Gravity and changes in the shape and position of our eyebrows can contribute to an aged appearance. There are many options available for rejuvenation of the brow and forehead. The least invasive option is Botox®, which uses a medication to relax the muscles of the forehead and brow, to soften vertical and transverse wrinkles. Ultherapy®, which uses ultrasound to stimulate the deep structural layers of the skin, can provide a gentle and subtle change in the position of the eyebrows. For patients with sagging or very low eyebrows, deep creases across the forehead, and more pronounced frown lines or furrows across the top of the nose, a surgical lift of the brow may be required. In some cases, a browlift needs to be combined with an upper lid blepharoplasty, in which excess skin and fat may be removed from the upper eyelids. The goal in every case is to produce a rejuvenated, refreshed appearance.
To determine the best procedure for a patient, we always start with our standard history and physical examination. I ask a patient what his or her goals are, specifically, how much of a change is desired? I also need to know if the patient has any visual problems or any major medical problems. The physical examination allows me to assess the facial bone structure, overlying quality of the skin, brow position, and the aesthetics of the eyes and eyelids.
The traditional browlift is performed in the operating room under general anesthesia. In this procedure, a long incision is made in the scalp and the skin is undermined to allow lifting of the deeper layers of the forehead. Excess skin may be excised at the time. An elegant procedure which uses smaller incisions is the endoscopic browlift, in which visualization is achieved with the use of a long, thin tube with a light source, which is then attached to a video camera. However, because the incision is small, the amount of lifting that can be performed is limited, so it is not the optimal technique for every patient. A hybrid technique, the limited incision technique, uses incisions at the outer parts of the scalp to achieve elevation. If an upper eyelid lift is performed at the same time, the frown lines between the eyebrows can be addressed through these incisions. The goal is always to achieve a smoother forehead with the eyebrows in an aesthetically pleasing position. Over-lifting with a tell-tale “permanently surprised” look should be avoided at all costs.