Endoscopic Brow Lift Treatment & Management
- Author: Jorge I de la Torre, MD, FACS; Chief Editor: Lars M Vistnes, MD, FRCSC, FACS more...
Botulinum toxin (BOTOX®) injections may be used to temporarily improve horizontal rhytides caused by frontalis activity and glabellar frown lines caused by corrugator action. This is less expensive and less invasive than surgery but is not a permanent solution and must be repeated every 4-6 months to remain effective. Although injections may help decrease the same wrinkles of the forehead that are addressed by brow lift, BOTOX® may actually lower the eyebrows as the frontalis muscle relaxes. (For more information, see the article BOTOX® Injections and Medscape’s Aesthetic Medicine Resource Center.)
A 5-mm 30° scope with a xenon light source is the most commonly used endoscope. This provides a small cannula to minimize incision size but offers adequate illumination within the temporary surgical cavity. A wide variety of instruments are available for endoscopic facial procedures, including dissectors of various shapes, scissors, nerve hooks, cutting instruments, and graspers. Practically speaking, only a few instruments are needed to perform this procedure adequately. The most commonly used instruments include periosteal elevators, flat "pancake" dissectors, up-cutting periosteal dissectors, and grasping forceps.
Endoscopic brow lifts most commonly are performed under general anesthesia or with intravenous (IV) sedation and local anesthesia. Although the procedure can be performed with local anesthesia alone, this may cause untoward anxiety for most patients because of associated sounds and sensations.
The 3 general steps of brow lift are dissection, muscle elimination, and fixation.
Patients may be asked to shampoo their hair with bacteriocidal soap the night before or morning of surgery. Hair can be placed in rubber bands to facilitate access to premarked incisions.
The periosteum can be dissected from the skull more easily if tumescent fluid (200 cc saline, 1 amp epinephrine, 25 cc 1% lidocaine [Xylocaine]) is injected beneath the periosteum prior to dissection. Accomplish this with a 60-cc syringe and 18-gauge needle. Temporary distortion of soft tissues with fluid resolves quickly and hastens the periosteal dissection.
Preparation and draping is standard for facial procedures. Position the patient's head at the edge of the bed to reduce obstruction for endoscopic instrumentation.
Intraoperative strategies are explained in the sections below.
Make several small incisions just behind the hairline (most surgeons make 3-5 incisions). Scalp incisions usually are placed radially. Some surgeons place incisions transversely to avoid inadvertent tearing of a radial incision, but this is not a significant risk. Radial incision in the anterior scalp avoids transection of supraorbital nerve branches, which have a parallel course in this area. Incisions in the temporal region may be either radial or vertical; use vertical incisions to continue a temporal facelift incision if necessary. In a patient who is balding or has an unusually high hairline, make small transverse incisions directly on the forehead. These are well hidden when placed in a forehead crease. See the image below.
Most commonly, the forehead is dissected from the skull at the periosteal level. This provides excellent illumination of the surgical cavity because of the white periosteum above and white skull below. This approach requires scoring of the periosteum at the orbital rim to access the corrugator and procerus muscles.
Some surgeons prefer to leave the periosteum intact and elevate the central forehead in the subgaleal plane, since this is more similar to the standard coronal approach. This allows direct access to corrugator muscles; however, the subgaleal level is more vascular, and this significantly can decrease illumination in the surgical cavity.
Perform dissection of the anterior forehead blindly to within 1-2 cm of the upper orbital rim. Occasionally, the supraorbital nerve exits from a foramen above the orbital rim (< 2% of patients), so exercise caution.
Temporally, perform dissection under direct vision to the deep temporal fascia. Confirm this level by nicking the fascia to reveal the temporalis muscle beneath. Perform blunt dissection to the level of the zygomatic arch. With experience, this also can be performed blindly. However, a sentinel vein at the lateral orbit can bleed significantly if torn, and this vein is in close proximity to the temporal branch of the facial nerve. Most surgeons prefer to dissect this area under vision.
The most difficult part of dissection is the transition zone between the frontal bone and the medial insertion of the deep temporal fascia. This fascial transition zone can be difficult to take down, especially at the outer upper edge of the orbit; however, a complete release of this area is necessary to allow a full release of the brow. Inexperienced surgeons may be hesitant to aggressively take down or dissect this area because of its proximity to the temporal branch of the facial nerve. However, confirmation that this dissection is taking place in the deepest possible plane is possible under direct vision, thus ensuring protection to the overlying nerve.
With the periosteal approach, the periosteum is separated to completely free the brow and to allow access to corrugator and procerus muscles. Supraorbital nerves are found just lateral to the mid point of the orbit. These nerves run in neurovascular bundles and are associated with multiple small veins. Nerve configuration varies greatly, from one large nerve to several branches of varying sizes. In general, one major branch can be identified and is easy to preserve. The nerve occasionally exits from a foramen above the orbital rim but usually exits beneath the rim in a groove.
Separate, avulse, or resect corrugator muscles. Separation by blunt avulsion of the muscle is unevenly effective in decreasing corrugator function. Resection of muscle is more effective in decreasing function, but overresection can lead to surface irregularities in skin. Ablation of muscles with a carbon dioxide laser is a successful method for weakening these muscles; however, this requires equipment not readily available to most surgeons. Additionally, some surgeons prefer to address corrugator muscles from below via upper eyelid incisions. Fat grafting into corrugator space is also an effective method to permanently decrease corrugator function. Regardless of technique, reducing the motor action of the depressor muscles is key to successful outcomes.[13, 14]
This portion of the procedure may vary widely, from no fixation, to temporary fixation, to permanent fixation. Permanent eyebrow elevation can be achieved by dissection alone without fixation, but this method is less predictable.[15, 16] See the images below.
Screws are posterior to the hairline; place staples or sutures around them to anchor the elevated brow into place for 10-14 days. Remove screws once the forehead structures have been allowed to stick into place. Permanent screws (eg, titanium, brass) require removal as a separate procedure in the office. Absorbable screws avoid this additional procedure; however, they add some operative time for tapping drill holes and placing sutures. Because these screws take several months to absorb, this fixation technique falls in between temporary and permanent fixation. Absorbable screws have become less bulky and slightly easier to use recently but, in some cases, still result in the formation of sterile abscesses.
Temporary suspension can also be achieved through the use of external suspension sutures. Nylon sutures placed through staples at the anterior hairline access incisions and several centimeters posterior can be used to provide suspension for 4-6 days. The staples are easily removed without any local anesthesia.
Perform permanent fixation with a Mitek anchor and suture, with a short permanent titanium screw, or by drilling a cortical tunnel in the bone through which a suspending suture can be secured. Proponents of permanent fixation argue that it provides a more predictable elevation to the brow, while proponents of temporary fixation argue that any suspending suture placed under tension ultimately "pulls through."
Changing Brow Shape and Asymmetry
Correcting an asymmetric brow can be difficult. When the forehead is dissected equally free on both sides, the entire forehead and brow tend to move as one unit. The assumption often is made that elevating and fixating one side of the brow higher than the other leads to long-term correction of asymmetry. Some correction may be observed for weeks, or even months, but in the long term a symmetric dissection most often results in a symmetric lift, maintaining any preexisting asymmetry. The same is true for brow shape. Excess pull in the lateral or middle brow may selectively elevate a portion of the eyebrow in the desired manner, but over several weeks, eyebrows tend to maintain their original shape. See the images below.
Changing eyebrow symmetry relative to one another or changing eyebrow shape requires an asymmetric dissection. If the surgeon wishes to raise the right brow more than the left, the dissection on the right must be more aggressive and complete, and the lift on this side must be exaggerated. Similarly, if the surgeon desires to selectively raise the lateral brow, its dissection must be more complete than the dissection medially. In this instance, the periosteum in the glabellar area can be left intact to prevent elevation and spread of the medial head of the eyebrow. See the images below.
Postoperative care following endoscopic brow lift is minimal. A soft compressive dressing usually is placed for 1-2 days. Swelling and bruising usually are minimal. Ice may be used for the eyes, which occasionally become significantly bruised even without concomitant eye surgery. Use standard analgesic medications. Many patients experience little or no postoperative pain, while others complain of moderate-to-severe headache.
Observe patients on the first day postoperatively and again during the first week. Remove sutures or staples at 5 days. If used, leave temporary fixation screws in place from 10-14 days depending on preference. Provide routine follow-up care at 1 and 3 months. Postoperative complications are rare. However, observe patients with complications more frequently as needed.
Complications from this procedure are infrequent. They include malpositioning or shaping of the brow, recurrence of brow ptosis (ineffective lift), forehead contour irregularities, alopecia, scarring, numbness and/or paraesthesia, and temporary or permanent paralysis of the frontalis muscle.
Nearly all patients undergoing this procedure reiterate their desire not to appear startled or surprised. The most common type of malposition observed is a brow that is elevated too high or over-elevated. Lowering a brow that has been over-elevated is difficult. If the periosteum between the brows and corrugator muscles is taken down extensively, brows can separate and elevate. When this occurs in conjunction with failure to adequately release the lateral brow, eyebrows can assume a downward slope, from medial to lateral, creating a sad appearance. A brow that is not adequately released or is excessively heavy may not remain elevated, leading to little change in appearance. In this instance, the procedure may need to be repeated.
This is a rare complication. Overresection of corrugator and procerus muscles can thin the glabellar area irregularly, leading to surface irregularities. In one patient who was operated on at a different facility, the author observed severe contour irregularities of the entire forehead appearing 4-5 months after endoscopic brow lift. The physician can treat this complication with fat grafting.
This complication is related closely to the fixation method. Any procedure requiring undermining of the scalp (eg, fixation by fascial imbrication) can lead to large areas of alopecia (3-cm diameter). Temporary screw fixation may lead to alopecia occasionally, but this is usually not a large area (< 1 cm). Placing temporary fixation screws in smaller separate stab incisions can eliminate this complication. Permanent fixation beneath the scalp should not cause alopecia. Large areas of alopecia (eg, entire scalp, front half of scalp) have been reported after endoscopic brow lift, but this also has been described after cosmetic surgery on the face and body and may be related to anesthesia or stress of surgery. These patients experience full recovery.
Scarring and poor wound healing
Because of the endoscopic technique, scarring should be minimal. This is one of the significant advantages of the procedure. However, even small scars may become unacceptably wide, creating noticeable areas of cicatricial alopecia. This is usually a function of incision length and fixation technique. Small incisions (1 cm) rarely, if ever, result in significant scars or cicatricial alopecia. Temporary fixation screws placed through access incisions may delay healing because of increased tension on the wound leading to a widened scar. Scars easily are excised under local anesthesia.
Numbness and paraesthesia
Forehead and scalp numbness is relatively common (40%) but short lived. Caused by edema and stretch of the supraorbital nerves, this usually resolves within days or weeks. Occasionally, numbness may persist for as long as 3 months. On rare occasions, severe scalp pain may occur, but it can be treated conservatively.
Permanent damage to the temporal branch of the facial nerve has been reported, but this is a rare complication. Transient loss of frontalis function may be observed on one or both sides, especially after a more aggressive lateral dissection. This also is a rare complication, occurring in fewer than 1% of patients. Motor deficits resolve within 3 months.
Outcome and Prognosis
Brow elevation present at 3 months tends to remain stable over the long term (1-5 y). Because of this, over-elevated brows have little chance of settling in the long term. Longer follow-up results will be available more readily in the future; longevity of results obtained with this procedure is expected to be excellent.
The efficacy of the endoforehead lift is supported by extensive, systematic, and long-term data. In particular, it demonstrates superior results when compared with transpalpebral approaches. The lack of efficacy after transpalpebral browpexy is most likely caused by a decrease of frontalis hyperactivity after the simultaneously performed blepharoplasty.
Future and Controversies
The endoscope gradually has been incorporated into most surgical specialties and now is used for multiple purposes in plastic surgery. Thus far it has proven most useful for brow procedures. Most plastic surgeons performing cosmetic procedures incorporate endoscopic brow lift into their practices. Of those who do not routinely use the procedure, most have at least tried it before deciding to use another method.
Many have concluded that this approach is not as effective or versatile as the standard open approach. However, surgeons with significant experience with endoscopic procedures are convinced of both its efficacy and of patient willingness to accept a procedure seen as less invasive and with less chance of scarring and complications.[20, 21, 22]
Current research in a rabbit model demonstrates that periosteal adherence does not become complete for 6 weeks. How this relates to the permanence of a brow lift performed with temporary versus permanent fixation is not yet determined. There is, however, a relative paucity of good comparative studies comparing open and endoscopic approaches with brow rejuvenation. It is important to recognize that there is still an important role for the open approach to brow aesthetic dilemmas.
The advent of the thread lift or Silhouette thread impacts minimally invasive approaches to facial rejuvenation and forehead lifts. Combined with muscle weakening and endoscopic undermining of the forehead, these threads allow for precise elevation of the forehead and shaping of the brow, particularly in the lateral portion of the forehead. Further evaluation of how best to implement these techniques is ongoing.
Core GB, Vasconez LO, Graham HD 3rd. Endoscopic browlift. Clin Plast Surg. 1995 Oct. 22(4):619-31. [Medline].
Lee CH, Lee C, Trabulsy PP, et al. A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair. Plast Reconstr Surg. 1998 Feb. 101(2):333-45; discussion 346-7. [Medline].
Eich BS 2nd, Fix RJ. New technique for endoscopic sural nerve harvest. J Reconstr Microsurg. 2000 May. 16(4):329-31. [Medline].
Freund RM, Nolan WB 3rd. Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females. Plast Reconstr Surg. 1996 Jun. 97(7):1343-8. [Medline].
Gunter JP, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr Surg. 1997 Jun. 99(7):1808-16. [Medline].
Janis JE, Ghavami A, Lemmon JA, et al. Anatomy of the corrugator supercilii muscle: part I. Corrugator topography. Plast Reconstr Surg. 2007 Nov. 120(6):1647-53. [Medline].
Janis JE, Ghavami A, Lemmon JA, et al. The anatomy of the corrugator supercilii muscle: part II. Supraorbital nerve branching patterns. Plast Reconstr Surg. 2008 Jan. 121(1):233-40. [Medline].
Knoll BI, Attkiss KJ, Persing JA. The influence of forehead, brow, and periorbital aesthetics on perceived expression in the youthful face. Plast Reconstr Surg. 2008 May. 121(5):1793-802. [Medline].
Griffin GR, Kim JC. Ideal female brow aesthetics. Clin Plast Surg. 2013 Jan. 40(1):147-55. [Medline].
Matarasso A. Endoscopically assisted forehead-brow rhytidoplasty: theory and practice. Aesthetic Plast Surg. 1995 Mar-Apr. 19(2):141-7. [Medline].
Trinei FA, Januszkiewicz J, Nahai F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg. 1998 Jan. 101(1):27-32. [Medline].
Kelly CP, Yavuzer R, Keskin M, et al. Functional anastomotic relationship between the supratrochlear and facial arteries: an anatomical study. Plast Reconstr Surg. 2008 Feb. 121(2):458-65. [Medline].
Miller TA, Rudkin G, Honig M, et al. Lateral subcutaneous brow lift and interbrow muscle resection: clinical experience and anatomic studies. Plast Reconstr Surg. 2000 Mar. 105(3):1120-7; discussion 1128. [Medline].
Hamas RS. Reducing the subconscious frown by endoscopic resection of the corrugator muscles. Aesthetic Plast Surg. 1995 Jan-Feb. 19(1):21-5. [Medline].
Foustanos A, Zavrides H. An alternative fixation technique for the endoscopic brow lift. Ann Plast Surg. 2006 Jun. 56(6):599-604. [Medline].
Ramirez OM. Endoscopic subperiosteal browlift and facelift. Clin Plast Surg. 1995 Oct. 22(4):639-60. [Medline].
Vasconez, LO, de la Torre, JI. Fine-tuning the endobrow lift. Aesthetic Surg J. 2002. 22:69-71.
De Cordier B, de la Torre JI. A retrospective analysis of 400 endoscopic forehead lifts. Plast Reconst Surg. 2002. 110:1558-1568.
Iblher N, Manegold S, Porzelius C, Stark GB. Morphometric long-term evaluation and comparison of brow position and shape after endoscopic forehead lift and transpalpebral browpexy. Plast Reconstr Surg. 2012 Dec. 130(6):830e-840e. [Medline].
Graham DW, Heller J, Kirkjian TJ, Schaub TS, Rohrich RJ. Brow lift in facial rejuvenation: a systematic literature review of open versus endoscopic techniques. Plast Reconstr Surg. 2011 Oct. 128(4):335e-341e. [Medline].
Guillot JM, Rousso DE, Replogle W. Forehead and scalp sensation after brow-lift: a comparison between open and endoscopic techniques. Arch Facial Plast Surg. 2011 Mar-Apr. 13(2):109-16. [Medline].
Angelos PC, Stallworth CL, Wang TD. Forehead lifting: state of the art. Facial Plast Surg. 2011 Feb. 27(1):50-7. [Medline].
Romo T 3rd, Sclafani AP, Yung RT, et al. Endoscopic foreheadplasty: a histologic comparison of periosteal refixation after endoscopic versus bicoronal lift. Plast Reconstr Surg. 2000 Mar. 105(3):1111-7; discussion 1118-9. [Medline].
Graham DW, Heller J, Kurkjian TJ, Schaub TS, Rohrich RJ. Brow lift in facial rejuvenation: a systematic literature review of open versus endoscopic techniques. Plast Reconstr Surg. 2011 Oct. 128(4):335e-341e. [Medline].