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shadow," says Dr. Rizk. "I prefer to use conservative fat grafting in this area whenever possible, often combined with PRP for skin rejuvenation." Surgical Solutions for the Upper Eye There are three main options for treating hooding of the eyelids and descending brow lines: brow lift, blepha- roplasty or a combination of both procedures. Choosing the correct procedure requires careful consideration. Dr. Stevens finds that many patients who come to him seeking a brow lift are misinterpreting what they see. They think their brows have dropped; instead their brows have defl ated where the soft tissue and bone around the upper part of the orbit is beginning to resorb. In these cases volume replacement may address their concerns, or a combination of lifting and filling may be required. When performing brow lifts, Dr. Stevens does offer a few cautions. "I have a very high tolerance for suggest- ing a brow lift because I really think it changes the way an individual looks in most circumstances," he says. "For some people, a brow lift actually makes them look better. But in others it makes them look different, so I always surgicalaestheticsmagazine.com | MARCH 2016 73 point out to a patient what a brow lift is going to do and how it will make them look different." Men and women often desire very different outcomes in the brow area. Men tend to have fl at brows with minimal arching, whereas women most often have—or prefer— an arched brow, says Dr. Rizk. "Women have a more defi ned arch that becomes more masculinized with age," he says. "Botox is an ideal fi rst-line treatment to lift the lateral brow temporarily and address glabellar creases and horizontal forehead lines." For patients who need more lifting than toxins can provide, Dr. Rizk performs an endoscopic brow lift. "These procedures do not require a long recovery, and the incisions are hidden in the hairline, which is what most patients want today," he says. In order to determine whether a brow lift alone will suffice or if a blepharoplasty is required, Dr. Alessi has the patient look in a mirror and uses his finger to hold the brow up. Then it becomes clear if significant blepha- rochalasis needs to be addressed. "Many patients will come in for a blepharoplasty second opinion," he says. "When the brow is held up, some will have no upper eyelid skin left to excise. A bleph on these patients can lead to a very hollowed out look that is not desirable." www.viscot.com 800.221.0658 maximum visibility after prep and Tumescent! #1447XL #1448XL Gold Standard for marking where preps or fuids remove the surgeon's marks. Visible up to 10x longer against all prep solutions. visit www.bit.ly/XLTrial for trial ofer