Brow lift

In brow lift surgery, we raise brows that sit low. Brow position and shape change facial expression. If you are considering a change to your whole brow or its outer end, we explain the options while also considering its relationship with the eyelid. We can perform a brow lift on its own or, when needed, together with eyelid surgery.

The inner, middle, and outer parts of the brow may sit at different heights. The surgical plan is based on their position relative to the bony rim around the eye and on tissue gathering over the upper eyelid. Approaches through the forehead and temple provide access to the tissues supporting the brow. Depending on the technique chosen, attachments that limit tissue movement are released, and the brow is repositioned and secured.

Brow drooping and its relationship with the eyelid

The beginning of the brow near the nose, its middle section, and its outer end extending toward the temple may sit at different heights. The location of the drooping affects the brow’s arch. The shape of the entire brow is therefore considered when determining the direction and amount of lift.

When the brow shifts downward, the skin fold over the upper eyelid may increase. Even after brow position changes, excess skin may remain in the eyelid itself. A brow lift addresses the tissues supporting the brow, while upper eyelid surgery addresses excess eyelid tissue. The origin of the fold over the eyelid helps explain which procedure may be considered.

During the examination, the brow may be supported by hand in its anatomical position. Watching in a mirror how the upper eyelid fold changes can help you understand the brow’s contribution to this appearance. The excess skin remaining when the brow is supported belongs to the upper eyelid itself, and this finding guides discussion of eyelid surgery.

Ptosis, meaning drooping of the eyelid, refers to a low position of the lash-bearing edge of the upper eyelid. Brow drooping, excess eyelid skin, and ptosis can occur in the same person, each involving a different structure. When correcting brow position, the function of the muscle that opens the eyelid is also checked separately, because the surgical plan for the height of the lid margin is different.

Straight or arched brow shape, forehead width, and the bone structure around the eyes vary from person to person. The beginning, peak, and outer end of the brow are marked separately to describe the portion being considered for repositioning. During this marking process, you can explain whether you would like to preserve your familiar brow arch or change the position of a particular section.

Visibility of the upper eyelid crease depends on the distance between the brow and eyelid, skin folding, and the position of the eye within the bony socket. When raising the brow is being considered, the examination also identifies which part of this crease is covered. The outer fold and fullness near the nose may involve different tissues. These regional relationships help explain how a change in the brow arch might affect eyelid appearance.

Forehead and temple anatomy

The forehead muscle raises the brows as part of facial expression. Some muscles between the brows and around the eyes contribute to pulling the brow downward and inward. The brow’s resting position relates to the balance between these muscles and the attachments beneath the skin. A photograph taken while the forehead muscle is active cannot, on its own, show the brow’s relaxed position.

The upper rim of the eye socket is the bony border felt beneath the brow. Soft tissues around the brow connect to this rim and to the connective tissue layers at the temple. Releasing the relevant parts of these attachments during surgery creates room for the brow tissue to move. The attachments at the outer brow are arranged differently from those near the nose.

Beneath the skin and subcutaneous tissue of the temple lie connective tissue coverings called fascia. These layers are continuous with tissues in the forehead and side of the face. In a temporal brow lift, these layers connect the entry site to the outer brow, so the incision location and the tissue plane used to reach the brow are chosen together.

The position of the hairline determines the vertical length of forehead skin. The distance between the brows and hairline is considered when choosing an approach within the hair-bearing scalp or along the hairline. Hair distribution at the temples and the shape of the existing hairline also inform the incision plan. People with similar brow drooping but different forehead heights may be considered for different approaches.

Who may be a candidate?

A brow lift may be considered when the brows sit low relative to the upper rim of the eye socket, particularly when outer brow drooping accompanies tissue gathering over the upper eyelid. The examination clarifies how laxity in the forehead and temple tissues contributes to brow position. For example, if the fold that concerns you is at the outer side of the eye, brow position and eyelid skin in that area are assessed separately.

The right and left brows may differ in their starting height, arch, or outer-end position. If drooping is concentrated on one side or in a particular part of the brow, surgical markings follow that distribution. The relationship between brow shape and the eyelid opening is measured separately on each side. The direction of lift is also marked according to each brow’s existing anatomy.

For someone whose brow is appropriately positioned and whose concern is limited to excess upper eyelid skin, an upper eyelid procedure may be considered. Forehead skin lines alone do not indicate a need for a brow lift. If the lash-bearing edge of the eyelid sits low, a separate assessment of the cause of ptosis is needed before lifting the brow.

The decision about a brow lift may be postponed if there is an uncontrolled chronic illness or another health condition that prevents surgery. If you have had forehead, eyelid, or brow surgery, you can share which areas were treated. The tissues involved in previous procedures and the relationship between your desired brow shape and existing bone structure affect the available approach.

Examination and surgical planning

The brow examination measures brow height relative to the bony rim, the distance from the upper eyelid, and differences between the right and left sides. The area you would like to change is matched to the part of the brow that can be moved. The hair-bearing border of the brow and the soft tissue beneath it are considered separately in these measurements.

Brow position in a photograph may differ from its position at rest. Because the forehead muscle raises the brows, their position is observed with the forehead relaxed and during facial movements. This examination in motion shows how outer brow drooping looks at rest and the direction in which the brow moves.

In some people, skin gathering over the upper eyelid may be accompanied by unconsciously holding the brows raised. Relaxing the forehead during the examination may reveal the brow’s lower position. Upper eyelid skin is measured with the brow in this resting position. The brow’s usual appearance in photographs is also included in the examination record.

You can share details of previous Botox, filler, or surgical procedures around the brows during your consultation. Treatments that affect muscle movement may change the relationship between the brow’s appearance in motion and at rest. Previous surgical incision sites also provide information about possible access points in the forehead and temple.

Moving the entire brow upward and directing its outer end upward and outward involve different plans. The location of skin gathering at the outer end, the existing brow arch, and the position of temple tissue guide the choice of direction. Tissue movement during examination by hand helps determine which portion will be released and where it will be secured in the surgical markings.

The line of brow hairs does not always coincide with the boundary of the soft tissue supporting the brow. Plucking or drawing in the brows can change the visible arch. Because the visible line and the tissue position felt by hand are examined separately, the part of the brow to be treated can be described in relation to the underlying structure.

You can come to a consultation without having chosen a particular brow lift technique. A specific description, such as a low outer end, a flattened brow, or skin folding over the upper eyelid, helps identify which tissue your expectation concerns. If discussing an example brow shape, individual anatomical differences such as eye socket width and forehead height are also considered. The same arch sits differently on different bony frameworks.

Endoscopic forehead and brow lift

For brow lifts, we use an endoscopic method, meaning that a camera provides a view from inside. As we advance toward the brow through an incision in the hair-bearing temple, we watch the working area on a screen. With this view, we release the ligaments that prevent the brow from moving upward.

We use sutures to raise the released brow and secure it in its new position. We also close the entry site in the scalp with sutures. We prefer general anesthesia for the operation and perform it in a hospital operating room.

In an endoscopic forehead and brow lift, incisions within the hair-bearing scalp can provide access to tissues around the forehead and brows. A camera shows the working area that cannot be seen directly from the skin surface. Once the attachments of the forehead tissues around the brow are released, these tissues can move in the planned direction. Entry-site locations and the extent of the working area vary according to drooping in the inner and outer brow.

To move the brow into its new position, the relevant parts of the attachments that limit its movement are released. This step, called release, is followed by securing the tissue to the chosen support point with sutures. The location of that point relates to the direction in which the brow will move. The support directing the outer end may therefore differ from the plan for the inner brow.

Other brow lift techniques

Brow lift through the temple (temporal approach)

The temporal approach aims to reach the outer brow through an entry site at the temple. Drooping concentrated at the outer end and the position of adjacent temple tissue define the scope of this technique. Any need to treat the central forehead or inner brow is considered separately. Temporal describes the entry area at the temple, while endoscopic refers to the use of a camera.

Brow lift through the hairline

In a hairline approach, the incision is placed at the boundary between forehead skin and the hair-bearing scalp. This provides access to the forehead skin and tissues supporting the brow. Forehead height and hairline position influence whether this option is considered. The skin to be removed is marked according to the relationship between brow movement and hairline placement.

In a hairline approach, both the height of the central forehead and the direction of the hairline toward the temples are measured. The planned area of forehead skin removal may vary according to the movement needed in the inner brow and outer end. The incision markings therefore include the hairline position on both sides of the face and the shape of the brow arch within the same plan.

Brow fixation through the upper eyelid

Brow fixation can be performed by reaching the tissues beneath the brow through the crease incision used for upper eyelid surgery. In this procedure, also called internal browpexy, sutures attach brow tissue to supporting structures around the upper rim of the eye socket. Treating the upper eyelid skin and outer brow through the same entry site may be considered. The brow area to be reached and the amount of repositioning needed determine the scope of the technique.

When brow fixation through an upper eyelid incision is considered, the mobility of the outer brow and the extent of forehead tissue drooping are examined. Since the entry is in the upper eyelid crease, the working area is connected to that region. If tissues in the central forehead and inner brow also need repositioning, how the surgical scope will extend to these areas is explained separately.

Direct lift above the brow

In a direct brow lift, the incision is placed next to the upper border of the brow, and the planned portion of skin is removed. Bringing the incision edges together changes brow position. The distribution of brow hairs, brow shape, and location of drooping are considered in the incision markings. This approach may be considered in certain anatomical situations where lifting the entire forehead is unnecessary.

How does a Botox brow lift work?

The term Botox brow lift describes a possible change in brow position from reducing contraction in specific muscles that pull the brow downward. This changes the balance between the forehead muscle that raises the brow and the muscles that lower it. The treatment targets this muscle movement. A surgical brow lift involves releasing retaining ligaments, repositioning tissue, and securing it with sutures.

The positional change that Botox may produce depends on how the muscles function initially and on the brow’s resting position. Substantial excess upper eyelid skin or sagging forehead tissue are separate surgical findings. In planning treatment around the brows, the contribution of muscle movement, downward displacement of brow tissue, and excess eyelid skin are defined separately.

Because the forehead muscle supports the brow’s raised position, its function is also part of Botox planning. The muscles pulling the outer and inner brow downward have different distributions. The treatment area is chosen according to which part of the brow’s muscle balance is to be changed. The location of the forehead line and brow movement are examined together in making this decision.

Horizontal forehead lines relate to movement of the muscle that raises the brows, while lines between the brows relate to the muscles in that area. A low resting brow position is a separate anatomical finding. If your concern centers on lines, you can describe how they change with facial expression; if it centers on brow shape, you can describe which part sits low at rest. Surgical options or options addressing muscle movement can be discussed on that basis.

Eyelid surgery, temple lift, and facelift

During a brow lift, we can also perform a temple lift and canthopexy, a procedure that supports the outer corner of the eye, through the same temple entry site. If there is excess upper eyelid skin, eyelid surgery can be added to the plan. During your consultation, you can describe the changes you would like in brow height, the eyelid fold, and the outer corner separately.

A temple lift addresses the position of temple tissues adjacent to the outer brow. Canthopexy addresses the supporting structure at the outer corner of the eyelid. Brow height, temple tissues, and the position of the outer corner of the eye determine which procedures are selected.

When a brow lift and upper eyelid surgery are planned together, the skin to be removed from the eyelid is marked according to the intended brow position. Supporting the brow may change the distribution of the fold over the eyelid. Eyelid skin measurements are therefore linked to the position planned for the brow.

If brow drooping is accompanied by sagging in the cheeks and along the jawline, a brow lift and facelift may be included in the same surgical plan. A brow lift reaches the forehead and temple tissues, while a facelift reaches the supporting layers of the cheeks and lower face. The directions in which the outer brow and cheek tissue will move are determined separately, taking the outer corner of the eye and the temple transition into account.