Master Techniques in Facial Rejuvenation 2

7  The Open Browlift
85
the follicles to allow them to grow through the inci­
sion as it heals over time. The hair in this area gener­
ally grows in an anterior direction, and the incision is
almost perpendicular to the follicles. The bevel must be
at an angle that transects the shaft of the follicle while
maintaining the base of the follicular unit, which has
regenerative properties. This bevel pattern is in oppo­
sition to the lateral, hair-bearing area of the incision.
When the surgeon chooses this approach preoperatively,
he or she should assess the growth pattern of these vital
The pretrichial and temporal incisions require alternat­
ing beveling techniques. In this technique, the surgeon
must be cognizant of three separate areas of the planned
incision (Figs. 7.8–7.11). The first is the anterior, visible,
aspect of the incision. In this area the beveling transects
A
C
B
60°
60°
90°
Figure 7.8  Varying angles of the blade are used during the trichophytic
incision.
B
A
Figure 7.9  The posterior aspect of the trichophytic incision is made
through the first few anterior hairs (A). This incision transects the fol­
licles so that they grow through, and thus mask, the healing wound.
The anterior aspect of the trichophytic incision is performed; the angle
of the bevel must be identical to that of the posterior portion of the
incision to optimize wound healing (B).
Figure 7.10  The angle of the blade transitions as the incision moves
laterally.
Figure 7.11  The lateral aspect of the trichophytic incision parallels the
hair follicles as in the coronal incision.

86
MASTER TECHNIQUES IN FACIAL REJUVENATION
(Fig. 7.12). This plane allows ease of dissection. With the
excision of tissue in the open technique, we do not need
to rely upon the periosteum readhering to the cranium
to ensure that the lift holds. Although subperiosteal dis­
section is acceptable, this technique does not rely on
periosteal refixation for its result and longevity, thus it
is easier and equally effective to dissect in the subgaleal
plane [26]. We employ the term “sliding plane” because
we feel it is descriptive of the dissection. The plane is
elevated with a No. 10 blade and Anderson bear claw
retractor in the original phase of flap elevation. When
approaching neurovascular structures medially (supra­
orbital and supratrochlear nerves) and laterally (frontal
branch of facial nerve), a nonpenetrating retractor is used
(Fig. 7.13). The supraorbital and supratrochlear bundles
are preserved at the orbital rim or notch, depending on
the patient’s anatomy. The frontal branch is also pre­
served by dissecting directly on the superficial layer of the
deep temporalis fascia. When approaching the zygomatic
arch we change dissecting instruments from a No. 10
blade to sharp, fine scissors and a cotton-tip applicator
for blunt dissection (Fig. 7.14). Along the lateral superior
orbital rim, a releasing incision can be made through the
anterior hairs. If the hairs grow posteriorly, the patient
may not be able to mask the incision by wearing the
bangs forward, and this should be discussed with the
patient. The second aspect of the incision is the interface
of the anterior region of the incision with the hair-bearing
areas laterally (see Figs. 7.8 and 7.10). At this juncture
the beveling must be altered from transecting the follicles
to running almost parallel to them. This is a brief transi­
tion and should quickly evolve into the standard follicle-
sparing angle seen with the coronal lift as the surgeon
goes deeper into the hair laterally (see Figs. 7.8 and 7.11).
It should be noted that the surgeon must utilize the same
angle of incision for both the posterior and anterior por­
tions of the incision to ensure the best possible closure.
The importance of proper beveling technique cannot be
overemphasized. When done improperly, alopecia and
noticeable—and thereby unattractive—scars result. Lack
of attention to these details has produced results that give
credence to the critics of these techniques. The hair is a
great ally of the cosmetic surgeon as long as it is handled
appropriately.
For the entire coronal incision and the lateral aspects
of the pretrichial incision, the blade is advanced with a
pushing motion, instead of the classic method of pulling
the knife toward oneself. This technique allows better
control of the knife through the thick skin of the fore­
head. It also enhances the surgeon’s ability to follow the
hair follicles correctly because the knife blade is visible.
This is vital when considering the exacting manner in
which the knife must be beveled for these procedures.
Whether the coronal or trichophytic lift is performed,
the incision must be beveled correctly throughout all
aspects of the incision. The incision is carried down to
the level of the subgaleal plane of dissection. After the
incisions have been created the excess skin is removed.
This is done one side at a time so that blood loss is kept
to a minimum. As all surgeons who operate in this area
know, the blood supply to the scalp is robust. Remov­
ing half of the excess skin and obtaining hemostasis will
help to avoid untoward complications. Frequently, the
superficial temporal vessels are transected laterally and
this bleeding should be immediately addressed. We prefer
bipolar cautery to reduce thermal damage to adjacent
hair follicles. With this concept in mind, the surgeon
should not pursue oozing vessels above the galea. There
are no major vessels superficial to the galea and we will
often attend to bleeding here with a cold compress in
lieu of electrocautery. Cautery above this level places the
hair follicles at undue risk. A complete examination of
the incision should be performed prior to placing a cool,
moist compress on the posterior portion of the incision.
Bleeding can persist in the lateral aspects of the inci­
sions and go unnoticed by the surgeon as he or she is
focused elsewhere. The surgeon must check both lateral
aspects of the incision periodically throughout the case
to ensure adequate hemostasis. Large amounts of blood
can be lost from scalp incisions. The contralateral skin
is removed, hemostasis is obtained, and the anterior flap
is then elevated.
A subgaleal dissection, with the No. 10 blade, is per­
formed until slightly superior to the supraorbital rim
Figure 7.12  The subgaleal dissection is performed with the No. 10
blade.
Figure 7.13  A nonpenetrating retractor is employed when approach­
ing neurovascular structures.

7  The Open Browlift
87
of the operation. Often, a supratrochlear vein is encoun­
tered in the region and should be dealt with accordingly.
The medial 2 to 3 cm is dissected free from the galea and
the muscle is transected after bipolar cauterization at its
medial attachment to the bone. The medial free edge of
the muscle is grasped and pulled laterally until approxi­
mately 2 cm is freed for excision. Again the muscle is
cauterized and resected with the sharp, fine scissors. This
is a true advantage of the open technique. It allows for
unparalleled exposure of this dense muscular complex.
With excision of this muscle the surgeon and patient
can be assured of a long-term benefit unattainable with
other methods such as botulinum toxin A. The concern
over muscle resection leading to a deficit of expression of
the brow is understandable, but fortunately this conse­
quence is exceedingly rare. Even with aggressive muscle
resection the patient usually has adequate expression
postoperatively.
The procerus is then addressed. With the flap elevated,
the procerus is scored horizontally with a Bovie (Fig.
7.17). This should be performed lightly through muscle
alone. If done too deeply, the patient will be left with a
soft tissue depression in the glabellar region. The scoring
periosteum with elevation of the periosteum off the rim
to the lateral canthus if additional flap mobilization is
needed for a tension-free closure. We generally do not
aggressively cauterize in this area secondary to poten­
tial thermal injury to the facial nerve; judicious bipolar
cautery is advised if necessary.
With the flap completely mobilized attention is then
directed to the glabellar musculature (Fig. 7.15). The flap
has been raised to the radix at this juncture and, using
Adson forceps and sharp, fine dissecting scissors, the cor­
rugators are dissected free and cauterized with bipolar
cautery. This dissection is greatly aided by the assistant
using a nonpenetrating retractor in the natural vector
of the corrugator to help expose the muscle (Fig. 7.16).
Care must be taken to avoid inadvertent trauma to the
supratrochlear neurovascular bundle during this phase
Figure 7.14  Sharp scissors and nonpenetrating retractor are used in
the lateral component of the dissection.
Frontalis m.
Corrugator m.
Supraorbital m.
Procerus m.
Figure 7.15  The anatomy of the everted forehead flap. m., Muscle.
Figure 7.16  The corrugator excision is performed with bipolar cautery
after transecting the muscle. This maneuver is aided by retraction in
the vector of the muscle.
Figure 7.17  The procerus is scored horizontally with monopolar
cautery.

88
MASTER TECHNIQUES IN FACIAL REJUVENATION
should center on the medial aspect of the muscle to ensure
that the supratrochlear neurovascular bundles are left
unperturbed. Occasionally in the heavy brow we will also
perform a vertical myotomy to allow for lateral spread of
the glabella to address vertical rhytids (Fig. 7.18).
In select cases we will also perform a horizontal
myotomy of the frontalis and a galeatomy (Fig. 7.19). We
choose to perform this at the level of the most prominent
midforehead rhytid. This is also performed with monopo­
lar cautery in the midline. By performing this maneuver
in the midline the surgeon allows the patient to retain
muscle function laterally, permitting lateral brow eleva­
tion. The lateral borders of this incision are the medial
aspects of the orbital rims. We are judicious in the use of
this technique secondary to the concern of imparting a
“surprised” look onto the patient.
A suction drain is then placed above the superior orbital
rims and the field is copiously irrigated with an antibiotic
solution. The drain is brought out through a puncture in
the posterior, nonelevated flap. Care should be exercised
not to traumatize the temporal vessel during placement of
the drain, causing further significant bleeding. Both open
techniques are closed in a two-layer fashion.
Figure 7.18  In select cases the glabellar region is scored vertically to
alleviate excessively heavy brows.
Figure 7.19  The frontalis is scored horizontally at the foremost fore­
head rhytid in most cases.
Figure 7.20  The galeal closure is performed with buried, absorbable
sutures in the coronal technique.
Figure 7.21  The coronal closure is completed with staples at the skin
level. Please note the hair-to-hair apposition, a frequently misunder­
stood concept with this technique.
For the coronal incision, a galeal closure is performed
with interrupted 3-0 polydioxanone (PDS) (Fig. 7.20).
This is followed by skin closure with wide staples (Fig.
7.21). The pretrichial lift closure is more detailed. The
deep-layer closure is done with 4-0 PDS (Fig. 7.22). These
deep sutures will cause a dimpling of the tissue immedi­
ately inferior to the incision in the midline. The patient
should be informed of this preoperatively as this will
resolve when the sutures dissolve. The skin in the visible
region of the incision is then closed with interrupted 5-0
Prolene in a vertical mattress fashion (Fig. 7.23). Skin
eversion is vital and must be attained with these sutures.
Once complete with the vertical mattresses, the suture
line is further enhanced with the use of a running, locking
6-0 nylon suture to maximize the wound approximation
(Fig. 7.24). The hair-bearing areas are closed with wide
staples on the lateral components and standard staples
as the surgeon nears the skin in the medial aspect of
the incision (Fig. 7.25). Although somewhat more time
consuming, this elaborate closure greatly enhances the
patient’s wound healing (Figs. 7.26–7.29).
The wound is then coated with antibiotic ointment and
a nonadhesive piece of Telfa is placed over the incision.
No dressing is applied.

7  The Open Browlift
89
POSTOPERATIVE CARE
The drain is often removed in the recovery room on the
evening of the procedure to decrease the headache and
nausea that often accompany drains in this area.
Patient comfort dictates whether he or she may return
home, go to a hotel, or spend a night in a medical facil­
ity. The patient may immediately begin using hydrogen
peroxide to keep the incision free of crusts. Showering
with baby shampoo is allowed 48 hours after the proce­
dure. The sutures for the pretrichial lift are removed on
postoperative days 3 to 5, depending on the nature of
the healing and logistics of removing sutures from other
rejuvenation procedures that may have been performed.
The staples are removed at 1 week after surgery. The
pretrichial incision is immediately taped in the non–hair-
bearing area after application of adhesive. The tape is
worn continuously for 1 week after the removal of the
sutures. After this point, the tape is kept on nightly for
Figure 7.23  The skin closure is accomplished with vertical mattress
sutures. We prefer nonabsorbable suture at the skin level to minimize
the inflammatory response.
Figure 7.24  A running, locking 6-0 nonabsorbable suture is used to
maximize wound closure and achieve the optimal postoperative result.
Figure 7.25  The lateral portions of the trichophytic incision are closed
with large staples laterally and smaller ones medially.
Figure 7.22  The trichophytic closure is begun with buried, absorbable
sutures at the galeal level.
approximately 1 month. The tape minimizes tension on
the skin, encouraging excellent camouflage of the healing
wound. In the coronal approach all staples are removed
1 week after surgery, and there are no sutures to remove.
The patient is advised that the edema in the forehead
will be most significant 2 to 3 days from the procedure.
This edema can be quite uncomfortable for the patient.
The patients are advised that this swelling will gradually
resolve and they may commence mildly strenuous activity
3 to 4 weeks after the procedure. They are also advised
to avoid using a curling iron or a blow-dryer on a hot
setting secondary to the changes in sensation in the first
6 weeks of the procedure. This paresthesia, a main issue
with those who support the endoscopic techniques, is
rarely an issue in our practice.
COMPLICATIONS
Despite the advances of endoscopic equipment and tech­
niques, we prefer the open method because of its excellent

90
MASTER TECHNIQUES IN FACIAL REJUVENATION
be numb for several months, and possibly permanently.
When discussed extensively in the preoperative phase this
issue is managed adequately. In our experience, this is of
marginal importance to the patient. It usually resolves in
the appropriate time period and is almost always a nonis­
sue when it has been addressed preoperatively.
Hematomas are also, fortunately, rare with the
technique. Despite the copious blood supply to this
region, hematomas are seldom seen. This is probably
because of the tense nature of the closure, edema, and
the unyielding cranium that tamponades any potential
result and patient acceptance. The highly publicized issues
with the open approach—alopecia, numbness, scarring—
have not been an issue in the senior author’s practice for
25 years [52–54]. Although a logical argument can be
made that these issues are serious, the theory and reality
diverge (unpublished data). In addition, when one of the
issues does arise, particularly numbness, the patient does
not see it as a priority and is generally so pleased with the
result that the issue fades. The most common troubling
complication is that of paresthesia. The patient must be
aware, preoperatively, that the forehead and scalp will
A
B
Figure 7.26  Preoperative frontal view of a 54-year-old woman (A). The tricophytic closure is barely visible when proper technique is used (B).
A
B
Figure 7.27  Preoperative (A) and postoperative (B) views of a 56-year-old patient who underwent a tricophytic browlift.

7  The Open Browlift
91
Relieved of the need for overcorrection, as is needed in
other techniques, we have not found this to be an issue
in our practice.
An occasional issue that arises postoperatively is pru­
ritus that occurs along the incision line. The patient may
scratch and rub this area, causing a focal alopecia. This
can be avoided with patient education. If the alopecia has
already occurred, the patient is advised not to disturb the
area further, and the hair often returns. Any undue scar­
ring is very rare and can be treated with steroid injections
of triamcinolone (Kenalog-10).
FUTURE CONSIDERATIONS
The continuing evolution of technology will undoubt­
edly benefit the patient in the long term. The surgeon
must be careful, however, to adhere to proven surgical
principles. We should expect that the patient’s demands
and desires will progress with these technologic advances,
and we must stay at the vanguard to offer our patients
the optimal care.
bleeding complications. The complication profile for the
open browlift is excellent at 0.4% for hematoma for­
mation, permanent alopecia, and “nerve damage” [55].
Others have also found very acceptable complication
rates [15].
Alopecia is also a rare occurrence. In the coronal
approach, the beveling of the incision and a hair-to-hair
closure alleviate this concern. In the pretrichial lift, the
hair will grow either through the healing incision or over
it in the form of bangs. Rarely, a patient may not be a
candidate if he or she has a high hairline and prefers to
wear the hair back at all times or has hair growing in a
vector unfavorable for masking the incision. Scar appear­
ance is also greatly aided by meticulous attention to detail
in the operating room, especially during the incision and
closure.
One of the most noted complications of this proce­
dure is the creation of a “surprised look,” evidenced
by a widened, elevated medial brow complex [56]. We
minimize this issue by judicious removal of tissue and
an appropriate resection of the glabellar musculature.
A
B
C
D
Figure 7.28  Preoperative (A and B) and postoperative (C and D) views of a 61-year-old female after a tricophytic lift. Again please note the excel­
lent healing of the tricophytic incision when executed properly.

92
MASTER TECHNIQUES IN FACIAL REJUVENATION
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93
Over the past 27 years, the endoscopic foreheadplasty
has evolved into the procedure of choice for aesthetic
surgeons with a goal of rejuvenating the brow-forehead
complex. Harmony between brow position, symmetry,
and improvement of forehead and glabella wrinkles can
be achieved if the surgeon possesses a thorough under­
standing of the endoscopic techniques, regional neuro­
vascular, muscular, and soft tissue anatomy. Since first
introduced in 1985, endoscopic foreheadplasty has been
refined by more precise methods of dissection, allowing
natural long-term results. Herein we discuss the basic
surgical technique of endoscopic foreheadplasty and
highlight important details necessary for surgical success.
HISTORY
Correction of brow asymmetry and softening of forehead
rhytids has been attempted for nearly 100 years. The first
known description of what is now known as forehead­
plasty was done by Passot in 1919 [1]. This description
involved various horizontal skin excisions on the higher
portion of the forehead in hopes of improving horizontal
rhytids. Soon thereafter, Passot’s work was expanded by
Hunt [2] in 1926 and Claoue [3] in 1933, both describ­
ing variations to the original technique. All the original
accounts revolved around soft tissue excision in hopes of
correcting wrinkling. In 1964, Castanares [4] expanded
traditional techniques of simple soft tissue excisions and
recommended modification of the frontalis muscles and
transection of the frontal branch of the facial nerve in an
attempt to improve aesthetic outcome. For the next 30
years, various surgeons expanded upon this technique,
giving rise to the biplanar approach and modification of
the procerus and depressor supercilii muscles. In 1989,
Keller introduced minimally invasive endoscopic laser
procedures for brow, midface, and neck procedures [5–8].
In 1992, Isse introduced a minimally invasive instru­
mental technique for foreheadplasty utilizing endoscopic
equipment [9]. Since that time, the endoscopic method of
rejuvenation has evolved into the procedure of choice for
many aesthetic surgeons.
PERSONAL PHILOSOPHY
The soft tissues of the brow-forehead complex are con­
stantly molded by the downward forces of gravity and
depressor muscles along with the opposing action of the
elevator muscle units. With time, this opposition results
in volume loss, weakening of ligamentous structures,
and general descent of tissues. For this reason, it is no
longer sufficient to perform a “simple blepharoplasty,”
but instead to rejuvenate the entire periocular area. As
one can expect, every aspect of foreheadplasty cannot be
covered in a single chapter, or even a single textbook.
However, in the following pages an outline of endoscopic
foreheadplasty will be presented along with important
details with respect to patient care, endoscopic equip­
ment, and surgical anatomy.
ANATOMY
Understanding the anatomy of the forehead and brow
is essential to performing an endoscopic foreheadplasty.
The eyebrow can be divided into three parts: medial,
central, and lateral. The medial aspect of the eyebrow lies
medial to the supraorbital nerve. Naturally, the medial
limit of the central eyebrow is the supraorbital nerve;
the lateral limit is the superior temporal crest. Lastly,
the lateral third of the eyebrow is found lateral to the
superior temporal crest. All subunits of the eyebrow are
controlled by a delicate interaction between depressor
and elevator muscle activity. These two muscle groups,
along with the corrugators, make up all human facial
expression around the brow.
The frontalis muscle is the main elevator of the eyebrow.
Its interaction with associated depressor muscle activity
is responsible for the horizontal rhytids seen on the fore­
head. The orbital portion of the orbicularis oculi muscle
is the main depressor of the eyebrow and responsible
for horizontal lines adjacent to the orbit. The depressor
supercilii and procerus muscles depress the head of the
medial brow and produce the “reverse parenthesis” and
horizontal rhytids at the root of the nose. Finally, the
corrugator supercilii muscle produces both an elevation
of the medial brow along with depression of the lateral
brow (Fig. 8.1). In 1852, Duchenne described an agonist/
antagonist relationship of the muscles acting on the brow
with the orbicularis, corrugator, procerus, and depressor
muscles functioning to depress the brow and the fronta­
lis muscle functioning to elevate the brow. This complex
muscle action is responsible for flattening of the glabellar
area and forehead wrinkles [10]. With appropriate under­
standing of eyebrow anatomy, endoscopic foreheadplasty
has the ability to modify all of these muscles as needed.
C H A P T E R 8 
Endoscopic Foreheadplasty:
A Twenty-Seven-Year Experience
Gregory S. Keller, MD, John W. Frederick, MD and Vishad Nabili, MD

94
MASTER TECHNIQUES IN FACIAL REJUVENATION
PREOPERATIVE ASSESSMENT
Endoscopic foreheadplasty is indicated when improve­
ment of the brow position and shape is desired, or when
the rhytids of the forehead, glabella, and periorbital areas
need to be softened. Generally, patients must be well
adjusted with a desire to restore a more youthful appear­
ance rather than achieve a “perfect” look. The following
conditions are indications for an endoscopic forehead­
plasty and should be considered during the preoperative
evaluation:
• Brow ptosis and malposition
• Glabellar rhytids (frown lines)
• Tissue sagging (root of nose)
• Pseudoptosis of upper eyelids
• Mild to moderate dermatochalasia (upper eyelids)
• Minimal ptosis of the upper eyelids
• Downward slanting of the lateral canthus
• Periorbital wrinkles (crow’s feet)
INSTRUMENTATION
Aside from a complete set of endoscopic equipment
(including a medical video camera, camera control unit,
light source, and fiber optic cable), very little specialized
equipment is required to perform endoscopic forehead­
plasty. One curved periosteal elevator, a straight elevator,
scissors (curved and straight), and a 30-degree endoscope
with open dissection sheath is the extent of necessary
equipment. While there is some variability in endoscope
and camera quality, the overall ability to perform the
surgery does not depend on these variables. Suction-Bovie
cautery and plasma knife instruments can offer some
benefit to dissection and when obtaining hemostasis.
SURGICAL TECHNIQUE
A combination of intravenous sedation and local anesthe­
sia is adequate, although general anesthesia can be used.
Local anesthesia is performed using 1.0% lidocaine with
epinephrine (1 : 100,000) for the forehead, temporal area,
eyelids, and scalp infiltration.
The following standard surgical steps are performed
during an endoscopic foreheadplasty:
• Preoperative marking
• Incisions
• Creation of an optical cavity
• Dissection of the forehead and temporal areas
• Release of tissue attachment to bone and deep fascia
• Tissue modifications
• Fixation
The Incisions
Following a rigid template for incision placement is not
possible for endoscopic foreheadplasty. The placement of
incisions must reflect surgical goals. Once the aesthetic
outcome of the operation is clear, incision placement
can be easily detailed. A vertical midline incision placed
immediately behind the hairline and taken through the
frontalis and periosteum is used in most patients. Vertical
incisions are then placed approximately 5 cm on either
side of the midline incisions, the aptly named parame­
dian incisions. These incisions are carried down to, but
not through, the fascia overlying the frontalis muscle.
The paramedian incisions should be performed with care.
The deep division of the supraorbital nerve passes close
to these, below the orbicularis [11]. Traditional inci­
sion length was limited to 1 to 2 cm. However, a longer
incision allows for improved visualization and reduces
hair loss in the immediate vicinity of the incision. For
these reasons, incisions up to 3 cm in length are now
regularly used.
Male patients offer unique challenges to incision place­
ment. Hair loss following the Norwood I to III clas­
sifications can be navigated quite well with the median
incision in the midfrontal area with temporal incisions
placed either in the midtemporal area or at the temporal
fringe. For more severe balding (Norwood IV–V), most
work can be accomplished through low lateral incisions
made on the temporal fringe [12]. At times, a midline
blepharoplasty incision can be used for retrograde dis­
section (Fig. 8.2).
Creation of the Frontal Cavity
In order to utilize endoscopic techniques for forehead­
plasty, an optical cavity must first be created. These
cavities can be created in a subcutaneous, subgaleal, or
subperiosteal plane. Of the listed techniques for frontal
brow dissection, most aesthetic surgeons employ a sub­
periosteal plane, which will be the only technique dis­
cussed here in detail. After incisions have been placed,
a 2-cm arc of blunt dissection is drawn over along the
entire length of the brow. Blind dissection is avoided
beyond this area in order to avoid injuring nerves emerg­
ing from the neural foramina near the orbital rim. The
initial dissection is blind and easily accomplished with a
curved endoscopic elevator (Fig. 8.3). This initial dissec­
tion is paramount for protection of the supraorbital nerve
and lateral supraorbital nerve branches emerging from
the bony orbital rim. Once the optical cavity is created,
the endoscope can be advanced through the incisions and
Procerus m.
Corrugator m.
Orbicularis
oculi m.
Depressor
supercilii m.
Figure 8.1  Myotomies of the depressor muscles (corrugator, orbicu­
laris oculi, depressor supercilii, and procerus) performed to “release”
the brow. m., Muscle.

8  Endoscopic Foreheadplasty: A Twenty-Seven-Year Experience
95
while more superficial fascial layers will. Blunt dissecting
scissors can be utilized to identify the correct layers of
dissection and form the initial dissection pocket. Iden­
tification of a loose areolar tissue layer separating the
temporoparietal fascia from the deep temporal fascia is
paramount (Fig. 8.4). This so-called innominate fascia
forms the deep extent of the temporal-parietal fat pad
and must be elevated in its entirety in order to protect
the facial nerve.
Once a dissection pocket is created beyond the hair­
line, an endoscope is advanced through the lateral inci­
sion along with a straight dissector. The innominate
fascia is swept upward, displacing the temporal parietal
fat pad and protecting the facial nerve branches. At the
inferior extent of dissection, approximately at the level of
the tail of the brow, a yellow tinge to the superficial layer
will provide a magnified view of the dissection cavity.
With the help of the endoscope, midline dissection is
carried to the origin of the corrugators. At this point the
surgeon will then enter a midline subgaleal plane over
the nose, successfully preserving the attachments of the
midline corrugators and associated ligaments. Lateral dis­
section is taken to, but not beyond, the level of the arcus
marginalis.
Creation of the Temporal Cavity
The temporal incision should be created and dissected
down to the superficial layer of the deep temporal fascia
directly overlying the temporalis muscle. The correct
fascial layer can easily be identified by direct movement
of the fascial skin. The superficial layer of deep tempo­
ral fascia will not move with pulling of the facial skin,
Central incision
Lateral
incision
Temporal
incision
Temporal
incision
A
B
C
D
Central incision
Temporal
incision
Temporal
incision
Supraorbital n.
corridor
Anterior
Hairline
Male fringe
Male
fringe
Upper
blepharoplasty
Figure 8.2  (A) Standard endoscopic forehead incisions. (B) Alternate incisions for female patients with high hairlines. (C) Endoscopic forehead
incisions for male pattern baldness (Norwood II–V). (D) Endoscopic forehead incisions for male pattern baldness (Norwood VI–VII). n., Nerve.

96
MASTER TECHNIQUES IN FACIAL REJUVENATION
resistance is usually encountered along the lateral orbit.
This area represents the precanthal tendon, also known
as the lateral orbital thickening. Transection of the pre­
canthal tendon is necessary in order to achieve adequate
lateral brow elevation and can be achieved easily at this
time.
After successfully releasing the orbicularis attachments
at the area of the lateral canthus, the frontal and temporal
pockets should be joined. Connection of these pockets is
achieved by elevating the conjoint fascia from the tem­
poral dissection pocket towards the frontal brow. As the
orbital rim and lateral brow are approached during this
process, the frontal ligament (also known as the con­
joint tendon) is encountered. This fascial band is excised
sharply and lifted with a curved elevator. After successful
release of the conjoint fascia, the frontal and temporal
dissection pockets are connected (Fig. 8.8).
Figure 8.3  Elevator used to blindly undermine in the subperiosteal
plane over the frontal bone. A semicircular area above the supraorbital
nerve is not elevated. (Reprinted from Keller GS. Endoscopic facial
plastic surgery. St. Louis, MO: Mosby-Year Book Inc.; 1997. p. 57.
Used with permission.)
Figure 8.4  Loose areolar tissue of the innominate fascia is swept
upward. (Reprinted from Keller GS. Endoscopic facial plastic surgery. St.
Louis, MO: Mosby-Year Book Inc.; 1997. p. 58. Used with permission.)
Figure 8.5  Sentinel vein is uncovered. (Reprinted from Keller GS.
Endoscopic facial plastic surgery. St. Louis, MO: Mosby-Year Book
Inc.; 1997. p. 60. Used with permission.)
Figure 8.6  Dissection showing another vein lateral to that shown in
Fig. 8.5. A nerve passing above this may represent a frontal branch of
the facial nerve. (Reprinted from Keller GS. Endoscopic facial plastic
surgery. St. Louis, MO: Mosby-Year Book Inc.; 1997. p. 60. Used with
permission.)
of deep temporal fascia is noticed. This distinct change in
color marks the boundary of the superficial temporal fat
pad and its separation from the superficial layer of deep
temporal fascia. This fascia is preserved in an attempt to
avoid postoperative wasting of the temple.
Dissection is continued until the sentinel vein is visual­
ized at the level of the zygomatico-frontal suture (Figs.
8.5–8.7). At this level of dissection, the zygomatico-facial
nerve and accompanying vein will be seen at the lateral
malar eminence. Dissection can safely be advanced onto
the midface between these two landmarks. Advancement
onto the malar eminence completes this portion of the
dissection, and contributes to further release of the tail
of the brow.
Release of Tissue Attachments to Bone and
Deep Fascia
As the temporal pocket is being created, prior to con­
necting the frontal and temporal dissection pockets,

8  Endoscopic Foreheadplasty: A Twenty-Seven-Year Experience
97
Dissection is carried in this manner until the supraorbital
nerve is identified (Figs. 8. 9 and 8.10).
The periosteum medial to the supraorbital nerve,
and lateral to the corrugators, is dense and frequently
requires sharp dissection in order to expose the corruga­
tor and procerus muscles. Once this periosteum has been
reflected, scissors, ultrasonic scalpel, or laser can be used
to incise the procerus, depressor, and corrugator muscles
(as discussed later).
Tissue Modifications
“Tissue modification” refers to the release of the depres­
sor muscles of the brow via myotomy and neurotomy.
These maneuvers can be used to achieve specific aesthetic
outcomes in all of the major areas of the forehead. In
performing tissue modification, we find that there is less
Further elevation of the periosteum to the arcus mar­
ginalis is accomplished with endoscopic guidance. Pro­
tection and preservation of the supraorbital nerve and
its associated branches is of utmost importance in this
region. Most commonly, the supraorbital nerve can be
found emerging from a notch in the orbit directly supe­
rior to the medial limbus. Whenever possible, the supra­
orbital, supratrochlear, and lacrimal nerves should be
identified and protected.
Periosteum over the orbit and the arcus marginalis are
elevated from lateral to medial. Once accomplished, dis­
section is carried down to the orbital septum and tarsal
plate. At times this dissection is not easily accomplished.
When resistance is encountered during the release of the
orbital periosteum, sharp dissection or energy dissec­
tion can be used to lyse and elevate the attachments.
A
B
Figure 8.7  (A) Bipolar cautery is placed on the sentinel vein. (B) Sentinel vein is cauterized. (Reprinted from Keller GS. Endoscopic facial plastic
surgery. St. Louis, MO: Mosby-Year Book Inc.; 1997. p. 61. Used with permission.)
A
B
C
D
Figure 8.8  (A) Periosteal elevator is placed on the temporal line. (B) Incision of the frontal periosteum at the temporal line. (C) Elevation of the
frontal periosteum. (D) Connection of the temporal and frontal dissections from lateral to medial. (Reprinted from Keller GS. Endoscopic facial
plastic surgery. St. Louis, MO: Mosby-Year Book Inc.; 1997. p. 62. Used with permission.)

98
MASTER TECHNIQUES IN FACIAL REJUVENATION
periorbicular eyelid rhytids and the patient denies having
dry eyes, then horizontal incisions are placed across the
orbicularis. The depressor supercilii and procerus receive
innervation from the zygomatic branch of the facial nerve
(Fig. 8.11). As such, myotomy of these muscles medial
and lateral to the supraorbital nerves can be safely accom­
plished. The pars orbitalis of the orbicularis oculi muscle
is the strongest depressor of the brow, and its myotomy
produces a sustained and long-lasting elevation of the
brow. Despite a complete muscle, a neurotomy of both
the seventh nerve branches from the frontal and zygo­
matic branches can and should be performed in order
to optimize forehead elevation. Persistence of a limited
frown will still exist and prevent the frozen forehead
appearance due to contraction of remaining orbicularis
fibers and disrupted corrugator, procerus, and depressor
muscles.
Fixation
After successful release of the entire brow-forehead
complex has been accomplished and myotomy per­
formed as indicated, it is essential to “fix” the tissues
in the correct position. Fixation methods vary widely,
ranging from absorbable suture to permanent micro­
screws. Selection of a fixation device should depend on
patient satisfaction and surgeons’ preference. Regardless
of what specific fixation device is chosen, research has
shown that periosteum reattaches after approximately
1 week.
There are two main types of fixation: paramedian and
temporal. Median fixation of the brow head is rarely
required, as the muscle release and antagonistic frontalis
muscle contraction usually provides sufficient elevation
of the brow head. Further, avoidance of medial fixation
avoids “splaying of the brow” and separating the two
brow heads.
Bitemporal fixation is commonly used as it produces
elevation of the brow tail. A 3-0 Ethibond suture is used
to grasp the superficial temporal fascia at the temporal
numbness, paresthesia, and bruising postoperatively if
a laser, plasma knife, or harmonic scalpel is used when
compared with sharp dissection. Complete release of the
depressor musculature is essential to achieve precise brow
placement. It is the release of the brow and not the
method of fixation that allows the surgeon to reliably
achieve the long-term goals of brow placement, modifica­
tion of muscular movement, and rhytid improvement. To
achieve this, the frontal dissection is carried downward
to elevate the arcus marginalis and sweep the periosteum
off of the corrugators. The corrugators, procerus, and
depressor supercillii are lysed, either with blunt or sharp
dissection using scissors or with other energy devices.
The endpoint of this dissection is to see orbital fat and
complete muscle separation from intact supraorbital and
supratrochlear nerves.
Orbicularis muscle modification varies widely. If the
function of the orbicularis is strong as evidenced by
Figure 8.9  Supraorbital bundle is seen to emerge from a foramen
1.5 cm above the orbital rim. If the surgeon were to blindly under­
mine to the orbital rim, he or she would avulse the nerve on this side.
(Reprinted from Keller GS. Endoscopic facial plastic surgery. St. Louis,
MO: Mosby-Year Book Inc.; 1997. p. 65. Used with permission.)
Figure 8.10  A left lateral supraorbital nerve branch is seen exiting
from a foramen 1 cm above the orbital rim. The main supraorbital
bundle is seen emerging from a notch below the supraorbital rim.
(Reprinted from Keller GS. Endoscopic facial plastic surgery. St. Louis,
MO: Mosby-Year Book Inc.; 1997. p. 65. Used with permission.)
Figure 8.11  Incision of the procerus muscle with straight scissors.
(Reprinted from Keller GS. Endoscopic facial plastic surgery. St. Louis,
MO: Mosby-Year Book Inc.; 1997. p. 68. Used with permission.)

8  Endoscopic Foreheadplasty: A Twenty-Seven-Year Experience
99
c. Arcus marginalis and associated periosteum
d. Muscular zone (corrugator, depressor, orbicu­
laris, procerus)
Rule 3: Four Danger Zones in the Dissection
a. Temporal vein and nerve lateral to the sentinel
vein (cranial nerve VII)
b. Temporal vein 0.5 cm lateral to the brow (cranial
nerve VII)
c. Supraorbital nerve foramina zone 2 cm superior
to the brow (cranial nerve V)
d. Deep branch of the supraorbital nerve near the
paramedian incision (cranial nerve V)
Rule 4: Four Common Methods of Fixation
a. Screw
b. Coapt plate
c. Bone tunnel
d. Suture fixation
Rule 5: Four Most Common Incisions
a. Midline
b. Paramedian
c. Lateral frontal (superior temporal line)
d. Lateral temporal
POSTOPERATIVE CARE
Immediately after the operation, a drain is placed and
a circumferential head dressing is applied to decrease
swelling over the forehead. The patients are routinely
seen on postoperative day 1 to assess all wounds and
remove drains and bandages. Instructions are given to
apply ice to the face for the first 72 hours and also to
avoid strenuous exercise for 3 weeks. Patients are encour­
aged to sleep with the head elevated for about a week.
Stitches or staples are removed at 7 to 10 days, except
for the vicryl sutures for fixation. Special attention is
given to the hair around or inside the wound in order to
prevent wound infection. Female patients can have their
hair tinted after 3 weeks assuming that all the wounds
are completely closed.
COMPLICATIONS
The most common complications associated with endo­
scopic brow lift are numbness of the scalp and temporary
alopecia due to inflammation or edema. Increased incision
length and meticulous dissection around the supratroch­
lear, supraorbital, and lacrimal nerves can help reduce
both of these complications. Paresis of the frontal branch
of the facial nerve occurs less frequently. In the senior
author’s experience, this has happened only three times
in over 2000 cases. These complications are all transient
and none require additional surgery. Recurrence of brow
ptosis is rare, occurring in less than 2% of the cases.
R E F E R E N C E S
1. Passot R. La chururgie esthetique des rides du visage. Presse Med
Care 1919;27:258–60, [in French].
2. Hunt HL. Plastic surgery of the head, face and neck. Philadelphia:
New York Lea & Febiger; 1926.
3. Claoue G. La ridectomie cervico-faciale par accrochage parieto-
temporo-occipital et resection cutanée. Bull Acad Med (Paris)
1933;109:257–65, [in French].
incision. The suture is then passed under the periosteum
of the forehead and grasped at the contralateral tem­
poral incision. Successful bitemporal fixation allows for
elevation of the brow tail while preserving the natural
elevation of the medial brow from the frontalis muscle.
As one would expect, this elevation is accentuated after
depressor myotomy is accomplished.
Temporal fixation is used for elevation and reposi­
tioning of the lateral orbicularis. This fixation technique
is easily accomplished by suturing the temporoparietal
fascia to the deep temporal fascia as posterior as possible.
Paramedian fixation is only occasionally utilized. The
avoidance of a “surprised” look is important. While we
have utilized different methods in the past, at the current
time, we utilize a simple suture method with a 3-0 vicryl
suture. Often paramedian fixation is placed unilaterally
to mitigate naturally occurring brow asymmetry. Dif­
ferences in the natural shape of the brow and/or the
underlying bony orbital anatomy, however, can still limit
the extent to which asymmetry can be improved with
paramedian fixation. It is important to avoid closing the
periosteum of the paramedian incisions, as the adherence
of the periosteum is presumably what contributes to the
long-term fixation.
LOWERING THE BROW
Lowering of the brow involves some of the similar inci­
sions used in brow elevation but fixation is in the reverse
order. Indications for lowering the brow involve cases
where the forehead (glabella to hairline) distance is great,
and the surgeon wishes to reduce it. A pretrichial incision
is performed first, usually limited to the area between the
extension upward of the supraorbital nerves. Then, an
inferior subcutaneous elevation is performed above the
frontalis muscle. A vertical incision (or incisions) is made
in the frontalis muscle to avoid deactivating it. Parame­
dian incisions may also be utilized, depending on need.
At the conclusion of the brow procedure, the galea is
undermined posteriorly to the nuchal ridge and the galea
is cross hatched. The hairline is then pulled forward, and
skin is excised in a trichophytic fashion. Coapt endotine
brow fixation devices are then reversed and used to hold
the scalp forward. The incisions are then closed and the
brow lowering is completed.
SUMMARIZING KEY STEPS IN THE ENDOSCOPIC
FOREHEADPLASTY PROCEDURE: “KELLER’S
RULES OF FOURS”
Rule 1: Four Layers to Know and Dissect
a. Temporal parietal fascia (superficial fascia) and
fat pad
b. Innominate fascia
c. Superficial layer of deep temporal fascia (inter­
mediate fascia)
d. Subperiosteal
Rule 2: Four Areas of Adhesion to Release
a. Lateral orbital thickening (precanthal tendon)
b. Conjoint fascia and tendon (frontal ligament)

100
MASTER TECHNIQUES IN FACIAL REJUVENATION
9. Isse NG. Endoscopic forehead lift. Evolution and update. Clin Plast
Surg 1995;22:661–73.
10. Sobotta J, Figge FHJ, Hild WJ, Becher H. Atlas of human anatomy.
New York: Hafner Press; 1974.
11. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg
1995;96:564–9.
12. Norwood OT. Male pattern baldness: classification and incidence.
South Med J 1975;68:1359–65.
4. Castanares S. Forehead wrinkles, glabellar frown and ptosis of
eyebrow. Plast Reconstr Surg 1964;34:406–13.
5. Keller GS. Endoscopic forehead lift. West J Med 1995;163:157.
6. Keller GS, Mashkevich G. Endoscopic forehead and brow lift.
Facial Plast Surg 2009;25:222–33.
7. Keller GS, Razum NJ, Elliott S, Parks J. Small incision laser lift for
forehead creases and glabellar furrows. Arch Otolaryngol Head
Neck Surg 1993;119:632–5, discussion 636.
8. Keller GS. KTP laser offers advances in minimally invasive plastic
surgery. Clin Laser Mon 1992;10:141–4.

101
INTRODUCTION
The shift towards less nonsurgical techniques to rejuve­
nate the periorbital area continues, and patient requests
for procedures involving minimal downtime with less
“surgical” results increase each year. The American
Society of Aesthetic Plastic Surgeons reported that patients
received a total of 8.9 million cosmetic nonsurgical proce­
dures, including 5.5 million injectable treatments and 2.1
million skin rejuvenation treatments [1]. Understanding
the underlying anatomy and aging changes represents a
critical component to successful nonsurgical treatment of
the periorbital region.
The aging face changes in all layers including the skin,
muscle, fat, and bone; addressing these changes will
allow for optimal facial rejuvenation [2–5]. The three-
dimensional contours of the face should also be kept in
mind when addressing facial aging. Deflation of the brow
and unveiling of periorbital hollows is a major concern
for patients seeking periorbital rejuvenation. Because of
this, soft tissue filling with hyaluronic acid gel (HAG)
fillers has reached an all-time high of 1.7 million proce­
dures. In line with this, botulinum toxin (BT) treatments
have increased to 3.6 million procedures and skin reju­
venation to 2.1 million procedures in the United States
alone [1].
Surgical and nonsurgical procedures can be comple­
mentary and can often be used in conjunction for peri­
orbital rejuvenation. Surgical treatments will be covered
elsewhere, and this chapter will focus on nonsurgical
rejuvenation of the brow and periorbital complex.
ANATOMY
When performing facial rejuvenation, it is important to
understand the anatomy of the area. A detailed descrip­
tion of the anatomy is beyond the scope of this chapter
but a general overview of the layers will be described.
The skin in the periorbital area has different thick­
nesses and elasticity, with the brow and forehead having
thicker skin and the eyelid having thinner skin. The elas­
ticity of the skin decreases with age. This, with subcu­
taneous volume loss, can also affect the apparent skin
quality and wrinkling.
The muscles of the periorbital area include the fronta­
lis, corrugator, procerus, and orbicularis oculi. Manipula­
tion of the action of these various muscles can be used to
change the position of both the eyebrows and eyelids. The
frontalis is the main elevator of the eyebrow, and inter­
digitates with the main depressors of the eyebrow: the
procerus, corrugator supercilii, depressor supercilii, and
orbicularis oculi [6]. Furthermore, laterally, the frontalis
may change slightly during aging, accounting for some
of the lateral brow descent, in addition to brow volume
deflation, found in older patients [7].
Volume deflation also unveils the underlying struc­
tures including the periorbital ligaments. The orbicularis
retaining ligament (ORL) encircles the entire bony orbit
and inserts into the dermis of the skin [8]. The ORL
contributes to hollows in both the upper and lower
eyelid depending on the adjacent volume loss or fat her­
niation. In the upper eyelid superior volume loss can
unveil the ORL especially in Asian patients. In the lower
eyelid, other periorbital hollows include the septal con­
fluence and the zygomaticomalar ligament [9]. Deflation
in the adjacent areas, such as the midface and temple,
can also affect the appearance of the periorbital area.
Therefore the periorbital area should not be treated in
isolation but rather in conjunction with these areas of
the face.
SKIN REJUVENATION
Skin ages via both intrinsic and extrinsic factors, which
result in changes including skin wrinkling, loss of elas­
ticity, the appearance of excess skin, and pigmentation
changes [10]. To address these changes, various proce­
dures can be performed including surgical or nonsurgical
procedures. Surgery alone, however, cannot change the
quality, texture, or elastic properties of the skin, which
is where chemical peeling and laser resurfacing can help
[11–14].
Nonsurgical skin rejuvenation procedures essentially
remove different layers of the skin and thus induce the
genesis of new collagen and elastin. Treatments can be
aimed at either superficial or deep treatments. The most
superficial layer of the skin can be addressed with various
exfoliants, retinoids, mild α-hydroxy acids, or abrasives.
Treating the deeper skin layers is usually accomplished
with chemical peeling or laser resurfacing.
In the periorbital area, 20% trichloroacetic acid peel
is commonly used. When used carefully with a frost and
feathering technique, light acid peels have minimal com­
plications. Other deeper chemical peels such as phenol
C H A P T E R 9 
Nonsurgical Brow and
Eyelid Rejuvenation
Catherine J. Hwang, MD, Shani Golan, MD and Robert Goldberg, MD

102
MASTER TECHNIQUES IN FACIAL REJUVENATION
present a higher risk for complications in the periorbital
area and are therefore not used as frequently [15].
Laser treatments can also be used in the periorbital
area but with care. Laser treatments have been classified
into superficial and deep. Superficial lasers produce injury
of the epidermis and dermis less than 750 µm, and deep
lasers produce injury greater than 750 µm [12,16]. The
eyelid skin is very thin and more superficial treatments
are generally favored to prevent full-thickness dermal
injury, which could lead to eyelid malposition. Near-
infrared, intense pulsed light devices, and nonablative
lasers have a very low complication rate, but unfortu­
nately they have minimal effects on wrinkle reduction and
collagen formation. Fully ablative lasers such as carbon
dioxide (CO2) and erbium:yttrium-aluminum-garnet
have been successfully used in periorbital rejuvenation,
but they carry a higher complication rate (prolonged
healing, erythema, and pigmentary changes). Fractional
CO2 lasers are intermediate in risk and reward, and may
have more of a role in the periorbital area. They produce
small columns of thermal injury with sparing of adja­
cent untreated skin, allowing for a more rapid healing
process [17].
NEUROTOXINS
Neurotoxins, or BTs, have become the mainstay in the
treatment of dynamic lines and wrinkles. BT is produced
by the bacteria, Clostridium botulinum. Serotypes A and
B are used for clinical procedures, with serotype A (BTA)
being used for most cosmetic purposes [18]. The most
prevalent BTA products include Botox Cosmetic (Aller­
gan, Irvine, CA, USA), Dysport (Medicis, Scottsdale, AZ,
USA), and Xeomin (Merz Aesthetics, San Mateo, CA,
USA). These neurotoxins inhibit the release of acetylcho­
line at the presynaptic neuromuscular junction, produc­
ing a localized and temporary reduction of function of the
muscle. The onset of these effects usually occurs over the
first 7 days and last 3 to 6 months. Botox, Dysport, and
Xeomin differ slightly in their storage, protein, and unit
measurement, and their use depends largely on injector
preference. Reconstitution of the product can be per­
formed with 0.9% sterile saline. The authors use 0.9%
sterile bacteriostatic saline to reconstitute the various
products, as it has been suggested that this may decrease
patient discomfort [19]. The traditional locations for
periocular BT injections include the following:
1. Glabella: the most common cosmetic use for BT
and the only one currently indicated by the Food
and Drug Administration. A typical treatment of
the glabellar lines involves intramuscular injection
into four sites: one injection in the central procerus,
two injections to the depressor supercilii on both
sides, and another two in the corrugators bilater­
ally (Figs. 9.1 and 9.2A). Approximately 20 U of
onabotulinum toxin A or incobotulinum toxin A is
typically injected into the glabellar region, with a
range of 10 to 30 U [20].
2. Forehead area: injection into the frontalis muscle
that elevates the brows. Neurotoxins will lessen
lines and wrinkles. Injection consists of several
subcutaneous injections along the frontalis, but one
should take into consideration that weakening the
frontalis muscle will also lower the brows and may
exacerbate brow or eyelid ptosis. To avoid this,
dilute BTA can be used in a grid pattern across
the upper two-thirds of the forehead or in various
patterns in order to achieve brow reshaping (Figs.
9.1 and 9.2B). Also, one should pay attention to
the temporal portion of the frontalis muscle, to
avoid the quizzical look of lateral eyebrow eleva­
tion (“Spock” brow appearance).
3. The crow’s feet or lateral canthal rhytids: these are
caused by contraction of the lateral orbital and
septal rings of the orbicularis oculi muscle. Treat­
ing them with neurotoxins is usually done with
two to four subcutaneous injections at a dose of
10 to 15 U, 1 cm lateral to the lateral orbital rim
(Fig. 9.2C).
4. “Bunny lines”: lines on the lateral aspect of the
nasal dorsum caused by the action of the nasalis
muscle. Typical dose in this area is usually 2 to 4 U
on each side of the nose.
Alternative uses of BT in the periocular region can be
used to address upper eyelid ptosis, asymmetric brow
position, and palpebral fissure asymmetry [18].
The most common adverse effects of neurotoxin
injections are injection site pain and localized bruising.
Asymmetry can occur, often related to underlying facial
asymmetry, and usually responds to “touch up” injec­
tions followed by adjustment of the subsequent dosing.
True complications are rare, and they include eyelid
ptosis, brow ptosis, “Spock look,” diplopia, ectropion,
and psychological depression [21].
SOFT TISSUE FILLERS
Soft tissue fillers have been used increasingly in the peri­
orbital area to address volume deflation often seen with
2
2
2
2
2
2
2
4
4
2
2
2
2
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Figure 9.1  Pattern of Botox treatment to the periorbital and forehead
areas.

9  Nonsurgical Brow and Eyelid Rejuvenation
103
whenever HA fillers are used. By varying the amount of
HYAL injected, some or all of the filler can be dissolved
[22–24].
In the periorbital area, the reversible and temporary
HAG fillers are preferred. Selection and placement of the
products rely on their rheological characteristics, primar­
ily the crosslinking and HA concentration (Table 9.2)
[25]. It has been found that the higher the HA concen­
tration, the more hydrophilic the product. This can be a
desired effect or cause excess edema, especially in the thin
lower eyelid skin. Therefore in the lower eyelid Restylane
and Belotero are preferred over Juvederm. In the other
aging. Patients seek soft tissue fillers for a more natural
result and less downtime. In addition, fillers have been
proposed to have positive effects on skin quality.
Fillers can be categorized into temporary or permanent,
and reversible or nonreversible (Table 9.1). The main
temporary and reversible filler is HAG fillers. The HAG
fillers are reversed by the use of hyaluronidase (HYAL),
which is an enzyme that breaks down hyaluronic acid.
There are two commercially available HYALs, Hylenex
(Halozyme, San Diego, CA, USA) and Vitrase (Bausch &
Lomb, Bridgewater, NJ, USA), which can be used to help
reverse the HA filler products and should be available
C
B
A
Figure 9.2  Two weeks after Botox injection to the forehead and periorbital area. (A) Preinjection (left) and postinjection (right) to the glabella;
(B) preinjection (left) and postinjection (right) to the frontalis muscle; (C) preinjection (left) and postinjection (right) to the lateral canthal rhytids.

104
MASTER TECHNIQUES IN FACIAL REJUVENATION
the contour assessed. Multiple sessions may be needed
typically 2 to 3 weeks apart to allow for gradual filling
and to assess the reaction of a patient to a particular filler
product. In addition, prior to the injection session, saline
can be used to see the effect of filling in that area.
Filler Placement
When thinking about the periorbital region, volume loss
in the following areas can be addressed: the eyebrow,
temporal area, upper eyelid superior sulcus, and lower
eyelid hollows. Fillers and BT are often used together
and can have an additive effect to help shape the upper
face [27].
In the eyebrow area, typically Restylane or Juvederm
Ultra are used; in the upper eyelid sulcus area dilute
Restylane or Juvederm Ultra; and in the lower eyelid
area typically Restylane or Belotero. The choice of HA
filler used in each area depends on the concentration of
the HA gel, which affects how hydrophilic the gel is.
The higher the HA concentration, the more hydrophilic
the gel is, and the more fluid retention can be expected.
This property can be used to draw more fluid into an
area such as the upper eyelid superior sulcus deformity,
but can cause excess fluid retention such as in the lower
eyelid hollows. Other complications with periorbital filler
injections include both nonischemic and ischemic com­
plications [23,24]. Some of the nonischemic complica­
tions include contour irregularities, bluish discoloration
or Tyndall effect, inflammatory reactions, and infection/
biofilm formation. The bluish hue, or Tyndall effect, is
commonly seen in lighter, thin patients and with anterior
migration of the material over time. Ischemic events such
as tissue necrosis and blindness, although rare, can occur
and should be discussed with patients receiving any filler
injections [23,24].
Eyebrow.  Brow ptosis, especially laterally, can be a sign
of aging. Contouring the eyebrows can be achieved with
both neurotoxins as well as volume replacement with
fillers. The plane of injection is in the suborbicularis/
preperiosteal plane. When performing this injection it
is important to feather the injection laterally to prevent
a prominent tail of the brow. In conjunction with this,
if there is temporal hollowing, filling this area either
periorbital areas where the skin is thicker, any of the
HAG fillers can be used.
Injection Technique
Soft tissue fillers can be placed using various techniques,
depending on the injector’s preference. The most com­
monly used techniques in the periorbital area include the
serial puncture and linear layered/cross-hatching tech­
nique [18,26]. Both sharp needles (e.g., 30 gauge) and
blunt tipped microcannulas (e.g., 25 gauge or 27 gauge)
can be used [8]. When performing the serial puncture
technique, multiple boluses of filler are placed with a
30-gauge needle perpendicular to the orbital rim perios­
teum, along the periorbital hollow, and then massaged
with a cotton tipped applicator. Small boluses in the
amount of 0.05 to 0.1 cc are placed and overfilling is
avoided. With the linear layered technique, some injectors
prefer the blunt tipped microcannula in a 25- or 27-gauge
1.5 inch (38mm) length to decrease multiple entries and
risk of bruising. The filler is injected in a retrograde
fashion (when the cannula is being pulled back) and with
a low injection pressure to prevent inadvertent injection
into a vessel. In addition, the filler is placed below the
level of the orbicularis muscle to help prevent contour
irregularities and decrease bruising. The filler material
can also be massaged with a cotton-tipped applicator and
TABLE 9.1  FDA-Approved Dermal Fillers
Product
Type
Temporary/Permanent
Reversible
Restylane
HAG
Temporary
Yes
Perlane
HAG
Temporary
Yes
Juvederm Ultra, Ultra Plus, Voluma
HAG
Temporary
Yes
Prevelle Silk
HAG
Temporary
Yes
Belotero Balance
HAG
Temporary
Yes
Radiesse
Calcium hydroxylapatite
Temporary
No
Sculptra Aesthetic
Poly-L-lactic acid
Temporary
No
Artefill
Polymethylmethacrylate
Permanent
No
FDA, Food and Drug Administration; HAG, hyaluronic acid gel.
TABLE 9.2  Summary of FDA-Approved
Hyaluronic Acid Gel Fillers
HAG
HAG Concentration
Crosslinking
Restylane
20 mg/mL
NASHA
Perlane
20 mg/mL
NASHA
Juvederm Ultra
24 mg/mL
Hylacross HAG
Juvederm Ultra Plus
24 mg/mL
Hylacross HAG
Prevelle Silk
5.5 mg/mL
NASHA
Belotero Balance
22.5 mg/mL
CPM
CPM, Cohesive polydensified matrix; FDA, Food and Drug
Administration; HAG, hyaluronic acid gel; NASHA, nonanimal
stabilized hyaluronic acid.

9  Nonsurgical Brow and Eyelid Rejuvenation
105
determine the best treatment option for the patient (i.e.,
surgical vs. nonsurgical rejuvenation).
When injecting the lower eyelid, it is important to stay
below the orbicularis or in the preperiosteal plane, to
avoid contour irregularities and possible bluish discolor­
ation. In addition, if there is preexisting eyelid fluid, HAG
fillers may cause further fluid retention. This should be
discussed with the patient prior to treatment. Fortunately,
if there is a need to dissolve the HAG filler, HYAL can
be used.
The lower eyelid–cheek transition often needs to be
addressed with not only lower eyelid filling, but also
midface/cheek filling. Addressing both of these areas will
help restore a youthful curve to the face. The difference
in filling these areas is based on the difference in the skin
and subcutaneous fat in the area. The lower eyelid is less
forgiving with its thin skin and lack of subcutaneous
tissue, therefore HA fillers such as Restylane and Belotero
are used (Fig. 9.6). In the midface/cheek area, the tissue
is thicker and various HAG fillers can be used as well
superficially or deep will also help reduce step-offs and
bring the lateral brow forward (Fig. 9.3) [28].
Superior Sulcus.  The superior sulcus hollow is prevalent
in aging patients, either due to the loss of fat or change
of the bony orbit. This aging change can be seen in both
Caucasian and Asian patients. When injecting the supe­
rior sulcus, it is important to lift the brow superiorly so
that the eyeball is not inadvertently injured. In addition,
this injection should be performed in small aliquots in
the suborbicularis plane and massaged in order to reduce
contour irregularities (Fig. 9.4) [29].
Lower Eyelid.  In the lower eyelid, there are three main
hollows: the infraorbital rim hollow, the septal confluence
hollow, and the zygomatic hollow [9]. When addressing
the lower eyelid hollows, it is important to first under­
stand the youthful configuration of the lower eyelid.
In youth, there is usually a short lower eyelid with a
smooth transition into the cheek. Often, especially in
Asian patients, a small orbicularis roll can be seen. With
age, the lower eyelid becomes longer with unveiling of the
infraorbital rim hollow and separation from the cheek.
This results in patients complaining of the “tired” look
(Fig. 9.5). When assessing the lower eyelid, it is impor­
tant to keep in mind other factors such as the cheek
projection, fat herniation of the lower eyelid fat pads,
and any signs of fluid, allergies, or hyperpigmentation/
hypopigmentation. Thin, inelastic skin does not provide
good coverage for fillers and may be a contraindica­
tion. These factors should be addressed and may help
A
B
Figure 9.3  Before and after injection of hyaluronic acid gel filler into
the eyebrow.
A
B
Figure 9.4  Before and after injection of hyaluronic acid gel filler in
the superior sulcus area.
Figure 9.5  Youthful lower eyelid and aged lower eyelid in the same
patient.

106
MASTER TECHNIQUES IN FACIAL REJUVENATION
evaluating and treating patients for periorbital rejuve­
nation it is important for the physician to understand
the patient’s wishes, and for the patient to have realistic
expectations. Sometimes surgery is needed, but some­
times nonsurgical rejuvenation can be used instead of or
in conjunction with surgery to achieve the desired result.
Thinking about the aging face and how it transforms
through the years will help us design optimal customized
treatments for our patients.
References available online at expertconsult.com.
R E F E R E N C E S
3. Lambros V. Observations on periorbital and midface aging. Plast
Reconstr Surg 2007;120(5):1367–76, discussion 77.
4. Fitzgerald R. Contemporary concepts in brow and eyelid aging.
Clin Plast Surg 2013;40(1):21–42.
9. Goldberg RA. The three periorbital hollows: a paradigm for peri­
orbital rejuvenation. Plast Reconstr Surg 2005;116(6):1796–804.
13. Hoenig JA, Shorr N, Morrow DM. In: Fagien S, editor. Chemi­
cal peel: eyelid and facial skin rejuvenation. New York: Elsevier;
2007.
14. Sundaram H, Kiripolsky M. Nonsurgical rejuvenation of the upper
eyelid and brow. Clin Plast Surg 2013;40(1):55–76.
18. Pao KY, Mancini R. Nonsurgical periocular rejuvenation: advanced
cosmetic uses of neuromodulators and fillers. Curr Opin Ophthal­
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23. DeLorenzi C. Complications of injectable fillers, part I. Aesthet
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25. Sundaram H, Cassuto D. Biophysical characteristics of hyaluronic
acid soft-tissue fillers and their relevance to aesthetic applications.
Plast Reconstr Surg 2013;132(4 Suppl. 2):5S–21S.
26. Goldberg RA. Nonsurgical filling of the periorbital hollows. Aesthet
Surg J 2006;26(1):69–71.
as other types of fillers such as calcium hydroxylapa­
tite (Radiesse, Merz Pharmaceuticals) and poly-L-lactic
acid (Sculptra, Galderma). Tung et al. [30] found that
using different fillers in these areas improved the aesthetic
outcome of patients.
SUMMARY
Periorbital rejuvenation includes addressing the skin,
muscle, and volume changes seen with aging. When
A
B
Figure 9.6  Before and after injection of hyaluronic acid gel filler to
the lower eyelid periorbital hollows.

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17. Bae-Harboe YS, Geronemus RG. Eyelid tightening by CO2 fractional
laser, alternative to blepharoplasty. Dermatol Surg 2014;40(Suppl.
12):S137–41.
18. Pao KY, Mancini R. Nonsurgical periocular rejuvenation: advanced
cosmetic uses of neuromodulators and fillers. Curr Opin Ophthal­
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19. Alam M, Dover JS, Arndt KA. Pain associated with injection of
botulinum A exotoxin reconstituted using isotonic sodium chlo­
ride with and without preservative: a double-blind, randomized
controlled trial. Arch Dermatol 2002;138(4):510–14.
20. Hankins CL, Strimling R, Rogers GS. Botulinum A toxin for glabellar
wrinkles. Dose and response. Dermatol Surg 1998;24(11):1181–3.
21. Vartanian AJ, Dayan SH. Complications of botulinum toxin
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2005;13(1):1–10.
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between hyaluronidase and commercially available hyaluronic-acid
based fillers. J Drugs Dermatol 2014;13(9):1053–6.
23. DeLorenzi C. Complications of injectable fillers, part I. Aesthet
Surg J 2013;33(4):561–75.
24. DeLorenzi C. Complications of injectable fillers, part 2: vascular
complications. Aesthet Surg J 2014;34(4):584–600.
25. Sundaram H, Cassuto D. Biophysical characteristics of hyaluronic
acid soft-tissue fillers and their relevance to aesthetic applications.
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26. Goldberg RA. Nonsurgical filling of the periorbital hollows. Aesthet
Surg J 2006;26(1):69–71.
27. Carruthers J, Carruthers A. A prospective, randomized, parallel
group study analyzing the effect of BTX-A (Botox) and nonanimal
sourced hyaluronic acid (NASHA, Restylane) in combination com­
pared with NASHA (Restylane) alone in severe glabellar rhytides in
adult female subjects: treatment of severe glabellar rhytides with a
hyaluronic acid derivative compared with the derivative and BTX-
A. Dermatol Surg 2003;29(8):802–9.
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diluted hyaluronic acid: the “dilution solution”. Aesthet Surg J
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29. Morley AM, Taban M, Malhotra R, Goldberg RA. Use of hyal­
uronic acid gel for upper eyelid filling and contouring. Ophthal
Plast Reconstr Surg 2009;25(6):440–4.
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bined upper cheek and tear trough augmentation: a systematic
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Drugs Dermatol 2012;11(9):1094–7.
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new concepts in facial aging. Curr Opin Otolaryngol Head Neck
Surg 2007;15(4):238–43.
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Reconstr Surg 2007;120(5):1367–76, discussion 77.
4. Fitzgerald R. Contemporary concepts in brow and eyelid aging.
Clin Plast Surg 2013;40(1):21–42.
5. Pessa JE, Zadoo VP, Yuan C, et al. Concertina effect and facial
aging: nonlinear aspects of youthfulness and skeletal remodel­
ing, and why, perhaps, infants have jowls. Plast Reconstr Surg
1999;103(2):635–44.
6. Drake RLVW, Mitchell AWM, et al. Gray’s atlas of anatomy. Phila­
delphia: Elsevier; 2007.
7. Costin BR, Plesec TP, Sakolsatayadorn N, et al. Anatomy and
histology of the frontalis muscle. Ophthal Plast Reconstr Surg
2015;31(1):66–72.
8. Briceno CA, Zhang-Nunes SX, Massry GG. Minimally invasive
options for the brow and upper lid. Facial Plast Surg Clin North
Am 2015;23(2):153–66.
9. Goldberg RA. The three periorbital hollows: a paradigm for peri­
orbital rejuvenation. Plast Reconstr Surg 2005;116(6):1796–804.
10. Situm M, Buljan M, Cavka V, et al. Skin changes in the elderly
people—how strong is the influence of the UV radiation on skin
aging? Coll Antropol 2010;34(Suppl. 2):9–13.
11. Prado A, Andrades P, Danilla S, et al. Full-face carbon dioxide laser
resurfacing: a 10-year follow-up descriptive study. Plast Reconstr
Surg 2008;121(3):983–93.
12. Brauer JA, Patel U, Hale EK. Laser skin resurfacing, chemical peels,
and other cutaneous treatments of the brow and upper lid. Clin
Plast Surg 2013;40(1):91–9.
13. Hoenig JA, Shorr N, Morrow DM. In: Fagien S, editor. Chemi­
cal peel: eyelid and facial skin rejuvenation. New York: Elsevier;
2007.
14. Sundaram H, Kiripolsky M. Nonsurgical rejuvenation of the upper
eyelid and brow. Clin Plast Surg 2013;40(1):55–76.
15. Hassan KM, Benedetto AV. Facial skin rejuvenation: ablative laser
resurfacing, chemical peels, or photodynamic therapy? Facts and
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16. Landau M. Chemical peels. Clin Dermatol 2008;26(2):200–8.

107
INTRODUCTION
Upper blepharoplasty has evolved significantly since its
early descriptions focused on rudimentary techniques of
skin excision only [1,2]. In the 20th century, the first
detailed description of internal upper eyelid anatomy
emphasizing the presence of distinct fat compartments
within the eyelid was published [3]. As, on first glance,
aged eyelids appear associated with skin, muscle, and fat
excess, the trend in surgery was to aggressively excise
variable amounts of these tissue substrates to debulk the
eyelid and impart what was considered a less prominent
and more aesthetic appearance [4]. This “subtractive”
form of surgery was in vogue for many years. The desired
and accepted upper blepharoplasty result was one with
a “hollower” upper sulcus, a high eyelid crease and a
prominent tarsal platform [5–7]. While immediately after
surgery patients noted a “lighter and less baggy” eyelid,
with time many of these changes simulated normal senes­
cence. In the end, many facial surgeons identified that this
type of surgery was more a form of iatrogenic aging than
a restoration of youth. As the 21st century approached, a
more contemporary understanding of facial aging became
apparent and surgeons learned that loss of volume is also
an essential component of eyelid aging [8,9]. In addition,
it became clear that when planning surgical cosmetic
enhancements of the eyelids, their adjacent structures
should also be considered to attain appropriate out­
comes. In the upper eyelid this meant paying close atten­
tion to the eyebrow and its transition to the upper eyelid
[10–12]. Consideration of the lower eyelid and cheek
as an aesthetic unit, with emphasis on adjuncts such as
fat transposition and augmentation, quickly became the
norm [13–17]. These concepts have lagged behind in
regards to the brow and upper eyelid, but more recently
have garnered attention [18–21].
In this chapter the authors detail various surgical
adjuncts to upper blepharoplasty that can be consid­
ered to enhance surgical results. These techniques are
quick, minimally invasive, easily incorporated to stan­
dard blepharoplasty surgery, generally complication free,
allow consideration of the brow and eyelid as a contin­
uum, and promote volume preservation. All, except for
one browpexy variant [22], are performed through the
blepharoplasty incision, making them easily incorporated
into standard eyelid surgery. The importance of these
procedures is that they provide the eyelid surgeon with
various simple options to potentially enhance surgical
results. Prior to the description of these techniques a brief
overview of relevant eyelid and periorbital anatomy and
aging changes is reviewed.
CLINICAL ANATOMY
(FOREHEAD/EYEBROW/EYELID)
The forehead is a complicated, multilamellar, dynamic
structure, which constitutes the upper third of the face. It
begins at the hairline and transitions to the upper eyelid
at the level of the eyebrow laterally and the glabella and
frontonasal groove centrally [23]. Its normal dimensions
are a width 2× its height (Fig. 10.1) [24], and it houses
the paired frontalis muscles, which control brow eleva­
tion and upper facial animation. The frontalis originates
from the galea aponeurotica, which splits and continues
above and below the muscle as a superficial and deep
layer [22]. The frontalis then inserts into the dermis of the
skin above the brow after interdigitating with the orbital
orbicularis, corrugator, and procerus muscles [23]. It is
innervated by the frontal (temporal) branch of the facial
nerve. The lateral extent of the frontalis muscle is the
arched superior temporal line at the approximate junction
of the body and tail of the eyebrow (Fig. 10.2). Beyond
this limit there is no brow elevator, which predisposes
this area to normal involutional brow descent [22,25].
With age, horizontal forehead rhytids develop related to
chronic contraction of the frontalis muscle. These rhytids
may be effaced with chemo-neuromodulating agents [26].
The eyebrow contour, position, and movement are
important features of facial expression. The brow cilia are
denser and more vertically oriented nasally, and become
more horizontal and sparse laterally. Generally speaking,
the medial and lateral extent of the brow lie in the same
horizontal plane, with the most medial aspect vertically
in line with the nasal ala, and the lateral extent in a line
drawn obliquely from the nasal ala through the lateral
canthus (Fig. 10.3) [24,25]. There are gender differ­
ences in the brow arch and contour, with the male brow
being flatter and running over or just below the supra­
orbital rim, and the female brow arching over the rim
with a natural peak in a line drawn tangent to the nasal
ala and the pupil or lateral limbus. Below the thick brow
skin lies the interdigitation of the frontalis muscle with
the brow depressor muscles: the orbital orbicularis oculi
throughout and the corrugator and procerus muscle
medially. The brow fat pad or retro-orbicularis oculi fat
(ROOF) lies below these muscles and above the frontal
C H A P T E R 10 
Minimally Invasive Complementary
Adjuncts to Upper Blepharoplasty
César A. Briceño, MD and Guy G. Massry, MD

108
MASTER TECHNIQUES IN FACIAL REJUVENATION
bone periosteum. The ROOF is encased by the anterior
and posterior leafs of the deep layer of the galea aponeu­
rosis [22]. The ROOF fat continues into the eyelid proper
as the post orbicular fascial plane in Caucasians [27] and
the preseptal fat in Asians [28]. The frontal periosteum
merges with the orbital periosteum at the rim, forming
the arcus marginalis.
The eyelid skin is thin and intimately adhered to
the underlying orbicularis muscle, the protractor of
the eyelid. The orbicularis muscle is subdivided into an
orbital segment with runs over the orbital rim, and a
palpebral segment further subdivided into preseptal and
pretarsal divisions named according to their underlying
anatomic structures [23]. Like the frontalis muscle, the
upper orbicularis oculi muscle is innervated by the frontal
branch of the facial nerve. The orbital septum originates
at the arcus marginalis periosteum overlying the orbital
rim and inserts onto the levator aponeurosis (LA). The
septum is an important anatomic landmark as it separates
the orbit from the eyelid. It is also an important surgi­
cal guide, as when divided eyelid/orbital fat is exposed
[29]. This fat lies above the LA. Identifying orbital fat is
an important step in blepharoplasty surgery as it defines
the location of the aponeurosis, a structure which must
be preserved to avoid postoperative eyelid malposition.
The levator muscle and aponeurosis function as one of
two eyelid retractors, the other being Müller’s muscle.
The levator complex originates at the orbital apex with
the aponeurosis inserting onto the anterior surface of the
tarsus. It is innervated by the upper division of the third
cranial nerve. Müller’s muscle (a secondary eyelid retrac­
tor), originates from the undersurface of the levator
muscle, inserts onto the upper tarsus. It is autonomi­
cally driven, and is responsible for eyelid elevation during
“fight or flight” responses (Fig. 10.4). Both retractors can
be manipulated in ptosis surgery.
EYEBROW/EYELID AGING
Eyelid and periorbital aging is a complex and multi­
factorial process involving tissue descent, deflation, and
X
2X
Figure 10.1  Normal forehead dimensions with a width 2× its height.
STL
Figure 10.2  Frontalis muscle anatomy. Note on frontal view the
muscle is encased in the anterior and posterior leafs of the galea aponeu­
rosis, and that the lateral extent of the muscle is the superior temporal
line (STL). Beyond the STL (or lateral brow) there is no brow-elevating
muscle.
Figure 10.3  Normal brow relationship to surrounding structures. The
medial and lateral brow is in a horizontal plane (red line). The medial
brow is vertically aligned with the nasal ala (black line), and the lateral
brow in a diagonal orientation through the lateral limbus and the nasal
ala (blue line). Male brows are flat and run over or below the orbital
rim. Female brows, as in this woman, are arched over the rim with their
peak at the junction of a line drawn from nasal ala through the pupil or
lateral limbus (dotted line). (In: Massry GG, Murphy MR, Azizzadeh B,
editors. Master techniques in blepharoplasty and periorbital rejuvena­
tion. New York: Springer; 2011. p. 25–31. Reprinted from Buchanon
AG, Holds JB. The beautiful eye: perception of beauty in the periocular
area. With permission.)

10  Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty
109
The upper eyelids also have characteristic age-related
changes. These include true or apparent skin/muscle and
fat excess, most obvious temporally (hooding), contour
changes with shadowing, central hollows (A-frame
changes), and changes in lid height (ptosis; Fig. 10.5) [25].
Eyelid ptosis, and its correction, are covered in another
chapter. As the temporal brow falls the outer part of the
eyelid becomes fuller. For this reason, a temporal brow lift
is often a needed adjunct to upper blepharoplasty. The fat
pads of the upper lid are different in make-up and clinical
appearance, which may lead to some typical age-related
eyelid changes [18,21]. The nasal fat is denser, paler, rela­
tively stem-cell rich, is an extension of deep orbital fat.
It is not separated from deeper fat by the LA, and clini­
cally becomes more prominent with age. The central fat
is separated from deeper fat by the LA and is thus called
preaponeurotic fat. It is less dense, more yellow, relatively
stem cell deficient, and tends towards clinical involu­
tion with age. The differences in clinical appearance of
the fat pads explains why traditional upper blepharo­
plasty has focused more on nasal than preaponeurotic fat
excision [5–7].
cutaneous changes [22]. As discussed, understanding the
role of volume loss with age has been an integral com­
ponent of contemporary aesthetic eyelid surgery [8,9].
With age the eyebrow tends towards temporal ptosis,
which is both a static and dynamic process (Fig. 10.5).
There are lateral brow depressors but no brow elevator
beyond the temporal line of the forehead (see anatomy
section earlier). As the brow fat pad and its underlying
skeleton involute with age, the lateral brow structurally
loses support. At the same time, the dynamic action of
the brow depressors continues unopposed, predisposing
to temporal ptosis. Brow position can be altered by many
factors, and certainly there are those whose brows elevate
with age [30], for instance as a result of compensation
for true eyelid ptosis. However, as a general rule, the
temporal brow tends to drop with age.
Figure 10.5  Typical appearance of age related temporal brow ptosis
which adds to lateral eyelid hooding. (From Massry GG, Nassif PN.
Transconjunctival lower blepharoplasty: fat excision or repositioning.
In: Massry GG, Murphy MR, Azizzadeh B, editors. Master techniques
in blepharoplasty and periorbital rejuvenation. New York: Springer;
2011. p. 173–85. With permission.)
A
B
Figure 10.6  Internal browpexy. (A) Transeyelid crease exposure of brow fat pad (black arrow) and frontal periosteum (red arrow). (B) ENDOTINE
anchoring with blue anchoring Prolene suture in place. (From Briceño CA, Zhang-Nunes SX, Massry GG. Minimally invasive surgical adjuncts to
upper blepharoplasty. Facial Plast Surg Clin North Am 2015; 23(2):137–51. With permission.)
Preaponeurotic fat pad
Orbital septum
Orbicularis oculi m.
Müller’s muscle
Levator aponeurosis
Tarsus
Conjunctiva
Figure 10.4  The important anatomic structures of the upper eyelid.
m., Muscle.

110
MASTER TECHNIQUES IN FACIAL REJUVENATION
include extended preperiosteal dissection, release of deep
retaining ligaments of the brow, extirpation of the tem­
poral brow depressor muscle (lateral orbital orbicularis
oculi), and the use of anchoring devices screwed into the
frontal bone (ENDOTINE; Coapt Systems, Palo Alto,
CA, USA; Fig. 10.6) [10,31–34]. All these procedures
have been reported to give good results with few com­
plications. The authors of this chapter rarely perform
internal browpexy as they prefer the external variant
described later. However, when using this technique they
typically extend the dissection and release the deep liga­
ments. These modifications have improved outcomes. In
general, many surgeons feel the internal browpexy does
not provide more than short-term results. This can be
attributed to surgeon experience, limitation of dissection,
weakness of the procedure, or some combination thereof.
There is one report in which a central (1.12 mm) and
lateral (1.77 mm) brow lift was achieved at 8.5 months’
follow-up [35].
More recently, an external variant of the browpexy
procedure has been described, which has been called the
“external browpexy” [22]. The idea for this procedure
developed from observing patients who had traumatic
full-thickness lacerations above the brow, down to the
bone. Some of these trauma patients developed a localized
elevation and peak in the brow as they healed. Extrapo­
lating from these observations, this technique creates a
controlled full-thickness incision to the periosteum with
suture anchor of the brow in the area of desired lift.
Patient marking is performed in the preoperative area in
the sitting position. A 7- to 8-mm mark is made within
or along the superior border of the eyebrow cilia, at the
junction of the body and tail of the brow. The location
should correspond to a line drawn through the nasal ala
and lateral limbus, but may be modified depending on
patient desires and gender. A finger is then used to elevate
this area to the desired brow height. The marking pen is
placed at the level of the upper border of the eyebrow
at this new height, and the brow is allowed to return to
its resting position. Without moving the marking pen
down, a second mark is then made on the skin above
the brow at this new desired height (Fig. 10.7). The
distance between the two marks is the amount of lift to
be achieved. The location of elevation (fixation) can be
measured as the distance of the second mark from the
orbital rim in millimeters. A linear incision is made to
the periosteum at the previously marked area just above
the eyebrow hairs. While the external incision is small,
an internal dissection extends medially and laterally to
the periosteum for about 25 mm or 3× the length of the
external incision. The internal dissection allows for more
raw surface area to form a larger cicatrix to support the
brow postoperatively. A 4-0 Prolene suture engages the
periosteum at the premarked brow height. This height
can be confirmed by measurement from the orbital rim.
Interestingly, the authors have found that this height
almost always corresponds to the new position of the
brow while the patient is supine and after injection of
anesthetic agent. The suture is then passed from below,
through the brow fat pad/orbicularis muscle and then
redirected from above through the orbicularis muscle/
INDICATIONS
All surgical adjuncts reviewed are appropriate additions
to standard upper blepharoplasty in patients aware of
the potential benefits and limits of each intervention.
Standalone blepharoplasty in the presence of brow ptosis
can further lower the brow, crowd the upper eyelid, and
lead to unnatural results. Browpexy is not a proven brow
lifting technique, but rather serves to stabilize the brow
position. It is a good option in patients averse to more
invasive brow lifting surgery. The external variant, which
may rarely be associated with visible scarring [22], is best
suited for men with thicker brow cilia. There are no evi­
dence-based studies proving the utility of nasal fat preser­
vation, and patients should be told that data on surgical
outcomes is anecdotal and based on individual surgeon
experience. However, the authors are well-versed on these
techniques and, with some experience, have found them
generally complication free and easy to learn. In addition,
the contemporary awareness that fat is a precious com­
modity within the eyelid should be explained to patients
and stimulate surgeon adaptation to these interventions.
Lacrimal gland suspension should clearly be discussed
with patients who have obvious clinical gland prolapse
on preoperative examinations. The decision on suspend­
ing a subclinical prolapse (isolated surgical finding) is
at the discretion of the operating surgeon. Finally, and
probably most controversial, is whether the addition
of brow fat-suspension sutures is a warranted addition
to blepharoplasty. Again, the authors have significant
experience with this technique with only very minor and
temporary complications. The authors also feel that brow
fat pad suspension does enhance aesthetic outcomes (see
discussion).
SURGICAL PROCEDURES
Internal and External Browpexy
As reviewed, temporal brow ptosis can accentuate tempo­
ral eyelid hooding and create a tired and aged appearance.
Since this is a common age-related phenomenon, stabiliza­
tion or elevation of the outer brow has become an essen­
tial adjunct to aesthetic upper blepharoplasty [11,12].
Formal brow lifting procedures are invasive, costly, and
carry risks of motor and sensory neurological injury [22].
A browpexy is a minimally invasive method for anchor­
ing the brow tissue (muscle/fat) to the periosteum of the
frontal bone [11]. It can provide stabilization or even
minimal lift to the temporal brow in conjunction with
standard blepharoplasty surgery. In the internal variant,
described by McCord and Doxanas [12], the subbrow
tissue is accessed through an upper eyelid crease inci­
sion, and the brow fat pad is dissected free of the frontal
periosteum. The targeted periosteal suspension location
is measured directly and a 4-0 Prolene suture engages the
periosteum at this location. The subbrow tissue is then
engaged at the inferior aspect of the brow (from the inter­
nal wound) with the same suture and tied, anchoring the
brow tissue. A total of two or three sutures are placed in
this way to secure the brow fat pad to its new position.
Modifications of the procedure have been described and

10  Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty
111
A
B
C
D
Figure 10.7  Preoperative marking for external browpexy. (A) Mark made at superior brow cilia. (B) Brow elevated to desired height with marking
pen hovering over the mark. (C) Brow released to its native position, and (D) second mark made at this brow position. The distance between marks
is the desired brow elevation.
Nasal Fat Pad Preservation and Translocation in
Upper Blepharoplasty
Hollowing of the upper eyelid and sulcus may occur as a
normal aging change or after traditional excisional (sub­
tractive) upper eyelid blepharoplasty. Volume depletion
unmasks the orbital rim, disrupts the smooth transition
between the brow and upper lid, and may create an
A-frame deformity [18]. In addition, a normal age-related
periorbital hollow can occur at the interface of the medial
eyebrow and upper lid, which has been called the orbito­
glabellar groove (OGG) because of its adjacent anatomic
structures (Fig. 10.10) [21]. This hollow, like the naso­
jugal groove (tear trough) at the lower eyelid cheek junc­
tion, cannot be addressed, and may be worsened, with
standard blepharoplasty surgery. Secondary interventions
such as fat transfer [37,38], dermis fat grafting [39], and
injectable fillers [40] may be used to address these post­
operative changes, but they may be prevented or lessened
by employing fat-preserving surgical interventions. Fat
transposition in lower blepharoplasty has gained wide
acceptance as a standard surgical adjunct, smoothing the
transition from the lower eyelid to the cheek and prevent­
ing the postoperative volume loss associated with fat
brow fat pad and tied. As the knot is tied, elevation and
anterior rotation of the brow is achieved. The wound is
then closed in layers (Fig. 10.8).
The best way to judge the utility of this procedure
is by assessing surgical outcomes in patients with mild
brow asymmetry. In this instance the normal brow can
act as a control after surgery. The authors have found a
consistent improvement in symmetry in these cases (Fig.
10.9). The senior author has performed this procedure
on over 100 patients over the last 4 years. The surgical
results have been good, with rare minor and reversible
complications. There has been negligible scarring, no
suture spitting or migration, no granuloma formation, no
infections, and no unexpected contour anomalies. A few
patients have noted prolonged pain or tenderness over
the brow suspension suture site. These symptoms have
resolved with time and serial injections of 5-fluorouracil
50 mg/mL and/or Kenalog 5 mg/mL. A current ongoing
study has shown a sustained brow elevation of 2.97 mm
laterally and 1.9 mm medially at 6 months’ follow-up
[36]. Long-term efficacy still needs to be studied. Overall,
the authors and patients have been pleased with this
procedure.

112
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
C
D
E
F
G
H
I
Figure 10.8  External browpexy surgical series. (A) Initial skin incision. (B) Division of muscle to periosteum. (C) Periosteum engaged with forceps.
(D) Prolene suture anchored to periosteum. (E) Orbicularis engaged pulling brow up. (F and G) Suture fed through orbicularis muscle and brow fat
pad. (H) Suture tied. (I) Final closure. (From Massry GG. The external browpexy. Ophthal Plast Reconstr Surg 2012;28(2):90–5. With permission.)
A
B
C
D
Figure 10.9  Before (A and C) and after (B and D) external browpexy and blepharoplasty results. In both cases, there was unilateral brow ptosis
on the right side which became much more symmetric after surgery. (From Massry GG. The external browpexy. Ophthal Plast Reconstr Surg
2012;28(2):90–5. With permission.)

10  Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty
113
of relative deficit (central eyelid or OGG) is the basis of
the nasal fat transposition procedure.
There are two variations of nasal fat transposition in
upper blepharoplasty. First, within the eyelid itself (Fig.
10.11) and second, outside of the eyelid (Figs. 10.12
and 10.13) [18,21]. The surgical steps are similar, and
only differ as to where the fat is translocated. In both
procedures, the skin is incised/excised, and the orbicularis
muscle and orbital septum are then divided to access
the nasal and central fat compartments. The nasal fat is
freed of all connective tissue attachments at its base, so
that it becomes a freely mobile fat pedicle. In doing so it
is critical to avoid injury to the superior oblique tendon
and trochlea, which separate the fat pads of the upper
lid (similar to how the inferior oblique muscle separates
the nasal and central fat pads of the lower lid). Damage
to these structures may lead to diplopia (pseudo-Brown’s
syndrome). The authors have had one such case early in
the development of this procedure, which resolved with
oral and injected steroid. The next steps are where the
procedures vary.
If fat is transposed within the eyelid, the nasal pedicle
is translocated to the central eyelid space and secured to
the periosteum of the superior orbital rim, undersurface
of the orbital septum, or orbicularis muscle. It is impor­
tant to assure tension-free transposition of the fat flap as
pressure on the LA can lead to mechanical ptosis. This
complication was observed in some early cases and did
resolve on its own with time, but is consistently avoided
by loose redraping of fat.
When fat is transposed outside of the eyelid it is placed
in the OGG. To fill the OGG, a preperiosteal dissection is
performed underlying this depression to create a pocket.
In upper lid, fat transposition it is important to dissect
preperiosteally. This is because the supraorbital neurovas­
cular bundle emerges from the orbit at a notch in the supe­
rior rim and not a distal foramen (as is the case with the
infraorbital nerve in the lower lid). A periosteal incision
in this location may damage the nerve. Also, when operat­
ing from the head of the bed, the authors have found that
simply spreading in the preperiosteal plane is a simple and
quick maneuver. The nasal fat flap (fashioned as previ­
ously described) is transposed into this pocket with a full-
thickness transcutaneous suture. The filling effect of the
fat softens the medial eyebrow/upper lid transition. Like in
excision [13–17]. Similar interventions in the upper lid
have also recently been described [18–21].
In 2010 Sozer et al. [20] reported the transposition of
the central (preaponeurotic) eyelid fat to the temporal
lid to create lateral fullness. It is interesting that these
authors translocated/repositioned eyelid fat, which tends
towards age-related involution, as their source of volume
enhancement. Soon after, Park et al. [19] reported on
inferior transposition of the combined nasal and central
eyelid fat pads from the level of Whitnall’s ligament to
the inferior eyelid in Asian patients. They termed this
“orbital fat relocation,” and felt it enhanced the fuller
appearance of eyelids in a patient population which
appears this way in youth. In both reports, the authors
reported no complications with excellent surgical results.
Nasal fat pad translocation is a novel adjunct in upper
blepharoplasty, in which nasal upper eyelid/orbital fat is
preserved and redistributed within or outside of the orbit
in an attempt to minimize the volume-related deficits
described [18,21]. As discussed in the eyelid aging section
of this chapter, nasal eyelid/orbital fat is denser, stem cell
rich, and clinically becomes more prominent with age.
Preserving and redistributing this rich source of eyelid fat
from an area of relative excess (nasal eyelid) to an area
A
B
Figure 10.11  Nasal fat preservation within the eyelid—surgical series. (A) Fat flap isolated. (B) Flap secured to central eyelid space. (From Massry
GG. Nasal fat preservation in upper eyelid blepharoplasty. Ophthal Plast Reconstr Surg 2011;27(5):352–5. With permission.)
Figure 10.10  The orbitoglabellar groove is a depression at the nasal
eyebrow/upper eyelid interface (black arrows). (From Yoo DB, Peng
GL, Massry GG. Effacing the orbitoglabellar groove with transposed
upper eyelid fat. Ophthal Plast Reconstr Surg 2013;29(3):220–4. With
permission.)

114
MASTER TECHNIQUES IN FACIAL REJUVENATION
A prolapsed lacrimal gland has been managed with
segmental resection, suture repositioning, and/or cautery
[42,43]. Segmental resection has largely fallen out of favor,
and suture suspension is the most common technique to
address the problem. In mild/moderate cases of prolapse,
the authors apply light cautery to the gland capsule and
superficial parenchyma to create a small cicatrix which
retroplaces the gland. Cautery is quick and simple, and
avoids the occasional bleeding encountered with suture
suspension. The authors feel the damage created from
cauterizing the tip of the gland and its capsule is not dif­
ferent than the injury associated with tissue penetration
and strangulation when associated with suture suspen­
sion. There has not been a comparative study of the two
procedures, but in the authors’ hands light cautery has
been safe and effective in treating mild/moderate LGP.
Suture suspension of the lacrimal gland is a straight­
forward and direct way to address moderate/severe LGP.
The prolapsed gland is identified through the standard
upper eyelid blepharoplasty wound. It is pale in color
with glandular elements, distinctly different than the
lower blepharoplasty fat transposition (the mirror image
of this procedure), the amount of fill is dependent in part
on how much fat there is to transpose. After fat transposi­
tion in both procedures, the upper eyelid skin is closed in
the usual fashion. Fig. 10.14 demonstrates typical results
from each fat-preservation technique.
Management of Lacrimal Gland Prolapse
With aging, after trauma, or in an idiopathic fashion, the
lacrimal gland can dislocate anteriorly and cause tempo­
ral fullness of the upper eyelid [41–44]. This phenomenon
is termed lacrimal gland prolapse (LGP), and it may be
observed clinically by asking the patient to look down
and watching for fullness below the superolateral orbital
rim (Fig. 10.15). If significant it can cause mechanical
pressure on the globe, but typically it is just a cosmetic
distraction. LGP has been reported to be present in 15%
of all upper eyelid blepharoplasty patients [41,43] and
in up to 60% of patients undergoing functional upper
lid blepharoplasty [42]. As such it can be considered a
normal involutional change.
A
B
C
D
E
F
Figure 10.12  Nasal fat preservation outside of the eyelid to the orbitoglabellar groove—surgical series. (A) Fat flap isolation. (B) Creation of pre­
periosteal pocket. (C) Suture engaging fat flap. (D) Exiting skin. (E) Fat pedicle transposed to the orbitoglabellar groove. (F) Suture tied. (From Yoo
DB, Peng GL, Massry GG. Effacing the orbitoglabellar groove with transposed upper eyelid fat. Ophthal Plast Reconstr Surg 2013;29(3):220–4.
With permission.)

10  Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty
115
transition creates a youthful periorbital appearance [25],
volumetric enhancement and support of the brow fat
pad can be a useful addition to blepharoplasty surgery.
If frank brow ptosis is present a separate formal brow
lift is often planned. However, the authors have found
that isolated brow fat pad suspension in the aged eyelid
patient consistently improves brow/lid contour and full­
ness, and the temporal eyelid fold and crease appearance.
In 1997, Zarem et al. [45] described an upper blepha­
roplasty variant in which the orbicularis muscle at the
upper edge of the blepharoplasty incision is secured to
the periosteum at the superior orbital rim in order to
create a larger tarsal platform and support the brow fat.
The technique was elaborated on by the same group in
2004 (Fig. 10.17) [46]. The authors of this chapter have
adopted a version of this suspension suture procedure ini­
tially described to the senior author by Jonathan Hoeing
MD (personal communication, 2008). This variation has
been called the “brassiere” suture suspension of the brow
fat pad. The technique’s primary focus is to elevate and
suspend the brow fat pad, creating a barrier for brow fat
descent. This suspension also causes the brow fat pad to
bunch up like an accordion, causing secondary anterior
projection and volume enhancement.
During routine blepharoplasty, the orbicularis muscle
and orbital septum are buttonholed nasally. The wooden
end of a cotton-tipped applicator is then inserted below
the septum and muscle, and advanced to the temporal
extent of the incision. The applicator is then elevated,
tenting the septum and muscle anteriorly, which protects
the LA from damage during division. The orbicularis
muscle and orbital septum are then incised the full width
of the eyelid (nasal to temporal) along the center of
the wound as to leave an equal amount of orbicularis
muscle above and below the opening. The central fat
pad is teased free from surrounding structures bluntly,
so that the superolateral rim of the orbit is in view. The
lacrimal gland is repositioned as described earlier, if need
be. Two 5-0 chromic gut sutures are placed from the
inferior wound edge orbicularis, to the superior orbital
rim periosteum (arcus marginalis), and then the superior
wound edge orbicularis, and tied. The knot secures the
orbicularis to the superior orbital rim and mechanically
elevates and projects the brow fat pad. The central place­
ment of the orbicularis-septum incision is crucial so that
there is equal muscle on both sides of the knot. This
prevents tethering of lid tissue from above and below to
the rim (Fig. 10.18). Although eyelid malposition and
reduced dynamic function of the eyelid are theoretical
risks with this procedure, the authors have not seen this
in isolated brow fat pad suspension. The blepharoplasty
wound is then closed in the standard fashion. Figs. 10.19
and 10.20 demonstrates results of adjunctive brassiere
suture fixation when added to blepharoplasty.
POSTOPERATIVE COURSE, CARE,
AND COMPLICATIONS
As all techniques described, except the external browpexy,
are performed within the blepharoplasty wound, postop­
erative care is the same as for standard blepharoplasty
clinical appearance of the adjacent central fat pad (Fig.
10.16). A 5-0 polypropylene suture on a P-3 needle is
passed through the gland capsule. The suture is then
secured to the anterior tip of the lacrimal gland fossa
perisoteum at the superior orbital rim. When the suture
is tied, the gland is repositioned into the fossa. The eyelid
is then closed in the standard fashion.
Brow Fat Pad Fixation or “Brassiere Suture”
Normal aging is associated with brow fat pad descent,
attenuation, and deflation. These are some of the changes
that underlie loss of structural support to the brow and
accompany brow ptosis. As the eyelid and eyebrow are a
continuous aesthetic unit, and a smooth contour in this
Fat pedicle
Preperiosteal
dissection
Repositioned fat
Orbicularis m.
Figure 10.13  Drawing of nasal fat transposition to the orbitoglabellar
groove showing fat pedicle isolation, creation of a preperiosteal pocket,
and translocation of a fat flap. m., Muscle. (Adapted from Yoo DB,
Peng GL, Massry GG. Effacing the orbitoglabellar groove with trans­
posed upper eyelid fat. Ophthal Plast Reconstr Surg 2013;29(3):220–4.
With permission.)

116
MASTER TECHNIQUES IN FACIAL REJUVENATION
D
E
F
A
B
C
Figure 10.14  Results of nasal fat-transposition surgery. (A and B) before and (D and E) after results of nasal fat repositioning within the eyelid.
(C) Before and (F) after result of nasal fat transposition outside of the eyelid to the orbitoglabellar groove. (From Briceño CA, Zhang-Nunes SX,
Massry GG. Minimally invasive surgical adjuncts to upper blepharoplasty. Facial Plast Surg Clin North Am 2015;23(2):137–51. With permission.)
B
A
Figure 10.15  (A and B) Clinical appearance of lacrimal gland prolapse.
Note temporal eyelid prominence (arrows). (From Briceño CA, Zhang-
Nunes SX, Massry GG. Minimally invasive surgical adjuncts to upper
blepharoplasty. Facial Plast Surg Clin North Am 2015;23(2):137–51.
With permission.)
Figure 10.16  Surgical appearance of a prolapsed lacrimal gland. Note
the gland is paler in color than adjacent preaponeurotic fat. (From
Briceño CA, Zhang-Nunes SX, Massry GG. Minimally invasive surgi­
cal adjuncts to upper blepharoplasty. Facial Plast Surg Clin North Am
2015;23(2):137–51. With permission.)
surgery. Although all adjuncts involve more surgical
dissection/manipulation than isolated blepharoplasty,
postoperative swelling is only minimally increased. A
low-dose steroid taper can always be added in the appro­
priate patient should this be a concern during recovery.
When the external browpexy is added, antibiotic oint­
ment is applied to the sutures (as with the crease inci­
sion in blepharoplasty). These are removed in a week.
Wound modulation with injectable steroid or fluorouracil
is added as deemed appropriate [22]. Rarely, when lac­
rimal gland suspension is added, temporal eyelid/orbital
pain or frank dacryoadenitis can develop. This can also
be managed with injectable and or oral antiinflammatory

10  Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty
117
B
A
Figure 10.17  The original description of brow fat suspension sutures by Zarem et al. [45,46]. (A) Suture engaging superior wound edge orbicu­
laris and arcus marginalis periosteum. (B) Suture tied. Note creation of a barrier for brow fat pad descent. (From Zarem HA. Browpexy. Aesthetic
surgery journal. Jul-Aug 2004;24(4):368–72. With permission.)
A
B
C
D
Figure 10.18  Surgical series of modified “brassiere” brow fat suspension suture technique. (A) Wooden end of cotton tip applicator tenting
orbital septum and orbicularis muscle with centralized muscle incision. (B) Cotton tip over levator aponeurosis, Colorado tip over arcus marginalis
periosteum. (C) 5-0 chromic suture engaging superior and inferior wound edge orbicularis muscle and arcus marginalis periosteum. (D) Suture
tied. (From Briceño CA, Zhang-Nunes SX, Massry GG. Minimally invasive surgical adjuncts to upper blepharoplasty. Facial Plast Surg Clin North
Am 2015;23(2):137–51. With permission.)

118
MASTER TECHNIQUES IN FACIAL REJUVENATION
C
A
D
B
Figure 10.19  (A and B) Frontal view and (C and D) oblique view of a woman who underwent upper blepharoplasty with brow fat suspension
sutures. (A and C) are preoperative photos and (B and D) postoperative photos. Note improvement in brow fullness, more youthful brow/lid transi­
tion, and maintenance of temporal lid fold/crease. (Courtesy of Guy G. Massry, MD.)
C
A
D
B
Figure 10.20  Oblique views of a man (A and B) and woman (C and D) who underwent upper blepharoplasty with brow fat suspension sutures.
(A and C) are before surgery and (B and D) are after surgery. The man (A and B) also had temporal direct brow lift (note absence of scar) and
ptosis repair. As with the patient in Fig. 10.20, note improvement in brow fullness, more youthful row/lid transition, and maintenance of temporal
lid fold/crease. (Courtesy of Guy G. Massry, MD.)

10  Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty
119
R E F E R E N C E S
4. Kulbersh JS, Massry GG. Azizzadeh B. Periorbital aesthetic
surgery: the evolution of a multidisciplinary surgical subspecialty.
In: Massry GG, Murphy MR, Azizzadeh B, editors. Master tech­
niques in blepharoplasty and periorbital rejuvenation. New York:
Springer; 2011. p. 3–11.
6. Siegel RJ. Essential anatomy for contemporary upper lid blepharo­
plasty. Clin Plast Surg 1993;20(2):209–12.
8. Lambros VS The dynamics of facial aging. Annual Meeting of the
American Society for Aesthetic Plastic Surgery; 2002; Las Vegas,
NV, USA.
11. Georgescu D, Anderson RL, McCann JD. Brow ptosis correc­
tion: a comparison of five techniques. Facial Plast Surg: FPS
2010;26(3):186–92.
16. Nassif PS. Lower blepharoplasty: transconjunctival fat reposition­
ing. Facial Plast Surg Clin North Am 2005;13(4):553–9, vi.
18. Massry GG. Nasal fat preservation in upper eyelid blepharoplasty.
Ophthal Plast Reconstr Surg 2011;27(5):352–5.
21. Yoo DB, Peng GL, Massry GG. Effacing the orbitoglabellar groove
with transposed upper eyelid fat. Opthal Plast Reconstr Surg
2013;29(3):220–4.
25. Fitzgerald R. Contemporary concepts in brow and eyelid aging.
Clin Plast Surg 2013;40(1):21–42.
34. Tyers AG. Brow lift via the direct and trans-blepharoplasty
approaches. Orbit 2006;25(4):261–5.
38. Massry GG, Azizzadeh B. Periorbital fat grafting. Facial Plast Surg:
FPS 2013;29(1):46–57.
preparations. If clinical signs of infection are present, oral
antibiotic treatment is mandated. It is normal for the tem­
poral crease incision to heal/mature slower when brow
fat suspension sutures are added. This typically involves
a somewhat puckered appearance with prolonged redness
to the wound. In general, by 1 month after surgery this
becomes unnoticeable to the patient. Should this persist,
a local injection of steroid or 5-fluorouracil can be added
at the surgeon’s discretion.
CONCLUSION
Refinements to upper blepharoplasty continue to emerge.
This chapter reviews various minimally invasive surgical
manipulations of the brow and upper eyelid, which can
be routinely added to upper blepharoplasty to poten­
tially enhance surgical results. Each procedure is quick,
straightforward, and generally complication-free with a
utility that is surgeon dependent and based on individual
preference and experience.
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rejuvenation. New York, NY: Springer; 2011. p. 25–31.
25. Fitzgerald R. Contemporary concepts in brow and eyelid aging.
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26. Yu KCY, Nettar KD, Mass CS. Neuromodulators and fillers for
periorbital rejuvenation. In: Massry GG, Murphy MR, Azizzadeh
B, editors. Master techniques in blepharoplasty and periorbital
rejuvenation. New York, NY: Springer; 2011. p. 289–97.
27. Putterman AM, Urist MJ. Surgical anatomy of the orbital septum.
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28. Seiff SR, Seiff BD. Anatomy of the Asian eyelid. Facial Plast Surg
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29. Hartstein M. Levator Ptosis surgery in the aesthetic patient with or
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301.
31. Cohen BD, Reiffel AJ, Spinelli HM. Browpexy through the upper
lid (BUL): a new technique of lifting the brow with a standard
blepharoplasty incision. Aesthetic Surg J 2011;31(2):163–9.
32. Georgescu D, Belsare G, McCann JD, Anderson RL. Adjunctive
procedures in upper eyelid blepharoplasty: internal brow fat sculpt­
ing and elevation, glabellar myectomy, and lacrimal gland reposi­
tioning. In: Massry GG, Murphy MR, Azizzadeh B, editors. Master
techniques in blepharoplasty and periorbital rejuvenation. New
York, NY: Springer; 2011. p. 101–8.
33. Niechajev I. Transpalpebral browpexy. Plast Reconstr Surg
2004;113(7):2172–80, discussion 2181.
34. Tyers AG. Brow lift via the direct and trans-blepharoplasty
approaches. Orbit 2006;25(4):261–5.
35. Georgescu D, Anderson RL, McCann JD. Brow ptosis correc­
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36. Mokhtarzadeh A, Harrison A, Massry G Quantitative efficacy of
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38. Massry GG, Azizzadeh B. Periorbital fat grafting. Facial Plast Surg:
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39. Czyz C, Lam VB, Foster JA. Management of complications of
upper eyelid blepharoplasty. In: Massry GG, Murphy MR, Azizza­
deh B, editors. Master techniques in blepharoplasty and periorbital
rejuvenation. New York, NY: Springer; 2011. p. 109–23.
40. Morley AM, Taban M, Malhotra R, Goldberg RA. Use of hyal­
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41. Beer GM, Kompatscher P. A new technique for the treatment of
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42. Massry GG. Prevalence of lacrimal gland prolapse in the func­
tional blepharoplasty population. Opthal Plast Reconstr Surg
2011;27(6):410–13.
43. Smith B, Lisman RD. Dacryoadenopexy as a recognized factor in
upper lid blepharoplasty. Plast Reconstr Surg 1983;71(5):629–32.
44. Smith B, Petrelli R. Surgical repair of prolapsed lacrimal glands.
Arch Ophthalmology. 1978;96(1):113–14.
45. Zarem HA, Resnick JI, Carr RM, Wootton DG. Browpexy: lateral
orbicularis muscle fixation as an adjunct to upper blepharoplasty.
Plast Reconstr Surg 1997;100(5):1258–61.
46. Zarem HA. Browpexy. Aesthetic Surg J. 2004;24(4):368–72.
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3. Castanares S. Blepharoplasty for herniated intraorbital fat: ana­
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4. Kulbersh JS, Massry GG, Azizzadeh B. Periorbital aesthetic
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5. Flowers RS. Upper blepharoplasty by eyelid invagination. Anchor
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6. Siegel RJ. Essential anatomy for contemporary upper lid blepharo­
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7. Siegel RJ. Contemporary upper lid blepharoplasty—tissue invagi­
nation. Clin Plast Surg 1993;20(2):239–44, discussion 245.
8. Lambros VS The dynamics of facial aging. Annual Meeting of the
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NV, USA.
9. Donath AS, Glasgold RA, Glasgold MJ. Volume loss versus gravity:
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11. Georgescu D, Anderson RL, McCann JD. Brow ptosis correc­
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12. McCord CD, Doxanas MT. Browplasty and browpexy: an adjunct
to blepharoplasty. Plast Reconstr Surg 1990;86(2):248–54.
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2012;28(2):90–5.
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120
HISTORY
The evolution of ptosis surgery can be studied and cat­
egorized from an anatomical point of view. These catego­
ries include skin excision, frontalis suspension, resection
of tarsus and/or Müller’s muscle, and levator resection.
Each technique has undergone periods of transformation,
falling in and out of favor over time [1].
The origin of ptosis surgery focusing on advancing the
levator muscle complex is credited to Bowman in 1857
when he described resection of the levator aponeurosis
and a portion of the tarsus via an internal incision [2].
The first to target the levator from an external incision
was Everbusch in 1883 [3]. Over the course of the fol­
lowing 75 years both the internal and external approach
to levator and tarsal resection underwent refinement, but
fell out of favor because of unpredictable results. It was
not until the 1960s that new concepts in ptosis surgery
surfaced. In 1961 Fasanella and Servat described the
combined conjunctival-tarsal-Müller’s muscle resection,
known as the Fasanella-Servat procedure [4]. It was more
predictable and reproducible than previous such tissue
resections, making it a popular choice among surgeons.
Putterman and Urist modified the Fasanella-Servat pro­
cedure by resecting only conjunctiva and Müller’s muscle
and leaving the tarsus intact. This procedure, published
in 1975, has become a standard among ptosis surgeons
[5,6]. Improvements in the levator-based approach to
ptosis surgery also developed during this era. Although
initially described and performed in the 1800s, it was
not until the published works of pioneers such as Beard,
Jones, Fox, and Anderson that levator-based surgery
came to the forefront [7–9].
PERSONAL PHILOSOPHY
The numerous descriptions of ptosis surgery over the
years speak to the challenging nature of the procedure.
With experience, the technical aspects of ptosis repair
have become less cumbersome; however, the difficulty
in attaining consistent and predictably symmetric height
and contour of the eyelid continues. The nuances of ana­
tomical variability, differences in levator function (LF),
and asymmetrical involutional changes all prevent the
surgeon from applying a universal method for correcting
all clinical presentations of ptosis.
There are four general surgical approaches that elevate
the eyelid margin. Firstly, standard blepharoplasty, in
the setting of skin overhanging the eyelid margin (der­
matochalasis), may result in an improved lid position by
alleviating mechanical ptosis. The remaining three proce­
dures are true ptosis corrections, two of which are com­
monly used in conjunction with aesthetic blepharoplasty.
These include external levator advancement (ELA) and a
posterior approach, Müller’s muscle conjunctival resec­
tion (MMCR). In ELA the levator aponeurosis/muscle is
isolated and advanced through an external eyelid crease
incision to elevate the upper eyelid margin. This tech­
nique is used for variable degrees of ptosis with adequate
levator muscle function. The procedure requires patient
cooperation to set and adjust eyelid height and contour,
and sometimes requires adjustment of the aponeurotic
position in the early postoperative period. Conversely, in
the MMCR procedure, Müller’s muscle is resected and
advanced from an internal (transconjunctival) approach.
This technique works well for small amounts of ptosis
with good LF and is particularly helpful if avoidance
of an eyelid crease incision is desired (such as in unilat­
eral ptosis repair). As opposed to ELA surgery, patient
cooperation is not needed, and the predictability of the
postoperative eyelid height and maintenance of existing
eyelid contour are both easier to achieve. This approach
is less technically demanding than the ELA procedure,
but is limited by the degree of ptosis that can be cor­
rected, typically 2 mm or less.
A final approach to ptosis correction involves linking
the eyelid proper to the frontalis muscle via a variety of
autologous or alloplastic materials (frontalis suspension
procedure). This technique is used in cases of ptosis asso­
ciated with poor LF. As the procedure is rarely employed
in conjunction with aesthetic blepharoplasty, it will not
be covered in this chapter.
It is not unusual for a patient to present with both
dermatochalasis and true eyelid ptosis (Fig. 11.2). Per­
forming isolated blepharoplasty in this situation may lead
to unhappy patients. For this reason it is incumbent upon
the aesthetic eyelid surgeon to master the procedures
needed to address these combined eyelid deficits or work
closely with an oculofacial plastic surgeon who can assist
with such cases. In this chapter the critical elements of
evaluation and surgery needed to address patients with
ptosis who desire blepharoplasty will be reviewed.
ANATOMY
The upper eyelid margin normally sits 4 mm above the
central corneal light reflex and peaks just nasal to the
center of the pupil. The eyelid crease is the natural inden­
tation of upper eyelid skin that results from levator apo­
neurotic attachments to the dermis. This is best seen
C H A P T E R 11 
Ptosis Repair and Blepharoplasty
Daniel Straka, MD and Jill Foster, MD

11  Ptosis Repair and Blepharoplasty
121
(oculomotor) cranial nerve, and is composed of a mus­
cular and tendinous (aponeurotic) portion. The muscular
portion originates in the orbital apex from the lesser
wing of the sphenoid bone. It is approximately 40 mm
in length. It courses directly above the superior rectus
muscle and transitions to aponeurosis 15 to 20 mm supe­
rior to the tarsal plate near a horizontal condensation of
connective tissue, visible as a distinct white band called
the superior transverse orbital ligament, or Whitnall’s
ligament (Fig. 11.3). This ligament has strong attach­
ments at the medial and lateral orbital bones. The levator
muscle complex redirects from a horizontal to vertical
direction as it reaches Whitnall’s ligament, and continues
as the aponeurosis for 14 to 20 mm until it attaches on
the anterior tarsal surface. It is thought that Whitnall’s
ligament acts as a pulley to reorient the force generated
by the levator muscle from horizontal to vertical.
Beyond Whitnall’s ligament, the levator aponeurosis
fans out to form both medial and lateral horns, the latter
of which is better defined. The lateral horn separates
the orbital and palpebral lobes of the lacrimal gland
and inserts on the lateral orbit at Whitnall’s tubercle.
Some of its fibers contribute to the lateral canthal tendon.
The medial horn has loose attachments to the medial
canthal tendon as well as the posterior lacrimal crest (see
Fig. 11.3).
As discussed in the chapter on upper lid blepharoplasty
(Chapter 10), the levator aponeurosis lies immediately
deep to the preaponeurotic (central) eyelid fat pad and
fuses with the orbital septum prior to inserting on the
anterior aspect of the tarsal plate and pretarsal fascia. It
attaches most firmly to the tarsal plate about 3 mm above
the eyelid margin. Proximal to its tarsal attachments,
the aponeurosis sends numerous small fibers anteriorly
through the orbicularis and subcutaneous tissue to the
skin. These fibrous attachments form the natural eyelid
crease.
Müller’s Muscle
Müller’s muscle, a secondary upper eyelid retractor, is
smaller than the levator muscle but plays an important
role in the upper eyelid position. The muscle is sympa­
thetically innervated, and interruption of this autonomic
function results in ipsilateral ptosis (Horner’s syndrome).
Müller’s muscle originates from the underside of the
Figure 11.1  The external eyelid landmarks and preoperative measure­
ments obtained in patients considering ptosis repair and blepharoplasty.
The white line indicates the margin reflex distance 1 (MRD1), the red
line indicates the margin reflex distance 2 (MRD2), and the blue line
indicates the vertical palpebral fissure. The yellow line indicates the
margin fold distance (MFD), a measurement that represents the pret­
arsal lid platform.
A
B
Figure 11.2  (A) Patient with marked bilateral upper lid ptosis with minimal redundant upper lid skin who would benefit from isolated ptosis
repair. (B) Patient with significant bilateral upper lid ptosis and dermatochalasis who will likely require a blepharoplasty in addition to ptosis repair.
when the patient looks downward. The crease typically
lies 7 to 10 mm above the lid margin and tapers nasally
and temporally to the respective canthi. When aponeu­
rotic ptosis is present the crease often lies higher than this
level. The lid fold (if present) is the overhang of skin that
can obscure the crease. The strip of pretarsal skin that
sits between the eyelid margin and the lid fold is called
the tarsal platform (Fig. 11.1). Symmetry of the tarsal
platform is an important aesthetic goal in blepharoplasty/
ptosis surgery. In addition to overhanging upper eyelid
skin, changes in eyebrow and upper eyelid position can
alter the eyelid crease and fold, with resultant changes
in tarsal platform show. As an example, the patient with
asymmetrical eyebrow position may have less tarsal plat­
form show on the side of the more ptotic eyebrow, even
if all other features of the eyelids are identical.
Levator Muscle
The levator palpebrae superioris is the main retrac­
tor of the upper eyelid. It is innervated by the third

122
MASTER TECHNIQUES IN FACIAL REJUVENATION
it means that the aponeurosis is either thinned, dehiscent,
or that it has been surgically elevated.
Tarsal Plate
The upper tarsal plate, a rigid structure comprised of
dense fibrous connective tissue, provides support and a
uniform contour to the upper eyelid. As stated, it serves
as a point of attachment for the eyelid retractors. Its
thickness varies, but on average is 1 mm. The central
vertical height is 10 to 12 mm and then gradually tapers
to 2 to 3 mm medially and laterally as it reaches the
canthal tendons [10]. There is no tarsal plate medial to
the punctum. The Meibomian glands, holocrine glands
that secrete the lipid portion of the tear film, originate
within the tarsus, and their small openings can be seen at
the posterior aspect of the lid margin. Loss of the tarsal
tissue or loss of tarsal rigidity makes ptosis repair more
challenging.
PREOPERATIVE EVALUATION
Patient Selection
A complete history and focused physical examination is
essential when evaluating patients with ptosis and der­
matochalasis. Some patients will state specific goals for
how they want their eyelids to appear, whereas others will
simply want their eyes “lifted.” It is up to the surgeon
to interpret the patient’s desires and then to determine
what is in the patient’s best interest. The authors have
found that having a mirror and drawing pad available to
show the patient the features of the eyelid that are being
discussed, and how surgery will address the issues, is a
useful tool to provide clarity to any surgical evaluation
and discussion.
History
A general medical, surgical, and ocular history is identi­
fied. The discontinuation of any medications, prescrip­
tion or herbal, which predispose to bleeding must be
discussed with the patient and their primary care physi­
cian or cardiologist. A history of previous blepharoplasty
or ptosis repair should be sought, as this may influence
the surgical plan. Multiple prior failed attempts at ptosis
repair suggest a more complicated procedure and referral
may be warranted. A history of dry eye or frequent use
of topical lubricants is important. Worsening or inducing
dry eye syndrome is a significant concern of blepharo­
plasty and ptosis surgery. Appropriate preoperative edu­
cation regarding this risk is essential.
The vast majority of patients with ptosis and derma­
tochalasis seeking surgical intervention will give a vague
history of a gradually worsening appearance and droop­
ing of the eyelids, and/or an awareness of blockage of
peripheral vision by the overhanging eyelid. This gener­
ally suggests an involutional etiology. Some patients will
have a history of contact lens use. In this instance oph­
thalmic care may be needed prior to surgical intervention.
On rare occasions a neurological cause of ptosis may
be present (i.e., Horner’s syndrome, third nerve paresis,
myasthenia gravis). A discussion of such entities is beyond
the scope of this chapter, but a basic understanding of
levator muscle just distal to Whitnall’s ligament and
inserts on the superior edge of the tarsal plate (8–12 mm
distance) [10]. The contraction of Müller’s muscle (epi­
nephrine dependent) elevates the eyelid margin, but it
may also contribute to eyelid position by transmitting the
force of the levator complex to the superior tarsus (Fig.
11.4). Just deep to Müller’s muscle is the conjunctiva. Fre­
quently, the peripheral arterial arcade can be seen running
horizontally on the anterior surface of Müller’s muscle.
This is an important landmark in ELA ptosis surgery to
help define the plane between the levator aponeurosis and
Müller’s muscle. When the surgeon sees the arcade vessel,
Superior transverse
ligament
Levator aponeurosis
Capsulopalpebral
fascia
Tarsus
Figure 11.3  The levator muscle aponeurosis can be seen coursing
down from the superior transverse ligament of Whitnall (Whitnall’s
ligament) to insert on the anterior surface of the tarsal plate.
Orbital septum
Orbicularis m.
Levator aponeurosis
Müller's m.
Tarsus
Tarsus
Capsulopalpebral
fascia
Septum
Figure 11.4  A sagittal section through the anterior orbit and eyelids.
Müller’s muscle can be seen originating from the underside of the
levator muscle distal to Whitnall’s ligament to insert onto the superior
border of the tarsal plate. m, Muscle.

11  Ptosis Repair and Blepharoplasty
123
who is not an eyelid specialist, when LF is at this level it
is best to refer the patient for further evaluation of the
cause of ptosis. Often these patients have a congenital
ptosis or an acquired neuromyopathic etiology of their lid
malposition. In this setting, frontalis suspension surgery
(not discussed) may be appropriate (Fig. 11.6). Patients
with LF greater than 10 mm have an excellent chance
of responding appropriately to either ELA or MMCR
surgery. Most adult patients presenting with ptosis fall
into this category and have what is classified as “invo­
lutional” ptosis. These patients typically have excellent
LF and no lagophthalmos. The term involutional can
be a misnomer, as patients who are not elderly may also
present this way
Cases of unilateral or asymmetric ptosis deserve
special attention because of a neurological phenomenon
known as Hering’s law of equal innervation. In sim­
plistic terms, this states that yoked extraocular muscles
(which include the levator muscles) receive equal degrees
of innervation. Therefore when one eyelid is ptotic, there
is an impulse sent to it and also to the opposite eyelid
to elevate (retract). When the ptotic lid comes up, the
drive may diminish and the opposite lid can drop. This
typically happens when the ptosis occurs in the dominant
eye. This can be assessed by manually raising the ptotic
eyelid, covering the ptotic eye with an occluder, or by
instilling 2.5% phenylephrine (PE) drops into the ptotic
lid (this may stimulate lid elevation) (Fig. 11.7). Coun­
seling the patient in regards to this potential outcome
of ptosis repair is valuable so that the patient is not
alarmed by the lower postoperative position of the
unoperated eyelid.
Finally, a thorough ocular examination should include
assessment of the pupils and ocular motility (abnormal
findings may be associated with neuromyopathic forms
of ptosis), the presence of a Bell’s response, orbicularis
strength, and dry eye syndrome. Severe dry eyes may be
noted by history, Schirmer testing, or slit lamp examina­
tion, and the condition is a relative contraindication for
ptosis repair. At a minimum it necessitates referral to a
specialist. Any patient with a history of inflammatory
or autoimmune disease, with or without dry eye symp­
toms, should be assessed for dry eye syndrome prior to
intervention.
these conditions should be sought by the aesthetic eyelid
surgeon who performs ptosis surgery.
Examination
Working from the top to the bottom, the examination
begins by assessing the position of the brow. The inter­
play of brow and eyelid position, and eyelid fullness,
is a complex and constantly evolving subject. Aesthetic
eyelid surgeons should familiarize themselves with this
literature. Any procedure that elevates the eyelid, true
or apparent, can reduce frontalis compensatory drive,
and thereby lower the brow. Thus in the presence of
ptosis or dermatochalasis, latent eyebrow ptosis may be
present but not manifest until after surgery. The preop­
erative assessment then moves to the eyelids. The degree
of upper eyelid skin redundancy, the presence and loca­
tion of orbital fat prolapse, and upper eyelid sulcus is
then assessed. Next, the position of the eyelid margin in
relation to the central corneal light reflex is evaluated.
This measurement is known as the margin reflex distance
1 (MRD1). It bears repeating that patients presenting for
droopy eyelid skin may not realize they have concomitant
ptosis. When deemed clinically appropriate, the surgeon
will manually elevate the eyelid skin to get an adequate
view of the eyelid margin. As previously discussed, a
normal MRD1 varies from person to person, but on
average is 4 mm. The margin reflex distance 2 (MRD2)
is the measurement from the central corneal light reflex
to the lower eyelid margin. A normal MRD2 is about
5 mm (Fig. 11.1). An abnormally large MRD2 indicates
possible lower lid retraction. When lower eyelid retrac­
tion is present, performing blepharoplasty or ptosis repair
may exacerbate corneal exposure.
The most critical factor in planning ptosis repair
surgery is quantifying lid excursion (LF). To measure this,
the patient looks down while the examiner applies pres­
sure to the patient’s eyebrow with their thumb to restrict
the action of the frontalis muscle. The patient then looks
up and the amount of LF is measured in millimeters (mm)
with a ruler. A normal LF is greater than 10 mm, an
intermediate level falls between 6 and 10 mm, and poor
LF is 6 mm or less (Fig. 11.5). With poor LF (<6 mm)
the likelihood of successful ptosis repair with either an
ELA or MMCR is poor. As a general rule, for the surgeon
A
B
C
Figure 11.5  Measuring the levator function is an essential step when evaluating a patient with ptosis (A). A ruler is used to measure the amount
of eyelid excursion in millimeters from downgaze (B) to upgaze (C) without recruitment of the frontalis muscle. The frontalis muscle can be negated
by digital pressure (C).

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MASTER TECHNIQUES IN FACIAL REJUVENATION
into the subcutaneous plane in the central eyelid. This
provides sufficient anesthesia for most cases. A higher
volume of local anesthetic can facilitate undesired diffu­
sion of epinephrine into Müller’s muscle, or lidocaine into
the orbicularis or levator muscle. All these factors may
adversely affect judgment of final lid position. A scalpel
is used to incise the demarcated eyelid crease in one
continuous, smooth pass. To allow intraoperative adjust­
ments, the decision on the final location of the upper
aspect of the blepharoplasty incision is typically post­
poned until after ptosis repair and fat modification are
complete. The orbicularis muscle is divided (Fig. 11.8A).
The surgical assistant can provide downward traction
with a double-pronged skin hook or forceps to aid in this
dissection (Fig. 11.8B). The orbital septum is then incised
and the preaponeurotic fat pad is exposed (Fig. 11.8C).
The fat serves as a consistent landmark when locating
the levator aponeurosis (always anterior to the levator
complex). Downward traction is placed on the levator
aponeurosis to reveal a natural plane between the apo­
neurosis and the fat. To help confirm the location of the
aponeurosis, the surgeon will ask the patient to look up
and down and observe movement. Once the aponeurosis
is isolated, it is dissected free from its distal attachment
to the tarsal plate. This is simplified by grasping the sub­
cutaneous tissue and orbicularis muscle along the lower
incision border and incising at a 45- to 60-degree angle
on the anterior surface of the tarsal plate (Fig. 11.8D).
As stated, because the techniques most likely to
be of benefit in aesthetic blepharoplasty are either ELA
or MMCR surgery, these procedures will be discussed
in detail.
EXTERNAL LEVATOR ADVANCEMENT
The ELA is a versatile procedure useful for the full spec­
trum of ptosis in the patient with normal or moderate LF.
The surgery is performed under local anesthesia or with
minimal sedation, as patient cooperation is required to
attain the best result. The eyelid crease incision is marked
preoperatively at its native position. This is best visual­
ized by having the patient sit upright and open and close
their eyes. The natural lid crease falls between 8 and
10 mm from the lid margin in women, and 7 to 9 mm
in men. In cases of levator aponeurotic dehiscence (invo­
lutional ptosis), the natural lid crease is less distinct or
displaced superiorly. Prior to marking the crease, calipers
are used to measure the incision height on each eyelid to
ensure symmetry. When combined with blepharoplasty,
the ellipse of skin for excision is also marked prior to
surgery. In general, 20 mm of upper lid skin (brow to lid
margin) is left behind to reduce the risk of postoperative
lagophthalmos.
One cubic centimeter (cc) of 2% lidocaine with epi­
nephrine 1 : 100,000, mixed equally with 0.75 bupiva­
caine and 10 to 15 units of hyaluronidase, is injected
A
B
Figure 11.7  A patient with unilateral ptosis before (A) and after (B) testing with 1 drop of phenylephrine ophthalmic solution 2.5% in the more
ptotic right eye. Note the exaggerated response to phenylephrine. There is no discernible Hering’s response in the contralateral eyelid. A 7-mm
resection was planned for her.
A
B
Figure 11.6  Preoperative (A) and postoperative (B) views of a patient with myotonic dystrophy and severe ptosis with poor levator function who
underwent frontalis suspension bilaterally.

11  Ptosis Repair and Blepharoplasty
125
F
D
B
E
C
G
A
Figure 11.8  (A–G) The surgical steps in levator advancement. After a
skin incision is made, the orbicularis is incised to reveal the underlying
orbital septum-levator aponeurosis complex (A). The inferior border of
the septum-levator aponeurosis complex is grasped, revealing a safe plane
of dissection to avoid damaging the levator aponeurosis (B). Once the
septum has been incised, the underlying preaponeurotic fat is visible on
the anterior surface of the levator muscle (C). The levator aponeurosis is
disinserted from the anterior aspect of the tarsal plate, revealing the firm,
white surface of the tarsus. Note the peripheral arterial arcade superior to
the tarsus on top of Müller’s muscle (D). A 6-0 Prolene suture is passed in
a horizontal mattress fashion through the anterior surface of the levator
aponeurosis (E). The suture is then passed partial thickness through the
tarsal plate while lifting the lid away from the globe (F). Finally, the suture
is passed back through the posterior surface of the aponeurosis and tied
down with a slip knot to check the height and contour of the lid (G).

126
MASTER TECHNIQUES IN FACIAL REJUVENATION
is excised or repositioned, other ancillary blepharoplasty
modifications of the eyelid area are made, and skin is
excised (as per surgeon judgment) and the incision closed.
There are many advantages to levator aponeurotic
ptosis surgery. The procedure has the greatest amount of
flexibility to address some of the more challenging cases of
ptosis, and it is the procedure of choice for cases of more
significant ptosis in the setting of normal LF. Also, the
surgeon has greater control over lid height and contour
during the operation, as this can be customized based
on aponeurotic resection/advancement. Finally, levator
repositioning may be added and performed through the
blepharoplasty incision. The main drawback with this
procedure is the inability of the surgeon to consistently
predict the height and contour of the eyelid based on
measurements or intraoperative findings. Obtaining
perfect symmetry, height, and contour for every case is a
challenging goal. For this reason, proper patient educa­
tion and counseling is paramount (Fig. 11.9).
MÜLLER’S MUSCLE CONJUNCTIVAL RESECTION
The Müllerectomy, also known as MMCR, is best suited
for patients with mild (≤2 mm) ptosis, good LF, and a
preoperative normal contour of the eyelid. The surgery
requires no external skin incisions, and with small
amounts of ptosis has relatively predictable outcomes.
A blepharoplasty can be performed concurrently, but
requires the additional step of skin incision. The combi­
nation of a bilateral Müllerectomy and upper lid blepha­
roplasty is an excellent option for cosmetic patients with
A
C
B
D
Figure 11.9  Before (A) and after (B) bilateral upper lid external levator advancement with blepharoplasty, and without blepharoplasty (C and D).
By disinserting the muscle here, the surgeon avoids incis­
ing Müller’s muscle and exposes the raw surface of tarsus
to facilitate resecuring the aponeurosis.
Depending on the degree of ptosis, the aponeurosis is
then advanced (with or without a graded resection based
on clinical experience) to the tarsus. A single horizontal
mattress suture (6-0 Prolene on a spatula needle) secures
the aponeurosis to the tarsus. The tarsal bite is placed just
nasal to the center of the eyelid margin, a point analogous
to the highest point of the lid arc. Additional sutures
may be passed to adjust height and contour as needed
(Fig. 11.8E). A spatula needle is used as it facilitates
partial-thickness bites through the anterior surface of the
tarsal plate. Prior to passing the suture, the eyelid should
be gently lifted away from the globe to protect against
inadvertent injury to the cornea (Fig. 11.8F). The eyelid is
everted to ensure that the suture has not been passed full
thickness, which would cause corneal irritation/abrasion.
After securing the tarsus, the suture is then passed back
up through the aponeurosis and tied down with a tempo­
rary slip knot (Fig. 11.8G). The patient is asked to open
their eyes and lid height and contour are assessed. In a
bilateral case, the same procedure is then performed on
the opposite eyelid. When both eyelids are temporarily
secured with the tarsal sutures, lid position is evaluated.
It is sometimes helpful to have the patient sit upright, as
the eyelids can appear different when supine. If needed,
adjustments in the sutures can be made at this time.
When the surgeon is satisfied with the height and contour
of the eyelids, the sutures are tied down permanently.
When blepharoplasty is also performed, orbital/eyelid fat

11  Ptosis Repair and Blepharoplasty
127
because the surgery is performed based on a predeter­
mined tissue-excision algorithm, rather than patient
cooperation. After the supraorbital block, 1 cc of local
anesthetic is injected transconjunctivally just above the
superior border of the tarsal plate by everting the upper
eyelid. When performed in conjunction with blepharo­
plasty, an additional 1 cc of local anesthetic is injected
subcutaneously into the central eyelid. The excision of
skin with or without fat sculpting or repositioning is
typically performed after the ptosis repair.
A 4-0 silk traction suture is placed through the central
upper lid near the margin and then the eyelid is flipped
over a Desmarres retractor, revealing the underlying
tarsus and conjunctiva (Fig. 11.10A). Additional local
anesthetic can be injected into the conjunctiva to balloon
up the tissue. The predetermined amount of conjunctiva
and Müller’s muscle to be resected is then measured by
placing calipers at the superior border of the tarsal plate
and marking the distance on the conjunctiva with small
bursts of monopolar cautery (Fig. 11.10B). A Putterman
ptosis clamp is used to grasp the conjunctiva and under­
lying Müller’s muscle using the superior border of tarsus
and cautery marks as one’s guide (Fig. 11.10C). The
tissue is then sutured from side to side with double-armed
6.0 mild chromic gut in a running mattress fashion under­
neath the clamp. The tissue within the clamp is removed
by cutting above the suture on the edge of the clamp with
mild ptosis and dermatochalasis. This is especially true
for the surgeon who is not an eyelid specialist, as the pro­
cedure is less technically challenging than ELA surgery,
and it requires no patient cooperation (patients can be
sedated or under general anesthesia)
Preoperative testing with 2.5% PE ophthalmic drops
facilitates the evaluation. Generally speaking, if eyelid
height is equal after PE testing, an 8-mm resection of con­
junctiva and Müller’s muscle is performed. This number is
adjusted higher or lower according to response to drops.
The drop test also helps show the patient how the eyelid
raises so that he/she knows what to expect postopera­
tively. The PE test can also unmask contralateral ptosis
(Hering’s law, as discussed earlier), which may dictate an
asymmetric bilateral repair.
If the patient is awake or sedated, a regional supra­
orbital nerve block is given (1 cc injection of the previ­
ously described anesthetic mixture). If blepharoplasty is
being performed at the same time, the measurements and
markings of the upper lid should be performed prior to
injecting local anesthetic. This ensures the most precise
execution of the blepharoplasty. As in levator surgery,
the local anesthetic is 2% lidocaine with epinephrine
1 : 100,000 mixed equally with 0.75% bupivacaine and
10 to 15 units of hyaluronidase. As opposed to levator
surgery, the effect of the local anesthetic on the muscles
of eyelid retraction or protraction is of less significance
A
B
C
D
E
F
Figure 11.10  Operative steps in a conjunctival Müller’s muscle resection. The upper eyelid is everted over a Desmarres retractor with the aid of a
4-0 silk traction suture (A). Calipers are used to measure the desired amount of resection and marked with electrocautery (B). A Putterman clamp
is used to grasp the tissue to be resected below the inferior edge of the tarsus to the marked conjunctiva (C). One arm of a double-armed 6-0 mild
chromic gut suture is then passed back and forth through the conjunctiva and Müller’s muscle 1 to 2 mm below the clamp (D). A No. 15 blade
is then used to resect the tissue, making sure to avoid the suture (E). The second arm of the suture is then passed in a similar manner to the first
arm to reapproximate the cut conjunctival and Müller’s muscle edges. The knot is tied underneath the conjunctiva to avoid postoperative irritation.
Alternatively, Tisseel fibrin glue can be used to reapproximate the edges if the surgeon prefers to avoid a suture (F).

128
MASTER TECHNIQUES IN FACIAL REJUVENATION
(≤2 mm) degrees of ptosis in situations where the surgeon
wishes to avoid an external incision. MMCR may be
successfully performed with blepharoplasty when small
degrees of ptosis repair will be sufficient (Fig. 11.11).
POSTOPERATIVE CARE
Postoperatively, patients are instructed to apply a com­
bination ophthalmic steroid/antibiotic ointment to the
sutures twice a day until follow-up. In posterior approach
surgery (MMCR), the ointment can be placed in the eye.
For either type of ptosis repair, “as needed” lubrication is
advised for comfort. In addition, ice or cool compresses
are applied every hour while awake for 15 to 20 minutes
for the first 48 hours to reduce edema. Patients are also
asked to keep the head slightly elevated during sleep for
the first week after surgery, and activity is restricted during
this time to reduce the risk of post­operative hemorrhage.
This includes bending, stooping, or lifting. Normal daily
activities can generally be resumed without risk of bleed­
ing. Finally, patients are advised to call for pain, vision
change, bleeding, or unusual eyelid shape or position.
The normal first follow-up is 1 week after surgery.
COMPLICATIONS
Asymmetry
In the early postoperative period, some degree of asym­
metry can be related to swelling. In this instance close
follow-up until swelling has diminished should continue
a No. 15 blade Bard Parker. The second arm of the suture
is then sewn in a running fashion to reapproximate the
cut edges of conjunctiva (Fig. 11.10D and E). When the
end of the resection is reached, both ends of the suture
are tied in a square knot with the tails trimmed short and
buried beneath the edges of the conjunctiva. This is the
traditional suturing technique described by Putterman.
Some surgeons prefer to initiate and complete the sutur­
ing externally through the upper eyelid so that the knot
is tied on the surface of the skin, away from the globe. A
pull-out suture of 6-0 nylon can be used in this fashion.
The surgeon can also use the fibrin sealant (Tisseel,
Baxter, Deerfield, USA) in lieu of sutures to close the
posterior incision. Although the cost is higher, the effi­
cacy is comparable and the risk of postoperative corneal
irritation is less [11]. In these cases, instead of passing a
suture, the tissue is secured with locking 0.5 forceps on
either end of the Putterman clamp and similarly resected.
The locking 0.5 forceps are left in place to align the tissue
and then the cut ends of conjunctiva and Müller’s muscle
are temporarily reapproximated using three small curved
hemostats. Tisseel is then applied to the edges of the
wound and allowed to sit for 2 minutes (Fig. 11.10F).
Excess sealant is excised with Wescott scissors, the eyelid
is flipped to its natural position, the 4-0 silk retraction
suture is removed, and the operation is complete.
The conjunctival Müller’s muscle resection is appealing
because of its reproducibility, predictability, and relatively
lower rate of reoperation compared with levator surgery.
It is the procedure of choice for the patient with mild
A
B
C
D
Figure 11.11  Preoperative (A) and postoperative (B) conjunctival-Müller’s muscle resection without blepharoplasty. Preoperative (C) and post­
operative (D) conjunctival Müllerectomy with blepharoplasty.

11  Ptosis Repair and Blepharoplasty
129
In such instances patients should be started on empiric
oral antibiotic therapy to cover the common gram-positive
organisms (skin/lash flora). In patients with a history of
colonization with methicillin-resistant Staphylococcus
aureus or those with suspected infection, coverage for
methicillin-resistant S. aureus should be initiated. If an
abscess forms, incision and drainage is warranted. In the
authors’ experience, most cases of suspected postopera­
tive infection will respond to outpatient oral antibiotic
therapy.
Incision-Related Complications
Patients are only aware of what they see regardless of how
nicely lid height, contour, and tissue excision improved
their overall appearance. For this reason, meticulous
wound closure, with special attention to avoiding dog
ears laterally and webs medially, should be emphasized.
Using inert, monofilament sutures (such as Prolene or
nylon) with timely removal at 5 to 7 days may limit post­
operative inflammation and improve the final appearance
of the incision. It is not unusual to develop an elevation
or thickening to the crease incision in the first 4 to 8
weeks after surgery. In this instance, a variety of over-the-
counter topical “scar creams,” a topical cortisone prepa­
ration, or injectable wound modulators such as cortisone
or fluorouracil, may be of benefit. This is at the discretion
of the surgeon depending on clinical experience, patient
presentation, and patient concerns. These incision-related
problems typically resolve spontaneously over time. If
persistent suture cysts develop, they can be excised in the
office under local anesthesia. Hyperpigmentation of the
incision often resolves with or without the use of topical
bleaching preparation, whereas hypopigmentation tends
to persist. Referral to a good tattoo artist to match the
eyelid skin color is a useful tool in this scenario.
CONCLUSION
It is imperative to identify preexisting ptosis in a patient
presenting for cosmetic blepharoplasty. Ignoring the
eyelid malposition will render an otherwise excellent
surgery as a failure in the patient’s eyes. As such, bleph­
aroplasty surgeons should familiarize themselves with
basic ptosis surgery. Alternatively, having an oculofacial
plastic surgery colleague available to help with such cases
may be beneficial. If surgeons who are not eyelid special­
ists perform ptosis surgery, the MMCR approach, for
appropriate indications, is more predictable. When elect­
ing to provide this service, the ability to manage compli­
cations, or having a process to facilitate prompt referral
for acute corneal care or other eyelid-related complica­
tions, is prudent.
References available online at expertconsult.com.
R E F E R E N C E S
1. Beard C. Ptosis. St. Louis: Mosby; 1976.
4. Fasanella R, Servat J. Levator resection for minimal ptosis. Another
simplified operation. Arch Ophthalmol 1961;65:493–6.
5. Putterman AM. A clamp for strengthening Müller’s muscle in
the treatment of ptosis. Modification, theory and clamp for the
prior to consideration of revision. If an overcorrection
occurs, depending on degree, downward digital massage
on the eyelid may improve the eyelid position. If not,
an adjustment may be necessary. With ELA surgery this
involves suture adjustment. Because the wound remains
partially numb after surgery, this is easiest to accomplish
in the first 2 to 3 weeks following surgery. With MMCR
surgery, eversion of the eyelid with splaying of the wound
will allow the eyelid to drop into better position. Under­
corrections with levator surgery are also managed with
repositioning of the sutures, but undercorrection with
the MMCR approach may require ptosis repair from the
levator approach. When asymmetry is minor, it is prudent
to wait 4 to 6 months prior to reoperation, as often these
minor changes become less apparent or less bothersome
to the patient.
Lagophthalmos/Dry Eye
The primary goal in managing postoperative lagoph­
thalmos (incomplete eyelid closure) is maintaining the
integrity of the cornea. This can be treated with digital
massage or lid-squeezing exercises (to stretch the lid),
ocular lubrication (drops during the day and ointment at
night), and punctal plugs (to occlude tear outflow). Com­
monly this is a result of short-term orbicularis deficit and
less so from over-elevation of the eyelid or over-resection
of skin. Orbicularis function is likely to improve with
time. Eyelid shortening or malposition is less likely to
recover spontaneously. When these issues do not improve,
revision will be needed depending on the primary deficit.
The treatment for dry eye is the same as for lagophthal­
mos. The authors separate these problems to emphasize
that dry eye after surgery can be present in the absence
of lagophthalmos, and is often related to a premorbid
condition that is exposed or exacerbated by the surgery.
Corneal Abrasion
On occasion lagophthalmos with corneal exposure can
lead to a corneal epithelial defect and potentially infec­
tion. A suture-related abrasion can occur with MMCR
surgery if the posterior suture or suture knot is exposed
and abrades the cornea. In these instances prompt refer­
ral to an ophthalmologist is important to prevent further
corneal decompensation.
Orbital Hemorrhage
Orbital hemorrhage is always a concern with eyelid
surgery as it can lead to permanent visual loss. Fortu­
nately this rarely occurs, with a reported incidence of 1
in 22,000 (0.0045%), with the greatest risk in the first 24
hours after blepharoplasty [12]. Patients with a history of
bleeding diathesis or who are on anticoagulant therapy
are educated regarding the increased risk for hemorrhage
and vision loss. In the instance of a vision-threatening
hemorrhage, the eyelid wound is opened and explored
for evacuation of the hematoma and control of any areas
of active bleeding.
Infection
As the blood supply to the eyelids is robust, infection is
rare after blepharoplasty, occurring in 0.2% of cases [13].

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MASTER TECHNIQUES IN FACIAL REJUVENATION
10. Jordan DR, Mawn L, Anderson RL. Surgical anatomy of the ocular
adnexa: a clinical approach. 2nd ed. New York, NY: Oxford Uni­
versity Press; 2012.
11. Foster JA, Holck DE, Perry JD, et al. Fibrin sealant for Müller
muscle-conjunctiva resection ptosis repair. Ophthal Plast Reconstr
Surg 2006;22:184–7.
Fasanella-Servat ptosis operation. Arch Ophthalmol 1972;87(6):
665–7.
6. Putterman AM, Urist MJ. Müller’s muscle-conjunctival resection in
the treatment of blepharoptosis. Arch Ophthalmol 1975;93:619–23.
7. Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeu­
rosis repair. Arch Ophthalmol 1975;93(8):629–34.
8. Anderson RL, Beard C. The levator aponeurosis. Attachments and
their clinical significance. Arch Ophthalmol 1977;95(8):1437–41.