The upper portion of the face contains the eyebrows and forehead. The brows are central in conveying human emotion, and aging changes can dramatically affect how others view us. Downward slanted eyebrows convey sadness or anger while droopy eyebrows convey an aged or tired look. As we age, the forehead and eyebrow descend, which is commonly called “brow ptosis.” The forehead lift is a face lift of the upper portion of the face that elevates and shapes the eyebrows while removing droopiness and wrinkles from the forehead. The forehead and the eyebrows may be lifted by multiple means and can often be done with relatively small incision techniques. The internal brow lift is a common approach and is performed in conjunction with upper blepharoplasty. An internal brow lift is accomplished via the same incision used to rejuvenate the upper eyelids and is effective in raising the eyebrows and removing the furrows between the brows.
Here’s an animation from plasticsurgery.org that will explain how forehead lifts are performed. Click Here.
Frequently asked questions about brow and forehead lifts:
1. Who should have a brow or forehead lift?
Patients generally asking for an eyelid lift often do not realize that oftentimes their eyes look bad because they have brow ptosis, which is abnormally low eye brows. This is because eye brow sagging causes excess skin to appear 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. Conversely, if you lift your eyebrow with your finger much of the excess upper eyelid skin resolves. Patients with substantial forehead wrinkles usually have brow ptosis as they have been using their forehead muscles to 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 requires incisions in the hair-bearing areas of the scalp.
2. When is a brow or forehead lift needed?
A brow and/or forehead lift is 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 sometime what is perceived as excess eyelid skin is actually the brow tissue pushing downward and 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 mild drooping of the brows, and they achieve the best result by having simultaneous upper eyelid surgery and brow/forehead lift surgery. In this group, the internal brow lift is usually performed. The last category has more significant sagging of the eyebrows. 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 actually sees 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 appearance.
3. How does Dr. Burroughs perform forehead/brow lifts?
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, as well as hairline and endoscopic forehead lifts.
4. Which brow lift is most popular?
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 has the fastest healing.
5. What is internal brow lift surgery?
This is a method of lifting the eyebrows using the same incision site used to remove excess skin from the upper eyelids. The tissue that holds the brow downward is released, some conservative fat sculpting of the brow is performed if applicable, and sometimes a few stitches are placed to stabilize the brow in the new elevated position.
6. Will an internal brow lift reduce forehead wrinkles and lines?
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 overusing their forehead muscles as they no longer need to elevate their brows to see better and this can soften the appearance of forehead lines.
7. What causes the lines (“11’s”) between our eyebrows?
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.
8. What can be done to get rid of the vertical wrinkles (“11’s”) in the area between the eyebrows?
These wrinkles can be reduced by weakening the corrugator muscle with either Botox or surgery. Botox requires repeat injections but has no recuperation period. Surgery is typically only performed once but requires a period for recuperation.
9. How are the corrugator muscles weakened by surgery?
The same incision used for an upper eyelid lift (blepharoplasty) is used to remove 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.
10. Does it take long to heal from corrugator weakening surgery?
Most patients have upper eyelid surgery done at the same time. This results in bruising and swelling that typically resolve after three weeks. Patients may also get some numbness between the eyebrows and the forehead after this procedure, and this can take several months and rarely up to a year to resolve.
11. What is a pre-hairline (trichophytic) forehead lift?
A pre-hairline lift is performed by removing skin and often some undermining in the forehead tissues to raise the forehead and brow tissues. This can be done for the entire forehead region, but it is most commonly done with 2-3 relatively small incisions that are well hidden at the hairline. Sometimes, the incisions can be placed behind the hairline as well, but this is done less commonly. This approach, though more costly than an internal approach, may still be performed in an office OR setting and has the benefit of addressing the forehead wrinkles as well as lifting the brow tissues. It is less costly than an endoscopic forehead lift and does not require general anesthesia.
12. What is an endoscopic forehead lift?
This is a method of lifting the forehead and the eyebrows in order to reduce wrinkles in the forehead and reduce droopiness of the eyebrows or to correct downward slanting eyebrows. It is a small incision, rapid recovery procedure.
13. Where are the incisions made for an endoscopic forehead lift?
One set of incisions are made behind the temporal hairline, and this incision runs parallel to the hairline. Another set of incisions is made behind the central hairline, and this incision is vertical, so it runs perpendicular to the hairline. The incisions are about an inch long and are nearly invisible as they heal within the hair. Patients with receding hairlines or baldness can still undergo the surgery, but adjustments to the incisions are made.
14. How does an endoscopic forehead lift work?
The attachments of the soft tissue to the bone are safely loosened with instruments while using the endoscope. 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 healing.
15. How is recovery for a forehead lift?
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 3 weeks. Hairline stitches and/or staples are generally removed between 10-14 days after the procedure. Patients may gently wash their hair 48 hours after surgery, but they should avoid hair treatments (e.g., coloring) for a few weeks. Many patients who have forehead lift surgery will get temporary numbness that can take a few weeks to resolve.
16. Does insurance ever pay for a forehead lift?
Very rarely. Visual disruption (e.g., reading and driving difficulties) from the overhanging tissue must meet strict visual field criteria. Medical photography demonstrating the issues will also be required.
17. Does insurance ever pay for eyebrow lift surgery?
Insurance will sometimes pay for eyelid surgery when it impairs vision, but this will have to be chart and photo documented to be causing visual problems and be confirmed 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.
18. What are the major advantages of an internal brow lift over a hairline or endoscopic forehead lift?
An internal brow lift can be performed through the same incision as the upper eyelid blepharoplasty surgery, so no additional incisions are needed. The internal and hairline lifts can be performed in the office setting while an endoscopic forehead lift surgery requires deeper anesthesia in an operating room setting. The internal brow lift is the least expensive option and has the fastest healing time.
19. What are the major advantages of a hairline or endoscopic forehead lift over an internal brow lift?
The hairline and endoscopic forehead lift surgeries are a facelift of the upper face while an internal brow lift just elevates your eyebrows. Forehead lifting reduces wrinkling of the forehead, and an internal brow lift will not do this. A forehead lift can also lift and smooth the crows feet wrinkles just adjacent to the outer corner of the eyelids, and it is easier to correct downward slanting eyebrows and asymmetrically positioned eyebrows with an endoscopic forehead lift surgery than with an internal brow lift.
20. What are the disadvantages of a hairline or endoscopic forehead lift?
Healing can take longer because larger and more numerous incisions are required as compared to the internal brow lift surgery. The sutures and/or staples are usually removed between 10-14 days after surgery.
21. Is brow and forehead lift surgery risky?
Seriously 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.