Brow Lift Dallas

What is a brow lift?

A brow lift is exactly what it means; elevating the eyebrow to obtain a youthful look. Unfortunately, in my opinion, this is one procedure that is often overdone, done incorrectly or done in circumstances where it should not have been done at all. I prefer to use the term brow reshaping as opposed to brow lift as this more correctly defines what needs to be done to achieve a natural result.

There is a very crucial and delicate balance between the eyebrows, eyelids and the lid cheek junction (the part where the lower lids merge into the cheek). Aging affects all of these and the consideration for a brow lift involves an analysis of all these factors.

Brow shape is more important than height: A slightly lower brow with appropriate shape will look attractive; conversely, a high brow with poor shape is not attractive. If an imaginary oval is drawn with the upper and lower margins of the oval at the brow and lid cheek junction respectively, in an attractive face the eye will occupy the center of the oval. With aging as the lid cheek junction gets lower, the brow needs to be raised such that the eye still occupies the center of the oval; conversely in youth, the lid cheek junction is high. Hence a brow that is normal or even lower may look ideal. In many patients a lower lid blepharoplasty elevates the lid cheek junction and hence a brow lift may not be required. Though these are simple concepts, they are not commonly taken into account. I often see patients with a good surgical result from brow lifting; unfortunately although the brow is elevated, either the brow shape is not appropriate or the brow is too high when compared to the lid cheek junction resulting in a face that is not balanced. If you are considering a brow lift, you can schedule an appointment with Dr. Solomon, a Dallas based plastic surgeon board certified in both facial plastic surgery and plastic surgery.

Important considerations

Although brows vary in shape across different people and ethnicities, in general the inner brow is lower than the outer brow. The peak of the brow occurs at the junction of its middle and outer thirds. Besides, there is a complex interplay of muscles that elevate and/or depress the brow. Due to the complexities involved, commonly the inner brow ends up higher than it should to give a surprised or puzzled appearance that is very hard to correct. I add several modifications to the standard endoscopic brow lift technique to prevent the inner brow from elevating to a high position.

Most brow lift techniques elevate the hairline. Although there are techniques to lower the hairline, the scars for this procedure are at the hairline as opposed to behind the hairline for a typical brow lift.

Certain brow lift techniques (coronal lift) can cause areas of numbness or decreased sensation over the scalp that can be permanent.

Although certain muscles can be modified during a brow lift to decrease rhytids (wrinkles) between the brows, this procedure will not significantly address forehead rhytids in the long term. Botox may be required if this is a consideration.

Types of brow lift

Coronal brow lift: The procedure involves an incision in the scalp from the top of the ear to a similar location on the other side within the hairline. This was the gold standard brow lift procedure but has now mostly been replaced by endoscopic brow lift. Drawbacks include long scars, potential for hair loss along the incision and sensory changes over the scalp that can be permanent. For these reasons, I rarely employ this technique in my practice.

Endoscopic brow lift: Four or five small incisions are made in the scalp, 2 to 3 centimeters in length and the forehead skin is released from the underlying bone down to the brow. The brow is then completely released, elevated and anchored in place using one of many fixation techniques. Although hair loss is possible along the incisions, since the incisions are small, it is typically well concealed. Besides, I bevel the incision parallel to hair follicles and close the incision meticulously with sutures. Scalp sensation changes are possible but are usually temporary. The longevity of an endoscopic brow lift is a much debated topic among plastic surgeons. When well done, I feel that the results are comparable to a coronal brow lift in most patients.

Hairline brow lift: The incision instead of being placed in the scalp behind the hairline, is placed at the hairline. It is used for patients with a high hairline that needs to be lowered.

Direct brow lift: In older patients especially men with coarse skin and extensive rhytids (creases) over the forehead, the incision can be placed at the upper margin of the brow or in a horizontal forehead crease.

Fat injection: Loss of fat beneath the brow with age causes deflation and descent. In appropriate patients, fat injection gives the illusion of a high brow as it fills the area and replaces the lost fat. This is a good technique for selected younger patients with minimal brow descent. Two small needle puncture incisions are all that is required for this technique.

Who is a good candidate?

The ideal candidate has a brow shape that is suboptimal or descent of brows from aging. In individuals in the sixth to eighth decades, the descent can be so dramatic that it obscures vision over the outer part of the visual field.

It is important to realize that lower placed brows by themselves, are not necessarily a sign of aging. There are several famous models that are young and attractive with a lower brow position. As mentioned earlier, several other factors including the eyelid shape and structure and location of the lid cheek junction need to be taken into consideration before attempting a brow lift. Not taking these factors into consideration when planning a brow lift causes inappropriately elevated brows with a persistent surprised or puzzled look.

Post-operative recovery

There is typically bruising around the eyes that can last for a few weeks, although by two weeks most patient can cover the resolving bruises with make up. A headache lasting 24 to 48 hours after the procedure is not uncommon. Occasionally there can be some sensation changes over the scalp that return to normal in several weeks. I use a very small drain after an endoscopic brow lift and remove it in 24 to 48 hours. Sutures are removed at one week. Overnight stay is not required for an endoscopic brow lift, even when it is combined with eyelid lifts.

Dr. Solomon’s approach

I prefer the endoscopic brow lift technique in most patients as the scars are small and the complication profile is much lower. Hair loss that can commonly occur around scalp incisions is secondary to hair follicle damage when making the incision. Often the incision is made straight down through the scalp; hairs exit the scalp at an angle and this angle varies in different parts of the scalp. Hence a vertical incision through the scalp damages follicles; instead an incision going parallel/beveled in the direction of the hair follicles leaves the follicles intact. This technique when combined with meticulous closure of the incision with sutures as opposed to staples (many surgeons use staples to close scalp incisions) preserves hair follicles and gives a very fine and imperceptible scar with hair growing through the scar. I also modify the traditional technique such that the inner brow is not raised too much; an overly raised inner brow is a telltale sign of a surgical lift and does not look natural.

Above all, my priority with brow lifts is to preserve the normal aesthetic relationship between the brows, eyelids and lid cheek junction with the priority being brow reshaping; although there is a lift to the brow, this is a secondary component and is in balance to the rest of the face.

Questions to ask before a brow lift

  1. Is my hairline low, normal or high? How will it change after the brow lift? As discussed, only a hairline incision, which is harder to conceal will prevent elevation.
  2. What do you do to prevent my inner brow from lifting up too high?
  3. What method do you use to fix the brow in position? Although there are several methods, none has been proven to be the best. Some techniques incur an additional cost due to need for special implantable devices.
  4. If the plan is to undergo a coronal brow lift, is it because the surgeon only does this type of lift or is there a special indication? As discussed coronal lifts will cause areas of scalp numbness and have the potential for large areas of hair loss along the incisions.