Forehead Lift (Brow Lift)

Upper Eyelid and Brow Surgery

Eyelid surgery is one of the most commonly performed cosmetic operations. It is done by a wide variety of surgeons to improve the excess skin that hangs over the upper eyelids. At Aesthetic Surgery Associates, we emphasize that the upper eyelids should never be evaluated for problems by itself. The appearance of the upper eyelid is heavily dependent on the position of the eyebrow. If you learn nothing else about the upper lids, please “take home” the fact that the upper eyelids and the brow are an integral unit. One should never be evaluated without simultaneously evaluating the other.

Q & A

Why has “excess” skin started to pile up on my upper eyelid? This is a bit more complicated than you think. Intuitively, most people think that it is due to “extra” skin that appears over the upper eyelid with age. Although this seems obvious, it is not entirely accurate. Skin does not magically appear anywhere in the body. It has to be created by forces that stretch it (such as the effect of pregnancy on the tummy), or by loss of underlying soft tissue volume (deflation as with massive weight loss that makes tummies and breasts sag). In the case of upper eyelid skin, there are several forces at work. The skin is stretched by upward movement of the eyebrows in combination with the opposing downward action of closing the upper eyelid. These opposing forces over time act to stretch the lid skin, which is some of the thinnest skin on the body. At the same time, soft tissue volume decreases with time resulting in “hollowing” of the eye socket. The combined effects of stretched skin and volume loss results in “loose” skin hanging over the upper eyelid

Is “excess” skin the only problem? Skin hanging over the upper lid is only part of the problem. A significant portion of the skin is not true excess. It is actually skin that “piles up” due to descent of the lateral eyebrow with time – a problem referred to as “brow ptosis”. You an easily demonstrate this by lifting the lateral eyebrow with your finger and watching a significant portion of the excess skin disappear. The reason that skin “hooding” is most pronounced in this area is that there is no muscle to elevate the lateral one-third of the brow. There is however, a strong muscle to elevate the middle two-thirds of the brow, and this is why wrinkles are usually very conspicuous across the middle of the forehead. In the lateral third of the brow, there is a strong muscle which pulls the brow down. It is the same muscle that causes “crow’s feet” at the outer corner of the eye. Over time, this strong muscle pulls the lateral eyebrow to a lower position where it remains and contributes to the skin overhanging the eyelid. In this situation, removing the eyelid skin alone will not adequately correct the problem.

Why not simply cut out the excess upper eyelid skin? This is commonly done and is referred to as a “blepharoplasty”. The scar is hidden in the natural fold of the upper eyelid, and the recovery period is fairly short. Ask yourself though, “if the skin disappears when I push up my eyebrows, is this really extra skin?” If eyebrow descent, or ptosis, is creating the appearance of “extra” skin, removing it will result in further descent of the eyebrow as the forehead muscles relax. Chronic contraction of the forehead muscles is present when there are transverse wrinkles across the forehead with the face at rest. This is a sign that the muscles have to pull up the brow to keep skin from weighing down the eyelids. When the skin is removed, the forehead muscles relax, resulting in a lower position for the eyebrow. This is fine for circus clowns who wish to project a sad affect, but most of us would prefer a more alert and rested appearance. In addition, when the brow descends, more skin piles up on the lid and can defeat the whole purpose of having had a blepharoplasty.

What else is done in addition to removing the excess skin? Typically, surgeons also remove fat and some muscle. Overly aggressive removal of fat can aggravate the natural hollowing of the eye socket that occurs with aging. Excess fat removal can also change the position of the eye in the socket by removing the supportive “padding” that cushions the eye and helps to maintain its position. Conservative fat removal can improve some “bulges” or “fullness” of the upper lids. Removal of muscle with the skin is typically done to further shape the final result. Muscle resection rarely, if ever, causes problems.

What are the surgical options? The most commonly performed operation is removal of the “extra” lid skin, or blepharoplasty. It is a popular procedure due to its simplicity and rapid recovery. For the reasons noted above, it also may not be the most appropriate or definitive operation. Many surgeons do not have the training or background to perform surgery to raise the brow, and so apply only the limited choices of operations is their personal armamentarium. The result can yield temporary relief of the problem, but recurrence of excess skin is common over the subsequent six months. In addition to blepahroplasty, there are several choices for raising the brow position:

1. Supra-brow lift: This operation cuts out a patch of skin above the eyebrow and leaves a scar just above it. It has a high rate of relapse, and the scar is very visible in nearly all patients who undergo the operation, even if attempts are made to hide the scar in a wrinkle. We do not recommend this operation.
2. Coronal brow lift: This operation makes an incision in the scalp from ear to ear and cuts out some of the hair-bearing scalp to pull the forehead and brow up. It typically also raises the forehead tissues up and weakens the muscles that tend to pull the brow position down. The scar is hidden in the scalp, but can spread with time and create a “part” in the hair at this location. Coronal brow lifts also create a permanent numb spot on the scalp in most patients.
3. Temporal Brow lift: Scars from this procedure are hidden in the scalp or along the hairline in the temples. It is a useful operation for raising the lateral brow, and the scars are well hidden in most patients.
4. Endoscopic Brow lift: Three to Five small incisions (2 cm) are place behind the hairline in the scalp and a special operating telescope and camera system are used to dissect down to the eyebrow to release the tissues holding it down, and weaken the muscles that pull it down. It is an excellent option for most patients, even those with thinning hair.
5. Hairline brow lift: Some patients have an extremely high forehead and lifting the brow can push the hairline back even further. To prevent backward migration of the hairline, excess forehead skin is removed by placing an incision just in front of the hairline. The scar is usually very cosmetic, but is in a visible area for some patients with thinning hair. Unfortunately, it is the only good option for those patients with high foreheads with deep wrinkles.

What are the risks of surgery? Although serious complications are very rare, the most feared complication is blindness. It is caused by bleeding within the eye socket post-operatively, and is a complication that few surgeons have seen. Another serious problem is inability to close the eyelid due to overly aggressive skin removal. The medical term for this condition is lagophthalmos. If surgery is done on both the brow and the eyelid, a mild lagophthalmos is common for the first three days following surgery. It almost always resolves quickly, and rarely creates problems. Scarring that creates complaints is very rare. If it occurs, it is due to the incision being carried too far laterally into the crow’s feet. With time, even these scars usually become inconspicuous. The most commonly voiced concern in our experience is asymmetry of the eyelids post-operatively. “Mis-matched” eyelids usually result from underlying facial asymmetries that are unmasked by the surgery. Careful study of you pre-operative photographs will enable you surgeon to point this out to you before surgery. After healing is complete, these asymmetries are usually subtle and seldom require correction.

How long does it take to recover from surgery? If only blepharoplasty is done, the majority of the recovery is complete at 7 to 10 days. Some patients have more extensive bruising which can take two weeks to completely clear, similar to a black eye. Stitches in the eyelid are usually removed in five days. When browlifts are done with the blepharoplasty, 10 days to two weeks are needed for swelling and bruising to resolve.

Is this surgery covered by insurance? Some eyelid surgery is covered by insurance if there is proof that the overhanging eyelid is interfering with vision. Evidence required by insurance companies is typically a formal visual field examination using specialized equipment in most optometrist’s or ophthalmologist’s offices. Like many insurance claims, patients may have to “jump through hoops” in order to persuade their insurer to reimburse the cost of the procedure.

To arrange a consultation, please call Aesthetic Surgery Associates at (254) 526-5106 or toll-free 1-866-232-0469