Brow Lifts and Forehead Lift
Strictly speaking, brow lifts and forehead lifts are a little different. A forehead lift raises the entire forehead from eyebrows to the hairline, smoothing out the wrinkle lines in between. Whereas the focus a brow lift is to raise and/or reshape the eyebrows and there may or may not be an effect on the forehead creases. Both forehead and brow lifts can help to smooth out and open up the upper eyelids, creating a more youthful, awake and alert appearance.
Although brow and forehead lifts are extremely popular in certain parts of the country and among plastic surgeons, very careful consideration must be given to whether or not an elevated eyebrow position is the most aesthetic choice. As in eyelid surgery, there is a fine line between doing too much and doing too little. An overdone brow or forehead lift in men can be profoundly feminizing and in women, there may be a “frozen,” “surprised,” or “operated” appearance. Therefore, significant thought and care must go into these procedures to achieve a rested, youthful and natural appearance.
Forehead lifts typically accomplish four things: 1) elevate the eyebrows, 2) weaken the scowling muscles between the eyebrows, 3) smooth the horizontal creases or wrinkle lines in the forehead, and 4) weaken the movement of the forehead, decreasing the ability to form new creases and lines.
Forehead lifts require an incision behind the hairline. For most people, that can be performed with small incisions and a camera, or endoscopically. For people with a short distance from eyebrows to the hairline or for people who wear their hair pulled or combed back, the incision is typically behind (above) the hairline. This lengthens the height of the forehead and hides the scar under the hair. On the other hand, people who wish to shorten their foreheads or those who wear their hair forward, the incision is typically a long arc directly in front of the hairline.
Endoscopic forehead lifts are probably the best choice for men with male-pattern baldness or anyone with thinning hair, given the small incisions.
For most people, the eyebrow in women lies just above the prominent bone above the eye, the so-called superior orbital rim. Whereas in men, most commonly the desired position is a bit lower, just below this bone.
The shape and position of the eyebrows can be almost as important as those of the eyelids in conveying emotion, demeanor, youthfulness, and alertness. Take for example these four faces.
Adding eyebrows of different shapes and heights dramatically alters facial expressions and often creates unintended messages such as anger, sadness/wistfulness, thoughtfulness, or surprise.
THE NORMAL BROW
The normal or natural brow generally lies just above the orbital rim in women and just below in men. The brow has a gentle arc with a peak at about the outer third of the eye. It is essential to maintain a little fat below the brow which allows the brow to glide easily over the underlying bone. The brow should be slightly thicker towards the nose and taper out towards the ear. Eyebrows may be reshaped during blepharoplasty surgery or through careful threading. Repeatedly waxing or plucking the brows can loosen the eyelid skin.
MEDIAL BROW PTOSIS
When the brow towards the nose droops, this is called medial brow ptosis. This can lead to an unintended angry or scowling appearance. This is neither a good place for dermal fillers nor for the botulinum toxins. Surgery is the only solution. Options include a central endoscopic brow lift from the hairline, direct removal of forehead tissue right above the eyebrow or within a forehead wrinkle line, or a re-suspension with procerus muscle-weakening through an eyelid crease incision.
LATERAL BROW PTOSIS
When the outer edge of the eyebrow falls, this is called lateral brow ptosis. A downward/outward slant to the brow often conveys sadness or fatigue. Of all of the eyebrow malpositions, this is often the easiest to correct with a hairline lift in front of and above the ear. Left uncorrected, an upper eyelid blepharoplasty (removal of extra upper eyelid tissues) can achieve only partial correction and the incision must extend well beyond the eye to incorporate the fallen tail of the eyebrow. Most of the time this incision can be camouflaged within the laugh lines beside the eye.
TOTAL BROW PTOSIS
A slightly lower eyebrow with an outward, upward arch was recently fashionable for women (look at photographs in fashion magazines where models’ chins are depressed causing them to look upward at the camera, creating fictitious mild brow ptosis). A lower position of the entire brow, however, induces a more masculine appearance, and when the whole brow is too low, the fat and skin below the eyebrow falls down into the eyelid, creating a message of advanced age and fatigue.
THE BROW LIFT SURGERIES
Several types of eyebrow lifts can be performed, depending upon which part(s) of the brow needs to be lifted. Most procedures small incisions camouflaged incisions. The muscles above the eyebrow are released from underlying tissue and elevated and retightened with some excess skin removal. The degree of correction must be individualized depending upon each person’s facial anatomy, ethnicity, gender, and specific goals. As with all rejuvenation procedures, careful assessment and planning is essential to achieve overall facial harmony and a relaxed, natural appearance.
BROW LIFTS AND UPPER EYELID BLEPHAROPLASTY
Although the forehead, eyebrow, and upper eyelid are all very different structures with different skin thickness and different underlying muscle orientation, they are all connected, and changing one will impact the others. For example, performing an upper eyelid blepharoplasty without recognizing the need for an eyebrow ptosis repair may have several consequences. First, someone with heavy upper eyelid skin who habitually raises his brows all the time to see may find that once the extra eyelid tissue is removed, the incentive to raise the brows vanishes and the eyebrows may drop to their relaxed state, appearing to have fallen. Second, if too much tissue is removed in an upper eyelid blepharoplasty, when a secondary brow lift is performed, so much tissue will have been removed that the upper eyelids will be unable to close – a disaster!
Conversely, an attempt to clean up the upper eyelid tissue or raise the eyelid height with a brow or forehead lift will only result in the eyebrows being overly elevated and will not completely address the eyelid issues which may then be more difficult to resolve in a fully aesthetic fashion. This is especially true in people with very prominent or forward-positioned eyes. A combination of a conservative eyelid lift and a conservative brow lift can address these issues, while also allowing the patient to fully close their eyes. Success!