For most of us, the first sign of facial aging occurs around the eyes. (Droopy jowls come later, thank goodness!) So we seek out a plastic surgeon for an eye lift, or blepharoplasty, and are surprised when we’re told that the real problem is a sagging forehead (brow). Dr. Mark Checcone of Facial Plastic Surgery Center at Washington University says his patients complain of excess eyelid skin or that they are frequently told they look tired or angry. “I take the time to educate them about how lifting the brow can open up the eye area, improve the contour of the brow, and reduce excess upper eyelid skin. When I manually lift the brow, they can see the effect.”

    Over time, gravity pulls on our brow and it lowers. Many of us, he says, help that process along by excessive squinting because we don’t wear sunglasses like we should. Being diligent in protecting our eyes from the sun not only will prevent premature brow droop, but those crows’ feet we love to hate. “We have competing muscle groups on our forehead; some pull the brow down, as when we squint or frown, and others lift it. For early brow sag, Botox can be very helpful in depressing the muscles that pull the brow down, enabling the lifting muscles to do their job. When that’s not enough, we have brow lifts.”

    Dr. Michael Nayak of Nayak Plastic Surgery says he can almost tell a candidate for a brow lift over the phone. “These people typically say they are repeatedly asked if they are tired, or told that they should smile more,” he says. “A low, straight brow is menacing and masculinizing. Women’s brows normally go up on the outsides. I have stopped calling brow lifts by that name because people associate the term with an ‘overdone’ or funny shape. I call them temple lifts. People say they have never seen a brow lift that looks good. That’s because if you can tell it’s a brow lift, it is by definition bad. A good brow lift makes you look rested and approachable.”

        Different types of lifts have different functions. Some can make the forehead higher or narrower. Placing them right at the hairline can shorten the forehead in people who always have to wear bangs, bringing facial features more into balance. For people with short foreheads, a longer incision can open the forehead and make their features seem more balanced. When facial proportions are already good, an endoscopic lift with small incisions back in the hair doesn’t lengthen or shorten.

    “The largest part of selecting the right surgery is defining what exactly is to happen and the goals of the procedure,” Nayak says. “The actual surgery is a small part of it. We have to balance forehead height, curve, where to place the incisions, and what to do about forehead wrinkles. In a person’s 30s, a brow lift can eliminate the need for upper eyelid surgery completely. After 40 or so, they may need a little of each: lifting the brow and taking a little excess skin off the upper eyelid.” He warns that if he fixes only the eyelids, it can make the brow look even lower.

    The good news, says plastic surgeon Dr. Paul Rottler, is that brow lifts last longer than most other lifts, because the brow skin is not as heavy or bulky as that in other areas. He says the ‘coronal lift,’ with its longer incision, gives the best results in all directions and lasts the longest. He also emphasizes focusing on the goals for the procedure. “If a patient has a face lift, but we don’t do the brow, it may be half the solution. We need to address what needs the most improvement, and prioritize any procedures,” Rottler notes.

    Another thing he does to maximize results is inject Botox around the crows’ feet a week before the surgery. “All facial muscles work in concert,” Rottler explains. “You have brow depressor muscles and elevator muscles. Every time you blink, the depressor muscles pull down. By relaxing those muscles ahead of the surgery, they won’t be pulling down on the brow while it’s healing in a higher position.”

    Rottler also cautions against forgetting about skin quality. He says a good skin care program helps maintain surgical results longer and gives a more youthful, finished look to the process. Having a relationship with a good aesthetician who can match products to your individual skin needs is important, along with using general products such as sunblock, retin-A and vitamin C, which are good for most aging skin.