Your Questions

Q: Dr. Eppley, I am 19 years old and have developed a problem with my face. It looks crooked and I don’t know why. I saw pictures of me before about 6 years ago and my face wasn’t crooked. So I’m kind of worried about what made it crooked. So can it be fixed?

A:  Thank you for sending your pictures. My assessment shows that your facial asymmetry is caused by a left-sided orbito-zygomatic deficiency. This is evident by a slightly lower eyebrow, a small amount of redundant upper eyelid skin, a lower globe (eyeball) position, a lower positioned lower eyelid and a small cheek bone on that side. This is caused by the underlying cheek and eye socket bones (orbito-zygomatic skeleton) being more underdeveloped than the right side. This makes the overlying soft tissues, including the eyeball, are positioned lower than the other side.

While this is a common facial skeletal deformity seen in cheek bone fractures, yours is clearly development and just grew that way. It has probably only become more evident as you are now nearing full facial skeletal development.

The facial asymmetry could be treated by a combination of procedures including a transpalpebral browlift through an upper eyelid incision (to lift the brow), orbital floor augmentation (to push the eyeball up), lateral canthoplasty (to reposition the outer corner of the lower eyelid) and a cheek implant. (to build up the smaller cheek area) I have attached some imaging which shows the predicted effect of those changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 40 year-old male and my eyebrows are bothering me. I have read that they can be lifted by opening the the upper eyelid and putting in some device to lift them.  I know that  this procedure does not lift much however. Do you think that it can resolve my problem or do you have another  suggestion for me. Please find me some solution to lift my brows. Perhaps a mid-forehead lift will lift my brows and then you can even take the excess skin that I have in my forehead out. I have two very deep long  wrinkles in my forehead that you can use. I know that there will be scars even inside  the wrinkles but we can not have something without scars so I am willing to correct a problem that is bothering me and accept scars that I can treat later with laser. Or you can do the direct brow lift by making a scar right above each brow. Please I want to lift those brows so there has got to be some way to do it for me. 

A: As for browlifting in young men, there is never a completely satisfactory solution. The endotine device to which you refer lifts the male brow slightly but does not nothing for the rest of the forehead or wrinkles. Whether the amount of lifting that can be achieved, which is just the middle to outer brow area, is enough show be considered carefully before surgery. No scar across the forehead would ever be acceptable in any male but an older one who already has deep horizontal forehead wrinkles. A mid-forehead or direct browlift is a major concern in younger men where the trade-offs for doing something are worse than the original problem. Male browlifting is a challenging issue, particularly in the younger patient. The endotine device approach through the upper eyelid is the only browlift option I would consider at your age.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 44 year-old male who has a heavy brow. I think a brow lift/ would be beneficial but I am a little worried about the hairline gong back, making my forehead even longer. Would a hair transplant to lower the hairline after work or is that a little to risky?  I think a brow lift would look good but worried that my hair line would become too high.

A: In men, browlifts are a difficult decision due to the instability or lack of a permanent stable frontal hairline. I think given the risks involved, I would be reluctant to do any open superior scalp approach to a browlift. It is a classic example of the risks being greater than the benefits. The safest approach to browlifting in men is the transpalpebral or eyelid approach, coning from below and pushing up with an endotine device. It does not produce as signfiicant a lift as that from above but it is always safer because there is no disturbance in the hairline. Another option is the endoscopic browlift which has much less scar than any open approach but it will lengthen the forehead as it works on the principle of an endocranial scalp/forehead shift superiorly to lift the brows.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to lift the eyebrows of the forehead area and reduce the protrusion of the forehead bone but I don’t want a coronal incision to do it. I need minimal incisions as I am a male.

A:  Browlift surgery in a male is a challenge due to the hair issue or lack thereof. Male browlift surgery can be performed either through an endoscopic technique with an epicranial shift or through the eyelids (transpalpebral) with or without an endotine device. The frontal hairline and density will determine which option is best.  When it comes to brow bone reduction, however, there are no other options that a coronal approach. The male brow bone is really frontal sinus expansion and must be reduced through an osteotomy approach. Even if the brows could be reduced by simple burring, good access is needed and an endoscopic approach can not be used. For most men, the coronal incision is an understandable objection and brow bone reduction is not possible.
Dr. Barry Eppley
Indianapolis, Indiana

Q : I am a 55 year-old male and am bothered by low hanging brows. It makes me look angry all the time and I am actually a good-natured and upbeat person. It seems my eyebrows are falling off of the brow bone and they look so heavy. My mother had a facelift and browlift several years ago and I am wondering if this would work for me.  

A: While a man can aesthetically tolerate a lower brow position than a woman, there is a point when the brow descent is too excessive. When the eyebrow is below the brow bone, the look that is created is a perpetual scowl or frowning. At the least, it makes the size of the eye look small and the forehead look very long.

Browlifting in men poses unique challenges that are not present in most women. The lack of a well-defined and permanent hairline with good hair density makes the options for a browlift more limited and less effective.  Browlift scars are not easily hidden and the risk of visible scarring is beyond just a theoretical possibility. None of the hairline or scalp approaches that are most commonly used for lifting the brows are worthy of that scar trade-off. In some cases, an endoscopic approach can be used but it stills creates small scars that can be visible through most men’s hair patterns.

There is a mid-forehead incision approach to a browlift but it requires a man to have a deep and prominent horizontal wrinkle in which to use. The scar with this approach takes a long time to settle and the redness to fade. While effective, this central forehead scar should be reserved for a few select patients.

This leaves the eyelid or transpalpebral approach as the only browlift option without the risk of adverse scarring. The eyebrow is lifted and sewn back up to the bone through an upper eyelid or traditional upper blepharoplasty incision. It is not as effective as a ‘superior-based’ browlift but the risk of adverse scarring is eliminated.

Dr. Barry Eppley

Indianapolis, Indiana