In facial cosmetic surgery, we divide the face and neck into three areas. The two lower areas, the midface and the neck, are treated with facelift procedures. The upper third of the face, or peri-orbital region, includes the forehead and eyebrows, upper eyelids and lower eyelids.
Aging changes in the upper third of the face tend to make us look not only older, but contribute to a more tired and fatigued appearance. Revitalizing the periorbital area helps restore a more youthful, renewed and radiant appearance.
An old man puts cream under his eyes.
In periorbital surgery, it is critical to treat all three areas of the upper face. Neglecting one or more will yield suboptimal results. Starting from the lower eyelids and moving upwards, the aging of the lower eyelids is most often characterized by the appearance of “bags under the eyes”. These are visible compartments of fat normally found around the eyeball, within the bony orbit.
The weakening of the connective tissue that otherwise contains these fat compartments leads to visible swelling. With cosmetic lower eyelid surgery, or blepharoplasty, excess orbital fat is removed in three separate compartments to create a smoother contour. This is often achieved through an incision on the inside of the eyelid, preventing any scarring of the lower eyelid skin.
Sometimes, excess skin is also present on the lower eyelid and contributes to an aged and tired appearance. In these cases, an incision is made on the outside of the eyelid, just below the eyelashes, allowing both excess skin and swollen, unnecessary fat to be removed.
A person in blue gloves raising one of someone’s eyebrows.
For the upper eyelids we have the opposite situation. Aging upper eyelids are most typically characterized by sagging, excess skin. Upper blepharoplasty surgery is primarily designed to remove excess skin through an incision within the fold of skin hidden in the upper eyelid. Again, when necessary, swollen, excess fat can also be removed from the internal orbit through this same incision.
Upper and lower eyelid surgery undoubtedly goes a long way in reversing the changes of aging and restoring the rejuvenated look we desire. However, to complete the process, we also need to lift and shape the eyebrows, and smooth the forehead wrinkles.
We have always done this with brow lift surgery. That was until 2002 when Botox came along and took over. Botulinum toxin injections accomplish much of what brow lift surgery does. They weaken the frown and squint muscles, which push the brows down, leading to an improved brow shape and position. At the same time, they smooth frown lines and crow’s feet. For injectors, the biggest finesse with Botox injections comes with treating the brow, lifting the muscles higher on the forehead.
A person moving around their eye area in front of a mirror.
We target these muscles to smooth the transverse folds of the forehead. A little too much can result in sagging brows even more than before. Not enough can leave wrinkles on the upper forehead or an overly arched brow. Overall, however, botulinum toxin injections have proven to be so effective in supplementing blepharoplasty surgery that we only perform a fraction of brow lift surgery now compared to before.
Even so, brow lift surgery still has an important role in periorbital aesthetic rejuvenation. Although botulinum toxin injections are generally more effective in smoothing upper facial wrinkles, brow lift surgery is a more powerful technique for lifting the brows. Some patients require or desire a greater degree of brow lift than can be achieved with Botox. Some also desire a more permanent or permanent brow lift compared to toxin injections, which require 2-4 treatments per year to maintain benefits. For these patients, I offer brow lift surgery.
My preferred technique for brow lift surgery is the endoscopic approach. (Photos show a patient two weeks before and after Endoscopic Brow Lift and Upper Blepharoplasty.)
A cosmetologist checking his results with medical instruments after brow lift surgery.
For this procedure, three small incisions are made just behind the hairline. Through them, with visualization through an endoscope, all the soft tissues of the forehead, including the eyebrows, are mobilized and pushed upwards. The brows are then fixed in their elevated position with absorbable bone anchors. Eyelid surgery is often done, in the same procedure, along with upper and lower blepharoplasty. The best candidates for this technique are those with a short forehead and frontal hairlines.
For patients with higher foreheads and more receding hairlines, I prefer to perform their brow lift through incisions made just along the hairline. This allows me to remove excess forehead skin and push the hairline forward while lifting the brows.
A man checking his forehead wrinkles in a mirror.
Men with receding hairlines are a challenge for brow lift surgery. Most people would be better off with botulinum toxin injections. In some cases, they may have existing, deep transverse forehead wrinkles, and a direct brow lift through incisions within these folds will effectively lift the brows and leave subtle scars.
Another more limited brow lift can be achieved in these difficult patients with a technique that uses small bone anchors, placed through the upper blepharoplasty incision.
If you’re looking for a more youthful and refreshed look around your eyes, or you’re no longer satisfied with the results of your Botox, consult a board-certified plastic surgeon to see if you can benefit from brow lift surgery.
Dr. Max Polo.
Dr. Polo is a graduate of University of Miami, Miller School of Medicine. He is a certified Plastic Surgeon and a partner in Miami Plastic Surgery. He has been in practice for over 20 years during which he has remained an active member of his medical staff Baptist Hospital and South Miami Hospital. Dr. Polo is dedicated to patient safety and Plastic Surgery education and has been recognized by his peers by being elected to leadership positions such as past president of the Miami Society of Plastic Surgeons and president-elect of the Florida Society of Plastic Surgeons . Dr. Polo is a specialist in Cosmetic Surgery of the face, neck, breast and body. His greatest expertise is in breast augmentation and moms. His practice also includes the full range of non-invasive treatments such as Botox, fillers, CoolSculpting, ultrasound, lasers and radio frequencies.
Favorite points of Dr. Polo on the island include Crandon Park Golf Course, the beach at Cape Florida Light and The Spa and Rum Bar at the Ritz Carlton.
You can email him questions at mpolo@miamiplasticsurgery.com.
To read the latest column by Dr. Polo, click here.
