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Dr. Barry Eppley

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Posts Tagged ‘endoscopic browlift’

Techniques in Endoscopic Browlift Forehead Rejuvenation

Sunday, April 26th, 2015


The upper third of the face, which is composed of the skin bearing forehead and the hair bearing brows, is major aesthetic unit of the face. Like the rest of the face below it, it is equally exposed to changes caused by aging such as the development of horizontal wrinkles and a lowering of the brows. While the number one aesthetic treatment of the forehead are Botox injections, some patients will need actual forehead rejuvenative surgery for substantial improvement.

The main surgery for forehead rejuvenation is that of the browlift. While once a wide open procedure done using a long scalp scar, the trend over the past two decades has been  to use a less invasive approach through endoscopic techniques. This fundamentally results in much less scalp scarring but what is done under the forehead flap is somewhat the same as in more open browlift procedures.

In the December 2014 issue of the journal Plastic and Reconstructive Surgery, an article on this topic appeared entitled ‘Finesse in Forehead and Brow Rejuvenation: Modern Concepts, Including Endoscopic Methods’. In this paper the author review their experience in 546 endoscopic browlift operations s a tailored approach to the endoscopic browlift using four small scalp incisions in normal length foreheads and permanent suture fixation through outer cortical bone tunnels. The endoscopic dissection is done in a more limited fashion at the medial brow level but mire extensive laterally to release the lateral brow retaining ligaments. In high or long foreheads a hairline incision is used and the frontal hairline is advanced and forehead skin removed to create a vertical forehead reduction at the same time as the browlift. No infections occurred in their series. They experienced no cases of permanent nerve injury of either the sensory or motor nerves. Only 2% of patients experienced any temporary hair loss issues. No case experienced any loss of brow fixation using suture fixation to cortical bone tunnels.

The endoscopic browlift is now the workhorse of surgical forehead rejuvenation. As this paper illustrates it can be used for a wide variety of brow sagging problems. Its limitation is that it will cause some increase in vertical forehead lengthening since it works through a generalized epicranial shift of tissues from the brows backward. In this cases a frontal hairline incision is needed to either keep the hairline at its existing location or to allow a simultaneous frontal hairline advancement with the browlift. The endoscope serves little use once a more open forehead technique is used.

Cortical bone tunnels for fixation offer a very effective method of forehead fixation. It does make the scalp incisions longer to get the proper angles for drilling. There remains a role for more direct fixation devices such as Lactosorb screws and even larger Endotine devices. They make the fixation process easier although probably sightly less secure. Th weak link in browlift fixation, however, is in the attachment of the suture to the forehead tissues and to do so without causing persistent skin dimpling.

Men remains a challenge for any type of browlifting due to the location and quality of their frontal hairline. (or often complete lack of it) This is why the transpalpebral browpexy technique, marginally effective as it is, is the browlift procedure of choice for many men. In men with reasonable fronta hairlines, however, I have been impressed with how well their scars can do as also evidenced in male frontal hairline advancements.

Dr. Barry Eppley

Indianapolis, Indiana

Patient Satisfaction and Long-term Stablity of the Endoscopic Browlift

Saturday, May 18th, 2013


Elevation of low or aging brows can be done by a variety of browlift procedures. But since its introduction in the mid-1990s, the endoscopic browlift has remained a popular method. Its appeal is in the much smaller incisions and the lack of scalp morbidity, such as scar widening and alopecia and persistent numbness that occurs from a transverse scalp incision regardless of whether it is at or way back in the hairline.

The advantages of the endoscopic browlift has never been an issue of debate, the reduction or elimination of complications. What is not as clear is whether it offers similar aesthetic benefits as more open traditional browlift operations…is it effective and does it have lasting effects? Given how long the endoscopic browlift has been around, one would assume that the clarity of its aesthetic effectiveness is well established and documented. While plastic surgeons, including myself, find it to be very effective in the properly selected patient its longer-term stability is less clear.

In the May 2013 issue of the journal Facial Plastic and Reconstructive Surgery, a published study shows that the majority of patients who had endoscopic browlift procedures were satisfied with its long-lasting results. The study reviewed 143 patients over a 13 year period based on questionnaires of satisfaction and postoperative complaints as well as before and after pictures of eyebrow-to-eye measurements.

The study showed that the vast majority of patients were women (96%) who had an average age of 60 years and was rated successful by 93% of patients with 96% saying they would recommend the bprocedure. Three-fourths( 64%) said they looked younger and less tired. Some scalp numbness and itching persisted 3 to 6 months after surgery. Photographic analysis found that brow elevation was maintined to at least 2 years after surgery with an average elevation of over 5mms.

The endoscopic browlift significantly reduces the mobidity of scalp scars with a high patient acceptance rate. This study shows that there is long-term stability of the brow elevation. Thus scalp mobilization (epicranial shift) does work in lieu of forehead or scalp tissue excision. This study did not assess what happens to the frontal hairline, however, which I know moves back (lengthens) as the brows are lifted. For those patients that already have a long forehead, the open hairline browlift will need to be used instead.

Dr. Barry Eppley

Indianapolis, Indiana

Patient Satisfaction and Long-Term Results with Endoscopic Browlifts

Wednesday, September 26th, 2012


Rejuvenation of the upper third of the face is based on improving the appearance of the upper eye and brow area. Besides an upper blepharoplasty to remove excess skin, lifting of the eyebrows may also be needed to improve upper eyelid hooding and elevate low hanging brows. The intent of both is to open the upper eye area for a more rested and refreshed look.

Browlifts can be done multiple ways and there are four basic techniques to do it. Three out of the four are done from far above the brows and use different scalp approaches. For the past 15 years, the endoscopic browlift has become one of the most common upper facial rejuvenation methods. Its advantages over scalp-based excisional approaches is the small amount of scar that is created as only enough incision is needed to introduce an endoscope and the instruments needs to work through it. This results in faster healing, less potential disruption of the hair follicles and decreased risk of permanent scalp numbness.

The appeal of the endoscopic browlift to a patient is obvious and plastic surgeons have embraced its use. But do patients find that it produces good results and are they happy they had it done? In the September issue of the Archives of Facial Plastic Surgery, a study reports on patient satisfaction and long-term results with the endoscopic browlift. Based on nearly 100 patients (almost all female patients with an average age of 60) who had the procedure between 1994 and 2007 with an average follow-up of over three years, the authors reviewed the incidence of complications and complaints as well as photographic measurements of before and after eyebrow-to-eye distances.

The endoscopic browlift had average satisfaction scores of 7 out of 10. It produced an average of just over 5.5mms of elevation after surgery with showed a gradual decline of almost 1mm per year out to the duration of the study. It is interesting to note that significant brow asymmetry existed between the eyes. Fully 63% of the patients said they would have the procedure again or recommend it to a friend while nearly 20% said they would not.

The study concludes that most patients find the procedure very satisfying. That being said one-third of the patients were not satisfied which I find to be a high percent for a cosmetic procedure. One of the reasons for not a higher rate of patient satisfaction may be the older age of the patients. The endoscopic browlift works on the basis of an epicranial shift, the brows are elevated because the entire scalp is moved backwards. (this is why the forehead gets longer with this type of browlift) This is fine if there is not too much brow ptosis (sagging) or a lot of horizontal forehead wrinkles. But when the patient is older, skin excision through an open browlift will produce a better result that will last longer. This relegates the endoscopic browlift, most of the time, to younger patients with earlier and less significant upper facial aging.

Dr. Barry Eppley

Indianapolis, Indiana

Sarah Palin and Plastic Surgery

Sunday, December 13th, 2009

Recent internet blogs purport that Sarah Palin has had some plastic surgery done recently. Using some apparent inside information, it is stated that she had a ‘nasolabial fold lift, cheek implants, midface lift, eyebrows fixed and a sideburn graft.’ A series of photographs are shown which are supposed to support these contentions.

Normally, I wouldn’t waste valuable computer time on a topic that, while interesting to some, doesn’t add any facts to those truly interested in what plastic surgery has to offer. And there are lots of tabloids, websites and even TV shows that analyze celebrities and what they may have had done. But there is some educational value in assessing some of this content to separate procedures that do exist from those that don’t.  And when and why they are used.

I will preface these comments by saying that I have no knowledge of whether Sarah Palin had plastic surgery or not. Nor it is this a negative commentary on those that purport that she did. Nor am I a supporter or detractor of hers.

A ‘nasolabial fold lift’ is a misstated procedure. The deepening of one’s cheek-lip groove, also known as the nasolabial fold, is a function of one’s cheek tissues beginning to sag downward against upper lip tissues which do not sag with age. A deep or prominent nasolabial fold can be softened with injectable fillers and this simple office procedure is one of the main uses of filler products.

Cheek implants are used to highlight cheek and midfacial prominences and are often overdone  and easy to spot. But Sarah Palin is about the last person who would need them. She has the congenital benefit of a naturally strong facial bone structure with high cheek bones. This is one of the main reasons for her facial attractiveness.

Midface lifts are designed to lift sagging cheek tissues. They can be done open or from an endoscopic approach. As previously mentioned and for reasons similar to that of cheek implants, there is nothing in Sarah Palin’s photos that would remotely suggest she would benefit from such a procedure. An open midface lift involves incisions across the lower eyelid and sometimes inside the mouth. When properly used, it is a very effective procedure but it can cause problems of prolonged swelling and potential lower eyelid problems. An endoscopic midface lift is different as it is done from incisions up in the scalp and is used when the midface sagging is less severe. She may have had this done but the benefits of doing so, and the results obtained if done, are certainly suspect.

The ‘eyebrows fixed’ procedure could very well mean that an endoscopic browlift was done. This is a very frequently used procedure done from behind the frontal hairline. It can lift sagging or flat eyebrows and create more of an eyebrow arch and open up the eyes. But injectable Botox can create in some patients very much of the same result.  While the pictures later in the year of Sarah Palin show higher arched eyebrows, that photo was taken from a different angle and the facial expression is not the same. More on photos later.

The alleged ‘sideburn graft’ procedure does not exist. There would be no reason to graft a sideburn and skin grafts are never used in any form of facial plastic surgery. What they undoubtably mean is that the sideburn has been altered. This would be due to a form of a facelift known as a limited or mini-facelift, also called a Lifestyle Lift by some. This simple tuck-up procedure uses an incision from inside the ear, around the earlobe below, and up into the hairline above. The one side view photo does show a very straight back part of her sideburn (preauricular tuft of hair) which is a likely sign that it is from an incision. There is also a lump in front of her ear, which is certainly unnatural, and could be a small residual fluid collection or swelling from the procedure. This  ‘mini-facelift’ is a common little jowl tuck-up method that is best used when only  a small amount of jowling (early facial aging) is present. This would be believeable from my perspective on her as, at best, she would only need such a limited procedure.

A comment on photographs.  One thing that plastic surgeons are acutely aware of is the influence of photographs on how the face can look.  You can take a patient, change the lighting and angle, and one can look like they have had some procedure that has changed their appearance. It is for this reason that the sentinel journal of plastic surgery, Plastic and Reconstructive Surgery, has specific photographic standards so that the results of procedures can be accurately judged. Many commercial cosmetic products and devices take advantage of these photographic nuances to promote sales.

Did Sarah Palin have plastic surgery? Maybe… but the procedures would not be as many or of the magnitude that have been suggested. She may have taken advantage of some of today’s minimally-invasive techniques such as an endoscopic browlift and a tuck-up facelift. The recovery from these would be very quick, less than 7 to 10 days, until one is able to be back in front of the public again.  

Dr. Barry Eppley

Indianapolis, Indiana


Endoscopic Browlifting in Men

Monday, March 23rd, 2009

As one ages, particularly in men with thicker skin and heavier forehead musculature, the brow will sag. This heavy brow look may be exaggerated by the concomitant contracture of the muscles between the eyebrow, creating a strong ‘eleven sign’ with deep horizontal forehead creases. Once the brow reaches at or below the supraorbital rim, one may consider the concept of browlifting ro help create a rejuvenated look… or at the least help the forehead and brow area appear less tense and more relaxed.


In men, the concept of browlifting takes on some different considerations than that of  women. The usual sparse and poor frontal hairlines and hair density usually preclude traditional forms of open browlifting. Open browlifts, while being really what most men need due to its superior ability for muscle management through partial removal, can not be done because of scar exposure from the lack of good quality hair. Also, browlifting will usually lengthen the forehead as the hairline goes back with the lift which is usually an aesthetic disadvantage. For these reasons, many men have to consider an inferior browlift done through an upper eyelid incision (which will have only a moderate effect) or abandon its consideration at all.


For select men, an endoscopic browlift may be a reasonable option. The endoscopic approach offers a minimal scar method which can lift the brows and provide some long-term weakening to the muscles between the eyebrows. It does at the expense of making a longer forehead. As a result, male candidates are those that have a good quality frontal hairline and a short or medium-length forehead…or those that will not be bothered by a hairline which moves higher.


An endoscopic browlift incorporates a periosteal release along the supraorbital rim, subtotal procerus and corrugator muscle resection around the supraorbital nerves, and an entire forehead (epicranial) shift backwards. The lifted forehead is secured by many different effective methods but my choice is resorbable screw (Lactosorb) fixation to the bone underneath the scalp incisions. This is a secure and rapid method that provides frrm fixation as the forehead heals with the screws dissolving away months later.


An endoscopic browlift is not unduly difficult to go through. A head dressing is on for one day only and is removed the day after surgery. One can shower and wash their hair the next day.  There will be some mild upper eyelid swelling which will completely go away in a week. Temporary numbness of the forehead and front part of the scalp is normal but the feeling completely returns in four to six weeks after surgery. The forehead muscles, particularly those between the eyebrows, will be weak for awhile. Some movement will always return and the goal is to have about 50% less movement between the eyebrows on a long-term basis.

Dr. Barry Eppley

Indianapolis, Indiana

Endoscopic Browlift Surgery with Lactosorb Screw Fixation

Sunday, February 8th, 2009

Sagging of the brows with age has historically been improved through browlift surgery. Traditionally browlift surgery was done through long incision back in the scalp and the lift of the brows and forehead obtained was gotten by removing scalp skin. Endoscopic browlift techniques have become very popular in the past decade as they can accomplish browlifting but without the need for long scalp scars.

Like laparoscopic abdominal surgery, endoscopic browlifts use a few small incisions in the scalp and rely on releasing the brow and forehead from the bone through the assistance of small cameras and instruments. The actual lifting of the brows is really accomplished by shifting the forehead and scalp backwards, rather than cutting out scalp as in open browlift surgery. An essential part of this ‘scalp shift’ is that it must be held up in place until the tissues heal back down to the bone. Some form of soft tissue suspension or fixation is needed to make endoscopic browlift surgery work.

While there are many touted methods of endoscopic browlift fixation, and they all appear to work reasonably well, I prefer to use a resorbable screw placed into the skull from the small scalp incisions. Onto these screws, the forehead tissue can be sutures up to the screws holding it in place after surgery. Studies have shown that the tissues must be held in place for at least two weeks and preferably up to one month after surgery. These resorbable screws hold their strength out to 6 to 8 weeks, well beyond what is needed to accomplish forehead healing.

I have used these resorbable endobrow screws (Lactosorb) for the past 12 years and find their use quick and secure. In the old days, I used to have to cut threads into the bone to place the screw, but this has been replaced by a push screw several years ago. Patients may feel the screw
heads for a few months after surgery if they push hard enough, but that feeling goes completely away between 4 and 6 months after surgery. While metal screws will work just as well, patients find comfort in knowing that no permanent devices are left behind on their skull.

Dr. Barry Eppley

Indianapolis, Indiana

Understanding the Different Browlift Surgery Options

Sunday, February 1st, 2009

An essential part of facial rejuvenation is the upper one-third of the face, the brows and the forehead. Browlifting historically was done by using an incision across the top of the scalp, otherwise known as a coronal browlift. While this is a highly effective browlifting method (and still the gold standard), there are tradeoffs for using it including a permanent scalp scar and numbness of the scalp. Not only do some patients not want these tradeoffs but long foreheads with high hairlines in women (they will get higher and longer after)and almost all men (due to hair density) are not good candidates.

The high hairline problem can be overcome by a modification of the coronal browlift. The incision is moved forward to the front of the hairline, thus lifting the brow but not the hairline. Good plastic closure of this hairline incision results in a very fine line scar which can be hard to detect.

The alternative of an endoscopic browlift, instead of a coronal browlift, has been popularized over the past fifteen years. It is probably used more today than the coronal browlift due to its greater acceptance because it doesn’t use a long scalp incision but several small incisions. It also does not cause permanent scalp numbness.

All of these methods of browlifting can produce significant elevation of the brow, although my experience is that the amount of brow elevationwith an endoscopic browlift  is somewhat less than any of the scalp incision methods. The lack of a permanent scalp scar makes this tradeoff very acceptable however and really eliminates the fear, or possibility, of an over elevated brow or the ‘deer in the headlights’ look. Because of the way endoscopic vs scalp browlifts work (shifting back vs removing skin or scalp), I have found that some each type works better for certain patients. Patients with moderately low brows, thin skin and not too many forehead wrinkles and frown lines do really well with the endoscopic browlift approach. Patients with thick forehead skin, low hanging brows, and a lot of muscle activity and wrinkles are better off with either of the scalp browlifting methods.

Men pose unique browlift problems due to their lack of good scalp hair in most cases. For this reason, browlift surgery in men is often done either endoscopically or through the upper eyelid, known as the transpalpebral browlift. By going through the upper eyelid, all scalp incisions are avoided. This approach usually produces just a subtle browlift which is what most men want anyway. Often a small resorbable device is fixed to the bone to hold the brows up as they heal. While this same approach can be used for women, most women want or need a more significant amount of brow elevation.

These three approachs allow browlifting to be tailored to each patient’s unique forehead and scalp anatomy and their desires. Contrary to the perception of some, there is no one best way to do a browlift.

Dr. Barry Eppley

Indianapolis, Indiana

The Endoscopic Browlift – How It Works and Who Is It For

Monday, July 21st, 2008

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

Indianapolis, Indiana

Open vs. Endoscopic Browlift Surgery

Wednesday, July 2nd, 2008

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

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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