I think you have handled this issue quite wisely. You haven't rushed into survey and have used Botox for brow elevation for five years. If the Botox is no longer producing the degree of elevation which you require, then considering the open brow lift is appropriate. I agree with your surgeon that patients with fair skin tend to heal nicely, although there can always be exceptions. If the incision is into the hairline and not at the junction of the hairline and forehead, you should not need to wear bangs and the scar will be camouflaged.
Brow Lift for Sagging Brows and High Forehead
The best procedure for a ptotic or sagging brow with a high forehead is the open hairline brow lift. This prevents the raising of the brow that would occur if a standard open incision was used.
The incision runs right along the hairline or just behind the first few hairs. In addition the incision is often beveled or angled to allow hair to grow through the incision. In fair skinned patients if the closure of the would prevents any tension on the skin the scar can be very good. But if too much tension is applied the incision can widen slightly.
But overall these scar tend to be well camouflaged.
Brow Lift and Hairline Lowering
With a "tricophytic" (in the hairline) incision you can raise your brows and lower the hairline at the same time. Hair will grow through and in front of the scar. This is a procedure we described many years ago and use frequently in our practice to maintain or lower hairline position. After the surgery you will not have to style your hair to hide the unfavorable hairline position.
High forehead + low brows = anterior hairline browlift
I have followed the above equation for ten years in my practice and can honestly say that I have not had any patients that were not pleased with the procedure, from the elevation of the brow, to the shortening of the forehead, to the nearly imperceptible scar. The incision should be beveled to allow hair to grow back through the scar, however.
Brow lift with scar at the hairline
Your surgeon"s recommendation is a reasonable option. Poor scar formation is a risk, but many times hairline scars can be nearly imperceptible after a period of time. You have tried BOTOX for a while and it no longer improving your low brow position. If you have a high forehead and hairline and the scar is placed behind the hairline then your hairline ends up being even higher. Your decision making, along with the advice of your surgeon is an analysis of all the "pros" and "cons" -the different "trade-offs" of the options.
How much does your brow position bother you? How high is your hairline now and could you accept it if it ended up a little higher? How much would it bother you if you got the brow position you wanted, but you didn't heal well and your scar was slightly visible? How much would it bother you if you couldn't pull your hair back.
Short-scar Temporal brow lifting may be an option worth investigating.
Depending on your surgeon, and your healing, a hairline-long-scar brow lift can lead to a favorable result. I'm not a big fan of brow lifting, in general, and typically get gratifying results with BOTOX.
The short-scar, Temporal brow lift described by Tonnard and Verpaele shouldn't change your hairline, and is effective at elevating the outer part of the brow near the temples.
I hope this is helpful, and best regards.
Scarring is Always A Concern
Scarring after any procedure is always a concern. You will likely not want to pull your hair back after a hairline incision as this can show the incision line. Most other hairstyles though should easily cover the incision. The biggest risk with these incisions is hair loss at the incision line. Fortunately, should this occur, a scar revision or hair transplant procedure is a good option for repair.
Browlift scars can be barely visible
IF you are seeking a brow lift and to raise your hairline at the same time, both and open browlift as well as an endoscopic brow lifts will raise your hairline as well. I agree that for a very low brow, the open browlift is more predictable regarding the hairline but equal when it comes to raising your eyebrows.
An incision behind the hairline usually heals quite well. Bangs are suggested only if the incision is at the hairline. In the latter case, a pre-trichial incision is actually through the hair follicles. That way when the hair re-grows it comes through the incision and helps to camouflage it. Bangs might be necessary for a few months during the healing period but not necessarily forever.
The bottom line is, that if your surgeon chooses the appropriate incision for you, it is usually not visible to the untrained eye.
Pretrichal or direct hairline forehead lift and the resulting scar.
Scarring is generally good but can vary. In some instances it can create an abrupt hairline transitiion giving the appearance of hair grafts. Techniques used to minimize this include the use of a zig-zag line and burying of hair follicles under the incision so that hair grows through and camouflages the scar. Some physicians advocate the use of skin needling at a later date to "blend" the scar. Occasionally the scar can be wide or prominent necessitating the use of bangs.
Wound Healing Following Browlift
It’s not unusual for patients who
have used Botox for prolonged periods of time to eventually require a
browlift. Although botox has a
profound impact on the upper facial muscles, the effects of gravity are unrelenting
and eventually result in drooping brows.
When this occurs a browlift is
usually necessary to correct the problem. In patients with high foreheads, an
open approach with a hairline incision may be necessary to avoid further
elevation of the hairline.
In the majority of patients who
undergo this type of browlift wound healing is excellent and scarring is
minimal. Blond light skinned
patients tend to heal with minimal scarring.
Despite this, wound healing is
variable and rarely patients can have noticeable scarring with this
approach. Under these
circumstances bangs are probably the best way to hide this type of scarring.
It’s important to discuss these
issues with your plastic surgeon.
Your surgeon should be able to answer your questions and make this a
more comfortable experience.