The Sagging Brow

Do friends sometimes think you’re angry, or tell you to smile? There is a cure for that furrowed brow that some of us develop with age: it’s called a brow lift. “Many people, when they hear ‘brow lift,’ think of an overdone, startled look, so I call it ‘brow shaping,’ ” says Dr. Michael Nayak of Nayak Plastic Surgery. Brow lifts are done to raise the brow, not to get rid of crows’ feet or the creases between the eyebrows, he explains. It can help those lines, because during the procedure the muscles that cause them are removed, but they’re not the main target. If, when you raise your brow manually, excess skin above the eyes disappears, only a brow lift is needed.

    Some people, however, still have excess skin on the upper lids after the lift, and still others have a brow in the correct position, but need the eyelids done. The aim is to have a nice-looking brow and eye complex that looks youthful and rested. The surprised look people fear from a brow lift results when the inner part of the brow is incorrectly raised higher than the outer edges, Nayak explains.

    There are several different approaches to brow lifts, depending on the hairline and head shape of the individual, he says. “People with a short forehead or low hairline usually need an endoscopic lift with several very short incisions,” Nayak says. “Bald men do well with the endoscopic lift because the tiny incisions aren’t noticeable. People with a high, rounded forehead generally already wear bangs to camouflage the height. For them, I would probably favor an open incision right at the hairline. When it’s done well, the hair grows back through the incision and it can shorten the forehead to bring the face into better balance.”

    The other type of brow lift he sometimes does, particularly for older people with droopiness at the outsides of the brow that may impact their vision, is the direct brow lift, which requires an incision over the outside half of each eyebrow. Older, thinner skin heals well, and the procedure is often covered by insurance.

        Dr. Marissa Tenenbaum of West County Plastic Surgeons of Washington University says people don’t often consider a brow lift when their eyelids droop because they have gotten into the habit of raising their brow to compensate. “When they come in, I lay my hand on their brow to get it to relax and see where the brow sits without that raising,” she says. “If it droops below the superorbital ridge, it needs lifting.”  Often, a patient will need both a forehead lift and some upper eyelid work, Tenenbaum notes, but she is very careful not to overlift the brow.

    She also reports using Botox to give a chemical lift by arresting the muscles at the outsides of the brow that pull it down, allowing the lifting muscles to do their job, and between the eyebrows for the vertical wrinkles.

    Dr. Samer Cabbabe of Cabbabe Plastic Surgery says three types of brow lifts are popular today. The conventional ‘open brow lift’ is one incision across the top of the forehead along the hairline. Through it, the muscle can be tightened and excess skin removed. Cabbabe says this method is the one most likely to cause scalp numbness.

    The brow lift he prefers is the endoscopic lift. “I use three small incisions through which I lift the skin and tissue off the forehead bone and weaken the muscles that depress the brow so the muscles that lift can work unopposed,” Cabbabe explains. “People do not look surprised.” He also does small brow lifts at the temples for women who have droop only at the outsides of their brow.

    Cabbabe says some surgeons put hooks and internal fixation screws under the tissue to anchor it, but he calls that unnecessary if the lift is done right. And the hardware can erode through, causing pain and tenderness, he adds. Many who need upper eyelid surgery also will need a brow lift, he maintains. “I’ve seen people who have had their upper eyelids done but the brow wasn’t addressed,” he says. “And because they had extra eyelid skin, they raised their eyebrows to keep their eyes open. But once that skin was removed with surgery, they relaxed the brow and it drooped.”

     The entire face must be treated as a unit, Cabbabe says. “When I treat faces, I look at the brow, face and neck,” he says. “If people come in for a face lift, there’s a good chance they need the brow lifted as well. If they want a neck lift, the neck can be nice and tight, but the rest of the face still droops. It has to be a total concept.”