Dr Maryam Zamani outlines her combination of non-surgical treatments to lift the brow
The periorbita and brow is an area where we often see the first signs of ageing and is a common request for rejuvenation. To understand patients’ concerns, we first need to understand how this part of the face ages.
Considerations for eyebrow rejuvenation
The ideal eyebrow was described in 1974 as a lateral arch with the apex terminating above the lateral limbus of the iris and where the medial and lateral ends of the eyebrows were at the same height.1,2 Since then, this ideal has been redefined and studies have indicated that patients and surgeons prefer an eyebrow where the arch is positioned just lateral to the lateral limbus.1,3,4,5 The focus of eyebrow rejuvenation is based on position, shape, and symmetry of the eyebrows. There are many factors that contribute to eyebrow shape, including ethnicity, facial shape and cosmetic practices to groom the brows.1
From my experience, criticism of both non-invasive and surgical procedures is generally focused on unnatural eyebrow shape, height, and appearance. In the upper third of the face, the effects of repetitive periorbital muscle contractions, decreased skin elasticity and loss of temporal support to the lateral brow result in brow ptosis.6 The eyebrows are maintained by the dynamic balance of the frontalis, corrugator supercilii and the orbicularis oculi muscles.7 As we age, studies have indicated that the position of the eyebrow actually becomes higher, with the medial brow being more elevated than the lateral eyebrow, regardless of ethnicity.8-10
Delyzer et al illustrated in patients younger than 50 that the eyebrow slope decreased due to the descent of the arch.1 Thereafter, there is an increase in eyebrow slope secondary to an increase in the arch apex that is likely caused by a reactionary hyperactivity of the frontalis, leading to increased muscle tone at rest.1 The resting tone of the medial depressors keep the medial eyebrow stable or slightly descended consistently through the ageing process. These findings are important in assessing eyebrow rejuvenation, particularly as focus and emphasis should be placed on the lateral brow and arch, while avoiding the medial brow.1 Consideration must also be made of volumetric changes to the brow; lateral eyebrow ptosis may be a result of soft tissue atrophy, bone loss and skin changes (loss of elasticity) combined with gravitational effects.11-12 The eyebrow fat, retro-orbicularis oculi fat (ROOF) pad, contributes to youthful periorbital fullness and with its atrophy and the lack of lateral frontalis muscle inserting into the very lateral brow, ptosis of the lateral brow occurs.13 Careful brow repositioning and volumisation of the temporal fossa can provide excellent results in properly chosen patients, as discussed above.14
Treatments for eyebrow rejuvenation
Brow rejuvenation can be categorised into two main groups: surgical and non-surgical. In the last decade, there has been increased demand for non-invasive procedures for rejuvenation15 and a simultaneous explosion of new non-surgical techniques and combinations of such treatments, aimed at improving and rejuvenating the skin around the periorbital and brow area. In treating the brow, there is a vast array of combination treatments that can be implemented. Often, the most successful aesthetic results come from combining different modalities together to create a more unified approach to rejuvenation and improve overall patient satisfaction. According to a study by Beer KR et al, subjects treated with botulinum toxin alone rated the combination treatment more superior at 64% and in my experience the combination of botulinum toxin A and hyaluronic acid (HA) appear to rejuvenate the brow with minimal adverse effects and with higher rate of patient satisfaction.16
Microfocused ultrasound (MFU) is a non-invasive treatment modality that uses visualisation to create thermal micro-injuries, also known as thermal coagulation points (TCP), in the dermis and subdermal tissue. Despite its low energy, MFU is capable of heating tissue to greater than 60C to a depth of 5mm within the mid to deep reticular layer of the dermis and subdermis, while sparing the overlying papillary dermal and epidermal layers of the skin.17,18 MFU causes collagen fibres in the superficial musculoaponeurotic system and deep reticular dermis to contract and stimulate de novo collagen.17 The lift is created in the healing of the TCP resulting in firming, tightening and shrinking of the dermis and subdermal tissues. The efficacies of ultrasound treatments vary on the vector direction of treatment and the total energy supplied. The treatment has a reputation of being painful; however, with proper pre-treatment analgesics, this is well controlled. Pain, oedema, headache, numbness, paresis, post-inflammatory hyperpigmentation (PIH), bruising, and welts are potential risk profiles that need to be discussed with the patient.19
Eyebrow ageing is a dynamic process related to differential muscle actions at rest and their relationships to one another. To maintain youthful eyebrows, weakening of the depressor muscles of the eyelid and brow can help restore muscle balance.7 Studies have indicated that in patients younger than 50, paralysing the central frontalis and lateral orbicularis oculi can help correct lateral brow ptosis.1 Botulinum toxin is an effective neuromodulator used to temporarily weaken the orbicularis oculi muscle, a brow depressor that pulls the lateral part of the eyebrow downwards with minimal side effects. As a low risk procedure, botulinum toxin is generally considered a relatively safe treatment.20 In older patients, this frontalis activity may be essential in maintaining brow height and should be treated with caution.
Hyaluronic acid fillers
HA fillers are playing an even larger role in treating the ageing upper face as a three-dimensional approach to rejuvenation, with particular attention to proportional ideals being sought. In determining which HA product is best to use in the brow, it is essential to look at the viscosity – how the gel flows from the needle, and G prime – gel stiffness of the product. I prefer using products from the Juvéderm Vycross family, particularly Volift, when trying to lift the lateral brow and replace volume loss, because of its lifting capabilities while spreading easily.
Volume restoration of the brow must be performed with consideration of the shape of the lateral brow, as well as consideration of the vascular and structural anatomy. HA can be injected into the lateral brow and temples with both deep (pre-periosteal and submuscular) and dermal injections in order to temporarily help improve volume loss. All HA injections in the periorbita carry significant risk (such as vascular compromise, overcorrection) and great care to the underlying anatomy must be taken to minimise potential pitfalls.21
Combination approach: Tri Brow Treatment (TBT)
In my practice, I have created a triad of treatments detailed above in a non-surgical protocol called the Tri Brow Treatment (TBT). I have a significant number of patients who present complaining of the appearance of the brow and seek non-surgical treatment options, instead of surgical intervention. The TBT combines botulinum toxin, HA fillers and ultrasound treatment in two sessions 10-14 days apart to treat brow ptosis in younger patients, generally aged 30-55.
In the first visit, Ultherapy, a FDA approved ultrasound device is used to treat the brow to promote lifting and tightening of the periorbita. Between 10-14 days after treatment with Ultherapy, patients return for tailored treatment of the lateral brow and temples with HA fillers as well as toxin to the brow depressor and the orbicularis oculi muscle. All patients are advised to wait three to six months before the final improvement can be seen with Ultherapy. It should also be noted that botulinum toxin and HA treatments require maintenance as botulinum toxin lasts three to five months and the duration of HA depends on the type of hyaluronic acid used in treatment.
In my experience, integrated treatments for the brow cater for the multifaceted changes that occur in the ageing face. These forms of treatment, among other combinations of treatments used for rejuvenation of the brow are of moderately long-lasting efficacy and offer high patient satisfaction.
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