Breaking the Brow into Subunits: Designing a Brow for Cosmetic Improvement

In a previous blog we discussed why low, full brows are sexy, youthful and attractive. In this blog, we will delve into the exact subcomponents of a brow that need to be filled to achieve that look.  I break the brow into multiple points depending on whom I am filling and to what extent in each area.  To summarize some basic goals, I am trying to create visible soft-tissue convexity in just the right areas and to manage areas of depression and bone exposure.  What bone exposure I am talking about is the bone of the orbital rim (think of a skull).  The bone around the eye that starts to become visible over time actually looks quite dreadful and older, and believe it or not but our brains can actually make the distinction between what is soft tissue and what is hard tissue (or bone).

Perhaps the most important area to fill is the lateral brow (the area of the brow outside toward the ear).  When I speak of the brow, I am not talking about the hairy eyebrow but the entire complex of soft tissue that resides between the hairy eyebrow and the upper eyelid.  This soft-tissue convexity when present creates a youthful appearance that captures light beautifully as it bounces off of it.  If you don’t understand this, find a youthful, attractive face and look for this feature that should almost always be present.

Another area of importance is the transition between the brow to the upper eyelid, i.e., the bone line that can be seen as one goes over the upper bony orbital rim.  This shadow of bone to me is very important to soften and to augment so that the concavity and bone exposure is filled in nicely.  Further inward toward the nose (what we call medial as physicians), there can be a dip that looks like an A shape, which we call an A-frame deformity.  This deformity exists in individuals with advanced aging who are very, very hollow or interestingly enough in those who have had traditional blepharoplasty in which a lot of skin and fat have been excessively removed.  Yes, I believe that traditional eyelid surgery can actually age a person further rather than make one look younger.

Deciding what to fill and how much clearly is a decision based on artistry and design that I execute almost on a daily basis.  I use both fat and fillers (temporary and permanent) to create works of art in which individuals look better and more youthful but always look like themselves.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum

When Do I Do an Upper-Eyelid Blepharoplasty and How?

But should we always just add fillers or fat to the upper frame of the eyelid and never remove any tissues?  The answer is no.  If the eyelid skin is above the eyelash margin, I rarely if ever remove skin.  Filling fat or fillers into the upper eyelid and soft-tissue of the brow is sufficient to make the eyelid look more youthful, even if this is not immediately intuitive.  If the eyelid skin edge is crêpey in appearance or hangs low, a combination of some skin removal with fat transfer is ideal for the best results.  However, if I had a choice based on a patient’s budget I would still rely on fat grafting as the principal method to make the upper eyelid better.  Because I remove so little skin and never fat or muscle from the upper eyelid, the eyelid crease height should change very little from its current and youthful position (which preserves identity and enhances youth) but also the individual can still close her eyes.  Unfortunately, I see too many individuals who have been subjected to traditional eyelid surgery that prevents their eyelids from closing, which can be dangerous especially when one is sleeping.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum

Like the upper eyelid, I find myself performing many more fat transfers to correct the aging process than traditional eyelid surgery.  Further, if I perform a traditional lower-eyelid procedure I will almost always use some fat transferred to improve the result.  In fact, I look at traditional eyelid surgery as a complement to fat transfer, rather than the other way around.

There are two principal ways to manage the lower eyelid traditionally, either a skin-muscle procedure in which there is an external incision or through what is known as a transconjunctival approach that has no skin incision.  I prefer the latter approach not to limit the risk of scarring, which is pretty minimal, but to avoid changing the shape and contour of the lower eyelid.  When surgeons use a skin-muscle flap, they must tack the suture to the lining of the bone.  When that occurs, there can be slight inaccuracy or change during the healing process such that the canthus (where the upper eyelid meets the lower eyelid) can be altered so the person does not look the same or worse yet does not look natural.  For this reason, I almost never make an incision in the lower eyelid skin if I can avoid it.

I use the analogy of the typical eyebags as “rocks” that appear only when the tide (fat level) is low and so the way to manage the eyebag is to refill the tide (fat) to a higher level to cover it up.  This works in about 90% of individuals.  At times however the eyebag is so prominent that you simply cannot cover it up with fat.  In these cases, which are less than 10% of the time, I have to remove some fat at the same time that I add it below the existing fat.  This combination of reducing the rocks and increasing the tide can help effect the most favorable desired change for a smoother result in the lower eyelids.

I have been asked though what about the wrinkles?  That is a matter for neurotoxin (Botox) and laser skin resurfacing to help manage the aging of the skin.  I believe cutting away wrinkles surgically simply does not work and can contribute to the problem mentioned above of changing the eyelid shape, which is a terrible thing.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum.

One of the most confusing things that I have encountered is how to manage the aging Asian eyelid.  The reason for this is twofold.  First, if an Asian is born without an upper-eyelid crease where do you make the incision so that you don’t have a visible scar?  Second, when you remove skin from the upper eyelid of an Asian, you raise the position of the crease, which may look okay in a non-Asian (I would disagree) but it can look absolutely fake in an Asian because Asians typically are not born with high eyelid creases.

I have divided the management into three clinical scenarios:  Asians who are born with a natural crease, Asians who are born without a crease (or a very partial crease), and Asians who have had a surgically created crease made for them in the past. In the first clinical scenario, Asians who are born with a crease may be viewed just like a white person, i.e., one could simply remove skin.  And that is true.  However, the problem is, as mentioned, when skin is removed, the eyelid crease can ascend to the point that it looks unnatural.  In my opinion if I just put fat into the eyelid and brow in an Asian, I am able to make that individual appear much more youthful but at the same time maintain his or her eyelid crease height at a normal or natural position.  In an Asian that has a very low hanging skin that folds over the eyelash margin, I will remove skin from that person but almost always in conjunction with adding fat to the upper eyelid at the same time to maintain the crease position so that it does not artificially go too high.

In an Asian born without an eyelid crease, the biggest mistake is to try to remove skin, for two reasons.  First, since there is no natural position where the skin creases over, there is no place to make the cut.  When you arbitrarily define a line for incision, you can see the scar and if you try to take fat out, you can create a partial crease adhesion so that the person develops a partial crease.  That is a bad thing because it can change the person’s appearance and at the same time still the individual does not have a definable crease.  If you try to make the incision very long along the eyelash margin, the problem is unpredictable scarring, as the incision should never be placed there in the first place.  Interestingly, because one has a narrower eyelid opening that one has when one does not have a crease even removing skin from the upper eyelid does not help to make the eyelid position really look more open, which disappoints patients.  There are two ways then to manage this situation of an Asian without a crease.  First, one can make a crease, which can truly make the eyelid appear more youthful.  The problem with this approach is that it does change the way an eyelid appears from when that person was youthful (if that is ok with the patient).  Furthermore, there can be a long recovery period when creating an upper-eyelid crease, and the patient must know that.  The second way to rejuvenate an Asian eyelid without a crease is simply to add fat or fillers, which can plump up the eyelid to make it more youthful in appearance without any incisions.

The final scenario is an Asian who had a crease made in the past.  If the crease were made only a few years ago, then typically the creases made during the period from the 2000s forward were quite natural.  In the 1980s however the creases made were quite artificial in nature since a lot of skin and fat were removed and the creases were made artificially too high.  Interestingly, over time many of these eyelids start to descend and the crease can actually look low again.  The problem of removing eyelid skin at this point is that one can then unmask the previously bad result and at times even make the result look more unnatural in appearance.  The reason for this is that in fact when one is removing the upper-eyelid skin one is actually just removing brow skin, which is thicker and unnatural.  If the surgeon has a question as to whether it was an old-style Asian blepharoplasty or a new one, all one need to do is to lift up the eyelid skin to evaluate the height of the crease to determine if it was made unnaturally in the past or not.  This algorithm will hopefully help Asian patients seeking eyelid rejuvenation and also help surgeons seeking to help Asian patients with eyelid rejuvenation.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum.

High or Low Brows?:  What is Sexier for Men and for Women?

I am reading a book called Survival of the Prettiest by Nancy Etcoff in which she says studies have shown that a higher brow actually looks less attractive to subjects who viewed various individuals with different brow heights.  A low brow was considered sexier, more alluring, and more attractive.  We know that to be true in men like Tom Cruise who has a low brow but this may be surprising information when we talk about women who think that a high-arched brow is the way to go.  I am not arguing that a very low deflated brow is attractive because an individual who is experiencing some aging will naturally pull up on the deflated brow and say, “Don’t I look better?”  And the answer would be a qualified yes.  However, we need to compare apples and apples rather than apples and oranges.  A brow that looks sagging actually is just plain empty.  I have used the analogy of a balloon deflating to have someone understand why an older brow actually looks sagging but in fact is just empty.  That is why I no longer do browlifts, occasionally do eyelid surgery but almost always put some degree of volume whether with fat grafting or fillers into the brow area.  A lower, fuller brow is the answer to a more attractive brow contour and position for both men and for women.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ Brow Lift Procedures or to ask Dr Lam a question please visit his plastic surgery forum.