7 A Guide to Eyebrow Contouring Options
Abstract
Eyebrow shape and position play a powerful role in expression of mood, youth, and, at times, the ability to maintain superior field of vision. Advances in our understanding of facial aging have shifted the focus on brow enhancement surgery from altering vertical position with a browlift to conceptual considerations for the shape of the brow in three dimensions. This book includes a description of several modern approaches to eyebrow rejuvenation. Incisionless approaches include muscular denervation with neurotoxin and volume replacement with synthetic filler or autologous fat. Surgical rejuvenation may be approached through an incision in the eyelid crease, above eyebrow cilia, in central forehead rhytids, and at or behind the superior forehead hairline. A focused history and physical exam should be performed to choose the optimal procedure. This chapter helps the reader understand how to integrate a patient’s goals and anatomy to choose the optimal eyebrow rejuvenation approach.
7.1 Introduction
The eyebrow region is an integral functional and aesthetic component of the upper face. Position and shape powerfully convey one’s mood and youth (Fig. 7.1). Any alterations in the form of the brow should take into account a patient’s gender, age, and harmony with the rest of the face. Anatomic understanding of the upper face and brow region is critical to performing many of the procedures safely and is covered in Chapter 2.
Surgical rejuvenation has classically focused on vertical eyebrow elevation. Recently, there has been an appreciation for the three-dimensional orientation of the eyebrow and focus on facial proportions. This chapter aims to provide the reader with a framework for understanding the “when and why” of eyebrow rejuvenation procedures described in the subsequent chapters, including the use of nonsurgical adjuncts such as hyaluronic acid gel fillers for soft tissue inflation and botulinum toxin placement for relaxation of eyebrow depressor and elevator muscles.
7.2 Evolving Trends in Brow Beauty
The desired eyebrow aesthetic has evolved over time. To understand where we are now, it is important to appreciate aesthetic trends over time, volume loss and tissue descent, and ideal eyebrow height associated with facial proportions.
7.2.1 History of Eyebrow Aesthetics
The ideal eyebrow and upper facial appearance is fluid, mirroring changes in fashion and ideal body aesthetics. The most notable shifts in the brow aesthetic occur with the feminine eyebrow and are associated most commonly with shape and cilia density. During the roaring 1920s, female celebrities preferred a pencil thin, downward sloping eyebrow tail that provided the moody appearance that was chic at the time. Eyebrows stayed thin in the 1930s but incorporated a round arch with the highest point closer to center. Evolving styles of grooming and makeup application following World War II brought further changes. In the 1950s, Marilyn Monroe exhibited a thicker brow, filled in with makeup, with its arch at the lateral third, closer to what we see today. Trends in brow shape and contour have continued to alternate throughout more recent decades, mirroring desires for a more natural upper facial aesthetic in the 1980s (e.g., Brooke Shields) and a more groomed and shaped appearance in the 1990s (e.g., Jennifer Lopez). If the past is any indication of the future, the ideal eyebrow shape will continue to evolve, and it is incumbent on the oculofacial plastic surgeon to maintain an awareness of these trends (Fig. 7.2).
7.2.2 Volume and Facial Aging
A youthful eyebrow exhibits convexity and forward projection of the upper eyelid–brow complex on side profile (Fig. 7.3). Loss of projection occurs with age, secondary to resorption of the frontal bone, soft tissue atrophy of the retro-orbicularis oculi fat, and tissue descent. Consideration to brow position and three-dimensional shape is critical to achieving optimal results in eyebrow rejuvenation. Replacement of volume with soft tissue fillers or autologous fat should be part of the modern surgeon’s toolbox.
7.2.3 Eyebrow Height and Proportions
Like many concepts in facial aesthetics, there should be awareness of proportions and age appropriateness when thinking of optimal brow position. Although counterintuitive, a youthful brow position is relatively low set, an orientation that provides harmony with a relatively short, volume-rich lower eyelid–cheek transition. Facial rejuvenation surgical practices do, however, commonly perform vertical brow lifting techniques because the aging orbit accommodates a relatively higher brow position to maintain proportions with the longer length of the lower eyelid–cheek transition in age (Fig. 7.4). In other words, to maintain harmony of the upper and lower eyelid aesthetic units, the aging face tolerates a relatively higher brow height to maintain similar proportions with the longer distance in the lower eyelid.1 The aesthetic surgeon should keep proportions in mind when assessing the potential for aesthetic improvement in the aging face. The surgeon should avoid overelevation of the youthful brow and consider the upper eyelid–eyebrow perceptual changes that may occur when shortening the lower eyelid–cheek transition with aesthetic lower eyelid blepharoplasty.
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