Brow Ptosis (Low Eyebrows)

The word “ptosis” means downward displacement. Brow ptosis is the medical term for a drooping eyebrow. Descent of the eyebrow can occur with natural ageing but can also occur as a result of weakness of the facial nerve (e.g. in patients with a Bell’s Palsy).

Brow ptosis can cause visual problems by causing hooding of the eyebrow or upper eyelid skin over the eye. This can interfere with light entering the eye and result in loss of the upper visual field in the affected eye. People with such significant brow ptosis often note that their field of vision improves or their vision is brighter if they raise their eyebrow.

Brow ptosis can result in an unsatisfactory facial appearance for some people. The eyebrows can look heavy and people may feel they convey an undesirable tired or angry appearance.

Brow ptosis can co-exist with hooded / sagging upper eyelid skin (dermatochalasis) or drooping of the upper eyelid (upper eyelid ptosis / blepharoptosis).

It is important that all of these factors are taken into consideration when seeking advice about the correct treatment. 

An oculoplastic surgeon is appropriately skilled to evaluate these problems and advise on the best way to treat them.

Procedures

There are a variety of surgical procedures which can be used to raise eyebrows. These will be discussed with you and the one selected will be that which is most appropriate to your age, appearance, general health and your specific problems. 

The procedures include: 

• The direct brow lift
• The endoscopic brow lift
• The transblepharoplasty (internal) brow fixation (Browpexy)
• The transblepharoplasty Endotine Brow Lift
• The pretrichial forehead and brow lift
• The coronal forehead and brow lift          

Direct Brow Lift

A direct brow lift is the most powerful brow lift and involves an incision above the brow. It is useful in patients with a marked descent of the brow. Older patients with some pre-existing forehead creases are the best candidates because the scar often blends with these creases well and is less noticeable. A temporal direct brow lift is useful for a patient who requires a moderate lift of the outer aspect of the eyebrow only. The postoperative scar is then confined to the outer aspect of the eyebrow only.

Endoscopic Brow Lift

An endoscopic brow lift is used for moderate degrees of brow ptosis in patients usually aged 40 years and over. It leaves small scars just behind the hairline. It has the benefit of hiding any incisions and scars. An endoscopic brow lift is often performed in conjunction with an upper eyelid belpharoplasty (an upper eyelid lift). It is less suitable for patients with hair loss or thinning of the hair or with a high hairline and prominent forehead.

Transblepharoplasty Brow Fixation (Browpexy)

A trans-blepharoplasty (internal) brow fixation is performed in conjunction with an upper eyelid blepharoplasty. The brow is accessed via the same upper eyelid incision used in the blepharoplasty and released internally from its local attachments and stitched to the lining of the bone just above the brow. The brow is not raised significantly but is prevented from descending any further following the upper eyelid blepharoplasty.

Transblepharoplasty Endotine Brow Lift

A transblepharoplasty (internal) brow lift is used to raise the tail of the brow by placing an Endotine implant in the bone underlying the brow. This implant is effective for patients who have a mild to moderate degree of brow ptosis. The implant dissolves after about 9 months by which time the brow has healed into the elevated position. The implant does, however, add expense to the procedure. The results of the surgery are maintained by 3-4 monthly botulinum toxin injections to weaken the brow depressor muscles. 

Pretrichial Brow Lift

The pretrichial brow lift is appropriate for patients with a high hairline who wish to avoid a potential scar above the eyebrow (as would be created by a direct brow lift). Incisions are made just in front of the hairline and the forehead and brow are raised by removing some of the forehead skin at this level. Patients with drooping of the outer part of the brows can have a modified pretrichial lift by making incisions only in the outer (temporal) part of the forehead just in front of the hairline. Some numbness of the scalp is likely to occur behind the incision.

Coronal Forehead & Brow Lift

The coronal forehead and brow lift involves an extensive incision running across the scalp behind the hairline. Some of the skin in this area is removed to pull the forehead and brow up.

The disadvantages of this more invasive approach are the scar and numbness of the scalp behind the incision.

Brow ptosis surgery steps:

Step 1 – Anaesthesia

Your comfort during your eyelid surgery is of paramount importance and the type of anaesthesia you have will be discussed in detail prior to you booking your surgery. Local anaesthesia with intravenous sedation (“Twilight anaesthesia”) administered by a consultant anaesthetist is often the best combination for brow ptosis surgery. You can be assured you are in the best care whilst the intravenous sedation makes you calm and relaxed during your procedure. It avoids the need for a general anaesthetic in the vast majority of people. If, however, you prefer the option of having a general anaesthetic then this can also be arranged.

Step 2 – Brow lift surgery

Please see the procedures here

Step 3 – Closing the incisions

Direct brow lift skin incisions are usually closed with removable sutures. These are usually removed at 5-7 days after surgery.

Endoscopic brow lift skin incisions are usually closed with staples. These are usually removed at 5-7 days after surgery.

Transblepharoplasty brow lift or browpexy procedures have skin incisions in the upper eyelids only. These are closed with removable stitches that are removed 5-7 days after surgery.

Step 4 –Results

The results of brow lift surgery will appear gradually as swelling and bruising subside to reveal a higher brow position. The vast majority of bruising will settle over the first 2 weeks.

Depending on the type and extent of the surgery it can take from 2 weeks to 3 months to see the full outcome of surgery.

Brow lift surgery risks and complications

• Blurred or impaired vision, including loss of eyesight (extremely rare)
• Corneal abrasion - this is a scratch to the surface of the eyeball that causes persistent pain. This is rare but can occur with any surgery on or near the eye and is treated with antibiotic ointment. Sometimes a “bandage” contact lens needs to be used.
• Dry eyes - eyelid closure can be impaired following surgery and usually improves over 2-3 weeks. You will be asked to use lubricants during the day and a lubricant ointment at night to prevent a dry eye.
• Bleeding (haematoma) - This can very rarely lead to a loss of vision, including blindness. A haematoma usually needs to be drained in the operating theatre.
• Bleeding. A collection of blood around the eyelids or in the forehead or temple. A haematoma usually needs to be drained in the operating theatre. If a blepharoplasty is performed at the same time bleeding around the eye can occur. This carries a very small risk of visual loss. 
• Infection-this is rare but it is important to follow post-operative wound care instructions to help to prevent such a problem.
• An upper eyelid ptosis (rare) can occur if the upper eyelid tissues are stretched or damaged during surgery.Tis can require a separate procedure to correct it.
• Asymmetry. The brows are often slightly asymmetrical prior to surgery. Although every effort will be made to have as symmetrical result as possible, some degree of asymmetry may be noted after surgery. This is usually mild and entirely acceptable but occasionally further surgery may be required to address this.
• Scarring. The direct brow lift is most likely to leave a visible scar. Most scalp wounds heal with scars that are flat and cosmetically good although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically.
• A brow or frontalis palsy. Sometimes facial nerve branch that supplies the forehead lifting muscle (the frontalis) can be bruised during the surgery and in this case recovery of brow movement may take a few weeks. A permanent palsy of one or both eyebrows is rare.
• Sensory loss. It is not uncommon to experience loss of sensation in the forehead and temple areas following brow lift surgery. Recovery can take several months. Permanent sensory loss is extremely rare.
• Hair loss. The hair follicles can be damaged by surgery. If this occurs and hair loss is noted around the incision sites the hair usually grows back after a few months. Permanent hair loss is possible however.
• Reoperation – this may be necessary to address some degree of asymmetry in the brow position or contour.

When you go home

If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately. Should any of these complications occur, you may require hospitalization and additional treatment.

Your consultation

The success and safety of your eyelid surgery procedure depends very much on your complete candidness during your cosmetic eyelid surgery consultation. You'll be asked a number of questions about your health, desires and lifestyle.

Please be prepared to discuss:

• Why you want the surgery, your expectations and desired outcome
• Medical conditions, drug allergies and previous medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol & tobacco
• Previous surgeries

The following will also take place at your consultation

• Evaluation of your general health and any pre-existing health conditions or risk factors
• An assessment of your vision and a thorough eye examination including a slit-lamp examination of the eye.
• Photographs for your medical record
• A discussion about treatment options
• Recommendations for treatment most appropriate for you
• Discussion about likely outcomes of eyelid surgery and risks or potential complications
• The type of anaesthesia that will be used (This is usually “Twilight anaesthesia” using local anaesthesia with intravenous sedation administered by a consultant anaesthetist. However, a full general anaesthetic can be arranged if you prefer this option)

After the consultation I will send you a letter summarising your concerns and desires relating to your appearance along with my assessment and advice to you regarding treatment options.

You will also receive a quote for your proposed surgery and have the opportunity to attend for a further consultation prior to proceeding should you wish to ask any further questions.

Arrange a consultation