Cosmetic Facial Surgery

Chapter 5  •  Mini Open Brow Lift
83
FIGURE 5-76.  Patient 1 week after transfollicular subcutaneous brow and
forehead lift. Unusual ecchymosis is present and not consistent for this
procedure.
A
B
FIGURE 5-77.  This patient has a successful transfollicular subcutaneous
brow and forehead lift, as evidenced by the brow position, but declined
the suggestion of simultaneous blepharoplasty. The result was not as
aesthetic; the dermatochalasis becomes the focus of the case. She later
lamented and returned for upper blepharoplasty.
FIGURE 5-78.  An unusual inflammatory reaction to the gut sutures used.
This case probably has an allergic component. She healed uneventfully,
although the inflammation persisted for several weeks.
A
B
FIGURE 5-79.  Patient has a poor job of permanent eyebrow makeup, and although her natural eyebrows are symmetric post-
operatively, her brow tattoos are not.

84
Chapter 5  •  Mini Open Brow Lift
A
B
C
FIGURE 5-80.  Patient is shown preoperatively (A); after her first surgery, which was suboptimal (B); and after a revision transfol-
licular subcutaneous brow and forehead lift (C), which improved her situation.
A
B
FIGURE 5-81.  Patient was undertreated with transfollicular subcutaneous brow and forehead lift. Her medial brow was elevated,
but the lateral brow is in need of further elevation.
A
B
C
FIGURE 5-82.  Patient needed further brow elevation after a transfollicular subcutaneous brow and forehead lift. B, Marks indicat-
ing areas to be elevated. A and C, Excess skin removed to elevate the lateral brow was only on the lateral margins of the
incision. This procedure is customizable, even in the revision phase.

Chapter 5  •  Mini Open Brow Lift
85
FIGURE 5-84.  Hypopigmentation of the incision scar can occur in some
patients. This usually improves with time but can be permanent.
A
B
FIGURE 5-85.  A, Hypopigmented transfollicular subcutaneous brow and
forehead lift scar. B, Good blending of the skin and scar color after resur-
facing the scar with the CO2 laser.
A
B
FIGURE 5-83.  A, Patient with a very noticeable angular scar (albeit early in
the healing process). B, Instead of attempting to replicate the widow’s
peak with the incision (blue line), a more aesthetically pleasing scar is
produced by incising through the lower third of the peak (dotted white line).
Hypopigmentation of hairline scars is a common problem,
worse in some patients than others (Figure 5-84). Much of this
will improve over time, but it can be permanent. Judicious
attention to technique assists normalized scars, but some
patients will simply hypopigment in this area. This must be
explained in the consent process. Makeup can cover some
of this in female patients, as can altering the hairstyle. Some
patients may opt for tattooing of the scalp to normalize the color
to the unoperated skin. CO2 laser resurfacing of the scar and
surrounding tissues has proven successful to blend the skin color
as well (Figure 5-85).
The TFSBFL can produce predictably aesthetic scars if per-
formed properly. The learning curve of the surgeon and the
healing variability of the patient can affect the final scar. I have
never had a “terrible” scar and never had a patient complain that
they hate the scar or had to permanently change their hairstyle.
I have, on the other hand, had patients who were satisfied with
their scar, but I was not and wanted to improve it because it is
reflective of my work. I have also had patients who tell me their
scar is “okay,” but they would like it to look better. I have always
agreed. Having said that, it is important for all surgeons to be
gatekeepers of the quality of all of their surgical scars for all
procedures. A surgeon can perform a brilliant facelift, but if the
suture scars are bad, they take away from the result and the
perception of all those who observe the scar. The surgical scar
is truly the “signature” of the surgeon, and while it may be
acceptable for doctors to have poor signatures on their prescrip-
tions, it is unacceptable to have poor signatures on their patients!
For this reason, I tell all surgical patients at the presurgical
consent appointment that we will evaluate their scars and revise
them at the appropriate time if required. Fortunately, most scars
do not require revision, but if they do, it is much easier if the
topic was discussed preoperatively. I do not routinely charge for
revision (other than a moderate materials fee), since it ultimately
makes my work look better and serves as marketing for my
practice and skill.
A problematic incision generally manifests as erythema,
unevenness of the level of skin on each side of the incision (step
off), thickening of the scar, or areas of scar depression. Each of
these problems warrants specific treatment, but I have had
impressive results with high-fluence multipass CO2 laser

86
Chapter 5  •  Mini Open Brow Lift
A
B
FIGURE 5-86.  A, Left half of a transfollicular subcutaneous brow and forehead lift scar being resurfaced with the CO2 laser to
improve scar aesthetics. Patient’s right-side scar has not yet been treated in this image. B, Ellman radiowave ball electrode
used to reduce hypertrophic raised areas of an incision scar.
A
B
C
FIGURE 5-87.  A, Transfollicular subcutaneous brow and forehead lift scar that has “step off” and areas of scar thickening.
B, Raised areas circled with surgical marker in anticipation of radiowave reduction. C, Revised scar 30 days after treatment
with radiowave ball electrode and CO2 laser.
A
B
C
FIGURE 5-88.  A, An unfavorable scar with uneven areas. B, The scar immediately after CO2 laser resurfacing. C, Scar 12 weeks
after treatment.
resurfacing over the entire scar. I usually perform this before the
8-week period if I feel the scar is not progressing in the right
direction. There is no problem treating scars older than 8 weeks.
Any scar that needs revision can be treated at any time, although
there is evidence that scars treated before 8 weeks may heal
better.26 Figure 5-86 shows a scar treated with the Lumenis CO2
laser and the Ellman radiowave ball electrode to reduce hyper-
trophic regions. Raised areas of the scar are selectively reduced
with the ball electrode until flat, and the entire scar is resurfaced
with multiple nondébrided laser passes. Sometimes only a single
modality is required, but this combination therapy has worked
well in revising TFSBFL scars. I have seen such impressive
improvement of the TFSBFL scar that I have considered offer-
ing all patients this treatment; it makes any scar better. Figures
5-87 to 5-90 show TFSBFL scar revision with CO2 laser
resurfacing.
Less frequently, depressed areas may be present on the scar,
and these can be raised with injectable filler. I have on occasion
injected silicone oil to plump a depressed scar (Figure 5-91).
I have had a single patient who healed with a noticeable
depression in the area of the frontalis muscle. I believe this
was a result of injury to the actual frontalis muscle during the
dissection, and I think the area of muscle damage became
bound to the dermis, thus fusing it to the muscle. Alternatively,

Chapter 5  •  Mini Open Brow Lift
87
A
B
C
FIGURE 5-89.  This scar was slow to heal and unacceptable to the patient. She is shown before CO2 laser resurfacing (A),
immediately after CO2 laser resurfacing (B), and 6 weeks after laser revision (C).
the muscle could have been damaged with atrophy and the
dermis bound to the galea or deeper tissues. In any event, the
patient has a depressed area on the right side that was somewhat
tethered to the deeper tissues and produced a bothersome
defect, especially during animation. This was treated by sub­
cision where a Nokore 18-gauge needle (BD Inc., Franklin
Lakes, NJ) was used to disrupt the deeper adhesions that were
tethering the dermis. This was performed on several occasions,
and the dimple improved. The area became more dynamic and
moved more freely with the frontalis muscle. The residual
depression was treated with three sessions of 0.2 mL of silicone
oil injection (Silikon 1000, Alcon Laboratories, Ft. Worth, TX)
(Figure 5-92).
Conclusion
The TFSBFL (also called trichophytic brow and forehead lift) is
an effective treatment for the aging upper face. It has the advan-
tages of being a direct-vision procedure, not raising the hairline,
and allowing suspension of the brow across the entire forehead,
without excess tension. Additional advantages include dramatic
reduction of horizontal forehead rhytids with the subcutaneous
approach and being able to effectively camouflage the scar with
new hair growth. TFSBFL does not require specialized instru-
mentation, has provided excellent stability, has a moderate
learning curve, and has earned a place in the armamentarium
of the cosmetic facial surgeon.

88
Chapter 5  •  Mini Open Brow Lift
A
B
C
D
FIGURE 5-90.  Patient requested a customized transfollicular subcutaneous brow and forehead lift that would only treat the lateral
brow but not the medial; therefore only lateral incisions were used. These incisions remained visible (A and C) and were treated
with CO2 laser resurfacing, producing excellent improvement (B and D).
FIGURE 5-91.  This patient had several areas of depressed scarring at her incision. These areas were plumped with injectable
silicone oil.

Chapter 5  •  Mini Open Brow Lift
89
A
B
FIGURE 5-92.  A, A tethered depression over the right frontalis muscle after transfollicular subcutaneous brow and forehead lift.
B, The patient after several treatments of subcision and silicone oil injection.
References
  1. Arneja JS, Larson DL, Gosain AK: Aesthetic and reconstructive brow lift:
current techniques, indications, and applications. Ophthal Plast Reconstr
Surg 21:405–411, 2005.
  2. Mottura AA: Open frontal lift: a conservative approach. Aesthetic Plast
Surg 30:381–389, 2006.
  3. Pedroza F, Coelho dos Anjos G, Bedoya M, Rivera M: Update on brow
and forehead lifting. Curr Opin Otolaryngol Head Neck Surg 14:283–288,
2006.
  4. Niechajev I: Transpalpebral browpexy. Plast Reconstr Surg 113:2172–2180,
2004; discussion 2181.
  5. Ellenbogen R: Transcoronal eyebrow lift with concomitant upper blepha-
roplasty. Plast Reconstr Surg 71:490–499, 1983.
  6. Ramirez OM: Why I prefer the endoscopic forehead lift. Plast Reconstr
Surg 100(4):1033–1039, 1997 Sep; discussion 1043–1046.
  7. Vasconez LO, Core GB, Gamboa-Bobadilla M, et al: Endoscopic
techniques in coronal brow lifting. Plast Reconstr Surg 94:788–793,
1994.
  8. Knize DM: Limited-incision forehead lift for eyebrow elevation to enhance
upper blepharoplasty. Plast Reconstr Surg 97:1334–1342, 1996.
  9. Kikkawa DO, Miller SR, Batra MK, Lee AC: Small incision nonendoscopic
browlift. Ophthal Plast Reconstr Surg 16:28–33, 2000.
10. Tabatabi N, Spinelli HM: Limited incision nonendoscopic brow lift. Plast
Reconstr Surg 119:1563–1570, 2007.
11. Wolfe SA, Baird WL: The subcutaneous forehead lift. Plast Reconstr Surg
83:251–256, 1989.
12. Guyuron B: Subcutaneous approach to forehead, brow, and modified
temple incision. Clin Plast Surg 19:461–476, 1992.
13. Ullmann Y, Levy Y: In favor of the subcutaneous forehead lift using the
anterior hairline incision. Aesthetic Plast Surg 22:332–337, 1998.
14. Guyuron B, Behmand RA, Green R: Shortening of the long forehead. Plast
Reconstr Surg 103:218–223, 1999.
15. Miller TA, Rudkin G, Honig M, et al: Lateral subcutaneous brow lift and
interbrow muscle resection: clinical experience and anatomic studies. Plast
Reconstr Surg 105:1120–1127, 2000; discussion 1128.
16. Taylor CO, Lewis JS: Cosmetic surgery of the forehead and brow. In
Fonseca RJ, editor: Oral and maxillofacial surgery, Philadelphia, 2000,
Sanders, p 382.
17. Owsley TG: Subcutaneous trichophytic forehead browlift: the case for
an “open” approach [review]. J Oral Maxillofac Surg 64:1133–1136,
2006.
18. Griffin JE, Jr, Owsley TG: Management of forehead and brow deformities.
Atlas Oral Maxillofac Surg Clin North Am 12:235–251, 2004.
19. Owsley TG: Subcutaneous trichophytic forehead browlift: the case for an
“open” approach. J Oral Maxillofac Surg 64:1133–1136, 2006.
20. Mayer TG, Fleming RW: Fleming-Mayer flap (modified after Juri) forehead
lifting. In Mayer TG, Fleming RW, editors: Aesthetic and reconstructive
surgery of the scalp, St. Louis, 1992, Mosby.
21. Niamtu J: The subcutaneous brow- and forehead-lift: a face-lift for the
forehead and brow. Dermatol Surg 34:1350–1362, 2008.
22. Niamtu J: Post trichial trichophytic incision in subcutaneous brow and
forehead lift. Am J Cosmet Surg 25:110–111, 2008.
23. Camirand A: Hairline incisions. Plast Reconstr Surg 103:736–737, 1999.
24. Camirand A: Why I no longer use short incisions in facial rejuvenation.
Aesthet Surg J 21:65–67, 2001.
25. Camirand A, Doucet J: A comparison between parallel hairline incisions
and perpendicular incisions when performing a face lift. Plast Reconstr Surg
99:10–15, 1997.
26. Burks J: Dermabrasion and chemical peeling in the treatment of certain
cosmetic defects and diseases of the skin, Springfield, IL, 1979, Charles C.
Thomas, pp 148–150.

90
6 
Brow and Forehead Lifting
I
f there is one procedure that can make a patient look great
when done correctly and hideous when not done correctly,
it is brow and forehead lifting. This procedure has been
performed for decades, but many cosmetic surgeons do not
appreciate its benefits or the intricacies of diagnosis and perfor-
mance. A surgeon proficient at brow and forehead lift, with
repeatable aesthetic results, is usually an exceptional surgeon.
Much lore surrounds brow and forehead lift, with many sides
weighing in on whether to perform it at all and if it produces
sufficient longevity. Some dermatologists think they can get the
same results with Botox. Some surgeons think that anyone not
using an endoscope is old school, and some open-brow pro­
ponents believe that endoscopic technique is a short-lived fad.
These issues will be addressed later in this text.
This chapter will focus on endoscopic and open-brow tech-
niques, but there are many other proposed means of upper facial
rejuvenation. The longest-standing brow lift is the coronal brow
lift. Although some surgeons still perform this procedure, it has
largely been displaced by other techniques. Significant problems
with the classic coronal technique include alopecia, unfavorable
scarring, and sensory nerve disturbances. I have seen many
patients over the last 12 years who were treated elsewhere with
coronal technique, and most of them would not do it again.
The lift was not worth the scar, hair changes, and sensory nerve
problems. Far less invasive techniques are now available. Numer-
ous other techniques have been developed for upper facial reju-
venation. Chapter 5 is devoted to my “mini open brow and
forehead lift,” which I think is a great technique.
Direct brow lifts have been done for years in conjunction
with blepharoplasty surgery. The premise of this technique is to
suspend the brow superiorly and attach it to the frontal perios-
teum through the blepharoplasty incision. Most surgeons will
agree this is a very limited technique that poorly controls the
brow and yields short-lived results. Older techniques included
direct midforehead excision brow lifts, in which the surgeon
simply excised some forehead tissue in a horizontal crease or
fold on the forehead or above the eye. This is not a contempo-
rary technique and may be viable on elderly patients, but placing
noticeable scars in the middle of the forehead to excise skin for
brow elevation is not an option with the average patient.
With the growing search for less-invasive methods, the
Contour ThreadLift was introduced in the early 2000s and just
as quickly abandoned for lack of results. Some well-regarded
surgeons still perform suture suspension brow lifting, but this
has not become a mainstream procedure for the average cos-
metic surgeon. Resorbable devices have gained popularity over
the past decade as retention hardware for endoscopic technique
and also for transblepharoplasty brow lift. Although these are
favored by some surgeons, they also have many drawbacks and
have not changed the paradigm of predictable, natural lifting
with acceptable longevity, especially with the transblepharo-
plasty technique.
Upper Facial Diagnosis
Understanding upper facial aging requires insight and experi-
ence, and some seasoned practitioners fail to understand the
intricacies between the forehead, brow, and eyelids. I feel that
in contemporary cosmetic facial surgery, failure to properly
diagnose and treat the ptotic brow and forehead is one of the
most overlooked and underappreciated situations.
Upper facial aging oftentimes occurs earlier than lower facial
aging and represents a complex relationship of changes involv-
ing many different tissues. Our hairline recedes, the skull
shrinks, the forehead wrinkles, the forehead and eyelid tissues
become ptotic and produce hooding and dermatochalasis, the
periorbital fat protrudes, and the skin undergoes actinic and
aging changes. Collectively, these tissues and their respective
changes produce a tired and aged appearance in the upper face.
A general rule is that the youthful female brow should lie above
the superior orbital rim, and the youthful male brow should lie
at the level of the rim. Most cosmetic facial surgeons agree that
an aesthetic lateral brow lies about 5 to 10 mm above the lateral
orbital rim.
Numerous surgical approaches for brow and forehead lifting
have been described over the last 50 years (Figure 6-1). Although
many of these approaches have fallen in and out of favor over
the years, no brow and forehead lift has received more contem-
porary attention than the endoscopic technique.1-14
One problem that exists, even among some very well-known
surgeons, is failure to diagnose ptotic changes in the forehead
and brow. I have seen patients who had blepharoplasty done by
competent surgeons from every specialty when in fact they
needed a browlift. Many of these patients are shocked to find
out that a brow and forehead lift (BFL) option existed and are
disappointed when they realize that after having eyelid skin
removed numerous times, they are no longer candidates for BFL
(Figure 6-2). In essence, these patients have been crippled by
previous excess lid skin removal and cannot have the required
or desired procedure for fear of permanent lagophthalmos. I am
familiar with at least one case of litigation for misdiagnosis and
treatment of a patient who clearly should have been offered a
BFL option but was repeatedly treated with aggressive blepha-
roplasty. Offering patients contemporary options is critical to
competent practice, even if the treating surgeon does not
perform that particular operation.
The average adult in their mid-40s has some component of
brow and forehead ptosis. It is informative to examine youthful
pictures of prospective patients to determine if they in fact ever

Chapter 6  •  Brow and Forehead Lifting
91
you in 2 seconds if they like or dislike the look. “That is exactly
how I used to look, and I miss that” would be an appropriate
response from a patient who appreciates the proposed change.
“I don’t like this, it looks unnatural or surprised” is a common
response from patients who find the anticipated change objec-
tionable. Today’s patients are sophisticated and keyed into
tabloid print and TV and we have all seen well-known celebri-
ties that were overtreated with BFL. This is a significant concern
for many patients that are BFL candidates, and readily so, as
few procedures look as unnatural as an over-elevated BFL.
Another means of predictive illustration for BFL is to recline
the patient to a supine position. In this position, gravity elevates
the brows and is a surprisingly accurate predictor of a postsurgi-
cal result.
When the brow is manually elevated, numerous things occur.
First, the brow is superiorly repositioned, improving appearance
and producing a fresh, youthful, and alert appearance. Second,
the upper eyelid complex is improved in numerous ways. The
elevated brow improves hooding and dermatochalasis because
it stretches the excess skin, providing a more youthful eye.
Lifting the brow repositions the protruding periorbital fat and
improves fat protrusion. The elevated brow also produces a more
had arched or higher-positioned brows. Many patients have
ptotic brows in adulthood, but some may not have had elevated
brows in youth (Figure 6-3).
Surgeons utilize various measurements and in some cases
complicated devices to attempt to quantify brow ptosis and
show where the brow should be. During cosmetic evaluation, I
take a more practical approach and perform a systematic, orderly
evaluation and diagnosis of the entire head and neck. Beginning
from the top and working down to the mid- and lower face has
worked well for me. Many patients present for consultation
thinking they need blepharoplasty when in reality they are BFL
patients. They may find the suggestion of BFL unusual or
foreign and meet it with resistance. “Oh no, I didn’t come here
for anything that drastic, I just want some skin clipped off” is
a common patient response at the mere mention of BFL. Such
responses merit patient education on the complex relationship
between upper facial aging and treatment options.
Sophisticated options are available to show patients a surgical
prediction of BFL, but I have found them to be time misspent.
Simply handing a patient a mirror and manually elevating their
brow into a proposed position gives a pretty accurate idea of
what a postsurgical result may resemble, and a patient can tell
A
B
FIGURE 6-1.  Some of the more popular brow and forehead lift surgical approaches. A illustrates (from superior to inferior) the
coronal approach, the trichophytic approach, and the pretrichal approach. B shows (from superior to inferior) the endoscopic
approach, the midforehead approach, and the direct approach. The latter two surgical approaches are not frequently performed
by most surgeons.
A
B
FIGURE 6-2.  Misdiagnosis of brow and forehead ptosis and excessive upper eyelid skin removal can rule out future options for
patients. A, Patient who requested BFL but previously had overaggressive blepharoplasty by another surgeon. B, When the
brow is elevated in consultation, there is inadequate upper lid skin for closure, limiting surgical options for this patient.

92
Chapter 6  •  Brow and Forehead Lifting
the new look over several hours at home (Figure 6-5). A pho-
tograph with the patient’s brow and forehead relaxed is easily
morphed to an elevated position with digital imaging software,
which can also be used for prediction and patient education. If
the surgeon does not have imaging software, he or she can take
a picture with the assistant elevating the patient’s brow (or
brows), then crop the assistant’s fingers from the picture to
mimic the surgical repositioning (Figure 6-6).
One caveat for the novice brow-lift surgeon (appreciated by
all experienced surgeons) is the fact that it is sometimes impos-
sible to get a female patient to relax their brows. Many females
spend their awake hours in a state of subconscious brow eleva-
tion to the point where they don’t realize their brow is elevated.
The surgeon asks them to relax their brow and they say it is
relaxed, even though their frontalis is wrinkled. Even while
looking in a mirror, some females cannot relax their brow. This
can be frustrating for the surgeon and can also make diagnosis
and treatment less accurate.
Patients Either Like the Look
of Elevated Brows or They Don’t
It sounds painfully simple but is actually a complex factor in
diagnosis and patient acceptance of brow and forehead lifting:
a patient either likes the look of elevated brows or they don’t.
Instead of employing standard classical measurements to deter-
mine brow position, I elevate the patient’s brow with my fingers
to the proposed position and ask if they like it. They can usually
answer in seconds. If they don’t like the result or are not sure,
I don’t consider them “psychological candidates” for brow and
forehead lift. Occasionally a patient will like the result but only
want “half” the amount of brow lift you showed them. I also
take this as a caveat. There is nothing wrong with a conservative
brow lift, but it is impractical to perform a 2-mm brow lift. I
explain to the patient that either they need a brow lift or they
don’t. Since it is difficult to precisely control the amount of
elevation in millimeter increments, the surgeon is better off not
distinct shelf between the ciliary margin and the upper lid
crease. The posed elevation will also stretch the ptotic frontal
skin and improve its appearance. Finally, elevating the midfore-
head will decrease the redundant tissue in the glabellar region,
giving a more youthful appearance. The sum of all of these
lifting changes is a more youthful upper-facial appearance
(Figure 6-4).
Another method to demonstrate predictive brow changes is
simply taping the brow to an elevated position on one or both
sides. This is helpful for some patients, because they can observe
FIGURE 6-3.  The author is shown 40 years after (left) the youthful picture
(right). Note that although there is significant eyelid skin excess, his brow
position has not largely changed.
A
B
FIGURE 6-4.  Manually elevating an aging brow can show the patient how the brow and forehead aesthetics can be improved.
It is important to point out to the patient that in the manual simulation, the brows become more youthfully arched, the upper
eyelid dermatochalasis is improved, and the aging glabella, which becomes wider and redundant, is more youthfully
narrowed.

Chapter 6  •  Brow and Forehead Lifting
93
subject to postsurgical lagophthalmos) and more aggressive lifts
in others.
In the consultation process, the patient must be made aware
of possible complications and sequelae, including overcorrec-
tion, undercorrection, the need for revision surgery, probable
temporary sensory nerve deficit or dysesthesia, temporary or
permanent alopecia at the incision lines, elevation of the hair-
line, the possible need for cranial fixation depending on the type
of lift, and surgical relapse.
All surgeons approach diagnosis and treatment differently,
but one thing that became apparent to me in my early years of
performing brow lift surgery was that virtually all brow-lift
patients also needed blepharoplasty. This would exclude younger
patients or those brow-lift patients whom have had previous
significant upper-lid skin removed. In 99% of my BFL surger-
ies, I am also performing simultaneous upper lid blepharoplasty,
and that fee is included as part of the brow lift. The reasons for
this are multifactorial. Many older patients will still have upper
lid skin excess after surgical brow elevation, so some conserva-
tive removal is advantageous for an aesthetic result. Experienced
surgeons may feel they have done a very successful brow lift—
the brow position was improved, the forehead elevated, the
glabella narrowed—but the patient focuses on the small amount
of upper lid skin redundancy that was not addressed. By per-
forming conservative blepharoplasty with most BFLs, there is a
symbiotic relationship: the brow lift makes the lid look better,
and the conservative blepharoplasty makes the brow look better.
In conjunction, they are a winning combo. Caution must be
exercised so as not to perform aggressive blepharoplasty; only
50% or less skin is removed when performing the BFL with
simultaneous upper blepharoplasty. In a typical case where I
might normally remove 10 to 12 mm of upper eyelid skin if
blepharoplasty were the sole procedure, I will remove 3 to 4 mm
of upper eyelid skin when performing concomitant BFL (Figure
6-7). When performing upper blepharoplasty with simultane-
ous BFL, I do not generally remove upper lid fat unless it is very
excessive. The small skin (and or orbicularis oculi) excision
simply serves to make a more defined brow/lid complex. When
performing blepharoplasty as a sole procedure, some lateral
expansion of the upper blepharoplasty incision is made to
account for lateral upper lid skin. I call this outline a “bird’s
beak” configuration (Figure 6-8, A). Since the excess lateral
upper lid skin is automatically addressed by lateral brow eleva-
tion when performing BFL in conjunction with upper blepha-
roplasty, no lateral incision modification is required. For upper
blepharoplasty in conjunction with BFL, I use a “Napoleon’s
hat” configuration (see Figure 6-8, B).
Other important preoperative details must also be consid-
ered. If the patient currently has a high hairline, they must be
made aware that endoscopic brow and forehead lift (EBFL) will
further elevate their hairline. If they are uncomfortable with
this, a trichophytic brow lift (described later in this chapter) is
preferred because it does not elevate the hairline. General hair
issues are always a concern. For example, almost all adult males
have some component of hairline recession. Although many
surgeons treat male patients with EBFL, it has been a rarity in
my practice. I know surgeons who say they routinely perform
EBFLs on males with pattern baldness, but I have chosen not
treating a patient who wants “half a brow lift.” This type of
patient is likely to feel they are overcorrected with the normal
amount of lift or feel they had no benefit from the surgery if a
small lift is achieved. The lesson is that if a patient dislikes the
look of brows elevated by finger traction, they may be unhappy
with any result. Having said that, it is reasonable to perform
conservative lifts in some patients (especially those who may be
FIGURE 6-5.  Taping the patient’s brow in an elevated position can help the
patient decide whether they like the proposed result.
A
B
FIGURE 6-6  A, A simple means of “morphing” a ptotic brow to an elevated
position is to have an assistant use the fingers to manually elevate the
brow. B, The picture is then cropped to “remove” the assistant’s visible
fingers, leaving a predictive picture.

94
Chapter 6  •  Brow and Forehead Lifting
Higher hairlines with frontal bossing or a very convex
forehead also complicate endoscopic technique insofar as the
straight endoscope is tangent to the arc of the frontal bone, and
it can be difficult to navigate the scope and instruments in this
situation. In these cases, I would be more apt to pursue a tricho-
phytic approach.
Endoscopic Brow and Forehead
Surgical Procedure
The evolution of endoscopically assisted brow and forehead lift
is well detailed, and numerous changes have been employed
since its inception.1-14
Instrumentation
When I wrote this type of chapter 12 years ago, I needed to be
very precise in terms of what equipment was required and avail-
able. At that time, EBFL was in its infancy, and most practicing
surgeons had not received residency training in the technique.
It was therefore necessary to be extremely specific about equip-
ment. Now that EBFL has become a frontline technique, the
available cameras, scopes, light sources, and surgical instruments
are refined and readily available. Realizing this, I will not spend
significant time in this chapter discussing armamentaria. I will
say that for the recent graduate with limited funds, discounted
or free used endoscopic equipment may be available from their
local hospital. Many specialties utilize cameras, scopes, and light
sources, and some hospitals and factory reps have older but
well-functioning equipment they are happy to part with. A
15-cm, 30-degree endoscope is preferred for EBFL. A decent
camera, scope, and light source are mandatory for a clear image
and precise surgical technique. Figure 6-9 shows an endoscope
and two popular types of sheaths with terminal retractors to
keep the soft tissue from obscuring the endoscopic field.
to. Perhaps being follicularly challenged heightens my sensitivity
to defacing someone’s scalp with incisions that will be forever
visible. If there is any hint of an unstable hairline, I shy away
from brow lift in males or females unless they are considering
a hairpiece.
10 mm
10 mm
FIGURE 6-7.  In the normal patient without BFL, 20 mm of skin is required
to close the lid; skin in excess of that can be removed. When performing
simultaneous blepharoplasty and browlift, much less skin is excised. When
performing blepharoplasty without brow lift, 10 to 12 mm of excess upper
lid skin is often excised (blue outline), but when performing simultaneous
BFL, about one third to one fourth of that normal amount is excised so as
not to cause lagophthalmos.
A
B
FIGURE 6-8.  A, Normal incision outline when per-
forming isolated blepharoplasty, which employs an
upsweep of the lateral incision that somewhat
addresses skin hooding. There is no need for this
upsweep when performing browlift with blepharo-
plasty; the brow lift addresses hooding. B, The
incision geometry when performing browlift and
simultaneous blepharoplasty.

Chapter 6  •  Brow and Forehead Lifting
95
Surgical Procedure
All EBFL patients are placed on preoperative antibiotics begin-
ning 24 to 48 hours preop and are given instructions to wash
the body and hair with antibacterial soap the night before and
morning of surgery. A preoperative series of pictures is taken,
with care to have the patient in neutral brow position. The hair
is combed back into a ponytail and parted at the temporal tuft
region for the temporal incisions.
Various surgeons utilize different markings and incisions. I
prefer to make three frontal incisions, one central at the midline
(Figure 6-13, 1) and two lateral incisions that correspond to the
approximate area of maximum desired brow elevation. This
most frequently corresponds to an imaginary line tangent to the
lateral limbus (see Figure 6-13, 2) and also to the junction of
Although a vast array of instruments are available for EBFL,
in reality, very few are necessary. A simple Molt Number 9
periosteal elevator can be used for about 80% of the subperios-
teal dissection (Figure 6-10). Numerous other instruments
facilitate subperiosteal dissection, especially around nerve trunks
and orbital rims (see Figure 6-10). Multiple instruments are also
available for incising periosteum and brow-depressor muscula-
ture (Figure 6-11).
Over the past 5 years, widescreen plasma and LCD television
monitors have become very affordable. These monitors have
been welcome additions to the cosmetic surgery office for
numerous reasons, including patient entertainment while
waiting, patient education and marketing, monitoring vital
signs during anesthesia, and endoscopic surgery (Figure 6-12).
A
B
C
FIGURE 6-9.  A, A common 15-cm, 30-degree endoscope. B, A camera
sheath with a soft-tissue retractor on the end designed to keep the supe-
rior tissues from obscuring the lens. C, A right-angle sheath that also
allows more efficient soft-tissue retraction. The pistol-grip sheath can be
useful in retracting the soft tissues as well as for camera stabilization by
the surgeon or assistant.
1
2
3
4
5
6
7
FIGURE 6-10.  Although hundreds of endoscopic brow and forehead lift
instruments are available, most are not necessary. The dissectors shown
are routinely used by the author. 1, Molt #9 periosteal elevator; 2, sharp
dissector for frontozygomatic region; 3, Batwing dissector for areas of
broad subperiosteal dissection such as the vertex; 4-5, smaller spoon
dissectors for subperiosteal dissection around smaller structures and
areas; 6, fine dissector with down-curved tip to elevate arcus marginalis
from superior orbital rim; 7, optional surgical knife to incise supraorbital
periosteum.
A
B
A
A
B
B
C
C
FIGURE 6-11.  Endoscopic brow and forehead lift requires the ability to precisely incise periosteum and brow-depressor mus-
culature, frequently in close proximity to neurovascular structures. Instruments used to do this include CO2 laser waveguides
(not pictured), endoscopic knife (A), Ellman radiowave long, curved microtipped electrode (B), and proprietary long, bendable
electrosurgery knife/suction devices (C).

96
Chapter 6  •  Brow and Forehead Lifting
descriptions, it is important for the surgeon to keep in mind
that each patient presents a different situation, and the lateral
frontal incisions should be in the anticipated region of maximum
brow elevation. Similarly, the temporal incisions should be
placed in a direction that will maximally elevate the lateral brow
when placed under tension.
The actual incision is first infiltrated with local anesthesia
and then made directly through periosteum with a scalpel.
It is important to place the incision far enough behind the
hairline to hide it but not too far posteriorly to make endoscopic
access difficult. Also, the incision should be long enough for
proper access. A too-small incision not only limits access of the
scope and instruments, it is also traumatic to the surrounding
scalp and hair follicles. The old surgical adage that incisions heal
from side to side, not end to end applies here. The hair follicles
must be continually protected from abrasion and tension from
the scope, instruments, and drill shafts. Although it is conve-
nient, the surgeon and staff should refrain from using the
hair to elevate the incision for portal entry. Damage to the
hair follicles and related postincision hair loss is an avoidable
complication. A small, wire eyelid speculum serves as a conve-
nient retractor to keep the wound open for entry and fixation
(Figure 6-15).11
After the patient is sedated, the entire region to be dissected
(central and lateral optical cavities) is infiltrated with tumescent
anesthesia at the periosteal level (Figure 6-16), and the incision
sites are infiltrated with 2% lidocaine with epinephrine in all
planes. Generally, all the incisions are made at the same time so
that the scalpel/incision portion of the surgery is completed.
Figure 6-17 shows the actual surgical incisions on a live patient.
Although most incisions are straight-line vertical, some sur-
geons prefer horizontal access incisions for the central and
lateral incisions. I also frequently utilize an elliptical tissue exci-
sion for the temporal incisions. Since many patients have excess
skin and scalp in this region, an ellipse of tissue is removed,
leaving an elliptical incision that when closed can assist with
tightening in the lateral brow areas (Figure 6-18). The initial
incision is made just to the subcutaneous plane and the ellipse
the central and lateral third of the brow. Two temporal incisions
are also made. These incisions are about 3-4 cm long and per-
pendicular to an imaginary line drawn through the ala and
canthus (see Figure 6-13, 3). It is also helpful to draw the
approximate position of the supraorbital and supratrochlear
nerves on the soft tissue over their hard-tissue landmarks (Figure
6-14). The supratrochlear nerve is located approximately 17 mm
lateral to the glabellar midline and the supraorbital nerve is
located approximately 27 mm lateral to the glabellar midline.
Although all of these incisions are relatively standard in text
A
B
FIGURE 6-12.  Widescreen television monitors are very useful in the operating suite for monitoring vital signs, displaying “time
out” patient information, and for endoscopic surgery. A, Endoscope in place. B, Widescreen TV monitor, which facilitates vision
for everyone in the room.
1
2
3
FIGURE 6-13.  Preoperative planning provides for incisions to be placed
about 2 cm posterior to the actual hairline. One incision is placed in the
midline (1); one incision is placed on either side of the head tangent to
the lateral limbus (2). A temporal incision is also placed on either side,
perpendicular to a line traversing the ala and canthus (3).

Chapter 6  •  Brow and Forehead Lifting
97
is removed. It is imperative to protect the frontal nerve when
working in this area.
If blepharoplasty is performed, it is very convenient to
perform some of the subperiosteal dissection through the eyelid
incision. This can accelerate and facilitate the “blind” frontal
dissection. In reality, most of the endoscopic EBFL can be
performed without an endoscope if the neurovascular bundles
are identified and preserved. Some surgeons isolate the supra-
trochlear and supraorbital nerves from the blepharoplasty inci-
sion and perform the entire procedure without ever using an
endoscope. This approach is optional and not an integral part
of EBFL. Much of the EBFL can be done without endoscopic
vision. When beginning transblepharoplasty dissection, the first
ST
SO
17 mm
27 mm
IT
SO
ST
IT
A
B
FIGURE 6-14.  A, The supratrochlear nerve, which exits the skull approximately 17 mm lateral to the midline, and the supraorbital
nerve, which exits the skull about 27 mm lateral to the midline. B, The sensory dermatome of these nerves.
FIGURE 6-15.  A wire eyelid speculum serves as an excellent self-retaining
retractor for endoscopic brow and forehead lift incisions.
FIGURE 6-16.  Tumescent anesthesia is injected in all anticipated planes of
dissection, and concentrated local anesthesia with epinephrine is injected
in the actual incision lines.
step is to incise through periosteum at the lateral orbital rim
(Figure 6-19).
Subperiosteal dissection is then begun medially over the
superior orbital rim to isolate the supraorbital nerve (Figure
6-20). Much of the frontal dissection can then be performed
superiorly and laterally (Figure 6-21).
A wide array of endoscopic instrumentation exists, and most
of what is used is personal preference. In some cases, the surgeon

98
Chapter 6  •  Brow and Forehead Lifting
A
B
FIGURE 6-17.  Frontal incisions (A) and lateral incisions (B) commonly used in endoscopic brow and forehead surgery.
A
B
FIGURE 6-18.  A, A temporal incision that excises a skin ellipse instead of a simple straight-line incision. B, The central tissue
is excised, and the resultant excision will result in local skin tightening that can assist in lateral brow elevation.
FIGURE 6-19.  A subperiosteal incision is made through the blepharoplasty
over the frontozygomatic suture region.
FIGURE 6-20.  The supraorbital neurovascular bundle is isolated and pro-
tected through the blepharoplasty incision.

Chapter 6  •  Brow and Forehead Lifting
99
A
B
FIGURE 6-21.  Much of the frontal dissection and the
lateral orbital rim dissection can be made through the
blepharoplasty incision if desired.
can have too many instruments. Figure 6-22 shows common
hand dissectors and close-ups of common dissector tips.
The pictured instrumentation is my basic endoscopic
instrumentation.
Once all the incisions are made, the initial goal is to create
the optical dissection pockets (Figure 6-23). Important tenets
of EBFL surgery are to stay in the subperiosteal plane for the
central optical pocket dissection and to stay intimate to the
superficial layer of the deep temporal fascia when dissecting
the temporal optical pockets. Staying in these prescribed tissue
planes will protect the frontal branch of the facial nerve.
Bone suture lines serve as dissection landmarks, and the
surgeon should be familiar with the frontozygomatic sutures,
which will be the inferior extent of the lateral orbital rim dis-
section (unless a midface procedure is planned); the coronal
suture, which will be the superior extent of the frontal dissec-
tion; and the nasofrontal suture, which will be the inferior
extent of dissection in the frontal region.
The initial dissection is begun with a Molt #9 periosteal
elevator, a curved spoon dissector or a curved thumbnail or
“batwing” dissector (Figure 6-24). It is imperative that the
instrument immediately enter the subperiosteal plane. When in
the correct plane, a scratching sound is heard as the instrument
moves across the bone. The first vector of dissection is superior
and extends to the cranial vertex while staying between the
temporal crests. This region is a safe plane and without signifi-
cant anatomy; it can be safely dissected “blindly” in less than
90 seconds. The elevator is moved laterally between the tempo-
ral crests to enlarge the pocket (Figure 6-25). The instrument is
then angled inferiorly and blind dissection continues to a point
2 to 3 cm short of the superior orbital rims to protect the neu-
rovascular bundles (Figures 6-26 and 6-27). In the midline,
dissection can proceed to the nasal radix (bridge of the nose) in
a blind fashion because this area lies medial to the supratrochlear
nerves. If the supratrochlear and supraorbital nerves exit bony
notches, they are less vulnerable; when dissecting, they are fre-
quently pushed forward. If these nerves exit a foramen instead
of a notch, then the nerve trunk can be more easily disrupted
as the dissector moves across the foramen and nerve. It is fre-
quently possible to palpate the supraorbital notch in many
patients, and this can be marked on the skin for guidance.
Figure 6-28 shows the supraorbital nerve exiting the notch in
the subperiosteal endoscopic view. It is important to note that
the supraorbital nerve has two branches after exiting the
foramen. The deep (also called lateral) division innervates the
more lateral and posterior portion of the forehead and scalp,
and a superficial division (also called medial) pierces the frontalis
muscle and runs superficially along the muscle and innervates
the forehead along the midpupillary line.
The location of the supraorbital nerve’s exit is relatively con-
sistent. The supraorbital foramen or notch is typically found
within 1 mm of a line drawn in a saggital plane tangential to
the medial limbus. The deep division has been known to exit as
often as 10% from another foramen that can be as high as
1.5 cm above the orbital rim. The supratrochlear nerves exit
from around the orbital rim at an average of 9 mm medial to
the exit of the supraorbital nerve. The nerves supply sensation
to the midforehead, with some overlap from the supraorbital
nerves. Infratrochlear nerves, also from division one of the tri-
geminal nerve, exit just below the supratrochlear nerves around
the medial orbital rim to supply sensation to the upper nose
and medial orbit.6,7
When working around the nerves, smaller spoon dissectors
are utilized for greater precision (Figure 6-29). For the endo-
scopic brow technique to be successful, all adhesions and attach-
ments must be freed, including the arcus marginalis at the
superior orbital rim. Curved-tip instruments facilitate dissection
over the shelf of the superior orbital rim, and it is imperative to
separate this attachment. Figures 6-30 and 6-31 show curved
dissectors negotiating the arcus marginalis at the superior orbital

100
Chapter 6  •  Brow and Forehead Lifting
*
A
B
FIGURE 6-22.  A, Common ergonomic-handled endoscopic dissectors. B, Close-up views of common dissector tips.
A
B
FIGURE 6-23.  The central optical cavity, which extends from the orbital rims inferiorly to the vertex of the skull superiorly and
lies medial to the temporal crests. The blue color represents the area that can be “blindly” dissected (without endoscopic
assistance), and the red area shows the region that typically is done with endoscopic guidance, owing to the presence of the
neurovascular structures. The yellow areas represent the temporal optical pockets.
A
B
C
FIGURE 6-24.  A #9 periosteal elevator is used to begin the dissection circumferentially around the frontal incisions.

Chapter 6  •  Brow and Forehead Lifting
101
A
B
FIGURE 6-27.  The subperiosteal dissection over the frontal area is performed with a large, blunt dissector.
A
B
C
FIGURE 6-25.  The initial frontal dissection is performed with a larger elevator, and the periosteum is elevated to the vertex of
the skull and laterally between the temporal crests.
A
B
C
FIGURE 6-26.  The brow region is dissected “blindly” to a point several centimeters above the sensory neurovascular bundles
(yellow stippled areas). At this point, the endoscope is inserted to perform the precise dissection around the supraorbital and
supratrochlear nerves.

102
Chapter 6  •  Brow and Forehead Lifting
A
B
FIGURE 6-28.  The supraorbital nerve is shown in an endoscopic subperiosteal view. A, The nerve exits a foramen. B, The nerve
exits a notch (which is the more common situation).
A
B
FIGURE 6-29.  A, A narrow spoon-type dissector used for greater precision around the sensory nerves. B, An arcus marginalis
dissector with a curved tip. Insert shows an endoscopic view of working around the supraorbital nerve.
A
B
FIGURE 6-30.  Various curved-tipped dissectors used to free the arcus marginalis from the superior orbital rim. This maneuver
is imperative for successful release and browlift, and the curved instruments facilitate the dissection.

Chapter 6  •  Brow and Forehead Lifting
103
planes come together in this region and are approached from
the frontal and temporal access incisions. I prefer to initially
dissect the dense lateral rim periosteum with a small, sharp-
edged flat dissector (same instrument shown in Figure 6-32).
This instrument with its small, flat head allows precise dissection
of these tightly attached tissues. The finger and thumb are
placed on either side of the lateral orbital rim to protect the
globe, should the instrument slip off the bone. Figures 6-33 and
6-34 show a representation of the area to be dissected on the
lateral orbital rim. This region will also be addressed from the
temporal incision.
After the central optical pocket is dissected, the temporal
dissections are performed. Surgeons vary on the order of these
dissections and may follow a different order of approach.
The frontal branch of the temporal nerve lies in the superfi-
cial fascia (temporoparietal fascia), which is the spiderweb-like
loose areolar tissue found beneath the dermis and above the
superficial layer of the deep temporal fascia. Realizing that the
frontal branch lies in this plane, the goal of the remainder of
the dissection is to stay directly on top of the superficial layer
of the deep temporal fascia (deep to the nerve branches) when
over the temporalis muscle (Figure 6-35). Figure 6-36 shows a
cadaver dissection with a hemostat placed under the temporo-
parietal fascia. A representation of the frontal branch of the
facial nerve that runs in that layer is illustrated.
Some surgeons prefer to make a small incision in this
superficial layer of the deep temporal fascia to confirm the
underlying muscle, thereby verifying the correct layer had
been previously reached. The correct layer is the shiny layer
of the superficial layer of the deep temporal fascia (shown in
Figure 6-35, C).
Much of the temporal dissection can be done with indirect
vision and can be performed with blunt spoon dissectors or
rim. When the arcus marginalis is free, the instrument will enter
the upper eyelid, and the assistant must protect the globe from
inadvertent trauma. If simultaneous blepharoplasty has been
performed and the incision is still open, the instrument will be
contiguous with this space (Figure 6-32).
One of the biggest problems in EBFL is incomplete dissec-
tion of the lateral orbital rim regions. Many connective-tissue
A
B
FIGURE 6-31.  The curved dissector (A) and intraoperatively (B).
FIGURE 6-32.  When the arcus marginalis is properly dissected, the instru-
ment will enter the upper eyelid. If concomitant blepharoplasty has been
performed, the instrument will exit the upper lid incision.

104
Chapter 6  •  Brow and Forehead Lifting
zygomatic arch in proximity to the lateral zygomatic temporal
vein.
At the region of the frontozygomatic suture, the superficial
layer of the deep temporal fascia leads to the periosteum of the
lateral orbital rim. While hugging the superficial layer of the
deep temporal fascia, the surgeon sounds the bone of the lateral
orbital rim and by twisting the periosteal elevator, tunnels under
the periosteum of the lateral orbital rim. This is a “safe” layer in
terms of avoiding significant anatomy, although it can be close
to the sentinel vein if proceeding laterally to the frontozygo-
matic suture region. Once the bone of the lateral orbital rim is
encountered, the subperiosteal dissection can be continued into
the malar region (Figure 6-39).
other specialized instruments. Direct endoscopic vision is pref-
erable as the inferior dissection proceeds towards the zygomatic
arch and the anterior dissection proceeds to the lateral orbital
rim regions.
The temporal dissection hugs the superficial layer of the deep
temporal fascia and progresses inferiorly to about the level of
the zygomatic arch (Figure 6-37 and 6-38). Blind dissection can
be performed to a level about 2 cm above the zygomatic arch.
At this point, owing to the presence of significant anatomy,
endoscopic visualization should be employed to the level of the
zygomatic arch. The lateral zygomatic temporal vein can be
encountered at the level of the zygomatic arch. The temporal
branch of the facial nerve exits the periosteum just above the
A
B
FIGURE 6-33.  The dense periosteal attachments at the lateral orbital rim must be totally freed for successful lateral brow
elevation.
A
B
FIGURE 6-34.  An intraoperative view of the lateral orbital rim dissection and related instrument.

Chapter 6  •  Brow and Forehead Lifting
105
(sometimes called conjoined ) tendon (also called the temporal
fusion line), which represents a fusion of the temporoparietal
fascia (superficial fascia) and the superficial layer of the deep
temporal fascia. This structure would be at the junction of the
blue and yellow areas in Figure 6-23. This can be a dense con-
nective-tissue band and especially difficult to dissect as it
approaches the lateral orbital rim. Although some surgeons
prefer to do this step under endoscopic vision, it is not necessary
and can easily be performed with a simple periosteal elevator,
facelift scissors, or the surgeon’s index finger in most cases. This
is true for the more superior portion of this structure, but as it
approaches the orbital rim, it becomes more dense and sur-
rounds other anatomy, requiring endoscopic vision. In addition,
excessive tissue stretching in this region can cause damage to the
frontal nerve, so care must be used.
The temporal fusion line (conjoint fascia) must be breached
to join the central and temporal dissections. It is preferable to
approach the frontal dissection from the temporal pocket, not
vice versa (Figure 6-41), because when going from bone to soft
tissue (frontal to temporal), it is possible to place the dissecting
instrument into unpredictable soft-tissue layers.
On the contrary, when dissection proceeds from the correct
temporal soft-tissue plane (temporal to frontal), breaking
through the conjoined fascia to bone allows the precise transi-
tion of tissue planes. Figure 6-42 shows an endoscopic view
from the frontal optical cavity. It shows a dissector perforating
the conjoint fascia from the temporal optical cavity.
The next step involves the final transection of the
remaining adhesions in the lateral orbital rim region. Even with
complete dissection of the frontal and temporal regions, remnant
adhesions are encountered in the lateral orbital rim and fronto-
zygomatic regions. If these adhesions are not released, it is
impossible to adequately elevate the lateral brow. Failure to
appreciate and address these adhesions can cause the endoscopic
brow lift to fail. Practitioners who say endoscopic brow lift does
Caution must be used when dissecting lateral to the lateral
orbital rim and frontozygomatic regions; the frontal branch
of the facial nerve is vulnerable here. The medial zygomatic
temporal vein (so-called sentinel vein) is a direct tributary of
the internal maxillary vein and predictably lies about 1 cm
lateral to the frontozygomatic suture. In addition, the medial
zygomaticotemporal nerve, a sensory branch of the fifth cranial
nerve, can travel in close approximation to the sentinel vein.
The sentinel vein is a cautionary region for the associated
anatomy described above, hence the name (Figure 6-40).
The operator should anticipate the vein and protect or cauterize
it. It can present bleeding that is difficult to control
endoscopically.
The next step is to connect the central and temporal optical
cavities. These spaces are separated by the so-called conjoint
A
B
C
FIGURE 6-35.  The frontal nerve lies in the temporoparietal fascia (also called superficial fascia), which appears as loose, spongy
areolar “spiderweb” tissue (A). This tissue is successively spread with a hemostat (B) until the shiny layer of the superficial
layer of deep temporal fascia is reached (C).
FIGURE 6-36.  A hemostat is placed under the temporoparietal fascia
(superficial fascia), which contains the frontal branch of the facial nerve.

106
Chapter 6  •  Brow and Forehead Lifting
addressed, periosteal release is performed superior and lateral to
the orbital rims and across the nasal radix. This maneuver allows
additional release of the brow and forehead tissues and allows
more freedom for elevation and fixation.
Previous dissection above the orbital rims in the subperios-
teal plane should have exposed the entire superior orbital rim
from each zygomaticofrontal suture. The curvature of the rims
should be visualized so that transection through the periosteum
can be made at the level of the rims. If deep horizontal forehead
wrinkles are present, some surgeons also make horizontal peri-
osteal incisions more superiorly along the frontalis. When tran-
secting through the periosteum across the entire orbital rim,
subgaleal fat is often encountered initially, except when the
transection is directly behind the supraorbital nerve at the rim
level where the deep (or lateral) division of the nerve is closely
not work may have failed to address this region. As outlined
previously, the lateral orbital rim and associated region is
addressed from both the frontal and temporal dissection pockets.
I prefer to address this area with endoscopic vision by placing
the scope in the lateral incision and using fine-tipped scissors
placed through the temporal pocket (Figure 6-43). When these
adhesions are properly released, the tissues in this region are
totally mobilized (Figure 6-44).
A means to determine whether adequate release has been
performed is to insert the index finger into the lateral orbital
rim area. The finger should pass into the lateral canthal region
unobstructed by the adhesions (Figure 6-45). Figure 6-46 shows
bilateral release of lateral orbital adhesions.
Once the frontal and temporal dissections are complete, the
conjoint fascia is transected, and the lateral orbital adhesions
A
B
FIGURE 6-37.  When the superficial layer of the deep temporal fascia is identified, the dissection is intimate to this layer lying
inferior to the temporoparietal fascia, which contains the frontal branch of the facial nerve. The dissection proceeds inferiorly
to a level just above the zygomatic arch. The dissection then proceeds anteriorly and will be lateral to the lateral orbital rim.
A
B
FIGURE 6-38.  Intraoperative temporal optical pocket dissection and a related instrument.

Chapter 6  •  Brow and Forehead Lifting
107
curved electrosurgical and radiowave microneedles, and curved
miniblades (Figure 6-47). Figure 6-48 shows the position of a
curved incision/suction device used to incise the supraorbital
periosteum. Figure 6-49 shows a rendering of the supraorbital
periosteum being incised with a curved miniblade. When the
periosteum is incised, the galeal fat pad is frequently encoun-
tered and can serve as a landmark because it lies below the
transverse head of the corrugator supercilii muscle. Figure 6-50
adherent to periosteum. Preoperatively marking a point on the
brow at a level tangential to the medial limbus iris facilitates
easy identification of the location of supraorbital vessels and
nerves.6,7 Dissection through the periosteum in this region
should be performed slowly and superficially to avoid injury to
these structures.
Numerous instruments are available for the supraorbital
periosteal incision, including laser wave guides, curved scissors,
FIGURE 6-39.  The temporal dissection is performed hugging the superficial
layer of the deep temporal fascia until the periosteum of the lateral orbital
rim is encountered. At this point, the periosteal elevator is used to burrow
under the periosteum, and safe dissection can proceed to the malar region
if desired.
FIGURE 6-40.  The temporal (blue) and periorbital (green) ligamentous
attachments that are firmly bound to the bone and require complete
release. A, temporal ligamentous adhesions; B, orbital ligamentous attach-
ments; C, sentinel vein; D, temporal branch of the facial nerve, and
E, zygomaticotemporal vein.
A
D
C
E
B
FIGURE 6-41.  The conjoint fascia requires complete transection from the
vertex to the orbit. It is best approached from temporal to lateral (A) and
then requires anterior/posterior release (B).
FIGURE 6-42.  This endoscopic image is made with the scope in the frontal
optical cavity, looking at an instrument piercing the conjoint fascia from the
temporal side.

108
Chapter 6  •  Brow and Forehead Lifting
A
B
FIGURE 6-43.  Releasing the connective tissue adhesions in the lateral orbital region is paramount to endoscopic brow lift effec-
tiveness and stability. Seen here are scissors cutting these adhesions through the temporal pocket under endoscopic vision
from the lateral frontal incision.
A
B
FIGURE 6-44.  Contiguous extension of frontal and temporal optical cavities in the lateral orbital region.
A
B
FIGURE 6-45.  A, Index finger encountering lateral orbital rim adhesions. B, Finger inserted after adhesions have been adequately
released.

Chapter 6  •  Brow and Forehead Lifting
109
FIGURE 6-46.  Bilateral release of significant adhesions in the lateral orbital
region.
A
A
B
B
C
C
A
B
FIGURE 6-47.  Left, Curved miniblade (A), curved radiowave microneedle (B), and a curved radiowave blade with attached
smoke evacuator (C). Right, Close-up of the tips of these instruments.
FIGURE 6-48.  Curved cutting instruments facilitate the utilization of this
radiowave incision and suction device.
FIGURE 6-49.  Demonstrated here is the incision of the supraorbital perios-
teum with a miniblade. Insert shows the endoscopic view.
FIGURE 6-50.  Electrosurgical microneedle incision of the supraorbital peri-
osteum. The dotted line shows the incised edges that have already been
cut on the patient’s right frontal region.

110
Chapter 6  •  Brow and Forehead Lifting
isolated, different surgeons do different things. Some totally
remove as much of the musculature as possible using endoscopic
forceps (Figure 6-55). Others prefer to merely disrupt the
depressors by incising across the muscle mass (Figures 6-56 and
6-57). The exact treatment of the depressors is controversial.
Some surgeons do not address them at all, and many brow and
forehead lift patients are regular Botox users, which keeps the
muscle contraction at bey. Excessive removal or disruption of
the depressors can be problematic and cause the glabellar region
and medial brows to splay apart or produce unnatural anima-
tion. Some surgeons who advocate extreme removal of these
muscles also use glabellar implants to fill in overtreated glabellar
depression. I personally perform moderate disruption of these
muscles but do not advocate radical ablation; I do not think
remaining muscle action in the glabella is paramount in EBFL
relapse. In most patients, the goal is to elevate the lateral brow.
shows the supraorbital periosteum incised with an electrosur-
gery microneedle Incision of the lateral orbicularis oculi muscle
is performed to further release the tissues.
At this point, all dissections are completed, and the supraor-
bital periosteum is released. The next step is to further release
the incised supraorbital periosteum by stretching it with a back-
action elevator (Figures 6-51 and 6-52). This maneuver allows
further tissue release and stretches the area between the perios-
teal incision. The elevator is inserted and superior traction
applied. Figure 6-53 shows endoscopic views of the stretching
of the periosteal incision.
With the supraorbital periosteum incised and stretched, the
brow-depressor musculature (corrugators, procerus) is accessible
(Figure 6-54). Further dissection toward the frontal skin may
be necessary to view the depressors. This can be done with any
of the aforementioned modalities. When the muscles are
A
B
FIGURE 6-51.  After the supraorbital periosteum is incised, a back-action elevator is used to stretch the incision for further release.
A
B
FIGURE 6-52.  A, Back-action elevator. B, Intraoperative view.

Chapter 6  •  Brow and Forehead Lifting
111
A
B
FIGURE 6-53.  Endoscopic views of the back-action stretching of the supraorbital periosteal incision.
F
P
C
C
FIGURE 6-54.  Cadaveric dissection showing the brow-depressor muscles
and the frontalis muscle (F), which is a brow elevator. The depressor
muscles have a similar position when viewed endoscopically after the
periosteum is incised. C, Corrugator supercilli muscle; P, procenus
muscle.
FIGURE 6-55.  Endoscopic view of a microforceps ablating portions of the
brow-depressor musculature.
P
P
N
N
C
A
B
FIGURE 6-56.  Endoscopic image showing the procerus muscle (P) in the
midline, the right-sided supraorbital neurovascular bundle (N), and the
corrugator supercilii muscle (C). The top image shows the corrugator being
treated with a laser, and the lower image shows the transected corrugator.
(Courtesy Angelo Cuzalina, MD, DDS.)
Significant elevation of the medial brow produces a surprised
look and is usually avoided. Having said this, it would make
sense that remaining central depressor muscular activity should
not have a great effect in pulling the laterally elevated brow back
down. I do prefer preoperative neurotoxin treatment for my
EBFL patients, because I think healing and superior periosteal

112
Chapter 6  •  Brow and Forehead Lifting
repositioning is facilitated when immediate postoperative move-
ment is minimized Incising the lateral orbicularis oculi muscle,
which does make sense in preventing lateral brow relapse.
The transverse head of the corrugator supercilii is seen at the
orbital rim level behind the supraorbital vessels and nerves. The
corrugator supercilii can be carefully transected or partially
excised. Medially, the oblique head of the corrugators is encoun-
tered, and by a transection through this portion of muscle, the
supratrochlear nerve and depressor supercilii muscle may be
seen and protected from injury. Medially in the glabella, the
procerus muscle, which is variable in thickness, is seen. Care
should be taken to avoid overaggressive muscle resection in thin
patients, because this can result in an atrophic defect in the
glabella.6
Fixation Techniques
At this point in the operation, the brow should be totally
released in all dimensions. Since the patient is in the supine
position on the operating table, the brows are usually passive in
the elevated position. The next and last step is to fixate the
frontal and temporal regions to the desired elevated position.
Although the vast majority of surgeons perform some type of
stable fixation, some surgeons do not advocate any suspension
and fixation to deeper tissues.8 This has never made sense to me,
and I have yet to perform this procedure without stable deep
tissue fixation.
Numerous fixation methods exist and are the preference of
the surgeon based on his or her ability, expertise, and instru-
mentation. Many fixation methods require drilling into the
outer table of the calvarium. The safest location for bone tunnels
or screws is located along a parasagittal line at approximately
the midpupil or lateral limbus line and just anterior to the
coronal suture.5 This can be safely performed at the lateral
A
B
SO
ST
IT
FIGURE 6-57.  A rendition of incisional disruption of the brow depressors and lateral orbicularis oculi muscle. A, The approximate
position of the brow depressors. B, The proposed transection incisions.
incisions; 4 mm is considered a safe depth. Because the saggital
sinus traverses the midline of the inner skull, midline screws are
generally not placed (Figure 6-58). Numerous venous lakes are
frequently encountered in the midline, which is another reason
to avoid midline fixation. The thinnest portion of the skull is
over the squamous portion of the temporal bone, which also
FIGURE 6-58.  The interior surface of the human calvarium. Midline drill holes
are generally not placed, because the saggital sinus and numerous
venous lakes can underlie the midline.

Chapter 6  •  Brow and Forehead Lifting
113
no blunt or sharp ends protrude (Figure 6-63). Switching to 2-0
or 0 Vicryl suture prevents suture perforation.
When initially described, the EBFL was fixated with long
screws or posts. When using this type of fixation, a skin hook
is placed in the cephalad portion of the lateral incisions in the
frontal region. Traction is placed on the skin hook, which ele-
vates the brow. A screw-off post is then inserted in the cranial
bone, and with the scalp under tension, a staple is placed behind
the screw to maintain the elevation when the skin hook is
released (Figure 6-64). Although this is an effective means of
temporary fixation, the tension on the scalp can cause alopecia,
and the thought of having screws protruding from the head for
2 weeks is disconcerting to most patients.
Bone tunnels are also another popular means of EBFL
fixation (Figure 6-65). These are economical (no specialized
material is required) but also challenging for those surgeons
who are not familiar with bone drilling. A Stryker 1.2-mm
cross-cut fissure bur (ref 2296-101-212) is used with an electric
drill to make the tunnel. Some surgeons make tunnels horizon-
tal to the brow, but I make them vertical. The tunnels do not
exceed 4 to 5 mm in depth. After the tunnels are drilled, I use
a curette or small round bur to “dull” the posterior bone bridge
that joins the tunnel so it does not lacerate the suture with a
sharp edge.
The Endotine fixation device (Coapt Systems, Palo Alto,
CA) is favored by some surgeons and involves a spiked resorb-
able plate with the spikes arranged at an angle that will skewer
and hold the scalp in an elevated position (Figure 6-66). This
system has gone through numerous modifications, with smaller
plates that dissolve at a faster rate. Proponents say that this
device allows a larger area of fixation and distributes the forces
when compared to suture fixation. Opponents complain of
palpable bumps that can be visible through the scalp and
remain for long periods. Other noninvasive fixation techniques
such as retention bolsters and bioglues are also used to fixate
the elevated brow, but I have no personal experience with these
methods.
Temporal fixation is also an integral part of the EBFL. It is
traditionally performed by using the same suture to suspend the
temporal scalp to assist in maintaining elevation of the lateral
brow. This involves securing the undersurface of the inferior
margin of the temporal incision with a double throw of the
suture and suturing it to the superficial layer of the deep tem-
poral fascia (Figure 6-67, A–B). The needle is passed through
the subdermal tissues (including the temporoparietal fascia)
with a double throw and must secure enough tissue to elevate
the lateral brow under tension without suture pull through. The
suture tails are again left long and tucked into the incision to
prevent extrusion. The suture is then anchored to the superficial
layer of the deep temporal fascia as shown in Figure 6-67, C–D.
Figure 6-67, E shows the suspended temporal incision with
multiple sutures.
At this point, the brows are inspected for symmetry, and the
suspension sutures are adjusted appropriately if necessary (Figure
6-67, F). The incisions are then closed with staples (see Figure
6-67, G–H) or 4-0 gut sutures, and the hair is washed with
hydrogen peroxide and sterile water (see Figure 6-67, I ).
overlies the middle meningeal vessels, and fixation is never
placed in this region.
I have used all the commonly described fixation techniques,
but I have grown to prefer a resorbable 2-mm Endo Push Screw
(Biomet Microfixation, Jacksonville, FL;
com) or the Bioplate Push-In Tack (Bioplate Inc., Los Angeles,
CA; ), which has a 1.9 mm diameter and a
height of 4.5 mm. These are resorbable threadless screws made
of poly-l-lactic acid and dissolve in 12 to 24 months. These are
friction retained in the drill hole and require no screwing or
tapping. They have a central channel in which the retention
suture is passed. Since these screws are low profile, they maintain
excellent anchorage and are not palpable through the scalp. In
the placement of these push screws, a 4-mm self-limiting drill
is used to place a bur hole at the lateral incisions. Since the
lateral incisions were initially made above the region of maximum
anticipated brow elevation, fixation in this region is necessary.
The self-limiting drill prevents overextension into the skull and
is done with adequate irrigation while drilling. Figure 6-59, A
and B show the drill bit and drilling in the calvarium. After the
hole is made (depending upon which company’s device is used),
the screw is placed in a carrier (see Figure 6-59, C and D) and
pushed into the bur hole with a tight friction grip (see Figure
6-59, E and F). Figure 6-60 shows similar preparations with the
Bioplate push-in screw.
Once the resorbable fixation screw has been placed, the
inferior portion of the lateral scalp incision is secured, and a
double pass is made with a 2-0 or 0 vicryl or braided nylon
suture. The suture secures the subdermal tissues, including the
galea, and must be secure enough to not pull through under
tension. The suture is then passed through the channel in the
screw head, and while the assistant retracts the scalp, the suture
is tied with multiple knots (Figure 6-61). Using a small, wire
eyelid speculum will retract the incision and protect the scalp
tissues and can facilitate working in this small area (Figure
6-62). Novice surgeons frequently ask how high to raise the
brow. Most seasoned EBFL surgeons will agree that it is difficult
to oversuspend using these techniques. It is not unusual for the
brow to appear overelevated in the first several weeks after
surgery, but it soon settles into a normal brow position. To
answer the question about how high to raise the brow, I would
recommend elevating as much as possible within reason. This
places significant tension on the frontal and lateral incisions,
but always seems to settle into an acceptable aesthetic result. If
the surgeon has a choice to err on under- or over-intraoperative
elevation, it is preferable to slightly overelevate, keeping in mind
that the patient is supine; when erect, gravity will have an effect
on brow position. Local anesthesia and intraoperative swelling
also can make the brow appear higher than it will be several
weeks later. If the brow appears extremely overelevated, the
suspension sutures should be removed and readjusted. “Pull it
as high and as tight as you can within reason” is the answer of
most experienced EBFL patients.
Important pearl: Never cut off suture tails too short if Prolene
sutures are used. These thick synthetic sutures are strong, and
if a short suture tail is left, it can easily perforate the patient’s
scalp and be palpable or create an abscess. It is best to leave
about 4 to 5 cm of suture tail and tuck it inside the incision so
Text continued on page 119.

114
Chapter 6  •  Brow and Forehead Lifting
B
C
D
E
F
A
FIGURE 6-59.  A, The 4-mm self-limiting drill bit. B, Hole preparation being made. C, Push screw in its carrier. D, Prepared bur
hole using the Lorenz system. E, Push screw being placed with the carrier. F, Fixation push screw with suture fixation of the
scalp.

Chapter 6  •  Brow and Forehead Lifting
115
A
B
C
D
FIGURE 6-60.  Drilling (A) and preparation with the Bioplate system (B). C, Bioplate screw carrier in place. D, Prepared bur hole.
A
B
FIGURE 6-61.  A, A 2-0 Prolene retention suture being passed through the periosteal side of the lateral incision. B, The suture
tied through the resorbable screw, hence retaining the elevated brow.

116
Chapter 6  •  Brow and Forehead Lifting
A
B
C
FIGURE 6-62.  A wire eyelid speculum is a convenient device to keep the incision retracted and prevent damage to the adjacent
hair follicles during screw fixation.
A
B
C
FIGURE 6-63.  Long suture tails are preferable; shorter ones can perforate the scalp. A, A suture with a 4 to 5 cm tail. B, The
tail being tucked into the incision. C, The long tails passively in place in the incision.
A
B
C
FIGURE 6-64.  A, Threadless retention posts that are available for brow lift fixation. B, A screw in place. C, Staple retention over
the screw, which holds the scalp in an elevated position.
A
B
C
FIGURE 6-65.  A, The small cross-cut fissure bur used for bone tunnels. B, A bone tunnel with a suture passed in a dried
specimen. C, An in vivo view of a bone tunnel with a suture in place.

Chapter 6  •  Brow and Forehead Lifting
117
A
B
C
D
FIGURE 6-66.  A, Endotine system drill. B, Hole preparation. C, Endotine fixation device being placed. D, Scalp being positioned
superiorly to engage fixation spikes.

118
Chapter 6  •  Brow and Forehead Lifting
C
D
E
F
A
B
FIGURE 6-67.  A–B, Deep subdermal tissues are secured with a double throw of the fixation suture. C, Suture needle passing
through the superficial layer of the deep temporal fascia. D, Incision approximation after the suture is tied. E, Temporal incision
suspended with multiple 2-0 Prolene suspension sutures. F, Patient shown intraoperatively after the final brow suspension.
The blepharoplasty incisions have not been closed at this point.

Chapter 6  •  Brow and Forehead Lifting
119
G
H
I
G–H, All incisions are closed with staples or 4-0 gut sutures. I, At the termination of the procedure, the
hair is washed with hydrogen peroxide and sterile saline.
FIGURE 6-67, cont’d
Although many surgeons advocate postoperative dressings, I
discontinued their use over a decade ago and have never seen a
post EBFL hematoma.
Postoperative Course
The patient is seen 24 hours postoperatively to evaluate brow
position and check for hematoma or seroma formation.
Although I have never had to do it, an overcorrected brow could
be repositioned in the first several weeks by opening the inci-
sions, freshening the dissection pockets, cutting the sutures, and
resuspending to a lower position. Some surgeons advise the
patient to wear a headband for the first week, but with my rigid
fixation techniques, I have not recommended postoperative
head dressings or bands.
Most patients will have some degree of swelling, and if con-
comitant blepharoplasty was performed, their eyes may swell
shut for 24 hours. Headache is a common complaint, and
various degrees of ecchymosis may be present. Some patients
may develop subconjunctival ecchymosis and chemosis. For
patients with extreme swelling, I place them on 60 mg of pred-
nisone daily for 5 days. Patients are asked to keep their activity
light and return for staple removal at 10 days.
Case Presentations
Figures 6-68 to 6-77 show before-and-after results of EBFL.
Some of the patients may have had other cosmetic facial
surgery procedures. It should be noted that some patients
are wearing makeup in the postoperative pictures. Patients
who allow the use of their pictures without makeup are hard to
come by!
Complications
Complications with EBFL are similar to other types of brow
lifts and include relapse, healing problems, nerve problems,
over- and undercorrection, bleeding, hematoma, infection,
suture problems, dry eye syndrome, corneal abrasion, and mis-
cellaneous other problems.
Although relapse can be a problem with any surgical proce-
dure, it appears that a significant number of surgeons complain
about stability with EBFL. Over the past decade, I have traveled
all over the world and met hundreds of cosmetic facial surgeons
from virtually every specialty. I have come across many who
have abandoned EBFL because their long-term results were
disappointing. There are extremely staunch supporters of this

120
Chapter 6  •  Brow and Forehead Lifting
A
B
FIGURE 6-68.  Two patients with their preoperative picture on the right and their postoperative picture on the left split in the same
picture. The brow correction is obvious.
A
B
FIGURE 6-69.  This patient underwent endoscopic brow and forehead lift, lower blepharoplasty, and lower lid chemical peel.
A
B
FIGURE 6-70.  This 43-old-patient had endoscopic brow and forehead lift without any other procedure.

Chapter 6  •  Brow and Forehead Lifting
121
A
C
D
B
FIGURE 6-71.  The same patient pictured in Figure 6-67 is shown in these views. A successful endoscopic brow and forehead
lift will not only improve the brow position but also tighten excess upper lid skin.
A
B
FIGURE 6-72.  This patient underwent endoscopic brow and forehead lift and light CO2 laser skin resurfacing.

122
Chapter 6  •  Brow and Forehead Lifting
A
B
FIGURE 6-73.  This 58-year-old patient underwent endoscopic brow and forehead lift without any other procedure.
A
B
FIGURE 6-74.  Patient before and after endoscopic
brow and forehead lift with simultaneous upper lid
blepharoplasty and lower lid CO2 laser resurfacing.
A
B
FIGURE 6-75.  This patient underwent
endoscopic brow and forehead lift,
upper blepharoplasty, and full-face
CO2 laser resurfacing.

Chapter 6  •  Brow and Forehead Lifting
123
A
B
FIGURE 6-76.  This patient underwent endoscopic brow and forehead lift without any other cosmetic facial procedures.
A
B
FIGURE 6-77.  This male patient underwent endoscopic brow and forehead lift and lower eyelid transconjunctival
blepharoplasty.
technique, however, who argue that stability is proportional to
surgical technique. I personally have experienced relapse with
some of my EBFL cases and wonder what I may have done
differently (or not done) in these patients. No discernable
pattern in my technique has equated to surgical relapse. I now
perform more trichophytic brow lift cases than endoscopic but
still use both techniques routinely. Figure 6-78 shows an EBFL
case that relapsed within the first 3 months.
Hematoma or seroma are possible in the early postoperative
period but rare. Should they occur, they can generally be treated
by aspiration (Figure 6-79).
Edema and ecchymosis are variable from patient to patient.
As mentioned, if EBFL is performed concomitantly with bleph-
aroplasty or midface surgery, the eyes may swell shut for 24
hours (Figure 6-80). Subconjunctival ecchymosis and chemosis
are also seen in some patients and usually resolve spontaneously
(Figure 6-81).
Motor and sensory nerve problems can be seen with all brow
lift techniques. With EBFL, it is not uncommon for patients to
have supraorbital nerve paresthesia for up to several months.
This is sometimes manifested as itching. This paresthesia is
usually transient but can be permanent.
Permanent motor nerve damage is rare, and I don’t believe I
have ever experienced it with any brow lift. Working around the
frontal branch of the facial nerve in the EBFL technique can
cause neuropraxia from dissection and stretching, as well as
transient nerve damage from cautery. This is generally mani-
fested as unilateral frontalis palsy, which will usually return to

124
Chapter 6  •  Brow and Forehead Lifting
A
B
C
D
FIGURE 6-78.  A–B, Surgical relapse of an endoscopic brow and forehead lift (EBFL) case. There was no apparent reason for
this change. C–D, The post EBFL relapse from a lateral view.
FIGURE 6-79.  A postoperative seroma of the temporal flap is aspirated 24
hours after surgery.
FIGURE 6-80.  Patient is shown 24 hours after endoscopic brow and fore-
head lift, upper and lower blepharoplasty, periorbital CO2 laser resurfacing,
and facelift. She demonstrates significant edema and ecchymosis of the
periorbital region.

Chapter 6  •  Brow and Forehead Lifting
125
FIGURE 6-81.  Patient after endoscopic brow and forehead lift has chemo-
sis of the bulbar conjunctiva several days after surgery. This cleared
spontaneously over the following week.
A
B
FIGURE 6-82.  A, Endoscopic brow and forehead lift patient with a left-sided frontalis palsy after surgery. B, The working side
is treated with Botox to normalize the forehead and expression until the affected side recovers.
FIGURE 6-83.  A localized infection over a resorbable fixation screw that
contains a suspension suture. The area was débrided and resolved
spontaneously.
normal function within 90 days. In the interim, the normal side
can be treated with a neurotoxin to stop the unilateral function
until the other side returns (Figure 6-82).
Infection has not been a problem and like most head and
neck procedures is rare in EBFL. I have witnessed several local-
ized infections or inflammatory granulomas around sutures or
screws (Figure 6-83). These respond well to local incision and
drainage, but if this does not clear the infection, the foreign
body must be removed.
Alopecia can occur in temporary and permanent states. Even
with extreme care and gentle handling of the flaps, follicles sur-
rounding the incision can undergo dormancy for several months;
this is referred to as hair shock. Normal hair growth typically
returns in 3 to 4 months, but some cases can be permanent due
to incision and port trauma, including pressure, tension, cautery,
pulling the hair for retraction, and stretching the scalp with the
scope or instruments (Figure 6-84). In the case of permanent
alopecia, the extent of the hair loss is usually quite localized and
easily excised with primary reapproximation of the hair-bearing
scalp (Figure 6-85).
A 2-0 Proline suture is a commonly used means of retention
for EBFL, although I have recently begun using 2-0 Vicryl the
same 2-0 braided nylon suture I use for facelifts. If Proline
suture is used, it must be kept in mind that like thick fishing
line, these sutures can be palpable and if left with short tails can
find their way through the scalp. As mentioned earlier, leaving
the tails long and tucking in the posterior incision can prevent
a short, sharp suture stump that could perforate the scalp. Figure
6-86 shows a 2-0 Prolene suture that extruded through the
healed scalp several months after surgery.

126
Chapter 6  •  Brow and Forehead Lifting
A
B
FIGURE 6-84.  Patient with balding in the area of the multiple incisions. Follicular dormancy was temporary, and hair regrew within
90 days.
A
B
C
FIGURE 6-85.  A, Area of alopecia surrounding a scalp incision site. B, Hairless scalp incision; insert shows the excised speci-
men. C, Healed surgical site 3 weeks post revision.
FIGURE 6-86.  A 2-0 Prolene suture extruded through the scalp several
months after surgery.
Resorbable devices can remain in place longer than antici-
pated and can also produce inflammatory problems. Figure 6-87
shows chronic inflammation from a resorbable fixation screw
placed a year earlier. The inflamed area was primarily excised.
Figure 6-88 shows a patient from another office who presented
with visible palpable and painful areas over Endotine anchors
that were placed more than 2 years previously.
In cases of asymmetric or overaggressive brow-depressor dis-
ruption, dysfunctional animation or even resting defects can
occur. Figure 6-89 shows a patient who is unhappy with her
scowl after brow-depressor disruption during EBFL. She has
small, dimpled depressions in the region of the corrugators
supercilii muscles bilaterally.
Conclusion
Endoscopic brow and forehead lift is an example of technologic
improvement of cosmetic surgery. This procedure is very

Chapter 6  •  Brow and Forehead Lifting
127
A
B
C
D
FIGURE 6-87.  1 year after endoscopic brow and forehead lift with resorbable fixation screw placement. A, Granulomatous lesion
was excised. B, Excised specimen. C, Minimal remnant of the dissolvable screw. D, Sutured surgical site.
FIGURE 6-88.  Arrows show visible prominences corresponding to Endotine
anchors placed 2 years previously.
FIGURE 6-89.  Patient exhibits bilateral dimpling from aggressive resection
of corrugators supercilii muscles.

128
Chapter 6  •  Brow and Forehead Lifting
technique oriented and has a significant learning curve, but
once the surgeon understands the procedure, equipment,
anatomy, and method, performing it is predictable, safe, effec-
tive, and enjoyable. The EBFL technique remains a mainstay in
the armamentarium of the cosmetic facial surgeon.
References
  1. Stuzin JM: Endoscopic brow lift, upper and lower blepharoplasty, retinacu-
lar canthopexy: personal approach. Plast Reconstr Surg 120(6):1697–1698,
2007 Nov.
  2. Nassif PS: Evolution in techniques for endoscopic brow lift with deep
temporal fixation only and lower blepharoplasty-transconjunctival fat repo-
sitioning. Facial Plast Surg 23(1):27–42, 2007 Feb; discussion 43–44.
  3. Patel BC: Endoscopic brow lifts uber alles [review]. Orbit 25(4):267–301,
2006 Dec.
  4. Niamtu J, 3rd: Endoscopic brow and forehead lift: a case for new technol-
ogy [review]. J Oral Maxillofac Surg 64(7):1129–1132, 2006 Jul. Erratum
in: J Oral Maxillofac Surg 64(9):1464, 2006 Sep.
  5. Cuzalina AL, Holmes JD: A simple and reliable landmark for identification
of the supraorbital nerve in surgery of the forehead: an in vivo anatomical
study. J Oral Maxillofac Surg 63(1):25–27, 2005 Jan.
  6. Cuzalina AL, Cuzalina A: Endoscopic forehead and brow lift. In Fonseca
RJ, Marciani RD, Turvey TA, editors: Oral and maxillofacial surgery,
Orthognathic Surgery, Esthetic Surgery, Cleft and Craniofacial Surgery, ed
2, vol 3, St. Louis, 2009, pp 595–609.
  7. Cuzalina A: Forehead and brow procedures. In Miloro M, Ghali GE,
Larsen PE, Waite PD, editors: Peterson’s principles of oral and maxillofacial
surgery, ed 2, St. Louis, 2004, Saunders, pp 1383–1406.
  8. Troilius C: Subperiosteal brow lifts without fixation. Plast Reconstr Surg
114(6):1595–1603, 2004 Nov; discussion 1604–1605.
  9. Watson SW, Niamtu J, 3rd, Cunningham LL, Jr: The endoscopic brow and
midface lift. Atlas Oral Maxillofac Surg Clin North Am 11(2):145–155,
2003 Sep.
10. Jones BM, Grover R: Endoscopic brow lift: a personal review of 538
patients and comparison of fixation techniques. Plast Reconstr Surg
113(4):1242–1250, 2004 Apr 1; discussion 1251–1252.
11. Niamtu J: A Simple Device for Incision Protection and Retraction in
Endoscopic Brow and Forehead lifting. Dermatol Surg 27(8):779–780,
2001 Aug.
12. Ramirez OM: Endoscopic techniques in facial rejuvenation. An overview.
Part 1. Aesthetic Plast Surg 8:141, 1994.
13. Isse NG: Endoscopic facial rejuvenation. Endoforehead, the functional lift.
Case reports. Aesthetic Plast Surg 18:21–29, 1994.
14. Tessier P: Ridectomie frontale. [Lifting frontale.] Gaz Méd Fr 75:55–65,
1968.

129
7 
Cosmetic Blepharoplasty
O
f all cosmetic facial surgery procedures, blepharoplasty
can be the most simple yet the most complex. Its
intricacies are significant but once mastered provide
great satisfaction for both surgeon and patient. If the eyes are
the windows to the soul, cosmetic surgery and facial rejuvena-
tion should open the blinds. The upper face frequently ages
earlier than the lower face, and the eyelids and brow are frequent
areas of concern in patients from the age of 35 on up. Younger
patients usually are concerned about droopy upper eyelids and
fat bags. Older patients have additional concerns about wrin-
kled skin and brow repositioning. For most patients, it is a
matter of cosmetics, but some have functional problems such
as eyelid ptosis, lid laxity, and visual obstruction. This is a basic
chapter on diagnosis and treatment, so our discussion will be
limited primarily to cosmetic blepharoplasty.
Numerous specialties have adequate training and experience
to understand and learn cosmetic blepharoplasty. Those special-
ties that deal with facial trauma have even a greater understand-
ing of the eye and periorbita.
Learning blepharoplasty surgery (for non-core-trained sur-
geons) begins with reading texts and journal articles, attending
cadaver and didactic CME courses, watching instructional
videos, observing live surgery, and finally proctoring actual
cases. In my experience, this learning curve requires 1 to 2 years
of study to become proficient. A number of wisdom pearls will
be discussed; some are critical to “staying out of trouble” with
cosmetic blepharoplasty. Eye complications can be devastating
for a patient and career ending for a cosmetic surgeon, but for
the most part they are rare when conservative technique is used
and some basic tenets are followed.
Orbital Anatomy
This is a surgical technique atlas, so space precludes an exhaus-
tive review of orbital anatomy. The orbits and eyes have some
of the most delicate and complex anatomy in the body, so a
thorough understanding of eye anatomy is essential to under-
standing blepharoplasty. In considering the external anatomy,
one must be familiar with certain structures and understand
their form and function:
  1. Eyelid skin
  2. Sclera
  3. Cornea
  4. Pupil
  5. Iris
  6. Lacrimal caruncle
  7. Punctum
  8. Upper and lower tarsi
  9. Conjunctiva
10. Medial and lateral canthus
11. Upper and lower lid fornices
12. Gray line (immediately associated with lashes)
One must be particularly familiar with the structures of the
upper eyelid (Figure 7-1):
1. Orbicularis oculi muscle
2. Retro–orbicularis oculi fat (ROOF)
3. Orbital septum (extension of periosteum)
4. Orbital fat pads (medial and central)
5. Lacrimal glands
6. Superior oblique muscle
7. Levator palpebrae superioris muscle
8. Levator aponeurosis
9. Müller’s muscle
The key structures of the lower eyelid (Figure 7-2) are:
1. Capsulopalpebral fascia (lower lid retractors)
2. Suborbicularis oculi fat (SOOF)
3. Lower lid fat pads (medial, central, lateral)
4. Inferior oblique muscle
5. Orbital rim
The layers of lamellae of the eyelids are the outer lamella,
which includes the skin and orbicularis muscle; the middle
lamella, which includes the orbital septum and fat; and the
inner lamella, which includes the tarsus and conjunctiva. (This
classification is described differently in various texts and also
varies by the specific level described.)
The eyelid skin is some of the thinnest in the body—
sometimes as thin as 0.2 mm. The underlying concentric orbi-
cularis oculi muscle is described in three portions: the pretarsal
Frontalis insertion
Arcus marginalis
Orbicularis oculi muscle
Orbital septum
Preaponeurotic fat
Levator aponeurosis
Tarsus
FIGURE 7-1.  Eyelid anatomy upper lid. (Redrawn courtesy Steve Bosniak,
MD.)

130
Chapter 7  •  Cosmetic Blepharoplasty
Orbicularis oculi m.
Pretarsal portion
Preseptal portion
Orbital portion
Orbital septum
Lower lid retractors
Fat
Tarsus
Conjunctiva
FIGURE 7-2.  Eyelid anatomy lower lid. (Redrawn courtesy Steve Bosniak,
MD.)
Orbicularis oculi muscle
Orbital
Preseptal
Pretarsal
FIGURE 7-3.  The orbicularis oculi muscle has three portions correspond-
ingly named with the structures it overlies.
A
B
FIGURE 7-4.  A, Orbicularis oculi muscle in the upper eyelid. B, Concentric
muscle fibers in the lower lid.
1
2
3
4
6
5
FIGURE 7-5.  The orbital septum (1), the levator muscle (2), the levator
aponeurosis (3), the lower lid retractors (4), the lateral canthal tendon (5),
and the medial canthal tendon (6).
portion, which overlies the cartilaginous framework of the lids;
the preseptal portion, which overlies the orbital septum; and the
orbital portion, which overlies the bony orbit (Figure 7-3).
Figure 7-4 shows the actual muscle intraoperatively. The orbital
septum is a connective-tissue layer that is an extension of the
periosteum and separates the muscle layer from the periorbital
fat (Figure 7-5). Figures 7-6 and 7-7 show clinical views of the
orbital septum.
Müller’s muscle is an autonomic muscle that lies deep to the
levator palpebrae superioris muscle (Figure 7-8) and is respon-
sible for approximately 2 mm of upper eyelid opening.
The tarsus represents the cartilaginous framework of the
eyelids. The upper tarsus is approximately 10 mm in height, and
the lower tarsus is about 4 to 5 mm in height.

Chapter 7  •  Cosmetic Blepharoplasty
131
only two fat pads in the upper lid. The lower eyelid has three
fat pads: the medial (sometimes called nasal ), the central, and
the lateral (sometimes called temporal). In the lower eyelid, the
inferior oblique muscle separates the medial and central fat
pads, and the arcuate expansion of the inferior oblique muscle
separates the central and lateral fat pads (see Figure 7-10). Figure
7-11 shows the right upper lid lacrimal gland. Innervation of
the periorbital area is complex; the main innervation of the
eyelids and associated structures is given in Box 7-1.
Aging Conditions of the Eyelids
and Periorbital Areas
As we age, various changes become evident in the eyelids (Figure
7-12). The most obvious is the presence of brow ptosis. Most
young males have flat brows at or above the level of the upper
orbital rim, and most young females have arched brows above
the level of the upper orbital rim. As we age, the brows and
The upper eyelid crease is determined by the insertion of the
fibers of the levator aponeurosis into the eyelid skin. The normal
Caucasian upper eyelid crease is 10 to 12 mm above the lashes
in females and about 8 to 10 mm above the lashes in males
(Figure 7-9, A). The Asian eyelid crease is 4 to 6 mm above the
lash line and is inferiorly positioned because the levator aponeu-
rosis fibers attach at a lower level (see Figure 7-9, B).
The globe is cushioned by periorbital fat positioned into
distinct fat pads in the upper and lower eyelid. These fat pads
are frequently reduced or repositioned in cosmetic blepharo-
plasty. There are two fat pads in the upper eyelid: the medial
(sometimes called nasal ) and the central (Figure 7-10). The
superior oblique muscle separates the medial and central fat
pads in the upper lid. Also sitting in the lateral upper orbit is
the lacrimal gland. This gland is pinkish and similar in consis-
tency to salivary glands; despite its appearance, it is sometimes
mistaken for fat and removed, with disastrous consequences. It
is imperative for the novice surgeon to remember that there are
FIGURE 7-6.  Orbital septum in the upper eyelid of a patient. Note that the
skin and orbicularis muscle fibers have been removed.
S
S
A
B
FIGURE 7-7.  A, Orbital septum (S) in the upper lid, with central fat pad protruding through a small incision. B, Central fat pad
of the lower eyelid, with the central fat pad protruding through a small incision in the orbital septum (S).
LM
LA
FIGURE 7-8.  The levator palpebrae superioris muscle fibers (LM) as they
insert into the levator aponeurosis (LA).