Brow lift should be undertaken with caution in the patient with any evidence of preexisting upper orbital fat hollowness.

If the brow is pulled higher in such a patient, hollowness previously camouflaged by draping skin will become more fully exposed and noticeable, thus resetting the center of visual attention away from the eye's pupil and up into the sunken area.

Not only does this "age" the eye unnaturally, but it effects a major layout change in facial appearance.

Young Patient After Brow Lift Performed Elsewhere

Preexisting upper (and lower) orbital
hollowness is not objectionable because
of a natural lower brow position. Eye
appears attractive and youthful.

After brow lift alone (no eyelid surgery),
a cavernous hollow has been exposed
showing skin collapsed beneath the
rim of bone (doll's eye deformity).

Because preexisting orbital hollowness often goes unrecognized by patient and surgeon until after brow surgery, this outcome is not at all rare. In most younger patients with a naturally-occurring low brow, the major anatomical determinant is an inherited relative paucity of upper orbital fat and not age-related stretching or drooping of the forehead. Without abundant support from below, the brow in such a person simply sits naturally lower but looks attractive because it is in its normal position.

Many people, for instance, of eastern European or southern Asian heritage (and these are only two examples) possess a naturally skimpy allotment of orbital fat. This should not be viewed as "abnormal." Low brow position in this population is the norm rather than the exception. Trying to impose an aesthetic taken from one group upon another can lead to disturbing outcomes.

If a brow lift is performed in this setting, the result can be counterproductive and very difficult to remedy.

The harsh appearance of upper hollowness exposed by undesirable brow lift can be softened by placement of orbital fat grafting. Simple injection of liposuctioned fat aspirate or temporary fillers into the fat pad of the brow is both fleeting and not cosmetically effective.