What patient wouldn’t want three or four very small incisions that heal rapidly with little or no scarring and no residual numbness, compared with a foot-long slice at or under the hairline that takes longer to heal and sometimes leaves a puffed-up scar and/or permanent loss of sensation?
Explore This IssueOctober 2006
Most opt for the smaller incisions, according to Oscar M. Ramirez, MD, Clinical Assistant Professor, Department of Plastic Surgery, Johns Hopkins University and University of Maryland, both in Baltimore. The endoscopic forehead lift is a much safer operation than the open forehead lift. The risks of infection, scarring, numbness, and hair loss are significantly less compared with the open approach.
A brow lift (also called a forehead lift) is done on its own or as part of an upper and/or lower blepharoplasty or a more comprehensive facelift. Its purpose is to rejuvenate the forehead, erase horizontal or vertical wrinkles and frown lines, raise sagging skin, and give a more open look to the face. The skin looks refreshed and younger, especially when combined with eyebrow elevation.
Endoscopic brow lift was first described in 1980, and the technique showed a clear advantage over the classic coronal brow lift, especially in the area of the superior and lateral orbital rims.
Aging and the squinting that results from worsening vision causes muscle constriction around the eyes, said Ricardo L. Rodriguez, MD, Head, Plastic Surgery Division, Greater Baltimore (MD) Medical Center. The brow is thus pulled down and creates an illusion of excessive skin, when in reality there is none. You get the appearance of excess skin from excessive brow movement over time, which creates wrinkles. Sometimes just lifting the eyebrows is enough to solve the forehead problem, but that’s getting ahead of the story.
He described an endoscopic brow lift: The hair is tied back and secured with rubber bands, or it may be trimmed around the planned incisions. Under local anesthesia with a light intravenous sedative, three or four small incisions (about an inch each) are made in the scalp above the hairline, and a 4 mm diameter endoscope is inserted at a 30-degree angle into one incision. The scope has a xenon light source that is connected to a camera and in turn hooked up to a video monitor. The light and camera provide a clear view of muscles and other tissues beneath the skin. Various surgical instruments are inserted into the other incisions.
The forehead skin is lifted, the corrugator and procerus muscles cut, and the brow repositioned. Other muscles and tissues may be released from their attachments around the orbital rim and the temple. The entire forehead is then lifted vertically and secured by small metal posts, which are removed 10 days later. The incisions are closed with sutures or clips and removed in about a week. The face is washed and either bandaged or not, depending on the surgeon’s preference. Bandages are taken off in a few days so the patient can shampoo.
The procedure usually takes no more than an hour and a half and is done on an outpatient basis in the surgeon’s office or outpatient surgery center. The patient can resume normal activities in a week or 10 days. Total recovery takes about thee weeks, although that, of course, varies. The lift itself lasts up to 10 years-although sometimes a lot less.
Dr. Ramirez said that numbness and hair loss are temporary and usually resolve within a few weeks or months. Swelling and recovery time are relatively short. Postoperative infection and bleeding are rare but not unheard of.
The most disturbing adverse event for the patient occurs during surgery. If there are a number of complications that cannot be resolved through the small incisions, the surgeon may have to abandon the endoscopic approach and switch to an open coronal procedure. This is disappointing for the patient because he or she will wake up with a much bigger incision and many more sutures than anticipated, but it happens less than 1% of the time.
Comparison with Traditional Lift
The major difference between the traditional (coronal) brow lift and the endoscopic procedure is the size and placement of the incision. A coronal lift involves an incision that extends from ear to ear on the top of the head, or if the patient is bald or has thinning hair, a mid-scalp incision that follows the natural pattern of the skull-so the resulting scar is less conspicuous. One of the advantages is that the surgeon can raise or lower the hairline as necessary, but a strong disadvantage is noticeable broad scarring that could necessitate additional surgery.
According to Al Aly, MD, a partner at Iowa City Plastic Surgery, the coronal procedure takes out a strip of skin in order to lift and smooth the remaining skin. The endoscopic procedure separates the skin from the underlying muscles and rotates it to provide the appearance of lift.
With a coronal lift, a small minority of patients (2%) suffer from postoperative alopecia (which, for unknown reasons, does not always occur along the incision line) that resolves in a few months. When the hair grows back, it may be thinner. When this procedure was first done, patients had considerable facial edema, but that has been mostly eliminated by speeding up the dissection. This does not happen with the endoscopic procedure.
A coronal lift produces much more postoperative pain, and there is usually more numbness at the incision than with the endoscopic procedure. The numbness is soon replaced by itching, which most people think is far worse, that can last up to six months.
With both procedures, vigorous physical activity (exercising, heavy housework, and sex, for example-anything that elevates blood pressure) should be restricted for several weeks.
Dr. Rodriguez does only endoscopic procedures and said that the percentage in comparison to the coronal procedure is increasing-about 50% overall compared with 20% five or six years ago. Dr. Aly, on the other hand, does only coronal procedures, although this is because the hospital where he practices refuses to purchase an endoscope. I used to do them at my previous hospital, and this one will probably buy one soon so I’ll be back to doing them. About 75 percent of my colleagues do the endoscopic lift if they or the hospital have the equipment.
He encourages patients to have the coronal procedure because he is able to get more lift. But he says that if a patient insists on the endoscope, he refers them elsewhere.
In terms of cost, there is little difference between the two procedures, but price varies significantly with geographical area. For instance, Dr. Rodriguez in Baltimore charges about $4000 for each endoscopic procedure, which includes use of the operating and recovery rooms, as well as most incidental hospital expenses. A few thousand miles away in Iowa City, Dr. Aly charges about $6000 for a coronal procedure, and that’s for his fee only. Hospital charges are extra.
Who Should and Shouldn’t Be Lifted
The best candidates for a brow lift are between 40 and 65 years of age, although some people in their 30s look much older than their years and can benefit from the procedure. Also, some people have inherited conditions, such as a very low or heavy brow (the Neanderthal brow) or deeply furrowed lines. Patients need good skin tone, and if they have ptosis of the eyebrows it should be in a very early stage. Sagging cheeks with deepening of the nasolabial crease and ptosis of the corners of the mouth are indications that a brow lift might not be as successful as anticipated. Patients should be in good health and preferably nonsmokers.
Patients for whom the surgery might be problematic are those with uncontrolled hypertension, blood clotting problems, or the tendency to develop thick scar tissue. Contraindications include:
- Excessive dry eye
- Past very aggressive blepharoplasty, which, although it would seem counterintuitive, can worsen dry eye by increasing keratitis, characterized by severe tearing and irritation
- Exophthalmic thyroid disease, which makes the eyes protrude
- Bell’s palsy
- Shortage of skin on the forehead
©2006 The Triological Society