“I feel really, really fantastic. Everyone stops and says, ‘Oh my gosh, you look so amazing, so rested!’ But they can’t put their finger on it… I’m loving every second of it!”
– Megan, a 37 year old patient of Dr. Armstrong
Forehead Surgery, Eye Brow & Cheek Lifts
If you feel like your eyes look heavy or tired, it may be due to sagging eyebrows. A brow lift will give your eyes a more open appearance and reduce the appearance of excess skin that weights down your eyelids. A brow lift, also called a forehead rhytidectomy, will also smooth out the wrinkles on your forehead – wrinkles that are caused by overuse of your forehead muscles to help hold your eyes open. We can also reduce the vertical creases between your eyebrows (glabellar frown lines) and any horizontal “bunny lines” across your nose. A brow lift is commonly recommended for patients who request eyelid surgery, and almost uniformly necessary before any revision upper eyelid surgery.
Frequently Asked Questions
If you can improve the appearance of your upper eyelids or eyebrows by lifting your forehead with your hand, then you would probably benefit from a forehead or brow lift. Place the palm of your hand and four fingers across your forehead, about a fingerbreadth above your eyebrows. While looking in the mirror, firmly raise your forehead and then release, to observe the difference. Does this reduce the appearance of excess skin in the upper eyelids? If it does, then you may wish to consider a brow lift. Look again at your upper eyelids with the brow elevated. Do you still have excess skin in the upper lids? Does any part of your eyelid block your vision? If so, you may wish to discuss a blepharoplasty (upper eyelid surgery) with your doctor as well.
In a traditional forehead lift, the surgeon tightens the forehead and lifts the eyebrows by removing a strip of skin at the top of the forehead or within the hairline. Placement of the incision is determined by the height of your existing forehead. If you have a short forehead with a low hairline, then the incision can be camouflaged within the hair bearing scalp across the top of your head. This is a very traditional procedure called a coronal forehead lift and probably describes the surgery that most people envision when they think of a forehead lift. For patients with a normal to high hairline, the incision can also be placed just inside the hairline at the top of the forehead. This is called a pretricheal skin excision, because it is placed “before the hair.” With careful technique, the surgeon can cut and sew the tissue so that the first few hairs grow through the scar. It is also called a trichophytic incision, which means that the incision is designed at an angle to preserve the hair follicles. With good technique and successful healing, you can likely comb your hair back several months after surgery with minimal visibility of the scar.
The principal advantage of a traditional forehead lift is that it requires no special equipment and can even be performed under local anesthesia in the office. The primary disadvantage of a traditional forehead lift is that the long horizontal incision predictably causes numbness in the scalp behind the incision. This numbness may be permanent.
In an endoscopic forehead lift, the surgeon elevates and smooths the forehead through four tiny incisions in the scalp, using an endoscopic camera rather than direct vision. The endoscopic technique smooths the forehead and raises the eyebrows with the least visible scarring. The incisions are completely behind the natural hairline. The surgeon elevates (loosens) the skin of the forehead and the scalp from the bone using small instruments and a video camera passed through one or more of these incisions. The forehead is pulled upward and secured in the new position. Small sutures or surgical staples are used to close the incisions.
The principal advantage of the endoscopic approach is the ability to hide all of the incisions inside the hair. The second advantage is that all incisions are parallel to the sensory nerves in the scalp, which greatly reduces the risk of postoperative numbness in the scalp. Finally, the endoscopic approach allows the surgeon to continue dissection down toward the midface and on some occasions assist with lifting the cheeks.
The hairline is always elevated with an endoscopic brow lift. This may be advantageous if you have a short forehead, or it may be a disadvantage if you have a receding hairline. Horizontal wrinkles are reduced by stretching the forehead from above, but the frontalis muscle that creates these wrinkles is usually preserved.
The first step is to consult a well-qualified plastic, oculoplastic, or facial plastic surgeon. Ask about training and credentialing by the appropriate specialty boards. The surgeon should take an interest in your concerns before jumping to a recommendation or decision. Before the appointment, take a good look in a mirror at various times a day and in different lighting, and write down the concerns that bother you the most. Discuss any concerns that you may have regarding your eyes with your surgeon, including vision problems, contact lenses, dry eyes, or allergies. After a thorough examination and in consideration of your concerns, the surgeon will make specific recommendations and discuss the alternatives, risks and costs of the procedure.
Eyebrow surgery is most commonly performed by plastic surgeons and by eye, ear, nose or throat surgeons with additional training and experience in cosmetic surgery of the face. Experienced surgeons will often be certified by the American Board of Facial Plastic and Reconstructive Surgery , or by the American Board of Plastic Surgery .
Board-certified facial plastic surgeons have generally completed at least 6 years of surgical training specializing in diseases of the ears nose and throat as well as surgery of the face, head and neck. They have demonstrated at least 2 years of professional experience in facial plastic surgery outside of residency and their work has been thoroughly evaluated through chart review and written and oral examinations. Facial plastic surgeons specialize in cosmetic and reconstructive procedures above the shoulders, including eyelids, facelifts, nasal surgery, ear surgery, cleft lip and palate, and skin cancer.
Board-certified general plastic surgeons have completed a residency in otolaryngology (ears nose and throat), orthopedics (bones), or general surgery, followed by a two-year residency in plastic surgery. Plastic surgeons are trained to care for a broad diversity cosmetic and reconstructive problems that may include facial surgery, breast reconstruction, body contouring, hand surgery and skin cancer.
Oculoplastic surgeons are eyelid specialists who have been certified by the American Board of Ophthalmology. Following initial training in medicine and surgery of the eye, these surgeons have specialized in surgery of the eyelid and surrounding structures, including the eye socket and the tear ducts.
For younger individuals, the eyebrows can be temporarily improved with Botox, fillers and skin care. Botox may temporarily relax muscles allowing eyebrows to drift upward. Botox is injected into the corrugator and depressor muscles between the eyebrows to relax the frown lines in the glabella. Botox is also injected into the lateral orbicularis oculi muscles that create the “crow’s feet.” By weakening all of the muscles that pull downward on the eyebrows, the forehead muscles pull upward without competition, lifting the eyebrows. This is referred to as a chemical brow lift. Botox is FDA-approved for both of these locations and lasts 3-4 months.
Botox may also be used to flatten the horizontal lines in your forehead. However, you must discuss his carefully with your surgeon, as relaxation of the forehead muscles may reduce your ability to lift the eyebrows, and even cause them to sag. The use of Botox in the forehead itself is considered off-label by the FDA.
Cosmetic facial plastic surgery is performed for your pleasure. Advance preparation can help to keep you comfortable and make this a relaxing experience. At least a week before surgery, discontinue smoking and all medications and herbal supplements that may increase the risk of bleeding. Fill your prescriptions, shop for groceries, and try to anticipate any other needs that may arise in the first week after surgery. Do not cut your hair – longer hair will be easier for your surgeon to tie out of the way, and may provide better options for camouflage in the early postoperative period. Arrange a ride home even if you are having office surgery, as eyelid swelling may temporarily impair your vision. Although some patients return to work as early as 3-5 days after a brow lift, it would be ideal if you have no responsibilities or obligations for the first week. You may wear make-up immediately, unless you have incisions on your face. Sutures or staples in the scalp will be removed in 1-2 weeks, but it will take at least 3 weeks for bruises to completely resolve.
Take care of all financial arrangements with our surgical coordinator. If your procedure is scheduled at the Medarva Stony Point Surgery Center , be sure to take care of operating room and estimated anesthesia fees with them as well. Payment is generally expected one week before cosmetic surgery, after which time the fee is non-refundable except in extreme circumstances.
On the morning of surgery, shampoo your hair twice, wash your face thoroughly, and apply no lotions or makeup. Wear a washable undershirt or camisole covered by a button-down or zip up shirt or jacket. Avoid tight fitting pullovers, such as a crew neck or turtleneck shirt. You should have a comfortably light meal and adequate fluids before any office procedure. If you are scheduled for sedation or anesthesia at the surgery center, then do not eat for 6 hours before arrival.
It is our goal to ensure your utmost comfort. If you have your browlift performed in the adjacent Medarva Stony Point Surgery Center , you will be comfortably sedated. Do not eat for 6 hours before your scheduled surgery. You may have black coffee, tea or water no more than 2 hours before surgery. You should arrive at the surgery center about 1 hour early. Expect a reminder call from the nurse the afternoon before surgery. She will provide you with an updated time to arrive.
After you register at the surgery center, the nurse will invite you back to a preoperative staging area. She will review your history, obtain vital signs, and start an IV in your arm. The anesthesiologist will then examine you and discuss the anesthesia plan. With minor procedures, you will most likely be briefly sedated while the surgeon injects local anesthesia. You may be allowed to awaken during surgery, as long as you are resting comfortably following the local anesthetic. For larger procedures, you may be more deeply asleep, with a breathing tube in the airway. You will most likely awaken in the recovery room feeling that very little time has passed.
If you are the type of person who can comfortably sit still for a dental procedure, then most likely you could sit still for a forehead lift in the office under local anesthesia. Facility fees are reduced and there is no anesthesia fee. You will feel a momentary pinch and burn when the local anesthetic is first injected. After that you may listen to music, doze off, or chat quietly with the surgeon. The skin of your face will be disinfected and covered with sterile towels. You will feel hands working about your face, but it should be no more uncomfortable than having your teeth cleaned or your hair done.
Forehead surgery will cause bruising and swelling around the eyes. You will need a driver to take you home after the procedure, even if you have not had sedation. Keep your head elevated and apply cool compresses as often as possible during the first 48 hours. Pain is variable, but you will likely receive a prescription pain reliever. You may resume walking immediately, but do not perform high impact aerobic activity or heavy lifting for at least a week. You may resume sedentary work in as little as 3 days, but there will be visible bruising for 2-3 weeks. You may apply makeup on any areas that do not have sutures. Avoid hair styling products until the sutures or staples have been removed. After that, you may style your hair as need to camouflage the incisions. The scars will be red for about 3 months, but will gradually fade as the scar matures. Limited hair loss may occur near the incision and last up to 6 months. As the hair regrows, the incision should become nearly invisible.
The biggest concern with a brow lift is numbness of the forehead or scalp. With transverse (horizontal) incisions as used in traditional approaches, numbness of the scalp above the incision is predicted, but usually improves somewhat over several months. Even with endoscopic techniques, the nerves to the forehead are usually seen and manipulated as they exit the skull. If they are damaged, there can be large areas of numbness affecting the forehead, as well as the scalp.
The facial nerve can be injured as it crosses the temple into the forehead. This is a very rare complication, but may cause permanent paralysis in the forehead. More commonly, the surgeon intentionally disrupts specific portions of the nerve or the muscles that are causing wrinkles, in hopes of creating a more permanent alternative to Botox injections.
Hair loss may occur at or very near the incisions. The hair usually regrows within six months, and the scars can usually be hidden with hair styling.
Severe pain, infection, and bleeding are rare after a brow lift. The risk of a serious injury that might leave permanent vision loss or double vision is exceedingly rare, but is always present with surgery on or near the eyes.
The most common complication of cosmetic surgery is disappointment. Surgery cannot correct every visible imperfection or asymmetry, and it is most important that you discuss your concerns with the surgeon preoperatively. It is equally important to ask questions and listen to your surgeon, so that you have realistic postoperative expectations. In most cases, asymmetries and imperfections can be improved with a minor touchup in the office under local anesthesia.
Medicare and most commercial insurance plans will cover a brow lift only if medically necessary to restore vision. If your eyebrows are so heavy that you cannot see above the horizon without struggling to hold your eyes open, then insurance is likely to pay for your surgery. In addition to a consultation with a facial plastic surgeon, you should also schedule an appointment with your ophthalmologist, who will measure your peripheral vision. This is called a visual field test. By examining the visual field test and by carefully examining your eyes, the ophthalmologist will determine whether the obstructed vision is due to sagging eyelids, eyebrows, or due to a disease within the eye, such as glaucoma.
A forehead rhytidectomy or brow lift is usually performed to improve your appearance rather than for treatment of a medical disease. As such, it is usually not covered by insurance. Performed in our office, a limited browlift costs $2900. An endoscopic browlift at the Medarva Stony Point Surgery Center is approximately $4,900, including the operating room and anesthesia fees. In some cases, the eyebrow is sagging such that it impairs vision. An eyebrow lift may be covered by insurance or Medicare if your ophthalmologist documents that it is medically necessary.