Brow lift

The problem is the position of the brow, and through that the expression around the eyes. A low brow, or a low tail, can make the upper lid look heavier than it is. In more marked cases the low position is enough to push the lower eyelids down and press over the eyelashes, and to limit slightly the upper lateral field of vision. Some patients remark after a brow lift that their environment seems brighter, simply because the eyes sit a little more open.

A low tail is often a hereditary feature. It is also produced by years of straining around the eyes, and by the ageing process itself. Non-surgical treatments that change muscle tone can lift the brow a little. When the lateral part of the eyebrow has been low from a young age, surgery tends to produce a more reliable change than toxin alone.

The operation can also take up a modest amount of spare skin in the upper eyelid. That is useful, but it is not a substitute for blepharoplasty when the lid itself is the main problem. Upper eyelid surgery is assessed together with brow position and shape — the sentence already on the blepharoplasty page — because treating one and leaving the other can look unfinished.

The endoscopic-assisted brow lift is the operation we use when both the tail and the rest of the brow need to move. It is a composite movement of the forehead, not a single pull on the outer brow. The oblique vector raises the tail. The vertical vector maintains the arch. Used together they avoid the two common errors of this area: a purely lateral lift that flattens the brow, and a central lift that leaves the face looking surprised.

The operation uses four or five access points within the hairline. After the attachments of the soft tissue to the rim of the bone have been released, the tissue is repositioned and supported with a variety of techniques. It can be carried out under general anaesthetic or under local anaesthetic with intravenous sedation. On its own it usually takes 1 to 1.5 hours, and the endoscopic approach is typically a day-case procedure. When eyelids or a facelift are done in the same sitting, the anaesthetic plan and the length of the day change with that combination.

The hair is not shaved. The direction in which the hair follicles grow through the skin is part of the planning of the incisions. If the incisions are bevelled to a similar angle to that growth, the scars take on their most discreet appearance. The wounds within the hairline tend to produce very faint lines that are difficult to notice once they have settled.

A smaller version of the same idea, the temporal lift, is used when only the tail of the eyebrow is low. Access sits within the temple hairline. The rest of the forehead is left alone. That is the proportionate choice when the centre of the brow is already in a reasonable place and the problem is confined to the outer third — whether that is hereditary, the result of straining around the eyes, or the way the brow has aged.

The temporal lift is also the operation that often travels with a deep plane facelift or a short scar facelift. A more vertical facelift vector pushes skin toward the temple. That excess can be managed by extending the facelift scar along the temple hairline, or by combining the facelift with a brow lift. The second option also reshapes brow position and the relationship between the brow and the upper eyelid, which is why it appears so often in the same sitting.

The live page already lists several forms of forehead lift. They remain relevant as options, not as a menu from which every patient should pick.

• Endoscopic-assisted brow lift — keyhole access within the hairline; composite movement of the forehead, with particular effect on the lateral brow and, when needed, the central brow as well. Usually 1 to 1.5 hours; typically day case.

• Temporal lift — the lateral brow only, through scars in the temple hairline.

• Combined eyebrow elevation and hairline advancement — the scar sits at the edge of the hairline, used when the hairline itself is part of the plan.

• Open forehead lift — a longer scar within the hairline. Less commonly used now, because the endoscopic and temporal approaches cover most of the work with a smaller wound.

The alternatives to these operations are non-surgical treatment with Botulinum toxin, a gliding brow lift, and a direct excision brow lift, which is carried out by removing a strip of tissue just above the eyebrows. Toxin changes muscle tone and can lift the brow a little; it does not reposition tissue that has descended, and it does not last in the way a surgical lift does. Direct excision puts the scar immediately above the brow. It can be the right choice in a selected face, but the scar is in a more visible place than a bevelled hairline incision. The gliding brow lift is another surgical method of moving the brow. Which of these is proportionate is an examination finding, discussed at consultation.

The brow, the upper eyelid and the outer corner of the eye are read as one unit. A brow lift can reduce a modest amount of spare skin in the upper lid and can open the outer eye. When the lid has its own excess, or when the fold and the fat pads need work, blepharoplasty belongs in the same conversation. Doing the lid and leaving a low tail in place often leaves the outer eye looking heavy. Doing the brow and leaving a true lid excess can look the same from the other direction.

When brow, face and neck laxity are all significant, the coherent plan in our practice is a deep plane facelift with a deep contouring neck lift and a brow lift. That combination reshapes the upper, middle and lower thirds together and reduces the contour artefacts that appear when one third is treated and the others are left behind. When the neck contour is already reasonable and the facelift is a short scar operation, the brow lift is still often included, for the temple excess and for the outer eyelid contours.

We have combined our own work in 3D evaluation of facial shape with anatomical study, so that the plan can be tailored to different facial characteristics. For the brow that means looking at height, the arch, the tail, the relationship to the upper lid, and the way the two sides already differ. A simulation is a planning tool. It is not a photograph of the outcome. There are always some differences between a simulation and the surgical result, and that limit should be part of the same conversation as the image.

A brow lift changes position and shape. It does not treat forehead lines or the quality of the skin as a primary aim, although a forehead that sits in a better place can make those lines less conspicuous. Texture — sun damage, crepe change, the etched horizontal lines of long-standing expression — is a mixed surgical and non-surgical problem. Toxin, skin treatments and the lift can sit together. They do not replace one another.

The consultation is where the target is named. Come with a list of medicines and previous procedures, and with a clear sense of what bothers you — a tired look around the eyes, a low tail that has always been there, a preoccupied expression you do not feel, a difference between the two sides, or spare skin in the upper lid that may or may not be a brow problem.

Medical history and current medicines matter. Blood thinners raise the risk of bleeding and have to be managed around the operation. Raised blood pressure does the same. Both need to be known and planned for; they are not incidental details on a form. Other conditions and medicines remain relevant and are taken in the usual way.

Fees are confirmed in writing after consultation. A figure offered before the plan exists — isolated temporal lift, endoscopic brow lift, or the same sitting as eyelids or a facelift — is rarely a useful one.

The endoscopic-assisted brow lift, on its own, usually takes 1 to 1.5 hours and is typically a day-case procedure. You go home the same day once you have recovered from the anaesthetic. When the brow lift is combined with eyelid surgery or a facelift, the length of the operation and whether an overnight stay is wiser follow that larger plan.

The first days are about swelling around the forehead and the upper lids, a tight feeling in the scalp, and bruises that can drop toward the eyes. The hairline wounds are small. They still need to be kept clean and not put under tension. We use manual lymphatic drainage in the practice after facial surgery to help the early swelling settle; whether that is part of the isolated brow-lift pathway should be confirmed for this page.

Most people can work from home once they are comfortable being seen on a screen. A return to an office and to exercise follows as the swelling and the tightness allow. Sleeping with the head up in the first nights helps. The scars in the hairline fade over months rather than weeks. Numbness or altered sensation in the scalp can last longer than the bruises and usually settles.

Any operation around the forehead carries the general risks of anaesthetic, bleeding, infection, delayed healing and an unsatisfactory or asymmetric result. Specific to this area are a change in scalp sensation, hair loss or thinning around the incisions if the follicles are not respected, a brow that sits too high or too central, and a difference between the two sides that remains visible because the sockets themselves are not symmetrical. A lift that is only central produces the surprised look already described. Over-elevation of the tail can look theatrical. Both are planning errors as much as healing ones.

The aim is a brow that belongs to the face, with an arch that still reads as that person, and with scars that sit inside the hair. There is no honest way to promise that every face will reach that point in one operation.