Operative Strategies
Browpexy
The presence of excess skin at the lateral brow is a com-
mon complaint of patients who have undergone upper
lid blepharoplasty. The author describes a browpexy
procedure that supports the lateral brow and enhances
the sulcus through the use of suturing of the superior
cut edge of the orbicularis muscle to the arcus margin-
alis with 2 to 4 absorbable 4-0 sutures. (Aesthetic Surg
J 2004;24:368-372)
M
y main catalyst for developing a simple method
of correcting lateral brow ptosis is a common
disappointment expressed by patients who have
undergone upper lid blepharoplasty. Patients frequently
complain, while grasping the lateral brow, “I still have
too much skin here.” In attempting to address this con-
cern, surgeons have made the mistake of excising what
appears to be excess upper eyelid skin and lower brow
skin, resulting in a misplaced sulcus and a noticeable
apposition of slightly pigmented upper eyelid and nonpig-
mented brow skin, yielding the illusion of a conspicuous
scar. In fact, this supposed scar is simply an unnatural
juncture of 2 types of skin with contrasting pigmentation.
Also, the issue of how much, if any, orbicularis muscle
should be excised can be simply resolved: A sulcus is cre-
ated by the browpexy, and the need to resect muscle is
obviated.
The browpexy (or sulcoplasty) is designed to accom-
plish 2 things: support the lateral brow and enhance the
sulcus. If the brow is ptotic below the surpraorbital rim,
the browpexy will raise the brow or at least fix it at the
level of the supraorbital rim.
Operative Technique
With the patient erect, mark the upper eyelid crease.
Some asymmetry is usually present, and it is acceptable to
select the higher of the 2 folds. With the patient’s eyes
open, note the degree of eyelid hooding and mark it. Keep
in mind that this mark will be higher than the desired loca-
tion of the upper incision because at this time (with the
patient erect) the brow is ptotic. The amount of skin resec-
368 AESTHETIC SURGERY JOURNAL ~ July/August
tion varies, but remember
that the tucking of the skin
into the sulcus takes up
enough of the skin laxity
that the skin resection should
be rather conservative.
In the operating room,
before infiltration of 1%
lidocaine and epinephrine Harvey A. Zarem, MD, Santa
Monica, CA, is a board-certified
1:100,000, confirm the
plastic surgeon and an ASAPS
markings. Perform the infil- member.
tration gently with a 30-
gauge needle to minimize the risk of ecchymosis, which
can disrupt the apparent anatomy. Although most of my
blepharoplasties are performed with the patient under
general anesthesia, I infiltrate lidocaine and epinephrine
for their anesthetic and vasoconstrictive effects. It is wise
to wait 5 minutes after injection to permit effective vaso-
constriction. Although the skin and underlying orbicu-
laris muscle may be resected together, I choose to resect
them separately to ensure that I resect less muscle than
skin. Resect a thin strip of orbicularis muscle with
Stevens scissors (Robbins Instruments, Chatham, NJ).
Perform this muscle resection close to the inferior cut
edge of skin to emphasize the superior lid margin on final
closure, but take care not to disrupt the insertion of the
levator aponeurosis to the tarsus.
When mild pressure is placed on the globe, the ret-
roseptal fat can usually be seen in the middle portion of
the upper lid. At this point, the orbital septum can be
opened. I prefer to open the septum for the length of the
lid and resect the bulging retroseptal fat with the use of
electrocautery to minimize the risk of bleeding from a
retracted blood vessel (Figure 1).
At this stage in the dissection, the orbital septum has
retracted and curled up to the arcus marginalis (the con-
fluence of the orbital septum and the supraorbital perios-
teum), which is readily visualized. It is important to
recognize that the arcus marginalis lies at the deep edge
of the supraorbital rim (Figure 2).
The browpexy is accomplished through suturing of
2004
 Operative Strategies

Figure 1. The arcus marginalis

is seen in sagittal section at the
superior edge of the orbital rim
as the confluence of the perios-
teum and the orbital septum.

Illustrations by William M. Winn, Atlanta, GA.

Figure 2. After resection of

redundant skin and the orbicu-
laris muscle, the orbital septum
is opened and the extruding fat
resected with a cautery.

Browpexy AESTHETIC SURGERY JOURNAL ~ July/August 2004 369

 Operative Strategies

B C

Figure 3. A, A 4-0 absorbable suture is placed through the arcus marginalis in the lateral third of the orbital rim and then (B) through the cut
edge of the orbicularis muscle. The cotton-tip applicator prevents the levator and areolar tissue from becoming entrapped in the suture. C, The
suture apposes the arcus marginalis and the orbicularis muscle to yield a well-defined sulcus.

the superior cut edge of the orbicularis muscle to the
arcus marginalis with 2 to 4 absorbable 4-0 sutures
(Figure 3). Begin suturing at the margin of the supraor-
bital rim, at the true arcus marginalis; otherwise, the tis-
sue will not curl in and will not produce a well-defined
sulcus. You may place the sutures at any point along the
supraorbital rim, but the usual goal is to support the lat-
eral third of the brow (Figure 4). Take special care to
ensure that the areolar tissue over the levator muscle is
not trapped in the sutures; otherwise, a check-rein effect
on lid closure will result in lagophthalmos.
Skin closure can be performed with simple running 6-

370 Aesthetic Surgery Journal ~ July/August 2004 Volume 24, Number 4

 Operative Strategies

Figure 4. The absorbable sutures

are placed laterally. The number
(usually 2–4) may vary, depending
on the desired effect.

Figure 5. The browpexy suture causes

the overlying skin to be “tucked” into
the sulcus, completing the sulcoplasty.

0 nylon sutures (Figure 5), which can be removed after 6 when the patient arrives home) helps control swelling and
or 7 days. The application of cold compresses immediate- ecchymosis of the eyelids.
ly on completion of the skin closure (not hours later, Browpexy is appropriate for both men and women.

Browpexy AESTHETIC SURGERY JOURNAL ~ July/August 2004 371

 Operative Strategies

A B
Figure 6. A, Preoperative view of a 50-year-old man. B, Postoperative view 16 months after upper lid blepharoplasty, browpexy, transconjunctival
lower lid blepharoplasty, and lateral canthoplasty.

A B
Figure 7. A, Preoperative view of a 31-year-old woman. B, Postoperative view 1 year after upper lid blepharoplasty and browpexy.

However, in men the creation of the sulcus is often the
definitive portion of the blepharoplasty, ensuring persis-
tence of the correction. The surgeon can demonstrate the
effect of the browpexy to the patient with the simple
maneuver of manually reinforcing the upper-eyelid sulcus
with a cotton tip. The benefit will be obvious.
The postoperative period is usually without complica-
Suggested Reading
Zarem HA, Resnick JI, Carr RM, et al. Browpexy: lateral orbicularis
muscle fixation as an adjunct to upper blepharoplasty. Plast Reconstr
Surg 1997;100:1258–1261.
Reprint requests: Harvey A. Zarem, MD, 1301 20th Street, Suite 470,
Santa Monica, CA 90404; e-mail: hzarem@ucla.edu.
Copyright © 2004 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$30

tions, as long as the patient avoids any straining or doi:10.1016/j.asj.2004.05.002

Valsalva maneuvers, which can cause bleeding during the

week following surgery. Mild lagophthalmos or upper-
eyelid ptosis is occasionally present in the first week, but,
in my experience, each condition has resolved without
exception during the second week. Long-term follow-up
of patients after upper lid blepharoplasty and browpexy-
sulcoplasty has demonstrated persistence of the sulcus.
Brow ptosis and recurrence of the excess skin in the
upper eyelid have been minimal (Figures 6–7).

372 Aesthetic Surgery Journal ~ July/August 2004 Volume 24, Number 4