The Endoscopic Browlift
Thirteen Caveats to Success

by Guy G. Massry and Paul S. Nassif, MD, FACS

The eyebrow lift, a procedure once considered traumatic and invasive, fraught with lengthy postoperative rehabilitation, and burdened with complications objectionable to the aesthetic patient (hair loss, anesthesia, scars, etc.), has become a welcomed surgical procedure to both the surgeon and patient. This has occurred as a result of the development of the endoscopic technique of eyebrow lifting. As with all new surgical procedures, a period of trial and error, and a steep learning curve, is inherent to the development and improvement of the technique. This has been especially true with the endoscopic brow lift, as most cosmetic surgeons, regardless of their particular background and specialty training, were not familiar with this technology when the procedure first emerged. As in the development of all new technology, perseverance, hard work, and diligent study and observation will eventually define the significance, worthwhile ness and feasibility of this new technique. This paradigm has held true with endoscopic brow lifting. Contemporary surgeons that routinely perform the procedure have found that it is an integral part of their surgical armamentarium, which has revolutionized, modernized and simplified eyebrow-lifting surgery.

The authors (GGM and PSN) have been performing endoscopic browlifts since 1996. Over the last 5 years, our surgical volume with the procedure has been significant and steadily increasing. Our surgical technique is relatively identical and our combined clinical observations with the procedure have led us to develop a series of caveats, which we feel are important to the success of any surgeon who currently performs the procedure or is interested in venturing into it.

We have called our series of observations: Endoscopic Browlift: 13 Caveats To Success. In the following paragraphs we will outline each caveat, briefly summarize its significance, and emphasize surgical pearls, which we feel are important.

In today's modern surgical era it is not uncommon for physicians to take an intensive course in a particular surgical technique and then begin performing it on a routine basis. In many instances there is nothing wrong with this, as most procedures are outgrowths of standard surgical technique learned during one's period of training. This, however, is not the case with endoscopic surgery. In this technology, one must become familiar with new instrumentation, holding instruments at a distance from the surgical site, performing surgery in a closed space dependent on a vide o monitor to view the field, reduced tactile sensation during surgery, and an appreciation of anatomy from deep anatomic planes rather than from the skin down.

In the best of circumstances this can be frustrating, even to the most seasoned of surgeons. We believe the best way to transition into endoscopic surgery is with appropriate preparation (knowledge of the current literature and anatomy), participating in an endoscopic brow-lifting course, and observing and performing a number of procedures with a surgeon experienced with the technique. Then and only then should you attempt to perform the endoscopic brow lift as the sole surgeon.

We routinely use three incisions (1 midline and 2 temporal) as entry for instrumentation and fixation points during surgery. The anteroposterior midline incision is approximately 2 cm posterior to the hairline and is 1 cm in length. The temporal incisions are 3 cm in length and are approximately 2 cm posterior to the hairline. The key to obtain a natural looking brow is to create a temporal incision parallel to the tail of the brow with its medial extent at the temporal conjoint fascia. It is not necessary to mark the incisions before surgery, as their location can vary without affecting the final outcome.

3 Use high volume, low concentration local anesthetic.

The most important surgical aspect of a successful outco me is creating an environment, which allows a clear view during surgery. To create this a bloodless field is critical. We have found that injecting two different concentrations and volumes of local anesthesia can attain this goal. The local anesthesia consists of 15 cc's of 1% Xylocaine with 1:100,000 Epinephrine is injected to all incisional sites, along the orbital rim where deep tissue release is performed, to the central glabellar musculature and for supraorbital and supratrochlear nerve blocks. The rest of the central forehead, parietal scalp, and the temporal region are infiltrated with approximately 30 40 cc's of ¼% Xylocaine with 1:800:000 or of a solution consisting of 500 cc's of normal saline mixed with 0.5 cc's of 1:1000 Epinephrine, 5 cc's of sodium bicarbonate and 25 cc's of 2% Xylocaine without epinephrine. The high volume of the above solution creates a vascular tourniquet and augments the hemostatic effect of the original higher concentration epinephrine injection.

A major complaint of traditional bicoronal brow lift surgery is hair loss. In the endoscopic technique, smaller incisions are made so less alopecia is seen. To further reduce the incidence of this complication, avoid cautery to the incision sites (with the aid of caveat #3), direct the incisions in line with the hair shaft (not through it), do  not excise temporal hair bearing scalp to aid in brow elevation, do not use subcutaneous sutures to close the temporal incision sites, and do not rigidly fixate the scalp (superfluous, as will be described later).

In general, the less manipulation of the surgical wound, the less the chance of hair loss. We feel this is an absolute dictum during surgery.

5 Periosteal release is a given, but temporal orbicularis release is essential. 

An emphasis on complete periosteal release (elevation, incision and spreading) has been stressed since this procedure was first described 1 . While this is a critical step in the surgical technique, it alone does not lead to sustained long-term brow elevation. In the postoperative phase, creating unopposed elevation of the temporal brow until it scars into place is critical. To achieve this one must strip the only temporal brow depressor (the temporal orbital orbicularis oculi muscle). We spread and release the muscle until the yellow brow fat pad is exposed. This additional step to periosteal and central brow depressor musculature release has been the most important adjunct to the surgery, which we have identified. It has not only stabilized long-term brow position, but has also obviated the need for paracentral bony fixation.

Rigid fixation of the scalp with staples behind screws (most common), or other techniques, puts undue tension on the scalp skin and hair follicles. This invariably leads to hair loss and scarring. With a complete release of periosteum 2 , central brow depressor musculature and lateral supraorbital orbicularis oculi muscle (caveat #5), the entire brow complex will elevate to an unnaturally high position without any tension (Figures 1 A-C) and obviate the need for paracentral fixation (see caveat #8). Avoiding this step reduces complications, shortens surgical time, does not adversely affect final outcome, and makes the procedure more accepting to patients.

Extirpating the central brow depressors (corrugator, procerus, depressor supercillii) may lead to an unnatural brow appearance (widened and elevated medial brow) and further complications. We have routinely seen indentations and depressions in the glabellar skin, prolonged sensory deficits, and unexpected intraoperative bleeding when employing this excisional technique. We counsel patients that the procedure elevates the ptotic brow well. We do not suggest that it consistently eliminates frown lines. Patients are instructed that Botox is an excellent adjunct to surgery if the desire is to reduce frown lines. 8 Deep temporal fixation only (DTFO) (with absorbable sutures) is all that is needed to maintain brow height. As previously discussed, we only fixate the released composite temporal flap. Brow fixation is achieved by securing the superficial temporal fascia medially to the deep temporal fascia in a superolateral

vector with 2 2-0 PDS horizontal mattress sutures while the brow is lifted laterally and over-corrected. Permanent suture fixation has led to possible long-term suture extrusion, granulomas, palpable masses and tenderness.

As with traditional brow lifting techniques, a degree of overcorrection of brow height is necessary to compensate for the inevitable drop in postoperative brow height. As described above, i f a complete release of all periosteum and brow depressor musculature is performed, the entire brow complex will elevate to an unnaturally high position. Even with the above statement and overcorrecting the brow height, the brow tends to settle to an optimum position within the first postoperative month. While we have had patients desire a higher height than has been obtained with surgery (usually an overexaggeration of normal brow position), the opposite has not occurred. As such, do not be concerned with what appears to be an over-elevated brow in the immediate postoperative period.

Botox can be used in the preoperative period to weaken (cause atrophy) of the orbital orbicularis and glabellar musculature. This ap pears to make release and spreading of these muscle groups easier. We prefer not to use Botox preoperatively. If an inadvertent ptosis was to occur it may require delaying surgery to a later time (especially if blepharoplasty is added).

Botulinum toxin may be used synergistically with the surgical brow depressor musculature release in an effort to weaken the inferior vector forces and promote the maintenance of the newly elevated brow.

Botulinum toxin is used to block the depressor function of the corrugator, procerus, depressor supercilii and lateral supraorbital orbicularis oculi muscles 3 . One to 2 weeks following surgery, patients are injected with botulinum toxin. The corrugator, procerus and depressor supercilii muscles (medial brow depressors) are typically injected with a total of 18 units of botulinum toxin and the lateral supraorbital orbicularis oculi muscles (lateral brow depressor) are injected with 4 6 units of botulinum toxin on each side. Botox in these areas helps assure unopposed frontalis muscle action (elevation of the brow) during the critical healing period after surgery; consequently no botulinum toxin is injected into the frontalis muscle. We have not found an increased risk of diffusion and ptosis from the surgery.

Motor nerve injury to the frontal branch of the fa cial nerve is a rare occurrence. When it does occur, it typically results from spread of heat from cautery to the superficial temporal vein, undue upward traction on the flap, or inadvertent dissection in an inappropriate plane (see caveat #1). In our experience, motor injury has occurred in less than 2% of cases and has universally resolved in the first 4 - 6 weeks following surgery, with or without the use of oral steroids.

Sensory deficit is common after surgery. We have found that at least 50 to 75% of patients describe some form of paresthesia. These changes include decreased sensation (most common), tingling, and itching.

Itching is the most troublesome (and fortunately rarest) symptom.

Sensory changes can last up to 6 months. They typically resolve first in the forehead, then the temples, and finally, the rest of the scalp.

We have found that compressive forehead dressings increase periorbital swelling and bruising. If bleeding may be an issue, place a 10-French drain into the right temporal incision and run it along the orbital rim until it reaches the opposite temporal wound (at the canthus). The drain is removed 24 48 hours following surgery. One of the authors

(PSN) uses platelet rich plasma routinely with good results. In either case, we find pressure dressings to be unnecessary.

When blepharoplasty is added to a brow lift, careful attention must be given to not over- resect eyelid skin. There are two particular areas in which we have found this to be important. When the brow is lifted in conjunction with blepharoplasty, the brow fat pad is elevated which may yield a more hollow appearance to the superior sulcus (especially medially). Consequently, conservative amounts of skin and fat should be excised. Secondly, when combined surgery is performed, we tend to avoid excising palpebral (eyelid) oribicularis muscle to preserve as much eyelid closure as possible after surgery.

The endoscopic brow lift has become an essential tool to the facial cosmetic surgeon. It has transformed the brow lift into a procedure, which is minimally invasive and performed through small incisions. The caveats described herein, are important observations developed over time and with experience. We believe that if one follows these guidelines, consistent, reproducible, and superior results may be achieved.

References:

1. Ramirez OM: Endoscopic subperiosteal browlift and facelift, Clin Plast Surg 22:639-660, 1995.

2. Nassif PS, Kokoska MS, Cooper P, et al.: Comparison of subperiosteal vs. subgaleal elevation techniques used in forehead lifts, Arch Otolaryngol Head Neck Surg 124(11): 1209-1215, 1998.

3. Zimbler MS, Nassif PS: Adjunctive applications for botulinum toxin in facial aesthetic surgery, Facial Plast Surg Clin North Am (In Press).