Part 1 – Understanding how the forehead, eyebrows and upper eyelids age.

A Facial Plastic Surgeon’s approach to improving the appearance of your forehead, eyebrows and upper eye lids.

As we age, our eyebrows start to drop or fall lower on our forehead. This results in a look that people often describe as ‘tired.’ The desire to reduce or eliminate this tired look is a very common reason why people seek the services of a facial plastic surgeon.

On the surface, this may seem like a simple and straightforward issue, but it is in fact one of the more complex problems in facial plastic surgery. There are many different muscles, tissue and facial aesthetic subunits involved (for more information on the aesthetic subunits, check out this previous blog). Furthermore, differences in eyebrows and the forehead vary considerably between men and women.

This topic can be confusing, so I will begin with a general description of a typical patient and what commonly occurs in our clinic.

It is not uncommon for men or women to begin to notice that their eyes appear tired with age. They may also notice a ‘heavy‘ feeling in their eyes and forehead or an extra skin fold over the top of their eyes. As a result of all this, most people often come to our clinic with very specific questions regarding the skin of their upper eyes.

Forehead, Eyebrows and Eyelids – The Bed Analogy

Obviously, these are all valid concerns and the skin of the upper eye is important. However, people often overlook the fact that there is a very intimate relationship between the skin of the upper eyelid and the forehead. To demonstrate this further, think of the forehead and upper eyelid skin as though they were a large blanket draped over a bed with the blanket is tucked into the foot of the bed so it cannot move (this would be analogous to where the skin connects to the upper eyelid). You may also have some pillows on the bed as decorations – these would be the eyebrows.

In a youthful forehead and eyebrow, the skin (or blanket) is all nice and tight, tucked in and snug. As you age, the skin (or the blanket) begins to loosen and fall towards the eyes (or the foot of the bed). This causes the skin to bunch up as the blanket would over the lower aspect of the bed while the pillows (or eyebrows) follow behind and assume a lower position on the bed (or forehead). In addition to this, the skin or the blanket loses its elasticity and becomes looser. Think about how fabric stretches and becomes looser over time – this also happens to your skin.

So, where does this leave us? Well, on our bed, the fabric is loose, there is extra fabric bunching up at the foot of the bed and our pillows are not in the position we want them in. The same goes for our skin, as we age our skin becomes less elastic and looser (for a discussion on skin changes see this prior blog post ).  This causes the skin to drop and ‘bunch’ up over the upper eyelids while the eyebrows assume a lower position on the forehead.

Now that we understand the cause, how do we fix it? How do we make our blanket nice and tight and our pillows well positioned? Well, let’s go back to our bed and figure this out (feel free to read this article in bed, it seems kind of fitting, no pun intended). We have three options.

Fixing the Situation – Option 1

We can just cut the portion of the blanket that is bunched up over the foot of the bed, sew it together and voila – a nice smooth blanket. Let’s think some more about this. Yes our blanket will no longer have the wrinkles but the pillows will be positioned low and the rest of blanket will still be loose or sagging.  So, similarly, if you just remove the extra skin over the eyes, you will still have low eyebrows and the forehead skin will be loose.

Fixing the Situation – Option 2

The second option would be to pull the blanket from the top into place where it should be. This will lift and reposition the pillows, reduce some of the bunching of the blanket at the lower end of the bed and give it a tailored look. This is a great idea, but remember our blanket has aged, so it is loose and even if we pull really hard, there will still be some extra-blanket because it stretched over time and is now loose. This is also true with our eyes and forehead, if we have extra skin over the eyelids and low positioned eyebrows, pulling the forehead skin higher will lift the eyebrows and help to reduce some of the eye lid skin. However, it will not be perfect. Some extra skin will remain.

Fixing the Situation – Option 3

Oftentimes, option three is required, which involves both treatments noted above. We pull the blanket  from the top lifting our pillows back to a better position and any extra blanket that is still bunching near the foot of the bed is trimmed and sewn nicely back together. This again is similar to our skin. As you will see in a later discussion, this is a common treatment for rejuvenation of the forehead, eyebrow and upper eyelid.

The key to eyelid and forehead surgery is understanding the interplay between the forehead, eyebrow and eyelids. A common mistake is to treat one area alone, assuming all the problems will go away.

This description is important to understand from both a patient’s and a cosmetic or a plastic surgeon’s perspective.

In Part 2 of the editorial on forehead, eyebrow and eyelid aging, I will discuss specific non-surgical treatments that are used to treat the forehead, eyebrow and upper eyelid including neuromodulators (ie Botox®), laser skin tightening and radiofrequency skin tightening.  In Part 3, we will discuss surgical treatments of the forehead, eyebrows and eyelids such as forehead lifting and blepharoplasty (eyelid surgery).