By the mid- to late 1990s, the impact of the less-invasive laparoscopic approaches to general surgery (particularly that of gall bladder removal) had reached plastic surgery. A wave of endoscopic (laparoscopic approaches infuse a lot of air to make the cavity, endoscopic just uses a camera without the extra air) approaches to a variety of facial (mainly) and other breast and abdominal procedures in plastic surgery had been caught up in adopting this technologic approach. The biggest benefit to any endoscopic approach is the simple fact of having less of an incision to do the surgery, which in plastic surgery is a big deal. By the time the dust settled from this enthusiastic push years later, the one plastic surgery procedure that has really benefited is the browlift. The endoscopic browlift is the one procedure that has stood the test of time and remains as one of the few remnants of the attempts at endoscopic adoption in plastic surgery.
It is easy to understand why the endoscopic approach to browlifting has stuck. The traditional open approaches, while tremendously effective, require an incision across the top of the head either way back in the hairline or at the hairline. That is a scary thought for some patients and some patients simply are not good candidates for that approach given the style and thickness of their hair density. Also, the endoscopic approach is not anatomically complex, you are sliding instruments and a camera done along the front part of the bony forehead. There is little in the way and it is hard to get lost and end up in the wrong place.
The endoscopic browlift, however, is not a perfect operation. It is not as effective at removing muscle between the eyebrows and up underneath the forehead skin as an open approach can do. And it can not lift the brow as well as open approaches where more aggressive brow release and actual skin removal is done. But for some patients, particularly younger women who do not have a lot of brow sagging and deep forehead wrinkles, the endoscopic approach is a nice option where the ‘solution matches the problem’.
There is one other consideration about endoscopic browlifting that receives little attention. The endoscopic browlift really works by what is known as an ‘epicranial shift’. This is a fancy term meaning the brow is lifted because the whole forehead and scalp is loosened and moves backward. This means the frontal hairline will move back as much, if not more, than the brows themselves with the lift. For those women with an already long forehead and high hairline, this may be too much of a hair-raising experience.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
As we age not only does extra skin and fat weight down our eyelids, but the overlying brows can often contribute to the problem. As the eyebrows fall below the bony rim of the forehead, ‘extra’ skin is created and the upper eyelids get heavier. Both the eyelids and the brow areas narrow the size of the eye making it look older and more tired. While many patients have eyelid surgery for improvement, some may benefit by a combination of eyelid and browlift surgery to create an overall better result.
In understanding browlift surgery, one has to appreciate not only the position of the eyebrow but the existing length of forehead skin (from hairline to brow) and the patient’s hairline pattern and density. These are key elements that help determine which type of browlift may be best for each individual patient. Fundamentally, there are really two main types of browlifts…open and closed. Closed or endoscopic browlifts are done from back in the scalp and uses two or four small incisions behind the hairline. Cameras are used under the skin to release the brow from underneath and entire scalp/forehead/brow unit is then shifted up and back. In the endoscopic browlift, the forehead usually gets longer and the frontal hairline moves back a bit. Also, if there is a lot of muscle action between the eyebrows, the endoscopic approach is more limited in how much can be removed. As a result, the endoscopic browlift in my hands is very good for those patients that have a short or average forehead length, do not have too much muscle action and deep forehead wrinkles, and whose brow only needs to be lifted a little. Open browlifts are done with an incision and resultant scar either at the frontal hairline or several inches behind it. When the open browlift is done with the scar back in the scalp, the patient with a high forehead has the same problem as the endoscopic browlift. When the incision is placed at the frontal hairline, this is a better choice as the hairline stays put or can even be moved forward or lower. Either scalp or hairline browlifts are better at removing overactive muscle as more muscle can be removed with wide open access under direct vision. (you can remove more when you can see it better)
While some browlifts are done alone, this is unusual as extra eyelid is often present if the brows are low in many patients. Conversely, it is much more common to have eyelid surgery (blepharoplasty) without browlifting. The combination of eyelid tucks and browlifting can make a dramatic difference in how one’s eyes look and the overall facial appearance and impression that it creates. The aesthetic key to browlifting is to not overdo it. No patient wants to have a ‘deer in the headlights’ look. For these reasons, it is important to carefully review beforehand with your plastic surgeon in front of a mirror what amount of browlifting you consider acceptabel and whether it adds enough to the results to justify the effort.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Botox is now the most well known injectable cosmetic facial treatment and is phenomenally effective at reducing undesired lines of facial expression, particularly in the forehead and eye area. The temporary paralysis effect of Botox works by reducing muscle pull on the overlying skin. Since lines and wrinkles form on the face from the pull of muscle that runs perpendicular to the line or wrinkle, this provides a strategy for where to place Botox injections. In the glabellar frown wrinkles, which are the number one facial area for Botox injections and the facial area from which the initial clinical studies for FDA approval were done, injection into the brow depressors (corrugator and procerus msucles are the main ones) is an effective approach.
Coincidentally, and with a simultaneous positive aesthetic result, paralysis of the brow depressors leaves the brow elevator muscles unopposed. In so doing, a minor brow lift is obtained in many patients. As the eyebrows are elevated by the vertical-running frontalis muscle, the lack of any down pull by the depressors allows this muscle to raise the eyebrows to some degree. Multiple clinical studies have shown that modest brow elevation occurs in the range of 1 to 3mms. This may sound like a modest amount, but in the face this can be a make a real observable difference.
Brow elevation with Botox can be done for the inner brow, outer brow, or both. It all depends on where one places the injections. As the most common area for Botox injections is in the glabellar area, only an inner brow lift will result. To create a more complete eyebrow lift, the outer brow depressors must be paralyzed as well. This means injecting out on the side of the brow to weaken the downward pull of the orbicularis oculi muscle. Injecting both inner and outer brows can create a ‘chemical’ brow lift which appears within seven days after the injections.
I have found that brow lifting with botox works best in female patients who do not have thick forehead skin or heavy brow tissue. It seems to be less effective in males although this probably dose-related as it is well known that larger muscles needs higher doses of Botox to be effective.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Men are more prone to eyebrows dropping down with age due to their often heavier foreheads. Fortunately, a low brow in a male is much more tolerable than in a woman. Male brows also have a different shape than a woman’s, being less arched and more at the level of the brow bone. When the brow gets low enough, combined with extra skin ini the upper eyelids, the resultant facial appearance can look very tired, sad, or even angry.
Brow lifting in men, however, presents issues that are different from most women. The lack of hair or a poor hairline eliminates the use of many traditional open brow lift surgeries that are so effective. The male forehead skin is often much thicker and the forehead muscles much stronger than a female’s. This eliminates the possibility of the minimally-invasive brow lift procedures such as suture suspensions or threadlifts. This leaves the options of either endoscopic brow lift approaches or direct brow procedures. In my experience, the endoscopic browlift is still of more limited usefulness in many males due to their hairlines. Even small scars, if visible, are not a good trade-off in most cases. I find the direct brow lift procedures, going through the upper eyelid incision, a good compromise. Most men are going to need an upper blepharoplasty anyway so no additional scar burden is incurred. Either suturing the brow up from underneath to a higher position on the frontal bone or using the resorbable endotine forehead device provides some modest brow elevation that is subtle but evident. It is easy to perform and adds little time to an upper blepharoplasty procedure. It is limited by the location of the supraorbital nerve at the inner aspect of the brow so the inner 1/3 of the brow is often not changed much. But injury to the nerve is not worth trying to get a few extra millimerters of lift in this area. Often a slight bulge will be evident after surgery just above the brow where the underneath dissection has stopped but no patient of mine has expressed any concern about it to me.
Fortunately, men want a more subtle change anyway, particularly in the brow area. And either the endoscopic browlift or the direct brow lift does just that.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
