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'Frightened' expression, hollow eyelid call for browlift revision surgery

Key iconKey Points

  • Over-elevated brows tend to make upper lids hollow, adding years to a patient's face
  • In primary or secondary browlift, shape is more important than height of brow
  • Botulinum toxin can correct some primary browlift deformities

Surgeons queried on the topic of eyebrow-lift procedures agree that the traditional browlift often results in an appearance that is not aesthetically pleasing; that the tail of the brow should always be lifted more than the central and medial portion; and that long-lasting results with lifting the tail of the brow can be a challenge to obtain.

For all of these reasons, browlift revision surgery is not uncommon. "With browlift surgery, it is usually the case that less is more," says Richard J. Warren, M.D., clinical professor of surgery, University of British Columbia, Vancouver. "In many individuals, small elevations in the lateral brow can have significantly positive effects on facial appearance."

Several articles in the literature have evaluated the results of browlift surgery. Freund and Nolan had observers evaluate results of conventional open browlifts and concluded that they often give unsatisfactory results.1 Swift and colleagues found that after endoscopic browlift surgery there was often over-elevation medially, and the lay public analyzed browlift results and determined that their ideas of a pleasing brow were different than typical lift results.2, 3


A female patient is shown preop (top) and postop following browlift revision surgery, which demonstrates that shape, not height, should be the aim of an Aesthetically pleasing eyebrow. (Photos credit: Michael J. Yaremchuk, M.D.)
Michael J. Yaremchuk, M.D., has published a paper that recounts how over-elevation is common and that the goal of browlift surgery should be restoration of a youthful brow shape and position rather than elevation. In an interview with Cosmetic Surgery Times, Dr. Yaremchuk, a professor of surgery, Harvard Medical School, and the chief of craniofacial surgery, Massachusetts General Hospital, Boston, says over-elevated browlifts can make patients look older, and over-elevated brows tend to make the upper lids hollow, which can also add years to a patient's face.

"Some patients are disappointed that they see little change in brow position after their surgery, while others are unhappy with the unnatural look that results after an over-elevated browlift," Dr. Yaremchuk says. "Secondary brow manipulation is appropriate when the patient is displeased with the over-elevated position of the brow, when expectations are realistic, and when the surgery is technically possible."

Dr. Warren says the traditional browlift was once all about lifting the entire eyebrow complex — medial, central and lateral portions. "In some people this worked well, but for many people the result did not meet the cosmetic ideal because their brow had not dropped in the first place," he says.

"Browlifting in the medial portion is relatively easy to achieve, but in the lateral portion, it is harder to maintain in the long term. This problem led to many browlift procedures, both coronal and endoscopic, resulting in over-elevated medial brows, but with little or no change in the lateral brow — a result that makes patients look surprised and maybe even a little older," he says.

SHAPE VERSUS HEIGHT Whether performing a primary or secondary browlift, it's important to appreciate that the shape of the brow is more important than the height of the brow.

"Over time, popular eyebrow shape has been dictated by fashion and culture, which in turn has been reflected by the way people shape their eyebrows or use makeup," Dr. Warren says. "A century ago, eyebrows were often turned down at the lateral end; 50 years ago, high arched eyebrows were popular. But currently, the ideal pop culture eyebrow shape is relatively low medially, higher laterally and peaking somewhere lateral to the iris. This seems to be consistent throughout the world and across races. Altering the shape of the eyebrow is more likely to bring people in line with popular perceptions of beauty, rather than arbitrarily placing the brow at a higher level."


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