The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

774
Part V  Brow Lift
Closure
The central access incision is closed first. I routinely fix the brow in the temporal
area with one or two sutures of 2-0 PDS, anchoring the temporoparietal fascia down
to the deep temporal fascia. If additional paramedian fixation is needed (between
the temporal crest and the central access incision), I place temporal fixation sutures,
but I do not tie them until the paramedian fixation is performed. Currently my
choices for paramedian fixation include external screw fixation or an absorbable
Endotine device. An Endotine device affords permanent fixation and multidirectional
vectors. It does require a separate incision and a special drill bit. Whether it is an
Endotine device or an external screw, a single hook is placed on the scalp behind the
planned fixation site. The scalp is then lifted, pulled upward, and rotated medially.
A hand drill and screw holder are shown. The drill has a 5 mm stop. For external
screw fixation, with the assistant maintaining the brow in the desired position through
the hook, a stab incision is made in the scalp, and a drill hole is made with the hand
drill. A self-tapping screw, 16 mm in length with a 5 mm thread, is placed in the drill
hole and secured. A staple is placed behind this screw, maintaining the brow position.

A separate 2 cm incision is made according to the preoperative vectors for insertion
of the Endotine device (right). The brow is then pulled close to its desired position.
The Endotine device has five prongs or tines to engage the periosteum and hold it
in the new position.
775
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
Next, with a power drill, a drill hole is made into which the device is placed with
the tines pointing backward. The Endotine device is inset into the drill hole. The de-
vice may be rotated according to the fixation desired.

The scalp is pulled upward and rotated medially. Then the scalp is pushed down
onto the device to engage the tines.
Once this paramedian fixation has been completed, the temporal fixation sutures
are tied, minimal scalp excision in the temporal area is performed if needed, and the
temporal incisions are closed.
Fixation Choices
Currently there is no consensus among surgeons regarding the preferred method of
brow fixation. In fact, there is even some debate about whether any fixation is needed,
because the muscle balance between the glabella and the frontalis is altered, and
therefore brow position will likely be maintained.
Who needs fixation, and which methods work? Temporal fixation—anchoring of
temporoparietal fascia down to the deep temporal fascia—is universally applied to
every patient in my practice. Paramedian fixation between the temporal crest and
midline with an upward and medial rotation is selectively applied on the basis of
the patient’s aging changes, brow position, brow shape, sex, and desired results.
776
Part V  Brow Lift

I am more likely to use permanent paramedian fixation in a man with heavy fore-
head skin and significant brow ptosis than in a woman with moderate or minimal
brow ptosis and normal forehead skin.
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Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
A variety of methods for brow fixation are available. I have had experience with all
of the fixation methods listed here, except for the Mitek anchors. The fixation meth-
ods can be further divided into temporary and permanent fixation. How long does
it take for brow position to become fixed? How long does the periosteum take to
adhere? Opinions vary: from 8 days to as long as 6 weeks. The only study available
in a rabbit model showed that it took the periosteum 6 weeks to stick back down.
The general consensus is that to be effective, the fixation should last at least a cou-
ple of weeks. Based on this information, I consider the external screws, which we
normally take out at 1 week to 10 days, to be temporary and the Endotine device
to be permanent.
Ancillary Procedures
Frequently ancillary procedures are performed in combination with an endoscopic
brow lift to further improve the result. These include peels, laser resurfacing, and in-
jection of tissue fillers. In patients with deep vertical frown lines at rest in whom
muscle modification alone will not eradicate the lines, I thread a piece of autologous
tissue, temporal fascia, or orbicularis muscle just deep to the dermis. I have found
this method to be rapid, effective, and relatively free of problems or complications.
The volume of the transferred tissue is preserved over time.
Endoscopic Brow Fixation Methods
Temporary
Permanent
Emory tapes
Vertex sutures
Mitek anchors
Bolster sutures
Internal screws
Permanent
Fibrin glue
Permanent
Absorbable
External screws
Absorbable
Cortical tunnels
Endotine device

778
Part V  Brow Lift
This woman in her thirties had brow ptosis and very deep, established glabellar
frown lines. She was a candidate for endoscopic brow lift and autologous temporal
fascia grafts to the grade 5 rhytids in her glabellar area.
During the endoscopic brow lift for this patient, a 1 by 3 cm piece of deep tempo-
ral fascia was harvested. The fascia was split in half longitudinally into equal 0.5 by
3 cm strips.

779
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
With a No. 57 Beaver blade, a subdermal tunnel was made under the left glabellar
rhytid. The blade not only creates the tunnel but also releases the deep dermal at-
tachments. The blade exits the lower end of the rhytid, making a small incision in
the skin.
A fine grasper is passed through the tunnel from above and out through the lower
incision. The grasper firmly holds the fascial strip, which is pulled into the tunnel.
The procedure is repeated on the right side. With both strips placed subdermally,
the protruding fascia is trimmed flush with the skin and the stab incisions are closed
with 6-0 suture material. My preference is 6-0 rapid-absorbing catgut.

Comparing the preoperative view with the patient’s postoperative results 1 year af-
ter treatment demonstrates improved brow position, improved upper eyelids with-
out an upper eyelid blepharoplasty, and effective elimination of the glabellar frown
lines. The split-face image confirms the improvement.
Postoperative Care
Because most endoscopic brow procedures in my practice are performed in conjunc-
tion with other aesthetic facial procedures, these patients usually spend the night in
our overnight facility. They are kept comfortable, with the head elevated and an ice
pack over the eyes. Every effort is made to alleviate nausea and to monitor blood
pressure and keep it under control.
Antihypertensive medication and sedatives are administered routinely in men and
as needed in women. The drain is usually removed the next morning before the pa-
tient goes home. The patient is advised to keep his or her head elevated, to avoid
strenuous activity for up to 3 weeks, and is scheduled to return for follow-up within
3 to 6 days.
780
Part V  Brow Lift

Outcomes
Patient acceptance of this procedure has been high. There have been few problems
such as alopecia, dysesthesias, and temporary nerve paralysis. In a personal series
of approximately 700 patients, there was no permanent facial nerve paralysis. Tem-
porary facial nerve paralysis was seen in less than 1% of patients, and alopecia at
the screw fixation site was seen in 4%.
781
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
This woman’s preoperative view demonstrates brow asymmetry, brow ptosis, glabel-
lar and transverse forehead rhytids (grade 4), and aging of the upper and lower eye-
lids with crow’s-feet. The patient underwent an endoscopic brow lift with external
screw fixation and upper and lower lid blepharoplasty. The early postoperative view
and a split-face image demonstrate improvement of brow asymmetry, elevation of
the brow position, and improvement of rhytids.
A close-up of the left side of her scalp shows
a 1 by 1.5 cm area of alopecia at the site of
the external screw fixation. This area was ex-
cised to eliminate the bald spot.
Most patients experienced mild temporary dysesthesias. I have personally reoper-
ated on only one of my earliest endoscopic brow patients for recurrent brow ptosis.

782
Part V  Brow Lift
Results
This woman in her late forties had brow ptosis, grade 5 glabellar lines, and full fa-
cial aging; she underwent an endoscopic brow lift with no paracentral fixation. She
also had upper and lower eyelid blepharoplasty and face and neck lift. Her postop-
erative result at 18 months demonstrates an elevated brow position with significant
improvement in the glabellar lines. This is most readily apparent in the split-face im-
age, demonstrating elevation of the medial and lateral brow.
This woman in her early fifties had heavy, ptotic brows with grade 4 glabellar rhytids.
She underwent an endoscopic brow lift with external screw fixation as well as a
lower lid blepharoplasty and transpalpebral midface lift. Her postoperative result
demonstrates improvement of brow position, amelioration of rhytids, and improve-
ment of the lower lid-cheek junction and midface area.

This man in his forties had a heavy ptotic brow and deep grade 5 transverse fore-
head lines. He underwent an endoscopic brow lift with Emory taping, upper lid bleph-
aroplasty, and transconjunctival removal of fat from the lower eyelids. Postoper-
ative results at 4 months and at 7 years demonstrate maintenance of brow elevation,
including the exaggerated medial brow elevation that was typical of our early en-
doscopic brow lifts with the central Emory T to V scalp excision. I abandoned the
central scalp excision because it led to these exaggerated medial brow elevations.
783
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
Preoperative
7 years postoperatively
Preoperative
4 months postoperatively
7 years postoperatively

This woman in her late forties had heavy brows and brow ptosis. She had an endo-
scopic brow lift with Emory taping. She is shown at 7 years and at 8 years postop-
eratively, demonstrating maintenance of the elevated brow position.
784
Part V  Brow Lift
Preoperative
7 years postoperatively
8 years postoperatively
Preoperative
8 years postoperatively
Preoperative
8 years
postoperatively

This 40-year-old woman had brow ptosis, grade 4 glabellar lines, and aging of the
midface and neck. Despite the high forehead, she elected to have an endoscopic brow
lift, a lower lid blepharoplasty with transpalpebral midface lift, and an endoscopic
neck lift. The postoperative view demonstrates repositioning of the brow, ameliora-
tion of the glabellar lines, improvement of the upper eyelids (without an upper eye-
lid blepharoplasty), and improvement of the lower lid and midface area.
Concluding Thoughts
Although the use of neurotoxins and even less-invasive brow lift techniques (see Chap-
ter 23) have gained in popularity and the overall numbers or coronal and endoscopic
brow lifts are in decline, there is still a role for the endoscopic approach. Based on
my 16-plus years of experience, during which I have performed several hundred en-
doscopic brow lifts, I conclude that the procedure is effective and safe, with lasting
results. With technical modifications, the exaggerated medial brow elevation has been
eliminated. The need for fixation, if any, and the type of fixation remain a matter of
debate, and we each have our own thoughts based on experience.
785
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach

Suggested Readings
Behmand RA, Guyuron B. Endoscopic forehead rejuvenation: II. Long-term results. Plast
Reconstr Surg 117:1137-1143, 2006.
Chajchir A. Endoscopia en cirugía plástica y estética. In Gonzalez Montaner LJ, Huriado
Hoyo E, Altman R, et al, eds. El Libro de Oro en Homenaje al Doctor Carlos Reussi.
Buenos Aires: Asociación Médica Argentina, 1993.
Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic Plast Surg 18:269-274, 1994.
Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing, 2004.
Core GB, Vasconez LO, Askren C, et al. Coronal face-lift with endoscopic techniques. Plast
Surg Forum 25:227-229, 1992.
Daniel RK, Tirkanits B. Endoscopic forehead lift. Aesthetics and analysis. Clin Plast Surg
22:605-618, 1995.
Daniel RK, Tirkanits B. Endoscopic forehead lift: an operative technique. Plast Reconstr
Surg 98:1148-1157; discussion 1158, 1996.
Clinical Caveats
 An endoscopic brow lift is a technology-dependent procedure. The surgeon and
operating room personnel should be familiar with the endoscopic equipment and
be able to troubleshoot problems involving the camera, light source, and monitor.
 The success of this procedure depends on adequate release of the periorbital septa
and adhesions.
 Vertical spreading should be avoided during the temporal dissection to prevent
stretch injury of the frontal branch of the facial nerve.
 Keeping the dissector firmly down on the deep temporal fascia and temporalis
muscle prevents any injury to the frontal branch of the facial nerve.
 Release of the periosteum is essential for brow elevation.
 While resecting the glabellar musculature, the surgeon should avoid removal of
subcutaneous fat, which could result in a depression.
 Every attempt should be made to preserve the sentinel vein. Sacrifice of the vein
leads to engorgement of the superficial veins, which will become readily visible in
thin-skinned individuals.
 If medial brow elevation is not desired, subperiosteal dissection should be avoided
in the medial brow area.
786
Part V  Brow Lift

787
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
De La Plaza R, Valiente E, Arroyo JM. Supraperiosteal lifting of the upper two-thirds of the
face. Br J Plast Surg 44:325-332, 1991.
Del Campo AF, Lucchesi R, Cedillo Ley MP. The endo-facelift: basics and options. Clin Plast
Surg 24:309-327, 1997.
Elkwood A, Matarasso A, Rankin M, et al. National plastic surgery survey: brow lifting
techniques and complications. Plast Reconstr Surg 108:2143-2150; discussion 2151-
2152, 2001.
Farkas LG. Anthropometrics and art in the aesthetic of women’s faces. Clin Plast Surg 14:599-
616, 1987.
Guyuron B. Endoscopic forehead rejuvenation: I. Limitations, flaws, and rewards. Plast Re-
constr Surg 117:1121-1133; discussion 1134-1136, 2006.
Hamas RS. An endoscopic brow lift that does not raise the hairline. Aesthetic Surg J 17:127,
1997.
Hamas RS. Reducing the subconscious frown by endoscopic resection of the corrugator mus-
cles. Aesthetic Plast Surg 19:21-25, 1995.
Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional lift. Case reports. Aes-
thetic Plast Surg 18:21-29, 1994.
Isse NG. Endoscopic forehead lift. Presented at the Annual Meeting of the Los Angeles
County Society of Plastic Surgeons, Los Angeles, September 12, 1992.
Isse NG. Endoscopic forehead lift: evolution and update. Clin Plast Surg 22:661-673, 1995.
Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharo-
plasty. Plast Reconstr Surg 97:1334-1342, 1996.
Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 120:1367-
1376; discussion 1377, 2007.
Mackay GJ, Nahai F. The endoscopic forehead lift. Oper Tech Plast Reconstr Surg 2:137,
1995.
Matarasso A, Matarasso SL. Endoscopic surgical correction of glabellar creases. Dermatol
Surg 21:695-700, 1995.
Moss JC, Mendelson BC, Taylor GL. Surgical anatomy of the ligamentous attachments in
the temple and periorbital regions. Plastic Reconstr Surg 105:1475-1490; discussion
1491-1498, 2000.
Nahai F, Saltz R. Endoscopic Plastic Surgery, 2nd ed. St Louis: Quality Medical Publishing,
2008.
Nassif PS, Kokoska MS, Homan S, et al. Comparison of subperiosteal vs subgaleal eleva-
tion techniques used in forehead lifts. Arch Otolaryngol Head Neck Surg 124:1209-
1215, 1998.
Oslin B, Core GB, Vasconez LO. The biplanar endoscopically assisted forehead lift. Clin Plast
Surg 22:633-638, 1995.
Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast Surg 20:129-134,
1996.
Ramirez OM. The anchor subperiosteal forehead lift. Plast Reconstr Surg 95:993-1003; dis-
cussion 1004-1006, 1995.

788
Part V  Brow Lift
Ramirez OM. Endoscopically assisted biplanar forehead lift. Plast Reconstr Surg 96:323-
333, 1995.
Ramirez OM. Transblepharoplasty forehead lift and upper face rejuvenation. Ann Plast Surg
37:577-584, 1996.
Roberts TL III, Ellis LB. In pursuit of optimal rejuvenation of the forehead: endoscopic brow
lift with simultaneous carbon dioxide laser resurfacing. Plast Reconstr Surg 101:1075-
1084, 1998.
Rohrich RJ, Beran SJ. Evolving fixation methods in endoscopically assisted forehead reju-
venation: controversies and rationale [review]. Plast Reconstr Surg 100:1575-1582; dis-
cussion 1583-1584, 1997.
Rosenberg GJ. The subperiosteal endoscopic laser forehead (SELF) lift. Plast Reconstr Surg
102:493-501, 1998.
Trinei FA, Januszkiewicz J, Nahai, F. The sentinel vein: an important reference point for sur-
gery in the temporal region. Plast Reconstr Surg 101:27-32, 1998.
Vasconez LO. The use of the endoscope in brow lifting. A video presentation at the Annual
Meeting of the American Society of Plastic and Reconstructive Surgeons. Washington,
DC, 1992.

Other Approaches to Brow Lift

FOAD NAHAI
CHAPTER 25

A
variety of options are available for rejuvenation/repositioning of the brow and
forehead, ranging from the open coronal forehead lift to neurotoxins and in-
cluding the following:
 Coronal brow lift
 Endoscopic forehead lift
 Lateral-temporal brow lift
 Transpalpebral excision of corrugator and procerus muscles
 Lateral-temporal brow lift combined with transpalpebral excision of corruga-
tor and procerus muscles
 Direct brow lift
 Transpalpebral browpexy
 Injection of neurotoxins
Successful rejuvenation of the brow and forehead includes repositioning of the hair-
bearing brow, improvement of vertical glabellar and horizontal forehead lines, re-
versal of the brow descent, and conversion of a tired or angry expression into a rested
and contented look.
As surgeons we look for safe and efficacious procedures rendering lasting results,
whereas our patients look for an effective procedure with minimal scarring and a
short recovery time.
The coronal lift remains the benchmark against which the results, morbidity, and
longevity of the other procedures can be compared. Not everyone undergoing facial
rejuvenation is a candidate for or will consent to a coronal brow lift. Therefore al-
ternatives must be sought to provide the desired result without the coronal incision.
Not all the alternatives will match the results of the coronal brow lift; however, they
are all far less invasive. Each alternative has its own benefits and limitations. Careful
patient evaluation facilitates matching the patient to the best option (see Chapters 23
and 24).
790
Part V  Brow Lift

SPECIFIC CLINICAL APPLICATIONS
Coronal Brow Lift
Despite the popularity of the endoscopic forehead lift (see Chapter 22), the coronal
brow lift is an excellent option. Many surgeons consider it the method of choice for
all patients; some surgeons limit the coronal lift to patients who are not candidates
for an endoscopic approach.
This approach affords excellent exposure, facilitating release of periorbital septa and
adhesions, muscle excision, and brow mobilization. Through scalp excision, the de-
sired preplanned brow elevation and brow shaping can be achieved.
Indications and Contraindications
The coronal brow lift may be applied universally to anyone who is a candidate for
forehead rejuvenation. It is my opinion that the best candidates are those who are
not suitable for the endoscopic approach; these include patients with high foreheads,
significant frontal bone convexity, a high or receding hairline, extremely thick skin
or deep lines, and significant brow ptosis with excess skin over the lateral brow and
glabella. Patients who would have similar results with less-invasive procedures would
not be candidates for the coronal approach.
Preoperative Planning
Markings
As with other brow-lift procedures, the coronal brow lift is rarely performed in iso-
lation. It is typically combined with other periorbital procedures or full facial reju-
venation. This is a full, open procedure; therefore preoperative markings are not as
critical as the markings for the endoscopic approach. However, it is useful to mark
the sentinel vein, the temporal crest, and the course of the supraorbital and supra-
trochlear nerves.
Incisions
The incision will vary, depending on the patient’s hairline and the desired results.
There are three options for planning the incision: (1) a standard coronal incision,
(2) a modified coronal incision, and (3) an anterior hairline incision.
791
Chapter 25  Other Approaches to Brow Lift

792
Part V  Brow Lift
The standard coronal incision is placed 6 to 8 cm behind the frontal hairline. It is
easily concealed within the hair in patients with normal hair thickness. The modi-
fied coronal incision is curved anteriorly in the frontal area. This is best for individ-
uals who have a normal temporal hairline but a very high frontal hairline. By mod-
ifying the incision and bringing it to the hairline in the frontal area, the height of the
forehead may be reduced. The frontal portion of the incision may be visible. The an-
terior hairline incision is best reserved for an individual with a high forehead and a
receding hairline in the temporal and frontal areas. In such individuals this incision
allows reduction in the forehead height and temporal hairline. This entire scar may
be visible, and most surgeons and patients prefer to avoid this incision. Any or all of
these incisions, particularly the anterior hairline incision, may be made in a zigzag
fashion to break up the resultant scar.
Vectors of fixation are also marked on the forehead; these will include a line pro-
jected onto the head from the most convex portion of the hair-bearing brow. These
vectors are a guide to scalp excision and brow positioning.
Modified
incision
Anterior
hairline
incision
Standard
bicoronal
incision

Operative Technique
Although the procedure can be performed with either a local or a general anesthetic,
our preference is general anesthesia, because other procedures are usually performed
in combination. With the patient lying supine on the operating table, with the head
slightly elevated to decrease venous engorgement, the hair is washed with soap and
braided, and the proposed area of scalp excision may be shaved. The entire area is
infiltrated with 0.5% lidocaine and epinephrine 1:200,000. The field is then pre-
pared with povidone-iodine (Betadine) and draped.
After allowing sufficient time (8 to 10 minutes) for the epinephrine to take effect, the
surgeon makes the incision through the scalp, down to the deep temporal fascia in
the temporal area, and more centrally down to the periosteum. The knife blade is
beveled so that it runs parallel with the hair roots to preserve as many hair follicles
as possible. This is more critical with the modified and anterior hairline incisions.
The anterior hairline incision is not made anterior to the hairline, as its name indi-
cates, but must be made 1 or 2 mm behind the hairline so that some hair follicles
are left within the cut edges.
793
Chapter 25  Other Approaches to Brow Lift
Once the incision is made, the elevation of
the forehead flap proceeds very rapidly in a
bloodless field between the temporoparietal
fascia and deep temporal fascia laterally and
the subperiosteal plane centrally. The flap is
elevated to the orbital rims. This elevation
will release the periorbital septa and allow
easy access to the glabellar musculature.
The anterior hairline approach will allow dis-
section in the subcutaneous plane. This sub-
cutaneous plane is directly over the frontalis
muscle. This allows significant reduction of
transverse forehead lines through the release
of the fibrous septa, which run between the
muscle and the overlying skin. An added ad-
vantage of this approach is better preserva-
tion of the scalp’s sensory innervation.
Periosteum
Galeal flap
Frontalis
muscle

794
Part V  Brow Lift
Once the flap is elevated, the corrugator, procerus, and depressor supercilii muscles
are easily identified. The muscles are divided, avulsed, or cauterized, according to
the surgeon’s preference. To weaken the frontalis muscle, the lowest portions of the
muscle are incised. The surgeon notes the course of the supratrochlear and supraor-
bital nerves and divides the frontalis muscle, carefully avoiding the nerves. A variety
of techniques have been used to weaken the frontalis in this area, including hori-
zontal division, crisscross division, and even a 1 cm strip excision. The scalp flap is
then retracted superiorly and the degree of elevation is adjusted.
Next the scalp is incised at key sites, and fixation sutures or staples are placed. Usu-
ally the scalp is fixed at three sites: one centrally and one on each side, according to
the preoperative vectors.
Supratrochlear
nerves
Supraorbital
neurovascular
bundle
Division of
procerus and
corrugator
muscles using
Colorado needle
Supratrochlear nerves
Frontalis muscle
Galeal flap
Supraorbital nerves
Corrugator muscle
Pericranium
Orbital portion of
orbicularis oculi muscle
Supraorbital
neurovascular bundle
ANATOMY
SURGEON’S VIEW
First staple
Second staple
Third staple

The intervening scalp is excised and closed in two layers with sutures and staples.
Postoperative Care
The patient’s head is elevated, ice packs are placed over the eyes, and measures are
taken to prevent an elevation in blood pressure and nausea and vomiting. Most pa-
tients undergoing a brow lift with additional procedures are kept overnight. Staples
and sutures are removed 5 to 7 days postoperatively, and physical activities are re-
stricted for 2 to 3 weeks.
Outcomes
This procedure has proved effective, with acceptable morbidity. The results have stood
the test of time. Complications include alopecia, dysesthesias, and sensory loss in
the scalp.
Direct Brow Lift
A direct brow lift is an effective method for elevating the brow, particularly the lat-
eral brow. However, the direct lift is rarely used, because it may leave a visible scar.
This approach offers excellent brow elevation through direct excision of the redundant
skin. It will also allow access to the muscles. It is a quick, simple procedure that can
be performed with a local anesthetic and carries minimal risk to the sensory nerves.
795
Chapter 25  Other Approaches to Brow Lift

796
Part V  Brow Lift
Indications and Contraindications
The best candidates are older individuals with heavy lateral brows and deep trans-
verse forehead creases where the scar can be hidden. This is a relatively quick pro-
cedure and may be an acceptable alternative for patients who are not candidates for
other options that require lengthier operations. The disadvantage is the scar.
Preoperative Planning
Markings and Incisions
The incision choices include an incision directly above the hair-bearing brow, which
follows the shape of the brow, or an incision higher up, within a preexisting crease.
For the incision along the hair-bearing brow, a mark is made that follows the upper
border of the hair-bearing brow. The skin above is then pinched to bring the brow
into the proposed position, and the upper border of the skin excision is marked.
The design is varied to allow direct upward elevation of the brow (left) or lateral el-
evation (right). The incision within the crease is marked with the patient actively el-
evating the brow. The amount of forehead skin to be excised is then assessed and
marked by pinching the forehead skin.

Operative Technique
The procedure is performed with a local anesthetic unless it is combined with other
procedures.
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Chapter 25  Other Approaches to Brow Lift
Following the markings for a central brow elevation, the surgeon excises the prede-
termined skin. This is limited to a skin excision to avoid injury to the frontal branch
of the facial nerve and the sensory nerves. (It is possible through the transverse inci-
sion to access the glabellar musculature; however, this is not commonly performed.
This operation is usually limited to skin excision.)
The wound is then closed in two layers with 5-0 Monocryl sutures to the dermis,
and the skin is closed with intracuticular Monocryl or simple 6-0 Prolene sutures.
Courtesy Clinton D. McCord, Jr., MD
Courtesy Clinton D. McCord, Jr., MD

798
Part V  Brow Lift
Postoperative Care
Postoperative swelling is prolonged and noticeable. To minimize this, it is important
to keep the patient’s head elevated, with ice packs on the eyelids. We also consider
the use of diuretics and a short course of methylprednisolone (Medrol Dose Pack).
Outcomes
The direct brow lift is an effective way of elevating the lateral brow. In carefully se-
lected patients, the scar may be imperceptible.
Results
This elderly man underwent a direct brow lift with upper and lower lid blepharo-
plasties. His postoperative result shows lateral brow elevation with an impercepti-
ble scar.
Transpalpebral Browpexy
The transpalpebral approach offers minimal lateral brow elevation through an up-
per lid blepharoplasty and is best as an adjunct to upper lid blepharoplasty rather
than a primary brow-lift procedure.
Indications and Contraindications
The limited elevation seen with this approach limits its application to patients with
mild lateral brow ptosis and with no medial brow ptosis or excess skin at the nasal
radix.
Courtesy Clinton D. McCord, Jr., MD

Preoperative Planning
Markings
The brow is held in the projected position, and the upper eyelid is marked for an up-
per lid blepharoplasty.
Operative Technique
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Chapter 25  Other Approaches to Brow Lift
The incisions are made and the skin-muscle excision for the blepharoplasty is com-
pleted. The orbicularis muscle is retracted upward with two Blair retractors and with
the cutting current and a Colorado tip. The dissection is continued deep to the or-
bicularis to the lateral orbital rim, staying above the periosteum. The dissection con-
tinues upward laterally for 2 to 3 cm. Care should be taken to preserve the sentinel
vein, which is easily identified. This dissection releases some of the adhesions and
septa of the lateral orbital area. The plane of dissection is deep to the course of the
frontal branches of the facial nerve.
The calipers are then used to mark a point 5 to 10 mm above the orbital rim.

Then a 5-0 absorbable PDS or permanent clear nylon suture is used to fix the hair-
bearing brow to the periosteum. The suture is first placed through the orbicularis,
the retroorbicularis oculi fat (ROOF), and the deep layers of the dermis, right in the
middle of the hair-bearing brow. Next, the needle is passed through the previously
marked periosteum. The suture is then tied, moving the brow upward. The eyelid
skin is closed. Dimpling may result if the suture through the orbicularis and ROOF
extends too far into the skin. Skin redundancy may result above the point of fixation
if the lateral brow is inadequately undermined.
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Part V  Brow Lift

Postoperative Care
Postoperative care is the same as for upper lid blepharoplasty (see Chapter 28).
Outcomes
Only minimal elevation is possible with this technique. The results have been effective
and maintained over time.
Results
801
Chapter 25  Other Approaches to Brow Lift
This patient was seen in consultation for upper and lower lid blepharoplasty. He re-
quested improvement of the heaviness of his upper eyelids and the excess skin and
bags of his lower eyelids. In addition to excess skin in the upper lids and aging of the
lower lids, he had lateral brow ptosis. He underwent upper and lower lid blepharo-
plasty with an internal transpalpebral browpexy. The split-view image shows his re-
sult at 2 years. Note the elevation of the brow through the internal browpexy suture.

802
Part V  Brow Lift
Concluding Thoughts
The popularity and effectiveness of injectable neurotoxins has led to a decline in the
number of brow lifts performed. Despite that, there is still a role for these alterna-
tive procedures. Patient selection and matching the procedure to the patient is the
key. Although coronal brow lifts and direct brow lifts have limited application in my
practice, the transpalpebral browpexy has proved very useful.
Clinical Caveats
Coronal Brow Lift
 The surgeon can avoid creating a surprised look by limiting traction and scalp
excision.
 The incision line is beveled to preserve hair follicles.
 The anterior hairline incision should be placed 1 to 2 mm behind the hairline to
preserve hair roots rather than in front of the hairline.
 Supraorbital and supratrochlear nerve branches should be preserved while divid-
ing the frontalis muscle.
Direct Brow Lift
 Incisions are best placed within preexisting creases.
 The excision should be limited to skin only to avoid nerve injury.
Transpalpebral Browpexy
 Dimpling can be avoided by limiting the suture placement to the deep dermis.
 An overhang can be avoided by adequately undermining the lateral brow.
Annotated Bibliography
Friedland JA, Jacobson WM, Terkonda S. Safety and efficacy of combined upper blepharo-
plasties and open coronal browlift: a consecutive series of 600 patients. Aesthetic Plast
Surg 20:453-462, 1996.
Many surgeons and several reports question the safety of blepharoplasty and open coro-
nal foreheadplasty being performed concomitantly. The technique used in this series is
presented in detail. The consistently excellent results obtained satisfy the aesthetic goals
of both patients and surgeons—and suggest a renewed interest in the technique based
on its simplicity and easily reproducible results.

Kaye BL. The forehead lift: a useful adjunct to face lift and blepharoplasty. Plast Reconstr
Surg 60:161-171, 1977.
The forehead lift, with interruption of the continuity of the frontalis muscle, has been
an effective method for improving the appearance of the upper third of the face. It can
be done independently, or combined with facial rhytidectomy, blepharoplasty, and/or
other ancillary procedures. In some cases of apparent upper lid redundancy, it can elim-
inate the need for upper lid blepharoplasty. The results are pleasing and seem to be last-
ing, while the complications have been few and mild. The authors describe the opera-
tion and discuss its indications, contraindications, advantages, and disadvantages.
Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharo-
plasty. Plast Reconstr Surg 97:1334-1342, 1996.
A forehead lift technique with temporal scalp incisions only 4.5 to 5.0 cm long can pro-
duce a result comparable with that of the coronal incision approach when combined
with transpalpebral resection of the corrugator supercilii muscles and transection of the
procerus muscle. This eyebrow elevation technique minimizes the risk of permanently
injuring the supraorbital nerve branches that innervate the frontoparietal scalp and can
effectively treat cases of advanced eyebrow ptosis. This forehead lift technique describes
a method for determining the appropriate area of eyelid skin for excision when a fore-
head lift and upper blepharoplasty are performed concomitantly.
Knize DM. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast
Reconstr Surg 95:52-60, 1995.
The author describes the most effective method for treating glabellar area skin contour
irregularities produced by hyperactive corrugator supercilii and/or procerus muscles.
A transpalpebral technique, performed on 40 patients who were followed for 6 to
24 months, is described, and the cadaver and nerve block studies on which this tech-
nique is based are discussed. The postoperative cosmetic improvement of the glabellar
area is comparable in appearance to that achieved from a coronal incision approach.
Paul M. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg
108:1409-1424, 2001.
For nearly 100 years, aesthetic improvement of the aging face has included surgical el-
evation of the brow. Within the past decade, the minimal incision approach to brow
lifting afforded with the endoscope radically changed surgical options in forehead reju-
venation. Further advances have added to these options and have provided a palette of
alternatives in aesthetic correction of the upper third of the aging face.
Suggested Readings
Castanares S. Forehead wrinkles, glabellar frown and ptosis of eyebrows. Plast Reconstr Surg
34:406-413, 1964.
Connell BF, Lambros VS, Neurohr GH. The forehead lift: techniques to avoid complications
and produce optimal results. Aesthetic Plast Surg 13:217-237, 1989.
Klatsky SA. Foreheadplasty for facial rejuvenation. Aesthetic Surg J 20:416-427, 2000.
Matarasso A, Terino EO. Forehead-brow rhytidoplasty: reassessing the goals. Plast Recon-
str Surg 93:1378-1389; discussion 1390-1391, 1994.
803
Chapter 25  Other Approaches to Brow Lift

McCord CD, Doxanas MT. Browplasty and browpexy: an adjunct to blepharoplasty. Plast
Reconstr Surg 86:248-254, 1990.
McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg
15:141-147, 1991.
Pitanguy I. Section of the frontalis-procerus-corrugator aponeurosis in the correction of
frontal and glabellar wrinkles. Ann Plast Surg 2:422-427, 1979.
Riefkohl R, Kosanin R, Georgiade GS. Complications of the forehead-brow lift. Aesthetic
Plast Surg 7:135-138, 1983.
Tirkanits B, Daniel RK. The “biplanar” forehead lift. Aesthetic Plast Surg 14:111-117, 1990.
Vinas JC, Caviglia C, Cortinas JL. Forehead rhytidoplasty and brow lifting. Plast Reconstr
Surg 57:445-454, 1976.
Vogel JE, Hoopes JE. The subcutaneous forehead lift with an anterior hairline incision. Ann
Plast Surg 28:257-265, 1992.
Wolfe SA, Baird WL. The subcutaneous forehead lift. Plast Reconstr Surg 83:251-256, 1989.
804
Part V  Brow Lift

EYELID SURGERY
PART VI

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Applied Anatomy of the
Eyelids and Orbit

MARK A. CODNER, MICHELLE B. LOCKE
CHAPTER 26

T
he fundamental key to success in surgery of the eyelids and periorbital region
is precise knowledge of the pertinent anatomy. The eyelids and periorbital area
represent an anatomically complex and intricate region that contains a number of
critical structures in close proximity to areas requiring surgical manipulation. The
anatomy of the eyelids and orbit also influences the form, function, and appearance
of the eyelids. Knowledge of the anatomy should include both the areas planned for
surgical correction and the areas that can be secondarily affected by surgical ma-
nipulation or by complications.
Many of the new techniques for eyelid surgery have an anatomic basis that requires
solid grounding in anatomy to ensure that these procedures are performed safely and
to maximize the aesthetic and functional results. Furthermore, knowledge of the
anatomy is required to avoid and treat complications that may occur after bleph -
aroplasty. Numerous studies have contributed to defining the anatomy of the eyelids
and orbit. Jelks and Zide described the anatomic structures encountered during bleph-
aroplasty; Jelks and Jelks described vector analysis of the globe and infraorbital re-
gion to identify patients at risk for lid malposition after blepharoplasty. Additional
clinical anatomic studies by Rees and LaTrenta discussed the morphologically prone
eye in which the risk of dry-eye syndrome is increased after blepharoplasty. Hirmand
et al used Hertel exophthalmometry preoperatively to identify patients with promi-
nent eyes, who are at high risk of lid retraction and scleral show following bleph -
aroplasty.
More recent anatomic studies have focused on the relationship between the lower
eyelids and the midface, including the orbital septum described by Pessa, the orbito-
malar ligament described by Kikkawa et al, and the anatomy of the malar mounds
described by Mendelson and colleagues. Rohrich et al and Mendelson et al described
the anatomic subcutaneous units of the periorbital region as well as the face, and
the aging changes associated with these structures.
Structures of the Eyelids and Orbit
The eyelid is a bilamellar structure consisting of an anterior lamella and a posterior
lamella. The anterior lamella consists of skin and the orbicularis oculi muscle; the
posterior lamella includes the tarsoligamentous sling, which comprises the tarsal
plate, the medial and lateral canthal tendons, the capsulopalpebral fascia, and con-
junctiva. The septum is the dividing layer, which originates at the arcus marginalis
along the orbital rim and inserts into the dermis, creating the upper and lower eye-
lid creases. The septum separates the anterior and posterior lamella, and is often
referred to as the middle lamella. The horizontal interpalpebral fissure is formed
by the lid margin and measures approximately 30 to 31 mm transversely and 8 to
10 mm vertically.
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Part VI  Eyelid Surgery

The lateral canthal angle is formed by the lateral commissure and is generally posi-
tioned approximately 2 mm superior to the medial canthus, giving the eyelid a slightly
upward lateral inclination to the palpebral fissure (canthal tilt). The position of the
lateral canthus, however, varies according to age, family traits, race, and sex. In pri-
mary gaze, the upper eyelid margin is positioned 1.5 mm inferior to the superior cor-
neoscleral limbus, and the lower eyelid margin rests just at the inferior limbus of the
cornea. The upper eyelid margin forms a smooth arch with the highest point posi-
tioned between the medial limbus and the pupil. With age, there is a gradual lateral
shift of this point as the tarsal plate migrates laterally. The horizontal crease in the
upper eyelid is formed by the dermal insertion of the levator aponeurosis after it
passes through the orbicularis muscle. The eyelid fold is the excess skin and muscle
that overhang the crease, which is a fixed line.
809
Chapter 26  Applied Anatomy of the Eyelids and Orbit
The degree of eye prominence depends on the relationship between the globe and
the bony orbit. This can be difficult to accurately assess clinically, because the soft
tissue anatomy of the region can mask the bony landmarks. Preoperative assessment
with Hertel exophthalmometry is the most reliable method. Normal protrusion is
15 to 17 mm and is slightly greater in black patients. This results in a negative vec-
tor to the globe–orbital rim relationship.
Upper lid crease
Upper lid fold
Canthal tilt
Lateral canthus
Lower lid crease
Eyelid-cheek junction
Upper lid sulcus
Medial canthus
Nasojugal groove
Normal eyelid surface anatomy
Prominent eye

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Part VI  Eyelid Surgery
Tarsal
plate
height
10
12
5
0
Range of fusion
Range of fusion
ASIAN
NON-ASIAN
The orbicularis oculi muscle lies deep to the dermis, with minimal subcutaneous fat.
The muscle is divided into three major portions: pretarsal, preseptal, and orbital.
The pretarsal portion of the orbicularis is superficial to the tarsal plate and func-
tions for lid closure during involuntary blinking. The pretarsal orbicularis is further
subdivided into a superficial and a deep head. The preseptal orbicularis also has a
Infraorbital nerve
Zygomaticus minor
muscle
Lateral raphe
Zygomaticus major
muscle
Depressor septi nasi
muscle
Frontalis muscle
Orbital orbicularis muscle
Preseptal orbicularis muscle
Anterior reflection of
medial canthal tendon
Levator labii superioris
alaeque nasi muscle
Pretarsal orbicularis muscle
Transverse part of
nasalis muscle
Levator labii superioris
muscle
Both the upper lid crease and fold vary according to sex. The lid crease in the eyelid
of an individual of European ancestry is approximately 7 mm above the lash mar-
gin at the midpupillary line in men and 10 mm above the lash margin in women. In
the lower lid, there is an analogous eyelid crease 2 to 3 mm from the lash margin,
which is more apparent in youth and diminishes with age. The Asian upper eyelid
typically has a crease that is more inferior, often 3 to 4 mm above the lash margin, be-
cause of the low insertion of the septum, which allows preaponeurotic fat to migrate
inferiorly into the pretarsal space.
Orbicularis Oculi Muscle

superficial and a deep component. In addition to controlling voluntary blinking, it
functions as part of the lacrimal pump for tear drainage. The orbital orbicularis is
the largest division of the orbicularis muscle and functions to protect the globe with
forced eyelid closure as well as medial brow depression. The orbicularis oculi is a
complex muscle that has multiple deep and superficial components. The origin of
the orbicularis is from the medial canthus and medial orbit, whereas the insertion
is at the lateral canthus and lateral orbit. The pretarsal fibers have a dense attach-
ment to the upper and lower lid tarsal plates. The deep pretarsal muscle, Horner’s
muscle, originates at the posterior lacrimal crest, and the superficial pretarsal muscle
originates from the anterior reflection of the medial canthal tendon, which origi-
nates from the frontal process of the maxillary bone. The lacrimal sac is clasped be-
tween the two heads. Both pretarsal orbicularis muscles insert laterally into Whit-
nall’s tubercle, 1.5 mm inside the lateral orbital rim. Riolan’s muscle is a dense group
of pretarsal orbicularis muscles that form the subcutaneous component of the gray
line along the lid margin. This is an important anatomic landmark that is used to re-
align the lateral canthus after canthoplasty.
The preseptal orbicularis also has a superficial and a deep component. The deep mus-
cle, Jones’s muscle, originates from the lacrimal sac fascia. The superficial preseptal
muscle originates from the anterior reflection of the medial canthal tendon, along
with the superficial pretarsal muscle. Both preseptal muscles insert onto the lateral
palpebral raphe, which creates the superficial component of the lateral canthus. With
each blink, contraction of Jones’s muscle creates negative pressure in the tear sac,
thereby draining the canalicular system. The lower lid orbital orbicularis originates
from the maxilla, and the upper lid orbital orbicularis originates from the frontal
bone converging on the superficial component of the medial canthal tendon. The lat-
eral insertion of the orbital orbicularis creates the anterior raphe along the lateral
orbital rim.
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Chapter 26  Applied Anatomy of the Eyelids and Orbit

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Part VI  Eyelid Surgery
The 10 separate heads of the orbicularis oculi muscle all originate from the medial as-
pect of the orbit and insert along the lateral aspect of the orbit. Therefore the me-
dial canthus represents the “business end” of the orbicularis muscle, including the
dominant blood supply and innervation originating medially and contributing to the
major contractile forces used for blinking, the lacrimal pump, and eye protection.
In contrast to the medial origin, the lateral insertion of the orbicularis oculi muscle
simply acts as a lateral anchor with a deep and a superficial component forming the
lateral canthal tendon and lateral orbital raphe. The lateral aspect of the orbicularis
represents the fixed anchor point to the bony rim, which functions as a relatively sta-
ble fulcrum for the eyelids, thereby allowing the forces of medial contraction to
change lid position. However, with extreme abduction of the globe, the lateral can-
thus can mobilize up to 2 mm.
Superior orbital muscle
Superior preseptal muscle
• Superficial
• Deep
Anterior limb of
medial canthal tendon
Lacrimal sac
Common canaliculus
Inferior orbital muscle
Superior pretarsal muscle
• Superficial
• Deep
Inferior pretarsal muscle
• Superficial
• Deep
Inferior preseptal muscle
• Superficial
• Deep
Deep limb of
lateral canthal tendon
Lateral orbital tubercle
Superficial limb of
lateral canthal tendon
Orbital orbicularis muscle
Lateral orbital raphe
Superior preseptal
orbicularis muscle
Superior pretarsal
orbicularis muscle
Inferior pretarsal
orbicularis muscle
Inferior preseptal
orbicularis muscle

Tarsoligamentous Sling
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Chapter 26  Applied Anatomy of the Eyelids and Orbit
Whereas the skin and muscles comprise the anterior lamella, the tarsoligamentous
sling creates the support structure for the posterior lamella. The tarsal plates con-
stitute the connective tissue framework of the upper and lower eyelids. The upper
lid tarsal plate is approximately 30 mm horizontally and 10 mm vertically at its
widest dimension. Attachments to the upper lid tarsal plate include the pretarsal or-
bicularis and the levator aponeurosis on the anterior surface, Müller’s muscle on the
superior border, and conjunctiva on the posterior surface. The lower lid tarsal plate
measures approximately 28 mm horizontally and 4 mm in vertical dimension. At-
tachments to the lower lid tarsal plate include the pretarsal orbicularis, capsu-
lopalpebral fascia, and conjunctiva. The tarsal plates of the upper and lower eyelids
are attached to the orbital rim by the medial and lateral canthal tendons and reti-
nacular support structures. The canthal ligaments are the fibrous extensions of the
tarsal plate, whereas the canthal tendons represent the insertion of the deep heads
of the orbicularis oculi muscle to the bone, thereby constituting a true tendon.
The medial canthus is a complex structure that forms the medial fixation point for the
medial commissure consisting of an anterior and posterior reflection of the medial
canthal tendon as well as the medial retinaculum. The anterior reflection of the me-
dial canthal tendon inserts on the anterior nasolacrimal crest formed by the frontal
process of the maxilla and is anterior to the lacrimal sac. The posterior reflection of
the medial canthal tendon is deep to the lacrimal sac and inserts on the posterior
lacrimal crest on the lacrimal bone. The medial retinaculum is a complex structure
formed by the deep head of the pretarsal orbicularis, the orbital septum, the medial
extent of Lockwood’s inferior suspensory ligament, the medial horn of the levator
aponeurosis, the medial rectus cheek ligaments, and Whitnall’s ligament. The medial
retinaculum represents a fixed fulcrum point to maintain medial canthal position,
allowing the orbi cularis muscles to act on lid position rather than medial canthal
position.
Lockwood’s inferior
suspensory ligament
Lateral canthal tendon
Arcuate expansion
Inferior tarsal muscle
Müller’s muscle
Posterior reflection
of medial canthal tendon
Lacrimal sac fossa
Anterior reflection
of medial canthal tendon
Posterior lacrimal crest
Anterior lacrimal crest

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Part VI  Eyelid Surgery
In addition to the tarsal plates and canthal tendons, support structures in the upper
and lower eyelids stabilize the tarsoligamentous sling. The superior transverse liga-
ment of Whitnall is partially formed by the fascia of levator palpebrae superioris.
Whitnall’s ligament has a medial insertion at the trochlea of the superior oblique
and a lateral insertion at the lacrimal gland pseudocapsule and the frontal bone of the
lacrimal sac fossa. The function of Whitnall’s ligament is to act as a fulcrum to con-
Eisler’s pocket
Anterior reflection
lateral canthal tendon
Whitnall’s tubercle
Lateral orbital raphe
Posterior reflection
lateral canthal tendon
The lateral canthus also consists of a complex connective tissue framework that func-
tions as an integral fixation point for the lower lid. The lateral canthal tendon, which
is approximately 5 mm in length, is formed by fibrous crura which connect the tarsal
plate to Whitnall’s lateral orbital tubercle within the lateral orbital rim. In addition,
the lateral retinaculum is formed by ligamentous structures from the lateral horn of
the levator aponeurosis, lateral rectus cheek ligaments, Whitnall’s suspensory liga-
ment, and Lockwood’s inferior suspensory ligament, which converge at the lateral
canthal tendon. Although the lateral retinaculum represents the lateral point of fix-
ation, there is some lateral mobility of the commissure during lateral gaze in order
to increase the lateral visual field. This anatomic finding predisposes the lateral can-
thus to the development of laxity and phimosis or medial migration with age, as op-
posed to the medial canthus, which remains relatively fixed.
Inferior rectus muscle
Lockwood’s inferior
suspensory ligament
Inferior tarsal muscle
Capsulopalpebral fascia
Inferior oblique muscle

vert the vector of pull of the levator palpebrae superioris muscle from a posterior
vector originating from the lesser wing of the sphenoid to a superior vector in order
to elevate the eyelid. Therefore Whitnall’s ligament functions as an anatomic pulley or
check ligament so that the upper lid does not pull away from the globe during open-
ing. The lower eyelid has an analogous inferior suspensory ligament, Lockwood’s
ligament. Lockwood’s ligament arises from the medial and lateral retinaculum and
fuses with the capsulopalpebral fascia anterior to the inferior oblique muscle, prior
to inserting on the inferior tarsal border. The arcuate expansion of Lockwood’s lig-
ament, Clifford’s ligament, inserts into the inferolateral orbital rim and fuses with
the interpad septum between the central and lateral fat compartments of the lower
eyelid. The function of Lockwood’s ligament is to stabilize the lower lid on down-
gaze, while the lower lid retractors cause lid depression of the eyelid to increase the
inferior visual field during downgaze.
Upper Lid Retractors
Levator Palpebrae Superioris and Müller’s Muscle
815
Chapter 26  Applied Anatomy of the Eyelids and Orbit
While the primary function of the orbicularis oculi muscle is to provide varying de-
grees of eyelid closure, the muscle antagonists located within the orbit function to
open the eyelids. The upper eyelid retractors include the levator palpebrae superioris
muscle and Müller’s superior tarsal muscle. The levator muscle is striated muscle and
is innervated by the superior division of the third cranial nerve. The levator muscle
originates from the lesser wing of the sphenoid at the orbital apex and inserts along
the anterior surface of the tarsal plate, stabilizing the pretarsal orbicularis muscle.
The levator aponeurosis begins at the musculoaponeurotic junction, which is 10 to
14 mm below Whitnall’s ligament and 5 to 7 mm above the superior border of the
tarsal plate. The levator aponeurosis inserts into the dermis at the superior tarsal
border and fuses with the septum to create the upper eyelid crease. Disinsertion of
Lockwood’s inferior
suspensory ligament
Lateral horn
of levator muscle
Arcuate expansion
Lateral retinaculum
Whitnall’s ligament
Levator palpebrae
superioris muscle
Trochlea
Capsulopalpebral
fascia
Inferior tarsal plate
Inferior oblique muscle
Orbital lobe
of lacrimal gland
Palpebral lobe
of lacrimal gland

the levator aponeurosis results in lid ptosis with descent of the tarsal plate and ele-
vation of the lid crease. Inferior to Whitnall’s ligament, the levator aponeurosis widens
to form lateral and medial horns. The lateral horn divides the lacrimal gland into
orbital and palpebral lobes, and inserts into the lateral orbital tubercle and lateral
retinaculum as well as the capsulopalpebral fascia of the lower eyelid. The medial
horn inserts into the posterior reflection of the medial canthal tendon. The function
of the levator horns is to distribute the forces of the levator muscle equally along the
aponeurosis, thereby allowing the majority of lid elevation to occur centrally.
In addition to the levator palpebrae superioris muscle, Müller’s superior tarsal mus-
cle contributes to eyelid opening. Müller’s muscle is smooth muscle that originates
from the posterior surface of the levator muscle and inserts into the superior tarsal
border. Müller’s muscle is innervated by the sympathetic nervous system from the
superior cervical ganglion. Innervation passes through the cavernous sinus and op-
tic canal to enter to orbit with the ophthalmic artery. As well as mechanical dehis-
cence of the levator aponeurosis, upper lid ptosis can be caused by abnormalities of
the third cranial nerve resulting in levator muscle weakness or by loss of sympathetic
nerve supply causing Müller’s muscle weakness resulting in Horner’s syndrome. Or-
bital Horner’s syndrome from orbital apex tumor or trauma includes ptosis and
meiosis, whereas Horner’s syndrome from a Pancoast thoracic tumor includes ipsi-
lateral anhydrosis to complete the triad.
Lower Lid Retractors
The lower lid retractors include the capsulopalpebral fascia and the inferior tarsal
muscle, which are closely applied. The capsulopalpebral fascia originates from the
inferior rectus fascia and splits to envelop the inferior oblique muscle. The capsu-
lopalpebral fascia inserts into the inferior tarsal border and the dermis to create the
lower eyelid crease. The capsulopalpebral fascia is lined by conjunctiva and the
inferior tarsal muscle. The inferior tarsal muscle is smooth muscle innervated by
the sympathetic nervous system, which functions to depress the lower lid on down
gaze. In the lower eyelid the capsulopalpebral fascia is analogous to the levator
aponeurosis in the upper lid, and the inferior tarsal muscle is analogous to Müller’s
muscle.
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Part VI  Eyelid Surgery

817
Chapter 26  Applied Anatomy of the Eyelids and Orbit
Orbital Septum
The orbital septum separates the anterior and posterior lamella, and helps maintain
periorbital fat within the anatomic confines of the orbit. The orbital septum origi-
nates from an area of periosteal thickening called the arcus marginalis at the orbital
rim. The orbital septum originates deep to the lacrimal sac along the posterior
lacrimal crest and continues around the orbit in a spiral fashion passing deep to
Whitnall’s tubercle at the level of the lateral orbital rim. Inferomedially, the septum
originates from the anterior lacrimal crest. It is therefore discontinuous at the me-
dial canthus. In the upper eyelid, the septum fuses with the levator aponeurosis ap-
proximately 2 to 3 mm above the tarsal plate. In the lower lid, the septum fuses with
the capsulopalpebral fascia just below the tarsal plate. There are numerous addi-
tional interpad and intrapad septal structures, which separate the central and nasal
fat pad in the upper eyelid and the central and lateral fat pad in the lower eyelid.
Lateral canthal tendon
Levator aponeurosis
Medial canthal tendon
Septum discontinuous
at medial canthus
Arcus marginalis
Arcus marginalis
Superior orbital septum
Inferior orbital septum
Path of inferior
oblique muscle
Lacrimal gland
Arcuate expansion
of Lockwood’s ligament
Lateral canthal tendon
Medial canthal tendon
Lateral fat pad
Nasal fat pad
Central fat pad
Preaponeurotic fat
Medial palpebral artery

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Part VI  Eyelid Surgery
Appreciation of the anatomy of the septum is important, particularly when surgical
procedures such as resetting, tightening, or excising the septum are considered. A rare
cause of blindness following blepharoplasty is retrobulbar hematoma, also known
as acute orbital compartment syndrome. The globe and retrobulbar contents are en-
closed within a relatively rigid cone, with bony walls to the orbit laterally and pos-
teriorly, and the inexpansile orbital septum anteriorly. Therefore any increase in or-
bital content volume increases pressure in the compartment and decreases tissue
perfusion. This can occur following blepharoplasty due to postseptal bleeding from
orbital vessels and can lead to blindness if not promptly treated. In 2004 Hass et al
published results of a survey of members of the American Society of Ophthalmic,
Plastic and Reconstructive Surgeons (ASOPRS) to ascertain the incidence of retro-
bulbar hematoma following blepharoplasty. The reported incidence was 0.055%
(149 of 269,433 patients), and the reported rate of permanent visual loss following
this was 0.0045% (12 patients). Most cases occurred within 3 hours, with 96% oc-
curring by 24 hours. Hemorrhage was commonly associated with Valsalva-type ma-
neuvers such as coughing or vomiting.
Orbital Fat Pads
Posterior to the orbital septum, the periorbital fat pads play an important role in
both upper and lower blepharoplasty. There are two main fat pads in the upper eye-
lid and three fat pads in the lower eyelid. The two upper fat pads are referred to as
the central and nasal fat pads, which are located in the preaponeurotic space just an-
terior to the levator aponeurosis. The interpad septum arises from the orbital sep-
tum and inserts into the levator aponeurosis. It separates the central and nasal fat
pads and is continuous with a septal fascial connection to the trochlea. The nasal fat
pad has been shown to be more fibrous and is pale in color compared to the more
yellow colored central fat pad.
Eisler’s fat pad
Nasal fat pad
Inferior oblique muscle
Lacrimal gland
Arcuate expansion
of Lockwood’s ligament
Lateral canthal tendon
Medial canthal tendon
Lateral fat pad
Interpad septum
Nasal fat pad
Central fat pad
Central fat pad

The intrapad septum separates the nasal fat into two compartments. The medial
palpebral artery is located in the inferior nasal compartment and can contribute to
significant bleeding during blepharoplasty. The central fat pad is superficial to the
levator aponeurosis, in the preaponeurotic space, and contributes to the fullness of the
upper lid fold. Histologically, the nasal fat pad has larger fat globules, and the central
fat pad has more intrapad septa and finer blood vessels. These differences are thought
to be due to different embryologic origins as well as different fatty acid constituents
of the nasal and central fat pads.
Although the lateral compartment of the upper eyelid consists of the lacrimal gland,
studies have shown that a lateral extension of the central preaponeurotic fat pad ex-
tends to the lateral upper compartment in 15% to 20% of patients. The lateral ex-
tension of the central fat pad is anterior to the orbital lobe of the lacrimal gland and
can be easily dissected away from the gland. The lacrimal gland lacks a true capsule,
and is divided into the orbital and palpebral lobes by the lateral horn of the levator.
The orbital lobe is positioned in the fossa glandulae lacrimalis, which is a shallow
fossa in the frontal bone at the superolateral orbit. The smaller palpebral lobe is con-
nected to the orbital lobe by an isthmus posterior to the lateral horn of the levator
muscle. Lacrimal gland ptosis is caused by dehiscence of Sommering’s ligaments,
which are the fibrous interlobular septa that connect the gland to the orbital rim
fossa. Fullness in the lateral aspect of the upper eyelid is often caused by lacrimal
gland ptosis. Lateral to the lacrimal gland is a separate compartment just above Whit-
nall’s tubercle. Eisler’s pocket, which was described by Kestinbaum, is formed by the
space created by the septum and the lateral canthal tendon inserting on Whitnall’s
tubercle. Eisler’s fat pad is a small accessory fat pad located in Eisler’s pocket, which
serves as a useful anatomic landmark for Whitnall’s tubercle. The location of this fat
pad is clinically useful during placement of the lateral canthoplasty suture.
There are three fat pockets in the lower eyelid: central, nasal, and lateral. The nasal
compartment in the lower eyelid is similar in makeup to the nasal compartment of
the upper eyelid with more fibrous, pale fat. The inferior oblique muscle is commonly
visible during blepharoplasty and separates the nasal and central fat compartments.
The central and lateral fat compartments are separated by an interpad septum as
well as a fascial extension from Lockwood’s ligament, the arcuate expansion. Recent
MRI imaging of the orbit has demonstrated an increase in the total orbital fat vol-
ume with age, particularly in the central and lateral regions. This increase was not
seen anterior to the orbital rim. Darcy et al think that increased fat volume is a con-
tributing factor to increased lower lid prominence with age and support the re-
moval of fat from the central and lateral compartments during blepharoplasty. The
arcuate expansion of Lockwood’s ligament should be preserved during lower lid dis-
section to maintain lateral support. Because the nasal and central fat pads envelop
the inferior oblique muscle, aggressive fat transposition techniques that suture the
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Chapter 26  Applied Anatomy of the Eyelids and Orbit

fat below the rim can result in diplopia from impaired inferior oblique function from
a lasso effect. The lateral extent of the lateral fat pocket includes the lateral retinac-
ulum and lateral canthal tendon.
The most posterior layer of the eyelid is the conjunctival lining, which reflects on it-
self at the fornix and covers Tenon’s capsule. The palpebral portion of the conjunc-
tiva is closely adherent to the posterior surface of the tarsal plate and the lid retrac-
tors. At the fornix, the conjunctiva becomes bulbar conjunctiva overlying the globe
to the corneoscleral limbus. Small accessory glands are located within the conjunc-
tiva, creating the aqueous portion of the tear film.
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Part VI  Eyelid Surgery
SOOF
Müller’s muscle
Levator palpebrae superioris muscle
Superior rectus muscle
Inferior rectus muscle
Inferior oblique muscle
Inferior orbital rim
Arcus marginalis
Superior orbital rim
Eyebrow
Brow fat pad (ROOF)
Postseptal fat
Orbital septum
Levator aponeurosis
Dermal insertions forming upper eyelid crease
Conjunctiva
Superior tarsal plate
Pretarsal orbicularis muscle
Inferior tarsal plate
Inferior pretarsal muscle
Capsulopalpebral fascia lid retractors
Postseptal fat
Inferior septum
Orbitomalar ligament
The cross-sectional anatomy of the eyelid and periorbital region demonstrates the
creation of the upper lid crease formed by the fusion of the orbital septum, levator
aponeurosis, and upper lid dermis. The anatomy of the lower eyelid fornix is clini-
cally important because the transconjunctival approach to blepharoplasty is often
used. The orbital fat can be removed by a transeptal (preseptal) approach, which di-
vides the conjunctiva, capsulopalpebral fascia, and septum, or by a retroseptal (post-
septal) incision through the conjunctiva and capsulopalpebral fascia, leaving the sep-
tum intact.

Neurovascular Supply
Motor Innervation
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Chapter 26  Applied Anatomy of the Eyelids and Orbit
The motor innervation to the orbicularis oculi muscle is quite diffuse, with contri-
butions from multiple branches of the facial nerve, including the frontal, zygomatic,
and buccal branches. The major nerve supply enters the medial aspect of the orbi -
cularis, along with an additional supply laterally. The terminal muscles innervated by
the frontal branch include the frontalis muscle and the transverse head of the corru -
gator supercilii. Additionally, the frontal branch provides innervation to the upper
lid pretarsal and preseptal divisions of orbicularis, which are noted clinically by the
presence of a weakened blink after frontal branch injury. The terminal muscles in-
nervated by the zygomatic branch of the facial nerve include the zygomaticus major
and the oblique head of the corrugator muscle. The buccal branch of the facial nerve
innervates the terminal facial mimetic muscles medially and the procerus muscle.
Cadaveric dissection reveals a diffuse plexus of nerves innervating the orbicularis
oculi muscle. These branches pass both superficial to the origin of the zygomaticus
major supplying the lateral orbicularis and deep to the zygomaticus major continu-
ing to supply the medial orbicularis.
Zygomatic nerve
branches
Buccal nerve
branches
Frontal nerve
branches
Buccal
nerve
branch
Zygomaticus
major muscle
or branch

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Part VI  Eyelid Surgery
The buccal branch also supplies a diffuse plexus of nerve branches to the medial
palpebral orbicularis, including the deep heads in both the upper and lower eyelid
that contribute to voluntary and involuntary lid closure. This is clinically evident by
impaired upper eyelid closure after an isolated medial lower lid incision over the na-
solacrimal crest following dacryocystorhinostomy (DCR) or Mohs surgery, despite the
absence of an upper lid incision.
Sensory Innervation
Sensory innervation of the eyelids arises from the ophthalmic and maxillary divi-
sions of the trigeminal nerve. Upper lid sensory impulses are transmitted through
supratrochlear, supraorbital, and lacrimal nerves, which are branches of the oph-
thalmic division. The ophthalmic nerve also provides sensation to the medial por-
tions of the upper and lower eyelids by the infratrochlear branch. The major sensory
input to the lower lid is from the infraorbital nerve, which is a major branch of the
maxillary nerve. The remainder of the lower lid receives sensory input from the zy-
gomaticofacial branch and the zygomaticotemporal branch of the maxillary nerve.
Zygomaticotemporal
nerve
Supraorbital nerve
Lacrimal nerve
Zygomaticofacial nerve
Supratrochlear nerve
Infratrochlear nerve
Infraorbital nerve