Non Surgical Brow Lift
Over time, factors such as our lifestyle, environment, and even genetic makeup contribute to the development of various signs of aging on the brow and forehead. Some of the most common of these aging symptoms include wrinkles and creases on the forehead, furrows between the eyebrows, drooping of the brow and upper eyelids, and loss of the brow’s natural arch. Luckily, brow lift (also known as forehead lift) can often be a great solution for minimizing these aesthetic concerns and restoring a rejuvenated and revitalized facial appearance.
In fact, the recent financial recession has resulted in a boom in Non surgical eyebrow lifts. There may be two reasons for this: Consumers who balk at the price of surgery are more willing to pay for the more affordable nonsurgical procedure, and cosmetologist regard the relatively easy chemical lift as a means to increase revenue in their practices.
They are willing to pay several hundred dollars for a non surgical eyebrow lift that might make their face appear more open and youthful—especially if that youthful appearance can help them hold on to a job, or snag one if they are unemployed. People are doing minimally invasive things that they view as less expensive. If you look at how much it costs to get repeated non surgical brow-lifts, it is more expensive over five years than a one-time surgical brow-lift. But people are thinking more about what a procedure will cost them now. But in addition to being cheaper, chemical lifts require little recovery time and have fewer risks than surgical procedures. People who get non surgical brow-lifts tend to be those who want a brighter look to their eyes and a higher brow, but don’t want invasive surgery. They may not have a lot of skin to remove surgically, and they’re not sure they want the permanence of a surgical procedure, Non surgical brow-lifts are for younger, active patients who really don’t want a convalescent period where they’re swollen and bruised.
With changing times a physician must change the procedure offered to meet the patient demands. Its not the procedure but the patient satisfaction that matters. The key factor now for physicians is to evaluate and make patient understand what can and cannot be achieved with non surgical methods to avoid dissatisfaction with results.
THE AESTHETICS OF THE EYEBROWS
Aesthetic Considerations in the Elevation of the Eyebrow
A review of several textbooks and articles that discuss brow position reveals a consistent consensus as to the proper qualitative relationships of the ideal eyebrow position; these include :
- The medial extremity of the eyebrow lies in a vertical plane passing through the alar base.
- The lateral eyebrow ends at an oblique line drawn from the alar base through the lateral canthus.
- The medial and lateral ends of the eyebrow lie at the same horizontal level.
- The apex of the eyebrow lies vertically above the lateral limbus of the eye at approximately the junction of the medial two thirds and the lateral third of the eyebrow.
- The eyebrow arches above the supraorbital rim in women and lies at the rim in men.
- The male eyebrow tends to be heavier and less arched than the female brow.
Some authors differ from this norm, stating that as the female brow rises laterally, it should peak at the lateral canthus and not at the lateral limbus . It should be noted, however, that the preceding criteria of the idealized brow are based on an idealized concept of facial shape-the oval-and do not account for different facial types among individuals.
(A) The “ideal” brow position. The high point of the brow is at the lateral limbus of the eye. (B) An attractive and balanced brow with the high point of the brow at the lateral canthus of the eye.
In reality, the ideal shape, length, and position of the brow must be appropriately altered to fit different shapes of faces. For instance, in round faces the brow is kept shorter and placed higher, as a longer lateral third would produce a moon-shaped face.
With makeup, aesthetic changes are made to the brow to balance and harmonize the face. The cosmetic surgeon can produce similar nuanced cosmetic changes with surgery. Discrete elevation of the medial, central, and/or lateral portions of the brow can be achieved with the variety of advanced brow and forehead lifting techniques. Thus, it is critical when balancing the face to know not only whether the brow should be elevated but also which parts of the brow elevated and why.
One of the major differences between the idealized brow of surgical texts and that of makeup artists is that the former is based on the ideal face-the oval-whereas the latter is individually matched to a person’s unique facial shape. As is seen with clothing and art, horizontal lines make long objects appear more round and vertical lines create the illusion of length in round objects.
There are five basic brow shapes: (1) curved, (2) sharp angled, (3) soft angled, (4) rounded, and (5) flat. For those brow shapes with an arch, further differentiation into low, medium, and high arch can be made. These eight primary brow characteristics can be manipulated to create the best balance for a given face shape.
The five basic eyebrow shapes.
The round brow shape softens and adds a gentle roundness to the face, toning down sharp, angulated features such as a pointed chin. The high, sharp peak of the sharp angulated brow adds energy and youth to the face. It can function to slim a round or diamond-shaped face, and it can complement and balance other strong facial features such as a square jaw or prominent cheek bones. The soft angled brow creates a similar effect while maintaining a softer, more feminine appearance. The curved brow projects a feeling of energy, confidence, and professionalism and works particularly well on a square or oval face. As mentioned earlier, the flat brow is perfect for individuals with a long face, creating a shorter, more ovalized look.
The Oval Face Shape
- This is the ideal facial shape. It is intrinsically balanced. The brow plays no significant role in making the face appear “more oval.”
- Selection can be guided by personal taste.
The Round Face Shape
- To make a round face appear oval, one should apply lines that go up the face. This draws the eye more up and down and stops it from going side to side.
- A high arched brow accomplishes this.
- The peak is best moved out toward the end of the brow. This lets the lines of the brow go up and down as much as possible. The tail should therefore be short.
The Heart Face Shape
- A rounded shape helps by adding curves to soften the face and emphasizes the lovely heart shape.
The Long Face Shape
- To make a long face appear oval, one should apply horizontal lines to the face. This draws the eye from side to side and stops it from going up and down.
- A flat brow stops the eye from going up the face.
The Square Face Shape
- Strong angled eyebrows balance a strong jaw line.
- The peak of the brow is most effective when directly above the square of the jaw.
The Diamond Face Shape
- A rounded brow softens an angular face or
- A peaked brow helps to narrow the width of the typical diamond wide face.
Analysis of periorbital region
Looking at the upper third of the face, we can note its role in facial expression. The acts of blinking, raising or lowering the eyebrows, frowning the glabella, elevating the upper lids, closing the eyes, and rotating the eye globes up or down are essential in communicating approval or disapproval, attention, surprise, indifference, and many other emotions. In the long term, the aging process progressively changes the external aspect of the upper third, as well as its dynamics.
For these reasons the analysis of the upper third of the face is not limited to a simple three-dimensional assessment of symmetry, proportion, and shape of the region, but must include the fourth dimension of dynamics and the fifth dimension represented by the effects of the aging process.
From the aesthetic and functional point of view, there is no sense in evaluating the eyebrow separately from the upper lid or any other component of the orbital region. The assessment of the skeletal support sustained by the orbital ridges and the globe to soft tissue requires the visualization in profile view of three different vertical reference lines, which, in the frontal view, pass through the center of the iris
- The corneal line. This is the reference line and requires that the eye globe be in a normal sagittal position.
- The upper orbital rim line. This is 8–10 mm anterior to the corneal plane line depending on the pneumatization of the frontal sinus and the morphology of the supraorbital bar.
- The lower orbital rim line. Its position can vary widely from posterior to anterior with respect to the corneal plane line. A protrusive lower orbital rim is associated with good lower lid support and a youthful aspect , whereas a recessive lower orbital rim line is a sign of infraorbital and midface hypoplasia, which is associated with inadequate support of the lower lid and poor aesthetics.
The elements of the upper lateral orbital quadrant should be inspected, giving special attention to:
- The bony rim. There should be no inferior protruding of the upper lateral orbital ridge, which is responsible for a sad and aged appearance in young subjects .
- The lateral portion of the brow. Its rest position should not appear to the observer as a sign of sadness, tiredness or astonishment, as discussed in the following paragraph .
- The lateral portion of the upper lid crease. It is important to detect a lateral extension over the eyelid and onto the lateral periorbital region of the upper lid crease (Connell‘s sign), which is a hallmark of forehead ptosis .
- The presence of a prolapsed lacrimal gland. It can produce an excessive fullness of the lateral third of the upper eyelid (there is no fat in the upper temporal angle of the orbit) . On the other hand, a moderate fullness of the lateral third of the upper eyelid is aesthetically favorable in women. Botox in these condition will exaggerate the lateral hooding.
- The lateral commissure. The laxity of the lateral canthal tendon (lateral canthal bowing) produces an inferior rotation of the commissure.
Position of brow to supra orbital ridge: The medial brow end is at or below the supra orbital ridge the mid brow is at level of orbital ridge, the lateral end of brow is above the orbital ridge. With age the lateral orbital ridge will reabsorb and cause drooping of brow thus a augmentation with fillers may provide support to brow.
The ideal attractive canthal axis is different in male and female. In males both canthi are at same level also the brow is more horizontal at level of orbital ridge. In females the lateral canthi is at a higher level than medial canthi with age both the brow and canthi droop correction of just brow without canthopexy will not result in a young looking upper face.
Signs of aging
Always expect and search for the signs of aging in the forehead and orbital region, as it can be detected much earlier than in other facial regions, giving me and my patient the opportunity to deal with these problems with a long term plan.
Essentially look for the following three signs: dermatochalasis, loss of lid tone (eyelid laxity), and herniated orbital fat.
- Dermatochalasis is the excess of eyelid skin. It is usually more relevant in the upper eyelids and is also a frequent condition in middle-aged subjects. The skin excess can be assessed by pinching the excess of eyelid skin with forceps until the eyelashes begin to evert.
- The loss of lid tone is usually more relevant in the lower lid. We refer to lid tone as the ability of the lids to maintain spontaneously and recover (recapture) quickly their normal position against the globe. The presence of horizontal lower lid laxity should be assessed performing the distraction test and the snap test . The lid should not be pulled more than 7 mm away from the inferior limbus (distraction test and, after the distraction, should snap back into its normal position immediately (snap test).
- The herniated orbital fat. By gently pressing on the globe, it is possible to produce the protrusion of fat pockets .The lower lid fat is also assessed with the subject in the upright sitting or standing position and gaze up eye globes orientation. In the supine position the orbital fat, due to its mobility, is spontaneously repositioned into the orbit and is not usually evident in young adults.
In eyebrow analysis, it is important to detect a lateral extension over the eyelid and onto the lateral periorbital region of the upper lid crease or Connell‘s sign, which is a hallmark of forehead ptosis . The correct vertical position of the eyebrow can be envisioned during the consultation, utilizing Flower‘s maneuver, by holding up the eyebrow with a fingertip.
In patient with lateral extension of upper eyelid crease indicates forehead muscle laxity and botox should be avoided in these condition. Also the fillers and thread lifts are not effective in brow lift these require a formal surgical forehead or brow lift.
Crow‘s Feet and Eyelid Wrinkles
Crow‘s feet and eyelid wrinkles are fine wrinkles or lines developing on the lower lid and the lateral aspect of the orbital region perpendicular to the fibers of the underlying orbicularis oculi muscle.
In the evolution towards more evident lines, the attenuation and elongation of the muscle fibers as well the skin laxity and gravitational descent also play a role
Lateral Canthal Bowing
Lateral canthal bowing is secondary to the progressive laxity of the lateral canthal tendon . The visible effect is an inferiorly rotated lateral lid commissure with a loss of the upward lateral tilt of the intercanthal axis.
The inferior scleral show is the presence of a strip of white sclera between the iris and the lower lid margin with the subject in natural head position and straight gaze. As a sign of aging, it is caused by the progressive laxity of the canthal tendons and the tarsus of the lower lid.
Scleral show in young is a sign of maxillary hypoplasia and infra orbital filllers may not be able to acheive good results. these cases a formal maxillary advancement or a malar implant better provide lid support.
Botox Brow lift
Hyperactivity of the lateral orbicularis oculi muscle can pull down on the lateral aspect of the brow. The orbicularis oculi muscle pulls down on the tail of the brow and opposes the lifting action of the frontalis muscle.
- Anatomic Considerations
The orbicularis oculi muscle is a strong brow depressor. The superolateral orbicularis oculi is positioned at or just inferior to the level of the hair of the lateral eyebrows.
Glabellar lines are created by three muscles: the frontalis, the procerus, and the corrugator supercilii muscle (CSM). Superomedial ﬁbers of the orbicularis oculi, also known as the depressor supercilii, are intertwined with the frontalis and the procerus. The CSM originates from the superomedial aspect of the orbital rim and passes superolaterally at 30° to attach to the dermis at the middle of the eyebrow. The CSM draws the eyebrow inferiorly and medially, producing vertical wrinkles on the forehead as when frowning. The CSM is found beneath the frontalis because its origin is the frontal bone.
The procerus m. originates from the nasal bone and the upper part of the lateral nasal cartilage. Its ﬁbers run vertically by merging with ﬁbers of the frontalis with some of them attaching to the skin over the radix and glabella area. The depressor supercilii m., the medial part of the orbicularis oculi m., draws the eyebrows down. If this muscle is injected with botulinum toxin, the eyebrows can be lifted upward. The muscles of the glabella are not separated but actually inter-twined with each other, and the toxin diffuses to the underlying muscle. Thus, injecting into the CSM can paralyze other neighboring muscles in the glabellar area.
- Injection Technique
The injection landmark for crow’s feet is 1.5–2 cm lateral to the lateral canthus. First, 2 U injected at this point. 2 U is injected 0.5 cm medial and 1 cm superior to the landmark; 2 U is injected 1 cm medial and 2 cm superior to the landmark; and 1 U is injected 0.5 cm medial and 1 cm inferior to the landmark. The sum is 6–8 U, which is a satisfactory dose for each side. There no reason to inject more than 3 cm lateral to the lateral canthus because the average length from lateral canthus to the lateral edge of the Orbicularis occuli 3.1 cm.
It is recommended that an injection be made into the CSM after the needle tip comes into contact with the frontal bone and is slightly withdrawn since the CSM is located deep inside. 3 U (4 U for male) is injected around the upper border of the medial orbital rim just above the medial canthus, the insertion area for the CSM. 2 U is injected into the midpoint between the insertion area of the depressor supercilii and the nasion (intercanthal midpoint) in order to treat the proerus and the depressor supercilii m. on each side. However, if patients show active movement above the eyebrows in the midpupillary line when making glabellar expression lines, 1 U per side should be injected intradermally into the same injection points above the brow in the midpupillary line.
Bruising is a risk in the brow area. The periocular area has many superficial veins, which may be visible through the surface of the skin. Injecting into the superficial subcutaneous tissue minimizes bruising.
- Post-Injection Instructions
Firm pressure should be applied. Bruising is more likely in this area..
Botox may paralyze the levator palpebrae superioris muscle.
- Pearls of Injection
Some patients will not be able to achieve significant brow elevation. Various studies have shown that the mid brw lifts by 1-2 mm and lateral brow lifts by 4-6 mm. Both patient and physician must be aware of this limitation.
Brow elevation results from the upward pull of the brow by the frontalis muscle; therefore, simultaneous injection of the lateral aspect of the frontalis and the lateral orbicularis muscles will counteract the upward lift of the brow in this region.
Fillers Brow lift
The oculofacial literature has shown recent concerns about the traditional excisional or “lifting” approach to
periocular rejuvenation.Although such surgery in the upper eyelid area certainly improves the brow ptosis and
dermatochalasis that develops with aging, it does not address the fundamental loss of soft-tissue volume that contributes to these aging changes. Consequently, such techniques often change a patient’s appearance and can paradoxically serve to age a patient further. For example, brow lifts can result in inappropriate elevation of the brow, which lengthens the orbital distance (the distance from the brow to the nasojugal fold) and emphasizes the superior orbital rim. This contrasts with the youthful eye, which actually has a relatively short orbital distance with low brows and a full supraorbital rim. A similar effect is seen in traditional excisional upper eyelid blepharoplasty where the orbit is often skeletonized.
Such effects age the eye by making it appear smaller, with the focus falling on the superior eyelid sulcus. However, the simultaneous lack of hooding or dermatochalasis following surgery produces a conﬂicting picture and can yield an unnatural appearance. Hyaluronic acid gel ﬁllers offer a versatile and safe method of replacing soft tissue lost from the upper eyelid/brow complex. Unlike autologous fat transfers they have no associated donor site morbidity, no risk of graft hypertrophy, the ability to be performed in the ofﬁce, the ability to be molded, the potential for complete reversibility, and minimal risk of lumpiness, bruising, or infection.
PDO Thread brow lift
Details of PDO thread lift has been described in the below article
- Choose the right patient, with minimal to moderate sagging have good soft tissue volume, less facial fat. Do not try to sell PDO lifts as an alternative to surgical procedure the results are moderate and patient may end up unhappy with results.
- Avoid patient with thin skin in which there is more chances of suture show, rippling effect and more bruising.
- It is postulated that a sinuous passage of the barbed suture is preferable to a straight one and both barbed and conventional sutures hold best when they engage connective tissue at a right angle to the collagen bundles. As the suture is tightened, a wavy path straightens causing alternative vectors of force pushing against the suture. If a suture begins to pull out, new ﬁbers then become pressed against the barbs. In contrast, the barbs in a suture that traverses a straight line will only encounter a loosened column of tissue as it is pulled out. Undulations impart also elasticity, helping to prevent suture breakage, particularly with ballistic movements of the engaged tissue.
- Use PDO threads in the first session if patient is happy with results and opts for a subsequent procedure suggest the use of PLLA threads they are more long lasting upto 2-3 years.