Our Experience with Endoscopic Brow Lifts

Ozan Sozer, M.D., and Thomas M. Biggs, M.D.

Istanbul, Turkey and Houston, Texas

Abstract. This is a retrospective review of our experience withthe endoscopic brow lift. We reviewed 128 procedures per-formed by two senior faculty members over the last 5 years. Weevaluated the age, gender, operating time, complications, andoutcome and conclude that endoscopic brow lift is a safe, ef-ficient procedure with a low complication rate. The operatingtime is short, and there is a very high patient acceptance. Theprocedure has taken its place as an integral part of facial reju-venation in our practice.

Key words: Endoscopic brow lift—Complications—Surgicalprocedure—Safety

Endoscopic brow lift has gained popularity since its in-troduction in 1994 [1] and we have performed 218 browlifts at St. Joseph Hospital since then. This is a retro-spective review of 128 cases performed over the last 5years by two senior faculty members.

Materials and Methods

Charts of patients who had had endoscopic brow liftsbefore December 31, 1998 were reviewed and the tech-nique was analyzed. Age, gender, operating time, otherprocedures performed, and outcomes were evaluated. Anobjective measurement of the brow elevation was notpossible because of the retrospective nature of the re-view. We chose random patients and performed subjec-tive analysis of the elevation by looking at the browposition, frown lines, transverse forehead rhytids, and bymaking comparisons with the preoperative pictures.

Technique

The technique has undergone various modifications,most of which involved the placement of incisions andthe way the elevation was secured. We started with ver-tical incisions where the incision was closed in a trans-verse fashion following resection of bilateral dog ears(Fig. 1). Then we placed a screw in the outer table of theskull through a vertical incision and secured the eleva-tion with a Prolene suture wrapped around the screw(Fig. 2). With our current fixation technique the foreheadand temporal and parietal scalp are infiltrated with 0.5%lidocaine with epinephrine. Three vertical incisions—one in the midline and one on each side leveled with theapices of the brows—are placed 1–2 cm behind the hairline (Fig. 3A). The infiltrated posterior scalp is elevatedin a subgaleal plane (B) and the forehead is elevated to apoint 2 cm cephalad to the supraorbital rim in a subperi-

Correspondence to Thomas M. Biggs, M.D., 1315 St. JosephParkway, Suite 900, Houston, Texas 77002, USA

Fig. 1. (A) The vertical incision.(B) The vertical incision isapproximated transversely and the dog ears are marked.(C)The dog ears are excised and incision is closed.Fig. 2. (A) The screw is placed in the outer table through theincision.(B) The elevation of the forehead is secured by wrap-ping a prolene suture around the screw.(C) The incision isclosed.

Aesth. Plast. Surg. 24:90–96, 2000DOI: 10.1007/s002660010017

© 2000 Springer-Verlag New York Inc.

osteal plane (C). Bilateral 3 cm incisions are placed overthe temporal areas and are perpendicular to the line thatconnects the nasal alae to the ipsilateral commissure ofthe eye (D). We try to keep these incisions as a temporalextension of the preauricular incision if we are perform-ing a facelift at the same time. These incisions are takendown to the deep temporal fascia but not through it. Aplane just superficial to the deep temporal fascia is de-

veloped and joins the subperiosteal plane of the foreheadthrough the temporal fusion line (E).

An endoscope is placed through the mid-vertical inci-sion (Fig. 4A) and after this point the operation requiresa different eye and hand coordination where the surgeonfaces the monitor rather than the patient (B). Under thedirect visualization of the endoscope the subperiostealdissection is carried down to the supraorbital rim (C), the

Fig. 3. (A) Location of incisions. Note that the actualincisions are behind the hair line and the arrow is pointing tothe location. One and a half and 2.5 cm markings indicatethe location of supratrochlear and supraorbital neurovascularbundles, respectively.(B) The infiltrated posterior scalp iselevated in a subgaleal plane.(C) The forehead is elevated toa point 2 cm cephalad to the superorbital rim in asubperiosteal plane.(D) The deep temporal fascia areexposed through the temporal incision.(E) The extent oftemporal dissection.

91O. Sozer and T.M. Biggs

nerves are identified (D), and the periosteum is dividedwith a reverse elevator directly over the supraorbital rim(E). Procerus and corrugator muscles are identified anddivided bluntly with the elevator (F) or with the use ofalligator forceps. The area is irrigated and no drains areplaced. Screws (13 mm) are placed through the verticalincisions (Fig. 5A) and elevated forehead is secured be-hind the screw with staples (B). Temporal incisions areclosed primarily with staples, or small fusiform segmentscan be excised from the anterior portion of the incisionand this part of the incision can be elevated and securedto the deep temporal fascia with an absorbable suture and

then closed primarily. If a face lift is done at the sametime, temporal incisions are closed at the end of the facelift.

Screws are kept in place until the periosteum adheresto its new position. Currently we keep it for 1–2 weeks.

Results

There were 128 patients (120 female, 8 male) included inthe study. The youngest patient was 32 years old, theoldest 74 years old (average 53.8, median 53) (Fig. 6).

We looked into average age of patients by year and

Fig. 4. (A) Endoscope is placed through a mid-vertical incision.(B) Thereafter, the operation requires a different eye and handcoordination.(C) The dissection is carried down to the supra-

orbital rim. (D) The nerves are identified.(E) The periosteumis divided (fat exposed).(F) The muscles are visualized (whitearrow) and divided. Neurovascular bundle (blue arrow).

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compared it with the average age of patients who hadbrow lift in 1993 when we were performing only opencoronal brow lifts (Fig. 7). This comparison showed thatwith the introduction of endoscopic brow lift we havestarted to perform this procedure on a younger group ofpatients as well.

The most common complication in our series was lo-cal alopecia (Table 1). All of these patients had the el-evation secured by either utilizing T-shaped incisions orusing Prolene suture wrapped around a screw which wasplaced on the outer table. Even with these patients thedegree of alopecia was very mild, or almost negligible(Fig. 8). With our current technique we have not had anyalopecia.

We had two patients with asymmetry, both of whomhad mild asymmetry before surgery but it became pro-nounced after surgery. The only wound dehiscence wasin the third patient in our series and this healed withsecondary intention. All these complications occurredduring the first 2 years of our experience. For the last 3years this procedure has been complication-free.

The operating time ranged between 50 and 70 minutesinitially; currently it is between 15 and 30 minutes. Sev-enty-five percent of the patients had face lifts at the sametime, 43% had upper blepharoplasty, and 41% had lowerblepharoplasty. We did not utilize botulinum toxin injec-tions with any of the patients.

We investigated the percentage of patients who hadface lifts over the last 6 years and brow lifts at thesame time. Our data indicate that with the introduc-tion of the endoscopic brow lift there is a significantincrease in the number of patients having the twooperations simultaneously (Fig. 9). Currently, 75% of thepatients who had face lifts also had endoscopic browlifts.

We could not objectively analyze the brow elevationand its persistence over the years because of the retro-spective nature of the study. We performed a subjectiveanalysis by choosing random patients and comparingpre- and postoperative pictures as well as the follow-uppictures. We evaluated the presence of frown lines, trans-verse rhytids, and position of the brows. In our experi-ence, up to 5 years of follow-up reveals that elevationpersists (Figs. 10–13 A, B).

Males on the other hand have heavy-set brows andforehead tissue is thicker. The elevation achieved withmales is less compared with females, but there is definiteimprovement of the appearance of the forehead (Fig. 14A, B).

Deep rhytids on the forehead respond partially to theendoscopic brow lift, but when combined with laser re-surfacing, better results can be achieved (Fig. 15 A, B).In our series, there is no increase in complication ratewhen these two procedures are combined.

Fig. 5. (A) The screw isbeing placed at the outertable.(B) Elevation issecured by staples placedbehind the screw.

Fig. 6. Distribution of thepatients according to the agegroup.

93O. Sozer and T.M. Biggs

Discussion

Endoscopic brow lift has become a popular procedure;we have been performing it for the last 5 years. Reviewof our experience has revealed that this is a safe and easyprocedure. The complication rate is low, with the mostcommon complication being mild alopecia. With the on-going refinements of the technique it is almost a com-plication-free procedure. The operating time is shortwhich gives us the opportunity to safely combine it withother procedures.

The minimally invasive nature of the procedure bringsa high patient acceptance rate and a younger group ofpatients have accepted this operation. Since its introduc-tion, the number of patients having brow and face lifts atthe same time has increased significantly. Currently, inour practice, 75% of our face lift patients also have en-doscopic brow lift at the same time. Up to 5 years offollow-up has shown that elevation persists, though lesswith males, but there is still improvement in the appear-ance of the forehead.

Deep rhytids on the forehead can be treated with en-doscopic brow lift combined with laser resurfacing.There is no increase in the complication rate when thesetwo procedures are combined.

In conclusion, endoscopic brow lift has become our

Fig. 8. Film of a patient with mild alopecia after an endoscopicbrow lift.

Fig. 9. Comparison of the number of patients who had face liftwith the number of patients who had face lift and brow lift atthe same time.

Fig. 7. Average age distribution ofpatients by year who had brow lift.

Table 1. Complications of patients undergoing endoscopicbrow lift

Complication No. of patients Percent

Alopecia 6 5Asymmetry 2 1.6Wound dehiscence 1 0.8Skin burn 1 0.8Conjunctivitis 1 0.8Nerve damage 1 0.8Double vision 1 0.8Total 13 10

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Fig. 10. (A) Preoperative brow lift.(B)Brow lift 4.5 years postoperative.

Fig. 11. (A) Preoperative brow lift.(B)Brow lift 3.5 years postoperative.

Fig. 12. (A) Preoperative brow lift.(B)Two years postoperative.

Fig. 13. (A) Preoperative.(B) One yearpostoperative.

95O. Sozer and T.M. Biggs

first choice procedure for brow lift. The number of browlifts we perform has increased significantly and it hasbecome an integral part of our methods for facial reju-venation.

References

1. Bostwick J, Eaves EF, Nahai F (eds): Endoscopic plasticsurgery. Quality Medical Publishing, St. Louis; 1995

2. Isse NG: Endoscopic facial rejuvenation: EndoForehead: thefunctional lift. Case reports. Aesth Plast Surg18:21, 1994

3. Ramirez OM, Daniel RK: Endoscopic plastic surgery.Springer-Verlag, New York; 1996

Addendum: Thomas M. Biggs, M.D.

The decade of the 90s has been one with significant leapsin technology. The lasers, ultrasonic devices, both inter-nal and external, various machines for facial skin reju-venation, and endoscopic approaches to the anatomyhave occupied a major portion of our literature, scientificpresentations, and exhibits at Congresses.

I have intuitively been reluctant to embrace these newtools, thinking that in some way they were to replacesound judgment and skillful scissors, scalpel, and suturetechniques. It is with this same reluctance that I ap-proached endoscopic brow lift. The coronal approachusing an incision from the top of one ear to the top of theother has been my approach to raising the forehead andeyebrows in patients who either genetically or as a resultof aging showed undue heaviness on the upper lids. Inthose patients for whom the direct approach through

blepharoplasty would not ameliorate the problem, thisoperation was suggested. As is always the case, wewould describe the benefits but also the difficulties.These included a long scar, the possibility of alopeciaalong the scar line, some alteration of nerve supply ceph-alad to the scar, and an additional 45 minutes to one houroperating time. In many instances patients would declinethis portion of the surgery, and we would rely on blepha-roplasty alone, or would perform some form of browelevation through the blepharoplasty incision, and oftenwould have an aesthetically inadequate result.

Since the introduction of this endoscopic technique forbrow lifting, we have been able to provide the elevationof the brows without the long scar, much less alopecia,and notable sensory protection carried out in a procedurerarely taking longer than 20 minutes. We have been ableto create a much more favorable risk/reward ratio. Fur-thermore, we now have significant experience with thistechnique to be confident of its durability. Because ofthese favorable outcomes our patients are more acceptingof brow lifts in conjunction with rhytidectomy, and theoverall results of the surgical experience are more fruit-ful. The procedure has been tested and proven to besuccessful and is now a strong component of our facialrejuvenation program. In these cases the endoscope hastaken its place beside scissors, scalpel, needle holder, andsuture and can be used to change the anatomy with mini-mal downside. Utilized with sound judgment and skill,the endoscopic brow lift offers the patient somethingmore for less, which is always our goal.

Fig. 14. (A) Preoperative brow lift.(B)Postoperative.

Fig. 15. (A) Preoperative.(B)Postoperative from laser resurfacing andendoscopic brow lift.

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