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.     

Secondary endoscopic forehead lift in patients with previous coronal brow lifts

INTRODUCTION: The development of endoscopic surgical techniques has allowed an evolution from the standard coronal forehead lift to a minimally invasive one. Endoscopy avoids many of the undesirable results of the coronal approach while it remains very efficacious. The purpose of this study is to evaluate the effectiveness and safety of endoscopic forehead lift in patients who have previously undergone coronal brow lift. MATERIALS AND METHODS: A retrospective review was performed on the medical records of 726 consecutive patients who had undergone endoscopic forehead lift between 1994 and 2004. Sixty-three patients were identified who had undergone prior coronal incision brow lift and then required subsequent elevation of the forehead using endoscopy. Those who had persistent low eyebrows and forehead wrinkles underwent the standard minimal incision endoscopic approach. Patients with severe brow ptosis and excessive height of the forehead underwent a biplanar endoscopic forehead lift. RESULTS: Of the 63 endoscopic forehead lifts performed, 49 used the minimal access technique, while 14 employed the biplanar approach. The subject population consisted of 58 female and 5 male patients whose average age was 57 years (range of 42 to 80 years). Eighty-seven percent of these brow lifts also had concomitant rhytidectomy, and 4% had blepharoplasty. Average follow-up was 21 months (range 1 to 7 years). Following the endoscopic procedure, none of the patients had frontal nerve injury, alopecia, or persistent glabellar wrinkle lines. Complications included 1 forehead dysesthesia, 1 forehead irregularity, 1 eyebrow malposition, 1 persistent horizontal forehead wrinkling, and 2 hematomas. Operative management was not required for any of these complications. CONCLUSION: The secondary endoscopic forehead lift is effective in rejuvenating the upper face in the patient who has had a previous coronal forehead lift. It elevates the eyebrows and reduces both transverse and vertical wrinkles while avoiding further displacement of the hairline. The low rate of complications is comparable to that of primary endoscopic forehead lifts. Finally, serial follow-up indicates that the results are effective at correcting brow ptosis and are long lasting.     

Concurrent brow lift and blepharoplasty with a resorbable fixation device

Background

Ageing changes on the forehead and the periocular area are of much concern to the patient not only from an aesthetic but a functional point of view as well. Many techniques exist for correction of upper periorbital ageing changes. We hereby present our technique of doing a brow lift and upper lid blepharoplasty as a combined procedure using a resorbable fixation device.

Methods

We carried out the study over a period of 36 months from July 2008 to July 2011. Only the patients requiring both brow lift and blepharoplasty were included in the study. Brow lift was performed through the upper lid blepharoplasty incision, and elevation was maintained by the resorbable fixation device screwed into the frontal bone. Following this, excess upper lid skin and muscle was excised to complete the upper lid blepharoplasty.

Results

A total of 25 cases including 17 females and 8 males were operated. The age ranged from 39 to 74 years, and the mean age was 54 years. Seven patients required both upper as well as lower lid blepharoplasty along with a brow lift, whereas 18 patients underwent only upper lid blepharoplasty along with a brow lift. In two of the patients who had a predominantly medial brow ptosis, we placed the Endotine device over the medial eyebrow. All patients were satisfied with the final result, and the device became impalpable over a period of 1 year.

Conclusions

The technique described is simple, reproducible and quick for addressing the upper lid and brow in one surgical sitting. A thorough preoperative discussion and demonstration of achievable result to the patient along with thorough understanding of the anatomy is the key to success.

Level of Evidence:

Level IV, therapeutic study.     

Approach to eyebrow ptosis through the modified technique of Castan?res

One of the first signs of facial ageing appears in the forehead, with the descent of the lateral part of the brow. This is a troubling condition for all patients and elevation of the lateral part of the brow becomes a more and more frequent demand. The authors present their experience in 350 consecutive cases of direct eyebrow lift (“butterfly wing” incision) alone or in combination with rhytidectomy and/or blepharoplasty. The majority of the patients were female (90%). The age ranged from 43 to 85 years. Eighty per cent of the cases were performed simultaneously with rhytidectomy and blepharoplasty, 16% were performed in association with blepharoplasty and eyebrow lift alone represented 4%. The most common complication was epidermal cyst (3.4%) and suture dehiscence (2%). The “butterfly wing” incision provides a useful alternative to correction of eyebrow ptosis. Indication for surgery is dependent more on the ageing signs than on the patient''s chronological age. The final results are consistently very gratifying to the patient and to the plastic surgeon alike.     

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     

Comprehensive periorbital rejuvenation with resorbable endotine implants for trans-lid brow and midface elevation

Periorbital rejuvenation can enhance a patient's appearance, with changes of only a few millimeters making a significant impact. Many patients undergoing blepharoplasty often have mild brow or midfacial changes for which they are unwilling to undergo additional concurrent forehead or midface procedures, however, because these procedures may be associated with an unacceptable postoperative recovery and may not provide adequate tissue fixation. This article describes limited incision procedures capable of providing excellent elevation and support to the brow and midface that can be incorporated easily into a comprehensive periorbital rejuvenation treatment plan using semi-permanent subperiosteal fixation devices.     

小切口额眉提紧术联合重睑术治疗中重度上睑皮肤松垂症

目的探讨小切口额眉提紧术联合重睑术治疗中重度上睑皮肤松垂症的方法及疗效。方法采用小切口额部提紧术联合重睑术治疗中重度眼睑皮肤松垂症25例,通过发迹内或发迹缘小切口行帽状腱膜下剥离,眉毛及发迹缘行埋没导引缝合悬吊额眉部软组织,额眉组织提升后再行重睑成形术。结果本组切口平均0.9(0.8～1.0)cm,术后5～10d消肿,术后1月眼部形态恢复,额眉眼比例恢复。无一例大血肿、皮肤坏死等并发症。术后平均随访32个月(3个月～6年),所有患者上眼睑皮肤提紧,手术疤痕不明显。结论小切口额眉提紧术联合重睑术治疗中重度上睑皮肤松垂症简单、有效,不需特殊设备,在解除眼部症状的同时,又能达到良好的美容效果。     

Endoscopic forehead lifting and contouring

The concept of endoscopic foreheadplasty is based upon a sub- or supraperiosteal dissection of the parietal, occipital and frontal scalp, incision and release of the superior and lateral orbital periosteum, selective myotomies of the brow depressor muscles, and brow elevation into a desired position with fixation and healing. A significant limitation of this procedure appears to be the ability to predict the long-term forehead and brow elevation. We review the anatomy relevant to forehead rejuvenation surgery and present our surgical technique for permanent fixation endoscopic forehead lifting. We discuss the scientific rationale for permanent fixation to ensure long-term forehead and brow position and draw our conclusions based upon the results of animal and clinical studies that have been completed.     

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.     

Aesthetic considerations in the elevation of the eyebrow

In an increasingly diverse and multicultural society, it becomes increasing imperative to understand the aesthetics and proper analysis of the face, particularly as it applies to forehead lifting and elevation of the eyebrow. Most articles published to date have emphasized the surgical anatomy and/or surgical technique of forehead lifting and addressed the question of brow aesthetics in a uniform, generalized fashion. In addition, the emphasis on brow elevation as a means to brow/upper lid rejuvenation can further distract the surgeon from appreciating each person's unique brow aesthetics. This article examines current surgical concepts of brow/upper lid proportion and harmony and compares and contrasts them with cultural notions of the "pleasing brow" as represented by the makeup and fashion industries. There is great variation in what is considered to be a "beautiful brow," and the facial plastic surgeon must understand the nuanced elements of eyebrow configuration that contribute to the overall balance and harmony of the face.     

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.     

额眉提紧联合眼睑整形术的临床研究

为了使求美者既能消除眼睑皱纹，又能增添眼部美观。作者对５９例行额眉提紧联合眼睑整形术，取得了较好的美容效果。本文重点从美学方面对联合手术的优点及单纯手术的不足进行了讨论。     

Elevation of the Lateral Brow Without the Help of an Endoscope

One of the first signs of facial aging appears in the forehead, with the descent of the lateral part of the brow. This is a troubling condition for young patients, and elevation of the lateral part of the brow becomes a more and more frequent demand in the young population. A simple technique that can be performed alone or at the time of a facelift is presented here. Results are shown to demonstrate the efficiency of the procedure.     

Small incision subperiosteal and trans-blepharoplasty forehead and browlift.

The purpose of the study is to evaluate the safety and efficacy of non-endoscopic, small-incision subperiosteal forehead and browlift in patients undergoing associated upper eyelid blepharoplasty. This is a retrospective, non-comparative case series of 14 consecutive patients in 12 months. Eleven patients underwent bilateral and three unilateral surgery. Unilateral surgery was performed in patients with facial palsy and was augmented with cable suspension. The technique involves five small scalp incisions to create a single subperiosteal and deep temporal cavity. Superior arcus marginalis release and direct visualisation of the supraorbital nerve was achieved via a trans-blepharoplasty approach. All patients achieved a desirable browlift and contour. Follow up ranged from 2 to 40 weeks. Minor complications included transient diplopia (1), reduced upper eyelid sensation (1), and brief postoperative bleeding from one of the small incision sites (1). Small incision and trans-blepharoplasty forehead and browlift is a safe and effective method to achieve a cosmetically desirable browlift in patients that require associated upper eyelid blepharoplasty, using standard oculoplastic equipment without the need for an endoscope.     

Surgical advances. A comprehensive approach to surgical rejuvenation of the eyes

Methods to rejuvenate the eye region include shortening of the forehead, raising the brow, improving the upper eyelids by excision of blepharochalasis tissue, and reducing lower eyelid fat pads by a transconjunctival approach and at the same time elevating the stretched lateral canthus by an effective canthopexy. The risks and complications of these procedures are minimal, circumscribing the shortcomings of conventional blepharoplasty.     

Use of BioGlue surgical adhesive for brow fixation in endoscopic browplasty

OBJECTIVE: To determine the efficacy, longevity, and safety of BioGlue Surgical Adhesive for periosteal fixation in endoscopic browlifts. METHODS: Retrospective review of 80 patients who underwent endoscopic browlift using BioGlue as the primary means of periosteal fixation. Visits were categorized as preoperative, 1 to 2 months, 3 to 6 months, and 7 to 12 months, and photographs of the first 15 patients were evaluated for change in brow position at each of these visits. Brow position was measured at the lowest brow hairs at the midpupillary and lateral canthus positions. Follow-up was 3 months to 3 years. RESULTS: All of the first 15 patients were included in the 1- to 2-month postoperative grouping, 13 in the 3- to 6-month grouping, and 10 in the 7- to 12-month grouping. At all postoperative visits, brow elevation was significantly maintained during 12-month follow-up. Revision has been required in only 1 of 80 patients to date. CONCLUSIONS: BioGlue is an effective and safe method of maintaining brow position in endoscopic browplasty. Brow elevation achieved using BioGlue was significantly maintained during the 7- to 12-month postoperative period. Tissue adhesives such as BioGlue have the potential to become significant adjuncts in facial plastic surgery and warrant more critical evaluation.     

Lower eyelid aesthetics after endoscopic forehead midface-lift

OBJECTIVE: To assess and quantitate the immediate effect of endoscopic forehead midface-lift on infraorbital hollowing and lower eyelid skin excision. METHODS: Twenty-five patients who underwent an endoscopic forehead midface-lift with a lower eyelid blepharoplasty or lower eyelid blepharoplasty without a midface-lift between January 1, 2005, and May 15, 2005, were included in the study. Preoperative and immediate postoperative measurements of the vertical height of the lower eyelid were taken in all patients. The change in the vertical height of the lower eyelid after endoscopic forehead midface-lift with blepharoplasty was compared with the change in lower eyelid height after either transconjunctival or lower eyelid skin pinch blepharoplasty or skin muscle flap blepharoplasty alone. The amount of lower eyelid skin excised after endoscopic forehead midface-lift with blepharoplasty was compared with both transconjunctival or lower eyelid skin pinch blepharoplasty and skin muscle flap blepharoplasty when a midface-lift was not performed. RESULTS: The average change in the vertical height of the lower eyelid after the endoscopic forehead midface-lift was 5 mm. Lower eyelid blepharoplasty alone, whether transconjunctival with skin pinch or skin muscle flap, did not affect the vertical height of the lower eyelid. The change in the vertical height of the lower eyelid with midface surgery over blepharoplasty alone was statistically significant (P < .001). The average amount of lower eyelid skin excised after endoscopic forehead midface-lift and lower eyelid skin pinch was 7.0 mm compared with 5.5 mm for both the transconjunctival lower eyelid skin pinch and the skin muscle flap techniques. The difference in skin excision when a midface-lift was performed compared with blepharoplasty alone was statistically significant (P = .008). CONCLUSIONS: The endoscopic forehead midface-lift can reduce the vertical height of the lower eyelid by an average of 5 mm and allows more skin excision over blepharoplasty alone. The endoscopic forehead midface-lift is a powerful tool for decreasing the vertical height of the lower eyelid, lessening infraorbital hollowing, and improving dermatochalasis.     

眉上提术在眼睑部整形中的应用

目的　解决眼睑松弛、眼眉下垂所至的容貌老态和功能障碍 ,如眼睑皮肤肌肉松弛、眼睑皱襞形成、眶隔脂肪松垂、倒睫、眼裂外下斜、眉梢下垂或眉形不美等。方法　通过眼轮匝肌悬吊进行眉上提术或联合重睑术式来进行眼睑整体的修复。结果　对 5 6例患者进行治疗 ,眼睑部修整与眼眉上提及眉形修整均得到满意效果。结论　应用眉上提术能解决以上所有老态或先天畸形 ,功能得到改善并达到持久的眼睑美化、年轻化 ,并且无并发症。     

Brow or Forehead Fixation with Sutures Only: A Preliminary Communication

Fixation of the brow, although not technically difficult, can be a time-consuming process. Screws, whether permanent or absorbable, are occasionally associated with minor undesirable problems. We present a technique of brow suspension that is quick, simple, and free of the problems associated with fixation to the calvarium. It involves the use of sutures only. A heavy PDS suture is passed (with the aid of an awl) from the dermis of the brow or forehead that needs to be fixed to the dermis of a small incisional wound located 5–8 cm away. This suture suspension technique has proven to be quick and easy to execute. It has provided satisfactory fixation of the forehead/brow without problems of suture reaction. The cost of calvarial screws has been eliminated. When brow or forehead fixation is necessary, suspension with sutures to the dermis of a more superior location is an excellent method to accomplish the task quickly and easily. Long-term follow-up of a large series of patients will be necessary to validate the initial impression of this new technique.     

Endoscopic excision of benign forehead masses: a novel approach for pediatric general surgeons

Purpose

Benign tumors of the brow and forehead are commonly managed by pediatric general surgeons by excision through an overlying incision. Cosmetic results in children can be suboptimal. Plastic surgeons have used endoscopic brow-lift techniques for the removal of these lesions. We review our experience after adopting this endoscopic technique in a pediatric general surgery practice.

Methods

We conducted a retrospective chart review of 9 consecutive outpatient procedures (5 girls and 4 boys; age range, 5 months to 12 years) between March and October 2005. Seven patients had lesions located on the lateral brow (left, n = 4; right, n = 3), 1 patient had a lesion on the left mid forehead, and 1 patient had a nasoglabellar cyst. All procedures were performed using endoscopic brow-lift equipment through a single small scalp incision 2 cm posterior to the hairline. Outcome measures included need for conversion, operative time, cosmetic outcome, and complications.

Results

All lesions (6 dermoid cysts and 3 pilomatrixomas) were successfully excised endoscopically. The mean operative time was 56 minutes (range, 22-90 minutes). There was no intraoperative or postoperative complication. All families were pleased with the cosmetic outcomes.

Conclusion

This case report shows that endoscopic excision of forehead masses is a safe and efficacious procedure in the hands of pediatric general surgeons.