Key Points

•The forehead and brows are an integral part of aesthetic rejuvenation of the upper face.

•Traditional brow lifting procedures involve large dissections, predispose to sensory deficits, and can lead to visible scars.

•The endoscopic brow lift offers a less invasive alternative to open brow lifting procedures.

•With appropriate training and experience, the procedure results in reliable and reproducible surgical outcomes.

•A detailed knowledge of relevant anatomy, especially the temporal dissection, is critical to avoiding complications.

lateral hooding, and lid redundancy, tends to convey fatigue, anger, suspicion, or disinterest – all despite the fact that the person may not truly harbor any of these sentiments. In this way, our expression is no longer a reflection of our true emotion. The result is an adverse effect on communications, personal interactions, and self-image.

The weight of these factors was the impetus for development of brow rejuvenation techniques over the last century [1]. Starting with direct and mid-forehead techniques in the early 1900, forehead and brow rejuvenation evolved to include the traditional coronal approach. The latter is still viewed by some to be the gold standard [2, 3]. For many surgeons and

niques, and an understanding of forehead/brow aesthetics.

•The main variable in surgery is the method of brow fixation to the calvarium. The authors prefer the bone bridge technique.

•The endoscopic approach to brow lifting reduces the likelihood of complications when compared to open approaches.

•Complications such as hematoma formation, alopecia, and sensory or motor nerve deficit can be avoided with strict maintenance of hemostasis and meticulous surgical dissection.

7.1Introduction

The gamut of human emotions, whether joy, surprise, anger, or grief, is written in our eyes. With age, that expression may be misconstrued. The aged brow, with its prominent rhytids,

approaches invariably result in visible, and sometimes detracting, scarring. The coronal lift requires greater dissection, has an increased risk of hematoma formation, and may cause alopecia or elevate the hairline. The trichial and pretrichial modifications of the coronal approach have been used as alternatives, but still carry many of the same potential risks. And this says nothing of the fact that all three carry varied risks of interrupted forehead or scalp sensation.

These are but a few of the reasons many surgeons worked to incorporate endoscopic techniques into their armamentarium once technology, cost, and their skill set permitted. First reported by Isse in 1992, the endoscopic brow lift has since gained wide acceptance, having proven to provide lasting cosmetic results [4]. Now, the greatest variability among surgeons appears to lie with the method used for brow fixation. Here, we present our technique for endoscopic brow rejuvenation with emphasis placed on salient points that have helped the senior author’s (TDW) results reproducibly stand the test of time.

T.D. Wang (*)

Professor and Chief, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology – Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA e-mail: wangt@ohsu.edu

7.2Forehead and Temporal Anatomy

The goals of endoscopic lifting are to provide reproducible and lasting restoration of the brow but to do so while concealing scars, preserving forehead and scalp sensation,

maintaining facial nerve function, and minimizing the potential complications found in each of the other operations. Meeting these objectives helps to set this technique apart from the other approaches. A detailed understanding of the associated anatomy is necessary to achieve these goals [5].

The brow and forehead fall within the superior horizontal third of the face and are delineated by the area lying between the trichion and the supraorbital rim. The organization of skin and soft tissue here is identical to that found in the scalp. The superficial skin overlies an underlying layer of subcutaneous tissue, which then rests upon the galea aponeurotica. The galea is a broad tendinous sheet that spans the scalp and connects the frontalis with the occipitalis posteriorly. Loose areolar connective tissue separates the galea from the deepest layer, the pericranium, which then densely adheres to the skull.

The brow musculature can be divided into those that elevate and those that depress the brow (Fig. 7.1). Each independentlycontributestotheformationofrhytidsperpendicular to their respective vector of contraction. The frontalis muscle is the primary brow elevator and is responsible for deep, prominent horizontal rhytids. Originating from the galea, it descents the forehead with insertions into the dermis. Brow depressors include the procerus muscle, the corrugator supercilii muscle, and the orbicularis oculi muscle. The procerus originates from the nasal bones and cephalic margin of the upper lateral cartilages. It ascends the nasal dorsum spanning across the radix to insert into the caudal frontalis muscle from below. The procerus’ contraction depresses the glabella, yielding finer horizontal rhytids in this area. The corrugators are responsible for drawing the brow medially and inferiorly. They originate from the nasal process of the frontal bone and extend obliquely over the supraorbital rim where they interdigitate with fibers from the frontalis and orbicularis. When

contracted, they cause vertical, paraglabellar furrows. Finally, the orbicularis oculi serves as the palpebral sphincter, and with contraction, will depress the brow along with closure of the upper lid. This is a minor depressor mechanism, but cannot be forgotten [5–7].

The temporal branch of the facial nerve provides voluntary and involuntary motor innervation to the brow musculature and the superior divisions of the orbicularis oculi muscle. Upon leaving the substance of the parotid gland, the nerve passes deep to the superficial aponeurotic muscular system (SMAS) and then passes over the middle third of the zygomatic arch in a plane between the SMAS and the zygomatic periosteum. Above the arch, the nerve continues its course within the substance of the temporoparietal fascia (TPF) before entering its respective musculature on the deep undersurface. The nerve enters the undersurface into the frontalis approximately 1 cm above the supraorbital rim [8]. A line drawn between a point 0.5 cm anterior to the tragus and a point 1.5 cm lateral to the taper of the lateral brow approximates the course of the nerve. This line typically crosses the middle third of the zygomatic arch, or “danger zone” for the nerve [5]. Here, the nerve is confined within tightly adherent tissue planes that are relatively immobile leaving the nerve prone to injury.

Sensation of the forehead, brow, and upper lids is conveyed via afferent branches of the ophthalmic division of the trigeminal nerve. The lacrimal nerve innervates the lateral upper lid and brow. The supraorbital and supratrochlear nerves both branch from the frontal nerve to provide afferent innervation to the remaining upper lid, forehead, and scalp. These nerves leave their respective supraorbital notches and pass through the periosteum where they then course in a supramuscular plane along the superficial surface of the

frontalis muscle. Knowledge of this plane is critical to the understanding of postoperative brow, forehead, and scalp sensation following any of the brow rejuvenating techniques.

The forehead and brow tissues receive their blood supply from both the external and internal carotid systems. The external carotid artery terminally branches into the superficial temporal artery, and its arborization supplies the temple and lateral forehead. A primary branch responsible for the lateral brow is the zygomaticotemporal artery. The internal carotid artery terminally branches into the ophthalmic artery. Its distal branches, the supraorbital and supratrochlear arteries, supply the medial and central forehead and anterior scalp. Cadaveric studies have found the supraorbital and supratrochlear arteries reliably located approximately 2.5 and 1.8 cm, respectively, lateral to the midline [9].

Venous drainage mirrors the arterial supply. One specific vessel, the zygomaticotemporal vein receives branches that span the potential space between the superficial temporoparietal fascia (STPF) and the deep temporal fascia (DTF). A prominent branch encountered during the endoscopic approach is commonly referred to as the sentinel vein because of its apparent proximity to the temporal branch of the facial nerve. Identified within temporal fat at the approximate level of the frontozygomatic suture, Quatela and colleagues found this vessel to consistently lie within 2 mm of the temporal branch of the facial nerve. In addition, they demonstrated that when multiple temporal vessels are seen endoscopically, each is associated with one of several temporal motor branches that appear to traverse the superficial fascia immediately above the vein [10]. Thus, cautery and manipulation of these vessels should be done along the dissection floor, directly on top of the DTF to prevent nerve injury.

Lastly, but arguably most important is an understanding of the fascial planes and compartments in the forehead, brow, and temple (Fig. 7.2). The superficial musculoaponeurotic system (SMAS) that envelops the musculature of the lower and middle thirds of the face extends above the zygomatic arch as the superficial TPF. The TPF then merges with the galeal layer in the brow and scalp. Below the TPF lies the DTF. Superficial and deep layers of the DTF envelop the temporalis muscle, and an intermediate layer helps to partition the temporal fat pad above the zygomatic arch. Superiorly, the deep and superficial layers of the DTF fuse with the frontoparietal periosteum at the origin of the temporalis muscle. This delineates the temporal line. Anterior, the DTF becomes densely adherent to the frontal and zygomatic periosteum at the lateral orbital rim and along the medial zygomatic arch. The lateral margin of the galea joins here as well, forming the conjoined tendon. Along the supraorbital rim, the fusion of the galea and frontal periosteum creates the arcus marginalis, an anchor for the brow that impedes brow elevation [8, 11]. As we shall discuss, an understanding of these layers is key to operative success and safety.

Fig. 7.2 Fascial planes. The superficial musculoaponeurotic system (SMAS) of the lower and mid-face is contiguous with the superficial TPF above the zygomatic arch. The temporal branch of the facial nerve runs within the substance of the TPF. The TPF merges with the galeal layer in the brow and scalp. The deep temporal fascia (DTF) lies below the TPF. Superficial and deep layers of the DTF envelop the temporalis muscle, and an intermediate layer helps to partition the temporal fat pad above the zygomatic arch. The temporal line represents the fusion of the deep and superficial layers of the DTF with the frontoparietal periosteum at the origin of the temporalis muscle

7.3Aesthetics and Aging

The shape and position of the eyebrow itself is key for brow aesthetics. Medially, the brow should be clubbed and rounded, and approximate a line drawn vertically tangent to the nasal ala. The brow should then arch superolaterally with its apex at the level of, or just lateral to, the lateral limbus. The brow should taper and end at an oblique line drawn from the nasal ala through the lateral canthus. In general, the youthful brow is positioned higher over a well-demarcated supraorbital rim. The supratarsal crease should also be visible. In the female patient, the brow should be arched and

Fig. 7.3 Ideal brow position. (a) In the female patient, the brow should reside above the supraorbital rim and arch between the lateral limbus and lateral canthus. (b) The male brow should be less arched and lie at the level of the supraorbital rim. Medially, both brows should be clubbed and

rounded, and in an approximate line drawn vertically tangent to the nasal ala. The brow should then arch superolaterally with its apex at the level of, or just lateral to, the lateral limbus. The brow should taper and end at an oblique line drawn from the nasal ala through the lateral canthus

reside above the supraorbital rim. Male patients, on the other hand, have more prominent frontal bossing. Their brow shape should be less arched and lie at the level of the supraorbital rim (Fig. 7.3). At rest, the youthful forehead is smooth without horizontal or vertical rhytids, and has a gentle convexity [5, 12, 13]. Aging is a multifactorial process that leads to deterioration of the youthful brow over time.

Aging results from the cumulative effects of both internal and external factors. Our skin inherently loses elasticity and there is regression of buoyant subcutaneous tissue as we grow older. Bone remodeling results in contour changes and an overall increase in bone resorption. Together, these processes contribute to tissue deflation and laxity. Other internal influences include genetics, gender, and skin type. External factors including gravity, ultraviolet light exposure, diet, sleep habits, unique personal facial expression, and smoking further compound these factors [13].

Brow aging typically progresses from lateral to medial, starting first in the lateral third of the brow. Ptosis initially manifests as lateral brow hooding, but as aging migrates medially, the brow, glabella, and forehead fall victim to deteriorating aesthetics as well. Early on, evolving tissue ptosis is countered by compensatory muscular contraction of the brow elevators. However, with subcutaneous tissue loss and progressive elastosis, pleating of the underlying muscles and fascia leads to wrinkle formation. The aged brow, with its prominent rhytids, lateral hooding, and lid redundancy, then conveys fatigue, anger, suspicion, or disinterest. In addition, the combination of brow ptosis in conjunction with frontal and temporal hairline recession leads to an increase of the vertical height of the upper facial third. This also detracts from overall facial harmony.

7.4Patient Selection

As with any cosmetic procedure, patient selection and identification of the appropriate indications for a given technique are keys to surgical success and patient satisfaction. Endoscopic lifting of the brow is no different.

The preoperative assessment begins with an understanding of a patient’s concerns, preferences, and expectations. It should also include an extensive critical facial analysis and exam [8, 11]. Skin type and evidence of photo aging are documented using the Fitzpatrick and Glogau classifications, respectively. This should include not only the extent but also the orientation of rhytids present. Attention is paid to evaluation of brow ptosis, differentiating between true brow ptosis and hooding that results from upper lid skin redundancy. Dynamic and static asymmetries should be noted in order to avoid the alteration of dynamic asymmetries that come from an individual’s unique facial expressions. The position and shape of the hairline must be documented, along with a history and exam for the presence of balding. And bony contours are assessed, noting any prominent frontal bossing or convexity that may impede visualization and dissection through the endoscopic approach. Additionally, a thorough past medical and family history is taken, specifically looking for a history of dry eyes, previous blepharoplasty, androgenic hair loss, and alopecia [6]. Finally, preoperative photographs are taken. This assessment is crucial because it will influence the ultimate surgical approach and help predict surgical outcome and overall patient satisfaction.

In general, patients with brow ptosis, lateral brow and eyelid hooding, forehead or glabellar rhytids, and/or visual