Brow Lift and Blepharoplasty
Brad Denney, MD discusses technical considerations and benefits of a Brow Lift or Blepharoplasty, and when to refer to the specialists at UAB Medicine.
Featuring:
Learn more about Brad Denney, MD
Release Date: October 30, 2019
Reissue Date: October 11, 2022
Expiration Date: October 10, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Brad Denney, MD, FACS
Assistant Clinical Professor in Plastic Surgery
Dr. Denney has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity.
Brad Denney, MD
Dr. Brad David Denney is a double board-certified Birmingham plastic surgeon specializing in complex wound care, hand surgery, breast and abdominal wall reconstruction, and cosmetic surgery. He is a Diplomate of the American Board of Plastic Surgery and the American Board of Surgery, as well as a member of the American Society of Plastics Surgeons, the American Society of Aesthetic Plastic Surgery, and the Southeastern Society of Plastic and Reconstructive Surgeons.Learn more about Brad Denney, MD
Release Date: October 30, 2019
Reissue Date: October 11, 2022
Expiration Date: October 10, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Brad Denney, MD, FACS
Assistant Clinical Professor in Plastic Surgery
Dr. Denney has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity.
Transcription:
Melanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.
Welcome. Today we’re talking about brow lifts and blepharoplasty, and my guest is Dr. Brad Denney. He’s an assistant professor and a double board certified plastic surgeon at UAB Medicine. Dr. Denney, such a pleasure to have you with us today. Tell us what is a blepharoplasty or a brow lift.
Brad Denney, MD (Guest): So a blepharoplasty is where it can be done for the upper eyelid or the lower eyelid, but more commonly for the upper eyelid. That can happen because as we age we lose collagen and elastin in our skin. So therefore our skin sags if you will. That can occur all over the body, but it can particularly occur around the eyes and in the brow. So if that happens in the eyes and if you develop really baggy skin in the upper eyelid, that skin can actually hang down and can block the peripheral vision. We can fix that in a procedure called a blepharoplasty. That’s where we excise the heavy, redundant upper eyelid skin and sometimes the brow is also heavy and sags. That can also effect vision. That’s where a browlift comes into play. Whether we do a browlift or an upper eyelid blepharoplasty at once or separate kind of depends on the patient, but they're more commonly done for the reason of that excess heavy skin effecting vision. Even if they're not cause for a functional problem, they're also done for cosmetic reasons as well.
Host: So then how do you decide which procedure you're gonna use? Explain some of the key variables that determine whether you're going to use a blepharoplasty or a browlift or even both to get the best results for a patient.
Dr. Denney: These procedures can potentially be covered by insurance. The way they are covered by insurance is we have to send documentation to the insurance companies that the skin of the brow or the upper eyelid is significant enough. In terms of the upper eyelid, that skin has to encroach upon the top aspect of the upper eyelid itself. In terms of the brown, the skin of the brow has to descend below the super orbital rim. That’s that bone that you feel that’s directly above your orbit. In addition to the photographs, we also have to have visual field testing from an ophthalmologist that documents decreased visual fields and improvement in the visual fields when the skin of the brow and upper eyelid is lifted.
In terms of whether a blepharoplasty and/or a browlift is performed is based upon a blepharoplasty is done if that upper eyelid skin encroaches upon the upper eyelid itself. The browlift is done if that brown skin descends below the super orbital rim, just as I mentioned with the test and the documentation that’s required from the insurance companies. I do tell patients if they don’t want the browlift, there is a chance that only doing a blepharoplasty alone could actually make the aesthetics of the brow worsen because if you take away that heavy upper eyelid skin then the brow no longer has to work hard to arch, if you will, and to suspend the upper eyelids. So therefore the brow could descend more.
In terms of the other reason to have one or both or one or the other done is for aesthetics. If patients aren’t experiencing functional deficits with their vision, if they’re unhappy with how their upper eyelids or how their brow looks, it can be done for cosmetic reasons.
Host: Is this a quick fix or is this a long term solution?
Dr. Denney: A quick fix would be Botox. That’s where we inject a solution that innervates the muscles in the forehead and around the eyelids. That will alleviate the deep creases in the forehead, and that is a temporary fix. But surgically, yes. A browlift and a blepharoplasty are permanent solutions. That’s the advantage of surgery.
Host: Well it certainly is. So then speak about patient selection criteria. Is there anyone for whom this is really not an option? Give us some clinical indications and contraindications for the institution of either one of these procedures.
Dr. Denney: Indications would be one, for aesthetics; two, to improve peripheral field vision. Now there are some contraindications. If patients have a history of dry eyes, then they would need clearance from their ophthalmologist before embarking on this surgery because both these surgeries do elevate the upper eyelid therefore exposing the cornea. With a history of dry eyes, these could make dry eyes worse. If patients have had the Lasik procedure, they need to wait at least six months to a year before embarking on the upper eyelid blepharoplasty or browlift. Patients need to be physically fit cardiovascular and they cannot be on any blood thinners. Bleeding after these operations—particularly an upper eyelid blepharoplasty—in rare cases bleeding significantly enough could lead to blindness if hematomas or post-operative bleeding are not caught or discovered early enough.
Host: Well thank you for that because I was going to ask you about some complications to keep a watch on. So are there some technical considerations, Dr. Denney, that you’d like other providers to know about? What's involved in the procedure?
Dr. Denney: An upper eyelid blepharoplasty is pretty simple. It’s just excision of that excess skin. We used to excise a lot of fat a few years ago as well, but we’ve tended to be more conservative with our fat resection because we found that the more fat we resect in the upper eyelid the more we actually age the patient in terms of appearance. So we tend to leave more fat than we used to. Another consideration is if the upper eyelid skin is one thing, but if the upper eyelid itself descends below the pupil then they may need to have a levator advancement or levator plication. The levator is the muscle that usually with aging has atrophied and therefore the eyelid may descend below the pupil. That’s a much more complicated procedure that would be done in conjunction with excision of the excess upper eyelid skin.
In terms of a browlift, a traditional browlift is done through a coronal approach meaning that a long incision will be made in the hairline approximately five centimeters posterior to the anterior hairline itself. There were problems with that. Patients would experience alopecia as well as paresthesia and sometimes loss of sensation of the scalp. So now we’ve advanced to where we’re now doing most of our brow lifts endoscopically in which three small incisions are placed in the anterior hairline. Of course, given that this is UAB I have to give a shout out to my mentor, Dr. Vasconez, who helped develop the endoscopic browlift.
Host: Tell us a little bit about your outcomes, Dr. Denney, and what can a patient or referring physician expect post-operatively?
Dr. Denney: Outcomes are excellent. Upper eyelid incisions heal extremely well as do browlift incisions. I think the most common complication or potential issue post-operatively would be asymmetry between each of the eyelids and the brows themselves. As a whole, most patients are extremely satisfied. In terms of referral, referring doctors could get in touch with the Kirklin clinic at UAB for referrals.
Host: As we wrap up, do you have any final thoughts? What you would like other providers to take away from this episode when they are referring as far as communication with the referring physician and what you want to tell us about your team.
Dr. Denney: If patients complain to their providers that they feel that their brows or their eyelids are heavy and they think it’s effecting their vision, then that’s a patient who would benefit from seeing a surgical provider who specializes in upper eyelid blepharoplasty or browlift. That patient may need visual field testing as those symptoms could be alleviated with these surgeries. We have an excellent team at the Kirklin clinic. We work well with our ophthalmology partners for coordination of visual field testing.
Host: Thank you so much, Dr. Denney, for joining us today and sharing your incredible expertise. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Medcast. For more information on resources available at UAB Medicine, head on over to our website at uabmedicine.org/physician. If you as a provider found this podcast informative, please share with your patients, share with other providers. Be sure not to miss all the other fascinating podcasts in the UAB library. Until next time, this is Melanie Cole.
Melanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.
Welcome. Today we’re talking about brow lifts and blepharoplasty, and my guest is Dr. Brad Denney. He’s an assistant professor and a double board certified plastic surgeon at UAB Medicine. Dr. Denney, such a pleasure to have you with us today. Tell us what is a blepharoplasty or a brow lift.
Brad Denney, MD (Guest): So a blepharoplasty is where it can be done for the upper eyelid or the lower eyelid, but more commonly for the upper eyelid. That can happen because as we age we lose collagen and elastin in our skin. So therefore our skin sags if you will. That can occur all over the body, but it can particularly occur around the eyes and in the brow. So if that happens in the eyes and if you develop really baggy skin in the upper eyelid, that skin can actually hang down and can block the peripheral vision. We can fix that in a procedure called a blepharoplasty. That’s where we excise the heavy, redundant upper eyelid skin and sometimes the brow is also heavy and sags. That can also effect vision. That’s where a browlift comes into play. Whether we do a browlift or an upper eyelid blepharoplasty at once or separate kind of depends on the patient, but they're more commonly done for the reason of that excess heavy skin effecting vision. Even if they're not cause for a functional problem, they're also done for cosmetic reasons as well.
Host: So then how do you decide which procedure you're gonna use? Explain some of the key variables that determine whether you're going to use a blepharoplasty or a browlift or even both to get the best results for a patient.
Dr. Denney: These procedures can potentially be covered by insurance. The way they are covered by insurance is we have to send documentation to the insurance companies that the skin of the brow or the upper eyelid is significant enough. In terms of the upper eyelid, that skin has to encroach upon the top aspect of the upper eyelid itself. In terms of the brown, the skin of the brow has to descend below the super orbital rim. That’s that bone that you feel that’s directly above your orbit. In addition to the photographs, we also have to have visual field testing from an ophthalmologist that documents decreased visual fields and improvement in the visual fields when the skin of the brow and upper eyelid is lifted.
In terms of whether a blepharoplasty and/or a browlift is performed is based upon a blepharoplasty is done if that upper eyelid skin encroaches upon the upper eyelid itself. The browlift is done if that brown skin descends below the super orbital rim, just as I mentioned with the test and the documentation that’s required from the insurance companies. I do tell patients if they don’t want the browlift, there is a chance that only doing a blepharoplasty alone could actually make the aesthetics of the brow worsen because if you take away that heavy upper eyelid skin then the brow no longer has to work hard to arch, if you will, and to suspend the upper eyelids. So therefore the brow could descend more.
In terms of the other reason to have one or both or one or the other done is for aesthetics. If patients aren’t experiencing functional deficits with their vision, if they’re unhappy with how their upper eyelids or how their brow looks, it can be done for cosmetic reasons.
Host: Is this a quick fix or is this a long term solution?
Dr. Denney: A quick fix would be Botox. That’s where we inject a solution that innervates the muscles in the forehead and around the eyelids. That will alleviate the deep creases in the forehead, and that is a temporary fix. But surgically, yes. A browlift and a blepharoplasty are permanent solutions. That’s the advantage of surgery.
Host: Well it certainly is. So then speak about patient selection criteria. Is there anyone for whom this is really not an option? Give us some clinical indications and contraindications for the institution of either one of these procedures.
Dr. Denney: Indications would be one, for aesthetics; two, to improve peripheral field vision. Now there are some contraindications. If patients have a history of dry eyes, then they would need clearance from their ophthalmologist before embarking on this surgery because both these surgeries do elevate the upper eyelid therefore exposing the cornea. With a history of dry eyes, these could make dry eyes worse. If patients have had the Lasik procedure, they need to wait at least six months to a year before embarking on the upper eyelid blepharoplasty or browlift. Patients need to be physically fit cardiovascular and they cannot be on any blood thinners. Bleeding after these operations—particularly an upper eyelid blepharoplasty—in rare cases bleeding significantly enough could lead to blindness if hematomas or post-operative bleeding are not caught or discovered early enough.
Host: Well thank you for that because I was going to ask you about some complications to keep a watch on. So are there some technical considerations, Dr. Denney, that you’d like other providers to know about? What's involved in the procedure?
Dr. Denney: An upper eyelid blepharoplasty is pretty simple. It’s just excision of that excess skin. We used to excise a lot of fat a few years ago as well, but we’ve tended to be more conservative with our fat resection because we found that the more fat we resect in the upper eyelid the more we actually age the patient in terms of appearance. So we tend to leave more fat than we used to. Another consideration is if the upper eyelid skin is one thing, but if the upper eyelid itself descends below the pupil then they may need to have a levator advancement or levator plication. The levator is the muscle that usually with aging has atrophied and therefore the eyelid may descend below the pupil. That’s a much more complicated procedure that would be done in conjunction with excision of the excess upper eyelid skin.
In terms of a browlift, a traditional browlift is done through a coronal approach meaning that a long incision will be made in the hairline approximately five centimeters posterior to the anterior hairline itself. There were problems with that. Patients would experience alopecia as well as paresthesia and sometimes loss of sensation of the scalp. So now we’ve advanced to where we’re now doing most of our brow lifts endoscopically in which three small incisions are placed in the anterior hairline. Of course, given that this is UAB I have to give a shout out to my mentor, Dr. Vasconez, who helped develop the endoscopic browlift.
Host: Tell us a little bit about your outcomes, Dr. Denney, and what can a patient or referring physician expect post-operatively?
Dr. Denney: Outcomes are excellent. Upper eyelid incisions heal extremely well as do browlift incisions. I think the most common complication or potential issue post-operatively would be asymmetry between each of the eyelids and the brows themselves. As a whole, most patients are extremely satisfied. In terms of referral, referring doctors could get in touch with the Kirklin clinic at UAB for referrals.
Host: As we wrap up, do you have any final thoughts? What you would like other providers to take away from this episode when they are referring as far as communication with the referring physician and what you want to tell us about your team.
Dr. Denney: If patients complain to their providers that they feel that their brows or their eyelids are heavy and they think it’s effecting their vision, then that’s a patient who would benefit from seeing a surgical provider who specializes in upper eyelid blepharoplasty or browlift. That patient may need visual field testing as those symptoms could be alleviated with these surgeries. We have an excellent team at the Kirklin clinic. We work well with our ophthalmology partners for coordination of visual field testing.
Host: Thank you so much, Dr. Denney, for joining us today and sharing your incredible expertise. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Medcast. For more information on resources available at UAB Medicine, head on over to our website at uabmedicine.org/physician. If you as a provider found this podcast informative, please share with your patients, share with other providers. Be sure not to miss all the other fascinating podcasts in the UAB library. Until next time, this is Melanie Cole.