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The introduction of fiberoptic endoscopes has
resulted in the development of minimally invasive tech-
niques in aesthetic facial plastic surgery. This technol-
ogy was first used for foreheadplasty in 1991, using en-
doscopic visualization to incise the procerus, corrugator,
and depressor musculature, and to perform temple lifts.1
Today endoscopic forehead- and brow-lifting
procedures are the most popular of endoscopic aesthetic
facial plastic surgery, and their popularization has
brought a decrease in bicoronal browlifting.The bicoro-
nal technique involves a large incision, skin excision,
and closure of the wound under tension, which can
result in elevation of the frontal hairline, skin hypesthe-
sia, alopecia, and hematoma. The endoscopic technique
is less invasive and better tolerated with less morbidity.
This new technology is best suited for rejuvena-
tion of the mildly to moderately ptotic brow, that is,
those patients requiring less than 1.5-cm elevation of
midbrow position. Substantial brow elevation (>1.5 cm)
is best treated with the bicoronal technique, which
includes skin excision. The endoscopic forehead lift is
based upon four maneuvers: a subperiosteal elevation
dissection of the frontal, parietal, and occipital scalp to
the level of the superior and lateral orbital rims; incision
and release of the superior and lateral orbital periosteum;
selective myotomies of the brow depressors; and perma-
nent versus temporary fixation of the elevated brow.
This article reviews the anatomy relevant to fore-
head rejuvenation surgery and presents our surgical
technique for permanent fixation endoscopic forehead
lifting. We also discuss the need for permanent fixation
to ensure long-term forehead and brow position based
upon the results of animal and clinical studies that have
been completed.
AESTHETIC AND SURGICAL ANATOMY
The cephalometrics of the upper third of the face are a
crucial component of the harmony and symmetry that
define the beauty of one’s face. The ideal eyebrow is a
3
Endoscopic Forehead Lifting and Contouring
Thomas Romo III, M.D.,1–3 Andrew A. Jacono, M.D.,1
and Anthony P. Sclafani, M.D., F.A.C.S.1,2
ABSTRACT
The concept of endoscopic foreheadplasty is based upon a sub- or suprape-
riosteal dissection of the parietal, occipital and frontal scalp, incision and release of the su-
perior and lateral orbital periosteum, selective myotomies of the brow depressor muscles,
and brow elevation into a desired position with fixation and healing. A significant limita-
tion of this procedure appears to be the ability to predict the long-term forehead and
brow elevation.
We review the anatomy relevant to forehead rejuvenation surgery and present
our surgical technique for permanent fixation endoscopic forehead lifting. We discuss the
scientific rationale for permanent fixation to ensure long-term forehead and brow posi-
tion and draw our conclusions based upon the results of animal and clinical studies that
have been completed.
KEYWORDS: Endoscopic browlift, forehead lift, facial rejuvenation
Facial Plastic Surgery, Volume 17,Number 1, 2001.Address for correspondence and reprint requests:Thomas Romo III, M.D., Division of Facial
Plastic Surgery, Lenox Hill Hospital, 135 East 74th St., New York, NY 10021. 1Department of Otolaryngology-Head and Neck Surgery;
2Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, New York, NY; 3Division of Facial Plastic Surgery, Lenox Hill
Hospital, New York, New York. Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel:
+1(212) 584-4662. 0736-6825,p;2001,17,01,003,010,ftx,en;fps00370x.
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gracefully arching structure that should lie at the
approximate level of the superior orbital rim, with its
highest point at the lateral limbic margin. In men this
highest point lies at the superior orbital rim, and in
women it lies slightly above this plane.2
With age skin loses its elasticity, muscles atrophy,
and the skeleton gradually resorbs. The resulting ptosis
of the upper brow complex contributes significantly to
the perception of facial aging. Animation of the upper
third of the face also influences the aging process. Ellis
and Masai3 have pointed out three basic patterns of
animation that advance forehead aging by promoting
ptosis and facial rhytids: eyebrow raising, frowning, and
squinting. Frontalis muscle contraction causes eyebrow
lifting, with long-term brow ptosis and horizontal fore-
head wrinkling. In some patients brow ptosis can con-
tribute significantly to superior and lateral visual field
defects and interfere with mobility of the upper lids.
Frowning brings the medial club heads of the eyebrow
together by action of the corrugator supercilia, resulting
in deep vertical glabellar rhytids. Squinting by contrac-
tion of the obicularis oculi causes the common “crow’s
feet”(Fig. 1). It should be noted that the depressor
supercili muscle is located on the medial arc of the obic-
ularis oculi muscle and is considered by some to be part
of obicularis. This muscle acts in concert with the cor-
rugator and aids in pulling down the medial head of the
eyebrow.
In addition to those muscles noted previously,
procerus muscle contraction contributes to forehead
aging. The procerus muscle lies over the upper nasal
bones as a pyramidal slip that decussates with the
medial and inferior border of the frontalis muscle. Its
contraction results in the lowermost horizontal fore-
head rhytid over the radix of the nose.
The anatomic basis for endoscopic forehead reju-
venation lies in this muscular anatomy. The frontalis
muscle is the major brow elevator, and its dissection in
either a subgaleal or subperiosteal plane and superior re-
suspension corrects brow ptosis. The corrugator super-
cilia, depressor supercili, obicularis oculi, and procerus
are the major brow depressors. Myotomies of these
muscles enhance brow elevation and also improve their
associated rhytids.
4FACIAL PLASTIC SURGERY/VOLUME 17, NUMBER 1 2001
Figure 1 Brow elevator and depressor muscular anatomy.
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SURGICAL TECHNIQUE
Preoperative Considerations
In evaluating patients for management of the ptotic
eyebrow it is imperative to assess the frontal hairline as
this may limit the ability to employ the endoscopic
technique due to visibility of the incisions. Patients who
are willing to accept the possibility of visible scars to
treat a ptotic brow, however, are still good candidates. It
is also imperative to inquire about a history of hyper-
trophic scaring and skin pigmentary changes as in all
aesthetic procedures. Patients with mild to moderate
brow ptosis, those requiring less than 1.5-cm elevation
of the midbrow, are the best candidates for the endo-
scopic technique. Those requiring more elevation are
best treated with a skin resection forehead/browlift pro-
cedure. Any existing asymmetries of the brow should be
noted.
Marking
All patients are marked preoperatively in an upright
position, marking the anticipated course of the tempo-
ral branch of the facial nerve, placement of the temporal
and parietal incisions, and the desired brow elevation
(5–8 mm medially and 8–10 mm laterally).
The desired amount of brow elevation is marked
in the following way. The position of the ptotic brow is
marked at its medial head, above the lateral limbus and
above the lateral canthus. Next, using accepted aesthetic
norms,2the brow is elevated to the desired position.
The brow is then released, and the corresponding areas
on the frontal skin are marked. The distances between
the pairs of marks are then measured (the desired eleva-
tion distance). Palpation and marking of the supraor-
bital notch is a useful landmark when later aggressive
endoscopic dissection is performed. The course of the
temporal branch of the facial nerve is marked by con-
necting the following points: one on the facial skin 1 cm
anterior to the inferior ear lobule, another 3 cm anterior
to the superior external auditory canal, and 1.5 cm lat-
eral to the lateral brow.
Six incisions are marked: two medial paramedian
incisions each 2 cm lateral to the midline, 1.5 cm long
and 5 mm behind the anterior hairline; two lateral para-
median incisions, centered on the lateral canthus,
1.5 cm in vertical length, just behind the anterior hair-
line; and two temporal incisions 2 cm long and approxi-
mately 2 cm behind and parallel to the temporal hair-
line (Fig. 2). If greater access is needed to the forehead
in the patient with a high curved forehead, additional
paramedian vertical incisions can also be marked behind
ENDOSCOPIC FOREHEAD LIFTING AND CONTOURING/ROMO ET AL. 5
Figure 2 Marking the incisions.
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the anterior hairline. One should not forget to move the
incisions further posterior in patients with anticipated
androgenetic hair loss.
Dissection
General endotracheal anesthesia may be utilized, but we
prefer monitored intravenous anesthesia in conjunction
with supplemental local anesthetics; 1% lidocaine with
1:100,000 epinephrine is our standard local anesthetic,
and we inject in the following order: first into the region
of the supraorbital and supratrochlear nerves to provide
a regional nerve blockade, the marked parietal scalp
incision sites, the surrounding parietal, frontal, and
glabellar soft tissues in a periosteal plane, and last the
temporal incisions and surrounding soft tissue in a sub-
cutaneous plane. Care is taken to prevent injury to the
superficial temporal artery and vein.
The parietal scalp incisions are made with a
#15 scalpel blade and are carried down to and through
the underlying periosteum. Control holes are drilled
into the calvarium at the anterior extent of the each ver-
tical incision with a hand drill fitted with a 1.7-mm
diameter drill bit and a 4-mm stop. Using a millimeter
caliper, the premeasured desired distance for brow ele-
vation is marked on the calvarium posterior to the four
control holes. Fixation holes are then drilled into the
calvarium at these points.
The temporal incisions are made, and a plane of
dissection deep to the superficial temporal fascia4is
developed with a broad periosteal dissector. A front-to-
back sweeping motion exposes the deep temporal fascia,
which is not penetrated. A superior and medial sweep-
ing motion with the elevator allows for incision of the
tightly adherent temporal fascia and periosteum at the
temporal crest.
Anterior dissection of the flap is performed down
to the edge of the superior lateral orbital rim using a
narrow skin retractor and a wide, blunt elevator. Care is
taken to avoid injury of the temporal branch of the
facial nerve. Multiple small blood vessels including
the sentinel vein may be encountered at this point of the
dissection and are cauterized medially to the elevated
flap with a bipolar cautery, as the temporal branch of
the facial nerve lies within the superficial temporal fas-
cia of the flap.5 An inferiorly directed motion carries the
dissection down to the lateral orbital rim, lateral to the
canthus, and superior edge of the zygomatic arch. A
curved and sharpened periosteal elevator is now intro-
duced to incise the periosteal attachments of the lateral
half of the superior and lateral orbital rim. This is
accomplished by direct visualization and blunt dissec-
tion, bilaterally.
A wide subperiosteal undermining of the pari-
etal, occipital, frontal, and glabella soft tissues is per-
formed using the same dissector without the endoscope.
This is carried down to approximately 2 cm from the
medial supraorbital rims. Continuity of this widely
undermined scalp flap with the temporal pockets is now
established.
With endoscopic visualization through a lateral
paramedian incision, the curved sharp dissector is
inserted through the temporal incision on the same side
of the head, and a lateral-to-medial dissection of the
periosteum from the supraorbital rim is performed. The
supraorbital and supratrochlear neurovascular bundles
are identified and preserved.
An upturned periosteal spreader is used along the
supraorbital rim in a lateral-to-medial direction. This
dissection provides for further periosteal release that
exposes the underlying retroorbicularis oculi fat pad and
produces limited myotomies in the overlying orbicularis
oculi muscle.
Next a thin nerve dissector is introduced to fur-
ther incise the medial supraorbital periosteum. The
neurovascular bundles and the depressor supercilii mus-
cle, corrugator supercilii muscle, and procerus muscle
are identified with this dissection. The endoscope is
then inserted through the medial paramedian incision
down to level of the glabella. A curved endoscopic fore-
head punch or grasping forceps in inserted through a
paramedian incision and then utilized to perform
myotomies of the procerus, corrugator, and depressor
supercilii muscles (Fig. 3). Myotomy of the corrugator
muscles is performed both medial and lateral to the
supratrochlear bundle. Hemostasis is controlled with
electrocautery applied to insulated forceps. A 10 French
fluted drain is routinely placed across the supraorbital
brow and brought out through the right superior
postauricular scalp.
The release of the brow and forehead soft tissues
allows intrinsic elevation of the brow with posterior pull
of the occipital-galea-frontalis complex (Fig. 4).
Permanent Fixation
Using the measured desired amount of brow elevation
for the lateral canthus a fixation point is identified supe-
rior and posterior to the inferior edge of the incisions.
Two 2-0 polygalactin sutures are placed in the deep
temporal at this point and are then passed through the
dermis and temporoparietal fascia at inferior edge of the
incision. Manual advancement of the inferior temporal
flap by an assistant is performed as the two polygalactin
sutures are tied down and secured. This provides eleva-
tion of the lateral brow. The edges of the temporal inci-
sions are approximated with a 3–0 prolene suture in a
vertical mattress fashion and then closed with stainless
steel staples.
Medial and central brow fixation is performed by
placement of a 2-mm diameter (3.5-mm length) Mitek
Tacit titanium anchor (Ethicon, Westwood, MA) in
6FACIAL PLASTIC SURGERY/VOLUME 17, NUMBER 1 2001
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ENDOSCOPIC FOREHEAD LIFTING AND CONTOURING/ROMO ET AL. 7
Figure 3 Function elevation of the eyebrows by the
frontalis muscle after periosteal release and depres-
sor muscle myotomies.
Figure 4 (A) Extent of superiosteal dissection. (B,
C) Suspension technique involving suspension su-
tures to microscrew.
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each of the four fixation holes. These small screws are
fitted with a 2–0 Ethibond (Ethicon) suture. The free
end of the suture is threaded through the eyelet of a free
needle. Next, the needle is passed through the peri-
osteal/galeal soft tissue at the anterior extent of each
incision and brought out of the incision. The sutures are
tied down under direct vision so that the anterior extent
of the incision lies over the titanium anchor (Fig. 4C).
This provides exact elevation and fixation at the desired
brow height. The parietal incisions are closed with 3–0
prolene in a vertical mattress manner and supplemented
with stainless steel staples.
A soft, mildly compressive circumferential head
dressing is placed and removed along with the drain on
the first or second postoperative day. The patient is
instructed to place antibiotic ointment on the scalp
suture lines two or three times per day. On the fifth
postoperative day gentle hair washing is allowed. The
sutures and staples are removed on the second postoper-
ative week (Figs. 5,6).
8FACIAL PLASTIC SURGERY/VOLUME 17, NUMBER 1 2001
Figure 5 (A, B) Preoperative and (C, D) postoperative photographs after endoscopic forehead lift and contouring.
AB
CD
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DISCUSSION
Minimally invasive endoscopic brow surgery is gaining
wide popularity among facial plastic surgeons. This is
not surprising as there are decreased rates of scarring,
hypesthesia, edema, alopecia, and hematoma when
compared with the standard bicoronal technique.6The
drawback of this new technology is the lack of knowl-
edge of its long-term efficacy. Most reports acknowl-
edge the need for more long-term follow-up because
long-term efficacy at this time is not known.7-11
Many aesthetic surgeons use a periosteal and
muscular release at the orbital rims and permanent fixa-
tion of the elevated scalp as described previously, but it is
debatable if either is an essential step to permanently
achieve brow elevation. In fact, some promote a sub-
galeal dissection and fixation at the brow level to circum-
vent the periosteal release.12 Most authors do admit that
some form of mechanical brow elevation and stabiliza-
tion in the immediate postoperative period is necessary.
The optimal technique and duration of elevated
scalp stabilization is currently unknown. A multitude of
fixation techniques has been reported, including
biodegradable screws,13 fibrin glue,14 K-wire fixation,15
transcalvarial suturing or bone anchoring,16-19 and tem-
porary titanium screws. In fact, the recommended tim-
ing of screw removal can range from 3 days to 2 weeks
postoperatively. De La Fuente and Santamatia20 have
shown a 2- to 4-mm “relaxation”in brow position after
1 month with fixation by screws removed at 2 weeks.
This brings into question how reliably one can predict
brow position with temporary fixation.
We have previously investigated periosteal refixa-
tion in an animal model.21 Our results demonstrated
that significant re-adherence of the periosteum required
at least 6 to 12 weeks. In the process of re-adherence,
fibrous ingrowth into bony microfissures in the outer
cortex of the calvarium, bony remodeling, and thicken-
ing of the periosteum were noted. Although results
from an animal model are not directly applicable, this
study shows that reasonable fixation techniques would
have to at least encompass an analogous time period in
humans.22
To further investigate this hypothesis we per-
formed a retrospective analysis on 259 patients, 116
who underwent endoscopic forehead lift with subpe-
riosteal and muscular release and temporary fixation
with screws removed at 2 weeks and 143 who under-
went the same dissection with permanent fixation as
described previously. Patients in the temporary fixation
group were statistically more likely than those in the
permanent fixation group to have postoperative partial
loss of brow elevation (15.5 vs. 7%, p< 0.0005).
From our animal studies and case series perma-
nent fixation appears to be the best choice. The small
Mitek permanent fixation system is easily and quickly
placed and is well tolerated with minimal complica-
tions compared with the temporary screws. The main
disadvantages of this fixation method are the perma-
nence of the titanium implant and the additional cost
($200-$300, depending on the number of anchors
used). Although the actual time to periosteal adherence
in humans is unknown, the process of periosteal fibro-
ENDOSCOPIC FOREHEAD LIFTING AND CONTOURING/ROMO ET AL. 9
Figure 6 (A) Preoperative and (B) postoperative photographs after endoscopic forehead lift and contouring in a patient with
alopecia.
AB
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sis around bony spicules and bone remodeling observed
in the animal model would require at least several
weeks in humans as well. If this is the primary mecha-
nism of periosteal fixation in humans, semipermanent
or permanent devices/techniques would be logical
choices to maintain fixation of the elevated brow.
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