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The upper third of the face, which is com-posed of the forehead and brow, is a critical aesthetic subunit, both independently and

in relation to the periorbita and midface.1,2 Senes-cent changes of the forehead, including rhytides, soft-tissue descent (e.g., segmental brow ptosis), and volume loss (especially temporal), are com-mon presenting complaints for patients seeking

facial rejuvenation. In 2012, nearly 25,000 surgi-cal forehead-lift procedures were performed in the United States, along with nearly 5 million neu-romodulator and filler injections—many of which were performed in the upper face.3,4

The evolution of forehead rejuvenation has mirrored that of other areas of surgery, with a shift toward minimally invasive approaches in the past

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Copyright © 2014 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0000000000000756

Brian C. Drolet, M.D.Benjamin Z. Phillips, M.D.,

M.P.H.Erik A. Hoy, M.D., M.B.A.

Johnny Chang, M.D.Patrick K. Sullivan, M.D.

Providence, R.I.; St. Louis, Mo.; Newark, Del.; and Palo Alto, Calif.

Background: The brow and forehead are essential elements of the facial aes-thetic architecture. Although frequently overlooked in youth, signs of facial aging are often most noticeable in the upper third of the face. Ptosis and loss of contour in the brows, along with temporal volume loss, sagging of periorbital tissue, and rhytides in the forehead, are common presenting complaints for aes-thetic surgery. Although use of nonsurgical procedures (e.g., neuromodulators) has become very common practice, knowledge of surgical anatomy and inter-ventions for brow and forehead rejuvenation are critical for a plastic surgeon. The earliest descriptions of brow-lift procedures are nearly a century old. Tech-niques have evolved significantly, to the point that patients may now return to work within 1 week of surgery, with minimal or no stigmata from an operation.Methods: The literature and a series of cases from the senior surgeon (P.K.S.) were reviewed.Results: A minimally invasive approach with an endoscope for dissection and repositioning of the brow was used in all patients. The authors have found that permanent suture fixation with cortical tunnels can produce an excellent, long-lasting aesthetic result for not only the forehead and brow but also the lateral periorbital and temporal regions.Conclusions: Although each operation is tailored to the patient’s individual anatomy, the authors’ approach to the endoscopic procedure is described in this article, along with a review of anatomical and surgical considerations. Fi-nally, several patients provide demonstrative results from the senior surgeon’s series of 546 patients. (Plast. Reconstr. Surg. 134: 1141, 2014.)CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

From the Department of Plastic Surgery, Rhode Island Hos-pital and the Warren Alpert Medical School of Brown Uni-versity; the Division of Plastic and Reconstructive Surgery, Washington University; Premier Dermatology & Cosmetic Surgery; and the Department of Plastic Surgery, Palo Alto Medical Foundation.Received for publication November 25, 2013; accepted March 25, 2014.Presented at the 79th Annual Meeting of the American Soci-ety of Plastic Surgeons, in Toronto, Ontario, Canada, Octo-ber 1 through 5, 2010.

Finesse in Forehead and Brow Rejuvenation: Modern Concepts, Including Endoscopic Methods

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www.PRSJournal.com).

COSMETIC

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three decades. Although Passot first described the brow-lift procedure in 1919, the modern coronal approach was not described until 1962 by Gonza-lez-Ulloa.5,6 Although this technique evolved over the following decades, the endoscopically assisted forehead lift was the next major advance, which was independently described by Vasconez et al. and Isse in 1994.7,8

Since that time, numerous descriptions of the procedure have been published. Several authors, including Jones and Grover, and Chiu and Baker, have described large series of patients demonstrat-ing safety, efficacy, and durability of endoscopic brow elevation.9–16 In the 1990s, a transpalpe-bral approach was described as an attempt to perform the entire brow lift through an upper eyelid incision. However, a recent retrospective review found significant postoperative descent in patients undergoing this approach compared with a cohort of patients undergoing endoscopic forehead lift, and the transpalpebral approach has been largely abandoned.17–19 A transpalpebral approach is still used by surgeons for modifying the corrugator supercilii muscle group to treat glabellar skin lines.

A recent systematic review of the literature by Graham et al. found that there were no data showing that the open coronal approach is infe-rior to the endoscopic technique.20 Based on their review, the open approach was found to have reliable results, with an acceptable rate of complications, although recent literature has favored the endoscopic technique. Although no prospective, randomized, controlled trials have been performed in the area of forehead rejuve-nation, two important findings are noted from an evidence-based review of the literature. First, Jones and Grover reported a statistically signifi-cant relapse in brow ptosis when fixation is per-formed with fibrin glue compared with cortical tunnels and anchor sutures.9 Second, Romo et al. found that bone anchors with temporary suture fixation (polyglactin) were considerably more likely to result in loss of brow elevation than when permanent suture was used (15.5 percent versus 0.7 percent; p < 0.05).14

In this article, we provide a review of anatomi-cal and aesthetic considerations, and a single sur-geon’s experience, in which the senior author (P.K.S.) prefers a tailored approach to endoscopic eyebrow, forehead, and temporal lift. We typi-cally use four parasagittal incisions, placed 1.5 to 2 cm behind the hairline, or hairline incisions in patients with a high forehead, along with endo-scopic dissection and permanent suture fixation

through two cortical tunnels per side.21 We do not use coronal incisions.

ANATOMICAL CONSIDERATIONSAge-related changes of the brow and forehead

are closely related to the underlying muscular anatomy. The frontalis muscle, which originates in the galea aponeurotica and inserts along the upper orbital portion of the orbicularis oculi, lifts the brow and lower portion of the forehead superiorly. This action creates horizontal furrows along the forehead, ultimately resulting in deep rhytides for some patients. The frontalis fuses inferolaterally along the superior temporal line of the skull, in the area of the zone of fixation.22 Along the lateral margin of the supraorbital rim, a broad retaining ligament has been identified in the galeal plane, which must be released to obtain elevation of the lateral brow23 (Fig. 1).

Great care must be taken during dissection in this area to identify two critical structures lateral to the orbit. First, the frontal branch of the facial nerve begins at the fibrofatty layer deep to the superficial musculoaponeurotic system over the zygomatic arch and enters the superficial temporal fascia roughly 1 to 1.5 cm lateral to the canthus.24,25 Damage to this nerve will result in ipsilateral weak-ness or paralysis of the frontalis muscle, the supe-rior portion of the orbicularis, and portions of the procerus and corrugator supercilii muscles. The second critical structure is the sentinel vein, which typically pierces the superficial temporal fascia 1.5 cm lateral and superior to the lateral canthus.26 Although some authors have described ligation of this structure, disruption of the sentinel vein may increase postoperative ecchymosis and impair intraoperative visualization, particularly during endoscopic surgery. In addition, damage to the sentinel vein may inhibit drainage of the superficial temporal venous system, causing dilata-tion of the venous plexus in the periorbital and lat-eral temporal regions. We use great care with the endoscope to visualize and preserve the sentinel vein during dissection. (See Figure, Supplemental Digital Content 1, which shows endoscopic visual-ization of the sentinel vein after careful dissection, http://links.lww.com/PRS/B134.)

Along the medial aspect of the forehead and the glabella are several paired depressor muscles. The antagonistic action of these muscles against the frontalis and their insertion in the dermis results in characteristic lines of aging, includ-ing glabellar “frown” lines from the corrugator supercilii, “crow’s feet” from the orbicularis oculi,

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and transverse glabellar lines from the procerus. Three medial retaining ligaments (superolateral, superomedial, and inferomedial) have been iden-tified that limit mobilization of the medial brow.23 The supraorbital and supratrochlear nerves pro-vide sensory innervation to the forehead and can be injured during dissection in the glabel-lar area. (See Figure, Supplemental Digital Con-tent 2, which shows superior and inferior medial retaining ligaments and proximity of sensory nerves to the forehead, demonstrated in a cadav-eric specimen, http://links.lww.com/PRS/B135.) The supraorbital nerve exits the bony orbital rim approximately 2.5 cm from the midline, whereas the supratrochlear nerve is found 1.5 cm from the midline along the orbital rim.27

AESTHETIC CONSIDERATIONS AND PREOPERATIVE PLANNING

The optimal aesthetic brow position is unique for each person based on the patient’s desires, artistic proportions, anatomy, and symmetry, which is why we emphasize a surgical approach tailored to each patient. However, in general, for the female patient, the aesthetic brow begins medially at a position above the medial canthus and alar base. Laterally, the brow ends at an axis connecting the lateral canthus to the alar base. The peak of the brow has been described at a posi-tion 5 to 10 mm superior to the lid margin and above the lateral limbus or (Fig. 2, left) at a vector

connecting the alar base and the lateral limbus28 (Fig. 2, right). In contrast, the aesthetic male brow has no distinct peak but follows a gentle curve at the level of the supraorbital rim.

In addition to medical and surgical evalua-tion, preoperative assessment includes evaluation of both brow mobility and symmetry. Manual fixa-tion of the brow into the desired postoperative position can give the patient a reasonable appre-ciation for the surgical goals, and brow and fore-head stability can be assessed (Fig. 3, right). Noting and discussing asymmetries with the patient can-not be overemphasized, as many patients have asymmetries they do not notice until the post-operative period. In addition, asymmetric brow ptosis may reflect a compensatory mechanism for unilateral ptosis, which may become more prominent if ptosis surgery is not performed at the time of the browplasty. Finally, evaluating the patient for a simultaneous upper blepharoplasty may improve patient satisfaction, as excess upper lid skin, upper lid ptosis, lateral hooding, or other age-related changes will detract from the final aes-thetic result of the browplasty.

OPERATIVE TECHNIQUE: ENDOSCOPIC FOREHEAD AND TEMPORAL LIFTThe primary goal of forehead rejuvenation is

to restore aesthetic contour to the brows by eleva-tion of the soft tissue into a youthful and symmet-ric anatomical position, and smoothing rhytides

Fig. 1. Demonstration of lateral brow retaining ligament. These broad retain-ing structures must be dissected to obtain adequate cephalad repositioning of the lateral brow. (From Sullivan PK, Salomon JA, Woo AS, Freeman MB. The importance of the retaining ligamentous attachments of the forehead for selective eyebrow reshaping and forehead rejuvenation. Plast Reconstr Surg. 2006:117:95–104.)

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along the forehead, glabella, and temporal and lateral periorbital regions. At the same time, great care must be taken to avoid overelevation of the brow and lateral spreading of the brows, which creates a “surprised-look” and operated appear-ance. To avoid this result, we focus on releasing the retaining ligaments of the lateral orbit, forehead, and temporal regions, where the dissection is fre-quently extensive, to obtain an adequate release and repositioning. Medial dissection, by contrast, is more limited but still adequate to expose and treat the corrugator and procerus muscles. Medial retaining ligaments are very selectively released if needed to treat eyebrow asymmetry. Frequently,

medial retaining ligaments are left completely intact to keep the medial brow at a low, aestheti-cally pleasing position. The extent of dissection for each patient is unique and may be different for each side of the face, depending on asymme-try of the brow preoperatively. However, as a gen-eral rule, dissection is performed medially to the midportion of the brow and inferolaterally to just above the zygomatic arch.

Careful and precise planning is absolutely crit-ical for achieving an optimal result. The patients are marked preoperatively for desired brow posi-tion and areas of upper eyelid volume deficit that might benefit from fat grafting. Brow lift can

Fig. 2. (Left) This 22-year-old woman demonstrates an aesthetically pleasing brow position, with a peak above the lateral corneo-scleral limbus, and a smooth contouring brow beginning at a position above the alar rim and ending at a vector from the alar rim through the lateral canthus. (Right) This 50-year-old woman, who has undergone an endoscopic brow lift, demonstrates ideal brow shape, position, and symmetry at 1 year postoperatively. Fat injections to the upper eyelid sulcus were performed during the same procedure.

Fig. 3. This 50-year-old woman has significant brow asymmetry, and she expressed the most concern with the position of her medial brow. A tailored endoscopic lift on the right brow (markings indicate a more medial dissec-tion) allows a more youthful and symmetric positioning of the brow. (Right) Image demonstrating manual lifting of the right brow to the desired postoperative position. The postoperative result is shown (left) at 1 year postop-eratively demonstrating successful lifting and fixation of the medial brow.

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unmask a deep upper eyelid sulcus that is in itself a hallmark of aging. A vertical line is placed on each side to show the medial limits of the lateral dissection (Fig. 3). This is critical for planning the position and shape of each brow independently so that asymmetries can be carefully identified and adequately treated. Each brow is divided into segments; thus, the end point of each segment is determined preoperatively.

With the patient in the upright position, the eyebrow is held in the planned postopera-tive position and the upper eyelid is evaluated. If excessive skin is to be removed, the incisions are determined at this time and drawn out with a fine-tip pen. The lateral extent of incision can be limited because of the planned, elevated posi-tion of the lateral brow and temporal skin from the brow lift. Although we have not identified this to be an issue, when blepharoplasty and brow lift are performed simultaneously, preoperative plan-ning should take into consideration the risk of overresecting the upper eyelid.

To provide access for the endoscope, two para-sagittal incisions are made 1.5 to 2 cm posterior to the hairline on each side of the midline. (See Figure, Supplemental Digital Content 3, which shows two parasagittal incisions made in the scalp. The lateral position of these incisions is chosen based on the vector of medial and lateral brow repositioning desired. The incision is generally placed 1 to 2 cm posterior to the hairline. Note the markings on the forehead, which indicate the medial extent of the subgaleal dissection, http://links.lww.com/PRS/B136.) The position of these four incisions is based on each patient’s individual anatomy and vector analysis for lifting of appro-priate areas of the brow and temporal region as described above. The incision is carried through the full thickness of the scalp to the pericranium; each incision is approximately 3 cm in length. A periosteal elevator is placed into the incisions on both sides of midline and subperiosteal dissection is performed laterally and posteriorly toward the vertex to mobilize the posterolateral scalp tissue.

Under endoscopic guidance, the forehead below the hairline is dissected in the loose areolar tissue of the subgaleal plane using an elevator. Care is taken to avoid violating the pericranium during this dissection, which is carried out from lateral to medial. Positioning of the surgeon’s hands for proper angulation of the instruments is critical dur-ing this portion of the procedure. We avoid tent-ing the skin with the endoscope, which is held in the nondominant hand. Meanwhile, the elevator is used both to raise a subgaleal flap and to lift the

dissected tissue to allow for careful advancement of the endoscope, allowing for ongoing visualization.

In the majority of patients, it is not necessary to free the retinacular structures medial to the supra-orbital nerves. The broad lateral retaining ligament along the supraorbital rim is released under direct endoscopic visualization, with great care taken to avoid traction injury to the frontal branch of the facial nerve and the supraorbital nerve and iden-tification and avoidance of injury to the sentinel vein. By avoiding dissection of the medial retain-ing ligaments, we can ensure adequate lateral brow elevation without overelevating the entire brow and creating the previously mentioned operated or surprised look. Depending on the need for a greater temporal lift, dissection is continued in the subgaleal plane to the zygomatic arch and along the lateral orbit. Care should be taken during this inferolateral dissection as the surgeon approaches the rami of the frontal branch of the facial nerve.

After this subgaleal dissection, the forehead and temporal soft tissues are mobilized adequately to allow for elevation of the brows to the desired position, which was determined preoperatively. Tension is applied in a superior (cephalad) direc-tion at each of the four hairline incisions in appro-priate vectors to establish this predetermined brow lift. The lower of the two brows is elevated first. A Desmarres retractor is placed in the posterior aspect of the incision starting first with the most lateral incision. This maneuver establishes the position of the first (anterior) drill hole of the cor-tical tunnels with the brow in the desired position. With tension applied, the drill is initiated with an 8-mm drill-stop, and the bone is entered at a 45-degree angle directed posteriorly. (See Figures, Supplemental Digital Content 4 and 5, which show the surgeon positioning the drill at the angles demonstrated in these images. Positioning is aided by an assistant and a surgical technician, who pro-vide traction with a Desmarres retractor and keep hair from binding in the drill, http://links.lww.com/PRS/B137. The drilling angle is 30 degrees posteri-orly, http://links.lww.com/PRS/B138.) Skin tension is released immediately after the bit has entered the outer cortex; this prevents damage to the scalp skin from contact with the drill. Multiple sweep-ing passes of the bit are made along an arc from the 5-o’clock to 7-o’clock positions to ensure con-nection with the posterior drill hole of the cortical tunnel. Three consecutively placed drill holes are placed beginning 2.5 mm posterior to the initial (anterior) tunnel; the drill should be oriented 45 degrees anteriorly, pointing in the direction of the first drill hole. (See Figure, Supplemental Digital

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Content 5, http://links.lww.com/PRS/B138.) Each posterior drill hole should be slightly more shallow than the previous hole. The holes are connected with a single anterior-to-posterior pass of the drill, creating a sweeping posterior mouth of the cor-tical tunnel. This process creates a wide anterior mouth for passing of a swedged-on needle to a gently sloping posterior channel.

The tunnel acts as a cleat for bony fixation, which has a strong cortical bridge. (See Figure, Supplemental Digital Content 6, which shows that the cortical tunnel acts as a cleat for fixation of the soft tissue. Although the holes are drilled under tension, when released, the soft tissue dem-onstrates 1 to 2 cm of laxity. The bone bridge is approximately 2.5 mm in length, http://links.lww.com/PRS/B139.) A swedged-on 3-0 nylon suture is passed through each of the cortical tunnels hug-ging the roof of the tunnel. This suture is secured using three passes and large (1 cm) bites of the deep dermal and galeal planes of the scalp. (See Figure, Supplemental Digital Content 7, which shows the nylon suture used for fixation. The needle is passed in a deep dermal fashion, with special care given to obtain a large bite of soft tissue with each of the three passes, http://links.lww.com/PRS/B140.) These permanent sutures are tied without any slack between the soft tissue and the bone, strongly fixating the suspended forehead and brow into the appropriate position. [See Figure, Supplemental Digital Content 8. Finally, the suture is tied without any slack to hold the soft tissue in a fixed and lifted position. After three passes through the soft tissue (one central and one toward each medial and lateral border of the anterior aspect of the incision), the suture is thread through the cortical tunnel. Tension is applied (panel B) providing the brow lift, http://links.lww.com/PRS/B141.] Finally, the edges of the skin incision are carefully everted with forceps and staples are used to close the incision.

Although we do not perform the coronal brow lift, we will use a hairline incision (patient 1) (Fig. 4, left) and, if desired, a scalp advancement for patients with a high forehead29 (patient 2) (Fig. 5). In this scalp advancement procedure, an incision is made following along the irregu-lar path of the hairline. A subperiosteal dissec-tion is performed along the entire scalp back to the occiput with releasing incisions being made every 1 to 1.5 cm. In addition, up to 2.5 cm of the forehead inferior to the hairline is undermined and then resected. Finally, the hair-bearing scalp is advanced to meet the resected margin of fore-head skin. Before closure of this advancement, the

same endoscopic release of lateral brow retaining ligaments and temporal structures is performed to allow for both hairline advancement and brow rejuvenation. Although not routinely practiced, this additional maneuver has produced excellent results in appropriately selected patients.

PATIENT RESULTSResults for patients 1 through 4 are shown in

Figures 4 through 7.

Patient 1In patient 1, a hairline incision for the endo-

scopic brow lift was designed to follow the irregular path of the hairline to better disguise the incision (Fig. 4). It was chosen on this 56-year-old man to avoid further elevating the hairline and to prevent the appearance of a higher forehead. The patient was also undergoing a face lift and neck lift; the brow and temporal lift decreased the laxity and hooding that is apparent in the lateral periorbital region and prevented bunching that would have occurred in the temporal region with the face lift.

Patient 2A 56-year-old woman had an abnormally high

hairline; this patient shows how the forehead can be lowered with a scalp advancement (Fig. 5).29 We also addressed her upper eyelid hooding and temporal and mild lateral brow ptosis with endo-scopic forehead rejuvenation. The lifting of the temporal soft tissue made it possible to completely hide the upper eyelid blepharoplasty scar in the upper eyelid crease rather than extending the incision into a visible area of the lateral upper lid.

Patient 3A 69-year-old businesswoman presented with

brow ptosis and hooding that accentuated her upper eyelid deformities (Fig. 6). She was very concerned that her brows would be too high and appear surgical; thus, we were especially conser-vative medially. The endoscopic temporal lift and brow lift was necessary to elevate the brows into a more natural position. Upper blepharoplasty alone would have left her with a brow position that would have been too low laterally. The inci-sion would have also extended laterally into a more visible area. A lower lid blepharoplasty was also performed.

Patient 4 A 51-year-old woman complained of heavy

forehead soft tissue and brow ptosis and signs of

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Fig. 4. Patient 1. (Above, left) Hairline incision for the endoscopic brow lift designed to follow the irregular path of the hairline to better disguise the incision. It was chosen on this 56-year-old man to avoid further elevating the hairline and to prevent the appearance of a higher forehead. The patient was also undergoing a face lift and neck lift; the brow and temporal lift decreased the laxity and hooding that is apparent in the lateral periorbital region and prevented bunching that would have occurred in the temporal region with the face lift.

Fig. 5. Patient 2. This 56-year-old woman has an abnormally high hairline and demonstrates how the forehead can be lowered with a scalp advancement. We also addressed her upper eyelid hooding and temporal and mild lateral brow ptosis with endo-scopic forehead rejuvenation. The lifting of the temporal soft tissue made it possible to completely hide the upper eyelid blepha-roplasty scar in the upper eyelid crease rather than extending the incision into a visible area of the lateral upper lid.

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aging in the upper and lower lids (Fig. 7). Rejuve-nation included a brow lift using a hairline inci-sion and an upper eyelid blepharoplasty without an extended visible upper lid incision. The lower lid was treated with both surgery and botulinum toxin. Botulinum toxin was also used in the fore-head and periorbital region. No attempt was made to overcorrect the brow position, as the emphasis

is always to have a normal appearance rather than an overdone, surgical appearance.

COMPLICATIONSPerhaps the most common complication of

endoscopic forehead rejuvenation is nerve injury resulting in forehead dysethesias and paresis or

Fig. 6. Patient 3. A 69-year-old businesswoman presented with brow ptosis and hooding that accentuated her upper eyelid defor-mities. She was very concerned that her brows would be too high and appear surgical; thus, we were especially conservative medially. The endoscopic temporal lift and brow lift were necessary to elevate the brows into a more natural position. Upper blepharoplasty alone would have left her with a brow position that would have been too low laterally. The incision would have also extended laterally into a more visible area. A lower lid blepharoplasty was also performed.

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paralysis of the frontalis muscle.20 We rarely expe-rience patient complaints of long-term sensory loss, although temporary numbness is reported. With great care taken during inferolateral dissec-tion, traction injury to the temporal branch of the facial nerve resulting in muscle paralysis can be avoided; we have had no cases of permanent temporal nerve paralysis. Although not well dis-cussed in the literature, bleeding and hematoma are a concern for both the endoscopic and open approaches to browplasty. During creation of the cortical tunnels, venous lakes may occasionally be encountered, and hemostasis can be obtained with bone wax placed into the drill hole. Care-ful hemostasis throughout the operation is criti-cal to avoid a hematoma. Given the proximity of the dura to these drilling planes, a cerebrospinal fluid leak is a possible complication, although we

have not experienced this issue and never expect to violate the inner cortex of the cranium. Using the drill stop and carefully drilling at the angles described should minimize the risk of damage to deeper structures while drilling. Finally, alopecia has been reported in as many as 19 percent of patients undergoing brow lift,11 but this can usu-ally be minimized by a tension-free closure for the dermal layer of the scalp. In our series, fewer than 10 patients (2 percent) experienced temporary alopecia, and one patient required local excision.21

Another concern is failure of brow suspension resulting in either asymmetry (unilateral) or the return of brow ptosis (bilateral). We have found that using permanent suture with cortical tunnels prevents loss of brow suspension, and we have not experienced a suture suspension failure requiring reoperation. Finally, an aesthetic complication is

Fig. 7. Patient 4. This 51-year-old woman complained of heavy forehead soft tissue and brow ptosis in addition to signs of aging in the upper and lower lids. Rejuvenation included a brow lift using a hairline incision and an upper eyelid blepharoplasty without an extended visible upper lid incision. The lower lid was treated with both surgery and botulinum toxin. Botulinum toxin was also used in the forehead and periorbital region. No attempt was made to overcorrect the brow position, as the emphasis is always to have a normal appearance rather than an overdone, surgical appearance.

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overelevation of the brows, especially the medial brows. This can result in an operated and unnatural appearance. We avoid this complication by avoiding overdissection of the medial retaining structures.

CONCLUSIONSIn this single-surgeon series, a total of 546

endoscopic brow operations have been per-formed without infection, temporal nerve paraly-sis, or failure of brow suspension. A small group of patients experienced temporary, self-resolving alopecia; one patient required local excision. We have found the endoscopic brow lift to be a reli-able and effective method for forehead rejuvena-tion and brow lift. This procedure is performed under intravenous sedation with propofol in less than 2 hours. Incisions are well disguised in the hairline or just behind the hairline, and the patients rarely experience complications.

Patrick K. Sullivan, M.D.235 Plain Street, Suite 502

Providence, R.I. 02905cosmetic@drsullivan.com

PATIENT CONSENTPatients provided written consent for the use of their

images.

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3. American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank Statistics 2012. Available at: http://www.surgery.org/sites/default/files/ASAPS-2012-Stats.pdf. Accessed May 13, 2013.

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9. Jones BM, Grover R. Endoscopic brow lift: A personal review of 538 patients and comparison of fixation techniques. Plast Reconstr Surg. 2004;113:1242–1250.

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14. Romo T III, Sclafani AP, Yung RT. Endoscopic forehead-plasty: Temporary vs. permanent fixation. Aesthetic Plast Surg. 1999;23:388–394.

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21. Hoy EA, Sullivan PK, Phillips BZ, Chang J. Browlifting and forehead rejuvenation: Proven, effective, reliable treat-ment. An analysis of over 500 cases. Paper presented at: 79th Annual Meeting of the American Society of Plastic Surgeons; October 1–5, 2010; Toronto, Ontario, Canada.

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