The evolution of the brow lift in aesthetic plastic surgery

Evaluating the results of eyebrow lift by combining methods of subcutaneous flap and thread support in patients with droopy eyebrows

BACKGROUND

Brow lift also known as eyebrow lift was first described in 1919, and since then, many changes have been made in the methods of doing it, although there is still no agreed method of absolute superiority for eyebrow lift. Most previous studies have reported the results generally qualitatively and based on patient or surgeon satisfaction. In this study, by combining two less complicated methods of eyebrow lift, we have evaluated the quantitative results.

METHOD

Before the surgery, a standard photograph of the face was taken. The vertical distance between the tail of the eyebrow and interpupillary line was determined.

RESULTS

This study was performed on 15 females with a mean age of 38.27 ± 6.82 years. The mean distance between the eyebrow and interpupillary line by photographic measurement before surgery, 3 weeks, and 6 months after surgery was, respectively, 10.45 ± 1.74, 15.72 ± 1.77, and 13.53 ± 1.69 mm using the tail of the eyebrow and 18.47 ± 1.67, 23.33 ± 1.57, and 21.55 ± 1.66 mm using the crown of the eyebrow. In the clinical measurement, the eyebrow tail was 11.98 ± 1.75, 19.22 ± 1.73, 17.35 ± 1.68 and 15.13 ± 1.76 mm away from the pupil line, and the crown of eyebrow was 20.45 ± 1.90, 27.12 ± 1.58, 25.00 ± 1.80, and 23.35±1.78 mm. There is a significant difference between the distance of the tail of the eyebrow and the crown of the eyebrow in both measurement methods (photographic and clinical) at different times (p-value <0.001).

CONCLUSION

Performing eyebrow lift with the Pretrichial method has many comparative advantages to other methods. Additionally, eyebrow lift with the thread support is a less invasive method.

Eyebrow Height Changes with Aging: A Systematic Review and Meta-analysis

The eyebrows play an important role in emotional facial expressions, nonverbal communication, and facial esthetics. A comprehensive understanding of the mechanisms underlying eyebrow aging is vital in allowing plastic surgeons to appropriately address these age-related changes and to recreate an aesthetically desirable outcome for patients seeking brow rejuvenation. The aim of this study is to summarize the current literature on eyebrow height changes with aging.

Association of Corrugator Supercilii and Procerus Myectomy With Endoscopic Browlift Outcomes

Importance

Glabellar wrinkling is a critical component of upper facial aging.

Objective

To compare the long-term outcomes on the wrinkle lines of the glabella and forehead following browlifts with vs without corrugator and procerus muscle resection.

Design, Setting, and Participants

A prospective cohort comparative trial was conducted of 23 patients who underwent browlift procedures by a single surgeon at a single institution (16 with glabellar muscle resection and 7 without muscle resection) between May 1, 2016, and July 1, 2017. All analysis took place between May 1, 2016, and May 14, 2018. The mean follow-up period was 16 months (range, 12-21 months). Sixteen of the 23 patients underwent a browlift with muscle resection procedure alone or in combination with other facial rejuvenation procedures to the brow, midface, jowl, and neck. Four of the 23 patients underwent browlifts only, and 19 had browlifts with other procedures. Seven of the 23 patients had browlift procedures without muscle resection and were designated as controls.

Interventions

Endoscopic browlift surgery was performed either with procerus and corrugator muscle resection or without muscle resection.

Main Outcomes and Measures

Neutral gaze and dynamic photographs of the upper face obtained preoperatively and after the 1-year postoperative mark were reviewed and scored in a blinded fashion by 2 physicians not affiliated with the study team using a modified Fitzpatrick Wrinkle Assessment score (FWA; from 0 [no wrinkling] to 5 [deep wrinkling with redundant skin]).

Results

The 23 study patients had a mean age of 60 years (range, 48-74 years); 21 were women, and 2 were men. There was a significant difference between the myectomy and control groups in the 12-month postoperative improvement in dynamic glabellar FWA scores (2.56 vs 1.07, P = .01). There was a difference between the myectomy and control groups in the improvements in resting glabellar FWA scores at 12-month follow-up, but it did not reach statistical significance (1.28 vs 1.00, P = .38). The 12-month postoperative improvements in dynamic (1.19 vs 1.29, P = .86) and resting forehead (1.0 vs 1.1, P = .70) FWA scores were not significantly different.

Conclusions and Relevance

In this study, the use of procerus and corrugator myectomy techniques appeared to achieve a superior long-term reduction in glabellar wrinkles vs forehead rejuvenation techniques without muscle resection.

Level of Evidence

3.

Simplified Lateral Brow Lift under Local Anesthesia for Correction of Lateral Hooding

Background

A limited incision lateral brow lift has been described as an alternative to the endoscopic or the bicoronal approaches. The senior author has developed a safe and effective lateral brow lift technique that can be performed in an office setting under local anesthesia.

Methods

We retrospectively reviewed 150 consecutive patients who underwent a brow lift by the senior author (TAM). The technique begins with an upper blepharoplasty incision which is used to divide the corrugator under direct vision, followed by a release of the periorbital retaining ligaments. The lateral temporal incision is the access point for dissection above the deep temporal fascia then connecting to the subperiosteal plane, allowing full mobility of the brow. Galea is advanced with sutures and redundant skin is excised.

Results

All patients treated with this technique had resolution of lateral brow hooding. Two temporary neuropraxias of the frontal branch of the facial nerve were observed with full resolution and no permanent nerve injuries occurred. The revision rate was 7% and there was a 3% incidence of delayed wound healing at the temporal incision with no infections. One hundred forty-two patients (97%) underwent this procedure with sedation, 52 of which (35%) were in the office with light oral sedation.

Conclusions

The limited incision lateral brow lift as described allows for safe elevation of the lateral brow. When complemented by upper blepharoplasty, this technique provides excellent and natural-appearing rejuvenation of the upper face.

Endoscopic Brow Lift Fixation With Mitek Suture Anchors: A 9-Year Experience of a New "Ideal" Technique

PURPOSE

In recent years, the endoscopic technique has emerged as a minimally invasive approach to forehead rejuvenation, although the specific need for and mode of brow fixation for endoscopic brow lifts remain under considerable debate. An ideal fixation device should provide non-palpable long-lasting fixation and allow retention of the device post-operatively without the need for removal. It should also allow precise intraoperative adjustment for symmetry and correction of brow ptosis.

METHODS

The authors describe an endoscopic brow lift technique using an absorbable bone anchor, Mitek Microfix. A retrospective chart review was conducted in patients who underwent endoscopic brow lift procedures utilizing this fixation method at an academic practice. Outcomes evaluated included operative times, reoperation rates, palpability, fixation device permanence, incremental costs comparisons to conventional methods, efficacy, and technical learning curve. Complication rates were evaluated and the economic, incremental cost analysis of current fixation methods was reviewed.

RESULTS

Eighty-two patients underwent single-procedure endoscopic brow fixation using the Mitek anchor over a 9-year period (2005-2014). The mean operative time was 100 minutes. There were no cases of implant palpability, alopecia, or other postoperative complications. Two patients underwent revision secondary lifts after an average of 5.5 months for temporal ptosis.

CONCLUSION

The Mitek Microfix QuickAnchor provides durable, long-lasting fixation without device palpability. Its technical ease of use is demonstrated by the reasonable mean operative time achieved with the active involvement of resident surgeons. This device is operator-friendly, easy to use, fully indwelling, and provides lasting fixation without the development of palpability or alopecia.

Transcutaneous Brow Shaping: A Straightforward and Precise Method to Lift and Shape the Eyebrows

BACKGROUND

The height of the eyebrow is less crucial aesthetically than is the relationship between the lateral and medial portions of the brow. Although various surgical procedures are effective in raising the brow, the authors maintain that transcutaneous brow shaping (TBS) is the only technique that enables precise shaping of the brow and correction of minor asymmetries.

OBJECTIVES

The authors described their experiences with direct TBS alone or in conjunction with blepharoplasty and facelift.

METHODS

A total of 212 patients underwent TBS performed by the senior author (M.P.C). All patients were evaluated clinically and by means of pre- and postoperative photographs. Patients completed questionnaires indicating scar quality and satisfaction with the results.

RESULTS

There were no major complications. Scar visibility was low, and patients expressed a high level of satisfaction with the aesthetic results of TBS.

CONCLUSIONS

A misconception of transcutaneous browlift procedures is that they yield visible scars. TBS requires accurate planning, preservation of subcutaneous volume, limited undermining, preoperative application of botulinum toxin, and perioperative administration of local vasodilators. When these requirements are fulfilled, the authors have found that TBS does not yield a visible scar and is the easiest, most precise, and most reliable procedure for brow shaping.

LEVEL OF EVIDENCE

4.

[Temporal rejuvenation]

The temporal region has imprecise limits in the young patient. During the aging process, it becomes individualized with the appearance of a temporal fossa, the temporal, orbital and zygomatic bone margins, the ptosis of the lateral part of the brow and the appearance of the wrinkles of the crow's foot. As this area frame the look, it should be taken into consideration during the clinical examination as well as the facial and cervical stages. The rejuvenation techniques are numerous, nuanced and gradual. As long as the eyebrow ptosis is not evident and the distance of the eyebrows unaltered, the volumizing techniques and the botulinum toxin can respond effectively and harmoniously to the patients' demand. Then the surgical techniques of temporal and brow liftings must be considered and coupled with the techniques of lipostructure that are more and more practiced. It should be noted that the demand for temporal rejuvenation is increasing and precedes the demand of cervicofacial rejuvenation. This underlines the importance of this region both in terms of preventing or at least slowing down the process than in terms of curing the stigma of aging.

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.

Lateral Brow Lift: A Multi-Point Suture Fixation Technique

Background

Descent of the lateral aspect of the brow is one of the earliest signs of aging. The purpose of this study was to describe an open surgical technique for lateral brow lifts, with the goal of achieving reliable, predictable, and long-lasting results.

Methods

An incision was made behind and parallel to the temporal hairline, and then extended deeper through the temporoparietal fascia to the level of the deep temporal fascia. Dissection was continued anteriorly on the surface of the deep temporal fascia and subperiosteally beyond the temporal crest, to the level of the superolateral orbital rim. Fixation of the lateral brow and tightening of the orbicularis oculi muscle was achieved with the placement of sutures that secured the tissue directly to the galea aponeurotica on the lateral aspect of the incision. An additional fixation was made between the temporoparietal fascia and the deep temporal fascia, as well as between the temporoparietal fascia and the galea aponeurotica. The excess skin in the temporal area was excised and the incision was closed.

Results

A total of 519 patients were included in the study. Satisfactory lateral brow elevation was obtained in most of the patients (94.41%). The following complications were observed: total relapse (n=8), partial relapse (n=21), neurapraxia of the frontal branch of the facial nerve (n=5), and limited alopecia in the temporal incision (n=9).

Conclusions

We consider this approach to be a safe and effective procedure, with long-lasting results.

The 19th Century Origins of Facial Cosmetic Surgery and John H. Woodbury

John H. Woodbury was an incredibly entrepreneurial, self-trained dermatologist who, between 1870 and 1909, built an empire of cosmetic surgery institutes in 6 states, with 25 physician/surgeon employees and an advertising budget of $150,000/year (1892 data). Under his management, his surgeons, and perhaps Woodbury himself, performed multiple facial cosmetic surgeries, including early versions of browlifts, frown excisions, lower facelifts, mid-face lifts, rhinoplasties, double-chin reductions, and dimple creation. In addition, Woodbury developed a proprietary soap and cosmetic line, which he sold to Jergens for $212,500 in 1901 (retaining a 10% royalty). Woodbury's story has been unknown until now because this nonacademic concentrated his publishing in articles and advertisements in lay magazines. Woodbury's life ended in bankruptcy, litigation, and suicide when the corporate practice of medicine and advertising were made illegal. In his legal proceedings, Woodbury conceded that he was not a doctor, although he went by the title. Regardless, his surgical innovations are of major historical significance, as these cosmetic procedures are the first of their kind to be noted in the lay or academic press and predate, by years and even decades, the previously earliest known cosmetic surgeries in the United States.

Concentric double cables fixation as an alternative suspension method for the endoscopic forehead lift

Fixation of the elevated eyebrow is an important final step in endoscopic forehead lifting. One of the most common methods of fixation includes temporal fasciae sutures for the tail of the eyebrow, and mini-screws for the body of the eyebrow. The concentric cables fixation is an alternative method for elevation of both the tail and the body of the eyebrow. This technique is compared to temporal fasciae suture and mini-screws fixation. Thirty-one patients were included in this study. They were divided into two groups; group I included patients who underwent fixation using fascia sutures and mini-screws, while group II patients underwent concentric cables suspension. Traditional screw and suture technique elevated the eyebrow tail by 7.2, 6.7, 6.3, and 6.0 mm, while the concentric cables resulted in 7.6, 6.8, 6.5, and 6.3 mm elevation at 1, 3, 6, and 12 months postoperatively, respectively. The mean values of brow body elevation were 6.8, 6.4, 6.2, and 5.9 mm for group I, while the mean values of group II were 6, 5.4, 4.8, and 4.7 mm. The concentric cables technique showed a fewer complications rate compared to traditional fixation. The concentric cables fixation offers an alternative inexpensive method to suspend the tail, and to a lesser extent the body, of both eyebrows simultaneously with long-term stability. A fewer complications rate was documented compared to traditional temporal fasciae sutures and mini-screws fixation.

Rhinoplasty and brow modification: a powerful combination

BACKGROUND

Plastic surgeons have long recognized the importance of performing chin augmentation concurrent with a rhinoplasty to achieve facial balance. However, few surgeons consider the benefits of combining a rhinoplasty with brow modification to achieve a better aesthetic result. By increasing the size of the middle third of the face, the nose will automatically appear smaller.

OBJECTIVE

The authors describe anatomical dissections that provided perspective on the facial anatomy of the areas being studied and report the results of concurrent browlift and rhinoplasty procedures in a retrospective series of patients.

METHODS

The present study consisted of 2 parts: anatomical dissections and a retrospective chart review. The nose and central forehead area were dissected in 7 fresh cadavers at the time of autopsy to understand the anatomical relationship between the various muscles in the radix/glabellar region and to assess the muscle resection occurring in the clinical procedures. We also reviewed the charts of 24 patients who underwent combined rhinoplasty and brow modification with the senior author (R.K.D.) during a 2-year period (July 2010 to June 2012). Younger patients underwent a central browlift (CBL) with screw fixation, while older patients (ages 34-60 years) underwent full 5-incision endoscopic forehead lifting.

RESULTS

The age range for patients in this series was 14 to 60 years. Two patients were men and 22 were women. There were 12 primary and 12 secondary procedures in the series; 13 patients underwent CBL and 11 had EFL. The mean follow-up was 18 months. One patient had a persistent fluid accumulation in the glabellar region, which required drainage. One patient requested additional refinement of her nasal tip.

CONCLUSION

Modification of the central brow can dramatically change the aesthetic polygons of the nose/glabellar region. A CBL with radix/glabellar muscle excision is important in younger patients who need a well-defined nasion and older secondary patients who feel that the upper third of their nose is still heavy. A full EBL can enhance the facial appearance of older patients in whom a rhinoplasty alone would have a modest impact.

The open brow lift

The open brow lift procedure is discussed in terms of relevant surgical anatomy, preoperative evaluation, and detailed surgical technique for pretrichial coronal forehead lift with hair-bearing temporal lift, direct incisional brow lift, and coronal brow lift. Complications are discussed, and information is presented on patient evaluation and expectations, with a discussion of what patients can expect before and after brow lift surgery.

Progressive craniofacial bone loss after cosmetic surgery at the forehead

We present the case of a 59-year-old woman with a history of plastic surgery at the forehead who complained of progressive indentations at the frontal skull. CT and MR scans revealed significant bone thinning, presenting as lytic skull lesions, which progressed over a period of 3 years. Biopsies were obtained from the lytic lesions and histology showed fibrotic tissue, synthetic residue of previous cosmetic procedure, and no evidence of infection or neoplasm. Progressive cranial bone resorption places the patient at increased risk for cerebral injury. This case highlights a potential complication after cosmetic facial surgery, with bony resorption resulting in both skull deformation and increased risk for cerebral injury.

Comparison of the transpalpebral and endoscopic approaches in resection of the corrugator supercilii muscle

BACKGROUND

Corrugator resection is an integral part of periorbital rejuvenation and can be accomplished through the open coronal, endoscopic, or transpalpebral technique. While most authors concur about the importance of corrugator resection during brow lift surgery, considerable debate remains regarding the efficacy and technical ease of muscle resection with these approaches.

OBJECTIVES

The authors conducted a cadaver study to compare the completeness of resection of the corrugator muscle with the transpalpebral and endoscopic techniques.

METHODS

A split-face study was performed in 10 fresh cadavers. On one side, the corrugator muscle was resected through an endoscopic approach, and on the opposite side of the face, a transpalpebral resection was performed. After the completion of both procedures, a coronal incision was made; gross observations were noted; photographs were taken; and muscle weights were recorded.

RESULTS

In 19 of 20 cadaver halves, subtotal or total resection of the corrugator muscle was accomplished. In only one endoscopic instance was any muscle left in continuity. This occurred along the superior aspect of the arcus marginalis release when the corrugator muscle was hidden by the upper edge of the cut periosteum.

CONCLUSIONS

Unlike the previous reports, the authors found that transpalpebral and endoscopic techniques both allow subtotal or total resection of the corrugator muscle. Inadequate resection is technique dependent rather than procedure dependent.

Browpexy through the upper lid (BUL): a new technique of lifting the brow with a standard blepharoplasty incision

BACKGROUND

Browpexy returns the brow to an anatomical, aesthetically-appealing location on the upper face. Recently, browlifting techniques have evolved from aggressive, open approaches toward less invasive, limited-incision techniques. Browpexy through the upper lid (BUL), an innovative technique based on earlier practices, anchors the underlying brow soft tissue to the bone, allowing for stabilization. Furthermore, this procedure can be performed concomitantly with an upper eyelid blepharoplasty through the same access incision.

OBJECTIVE

The authors evaluate the efficacy of BUL in patients with ptotic eyebrows requiring stabilization and/or elevation and in patients with prominent brow fat pads.

METHODS

The charts of 21 patients who were treated with BUL by the senior author (HMS) between February 2007 and October 2008 were retrospectively reviewed.

RESULTS

The age range of the 21 patients in this study was 54 to 70 years. Twelve patients were men; nine were women. Each patient presented with complaints of tired-appearing or "weighed-down" upper eyelids. All patients were uniformly happy with their postoperative aesthetic results. There were no major immediate or long-term complications (including, but not limited to, uneven postoperative brow position, loss of suspension, frontal nerve injury, hematoma, infection, or wound dehiscence). No patients required reoperation for recurrent brow ptosis or upper lid deformity.

CONCLUSIONS

BUL is ideal for patients with ptotic eyebrows who need brow stabilization and/or elevation, as well as for patients with prominent brow fat pads who require stabilization. BUL achieves excellent results through a standard upper eyelid blepharoplasty incision, and allows the surgeon to perform a concomitant upper eyelid blepharoplasty and browpexy without a traditional coronal, scalp, or forehead incision.

Approach to eyebrow ptosis through the modified technique of Castanares

One of the first signs of facial ageing appears in the forehead, with the descent of the lateral part of the brow. This is a troubling condition for all patients and elevation of the lateral part of the brow becomes a more and more frequent demand. The authors present their experience in 350 consecutive cases of direct eyebrow lift ("butterfly wing" incision) alone or in combination with rhytidectomy and/or blepharoplasty. The majority of the patients were female (90%). The age ranged from 43 to 85 years. Eighty per cent of the cases were performed simultaneously with rhytidectomy and blepharoplasty, 16% were performed in association with blepharoplasty and eyebrow lift alone represented 4%. The most common complication was epidermal cyst (3.4%) and suture dehiscence (2%). The "butterfly wing" incision provides a useful alternative to correction of eyebrow ptosis. Indication for surgery is dependent more on the ageing signs than on the patient's chronological age. The final results are consistently very gratifying to the patient and to the plastic surgeon alike.

Endoscopic brow and forehead lift: a case for new technology

As with most things in life, the passage of time usually brings progress through advancing technologies. At one time, the horse was a state-of-the-art military fighting machine and a simple compass represented advanced navigational technology. Things come and go and while some leave a lasting impact others are replaced, never to be revisited. Surgical techniques are continually evolving, and while quantum strides have been made in the last century, just because something is new, this does not make it better. For this reason we all owe it to our respective professions to carefully evaluate emerging trends and technologies before abandoning procedures that are proven to be safe and effective. Some surgeons too eagerly embrace new technologies, while others are late in acceptance or in some cases never progress.

Eyebrow Reconstruction: Options for Reconstruction of Cutaneous Defects of the Eyebrow

BACKGROUND

Reconstruction of cutaneous eyebrow defects is a challenge, as eyebrow positioning provides an important role in communication, cosmesis, and signaling age, gender, and emotional status. Special consideration must be paid in order to maintain eyebrow symmetry and to avoid distortion of the hairline.

OBJECTIVE

To demonstrate reconstructive options for the eyebrow that preserve maximal function and cosmesis.

METHODS

The anatomy and function of the eyebrow are reviewed. Descriptions of five techniques of eyebrow reconstruction are then presented, including specific limitations and benefits of each closure option. Pertinent details regarding flap mechanics, design, and patient selection are also included.

RESULTS

There are several options available for reconstruction of the eyebrow. Each closure method has advantages and disadvantages. The selection must be individualized, depending on the extent and location of the eyebrow defect relationship to other structures, gender, and age of patients. Each of the five closure options aid to maintain the function and aesthetic appearance of the eyebrow.

CONCLUSION

Understanding the unique anatomy and function of the eyebrow, including its movement in facial expression, is useful in achieving good reconstructive outcomes while maintaining normal eyebrow function.

Endoscopic Brow Lift:

Since the introduction of endoscopic brow lifting in the mid-1990s, it has become widely accepted as a method for rejuvenation of the upper third of the face. Despite the multitude of brow fixation techniques, there are few long-term studies providing accurate analysis of outcome. The aims of this investigation were to evaluate the long-term objective results of endoscopic brow lifting and to establish whether the technique of fixation altered the longevity of aesthetic outcome. The outcome of endoscopic brow lifts carried out on 538 consecutive patients over a 6-year period was assessed. For each patient, midpupil-to-brow distance was measured preoperatively and at intervals postoperatively. Two different fixation methods were compared: fibrin glue (n = 189, group 1; 104 records available) and polydioxanone sutures tied through bone tunnels (n = 349, group 2; 220 records available). In 214 patients, an upper lid blepharoplasty was performed simultaneously (85 in group 1 and 129 in group 2). At 1 month postoperatively, each fixation technique had produced a significant change in mean pupil to brow height (5.93 mm in group 1 and 6.21 mm in group 2, with no significant difference between the two methods; p = 0.17). However, when measurements were compared more than 3 months postoperatively (mean, 9.4 months), there was a significant difference, with some relapse in the patients treated with fibrin glue (p < 0.01). However, in group 2 (tunnel fixation), measurements remained stable, with 6.21 mm at 1 month compared with 6.16 mm long term (no significant difference, p = 0.34). In contrast, in group 1 (fibrin glue), measurements showed significant reduction, with a 1-month result of 5.93 mm and a long-term outcome of 3.79 mm (p < 0.01). Upper lid blepharoplasty had no effect on the long-term outcome of either group (p > 0.3 in group 1, p > 0.4 in group 2). Complications were few in both groups. In group 1, there was one infection, two instances of significant alopecia (both temporary), and one reoperation for relapse. In group 2, four patients required minor surgical revision of a lateral port scar and three minor areas of temporal alopecia, which recovered in less than 3 months. One patient had a paresis of the frontal branch that had recovered after 4 months. The endoscopic brow lift is therefore a safe and effective technique for increasing mean pupil to brow height. Fixation with polydioxanone sutures tied through bone tunnels produces a significantly more stable result than fibrin glue, without greater risk. This lends weight to experimental evidence that periosteal fixation must be maintained for at least 6 weeks to be secure.

Endoscopic brow lift: a retrospective review of 628 consecutive cases over 5 years

Since its introduction in 1992, endoscopic brow lift has gained tremendous recognition because it has been promoted as a novel technique to correct brow ptosis as well as glabella rhytids in a minimally invasive manner with fewer complications than the classic coronal brow lift method. In this retrospective study, 628 endoscopic brow lift procedures performed over a 5-year period (1997-2001) at Manhattan Eye Ear and Throat Hospital were reviewed. The number of endoscopic brow lift procedures performed at this institution has declined 70 percent. The purpose of this study was to elucidate the causes of this striking trend by soliciting the opinions of 21 New York plastic surgeons on their current brow ptosis management. The response rate was 84 percent (21 of 25 surgeons contacted). Currently, 25 percent of the interviewed plastic surgeons perform endoscopic brow lift regularly, 50 percent of the plastic surgeons perform endoscopic brow lift occasionally, and 25 percent of the participants no longer perform endoscopic brow lift. While most patients (70 percent) were satisfied with their results, only 50 percent of the plastic surgeons were pleased with the long-term results (after more than 2 years of follow-up). Observed postsurgical complications of endoscopic brow lift included alopecia, hairline changes, infected hardware, brow asymmetry requiring surgical revision, prolonged forehead/brow paresthesia, frontal branch nerve paralysis, and scalp dysesthesia. These complications were similar to those resulting from open brow lifts. Seventy-one percent of the surveyed New York plastic surgeons routinely administered botulinum toxin type A (Botox) within 6 months of the endoscopic brow lift procedure. Possible explanations for the decline in the overall number of endoscopic brow lift procedures include the following: (1) the selection criteria for the ideal endoscopic brow lift patients are currently more limited; (2) other techniques equal or surpass endoscopic brow lift in effectiveness and predictability; and (3) endoscopic brow lift is ineffective in the majority of patients. There is no single superior surgical procedure for brow ptosis management available at this time.