When patients desire rejuvenation of the upper face, I evaluate the upper eyelids as well as the eyebrows. In some, the upper eyelids have too much skin and I suggest an upper lid blepharoplasty. In others, the forehead is droopy with heavy eyebrows lying on the upper lids and I suggest a brow lift. Occasionally, the upper lids and eyebrows are droopy and both need to be corrected at the same time for maximum improvement.

The eyebrows are one of the most expressive parts of the face. If they are curved downward between the eyes, it gives an angry look (even if one is happy). If they are curved downward at the corner of the eyes, it gives a sad look. Eyebrows that are droopy along the entire eye gives a tired look. A brow that is high and arched in the center gives a surprised or startled look. Ideally, the eyebrows have a gentle curve (see diagram 1).

The brow lift treats three parts of the face: the position of the eye- brows (as discussed above), the wrinkles between the eyes, and the wrinkles of the forehead. The wrinkles between the eyes are caused by the (over-activity of muscles (corrugators and procerus). If the lines are deeply etched in the skin, even removing the muscles can not completely eliminate these lines. The wrinkles of the upper forehead are caused by an (over-thickening of the frontalis muscle. These muscles are thinned greatly reducing the lines. There are two techniques to the brow lift: the open approach and the closed approach [1,2]. I have performed the open approach since 1981.
Ideally, the face is divided into three parts: the forehead, the midface, and the lower face.

These three parts should be equal in size. If the forehead is smaller than the other two areas of the face, an open brow lift is beneficial. Lifting the brow increases the height of the forehead proportionally to the rest of the face. The open approach is also useful if the brow is very droopy or if the forehead wrinkles are deeply ingrained. An incision is made far behind the hairline. No shaving is performed so damage to the hair follicles is minimal. A portion of the scalp is removed, resulting in a very long-lasting procedure that opens the eyes and gives a restful, pleasing look.

The second approach is the closed brow lift (endoscopic brow lift). This contemporary procedure was more recently developed and is preferred for men and women with thin hair, extremely high foreheads, or foreheads with minimal lines and droop.

The procedure is performed by making several small incisions just behind the hairline (see diagram 2). The forehead is then released from the underlying bone. An endoscope (a small telescope attached to a digital T.V. monitor) is used for complete visualization. Also, like the open brow lift, the frowning muscles are treated. No scalp is removed in this approach. Permanent sutures are placed to hold the brow. Some doctors resort to screws placed in the skull. Other doctors drill a tunnel in the skull bone for suspension sutures. I do not feel these approaches are necessary since they increase the chances of infection and other problems. I prefer to place permanent anchor sutures under the scalp.

With the open approach, the hair is washed the next day and no further dressings are needed. With the endoscopic approach, however, the hair is usually washed the next day and a turban-like bandage is placed for five days. Temporary scalp numbness and itching are common with both techniques.

In my opinion, the brow lift is often the first procedure to do to rejuvenate the upper eyelids [3]. I would prefer lifting the brow to the desired position and in several months or years, removing any extra eyelid skin to achieve the desired aesthetic result. Instead, when a doctor treats a droopy brow by performing an upper lid blepharoplasty, there is a tendency to take off too much eyelid skin. This actul1lly pulls the brow downward, worsening the problem and creating an undesirable aesthetic result. Also, if a lot of eyelid skin is removed, it gives a wide- eyed “plastic surgery” look, and it can increase the dryness of the eyes prematurely, a condition which naturl1lly occurs with age and with living in a desert climate such as Southern California. Finally, if a lot of upper lid skin is removed, this prevents an effective brow lift from ever being done in the future.

Another Way to temporarily treat aging eyebrows is with Botulism toxin, or Botox. Botox is a muscle paralyzing agent that is infused into the forehead. It can be used to temporarily weaken the muscles of the glabella (the area between the eyes). This softens the angry forehead look. It lasts about 4-5 months and can be repeated indefinitely. It is useful for patients that arc not quite ready for a brow lift.

In summary, I often feel that a brow lift is the best intervention in a patient with aging eyes. If done with a gentle hand and a trained, aesthetic eye, a brow lift gives a relaxed, refreshed, and happy appearance.

Questions and Answers About Brow Lift

  1. Am I a candidate for a brow lift?
    A person is ready for a brow lift when they have: droopy eyebrows, lines between the eyes, or lines on the forehead.
  2. Where are the incisions?
    With the open brow lift, the incision is made in the hair behind the ears. With the endoscopic brow lift, five small
    incisions are made just behind the hairline.
  3. How long is the recovery?
    It usually requires one week off from work. Complete healing takes up to six months and sensation changes may take even longer to resolve.
  4. How long do the sutures stay in?
    All sutures are removed in one week.
  5. Is there bruising?
    Most bruising has resolved within seven to ten days. At that time, any residual bruising can be covered with camouflage make-up.
  6. Is the recovery painful?
    The procedure is uncomfortable rather than painful. The head feels tight, as if one is wearing a cap.
  7. What type of anesthesia is used?
    Usually general anesthesia is utilized.
  8. Will it affect my vision?
    It may improve one’s vision if the brow is very droopy.
  9. Can I have a brow lift if I have had eye problems or previous eyelid surgery?
    If an aggressive upper eyelid surgery has previously been done and the eyes do not completely close, then the brow cannot be lifted, but the wrinkles can still be removed.
  10. Does having breast augmentation mean I will be unable to breast feed when I have children?
    The mammary ducts are left in place so breast feeding should be possible.
  11. Do implants cause breasts to droop?
    If the patient has a lot of skin and sagging prior to the augment, the breast will continue to sag as the years pass.
    An eventual lift may be necessary.
  12. How long do the results last?
    An open brow lift can last fifteen years or longer. An endoscoscopic brow lift may loosen earlier.

References

1. Ramirez, Oscar; The Endoscopic Forehead Lift, Plastic and Reconstructive Surgery: Vol. 100, p. 1033-1039, 1997.

2. Guyuron, Bahman; Refinements in Endoscopic Forehead Rejuvenation, Plastic and Reconstructive Surgery; Vol. 100, p. 154-160, 1997.

3. Benvenuti M.D., David; Alternative Procedure Eliminates Loose Eyelid Skin without Making Large Incisions, Daily Pilot; 3/3/92.

4. Benvenuti M.D., David; Refraction After Brow Lift, Plastic and Reconstructive Surgery, Vol. 92, p. 93, 1993.