Brow Lift

Patients generally asking for an eyelid lift often do not realize that their eyes look bad to them because they have brow ptosis, which is abnormally or suboptimally low positioned eyebrows. This is because eyebrow sagging causes excess skin to be noticeable and “bunch” up in the upper eyelids. A useful test is to look at a mirror and push down on your eyebrows. This will cause excess skin to appear in the upper eyelids.  If this extra skin is prominent upon gently pushing on the eyebrows then likely a brow or forehead lift is required, in addition to an upper eyelid lift “blepharoplasty,” for the best and longest lasting result.  However, if you lift your eyebrow with your finger, and the excess upper eyelid skin resolves then a brow or forehead lift maybe all that you need. Patients with substantial forehead wrinkles usually have brow ptosis, as they have been using their forehead muscles to compensate and lift the eyebrows higher. Some of this wrinkling will improve with a brow lift, but the most improvement will be achieved by lifting the forehead tissues as well. Forehead lifting surgery requires incisions in the hair-bearing areas of the scalp.  There are also non-surgical methods including botulinum injections, radiofrequency and suture lifting.  Typically, surgery provides the most superior and longest results.

A brow and/or forehead lift is generally needed when the eyebrows are below the upper orbital bony rim in men and at or below in women. An upper blepharoplasty will address extra upper eyelid skin—but sometimes, what is perceived as excess eyelid skin is actually the brow tissue pushing downward causing the upper eyelid skin to bunch and fold upon itself.

There are generally three categories of patients that seek forehead or eyelid lift surgery. First are patients that only have excess skin of the upper eyelids but don’t have drooping of the eyebrows or forehead, and therefore, they only need eyelid surgery. The next group have excess upper eyelid skin and very mild drooping of the brows. In this group, the internal brow lift (browpexy or browfat-pexy) is usually performed. The last category has more significant sagging of the eyebrows, and they achieve the best result by having simultaneous upper eyelid surgery and brow/forehead lift surgery.

A useful test is to close your eyes and put a finger on your central eyebrow and see where your finger is relative to the bony orbital rim of the eye socket. Close your eyes and put your fingers on your eyebrows. If your finger is below the orbital rim, then a more powerful lift will be required, and a good result will not be achieved from upper eyelid surgery alone as it will actually lower the eyebrows.

Dr. Burroughs is consulted by a significant number of patients that had upper eyelid surgery alone when a brow/forehead lift was really what was needed or in conjunction with the upper eyelid surgery. Unfortunately, the surgical removal of eyelid skin below a low eyebrow is not aesthetically desirable, as it causes an angry and tired appearance.

Each patient is different in terms of their specific needs and goals. Dr. Burroughs therefore customizes the approach that best meets the specific needs of each patient after careful discussion of the options. Dr. Burroughs offers internal and direct brow lifts, hairline (trichial), post-hairline, suture, radiofrequency, and endo-type forehead lifts and contouring.

Most patients with only mild brow ptosis do very well with an internal approach that is done in conjunction with an upper eyelid lift, and this is the most popular approach in Dr. Burroughs’ practice. The internal approach also has the fastest healing.  However, advancement in forehead lifting techniques has allowed amazing results through small incisions behind the hairline with much faster healing than times past. 

Yes, but it is more of a brow stabilization to reduce descent of the brow that is often seen following a standard-type upper blepharoplasty. This is a method of lifting the eyebrow fat pads such that the overlying skin and brow tissue is gently raised upward and outward. To achieve this, the tissue that holds the brow downward is released; the brow fat pads are then released and resutured higher up above the orbital rim. The suture placement is altered depending upon the end goal. For instance, in some cases, the brows have become flat in shape and need some added projection or a contour adjustment. This can be achieved with site-specific placement of the brow fat pad sutures and site and height-specific suturing to the tissues above the orbital rims. It other words, it is customizable to a degree. In rare circumstances, true brow elevation and lifting can be achieved but generally a dedicated forehead lift or brow lift (not performed internally) is more reliable and powerful.

Generally no, as forehead wrinkle improvement requires lifting the forehead as well as the eyebrows. However, after the brow is lifted, many patients will begin to stop the unconscious overuse of their forehead muscles as they no longer need to elevate their brows to see better or lift the heaviness, so this can soften the appearance of forehead lines. Typically, lasering or radiofrequency microneedling can more reliably improve the forehead lines especially in conjunction with a forehead lift. Botulinum injections can also be helpful to help the forehead muscle relax and “relearn” that it is not longer needed to the degree it was before upper eyelid or brow/forehead lifting surgery.

The corrugator “eyebrow” muscles cause vertical wrinkles to form in the area between the eyebrows. Patients do not like these wrinkles as they can make one look concerned, intense, or angry. Many frontal area headaches are attributed to overuse of the corrugator muscles.

These wrinkles can be reduced by weakening the corrugator muscle with either Wrinkle Blocker injections (botulinum) or surgery. Wrinkle Blocker requires repeat injections but has no recuperation period. Surgery is typically only performed once but requires a period for recuperation longer than with a standard upper blepharoplasty. Generally, the botulinum injections is the most reliable to improve these lines. Rarely, filler or fat injections can be done but injections in this area carry risk for skin necrosis or even blindness if the large vessels get fat or filler injected directly into them especially if done under high pressure.

The same incision used for an upper eyelid lift (blepharoplasty) is used to remove large portions of the corrugator muscles. Additional dissection is required, but additional skin scarring is not an issue as the upper eyelid incision had already been made for the upper blepharoplasty. Dr. Burroughs has performed thousands of these surgeries, but most patients opt for botulinums as they carry no downtime.

Most patients have upper eyelid surgery done at the same time. This results in bruising and swelling that typically mostly resolves over several weeks to a few months. Patients may also get numbness between the eyebrows and the forehead after this procedure, and this can take months and rarely up to a year to resolve. Permanent numbness is only very rarely seen.

This can be attributed to lax skin that has sagged from aging or rarely other causes such as significant weight loss. These are difficult to treat, and may require a multi-stepped approach with surgery, fillers, fat grafts, and skin resurfacing.

These can be from either chronic muscle action of the lateral frontalis (brow lifting muscle) or from sleep positioning of the head (“sleep face.”) Those that sleep on their sides or stomach (prone) may cause a crease to form in the skin from the way their forehead skin is pushed while sleeping over the course of many years. This can be difficult to manage once it has become prominent, but sometimes botulinum wrinkle blockers, fillers, and skin resurfacing can help.

A pre-hairline lift is performed by removing skin and often some superficial undermining in the forehead skin tissues to raise the forehead and brow tissues. This can be done for the entire forehead region, but is most commonly done with two to three relatively small incisions that are well hidden at the hairline. The incisions are designed and oriented that the hair can grow through them over time to further help camouflage their presence.

Bitemporal lifting is done with either a hairline or behind the hairline incision. Sometimes skin is removed, but oftentimes it is not required. Deep sutures are often placed to achieve the desired lateral and upward pull. This approach, is more costly than an internal brow approach, but it has the advantage of also more substantially contouring and lifting the lateral brow tissues especially important in female patients and it can improve the crows feet wrinkles and folds. Generally with a full Foreheadplasty or lift, the bitemporal approach is performed in conjunction with other forehead incisions behind the hairline or at the hairline. It is less costly than an endoscopic or endo-style forehead lift.

This is a method of lifting the forehead that uses small incisions and a rigid endoscope camera. It can be used to lift the entire forehead or just the lateral brows to reduce wrinkles, improve brow contours (angles), reduce brow ptosis, and improve the crows feet/folds. It has small incisions and a rapid recovery. It can be done in the office, and in Dr. Burroughs experience does not require general anesthesia though some light IV sedation is preferred by most.

This is a method of lifting the forehead and the eyebrows using the same incisions as an endoscopic approach, but a camera is not utilized. Generally, the endoscope camera is interesting to see anatomy, but is not essential as techniques and the understanding of the pertinent anatomy has advanced over the last 30 years that many surgeons no longer use a camera but otherwise perform the similar technique. Just like with facelifting, there are many approaches and many surgeons use multiple approaches as each patient is unique with variable anatomy, end goals, and recovery time-frames.

The number of incisions and placement depends upon an individual’s need for brow contouring and elevation. Sometimes incisions can be behind the temporal hairline, and this incision runs parallel to the hairline. Another set of incisions may be made behind the central hairline, and this incision is vertical, so it runs perpendicular to the hairline. The incisions are about 1-2 inches long and can be nearly invisible as they heal within the hair. Patients with receding hairlines or baldness can still undergo this surgery, but adjustments to the incisions are made.

The attachments of the soft tissue to the bone are safely and uniquely loosened according to the specific needs with special instruments and scissors. The forehead can then be lifted and fixed in position. The tissues can be fixated with either sutures, anchors, or screws that maintain the raised forehead position during the 1st several weeks-months of healing. Fixation is not always needed.

To obtain the best result, most patients undergoing forehead lift surgery will also undergo eyelid surgery at the same time. Eyelid surgery typically causes more bruising and swelling than forehead lift surgery, and this bruising and swelling are mostly resolved within a few weeks but can be much quicker with the use of the LidLift goggles, TXA medication, and sometimes a surgical drain. Hairline sutures and/or staples are generally removed 8-10 days after the procedure.  Sometimes an easily removed drain is also placed to reduce swelling, but most commonly is not required.

Patients may gently wash their hair 48 hours after surgery, but they should avoid hair treatments (e.g., coloring) for a few weeks. Most patients, who have forehead lift surgery, will get temporary forehead and scalp numbness that can take a few weeks to months to resolve.

Insurance will sometimes pay for eyelid surgery when it impairs vision, but this will have to be documented by photographs and charts to be causing visual problems and be confirmed with visual field testing. Insurance only very rarely and almost never covers forehead lifting. Again, very strict criteria to include visual interference (e.g., reading and driving difficulties) from the overhanging tissue must be occurring and correlate with visual field testing. Facial nerve weakness causing paralysis of one side of the face from a stroke or Bell’s palsy will sometimes be medically covered by insurance to improve visual function. Most importantly, standardized medical photography must demonstrate a corneal central light reflex to lid margin or skin distance of 2mm or less.

An internal brow stabilization can be performed through the same incision as the upper eyelid blepharoplasty surgery, so no additional incisions are needed. The internal brow stabilization is the least expensive option and has the fastest healing time. Only rarely, can the brows be substantially lifted and contoured through the internal (through the eyelid incision) approach. More powerful brow lifting and contouring requires additional incisions and forehead lifting is the most powerful, long-lasting, and customizable procedure for the upper face.

The bitemporal, hairline and endo- forehead lift surgeries are essentially a facelift of the upper face, while an internal brow stabilization just protects the brows from substantially dropping after an upper blepharoplasty or eyelid ptosis surgery. Forehead lifting reduces wrinkling of the forehead, and an internal brow stabilization will not do this. A forehead lift can also lift and smooth the crows feet wrinkles/folds just adjacent to the outer corner of the eyelids, and it is easier to correct downward slanting eyebrows and asymmetrically positioned eyebrows with browlift or forehead lift surgery than with an internal brow stabilization.

Healing can sometimes take longer because larger and more numerous incisions are required as compared to the single upper eyelid incision for internal brow stabilization surgery. The sutures and/or staples are usually removed between 8-10 days after brow or forehead lifting surgery.

Serious complications are very rare, but there are risks associated with any medical and surgical procedure. Dr. Burroughs will discuss the most common issues encountered during healing (e.g., bruising, numbness) as well as the potential serious risks. Motor nerve injury is very rare, and usually temporary.