Endoscopic Brow Lift – Tampa

“Brow Lift” is just what it says. It is also referred to as a browpexy. The brow lift addresses the sagging of the eyebrows, and underlying forehead and frown muscles. Signs of aging in the upper third of the face include a receding hairline, transverse forehead rhytids (the spaghetti looking wrinkles that run across the forehead), glabellar rhytids and furrowing (lines between the brows caused by frowning), “bunny lines” (over the junction of the nose with the forehead, brow ptosis (droopy eyebrows), excessive upper lid skin (dermatochalasis), and periorbital rhytids (“crow’s feet”). The brow lift is used to lift sagging eyebrows, remove some of the muscle causing glabellar furrowing and forehead creases, and possibly tighten the skin to the outside of the eyes to take care of any excess contributing to crow’s feet. If deep wrinkles are present, the brow lift may be combined with carbon dioxide (CO2), or erbium laser resurfacing. Phenol or TCA peels may be added as well.

This procedure is reserved for patients who will be undergoing upper blepharoplasty (or upper eyelid skin, muscle, and/or fat excision) and have very little excess skin in the forehead, have little in the way of cross-forehead creases, but do have significant brow droop (brow ptosis). It may also be used in cases where skin and creases are present, but the patient only wants to address brow position, and through the least invasive approach. Marks are made to outline the amount of skin to be removed from the upper eyelids. The skin is excised, along with muscle, and possibly fat. Excess is gained to the space under the eyebrows, and over the skull bone. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. Two symmetric drill holes are made in the outer portion of the skull. This is done with a drill bit that is protected from entering too deep into the bone. The fixation devices are deployed. They look like plastic hang-hooks. The skin is re-draped over the hooks in the desired position. A compressive dressing is then applied to allow the forehead soft tissues to scar in the appropriate position.

The naturally pleasing configuration of the female brow is to have the outer third ride higher than the part closer to the nose. Plastic surgeons believe that the highest point of the brow in a female should have its most superior (highest) point at the junction of its middle and lateral (outside) third. This lift addresses that part of the brow. Apart from using this as a lateral brow lift, the lift is used to help in certain cases of mid-face lifting. When skin and underlying soft tissue of the lower lid and cheek, and the outside of the eye bunch up – this temporal lift takes up that tissue by moving it up. The incision may be placed in front of the hairline (anterior hairline incision), but more often the skin could be adequately redistributed by hiding the scar behind the hairline (posterior hairline incision). The choice of incision depends on the patient’s preference, surgeon’s preference, and the position and configuration of the patient’s forehead and hairline.

The goal of aesthetic surgery is to improve appearance. In some cases, as a trade-off this involves inconspicuously places incisions, in other cases a desired result may be obtained through a minimal incision. In any case, smoking undermines both efforts to produce an aesthetically pleasing outcome by impairing blood flow to healing tissues, in some instances causing significant compromise of the operated tissue and/or soft tissue loss, in all cases causing a substantial delay in healing. It makes no difference if the smoke is second hand, or the nicotine is delivered via a different vehicle. A nicotine patch, tobacco chew, or nicotine gum may not affect the pulmonary system, but vascular compromise is just the same. What this translates into is a possible loss of skin, fat and sometimes muscle at the edges of the incision, internal, and external, a poor quality of scar both inside and outside, possibly even keloid on the outside, and a tough fibrous scar/capsule on the inside, and an increase in the amount of time spent recovering. Specifically performing a brow lift on a smoker may exacerbate hair loss, noticeable wide, firm or discolored scarring in front of hairline, and wound breakdown. Endoscopic brow lift surgery is probably not as hazardous owing to the smaller incisions, but it cannot address severe skin excess. Wound breakdown can lead to the nuisance of wound care with healing taking up to six months. To diminish the effects of smoking and nicotine on surgery and healing a minimum of six weeks of abstinence is necessary.

• Customary, Standard, or Traditional Brow Lift or Browpexy
• Endoscopic Brow Lift
• Endotine Brow Lift
• The Trans-blepharoplasty or TransBleph Brow Lift using the ENDOTINE® Device
• Lateral Brow Lift or Temporal Lift
• Mitek Tac-it® Endoscopic Brow Lift

Browpexy can restore a youthful appearance to the aging face. It can take up extra skin, smooth forehead lines, wrinkles, and furrows. Frequently, the “tired” look is entirely gone. Most patients report compliments to the effect of “you look so refreshed.” When associated with visual field impairment because of overhanging and/or pushing down upper eyelid skin, brow lifting surgery with or without upper eyelid skin excision (blepharoplasty) may improve vision.

Generally, any drains (present after the procedure) are discontinued the day after surgery, if drainage is excessive, the drains stay in until drainage is deemed minimal. Should the tube opening start draining, dry it, then place 4X4 gauze around the skin where the drain comes out, tape the dressing. Please strip the tube every time you empty the drain, and record the drainage.

It is not a good idea to drive a car or engage in activities that depend on your coordination for 48 hours after your brow lift surgery, or after taking any of the pain, nausea or insomnia medications prescribed. Walking and getting about is highly encouraged for multiple reasons, including a decrease in the incidence of clot formation in the veins of your legs. A companion should be with you for the first 24 hours to monitor and help you get about as necessary. It helps to apply refrigerated conforming gel masks over the forehead for the first 2 days after surgery to reduce swelling and discomfort. Ice should not be applied directly, and will be changed every 15-20 minutes to maintain cold temperature. If the gel pads are no longer useable, frozen vegetable packs, especially frozen peas, work well. A cold compress (damp from a thoroughly wrung out towel) may be substituted for gel or frozen packs if you find this more tolerable. On the third day after surgery, gel pads or frozen pack applications are stopped. While moving about in the first postoperative week, it is best to rotate your head and shoulders together, (rather than just turning your neck). When resting/sleeping, laying on your back with several pillows under your head and back, or placing a pillow or rolled blanket under the head of your mattress, will decrease swelling.
You should not sleep in the supine position supine for at least 2 weeks after facial surgery. When getting up from bed, you can help yourself by using one hand to support your head, and using the other to grasp a stationary object or to push off the bed. Plan to be away from work for one week, assuming your post-operative course is uncomplicated. For the first week, avoid activities that raise your blood pressure such as heavy manual labor, repeated heavy lifting, strenuous exercise, or bending over. Refrain from sexual activity for 1 month after your surgery. After 1 week you may engage in light exercise only, walking for example. Social activities may be resumed within 1 week of surgery, but may necessitate camouflage make-up. No heavy lifting is permitted (10 lbs or more) for 2 weeks after rhytidectomy. No smoking and no nicotine substitute (patches, chewing tobacco, etc.) should be used for at least 6 weeks after surgery, smoking will decrease blood and oxygen flow to healing tissues and can cause loss (death) of skin, fat, and muscle in the operated field, especially along the incisions. It can slow down healing to double of normal time, worsen scar appearance on the outside, lead to a tough, fibrous scar on the inside, and increase the risk of fluid pockets.

Generally speaking, a severe amount of skin laxity in the forehead cannot be corrected as well with less invasive methods, as they may be with a full coronal brow-lift. Some of the treatments may help improve the situation, but as a rule of thumb, the more invasive the procedure, the more dramatic the result. Laser resurfacing, chemical peeling, botox, injectable fillers can all, to a variable degree achieve some improvement, but they should not be thought of as a substitute for a traditional brow lift or and endoscopic brow lift. In fact, when combined with an upper facial rejuvenation, such techniques can dramatically improve the outcome of brow lift surgery. Beware of the quickfix fad procedures and “newer” modalities, and technologies that promise results to match, or even come remotely close to those obtained through surgical intervention. Often, the before and after pictures are of different quality, out of focus, taken from a different angle, etc. The best way to tell whether a set of pictures is legitimate is to compare the background, lighting, distance from camera, and quality of a zoom view. The majority of before and after photos are missing most of such details, and probably for a good reason.

Typically, there is no right age for endoscopic browpexy. Brow Lifting can be classified as reconstructive, restorative, or cosmetic. Reconstructive brow lifting is typically performed as early as adolescence because it addresses either the total absence of facial musculature, as may be found in certain syndromes, or paralysis of the facial muscles, whether traumatic, or congenital. Restorative endoscopic brow lifting is used to set back some of the changes brought about by aging. This is performed to restore natural eyebrow position, typically in conjunction with removal of excess upper eyelid skin. The creases or “crow’s feet” to the outside of the eyes are also addressed. It is called restorative endoscopic browpexy because the plastic surgeon attempts to replace the skin back to it original position. Endoscopic browpexy and endoscopic blepharoplasty performed to restore a normal field of vision in a patient with acquired brow drooping is also a form of restorative endoscopic browpexy, performed for functional rather than cosmetic reasons, with the fringe benefit of improvement in appearance. Patients may be candidates for this as early as their thirties. It all has to do with how severe the changes are, and what the patient desires. Typically, the massive weight loss patient will present at an earlier age, while most will present later in life. Minimal changes will likely be corrected with less invasive methods, whereas severe aesthetic disturbances may need a full coronal approach combined with other surgical and non-surgical modalities. Provided the patient is healthy, there is no upper age limit to endoscopic browpexy or endoscopic brow lift surgery.

Uneven swelling and bruising may be the result of bleeding, which would require a prompt decompression. Uneven swelling later in the postoperative course may signify an infection, which is treated via antibiotics and possibly drainage. Cloudy drainage, fever, or spreading redness all point to an infection as well.

It is common in this day and age to use dilute local anesthetic before making an incision. This type of pre-emptive anesthesia reduces post-brow lift discomfort immensely. In general it takes several hours for the effects of the local to wear off. Soreness improves over several days following face lift surgery, and is very well controlled with oral pain medication.

Because every surgeon has a preference for a particular procedure, every surgeon will have a different idea as to what constitutes the traditional brow lift. The most common interpretation of the “standard” brow lift is the open approach involving a coronal incision, whereby the cut is made either behind or along the forehead hairline. The forehead is undermined to the level of the eyebrows, either on top of the bone (subperiosteal), or on top of the bone covering (subgaleal). Frown muscles (corrugators, procerus, and depressors) are resected (removed). In some cases, sections of the frontalis (the eyebrow raising muscle, and the same one that causes the cross-forehead creases) are also removed. The brows are fixed in a symmetric configuration that is aesthetically pleasing, taking into account patient sex, and preoperative preference. A sliver of skin is removed at the edge of the incision, which serves to tighten skin laxity.

Age related changes in the face usually become apparent in the fourth decade of life. The degree to which a patient is affected has to do with multiple factors, the most likely of which are smoking, significant weight-loss, prolonged or intense sun exposure, and genetic predisposition. In fact, some patients would benefit from an endoscopic brow lift as early as in their thirties. There are variations on a brow lift, with respect to depth of dissection, incision placement, and open versus endoscopic techniques that may be tailored to the individual patient’s needs, in terms of how aggressive the correction has to be to obtain a good result. The ideal candidate for a brow lift would have prominent crosswise forehead creases, furrowing, “bunny lines,” and”crow’s feet.” Apart from this, a good candidate would be emotionally secure, with appropriate reasons for desiring surgery, at a stable time in his or her life, and be in good health.

Every physician, plastic surgeons included, is different, and has a different approach to the patient. Most plastic surgery doctors, however, are very compulsive, and have a set routine. Established pre and post-operative routines set up a significant degree of certainty in surgical outcomes, and ensure appropriate treatment when problems do arise. Adequate patient instruction prepares the patient for surgery in a number of ways. Patients know what to expect, so that anxiety is greatly reduced. Patients are educated in fitting versus harmful peri-operative activities, helping to minimize a poor outcome based on an inappropriate patient action. Finally patients become familiar with the correct course of action in the event of an otherwise unexpected event.

Dr. Gerzenshtein’s typical routine includes a thorough physical examination with particular attention to areas of concern. The patient is asked for the most important aspect of the concern, the full smile lines, the jowls, the sagging neck, etc. A global assessment is then formulated and presented to the patient. Dr. Gerzenshtein seeks to then marry his opinions with the patient’s dislikes to devise a mutually agreeable plan. A pre-operative sheet is then given to all prospective plastic surgical candidates. This is because in most circumstances, not satisfying the conditions presented in the pre-operative plastic surgery guidelines, such as discontinuing aspirin for at least two weeks prior to cosmetic surgery, will lead to a delay of procedure. Should the prospective aesthetic surgery patient decide to have cosmetic surgery, a pre-operative visit is scheduled. This is where the details of the particular aesthetic facial surgery treatment are reviewed. The visit includes either a complete physical examination, or review of a physical performed by the patient’s primary care physician, all to determine fitness for brow lift and/or blepharoplasty plastic surgery. Appropriate laboratory evaluations are ordered, or reviewed, as are any other pertinent studies. A complete discussion of all risks and complications associated with rhytidectomy or rhytidoplasty surgery are reviewed, pre-operative photographs are obtained. Finally, thorough postoperative instructions are given, along with prescriptions for after surgery. In this manner, a patient is thoroughly familiar with the particulars of the surgery, expected outcomes, and postoperative care after a face lift.

The endoscopic brow-lift is typically performed in younger patients, in whom the problems include brow ptosis or drooping, with or without excess upper eyelid skin, as well as crow’s feet, but without significant forehead excess skin. Because minimal skin excision is needed, the brow lift is performed through three small incisions behind the hairline. There is a multitude of devices available for fixation of the brows. Dr. Gerzenshtein prefers the Endotine® Forehead fixation device. The two outside (lateral) incisions serve as points of small triangular skin excisions. In addition, the lateral brow-lift may be added to the endoscopic approach to correct any skin excess, especially when the brow lift is combined with the lower blepharoplasty, with or without the midface lift procedure.

The ENDOTINE® Endoscopic Forehead Lift Procedure is essentially the endoscopic browpexy that uses the ENDOTINE® Forehead fixation device to achieve stable fixation of the forehead tissues. Three incisions are made behind the hairline, one in the center, the other two behind the highest portion of the non-hair bearing scalp in the front. Dissection is carried out under endoscopic guidance to achieve release of the forehead skin and underlying soft tissues. Furrow-causing muscles are removed, and cross crease muscles are weakened. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. Two symmetric drill holes are made in the outer portion of the skull. This is done with a drill bit that is protected from entering too deep into the bone. The fixation devices are deployed. They look like plastic hang-hooks. The skin is re-draped over the hooks in the desired position. Extra skin is removed from the two outside incisions, and the incisions are closed.

This procedure is reserved for patients who will be undergoing upper blepharoplasty (or upper eyelid skin, muscle, and/or fat excision) and have very little excess skin in the forehead, have little in the way of cross-forehead creases, but do have significant brow droop (brow ptosis). It may also be used in cases where skin and creases are present, but the patient only wants to address brow position, and through the least invasive approach. Marks are made to outline the amount of skin to be removed from the upper eyelids. The skin is excised, along with muscle, and possibly fat. Excess is gained to the space under the eyebrows, and over the skull bone. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. Two symmetric drill holes are made in the outer portion of the skull. This is done with a drill bit that is protected from entering too deep into the bone. The fixation devices are deployed. They look like plastic hang-hooks. The skin is re-draped over the hooks in the desired position. A compressive dressing is then applied to allow the forehead soft tissues to scar in the appropriate position.

Facial rejuvenation surgery such as a face lift or brow lift will address loose skin most effectively. Wrinkles or rhytids that form secondary to this skin excess will no doubt be taken up by excising this extra skin caused by gravity and aging, and tightening the remaining skin. Small creases in the skin, etched over the years, will need a form of skin resurfacing to fix effectively. This may be in the form of carbon dioxide laser, erbium laser, trichloroacetic acid (TCA) peel, phenol peel, Blue Peel ™. Either an endoscopic forehead or brow lift, or an open forehead or brow lift include the division and partial removal of the corrugators, depressor, and procerus muscles. Muscles that are responsible for the furrowing between the brows and just above them whilst frowning. Repositioning, or excising the forehead skin will address the forehead lines. So the short answer is that an open brow lift will address all of the above concerns, while the endoscopic brow lift may not address forehead lines as effectively. Any residual lines, crinkles, and creases will be handled effectively via skin resurfacing modalities.

There are two temporary effects of endoscopic brow lifting and/or face lifting that patients find bothersome to manage; healing incisions, and bruising/swelling. Although it is possible to apply make-up as early as two to three days after browpexy, it is probably not very useful. Doing this would camouflage bruising. The swelling and the incisions would not be addressed. This is because incision lines should not be covered while sutures are still in, or in the case of absorbable suture, for the first 7-10 days. Because of this, it would make little sense to use cover-up early, as bruising and swelling may be covered, but healing incisions will not. So the bottom line is that realistically, an endoscopic brow lift or face lift patient should not expect to look presentable until seven to ten days after surgery. After one week, any of the commercially available camouflage packages may be used to conceal the early effects of face lift surgery. Aestheticians working alongside a plastic surgeon may demonstrate the appropriate techniques for getting the most out of the cover-up makeup in masking the consequences of rhytidectomy or brow lift surgery. The basics of appropriate camouflaging include concealing, color correcting, and contouring may be found below.

Concealers are heavier and less transparent than standard foundation makeup. They are used to hide healed incisions, scars, bruises, or stretch marks, whether facial or elsewhere. When selecting a concealer, pick a waterproof, opaque make-up, but one sufficiently creamy not to place traction on your skin in application. If you hit upon a kind of concealer that strongly resembles your skin tone, the need for foundation may be obviated. The paper thin, fragile skin about the eyes does not do well with concealer, collecting the thick substance within the periocular creases. Standard liquid foundation, eye make-up, or a color corrector should be used in this area.

To hide the redness produced by laser or chemical skin resurfacing/peeling, or to conceal the myriad of colors produced by post-surgical bruising over time, color correctors may be used. Correctors have the consistency of foundation, but are applied under it. Various shades may be used to counter the aforementioned variety of colors found with bruising.

Contouring may more aptly be described as the use of two dimensional illusion to create the appearance of three dimensional contrast, through the use of light and shadow. Deep plane rhytidectomy, alloplastic implanting, and rhinoplasty (nose surgery) all result in profound swelling that may be especially helped by this technique. Lightening, through the use of a highlighter, several shades lighter than the standard foundation, improves projection, while rendering an area dark, with foundation several shades darker, results in the impression of concavity. Ensuring a smooth transition through careful blending will not give away the use of contouring by leaving behind sharp areas of transitioning bands.

Unsatisfactory results may be divided into two categories, true surgical complications, and incongruence between patient expectations and achieved results. Depending on the severity of a true complication, it may or may not be significantly improved via further surgery. Improper re-draping, inadequate tightening, poorly placed scars, and prominent scars may all be improved by revision open or endoscopic browpexy. You should discuss your dissatisfaction with your surgeon to see if he or she feels that the situation may be helped, prior to seeking the advice and intervention of Dr. Gerzenshtein.

The ENDOTINE® Endoscopic Forehead Lift Procedure is essentially the endoscopic browpexy that uses the ENDOTINE® Forehead fixation device to achieve stable fixation of the forehead tissues. Three incisions are made behind the hairline, one in the center, the other two behind the highest portion of the non-hair bearing scalp in the front. Dissection is carried out under endoscopic guidance to achieve release of the forehead skin and underlying soft tissues. Furrow-causing muscles are removed, and cross crease muscles are weakened. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. Two symmetric drill holes are made in the outer portion of the skull. This is done with a drill bit that is protected from entering too deep into the bone. The fixation devices are deployed. They look like plastic hang-hooks. The skin is re-draped over the hooks in the desired position. Extra skin is removed from the two outside incisions, and the incisions are closed.

“Beauty is in the eye of the beholder.” What is considered attractive in some social or ethnic circles is frowned upon in others. For this reason, ethnic, including social, and/or religious considerations determine a patient’s opinion of what is desirable. Only this consideration may alter the choice of one procedure over another. Assuming the outcome is predefined, that is the goals of surgery are clearly delineated, outcomes should be uniform with few exceptions. Genetic factors and complexion may predispose a patient to loss of pigmentation, or an increase in the same. This is generally observed with resurfacing modalities, like laser CO2, phenol, or TCA peels, rather than brow lifting itself. Keloid formation would be an unusual, but cosmetically devastating complication, and is more prevalent in the darker skin patient.

The naturally pleasing configuration of the female brow is to have the outer third ride higher than the part closer to the nose. Plastic surgeons believe that the highest point of the brow in a female should have its most superior (highest) point at the junction of its middle and lateral (outside) third. This lift addresses that part of the brow. Apart from using this as a lateral brow lift, the lift is used to help in certain cases of mid-face lifting. When skin and underlying soft tissue of the lower lid and cheek, and the outside of the eye bunch up – this temporal lift takes up that tissue by moving it up. The incision may be placed in front of the hairline (anterior hairline incision), but more often the skin could be adequately redistributed by hiding the scar behind the hairline (posterior hairline incision). The choice of incision depends on the patient’s preference, surgeon’s preference, and the position and configuration of the patient’s forehead and hairline.

On the night you return home after surgery and on the first day after surgery call the office to check in and let us know how you are doing. Thereafter, call if you have pus-like (greenish or yellowish) or foul smelling drainage, temperature greater than 100 degrees, redness that is spreading or greater on one side, excessive swelling or bleeding, uncontrolled by light pressure, especially if you notice a difference between two sides, increased pain that is intolerable, and not relieved by medication, Also call if you believe you are experiencing side effects from any of the prescribed medications like rash, swelling away from the operative site, difficulty breathing, nausea/vomiting, headache, difficulty breathing, chest pain, loss of sensation, strength, or motion. Finally, call us about absolutely anything you would consider unexpected or unusual after surgery.

The Mitek Tac-it® Brow or Forehead Lift Procedure is essentially an endoscopic browpexy that uses the Mitek Tac-it® fixation device to achieve stable fixation of the forehead tissues. Three incisions are made behind the hairline, one in the center, the other two behind the highest portion of the non-hair bearing scalp in the front. Dissection is carried out under endoscopic guidance to achieve release of the forehead skin and underlying soft tissues. Furrow-causing muscles are removed, and cross crease muscles are weakened. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. Two symmetric drill holes are made in the outer portion of the skull. This is done with a drill bit that is protected from entering too deep into the bone. The fixation devices are deployed. They are screws designed to accommodate a suture that runs from the soft tissues of the brows and forehead and is anchored to the device to achieve stable suspension. Extra skin is removed from the two outside incisions, and the incisions are closed.

Do not manipulate the incisions until the first post-operative appointment (24 hours after surgery). The routine closure will have non-absorbable suture without an external dressing and a coat of antibiotic ointment. On occasion incisions will be closed with absorbable suture and covered via steri-strips. At the initial visit any post-operative dressing will be removed, so please bring a scarf with you for the trip home, as your hair will be disheveled. You may shower or wash over the steri-strips or exposed suture material. Do not bathe, or submerge, for at least 3 weeks after surgery. Be gentle and pat when applying soap, rinsing, and drying. After drying, steri-strip covered incisions do not need any more attention. After drying over incisions with exposed suture, apply a thin layer of triple antibiotic ointment. If present, when the edges of the steri-strips become frayed, trim them. With time, as very little is left behind, they may be removed (usually 2-4 weeks). In some cases additional tape will be used for removing tension from the suture line, or placing tissue in the desired position of healing. If such tape is present, it will be re-applied at the first office visit, and you will be shown how to do this on your own.

As a general rule, keeping the incisions clean and dry will result in the most aesthetically pleasing healed incision with minimal scarring. Do not allow scabs to accumulate, if present you may gently tease it off with peroxide soaked q-tip. While tending to the incision, watch for signs of problems as outlined below. It is not routine to have drains placed at the time of surgery, however, at times, if bleeding is diffuse, and cannot be addressed via surgical maneuvers (clipping, suturing, tying) it may be safer to leave behind a drain in attempting to prevent a hematoma (blood collection). If present, the drains will be removed within one to three days. If non-absorbable sutures were used, they will be removed 7 days after surgery. All incisions behind the hairline/scalp will have clips or suture removed 10-14 days from surgery. Do not expose incisions to the sun and/or tanning UV light for at least 1 year, however, you may begin tanning 4 weeks after surgery while keeping incisions covered. If sun exposure in unavoidable, use a product with SPF of at least 30. On the third day after surgery, discontinue gel pad application.

There are two basic reasons to perform a brow lift with or without blepharoplasty, one is to improve appearance, the other is to improve vision. Obviously operations done for purely cosmetic reasons would not be covered by a health insurance policy. Functional impairment, however, is a different matter. Requirements vary between insurers, but generally speaking, patients with documented visual field loss that is improved at least 30% by manual elevation of the brows may seek coverage. Patients who feel as though the upper part of their visual field is blocked, have difficulty keeping their eyes open as the days wears on, or suffer from spasms or headaches as a result of constantly trying to elevate their brows would be considered candidates for a functional brow lift and/or blepharoplasty.

Skin resurfacing, whether laser (CO2 or erbium laser) or chemical (TCA or phenol, or blue peel), brow lifting (brow-pexy) and face lifting (rhytidectomy surgery), are not mutually exclusive. In fact, resurfacing, brow-lifting, and rhytidectomy are complimentary. Skin resurfacing addresses fine wrinkles, pigment changes, and irregularities associated with aging. Facelifting addresses creases, skin and fat excess, as may be found in smile lines, marionette lines, jowling, and “turkey neck.” Brow Lifting addresses forehead creases, droopy brows, and furrows. To get the best possible result from facial rejuvenation, it is often necessary to perform rhytidectomy, brow lift, forehead smoothing surgery, and some type of laser or chemical resurfacing either at the same time or after recovery from the face lift.

The results of a properly performed, and surgically sound, operation will typically last up to a decade. The surgery obviously cannot halt the aging process, and to a certain degree just give the illusion of setting back the hands of time. Aging then takes over once again, but not to the same degree, or at the same rate. This is because some of the skin was removed, and some of the underlying tissue repositioned, at times more superior than in youth. This allows for less tissue to be acted upon by gravity. Beware of miracle cure operations that promise lasting results with less surgery. Such procedures may be more profitable to the “surgeon” performing them, more surgeries may be done because they do not take as long, but the patient will generally be back to square one within six months, plus a few “minimally invasive” incisions, and minus some had-earned capital.

On waking from anesthesia, you will find yourself in the recovery room with dressings, and ice or gel pack in place. Your vision may be blurry owing to protective ointment applied to your eyes during surgery. You will be able to depart once sufficiently recovered from anesthesia, and lucid. A friend or family member will drive you home and stay with you for the next 2 days to help you with activities of daily living. Initially, you will feel tired and run down. This will be at its worst in the first several days after surgery. The lethargy may be attributed to general anesthesia and will improve substantially over the first week after a brow lift. Discharge from your incisions should be minimal over the 1st 2 days after surgery, though bleeding may occur with excessive activity, and at least some spotting over the dressing is normal. The dressing present after surgery will be removed, along with a special garment, during the first post-operative visit. Drains, if present, will likely be discontinued at the same time. If dilute local solution was used (superwet or tumescent technique) pain and discomfort will be mild initially, and will increase and peak within two days. The pain will then subside over the course of one to two weeks. Use of prescription pain medication will help significantly. Nausea and vomiting in the postoperative period is not uncommon and has to do with the type of anesthesia used and overall patient sensitivity to the various medications. It generally resolves within 1 to two days after surgery. Increasing fluid intake (provided you have no history of heart or fluid trouble), especially via one of the “ade” (Gatorade, PowerAde, etc.) solutions available for sports use, combined with anti-emetic medication should minimize this problem. Use of opiate pain medication, combined with inactivity, and dehydration may lead to constipation. Increasing fluid intake will help this as well, especially in combination with walking, and use of a stool softener. Swelling and bruising peak within three days of surgery and gradually subside over the following week, but may persist for up to four weeks. The two sides rarely bruise to the same degree, and a mild difference in swelling is normal, however, if swelling is notably different you will need to come in for evaluation immediately. Your appearance early on in the course of recovery may be distorted by a significant amount of swelling, giving you a bloated, puffy, pale appearance with blotchy bruising. Do not be disturbed, this will pass, and you will look and feel much better within several weeks. Apart from swelling and bruising, most patients will experience tightness and numbness over the forehead. Most numb places will regain sensation over several months, in the case of the open or coronal brow lift approach; this may take up to six months. Expect improvement in all of your symptoms, worsening over the course of recovery is not normal and needs to be addressed via a prompt phone call. Hair may be lost around the incision 1 month after the surgery. It will usually return within 4 months after the initial loss. Healing incisions will adopt a pinkish hue which should gradually fade over the next six months to a year. Some patients react to absorbable (inside) suture, small pustules or whiteheads along the incision may signal this. The suture may be removed in the office if the problem becomes bothersome. Facial camouflage make-up may be applied two weeks after surgery to conceal bruising, and healing incisions. Tell-tale signs of surgery will resolve within 1-2 months. The final result will be obtained once all of the swelling has resolved, typically around six months.

When prescribed, antibiotics are extremely important to take as directed for proper blood levels and effect. Antibiotics may cause gastrointestinal symptoms, loose bowel movements, or yeast infections. Prompt notification is the key. Anti-emetic (nausea), analgesic (pain), a sleeping aid, and a stool softener should also be prescribed, and taken as directed. If you are sensitive to narcotic medication, start off slowly, with ½ or ¼ dose and work up (this class of pain medication may not only make you disoriented, lethargic and nauseated, but also constipated, and can cause you to have a difficult time urinating).

You should never mix Tylenol™ with certain combination narcotics that already contain acetaminophen, as this may cause damage to your liver. If you do not want to take the prescribed pain medication for any reason, simply substitute it with Tylenol™. Any of the prescribed medications may cause an allergic reaction. If you notice swelling, redness, raised wheals over any portion of your skin notify the office. If you have trouble talking, breathing, have tongue and mouth swelling; consider it a medical emergency and cal 911 without delay. Finally, do not drink alcohol while using the prescribed medicines for at least two weeks until after surgery. This is because there are dangerous interactions between alcohol and pain, nausea, and insomnia medication. Alcohol may render the antibiotic useless, worsen fluid exacerbation, and result in a dehisced incision from bumps or falls sustained while inebriated.

If you are not a local resident, you should plan to arrive at least a day prior to the procedure to familiarize yourself with your temporary habitat. You will need to remain here, whether at a local hotel, or with a relative or friend for approximately one week after surgery. You will also need to notify the office of your planned residence. If a resurfacing procedure is planned along with face lifting for total facial rejuvenation, you will need to pre-treat for approximately six weeks before surgery. Our aestheticians will help with this. Of course all prohibited medications must be stopped at least 2 weeks prior to surgery. Make sure there is someone who can help you get about for the first several days after surgery as swelling and discomfort may limit your ability to do so. Preparing meals in advance, having someone cook for you, or planning to order out are all things to consider and have arranged prior to surgery. Ice packs should be stocked to last for 48 hours. A less expensive alternative may be frozen vegetable packs.

If you are a nicotine user you must quit nicotine 6 weeks before surgery. That means you must quit smoking tobacco, chewing tobacco, chewing nicotine gum, using the nicotine patches, or any other imaginable method of nicotine delivery. A pre-operative history and physical must be performed by your primary care physician, within four weeks of having surgery. You have, or will be given a list of prohibited medications. Please refer to this list to guide you in substances incompatible with, or not conducive of surgery. The most important of such medications not take for at least 2 WEEKS prior to surgery include drugs which interfere with clotting (‘thin”) your blood such as aspirin, or any non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (advil,motrin,nuprin) or naproxen (aleve, naprosyn), blood thinners (coumadin or lovenox for example), and/or vitamin E. You must check with your primary care physician or cardiologist prior to discontinuing the aforementioned drugs. The prohibited medication list includes any herbal or non-traditional substances or medications, and diet medications. Do not consume any alcohol, or use any illicit drugs for at least two weeks prior to surgery. If you develop a viral illness, cold, upper respiratory tract infection, urinary tract infection, sores, boils, or any other new medical problem before surgery, notify our office as soon as possible. If you are not spending the night in the hospital or recovery suite after your surgery, please make arrangements to have a responsible friend, or relative drive you to the facility, and drive you home after the surgery.

The price for a brow lift varies very widely, and depends on several factors.

1. How competitive is the market?
2. How reputable is the surgeon?
3. Is the rhytidectomy done in the hospital or office?
4. Is the rhytidectomy done under general anesthesia, or sedation?
5. How invasive is the face lift, or how long will it take?

Based on the above the bottom line can range from five thousand to fifty thousand dollars. Why the discrepancy? The more saturated the market is with surgeons who fancy themselves brow lift operators; the more likely they are to try to undersell the competition. Of course, if the surgeon is completely booked, has an impeccable record for outstanding results, and/or is recognized nationally, he or she will operate on the most affluent patients, and the asking price will be substantially higher. Procedures performed in the hospital will run more because of the customary mark-ups, unless your plastic surgeon has worked out a special deal. General anesthesia introduces the anesthesiologists’ fee. Finally, the particular technique matched to the patient’s problem may require less than two hours of operating time, or more than six. This not only affects facility, and anesthesia fee, but most surgeons will charge considerably more for a more involved operation.

Depending on the type of brow lift performed, recovery can last from as little as several days to as long as three to four weeks. Assuming the most invasive form of brow lift was carried out; the sequence would include a possible overnight stay. In either instance, assuming an uncomplicated course, immediate recovery from anesthesia takes from one half to a full hour. Patients go may go to a private suite prior to discharge, or when staying overnight, to an appropriate room. Drains would likely be present, and be removed the following day. Swelling is worst at 48-72 hours, and should gradually subside thereafter. Sleeping with the head elevated on several pillows will do much to aid in drainage and diminish facial puffiness. Pain begins to improve significantly after 3-4 days. Oral pain medication will do a lot to alleviate most of the discomfort. Numbness about the central forehead does not affect the majority of patients, but it is not rare. Numbness behind the hairline incision in the case of open or coronal brow lifting is a drawback to this type of procedure. This is why endoscopic brow lifting is preferred to the coronal approach. If loss of sensation is present, parenthesis may take from six to twelve months to resolve. Bruising is normal, and may change color over days. Uneven swelling and bruising are not normal, and may signal a bleeding problem, early on, and infection later in the course. Both of which are not very common. In any case, notifying Dr. Gerzenshtein as soon as possible is essential to a good outcome. Other findings that may merit the same action are loose sutures, cloudy drainage, fever, or redness. Visible sutures are removed within 5-7 days. Sutures or staples behind the hairline and ears are left in for 10-14 days.

Make-up may be applied after one week. Light exercise may begin 7-10 days after surgery, while more strenuous activity should wait until after one month has passed.

Risks associated with brow lift surgery may be grouped into anesthesia risks, and surgical complications. Anesthesia risks are common to any surgery and are discussed elsewhere. Events such as cardiac complications (heart attacks or myocardial infarctions), allergic or anaphylactic reactions, lung-related adverse effects (pulmonary embolism, pneumonia), kidney, liver, or any other organ system problem would all fall under that category. Complications related to the act of surgery may be grouped into risks involved in undergoing any procedure, and risks particular to brow-pexy, or brow lifting. Risks of any procedure include bleeding or hemorrhage, infection, whether skin, soft tissue, abscess, or necrotizing, acute and chronic pain, and acute or chronic skin sensitivity. Delayed healing is more common is persons with vascular disease and smokers. Fluid collections known as seroma may occur in the dissected space, this typically resolves with fluid drainage. Fine results are anticipated but never guaranteed. Dissatisfaction with the cosmetic outcome of any procedure will require procedural correction.

Complications related to brow lift surgery include asymmetry, which may need surgical correction through re-operation, inadequate correction of the low brow, over-correction of the brow leading to either a “surprised look,” or even an inability to close the lids (which may lead to its own problems with the cornea, tearing, dryness, etc. and is usually a result of a combination procedure with upper blepharoplasty – persistent symptoms of this nature may require surgical reconstruction). Alopecia, or hair-loss around the incision is not a frequent complication, but is not rare, and my necessitate hair replacement or re-positioning for correction. In some cases, the endoscopic brow lift approach must be changed to the open approach. This is dictated by factors unforeseen preoperatively, such as inadequate exposure, inadequate correction, uncontrollable bleeding, etc. Contour abnormalities, divots, lumps, bumps, wrinkles may result from a brow lift. This is caused by the dissection, or by the use of a fixation device. When presenting weeks after surgery, irregularities may be a result of internal scarring. They typically resolve without issue, but may need correction in some cases. Recurrence of the brow droop is also a common negative outcome in brow lift surgery, in which case the brows need to be re-positioned. Fixation devices, as a matter of a rare complication may also penetrate the skull, and cause intracranial bleeding and/or injury necessitating emergent treatment. Visible or “feel-able” hardware may need to be removed once a stable result has been achieved. “Dog ears” are more of a possibility with the open approach, and may also require secondary correction. Scars are not particular to the browpexy procedure, but their prominence, or asymmetry if present, after this procedure may be hard to mask, and may require revision brow lift surgery or other means of making the inconspicuous. Dissection in any brow lift whether open or endoscopic proceeds in a space that is close to sensory nerves which supply or give feeling to the front scalp, and the forehead. Cutting such nerves will result in loss of sensation to the innervated skin. This is much less common with the endoscopic approach, and is guaranteed to happen for the scalp skin in the back of the incision after the open or coronal approach. Sensation usually returns without a problem. Damage to nerves that innervate muscles of the face is also possible but rare.

Intermittent application of ice packs, or more economically frozen veggie packs will diminish swelling, as will a compression garment designed specifically for brow lift patients. When it comes to reducing bruising two natural substances, bromelain, and arnica can help. Their properties are listed below.

• http://www.anyvitamins.com/bromelain-info.htm
• http://www.botanical.com/botanical/mgmh/a/arnic058.html
• http://www.alpinepharm.com

There may be many reasons why undergoing a brow-pexy or brow lift would be dangerous or ill-advised. The most commonly reversible causes include medications that interfere with normal blood clotting mechanisms, have interactions with anesthetic agents, or impair healing. Such contraindications are usually not problematic, in that most patients can temporarily suspend the use of these substances prior to surgery. More serious reasons not to undergo a brow lift include health problems such as coronary artery disease, pulmonary disease, etc. Such disorders significantly increase the chances for adverse outcomes, especially with the use of general anesthesia. In addition certain connective tissue disorders may pose relative and some even absolute contraindications for rhytidectomy. Ehlers-Danlos Syndrome aka Cutis Hyperelastica, Cutis Laxa, Pseudoxanthoma Elasticum, Progeria aka Hutchinson-Gilford Syndrome, Adu1t Progeria aka Werner’s Syndrome, Meretoja Syndrome, Idiopathic Skin Laxity.

If you need to take something for relief of minor pain, you may take Tylenol.

If your eyes become matted gently cleanse with a warm washcloth. You may shower 24 hours after surgery only if you have a handheld shower and you can direct it at away from your face, keeping your head dry. 48 hours after surgery, remove dressing if present, leaving steri-strips in place. You may now wash your face and hair. When shampooing and washing your hair, do it with your head and hair flung back, in a salon style fashion. Be gentle around the incisions but wash the area thoroughly. It is best to use a mild, unscented soap for washing your face. When washing, and when drying, pat over the incisions, don’t wipe. Do not use the “hot” setting when blow-drying your hair, some skin areas may have lost sensation temporarily and you will not be able to feel yourself getting burned when too close or when using the hair dryer too long in one area. If you dye or bleach your hair, you may resume 1 month after surgery. Do not make use of a steam room, sauna, bathe or submerge in a pool or whirlpool, for at least 3 weeks after surgery.

The short answer is yes, especially if you are well away from your target weight. Losing significant amounts of weight after a skin-tightening may cause recurrence of sagging. If you are very close to target weight, you should probably wait until you’ve reached it, since disruption in your exercise/diet routine caused by face lift surgery and recovery from the rhytidectomy may set you back a bit. If you are having the operation performed for functional reasons (partial loss of visual fields), it will be a matter of what bothers you more.