The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

My preferred surgical options and the frequency with which each is performed are
as follows:
 Full endoscopic (20%)
 Lateral-temporal (15%)
 Transpalpebral muscle excision (5%)
 Combination—lateral-temporal plus transpalpebral muscle excision (60%)
Open Coronal Forehead Lift
724
Part V  Brow Lift
The open coronal approach affords excellent exposure and facilitates release of ad-
hesions, muscle excision, and brow mobilization. The scalp excision is tailored to el-
evate the brow as desired and enhance its shape. The extensive incision involved, to-
gether with the risk of sensory changes, including dysesthesias, numbness, and
alopecia, are perceived as deterrents by patients who decline this approach. Since the
introduction of the endoscopic approach in 1993, I have not performed an open
coronal brow lift. Before 1993, only 10% to 15% of the patients undergoing facial
rejuvenation in my practice would accept the open coronal lift. Today almost all of my
facial rejuvenation patients undergo brow rejuvenation through one of the four pro-
cedures listed above.
Full endoscopic
20%
Lateral-temporal
15%
Transpalpebral
muscle excision
5%
Combination—
lateral-temporal 
transpalpebral
muscle excision
60%

725
Chapter 22  Clinical Decision-Making in Brow Lift
The endoscopic forehead lift is not without its limitations. Although it can be uni-
formly applied in every patient, the results will vary according to the patient’s ana -
tomic features as well as the aging changes present. There are certain anatomic fea-
tures that make the endoscopic approach rather challenging. These patients are best
served by one of the alternative approaches.
The endoscopic approach affords excellent exposure for release of the periorbital ad-
hesions and septa; the magnification offered through the endoscope facilitates mus-
cle excision and nerve preservation. Scalp excision is rather limited with the endo-
scopic approach, so elevation and maintenance of brow position rely primarily on
muscle balance and fixation techniques compared with the open coronal approach,
in which scalp excision maintains brow position. Even 17 years after the endoscopic
approach was introduced, there is still no consensus on endoscopic fixation. Opinions
range from “muscle balance is all that counts; fixation is not necessary,” to the other
extreme: some insist that fixation must be permanent. I individualize the need for
fixation, whether permanent, temporary, or not at all.
There is no question that the coronal approach is the best option for some patients.
These are patients in whom a high hairline and a convex frontal bone would make
the endoscopic approach rather challenging. In such individuals, I prefer a combi-
nation of the lateral approach with transpalpebral muscle excision. Those with a
high forehead also present a challenge to the endoscopic approach, making it tech-
nically very difficult, if not impossible. An alternative would be an open coronal bi-
planar approach to forehead rejuvenation, allowing shortening of the forehead height.
Endoscopic Forehead Lift

726
Part V  Brow Lift
FAVORABLE CANDIDATE
UNFAVORABLE CANDIDATE
Endoscopic Forehead Lift: Favorable and Unfavorable Candidates
Anatomic Features
Favorable
Unfavorable
Forehead
Height
Short
High
Convexity
Flat
Convex
Hairline
Height
Short
High
Receding
Nonreceding
Receding
Hair quality
Thick
Thin
Skin
Thickness
Normal
Thick
Rhytids
Superficial
Deep

The lateral-temporal approach affords excellent repositioning and elevation of the
lateral brow through a temporal incision. Suturing of the temporoparietal fascia to the
deep temporal fascia provides permanent fixation.
Muscle modification, although theoretically possible, especially with an endoscope,
is not usually performed with this approach. This approach is best combined with
a transpalpebral excision of the corrugator supercilii and division of the procerus
muscles for an effective brow lift.
The best candidates for this combined approach are patients with little if any excess
skin at the nasal radix, individuals requiring little if any medial brow repositioning,
and those who are candidates for upper lid blepharoplasty. Advantages are the min-
imally invasive approach and the minimal risk of sensory changes.
Lateral-Temporal Brow Lift
727
Chapter 22  Clinical Decision-Making in Brow Lift

Direct Approach
728
Part V  Brow Lift
Minimal lateral brow elevation is possible through this approach, in which the lateral
brow is repositioned through the upper eyelid incision and sutured down to the peri-
osteum. The limited elevation achieved with this approach restricts this procedure
to patients with mild lateral brow ptosis without any medial brow ptosis or excess
skin at the nasal radix.
The direct approach is effective in elevating the lateral brow, but it is rarely per-
formed, because it leaves a scar directly over the hair-bearing brow or in a transverse
forehead line. The best candidates are elderly patients or those with pronounced
lower forehead transverse creases where the scar can be concealed. This approach
offers excellent brow elevation and access to the muscles. Traditionally, the excision
has not been combined with muscle excision. The advantages of this method are that
it is simple and quick, it can be performed with local anesthesia in many instances,
and it carries minimal risk to the sensory nerves. The scar is the only potential dis-
advantage.
Transpalpebral Browpexy

Transpalpebral Excision of Corrugator and Procerus Muscles
729
Chapter 22  Clinical Decision-Making in Brow Lift
This patient with brow asymmetry, glabellar frown lines, and aging of the upper and
lower lids underwent upper and lower lid blepharoplasty with transpalpebral excision
of the corrugator and division of procerus muscles. Postoperative views and a split-
face view at 18 months postoperatively show elimination of glabellar frown lines,
improvement of asymmetry, and appropriate brow position.
Modification of the glabellar muscles through the upper eyelid results in improve-
ment of glabellar lines with minimal medial elevation of the brow. Lateral brow el-
evation is performed through the lateral-temporal lift. The best candidates are indi-
viduals with glabellar frown lines with minimal if any medial or lateral brow ptosis.
In combination with a lateral-temporal brow lift, this is my preferred choice for brow
rejuvenation in patients requiring minimal or no medial brow elevation.

Injection of Toxins
730
Part V  Brow Lift
The brow lift is one component of periorbital rejuvenation. I rarely perform an iso-
lated brow lift. In a personal series of 100 consecutive endoscopic brow lifts per-
formed over 14 months, 79 patients underwent upper and lower lid blepharoplasty,
2 underwent upper lid blepharoplasty only, and 19 underwent lower lid bleph -
aroplasty. Most of the patients undergoing a lower lid blepharoplasty also had a
transpalpebral midface lift. There were no isolated endoscopic brow lifts during the
period studied. These regional procedures reflect our approach to facial rejuvenation
addressing facial zones or the entire face rather than individual components such as
the brow or the eyelids.
Toxin injections are the most popular procedure for brow rejuvenation, represent-
ing a safe and effective method for mild to moderate brow elevation through alter-
ations to muscle balance. Advantages include the fact that it is nonsurgical and less
expensive in the short run. Limitations include the temporary nature of the correction,
the necessity for repeated injections, and the expense over time.
Regional Procedures
Quad blepharoplasties
Cheek lifts
Upper lid only
Lower lid only
Lower lid with TC upper lids

731
Chapter 22  Clinical Decision-Making in Brow Lift
Ancillary Procedures
The surgical procedures described reposition the brow and improve forehead and
glabellar lines. Frequently, additional ancillary procedures are needed to further im-
prove the result. These include peels and laser resurfacing, and the use of tissue fillers.
We will often improve the vertical frown lines by threading a piece of autologous
temporal fascia or orbicularis muscle just deep to the dermis. If the temporal fascia
is exposed during the brow-lift procedure, my preference is to harvest the temporal
fascia and use it as a filler. If an upper eyelid incision is made, the orbicularis oculi
muscle would be an alternative source of autologous tissue. In my practice, laser
resurfacing and autologous fillers for forehead and glabellar lines are the two most
common ancillary procedures in forehead lifting.
This split-face view demonstrates preoperative and 5-year postoperative results af-
ter an endoscopic brow lift with external screw fixation and laser resurfacing. Other
procedures performed in this patient included upper and lower lid blepharoplasties,
face lift, neck lift, and perioral laser resurfacing.

732
Part V  Brow Lift
Choosing the Best Option
Ancillary
Lateral/
Temporal
Brow Lift 
Transpalpebral
Transpalpebral
Morphology
Procerus/
Procerus/
Auto-
and Aging
Endo-
Lateral/
Corrugator
Corrugator
Brow-
logous
Changes
Coronal
scopic
Temporal
Excision
Excision
Direct
pexy
Laser
Filler
Forehead
High





Low






Flat






Convex





Hairline
High




Low






Receding




Skin Excess
Lateral






Medial



Skin
Thick





Normal





Deep rhytids






Superficial






rhytids
Brow Position
Lateral
Normal
Low






Medial
Normal




Low



733
Chapter 22  Clinical Decision-Making in Brow Lift
Suggested Readings
Behmand RA, Guyuron B. Endoscopic forehead rejuvenation: II. Long-term results. Plast Re-
constr Surg 117:1137-1143; discussion 1144, 2006.
Byrd HS, Burt JD. Achieving aesthetic balance in the brow, eyelids and midface. Plast Re-
constr Surg 110:926-933; discussion 934-939, 2002.
Carruthers A, Carruthers J. Eyebrow height after botulinum toxin type A to the glabella. Der-
matol Surg 33(1 Spec No):S26-S31, 2007.
Farkas LG. Anthropometrics and art in the aesthetic of women’s faces. Clin Plast Surg 14:599-
616, 1987.
Knize DM. Reassessment of the coronal incision and subgaleal dissection for foreheadplasty.
Plast Reconstr Surg 102:478-489; discussion 490-492, 1998.
Knize DM. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast
Reconstr Surg 95:52-60; discussion 61-62, 1995.
Tyers AG. Brow lift via the direct and trans-blepharoplasty approaches. Orbit 25:261-265,
2006.

This page intentionally left blank
This page intentionally left blank

Temporal Brow Lift

FOAD NAHAI
CHAPTER 23

0
10,000
1997
2005
2006
2007
2008
BROW LIFTS
20,000
30,000
40,000
50,000
60,000
70,000
80,000
THE AMERICAN SOCIETY FOR
AESTHETIC PLASTIC SURGERY, INC.
O
ur goals for brow rejuvenation include repositioning the eyebrows according
to cultural norms and individual tastes, eliminating or at least improving lines
at rest or on animation, reducing lateral orbital crowding, and correcting excess
glabellar skin over the nasal radix. Very often brow rejuvenation is combined with
an upper lid blepharoplasty. In these patients the upper eyelid will be the gateway to
the brow, as the lower eyelid has become an important gateway for rejuvenating the
lid-cheek junction and the midface. In this chapter I will discuss the role of the up-
per eyelid as a gateway to the brow and its role in periorbital rejuvenation.
With the many options for brow repositioning and rejuvenation (discussed in Chap-
ters 22, 24, and 25), selection of a procedure based on the patient’s individual needs
is the key. Not every patient requires, nor should every patient undergo, an endo-
scopic or coronal brow lift to achieve an ideal result.
Through a limited temporal incision similar to that for the three-incision endoscopic
brow lift, the periorbital septa and adhesions are easily divided, and subperiosteal
dissection almost to the midline is also possible. Although challenging, even glabel-
lar muscle modification is possible through this incision. However, my preference is
to modify the glabellar muscles through the upper eyelid in this combination ap-
proach. Lateral brow elevation and fixation is easily achieved with this approach.
Injectable toxins and this combination approach have reduced the number of endo-
scopic brow lifts in my practice. A review of the procedural statistics published an-
nually by the American Society for Aesthetic Plastic Surgery (ASAPS) reveals that the
number of brow lifts performed in the United States peaked in 2005 and currently
stands below 1997 levels, when ASAPS started collecting procedural statistics.
736
Part V  Brow Lift
I believe this reflects the impact of toxin use and transpalpebral muscle modification
on brow rejuvenation. The lateral temporal brow lift, with or without endoscopic
assistance, accomplishes the mobilization and fixation of the middle to lateral brow,
whereas muscle modification is undertaken through the upper eyelid with loupe
magnification.

Indications and Contraindications
The lateral brow lift is best for patients with no medial brow ptosis, no glabellar skin
excess above the nasal radix, and forehead aging limited to the lateral brow. For pa-
tients with glabellar lines, modest medial brow depression, and no excess skin above
the nasal radix, the combination approach, including transpalpebral modification
of the glabellar muscles, is an excellent option, with results matching those achieved
with endoscopic and even open coronal techniques. I often combine this approach
with an upper lid blepharoplasty and midface rejuvenation or a full face lift. This is
not an effective procedure for patients with significant medial brow ptosis, excess
glabellar skin over the nasal radix, and deep forehead lines at rest. These individu-
als are better suited for an endoscopic or coronal approach.
Preoperative Planning
Brow Markings
737
Chapter 23  Temporal Brow Lift
The patient is instructed to clench the teeth while contracting the temporalis mus-
cle, so the surgeon can palpate this; the temporal crest–temporal line of fusion is
marked along the anterior border of the contracted muscle. If the sentinel vein is
readily visible with the patient in a sitting position, it is marked.

Otherwise, the patient is asked to lie supine, and the sentinel vein is marked. The
temporal incision is marked 2 to 3 cm behind the temporal hairline, extending no
higher than the temporal crest to avoid injury to the lateral branch of the supraor-
bital nerve. The incision is planned directly over the muscle to facilitate anchoring
of the temporoparietal fascia to the deep temporal fascia. Incisions beyond the ex-
tent of the temporalis muscle should be avoided.
Eyelid Markings
738
Part V  Brow Lift
Temporal ridge
Sentinel vein
10 mm
10 mm
6 mm
The upper eyelid is marked for blepharoplasty with the upper eyelid crease at the level
of the midpupillary line, usually 8 to 10 mm above the lashes in women and a little
lower in men. The lateral marking should be at least 6 mm above the lateral canthus,
with a lateral extension within one of the crow’s-feet, if present. At least 10 mm of
skin should be preserved between the upper marking and the hair-bearing brow. In
addition, I ask the patient to frown so I can mark the extent and bulk of the corru-
gator muscle. If there are any horizontal glabellar lines, indicating procerus hyper-
activity, those are marked as a reminder to section the procerus muscles.

Operative Technique
Anesthesia
The procedure may be performed with the patient under local or general anesthe-
sia. In my practice, because most of these procedures are combined with full facial
rejuvenation, I prefer a general anesthetic. I always infiltrate the surgical field with a
combination of lidocaine and epinephrine.
I prefer to do the lateral temporal brow lift first, simulate the new brow position to
confirm the upper eyelid skin excision, and then proceed with the upper eyelid com-
ponent of the operation.
Lateral Temporal Brow Lift
739
Chapter 23  Temporal Brow Lift
I perform this portion of the operation exactly as I do for an endoscopic brow lift.
The incision is placed coronally or horizontally or anywhere in between, depending
on the desired final brow position. The incision is made and continued through the
temporoparietal fascia onto the deep temporal fascia. The initial dissection is made
bluntly, with the scissors pushing along the deep temporal fascia toward the lateral
orbital rim to establish an optical cavity. From this point on, the dissection can con-
tinue under endoscopic control or, my preference, direct vision with the aid of a lighted
retractor or an Aufricht retractor and a headlight.
The endoscope is introduced, and dissection proceeds rapidly with an endoscopic
dissector in this avascular plane toward the lateral orbital rim. The sentinel vein is
easily identified, and I prefer to preserve it. The septa and adhesions are released,
usually with the endoscopic dissector. To ensure complete release and thus mobiliza-
tion of the lateral brow, I make a point of skeletonizing the sentinel vein.

740
Part V  Brow Lift
Sentinel veins
Some of the septa and adhesions, especially beyond the vein, may require division
with endoscopic scissors. Following the skeletonizing of the sentinel vein, dissection
continues minimally beyond the orbital rim and then laterally through the temporal
crest and into the subperiosteal space.
The extent of the medial subperiosteal dissection varies from patient to patient and
depends on brow shape and the desired final result.
At this stage the lateral brow is tested with upward traction at the skin edge to en-
sure mobility by observing the upward and medial rotation of the lateral brow. If
the lateral brow moves only minimally, further dissection must be performed; oth-
erwise, there may be no brow elevation. The brow is not fixed at this stage. I then
proceed with upper lid blepharoplasty and glabellar muscle modification.

Transpalpebral Glabellar Muscle Modification
I perform the glabellar muscle modification with loupe magnification. The upper
eyelid skin–muscle is excised as marked. The dissection proceeds superiorly deep to
the orbicularis oculi, facilitated by two Blair retractors suspending the upper edge
of the resected orbicularis. I prefer to operate with the cutting current of the Col-
orado tip needle. Alternatively, the dissection can be performed easily with a pair of
scissors. At this stage, even if I am planning to resect upper eyelid fat, I leave the or-
bital septum intact, and any planned fat removal is delayed until after the glabellar
muscle is excised, thus facilitating dissection of the orbicularis off the orbital sep-
tum. Laterally, the dissection is continued along the deep surface of the orbicularis un-
til the lateral orbital dissection through the eyelid is continuous with the endoscopic
dissection from above.
741
Chapter 23  Temporal Brow Lift
Once the communication between the eyelid and brow plane of dissection has been es-
tablished, I make a number of radial cuts into the lateral orbicularis, not to perma-
nently weaken it but to weaken it temporarily to prevent the downward pull of the
orbicularis during the early postoperative phase to help maintain lateral brow posi-
tion. The radial cuts are made in the muscle with the Colorado tip, and with a finger
placed behind the hair-bearing brow pushing the muscle forward to facilitate scoring.

742
Part V  Brow Lift
Supraorbital
nerve
Supratrochlear
nerve
Corrugator
muscle
Supratrochlear nerve
Medially, the dissection approaches the supraorbital rim. The orbicularis fibers run-
ning horizontally must be divided to reach the diagonally running muscle fibers of
the corrugator supercilii muscle.
Branches of the supratrochlear nerve may also be visible at this stage.
The orbicularis muscle is divided with the Colorado tip or by spreading with the tips
of scissors or a fine mosquito clamp. This immediately brings the corrugator muscle
and a branch or two of the supratrochlear nerve into view.

Although the corrugator muscle can be divided in stages, I prefer to insert the tips
of the fine mosquito clamp around the entire muscle belly if possible; otherwise,
I insert the tips partially through it, spread the tips, and resect the intervening seg-
ment of muscle. I often encounter a branch or two of the supratrochlear nerve cours-
ing through the muscle. The supraorbital nerve is usually lateral to this dissection.
743
Chapter 23  Temporal Brow Lift
Supraorbital
nerve
Supratrochlear nerve
Corrugator muscle
Incision
A segment of the muscle has been removed, revealing at least two intact branches
of the supratrochlear nerve. These nerves are often accompanied by blood vessels
that can bleed. I make every attempt to avoid these vessels. If they bleed, I cauterize
them with a bipolar cautery rather than a unipolar coagulating current. The muscle
division/excision should be complete to prevent postoperative recurrence of glabel-
lar function and lines. At the completion of the procedure, there should be a signifi-
cant gap in the muscle with preservation of the supratrochlear and supraorbital
branches. Theoretically, dissection in the upper medial corner of the orbit may in-
jure the trochlear or superior oblique muscles. Such injuries are very rare and are
easily avoided by limiting the dissection behind the origin of the corrugator muscle.
It is rare that any contour deformities result from this excision of the corrugator;
however, if there is any concern, fascia or periorbital fat serve well as filler between
the cut ends of the corrugator muscle.

744
Part V  Brow Lift
In patients who have transverse glabellar or dorsal nasal skin lines resulting from
procerus muscle activity, the procerus is transversely divided through the blepharo-
plasty incision by elevating the orbicularis and then pushing a pair of scissors deep
to the skin toward the nasal radix, cutting the fibers off the procerus under the skin.
If necessary, periorbital fat is excised at this time.
The next step is brow fixation. The brow is rotated upward and medially, and the
temporoparietal fascia is anchored down to the deep temporal fascia. I usually place
two sutures of 2-0 PDS between the temporoparietal fascia and the deep temporal
fascia in a diagonal or vertical vector. More medial screw fixation may be necessary,
but this is rare. A minimal amount of excess scalp is excised, and the scalp incision
is closed with staples. The upper eyelid incision is closed.

745
Chapter 23  Temporal Brow Lift
Postoperative Care
To minimize swelling, the patient’s head is kept elevated, and ice packs are applied
to the periorbital area.
Results
This middle-aged woman underwent a temporal brow lift, transpalpebral corruga-
tor excision, a nasal compartment orbital fat flap to correct the A-frame deformity
of the upper lids, transconjunctival lower blepharoplasty with fat distribution, and
a face lift. She is shown several months postoperatively.

This 50-year-old woman exhibited aging of the upper and lower lids, lid-cheek junc-
tion, and face. Rejuvenation of the periorbital area and lower face was planned. She
underwent a lateral temporal lift, upper and lower blepharoplasty, and a short-scar
blepharoplasty. She is shown 4 years postoperatively; the improved lateral brow po-
sition has been maintained.
Problems and Complications
Infection and bleeding are rare. Alopecia may be seen along the temporal incision
line. This risk is minimized by avoiding excessive tension in the scalp closure and
limiting the use of coagulating current along the cut edges of the incision. Inade-
746
Part V  Brow Lift

quate lateral temporal release may lead to relapse or recurrence of brow ptosis. The
upper eyelid procedure increases the risk of bleeding and swelling beyond that of a
standard upper eyelid blepharoplasty. Hemostasis in the corrugator muscle bed is
essential. Unless combined with lower lid procedures, chemosis and other bleph -
aroplasty complications are rarely seen.
Concluding Thoughts
Combining a lateral/temporal lift with an upper lid blepharoplasty and transpalpe-
bral excision of the corrugator muscle through the upper eyelid is a safe and effec-
tive option for rejuvenation of the brow. It requires no special equipment beyond a
pair of loupes. The best candidates have moderate lateral brow ptosis, appropriate
medial brow position, and moderate vertical glabellar frown lines.
Clinical Caveats
 The temporal incision must be kept over the temporalis muscle. This not only elimi-
nates the risk of injury to the lateral branch of the supraorbital nerve, it also ensures
that the temporoparietal fascia can be anchored down to the deep temporal fascia.
 Complete release of the lateral orbital attachments, adhesions, and septa is essen-
tial; otherwise, the lateral brow cannot be successfully elevated.
 Dissecting instruments should be kept firmly down over the deep temporal fascia
to avoid frontal branch injury.
 Vertical spreading in the vicinity of the sentinel vein should be avoided to mini-
mize the risk of stretch injuries to the frontal branch.
 Loupe magnification greatly facilitates the transpalpebral excision of the corruga-
tor muscle.
 Connecting the lateral upper lid and brow dissections through the lower lid dis-
section facilitates lateral brow elevation.
 Serial scoring of the lateral orbicularis oculi muscle minimizes downward pull of
the orbicularis during the postoperative period, which assists fixation of the lat-
eral brow position.
747
Chapter 23  Temporal Brow Lift

Annotated Bibliography
Guyuron B. Corrugator supercilii muscle resection through blepharoplasty incision. Plast
Reconstr Surg 95:691-696, 1995.
One of the early papers describing corrugator excision through the upper eyelid.
Knize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper blepharo-
plasty. Plast Reconstr Surg 97:1334-1342, 1996.
An early description of the combination of a temporal lift with corrugator excision
through the upper eyelid.
Suggested Readings
Farkas LG. Anthropometrics and art in the aesthetics of women’s faces. Clin Plast Surg 14:
599-616, 1987.
Guyuron B. Refinements in endoscopic forehead rejuvenation. Plast Reconstr Surg 100:154-
160, 1997.
Knize DM. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast
Reconstr Surg 95:52-60, 1995.
Niechajev I. Transpalpebral browpexy. Plast Reconstr Surg 113:2172-2180, 2004.
Paul M. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg
108:1409-1424, 2001.
Tyers AG. Brow lift via the direct and trans-blepharoplasty approaches. Orbit 25:261-265,
2006.
748
Part V  Brow Lift

Endoscopic Brow Lift:
The Three-Portal Approach

FOAD NAHAI
CHAPTER 24

750
Part V  Brow Lift
For too long we have focused on brow position rather than brow shape and fullness
as representing beauty and youth. Perhaps our emphasis on brow height during the
early days of endoscopic brow lifting was not only a carryover of the thinking in the
early 1990s, but also a desire to establish that endoscopic brow lifting could elevate
and maintain brow height. Since then, our understanding of facial aging and the role
of volume and deflation has been advanced significantly through the work of Lam-
bros and Coleman. Numerous publications have also established the efficacy of the
endoscopic brow lift to elevate and maintain brow position. Our current view is that
a youthful or beautiful brow is related more to volume and shape than to height.
Endoscopic procedures have been modified with these ideals in mind. Reposition-
ing the brow with amelioration of forehead and glabellar lines is an integral part of
periorbital and full facial rejuvenation. In a balanced, youthful face, the eyebrow is
lower medially and higher laterally, with a variable arch in between. Several publica-
tions have attempted to describe the youthful or beautiful brow through numeric
measurements and formulas. However, there are many youthful and beautiful women
without high eyebrows. Given these variations of beauty and normalcy, neither ag-
ing nor the success of rejuvenation in the periorbital area should be judged by brow
height; brow shape and volume are far more important than brow height.
Low brow
Full brow
Deflated brow
High brow

Early signs of brow and periorbital aging include deflation and brow ptosis with a
lowering of the medial and lateral hair-bearing brow and development of vertical
glabellar and horizontal forehead lines. These changes often result in alterations to
facial expression, producing a tired, concerned, or even angry look. There is also real
or apparent excess skin on the upper eyelid. A variety of techniques are available to
reposition and reshape the brow and to soften vertical and horizontal frown lines.
Most involve mobilization, repositioning, and fixation of the forehead and brow
with modification of the forehead musculature. The open standard coronal brow lift
was for many years the only option for forehead rejuvenation; it remains an effec-
tive, proven operation, the benchmark against which other techniques are measured.
751
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach

In 1992 Isse and Vasconez independently pioneered what we refer to today as the
endoscopic brow lift. Since that time, this technique has evolved significantly: it has
been simplified, the instrumentation minimized, and the anatomy defined. It has
steadily gained in popularity and was once, without doubt, the most common en-
doscopic procedure, not only in aesthetic surgery but in all of plastic surgery. How-
ever, the popularity and effectiveness of toxins in reshaping and repositioning the
brow and the effectiveness of transpalpebral glabellar muscle modification combined
with a temporal brow lift have affected the number of endoscopic brow lifts per-
formed. Despite these recent developments, the procedure continues to enjoy tremen-
dous patient acceptance. Before endoscopic forehead lifts were introduced, approx-
imately 1 in 10 of my patients undergoing a face lift would accept a coronal brow
lift. Today some form of brow lift, whether endoscopic, transpalpebral, or lateral
temporal, is my routine for almost all patients undergoing facial rejuvenation.
My experience with several hundred endoscopic brow lifts over 16-plus years has
been favorable. Patient acceptance has been high, morbidity low, and my results have
compared favorably with those of the coronal brow lift.
The endoscopic approach affords excellent exposure for release of periorbital adhe-
sions; muscle excision and nerve preservation are facilitated through the endoscope’s
magnification. The approach results in shorter scars and reduces the risks of sensory
denervation of the scalp and alopecia. However, scalp excision is limited with this
approach, so that elevation and maintenance of brow position must rely on muscle
balance and fixation techniques, compared with the open coronal method in which
scalp excision maintains brow position.
752
Part V  Brow Lift
Advantages and Disadvantages of the Endoscopic Brow Lift
Advantages
 Excellent exposure for release of periorbital adhesions
 Shorter scars
 Endoscopic magnification
 Reduced risk of alopecia and scalp sensory changes
Disadvantages
 Initial cost of equipment and special instrumentation
 Technology-dependent nature of the procedures—equipment failure may prevent com-
pletion of the procedure
 Learning curve involved
 Need for additional fixation

753
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
POOR CANDIDATE
GOOD CANDIDATE
Indications and Contraindications
The best candidates for an endoscopic forehead lift are patients with short, flat fore-
heads with nonreceding, thick hairlines and normal skin, moderate rhytids, and min-
imal true skin excess laterally and over the nasal radix. Poor candidates have a high
convex forehead, a high, receding hairline with thin hair, thick skin, deep rhytids,
and true excess skin on the forehead and brow.

754
Part V  Brow Lift
Forehead height and shape are limiting factors for a rigid endoscope. In a patient
with a short, flat forehead, it is relatively easy for the surgeon to maneuver the en-
doscope to visualize the glabellar musculature and orbital rim. A convex forehead
makes it difficult to maneuver the rigid, straight endoscope, and a high forehead
places limitations on the reach of the endoscope.
Pertinent Anatomy
Key anatomic points include the sentinel vein, the temporalis muscle and temporal
crest, periorbital septa and adhesions, glabellar muscles, and the supratrochlear and
supraorbital nerves.
Sentinel Vein
De La Plaza et al described and named perforating vessels in the temporal region
sentinel vessels of the lateral wall of the orbit. These zygomaticotemporal veins are
communicating veins between the superficial and deep systems. There are usually
two veins, one medial and the other lateral; the medial is larger and is referred to as
the sentinel vein.
This endoscopic view shows the medial and lateral zygomaticotemporal veins. The
smaller, or lateral one, is often accompanied by the zygomaticotemporal nerve.

The sentinel vein (top) is a useful landmark for preoperative planning (bottom) and
a key point for the release of the periorbital septa and adhesions during the opera-
tion. In most patients in the recumbent position, the sentinel vein is located 1.5 cm
above and lateral to the lateral canthus. The lowest of the frontal nerve branches
usually passes approximately 1 cm above the level of the sentinel vein. Thus the sen-
tinel vein defines a danger zone for the frontal branch. I can operate rapidly toward
the zone with safety; however, when approaching the vein, the dissection is slowed
under endoscopic control to prevent any direct damage or stretching of the nerve.
755
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
Temporal crest
Projected course
of frontal branch
of facial nerve
Sentinel vein
Temporal crest
Sentinel vein
Projected course
of frontal branch
of facial nerve

756
Part V  Brow Lift
Temporalis Muscle and Temporal Crest
The temporal crest marks the transition from the dissection to the temporoparietal
fascial (subfascial) to the subperiosteal plane by elevating the temporal line of fu-
sion at the temporal crest. The temporal crest also marks the lateralmost course of the
lateral branch of the supraorbital nerve. Preoperatively I ask patients to clench their
teeth, and I mark the temporal crest, as seen here. My left hand rests over the con-
tracting muscle while the pen held in my right hand outlines the temporal crest just
anterior to the contracting muscle. The sentinel vein is also marked.
Sentinel
vein

757
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
Periorbital Septa and Adhesions
Although several authors have referred to ligaments in the periorbital area, Moss et
al pointed out that rather than true ligaments, there are multiple septa and adhe-
sions in the periorbital area. To mobilize the brow, especially the lateral periorbital
brow, all of the septa and adhesions must be completely divided. I have found that
skeletonizing the sentinel vein effectively releases septa and adhesions, allowing el-
evation of the brow.
Temporal
ligamentous
adhesion
Temporal branches of facial nerve
Supraorbital
ligamentous
adhesion
Zygomatico-
temporal nerve
Inferior
temporal septum
Sentinel vein
Lateral brow
thickening of
periorbital septum
Lateral orbital
thickening of
periorbital septum
Periorbital septum
Adhesions

758
Part V  Brow Lift
Glabellar Muscles
The corrugator supercilii is the first muscle encountered with the endoscopic ap-
proach in the glabellar region. Medial to the corrugator are fibers of the orbicularis
oculi muscle, called the depressor supercilii. More superficially and in the midline
lie the procerus muscles. The supratrochlear nerves run within or just superficial to
the corrugator. The bulk of the orbicularis muscle lies superficial to the corrugator
and is only viewed once the corrugator has been excised.
Supratrochlear and Supraorbital Nerves
The supratrochlear nerves are several small filamen-
tous nerves lying within or just superficial to the de-
pressor supercilii and corrugator muscles. These
nerves almost always emerge through notches in the
supraorbital rim. Injury to one or more of these
small filaments is inevitable during excision of the
corrugator muscle and is of relatively little signifi-
cance. A useful clinical landmark for the supra-
trochlear nerves is the vertical glabellar frown line
if present; it is usually 1.5 to 2 cm from the midline.
Two heads of
corrugator muscle
Procerus muscle
Depressor supercilii
Frontalis muscle
Orbital portion of
orbicularis oculi muscle
Preseptal portion of
orbicularis oculi muscle

The supraorbital nerve is much larger than the supratrochlear nerves; it is usually
one single large nerve, although occasionally two or three branches may be seen. It
emerges from the orbit through a definite notch or occasionally through a foramen
that may be up to 2 to 4 cm above the supraorbital rim. Although the supratrochlear
nerves lie within the fibers of the corrugator, the supraorbital nerve is usually deep to
the corrugator. The lateral branch of the supraorbital nerve may course as far lat-
eral as the temporal line of fusion. Any incision in the scalp that is medial to the tem-
poral line of fusion runs the risk of dividing this branch, resulting in sensory loss in
the forehead. A useful landmark for this nerve is the midpupillary line, or a distance
of 3 to 4 cm from the midline.
Preoperative Assessment
Patient evaluation includes an assessment of the medial and lateral brow position,
position of the brow in relation to the upper eyelid, assessment of glabella and fore-
head lines at rest and on animation, and assessment of frontal bone convexity, fore-
head height, and hairline. This evaluation influences the surgeon’s choice of proce-
dure. If the endoscopic brow lift is chosen, this evaluation influences the location of
the incisions, extent of muscle modification, and fixation techniques, if any are
needed.
In patients with normal or minimal medial brow descent, minimal or no glabellar
skin excess over the radix, modest lateral brow ptosis, and superficial forehead lines
at rest, I prefer the combination of a lateral temporal brow lift and transpalpebral
corrugator excision, as described in Chapter 25.
The surgeon advises the patient about the following:
 The number, location, and length of the incisions, and if fixation is required,
the type of fixation (for example, external screws or an Endotine fixation de-
vice [Coapt Systems, Palo Alto, CA]) and any additional incisions required for
fixation
 Although the risk is minimal, there may be some alopecia at the incision sites
and around the external screw fixation sites
 Temporary or even permanent sensory changes may occur in the scalp
 Some downward movement of the brow will occur within the first few months
after the procedure, and over the long term the brow will not be as high as the
initial result
759
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach

Preoperative Planning
As with any technology-dependent technique, the surgeon must have a basic under-
standing of the principles. In endoscopic aesthetic surgery, the surgeon needs to have
the following:
 The necessary training
 Appropriate mechanical equipment
 Knowledge of equipment troubleshooting and
safety measures
 The technical skills to perform the procedure
Today endoscopic equipment, including the endoscope,
camera, monitors, and so on, has become standard in
operating rooms where aesthetic surgery is performed.
Operating room personnel are now quite familiar with
this equipment and its maintenance.
760
Part V  Brow Lift
Team Preparation
The Surgeon
 Take a CME-approved endoscopic plastic surgery teaching course.
 Familiarize yourself with the endoscope and camera.
 Study a DVD or videotape of the procedure.
 Watch a colleague perform the procedure.
 If possible, have an experienced endoscopic surgeon assist you with your first case.
 Practice setting up the equipment.
The Operating Room Staff
 Receive in-service instruction from experienced operating room personnel or a manu-
facturer’s representative.
 Dismantle and set up equipment.
 Learn troubleshooting techniques.
 Be aware of the location of backup equipment.
 Stage a dress rehearsal before performing an actual procedure.
 Learn the names of the endoscopic instruments.
 Arrange endoscopic instruments in the order in which the surgeon will use them.
 Watch a DVD or videotape of a procedure.
 Visit an operating room where these procedures are routinely performed.

Originally, up to 25 special instruments were designed and marketed for the endo-
scopic brow lift. Today most of us have our own half-dozen or more favorite instru-
ments for this procedure.
As a safeguard, it is important to have a backup system available, including a sec-
ond endoscope, camera, and light source. These are readily available in a large hos-
pital or surgical center but perhaps not in a small office-based operating room. Be-
fore every operation, either the surgeon or the operating room nurse should not only
test the system but also inspect all of the instruments, especially the endoscopic
graspers. I specifically look for breaks in the insulation of the graspers. Because we
use the graspers for cauterization, any break in the insulation could cause a burn.
Markings
The major landmarks for this procedure include the sentinel vein, the temporal crest,
and fixation vectors. If the sentinel vein is readily visible with the patient sitting
down, I put a mark over it and then draw the likely course of the frontal branch of
the facial nerve 1 cm or so above the sentinel vein. If the sentinel vein is not visible
with the patient in the sitting position, I ask the patient to lie flat, and in most pa-
tients the vein is then visible.
761
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
Minimum Equipment Needs
Endoscope
Endoscope warmer
4 or 5 mm 30-degree angle Hopkins rod
Defogging solution
Endoscopic cannula or endoretractor—
Electrocautery
4 or 5 mm
Instrumentation
Endoscopic cart
Curved elevators (two or three)
Monitor
Endoscopic scissors
Light source
Insulated graspers
Camera (at least three-chip)
Fixation devices

I then ask the patient to clench his or her teeth firmly. This enables me to palpate
the muscle with my left hand as my right hand outlines the temporalis muscle and
the temporal crest on the forehead just anterior to the contracting muscle. I then
mark the access incision 1 or 2 cm behind the temporal hairline, making certain that
I am over the temporalis muscle. This will facilitate fixation of the temporoparietal
fascia down to the deep temporal fascia.
These markings are made symmetrically on both sides of the head. The orientation
of this temporal incision varies from radial to coronal. I individualize this based on
the patient’s anatomy and our goals. I prefer a coronal or horizontal incision to a
radial incision, because with the radial incision I am limited to one fixation suture,
whereas the other approach allows me to put in a minimum of two fixation sutures.
762
Part V  Brow Lift

I then ask the patient to frown, which outlines the origin and insertion of the cor-
rugator muscle. Next I mark the glabellar frown line and the course of the muscle
lateral to it to be a guide for muscle excision. I also mark the midpupillary line, in-
dicating the course of the supraorbital nerve. Another mark is placed 2 to 4 cm above
the orbital rim in the midpupillary line, indicating a danger zone where the supra-
orbital nerve could emerge through a foramen.
Finally, the vectors for fixation are marked. For temporal fixation, I routinely rely
on vector from the alar base to the lateral canthus projected onto the forehead. An
alternative line is drawn from the oral commissure to the lateral canthus and then
onto the forehead. This vector provides a more vertical and upward elevation of the
lateral brow.
If extra fixation is planned, such as with a screw or an Endotine device, I individu-
alize these vectors. In general, I place them on the scalp in line with the most con-
vex arch of the brow.
763
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
The projection of the most convex part of the brow onto the scalp is marked as the
site for additional fixation.
The patient is shown with all of the final markings.
Midline
Temporal
crest
Sentinel
vein
Course of
supraorbital
nerve
Projection line
representing highest
point of brow arch
Temporal
crest
Projection line
representing highest
point of brow arch
Sentinel
vein
Course of
supraorbital
nerve
Midline

764
Part V  Brow Lift
Patient Positioning
The patient is placed supine on the operating
table with the head extending slightly beyond
the headpiece. This facilitates maneuvering of the
endoscope and endoscopic instruments. The pro-
cedure can be performed with the patient under
local or general anesthesia. I prefer a general
anesthetic because, in my practice, endoscopic
brow-lift procedures are almost always per-
formed in combination with other periorbital
and facial rejuvenation procedures.
Back table
Mayo stand
Videoendoscopic
equipment
(including monitor)
Operative Sequence
1. Hair preparation
8. Muscle modification
2. Infiltration
9. Drain placement
3. Right temporal incision and dissection
10. Closure of central access incision
4. Left temporal incision and dissection
11. Placement of temporal fixation
5. Central access incision
sutures
6. Subperiosteal dissection
12. Additional fixation, if needed
7. Division of periosteum from one lateral
13. Tying of temporal fixation sutures
orbital rim to the other
14. Temporal scalp excision, if needed

Operative Technique
Hair Preparation
765
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
With the patient under general anesthesia, I cleanse the hair with a soapy solution
and braid the hair to expose the proposed incision sites. Braiding keeps the hair out
of the way during the procedure; alternatively, the hair may be stapled on each side
of the proposed incisions.
Infiltration
The brow area is infiltrated with a solution of 1% lidocaine (Xylocaine) and epi-
nephrine 1:100,000, encompassing the entire area that will be undermined.
Temporal access site
Fixation site
Central
access site
Proposed
fixation site

Temporal Incisions and Dissection
I begin the procedure on the right side; the incision is made through the scalp down
to the deep temporal fascia over the temporalis muscle.
766
Part V  Brow Lift
Sentinel vein
Temporal crest
Sentinel vein
Temporal crest
Sentinel vein
Temporal crest
With a hook elevating the lower edge, I dissect in the plane between the temporopari-
etal fascia and the deep temporal fascia. This is a bloodless field, and the dissection
proceeds rapidly toward the lateral orbital rim.
Once the dissection is started, I switch from Metzenbaum scissors to a Ramirez No. 4
dissector. I dissect rapidly toward the orbital rim, without the endoscope but under
direct vision, with an Aufricht retractor and a headlight, keeping the tip of the dissec-
tor firmly down on the deep temporal fascia. This avoids any possible risk of dam-
age or stretching of the frontal branch. The dissection is stopped within 1 cm of the
sentinel vein. This nonendoscopic dissection is continued medially through the tem-
poral line of fusion and then in a superior direction so that the temporal line of fu-
sion is elevated and the subperiosteal space is entered. At this stage the endoscope
is introduced, and with the same dissector the dissection is continued toward the
sentinel vein and the lateral orbital rim.

The sentinel veins are easily identified. In most patients I am able to divide the septa
and adhesions around the sentinel vein and extend the dissector into the upper eye-
lid, deep to the orbicularis and the retroorbicularis oculi fat (ROOF).
767
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
Sentinel vein
(medial zygomatico-
temporal vein)
Lateral
zygomatico-
temporal vein
Zygomatico-
temporal
nerve
Sentinel vein
(medial zygomatico-
temporal vein)
Sentinel vein
(medial zygomatico-
temporal vein)
Division of periorbital adhesions
with endoscopic scissors
If the adhesions around the sentinel vein cannot be taken down with the dissector,
I complete their division with the endoscopic scissors under direct endoscopic
control.

I make every effort to preserve and skeletonize the sentinel vein. At this stage I place
traction on the lower edge of the incision, pulling the brow upward. This confirms
whether all of the adhesions have been released and that the lateral brow is now
mobile. Failing to release the lateral brow limits the result. The procedure is then re-
peated in exactly the same way on the left side.
Central Access Incision
The central access incision is made in the midline, approximately 1 cm behind the
hairline. This is a radial incision extending straight through to the periosteum.
768
Part V  Brow Lift
The subperiosteal dissection is initiated with a straight periosteal elevator and ex-
tended toward the glabella, laterally toward the temporal incisions, and posteriorly
for 3 or 4 cm. This dissection is fairly rapid, and I progress through two other peri -
osteal elevators with increasing curvature.
Sentinel vein
(all adhesions
have been divided)

The subperiosteal dissection is connected with both temporal dissections and ex-
tended in the midline to the glabella and to a level approximately 2 to 4 cm above
the supraorbital rim. This subperiosteal dissection is performed blindly.
769
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
The endoscope is then introduced through this central access incision so that the
subperiosteal dissection, which is completed down to the supraorbital rim, is con-
tinued under endoscopic control to permit identification and easy preservation of
the supraorbital nerve if it emerges through a foramen above the supraorbital rim.
Square-tipped,
curved elevator
Periosteum
Bone

770
Part V  Brow Lift
Division of the Periosteum
At this stage the periosteum is divided from one lateral orbital rim to the next. This
periosteal division serves two purposes:
1. Division of the periosteum to allow further brow elevation laterally. The me-
dial brow and glabellar periosteum may be left intact if medial brow eleva-
tion or separation is not desired.
2. Division of the periosteum to permit access to the glabellar musculature.
Muscle Modification
After the periosteum is divided, the corrugator, procerus, and depressor supercilii
are easily seen. The direction of the muscle fibers aids in identifying each individual
muscle. The procerus fibers have a slightly deeper color, with the fibers running ver-
tically. The depressor fibers are lighter in color and vertically oriented also, whereas
the corrugator fibers run diagonally.
Sharp, square-
tipped, periosteal
rim elevator
Periosteum
Bone
Corrugator seen
through split in
periosteum
Divided edge
of periosteum

771
Chapter 24  Endoscopic Brow Lift: The Three-Portal Approach
I have tried various instruments for muscle modification, including Takahashi for-
ceps, coagulating current, a laser, and even a periosteal elevator. My preference now
is the endoscopic grasper; I grasp a little muscle at a time and tease it upward.
I have found that the muscle tears very easily, but the branches of the supratrochlear
nerve are more resilient. Depending on the bulk of the muscle and the severity of the
patient’s glabellar lines, I vary the extent of muscle division and the amount of mus-
cle I remove.
Takahashi
forceps
Corrugator
muscle
Supraorbital nerves
Supratrochlear
nerves
Vein
Vein
Corrugator
muscle
Supraorbital nerves
Supratrochlear
nerves
Vein
Vein
Corrugator
muscle
Supraorbital nerves
Supratrochlear
nerves
Vein

At the end of the muscle modification, the branches of the supratrochlear nerve
should lay bare within the optical field. Sometimes with a heavy muscle I extend the
dissection laterally, superficial to the supraorbital nerve.
772
Part V  Brow Lift
Orbicularis
muscle
seen after
corrugator
removal
Nerves
Supratrochlear
vein
Supratrochlear
nerves
Supratrochlear
nerve
Supraorbital
nerve
Supratrochlear
vein