Explore Plastic Surgery - Dr. Barry Eppley

Frowning is a very common human facial movement that can indicate a variety of expressive emotions. Most commonly, it suggests concern, concentration and even anger.  As the eyebrows move closer together, a pair of vertical lines or grooves develops between them. Known as glabellar furrows, these indentations start out as appearing only when one is making an expression. Over time with repeating impressions on the skin, these glabellar furrows become etched into the skin and are present even when one is making no expression at all.

Glabellar furrows are the result of complex muscle movements, six in total, that converge to pull the eyebrows inward. This common, but undesired, facial expression is one of the main reasons that Botox became a cosmetic injection treatment. While Botox is tremendously effective, its results are only temporary.

More permanent solutions to glabellar frowning can be done through a corrugators myotomy (partial muscle release) or a myectomy. (complete muscle resection) Altering the paired corrigator muscles is often a part of  browlift surgery or  a modifications of it.

In browlift surgery, visual access is gained to the glabellar area from underneath. Either the forehead skin is turned down (from either a scalp or hairline incision, i.e., open browlift) or  through an endoscopic approach from small scalp incisions. (endoscopic browlift) In either case, the corrugators muscle is easily found and removed. Whether it is just cut or more aggressively removed is a matter of debate amongst plastic surgeons. Longer-term reduction in glabellar movement is probably obtained by more muscle removal. However one must be careful to not remove too much as it can create an undesirable depression in the area between the brows, and some also believe it creates an unnatural permanently “surprised” look in patients.

But what if one doesn’t need a formal browlift? Glabellar muscle resection can still be done using the endoscopic browlift technique….but without lifting the brow. Is this treatment worth the surgical effort? No long-term studies have ever been published on its effectiveness but, in my Indianapolis plastic surgery practice, I have performed it occasionally. My observations is that its eventual results are not as profound as Botox but some permanent muscle activity is obtained.

Endoscopic corrugator (and procerus) muscle resection is also a good option to consider when one has recurrent migraines that are proven to eminate from the supraorbital and supratrochlear frontal nerves. Relief with Botox injections is a good diagnostic test to verify that muscle resection could provide some long-term migraine reduction. In a few cases, I have had medical insurance pay for this endoscopic treatment although this would be uncommon as it is not a procedure yet reviewed as the standard of care for this problem.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

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