The October 2018 issue of Aesthetic Surgery Journal had an article on using Botox prior to doing upper eyelid or browlift surgery. The article, “Preoperative Use of Neuromodulators to Optimize Surgical Outcomes in Upper Blepharoplasty and Brow Lift.”
So why would you use botox prior to having brow or eyelid surgery?
The authors state in their background for the article that many people who seek having their eyes done have hyperactivity of their forehead muscle.
This is totally true. I see it all of the time, and it actually signals to us, the plastic surgeon, how much you are compensating for your droopy brow and eyelids. In English, this means if your eyelid is hanging in your eye, subconsciously you raise your eyebrows and forehead muscle. All day. Every day. This gives you forehead wrinkles. And we can see how much you are compensating by the number and depth of the wrinkle.
Why do we care?
Well, when you are raising your forehead muscle is distorts what is really going on. Where is the true position of your brow? How droopy and hooded is your upper eyelid really? When you raise your forehead, you are making the brow position higher and better, and reducing the hooding of the eye.
For a sneak peek at where things really are, look in the mirror first thing when you wake up in the morning. When you are asleep, you aren’t reading/ watching tv/ using your eyes. So your forehead relaxes fully. When you first wake up, your forehead isn’t “on duty” yet, so it isn’t compensating. Because of this, you likely look really “tired” in the morning. This is your true brow position.
If you are compensating and don’t realize it, after you do a surgery you might be surprised by the results. Or you may have the wrong surgery to fix what bugs you.
Study:
- 520 patients,
- two weeks prior to surgery they got 15-20 units of Botox into the frontalis (forehead) muscle.
Findings:
- Botox revealed the true brow position
- It helped them decide if they needed upper eyelid surgery, brow surgery, or both
- It showed hidden eyelid ptosis in 39 patients
Discussion
In their discussion, they talk about how many patients are unaware of their asymmetries, how many have droopy brows and eyelids which are worse than the patient thought, and how some had an issue with ptosis (where the eyelid can’t fully raise). They discussed the reason the forehead hides ptosis–mainly when you have ptosis it triggers hyperactivity of the forehead muscle to compensate for it. They also discuss how the brain creates a bilateral stimulation to the muscles to make them symmetric to align the eyes. If you correct the extra skin on the eyelid, this changes the nerve input and lets the forehead muscle relax. This brain bilateral stimulation can also be a problem if you have ptosis on one side and not the other- when you correct the one side, it may unmask it on the other.
My thoughts?
I can tell in many of my patients when they are compensating with their forehead. It is a common occurrence, and the number and depth of the lines gives a clue. I found it interesting how pre surgery Botox unmasked ptosis on 39 patients- that is not an insignificant number. Doing Botox two weeks ahead means additional cost and risk, and it involves you walking around for two weeks looking “really tired,” when your forehead can’t lift up. I do like it lets the patient see what is really going on. It lets them see asymmetries, the true brow position, and how droopy their eyes really are. Education and expectations are everything in plastic surgery.
How can you know how much things are better when you were masking how bad they really were?
What if you are having your eyelids done, but what bugs you really is the low position of your eyebrow?
In the commentary about the article, I thought they brought up some good points, including
- how people can have a dominant eye which they naturally hold more open, so they raise the forehead up more on that side. This could persist after surgery and if you blocked it with Botox, it doesn’t change the fact you will hold it more open after surgery.
- how when the extra skin is fixed, some people revert to holding their forehead muscle up, even though it is no longer necessary- why?
- do you need to do this chemically with botox or can you assess this with a good exam and a mechanical block? (I agree, though then the patient doesn’t see and live with it for 2 weeks)
- Botox to the brow can alter brow shape, arch, contour and height. Botox can also cause ptosis.
All good points.