What Is Endoscopic Brow Lift -

The endoscopic brow lift, also known as the endoscopic transcutaneous rhytidectomy (ETR) is a procedure that lifts, tightens and refreshes the skin in the upper third of your face. This procedure replaces traditional brow, nose and chin lifts with a single approach.

In this guide, we find out: What Is What Is Endoscopic Brow Lift, endoscopic brow lift technique, endoscopic brow lift complications, and endoscopic brow lift instruments.

What Is What Is Endoscopic Brow Lift

A brow lift is a cosmetic surgery procedure that can enhance the appearance of your face by making you look younger. It’s often performed at the same time as a facelift and helps to remove sagging skin in areas such as your eyelids, cheeks and upper lip. An endoscopic brow lift is a similar procedure that involves making small incisions in the scalp (instead of under the chin), then inserting an endoscope — a thin tube with a camera on its end — through those incisions to lift up the forehead and eyebrows. This creates a more youthful look by reducing wrinkles and frown lines between your eyes and on your forehead.

An endoscopic brow lift is a procedure that involves a surgeon making small incisions in the scalp (similar to what would be done for a facelift).

An endoscopic brow lift is a procedure that involves a surgeon making small incisions in the scalp (similar to what would be done for a facelift). The surgeon then inserts an endoscope, which is a small camera that allows him or her to see what’s going on inside your skin from outside of it.

At this point, he or she can make adjustments and corrections as needed before stitching everything up with tiny stitches so you don’t have any visible scars after healing has taken place.

The doctor then uses an endoscope — a thin tube with a camera on its end — to lift the forehead and eyebrows through the incisions.

The endoscope can also be used to remove fat from the forehead.

This creates a younger look; it also may reduce wrinkles and frown lines between the eyes and on the forehead.

Brow lifts can help you look younger by reducing wrinkles and frown lines between the eyes and on your forehead. A brow lift also reduces sagging of skin in this area, as well as drooping or asymmetry.

If you are interested in learning more about how a brow lift can benefit you, please contact us today!

A brow lift requires general anesthesia and takes one to three hours.

A brow lift requires general anesthesia and takes one to three hours. The surgeon will explain the procedure to you before surgery, including their method of anesthesia, what instruments they’ll use and how long it will take.

During your consultation with your plastic surgeon, he or she may recommend an endoscopic brow lift if:

Your skin has good elasticity and texture; this makes it easier for the surgeon to remove excess fat from around your eyes without damaging any underlying tissue
You have moderate sagging of the forehead or a deep horizontal crease across the bridge of your nose (a double crease)

Serious complications are rare, but recovery time can last several weeks.

Serious complications are rare, but can include infection or bleeding. Recovery time can last several weeks.

The patient should avoid strenuous activity for several weeks after the procedure. The patient should also avoid sun exposure while their incisions heal and should not swim until they have been cleared by their doctor.

An endoscopic brow lifts can have lasting results.

Endoscopic brow lifts are a good option for people who are interested in a permanent solution. Most people who have this procedure done are happy with the results and don’t want to go through the process again.

There is no need for stitches or scars
You will not have to return for any follow-up procedures

endoscopic brow lift technique

The endoscopic forehead and brow lift is used to elevate the position of the eyebrows and forehead. Indications for this procedure are multiple, and it is performed to correct brow ptosis and to treat the glabellar frown lines created by the corrugator and procerus muscles. [1, 2] Various factors, including natural aging, facial nerve injury, and facial trauma, can cause brow ptosis, although congenital or hereditary factors also may cause the condition. Brow lifting or forehead lifting is not a new concept, but the application of endoscopic techniques to this procedure is recent. [3, 4] See the image below.

History of the Procedure

In 1994, Vasconez et al first described endoscopic forehead lift in the United States. They detailed use of the endoscope to guide the release of the supraorbital and glabellar soft tissues. The dissection was performed in the subgaleal plane and involved dividing the procerus and corrugator muscles and scoring of the frontalis muscle. The fixation technique was not well described and appears to have varied.

Since this first description, multiple variations have been used. Most variations pertain to placement of incisions, planes of dissection, and methods of fixation of the forehead and brows. Because endoscopic forehead lift has been performed in the United States only since 1994, results of long-term follow-up studies of more than 5 years’ duration have not been published. Results directly comparing the more established methods of forehead and brow lifting with those of the newer endoscopic techniques are also scarce.

To date, reports on endoscopic forehead and brow lifting show that excellent results are obtained with this technique. Advantages over the coronal and trichophytic approaches include significant reduction in the length of incisions, improvement in the camouflage of these incisions, and reduction of blood loss and surgical trauma. Also, the endoscopic forehead lift reduces scalp hypesthesia. Disadvantages include increased cost because of the need for more sophisticated equipment and risk of injury to either the sensory nerves or the motor nerves in this region. Additionally, surgeons must negotiate a learning curve before achieving proficiency in this procedure. In a study published in 2002, Puig and LaFerriere compared the results of open versus endoscopic forehead/brow lifts and found no statistical difference in the measurable results obtained with these procedures.

Depending on the type of fixation method used, a theoretical risk of cerebrospinal fluid (CSF) leak or meningitis exists. The present authors found only 1 case report of a CSF leak associated with endoscopic brow lift, and this appears to have involved improper preparation rather than a fundamental problem with a particular fixation technique. Despite this report, endoscopic brow lift appears safe and effective when performed by properly trained surgeons, and the procedure represents an additional tool for the restoration of a symmetric, youthful appearance in the upper part of the face.

Problem

The problems addressed in endoscopic forehead and brow lift are brow ptosis and/or forehead or glabellar rhytidosis. Eyebrow ptosis is considered to be present when the eyebrow occupies a position relative to the superior orbital rim that is lower than that on the other side in cases of unilateral brow ptosis, or one that is lower than that desired by the patient. For women, the desired position generally lies at or slightly above the medial aspect of the superior orbital rim, laterally arching superior to varying degrees. For men, the brows look most natural at or slightly above the supraorbital rim with less of an arch.

Ptotic eyebrows can give the appearance of anger, worry, or weariness despite a lack of emotional intent or physical condition. Unilateral brow ptosis or brow asymmetry, whether naturally occurring or related to facial nerve dysfunction, creates the appearance of a smaller eye on the ptotic side. Glabellar frown lines are the rhytides or wrinkles just above the nasal dorsum between the eyebrows that are caused by activity of the procerus and corrugator muscles. Endoscopic forehead and brow lift addresses and improves these areas.

endoscopic brow lift complications

Treatment/surgical technique

After adequate informed consent, the patient is marked for surgery in a standing or sitting position. A temporal incision is marked along a superior lateral vector line from the nasal ala crossing the lateral canthus and continues to a point approximately 2 cm behind the temporal hairline. A 2-cm curved line is then marked medial to that point in both temporal areas. Paramedian incisions are marked by a straight line, from the mid-pupil superiorly to the anterior frontal hairline. A 1-cm vertical line posterior to the hairline is marked in those areas for the paramedian incisions (Fig. 8.6).

The location of the supratrochlear and supraorbital nerves are also identified and marked. The location of the deep branch of the supraorbital nerve when it reaches the hairline is also marked approximately 1 cm medial to the temporal crest line. If the patient has brow asymmetry on preoperative evaluation, careful examination should be performed for true brow asymmetry or for underlying unilateral upper lid ptosis, which causes ipsilateral elevation of the brow to compensate. In the latter situation, repair of the eyelid ptosis often equalizes brow position, thus avoiding overcorrection of one brow compared to the other.

Most commonly, the patient is placed under general anesthesia using an endotracheal tube secured to the upper teeth with dental floss. Infiltration is achieved using a mixture of 20 mL of 2% lidocaine, 20 mL of 0.25% Marcaine, 1 mL of epinephrine solution in 140 cc of normal saline. Infiltration is done using a 20-gauge spinal needle in a tumescent fashion. The patient is prepped and draped in a sterile fashion. The endotracheal tube is wrapped with sterile plastic drape so it is inside the sterile field during the entire procedure and easily manipulated when the head is turned to either side.

While the use of the endoscopic brow lift has nearly eliminated the need for open coronal brow lifts, there are additional equipment requirements (Fig. 8.7). Equipment should be tested prior to induction of general anesthesia and back-up equipment should be available. The endoscopic equipment on the cart for visualization includes a monitor, preferably high definition; a three-chip camera; light source; ability to record the procedure digitally as well as take still photographs; electrocautery base unit; and suction. The additional equipment on the field include an endoscope, most commonly a 4–5 mm, 30° Hopkin rod with an endoscopic sheath camera connector, light source connector, endoscopic dissectors, endoscopic forceps and ronjeurs, and a malleable Durden suction cautery. Many different devices can be used for fixation: a drill for cortical tunnels, a drill for temporary screw fixation, a drill for use of the Endotine devices, or a variety of other fixation methods. The endoscopic cart should be positioned at the foot of the bed with the surgeon positioned at the head of the bed.

The procedure starts approximately 20 min after infiltration is completed to obtain maximum vascular constriction. The temporal incision allows visualization and dissection on top of the deep temporal fascia. Blunt dissection is completed in the temporal areas as well as the subperiosteal plane over the frontal bone. Both areas are then communicated after division of soft tissues over the temporal crest (Fig. 8.8). At this point, a 4-mL 30° scope is introduced to continue the dissection. The sentinel veins are identified and preserved (Fig. 8.9). The “fusion ligament” is identified and divided using endoscopic scissors. The dissection continues medially, where the supraorbital nerve is identified and preserved. I do not transect the periosteal attachments in between the corrugator muscles so as to minimize the medial brow elevation and the so-called “surprised look”. At this point, the corrugator muscles are identified and completely excised (Fig. 8.10). Manual palpation and gentle pressure over the skin avoids trauma to the dermis and possible indentations during endoscopic corrugator resection. In case of very thin skin and possible indentation, I recommend immediate placement of fat grafts with suture fixation. At this point, the surgeon should feel how mobile the lateral brow is and be sure both are equally mobile and symmetrical. Temporal fixation is achieved by using three interrupted Mersilene sutures from the superficial temporal fascia (and galea) into a superior cephalic lateral direction to the deep temporal fascia. The central portion of the inferior scalp flap may be excised in triangular wedges in order to prevent redundancy at the lateral brow. Fixation of the paramedian incisions is achieved with the Endotine device (Coapt Systems, Inc, Palo Alto, CA) (Fig. 8.11). At this point, still under general anesthesia, the patient is examined in a sitting position for final brow position and brow symmetry. Measurements for comparison include the mid-pupil to top of the middlebrow and the lateral cantus to the tail of the brow. Measures are recorded and documented in the operative report for future comparison. The incisions are then approximated with 4-0 plain gut. The hair is shampooed, and the patient is extubated and taken to the recovery room. No dressings are applied.

Editors:Shahrokh C. BagheriHusain Ali Khan, … Husain Ali KhanChris JoShahrokh C. Bagheri, in Clinical Review of Oral and Maxillofacial Surgery (Second Edition), 2014

Complications

Endoscopic brow lift has minimal complications (infection, hematoma, nerve injury, alopecia, scarring, and brow malposition). As with all facial cosmetic procedures, relapse is the biggest concern for the surgeon, and long-term stability is one of the main goals of cosmetic surgery. Transient forehead paresthesia (anesthesia, hypoesthesia) is a consequence of surgery and is not considered a complication. Permanent nerve injury, although uncommon, may occur if the supraorbital or supratrochlear nerve is injured beyond a stretch injury (neuropraxia); this is usually avoided by performing careful dissection assisted by an endoscope. Despite correct technique and a thorough knowledge of the regional anatomy, nerve injuries can happen.

Evaluation of the brows should be done with particular attention to the upper eyelids. It is important to avoid performing an upper eyelid blepharoplasty on a patient who really requires a brow lift procedure. Lifting the brow to an ideal position may subsequently cause lagophthalmos due to excess upper eyelid skin excision.

endoscopic brow lift instruments

Specialty surgical instruments used in Endo Brow Lift procedures include:

Elevators.
Nerve protectors.
Graspers.
Scissors.
Cannulas and Scope Sheaths.
Endoscopes.
Electrodes.

What Is Endoscopic Brow Lift