The term “brow” usually refers to one’s eyebrows; however, the surgical modification of the brow complex, or simply a brow surgery, is known as a brow lift (or forehead lift). Brow surgery is one of the common procedures in the field of plastic and reconstructive surgery. It is neither as easy nor as straightforward as, for example, tattoo removal. For one thing, there are several different types of surgery and related techniques, but also it can be purely cosmetic (elective) or medically necessary (reconstructive). This is because significant drooping of the skin and soft tissues of the forehead and brow can be both a serious aesthetic issue but also become functional, in the way it impedes the vision and restricts the superior visual field of an individual. This article will serve to examine several important aspects of this interesting and important surgical procedure. It will briefly cover anatomy of the aging brow, different surgical techniques, indications and goals (functional vs. cosmetic), patient experience (before, during, and after surgery), and realistic expectations.
Facial appearance is an extremely important part of how one is perceived by others, and many important cues can be read by a person’s brow position and shape. The position of the eyebrow is determined by the action of several muscles and soft tissues. The most important muscle that elevates the brow is the frontalis muscle, a vertical muscle that runs the length of the forehead. The two main muscles that oppose the frontalis and pull the brows down and together are corrugator supercilii and procerus. When a person frowns, the corrugator muscles pull the brows down and together, producing the vertical lines between the brows, and the procerus produces the horizontal furrows between the brows on the bridge of the nose. As one ages, years of repeated movement by these muscles as well as gravity, sun damage, and genetics cause certain predictable changes to occur. The skin becomes less elastic, subcutaneous fat atrophies and depletes, and the entire brow complex begins to gradually droop downward. This downward movement can cause the skin to fold over the upper eyelids (called hooding), the brow to flatten and even develop a characteristic saddling effect or downward concavity, and the dynamic lines described above to become permanent, deep creases in the skin. The look this creates is often one of chronic tiredness, anger, or sadness, even when a person does not feel that way at all. As a result, many patients who experience this develop a desire to have it fixed.
At this time, there are several main types of surgical approaches that can be used to treat the drooping, aged brow. The surgeon and the patient usually work together to decide which one will be the most effective for a given individual. The oldest and most widely known technique, the coronal brow lift, is a long, ear-to-ear incision made across the top of the head just behind the hairline. This approach has excellent exposure and great ability to lift and fixate the brow at the new location as well as allowing for muscle dissection or repositioning if necessary. However, this is also the most invasive method with the longest recovery time and potential for issues such as permanent scalp numbness and a higher hairline. The trichophytic brow lift is a slightly modified version that places the incision just at the front of the hairline. This is a good option for a high forehead but requires a very meticulous closure and can be associated with more visible scarring. In the past two decades, endoscopic surgery has become more and more popular. This method uses several small scalp incisions just within the hairline that are hidden by the hair, through which a tiny camera (called an endoscope) and other surgical instruments are inserted. The surgeon is able to view the inside of the head on a monitor and then proceeds to lift and elevate the tissues and release the procerus and corrugator muscles to soften the frown lines. The brow is then secured in its new, elevated position using temporary internal sutures or small fixation devices. The endoscopic approach is associated with faster recovery, less numbness, and less scarring but is not always an option for patients with a very high or significantly drooping forehead.
As mentioned above, in addition to the cosmetic desire to look younger and refreshed, there are several very important functional reasons for having a brow lift. One of the most pressing issues with significant brow ptosis is that it can actually begin to physically fall and rest on the upper eyelids, decreasing or obscuring the superior visual field. A patient may also get in the habit of chronically raising their brows to see, thus activating the frontalis muscle, leading to headaches and compensating for the loss of visual field by tilting their head back, leading to neck issues. These issues make a brow lift not simply a cosmetic choice but a medically necessary procedure to help restore the patient’s quality of life and vision. This difference can even be picked up on by ophthalmologists in conjunction with a plastic surgeon and supported by tests that show how much a ptotic brow impacts a patient’s superior visual field. With documentation of this nature, insurance companies will sometimes pay a portion of the procedure, drawing a clear line between elective cosmetic surgery and medically necessary reconstructive surgery.
As described above, the initial consultation is the most important part of the brow lift process. A properly trained and certified plastic surgeon will be sure to take a comprehensive medical history and perform a detailed facial analysis of a patient, examining the skin quality, position of the brow relative to the orbital bone, muscle activity, position of the hairline, and general facial symmetry. The surgeon will then explain the goals, surgical options, and potential complications (risk of infection, bleeding, scarring, hair loss around the incisions, asymmetry, and nerve injury that could lead to temporary or permanent paralysis or weakness of forehead movement) and recovery timeline. It is crucial that expectations are realistic; the goals of surgery should be a more harmonious, natural, and youthful appearance, but not an elimination of expression or surprised appearance. Pre-operative photos will be taken, and certain medications or supplements will need to be stopped that increase bleeding risk.
The surgery is done on an outpatient basis under either general anesthesia or IV sedation. The actual procedure can take anywhere from one to three hours, depending on the method chosen. For an endoscopic brow lift, after the small incisions are made and the camera is in place, the surgeon gently elevates the forehead and brow complex off of the underlying bone to gain access to the procerus and corrugator muscles, which are then carefully weakened or removed to soften the frown lines. The brow itself is then repositioned and secured in its new, higher position and the incisions are closed with sutures or staples. A traditional brow lift is similar in principle but uses a single, long incision.
The post-op experience and recovery is typically well managed by an experienced surgeon. Swelling, bruising, and numbness of the forehead and periocular areas are expected and peak around 48-72 hours post-operatively. These can be controlled by applying cold compresses and keeping the head elevated for the first few days. Pain is usually minimal and can be managed by prescribed medication. On occasion, drains are placed that will be removed within a few days after surgery if there was a significant amount of fluid build-up from the surgery (more common with a traditional approach). Stitches or staples are removed within one to two weeks. Most patients are able to return to non-strenuous work and social life within ten to fourteen days, but some swelling and numbness may persist for several weeks to months. The final result is revealed after most of the swelling subsides, usually three to six months after surgery. The softening of the frown lines and flattening of the brow, along with an overall smoother forehead, should create a softer, more open, and alert appearance. The eyes are better framed by the brow, the forehead is smoother, and the angry or fatigued look is significantly improved, but expression is still preserved.
In summary, the surgical art of brow lifting is a highly-refined, powerful, and popular surgical discipline. It is one of the successful examples of the merger of the anatomical sciences with aesthetic artistry. The procedure works to combat the obvious and aesthetically displeasing effects of the aging process in the upper third of the face. The evolution from the traditional “open” approach to an endoscopic technique reflects the medical community’s ongoing dedication to creating patient-centered, safe, and minimally invasive treatments that do not compromise quality of results but rather aim to get there as quickly and with the least disruption to the patients’ lives as possible. However, successful brow surgery relies heavily on an honest and trusting relationship between the patient and surgeon, a deep understanding of facial anatomy, and realistic and shared expectations for the procedure. For patients burdened with an aging, heavy, drooping brow that no longer accurately reflects their true vitality or that even hinders their vision, the brow lift represents a scientifically-sound and artistically-performed route to a brighter, more representative, and more comfortable facial aesthetic.
