An elevated arched brow is a common request from patients seeking facial cosmetic surgery. The brows may descend over time in association with periorbital (eye) aging. This may lead to a heavy appearance of the brow, increased prominence of forehead rhytids (wrinkles), and accentuation of excess skin and hooding of the upper eyelids. Brow position is a key determinant in consultation regarding periorbital aging. A patient’s complaint of upper lid heaviness and loose skin may in fact be related to descended brow position (referred to as brow ptosis) as opposed to an intrinsic issue with the upper lid.
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Browlift is an outpatient surgical procedure that is performed to elevate brow position. It resuspends the brows to a higher and more youthful appearance and may also be performed to correct asymmetry. Browlift may reduce the appearance of redundant upper eyelid skin that develops secondary to brow ptosis. Browlift may elevate overall brow position or address the lateral (outer) brow position alone through a temporal browlift. This will depend on a patient’s aesthetic goals and clinical presentation. Incision placement for browlift varies according to which aspect of the brow is being lifted.
Many patients ask about the so-called Botox browlift. This is a non-surgical technique that may achieve subtle elevation of the outer brow. It works by weakening the muscle that depresses the brow in this region (called the orbicularis oculi) and leaves the frontalis muscle (which elevates the brow) unopposed.
While a Botox browlift may be an option for patients seeking mild elevation, a surgical browlift is a more powerful technique. It may result in more dramatic brow elevation and address different regions of the brow. It is most commonly performed under general anesthetic to ensure maximum patient comfort and safety during the procedure.
Local freezing is also infiltrated once the patient is placed under general anesthetic. There are many advantages of the local anesthetic, including:
The local anesthetic lasts for several hours and will reduce pain upon awakening from the general anesthetic. It serves as a bridge until oral pain medication takes effect. Local anesthetic may reduce overall requirements for pain medication post-operatively.
The local freezing also has epinephrine, which is a vasoconstrictive agent. It constricts blood vessels to reduce bleeding during surgery. This may reduce the need for using electrocautery during browlift, which also lowers the risk of injury to hair follicles and localized hair loss.
Incision placement varies based on the planned browlift technique. Some patients may benefit from a more extensive approach (coronal incision), which leaves a scar that is generally hidden within the hair-bearing scalp from ear to ear. This is the most powerful technique in achieving brow elevation. For patients interested in achieving elevation of only the outer brow, a limited temporal incision may used. The incision for a temporal browlift is placed at the hairline in the temple region. Occasionally in patients with prominent forehead creases and male pattern hair loss, a direct browlift may be an option to avoid placing a more prominent scar on the scalp. The incision for a direct browlift is placed just above the hair-bearing brow.
A candidate for browlift surgery wishes to elevate their brow position for periorbital enhancement. It may also be performed to correct brow asymmetry or to reduce the appearance of excess upper eyelid skin that is due to a heavy or lowered brow. By elevating the brows, the appearance of redundant upper lid skin may be reduced in these cases. Many patients consider a surgical browlift when pleased with the results of Botox browlifts, but no longer wish to undergo repeat injections. Surgical results may achieve more long-lasting results than undergoing repeat injections every 3-6 months. In addition to elevating brow position, browlift may soften forehead wrinkles and creases to achieve a more youthful forehead and periorbital appearance. If recurrent brow ptosis develops through natural facial aging following history of browlift, a patient may also be a candidate for repeat browlift.
The most appropriate candidate for browlift surgery is otherwise healthy. Other medical conditions should be optimized before undergoing elective cosmetic surgery. Non-smokers are the best candidates for browlift, although it may be possible to undergo surgery if smoking cessation is achieved for at least one month before and after surgery. Following this guideline has been shown to lower the risk of surgical site infections and other wound healing complications. A patient’s aesthetic goals will also be discussed in detail to assess whether they may be realistically met with browlift surgery.
Procedure options for browlift surgery will depend on a patient’s aesthetic goals and clinical presentation. Different options include:
While this option often seems the most invasive to many patients, it may result in the most dramatic and long-lasting brow elevation as compared to other techniques. The scar is confined to the hair-bearing scalp and great care is taken to minimize risk of injury to surrounding hair follicles through surgical technique. The hairline is carefully examined pre-operatively when designing incision placement to avoid elongating a prominent forehead. The scalp and forehead tissues are undermined to the orbital rim region and elevated. The deep tissues are resuspended and secured to achieve brow elevation. Redundant skin is then removed to reduce the appearance of forehead wrinkles and creases.
For patients wishing to achieve elevation of the outer brow, a limited temporal browlift is an option. It is less invasive than a coronal browlift and involves a small incision at the hairline in the temple regions. Through this smaller incision, the outer brow may be elevated and redundant skin removed.
This procedure is not commonly performed for cosmetic browlifts, however may be an option for patients with more pronounced forehead creases and male pattern hair loss. The incision is placed directly above the hair-bearing eyebrow and elevates the brow through direct skin resection at this site. It may be an appropriate option in patients within hair thinning to avoid placing a more prominent scar at the top of the head.
An endoscopic browlift utilizes small incisions in the hairline to resuspend the brow under camera visualization. The muscles of the glabellar region may also be weakened to reduce the appearance of dynamic wrinkles at this site. The results are not long-lasting based on plastic surgery research and the amount of brow elevation is limited. It may also result in a region of alopecia (localized hair loss) at the site of brow suspension. Based on these findings, I do not recommend this procedure in my practice.
Browlift surgery may lead to aesthetic improvements relating to the brows, forehead, and upper lid skin. It elevates the brow, reduces the appearance of forehead wrinkles and creases, and through a secondary effect it may reduce the appearance of excess upper lid skin. Although aging will continue and brow position may gradually lower over time, the results are more long-lasting and dramatic than those achieved following non-surgical techniques. A Botox browlift may result in a few millimeters of brow elevation. A surgical browlift is a much more powerful technique to achieve brow elevation. Muscles in the glabellar region that create dynamic wrinkles may also be partially resected during a surgical browlift. This may reduce or eliminate the need for Botox injections post-operatively.
If patients undergo routine Botox injections of the forehead or glabellar regions, it is important for the treatment effect to have worn off by the time of browlift to avoid distortion of clinical examination.
Risks of browlift surgery include bleeding, hematoma, infection, delayed wound healing, and potential injury to surrounding structures. Aesthetic complications include over- or undercorrection, asymmetry, and potential hair loss surrounding incisions due to injury to hair follicles. When performed in appropriately selected patients with well-defined surgical goals, browlift surgery is generally a well-tolerated procedure with low risk of complications.