Forehead lift surgery can elevate the sagging brows, eliminate the vertical creases between the eyes and the horizontal lines across the forehead, and change the hairline height if the patient requests for it.
(Forehead lift surgery and brow lift are basically the same procedure—the incision patterns and “cosmetic effects” are similar—although there are techniques that can elevate or reshape the brows without lifting the entire forehead.)
Serrated incision during forehead lift surgery is made precisely at the hairline so the scar blends into the background.
As with any facial plastic surgery, the ideal forehead lift technique depends on the patients’ underlying anatomy and the “cosmetic effects” they are after. For instance, some like to shorten their forehead, while others want to maintain its height after elevating the brows.
If one of the goals is to reduce or maintain the forehead height, leading Los Angeles plastic surgeon Dr. Tarick Smiley says the ideal technique involves an irregular (serrated) incision made precisely at the hairline. This is different from the standard or coronal lift in which the incision goes from ear to ear, across the top of the head.
The coronal lift does not suit patients with high forehead because it inadvertently elevates the forehead by up to 1 inch, an “effect” some people humorously call “five-head.”
(“Four-head” is when the person can fit four fingers between her eyebrows and hairline. “Five-head” when it is too wide that five fingers can all fit on it.)
Fortunately, the hairline incision technique, or medically referred to as trichophytic, does not cause the dreaded five-head effect and in fact may even shorten the appearance of wide forehead by moving the hairline slightly more forward. Nonetheless, it should not be overdone otherwise the “primitive appearance” may ensue.
This is not to say that the hairline incision technique is superior to the coronal lift because it all boils down to the patients’ anatomy. For instance, women with a notably short forehead may consider getting the coronal approach to slightly increase its height.
Some surveys have suggested that women with a slightly large forehead, along with other “cute” or babyish features such as fuller lips, large eyes, and prominent cheeks, are generally regarded as attractive and youthful by other people.
Nonetheless, should there is a need to alter the hairline height during surgery, it must not be lifted excessively because a high hairline is masculinizing for women. And even in men, overzealous elevation is avoided to prevent unnatural results.
Brow lift for high forehead must use specific techniques to prevent further elevating the hairline. For this reason the standard method does not work for patients with such “feature.”
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says the coronal brow lift, which is today’s gold standard, uses an incision that runs from ear to ear across the top of the head. While the technique provides the most elevation by removing the excess skin from the hair-bearing area, it ultimately raises the patient’s hairline to about half an inch.
Fortunately, newer brow lift techniques eliminate this key disadvantage, says Dr. Smiley.
In one of his Snapchat videos, he has demonstrated a modified technique of the coronal brow lift. Instead of placing the incision behind the scalp, he positioned it precisely at the hairline so the resulting scar is perfectly concealed by the hairline-forehead junction.
The aforementioned technique is called trichophytic and it removes the excess skin from the forehead, causing no direct hair loss. And if needed, the surgeon can also move forward the hairline; hence, it is also a good procedure in patients seeking revision brow to correct over-elevation created during the initial surgery.
Aside from proper scar placement, Dr. Smiley highlights the importance of using a serrated incision pattern (it resembles small Vs connected to each other), as opposed to a straight one, during trichophytic technique. This technique not only promotes “favorable” scarring but also allows the hair to regrow naturally.
To further conceal the scar that is positioned precisely at the forehead-hairline junction, Dr. Smiley says there should be no or very little tension on the skin. For this reason he always closes the wound in several layers, with the deepest having the most tension, which gradually decreases as they reach the skin surface.
In the video, he says that without tension on the skin, the scar tends to heal better and fade quicker.
Another possible way to perform brow lift for high forehead is to use an endoscopic technique. Four to five small incisions behind the hairline are usually created in order to insert an endoscope or tiny camera so the surgeon can see the underlying anatomy.
However, the endoscopic brow lift only has a minimal lifting effect because it does not remove any loose skin, i.e., it only elevates the forehead through internal fixation. For this reason it is generally suitable for younger patients aged between 30s and 40s.
Forehead lift results are supposed to look natural; hence it is of critical importance to take into account the patients’ race, gender, and age to determine the ideal brow position, as suggested by renowned Beverly Hills plastic surgeon Dr. Tarick Smiley.
(Note: Aside from correcting the sagging brow, forehead lift surgery also corrects the deep furrows between the eyes and the horizontal creases on the forehead.)
Despite the aforementioned variables that determine the ideal brow position, there are generally accepted parameters. For instance, the inner or medial brow should begin on the same vertical plane as the inner aspect of the eye.
Another generally accepted guideline to create natural-looking forehead lift results is to ensure that the medial brow and the tail end are of the same horizontal level.
Gender is one of the most influential factors in determining the ideal brow position. In men, there is a need to preserve the brow’s “heavy” look, so it must remain at or even slightly below the orbital rim. Furthermore, it should have a very minimal arch.
The female brow, meanwhile, should ideally lie a few millimeters above the orbital rim. In addition, it has a more arched appearance compared to the male brow, says Dr. Smiley.
An over-aggressive elevation of the medial brow typically creates a perennially surprised appearance in both men and women. Nonetheless, failure to raise a low-lying inner brow and over-elevation of the tail end can lead to an angry look. To avoid these problems, the aforementioned guidelines must be acknowledged.
Forehead lift comes in various incision techniques, depending on the amount of elevation required, the patient’s underlying anatomies, and their personal preference and cosmetic goals.
In standard technique, a long incision placed at ear level is made across the top of the scalp. Occasionally, it is more ideal to place the scar precisely at the hairline, a technique that favors patients whose forehead is wide prior to surgery.
Other possible techniques involve 2-5 short incisions behind the hairline where an endoscope or small fiber-optic camera is inserted so the surgeon can see the underlying structures of the forehead. The temporal lift (i.e., one tiny incision on each temple) favors patients who only require the lateral or tail end of their brow to be elevated.
To achieve more natural forehead lift results, the surgery is occasionally combined with other procedures such as eyelid surgery, standard facelift, mid facelift, fat grafting, among others.
A brow lift forehead technique that uses a frontal hairline incision can provide impressive rejuvenating effects to the right patients, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
In the past, brow lifts were typically performed with an ear-to-ear incision placed in the scalp. While this technique can elevate the forehead/brow and soften the wrinkles, in patients with a high forehead this could aggravate such appearance, hence they look odd after surgery.
To help would-be patients understand the benefits of brow lift forehead technique via frontal incision, Dr. Smiley has released a YouTube video showing how the surgery is accomplished.
In the video, Dr. Smiley says the relatively new brow lift technique favors patients with a high forehead because it allows him to shorten it through skin reduction and/or scalp advancement.
Contrary to popular belief, placing the incision exactly at the hairline does not lead to more visible scarring. For optimal scar camouflage, Dr. Smiley says he prefers a “zigzag” pattern, as opposed to a straight one, as the wound heals better, thereby leading to “favorable” scars—i.e., they are very hard to detect even by the patients.
To further promote favorable scarring, Dr. Smiley employs suturing techniques in which there is very minimal tension on the wound, thus allowing it to heal better and fade into imperceptible scar.
With the brow lift forehead technique, the renowned plastic surgeon says he is able to release the brow and the entire forehead skin, including the area above the bridge of the nose. To achieve a more natural result, he highlights the importance of lifting the tissue more laterally, as opposed to a “straight up” elevation.
By focusing on the lateral aspect of the forehead, he can reshape the tail end of the brow, which tends to droop with advancing age. Nevertheless, he says brow lift is a surgery by millimeter in a sense that the amount of elevation must be very precise to avoid surgical stigmata such as startled expression or overly tight appearance.
A forehead lift with Botox might be a good alternative to surgery, especially if the patient does not want the prolonged social downtime or has a medical condition that precludes elective surgery.
Botox works by paralyzing a certain group of muscle that is responsible for wrinkles or drooping brow appearance. Upland plastic surgery expert Dr. Tarick Smaili says the procedure is most predictable when used in the upper third of the face, specifically the forehead lines, crow’s feet, and glabellar creases or “11” lines between the eyebrows.
Photo credit: Ambro at FreeDigitalPhotos.net
While forehead lift with Botox can provide rejuvenating effects, a more conservative approach (or less injected volume) is ideal to achieve natural-looking results.
If the tail of the brow sags, injecting a small amount of Botox above the upper lid can create some lifting effect. In doing so, some patients may also notice improvements in their eyelid platform, thus eliminating or at least postponing the need for an actual eyelid surgery.
Aside from lifting the brow that has sagged, judicious Botox injection can also reshape it (more arched in women, or more horizontally oriented in men) based on the patient’s cosmetic goals, gender, and underlying anatomies.
The good thing about Botox injection is that it truly is a lunchtime treatment, allowing the patient return to her work or usual routine. However, some may experience slight redness and bruising, which tend to disappear after a few days.
But Botox in patients with excess, loose skin and significant brow descent cannot expect the same amount of improvements provided by a surgery.
Forehead lift surgery typically uses a few incisions behind or within the hairline to lift the sagging eyebrow and soften the horizontal creases. But for someone with a significant brow descent, an ear-to-ear incision across the top of the scalp might be a better choice.
Also, the surgery’s results can last for many years, while Botox is supposed to be repeated 2-3 times a year to preserve its effects. For this reason, in the long run a forehead lift is cheaper than its non-surgical alternative.
Occasionally, Botox and forehead lift are combined to achieve a more youthful countenance. Dermal filler injection could further enhance their results by correcting the hollowed orbital rim or “skeletonized” eye socket.
Dermal fillers, also referred to as volumizers, can also provide some lifting effect when injected into the skin below the tail end of the brow, as suggested by some Upland plastic surgery experts.
A brow lift surgery removes or softens the horizontal lines across the forehead, raises the sagging brows that may cover some part of the upper eyelids, and eliminates the “11” lines between the eyebrows.
Depending on the amount of excess skin, forehead height, hairline (or hair loss problem if there is any), and skin quality, the surgery may involve one continuous incision from ear to ear, or 2-5 shorter cuts behind the hairline.
Beverly Hills plastic surgeon Dr. Karan Dhir says the traditional brow lift called coronal technique can make the forehead look higher by increasing the space between the hairline and the eyebrows. This is an issue for someone whose preoperative forehead is already large.
During a coronal brow lift, an ear-to-ear incision behind the hairline is created to lift the saggy skin and deeper structures. But due to such “mechanism,” it is only ideal for patients without a high forehead and do not require specific or “spot” correction of their brows.
The distance between the incision and the brow gives a coronal lift less accuracy when it comes to brow elevation. Another potential risk is the bald patch, which happens if there is an excessive amount of trauma/injury to the hair follicles and their surrounding blood supply.
Due to the side effects of coronal brow lift, a growing number of plastic surgeons are becoming partial to the use of minimally invasive techniques in which shorter incisions behind the hairline are used instead of one straight cut.
One popular technique is called endoscopic brow lift in which 2-5 small incisions are created so that a fiber-optic camera (attached to a screen) allows the surgeons to view the deeper structures of the forehead.
Another less invasive approach is the lateral lift in which a small temporal incision on each side of the face is used to lift the lateral brow, resulting in an elegant, more rested appearance. Some experts believe that a good number of patients will benefit from this procedure because it is quite rare for anyone to need her/his entire brow to be lifted.
A lateral brow lift is particularly suitable for male patients whose brow is innately lower and appear “heavier” than women’s. For this demographic, aggressive lifting of the forehead skin can either lead to a quizzical look or effeminate appearance.
In general, minimally invasive brow lifts will not alter one’s hairline or lead to a higher forehead.