Overview of Endoscopic Brow Lift
The position of the eyebrows can change as we age. The eyebrows start to droop – a condition called ‘ptosis’ – which can result in the upper eyelid appearing heavy or having extra skin called ‘hooding’. This can sometimes interfere with your field of vision. People might also think you look tired or upset when you’re actually well-rested and in a good mood. This change in appearance can be part of the natural aging process.
There are different types of surgeries that can help restore the position and appearance of the eyebrows. These range from traditional, more invasive surgeries, to less invasive techniques using an endoscope (a small device with a light and camera). Every method has its own pros and cons, and there isn’t a definitive ‘best’ surgery for everyone.
The endoscopic brow lift, a type of less invasive surgery, was first introduced by Nicanor Isse in 1994. Since then, it has become more popular and the techniques have improved. Today, more than half of all procedures to rejuvenate the appearance of eyebrows are done with endoscopes. This likely reflects a growing preference for less invasive cosmetic surgeries. It’s important for cosmetic surgeons to understand this method, as it can give effective and lasting results.
Anatomy and Physiology of Endoscopic Brow Lift
The upper part of your face can show specific signs of aging. Here are a few:
- Vertical lines between your eyebrows: These are created by a muscle in your face called the corrugator supercilii muscle.
- Oblique (slanted) lines between your eyebrows: These are caused by a combination of several muscles around your brow and eye.
- Lines going across your forehead: These are made by a muscle in your face called the procerus muscle.
- Drooping eyebrows: This can happen due to gravity, changes in the fatty tissue under the skin, muscle action, and changes in the layers of skin and tissue in your face.
- Excess skin on the upper eyelids: This can happen when your eyebrow drops, especially on the side. When the skin from your upper eyelid hangs down over your eyelashes, it can make it look like you have drooping eyelids.
- Lines going across your forehead: These lines are caused by the action of a muscle called the frontalis muscle. This is the only muscle that lifts your brows.
During a procedure called an endoscopic brow lift, certain structures in the face need to be loosened:
- Zone of adhesion: This is an area about 6 mm wide on the skull where a layer of tissue (the periosteum) and skin are stuck to the bone.
- Conjoint tendon: This is a tendon formed by several layers of tissue joining together. It acts like a band that holds the skin in place.
- Arcus marginalis: This is where two types of tissue meet and form a boundary at the brow ridge (supraorbital rim). This boundary holds the brow in place.
During this procedure, there are certain areas that should be avoided:
- Supraorbital nerve: This is a nerve that leaves the top part of the eye socket (the orbit) and branches out to provide feeling to the skin on top of the head and the upper eyelid. This nerve can leave the skull in different ways in different people.
- Supratrochlear nerve: This nerve is usually found 1 cm from the supraorbital nerve, towards the middle of the face. It provides feeling to the skin between the eyebrows, the upper eyelid, and a part of the conjunctiva (a clear layer on the front of the eye).
- Temporal branch of the facial nerve: This nerve provides movement to the muscles of the brow and the top part of a muscle that controls the eyelids. The nerve travels near the cheekbone and beneath a layer of tissue in the head. An estimated path for this nerve might be drawn using an established method called Pitanguy’s line.
- Sentinel vein: This is a vein found about 1 cm from a joint in the skull, next to a nerve.
- Hair follicles: Losing hair can be avoided by making cuts along the direction of hair growth, closing cuts without pulling or stretching the skin, and using cautery (a procedure that burns or destroys tissue) carefully in areas with hair.
Why do People Need Endoscopic Brow Lift
Brow lift surgery might be needed for several reasons. These can include a drooping brow, deep wrinkles or furrows on the forehead, glabella (the space between the eyebrows and above the nose), or nasal root (the area where the nose begins). The surgery could also help if there is excess or sagging skin on the forehead or temples, or if the appearance of drooping eyelids limits vision.
Deciding between less invasive techniques done with a special camera (endoscopic) or more traditional open surgery is subjective and depends on a few factors. Some patients might prefer endoscopic surgery because it’s less invasive and often leaves smaller scars. This type of surgery might also be a better fit for patients with a short forehead that measures less than 6 cm from the brow to the hairline.
When a Person Should Avoid Endoscopic Brow Lift
There are certain situations in which a doctor may advise against a Brow Lift Surgery. Here are some of them:
If a person can’t completely close their eyes (a condition known as Lagophthalmos), a brow lift may not be suitable.
When a person’s two eyebrows are uneven by more than 3-4 millimeters, a brow lift might be challenging. This is because the procedure lifts the entire forehead uniformly, making it tricky to provide additional lift to just one side.
If a person suffers from dry eyes or has had previous eyelid surgery (blepharoplasty), they could have a heightened risk of developing Lagophthalmos.
If a patient has unrealistic expectations about their post-surgery brow shape, this could also be a deterrent. In women, the ideal brow is slightly curved and located just above the upper edge of the eye socket. However, this differs from men, whose brows should be more flat and positioned on the edge of the eye socket. There’s no one-size-fits-all “perfect eyebrow”, so good communication between the doctor and the patient is crucial to achieve the best results.
If a patient suffers from Body Dysmorphic Disorder, a condition where a person obsesses over perceived defects in their appearance, a brow lift may not be advisable.
Similar precautions apply to a specific method called Endoscopic Brow Lift Surgery. This method may not be suitable for individuals with:
Significant hairline recession, as this procedure could potentially further lift the hairline.
Excessively curved forehead or prominent brow ridges (frontal bossing), which could make the use of the small camera (endoscope) tricky around the area around the eye (periorbita).
Equipment used for Endoscopic Brow Lift
Before the Operation
The doctor will use an alcohol solution or pad to clean your skin to prepare for the operation and draw on it with a surgical marker to indicate where the incisions will be made. They’ll use a local anesthetic like lidocaine mixed with a small amount of epinephrine to numb the area; the maximum dosage is 7 mg per kg of your weight. Another substance, known as a tumescent solution (a mixture of lidocaine, epinephrine, and saline), might also be used. After that, they’ll apply a topical antiseptic like povidone-iodine to kill bacteria on the skin. To protect your eyes during the operation, a corneal shield and lubrication may be used.
During the Operation
Your doctor will use a special instrument called an endoscope to look inside your body during the surgery. This device has a light and camera on it and is attached to a video monitor to make it easier for the surgeon to see what they’re doing. They’ll use a variety of tools like curved dissectors and periosteal elevators, which are designed to separate and lift tissues gently. The device used to secure things in place, or fixation method, can vary; options include sutures (stitches) fixed to screws, plates, and bone tunnels, as well as reabsorbable devices that grip both the outer layer and the bone underneath.
To perform the operation, the surgeon may use a scalpel with a #15 blade, fine-toothed forceps designed for gentle handling of soft tissues, facelift or other types of scissors for dissection, an electrocautery device to stop bleeding, skin hooks and small retractors to hold tissues apart, and both absorbable (dissolves on its own) and non-absorbable sutures or staples to close wounds.
After the Operation
When the operation is complete, the doctor will apply an ointment like petrolatum or an antibiotic ointment to the area where the surgery was performed. Finally, they’ll use a non-stick dressing material, a kerlix wrap, and an ace wrap to cover the area and keep it clean as it heals.
Who is needed to perform Endoscopic Brow Lift?
The medical team that will be taking care of you in the operation room includes multiple professionals. The person who actually performs the surgery is called a surgeon. An anesthesiologist is a special kind of doctor who gives you medicine to help you sleep during the surgery so you don’t feel any pain. Nurses specifically trained to work in the operation room also form part of the team.
There is also a scrub technician, who is responsible for handling all the instruments used during the surgery. They make sure they are clean, safe, and ready for the surgeon to use. The surgical assistant is another key member of the team, who assists the surgeon throughout the procedure. They have specialized training to support during the operation. This team works together to ensure your surgery goes as smoothly and safely as possible.
Preparing for Endoscopic Brow Lift
When a person is about to undergo a surgery involving the face, such as a brow lift, doctors first take several close-up pictures of the person’s face from different angles. These images are especially important for the patient and the doctor to understand what changes need to be made. The person is usually asked to sit up straight, relax their face muscles and look in different directions for these photos.
To get a clear comprehension of the alterations to be made, doctors mark out specific points on the face. These points help guide their work and they include spots like the point above the eye socket, the optimum spot for raising the eyebrow, the track of a crucial facial nerve and a significant vein.
The doctor then begins to place marks on the face to show where they plan to make incisions during surgery. Usually, three marks are made along the hairline of the forehead, and an additional two marks are made near the hairline of the temples. These spots will be used for small incisions during the operation. Contrary to what many believe, the hair in this region doesn’t need to be shaved off, although hair ties can be used to keep hair out of the way for a better view during surgery.
Next, the person is comfortably laid on their back with the surgery monitor in sight at the foot of the bed. An anaesthetic is then introduced to numbing the upper and the side parts of the eyes to reduce any discomfort during the procedure. More of this solution is then applied to different parts of the face and head. This procedure can be carried out using local anaesthetic solely, but general anaesthetics or sedation are often recommended for improved comfort.
Lastly, the patient is given a single dose of antibiotics directly into the vein. This helps to prevent any possible infections, which is particularly important if any implantable devices, like screws or clips, are being used during the operation.
How is Endoscopic Brow Lift performed
An endoscopic brow lift is a surgical procedure to raise the brows and improve the appearance of the forehead, upper eyelids, and eyebrows. Like any surgery, the success of this procedure depends on a surgeon’s careful techniques, understanding of the human anatomy, and ability to see specific structures during the surgery.
Here’s how an endoscopic brow lift works:
First, the surgeon makes small cuts in the scalp, down to the skull. In some areas, the cuts only reach the layer of connective tissue called fascia covering a chewing muscle called the temporalis muscle.
Using a thin medical instrument, the surgeon creates a small pocket in the scalp by carefully separating the layers. This is done without the help of the endoscope (a small camera used to see inside the body during surgery). This pocket is made larger towards the forehead and the sides of the eyes.
Then, the surgeon inserts the endoscope and special instruments through the cuts. Using the endoscope for a better view, they carefully cut some tissues near the eyes, avoiding any damage to important blood vessels and nerves.
Depending on the patient’s condition, the surgeon may choose to remove or weaken some of the muscles in the forehead and between the eyebrows. This step is typically used for patients with deep wrinkles in the forehead and frown lines.
Using a medical instrument, the surgeon then separates two layers of fascia in the temple area. This is done under direct visibility. The purpose of this step is to free up more space and avoid injuring an important nerve on the face.
The surgeon then connects different areas of the scalp that have been dissected by cutting through a specific zone in the temple area. They also open a certain tendon above the eyebrow to connect the different dissected areas.
Next, the surgeon fixes the position of the brows. This usually starts from the temple area. They use a strong, long-lasting stitch to attach the connective tissue of the temple area to the fascia of the chewing muscle. The surgeon then fixes the position at the other incisions, which can be done in various ways.
The final step is to close the incisions on the scalp with stitches or staples and apply an ointment to help healing. Drains are usually not needed. A light bandage is placed around the forehead. Care is taken to avoid any downward pressure on the forehead, which may lessen the lifting effect.
If additional procedures on the upper eyelids, known as upper blepharoplasty, are planned, they should only be performed after the brow lift. This is because the brow lift reduces the amount of sagging skin on the upper eyelids, which in turn reduces the amount of skin needed to be removed during blepharoplasty.
Possible Complications of Endoscopic Brow Lift
After a type of forehead surgery called an endoscopic brow lift, some people may experience complications. The most common issues include feelings of numbness or unusual sensations (paresthesia/dysesthesia), unevenness (asymmetry), hair loss (alopecia), inability to fully close the eyes (lagophthalmos), and the necessity for additional surgery (revision). The rarest but most feared complication is motor nerve injury to a part of the facial nerve that controls forehead and eyebrow movements. Luckily, temporary weakness (paresis) is much more common than permanent paralysis.
There can also be other complications including swelling (edema), wound reopening (wound dehiscence), eye problems, irregularity in the space between eyebrows (glabellar irregularity), abnormal tissue mass formation (granuloma), collection of blood outside of blood vessels (hematoma), infections or pain. In some cases, people can feel the implanted materials like screws or tines under the skin, experience itchiness (pruritus), visible screws, fluid-filled sac (seroma), skin burn, and scarring.
Despite these potential complications, most people are very satisfied with the results of an endoscopic brow lift, with a satisfaction rate of over 98%. Significant complications are very rare.
Lastly, while this type of brow lift generally has fewer complications compared to the traditional open methods, sometimes the older methods might provide a more noticeable or lasting lift. However, there isn’t much information available on this topic.
What Else Should I Know About Endoscopic Brow Lift?
An endoscopic brow lift is a surgical procedure that gives your face a younger and more refreshed look. To get the best results and keep the procedure safe, the surgeon must be very precise and stick to the natural layers of the face. They also need to carefully watch what they’re doing during the key parts of the procedure. This helps to make the whole process more thorough, leaving you as a patient happier with the end results.