You are in: eMedicine Specialties > Plastic Surgery > BROW LIFT Brow Lift, EndoscopicArticle Last Updated: Jun 2, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Jorge I de la Torre is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama Coauthor(s): John T Alexander II, MD, Consulting Staff, Department of Plastic Surgery, Scripps La Jolla Hospital Editors: R C A Weatherley-White, MD, Associate Clinical Professor of Surgery (Plastic), University of Colorado; Medical Director, Department of Plastic Surgery, Columbia Rose Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; R Edward Newsome, MD, Associate Professor, Program Director and Chief, Department of Surgery, Section of Plastic Surgery, Tulane University Health Sciences Center; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: browlift, brow-lift INTRODUCTIONSection 2 of 12
  Technology has created a trend for less invasive procedures in all surgical specialties. The endoscope, with its accompanying instrumentation, has been the key development supporting this trend. It has helped surgeons in nearly every surgical specialty, including plastic surgery, develop less invasive techniques. With new technology comes patient demand and expectation for less invasive procedures, or at least for procedures perceived as such. The endoscope now is used in a variety of reconstructive and cosmetic plastic surgical applications, with the endoscopic brow lift the first procedure to gain widespread acceptance. History of the ProcedureOver the last 3 decades, more surgical specialties have incorporated fiberoptic and endoscopic technology. Endoscopes have been widely used by gynecologists since the 1970s for diagnostic and therapeutic procedures. By the end of that decade, the same technology was gaining acceptance in the orthopedic community for diagnostic procedures. As instrumentation improved, less invasive therapeutic procedures became common. Endoscopic procedures were introduced into general surgery in 1986, and laparoscopic (endoscopic) cholecystectomies became standard by 1990, with increasingly complex surgeries gradually transitioning to less invasive approaches. In the early 1990s, the first endoscopic brow lift was performed. Shortly thereafter the endoscope was incorporated into plastic surgery of the mid and lower face, breast, abdomen, hand (in carpal tunnel surgery), and trunk. The advent of the endoscopic approach to the face and, in particular, the brow was brought about in large part by the ability to create a sufficient optical cavity. Specialized dissection instruments and understanding of principles of brow suspension were also significant contributing factors. ProblemWhen evaluating the face for rejuvenation or other cosmetic improvement, surgeons classically divided the face into 3 sections: face and/or neck, brow, and eyes. As techniques and technology advanced, analysis of the face became more complex, changing relationships between these classifications. The face and neck now are analyzed as mid face, lower face, and neck. Evaluation of eyelids now includes examination of the mid face. Brow examination must include evaluation of lids and general orbital area. Surgeons should examine the face as a whole to better determine which procedures will aid in helping the patient achieve the goal of a balanced natural appearance. Although most facial soft tissue structures tend to descend under constant forces of gravity and time (eg, cheeks, neck), the brow is often an exception. Some individuals naturally have a low-set brow. Others may show significant signs of facial aging but have little or no brow ptosis. Just because a brow can be elevated does not mean it should be elevated. Perform the endoscopic brow lift for the following reasons:
PathophysiologyPoor brow position can be an inherited condition or an acquired condition associated with aging. As with other soft tissue structures of the face, the brow may become ptotic with increasing age; however, note that in the youthful face the brow is often quite low yet still attractive. As the face ages, fat is lost from the orbital rim between the brow and eyelid, creating an aged or ptotic appearance. Repetitive or hyperactive use of corrugator muscles can depress the medial head of the eyebrow over time. Similarly, overuse of frontalis muscles, especially on one side, can create noticeable asymmetry in eyebrow height. In addition, patients who have significant upper lid ptosis may attempt to compensate by overusing the frontalis muscle to lift the brows and, subsequently, the lids out of the field of vision. ClinicalGood candidates for endoscopic brow lift present in several ways. The patient may note that the brow is ptotic or low. These patients commonly complain that their eyes have a tired or heavy appearance. Often they note that they "have always had this" or that it "runs in the family." Frequently, the patient has practiced achieving the desired look by pulling the lateral brow up with his or her hands while looking in the mirror. Patients often present complaining of excess upper eyelid skin. Carefully evaluate the brow in any patient evaluated for cosmetic eyelid surgery, because the brow may be involved in 50% of patients. Patients often present with a chief complaint of deep glabellar rhytides caused by excessive corrugator activity. They often are frustrated that they look angry, upset, or tired when they do not feel this way. They have a frequent subconscious tendency to frown. Additionally, patients may be concerned with horizontal forehead creases caused by excessive frontalis activity. INDICATIONSSection 3 of 12
In the normal brow (see Image 1), the medial eyebrow extends to the medial canthus of the eye, and the lateral eyebrow extends to the intersection of an imaginary line drawn from the nasal ala through the lateral canthus of the eye. Head of the medial eyebrow can begin below or at the medial orbital rim. Tail of the lateral brow is positioned above the bony orbital rim, often dropping to the same horizontal level as the medial head of the eyebrow. Tail of the brow normally may be found above the horizontal line of the medial brow. Apex of the brow arch lies immediately above the lateral edge of the iris. In fashion models, the apex tends to be at the point dividing the medial and lateral third of the brow, or sometimes even more laterally, creating a stylized or more exotic appearance. In the average patient the apex of the brow often is located more centrally, but this still can produce an attractive brow. In evaluating the orbit, note several essential things, including depth of the orbit or eye socket and shape of the overall orbit. In a patient with deep-set eyes, an overly elevated brow appears more abnormal, whereas a patient with a shallower orbit can tolerate overelevation of the brow and still appear within normal limits. As the face ages, the orbital shape changes from an oval or egg shape to a circular shape, caused most often by ptosis of the mid face. In patients with significant nasojugal crease from midface ptosis, avoid elevating the brow as an isolated procedure, since this accentuates the circular shape of the orbit and increases the aged appearance. Consider performing a facelift or mid facelift in conjunction with brow lift. A mid facelift also can be performed in conjunction with a lower eyelid procedure. Check for asymmetry, which often goes unnoticed by the patient. Noticeable asymmetry of eyebrows is present in approximately one third of patients. Often the distance from orbit to brow is the same bilaterally even though the brows appear uneven. In this situation, the entire orbit on one side of the face is usually lower. Decide which approach provides a more symmetric look—raising the brow the same degree bilaterally, which maintains the asymmetry of the brow, or raising the eyebrows asymmetrically, which equalizes the eyebrows but may introduce a new asymmetry in distances between brows and eyes. Computer imaging helps determine the more suitable approach. Although any brow can be elevated, evaluate the amount of redundant skin in the lateral canthal region. Significant overhanging skin near the "crow's feet" is difficult, if not impossible, to remove with eyelid surgery alone. Elevating the lateral brow may be necessary. This is one helpful indication in addressing the need for brow elevation, especially in the patient presenting with heavy upper eyelids. RELEVANT ANATOMYSection 4 of 12
Scalp Scalp layers include skin, subcutaneous tissue and fat, the galeal aponeurosis, and periosteum. As the scalp joins the forehead, an additional layer of muscle (frontalis muscle) is found between the subcutaneous and galeal layers. Vascular anatomy Supraorbital vessels exiting supraorbital foramina above each orbit supply the forehead. These vessels coalesce with superficial temporal arteries and occipital vessels in the posterior scalp to provide a redundant blood supply to the scalp. The entire scalp can survive on one major arterial vessel. Additional blood to the central forehead is supplied by supratrochlear vessels exiting the orbits superomedially and extending in a cephalad direction. Neurologic anatomy Sensory nerves to the forehead (supraorbital and supratrochlear nerves) exit the orbits in neurovascular bundles with supraorbital arteries and supratrochlear arteries. These nerves may be large singular nerves or smaller bundles. Usually a dominant single nerve is present. Supraorbital nerves exit approximately 2.7 cm from the mid line. Nerves easily are seen and preserved. Motor nerves The facial nerve's temporal branch (VII) provides innervation to the frontalis muscle. Its course follows a line drawn from the tragus through a point 1-1.5 cm lateral to the eyebrow's lateral tail. The nerve is found in a fatty layer between the temporoparietal fascia and superficial layer of the deep temporal fascia (see Image 2). During dissection, one can identify the general location of this motor nerve by locating a predictable vein (see Image 3), referred to as the "sentinel vein." Injury to this nerve can cause temporary or permanent frontalis muscle paralysis. Muscle anatomy The frontalis muscle is a broad flat bilateral muscle of facial expression spanning the forehead that raises the eyebrows. Corrugator muscles are small fan-shaped muscles that lie nearly under the eyebrows. They also are muscles of facial expression that cause frowning in the glabellar region. The procerus muscle extends from the upper nose to the lower forehead, and its action wrinkles the upper nose. CONTRAINDICATIONSSection 5 of 12
As with eyelid procedures, question patients regarding a history of dry eyes. Excessive brow elevation, especially in conjunction with upper eyelid surgery, can exacerbate a previous condition. Confirm adequate eye tearing or lubrication with a Schirmer test if necessary. Patients with an excessively high hairline may not be good candidates for this procedure. Contrary to common belief, an endoscopic brow lift raises the hairline at least the distance the brow is elevated, if not more, depending on elasticity of skin and brow. Advise patients with high hairlines that the hairline may appear higher and offer them an anterior hairline approach, which can elevate the brow while shortening the forehead. Disadvantages of the anterior hairline approach are more visible scarring, temporary or permanent scalp paraesthesia, and longer operative time. Evaluate all cosmetic surgery patients for psychological instability or unrealistic expectations. WORKUPSection 6 of 12
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TREATMENTSection 7 of 12
Medical therapyBotulinum 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. (See the article BOTOX® Injections for more information.) Surgical therapyInstrumentation 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. Anesthesia 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. Surgical technique The 3 general steps of brow lift are dissection, muscle elimination, and fixation. Preoperative detailsPatients 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 detailsDissectionMake 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 Image 4). Periosteal approach 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. Subgaleal approach 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. Anterior approach 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. Temporal approach 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. Muscle eliminationIf using a periosteal approach, separate or divide the periosteum 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. FixationThis 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 (see Images 5-6), but this method is less predictable. Temporary fixation 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 abcesses. 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. 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. Permanent fixation 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 asymmetryCorrecting 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 Images 7-8). 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 (see Image 9). 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 Images 10-12). Postoperative detailsPostoperative 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. Follow-upObserve 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. COMPLICATIONSSection 8 of 12
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. Malposition 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 overelevated. Lowering a brow that has been overelevated 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. Contour irregularities 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. Alopecia 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. Motor loss 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 PROGNOSISSection 9 of 12
Brow elevation present at 3 months tends to remain stable over the long term (1-5 y). Because of this, overelevated 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. FUTURE AND CONTROVERSIESSection 10 of 12
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, those 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. As with all new procedures, time will determine the true value and efficacy of the endoscope in this and all other applicable plastic surgical procedures. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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