47.3 Endobrow Lift

47.3.1 Objectives of a Brow Lift

A forehead lift is most commonly performed to minimize the visible effects of aging. It can help to:

1.Correct a low, heavy or droopy brow, achieving a more alert and refreshed look.

2.Correct furrows and frown lines which have developed around the brow and eye.

3.Achieve a better overall result from facial surgery, for example, when used in conjunction with blepharoplasty (eyelid surgery), where addressing aging of the eyelids alone does not always yield the best results, or in conjunction with a face-lift to rejuvenate the face.

Drooping eyebrows can cause a visual field problem. Fatigue and headaches at the end of the day may be caused by overaction of the forehead muscles which

raise the eyebrows. There are also aesthetic/cosmetic reasons [5].

47.3.2 Preoperative Counseling

It is important to spend time with patients and ascertain what exactly is bothering them. The options open to the patients must be discussed in detail, including possible complications, as well as both pre and postoperative instructions (Table 47.1). To avoid problems, it is imperative to make sure that the patient has realistic expectations.

47.3.3 Learning Curve

It is of paramount importance that the cosmetic surgeon achieves a leaning curve to understand the procedure and its effects toward the best results. This reduces

operative time and minimizes postoperative complications. Towards this aim, a solid knowledge of anatomy is vital as well as an understanding of the aesthetic elements of brow rejuvenation.

47.3.4Patient Satisfaction and Cost-Effectiveness

In order to guarantee success in one’s practice, it is important to achieve patient satisfaction and costeffectiveness. One must be able to understand the needs of the patient and the downtime they will require, in order to suggest the correct treatment. One must also be able to give the patient an idea of the longevity of a particular procedure.

47.3.5Surgical and Nonsurgical Treatments of Forehead Rejuvenation

There are various approaches used to raise the eyebrows, ranging from a direct incision, just above the eyebrow, to incisions within the scalp, above the hairline using a coronal incision.

47.3.6 Direct Operations to the Brow

This involves removal of a segment of scalp tissue from above the eyebrow. It does not correct the forehead position nor remove forehead wrinkles and lines; it only corrects the eyebrow position. This type of operation is mostly recommended for the older and frailer patient, or the patient with facial palsy, as it can be done under local anaesthesia. It leaves a small scar which is hidden within natural creases and wrinkles of the eyebrow.

four incisions, two on each side of the midline. The first is a longitudinal incision 7–10 cm from midline. The second is a transverse incision in the temporal region. The area is infiltrated with a tumescent solution of saline, lignocaine, and epinephrine. The transverse incision is dissected to the deep temporal fascia and the midline incision is dissected subperiosteally. This is important in order to avoid injury to the superficial branch of the temporal nerve as well as other nerves including the supraorbital and supratrochlear nerves. The endoscope will be able to demonstrate these clearely.

The arcus marginalis and the periosteum must be released in order to allow free movement and elevation of the brow and this is accomplished endoscopically. For this, the author uses the Ramirez dissectors. Fixation can be achieved by three methods: (1) by suturing in two different planes, one superficially and one deep to anchor to the temporal fascia, (2) by screw fixation, or (3) by the use of surgical glue. Each has positive and negative aspects, and the surgeon must decide which method is best in their practice.

Both the eyebrows and the forehead are lifted and this removes the horizontal lines. Surgery is done through incisions in the scalp above the hairline. Incisions can be long (coronal incision), or short Y to V shaped, or short and straight. Usually two or three small incisions are made above the hairline, and a further two small incisions placed a small distance above the ears. A tunnel is made underneath the forehead, to free up all the ligaments holding it down and raise the forehead and eyebrows upward. An absorbable embedded fixation plate is used to secure the new brow-height, or tissue may be excised, in which case fixation is not required.

Forehead and brow lifting is usually done under general anaesthesia, with addition of local anaesthesia to the scalp to reduce bleeding during the surgery. Endoscopic forehead and eyebrow lift is very suitable for patients aged 30–60 years, who have furrows between the eyebrows, eyebrow ptosis, and deep horizontal forehead lines. It gives a good brow and forehead lift, but is a longer operation than the direct or transeyelid/blepharoplasty incision approach.

47.3.7 Endoscopic Brow Lift

The endoscopic brow lift has revolutionized forehead rejuvenation and has almost certainly made coronal incisions obsolete. It can be performed under intravenous sedation or general anesthesia. It is performed through

47.3.8 Risks

When complications arise during an endoscopic forehead lift, which occurs in about 1% of cases, a switch to the open forehead lift method must be performed.