Services-ForeheadRejuvenation of the upper one third of the face includes the forehead, brows and eyelids. Easily regarded as the most expressive facial area, our brow position and eyes can depict our mood and state of mind (figure 1). In general, the brows should be on the supraorbital rim in men and above it in women.

FocusForehead1While BOTOX® Cosmetic effectively reduces or eliminates the frown lines between the brows, it can also simultaneously elevate the medial brows by chemically weakening the four pair of depressor muscles. When strategically placed laterally, BOTOX® can raise the lateral brows and of course, it can soften the horizontal lines of the forehead and the smile lines or “crows feet” of the eyes. Remember, with continued use of BOTOX® (every 3-4 months), a longer interval between injections can be achieved and you are reducing the development of forehead lines or rhytids as you age.

FocusForehead2Depending on the age, gender and anatomical findings of the patient, our practice uses six different surgical methods to raise the brows and improve the aesthetics of the forehead and eyes (see Figure 2).

  1. The Coronal Forehead/Brow lift is the original procedure and it is considered by some to be the “Gold Standard” of forehead/brow lifting. The incision is placed entirely in the scalp 5 cm from the hairline and it goes completely across the scalp from above one ear to the other. It does raise the forehead 1-2 cm and it is an excellent choice for the woman with a short forehead or the woman with a normal forehead height who can wear her hair over the frontal hairline postoperatively. Frown and horizontal lines are permanently altered with direct muscle excision.

  2. Our Small Incision Forehead/Brow lift is for the younger patient who doesn't have many forehead or frown lines. BOTOX® is used two weeks before the procedure and three months after the procedure to weaken the brow depressor muscles while the undermined forehead fixes and heals to the underlying tissue. Two small 2 cm incisions are placed in the scalp lateral to the widow’s peak and a 4cm hidden incision is placed in the scalp of each temple. Through these incisions, the entire forehead and brow can be lifted using endoscopic instruments. This procedure can be done quickly and it heals rapidly with the shortest downtime for the patient.

  3. The Trichophytic (Hairline) Forehead/Brow lift is used frequently in women who do not want their forehead height changed. The normal distance from the superior edge of the brow at the pupil to the hairline is 5.0 to 6.5 cm and most women have a normal forehead height. An irregular beveled incision is created in the soft hairs of the frontal hairline to allow hair to grow through the final well-camouflaged scar. Frown and horizontal lines can be permanently altered with this approach, and the frontal hairline position can be maintained as discussed or raised and lowered.

  4. The Midforehead/Brow lift is used frequently in our practice for men with male-pattern baldness. Asymmetric forehead creases are chosen as the incision sites 1.5 to 2.5 cm above the brows. By suture fixation through this incision, the brows are raised to the level of the superior orbital rim. Frown muscles can be permanently altered through this approach. Sutures are placed under the incision and the resultant scar is imperceptible at 3-6 months. We have so much confidence and experience with this procedure that we use it in women with a unilateral brow droop or ptosis.

  5. The Direct Brow lift incision is placed at the superior edge of the brow and it is used only for paralytic, traumatic and malignant conditions.

  6. The Transblepharoplasty approach can be used in select male or female patients to raise the brows and remove the frown lines. The upper eyelid incisions to remove excess skin are used to expose the lateral tethering brow ligaments, the fat pad and the medial brow depressor muscles. By removing and modifying these tissues, the brow can be raised and the eyelid aesthetics improved. The horizontal lines can’t be changed with this approach and there is more swelling and discoloration than with a conventional four eyelid blepharoplasty.

All six procedures can be done as an outpatient, and they can be combined with Upper and Lower Lid Blepharoplasties and other facial plastic surgical procedures. In certain patients, it is best to delay the upper eyelid surgery for 2-3 months. By waiting for the final brow position, the precise amount of upper eyelid skin to remove can be determined, and the surgery can frequently be done in our office.