The Forehead Is One of the Most Misunderstood Areas in Facial Rejuvenation
Treating the forehead is not about creating high eyebrows. Often only upper eye shape is the goal. A forehead lift is a cosmetic surgery procedure that tightens the soft tissue and skin of the entire forehead. The majority effect is often seen around the eyes, especially between the eyebrows and on the drooping soft tissue hanging over the lateral/side of the upper eyelids. The appearance of an aging forehead brow lift is often emotionally negative with the eyes becoming heavy-looking, creating a tired, unhappy or angry look. Thus treating the forehead is especially effective, and necessary in older people, in rejuvenating the upper eyelids. Many patients undergo forehead rejuvenation alone to treat perceived upper eyelid sagging.
It is often necessary to combine forehead procedures with facelifts to create balanced, complete results. The better the facelift result, the greater the need for a combined forehead procedure to both balance the lower face and neck result and ensure the transition from the lifted repositioned lower face so that it does not bunch or pleat as it meets the sagging, unlifted forehead.
Commonly, people do not perceive their forehead aging changes as much as they notice jowl or a lax neck. The reason is that we have an unconscious reflex that does not let our eyebrows become noticeably low in many people. This would cause limitations in our upward vision so our brain uses our forehead muscles to silently activate, lift our brows but creates the furrows instead. This is why Botox® has become popular to treat our forehead furrows.
Botox does not replace Forehead Rejuvenation. Unfortunately, if the forehead has been affected by gravity changes and is truly sagging, Botox® injections will paralyze the forehead muscles causing the brow/forehead to fall and make our eyes appear worse.
If our lower faces have drooped and fallen enough for someone to need a lower facelift, their forehead has been affected similarly. Since the signs of a loose forehead can be around the eyes or hidden in furrows, prospective patients are not always aware that the upper face has been affected significantly by aging and unbalanced procedures will reveal noticeable discrepancies from the rejuvenated to the untreated area. Also, bunching and pleating around the eyes is a hallmark of an imbalanced procedure, since folds are not naturally occurring in this area of the face. In circumstances in which a forehead procedure is not combined with a facelift, it can be necessary to limit the result in the lower face and neck to avoid imbalances and disharmonies. The worse the neck or nasolabial folds, the greater the need for a combined facelift and forehead procedure.
Since older facelift techniques did not reposition the drooping soft tissue as effectively as vertical platysma advancements or deep-plane facelifts do today, forehead procedures were not always combined with facelifts as better facelifts necessitate today.
As an innovator in facial plastic surgery, Dr. Gordon has worked with all forehead rejuvenation techniques and developed a unique procedure that he can individualize to each prospective patient’s hairline, appearance, and desire, the Vertical Galea Advancement.
Ultimately, it is the consumer who will decide what they desire, but whether it is underdoing the neck result or changing the vector in the lower face/neck to avoid pleating, the effects of an unbalanced procedure cannot be avoided in any hands using any technique. By educating the consumer they can understand the issues and make an informed decision based on what’s right for them.
The Vertical Galea Advancement
The forehead is one of the most misunderstood areas of facial rejuvenation. The goal in treating the forehead does not involve raising the eyebrows to a position they never were in earlier life. Unlike the lower face and neck where gravity’s effects are visible and obvious, forehead aging is often masked and not evident to the layperson’s eye. Since a drooping face will not cause any functional problem, such as limited visual fields, we do not prevent our face from sagging. But if the upper face drooped similarly our visual fields would become obstructed. This is why we make furrows subconsciously, without thinking, as a way to protect and offset a progressively loose forehead. How could only our lower face age and not our upper face?
This is why Botox or other muscle relaxants are most useful in earlier ages when our gravity changes are minimal. Once the forehead is truly lax (usually once we have a loose neck) paralyzing the forehead muscles that are purposely working subconsciously to protect our visual fields will produce the typical angry, “Spock-like” appearance of inappropriate use of Botox or relaxants. Also, inappropriate Botox sacrifices the appearance of our eyes by covering them, producing a flat forehead with odd-unnaturally arched eyebrows.
Since the majority of people are motivated by their lower face or neck and aging is due to vertical stretching out of the face, vertical repositioning of the soft –tissue using the underbelly layer effectively reverses these aging changes. If only the lower face is approached then the repositioned soft tissue would bunch or pleat around the sides of the eyes. This can only be avoided by changing the vector of repositioning from vertical to sideways or backward, the problem is that if we drop an object it doesn’t go sideways or backward, it goes vertically down.
The goal of treating the forehead is not about raising the eyebrows, normal forehead muscle action keeps most eyebrow complexes in a relatively normal position.
The goals are to create the same soft-tissue tone in the upper face as in the lower face, make the transition from the lower face smooth, allowing full vertical repositioning of the lower face, and open up and frame the eyes.
The Vertical Galea Advancement is a procedure developed by Dr. Gordon to predictably achieve these results. Unlike brow lifts, Vertical Galea Advancement cannot produce high eyebrows or a different eyebrow pattern that someone never had. Since it also focuses on using the underbelly layer (galea), it is an invisible procedure that balances the upper face to the rejuvenated lower face, opens the eyes, and allows the maximum result in the nasolabial folds and neck.
Similar to Vertical Platysma Advancements, no skin tension is ever needed and it can be couture’d to unique patient features. Hairlines can be customized, raised, or lowered according to the individual and, most importantly, hair preserved as the procedure produces no surface tension. Vertical Galea Advancement is truly a unique technique that balances the face, treats the eyes, and allows the maximal result in treating the neck in a consistent, predictable manner.
In performing an eyelid lift, called a blepharoplasty, the surgeon lifts the lids by removing sagging eyelid tissues. This procedure can be performed on both the upper and lower eyelids. After an eyelid lift, the eyes are unburdened of excess skin and fat that have distorted their shape, and the result is a more rested, youthful, and alert look.
Most darkness under the lower eye is from the shadow effect from the fat bulging underneath the eyes. Note that an eyelid lift alone is not intended to correct fine lines or wrinkles around the eyes. This explains the necessity of combining eye lift procedures with other rejuvenation procedures such as browlifts and skin rejuvenation treatments such as laser skin resurfacing. Also, an eyelid lift will not correct dark circles under the eyes if the circles are caused by the muscle and other tissues showing through thin skin. These distinctions can be defined during the consultation.
Upper Eyelid Lift
For the upper eyelid lift (blepharoplasty), the incision is hidden in the eyelid crease. This crease is hidden when our eyes are open. Excess skin and fat are removed proportionally to restore the original shape and contour. The upper eyelift does not ‘open’ your eyes, it recreates the eyelid depth. A brow lift reopens the eyes. In most people seeking eyelid rejuvenation, eyelid procedures are combined with brow lifts and/or laser skin resurfacing to achieve natural, balanced, and complete results. This is especially true of people over 45.
Lower Eyelid Lift
A lower eyelid lift can be accomplished by a procedure that has two distinct variations. The older procedure for a lower eyelid lift is transcutaneous/subciliary, which means the incision is through the external skin underneath the eyelashes, while the other is transconjunctival, on the inside of the eyelids.
Although the subciliary approach can tighten the skin without the need for adjunct procedures such as laser resurfacing, this type of incision can exacerbate dry eyes and alter eye shape. This is why the preferred approach in most people is transconjunctival, with the incision invisible on the inside of the eyelids.
More importantly, this technique avoids creating an incision through the muscle that supports the eyelid, necessary in a subciliary procedure, to access and alter the bulging fat.