Overview of Mid Forehead Brow Lift
Brow Ptosis, or droopy eyebrows, is a condition that doesn’t have a specific numerical measurement for diagnosis. It largely depends on the doctor’s judgment and experience to determine if the condition exists. Some people might have a lower brow placement that might seem abnormal to one person but is completely natural for another. But, if the drooping brow affects the person’s appearance or function, then it’s seen as brow ptosis.
Our eyebrows are continually moving and can be impacted by various factors like age, exposure to the sun, facial expressions, injuries, and gravity. So, over time, everyone will experience some level of drooping brow. The “ideal” position of the eyebrow can vary greatly between different genders, ethnicities, ages, and even generations. In some cultures, changing the eyebrow’s position or shape is seen as undesirable. But, in many Western cultures, it’s common.
Certain guidelines describe the ideal position of the brow. For women, it’s generally above the bony rim around the eye, arching upwards. For men, the eyebrows usually sit at or just above this rim, with a flatter shape. Factors like age, culture, jobs, and environmental influences can affect not just the position and shape of the brow but also what people perceive as appealing. A farmer, for instance, might have a lower-positioned brow that protects from sunlight, dust, and wind. A model might need higher brows to look more youthful or attractive, regardless of their gender. Changes in brow shape can even subtly signal certain emotions, like fatigue for flat or low brows and surprise for overly-raised brows.
The common causes of droopy eyebrows can be aging, facial paralysis, injury, and tumors. It can affect the person’s appearance, cause an obstructed vision, uneven eyebrow position, and irritation due to drooping eyelashes. Brow ptosis usually develops slowly over time due to natural causes like aging, without any trauma or disease. It’s normal for most people above the age of 40, both men and women, to have some degree of it, but not everyone will need surgical correction.
Several surgical treatments can correct brow ptosis, including a direct brow lift, mid-forehead brow lift, pretrichial brow lift, temporal brow lift, coronal brow lift, endoscopic brow lift, and internal brow lift. This piece will primarily focus on discussing the process and planning of brow lifts, particularly the mid-forehead lift.
The history of brow lift surgery goes back to the early 20th century when the first forehead lift was reported. However, these early techniques had limited results. The field saw significant advancement in the mid-1970s when surgeons started manipulating muscles to reduce wrinkles and stretch the skin. Since then, several methods have been developed and refined, and now the coronal brow lift is a well-established procedure for lifting brows.
Anatomy and Physiology of Mid Forehead Brow Lift
If you’re having surgery near your eyebrows, the doctor needs to understand quite a few things about the surface of your brow, like its position and shape. For example, men’s brows tend to be straighter, while women’s brows are more curved. This curve is usually most pronounced between the side of your eye and the outer corner of your eye. The inner part of the brow in both men and women is ideally about 1 cm above a bony ridge in the eye socket. Over time, this part of the brow tends to drop lower in men than in women.
The scalp and forehead area is made up of five layers:
- The skin,
- A fatty layer under the skin,
- A tough, fibrous layer called the galea aponeurotica, which is connected to the muscles at the back and front of your head,
- Loose tissue that lies between the bony layer under the skin and the above fibrous/muscular layer,
- The bony layer under the skin, known as the periosteum.
Our eyebrow-forehead complex is made up of several major muscles, all controlled by the facial nerve:
- Occipitofrontalis – This muscle runs along the top of your head, from the forehead to the back of your head. It has two parts—the frontalis in the front (forehead), and the occipitalis at the back. A tough, fibrous tissue associates them.
- Orbicularis Oculi – This muscle circles your eye and has parts that help close the eyelids. The part that runs along the eye socket can also pull down the eyebrows, forehead, and sides of your face. Injecting a substance called botulinum toxin can weaken this muscle which can help lift the brow.
- Corrugator Supercilii – These muscles are just under your eyebrows and are the muscles you use to frown. They are important to consider when botox is being given for cosmetic reasons or when planning certain surgical procedures.
- Procerus Muscle – This muscle starts from your nasal bones and draws down the inner part of your eyebrows, which can cause horizontal wrinkles above your nose.
Beneath the muscles around your eyebrows and eye, there is a fatty layer of tissue often called the brow fat pad or the retro-orbicularis oculi fat pad. This fat is what gives younger people a full appearance to their eyebrows. As we age, this fat tends to get lesser, making the eyebrows look boney.
The muscles in your forehead, brows and around your eyes work because they are supplied by the facial nerve, which leaves the skull near your ear. This facial nerve branches out to different areas, one of which is the frontal or temporal branch. This branch supplies muscles in and around the eye including the frontalis muscle and the corrugator supercilii muscles. The exact pathway of the nerve can vary between different people.
Why do People Need Mid Forehead Brow Lift
Brow lifting is a procedure that can help people who have droopy eyebrows, which can limit their field of vision and cause excess skin on the upper eye area. If the outer part of the brow droops, it can lead to heavy appearing eyelids and sagging eyelashes. In terms of appearance, your eyebrows can say a lot about your mood. So altering the shape or curve of the brows through a lift can make a face look less tired or less angry. People with facial nerve damage can experience a severe droop in their eyebrows which can obstruct their vision. Some people may have previously had surgery on their upper eyelids to treat droopiness (known as ‘ptosis’), but they still have droopy eyebrows. This could have caused or worsened drooping eyelids.
Although it’s not performed often, a mid-forehead brow lift has advantages. This procedure is particularly beneficial for men with deep forehead lines. Surgeons can make incisions along these lines, much nearer to the brows compared to other techniques. This gives greater control during the lift process. In some cases, this process can even lower a high hairline. People with high hairlines or who are bald may not be able to undergo other types of brow lifts, because of potential visible scarring. Instead, they might prefer a scar that is tucked away in a forehead crease, rather than scars above the eyebrows. While some people, especially men, may not mind a crosswise scar on the forehead provided it’s well concealed, it can be challenging to avoid scar widening or visible suture marks after the operation. Therefore, having a plan in place for aftercare and scar management can certainly help reassure the patient before surgery.
When a Person Should Avoid Mid Forehead Brow Lift
A mid-forehead brow lift is a surgery where a cut is made in the middle of your forehead to lift your brows. However, even when done most carefully, a visible scar can be left behind. If you wouldn’t be okay with having visible scars, you should consider other options.
There are certain situations where this surgery might not be recommended:
Absolutely not recommended:
- If your forehead is smooth without lines (furrows), even the smallest scars from the surgery can be visible.
- If you absolutely don’t want to have a visible scar on your forehead.
May not be recommended:
- If your hairline is low, this surgery may not be advised.
- If you’re a woman. There are usually better ways to lift the forehead and brows, like less invasive surgeries (endoscopic or pretrichial approaches).
- If you’re a young male and have a smooth forehead without horizontal lines (rhytides), this might not be the best option.
- If there are other surgeries available that are just as likely to give you the results you want, but with less scarring.
- If you have facial paralysis, since your eyebrows might not be symmetrical. In these cases, a brow lift that directly pulls on the brows (direct brow lifting or suture suspension techniques) may be more effective because they can better balance the two sides.
Equipment used for Mid Forehead Brow Lift
If you are getting a brow lift on your mid-forehead, these are the things your doctor may use:
* A skin marker, which is like the marker you use to write but safe to use on skin
* A type of local anesthetic, which is the medicine that numbs a specific part of your body. In this case, it’s 1% lidocaine with 1:100,000 epinephrine – this helps you to not feel pain during the procedure
* A handle and blade (#3 and #15 respectively) for a Bard-Parker scalpel, which is a small, sharp tool that can cut skin
* Tissue forceps, such as Adson-Brown for holding tissues. It’s like a tweezer but for surgery
* Skin hooks, like the Joseph or Senn rakes, which help to pull back your skin so the doctor can see clearly
* Dissecting scissors, like Kaye blepharoplasty scissors, for cutting tissue
* Suture scissors, like iris scissors, for cutting stitches
* A needle holder, such as Halsey and/or Castroviejo, used for holding the needle when sewing the tissues together
* Electrocautery, which uses electrical power to heat the body tissue to stop bleeding or to cut through tissue
* Both absorbable and non-absorbable stitch thread (5-0 and 6-0 sizes) – absorbable ones disappear over time as your body heals, while non-absorbable ones may need to be removed by the doctor later
Who is needed to perform Mid Forehead Brow Lift?
A mid-forehead brow lift is a type of procedure that can be performed under local anesthesia (which numbs a small part of the body) or general anesthesia (which puts you to sleep). General anesthesia is most often used if the doctor is going to do other procedures at the same time. These might include four lid blepharoplasty (surgery to repair droopy eyelids), ablative LASER resurfacing (a procedure that uses a laser beam to reduce skin irregularities), or rhytidectomy (also known as a facelift).
In addition to the surgeon (a highly trained doctor who performs operations), a nurse will be there to keep you comfortable and help the surgeon. A surgical technologist, who ensures all the necessary equipment is ready and working, is also present in the room. An anesthesia provider, who is in charge of administering anesthesia, and a surgical first assistant (a trained professional who assists the surgeon) are often available in the operating room as well. All these professionals work together to ensure the procedure goes smoothly.
Preparing for Mid Forehead Brow Lift
For a brow lifting procedure, you and your doctor will have a detailed talk about the entire process before the surgery begins. Firstly, it’s important for your doctor to know how long you’ve been having the issues and what’s concerning you the most. They will also try to understand your emotional wellbeing, as people who are likely to feel unhappy or angry after the surgery are usually not recommended for this procedure. Your doctor will also communicate with you about what the surgery can do, what you can expect, and any possible risks.
During the consultation, you’ll be sitting upright so your doctor can see your brow height and shape. If you have any old pictures of yourself that you like, you can bring them in. They can help your doctor understand what you want to achieve with the surgery. However, it’s important to have realistic expectations. Your doctor won’t push their aesthetic preferences on you but will provide advice based on their experience. To better understand your preferences, your doctor might lift your brow in different ways while you hold a mirror, showing you how the changes can reduce wrinkles and excess skin on your upper eyelids.
Different surgical techniques leave different marks and have different pros and cons. Your doctor will explain all of this to you. Looking at before and after pictures of other patients might help you anticipate what can be achieved with the surgery- it can also encourage you to ask questions based on what you see. You’ll also likely see pictures of surgical scarring. Pictures will be taken of you as well; these will help with planning the surgery and can be used after the operation to help answer any questions you may have.
Some things that your doctor will explain in detail are:
– That the brows won’t be perfectly symmetrical as no one has perfectly symmetrical brows.
– That the brow might lower a bit after a few weeks following the surgery.
– The goal is to give you a natural-looking brow height and shape.
– Numbness in the area is normal, and can take weeks or sometimes months to reduce.
– Over time and with age, the brows will droop again.
– The biggest risk is one being unhappy with the result. Other risks include pain, bleeding, numbness, scarring, infection, and sometimes, the need for another surgery.
For reference, your photos will be taken from different angles including: front, 45 degrees right and left, and 90 degrees right and left. Close-up photos will also be taken of both eyes, forehead, brows, and upper and lower eyelids.
Before the surgery, avoid things that can cause significant bruising like aspirin, most vitamins, and herbal supplements. However, Arnica montana, a plant, might help reduce any bruising. Please remember to remove all makeup the night before the operation and come in clean-faced. You should also cleanse your skin before the surgery to ensure the removal of all makeup products.
Your doctor should have more than one meeting with you where they can understand your needs and concerns better. Through these meetings, your doctor can also figure out if you’re a good candidate for this surgery. And remember, both you and your doctor need to agree to move forward with the procedure, and either one can cancel it at any time before the anesthesia is administered.
How is Mid Forehead Brow Lift performed
This is a summary of the process of a procedure called a “forehead lift.” The steps have been simplified to make them easier to understand for those without a medical background.
First of all, the surgeon makes a decision on where to incise (make a cut) the forehead based on the person’s natural brow lines and forehead wrinkles. They will choose whether to make one long cut across the forehead or separate cuts on each side. When the cut doesn’t go across the whole forehead, the two cuts will be set off from each other to avoid making a long, noticeable scar.
Next, the area is prepped with anesthetic. This includes injections at the brow, under the forehead, and around the nose, as well as along the cut. Cold compresses are used to minimize bruising and swelling. There is a 10-15 minute waiting period before the procedure begins to ensure that the anesthesia has taken effect.
The surgeon then makes the incisions using a special type of knife called a blade. It’s crucial that the incisions on the sides of the forehead are only skin-deep.
Then comes the dissection, where the surgeon lifts on your skin, making a path to the surface of your skull. Throughout this process, they’re careful not to harm the muscle that’s involved in raising your eyebrows. Further incisions are made into the muscles around the brow to relax this area. The amount the muscles are weakened depends on the condition of the patient before the surgery.
In some cases, to both fill potential hollows and smooth forehead wrinkles, the surgeon will move fat from the eyelids or elsewhere in the face to the area where muscles were removed. The skin above the forehead incision is loosely disconnected to make the closure of the wound easier at the end.
The surgeon then pulls the skin under the incision up until the eyebrow is a bit higher than its ideal position, as this overcorrection makes room for the brow to naturally settle a bit after surgery. After the brow is in position, the excess skin is trimmed off.
The wound is then sewn up and carefully treated to minimize the chances of any infections. A bandage is applied, which is carefully wrapped so it doesn’t put any pressure on the brows.
After the procedure, the bandages are removed the next day and any stitches or skin glue are removed after seven days. You can expect your brows to be higher than their final position for the first few weeks, but they will settle about 25% from the initial position.
The surgeon will follow up and monitor your progress regularly for up to a year after the surgery, typically at two months and six months post-surgery.
Possible Complications of Mid Forehead Brow Lift
During a surgery that involves lifting your eyebrows, such as a brow lift, usually the forehead region heals relatively fast as it has good blood supply. However, because of this, the surgery could involve a little more bleeding than usual. If after the surgery a hematoma – a pocket of blood – forms, it needs to be drained quickly. This helps to prevent damage to the skin and preserves the effects of the brow lift.
There is also a chance that the facial nerve could be injured during this procedure, especially if the incision is made a bit too deep. If this happens, you might temporarily lose some muscle function, but it should recover with time. With this in mind, your surgeon will take great caution when operating in this area to limit any potential damage.
Sometimes the surgery can also affect the sensory nerves in your forehead. This might make your forehead feel numb or tingly for a few weeks, but this usually gets better over time. In rare cases, if certain nerves are injured, you may experience long-term numbness or pain in your forehead.
After the surgery, it’s very common to feel an itching sensation around the incision site for a week or two. As for the scar from the surgery, its appearance can vary and is hard to predict. Sun exposure or darker skin might result in a lighter or darker scar, and there is sometimes a chance the scar could widen. However, there are several treatments, like laser resurfacing and silicone gels, that can help improve the appearance of the scar.
Following a brow lift surgery, your eyebrows might be a bit uneven – but this is quite normal, as eyebrows naturally are often not completely symmetrical. Similarly, the shape of your skin and muscles around your eyebrows might change slightly after the surgery. To improve the look and feel after surgery, your surgeon might consider adding fat grafting, which involves adding fat to certain areas to improve overall appearance.
Sometimes, you may have a bit of trouble closing your eyes fully after the surgery, but this should only last for a few days. If you’re experiencing symptoms like dry eyes or inability to close your eyes prior to the surgery, your surgeon may adjust the procedure or plan surgeries at different times to ensure the best outcome.
What Else Should I Know About Mid Forehead Brow Lift?
In the past, a procedure known as a mid-forehead brow lift was common to improve the forehead’s appearance. This surgery has become less popular as new less invasive methods, like small incision and endoscopic (using a tiny camera) procedures, have been developed. These newer techniques are now widely used and considered the “gold standard”.
However, there are certain people who could benefit more from the older mid-forehead brow lift. These typically include men who have thinning or no hair, deep wrinkles on their forehead, and little eyebrow hair. When the right people are selected for this surgery, the results can be really satisfying and make a significant improvement to their appearance.
The main advantage of the mid-forehead brow lift is that it provides better control than the newer methods. This is because the surgeon works closer to the eyebrow, allowing them to more effectively and reliably alter the height and shape of the brow. This method also makes it easier to correct any differences in the appearance between the two eyebrows. Moreover, the mid-forehead brow lift is a relatively simple procedure that can be performed in an office and doesn’t require the patient to stay in the hospital.”
