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Brow lift surgery, as mentioned in our last post, can be achieved by several different methods. We’ve already mentioned coronal and pre-trichial techniques. In this post, we’ll talk about endoscopic brow lift surgery, direct brow lift surgery, and the internal browpexy.

 

Endoscopic brow lift incisions

Endoscopic brow lift incisions

Endoscopic brow lift surgery

Endoscopic brow lift surgery is performed by making 2-3 small incisions just behind the hairline. Through these incisions, the forehead and brow skin and muscles are lifted off the bone, pulled up, and then held in place with either stitches or a fixation device. Like the other brow lift surgeries mentioned before, the head is wrapped for a few days afterward. Recovery is usually fast with minimal pain. Incisions are closed with staples, which are removed after about a week. Bruising tends to be minimal, unless paired also with an eyelid procedure. Pros: Less invasive than coronal or pre-trichial brow lift surgery due to the smaller incisions; scars are hidden within the hairline; it raises the forehead and brows giving a nice outcome. Cons: Because no tissue is removed, results can be temporary; may not be any more effective than browpexy, but has harbors more risk. My conclusion: Endoscopic brow lift surgery was once my surgery of choice for droopy brows. It seemed to offer the lowest risk of scarring and resulted in a nice looking brow elevation.  After performing dozens of these procedures and then watching patients long term, I found that the results just weren’t as compelling as I wanted. It seemed that most of the improvement came from the eyelid surgery done at the same time. I have almost completely stopped doing this procedure for this reason.

Internal browpexy

The internal browpexy is a way of lifting or supporting the brows using the same incision made to lift the eyelids. After excess eyelid skin is removed, further dissection is made under the eyebrows, which releases the muscles that hold them down, allowing them to rise. The brows are the stitched in a higher position. The eyelid surgery is then finished and the wound is closed. The eyelids are covered in antibiotic ointment. No bandages are needed.  Recovery is just like that of eyelid surgery, with some tenderness of the brows. The deep stitches take 6-8 weeks to fully dissolve, which can cause tenderness when the brows are touched.  Pros:  Least invasive of all the brow lifting techniques; can lift the brows 3-4 millimeters and prevent them from falling further; scars are well hidden. Cons: Because no skin is removed, it is likely to eventually fail as gravity and skin changes continue. My conclusion: I use browpexy on many patients who either don’t want or couldn’t tolerate a larger brow lift surgery. In many cases our goal is to simply keep the brows from falling further, which can happen after eyelid surgery. Browpexy does this well. I always explain that it isn’t a true brow lift and shouldn’t be expected to make a striking difference in their appearance. It is most helpful when the vision is being blocked by both the eyelids and brows and both need some attention.

As you can see, there are many ways to lift the brows. Brow lift surgery is well tolerated and most patient have great outcomes with better peripheral vision. If you have questions, feel free to call us at (801)264-4420.

Eyebrow trends change with time, but droopy brows are never in style. When the brow starts to descend, it can cause a hooded look pushing down the eyelids and leaving you looking tired. While you can’t avoid getting older and losing skin elasticity, there are several ways to approach beautification of the brows.

Eyebrow proportions

Eyebrow proportions from britneybeauty.com

1. First, figure out the best eyebrow shape and color for you, and actively maintain it. Choose a shape you like, but keep it natural. An overly-thin brow makes you look older while very thick or dark brows can dominate your face and take attention from your eyes. Understanding the proportions of a beautiful brow is important. The head of the brow should start in line with the inner corner of the eye and ideally with the outer corner of the nostril (see #1 on Angelina Jolie above).  The peak of the arch should line up with a line drawn from the outer corner of the iris to the corner of the nostril (see #2 above). The end of the brow should fall on a line from the outer corner of the eye to the corner of the nose (see #3 above).

2. Consider reshaping drooping brows with Botox injections. When injected above the brow, it will help to lift the brow into a more youthful-looking position by immobilizing the muscles.

3. Fillers, such as Juvéderm and Radiesse, can be injected and instantly lift the end of a brow that’s begun to sink over time.

4. If you need a dramatic lift, browlift surgery is a permanent fix that can be done endoscopically, which makes it a minimally invasive procedure. During a browlift, the muscles are repositioned to lift the brow into a more natural position. Plus, any sagging excess eyelid skin can be removed as well.

For a few tips on shaping and tweezing the brows properly, click here and here for some excellent articles on Elle.com and here for a video demonstration.  Taking a little time to properly learn to shape your brows can give a whole new look to your eyes.

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.
    Brow lift and upper eyelid blepharoplasty

    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].