With ageing and frowning our brows begins to descend (brow droop or ptosis) ultimately leading to hooding of the sides of the upper eyelids and a tired, ‘lived-in’ look. Our brow posture determines the way our mood is subconsciously perceived by others. A low brow with marked glabellar creases is usually taken to indicate tiredness, frustration, anger or irritability.
THE RELATIONSHIP BETWEEN THE BROW AND THE UPPER EYELID
Patients almost never visit the surgeon requesting browlifting surgery as the consequences of a droopy brow are most often manifested in the upper eyelid region. Patients will often request upper eyelid surgery when a browlift is by far the most appropriate option. It is therefore important for the plastic surgeon to recognise brow droop as a separate entity and not confuse it with blepharochalasis (excessive upper eyelid skin) although both can occur (and be corrected) simultaneously.
WHAT DOES THE SURGERY INVOLVE?
In endoscopic browlifting, several (four or five) small incisions are made behind the hairline, forehead and scalp which are mobilised using keyhole surgery techniques. The layer that links the soft tissue to the bone at the brow ridge (the periosteum) is then released and the brow depressor muscles are divided and partially removed. The brow is then repositioned and fixed in place with a superomedial lift vector in order to reestablish an alluring arch shaped eyebrow. The fixation is performed with an ingenious resorbable device known as an endotine, which closely resembles an absorbable carpet tack. A lift of up to 1.5cm can be achieved using the endoscopic technique, although 5-10mm is more usual for a subtle but definite freshening effect.
Open browlifting is more appropriate in older patients with very severe brow droop, or in patients with a combination of a high hairline and a drooping brow. It involves making an incision at or behind the hairline and undermining the forehead skin in a deep plane. The forehead is then advanced upwards and the excess skin or scalp removed. When a high hairline is advanced downwards, this is called a hairline lowering foreheadplasty, and is a variant of open browlifting. The incision is then sutured (stitched) if it involves skin, but clipped together if it involves scalp. Patients spend one night in hospital after surgery and are allowed home on post-op day one with a stretchy removable bandage in place.
WHAT ARE THE SCARS LIKE?
With endoscopic browlift techniques the scars should be barely visible – scar visibility is even less of a problem since the endotine was introduced as it applies tension to the deepest layers of the scalp only and there is little or no traction placed on the surface closure; leading to almost imperceptible scars. In the case of an open browlift the scars are long but usually nicely disguised by the hair, designing the initial incision in a wavy line can help to hide the ultimate scar. In the case of scars hidden along the frontal hairline, only rarely do these become visible and require revision as this area heals extremely well. Occasionally after an open browlift the scars can become itchy and there may be mild discomfort associated with this as well as persistent numbness in the region of the scalp behind the incision line.
HOW PAINFUL IS IT?
With an endoscopic browlift expect a mild headache for the first few days with usually very little bruising. With an open browlift the discomfort may be greater due to the longer incision used. Patients are offered a short course of pain killers on discharge from hospital.
The endotine dissolvable fixation devices can occasionally be felt under the skin but are only rarely uncomfortable. They can take several months to dissolve away completely but during this time are doing a great job of maintaining vertical correction of the brow ptosis.
WHAT HAPPENS AFTER SURGERY?
Patients return to the clinic after approximately one week for removal of clips and/or sutures. It is important to wear the stretchy bandage for the first post-operative month as it takes some time for the forehead to get fixed in place and the bandage helps to hold it up whilst this healing process is happening. Patients are reviewed after three months and post-operative photographs obtained.
WHAT COULD GO WRONG?
Complications are rare but can occur. The scalp can occasionally bleed causing a blood clot or haematoma which may require evacuating. Infection is extremely rare as the circulation of the scalp and forehead are so good. Very rarely (less than 0.5% of the time) the frontal branch of the facial nerve, which controls the movement of the eyebrows, might be stretched or cut. If it is stretched then one or other eyebrow will fail to raise for a period of a few weeks, to months, following surgery but a full recovery will occur. If the nerve is cut however this will not be the case and a permanently inactive eyebrow may result.