A retrospective comparison of open and endoscopic brow-lifts

Change in Brow Position After Upper Blepharoplasty With or Without Internal Browpexy

BACKGROUND

Only upper blepharoplasty can cause a change in the eyebrow position, so browpexy can be combined with blepharoplasty in selected patients. There are many brow lifting techniques, both surgical and nonsurgical, and internal browpexy is one of the most widely used surgical brow lifting techniques. The purpose of this study was to evaluate the change in brow position after upper blepharoplasty with or without internal browpexy using preoperative and postoperative photographs.

METHODS

Patients who underwent upper blepharoplasty by a single surgeon at Dokuz Eylul University Hospital between 2018 and 2022 were retrospectively evaluated. A total of 48 patients, 30 of whom underwent upper blepharoplasty only and 18 of whom underwent upper blepharoplasty combined with internal browpexy, were examined to present the change in brow position postoperatively. Preoperative and postoperative photographs were analyzed using the ImageJ program and the proportional changes in brow height were shown.

RESULTS

The first group, which only underwent upper blepharoplasty only, consisted of 30 patients (62.5%), all female; the second group, which underwent upper blepharoplasty and internal browpexy, consisted of 18 patients (37.5%), all female. The change at the midpupil level was determined as a 6.13% decrease in the first group and a 2.99% increase in the second group; at the brow peak level, this change was a 6.2% decrease in the 1st group and a 4.38% increase in the 2nd group.

CONCLUSIONS

In cases of dermatochalasis, blepharoplasty alone can cause a shortening of the distance between the eyebrow and the upper eyelid groove and an unaesthetic appearance. Internal browpexy is an easy-to-apply technique that allows stabilization of the eyebrow after skin excision and a small amount of elevation.

Male Brow Lift and Blepharoplasty

After reading this article, one should better understand the anatomy of the forehead, brow, and eyelid complexes in the male patient. A thorough history and physical examination allows the facial plastic surgeon to properly select male patients in whom blepharoplasty and brow lift may be indicated. Specific surgical approaches to upper and lower blepharoplasty are discussed in detail. Surgical techniques and indications for each approach to brow lift in men, including direct, midforehead, coronal, pretrichial, endoscopic, temporal, and transblepharoplasty are explicitly outlined.

An Algorithm for Correction of the Aging Upper Face

As the approach to the upper face has evolved in recent years, so has the focus of aesthetic brow procedures. Brow position was the primary focus early in the late twentieth century, with the coronal brow lift the primary means of surgical correction. In more recent years, improving or maintaining brow shape has taken on greater importance and has increasingly been addressed by contemporary techniques. These include the endoscopic, temporal, direct, gliding approaches as well as nonsurgical brow lifts. As each patient has individual facial characteristics and expectations, every technique comes with a unique set of indications.

Pain Following Endoscopic Foreheadplasty Surgery in Women

BACKGROUND

Endoscopic foreheadplasty surgery (EFS) is a common procedure; however, little has been reported about the nature or treatment of postoperative headache pain and associated symptoms.

OBJECTIVES

The objective of this study was to describe the intensity, quality, location, and duration of headache pain in women following EFS. We also compared post-EFS symptoms with migraine, described medication use and efficacy, and measured emotional and functional outcomes.

METHODS

This descriptive study used an observational repeated-measures design. Forty-two women (mean [standard deviation] age, 59.0 [7.9] years) undergoing EFS were prospectively recruited from 12 private cosmetic practices in 3 California counties. Telephone interviews with the Acute Short-Form 12v2 and the Headache Pain Questionnaire were conducted on postoperative days (POD) 1, 3, 7, and 30.

RESULTS

On POD 1, 93% reported at least moderate pain and 64% severe pain. Severe pain was characterized as throbbing (71%), sharp (53%), dull (76%), exploding (41%), imploding (53%), continuous (53%), or intermittent (41%) on POD 1. Moderate pain was most frequent on POD 3 (21%) compared to POD 1 (19%), 7 (12%) and 30 (12%). Mild pain predominated on POD 3 (40%) and 7 (40%), with 20% remaining on POD 30. The majority (79%) of post-EFS symptoms included light sensitivity and nausea, and therefore met most International Classification of Headache Disorders criteria for migraine. Analgesic use provided inconsistent relief. Functional and emotional status did not return to baseline throughout the 30-day postoperative period.

CONCLUSIONS

Immediately following EFS, most women experience moderate to severe headache pain, despite use of medications. Pain persists in many patients for up to 1 month. Headache is associated with migraine symptoms, including light sensitivity and nausea.

LEVEL OF EVIDENCE: 4

Long - Term Evaluation of Endoscopic - and Pre - Trichial Open Forehead Lifts: a Morphometric Analysis

BACKGROUND

The aim of this study is to evaluate and compare the long-term (average 6 years, range 3-11 years) follow-up results of both the endoscopic - and pre - trichial open forehead lift. Both the amount of eyebrow elevation, as well as patient satisfaction (FACE-Q questionnaires) were analyzed.

METHODS

Preoperative and postoperative eyebrow positions of sixty-five patients were measured. Both eyebrow sides were measured at three different points. Thirty-two patients completed the FACE-Q questionnaires (10 domains, Dutch translated).

RESULTS

Both the endoscopic - as well as the pre - trichial open forehead lift raised the eyebrow significantly at all measured points for each eye. This elevation effect was maintained significantly after the long-term evaluation (average 6 years, range 3-11 years) with no significant difference reported among both techniques. After both procedures, patients were satisfied or strongly satisfied according to the FACE-Q questionnaires.

CONCLUSION

Both the endoscopic - and the pre - trichial open forehead lift raises the eyebrow significantly and both have either a long-term effect with long-lasting satisfied or strongly satisfied patients, as evaluated according to the FACE-Q questionnaire.

Aesthetic Analysis of Alteration of Eyebrow and Forehead Position After Endoscopic Eyebrow lift

BACKGROUND

Some of the surgeons performing endoscopic brow lift believe that this technique does not lead to clinically significant enlargement of the forehead.

PURPOSE

The goal of this study is to determine the change in eyebrow and forehead height after endoscopic brow lift and to assess the durability of the result over time.

METHODS

The pre- and postoperative photographs of 97 patients who underwent endoscopic brow lift from January 2016 to July 2020 were standardized and analyzed. The distance between median hairline and upper edge of eyebrow, the distance between upper edge of the eyebrow and edge of the lower eyelid and the distance between edge of the lower eyelid and the nasal base were measured, and the change in the upper face proportion was measured and analyzed.

RESULTS

There was statistically significant brow elevation after endoscopic brow lift in all three time periods (less than 1 month, 1-6 months and greater than 6 months). Forehead height did not change to a significant degree, while eyebrow height was increased statistically significant. A longitudinal study on 14 patients for whom multiple follow-up data were available showed that the increase in periorbital height appears to be sustained over time, whereas the change in the forehead height is not as readily apparent, resulting in a bigger relative change in the periorbital compared to the forehead height.

CONCLUSIONS

The brow height increased more than the forehead height, corroborating the fact that most of our patients have not complained about forehead becoming larger.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Direct brow lifting: Specific indications for a simplified approach to eyebrow ptosis

Context:

Brow lifting is an essential element in the rejuvenation of the ageing face. Various surgical techniques have been described. Among these, the direct brow lifting is an easy and effective technique that is often neglected because the scar can remain visible. Thus, this approach is usually reserved for elderly patients and males, with thick bushy brows.

Aims:

The authors present their result from a series of fifty consecutive patients treated over 2 years with direct brow lift. The aim is to demonstrate when the hairline is high or temporal alopecia is present and whether this technique is the best in bald patients, when some surgical steps are carefully adhered to. In these cases, the scar is less visible, hidden in the brow and is a good solution in women too.

Subjects and Methods:

Between January 2011 and January 2013, fifty patients underwent direct brow lift surgery. All were men. In all the cases, brow lifting was undertaken together with an upper blepharoplasty. The amount of brow elevation produced was assessed by comparing the vertical distances between the superior eyebrow hairline and the inter-pupillary line, pre- and post-operatively. The result and the scar quality were assessed both by the patient and the surgeon.

Statistical Analysis Used:

The paired t-test.

Results:

The authors obtained statistically significant results in brow elevation in 98% of the patients after a 12-month follow-up. The main complication associated with this procedure was visibility of the scar in two patients.

Conclusions:

The direct brow lift technique in bald men and with a high anterior hairline provides excellent and long-lasting results.

Brows Asymmetry Correction With the Direct Approach: Myth or Reality?

OBJECTIVES

The current article is aimed to test the effectiveness of direct and indirect brow lifting to correct brows asymmetry.

METHODS

Fifty patients treated with direct brow lift between January of 2011 and January of 2013 were investigated. All patients were men and treated under local anesthesia. In all patients, the brow lifting was associated with an upper blepharoplasty. The amount of brow elevation produced was assessed by comparison of the preoperative and at 1-year postoperative vertical distances between the superior eyebrow hairline and the interpupillary line at midpupil and at lateral and medial canthus. Paired sample t-test was used to investigate brow lifting amelioration after 1 year. The differences in measurements between the 2 sides were plotted to evaluate the degree of symmetry between 2 sides. In addition, a comparison was performed; a series of 45 patients treated with temporal (ie, indirect) approach.

RESULTS AND CONCLUSIONS

The paired sample test demonstrated that direct brow lifting is a proper surgical technique to correct brow asymmetry. Also temporal (ie, indirect) approach is able to ameliorate brow asymmetry but direct technique provide better results. The direct brow lifting is a reliable, reproducible and safe surgical procedure, provides excellent and long-lasting results, and is very efficacious in brows asymmetry correction.

Safety and Effectiveness of a Small Incision Lateral Eyebrow Ptosis Repair Technique Using a Frontalis Muscle Transposition Flap

PURPOSE

To evaluate the safety and effectiveness of a frontalis muscle transposition flap for treatment of lateral eyebrow ptosis.

METHODS

The charts of all patients undergoing frontalis muscle transposition flap eyebrow ptosis repair from December 2013 to September 2014 were reviewed. Charts with inadequate photographs were excluded. Charts were reviewed for demographics, preoperative and postoperative photographs, surgical technique, and complications. The following parameters were assessed on preoperative and postoperative photographs: corneal diameter, central brow height, and lateral brow height. Measurements were normalized to a standard corneal diameter of 11.5 mm. Statistical analysis was performed in conjunction with the Cleveland Health Institute Biostatistics Department.

RESULTS

Forty-six total patients underwent frontalis muscle transposition flap eyebrow ptosis repair and the charts of 31 patients (53 cases) were reviewed. There were 20 female and 11 male patients. Average age was 69.1 ± 7.7 years (range: 50 - 86 years). There were 9 unilateral and 22 bilateral cases. Concomitant surgeries included upper blepharoplasty (33 cases), conjunctival-Mullerectomy blepharoptosis repair (3 cases), and intralesional tetracycline injection for festoons (3 cases). Average follow-up interval between surgery and the final postoperative photograph was 10.2 weeks (range: 6-26 weeks). Overall, lateral brow height increased postoperatively by 1.78 mm (p < 0.05). In patients that underwent frontalis muscle transposition flap alone, lateral brow height increased by 2.86 mm (p < 0.05). Scalp hypesthesia was documented in 10/31 patients, and resolved in 8/10 patients at last follow up.

CONCLUSIONS

A frontalis muscle transposition flap effectively addresses lateral eyebrow ptosis repair through a small, relatively concealed incision. It produces temporary scalp hypesthesia in a significant number of patients, and long-term results remain unknown.

Cortical thickness parameters for endoscopic browlift fixation

BACKGROUND

Techniques for endoscopic browlift include bony fixation over the lateral frontal region and soft tissue fixation over the temporal region. Although bony fixation over the lateral frontal region is advocated universally, limited information exists about bicortical thickness in this area.

OBJECTIVES

The authors provide bicortical thickness measurements between the frontal midline and the most inferior temporal region to assist surgeons in identifying appropriate fixation planes.

METHODS

Bicortical thickness was measured in the hemicraniums of 13 female cadavers, along the coronal planes that travel through the anterior border of the mandibular condyles and at the junction of the posterior mandibular condyles and the external auditory meatuses. Measurements began at the midline and coursed laterally at 1-cm intervals.

RESULTS

Average cranial thickness along the frontal region ranged from 8.9 ± 2.4 mm to 6.4 ± 2.8 mm over the anterior coronal line and 8.8 ± 2.2 mm to 5.6 ± 1.8 mm over the posterior line. Average thickness along the temporal region ranged from 5.6 ± 2.8 mm to 2.8 mm ± 1.4 mm over the anterior coronal line and 5.1 ± 1.8 mm to 3.4 ± 1.4 mm over the posterior line. Minimum thickness was 3.7 mm and 1.3 mm over the frontal and temporal regions, respectively. There was no significant difference between left and right hemicranial thickness.

CONCLUSIONS

To avoid violation of the inner cortex during surgery, endoscopic browlift procedures should include measurement of cortical thickness at various fixation points. Bony fixation over the temporal region should be avoided. Minimal bicortical thickness was observed in the lateral frontal region.

The case for open forehead rejuvenation: a review of 1004 procedures

OBJECTIVE

To review the role of open forehead procedures in upper-face rejuvenation.

METHODS

The clinical records of consecutive patients undergoing a coronal or trichophytic brow-lift from July 1, 1993, to June 30, 2005, were reviewed. Patient demographics and complication rates were tabulated and compared with published rates for endoscopic brow-lifts. Patient questionnaires were sent to correlate subjective outcome measures with objective clinical record data. To obtain population-based perceptions, 200 women aged 30 to 70 years were surveyed at a local mall.

RESULTS

A total of 628 coronal and 376 trichophytic forehead-lifts were performed for which there were clinical records. There were 6 revisions (0.57%), no hematomas, 12 cases of permanent numbness (1.20%), 7 cases of permanent alopecia (0.70%), and no cases of permanent frontal branch weakness. The adjusted response rate for the questionnaire was 64.0% (416 of 650).

CONCLUSIONS

Open procedures in this series had a complication rate equal to or lower than published rates in endoscopic brow-lift series. Open brow-lift procedures are an effective means of upper-face rejuvenation and, when performed correctly, demonstrate high rates of patient satisfaction.

Eyebrow position recognition and correction in reconstructive and cosmetic surgery

OBJECTIVES

To improve (1) recognition of eyebrow ptosis, asymmetry, or deformity and (2) selection of the appropriate surgical technique based on the patient's underlying etiology.

DESIGN

Nonrandomized, retrospective study of patients undergoing surgical correction of eyebrow asymmetry. Forty consecutive patients were identified as having asymmetric eyebrow ptosis or deformity. Varying etiologies included those that were congenital, posttraumatic, age-related, iatrogenic, or idiopathic, with or without facial nerve paralysis. Patients underwent a variety of surgical approaches for correction of the eyebrow malposition, including transblepharoplasty, midforehead, coronal, and endoscopic procedures. Preoperative evaluation of patients, identification of patient-specific appropriate surgical technique, and photographs and grading of postoperative results are discussed.

RESULTS

All patients had a minimum follow-up period of at least 4 months (mean, 15 months; range, 4 months to 3 years). Preoperative and postoperative photographs were obtained and graded. Complete symmetry was achieved in 8 patients (20%), considerable improvement in 23 patients (57%), modest improvement in 7 patients (18%), and no improvement in 2 patients (5%). No notable postoperative complications were reported. Recommendations for improving results are included.

CONCLUSIONS

The key to correction of eyebrow ptosis in patients undergoing reconstructive and cosmetic surgery is to first recognize the asymmetry. It is also important to note the effect of reconstructive and cosmetic surgical procedures on eyebrow position in order to limit the need to perform additional procedures to correct resultant eyebrow asymmetries and deformities. Finally, the surgeon must consider which eyebrow-lift technique is optimal for the patient's underlying etiology to improve postoperative results and patient satisfaction.

Subgaleal endoscopic browlift with absorbable fixation

Rejuvenation of the upper third of the face by browlift has been performed endoscopically since the early 1990s and is commonly done in the subperiosteal plane with variable methods of fixation. The longevity of browlift recently has been questioned, as has the optimal plane of dissection and ideal type of fixation. From review of the literature, published study of brow soft tissue mechanics, and long-standing clinical experience with this procedure, we describe the senior author's (J.R.T.) rationale for and technique of subgaleal rather than subperiosteal endoscopic browlift. The author's technique has evolved from previous reports to now incorporate advances in absorbable fixation. Both male and female patients have been treated, as well as patients with pre-existing brow assymmetries, with excellent, durable results.

Endoscopic Forehead Rejuvenation: II. Long-Term Results

BACKGROUND

The purpose of this study was to analyze the long-term objective and subjective outcomes in patients who have undergone endoscopic forehead rejuvenation.

METHODS

Preoperative and postoperative photographs of 100 patients who underwent endoscopic forehead rejuvenation by one surgeon (B.G.) between 1993 and 2001 were objectively analyzed. Postoperative changes in left and right eyebrow position were assessed in each patient by counting the number of pixels in the digitalized photographs and by clinical measurements, and compared with preoperative values. In addition, subjective ratings of the surgical outcome obtained from both the patient and the evaluating surgeon were compared. All data were analyzed using the paired t test.

RESULTS

The average postoperative follow-up was 44 months (range, 12 to 95 months). Statistically significant differences in brow position between the preoperative and postoperative periods were observed in the following categories: the average distance from the lower brow margin to the upper eyelid margin (p < 0.005), the average distance from the lateral brow margin to the medial canthus horizontal line (p < 0.001), elevation of the lateral canthus relative to the medial canthus (p < 0.001), and the distance between the medial margins of the eyebrows (p < 0.001). In addition, preoperatively, 74 percent of eyebrows were positioned below the superior orbital rim, whereas 97 percent were positioned at the rim or above postoperatively, with 82 percent positioned above the rim. The most common complications were some degree of persistent paresthesia (50 percent), itching (14 percent), and forehead dynamic imperfections and irregularity (10 percent).

CONCLUSION

Endoscopic forehead rejuvenation improves brow position relative to the orbital rim, brow arch form, vertical frown lines, and horizontal frown lines of the forehead, with stable results many years after surgery.

Use of the Endoscopic Forehead-Lift to Improve Brow Position in Persistent Facial Paralysis

Traditionally, the asymmetrical brow in facial paralysis has been treated with open procedures. There are few data that support the use of endoscopic procedures to treat patients with facial palsy or paralysis. We sought to evaluate a single surgeon's experience with the use of endoscopic forehead-lifts to treat asymmetrical brow positioning resulting from facial nerve disorders. All cases involving patients who underwent endoscopic brow-lifts by the senior author (Y.D.) from 1997 through 2003 with a minimum follow-up of 12 months were retrospectively reviewed. Demographic data were collected, and patient satisfaction was determined from postoperative interviews conducted at follow-up visits. Standard photographs were used to measure the degree of preoperative and postoperative brow asymmetry. A total of 31 cases were available for review. The average age of our patient population was 47 years (age range, 22-76 years), with a male-female ratio of almost 1.5:1. Twenty-three patients had a complete paralysis, and 8 patients had a palsy. The average preoperative difference in height at the desired apex of brow was 5.9 mm, with a range of 3.0 to 9.0 mm. The average postoperative difference (as measured at 12 months) in brow position was only 1.3 mm, with a range of 0 to 3 mm. Adjunctive periorbital procedures were performed in the majority of patients (90%) at the time of endoscopic brow-lifting. All patients felt that their brow position was much improved after surgery. No major complications were encountered. A single patient underwent a secondary open direct browpexy to optimize his result. Endoscopic brow-lifting may be associated with favorable outcomes in the majority of patients with facial nerve palsy or paralysis. Performing concurrent adjunctive periorbital procedures as deemed necessary to optimize lower eyelid position, eyelid closure, and upper eyelid symmetry appears to be safe and reliable.

Endoscopic Forehead-Lift Using a Bioabsorbable Fixation Device

Endoscopic brow-lift is the method of upper face rejuvenation preferred by facial plastic surgeons and patients alike. The technique has undergone significant scrutiny regarding methods of fixation. Many techniques have been described, including external bolster dressings, tissue adhesives, Kirschner-wire fixation, cortical tunnels and troughs, and permanent or temporary screw and plate fixation. Many of these techniques are associated with postoperative alopecia, poor reliability, possible intracranial complications, and palpable hardware. Thus, the search for a safe, effective, reliable, and straightforward procedure continues. We describe our experience with an easy-to-insert bioabsorbable device that is fixed to the calvaria and provides multipoint fixation to the soft tissue.

Current treatments for brow ptosis

PURPOSE OF REVIEW

In this text, we describe and compare the most current brow-lifting techniques, including endoscopic, coronal, and pretrichial approaches, as well as subperiosteal and subgaleal dissection planes, and we discuss the advantages and disadvantages of each.

RECENT FINDINGS

Over the past decade, we have witnessed tremendous advances in the anatomic understanding of brow ptosis and in the procedures used to correct the resulting functional and aesthetic deformities.