Endoscopic Forehead Lift

The endoscopic forehead and brow lift is used to elevate the position of the eyebrows and forehead. Indications for this procedure are multiple, and it is performed to correct brow ptosis and to treat the glabellar frown lines created by the corrugator and procerus muscles. ^{[1, 2]} Various factors, including natural aging, facial nerve injury, and facial trauma, can cause brow ptosis, although congenital or hereditary factors also may cause the condition. Brow lifting or forehead lifting is not a new concept, but the application of endoscopic techniques to this procedure is recent. ^{[3, 4]}  See the image below.

Endoscopic forehead lift. Normal female brow position with the brows at or slightly above the orbital rim at the medial aspect and arching superior to varying degrees at the lateral aspect.

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In 1994, Vasconez et al first described endoscopic forehead lift in the United States. ^[5] They detailed use of the endoscope to guide the release of the supraorbital and glabellar soft tissues. The dissection was performed in the subgaleal plane and involved dividing the procerus and corrugator muscles and scoring of the frontalis muscle. The fixation technique was not well described and appears to have varied.

Since this first description, multiple variations have been used. Most variations pertain to placement of incisions, planes of dissection, and methods of fixation of the forehead and brows. Because endoscopic forehead lift has been performed in the United States only since 1994, results of long-term follow-up studies of more than 5 years' duration have not been published. Results directly comparing the more established methods of forehead and brow lifting with those of the newer endoscopic techniques are also scarce.

To date, reports on endoscopic forehead and brow lifting show that excellent results are obtained with this technique. Advantages over the coronal and trichophytic approaches include significant reduction in the length of incisions, improvement in the camouflage of these incisions, and reduction of blood loss and surgical trauma. Also, the endoscopic forehead lift reduces scalp hypesthesia. Disadvantages include increased cost because of the need for more sophisticated equipment and risk of injury to either the sensory nerves or the motor nerves in this region. Additionally, surgeons must negotiate a learning curve before achieving proficiency in this procedure. In a study published in 2002, Puig and LaFerriere compared the results of open versus endoscopic forehead/brow lifts and found no statistical difference in the measurable results obtained with these procedures. ^[6]

Depending on the type of fixation method used, a theoretical risk of cerebrospinal fluid (CSF) leak or meningitis exists. The present authors found only 1 case report of a CSF leak associated with endoscopic brow lift, and this appears to have involved improper preparation rather than a fundamental problem with a particular fixation technique. Despite this report, endoscopic brow lift appears safe and effective when performed by properly trained surgeons, and the procedure represents an additional tool for the restoration of a symmetric, youthful appearance in the upper part of the face.

The problems addressed in endoscopic forehead and brow lift are brow ptosis and/or forehead or glabellar rhytidosis. Eyebrow ptosis is considered to be present when the eyebrow occupies a position relative to the superior orbital rim that is lower than that on the other side in cases of unilateral brow ptosis, or one that is lower than that desired by the patient. For women, the desired position generally lies at or slightly above the medial aspect of the superior orbital rim, laterally arching superior to varying degrees. For men, the brows look most natural at or slightly above the supraorbital rim with less of an arch.

Ptotic eyebrows can give the appearance of anger, worry, or weariness despite a lack of emotional intent or physical condition. Unilateral brow ptosis or brow asymmetry, whether naturally occurring or related to facial nerve dysfunction, creates the appearance of a smaller eye on the ptotic side. Glabellar frown lines are the rhytides or wrinkles just above the nasal dorsum between the eyebrows that are caused by activity of the procerus and corrugator muscles. Endoscopic forehead and brow lift addresses and improves these areas.

Frequency

The frequency of age-related changes is 100%—every living person ages. Brow ptosis is one of the earlier age-related changes and usually begins in the fourth decade of life. Other causes of brow ptosis, such as scarring or facial paralysis, are relatively rare.

See Problem.

See Problem.

See Problem.

Indications vary and include age-related changes of the upper part of the face and congenital or acquired brow ptosis. In most cases, this procedure is performed to improve the cosmetic appearance of the upper face and brow. The procedure is generally performed for age-related facial changes, but it also may be performed for acquired ptosis due to trauma, facial nerve paralysis, or other conditions.

Patients with an upper visual field defect due to ptotic eyebrows may benefit from an endoscopic forehead and brow lift, depending on whether the predominant reason for the visual field defect is brow ptosis or redundant eyelid skin. Commonly, visual field loss is caused by a combination of these 2 problems, and a combined procedure of endoscopic forehead and brow lift with upper eyelid blepharoplasty is required.

The combination of forehead and brow lift with upper eyelid blepharoplasty is also commonly performed to treat the eyelid and forehead and brow changes of the aging face. Some authorities advocate performing these procedures at separate times. In the authors' experience, however, both procedures can be performed simultaneously with safety. The order in which they are performed varies with the surgeon's preference.

The forehead and eyebrows are multilaminar structures beginning at the superior aspect of the orbits and extending superiorly to blend into the scalp. Beginning with the skin, the layers at the level of the eyebrows include the skin, subcutaneous fat, muscle (orbicularis muscle laterally and procerus and corrugator muscles medially), aponeurosis (galea), periosteum, and bone.

The arcus marginalis is an area of thickening of this aponeurosis at the superior aspect of the orbit and serves as a point of attachment for the orbital septum. Critical nerves at this level are the supraorbital and supratrochlear nerves, which exit from their respective foramina at the medial and mid aspect of the orbit to travel through these layers and ramify into the appropriate skin receptors.

Proper release of the arcus marginalis and sectioning of the procerus and corrugator complex with preservation of the integrity of the sensory nerves in the supraorbital area are the most critical parts of the endoscopic forehead and brow lift. Obviously, avoiding injury to the frontal branch of the facial nerve as it passes lateral and superior to the orbit is critical for a desirable outcome. The sentinel vein is a good anatomic landmark visible near where the lateral orbital rim rises to meet the frontal bone. The frontal branch of the facial nerve runs immediately superficial to that structure. Care should be taken not to detach the lateral canthus because detachment can be associated with distortion of the normal position of the lateral commissure of the palpebral fissure.

Caution is advised in patients with previous frontal craniotomy, or with frontal bone, superior orbital, or frontal sinus fractures.