December 24, 2015

Cleveland Clinic Physicians Review Frontalis Muscle Transposition Flap Procedure for Lateral Eyebrow Ptosis Repair

Small concealed incision and few side effects result

650×450-FMTF

Three physicians recently conducted a retrospective review to assess the early-term effectiveness and safety of a novel browlifting technique used to treat lateral eyebrow ptosis at Cleveland Clinic’s Cole Eye Institute. The technique is used to transpose a flap of frontalis muscle laterally to provide more elevator force to the lateral eyebrow region.

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The doctors’ review concluded that the frontalis muscle transposition flap (FMTF) procedure effectively addressed eyebrow ptosis through a small, relatively concealed incision, with few adverse events. They presented results of their review in a poster at the 2015 Association for Research in Vision and Ophthalmology Annual Meeting in Denver, Colorado, in May 2015.

Procedure counters effects of aging: Eyebrow ptosis or ‘lateral hooding’

Senescence is almost always marked by eyebrow ptosis, a problem that is both cosmetic and functional, and which has been historically difficult to treat. It has many contributing factors, including age-related elastolysis, loss of collagen, gain of subcutaneous fat and varying bone structure. It is the result of an incomplete interdigitation between the frontalis and orbicularis muscles, where gravity draws down periocular skin, musculature and fat pads. Lateral forehead antagonist muscle inequality may also play a part in contributing to ptosis and “lateral hooding.”

Bryan Costin, MD, and Julian Perry, MD, recently (2015) described the FMTF technique to provide more elevatory force to the lateral eyebrow region. The study did not quantify efficacy or safety, so Dr. Perry, Preethi S. Ganapathy, MD, and Rao V. Chundury, MD, of the Cole Eye Institute, designed the retrospective review of 31 charts (53 cases) to assess these factors.

The review covers patients who underwent FMTF eyebrow ptosis repair between December 2013 and September 2014 at Cole Eye Institute. All repairs were done by the same surgeon,

In each case, the incision site fell within a forehead rhytid or along the superior-most brow cilia, and was approximately 15 mm long, with excision of a 2 to 4 mm ellipse of skin in some cases to aid in subcutaneous dissection and visualization. The surgeon used scissors to bluntly expose the FOA and dissect anterior to the frontalis muscle approximately 2 cm around the incision. A pedicle flap of lateral frontalis muscle was created, trimmed and transposed laterally to achieve optimal brow position and contour by redirecting elevatory force to the lateral eyebrow. The transposition flap was then fixated to the orbicularis muscle with suture and the incision was closed.

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Afterward, the surgeon assessed corneal diameter, central brow height and lateral brow height.

Review assesses early-term effectiveness and safety of FMTF

“Overall, the technique results in a modest but clinically significant lateral brow elevation of close to 2 mm,” the authors reported in their review. “The technique is associated with few complications and low reoperation rate.”

Of the 31 charts reviewed, 20 were female and 11 male, with an average age of 69.1 +/- 7.7 years. There were nine unilateral and 22 bilateral cases, and 18 patients (33 cases) underwent concomitant upper blepharoplasty.

These results compared favorably to other browlifting studies, said the authors, citing bicoronal subgaleal browlift; blepharoplasty plus open bicoronal subgaleal browlift; or coronal, trichophytic or endoscopic eyebrow lifts. The authors conceded that the FMTF procedure might not provide enough elevation for cases of severe eyebrow ptosis.

Adverse events were few. Despite dissecting in the region of the frontal branch of the facial nerve, there were no cases of seventh nerve paresis.

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Scalp hypesthesia was documented in 10 of the 31 patients. It resolved completely in three, was mild or improving in five, and was persistent in only two. The authors noted that the hypesthesia was unexpected. They added that, intraoperatively, a relatively conserved neural structure could often be identified and avoided in the flap region.

Only one patient underwent reoperation six months postoperatively for undercorrection.

The surgery produced a statistically significant change (average 1.78 mm) in lateral eyebrow height (p = 0.002). The change in central eyebrow height was not significant.

The authors concluded that the FMTF browlift modestly improved brow position either alone or in conjunction with upper blepharoplasty. The technique appeared to avoid seventh nerve injury, but could produce sensory hypesthesia. Long-term results remain unknown.

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