Determining the Need for Browlift vs Temporal Lift During Upper Blepharoplasty
Direct Assessment Criteria
The decision between browlift and temporal lift during upper blepharoplasty depends primarily on the pattern and location of brow ptosis: lateral brow ptosis alone indicates temporal lift, while medial and central brow ptosis requires direct browlift. 1
Anatomical Assessment Algorithm
Step 1: Identify the Pattern of Brow Ptosis
Measure brow position at specific landmarks:
- Lateral canthus position
- Lateral limbus position
- Mid-pupil position
- Medial limbus position 2
Key decision points:
- Lateral two-thirds ptosis only → Temporal lift or internal browpexy 1, 3
- Medial and central ptosis → Direct browlift 1
- Total brow ptosis → Frontal lift (not temporal lift) 3
Step 2: Assess the Degree of Ptosis
Mild to moderate lateral brow ptosis:
- Trans-blepharoplasty internal browpexy is effective and can be performed through the same blepharoplasty incision 1
- External browpexy provides superior lateral brow elevation compared to internal browpexy (significant elevation across whole brow vs lateral side only at 3 months) 4
Marked brow ptosis:
- Direct browlift is more appropriate for any degree and pattern of severe ptosis 1
- Consider pretrichial approach for combined dermatochalasis and moderate brow ptosis (achieves mean 1.85 mm lift at lateral canthus) 2
Technical Considerations by Approach
Temporal Lift Indications
- Primary indication: Lateral ptosis of the tail of the brow 3
- Frequently combined with cervico-cheek lift 3
- Can be performed concomitantly with blepharoplasty 3
Internal Browpexy (Trans-blepharoplasty)
- Best for: Relatively small degrees of brow ptosis affecting mainly lateral two-thirds 1
- Performed through the same blepharoplasty incision 1
- Provides significant lateral brow elevation that persists at 6 months (mean LBPL increase from 15.09 mm to 17.43 mm) 5
- Superior long-term stability compared to temporal brow lift for lateral brow elevation 5
External Browpexy
- Provides better brow-lift outcomes than internal browpexy (significant elevation across entire brow vs lateral side only) 4
- Both internal and external browpexy prevent brow ptosis that occurs with skin excision alone 4
Direct Browlift
- Suitable for: Any degree and pattern of brow ptosis, particularly medial and central 1
- Patient selection: Males, older females, patients with facial paresis, or marked involutional ptosis 1
- Additional lateral lift may be needed, achieved with temporal external lift or internal lift combined with blepharoplasty 1
Critical Pitfalls to Avoid
Performing blepharoplasty alone without addressing brow ptosis:
- Upper eyelid skin excision without browpexy results in whole brow ptosis postoperatively 4
- The ptotic brow drops below the supraorbital rim and exacerbates dermatochalasis by pushing upper lid skin further down 2
Choosing temporal lift for total brow ptosis:
- Temporal lift is contraindicated when total brow ptosis is present; frontal lift is required instead 3
Potential complications to counsel patients about:
- New-onset diplopia can occur after upper lid blepharoplasty, sometimes associated with trochlear damage 6, 7
- Scarring, hemorrhage in adjacent tissue, or fat adherence 6, 7
- With direct browlift: cosmetically disturbing scar, granuloma formation with braided sutures, temporary forehead numbness 1
- With trans-blepharoplasty approach: less lift than desired, suture-related skin dimpling 1
Practical Decision Algorithm
- Assess brow position at lateral canthus, lateral limbus, mid-pupil, and medial limbus 2
- If lateral two-thirds ptosis only → Consider internal browpexy (best long-term stability) or external browpexy (better immediate lift) through blepharoplasty incision 5, 4
- If medial/central ptosis present → Direct browlift with possible additional lateral temporal component 1
- If total brow ptosis → Frontal lift, not temporal lift 3
- Never perform isolated upper blepharoplasty when brow ptosis is present, as this will worsen brow descent 2, 4