The ideal female brow lies above the bony rim above the eye, has an arch that peaks at the outer part of the cornea (colored part of the eye), the lateral extent lies in a diagonal from the outer part of the nose through the outer corner of the eye, and both the inside and outside extent are at the same level. In the male, the brow lies at the bony rim in a horizontal fashion with less of an arch, is more full, and both the inside and outside extent are at the same level.
With age the brow begins to drop, and the outside corner turns downward. WIth excess ptosis (drooping), the brow can push down on the upper eyelid and even begin to obstruct your vision. It is important to distinguish between the brow and the upper eyelid as the cause for a “tired” eye as the treatment, although complimentary, differs.
When it comes to raising the brow there are many options depending on your individual anatomy. From a non surgical standpoint you can use a neuromodulator like Botox or Dysport to help raise up the outer corner of the eyebrow a millimeter or two. This is accomplished by relaxing a muscle that is pulling down on the brow as there is no muscle on the outside pulling it up. For a longer lasting result, there are various surgical approaches to reposition the eyebrow.
The first option is the direct approach. This involves making an incision directly above the eyebrow. This is very rarely chosen as it leaves a noticeable scar, but for patients with facial paralysis and one eyebrow drooping, it can be a great option. The benefit as this is the most effective to predictably raise the brow, but the resulting scar is not usually acceptable.
The second option is the indirect or mid forehead approach. This involves making two separate incisions in wrinkles present in the forehead. This is only an option for patients with very deep forehead wrinkles that would hide the incisions. Similarly to the direct approach, it can reliably raise the brow, but the scar is not usually acceptable except as noted above.
The third option is the pretrichial (just in front of the hairline) incision. The nice part about this incision is that it can help to lower a high hairline at the same time that it raises the brows. It does lead to temporary and in some cases permanent numbness of the top of the head, but can do a nice job raising the brow and lowering the high hairline.
The fourth option is the coronal incision. This is similar to the pretrichial approach except the incision is about an inch farther back within the hair. This is nice in that it completely hides the incision, but it does raise the hairline which may not always be a good option. It also has the same risk of numbness as the pretrichial approach.
The fifth option is the temporal incision. This is useful when just the outer corners of the brows have fallen. This incision is within the hairline but is much smaller than the coronal or pretrichial incisions. This is often included as part of a facelift.
The final option is the endoscopic approach. This involves the use of several smaller incisions within the hairline and using endoscopic cameras to raise the brows. The nice thing about this is that it hides all of the incisions within the hairline and the risk of numbness is less. However, the longevity of this lift is not as long as the other techniques.
Each approach has pros and cons, and Dr. Guy will recommend the most appropriate one for you based your desires and physical characteristics in the consultation.