A brow lift is an operation that raises eyebrows which have become droopy (brow ptosis). The operation may be performed in isolation or in conjunction with an upper eyelid blepharoplasty. The surgery may be supplemented by the use of anti-wrinkle injections and fillers e.g. Restylane.

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 becomes lower with age from the effects of both gravity and the muscles which draw the eyebrow down. In some patients the position of the eyebrow can be improved with the use of anti-wrinkle injections injected into the muscles between the eyebrows which produce the frown lines, and into the “laughter lines” at the outer aspects of the eyelids. The injections are very quick and simple to perform and are repeated every 4-6 months. Anti-wrinkle injections can also improve the outcome of surgery performed to raise the eyebrows by preventing the action of the muscles which pull the eyebrows down.

Surgery is indicated when the eyebrows are causing:

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

What happens at surgery?

Brow lift surgery can be performed under local anaesthesia, local anaesthesia with sedation by an anaesthetist, or under general anaesthesia. There is 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 direct brow lift
• The mid-forehead brow lift
• The temporal eyebrow lift
• The endoscopic brow lift
• The transblepharoplasty (internal) brow lift
• The coronal forehead and 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 mimic forehead creases once completely healed.

A direct brow lift

A patient with marked bilateral brow ptosis And excess upper eyelid skin

Postoperative appearance of the same patient 3 months after a bilateral direct brow lift and a bilateral upper eyelid blepharoplasty

A mid-forehead brow lift is suitable for older patients with a severe brow ptosis who have very marked forehead wrinkles. The incisions are made within the wrinkles and redundant forehead tissue is removed.

A temporal brow lift is useful for a patient who requires a moderate lift of the outer aspect of the eyebrow only. The incision is made in the temple just behind the hairline and involves the removal of a strip of hair-bearing skin.

An endoscopic brow lift is used for moderate degrees of brow ptosis in patients usually aged 40-55. It is more time-consuming and more expensive. It can cause more postoperative pain, headache and discomfort than less invasive procedures. It leaves small scars just behind the hairline. It is generally unsuitable for patients with hairloss or with a very high hairline and prominent forehead.

The sites of incisions for an endoscopic brow lift

The forehead is lifted off the underlying frontal bone

The tissues around the brow are carefully dissected

Preoperative appearance of a male patient with "hooded" upper eyelids due to a bilateral brow ptosis (droop)	Postoperative appearance of the same patient 2 weeks following a bilateral endoscopic brow lift

A transblepharoplasty (internal) brow lift is performed in conjunction with an upper lid blepharoplasty. The brow is released internally from its local attachments and sutured to the lining of the bone (periosteum) just above the brow with a nylon suture. The brow is not raised significantly but is prevented from becoming droopy 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.

The coronal forehead and brow lift is the most invasive approach to brow lifting. This involves an extensive incision running across the scalp either just in front of the hairline (pretrichial incision) or a few centimeters behind the hairline. Although considered rather out-moded this approach is still required for patients with a marked brow ptosis who are unsuitable for alternative approaches. The disadvantages of this approach are the scar and permanent numbness of the scalp behind the scar which extends to the centre of the scalp.

What happens before eyebrow surgery?

You will visit the clinic a few days or weeks before the date of your surgery to have a preoperative consultation with your surgeon. He will ask you questions about your current and past health, and will need to know about any allergies you may have, medications you are taking (including over the counter products e.g. aspirin, indomethacin or vitamin supplements), previous surgery, previous anti-wrinkle injections or the use of fillers, and whether you smoke. 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 an anaesthetic. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), chest x-rays, or complete blood cell counts. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing may be necessary if you are in good health and younger than age 55.

Please answer all questions completely and honestly as they are asked only for your own wellbeing, so that your surgery can be planned as carefully as possible. 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. If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your eyes are examined carefully; your vision in each eye is measured, the pressure within each eye is measured, and the back of the eye (called the retina) is examined as well as the eyelids and the brows. The surgeon examines the general state of your skin, for example the presence of acne or scars, and takes a photograph of your face before surgery so that the results of surgery can be compared with the original appearance.

The procedure will be explained to you and you will then be asked to sign a consent form saying that you understand the procedure and that you have been told about any possible 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 worries, make sure they are answered, before you sign the consent form. You are quite free to go away and consider the options before committing yourself to any surgery. You can then write to us or email us requesting further information if required.

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

Complications after 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 eye 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). If blurring persists for longer than 48 hours, it is important to inform the surgeon.
  
  
• Watery eyes - this is common for the first few days after the operation if a blepharoplasty has also been performed.
  
• Dry eyes symptoms may persist for two to three weeks. You will need to lubricate your eyes using artificial tears during the day (Viscotears) and an ointment at night (Lacrilube). These will be prescribed for you.
  
  
• Injury to the surface of the eyeball that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. This is extremely rare in the hands of an oculoplastic surgeon.
  
  
• 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.
  
  
• When closing the eye, the eyelids do not cover the eyeball completely. This may occur for a short time after the operation because there is swelling around the eye. As the swelling settles, the problem resolves.
  
  
• Infection. This is extremely rare but it is very important to follow all after-care instructions carefully keeping the wounds meticulously clean and applying antibiotic ointment as prescribed.

Most brow lift procedures are performed as day cases where you arrive at the hospital in the morning and leave the same evening after the operation. 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 live some distance from the hospital.

After surgery, the eyes are initially covered with pressure dressings to reduce postoperative swelling and treated with antibiotic ointment. These are then removed and replaced with ice packs and the eyes watched closely for any excessive bruising. You will be asked to clean the wounds and repeat the application of ointment to the wounds 3 times a day for 2 weeks. The sutures (stitches) are dissolvable for some procedures but for others are removed after 2 weeks. Wearing make-up should be avoided for at least 2 weeks. Postoperative bruising and swelling usually takes at least 2-3 weeks to subside. This should be taken into consideration when scheduling the operation. The scars gradually fade to fine marks within a few months. Those in the upper eyelid are hidden within the skin crease. You will need to use frequent artificial tears for the first 2-3 weeks following surgery. These will be prescribed for you e.g. Systane drops preservative free, Viscotears preservative free, Liquifilm tears preservative free, Celluvisc and Lacrilube ointment at night.