Brow Lift

Overview

Browlifts is a common cosmetic procedure in which the soft tissue and skin of the eyebrows and forehead are elevated to a position approximating its level in the patient's mid-20s. Such surgery typically is performed to combat the effects of aging on the forehead and brow line. The procedure can give a face a more rested, youthful appearance and soften the forehead's “worry” or “frown” lines.

Who seeks this surgery?

People who consider browlifts for cosmetic reasons typically are 40 or older, and have a brow line that makes them look tired or angry. Browlifts also can be done for medical reasons: A severe brow droop can directly obscure a person's upper visual field, and a drooping brow can contribute indirectly to hooded eyelids, which also obscure vision. Facial trauma affecting the forehead also can necessitate a browlift.

Most people seeking cosmetic surgery don't ask for a specific procedure – rather, they'll see a physician and ask, "What do I need done?" to diminish the appearance of tired eyes, deep lines across the forehead, or heavy eyelids. Some patients want to raise their hairline so they have a higher forehead, like celebrities Charlize Theron and Tyra Banks.

Eye expertise distinguishes oculoplastic surgeons

Ophthalmologists and oculoplastic surgeons draw on expertise gained from treating patients' eyes and surrounding musculature and tissues, including the tear drain and orbit. They are adept at recognizing how small surgical changes can significantly improve a person's appearance and expression. They understand subtleties of the facial areas' convergence zones, skin tension, and fat deposits. They know how to achieve desired results without overcorrecting – which can make a face appear unnaturally taut or give a person a look of perpetual surprise.

Based on an initial exam, the physician will identify whether excess tissue on the eyelids, or the brow's droop, or both, are contributing to the perceived poor appearance. (Browlift surgery commonly is performed in tandem with eyelid surgery.) The physician will present his findings to the patient and, based on the patient's perceptions and desires, will make a decision about which surgical approach is used to raise the patient's brow. To be clear, in some cases the physician might recommend against cosmetic surgery to the brow. Patients who have had previous eyelid surgeries or problems with dry eye, or whose eyes don't close well might be deemed poor surgery candidates.

The surgeon and patient must decide which approach is most appropriate. (Several approaches exist, outlined below; the closer the incision is made to the eyebrow, the more effective it is in raising the eyebrow.) Details follow about the approaches, listed from most invasive to least invasive and, anatomically, from top to bottom.

Procedural Details

Coronal approach
With this traditional approach, the incision is made across the top of the head from ear to ear, through the hair. The surgeon peels the scalp, skin and forehead tissue away from the skull, down to the eyebrow level, elevates and pulls it up and, working from the center to each side, excises the excess skin atop the scalp and reconnects tissue to skull with sutures.

This approach also would raise the patient's hairline – so it might not be desirable for a patient whose hairline is high or who is losing his hair from the front. It is not always necessary to shave the head for this procedure; sometimes hair can be adequately pulled or braided away from the incision. In the aftermath of surgery, the incision is completely hidden. This procedure would require the surgeon to gather more total skin and tissue to excise, upward of 15mm. Procedures closer to the brow itself typically require incrementally less gathering of tissue to excise. The procedure takes 2 to 2.5 hours to complete.

Pretrichial approach
The incision is made right at the patient's hairline, at the top of the forehead, and continues backward to the topmost point of the ear. This procedure has the advantage of preserving an already-high hairline. The scar is easily hidden with bangs. The procedure takes about 2 hours to complete.

Mid-forehead approach
The incision is made in the middle of the forehead, typically in an existing skin crease. Any skin below the incision site would be smoothed out; skin above the incision would not be affected. The procedure takes 1 to 1.5 hours to complete.

Suprabrow approach
The incision is made directly above the eyebrow hairs -- and often done in males whose bushy eyebrows can help hide the scars. Because this incision is so close to the eyebrow, it is more effective for people whose surgeries are more functionally related to drooping brows that obscure their sight. The incision travels from slightly beyond the outside edges of each eyebrow. This procedure would require the surgeon to gather less total skin and tissue to excise -- maybe 5mm. The procedure takes 1 to 1.5 hours to complete.

Endoscopic approach
This most-advanced approach is probably the most cosmetically pleasing. Four or five small incisions are made behind the hairline, and with the aid of an endoscope (straw-like tube that enables laser use) the forehead is resected away from the skull, down to the eyebrow. The eyebrow is pulled up and fixated to the skull under the skin. The advantages of this procedure are less scalp numbness and no visible scarring. The procedure takes about 2 hours to complete.

Botox
Botox does not involve surgery, but is identified here for comparison’s sake. A Botox injection diminishes muscle activity that causes “worry” or “frown” lines on the forehead. It cannot physically raise the brow, but only subtly suggest a raised brow by smoothing the skin. The effects of a Botox infection are temporary, and would require re-injection every three to six months to maintain the physical effect.

Recovery

Any of these procedures typically is performed on an outpatient basis; it is rare for a patient to need to remain overnight in the hospital. Mild discomfort and mild bruising on the forehead are common after surgery. Cold compresses can help reduce swelling and maintain comfort. Antibiotic ointment would be prescribed, typically in concert with pain medication.

A bandaged dressing is used for the initial 24 hours postop, after which it is removed and the hair may be washed. Often patients who have undergone endoscopic, coronal, or pretrichial procedures receive a head wrap to wear over their bandages. Patients might want to plan to take a week off from work to manage pain and swelling. Discoloration and swelling of the forehead skin improves after one to two weeks but complete settling of the scar might take as long as six to nine months.

Medications

Intravenous sedation and/or general anesthesia will be given to you before surgery. Your doctor will recommend the best choice for you.

Considerations

People who are unhappy with the effect of aging or trauma’s effects on their eyes or foreheads, or who desire a more youthful or otherwise refreshed appearance are candidates for browlift surgery. A browlift is a very individualized procedure; some people may want a very subtle change, such as a higher hairline, while others seek a more profound removal of hooded brows that obscure their vision. Patients should be physically healthy, have realistic goals for surgery, and fully comprehend the procedure’s limitations.

Women and men don't necessarily benefit equally from the same approach. Other considerations are whether the patient has a full head of hair or is balding, the position of the hairline, skin thickness, and potential for scarring. Patients who are diabetic or who smoke sometimes don't heal well; those factors could influence the decision, as well. Patients who smoke might be required to stop the habit months in advance of surgery.

Effectiveness

Anecdotally, 90 percent of patients are more are satisfied with their result. Browlifts are not permanent; they generally last five to seven years but their effectiveness can flex from two years to 15 years. Many patients choose to have the procedure a second time; however, those patients might have fewer options the second time. For example, a patient who undergoes a coronal approach initially might not be a good candidate for pretrichial or hairline incision because the blood supply can be compromised.

Risks

Any surgery around the brow risks numbness to the scalp and forehead because of the potential for damage to nerves that run across the area. It is a known side effect for this surgery, and should be disclosed as such. The approaches that involve the largest incisions are at greatest risk for this side effect; the endoscopic procedure would have the least risk for resulting numbness.

Other risks include the following:
  • Lasting Pain
  • Scarring
  • Bleeding
  • Infection
  • Slow healing
  • Dryness or itching at the incision site
  • Under-correction or over-correction, compared with surgical goals
  • Hair loss at site of incision
  • Paralysis to part of the face, due to nerve damage (rare)