Browlift basics

In this era of smoothing forehead wrinkles with Botox and lasers, has the forehead lift, AKA brow lift or upper facelift, been relegated to the dust-bin of surgical history?

Hardly! The browlift is still an extremely useful and powerful operation for rejuvenating the forehead, the eye area, and upper face.

Why do a browlift?

Well, as musicians say, "Let's take it from the top."

Very few patients come in thinking about a browlift. Instead, they usually point out the baggy skin around their eyes. In this situation, the alert plastic surgeon has to analyze what has happened to the patient's facial anatomy, and make the correct diagnosis. We have to sort out whether the problem is caused by a low brow position, or a puffy, baggy upper eyelid with a normal brow position.

If the eyebrow position is too low ("brow ptosis"), this makes the bagginess of the upper eyelid look worse. Try this on yourself - in a mirror, push down on your eyebrow, and watch what happens to the appearance of the upper eyelid area. Now lift the eyebrow up, and see how the eyelid area looks better. Neat, eh?

People often subconsciously compensate for their drooping & falling brows - by activating their forehead musculature, trying to raise their eyebrows. But instead of doing it for a few seconds, like when we show an expression of surprise, it happens continuously. Plastic surgeons now call this "compensated brow ptosis", a term coined by Dr. Bob Flowers, who has taught extensively about forehead anatomy and surgery.

Here's the rub: if somebody with brow ptosis has an aggressive excision of upper eyelid skin with a blepharoplasty (eyelid tuck), instead of the more appropriate brow lift, the following problems can occur...
- the brow is puller lower by the eyelid skin excision,
- the patient looks more tired and angry,
- wrinkles in the forehead can actually get worse, as the patient strains even more to compensate for the low brow position,
- the future potential to have a curative browlift may be eliminated.

So, just like everything else in plastic surgery (and life!), accurate analysis of the facial anatomy is essential to planning and choosing the correct surgery.

Brow aesthetics:
Many people are worried about browlifts, because of the fear of an "overdone" look. Yes, sadly it is true, in the past, surgeons have lifted some brows more than they should have. This is an example of "more is not better".

If you over-do the lift laterally, it can create a quizzical or diabolical expression. If you over-do the lift centrally, it can look overly concerned or worried, an expression that actor Nathan Lane makes naturally!

The key to a nice result is moderation combined with an artistic sense. An attractive female eyebrow should be at, or above, the level of the bony rim of the eye socket. It should be arched nicely, with the peak of the arch near the outer one-third to one-quarter of the brow, and the outer end of the brow should be higher than the inner end.

How do we do it?

There are a number of surgical options to perform a browlift, ranging from endoscopic and short-incision methods to the classic coronal browlift. Having used all of these methods, I keep coming back to the classic coronal method. It's powerful, it lasts, and allows many options for upper facial improvement.

We'll talk more about forehead lifts in future chapters of PSB - the Plastic Surgery blog.