INTRODUCTION
With aging, the eyebrows may descend and frown lines may develop, causing an unflattering stern or disapproving facial expression.
In the past, forehead lifts (synonymous with brow lifts) required a long incision across the top of the head (the “coronal” or “open” approach), or surgeons made an incision along the hairline and then raised a big flap, exposing the frontal skull. This is quite a sight for a layperson, who may be understandably reluctant to have this procedure after seeing it on TV or the internet.
Even today, there are plastic surgeons who continue to use the old coronal incision (from ear-to-ear) because they have found it effective and they are simply accustomed to doing it. Some old-school surgeons believe the endoscopic approach does not work. However, recent photometric studies have confirmed the effectiveness of the endoscopic forehead lift, which makes use of much smaller incisions and avoids the dreaded “perpetually surprised” look that an overdone coronal lift can produce. There is no doubting its advantages in terms of less operating time, scarring, recovery time, and better preservation of scalp sensation.
A facelift treats the middle (cheek) and lower (jowl) thirds of the face in addition to the neck. A forehead lift rejuvenates the upper third of the face, completing a full facial rejuvenation for the top of the head to the neck.
A 1990s Breakthrough
In the early 1990s, endoscopic technique found an excellent application in forehead lift surgery. Endoscopic instruments had already had a tremendous impact in the fields of gynecology and general surgery. Now the incisions could be made much smaller. No more long cut across the top of the head. The release of tissue over the eyebrows could be done using endoscopic visualization. Fine instruments could be passed through small openings hidden behind the hairline.
Prior to doing my first endoscopic forehead lift in 1995, I was reluctant to offer coronal forehead lifts to my patients because of the morbidity of the long scalp incision, which left a long scar. Although the scar was within the hair-bearing scalp, there was hair loss along the scar, which could be visible. The coronal lift was also a long procedure with substantial bleeding. It was possible to overdo the lift and create an overly surprised expression. The coronal forehead lift seemed like a long way to go to produce a marginal improvement. The cost/benefit ratio was equivocal. Before 1995, I performed only about one coronal brow lift a year and the eyebrows had to be pretty saggy before I’d recommend it.
The endoscopic lift totally changed my approach. It removed the negatives associated with the open procedure. It now became an elegant, truly minimally invasive procedure, with a very favorable cost/benefit ratio. Surprisingly, despite working through smaller openings, visualization is actually improved, due to magnification and illumination on the monitor. With this technique, there is less elevation of the hairline and less likelihood of over-elevating the eyebrows, which can happen if too much scalp tissue is removed using the old open technique.
Before adopting the endoscopic technique, I rarely offered a forehead lift. Now I was doing forehead lift on just over half (53%) of my facelift patients. The operative time was reduced from about 2 hours to just 30 minutes, with much less blood loss. The scars were usually negligible. The discomfort level was minimal. The forehead could be rejuvenated along with the rest of the face without substantially affecting the level of discomfort or length of recovery.
Botox as an Alternative
Botox can be very helpful in relieving the frown lines between the eyebrows by relaxing the underlying corrugator muscles that create these frown lines in the first place. There can even be a slight elevation in brow position (“chemical lift”) with simultaneous relaxation of the orbicularis muscles in the area of the crow’s feet. Of course, this effect wears off in about 3 to 4 months.
Botox injection is a good option for patients who want some of the effects of a forehead lift, but are not ready for surgery. The limitation is brow elevation. An endoscopic forehead lift is usually more effective than Botox in raising the brow position (if this is desired), and the duration of the result is likely to be longer.
A forehead lift does not mean that Botox will no longer be needed. Many patients still benefit from Botox injections even after having a forehead lift. The corrugator muscles are weakened by surgery but not eliminated. It can be helpful to inject these muscles and the crow’s feet to maintain a youthful upper face.
Migraine Headaches
Similar to Botox injections, an endoscopic forehead lift may be useful for people who suffer from migraine headaches. An endoscopic forehead lift makes use of physical decompression of the sensory nerves to the forehead, as opposed to chemical relaxation of the corrugator muscles provided by Botox. Accordingly, it may offer a more lasting benefit. A study among migraine sufferers found that migraine headaches were eliminated in 57% of patients compared with just 4% in a sham group (patients who did not have muscle decompression). This is good news for the 30 million Americans who suffer migraines. A procedure conceived for cosmetic improvement has real and potent physical benefits too.
PATIENT PHOTOS
C.L., Age 53
Procedure: Endoscopic forehead lift, submental lipectomy, excision of two facial skin lesions, and pulsed dye laser treatment of cheeks. Second procedure, 1 year later: fat injection (26 cc), upper and lower blepharoplasties, CO2/erbium laser resurfacing, and revision of submental lipectomy and forehead lift. Third procedure, 2 years later: facelift, fat injection (15 cc), and touch-up erbium laser resurfacing.
Before, 2½ years after forehead lift (7 months after facelift).
2½ years after
K.H., Age 54
Procedure: Endoscopic forehead lift, facelift, submental lipectomy, upper and lower transconjunctival blepharoplasties, and CO2 laser resurfacing.
Before, 3 months after
R.M., Age 60
Procedure: Endoscopic forehead lift and upper blepharoplasties.
Before, 1 month after
An endoscope is a metal tube with a fiber-optic light attached that allows surgeons to see and operate through small incisions that can be placed at a distance from the tissues being manipulated. The image is magnified and displayed on a TV monitor.
The forehead is accessed using small incisions hidden behind the hairline. Specialized instruments are introduced through three small incisions and used to lift up the tissues of the forehead and eyebrows, working under the skin and connective tissue layer of the forehead.
The corrugator muscles between the eyebrows are teased apart, weakening them to relieve the frown lines. The attachments (“periosteum”) holding the eyebrows down to the bony supraorbital rims are released. The deep forehead connective tissue layer (“galea”) is then lifted upward, correcting the position of the brows. Tiny dissolving fasteners are used to hold the position of the elevated forehead until the tissues take hold in their new position. The sutures are inconspicuous, hidden behind the hairline. They are removed in about 10 days. The hair is not shaved.
Even surgeons doing endoscopic forehead lifts use a variety of techniques. Some make as many as five incisions. However, with more incisions, the forehead lift starts to lose its minimal-scarring advantage. Surgeons use a variety of means of fixing the elevated forehead to the skull including:
- No fixation.
- Drilling small holes in the outer table of the skull and tunneling a suture through it (cortical tunnel).
- Temporary external screws that stick out of the scalp.
- Dissolving screw.
I prefer either a dissolving screw or a cortical tunnel approach using LactoSorb devices that are made out of a material similar to dissolvable sutures. The fasteners last long enough for the tissues to adhere to the underlying skull, and once their job is done, they go away. This way, the patient does not feel any bumps later on.
- There is typically minimal discomfort after an endoscopic forehead lift.
- There is usually some swelling around the eyes, and bruising of the eyelids, caused by blood that has tracked down due to gravity.
- Numbness of the scalp behind the incisions is expected. The sensation gradually returns.
- Scalp sutures come out easily in about 10–14 days (the same time as the facelift sutures). The little screws (if they are used) that anchor the underside of the scalp to the bone dissolve in a few months. By this time, the scalp has adhered to the bone and these fasteners are no longer necessary. They are tiny and difficult to feel even before they dissolve.
- There may be some puckering of the scalp (dog ears) on each side of the scalp incisions that settle down within a few weeks.
- Occasionally, there may be weakness of the forehead on one side due to stretching of the frontal branch of the facial nerve. This weakness is typically of a temporary nature. It is unusual after a forehead lift alone. It is more common when the forehead lift is done at the same time as a facelift.
- Hair follicles located at the incisions take several months to grow hair again, so there are typically small areas of hair loss at these small incision sites behind the frontal hairline.
- There is minimal or no upward movement of the hairline, which is an advantage of this technique over the older coronal forehead lift.
- The endoscopic technique is less likely to cause an overly surprised expression that can result if there is excessive elevation of the eyebrows.
- Frown lines may still be visible, although they are likely to be softer than before surgery. Botox injections and fillers can help maintain the result.
Inadequate Lift Requiring a Second Procedure
Although overcorrection is unusual using the endoscopic technique, undercorrection can happen. Sometimes the brows descend again and can benefit from another lift. Sometimes this happens within a few years. Fortunately, an endoscopic forehead lift can be revised using the same small incisions, so there are no new scars.
Hair Loss (“Alopecia”) at Scalp Wounds
A period of 6 months is allowed for hair regeneration in the area of the scars. If there is still a noticeable bald area, the scar may be revised under local anesthesia in the office. The small patch of bald scalp is removed and the hair-bearing edges are brought together to reduce the hair-free area to just the scar itself (scar tissue does not grow hairs), which tends to be inconspicuous.
Persistent Frown Lines
The corrugator muscles are remarkably resilient. This procedure weakens the muscles causing frown lines but not totally inactivate them, which would be undesirable anyway. Persistent frown lines can be treated with Botox. A filler such as fat can be used to treat deep creases. Laser resurfacing can soften surface lines that are “etched” into the skin.
Overresection
Sometimes surgeons, in a well-intended effort to eliminate frown lines, remove all the corrugator muscle they can see. As might be expected, this resection may produce a contour depression of the area between the eyebrows (glabella) because of tissue loss below the skin. Overresection of the corrugators can allow the eyebrows to drift because of loss of traction medially on the brows. The experienced plastic surgeon learns to strike a balance between weakening these muscles by teasing them apart and excision, which might produce these secondary problems.
Asymmetry
Eyebrow asymmetry is brought to the patient’s attention before surgery. Usually both sides are treated and the brow is elevated more on the lower side. Occasionally, a unilateral lift (right or left side only) may be recommended.
Frontal Nerve Weakness
The frontal branch of the facial nerve may be traumatized and cause weakness of eyebrow elevation, usually on one side. This problem is almost always temporary and usually related to stretching from a facelift done simultaneously.
Scalp Numbness.
There is always some degree of scalp numbness from division of small sensory nerve branches. This numbness gradually recedes over several months. The major sensory nerves of the forehead, the supraorbital nerves, are well-seen during the procedure and unlikely to be injured. The small supratrochlear nerves are also visible. They are small enough to be of little consequence.
Getting Back to Normal
• Wash normally the day after surgery. It is fine to shampoo your hair.
• The sutures do not need any specific care. They come out 10–14 days after surgery.
• You may notice numbness of your scalp. This is normal.
Q: Will this surgery make me look overly surprised?
A: Very unlikely. An experienced surgeon avoids this unwanted expression, which is more commonly seen after the old coronal approach, in which a strip of scalp tissue is removed, pulling the brows up. There is a margin of safety built into the endoscope approach.
Q: Will the forehead lift raise my hairline?
A: There is minimal or no elevation of the hairline, because tension is applied to the connective tissue layer underneath the skin (galea) rather than to the skin itself, and there is no removal of a swath of hair-bearing scalp. There is some skin redundancy (dog ears) at the three incisions, but these small bumps gradually settle down with little, if any, perceptible change in the level of the hairline.
Q: When can I color my hair?
A: You can color your hair when the scalp incisions are well-healed, with no crusting, so there is little likelihood of any chemical penetrating the wounds, usually a few days after the sutures come out. Most patients who also have a facelift wait another week or two anyway, until they feel comfortable enough with their overall appearance to go to the hairdresser.
Q: If I decide not to have the forehead lift, will my face look weird, having a facelift but no forehead lift?
A: No. If the degree of brow sagging is minimal and forehead rejuvenation is not a priority, this is a procedure you can “leave out of the shopping cart” without looking incongruous.
Q: Does it hurt?
A: There is very little pain associated with this procedure. It is commonly done simultaneously with a facelift.
Q: What if I just had Botox injected? Can I still have a forehead lift?
A: You can still have an endoscopic forehead lift even if you have Botox working. Many patients eventually decide to have a forehead lift after starting with Botox injections. It is possible to achieve more brow elevation this way. The surgery may reduce the need for Botox, injections by weakening the corrugator muscles.