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Endoscopic Forehead Lift: Review of Technique, Cases, and Complications


Abstract and Figures

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.
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Techniques in
Cosmetic Surgery
Endoscopic Forehead Lift: Review of
Technique, Cases, and Complications
Benoit C. De Cordier, M.D., Jorge I. de la Torre, M.D., Mazin S. Al-Hakeem, M.D.,
Laurence Z. Rosenberg, M.D., Paul M. Gardner, M.D., Antonio Costa-Ferreira, M.D., R. Jobe Fix, M.D.,
and Luis O. Vasconez, M.D.
Birmingham, Ala.
Endoscopy has provided a significant improvement
in the surgical rejuvenation of the upper face. It offers
a minimally invasive alternative that avoids many of the
undesirable effects associated with the coronal ap-
proach. The standard minimal access forehead endo-
scopic procedure consists of a subperiosteal undermin-
ing through three small triangular prehairline incisions.
To successfully elevate the eyebrows, it is essential to
release the periosteum at the level of the supraorbital
rims and ablate the brow depressor muscles of the gla-
bella. Until the periosteum reattaches itself, elevation is
maintained by a temporary suspension suture between
staples at the incision sites and 5 cm posterior to the
hairline. The transverse closure of the triangular skin
incisions achieves some additional elevation. The bi-
planar approach adds a partial subcutaneous under-
mining of the forehead to the endoscopic technique
and allows plication of the frontalis muscle and excision
of excess forehead skin. It is offered to patients with very
ptotic eyebrows, deep transverse wrinkles, or a high
forehead. The prehairline incision is a disadvantage but
is tolerated quite well in older patients. The medical
records of 393 consecutive patients who underwent en-
doscopic forehead lift from 1994 to 2000 were reviewed.
Because seven patients had the endoscopic forehead lift
repeated, the number of forehead endoscopies totaled
400. The complication rate was quite acceptable and did
not markedly increase when a forehead lift was per-
formed in combination with other facial procedures. The
endoscopic forehead lift consistently attenuated the trans-
verse forehead wrinkles, reduced the glabellar frown lines,
and raised the eyebrows. It provided an appearance that
was less tired and angry in addition to opening the area
around the eyes. Long-term follow-up has shown that the
endoscopic forehead lift produces lasting and predictable
results. (Plast. Reconstr. Surg. 110: 1558, 2002.)
Rejuvenation of the upper third of the face
by means of a coronal forehead lift frequently
results in a long scalp scar, scalp dysesthesia,
and alopecia. These drawbacks, in addition to
the surprised look that occurs with overeleva-
tion of the medial eyebrows, deter many pa-
tients from forehead rejuvenation.
The introduction of endoscopy has popular-
ized the forehead lift because it avoids these
adverse effects and allows faster recovery.
addition, this simple and minimally invasive
technique can easily be combined with other
facial procedures to create a more harmonious
restoration of the appearance of youth. How-
ever, the benefits of the endoscopic forehead
lift and its place in resident education have
been questioned by some, prompting us to
evaluate the complications and long-term re-
sults of this procedure.
General anesthesia is preferred, especially
when concomitant procedures are performed.
The surgeon has complete access to the entire
area around the head, and the video-monitor is
placed at the foot of the bed in the surgeon’s
line of vision. Before initiating the forehead
procedure, the patient is placed in the reverse
Trendelenburg position. Xylocaine 0.5% with
1:200,000 epinephrine is injected in the areas
to be operated on.
From the Division of Plastic Surgery, University of Alabama at Birmingham; and the Center for Advanced Surgical Aesthetics. Received for
publication August 9, 2000; revised March 22, 2002.
Presented at the 69th Annual Meeting of the American Society of Plastic Surgeons, in Los Angeles, California, in October of 2000.
DOI: 10.1097/01.PRS.0000029815.87106.CB
The midline and a bilateral line, at the level
of the pupil or lateral corneal limbus, are
marked from the supraorbital rim to the hair-
line. On each of these three lines, a small
triangular skin incision with the base toward
the scalp is outlined at the prehairline level.
The location of the parasagittal skin triangles
depends on where most of the eyebrow eleva-
tion is required (Fig. 1).
At these three forehead incisions, the skin is
excised and access is gained to the subperios-
teal plane with the help of a hemostat. A
scratching maneuver parallel to the fibers of
the frontalis muscle divides the periosteum.
The hemostat is then spread to create a formal
port (Fig. 2). This method spares the nerve
endings of the superficial branch of the su-
praorbital nerve.
A periosteal elevator is then
introduced, and blind subperiosteal undermin-
ing is performed from one transition zone be-
tween frontal periosteum and deep temporal
fascia to the other, and from the hairline to the
supraorbital rims. This undermining is not ex-
tended posteriorly toward the vertex (Fig. 3).
Unless the patient has undergone a previous
rhinoplasty, a small, rounded, blunt elevator is
used to extend the undermining to the radix of
the nose. The dissector is then rotated 180
degrees and advanced to the tip of the nose.
This permits the release of the procerus muscle
and subsequent improvement of the transverse
frown lines of both the glabella and nasal radix
(Fig. 4).
Next, cutaneous retraction sutures are
placed above the supraorbital rims at the level
of the glabella and supraorbital notch bilater-
ally. This enables tenting of the forehead soft
tissues and creates an optical cavity, which will
facilitate maneuvering in the subperiosteal
plane (Fig. 5).
The 30-degree wide-angled endoscope is
placed through the central opening. While the
assistant is handling the endoscope, the sur-
geon frees the periosteum in the midline and
over the supratrochlear and supraorbital
nerves with a blunt periosteal elevator placed
through one of the lateral ports. With a hook
knife similar to that used for endoscopic carpal
tunnel release, the periosteum is now divided
under endoscopic control, at the level of the
. 1. Three triangular prehairline incisions with the cu-
taneous retraction sutures at the level of the glabella and the
supraorbital notches.
. 2. The three triangular skin excisions that allow ac-
cess to the subperiosteal plane.
. 3. The subperiosteal undermining is extended ante-
rior to the three portals but not posterior to the ports or
toward the temporal region.
Vol. 110, No. 6 /
supraorbital rims from lateral to the supraor-
bital nerves to the level of the lateral orbital
rim. The limiting of the lateral release of peri-
osteum avoids damage to the frontal nerve.
Over the lateral third of the eyebrow, the hook
knife is curved superiorly as a periosteal back-
cut (Fig. 6). No formal undermining or eleva-
tion is performed in the temporal region un-
less an endoscopic midface elevation is
The corrugator and procerus muscles are
then ablated using the left hand to palpate the
skin over the glabella and the right hand to
remove the depressor muscles in a piecemeal
manner with a grasping forceps. This bimanual
maneuver allows for more precision in the re-
moval of the periosteum and avoids injury to
the supratrochlear and supraorbital nerves. If
bleeding occurs to a vein of the supraorbital
bundles, it can be stopped with the disposable
suction coagulator.
The cutaneous retraction sutures are then
removed, the forehead cavity is irrigated, and a
small drain is passed through one of the lateral
ports. A Vicryl suture approximates the perios-
teum and subcutaneous soft tissues of the three
triangular prehairline incisions and turns them
into three short transverse scars. This will result
in a slight elevation above the midline and
each limbus.
Elevation of the forehead is maintained by
temporary suspension sutures between staples
at the incision sites and 2 to 3 cm posterior to
the hairline (Fig. 7). The forehead is taped
together over its entire width, including the
glabella and radix. The skin taping will also
include the nasal dorsum if the dissection was
extended to the tip of the nose.
The biplanar forehead lift combines the
standard minimal access endoscopic lift with a
limited subcutaneous forehead undermining.
The incision extends from one temporal re-
gion to the contralateral side and is placed at
the anterior hairline. It is beveled to preserve
the hair follicles and render the final scar more
inconspicuous by permitting preincisional hair
. 6. Below the level of the eyebrows, the periosteum is
divided over the entire width of the frontal region. Over the
lateral third of the brow, this periosteal release is directed
superiorly as a back-cut.
. 4. The blunt periosteal elevator rotated 180 degrees
at the nasal radix to continue the undermining to the tip of
the nose. Note how the instrument curves parallel the fore-
head, the nasofrontal angle, and the dorsum of the nose.
. 5. The three temporary cutaneous sutures suspend
the skin and create an optical cavity.
,November 2002
The forehead skin is freed from the under-
lying frontalis muscle 3 to 4 cm anterior to the
hairline (Fig. 8). This is achieved by blunt dis-
section with a hemostat to spare the nerve
endings of the superficial branch of the su-
praorbital nerve. Standard forehead endos-
copy is now initiated, and access is gained to
the subperiosteal plane through the exposed
frontalis muscle above the midline and each
midpupillary line. The optical cavity is again
created using three skin retraction sutures at
the supraorbital rims. Once the forehead peri-
osteum has been adequately released and the
eyebrow depressor muscles removed or weak-
ened, the three access ports are closed, avoid-
ing the supraorbital nerve endings readily seen
on top of the exposed frontalis muscle.
The frontalis muscle is now plicated in front
of the hairline over the entire width of the
forehead by means of five to six horizontal
mattress sutures of clear nylon. The sutures
plicate 1 to 1.5 cm and can be used to correct
eyebrow asymmetry. The nerve endings of the
supraorbital nerve and the supratrochlear
nerve are avoided.
Because the supraorbital skin is still attached
to the lower part of the frontalis muscle, the
plication of the upper part will consistently
elevate the eyebrows. It also results in excess
skin at the hairline that is resected to allow
inset and closure without tension. The frontalis
muscle plication obviates the need for the tem-
porary suture suspension, as is needed with the
standard endoscopic forehead lift. The wound
edges are approximated with half-buried hori-
zontal mattress sutures, and the forehead and
nose are taped over the area of undermining.
Because the endoscopic forehead lift cor-
rects only one aspect of periorbital aging, it is
often supplemented with additional upper and
lower eyelid procedures to attain a more ho-
mogenous periorbital rejuvenation.
In par-
ticular, improvements to the upper eyelid may
enhance the effect that forehead endoscopy
has on opening the periorbital region. The
upper lid skin and orbicularis oculi resection is
If senile ptosis is present, the levator palpe-
brae aponeurosis is exposed before other peri-
orbital dissection to facilitate its dissection
through intact anatomical planes. At the level
of the midpupillary line, the levator aponeuro-
sis is plicated with one horizontal nylon mat-
tress suture.
Limited fat resections of the me-
dial and lateral compartments then follow. The
lateral upper eyelid is explored for ptosis of the
lacrimal gland, which may be corrected by re-
suspending the gland to the periosteum of the
lateral roof of the orbit. On a few patients,
when appropriate, the fat over the supraorbital
rims and under the orbicularis muscle is partly
Extending the undermining of the endo-
scopic forehead lift to the tip of the nose allows
a slight elevation of the aging, drooping nasal
. 7. Conversion of the three triangular skin excisions
into transverse scars at closure enables a small amount of
elevation. Temporary suture suspensions (arrows) between
staples at the incision sites and 5 cm more posteriorly are kept
in place for 3 to 5 days.
. 8. A biplanar approach adds a 3- to 4-cm subcutane-
ous undermining to the forehead endoscopy. The large arrow
points to the central port of the endoscopy. The small arrows
represent the extent of the frontalis muscle plication (1 to 1.5
Vol. 110, No. 6 /
tip. In a number of patients, further tip refine-
ment and support is provided by a cephalic
trim of the alar cartilages, umbrella type onlay
tip graft, and/or columellar strut.
A retrospective review of the medical records
of 393 consecutive patients who underwent en-
doscopic forehead lift from January of 1994 to
January of 2000 was conducted. Data pertain-
ing to previous facial rejuvenation, the actual
endoscopic forehead lift, the concomitant pro-
cedures, the age and sex of the patient, the
time of follow-up, and the complications were
Seven of the 393 patients had the endo-
scopic forehead lift repeated; therefore, the
number of forehead endoscopies totaled 400.
The 358 women had an average age of 55 years
(range, 21 to 80 years), and the 35 men had an
average age of 56 years (range, 11 to 73 years),
with an 11-year-old boy being treated for a
frontal nerve paralysis. The average follow-up
was 19.5 months (range, 1 to 6 years).
The forehead endoscopies consisted of 336
minimal access, 59 biplanar, and five com-
bined hemi-biplanar/hemiminimal access en-
doscopic forehead lifts (Figs. 9 through 11).
Among the 400 endoscopic forehead lifts, 39
were secondary. The previous forehead proce-
dure consisted of a coronal lift in 32 and an
endoscopic lift in seven cases. Of the seven
patients with a secondary endoscopic forehead
lift, four underwent a biplanar and three a
minimal access endoscopic lift.
To obtain a harmonious and global restora-
tion of the youthful proportions, a significant
number of other facial procedures were per-
formed in conjunction with the endoscopic
forehead lifts (Table I).
Included were up-
per and lower blepharoplasty in 50 percent of
the patients and face and neck lifting in 86
percent. The complications included dysesthe-
sias, nerve injuries, forehead irregularities, and
alopecia. Alopecia occurred in one instance
only. Placement of the minimal access incisions
and/or biplanar skin incision at the prehair-
line level, together with a tension-free skin clo-
sure, avoided that complication. One might
argue that the alopecia was traded for more
noticeable forehead scarring. However, espe-
cially in patients older than 55 years of age,
these prehairline scars can become impercep-
tible. Only three patients required a scar revi-
sion to correct a conspicuous scar depression.
Patients younger than 55 years of age seek
mainly a brow lift and an improvement of their
glabellar frown lines. The classic endoscopic
forehead lift can meet their expectations
through minimal access incisions.
Although most patients experienced some
transient scalp numbness and paresthesia, ap-
proximately 2 percent complained of persis-
tent forehead and/or scalp itching or dysesthe-
sia (Table II). The addition of a subcutaneous
component in the case of a biplanar forehead
lift did not increase this complication. The
numbness seemed to be less of a problem with
time as the patients adjusted to it. The severe
itching was managed by infiltrating a solution
of triamcinolone and lidocaine at the level of
the supraorbital foramen or notch. Five pa-
tients required these infiltrations. Almost 2
percent (seven patients), all with the minimal
access endoscopic forehead lift, experienced a
temporary frontal nerve weakness. Of note is
that all frontal nerve injuries were mild and
temporary. This low incidence and severity
compare very favorably with those reported in
other series.
In total, 7 percent of the patients experi-
enced difficulty closing the eyes, 8 percent ex-
perienced eye irritation, 8 percent experi-
enced upper eyelid asymmetry, and 3 percent
experienced eyebrow malposition. Overall, 80
percent of the forehead endoscopies mani-
fested none of these complications. The prob-
ability of no periorbital complications after an
isolated endoscopic forehead lift was 88 per-
cent. This decreased to 80 percent with the
addition of an upper blepharoplasty, and to
only 46 percent with further addition of a pto-
sis correction (Table III).
Forehead hematoma occurred in 3.5 per-
cent of the patients who underwent forehead
endoscopy without the addition of a face or
neck lift. These hematomas were minor and
were drained in the clinic at the first postoper-
ative visit. The use of a small forehead drain
has since eliminated this problem.
The technique of the standard endoscopic
forehead lift as described in 1995 has under-
gone six major changes: (1) As opposed to the
generally held recommendation, the upper
eyelid surgery is now performed before the
forehead lift. (2) The subperiosteal undermin-
,November 2002
ing is limited to the forehead proper and is no
longer extended to the temporal area. (3) The
dissection is not extended to the vertex. (4)
The minimal access incisions are now placed at
the hairline. (5) The suspension is performed
simply and temporarily with cable sutures.
The eyebrow depressor muscles are ablated.
Upper Eyelid Surgery Performed before the Endoscopic
Forehead Lift
Contrary to others, we prefer to improve the
upper lid before the forehead and brow.
should be emphasized that the conservative
skin resection of the upper lid is outlined pre-
operatively with the patient sitting and with the
eyes in a straight gaze. While marking with the
right hand, the left slightly elevates the brow to
a more youthful position. Performing the up-
per blepharoplasty first is simpler in that it is
done on a lid that is not edematous and it
allows accurate plication of the levator muscle;
in no case has it resulted in overresection of
No Undermining in Temporal Region
Dissection lateral to the frontotemporal line
has been proposed to elevate the lateral corner
of the eyebrow.
However, the patient popula-
. 9. A 53-year-old woman before (left, above and below) and after (right, above and below)an
endoscopic forehead lift and face lift, without a blepharoplasty.
Vol. 110, No. 6 /
tion included in this retrospective study was
probably older than that encountered in most
plastic surgery practices. Consequently, most
were candidates for a global facial rejuvena-
tion, which is reflected in the 86 percent who
underwent a concomitant face lift procedure.
The face was rejuvenated through a prehair-
line approach, which in the temporal region
extended to above the eyebrow level. It consis-
tently included a vertical elevation of the malar
fat pad and a superolateral suspension of the
lateral orbicularis oculi. The facial skin flap was
redraped in a vertical direction with excision of
most of the skin excess at the temporal prehair-
line incision. Therefore, the inferomedial ro-
tational descent of the orbicularis oculi was, at
least partially, reversed by its superolateral sus-
pension, and the lateral orbital skin was im-
proved by the skin excision at the temporal
hairline (Figs. 2 and 4).
No Posterior Scalp Undermining
The eyebrow elevation of note occurs as
measured from the midpupil to the eyebrow.
. 10. A 54-year-old woman before (left, above and below) and 14 months after (right, above
and below) an endoscopic forehead lift, in addition to upper lid blepharoplasty, face lift, and neck
,November 2002
The frontalis muscle is the key. The frontalis
muscle is, in fact, tethered to the frontal bone
over a 2-cm supraorbital band because of the
continuation of its one-layered deep galea
plane of the upper forehead into the firmly
fixed deepest layer of the multilayered deep
galea plane of the lower forehead.
Because of
this tethering, the mobile lower frontalis mus-
cle will need a higher resting tone to effect
some eyebrow elevation. This will reflect on the
forehead skin as the appearance of definite
transverse creases, thanks to the multiple fi-
brous septa connecting this muscle to the der-
mis. Transecting this deepest layer of the lower
forehead deep galea, depending on the ap-
proach together with the periosteum, will
loosen the frontalis muscle. Consequently, the
frontalis will now be able to elevate the brow
more and with a lower resting tone and, thus,
fewer skin creases. A concomitant ablation of
. 11. A 62-year-old woman, who wore a wig because of a high forehead, before (left, above
and below) and 7 months after (right, above and below) a biplanar endoscopic forehead lift with
lower blepharoplasties, a face lift, and perioral dermabrasion. She did not have upper bleph-
aroplasties. The wig was removed for the postoperative photographs to allow good exposure of
the forehead and hairline.
Vol. 110, No. 6 /
the eyebrow depressor muscles will further re-
duce the counteracting forces to the frontalis
muscle. An additional undermining posterior
to the three portals, especially one going all the
way back to the occiput, will offer little if any
extra elevation of the brows. This extensive
posterior dissection was initially deemed nec-
essary to accommodate the superior reposi-
tioning of the brows.
However, scalp flaps are
known for their lack of resilience that surgeons
try to overcome by making relaxing incisions in
the aponeurotic layer. Therefore, it seems un-
likely that a posterior undermining of the scalp
would result in a significant soft-tissue
Prehairline Portal Incisions
The minimal access incisions are now placed
at the frontal hairline (Fig. 1). Doing so facili-
tates the subperiosteal undermining and en-
hances the endoscopic visualization, which in
turn will increase the safety and accuracy of the
periosteal release and ablation of the brow de-
pressor muscles. This is particularly of value in
repairing a very convex forehead.
The three triangular skin excisions are used
for several reasons. Their conversion into
transverse scars at closure will achieve a small
amount of elevation. Also, at the level of both
lateral limbi of the corneas, their use will, to a
certain extent, redefine the apex of the eye-
brows in an effort to meet the classic descrip-
tion of the ideal brow.
This skin access design
makes it easier to introduce the endoscope and
instruments into the portals and causes less
trauma to the surrounding tissue. Therefore, it
will improve the quality of the scars and keep
them shorter than if the instruments were to be
placed through transverse or vertical slit inci-
sions. We have found these prehairline scars to
be quite inconspicuous, especially in patients
older than 55 years (Figs. 7 and 8). In cases of
a high forehead or a male receding hair pat-
tern, the minimal access incisions are placed in
one of the forehead creases, and this appears
not to detract from the scar quality (Fig. 9).
Placing the skin incisions a few centimeters
behind the frontal hairline would complicate
the forehead endoscopy and could cause no-
ticeable scars in the event of alopecia.
It is generally agreed that once the frontal
periosteum is released and the brow depressor
muscles ablated, the now-elevated forehead
flap should be maintained in position until its
periosteum can re-adhere to the frontal bone.
The time frame for this to occur varies from
several days to 12 weeks.
Therefore, fixation
methods, whether permanent or with slow re-
sorption, are increasingly favored.
In our technique, a slight amount of fore-
head elevation is obtained with the advance-
ment and transverse skin closure at the trian-
gular incision sites. The elevation at these
three endoscopy portals is further sustained by
means of a temporary cable suture suspension
that stays in place for only 3 to 5 days. In
contrast to mainstream opinion, we still rely on
a functional lift of the eyebrows by means of
the unopposed pull of the frontalis muscle.
Once the frontalis muscle is released from its
counteracting forces at the supraorbita, it will
drift, particularly in its mobile part, superiorly.
There is no reason to suspect that the frontalis
muscle would droop again significantly in the
postoperative period. Therefore, we are not
convinced that a secure periosteal fixation is of
paramount importance in maintaining the
gain in forehead elevation.
Rigid permanent fixation of the lifted fore-
head flap will afford a more dramatic immedi-
ate postoperative result. However, in an effort
to stabilize the obtained eyebrow rejuvenation,
overcorrection can occur. The surprised or
startled look is a stigma and a primary concern
in patients seeking upper face rejuvenation.
Endoscopic Forehead Lifts and Concomitant Procedures
Total endoscopic procedures 400 100
Face lift procedures 342 86
Submental lipectomy and platysmal plication 305 76
Upper lid blepharoplasty 200 50
Lower lid blepharoplasty 198 50
Tip rhinoplasty 154 39
Persistent dysesthesias 9 2.3
Frontal branch weakness 7 1.8
Forehead irregularity 7 1.8
Alopecia 1 0.3
Wound dehiscence 1 0.3
Suture abscess 1 0.3
*Some patients had more than one complication.
,November 2002
Ablation of Eyebrow Depressor Muscles
It is our belief that ablation of the brow
depressor muscles should be an integral part of
the endoscopic forehead lift. Although sagging
of the lateral eyebrow occurs earlier and to a
greater extent, the glabellar area in older pa-
tients tends to become crowded with the in-
feromedial drift of the medial brows. In our
opinion, some degree of elevation and spread-
ing of the medial eyebrows is beneficial to the
outcome of the forehead endoscopy.
Treatment of the procerus is conservative, to
avoid a noticeable glabellar depression, but the
muscle mass in between the supratrochlear and
supraorbital nerves is aggressively resected. The
corrugator supercilii, part of the orbital orbicu-
laris oculi, and (possibly) part of the depressor
supercilii are removed during a muscle resection
that stops when the subcutaneous fat is visible.
Together with the weakening of the procerus,
this will improve the transverse, oblique, and ver-
tical wrinkles of the glabella in addition to elevat-
ing the medial brow. Furthermore, the corru-
gator ablation is essential to eliminate
counteracting the frontalis muscle over the lat-
eral eyebrow. Despite the aggressive muscle
ablation in between the supratrochlear and
supraorbital nerves, some frowning ability will be
retained. This ensures a rejuvenated yet natural
glabella that is not devoid of expression.
Biplanar Endoscopically Assisted Forehead Lift
The standard endoscopic forehead lift may
fall short in providing an adequate overall re-
juvenation in patients with a very furrowed or
high forehead or with a pronounced brow pto-
sis or asymmetry. Under these conditions, we
favor the biplanar endoscopic forehead lift as
proposed by Ramirez.
The addition of a frontal prehairline incision
with a limited 3- to 4-cm skin undermining over
the superior part of the forehead affords a more
direct impact on the eyebrow and transverse skin
creases. Freeing the forehead skin over the upper
half severs all the fibrous septa between the mus-
cle and the dermis so as to soften the transverse
creases in the area where they physiologically
most often occur. In addition, plicating the fron-
talis muscle just cephalad of its mobile lower part
and connected supraorbital skin permits a more
accurate correction of the position, shape, and
possible symmetry of the eyebrows. Furthermore,
it achieves these objectives without the patients
incurring scalp anesthesia, itching, and alopecia,
the typical drawbacks of the coronal ap-
In patients with a high forehead, pos-
sibly after a previous coronal lift, the biplanar
forehead lift will avoid further elevating the hair-
line and may be used to decrease this excess
forehead height.
We believe the results of the biplanar endo-
scopically assisted forehead lift to be superior to
those of the standard forehead endoscopy. If a
patient, particularly if older than 55 years, is will-
ing to accept a prehairline incision, we would
rather advise the biplanar endoscopic forehead
lift. Obviously, the older the patient, the less no-
ticeable the final prehairline scar. However,
along with benefiting the scar quality, another
hallmark of this technique is the tension-free skin
closure: Plication of the frontalis muscle ad-
dresses the brow ptosis, so the skin can be re-
draped and inset without tension.
A limited number of mainly younger pa-
tients underwent a combined hemistandard
endoscopic and hemibiplanar endoscopic
forehead lift. These patients had significant
discrepancy in eyebrow height, which in most
cases was because of a unilateral frontal nerve
paralysis. The forehead lift that was performed
on the 11-year-old boy was a reconstructive
procedure for frontal nerve injury.
Concomitant Upper Lid Ptosis Correction
The ptotic upper lid (in particular, senile lid
ptosis) may cause the patient to increase the
resting tone of the frontalis muscle in an effort
to fully open the eye and fully restore the
superior visual fields. Therefore, upper lid sur-
gery will not only improve the periorbital ap-
pearance, but it may also decrease the trans-
verse forehead wrinkling. Upper lid ptosis is
corrected using a suture plication of the leva-
tor aponeurosis. If the patient has postopera-
tive upper lid asymmetry or eye irritation that
requires revision, the suture plication can be
adjusted simply under local anesthesia. Correc-
tion of upper lid ptosis clearly improves the
periorbital area; however, some authors pro-
pose it as a second-stage procedure to reduce
the occurrence of complications.
Periorbital Complications
None 319 80
Eye irritation 33 8
Difficulty with eye closure 28 7
Eyebrow malposition 10 3
Vol. 110, No. 6 /
the untoward effects of the concomitant leva-
tor palpebrae plication were common, most of
them resolved spontaneously within a few
weeks when the edema subsided.
The endoscopic forehead lift consistently at-
tenuated the transverse forehead wrinkles, re-
duced the glabellar frown lines, and raised the
eyebrows. It created an open appearance of the
eyes, and the patients looked less tired and
angry. The complication rate was quite accept-
able and did not markedly increase with the
addition of other facial procedures. The excep-
tion was concomitant ptosis correction, which
resulted in a definite increase in periorbital
complications. Of the patients reviewed, 8 per-
cent had a coronal face lift before the endo-
scopic forehead lift, and 2 percent needed
their forehead endoscopy repeated. The endo-
scopic forehead lift was reliable and safe when
performed as a secondary procedure in these
patients. Although other techniques require
permanent fixation to obtain long-lasting re-
sults, we found our suspension technique to be
simple, safe, and reliable.
Jorge de la Torre, M.D.
Division of Plastic Surgery
University of Alabama at Birmingham
1813 6th Avenue South, MEB 524
Birmingham, Ala. 35294
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,November 2002
... Therefore, endoscopic procedures are often substituted for procedures involving a coronal incision [1]. Many studies have investigated the effects of endoscopic forehead lift in terms of eyebrow morphology, aesthetics, longevity, and complications [2][3][4][5]. ...
... In the early 2000s, a study showed that endoscopic forehead lift had no significant advantage over the existing method in terms of complications and effectiveness [5]. Furthermore, it is considered to be a safe procedure with fewer complications than the traditional technique, although there are some limitations in terms of its application [4]. Over the years, this technique has improved, and its advantage of being less invasive helps many patients agree to undergo surgery using this method more readily than existing open procedures. ...
... The general complications of endoscopic forehead lift are bleeding, nerve injury, scarring alopecia, brow asymmetry or malposition, lagophthalmos due to brow over-elevation, and dry eye syndrome [4,10]. We investigated changes in the height of the forehead, which is an issue that may arise after surgery, even though it is not classified as a complication. ...
Full-text available
Background Endoscopic forehead lift effectively corrects brow ptosis, and is less invasive and has fewer complications than classic forehead lift. Therefore, endoscopic procedures are often used instead of making a coronal incision. However, very few studies have investigated changes in the height of the hairline and documented exact values regarding the extent of forehead elongation after these procedures. Therefore, we conducted this study to determine the degree to which the height of the forehead changes after endoscopic forehead lift. Methods Patients’ medical records were retrospectively analyzed and measurements of clinical photography were made to investigate changes in the height of the forehead after the procedure. Subjects were divided into an experimental group (n=33) and an age-matched control group (n=33) for analysis; the experimental group comprised those who underwent endoscopic forehead lift from January 2015 to March 2018, and the control group comprised those who underwent upper blepharoplasty without forehead rejuvenation from July 2009 to September 2017. Results The changes between the preoperative and postoperative height of the forehead in the experimental group were not statistically significant (right, P=0.163; left, P=0.256; midline, P=0.545). However, the changes in the height of the forehead in the control group were statistically significant on the right side (P=0.026) and left side (P=0.028), but not at the midline (P=0.244). Conclusions We investigated the extent of forehead elongation that occurred in cases of endoscopic forehead lift and verified that significant forehead height changes did not occur after endoscopic forehead lift.
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Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989–April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms “lower blepharoplasty”, “upper blepharoplasty”, “browlift”, “browplasty”, “endobrow lift”, “endoscopic brow”, “Foreheadplasty”, “lower eyelid anatomy”, “upper eyelid anatomy”, “forehead lift”, “eyelid rejuvenation”, “canthopexy”, “canthoplasty”, “eyelid fat pad”, “orbital fat pad”, “tear trough”, and “eyelid bags” were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author’s primary specialty, the focus of the article, the corresponding author’s country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989–1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.
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Background In the present report, an innovative alternative approach for rhytidoplasty is described. Rhytidoplasty Through Minimal Incisions (Rhythmic) is an effective, efficient, safe, and reproducible alternative procedure for facial rejuvenation. It has several advantages over traditional procedures. Objective The main objective of this report is to describe the surgical technique of Rhythmic. Methods The surgical technique for the foreheadplasty requires only a transverse ~7 mm incision ~1 cm behind the hairline at the midline. The upper and lower blepharoplasty are made with incisions of ~3 mm, and no suture is needed. Liposuction of the neck can also be performed, and the face lift can be achieved through preauricular incisions. Results Here, we summarize the results obtained in 741 patients subjected to rhytidoplasty through minimal incisions. The follow-up of these patients extended up to 20 years. This technique drastically reduced the length of scars; the eyebrows elevated 8-13 mm, and in some cases, the tip of the nose was also elevated ~7 mm. It minimized or eliminated the vertical frownlines and the horizontal furrows in the forehead. The use of this technique allowed an excellent definition of the cervico-facial angle in the patients. Conclusions In conclusion, rhytidoplasty through minimal incisions drastically reduced the length of scars, bleeding, surgical time, avoided the use of drains, reduced costs, and shorted the convalescent period. It also offered the patients a natural appearance with minor complications.
Facial cosmetic surgery is a unique area of practice within the scope of oral and maxillofacial surgery in that procedural interventions offered to patients are typically not required from a medical standpoint. This chapter aims to outline the common complications that may be encountered with cosmetic procedures of the head and neck. It discusses management strategies to minimize, or eliminate, long‐term sequelae of these complications. When brow ptosis and/or deep forehead rhytids are not amenable to less invasive treatments, brow lifting procedures can provide excellent results in upper facial rejuvenation. Facelift procedures, otherwise known as cervicofacial rhytidectomy, are an effective way to treat facial rhytids not amenable to less invasive forms of therapy. A neck lift procedure may be considered a facelift that lacks a preauricular and temporal component. Hematoma and seroma are common complications of cervicofacial rhytidectomy, and liposuction procedures and can lead to skin necrosis if not identified and treated promptly.
The techniques presented in article will allow the facial plastic specialist to use the anatomy of each individual patient as a guide for the surgical release of the brow performed during endoscopic brow lift. The author presents his 15 years of experience in which he developed this approach. Five different surgical releases of the brow will be demonstrated and discussed in terms of which patients would best benefit from which release. Adopting this approach has made the predictability of the authors brow lift results much better and therefore improved patient satisfaction. This concept has not been described in the literature and the author firmly believes using a preoperative anatomical approach is a better way to approach endoscopic brow lift surgery.
Although frontal sinus fractures are relatively uncommon, the potential for long-term morbidity is significant. Management strategies remain controversial due to a lack of strong clinical evidence. Despite a paucity of strong literature, a logical treatment algorithm is presented based on the structural integrity of three anatomic parameters: anterior table, frontal sinus outflow tract, and the posterior table/dura. The literature supports a paradigm shift from open surgical management to a more conservative treatment algorithm emphasizing observation and minimally invasive endoscopic techniques. Long-term follow-up for complex frontal sinus injuries is critical.
Asians have anatomic and clinical characteristics to be considered before forehead lift. Because of the anatomic characteristics of Asians, for the better outcomes of blepharoplasty or augmentation rhinoplasty, forehead lift as a combined surgery must be considered beforehand. Forehead lift is frequently indicated in young Asian patients. Endoscopic browlift without visible scar is favored for patients, and it can be done in a modified multiplane fashion for better outcomes in patients with thick and redundant skin. There are rare but severe complications of endoscopic forehead lift, such as motor nerve paresis and diplopia, although they are temporary in most cases.
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- Peripheral Nerve Surgery - Endoscopy - Neurosurgery - Minimally Invasive Surgery - Nerve Surgery - Orthopaedics
Zum Stirnlift gibt es verschiedenste chirurgische Ansätze. Bei der Entscheidung für eines der Verfahren muss neben den anatomischen Begebenheiten, Vorlieben und Erwartungen des Patienten, auch das Know-how des Chirurgen berücksichtigt werden.
Treatment of eyebrow ptosis to enhance the cosmetic effect from blepharoplasty is commonly done with a forehead lift using a coronal incision approach. The coronal scalp incision is associated with the annoying sequelae of frontoparietal scalp numbness, itching, and paresthesias, all of which can be permanent. A forehead lift technique with temporal scalp incisions only 4.5 to 5.0 cm in length can produce a result comparable with that of the coronal incision approach when combined with transpalpebral resection of the corrugator supercilii muscles and transection of the procerus muscle. This eyebrow elevation technique, like the endoscopic approach, minimizes the risk of permanently injuring the supraorbital nerve branches that innervate the frontoparietal scalp. Unlike the approach using only endoscopy, however, this technique can effectively treat cases of advanced eyebrow ptosis. The appropriate area of eyelid skin for excision may be difficult to assess when a forehead lift and upper blepharoplasty are done concomitantly. The described forehead lift incorporates a method to determine this area. This forehead lift technique, combined with a technique for protecting against overresecting upper eyelid skin, is described as used effectively on 140 blepharoplasty cases followed for 3 months to 4 years.
In the endoscopic brow lift, modifications in placement of incisions, extent and plane of dissection, and method of suspension can improve scars, reduce dynamic rhytids, and prevent alopecia, according to the authors. Changes in their technique over a 10-year period are discussed here. (Aesthetic Surg J 2002;22:69-71.).
A technique for eyebrow lift is presented which employs the eyebrow arch used by makeup artists to add subjectively to the operation and prevent the aesthetically displeasing result of a too highly arched brow. The marking technique to achieve the proper life is outlined. A concomitant blepharoplasty technique and its indications are presented.
A detailed description of the anatomical relationships of the supraorbital nerve as it courses across the forehead and under the scalp cannot be found in most anatomy textbooks, and illustrations of the nerve beyond the superior orbital rim frequently misrepresent its course. Because the supraorbital nerve is a structure at risk in many plastic surgical techniques, the plastic surgeon would benefit from a clearer understanding of its anatomy and function. The supraorbital nerve was studied anatomically in 12 (24 half-head) fresh cadaver specimens, and its sensory distribution was studied in 30 living subjects using selective nerve blocks. Beyond the orbital rim, the supraorbital nerve has two consistently present divisions: (1) a superficial (medial) division that passes over the frontalis muscle, providing sensory supply to the forehead skin and only to the anterior margin of the scalp in 90 percent of the study subjects; and (2) a deep (lateral) division that runs cephalad across the lateral forehead between the galea aponeurotica and the pericranium as the sensory nerve to the frontoparietal scalp. When a forehead lift is performed, injury to this deep division causes most of the distressful sequelae of scalp numbness and paresthesia. Unlike the superficial division, the course of the deep division in all cadaver specimens and its sensory distribution in all living volunteer subjects was consistent. This study has application for any procedure requiring scalp or forehead incisions, such as the forehead lift and the endoscopic facial techniques.(ABSTRACT TRUNCATED AT 250 WORDS)
Laboratory investigations in fresh cadaver heads demonstrated the feasibility of endoscopic techniques applicable to aesthetic surgery of the face, including the cheeks, the forehead, the orbit, the nose, and the nasal septum. Clinical experience with coronal brow lifting in 32 patients using endoscopic techniques is also presented. The elimination of the ear-to-ear coronal incision is an obvious advantage. The endoscopic approach accomplishes division and weakening of the corrugators, procerus, and frontalis muscles, as well as moderate elevation of the eyebrows. Excess skin is accommodated by dissecting the scalp posteriorly toward the occiput.