British Journal of Plastic Surgery (2002), 55, 20- 24

9 2002 The British Association of Plastic Surgeons

doi: 10.1054/bjps.2001.3707
B R I T I S H J O U R N A L O F [ ~ J P L A S T I C S U R G E R Y
O n e h u n d r e d c a s e s o f e n d o s c o p i c b r o w l i f t
S. Withey, H. Witherow and N. Waterhouse
Department of Plastic Surgery, The Wellington Hospital, London, UK
SUMMARY. The senior author' s experience of using the endoscopic brow lift for rejuvenation of the upper third of
the face is presented. One hundred patients underwent endoscopic brow elevation. In 98 cases this was done in combi-
nation with other aesthetic procedures. Patient follow-up ranged from 4 months to 53 months (mean: 17 months). No
major complications were experienced, although a patient questionnaire identified a number of troublesome but tran-
sient minor complications. Levels of patient satisfaction were found to be high. The continuing evolution of this tech-
nique is reviewed, particularly relating to methods of brow fixation. 9 2002 The British Association of Plastic Surgeons
Keywords: brow lift, endoscopy, forehead.
The upper third of the face is more resistant to the effects
of ageing than the midface and the lower face, but it is
still subject to the effects of time and gravity. 1
Gravitational and muscular forces are responsible for
the development of glabellar and brow frown lines, brow
ptosis and palpebral redundancy. Traditionally, the fore-
head lift has been carried out through a bicoronal inci-
sion, an approach that has relied on soft-tissue resection
and traction with minimal tissue modification. 2
In 1992 Isse introduced the endoscopically assisted
forehead lift with the intention of minimising scalp scar-
fing and reducing operative morbidity? At the time of
writing, the senior author (NW) has performed over 350
similar procedures. The results of the first 100 patients
are reviewed in this study. Over the study period the pro-
cedure, particularly the method of brow fixation, has
been refined in an attempt to provide a reliable adjustable
method of elevation that is able to recreate the aesthetic
ideals of the brow. The evolution of the operation and our
modifications are described and discussed.
Materials and methods
Preoperative assessment
Patients requesting upper-third facial rejuvenation require
assessment of the forehead rhytides and glabellar frown
lines, the eyebrow position with respect to the supra-
orbital ridge, and the height of the forehead. Full assess-
ment of the upper lid is also essential, particularly i f there
is a history of previous upper-lid surgery. At the preoper-
ative assessment it is important to explore the patient' s
expectations of surgery, and the desired vector and extent
of lift. Formal documentation of the distance between the
upper-lid margin and the eyebrow and from the eyebrow
to the hairline is used to determine the extent of brow
ptosis and record postoperative changes.
Patients are warned specifically about the high proba-
bility of transient itching and tightness of the scalp.
Temporary alopecia related to the incision and clips
usually resolves within 6 months. Occular symptoms, for
example itching, soreness and temporary lagophthalmos,
may occur, but rarely persist. Permanent frontal-nerve
damage, asymmetry and relapse are, in the senior author' s
experience, rare.
Operative procedure
The operation is performed under general anaesthesia.
A local anaesthetic solution containing adrenaline, bupi-
vacaine, hyaluronidase, hydrocortisone and saline is infil-
trated into the operative field in the subperiosteal plane.
This manoeuvre assists in hydrodissection of the brow,
and minimises intraoperative bleeding. The presence of
hair in the wound is undesirable and may increase the
chances of infection? No shaving of the scalp is neces-
sary, but the hair is covered with gel and plaited to avoid
introducing hairs into the operative field.
Surgical access to the brow is obtained through five
incisions. One midline 1.5 cm incision is made 1 cm
behind the hairline, and two similar incisions are made
about 5 cm lateral to this along the vector of proposed
maximal brow lift. This vector usually corresponds to the
continuation of a vertical line that lies halfway between
the lateral edge of the pupil and the lateral canthus. Two
temporal incisions are made over the temporalis muscle
on the continuation of a line drawn from the alar base
through the lateral canthus, and are bevelled parallel to
the hair follicles. The planes of dissection used are the
subperiosteal plane from the midline to the temporal
crests, and the sub-temporoparietal fascial plane in the
temporal region. A 4 mm rigid Storz endoscope with a
30 ~ angle is used to assist with the dissection; a medical-
quality video camera relays the image to a monitor that is
equipped with a video camera.
Dissection of the scalp, temporal and forehead pockets is
performed using custom-made dissectors. Early dissectors
possessed straight shafts and blunt tips. Experimentation
20
One hundred cases of endoscopic brow lift 21
has led to the development of sharp-tipped elevators with
varying curves to match the curvature of the skull. We
use a seven piece set (Snowden Penser). Other instru-
ments used include insulated graspers and scissors.
The initial dissection of the midline subperiosteal
plane is performed blind using a curved sharp-tipped
periosteal elevator, both posteriorly to the level of the
interauricular line and forwards to a point 1 cm above the
supraorbital rim. Laterally, once the t emporal plane has
been identified, a silk traction suture is placed through the
skin and the temporoparietal fascia, thus allowing these
structures to be lifted together, ensuring that the chosen
plane, beneath the temporoparietal fascia, is entered each
time the instruments are reintroduced. The dissection of
the temporal pocket is easily carried out blindly to a point
about 1 cm above the zygomatic arch, and medially until
the temporal crest is reached. Sharp dissection is required
to elevate the fascia from the temporal crest. This manoeu-
vre is ideally performed from lateral to medial to avoid
inadvertently entering the wrong plane. The lower end of
this dissection extends beyond the level of the frontozy-
gomatic suture, at which point a ' sentinel' branch of the
internal maxillary vein may be identified.
The endoscope is introduced into a frontal pocket, and
dissection is continued under direct vision toward the
supraorbital rim. The subperiosteal dissection is contin-
ued over the supraorbital ri m to ensure that mobilisation
has been achieved below the lower limit of the eyebrow.
The supraorbital neurovascular bundles are identified and
preserved.
Once this release has been accomplished, a 15 blade
is introduced, and the arcus marginalis is divided at a
level 1 cm above the orbital rim. This manoeuvre is clas-
sically done using the upcutting elevator, although the
senior author chooses to divide the peri ost eum using a
blade rather than an up cutter because it provides a
cleaner and more precise incision in the tissues and is
less likely to cause a traction neuropraxia of the supraor-
bital nerves.
The corrugator and procerus muscles may be debulked
using grabbing forceps. When debulking the muscles,
care should be taken to avoid damagi ng the supra-
trochlear nerve that is within the substance of the corru-
gator muscle; 5 the branches of the nerve are easily
displayed i f the muscle fibres are spread with a pair of
grasping forceps. Debulking must be adequate, but over
resection can lead to medial separation of the eyebrows.
Care must be taken to ensure that over resection does
not result in a visible contour defect in the gl abel l ar
region. I f this is evident, the defect can be primarily
reconstructed with temporal fascia or a fat graft. For this
part of the procedure, visibility may be i mproved by ele-
vating the released glabellar tissues using a skin hook
placed at the root of the nose. It has been suggested that
dividing, scoring or even resecting portions of the
frontalis muscl e is essential to alleviate transverse frown
lines. 6 We do not believe that it is necessary to alter this
muscle surgically, and instead rely on reducing the
depressor power to achieve improvement. The intact
frontalis muscl e continues to act as a brow elevator.
After careful inspection of the cavity to ensure that
haemostasis has been secured and that no stray hairs have
been introduced, the cavity is washed out and the instru-
ments are removed.
After an endoscopic procedure, the elevated brow posi-
tion must be held while skin retraction and scarring take
place. 7 The ideal met hod of fixation should be flexible
enough to enable the components of the lift to be
addressed individually, hold the brow long enough for
healing to take place, be reproducible, have few compl i ca-
tions and require minimal training and equipment.
Rohrich and Beran have reviewed the recent history of
brow fixation, and divide the techniques into exogenous
and endogenous methods. 7 Methods of exogenous fixa-
tion rely on wires or screws to hold the position.
Exampl es of endogenous-fixation methods include: the
application of tissue adhesives; the use of elliptical scalp
excision at the port sites, which produces advancement as
the skin edges are opposed; the application of exterior
bolsters that bunch up rolls of scalp until an adequate lift
has been achieved; and the use of sutures l ooped through
cortical tunnels.
The exogenous-fixation techniques are generally con-
sidered to be more precise, but are technically more
demanding and all hold the potential of dural injury. Over
the 6 years that the senior author has been performing this
procedure, the chosen fixation methods have evolved. For
the first 15 patients fixation was maintained with tissue
glue (Tisseel, Immuno AG, Vienna, Austria) introduced
into the subperiosteal plane. 8 The following 14 cases were
fixed with a combination of fibrin glue and sutures held
within cortical bone tunnels. These cortical bone tunnels
provided an excellent fixation technique. Fibrin glue was
used to augment fixation and to allow alternative vectors of
lift, particularly over the lateral aspect of the brow. The tun-
nel within the outer table was created using a 1.2 mm drill.
A suture attached to the galea was then threaded through
the tunnel and tied in order to secure the position of the
forehead. The technique has the advantage of precise reli-
able fixation of the tissue, but does not allow the height of
the lift to be changed in the postoperative period. The use
of cortical screws and clips to secure the tissue provides
this flexibility, and was used in combination with fibrin
glue to secure the lateral aspect of the brow in the follow-
ing 50 patients. For the last 21 patients, and for all subse-
quent cases, fixation has been provided with screws and
clips alone. We have ceased using glue in accordance with
internal hospital practice. In these cases, using screw and
clip fixation alone, excellent fixation has been achieved.
Fibrin glue is not only unnecessary but also expensive.
The most accurate and yet flexible technique for
securing the brow position is the ' adjustable screw-st apl e
scalp fixation' . 9,~~ Fixation of the brow is performed fol-
lowing elevation to the desired position using skin hooks.
Fourteen millimetre screws are introduced into the poste-
rior third of the two frontolateral incisions, the scalp is
then elevated to the desired position. The position is
maintained by the use of staples to close the wound
behind the screws (Fig. 1). Should the elevation appear
excessive, removal of the staple closest to the screw will
allow some brow descent. This can be performed the fol-
lowing day if necessary, allowing the brow to descend.
We have used this technique in 71 patients and have
changed the position of the brow within 48 h in one case.
22 British Journal of Plastic Surgery
A
B
@,
\
Figure 1--(A) Schematic drawing showing stage one of the adjustable
screw-staple fixation technique. When the desired position of the brow
has been assessed, a 14 mm screw is inserted into the skull midway or
towards the back of each lateral incision. (B) Schematic drawing show-
ing stage two of the fixation technique. The brow is elevated so that
most of the incision lies behind the screw and staples are used to close
the incision.
Further modification of the lift, particularly laterally,
may be achieved by suturing the anterior leaf of the tem-
poroparietal fascia upwards and backwards onto the deep
temporal fascia. All incisions are closed with staples. We
have never used drains or head dressings. The screws and
staples are left in position for 14 days, after which
removal is undertaken in an outpatient setting. No anaes-
thesia is required for screw removal.
and a stamped addressed envelope. We received 80 replies
and analysed the responses.
Resul ts
The results of this study were assessed following a retro-
spective review of the notes of 100 patients, and the
analysis of a questionnaire that was sent to these patients.
The response rate to the questionnaire was 80%.
Between June 1994 and May 1999 100 patients had an
endoscopic brow lift performed by the senior author.
Overall, 90 of the patients were female (age range: 29-69
years; mean: 52 years) and 10 were male (age range:
31-62 years; mean: 54 years). Three of the brow lifts
were performed to treat facial asymmet ry in patients with
facial palsy. Patient follow-up ranged from 4 months to
53 months (mean: 17 months).
At the time of presentation, only 21 of the patients in
the aesthetic group were aware of the relevance of their
upper-third ageing and directly requested brow rejuvena-
tion. The majority (76) of the patients complained of a
tired, sad or angry look, but did not directly relate this to
brow ptosis or upper-third ageing. At the time of their out-
patient visit, 24 of these patients were unaware of the exis-
tence of the brow-lift procedure. Two patients underwent a
brow lift alone; the remaining 98 patients underwent a
total of 157 other procedures (Table 1).
Rohrich and Beran report that removable screws
should be left in place long enough for healing to occur
and for scar tissue to gain maxi mum strength, and sug-
gest leaving the screws for 42- 60 days. 7 In this series, we
have removed the screws at 14 days and have had no
reports of an early change in brow position.
The screws are simple to remove in the outpatient
clinic, and no patient has had any concern about the use
or removal of external screws. The one concern that we
have with this technique became apparent following the
review of the patient questionnaire: 29% of patients
whose brows were fixed with screws and clips com-
plained of temporary alopecia, compared with 6% of
patients whose brows were fixed by other techniques. No
significant difference in complication rate or severity was
found between the different fixation methods.
There were no serious postoperative ophthalmic
complications. Temporary lagophthalmos was noted in
four patients, three of whom had previously undergone
blepharoplasty.
There were no clinically significant haematomas or
seromas, although 23% of patients complained of post-
operative swelling that lasted for a mean of 1.2 months.
Patient questionnaire
From the practice database, 100 patients were identified
who had undergone endoscopic brow lift. All the clinical
records and photographs were reviewed. Information was
recorded on age, presenting complaint, previous surgical
history and postoperative progress. Operating notes were
also reviewed to determine the fixation techniques.
A questionnaire was designed with specific attention to
complications and problems. The patients were also sent a
covering letter explaining the purpose of the questionnaire,
Table 1 Procedures performed at the same time as
the endoscopic brow lift
Procedure Number of patients
facelift 63
laser 23
platysmaplasty 22
lower-lid blepharoplasty and laser 16
upper-lid blepharoplasty 9
rhinoplasty 6
other procedures 18
One hundred cases of endoscopic brow lift 23
Table 2 Complications reported in the
questionnaire survey
Complication Number o f pat i ent s a
numbness 57
itching 37
hair loss 19
swelling 18
asymmetry 9
eye problems 5
relapse of brow position 4
irregularity of glabella 1
aTotal number of replies to the questionnaire: 80.
Questionnaire analysis
When the questionnaires were reviewed, 73 of the patients
(91%) complained of minor complications (Table 2).
Patient satisfaction with the procedure was high: 84% of
the patients confirmed that, if necessary, they would
undergo the procedure again, and 75% commented that
they would recommend the procedure to a friend.
Di s c u s s i o n
Ptosis of the forehead, eyebrows and upper lid, and glabel-
lar frown lines are the primary indications for forehead
elevation. ~ In this series, it is of interest that few patients
with classical signs of upper-third ageing appreciated that
their brow contributed significantly to their aged look.
As the endoscopic technique is focused on tissue mod-
ification rather than tissue excision, the predominant
positions of the rhytides are noted so that the relative
contributions of the frontalis, procerus, corrugator and
orbicularis muscles can be determined. This allows
selective debulklng to be undertaken.
Differing planes of dissection have been employed by
various authors. L6,]~ Kaye describes the use of the sub-
galeal plane for forehead dissection to avoid the develop-
ment of adhesions between the flap and the underlying
bone? Daniel and Tirkanits develop the subgaleal plane
posteriorly and use the subperiosteal plane for the ante-
rior dissection. H We favour the subperiosteal approach,
using a quarter-curved elevator for both anterior and pos-
terior dissection. Ramirez advocates the use of a subpe-
riosteal approach for three reasons: the inherent rigidity
of the tissues overlying the subperiosteal dissection
means that this technique is the most effective at lifting
the brow and the least likely to suffer from stress relax-
ation; the scarring following subgaleal dissection pro-
duces variable adherence of the tissues to the pericranium
and, subsequently, unnatural forehead activity; and the
subperiosteal dissection preserves the areolar tissue at the
galea-periosteal interface, maintaining the normal glid-
ing of the frontalis muscle complex over the periosteum. 6
The dissection of the temporal plane is beneath the tem-
poroparietal fascia regardless of the preferred anterior
dissection technique.
The principle of the endoscopic approach to the brow
lift is one of soft-tissue release, muscle debulklng and
suspension, rather than soft-tissue excision, which is the
mainstay of the open technique. While simple release of
the depressors is inadequate, allowing the muscles to
reattach quickly to the glabella, 6 muscle debulklng should
not be too radical because this may lead to the develop-
ment of irregularities of the glabella and widening of the
medial portion of the brow.
Following an open brow lift, the modified position of
the brow is held as a consequence of skin resection. After
an endoscopic procedure, the elevated brow position must
be held while skin retraction and scarring take place. 7 The
ideal method of fixation should be flexible enough to
enable the components of the lift to be addressed individ-
ually, hold the brow long enough for healing to take place,
be reproducible, have few complications and require mini-
mal training and equipment. The one concern that we
have with our technique became apparent following the
review of the patient questionnaire: 29% of patients
whose brows were fixed with screws and clips com-
plained of temporary alopecia, which we presume
occurred because of local ischaemia at the points where
the clips abutted the screws. Biodegradable screws have
been used to secure the position of the forehead, ~2 but as
the position of the brow cannot be altered once they have
been inserted they have no advantage over cortical bone
tunnels.
Reported complications of endQscopic brow lifting
include frontal-nerve palsy, neuropraxia, infection,
haematoma, alopecia, forehead diathermy bums and poor
positioning of the brow? 1.~3.~4 We report no serious compli-
cations, although we were surprised by the high incidence
of minor complications (91%) revealed by the question-
naire (Table 2). Less than 5% of patients had reported com-
plications to the surgeons at the time of follow-up, and
patient satisfaction remained high. The high level of tran-
sient altered sensation (lasting for a mean of 3 months)
probably reflects traction on the supraorbital and supra-
trochlear nerves at the time of dissection and elevation.
Levels of temporary alopecia (lasting for a mean of 5
months) were high (24%), and analysis of the different fix-
ation groups revealed that 29% (18/63) of the group who
had undergone fixation with clips and screws complained
of alopecia, compared with 6% (1/17) of the patients who
had undergone other fixation techniques; this is significant
P = 0.003 (Fisher's exact test). Levels of glabellar irregular-
ities were considered high at 6%, but all of these patients
were treated early in the series, when more aggressive
resectioning of the glabellar muscles was undertaken.
Subsequently, with more selective muscle debulking, we
have had no further complaints of irregularities. Overall,
5% of patients reported brow asymmetry, although none of
these patients had complained at their postoperative review
clinics. Despite reporting asymmetry, all of these patients
expressed satisfaction with the results of surgery and
claimed that they would undergo the procedure again.
Finally, three patients complained of some relapse in
the brow position. All three had undergone the procedure
at least 20 months before the review.
As a result of this study, patients are now informed of
the potential for all the complications we have identified.
Few reports on the aesthetic ideals of the brow-lift
procedure have been published. Freund and Nolan have
attempted to determine the ideal position of the female
brow. 15 They conclude that, while there is little agreement
24 Bri t i sh Journal of Plastic Surgery
in the medical literature regarding the aesthetics of the
brow, there are common criteria for an attractive brow
that can be identified. They suggest that the medial eye-
brow should be located at or just below the supraorbital
rim, not above it, and that the eyebrow shape should have
an apical lateral slant. We agree with their findings, and
tend to design the vector of maximal lift over the junction
of the middle and lateral thirds of the brow. We feel that
the majority of the improvement medially is achieved by
muscle debulking that reduces the brow rhytides. Figure 2
shows preoperative and postoperative views to demon-
strate some of the benefits of the endoscopic brow lift.
As there are no universally accepted objective meth-
ods for measuring brow elevation, patient satisfaction and
subjective evaluation by the surgeon remain important
determinants of success. TM Measurements of brow posi-
tion in relation to the pupil are useful for determining
whether a successful lift has been sustained, but the
individual figures may not correlate with aesthetic
outcome because each lift is individualised.
Figure 2---Appearance (A) before and (B) after an endoscopic brow lift.
Patient satisfaction is an important criterion for the
evaluation of aesthetic surgical procedures, and the ques-
tionnaire responses demonstrate that levels of patient sat-
isfaction were high. Equally, although the number of
minor complications was high, these were temporary and
well tolerated.
No conclusions can be drawn as to whether the compli-
cation rate differs from that experienced with open brow
lifting as, to our knowledge, no studies have been reported.
References
1. Kaye BL. The forehead lift: a useful adjunct to face lift and ble-
pharoplasty. Plast Reconstr Surg 1977; 60: 161-71.
2. Isse NG. Endoscopic forehead lift: evolution and update. Clin Plast
Surg 1995; 22: 661-73.
3. Isse NG. Endoscopic facial rejuvenation: endoforehead, the func-
tional lift. Case reports. Aesthetic Plast Surg 1994; 18: 21-9.
4. Guyuron B, Michelow BJ. Refinements in endoscopic forehead
rejuvenation. Plast Reconstr Surg 1997; 100: 154-60.
5. Sasaki GH. Anatomic considerations. In Fodor PB, Isse NG, ed.
Endoscopically Assisted Aesthetic Plastic Surgery. St Louis:
Mosby Publishing, 1995: 13-27.
6. Ramirez OM. Endoscopic full facelift. Aesthetic Plast Surg 1994;
18: 363-71.
7. Rohrich RJ, Beran SJ. Evolving fixation methods in endoscopically
assisted forehead rejuvenation: controversies and rationale. Plast
Reconstr Surg 1997; 100: 1575-82.
8. Marchac D, S5ndor G. Face lifts and sprayed fibrin glue: an out-
come analysis of 200 patients. Br J Plast Surg 1994; 47: 306-9.
9. Putterman AM. Intraoperatively controlled small-incision forehead
and brow lift. Plast Reconstr Surg 1997; 100: 262-6.
10. McKinney P, Celetti S, Sweis I. An accurate technique for fixation
in endoscopic brow lift. Plast Reconstr Surg 1996; 97: 824-7.
l 1. Daniel RK, Tirkanits B. Endoscopic forehead lift: an operative
technique. Plast Reconstr Surg 1996; 98:1148-57.
12. Pakkanen M, Salisbury AV, Ersek RA. Biodegradable positive fixa-
tion for the endoscopic brow lift. Plast Reconstr Surg 1996; 98:
1087-91.
13. Nahai F, Eaves FF III, Bostwick J III. Forehead lift and glabellar
frown lines. In Bostwick J III, Eaves FF, Nahai F, ed. Endoscopic
Plastic Surgery. St Louis: Quality Medical Publishing, 1995:
165-231.
14. Bostwick J III, Nahai F, Eaves FF III. Evaluation and planning for
aesthetic surgery of the face and neck: an integrated approach. In
Bostwick J III, Eaves FF, Nahai F, ed. Endoscopic Plastic
Surgery. St Louis: Quality Medical Publishing, 1995: 137-65.
15. Freund RM, Nolan WB III. Correlation between brow lift outcomes
and aesthetic ideals for eyebrow height and shape in females.
Plast Reconstr Surg 1996; 97: 1343-8.
The Authors
Simon Withey MS, FRCS, FRCS(PIast), Aesthetic Fellow
Norman Waterhouse FRCS, FRCS(PIast), Consultant Plastic
Surgeon
Department of Plastic Surgery, The Wellington Hospital,
London NW8, UK.
Helen Witherow FDS, RCS, FRCS, Maxillofacial Specialist Registrar
Queen Mary' s Hospital Roehampton, London SW15 5PN, UK.
Correspondence to Mr N. Waterhouse, Consultant Plastic Surgeon,
55 Harley Street, London W1N 1DD, UK.
Paper received 8 January 2001.
Accepted 10 September 2001, after revision.