Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and Brow Lift

Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and... Abstract Background Upper eyelid dermatochalasis often triggers frontalis hyperactivity in an effort to elevate the upper lids away from the visual axis. Similarly, prior neuromodulator treatment of the brow depressors may cause false elevation of the brows, diminishing the extent of preoperative brow ptosis or dermatochalasis. Studies have quantified postoperative brow ptosis and recurrent dermatochalasis following upper blepharoplasty, but a methodology to predict the postoperative brow position remains to be elucidated. Objectives The authors present our comprehensive perioperative protocol utilizing neuromodulators to optimize results of upper blepharoplasty and brow lift. Methods In patients presenting with upper lid dermatochalasis and frontalis hyperactivity, who request upper blepharoplasty, the authors apply a neuromodulator treatment protocol. Patients with prior neuromodulator treatment of brow depressors wait four months after the last treatment to allow for product attrition. Two weeks prior to surgery, the authors treat the frontalis with 15 to 20 units of Botox Cosmetic. Results From 2002 to 2016, the authors treated 521 patients (458 women, 63 men) with frontalis hyperactivity who presented for periorbital rejuvenation. This method has led to neither excessive resection of upper eyelid skin tissue nor lagophthalmos. Preoperatively, the authors have unveiled upper eyelid ptosis in 39 patients (31 women, 8 men) and brow ptosis in 131 patients (97 women, 34 men). Conclusions Brow position and frontalis hyperactivity should be taken into consideration during preoperative evaluation for upper blepharoplasty and brow lift. Routine preoperative treatment of the hyperactive frontalis with neuromodulator, along with attrition of prior neuromodulator in the brow depressors, reveals the true anatomic brow position to optimize surgical planning. Level of Evidence: 4 The periorbital region is one of the first areas to demonstrate signs of facial aging.1 Periorbital aging manifests with fat loss resulting in contour hollows along the upper lid sulcus and tear trough, dermatochalasis, prolapsed orbital fat, transverse and vertical forehead rhytids, crow’s feet, dermal elastosis and ptosis of the eyebrow complex especially laterally.2,3 In aesthetic rejuvenation, it is imperative to have a thorough understanding of the brow-lid continuum, the lid-cheek junction, and the soft tissue as well as bony changes that lead to perceived aging.1,2 The brow-lid continuum is composed of the upper third of the face, the forehead, brow, and upper eyelid.1 In examining this region, one must evaluate the static and mimetic changes and not focus on a single structure in isolation. Failure to do so prevents the examiner from recognizing latent problems masked by compensatory mechanisms. Unless there is comprehensive understanding of how these mechanisms affect the underlying brow-lid anatomy, attempts at aesthetic procedures to address patients’ concerns may be imprecise, necessitating secondary procedures. One of the most common compensatory mechanisms occurs when upper eyelid dermatochalasis or ptosis triggers or exacerbates hyperactivation of the frontalis muscle. This persistent contraction of the frontalis muscle while at rest chronically elevates the brows, often asymmetrically, thereby diminishing the accuracy in our assessment of the extent of brow/eyelid ptosis and full extent of upper lid dermatochalasis. If the upper eyelid dermatochalasis is surgically corrected in isolation, it will diminish the extent of hyperactivation of the frontalis muscle postoperatively, revealing the masked brow or lid ptosis.1 Preoperative neutralization of the frontalis muscle in cases of frontalis hyperactivity would minimize opposing vectors on the brow and upper eyelids to allow more accurate assessment and selection of the proper surgical approach to optimize the postoperative upper blepharoplasty results. Opposing the frontalis, the brow depressors act as counter vectors on the brow. Neutralization of the brow depressors preoperatively, a method often used in noninvasive treatment of brow ptosis or corrugator supercilii rhytids, leaves the frontalis muscle unopposed and accentuates the arch of the brow, which camouflages the extent of brow ptosis and upper eyelid dermatochalasis. Therefore, the degree of brow ptosis must be measured without the neuromodulator effect on the brow depressors. Contrarily, failure to recognize preoperative hyperactivation of the corrugator supercilii, procerus, and orbicularis oculi muscles could result in a postoperative diminished and suboptimal brow lift effect secondary to uninterrupted counter vectors. Therefore, unaltered depressor muscles in the preoperative period in conjunction with neutralization of the depressor muscles during the healing period following the brow lift procedure minimizes confounding factors on the brow and optimizes the ultimate result. Many studies outline relevant anatomy and emphasize the importance of evaluating the full brow-lid continuum in preoperative assessment.1,2,4-7 However, the method with which to optimize the final aesthetic result in patients who present for brow lift or blepharoplasty remains to be elucidated. Since the FDA approval of neuromodulators in the treatment of glabellar rhytids in 2002, we have gained experience with their utility in adjacent landmarks, including the brow elevator (frontalis muscle) and all of the brow depressors, (corrugator supercilii, procerus, and orbicularis oculi muscles). Neuromodulators can also be used to manipulate brow position in order to achieve an aesthetically pleasing brow shape by selectively treating opposing muscle groups. They have provided a noninvasive method to treat periorbital aging; consequently, they add another dimension to consider in preoperative evaluation in patients undergoing concomitant treatment with neuromodulators. In this paper, we hope to bridge the gap between nonsurgical and surgical treatment methods of lid/brow ptosis and dermatochalasis. We will outline our protocol for both the routine perioperative use of neuromodulators in the brow elevators and the strict avoidance of neuromodulators in the brow depressors in patients presenting with signs of periorbital aging and frontalis hyperactivity to improve aesthetic outcomes following upper blepharoplasty and brow lift procedures. METHODS This study describes a two-surgeon experience (I.S. and M.C.) in academic and private practice settings between July 2002 and July 2016. This is a retrospective chart review of 521 consecutive patients (458 women and 63 men) who presented for periorbital rejuvenation with frontalis hyperactivity. This is not an IRB-approved study; however, we have adhered to the guidelines set forth in the Declaration of Helsinki, with respect for the individual, their right to self-determination, and the right to make informed decisions regarding participation in research. Preoperative workup of our patients adhered to the current standard of care. In 2002, Botox Cosmetic (Allergan Pharmaceuticals Ireland, a subsidiary of Allergan, Inc., Irvine, CA) was FDA-approved for amelioration of glabellar lines. Hence, despite recent FDA-approval of Botox Cosmetic for temporary improvement of forehead lines associated with frontalis muscle activity in adults, our protocol does reflect off-label use of the product. All risks and benefits of treatment were discussed, and informed consent for treatment and surgery was obtained from all patients. Specific photo release consent forms were obtained from the patients’ whose photos we submitted. We have defined frontalis hyperactivity as the persistent contraction of the frontalis muscle while at rest. We have classified blepharoptosis by the position of the upper lid relative to the pupil, and brow ptosis by the position of the brow relative to the superior orbital rim, with the ideal female brow arching above the superior orbital rim, and the ideal male brow following the border of the superior orbital rim. Patients who underwent bilateral upper blepharoplasty were included into the study, while patients in whom we identified veiled upper eyelid ptosis were excluded from the study and referred to an oculoplastic surgeon. In surgical planning for brow lift and upper blepharoplasty, our goal is to achieve adequate elevation of the brow/lid continuum as well as address the skin and pseudoherniated fat pads of the upper eyelid. Hence, we must first neutralize all other confounding vectors that are falsely elevating the brow preoperatively, which includes frontalis muscle hyperactivity as well as neuromodulator-induced brow depressor muscle inactivity, leaving the frontalis muscle unopposed. In addition to the routine preoperative workup and evaluation of our patients according to the current standard of care, we have developed and adhere to a neuromodulator treatment protocol for patients presenting for upper blepharoplasty and brow lift procedures (Figure 1). All patients were treated with only one type of neuromodulator, Botox Cosmetic. Figure 1. View largeDownload slide Neuromodulator treatment protocol for patients presenting for upper blepharoplasty and brow lift procedures, following standard workup. Figure 1. View largeDownload slide Neuromodulator treatment protocol for patients presenting for upper blepharoplasty and brow lift procedures, following standard workup. Brow Elevators The prime elevator of the brow is the frontalis muscle. Most patients have some degree of frontalis resting tone, which keeps the eyebrow and eyelid skin out of the visual axis.7 Blepharoplasty or ptosis surgery decreases the frontalis compensatory drive once the excess skin is removed from the visual axis, which may result in eyebrow descent and subsequent superior sulcus effacement by the recruited eyebrow fat pad with shortening of the tarsal platform show.7 In addition, preoperative asymmetry may exacerbate as the asymmetric compensatory mechanism resolves. Prior to upper blepharoplasty, we treat the frontalis muscle with 15 to 20 units of Botox Cosmetic two weeks prior to the date of surgery, allowing the neuromodulator to reach its peak action prior to surgery. This neutralizes the hyperactivity of the frontalis and distinguishes the compensatory drive from intrinsic eyebrow asymmetry. Four to eight injection sites should be distributed along the deep rhytids of the forehead, spanning the width of the frontalis bilaterally, avoiding the midline (Figure 2). The dose of the Botox Cosmetic is dependent on the extent of frontalis hyperactivity and mimetic rhytids. We unveil the true eyebrow and eyelid position, and hence, the true extent of dermatochalasis, which allows us to perform a more adequate upper blepharoplasty and/or brow lift. We are also able to identify and address any underlying masked eyelid ptosis and true asymmetry in the brow position or extent of dermatochalasis in our surgical planning. Figure 2. View largeDownload slide A 61-year-old woman with frontalis hyperactivity, deep forehead rhytids at rest, and notable dermatochalasis. Four to eight neuromodulator injection sites should be distributed along the deep rhytids of the forehead, spanning the width of the frontalis bilaterally, avoiding the midline. Figure 2. View largeDownload slide A 61-year-old woman with frontalis hyperactivity, deep forehead rhytids at rest, and notable dermatochalasis. Four to eight neuromodulator injection sites should be distributed along the deep rhytids of the forehead, spanning the width of the frontalis bilaterally, avoiding the midline. Brow Depressors The corrugator supercilii, procerus, and orbicularis oculi muscles are brow depressors. Paralysis of these muscles through neuromodulation can falsely elevate the eyebrow, which impacts the measurements obtained in assessing the degree of brow elevation necessary in a brow lift and the degree of skin resection needed to address the dermatochalasis during an upper blepharoplasty. Supplemental Figure 1 illustrates the impact of neuromodulation on eyebrow position. This is a 65-year-old female who presented with dermatochalasis of the upper eyelids with notable eyebrow asymmetry, desiring facial rejuvenation. The patient’s right eyebrow is slightly higher, resulting in less apparent dermatochalasis compared to the left side (Supplemental Figure 1A). She was treated with 20 units of Botox Cosmetic in the brow depressors and along the outer orbicularis oculi. Two weeks later, in addition to having notable improvement in the asymmetry between the right and left brow and upper eyelids, she appears to have decreased severity in dermatochalasis (Supplemental Figure 1B). Prior neuromodulator treatment can confound the physical exam. Postoperatively, this may manifest as brow ptosis and upper eyelid dermatochalasis, respectively, once the neuromodulator effect wears off. In patients who have had prior neuromodulator treatment, we recommend waiting four months after the last treatment date before scheduling treatment to allow attrition of the preexisting product. RESULTS This is a retrospective chart review of 521 consecutive patients (458 women and 63 men) who presented for periorbital rejuvenation and upper blepharoplasty with frontalis hyperactivity. Patient age ranged from 18 to 74 years (mean, 52 years). Patients who underwent bilateral upper blepharoplasty were included into the study, while patients in whom we identified veiled upper eyelid ptosis were excluded from the study. One patient elected not to have surgery, and continued with only neuromodulator treatment. All patients were followed up for more than one year. Follow-up period ranged from one to 15 years (mean, 7 years). In our experience, preoperative treatment of the hyperactive frontalis with neuromodulators in the upper blepharoplasty cases has led to satisfactory results, without demand or need for revision surgery. Our treatment protocol has allowed us to preoperatively identify veiled upper eyelid ptosis in 39 patients (31 women and 8 men) and veiled brow ptosis in 131 patients (97 women and 34 men). All patients with upper eyelid ptosis were referred to an oculoplastic surgeon, while patients with brow ptosis were offered concurrent temporal brow lift. Of the 131 patients with brow ptosis, 19 patients consented to and underwent concurrent temporal brow lift. The remaining patients were content with the new lowered position of the brow, and accepted the position, choosing to undergo only bilateral upper blepharoplasty without concurrent temporal brow lift. As unveiling eyelid or brow ptosis potentially changes the operative management and plan, our protocol has the potential to impact the course of treatment for these patients. It allows the patient to recognize their final brow position prior to surgery, which enables them to make an informed decision on whether to proceed with a concurrent temporal brow lift vs noticing it postoperatively as an unforeseen complication of surgery. However, in the majority of cases, we are faced with more aesthetic nuances of symmetry and severity of dermatochalasis. No patients complained of altered brow position postoperatively, desiring revision surgery. Patient satisfaction was not assessed by a standardized survey; however, it is reflected in 100% patient retention rate with long-term follow up. In addition, this technique has not lead to excessive resection of upper eyelid skin tissue or any cases of lagophthalmos. Six patients had minor dehiscence at the lateral most portion of the incision secondary to minor trauma in the area—one patient fell, one patient rubbed her eye, and the remaining four occurred while the patients were sleeping. There were no cases of postoperative wound infection. We have included photos of three patients to illustrate the impact of neuromodulator usage preoperatively. The first patient is a 61-year-old female who presented with frontalis hyperactivity and deep forehead rhytids at rest along with notable dermatochalasis (Figure 3A). On presentation, she was neuromodulator naive. Two weeks after treatment of the frontalis muscle with 20 units of Botox Cosmetic, the frontalis was neutralized with amelioration of her forehead rhytids and increased severity of dermatochalasis (Figure 3B). Eighteen months after bilateral upper blepharoplasty, the appearance of the forehead rhytids has further improved without prolonged Botox Cosmetic treatment of the frontalis muscle (Figure 3C). Figure 3. View largeDownload slide (A) This 61-year-old woman who presented with frontalis hyperactivity and deep forehead rhytids at rest along with notable dermatochalasis. On presentation, she was neuromodulator naive. (B) Two weeks after treatment of the frontalis muscle with 20 units of Botox Cosmetic, the frontalis was neutralized with amelioration of her forehead rhytids and increased severity of dermatochalasis. (C) Eighteen months after bilateral upper blepharoplasty, the appearance of the forehead rhytids has further improved without prolonged Botox Cosmetic treatment of the frontalis muscle. Figure 3. View largeDownload slide (A) This 61-year-old woman who presented with frontalis hyperactivity and deep forehead rhytids at rest along with notable dermatochalasis. On presentation, she was neuromodulator naive. (B) Two weeks after treatment of the frontalis muscle with 20 units of Botox Cosmetic, the frontalis was neutralized with amelioration of her forehead rhytids and increased severity of dermatochalasis. (C) Eighteen months after bilateral upper blepharoplasty, the appearance of the forehead rhytids has further improved without prolonged Botox Cosmetic treatment of the frontalis muscle. The second patient is a 52-year-old female who presented with dermatochalasis, forehead rhytids, and brow asymmetry (Supplemental Figure 2A). Two weeks after treatment of the frontalis muscle with 15 units of Botox Cosmetic, the frontalis was neutralized with lowering of the right eyebrow and slight increase in severity of dermatochalasis of the right upper eyelid (Supplemental Figure 2B). Four months after bilateral upper blepharoplasty, improved symmetry of her eyebrows persists, with increased tarsal platform show (Supplemental Figure 2C). The third patient is a 57-year-old male, who presented with dermatochalasis and frontalis hyperactivity with associated forehead rhytids (Figure 4A). He underwent treatment of the frontalis muscle with 15 units of Botox Cosmetic two weeks prior to bilateral upper and lower blepharoplasty. Posttreatment, neuromodulator use was not continued. At three years posttreatment, he has maintained resolution of the dermatochalasis as well as relaxation of his frontalis muscle, with resulting improvement of his forehead rhytids (Figure 4B). Figure 4. View largeDownload slide (A) This 57-year-old man who presented with dermatochalasis and frontalis hyperactivity with associated forehead rhytids (as shown). He underwent treatment of the frontalis muscle with 15 units of Botox Cosmetic two weeks prior to bilateral upper and lower blepharoplasty. (B) At three years postoperatively, he has maintained resolution of the dermatochalasis as well as relaxation of his frontalis muscle, with resulting improvement of his forehead rhytids. Figure 4. View largeDownload slide (A) This 57-year-old man who presented with dermatochalasis and frontalis hyperactivity with associated forehead rhytids (as shown). He underwent treatment of the frontalis muscle with 15 units of Botox Cosmetic two weeks prior to bilateral upper and lower blepharoplasty. (B) At three years postoperatively, he has maintained resolution of the dermatochalasis as well as relaxation of his frontalis muscle, with resulting improvement of his forehead rhytids. DISCUSSION Accurate preoperative assessment is a prerequisite for achieving optimal postoperative results. The anatomy of the brow-lid continuum has been well described.1,2,6,8 Numerous studies describe “the beautiful eye” and its ideal aesthetics, for which various measurements have been accepted as standard normal deviation. Symmetry alone is of paramount importance.9 Many patients are unaware of their own asymmetries; surgeons must point out and document all asymmetries in detail and counsel patients that at least a small degree of asymmetry will likely persist postoperatively. Analysis of ideal proportions differs amongst diversity of cultures. In the Western eyelid, the peak height of the upper lid is located between the pupil and lateral limbus without excessive droop or scleral show.9 The ideal upper eyelid should have neither excess fat nor skeletonization with hollowing of the sulcus.9 The Asian upper eyelid differs in the eyelid fold, lower marginal position, and more temporal peak in the lid height. The marginal reflex distance (MRD) is widely used to evaluate upper eyelid position. MRD1 is the measurement from the corneal light reflex to the upper eyelid margin, while MRD2 is the measurement from the corneal light reflex to the lower eyelid margin. Normal Western MRD1 ranges from 3.5 mm to 4.5 mm.9 Levator function is isolated by measuring upper eyelid excursion while holding the eyebrow in its normal position—normal levator function is greater than 12 mm, with an average of 15 mm. A normal, Western, upper eyelid crease is 10 to 12 mm above the central eyelid margin in women, and 7 to 8 mm in men. In Asians, these distances are decreased. The tarsal platform show (TPS) is the amount of fixed pretarsal skin that is visible inferior to the skin overlying the eyelid crease. The normal Western TPS is 3 to 6 mm. Brow fat span (BFS) is the distance between the skin fold overlying the eyelid crease (the top of TPS) to the inferior brow hairs (Figure 5).9 The ideal brow is gently curved, with its apex aligned approximately above the lateral corneal limbus, and its medial edge aligned on the same vertical line as the lateral nasal ala and inner canthus. The male brow should have similar medial to lateral alignment, but is usually lower and straighter. Figure 5. View largeDownload slide Representative 61-year-old woman. Brow fat span (BFS) is the distance between the skin fold overlying the eyelid crease to the inferior brow hairs. Tarsal platform show (TPS) is the amount of fixed pretarsal skin that is visible inferior to the skin overlying the eyelid crease. Margin reflex distance (MRD1) is the measurement from the corneal light reflex to the central upper eyelid margin. Figure 5. View largeDownload slide Representative 61-year-old woman. Brow fat span (BFS) is the distance between the skin fold overlying the eyelid crease to the inferior brow hairs. Tarsal platform show (TPS) is the amount of fixed pretarsal skin that is visible inferior to the skin overlying the eyelid crease. Margin reflex distance (MRD1) is the measurement from the corneal light reflex to the central upper eyelid margin. Aging brings on a multitude of bony and soft tissue changes. The orbital aperture increases in size with vertical lengthening and scalloping of the superomedial and inferolateral orbit, allowing descent of soft tissues, which contributes to the appearance of brow ptosis, dermatochalasis, and lateral orbital hooding with deepened sulci, enophthalmos, and eyelid ptosis.6 There are skin changes and deflation of fat compartments, resulting in hollowing of the temples and adjacent periorbital areas. The forehead-eyebrow complex is 3-dimensional—a ptotic brow may result from gravitational changes, loss of volume in the brows and temples, as well as loss of tissue elasticity and connective tissue degeneration, changes that exacerbate dermatochalasis and temporal eyelid hooding.6,10 In aponeurotic ptosis, the lid crease elevates and the upper eyelid sulcus deepens as the central fat pad recesses into the orbit, giving the appearance of a hollow superior orbit.6 Because of these multidimensional changes, adjunct procedures are often considered, such as blepharoplasty, orbital volume augmentation, brow lift, and skin resurfacing in addressing periocular aging. A dynamic interplay of opposing muscles complicates the brow-lid continuum by acting as counter vectors on the brow and eyelid position, which in turn affects the severity of dermatochalasis. The prime elevator of the brow, the frontalis muscle, also contributes to elevation of the upper eyelid. Thus, the resting tone of the frontalis muscle can affect the position of the upper lid margin relative to the pupil; conversely, upper lid ptosis can also trigger frontalis muscle hyperactivity as a compensatory mechanism to elevate the upper lid out of the visual axis.7 According to Hering’s law, afferent innervation to the brainstem from the visual system drives a bilateral symmetrically mediated motor response that aligns the eyes. This law can be applied to the frontalis and levator muscles; correction of the upper eyelid dermatochalasis diminishes afferent input to the frontalis muscles, potentially causing the brows to drop after upper blepharoplasty. In cases of upper eyelid asymmetry with unilateral ptosis, after the unilateral ptosis is surgically corrected, the levator muscles decompensate bilaterally, and latent brow and/or eyelid ptosis may become evident on the contralateral side.6 In short, hyperactivity of the frontalis muscle can mask brow or lid ptosis. In similar fashion, neuromodulation and paralysis of the brow depressors, the corrugator supercilii, procerus, and orbicularis oculi muscles, can also falsely mask brow or lid ptosis, as the activity of the frontalis muscle remains unopposed. Studies have quantified the unmasking of brow ptosis after blepharoplasty following postoperative resolution of compensatory frontalis hyperactivity.11,12 Hassanpour et al reported brow ptosis after upper eyelid blepharoplasty in 29% of females and 58% of males. Brow ptosis was determined based on distance measurements in relation to the pupil as well as the medial and lateral canthi. Fifty seven (57) of 70 patients reported underwent surgery for dermatochalasis, 13 of whom had preoperative visual field impairment. This study recognizes the unmasking of brow ptosis postoperatively, and suggests that a concomitant brow lift or internal brow fixation through the blepharoplasty incision may play a role in these patients. Lee et al evaluated brow position after blepharoplasty vs levator advancement (for ptosis), concluding that the distance between the upper lid margin and the brow was shortened after both procedures, but that there was a greater change in brow height following levator advancement compared to blepharoplasty.12 This study also recognizes the phenomena of unmasking brow ptosis postoperatively. Lew et al advocate preoperative delineation of the degree of eyebrow compensation by differentiating it from intrinsic eyebrow asymmetry using a phenylephrine drop in the more ptotic eye to elevate the eyelid and to neutralize the compensatory action of the frontalis muscle.7 This paper focuses on the symmetry, or lack thereof, of the tarsal platform preoperatively. It suggests that in cases of unilateral blepharoptosis with asymmetric tarsal platform, unilateral ptosis surgery will likely improve symmetry, while in cases of unilateral blepharoptosis with symmetric tarsal platform, surgical planning should include consideration of bilateral asymmetric blepharoplasty, as the compensatory drive resolves postoperatively. Given the dynamic muscular interaction in the periorbital region and the degree of precision necessary to properly correct eyelid dermatochalasis, brow position, and brow asymmetry, anticipation alone of these compensatory mechanisms remains an inadequate guideline for the aesthetic surgeon. Depending on the physical findings and the anticipated surgical procedure, we recommend utilizing neuromodulator and/or allowing for attrition of neuromodulator effect in the respective landmarks as an instrument in preoperative planning. Doing so achieves decompensation of the counter vectors on the eyebrow and eyelid preoperatively in order to unmask their intrinsic positions prior to surgery. Instead of having to anticipate and guess the extent of the impending postoperative decompensation, we remove the variables of the counter vectors altogether. To neutralize hyperactivity of the frontalis muscle, we treat it with 15 to 20 units of Botox Cosmetic two weeks preoperatively. To address paralysis of the brow depressors, we ensure attrition of the neuromodulator effect by waiting at least four months before performing an upper blepharoplasty. By utilizing these techniques, we achieve a more accurate preoperative assessment of each patient’s periorbital region without the camouflage of the compensatory mechanisms, and execute a very precise surgical procedure to optimize the patient’s results. Despite our long-standing use of these techniques, we recognize the limitations of our work. As our practice has evolved, we have adapted this technique uniformly for patients with frontalis hyperactivity who meet the indications; thus, we have no control group of patients with frontalis hyperactivity who are not pretreated with a neuromodulator. In this paper, we are merely presenting our protocol as a starting point, not claiming superiority of the technique. Secondly, we do not include objective measurements of the brow or eyelid position, as were described in some of the references; hence, we cannot quantify the discrepancy in the skin resection that we are able to achieve with neuromodulator use. In an effort to quantify our results for future examination, we have begun to measure the brow distance from the level of the medial canthus, the midpupil, and the lateral canthus during each stage of care. Finally, we have observed a difference in the amount of neuromodulator that effects optimal neutralization of frontalis hyperactivity depending on the severity of the hyperactivity and on gender. With further study, our dosage recommendations will be more quantifiable and better elucidated. CONCLUSIONS Brow position after upper blepharoplasty has been somewhat controversial; nevertheless, it is widely recognized that brow and lid ptosis can be unmasked after upper blepharoplasty due to resolution of the compensatory frontalis hyperactivity to elevate the upper lids away from the visual axis. With increasing prevalence in neuromodulator use, neuromodulators act as an accessible instrument to bridge the gap between noninvasive and surgical treatment. In consideration of the dynamic interplay of muscles along the brow-lid continuum, we advocate the use of neuromodulators in the frontalis muscle in patients with frontalis hyperactivity to optimize preoperative assessment for upper blepharoplasty procedures. Similarly, we must allow for attrition of neuromodulator effects on the brow depressors, prior to blepharoplasty and brow lift procedures to expunge the confounding counter vectors on the brow that may mask the extent of brow or lid ptosis, dermatochalasis, and asymmetries. Only by performing an accurate preoperative evaluation can we develop a surgical plan to fully address the patients’ periorbital aging and achieve the most precise aesthetic outcome. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures Dr Sweis is a consultant for Allergan. Drs Hwang and Cohen declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Czyz CN , Hill RH , Foster JA . Preoperative evaluation of the brow-lid continuum . Clin Plast Surg . 2013 ; 40 ( 1 ): 43 - 53 . Google Scholar CrossRef Search ADS PubMed 2. Fitzgerald R . Contemporary concepts in brow and eyelid aging . Clin Plast Surg . 2013 ; 40 ( 1 ): 21 - 42 . Google Scholar CrossRef Search ADS PubMed 3. Aston SJ , Steinbrech DS , Walden JL . Blepharoplasty . In: Aston SJ , Steinbrech DS , Walden JL , eds. Aesthetic Plastic Surgery . 1st ed . China : Elsevier ; 2009 : 367 - 404 . 4. Hahn S , Holds JB , Couch SM . Upper lid blepharoplasty . Facial Plast Surg Clin North Am . 2016 ; 24 ( 2 ): 119 - 127 . Google Scholar CrossRef Search ADS PubMed 5. Zoumalan CI , Roostaeian J . Simplifying blepharoplasty . Plast Reconstr Surg . 2016 ; 137 ( 1 ): 196e - 213e . Google Scholar CrossRef Search ADS PubMed 6. Lam VB , Czyz CN , Wulc AE . The brow-eyelid continuum: an anatomic perspective . Clin Plast Surg . 2013 ; 40 ( 1 ): 1 - 19 . Google Scholar CrossRef Search ADS PubMed 7. Lew H , Goldberg RA . Maximizing symmetry in upper blepharoplasty: the role of microptosis surgery . Plast Reconstr Surg . 2016 ; 137 ( 2 ): 296e - 304e . Google Scholar CrossRef Search ADS PubMed 8. Sand JP , Zhu BZ , Desai SC . Surgical anatomy of the eyelids . Facial Plast Surg Clin North Am . 2016 ; 24 ( 2 ): 89 - 95 . Google Scholar CrossRef Search ADS PubMed 9. Neimkin MG , Holds JB . Evaluation of eyelid function and aesthetics . Facial Plast Surg Clin North Am . 2016 ; 24 ( 2 ): 97 - 106 . Google Scholar CrossRef Search ADS PubMed 10. Rohrich RJ , Pessa JE . The fat compartments of the face: anatomy and clinical implications for cosmetic surgery . Plast Reconstr Surg . 2007 ; 119 ( 7 ): 2219 - 2227 ; discussion 2228. Google Scholar CrossRef Search ADS PubMed 11. Hassanpour SE , Khajouei Kermani H . Brow ptosis after upper blepharoplasty: findings in 70 patients . World J Plast Surg . 2016 ; 5 ( 1 ): 58 - 61 . Google Scholar PubMed 12. Lee JM , Lee TE , Lee H , Park M , Baek S . Change in brow position after upper blepharoplasty or levator advancement . J Craniofac Surg . 2012 ; 23 ( 2 ): 434 - 436 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and Brow Lift

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Oxford University Press
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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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Abstract

Abstract Background Upper eyelid dermatochalasis often triggers frontalis hyperactivity in an effort to elevate the upper lids away from the visual axis. Similarly, prior neuromodulator treatment of the brow depressors may cause false elevation of the brows, diminishing the extent of preoperative brow ptosis or dermatochalasis. Studies have quantified postoperative brow ptosis and recurrent dermatochalasis following upper blepharoplasty, but a methodology to predict the postoperative brow position remains to be elucidated. Objectives The authors present our comprehensive perioperative protocol utilizing neuromodulators to optimize results of upper blepharoplasty and brow lift. Methods In patients presenting with upper lid dermatochalasis and frontalis hyperactivity, who request upper blepharoplasty, the authors apply a neuromodulator treatment protocol. Patients with prior neuromodulator treatment of brow depressors wait four months after the last treatment to allow for product attrition. Two weeks prior to surgery, the authors treat the frontalis with 15 to 20 units of Botox Cosmetic. Results From 2002 to 2016, the authors treated 521 patients (458 women, 63 men) with frontalis hyperactivity who presented for periorbital rejuvenation. This method has led to neither excessive resection of upper eyelid skin tissue nor lagophthalmos. Preoperatively, the authors have unveiled upper eyelid ptosis in 39 patients (31 women, 8 men) and brow ptosis in 131 patients (97 women, 34 men). Conclusions Brow position and frontalis hyperactivity should be taken into consideration during preoperative evaluation for upper blepharoplasty and brow lift. Routine preoperative treatment of the hyperactive frontalis with neuromodulator, along with attrition of prior neuromodulator in the brow depressors, reveals the true anatomic brow position to optimize surgical planning. Level of Evidence: 4 The periorbital region is one of the first areas to demonstrate signs of facial aging.1 Periorbital aging manifests with fat loss resulting in contour hollows along the upper lid sulcus and tear trough, dermatochalasis, prolapsed orbital fat, transverse and vertical forehead rhytids, crow’s feet, dermal elastosis and ptosis of the eyebrow complex especially laterally.2,3 In aesthetic rejuvenation, it is imperative to have a thorough understanding of the brow-lid continuum, the lid-cheek junction, and the soft tissue as well as bony changes that lead to perceived aging.1,2 The brow-lid continuum is composed of the upper third of the face, the forehead, brow, and upper eyelid.1 In examining this region, one must evaluate the static and mimetic changes and not focus on a single structure in isolation. Failure to do so prevents the examiner from recognizing latent problems masked by compensatory mechanisms. Unless there is comprehensive understanding of how these mechanisms affect the underlying brow-lid anatomy, attempts at aesthetic procedures to address patients’ concerns may be imprecise, necessitating secondary procedures. One of the most common compensatory mechanisms occurs when upper eyelid dermatochalasis or ptosis triggers or exacerbates hyperactivation of the frontalis muscle. This persistent contraction of the frontalis muscle while at rest chronically elevates the brows, often asymmetrically, thereby diminishing the accuracy in our assessment of the extent of brow/eyelid ptosis and full extent of upper lid dermatochalasis. If the upper eyelid dermatochalasis is surgically corrected in isolation, it will diminish the extent of hyperactivation of the frontalis muscle postoperatively, revealing the masked brow or lid ptosis.1 Preoperative neutralization of the frontalis muscle in cases of frontalis hyperactivity would minimize opposing vectors on the brow and upper eyelids to allow more accurate assessment and selection of the proper surgical approach to optimize the postoperative upper blepharoplasty results. Opposing the frontalis, the brow depressors act as counter vectors on the brow. Neutralization of the brow depressors preoperatively, a method often used in noninvasive treatment of brow ptosis or corrugator supercilii rhytids, leaves the frontalis muscle unopposed and accentuates the arch of the brow, which camouflages the extent of brow ptosis and upper eyelid dermatochalasis. Therefore, the degree of brow ptosis must be measured without the neuromodulator effect on the brow depressors. Contrarily, failure to recognize preoperative hyperactivation of the corrugator supercilii, procerus, and orbicularis oculi muscles could result in a postoperative diminished and suboptimal brow lift effect secondary to uninterrupted counter vectors. Therefore, unaltered depressor muscles in the preoperative period in conjunction with neutralization of the depressor muscles during the healing period following the brow lift procedure minimizes confounding factors on the brow and optimizes the ultimate result. Many studies outline relevant anatomy and emphasize the importance of evaluating the full brow-lid continuum in preoperative assessment.1,2,4-7 However, the method with which to optimize the final aesthetic result in patients who present for brow lift or blepharoplasty remains to be elucidated. Since the FDA approval of neuromodulators in the treatment of glabellar rhytids in 2002, we have gained experience with their utility in adjacent landmarks, including the brow elevator (frontalis muscle) and all of the brow depressors, (corrugator supercilii, procerus, and orbicularis oculi muscles). Neuromodulators can also be used to manipulate brow position in order to achieve an aesthetically pleasing brow shape by selectively treating opposing muscle groups. They have provided a noninvasive method to treat periorbital aging; consequently, they add another dimension to consider in preoperative evaluation in patients undergoing concomitant treatment with neuromodulators. In this paper, we hope to bridge the gap between nonsurgical and surgical treatment methods of lid/brow ptosis and dermatochalasis. We will outline our protocol for both the routine perioperative use of neuromodulators in the brow elevators and the strict avoidance of neuromodulators in the brow depressors in patients presenting with signs of periorbital aging and frontalis hyperactivity to improve aesthetic outcomes following upper blepharoplasty and brow lift procedures. METHODS This study describes a two-surgeon experience (I.S. and M.C.) in academic and private practice settings between July 2002 and July 2016. This is a retrospective chart review of 521 consecutive patients (458 women and 63 men) who presented for periorbital rejuvenation with frontalis hyperactivity. This is not an IRB-approved study; however, we have adhered to the guidelines set forth in the Declaration of Helsinki, with respect for the individual, their right to self-determination, and the right to make informed decisions regarding participation in research. Preoperative workup of our patients adhered to the current standard of care. In 2002, Botox Cosmetic (Allergan Pharmaceuticals Ireland, a subsidiary of Allergan, Inc., Irvine, CA) was FDA-approved for amelioration of glabellar lines. Hence, despite recent FDA-approval of Botox Cosmetic for temporary improvement of forehead lines associated with frontalis muscle activity in adults, our protocol does reflect off-label use of the product. All risks and benefits of treatment were discussed, and informed consent for treatment and surgery was obtained from all patients. Specific photo release consent forms were obtained from the patients’ whose photos we submitted. We have defined frontalis hyperactivity as the persistent contraction of the frontalis muscle while at rest. We have classified blepharoptosis by the position of the upper lid relative to the pupil, and brow ptosis by the position of the brow relative to the superior orbital rim, with the ideal female brow arching above the superior orbital rim, and the ideal male brow following the border of the superior orbital rim. Patients who underwent bilateral upper blepharoplasty were included into the study, while patients in whom we identified veiled upper eyelid ptosis were excluded from the study and referred to an oculoplastic surgeon. In surgical planning for brow lift and upper blepharoplasty, our goal is to achieve adequate elevation of the brow/lid continuum as well as address the skin and pseudoherniated fat pads of the upper eyelid. Hence, we must first neutralize all other confounding vectors that are falsely elevating the brow preoperatively, which includes frontalis muscle hyperactivity as well as neuromodulator-induced brow depressor muscle inactivity, leaving the frontalis muscle unopposed. In addition to the routine preoperative workup and evaluation of our patients according to the current standard of care, we have developed and adhere to a neuromodulator treatment protocol for patients presenting for upper blepharoplasty and brow lift procedures (Figure 1). All patients were treated with only one type of neuromodulator, Botox Cosmetic. Figure 1. View largeDownload slide Neuromodulator treatment protocol for patients presenting for upper blepharoplasty and brow lift procedures, following standard workup. Figure 1. View largeDownload slide Neuromodulator treatment protocol for patients presenting for upper blepharoplasty and brow lift procedures, following standard workup. Brow Elevators The prime elevator of the brow is the frontalis muscle. Most patients have some degree of frontalis resting tone, which keeps the eyebrow and eyelid skin out of the visual axis.7 Blepharoplasty or ptosis surgery decreases the frontalis compensatory drive once the excess skin is removed from the visual axis, which may result in eyebrow descent and subsequent superior sulcus effacement by the recruited eyebrow fat pad with shortening of the tarsal platform show.7 In addition, preoperative asymmetry may exacerbate as the asymmetric compensatory mechanism resolves. Prior to upper blepharoplasty, we treat the frontalis muscle with 15 to 20 units of Botox Cosmetic two weeks prior to the date of surgery, allowing the neuromodulator to reach its peak action prior to surgery. This neutralizes the hyperactivity of the frontalis and distinguishes the compensatory drive from intrinsic eyebrow asymmetry. Four to eight injection sites should be distributed along the deep rhytids of the forehead, spanning the width of the frontalis bilaterally, avoiding the midline (Figure 2). The dose of the Botox Cosmetic is dependent on the extent of frontalis hyperactivity and mimetic rhytids. We unveil the true eyebrow and eyelid position, and hence, the true extent of dermatochalasis, which allows us to perform a more adequate upper blepharoplasty and/or brow lift. We are also able to identify and address any underlying masked eyelid ptosis and true asymmetry in the brow position or extent of dermatochalasis in our surgical planning. Figure 2. View largeDownload slide A 61-year-old woman with frontalis hyperactivity, deep forehead rhytids at rest, and notable dermatochalasis. Four to eight neuromodulator injection sites should be distributed along the deep rhytids of the forehead, spanning the width of the frontalis bilaterally, avoiding the midline. Figure 2. View largeDownload slide A 61-year-old woman with frontalis hyperactivity, deep forehead rhytids at rest, and notable dermatochalasis. Four to eight neuromodulator injection sites should be distributed along the deep rhytids of the forehead, spanning the width of the frontalis bilaterally, avoiding the midline. Brow Depressors The corrugator supercilii, procerus, and orbicularis oculi muscles are brow depressors. Paralysis of these muscles through neuromodulation can falsely elevate the eyebrow, which impacts the measurements obtained in assessing the degree of brow elevation necessary in a brow lift and the degree of skin resection needed to address the dermatochalasis during an upper blepharoplasty. Supplemental Figure 1 illustrates the impact of neuromodulation on eyebrow position. This is a 65-year-old female who presented with dermatochalasis of the upper eyelids with notable eyebrow asymmetry, desiring facial rejuvenation. The patient’s right eyebrow is slightly higher, resulting in less apparent dermatochalasis compared to the left side (Supplemental Figure 1A). She was treated with 20 units of Botox Cosmetic in the brow depressors and along the outer orbicularis oculi. Two weeks later, in addition to having notable improvement in the asymmetry between the right and left brow and upper eyelids, she appears to have decreased severity in dermatochalasis (Supplemental Figure 1B). Prior neuromodulator treatment can confound the physical exam. Postoperatively, this may manifest as brow ptosis and upper eyelid dermatochalasis, respectively, once the neuromodulator effect wears off. In patients who have had prior neuromodulator treatment, we recommend waiting four months after the last treatment date before scheduling treatment to allow attrition of the preexisting product. RESULTS This is a retrospective chart review of 521 consecutive patients (458 women and 63 men) who presented for periorbital rejuvenation and upper blepharoplasty with frontalis hyperactivity. Patient age ranged from 18 to 74 years (mean, 52 years). Patients who underwent bilateral upper blepharoplasty were included into the study, while patients in whom we identified veiled upper eyelid ptosis were excluded from the study. One patient elected not to have surgery, and continued with only neuromodulator treatment. All patients were followed up for more than one year. Follow-up period ranged from one to 15 years (mean, 7 years). In our experience, preoperative treatment of the hyperactive frontalis with neuromodulators in the upper blepharoplasty cases has led to satisfactory results, without demand or need for revision surgery. Our treatment protocol has allowed us to preoperatively identify veiled upper eyelid ptosis in 39 patients (31 women and 8 men) and veiled brow ptosis in 131 patients (97 women and 34 men). All patients with upper eyelid ptosis were referred to an oculoplastic surgeon, while patients with brow ptosis were offered concurrent temporal brow lift. Of the 131 patients with brow ptosis, 19 patients consented to and underwent concurrent temporal brow lift. The remaining patients were content with the new lowered position of the brow, and accepted the position, choosing to undergo only bilateral upper blepharoplasty without concurrent temporal brow lift. As unveiling eyelid or brow ptosis potentially changes the operative management and plan, our protocol has the potential to impact the course of treatment for these patients. It allows the patient to recognize their final brow position prior to surgery, which enables them to make an informed decision on whether to proceed with a concurrent temporal brow lift vs noticing it postoperatively as an unforeseen complication of surgery. However, in the majority of cases, we are faced with more aesthetic nuances of symmetry and severity of dermatochalasis. No patients complained of altered brow position postoperatively, desiring revision surgery. Patient satisfaction was not assessed by a standardized survey; however, it is reflected in 100% patient retention rate with long-term follow up. In addition, this technique has not lead to excessive resection of upper eyelid skin tissue or any cases of lagophthalmos. Six patients had minor dehiscence at the lateral most portion of the incision secondary to minor trauma in the area—one patient fell, one patient rubbed her eye, and the remaining four occurred while the patients were sleeping. There were no cases of postoperative wound infection. We have included photos of three patients to illustrate the impact of neuromodulator usage preoperatively. The first patient is a 61-year-old female who presented with frontalis hyperactivity and deep forehead rhytids at rest along with notable dermatochalasis (Figure 3A). On presentation, she was neuromodulator naive. Two weeks after treatment of the frontalis muscle with 20 units of Botox Cosmetic, the frontalis was neutralized with amelioration of her forehead rhytids and increased severity of dermatochalasis (Figure 3B). Eighteen months after bilateral upper blepharoplasty, the appearance of the forehead rhytids has further improved without prolonged Botox Cosmetic treatment of the frontalis muscle (Figure 3C). Figure 3. View largeDownload slide (A) This 61-year-old woman who presented with frontalis hyperactivity and deep forehead rhytids at rest along with notable dermatochalasis. On presentation, she was neuromodulator naive. (B) Two weeks after treatment of the frontalis muscle with 20 units of Botox Cosmetic, the frontalis was neutralized with amelioration of her forehead rhytids and increased severity of dermatochalasis. (C) Eighteen months after bilateral upper blepharoplasty, the appearance of the forehead rhytids has further improved without prolonged Botox Cosmetic treatment of the frontalis muscle. Figure 3. View largeDownload slide (A) This 61-year-old woman who presented with frontalis hyperactivity and deep forehead rhytids at rest along with notable dermatochalasis. On presentation, she was neuromodulator naive. (B) Two weeks after treatment of the frontalis muscle with 20 units of Botox Cosmetic, the frontalis was neutralized with amelioration of her forehead rhytids and increased severity of dermatochalasis. (C) Eighteen months after bilateral upper blepharoplasty, the appearance of the forehead rhytids has further improved without prolonged Botox Cosmetic treatment of the frontalis muscle. The second patient is a 52-year-old female who presented with dermatochalasis, forehead rhytids, and brow asymmetry (Supplemental Figure 2A). Two weeks after treatment of the frontalis muscle with 15 units of Botox Cosmetic, the frontalis was neutralized with lowering of the right eyebrow and slight increase in severity of dermatochalasis of the right upper eyelid (Supplemental Figure 2B). Four months after bilateral upper blepharoplasty, improved symmetry of her eyebrows persists, with increased tarsal platform show (Supplemental Figure 2C). The third patient is a 57-year-old male, who presented with dermatochalasis and frontalis hyperactivity with associated forehead rhytids (Figure 4A). He underwent treatment of the frontalis muscle with 15 units of Botox Cosmetic two weeks prior to bilateral upper and lower blepharoplasty. Posttreatment, neuromodulator use was not continued. At three years posttreatment, he has maintained resolution of the dermatochalasis as well as relaxation of his frontalis muscle, with resulting improvement of his forehead rhytids (Figure 4B). Figure 4. View largeDownload slide (A) This 57-year-old man who presented with dermatochalasis and frontalis hyperactivity with associated forehead rhytids (as shown). He underwent treatment of the frontalis muscle with 15 units of Botox Cosmetic two weeks prior to bilateral upper and lower blepharoplasty. (B) At three years postoperatively, he has maintained resolution of the dermatochalasis as well as relaxation of his frontalis muscle, with resulting improvement of his forehead rhytids. Figure 4. View largeDownload slide (A) This 57-year-old man who presented with dermatochalasis and frontalis hyperactivity with associated forehead rhytids (as shown). He underwent treatment of the frontalis muscle with 15 units of Botox Cosmetic two weeks prior to bilateral upper and lower blepharoplasty. (B) At three years postoperatively, he has maintained resolution of the dermatochalasis as well as relaxation of his frontalis muscle, with resulting improvement of his forehead rhytids. DISCUSSION Accurate preoperative assessment is a prerequisite for achieving optimal postoperative results. The anatomy of the brow-lid continuum has been well described.1,2,6,8 Numerous studies describe “the beautiful eye” and its ideal aesthetics, for which various measurements have been accepted as standard normal deviation. Symmetry alone is of paramount importance.9 Many patients are unaware of their own asymmetries; surgeons must point out and document all asymmetries in detail and counsel patients that at least a small degree of asymmetry will likely persist postoperatively. Analysis of ideal proportions differs amongst diversity of cultures. In the Western eyelid, the peak height of the upper lid is located between the pupil and lateral limbus without excessive droop or scleral show.9 The ideal upper eyelid should have neither excess fat nor skeletonization with hollowing of the sulcus.9 The Asian upper eyelid differs in the eyelid fold, lower marginal position, and more temporal peak in the lid height. The marginal reflex distance (MRD) is widely used to evaluate upper eyelid position. MRD1 is the measurement from the corneal light reflex to the upper eyelid margin, while MRD2 is the measurement from the corneal light reflex to the lower eyelid margin. Normal Western MRD1 ranges from 3.5 mm to 4.5 mm.9 Levator function is isolated by measuring upper eyelid excursion while holding the eyebrow in its normal position—normal levator function is greater than 12 mm, with an average of 15 mm. A normal, Western, upper eyelid crease is 10 to 12 mm above the central eyelid margin in women, and 7 to 8 mm in men. In Asians, these distances are decreased. The tarsal platform show (TPS) is the amount of fixed pretarsal skin that is visible inferior to the skin overlying the eyelid crease. The normal Western TPS is 3 to 6 mm. Brow fat span (BFS) is the distance between the skin fold overlying the eyelid crease (the top of TPS) to the inferior brow hairs (Figure 5).9 The ideal brow is gently curved, with its apex aligned approximately above the lateral corneal limbus, and its medial edge aligned on the same vertical line as the lateral nasal ala and inner canthus. The male brow should have similar medial to lateral alignment, but is usually lower and straighter. Figure 5. View largeDownload slide Representative 61-year-old woman. Brow fat span (BFS) is the distance between the skin fold overlying the eyelid crease to the inferior brow hairs. Tarsal platform show (TPS) is the amount of fixed pretarsal skin that is visible inferior to the skin overlying the eyelid crease. Margin reflex distance (MRD1) is the measurement from the corneal light reflex to the central upper eyelid margin. Figure 5. View largeDownload slide Representative 61-year-old woman. Brow fat span (BFS) is the distance between the skin fold overlying the eyelid crease to the inferior brow hairs. Tarsal platform show (TPS) is the amount of fixed pretarsal skin that is visible inferior to the skin overlying the eyelid crease. Margin reflex distance (MRD1) is the measurement from the corneal light reflex to the central upper eyelid margin. Aging brings on a multitude of bony and soft tissue changes. The orbital aperture increases in size with vertical lengthening and scalloping of the superomedial and inferolateral orbit, allowing descent of soft tissues, which contributes to the appearance of brow ptosis, dermatochalasis, and lateral orbital hooding with deepened sulci, enophthalmos, and eyelid ptosis.6 There are skin changes and deflation of fat compartments, resulting in hollowing of the temples and adjacent periorbital areas. The forehead-eyebrow complex is 3-dimensional—a ptotic brow may result from gravitational changes, loss of volume in the brows and temples, as well as loss of tissue elasticity and connective tissue degeneration, changes that exacerbate dermatochalasis and temporal eyelid hooding.6,10 In aponeurotic ptosis, the lid crease elevates and the upper eyelid sulcus deepens as the central fat pad recesses into the orbit, giving the appearance of a hollow superior orbit.6 Because of these multidimensional changes, adjunct procedures are often considered, such as blepharoplasty, orbital volume augmentation, brow lift, and skin resurfacing in addressing periocular aging. A dynamic interplay of opposing muscles complicates the brow-lid continuum by acting as counter vectors on the brow and eyelid position, which in turn affects the severity of dermatochalasis. The prime elevator of the brow, the frontalis muscle, also contributes to elevation of the upper eyelid. Thus, the resting tone of the frontalis muscle can affect the position of the upper lid margin relative to the pupil; conversely, upper lid ptosis can also trigger frontalis muscle hyperactivity as a compensatory mechanism to elevate the upper lid out of the visual axis.7 According to Hering’s law, afferent innervation to the brainstem from the visual system drives a bilateral symmetrically mediated motor response that aligns the eyes. This law can be applied to the frontalis and levator muscles; correction of the upper eyelid dermatochalasis diminishes afferent input to the frontalis muscles, potentially causing the brows to drop after upper blepharoplasty. In cases of upper eyelid asymmetry with unilateral ptosis, after the unilateral ptosis is surgically corrected, the levator muscles decompensate bilaterally, and latent brow and/or eyelid ptosis may become evident on the contralateral side.6 In short, hyperactivity of the frontalis muscle can mask brow or lid ptosis. In similar fashion, neuromodulation and paralysis of the brow depressors, the corrugator supercilii, procerus, and orbicularis oculi muscles, can also falsely mask brow or lid ptosis, as the activity of the frontalis muscle remains unopposed. Studies have quantified the unmasking of brow ptosis after blepharoplasty following postoperative resolution of compensatory frontalis hyperactivity.11,12 Hassanpour et al reported brow ptosis after upper eyelid blepharoplasty in 29% of females and 58% of males. Brow ptosis was determined based on distance measurements in relation to the pupil as well as the medial and lateral canthi. Fifty seven (57) of 70 patients reported underwent surgery for dermatochalasis, 13 of whom had preoperative visual field impairment. This study recognizes the unmasking of brow ptosis postoperatively, and suggests that a concomitant brow lift or internal brow fixation through the blepharoplasty incision may play a role in these patients. Lee et al evaluated brow position after blepharoplasty vs levator advancement (for ptosis), concluding that the distance between the upper lid margin and the brow was shortened after both procedures, but that there was a greater change in brow height following levator advancement compared to blepharoplasty.12 This study also recognizes the phenomena of unmasking brow ptosis postoperatively. Lew et al advocate preoperative delineation of the degree of eyebrow compensation by differentiating it from intrinsic eyebrow asymmetry using a phenylephrine drop in the more ptotic eye to elevate the eyelid and to neutralize the compensatory action of the frontalis muscle.7 This paper focuses on the symmetry, or lack thereof, of the tarsal platform preoperatively. It suggests that in cases of unilateral blepharoptosis with asymmetric tarsal platform, unilateral ptosis surgery will likely improve symmetry, while in cases of unilateral blepharoptosis with symmetric tarsal platform, surgical planning should include consideration of bilateral asymmetric blepharoplasty, as the compensatory drive resolves postoperatively. Given the dynamic muscular interaction in the periorbital region and the degree of precision necessary to properly correct eyelid dermatochalasis, brow position, and brow asymmetry, anticipation alone of these compensatory mechanisms remains an inadequate guideline for the aesthetic surgeon. Depending on the physical findings and the anticipated surgical procedure, we recommend utilizing neuromodulator and/or allowing for attrition of neuromodulator effect in the respective landmarks as an instrument in preoperative planning. Doing so achieves decompensation of the counter vectors on the eyebrow and eyelid preoperatively in order to unmask their intrinsic positions prior to surgery. Instead of having to anticipate and guess the extent of the impending postoperative decompensation, we remove the variables of the counter vectors altogether. To neutralize hyperactivity of the frontalis muscle, we treat it with 15 to 20 units of Botox Cosmetic two weeks preoperatively. To address paralysis of the brow depressors, we ensure attrition of the neuromodulator effect by waiting at least four months before performing an upper blepharoplasty. By utilizing these techniques, we achieve a more accurate preoperative assessment of each patient’s periorbital region without the camouflage of the compensatory mechanisms, and execute a very precise surgical procedure to optimize the patient’s results. Despite our long-standing use of these techniques, we recognize the limitations of our work. As our practice has evolved, we have adapted this technique uniformly for patients with frontalis hyperactivity who meet the indications; thus, we have no control group of patients with frontalis hyperactivity who are not pretreated with a neuromodulator. In this paper, we are merely presenting our protocol as a starting point, not claiming superiority of the technique. Secondly, we do not include objective measurements of the brow or eyelid position, as were described in some of the references; hence, we cannot quantify the discrepancy in the skin resection that we are able to achieve with neuromodulator use. In an effort to quantify our results for future examination, we have begun to measure the brow distance from the level of the medial canthus, the midpupil, and the lateral canthus during each stage of care. Finally, we have observed a difference in the amount of neuromodulator that effects optimal neutralization of frontalis hyperactivity depending on the severity of the hyperactivity and on gender. With further study, our dosage recommendations will be more quantifiable and better elucidated. CONCLUSIONS Brow position after upper blepharoplasty has been somewhat controversial; nevertheless, it is widely recognized that brow and lid ptosis can be unmasked after upper blepharoplasty due to resolution of the compensatory frontalis hyperactivity to elevate the upper lids away from the visual axis. With increasing prevalence in neuromodulator use, neuromodulators act as an accessible instrument to bridge the gap between noninvasive and surgical treatment. In consideration of the dynamic interplay of muscles along the brow-lid continuum, we advocate the use of neuromodulators in the frontalis muscle in patients with frontalis hyperactivity to optimize preoperative assessment for upper blepharoplasty procedures. Similarly, we must allow for attrition of neuromodulator effects on the brow depressors, prior to blepharoplasty and brow lift procedures to expunge the confounding counter vectors on the brow that may mask the extent of brow or lid ptosis, dermatochalasis, and asymmetries. Only by performing an accurate preoperative evaluation can we develop a surgical plan to fully address the patients’ periorbital aging and achieve the most precise aesthetic outcome. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures Dr Sweis is a consultant for Allergan. Drs Hwang and Cohen declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Czyz CN , Hill RH , Foster JA . Preoperative evaluation of the brow-lid continuum . Clin Plast Surg . 2013 ; 40 ( 1 ): 43 - 53 . Google Scholar CrossRef Search ADS PubMed 2. Fitzgerald R . Contemporary concepts in brow and eyelid aging . Clin Plast Surg . 2013 ; 40 ( 1 ): 21 - 42 . Google Scholar CrossRef Search ADS PubMed 3. Aston SJ , Steinbrech DS , Walden JL . Blepharoplasty . In: Aston SJ , Steinbrech DS , Walden JL , eds. Aesthetic Plastic Surgery . 1st ed . China : Elsevier ; 2009 : 367 - 404 . 4. Hahn S , Holds JB , Couch SM . Upper lid blepharoplasty . Facial Plast Surg Clin North Am . 2016 ; 24 ( 2 ): 119 - 127 . Google Scholar CrossRef Search ADS PubMed 5. Zoumalan CI , Roostaeian J . Simplifying blepharoplasty . Plast Reconstr Surg . 2016 ; 137 ( 1 ): 196e - 213e . Google Scholar CrossRef Search ADS PubMed 6. Lam VB , Czyz CN , Wulc AE . The brow-eyelid continuum: an anatomic perspective . Clin Plast Surg . 2013 ; 40 ( 1 ): 1 - 19 . Google Scholar CrossRef Search ADS PubMed 7. Lew H , Goldberg RA . Maximizing symmetry in upper blepharoplasty: the role of microptosis surgery . Plast Reconstr Surg . 2016 ; 137 ( 2 ): 296e - 304e . Google Scholar CrossRef Search ADS PubMed 8. Sand JP , Zhu BZ , Desai SC . Surgical anatomy of the eyelids . Facial Plast Surg Clin North Am . 2016 ; 24 ( 2 ): 89 - 95 . Google Scholar CrossRef Search ADS PubMed 9. Neimkin MG , Holds JB . Evaluation of eyelid function and aesthetics . Facial Plast Surg Clin North Am . 2016 ; 24 ( 2 ): 97 - 106 . Google Scholar CrossRef Search ADS PubMed 10. Rohrich RJ , Pessa JE . The fat compartments of the face: anatomy and clinical implications for cosmetic surgery . Plast Reconstr Surg . 2007 ; 119 ( 7 ): 2219 - 2227 ; discussion 2228. Google Scholar CrossRef Search ADS PubMed 11. Hassanpour SE , Khajouei Kermani H . Brow ptosis after upper blepharoplasty: findings in 70 patients . World J Plast Surg . 2016 ; 5 ( 1 ): 58 - 61 . Google Scholar PubMed 12. Lee JM , Lee TE , Lee H , Park M , Baek S . Change in brow position after upper blepharoplasty or levator advancement . J Craniofac Surg . 2012 ; 23 ( 2 ): 434 - 436 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Aesthetic Surgery JournalOxford University Press

Published: Sep 1, 2018

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