The Forehead Lift: Endoscopic Versus Coronal Approaches

Rejuvenation surgery of the upper one-third of the face can be accomplished by a number of well-known techniques and approaches. The objectives of this study were to: (1) determine if endoscopic-assisted forehead lifts achieve the same degree of correction as the coronal/pretrichial forehead lifts, (2) to assess the effect of concurrent blepharoplasty on brow elevation, and (3) to evaluate long-term results of coronal/pretrichial forehead lifts. The study was a retrospective blinded comparison of pre- and postoperative photographs of patients who underwent forehead lifts. In order to control for the differences in photographs, ratios of distances were measured utilizing standard anthropometric sites of the brow, medial canthus, and subnasale. All reviewed cases were operated on by the same surgeon (S.W. Perkins, M.D.). A total of 140 patients having undergone forehead lift procedures and with 12-month postoperative photographic documentation were included in the study. Of these 121 patients had coronal forehead lifts and 19 had endoscopic-assisted forehead lifts. Results revealed that at 1 year follow-up both methods achieved brow elevation without a significant difference in the approach. Concomitant blepharoplasty had no statistical effect on brow position. Additionally, long-term follow-up on the coronal/pretrichial lifts revealed a gradual drop in brow position over 5 years. We conclude that both endoscopic and coronal/pretrichial forehead lifts provide for comparable elevation at 1-year follow-up. Concomitant blepharoplasty has minimal to no significant effect on brow position. Brow elevation in coronal/pretrichial forehead lifts may be temporary.     

Forehead rhytidoplasty: Endoscopic approach

The difficulty in determining how much skin must be resected to achieve an adequate forehead and eyebrow lift through the coronal approach led the author to search for another forehead rhytidoplasty procedure. The endoscopic approach yields a natural lift of the eyebrows without skin excision through a minimal incision. It has been useful for patients who have a prominent forehead or have had a forehead rhytidoplasty. In addition, this technique provides a smooth forehead that is achieved by breaking the continuity of the forehead and glabella muscles. Despite the fact that the endoscopic approach is in the early stages of development, the results obtained from its use allow it to be an alternative procedure for treating the aging forehead and glabella.     

Modifications in endoscopic facelifts.

Since 1996, 72 patients (66 women and 6 men) have undergone endoscopic upper and midface rejuvenation. Sixteen of these patients had concomitant lower face rejuvenation at the same time. The patients were operated using a personal endoscopic technique, including biplanar endoscopic dissection (subgaleal and subcutaneous) at the forehead and temporal regions, excision of a galeal strip approximately 1 cm in thickness (to achieve a stable forehead lift), and a lower blepharoplasty incision for midface lifting and fixation of the malar fat pad. This approach helps to prevent midface widening-a concern of most surgeons. Regarding patient satisfaction, 51 patients had excellent results, 16 patients had good results, and 5 patients had an improved appearance of the mid and upper face. Complications included 11 incidences of temporary numbness in different regions of the upper and mid face, three incidences of temporary lower lid retraction (which did not require additional revision), three relapses of eyebrow elevation (which were reoperated), and unbalanced eyebrows in 2 patients (which were corrected during secondary revisional procedures).     

Criteria for the forehead lift

We have developed clinically useful measurements to assist the surgeon in deciding when to do the forehead lift and where to place the incision. Also, we have reviewed our experience over the past decade and discuss the four categories and applications of forehead lifts. We use three indications for forehead lift: ptosis, creases, and previous facelift (PCP). There are four basic surgical techniques applicable to the upper face: (1) direct browlift, (2) midforehead crease incision, (3) prehairline incision, and (4) posthairline incision. We determined more accurate guidelines from measurements taken on 50 volunteers, as well as patients seeking a facelift. The line of measurement in a vertical plane extends from the midpupil to the top of the eyebrow and up to the hairline. We have found that the normal distance from the midpupil to the upper edge of the eyebrow on average is 2.5 cm and that the distance from the upper edge of the eyebrow to the hairline is approximately 5 cm on average. If the distance from pupil to brow is less than 2.5 cm, then the patient may benefit from a forehead lift. If the distance from brow to hairline is less than 5 cm, then we use a posthairline incision in females. If this same distance is greater than 5 cm in females, we advise the prehairline incision. In male patients we strongly consider direct crease incision. The direct browlift is reserved for minimal ptosis, asymmetry, or patients who wish a minimal procedure. We have found these criteria for the forehead lift to be simple, reliable, and clinically useful.Presented at the 22nd Annual Meeting of the American Society for Aesthetic Plastic Surgery, Orlando, FL, April 1989, and at the Xth Biennial Congress of the International Society of Aesthetic Plastic Surgery, Zurich, September 1989     

ENDOSCOPIC FOREHEAD LIFT FOR PTOSIS OF THE BROW CAUSED BY FACIAL PARALYSIS

Twelve patients with ptosis of the brow caused by facial nerve paralysis were treated by endoscopic forehead lift. Four had an isolated paralysis of the temporal branch of the facial nerve and in eight the entire facial nerve was affected. In two of these patients the facial paralysis was bilateral, caused by Finnish hereditary amyloidosis. A standard subperiosteal endoforehead approach was used and the forehead was fixed by biodegradable pins (n = 8), anchor screws (n = 3), or a suture to the posterior scalp (n = 1). The procedure was a success in 10 patients, and failed in two after initially good results. The endoscopic brow lift is a good method of treating ptosis of the brow caused by paralysis of the temporal branch of the facial nerve.     

Endoscopic forehead lift for ptosis of the brow caused by facial paralysis.

Twelve patients with ptosis of the brow caused by facial nerve paralysis were treated by endoscopic forehead lift. Four had an isolated paralysis of the temporal branch of the facial nerve and in eight the entire facial nerve was affected. In two of these patients the facial paralysis was bilateral, caused by Finnish hereditary amyloidosis. A standard subperiosteal endoforehead approach was used and the forehead was fixed by biodegradable pins (n = 8), anchor screws (n = 3), or a suture to the posterior scalp (n = 1). The procedure was a success in 10 patients, and failed in two after initially good results. The endoscopic brow lift is a good method of treating ptosis of the brow caused by paralysis of the temporal branch of the facial nerve.     

额眉提紧联合眼睑整形术

对中老年人施行额眉提紧联合眼睑整形术59例,其伤口隐蔽,能舒平额部皱纹,矫正眉下垂,美化面容,取得了较好的美容效果。并从美学角度面对联合手术及单纯手术的优点与不足进行了讨论。     

平行切断法处理额肌的内镜额部除皱术

目的探讨一种新的内镜额部除皱方法并总结其临床效果。方法2010年1月至2017年1月,北京大学第三医院成形外科119例患者行内镜额部除皱术。该术式在额肌上做平行切断以改善额部皱纹。部分降眉肌、皱眉肌用微创钳钝性咬除。术中不使用固定装置,也不行缝扎固定。术后对患者发放相关FACE-Q量表评估满意度,并测量手术前后眉部位置。结果术后1周,119例患者肿胀基本消除,眉间纹、额横纹明显减轻或消失。眉部测量显示,患者眉毛有明显抬高。FACE-Q量表结果显示,患者对术后额部皱纹、眉间皱纹改善满意度高,对手术结果满意度高;患者自觉年轻7岁。该术式常见的早期并发症是额部暂时性皮肤麻木,其次是发际线后退。结论内镜额部除皱术式可有效改善额部、眉间皱纹,满足患者需求。     

Facial rejuvenation: A combined conventional and endoscopic assisted lift

This article describes our personal approach for facial rejuvenation combining conventional and endoscopic procedures. For a forehead lift we use an endoscopic assisted technique. However, for the face and neck we still prefer the conventional lift. Good candidates for subperiosteal endoscopic midface lifts without skin resection are young or middle-age patients with midface ptosis and pronounced nasolabial/nasoyugal folds, without significant skin excess. Ptosis of the temporo-malar or facial area is also a good indication for subcutaneous endoscopic assisted lift. Aesthetic improvement of the forehead is evaluated with objective data of preoperative and postoperative measurements. We find this minimally invasive technique less traumatic and time consuming. It allows a greater range of possibilities for individual needs because it limits the incision and dissection to the required areas and has a higher level of acceptance by the patients. It is also a good complement to a conventional face lift.     

Subperiosteal transblepharoplasty forehead lift

Contemporary options for correction of the aging upper one-third of the face include open techniques with a coronal or anterior hairline incision, endoscopic access to the forehead including muscle transection, brow lift through direct forehead skin excision and various forms of brow-pexies. Realizing the common need for aesthetic improvement in the upper eyelids and desiring minimal incisions for forehead rejuvenation, an approach through the blepharoplasty incision has been developed which addresses all of the components of the aging upper third of the face: A combined subperiosteal approach for forehead elevation and transection of corrugator and procerus muscles through the blepharoplasty incision is presented. The postoperative improvements in the position of the brow as well as improvement in the glabellar area rivals other approaches and allows simultaneous improvement in upper eyelid aesthetics.Presented at the Annual Meeting of The American Society for Aesthetic Plastic Surgery, Inc., March 1995 and at the 13th International Congress of The International Society of Aesthetic Plastic Surgery, September 1995     

The subcutaneous forehead lift with an anterior hairline incision.

This review of patients after forehead rhytidectomy represents the longest published postoperative follow-up to date. Fifty patients who had undergone subcutaneous forehead rhytidectomy through an anterior hairline incision were assessed by chart review, detailed questionnaire, and physical examination. The mean follow-up was 7.5 years with a range of 1 to 17 years. Benefits of the technique described include maintenance of forehead size, a mechanically efficient lift, a direct attack on wrinkles, and a low incidence of hair loss. Patient assessment indicates that the benefits of the procedure are long lasting. The disadvantages include the added precision required in executing the incision, closure, and time-consuming dissection.     

Das „upper face-lift“

The “upper face lift” is a modified treatment of the cranial two thirds of the face (forehead, brow, temporal, cheeks) which can be tailored to the patient’s individual requirements and extent of aging. It is essential in the treatment of ptosis of the forehead, brow and temporal region (including pseudoblepharochalasis of the eyelid, “crow’s feet”, frowning, horizontal folds and wrinkles) which is sometimes accompanied by sagging of the cheek (deeper nasolabial fold, hamster cheek). Together, these changes reinforce the impression of a negative, sad and/or tired or resigned expression. The method of choice for the correction and improvement of this loss of youthful appearance is, in our opinion and according to our experience, the subcutaneous forehead/brow lift with an individually formed hairline incision and cranialisation and dynamisation of the sagged superficial musculoaponeurotic system (SMAS) in the cheek area. Only the combination of forehead/brow lift with dynamisation of the cheek area achieve the desired and optimal result with a refreshed, naturally youthful appearance and restored attractiveness, thus ensuring full patient satisfaction and durability with minimal morbidity.     

Orbicularis oculi muscle and crow's feet. Pathogenesis and surgical approach]

Crow's feet is one of the characteristic signs of the aging face. Minor techniques designed to obliterate these lesions rapidly demonstrate their limits. The orbital fibers of the orbicularis oculi muscle play a fundamental role in the pathogenesis of wrinkles. Their contracture will create wrinkles in a similar way to the spokes of a wheel perpendicularly to the orientation of the muscle fibers. The dynamic action of the zygomatic muscles contributes to exaggerate these wrinkles. Statically, ptosis of the lateral brow and the aging skin also contributes to these lesions. Surgical treatment can be accomplished by a temporal lift or via a blepharoplasty approach. The vertical fibers of the orbicularis oculi muscle must be corrected by muscle incision or resection, muscle incision and suspension, muscle redraping and fixation, covering of the orbicularis oculi muscle with the malar SMAS. In patients with ptosis of the tail of the eyebrow one must either do a forehead lift or a mask-lift that will redrape the skin. The surface of the skin may require peeling by dermabrasion. Of course, these surgical techniques require a detailed knowledge of the anatomy of this region and especially the distribution of the branches of the facial nerve. The author analyses and compares the results of the different techniques.     

Continuing Medical Education Examination—Facial Aesthetic Surgery In Pursuit of Optimal Periorbital Rejuvenation: Laser Resurfacing With or Without Blepharoplasty and Brow Lift

Learning Objectives: The reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to:

• 1.Recognize the 11 major signs of periorbital aging.
• 2.Realize the benefits of laser techniques applied to periorbital rejuvenation surgery.

Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 333. Although blepharoplasty and coronal foreheadplasty have been the traditional methods for improving the periorbital region, in our opinion these techniques together can address only three of the 11 major signs of periorbital aging. We found no improvement with skin-muscle flap type blepharoplasty and coronal lift in the wrinkling and pigmentation changes in the infrabrow, crow’s-foot, lower lid, and malar regions, and no improvement in malar bags, “dark circles” under the eyes, or the apparent lengthening of the vertical height of the lower lid and its associated sharp transition between cheek and lid skin. CO₂ laser resurfacing can improve these signs of periorbital aging and permits the laser transconjunctival approach if blepharoplasty is necessary, thus eliminating a visible lower lid incision. When brow ptosis is present, we prefer endoscopic brow lift to minimize dysesthesia and incision size. We evaluated 174 patients and contrasted the results of the traditional approach versus laser resurfacing with or without laser blepharoplasty and endoscopic brow lift. The mean time to evaluation was 9 months, ranging up to 2 ½ years. We found that the laser approach can address almost all of the 11 major signs of periorbital aging at one procedure. It is minimally invasive, technically simple and fast, offers lasting improvements, and yields high patient satisfaction and better results with fewer persistent problems than the traditional surgical approach.     

Stirnlift

Background

Worldwide the demands for anti-aging surgery have grown. Additionally, the patients’ demand for minimallyinvasive operative procedures for effective, facial rejuvenation has increased. The clear trend is toward endoscopic procedures with high effectiveness. Facelifts, which can be categorized into forehead lifts, midface lifts and neck lifts are effective methods for facial rejuvenation. The forehead lift focuses on the patient’s youthful appearance of the forehead and eyebrow region. In this context, the new static and functional position of the eyebrows is of great importance for the postoperative appearance and satisfaction of the patients. The choice of the operative procedure is dependent of the forehead anatomy and the individual expectations of the patients.

Methods

This article combines a literature search with the personal experiences of the authors regarding forehead surgery.

Results

The characteristic signs of the aging forehead that are addressed with the forehead lift are ptotic eyebrows, transverse forehead skin lines and vertical/oblique/transverse glabellar skin lines. Over the last decades, the forehead lift with a long incision posterior to the frontal hairline or in the frontal hairline (hairline cut, which is also used in cases of an extended facelift) were the commonly used operative methods. Today, the clear trend is towards minimallyinvasive procedures performed using shorter incisions. The endoscopic approach has revolutionized aesthetic forehead surgery; however, the safe and reliable application of the endoscopic technique depends on the technical expertise with the endoscopic equipment and the specific operative procedure.

Conclusion

The endoscopic forehead lift is an effective method to recover the patient’s youthful appearance. Over the last decades, the forehead lift with a large incision posterior to the frontal hairline was the commonly used operative method; however, worldwide the clear trend is toward minimally invasive procedures.

     

Evolution in techniques for endoscopic brow lift with deep temporal fixation only and lower blepharoplasty-transconjunctival fat repositioning

As we become more confident with our surgical skills following our fellowship training, some of our approaches and techniques will be modified or changed. My primary evolutionary change involves procedures of the upper third of the face, primarily the brow lift and treatment of lower eyelid fat techniques. Traditional methods of forehead and brow rejuvenation, such as coronal, pretrichal, and direct brow lifts, have provided facial plastic surgeons with effective brow elevation for many years. In the past decade, the endoscopic brow lift has rapidly become accepted as part of the surgical armamentarium and is frequently the technique of choice. In general, the temporal dissection, temporal fixation, forehead subperiosteal or subgaleal dissection with release, and treatment to the brow depressor musculature have been standardized. Methods of bony fixation remain a controversial topic as there are numerous methods. We advocate deep temporal fixation only without bone fixation to achieve effective, long-term brow elevation. Traditionally, lower eyelid herniated fat is removed, which may cause a sunken or hollow lid appearance, especially in patients with a tear trough deformity (nasojugal groove). Lower eyelid transconjunctival fat repositioning, defined as the subperiosteal repositioning of the medial and central lower eyelid herniated orbital fat into the nasojugal fold, may prevent the surgical, hollow lower eyelid appearance while treating the herniated fat. Fat repositioning may be combined with an endoscopic subperiosteal midface-lift, transcutaneous skin pinch, and transconjunctival orbicularis oculi excision. This technique offers a powerful tool in the surgical armamentarium of the facial plastic surgeon.     

An alternative fixation technique for the endoscopic brow lift

BACKGROUND: Endoscopic brow lift has become widely accepted as a procedure for restoring a youthful brow, since only 3 hardly noticeable incisions of the scalp are needed for this subperiosteal dissection and final repositioning of the brow. It has become an acceptable technique, an alternative to the conventional technique or transcoronal browpexy. One of the controversial points is the fixation of the flap in the elevated position. METHOD: Endoscopic brow lift allows separation and repositioning of the periosteum of the orbital rims and zygomaxilla. In a 6-year period from September 1999, 300 patients underwent endoscopic brow lift using our fixation approach, which was accomplished with an absorbable suture subperiosteally. RESULTS: Satisfactory forehead rejuvenation was obtained in all patients, with correct eyebrow movement. CONCLUSIONS: Long-term results of 6 years confirm the strength and durability of this fixation approach. We consider this approach to be a simple, secure, and reliable forehead fixation method, an alternative to other fixation methods, that allows satisfactory and long-lasting cosmetic results.     

内镜额部除皱术结合传统切开法除皱的效果

目的探讨内镜除皱术与传统除皱术相结合的治疗方式及效果。方法仅存在额部皱纹、眉间纹及眉下垂者采用内镜额部除皱术,切除或切断皱眉肌、降眉肌和额肌,必要时结合额部皮瓣上提悬吊技术即可;如同时存在中下面部皮肤老化、松弛下垂,则内镜额部除皱术尚需结合传统切开法的中面部或中下面部除皱术,做浅表肌腱膜系统（sMAs）筋膜的折叠或切除缝合,以及多余皮肤的切除剪裁。结果104例采用额部内镜除皱术,均取得良好的除皱和眉提升效果。并发症较少而轻微,包括表情肌去除部位的轻度凹陷、额部皮肤麻木、发际线轻微后移、皱纹去除不彻底等。无面神经颞支损伤等严重并发症发生。其中84例存在中下面部皮肤松弛下垂,在做内镜额部除皱的同时行耳前切口的传统除皱术,明显改善中下面部的皮肤老化,并使面部上下的年轻化协调一致。结论内镜额部除皱术设计合理、操作安全、效果明确,是一项切口小、损伤轻的微创技术,符合整形外科的发展趋势。对于同时存在有中下面部皮肤松弛者,如能结合传统切开法除皱术,面部年轻化的整体效果可进一步优化。     

In Favor of the Subcutaneous Forehead Lift Using the Anterior Hairline Incision

We present our experience with 980 women who had subcutaneous forehead lifts using the anterior hairline incision, during the years 1989–1996. The dissection is easy and fast; the forehead wrinkles are smoothed by the separation of the septa between the frontalis and the skin. The access to the corrugator and the procerus muscles is easy, and the adjustment of the brows to the desired location can be accurate. We use this approach for 90% of women who are eligible for upper face rejuvenation. We have obtained a 96% satisfaction rate; only 1.8% of our patients had minor and reversible complications. The scar, which is supposed to be the main disadvantage of this procedure, is almost unnoticeable, and none of our patients has permanently changed her hairstyle due to this operation. Now, during the peak of interest in forehead lifts with limited scars using the endoscope, is the time to highlight this time-worn, safe, reproducible, and effective approach.     

Transblepharoplasty brow suspension: an expanded role

Brow position and hyperfunction of the muscles of forehead facial expression contribute to the aging diathesis of the upper one third of the face. In many cases, the eyelids and brows are addressed together to achieve a satisfying rejuvenation effect. Many different approaches to the brow are used, including the long coronal or pretricheal incisions, direct incision of the suprabrow or forehead, and finally the use of smaller incisions with an endoscopic technique. Another technique, deserving of further consideration, is the transblepharoplasty brow lift (TBBL). Though generally reserved for occasional use, this technique is easy to perform, minimizes facial incisions and operative time, and can achieve results comparable to other, more extensive, approaches.