Brow Lifts: The Most Underrated Operation in Facial Rejuvenation

In this episode, Dr. Jejurikar and Dr. Pacella tackle one of the most underappreciated operations in cosmetic plastic surgery: the brow lift. Most patients never come in asking for one. They come in saying they look tired, they want something done about their eyes, and the brow is the hidden culprit. The guys break down why the high, pulled look of the 1990s coronal brow lift is outdated, why endoscopic brow lifts tend to disappoint over time, and why the subcutaneous sliding brow lift has become their preferred approach. They also get into the role of fat grafting in brow rejuvenation, the hemostatic net technique, and how Botox fits into the picture long-term. For male patients, the conversation shifts to brow stabilization rather than elevation, including the direct brow lift and the scarless trans-palpebral approach. If you've ever wondered why your upper eyelid surgery didn't give you the result you hoped for, this episode might explain why. 

Transcript

SPEAKER_02 0:00

I think women in general are more attuned to using Botox and having a smooth forehead. You know, it's very rare that we may have. You're not doing a lot of Botox. Okay. I think I think it's San Diego. People are just squinting a lot for getting in the sun.

SPEAKER_00 0:13

All right.

unknown 0:17

Dr.

SPEAKER_01 0:17

Jay, how are you doing this morning? I'm doing great. I'm loving our new locale. This is our second season of the podcast, and this that is beautiful. We're trying something new this season. So I think this is going to be amazing. Looking forward to uh everything that we have in store for the viewers.

SPEAKER_02 0:32

So we're going to be talking about a really fantastic concept today, an operation that I think is really underrated in cosmetic plastic surgery, brow lifts. So brow lifts, tell us a little bit about the evolution of brow lifts. Kind of what in your training, what did you learn about it? How did you learn to do the operation? Who's it for?

SPEAKER_01 0:53

Yeah, I mean, I think brow lifts are a really interesting conversation to have with a patient because a lot of times I'll start talking to them about an operation and it's not even something they actually contemplated. But if you think about it, you know, no very few people look at themselves, evaluate their signs of aging, and think, oh my God, I have low brows, I need to do something about it. What they usually come in and they tell us is that, hey, I look tired. Um, I've got excess skin along my eyes. And what you have to try to explain to people is that when you know the eyelid basically ends on the lateral canthus, you know, we can look in the mirror and see where I begins and ends, but a lot of times we have hooding that goes beyond that. And so what one of the things that I have to talk to a patient about is why they might actually even need a brow lift. Sometimes we weren't even contemplating that. So in our training, um, you know, the concept of what constituted a youthful brow was very different than what we think it is right now. If you think about the brow lifts that we did in the late 90s, early 2000s when we were training, the concept was the more you pulled the brow up and the less skin you had around the eyes, the more youthful somebody looked.

SPEAKER_02 2:05

I don't think we think that's the right aesthetic anymore. Well, let's let's stop right there for a second. So I want to say that when I agree with you, you know, throughout our training, it was all about raising the brows up, right? And I gotta say, through most of my career, when I've used that approach, patients come out looking like Nancy Pelosi, right? Look terrible. Just brows really high, over resected. So, you know, I really spent a lot of time in the last few years really trying to understand brow anatomy and brow aesthetics. So, you know, I have I give a talk um at some various meetings, and there's a couple pictures of some really beautiful ladies. I have a picture of Sophia Loren. Okay. Sophia Loren has a very high brow, and she's got a little bit of TOSIS on her eyelids.

SPEAKER_01 2:52

I do think for our audience, they may not know Sophia Lorenz.

SPEAKER_02 2:55

But we're gonna show a little picture here still. Sophia Loren has a very unique brow. Yeah, okay. Somebody who's very similar to her, newer generation, um, Gigi Hadid, okay. She's got a very rounded looking brow. But then you look at somebody like Heidi Klum, who has a very flat brow. It's very tapered out towards the sides, right? And so if you took Heidi and you tried to do a traditional brow lift like we learned in the 1990s, she's gonna look terrible, right? Yeah. So it's to me, there arguably there's no other operation in plastic surgery that needs to be tailored exactly to the patient's youth as a brow lift.

SPEAKER_01 3:35

Completely agree with that. And I think the other thing, too, which you probably touch on in your talk, is much like other places of the face, a loss of volume of the brow can contribute to aging. And so what we're realizing is pulling up higher is not the answer for virtually everybody. It's creating a look that matched what they were when they were younger. And a lot of times they've actually deflated as well. And so I find fat crafting to be a really relevant part.

SPEAKER_02 3:58

Okay, so let's talk about that for a second. So, traditional brow lift, the way maybe some old school surgeons have done it, coronal brow lift. Do you ever do that operation anymore?

SPEAKER_01 4:08

Um, about once or twice a year, I'll do a variation of a coronal brow lift. So, what's a coronal brow lift? First of all, coronal brow lift is an operation that's typically one or two centimeters behind the hairline. You're basically, for lack of a better term, scalping the patient. You know, you are uh cutting all the way across the top of the head in the traditional form of a coronal brow lift. Um And that sounds brutal to me. I hate that operation. I love I love doing that operation, but talking to the patient when their scalp was numb for months afterwards, when they would lose hair around the incision, yeah, it's it's it's it's a it's a problematic operation. In the traditional form of that operation, we operate in the plane just on top of the bone. Um and what I find, and I think you'd probably agree with this, is that even when you do that, you don't fix two issues. One, you don't really fix wrinkles between the skin and the underlying muscle. And two, um, you know, the longevity of it is is quite good, um, but the patients have a lot of morbidity afterwards. They feel a numb scalp for a long time, um, and they will commonly lose hair, even transiently for several months, which is really, you know, really disfiguring. So I say I do a variation of it. The variation I'll do once or twice a year is uh in patients who have really strong um wrinkles across their forehead. I'll do one at the hairline itself, so a variation of a coronal brow lift. Um but you're doing it on top of the bone, right? I'm not. So I'm doing I'm doing it in the subcutaneous plane, so in the plane between the muscle and the skin, which I tell them poses a little bit more of a risk from a healing standpoint where the skin's involved, but it's the most powerful way I have to release really deep set wrinkles.

SPEAKER_02 5:50

But the traditional coronal brow lift was cut all the way down to bone and jacked up really, really high. I never do that, and you never do that. Yeah. No, I mean uh I would say that a variation of what I may do every two years, perhaps, is somebody who has a very high brow that needs to be lowered. I think that's an option for doing a coronabrow lift.

SPEAKER_01 6:11

A high hairline, probably.

SPEAKER_02 6:13

High hairline. Yeah, exactly. Yeah. Um what about endoscopic brow lifts? Yeah.

SPEAKER_01 6:17

So I still have people asking about those.

SPEAKER_02 6:20

So endoscopic brow lifts, that's I would say for most of my career, that is the operation that I had done, right? And you know, the idea is you make a couple little tiny cuts on the top of the brow. You may make a little zigzag cut along the side of the brow, and it's all about the plane that you're in. On the side of the brow, you want to be right on top of the what's called the fascia, right? But as you get towards the middle here, there's a really thick band, and that band extends along the brow and then along the cheekline here. Okay. And so the camera, we put the camera in to elevate all this, right? And the problem is, is it looks really awesome for the first couple months. And then I found throughout my career that these things drop down. And it really is related to this attachment of tendon kind of along the cheek area. You have to go down and release this, and even when you do, there's no way to really fully release it. And I just think these muscles are always pulling things downwards and downwards and downwards. And I've just been really dissatisfied with that operation.

SPEAKER_01 7:22

Your thoughts. Yeah, I think what you're saying is is very true. Um meta-analyses that have done where they've looked at endoscopic brow lifts through a variety of different fixation techniques. So the other portion of an endoscopic brow lift is how you hold everything up, and people will drill tunnels into the bone. They'll use suture to hold it to the bone, they'll use these little um little devices, these like little tines called endotines to hold it there. Regardless of the type of fixation, when you look at long-term results with endoscopic brow lifts, results are kind of disappointing. And it's exactly for the reason you said I hate to always agree with you here, but it's release, inadequate release is very, very common with endoscopic brow lifts. And so I find that operation to have completely disappeared from my armament area. So then I know we do some similar things. Tell me how you are doing your brow lifts as your preferred method right now.

SPEAKER_02 8:15

So about five to six years ago, I switched to uh what's called a subcutaneous or um gliding or sliding brow lift. You may have some various uh descriptions in the literature or various surgeons, right? Um, so what I do for that is very simple operation, could be done in the office setting, do it very frequently in the office. Uh, I make a little zigzag incision along the side of the brow here. The idea is we want to raise the brow up laterally and obliquely. We don't want to do it vertically necessarily, right? And to me, I'm always doing this in the setting of a lower blefroplasty or an upper bleferplasty. And what I'm doing is I'm trying to raise that tissue up from the side and to avoid redundancy just underneath the eyelid. So we go underneath the skin for this. Um, we try to go relatively superficial and then down to the level of where the hair-bearing brow is. And so then I put some placation sutures on the inside to take off the tension, trim the hair very, or trim the skin very lightly. We don't want to really put a lot of tension on the incision because that could cause hair loss. And then I use uh some plication sutures that are on top of the skin. Um, there's a big buzzword in plastic surgery, something called a hemostatic net. Um, surgeons do it various differently. They may take a proline suture or a big thick plastic suture and do a running stitch. I like to tie this down with what's called a pledge. Um, it's a a little piece of gauze that we tie down uh on top of the uh knot so that it doesn't corrosive the skin. And um the disadvantages of the technique, I think you know, the skin sometimes is a little bit tenuous, so you got to be very careful with how you pull it. But the other challenge with a subcutaneous brow lift is what we talked about at the beginning of the podcast, which is fat, right? So tell me a little bit about how you manage adding fat into the brow if you're doing a subcutaneous brow lift.

SPEAKER_01 10:09

I don't really struggle adding fat when I'm doing a subcutaneous brow lift because I'll inject the fat into the superperiosteal plane. So for our viewers, we have skin, fat, muscle, bone, and that's the order that it goes. I'm elevating a subcutaneous brow lift, I'm elevating in a plane that's superficial to the muscle, and I'm injecting the fat deeper to the muscle. I'll use relatively small amounts, one to two mLs of fat, of fractionated fat into that area to add a little bit of volume. And typically I find that it I'm I'm able to hold it where I want to by putting in a different anatomic plane. Just one or two CCs? Um if I'm doing it in combination with the brow lift, yeah. Um let's talk about the hemostatic net just a little bit as well.

SPEAKER_02 10:54

Because I think Because that's the challenge, right? If you to me, that's what I meant by the challenge is if I'm suit if I'm putting fat into the brow, what am I doing with those sutures? Because I don't want to necros where I put the fat. I don't want to displace where I'm putting the fat, right?

SPEAKER_01 11:08

Um sure, but the timing of it matters a little bit too, right? In terms of the timing that you're doing your operation. So um you can always add your fat afterwards. And that's typically the time where I will do it. So the order weeks afterwards? No, no. So, so I mean, usually when I'm doing a brow lift, you were talking about doing it in the office. Commonly, when I'm doing a brow lift, more often than not, I'm doing it in combination with an upper and lower eyelid lephroplasty and a facelift and a necklift at the same time. Order in which we do it, we harvest the fat first, and I immediately go to doing a subcutaneous brow lift. Subcutaneous brow lift is a very fast operation. Um, it is something that I can typically do in 15 to 20 minutes. You were describing a zigzag incision in the hairline. I make a two and a half to three centimeter incision now that's really small just behind the hairline. The dissection is very quick. And then I find the hemostatic net to be useful because you're creating points of fixation between the skin and the muscle. So you are distributing the tension not just on the incision, but uniformly throughout the skin so that you're gonna get less hair loss. Around the time that I'm finishing the hemostatic net, and the other thing I'm doing with the hemostatic net, by the way, is you know, we touch on the lateral brow, but depending on the amount of dissection you do immediately, you can actually shape the inner portion of the brow as well. I also use pledgets like you do. I have in the past not used pledgets, and and although the little track marks go away, I find that it takes much longer for it to go away, and the patients are a little worried for three or four weeks afterwards. As soon as I'm done with that, my fat's ready to inject, and that's the timing that I inject my fat. And I typically don't have problems putting it where I want to. I do it after the hemostatic net in that area.

SPEAKER_02 12:50

So you do it after the hemostatic net is removed.

SPEAKER_01 12:53

After the hemostatic net is placed. So 30 minutes. You know, that it takes, I'm usually harvesting 50 or 60 cc's of fat total for patients.

SPEAKER_02 13:04

But don't you don't you find that that limits where you're putting your fat? I mean, if you're so are you putting the net kind of a little bit more posterior?

SPEAKER_01 13:11

Like I'm putting the net over the lateral brow, the non-hairbearing brow. And I'm not putting it directly on the brow, I'm putting it all throughout the skin. So no, I don't, I don't tend to have that that it's not been a problem that I've encountered.

SPEAKER_02 13:26

Good. Awesome.

SPEAKER_01 13:27

Let's talk about a couple things um philosophically. So, how has Botox in the world of aesthetic medicine changed the frequency with which you do brow lifts?

SPEAKER_02 13:37

I would say it hasn't, really. Um, you know, Botox to me is a tool that helps with the center of the brow, to me. Okay. And, you know, occasionally we inject Botox into the lateral crow's feet area. That can give a little bit of brow elevation. You know, maybe good for younger patients. But doing a brow lift, years ago when we would do endoscopic brow lifts, we would cut these muscles called the globeller muscles right here. And to me, that looks terrible. It just looks like the the brow gets widened over time. It just looks scooped out. I'm not at all pleased with it. So the nice thing about the way we're doing brow lifts today is they're a little bit more minimally invasive. The trade-off is you still have to treat these muscles here. So doing a brow lift does not negate the fact that I need to still use a neuromodulator or Botox or Discord or something.

SPEAKER_01 14:29

Yeah, and I think philosophically I'm I'm different than that. Um there's many of my patients that have probably gone decades without having some sort of neuromodulator, whether it's Botox or a competitor in them. So, one, they'll present in a manner where they don't have as much brow descent. I disagree that it's just helpful for the medial aspect of the brow, for the inner brow. I do think that when you inject the tail end of the lateral brow depressors and the, you know, in the orbicularisoculli muscles, that you do get some brow elevation. Three or four millimeters can be enough to help with hooding. Because again, the majority of my patients are rarely coming to me saying that the brow is an issue. They're much more concerned about the lids. About the lids. If you get fixation of the brow a little bit higher, three or four millimeters, that may be the difference between a relatively simple in-office blephroplasty or a more, you know, more uh drastic recovery.

SPEAKER_02 15:25

So you're to you're saying that when you're injecting Botox laterally here, you're getting three to four millimeters of brow elevation.

SPEAKER_01 15:32

Well, again, I I don't I rarely inject Botox myself, but uh let's say it's usually usually injectors in my practice. But yeah, I think I think you can, I mean, I I think um that that's that's an accepted thing where you can get just a few millimeters of elevation laterally when you do the tail of of the orbicular as oculine, you can you can get some elevation. Just a little bit is all you need to help with that.

SPEAKER_02 15:55

But to me, it's just a matter of time before that drops back down. And I think patients are a little bit unhappy. I mean, you know, early in my practice, I was, oh, this is a chemical brow lift, this works really well. And I think for the first year or two, they're pretty happy with it. But I guess that's the inevitable laws of aging. They just come back for a brow lift or a blef after.

SPEAKER_01 16:14

And I think if we look at our relative foreheads, right? Like you and me, 25 years of nonstop Botox, there's a change in how people age. I mean, you know, minimalist. Yeah. So I think I look at these, look. See that? It moves. So but but I can move my brow a little bit. But I mean, but but I but I do think many of the patients that we see in our practices, if they've had decades of Botox, their brow is not aging in the same manner. I really genuinely believe that.

SPEAKER_02 16:43

Yeah, yeah. And I would say, you know, the fat loss that we see just looks much worse when you've had 20 years of Botox. The fat loss in the temporal region. You know, so you have you not only have loss, fat loss related to aging, but you also have the fat, the muscle atrophy centrally. And I think that just skeletonizes the upper brow, you know. So to me, the years of Botox make doing a brow lift a little bit more challenging for volume.

SPEAKER_01 17:16

Yeah, I mean, I I think that's true. I I don't really have many people in my practice that haven't been on Botox for a long time, though. And I bet that's probably true with you too. It's not a question we always ask. Now there is uh there are a couple of operations that we that you perform that I don't. Um there's a direct brow lift. Uh you want to explain to people what that is?

SPEAKER_02 17:34

Yeah, so let's kind of shift a little bit. So now I think we we're kind of talking about variations in men, right? Okay. So in men, I think it's a different beast, right? If you I constantly tell my male patients, they come in, we talk about the eyelids, and they and I talk about elevating the brow, or what I like to do is talk about stabilizing the brow. Okay, very different concept. Say, I don't want to look like Kenny Rogers, I don't want to look like um Barry Manilo. You know, these guys have really high brows, it looks very unnatural, very overdone. Okay, so to me, men want an elevated brow, but it should be flat and it should be stabilized. Okay. Two really straightforward operations I do, which I absolutely adore, are one called the direct brow lift. And what that is, is men oftentimes have a pronounced um bunch of wrinkles in their forehead. Okay, unless they're like you, of course, they have no wrinkles.

unknown 18:31

Okay.

SPEAKER_02 18:31

But most of the men I take care of have a little bit of sun damage, a little bit of wrinkling. It's here in San Diego, so you know. Um, so we arbitrarily choose one of these lines, we excise a little bit of skin, and I can undermine at the brow and really tailor that to raise the brow upwards. Now, the big disadvantage is you're gonna have a scar there, but that scar really fades nicely right within that natural crease.

unknown 18:56

Okay.

SPEAKER_01 18:56

The other operation I do, if you let me ask you two follow-up questions on that first. Go ahead, please. Do you do that operation on men of all skin types? And do you do that operation in women?

SPEAKER_02 19:06

I don't usually do it in women because in general, women require a a bit of a higher elevation of the brow, which I can't necessarily achieve with that front incision. And, you know, like you said, I think women in general are more attuned to using Botox and having a smooth forehead. You know, it's very rare that we may have You're not doing a lot of Brotox.

SPEAKER_00 19:26

Okay. Okay.

SPEAKER_02 19:29

Yeah, we've I I think I think it's San Diego. People are just squinting a lot for getting in the sun. Oh right. Um, so go ahead.

SPEAKER_01 19:36

Sorry. What about uh all skin types? Will you do that operation of men with skin like mine? Or uh are you worried that the scarring might be visible?

SPEAKER_02 19:44

Yeah, so in darker skin types, Fitzpatrick, four or five, okay. Um, that's a little bit out of the tougher operation. So I think scar can pigment a bit, it can be a little bit more visible if your skin tone is a little darker. So what do I do in those scenarios? Well, there's another operation which was taught to me by one of my mentors, Dr. Nahay, a little shout out to him. Uh, it's called a transpalpral or through the lid brow lift. And so, how do we do that? Well, during the upper bleproplasty, we excise the skin, then we go underneath the brow and put a couple stabilization stabilization sutures on the brow. And so, what that does is it's not really elevating the brow, it's just stabilizing it from dropping. The disadvantage of that technique is sometimes you can see a little indentation of the sutures along the edge. Those go away over time because they're all absorbable sutures. Um, the massive advantage to this operation is no scar. The only scar is the upper eyelid. And I think that is an operation that I truly believe in and have believed in for the last 18 years.

SPEAKER_01 20:44

Yeah. And I and I But you don't do that, right? I did that operation when I was in Manhattan I'm doing my fellowship. Um, you know, I guess I never viewed it in the same way you just explained it. I found it to be very underpowered for elevating the brow, but you're not using it for that. You're using to stabilize the brow. So I think if I were to limit the application to male patients strictly for brow stabilization, I would I think that that would actually make a lot of sense to me. I think I have very few patients that fall just into that category. Typically, if I if I'm trying to do something on a man, there's at least a little bit of brow elevation. So I don't, I don't really find that operation to be that useful for me. Well, I think we've covered sort of the full gamut that there is to talk about with brow lifting surgery. You know, I think um what I would try to impress upon viewers is that brow lift surgeries, even though you may not have heard it, if it's not performed, many times it's the number one reason why a blephyroplasty or an upper lift doesn't give you the uh the appearance that you want.

SPEAKER_02 21:46

Yeah, and I think, you know, my my last point would be that I think it's I think a good chunk of upper orbital periorbital rejuvenation should be with a brow too. It's Very rare that I would do an upper blepherplasty without doing some sort of brow procedure. Okay. Um, well, want to thank everybody for joining in and thanks for this latest episode of Beauty and the Beast podcast. Dr. J. Cheers. Cheers.