Internal brow fixation browpexy

This is useful for the treatment of mild unilateral or bilateral, predominantly lateral, brow ptosis. It is often undertaken in conjunction with blepharoplasty.

The amount of brow lift is determined as outlined above. After a standard blepharoplasty upper lid skin crease incision, dissection is continued superiorly and laterally in the submuscular fascia plane over the orbital rim. Deep to the plane of dissection the brow fat pad is identified overlying the lateral orbital rim.This is excised on to periosteum. Between one and three 4/0 Prolene sutures are then used to fixate or plicate the brow to the periosteum in the desired position. The number of sutures used depends upon the amount and extent of the brow lift required. The sutures are positioned 1cm apart and passed transcutaneously through the lower brow on to periosteum and horizontally through periosteum 1-1-5cm above the orbital rim. The suture is then passed back, again horizontally, through the brow muscle at the level of the transcutaneous suture avoiding superficial placement; the transcutaneous end of the suture is pulled through the brow tissue (but not the periosteum) and tied (Figure 8.3). This manoeuvre is a straightforward way of accurately positioning the suture with regard to both the periosteal and brow tissues. Additional sutures are used as required; if more than one suture is necessary then tying of the suture is best delayed until all sutures have been positioned. The height and curvature of the brow are assessed and adjusted as necessary. The skin incision is closed in the conventional way as for upper lid blepharoplasty.

Transcutaneous suture

Reflected flap

Medial lid

Reflected flap

Transcutaneous suture

Medial lid

Orbital rim Lateral lid

Figure 8.3 This demonstrates the horizontal periosteal suture, and return suture pass, before the transcutaneous suture is drawn through flap tissues only and tied.

Periosteum

Orbital rim Lateral lid

Figure 8.3 This demonstrates the horizontal periosteal suture, and return suture pass, before the transcutaneous suture is drawn through flap tissues only and tied.

Complications including skin dimpling, skin erosion and cheese-wiring of the sutures can occur with superficial placement. Contour and brow height abnormalities are seen with inappropriate suture placement. Recurrent brow ptosis may occur particularly if absorbable sutures have been used. Reduced eyelid elevation on upgaze is described which is an unavoidable limitation of the technique.

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