In most medical conditions, definitions rely upon exact numbers. In the case of brow ptosis, it is judgment combined with measurements. Brow ptosis exists when it interferes with aesthetics or function. The level of brows deemed low in one person may be perfectly acceptable or "normal" in another. Brows descend over time in everyone. With the brow being a mobile structure and with the secondary effects of age, solar elastosis, muscle action, trauma, lesions and gravity, some degree of brow descent will occur in everyone. The brow position is regarded differently in different genders, races, ages, and even generations. In some communities, the concept of changing a brow position or curve as we age is considered anathema. In many Western societies, it is an accepted desire. Age-related eyebrow ptosis is secondary to gravitational, involutional, and exposure changes. In women, brows normally sit above the orbital rim and arch upward and outward so that the peak of the brow is at the lateral limbus, although in some societies, a further lateral flare is even more desirable. Therefore, in women, brow ptosis would is present if the brow is lower than this ideal. Even a brow above the orbital rim may be low (have brow ptosis) and repair or repositioning may be desired. In men, eyebrows normally sit at or just above the superior orbital rim with the brow shape being more horizontal. There is variability in the ideal brow in men and women depending upon age, cultural influences, occupations and secondary effects of the environment. Therefore, in a weather-worn farmer, a low brow would be considered normal as it would protect the farmer from environmental factors like light, dust, and wind. In an actor, there may not be an ideal brow position as the brow movement would be utilized to show different expressions in that profession. In a lorry driver or train driver, where peripheral vision is vital, the brow position may need to be higher than in other patients, male or female. So unlike say ptosis, where clinicians measure corneal reflex-lid margin distance and levator function and diagnose ptosis numerically, brow ptosis is a subjective assessment based upon many factors. Brow ptosis is rarely symmetrical because of many factors including differences between the right and left sides of the face (sometimes with hemifacial microsomia), different exposure to the elements, and the side a patient may sleep on, among others. : Aging. Facial palsy. Tumors. Trauma. Cosmetic. Visual obstruction caused by secondary dermatochalasis. Asymmetric brow positions. Irritation caused by secondary lash ptosis. Brow ptosis in the absence of trauma, paralysis, or disease occurs slowly and most patients will not be aware of the brow ptosis until pointed out after a clinical examination. Almost everyone over the age of 40 years, male or female, will have some degree of brow ptosis. Most of these patients will not need surgical correction. : Direct brow lift. Mid-forehead brow lift. Pretrichial brow lift. Temporal brow lift. Coronal brow lift. Endoscopic brow lift. Internal brow lift This article reviews the assessment and planning of brow lifts, in general, and indications for the mid-forehead lift, in particular.  Historically, many surgical procedures such as cataract surgeries, nose reconstructions, skin flaps, have been performed for hundreds of years and in some, like cataract surgery, thousands of years. Surprisingly, brow lift surgery was only recorded in the last century when Lexer first discussed and presented the forehead lift in 1910. Subsequently, a coronal incision and resection of tissue were described by Hunt, who did not undermine any of the tissues, which led to limited results. Joseph in 1931 presented detailed descriptions of a pretrichial brow lift and also incisions made lower on the forehead used to lift the brows. Many surgeons continued simple tissue resection without any undermining of the proximal or distal tissues until Passot improved upon excision of skin behind the hair with temporal facial nerve denervation in 1933. This would improve the forehead wrinkles; however, the tonic component of the frontalis muscle would be lost and was therefore not a good advance to brow lifts. For reasons not exactly clear, surgeons continued to explore nerve destruction. Edwards presented isolated temporal neurectomy as recently as 1957. A more anatomical approach was presented by Bames in 1957 when he described a direct eyebrow lift. Through this approach, he weakened the corrugator muscles and undermined the forehead all the way up to the hairline, while crosshatching the frontalis muscle. Modern hairline and coronal approaches (1 cm behind the hairline) to the forehead lift and brow lift were ushered in by Pangman and Wallace in 1961. Further refinement in cosmetic surgery was achieved when in 1962, Gonzalez-Ulloa performed the forehead lift by incorporating it into his facelift procedure. In spite of the initial enthusiasm for coronal lifts, reports in the 1960s and 1970s suggested that results of coronal forehead lifts were short-lived which led to the procedure losing favor. It had not been appreciated that without undermining after excision of a strip and somehow modifying the frontalis muscle; the results were bound to be temporary. So until the early 1970s, most surgical procedures consisted or resection and repair without undermining or manipulation of the forehead muscles. This was partly because the anatomy and physiology of the forehead were not properly appreciated. A major advance occurred in the mid-1970s when several surgeons (Skoog, Vinas, Hinderer, Griffiths, Marino, and others) began to manipulate the frontalis muscle, usually by excising a strip of the muscle to eliminate the dynamic lines on the forehead. This also allowed better stretching of the superficial tissues. Washio was one of the first to carry out cadaver studies when he noted (1975) that removal of a transverse section of the frontalis muscle resulted in a significant elevation of the forehead. More dramatic surgical innovations by Tessier, LeRoux, and Jones (1974) advocated the complete removal of the frontalis muscle. Not surprisingly, this overtly destructive approach did not endure. In the 1980s and 1990s, the coronal brow lift became the established approach to brow lifting. This was partly because of the advances made by Tessier and his group in the approach to the skull via subperiosteal approaches. It has been said, not entirely in jest, that the coronal brow lift with the associated loss of hair and sensation and the overly tight look to the forehead and the brows was "a surgical procedure designed by men to be used on women." In the 1990s, endoscopic approaches to brow lifts were developed. After evolution of fixation techniques, it became apparent that in "brow lifting", brow shaping was more important and repositioning of the brows and forehead could be controlled with a proper release of the periosteum from the "lateral canthus to the lateral canthus" across the superior orbital rims and the nasal bridge, combined with manipulation of the depressor and elevator muscles of the brows. Anatomical details were studied and understood so that safe approaches could be designed using minimal incision approaches. Understanding the sensory and motor innervation of the forehead and the periorbital tissues allowed more accurate manipulation and modification of the tissues and allowed more limited lifts like the pretrichial lift and the temporal brow lift. After some debate about the longevity and effectiveness of endoscopic brow lifts when compared to coronal brow lifts, there are now 2 schools: one school still largely performs coronal brow lifts. However, more and more surgeons are becoming experts at performing endoscopic brow lifts. When patients are chosen correctly, these endoscopic brow lifts are creating reliable and long-lasting results. Coronal brow lifts, pretrichial brow lifts, mid-forehead brow lifts, direct brow lifts, and temporal brow lifts are now performed for specific indications. The so-called internal brow lift should be called a supporting procedure than a proper brow lift. No long-term studies show effective brow lifting and the design of the procedure does not address the complete arch of the brow, nor the forehead. The midforehead lift procedure has specific indications, advantages and limitations. We have found this approach to be useful in males who have heavy brows with overactive frontalis muscles and deep forehead wrinkles. The thicker, more sebaceous skin allows one to hide scars better although there is some debate about this. A common refrain in plastic surgery is "I am becoming my mother" or "I look like my dad." What the patient is saying is that family characteristics (bone structure, genetics, among others) are manifesting. The commonest cause of brow ptosis is aging (time and the environment). Everyone has an "aging clock" which is genetically determined, but skin and structures are also affected by environmental factors such as smoking, exposure to ultraviolet (UV) light, health and diet, among others. It is helpful to examine photographs, not only of the patients when they were younger, but also photographs of their parents. Patients exposed to the elements (farmers, sportsmen, and women) will show marked overaction of the corrugator, procerus and frontalis muscles, especially if they have not protected their eyes from sunlight and other harsh environmental factors. The "weathered face" as one describes it, seen in sailors and farmers (and the explorers of the 19th century) shows these changes well, not just in the region of the forehead and the brows but also the lower face and neck. These patients develop marked corrugator and procerus muscle lines which are the vertical "elevenses" and the horizontal lines at the root of the nose, respectively. The eyebrow heads will appear closer because of the overaction of the corrugator muscles and in these patients, contrary to common teaching, surgeons make an effort to elevate and separate the brow heads when a surgical procedure is performed. There will be deep horizontal forehead lines secondary to a constant frontalis overuse. There is also a "fat nose syndrome" appearance that these patients develop. This is caused by the downward slide of the procerus muscle and the inward movement of the corrugator and procerus muscles. This results (especially obvious in ladies), a widened bridge of the nose with the soft tissues "collapsing" downwards and inward. In these patients, especially when addressing them for cosmetic reasons, it is vital to slim this "fat nose syndrome." It is always helpful to compare the current appearance of the patient with photographs when the patient was younger to assess the degree to which the brow positions and curves have changed. Sometimes one is surprised to see that the brows have changed very little from their teenage years. Another truism is that the young look good with brows high or low; with age people look a little better with somewhat higher brows. Besides the central and medial changes to the brows, lateral brow droop is almost always exaggerated because of a lack of support by the frontalis muscle. This anatomical insertion of the frontalis muscle changes as we age, and it has recently been shown that the angle of insertion between the frontalis muscle and the orbicularis muscle becomes more acute, thereby leading to further loss of support laterally: this gives the temporal hooding, lash ptosis and temporal brow droop in such patients, with secondary crow's feet. On occasion, and often in men, one will see an exaggerated temporal brow droop because of the lack of support by the frontalis muscle, with almost an acute change in the curve of the brow, demanding modified approaches to correct the problem. Presentation of brow ptosis varies from cosmetic complaints of forehead lines, secondary heaviness (hooding) of the upper eyelids, to the presence of frown lines and problems with vision. Patients will only rarely complain that their brows are heavy or droopy. Indeed, unlike many other aging changes of the face, brow ptosis is one condition that is explained to the patient with the help of a mirror as most patients will not be aware of the changes they are shown. Cosmetic patients will also mostly focus on the "heavy upper eyelids and excessive upper eyelid fullness." Other complaints may include "looking tired, looking angry or unhappy" either from the patient or from family and colleagues. A thorough preoperative assessment of any surgical patient is vital. Past illnesses, medications, allergies, and any history of unusual scarring are noted. Specific emphasis is placed upon any history of thyroid disease, prior eyelid or brow surgery, unusual scarring tendency, and any tendency to develop unusual edema. Patients with thyroid disease must be controlled and stable, ideally for at least 6 months. Patients with thyroid disease will have deeper frown lines and may suffer from madarosis of the brow hairs. These patients also tend to develop prolonged edema after any facial surgery. We always examine the whole face whenever assessing patients with a complaint of problems with lids, brows, jowls or neck. Indeed, it is good practice to develop an examination technique and routine which ensures that you can detect any age-related and other changes which may not be apparent to the patient but need to be discussed. The differences between the right and the left sides of the face are examined for asymmetry, an assessment is made of which side the patient sleeps on, and the presence of any lingering edema (often seen in the malar regions) noted. Sometimes, what a patient sees may not be what you see when you examine the whole face. There have been patients who present for a forehead lift who are better served with a blepharoplasty and lower lid and face surgery and vice versa. : Assess the hairlines. Assess the density of scalp hair centrally and temporally. Measure the height of the forehead (distance between the corneal reflex and the anterior hairline or the distance between the central brow and the anterior hairline. Measure brow position compared to the opposite side. Measure brow position: there are several ways to do this. The surgeon should develop his/her system that is repeatable. The brow can be measured in relation to the superior orbital rim or measured from the lid margin to the brow or from the corneal reflex to the brow centrally and from the medial limbus and the lateral limbus to the brow medially and laterally. Others use the medial and lateral canthi as the reference points. Measure the degree of true dermatochalasis as opposed to secondary dermatochalasis caused by the brow ptosis. Assess the medial and central fat pads and any lacrimal gland prolapse. Assess forehead rhytids Assess corrugator and procerus lines. Assess crow's feet. Assess any blepharoptosis that may be present. Basic lower eyelid assessment must always be performed whenever considering brow surgery or upper eyelid surgery (or indeed any facial surgery). When documenting brow ptosis, one measurement that is repeatable is the measurement of the distance between the inferior limbus and the center of the brow. Determine if brow ptosis is present: in most patients, this distance will be more than 22 mm. Although a measurement of less than 22 mm will suggest brow ptosis, this will be determined by the many other factors we discussed above: age, gender, occupation, among others. Ideal brow position is an individual feature best determined by the surgeon and patient. Surgeons customarily review photographs of all patients to determine if an age existed when the brows were located in a position that the patient considers acceptable. Furthermore, brow shape is a more crucial determinant of an aesthetic brow. In other words, position and shape go together. With a ruler held medially, centrally, and laterally, the brow is elevated and moved (sometimes more lateral) to assess the degree of brow ptosis. Location is measured in 3 positions, and the difference between the desired brow position and the relaxed brow position indicates the degree of brow ptosis. However, the frontalis will be active to different degrees in different patients and also at different times of the day, making exact measurements difficult. Brow asymmetry also needs to be assessed and documented. Patients are shown the findings in front of a mirror as many will be unaware of asymmetry. Although all discussions concentrate on the brow and the brow height and curve, surgeons must not forget that the forehead is just as important; they should document the severity of glabellar, corrugator, and frontalis lines and also skin changes related to solar elastosis. The distance between the brow and the anterior hairline needs to be measured because in some patients it may be desirable to bring the hairline forward. In these cases, a properly performed pretrichial brow lift will give excellent results. Bear in mind that cultural, racial, gender, and age-related differences make it difficult to give exact normal measurements. Every patient seen for or considering a brow lift should have their upper eyelids and lower eyelids assessed. The forehead/brow, upper eyelid, and lower eyelid region are a continuum as procedures done above the canthus (brows and upper eyelids) may be influenced by lower eyelid changes (laxity, retraction, ectropion), and procedures on the lower eyelids may affect the final appearance of upper eyelids, especially if there is an underlying ptosis or dermatochalasis, primary or secondary. Indeed, one may argue that the continuum should be forehead, brows, upper lids, and cheeks. It has been shown that one raises the nasojugal and malar groove (sometimes called the orbital groove), it makes the brows look better even when nothing is done to the brows. This is an interesting and important observation that the serious aesthetic surgeon would do well to study further. Discuss this in the overall assessment of the face in aesthetic patients. Assessment of the upper eyelid should include the following: Corneal reflex-lid margin distance. Position and presence of upper eyelid skin crease. Assess if the patient has primary and secondary skin creases. Amount of tarsal platform show. Degree of dermatochalasis: primary and secondary. Upper-fat herniation medial and central. Assess lacrimal gland prominence. Assess upper eyelid skin condition (solar elastosis, vertical wrinkles, vessels showing, among others). Assessment of the lower eyelid should include the following: Medial canthus: Position, laxity, dystopia, scarring, webbing. Lateral canthus: Position, dystopia, laxity, scarring, webbing. Lower eyelid distraction test. Lower eyelid snapback test. Inferior scleral show. Presence of medial central and lateral fat pads. Nasojugal and malar grooves. Malar angle. Bell's phenomenon. Tear film integrity and tear breakup time. Blink completeness. Corneal sensation and health. Hertel measurement of the globe (proptosis or enophthalmos may be present). A summary of patient evaluation that is specific for forehead and brow elevation is as follows: Hair: Density and distribution. Hairline: Frontal and temporal. Forehead height relative to facial proportions and racial characteristics. Forehead height: Eyebrows to anterior scalp hairline. Forehead transverse rhytids: Distribution and depth. Forehead temporal rhytides. Crow's feet. Skin thickness, quality, and sebaceous quality. Eyebrow shape and symmetry. Eyebrow position (degree of medial, central, and lateral ptosis). Eyebrow hair distribution: Evidence of plucking, loss, other changes. Eyebrow mobility: Paralysis, scarring, tumor. Severity and distribution of glabellar and nasal root rhytides. Degree of dermatochalasis, hooding, and eyelid ptosis. Facial nerve function and any history of prior facial palsy. Prior scars. Do not forget to assess lower eyelid tone, position, and canthal position.
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