Different Types of Browlifts

Dr. Zubowicz, at the Emory Aesthetic Center, discusses different types of browlifts.

With aging, the brow can descend over the orbital rims contributing to fullness of the upper lid area (if not being totally responsible for the fullness). In addition, expression in the forehead can create permanent creases as elasticity of the skin is lost and can no longer snap all the way back to the resting position. A family of operations has been developed to deal with these problems referred to collectively as “browlift.” The browlift is, however, not one operation but a spectrum of options available to the surgeon and patient to address specific problems of brow aging.

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What options are best for me?

Frequently Asked Questions About Browlift

Ptosis of the brow is droopiness usually a product of aging. Ptosis of the brow manifests itself as heaviness in and above the upper eyelids, folds over the lateral (outside) aspect of the eyelids, and transverse forehead creases. These creases are caused by muscular elevation of the eyebrows by the frontalis muscle to remove the heavy brow from obstructing vision.

In the brow, aging can produce persistent expression lines in the glabellar area (the space between the eyebrows). The crease or creases that are vertically oriented are caused by the function of the corrugator muscles. These two muscles originate on the skull and insert near the midpoint of each eyebrow. When they contract, the eyebrows are brought closer together. This generates an expression of anger, concern, or trouble. When the skin loses the elasticity needed to recover when the corrugator muscles have gone to rest, these expressions persist as a permanent feature. The procerus muscle arises on the nose and inserts into the skin of the forehead just above the nose. Its function is to shorten this distance and may result in transverse creases on that portion of the nose that is between the eyebrows.

The goal of a browlift, in general, is to restore the eyebrows to a suitable resting position, thus correcting the ptosis. The glabellar area should be relaxed to eliminate the furrows demonstrating anger or concern. These goals should be attained without leaving the patient with the appearance of surprise due to overcorrection.

The hairline is probably the premiere consideration when deciding what operative strategy to employ in rejuvenating the brow. The patient may aesthetically benefit from having the hairline elevated, lowered, or remain essentially the same (the most common situation). Forehead height and hairline therefore will influence the choice of browlift done. Concurrent facial surgery influences the browlift outcome, particularly aesthetic surgery of the upper eyelids. Since aging around the eyes may be contributed to by both brow ptosis and blepharochalasis (redundancy of eyelid skin and fat), the effects of one will influence those of the other. The surgeon must plan interrelated operations with care to guarantee optimal results.

Browlifts are commonly done with standard facelifts. The operations compliment one another and use a portion of the same incisions (those directly above the ear and in the scalp). Although the operations complement one another, they have separate purposes. The browlift rejuvenates from the eyebrows up while the facelift rejuvenates from the eyebrows down to the clavicles.

Browlifts, regardless of the specific approach, are operations with associated risk, morbidity, and convalescence. Obviously, it would be desirable to be able to achieve similar improvement with therapies that are less involved. This, parenthetically, applies to all areas of cosmetic surgery, not just browlifts. In special cases, treatments of lesser magnitude may produce acceptable results.

Botox is a protein that effectively poisons a muscle into which is injected. Because it is the action of muscle on skin that generates many wrinkles and furrows, eliminating the action of a given muscle may result in aesthetic improvement of the aging lines created by the activity of that muscle. Botox eliminates the function of the corrugator muscles, reducing the depth and possibly eliminating glabellar furrows. The injections are modestly painful and several treatments may be required for optimal results. The benefits are temporary lasting anywhere from 3 to 5 months. Repeat treatment is then necessary. Whether repeated treatment will result in longer lasting and maybe permanent results is not known. Long term systemic effects of Botox are still not totally defined, if indeed there are any in the first place.

Dermal fillers (collagen, Restylane, Juviderm, etc.) may be used to camouflage furrows and creases.. These products ultimately are removed by the body so re-treatment is necessary. Fillers are very safe and injected in the office. The development of longer lasting products continues.

Patients who grow weary of returning for injectables will turn to a browlift for a much longer lasting result. The vast majority of patients who seek rejuvenation of the brow have only one browlift in a lifetime.

If the incision for a coronal lift is at the hairline (centrally), the hairline can actually be lowered while the brow is elevated. In patients with abnormally high hairlines, a small incision at the interface between hairbearing and non hairbearing may be worth the improvement in the topography of the forehead and brow.

Because the incision is coronal, there will be anesthesia behind the incision. The scar, particularly when it is behind the hairline, is of little aesthetic concern since it is hidden by the hair. Hairline advancement will leave a scar at the junction between the hair bearing and non hairbearing forehead, but they are generally inconspicuous in time.

There are two basic types of browlifts: open and endoscopic. The open variety has two main subgroups based on placement of the incision: coronal and along the hairline. With an open browlift, the incision will effectively extend from the top of one ear, along the scalp to the top of the other ear.

The endoscopic browlift address the facets of brow aging through interrupted incisions which allow access to the entire brow region using fiberoptic technology. Three incisions about 1 to 2 inches in length are used for surgical access. The corrugator muscles are pulled away from the skin during the operation to eliminate or lessen the pull of these muscles on the skin. This flattens or even eliminates the furrows in the glabellar region (between the eyebrows). The procerus muscle is handled similarly to improve the transverse furrows along the bridge of the nose.

The endoscopic lift has the main advantage of decreasing anesthesia of the scalp behind the incisions. The nerves that provide sensibility to the top of the scalp arise from 4 tiny holes in the skull, just above the eye sockets, and course upwards towards the top of the scalp. A coronal incision will cut through nearly all of the small nerve branches and create longstanding anesthesia (possibly permanent) on the top of the scalp. Since the endoscopic approach leaves areas between the three required incisions intact, many of the small filaments that innervate the top of the scalp are not injured and should restore normal sensibility of the scalp shortly after surgery.

The main disadvantage of the endoscopic approach is the limited amount of lifting that can be obtained. In patients who need a sizeable amount of ptosis correction, the endoscopic technique may be unsuitable. The judgment of the surgeon and the expectations of the patient determine the utility of this approach on an individual basis. The endoscopic browlift does a poor job of eliminating transverse furrows if they are deep in the forehead. This is because the frontalis muscle is not as easily altered (the muscle that creates these furrows) and because the lifting ability of this technique is limited. The shortcomings of the endoscopic browlift in elevating the brow is reinforced by the number of ways surgeons have chosen to “fix” the brow after its upward movement. Everything from screws to dropwires have been proposed. In general, because so many techniques are proposed, it can be assumed that none works particularly well.

In summary, the endoscopic browlift is most suited for patients who have minimal brow ptosis and satisfactory hairline position or high hairline position (the endoscopic approach does not appreciably effect the resulting hairline). It works well to improve glabellar furrows and transverse creases at the top of the nose.

In patients where the hairline should be lowered, the endoscopic browlift has no role. It falls well short of the coronal browlifts when addressing deep transverse forehead creases. In patients with very heavy brows, the coronal browlift, longer incision notwithstanding, is probably a better choice.

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VINCENT N. ZUBOWICZ MD VNZ Plastic Surgery Emory University Hospital & Health Clinic 5 Star Rated Facelift and Breast Aug Makeover

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