Fig. 44.7 Dissection planes in endoscopic forehead-lift. (a) Superficial temporal fascia (superficial fascia). (b) Superficial temporal fat pad. (c) Superficial layer of the deep temporalis fascia (intermediate fascia). (d) Zygomatic arch. (e) Intermediate temporal fat pad. (f) Deep layer of the deep temporalis fascia (deep fascia). (g) Deep temporal fat pad

a

b

c

Fig. 44.8 Sensory forehead innervation. (a) Supratrochlear branch. (b) Supraorbital branch. (c) Zygomatic facial branches

supraorbital branches and, laterally, by the facial zygomatic branches. The supratrochlear branch arises from the orbit at the level of the superior oblique muscle pulley and crosses the corrugator supercilii. The supraorbital branch arises at the level of the supraorbital orifice. On occasions, this orifice is replaced by a cleft that does not form a true bony conduit.

These nerves cross the forehead periosteum and muscles after they emerge from the bony conduit before proceeding cephalad. This emergence of the nerve bundles makes dissection difficult and requires the use of endoscopic visualization for correct management and preservation (Fig. 44.8).

44.5Endoscopic Forehead Lift Surgery: Rationale

Endoscopic forehead lift is a permanent method to elevate the position of the brows. Moreover it provides significant improvement of horizontal forehead lines, glabellar furrows, and crow’s feet.

In essence, the surgery consists of detaching and cutting the periosteum through small incisions inside the scalp under the eyebrow implantation in order to weaken the brow depressor muscles. This allows the frontalis muscle to apply upward traction on the periosteum and subsequent fixation of the brow in a higher position. It also reduces lines produced by the action of

Fig. 44.9 The key in endoscopic forehead-lift is to weaken the action of the muscles that pull the brow down, allowing the frontalis to act without opposition. This will lift eyebrow position

the procerus, corrugator supercilii, and orbicularis oculi muscles. In this technique, the elevation of the entire periosteum and of the arcus marginalis is mandatory [6, 9, 13], in order to obtain consistent longterm results [10–12] (Fig. 44.9).

Potential fixation systems include screws, sutures, bone tunneling, and more recently, periosteal suspension and fixation mechanisms by means of