Maas San Francisco Maas Tahoe
The anatomic changes that occur in the upper face associated with aging include; the descent or drooping down of the eyebrows over the orbital rim, hooding of eyelid skin over the lid shelf (where eye shadow is worn) and increasing wrinkles – horizontally oriented associated with the individual contracting the muscles that lift the eyebrows and vertical lines between the eyebrows – the result of making a frowning expression. These changes become more profound with age as the skin loses its elasticity and the effects of gravity and facial expression take their toll. More than just aging the effects described have a marked effect on making one look tired, angry and/or frustrated. The brow and upper face provide very important social clues as to the “well-being” of an individual.
It is important to remember that the same loss of skin elasticity of the forehead skin profoundly affects the eyelid skin causing crepiness and skin hooding independent of the eyebrows descent. This eyelid condition is often referred to as dermatochalasis and is treated either with or without browplasty with eyelid surgery known as blepharoplasty.
The historical use of the term browlifting accurately described some of the early techniques used to treat the gravity and age dependent drooping of the eyebrows and hooding skin of the eyelid. The more appropriate modern term is browplasty with a comprehensive approach to the aging brow, one is able to achieve much more than just lift the brow, but shaping the brow and reversing the signs of aging. These techniques are classified and defined as follows:
1. Direct brow lift:
A carefully measured elipitical (banana) shaped section of skin is removed with within and along the very upper hairs of the eyebrow. This technique is very effective reducing the drooping or ptosis of the eyebrow and can be done with local anesthesia in office. The resultant scar, however carefully closed, is visible as at fine white line at the upper border of the eyebrow. This scar, for many patients, is not acceptable.
2. Midforehead brow lift:
This technique employs a carefully designed skin excision placed in one of the deep lines located above the eyebrows. The optimal design places the incisions over each eyebrow at different levels. This discontinuity makes the resultant scars much more difficult to identify once the wound has adequate time to heal. Midforehead browlifts (forehead lifts) are generally provides more cosmetically favorable outcomes in my opinion but is reserved in most cases in our practice for men with deep forehead lines. Endoscopic brow lift has in most cases replaced this technique even for men.
3. Coronal brow lift:
This technique, which has gained a resurgence in popularity in recent times employs and “ear to ear” incision over the top of the head. For obvious reasons balding men are not considered good candidates for this approach. The scalp and forehead soft tissues are carefully elevated and the strong muscles (corrugators) that are commonly treated with BOTOX® Cosmetic or Dysport are cut. These muscles function is strictly limited to making frowns and pulling the eyebrows down. The scalp tissues are then elevated to appropriate levels and a swath of scalp is removed with closure using surgical clips or sutures. For patients with a high hairline this technique is not often employed as it is expected to raise the hairline by up to several centimeters. Many patients experience permanent scalp anesthesia (loss of sensation) and/or paresthesias (tingling and discomfort) with this approach. However, the incision is well hidden behind the hairline.
4. Pretrichial or Trichophytic brow lift:
This technique employs a “wavy” incision along and into the hairline that allows hair to grow back through the scar thus disguising the scar. Patients with higher hairlines are ideal candidates for this approach as the hairline position is preserved. This technique is also used for hairline lowering. Hairline lowering, for patients that have a very high forehead (representing more than one third of the face when viewed from the front) can be combined with browplasty/lifting or done as an independent procedure. San Francisco cosmetic surgeon, Dr. Maas has employed this technique to correct hairline that have been “over-elevated” with previous coronal brow lift surgery.
This modern technique employs sophisticated telescopic camera technology to allow elevation of sagging brow tissues with much smaller incisions. Typically, 3 – 5 small incisions are made behind the hairline, elevation of the sagging tissues is achieved, frown muscles are truncated and the brow is repositioned. The repositioned brow is held in place by one of several “fixation:” techniques. Most commonly, small partial holes are drilled into the “outer cortex” of the skull bone and small absorbable devices are secured in these bone dimples and the overlying and repositioned soft tissues. Over time, these small “plates” dissolve and providing good long-term brow position. Alternatively, my preference is to avoid drilling the skull bone a use, in an off-label fashion, an FDA approved biologic glue commonly employed in heart surgery. Bioglue, has provided good results for us in securing brow position while the healing process occurs and is absorbed over time by the body. Our early paper published in the medical literature is available on our website.
6. Non-surgical brow lift:
First described in the medical literature by myself and one of our fellows, neuromodulators such as BOTOX® Cosmetic or Dysport can be very effective in lifting the brow, particularly in younger patients. One common misconception that I have had many patients and even some doctors report is that treating ABOVE the eyebrows with BOTOX® Cosmetic or Dysport can somehow lift the brow. This is counterintuitive. BOTOX® Cosmetic or Dysport relax muscles. In order to lift the brow we want to relax the muscles that are BELOW the eyebrow as they are responsible for pulling the eyebrows down when squinting or frowning. Non surgical brow lift thus provides two benefits – reducing wrinkles and elevating the eyebrows.