Endoscopic Brow Lift


Article Author:
Blake Raggio


Article Editor:
Ryan Winters


Editors In Chief:
Brian Downs
Ziad Katrib


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
9/10/2019 1:12:27 PM

Introduction

The brows play a fundamental role in the aging face. During the aging process, the brow becomes ptotic, which may cause lateral upper eyelid hooding with or without visual field deficits. Moreover, patients with these characteristic signs of aging are often perceived by others as being fatigued, despite being well-rested and in good health.[1] Currently, there exist several well-described surgical approaches to address brow aesthetics, ranging from the traditional open approaches to newer endoscopic techniques. While each technique has associated benefits and limitations, no clear evidence exists to indicate which method of brow lift surgery is superior.[2] Nevertheless, more than half of brow rejuvenation procedures performed today are performed endoscopically, which likely reflects the current trend toward minimally invasive cosmetic surgery.[3] Therefore, the modern-day aesthetic surgeon should possess thorough knowledge regarding endoscopic brow lift, a technique used to produce reliable and lasting brow restoration.

Anatomy

Characteristic signs of aging in the upper face[4]:

  • Vertical glabellar lines: caused by the action of the transverse head of corrugator supercilia muscle (CSM)
  • Oblique glabellar lines: caused by the action of the brow depressors including the oblique head of CSM, depressor supercilii muscle, and medial orbicularis oculi muscle (OOM)
  • Transverse dorsal skin lines: caused by the action of the procerus muscle
  • Lateral eyebrow ptosis: caused by gravity, galeal fat pad descent, instability of the superficial temporal fascia plane, and action of the CSM (transverse head) and the OOM (lateral portion)
  • Pseudo-excess upper eyelid skin (lid hooding): a result of brow ptosis, particularly evident laterally
  • Transverse forehead skin lines: caused by the action of the frontalis muscle, the sole brow elevator

Structures requiring release during endoscopic brow lift:

  • Zone of adhesion: A 6-mm-wide zone medial to the superior temporal fusion line of the skull where periosteum and galea are fixed to the bone
  • Conjoint tendon: The fusion of the galea, superficial and deep temporal fascia and periosteum (pericranium) within the anterior temporal region at the inferior end of the zone of adhesion. The conjoint tendon functions like a retaining ligament
  • Arcus Marginalis: The fusion of the galea and frontal periosteum at the supraorbital rim which function to anchor the brow and act as the peripheral attachment of the orbital septum

Anatomic Structures at risk:

  • Supraorbital nerve: The trunk exits the superior orbit parallel to the medial limbus and forms branches, providing innervation to the frontoparietal skin (deep branch) and upper eyelid (superficial branch).
  • Supratrochlear nerve: Located approximately 1 cm medially to the supra­orbital nerve, the supratrochlear nerve innervates the skin of the midline glabella, the medial upper eyelid, and a portion of the conjunctiva.
  • Temporal Branch of the Facial Nerve (CN VII): The temporal branch provides motor innervation to the musculature of the brow and the superior portion of the orbicularis oculi muscle. As the temporal branch courses superiorly to the zygomatic arch, it runs within or along the undersurface of the temporoparietal fascia. The anticipated path of the temporal branch can be estimated by rendering a line from a point 5 mm anterior to the tragus connecting a point 15 mm lateral to the lateral taper of the ipsilateral brow.[1]
  • Sentinel vein: This large perforating vein in the zygomaticotemporal venous system located approximately 1 cm lateral to the frontozygomatic suture line and predictably falls within 2 mm of the temporal branch of the facial nerve.[5]
  • Hair follicles: Alopecia is avoidable with incisions placed parallel to hair follicle orientation, tension-free closure of incision lines, and limited cauterization to the undersurface of hair-bearing areas.

Indications

Indications for brow lift surgery:

  • Brow asymmetry
  • Brow ptosis
  • Deep rhytids and/or furrows traversing the forehead, glabella, and/or nasal radix
  • The appearance of heavy or redundant forehead or temporal skin
  • Pseudo-blepharoptosis and/or visual field restriction

Indications for endoscopic versus open techniques include:

  • Patient preference for a less invasive procedure and/or less visible scars
  • Patient with a short forehead (less than 6 cm from brow to hairline)

Contraindications

Contraindications to brow lift surgery:

  • Lagophthalmos
  • History of dry-eye symptoms or previous blepharoplasty (increased risk of lagophthalmos)
  • Unrealistic patient expectations. In women, the brow should be arched with its highest point at the lateral limbus or lateral canthus, and lie just above the supraorbital rim. This approach contrasts to men, however, whose brow contour should be flatter and sit at the supraorbital rim. Nevertheless, a standardized ideal eyebrow does not exist; thus, surgeon-patient communication is essential to optimize outcomes.[6]
  • Body dysmorphic disorder

Contraindications to endoscopic brow lift surgery:

  • Excessive hairline recession (endoscopic brow lift procedure may raise the hairline slightly)
  • Excessively curved forehead and/or frontal bossing (inhibits the passing of endoscopic instruments to the periorbita)

Equipment

Preoperatively

  • Alcohol solution or pad (cleanse skin before injection and marking the landmarks and incisions)
  • Surgical marker (marking planned incision sites)
  • Local anesthesia (such as lidocaine 1% with epinephrine 1 to 100000; maximal dosage of lidocaine is 7 mg/kg)
  • Tumescent solution (such as 0.1% lidocaine with epinephrine 1 to 1000000 and saline)
  • Topical antiseptic, such as povidone-iodine
  • Corneal shield and lubrication to protect the eyes

Intraoperatively  

  • Endoscopic equipment (ex. 5-mm 30 degrees rigid endoscope with retractor/cowling) with monitor
  • Variety of curved dissectors and periosteal elevators
  • Fixation Method: Multiple options exist, including suture fixation to screws, plates, and bone tunnels, and resorbable tine-fixation devices are also available that engage both the periosteum and the underlying bone.[7]
  • Scalpel (#15 blade)
  • Forceps (with teeth for atraumatic soft tissue handling)
  • Facelift scissors (or other dissecting scissors)
  • Electrocoagulation/electrocautery device
  • Skin hooks and/or small retractors
  • Suture (absorbable and nonabsorbable) or staples

Postoperatively

  • Petrolatum or antibiotic ointment
  • Headwrap materials (non-stick dressing, kerlix wrap, ace wrap)

Personnel

  • Anesthesiologist
  • Operating room nurse 
  • Scrub technician
  • Surgical assistant

Preparation

Photographic views should be obtained using a 5-view head series with the patient in a seated and upright position with no facial animation. Close-up views of the eyes (closed/open/upward gaze/lateral gaze) require documentation as well.[1]

Landmarks identified include the supraorbital notch, the proposed highest point of the brow, course of the frontal branch of the facial nerve, and sentinel vein.

Incisions are marked. Placement of three frontal hairline incisions (1 median and two paramedian) is 1 cm posterior to the hairline, typically less than 2 cm in length. The paramedian incisions are marked vertically above and slightly medial to the planned highest point of the brow arch. Two temporal incisions are marked parallel and posterior to the temporal hairline on a vector line drawn from ala through lateral canthus extended into the hairline. There is no recommendation to shave the incision sites, though hair ties may be used to corral the hair on both sides of the proposed incision sites for improved visualization.

The patient is positioned supine with the endoscope monitor at the foot of the bed within view of the surgeon.

Local anesthesia infiltrates along the supraorbital and lateral orbital rims. Tumescent solution is injected subperiosteally from the supraorbital rim to the vertex between the superior temporal lines, and then into the superficial temporal spaces bilaterally. The endoscopic brow lift may be performed entirely under local anesthesia; however, general anesthesia or intravenous (IV) techniques are advisable to ensure patient comfort. When using intravenous sedation, the recommendation is for nerve blocks of the auriculotemporal and zygomaticotemporal nerves.

A single dose of intravenous antibiotics is the recommended prophylaxis before the start of the procedure.

Technique

The successful endoscopic brow lift requires the surgeon to utilize the careful surgical technique, adhere to anatomic dissection planes, and directly visualize specific anatomic structures at key points in the procedure. Herein we present safe and reliable endoscopic brow lift techniques.[7][8][1]

The surgeon makes midline and paramedian incisions through all layers of the scalp to the cranium. The temporal incisions only carry to the superficial layer of the deep temporal fascia.

Using a curved periosteal elevator, the midline and paramedian ports are used to perform blind dissection (without the endoscope) to develop a full-thickness subperiosteal pocket between the temporal lines. Blind dissection carries anteriorly to a point 1 to 2 cm cephalic to the supraorbital rims and anterolaterally along the lateral orbit rims to the lateral canthus.

The 30-degree endoscope (inserted through the midline port) and endoscopic instruments (inserted through the paramedian ports) are used to fully release the Arcus Marginalis while taking care not to violate the supraorbital neurovascular bundles

With the completion of periosteum exposure and scoring, resection or ablation of the frontalis, corrugators and procerus muscles may follow if desired, a maneuver typically reserved for patients with deep forehead and glabellar rhytids.[9] Note: Aggressive release of the corrugators has the risk of widening the inter-brow distance.

A curved elevator is then used via the temporal port to blindly dissect the tissue plane between the temporoparietal fascia (superficial temporal fascia) and the temporalis fascia (deep temporal fascia) that overlies the temporalis muscle. The entirety of the superficial temporal space gets released anteriorly and posteriorly and inferiorly approximately 1 cm above the zygomatic arch to avoid injuring the facial nerve as it crosses the zygoma. The sentinel vein, usually identified 1 cm lateral to the frontozygomatic suture line, should not be cauterized if possible as to decrease the risk of facial nerve injury.

The lateral and the central dissection planes are then connected by sharply dividing the zone of adhesion at the superior temporal line. Similarly, the conjoint tendon is then opened above the supraorbital rim and posteriorly until there is a complete connection between the lateral and central dissection pockets.

Fixation is usually accomplished first at the temporal ports and then at the paramedian ports. Large permanent or semi-permanent suture (ex. 0-0 nylon or polydioxanone) is utilized to affix the temporoparietal fascia to the deep temporalis fascia in a vector that follows the line formed from the ala to the lateral canthus. Fixation at the paramedian incision is then performed, which is possible via a multitude of techniques. The surgeon can use a tissue fixation device. Holes are drilled in the skull through the paramedian incisions to place the devices bilaterally. The inferior scalp flap is then lifted off the bone and suspended superiorly onto the device prongs with the help of an assistant. This maneuver holds the periosteum in place and sets the height and arch of the brows. Note: In general, approximately 5 mm of vertical relapse should be anticipated depending on the thickness and redundancy of the preoperative forehead.

Scalp incision closure is with either skin staples or sutures, and petrolatum or antibiotic ointment is applied. Drains are usually not necessary, and one may use a light forehead wrap placed as a pressure dressing.

Lastly, if planning a concurrent upper blepharoplasty, it should only be performed after completing the brow lift as the brow lift decreases upper eyelid skin redundancy and reduces the amount of skin excised during blepharoplasty.

Complications

The most common complications of the endoscopic brow are paresthesia/dysesthesia, asymmetry, alopecia, lagophthalmos, and need for revision. Motor nerve injury to the frontal branch of the facial nerve, the most feared complication, is less common. Other complications include edema, wound dehiscence, eye problems, glabellar irregularity, granuloma, hematoma, infection, pain, palpability of implanted materials (i.e., screws), pruritus, screw exposure, seroma, skin burn, and scar.[10][2]

Nonetheless, patient satisfaction with endoscopic brow lift is high (greater than 98%), and only rarely are significant complications reported.[3]

Lastly, while the endoscopic brow lift may portend a lower complication profile compared to the traditional open approaches, this finding remains inconclusive due to the lack of well-designed studies and standardized outcome measures in brow rejuvenation.[11]

Clinical Significance

An endoscopic brow lift aims to restore a more youthful and rested appearance. When performing an endoscopic brow lift, it requires meticulous surgical technique, strict adherence to anatomic dissection planes, and direct visualization used at crucial points in the procedure enabling a safer, more-complete dissection and ultimately a better outcome.

Enhancing Healthcare Team Outcomes

Is imperative to identify the risk factors and perform a thorough assessment of the patient before an endoscopic brow lift. A team approach is an ideal way to limit the complications of this procedure. Prior to surgery, the patient should have the following done:

  • Evaluation by a surgeon experienced in selecting the appropriate patient for the surgery.
  • Evaluation by the primary care physician, anesthesiologist, and nurse anesthetist to ensure that the patient is fit for general anesthesia.
  • Evaluation by the optometrist or ophthalmologist if the patient suffers from dry eye, ptosis, or lagophthalmos.
  • Evaluation and monitoring by the pre, operative, and post-operative specialty nurses to assist with coordination of care and patient and family education.

An interdisciplinary team of an operative clinician, anesthesiologist, and surgical assistants and operative nurses should perform the endoscopic brow lift for the best outcomes. A nurse dedicated to the monitoring of the patient during anesthesia is highly recommended. Pharmacist involvement comes in the form of prophylactic antibiotic verification (e.g., dose, appropriateness of agent selected), post-operatively, with pain control and corticosteroid dosing and duration recommendations, along with a complete medication reconciliation to ensure no drug-drug interactions, reported to the healthcare team is present. Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the postoperative care of endoscopic brow lifts, should monitor the patient for possible complications including hematoma formation. The patient will also require education on avoiding strenuous activity, heavy lifting, or bending over during the first several days post-operatively to prevent such complications. Only through this type of interprofessional healthcare team approach can outcomes for this procedure achieve their optimal result. [Level V]

Nursing Actions and Interventions

Adequate pain medication is necessary, as patients often report severe tension headache-like discomfort for the first day or two postoperatively. Ice packs should be placed intermittently around the eyes for the initial 24 hours. The head dressing gets removed on postoperative day 1, at which time showering may resume. Sleeping with the head elevated for 1 week, avoiding vigorous activity for 2 weeks after surgery, and a low dose corticosteroid taper may help lessen bruising and swelling. Patients are asked to return at 1 week for wound assessment and staple/suture removal. Hair coloring is safe to perform at 1 month. At 6 to 8 weeks, the result is considered stable. It is not uncommon that the tine-fixation devices remain palpable out to 5 months. Photographic documentation should occur at the 3-month and 12-month visits.

Nursing Monitoring

Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the postoperative care of endoscopic brow lifts, should monitor the patient for possible complications including hematoma formation.


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Endoscopic Brow Lift - Questions

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A 54-year-old woman presents for follow-up 1 week after receiving an endoscopic brow lift. She is doing well overall but complains of paresthesia to the middle of her forehead and glabella. Aggressive dissection and/or release of which area most likely contributed to this postoperative complication?



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A 63-year-old Caucasian male presents to the office for an upper forehead rejuvenation consultation. Physical examination shows a relatively short forehead and normal hairline. His main concerns are his deep glabellar rhytids, brow ptosis, lateral hooding, and severely redundant upper eyelid skin, all of which he would like to improve. The patient also makes you aware that he would like to avoid any visible scars if possible. Which procedure(s) is/are most appropriate for this patient?



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A 33-year-old woman presents for follow-up 1 day after receiving an endoscopic brow lift, with right-sided forehead weakness and lagophthalmos. Which of the following is the most reliable landmark to help identify the location of the nerve that was likely injured in this patient?



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A 70-year-old Caucasian male presents to the office for an upper forehead rejuvenation consultation. Physical exam shows a relatively long forehead with a receding hairline, male pattern baldness (Norwood 4), and frontal bossing. He also displays deep glabellar rhytids, moderate brow ptosis, lateral hooding, and severely redundant upper eyelid skin. He also has a right-sided lagophthalmos, which he dismisses as a minor effect of a small stroke he had several years ago. The patient emphasizes he is not interested in correcting the lagophthalmos, but would rather the clinician focus their attention on the forehead rhytids, brow ptosis, lateral hooding, and excess lid skin. Which procedure(s) would offer the patient the best chance of improving all these signs of aging simultaneously?



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A 50-year-old female patient presents to the office for upper forehead rejuvenation consultation. She is deemed a good candidate for an endoscopic brow lift surgery; however, she is quite concerned about experiencing any postoperative complications. She is reassured that patient satisfaction with endoscopic brow lift is very high (greater than 98%), and major complications are rarely reported. Moreover, the advantages of performing endoscopic brow lift versus traditional open techniques are outlined. Which of the following complications occurs less often with endoscopic brow lifts compared to traditional open approaches?



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A 60-year-old male presents for follow-up 6 months after receiving an endoscopic brow lift. He was initially happy with his results, but over the last several weeks, he has noticed that his brows have almost returned to their preoperative state. Which of the following is the most likely explanation for his recurrent brow ptosis?



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Endoscopic Brow Lift - References

References

Terella AM,Wang TD, Technical considerations in endoscopic brow lift. Clinics in plastic surgery. 2013 Jan;     [PubMed]
Graham DW,Heller J,Kurkjian TJ,Schaub TS,Rohrich RJ, Brow lift in facial rejuvenation: a systematic literature review of open versus endoscopic techniques. Plastic and reconstructive surgery. 2011 Oct;     [PubMed]
Elkwood A,Matarasso A,Rankin M,Elkowitz M,Godek CP, National plastic surgery survey: brow lifting techniques and complications. Plastic and reconstructive surgery. 2001 Dec;     [PubMed]
Knize DM, Anatomic concepts for brow lift procedures. Plastic and reconstructive surgery. 2009 Dec;     [PubMed]
Sabini P,Wayne I,Quatela VC, Anatomical guides to precisely localize the frontal branch of the facial nerve. Archives of facial plastic surgery. 2003 Mar-Apr;     [PubMed]
Park J,Yun S,Son D, Changes in Eyebrow Position and Movement with Aging. Archives of plastic surgery. 2017 Jan;     [PubMed]
Core GB,Vasconez LO,Graham HD 3rd, Endoscopic browlift. Clinics in plastic surgery. 1995 Oct;     [PubMed]
Punthakee X,Mashkevich G,Keller GS, Endoscopic forehead and brow-lift. Facial plastic surgery : FPS. 2010 Aug;     [PubMed]
Starkman SJ,Sherris DA, Association of Corrugator Supercilii and Procerus Myectomy With Endoscopic Browlift Outcomes. JAMA facial plastic surgery. 2019 May 2;     [PubMed]
Byun S,Mukovozov I,Farrokhyar F,Thoma A, Complications of browlift techniques: a systematic review. Aesthetic surgery journal. 2013 Feb;     [PubMed]
Cho MJ,Carboy JA,Rohrich RJ, Complications in Brow Lifts: A Systemic Review of Surgical and Nonsurgical Brow Rejuvenations. Plastic and reconstructive surgery. Global open. 2018 Oct;     [PubMed]

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