The majority of the brown ptosis cases occur as weakening (e.g. involutional changes) or descent of the periorbital and/or facial soft tissue. This typically occurs at the temporal side of the brow first, mainly and the most temporal 1/3 of the eyebrow. Anatomically, the frontalis muscle raises the eyebrow and the frontal branch of the facial nerve is responsible for the innervation of this muscle. Normally the frontalis muscle lifts the medial 2/3 of the eyebrow and with increasing age, laxity of tissues (in particular collagen) combined with the descent of facial/periorbital soft tissue, patients develop lateral brow droop.

In terms of differential diagnosis, brow ptosis can occur with the following diseases: 1) paralysis or weakness of the frontalis muscle (facial nerve palsy, Bell’s palsy, acoustic neuroma, surgical trauma, birth trauma, congenital diseases ¹ , myasthenia gravis, myotonic dystrophy, or oculopharyngeal muscular dystrophy); 2) involuntary contraction of the orbicularis oculi (blepharospasm or facial dystonias); and 3) mechanical causes, which can result in descent of the brow (neoplasms: basal cell carcinoma; squamous cell carcinoma; keratoacanthoma or melanoma).

There is a need to provide relevant evidence in patient care in (aesthetic) brow surgery, since most browlift techniques are done from experience and not necessarily evidence based. So therefore we took a number of key questions into account:

The primary objective of this study is to determine if our browlift technique is comparable or superior to existing types of browlifts using facial observation questionnaires administered pre- and postoperatively:

Research design. A prospective observational study will be performed on all available data from patients who undergo a browlift procedure in the Haaglanden Medical Center (HMC) from 1-6-2021 until 31-5-2022. The Medical Ethics board of the Haaglanden Medical Center judged that this research (protocol number N21.009/ML/ml) is mainly an evaluation of a common treatment method and therefore does not need a formal ethics approval procedure. Since this is an exploratory pilot study, no formal power and sample size calculation was done and we aim to include at least 50 patients (1 per week)

History

Every patient that presents with droopy eyelids and/or eyebrows should undergo a thorough medical and family history, including at least the following aspects:

Physical examination

A complete plastic ophthalmic examination should be conducted in every patient, including:

All patients will be evaluated to check if there is dermatochalasis/ptosis and concomitant brow ptosis. Additionally, every patient scheduled for blepharoplasty will be checked if brow-repositioning surgery is necessary.

Pre-operatively the patient is informed about the procedure and information is given about (visible) scar formation, asymmetry and post-operative pain.

The patient is evaluated in the upright position. The degree of ptosis and position of the hairline is noted and compared with the contralateral side. Manual elevation of the brow to the ideal position will help to determine how much of the visual field deficit is secondary to the brow ptosis alone. Since exuberant brow lifting may compromise eye closure, attention should be paid to any degree of lagophtalmos if present. Secondly, injections with xylocaine + adrenalin 1:100.000 are administered into the dermis and subdermal until the periost of the lateral frontalis muscle region for adequate local anaesthesia. Two horizontal incisions (approximately 1-1.5 cm) are made, just above the lateral 1/3 of the eyebrow and the other just cranial to the hairline in line with the frontalis muscle. These locations are chosen to avoid injury to the frontal nerve ( Figure 1). Secondly, the frontalis muscle is bluntly dissected from the underlying periost. The frontalis muscle is then suspended 2–5mm and fixated at the cranial site to the periost of the frontal bone using a 3-0 (Ethilon) suture. Then the muscle is also suspended 2–5mm at the caudal site using a 3-0 (firstly Ethilon, later Prolene) suture fixing it to the periost of the frontal bone. Attention is paid to achieve perfect symmetry between both sides. Finally, the skin is closed with Ethilon 5-0 sutures. The head is than wrapped with a bandage for 24–48 hours. The duration of the procedure is 20–30 minutes. For graphical depiction of technique, see Figure 2.

Surgical complications are relatively uncommon. However, bleeding, numbness and tingling, injury to the facial nerve resulting in paralytic brow ptosis, infection and postoperative asymmetry have been described in previous browlift studies ( ^{25– 35} ) and will be documented accordingly.

Patients with an indication for brow correction will receive information to review study specific information. Two weeks after patients have received the study information, they will be asked to participate in our study. see Table 1 for patient assessment moments.

Demographic information of patients will also be collected, such as age, race, and gender, as well as surgical indication and level of brow depression (see Figure 1).

Vectra XT. The Vectra XT 3D-imaging device (M3) produced by Canfield can be used for a wide variety of medical indications where accurate measurements can provide clear and clinically relevant information for both the practitioner and the patient.

A 3D-image can be easily made with the Vectra XT by correct positioning of the patient in front of the device. The device provides standard outlines, so correct positioning can be achieved relatively easily. The device and its accompanying software subsequently provide the practitioner with some standard measurements, which can be supplemented with additional measurements. (see Figure 1 for the overview). Additionally, the Vectra XT software can automatically provide before and after surgery differences in facial measurements by overlaying the produced photographs within one patient file.

Photographer instructions ( Table 2)

Patient instructions

For analyses we will use descriptive statistics and inferential statistics. A Kolmogorov-Smirnov test, a Q-Q plot and Levene’s test will first test all data for normality. Categorical variables will be expressed as n (%). Continuous normally distributed variables will be expressed by their mean and standard deviation, not normally distributed data by their median and interquartile range for skewed distributions. To test groups, categorical variables will be tested using the Pearson’s Chi-square test or Fisher’s exact test, when appropriate. Normally distributed continuous data will be tested with the independent samples Students t-test and in case of skewed data, with the independent samples Mann-Whitney U-test. Not normally distributed data will be tested by a Log rank test. When appropriate, for testing multiple possible factors for survival, a Cox proportional hazards analysis will be used. Statistical Package for Social Sciences (SPSS, Chicago, IL, USA Version 20.0) will be used to prepare the database and for statistical analysis.

The local data originating from the HMC-population will be coded. Each subsequent included and eligible case will be given a number, which is linked to the identifying patient details. The key to translate the code will be held by the main investigator in the HMC, Dr. de Jongh. The coded data will be stored by the aforementioned local investigators of this study in a spreadsheet that is secured by a password only known by these investigators. Only they will therefore have access to this data. Data will be kept in storage for 15 years. After the study ends the data will be made available on request. Each request will be assessed by dr. de Jongh.

No underlying data are associated with this article.

figshare: Data Protocol Browlift Study. https://doi.org/10.6084/m9.figshare.17207579.v1 ³⁶

This project contains the following files:

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).