Endoscopic browlift is the preferred approach for rejuvenation of the upper third of the face.

Abstract

Aging of the upper one third of the face is primarily the result of gravity and loss of elastic tissue support caused by collagen changes in the dermis. This leads to brow ptosis, which can give a crowded or angry appearance to the eye and brow complex. In addition to brow ptosis, the aging brow and forehead may display “hyperkinetic” or “dynamic” facial lines. These furrows are caused by the repeated pull on the skin of underlying facial mimetic muscles. Chronic upward contraction of the frontalis muscle leads to horizontal forehead creases. Repeated frowning overuses the procerus and corrugator supercilii muscles, which causes the development of horizontal creases at the root of the nose and vertical interbrow furrows, respectively. Patients require varying combinations of brow elevation (prior to blepharoplasty), correction of brow asymmetries, and hairline-preserving forehead positioning. Some may only require excisional or paralytic procedures of the corrugator muscles and procerus muscle. Traditional surgical approaches to the aging upper third of the face are varied and include the coronal, pretrichial, direct glabellar, midforehead, and direct browlifts. Nonsurgical approaches include the use of botulinum toxin intramuscular injection. The use of surgical endoscopes and specially designed instruments to achieve these goals via small incisions was first reported in 1984 by Santana. Since that time, a number of refinements in techniques and instrumentation have been made creating a relatively new surgical procedure known as the endoscopic browlift for the correction of the aging forehead. Figure 1 illustrates the various approaches. A MEDLINE literature search was performed for the following medical subject headings: “surgical procedures,” “endoscopic,” and “forehead.” There were no search limits applied; 99 articles were initially found, all of which were published between 1994 and 2000. Of the 99 articles retrieved, 72 pertained to the topic at hand. These 72 could be neatly categorized into the following main topics: review/ overview of technique (n=25); fixation techniques (n=16); technical variations (“how-I-do-it”) (n=16); supraorbital nerve anatomy and management (n=3); complications (n=3); endoscopic resection of the corrugator muscles (solitary procedure) (n=3); subperiosteal vs subgaleal dissection plane (n=3); surgical anatomy (n = 2); and specific instrumentation (n=1). Many of the review/overview articles seemed to serve as introducing this approach to another specialty’s literature. There were no articles that objectively compared the longevity of results with that of traditional procedures.