Described in 1992 by Vasconez, the endoscopic technique quickly gained popularity. As a “minimally invasive” approach, the endoscopic technique avoids an incision extending across the entire length of the scalp. The incisions are typically 1.5 cm in length and hidden in the hair along the frontal and temporal scalp by about 1 to 1.5 cm behind the hairline. Many different suspension techniques have been described including mattress sutures, cortical tunnels, bone screws, absorbable suspension devices, bolster fixation, and fibrin glue. I prefer a suture suspension technique that avoids costly or cumbersome implants as well as the need for drilling bone. The endoscopic technique is very effective for patients with adequate hair to cover the incision sites and a normal to low positioned hairline. A high hairline presents two technical issues. First, the endoscopic approach can tend to bring the hairline higher, which works well in patients with normal to low hairlines but is not ideal in a patient with an already broad, tall forehead. Next, a high hairline requires a more posterior placement of the incisions in order to hide them within the hair. This placement can orient the incisions behind the curvature of the frontal skull making visualization of the supraorbital structures difficult with the rigid, linear endoscope. The endoscopic approach has a clear advantage in scar camouflage and has been demonstrated to yield durable results. Many surgeons currently apply this technique as their method of choice in appropriate candidates.

The coronal brow lift technique has been in use for almost a century since it was described by Hunt in 1926. The incision is designed in curvilinear fashion approximately 4 to 6 cm behind the hairline. Elevation has been described in multiple different planes, but generally, I prefer a subgaleal plane. The coronal lift will raise the hairline and therefore should be reserved for patients who begin with a lower hairline. Forehead rhytids are typically better treated with a coronal rather than endoscopic technique, especially compared to endoscopic techniques with dissection in the subperiosteal plane. The coronal approach may afford some advantage over the endoscopic approach regarding correction of asymmetry, but the direct brow lift is the best choice for reliable correction of significant brow asymmetry. Patients undergoing the coronal lift tend to complain of prolonged numbness of the scalp compared to the endoscopic technique, although the long-term difference in scalp sensation is questionable. Coronal lifts should be performed with careful consideration in men.
Men prone to male pattern baldness may ultimately lose enough hair to expose the operative scar, which would be unsightly and very difficult to camouflage.

The direct brow lift is designed either just above the eyebrow or in a deep rhytid above the eyebrow (a mid-forehead lift). A subcutaneous plane is developed, and the skin excision is designed to correct the ptotic brow. The skin excision can be customized to remove more tissues laterally or medially and ultimately provide more elevation where it is needed. This is very effective approach for correction of brow asymmetry. The orbicularis is typically suspended to the periosteum, and the skin is closed meticulously in layers. The primary disadvantage of the direct and midforehead lift is the scar placement. When designed properly, both techniques can heal with acceptable results but generally are not as well camouflaged as the other approaches. Men are generally considered better candidates for midforehead incisions, which avoid a scar across the length of the scalp. The deeper rhytids in men tend to hide the incisions to a greater degree compared to women. The scar above the brow complex is equally difficult to conceal in both genders.