Aging and genetic factors can affect the upper eye lids and their associated structures.  The upper eye lid changes which may occur include excess skin and rarely protruding fat, and brow ptosis.  Brow ptosis or sagging of the eyebrows result in the eyebrows dropping at or below the level of the upper orbital rim (the orbital rim is the edge of bone which houses the eye ball).  With brow ptosis, the skin at the edge of the eye brow will be so low that a skin “hood” will be seen from side view.  Basically, the skin will hang over the lateral edge of the eyebrow, creating a hood.

The only correct way to address brow ptosis is with a brow lift.  As the name implies, brow lifting involves lifting the forehead skin so the eyebrows are positioned in their normal anatomical position.  Frequently, the frown muscles are also addressed at the same time, to provide a softer look to the middle eye brow.  There are three types of brow lifting:  open coronal, open hairline, and endoscopic.  Both open techniques involve making an incision either in the middle of the scalp (coronal) or in front of the forehead hairline (hairline), and elevating the forehead skin.  The excess skin and muscle is then removed and the brow is positioned in its new position.  The incision is then closed.  The advantage of open technique is its long term reliability.  The open technique is the gold standard and is a proven method.  In my opinion, the open technique is the only correct approach for heavy, droopy eye brows and thick forehead skin.  The disadvantage is the longer scar, and the loss of sensation in the scalp behind the incision.  Although in most patients some sensation returns, it may not be complete.  The endoscopic approach involves making several separate incisions in the scalp and elevating the forehead skin using an endoscope.  The amount of skin remove is minimal and the theory is internal scarring will keep the brow in its new position.  My opinion regarding endoscopic brow lift is that it may be useful for minor brow ptosis, and perhaps most patients receiving endoscopic brow lift did not require a brow lift in the first place.  I am not aware of a patient with moderate to severe brow ptosis having long term success with the endoscopic approach.  The advantage of endoscopic technique is less incisions, and the ability to maintain sensation in the scalp.

In the previous paragraph, I mentioned there is a correct way of addressing brow ptosis.  If one only removes the hanging skin without elevating the eye brow, the eye brow will eventually drop more.  The forehead muscle is used to the weight of the hanging eye brow.  If the weight is removed, the forehead muscle will weaken, causing worsening of the brow ptosis.  This may seem counter-intuitive.  Trust me; plastic surgeons many decades ago learned this the hard way!

Once the brow ptosis is corrected, there may be some or no excess skin remaining.  If excess skin is remaining, an upper blepharoplasty can be performed.  This involves removing any excess skin in the upper eye lid, resulting in smooth skin without folds or crease.   During a brow lift, it is usually very difficult to know how much excess eye lid skin is remaining.  This is due to swelling at the time of surgery, which will “lift” the excess skin.  Most of the time, therefore, I perform the brow lift and wait 4-6 months for the brow to settle down.  The upper eye lid surgery is then performed, resulting in a much more predictable result.

It is important to realize that the position of the eye brow is different in men and women.  With women, the eye brow is lifted above the orbital rim and a slight arch in the eyebrow is desirable.  The upper eye lid surgery also is more aggressive in women.  In men the position of the eye brow should be lower and removing too much eye lid skin will result in a feminine look.

I have attached before and after photo to illustrate the effectiveness of this procedure.

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Dr. Jazayeri is a board certified plastic surgeon with over 10 years of experience.  His office is located centrally in Orange County, in the city of Santa Ana.  If you like to schedule a complimentary consultation, please call 714-834-0101.