Introduction

“Welcome to Plain Talk About Plastic Surgery, a podcast that educates you about plastic surgery procedures and operations with down to earth and practical information.

I’m your host, Doctor Elizabeth Kerner. I’m a plastic surgeon in Plano, Texas, and I’ve been in practice for 32 years. I’m here to tell you about the sorts of things that plastic surgeons do so that when you’re considering an operation, you have another source of information.

Today, we’re going to have a fairly brief podcast and I’m going to talk about brow lifts or forehead lift.

I realized when I was discussing blepharoplasty that there’s no way to talk about lids without talking about your forehead as well. So today we’ll delve into the anatomy and the operations that can be done to rejuvenate the aging forehead. You probably didn’t even know that there’s such a thing as an aging forehead, but there is.

Understanding the Anatomy of Your Forehead

So let’s go over the anatomy of the forehead fairly briefly.

The Frontalis Muscle and the Temporal Fusion Line

There’s one muscle that holds your eyebrows up that’s called the frontalis muscle. So if you pull your eyebrows up right now and look in the mirror and you see those transverse lines, the horizontal lines that go across your forehead, that’s the frontalis muscle wrinkling, and it goes about two thirds of the way across your frontal bone.

It ends fairly close to the arch of your eyebrow if you’re a female. That’s called the temporal fusion line, and that’s where the muscle inserts into the bone. Since the muscle does not go all the way across the forehead, it does not exert its effect on the tail of the brow or the outside part of your eyebrow, which, as you get older, is the part that hangs down and causes more fullness and bulging on your upper lid to the outer side.

The anatomy is important because this is the only muscle that pulls your eyebrows up. So if for any reason you have a weak forehead muscle, let’s say you had Botox done and they injected it all over the muscle, you’re not going to be able to pull your eyebrows up and you’re going to have a lower brow look.

You could also just have a weak muscle naturally. I see many, many patients that have an asymmetry with one brow being higher than the other.

And it’s hard to know; is half of the muscle more active and stronger and the other half weaker; is one half normal and again the other half could be stronger or weaker. But asymmetry between the two halves of your forehead, I would say, is more the norm than the exception.

The Superficial Corrugator Muscles and the Procerus Muscle

There are also three little muscles that pull the inner part of your brows down. One on either side is called the superficial corrugator; if you think about a cardboard box because it wrinkles up your forehead. And then the procerus is a little muscle that goes from the root of the nose up to the frontal bone.

So those three little muscles in the middle between the inside parts of your eyebrow hair are what give you what is now known as the “elevens”. That’s what Botox is used predominantly to treat – those little muscles and make them not work – and then it allows your frontal muscle to exert its pull, pulling up your brows unopposed.

The Orbicularis Muscle

The other muscle that pulls your eyebrows down is the circular muscle that goes around the eyelid, top and bottom. That is called the orbicularis.

This muscle has its own enervation out from the side, from one of the facial nerve branches, and this is the muscle that allows you to close your eyelids and to blink and to squint. This is a pretty important muscle because it has a big function to it, and so we can’t make it not work. But it’s also very strong, and especially out to the tail of the brow – remember to the outside part of the brow – when you squint down that’s what’s pulling the outer aspect of your brow down.

And there’s just not an enormous amount that can be done for that in terms of Botox, because if you make the muscle not work, you can’t close your eyes and that’s not going to work at all.

So we’ve touched on Botox as one treatment, and that certainly can be used judiciously to make those three little muscles between the eyebrows not work, and most people will notice that they get a small brow lift. I also put little drops of Botox across the forehead to smooth out the wrinkles but I still want the muscle to work.

Let’s say this isn’t working for you, though. You still feel like you have heavy, low brows. You look like you’re sad, you’re angry or you’re mad all the time. Then we talk about a brow lift.

The Coronal Forehead Lift and the Endoscopic Forehead Lift

In its simplest form, a brow lift is accomplished by pulling on the frontal muscle and pulling on the eyebrows to mechanically elevate them. This can be done through a standard approach, which is a coronal forehead lift.

In this operation, we make a cut either back behind the hairline, which is usually the preference, and this goes across the crown of the head, or if you have a high forehead and hair and bangs, we can make the incision right at the junction of the skin and your bangs.

You can also have an endoscopic forehead lift where smaller incisions are made to try and accomplish the same elevation.

Direct Brow Lift Considerations for Men

I’m going to talk about direct brow lift first. In men, because lots of men don’t have hair to hide the scar and don’t have bangs, there’s no way to do the standard old coronal forehead lift.

There are several options. An incision can be made just above the brow. So we mimic the shape of the brow and take what would look like kind of a bird’s wing strip of skin out right above the eyebrow. If you’re a gentleman who has a big, bushy eyebrows, this could work relatively well.

The problem is most men have a flatter eyebrow shape and to get the elevation, we tend to make it more of an arch. And so for men, the drawback to doing a direct brow excision is that you may look just a little too arched. Now, you won’t be Jack Nicholson in ‘The Shining’ weirdly arched but it’s not for most people a great place to put the scar.

A secondary approach is to do – if you have really deep horizontal forehead lines – the same thing. We can take a direct strip of skin out in the mid portion of the forehead and then create it so that the scar hides in the horizontal line.

And I think this works reasonably well; both of those in the older male whose brows are so low that he just can’t see. Because when you do an upper eyelid, I have to leave some skin on the eyelid. You don’t want to pull the eyebrow hair down into the eyelid crease. If it’s dropped there already then the only way to correct that is to pull the eyebrows up.

Some people will also go internally when they do the upper lid and try and suture the brow internally, that eyebrow portion of your skin up to the bone in the muscle. I don’t think it actually works too well, but I know it’s a favorite of lots of surgeons. I just haven’t been very impressed with the results.

Coronal Forehead Lift Surgery Steps and Considerations

Back to the coronal forehead lift. So normally, I’m going to put an incision about an inch and a half behind the hairline. We do this operation, of course, with you asleep, because it would be a little creepy to have your forehead pushed down over your eyeballs and be able to see.

So the incision is made beveling, or creating the cut on a slant, so that when everything heals back in those hair follicles will just grow right through the scar and it won’t be as noticeable.

So you make the cut and go down. Generally, we go underneath of the muscle. So there’s a plane between the muscle and the bone. It’s pretty easy to elevate or lift that muscle up off of the bone. Then when you get down towards the brow, there’s lots of little attachments there and those are opened up.

And then the three little muscles between your eyebrows are weakened and or taken out. There are negatives to completely taking them out because they do hold the inside part of the brows closer together.

So if you completely remove them, you’ll have a little flatness there and your eyebrows will be spread apart just a bit. But we always do something to them. Then we release all of that tissue along the rim above your eye.

And then mechanically that whole forehead muscle/skin is pulled upwards and the extra tissue is taken out back in the hair where it is sewn up, where we try very hard to make the scar invisible by cutting it and sewing it in such a fashion that hair follicles will grow back through the scar. That used to be the biggest problem with the brow lift: patches of hair loss called alopecia, where the scar would be visible.

The second problem with a coronal brow lift, if you think about the physical aspect of it, it is pulling the hairline up higher. So if you have a high forehead after a coronal brow lift you’re going to look like you have an even higher forehead. So a coronal incision does really well for someone who has a short forehead.

Anterior Hairline Incisions and Their Usage in Brow Lifts for Women

The other is an anterior hairline incision, where this is placed right where the skin and the hairline come together. Again, I don’t think I’ve ever done this on a male because of the risk of frontotemporal balding, which seems to afflict so many men as they get older.

But with women, if they have pretty good thick hair, not much of a family history of getting thin, and they wear bangs, this is a great approach to do and that scar hides pretty well. It’s only right along the hairline in the central part of the forehead and then it sort of swoops back into the hair in the temporal area.

Endoscopic Brow Lift

The endoscopic approach was very, very popular in the early 2000s, and I certainly embraced it heavily because it left virtually no scarring. We would make four about one inch vertical cuts: two in the temporal area, one on either side, and two in the frontal area, and go down and release all of this tissue using an endoscope, just like when you have your knee scoped.

Then to create the fixation, somebody really smart came up with a little small dissolvable plate made out of a suture material that dissolves. And we would create a very tiny hole in the skull, like a little two millimeter hole, and this plate would pop in.

And on the top of it, it had tines, so little sticky-up things like fork tines, that you could basically hook the scalp on. And that would create a point of fixation which would then later create a point of scarring and hold the brow up. So no skin was removed at all. It was just an elevation of the brow.

The problem is for some people, their muscles are so strong, especially that frontal muscle and the orbicularis, that that scar gave way and the tissue just above it sort of continued to slide off of the point of fixation with endotine.

I still use it occasionally but because I think the relapse rate is much higher I don’t suggest it as often as I did.

The Lateral Temporal Lift

The lateral temporal lift has also become quite popular, again as an attempt to minimize scarring. And this is an incision that’s put back behind the sideburns, you know, kind of running above your ear up towards the frontal part of your skull. And the same thing is done; you can release almost the whole forehead from this incision and then they’ll use another internal fixation device for that.

I haven’t seen any good long term studies on it, but again, I’m a little concerned because it doesn’t respect the contours of the eyebrow. You really don’t want to just have an eyebrow that’s pulled to the side. That looks like a flying buttress and I don’t think is very attractive.

Most eyebrows, you want to have different vectors of pull. So the inside part of the brow goes up just a little bit, and you have a little more tug on the middle part where you’re creating that arch, and then a little less tug on the outside part so that you still maintain a nice arch in a female. And in a male you really don’t want to arch the brow. You need to keep it kind of flat.

Brow Lift Surgery Recovery and Healing

So those are the options for brow lift. Like I said, I do this in the operating room. I do put you to sleep. Depending on the person and the approach, it could be an hour-ish to two hours operation. Sutures are in about seven to eleven days. There is some numbness of the forehead that takes a couple months to go away.

And some people do get some numbness in the back part of the scalp. There’s a little nerve that a surgeon in Colorado identified in the late 1990s. So we know if we stay away from that, you usually won’t get any permanent numbness but sometimes it’s really hard not to injure or cut that nerve to achieve the aesthetic result that you’re looking for. I do put a little drain in if it’s an open brow for just a day and then that comes out.

You look kind of weird for the first week because you’re sort of swollen, and then the bruising settles down around your eyes and then into your cheeks just by gravity, then is gone usually by seven to eight or nine days, something like that.

Exercising we limit for about two weeks. By three months or so your forehead muscles should be working again and that’s about your final result.

Normally, one has to overcorrect because that muscle around your eye is strong and it’s going to pull the brow down. So I normally try about a 20 percent overcorrection in hopes that the relapse rate won’t be too high.

But it’s tough. It’s tough to get the outside part of the brow up without creating, again, that kind of flying buttress look or a weird arch. You just have to expect that there’s going to be a little relapse of it.

As I said at the first, if your brows are so low that the eyebrow hair is now sitting really below the bony arch that’s called the super orbital rim, so that little rim of bone just above your eyeball. If your hair is below that for your eyebrow, it’s not really going to be possible to correct all that redundancy of the upper lid just with an upper blepharoplasty. You’re almost always going to have to do something with the brow.

Conclusion