Eyebrow in orofacial harmonization: anatomy and care

The eyebrow (supercilium) is the strip of hair-bearing skin that follows the upper border of the orbit. It sits in the upper third of the face, at the transition between the forehead and the eyelid, and it weighs heavily on how the gaze reads: a few millimeters of difference in height or slope change the expression from rested to tired, sad or angry. In orofacial harmonization, it is rarely treated on its own. It almost always enters the plan as a consequence of what is done in the forehead, glabella and temples.

What are the boundaries and parts of the eyebrow?

To describe the eyebrow, it is usually divided into three parts:

• Head: the medial portion, close to the glabella, generally wider and lower.
• Body and peak: the central portion, where the curve reaches its highest point, usually at the level between the lateral limbus of the iris and the lateral canthus.
• Tail: the lateral portion, which tapers toward the temple.

The position considered harmonious varies with sex, ethnicity and era. In general, the female eyebrow is described as more arched and slightly above the orbital rim, and the male eyebrow as straighter and lower, near the rim. These references are for conversation, not a template: the patient's natural eyebrow is the starting point.

Under the skin lie the subcutaneous tissue, the muscles, a layer of retro-orbicularis fat (the pad called ROOF) and the periosteum of the frontal bone. This pad gives support and volume to the eyebrow, especially in the lateral portion. See more about these compartments in fat pads.

Which muscles move the eyebrow?

The position of the eyebrow is a tug of war:

One anatomical detail explains a lot: the frontalis fibers usually end before the most lateral portion of the eyebrow. The tail is left without a direct elevator and under the pull of the orbicularis. That is why drooping with age tends to begin laterally.

Vessels and nerves to watch

• Supraorbital and supratrochlear arteries, which leave the orbit and rise over the forehead. They communicate with the circulation of the ophthalmic artery.
• Frontal branch of the superficial temporal artery, in the lateral portion.
• Supraorbital and supratrochlear nerves, responsible for sensation in the forehead.
• Temporal branch of the facial nerve, which crosses the temporal region to the frontalis. Injury to it can prevent raising the eyebrow on the affected side.

Why does the eyebrow droop?

Brow ptosis (drooping of the supercilium) has causes that add up:

• Aging of the layers: loss of volume in the fat pad, loosening of the ligaments and skin, bone resorption of the orbital rim.
• Muscle imbalance: strong depressors against a frontalis already working at its limit.
• Iatrogenic cause: botulinum toxin that reduces the strength of the frontalis too much.
• Neurological cause: injury to the temporal branch of the facial nerve, which calls for medical assessment.

It is important not to confuse brow ptosis with eyelid ptosis, which is drooping of the upper eyelid, or with excess eyelid skin. All three can coexist, and many patients compensate for eyelid weight by contracting the frontalis all the time.

What do patients usually ask for?

Concerns come in like this:

• "I want to lift my eyebrow with botox." (the popular term comes from a brand name)
• "My gaze looks droopy, I look tired."
• "One eyebrow is higher than the other."
• "I saw that threads lift the eyebrow, are they right for me?"
• "After the injection in my forehead, my eyebrow dropped."

Does botulinum toxin lift the eyebrow?

It can lift it, subtly. The reasoning is one of balance: by reducing the strength of the depressors, the frontalis meets less resistance, and the eyebrow tends to rise a little. In the literature, this effect is called chemical brow lift. It is small, temporary and less predictable than the patient imagines.

What changes the result:

• Frontalis strength: if it is already weak or was treated with a high dose, there is no elevator to take advantage of the relaxed depressors.
• Tissue weight: in very lax skin or with excess eyelid skin, the gain is usually small.
• Joint planning: forehead and glabella treated without considering each other change the shape of the eyebrow unpredictably.

Distribution, doses and injection sites are the decision of the qualified professional, based on the product's label and the rules of their professional council in Brazil. The fundamentals of planning are in botulinum toxin in HOF.

PDO threads in the eyebrow: what to expect?

Absorbable thread lifts, such as PDO threads, are used by some professionals to support the tail of the eyebrow. The described effect is mechanical, a subtle repositioning, added to local tissue stimulation.

Points for the indication:

• The effect is usually more subtle and shorter-lived than the patient expects.
• Thick skin, significant laxity or excess eyelid skin limit the result.
• Reported complications include facial asymmetry, irregularity or visibility of the thread, extrusion, pain, infection and, because of the proximity, injury to nerve branches in the temporal region.

When the drooping is significant, surgical assessment may be the most honest path, and the patient should be told so.

Filler in the eyebrow: when is it considered?

Hyaluronic acid filler in the eyebrow aims to replace lost support, especially in the tail, where the fat pad shrinks with age. Often, however, the lateral eyebrow improves when the neighboring area is treated: the concavity of the temples takes support away from the tail, and temple filler can restore part of that support.

Technique, product, plane and the choice between cannula and needle are the decision of the qualified professional, according to the rules of their professional council.

How to assess the eyebrow before treating

1. Rest and contraction: observe the position with the face relaxed and with the eyebrows raised.
2. Compensatory use of the frontalis: ask the patient to close their eyes and open them slowly, without raising the forehead. If the eyebrow drops a lot, they are using the frontalis to open the gaze.
3. Upper eyelid: excess skin or prior eyelid ptosis changes the indication.
4. Pre-existing asymmetry: very common. Record it and show it to the patient before any injection.
5. Temples and orbital rim: lateral volume loss usually goes along with drooping of the tail.

Precautions, contraindications and complications

The general contraindications of each procedure apply, summarized in general contraindications in HOF: for toxin, neuromuscular diseases, medications that interfere with the neuromuscular junction, pregnancy and breastfeeding; for filler and threads, active infection at the site, uncontrolled autoimmune disease, allergy to the components and unrealistic expectations.

Complications reported in the region:

• Drooping of the eyebrow or eyelid after toxin.
• Excessive arching or asymmetry between the sides.
• Swelling and bruising, more visible because of the thin skin in the region.
• Irregularity, extrusion or visibility of threads.
• Vascular occlusion with filler.

The full picture is in the safety and complications overview.

How does the eyebrow appear in Harmy?

The eyebrow has no point of its own in Harmy's marking. The available points are Glabella, Temple, Tear Trough, Cheekbone, Nasolabial Fold, Mouth Corner, Lips, Chin and Jawline.

How to talk to the patient about the eyebrow

Patients often arrive with the idea that toxin "lifts" the eyebrow like a surgery. It is worth setting expectations right at the start, showing in the mirror what is true drooping, what is forehead compensation and what is congenital asymmetry. If you show an illustrative simulation of another area of the plan, remember that the eyebrow is not represented in it.

To connect the eyebrow with the rest of the upper third, see the forehead lines and periorbital areas.