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Facial asymmetries that more completely involve the whole face or just the upper half of the face create eyebrow asymmetries. Almost always the affected eyebrow is lower and may be associated with a lower tail of the brow bone and the upper eyelid as well. As a result, uplifting of the lower eyebrow is often a part of the overall facial asymmetry correction.

Lifting of the asymmetric eyebrow can be done by a variety of well known techniques, most commonly done by an endoscopic technique. Other effective methods include hairline-based approaches along the frontal or temporal hairlines. But for men with eyebrow asymmetry the absence of a well defined frontal hairline or a general lack of good hair density can make these browlift options not good ones.

An alternative approach is the transpalpebral browlift technique, which changes the approach from a high (superior) to a low (inferior) direction, gaining access through the upper eyelid. The transpalpebral technique is most commonly associated with the endotine device and in male brow lifting in particular. It achieves through subperiosteal release of the brow tissues and lifts it by placing it over a reservable pronged device drilled into the bone. It is a good approach for men in particular because it avoids any hairline issues as well as the risk of overcorrection both of which are of particular value in men.

In a similar transpalpebral method the endotine device can be replaced by a screw anchor technique that is made from a restorable suture attached to a small self-tapping screw. Once the subperiosteal release has been done through a lateral upper eyelid incision, a 3-0 vicryl suture is attached to a screw. The self tapping screw need to be no longer than 5mm in length at most.

The screw is placed as high as possible above the brow bone and screwed down flush to the bone. Getting it flush to the bone is important so it is can not be felt through the skin. The suture is then passed through the periosteal edge in the underside of the eyebrow tissue that has been released along the lower edge of the brow bone. By tightening down the suture the eyebrow remains higher in position. One or two suture-screw anchors can be used, one in the middle and one more lateral.

In some cases I will add a 2mm ePTFE implant to built up the lateral brow bone if it has inadequate projection…which they often do.

The upper eyelid incision is closed in two layers with fine 6-0 plain sutures for the skin. The upper eyelid incision also provides an opportunity to perform a lateral canthoplasty to raise up the outer eye corner and lower lid if it is also tilted downward.

The transpalpebral browlift technique is device-dependent as the brow needs to be lifted by a mechanical method. It produces a moderate browlift which is appropriate in many facia asymmetries where the brow ptosis may only be 5 to 7mms at most.

Dr. Barry Eppley

Indianapolis, Indiana

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