Forehead Lift

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

A forehead lift is a cosmetic surgery procedure intended to improve a person’s appearance by correcting the shape of the eyebrows and reducing horizontal wrinkles or furrows in the skin of the forehead. It is also known as a brow lift.

Purpose

The purpose of a forehead lift is improvement of the patient’s external appearance, particularly with regard to the upper third of the face. Some people have clearly marked frown lines or drooping of the eyebrows or eyelid caused by loosening of the tissues and muscles around the eyes during the aging process. The drooping of the eyelid is sometimes referred to as ptosis, which comes from a Greek word meaning “fall.” In some cases, these signs of aging make the person look angry, anxious, or sad. A forehead lift is not done to cure disease or repair a major wound or injury.

Demographics

Like other cosmetic surgery procedures, forehead lifts are performed much more frequently than they were even a decade ago. According to the American Society of Plastic Surgeons (ASPS), the number of forehead lifts performed in the United States has risen 172% since 1992. These changes are attributed in part to concerns about appearance in the so-called baby boomer generation. Adults born between 1945 and 1960 are generally more image-conscious than previous generations of Americans. In addition, newer surgical techniques have made forehead lifts less painful, easier to perform, and less likely to have complications.

Most plastic surgeons recommend that a forehead lift should be done when the patient is between 40 and 60 years old, although it is sometimes done on younger patients who have very deep frown lines due to stress or have inherited very low and heavy brows. In addition, people whose facial skin has aged prematurely due to sun exposure or heavy smoking may be candidates for a forehead lift in their mid-30s. In 2002, the average age of patients of either sex who had forehead lifts done in the United States was 47.

Statistics published by the American Academy of Cosmetic Surgery (AACS) in January 2003 indicate that although more men are choosing to have cosmetic surgery than in the past, the female:male ratio for forehead lifts is still 6:1. In 2002, surgeons who are AACS members performed 7,882 forehead lifts on women compared to 1,139 procedures on men. Forehead lifts account for a little less than 1% (0.96%) of all cosmetic surgery procedures performed each year in the United States and Canada.

The American Society of Plastic Surgeons reported that a total of 1,852,012 cosmetic procedures and 9,138,275 nonsurgical procedures were performed in the United States in 2006, totaling almost 11 million procedures. Of that number, 52,525 were forehead lift procedures.

Although most forehead lifts and other facial cosmetic procedures are still performed on Caucasian patients, this type of surgery is gaining rapidly in popularity among Hispanics, Asian Americans, and African

KEY TERMS

Blepharoplasty— Plastic surgery performed on the eyelids.

Body dysmorphic disorder (BDD)— A psychiatric condition marked by excessive preoccupation with an imaginary or minor defect in a facial feature or localized part of the body. Many people with BDD seek cosmetic surgery as a treatment for their perceived flaw.

Botulinum toxin— A toxin produced by the spores and growing cells of Clostridium botulinum. It causes muscle paralysis, therefore this toxin can be used to reduce frown lines by temporarily paralyzing the muscles in the face that contract when a person frowns or squints.

Collagen— A type of protein found in connective tissue that gives it strength and flexibility. Collagen derived from cattle can be injected into wrinkles or lines in the face as an alternative to cosmetic surgery.

Cosmetic surgery— Surgery that is intended to improve a patient’s appearance or correct disfigurement. It is also called aesthetic surgery.

Endoscope— An instrument that allows a surgeon to look underneath skin or inside a hollow organ while performing surgery.

Ptosis— The medical term for drooping of the upper eyelid.

Americans. Between 1999 and 2002, the proportion of cosmetic procedures performed on Hispanics has increased by 200%, on African Americans by 323%, and on Asian Americans by 340%. As of 2003, Caucasians account for only 77% of patients having elective facial surgery, compared to 83% in 1999.

Description

There are two main types of forehead lifts. The classic, or open, forehead lift involves a long incision along the top of the forehead and lifting of the skin of the forehead. The second type of forehead lift, known as an endoscopic lift, is performed with special instruments inserted through four or five small incisions behind the hairline.

In some cases, a forehead lift is combined with plastic surgery on the eyelids (blepharoplasty) or with a face lift.

Classic forehead lift

The classic forehead lift takes about one to two hours and may be performed with either general or local anesthesia. After the patient has been anesthetized, the surgeon makes a long incision across the top of the scalp from ear to ear. The exact location of the incision depends on the condition of the facial muscles to be removed or modified and the position of the patient’s hairline. The most common type of incisionin an open forehead lift is a coronal incision, which is made slightly behind the hairline. A second type of incision is called a pretrichial incision. It is similar to the coronal incision except that the central part of the incision lies directly on the hairline. A third type of incision, which is used mostly on male patients with very deep forehead creases, is placed directly inside the creases in the mid-forehead.

After the incision has been made, the surgeon lifts the skin of the forehead very carefully and cuts away excess underlying tissue. Some of the muscles that cause frowning may be loosened (released) or altered. If necessary, the brows will be lifted and excess skin along the line of the incision will be trimmed away. The incision is usually closed with stitches or staples, although some surgeons use tissue glues to hold the skin in place. The patient’s face is then carefully washed to prevent infection and irritation. Some surgeons prefer to cover the incision with a gauze dressing held in place by an elastic bandage, but others do not apply any dressing.

One disadvantage of the classic forehead lift from the standpoint of male patients is that men’s hairstyles will not usually cover the incision scar. It is easier for women, even those who prefer to wear their hair very short, to let the hair grow for several weeks before the procedure so that it will be long enough to cover the scar.

Endoscopic forehead lift

An endoscopic forehead lift is performed with the help of an endoscope, which is an instrument designed to allow the surgeon to see the tissues and other structures underneath the skin of the forehead. Instead of making one long incision, the surgeon makes four or five shorter incisions, each less than an inch (2.5 cm) long. The endoscope is inserted through one of these incisions; the others are used for the insertion of instruments for removing excess tissue and reshaping the facial muscles. If the eyebrows are being lifted, they may be kept in place in their new position by tiny stitches under the skin or fixation tacks placed behind the hairline. The incisions are closed and the patient’s face washed and dressed in the same way as in the classic forehead lift.

Diagnosis/Preparation

Diagnosis

It is somewhat misleading to speak of diagnosis on the context of forehead lifts and similar procedures because cosmetic surgery is unique in one respect—it is the only type of surgery in which the patient initiates “treatment” rather than the doctor. This difference means that many plastic surgeons now screen patients for psychological stability as well as general physical fitness for surgery. Beginning in the 1970s and 1980s, psychiatrists began to see patients who were obsessed with a particular facial feature or other small part of their body, as distinct from over-concern about weight or general body shape. This condition, which is called body dysmorphic disorder (BDD), became an official psychiatric diagnostic category in 1987. Patients with BDD frequently seek plastic surgery as a solution for their dissatisfaction with their looks; however, in many cases, the “flaw” that the patient sees in his or her face is either exaggerated or nonexistent. Ironically, although men are less likely than women to request facial surgery, a higher percentage of male cosmetic surgery patients are emotionally disturbed; one survey of plastic surgeons estimated that six out of every 100 female patients and seven out of every 100 male patients meet the diagnostic criteria for BDD.

When a person consults a plastic surgeon about a forehead lift or similar procedure, the doctor will spend some time talking with the patient about his or her motives for facial surgery as well as taking a general medical and surgical history. Good candidates for facial surgery are people who have a realistic understanding of the risks as well as the benefits of this type of surgery, and equally realistic expectations of the outcome. On the other hand, the following are considered psychological warning signs:

• The patient is considering surgery to please someone else, most often a spouse or partner.
• The patient expects facial surgery to guarantee career advancement.
• The patient has a history of multiple cosmetic procedures and/or complaints about previous surgeons.
• The patient thinks that the surgery will solve all his or her life problems.
• The patient has an unrealistic notion of what he or she will look like after surgery.
• The patient seems otherwise emotionally unstable.

If the surgeon thinks that the patient is a good candidate in terms of motivation, he or she will continue the diagnostic assessment by examining the patient’s face at close range. To make an initial evaluation of the possible results of a forehead lift, the surgeon will gently lift the skin at the outer edges of the eyes above the brows in an upward direction. He or she may also ask the patient to look in a mirror and describe what they don’t like about their face. Next, the surgeon will ask the patient to frown, smile, or make a variety of other facial expressions. This technique allows the surgeon to observe the activity of the patient’s facial muscles. Depending on the amount of loose skin in the upper eyelid, the height of the patient’s hairline, and the relative position of the eyebrows, the surgeon may recommend a blepharoplasty or other procedure instead of a forehead lift.

Preparation

Preparation for a forehead lift involves practical as well as medical concerns.

FINANCIAL CONSIDERATIONS. Most cosmetic facial procedures are not covered by health insurance because they are regarded as nonessential elective procedures. As a result, many cosmetic surgeons request that fees be paid in full before the operation. According to the AACS, 13.4% of cosmetic surgery patients take out loans to finance their procedure. In 2002, the average cost of a forehead lift was $3,300.

MEDICAL AND HOME CARE ISSUES. A patient scheduled for a forehead lift will be asked to prepare for the operation by quitting smoking and discontinuing aspirin or any other medications that thin the blood. The surgeon will ask for a list of all medications that the patient is taking, including alternative herbal preparations and prescription drugs, to make sure that there will be no interactions with the anesthetic.

Patients are advised to have someone drive them home after the procedure and help them with routine chores for a day or two. If the forehead lift is combined with a face lift or blepharoplasty, the surgeon may have the patient remain in the hospital overnight. Although cosmetic surgery on the face does not interfere with walking or routine physical activity, most patients tire easily for the first few days after the procedure.

Aftercare

Classic forehead lift

Aftercare for a classic forehead lift is somewhat more complicated than for an endoscopic procedure. Pain or numbness around the incision is likely to last longer than for an endoscopic procedure. It is controlled with prescription medication. Patients are usually advised to keep the head elevated for two to three days after surgery to minimize swelling. Bandages are removed a day or two after the procedure; stitches or staples are taken out between 10 days and two weeks after surgery. The patient is asked to rest quietly for one or two days after surgery. Most patients can return to work after a week or 10 days.

Endoscopic forehead lift

Fixation devices around the eyebrows are usually removed within 10 days after endoscopic surgery. As of early 2003, new absorbable fixation tacks that do not require later removal are being used with good results.

Patients who have had either type of forehead lift should not wash their hair until the bandage or dressing is removed, usually within two days. Heavy lifting, vigorous athletic activity, sexual activity, or any type of exertion that raises the blood pressure should be avoided for five to six weeks after the surgery. The skin around the incision should be protected from direct exposure to the sun for at least six months, because the new tissue is much more vulnerable to sunburn than normal skin. Most surgeons advise patients to use a sunblock cream to protect the skin even after the first six months.

Patients can use a special camouflage makeup to cover the bruising or swelling that often occurs after surgery, although they should be careful to keep the makeup away from the incision. Most of the bruising and other signs of surgery will fade within about three weeks.

Risks

Major complications of a forehead lift are unusual. The most common risks from the procedure are as follows:

• Headaches for a day or two after surgery. This complication is much more common with a classic forehead lift than with endoscopic surgery.
• Mild pain around the incision for a few days after surgery.
• Numbness or itching sensations on the top of the scalp. These may last for as long as six months after surgery.
• Mild bruising or swelling around the eyelids and cheeks.
• Hair loss or thinning in the area of the incision. The hair will usually regrow within a few weeks or months.
• A feeling of numbness or dryness in the eye.
• Loss of function of the eyelid. This complication is corrected by another operation.
• Bleeding or infection. These are rare complications with forehead lifts.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A forehead lift is a specialized procedure performed only by a qualified plastic surgeon. Plastic surgeons are doctors who have completed three years of general surgical training followed by two to three years of specialized training in plastic surgery after completing their M.D. or D.O. degree.

A forehead lift may be performed either in a hospital or in an outpatient clinic that specializes in cosmetic surgery. Most endoscopic forehead lifts are performed in outpatient facilities.

Normal results

Normal results of a forehead lift are an improvement in appearance that is satisfying to the patient. Specifically, the forehead should look less creased or wrinkled and frown lines should be lighter. The cosmetic effects of a forehead lift last between five and 10 years, depending on the person’s age and the condition of their skin when the procedure was performed.

Morbidity and mortality rates

In general, mortality and morbidity rates for forehead lifts and similar facial cosmetic procedures are very low. Almost all cases of mortality following facial cosmetic surgery involve patients who were treated for facial disfigurement because they had been severely burned or attacked by animals. Moreover, many plastic surgeons do not consider morbidity and mortality rates to be as significant as other factors in evaluating the success of facial cosmetic procedures. One group of researchers at the University of Washington maintains that “[t]he most important measures of outcome in facial cosmetic surgery are quality of life and patient satisfaction, in contrast to other, more objective measures such as complications or mortality rates.”

Several American studies have reported that the rate of complications is no higher when a forehead lift is done in combination with other facial procedures than when it is done by itself.

Alternatives

Soft tissue fillers

Alternatives to surgical treatment for frown lines and wrinkles of the forehead include injections of filler materials under the skin to smooth wrinkles or injections of botulinum toxin to paralyze the facial muscles

QUESTIONS TO ASK THE DOCTOR

• How many forehead lifts have you performed?
• Should I consider combining the forehead lift with a face lift?
• Am I a candidate for an endoscopic forehead lift?
• Would I benefit from nonsurgical alternatives to a forehead lift?
• How long can I expect the effects of this surgery to last?

involved in frowning or brow wrinkling. The most commonly used filler materials are collagen and fat. Collagen is a protein found in human and animal connective tissue that makes the tissue strong and flexible. Most collagen that is used for cosmetic injections is derived from cattle, which produces allergic reactions in some people. Fat injections use fat taken from the patient’s abdomen, thighs, or buttocks. The fat is then reinjected under the skin of the forehead to smooth out lines and wrinkles.

One drawback of both collagen and fat injections is that the effects are not permanent. Some new injectable filler substances are said to be permanent wrinkle removers. They include Artecoll, which contains small plastic particles that supposedly stimulate the body to produce its own collagen; and Radiance, which is made of a chemical called calcium hydroxylapatite. Still other injectable tissue fillers are made from synthetic hyaluronic acid, which has been used for a number of years to treat joint pain. Since hyaluronic acid is produced naturally in the body, allergic reactions to this type of tissue filler are relatively rare.

Botulinum toxin

Botulinum toxin is a compound produced by the spores and growing cells of the organism that causes botulism, Clostridium botulinum. The toxin causes muscle paralysis. It was first used clinically in the 1960s to treat neurological disorders but also proved to be effective in paralyzing the facial muscles that cause crow’s feet and frown wrinkles. Botulinum toxin, or Botox, was approved by the U.S. Food and Drug Administration (FDA) in April 2002 as a treatment for facial lines and wrinkles.

Both soft tissue fillers and Botox injections are regarded as effective though temporary alternatives to a forehead lift for reducing frown lines. Collagen injections must be repeated every three to six months, while Botox injections are effective for about four months.

Resources

BOOKS

Engler, Alan M. BodySculpture: Plastic Surgery of the Body for Men and Women, 2nd ed. New York: Hudson Publishing, 2000.

Irwin, Brandith, and Mark McPherson. Your Best Face Without Surgery. Carlsbad, CA: Hay House Inc., 2002.

Man, Daniel. New Art of Man. New York: Beauty Art Press, 2003.

Papel, I. D., J. Frodel, G. R. Holt, W. F. Larrabee, N. Nachlas, S. S. Park, J. M. Sykes, and D. Toriumi. Facial Plastic and Reconstructive Surgery, 2nd ed. New York: Thieme Medical Publishers, 2002.

PERIODICALS

Dayan, S. H., S. W. Perkins, A. J. Vartanian, and I. M. Wiesman. “The Forehead Lift: Endoscopic Versus Coronal Approaches.” Aesthetic Plastic Surgery 25, no. 1 (January–February 2001): 35–39.

De Cordier, B. C., J. I. de la Torre, M. S. Al-Hakeem, et al. “Endoscopic Forehead Lift: Review of Technique, Cases, and Complications.” Plastic and Reconstructive Surgery 110, no. 6 (November 2002): 1558–1568.

Landecker, A., J. B. Buck, J. C. Grotting, and B. Guyuron. “A New Resorbable Tack Fixation Technique for Endoscopic Brow Lifts.” Plastic and Reconstructive Surgery 111, no. 2 (February 2003): 880–890.

Morgenstern, K. E. and J. A. Foster. “Advances in cosmeticoculoplastic surgery.” Current Opinion in Ophthalmology 13, no. 5 (October 2002): 324–330.

Most, S. P., R. Alsarraf, and W. F. Larrabee, Jr. “Outcomes of Facial Cosmetic Procedures.” Facial Plastic Surgery 18, no. 2 (May 2002): 119–124.

Namazie, A. R., and G. S. Keller. “Current Practices in Endoscopic Brow and Temporal Lifting.” Facial Plastic Surgery Clinics of North America 9, no. 3 (August 2001):439–451.

Paul, M. D. “The Evolution of the Brow Lift in Aesthetic Plastic Surgery.” Plastic and Reconstructive Surgery 108, no. 5 (October 2001): 1409–1424.

OTHER

“Browlift.” American Society of Plastic Surgeons. http://www.plasticsurgery.org/public_education/procedures/Browlift.cfm (February 2008).

“Forehead Lift.” American Society for Aesthetic Plastic Surgery. http://www.surgery.org/public/procedures/forehead_lift (February 2008).

Sclafani, Anthony P., and Kyle S. Choe, MD. “Psychological Aspects of Plastic Surgery.” eMedicine. August 29, 2006. http://www.emedicine.com/ent/topic36.htm (February 28, 2003).

Siwolop, Sana. “Beyond Botox: An Industry’s Quest for Smooth Skin.” New York Times March 9, 2003. http://query.nytimes.com/gst/fullpage.html?res=9806EFD7FF93AA35750C0A9659C8B63 (March 9,2003).

ORGANIZATIONS

American Academy of Cosmetic Surgery, 737 North Michigan Avenue, Suite 820, Chicago, IL, 60611-5405, (312) 981-6760, http://www.cosmeticsurgery.org.

American Academy of Facial Plastic and Reconstructive Surgery, 310 S. Henry Street, Alexandria, VA, 22314, (703) 229-9291, http://www.aafprs.org/.

American Board of Plastic Surgery, Seven Penn Center, Suite 4001635 Market Street, Philadelphia, PA, 19103-2204, (215) 587-9322, http://www.abplsurg.org/.

American College of Surgeons, 633 North Saint Claire Street, Chicago, IL, 60611, (312) 202-5000, http://www.facs.org/.

American Society for Aesthetic Plastic Surgery, 11081 Winners Circle, Los Alamitos, CA, 90720, (888) 272-7711, http://www.surgery.org/.

American Society of Plastic and Reconstructive Surgeons, 444 E. Algonquin Road, Arlington Heights, IL, 60005, (847) 228-9900, http://www.plasticsurgery.org.

Rebecca Frey, Ph.D.

Laura Jean Cataldo, R.N., Ed.D.