Endoscopic Forehead Lift 

Updated: Nov 30, 2021
Author: Keith A LaFerriere, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

The endoscopic forehead and brow lift is used to elevate the position of the eyebrows and forehead. Indications for this procedure are multiple, and it is performed to correct brow ptosis and to treat the glabellar frown lines created by the corrugator and procerus muscles.[1, 2] Various factors, including natural aging, facial nerve injury, and facial trauma, can cause brow ptosis, although congenital or hereditary factors also may cause the condition. Brow lifting or forehead lifting is not a new concept, but the application of endoscopic techniques to this procedure is recent.[3, 4]  See the image below.

Endoscopic forehead lift. Normal female brow posit Endoscopic forehead lift. Normal female brow position with the brows at or slightly above the orbital rim at the medial aspect and arching superior to varying degrees at the lateral aspect.

History of the Procedure

In 1994, Vasconez et al first described endoscopic forehead lift in the United States.[5] They detailed use of the endoscope to guide the release of the supraorbital and glabellar soft tissues. The dissection was performed in the subgaleal plane and involved dividing the procerus and corrugator muscles and scoring of the frontalis muscle. The fixation technique was not well described and appears to have varied.

Since this first description, multiple variations have been used. Most variations pertain to placement of incisions, planes of dissection, and methods of fixation of the forehead and brows. Because endoscopic forehead lift has been performed in the United States only since 1994, results of long-term follow-up studies of more than 5 years' duration have not been published. Results directly comparing the more established methods of forehead and brow lifting with those of the newer endoscopic techniques are also scarce.

To date, reports on endoscopic forehead and brow lifting show that excellent results are obtained with this technique. Advantages over the coronal and trichophytic approaches include significant reduction in the length of incisions, improvement in the camouflage of these incisions, and reduction of blood loss and surgical trauma. Also, the endoscopic forehead lift reduces scalp hypesthesia. Disadvantages include increased cost because of the need for more sophisticated equipment and risk of injury to either the sensory nerves or the motor nerves in this region. Additionally, surgeons must negotiate a learning curve before achieving proficiency in this procedure. In a study published in 2002, Puig and LaFerriere compared the results of open versus endoscopic forehead/brow lifts and found no statistical difference in the measurable results obtained with these procedures.[6]

Depending on the type of fixation method used, a theoretical risk of cerebrospinal fluid (CSF) leak or meningitis exists. The present authors found only 1 case report of a CSF leak associated with endoscopic brow lift, and this appears to have involved improper preparation rather than a fundamental problem with a particular fixation technique. Despite this report, endoscopic brow lift appears safe and effective when performed by properly trained surgeons, and the procedure represents an additional tool for the restoration of a symmetric, youthful appearance in the upper part of the face.

Problem

The problems addressed in endoscopic forehead and brow lift are brow ptosis and/or forehead or glabellar rhytidosis. Eyebrow ptosis is considered to be present when the eyebrow occupies a position relative to the superior orbital rim that is lower than that on the other side in cases of unilateral brow ptosis, or one that is lower than that desired by the patient. For women, the desired position generally lies at or slightly above the medial aspect of the superior orbital rim, laterally arching superior to varying degrees. For men, the brows look most natural at or slightly above the supraorbital rim with less of an arch.

Ptotic eyebrows can give the appearance of anger, worry, or weariness despite a lack of emotional intent or physical condition. Unilateral brow ptosis or brow asymmetry, whether naturally occurring or related to facial nerve dysfunction, creates the appearance of a smaller eye on the ptotic side. Glabellar frown lines are the rhytides or wrinkles just above the nasal dorsum between the eyebrows that are caused by activity of the procerus and corrugator muscles. Endoscopic forehead and brow lift addresses and improves these areas.

Epidemiology

Frequency

The frequency of age-related changes is 100%—every living person ages. Brow ptosis is one of the earlier age-related changes and usually begins in the fourth decade of life. Other causes of brow ptosis, such as scarring or facial paralysis, are relatively rare.

Etiology

See Problem.

Pathophysiology

See Problem.

Presentation

See Problem.

Indications

Indications vary and include age-related changes of the upper part of the face and congenital or acquired brow ptosis. In most cases, this procedure is performed to improve the cosmetic appearance of the upper face and brow. The procedure is generally performed for age-related facial changes, but it also may be performed for acquired ptosis due to trauma, facial nerve paralysis, or other conditions.

Patients with an upper visual field defect due to ptotic eyebrows may benefit from an endoscopic forehead and brow lift, depending on whether the predominant reason for the visual field defect is brow ptosis or redundant eyelid skin. Commonly, visual field loss is caused by a combination of these 2 problems, and a combined procedure of endoscopic forehead and brow lift with upper eyelid blepharoplasty is required.

The combination of forehead and brow lift with upper eyelid blepharoplasty is also commonly performed to treat the eyelid and forehead and brow changes of the aging face. Some authorities advocate performing these procedures at separate times. In the authors' experience, however, both procedures can be performed simultaneously with safety. The order in which they are performed varies with the surgeon's preference.

Relevant Anatomy

The forehead and eyebrows are multilaminar structures beginning at the superior aspect of the orbits and extending superiorly to blend into the scalp. Beginning with the skin, the layers at the level of the eyebrows include the skin, subcutaneous fat, muscle (orbicularis muscle laterally and procerus and corrugator muscles medially), aponeurosis (galea), periosteum, and bone.

The arcus marginalis is an area of thickening of this aponeurosis at the superior aspect of the orbit and serves as a point of attachment for the orbital septum. Critical nerves at this level are the supraorbital and supratrochlear nerves, which exit from their respective foramina at the medial and mid aspect of the orbit to travel through these layers and ramify into the appropriate skin receptors.

Proper release of the arcus marginalis and sectioning of the procerus and corrugator complex with preservation of the integrity of the sensory nerves in the supraorbital area are the most critical parts of the endoscopic forehead and brow lift. Obviously, avoiding injury to the frontal branch of the facial nerve as it passes lateral and superior to the orbit is critical for a desirable outcome. The sentinel vein is a good anatomic landmark visible near where the lateral orbital rim rises to meet the frontal bone. The frontal branch of the facial nerve runs immediately superficial to that structure. Care should be taken not to detach the lateral canthus because detachment can be associated with distortion of the normal position of the lateral commissure of the palpebral fissure.

Contraindications

Caution is advised in patients with previous frontal craniotomy, or with frontal bone, superior orbital, or frontal sinus fractures.

 

Workup

Laboratory Studies

Perform routine preoperative studies, as indicated by an anesthesiologist and/or hospital guidelines.

Imaging Studies

Routine preoperative photographs are as follows:

  • Frontal view

  • Three-quarter view (bilateral)

  • Lateral view (bilateral)

  • Frowning view (frontal)

Other Tests

Perform appropriate tests as indicated by the medical history.

Diagnostic Procedures

Visual field testing can be performed if lateral hooding with superior visual field deficit secondary to brow ptosis is suspected.

 

Treatment

Medical Therapy

Botulinum toxin (BOTOX®) has been proven successful in temporarily treating medial brow ptosis, and many surgeons use BOTOX® injections as a substitute for sectioning of the corrugator and procerus muscles. Used preoperatively, some believe that these injections facilitate adherence of the periosteum to its new, elevated position by eliminating the effect of the medial brow depressors. The drawback to botulinum toxin is the need for repeated injections.

Surgical Therapy

Variations of the original technique described by Vasconez et al are multiple and evolving.[5] Experience and personal preference often dictate a surgeon's choice of technique. A description of these various techniques is beyond the scope of this article; therefore, the authors' preferred technique is described here, and some of the more common variations are identified.

Preoperative Details

With the patient in the upright sitting position, the desired brow elevation is determined by manually elevating the brow to the desired position, by placing a marking pen on the superior aspect of the brow, and by letting the brow drop with gravity while holding the pen on the skin. A mark is made on the skin to measure the desired amount of brow elevation. This marking is performed medially and laterally along the brow to allow the surgeon to determine the amount of medial and lateral elevation desired.

The amount of medial and lateral elevation desired varies according to the patient's anatomy. Most typically, five 2-cm incisions are used: 1 medially, 1 paramedially aligned with each lateral canthus, and 1 in each temporal area. The midline and paramedian incisions are placed vertically, approximately 1.5 cm posterior to the hairline. The temporal incisions are placed approximately 4 cm posterior to the temporal hairline, in line with the preauricular crease, and transected in its midpoint by an imaginary line from the nasal ala through the lateral canthus.

Either general anesthesia or local anesthesia with conscious sedation can be used, depending on patient's and surgeon's preference. If local anesthesia with sedation is used, supraorbital and supratrochlear nerve blocks are performed first, followed by infiltration of the incisions, the orbital rims to the lateral canthi, and the area overlying the temporalis muscles. A ring block of the scalp may be performed, but this is seldom necessary. Xylocaine 1% with 1:100,000 epinephrine is most commonly used.

Intraoperative Details

After proper anesthesia is induced, the incisions are made, with midline and paramedian incisions made down through the periosteum. Some surgeons advocate the use of a subgaleal plane at this point. The authors prefer a subperiosteal approach for the ease of dissection and release of the arcus marginalis at the orbital rim, the relatively bloodless dissection, and the fixation of the periosteum to the cranium at the desired elevation. The temporal incisions extend down through the temporoparietal fascia to the superficial layer of the deep temporal fascia (shiny white fascia adherent to the temporalis muscle).

A 1-mm drill bit is used to mark the preoperative level of the forehead and brow complex through the median and paramedian incisions. This mark is used as a reference point to place the cortical tunnels for later fixation.

Subperiosteal elevator dissection then proceeds, first posteriorly to elevate the scalp off the cranium to the occiput, and then anteriorly down to approximately 1 cm above the supraorbital rims. Sharp elevator dissection of a temporal pocket is then performed directly on top of the superficial layer of the deep temporal fascia to approximately 1 cm above the zygomatic arch and also posteriorly from the temporal incision approximately 6 cm. This posterior dissection is connected at the temporal line with the posterior subperiosteal dissection. Under endoscopic guidance, the upper/medial portion of this temporal pocket is then connected to the subperiosteal dissection at the temporal line. This dissection is carefully taken down to the lateral aspect of the supraorbital rim, again under endoscopic guidance.

The sentinel vein is often encountered in this region and represents a landmark for the temporal branch of the facial nerve. The nerve in this region is usually superficial in the temporoparietal fascia and courses superior to this vein. The sentinel vein should be preserved when possible because interruption of this venous drainage system can lead to varicosities of the venous system in the periorbital and temporal regions. Proceeding from the lateral aspect at the level of the lateral canthus to medial, the periosteum is released from the supraorbital rims at the arcus marginalis.

Once the region of the supraorbital nerves is reached, the nerves are endoscopically identified and preserved. Dissection proceeds medially to the glabellar region to complete the release of the periosteum along the entire length of the supraorbital rims to the midline. The procerus and corrugator muscles are then identified and either divided or resected, with an attempt made to preserve the supratrochlear nerves, which lie superficial to the corrugator muscles.

Dyer et al described an alternative approach that uses botulinum toxin to paralyze the depressor function of these muscles during the healing phase, thereby avoiding the need to divide or resect the corrugator and procerus muscles.[7] Complete release of these soft tissues from lateral canthus to lateral canthus is the most critical part of this procedure. It allows for unhindered elevation of the forehead and brow complex. Suction cautery is used for hemostasis.

Once this release is complete and the procerus and corrugator muscles are lysed, fixation of the forehead and brow complex at the desired level is performed. A variety of described fixation techniques apparently yield successful results. The authors' preferred method involves the creation of 3 outer cortical bone bridges in the cranium, 1 at each paramedian incision and 1 at the midline incision.

The locations of the bone bars are determined by measuring the desired lift in relation to the markings made preoperatively at the medial and lateral aspects of the brows (described above) and by adding 2 mm to this measurement. This length determines the placement of the bone bar posterior to the reference drill mark made before the forehead and brow complex is released (described above).

Placement is facilitated by placing one prong of a caliper (set at the desired measurement of elevation) in the reference drill hole and by marking the level of elevation with the other prong. This method ensures that the bone bar is placed at a level far enough posteriorly to create the desired lift. The bone bars are created by using a 1-mm drill bit and by drilling 2 troughs in line with each other and separated by 2 mm. The depth of the troughs is the diploic space.

The troughs are connected under the cortex by creating a 2-mm cortical bone bridge. A permanent or long-lasting 2-0 suture can be passed from one trough, under the bone bridge, to the other trough for retrieval. The periosteum at the anterior aspect of the incision then is suspended with either permanent or long-lasting absorbable sutures to this bone bridge. This technique results in a stable, predictable fixation point that avoids the need to use skull screws.

This method of fixation has been used since 1995, and the authors have had no associated cases of CSF leakage or complication. Other fixation methods include the use of permanent or absorbable screws or plates, k-wires, bolsters, spanning sutures, tissue adhesives, and various nonfixation techniques involving skin excisions.

An absorbable device called the Endotine Forehead device (Coapt Systems, Inc., Palo Alto, California) has gained popularity over recent years, and has been found to be safe and effective.[8] It has been shown to be as effective a fixation device as suture suspension through bone tunnels.[9] Proponents list ease of use, absorbability, and adjustable nature of suspensions as key advantages.

In a 2000 article, Romo et al compared permanent screw fixation with temporary (2-wk) screw fixation in 259 patients over a 3-year period.[10] Results suggest that temporary fixation is more commonly associated with loss of brow elevation than permanent fixation. However, various fixation techniques have been used successfully with, as previously described, release of the forehead and brow complex being the only common factor. In the authors' opinion, this release is the critical factor.

A study by Massoud and Aboelatta suggested that eyebrow fixation with concentric cables in endoscopic forehead lift leads to fewer complications than does the use of temporal fasciae sutures and miniscrews, while offering long-term stability. Mean elevation of the eyebrow tail via concentric cables was consistently higher than with sutures and screws at 1, 3, 6, and 12 months postoperatively, although mean elevation of the eyebrow body was lower in the concentric cable patients than in the suture-and-screw cases at these postoperative periods.[11]

Postoperative Details

The placement of drains in the dissection space also seems to vary among surgeons. The authors do not typically use drains and have had only 1 patient with prolonged fluid accumulation in the dissection space. The placement of drains is certainly acceptable and commonly performed. Drains, when used, are generally removed on the first postoperative day.

Dressings are commonly used and generally include the application of an antibiotic ointment on the incisions, as well as coverage with a light dressing to collect any seepage. The dressing is removed on the first postoperative day, and local wound care is established. In the event of fluid (blood or serum) accumulation, needle aspiration is usually effective. Skin sutures and/or staples are generally removed after 1 week.

Advise the patient that swelling can occur for a variable period after surgery. Generally, swelling and bruising subside by the second postoperative week, but in rare cases, it may last for a few weeks. Varying degrees of numbness in the forehead and in the scalp (to the vertex) may also occur, and this can last for several months. Phantom itching can occur as sensation returns. This can usually be controlled with antihistamines. Typically, itching resolves with time, but complete resolution may require as long as a year.

Follow-up

Generally, the patient or the patient's caretaker is called the evening of the surgery. The patient is usually seen the first postoperative day, when the light dressing is removed and routine wound care counseling is given. Thereafter, the frequency of follow-up visits depends on the surgeon's discretion and on the patient's condition.

Complications

Results are comparable with those seen with open approaches, but with fewer complications. Permanent frontal nerve paralysis, permanent anesthesia due to injury to the supraorbital and/or supratrochlear nerves, hematoma, seroma, and CSF leakage are reported. The authors have encountered none of these complications, with the rare exception of seroma.

The recurrence of brow ptosis that requires revision has been reported. The authors have observed this problem and believe that it probably represents inadequate release of the supraorbital structures along with incomplete lysis of the procerus and corrugator muscles. Failed unilateral suspension, either due to the suture pulling through the tissues or due to it becoming detached from the fixation site, is also possible. Overall, however, endoscopic forehead and brow lift is an effective and safe procedure when performed by properly trained surgeons.

Outcome and Prognosis

The outcome of this procedure is usually satisfactory, and most patients with realistic goals are happy with the results. Long-term follow-up studies are scarce; however, in the authors' experience, good results usually last for years.

In a study of 31 patients who underwent a subperiosteal endoscopic brow lift, Jones and Lo found that many of the results persisted at 5.4-year follow-up. Using computer software to obtain objective measurements, the investigators found that all areas of the brow except the tail of the eyebrow maintained a subtle elevation of less than 5 mm. In addition, using regional and global aesthetic scoring systems, it was found that changes from the brow lift remained apparent to observers at 5.4 years, with 64% of patients being perceived at follow-up as better looking than they were before the brow lift. However, forehead lines, despite improvement after surgery, were perceived as having resumed their presurgical appearance by follow-up.[12]

A retrospective study by Homer et al indicated that endoscopic forehead lifting can subjectively and quantitatively improve nasal contour and length. Independent judges using the Global Aesthetic Improvement Scale found that of patients who underwent the lift, 79.4% had clinically improved nasal contour, including 11.1% who were “very much improved.” Average nasal length and the length-to-base ratio were found to have undergone a statistically significant increase. The surgery in the study involved subperiosteal blunt release of soft tissues overlying the radix.[13]

Future and Controversies

The endoscopic brow and forehead approach is also being used to rejuvenate the upper part of the face in the malar and midfacial region. Extension of the techniques of endoscopic forehead and brow lifting will undoubtedly involve access to other regions of the face.

Controversies related to this procedure are discussed above and generally involve fixation techniques, planes of dissection, and the extent of forehead and brow release.