Direct brow lift Figure

The principle is to raise the brow by the excision of an ellipse of skin and frontalis

Tarsal plate -

_ Orbicularis muscle

sutured to

tarsal plate

plate and orbicularis muscle, (b) orbicularis muscle

plate and orbicularis muscle, (b) orbicularis muscle

Deep Sutures
Figure 7.7 Deep sutures inserted in direct brow lift.

muscle, fixing it to the periosium of the forehead.

The technique is as follows:

• Mark the ellipse of tissue to be excised: mark first the superior border of the brow across its full width. Now manually lift the brow to the intended position, note the position, and allow the brow to fall again. Mark on the forehead skin the intended position of the superior border of the brow. Aim to over-correct slightly. Complete the marking of the ellipse with curved lines which join at the medial and lateral ends of the brow.

• Identify and mark the supraorbital notch through which the supraorbital nerve and vessels pass.

• Incise the ellipse of skin to the level of the frontalis muscle on the deep surface of the subcutaneous fat. Excise the ellipse of tissue. Special care is needed in the region of the supraorbital nerve and vessels.

• Close the deep layers with 4/0 nonabsorbable or long-acting absorbable sutures which include a deep bite through the periostium at the level of the superior wound edge. Omit the deep bite in the region of the supraorbital nerve and vessels. An extra row of more superficial subcutaneous sutures may be needed.

• Close the skin with a 4/0 monofilament subcuticular suture. Remove this at one week.

Complications - altered sensation in the forehead may occur due to damage to the supraorbital nerve.This may recover gradually over several months but it may be permanent. The position of the brow commonly droops again slightly in the weeks following surgery.

Corneal exposure

The risk factors for corneal exposure are well known: lid lag (inadequate eyelid closure), poor Bell's phenomenon, insensitive cornea and dry eye. Apart from release of a tight inferior rectus muscle to improve Bell's phenomenon and reduce upper lid retraction indirectly, the only surgical option in corneal exposure is to improve eyelid closure with or without overall reduction in the palpebral aperture. The latter may be achieved in either a vertical direction by lowering the upper lid and stabilising the lower lid or in a horizontal direction by approximating the lids at the inner or outer canthi.

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