Mr Marc Pacifico discusses how to successfully recognise and treat compensated brow ptosis
Do you understand compensated brow ptosis? Do you examine for it routinely prior to considering rejuvenation of the upper face? Do you have a plan if you recognise it?
We are all likely to see patients with compensated brow ptosis as part of our upper facial rejuvenation practice. Recognising it is key, as failure to do so can result in poor planning and treatment decision- making, even if the execution of the chosen procedure goes well. Compensated brow ptosis is usually a feature that the patient will
be unaware of and they are more likely to notice wrinkles on their forehead, excess upper eyelid skin or occasionally, but not often, they may notice that their brow is low. Rarer still are those who realise they are raising their eyebrows to compensate for this.
However, if it is present, educating patients on its occurrence is vital to successfully managing their expectations and ensuring that they understand the recommended treatment options.
This article addresses the sometimes complex issues surrounding compensated brow ptosis and how to manage patients in whom it presents, as well as the pitfalls and problems that can be encountered if it is not recognised.
Compensated brow ptosis is brow ptosis (droop) that is corrected subconsiously by the patient, through contraction of the frontalis muscle in the forehead to raise the brow to a more desirable or functional position. Instead of doing it for a short time such as when showing expressions, it happens continuously.1-4
Two factors principally contribute to compensated brow ptosis. The first is the brow ptosis itself, where, with age, the brow gradually descends to a more low lying position. This is most apparent at the lateral (outer) brow, while the mid-brow can often be associated too. Interestingly, the medial brow usually maintains a reasonably good position, despite descent of the other parts of the brow. The second contributory factor can occur because of the weight of excess upper eyelid skin (dermatochalasis).1-4 Both a low-lying brow and heaviness of the upper eyelid skin will be recognised by the patient subconsciously and will therefore stimulate contraction of the frontalis, to raise the brow to a better, more functional position. This alleviates the heaviness of the brow, but also helps to take the weight off the upper lids in those with excess upper lid skin.
Patients with compensated brow ptosis typically present for treatment of forehead rhytids, or alternatively present with upper eyelid skin excess. Understandably, I have found that they rarely appreciate the significance of their brow, its position or the contraction of their frontalis. The way I find most useful to assess a patient for compensated brow ptosis is to ask the patient to close their eyes and relax.
As they do this, I look for a descent of the brow, and improvement in their transverse forehead rhytids. I then ask them to open their eyes and look at me, and inevitably see their brows elevate and the restoration of the forehead lines.
From my experience, another good tip is to look for lateral eyelid hooding. If there is hooding that extends laterally beyond the lateral canthus, it is inevitably the result of lateral brow descent that may not be fully compensated for.
I would also always encourage patients to bring photographs of themselves when they were in their 20s, prior to age-related brow changes, to the consultation. This will enable a comparison of the brow position (on eye closure and opening) as well as the appearance of their forehead, eye shape, and relationship of brow to upper lids.
The brow and upper lids are intimately linked, and whether patients are presenting for treatment of their forehead lines or are presenting with complaints of excess upper eyelid skin, if compensated brow ptosis is not recognised and discussed, it can often lead to problems.
For example, if the forehead is treated with botulinum toxin injections to improve the transverse rhytids, the brow will subsequently descend. Whilst the rhytids will improve (which the patient is likely to be happy with) it will often be at the expense of the brow descending to an unaesthetic position. The patient may then complain of a heaviness to their brow, and often dislike the ‘natural’ position to which the brow has dropped, as they will not be used to seeing their brow in this position.
Furthermore, the descent of the brow will have a knock-on effect on the upper lid skin, which will, in effect, be squashed down, giving the impression of the patient requiring an upper blepharoplasty, when in fact the primary problem is the brow.
On the other hand, a patient may present for an upper blepharoplasty, which may be entirely reasonable; however, if the brow is not addressed simultaneously, the outcome will be disappointing. Removal of the ‘heavy’ upper lid skin will often provoke a subconscious relaxation of the brow, as it no longer has to contribute to alleviating the weight on the upper lids. Again, this will result in descent of the brow and give the impression that the upper blepharoplasty was under-treated.1-4
As ever, managing patient expectations is key. If you discuss potential issues before you treat the patient, it comes across as an explanation, but if you try to explain it after a procedure, it sounds more like an excuse. It is much harder to regain your patient’s confidence and trust again after this.
In an upper blepharoplasty consultation, I have found that a discussion about a patient’s brow often comes as a surprise to the patient as they would never know that their frontalis is the underlining issue.
However, if a full and clear explanation is given, along with a demonstration (I find taking a photograph of the patient with their eyes closed and then eyes open immediately afterwards is very helpful), most patients understand what you are talking about.
Similarly, when patients come in for botulinum toxin injections, it is important to explain to them that using toxin to carefully balance the alleviation of forehead rhytids, with simultaneous relaxation of brow depressors to minimise brow descent, can be challenging. This challenge can be seen in the occasional ‘Mephisto brows’ when attempting to elevate the brow using toxin injections just under the lateral brow.
This refers to an unnatural appearance of raised lateral brows, with increased lines only on the edges of the forehead, much like the appearance of Mephistopheles, the demon from folklore. Again, this comes back to managing patients’ expectations, and clearly explaining what effect they are likely to experience if the impact of any compensated brow ptosis is not taken into account.
Compensated brow ptosis is brow ptosis (droop) that is corrected subconsiously by the patient, through contraction of the frontalis muscle in the forehead to raise the brow to a more desirable or functional position.
As discussed, a patient with compensated brow ptosis will present with forehead rhytids. Therefore, using botulinum toxin alone is challenging. A combination of low dose toxin to ‘soften’ the forehead rhytids, whilst also injecting doses just inferior to the tail of the brow, and superficially into the corrugators may help to achieve a degree of brow elevation. It is important to ensure that there is a dose given to the lateral forehead just medial to the temporal crest to avoid a ‘Mephisto brow’ being created.
Hyaluronic acid (or other) filler can be used to subtly re-volumise and build the bony orbit, which, in some circumstances, can help to support the brow to compensate for the use of toxins. However, it is not fundamentally a bony support issue, so trying to solve the problem by building up the hard tissues will have limited effectiveness.
Therefore, in my opinion, it may be best to get a plastic surgeon’s opinion in cases when botulinum toxin has not worked, rather than use hyaluronic acid fillers, which may raise the patient’s expectations without being able to reliably deliver the results hoped for. Skin resurfacing to tighten the forehead will help with the rhytids and may also achieve a degree of skin contraction that will help to elevate the brow.
Deeper resurfacing, such as CO2 laser or chemical peels would usually be required to achieve a meaningful result.
There are a number of surgical procedures to elevate the brow. If the brow is satisfactorily elevated, the frontalis will no longer need to contract and the rhytids will usually improve. If they do not improve, then there is more leeway in using toxins, as the brow is now supported and should not descend.
Indeed, I would recommend treatment of the forehead with toxin prior to a brow-lifting procedure to minimise tension from the muscles in the early post-operative period.
Under local anaesthetic, a direct brow lift, leaving a relatively inconspicuous scar just above the lateral half of the brow can achieve excellent results. This involves a carefully planned skin excision in the appropriate part of the upper border of the brow, with or without fixation of the dermis to the underlying periosteum. Alternatively, a brow lift can be achieved via an upper blepharoplasty incision in some cases.
The endoscopic (key hole) brow lift remains the gold standard procedure for the brow. Recognition that the medial brow rarely descends has shifted emphasis towards the central and lateral brow elevation, with toxin treatment for the glabella.
Previously, the glabella musculature was addressed by surgical excision from the deep surface as part of the brow lift, however this gave rise to an undesired elevation of the medial brow (producing a surprised appearance) as well as limited effectiveness, on occasion, due to a lack of spacer being inserted (such as fat graft) to prevent the muscle and scar going on to re-produce movement in this area.1-4
In cases of pure lateral elevation of the brow, an endoscopically- assisted lateral temporal brow lift is an excellent procedure. This is a relatively quick and straightforward day case operation to perform, but requires a general anaesthetic due to the deep planes in which the surgery is performed, between the superficial and deep temporal fascia.
Patient A, shown in Figure 1, requested a 4-lid blepharoplasty (a combined upper and lower blepharoplasty). His compensated brow ptosis was pointed out and a brow lift was recommended as the severity of his symptoms meant no non-surgical methods would be effective for this patient and he declined the brow procedure.
He did this as he was losing his hair so he wanted to see what result he got without any further risk of scarring. Note the evidence of forehead rhytids, as well as his upper lid skin excess. Post-operatively, a good result can be seen on his lower lids; however, his upper lids look under-done because his brow lowered after surgery as the brow elevation no longer happened. Note the lowering of his eyebrows compared with the pre-operative photograph.
This is actually a phenomenon of brow descent due to the relaxation of the frontalis, after the upper lid skin has been removed. The brow descent has effectively squashed down the upper lid skin. The correct further treatment is a surgical brow lift.
Patient B (Figure 2) presented with over-compensated brow ptosis, because of the weight of the upper eyelid skin and the unaesthetic cranial position of her brows. Following a local anaesthetic upper blepharoplasty, the brow has subconsciously descended to a more desirable position.
In addition, the forehead rhytids have improved due to the lack of contraction of the frontalis.
More people have a degree of compensated brow ptosis than many may think. Although I cannot find any official statistics, in my experience, at least 50% of upper blepharoplasty consultations involve a discussion about the brow that the patient was not expecting.
Whilst occasionally a degree of brow descent can be desirable if the brow is over-elevated, in my experience brow descent is usually unwanted.
Recognising compensated brow ptosis and educating patients on its occurrence is key to helping manage their expectations and allowing them to understand why you may be recommending additional procedures or referring them for surgical intervention.
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