As the face ages it loses volume, the skin loses elasticity and becomes wrinkled, and the soft tissues drop. In the upper face or what we call the brow, this can cause wrinkles across the forehead, wrinkles between the eyebrows (11 lines), lowering of the position of the eyebrows, and heaviness in the upper eyelids. The heaviness in the upper lids may even cause patients to constantly contract their forehead muscles in an attempt to hold up their eyebrows and upper eyelids. This produces even greater wrinkling.
The volume loss we see is located in the temples and patients with age get more and more hollow in this region. This can be associated with hooding of the lateral eyebrow and can affect patient's visual fields.
Patients start to notice changes in their brows and upper eyelids beginning in their 30's. Patients often are seen in consultation because the excess skin they perceive in their upper eyelids bothers them. I believe it is very important to find out what the patient looked like in their 20's and early 30's before making a recommendation. It is important to evaluate the position of the eyebrows: how they arch, the eyebrow height, and the eyebrow shape. It is also important to evaluate the effect of the eyebrow position on the upper eyelid.
Classically we will see a patient who believes that their problem is their upper eyelids. However, when we evaluate their more youthful photographs we notice that the problem is not their upper eyelids; the problem is the brow position has dropped. If this is the case, then we recommend elevating the brow to restore the youthfulness of the upper face rather than recommending upper eyelid blepharoplasty. If however, the patient's brow position remains the same as it did in their youth, then we would recommend upper eyelid blepharoplasty. There are some cases where patients have both upper eyelid redundancy and brow descent. In these situations we recommend both procedures.
Rejuvenating the brow takes into consideration all of the aging changes that are present. The surgeon must address not only the position of the eyebrow, but the wrinkling changes in the skin that are present. Muscles whose direct action causes a folding of the skin cause the brow wrinkles. The 11 lines between the eyebrows are caused by the corregator muscles that move the two eyebrows together. The procerus muscle located between the eyebrows and on the nose causes wrinkling across the top of the nose. The frontalis muscle located over the broadness of the brow causes transverse wrinkles across the forehead. The depressor muscles actually cause the brow to lower.
Therefore, when we are discussing the options for brow rejuvenation, we need to address the individual muscles and their effects, the wrinkling that is present and the position of the eyebrow and its affect on the upper eyelid. There are many options, both surgical and non-surgical that allow the plastic surgeon to create a youthful appearance with no to minimal recovery.