“The eyes are the window to the soul,” or so goes the common aphorism. Much less discussed in polite conversation is the impact of the eyebrows on attractive eyes. Intuitively, women today understand the importance of eyebrow grooming on a youthful appearance. Makeup, tattoos, plucking, threading, shaping, and even latisse for thin eyebrows are common techniques used today. Unfortunately, certain forehead shapes, sun damage or smoking premature age the eyebrows and forehead leading to a “tired” or “sad” around the eyes. Patients can even experience headaches from overuse of forehead muscles to compensate for drooping. Fortunately, today a plethora of techniques are available to rejuvenate the upper face and eyebrow region without that “surprised” look of the past.
A pleasing look to the eyebrows and the face is based on the concept of the “Golden Ratio” originally defined by Luca Pacioli in his treatise De divina Proportione as early as 1509. This contemporary and collaborator of Leonardo Da Vinci influenced aesthetic analysis in Art, Architecture and Mathematics for centuries thereafter. This influence has continued in Aesthetic Surgery today. Intuitively, our eyes can pick up when a face, body, or structure is in proportion or balance. Objects, buildings and faces that are more symmetrical and balanced are perceived as more pleasing. The Face is typically divided into three zones, the upper face, midface and lower face. These three zones should roughly be equal in length and the width of the face should be 66.7% of the length of the face and symmetrical. Leonardo Da Vinci’s diagrams about these proportions and “Golden Ratio” continues to influence us today even with respect to brow shaping. The lateral third of the eyebrow should be the highest zone taper off gradually as you move laterally and the medial two thirds should slope gently down to the bridge of the nose. In women, the lateral brow should be 0.5-1.0 cm above the boney rim and 0-0.5 cm in men. The further away we move from these ideals as demonstrated in Leonardo Da Vinci’s early drawings, the eye perceives an imbalance that is not pleasing.
For most patients, salon and spa eyebrow services at some point become less effective for shaping the eyebrows. Over plucking can lead to thin eyebrows that sometimes need to be treated with Latisse in an “Off FDA Label” application. Tattooing can lead to unnatural shapes or appearance due to bleeding of the pigment. Modern cosmetic tattooing can be adjusted, but is not always the best option. Injectable Fillers are also a nice adjunct to restore upper face volume loss that contributes to brow drooping. One of the most popular treatments across the country today is a “Botox” or neuromodulator brow lift. By re-balancing the upper face muscles with neuromodulators such as Botox, Dysport or Xeomin you can deliver a pleasing and natural lifting of the lateral third of the eyebrows…all without surgery or recovery! Well done Botox for brow-lifting should not result in the dreaded “Jack Nicholson” look. Many patients with chronic tension headaches and some forms of migraine anecdotally also report improvement in their symptoms with this treatment.
With increasing severity of drooping minimally invasive or traditional brow procedures may be a more effective solution. In 2011, over 28,000 patients chose surgical brow procedures in the U.S. alone. Internal brow-pexy through an upper eyelid procedure is most effective for stabilizing the brow after an eyelid lift to prevent further descent. A direct brow lift above the brow or in the forehead works well, but is more appropriate for a patient with severe drooping, thick skin and forehead wrinkles and a good reason for not performing a formal brow procedure. A lateral brow-pexy is effective for lifting the lateral third of the brow in patients without severe drooping or in conjunction with an upper eyelid procedure. All of the aforementioned procedures can be safely and effectively performed under local anesthesia in the privacy and comfort of the office. An endoscopic browlift works well to lift the brow with minimal incisions. Usually some fixation device such as a screw or absorbable plate is used to secure the lifted forehead. Muscle work can be performed endoscopically, but the procedure can worsen an already receding hairline. The “gold standard” is still the open browlift. It is most effective in treating all of the signs of aging of the forehead muscles and eyebrow region. Unfortunately, it comes at the price of a longer incision and prolonged numbness, but most patients do very well. Today all of these techniques have been adjusted to reduce the downsides including a surprised look, high hairlines, numbness, bolts and painful recovery. Modern brow procedures today are effective, natural and can be done with minimal downtime. As can be seen in this 1954 Life Magazine cover photo of Grace Kelly, the attractiveness of well placed eyebrows and a proportional face is timeless!
George Bitar, MD, FACS is an award-winning, board-certified cosmetic and reconstructive plastic surgeon, the Founder and Medical Director of Bitar Cosmetic Surgery Institute in Virginia. He specializes in the latest surgical and minimally invasive techniques to scar management and reduction. Dr. Bitar is involved in groundbreaking research and education in plastic surgery and has authored numerous articles, abstracts, and chapters.
