Tuesday, February 16, 2016

How can I get my eyebrows to lift back up?

As we age (oh, that dreaded word), we sometimes notice that our eyebrows are beginning to droop, causing our eyelids to look heavier.  What can we do to fix this and why does it happen?  Similar to the drooping we experience in the lower face, jowls and neck, we see a loss of volume, specifically in the temples and above the brows, loosening of the fibromuscularature under the skin and loss of elasticity and collagen in the skin itself as being the prime factors.  Correcting some or all of these factors can give very pleasing and natural results.

Starting with the fibromusculature, there are several ways to achieve tightening of this layer.  First and most dramatic is a surgical or endoscopic eyebrow lift.  This is accomplished with an incision behind the hair line and lifting of the brow area much like a facelift.  If one wishes to avoid incisions and scars, recovery time, and the risk of an "overdone" appearance, there are several excellent noninvasive, nonsurgical options.  The best is Ultherapy.  Ultherapy delivers focused ultrasound energy directly onto the fibromuscular layer to cause a contraction and tightening to occur in this structure without having to suture it surgically.  The area treated is right above the eyebrow to the hair line.  Furthermore, Ultrasound energy is focused also into the deep dermis where it stimulates new collagen and elastin fiber formation.  Results are seen gradually over 4 to 6 months.  Cost for an Ultherapy brow lift procedure is $1500.  The lower eyelids can also be tightened for an additional charge.  If there is concurrent loosening and drooping of the upper eyelid, I recommend using Thermismooth, Exilis elite or Thermage to tighten the eyelid skin.  Ultrasound can not be used so close to the eye area.  Thermismooth, Exilis elite and Thermage are all monopolar radio frequency procedures which heat the skin to a target temperature of 42-44 degrees, inducing new collagen and elastin fiber formation.  The heat also likely affects the ligaments and fascia inducing a contraction within those tissues.  These radiofrequency procedures range from $650-$3500 depending on the technology used.  None of these procedures have any recovery time outside of mild redness and swelling from a few hours to a day.  Make up and  moisturizer can be worn immediately and all normal and strenuous activities can be resumed right away.  Patients can return to work and social activities immediately.  Possible side effects could include bruising, temporary sensation changes such as numbness or a possible skin burn.  While very effective, results can be dramatic or subtle from patient to patient.  Experience in administration and delivering the energy at the correct angle and temperature and time all work to give a superior experience and result for our patients.

Next, we can use fillers.  Fillers are made of natural safe ingredients such as sugar polymers (hyaluronic acid) or calcium particles.  Some of the fillers you may have heard of include Juvederm, Juvederm Ultra, Juvaderm UltraPlus, Volume, Restylane, Perlane and Radiesse.  I have not once seen an allergic reaction from fillers and allergy testing is not required.  Care must be taken that the filler is not injected into a blood vessel or near a neurovascular bundle as it could cause occlusion to these structures.  It's important to choose an experienced injector for this procedure.  Placement is of greatest importance with fillers.  The fillers will last anywhere from about 1 year to 2 years.  For a longer lasting result, I will use Bellafilll in patients who have already experienced fillers and are ready for a more permanent result.  To achieve a brow lift with a filler, I recommend first checking the temple area.  We often see hollowing of this area--the temples begin to look concave versus the youthful convex shape.  Adding volume back to the temples is very gratifying as it helps the brows and also helps to give a lift to the lower face.  The second area to inject is right under and right above the eyebrow itself.  This gives an instant lift to the eyebrow.  There's a small chance of bruising, but can be easily covered with makeup if that does occur.  Cost for filler is $500 and up per vial and several vials of filler may be required to get the right effect.  We will often combine a noninvasive approach such as Ultherapy, Thermage, Thermismooth or Exilis elite with a filler to get immediate and best results.

Another procedure I really like is called ThermiRase.  ThermiRase is a unique procedure using a small probe in the temple area right under the skin via a tiny needle puncture.  I can identify the nerve that causes the brows to move downwards towards the middle of the forehead.  This occurs when one looks angry or is frowning or concentrating.  We often Botox in this area to relax this tense expression and help soften the vertical lines that form between the brows called the elevens.  With ThermiRase, the probe rests directly on the nerve that causes the contraction and zaps it with direct heat, disabling the nerve.  If I can disable about 2 cm of this nerve, it rarely grows back and gives a permanent Botox like effect for the frown lines.  Eliminating the frown expression gives an immediate lift to the eyebrows as the downward pull from the frown muscles is eliminated.  If one is not ready for ThermiRase, of course Botox itself will also give a beautiful brow lift.  Botox will last about 3-4 months, but may not be required as frequently with consistent use, as it relaxes the muscle and the muscle memory or tetany.   Adding a little Botox to the RIGHT areas in the forehead and the lateral brow can give an amazing instant brow lift.  The right areas is emphasized because if injected into the wrong muscle groups, it can do the opposite and cause the brows to droop.  Fortunately, this very rare possibility completely reverses itself within a few weeks if it does occur.   Again, an experienced injector is key.

If one has wrinkles, extensive sun damage, and laxity of the skin, laser skin resurfacing works beautifully to rejuvenate the top layers of the skin and tighten the skin as well for a very dramatic beautiful result.  Recovery time can be from 4-10 days varying on the technology used and depth of laser ablation.  This is the only procedure with any significant recovery time issues.

I hope this is helpful in sorting out some of the options for brow lift.  I will mention but not recommend another procedure out there using threads under the skin to pull tissue up.  I used to do these types of treatments many years ago, but do not offer them any longer as the threads are not strong enough to get any type of long lasting benefit.  The problem is the thread may or not pierce and grab hold of the fibromuscular layer.  Usually it only travels through the subcutaneous fat which does not grab and hold the suture well.  With an exaggerated movement, it is easy to loosen the sutures under the skin and loose the intended effect.

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