysterectomy, and bunion removal. She does not use tobacco or alcohol. Her only reported allergy is codeine, which she said makes her nauseous.
Examination
She is a well-developed, well-nourished female with appropriate age-related changes to her facial appearance. She has Fitzpatrick II and Glogau 2 skin. Evaluation of her face shows gross facial symmetry with even vertical facial thirds. She has mild jowling with no significant platysmal banding. She has a slightly accentuated nasolabial fold with early downturn of the lateral labial commissures. The malar region shows appropriate volume and no significant nasojugal groove, likely an indication of under-eye dermal filler placement. There are no significant lower eyelid fat pockets visible. Evaluation of the eyelid and eyebrow shows that there is not a peak in her eyebrow and it sits along the superior orbital rim. There is mild dermatochalasis apparent in the upper eyelid, which resolves on manual elevation of the eyebrow. Her Marginal Reflex Distance (MRD) 1 and 2 are both normal. The distance from her eyebrow to the trichion is approximately 5 cm and has dense hair along the hairline.
The normal position of the eyebrow in a female lies above the superior orbital rim, with a peak at approximately the lateral third of the eyebrow. It generally begins as a thicker strip of hair, tapering as it moves laterally. It is highly important to evaluate the eyebrow position for anyone concerned with their upper eyelid because patients may expect a blepharoplasty when the treatment indicated is actually an eyebrow lift. Dermatochalasis and eyebrow ptosis can exist together and often are treated together, but eyebrow ptosis alone may give the appearance of dermatochalasis.
Imaging
No imaging studies are indicated for this evaluation.
Labs
No routine lab studies are indicated for this condition.
Assessment
Age-related eyebrow ptosis.
Treatment
This patient underwent an endoscopic eyebrow lift. There are several approaches to an eyebrow lift—transblepharoplasty, direct, trichophytic, endoscopic, and coronal—which all have different advantages and disadvantages ( Fig. 91.1 ).
Transblepharoplasty is usually done in conjunction with a blepharoplasty and is only capable of modest improvement in eyebrow position, but it spares a second incision.
Direct eyebrow lift is performed with an incision on the superior aspect of the eyebrow and can be done with or without a midforehead eyebrow lift to treat the medial eyebrow. These are generally done more in males because their thicker eyebrow hair and midforehead rhytids can better hide the incision. The ease of the procedure as well as the 1:1 change in position are the main advantages; the disadvantage is that the incisions may be more visible.
Trichophytic eyebrow lift is a subcutaneous dissection that can be used in a patient with a longer forehead to shorten the forehead while maintaining the hairline position ( Fig. 91.2 ). The main disadvantage is that the incision may be visible, especially in a patient with lowered density of the anterior hairline. Other variations of the trichophytic eyebrow lift can also advance the hairline.
