The upper one third of the face is the first area in which the earliest signs of aging become apparent. It is the most expressive portion of the face inasmuch that the eyes often have been described as “the windows to the soul.” The eyelid/eyebrow complex is an area in which minor improvements can translate into excellent aesthetic results. However, this region is also an area in which minor imperfections are easily recognizable and, therefore, cosmetically unacceptable. The forehead, eyes, and brow must each be assessed independently, but their subtle and highly important interrelationships merit thoughtful analysis before treatment .
Factors such as sun exposure, gravity, and genetics contribute to the loss of skin elasticity, which may result in brow ptosis. Brow ptosis subsequently may impart an appearance of tiredness, sadness, and often anger. A patient may express that their eyelid/eyebrow complex projects an appearance that is discordant with their subjective overall feeling of good health and vitality.
Brow ptosis commonly represents only a cosmetic concern. However, on occasion, a functional component exists in the form of limitation in the superolateral visual fields. Brow ptosis is often unrecognized by the patient. More commonly, the patient may complain about excessive upper eyelid skin with hooding, all the while not cognizant of brow position as a major contributing factor to the resultant appearance of upper lid redundancy. It is imperative that we, as facial plastic surgeons, instruct the patient with regard to the important role brow position plays in upper lid redundancy and, most importantly, stress the importance of brow repositioning before any intervention of the upper lid skin. In fact, in some individuals, brow repositioning alone may remedy the problem entirely.
Here we describe the aesthetics of ideal brow positions in both men and women. We discuss the various types of brow lifting procedures, the ideal surgical candidate for each procedure, and include some surgical pearls related to each technique.
Brow aesthetics
The ideal brow shape and position varies considerably with age, gender, culture, and current aesthetic trends. In most regards, brow aesthetics largely have remained unchanged, although some minor modifications over the last several years have been noted.
The ideal female brow should rest at or above the supraorbital rim. The medial head and the lateral tail of the brow should begin and end, respectively, at the same horizontal level with a peak located just superior to a region between the lateral canthus and lateral limbus. The current trend for the aesthetically preferred brow peak seems to be slowly migrating laterally, that is, more toward the region overlying the lateral canthus than that of the lateral limbus .
The lateral brow should end on a line extending from the nasal ala to the lateral canthus and should begin on a vertical line extending from the nasal ala or from the medial canthus. The medial brow should be full, but should taper gracefully as it transverses laterally.
These general guidelines for the female brow can be modified to accommodate variations in nasal shape. For example, a narrow nose can be made to appear wider if the medial aspect of the eyebrow is plucked medially to a vertical line extending from the nasal ala (as described above) and if the eyebrow is shaped in a reasonably straight fashion rather than a highly arched fashion. However, a broad nose will appear more slender if the eyebrows are slightly closer together and if the medial edge is squared rather than rounded.
The average height of the female brow (eyebrow to hairline) should be between 5 and 6 cm . For forehead heights 7 cm and greater, techniques to shorten the forehead should be considered ( Fig. 1 ).
The male brow should sit at or just below the supraorbital rim. The eyebrow should primarily be straight in configuration because an arched appearance of the eyebrow tends to feminize the appearance. In addition, positioning of the eyebrow above the supraorbital rim similarly may result in a feminized appearance. Although numerical position for the male brow has been described by several investigators , it is our opinion that ideal male brow position should be individualized to achieve a balance with the forehead height in conjunction with the vertical features of the face.
The male brow is thicker and flatter than that of the female brow and should taper only slightly as it traverses laterally from its medial origin. Medially, the eyebrows should not be excessively crowded. The appearance of glabellar furrows, which result from excess activity of the corrugators and procerus musculature, tend to yield an angry, worried or excessively fatigued appearance . When addressing the male brow, attention to the glabellar complex is on occasion of greater significance than a sole focus on the vertical height of the brow when the goal is a balanced and pleasant aesthetic outcome ( Fig. 2 ).
Diagnosis and technical considerations
When analyzing brow position, the facial plastic surgeon must appreciate the subconscious tendency of the patient to elevate falsely their brows when gazing into a mirror or when being photographed. We routinely have the patient close their eyes and completely relax the brow. The patient is then given a mirror while we stabilize the frontalis muscle in repose to show the resting brow position. Many patients are quite surprised to discover their brow positions are much lower than originally assumed. ( Fig. 3 A, B, and C).
In addition to brow position, we also observe the height of the forehead and the positions of the frontal and temporal hairlines. Other important factors, such as skin thickness, static transverse forehead creases, glabellar creases, frontal bossing, trends of male pattern baldness, pre-existing asymmetry, and preferred hairstyle must also be considered.
Diagnosis and technical considerations
When analyzing brow position, the facial plastic surgeon must appreciate the subconscious tendency of the patient to elevate falsely their brows when gazing into a mirror or when being photographed. We routinely have the patient close their eyes and completely relax the brow. The patient is then given a mirror while we stabilize the frontalis muscle in repose to show the resting brow position. Many patients are quite surprised to discover their brow positions are much lower than originally assumed. ( Fig. 3 A, B, and C).
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