Botox works well to fight our eye and brow anatomy. And by doing so it can distort it. This study wanted to look at that issue. When we evaluate a patient for brow or eyelid lift, are we doing the right surgery? If they have had recent botox (within the last 4 months), is it affecting what we see?
This is out of the Aesthetic Journal, September 2018. “Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and Brow lift.”
This was a study of 521 patients, seen from 2002 to 2016. They wanted to see if your pre surgery brow position is distorted when you do pre surgical botox. Botox of the forehead muscle, the frontalis, will lower the brow. Botox of the crows feet eye area will actually lift the brow. When you are deciding to do eyelid surgery vs. brow surgery. vs doing both, your position of the eyebrow is an important factor.
- The forehead muscle has resting tone which elevates the brow position.
- To block this, they use 15 to 20 units of botox 2 weeks prior to surgery date to allow it to reach peak action prior to surgery.
- They do this to “unveil” the true eyebrow and eyelid position.
- They think this allows for better upper blepharoplasty and browlift
- they unmask eyelid ptosis
- the unmask asymmetry of the brow position.
Findings?
- They found ptosis unmasked in 39 patients.
- 131 patients had a lowered brow position. Of those 19 chose to do a temporal browlift, the others accepted a lower brow position.
Conclusion:
Brow position after upper bleph is controversial, though it is known that brow and lid ptosis (droopiness) can be unmasked by doing upper eyelid surgery. They value botox use of the forehead only to show patients their true brow position, and unmask hidden brow or eyelid ptosis.
What do I think?
I think not all patients need botox to know this, though it is likely helpful for them to see the actual position of their brow. If you have deep forehead lines, or many forehead lines, you are compensating with your forehead muscle to lift the brow. If when you wake up in the morning your eyes look “really tired” and hooded, you are likely compensating with your forehead. So if you are compensating with your forehead, know your brow will drop after you remove the excess upper eyelid skin as your forehead relaxes when that extra skin is gone.
I found it interesting that of the 131 patients who were told their brow would be low, only 19 of them chose to address it. I now am doing fat grafting to the lateral brow on most of my bleph patients, and in some of them have achieved a mild browlift from just injecting fat.
I also liked the fact these patients really got to see the true position of their brow, and had to decide to fix it (browlift) or accept it.