The Eyebrow: Our Emotion Maker w/ Dr. Jason Bloom

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is The Eyebrow: Our Emotion Maker. Today we're planning on talking about the eyebrow and brow lifting. Dr. Bass, why is this a topic unto itself?

Dr. Lawrence Bass (00:33):
Well, if we look back to the 1980s when there were little more than a handful of aesthetic surgery procedures, the brow lift was one of them. So this is one of the old standbys. In that sense, it's historically a cornerstone of facial rejuvenation, but it's also been a central part of facial aesthetic treatments, makeup, beauty, because of the role the brow plays in expressing facial emotions.

Doreen Wu (01:02):
What are the main aesthetic issues regarding the brow?

Dr. Lawrence Bass (01:05):
The big issue with aging is brow ptosis or drooping. So this narrows the visible eye space, and the brow also tends to flatten as we age, so we lose some of the youthful shape.

Doreen Wu (01:24):
Is there any more to the history I should know?

Dr. Lawrence Bass (01:26):
Actually, yes. The traditional brow lift, what's called a coronal brow lift, is largely historical at this point. And this is a procedure that people heard horror stories about, and I don't want to make a lot of the fact that what we have now is not surprisingly better than what we had 40, 50, 60 years ago. But the procedure made a long incision across the top of the head from just above the top of one ear to the top of the ear on the other side, and then the brow would be released from the forehead to allow the work to be done. And this procedure worked very well to elevate the brows, but there were several drawbacks that really are not acceptable to us these days. There was a fairly long healing time, months to restore sensation to the scalp, and people could see a receding hairline or occasionally a bad scar with hair loss along the incision. So these account for many of those negative tails that I mentioned about brow lift. But because this technique is not really in use any longer, except occasionally for specific reasons, all of those horror stories should largely be ignored since other techniques have come into use. And I'm going to turn to our guest on the podcast today who's agreed to return and join us. Dr. Jason Bloom. He's a facial plastic surgeon in Bryn Mawr, Pennsylvania, who's joined us previously on a number of episodes. Dr. Bloom, what are the most common surgical approaches nowadays for brow lifting?

Dr. Jason Bloom (03:18):
So the most common surgery approaches for brow lifting that we utilize in our practice are the number one would probably be an endoscopic brow lift. And this is kind of a closed approach through a number of five different small incisions made back in the hairline that allows us to access the musculature, the ligamentous attachments of the brow through basically these small ports, part of which we use under direct visualization and some parts with a video camera. Then you have the open brow lift approaches, which as you were describing would be a coronal brow lift, which is basically an incision from ear to ear as well as what we call a trick or a hairline incision brow lift. These are larger procedures where you're actually pulling down the scalp, working on the musculature directly. And then I will say there is something more recently that I've been doing a little bit more of called a temporal brow lift when the lateral parts of the brow are depressed and you can actually point to just the most lateral part of the brow kind of hooding, you can directly access over the temporalis muscle to lift that up.

(04:49):
And then the last ones I would say are used mostly at this point for more functional issues where there is a lot of asymmetry between the brow. And that would be a direct brow lift, meaning making an incision right over the brow or a mid forehead lift, brow lift where you're using right or wrinkles in the forehead to address the brow height more directly.

Dr. Lawrence Bass (05:20):
Yeah, and that's a good summary of what's out there. I'll just add a wrinkle, if you'll pardon the pun to that approach with the direct brow lift. The direct brow lift, as you said, has classically used an incision right above the hair of the eyebrow. But there is an approach that I use, and I'll tell you the reason, through an upper blepharoplasty incision, to access the ligamentous structures them and allow elevation of the brow. Now, the difficulty with taking that approach was obtaining fixation and fixation with good control. So you release the brow, but now you have to hold it up exactly where you want it while it heals. But some newer technologies have allowed us to get stable fixation, and that allows that approach to be used, which conceals the incision. And the place I use that the most is for men with a receding hairline because it's difficult to put an open incision on them. Men don't always heal to make quite as nice a scar as women will with a hairline brow lift. And if their hairline is receded, doing an endoscopic approach may be challenging and may not give you the fixation you want over that long distance. So I'll take a direct approach, but through the upper blepharoplasty incision,

Dr. Jason Bloom (07:04):
I utilize that occasionally, and I think that's a great population that you're talking about is these male population. And that's, we call that a transbleph, and I use it less for a brow lift, but more for what I call a browpexy to kind of hold the brow at its position and prevent further posis or lowering of the brows.

Doreen Wu (07:32):
Building on this discussion of populations who are appropriate candidates for a brow lift, what are some typical ages to undergo this procedure?

Dr. Jason Bloom (07:41):
So I would have to say in my patient population, most of the patients that I'm doing brow surgery on, and I would say if I'm doing a brow surgery on a patient, there's about an 85% chance I'm doing, 85 to 90% chance, I'm doing some other periocular rejuvenation surgery at the same time, but they typically are in there, I would say early to mid fifties. And the candidates really depend on, we were talking about the differences between males and females. When I look at a male brow, for example, male brows tend to be flatter, less arched, and if you feel the orbital rim, a typical male brow tends to be just above or at the orbital rim. A female brow is a little bit different. A female brow should be above the orbital rim the entire way with the peak of the brow kind of arching somewhere between the lateral peak or arch of the brow should be somewhere between the lateral limbus of the eye, which is the colored part of the iris of the eye and the lateral canthus of the eye. So you want the peak to be aesthetically somewhere between those two points.

Dr. Lawrence Bass (09:03):
Yeah, I mean, the gender specific differences of brow position and brow shape are really important to remember. And either if we're trying to preserve gender identity, we need to take one approach in each gender to keep them with an appropriate looking eyebrow or if the goal is to try to change it. I find like Dr. Bloom, I brow lift more often in conjunction with a blepharoplasty or some other periocular procedures than by itself. And that's typically in patients that are older than what we thought in the 1990s were good candidates for brow lifting. There was a view that brow ptosis occurs early in facial aging in the late thirties, and 35 to 45 was a good time for an endoscopic brow lift. And I'm not sure that that would be the view today where we typically will wait longer. But I also see people who have had a major facial rejuvenation in their fifties and are now in their late sixties or early seventies, and they may have gotten away without a brow lift at the first go round, but they're more likely to need it at the second go round, although that raises the challenge of dealing with where their hairline has gotten to with aging.

Doreen Wu (10:46):
Now let's talk about the difference between a brow lift and a blepharoplasty. Should I be getting a brow lift or a blepharoplasty? How do I decide which is right for me?

Dr. Lawrence Bass (10:56):
Each procedure does different things of course. So if the brow is low or the visible lid space is very narrow, then lifting the brow is reasonable and that Dr. Bloom gave that technical definition of where the brow is supposed to be in youth, usually just at or above the bony orbital rim. But if we look at a lot of people, their high school yearbook picture, their brow is lower than that. So it's not necessarily that they look old because the brow is low, if that's how they've always looked, it may be a mistake to lift their brow and change who they look like. It's always a mistake to over elevate the brow to clean up excess skin in the upper lid that gives a surprised look or deer in the headlights look. That's very unnatural. So if you bring the up to the point where it's anatomic and their upper lid looks clean, maybe they just need a brow lift. But if you bring the brow to a natural position and there's still excess skin in the upper lid, I think first and foremost they need an upper lid blepharoplasty. And then you consider if there's enough aesthetic advantage to need a brow lift in addition. Dr. Bloom, how do you parse this?

Dr. Jason Bloom (12:24):
In very much the same way as you're explaining. I would say if the brow is low and when you bring it up to the correct position, even just standing in front of the patient and playing with their eyebrows and kind of getting it to the right position, if there still is what we call dermatochalasis or hooding at that point, then I tend to do a brow lift in combination with an upper blepharoplasty. But if the patient has a good brow position and they just have, for example, hooding of the upper eyelid that you can see, and when you pinch that extra upper eyelid skin that is a patient in my hands for just for example, an upper blepharoplasty. One of the biggest, I think, giveaways to a patient needing a brow lift is a patient sometimes with really deep forehead wrinkles. Because it's very interesting that when a patient has a lower brow, the frontalis or the forehead muscle, as we know is the only lifter of the eyebrows. And a lot of times when a patient has deep forehead wrinkles, it's because it's a compensatory mechanism. They are constantly trying to lift their brows up so they can see, and literally they're trying to lift their brows so they can actually see and remove some of the extra upper eyelid hooding, and they're lifting their brows. So if you see a patient with deep forehead wrinkles, there usually is a brow ptosis in conjunction.

Doreen Wu (14:11):
Let's talk about the forehead then. Is it brow lifting or Botox or something else that'll address this?

Dr. Jason Bloom (14:18):
Well, it really depends. I was just talking, if you see some heavy forehead wrinkles, those patients usually need some kind of procedure to lift the browse because if you, for example, you can use neuromodulator in those cases to weaken the brow depressor muscles, which would be in between the eyes and underneath and around the eyes, the orbicularis muscle and the corrugator and proce muscles. But if you treat a patient like that with heavy forehead lines and wrinkles and a lower brow with Botox in their forehead, you've now just weakened the only muscle in their face that lifts their brows, and that is going to make their brows actually heavier and more kind of dense or lower. So in those kind of patients, you only want to treat in between and around the eyes with Botox so that the muscles that pull down the eyes or the brow depressor muscles are weakened and allow the forehead muscle to lift. So it's an understanding of what muscles lift and what muscles pull down, and how we use either toxins or surgery to modulate those muscles.

Dr. Lawrence Bass (15:52):
And a lot of that is probably about the individual patient and their muscle dynamics. So I agree with you a hundred percent, and I think this is very poorly understood by a lot of people who are out there doing a lot of Botox treatments. That balancing first by relaxing the depressors, and then if you can get away with it, doing a little smoothing by very minimally relaxing, the only lifter muscle, the frontalis, which is the one that makes those forehead lines. And if you can't get away with that, then you maybe should be thinking hard about getting a brow lift so that the brow is elevated without you having to pull it up with your muscles all day long.

Dr. Jason Bloom (16:48):
Yeah, I mean, this is extremely poorly understood how many patients, Dr. Bass come into your office and they go, "I just need some Botox in my forehead to lift my brows." And they're pulling on their forehead. They do that. I mean every single patient, right?

Dr. Lawrence Bass (17:03):
And they don't understand how we trick the brow into coming up, which is a very backhanded or paradoxical way of doing it.

Doreen Wu (17:13):
Now I'm wondering what kind of control do these various techniques have for brow shape? Let's say my main goal is brow shaping, not repositioning per se. Are there nonmedical approaches that might work better?

Dr. Jason Bloom (17:26):
I feel that honestly, neuromodulators give us great control of brow shape in understanding how these muscles pull, as we were just describing in some of the muscles pulling down and some of the muscles lifting, you can actually pinpoint and get precise areas of brow lifting and flattening of the brow depending by using small amounts, micro amounts of neuromodulator placed expertly. And in my hands, neuromodulator works way better for that than brow lift surgery.

Dr. Lawrence Bass (18:06):
Yeah, I agree. I think the thing that has the most potential for control, control of brow shape is neuromodulators. And then things like surgery or some of the energy treatments that can elevate the brow are less, they're maybe more durable, and they may be able to get a greater degree of elevation, but they don't have as much shape control. The other thing that does offer potential, if the brow height basically is reasonable, it's not very droopy, shaping the brow itself can be done with, the estheticians do this, by tweaking which hairs they leave and which hairs they take out or by tattooing the brow or micro bleeding to introduce a certain shape by how much brow hair you leave and how much you remove in different places. To create a very dramatic arching to the brow, more of an average arching. Men's brow tends to be straighter to help the brow look straighter. And so sometimes if the brow is not sitting too low, but you just want a shape to the brow, these beauty treatments might be more fruitful than a medical approach with neuromodulator or surgery.

Doreen Wu (19:43):
Lastly, before we conclude Dr. Bass, what should our listeners take away from today's episode?

Dr. Lawrence Bass (19:49):
So like everything we do in aesthetic plastic surgery, natural is the key and brow lifting and non-surgical treatments for the brow can give a perfectly natural looking brow in the proper hands, but important not to overdo things. The goal is to open the eye space, which makes you look more present and awake and to shape the brow. But we talked about gender differences in brow shape, women's brows tend to be arched. They raise towards the outer third and peak and then drop off where men's brows tend to be straighter. And so changing that when that is not the intent, can create a very unnatural look, and that needs to be avoided. There are a range of techniques that are patient specific on how old you are, where your hairline is, and any previous surgery you've had. But Botox and other neuromodulators and energy treatments have a big role for many, many patients. It's never one size fits all.

Doreen Wu (21:05):
Dr. Bloom, any takeaways to add?

Dr. Jason Bloom (21:08):
I'll just add three quick things about the brow and brow procedures and brow surgery. What I found, number one is that getting a really long lasting good brow lift surgical result is very hard. I think even when we do an amazing brow lift to us, I think getting longevity with this procedure is very difficult because you're constantly battling gravity. As a corollary to that, I would say number two is that less is more in brow lifting. And I think many people talk about how the release of the attachments and the ligamentous attachments that kind of bind down the brows are way more important than the kind of suspension or methods we use to resuspend the browse. So it's more about the release and what we do instead of the resuspension. And third, I will say that as we discussed kind of earlier, I think injectables and energy-based treatments are really keeping brows and brow positions looking better for longer before surgery is needed in a lot of these patients. So as Dr. Bass was saying early on, years ago, it used to be patients who are getting brow lifts in their thirties and forties. I think that some of the non-invasive stuff in non-surgical treatments are keeping brows looking better for longer, and we're kind of moving brow lifting surgery to patients in more advanced ages.

Doreen Wu (22:52):
Thank you, Dr. Bloom, Dr. Bass, for sharing your perspectives and expertise on this eyebrow raising topic. No pun intended.

Dr. Jason Bloom (22:59):
Thank you guys so much for having me again on the podcast. It's always a pleasure of mine to be here with you guys.

Doreen Wu (23:06):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.