Raising Eyebrows – The science behind eye and brow lift procedures

By Robert Clement, M.D. – November 17, 2012

If the eyes are the window to the soul, why does gravity try to close them? I am not sure why this happens, but I know how. In our youth, the brow sits just over the orbital rim medially and arches slightly laterally. There is no excess skin or bulging fat in the youthful eye. As we age, the bony support, fat, fullness, and elasticity of the skin all change. As elasticity of the skin decreases, the brow slides down over the orbital rim adding excess skin to the upper lid. This is in conjunction with the loss of elasticity in the upper eyelid skin itself as well as herniation of fat in the upper eyelid. The lower eyelid, which is a separate compartment, also loses elasticity and has bulging fat which leads to the bags we see as we age. To counteract the heaviness in the brow, we elevate the brow with the frontalis, or forehead muscle, which leads to the creases and grooves in our foreheads. There can be enough heaviness, either from the brow drooping or the excess eyelid skin and fat, to interfere with our vision. It also leads to a worried, angry, or sad look depending on the position of the medial and lateral ends of the brow. Downward movement of the medial brow is accentuated by the heavy depressor muscles which lie just over the orbital rim and are attached to the skin at the root of the nose creating the "11s" that develop between the eyebrows. With time, the septal system, which holds the fat in position, relaxes in the upper and lower lids. This leads to the bulging of the fat around the globe or eyelid causing the bags we see in the upper and lower lids. In addition to the excess skin, we have the additional weight of the fat to further encroach on the eyelid opening. For correction of the lower lid, the skin and muscles are elevated and then the fat is either reduced or repositioned to fill in the groove in the bony rim at the lower lid. Once the contour has been achieved, pressure is placed on the upper lid to elevate the lower lid and then the lower lid skin is draped and trimmed while the lids are in this elevated position, preventing the retraction of the lower lid due to excess tension. The upper lids are marked separately, with the surgeon trying to create symmetry as much as possible even though the contour of the eyes are not absolutely symmetrical. Then an elliptical strip of skin is removed from the upper eyelids. If there is herniated fat, this is reduced or removed to re-contour the eye. In upper eyelids, if there is not a distinct crease in the eyelid, this can be recreated by attaching the skin, when the eye is closed, to the underlying muscle of the eyelid. Both the upper and lower eyelid are closed with very fine sutures and then usually taped for support for about five days. The brow is elevated by doing a “browlift,” using either open or endoscopic surgical techniques. The open browlift can be done at the hairline or farther back in the hair. By doing this, the entire forehead is lifted up, giving access to the depressor muscles, which are then markedly reduced and the space filled with fascial material from the temporalis muscle. With the endoscopic browlift, an endoscope is used, through multiple incisions in the scalp, to elevate the brow and to reduce the muscle pull in the medial aspect of the brow. In the open surgical technique, the brow is elevated and either the excess skin is removed at the hairline or, if it is back in the hair, a strip of hair is removed by cutting parallel to the hair follicles, which makes the scar very minimal. The closure of the skin is completed with sutures. The closure in the hairline is completed with staples, using either the open or the endoscopic technique. The potential risk with either of these procedures is bleeding, scarring, problems with the hair follicles, and scarring of the eyelids. It is very important to fully support the lower eyelid so that the lid will not be pulled away from the globe. Patients are comfortable going back in public usually ten to 14 days following the procedure. Full physical activities can be resumed after four weeks.


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