Endoscopic Forehead Lift Treatment & Management
- Author: Keith A LaFerriere, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Botulinum toxin (BOTOX®) has been proven successful in temporarily treating medial brow ptosis, and many surgeons use BOTOX® injections as a substitute for sectioning of the corrugator and procerus muscles. Used preoperatively, some believe that these injections facilitate adherence of the periosteum to its new, elevated position by eliminating the effect of the medial brow depressors. The drawback to botulinum toxin is the need for repeated injections.
Variations of the original technique described by Vasconez et al are multiple and evolving. Experience and personal preference often dictate a surgeon's choice of technique. A description of these various techniques is beyond the scope of this article; therefore, the authors' preferred technique is described here, and some of the more common variations are identified.
With the patient in the upright sitting position, the desired brow elevation is determined by manually elevating the brow to the desired position, by placing a marking pen on the superior aspect of the brow, and by letting the brow drop with gravity while holding the pen on the skin. A mark is made on the skin to measure the desired amount of brow elevation. This marking is performed medially and laterally along the brow to allow the surgeon to determine the amount of medial and lateral elevation desired.
The amount of medial and lateral elevation desired varies according to the patient's anatomy. Most typically, five 2-cm incisions are used: 1 medially, 1 paramedially aligned with each lateral canthus, and 1 in each temporal area. The midline and paramedian incisions are placed vertically, approximately 1.5 cm posterior to the hairline. The temporal incisions are placed approximately 4 cm posterior to the temporal hairline, in line with the preauricular crease, and transected in its midpoint by an imaginary line from the nasal ala through the lateral canthus.
Either general anesthesia or local anesthesia with conscious sedation can be used, depending on patient's and surgeon's preference. If local anesthesia with sedation is used, supraorbital and supratrochlear nerve blocks are performed first, followed by infiltration of the incisions, the orbital rims to the lateral canthi, and the area overlying the temporalis muscles. A ring block of the scalp may be performed, but this is seldom necessary. Xylocaine 1% with 1:100,000 epinephrine is most commonly used.
After proper anesthesia is induced, the incisions are made, with midline and paramedian incisions made down through the periosteum. Some surgeons advocate the use of a subgaleal plane at this point. The authors prefer a subperiosteal approach for the ease of dissection and release of the arcus marginalis at the orbital rim, the relatively bloodless dissection, and the fixation of the periosteum to the cranium at the desired elevation. The temporal incisions extend down through the temporoparietal fascia to the superficial layer of the deep temporal fascia (shiny white fascia adherent to the temporalis muscle).
A 1-mm drill bit is used to mark the preoperative level of the forehead and brow complex through the median and paramedian incisions. This mark is used as a reference point to place the cortical tunnels for later fixation.
Subperiosteal elevator dissection then proceeds, first posteriorly to elevate the scalp off the cranium to the occiput, and then anteriorly down to approximately 1 cm above the supraorbital rims. Sharp elevator dissection of a temporal pocket is then performed directly on top of the superficial layer of the deep temporal fascia to approximately 1 cm above the zygomatic arch and also posteriorly from the temporal incision approximately 6 cm. This posterior dissection is connected at the temporal line with the posterior subperiosteal dissection. Under endoscopic guidance, the upper/medial portion of this temporal pocket is then connected to the subperiosteal dissection at the temporal line. This dissection is carefully taken down to the lateral aspect of the supraorbital rim, again under endoscopic guidance.
The sentinel vein is often encountered in this region and represents a landmark for the temporal branch of the facial nerve. The nerve in this region is usually superficial in the temporoparietal fascia and courses superior to this vein. The sentinel vein should be preserved when possible because interruption of this venous drainage system can lead to varicosities of the venous system in the periorbital and temporal regions. Proceeding from the lateral aspect at the level of the lateral canthus to medial, the periosteum is released from the supraorbital rims at the arcus marginalis.
Once the region of the supraorbital nerves is reached, the nerves are endoscopically identified and preserved. Dissection proceeds medially to the glabellar region to complete the release of the periosteum along the entire length of the supraorbital rims to the midline. The procerus and corrugator muscles are then identified and either divided or resected, with an attempt made to preserve the supratrochlear nerves, which lie superficial to the corrugator muscles.
Dyer et al described an alternative approach that uses botulinum toxin to paralyze the depressor function of these muscles during the healing phase, thereby avoiding the need to divide or resect the corrugator and procerus muscles. Complete release of these soft tissues from lateral canthus to lateral canthus is the most critical part of this procedure. It allows for unhindered elevation of the forehead and brow complex. Suction cautery is used for hemostasis.
Once this release is complete and the procerus and corrugator muscles are lysed, fixation of the forehead and brow complex at the desired level is performed. A variety of described fixation techniques apparently yield successful results. The authors' preferred method involves the creation of 3 outer cortical bone bridges in the cranium, 1 at each paramedian incision and 1 at the midline incision.
The locations of the bone bars are determined by measuring the desired lift in relation to the markings made preoperatively at the medial and lateral aspects of the brows (described above) and by adding 2 mm to this measurement. This length determines the placement of the bone bar posterior to the reference drill mark made before the forehead and brow complex is released (described above).
Placement is facilitated by placing one prong of a caliper (set at the desired measurement of elevation) in the reference drill hole and by marking the level of elevation with the other prong. This method ensures that the bone bar is placed at a level far enough posteriorly to create the desired lift. The bone bars are created by using a 1-mm drill bit and by drilling 2 troughs in line with each other and separated by 2 mm. The depth of the troughs is the diploic space.
The troughs are connected under the cortex by creating a 2-mm cortical bone bridge. A permanent or long-lasting 2-0 suture can be passed from one trough, under the bone bridge, to the other trough for retrieval. The periosteum at the anterior aspect of the incision then is suspended with either permanent or long-lasting absorbable sutures to this bone bridge. This technique results in a stable, predictable fixation point that avoids the need to use skull screws.
This method of fixation has been used since 1995, and the authors have had no associated cases of CSF leakage or complication. Other fixation methods include the use of permanent or absorbable screws or plates, k-wires, bolsters, spanning sutures, tissue adhesives, and various nonfixation techniques involving skin excisions.
An absorbable device called the Endotine Forehead device (Coapt Systems, Inc., Palo Alto, California) has gained popularity over recent years, and has been found to be safe and effective. It has been shown to be as effective a fixation device as suture suspension through bone tunnels. Proponents list ease of use, absorbability, and adjustable nature of suspensions as key advantages.
In a 2000 article, Romo et al compared permanent screw fixation with temporary (2-wk) screw fixation in 259 patients over a 3-year period. Results suggest that temporary fixation is more commonly associated with loss of brow elevation than permanent fixation. However, various fixation techniques have been used successfully with, as previously described, release of the forehead and brow complex being the only common factor. In the authors' opinion, this release is the critical factor.
A study by Massoud and Aboelatta suggested that eyebrow fixation with concentric cables in endoscopic forehead lift leads to fewer complications than does the use of temporal fasciae sutures and miniscrews, while offering long-term stability. Mean elevation of the eyebrow tail via concentric cables was consistently higher than with sutures and screws at 1, 3, 6, and 12 months postoperatively, although mean elevation of the eyebrow body was lower in the concentric cable patients than in the suture-and-screw cases at these postoperative periods.
The placement of drains in the dissection space also seems to vary among surgeons. The authors do not typically use drains and have had only 1 patient with prolonged fluid accumulation in the dissection space. The placement of drains is certainly acceptable and commonly performed. Drains, when used, are generally removed on the first postoperative day.
Dressings are commonly used and generally include the application of an antibiotic ointment on the incisions, as well as coverage with a light dressing to collect any seepage. The dressing is removed on the first postoperative day, and local wound care is established. In the event of fluid (blood or serum) accumulation, needle aspiration is usually effective. Skin sutures and/or staples are generally removed after 1 week.
Advise the patient that swelling can occur for a variable period after surgery. Generally, swelling and bruising subside by the second postoperative week, but in rare cases, it may last for a few weeks. Varying degrees of numbness in the forehead and in the scalp (to the vertex) may also occur, and this can last for several months. Phantom itching can occur as sensation returns. This can usually be controlled with antihistamines. Typically, itching resolves with time, but complete resolution may require as long as a year.
Generally, the patient or the patient's caretaker is called the evening of the surgery. The patient is usually seen the first postoperative day, when the light dressing is removed and routine wound care counseling is given. Thereafter, the frequency of follow-up visits depends on the surgeon's discretion and on the patient's condition.
Results are comparable with those seen with open approaches, but with fewer complications. Permanent frontal nerve paralysis, permanent anesthesia due to injury to the supraorbital and/or supratrochlear nerves, hematoma, seroma, and CSF leakage are reported. The authors have encountered none of these complications, with the rare exception of seroma.
The recurrence of brow ptosis that requires revision has been reported. The authors have observed this problem and believe that it probably represents inadequate release of the supraorbital structures along with incomplete lysis of the procerus and corrugator muscles. Failed unilateral suspension, either due to the suture pulling through the tissues or due to it becoming detached from the fixation site, is also possible. Overall, however, endoscopic forehead and brow lift is an effective and safe procedure when performed by properly trained surgeons.
Outcome and Prognosis
The outcome of this procedure is usually satisfactory, and most patients with realistic goals are happy with the results. Long-term follow-up studies are scarce; however, in the authors' experience, good results usually last for years. Because this procedure has been performed only since 1994, only 5- to 6-year follow-up results are available at this writing. In most cases, results can still be appreciated 5-6 years after the procedure.
For example, in a study of 31 patients who underwent a subperiosteal endoscopic brow lift, Jones and Lo found that many of the results persisted at 5.4-year follow-up. Using computer software to obtain objective measurements, the investigators found that all areas of the brow except the tail of the eyebrow maintained a subtle elevation of less than 5 mm. In addition, using regional and global aesthetic scoring systems, it was found that changes from the brow lift remained apparent to observers at 5.4 years, with 64% of patients being perceived at follow-up as better looking than they were before the brow lift. However, forehead lines, despite improvement after surgery, were perceived as having resumed their presurgical appearance by follow-up.
Future and Controversies
The endoscopic brow and forehead approach is also being used to rejuvenate the upper part of the face in the malar and midfacial region. Extension of the techniques of endoscopic forehead and brow lifting will undoubtedly involve access to other regions of the face.
Controversies related to this procedure are discussed above and generally involve fixation techniques, planes of dissection, and the extent of forehead and brow release.
Hafezi F, Naghibzadeh B, Nouhi A, Naghibzadeh G. Eliminating frown lines with an endoscopic forehead lift procedure (corrugator muscle disinsertion). Aesthetic Plast Surg. 2011 Aug. 35(4):516-21. [Medline].
Angelos PC, Stallworth CL, Wang TD. Forehead lifting: state of the art. Facial Plast Surg. 2011 Feb. 27(1):50-7. [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].
Vasconez LO, Core GB, Gamboa-Bobadilla M, Guzman G, Askren C, Yamamoto Y. Endoscopic techniques in coronal brow lifting. Plast Reconstr Surg. 1994 Nov. 94(6):788-93. [Medline].
Puig CM, LaFerriere KA. A retrospective comparison of open and endoscopic brow-lifts. Arch Facial Plast Surg. 2002 Oct-Dec. 4(4):221-5. [Medline].
Dyer WK Jr., Yung RT. Botulinum toxin-assisted brow lift. Facial Plast Surg. 2000 Aug. 8(3):343-54.
Byrne PJ. Efficacy and safety of endotine fixation device in endoscopic brow-lift. Arch Facial Plast Surg. 2007 May-Jun. 9(3):212-4. [Medline].
Honig JF, Frank MH, Knutti D, de La Fuente A. Video endoscopic-assisted brow lift: comparison of the eyebrow position after Endotine tissue fixation versus suture fixation. J Craniofac Surg. 2008 Jul. 19(4):1140-7. [Medline].
Romo T 3rd, Sclafani AP, Yung RT, McCormick SA, Cocker R, McCormick SU. 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].
Massoud KS, Aboelatta YA. Concentric double cables fixation as an alternative suspension method for the endoscopic forehead lift. J Plast Surg Hand Surg. 2015 Jun. 49 (3):141-6. [Medline].
Jones BM, Lo SJ. The impact of endoscopic brow lift on eyebrow morphology, aesthetics, and longevity: objective and subjective measurements over a 5-year period. Plast Reconstr Surg. 2013 Aug. 132(2):226e-238e. [Medline].
Foustanos A, Zavrides H. An alternative fixation technique for the endoscopic brow lift. Ann Plast Surg. 2006 Jun. 56(6):599-604. [Medline].
Morgan JM, Gentile RD, Farrior E. Rejuvenation of the forehead and eyelid complex. Facial Plast Surg. 2005 Nov. 21(4):271-8. [Medline].