Often when people come to our office complaining that their eyelids are sagging, they actually have a drooping forehead and brows. This downward sliding skin causes the upper eyelid to look especially redundant and fold over the eye. Many times, especially in men, the brow hairs are down at the level of the eyelashes and the brows block out their entire upper visual field. Simply raising the forehead without even touching the eyelids corrects most of the problem and dramatically improves their visual angle. Recently, a couple of patients told me they just couldn’t believe how much of their world they were missing out on seeing because of their heavy brows. So in this article, we’ll talk briefly about what causes this problem and what are the main ways of treating it, including their pros and cons.

What causes brow and forehead descent?

• The main cause is aging. With age the skin of the forehead becomes less elastic and gravity causes it to descend. It is fairly firmly attached at the top of the head, but more mobile over the forehead where the frontalis muscle allows the skin to move up and down with facial expression. In time this skin gets stretched and has no place to go but down.
• Weight loss can also cause drooping of the brows. Heavier individuals develop a layer of fat under the forehead and brow skin, which when lost can lead to forehead droop.
• Certain illness can cause loss of tissue elasticity and drooping brows. Others cause damage to the nerves that innervate the forehead and brow muscles, such as Bell’s palsy or facial nerve injury. The brow and forehead droop

What are the main ways it is treated? With my patients I like to divide the treatments into good, better and best.

• Good: Direct brow lift will raise the brows very well. It involves an incision above the brow hairs full thickness and removal of a strip of skin. The brow is then raised with heavy sutures stitched from the deep skin below the hairs into the muscle and covering of the bone up higher. Its biggest drawback is the scarring it can produce. A man with very bushy eyebrows may be able to hide the long linear scars, but in most they are very apparent, even after months of healing. The shape of the brow often tends to be more rounded, which looks fine in a woman, but unusual in men.
• Better: Newer techniques are being used to raise the brows, either through small incisions above the brow hairs, or through the upper eyelid incision used in blepharoplasty. These techniques, call browpexy, essentially just raise the brow height with sutures without removing skin or shifting underlying tissue planes. They produce relatively smaller scars, but generally aren’t as powerful and tend to regress quickly. I do think they are better than direct brow lift, however, due to their less noticeable scarring.
• Best: Moving the entire forehead, or a large portion of it, will give the longest lasting, best looking brow lift. This can be done in several different ways, some which involve raising the hairline and others that are remove a portion of skin, leaving the hairline intact.

  Patient who wanted a conservative brow lift and eyelid lift due to skin blocking his vision

  How do the methods of forehead elevation differ and which is best?

  • The median forehead lift involves making an incision across the entire forehead through a deep crease (if you’ve got one), removing a strip of skin, and suturing up the forehead and brows in similar fashion to the direct brow lift. The scar can be noticeable, but in the right person is a good choice.
  • Endoscopic brow lift is my method of choice for forehead elevation. It involves making 3-5 incisions behind the hairline through which instruments are introduced to elevate the skin off of the forehead down to the brow area. A camera is used to directly visualize the dissection around the brows to avoid damaging the nerves and blood vessels in this area, and to partially remove the muscles of the brow which cause the furrow above your nose (think of it as permanent Botox). A portion of skin can be removed above and behind the ear to create lift in an outward/upward direction as well. The forehead tissues are then fixated in a higher position using either a suture and screw or a resorbable fixation device called an endotine. I was recently introduced to absorbable screws (Lactosorb) combined with sutures and find this to be a very stable method of fixation that can’t be easily undone by a patient not properly caring for the tissue flap after surgery.
  • A pretrichial (meaning in front of the hairline) lift involves an irregular incision along the hairline with a portion of the forehead skin removed. This gives a great forehead lift without raising the hairline. It can cause noticeable scarring and works best for someone who has thicker hair and wears it forward.
  • The supposed “gold standard” forehead lift is the coronal lift. This involves an incision from ear to ear over the top of the head, with dissection down over the forehead and brows and removal of a portion of the scalp and hair. Many plastic surgeons swear by this procedure, and in actuality it is the most long lasting along with the pretrichial lift, but it requires a large amount of skin removal, a large scar which is often noticeable even in thick haired people, it causes numbness of the scalp behind the incision, and it can dramatically raise the hairline.

  Forehead and brow lifting can make a dramatic improvement to a tired appearing face. Of all the procedures I perform, this procedure leaves patients the most satisfied as it so dramatically improves their visual field and appearance. If you have further questions or think you might be a candidate, give our office a call or email me directly at [email protected].