Aesthetic Plastic Surgery

, Volume 42, Issue 6, pp 1551–1555 | Cite as

Horizontal Forehead Lines: A Reflection of Eyelid Ptosis or Blepharodermachalasia

  • Yuewei Wu-Fienberg
  • Kunaal R. Bafna
  • Bahman GuyuronEmail author
Original Article Facial Surgery



In his facial aesthetics practice, the senior author (B.G.) observed that many patients presenting with horizontal forehead lines also demonstrated upper eyelid ptosis or enough blepharodermachalasia to require compensation. This study was conducted to investigate this observation.


Photographs of patients presenting for facial rejuvenation were retrospectively reviewed for the presence of forehead lines, ptosis, brow ptosis, and blepharodermatochalasia. Patient age, gender, and race were reported. Only patients over age 50 were included. Patients who had previous eyelid or forehead surgery, congenital abnormalities, or post-traumatic deformities were excluded. Ptosis was defined as more than 1.5-mm overlap between the upper eyelid and the iris. Patients were divided into two groups based on presence of forehead lines for comparative analysis.


One hundred sixty patients, including 100 patients with and 60 patients without horizontal forehead lines, were included. Patients with forehead lines were likely to be older (age 61.56 ± 8.93 vs. 58.58 ± 7.59; P = 0.0337), male (36 vs. 11.67%; P = 0.0008), have ptosis (90 vs. 76.67%; P = 0.0377), and have blepharodermatochalasis (20 vs. 5%; P = 0.0097). All 28 patients with unilateral forehead lines (17 left, 11 right) had ipsilateral ptosis.


Ptosis and blepharodermatochalasis may result in the development of horizontal forehead lines through compensatory frontalis activation. Whenever horizontal forehead rhytids are noted, it is imperative to search for ptosis or blepharodermachalasia in repose. Otherwise, forehead rejuvenation may fail to eliminate these compensatory forehead lines, and chemodenervation may have significant adverse effects on the visual field by forcibly blocking frontalis compensation.

Level of Evidence III

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


Forehead lines Ptosis Blepharodermatochalasia Frontalis Compensation 


Compliance with Ethical Standards

Conflict of interest

None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this manuscript.


  1. 1.
    Lam VB, Czyz CN, Wulc AE (2013) The brow-eyelid continuum. Clin Plast Surg 40:1–19. CrossRefPubMedGoogle Scholar
  2. 2.
    Karacalar A, Korkmaz A, Kale A, Kopuz C (2005) Compensatory brow asymmetry: anatomic study and clinical experience. Aesthet Plast Surg 29:119–123. CrossRefGoogle Scholar
  3. 3.
    Fagien S (1992) Eyebrow analysis after blepharoplasty in patients with brow ptosis. Ophthal Plast Reconstr Surg 8:210–214CrossRefGoogle Scholar
  4. 4.
    Huijing MA, van der Palen J, van der Lei B (2014) The effect of upper eyelid blepharoplasty on eyebrow position. J Plast Reconstr Aesthet Surg 67:1242–1247. CrossRefPubMedGoogle Scholar
  5. 5.
    Kim D, Son D, Kim M et al (2015) Does upper blepharoplasty affect frontalis tonicity? J Plast Reconstr Aesthet Surg 68:638–644. CrossRefPubMedGoogle Scholar
  6. 6.
    Lew H, Goldberg RA (2016) Maximizing symmetry in upper blepharoplasty. Plast Reconstr Surg 137:296e–304e. CrossRefPubMedGoogle Scholar
  7. 7.
    Karacalar A, Korkmaz A, Kale A, Kopuz C (2005) Compensatory brow asymmetry: anatomic study and clinical experience. Aesthet Plast Surg 29:119–123. CrossRefGoogle Scholar
  8. 8.
    Ezure T, Amano S (2010) The severity of wrinkling at the forehead is related to the degree of ptosis of the upper eyelid. Skin Res Technol 16:202–209. CrossRefPubMedGoogle Scholar
  9. 9.
    Rossi AM, Eviatar J, Green JB et al (2017) Signs of facial aging in men in a diverse, multinational study. Dermatol Surg 43:S210–S220. CrossRefPubMedGoogle Scholar
  10. 10.
    Shah CT, Nguyen EV, Hassan AS (2012) Asymmetric eyebrow elevation and its association with ocular dominance. Ophthalmic Plast Reconstr Surg 28:50–53. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2018

Authors and Affiliations

  • Yuewei Wu-Fienberg
    • 1
  • Kunaal R. Bafna
    • 2
  • Bahman Guyuron
    • 1
    • 3
    Email author
  1. 1.Department of Plastic SurgeryUniversity Hospitals Cleveland Medical CenterClevelandUSA
  2. 2.University of Toledo College of Medicine and Life SciencesToledoUSA
  3. 3.ClevelandUSA

Personalised recommendations