The Clinical Problem
The aging brow that requires an endo brow lift has to be considered within the aging face as a whole if a rejuvenation procedure is to be successful. A high frontal hairline, a brow ptosis causing visual field disturbance, a heavily wrinkled or creased forehead, a tendency to a poor scar, hair loss, or infection, associated medical conditions, and skin type are reasons to be careful before proceeding. The patient wants minimal surgical intervention and inconvenience and a low-risk, high-reward surgery that improves the appearance of the forehead and position and symmetry of the eyebrows. Often associated with this is improvement in the pseudoptosis of the upper eyelids.
Also associated with the endo brow approach is the final fixation of the elevated forehead. This can be accomplished using screws, an Endotine fixation device (MicroAire Surgical Instruments, Charlottesville, VA), and sutures and may involve the use of fibrin spray technology.
I believe that an endo browlift combined with a four-lid blepharoplasty can produce the most dramatic rejuvenation of the face. It can also be used for facial palsy correction. The brow lift should always be carried out before upper lid reduction; otherwise, an upper lid skin shortage may result.
Surgical Preparation and Technique
Preoperative Assessment
Using a mirror, ask the patient to demonstrate the shape of eyebrow and degree of elevation that is desired by screwing up the eyes and then slowly opening them ( Fig. 5.1 ). Leaving the forehead relaxed shows the degree of brow ptosis. Then, the patient mimics the pull of an Endotine fixation device using one finger to create the brow shape that is desired. Mark this line of pull using a permanent marker.
Preparation for Surgery
While the patient is being anesthetized, ask the nurse to make up a mixture of the following: hyaluronidase (Hyalase), 1500 IU; adrenaline, 1 mg; treprostinil sodium (Adcortyl), 20 mg in 500 mL saline ready for injection.
When the patient is settled on the operating table, ensure that the head is level with the top edge of the table. This will help access, with the head raised and supported on a head rest.
Mark the incision for the port sites ( Fig. 5.2 ). I use three, each extending from just behind the hairline, one center in line with the nose and the other two in line with the desired line of pull.
Inject 40 to 60 mL of the solution. Use a white 19-gauge needle, pushing through the skin and straight onto the bone and ensuring that the bevel is parallel to the bone so the fluid will be injected subpericranially ( Fig. 5.3 ).
On completion of the injection, press firmly for a short time at the point of penetration at the pericranium to avoid extravasation. I usually inject about 20 mL at each of the three ports.
I inject 10 mL of bupivacaine (Marcaine) 0.5% with adrenaline 1 in 200,000 ( Fig. 5.4 ). The bupivacaine hopefully will block any supraorbital nerves, and the adrenaline cuts down the bleeding from the accompanying vessels. I use the same around the ports and I inject any surplus into the subpericranial.
