CLINICAL STUDY
Brow Ptosis: Is Transblepharoplasty Internal Browpexy
Suitable for Everyone?
Arie Y. Nemet, MD
Purpose: Transcutaneous internal browpexy can provide patients
with mild-to-moderate lateral brow ptosis, stabilization and modest
lift of the lateral brow. Questions regarding effectiveness of this
procedure and appropriate indications remain.
Methods: The authors measured consecutive patients who
underwent upper eyelid blepharoplasty with transblepharoplasty
internal browpexy (TIB) September 2014 to December 2017.
Pre- and postoperative brow elevation was assessed based on
before and after photographs of each patient. Patient photographs
were assessed for medial and lateral brow elevation, brow
contouring and asymmetry. Optimal lateral brow elevation was
classified as bilateral symmetrical and above the supraorbital rim
for women, and symmetrical and at the supraorbital rim for men.
Results: A total of 239 patients underwent bilateral TIB and 39
underwent unilateral TIB (517 eyelids in total). Pre- and post-
operative measurements were taken in 98 patients (41%), with an
average elevation of the lateral brow position of 2.54 mm.
Six patients had an underlying infection in the first postoperative
week that resolved completely. Three patients underwent a second
stage direct brow lift repair and 3 needed unrecognized ptosis repair
as a second stage.
Conclusions: Transblepharoplasty internal browpexy is an
important tool that can be used in most patients with lateral and
central brow ptosis, asymmetric brow ptosis and irregular contour
of the brow. Additionally, browpexy adds to the success and
longevity of upper blepharoplasty, while preventing early
recurrence of lateral upper eyelid hooding. Patients with
significant ptosis, heavy brows, medial greater than lateral
ptosis, and post-facial palsy may not be good candidates for this
procedure.
Key Words: Blepharoplasty, brow ptosis, transblepharoplasty
internal browpexy
(J Craniofac Surg 2019;30: 2425–2428)
From the Department of Ophthalmology, Meir Medical Center, Kfar Sava,
Israel.
Received December 27, 2018.
Accepted for publication April 24, 2019.
Address correspondence and reprint requests to Arie Y. Nemet, MD,
Department of Ophthalmology, Meir Medical Center, Kfar Sava, Israel;
E-mail: nemet.arik@gmail.com
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005680
The Journal of Craniofacial Surgery  Volume 30, Number 8, November/December 20192425
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
B row ptosis is an important part of the preoperative assessment of
blepharoplasty patients. A subset of patients will manifest latent
brow ptosis after eyelid surgery. It has been shown that ptosis
surgery, whether done via Muller’s muscle-conjunctival resection
or by external levator advancement, leads to a decrease in brow
height.1,2 In cases of blepharoplasty alone, results regarding change
in brow height are mixed.3 Ptosis of the tail of the brow is the most
frequently encountered brow deficit4,5 and minimally invasive
browpexy procedures have been described to address this issue.4,6
Traditional browpexy involves internal brow suspension accessed
through an eyelid crease incision during blepharoplasty.7 Several
articles have presented modifications of the original technique.6
Browpexy procedures can provide patients who have mild-to-
moderate lateral brow ptosis, stabilization and modest lifting
of the lateral brow. They can create a subjectively more pleasing
3-dimensional contour of the brow fat pad.6
Transblepharoplasty internal browpexy (TIB) is performed from
below, whereas external browpexy and temporal brow lift techni-
ques are from above. Thus, it was expected that TIB would result in
less elevation compared to the other methods. However, 2 recent
papers have shown that internal browpexy (IB) is an appropriate
choice and provides a favorable outcome. Zandi et al concluded that
compared to temporal brow lift, TIB could be considered the better
procedure for patients with upper eyelid dermatochalasis in terms of
long-lasting stability and lateral brow elevation.8 Another study
reported that TIB provided an average of 2.29 mm of lateral lift,9
with no statistically significant difference compared to external
browpexy.
The purposes of the present study were to learn which brow
cases should be considered appropriate for TIB, whether the
procedure is appropriate for asymmetric brow ptosis cases and
its advantages and the disadvantages.
METHODS
Study Population
All consecutive patients who underwent upper eyelid blepharo-
plasty with additional TIB from 9/2014 through 12/2017 were
evaluated. All surgeries were performed by the author. Patients’
head position, gaze, and camera position are standardized during all
measurements to provide a reproducible and accurate photograph of
the eyelids.
Eyelid evaluation included clinical assessment of eyelids, lid
crease, and excess skin and muscle. Brow assessment included
height, stability, contour, and symmetry. Ptosis measurements
included marginal reflex distance1, levator function, the palpebral
fissure, and the presence of Bell’s phenomena. All patients under-
went Hertel exophthalmometry in the sitting position to measure
any difference in prominence of the globes. Lateral eyebrow height
was measured as the distance from the central inferior corneal
limbus under loupe magnification. This provides normative mea-
surements for eyebrow position.10
Inclusion criteria were unilateral and bilateral brow ptosis, with
or without brow instability, ages 45 to 70 years, no history of
congenital or acquired peri-orbital or orbital pathology or surgery,
Nemet The Journal of Craniofacial Surgery
and no strabismus. The study was approved by the institutional
review board. Informed consent was not required. The study
adhered to the ethical principles outlined in the Declaration of
Helsinki as amended in 2013.
Pre-operative Planning and Surgical Technique
The proper brow position and number of stitches was determined
with the patient in a sitting position. Any differences in the contour
and symmetry of the brows were considered.
Patients underwent standard upper blepharoplasty. Before clos-
ing the incision, the lower orbicularis muscle plane toward the
orbital rim was dissected with a blunt scissors. When the orbital rim
was exposed, dissection was extended to the periosteal plane using
a blunt instrument (Freer periosteal elevator or an applicator).
As hemostasis was achieved, a mattress suture using Vicryl 4-0
(polyglactin 910) (Ethicon Inc., Bridgewater, NJ) was used to attach
the superior orbital rim periosteum to the orbicularis oculi beneath
the temporal portion of eyebrow (Supplementary Digital Content,
http://links.lww.com/SCS/A572). Usually, 2 stitches were used on
each side, but sometimes 1 or 3 stitches were needed. It is important
to place the stitches tightly in all cases; especially those with severe
brow ptosis. This can limit the movement of the brows in the early
stages and immediate postoperative overcorrection is desired. At
this stage, the area between the skin and the orbicularis was
undermined to create a free skin flap, to prevent postoperative
dimpling. The blepharoplasty incision was sutured in a standard
manner with running 6–0 Vicryl Rapide (polyglactin 910) suture
(Ethicon). This was repeated on the contralateral side.
Patients were seen for follow-up 1 week, and 3 and 6 months
after the procedure. Pre- and postoperative degree of brow
elevation was assessed using before and after photographs for
each patient. Photographs were taken in the frontal, oblique, left,
and right positions before the procedure and during each patient’s
final postoperative visit. Patient photographs were assessed
for lateral brow elevation. Optimal lateral brow elevation was
classified as symmetrical and above the supraorbital rim bilater-
ally for women, and symmetrical and at the supraorbital rim
for men.
RESULTS
This study reports the results of 239 patients (of total of 2880 eyelid
surgeries [8.3%]), who underwent bilateral TIB and 39 who under-
went unilateral TIB. The remaining brow surgeries performed
during the same period included 15 patients who underwent
subcutaneous temporal brow lift, 10 of which underwent bilateral
direct brow lift, and 5 had unilateral direct brow lift. Pre- and
post-operative measurements were taken in 98 patients (41%). The
average elevation in lateral brow position was 2.54 mm (at the final
follow-up).
The area above the brow sutures was swollen for 2 to 4 weeks
postoperatively. There was usually tenderness for 2 weeks and then
primarily only tenderness to touch. Six patients (1.15%) had an
underlying local infection in the first postoperative week,
which resolved completely with a 7-day course of oral antibiotics.
Three patients needed a second stage repair of direct brow lift,
(1 bilaterally and 2 unilaterally), and 3 needed repair of previously
unrecognized ptosis as a second stage.
DISCUSSION
Traditional brow lift techniques involve suprabrow incisions or
mobilization of the entire forehead and brow through open or
endoscopic approaches. These techniques produce a powerful lift
and are excellent options for the appropriate patient. However, they
2426
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 8, November/December 2019
can be associated with unsightly scarring, alopecia, neurosensory
deficit and can be cost-prohibitive.3,9
A direct brow lift can provide excellent results in patients who
have deep suprabrow rhytids or bushy eyebrows, but the scar can be
difficult to hide. The procedure can noticeably change the brow
contour, as well.11
Other surgical options involve less invasive browpexy proce-
dures.4,12 These include TIB. McCord and Doxanas7 first described
what has become known as an IB. The TIB can prevent the descent
of the lateral brow after blepharoplasty following volume loss. The
TIB is attractive due to the lack of an additional external incision,
minimal tissue damage, and bleeding. It is generally straightforward
and free of complications and is easily learned by clinicians.13
Eyebrows and eyelids vary among races, ages, and genders. It is
clear that each case is different and that adjusting the position of the
eyelids and brows is complex, with interplay between muscles and
connective tissue structures with neuronal pathways and interac-
tions.6 The current paper discussed the primary considerations
regarding brow ptosis repair and considerations for when TIB
is appropriate.
Infection
Six patients (1.16%) had an underlying local infection in the first
postoperative week, which resolved completely with a 7-day course
of oral antibiotics. It seemed to be related to sutures. We used Vycril
4-0 which dissolves. The suture entry sites into the skin may provide
a conduit for transmitting infectious agents from the external
environment.14 Studies in mice have demonstrated increased
adherence of bacteria to multifilament (braided) subcutaneous
sutures when compared with monofilament sutures.15 This
increased bacterial adherence is correlated with higher infection
rates when multifilament sutures are used.
Excessive manipulation of the wound edges and suture place-
ment that impairs dermal capillary blood flow leads to ischemia,
thereby increasing infection risk. Electrocautery results in necrotic
tissue, which causes a local immune reaction. Dead space in the
wound and ineffective hemostasis predispose to the development of
hematoma and seroma, which provide an ideal growth medium for
bacteria and causes tension on wound edges.16
It is possible that using a mono filament absorbable suture such
as PDS or small non absorbable such as Nylon or Propylene would
prevent such a stitch infection.
Considerations When Selecting Cases
When dealing with brow ptosis, 1 objective is lifting the brow.
However, the amount of elevation is only 1 aspect of brow eleva-
tion. Other key factors include achieving symmetrical height of the
brows, stability and proper contouring.
Brow Contouring
For the modern acceptable concept of the ideal brow, the apex of
the brow should lie on a vertical line directly above the lateral
limbus, while the medial and lateral ends of the brow are approxi-
mately in the same horizontal plane.17 Medial placement of the
brow peak would create an undesirable ‘surprised’ appearance,
while a low medial brow with a high lateral peak induces an angry
look.17
Lateral Brow Elevation
The level of the brow and the amount of upper lid skin are highly
dependent on frontalis activation, a process that is dependent on the
position of the head, direction of gaze, level of activation, and other
factors, most of which are not under complete voluntary control.18
# 2019 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 30, Number 8, November/December 2019Transblepharoplasty Internal Browpexy

The brow position after the transpalpebral browpexy significantly

descends, despite an improvement in subjective aesthetic out-
come.19 It is generally accepted that the skin/muscle resection
during blepharoplasty has a pronounced effect on the dynamic
eyelid/eyebrow system in such a way that the frontalis activation
necessary to compensate for the upper lid with dermatochalasis is
markedly reduced, leading to descent of the brow.20 Throughout the
postoperative observations, there was evidence of stabilization of
descent of the brows of 0.5 mm to 1 mm (after 6 months). The final
lift averaged 2.54 mm. Some studies have evaluated the amount of
elevation in brow lifting procedures.6 Mokhtarzadeha et al showed
that the average elevation in lateral brow position was 2.29 mm, and
1.47 mm in the central brow position TIB group, and 2.97 mm/
1.90 mm in the external browpexy group.21 Baker reported that the
quantitated internal suture browpexy prevented brow descent, with
lateral brow elevation of 1.3 mm (right eye) and 0.9 mm (left eye).22
In cases of brow ptosis with lateral hooding, TIB can result in
significant elevation. The amount of lateral brow lift depends on the
position of the brow attachments to the periosteum. If the drooping
is on the tail of the brow, and the body is stable and equal between
the 2 sides, TIB is a good option and can lift even 4 to 5 mm. At least
2 stitches should be used on the lateral brow to achieve this. The
new attachment to the brow is strong and has long-lasting stability
(Fig. 1A-D).

Gender Differences of Eyebrow Shapes

The male and female brows differ in shape and position. Any
surgical brow procedure should consider the patient’s gender. The
normal male brow is flat, more prominent and fuller than the female
brow, which is thinner and typically arched, with the highest point
above the lateral canthus or slightly more medially. The male brow
is fixed squarely at the superior orbital rim, while the position of the
female brow is well above the rim, especially temporally, where the
superior lateral part of the bony rim contour is visible and easily
palpable.17,23
Asymmetry
In our experience, IB can be performed for asymmetric brow
ptosis if the brow is free of deep attachments and if every point of
change differs less than a maximum of 4 mm as compared to the
opposite side. In cases of irregular contour, IB is even more accurate
than is mobilization of the entire forehead and brow through open or
endoscopic approaches, as it can precisely address the point of
drooping.9 In the current series, 3 patients needed a second stage
repair of direct brow lift, (1 bilaterally and 2 unilaterally). We did
not notice postoperative asymmetry in bilateral brow ptosis cases.
Asymmetry improved in all unilateral cases. Preoperative assess-
ment of asymmetry is imperative to achieve postoperative symme-
try. This is important to note, given the importance of facial
symmetry in defining beauty.24 Symmetric eyelids are very impor-
tant and depend on the marginal reflex distance 1, excess eyelid skin
and brow height. Eyelid asymmetry caused by asymmetrical eye-
brows will tend to be more obvious postoperatively if the brow level
is not corrected. Preoperative evaluation is sometimes challenging
as some forms of asymmetry are camouflaged by pronounced
blepharochalasis and blepharoptosis.25
When evaluating for blepharoplasty, patients often desire
improved cosmesis and/or correction of visual field deficits. How-
ever, they are frequently unaware of their own eyelid or brow
asymmetry.26,27 One study evaluated 100 patients for brow and
eyelid symmetry preoperatively and found that 93% had at least 1
asymmetric measurement greater than 1 mm. Also, 75% had at least
1 measurement greater than 2 mm, while 37% had at least 1
asymmetrical measurement more than 3 mm.28
FIGURE 1. A 46-year-old male with upper lid dermatochalasis and lateral brow
hooding pre (A) and post (B) transblepharoplasty internal browpexy and upper
lid blepharoplasty. A 51-year-old female with upper lid dermatochalasis and
lateral brow hooding pre (C) and post (D) transblepharoplasty internal
browpexy and upper lid blepharoplasty. A 58-year-old male with significant
brow asymmetry and right brow ptosis, pre (E) and post (F) transblepharoplasty
internal browpexy and upper lid blepharoplasty. A 6 mm lateral brow lift was
achieved. A 52-year-old female with significant brow asymmetry and left brow
ptosis, pre (G) and post (H) transblepharoplasty internal browpexy and upper lid
blepharoplasty. A 5 mm lateral brow lift was achieved. A 66-year-old woman,
post-facial nerve palsy with left brow ptosis, pre (I) and post (J) left direct brow
ptosis repair.
Mühlbauer et al explored the causes of eyebrow asymmetry.
Several people develop mimetic brow asymmetry with 1 side higher
than the other. Over time, this habitually raised eyebrow may lead
to unilateral hyperkinesia of 1 frontalis muscle. Patients are unable
to relax the frontalis muscle voluntarily while awake. Mimetic
hyperactivity or emotional stress may accentuate the asymmetry.
The muscular hyperkinesia may be documented with electromyog-
raphy.25 Brow asymmetry can occur along the entire length or in
1 region—the head, body or tail of the brow. When brow lift is
performed from the forehead, the whole brow is lifted, whereas in
IB some of the points that are drooping can be addressed more
precisely (Fig. 1E-H).
Full-Length Brow Ptosis
In cases where the entire length of the brow droops, IB may still
be a good option when the attachments are lax, the brow is free to
move upward, and there are significant differences between brow
heights. We have 6 cases in which a 6 mm lift was achieved (Fig. 1E
and F). In such a case, the periosteum should be exposed along the
full length of the eyelid, taking care to prevent damage to the
supraorbital vessels. Three to 4 stitches should be used to achieve an
even contour of the brow. Overcorrection of 2 mm is required and
lifting the central portion usually adds up to 2 mm of lift.

# 2019 Mutaz B. Habal, MD 2427

Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Nemet The Journal of Craniofacial Surgery
Cases Inappropriate for TIB and Other
Considerations Regarding TIB
In our series, we found that TIB has significant advantages when
performed for the right indications. However, patients with
the following conditions might not be good candidates for this
procedure:
 A large brow descent—whenever the difference between
brows is more than 6 mm, IB probably will not achieve the
required elevation. However, a lift of 6 mm was achieved in
some of our cases.
 Facial palsy—in cases of a brow descent resulting from palsy,
since there is no active muscle, the brow must be lifted much
more aggressively, usually using a direct brow lift (Fig. 1I and J).
 Deep set eyes—whenever the eyes are very deep set, usually
as result of atrophy of the periocular fat, brow lift might
accentuate the difference between the eyelids as pulling the
brow pulls the eyelid skin. In such cases, the deep sulcus
below the brow may remain prominent. Despite stabilization
of the brow, the paucity of subcutaneous fat makes the points
of fixation more prominent. In these cases, soft tissue should
be added to this area.
 Heavy brows—some patients have thick skin, subcutaneous
tissue, and brow, which causes a feeling of heaviness over the
eyes. The distance between the brow tail and the rim of the
bone is narrow. In some of these conditions, the brow position
is very low and lifting may achieve limited improvement
if any. In some cases, direct brow lift can achieve
greater improvement.
 Complex cases—for cases with a combination of blephar-
optosis, dermatochalasis, and brow ptosis, each part of the
droopy eyelid should be considered. Preoperatively, it is
important to measure the brow height while relaxing the
uncontrolled muscles, especially the frontalis muscle. This is
accomplished by placing hand pressure over the brows and
asking the patient to relax the periocular muscles.
CONCLUSION
The TIB allows surgeons to treat dermatochalasis and/or blephar-
optosis, while simultaneously treating lateral brow ptosis, and even
the central brow through the same incision. Additionally, browpexy
adds to the effectiveness and longevity of upper blepharoplasty,
while preventing early recurrent lateral upper eyelid hooding. This
method has significant advantages when performed for the right
indications. However, patients with significant ptosis, heavy brows,
medial greater than lateral ptosis, or post-facial palsy might not be
good candidates for this procedure.
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# 2019 Mutaz B. Habal, MD