Treatments: Brow Lift

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A brow lift is an operation that raises eyebrows which have become droopy (brow ptosis). The operation may be performed in isolation or, more commonly, in conjunction with an upper eyelid blepharoplasty (an upper eyelid lift or cosmetic eyelid operation). The surgery may be supplemented or assisted by the use of anti-wrinkle (botulinum toxin) injections and dermal fillers e.g. Restylane or Juvéderm. .Some patients also undergo Coleman fat injections (structural fat grafting) to improve hollowing of the adjacent temples at the same time or at a later stage.

The position of the eyebrows affects facial expression and influences the way in which a patient's mood and personality are judged by others. There are a variety of eyebrow shapes. In general the female brow has a higher arch than a male's which tends to be flatter. The brow position, particularly the tail of the brow, tends to become lower with age from the effects of both gravity and due to the effects of the muscles which draw the eyebrows down. Paradoxically, in some patients who have droopy eyelids (blepharoptosis), the brows may actually rise as a compensatory mechanism to improve the patient’s visual field.

In some patients the position of the eyebrow can be improved with the use of anti-wrinkle injections alone.  Botulinum toxin is injected into the muscles between the eyebrows which cause the frown lines, and into the muscle which causes the "laughter lines" at the outer aspects of the eyelids. The injections are very quick and simple to perform but need to be repeated every 3-4 months.

Anti-wrinkle injections can also improve the outcome of surgery performed to raise the eyebrows and can help to maintain the effect for a longer period of time by preventing the action of the muscles which pull the eyebrows down  (the brow depressor muscles – the corrugator, the procerus and the orbicularis muscles). This allows the muscle which lifts the brows (the frontalis muscle) to work unimpeded.

Anti-wrinkle injections are never given at the time of surgery or within the first few weeks after surgery as postoperative tissue oedema (swelling) can cause the botulinum toxin to spread to other muscle groups. For this reason the injections are given 2-3 weeks before surgery. Once the maximal effects of the injections are seen (usually after 7-8 days) the toxin cannot migrate to affect unwanted muscles e.g. the muscle of the upper eyelid.

Surgery is indicated when the eyebrows are causing the following problems which non-surgical treatments cannot address adequately:

• A cosmetic problem
• A visual field problem
• Headaches from fatigue of the frontalis muscle in the forehead which is responsible for raising    the eyebrows

 

 

 

What happens at surgery?

Brow lift surgery can be performed under local anaesthesia, local anaesthesia with sedation by an anaesthetist "twilight anaesthesia", or under general anaesthesia. There are a variety of surgical procedures which can be used to raise eyebrows. These will be discussed with you and the one selected will be that which is most appropriate to your age, appearance, and problems. The procedures include:

The transblepharoplasty (internal) brow fixation The transblepharoplasty (internal) Endotine brow lift The endoscopic brow lift The direct brow lift The coronal forehead and brow lift The pretrichial brow lift

Transblepharoplasty (internal) brow fixation

A transblepharoplasty brow fixation is performed in conjunction with an upper lid blepharoplasty. The brow is released internally from its local attachments via the upper lid blepharoplasty incision. The internal aspect of the brow is sutured (stitched) to the lining of the bone (periosteum) just above the brow with a nylon suture. The brow is not raised significantly but is stabilised and prevented from becoming droopier following the upper lid blepharoplasty. This procedure often leaves a temporary area of numbness at the outer aspect of the brow and a tender swelling around the brow suture for a few weeks.

This operation is generally performed under “twilight anaesthesia” on a day case basis.

Transblepharoplasty (internal) brow lift

In carefully selected patients the brow can be raised via the same upper lid blepharoplasty incision using a special device called an "Endotine" implant. This is a small device which has some projections which anchor the elevated brows in an elevated position until the brows heal. The device is fixed into the bone just above the eyebrow using a small partial thickness drill hole. The implant dissolves after 6-9 months. The implant can be felt until it dissolves but it is not visible. This device is very popular and effective when used for the appropriate patient but its disadvantage is that it is quite expensive. A very similar device can also be used in the region of the frontal hairline to provide fixation of the forehead in an endoscopic brow lift.

Anti-wrinkle injection are usually given 2-3 weeks before the operation

This operation is generally performed under “twilight anaesthesia” on a day case basis.

Endoscopic brow lift

An endoscopic brow lift is used for moderate degrees of brow ptosis, often in conjunction with an upper lid blepharoplasty, in patients usually aged 40-55. It is a more time-consuming and more expensive operation as more expensive operating theatre equipment is required. It can cause more postoperative pain, headache and discomfort than less invasive procedures.

In this operation, 5 incisions are made just behind the hairline. 2 of these incisions are in the temple. (See the drawings below). The operation is performed using a telescope so that most of the dissection of the brow tissues is undertaken using a video monitor. Once the forehead and brows have been released, the tissues are fixated either using a small bone tunnel, created using a drill, and sutures, or with an Endotine implant.

It leaves small scars just behind the hairline. This procedure is generally unsuitable for patients with thinning of the hair, a very high hairline and prominent forehead. Most patients prefer to undergo this surgery under general anaesthesia, with an overnight stay in hospital.

 

	Preoperative appearance of a female patient which “hooded” upper eyelids due to a bilateral brow ptosis (brow droop).		Postoperative appearance of the same patient 6 weeks following a bilateral endoscopic brow lift (without an upper lid blepharoplasty)

Direct brow lift

The direct brow lift involves the removal of redundant tissue just above the eyebrow and is mainly used in older patients with a marked brow ptosis. The scars are visible but they tend to mimic forehead creases once completely healed. The procedure is quick to perform, effective and long lasting. It is generally performed under local anaesthesia, or under “twilight anaesthesia”, on a day case basis.

	Preoperative appearance of a patient with a bilateral asymmetric brow ptosis and hooding of the upper eyelids		Postoperative appearance 4 weeks following a bilateral temporal direct brow lift and bilateral upper eyelid blepharoplasty. This patient also underwent a bilateral transcutaneous lower lid blepharoplasty and Coleman fat injections to the upper cheeks.

Coronal forehead and brow lift

 The coronal forehead and brow lift is the most invasive approach to brow lifting. This involves an extensive incision running across the scalp a few centimetres behind the hairline. Although considered rather out-moded, this approach is still required for patients with a very severe brow ptosis who are unsuitable for alternative approaches. The disadvantages of this approach are the extensive scar and permanent numbness of the scalp behind the scar which extends to the centre of the scalp.

Pretrichial brow lift

The pretrichial brow lift involves an incision running across the forehead just in front of the hairline. This approach is generally required for patients with a significant degree of brow ptosis and a high forehead who are unsuitable for alternative approaches. Apart from the scar, it also leaves an area of numbness in the scalp.

What happens after a brow lift?

After transblepharoplasty brow lift surgery, the eyes and forehead are initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the eyelid wounds are treated with antibiotic ointment. The dressings are then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding.

Following an endoscopic brow lift, the dressings are usually kept in place overnight and removed the following morning. The sutures or staples are removed after 10-14 days in clinic.

You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used are dissolvable but are usually removed in clinic after 2 weeks. The skin around the eyes should be protected from direct sunlight, by avoidance if possible or by using protective sunglasses. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended. (The aesthetics nurses at the clinic Face & Eye can demonstrate this to you).

A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely.  Swelling takes longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.

The scars gradually fade to fine white marks within a few months. Those in the upper eyelid are hidden within the skin crease unless an additional skin incision is required to remove a “dog-ear” of excess skin just below the tail of the eyebrow.

You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops. These will be prescribed for you e.g. Hyabak drops, Systane eye drops preservative free, Viscotears preservative free, Liquifilm tears preservative free, or Celluvisc drops and Lacrilube ointment at bedtime.  

It is often recommended that you use Lacrilube ointment to the eyes 2 hourly for the first 48 hours after surgery but note that this will cause blurring of vision. (You should not drive for the first few days after surgery). These medications can be purchased from my clinic Face & Eye or online from the clinic’s online shop (www.faceandeyeshop.co.uk).

You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.

Contact lenses should not be worn for a few weeks following this type of surgery.

What happens before brow lift surgery?

You will visit the clinic to have a preoperative consultation with me. This usually lasts 30-45 minutes. You will be asked to complete a healthcare questionnaire before seeing me, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery, and any previous non-surgical aesthetic treatments e.g. Botox injections, dermal fillers injections, the use of IPL or laser treatments.  I need to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. I need to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not you smoke.

You will have your blood pressure checked by the nurses. You may also be required to have a physical examination of your heart and lungs by the anaesthetist to make sure it is safe for you to have a general anaesthetic. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), a chest x-ray, or a blood cell count. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing is usually necessary, however, if you are in good health and younger than age 55.

The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use. They can also advise you about additional non-surgical treatments.

Please answer all questions completely and honestly as they are asked only for your own wellbeing, so that your cosmetic surgery can be planned as carefully as possible. The information is treated confidentially. If you are unsure of the names of any medications, bring them with you.

You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.

If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) is examined as well as the eyelids themselves. The rest of your face is then examined. The general state of your skin is assessed and photographs of your face and eyelids are taken before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.

What should I expect at the clinic?

Following a consultation I advise you to consider the options discussed carefully in your own time. I will send you a written report detailing what we have discussed. The letter will only be sent to you unless you have specified that you are happy for the letter to be sent to your GP. You can then research the options further.

Wherever possible, I prefer that you come back to see me for a follow-up consultation before proceeding with surgery. At this consultation you will then be asked to sign a consent form saying that you understand the procedure and that you have been told about any risks or potential complications. Very rare complications will be described, as well as any more common ones, so try to keep things in perspective.

If you have any questions or concerns I will do my best to answer these for you.

What are the possible common complications of brow lift surgery?

Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.

Complications from brow lift surgery performed in conjunction with an upper lid blepharoplasty (cosmetic eyelid surgery) include:

• Blurred or double vision, mainly for a few hours, up to a day or two after surgery. This may occur for several reasons - ointment put in the eyes immediately after the operation, local anaesthetic used in the operation, weakening of the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Swelling of the conjunctiva is referred to as "chemosis" and in some patients can take a few weeks to resolve. If blurring persists for longer than 48 hours, it is important to inform me at the clinic.
• Watery eyes - this is quite common for the first few days after the operation due to some irritation of the eyes and an incomplete blink.
• Dry eyes may persist for two to three weeks or sometimes longer. You will need to lubricate your eyes every 1-2 hours using artificial tears during the day (e.g. Viscotears) and an ointment at night (Lacrilube). These will be prescribed for you. You will gradually reduce the frequency until you can dispense with them altogether. It is very rare for patients to have to continue with them long-term but this is possible. This is why it is important to exclude a dry eye problem before proceeding with this type of surgery.
• Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon.
• Collection of blood around the eyelids or behind the eyeball, called a haematoma. A sudden haematoma behind the eyeball can cause loss of eyesight if not managed appropriately. This is the most serious potential complication of this surgery. An oculoplastic surgeon is trained to prevent and to manage such a problem.
• Damage to the muscles that move the eyeball causing double vision is an extremely rare problem and this usually resolves by itself with time.
• A ptosis (the upper eyelid does not open because of stretching of the muscle or tendon that controls it). Another operation may be necessary to repair this. An oculoplastic surgeon undertakes ptosis surgery almost every week routinely.
• When blinking the eyelids do not cover the eyeball completely. This often occurs for a short time after the operation and is treated routinely with artificial tear drops. If too much skin is removed from the upper eyelids, the eyelid closure can be compromised long term. This may require further surgery to correct it. For this reason, great care is taken to mark the skin to be removed before surgery is commenced. Such a problem is extremely unlikely in the hands of an oculoplastic surgeon.
• A sunken-looking eye can occur if too much fatty tissue is removed. Should this occur, further surgery can be undertaken to replace fat. This is usually taken as tiny fat pearls from just below the umbilicus (the tummy button).
• Acute glaucoma - this is raised pressure within the eye, which results in pain in the eye, haloes around lights or severe blurring of vision, a headache above the eye, and vomiting. A patient at risk of such a postoperative problem would be identified by an oculoplastic surgeon. An oculoplastic surgeon is trained to diagnose and treat such a problem.
• Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These are given in writing for you to take home following surgery.
• Numbness in the forehead. This is due to bruising of the sensory nerves to the forehead. This is usually temporary but it may take some months for normal sensation to recover.
• Hair loss. This can occasionally occur around the incisions in the case of an endoscopic brow lift which is why this procedure is not well suited to those with thin hair.
• Frontalis palsy. A paralysis of the upward movement of the eyebrows can occur due to damage to the nerve supply to the frontalis muscle. A palsy (weakness) immediately following surgery may occur due to a “neuropraxia” (blunt injury to the nerve caused by intraoperative manipulation of the tissues). This usually resolves in a few weeks. A permanent paralysis is extremely rare.
• Scarring. The scar following a direct brow lift is usually fine. Hypertrophic or keloid scarring is possible but extremely rare in this location.

 

You will be given a document which outlines these risks.
To put this in perspective, I have been undertaking blepharoplasty and brow surgery for almost 20 years as a consultant. I perform these operations every week. I have never had a serious complication of such surgery.

Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.

How long will I stay at the clinic/hospital/?

Most cosmetic brow lift and eyelid surgery procedures are performed as day case procedures where you arrive at the hospital in the late morning and leave the same afternoon or evening after the operation. If your surgery is undertaken in our ambulatory surgical centre clinic, Face & Eye, you will be able to leave within an hour after the completion of your surgery. Someone must be available to take you home and stay with you for up to 24 hours after the operation. Alternatively an overnight stay may be required if you are to undergo an endoscopic brow lift procedure or if you live some distance from the hospital/clinic. Some patients like to stay in a local hotel close to the clinic rather than in hospital over night. You can then return to see the nurses in the clinic the following day for a check before going home.

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