Look At Your Brows First

Many clients ask me about their options to rejuvenate their eyelids; nearly all are surprised to learn that an important part of achieving their goal involves improvement of the eyebrow. However, this improvement needs not necessarily involve surgery – let’s explore opportunities in the context of some very common brow concerns:

1)    “My eyebrows are too low.”

Indeed, this is perhaps the most common concern once a client truly takes pause to evaluate their eyebrows in the mirror. Classically, this is corrected using a “brow lift” surgery. Such procedures may involve lifting the eyebrow via incisions made high in the hairline, the hairline itself, or by endoscopic means. For patients needing just a slight lift, approximately 5 mm, the eyebrow may be lifted by a minimally-invasive procedure called a “browpexy.” The browpexy is accomplished by using the same incision as the upper eyelift procedure thus resulting in excellent scar concealment and rapid recovery.

Brow lifts may be performed “chemically” too. The “chemical brow lift” or the “Botox brow lift” is accomplished by injecting minute amounts of the temporary muscle-weakening medications Botox or Dysport to selectively weaken the brow depressing muscles as well as some of the other muscles around the area of the eyebrow to allow the muscles which elevate the tail of the brow to function maximally.

Micropigmentation, or permanent makeup, affords a potent illusion of an elevated brow which may serve as an excellent alternative or complement to the above techniques.

2)    “My brows look deflated.”

As in other areas of the face, especially, we lose volume. This volume loss takes the form of thinning skin, thinning bone, and most importantly, loss of fat. This lost fat volume may be replaced by many of the commercially-available synthetic fillers such as Restylane, Perlane, Juvederm, Sculptra, Radiesse, and others as well as fat grafts. As opposed to the synthetic fillers, fat grafts are obtained from the same patient using a small-scale liposuction technique. Success in a forehead lift surgery hinges on the accurate diagnosis and correction of volume loss not just laxity.

3)    “My brows look light and thin.”

Loss of hair pigment or lack of hair, by whatever cause, generally leads to an aged appearance of the brows. Cosmetics and coloring may provide sufficient improvements, however, permanent makeup can affect a thickened, darker brow in most clients.

4)    “My brows are flat.”

Though flat brows are generally considered acceptable for men, most of my female clients are looking for an arch. There is controversy among physicians who perform aesthetic brow lift procedures on the brow area as to the ideal female brow shape particularly related to where the peak of the brow should be located. I challenge my patients to look at the brows of movie stars from every decade of cinema – the ideal brow changes periodically and does, indeed, recapitulate over time. Furthermore, cultural and genetic factors must be considered as well. For most women, the peak of the brow looks excellent above the bony rim of the eye when it is located between the lateral limbus (the outermost margin of the color of the eye) and the lateral canthus (where the eyelids meet at the outer eye). However, an early peak (at the midportion of the pupil) or late peak (outside of the lateral canthus) can be not only dramatic, but quite beautiful in select individuals.

Brow shape can be optimized with above techniques as well as with careful hair removal for a polished look.

I strongly believe the best aesthetic outcomes result from a combination of the above techniques, driven by an accurate diagnosis, and in the context of the patient’s actual desires. Disappointing results can occur when a technique, ill suited for the primary concern, is used. This is particularly true when such a technique is used in an over-compensating manner for the lack of other corrective measure. The classic example of this in eyelid rejuvenation occurs when too much eyelid skin is removed in an eyelid lift procedure to compensate for a heavy, untreated, eyebrow. The result of this can be aesthetic concerns such as worsened brow drooping, a “feminized” eyelid in men, and gauntness as well as medical concerns.

As with many other aesthetic procedures, if there was only one optimal way to reach a client’s goals, all procedures would be done the same way for everyone. This is why options for forehead lifts must not be looked at with frustration but with the promise of opportunity.