Minimally invasive cosmetic surgery techniques continue to have great appeal. Most everyone would like to look better without a major effort like some form of surgery. Or, at the least, they would like the surgery to be ‘minimal’.
Sagging brows, or brow ptosis, is one sign of facial aging that makes one look tired and increases the amount of extra skin that appears in the upper eyelids. Brow lifting is a common cosmetic procedure for its treatment which can be very effective. Minimal browlifting techniques today are largely about using an endoscopic technique rather than removing skin or scalp tissue. This is a procedure that involves an epicranial shift or the repositioning of forehead and scalp tissue backward after being loosened. The tissues are loosed off of the bone through the aid of an endoscope. As the forehead shifts backward (and the hairline moves back as well), the brows are carried with it and end up in an uplifted position.
While an endoscopic browlift appears minimal from an incision standpoint, the extent of surgery under the skin is the same as a more traditional open browlift operation. A true minimally-invasive browlift is better illustrated in the once popular and now defunct procedure known as a threadlift. Using plastic sutures that had barbs along their length (machined cuts that allowed pieces of the plastic suture to stick out, they were thread in with a needle from the scalp down into the brow area. Once tightened and tied, the brows were lifted to some degree. This approach uses a skin shifting concept without separating it from the bone. While the procedure had a lot of appeal because it didn’t require real surgery, it is no longer performed because its results were at best minimal and not sustained.
In the spirit of minimally invasive browlifting, I recently saw a modification of the threadlift brow concept. Using small stab incisions in the scalp and the tail of the brow, small permanent sutures are threaded in to create a horizontal mattress suture pattern when tied. This can be done in three areas at the outer, middle, and inner aspects of the brow. In looking at patient results, it appeared to be effective for the tail of the brow but not impressive in the other brow areas. This is most likely because the tail of the brow is more moveable and less fixed to the underlying bone than the rest of the brow.
While this form of brow threadlifting looks appealing and certainly qualifies as minimally-invasive (could be done in the office under local anesthesia), it is still a skin only lift which does not change the whole thickness of the forehead tissues. For this reason, such a procedure is doomed to have results that will not last.
Effective browlifting requires that the entire forehead tissue unit must be mobilized and repositioned for significant brow elevation and sustained results. It is anatomically incorrect to think that any form of ‘tunneled’ skin tightening is an adequate replacement. However, when combined with other procedures such as Botox and skin resurfacing in a patient with only a minimal brow problem, this type of ‘minimal browlift’ may be useful and desireable for select patients.
Barry L. Eppley, M.D., D.M.D.
Indianapolis, Indiana