Brow lift vs forehead lift: What's the difference and which is right for you?

Facelifts are a well-known procedure, but you may not be aware of more targeted facial rejuvenation surgeries like a brow lift or forehead lift. These procedures can be done as a standalone surgery or in conjunction with other facial procedures to provide a lifted, tighter and more youthful appearance.

Patients may ask whether the targeted results provided by these surgeries are a better fit for their aesthetic goals than a facelift. But how do you make this determination?

To gather more insight on the topics of brow lifts and forehead lifts, we reached out to ASPS Member Surgeons Chaowen Wu, MD, PhD, and Daniel Murariu, MD, MPH, MBA, FACS. Get their thoughts on both of these procedures and their recommendations for how to determine which procedure is right for you.

ASPS: When considering rejuvenating facial aesthetic procedures within plastic surgery, many patients are familiar with the popular facelift procedure, and fewer are as acquainted with targeted brow lift or forehead lift procedures. How popular are these procedures at your practice currently? Is one procedure more commonly requested than the others?

Dr. Wu: Patients often attribute signs of aging to more obvious changes in their face, neck and eyelids. But there is a subtlety to brow position that changes over time, which can also contribute to tired eyes, heavy eyelids or an angry expression. For this reason, fewer patients think about a brow lift procedure prior to consultation; however, after reviewing their facial rejuvenation goals together, we often determine that a brow lift would be beneficial. In my practice, a temporal brow lift is often performed with a deep plane face and neck lift to achieve more comprehensive facial rejuvenation results.

Dr. Murariu: They are commonly done in conjunction with the facelift, as the majority of patients request to have their eyes done. The upper eyelid and the brow are closely intertwined, and although a patient may generically point to the upper eyelid as a cause of dissatisfaction, on many occasions, a brow lift is indicated as well. A targeted brow lift is probably more common than a coronal (classic) brow lift, even more so in men.

ASPS: How do you typically work with patients to determine the right procedure to rejuvenate their face?

Dr. Wu: To determine facial rejuvenation procedures that fit the patient's goals, we begin with an in-depth consultation to assess facial aesthetics along with medical history. Many of our patients travel from out of town, and we have adapted this process into our virtual consultations by utilizing patients' own photos to help visualize the outcomes of different procedures. Often, a combination of procedures is recommended to achieve a balanced and harmonious result. The final decision is made together with the patient prioritizing their most important goals and, more importantly, avoiding unnecessary procedures.

Dr. Murariu: I believe taking a detailed history and physical helps me guide the patient in which procedure they would benefit the most. If the brow ptosis (drooping/sagging) is significant and the patient has severe forehead and glabellar (area between the eyes) wrinkling that bothers them, then a coronal lift may be more beneficial. But if the patient has thinning hair or is experiencing hair loss with a pronounced widow's peak, then a coronal lift may result in a scar too visible.

While most of the incision is kept several centimeters within the hairline, some patients with an elongated forehead may benefit from the incision placed in front of the hairline, thereby slightly shortening the forehead while lifting the position of the brows and excising any excess skin. Another benefit of these procedures would be the direct excision of the muscles that cause the so-called 11 lines. Of course, the advent of neuromodulators (commonly known as Botox) is used as an alternative to permanent excision of the muscles.

A targeted brow lift can result in improved balancing with a smaller scar. This can typically be done using an endoscope – a small camera attached to a skinny instrument – with a very short scar within the hairline for camouflage. Other techniques have also been described. For a small correction a small scar can be placed in an inconspicuous location such a preexisting wrinkle or at the hairline. A small hole is drilled into the bone, and a slow resorbing anchor implant is secured in it while the forehead skin is advanced superiorly and into the hooks on the implant. Another option that is fairly frequent in Hawaii is a direct browlift, partly because many ladies here use semi-permanent tattoos to enhance their brows. This technique allows for significant and durable results, is less invasive and has the added benefit that the scar, although at the junction of the brow hairline, can be tattooed to avoid detection.

ASPS: How is a brow lift typically performed at your practice? How does it differ from a forehead lift and a facelift?

Dr. Wu: The most performed brow lift technique in my practice is a temporal brow lift performed through incisions hidden in the hair of the temporal scalp. This is ideal for reshaping the tails of the eyebrows to restore a youthful arch without affecting the central brow or forehead, therefore it's a versatile technique for most individuals.

For those with more advanced aging with a combination of heavy and low brows, deep furrows, deep forehead wrinkles and a high hairline or tall forehead, a coronal brow lift or forehead lift using an incision camouflaged at the frontal hairline would be recommended. The benefits of a coronal brow lift provided in these cases can soften forehead wrinkles and lift the brows while simultaneously lowering the hairline. A brow lift rejuvenates the upper third of the face, which makes it a great complement to a facelift that addresses the lower two-thirds.

Dr. Murariu: The brow lift is typically performed at the time of the facelift or as a standalone procedure. Depending on the patient's anatomy and wishes related to incision size, placement and expected results, either a targeted brow lift is performed or a coronal lift. For those needing just a slight lateral brow lift, that will be accomplished with the facelift. We prefer either IV sedation or local and avoid general anesthesia altogether. Compared to general anesthesia, patients recover faster, and the surgical risk is decreased significantly, especially in the elderly.

ASPS: Who are the patients that typically come to you for a brow lift? Do they differ from those who are interested in forehead lifts or facelifts?

Dr. Wu: Patients seeking a brow lift alone are typically younger without advanced signs of facial aging but are bothered by the heaviness of their brows or upper eyelids, causing them to look and feel tired. These concerns can differ from those of patients interested in a facelift, who are usually more focused on addressing sagging in the lower face and neck. Forehead lift patients might share similar concerns to brow lift patients but may have an additional desire to soften their forehead lines and wrinkles and lowering their frontal hairline.

Dr. Murariu: The patients who come for brow ptosis correction are those who have noticed their brows lower than the superior orbital rim, resulting in eye heaviness, oftentimes with upper eyelid fullness or overactive glabellar and proceri (between the eyes) muscles. This combination results in tired or even sad-looking eyes. The eyes are the first area of the face we notice when we first meet someone. The eyes are often described as the "window to the soul," which may conflict with how one's disposition is reflected, i.e., the person is jovial on the inside, but the eyes have intrinsic aging, resulting in sad-looking eyes. Rejuvenating procedures around the eyes stand not only to improve the aesthetics of the area, but also to match how one feels on the inside.

Our practice likely sees a larger number of patients wishing coronal lifts as a testament to my partner, Dr. Robert Peterson, who earlier on in his career was partners with Dr. Robert Flowers, a world-renowned plastic surgeon and considered by many an expert in coronal brow lifts. The legacy continues in our practice, and we are actively tweaking and improving the procedures. Currently, we are evaluating a minimally invasive way to achieve a permanent Botox-like result to the 11s.

ASPS: What is the typical postop recovery process like for this family of procedures? Is one more intensive than the others?

Dr. Wu: The downtime from a temporal brow lift is typically one to two weeks, which is the time it takes for swelling and bruising to dissipate enough to be public-ready. The downtime is a bit longer for a coronal brow lift or forehead lift, which averages about two weeks due to a longer incision. Fortunately, this is also the downtime for facelift recovery, so combining the procedures does not generally require more time. We provide comprehensive postoperative care instructions and tips to help support our patients throughout their recovery.

Dr. Murariu: Depending on the technique chosen, the postop recovery can be fairly light for those on the lesser invasive, such as endoscopic or direct brow lifts, with minimal discomfort, some minor swelling and bruising. A coronal brow lift, on the other hand, results in swelling most pronounced in the first two weeks, and extra care should be taken postoperatively to avoid blood or fluid collections, also known as hematomas or seromas, respectively. Since all our aesthetic procedures are performed under local or IV sedation, patients experience the same degree of comfort as general anesthesia, but with fewer side effects, including nausea and vomiting, and are able to literally get up and walk pain-free within half an hour after the end of the procedure.

ASPS: Do you have any tips or advice for patients who are considering pursuing any of these procedures?

Dr. Wu: If you are thinking about facial rejuvenation surgery, take time to optimize your health because it will be the foundation for achieving the best results and smoothest healing. Choosing the right surgeon can be daunting because it is your face after all, so here are a few tips to keep in mind:

• Research your surgeon(s): Choose a board-certified plastic surgeon who is an ASPS member with substantial experience in facial rejuvenation procedures. Examine the before and after photo galleries because this is where you will get a sense of the surgeon's aesthetic eye. Ask yourself if you would be happy with similar results as what the surgeon provides.
• At consultation: Be yourself, and be open and honest about your goals and expectations. This is a time when listening to your gut instinct is a must. Did you connect with the surgeon during your consultation? Do you trust them with your face?
• Prepare properly for surgery: Anticipate two weeks of downtime following surgery. Follow all preoperative instructions, such as avoiding certain medications and ceasing smoking, to reduce the risk of complications.
• Recovering after surgery: Adhere to all aftercare instructions provided by your surgeon. Recovery takes time and cannot be rushed. The great majority of patients will look appropriate to go back to work comfortably after two weeks, but full healing takes six to 12 months.
• Have realistic expectations: Understand the limits of what surgery can achieve and have realistic expectations for the outcome, discussing these openly with the surgeon.

Dr. Murariu: Of course! Always seek a board-certified plastic surgeon who is an ASPS member for any aesthetic procedure, and always inquire about seeing before and after photos. Look for natural-looking and lasting results that maintain the patient's natural defining points. The goal should be to rejuvenate one's appearance without seeming to put them in the Witness Protection Program. As one of the busiest facial aesthetics practices in Honolulu, we take pride in delivering great, natural-looking results in a personalized fashion.

ASPS: Do you have any additional insights around this topic that you'd like to share?

Dr. Wu: Many people are unaware that poor posture, which contributes to the shortening of the neck, is a big contributor to premature aging and sagging in the face and neck. So, we always recommend practicing proper posture both before and after surgery to help enhance and maintain results.

Dr. Murariu: I think that brow rejuvenation is often treated as a secondary adjunct to facelifts, whereas they are an integral part of facial rejuvenation and should be discussed more readily.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.