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The upper third of the face, which includes the forehead and eyelids, is the focal point of our facial expression and appearance. The eyebrow and eyelids may descend (or droop) for several reasons. Gravitational forces have a major role in the development of eyebrow "ptosis" (pronounced toe-sis) or droop. Over time, gravity may result in a gradual downward positioning of the eyebrows and a more full upper eyelid appearance. A less common cause of eyebrow ptosis is cranial seventh nerve palsy following trauma, surgery, or unknown causes (Bell's palsy).
The downward positioning of the eyebrow can lead to full upper eyelids and contribute to excess skin in the upper eyelid area. This fullness may actually interfere with the superior visual field. Often times, downward descent of the eyebrow is the major contributor to upper eyelid skin redundancy and fullness and with surgical elevation of the eyebrow minimal eyelid skin may actually need to be removed. If significant eyebrow ptosis is present, eyelid surgery alone may not adequately improve eyelid fullness or expand the lateral or superior visual field (see Blepharoplasty and Ptosis Repair).
Elevation of the eyebrow and forehead can be an important procedure in reversing some of the aging changes of the upper face. An eyebrow and forehead lift can improve the "tired" look that may result from the degenerative changes of aging. See Preoperative and Postoperative Patient Photographs.
There are several different surgical approaches to elevate the eyebrow and forehead. The Direct Brow Lift involves an incision just above the eyebrow and provides the most direct elevation of the lateral eyebrow. A Mid-Forehead Lift involves an incision within the furrows (wrinkles) of the forehead. If concealing the incision sites is an important patient consideration, then a surgical approach designed behind the hairline is indicated. The Endoscopic Forehead Lift with incisions in the anterior scalp is the most frequently utilized cosmetic technique.
The Direct Brow Lift involves incisions just above the eyebrow. Patients with thick eyebrows and significant lateral brow ptosis are good candidates for this procedure. Local anesthetic with or without intravenous sedation provides adequate anesthesia. A modified ellipse of tissue is removed from the area above the eyebrow, and the incision site is closed with nonabsorbable sutures. Nonabsorbable sutures diminish scarring in this area and require removal one week following surgery. Women may utilize makeup on the incision sites following suture removal. Scars are well hidden in patients with thick eyebrows.
The Mid-Forehead Lift involves incisions within the furrows (wrinkles) of the mid-forehead. Patients with deep furrows or rhytids and significant lateral brow ptosis are good candidates for this procedure. As with the direct approach, an ellipse of tissue is removed from the forehead and the incision site is closed with nonabsorbable sutures. Nonabsorbable sutures diminish scarring in this area and require removal one week following surgery. Women may utilize makeup on the incision sites following suture removal. Scars are well hidden in patients with deep furrows and gradually fade into the natural forehead wrinkles over the ensuing weeks to months.
In the endoscopic forehead approach small incisions are made behind the hairline. This minimally invasive cosmetic technique is excellent for younger patients with few forehead wrinkles. It is also more effective for treatment of the medial portion of the eyebrow and glabellar region (area between the eyebrows). Endoscopic forehead elevation is typically performed under general anesthesia. The entire forehead and eyebrow is undermined and elevated with the use of an endoscope and video monitoring equipment. Incisions are made in the scalp just behind the hairline. The hair is not shaved or cut. The repositioned forehead is typically secured in place with a dissolvable implant fixated to the frontal bone. Scalp incisions are closed with staples that are removed 10-14 days after surgery.
Temporary numbness of the forehead is common following all of the surgical approaches and typically improves over 1 to 4 months. Permanent numbness can occur but is rare. Damage to the facial nerve (nerve responsible for facial muscle contraction) can be damaged in the mid-forehead and endoscopic approaches and result in an upper facial droop. Fortunately, this is very rare. Postoperative bleeding and infection can potentially occur following any surgery. Over elevation, under elevation, and asymmetric eyebrow appearance are potential aesthetic concerns. Touch-up procedures may occasionally be necessary.
Patients undergoing direct and mid-forehead lifts need to elevate the head and apply ice packs for 3 days following surgery. Heavy lifting and straining should be avoided during the first postoperative week. Suture removal is typically required at 1 week.
Following endoscopic surgery, icepacks are applied to the forehead for 3 days. Patients need to sleep with the head of the bed elevated for 2 weeks. Heavy lifting and straining should be avoided for 2 weeks. Clip or screw removable may be necessary at 2 weeks. When to return to work will be based upon your occupation and what other procedures were performed at the time of your eyebrow lift. Generally, patients will need to wait up to 10 days before returning to most social and work activities.
If eyebrow and forehead ptosis is a result of a seventh nerve palsy (surgery, trauma, Bell's palsy) and the resulting eyelid and eyebrow fullness interferes with the superior visual field, then surgery may be covered by some insurance carriers. In many cases, eyebrow surgery is considered cosmetic and not covered by insurance or Medicare. The direct and mid-forehead surgical approaches are less expensive than the endoscopic procedure since they are more straightforward and do not require the operative time and expensive equipment necessary to perform an endoscopic forehead lift.
The total cost of surgery will depend on which other procedures are performed at the same time, the facility selected for surgery, and the type of anesthesia.
Stephen R. Klapper, M.D., F.A.C.S. is a board certified Ophthalmologist and has completed extensive fellowship training in Ophthalmic Plastic and Reconstructive Surgery. In addition to his clinical practice Dr. Klapper has published numerous scientific articles in peer reviewed journals and presented several papers at regional, national, and international meetings on topics related to the field of eyelid and facial plastic surgery. Dr. Klapper's practice is limited to adult and pediatric cosmetic and reconstructive eyelid and facial surgery, tear duct surgery, orbital disease, thyroid eye disease and the anophthalmic patient. Dr. Klapper also has extensive experience performing facial Botox® injections and Restylane® lip and facial fold injections.
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Contact our office to discuss your eyelid problem with Dr. Klapper or a member of his staff. (317) 818-1000
