This article describes the use of the endoscopic brow-lifting technique in addressing periorbital aging. This article discusses the advantages and disadvantage of the endoscopic versus traditional techniques of brow lifting and gives our treatment algorithm depending on patient needs.
Key points
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The advantages and disadvantages of endoscopic versus traditional brow-lifting techniques have not been proved using rigorous scientific studies.
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We have found that endoscopic brow lifting alone or combined with a trichophytic skin resection can be used to achieve excellent brow and periorbital rejuvenation in most patients with minimal complication and excellent longevity.
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Complication rates, outcomes, and longevity of these procedures using different approaches remain to be studied.
Results, outcomes, and complications of the coronal and pretrichial approach versus the endoscopic approach
To know and appreciate the advantages and disadvantages of the endoscopic versus coronal or pretrichial techniques would require a prospective, randomized controlled trial to directly compare the sequelae of each type of surgery. Lacking this, Graham and colleagues systematically reviewed the literature published over the last 20 years, since the original description of endoscopic brow lifting. Their search for studies containing original content and no fewer than 20 patients produced 15 articles, which were all retrospective case series. Although these studies show comparable rates of complications and outcomes between the traditional open approaches and the endoscopic approach, a closer study of each article and its methods of determining surgical outcomes and complication rates becomes a convoluted process. The problem in attempting comparisons between the outcomes is that each study used different criteria and outcome measures. These different outcomes measures preclude any type of specific comparison.
The flaw in comparisons made between these studies is highlighted in reported rates of complications such as dysesthesia. Knowledge of the anatomic basis of surgical dissection in a coronal or pretrichial brow lift would mandate higher dysesthesia rates than the endoscopic dissection, but a comparison of studies published to date shows higher dysesthesia rates with the endoscopic approach. One possibility for this is reporting bias. It may be that dysesthesia after a coronal brow lift is often expected and, as such, not reported as a complication in studies involving a coronal approach.
What can be concluded from large series such as that published by Cilento and Johnson is that, when performed carefully by experienced surgeons, each technique can have few complications and high patient satisfaction rates. In a recently published series, the endoscopic brow-lift approach has been used in patients with male pattern baldness. In another study endoscopic surgery using a small trichophytic incision to lower the hairline was also used in patients with a high hairline. Although endoscopic brow lifting has traditionally not been used for patients with male pattern baldness or high hairlines, these studies show that, with appropriate patient selection, surgical execution, and surgeon’s comfort and experience, endoscopic techniques can be used for a variety of nontraditional indications.
Proponents of nonendoscopic (coronal or pretrichial) brow lifts maintain that these are the gold standard procedures for brow lifting. However, there have been no good prospective studies with long-term follow-up including accepted measurement criteria or reporting of complication rates to support this assertion. The question remains, are coronal, subgaleal approaches more efficacious? Do they have better longevity? Or is it just that these are older techniques and surgeons have classically been more comfortable with performing them? These assertions require specific assessment with long-term follow-up studies. Another commonly cited benefit of the open techniques is that they are more efficacious for treatment of forehead rhytids. Forehead rhytids can be treated by myomectomy with endoscopic or open techniques, depending on the needs of each individual patient. At first, all brow-lifting techniques can improve the appearance of forehead rhytids because of the postoperative swelling that accompanies these procedures for months following surgery. Long-term decrease in forehead rhytids is achieved by cutting of the responsible muscles, which can be done with endoscopic or open techniques depending on the needs of each individual patient.
Results, outcomes, and complications of the coronal and pretrichial approach versus the endoscopic approach
To know and appreciate the advantages and disadvantages of the endoscopic versus coronal or pretrichial techniques would require a prospective, randomized controlled trial to directly compare the sequelae of each type of surgery. Lacking this, Graham and colleagues systematically reviewed the literature published over the last 20 years, since the original description of endoscopic brow lifting. Their search for studies containing original content and no fewer than 20 patients produced 15 articles, which were all retrospective case series. Although these studies show comparable rates of complications and outcomes between the traditional open approaches and the endoscopic approach, a closer study of each article and its methods of determining surgical outcomes and complication rates becomes a convoluted process. The problem in attempting comparisons between the outcomes is that each study used different criteria and outcome measures. These different outcomes measures preclude any type of specific comparison.
The flaw in comparisons made between these studies is highlighted in reported rates of complications such as dysesthesia. Knowledge of the anatomic basis of surgical dissection in a coronal or pretrichial brow lift would mandate higher dysesthesia rates than the endoscopic dissection, but a comparison of studies published to date shows higher dysesthesia rates with the endoscopic approach. One possibility for this is reporting bias. It may be that dysesthesia after a coronal brow lift is often expected and, as such, not reported as a complication in studies involving a coronal approach.
What can be concluded from large series such as that published by Cilento and Johnson is that, when performed carefully by experienced surgeons, each technique can have few complications and high patient satisfaction rates. In a recently published series, the endoscopic brow-lift approach has been used in patients with male pattern baldness. In another study endoscopic surgery using a small trichophytic incision to lower the hairline was also used in patients with a high hairline. Although endoscopic brow lifting has traditionally not been used for patients with male pattern baldness or high hairlines, these studies show that, with appropriate patient selection, surgical execution, and surgeon’s comfort and experience, endoscopic techniques can be used for a variety of nontraditional indications.
Proponents of nonendoscopic (coronal or pretrichial) brow lifts maintain that these are the gold standard procedures for brow lifting. However, there have been no good prospective studies with long-term follow-up including accepted measurement criteria or reporting of complication rates to support this assertion. The question remains, are coronal, subgaleal approaches more efficacious? Do they have better longevity? Or is it just that these are older techniques and surgeons have classically been more comfortable with performing them? These assertions require specific assessment with long-term follow-up studies. Another commonly cited benefit of the open techniques is that they are more efficacious for treatment of forehead rhytids. Forehead rhytids can be treated by myomectomy with endoscopic or open techniques, depending on the needs of each individual patient. At first, all brow-lifting techniques can improve the appearance of forehead rhytids because of the postoperative swelling that accompanies these procedures for months following surgery. Long-term decrease in forehead rhytids is achieved by cutting of the responsible muscles, which can be done with endoscopic or open techniques depending on the needs of each individual patient.
Treatment goals of brow lift
The appearance of the eyelid and periorbital region is among the most important aesthetic unit of the face. This region projects a person’s mood and is the most frequently watched area by the casual observer. The shape and position of the eyebrows contribute greatly to the overall appearance of the upper one-third of the face. An aesthetic, youthful appearance of the orbit and eyelids requires a well-supported and positioned brow. Ptosis of the eyebrows and peribrow soft tissues is often a part of the normal aging process. The eyebrows may descend below the level of the supraorbital rims, affecting the function and appearance of the upper eyelids ( Fig. 1 ).
The goal of the brow-lift procedure is to restore a youthful position to the brow and to improve the aesthetics and function of the upper face and eyelids. When brow ptosis exists and is not surgically corrected, upper blepharoplasty alone can exacerbate brow ptosis and impart a tired or sad appearance to the eyes.
Decision algorithm for determining invasive versus less invasive surgery
Patient Selection and Preoperative Planning
Ideal brow position
Ideal brow position varies between gender and race. In men, the brow is generally heavier and thicker, with little arc present, and often lies at or below the level of the superior orbital rim. The female brow is more refined with a club shape medially and tapering laterally. Although ideal brow positions and shapes are often discussed in articles/texts, no ideal eyebrow position or shape exists. The position of the brow is related to the relative contraction of the elevators (frontalis muscle) versus the relative tone of the depressors (orbicularis oris, procerus, and corrugator muscles). The ideal female brow should lie just above the superior orbital rim ( Fig. 2 ). The medial border of the brow lies on a vertical line drawn up from the alar-facial crease. The lateral end of the brow lies on a line drawn from the alar-facial crease tangent to the lateral canthus. The medial and lateral ends of the brow are on the same horizontal plane. The highest arch of the brow in women is ideally at the lateral limbus or just lateral to it.
The medial and lateral brow should be evaluated separately with regard to their position. The lateral brow often warrants more vigorous elevation, whereas the medial brow is best approached conservatively and should not be overly elevated. We prefer a more conservative medial release to avoid overly elevated medial brows with a postoperative surprised appearance. Our decision algorithm for surgical planning takes into consideration the patients’ forehead height and hairline, as well as depth of forehead rhytids and general condition of the patient ( Fig. 3 ).
Patient presentation
Many patients present with asymmetry in their brow shape and position. It is the surgeon’s responsibility to point out these asymmetries and the important effect of brow position on the upper eyelid. It is also important to recognize and communicate why correcting excess eyelid skin and fat herniation fails in improving the appearance of the eyes and upper face if a ptotic brow is not addressed.
Patients with upper eyelid ptosis may often compensate by tonic contraction of the frontalis muscle, which can result in horizontal forehead rhytids. Therefore, it is important for the patient to be in complete repose during preoperative evaluation. To achieve full repose, we ask patients to close their eyes, focus on relaxing the forehead, and gently open their eyes. McKinney and colleagues described certain quantitative measurements to aid in selection of the appropriate lifting technique. They used measurements in a vertical plane from midpupil to the top of the eyebrow and up to the hairline to indicate which procedures and approaches should be used for brow lifting.
Preoperative brow and periocular evaluation can be done effectively by focusing on specific anatomic landmarks. These landmarks include the evaluation of the eyelid including ptosis and levator function, evaluation of the forehead, and overall patient health including overall fitness for cosmetic surgery as previously described.
Eyelid ptosis
If a patient has underlying eyelid ptosis on 1 or both sides, which is best determined by assessing the marginal reflex distance (MRD). MRD-1 is the noted distance between pupillary light reflex and the margin of the upper lid; a distance of 4 to 4.5 mm is normal. The upper lid should lie just below the superior limbus by approximately 1 to 1.5 mm. The MRD-2 is the distance, measured again in primary gaze, between the pupillary light reflex and lower lid margin; a distance of greater than 5 mm is adequate.
Levator function
Levator function must also be measured and recorded when evaluating the periorbital region. This evaluation is performed by holding the brow in position (nullifying the effect of the frontalis muscle) and requesting the patient to first look down and then up. The difference between the position of the eyelid margin looking downward and then upward is the levator function. If a measurement of less than 4 mm is found between maximum down gaze and maximum up gaze, the levator function is deemed as poor; a movement of 5 to 7 mm is fair, 8 to 15 mm is good, and more than 15 mm is excellent or normal.
Upper lid
Upper lid evaluation is to be performed in conjunction with brow evaluation. Analysis of the upper eyelid should include assessment of skin, fat, the height of the supratarsal crease, and aperture opening. If upper blepharoplasty is to be performed simultaneously with brow lifting, it is important to maintain sufficient skin after completion of the procedures to avoid postoperative lagophthalmos. Dermatochalasia is the general term used for the presence of excessive skin and its laxity associated with aging as well as fat herniation. Blepharochalasis is a rare occurrence of unknown cause that occurs typically in women and is manifest by edema, causing decreased elasticity and notable atrophic changes.
Forehead length/hairline position
The forehead may mandate the appropriate brow procedure. Deep forehead rhytids with a high hairline make midforehead lift a reasonable approach.
Patient health
The patient’s health may also play a role in preoperative decisions. Unhealthy patients who are not suited for longer surgeries or general anesthesia may preclude more extensive procedures and elect a direct brow approach. In addition, patient psychology and candidacy for aesthetic surgery must be considered.
Preparation for Brow-lift Surgery
Before brow-lift surgery, the use of botulinum toxin helps to eliminate the function of brow depressors, including the corrugator, procerus, and orbicularis oculi muscles ( Fig. 4 ). Botulinum toxin use in the forehead elevators (frontalis muscle) is usually not performed perioperatively. The absence of persistent depressor function promotes longevity of the brow lift and allows readherence of the forehead flap to the underlying cranium. This readherence has been shown to occur within 1 week after surgery. Botulinum toxin injection is performed at least 10 days preoperatively to allow adequate neurotoxin effect. We like to use 16 to 25 units of Botox in the procerus/corrugator complex and 18 to 25 units of Botox in the region of crow’s feet/lateral orbicularis oculi.
