Forehead lift

A brow that has moved downwards can contribute to a bunched appearance over the upper eyelid; that appearance does not always come from excess skin on the lid alone.¹ In planning a forehead lift, the position of the brow, the forehead tissues and the lid itself are assessed separately.²¹

What is a forehead lift?

A forehead lift is an operation that aims to release the forehead and brow tissues and fix them in a higher position.² Not only the outer end of the brow but its middle and inner parts are included in the plan.² The scope is determined by which part of the brow has dropped and which change in the forehead tissues is intended.³²

Lifting the brow can reduce the bunching over the upper eyelid, but it does not remove the lid skin.⁴ Surgery directed at the lid skin, and repair of ptosis related to the structures that open the lid, are separate procedures.¹ Procedures aimed at changing the shape of the outer corner of the eye are outside the scope of this article.

Who is it suitable for?

A forehead lift can be considered in people whose forehead and brow tissues have moved downwards, particularly where the middle and inner brow also need assessing.² Brow drooping can be accompanied by a feeling of heaviness over the eyes and a bunched appearance on the upper lid.⁴ A procedure is not chosen on appearance alone, without understanding which tissue the complaint arises from.¹

General health, smoking, previous surgery and expectations are part of the assessment of suitability.³ Age by itself does not determine the route of incision or the amount of lift; the starting position of the brow, the hairline and the structure of the forehead are assessed together.² Where the brow position is suitable and the problem is found to relate mainly to the lid skin, the focus of the plan can be different.¹

It is not assumed that every line on the forehead will be removed by the same operation; the appearance of the skin, the movement of the muscle and the position of the brow are not the same target.² Non-surgical applications such as botulinum toxin are separate options; this article does not cover how they are applied.²

What does the examination assess?

Brow and forehead: The resting position of the brows, their inner, middle and outer parts, the difference between the two sides and the movement of the forehead muscle are examined.² Asymmetry present at the outset is recorded; it is taken into account that the two brows may not have been exact copies of one another before surgery either.¹ The effort of constantly holding the brow up is taken into consideration in assessing the brow and the lid.²

Eyelid and ocular surface: The amount of lid skin, the position of the lid margin, the closing of the eyes and complaints of dryness are assessed.¹ Previous eye or lid surgery, eye disease and drops in use should be reported.¹ Excess skin, brow drooping and ptosis can occur together; finding one does not make assessing the others unnecessary.¹

Hairline and incision: The height of the forehead, the position of the hairline, hair density and previous scars affect the choice of incision.² The likelihood of the scar being covered when the incision lies within the hair, and any shift of the hairline, are assessed separately.⁵² Where the hairline is already high, the suitability of an approach that could raise it further is considered separately.⁵

How is the operation planned?

Which part of the brow is targeted?

The aim is not to move every part of the brow up by the same amount; the starting position of the inner, middle and outer parts is assessed together with the state of the forehead tissues.² The shape of the brow and the balance of the two sides are matters for assessment separate from a single measure of height.² No single brow height or amount of lift is set as valid for every face.²

A procedure on the muscles that pull the brow down can be part of some methods, but the same muscle procedure does not need to be carried out in every forehead lift.² A review of endoscopic series likewise reports that the handling of the muscles and the methods of fixation differ between studies.⁶

Endoscopic or open?

Either an endoscopic or an open method can be used in this practice. The choice varies according to the person and the surgeon's assessment.

In the endoscopic approach the forehead tissues are reached with the help of a camera through small incisions within the hair-bearing scalp; the tissues are released and fixed in their new position.⁵ In the open approach the same region is reached directly through a longer incision; coronal incisions and incisions close to the hairline are different examples of this.² The length of the incision, the plane in which the tissues are released and the method of fixation are separate technical features; using an endoscope alone does not define all of them.²

In a retrospective study comparing endoscopic and pretrichial open forehead lifts, the brow position of 65 people was measured.⁷ Both methods are reported to have raised the brow significantly at every point measured, that this effect was maintained at a follow-up averaging 6 years and ranging from 3 to 11 years, and that no significant difference between the techniques was reported.⁷ The 32 people who completed the satisfaction questionnaire were reported as satisfied or strongly satisfied.⁷ This selected, non-randomised study does not show that the methods are equivalent in every respect, nor that everyone will obtain the same result.

Where is the incision made, and does the hairline change?

In the endoscopic method the incisions usually lie within the hair-bearing scalp.⁵ In the open method a coronal incision can run behind the hairline, within the scalp; in the pretrichial approach the incision is made close to the hairline.² These options do not mean that the same scar and the same change in the hairline will occur.²

Some lifts carried out from behind the hairline can increase the height of the forehead; an approach through the hairline can be chosen with the aim of preventing the line from rising further.⁵ Where the incision lies outside or at the edge of the hair, the visibility of the scar is taken into account separately.² The length of a scar and how much it will be noticed are not the same thing; hair density and wound healing also affect the outcome.²

How does it differ from a temporal lift?

A temporal lift affects the outer third of the brow more. In a forehead lift the middle and inner parts of the brow are lifted as well.

The details of the limited approach directed at the outer brow and the temple are in the temporal lift article. The planning here also covers the inner and middle brow and the forehead tissues.² Which parts will be targeted in a given person is determined by examination; not all brow lifting operations are assessed as having the same scope.²

Is a separate procedure on the eyelid needed?

Lifting the brow can reduce the bunched appearance of the lid skin beneath it; whether genuine excess skin remains is assessed separately.⁴¹ Upper eyelid surgery addresses the lid skin; adding it to a forehead lift is not a step that everyone needs.¹ Ptosis, in which the lid margin sits low, is also assessed separately and is not counted as the same procedure as lifting the brow.¹

A request concerning the position or the shape of the outer corner of the eye is kept apart here from the aim of lifting the brow. The scope relating to that aim is in the almond eye surgery article. The care and the risks of added lid or eye corner procedures are not presented as belonging to the forehead lift alone.¹

How is the anaesthetic planned?

A general anaesthetic is used in this practice. The operation is planned as 1-2 hours and the hospital stay as 1 night. Where an added procedure is needed, the operation and the recovery plan are assessed separately. Personal risks relating to the anaesthetic are covered at the preoperative assessment.³

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.⁸ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.⁹ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹⁰ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹¹ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹² Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹² The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

What is recovery like?

The times below are the clinical timetable set by the surgeon for this practice. They are not an average from the research, nor a promise that everyone will reach the same state on the same day.

• The first check-up is within the first week.
• Stitches that need removing are taken out within 1-2 weeks, with the incision checked.
• 1 week is planned for returning to desk work.
• An interval of 1-3 days is assessed for driving; the safe driving conditions below must be met.
• A return to sport is planned in stages within 2-4 weeks, according to the sport.
• 4 weeks is expected for a full return to daily life.

Bruising is expected to settle over 7-10 days and marked swelling over 2 weeks. The timetable for returning to work is kept separate from the timetable for visible bruising and swelling to settle.

The shape becomes possible to assess over 2-3 months, while residual mild swelling can last 3-4 months. Beginning to assess the shape therefore does not mean that all the swelling has finished at the same time. Maturing of the scar is a separate process, and in this practice it is followed over 6 months to 1 year.

What to pay attention to after surgery

The care plan below is the framework of this practice. The discharge instructions given to you take precedence.

Strips and check-ups: A dressing and wound closure strips are used after surgery. Only the strips remain on discharge. No drain is used. The first check-up is within the first week; the care and changing of the strips are assessed at that visit.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued.¹³ A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Washing your hair: The timing of the first hair wash is decided according to healing and is planned as 1 week on average. The surgeon's instructions on how the hair and the area around the incision are washed are followed. Changing the strips or applying a product over the incision is not decided independently.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided.¹³ Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There may be tenderness and tightness in the forehead, and headache.⁴ Pain treatment is applied according to the plan given by the surgeon. Where increasing pain is accompanied by eye pain or a change in vision, the scheduled check-up is not waited for.¹⁴

Returning to work and sport: 1 week is allowed for returning to desk work; for work with a heavy physical load, suitability is assessed separately. A return to sport is staged within 2-4 weeks. The 4 weeks given for a full return to daily life does not mean that the scar has also finished maturing. Whether the activity puts pressure or friction on the incision area, or causes straining, is taken into account.¹³

Driving: A return to driving can be assessed within 1-3 days. Drowsiness and impaired judgement can follow a general anaesthetic; the driving restriction given after an anaesthetic must be observed.¹⁵ Where there is a change in vision, assessment is needed first.¹⁴ The interval given is not an automatic permission to drive; the return is determined by the surgeon's instructions. A companion is arranged for the journey home on discharge.¹²

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the head and temple area, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Swelling, bruising and tenderness in the forehead and around the eyes, and numbness around the incision, can occur.⁴ Where these findings increase rather than settle, or a new eye complaint is added to them, reassessment is needed.¹⁴¹⁶ A sudden reduction in vision is not counted as part of ordinary healing.¹⁴

How do the scars change?

An incision made in the hair-bearing scalp also leaves a scar; the hair covering the scar does not mean no scar has formed.² The visibility of an incision close to the hairline or in hairless skin can differ.² Incision scars can fade over time, but a conspicuous or unwanted scar can develop.¹⁷¹⁸

In this practice the maturing of the scar is assessed over 6 months to 1 year. The time given for assessing the shape and the timetable for the scar are not used in place of one another.

Scar care by area: Only a dressing is applied to incisions in the hair-bearing scalp; silicone gel and massage are not advised there. Where there is an incision in hairless skin, silicone gel and massage are advised. When they are begun and how they are applied are determined by the surgeon after assessing how the incision is healing. This distinction is the care decision of this practice.

Separation of the incision, discharge or steadily increasing redness should not be attributed to the maturing of the scar alone.¹⁶ Protection from the sun is among the recommendations for preserving the result after a brow lift.¹⁷

Risks and complications

The risks are assessed according to the person's features, the incision and fixation method, and any added procedures.² A systematic review of brow lift complications states that the techniques, the follow-up periods and the reporting of complications are not standardised.¹⁹ The research rates below are not a calculation of personal risk, and they do not form a single shared rate for open and endoscopic operations.¹⁹

Problems of brow position, symmetry and shape

The brow can be raised less or more than intended, a difference can remain between the two sides, or a drop can be seen again over time.⁴ A further procedure may be needed to correct the result.¹⁸

In the review by Cho and colleagues, 34 publications covering endoscopic brow lifting were assessed, with 7,273 patients in total.¹⁹ In that group asymmetry was reported at 0.7 per cent and revision at 1.2 per cent.¹⁹ These rates are compiled from different series; no meta-analysis was carried out and no direct comparison with the open method under the same conditions was presented.¹⁹

Change in sensation and forehead movement

The supraorbital and supratrochlear nerves, which carry sensation from the forehead and scalp, and the branch of the facial nerve that carries movement to the forehead muscle are different structures.²⁰ Numbness and weakness in raising the brow are therefore not the same problem.²⁰ A change in feeling, marked itching or numbness can occur after brow lifting; the change in sensation can be temporary, but it can also be permanent.¹⁸⁴

In the 7,273-patient endoscopic group of the Cho review, numbness was reported at 2 per cent; that combined figure is not a separate rate for permanent numbness.¹⁹ Involvement of the temporal branch of the facial nerve, also called the frontal branch, can impair the movement of the forehead muscle.²⁰ New weakness in raising the brow, or a new difference in movement between the two sides, should be assessed by the surgeon.¹⁸

Hair loss and the hairline

Hair loss around the incision and a rise of the hairline are among the reported risks of brow lifting.¹⁸ Temporary thinning of the hair and a permanently hairless area are not the same thing; the course of the hair loss is followed separately.²

In the endoscopic group of the Cho review, hair loss was reported at 2.8 per cent.¹⁹ That rate was not given as the rate of permanent hair loss alone.¹⁹

The wound, bleeding and infection

A collection of blood or fluid in the operated area, infection, delayed healing of the wound and skin loss can develop.¹⁸ Spreading redness, increased warmth, discharge, fever or separation of the wound edges call for assessment by the surgeon.¹⁶ Treatment directed at infection is decided according to the findings at examination.¹⁶

Rare situations that threaten sight

The information from Worcestershire Acute Hospitals NHS Trust, which describes direct brow lifting, states that bleeding in the eye socket can raise the pressure and, rarely, threaten sight.¹⁴ That source is for direct brow lifting; it does not mean the same frequency has been shown for endoscopic or open forehead lifting on its own.¹⁴

Sudden reduction in vision, loss of vision or severe eye pain calls for urgent assessment.¹⁴ Difficulty closing the eyes and marked dryness should also be reported to the surgeon.¹⁴

Anaesthetic and general surgical risks

Risks relating to a general anaesthetic are covered together with the health history and the anaesthetic assessment; heart and breathing problems are also within the scope of that assessment.⁴

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Does the position of the brow change again over time?

Ageing continues and the brow can move downwards again.⁴¹⁷ The long follow-up period of a study is not a personal promise that the result will remain unchanged for the same length of time.⁷

In the review by Şibar and colleagues, which assessed 12 studies and 478 people with at least 1 year of follow-up, the change in brow height after endoscopic lifting was pooled separately by region.⁶ The pooled average elevation was reported as 3.25 mm (2.44-4.06) for the inner part, 3.86 mm (2.93-4.80) for the middle and 4.35 mm (3.06-5.64) for the outer part.⁶ The ranges in brackets show the uncertainty of the estimate; they are not an interval to be given to a person. The value for the outer part is not the amount by which the tail of the brow is raised; measurements of the brow tail were not included in the meta-analysis.⁶

That review covered the classical subperiosteal endoscopic approach, found high variation between the studies, and also included series with accompanying upper lid surgery.⁶ The figures are therefore not transferred to open forehead lifting, and they are not used as a target for how many millimetres will be lifted in a given person.⁶

What can be expected from the result?

The aim is a change of position that assesses the middle and inner parts of the brow together with the forehead tissues, in keeping with the person's starting structure.² Requests relating to the lid skin, to a low lid margin and to the shape of the corner of the eye are kept separate.¹² Raising the brow does not mean that every line will disappear or that perfect symmetry will be obtained.²¹⁸

In this practice the shape becomes possible to assess over 2-3 months; mild swelling lasting longer does not invalidate that assessment. The brow height measured in research is not a result that describes a person's whole appearance and satisfaction on its own.⁷ In assessing the result, the position of the brow, its movement, its relationship with the eyelid and the scars are considered together.²

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations:

• Rapidly increasing swelling and tightness in the forehead or around the eyes
• Pain that increases rather than settling, or becomes marked despite the pain treatment given
• Fever, spreading redness or discharge from the incision line
• Separation of the wound or bleeding that does not stop
• New loss of brow movement or a marked difference in movement
• Difficulty closing the eyes, marked dryness or a steadily increasing eye complaint

Sudden reduction in vision, loss of vision or severe eye pain calls for urgent assessment. Severe pain after surgery around the eye can be a sign of a problem such as bleeding that raises the pressure in the eye socket; it should not be waited out.¹⁴

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. Where there is a sudden breathing or visual problem in particular, urgent assessment is not delayed while trying to reach the surgeon.

About the numbers in this article

The timetable for the operation and the hospital stay, stitch removal, returning to work and to activity, and for bruising, swelling, the shape and the scar, is the clinical framework approved by the surgeon. These are not presented as results from the source articles that apply to every patient.

The complication rates in the Cho review belong to the endoscopic group and are not a comparative risk estimate from a meta-analysis.¹⁹ The millimetre values in the Şibar review relate to the height of particular parts of the brow; without the same measurement point, method and follow-up period they are not compared with another operation.⁶ A study finding no significant difference between the open and endoscopic methods does not show that the methods are equivalent in every situation.⁷

The results in the smoking cessation studies cover different operations; neither a complication percentage specific to a forehead lift nor a conclusion that the same effect has been shown for all nicotine products is drawn from them.⁹¹⁰¹¹

References

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