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Finesse in Forehead Lifting-Asymmetric Ligament Release for Asymmetric Brow Ptosis
Henry Bair1, Tiffany S Cheng1, Sathyadeepak Ramesh2,3
1Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
Background:
Asymmetric brow ptosis presents a unique surgical challenge. It has been traditionally managed with full deep-plane release of the forehead retaining ligaments, which often leads to overcorrection or persistent asymmetry. This case series evaluates an approach using titrated asymmetric ligament release and selective fixation to address brow asymmetry while minimizing complications.
Methods:
We conducted a retrospective analysis of 50 consecutive patients (average age: 62.1 years) with preoperative brow asymmetry greater than 2 mm who underwent endoscopic brow lift between 2022 and 2024. All patients underwent bilateral temporal dissection and fixation. The surgical refinements included extended lateral ligament release (lateral release to the helical root performed on 100% of ptotic sides), selective medial dissection (performed on 62% of ptotic sides), and unilateral paramedian fixation (performed on 25% of cases). We evaluated postoperative symmetry, defined as less than 2 mm asymmetry, and any complications using standardized photographs and clinical assessments.
Results:
At an average follow-up of 12.5 months, 88% of patients achieved postoperative symmetry, with preoperative asymmetry improving from 4.5 mm ± 1.9 mm to 0.8 mm ± 0.9 mm (p < 0.001). Medial asymmetry, brow peak asymmetry, and lateral brow asymmetry were also all significantly improved (p < 0.0001). Six patients (12%) had residual asymmetry >2 mm (mean: 2.5mm), but all had significant improvement from baseline. Complications included temporary frontalis apraxia (8%, resolved by 8 months) and sensory deficits (4%, resolved by 12 months), with no cases of permanent nerve injury or alopecia.
Conclusion:
A patient-specific approach in endoscopic brow lift with asymmetric ligament release and selective fixation yields better results for patients with asymmetric ptosis compared to conventional techniques. Understanding individual anatomical variations can help surgeons minimize the risk of overcorrection and achieve more natural-looking outcomes.
Level Of Evidence Iv:
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
