21 Endoscopic Brow Lift
Summary
The endoscopic brow lift is a minimally invasive technique that allows for elevation of the entire brow and glabellar area, while utilizing a well-hidden, post hairline approach. Other methods, like a direct brow surgery, do not address glabellar ptosis and have visible scars or, in the case of pretrichial and coronal approaches, have much larger surgical incisions and have the potential for more postoperative scalp numbness and scalp alopecia. 1 These aspects are unappealing for most patients. The minimally invasive approach of endoscopic brow lifts also decreases postoperative healing time and morbidities compared to the conventional coronal or pretrichial incision. 1
Using an endoscopic approach and fixation devices, the glabellar area is addressed, visible scars are avoided, and a long-lasting, natural appearing result can be achieved. Instrumentation is inserted through a 4- to 5-cm elliptical incision over the temple posterior to the hairline, staying deep to the deep temporalis fascia. Superiorly, one to three incisions are made posterior to the hair line. Once periosteal attachments, as well as procerus and corrugator muscle attachments, to the orbital rim are released, the fixation device holes are drilled into the cranium and the fixation device placed. The brow is then lifted and secured to the fixation devices to give the appropriate height and contour. In the temporal incisions, the deep temporal fascia is closed with 2–0 PDS suture and the scalp incisions are closed with skin staples. This safe and effective mode for addressing brow ptosis leads to excellent results with no visible scars.
21.1 Goals
An endoscopic brow lift encompasses three goals. First, it lifts and reshapes the brow, glabella, and temporal skin without a visible scar. Second, the surgery decreases transverse forehead rhytides and vertical glabellar rhytides, improves lateral canthal hooding, and thins the nose at the level of the nasofrontal angle (Fig. 21‑1). Finally, it achieves a long-lasting result with less morbidity and a shorter postoperative recovery time.
21.2 Advantages
Excellent, long-lasting elevation of eyebrows and glabella (direct brow lifts do not address the glabellar area).
Ability to decrease function of procerus and corrugator muscles, which decreases dynamic wrinkling.
Ability to avoid visible scars (direct brow and pretrichial approaches have incisions in more easily apparent areas, Fig. 21‑2a,b).
Ability to be used in patients who wear their hair pulled back or have minimal to moderate receding hairlines, which are typical contraindications for the pretrichial approach (Fig. 21‑2c).
Shorter operative times, shorter postoperative recovery period (smaller incisions than coronal approach, Fig. 21‑2a,b). 1
Fig. 21.2 Brow lift incision sites for four types of approaches: coronal, endoscopic, pretrichial, and direct. (a) Profile view. (b) Bird’s-eye view. (c) Alternative approach for receding hairlines Birds eye view.
21.3 Expectations
The expectation of endoscopic brow lift is to achieve an elevation of the entirety of the brow, as well as the glabellar area. Endoscopic brow lift is intended to be performed in conjunction with fixation, typically via two Endotines (Microaire Aesthetics, Inc, Charlottesville, VA).
21.4 Key Principles
Excessive corrugator activity and brow ptosis can create an unintended appearance of being angry, upset, or tired (Fig. 21‑1a,b).
Endoscopic brow lifts allow for elevation and shaping of the entire brow and glabellar area, whereas direct brow lifts cannot lift the glabellar area and result in surgical scars in visible locations.
Minimally invasive endoscopic approaches have been shown to be associated with less blood loss, reduced operating room time, and reduced recovery time when compared to the conventional open approaches. 2
21.5 Indications
Poor brow position can be inherited or acquired, whether via age, paralysis, or trauma. Descent of the eyebrow can occur in the head, the body, or the tail, with the tail being the most frequent in involutional brow ptosis. Brow ptosis should be on the differential for any patient with redundant upper eyelid skin. Significant overhanging skin in the upper lid, especially medially next to the nose and laterally in the “crow’s feet” area, is unlikely to improve with eyelid surgery alone and therefore raising the brow should be considered.
The role of brow ptosis can easily be underestimated, by both surgeons and patients. Both can be mistaken into believing a blepharoplasty will resolve the “upper lid” redundancy, but postoperative disappointment awaits the misinformed. For this reason, understanding normal anatomy is important. In women, the eyebrow typically is arched, resting superior to the orbital rim. In men, the brow is typically more flat and is positioned on the orbital rim. 3 Measuring brow ptosis in all droopy upper eyelid complaints aids in establishing patient expectations, in addition to obtaining a great surgical outcome and happy patient.
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