One hundred cases of endoscopic brow lift

Comparison of the effectiveness and safety of the "endoscope-assisted polypropylene mesh lift" and "gliding brow lift" techniques for the treatment of lateral brow ptosis

BACKGROUND

There are many techniques used to treat lateral brow ptosis. This study compared two techniques that are used for lateral brow rejuvenation in terms of effectiveness and safety-namely, endoscope-assisted polypropylene mesh lift (EAML) and gliding brow lift (GBL).

METHOD

Eighty-six patients who underwent brow lift surgery between March 2018 and June 2020 were included in this retrospective study. Forty-four patients were operated on using the EAML technique, whereas 42 patients were operated on using the GBL technique. The measurement of defined distances in photographs was carried out using a software, and the Brow Positioning Grading Scale (BPGS) and Global Aesthetic Improvement Scale (GAIS) were applied in the pre and postoperative periods.

RESULTS

The measurement results obtained in the postoperative period were better than those obtained in the preoperative period for both the techniques, whereas the results obtained at postoperative month 3 were found to be better than those obtained at month 12 (p < 0.05). The results were similar between the measurements at postoperative months 3 and 12 for both the techniques. The loss of brow height from postoperative months 3-12 was greater in the GBL group (p < 0.05). The postoperative scores on the BPGS were found to be better in both techniques than the preoperative scores (p < 0.05). The GAIS score at postoperative month 12 was found to be better in the EAML group. The two groups had similar rates of complications.

CONCLUSION

The two techniques were found to have similar effectiveness and safety profiles for brow rejuvenation.

LEVEL OF EVIDENCE: 4

Brow gliding: A new non-surgical concept for almond upturned eyes

BACKGROUND

The eyes are one of the most prominent features of the face. To date, a vast majority of procedures have been described for periorbital rejuvenation. Among them, non-surgical threading is an alternative and minimally invasive technique.

OBJECTIVE

We developed a new non-surgical threading technique to achieve long-lasting almond-shaped upturned eyes with brow lifting that we call "brow gliding". We developed a new non-surgical threading technique to achieve long-lasting almond-shaped upturned eyes with brow lifting that we call "brow gliding". Here, we present details of our procedure and the clinical experience of our patients who have at least a 6-month follow-up period.

METHODS AND MATERIALS

We used polydioxanone cog threads in combination with knots to lift the lateral sides of the brows and eyes. By burying these knots in the subcutaneous tissue and extending the threads to the scalp fascia, we were able to spread the load of the threads over multiple stable structures in order to achieve an effective lifting impact.

RESULTS

According to the subjective assessment scale, all patients described the improvements as very good or beyond expectations after the procedure. During the follow-up period, 4 of 34 (11.8%) patients stated it was very good and 19 of 34 (55.9%) patients stated that it was still beyond expectations.

CONCLUSION

The Brow Gliding technique is a promising office-based cosmetic procedure for periorbital aesthetics with a prominent outcome and minimally invasive fashion.

An Algorithm for Correction of the Aging Upper Face

As the approach to the upper face has evolved in recent years, so has the focus of aesthetic brow procedures. Brow position was the primary focus early in the late twentieth century, with the coronal brow lift the primary means of surgical correction. In more recent years, improving or maintaining brow shape has taken on greater importance and has increasingly been addressed by contemporary techniques. These include the endoscopic, temporal, direct, gliding approaches as well as nonsurgical brow lifts. As each patient has individual facial characteristics and expectations, every technique comes with a unique set of indications.

Short- and Long-term Patient Satisfaction and Complications in 650 Endoscopic Forehead Lift Procedures

PURPOSE

The aims are to compare short- versus long-term patient satisfaction and report temporary versus permanent complications in 650 patients with endoscopic forehead lift procedure (EFL).

METHODS

This is a retrospective study on all of the consecutive patients with EFL. Patients with previous trauma and surgery and less than 2 years follow up were excluded. Short- (6 months) and long-term (≥2 years) patient satisfaction (visual analog score [VAS], 0-100) were recorded. Patients' perspectives on temporary versus permanent complications were also documented.

RESULTS

Mean age and follow up were 46.4 and 7.1 (2-13) years, respectively. Long-term satisfaction (79.9) was significantly lower than the short term (96.6). The long-term satisfaction decreased in 95.7%, increased in 2.7%, and remained the same in 1.6% of the patients. Intraoperative skin laceration occurred in 3 patients (0.5%). Mean time of forehead numbness recovery was 2.3 months. Temporary complications were itching (13.7%), headache (6.3%), unilateral facial nerve palsy (5.8%), acne (3.2%), and remained staples (1.7%). Permanent complications included undercorrection (7.1%), alopecia (4.2%), forehead irregularities (2.3%), surprised look (2.2%), incision site complications (2%), and glabellar depression (0.9%). Reoperation (1.2%) was performed for undercorrection and alopecia. While short-term satisfaction was significantly lower in patients with temporary facial nerve paresis, long-term satisfaction was lower in patients with undercorrection and reoperation.

CONCLUSION

A high satisfaction scores of 96.6 and 80 were observed in the short- and long-term follow up after the EFL. Frequency of temporary and permanent postoperative complications was 30.3% and 15.8%. Reoperation rate was 1.2%.

Investigating Long-Term Brow Stabilization by Endotine-Assisted Endoscopic Brow Lift with Concomitant Upper Lid Blepharoplasty

OBJECTIVE

To determine whether Endotine-assisted endoscopic brow lift with concomitant upper lid blepharoplasty provides long-term brow elevation.

METHODS

Pre- and post-operative photographs from 35 patients who underwent endoscopic brow lift using Endotine Forehead 3 mm implants with concomitant upper lid blepharoplasty were measured to determine changes in brow height with surgery and up to 55 months post-operatively. Photographs of 20 control subjects who did not undergo periorbital surgery and 11 control subjects who underwent upper blepharoplasty without brow lifting were also measured to provide a basis for comparison. Emotrics software was used to perform automated brow height measurements in order to determine elevation and longevity achieved with endoscopic brow lifting in conjunction with upper lid blepharoplasty.

RESULTS

There was a statistically significant increase in brow height post-operatively, averaging 1.6 mm (P < .0001, 95% confidence interval 0.95-2.18 mm). Fifty-four percent of patients had follow-up beyond 6 months post-operatively and 40% had follow-up beyond 1 year. Elevation remained stable over time with no statistically significant change across all serial post-operative visits. There was no statistically significant difference in brow elevation based on gender or age, or between right and left sides.

CONCLUSION

Endotine-assisted endoscopic brow lift in conjunction with upper lid blepharoplasty provides modest brow elevation and long-term brow fixation as demonstrated by stable post-operative brow height measurements for up to 55 months.

Techniques of Eyebrow Lifting: A Narrative Review

None of brow lift techniques are completely satisfactory because of their limited effectiveness, lack of longevity, and potential complications. The aim of this study was to provide a comprehensive review of the literature on the pros and cons of the most popular techniques in brow and forehead lift. Relevant original articles in the PubMed database (English language) were sought using the search terms “eyebrow lift", “forehead lift", "periorbital rejuvenation", "eyebrow ptosis", "blepharoplasty and eyebrow change", "surgical eyebrow lift", and "non-surgical eyebrow lift", No date limitation was considered. Titles and abstracts were scanned to include the most pertinent articles. Subsequently, full texts of included articles (111 articles) were skimmed and finally 56 references were selected for the review. A narrative synthesis of data was finally undertaken with particular attention to the indications, techniques, and common complications of the eyebrow lift procedures. Ten popular techniques including two non-surgical methods (Botulinum toxin A and soft tissue fillers) were reviewed in this article. In general, non-surgical methods of forehead/brow lift are temporary, need less experience and correction would be easier should any complication occur. Surgical methods are divided into three categories: trans-blepharoplasty eyebrow lift, direct eyebrow lift, and trans-forehead eyebrow/forehead lift. Currently, the most popular method is the endoscopic forehead lift approach even though its longevity is limited. Direct brow-lift is particularly useful in patients with facial palsy and those who are more likely to be accepting of the scar (male gender, high forehead hair line).

Aesthetic analysis of the ideal eyebrow shape and position

The aesthetic importance of the eyebrow has been highlighted for centuries. In this paper, we investigated ideal eyebrow. Eyebrows and eyelids, varies among different races, ages and genders. It is considered to be of primary importance in facial expression and beauty. We present one form of the ideal eyebrow aesthetic and discuss methods of optimising surgical results. For the modern acceptable concept of the ideal brow, the medial brow should begin on the same vertical plane as the lateral extent of the ala and the inner canthus and end laterally at an oblique line drawn from the most lateral point of the ala through the lateral canthus. The medial and lateral ends of the brow lie approximately at the same horizontal level. The apex lies on a vertical line directly above the lateral limbus. Individual perceptions and expectations also differ from person to person. The brow should over lie the orbital rim in males and be several millimetres above the rim in female. Male tend to have a heavier, thicker brow with a little arch present. There are some pitfalls in brow aesthetics. Overelevation creates an unnatural, surprised and unintelligent look which is the most common surgical mistake in brow lifting. Medial placement of the brow peak would create an undesired 'surprised' appearance. Moreover, a low medial brow with a high lateral peak induces an angry look. Overresection of the medial brow depressors may lead to widening and elevation of the medial brow, which creates an insensitive look and can also lead to glabellar contour defects. It is impossible to define an ideal eyebrow that is suitable for every face. However, one must consider previously described criteria and other periorbital structures when performing a brow surgery.

Complications of browlift techniques: a systematic review

BACKGROUND

There is ongoing debate over which surgical technique is the safest for brow elevation.

OBJECTIVES

The authors outline complication rates for a variety of open and endoscopic browlift techniques based on the results of a literature review.

METHODS

The following databases were searched to capture relevant studies: MEDLINE, EMBASE, CINAHL, LILACS, Web of Science, Cochrane Libraries, controlled-trials.com, and clinicaltrials.gov. Eighty-two studies met the inclusion criteria. Assuming between-study heterogeneity due to the limitations and biases inherent to case series, a random-effects model was used to calculate weighted proportions. Pooled weighted proportions with 95% confidence intervals were determined.

RESULTS

All open and endoscopic procedures are associated with a variety of complications. Unacceptable scarring and paresthesia are the most common complications among all surgical browlifts. For anterior hairline incision with subcutaneous dissection, alopecia occurred in 8.5% of patients, paresthesia in 5.4%, unacceptable scarring in 2.1%, and skin necrosis in 1.8%. For coronal incision with subgaleal dissection, unacceptable scarring occurred in 3.6% of patients, hematoma in 0.5%, and infection in 0.2%. Endoscopic techniques with subperiosteal dissection had the highest complication rates: 6.2% for paresthesia, 3.6% for asymmetry, 3.0% for alopecia, and 2.7% for lagophthalmos.

CONCLUSIONS

Although complication rates vary with respect to incision site and plane of dissection, endoscopic techniques are associated with a larger variety of complications than open approaches. The findings should be interpreted with caution due to the limitations inherent to a case series. A well-designed comparative study is needed to evaluate the "true" rate of complications among the various browlift techniques.

LASIK world literature review: quality of life and patient satisfaction

PURPOSE

To analyze the patient reported outcome of satisfaction after LASIK surgery.

DESIGN

Systematic review.

PARTICIPANTS

Patient data from previously reported studies.

METHODS

A literature search conducted for the years 1988 to 2008 that included pertinent LASIK surgery information from the review of 2915 retrieved citations. All abstracts from these citations were reviewed and 1581 were deemed to be relevant for review. Complete copies of each of these relevant (1581) articles were obtained, and after thorough analysis each was rated based on the strength of the study design and weight of evidence. A level I rating was assigned to properly conducted, well-designed, randomized clinical trials; a level II rating to well-designed cohort and case-control studies; and a level III rating to case series, case reports, and poorly designed prospective and retrospective studies. Level I and II rated, peer-reviewed articles were entered into a database, and level III articles were eliminated. A total of 309 articles were incorporated into this database, representing level I and level II well-controlled studies of primary LASIK surgery.

MAIN OUTCOME MEASURES

Patients' satisfaction rates and factors associated with dissatisfaction.

RESULTS

Nineteen of the 309 database articles (6.1%) reported on both patient quality of life and satisfaction and together encompassed a total of 2198 subjects. The procedures from these 19 articles took place between 1995 and 2003. The overall patient satisfaction rate after primary LASIK surgery was 95.4% (2097 of 2198 subjects; range of patient satisfaction for the 19 articles was 87.2%-100%). The patient satisfaction rate after myopic LASIK was 95.3% (1811 of 1901 patients), and after hyperopic LASIK was 96.3% (286 of 297 subjects).

CONCLUSIONS

Based on this review, worldwide, an average 95.4% of patients were satisfied with their outcome after LASIK surgery. With 16.3 million procedures performed worldwide, and more than a decade of clinical studies and technological innovation, LASIK surgery should be considered among the most successful elective procedures. LASIK surgery compares more favorably with other elective surgical procedures in terms of generally higher satisfaction rates.

Periosteal fixation during subperiosteal brow lift surgery

OBJECTIVE

To report the efficacy of periosteal fixation combined with Y-to-V scalp incisions during small-incision subperiosteal forehead and brow lift.

METHODS AND MATERIALS

This is a retrospective case series of 19 patients over 12 months; 16 patients underwent bilateral and 3 unilateral surgery. Unilateral surgery was performed in patients with facial nerve palsy and was augmented with cable suspension. Superior arcus marginalis release and visualization of the supraorbital nerve was achieved using an endoscope or a transblepharoplasty approach.

RESULTS

All patients achieved a desirable brow lift and contour, with a mean lift of 2.4 +/- 1.0 mm. The mean follow-up was 11 months. During follow-up, there was no evidence of recurrence of brow ptosis. All patients had an improvement of the glabellar furrows. Minor complications included transient diplopia (n=1), reduced medial upper eyelid sensation (n=1), brief postoperative bleeding from one of the small-incision sites (n=1), and persistent sensory loss involving the central scalp incisions (n=2). No long-term alopecia was noted in any case.

CONCLUSION

Our results suggest that with periosteal fixation combined with Y-to-V scalp incisions, bone fixation is not necessary to achieve a desirable height during small-incision subperiosteal forehead and brow lift.

In vitro characteristics of a bioabsorbable suspension screw and suture system for endoscopic brow lift surgery

The time requirement for endoscopic subperiosteal brow lift fixation is as little as 10-14 days. Many types of bioabsorbable fixation have been applied to this procedure, including bioabsorbable suture coupled with a bioabsorbable bone anchor, with excellent outcomes. Typically, the anchor and suture materials differ, each having their own hydrolytic strength loss profile. The dynamic relationship between the instantaneous state of degradation of the bone anchor and the suture components can affect fixation strength and failure mode, a poorly understood phenomenon. We examined the use of 2x5 mm PLLA-PGA (82:18) copolymer screws containing a suture eyelet in the head, paired with one of four types of bioabsorbable suture (2-0 and 3-0 Vicryl and 2-0 and 3-0 PDS-II), in a model system designed to mimic brow lift fixation. Constructs were inserted into a synthetic bone substrate and incubated in pH 7.4 buffer at 37 degrees C for up to 3 weeks, then loaded to failure. Initial failure loads were dependent upon suture size but not suture material, with 2-0 suture constructs (63-70N) failing at twice the load of the 3-0 suture constructs (30-35N). The following 3 week strength retentions were obtained: 40-55% for 2-0 and 3-0 Vicryl suture, 100% for 3-0 PDS-II suture, and 58% for 2-0 PDS-II suture constructs. The predominant failure mode was suture breakage at the knot, with the later intervals utilizing 2-0 PDS-II suture including some screw head failures. This suspension screw, when coupled with an appropriate suture, appears to have suitable mechanical properties for endoscopic brow lift fixation.

Ophthalmic Management of Facial Nerve Palsy: A Review

Facial nerve palsy affects individuals of all ages, races, and sexes. Psychological and functional implications of the paralysis present a devastating management problem to those afflicted, as well as the carriers. Since Sir Charles Bell's original description of facial palsy in 1821, our understanding and treatment options have expanded. It is essential that a multidisciplinary approach, encompassing ophthalmologists; Ear, Nose, and Throat surgeons; plastic surgeons; and psychologists work closely to optimize patient management in a staged approach. Although the etiology remains unknown, strong histological, cerebral spinal fluid, and radiological evidence suggests a possible association with herpes simplex virus in idiopathic facial nerve palsy (Bell's palsy). The use of steroids has been suggested as a means of limiting facial nerve damage in the acute phase. Unfortunately, no single randomized control trial has achieved an unquestionable benefit with the use of oral steroid therapy and thus remains controversial. In the acute phase, ophthalmologists play a pivotal role in preventing irreversible blindness from corneal exposure. This may be successfully achieved by using intensive lubrication, medical therapy (botulinum toxin), or surgery (upper lid weighting or tarsorraphy). Once the cornea is adequately protected and recovery deemed unlikely, longer term planning for eyelid and facial reanimation may take place in an individualized manner. Onset is sudden and management potentially lengthy. Physician empathy, knowledge, and experience are essential in averting long-term lifestyle and psychological discomfort for patients.

Small incision subperiosteal and trans-blepharoplasty forehead and browlift

The purpose of the study is to evaluate the safety and efficacy of non-endoscopic, small-incision subperiosteal forehead and browlift in patients undergoing associated upper eyelid blepharoplasty. This is a retrospective, non-comparative case series of 14 consecutive patients in 12 months. Eleven patients underwent bilateral and three unilateral surgery. Unilateral surgery was performed in patients with facial palsy and was augmented with cable suspension. The technique involves five small scalp incisions to create a single subperiosteal and deep temporal cavity. Superior arcus marginalis release and direct visualisation of the supraorbital nerve was achieved via a trans-blepharoplasty approach. All patients achieved a desirable browlift and contour. Follow up ranged from 2 to 40 weeks. Minor complications included transient diplopia (1), reduced upper eyelid sensation (1), and brief postoperative bleeding from one of the small incision sites (1). Small incision and trans-blepharoplasty forehead and browlift is a safe and effective method to achieve a cosmetically desirable browlift in patients that require associated upper eyelid blepharoplasty, using standard oculoplastic equipment without the need for an endoscope.

Video-Assisted Endoscopic Transtemporal Multilayer Upper Midface Lift (MUM-Lift)

Minimally invasive surgery has been used successfully recently to improve brow ptosis and forehead rhytids. Because the face tends to age more vertically, rather than obliquely, it makes sense to perform the correction in a more vertical direction. Therefore, the authors introduce a video-assisted endoscopic transtemporal approach to allow a multiplanar (subperiosteal, sub-SMAS, and subcutaneous) vertical upper midface elevation (MUM-Lift) avoiding extensive lateral temporal and preauricular incisions. Between 1996 and 2003, 53 patients (8 males, 45 females; age, 47 +/- 6 years) underwent MUM-Lift. This includes simultaneous forehead lift, blepharoplasties and video-assisted transtemporal sub-SMAS and subcutaneous upper midface tissue release, vertico-lateral repositioning, and fixation. Using the various planes of release in the midface produces less tension on each layer and provides a natural and improved facial rejuvenation of the forehead, as well as of the upper midface. The results confirmed that limited incision forehead-plasty techniques in combination with a transtemporal sub-SMAS and subcutaneous upper midface lift (MUM-Lift) reduces unnecessary vascular compromise on any particular layer and can be safely and predictably performed over the zygomatic muscle. This newly introduced procedure is an exciting feature that has evolved into a useful modality. It provides natural and improved facial rejuvenation.

The direct brow lift: efficacy, complications, and patient satisfaction

BACKGROUND/AIMS

The direct brow lift operation can be used to treat brow ptosis arising from either involutional changes or facial nerve palsy. The authors reviewed their experience with this operation to establish its efficacy and complication rate in the light of concerns over poor scar cosmesis and forehead paraesthesiae in the postoperative period.

METHODS

A retrospective review of patients undergoing direct brow lifting from 1989 to 2002 was conducted, and information gained on patient satisfaction by questionnaire.

RESULTS

The direct brow lift operation was found to give a predictable outcome, with high levels of patient satisfaction. With careful wound closure, postoperative scars are rarely cosmetically unacceptable to the patient. Paraesthesiae are a common but well tolerated sequelae.

CONCLUSIONS

The direct brow lift was found to be a reliable method for treating brow ptosis arising through involutional change or facial nerve palsy in both men and women. The postoperative scars may be more evident in younger patients so the authors reserve this technique for "rehabilitative" rather than cosmetic brow lifts in patients of middle age and beyond.

Endoscopic Brow Lift:

Since the introduction of endoscopic brow lifting in the mid-1990s, it has become widely accepted as a method for rejuvenation of the upper third of the face. Despite the multitude of brow fixation techniques, there are few long-term studies providing accurate analysis of outcome. The aims of this investigation were to evaluate the long-term objective results of endoscopic brow lifting and to establish whether the technique of fixation altered the longevity of aesthetic outcome. The outcome of endoscopic brow lifts carried out on 538 consecutive patients over a 6-year period was assessed. For each patient, midpupil-to-brow distance was measured preoperatively and at intervals postoperatively. Two different fixation methods were compared: fibrin glue (n = 189, group 1; 104 records available) and polydioxanone sutures tied through bone tunnels (n = 349, group 2; 220 records available). In 214 patients, an upper lid blepharoplasty was performed simultaneously (85 in group 1 and 129 in group 2). At 1 month postoperatively, each fixation technique had produced a significant change in mean pupil to brow height (5.93 mm in group 1 and 6.21 mm in group 2, with no significant difference between the two methods; p = 0.17). However, when measurements were compared more than 3 months postoperatively (mean, 9.4 months), there was a significant difference, with some relapse in the patients treated with fibrin glue (p < 0.01). However, in group 2 (tunnel fixation), measurements remained stable, with 6.21 mm at 1 month compared with 6.16 mm long term (no significant difference, p = 0.34). In contrast, in group 1 (fibrin glue), measurements showed significant reduction, with a 1-month result of 5.93 mm and a long-term outcome of 3.79 mm (p < 0.01). Upper lid blepharoplasty had no effect on the long-term outcome of either group (p > 0.3 in group 1, p > 0.4 in group 2). Complications were few in both groups. In group 1, there was one infection, two instances of significant alopecia (both temporary), and one reoperation for relapse. In group 2, four patients required minor surgical revision of a lateral port scar and three minor areas of temporal alopecia, which recovered in less than 3 months. One patient had a paresis of the frontal branch that had recovered after 4 months. The endoscopic brow lift is therefore a safe and effective technique for increasing mean pupil to brow height. Fixation with polydioxanone sutures tied through bone tunnels produces a significantly more stable result than fibrin glue, without greater risk. This lends weight to experimental evidence that periosteal fixation must be maintained for at least 6 weeks to be secure.

The endoscopic brow and midface lift

Improvements in technology have increased the level of patient care in all aspects of medicine and surgery. This is no less true in the area of cosmetic surgery. The use of endoscopy has led to improved aesthetics with respect to postoperative scarring, decreased healing time for patients, and an increase in overall patient satisfaction. Because the endoscopic brow and midface lift accomplishes the three primary goals of facial cosmetic surgery (restoration, rejuvenation, and enhancement) while adhering to the concepts of working from inside out and repositioning rather than excising, it could be concluded that there is no longer any indication for either the coronal or trichophillic brow lifts. An argument could be made that a direct brow lift may be indicated in cases of extreme brow ptosis with deep frontal rhytids to allow concealment of the scar; however, even moderate-to-severe brow ptosis can be corrected endoscopically when deep forehead rhytids are not present.