• Oculoplastics/Orbit

    Over the past 15 years, the development of small incision endoscopic techniques has revolutionized aesthetic brow lifting. Compared with direct brow lifting or open forehead lifting, endoscopic brow and forehead surgery is associated with higher patient acceptance, better aesthetic outcomes, fewer postoperative complications, and faster recovery times. During the past decade, the endoscopic brow lift has evolved to become even more surgeon and patient friendly, and the procedure is now a preferred technique for eyebrow and forehead elevation for most patients.

    Patient Selection

    The main benefits of elevating the brow endoscopically are the hidden incisions and faster recovery time compared to open techniques. However, as with other aesthetic procedures, the endoscopic brow lift is not the ideal surgery for all patients. Thanks to increasing experience with the procedure, surgeons now have a better understanding of the limitations of endoscopic brow lifting. Understanding these limitations helps physicians to set realistic expectations and improves patient satisfaction. Patients with heavy eyebrows, a thick corrugated-type forehead, and significant skin laxity are not as easily or successfully treated with endoscopic surgery. These patients would probably benefit more from direct brow, mid-forehead, pre-trichial, or coronal lifting procedures. Most other patients, however, can benefit from the small incision endoscopic brow lift.

    While there is often concern for elongation of the forehead, most reports in the medical literature demonstrate only minimal to moderate forehead elongation after endoscopic brow lifting. This is particularly reassuring to male patients who have a receding hair line or any patient that has a long forehead preoperatively.

    Anesthesia

    Although many patients undergoing extensive facial aesthetic surgery choose to use general anesthesia, the endoscopic brow lift can be performed under local anesthesia with intravenous sedation. This is particularly desirable when the procedure is performed alone or in conjunction with other eyelid procedures, since the total operative time is relatively short. When using local anesthesia, many surgeons prefer the tumescent technique for infiltrating the anesthetic.

    After diluting 25 milliliters of 2% lidocaine with 1:100,000 epinephrine in 500 milliliters of saline, the solution is placed under pressure, and the anesthetic is infiltrated under the periosteum with a 19 or 21 gauge needle until the entire forehead is tumesced. Additional infiltration of a more concentrated anesthetic is given to the superior orbital rims. The tumescent technique provides excellent anesthesia as well as the added benefit of improved hemostasis from diffuse infiltration of epinephrine, and hydrodissection of the subperiosteal plane simplifies and facilitates the entire procedure.

    Incision Placement and Dissection

    Depending on the degree of brow elevation and contouring desired, the endoscopic brow lift can be performed through 2 to 5 incisions. The paracentral incisions should be placed inline with where the arch of the brow is desired. A central incision is usually only needed for large foreheads. When lateral lifting of the brow is needed, temporal incisions should be placed perpendicular to the line connecting the nasal ala and the lateral canthus of the eye.

    The key step in adequately mobilizing and elevating the eyebrow and forehead is to release and open the periosteum along the superior and lateral orbital rims. Although some attachments between the medial brow and the nose should be maintained to prevent flattening of the brow, the periosteal release needs to be fully extended laterally to achieve adequate eyebrow elevation. Once the periosteum is opened, the eyebrow musculature can be identified and excised, and the entire forehead flap should be easily mobilized.

    Fixation

    Over the years, nearly a dozen fixation techniques have been described for securing the eyebrow and forehead in its elevated position. Although most of these techniques were effective, they were often inconvenient or difficult to place correctly. The introduction of the Endotine device (Coapt Systems, Inc.) has dramatically simplified fixation of the forehead flap. This multipoint absorbable device is easily placed and provides secure fixation while distributing the tension of the fixation over a large area to minimize the risk of excessive brow peaking. Although long-term reports are still pending with this device, the results are likely to be favorable, since periosteal re-adherence usually occurs relatively quickly.

    Summary

    Having been performed since the early 1990s, endoscopic brow lifting can no longer be considered a “new” technique. However, even today this procedure continues to evolve, and with new refinements and new devices surgeon and patient satisfaction continue to improve. While there will always be indications for direct brow or open forehead lifting, the endoscopic brow lift has become the procedure of choice for many aesthetic surgeons.

    References

    1. Guyuron B. Endoscopic forehead rejuvenation: I. Limitations, flaws, and rewards.Plast Reconstr Surg. 2006;117:1121-1133.
    2. Behmand RA, Guyuron B. Endoscopic forehead rejuvenation: II. Long-term results.Plast Reconstr Surg. 2006;117:1137-1143.
    3. Ramirez OM.Anchor subperiosteal forehead lift: from open to endoscopic.Plast Reconstr Surg. 2001;107:868-871.
    4. Berkowitz RL, Jacobs DI, Gorman PJ. Brow fixation with the Endotine forehead device in endoscopic brow lift.Plast Reconstr Surg. 2005;116:1761-1767.
    5. Arneja JS, Larson DL, Gosain AK. Aesthetic and reconstructive brow lift: current techniques, indications, and applications.Ophthal Plast Reconstr Surg. 2005;21:405-411.

    Author Disclosure

    The author states that he has no financial relationship with the manufacturer or provider of any product or service discussed in this article or with the manufacturer or provider of any competing product or service.