J Oral Maxhfac Surg

54569.577, 1996
Endoscopic Forehead Lift: Technique
and Case Presentations
CLARK 0. TAYLOR, MD, DDS,* JAMES G. GREEN, MD, DDS,t
AND DAVID P. WISE, MD, DDS*
Purpose: The advent of the endoscopic forehead lift has provided an alterna-
tive to the conventional open approach. This article describes the basic tech-
nique, with some modifications, and reports three clinical cases.
Results: The subperiosteal forehead technique rejuvenates the upper third
of the face with no scalp resection, minimal risks of hypesthesia, limited risk
of alopecia, reduced tissue trauma, small camouflaged scars, less bleeding
and edema, improved postoperative comfort, and faster recovery compared
with the standard open techniques.
Conc/usions: The endoscopic subperiosteal forehead lift is a useful tech-
nique for providing rejuvenation of the upper third of the face. It reduces or
eliminates forehead rhytids by eliminating the reflex contracture of the frontalis
and contributes to softening of the vertical glabellar rhytids. Longitudinal stud-
ies will be required to assess the effectiveness of this technique compared
with open techniques.
The introduction of endoscopic surgical procedures
has provided an alternative to traditional approaches
for performing facial cosmetic surgery. The endo-
scopic technique allows controlled, precise surgery
through small incisions placed in inconspicuous loca-
tions. The development of endoscopic equipment de-
signed for esthetic surgery now permits rejuvenation
of the upper third of the face with no excision of hair-
bearing scalp, elimination or reduction of visible scar-
ring, and decreased risk of alopecia, anesthesia, or hyp-
esthesia. The basic techniques for the endoscopic
forehead lift, with some modifications and clinical
cases, are presented.
Indications and Preoperative Evaluation
The rationale for performing a forehead lift is to
reestablish the esthetic balance between the upper and
* Associate Professor, University of Nebraska Medical Center,
Director of Institute of Facial Surgery, Bismarck, ND.
t Senior Oral and Maxillofacial Surgery Resident, Department of
Oral and Maxillofacial Surgery, University of Nebraska Medical
Center, Omaha, NE.
$ Senior Oral and Maxillofacial Surgery Resident, Department of
Oral and Maxillofacial Surgery, University of Nebraska Medical
Center, Omaha, NE.
Address correspondence and reprint requests to Dr Taylor: Insti-
tute of Facial Surgery, 416 N 6th St, Bismarck, ND 58501.
0 1996 American Association of Oral and Maxillofacial Surgeons
0278-2391/96/5405-0006$3.00/O
middle thirds of the face that have been lost because of
the aging process. The position of the brow represents. a
key anatomic structure in rejuvenation of the upper
third of the face. Elimination or reduction of transverse
and vertical rhytids of the forehead and nasal region
represents the second important component of the fore-
head lift. Critical evaluation of postoperative results
shows that perhaps the most important effect of fore-
head rejuvenation is not the magnitude of brow eleva-
tion or the precision of brow position, but the elimina-
tion of the tense forehead. This is the result of
proper depressor muscle resection and forehead tissue
elevation and fixation.
The indications for a forehead lift are represented
by the anatomic changes of the aging upper face. These
include brow ptosis; lateral hooding; hypertrophic or
hyperactive corrugator, frontalis, and procerus mus-
cles, creating a tense forehead; disruption of the
smooth sweep of the brow into the nose; brow skin
descending over the orbit (pseudoblepharochalasis);
brow asymmetry; and reduction of the distance from
the upper eyelid tarsal crease to the eyebrow.] Some
of these changes may interfere with the patients vision
and necessitate surgical correction. Another common
indication for forehead rejuvenation is a history of pre-
vious cervicofacial rhytidectomy. Many patients who
undergo a facelift operation do not have a simultaneous
forehead lift performed. Postsurgical results often ac-
569
570 ENDOSCOPIC FOREHEAD LIFT
centuate the difference between the rejuvenated lower
two thirds and the untreated upper one third of the
face.
The aging upper face develops as gravity pulls the
forehead tissues down over the supraorbital rims and
eyelids, creating the appearance that the patient is tired,
angry, or sad. Decent of brow skin over the upper
eyelid can lead to inappropriate or excessive upper
blepharoplasty if normal brow position is not reestab-
lished first. The upper eyelid skinfold may extend be-
yond the lateral canthus onto the lateral periorbital
region (lateral hooding) and represents a hallmark of
brow ptosis. The forehead musculature becomes re-
flexively hyperactive in an effort to reposition the eye-
brows to a normal position. The constant counter-
action between the brow elevators (frontalis and
corrugator muscles) and the depressors (orbicularis,
procerus, corrugator, and depressor supercilii muscles)
leads to the development of characteristic transverse
and vertical rhytids and the classic clinically tense
forehead. The tense forehead may result in the brow
being held in the normal position at rest. The chronic
contraction of the forehead muscles is an often over-
looked cause of frontal headaches. Eventually, the ver-
tical distance between the brows and the hairline in-
creases, disrupting the balance between the upper and
middle thirds of the face. The distance between the
upper eyelid crease and eyebrow is also noted to de-
crease.lT4
Evaluation of the patient for a forehead lift requires
an understanding of the variations between female and
male esthetics. In women, the highest point of the
arched brow should be at the lateral limbus or canthus
of the eye. The relationship of the brow with the medial
orbital rim should create a smooth Y-shaped curvature.
The brow should be positioned slightly above the su-
praorbital rim, and the forehead should have few or
no horizontal or transverse rhytids. Men normally have
the brow positioned at the supraorbital rim, and the
brow creates a T-shaped configuration with the medial
orbital rim. The brow appears horizontal or mildly
arched, and variable amounts of vertical and horizontal
rhytids are acceptable. In both men and women, the
medial and lateral brow margins should be at the same
height to avoid a surprised, sad, tired, annoyed, or
angry appearance.5
Sex, age, skin quality, hair quantity and quality, hair
pattern, hairline, eyebrow position and shape, presence
of forehead, glabellar, and nasal rhytids, motor func-
tion of the forehead musculature, and bony architecture
must be systematically evaluated.6 Thorough evalua-
tion leads to identification of specific anatomic prob-
lems, selection of the proper surgical approach, and
improved treatment results. Although the literature
contains specific numbers for the diagnosis of brow
ptosis (less than 2.5 cm from the midpupil to the upper
edge of the brow), deficient brow-to-hairline measure-
ment (less than 5 cm from the top of the brow to
the hairline), and deficient upper eyelid crease-to-brow
distance (less than 1.5 cm), the patients input before
surgery and the surgeons assessment at the time of
surgery remain critical factors.* However, these mea-
surements can assist the surgeon in determining which
areas require treatment and which surgical approach
should be used.
The indications for an endoscopic forehead lift are
the same as those for the traditional approaches. The
best candidates are 30 to 50 years of age, with limited
skin excess, who show the early or classic signs of
brow ptosis. The endoscopic procedure is also suitable
for older individuals with excess skin but who are
unwilling to accept the undesirable sequelae of tradi-
tional open approaches. The endoscopic technique of-
fers the following advantages: no scalp resection, mini-
mal risk of hypesthesialanesthesia, limited risk of
alopecia, less tissue trauma, small camouflaged scars,
less bleeding and edema, improved postoperative com-
fort, and faster recovery.-
Endoscopic Technique
The patient is initially positioned in the semisupine
position, and intravenous sedation is induced. Before
beginning the forehead dissection, 2% lidocaine with
epinephrine 1: 100,000 is infiltrated in all proposed in-
cision marks and in the region of the supratrochlear
and supraorbital nerves. A small volume of anesthetic
solution (approximately 30 mL) is infiltrated in the
subgaleal plane to facilitate the dissection and for addi-
tional anesthesia. Further discussion regarding the tu-
mescent technique can be found in the article by
Schoen et al.
Three sagittal incisions, through periosteum to bone,
are initially made approximately 1 to 3 cm posterior
to the hairline. In addition, two horizontal incisions
down to the deep layer of the superficial temporalis
fascia are made in the temporal hair-bearing region of
the scalp over the temporalis muscle (Fig 1). The
proper layer is identified by manipulating both edges
of the surgical wound and observing the scalp tissues
sliding directly over the deep layer of the temporalis
fascia. The incisions are made approximately 1 to 1.5
cm in length to allow introduction of the endoscopic
telescope and instrumentation.
The pericranium is elevated with periosteal dis-
sectors using a blind technique, taking care to avoid
tearing the periosteal layer during elevation of the flap.
The entire forehead region is elevated down to ,a point
approximately 3 cm above the bony orbital rim. Poste-
riorly, the entire scalp is elevated blindly in a subperi-
osteal plane to the attachment of the occipitalis muscles
and laterally into the suprahelical areas. The endoscope
TAYLOR, GREEN, AND WISE
FIGURE 1. Artist rendition of the five incisions needed for the
endoscopic brow technique. Incisions 1 and 3 are parasagittal inci-
sions, incision 2 is a midsagittal incision, and incisions 4 and 5 are
temporal incisions (fifth incision is not shown).
is then inserted through one of the three sagittal access
ports to allow completion of the forehead dissection
under direct visualization in a color monitor (Fig 2).
The dissection is accomplished throughout the re-
maining extent of the forehead and in the area of the
supratrochlear and supraorbital neurovascular bundles
(See Fig 3 for overlying anatomy). Visualization is
optimized with saline irrigation, and suction is pro-
vided by a Frazier tip inserted into one of the open
sagittal incisions. Using soft tissue dissectors, the neu-
rovascular bundles are identified (Fig 4). Once the neu-
rovascular bundles are identified, the corrugator and
procerus muscles are directly visualized through the
endoscope, and they are either avulsed with a biting
instrument or their dermal attachments are transected
while taking care to avoid the neurovascular structures
in the area (Fig 5). Care is taken during this portion
of the procedure to avoid damage to the subcutaneous
or dermal tissues.
The temporal dissector is now inserted through the
temporal incision into the plane just superficial to the
deep layer of the superficial temporalis fascia. Under
direct visualization, the temporal dissector is used to
transect the temporalis fascial attachments along the
I3
FIGURE 2. A, Intraoperative view of endoscope and dissector in
place. B, Artist rendition of endoscope in the subperiosteal tissue
plane.
572 ENDOSCOPIC FOREHEAD LIFT
FIGURE 3. Artist rendition of the pertinent overlying anatomy in
the region where the endoscopic brow lift procedure is performed
(not shown are the corresponding arterial and venous counterparts
and the frontal branch of the facial nerve).
FIGURE 5. View through the endoscope showing the endoscopic
biting forceps resecting the corrugator supercilii muscle.
temporal crest and thus release the scalp flap from the
temporal crest region (Fig 6). Maintaining a proper
tissue plane is extremely important during this portion
of the procedure to avoid damage to the frontal branch
of the seventh cranial nerve. The temporalis fascial
attachments are released posteriorly until the entire
temporal and frontal flaps are mobile. Reference points
are marked on the bony skull at the anterior extent of
the coronal sagittal incisions and at the planned poste-
rior movement position using rotary air-driven instru-
mentation. The average posterior positioning in the
midsagittal region is 8 to 10 mm, whereas in the para-
sagittal region this movement is 10 to 12 mm. Using
skin hooks, the scalp is advanced posteriorly, and
screw holes are placed at the posterior reference mark.
Care is taken to recognize penetration through the outer
cortex to avoid perforation into the dural sinus or into
the brain. Luhr (Howmedia Inc, Rutherford, NJ) pan-
fixation screws are then inserted through the anterior
extent of the scalp flap into the prepared posterior hole
to anchor the scalp in a posterior position while simul-
taneously observing the brows for ideal orientation.
Traction is then placed in the temporal region to elimi-
nate any lateral hooding and to allow a smooth transi-
tion between the temporal and facial regions. This ad-
vancement in the temporal region is secured by
anchoring the anterior extent of the incision to the
temporalis fascia using a Maxon or .PDS (D & G
Monofil Inc, Manati, Puerto Rico) suture.
Should bleeding be encountered during any segment
of the procedure, it is easily controlled with electrocau-
tery. The sagittal and temporal incisions are then closed
with either staples or 4-O nylon sutures. A light pres-
sure dressing is placed for 48 hours. The patient is
given preoperative antibiotics and is maintained on
postoperative antibiotic therapy for 7 days. The cuta-
neous sutures are removed at 7 days, and the percutane-
ous cranial screws are removed at 12 to 14 days. After
the initial 48 hours, and for an additional 2 weeks after
FIGURE 4. View through the endoscope showing the supraorbital
neurovascular bundle and the endoscopic dissector.
FIGURE 6. View through the endoscope showing the temporal
dissector perforating through the junction of the temporalis fascial
attachments along the temporal crest region (lower right) to release
the scalp flap.
TAYLOR, GREEN, AND WISE
573
removal of screws, an elastic forehead dressing, such
as a tennis headband, is worn at night until full adher-
ence of the periosteum to the cranium is noted.
Report of Cases
Case 1
A 35-year-old white woman had features of an aging face,
including brow ptosis, herniated lower eyelid fat pads, and
lateral eyelid laxity, along with a indistinct mentocervical
angle (Fig 7). She underwent the following procedures: en-
doscopic forehead lift with corrugator resection, transcon-
junctival preexcision lower lid blepharoplasty, and sub-
mental liposuction. Her preoperative and postoperative
photographs demonstrate substantial improvement in her fa-
cial appearance. Note the significant decrease in the vertical
glabellar rhytids and lack of reflex contraction of the frontalis
muscle.
Case 2
A 67-year-old white woman presented 10 years after a direct
browlift with severe glabellar rhytids and medial brow ptosis
(Fig 8). She underwent an endoscopic forehead/brow rejuve-
nation technique with procerus and corrugator supercilii
muscle resection. Note the lack of significant forehead rhyt-
ids in the postoperative photographs, which were present
preoperatively.
Case 3
A 45-year-old woman presented with brow ptosis and corru-
gator hyperactivity (Fig 9). She underwent an endoscopic
forehead/brow rejuvenation technique with brow elevation
and corrugator resection.
Discussion
The endoscopic forehead technique is in its infancy,
and a number of different approaches and techniques
have been used with modifications being incorporated
on a trial-and-error basis. Incision design, tissue plane
approach, necessity for disruption of the frontalis mus-
cle, and tissue stabilization methods represent current
areas of controversy. With continued experience and
further research, the endoscopic approach will continue
to evolve and become more standardized.
The endoscopic forehead lift can be adequately per-
formed through the five incisions described. T-shaped,
chevron, and straight sagittal incision designs also have
been described. We favor the straight sagittal and para-
sagittal incisions over the T-shaped and chevron de-
signs because they can be closed with minimal diffi-
culty, are more esthetic, do not require scalp excision
with forehead repositioning, and carry a lower risk of
alopecia.
Although both subperiosteal and subgaleal ap-
proaches can be performed with the endoscopic tech-
nique, the subperiosteal plane has several advantages.
It is safe, quick, and can be done in a blind fashion
over a large percentage of the forehead. The lymphatic
and vascular channels are not disrupted, thereby pro-
ducing less edema and hemorrhage. Maintenance of
the lymphatics also permits early resolution of the sur-
gical edema. The subperiosteal approach allows for
creation of a nearly bloodless optical chamber, which
improves visualization of critical anatomic structures
(supratrochlear and supraorbital nerves, a small branch
of the superficial temporal artery associated with the
fat pad containing the frontal branches of the facial
nerve and the corrugator and procerus muscles). The
periosteum can also be elevated down to or slightly
beyond the supraorbital rim. Additionally, the perios-
teum is inelastic, and the released periosteum allows
effective traction for forehead and brow repositioning.
Readaptation to the cranium appears to be faster, giv-
ing earlier stability to the elevated tissues, and the
subperiosteal approach is less likely to suffer from
stress relaxation. The normal gliding mechanism of the
occipitalis-frontalis muscle is preserved, maintaining a
dynamic and stable brow position.
Access to the procerus and corrugator muscles is
excellent with either the subperiosteal or subgaleal ap-
proach. Resection can be accomplished easily after the
supratrochlear and supraorbital nerves have been iden-
tified and isolated. Partial or complete resection of
these muscles results in elimination or improvement
of the vertical glabellar and transverse nasal rhytids.
The muscle-dermis junction is easily identified, and
care should be used to avoid damage to the dermal
and cutaneous layers. External cutaneous depressions
have not been a problem, and fat grafts to replace the
resected muscle have not been necessary. Redraping
of the forehead tissue without depressor muscle resec-
tion is not advocated because the hyperactive muscle
activity is not eliminated and may reappear with adher-
ence of the periosteum to the cranium or the subgaleal
tissues to the pericranium.
Treatment of the frontalis muscle is controversial,
and some surgeons do not believe that sectioning or
scoring of the frontalis muscle is required or advisable.
The frontalis muscle is the primary elevator of the
brow, and diminishing its effect is not advantageous.
Proper brow and forehead repositioning appear to re-
duce frontalis hyperactivity and provide gradual im-
provement in the forehead rhytids and elimination of
the clinically tense forehead. In addition, elimina-
tion of the antagonistic effect of the forehead depressor
muscles further diminishes frontalis activity.
Posterior dissection of the parietal and occipital por-
tions of the scalp can be performed in either the subperi-
osteal or the subgaleal plane. Release in either plane
allows posterior sliding of the scalp and soft tissue
contracture. Hemorrhage, hypesthesia, and alopecia are
of minimal concern with either method.
HEAD LIFT
FIGURE 7. Case 1. Patient with an aging face showing brow ptosis, herniated lower eyelid fat pads and lateral eyelid laxity with an indistinct
mentocervical angle. A, Preoperative relaxed view. B, Preoperative frown. C, 6-month postoperative relaxed view. D, Postoperative frown.
TAYLOR, GREEN, AND WISE
FIGURE 8. Case 2. Sixty-seven-year-old woman who had a direct browlift performed approximately 10 years earlier. Note her recurrent
glabellar rhytids and medial brow ptosis. A, Preoperative relaxed view. B, Preoperative frown. C, h-month postoperative relaxed view. 0,
Postoperative frown.
576 ENDOSCOPIC FOREHEAD LIFT
FIGURE 9. Case 3. Patient with brow ptosis and corrugator hyperactivity. A, Preoperative relaxed view. B, Preoperative frown. C, 6-month
postoperative relaxed view. D, Postoperative frown.
TAYLOR, GREEN, AND WISE
Techniques for forehead and scalp fixation have
used sutures, miniscrews, or a combination of both.
Our technique precisely fixes the tissue directly to the
cranium with 1.7~mm diameter vitallium miniscrews
at the midsagittal and parasagittal incisions. Mini-
screws can be selected by length to match the level of
the scalp so as to reduce visibility and avoid interfer-
ence with daily hair hygiene. The concomitant use of
suspension sutures is eliminated, and the concern about
suture slippage or breakage is negated. The scalp tissue
does not react adversely to the vitallium miniscrews,
and removal can be accomplished without local anes-
thesia. When combined with the sagittal incisions,
scalp excision is not required, the risk of alopecia is
minimal, and wound closure is simple and esthetic.
The risk of entering the cranial vault or sagittal sinus
is minimal if the appropriate equipment and technique
are used. Suspension sutures are used to reposition the
lateral orbital and temporal tissues at the appropriate
level by attachment to the temporalis fascia.
The use of the endoscopic technique can be limited
by a number of predisposing factors. Significant
fronto-orbital bony irregularities that require extensive
recontouring and the need for excision of skin preclude
the use of the procedure. The presence of an exces-
sively high hairline (>6.0 to 6.5 cm from the brow)
also precludes any technique that will further lengthen
the forehead. The thick or tight skin and prominent
frontal and periorbital attachments in Asians, Ameri-
can Indians, and Latinos make elevation difficult, even
with open techniques. Other limiting factors include
the learning curve required to achieve optimal results,
use of new instrumentation, staff training, and the asso-
ciated overall investment.
Endoscopic and open forehead lift procedures are not
without possible complications and postoperative prob-
lems. However, certain postoperative problems may be
less frequent or totally avoidable with the endoscopic
technique. Anesthesia or hypesthesia associated with
coronal or trichophilic incisions are minimal or nonexis-
tent because the incisions are placed parallel to the sen-
577
sory nerves and dissection is subperiosteal. Alopecia is
also avoidable because there is minimal damage to hair
follicles, skin excision is not required, and there is less
tension on the scalp, reducing ischemia. Scarring is min-
imized because the incisions are hidden in the scalp,
small, and easily closed with simple techniques. Infec-
tion, hematoma, unsatisfactory contours, suboptimal
correction, skin slough, xerophthahnia, and cranial
nerve V (supratrochlear and supraorbital nerves) and
cranial nerve VII (frontal branch) injuries are possible
complications related not to a specific surgical approach,
but rather to improper operative technique and surgeon
error. Currently, no long-term studies exist to document
the potential for, and rate of, relapse of brow ptosis with
the endoscopic technique.
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