Another name
for brow lift is forehead lift. Aging affects the entire
face. Some areas, such as around the eyes, have more obvious
aging changes. The eyes appear to be the most affected because
they have so much expression and, therefore, patients often
come in requesting eyelid cosmetic
surgery. Quite often, however, the more significant problem
lies within the eyebrows. As we age, the eyebrows descend;
especially the outer part or part closer to the temple which
falls much more than the part of eyebrows closer to the nose.
Take a look at most older people and you will see this to
be true.
Most people do not realize it, but the
descent of the eyebrow is largely responsible for what we
think of as an old looking face. In the youthful face, especially
in women, the eyebrow is located above the bony rim of the
eye socket. With aging, the eyebrow falls to the level of
the rim and often below the rim becoming almost part of the
upper eyelid. Even more dramatic is the fact that the outer
eyebrow falls much more than the inner eyebrow giving the
typical appearance of aging. You can try this on yourself.
Stand in front of a mirror. Take your fingers and elevate
the outer part of your eyebrow. Most likely, this will create
a more elegant and youthful look. It also tends to help the
aging problems of the upper eyelid. This is what a properly
performed brow lift will do.
The effects of aging cannot be completely
reversed with a brow lift because there are other components
involved such as changes in both the subcutaneous fat and
muscles. But as you can see by simply elevating the outer
part of your eyebrow much can be done to re-create the youthful
look.
There are many different types of brow
lifts. It is important as a plastic surgeon to have expertise
in all of the different brow lifts so that the doctor can,
without bias, choose the one that is best for you. The 3 types
of brow lifts that many doctors find most effective are 1)
the minimal incision brow lift, 2) the endoscopic brow lift,
and 3) the brow lift through an upper eyelid incision. There
is a fourth type of brow lift called the open brow lift that
which is performed occasionally but, usually, only when there
is a significant amount of loose skin within the upper forehead.
The minimal incision brow lift
is a very effective way to obtain the desired elevation of
the lateral brow and “crow's feet” area with only
a small incision within the hairline or just above the hairline.
The endoscopic brow lift
is almost the exact same as the minimal incision brow lift
except, of course, with the addition of the endoscope. The
endoscope helps visualize the dissection and what needs to
be lifted. The incisions are within the scalp.
The third type, brow lift through
an upper eyelid, is frequently performed at the same
time as an upper blepharoplasty. This is a great way to add
a brow lift when you are already having cosmetic surgery on
the upper eyelid. Some doctors elevate not only the brow
but also the fat and muscles. Fat and muscle descent contributes
to the appearance of the aging eyebrow just as much, if not
more, as lax skin. It must be pointed out, however, that
this type of brow lift does not elevate as much as the other
two but it is an effective way to elevate the brow without
having to make another incision.
The fourth and final brow lift mentioned
above is the open technique. This is a very
effective way to perform a brow lift but it involves a very
long incision usually within the scalp but may be done at
the hairline. It is useful when there is a significant amount
of loose skin within the forehead and the eyebrows have descended
a great deal. Most doctors do not use this type of brow lift
often as he they are usually able to accomplish the desired
brow elevation using much smaller incisions.
Often, a brow lift is performed in conjunction
with other facial cosmetic procedures such as eyelid surgery
and facelift. The reason for this is that facial aging does
not affect just one part but the entire face.
 Benefits
Eyebrows that have descended makes one look old and tired. The eyebrows of youth are positioned above the rim of the
eye socket with the outer part of the eyebrow higher than
the part toward the nose. You may benefit from a brow lift
if you have any of the following problems.
- An additional benefit to brow lifting is that it significantly
helps diminish the wrinkles in the crow's feet area.
Are
you a good candidate?
Descent of the eyebrows is a universal
part of aging. It becomes evident in the late 30s and early
40s and is progressive. Just because you have eyebrow descent
does not necessarily mean that a brow lift would be beneficial
to you. The best way to determine if a brow lift would be
beneficial is to stand in front of a mirror, place your fingers
about an inch above the outer portion of your eyebrows on
both sides and elevate the outside part of your eyebrows.
Does this obtain the look that you want? If it does, you
most likely would benefit from a brow lift. You will most
likely be a good candidate if you have any of the following:
- Your eyebrows have descended and are
at or below the eye socket rim.
- Your eyebrows appear too close to
your eyelids.
- You strain and wrinkle your forehead
to elevate your eyebrows.
- The outer part of your eyebrow is
lower or at the same level as the portion of the eyebrow
closer to the nose.
- Your upper eyelids and eyebrow area
appear tired.
Possible
complications
The most common complication across the nation is inadequate
elevation of the eyebrow. Other possible complications, unique
to brow lifting, are nerve injury to the nerve that elevates
the eyebrow, asymmetry between the two brows, and hair loss
around the incision.
Do's
and Don'ts prior to surgery
-
Medications.
Certain medications thin your blood and should not be
taken within 3 weeks of surgery. The most notable is
aspirin and aspirin containing products. Vitamin E and
many herbal products also thin the blood and should not
be used within 3 weeks of surgery. Your doctor will go
over this more thoroughly prior to the procedure.
-
Sleep. It is important to get a good night's rest prior to the
procedure. If you think this may be a problem, please,
do not hesitate to ask your doctor for something to help
you sleep.
-
Smoking.
It is important to not smoke within 3 weeks before and
after surgery. Smoking has a profound effect on reducing
wound healing capabilities. It significantly increases
the likelihood for infection, wound healing problems,
and scar formation. It also affects your airway and,
therefore, makes anesthesia much more difficult.
-
Eating.
Do not eat within 8 hours of surgery and do not drink
within 6 hours of surgery. Please discuss all medications
with your plastic surgeon and the anesthesiologist.
-
Washing.
Wash your hair thoroughly the morning before surgery and
be sure to use a conditioner so that your hair is manageable.
Style your hair very simply and do not use hair spray
or put anything else into your hair. It is helpful if
you merely comb your hair back. Wash your face as well
but do not apply any makeup.
-
Arrival.
It is best to arrive on time to make sure everything goes
smoothly. Please be sure to have someone else drive you
home.
-
State of mind.
Remember, this should be a happy and exciting time. A
certain amount of nervousness is normal but you must not
be overly concerned. Excessive worrying can actually
be detrimental. If you are a very anxious person you should
discuss this with your doctor prior to surgery so that
something can be prescribed to make sure you remain calm.
Anesthesia
The anesthesiologist
will discuss with you what type of anesthesia is best for
you prior to the procedure. He/she will take into consideration
your medical history, the procedure, and your personal wishes.
Normally, most doctors perform brow-lifting
under the general anesthesia. It is possible, however, to
perform the minimal incision brow lift under local anesthesia
with or without sedation.
After
the procedure
The procedure itself will take about
2 hours.
Immediately.
Right after the operation you will be watched for 1 or 2 hours
and encouraged to walk around. You will be given as much
pain medication as necessary both immediately after the operation
and for the next 4 to 5 days. You will have a dressing around
your head and ice packs above your eyes to decrease swelling.
You must sit or lie with your head elevated to decrease swelling.
That
evening. It is recommended that you take
it easy. You can walk around, eat, but not too much more. You should take as much pain medication as necessary and try
to go to sleep early. Remember to sleep with at least 3 pillows
to keep your head elevated so swelling is reduced. Do not
move your forehead muscles for the first 2 weeks after the
procedure.
First
48 hours. The next day you should remove your
dressings and take a cool shower. You may have dried blood
in your hair. Gently wash your hair with a shampoo with a
conditioner. When you get out of the shower simply dab dry,
comb your hair gently back, and sit most of the day to keep
your head elevated. Your are encouraged to walk around but
do not do anything that requires bending over or lowering
your head in any way. You can expect to see bruising and swelling
around the eyes.
First
week. At about day 3 you can move around
normally. Continue to keep your head elevated until at least
day 7. Your first postoperative visit with your plastic surgeon
will be approximately after 1 week. The majority of the bruising
and swelling will go away in about 2 to 3 weeks.
Beyond.
Swelling will not completely resolve for about 6 months but,
as mentioned above, the majority of it will be gone by 3 weeks.
Recovery
time
Some people with sedentary jobs go back to work in less than
a week. If your job, however, requires strenuous activity
it may take as long as 4 weeks to return to work. Most people
return to work after about 10 days. You must understand,
however, that the bruising may not be gone for up to 2 weeks.
Consultation
We have outlined below what you can expect
from your brow lift consultation. Read carefully, as there
are many suggestions that will save you time, clear up questions,
and help you convey to your plastic surgeon what it is you
want to accomplish.
Health
History
All cosmetic surgery consultations
begin with a thorough health history. This is especially
true if general anesthesia is being used but also applies
to local anesthesia. Prior to meeting with the plastic
surgeon you will be given a health
history questionnaire. There are five areas of your
health you will be asked about. Be sure to answer it with
detail so that your surgery and anesthesia can be optimized
for you.
General health problems are important
to discuss so that your surgery is as safe as possible.
Be sure to mention any chronic illness. Of particular concern
are high blood pressure, diabetes, heart problems, liver
and kidney disease, stroke, cancer, bleeding problems, and
wound healing problems.
What will the plastic surgeon do
if I have medical problems?
In short, he/she will make sure your
health is optimized as much as possible to ensure your safety.
This may mean referring you to your private physician.
If you have a
health problem or are over 50 years of age you can often
save yourself time by getting a letter from your private
physician prior to your cosmetic consultation stating what
the problem is, how it is being treated, and whether or
not you are able to tolerate general anesthesia safely.
If you are seeing
any specialist (cardiologist, kidney doctor, psychiatrist,
etc. ) be sure to bring a letter from them stating you are
able to tolerate surgery.
If you are not able to tolerate general
anesthesia it may be possible for your procedure to be done
under local anesthesia. This must be discussed with your
plastic surgeon.
On your questionnaire you will be asked
about previous surgeries. Be sure
to identify any problems you may have had with anesthesia.
Of particular concern are previous cosmetic surgeries especially
if you do not like the result and are interested in revision.
Be sure to list all medications including
aspirin and over-the-counter medications. These are important
as they may increase bleeding and affect your surgery.
It is extremely important to stop taking aspirin and aspirin
containing products at least 10 days before surgery. Tylenol
is a good alternative. Here is a partial list of aspirin containing products and other products
to be avoided prior to surgery.
Information about medications that
cause allergies is very important so that these medications
can be avoided. Of particular importance is the reaction
you had, especially if you had trouble breathing. Be
sure to include this information! Nausea is not an
allergy but it is important to mention as well.
These there will certainly affect your surgery and MUST
be mentioned so that your surgery can be optimized. Smoking
causes a profound decrease in wound healing and will lead
to worse scarring and a less favorable result. With
large procedures such as a face lift, neck lift, tummy
tuck, and breast lift smoking must be stopped at least
2-3 weeks before and after surgery. Otherwise, the results
could be disastrous leading to non-healing wounds, poor
scarring, and/or infection. With smaller procedures
such as eyelid surgery, nose surgery, breast augmentation,
and liposuction smoking will hurt the overall result but
this may or may not be noticeable. In this case smoking
cessation is strongly advised but is not mandatory.
What Do You Want To Change?
It is important that you have a
clear idea of what you want changed when you go for
a consultation. The least favorite thing a plastic
surgeon wants to hear is: What do you think I need done?
Look in a mirror and identify what
bothers you. Be specific. It is helpful to break up
the forehead region into 4 parts. 1) Forehead 2)
Lateral (outside) Brow 3) Medial (inside) Brow 4)
Upper Eyelid. Evaluate
each one of these areas individually as this is what
the plastic surgeon will do in his/her exam.
Common complaints
Ideal Brow Shape
Physical
Exam
The key to the face physical exam
is to determine exactly what is causing the problem. Below is a typical sequence that an experienced plastic
surgeon uses to evaluate the brow and what can be done
to correct problems.
Wrinkles of the forehead are caused
by over-active frontalis muscles. Often, these are
best treated with Botox® injections. The most significant drawback is that these injections
must be repeated. Click here
to get more information on Botox®. A brow lift can diminish
these wrinkles if the plastic surgeon removes part of
the frontalis muscle but this is not predicable.
During your consultation, your
plastic surgeon will evaluate the position of your lateral
brow in relation to your medial brow and to the bony
rim below. He/she will then elevate your lateral brow
with his/her finger to determine where it should be
repositioned. You can do this to yourself at home in
the mirror. Often, elevating the lateral brow gives
a more youthful appearance to the brow and eye region.
Also, this elevation tightens some of the wrinkled,
excess skin within the crow's feet area.
The medial brow should be at or
above the level of the bony rim below. Elevating the
medial brow is not nearly as common as the lateral brow
because it is less likely to descend. Elevating the
lateral brow creates an elegant, youthful appearance.
Elevating only the medial brow is rare as it can cause
an unnatural, surprised look.
Wrinkles between the 2 brows can
be treated during a brow lift or an upper blepharoplasty
by removing the muscles that cause them. Treatment
in this fashion is permanent. Sometimes, with this
technique, it is necessary to fill the void where the
muscle was removed by replacing it with fat transplantation.
When your plastic surgeon elevates
your brow with his fingers, he/she will also determine
its effect on the upper eyelid. If, by elevating the
brow, the desired result is obtained, then it is clear
that only a brow lift is necessary. If, however, excess
skin and/or fat persists in the upper eyelid, then an
upper blepharoplasty is also required. Click here for
further information on Upper Eyelid Surgery
Procedures
There are 3 common ways to perform
a brow lift.
An endoscopic brow lift has the
advantage of leaving only small scars in the hair bearing
scalp. Usually 3 or 5 of these short incisions are
used to elevate the brow. Another advantage is that
the muscles that cause wrinkles between the 2 brows
can be removed with this technique. This can significantly
improve these wrinkles permanently. Endoscopic brow
lifting first became popular in the early 1990's. Some
plastic surgeons feel that some skin excision is necessary
to maintain a brow lift in its elevated position, therefore,
they have switched back to the short scar technique.
The short scar technique is the
most common. It utilizes 2 incisions on both sides
of the scalp. Each incision is 1-2 inches in length
and is placed either at the hairline or within the hair-bearing
scalp. The hairline incision has the advantage of lowering
the hairline slightly. The incision within the scalp
has the advantage of a hidden scar. It must be pointed
out, however, that the hairline incision becomes almost
undetectable.
The most aggressive brow lift is
the coronal incision. The incision extend all the way
across the scalp from one side to the other. This is
the most effective way of correcting severe brow sag
especially within the medial brow. Effective removal
of wrinkle causing muscles can be performed. The obvious
downside is the long incision. Another complication
is the loss of sensation to the scalp posterior to the
incision. This is why this technique is done only when
there is severe brow descent.
All 3 methods involve repositioning
of the brow superiorly. As with all of plastic surgery
procedures, excellent results can be achieved with each
method. The results depend on the experience and technical
abilities of the plastic surgeon not the technique used.
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