Speaker 1: Welcome to Plastic Surgery Talk with Dr Stephen Mulholland, brought to you by SpaMedica.
Dr. Mulholland: Hello and welcome, Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk. Welcome to our latest installment of our podcast series. This podcast is on a brow lift, the modern approach to brow lift surgery. If you’re interested in these podcasts, you find them interesting or entertaining, please subscribe, share and comment.
So, what is a brow lift? A brow lift is a surgical repositioning of the eyebrows, such that it provides a more aesthetically pleasing upper facial, upper lid and brow unit. It can be subdivided into a full brow lift and repositioning, a tail of the brow repositioning, or even a central brow repositioning.
So, the modern approach to brow lift surgery has been limited access, subtle, to focus repositioning of the droopy or the ptotic, as it’s called. The ptotic meaning droopy elements of the brow that gives a more pleasing look to the eyebrow contour and accentuates the upper lid appearance.
So, how are brow lift performed? Well, it depends on the type of brow lift. Typical brow lift performed in a woman now is going to be a limited port incision. That means small access ports in the hair, so it’s hidden, no longer extending from ear-to-ear, like when I trained in the ’80s. The old bicoronal incisions typically aren’t done anymore, unless it’s a very, very heavy-browed, older patient, male or female.
Typically [means 00:01:36] unlimited access, small port access, undermining of the soft-tissue envelope, and then repositioning and fixation with high tech techniques, such as tying the middle fixation by absorbable screws or by absorbable constructs that hold the brow in place and then dissolve away, bioabsorbable suture suspension threads that hold the elevated brow up until the brow heals to itself, and then that focused elevation brow can be a longterm result.
Who’s a candidate for a brow lift procedure? Well, any patient, female or male, that has droopiness or heaviness of the brows, where the brow itself subtends or descends upon and over the orbital rim, and leads to a very excess folds of skin of the upper lid. It can be combined with or without an upper lid blepharoplasty or upper lid job.
And typically, we start with elevating the brows, and then see how much lid skin or excess flesh remains. And then, take away a little bit of the upper lid skin and tissue, and that’s called an upper lid blepharoplasty. It’s very common to perform those two in tandem.
So, a male or female candidate who are medically well, who don’t have any ocular pathology, such as dry eye syndrome, or lid closure abnormalities, or inflammatory conditions of the eye, or untreated and undiagnosed glaucoma, or macular degeneration. Any of the common medical conditions of the eye need to be treated first.
Most patients generally have to have reasonable expectations of what can be achieved. And typically, they need to have hair to hide even the very small, limited incisions, like the one or two centimeter incision ports we now use.
If a patient happens to be male and completely bald, we do have a brow lift that can be done through the upper lid incision, called a transblepharoplasty brow lift. And the transblepharoplasty brow lift, or TBB, is a nice elegant way to elevate a very hooded tail of the brow on a male patient.
So, the best candidates have reasonable expectations, reviewed the informed consent document for risk and benefits, don’t have any medical, uncontrolled medical conditions, and are willing to undergo a procedure that requires a good week of recovery.
Contraindications to a brow lift would be unrealistic expectations, uncontrolled medical conditions that negate the ability to do surgery. Periocular eye issues that are unresolved, such as medical eye conditions, poor eye closure, dry eye syndrome. These are the common contraindications to surgery.
Of course, a woman shouldn’t be pregnant, and should have no inflammatory conditions in the region of the surgery or undiagnosed lesions in the area of the surgery that haven’t been managed.
So, what are the specific steps of a brow lift? Well, typical brow lift, for a male and a female, is designed to selectively elevate the droopy elements of the brow. Typically, that will be the outer half or third, called the tail of the brow. Elevating that tail of the brow elevates some of the droopy elements of the upper eyelid and that can allow us to be a more limited incision, upper blepharoplasty.
So, we start with local anesthesia. Often, brow lifts are performed under local anesthesia, with some light oral sedation. The subcutaneous envelope of the skin is elevated off the bony aspects and the deep muscle of the brow, and that can be done in several manners and techniques.
Bits of excess brow in the hairline can be excised, and then fixation and stabilization can be occurring through very, very small ports. I typically use a barbed by absorbable sutures to support the brow while it’s healing, then it heals to itself.
And typically, patients need to have their brow wrapped and protected for about five to seven days, so typically, about one week off work until they’re back into makeup.
And again, it is very, very common to combine a brow lift, in a male and female, with an upper lid blepharoplasty. So, we elevate the brow to increase the distance between the eyebrow and the eyelashes, and then remove the unwanted, extra flesh that exists between the eyebrow and eyelash. And that’s called the blepharoplasty.
What’s the recovery from a typical, minimal access, modern brow lift? Typically, about seven days. There’s a little bit of swelling and bruising in the eye area, but typically, that will resolve very quickly. It’s not very painful because a limited access ports and undermining, there’s no numbness in the scalp, no prolonged sensitivity to the scars.
Typically, there’s very little, if any, hair loss, or [to loss fluid 00:00:05:54] or shock hair around the elevation. And patients can look quite good in makeup at one week. It takes up to six weeks for stabilization and elevation to heal, and about three months for the bioabsorbable fixation systems, the tiny little endotines or the bioabsorbable sutures, to go away, and the brow is held together by its own inherent autogenous lifting and wound healing capabilities.
Patients described the postoperative pain as modest. Let’s say, aesthetic surgery could be an eight or nine out of ten with a tummy tuck with muscle work or under the muscle breast augmentation. Brow lifts are typically described as a level one or two out of ten pain, so very tolerable.
Typically, anti-inflammatory medications, all that is required. Occasionally, there will be a drain left under more extensive elevation of the brow, but typically, tail of the brow lifts do not require a drain, and they wear a wrap for a couple of days, that’s removed.
And patient sutures, if they do an upper lid blepharoplasty, come out on day six or seven. The little sutures, the tiny ones inside the hairline, are removed within that one week period, and most patients are back to work on the eighth to the tenth day.
What kind of results can a patient expect from a brow lift? Well, typically, the results are customized to the needs of the patient. Is it a full brow elevation? Is it the middle part? Is it the tail of brows? Or the middle and the tail?
So, we customize the anatomic locations are going to be elevate. We customize the limited incision approach to the access. We customize how many millimeters the tail of the brow actually needs to be elevated, but patients can expect a customized, individualized approach to their elevation.
The brow elevation needs to be pleasing, but not over done. You don’t want to look like a scared, startled deer in a headlight. So, a subtle to modest elevation, anywhere between three and six millimeters of brow elevation is typical.
And then, we assess how much upper lid skin exists after the brow’s been reposition, and that is also customized in how much is excised, whether the fat pads are removed, the extent of the incision and the placement of the incisions.
So, I think patients in nowadays, modern brow lift surgery can expect a very customized, modest to pleasing elevation of the brow with customized eyelid contouring and upper blepharoplasty. And the whole effect should be creating a much more youthful, fresh, rested, non-tired look to the periocular eyebrow and eyelid anatomy.
So, how long will your brow lift last and what is the cost? Typically, a brow lift will last five to seven years. With constant pulling down effects of the muscles of facial depression in the brow, particularly the depressors, with ongoing gravity and age, it’s very important that the brow lift patient commit in concept to the idea of doing Botox, to help protect their brow lift.
The Botox will soften the muscles that pull their brow down, allowing the elevators to exert their effect tonically without competition and will make your brow lift last eight to ten years, by simply doing a simple, periocular, post brow lift, depressor muscle, Botox treatments after your brow lift surgery.
The cost of a brow lift is really relative to the amount of elevation, whether you’re doing an upper lid blepharoplasty, it depends on the market and the surgeon. But, typically in North America, most brow lifts are anywhere between six and twelve thousand dollars.
The upper lid blepharoplasty might be another between four and eight thousand dollars extra. So, combination, brow lift, upper lid blepharoplasty, can cost anywhere from seven or eight to fifteen, sixteen thousand dollars, depending on how much elevation needs to be done, the surgeon’s reputation, the market you live in and the kind of aging change that you’re presenting with.
So, what are common combination procedures done at the same time as a brow lift? Brow lift, upper lid blepharoplasty, for sure. Brow lift, upper and lower lid blepharoplasty. Brow lift with a cheek lift or a mid face lift. Brow lift with neck work. Brow lift with lip augmentation.
Virtually, brow lift with any facial procedures, including facial resurfacing for wrinkle reduction, can be a good combination approach. And so, quite often, you’ll go through the areas that concern you, the upper third, brow, upper lid; the middle third, lower lid, cheek; the lower third, jaw line and neck. And then, decide what combination treatments, renovate the whole home or just do the top floor, makes sense to you.
Are there any brow lift of complications that consumers, potential patients need to think about? Well, there are and you need to think about damage to the facial nerve. The nerve that serves the elevator muscle of the brow. Very uncommon to have that injured. I think I’ve had one or two temporary brow weaknesses from muscle stretching that always return, but there’s the risk of injury to the facial nerve to the brow.
There’s a risk of over elevation, looking startle. There’re risk of under elevation, being too subtle. There’s the risk of a scar in the brow, which is small, usually one or two centimeters in length, leading to lack of hair growth in that area and what’s called traumatic alopecia, or hair loss around the scar, that may necessitate PRP, platelet rich plasma, or even inherit transplantation around that area of hair loss within the scar.
There is the risk of sensory loss, even those limited incision, sometimes a nerve, sensory nerve, can be injured and it doesn’t return to full functioning, of an area of numbness, or irritation, or itching or even pain, in the scalp.
The biggest risk is suddenly asymmetries, that one side doesn’t look quite like the other. So, discussing the relative merits of differential elevation depending on the height of each uni brow is a very important part of your preoperative evaluation, with you and your brow lift surgeon.
So, thank you again for joining me on our weekly podcast series. Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk. Our podcast this week was on brow lift, a modern approach to brow lift surgery. If you found this informative, entertaining, engaging, please share, subscribe and comment. See ya next time.