11.1 Introduction

Forehead aging is a common aesthetic concern in aging patients. It reflects or communicates fatigue, anger, and sadness in affected individuals. Commonly encountered signs of forehead aging include brow deflation and ptosis with lowering of the medial and lateral hair-bearing brow and development of forehead and glabellar wrinkles. Browlift is a surgical procedure that addresses the drooping brow and rejuvenates the forehead.

Multiple techniques and approaches have been described for browlifting. They can generally be divided into open and endoscopic techniques. Open techniques include coronal, temporal, midforehead, anterior hairline, and transpalpebral approaches. ^{1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10} These techniques vary with respect to the site of incision, plane and method of dissection, and type of fixation. Generally, most of these techniques, both open and endoscopic, involve mobilization, repositioning, and fixation of the forehead and alteration of the forehead muscles.

In most surgical specialties, technology has created a trend toward less invasive techniques. Plastic surgery and browlift are no exception. Endoscopy has been used by gynecologists since the 1970s for diagnostic and therapeutic purposes. In the mid-1980s, endoscopy was introduced into general surgery, and by 1990 laparoscopic procedures became standard of care in general surgery. The first endoscopic browlift was performed at the University of Alabama in 1992. The endoscopic approach was developed as an alternative to the open techniques in selected patients to avoid long transverse incisions and their potential complications. Also, it can improve intraoperative magnification and visualization of small anatomical structures and allows more accurate dissection. ¹¹ Over the last two decades, endoscopic techniques have evolved significantly, instruments have improved, and relevant anatomy has been better defined. Currently, endoscopic browlift is one of the most commonly performed endoscopic procedures in plastic surgery.

11.2 Authors’ Personal Experience

Consensus on browlifting has been hard to come by. After initially being a “blackballed” procedure in the United States, the open browlift gradually became an accepted part of the plastic surgeon’s armamentarium (personal communication, Bruce Connell, 1997).

Over time, surgeons and patients alike became disenchanted with the drawbacks of coronal browlifting. Some of these were technique and surgeon dependent, whereas others were inherent parts of the nature of the procedure. ^{12 , 13} With the introduction of the endoscopic browlift, a renewed enthusiasm for the benefits of brow–forehead rejuvenation emerged. As with all things, this enthusiasm “at times runneth over,” leading to a battle for whose and which technique would produce the highest and most lasting elevation. Lost in the “race to the top” was the aesthetic and beauty sense that would define the success of the procedure. As a result, practices have divided into two camps.

One faction has dismissed and discarded the browlift entirely, citing complications and unnatural creations. ^{12 , 13} A second group has sought the aesthetics of natural beauty. While this trail has been evolving, a variety of approaches that may be effective in unique situations have been developed. ^{1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10} Also, refinements in the endoscopic browlift have emerged to become the mainstay for those who decline to “throw out the baby with the bathwater.” ^{11 , 14 , 15 , 16}

Over time, in the practitioners’ browlift experience, as well as in the literature, there has been an increased appreciation for the aesthetics of youth and natural beauty, as well as individual variation. To try to create an elegant arch on someone with a naturally low, straight brow works no better than to cut and paste a large broad smile onto a small thin face; the mismatch and imbalance offend the eye.

Nevertheless, there are certain consistent, cross-cultural, transcontinental desirable features, whether in South America or Scandinavia. Those include smooth, full, soft tissue drape over the lateral orbital rim; no fold past the corner of the eye; an arch (if present) that peaks between the medial two-thirds and lateral one-third of the brow; and the lack of vertical glabellar furrows medially. In addition, minimalization of static transverse forehead lines is desirable.

Given these features, we have developed a standardized method for evaluating the brow–forehead complex using this methodical approach. A customized aesthetic improvement can be offered to each individual patient.

11.3 Pertinent Anatomy

11.4 Advantages and Disadvantages of Endoscopic Browlift ¹⁸

11.5 Preoperative Assessment

• 
  

  The importance of a thorough patient interview during the initial consultation cannot be overemphasized. It is during this encounter that the surgeon and the patient start establishing a personal relationship that creates a comfortable environment, which is essential in order for patients to share their concerns and expectations with transparency. ¹⁹

  
  
• 
  

  Before the initial consultation, we ask our patients to fill out a consultation sheet to report their chief complaints, demographics, medical history, prior surgeries, allergies, medications, and social history.

  
  
• 
  

  Chief complaint: Patients state the reason for the consultation using their own words. This gives the surgeon a guideline for tailoring the history and physical examination. Also, it prevents embarrassing situations in which the surgeon assumes that the patient is here to address a certain aesthetic deformity when the patient is consulting for something else.

  
  
• 
  

  Demographics: Age, gender, occupation, marital status, children, level of education, and contact information.

  
  
• 
  

  Medical history: This is a crucial component of the preoperative assessment. The surgeon should be aware of medical conditions that might compromise wound healing, like diabetes, autoimmune or connective tissue disorders, renal or hepatic insufficiencies, or chronic diseases. Other comorbidities of significant impact on perioperative planning include hypertension, peripheral vascular disease, and cardiopulmonary diseases. In patients with significant comorbidities, the surgeon might elect to stage the planned procedures or order additional preoperative workup and clearance.

  
  
• 
  

  Psychiatric evaluation: Selecting the appropriate surgical candidates relies on the surgeon’s intuition and experience. It is of paramount importance for the surgeon to be able to identify patients with significant psychiatric conditions that require further evaluation.

  
  
• 
  

  Prior surgeries and interventions: Patients should list all interventions, both surgical and nonsurgical, to the forehead and the face in general. Prior surgeries can alter the anatomy and warrant modifications to the procedure. If possible, we ask our patients to provide operative reports from their previous surgeries.

  
  
• 
  

  Medications and supplements: In addition to the known anticoagulants (warfarin, aspirin, and clopidogrel), other medications and herbal and health supplements can cause coagulopathy and platelet dysfunction. The surgeon should ask about the use of vitamin E, ginkgo biloba, St. John’s wort, and other supplements, all of which should be stopped 2 weeks before the planned procedure. There is also evidence that the use of steroids and retinoid components might delay wound healing. ^{20 , 21}

  
  
• 
  

  Social history: Smoking is a significant risk factor for wound complications. ²² Patients are encouraged to quit smoking ideally 2 weeks preoperatively.

Related posts:

6. Facial Sculpting and Facial Slimming with Neurotoxins 20. Comparison of Midface Rejuvenation Techniques 22. Lower Eyelid Blepharoplasty 5. Energy-Based Treatments for Facial Aging 9. Male versus Female Facelift Surgery. Is There a Difference? 12. Primary Superficial Musculoaponeurotic System (SMAS) Facelift and Neck Lift

Stay updated, free articles. Join our Telegram channel

Join