7 Methods for Non-Surgical Eyebrow Rejuvenation—Part 1
Eyebrows are an important facial feature that can convey emotions and expressions. However, as we age, our eyebrows may lose their shape, density, and position, making us look tired, angry, or sad. While surgical eyebrow lifts can provide dramatic and long-lasting results, they also carry risks, downtime, and costs that may not be feasible or desirable for everyone. Non-surgical eyebrow rejuvenation, on the other hand, offers a less invasive, less expensive, and less risky alternative for those seeking to enhance their eyebrows' appearance without going under the knife.
In this article, we will explore 7 of the most popular non-surgical eyebrow rejuvenation techniques, their benefits and limitations, and what to expect from each of them. These techniques are
1) Botulinum Toxin,
2) Dermal Fillers,
3) Fractional Radiofrequency and Radiofrequency fractional Microneedling,
4) High-Intensity Focused Ultrasound (HIFU),
5) Thermo-Mechanical Ablation,
6) Lasers
7) Thread Lifting.
Part 1 of this article will discuss the 3 techniques—Botulinum Toxin, Dermal Fillers, Fractional Radiofrequency and Radiofrequency fractional Microneedling. We will discuss the remaining 4 techniques in Part 2 next week.
The brow region is one of the major aesthetic features visible on the face and plays a significant role in facial and mood expressions. The brow is a complex and dynamic structure influenced by an individual’s gender and age. The male brow is broader and heavier than the female brow and lies over the superior orbital rim with little arch on a horizontal plane, whereas the female brow begins medially at or below the rim and ascends laterally with an arch, peaking in the lateral third as it tapers laterally.
Aging causes a decrease in bone, fat, collagen, and muscle volume in the supraorbital compartment, giving the face a sunken aspect. Furthermore, textural inconsistencies and a loss in tissue quality and elasticity reduce the superior orbital rim’s scaffolding ability, resulting in downward sagging of the brow, which not only gives an individual a fatigued, sad, or sunken appearance but may also impede vision. The lateral brow segment is more vulnerable because it receives less support from deeper structures than the medial brow. Although both men’s and women’s brows can descend with age, men’s brows are usually more resistant to such descent until they are 50 or older. However, current research indicates that the influence of aging on brow position is a complex process.
Moreover, temporary eyebrow shaping has become more frequent and is under higher demand among the younger population due to fast-evolving and changing beauty standards. The ideal aesthetic look of the brows varies by gender, with women preferring higher and more arched brows than men. Patients frequently contemplate brow lifting to correct extra skin; however, this procedure requires a major and sometimes expensive surgical procedure, with significant downtime and possible consequences such as deformity or scarring. As a result, non-surgical and minimally invasive rejuvenation procedures have grown in popularity over the last decade, with benefits such as reduced downtime, a higher cosmetic return, and a lower risk of side effects. This article provides a brief overview of recent publications on non-surgical brow lifting and reshaping procedures, and our feedback and practical experience on best practices in this field.
Ideal Brow Shapes
Eyebrow shapes have changed over the years, with different eras and cultures favoring different looks. In recent years, there has been a trend towards more natural-looking eyebrows, as opposed to the heavily arched brows that were popular in the 1990s. There are differences in gender and ethnicity in the upper face features, including the eyebrow shape and elevation. In the era of the metaphase, social media influencers and make-up artists significantly influence the norms and definitions of physical beauty and ideal facial features, including eyebrow shape and height.
The influence of make-up artists started decades earlier, as Westmore contributed to modern notions of the perfect female brow in the 1970s. Most of the debates were on the position of the eyebrow apex (EA) between the lateral limbus (LL) and lateral canthus (LC). The individual’s age determines the attractiveness of the female eyebrow shape and position. The 2007 statistics indicated that the desire for a certain eyebrow shape varied with age. Young participants up to 30 years old favored lowered and rejected arched eyebrows. Respondents older than 50 had the opposite preference. The position of the eyebrow apex is the main factor that affects the shape of the eyebrow (shown in the figure below). Regardless of the position of the EA, there is a consensus on the height of the eyebrow. The ideal height is 2.5 cm between the mid-pupil and the top edge of the eyebrow and 5 cm from the upper edge of the eyebrow to the female hairline.
Figure below shows the different eyebrow apex positions: (A) above the lateral limbus, (B) halfway between the lateral limbus and lateral canthus, (C) above the lateral canthus, and (D) later almost brow. EA, the apex of the eyebrow; LC, lateral canthus; LL, lateral limbus:
Forehead Anatomy
Below shows an eight-layer configuration that has been identified in the forehead, as shown in Figure 3. These layers, from superficial to deep, are as follows:
The eight-layer forehead configuration system. The fascial layers are exposive fashion, beginning at the skin (medially) and progressing deeper till they reacally, temporal crest). The hue of the neighboring fat can also be used to determine structure. The superficial fatty layer is the lightest (yellow), the retrofrontalis fat (bright orange), and the preperiosteal fat is the darkest (dark orange). Note how the orbicularis retaining ligament and the supraorbital ligamentous adhesion transition into more superficial layers and provide boundaries for cranial and caudal compartments.
Layer 1: skin;
Layer 2: superficial fatty layer;
Layer 3: suprafrontalis fascia;
Layer 4: orbicularis oculi and frontalis muscle (same plane);
Layer 5: a homogenous layer of fat (preseptal fat (in the upper eyelid), retro-orbicularis oculi fat (deep to the orbicularis oculi muscle), and retrofrontalis fat (deep in the occipitofrontalis muscle));
Layer 6: subfrontalis fascia;
Layer 7: preperiosteal fat within the prefrontal space in the lower forehead and deep compartments in the upper forehead;
Layer 8: periosteum bone.
Non-Surgical Eyebrow Lift Treatments
1. Botulinum Toxin
Although there is no direct attachment of the brow to the underlying bone, it is sensitive to the interaction of the numerous periorbital muscles, which, when functioning together, allow key nonverbal cues to be delivered. Understanding the balance and interplay of these muscles is critical when using neuromodulators to target the periorbital area. The 3D movement of the brows is controlled by four muscles.
Table below shows an overview of the three axes of eyebrow movement and the function of each periorbital muscle.
Botulinum toxin (BTX) is the most common non-surgical eyebrow lift treatment. A study noticed that their patients experienced eyebrow lifts after receiving BTX injections in the glabellar and crow’s feet areas. They concluded that the botulinum toxin allows the occipitofrontalis muscles to act without resistance from the depressor supercilii muscles (orbital orbicularis oculi, procerus, corrugator superciliis, and depressor supercilii) to provide a lateral eyebrow lift. However, no treatment protocol was proposed. Following this, various protocols with varying degrees of simplicity and injection points have been proposed. A recent review summarized the different techniques using BTX for brow elevation and shaping. In addition to the traditional hypodermic needle for BTX delivery, recent research has suggested microbotox, which combines topical delivery with increased skin permeability via thermal injury. The location and the depths of the BTX injection should be relative to the muscles’ function and placement in individuals.
Below shows the red dots that approximate the placement of botulinum toxin injections for brow elevation and shaping:
Below shows the red dots approximate the placement of botulinum toxin injections for the microdroplet lift:
Below shows the illustration of (1) frontalis muscles, (2) corrugator supercilia, (3) lateral part of the orbital orbicularis oculi, (4) procerus, and (5) depressor supercilii from a frontal and 45-degree position:
Below shows the five glabellar complex sites; eight crow’s feet line sites are injected (four on each side).Note that the various symbols used here represent different injection depths: squares indicate fullneedle depth, Xs indicate one-half needle depth, and asterisks indicate one-third needle depth:
The depressor supercilii is superficial and lowers the eyebrow. Therefore, the BTX injection should be shallow (approximately one third of the needle). The procerus draws down the eyebrow and is positioned under the depressor supercilii. Therefore, the BTX injection should be of medium depth (around one half of the needle). The corrugator supercilii draws the eyebrow downwards and medially and is positioned under a group of muscles. Therefore, the BTX injection should be deep (approximately the whole needle length). The lateral part of the orbital orbicularis oculi is superficial and draws the eyebrow downwards and medially. Therefore, the BTX injection should be shallow (approximately one third of the needle).
The eyebrows are a relatively inaccurate cutaneous landmark, particularly in females, due to their inclination to alter eyebrow shapes, such as tweezing or plucking. The treatment technique should be determined by the subject’s muscle mass, muscle shape, muscle activity pattern, and what is cosmetically acceptable in the context of the entire facial structure. Examining the overlaying soft tissues, such as fat and skin, is a useful adjuvant. Dosages are adjusted based on muscle activity and mass, while injection site placement is influenced by muscle shape. Practitioners should individualize the number of BTX units for each patient; for example, Asian people may need a lower BTX amount compared to Caucasian ones. Because the substance metabolizes within 3–4 months, major long-term effects of BTX therapy are uncommon. As a result, small problems are more likely and might be troublesome in the short term. Botulinum toxin difficulties fall into three categories: (1) injection-related complications, (2) complications inherent to the toxin’s pharmacologic qualities, and (3) the practitioner’s injection method in particular anatomical regions. Pain, swelling, bruising, a heavy feeling, and headache are common injection-related consequences. However, practitioners may consider applying particular approaches to alleviate these issues.
2. Dermal Fillers
In addition to BTX injections, there is also the dermal filler approach. Fillers are often utilized with BTX or when BTX fails to raise the eyebrows sufficiently. In addition to the eyebrow lift, fillers may increase the volume and shape of the eyebrows. The most common filler base is hyaluronic acid (HA). An upper-face-focused facial assessment and injection guide for BTX and HA fillers was published in 2017. The guide demonstrated a consensus for BTX injection positioning and low- and high-density HA filler density to enhance and elevate brows, and it was adapted in 2019. HA fillers are not the only ones reported for this purpose, as calcium hydroxylapatite fillers have also been used for the cosmetic enhancement of the brow.
There are three main factors to consider when injecting HA filler for eyebrow reshaping and elevation:
The entry points;
The depth and extension;
Injection techniques.
The Entry Points
Determining the entry point is critical to minimize the risk of bruising and other vascular adverse events. Furthermore, when using a cannula, a well-planned entry point may make the treatment more comfortable by reducing the number of entry points.
Below shows the typical branching pattern of the supraorbital artery and vein (S.O.A. and S.O.V.), the supratrochlear artery and vein (S.T.A. and S.T.V.), the dorsal nasal artery (D.N.A.), the angular vein (An.V.), and the zygomaticoorbital artery and vein (Zo.A. and Zo.V.), as well as the cannula entrance positions (green circles:
The ocular arteries are blood vessels in the circulatory system that supply oxygenated blood to the eyes. They arise from the internal carotid artery and pass into the orbit, or eye socket, through the orbital canal. The branches of the ophthalmic artery supply the orbit, the muscles, and the bulb of the eye, including the sclera, retina, and choroid. There 11 branches of the ophthalmic artery, including the
Supratrochlear artery (A. supratrochelaris—S.T.A.);
• Supraorbital artery (A. supraorbitalis—S.O.A.).
The other two major arteries in the periorbital areas are an external carotid artery branch:
• Zygomaticoorbital artery (A. zygomaticoorbitalis—Zo.A.);
• Dorsal nasal artery (A. dorsalis nasi—D.N.A.).
It is recommend one of three entry points to avoid filler injections in the supraorbital artery and supratrochlear artery:
• On the zygomaticofrontal suture to elevate the area lateral to the LC line;
• Lateral to the zygomaticofrontal suture, to elevate the area between the LL and LC lines;
• Medial to the mid-pupillary line to elevate the area medial to the LL lines.
The Depth and Extension
There have been several recommendations about filler injection depth. It also has been demonstrated that placing the fillers at the pre-periosteal plane requires a smaller volume of filler and is associated with reproducible results. Others suggest injecting into the subcutaneous plane rather than the sub-orbicularis and subcutaneous fat.
It is recommended injecting into the retro-orbicularis oculi fat (ROOF) pad as it has suitable depth, thickness, and dimensions for filler implementation. The ROOF fat compartment is approximately 1.2 cm in depth, with a mean thickness of 1.40 ± 0.2/1.30 ± 0.2 mm (mid-pupillary/lateral canthus), respectively. The mean length of this fat compartment (i.e., the distance between the orbicularis retaining ligament and the supraorbital ligamentous adhesion) is 13.68 ± 0.8/13.64 ± 0.9 mm.
The Injection Technique
The periorbital area is heavily vascularized. Therefore, soft tissue necrosis and visual impairment are examples of ischemic problems associated with filler injections that should be mentioned to patients undergoing filler injections. The incidence of vascular occlusion with face HA injections may be slightly lower at 3-9/10,000 injections. The glabellae and nasal region are the most at risk, although they can occur everywhere in which an artery runs, including the lip, nasolabial fold, and temple.
There are precautions that can be taken to avoid accidental intra-arterial product injection. However, no strategy is 100% efficient in preventing ischemic consequences. Utilizing local anesthetics with epinephrine to vasoconstrict arteries before injection, injecting tiny quantities at each pass, aspiration before injection, using a low injection pressure, avoiding scarred regions, and contemplating using blunt cannulas are some strategies that might be effective. Blunt cannulas, on the other hand, can reduce the risk but may behave similarly to needles, especially when used in scarred areas, where vessels are more prone to being tethered. Hyaluronidase injection into the vitreous cavity has been used in the past safely.
Below shows the injection techniques to help avoid ischemic complications:
It is highly recommend using a blunt cannula to minimize the risk of bruising and vascular occlusion. It is also recommend a multi-level technique with several retrograde linear paths. The filler should be first injected into the ROOF and then could be augmented by a deeper layer at the pre-periosteal plane. The volume of the filler depends on the expected results. Each eyebrow should receive a modest aliquot (0.2–0.5 mL) of filler until the clinical impact is obvious.
Practitioners who use the “pinch and pull” procedure should understand the anatomical changes associated with this technique. The “pinch and pull” technique separates the surface mobile tissue layers from the deeper layers. Because the blood arteries in the top two thirds of the forehead are being dragged up using a “pinch and pull” approach, injecting the filler at a deeper layer would be much safer. Because the blood vessels in the lower one third of the forehead and brow region, namely the SO artery and ST artery, are not pulled up with the “pinch and pull” maneuver, injecting the filler at a deeper layer in the lower third would be dangerous, and a superficial filler injection plane is preferred, particularly in the brow region.
Below shows the cadaver dissection demonstrates the “pinch anatomy” of the forehead, with the superficial mobile layers sliding across the periosteum to bunch up, allowing greater room for a needlebevel during filler injection in the loose areolar tissue layer:
Below shows the forehead cadaver dissection and filler material’s position (green color) in the relatively avascular, loose areolar tissue layer:
3. Fractional Radiofrequency and Radiofrequencyfractional Microneedling
As recently reviewed, radiofrequency (RF) devices produce controlled heating to encourage tissue regeneration and tightness. The proof of concept for the use of volumetric heating by radiofrequency (RF) was performed in 2004. Since then, the technology has evolved into bipolar, fractional delivery for RF. The ideal temperature for constant collagen, elastin, and hyaluronic acid production in the reticular dermis is 67 degrees Celsius, sustained for three seconds.
In addition to the traditional method of performing RF microneedling, a study found that if both the reticular dermis and the mimetic muscles were treated with microneedle penetration and fractional RF radiation, more benefits could be realized. The muscle and skin are closely connected and move as a unit in the lower eyelid, crow’s feet, upper lip, and commissure, making the intramuscular administration of RF energy possible.
A 2021 case reported the results of using a bipolar RF fractional microneedling device to achieve a non-surgical brow lift on two patients; the patients exhibited between 2 and 2.5 mm of brow elevation at their follow-up appointments.
We will discuss the remaining 4 techniques in Part 2 of Non-surgical Brow Lifting next week. Stay tuned!
Reference
Expert Opinion on Non-Surgical Eyebrow Lifting and Shaping Procedures (2022)
The fat compartments of the face: anatomy and clinical implications for cosmetic surgery (2007)
Anatomy of the SMAS revisited (2003)
Surgical anatomy of the mimic muscle system and the facial nerve: importance for reconstructive and aesthetic surgery (2000)
Uncovering the benefits, indications, & limitations of thread lifting in our upcoming Advanced Asian Non-Surgical Face Lifting Master Class happening globally:
IFAAS Master Class (Hands-On)
Korean Advanced Non-Surgical Face Lifting
Using Aesthetic Injectables, Devices and Thread Lifting
July 2, 2023 - London, United Kingdom - [Register Now]
IFAAS Master Class (Hands-On)
Korean Advanced Non-Surgical Face Lifting
Using Aesthetic Injectables, Devices and Thread Lifting
July 15-16, 2023 - Sydney, Australia - [Register Now]
IFAAS Master Class (Hands-On)
Korean Advanced Non-Surgical Face Lifting
Using Aesthetic Injectables, Devices and Thread Lifting
Sept 9-10, 2023 - Vancouver, Canada - [Register Now]
More Upcoming Aesthetic Trainings Happening Globally