AESTHETIC SURGERY OF THE UPPER FACE
(Forehead, Brow and Eyelids)
Patient Information
Attractiveness and beauty can be appreciated in every individual regardless of gender, race or age. These qualities may
be attributed to personality, attitude, spirit, a smile, or physical attributes. Aesthetic beauty of the upper third of the face
is defined by individual facial features, forehead proportions, and the relationships of the hairline, eyebrows and eyes.
These physical characteristics are influenced by both static and dynamic components portraying individual identity,
emotion and expressions. The eyes are unique with respect to shape, size, color and angulation. The eyes, “the
windows to the soul,” communicate and project our emotions from infancy to our stately years. The eyes form the basis
for individual recognition and they establish the initial contact when people meet and interact, being the most noticed
feature of the human face. The eyes are considered to be the most important feature of an attractive or youthful face.
The eyebrows overshadow or accentuate the eyes, while the hairline frames the face and forehead.
With the passage of time, aging influences such as gravity, environmental elements and sun exposure, lifestyle,
emotions, and genetics invariably alter one’s appearance. The lines of expression of the eyes are earned with age, and in
some the signs of aging are considered attractive attributes. “Laugh lines” or the characteristic “crow’s feet” radiating
from the outer aspects of the eyes project much of the expression in adults and are generally not regarded as
unattractive. Laugh lines or crow’s feet expressed in a smile project a friendly or inviting gesture.
Some aging characteristics are regarded differently, particularly when lines are accompanied by deep furrows in the
midbrow area, and overhanging redundant skin of the upper lids occur and the lower lids become full and bulging.
Frown lines often project a harsh or weathered look, aggression or anger.
An aged look to the eyelids may occur at any age from a variety of causes. In young children, this may be genetic or
the result of swelling which accumulates around the eyes during sleep, allergies, or from medical disorders. Teens and
younger adults sometimes have genetic lower eye bagginess, usually from an overabundance of fat or skin around the
eye. Recurrent swelling at this age group can be from allergies, hormones, diet (alcohol), medical conditions, or sleep
deprivation. During middle age, characteristic changes occur at the eyelid and brow regions. Typically, the forehead
descends causing the eyebrows to droop, contributing to the upper eyelid skin excess. Such aging changes may
adversely affect facial expression by portraying a very stern, angry or tired appearance. Extra skin folds, creases, loose
skin and fat protrusion accentuate these changes. Because these changes are considered part of the normal lifelong
process, most adults accept their occurrence and appearance.
The sequence of physical changes that occur with the aging process of the upper facial area is relatively predictable. In
youth, the hairline is consistent and well defined, the complexion homogenous, the forehead soft and smooth, eyebrows
arched, eyes wide open, shapely and alert. As one matures and ages, hairlines shift and recede, the complexion
becomes etched with lines and creases of expression. The brows descend, and the eyes close and narrow. The lowering
of the eyebrows from squinting or frowning accelerates the onset of wrinkles and eventually makes the eyes appear
closed or smaller. As this aging process continues, the upper eyelids become lost by the redundant overlying skin.
Compensatory forehead horizontal skin lines and furrows appear as one attempts to counter these gravitational changes
occurring with the upper lids by unconsciously raising one’s eyebrow in an effort to open the eyes. Advanced stages of
upper eyelid skin excess may even lead to vision impairment, particularly affecting peripheral vision. (Upper lid
correction to improve legitimately obscured visual fields from overlying skin excess is actually a functional surgery.)
With passage of time and the loss of collagen elasticity in the skin, the resulting furrows and lines from these
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expressions become permanent and fixed, and the brow descent reflects a sullen, sad, angry, or stern appearance despite
one’s frame of mind. Furthermore, an illusion of fatigue and tiredness may be projected from the aging face to others as
the overlying eyelid skin encroaches upon the eye below.
Baggy lower eyelids can occur at any age from a variety of causes. In young individuals, lower eyelid swelling may
result from positioning during sleep, allergies, limited sleep and chronic fatigue and other medical conditions, or simply
genetics. With aging, skin surrounding the eyes loosens due to loss of elasticity, becoming redundant and wrinkled.
Small fat pads which surround the eyes bulge and protrude forward giving the eye a swollen appearance, producing
what is commonly called “under-eye bags.” Shadowing and circles secondarily occur contributing to a tired and aged
appearance. Because the changes of aging occur progressively, we do not fully appreciate these changes until we revisit
our past photographs or receive uncomplimentary comments from spouses, friends or peers. We often appreciate aging
in the world that surrounds us, but fail to observe the truth of aging in ourselves.
Individuals respond differently to aging and change. Some people choose to embrace maturity, honoring a healthy
lifestyle, diet and exercise to prevent premature aging. Some choose to incorporate noninvasive therapies to improve
the look and feel of the skin, while many others seek traditional cosmetic surgery as an option for self improvement.
Today, treatment for the improvement of the aging forehead, brows and eyelids is one of the most common cosmetic
requests. Whatever methods one might choose to prevent and reverse these aging changes, the overall goal is to refresh
and renew the appearance in order to look one’s best -- at any age.
Treatment Options
Cosmetic treatments and cosmetic surgery of the upper third of the face may correct fine lines and wrinkles,
pigmentation problems, visible capillaries and spider veins, skin excess, forehead wrinkles, elevate eyebrows, restore
hairlines, and sculpt and remove aging changes around the eyes. The recommended cosmetic procedure to improve
your appearance will depend upon an understanding of your cosmetic concerns and expectations from the procedure,
your specific physical changes, and your personality and lifestyle.
Injectibles such as collagen (Zyderm, Zyplast, Cosmoderm, Cosmoplast), Restalyne, Botox and others are indicated to
soften and reduce the wrinkles and furrows of the forehead. Botox is unique because it works by selectively weakening
the muscles of the forehead and around the eyes, smoothing the secondary wrinkles. Because of its simplicity, efficacy
and low risk, Botox has quickly become one of the most popular noninvasive techniques for reversing the signs of
aging: frown lines, crow’s feet and fine lines and wrinkles. Botox injections are targeted selectively to specific muscles
to achieve a “chemical forehead lift” by elevating the brows and softening the forehead.
Laser and Intense Pulsed Light (IPL) systems have revolutionized the way in which surgeons can reverse the signs of
aging. Intense Pulsed Light therapy, CO2 laser skin resurfacing, radiofrequency and chemical peels address a variety of
signs of aging including age spots, redness and broken capillaries, rosacea, textural concerns, photodamaged skin and
selective wrinkles. These treatments often are combined with surgical procedures, thus providing optimal results.
However, laser and IPL technology have not replaced the art of aesthetic facial plastic surgery. In order to achieve the
results some people desire, facelifts, eye lifts and brow lifts may be the best choice. Particularly if loose skin exists,
surgical management may be required to optimize results.
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The brows may be elevated in order to achieve a more arched or feminine appearance with either a traditional (open)
forehead lift or closed (endoscopic) forehead lift. Forehead wrinkles may also be addressed surgically during these
techniques by muscle weakening. Whether the open technique or the closed endoscopic approach will be utilized
depends upon age, skin laxity and type, gender and hair patterns. This procedure may be complimented for some
patients with follicular transplantation (hair grafting) to redefine the hair line.
Upper eyelid skin (upper blepharoplasty) corrects the excessive skin overhanging the upper eyelid, opening the eye and
restoring shape. Since the optimal result of an eyelift should respect specific personal, feminine or masculine features,
eyelifts are truly an art. If brow descent and upper eyelid skin excess occur concurrently, combined or staged forehead
lifting/blepharoplasty/laser techniques may be essential to optimize the overall results. In addition, Botox may be
recommended to maintain the longevity of the result. Certain individuals may benefit from upper eyelid blepharoplasty
for functional concerns by removing excessive or overlapping upper eyelid skin obscuring the visual fields.
Lower eyelid problems are corrected by chemical peels, laser resurfacing, or by a variety of surgical lower eye lift
(lower blepharoplasty) techniques. Resurfacing techniques address early skin laxity, discoloration and wrinkles. The
blepharoplasty technique may be performed as an open (traditional) or closed (transient) conjunctival approach
dependent upon the individual cosmetic problem for correction. Lower eyelid surgery corrects loose lower eyelid skin,
a flaccid rounded lower eyelid, bulging fat pads, lower eyelid creases, wrinkles and cheek pad changes. Commonly, the
transconjunctival lower lid blepharoplasty is combined with an overlying skin resurfacing technique. This approach to
the lower eyelid does not remove skin excess by the nature of the hidden incision. Therefore, any loose or deflated skin
should be addressed by a tightening technique because the removal of the fat pad alone may result in loose, wrinkled
skin. Tightening techniques vary, the most common are chemical peels, laser resurfacing, or a surgical technique called
a canthoplasty.
Blepharoplasty incisions generally heal quite well and are placed within natural skin creases. It is not uncommon to
experience incomplete eyelid closure immediately after the surgical procedure due to lid swelling. This will resolve as
the swelling resolves.
Procedure
The aforementioned procedures are performed in our private office surgical suite, or at a surgery center or hospital
dependent upon the individual case and preference. All procedures are routinely performed on an outpatient basis. Outof-town patients are encouraged to arrange lodging accommodations nearby for follow up. Our staff would be happy to
assist in making these arrangements.
All patients receiving a sedative or intravenous sedation must be accompanied by a responsible adult who shall
transport and closely observe your progress during the first 24 hours after surgery. Preoperative medication to alleviate
anxiety is available and local/intravenous sedation may be recommended prior to your procedure.
Recovery times will vary from person to person and generally are dependant upon which surgical technique you choose
and the incisions required for that procedure. For example, an upper lid blepharoplasty requires an incision in the upper
eyelid fold. A lower lid blepharoplasty requires an incision below the lash line (external approach) or an incision within
the lower eyelid sill with extension to the lateral eye (transconjunctival). These incisions, being placed in natural skin
folds, go virtually unnoticed when completely healed. The protruding fat pouches, excessive muscle and loose skin are
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corrected through these incisions. Incisions hidden within the hairline tend to elevate the frontal hairline and elongate
the forehead. Incisions placed at the hairline, though more visible, preserve the forehead height.
The direct or midforehead brow lift procedure designed to remove skin above the brows and elevate the muscles around
the eyes to improve drooping of the brows themselves requires visible forehead incisions. The midforehead lift
procedure is most successful with men, since they usually have permanently etched horizontal forehead creases in
which to hide the resulting scars. Furthermore, many men experience some degree of hair loss, which prohibits the use
of a lengthy scalp incision. Forehead lifts performed in natural horizontal forehead creases, often take time to heal, and
result in a scar located within the crease. Direct brow lifts feminize the brow with an incision placed immediately
adjacent to the upper brow. This technique is used infrequently with women and only those with considerable forehead
wrinkling. With the direct brow lift incisions are placed immediately adjacent to the upper edge of the eyebrows. The
excessive skin above the brow is then removed and the brow advanced upward to its new position. This technique is
the most effective method for repositioning the brow, but it does feminize the appearance of the brows and has a visible
scar.
Today most patients opt for an operation that not only elevates the brow, but also diminishes the forehead wrinkles and
frown lines. The procedure, a forehead lift, may be performed as a traditional open or a closed endoscopic forehead
technique. The open technique requires an incision located either at the hairline or inconspicuously placed behind the
hairline. The elevated forehead skin is advanced upwards, repositioning the brows to a more superior rejuvenated
position with the excessive skin being removed. With the endoscopic closed technique, five small incisions are
performed in the natural upper eyelid crease are used to elevate the forehead with the utilization of fine instruments
through these supports. The forehead is shifted upward and posteriorly, and requires fixation techniques. This
technique does elevate the hairline and is indicated in individuals who require limited forehead management, are
younger, and have low hairlines. Often, after addressing the aforementioned brow and forehead problems, a certain
degree of excess upper eyelid skin may be corrected to achieve the desired results. Such excess upper eyelid skin is
removed with the belpharoplasty which may be performed in combination during a forehead lift technique or at a
separate time.
After the surgical procedure(s), all patients should expect some degree of swelling and bruising. This swelling may
involve the adjacent and lower facial areas. With extended forehead lift procedures, numbness above the incision into
the scalp occurs. This is usually temporary and recedes over a few months on the average. Itching of the scalp is
common during the healing process and you should refrain from rigorous scratching activity to avoid permanent scalp
trauma. Medication is available for symptomatic relief.
Risks/Complications
As with any surgical procedure, and despite the expertise and care rendered by the surgeon, certain risks can occur.
Surgical results cannot be guaranteed because eyelid/forehead surgery is not an exact science and the final results are
dependent upon the healing characteristics of each individual patient. Even when the surgeon uses the utmost surgical
skill and judgment during the procedure, postoperative complications can occur.
With forehead lifting techniques, slight overcorrection is practiced as upon resolution of swelling a certain degree of
relaxation of the forehead occurs. The initial healing process for eyelid/forehead surgery takes several days and
response to surgery is individual with respect to swelling and bruising, and it is not uncommon to experience emotions
of anxiety, melancholy, fatigue or even slight depression after a cosmetic procedure since there is isolation and a
recovery period required prior to appreciating the cosmetic result.
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Risks associated with cosmetic eyelid and forehead surgery may include anesthesia risks, reactions to medication,
infection, bleeding, poor healing, excessive scarring, skin loss, prolonged or recurrent swelling, hair loss (temporary or
permanent), nerve injury (forehead/scalp numbness or forehead weakness), hairline shifts, recurrence of deformity,
visual disturbance, loss or problems, eye irritation or dry eye syndrome, eyelid rounding, and others. Additional risks
may occur, though infrequent, will also be reviewed prior to surgery.
Fees
Fees for cosmetic surgery are usually not covered by insurance. Occasionally, upper lid blepharoplasty performed for
functional visual improvement may be covered by insurance, but requires appropriate testing preoperatively and
preauthorization. In this situation, the insurance company will be contacted prior to the procedure regarding payment
and approval.
Elective cosmetic surgery fees are required in advance of the proposed surgery to include the surgeon’s fee, anesthesia
provider fee and the surgery center fee.
I look forward to personally working with you for your cosmetic needs. Overall, you should realize that these surgeries
are very successful and are very commonly performed. I feel that it is important to communicate to you as my patient
so that you can make an informed and educated decision, and to have your anxieties alleviated prior to undertaking your
surgery. My staff and I will address any questions you may have and offer any support you need throughout your
recovery period.
Please acknowledge your review and understanding of this information by signing below.
_________________________________
Patient Signature
_________________________________
Peter M. Schmid, D.O.
________________________
Date
________________________
Date
PMS/rdc-5/23/11
Our philosophy at the Institute of Aesthetic Plastic & Reconstructive Surgery is that humans are unique individuals with
respect to our concerns, perceptions and goals to improve the appearance. Our primary goal is to provide specialized
and personalized patient care for correction and improvement of aging features.
During your initial consultation, your cosmetic inquiries and physical features will be reviewed and discussed. This
consultation will offer an educational process with respect to your unique aging changes and options to manage these
concerns, assessing the contributions of the forehead, brows and eyelids to the aging process. Facial asymmetries will
also be reviewed at that time as it is common to have uneven brow heights, eyelid creases and facial proportions.
Expertise, communication, experience with a variety of techniques, and an artistic vision are all necessary to achieve
successful, natural-looking results in any cosmetic treatment and surgery. Both state-of-art noninvasive and surgical
options are available, and will be discussed during your consultation.
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