As one ages, there are numerous changes that occur around the eye area. Excess skin and wrinkles are the most commonly recognized but sagging of the brows can also occur. Sometimes the amount of excess skin on the upper eyelids is made worse by low hanging brows. This is why in some cases of periorbital rejuvenation a browlift is performed with upper and lower blepharoplasties.

Despite the many different types of browlift surgery, they all rely on lifting the brow from a superior point at or in the hairline. Unlike a facelift where the greatest benefit comes from moving tissues closer to the point of pull, a browlift attempts to correct a structure at the furtherest point from its lifting position. This can result in unpredictable changes in the position or shape of the eyebrow.

Eyebrow lift procedures are well known to result in undesireable brow changes. Everyone recognizes the ‘deer in the headlights’ results where the eyebrows have been pulled too high. This can make one look older and give the upper lids a hollowed out appearance. Shape issues can also occur with the arc of the eyebrow becoming flat or even having a reverse arc to it. (the tail of the eyebrow should be lifted more than the central or inner aspect of the eyebrow in women) Because the inner part of the eyebrow is easier to lift than the outer part, it is not uncommon to have an undesired brow appearance.

Another problem in browlift surgery is that it is often done when it is not needed. It is one of the few anti-aging facial procedures that is probably the most overused, done in patients in which they did not have any significant brow sagging prior to surgery.

The goal of browlift surgery should be to produce a more pleasing shape not just upward elevation. While browlift shapes have changed over the years, the most pleasing shape has been shown to be an outward arc with the tail of the brow being higher than the rest with a slightly off-center peak above the outer edge of the iris. For many patients it is the tail of the eyebrow that is down while the rest of eyebrow position and shape is just fine.

Postoperative browlift problems fall into two main categories. The first and the most common is a browlift surgery that produces little if any improvement. This is either the result of inadequate mobilization or elevation of the brow tissues or inadequate or unstable fixation of the elevated tissues. Regardless of the reason why, most patients do not really want to go through another procedure. If they do, a different browlift method should be chosen. Failure of adequate elevation is usually seen in the tail of the eyebrow as it is harder to elevate and lacks a solid bony anchorage point like the other 2/3s of the brow.

The second category is that of an undesireable brow shape. It is almost always because one portion of the brow is elevated too high. This is most common with too much inner brow elevation. Time will likely help the brow drop somewhat and this can also be aided or accelerated with Botox injections to the frontalis muscle above it. This can help push the brow down somewhat and with time it may become a self-solving problem. If the brow remains too high, a secondary subperiosteal release with tacking the brow down in a lower position can usually make an adequate correction.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

By the mid- to late 1990s, the impact of the less-invasive laparoscopic approaches to general surgery (particularly that of gall bladder removal) had reached plastic surgery. A wave of endoscopic (laparoscopic approaches infuse a lot of air to make the cavity, endoscopic just uses a camera without the extra air) approaches to a variety of facial (mainly) and other breast and abdominal procedures in plastic surgery had been caught up in adopting this technologic approach. The biggest benefit to any endoscopic approach is the simple fact of having less of an incision to do the surgery, which in plastic surgery is a big deal. By the time the dust settled from this enthusiastic push years later, the one plastic surgery procedure that has really benefited is the browlift. The endoscopic browlift is the one procedure that has stood the test of time and remains as one of the few remnants of the attempts at endoscopic adoption in plastic surgery.

 
It is easy to understand why the endoscopic approach to browlifting has stuck. The traditional open approaches, while tremendously effective, require an incision across the top of the head either way back in the hairline or at the hairline. That is a scary thought for some patients and some patients simply are not good candidates for that approach given the style and thickness of their hair density. Also, the endoscopic approach is not anatomically complex, you are sliding instruments and a camera done along the front part of the bony forehead. There is little in the way and it is hard to get lost and end up in the wrong place.

 
The endoscopic browlift, however, is not a perfect operation. It is not as effective at removing muscle between the eyebrows and up underneath the forehead skin as an open approach can do. And it can not lift the brow as well as open approaches where more aggressive brow release and actual skin removal is done. But for some patients, particularly younger women who do not have a lot of brow sagging and deep forehead wrinkles, the endoscopic approach is a nice option where the ‘solution matches the problem’.

 
There is one other consideration about endoscopic browlifting that receives little attention. The endoscopic browlift really works by what is known as an ‘epicranial shift’. This is a fancy term meaning the brow is lifted because the whole forehead and scalp is loosened and moves backward. This means the frontal hairline will move back as much, if not more, than the brows themselves with the lift. For those women with an already long forehead and high hairline, this may be too much of a hair-raising experience.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

As we age not only does extra skin and fat weight down our eyelids, but the overlying brows can often contribute to the problem. As the eyebrows fall below the bony rim of the forehead, ‘extra’ skin is created and the upper eyelids get heavier. Both the eyelids and the brow areas narrow the size of the eye making it look older and more tired. While many patients have eyelid surgery for improvement, some may benefit by a combination of eyelid and browlift surgery to create an overall better result.

 
In understanding browlift surgery, one has to appreciate not only the position of the eyebrow but the existing length of forehead skin (from hairline to brow) and the patient’s hairline pattern and density. These are key elements that help determine which type of browlift may be best for each individual patient.

Fundamentally, there are really two main types of browlifts…open and closed. Closed or endoscopic browlifts are done from back in the scalp and uses two or four small incisions behind the hairline. Cameras are used under the skin to release the brow from underneath and entire scalp/forehead/brow unit is then shifted up and back. In the endoscopic browlift, the forehead usually gets longer and the frontal hairline moves back a bit. Also, if there is a lot of muscle action between the eyebrows, the endoscopic approach is more limited in how much can be removed. As a result, the endoscopic browlift in my hands is very good for those patients that have a short or average forehead length, do not have too much muscle action and deep forehead wrinkles, and whose brow only needs to be lifted a little. Open browlifts are done with an incision and resultant scar either at the frontal hairline or several inches behind it. When the open browlift is done with the scar back in the scalp, the patient with a high forehead has the same problem as the endoscopic browlift. When the incision is placed at the frontal hairline, this is a better choice as the hairline stays put or can even be moved forward or lower. Either scalp or hairline browlifts are better at removing overactive muscle as more muscle can be removed with wide open access under direct vision. (you can remove more when you can see it better)

 
While some browlifts are done alone, this is unusual as extra eyelid is often present if the brows are low in many patients. Conversely, it is much more common to have eyelid surgery (blepharoplasty) without browlifting. The combination of eyelid tucks and browlifting can make a dramatic difference in how one’s eyes look and the overall facial appearance and impression that it creates. The aesthetic key to browlifting is to not overdo it. No patient wants to have a ‘deer in the headlights’ look. For these reasons, it is important to carefully review beforehand with your plastic surgeon in front of a mirror what amount of browlifting you consider acceptabel and whether it adds enough to the results to justify the effort.

Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis