The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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The best solution is to combine this technique with further har-
vesting of posterior scalp donor hair to create more small grafts
for filling in between previous grafts.
Patients with unnatural hairlines may present special prob-
lems, such as improper angulation of the original grafts, or
hairlines placed too low, too high, or too straight. Again, a proper
preoperative evaluation is critical, depending on which of these
four problems is present. In a patient with improper angulation
of previous grafts, simply filling in between with new grafts will
not solve the problem. These grafts must be excised carefully,
as previously discussed; regrafting of the entire area is the best
solution using both the old recut grafts along with new ones. In
patients whose hairlines are too low, more aggressive treatment
may require scalp excision and a forehead lift in addition to plug
excision and graft recycling (Fig. 25.9).
Avoiding Donor Site Problems in Patients
with Previous Transplant Procedures
• The tension in the donor site closure should be minimized.
• Scalp elasticity should be evaluated in patients with multiple
donor site scars.
• The closer the previous scars are to the lower neck hairline,
the better the elasticity, because it is possible to recruit neck
skin.
• The higher the previous donor site scars and the closer to the
fixed occipital scalp, the less elasticity will be available. This
makes further donor site excisions more difficult to close.
• Patients who had previous plug grafts harvested from the
donor area have stiffer donor tissue, making closure of strip
excisions more difficult.
• Multiple previous transverse strip excision donor sites should
be noted because of the risk of tissue devascularization asso-
ciated with further harvesting of donor tissue.
Fig. 25.6 In this case, hair was transplanted along the patient’s right
frontal hairline at the wrong angle. Even though the grafts were small
and natural-appearing, because of their incorrect angulation, they
created a strange appearance. This patient requested correction,
which required excision of the scalp in the area marked by the ellipse.
After this area healed, grafts were inserted at the correct angle,
solving the problem.
Fig. 25.7 This patient’s hair grafts were inserted at too acute an angle.
The hairs are growing straight forward from the scalp, yielding a very
unnatural appearance. To correct this problem, excision, recycling, and
new grafting were all required.
Fig. 25.8 Treatment of patient with unsightly previous plug grafts.
(a) Partial plug removal. (b) Plugs removed to be recycled into
minigrafts; (c) Additional micrografts and minigrafts. (d,e) Immediate
postoperative result.
b
a
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25.7 Patient Examples
25.7.1 Cornrow Plugs
A case in which the techniques previously described were used
to correct a cornrow appearance due to the use of large plug
grafts in a patient with light skin and dark hair is summarized
in Fig. 25.10.
25.7.2 Isolated Frontal Forelock
Some patients develop an isolated frontal forelock as they age
(Fig. 25.11). :hen connecting this forelock with the hair poste-
riorly, it is important not to drop the hairline too low. It may be
necessary to begin transplanting behind the frontal forelock.
25.7.3 Temporal Alley Defect
In patients who have had previous transplants along the superior
scalp and occipital area, a gap or ´alleyµ may develop as the hair
recedes inferiorly along the sides of the head (Fig. 25.12). In this situ-
ation, a combination of procedures is required, including excision of
the scalp as well as further grafting (Fig. 25.13; Fig. 25.14; Fig. 25.15).
A common problem after scalp excision, however, is the phe-
nomenon of ´stretch back.µ This refers to the progressive widening
over time of the excised area as a result of tissue relaxation (Fig.
25.16).
25.7.4 Abnormally Low Hairline
One of the most difficult problems to correct is a hairline that has
been placed too low, especially if unsightly plugs were used. In
this situation, the old plugs must be carefully excised and recut
into small grafts. Scalp excision and forehead lift may also be
required. In these complex cases, multiple stages are frequently
required (Fig. 25.17; Fig. 25.18; Fig. 25.19; Fig. 25.20).
Fig. 25.9 Management of secondary cases.
Fig. 25.10 (a,c) This patient presented with noticeable plug grafts along
the hairline. Because the patient had a high-contrast component with
dark hair and light skin, the plugs seemed even more obvious. Correction
of this common problem was accomplished using three different
techniques. First, the old plugs along the outer edge were excised; next,
the plugs were cut into small follicular units to be reinserted. At the same
time, an ellipse of posterior scalp measuring 1.8 cm wide and 16 cm
long was excised and cut into 1,200 follicular units. These small grafts
plus those that were recycled were then placed between and in front of
the remaining plugs. The excised plug sites, which usually measure 5 to
6 mm in diameter, were closed with a single 5–0 nylon suture that was
left in for approximately 1 week. (b,d) One year postoperatively, the
patient is healed and has had complete correction of the artificial plug
look. The results here demonstrate that hair transplants should not be
recognizable but should resemble natural hair.
a
c
b
d
Fig. 25.11 (a,b) This patient demonstrates the appearance of an
isolated frontal forelock. He has two isolated tufts of hair on his head,
creating a bizarre, unnatural appearance. To correct this problem,
a single session of 1,500 follicular grafts was used to connect the
two isolated forelocks with the hair posteriorly. (c) This approach
produced improved framing of the face and a much more normal
appearance to the hairline. Also, the hair was placed in an irregular
pattern, which produced a more natural appearance.
b
c
a

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Fig. 25.15 At a separate session with the patient in Fig. 25.14, 4 months later, approx-
imately 1,200 follicular grafts were placed in the area, completing the restoration and
significantly improving the appearance in the temporal area.
Fig. 25.16 A common problem after scalp excision,
however, is the phenomenon of “stretch back.” This
refers to the progressive widening over time of the
excised area as a result of tissue relaxation.
Fig. 25.14 The edges of the excised defect shown in Fig. 25.13 were pulled together, thereby reducing the amount of stretch.
Fig. 25.12 This patient presented with a temporal alley defect after an
unsuccessful attempt at hair transplantation.
Fig. 25.13 The skin containing the temporal alley defect in the patient
in Fig. 25.12 was excised and a hole was created for the Mitek suture
fixation device, which was placed on either side of the defect.

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Fig. 25.17 This patient presented with an abnormally transplanted hairline, with the grafts placed too low in the temporal region. Besides the
original transplanted hairline being too low, the grafts had also been placed incorrectly in a curved line so that the temporal area was rounded off,
thus losing a normal frontotemporal angle.
Fig. 25.18 (a) A more aggressive approach was required for revision of the case in Fig. 25.17. A radical excision of the previous plug grafts was done,
along with excision of a segment of scalp along the frontal and temporal areas. (b,c) Holes were then made at multiple sites for insertion of Mitek
devices.
a
b
c
Fig. 25.19 (a) The Mitek device with 2–0 Ethibond sutures attached was inserted into the defect shown in Fig. 25.18. The sutures were tied with
significant elevation of the forehead in both the midline and the temporal area. (b) The incision was allowed to heal for several months, and then the
patient underwent micrografting to the area.
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b

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Correction of a Low Hairline:
Operative Overview
1. The frontal hairline scalp, including the old unsightly plugs,
is excised as a circumlinear ellipse.
2. The galea is left intact and the ellipse of skin with its old plug
grafts is recycled, as described earlier, creating new, small,
one- to two-hair grafts for replanting.
3. Next, a forehead lift is performed while the excised hair is
being recut.
4. Unlike a traditional forehead lift, in which the goal is
elevation of the eyebrows and upper lids, this forehead
lift advances the forehead skin superiorly to raise the new
future hairline, leaving the eyebrows alone. This is accom-
plished by not dissecting below the superior orbital ridges
and releasing these tissues.
5. The frontal forehead is stretched superiorly by making
numerous parallel, horizontal releases in the periosteum in
a subperiosteal dissection or in the galea in a subcutaneous
dissection.
6. Next, deep sutures of 3–0 Ethibond (Johnson Johnson,
New Brunswick, NJ) are used with the Mitek fixation device
(Mitek Products, Westwood, MA), outer table drill holes, or
the Endotine device (Coapt Systems, Palo Alto, CA) to fix
the forehead in an elevated position. (I have used all three
techniques with excellent results.)
7. The suture fixation device is placed several centimeters
above the new future hairline to allow maximal elevation
while it is being tied.
8. Once the forehead has been adequately elevated along its
superior aspect, the skin is closed with 3–0 polyglactin 910
(Vicryl, Johnson Johnson, New Brunswick, NJ) sutures and
a running 3–0 or 4–0 poliglecaprone 25 (Monocryl, Johnson
Johnson, New Brunswick, NJ) suture.
9. The old plugs, which have been recut into small grafts, are
now reinserted behind the suture line.
10. After the skin is adequately healed in 3 to 4 months, large-
volume grafting is begun to create a new, natural hairline.
25.7.5 High Hairline
In men, hairlines that are too high are rarely a problem, and as
long as donor hair is available, further sessions of grafting, using
small grafts with an appropriate irregular hairline, solve these
patients’ problems. However, in women who have had an overly
aggressive forehead lift, a high hairline can create an abnormal
appearance, especially if it also creates a masculinizing acute
temporal recession.
25.7.6 Straight Hairline
Another problem that presents a reoperative challenge is a
transplanted hairline that is extremely straight. Hairlines need
to be irregular; even in patients with small grafts, straight hair-
lines are noticeable. Obviously, if the straight hairline includes
unsightly plugs, these must be excised and recycled, as previ-
ously described. In many of these patients, as long as the hairline
is not too low, it can be improved by placing small one- to
two-hair grafts in an irregular pattern in front of the previously
grafted areas. It is easier to improve the hairline in patients
with light skin and light-colored hair, because the color contrast
is less obvious than in patients with dark hair and light skin.
In high-contrast patients with dark hair and light skin or light
hair and dark skin, a greater number of grafts will be required
to mask the previous procedure and create irregularity. This is
true for all corrective procedures. Color contrast is a subtle but
important issue when performing secondary hair restorations.
25.7.7 The Noticeable Donor Site Scar
Independent of the problems associated with the recipient
site is the problem of a noticeable linear donor site scar. With
the development and refinement of follicular unit extraction
(FUE), a technique of camouflaging the linear donor site scar is
available.
The FUE grafts are harvested above and below the previous
linear scar and are primarily used for further grafting in the areas
of general hair loss. However, a small percentage of the grafts are
retained to be placed directly into the previous linear scar.
Typically, the FUE grafts cannot be placed as close together in
scar as in the normal recipient areas but must be placed farther
apart because of the characteristics of scar tissue. Scar tissue may
have decreased blood supply compared to normal scalp, and spac-
ing the follicular grafts farther apart than the traditional spacing
in the scalp ensures their viability. Also, it is more difficult to place
grafts into scar tissue compared to normal scalp because the scar
does not have the elasticity of normal tissue (Fig. 25.21).
25.7.8 Traumatic Hair Loss
One of the most common causes of traumatic hair loss is aes-
thetic facial surgery. This can be caused either by direct damage
to the follicles from superficial elevation of the skin flaps or by
Fig. 25.20 Postoperatively in the patient shown in Fig. 25.19 (a,c)
a significant elevation of the forehead is evident, with creation of a
normal frontotemporal angle in contrast to the preoperative condi-
tion. (b,d) The patient has a visible scar in the temporal area from the
forehead lift. However, this scar could not be avoided, because further
grafting in this area would have re-created the abnormal appearance.
a
c
b
d

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Fig. 25.21 This patient had a strip harvesting procedure 5 years
previously and requested a follicular unit extraction (FUE) procedure
for his second hair transplantation. FUE grafts were placed directly into
the previous linear scar, as seen on the right side, prior to insertion on
the left. The grafts are spaced far enough apart to ensure viability.
excessive tension leading to ischemia. The skin may not visibly
show signs of ischemia after aesthetic surgery, but there may
be enough relative decrease in tissue perfusion to damage the
follicles. In most patients, the hair regrows after 4 to 6 months,
but in some cases the hair loss is permanent.
In some patients, simple excision of the non-hair-bearing scar
can be successful. However, this maneuver often fails, because
the new scar may also lose its hair, and reexcision, because of the
risk of undue tension, will lead to ischemia and further hair loss.
For these reasons, many patients with traumatic hair loss require
hair transplantation to fill in the defect (Fig. 25.22). Remarkably,
small hair transplants placed directly into scar tissue consistently
grow. The problem with placing small grafts into scar tissue is
mechanical. Unlike normal scalp, which is relatively thick, areas of
hair loss with or without scar tissue are frequently thin, and it can
be difficult to insert the grafts in these areas. Using a tumescent
technique in the recipient areas is particularly helpful in this sit-
uation. The tumescent fluid creates the depth necessary for graft
insertion. In some of these patients the grafts cannot be placed as
close together, because the scar is thin and relatively ischemic. In
these patients several sessions performed over a period of time
may be more useful.
Most patients with traumatic hair loss have their hair restored
in two sessions of grafting. Combining excision with grafting may
be the ideal situation, because excising a portion of the non-hair-
bearing area produces a smaller area requiring grafting. :hen
combining these two procedures, the surgeon should excise the
skin conservatively, because further tension and ischemia will
lead to more hair loss and may create a relatively hypoxic environ-
ment in which few of the transplanted grafts survive.
One of the benefits of today’s micrografts or follicular grafts is
their high success rate. These small grafts have fewer metabolic
demands than the larger grafts previously used and usually do
well in areas of scar tissue and even in skin grafts. The older-style
plugs, especially those with 10 to 20 hairs in each plug site, had
less tolerance for ischemia. Frequently, patients with old plugs
have sites or areas within the plugs with poor hair growth.
One also sees scars from the old plugs creating a ´cobblestoneµ
appearance, with little or no hair growth. This occurs because
the skin of the plug graft was neovascularized and survived, but
the follicles within never successfully grew hair. This cobblestone
look is unsightly, and excision of the non-hair-bearing skin plugs
is frequently the best solution, followed by further grafting when
possible.
25.8 Postoperative Care
Of all the areas of aesthetic surgery, hair transplantation,
whether primary or secondary, is one of the easiest procedures
to deal with in the postoperative period. Every physician has his
or her own protocols. I put patients in a protective head dressing,
Fig. 25.22 (a,c) This woman had posttraumatic hair loss in both the
preauricular temporal area and the posterior neck–postauricular area
after a facelift. In one session, 350 grafts were placed in the temporal
area and 400 in the posterior neck–postauricular area. Care was taken
to angulate the hair grafts properly; this maneuver is essential to
achieving a natural result. In the temporal area, hair naturally grows in
a downward and slightly posterior direction. In the posterior neck, the
hair needs to grow downward and slightly backward. (b,d) Following
these guidelines, significant improvement can be achieved in a patient
with traumatic hair loss after aesthetic surgery.
a
c
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similar to a facelift dressing, for 24 hours and then remove it.
Where there is a donor site closure with sutures, the patient
washes this area in a normal manner. :here the grafts have
been inserted, I instruct patients that after the first 24 hours,
they should blot a mild shampoo on the recipient site once a day
and rinse the area using a cup, avoiding a direct shower stream
hitting the recipient grafts. After 6 days patients can wash the
recipient areas without any restrictions, since the small grafts
are well fixed at this time. I usually leave sutures in for 10 to 12
days in the linear donor site area and where a forehead lift has
been performed because of significant tension. Otherwise, noth-
ing unique is required in the immediate postoperative period for
management of these patients.
25.9 Concluding Thoughts
Many factors go into creating a successful hair transplant.
Avoiding complications before they occur is obviously the opti-
mal situation. Many of the problems associated with less than
satisfactory results after hair transplantation are more often
associated with mistakes in judgment and less likely the result
of errors in surgical technique. To avoid an unnatural result, the
surgeon must realize that hair loss is progressive in nature. It is
important to design a hairline that will be aesthetically accept-
able over time as the patient matures and hair loss continues.
Clinical Caveats
• The following four characteristics are associated with unsuc-
cessful hair transplantation: (1) large, unnatural plug grafts,
(2) an extremely straight hairline, (3) a blunted frontotempo-
ral angle, and (4) a hairline that is too low.
• Surgical correction of large, unnatural plug grafts requires
graft excision, recutting into individual one- and two-hair
grafts, reimplantation of new small grafts, and closure of
individual donor sites with single small sutures.
• Surgical correction of a hairline that is too straight involves
removal of periodic grafts along the hairline if plugs are pres-
ent, with recycling farther back, and use of small single-hair
grafts to create a feathered, irregular hairline.
• Surgical correction of a blunted frontotemporal angle includes
removal of hair grafts and elevation of the temporal skin, with
advancement superiorly and posteriorly.
• Surgical correction of an abnormally low transplanted hairline
requires excision of frontal grafts, with reimplantation farther
back, excision of skin along the transplanted hairline, and a
forehead lift and closure of the defect.
• Color contrast is a subtle but important consideration when
performing secondary hair restorations.
Suggested Reading
>1@ Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting. St.
Louis, MO: 4uality Medical Publishing; 2002
>2@ Barrera A. The use of micrografts and minigrafts for the treatment of burn alope-
cia. Plast Reconstr Surg 1999;103(2):581–584
>3@ Barrera A. The use of micrografts and minigrafts for the correction of the post-
rhytidectomy lost sideburn. Plast Reconstr Surg 1998;102(6):2237–2240
>4@ Bernstein RM, Rassman :R. Follicular transplantation. Patient evaluation and
surgical planning. Dermatol Surg 1997;23(9):771–784, discussion 801–805
>5@ Bernstein RM, Rassman :R. The aesthetics of follicular transplantation. Derma-
tol Surg 1997;23(9):785–799
>6@ Epstein -S. Revision surgical hair restoration: repair of undesirable results. Plast
Reconstr Surg 1999;104(1):222–232, discussion 233–236
>7@ Greco M, Raposio E, Raposio E, et al; 1ordstr|m REA. The ´1ordstrom sutureµ to
enhance scalp reductions. Plast Reconstr Surg 2001;107(2):577–582, discussion
583–585
>8@ Orentreich 1. Autografts in alopecias and other selected dermatological condi-
tions. Ann N Y Acad Sci 1959;83:463–479
>9@ Uebel CO. Hair Replacement Surgery: Micrografts and Flaps. 1ew Springer-Verlag; 2000
>10@ Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann
Plast Surg 1991;27(5):476–487
>11@ Vogel -E. Correction of the cornrow hair transplant and other common problems
in surgical hair restoration. Plast Reconstr Surg 2000;105(4):1528–1536, discus-
sion 1537–1541
>12@ Vogel -E. Advances in hair restoration surgery. Plast Reconstr Surg
1997;100(7):1875–1885, discussion 1886–1889

Part V
Brow Lift
V

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26 Clinical Decision Making in Brow Lift: Brow Rejuvenation
Foad Nahai
Abstract
There are a variety of surgical and nonsurgical procedures for
rejuvenation of the brow. Clinical applications of each and its role
in periorbital rejuvenation including brow lift are discussed.
Keywords
neuromodulators/toxins, coronal brow lift, endoscopic brow lift,
temporal lift, direct brow lift brow pexy
26.1 Evaluation
:e evaluate the entire face rather than isolated zones. The
hallmark of a youthful face is the smooth transition from zone
to zone; for example, brow to eyelid, eyelid to cheek, cheek to
perioral area, perioral area to jawline, jawline to neck. For best
results, procedures are planned to rejuvenate all of these areas
and to restore a harmonious transition from zone to zone.
It comes as a surprise for a patient seeking an ´eyelid liftµ to
be advised that in addition to blepharoplasty, a brow lift is also
recommended. Most patients will accept the surgeon’s recom-
mendation, yet others resist, saying they want only to remove
the excess skin or bags from their eyelids. For some it becomes a
financial consideration, with concerns that each added procedure
will increase the cost. Regardless, we explain to the patient that
regional or full facial rejuvenation would be the best option rather
than localized, isolated procedures. :e leave the final decision to
the patient.
In my practice, an isolated brow lift is a rarity. I consider a brow
lift to be one component of periorbital rejuvenation, encompass-
ing the brow, upper and lower eyelids, eyelid–cheek junction, and
midface. 1o brow or forehead rejuvenation is complete without
considering rejuvenation of at least the upper eyelids, if not the
entire periorbital area. :hen evaluating a patient’s face, I make
note of the morphologic structure and anatomic features; then I
evaluate the changes resulting from the aging process. Morphology
refers to the study of the shape or form of an anatomic structure;
thus it is the morphologic structure of the face, breast, and body,
rather than the anatomy, that we change through aesthetic sur-
gery. themselves is essential in aesthetic surgery. This includes bony
prominences, eye prominence, nasal prominence, and hairline
shape, whereas aging changes include changes in the skin, subcu-
taneous tissues, deeper soft tissues, and even the bones.
26.1.1 Anatomic Features
The convexity of the forehead and any supraorbital bony prom-
inence is noted. The thickness of the retro–orbicularis oculi fat
(ROOF) is assessed. The hairline and height of the forehead are
noted. :e also note how thick the hair is and areas where the
hairline is receding (Fig. 26.1).
26.1.2 Evaluation of the Aging Forehead
and Brow
Features to Assess
• Brow position³lateral and medial
• Rhytids³horizontal and vertical, at rest and on animation
• Crows’ feet
• Lateral orbital crowding
• Skin
Evaluation should include an assessment of the position of the
brow laterally and medially, the relationship of the brow to the
upper eyelid, and the distance from the upper lid sulcus to the
hair-bearing brow. Horizontal and vertical forehead and gla-
bellar rhytids are assessed at rest and on animation, as are the
crow’s feet. (Horizontal forehead rhytids are more common in
men.) The quality, elasticity, and thickness of the forehead skin
are also evaluated. Lateral orbital bunching or crowding is noted
with the eyebrow at rest and when elevated (Fig. 26.2).
Evaluation of Brow Position
The medial brow is usually lower than the lateral brow, with
a variable arch in between. The position of the brow is judged
based on the relationship of the hair-bearing brow to the supra-
orbital rim. A lower brow position is typically seen in men; in
fact, brow position varies with sex, age, and ethnic background.
The ideal brow position also varies according to fashion and cul-
ture. High, arched brows are more common and more desirable
among those of Hispanic, Latin, and Mediterranean origins. Low
brow position is associated with a tired, unhappy appearance,
whereas excessive brow elevation is associated with a frightened
or surprised look.
Fig. 26.1 Factors to consider when anatomically evaluating the face.

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Brow height does not necessarily signal youth. Brow fullness
and shape are far more important than height, as indicated by the
three images of young women shown in Fig. 26.3.
Evaluation of Rhytids, Crow’s Feet, and the
Lateral Orbital Area
The patient is asked to frown, elevate the brow, and tightly close
his or her eyes so that the glabella, forehead, and crow’s-feet
rhytids can be assessed. Brow position and the lateral orbital
area are also evaluated during each of these facial movements. By
observing these muscle contractions in relation to brow, eyelid,
and lateral orbital movement, the surgeon can assess muscular
interactions. Success in relocating the brow to the desired posi-
tion will largely depend on modification of this muscle balance.
Evaluation of Skin
The quality and quantity of the skin on the forehead, upper eyelid,
and lateral orbital area are evaluated for thickness, elasticity,
and the presence of rhytids. The depth of the rhytids and the
skin texture are noted. Any excess skin is also noted, including
determining whether the skin excess is real or apparent, with
particular attention to whether there is excess skin in the gla-
bella over the nasal radix (Fig. 26.4).
26.2 Treatment Options
There are a variety of surgical and nonsurgical options as pri-
mary procedures. Adjunctive treatments such as resurfacing
may be performed at the same time to enhance the results.
Fig. 26.2 Comparison of a youthful and aged forehead and brow
region: the brow position (medial and lateral) needs to be evaluated
along with location and direction of rhytids of the forehead, brow, and
periorbital regions.
Fig. 26.3 Brow height does not necessarily signal youth. Brow fullness and shape are far more important than height, as indicated by the three
images of young women shown here.

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Treatment options range from toxin injections to the traditional
open coronal forehead lift.
26.2.1 Options for Forehead
Rejuvenation
The goals of forehead rejuvenation are to reposition or reshape
the brow into a more youthful position or desired shape. Brow
shape is far more important than brow elevation. Injection of
toxins is effective not only in elevation of the brow, but also
in reshaping. Surgical rejuvenation of the brow leads to brow
repositioning or shaping through a combination of steps,
including mobilization of the brow and modification of muscles
to assist in maintaining brow position and ameliorating rhytids.
The open coronal lift was for years considered the standard
procedure; now, with several options available, it is considered
the benchmark procedure to which all others are compared. In
Table 26.1, I have compared the various procedures, including
injectables, in terms of ease of exposure of the anatomic
structures, muscle excision, and forehead mobilization. Scalp
excision is included, because at one time it was the only option
for fixation. I have found the endoscopic approach to be as effec-
tive as the coronal, and in selected patients the combination of
a lateral approach with transpalpebral muscle excision has also
proved satisfactory.
Selection of a technique is based on aging changes and the
patient’s anatomy. As important in this selection process is the
surgeon’s familiarity and experience with each procedure, and
in the final analysis, we will each select a procedure that in our
hands will produce the best result with minimal morbidity (Fig.
26.5).
My preferred surgical options and the frequency with which
each is performed are as follows (Fig. 26.6):
• Full endoscopic (1)
• Lateral-temporal (30)
• Transpalpebral muscle excision (5)
• Combination³lateral-temporal plus transpalpebral muscle
excision (64)
Open Coronal Forehead Lift
The open coronal approach affords excellent exposure and
facilitates release of adhesions, muscle excision, and brow mobi-
lization (Fig. 26.7). The scalp excision is tailored to elevate the
brow as desired and enhance its shape. The extensive incision
involved, together with the risk of sensory changes, including
dysesthesias, numbness, and alopecia, is perceived as a deterrent
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
preferred procedures listed previously.
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 combination of
the lateral approach with transpalpebral muscle excision. Those
with a high forehead also present a challenge to the endoscopic
approach, making it technically very difficult, if not impossible. An
alternative would be an open coronal biplanar approach to fore-
head rejuvenation, allowing shortening of the forehead height.
Endoscopic Forehead Lift
The endoscopic forehead lift (Fig. 26.8) is not without its limita-
tions. Although it can be uniformly applied in every patient, the
results will vary according to the patient’s anatomic features as
well as the aging changes present. There are certain anatomic
features that make the endoscopic approach rather challenging.
Patients with those features are best served by one of the alter-
native approaches (Fig. 26.9; Table 26.2).
The endoscopic approach affords excellent exposure for release
of the periorbital adhesions and septa; the magnification offered
Fig. 26.4 Factors to consider when evaluating the forehead include
both anatomic features related to the shape and framing of the
forehead and brow and age-related changes.
Table 26.1 Options for forehead rejuvenation
Exposure
5eOeDVe RI DdKeViRnV
Muscle excision
)RreKeDd mREiOi]DWiRn
Scalp excision
Open coronal
++++
++++
+++
++++
++++
Endoscopic
++
++++
++++
++++
+
Direct approach
+++
+++
+
+++
++++
Transpalpebral
++
+
+++
+++
—
Lateral approach
+++
+++
—
+++
+++
Toxins
NA
NA
Temporary paralysis
+++
NA
Degree of effectiveness indicated by the number of pluses. NA, not applicable; —, not possible.

286
V Brow Lift
Fig. 26.5 Various approaches for brow rejuvenation. One must weigh the advantages and disadvantages of these approaches when deciding on a
treatment plan.
Fig. 26.6 The author’s preferred surgical approaches and their
frequencies. The author’s most frequent approach is combination of
treatments to include a lateral temporal brow lift with a transpalpebral
muscle excision.
Combination—
lateral–temporal+
transpalpebral
muscle excision
64%
Lateral–temporal
30%
Full endoscopic
1%
Transpalpebral
muscle excision
5%
Fig. 26.7 An open coronal brow lift can provide excellent exposure
and mobilization of the brow along with an ability to perform muscle
excision. Shown is a peak centered at the midline (bicoronal brow lift).
Variations of this incision can be made to help better camouflage the
incision depending on the patient’s hairline.

 &OiniFDO 'eFiViRn 0DNing in %rRZ /iIW %rRZ 5eMuYenDWiRn
287
through the endoscope facilitates muscle excision and nerve
preservation. Scalp excision is rather limited with the endoscopic
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 main-
tains brow position. Even 26 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 necessaryµ to the other extreme: that fixation must be per-
manent. I individualize the need for fixation, whether permanent,
temporary, or not at all. :e must bear in mind that toxins provide
a way to reposition the brow effectively through altering muscle
balance without any surgical fixation.
Lateral–Temporal Brow Lift
The lateral–temporal approach affords excellent repositioning
and elevation of the lateral brow through a temporal incision
(Fig. 26.10). 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
Fig. 26.9 The shape of the forehead and hairline can have significant
implications on access and visualization for an endoscopic approach.
The patient at left has a shorter forehead with a flatter contour,
making it more favorable for an endoscopic approach. Hair thickness,
skin thickness, and depth of rhytids are other considerations to take
into account.
Table 26.2 Endoscopic forehead lift: favorable and unfavorable
candidates
AnDWRmiF IeDWureV
)DYRrDEOe
8nIDYRrDEOe
)RreKeDd
Height
Short
High
Convexity
Flat
Convex
Hairline
Height
Short
High
Receding
Nonreceding
Receding
Hair quality
Thick
Thin
SNin
Thickness
Normal
Thick
Rhytids
Superficial
Deep
Fig. 26.10 Lateral–temporal brow lift approach, which allows for
repositioning and elevation of the lateral brow.
Fig. 26.8 An endoscopic approach to brow lifting through the central
port to access corrugator excision.

288
V Brow Lift
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, those requiring
little if any medial brow repositioning, and those who are candi-
dates for upper lid blepharoplasty. Advantages are the minimally
invasive approach and the minimal risk of sensory changes.
Direct Approach
The direct approach is effective in elevating the lateral brow,
but it is rarely performed, 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 disadvantage
(Fig. 26.11).
Transpalpebral Browpexy
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 periosteum (Fig. 26.12).
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.
Transpalpebral Excision of Corrugator and
Procerus Muscles
Modification of the glabellar muscles through the upper eyelid
results in improvement of glabellar lines with minimal medial
elevation of the brow (Fig. 26.13). Lateral brow elevation is per-
formed through the lateral–temporal lift. The best candidates are
individuals 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.
The patient with brow asymmetry, glabellar frown lines, and
aging of the upper and lower lids shown in Fig. 26.14 underwent
upper and lower lid blepharoplasty with transpalpebral excision
of the corrugator and division of procerus muscles. Postoperative
views and a split-face view 18 months postoperative show elim-
ination of glabellar frown lines, improvement of asymmetry, and
appropriate brow position.
Injection of Toxins
Toxin injections are the most popular procedure for brow reju-
venation, representing a safe and effective method for mild to
moderate brow elevation through alterations to muscle balance.
Advantages include the fact that this treatment 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 (Fig. 26.15).
26.2.2 Ancillary Procedures
The surgical procedures described so far reposition the brow
and improve forehead and glabellar lines. Frequently, additional
ancillary procedures are needed to improve the result further.
These include peels, laser resurfacing, and fillers. :e will
often improve the vertical frown lines by threading a piece of
Fig. 26.11 Direct brow lift incisions as shown are best for older
patients or those with pronounced lower forehead transverse creases
as shown.
Fig. 26.12 Transpalpebral brow pexy approach.
Fig. 26.13 Transpalpebral brow approach for corrugator and procerus
muscle excision.

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289
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 orbicu-
laris 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.
The split-face view in Fig. 26.16 demonstrates preoperative and
5-year postoperative results after an endoscopic brow lift with
external screw fixation and laser resurfacing. Other procedures
performed in this patient included upper and lower lid blepharo-
plasties, face lift, neck lift, and perioral laser resurfacing.
26.3 Choosing the Best Option
Guidance for choosing the best option for brow lifting is given in
Table 26.3.
Fig. 26.15 Botulinum toxin being administered in the area of the corrugator supercilii to treat vertical and oblique rhytids of the glabellar region.
Fig. 26.16 Split-face view demonstrating preoperative and 5-year
postoperative results after an endoscopic brow lift with external screw
fixation and laser resurfacing. Other procedures performed in this
patient included upper and lower lid blepharoplasties, facelift, neck
lift, forehead, and perioral laser resurfacing.
Fig. 26.14 (a) Before and (b) after results, (c) with a split-face comparison, of a patient who underwent an upper and lower blepharoplasty and
transpalpebral approach for muscle excision.
a
b
c

290
V Brow Lift
Suggested Reading
>1@ Behmand RA, Guyuron B. Endoscopic forehead rejuvenation: II. Long-term
results. Plast Reconstr Surg 2006;117(4):1137–1143, discussion 1144
>2@ Byrd HS, Burt -D. Achieving aesthetic balance in the brow, eyelids, and midface.
Plast Reconstr Surg 2002;110(3):926–933, discussion 934–939
>3@ Byun S, Mukovozov I, Farrokhyar F, Thoma A. Complications of browlift tech-
niques: a systematic review. Aesthet Surg J 2013;33(2):189–200
>4@ Carruthers A, Carruthers -. Eyebrow height after botulinum toxin type A to the
glabella. Dermatol Surg 2007;33(1 Spec 1o.):S26–S31
>5@ Farkas LG, .olar -C. Anthropometrics and art in the aesthetics of women’s faces.
Clin Plast Surg 1987;14(4):599–616
>6@ .nize DM. Reassessment of the coronal incision and subgaleal dissection for
foreheadplasty. Plast Reconstr Surg 1998;102(2):478–489, discussion 490–492
>7@ .nize DM. Transpalpebral approach to the corrugator supercilii and procerus
muscles. Plast Reconstr Surg 1995;95(1):52–60, discussion 61–62
>8@ Mahmood U, Baker -L -r. Lateral subcutaneous brow lift: updated technique.
Aesthet Surg J 2015;35(5):621–624
>9@ Pelle-Ceravolo M, Angelini M. Transcutaneous brow shaping: a straight-
forward and precise method to lift and shape the eyebrows. Aesthet Surg J
2017;37(8):863–875
>10@ Sweis IE, Hwang L, Cohen M. Preoperative use of neuromodulators to optimize
surgical outcomes in upper blepharoplasty and brow lift. Aesthet Surg J
2018;38(9):941–948
>11@ Tyers AG. Brow lift via the direct and trans-blepharoplasty approaches. Orbit
2006;25(4):261–265
Table 26.3 Choosing a brow lift option
Morphology and
aging changes
Coronal
Endoscopic
/DWerDO
WemSRrDO
7rDnVSDOSeErDO
SrRFeruV
corrugator
excision
/DWerDO7emSRrDO ErRZ
OiIW  WrDnVSDOSeErDO
SrRFeruVFRrrugDWRr
excision
Direct
%rRZSe[y
Ancillary
Laser
Autologous
)iOOer
)RreKeDd
High
̍
̍
̍
̍
̍
Low
̍
̍
̍
̍
̍
̍
Flat
̍
̍
̍
̍
̍
̍
Convex
̍
̍
̍
̍
̍
Hairline
High
̍
̍
̍
̍
Low
̍
̍
̍
̍
̍
̍
Receding
̍
̍
̍
̍
SNin ([FeVV
Lateral
̍
̍
̍
̍
̍
̍
Medial
̍
̍
̍
SNin
Thick
̍
̍
̍
̍
̍
Normal
̍
̍
̍
̍
̍
Deep rhytids
̍
̍
̍
̍
̍
̍
̍
Superficial rhytids
̍
̍
̍
̍
̍
̍
̍
%rRZ 3RViWiRn
Lateral
Normal
Low
̍
̍
̍
̍
̍
̍
Medial
Normal
̍
̍
̍
̍
̍
Low
̍
̍

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27 Temporal Brow Lift
Foad Nahai
Abstract
The temporal approach for repositioning of the central and lat-
eral brow is described. It may be combined with transpalpebral
excision of the corrugator and procerus muscles.
Keywords
temporal lift, corrugator excision, procerus modification
27.1 Introduction
Our 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 gla-
bellar 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 upper eyelid as a gateway to the brow and its role
in periorbital rejuvenation.
:ith the many options for brow repositioning and rejuvena-
tion, selection of a procedure based on the patient’s individual
needs is the key. 1ot every patient requires, nor should every
patient undergo, an endoscopic 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 approach. Lateral brow elevation
and fixation are easily achieved with this approach.
Injectable toxins and this combination approach have signifi-
cantly reduced the number of endoscopic brow lifts in my prac-
tice. Today I undertake an endoscopic brow lift only in patients
who would benefit from medial brow elevation as well as lateral
brow repositioning.
27.2 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 patients with
glabellar lines, modest medial brow depression, and no excess
skin above the nasal radix, the combination approach, includ-
ing 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 facelift. This is not an effective procedure
for patients with significant medial brow ptosis, excess glabellar
skin over the nasal radix, or deep forehead lines at rest. Those
individuals are better suited for an endoscopic or coronal
approach.
27.3 Preoperative Planning
27.3.1 Brow Markings
The patient is instructed to clench the teeth while contracting
the temporalis muscle, so the surgeon can palpate the muscle
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
(Fig. 27.1).
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 supraorbital nerve. The
incision is planned directly over the muscle to facilitate anchoring
of the temporoparietal fascia to the deep temporal fascia. Incisions
beyond the extent of the temporalis muscle should be avoided
(Fig. 27.2).
27.3.2 Eyelid Markings
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 lat-
eral marking should be at least 6 mm above the lateral canthus,
with a lateral extension within one of the crows’ 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 that I can mark the extent and bulk of the corrugator
muscle. If there are any horizontal glabellar lines, indicating pro-
cerus hyperactivity, those are marked as a reminder to section
the procerus muscles (Fig. 27.3).
27.4 Operative Technique
27.4.1 Anesthesia
The procedure may be performed with the patient under local
or general anesthesia. 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.

292
V Brow Lift
I prefer to start with 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 component of the operation.
27.4.2 Lateral Temporal Brow Lift
I perform this portion of the operation exactly as I do for an endo-
scopic brow lift. The incision is placed coronally or horizontally or
anywhere in between, depending on the desired final brow posi-
tion. The incision is made and continued through the temporopa-
rietal 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 continue under endoscopic
control or, my preference, direct vision with the aid of a lighted
retractor or an Aufricht retractor and a headlight (Fig. 27.4).
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
mobilization of the lateral brow, I make a point of skeletonizing
the sentinel vein (Fig. 27.5).
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 (Fig. 27.6).
At this stage the lateral brow is tested with upward traction at
the skin edge to ensure mobility by observing the upward and
medial rotation of the lateral brow. If the lateral brow moves only
minimally, further dissection must be performed; otherwise,
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.
Fig. 27.1 Marking out the anterior border of the temporalis muscle.
Fig. 27.2 The patient is supine with the temporal incision marked 2 to 3 cm behind the hairline below the temporal crest. The sentinel vein is marked
as well at this point if it was not already identified in the upright position.

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27.4.3 Transpalpebral Glabellar Muscle
0RdiÀFDWiRn
I perform the glabellar muscle modification with loupe magnifi-
cation. The upper eyelid skin and muscle are 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 Colorado 1eedle (Stryker CMF, .alamazoo, MI).
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 orbital 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 septum.
Laterally, the dissection is continued along the deep surface of
the orbicularis until the lateral orbital dissection through the
eyelid is continuous with the endoscopic dissection from above.
Once the communication between the eyelid and brow plane
of dissection has been established, I make a number of radial cuts
into the lateral orbicularis, not to permanently weaken it but
rather to weaken it temporarily to prevent the downward pull
of the orbicularis during the early postoperative phase to help
maintain lateral brow position. The radial cuts are made in the
muscle with the Colorado 1eedle and with a finger placed behind
the hair-bearing brow pushing the muscle forward to facilitate
scoring (Fig. 27.7).
Medially, the dissection approaches the supraorbital rim. The
orbicularis fibers running horizontally must be divided to reach
Fig. 27.3 The temporal dissection is similar to that of the endoscopic approach and easily completed without the endoscope.
Fig. 27.4 The lateral brow is elevated and the sentinel vein skeletonized for better mobilization.
Fig. 27.5 After lateral mobilization and skeletonizing of the sentinel
vein, a variable amount of medial dissection is performed.

294
V Brow Lift
the diagonally running muscle fibers of the corrugator supercilii
muscle (Fig. 27.8). Branches of the supratrochlear nerve may also
be visible at this stage (Fig. 27.9).
The orbicularis muscle is divided with the Colorado 1eedle 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 (Fig. 27.10).
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 segment of
muscle. I often encounter a branch or two of the supratrochlear
nerve coursing through the muscle. The supraorbital nerve is
usually lateral to this dissection (Fig. 27.11).
Removal of a segment of the muscle reveals one or more intact
branches of the supratrochlear nerve (Fig. 27.12). 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 pre-
vent postoperative recurrence of glabellar function and lines. At
the completion of the procedure, there should be a significant gap
Fig. 27.8 Branches of the supratrochlear nerve are identified through the medial orbicularis window.
Fig. 27.7 Medially, exposure of the corrugator supercilii via a transpalpebral approach through a window in the medial orbicularis.
Fig. 27.6 The patient has both the upper eyelid blepharoplasty and associated glabellar bulk/creases caused by the corrugator or procerus muscles
marked. The lateral extension of the blepharoplasty should be placed within one of the crow’s feet.

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295
in the muscle with preservation of the supratrochlear and supra-
orbital branches. Theoretically, dissection in the upper medial
corner of the orbit may injure 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 and
periorbital fat serve well as filler between the cut ends of the
corrugator muscle.
In patients who have transverse glabellar or dorsal nasal skin
lines resulting from procerus muscle activity, the procerus is
transversely divided through the blepharoplasty incision by ele-
vating the orbicularis and then pushing a pair of scissors deep to
the skin toward the nasal radix, cutting the fibers off the procerus
Fig. 27.9 The orbicularis muscle window is made with a fine mosquito clamp.
Fig. 27.10 Exposure and isolation of the corrugator muscle belly.
Fig. 27.11 Excision of the corrugator muscle segment and exposed branches of the supratrochlear nerve.

296
V Brow Lift
under the skin. If necessary, periorbital fat is excised at this time
(Fig. 27.13).
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 2–0 polydioxanone
sutures (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 sta-
ples. The upper eyelid incision is closed (Fig. 27.14).
27.4.4 Postoperative Care
To minimize swelling, the patient’s head is kept elevated, and ice
packs are applied to the periorbital area.
27.5 Results
The middle-aged woman shown in Fig. 27.15 underwent a
temporal brow lift, transpalpebral corrugator 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 facelift.
The 50-year-old woman shown in Fig. 27.16 exhibited
aging of the upper and lower lids, lid–cheek junction, and face.
Rejuvenation of the periorbital area and lower face was planned.
She underwent a lateral temporal lift, upper and lower blepha-
roplasty, and a short-scar blepharoplasty. Four years postopera-
tively, the improved lateral brow position has been maintained.
27.6 Problems and Complications
Infection and bleeding are rare. Alopecia may be seen along the
temporal incision line. This risk is minimized by avoiding exces-
sive tension in the scalp closure and limiting the use of coagulat-
ing current along the cut edges of the incision. Inadequate 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 blepha-
roplasty. Hemostasis in the corrugator muscle bed is essential.
Unless combined with lower-lid procedures, ecchymosis and
other blepharoplasty complications are rarely seen.
Fig. 27.13 Sharp division of the procerus muscle off its skin insertion.
Fig. 27.14 Anchoring of the temporoparietal fascia to the deep
temporal fascia.
Fig. 27.12 Radial cuts are made through the lateral orbicularis to weaken it temporarily and prevent downward pull while the lateral brow heals in its
new position.

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27.7 Concluding Thoughts
Combining a lateral/temporal lift with an upper-lid blepharo-
plasty and transpalpebral excision of the corrugator muscle
through the upper eyelid is a safe and effective option for reju-
venation 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 eliminates the risk of injury to the lateral branch
of the supraorbital nerve but also ensures that the temporopa-
rietal fascia can be anchored down to the deep temporal fascia.
• Complete release of the lateral orbital attachments, adhe-
sions, and septa is essential; 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 minimize the risk of stretch injuries to the frontal
branch.
• Loupe magnification greatly facilitates the transpalpebral
excision of the corrugator muscle.
• Connecting the lateral upper-lid and brow dissections through
the lower-lid dissection 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 lateral brow position.
Suggested Reading
>1@ Byun S, Mukovozov I, Farrokhyar F, Thoma A. Complications of browlift tech-
niques: a systematic review. Aesthet Surg J 2013;33(2):189–200
>2@ Farkas LG, .olar -C. Anthropometrics and art in the aesthetics of women’s faces.
Clin Plast Surg 1987;14(4):599–616
>3@ Guyuron B, Michelow B-. Refinements in endoscopic forehead rejuvenation. Plast
Reconstr Surg 1997;100(1):154–160
>4@ Guyuron B, Michelow B-, Thomas T. Corrugator supercilii muscle resection
through blepharoplasty incision. Plast Reconstr Surg 1995;95(4):691–696
>5@ .nize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper
blepharoplasty. Plast Reconstr Surg 1996;97(7):1334–1342
>6@ .nize DM. Transpalpebral approach to the corrugator supercilii and procerus
muscles. Plast Reconstr Surg 1995;95(1):52–60, discussion 61–62
>7@ Mahmood U, Baker -L -r. Lateral subcutaneous brow lift: updated technique.
Aesthet Surg J 2015;35(5):621–624
>8@ 1iechajev I. Transpalpebral browpexy. Plast Reconstr Surg 2004;113(7):2172–
2180, discussion 2181
>9@ Paul MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr
Surg 2001;108(5):1409–1424
>10@ Tyers AG. Brow lift via the direct and trans-blepharoplasty approaches. Orbit
2006;25(4):261–265
Fig. 27.15 (a,c) This middle-aged woman underwent a temporal brow
lift, transpalpebral corrugator excision, a nasal compartment orbital fat
flap to correct the A-frame deformity of the upper lids, transconjuncti-
val lower blepharoplasty with fat distribution, and a facelift. (b,c) She is
shown several months postoperative.
a
b
c
Fig. 27.16 (a,c) This patient underwent rejuvenation of the periorbital
area and lower face with a lateral temporal lift, upper and lower
blepharoplasty, and a short-scar blepharoplasty. (b,c) Her 4-year
postoperative photo shows that her improved lateral brow position has
maintained.
a
b
c

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28 Endoscopic Brow Lift
Foad Nahai
Abstract
There have been many modifications to the original three-port
Emory endoscopic brow lift since 1993. The indications, instru-
mentation, and fixation options have all evolved. Those modifi-
cations and the author’s current indications for the endoscopic
approach are discussed.
Keywords
brow lift, brow shaping, endoscopic brow lift
28.1 Introduction
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 Lambros and Coleman.
1umerous publications have also established the efficacy of the
endoscopic brow lift for elevating and maintaining brow position.
Our current view is that a youthful or beautiful brow is related
more to volume and shape than to height (Fig. 28.1).
Endoscopic procedures have been modified with these ideals
in mind. Repositioning 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 publications 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 aging 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.
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 ver-
tical and horizontal frown lines. Most involve mobilization, repo-
sitioning, 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 effective, proven operation, the benchmark against
which other techniques are measured (Fig. 28.2).
In 1992 Isse and Visconez 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
Fig. 28.1 Comparison of brow positions show that both a low and high
brow can maintain a youthful appearance through fullness and brow
shape.
Fig. 28.2 Side-by-side comparison of the characteristics seen in a
more youthful (left) versus aging (right) brow and periorbital region.

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steadily gained in popularity and was once, without doubt, the
most common endoscopic procedure, not only in aesthetic sur-
gery but also in all of plastic surgery. However, the popularity and
effectiveness of toxins in reshaping and repositioning the brow
and the effectiveness of transpalpebral glabellar muscle modifica-
tion combined with a temporal brow lift have affected the number
of endoscopic brow lifts performed. Despite these recent devel-
opments, the procedure continues to enjoy tremendous patient
acceptance. Before endoscopic forehead lifts were introduced,
approximately 1 in 10 of my patients undergoing a facelift 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
18-plus years has been favorable. Patient acceptance has been
high, morbidity has been low, and my results have compared
favorably with those of the coronal brow lift.
The endoscopic approach affords excellent exposure for release
of periorbital adhesions; muscle excision and nerve preserva-
tion 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 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.
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 completion of the procedure
• Learning curve involved
• Need for additional fixation
28.2 Indications and
Contraindications
The best candidates for an endoscopic forehead lift are patients with
short, flat foreheads who have nonreceding, thick hairlines and
normal skin, moderate rhytids, and minimal true skin excess lat-
erally 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 (Fig. 28.3).
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 endoscope 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.
28.3 Pertinent Anatomy
.ey anatomic points include the sentinel vein, the temporalis
muscle and temporal crest, periorbital septa and adhesions, gla-
bellar muscles, and the supratrochlear and supraorbital nerves.
28.3.1 Sentinel Vein
De La Plaza and coworkers described and named perforating
vessels in the temporal region and sentinel vessels of the lateral
wall of the orbit. These zygomaticotemporal veins are communi-
cating veins between the superficial and deep systems. There are
usually two zygomaticotemporal veins, one medial and the other
lateral; the medial is larger and is referred to as the sentinel vein.
The endoscopic view in Fig. 28.4 shows the medial and lateral
zygomaticotemporal veins. The smaller, or lateral one, is often
accompanied by the zygomaticotemporal nerve.
The sentinel vein (Fig. 28.2, top) is a useful landmark for preop-
erative planning (Fig. 28.2, bottom) and a key point for the release
of the periorbital septa and adhesions during the operation.
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 sentinel vein defines
a danger zone for the frontal branch. I can operate rapidly toward
the zone with safety; however, when approaching the vein, the
Fig. 28.3 Side-by-side comparison of a good and a poor candidate
for endoscopic brow lift. The left shows a good candidate for an
endoscopic brow lift, with a short, flat forehead, nonreceding and
thick hairline, normal skin, moderate rhytids, and minimal skin excess
medially over the nasal radix and laterally.

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dissection is slowed under endoscopic control to prevent any
direct damage or stretching of the nerve.
28.3.2 Temporalis Muscle and Temporal
Crest
The temporal crest marks the transition from the dissection to
the temporoparietal fascial (subfascia) to the subperiosteal plane
by elevating the temporal line of fusion 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 in Fig.
28.5. My left hand rests over the contracting 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.
28.3.3 Periorbital Septa and Adhesions
Although several authors have referred to ligaments in the perior-
bital area, Moss and coworkers pointed out that rather than true
ligaments, there are multiple septa and adhesions in the perior-
bital 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 elevation of the brow (Fig. 28.6).
28.3.4 Glabellar Muscles
The corrugator supercilii is the first muscle encountered with
the endoscopic approach 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 viewed only once the
corrugator has been excised (Fig. 28.7).
28.3.5 Supratrochlear and Supraorbital
Nerves
The supratrochlear nerves are several small filamentous nerves
lying within or just superficial to the depressor 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 cor-
rugator muscle and is of relatively little significance. A useful
clinical landmark for the supratrochlear nerves is the vertical
glabellar frown line if present; it is usually 1.5 to 2 cm from the
midline.
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 lateral as the
temporal line of fusion. Any incision in the scalp that is medial to
the temporal 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 (Fig. 28.8).
Fig. 28.4 Endoscopic view showing the medial and lateral zygoma-
ticotemporal veins, which are communicating veins between the
superficial and deep systems.
Fig. 28.5 Preoperative marking of the temporal crest, performed by
asking the patient to clench the teeth and feeling the edge of the muscle.

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Fig. 28.6 =ones of adhesion in the brow and periorbital region. (Modified with permission from Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy
of the ligamentous attachments in the temple and periorbital regions. Plast Reconstr Surg. 2000; 105:1475-1490.)
Fig. 28.7 Anatomic relationships of the muscles in the glabellar region, with the corrugator muscles being the first encountered through the endoscope.

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28.4 Preoperative Assessment
Patient evaluation includes an assessment of the medial and lat-
eral brow position, position of the brow in relation to the upper
eyelid, assessment of glabella and forehead lines at rest and on
animation, and assessment of frontal bone convexity, forehead
height, and hairline. This evaluation influences the surgeon’s
choice of procedure. 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.
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 Forehead fixation device >MicroAire, Charlottesville,
VA@) and any additional incisions required for fixation
• Although the risk is minimal, the possibility of alopecia at the
incision sites and around the external screw fixation sites
• Possible temporary or even permanent sensory changes in the
scalp
• To expect some downward movement of the brow within the
first few months after the procedure, as well as that over the
long term the brow will not be as high as the initial result
28.5 Preoperative Planning
As with any technology-dependent technique, the surgeon must
have a basic understanding of the principles. In endoscopic aes-
thetic surgery, the surgeon needs to have the following:
• The necessary training
• Appropriate mechanical equipment
• .nowledge 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 (Fig. 28.9).
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.
7Ke 2SerDWing 5RRm SWD̵
• Receive in-service instruction from experienced operating
room personnel or a manufacturer’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.
Minimum Equipment Needs
• Endoscope—4- or 5-mm 30° angle Hopkins rod
• Endoscopic cannula or endoretractor—4 or 5 mm
• Endoscopic cart
̑ Monitor
̑ Light source
• Camera (at least three-chip)
• Endoscope warmer
̑ Defogging solution
• Electrocautery
• Instrumentation
̑ Curved elevators (two or three)
̑ Endoscopic scissors
̑ Insulated graspers
• Fixation devices
Originally, up to 25 special instruments were designed and
marketed for the endoscopic brow lift. Today most of us have our
own half-dozen or more favorite instruments for this procedure
(Fig. 28.10).
Fig. 28.8 The relationship of the various nerves in the periorbital
region. The supratrochlear nerves are medial with smaller-caliber
fibers, which run more superficially than the larger supraorbital nerve.

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As a safeguard, it is important to have a backup system avail-
able, including a second endoscope, camera, and light source.
These are readily available in a large hospital or surgical center but
perhaps not in a small office-based operating room. Before 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.
28.5.1 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 patients the vein is then visible (Fig. 28.11). 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 ante-
rior to the contracting muscle (Fig. 28.12). 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.
I then ask the patient to frown, which outlines the origin and
insertion of the corrugator muscle. 1ext 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, indicating 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 supraorbital 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 Forehead device, I individualize these vectors. In general,
I place them on the scalp in line with the most convex arch of the
brow. The projection of the most convex part of the brow onto the
scalp is marked as the site for additional fixation (Fig. 28.13).
The patient is shown in Fig. 28.14 with all of the final markings.
28.5.2 Patient Positioning
The patient is placed supine on the operating table with the head
extending slightly beyond the headpiece. This facilitates maneu-
vering 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 performed
in combination with other periorbital and facial rejuvenation
procedures (Fig. 28.15).
Operative Sequence
1. Hair preparation
2. Infiltration
3. Right temporal incision and dissection
4. Left temporal incision and dissection
5. Central access incision
6. Subperiosteal dissection
7. Division of periosteum from one lateral orbital rim to the other
8. Muscle modification
9. Drain placement
10. Closure of central access incision
11. Placement of temporal fixation sutures
12. Additional fixation, if needed
13. Tying of temporal fixation sutures
14. Temporal scalp excision, if needed
Fig. 28.9 An example of the video tower for endoscopic brow lift.
Fig. 28.10 Standard instruments for an endoscopic brow lift.

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Fig. 28.12 Preoperative marking of the temporal crest, performed by asking
the patient to clench the teeth and feeling the edge of the muscle.
Fig. 28.13 Preoperative marking of the most convex part of the brow
onto the scalp as site for additional fixation.
Fig. 28.11 (a) Endoscopic view of the sentinel vein. (b) The sentinel vein can help as a preoperative landmark both for a key point to release perior-
bital septa and also to define a danger zone for the frontal nerve, whose lowest branch runs approximately 1 cm above the sentinel vein.
a
b

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28.6 Operative Technique
28.6.1 Hair Preparation
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 (Fig. 28.16).
28.6.2 ,nÀOWrDWiRn
The brow area is infiltrated with a solution of 1 lidocaine
(Xylocaine,
Astra=eneca,
Cambridge,
U.)
and
epineph-
rine 1:100,000, encompassing the entire area that will be
undermined.
28.6.3 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.
:ith a hook elevating the lower edge, I dissect in the plane
between the temporoparietal fascia and the deep temporal fascia.
This is a bloodless field, and the dissection proceeds rapidly
toward the lateral orbital rim (Fig. 28.17).
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 dissector firmly down on the deep temporal fascia. This
avoids any possible risk of damage 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 temporal line of fusion and then in a superior
direction so that the temporal line of fusion is elevated and
the subperiosteal space is entered. At this stage the endoscope
is introduced, and with the same dissector the dissection is
Fig. 28.15 Operative setup for an endoscopic brow lift.
Fig. 28.14 Final preoperative markings for an endoscopic brow lift.

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V Brow Lift
continued toward the sentinel vein and the lateral orbital rim
(Fig. 28.18).
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 eyelid, deep to the orbicu-
laris and the retro–orbicularis oculi fat (ROOF; Fig. 28.19).
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 (Fig. 28.20).
I make every effort to preserve and skeletonize the sentinel vein
(Fig. 28.21).
At this stage I place traction on the lower edge of the inci-
sion, 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 repeated in exactly the same way on the
left side.
28.6.4 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.
The subperiosteal dissection is initiated with a straight
periosteal elevator and extended toward the glabella, later-
ally toward the temporal incisions, and posteriorly for 3 or
4 cm. This dissection is fairly rapid, and I progress through
Fig. 28.16 Preparation of hair and incision sites.
Fig. 28.17 Temporal incision made and dissection taken down to the
deep temporal fascia.

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Fig. 28.18 Blunt dissection performed in the avascular plane on top of the deep temporal fascia.
Fig. 28.19 (a) Endoscopic view of a dissected sentinel vein, lateral zygomaticotemporal vein, and nerve. (b) Endoscopic view with the sentinel vein
dissected free circumferentially assuring release of all sepra and adhesions.
a
b

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V Brow Lift
two other periosteal elevators with increasing curvature
(Fig. 28.22).
The subperiosteal dissection is connected with both temporal
dissections and extended 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 (Fig. 28.23).
The endoscope is then introduced through this central access
incision so that the subperiosteal dissection, which is completed
down to the supraorbital rim, is continued under endoscopic
control to permit identification and easy preservation of the
supraorbital nerve if it emerges through a foramen above the
supraorbital rim (Fig. 28.24).
28.6.5 Division of the Periosteum
At this stage the periosteum is divided from one lateral orbital
rim to the next (Fig. 28.25). This periosteal division serves two
purposes:
1. To allow further brow elevation laterally; the medial brow and
glabellar periosteum may be left intact if medial brow elevation
or separation is not desired.
2. To permit access to the glabellar musculature.
28.6.6 0uVFOe 0RdiÀFDWiRn
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 vertically. The depressor fibers are lighter in color and
are vertically oriented also, whereas the corrugator fibers run
diagonally.
I have tried various instruments for muscle modification,
including Takahashi forceps, 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 (Fig.
28.26).
I have found that the muscle tears very easily, but the branches
of the supratrochlear nerve are more resilient. Depending on the
Fig. 28.20 Dividing the periorbital adhesions with endoscopic scissors,
allowing dissection to extend into the upper eyelid, deep to the
orbicularis oculi and retro–orbicularis oculi fat.
Fig. 28.21 Fully skeletonized sentinel vein.
Fig. 28.22 Central access incision with subperiosteal dissection with
progressively curved elevators.
Fig. 28.23 Subperiosteal dissection is connected with both temporal
dissections.

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Fig. 28.24 (a–c) Endoscopic view of the central access subperiosteal dissection.
b
c
a
Fig. 28.25 (a–c) Endoscopic division of the periosteum at the level of the orbital rim.
b
c
a

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V Brow Lift
bulk of the muscle and the severity of the patient’s glabellar lines,
I vary the extent of muscle division and the amount of muscle I
remove (Fig. 28.27).
At the end of the muscle modification, the branches of the
supratrochlear nerve should lie bare within the optical field.
Sometimes with a heavy muscle I extend the dissection laterally,
superficial to the supraorbital nerve (Fig. 28.28).
The supraorbital nerve and a separate lateral branch are
shown after muscle excision in Fig. 28.29. I rarely need to
cauterize any vessels. The combination of the slight elevation
of the head of the table and epinephrine infiltration yields a
relatively bloodless field. Occasionally bleeding is encountered
from veins accompanying the supratrochlear and supraorbital
nerves; this bleeding is easily controlled by holding the vein
with the endoscopic grasper, pulling it away from the skin, and
then gently cauterizing it. It is important to pull the vein away
from the skin and to set the electrocautery on a low level to
avoid injury to the surrounding nerves and even the overlying
skin. If there is bleeding in the field, I have found neurosurgical
patties to be very useful for drying up the field. I also like to
have a 10-mL syringe filled with saline solution attached to the
endoscopic sheath for irrigation. This irrigation is useful for
clearing the field, if needed, but most of all to eliminate fogging
of the endoscope.
28.6.7 Drain Placement
I routinely drain all endoscopic brow lifts for up to 24 hours.
Although there is minimal drainage, 20 to 25 mL at most, I believe
this makes a big difference with regard to upper lid swelling and
ecchymosis, especially when the endoscopic brow procedure is
combined with upper-lid blepharoplasty. I prefer to place a 10
French drain directly along the supraorbital rim with the tubing
exteriorized behind the ear on one side (Fig. 28.30).
Fig. 28.26 Takahashi forceps to resect the corrugator muscle.
Fig. 28.27 Endoscopic grasper to resect the corrugator muscle.

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Fig. 28.28 Endoscopic views of the relation between the supratrochlear and supraorbital nerves with its corresponding veins after corrugator muscle excision.
Fig. 28.29 Endoscopic view of the supraorbital nerve and the lateral
branch of the supraorbital nerve.
Fig. 28.30 Routine placement of a 10 French drain along the supraor-
bital rim after endoscopic brow lift.

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28.6.8 Closure
The central access incision is closed first. I routinely fix the brow
in the temporal area with one or two 2–0 polydioxanone sutures,
anchoring the temporoparietal fascia down to the deep temporal
fascia. If additional paramedian fixation is needed (between the
temporal crest and the central access incision), I place temporal
fixation sutures, but I do not tie them until the paramedian
fixation is performed. Currently my choices for paramedian fix-
ation include external screw fixation or an absorbable Endotine
Forehead device. The Endotine Forehead device affords perma-
nent fixation and multidirectional vectors or modified Emory
taping. It does require a separate incision and a special drill bit.
:hether it is an Endotine device, an external screw, a single
hook is placed on the scalp behind the planned fixation site. The
scalp is then lifted, pulled upward, and rotated medially.
External screw fixation using a hand drill and screw holder is
shown in Fig. 28.31. The drill has a 5-mm stop. With the assistant
maintaining the brow in the desired position through the hook,
a stab incision is made in the scalp, and a drill hole is made with
the hand drill. A self-tapping screw, 16 mm in length with a 5-mm
thread, is placed in the drill hole and secured. A staple is placed
behind this screw, maintaining the brow position.
For insertion of the Endotine Forehead device, a separate 2-cm
incision is made according to the preoperative vectors (Fig. 28.32).
The brow is then pulled close to its desired position. The Endotine
Forehead device has five prongs or tines to engage the periosteum and
hold it in the new position. 1ext, with a power or hand drill, a drill
hole is made, into which the device is placed with the tines pointing
backward. The Endotine Forehead device is inset into the drill hole.
The device may be rotated according to the fixation desired (Fig.
28.33). The scalp is pulled upward and rotated medially. Then the
scalp is pushed down onto the device to engage the tines (Fig. 28.34).
Once the paramedian fixation has been completed, the temporal
fixation sutures are tied, minimal scalp excision in the temporal
area is performed if needed, and the temporal incisions are closed.
28.6.9 Fixation Choices
Currently there is no consensus among surgeons regarding the
preferred method of brow fixation. In fact, there is even some
debate about whether any fixation is needed, because the muscle
balance between the glabella and the frontalis is altered, and
therefore brow position will likely be maintained.
Fig. 28.33 Drill hole placement and Endotine Forehead device being
fixated to the calvarium.
Fig. 28.34 Fixation of the scalp on the Endotine Forehead device.
Fig. 28.31 (a) A hand drill and screw holder are used for (b,c) external
screw fixation through a stab incision.
b
c
a
Fig. 28.32 (a) A 2-cm incision is made based on predetermined
vectors (b) for placement of the Endotine Forehead device.
a
b

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313
:ho needs fixation, and which methods work" Temporal
fixation³anchoring of temporoparietal fascia down to the deep
temporal fascia³is universally applied to every patient in my
practice. Paramedian fixation between the temporal crest and
midline with an upward and medial rotation is selectively applied
on the basis of the patient’s aging changes, brow position, brow
shape, sex, and desired results.
I am more likely to use permanent paramedian fixation in a man
with heavy forehead skin and significant brow ptosis than in a woman
with moderate or minimal brow ptosis and normal forehead skin.
A variety of methods for brow fixation are available. I have had
experience with all of the fixation methods listed in Table 28.1,
except for the Mitek anchors. The fixation methods can be further
divided into temporary and permanent fixation. How long does
it take for brow position to become fixed" How long does the
periosteum take to adhere" Opinions vary from 8 days to as long
as 6 weeks. The only study available, which was in a rabbit model,
showed that it took the periosteum 6 weeks to stick back down. The
general consensus is that to be effective, the fixation should last at
least a couple of weeks. Based on this information, I consider the
external screws, which we normally take out at 1 week to 10 days,
to be temporary and the Endotine Forehead device to be permanent.
28.7 Ancillary Procedures
Frequently ancillary procedures are performed in combination
with an endoscopic brow lift to improve the result further. These
include peels, laser resurfacing, and injection of tissue fillers. In
patients with deep vertical frown lines at rest in whom muscle
modification alone will not eradicate the lines, I thread a piece
of autologous tissue, temporal fascia, or orbicularis muscle
just deep to the dermis. I have found this method to be rapid,
effective, and relatively free of problems or complications. The
volume of the transferred tissue is preserved over time.
The woman in her 30s shown in Fig. 28.35 had brow ptosis and
very deep, established glabellar frown lines. She was a candidate
for endoscopic brow lift and autologous temporal fascia grafts to
the grade 5 rhytids in her glabellar area.
During the endoscopic brow lift for this patient, a 1 ð 3-cm
piece of deep temporal fascia was harvested. The fascia was split
in half longitudinally into equal 0.5 ð 3-cm strips (Fig. 28.36).
:ith a no. 57 Beaver blade, a subdermal tunnel was made
under the left glabellar rhytid. In this procedure the blade not only
creates the tunnel but also releases the deep dermal attachments.
The blade exits the lower end of the rhytid, making a small inci-
sion in the skin (Fig. 28.37).
Fig. 28.35 Patient with brow ptosis and grade 5 glabellar rhytids.
Fig. 28.37 A subdermal tunnel being made with a Beaver blade.
Fig. 28.38 Placement of temporal fascial grafts in a subdermal tunnel
for glabellar rhytids.
Fig. 28.36 Temporal fascial grafts harvested during the endoscopic
brow lift.
Table 28.1 Endoscopic brow fixation methods
7emSRrDry
3ermDnenW
Emory tapes
Vertex sutures
Mitek anchors
Bolster sutures
Internal screws
Permanent
Fibrin glue
Permanent
Absorbable
External screws
Absorbable
Cortical tunnels
Endotine device

314
V Brow Lift
A fine grasper is passed through the tunnel from above and
out through the lower incision. The grasper firmly holds the
fascial strip, which is pulled into the tunnel. The procedure is
repeated on the right side. :ith both strips placed subdermally,
the protruding fascia is trimmed flush with the skin, and the stab
incisions are closed with 6–0 suture material. My preference is
6–0 rapid-absorbing catgut (Fig. 28.38).
Comparing the preoperative view with the patient’s postop-
erative results 1 year after treatment demonstrates improved
brow position, improved upper eyelids without an upper
eyelid blepharoplasty, and effective elimination of the glabellar
frown lines. The split-face image confirms the improvement
(Fig. 28.39).
28.8 Postoperative Care
Because most endoscopic brow procedures in my practice are
performed in conjunction with other aesthetic facial procedures,
these patients usually spend the night in our overnight facility.
They are kept comfortable, with the head elevated and an ice
pack over the eyes. Every effort is made to alleviate nausea and
to monitor blood pressure and keep it under control.
Antihypertensive medication and sedatives are administered
routinely in men and as needed in women. The drain is usually
removed the next morning, before the patient goes home. The
patient is advised to keep his or her head elevated and to avoid
strenuous activity for up to 3 weeks and is scheduled to return for
follow-up within 3 to 6 days.
28.9 Outcomes
Patient acceptance of this procedure has been high. There
have been few problems such as alopecia, dysesthesias, and
temporary nerve paralysis. In a personal series of approximately
700 patients, there was no permanent facial nerve paralysis.
Temporary facial nerve paralysis was seen in less than 1 of
patients, and alopecia at the screw fixation site was seen in 4.
The preoperative view of the woman shown in Fig. 28.40
demonstrates brow asymmetry, brow ptosis, glabellar and trans-
verse forehead rhytids (grade 4), and aging of the upper and lower
eyelids with crow’s feet. The patient underwent an endoscopic
brow lift with external screw fixation and upper and lower lid
blepharoplasty. The early postoperative view and a split-face
image demonstrate improvement of brow asymmetry, elevation
of the brow position, and improvement of rhytids. A close-up of
the left side of her scalp (Fig. 28.41) shows a 1 ð 1.5-cm area of
alopecia at the site of the external screw fixation. This area was
excised to eliminate the bald spot.
Most patients experienced mild temporary dysesthesias. I have
personally reoperated on only one of my earliest endoscopic brow
patients for recurrent brow ptosis.
28.10 Results
The woman in her late 40s shown in Fig. 28.42 had brow ptosis,
grade 5 glabellar lines, and full facial aging; she underwent
an endoscopic brow lift with no paracentral fixation. She also
had upper and lower eyelid blepharoplasty, facelift, and neck
Fig. 28.41 A close-up of the left side of the scalp of the patient in Fig.
28.40 shows a 1 × 1.5-cm area of alopecia at the site of the external
screw fixation. This area was excised to eliminate the bald spot.
Fig. 28.39 (a,c) Pre- and (b,c) 1-year postoperative results showing
improved brow position, upper eyelids, and glabellar frown lines after
endoscopic brow lift and temporal fascia grafts for the glabella.
a
c
b
Fig. 28.40 (a,c) Pre- and (b,c) postoperative photos of a patient who
underwent correction of brow asymmetry, brow ptosis, glabellar and
transverse forehead rhytids (grade 4), and aging of the upper and
lower eyelids with crow’s feet. She underwent an endoscopic brow lift
with external screw fixation and upper and lower lid blepharoplasty.
a
b
c

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315
lift. Her postoperative result at 18 months demonstrates an
elevated brow position with significant improvement in the
glabellar lines. This is most readily apparent in the split-face
image, demonstrating elevation of the medial and lateral brow.
The woman in her early 50s shown in Fig. 28.43 had heavy,
ptotic brows with grade 4 glabellar rhytids. She underwent an
endoscopic brow lift with external screw fixation as well as a
lower lid blepharoplasty and transpalpebral midface lift. Her
postoperative result demonstrates improvement of brow position,
amelioration of rhytids, and improvement of the lower lid–cheek
junction and midface area.
The man in his 40s shown in Fig. 28.44 had a heavy ptotic brow
and deep grade 5 transverse forehead lines. He underwent an
endoscopic brow lift with Emory taping, upper lid blepharoplasty,
and transconjunctival removal of fat from the lower eyelids.
Postoperative results at 4 months and at 7 years demonstrate
maintenance of brow elevation, including the exaggerated medial
brow elevation that was typical of our early endoscopic brow lifts
with the central Emory T to V scalp excision. I abandoned the
central scalp excision because it led to these exaggerated medial
brow elevations.
The woman in her late 40s shown in Fig. 28.45 had heavy
brows and brow ptosis. She had an endoscopic brow lift with
Emory taping. She is shown at 7 years and 8 years postoper-
atively, demonstrating maintenance of the elevated brow
position.
Fig. 28.44 Pre- and postoperative photos of a patient who underwent
an endoscopic brow lift with Emory taping, upper lid blepharoplasty,
and transconjunctival removal of fat from the lower eyelids.
Fig. 28.45 Pre- and postoperative photos of a patient who underwent
an endoscopic brow lift with Emory taping.
Fig. 28.42 (a,c) Pre- and (b,c) postoperative photos of a patient who
underwent correction of ptotic brows with grade 5 glabellar lines and
facial aging. She underwent an endoscopic brow lift with upper and
lower lid blepharoplasty, facelift, and neck lift.
a
b
c
Fig. 28.43 (a,c) Pre- and (b,c) postoperative photos of a patient who
underwent correction of heavy, ptotic brows with grade 4 glabellar
rhytids.
a
b
c
Fig. 28.46 (a,c) Pre- and (b,c) postoperative photos of a patient who
underwent an endoscopic brow lift, lower lid blepharoplasty with
transpalpebral midface lift, and endoscopic neck lift.
a
b
c

316
V Brow Lift
The 40-year-old woman shown in Fig. 28.46 had brow ptosis,
grade 4 glabellar lines, and aging of the midface and neck. Despite
the high forehead, she elected to have an endoscopic brow lift, a
lower lid blepharoplasty with transpalpebral midface lift, and
an endoscopic neck lift. The postoperative view demonstrates
repositioning of the brow, amelioration of the glabellar lines,
improvement of the upper eyelids (without an upper eyelid bleph-
aroplasty), and improvement of the lower lid and midface area.
28.11 Concluding Thoughts
Although the use of neurotoxins and even less invasive brow
rejuvenation techniques have gained in popularity, and the
overall numbers of coronal and endoscopic brow lifts are in
decline, there is still a role for the endoscopic approach. Based on
my 16-plus years of experience, during which I have performed
several hundred endoscopic brow lifts, I conclude that the pro-
cedure is effective and safe, with lasting results. :ith technical
modifications, the exaggerated medial brow elevation has been
eliminated. The need for fixation, if any, and the type of fixation
remain a matter of debate, and we each have our own thoughts
based on experience.
Clinical Caveats
• An endoscopic brow lift is a technology-dependent procedure.
The surgeon and operating room personnel should be familiar
with the endoscopic equipment and be able to troubleshoot
problems involving the camera, light source, and monitor.
• The success of this procedure depends on adequate release of
the periorbital septa and adhesions.
• Vertical spreading should be avoided during the temporal
dissection to prevent stretch injury of the frontal branch of
the facial nerve.
• Keeping the dissector firmly down on the deep temporal
fascia and temporalis muscle prevents any injury to the fron-
tal branch of the facial nerve.
• Release of the periosteum is essential for brow elevation.
• While resecting the glabellar musculature, the surgeon
should avoid removal of subcutaneous fat, which could result
in a depression.
• Every attempt should be made to preserve the sentinel vein.
Sacrifice of the vein leads to engorgement of the superficial veins,
which will become readily visible in thin-skinned individuals.
• If medial brow elevation is not desired, subperiosteal dissec-
tion should be avoided in the medial brow area.
Suggested Reading
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results. Plast Reconstr Surg 2006;117(4):1137–1143, discussion 1144
>2@ Chajchir A. Endoscopia en cirugía plástica y estética. In Gonzalez Montaner L-,
Huriado Hoyo E, Altman R, et al, eds. El Libro de Oro en Homenaje al Doctor Carlos
Reussi. Buenos Aires: Asociaciyn Mpdica Argentina; 1993:74–78
>3@ Chajchir A. Endoscopic subperiosteal forehead lift. Aesthetic Plast Surg
1994;18(3):269–274
>4@ Coleman SR. Structural Fat Grafting. St. Louis: 4uality Medical Publishing, 2004.
>5@ Core GB, Visconez LO, Askren C, et al. Coronal face-lift with endoscopic tech-
niques. Plast Surg Forum 1992;25:227–229
>6@ Daniel R., Tirkanits B. Endoscopic forehead lift. Aesthetics and analysis. Clin Plast
Surg 1995;22(4):605–618
>7@ Daniel R., Tirkanits B. Endoscopic forehead lift: an operative technique. Plast
Reconstr Surg 1996;98(7):1148–1157, discussion 1158
>8@ De La Plaza R, Valiente E, Arroyo -M. Supraperiosteal lifting of the upper two-
thirds of the face. Br J Plast Surg 1991;44(5):325–332
>9@ Del Campo AF, Lucchesi R, Cedillo Ley MP. The endo-facelift. Basics and options.
Clin Plast Surg 1997;24(2):309–327
>10@ Elkwood A, Matarasso A, Rankin M, Elkowitz M, Godek CP. 1ational plastic
surgery survey: brow lifting techniques and complications. Plast Reconstr Surg
2001;108(7):2143–2150, discussion 2151–2152
>11@ Farkas LG, .olar -C. Anthropometrics and art in the aesthetics of women’s faces.
Clin Plast Surg 1987;14(4):599–616
>12@ Guyuron B. Endoscopic forehead rejuvenation: I. Limitations, flaws, and rewards.
Plast Reconstr Surg 2006;117(4):1121–1133, discussion 1134–1136
>13@ Hamas RS. An endoscopic brow lift that does not raise the hairline. Aesthet Surg J
1997;17(2):127–129
>14@ Hamas RS. Reducing the subconscious frown by endoscopic resection of the
corrugator muscles. Aesthetic Plast Surg 1995;19(1):21–25
>15@ Isse 1G. Endoscopic facial rejuvenation: endoforehead, the functional lift. Case
reports. Aesthetic Plast Surg 1994;18(1):21–29
>16@ Isse 1G. Endoscopic forehead lift. Presented at the Annual Meeting of the Los
Angeles County Society of Plastic Surgeons, Los Angeles, September 12, 1992.
>17@ Isse 1G. Endoscopic forehead lift. Evolution and update. Clin Plast Surg
1995;22(4):661–673
>18@ .nize DM. Limited-incision forehead lift for eyebrow elevation to enhance upper
blepharoplasty. Plast Reconstr Surg 1996;97(7):1334–1342
>19@ Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg
2007;120(5):1367–1376, discussion 1377
>20@ Mackay G-, 1ahai F. The endoscopic forehead lift. Oper Tech Plast Reconstr Surg
1995;2:137
>21@ Matarasso A, Matarasso SL. Endoscopic surgical correction of glabellar creases.
Dermatol Surg 1995;21(8):695–700
>22@ Moss C-, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous
attachments in the temple and periorbital regions. Plast Reconstr Surg
2000;105(4):1475–1490, discussion 1491–1498
>23@ 1ahai F, Saltz R. Endoscopic Plastic Surgery, 2nd ed. St Louis: 4uality Medical
Publishing; 2008
>24@ 1assif PS, .okoska MS, Homan S, Cooper MH, Thomas -R. Comparison of subperi-
osteal vs subgaleal elevation techniques used in forehead lifts. Arch Otolaryngol
Head Neck Surg 1998;124(11):1209–1215
>25@ Oslin B, Core GB, Vasconez LO. The biplanar endoscopically assisted forehead lift.
Clin Plast Surg 1995;22(4):633–638
>26@ Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast Surg
1996;20(2):129–134
>27@ Ramirez OM. The anchor subperiosteal forehead lift. Plast Reconstr Surg
1995;95(6):993–1003, discussion 1004–1006
>28@ Ramirez OM. Endoscopically assisted biplanar forehead lift. Plast Reconstr Surg
1995;96(2):323–333
>29@ Ramirez OM. Transblepharoplasty forehead lift and upper face rejuvenation. Ann
Plast Surg 1996;37(6):577–584
>30@ Roberts TL III, Ellis LB. In pursuit of optimal rejuvenation of the forehead:
endoscopic brow lift with simultaneous carbon dioxide laser resurfacing. Plast
Reconstr Surg 1998;101(4):1075–1084
>31@ Rohrich R-, Beran S-. Evolving fixation methods in endoscopically assisted
forehead rejuvenation: controversies and rationale. >review@ Plast Reconstr Surg
1997;100(6):1575–1582, discussion 1583–1584
>32@ Rosenberg G-. The subperiosteal endoscopic laser forehead (SELF) lift. Plast
Reconstr Surg 1998;102(2):493–501
>33@ Trinei FA, -anuszkiewicz -, 1ahai F. The sentinel vein: an important reference
point for surgery in the temporal region. Plast Reconstr Surg 1998;101(1):27–32
>34@ Visconez LO. The use of the endoscope in brow lifting. A video presentation
at the Annual Meeting of the American Society of Plastic and Reconstructive
Surgeons. :ashington, DC, 1992

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29 Endoscopic Brow Lift: My Personal Approach
H. Devon Graham III
Abstract
:ith the adaptation of endoscopic techniques from sinus sur-
gery to aesthetic surgery a new era was ushered into our field in
the mid 1980s. The endoscopic brow lift procedure has evolved
over time as refinements have been made with increased
surgical experience and better understanding of the surgical
anatomy of the upper face. This chapter is the culmination of
25 years of practice with plenty of errors and triumphs along
the way. It includes my surgical technique as it stands today
as well as patient selection and representative results. The
endoscopically assisted brow lift procedure is an invaluable
option for brow rejuvenation. It is not, however, the end-all
for every patient. Excellent results can be achieved only with
proper patient selection and proper execution by the surgeon.
Communication, in any relationship, is paramount, and the
doctor–patient partnership is no exception. :ith the proper
patient, realistically addressed expectations, and meticulous
execution this technique can achieve superior, lasting results
with minimal morbidities.
Keywords
endoscopic, brow lift, arcus marginalis, conjoined tendon, senti-
nel vein, ptosis, rejuvenation, suspension
29.1 Introduction
The advent of endoscopic techniques for sinus surgery in the
mid-1980s ushered in a new era in the field of facial rejuvenation.
Soon afterward these instruments were adopted by innovative
surgeons performing facial cosmetic surgery, with the goal
being, as it was with sinus surgery, to reduce the morbidity of the
procedures performed while maintaining or improving results.
:hen meeting someone, the first thing we see is his or her
eyes. The eyes and brow/forehead complex are under the control
of many sets of muscles that are completely expressive in nature.
They are considered by some to be the ´windows to the soulµ;
however, aging, gravitational forces, and genetic factors all can
contribute to ptosis of the brow/forehead complex and a tired,
sad, or even angry appearance at rest (Fig. 29.1). This may not
be how the individual feels, but it is what is conveyed to those
around him or her. These are the patients who present to us for
upper facial rejuvenation.
29.2 Indications and
Contraindications: Patient
Selection
Early on in my career I learned from one of my mentors, Dr.
Gene Tardy, that patient selection is paramount to achieving
a result with which both the patient and surgeon are happy.
Best candidates for the endoscopic approach are the patients
with bilateral brow ptosis and a relatively short forehead as
well as deeper-set eyes (Fig. 29.2; Fig. 29.3). Less ideal candi-
dates for endoscopic approach are those patients with a long
forehead and high hairline (Fig. 29.4; Fig. 29.5) or patients
with thick, heavy, or sun-damaged skin (Fig. 29.6; Fig. 29.7).
1oncandidates include patients with frontal branch paralysis
(Fig. 29.8).
Fig. 29.1 Ptosis of the brow/forehead complex contributing to a tired,
sad, even angry appearance at rest.
Fig. 29.2 Patient with bilateral brow ptosis and a relatively short
forehead as well as deeper-set eyes.

318
V Brow Lift
Fig. 29.3 Type I: Ideal candidate: thin-skinned, deep-set eyes; minimal
rhytids.
Fig. 29.5 Type III: Good candidate: relatively thin-skinned; more lateral
brow ptosis; some hypertrophy of corrugators; moderate rhytids.
Fig. 29.7 Type V: Less desirable candidate: thick, sebaceous skin;
heavy brows with deep rhytids.
Fig. 29.4 Type II: Excellent candidate: relatively thin-skinned; mostly
medial brow ptosis; minimal to moderate rhytids.
Fig. 29.6 Type IV: Good candidate for experienced surgeon: moder-
ately thick skin; bilateral brow ptosis with asymmetry.
Fig. 29.8 Type VI: Not an appropriate candidate: facial nerve paralysis,
no brow elevator muscle; will need renervation procedure or static
sling and skin excision for brow repositioning.

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29.3 Pertinent Anatomy
Prerequisite for any facial aesthetic procedure is a working
knowledge of the functional and static anatomy of the forehead.
The functional anatomy of the brow/forehead complex consists
of paired muscles that act in conjunction or opposition, leading
to a myriad of facial expressions. These muscles are divided into
elevators and depressors.
The major elevator of the brow/forehead complex is the paired
frontalis muscles, which, along with the paired occipital muscles
and the interconnecting galea aponeurotica, form the epicranium.
The galea is a tendinous inelastic sheet that connects the frontalis
muscle to the occipitalis muscle and merges laterally with the
temporoparietal fascia (TPF), which is continuous with the super-
ficial musculoaponeurotic system (SMAS) in the lower face. The
frontalis muscle originates from the galea, inserts in the forehead
skin, and acts as the primary elevator of the brow. These muscles,
acting in concert, draw the scalp superiorly to raise the eyebrows.
Motor nerve supply to the frontalis muscle is via the frontal branch
of the facial nerve. The frontalis muscle is by far the major elevator
of the brow, although the corrugator muscles have a very small
role in elevation of the medial portion of the brow upon contrac-
tion. The antagonistic depressor muscles of the brow include the
paired corrugator supercilii muscles, the orbicularis oculi, and the
depressor supercilii muscles. The corrugator supercilii muscles are
the primary muscles responsible for the often deep vertical rhytids
of the glabella that trouble most patients. The procerus muscle,
originating from the nasal bones, produces the transverse rhytids
in the nasion. An excellent anatomic study of the function of these
muscles can be found in the work of G.-B. Duchenne from 1862.
The static forehead anatomy includes the skin, subcutaneous
tissue, and adnexa as well as the underlying layers of fascia that
overlie, underlie, or envelop the facial musculature. Also included
in the static anatomy are the sensory and motor nerves along
with the accompanying arterial and venous supply to these mus-
cles and the overlying soft tissue. An excellent description and
demonstration of these structures, as well as their pertinence and
relationships in terms of surgical procedures, may be found in the
work of Larrabee and Maeielski.
Understanding the anatomy for surgical dissection is often
distinguished from that encountered in the gross anatomy lab.
The same principle must be altered to facilitate anatomic findings
encountered during the endoscopic approach to the brow as well.
During the subperiosteal endoscopic forehead lift, the frontalis
muscle is not usually visualized, as the dissection is in the sub-
periosteal plane. Through the endoscope, familiar structures are
viewed in an unfamiliar manner; therefore, a thorough grasp of
the anatomy and the fascial planes is indispensable.
29.4 Aesthetics of the Brow
The ´classicµ eyebrow position has gone through various phases
over the years, but the basic tenets remain the same. The medial
origin should lie along a vertical line drawn through the nasal alar–
facial junction. The lateral brow should end on the same horizontal
plane as the medial brow and on its intersection with a line drawn
from the nasal alar–facial junction through the lateral canthus. In
women the brow arcs softly above the orbital rim with the high
point above the lateral canthus; in men the brows should lie in a
more horizontal position. These relations are shown in Fig. 29.9.
29.5 Preoperative Assessment
29.5.1 Patient Evaluation
As previously discussed, prospective patients fall into the following
types with respect to their candidacy for endoscopic brow lifting:
• Type I: Ideal candidate; thin-skinned, deep set eyes; minimal
rhytids (Fig. 29.3)
• Type II: Excellent candidate; relatively thin-skinned; mostly
medial brow ptosis; minimal to moderate rhytids (Fig. 29.4)
• Type III: Good candidate; relatively thin-skinned; more lateral
brow ptosis; some hypertrophy of corrugators; moderate
rhytids (Fig. 29.5)
• Type IV: Good candidate for experienced surgeon; moderately
thick skin; bilateral brow ptosis with asymmetry (Fig. 29.6)
• Type V: Less desirable candidate; thick sebaceous skin; heavy
brows with deep rhytids (Fig. 29.7)
• Type VI: 1ot an appropriate candidate; for example, facial
nerve paralysis (Fig. 29.8).
Fig. 29.9 The “classic” eyebrow has gone through various phases over
the years but the basic tenants remain the same. The medial origin
should lie along a vertical line drawn through the nasal alar–facial
junction. The lateral brow should end on the same horizontal plane as
the medial brow and on a line drawn from the nasal alar–facial junction
through the lateral canthus. In women the brow arcs softly above the
orbital rim with the high point above the lateral canthus. In men the
brows should lie in a more horizontal position.

320
V Brow Lift
:hen evaluating a patient for forehead and brow rejuvena-
tion, there are several factors to consider. As stated earlier, a
shorter forehead and lower hairline are ideal. If the patient has
deeper-set eyes, then an endoscopic brow lift could be the only
rejuvenation procedure needed. If the patient has upper lid der-
matochalasis, then it is imperative that the brow be addressed
first and then the upper lid. Thicker-skinned patients are not a
contraindication; however, the range of skin slide in the galeal
layer is greater than that of a thin-skinned individual, and thus
some degree of initial overcorrection is needed. :hen exam-
ining patients, I ask them to completely relax their brow with
their eyes closed. This simple task is often quite difficult, as
they have been contracting their frontalis muscles constantly
for so long in order to bring their brows to a good position that
it is difficult to relax them. I will assist them by pushing down
on the brow until I feel it relax (Fig. 29.10). At this point I have
them open their eyes just enough to see straight ahead in the
mirror (Fig. 29.11). Here you can demonstrate to them their
ptotic brow position at rest and can show them, by raising
the brow with your fingers, what a brow lift could achieve
(Fig. 29.12).
29.6 Preoperative Planning
29.6.1 Surgical Markings and Positioning
The first step for preop markings is to locate the supraorbital
notch or depression (Fig. 29.13). This corresponds to the
Fig. 29.10 Examination of a patient before surgery. Patient is asked to
relax her brows.
Fig. 29.11 Examination of a patient before surgery. The patient is
asked to open her eyes just enough to see straight ahead in the mirror.
Fig. 29.12 Examination of a patient before surgery. The author
demonstrates to the patient her ptotic brow position at rest and shows
her what a brow lift could achieve by raising the brow with his fingers.

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321
supraorbital neurovascular bundle, which is imperative to
preserve to avoid numbness of the forehead and scalp. Once
these are marked (Fig. 29.14), the desired vectors of elevation
are determined (Fig. 29.15) and the central pocket incisions
are marked a centimeter or so inside the hairline (Fig. 29.16).
The temporal elevation and support are then determined (Fig.
29.17), and those planned incisions are also marked within the
temporal hairline (Fig. 29.18).
29.6.2 Injections
Injections are begun just lateral to the supraorbital neurovascu-
lar bundles along the orbital rim medially to the midline (Fig.
29.19). Through the same injection site the needle is pivoted
laterally and injection is made along the orbital rim to the level
of the lateral canthus (Fig. 29.20). The portal incisions are then
injected individually (Fig. 29.21).
The temporal pocket is then injected with a 22-gauge spinal
needle, and the local with epinephrine is fanned across this
area. It is critical here that the patient not have any paralytic
on board from anesthesia staff, as the injector should watch
for any stimulation of the frontal nerve branch. If that occurs,
then adjustment of the plane and angle of injection is required
(Fig. 29.22).
Fig. 29.13 Palpation for the supraorbital notch.
Fig. 29.14 Bilateral notches are marked.
Fig. 29.16 Planned incisions for central ports are marked inside the
hairline along the required vectors.
Fig. 29.15 Determine (a) the intended displacements and (b) the vectors of pull desired to elevate and support the brows.
a
b

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V Brow Lift
Fig. 29.19 Injection just lateral to the supraorbital neurovascular
bundles along the orbital rim medially to the midline.
Fig. 29.20 Lateral injection along the orbital rim through the same
injection site used for the medial injection.
Fig. 29.17 Lateral vectors of pull are likewise (a) planned and (b) marked: more upward in women and more horizontal in men.
a
b
Fig. 29.18 Artist’s rendition of portal incisions: (a) central; (b) temporal.
a
b