Implications of Upper Eyelid Ptosis and Blepharodermatochalasis on Fixed Horizontal Forehead Lines

Background: The contribution of photoaging to the development of fixed wrinkles based on lines of mimetic muscle activation has been studied extensively^1,2. In the forehead, the frontalis muscle, in addition to its primary role of elevating the eyebrow during facial expression, serves a secondary role in eyelid elevation. In patients with ptosis or dermatochalasis of the upper eyelid, greater frontalis activation is thought to compensate to help restore the visual field. This compensatory mechanism  has increasingly been implicated in the development of both transient and fixed horizontal forehead lines³.

Purpose: In the present study, we examine the correlation between ptosis, brow ptosis, and blepharodermatochalasis, with the presence of forehead lines, in a facial rejuvenation patient population.

Methods: Photos of patients presenting to the senior author (B.G.)'s practice for facial rejuvenation between July 2015 and July 2017 were retrospectively reviewed for the presence of forehead lines, ptosis, brow ptosis, and blepharodermatochalasis. Patient age, gender, and race were also included for analysis. Inclusion criteria were patients over age 50 with high-quality frontal facial photographs. Patients with previous eyelid or forehead surgery, congenital abnormalities, or post-traumatic deformities were excluded. Ptosis was defined as more than 1.5mm of overlap between the upper eyelid and the iris. Brow ptosis was judged through a review of patient photographs by the senior author (B.G.), an experienced facial aesthetic Plastic Surgeon. Blepharodermatochalasis was defined as the presence of redundant upper eyelid skin that drapes over the lash line. Patients were divided into a group with fixed forehead lines and a group without fixed forehead lines for purposes of comparative analysis. A two-tailed Fisher's exact test was used to evaluate statistical significance for categorical variables, and a two-tailed t-test was used for continuous variables. Significance was assessed at P<0.05.

Results: One hundred sixty patients met inclusion criteria for the study, including 100 patients with fixed forehead lines and 60 patients without fixed forehead lines. Patients with forehead lines were statically more likely to be older (age 61.56±8.93 vs. 58.58±7.59; P=0.0337), to be male (36% vs. 11.67%; P=0.0008), to have ptosis (90% vs. 76.67%; P=0.0377), and to have blepharodermatochalasis (20% vs. 5%; P=0.0097). All 28 patients with unilateral fixed forehead lines (17 left, 11 right) were noted to have ptosis on the ipsilateral side. No correlation was found between the presence of forehead lines and patient race or presence of brow ptosis.

Conclusions: These findings suggest that ptosis and blepharodermatochalasis may contribute to the development of fixed forehead lines through compensatory frontalis activation, with the implication that upper eyelid blepharoplasty and ptosis repair may be important adjuncts that can increase the longevity of the results of surgical forehead rejuvenation.

1. Kligman AM, Zheng P, Lavker RM. The anatomy and pathogenesis of wrinkles. Br J Dermatol. 1985;113(1):37-42.
2. Fisher GJ. The pathophysiology of photoaging of the skin. Cutis. 2005;75(2 Suppl):5-8-9.
3. Ezure T, Amano S. The severity of wrinkling at the forehead is related to the degree of ptosis of the upper eyelid. Skin Res Technol. 2010;16(2):202-209.