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Brow lift
Overview
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.
Dr. Cruise has done much research on
what causes aging of the brow and around the eyes. 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. Dr. Cruise has significant experience with all of the brow lifting
techniques. The 3 types of brow lifts that Dr. Cruise
has found 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 Dr. Cruise does 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 routinely performed
by Dr. Cruise 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. Dr. Cruise has
developed a unique way to, at the same time, 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. Dr. Cruise
does not use this type of brow lift often as he is 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.
 Dr. Cruise's philosophy regarding Brow Lift
Aging affects the eyebrows more than other parts of the face. It creates an old and tired appearance to the upper eye region. Often, patients come to me requesting upper eyelid cosmetic surgery when what they really need is a brow lift. I think the above test that elevates the lateral part of your eyebrow is an excellent test to determine if you would benefit from a brow lift.
The reality is, most people by their early 40s could benefit from a brow lift. I find it especially effective to elevate the lateral brow. This has multiple positive effects. It provides a more youthful, elegant look to the upper eyelid region and gives the face a brighter appearance. It also effectively improves the wrinkles in the crow's feet area.
As mentioned in the overview section above, I routinely do brow lifts several different ways depending on what the patient needs. I do not feel it is necessary to make long incisions. In fact, over 98 per cent of my brow lifts are done with incisions about an inch and a half long within the hairline.
If I am performing an upper blepharoplasty, I find it most effective to perform a concurrent brow lift at the same time through the same incision. The brow lift obtained is not as dramatic as one done through an incision above the eyebrow but it is very effective in elevating the tissues that have over time fallen into the upper eyelid. It is a way of improving the results of a cosmetic upper eyelid surgery without making any new incisions.
Benefits
Eyebrows that have descended make 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 near the nose. The benefits
brow lift are:
- 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.
- An additional benefit to brow lifting
is that it significantly helps diminish the wrinkles in
the crow's feet area.
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.
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.
Prior to surgery
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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. Dr. Cruise will go over this
more thoroughly prior to the procedure.
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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 Dr. Cruise for something to help
you sleep.
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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.
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Eating. Do
not eat within 8 hours of surgery and do not drink within
6 hours of surgery. Please discuss all medications with
Dr. Cruise and the anesthesiologist.
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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.
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Arrival. It
is best to arrive on time to make sure everything goes
smoothly. Please be sure to have someone else drive
you home.
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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. Dr. Cruise and ICRS are both well trained
and experienced. Excessive worrying can actually
be detrimental. If you are a very anxious person you should
discuss this with Dr. Cruise prior to surgery so that
something can be prescribed to make sure you remain calm.
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 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
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Forehead: Wrinkles (especially with animation)
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Lateral Brow: Droopy
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Medial Brow: Droopy, wrinkles between the brows
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Upper Eyelid: Droopy, excess skin, excess fat
Ideal Brow Shape
- Forehead
- Smooth; few wrinkles with animation and no wrinkles at rest
- Lateral Brow
- The lateral brow should be 2-3 mm higher than the medial brow in women and at least the same height or higher in men.
- There should be no crow's feet at rest and only a minimal amount with animation.
- Medial Brow
- Should be higher than the bony rim that surrounds the eye.
- The bridge of the nose should be smooth.
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 three 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.
Anesthesia
ICRS uses only board certified anesthesiologists
to make sure you have the best anesthesia possible. The anesthesiologist
will discuss with you what type of anesthesia is best for
you. He/she will take into consideration your medical history,
the procedure, and your personal wishes.
Normally, Dr. Cruise performs 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. Dr. Cruise is a strong advocate
of good pain relief so 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 Dr. Cruise 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.
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