Brow Ptosis

What is Brow Ptosis?

Brow ptosis is a condition where the eyebrow lowers from its usual position to a point that makes it cosmetically unappealing or causes problems with vision due to excess skin pushing down on the eyelid. This condition is usually seen in older people because of the natural aging process changing the face’s soft tissues. Brow ptosis can also happen if there’s damage to a particular nerve in the face, which stops or weakens the muscle that lifts the brow or keeps it in the right place when the face is at rest.

When the brow lowers, it squashes the soft parts of the eyelid, forcing them down and allowing too much skin to fall over the edge of the eyelid and touch the eyelashes. This is called pseudoptosis. While pseudoptosis might seem similar to a condition called blepharoptosis, they are actually relatively easy to tell apart. If you lift the brow back to its correct spot and the problem goes away, it’s pseudoptosis. However, if after lifting the brow the lid margin still stays low, then it’s true blepharoptosis. It’s worth noting that somebody could have both conditions at the same time, as one does not necessarily rule out the other.

What Causes Brow Ptosis?

Brow ptosis, which is a sagging or drooping of the eyebrow, usually happens as a response to certain external factors. It is not generally present at birth. A rare instance where it can be present from birth is when the facial nerve and/or muscles controlling facial expressions are not fully developed.

Here are some ways in which the condition can occur with time:

1. Aging: The most common reason for brow ptosis is age. As we grow old, the tissues of the brow become loose. The skin and the frontalis muscle, which controls the movement of the eyebrows, starts to sag. Firstly, the drooping is noticeable in the outer part of the eyebrow, but if left untreated, the inner two-thirds may also begin to droop.

2. Injury: Brow ptosis can result from an injury to the facial nerve located in various regions of the head. For example, a fracture of the bone above the ear is one of the most common injury-related causes. Other causes can be injuries to the saliva-producing gland below the ear, the bone forming the cheek, or the lower jawbone.

3. Muscle-related: Certain muscle diseases that specifically affect the facial muscles or muscles all over the body can result in brow drooping due to the loss of muscle mass or nerve connection in the frontalis muscle. Some of these diseases include Myasthenia Gravis and muscular dystrophy, which affect the muscle strength.

4. Infections: Infections can also cause sagging eyebrows. Ramsay Hunt Syndrome is an example, where a previous chickenpox virus gets reactivated and causes facial paralysis along with a rash. This condition includes eyebrow drooping as a symptom. Other infections that can cause this issue include herpes, Lyme disease, syphilis, West Nile virus, HIV, SARS-CoV-2, polio, and COVID.

5. Spasm-induced: Brow ptosis can also be caused by frequent or long-lasting spasms (sudden, involuntary muscle contractions) of the muscle around the eyes that pulls the brow down and displace it from its anatomical position, making the change permanent. This happens in conditions like eyelid spasm or partial facial spasm.

6. Tumors: Tumors in and around the facial nerve can affect its functioning and result in brow drooping. Examples of such tumors include skin cancers like melanoma and squamous cell carcinoma, or tumors near the ear.

7. Medical procedures: Surgical operations in the area around the brow pose a significant risk, as they can affect the nerve supply and structure of the brow. Procedures that carry the highest risk include biopsy of the temple artery, removal of tumors near the ear, and jaw joint procedures. Cosmetic procedures on the face, like facelifts, can also unintentionally lead to this issue, but the risk is less than 1%. Lastly, injections of a medicine called botulinum toxin can also lead to eyebrow drooping if they are not administered properly.

Risk Factors and Frequency for Brow Ptosis

Most cases of brow ptosis, or drooping of the eyebrow, seem to be related to aging. However, there isn’t a lot of scientific research on this specific subject. Only a small percentage, about 4.9%, of these cases are present at birth, a condition known as congenital brow ptosis. The rest of the cases are due to various other causes, as mentioned earlier.

Signs and Symptoms of Brow Ptosis

When examining a patient with drooping eyebrows (brow ptosis), it’s important to gather a comprehensive history to identify the root cause. This includes understanding when and how the symptoms started, the patient’s medical and surgical history, and factors in their lifestyle that could contribute to the condition. The speed at which the condition develops can hint at specific causes: a slow progression could suggest an age-related cause, while a quick onset may imply conditions like Bell’s palsy or trauma, etc. Furthermore, a history of prior facial paralysis, exposure to chemotherapy or radiation, or any procedures in the eyebrow or facial nerve area can provide useful insights. Lifestyle factors such as sun exposure, smoking, and drug use could accelerate changes related to aging.

The physical exam for such a patient follows a methodical step-by-step approach.

• The brow’s neutral position should be evaluated by asking the patient to close their eyes, relax their face, then gently open their eyes without lifting the brows.
• In case there’s a drooping lid or brow, manually elevating the brow to its neutral position will help differentiate between the two.
• The degree of droopiness in the eyelids (blepharoptosis) is measured using the margin-reflex distance (MRD), i.e., the distance from the corneal light reflex to the eye’s upper or lower lid margin. Certain values of MRD indicate blepharoptosis.
• If there’s brow asymmetry or symptoms of myasthenia gravis, further tests like the ice pack test should be administered.

Other conditions like Hering phenomenon, in which the elevation of one droopy eyelid causes the other eyelid to droop, and facial asymmetry caused by conditions like hemifacial microsomia should also be evaluated.

Additional aspects relevant to a thorough examination of the eye area include assessing eyelid laxity using the snap test, determining lower eyelid vector (relating to aging and risk of eyelid turning outwards), and evaluating tear production using the Schirmer test. The forehead’s shape and position of the hairline should be visually examined to guide the surgeon’s approach.

Lastly, a detailed cranial nerve exam is recommended, especially if damage to the facial nerve is suspected.

Testing for Brow Ptosis

Assessing eyebrow droopiness, or brow ptosis, typically involves a detailed history and physical exam. For the most part, additional tests are not required, but they can sometimes be useful. Certain lab tests can help in pinpointing muscle-related causes of brow ptosis, such as myasthenia gravis, which is diagnosed using a specific blood test for antibodies to a protein called acetylcholine receptor.

If a tumor is the cause of the drooping eyebrow, a more detailed investigation of the abnormal growth will be necessary. Depending on what kind of tumor is suspected, various assessments may be used, ranging from a simple skin biopsy to advanced imaging scans like magnetic resonance imaging (MRI) or positron emission tomography (PET).

Treatment Options for Brow Ptosis

Brow ptosis, or a drooping brow, can be treated in many ways, and the method used often depends on different factors like how the brow looks, why it’s drooping, how severe the drooping is, and what the patient hopes to achieve. Although we often see this in older individuals due to the natural aging process, surgery is typically the most effective solution, but it can also be used for other causes like injury, growths, or side effects from other procedures. Besides surgery, there are other treatments, and these are often done alongside other procedures that help refresh the face, like upper eyelid surgery, injections of Botox, or skin resurfacing.

One common method is the endoscopic brow lift, also known as the “endobrow” procedure, where small cuts are made in the forehead and scalp and the area above the eyes is lifted and secured in place with dissolvable implants or staples and stitches. It is best suited for those with low or average brow height and not a lot of forehead curvature. A key benefit of this method is it can aid with wrinkles between the eyebrows by separating the muscles that cause them. However, it has limitations such as not being great for correcting asymmetry, the chance of nerve damage, causing forehead numbness, and being unable to achieve dramatic lifting.

Open coronal procedures, a more traditional method, use cuts either in or just in front of the hairline, or within the hairline. The skin is lifted and excess skin and soft tissue are removed. This allows for greater lifts than with the endobrow procedure, but these surgeries can lead to significant scarring that may be worsened by hair loss, and are often associated with complications such as forehead numbness, itching, hair loss, and decreased sensation.

The direct brow lift, on the other hand, cuts just above the brow where the hair is. Surplus skin and soft tissue are removed, resulting in a substantial lift with a relatively minor procedure. Although it poses risks like visible scarring and over lifting that may result in a surprised look, it is ideally suited for addressing any unevenness of the brows.

The transblepharoplasty browpexy is a method that consolidates the treatment of loose or drooping upper eyelid skin with the treatment of a drooping brow. Similar to the results of the endobrow, the outcomes are limited.

For severe brow asymmetry especially in patients with facial paralysis and heavy soft tissues, suturing the drooping brow to a small piece of titanium attached to the skull bone may be effective.

The mid-forehead brow lift is a mostly outdated procedure where an incision is hidden within a deep face wrinkle. It’s not commonly used now because the resulting scars are hard to hide, and other methods offer a similar amount of lift.

Finally, non-surgical treatments may be an option in some cases. Botox injections, for instance, can treat spastic brow ptosis, where the brow droops due to certain muscles contracting too much, or can even slightly elevate the brow by reducing the force of the muscle that pulls down the brow. More systemic causes like myasthenia gravis, a condition causing muscle weakness, will need specific medical treatment.

What else can Brow Ptosis be?

Brow ptosis, or drooping brows, is generally a straightforward diagnosis. But sometimes, other eye area problems can make this condition hard to spot. For instance, if one brow droops more noticeably than the other, it may seem that only one side is affected. Also, conditions like excessive eyelid skin or drooping eyelids can take attention away from drooping brows. A detailed health history and physical examination are needed to determine the cause of brow ptosis. It could be due to ageing, trauma, muscle-related problems, involuntary contractions, infections, growths, or caused by a previous medical treatment.

What to expect with Brow Ptosis

The outcome of treatment greatly depends on the cause of the problem and the patient’s main worries. If patients are primarily bothered by visual field issues caused by their droopy brows, treatment can generally fully resolve the issue, leaving them satisfied. However, patients concerned primarily about appearance tend to be less satisfied with the results. Patients whose problems are not related to aging might see a wider range of outcomes.

Possible Complications When Diagnosed with Brow Ptosis

Brow ptosis, or drooping of the eyelid, rarely leads to severe complications. The most noticeable issue can be an obstructed field of vision, which typically starts on the outer edge (lateral) and moves towards the middle (medial). People who have surgery to correct brow ptosis might experience issues such as not being satisfied with the results, forehead numbness due to nerve damage, hair loss, and uneven brows. However, these complications are infrequent. Non-surgical treatments to rejuvenate the brow have very seldom complications. The most common one after botulinum toxin treatment (like Botox) is bruising around the eyes, but this only tends to affect a small percentage of patients.

Common Complications:

• Unsatisfied with the results of the surgery
• Numbness of the forehead due to nerve damage
• Hair loss
• Uneven eyebrows
• Periorbital bruising after botulinum toxin treatment

Preventing Brow Ptosis

It’s important for patients to understand what causes their brow to droop, also known as brow ptosis. We make sure to explain this in a way that is easy for them to understand. Once they have a good understanding of the condition, we can then discuss the various options for treatment, which can be with or without surgery. We believe it’s crucial for patients to make an informed decision regarding their treatment. Therefore, we take the time to have a detailed conversation about the potential risks and complications that could arise from their chosen treatment method before we proceed with any surgery.