Brow Forehead Lift

From the early to mid 1900s, forehead lifts were only performed using large incisions that extended from ear to ear over the top of the scalp (coronal incision). Over the last two decades, with the advent of new surgical tools involving endoscopic equipment, forehead lifts have become more popularized. Today, endoscopic forehead lifts are performed requiring limited scalp incision lines hidden in the hair bearing scalp as well as quicker recovery times.

Candidates for brow/forehead lift surgery should be in good general health, both physically and mentally. Often times, patients may think that they are suitable candidates for upper eyelid surgery, but instead may benefit from brow lift surgery. Brow/forehead lift surgery can reduce the drooping of the eyes resulting from redundant upper eyelid skin because correcting sagging brows will hoist up the upper eyelid skin. Additionally, brow/forehead lift surgery reduces wrinkles in the forehead and upper nose region, repositions asymmetrical eyebrows, and raises the eyebrows to a more aesthetically pleasing and youthful position. This procedure can be performed on both men and women who would like to reduce the effects of aging in the brow and forehead region, or to elevate the brows to improve vision. Two brow/forehead lift techniques which include the endoscopic vs. the direct anterior hairline brow/forehead lift are available to correct your brow position/forehead contour depending on the over all length of your forehead and position of the leading edge of your scalp.

The endoscopic forehead lift requires placing several incisions measuring 1.5cm each in the hair bearing scalp which are utilized for endoscopic tool access. Then, an endoscope (a medical instrument with a small camera connected to a monitor) and endoscopic instruments will be inserted through these incisions, which allow the surgeon to dissect the forehead tissue, elevate the brows, and smoothen unwanted muscles between the brows. This surgery allows for the repositioning of the brow and forehead to a higher and more desirable youthful position. For patients with a high preoperative hairline and/or long forehead, an anterior hairline incision forehead lift is recommended. An anterior hairline incision forehead uses an incision placed at the junction of the forehead and the front edge of the scalp which allows for not only the elevation of the brow but also the reduction of the forehead length and lowering of the scalp hairline. A special incision, termed the favorable incision, allows for the hair follicles at the front edge of the scalp to grow through the incision, making the incision nearly imperceptible. A consultation with a board certified plastic surgeon will allow you to determine which brow/forehead lift is appropriate for you.

On your initial visit, your surgeon will evaluate your health status by obtaining blood work. If you are a smoker, you should quit for 1 month prior to your brow surgery to minimize the risks prolonged incision redness and potential scalp hair loss. Patients should also avoid taking aspirin or other medications that will thin the blood which will predispose you to unnecessary bleeding. Finally, you will need to arrange for a friend or a spouse to care for any small children who may need to be lifted since you will not be allowed to undertake any physical activity for the first 4 days following surgery.

Since brow lift surgery requires general anesthesia, you must take several precautions prior to surgery. First, you will have to avoid eating and drinking after midnight on the day before surgery. This precaution ensures that your stomach is clear of digested foods that could potentially be aspirated into your lungs during induction of anesthesia. Since, you will have anesthetic medications administered throughout the case; you will remain groggy for several hours and will require a ride to and from the surgery center. You should also wear loose, comfortable clothing that buttons or zips in the front in order to avoid put clothes over your head after surgery. Make sure to choose a caretaker who is conscientious and who can spend the first two nights with you.

Patients will enjoy a more youthful and refreshed appearance that lasts for many years to come. By providing a thorough preoperative workup, safe intraoperative course, and frequent postoperative visits, patients should expect a speedy recovery. Although gravity will decrease the firmness and youthful appearance of your brow and forehead region over time, an enhanced appearance compared to pre-operative conditions is maintained for a decade or more.

A forehead lift is usually done in a surgeon office-based facility or an outpatient surgery center, and is occasionally done in the hospital. It is extremely important for patients to make sure that the office facility is accredited by a surgical accreditation body such as AAAAS.

Since brow/forehead lift surgery requires elevation of forehead and brow tissue off of the bony cranium, general anesthesia is required.

Patients will experience fatigue and soreness after surgery and will need to stay rested at home with their head kept elevated for several days. Surgical drains will be put in place to drain excess fluids and bandages will cover your incision sites. You will experience bruising and swelling that will mostly subside in 3 to 4 days and be minimized by frequent use of ice packs. Pain medication and antibiotics will be prescribed by your plastic surgeon. You will also experience numbness in the forehead area after surgery which usually turns into an itching sensation and resolves within several weeks. Permanent loss of sensation in the surgical area may occur in rare cases.

Drains and removed within 48 hours and sutures are removed 10 days after surgery. You may notice minimal swelling, discoloration and unevenness in the forehead area, but these are temporary and resolve within 3 to 4 days. It is important to avoid strenuous activity such as heavy lifting or sports for about 4 weeks. However, light work may be resumed at 2 weeks when the remaining sutures or screws are removed. Patients should minimize sun exposure and stop cigarette use during the recovery period.

Most patients can return to work within 10 days after surgery. However, each patient’s recovery is unique and longer work restrictions may apply depending on the patient’s type of work, the technique of brow lift utilized, and the degree of correction.

a) Numbness: Swelling after surgery usually results in loss of feeling in the forehead area during the first several weeks. This impairment of sensation should be temporary and last no longer than a few months. In some cases, the loss of feeling in the scalp region may be prolonged depending on the technique of brow/forehead lift technique utilized.

b) Scarring: Incisions may be lumpy and red for a few months, but they become less apparent over time and can even fade to thin white lines. Healing scars for the endoscopic technique are located behind the hairline and should not be visible. Healing scars for the anterior forehead lift are located in front of the scalp edge and are camouflaged by the direction of hair growth due to favorable incision utilized during surgery. Please note that smoking impedes the healing process and typically results in more prominent surgical scars. For patients undergoing endoscopic forehead lift, smoking may result in temporary or rarely permanent loss of hair.

c) Brow/forehead asymmetry: Brows may present residual asymmetry especially if asymmetry was prominent preoperatively. In general patients should expect significantly improved symmetry following brow/forehead lift surgery.

a) Hematoma: Hematoma refers to the accumulation of blood in the early postoperative period which pools into a pocket. Hematomas provide a perfect medium for harboring growth of bacteria. So if you have an infection anywhere in your body, the bacteria will travel through the blood stream and grow in the hematoma; this can lead to an infection as well as an open wound. In order to avoid a hematoma, drains are placed in surgery so that any fluid accumulation can be drained. Drains are usually kept in place for only 24 to 48 hours. In addition, patients are checked preoperatively to make sure that they do not have a blood clotting deficiency in an attempt to avoid this complication.

b) Seroma: Seroma formation refers to the accumulation of plasma fluid in pockets created by surgical elevation of the soft tissue and disruption of lymphatic vessels. Patients with a low blood count and poor nutrition (protein deficiency) are prone to this complication. This fluid can be a nuisance to patients requiring several aspirations in the office prior to its resolution. Drains are placed routinely in surgery and are very effective in preventing seroma formation.

c) Infection: An infection can occur but is rare following brow/forehead lift surgery. The infection will disrupt the incision line and may leave the patient with localized hair loss. Prolonged antibiotics may be required to fight the infection and to prevent further extension of the infection. Infections are usually avoided by using sterile technique, using intra-operative antibiotics, and sealing all incisions sites so that bacteria can’t get in through external contact. In addition, infections are less likely in patients who don’t smoke cigarettes or in patients who quit smoking for at least 1 month prior to surgery.

d) Pulmonary embolism: Blood clots in large veins (deep vein thrombus) may travel up to the heart and lungs and cause pulmonary embolisms (a blockage of the pulmonary artery or one of its branches). Although pulmonary embolisms are the leading cause of death after surgery, they are a rare complication of surgery.

Brow forehead lift surgery is performed to raise the eyebrows to a higher position in order to alleviate obstructed vision or reduce signs of aging. This procedure will minimize wrinkles in the forehead and upper nose region which results in a firmer, more rested and youthful appearance.

Your plastic surgeon will determine if you will benefit most from a browlift, eyelift or both by testing the movement of your forehead skin and eyelid skin independently. For example when testing the eyelid skin, your physician will fold the brows in place so that they do not affect the eyelid skin. If most of your upper eyelid skin disappears from raising your forehead skin to an appropriate level, then the drooping of your eyelids can be corrected with a brow lift alone. If most of the eyelid skin does not disappear with the forehead skin raised and/or the brows are in an appropriate position, an upper eyelid lift may be more appropriate. If raising the forehead skin removes some of the excess skin, but eyelid drooping still remains, both brow lift and upper eyelid lift may be necessary.

The appropriate position of the eyebrows is determined by evaluating the lateral 1/3rd arch peak which is observed over the lateral aspect of the brow. In females, the lateral 1/3rd peak should be positioned approximately 1cm above the superior orbital rim, the ridge of bone which is part of the eye socket and located above the eyeball; in contrast, in males the lateral 1/3rd arch peak can be located at the superior orbital rim.

Muscle tension in the forehead region causes the formation of two types of brow wrinkles. Glabellar wrinkles are vertical and are located between the eyebrows and caused by muscles called corrugator muscles. Frontalis wrinkles are horizontal and fall across the central part of the forehead and are caused by the frontalis muscle pulling up the eyebrows.

An endoscopic forehead lift will lift the anterior hairline at the front edge of the hair bearing scalp. Thus for patients who have a high hairline or who have elongated foreheads, a direct anterior hairline lift is recommended which will not only shorten the forehead but allow for dropping the hairline forward. A consultation with a board certified plastic surgeon will determine which technique is best for you.

Yes, patients often receive a brow lift and upper eyelid lift in order to alleviate both sagging brows and drooping eyelids at the same time. Your surgeon will complete a thorough and independent evaluation of both your brow position and eyelids in order to determine which procedure or if combined procedures will be the best option for you.

Although the term ‘brow lift’ suggests that the brows are always raised in this procedure; that is not the case. Brows can be elevated, lowered or kept at the same position depending on the patient’s condition and desired result. When brows are elevated however, patients usually observe a “surprised look” only for 2 weeks following surgery. This is because the brows have to be aggressively lifted to compensate for the relaxation of the frontalis muscle observed postoperatively. Once the brows are lifted to the appropriate position, the frontalis muscle which functions to lift the brows will relax and this can compromise the lift. As such, your surgeon will aggressively lift your brows to compensate for this relaxation phenomenon. You should discuss with your surgeon about the appearance your desire in order to achieve realistic and pleasing results.

The traditional coronal brow lift has been implemented for the longest period of time. It requires one long incision across the scalp and allows the surgeon to view the forehead muscles with greatest clarity. However, since the recovery period is also longer than more modern surgical techniques and it is associated with increased propensity for hair loss, it is no longer used.

Endoscopic brow lift requires 2 to 5 incisions small incisions placed over the hair bearing scalp that are less than an inch long. The forehead region is viewed by an endoscope (a device with a small camera) connected to a monitor. Your surgeon will use the other incision sites to remove or alter muscles that cause wrinkling of the forehead region. The brows can then be elevated and repositioned at a higher location on the forehead.

The direct anterior hairline forehead lift allows for an incision along the anterior front edge of the hair bearing scalp. This approach allows for shortening of the forehead length as well as dropping down the anterior front edge of the scalp. This procedure is ideal for patents with long foreheads and high hairlines.