field deficits that result from these meet criteria for brow and/ or periocular rejuvenation. The “ideal” patient for the application of the endoscopic technique is a Caucasian patient with medium to thin skin thickness, glabellar rhytids, minimal brow ptosis, and minimal skin redundancy. At the same time, relative contraindications exist for women with high hairlines and men with male pattern baldness, patients with thick, densely adherent skin, and patients with extensive bone attachments and protuberances [6, 8, 11]. Blepharoplasty is not a topic addressed in this discussion, but it should be noted that determination of the need for concomitant eyelid or ptosis surgery is necessary prior to brow rejuvenation. If needed, lid skin excision should follow after elevation and fixation of the brow to avoid untoward postoperative lagophthalmos.

The prospective benefits of the endoscopic technique include the use of smaller incisions with subsequently less scarring, decreased risk of sensory neuropathy, decreased risk of alopecia, less bleeding, and reportedly decreased recuperative time. On the other hand, the use of this approach requires more specialized training, a steeper learning curve, and costly operative equipment. It also does not permit the excision of brow or scalp skin redundancy, and may be limited by any of the less than ideal patient characteristics previously mentioned.

7.5Instrumentation

The senior author prefers endoscopic browlift instruments by Snowden Pencer® (Table 7.1) and:

•Endoscopy tower with telescopic input and video display

•Storz Hopkins® II 30° Telescope, 7228 BA (Karl Storz Endoscopy-America, Inc., El Segundo, CA, USA)

•Synthes drill bit 1.5 × 4 mm with stop (Synthes, Inc., West Chester, PA, USA; http://us.synthes.com)

•Stryker TPS (Total Performance System) Drill (Stryker Craniomaxillofacial, Portage, MI, USA)

7.5.1Technique

Once the patient is secure in the operating room with the desired level of anesthesia induced, the head of the bed is turned away from anesthesia. This permits positioning of the endoscopic tower at the foot of the table where it lies in direct line of sight to the operating surgeon at the head of the bed. The plane of the bed is then placed in 5–10° of reverse Trendelenburg or a beach chair configuration to maintain slight elevation of the head.

First, a topographical line predicting the course of the facial nerve is drawn as a point of reference. Then, five access incisions, none greater than 2 cm in length, are marked for

Table 7.1 Endoscopic browlift instruments by Snowden Pencer®

Distributed by CareFusion (San Diego, CA, USA and http://www.cardinal.com/legacy/vmueller/vmcatalog/vmueller.html)

creation of the optical pockets. The midline incision is drawn approximately 1.5 cm posterior to the hairline and oriented in the coronal plane, paralleling the anterior hairline. Two lateral incisions are placed just medial to the temporal line approximating both the position of anticipated greatest brow height and the vector of brow suspension. These lay equidistance from the hairline, but are drawn in a sagittal plane. Finally, right and left temporal access incisions are drawn in the temporal hair tuft. These are drawn in the coronal plane and approximate the vertical level of the lateral canthus. These typically are 2–3 cm behind the anterior hairline and should be well behind the previously drawn anticipated course of the facial nerve. Hair is then parted at each of the planned incisions and secured in small, twisted tufts using dental elastic rubber bands (Fig. 7.4).

Next, each incision and the brow is injected with the authors’ preferred local anesthetic mixture consisting of a 50:50 blend of 1% lidocaine, 0.5% bupivacaine, and epinephrine in a 1:100,000 concentration. Care is taken to inject precisely within the anticipated plane of dissection. Each access point is injected in the subcutaneous plane with approximately 0.5 cc of local anesthetic. The forehead is then injected in a ring-block fashion in the subgaleal or subperiosteal plane, injecting the inferior margins of dissection across the supraorbital rim, medially over the glabella, the lateral orbital rim at the conjoined tendon, laterally along each temporal line, and superiorly along the hairline. The patient is then prepped and draped in the standard sterile fashion.

At the start of the case, the forehead and brow are first examined and manipulated. An attempt is made to manually elevate the brow to demonstrate its ideal position and arching shape. In doing so, it is easy to appreciate the anatomic

Fig. 7.4 Endoscopic access incisions. Five access incisions, none greater than 2 cm in length, are used to create optical pockets needed for elevation and suspension. These include a midline incision approximately 1.5 cm posterior to the hairline and oriented in the coronal plane, two lateral incisions in a sagittal plane medial to the temporal line approximating the desired position of greatest brow height and the vector of brow suspension, and bilateral temporal incisions in the temporal hair tufts. The latter are drawn in the coronal plane and approximate the vertical level of the lateral canthus

separation between the brow and upper lids due to fixation of the arcus marginalis. With elevation of the brow, the lids will remain in repose. This provides a reference point for adequate arcus release later in the case.

Starting with the left temporal access point and continuing to the right, all five points are incised using a No. 15 blade. Each incision is superficial and deep enough to only break through the dermis. Then, with the aid of an assistant, narrow, double skin hooks are used to retract the incision margins to reveal the underlying subcutaneous tissue and hair follicles. Blunt scissors are then spread perpendicular to the long axis of the wound to gently separate the underlying fascial attachments. To avoid injury to adjacent hair follicles, distinct bleeding vessels are judiciously cauterized only when necessary. Similarly, dissection within the temporal tuft proceeds cautiously to avoid injury to the superficial temporal vessels. Dissection in the three central access points is carried down to the pericranium, which is then incised with electrocautery. Dissection in the lateral temporal incisions is taken to the level of the superficial layer of the DTF.

Elevation of the optical pockets begins first at the midline incision and progresses from territory known to unknown. Using the nondominant hand to stabilize the head at nasal root, a curved periosteal elevator is used to elevate the

midline and superior forehead pericranium. This subperiosteal pocket is extended laterally to, but not through, the temporal line using the temporoparietal access points. If the temporal line were violated from the medial pocket, the dissection plane would become uncertain. Initially, the caudal extent of the dissection is limited due to the curvature of the skull. This can be overcome using instruments with progressively greater angulation. However, the surgeon will find that the farther posterior the incisions are placed, the greater the restriction in caudal dissection. Direct visualization is not used at this point. Rather, the surgeon relies on tactile and auditory feedback to ensure dissection immediately on top of bone. The inferior extent of the dissection ceases once elevation progress to the arcus marginalis and the conjoined tendon. In addition, palpating the supraorbital notch provides the mind’s eye with the anticipated location of the sensory nerves. Dissection within a 1 cm radius about this point is avoided as well.

Next, the temporal optical pockets are generated using the temporal tuft incisions, starting again on the left side of the patient. Using the spatula-shaped “T-Dissector,” the STPF is swept from the underlying DTF. This delineates the floor of the pocket. The elevator is used as a fulcrum to lift the STPF from the underlying DTF and then slowly advanced in a path aiming for the ipsilateral temporoparietal incision. The elevator is never blindly advanced, ensuring that it never violate an adjacent and inappropriate fascial plane. Once the pocket becomes constrained at the temporal line, the elevator is advanced through the temporal line, into the subperiosteal pocket, and visualized through the temporoparietal incision. The elevator is then withdrawn and replaced, again ensuring dissection directly on the floor of the pocket. Dissection then progresses along a new radius slightly inferior to the previous plane, the temporal line is again encountered, and the elevator advances through the line into the subperiosteal pocket. This method is continued until the entire pocket is open from an inferior margin that approximates the lateral canthal height, and medial to the zygomaticofrontal buttress and the conjoined tendon. The temporal line now contains postage stamp breaks that can now be connected by sweeping the elevator superiorly and inferiorly. In this way, both optical pockets are connected, while at the same time preserving the temporal branch of the facial nerve within the fascia superficial to the pocket. An identical method is used then to open the temporal pocket on the right.

Once each temporal compartment is connected to the central subperiosteal dissection, release of the arcus and conjoined tendon may commence. First, the lateral brow is palpated with the nondominant hand and an elevator is used to free the arcus and conjoined tendon from the superior outer orbital rim. The surgeon realizes the appropriate plane when

Fig. 7.5 Identification of the sentinel vein. Following release of the arcus and conjoined tendon, the sheathed 30° endoscope and dissector are inserted via adjacent temporal and temporoparietal incisions, respectively. Remaining attachments are visualized and released, elevating the TPF laterally to identify the sentinel vein. Here, the dissector is shown carefully freeing associated fascial bands without injury to the vein itself

Fig. 7.6 Arcus marginalis release. Here, the arcus marginalis is shown elevated above the supraorbital rim as a back elevator demonstrates the more medial supraorbital neurovascular bundle. Retroorbicularis oculi fat (ROOF) is seen inferior to the arcus line, denoting adequate elevation is complete

the elevator leaves the thicker, denser brow tissue and is appreciated beneath the thinner soft tissue of the upper lid. Next, the sheathed 30° endoscope is inserted into the left temporal optical pocket and a dissector introduced via the adjacent temporoparietal incision. Under direct visualization, the remnants of the broken temporal line and conjoined tendon are examined. Remaining attachments are freed, sweeping and elevating the overlying scalp from superior to inferior. As this tissue is elevated laterally, the surgeon should work to identify the sentinel vein. Care is taken to preserve this vessel in order to prevent surrounding postoperative venous engorgement that may lead to visible temporal varicosities. However, an attempt is also made to free any associated dense fascial bands that may hinder adequate release and elevation. Once the level of the lateral canthus is reached, within approximately one fingerbreadth of the zygomatic arch, the dissection is complete (Fig. 7.5).

The arcus marginalis is viewed as a condensed fascial line that parallels the orbital bony contour. With elevation, underlying retroorbicularis oculi fat (ROOF) is seen inferior to this well-demarcated line. More aggressive release is required at this point to ensure significant brow elevation. A back-eleva- tor is useful here to draw the arcus up and onto the supraorbital rim. Continuing with the dissection from lateral to medial, the arcus is released completely from the lateral twothirds of the orbital margin. Approaching the midline, the supraorbital and then supratrochlear neurovascular bundles are encountered. The periosteum is freed about these as well (Fig. 7.6). Arcus elevation does not continue medial to the bundles in order to prevent excessive medial brow elevation that leads to a “disappointed” appearance.

Once bilateral arcus marginalis release is complete, corrugator and procerus muscle fibers are identified over the glabella. The muscle fibers are typically sectioned and teased apart with an elevator. However, the fibers are occasionally more robust, particularly in male patients. They may also bleed. In either case, sectioning and hemostasis can be achieved using endoscopic electrocautery forceps.

At this point, the entire forehead and brow should be free and mobile as a single unit. This can be tested with reexamination of the brow itself. Manual elevation of the forehead should now draw the brow with it, and in turn, secondarily elevate the upper lids. This is evident by either the reduction of upper lid skin redundancy or lagophthalmos and resulting upper lid lash eversion. It is for this reason that blepharoplasty should follow rather than precede brow elevation and fixation.

Our preferred method of brow fixation involves anchoring the scalp with 2–0 resorbable suture to the outer table of the calvarium using a bone bridge located beneath the supe- rior-most margin of the right and left temporoparietal access incisions. First, the right incision is splayed apart using two wide, double pronged skin hooks. An assistant then not only holds the incision open but also pulls the brow superior, posterior, and approximately 10° lateral. This mimics the vector of suspension force and provides not only brow elevation but also a brow arch as well. Next, the underlying periosteum is incised with electrocautery and the bony cortex is exposed. A Stryker TPS Drill creates the actual tunnel using a 1.5 × 4 mm bit with a stop. The bit must engage the bone in a line nearly tangent to the surface, drilling first the superior and then the inferior limb of the tunnel. These must communicate beneath an intervening bridge of bone that is

Fig. 7.7 Brow fixation using bone bridges. Wide-double skin hooks retract a temporal incision and simultaneously elevate the brow. The completed bone bridge is shown while 2–0 Vicryl suture is threaded through the tunnel using wire

2–3 mm wide by 2 mm deep. If the bit enters the cortex at a more acute angle or the entry points are too distant from one another, the limbs will not communicate. And if the entry points are too close, the bridge will be thin and fracture during the suspension. A 26-guage wire is then folded on itself and fashioned into the letter “J,” passing the curled end through the tunnel. A 2–0 Vicryl suture is threaded through the wire and the wire is withdrawn, pulling the suture beneath the bone bridge (Fig. 7.7). With the hooks released, the suture is placed in a buried fashion into the dermis, galea, and periosteum approximately 2–3 cm inferior to the inferior apex of the incision. Retraction on the suture should dimple the overlying dermis. The right and left suspension sutures are tied simultaneously while an assistant manually elevates the brow and reduces the tension on the flap. A smooth Webster needle driver may be used, if needed, to clasp the suture’s first throw so that it is less apt to recoil under tension before the knot is locked. Ideally, 1–2 mm of lagophthalmos will be present once the fixation is complete.

Lastly, the temporal suspension is performed, again using an inverted, buried 2–0 Vicryl suture. Grasping the same layers of the scalp anterior to the temporal access incisions, the right and left temporal flaps are anchored back to the DTF. When placing this suture, the surgeon must remain mindful of the facial nerve course and the underlying superficial temporal vessels. Once both sides are complete, all incisions are closed with 5–0 Vicryl Rapide suture in run-lock fashion. If blepharoplasty is planned, it is done at this time. At the completion of the case, the elastics bands are removed from the hair, antibiotic ointment applied to the incisions, and a Kerlix™ gauze

head wrap applied to help eliminate optical pocket dead space. Drains are not used.

7.5.2Complications

There are number of potential complications inherent to brow lifting. For the most part, the endoscopic approach reduces the likelihood of them all. The risk is never completely eliminated, though. In general, bleeding and resultant hematoma formation is possible with any of the techniques. The greater the dissection, elevation, and dead space created below the flaps, the greater the risk [5–7]. When bleeding does occur, the superficial temporal or zygomaticotemporal vessels are the typical culprits. Endoscopic lifting carries these same potential risks, only eliminating the risk of scalp bleeding associated with coronal lifting. Preoperative injection and meticulous dissection help avert this risk in our procedure. In addition, the postoperative head dressing helps to compress the dead space and reduce the possibility of hematoma formation.

Lagophthalmos is also a potential risk that may follow brow elevation. Particularly, susceptible patients are those who have previously undergone blepharoplasty. The probability also rises when blepharoplasty is done prior to brow elevation and suspension. As previously discussed, we have minimized this risk by adhering to conservative lid skin resection following all brow procedures [7, 8, 11].

Alopecia is also worth mentioning. This, too, is more often experienced in larger dissections, particularly the coronal approach. Even so, local follicle loss can occur at each of the incision sites. The key to prevention in this case is limited use of electrocautery. Again, local injection with epinephrine and precise dissection help to reduce the chances of hair loss.

Most feared of all is the risk of nerve injury. Temporary or permanent hypesthesia or anesthesia typically results from severing sensory nerve rootlets. Although temporary loss of sensation may occur with the endoscopic approach, this appears to result from traction neuropraxia, and in the senior author’s experience, has never resulted in permanent loss of sensation. Making the patient aware of this potential transient loss during the preoperative discussion will help to allay their concerns. Temporal nerve damage, on the other hand, is not expected. Risk to this nerve can be avoided with comprehensive knowledge of the facial nerve’s path and the associated fascial compartments. Together with the operative technique submitted above, the surgeon may then circumvent permanent injury to this nerve and its branches. If dissection is meticulous and weakness is recognized immediately following surgery, the weakness is more commonly the result of residual local anesthetic effects.