Our Experience with Endoscopic Brow Lifts

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1 Aesth. Plast. Surg. 24:90 96, 2000 DOI: /s Springer-Verlag New York Inc. Our Experience with Endoscopic Brow Lifts Ozan Sozer, M.D., and Thomas M. Biggs, M.D. İstanbul, Turkey and Houston, Texas Abstract. This is a retrospective review of our experience with the endoscopic brow lift. We reviewed 128 procedures performed by two senior faculty members over the last 5 years. We evaluated the age, gender, operating time, complications, and outcome and conclude that endoscopic brow lift is a safe, efficient procedure with a low complication rate. The operating time is short, and there is a very high patient acceptance. The procedure has taken its place as an integral part of facial rejuvenation in our practice. Key words: Endoscopic brow lift Complications Surgical procedure Safety Endoscopic brow lift has gained popularity since its introduction in 1994 [1] and we have performed 218 brow lifts at St. Joseph Hospital since then. This is a retrospective review of 128 cases performed over the last 5 years by two senior faculty members. Technique The technique has undergone various modifications, most of which involved the placement of incisions and the way the elevation was secured. We started with vertical incisions where the incision was closed in a transverse fashion following resection of bilateral dog ears (Fig. 1). Then we placed a screw in the outer table of the skull through a vertical incision and secured the elevation with a Prolene suture wrapped around the screw (Fig. 2). With our current fixation technique the forehead and 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 the apices of the brows are placed 1 2 cm behind the hair line (Fig. 3A). The infiltrated posterior scalp is elevated in a subgaleal plane (B) and the forehead is elevated to a point 2 cm cephalad to the supraorbital rim in a subperi- Materials and Methods Charts of patients who had had endoscopic brow lifts before December 31, 1998 were reviewed and the technique was analyzed. Age, gender, operating time, other procedures performed, and outcomes were evaluated. An objective measurement of the brow elevation was not possible because of the retrospective nature of the review. We chose random patients and performed subjective analysis of the elevation by looking at the brow position, frown lines, transverse forehead rhytids, and by making comparisons with the preoperative pictures. Correspondence to Thomas M. Biggs, M.D., 1315 St. Joseph Parkway, Suite 900, Houston, Texas 77002, USA Fig. 1. (A) The vertical incision. (B) The vertical incision is approximated 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 the incision. (B) The elevation of the forehead is secured by wrapping a prolene suture around the screw. (C) The incision is closed.

2 O. Sozer and T.M. Biggs 91 Fig. 3. (A) Location of incisions. Note that the actual incisions are behind the hair line and the arrow is pointing to the location. One and a half and 2.5 cm markings indicate the location of supratrochlear and supraorbital neurovascular bundles, respectively. (B) The infiltrated posterior scalp is elevated in a subgaleal plane. (C) The forehead is elevated to a point 2 cm cephalad to the superorbital rim in a subperiosteal plane. (D) The deep temporal fascia are exposed through the temporal incision. (E) The extent of temporal dissection. osteal plane (C). Bilateral 3 cm incisions are placed over the temporal areas and are perpendicular to the line that connects the nasal alae to the ipsilateral commissure of the eye (D). We try to keep these incisions as a temporal extension of the preauricular incision if we are performing a facelift at the same time. These incisions are taken down to the deep temporal fascia but not through it. A plane just superficial to the deep temporal fascia is developed and joins the subperiosteal plane of the forehead through the temporal fusion line (E). An endoscope is placed through the mid-vertical incision (Fig. 4A) and after this point the operation requires a different eye and hand coordination where the surgeon faces the monitor rather than the patient (B). Under the direct visualization of the endoscope the subperiosteal dissection is carried down to the supraorbital rim (C), the

3 92 Endoscopic Brow Lifts nerves are identified (D), and the periosteum is divided with a reverse elevator directly over the supraorbital rim (E). Procerus and corrugator muscles are identified and divided bluntly with the elevator (F) or with the use of alligator forceps. The area is irrigated and no drains are placed. Screws (13 mm) are placed through the vertical incisions (Fig. 5A) and elevated forehead is secured behind the screw with staples (B). Temporal incisions are closed primarily with staples, or small fusiform segments can be excised from the anterior portion of the incision and this part of the incision can be elevated and secured to the deep temporal fascia with an absorbable suture and Fig. 4. (A) Endoscope is placed through a mid-vertical incision. (B) Thereafter, the operation requires a different eye and hand coordination. (C) The dissection is carried down to the supraorbital rim. (D) The nerves are identified. (E) The periosteum is divided (fat exposed). (F) The muscles are visualized (white arrow) and divided. Neurovascular bundle (blue arrow). then closed primarily. If a face lift is done at the same time, temporal incisions are closed at the end of the face lift. Screws are kept in place until the periosteum adheres to its new position. Currently we keep it for 1 2 weeks. Results There were 128 patients (120 female, 8 male) included in the study. The youngest patient was 32 years old, the oldest 74 years old (average 53.8, median 53) (Fig. 6). We looked into average age of patients by year and

4 O. Sozer and T.M. Biggs 93 Fig. 5. (A) The screw is being placed at the outer table. (B) Elevation is secured by staples placed behind the screw. Fig. 6. Distribution of the patients according to the age group. compared it with the average age of patients who had brow lift in 1993 when we were performing only open coronal brow lifts (Fig. 7). This comparison showed that with the introduction of endoscopic brow lift we have started to perform this procedure on a younger group of patients as well. The most common complication in our series was local alopecia (Table 1). All of these patients had the elevation secured by either utilizing T-shaped incisions or using Prolene suture wrapped around a screw which was placed on the outer table. Even with these patients the degree of alopecia was very mild, or almost negligible (Fig. 8). With our current technique we have not had any alopecia. We had two patients with asymmetry, both of whom had mild asymmetry before surgery but it became pronounced after surgery. The only wound dehiscence was in the third patient in our series and this healed with secondary intention. All these complications occurred during the first 2 years of our experience. For the last 3 years this procedure has been complication-free. The operating time ranged between 50 and 70 minutes initially; currently it is between 15 and 30 minutes. Seventy-five percent of the patients had face lifts at the same time, 43% had upper blepharoplasty, and 41% had lower blepharoplasty. We did not utilize botulinum toxin injections with any of the patients. We investigated the percentage of patients who had face lifts over the last 6 years and brow lifts at the same time. Our data indicate that with the introduction of the endoscopic brow lift there is a significant increase in the number of patients having the two operations simultaneously (Fig. 9). Currently, 75% of the patients who had face lifts also had endoscopic brow lifts. We could not objectively analyze the brow elevation and its persistence over the years because of the retrospective nature of the study. We performed a subjective analysis by choosing random patients and comparing pre- and postoperative pictures as well as the follow-up pictures. We evaluated the presence of frown lines, transverse rhytids, and position of the brows. In our experience, up to 5 years of follow-up reveals that elevation persists (Figs A, B). Males on the other hand have heavy-set brows and forehead tissue is thicker. The elevation achieved with males is less compared with females, but there is definite improvement of the appearance of the forehead (Fig. 14 A, B). Deep rhytids on the forehead respond partially to the endoscopic brow lift, but when combined with laser resurfacing, better results can be achieved (Fig. 15 A, B). In our series, there is no increase in complication rate when these two procedures are combined.

5 94 Endoscopic Brow Lifts Fig. 7. Average age distribution of patients by year who had brow lift. Table 1. Complications of patients undergoing endoscopic brow lift Complication No. of patients Percent Alopecia 6 5 Asymmetry Wound dehiscence Skin burn Conjunctivitis Nerve damage Double vision Total Discussion Endoscopic brow lift has become a popular procedure; we have been performing it for the last 5 years. Review of our experience has revealed that this is a safe and easy procedure. The complication rate is low, with the most common complication being mild alopecia. With the ongoing refinements of the technique it is almost a complication-free procedure. The operating time is short which gives us the opportunity to safely combine it with other procedures. The minimally invasive nature of the procedure brings a high patient acceptance rate and a younger group of patients have accepted this operation. Since its introduction, the number of patients having brow and face lifts at the same time has increased significantly. Currently, in our practice, 75% of our face lift patients also have endoscopic brow lift at the same time. Up to 5 years of follow-up has shown that elevation persists, though less with males, but there is still improvement in the appearance of the forehead. Deep rhytids on the forehead can be treated with endoscopic brow lift combined with laser resurfacing. There is no increase in the complication rate when these two procedures are combined. In conclusion, endoscopic brow lift has become our Fig. 8. Film of a patient with mild alopecia after an endoscopic brow lift. Fig. 9. Comparison of the number of patients who had face lift with the number of patients who had face lift and brow lift at the same time.

6 O. Sozer and T.M. Biggs 95 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 year postoperative.

7 96 Endoscopic Brow Lifts Fig. 14. (A) Preoperative brow lift. (B) Postoperative. Fig. 15. (A) Preoperative. (B) Postoperative from laser resurfacing and endoscopic brow lift. first choice procedure for brow lift. The number of brow lifts we perform has increased significantly and it has become an integral part of our methods for facial rejuvenation. References 1. Bostwick J, Eaves EF, Nahai F (eds): Endoscopic plastic surgery. Quality Medical Publishing, St. Louis; Isse NG: Endoscopic facial rejuvenation: EndoForehead: the functional lift. Case reports. Aesth Plast Surg 18:21, 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 leaps in technology. The lasers, ultrasonic devices, both internal and external, various machines for facial skin rejuvenation, and endoscopic approaches to the anatomy have occupied a major portion of our literature, scientific presentations, and exhibits at Congresses. I have intuitively been reluctant to embrace these new tools, thinking that in some way they were to replace sound judgment and skillful scissors, scalpel, and suture techniques. It is with this same reluctance that I approached endoscopic brow lift. The coronal approach using an incision from the top of one ear to the top of the other has been my approach to raising the forehead and eyebrows in patients who either genetically or as a result of aging showed undue heaviness on the upper lids. In those patients for whom the direct approach through blepharoplasty would not ameliorate the problem, this operation was suggested. As is always the case, we would describe the benefits but also the difficulties. These included a long scar, the possibility of alopecia along the scar line, some alteration of nerve supply cephalad to the scar, and an additional 45 minutes to one hour operating time. In many instances patients would decline this portion of the surgery, and we would rely on blepharoplasty alone, or would perform some form of brow elevation through the blepharoplasty incision, and often would have an aesthetically inadequate result. Since the introduction of this endoscopic technique for brow lifting, we have been able to provide the elevation of the brows without the long scar, much less alopecia, and notable sensory protection carried out in a procedure rarely taking longer than 20 minutes. We have been able to create a much more favorable risk/reward ratio. Furthermore, we now have significant experience with this technique to be confident of its durability. Because of these favorable outcomes our patients are more accepting of brow lifts in conjunction with rhytidectomy, and the overall results of the surgical experience are more fruitful. The procedure has been tested and proven to be successful and is now a strong component of our facial rejuvenation program. In these cases the endoscope has taken its place beside scissors, scalpel, needle holder, and suture and can be used to change the anatomy with minimal downside. Utilized with sound judgment and skill, the endoscopic brow lift offers the patient something more for less, which is always our goal.

cally, a distinct superior crease of the forehead marks this spot. The hairline and

cally, a distinct superior crease of the forehead marks this spot. The hairline and 4 Forehead The anatomical boundaries of the forehead unit are the natural hairline (in patients without alopecia), the zygomatic arch, the lower border of the eyebrows, and the nasal root (Fig. 4.1). The

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