THE FURROWED BROW 

In a previous article for this publication, I spoke about facial rejuvenation
surgery which, of course, is "anchored" by "Facelift", a
procedure probably first undertaken intentionally to improve facial appearance
some 75 or more years ago. While that procedure has undergone a variety of refinements
over that period of time, especially over the last decade or so, the common
denominator of all "Facelifts" remains the removal of excess facial
and neck skin through a somewhat lengthy incision beginning in the temporal
area of the scalp and continuing inferiorly (downward) along the ear and then
posteriorly (backward) into the mastoid area of the scalp. Were that incision
straightened, it would, in many individuals, translate to almost a foot in length.
Because it is hidden for the most part by hair in the temporal and mastoid areas
of the scalp and hugs the ear and usually proves to be very good to excellent
in just about anyone who undergoes the procedure, the resulting scar, once "mature",
proves difficult to identify even under adequate lighting by the most "critical" observer.
Advancements in recent years in facial rejuvenation surgery are not so much
a result of an improvement in "Facelift" as they are a function of
adjunctive surgical procedures which are "piggybacked" onto a "Facelift" and
which address areas of the aging face which a "Facelift", regardless
of the specific technique employed, cannot address. Perhaps the most significant
improvement in facial rejuvenation surgery is a result of the recognition of
the importance of brow position to overall facial appearance and the development
of surgical procedures to address brow position.
As we age our skin loses elasticity (not unlike a used rubberband) and the
resultant laxity or looseness of facial skin can impart a fatigued, worn
appearance to our faces. Perhaps just as important (if not more important)
to changes in
our facial appearance is the action of muscles of facial expression (known
as the "mimetic" muscles) upon facial skin. By virtue of their frequent
contraction and relaxation, they exert pull on the facial skin which translates
into lines of facial expression, specifically deep nasolabial folds (those
folds running from the sides of the nose to the corresponding corners of
the mouth
and beyond); perioral wrinkling (often known as "smoker's lines");
glabellar frown lines, situated in the lower forehead just above the nasal
bridge and between the medial (inner) ends of the eyebrows; and, of course,
horizontal
furrows of the forehead. I am amused by claims in the media of improvement
in one's facial appearance secondary to exercise of facial muscles since
exercise of such muscles translates into more - rather than less - prominent
lines of
facial
expression.
The actions of these facial muscles often result in an angry appearance and,
in the case of ptotic (droopy) eyebrows, a sinister appearance owing to hooding
of the eyes. The most effective solution to ptotic eyebrows is a Forehead (Brow)
Lift which begins with nothing more than a continuation of the bilateral "Facelift" incisions
from temple to temple. Generally the Forehead Lift incision is positioned well
posterior to or behind the frontal hairline so that the resulting scar (which,
like the "Facelift" scar, generally proves to be an excellent scar)
is well camouflaged by adjacent hair. High foreheads often call for a Forehead
Lift incision at the frontal hairline. The procedure then continues inferiorly
as the forehead skin is separated from underlying forehead muscles and lifted
in order to unfold the furrows within that skin or the forehead skin is lifted
in conjunction with the underlying forehead muscles to produce what some plastic
surgeons feel is an even longer lasting result in terms of improvement of forehead
furrows. Furthermore, those muscles which contribute to unpleasant glabellar
frown lines (known as the corrugator muscles) can be removed, thereby eliminating
the glabellar frown lines and preventing them from occurring again or at least
from becoming as prominent they were. Keep in mind that, unlike most muscles,
the muscles of facial expression are not essential to our physical well being
and function and some muscles (again like the corrugator muscles) can be eliminated
without harm.
Even though the Forehead Lift incision is less in length than is either one
of the bilateral "Facelift" incisions, I find that many patients to
whom I offer a Forehead Lift do not want to consider the procedure because I
suspect they associate an incision involving the coronal scalp (or the "crown" of
the head) with neurosurgery ("brain surgery") and assume that a Forehead
Lift is a much more drastic undertaking than is a "Facelift". In my
opinion, a Forehead Lift is even safer than is a "Facelift", owing
to the excellent vascularity of scalp and forehead skin/muscle which in turn
translates to excellent wound healing and owing to the relative absence of any
structures within the forehead which, if injured, could produce disability.
A variation of the Forehead Lift which is gaining popularity and which I employ
often is elevation of the eyebrows through upper eyelid incisions, usually undertaken
in conjunction with Bilateral Upper Blepharoplasty or surgery of both upper
eyelids. While such a procedure may not address forehead furrows, it does address
ptotic eyebrows and is particularly suited to men, especially balding men who
cannot accommodate a coronal scalp incision, or in men and women whose problem
is primarily ptotic eyebrows and hooding of the eyes rather than furrowed forehead
skin.
In most of us the forehead represents one-third (in some cases, more) of the
entire face, so undertaking a "Facelift" (which ordinarily does not
address forehead problems) alone in an individual in need of total facial rejuvenation
ignores a significant contributor to his/her unpleasant facial appearance.