Summary

Recognition of this volume loss in the upper face and its effects has changed our understanding and treatment of facial aging. A brow lift, also commonly called a forehead lift, rejuvenates the face above the eyes to restore a more refreshed appearance that better reflects a patient’s natural vibrancy. By removing excess sagging skin on the forehead and repositioning the underlying muscles and tissues, a brow lift can correct a heavy, sagging brow, eliminate deep furrows, and restore a smoother, more youthful contour to the upper one-third of the face. dThrough fat augmentation, the brow is directed outward and can support the overlying skin without raising the brow to an unnaturally high position.  The superior orbital rim is approached through a lateral forehead entry site. A midline entry site is then utilized to blend the fat into the medial rim and glabellar region, totaling 1 to 2 mL per side. Upper eyelid sulcus grafting may take place at this time utilizing an entry site in the brow.

A brow lift, also commonly called a forehead lift, rejuvenates the face above the eyes to restore a more refreshed appearance that better reflects a patient’s natural vibrancy. By removing excess sagging skin on the forehead and repositioning the underlying muscles and tissues, a brow lift can correct a heavy, sagging brow, eliminate deep furrows, and restore a smoother, more youthful contour to the upper one-third of the face. 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 brow lift surgery are numerous.  With upper eyelid surgery, the upper lids are improved, but the brow position is unchanged.  However, the brow lift improves the loose upper eyelid skin and elevates the brows to a more active.

Not every patient is a candidate for brow lift as some patients do not look natural with elevated brows. One right way to “preview” the brow and forehead lift results 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 surgeons do not offer some patients the option of brow lift. Before any upper eyelid procedure, I should discuss a brow lift.  If too much skin is removed from the upper lids, a future brow lift may be impossible as there will not be enough skin to close the eyes.

Who Need Eyebrow and Forehead Lift Surgery?

The problem with an aging forehead is its effect on our facial expressions—a sagging, heavily furrowed brow can cause us to look constantly tired, worried, or even angry. Some of us are also genetically inclined to have a more substantial, thicker brow, making us look like we are wearing a frown even when feeling our best. A brow lift directly addresses these issues, helping patients enjoy a more naturally refreshed appearance as well as other positive changes:

• Others may find you more approachable, as they no longer mistakenly perceive you as angry or concerned.
• Your eyes will appear brighter and more naturally alert
• Self-confidence can improve as you are no longer worried about looking “worried.”

 Who is a Candidate for Eyebrow and Forehead Lift Surgery?

• 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

As we age, unsightly wrinkle lines may appear on the forehead. Frown lines between the brows can make us look angry or “too serious.” Skin relaxation may cause the eyebrows to drop, hooding our upper eyelids, and making us look tired. If you are bothered by these signs of aging in the brow region, a brow lift may be right for you.

Who is not a Candidate for Eyebrow and Forehead Lif Surgery?

• Patients who look surprised or unnatural with elevated brows
• Patients who have had multiple upper lid surgeries and do not have enough skin to close the lids
• Patients with unstable hairlines (although some techniques use hidden scars)

What is the Intended Result of Eyebrow and Forehead Lift Surgery?

• More youthful eyebrow position
• Reduced appearance of brow and forehead wrinkles
• Improvement of baggy and droopy upper eyelids

What Should I Expect During a Consultation for Eyebrow and Forehead Lift Surgery?

During your brow lift consultation, be prepared to discuss:

• Your goals for your appearance
• Your complete medical history
• Your current prescription medications, including vitamins, herbal supplements, alcohol, tobacco, and drug use

Your brow lift surgeon will also:

• Evaluate your general health status and any risk factors
• Discuss your options
• Examine and measure different parts of your face
• Take photographs
• Recommend a course of treatment
• Discuss likely outcomes of brow lift surgery and any potential complications

It’s essential to understand all aspects of your arm lift procedure. It’s natural to feel some anxiety, whether excitement for your anticipated new look or a bit of preoperative stress. Don’t be shy about discussing these feelings with your cosmetic surgeon.

What are the Differences between Eyebrow and Forehead Lift and Face Lift Surgery?

It can be challenging to know which procedure you need to address the signs of aging affecting you regarding facial cosmetic surgery. Do you need a facelift or an eyelid lift if you have sagging, hollowed cheeks and eyelid bags? Will an eyelid lift or a brow lift help you the most if you have a tired, concerned appearance? While the best way to find out the most appropriate procedure or procedures for you is to discuss your concerns with an experienced, qualified cosmetic surgeon, it may help to associate each facial procedure with a particular area of aging:

• Brow Lift: improves the forehead and above the eyebrows
• Eyelid Lift: improves the orbital region around the eyes from the cheekbone to the brow bone.
• Face Lift improves the mid to lower face, from the cheekbones to the chin and jawline.
• Neck Lift improves the neck, from the chin to the collar bone.

Of course, these are general areas that each facial procedure will address; your cosmetic surgeon may employ techniques from one or more of these procedures to address your unique concerns.

Procedure Description of Eyebrow and Forehead Lift Surgery 

• The procedure is generally performed with IV or general anesthesia but can sometimes be performed with local anesthesia.
• The most common techniques use incisions hidden in the hairline.  Some surgeons use endoscopic procedures while other surgeons employ open surgical methods.  Much of this depends on factors such as patients with high hairlines or hair loss.
• Patients with brow asymmetries may experience a correction. Still, the asymmetry may be due to skull size or soft tissue differences and are harder to correct in some cases.
• The procedure may be combined with upper and lower eyelid surgery, facelift, or other cosmetic procedures.

What are the Types of  Eyebrow and Forehead Lift Surgery?

Cosmetic surgeons use different techniques for brow lift surgery, which is best for any given patient depends on a patient’s goals, unique anatomy, and the extent of corrections needed to achieve the desired results.

Endoscopic Brow Lift

Increasingly, cosmetic surgeons use the endoscopic method for brow lift surgery, which is much less invasive than previous techniques, yet can often achieve an equally desirable result. For an endoscopic brow lift, your cosmetic surgeon will make a series of very short incisions (about ¾” in length) just behind the hairline. Then, using a special tiny camera and thin instruments, he will reposition the muscles and lift the underlying tissues of the forehead, removing excess fat and tissue as needed to create a naturally more youthful brow.

Temporal or Limited Incision Brow Lift

A temporal brow lift involves slightly longer incisions than an endoscopic brow lift and is most commonly performed in conjunction with eyelid surgery. Incisions about 1 inch long are made just above each temple, behind the hairline. Through these incisions, your cosmetic surgeon will lift and reposition the tissues of the outer brow area. Then, through the incisions made for an upper eyelid procedure, the space between the eyebrows is lifted to smooth out frown lines.

Classic or Coronal Brow Lift

Once the standard technique, the coronal brow lift, has generally fallen out of fashion, well-qualified cosmetic surgeons are typically able to make needed improvements with more minor invasive procedures. However, a coronal brow lift may be necessary to achieve a patient’s desired results in some instances. This technique involves one long incision made behind the hairline, running from ear to ear. Excess skin, fat, and tissue are removed, and the remaining skin and brow muscles are repositioned into a more youthful appearance.

What Should I Expect During My Recovery after Eyebrow and Forehead Lift Surgery?

During your brow lift recovery, your forehead may be taped, and I may loosely wrap your head to minimize swelling and bruise after the procedure is completed. A thin tube may be present to drain any excess blood or fluid that may collect under the skin. You will be given specific instructions that may include:

• How to care for the surgical site and drains
• Medications to apply or take orally
• Specific concerns to look for at the surgical site or in your general health
• When to follow up with your cosmetic surgeon.

You should keep your head elevated and perform no vigorous physical activity for as long as your surgeon recommends. Do not use ice or heat on the operated area. Be sure to ask your cosmetic surgeon specific questions about what to expect during your recovery period.

• What medication will I need after surgery?
• Will I have dressings/bandages?
• When will they be removed?
• Are stitches removed? When?
• When can I resume regular activity and exercise?
• When do I return for follow-up care?

Patients typically experience very little pain after a brow lift, but it is common to feel slight discomfort and a sensation of tightness throughout the forehead. Swelling and bruising are most common during the first ten days after surgery and are mostly resolved after about two weeks. The timeline for resuming activity after a brow lift depends on the individual—if you have a brow lift alone, recovery is usually much quicker than that for a patient having a brow lift in conjunction with a facelift or other more extensive procedure. Below are typical recovery milestones following brow lift surgery:

• Day of surgery: walking around the house is encouraged.
• 1 to 2 days after surgery: showering is permitted; be gentle around your incision sites.
• One week after surgery: return to a sedentary job; some patients can return to work earlier. You may tire more quickly, so consider a limited work schedule initially. If you are concerned about visible bruising, your cosmetic surgeon can recommend options for camouflage makeup.
• 1 to 2 weeks after surgery: resume driving if you have full mobility and are no longer taking prescription pain medication.
• 2 to 4 weeks after surgery: gradually return exercise; your cosmetic surgeon will guide which activities are allowed.

What Results Should I Expect after Eyebrow and Forehead Lift Surgery?

The results of your brow lift surgery are immediately visible. Over time, post-surgical swelling will resolve, and incision lines will fade. Satisfaction with your new image should continue to grow as you recover from surgery. The results of your surgery will appear over the next few months. Although good results are expected from your procedure, there can be no guarantee. Life-long sun protection will help to maintain your rejuvenated appearance by minimizing sun damage. A healthy lifestyle will also help extend the results of your surgery. When performed by an experienced cosmetic surgeon, the improvements made with brow lift surgery will last for many years to come. However, nothing can stop the normal aging process, and eventually, your forehead tissues will begin to settle with time and gravity. You can help keep your results looking their best by living a healthy lifestyle. Wear sunscreen daily, eat a diet rich in whole foods and vitamins, and don’t smoke. This will help keep your body healthy, and your skin is looking its best.

What are the Risks of Eyebrow and Forehead Lift Surgery?

The decision to have plastic surgery is highly personal. You will have to decide if the operation will achieve your goals and if a brow lift’s risks and potential complications are acceptable. You will be asked to sign consent forms to ensure that you fully understand the procedure and any risks and possible complications.

Brow lift surgery risks include:

• Anesthesia risks
• Bleeding
• Loss of hair around the incisions
• Elevated hairline
• Eye irritation or dryness
• Facial asymmetry
• Facial nerve injury with weakness or paralysis
• Fluid accumulation
• Infection
• Numbness or other changes in skin sensation or intense itching
• Pain, which may persist
• Poor wound healing
• Possibility of revision surgery
• Skin loss
• Unfavorable scarring
• Rare risk of deep venous thrombosis (blood clots) that can result in pulmonary embolism with chest pain, shortness of breath

I will thoroughly discuss these risks and others before your consent. It would be best if you addressed all your questions directly with your cosmetic surgeon.

The periorbital region is one of the first facial regions to show signs of aging. Typically, the nasojugal crease is more evident with aging, the malar fat pad has atrophied, the temples have hollowed, and the brow and upper lid have lost volume. This volume loss is accentuated by brow lifts and blepharoplasty procedures that alter brow position and remove fat, further skeletonizing the patient.

The loss of subcutaneous fullness results in pan-facial deflation, the results of which were previously attributed solely to skin redundancy and descent. Recognition of this volume loss and its effects has changed our understanding and treatment of facial aging. Surgeons can no longer excise or reposition tissue in a singular vector and claim to have achieved a correct restoration. Prof Moawad is a pioneer in rejuvenating the periorbital region through volume restoration using autologous fat transplantation.

A conservative trans-conjunctival blepharoplasty or skin-only upper blepharoplasty combined with fat grafting can provide reliable rejuvenation and limit morbidity associated with higher volumes of fat grafting that would otherwise be necessary without concomitant excisional-based surgery.

Fat transfer to the forehead is an excellent method to lift the eyebrows. The brow is directed outward through fat augmentation and can support the overlying skin without raising the brow to an unnaturally high position.  Prof Moawad uses the “Pearl” technique with small quantities of fat tissue injected through a 1-mL Luer-lock syringe and a 20-gauge microcannula with one hole for better control. In a novel approach, platelet-rich plasma is added to micro fat were injected, giving a promising natural result.

The superior orbital rim is approached through a lateral forehead entry site. A 1.2 mm cannula is used for all upper face injections barring the upper eyelid sulcus, where 0.9 is utilized. The fat is placed over the rim in much the same way as the lower orbital rim, using non-dominant tactile feedback. Overall, 1 to 2mL is placed over the lateral edge. A midline entry site is then utilized to blend the fat into the medial rim and glabellar region, totaling 1 to 2 mL per side. When the orbital rim is grafted, the brow will have a Cro-magnon–like appearance that can be pretty disturbing. However, by adding fat to the forehead in a subcutaneous plane, this appearance will quickly disappear as the forehead deficiency is filled and the entire upper face blended into the volume restored orbital rim.

When fat is grafted to the brow, millifat is used to provide a structural change in brow projection and is grafted retrograde in tiny threads or pulses, depositing the fat in the shape of a multidimensional wedge. Hence, it blends into both the medial and superior brow. The fat graft is injected under the eyebrow and slightly biased inferiorly. If mild brow ptosis is associated with excessive upper eyelid skin lateral to the lateral canthus, fat grafting is performed to lift the lateral brow. If moderate to severe brow ptosis is present fat grafting is carried out first, followed by endoscopic or minimally invasive temporal browlift.

Upper eyelid sulcus grafting may take place at this time utilizing an entry site in the brow. During the consultation, a specific conversation about this area is advised to the patient. Many will not understand the concept of a volume-restored upper eyelid, and some may be displeased with the outcome. Comparing youthful photos of the patient is helpful to explain to them how their upper eyelids had more volume in youth, assuming they have not had a deep sulcus naturally. In our experience, however, even with an explanation, many women prefer more tarsal show than an entire lid and opt for an upper eyelid skin removal rather than volume restoration.

If volume replacement is chosen, 0.5 to 1.0 mL of fat is placed into the upper sulcus, starting in the infra brow and working inferiorly. Additional micro-fat or nano fat grafting can be performed for refinement of the subcutaneous tissue of the upper eyelid. Nano fat can also be delivered by micro-needling.