non - melanoma skin cancer ( nmsc ) is a disease affecting mostly adult patients in their second half of life .
forehead and temple are commonly affected by the major types of nmsc , i.e. basal cell carcinoma ( bcc ) and squamous cell carcinoma ( scc ) .
the treatment of choice in particular for larger tumours is mohs surgery . in the case of deeper infiltration of the subcutaneous tissue ,
the preservation of the first branch of the facial nerve is not always possible to achieve a r0 resection ( complete removal with tumour - free excision margins ) . in these patients , upper lid ptosis and/or brow ptosis
the correction of resulting functional impairment , especially of the lateral view , has priority .
since most patients are elderly with significant dermoheliosis of facial skin , often dermatochalasis and significant comorbidities , the procedures should not add another significant risk .
a 61-year - old male patient presented with a large and deep infiltrating bcc of the left temple .
however , a combined brow and upper lid ptosis had developed and hampered his lateral view [ figure 1a ] . on the other hand
( e ) final wound closure of the direct brow lift and the upper lid blepharoplasty since he had a blepharochalasis , we used a combined approach , i.e. blepharoplasty of the upper lid and direct brow lift .
the procedures were performed under local anaesthesia . because there was no prolapse of the adipose tissue , a simple skin resection of the upper lid skin was performed and sutured with 4 - 0 prolene ( ethicon , norderstedt , germany ) sutures .
for the brow lift , an elliptical incision on the apical border of the brow was performed [ figure 1b ] .
the height of the incision was measured before by pulling the brow to its intended height and marking the position .
after the removal of skin , the deeper layers were carefully removed down to the insertion of the insertions of muscle fibres of the venter frontalis .
the skin adjacent to the incision borders was loosened by blunt preparation to ensure a tension - free suturing .
the frontalis muscle was resected and the ends were sutured by 4 - 0 pds ( ethicon ) sutures to position the brow [ figure 1c , d ] .
wound closure was done by suturing the subcutaneous tissue with deep knots ( 4 - 0 pds ) and final wound closure with cutaneous 4 - 0 ethilon ( ethicon ) sutures [ figure 1e ] .
after the removal of the suture , we recommended a preventive topical scar treatment ( cicaplast ; la roche posay , asnieres , france ) .
an 86-year - old patient presented with a large scc in the left fronto - temporal region .
four weeks later , she presented with a mild brow ptosis and an upper lid ptosis combined with blepharochalasis [ figure 2a  c ] .
( a ) patient 2 after radical excision of a scc with upper lid and brow ptosis ( 1.8 mm in rest ) on the left side .
( b ) during upwards motion of the frontalis muscle , the left side does not improve .
five days after bilateral upper lid blepharoplasty : frontal look with ( d ) closed eyes 1 week after surgery with sutures in place and ( e ) with open eyes demonstrate an acceptable aesthetic and functional outcome she did not want to have a correction of the brow but the upper lid . in this case , we performed blepharoplasty under local anaesthesia . after the resection of the upper lid skin with a monopolar radiofrequency tip ( ellman device [ ellmann int . ,
oceanside , ny ; usa ] ,  cut and coag  mode ) , conservative fat pad removal was done by the incision of the medial and central septum .
the patient was pleased with the outcome during the follow - up period of 2 years [ figures 2d  e ] .
a 61-year - old male patient presented with a large and deep infiltrating bcc of the left temple .
however , a combined brow and upper lid ptosis had developed and hampered his lateral view [ figure 1a ] . on the other hand
( e ) final wound closure of the direct brow lift and the upper lid blepharoplasty since he had a blepharochalasis , we used a combined approach , i.e. blepharoplasty of the upper lid and direct brow lift .
the procedures were performed under local anaesthesia . because there was no prolapse of the adipose tissue , a simple skin resection of the upper lid skin was performed and sutured with 4 - 0 prolene ( ethicon , norderstedt , germany ) sutures .
for the brow lift , an elliptical incision on the apical border of the brow was performed [ figure 1b ] .
the height of the incision was measured before by pulling the brow to its intended height and marking the position .
after the removal of skin , the deeper layers were carefully removed down to the insertion of the insertions of muscle fibres of the venter frontalis .
the skin adjacent to the incision borders was loosened by blunt preparation to ensure a tension - free suturing .
the frontalis muscle was resected and the ends were sutured by 4 - 0 pds ( ethicon ) sutures to position the brow [ figure 1c , d ] .
wound closure was done by suturing the subcutaneous tissue with deep knots ( 4 - 0 pds ) and final wound closure with cutaneous 4 - 0 ethilon ( ethicon ) sutures [ figure 1e ] .
after the removal of the suture , we recommended a preventive topical scar treatment ( cicaplast ; la roche posay , asnieres , france ) .
an 86-year - old patient presented with a large scc in the left fronto - temporal region .
four weeks later , she presented with a mild brow ptosis and an upper lid ptosis combined with blepharochalasis [ figure 2a  c ] .
( a ) patient 2 after radical excision of a scc with upper lid and brow ptosis ( 1.8 mm in rest ) on the left side .
( b ) during upwards motion of the frontalis muscle , the left side does not improve .
five days after bilateral upper lid blepharoplasty : frontal look with ( d ) closed eyes 1 week after surgery with sutures in place and ( e ) with open eyes demonstrate an acceptable aesthetic and functional outcome she did not want to have a correction of the brow but the upper lid . in this case , we performed blepharoplasty under local anaesthesia . after the resection of the upper lid skin with a monopolar radiofrequency tip ( ellman device [ ellmann int . ,
oceanside , ny ; usa ] ,  cut and coag  mode ) , conservative fat pad removal was done by the incision of the medial and central septum .
the patient was pleased with the outcome during the follow - up period of 2 years [ figures 2d  e ] .
our department is a centre for dermato - oncology and dermato - surgery with inpatient and outpatient service and interdisciplinary tumour boards .
careful surgical removal ensures a low rate of tumour recurrence and surgical complications . as long as the r0 resection is the primary goal of treatment , the preservation of facial ( or other ) nerves is not always possible .
therefore , we need rehabilitative tools to deal with post - procedural palsy . in this report , we focussed on two procedures that are useful to correct upper lid and brow ptosis after nscm tumour surgery .
the approaches aim to correct the resulting impairment , i.e. lateral or frontal limitations in eye view .
since most of the patients are older than 60 years , often with significant comorbidities , the surgical approach has to respect this .
aesthetic concerns are less important compared to the surgical correction of the ageing face without nmsc and palsy .
there are a number of factors that need consideration when planning corrective surgery : age , ethnicity , skin type , forehead furrows , degree of visual impairment , and dermoheliosis .
the use of simple but effective procedures that will not add an additional risk for the multi - morbid patients is our practical approach .
we use a modification with suturing the frontalis muscle to obtain a significant lifting without placing any tension on the cutaneous sutures .
a necessity of the technique is the careful avoidance of the dissection of the supraorbital neurovascular bundle .
other adverse effects are rare and manageable . to ensure an aesthetic scar , preventive topical treatment by appropriate scar ointments or gels is recommended .
the procedure can be combined with upper lid blepharoplasty to further improve the functional outcome .
it has been suggested that patients with prominent brow fat pads will benefit from this technique . in a comparative study of brow lifting techniques , georgescu et al . observed a mean brow elevation of 1.74 mm using this method . in the particular situation , however , the limitations in the brow lift make this attempt less attractive for rehabilitative surgery . an endosopic brow lift results in greater amplitudes of brow elevation ( 3.44 mm ) .
the procedure is more sophisticated than the direct brow lift but will be preferred in aesthetic indications .
the direct brow lift , on the other hand , can also be employed for severe brow ptosis of > 4 mm . in some older patients ,
however , blepharoplasty alone can achieve a functional and aesthetic outcome that satisfies the patient without adding a surgical risk to his or her pre - existent comorbidities . from the functional point of view , upper lid blepharoplasty is not dependent on the resection of the orbicularis oculi muscle .
recently , a less aggressive surgical approach to upper eyelid ptosis has been favoured for blepharoplasty .
they way of dealing with post - surgical palsy has to be discussed with patients to identify their needs and complaints .
keeping it simple often is a good compromise between the attempts of the surgeon to be ( almost ) perfect and the reality of the patient .
 radical surgery of fronto - temporal non - melanoma skin cancer ( nmsc ) sometimes causes palsy of the frontal facialis branch . 
 patients may experience visual impairment due to brow and upper eyelid ptosis . since nmsc predominantly affects elderly people , 
 the corrective surgical procedures have to be adapted to age , comorbidities and individual needs . the direct brow lift and the upper lid blepharoplasty are two reliable and safe surgical techniques with proved efficacy . here 
 we present our way to deal with post - surgical brow and lid ptosis . 
INTRODUCTION
CASE REPORTS
Case 1
Case 2
DISCUSSION