Ptosis or droopiness of the forehead is in many cases the earliest sign of aging, anticipating many years to other stigmata such as wrinkling, sagging face and neck or the eyelids bags.
The anatomy of deep facial rejuvenation (excludes skin aging and wrinkles) is divided into three thirds or units, which partially overlap to each other. The upper third (excludes the eyelids) or frontal, eyebrow and orbital complex along with the cheekbones and the upper part of the cheek, the middle third or cheekbones, cheek, nasolabial region and mandibular profile, and the lower third that extends from the mandibular edge to the lowest part of the neck.
Forehead droopiness is a simplified way of naming the gravitational aging of the upper third of the face, including forehead, eyebrows and upper cheek, which due to aging migrates inferiorly, being more striking in the tail of the eyebrow.
Although there are cases of severe forehead droopiness in young or very young people due to familiar hereditary factors which may require corrective treatment, the most common scenario is patients showing a marked degree of forehead droopiness from the 40s and on, often as the only remarkable sign of facial aging or associated with eyelids aging.
In many occasions the patient is unable to detect the eyebrows droopiness, attributing their dissatisfaction to the aging of drooping upper eyelids. In the border region between the brow (frontal territory) and the upper eyelid (orbital territory) there is a very clear frontier between a thin, dark and elastic skin that belongs to the upper eyelid and a lighter, thicker and firmer skin that corresponds to the eyebrow and therefore does not belongs to the upper eyelid.
Some patients call droopy upper eyelids what is really eyebrow droopiness, or both problems coexist so we would be before a case of excess skin on the upper eyelid aggravated by the descent of the tail of the eyebrow. It must be borne in mind that when the eyebrows descend they cause a severe aggravation of the upper eyelid skin excess, which may confuse patients and surgeons who are not experienced in facial plastic surgery. In other words, the greater the descent of the eyebrows, the more it seems that upper palpebral skin is left over, but it is not the real amount of excess skin on the upper eyelid; the actual amount of excess skin on the upper eyelids is diagnosed with the eyebrows in their correct position.
It is very important that the patient receives an exact diagnosis, because under no circumstances should eyebrow skin be removed for misinterpreting that much upper eyelid is in excess, which would cause even greater lowering of the eyebrow, just as you cannot pretend to remove the excess of upper palpebral skin by an aggressive treatment of the eyebrow, as it would entail a grotesque and artificial appearance or even a functional limitation of upper eyelid closure.
In most cases, the patients suffer at the same time from skin and muscle excess on the upper eyelid along with a greater or lesser degree of eyebrow droopiness, so it is usual to simultaneously perform the treatment of both problems.
As a rule of thumb it can be said that the forehead should be at the same level as the upper edge of the orbital rim (bony frame that surrounds the eye) or slightly above; in some cases and especially in women the tail of the forehead should be noticeably above of the mentioned edge of the orbital bone.
Best state of the art treatment for the droopy forehead is the temporal fossa (temple) short incisions supraperiosteal eyebrows and forehead extended into cheeks lift with interfascial anchoring support.