Brow and Forehead Surgery
As we age one of the most noticeable features is the descent of the eyebrows. The female eyebrows are normally arch shaped and above the level of the bony rim above the eyeball. The normal male eyebrow is usually at the level of the bony rim. In both males and females, aging causes the eyebrows to droop and overlap the eyelids.
Many people feel that they need eyelid surgery because they have droopy upper eyelids. In actuality, they may need their forehead and eyebrows suspended back to their youthful position. If excess eyelid skin is removed in a patient with sagging brows, the condition can actually be worsened, because the tightening may cause the brow to descend even more. For this reason, it is important for the surgeon and patient to fully realize the contribution of droopy brows before removing eyelid skin. If the patient has droopy brows and excess eyelid skin, then they may be addressed at the same surgery.
Some surgeons may fail to evaluate brow position and if too much eyelid skin is removed, a brow lifting procedure may be impossible in the future. For this reason, evaluation of the brow position must be considered.
Elevating the eyebrows, a forehead and brow lift smooths the horizontal forehead wrinkles and decreases the activity of the muscles between the eyes and on the forehead that are responsible for scowling.
Brow and Forehead Lift Overview
Brow and forehead lift is a surgery that elevates aging brows and forehead and improves droopy eyelids. Some browlift techniques also improve forehead and brow wrinkles. While almost every adult over 50 is a candidate for upper eyelid surgery, they may or may not be a candidate for brow and forehead lift.
The difference between upper eyelid surgery and browlift surgery are numerous. With upper eyelid surgery, the upper lids are improved but the brow position is unchanged. The browlift, however, improves the baggy upper eyelid skin and also elevates the brows to a more youthful position.
Not every patient is a candidate for brow lift as some patients do not look natural with elevated brows. One good way to “preview“ the results of a brow and forehead lift is to lie flat on your back, elevate your chin and hold a mirror directly over your face. In most cases this approximates the position of elevated brows.
One common problem is that some patients are not offered the option of brow lift by some surgeons. Before any upper eyelid procedure, a browlift should be discussed. If too much skin is removed from the upper lids, a future browlift may be impossible as there will not be enough skin to close the eyes.
Who is a Candidate for Brow Lift?
- Patients with low eyebrow position that desire elevation
- Patients with eyebrow asymmetry
- Patients with excess or droopy upper eyelids
- Patients with forehead or brow wrinkles
Who is not a Candidate?
- Patients who look surprised or unnatural with elevated brows
- Patients who have had multiple upper lid surgeries and do not have sufficient skin to close the lids
- Patients with unstable hairlines (although some techniques use hidden scars).
- More youthful eyebrow position
- Reduced appearance of brow and forehead wrinkles
- Improvement of baggy and droopy upper eyelids
- The procedure is generally performed with IV or general anesthesia.
- The most common techniques use incisions hidden in the hairline. Some surgeons use endoscopic techniques while other surgeons employ open surgical methods. Much of this depends on factors such as patients with high hairlines or hair loss.
Mini Open Brow Technique (Transfollicular Brow Lift)
Most types of brow and forehead lifts can elevate the hairline, fail to address deep forehead wrinkles and may require screws, holes or plates in the skull to maintain the elevation.
All of these problems can be alleviated by the mini open brow technique. This surgical approach utilizes a special incision know as a transfollicular or trichophytic incision. This incision is made just behind the hairline and done in such a manner that the hair will regrow through the incision scar. This technique is done only under the skin as opposed to the deep tissues like other techniques. The hairline is not elevated and can actually be lowered with the mini open brow technique. Since this is a skin incision technique, no holes are drilled in the skull and no hardware is required. In addition, many surgeons feel that this technique is the most stable type of browlift and the results can last longer. The mini open brow technique should not be confused with the older type of coronal brow incisions. These older techniques required extremely large incisions on the scalp and very deep dissection. That is not the mini open brow technique. The mini open brow technique can be thought as a facelift for the brow as it is a very similar technique to facelift surgery where excess skin is removed to increase longevity of the operation.
The basis of this technique is a precision incision that allows the hair follicles to regrow through the scar. This is called a transfollicular or trichophytic incision method. The result is an incision scar that is barely noticeable. The diagram below illustrates how the hair follicles grow through the precision incision. As the healing progresses, the hair regrowth becomes evident which camouflages the scar. The picture below show a patient’s hairline before mini open brow lift and 8 weeks after surgery with new hair growth surrounding the scar.
Mini Open Browlift Recovery and Results
This patient shown before and after “mini open brow” lift performed by Dr. Niamtu
The hairline is shown in the same patient as the picture on the left before and after “mini open brow lift”
Mini open browlift with blepharoplasty can restore a more youthful appearance
Both the endoscopic and the mini open brow techniques are excellent options and Dr. Niamtu can discuss the relative advantages for each specific patient.
Endoscopic Forehead and Brow Lifting
Older methods of brow and forehead lifting require large incisions that extend across the entire scalp. These surgical approaches may lead to scalp numbness and hair loss.
The new methods of brow lifting are done with endoscopes or conservative incision technique. This is the same type of technology that is used for arthroscopic knee and shoulder surgery. Several small incisions are placed within the hairline and the endoscope is inserted under the scalp and the surgeon can visualize the tissues of forehead and eyebrow. Using special instrumentation, the surgery is performed without any large incisions and the recovery and complications are decreased.
The video below shows Dr. Niamtu releasing tissue for brow elevation using the endoscopic technique. The tiny camera is placed under the patient’s scalp and the instruments are inserted through button hole incisions that are hidden by the hair.
Endoscopic forehead and brow lifting is usually performed in the office surgery center environment with sedation. Recovery is about 7-10 days.
More information about Brow and Forehead Surgery from Dr. Niamtu's library of articles
The video below shows Dr. Niamtu performing the Mini Open Brow Lift. It is actual surgical footage and may be too graphic for some viewers. If you are sensitive to this type of material, view at your own discretion.
The Video below shows a mini open brow lift patient 6 days after surgery
Surgical brow lifting is one of my favorite procedures and is the only true way to treat moderate to severe upper facial aging in a natural and lasting manner. I perform this surgery endoscopically and in a “mini open” technique as well.
Many patients do not require surgical brow lift and can benefit from injectable, non-surgical brow lift. This technique can be performed with neurotoxins (Botox, Dysport and Xeomin) and injectable fillers such as Restylane and Juvederm. The Botox allows the depressor muscles ( the muscles that pull the brow down) to relax and the elevator muscles ( the muscles that lift the brow to remain selectively active. This combination can produce a mild brow elevation when the patient moves their brow. This is generally a subtle lift and is not reproducible in all patients. Injecting filler under the eyebrow serves to fill out the hollow in that area and can actually inflate and lift a mild to moderate drooping brow. Injecting filler in the brow is more effective than Botox and is an immediate result. I prefer to combine the Botox and filler for the optimum result as one treats the muscles and the other volumizes and lifts the brow.
The entire treatment takes about 5 minutes and is painless because the area is numbed with local anesthetic. Due to the presence of the filler the treatment can last a year. In the rare case that the patient is not happy with the result, the filler can be dissolved overnight.
It is important for patients to understand that this type of brow lift does not equal the results of surgical procedures and is not intended to do so, but rather to be a minimally invasive method to produce some level of lifting for patients that do not desire surgery.
The picture above shows the technique for the “Botox” brow lift. The same technique is also used with Dysport or Xeomin
The image above show the method for “Filler Brow Lift” and a patient before and immediately after the procedure.
Again, this technique is not a substitute for surgical brow lift, but rather an alternative option for selected patients.
Dr. Niamtu has published a 1,000 page comprehensive textbook on cosmetic facial surgery which includes a large chapter on his browlift techniques. Few surgeons receive the honor to publish such a text with a major medical publisher like Elsevier .
Dr. Niamtu lectures frequently on brow and forehead lift surgery. The photo to the left shows Dr. Niamtu demonstrating endoscopic brow lift at the University of St. Louis Cosmetic Facial Surgery Course cadaver lab. Also shown is course director Dr. Mike Nayak.
The brochure to the left is from a multispecialty cosmetic facial surgery course at the University of St. Louis in July of 2006 where Dr. Niamtu lectured on eyelid and brow surgery.
Click on the image to enlarge.
The brochure to the left is from a multispecialty cosmetic facial surgery course at the University of St. Louis in February of 2007 where Dr. Niamtu has been a regular lecturer on eyelid and brow lift techniques.
Click on the image to enlarge.