How is upper eyelid blepharoplasty combined with brow lift?

Upper eyelid blepharoplasty typically follows either an open (coronal approach) or an endoscopic approach to brow elevation. The reason to perform the operation in such a sequence is to ensure that an excessive amount of skin is not removed; often lifting the brows will stretch out the upper eyelid skin, correct much of the redundancy and permit correction with much less of an upper eyelid skin excision. Performing the upper eyelid surgery first, risks excising too much skin, and not realizing this until the after brow elevation takes up additional skin. The open browlift is performed as follows. A cut is made either behind or along the forehead hairline. The forehead is undermined to the level of the eyebrows, either on top of the bone (subperiosteal), or on top of the bone covering (subgaleal). Frown muscles (corrugators, procerus, and depressors) are resected (removed). In some cases, sections of the frontalis (the eyebrow raising muscle, and the same one that causes the cross-forehead creases) are also removed. The brows are fixed in a symmetric configuration that is aesthetically pleasing, taking into account patient sex, and preoperative preference. A sliver of skin is removed at the edge of the incision, which serves to tighten skin laxity. The endoscopic brow-lift is typically performed in younger patients, in whom the problems include brow ptosis or drooping, with or without excess upper eyelid skin, as well as crow’s feet, but without significant forehead excess skin. Because minimal skin excision is needed, the browlift is performed through three small incisions behind the hairline. There is a multitude of devices available for fixation of the brows. Dr. Gerzenshtein prefers the Endotine® Forehead fixation device. The two outside (lateral) incisions serve as points of small triangular skin excisions. In addition, the lateral brow-lift may be added to the endoscopic approach to correct any skin excess, especially when the browlift is combined with the lower blepharoplasty, with or without the midface lift procedure. The previously marked upper eyelid skin is excised. Redundant muscle may be excised as well. The septum (membrane behind which the fat-pads are found) is either entirely opened, or opened at intervals. Fat from both eye-sockets is excised and compared for symmetry. The septum may be closed. At this point if the muscles elevating the eyes are to be repaired, this is performed. The skin and muscle is closed together on both sides.