Want a Brow Lift? Here’s What You Should Know

Droopy eyelids is a common complaint Caroline Vloka, MD, hears from patients. As an oculofacial plastic and orbital surgeon at the Sue Anschutz-Rodgers Eye Center, she sees many patients who need surgeries related to the surrounding structures of their eyes. Although many of these patients with droopy eyelids may initially ask about getting an eyelid procedure, there is another eyebrow-raising option that may alleviate their issue.

“A lot of people who come in for droopy lids actually just need a brow lift,” says Vloka, an assistant professor in the University of Colorado Anschutz Department of Ophthalmology. “Because the brow is much heavier and thicker than the eyelid, it causes a lot of mechanical pressure that can lead to this droopiness. When we lift the eyebrow back to where it is supposed to be, we can see that it usually lifts the eyelid as well.”

Brow lifts are a fairly common procedure at the eye center, she explains, estimating that roughly half of her patients who are getting a blepharoplasty — a common surgical procedure to remove excess skin from the eyes — will also get a brow lift. However, there are different types of brow lifts, making it essential for patients to be well informed about their options before opting for surgery. We recently spoke with Vloka to learn more about the variations of brow lifts and key distinctions to look out for.

The following interview has been edited and condensed.

Some people think of brow lifts as a purely cosmetic procedure. What are the medical reasons why a person may need a brow lift?

Most people come into our clinic complaining about their eyelids drooping so much that they get in the way of their vision. For some people, their eyelids are so low that their eyes look half closed when fully opened, so they have to really raise their eyebrows to be able to see properly.

The brows are supposed to be located slightly above, or directly on, the eyebrow bone, also called the supraorbital ridge or brow ridge. I tell patients who come in to close their eyes and relax their face as much as possible before pressing on their eyebrow — and oftentimes, they are pressing on their eyeball because their brow has fallen so much.

When performing a brow lift, do you normally operate on the eyelids as well?

It depends. When we lift the brow, if the eyelid is in a good position and there is no excess skin that is causing an obstruction of vision, then we won’t. When I lift the brow, if there is still a droopy eyelid because the muscle has slipped or there is excess skin, then we may do a combined procedure, such as a blepharoplasty or ptosis repair.

Not everyone realizes that certain ophthalmologists, specifically oculoplastic and orbital surgeons, can perform brow lifts. Can you explain the type of training ophthalmologists like yourself receive to perform this type of procedure?

Oculoplastic surgeons go through medical school and complete residency training in ophthalmology. Our main priority from that training is making sure that patients’ eyes are safe and their vision is either better or improved when performing procedures. Following residency, we complete two additional years of training in oculoplastic and facial surgery. Our main focus during those years is the soft tissues of the eyelids, the eyebrows, the eye socket, and the middle facial structures.

Are there certain brow lifts that are performed only by facial plastic surgeons versus oculoplastic and orbital surgeons?

No, both types of surgeons can perform brow lifts. However, I think that most functional brow lifts are performed by oculoplastic and orbital surgeons given their ophthalmology training, and I recommend patients go to a surgeon who has extensive experience in brow lifts.

How many different types of brow lifts are there?

There are a lot. There is a direct brow lift, where an incision is made right above the brow hairs, and we lift the brow by directly removing some skin and then closing it up. We try to hide the incision as much as possible, but it is visible.

For patients with deep forehead wrinkles, we can hide an incision in a forehead wrinkle through a mid-forehead brow lift. You’re essentially hiding the scar within the wrinkle.

A pretrichial brow lift is where we create an incision in the hairline to lift the eyebrows and skin. This can be a better option for people with thick hair and bangs, but it’s not something that we’d recommend performing on a person who is balding, because these are bigger scars that will be prominent unless they can be hidden in someone’s hairline.

An endoscopic brow lift is where we make several tiny incisions behind the hairline. We insert an endoscope into one of the incisions to view the tissues and muscles. Then, we use another device that is placed in a different incision to make alterations to lift the eyebrows and some forehead wrinkles.

We can also do an internal browpexy, which is a more minimal procedure. We go through an eyelid incision and raise the brow with an internal suture to help suspend the brow. But in my opinion, that procedure doesn’t always produce as natural of a result and is not as long lasting. I rarely perform it, and it usually is only a good option for a patient whose eyebrows are partially drooping along the outer part of the brow.

At the 29th Annual Sue Anschutz-Rodgers Eye Center Symposium, yourself and your colleague Daniel Ozzello, MD, debated the pros and cons of an endoscopic versus direct brow lift. You argued in favor of direct brow lifts — why is that?

I likely perform the most direct brow lifts out of anyone in our practice, and I think they’re great. And as long as patients keep their incision out of the sun for about six months, then the scar usually heals really nicely.

Also, insurance is more likely to cover a direct brow lift. An endoscopic brow lift likely won’t be covered because it’s generally deemed a cosmetic procedure rather than a functional one. The direct brow lift is more of a functional surgery with the benefit of anatomical correction of where the brow is, but it does have a visible scar. That’s why this surgery is usually reserved for older adults.

What are the most common types of brow lifts that are performed in your practice?

In my practice, for the vast majority of patients, the discussion is often between either a pretrichial brow lift or direct brow lift. The added benefit of the pretrichial brow lift is that if patients have deep wrinkles on their forehead, you can help remove some of those wrinkles by pulling the skin toward the hairline.

Generally speaking, what is the recovery process like of a brow lift?

If we’re doing just a simple brow lift without anything else, recovery is typically easy. The patient may experience some bruising, but I’ve never had anyone complain of any blurry vision from a simple brow lift. The sutures are usually removed about a week after the procedure. For the first two to three months, the incision site is a bit more visible before the scar matures. With a pretrichial brow lift, there may be a slightly longer initial downtime because of the larger incision.

How do you go about working with your patients to decide which type of brow lift is the best option for them?

With my patients, I present all the information to them, including the estimated costs, recovery process, potential risks and benefits, and what the side effects can be. We discuss their goals and what are acceptable outcomes for them. For instance, I’ve had patients who decided they didn’t want to get a direct brow lift because they were concerned about the scar it could create, so instead, we decided to focus on a procedure just for their eyelids.

It really depends on the patients’ preferences, and I prioritize tailoring my approach to fit their informed decisions.