Endoscopic Brow Lift

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 by Michael T Yen, MD on October 26, 2020.


Background

The superficial anatomy of the face consists of soft tissue that gradually undergoes change with the passage of time. The various layers of the face, including the skin, subcutaneous fat, and muscles of facial expression, manifest aging in different ways. For example, in the upper third of the face, it has been suggested that muscle activity has a more significant contribution to forehead deformities than skin laxity and fat deflation.[1] Crow’s feet, which are rhytids in the region of the lateral canthus, manifest from long term changes in the skin due to contraction of the orbicularis oculi. The opposing attempt of the frontalis muscle to contest the actions of the forehead depressors results in unsightly horizontal rhytids. The corrugator muscles lead to the formation of vertical frown lines in the region of the glabella. Nonetheless, the skin lays claim to a notorious role as well; as its elastic nature deteriorates, the forehead and glabellar regions descend with it.[2] Following suit, the brow gravitates inferiorly below the supraorbital rim. The correction of these altering tissues in cosmetic surgery allows patients to improve and modify their aesthetic appearance. This includes aging patients, as well as those with physiologically low brows, who are unhappy with their appearance. In deciding whether to pursue aesthetic surgery, important factors for patients to consider are the invasiveness and risks of the procedure, as well as the scar appearance. Over time, advancements in the field of oculoplastic surgery have led to procedural work that results in remarkable improvement with only minimal residual scarring to show for it. One such example of this development is the endoscopic approach to brow lifting. In this procedure, skin incisions are hidden within the patient’s hairline, allowing elevation of the entirety of the drooping forehead, in addition to reducing the muscle action of the corrugator supercilii. This is all achieved without the more objectionable associations of the more open approaches, such as a conspicuous scar, transection of terminal branches of the frontal nerve, as well as prolonged recovery time and post-operative numbness.[3] Because of these advantages, endoscopic brow lifting is one of the most popular choices for surgical correction of the aging forehead.[4]

Figure 1: Before and after photos of a patient who received an endoscopic brow lift for the correction of brow ptosis.

History

The brow lift is a procedure that has been repeatedly improved upon over the past century.[5],[6] The natural course of its evolution has been driven by the desire of surgeons to achieve two highly sought-after benchmarks: better outcomes and less invasiveness. Dr. Passot is credited with popularizing the direct brow lift procedure in the 1930’s when he described the technique of removing small, symmetrical areas of skin superior to each brow.[7] The skin is then reapproximated, elevating the brow. Although effective, this procedure commonly leads to a visible scar in the area of the incision above the brow and also does not address forehead ptosis in the glabellar region.[8] An adaptation of this procedure, the mid-forehead brow lift, places the incision in a prominent mid-forehead wrinkle.[9] Nonetheless, because these two procedures fail to release the retaining ligaments of the brow, their lasting effect on the aesthetic profile of the patient is not fully realized. The procedural techniques of the brow lift were further revolutionized with the advent of the coronal brow lift. The coronal lift consists of either a subperiosteal or subgaleal dissection of forehead tissue from an ear-to-ear incision line all the way down to the level of the orbital rim. After releasing retaining ligaments, the entirety of the musculocutaneous field can be folded over for further manipulation so that the skin can be lifted unfettered by the hold of the frontalis. Although the coronal brow lift has the ability to achieve good results, it is afflicted by its relative invasiveness and suboptimal recovery time. Further, because the incision is made across the hairline, the supra-orbital and -trochlear nerves become easily exposed to inadvertent excisions that can result in numbness of the scalp region. The trichophytic brow lift developed in the 1980’s attempted to correct this resulting numbness by utilizing a subcutaneous dissection pattern instead of a subperiosteal or subgaleal one.[10] However, the visibility of the scar along the hairline can be problematic. This led to the use of endoscopic technology for brow lifting in the 1990’s by Dr. Vasconez.[11]

Physical Exam

Patients that are candidates for endoscopic brow lifts can either have a genetically low or “heavy” brow or one that is aesthetically unpleasing because of the normal descent that occurs with aging. Regarding the aging process, the tissues in the brow area deflate in a way that causes the related structures to collapse downward. Because of its immediate proximity to the orbital region, a sagging brow must be on the differential for any patient with a perceived excess of upper eyelid skin.[12] This can’t be emphasized enough: if an aging brow is contributing to the appearance of a drooping eyelid, then the surgical outcomes of an isolated blepharoplasty will not meet the patient’s expectations. It is therefore imperative that surgeons have a keen understanding of the appropriate brow anatomy. A female patient’s brow is typically arched and positioned superior to the orbital rim, whereas a male patient’s brow has more of a horizontal appearance along the orbital rim.[13] Using these approximated standards as guidelines, one can measure the extent of brow ptosis for a patient concerned about a droopy eyelid. Examining for the presence of blepharoptosis or dermatochalasis is also essential. If these conditions are present, then the patient should be evaluated for a concurrent ptosis repair or blepharoplasty in addition to the brow lift. Another element to be cognizant of during the examination is the presence of dry eye, lagophthalmos, or exposure keratopathy, as an elevation of the brow could exacerbate these pathological states.[12] Finally, careful examination of the patient’s hairline is important in evaluation of surgical candidacy. Although there is less scar formation with the endoscopic approach to brow lifting, incisions are still being made in the skin. A patient who is either balding or has a receding hairline will have greater difficulty of scar concealment and they must be made aware of this potential challenge before proceeding with the surgery.

Preoperative counseling

In performing any sort of cosmetic surgery, it is important to evaluate patient goals and to ensure that appropriate patient selection occurs. In addition to determining whether a patient’s facial appearance makes them a fitting candidate for the procedure, it is crucial to assess their realistic expectations and motivation for undergoing the brow lift.

Procedure

In the endoscopic brow lift, a series of preoperative skin markings are made in the posterior region of the hairline. A surgeon will typically make one median marking, two paracentral markings superior to the lateral third of the brow, and two lateral markings in the regions of the right and left temporal crescents. It is also essential to mark the 1-2 cm encompassing region of the supraorbital notch in order to better protect the supraorbital and supratrochlear nerves during the subperiosteal dissection.[12]

Figure 2: Sketch demonstrating the five preoperative skin markings made along the posterior region of a patient’s hairline.

In the areas identified by the median and paracentral markings, incisions are made using a 15 blade down to the bone.[14] The tissue is then dissected inferiorly to the orbital rim using a straight, spatulated raspatory with undermining being achieved in the subperiosteal plane. Blunt tipped scissors should be used to carefully dissect the marked location of the supraorbital and supratrochlear nerves. Periosteal attachments to the orbital rim are then released and corrugator and procerus muscles are released as needed to address glabellar rhytids. The endoscope is used to visualize periosteal release and location of the supraorbital nerve. The temporal incisions are first made down to the superficial temporalis fascia in order to avoid damage of the temporal branch of the facial nerve. Dissection is then achieved with a spatulated raspatory in the superficial temporal space to the orbital rim. Excellent release of periosteal attachments to the orbital rim are crucial. The tissue of the forehead and scalp are then mobilized upwards to arrive at adequate elevation of the brow regions. Following the lift, the tissue is commonly secured and fixed to the bone with either anchored sutures or inserted dissolvable implants, such as Endotines. Skin closure can be done with staples or a suture, such as a 5-0 nylon.

Post-operative Care

Post-operative care varies and may include an overnight compressive forehead bandage. Some surgeons recommend oral antibiotics for infection prophylaxis, as well as oral methylprednisolone to address post-operative edema. Most recommend follow up for their first post-operative visit after about seven to eleven days to remove staples.

References

  1. Matarasso A. Endoscopically assisted forehead-brow rhytidoplasty: theory and practice. Aesthetic Plast Surg. 1995 Mar-Apr;19(2):141-7.
  2. Nassif PS. Evolution in techniques for endoscopic brow lift with deep temporal fixation only and lower blepharoplasty-transconjunctival fat repositioning. Facial Plast Surg. 2007 Feb;23(1):27-42; discussion 43-4.
  3. 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.
  4. Byrd HS. The extended browlift. Clin Plast Surg. 1997 Apr;24(2):233-46.
  5. Rohrich RJ, Cho MJ. Endoscopic Temporal Brow Lift: Surgical Indications, Technique, and 10-Year Outcome Analysis. Plast Reconstr Surg. 2019 Dec;144(6):1305-1310.
  6. Paul MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg. 2001 Oct;108(5):1409-24.
  7. Passot R. Chirurgie esthetique pure: techniques et results. Paris: Gaston Doin et Cie, 1930.
  8. Booth AJ, Murray A, Tyers AG. The direct brow lift: efficacy, complications, and patient satisfaction. Br J Ophthalmol. 2004;88(5):688-691.
  9. Rafaty FM, Goode RL, Abramson NR. The brow lift operation in a man. Arch Otolaryngol1978;104:69–71.
  10. Guyuron B, Davies B. Subcutaneous anterior hairline forehead rhytidectomy. Aesthetic Plast Surg. 1988 May;12(2):77-83.
  11. Vasconez LO. The use of an endoscope in brow lifting. A video presentation at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons. Washington DC, 1992.
  12. Barmettler, A. (2020). Chapter 21: Endoscopic Brow Lift. In S. K. Freitag, N. G. Lee, D. R. Lefebvre, & M. K. Yoon, Ophthalmic plastic surgery: Tricks of the trade. New York, NY: Thieme.
  13. Black EH NF, Gladstone G, Calvano CJ, MR Levine. Smith and Nesi's Ophthalmic Plastic and Reconstructive Surgery. New York: Springer; 2012.
  14. Perenack JD. The Endoscopic Brow Lift. Atlas Oral Maxillofac Surg Clin North Am. 2016 Sep;24(2):165-73.