April 16, 2024
The Eyebrow: Our Emotion Maker w/ Dr. Jason Bloom
The eyebrow plays a vital role in how we express our emotions, so it’s no surprise that many people seek solutions when their brows start to droop, flatten, and lose their shape.
The horror stories you may have heard about brow lift are nothing to worry about today, as techniques have greatly improved over the years.
Longevity is difficult when it comes to the brows as you're constantly battling gravity. Luckily today, injectables and energy treatments postpone the need for surgical intervention and can in turn help maintain surgical results much longer.
Brow lift is a highly customizable treatment. Brow position and shape for men and women are much different, so specific techniques are used to preserve gender identity. Depending on how low the hooding is, a brow lift may be done in combination with a blepharoplasty.
Facial plastic surgeon Dr. Jason Bloom returns to the podcast with Dr. Bass to discuss how brow lift surgery has improved over the years, the most common techniques they use today, and how to decide if a brow lift, blepharoplasty, or both is right for you.
About Jason Bloom, MD
Located in Bryn Mawr, Pennsylvania, Dr. Jason Bloom is a double board certified facial plastic and reconstructive surgeon. He is an Adjunct Assistant Professor of Otorhinolaryngology – Head & Neck Surgery at the University of Pennsylvania and Clinical Assistant Professor (Adjunct) of Dermatology at the Temple University School of Medicine.
Read more about Philadelphia facial plastic surgeon Jason Bloom, MD
Learn more about brow lift
About Dr. Lawrence Bass
Innovator. Industry veteran. In-demand Park Avenue board certified plastic surgeon, Dr. Lawrence Bass is a true master of his craft, not only in the OR but as an industry pioneer in the development and evaluation of new aesthetic technologies. With locations in both Manhattan (on Park Avenue between 62nd and 63rd Streets) and in Great Neck, Long Island, Dr. Bass has earned his reputation as the plastic surgeon for the most discerning patients in NYC and beyond.
To learn more, visit the Bass Plastic Surgery website or follow the team on Instagram @drbassnyc
Subscribe to the Park Avenue Plastic Surgery Class newsletter to be notified of new episodes & receive exclusive invitations, offers, and information from Dr. Bass.
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Welcome to Park Avenue
Plastic Surgery Class,
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the podcast where we explore controversies
and breaking issues in plastic
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surgery. I'm your co-host, Doreen Wu,
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a clinical assistant at Bass
Plastic Surgery in New York City.
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I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,
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educator and technology innovator.
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The title of today's episode is
The Eyebrow: Our Emotion Maker.
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Today we're planning on talking about
the eyebrow and brow lifting. Dr. Bass,
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why is this a topic unto itself?
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Well, if we look back to the 1980s
when there were little more than a
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handful of aesthetic surgery procedures,
the brow lift was one of them.
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So this is one of the old
standbys. In that sense,
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it's historically a cornerstone
of facial rejuvenation,
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but it's also been a central part of
facial aesthetic treatments, makeup,
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beauty,
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because of the role the brow
plays in expressing facial
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emotions.
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What are the main aesthetic
issues regarding the brow?
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The big issue with aging is brow ptosis
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or drooping. So this narrows
the visible eye space,
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and the brow also tends
to flatten as we age,
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so we lose some of the youthful shape.
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Is there any more to the
history I should know?
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Actually, yes. The traditional brow lift,
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what's called a coronal brow lift,
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is largely historical at this point.
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And this is a procedure that
people heard horror stories about,
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and I don't want to make a lot
of the fact that what we have now
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is not surprisingly
better than what we had
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40, 50, 60 years ago.
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But the procedure made a long incision
across the top of the head from
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just above the top of one ear
to the top of the ear on the
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other side,
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and then the brow would be
released from the forehead
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to allow the work to be done.
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And this procedure worked very
well to elevate the brows,
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but there were several drawbacks
that really are not acceptable to us
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these days. There was a
fairly long healing time,
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months to restore sensation to the scalp,
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and people could see a receding
hairline or occasionally a bad
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scar with hair loss along the incision.
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So these account for many of those
negative tails that I mentioned about brow
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lift. But because this technique
is not really in use any longer,
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except occasionally for specific reasons,
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all of those horror stories should
largely be ignored since other techniques
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have come into use.
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And I'm going to turn to our
guest on the podcast today who's
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agreed to return and
join us. Dr. Jason Bloom.
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He's a facial plastic surgeon
in Bryn Mawr, Pennsylvania,
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who's joined us previously on a
number of episodes. Dr. Bloom,
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what are the most common surgical
approaches nowadays for brow lifting?
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So the most common surgery
approaches for brow lifting that
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we utilize in our practice are
the number one would probably be
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an endoscopic brow lift.
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And this is kind of a closed
approach through a number
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of five different small incisions
made back in the hairline that
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allows us to access the musculature,
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the ligamentous attachments of the
brow through basically these small
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ports,
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part of which we use under direct
visualization and some parts
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with a video camera.
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Then you have the open
brow lift approaches,
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which as you were describing
would be a coronal brow lift,
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which is basically an incision from ear
to ear as well as what we call a trick
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or a hairline incision brow lift.
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These are larger procedures where
you're actually pulling down the scalp,
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working on the musculature directly.
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And then I will say there is something
more recently that I've been doing a
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little bit more of called a
temporal brow lift when the lateral
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parts of the brow are depressed and you
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can actually point to just the
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most lateral part of the
brow kind of hooding,
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you can directly access over the
temporalis muscle to lift that up.
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And then the last ones I would
say are used mostly at this
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point for more functional issues where
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there is a lot of
asymmetry between the brow.
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And that would be a direct brow lift,
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meaning making an incision right
over the brow or a mid forehead lift,
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brow lift where you're using right
or wrinkles in the forehead to
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address the brow height more directly.
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Yeah, and that's a good
summary of what's out there.
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I'll just add a wrinkle,
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if you'll pardon the pun
to that approach with the
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direct brow lift. The direct brow lift,
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as you said,
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has classically used an incision
right above the hair of the
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eyebrow. But there is
an approach that I use,
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and I'll tell you the reason,
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through an upper blepharoplasty incision,
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to access the ligamentous structures them
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and allow elevation of the brow. Now,
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the difficulty with taking that
approach was obtaining fixation
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and fixation with good control.
So you release the brow,
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but now you have to hold it up exactly
where you want it while it heals.
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But some newer technologies
have allowed us to get stable
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fixation,
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and that allows that approach to be used,
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which conceals the incision.
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And the place I use that
the most is for men with a
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receding hairline because
it's difficult to put an open
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incision on them.
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Men don't always heal to make
quite as nice a scar as women
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will with a hairline brow lift.
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And if their hairline is receded,
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doing an endoscopic approach may
be challenging and may not give
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you the fixation you want
over that long distance.
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So I'll take a direct approach,
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but through the upper
blepharoplasty incision.
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I utilize that occasionally,
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and I think that's a great population
that you're talking about is these male
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population. And that's,
we call that a transbleph,
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and I use it less for a brow lift,
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but more for what I call a
browpexy to kind of hold the brow
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at its position and prevent further
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posis or lowering of the brows.
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Building on this discussion of populations
who are appropriate candidates for a
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brow lift, what are some typical
ages to undergo this procedure?
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So I would have to say
in my patient population,
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most of the patients that
I'm doing brow surgery on,
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and I would say if I'm doing
a brow surgery on a patient,
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there's about an 85% chance I'm doing,
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85 to 90% chance,
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I'm doing some other periocular
rejuvenation surgery at the same time,
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but they typically are in there,
I would say early to mid fifties.
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And the candidates really depend on,
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we were talking about the differences
between males and females.
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When I look at a male brow, for
example, male brows tend to be flatter,
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less arched, and if you
feel the orbital rim,
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a typical male brow tends to be
just above or at the orbital rim.
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A female brow is a little bit different.
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A female brow should be above
the orbital rim the entire way
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with the peak of the brow kind
of arching somewhere between
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the lateral peak or arch of the brow
should be somewhere between the lateral
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limbus of the eye,
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which is the colored part of the iris of
the eye and the lateral canthus of the
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eye. So you want the peak to be
aesthetically somewhere between those two
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points.
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Yeah, I mean,
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the gender specific differences
of brow position and
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brow shape are really
important to remember.
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And either if we're trying
to preserve gender identity,
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we need to take one approach
in each gender to keep
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them with an appropriate looking
eyebrow or if the goal is to try to
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change it.
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I find like Dr. Bloom,
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I brow lift more often in
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conjunction with a blepharoplasty
or some other periocular
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procedures than by itself.
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And that's typically in
patients that are older
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than what we thought in the
1990s were good candidates
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for brow lifting.
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There was a view that brow
ptosis occurs early in
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facial aging in the late thirties,
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and 35 to 45 was a good time for an
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endoscopic brow lift.
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And I'm not sure that that would be
the view today where we typically
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will wait longer.
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But I also see people who have had
a major facial rejuvenation in their
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fifties and are now in their late sixties
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or early seventies,
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and they may have gotten away
without a brow lift at the first go
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round, but they're more likely to
need it at the second go round,
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although that raises the challenge of
dealing with where their hairline has
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gotten to with aging.
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Now let's talk about the difference
between a brow lift and a blepharoplasty.
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Should I be getting a brow
lift or a blepharoplasty?
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How do I decide which is right for me?
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Each procedure does
different things of course.
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So if the brow is low or
the visible lid space is
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very narrow,
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then lifting the brow is
reasonable and that Dr. Bloom
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gave that technical definition of where
the brow is supposed to be in youth,
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usually just at or above
the bony orbital rim.
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But if we look at a lot of people,
their high school yearbook picture,
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their brow is lower than that.
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So it's not necessarily that
they look old because the brow
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is low, if that's how
they've always looked,
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it may be a mistake to lift their
brow and change who they look like.
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It's always a mistake to over
elevate the brow to clean up excess
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skin in the upper lid that gives
a surprised look or deer in the
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headlights look. That's very unnatural.
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So if you bring the up
to the point where it's
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anatomic and their upper lid looks clean,
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maybe they just need a brow lift.
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But if you bring the brow to a
natural position and there's still
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excess skin in the upper lid,
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I think first and foremost they
need an upper lid blepharoplasty.
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And then you consider if
there's enough aesthetic
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advantage to need a brow
lift in addition. Dr. Bloom,
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how do you parse this?
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In very much the same
way as you're explaining.
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I would say if the brow
is low and when you
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bring it up to the correct position,
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even just standing in front of the patient
and playing with their eyebrows and
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kind of getting it to the right position,
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if there still is what we call
dermatochalasis or hooding at that point,
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then I tend to do a
brow lift in combination
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with an upper blepharoplasty.
But if the patient
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has a good brow position and
they just have, for example,
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hooding of the upper
eyelid that you can see,
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and when you pinch that
extra upper eyelid skin
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that is a patient in my hands for just
for example, an upper blepharoplasty.
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One of the biggest, I think,
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giveaways to a patient
needing a brow lift is a
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patient sometimes with really
deep forehead wrinkles.
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Because it's very interesting
that when a patient has a
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lower brow, the frontalis
or the forehead muscle,
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as we know is the only
lifter of the eyebrows.
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And a lot of times when a patient
has deep forehead wrinkles,
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it's because it's a
compensatory mechanism.
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They are constantly trying to lift
their brows up so they can see,
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and literally they're trying to lift
their brows so they can actually
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see and remove some of the
extra upper eyelid hooding,
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and they're lifting their brows.
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So if you see a patient
with deep forehead wrinkles,
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there usually is a brow
ptosis in conjunction.
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Let's talk about the forehead then.
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Is it brow lifting or Botox or
something else that'll address this?
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Well, it really depends.
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I was just talking, if you see
some heavy forehead wrinkles,
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those patients usually
need some kind of procedure
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to lift the browse because
if you, for example,
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you can use neuromodulator
in those cases to weaken the
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brow depressor muscles,
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which would be in between the eyes
and underneath and around the eyes,
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the orbicularis muscle and the
corrugator and proce muscles.
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But if you treat a patient like that
with heavy forehead lines and wrinkles
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and a lower brow with
Botox in their forehead,
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you've now just weakened
the only muscle in
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their face that lifts their brows,
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and that is going to make their
brows actually heavier and more
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kind of dense or lower. So
in those kind of patients,
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you only want to treat in
between and around the eyes with
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Botox so that the muscles
that pull down the
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eyes or the brow depressor
muscles are weakened and allow
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the forehead muscle to lift.
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So it's an understanding of
what muscles lift and what
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muscles pull down,
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and how we use either toxins or surgery to
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modulate those muscles.
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And a lot of that is probably about
the individual patient and their muscle
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dynamics. So
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I agree with you a hundred percent,
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and I think this is very poorly understood
by a lot of people who are out there
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doing a lot of Botox treatments.
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That balancing first by relaxing the
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depressors, and then if
you can get away with it,
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doing a little smoothing by very minimally
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relaxing, the only lifter muscle,
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the frontalis,
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which is the one that
makes those forehead lines.
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And if you can't get away with that,
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then you maybe should be thinking
hard about getting a brow lift so
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that the brow is elevated without you
having to pull it up with your muscles
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all day long.
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00:16:48,380 --> 00:16:52,370
Yeah, I mean, this is extremely
poorly understood how many patients,
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Dr. Bass come into your
office and they go,
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"I just need some Botox in my forehead
to lift my brows." And they're pulling on
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00:16:59,541 --> 00:17:02,690
their forehead. They do that. I
mean every single patient, right?
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And they don't understand how we
trick the brow into coming up,
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which is a very backhanded or
paradoxical way of doing it.
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Now I'm wondering what kind of control
do these various techniques have for brow
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shape? Let's say my main goal is brow
shaping, not repositioning per se.
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Are there nonmedical approaches
that might work better?
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I feel that honestly,
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00:17:28,320 --> 00:17:32,750
neuromodulators give us
great control of brow shape
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in understanding how these muscles pull,
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as we were just describing in some of
the muscles pulling down and some of the
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muscles lifting,
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you can actually pinpoint and get precise
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areas of brow lifting
and flattening of the
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brow depending by using small amounts,
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micro amounts of
neuromodulator placed expertly.
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And in my hands,
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neuromodulator works way better
for that than brow lift surgery.
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00:18:06,450 --> 00:18:11,310
Yeah, I agree. I think the thing
that has the most potential for
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control, control of brow
shape is neuromodulators.
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00:18:17,190 --> 00:18:22,080
And then things like surgery or some
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00:18:22,081 --> 00:18:26,100
of the energy treatments
that can elevate the brow
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00:18:27,240 --> 00:18:32,190
are less, they're maybe more durable,
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00:18:32,490 --> 00:18:36,120
and they may be able to get a
greater degree of elevation,
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00:18:36,121 --> 00:18:38,490
but they don't have as much shape control.
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00:18:39,210 --> 00:18:42,240
The other thing that does offer potential,
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00:18:42,241 --> 00:18:46,140
if the brow height
basically is reasonable,
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00:18:46,141 --> 00:18:51,120
it's not very droopy, shaping
the brow itself can be done
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00:18:52,720 --> 00:18:55,740
with, the estheticians do this,
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00:18:56,010 --> 00:19:00,750
by tweaking which hairs they leave
and which hairs they take out or
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00:19:00,751 --> 00:19:05,310
by tattooing the brow or
micro bleeding to introduce a
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00:19:05,311 --> 00:19:09,780
certain shape by how much brow hair you
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00:19:09,781 --> 00:19:13,200
leave and how much you
remove in different places.
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00:19:13,590 --> 00:19:16,710
To create a very dramatic
arching to the brow,
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00:19:16,740 --> 00:19:20,040
more of an average arching.
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00:19:20,040 --> 00:19:22,740
Men's brow tends to be
straighter to help the brow look
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00:19:22,741 --> 00:19:23,574
straighter.
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00:19:25,560 --> 00:19:29,850
And so sometimes if the
brow is not sitting too low,
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00:19:29,860 --> 00:19:32,580
but you just want a shape to the brow,
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00:19:32,970 --> 00:19:37,800
these beauty treatments
might be more fruitful than
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00:19:38,370 --> 00:19:42,480
a medical approach with
neuromodulator or surgery.
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00:19:43,500 --> 00:19:45,840
Lastly, before we conclude Dr. Bass,
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00:19:46,080 --> 00:19:48,390
what should our listeners take
away from today's episode?
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00:19:49,470 --> 00:19:53,070
So like everything we do in
aesthetic plastic surgery,
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00:19:53,071 --> 00:19:57,570
natural is the key and brow lifting and
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00:19:57,900 --> 00:20:02,760
non-surgical treatments for the brow
can give a perfectly natural looking
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00:20:02,761 --> 00:20:05,100
brow in the proper hands,
305
00:20:05,130 --> 00:20:07,830
but important not to overdo things.
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00:20:08,280 --> 00:20:11,820
The goal is to open the eye space,
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00:20:12,450 --> 00:20:17,190
which makes you look
more present and awake
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00:20:18,330 --> 00:20:19,740
and to shape the brow.
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00:20:20,700 --> 00:20:24,360
But we talked about gender
differences in brow shape,
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00:20:24,420 --> 00:20:26,910
women's brows tend to be arched.
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00:20:26,940 --> 00:20:31,620
They raise towards the outer third
and peak and then drop off where
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00:20:31,621 --> 00:20:33,780
men's brows tend to be straighter.
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00:20:34,890 --> 00:20:38,670
And so changing that when
that is not the intent,
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00:20:39,090 --> 00:20:43,770
can create a very unnatural look,
and that needs to be avoided.
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00:20:44,370 --> 00:20:48,970
There are a range of techniques that
are patient specific on how old you are,
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00:20:48,971 --> 00:20:53,320
where your hairline is, and any
previous surgery you've had.
317
00:20:54,550 --> 00:20:59,440
But Botox and other neuromodulators
and energy treatments have
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00:20:59,441 --> 00:21:02,710
a big role for many, many patients.
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00:21:02,711 --> 00:21:05,020
It's never one size fits all.
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00:21:05,860 --> 00:21:07,540
Dr. Bloom, any takeaways to add?
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00:21:08,260 --> 00:21:12,760
I'll just add three quick
things about the brow and
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00:21:12,761 --> 00:21:16,720
brow procedures and brow
surgery. What I found,
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00:21:16,721 --> 00:21:21,220
number one is that getting
a really long lasting
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00:21:21,221 --> 00:21:25,270
good brow lift surgical
result is very hard.
325
00:21:25,990 --> 00:21:30,040
I think even when we do an
amazing brow lift to us,
326
00:21:30,100 --> 00:21:34,870
I think getting longevity with this
procedure is very difficult because
327
00:21:35,050 --> 00:21:39,340
you're constantly battling gravity.
328
00:21:39,340 --> 00:21:40,510
As a corollary to that,
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00:21:40,540 --> 00:21:44,980
I would say number two is
that less is more in brow
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00:21:45,640 --> 00:21:50,200
lifting. And I think many people
talk about how the release of the
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00:21:50,201 --> 00:21:55,120
attachments and the ligamentous
attachments that kind of bind down the
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00:21:55,121 --> 00:21:59,860
brows are way more
important than the kind of
333
00:22:01,300 --> 00:22:04,780
suspension or methods we
use to resuspend the browse.
334
00:22:04,781 --> 00:22:08,020
So it's more about the
release and what we do
335
00:22:09,460 --> 00:22:12,460
instead of the resuspension. And third,
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00:22:12,820 --> 00:22:16,300
I will say that as we
discussed kind of earlier,
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00:22:17,050 --> 00:22:21,970
I think injectables and energy-based
treatments are really keeping brows
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00:22:21,971 --> 00:22:26,620
and brow positions looking
better for longer before
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00:22:26,621 --> 00:22:28,840
surgery is needed in a
lot of these patients.
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00:22:28,841 --> 00:22:33,670
So as Dr. Bass was saying
early on, years ago,
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00:22:33,671 --> 00:22:36,760
it used to be patients who are getting
brow lifts in their thirties and forties.
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00:22:37,060 --> 00:22:41,590
I think that some of the
non-invasive stuff in non-surgical
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00:22:41,591 --> 00:22:45,250
treatments are keeping brows
looking better for longer,
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00:22:45,520 --> 00:22:50,380
and we're kind of moving brow
lifting surgery to patients in more
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00:22:50,381 --> 00:22:51,610
advanced ages.
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00:22:52,630 --> 00:22:54,130
Thank you, Dr. Bloom, Dr. Bass,
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00:22:54,131 --> 00:22:57,850
for sharing your perspectives and
expertise on this eyebrow raising topic.
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00:22:57,970 --> 00:22:58,870
No pun intended.
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00:22:59,290 --> 00:23:02,470
Thank you guys so much for
having me again on the podcast.
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00:23:02,480 --> 00:23:05,260
It's always a pleasure of
mine to be here with you guys.
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00:23:06,520 --> 00:23:10,210
Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.
352
00:23:10,600 --> 00:23:12,100
Follow us on Apple Podcasts,
353
00:23:12,130 --> 00:23:14,230
write a review and share
the show with your friends.
354
00:23:14,620 --> 00:23:17,740
Be sure to join us next time to avoid
missing all the great content that's
355
00:23:17,741 --> 00:23:21,220
coming your way. If you want to
contact us with comments or questions,
356
00:23:21,230 --> 00:23:22,870
we'd love to hear from you.
357
00:23:22,870 --> 00:23:26,860
Send us an email at podcast@drbass.net
or DM us on Instagram
358
00:23:27,760 --> 00:23:27,850
@drbassnyc.
00:00:00,540 --> 00:00:03,210
Welcome to Park Avenue
Plastic Surgery Class,
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00:00:03,600 --> 00:00:07,230
the podcast where we explore controversies
and breaking issues in plastic
3
00:00:07,231 --> 00:00:09,660
surgery. I'm your co-host, Doreen Wu,
4
00:00:09,870 --> 00:00:13,050
a clinical assistant at Bass
Plastic Surgery in New York City.
5
00:00:13,500 --> 00:00:17,940
I'm excited to be here with Dr. Lawrence
Bass, Park Avenue plastic surgeon,
6
00:00:18,240 --> 00:00:20,400
educator and technology innovator.
7
00:00:21,300 --> 00:00:25,320
The title of today's episode is
The Eyebrow: Our Emotion Maker.
8
00:00:26,280 --> 00:00:30,930
Today we're planning on talking about
the eyebrow and brow lifting. Dr. Bass,
9
00:00:30,930 --> 00:00:32,460
why is this a topic unto itself?
10
00:00:33,420 --> 00:00:38,220
Well, if we look back to the 1980s
when there were little more than a
11
00:00:38,221 --> 00:00:42,540
handful of aesthetic surgery procedures,
the brow lift was one of them.
12
00:00:42,541 --> 00:00:46,650
So this is one of the old
standbys. In that sense,
13
00:00:46,651 --> 00:00:50,520
it's historically a cornerstone
of facial rejuvenation,
14
00:00:51,330 --> 00:00:55,410
but it's also been a central part of
facial aesthetic treatments, makeup,
15
00:00:55,411 --> 00:00:56,244
beauty,
16
00:00:56,400 --> 00:01:00,600
because of the role the brow
plays in expressing facial
17
00:01:00,601 --> 00:01:01,500
emotions.
18
00:01:02,340 --> 00:01:05,040
What are the main aesthetic
issues regarding the brow?
19
00:01:05,910 --> 00:01:10,770
The big issue with aging is brow ptosis
20
00:01:10,771 --> 00:01:15,060
or drooping. So this narrows
the visible eye space,
21
00:01:15,090 --> 00:01:19,800
and the brow also tends
to flatten as we age,
22
00:01:19,950 --> 00:01:22,890
so we lose some of the youthful shape.
23
00:01:24,150 --> 00:01:26,100
Is there any more to the
history I should know?
24
00:01:26,670 --> 00:01:29,310
Actually, yes. The traditional brow lift,
25
00:01:29,320 --> 00:01:31,800
what's called a coronal brow lift,
26
00:01:31,830 --> 00:01:34,500
is largely historical at this point.
27
00:01:35,460 --> 00:01:39,840
And this is a procedure that
people heard horror stories about,
28
00:01:40,260 --> 00:01:45,000
and I don't want to make a lot
of the fact that what we have now
29
00:01:45,001 --> 00:01:48,810
is not surprisingly
better than what we had
30
00:01:48,811 --> 00:01:51,540
40, 50, 60 years ago.
31
00:01:52,350 --> 00:01:57,180
But the procedure made a long incision
across the top of the head from
32
00:01:57,190 --> 00:02:02,070
just above the top of one ear
to the top of the ear on the
33
00:02:02,071 --> 00:02:02,910
other side,
34
00:02:03,060 --> 00:02:07,770
and then the brow would be
released from the forehead
35
00:02:07,830 --> 00:02:09,780
to allow the work to be done.
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00:02:10,560 --> 00:02:14,760
And this procedure worked very
well to elevate the brows,
37
00:02:14,761 --> 00:02:19,620
but there were several drawbacks
that really are not acceptable to us
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00:02:19,621 --> 00:02:23,460
these days. There was a
fairly long healing time,
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00:02:24,600 --> 00:02:27,870
months to restore sensation to the scalp,
40
00:02:28,290 --> 00:02:33,240
and people could see a receding
hairline or occasionally a bad
41
00:02:33,241 --> 00:02:36,090
scar with hair loss along the incision.
42
00:02:36,960 --> 00:02:41,280
So these account for many of those
negative tails that I mentioned about brow
43
00:02:41,290 --> 00:02:45,570
lift. But because this technique
is not really in use any longer,
44
00:02:45,571 --> 00:02:50,010
except occasionally for specific reasons,
45
00:02:50,910 --> 00:02:55,710
all of those horror stories should
largely be ignored since other techniques
46
00:02:55,711 --> 00:02:57,090
have come into use.
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00:02:57,780 --> 00:03:02,020
And I'm going to turn to our
guest on the podcast today who's
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00:03:02,380 --> 00:03:05,500
agreed to return and
join us. Dr. Jason Bloom.
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00:03:06,100 --> 00:03:09,460
He's a facial plastic surgeon
in Bryn Mawr, Pennsylvania,
50
00:03:09,730 --> 00:03:13,780
who's joined us previously on a
number of episodes. Dr. Bloom,
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00:03:13,781 --> 00:03:17,890
what are the most common surgical
approaches nowadays for brow lifting?
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00:03:18,970 --> 00:03:23,680
So the most common surgery
approaches for brow lifting that
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00:03:23,710 --> 00:03:28,690
we utilize in our practice are
the number one would probably be
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00:03:28,691 --> 00:03:30,610
an endoscopic brow lift.
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00:03:30,730 --> 00:03:35,560
And this is kind of a closed
approach through a number
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00:03:35,561 --> 00:03:40,420
of five different small incisions
made back in the hairline that
57
00:03:40,421 --> 00:03:43,330
allows us to access the musculature,
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00:03:43,331 --> 00:03:48,190
the ligamentous attachments of the
brow through basically these small
59
00:03:48,191 --> 00:03:49,024
ports,
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00:03:49,600 --> 00:03:54,370
part of which we use under direct
visualization and some parts
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00:03:54,371 --> 00:03:56,650
with a video camera.
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00:03:57,130 --> 00:04:00,850
Then you have the open
brow lift approaches,
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00:04:01,030 --> 00:04:04,900
which as you were describing
would be a coronal brow lift,
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00:04:04,901 --> 00:04:09,760
which is basically an incision from ear
to ear as well as what we call a trick
65
00:04:10,840 --> 00:04:14,050
or a hairline incision brow lift.
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00:04:14,051 --> 00:04:18,400
These are larger procedures where
you're actually pulling down the scalp,
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00:04:18,401 --> 00:04:21,400
working on the musculature directly.
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00:04:22,420 --> 00:04:25,900
And then I will say there is something
more recently that I've been doing a
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00:04:25,901 --> 00:04:30,610
little bit more of called a
temporal brow lift when the lateral
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00:04:30,611 --> 00:04:35,380
parts of the brow are depressed and you
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00:04:35,381 --> 00:04:40,050
can actually point to just the
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00:04:40,051 --> 00:04:43,690
most lateral part of the
brow kind of hooding,
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00:04:44,050 --> 00:04:48,910
you can directly access over the
temporalis muscle to lift that up.
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00:04:49,270 --> 00:04:54,190
And then the last ones I would
say are used mostly at this
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00:04:54,191 --> 00:04:58,270
point for more functional issues where
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00:04:59,380 --> 00:05:01,750
there is a lot of
asymmetry between the brow.
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00:05:01,900 --> 00:05:04,810
And that would be a direct brow lift,
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00:05:05,020 --> 00:05:09,490
meaning making an incision right
over the brow or a mid forehead lift,
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00:05:10,030 --> 00:05:15,010
brow lift where you're using right
or wrinkles in the forehead to
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00:05:15,700 --> 00:05:19,390
address the brow height more directly.
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00:05:20,620 --> 00:05:23,530
Yeah, and that's a good
summary of what's out there.
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00:05:23,531 --> 00:05:27,040
I'll just add a wrinkle,
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00:05:27,041 --> 00:05:31,480
if you'll pardon the pun
to that approach with the
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00:05:31,481 --> 00:05:35,830
direct brow lift. The direct brow lift,
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00:05:35,831 --> 00:05:36,670
as you said,
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00:05:36,790 --> 00:05:41,230
has classically used an incision
right above the hair of the
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00:05:41,240 --> 00:05:46,030
eyebrow. But there is
an approach that I use,
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00:05:46,120 --> 00:05:47,920
and I'll tell you the reason,
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00:05:49,630 --> 00:05:52,750
through an upper blepharoplasty incision,
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00:05:53,530 --> 00:05:58,130
to access the ligamentous structures them
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00:05:58,940 --> 00:06:01,190
and allow elevation of the brow. Now,
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00:06:01,191 --> 00:06:06,080
the difficulty with taking that
approach was obtaining fixation
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00:06:06,081 --> 00:06:10,010
and fixation with good control.
So you release the brow,
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00:06:10,011 --> 00:06:14,390
but now you have to hold it up exactly
where you want it while it heals.
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00:06:14,990 --> 00:06:19,340
But some newer technologies
have allowed us to get stable
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00:06:19,341 --> 00:06:20,420
fixation,
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00:06:21,440 --> 00:06:25,370
and that allows that approach to be used,
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00:06:25,371 --> 00:06:27,560
which conceals the incision.
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00:06:27,980 --> 00:06:32,600
And the place I use that
the most is for men with a
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00:06:32,601 --> 00:06:37,400
receding hairline because
it's difficult to put an open
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00:06:37,401 --> 00:06:38,810
incision on them.
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00:06:38,900 --> 00:06:43,820
Men don't always heal to make
quite as nice a scar as women
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00:06:43,821 --> 00:06:46,610
will with a hairline brow lift.
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00:06:47,450 --> 00:06:49,700
And if their hairline is receded,
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00:06:49,850 --> 00:06:54,710
doing an endoscopic approach may
be challenging and may not give
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you the fixation you want
over that long distance.
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So I'll take a direct approach,
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but through the upper
blepharoplasty incision.
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I utilize that occasionally,
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and I think that's a great population
that you're talking about is these male
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population. And that's,
we call that a transbleph,
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and I use it less for a brow lift,
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but more for what I call a
browpexy to kind of hold the brow
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at its position and prevent further
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posis or lowering of the brows.
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Building on this discussion of populations
who are appropriate candidates for a
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brow lift, what are some typical
ages to undergo this procedure?
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So I would have to say
in my patient population,
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most of the patients that
I'm doing brow surgery on,
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and I would say if I'm doing
a brow surgery on a patient,
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there's about an 85% chance I'm doing,
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85 to 90% chance,
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I'm doing some other periocular
rejuvenation surgery at the same time,
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but they typically are in there,
I would say early to mid fifties.
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And the candidates really depend on,
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we were talking about the differences
between males and females.
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When I look at a male brow, for
example, male brows tend to be flatter,
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less arched, and if you
feel the orbital rim,
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a typical male brow tends to be
just above or at the orbital rim.
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A female brow is a little bit different.
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A female brow should be above
the orbital rim the entire way
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with the peak of the brow kind
of arching somewhere between
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the lateral peak or arch of the brow
should be somewhere between the lateral
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limbus of the eye,
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which is the colored part of the iris of
the eye and the lateral canthus of the
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eye. So you want the peak to be
aesthetically somewhere between those two
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points.
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Yeah, I mean,
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the gender specific differences
of brow position and
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brow shape are really
important to remember.
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And either if we're trying
to preserve gender identity,
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we need to take one approach
in each gender to keep
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them with an appropriate looking
eyebrow or if the goal is to try to
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change it.
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I find like Dr. Bloom,
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I brow lift more often in
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conjunction with a blepharoplasty
or some other periocular
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procedures than by itself.
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And that's typically in
patients that are older
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than what we thought in the
1990s were good candidates
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for brow lifting.
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There was a view that brow
ptosis occurs early in
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facial aging in the late thirties,
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and 35 to 45 was a good time for an
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endoscopic brow lift.
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And I'm not sure that that would be
the view today where we typically
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will wait longer.
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But I also see people who have had
a major facial rejuvenation in their
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fifties and are now in their late sixties
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or early seventies,
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00:10:29,550 --> 00:10:34,410
and they may have gotten away
without a brow lift at the first go
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round, but they're more likely to
need it at the second go round,
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although that raises the challenge of
dealing with where their hairline has
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gotten to with aging.
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Now let's talk about the difference
between a brow lift and a blepharoplasty.
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Should I be getting a brow
lift or a blepharoplasty?
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How do I decide which is right for me?
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Each procedure does
different things of course.
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So if the brow is low or
the visible lid space is
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very narrow,
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then lifting the brow is
reasonable and that Dr. Bloom
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gave that technical definition of where
the brow is supposed to be in youth,
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usually just at or above
the bony orbital rim.
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But if we look at a lot of people,
their high school yearbook picture,
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their brow is lower than that.
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00:11:25,501 --> 00:11:30,300
So it's not necessarily that
they look old because the brow
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is low, if that's how
they've always looked,
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00:11:33,601 --> 00:11:38,070
it may be a mistake to lift their
brow and change who they look like.
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00:11:38,790 --> 00:11:43,650
It's always a mistake to over
elevate the brow to clean up excess
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skin in the upper lid that gives
a surprised look or deer in the
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headlights look. That's very unnatural.
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00:11:51,301 --> 00:11:56,020
So if you bring the up
to the point where it's
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00:11:56,140 --> 00:11:59,920
anatomic and their upper lid looks clean,
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maybe they just need a brow lift.
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00:12:02,440 --> 00:12:07,060
But if you bring the brow to a
natural position and there's still
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00:12:07,070 --> 00:12:08,770
excess skin in the upper lid,
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00:12:09,100 --> 00:12:12,790
I think first and foremost they
need an upper lid blepharoplasty.
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00:12:13,780 --> 00:12:18,040
And then you consider if
there's enough aesthetic
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00:12:18,041 --> 00:12:22,510
advantage to need a brow
lift in addition. Dr. Bloom,
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how do you parse this?
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In very much the same
way as you're explaining.
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I would say if the brow
is low and when you
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00:12:32,681 --> 00:12:35,380
bring it up to the correct position,
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even just standing in front of the patient
and playing with their eyebrows and
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kind of getting it to the right position,
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00:12:42,490 --> 00:12:46,960
if there still is what we call
dermatochalasis or hooding at that point,
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then I tend to do a
brow lift in combination
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00:12:51,971 --> 00:12:55,480
with an upper blepharoplasty.
But if the patient
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has a good brow position and
they just have, for example,
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00:13:01,211 --> 00:13:03,850
hooding of the upper
eyelid that you can see,
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00:13:03,851 --> 00:13:07,000
and when you pinch that
extra upper eyelid skin
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00:13:08,890 --> 00:13:13,750
that is a patient in my hands for just
for example, an upper blepharoplasty.
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00:13:14,890 --> 00:13:16,420
One of the biggest, I think,
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giveaways to a patient
needing a brow lift is a
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00:13:21,671 --> 00:13:25,690
patient sometimes with really
deep forehead wrinkles.
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00:13:26,050 --> 00:13:30,790
Because it's very interesting
that when a patient has a
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00:13:30,791 --> 00:13:34,570
lower brow, the frontalis
or the forehead muscle,
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00:13:34,930 --> 00:13:39,070
as we know is the only
lifter of the eyebrows.
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And a lot of times when a patient
has deep forehead wrinkles,
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00:13:43,750 --> 00:13:47,110
it's because it's a
compensatory mechanism.
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They are constantly trying to lift
their brows up so they can see,
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00:13:52,540 --> 00:13:57,160
and literally they're trying to lift
their brows so they can actually
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00:13:57,430 --> 00:14:01,390
see and remove some of the
extra upper eyelid hooding,
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00:14:01,720 --> 00:14:03,850
and they're lifting their brows.
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00:14:04,330 --> 00:14:06,850
So if you see a patient
with deep forehead wrinkles,
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00:14:07,060 --> 00:14:10,420
there usually is a brow
ptosis in conjunction.
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00:14:11,710 --> 00:14:13,210
Let's talk about the forehead then.
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Is it brow lifting or Botox or
something else that'll address this?
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00:14:18,610 --> 00:14:22,690
Well, it really depends.
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00:14:23,410 --> 00:14:27,340
I was just talking, if you see
some heavy forehead wrinkles,
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00:14:27,790 --> 00:14:32,770
those patients usually
need some kind of procedure
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00:14:33,130 --> 00:14:36,760
to lift the browse because
if you, for example,
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00:14:37,360 --> 00:14:41,950
you can use neuromodulator
in those cases to weaken the
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brow depressor muscles,
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00:14:44,290 --> 00:14:48,880
which would be in between the eyes
and underneath and around the eyes,
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00:14:48,881 --> 00:14:53,510
the orbicularis muscle and the
corrugator and proce muscles.
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00:14:55,430 --> 00:15:00,260
But if you treat a patient like that
with heavy forehead lines and wrinkles
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and a lower brow with
Botox in their forehead,
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you've now just weakened
the only muscle in
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00:15:10,731 --> 00:15:12,980
their face that lifts their brows,
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00:15:13,370 --> 00:15:18,050
and that is going to make their
brows actually heavier and more
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00:15:18,380 --> 00:15:22,130
kind of dense or lower. So
in those kind of patients,
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00:15:22,280 --> 00:15:26,360
you only want to treat in
between and around the eyes with
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Botox so that the muscles
that pull down the
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00:15:31,041 --> 00:15:35,900
eyes or the brow depressor
muscles are weakened and allow
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00:15:35,901 --> 00:15:37,850
the forehead muscle to lift.
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00:15:39,170 --> 00:15:43,760
So it's an understanding of
what muscles lift and what
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00:15:43,761 --> 00:15:45,050
muscles pull down,
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and how we use either toxins or surgery to
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00:15:50,210 --> 00:15:51,770
modulate those muscles.
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And a lot of that is probably about
the individual patient and their muscle
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dynamics. So
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I agree with you a hundred percent,
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and I think this is very poorly understood
by a lot of people who are out there
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doing a lot of Botox treatments.
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That balancing first by relaxing the
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00:16:15,741 --> 00:16:19,580
depressors, and then if
you can get away with it,
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doing a little smoothing by very minimally
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00:16:24,381 --> 00:16:28,250
relaxing, the only lifter muscle,
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the frontalis,
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which is the one that
makes those forehead lines.
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And if you can't get away with that,
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then you maybe should be thinking
hard about getting a brow lift so
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that the brow is elevated without you
having to pull it up with your muscles
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all day long.
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00:16:48,380 --> 00:16:52,370
Yeah, I mean, this is extremely
poorly understood how many patients,
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00:16:52,371 --> 00:16:54,980
Dr. Bass come into your
office and they go,
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00:16:55,130 --> 00:16:59,540
"I just need some Botox in my forehead
to lift my brows." And they're pulling on
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00:16:59,541 --> 00:17:02,690
their forehead. They do that. I
mean every single patient, right?
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And they don't understand how we
trick the brow into coming up,
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00:17:08,150 --> 00:17:12,140
which is a very backhanded or
paradoxical way of doing it.
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Now I'm wondering what kind of control
do these various techniques have for brow
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00:17:17,811 --> 00:17:22,700
shape? Let's say my main goal is brow
shaping, not repositioning per se.
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Are there nonmedical approaches
that might work better?
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I feel that honestly,
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00:17:28,320 --> 00:17:32,750
neuromodulators give us
great control of brow shape
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in understanding how these muscles pull,
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as we were just describing in some of
the muscles pulling down and some of the
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muscles lifting,
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00:17:42,680 --> 00:17:46,760
you can actually pinpoint and get precise
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areas of brow lifting
and flattening of the
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brow depending by using small amounts,
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micro amounts of
neuromodulator placed expertly.
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And in my hands,
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neuromodulator works way better
for that than brow lift surgery.
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Yeah, I agree. I think the thing
that has the most potential for
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00:18:12,990 --> 00:18:16,800
control, control of brow
shape is neuromodulators.
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And then things like surgery or some
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00:18:22,081 --> 00:18:26,100
of the energy treatments
that can elevate the brow
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00:18:27,240 --> 00:18:32,190
are less, they're maybe more durable,
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00:18:32,490 --> 00:18:36,120
and they may be able to get a
greater degree of elevation,
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00:18:36,121 --> 00:18:38,490
but they don't have as much shape control.
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00:18:39,210 --> 00:18:42,240
The other thing that does offer potential,
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00:18:42,241 --> 00:18:46,140
if the brow height
basically is reasonable,
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00:18:46,141 --> 00:18:51,120
it's not very droopy, shaping
the brow itself can be done
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00:18:52,720 --> 00:18:55,740
with, the estheticians do this,
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00:18:56,010 --> 00:19:00,750
by tweaking which hairs they leave
and which hairs they take out or
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00:19:00,751 --> 00:19:05,310
by tattooing the brow or
micro bleeding to introduce a
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00:19:05,311 --> 00:19:09,780
certain shape by how much brow hair you
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00:19:09,781 --> 00:19:13,200
leave and how much you
remove in different places.
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00:19:13,590 --> 00:19:16,710
To create a very dramatic
arching to the brow,
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00:19:16,740 --> 00:19:20,040
more of an average arching.
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00:19:20,040 --> 00:19:22,740
Men's brow tends to be
straighter to help the brow look
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00:19:22,741 --> 00:19:23,574
straighter.
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00:19:25,560 --> 00:19:29,850
And so sometimes if the
brow is not sitting too low,
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but you just want a shape to the brow,
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00:19:32,970 --> 00:19:37,800
these beauty treatments
might be more fruitful than
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00:19:38,370 --> 00:19:42,480
a medical approach with
neuromodulator or surgery.
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Lastly, before we conclude Dr. Bass,
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00:19:46,080 --> 00:19:48,390
what should our listeners take
away from today's episode?
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00:19:49,470 --> 00:19:53,070
So like everything we do in
aesthetic plastic surgery,
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00:19:53,071 --> 00:19:57,570
natural is the key and brow lifting and
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00:19:57,900 --> 00:20:02,760
non-surgical treatments for the brow
can give a perfectly natural looking
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brow in the proper hands,
305
00:20:05,130 --> 00:20:07,830
but important not to overdo things.
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The goal is to open the eye space,
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which makes you look
more present and awake
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and to shape the brow.
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00:20:20,700 --> 00:20:24,360
But we talked about gender
differences in brow shape,
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00:20:24,420 --> 00:20:26,910
women's brows tend to be arched.
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00:20:26,940 --> 00:20:31,620
They raise towards the outer third
and peak and then drop off where
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00:20:31,621 --> 00:20:33,780
men's brows tend to be straighter.
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00:20:34,890 --> 00:20:38,670
And so changing that when
that is not the intent,
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00:20:39,090 --> 00:20:43,770
can create a very unnatural look,
and that needs to be avoided.
315
00:20:44,370 --> 00:20:48,970
There are a range of techniques that
are patient specific on how old you are,
316
00:20:48,971 --> 00:20:53,320
where your hairline is, and any
previous surgery you've had.
317
00:20:54,550 --> 00:20:59,440
But Botox and other neuromodulators
and energy treatments have
318
00:20:59,441 --> 00:21:02,710
a big role for many, many patients.
319
00:21:02,711 --> 00:21:05,020
It's never one size fits all.
320
00:21:05,860 --> 00:21:07,540
Dr. Bloom, any takeaways to add?
321
00:21:08,260 --> 00:21:12,760
I'll just add three quick
things about the brow and
322
00:21:12,761 --> 00:21:16,720
brow procedures and brow
surgery. What I found,
323
00:21:16,721 --> 00:21:21,220
number one is that getting
a really long lasting
324
00:21:21,221 --> 00:21:25,270
good brow lift surgical
result is very hard.
325
00:21:25,990 --> 00:21:30,040
I think even when we do an
amazing brow lift to us,
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00:21:30,100 --> 00:21:34,870
I think getting longevity with this
procedure is very difficult because
327
00:21:35,050 --> 00:21:39,340
you're constantly battling gravity.
328
00:21:39,340 --> 00:21:40,510
As a corollary to that,
329
00:21:40,540 --> 00:21:44,980
I would say number two is
that less is more in brow
330
00:21:45,640 --> 00:21:50,200
lifting. And I think many people
talk about how the release of the
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00:21:50,201 --> 00:21:55,120
attachments and the ligamentous
attachments that kind of bind down the
332
00:21:55,121 --> 00:21:59,860
brows are way more
important than the kind of
333
00:22:01,300 --> 00:22:04,780
suspension or methods we
use to resuspend the browse.
334
00:22:04,781 --> 00:22:08,020
So it's more about the
release and what we do
335
00:22:09,460 --> 00:22:12,460
instead of the resuspension. And third,
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00:22:12,820 --> 00:22:16,300
I will say that as we
discussed kind of earlier,
337
00:22:17,050 --> 00:22:21,970
I think injectables and energy-based
treatments are really keeping brows
338
00:22:21,971 --> 00:22:26,620
and brow positions looking
better for longer before
339
00:22:26,621 --> 00:22:28,840
surgery is needed in a
lot of these patients.
340
00:22:28,841 --> 00:22:33,670
So as Dr. Bass was saying
early on, years ago,
341
00:22:33,671 --> 00:22:36,760
it used to be patients who are getting
brow lifts in their thirties and forties.
342
00:22:37,060 --> 00:22:41,590
I think that some of the
non-invasive stuff in non-surgical
343
00:22:41,591 --> 00:22:45,250
treatments are keeping brows
looking better for longer,
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00:22:45,520 --> 00:22:50,380
and we're kind of moving brow
lifting surgery to patients in more
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advanced ages.
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Thank you, Dr. Bloom, Dr. Bass,
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for sharing your perspectives and
expertise on this eyebrow raising topic.
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No pun intended.
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Thank you guys so much for
having me again on the podcast.
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It's always a pleasure of
mine to be here with you guys.
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Thank you for listening to the Park
Avenue Plastic Surgery Class podcast.
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00:23:10,600 --> 00:23:12,100
Follow us on Apple Podcasts,
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write a review and share
the show with your friends.
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Be sure to join us next time to avoid
missing all the great content that's
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coming your way. If you want to
contact us with comments or questions,
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we'd love to hear from you.
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Send us an email at podcast@drbass.net
or DM us on Instagram
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@drbassnyc.
Jason Bloom, MD
Plastic Surgeon
Located in Bryn Mawr, Pennsylvania, Dr. Jason Bloom is a double board certified facial plastic and reconstructive surgeon. He is an Adjunct Assistant Professor of Otorhinolaryngology – Head & Neck Surgery at the University of Pennsylvania and Clinical Assistant Professor (Adjunct) of Dermatology at the Temple University School of Medicine.