Endoscopic Brow Lift
One of the advances in cosmetic surgery in the last twenty years has been an understanding of the part the brow and the forehead play in the appearance of the eyes and upper face. When looking at the upper eyelids for signs of ageing we may notice folds of redundant skin or pouting bags of extra fat, especially in the inner parts of the upper eyelid. However, one should also pay attention to the position of the eyebrow. The youthful eyebrow should lie above the level of the bony edge of the orbit, which can easily be felt. If the eyebrow descends to or below this level it crowds the upper eyelid by pushing the skin and fat into that space. An accurate appreciation of how much the appearance of ageing in the upper eyelid is caused by excess skin and fat in the eyelids itself, can only be made when the eyebrow is held back in its youthful position above the edge of the orbit.
It can be seen from this that sometimes correction of the appearance of ageing in the upper eyelid may also require correction of the appearance of the brow and indeed there are many instances where repositioning the brow reveals a relatively youthful upper eyelid that needs no further surgery.
The brow changes position in life for a number of potential reasons. Some people have brows that are naturally lower than the average and may especially be lower in their outer aspects producing some hooding appearance of the eyes. In others, and most commonly, the brow position is the result of a struggle between muscles of facial expression some of which pull the brow downwards and some of which pull the brow upwards. Those that pull the brow downwards often also pull the eyebrows together causing the vertical frown lines on the forehead above the bridge of the nose. These are often the same muscles that maybe deliberately weakened using Botox whose affect is both to smooth out these frown lines and by weakening the muscles that pull the brow down to allow the brow to rise somewhat. This effect however maybe relatively mild and a more satisfactory solution for the descended brow (and sometimes for the overactive frown muscles) is a brow-lift.
Brow lifting simply refers to the process of moving the front part of the scalp and brow up and backwards, and fixing it into position by some means. This was originally done with a long incision across the top of the head, removing a strip of skin and pulling the brow backwards. This was known as bicoronal brow-lift and whilst very effective had the disadvantage that it left an area of profound numbness on the top of the head and a scar that might be visible even through the hair.
In more recent years the endoscopic brow-lift has come about and this is an extension of keyhole surgery. Through a number of small incisions at the front of the hair bearing scalp (usually four short incisions) a small surgical endoscope is placed under the skin of the forehead and using instruments placed through one of the adjacent small incisions the brow is gently dissected off the attachments to the bone above the orbit. When this has been achieved with careful preservation of the nerves the brow can be repositioned. During this dissection it is also possible to deliberately and permanently weaken some of the muscles of frowning. Once the brow has been completed freed it is fixed in place whilst healing occurs and usually in my practice this is done by some form of attachment of the brow at the level of the hairline, usually by suture anchored or passed through bone.
Endoscopic brow-lift is a reliable and safe procedure, although like all surgery some risks must be acknowledged. Usually the patient will be discharged the following day (depending on what other surgery they have had) and will be seen again at one week when the small clips used to close the small incisions at the edge of the hairline are removed. Sometimes there is also an incision above and in front of the ear, which serves to reposition the outer aspect of the brow and these incisions also bear clips which require removal at a week.
Bruising is relatively unusual with this procedure unless other elements of eyelid surgery or face lifting have also been conducted, and healing is usually very predictable. Unintended consequences or complications that can occur are some infection in the wound, bleeding (very rare), and as the small incisions at the front of the hairline heal there may be one or two areas where hair follicles are lost, although this is usually temporary and hard to see. The scars are usually fine and of good quality but occasionally when feeling them one may feel a slight depression in the region of the scar. It is not uncommon to lose some feeling on the front part of the scalp, although this usually returns in about six months to a year. It is of no functional consequence.
The most feared complication and one that is extremely rare is weakness of the forehead in an unpredictable manner due to injury to the nerves of the forehead. This is an unusual consequence but if it does occur is likely to be transient, but it has to be acknowledged that in very rare cases it can be permanent.
In summary endoscopic brow-lift is a relatively modern technique which allows that component of facial ageing that is due to the brow to be corrected and has improved greatly the outcome of surgery to rejuvenate the upper face and eyes, is reliable and very rarely has any significant complication.