Inside Cosmetic Surgery speaks with Dr. Marc Cohen about the often overlooked area of the face between the upper eyelids and the hairline: the forehead.
Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Marc Cohen, an ophthalmic plastic surgeon with a private practice in the Philadelphia area. Hi Dr. Cohen, how are you?
Dr. Marc Cohen (DMC): Fine, thanks. How are you, Sharon?
SO: I’m great. Thank you. Well, today’s topic is forehead rejuvenation. And let’s just start out by asking what is forehead rejuvenation exactly.
DMC: Well, forehead rejuvenation is anything that would be included in things to make your forehead and eyebrows look younger and more attractive, and that really includes somewhat the eyelids also because the eyebrows and the eyelids are now considered to be one cosmetic unit.
So it’s really the area from your upper eyelid up to your hairline. And taking care of wrinkles and eyebrow position and having the fullness and the natural curves that we would like to see in a young attractive forehead.
SO: What about the dermal fillers that are on the market? I mean, how do they play into the forehead rejuvenation?
DMC: Well, we’ve learned over time that faces tend to deflate rather than just fall. We used to think of things two dimensionally that foreheads and the rest of our faces fell downward. But now we could think of them as sinking inward. Fillers add volume, so we can re-inflate the eyebrows and parts of the forehead to make them look like they did when they were younger.
SO: So the fillers play a very important role in the rejuvenation process. Is that all there is to it, just the fillers?
DMC: Well, we treat foreheads with fillers. We also treat with neuromodulators, which are things like Botox Cosmetic, Dysport and Xeomin, and those help to reposition the eyebrows and shape the eyebrows and then we do things to treat the skin of the forehead like we do in other places of the face with things like skin resurfacing with these various lasers or with topical creams to make the skin look younger and more attractive.
SO: Now, what about fat transfer, how does that play into this?
DMC: Well, fat transfer is really another type of a filler. It adds volume and it’s very popular among some surgeon and less popular among other surgeons. Fat transfer has the benefits of being possibly more permanent, which is an advantage. Some of the disadvantages are it’s much more of a surgical procedure. There is more bruising afterwards and more downtime. It’s done generally in an operating room as opposed to fillers, the other types of fillers I’m talking about, which are done in an office setting.
Also fat does not always last permanently and sometimes when it does not last, it resorbs, it dissolves in an uneven way at times. And if that happens, it can leave you with some irregularities which are always easy to repair, but there are many surgeons who believe much in fat transfer and certainly some of them get very good results.
SO: What is the difference between forehead rejuvenation and the traditional brow lift?
DMC: So a brow lift is really an upper facelift. It involves taking the forehead and mostly the eyebrows and raising them to a higher position, and that’s a form of rejuvenation. Also, it’s a surgical rejuvenation that lifts the brows.
The approach we tend to take now is to feel that generally eyebrows do not fall a lot. In many patients, they don’t fall at all as they get older. They just sort of look like they have fallen because they have deflated. There is less full fat beneath the brows and because of that, because the curves of your youth are not there, it gives the illusion that the brows are lower than they actually are.
So we often add volume underneath the brows in order to return those natural curves rather than doing a surgical lift, which just makes the brows higher and often puts the brows in an unnaturally high position.
SO: When did you shift to more forehead rejuvenation versus the traditional brow lift?
DMC: Well, it was sort of a gradual transition. Forehead lifts became very popular in the 80’s and in the 90’s. And in the 90’s, Botox Cosmetic came along, so we started doing some rejuvenation with Botox and lifting of the brows somewhat with that. Then in the mid-2000s, around 2004, hyaluronic fillers became available and that was sort of an ideal weight and volume to the forehead. So it was sort of a gradual transition.
SO: And I imagine it’s better because it’s less invasive.
DMC: Well, it’s definitely less invasive. People that have rejuvenation with hyaluronic acid fillers tend to have it done as a lunchtime procedure and they may have a little bit of swelling, and it’s always possible they could have bruise, but basically they are back to work either that day or the next day after they have it done.
SO: Is that the general trend to move towards fillers versus the traditional lift?
DMC: Well, there certainly are some surgeons who still do a lot of forehead lifts, but there is a trend in general to minimally invasive treatments like fillers. Last year, about 85% of all cosmetic treatments done were minimally invasive rather than surgical procedures.
SO: I can see why. It’s so much better for the patient, I would think. But how often do patients come in and say that they want a forehead lift and you talk them into fillers instead?
DMC: Well, basically, I don’t think cosmetic surgeons should really talk their patients into having a procedure that they don’t want to have. So when someone comes in to see us, we evaluate them and listen to their concerns and then we educate them as to the available options.
As I mentioned before, most people don’t realize this, but a young and attractive woman would, let’s say, tends to have very full and relatively low eyebrows. In youth, there is a small, smooth curve that goes in the eyebrow then all the way down to the eyelid crease. Brows can look lower as they deflate so people sometimes think their brows have dropped even though they haven’t.
So I’ll often ask patients to bring in old photographs and we compare them to their recent pictures. Most people’s eyebrows are not significantly lower than they were years ago, they are just flatter, and when people realize that, the often like the idea of brow filling rather than brow lifting.
SO: Once you’ve presented the less invasive option, do they usually choose to do that instead?
DMC: They often choose to do that. Often it starts with the idea of, “Well, let’s give that a try because it’s less invasive and it doesn’t tend to be permanent.” And so we will give that a try and then they feel they have the option to later have a surgical treatment if they want to, but usually it doesn’t even come to that.
SO: How often do they come back and say, “You know, this is great, but I want the lift?”
DMC: It’s pretty rare in our practice, I would say. I would say most people feel they get a nice, natural rejuvenation with things like fillers and modulators and then they do not tend to have surgery.
SO: What are the potential risk and side effects of forehead rejuvenation?
DMC: Well, basically, anytime there is anything with injections, there is always a chance of bruising and swelling and that can occur with any treatment. That’s a very minor side effect. It’s almost hard to call that a side effect, but it certainly can happen.
You can get lumps and bumps with hyaluronic acid fillers or with any type of filler. Fortunately, if you are using fillers, particularly hyaluronic acid fillers, they are very easy to correct. There are some more serious side effects, which are extremely rare, with things like scarring and infection and even the possibility of visual loss when having treatments that close to the eye.
DMC: The fillers that we prefer are the hyaluronic acid fillers, and of those, the ones that we use are the Juvéderm family of fillers and the Restylane family of fillers.
SO: What are the limitations of using fillers versus the traditional brow lift?
DMC: Well, basically, they are not permanent. Of course, brow lifts are not really permanent either, but they last a lot longer than fillers do. So patients who get fillers tend to come in for repeat treatments.
However, with hyaluronic acid fillers, they tend to last longer than most people think. In the forehead area, it’s not unusual for fillers to last a year or even longer and that’s from the initial treatment, and on repeat treatments, they last even longer.
There are some patients who are sort of born with very, very low eyebrows. That’s just sort of their look and if they don’t like that and they want their brows to look physically higher and that’s really what their problem is, then a forehead lift is better for them than fillers.
SO: With forehead rejuvenation, would you say that it affects a certain age group or a particular gender?
DMC: Well, it’s certainly both men and women who have brow rejuvenation, but like almost all cosmetic procedures, it’s much more common in women than in men and like most cosmetic procedures, the most popular age groups are in the sort of 40 to 65 year age group.
SO: Yes, I noticed that. Most of the surgeries tend to be focused towards women, but more and more men are getting cosmetic surgeries these days, correct?
DMC: Yeah, there is no question. There are plenty of men who have cosmetic surgery. They feel they would like it for career advancement or for social reasons. Certainly, it’s not unusual, for men to have cosmetic surgery. But in terms of the overall statistics, it’s certainly more common in women than men.
SO: Do you have any cases where someone comes in for the forehead rejuvenation and then they will say, “You know, now, my lower face needs some work.” Does that ever happen?
DMC: It is quite common, not because having one thing done makes it look more necessary to have other parts of your face done, but it’s rather sort of getting your toe in the water. You’ve tried it and you found it to be a pleasant experience. You like the fact that you look better and you didn’t find it to be difficult to do.
So people are then interested in exploring other avenues of looking better just like they did with their forehead. It works in both directions, of course. Some people come in with lower face questions and then later on have brow rejuvenation or the other way around.
SO: You specialize in forehead rejuvenation or do you specialize in the face?
DMC: Well, I specialize in both and really anything to do with the face. I’m a board certified in cosmetic surgery as well as in ophthalmology.
SO: So I would imagine that anything involving the eyes that someone would have to be specialized, right, because you have to be very careful around the eyes, correct?
DMC: Well, I mean, there are certainly are very good cosmetic surgeons of different specialties that do eyelid surgery, but we focus on that particularly because of our background in ophthalmology, yes.
SO: Do you have any patient stories you would like to share, no names, of course, but just examples of success stories?
DMC: Boy, I’m not sure I can think of a specific story. I mean, I think that there are many patients that have forehead rejuvenation and they often have their surgery and are delighted with the results. The most successful ones, people who look at them don’t realize that anything specific was done. They just feel as if they look like they’ve had a vacation or they’ve changed their hairdo or new type of glasses.
They are people that were the most excited about in terms of results because we’d like people to look like nothing was done, but just to look better.
SO: Well, is there anything else you would like to tell our listeners about forehead rejuvenation? Perhaps tell us about your practice, your website?
DMC: Well, we are in practice in the Philadelphia area in the suburbs of New Jersey and the Main Line in Philadelphia. Our website is www.cosmetic-eyes.com and you can read more about us there if you would like.
SO: And you are in practice with your wife, correct?
DMC: I’m practicing with my wife, Dr. Nancy Swartz. The two of us both are active plastic surgeons, and we have a mom and pop practice.
SO: Excellent, and you are also a member of the AACS (American Academy of Cosmetic Surgery)?
DMC: Absolutely! I’m a proud member of the AACS. We think it’s a wonderful organization. It promotes people from many different specialties, all of whom are interested in cosmetic surgery, and we all learn from each other and it’s a wonderful avenue for the advancement of cosmetic surgery.
SO: Thank you. This has been great, and I really appreciate your time and we will talk to you soon.
DMC: Thank you.