Defeating the Tired, Angry Look

Saturday, March 2nd, 2013

Have you been told you look tired or angry? A furrowed brow may be the problem. While the brow can express curiosity, it can also convey anger and tiredness. When your brow conveys other than your feelings, you may decide something needs to be done.  What is required to correct the problem depends on the cause.

Three things affect the brow.  First, the underlying muscles frequently hypertrophy and cause unintended expressions, even if we are not tired, curious or angry.  Second, gravity causes the brow to descend giving us a tired, sleepy look.  This is frequently made worse by muscle overaction, which tends to also pull the brow down. The third force that affects the brow is the sun, which causes the skin to age and thin.  As the skin thins, the lines created by both descent of the brow and muscle action become indelible and are constantly present, even without the causative force.

Many people say that they seemed to have no problem, and then, suddenly, over a short period, noticed aging around the brow.  This is generally because the frontalis muscle (overlying the brow) retains normal brow position against the forces of aging.  When this muscle finally becomes tired, the brow descends.  This is also why we frequently look better in the morning than we do at night, since the frontalis muscle is fresher in the morning.

Of all the forces that happen to the brow, the easiest to overcome are those of muscle function.  This is why Botox® has become so popular.  Botox® was, in fact, first used cosmetically to treat the lines between the eyebrows.  These lines are caused by two different muscles which pull the brows together as well as down, causing both vertical lines between the eyebrows as well as horizontal lines in the upper part of the nose. By injecting these muscles with Botox®, before they have formed permanent creases within the skin, the lines can be eliminated.  Likewise, the lines around the lateral eyes (the “crows’ feet”) can be eliminated or markedly reduced by injection with Botox®, if there are no permanent lines there. Since this muscle also pulls the brow down, blocking it can cause brow elevation.  Transverse forehead lines can also be reduced or eliminated with Botox®; however, one must be exceptionally careful since frequently the reason that the lines are present is that the underlying muscle causing them is holding up the eyebrows.  Therefore, if the muscle is relaxed, the eyebrows drop significantly.  Sometimes this can be balanced by also treating the muscles that are pulling the eyebrow down. These two injections tend to negate each other as far as brow position, but eliminate the wrinkles.

When the lines are permanent and the use of Botox® will not eliminate them, then a filler such as Juvéderm® or Radiesse®, can plump up the line and eliminate it. Although it is possible to eliminate the line somewhat with just the filler, it is usually best to eliminate the cause, which is the muscle, as well as to fill the resultant crease or fold.

Once the process has evolved to where the lines cannot be eliminated without dropping the brow, then the only option is a brow lift.  Fortunately, this procedure has changed dramatically over the last number of years.  Initially, the muscle lifting the brow was paralyzed and the brow pulled up with an incision across the entire forehead, just behind the hairline.  This gave a very unnatural appearance.  It also caused numbness in a great deal of the scalp.

Presently the procedure is done using an endoscope (a small lighted tube connected to a video screen) through small incisions in the hairline between the nerves. This simply repositions the brow as well as removes the excess muscles that are causing a lot of the lines in the area between the eyebrows.  This method also allows us to pull the tissues up more laterally, recreating the normal eyebrow arch, pulling the brow skin out of the upper eyelid and eliminating a lot of the crow’s feet. Thus, the procedure generally eliminates the need for Botox®.

Many of the people who see me seeking upper blepharoplasty to remove the excess skin in their upper eyelids need only a brow lift to elevate the skin of the brow back to where it belongs, pulling it out of the upper lid.  This restores the normal curve laterally and removes a great deal of the skin within the lid.  Even if there is extra skin, the amount that needs to be removed is minimal.

This has prevented one of the major stigmata of upper blepharoplasty, the hollow eye.  When a needed brow lift was not done, the tendency in the past has been to simply resect lots of fat to try to recreate a normal looking lid.  This was never totally successful and created an upper lid that looked quite gaunt.  By pulling the tissues upward and laterally and flattening the crows’ feet, we can improve the lateral orbits significantly better than with just a blepharoplasty alone.

The brow thus has the potential of making us look quite old, tired, or angry, or it can make us look young and rejuvenated.  The approach to achieving this varies by the underlying cause and can be as simple as minimal skin care or injection or as complex as brow lift combined with an upper blepharoplasty.

Dr. Buchanan is experienced with both injectables, including Botox®, Juvéderm®, and Radiesse®, as well as skin care, brow lift and blepharoplasty.  All of his brow lifts are done endoscopically through very small incisions, with very rapid recovery and almost no bruising.