Endoscopic brow lift

What it is

• The outer part of the brow usually drops first. Beyond the ridge at the side of the forehead, the forehead muscle no longer holds the brow up, and the soft tissue slides down while the frown muscles and the muscle around the eye pull it lower (PMID 8643714).
• The whole brow does not simply fall with age: in women aged 50 to 60 the inner and middle brow sat higher than in women aged 20 to 30, while the outer brow had changed little. Lifting the outer brow gives a younger shape, and lifting the inner brow does not (PMID 19935315).
• The surgeon frees the forehead from the bone through the scalp incisions, releases the tissue at the upper rim of the eye socket, weakens or removes the frown muscles and fixes the brow higher while it heals (PMID 12409778).

Where it came from

• In 1977 Kaye described the open forehead lift as a step done alone or with a facelift and eyelid surgery (PMID 887657). The open lift uses a long incision across the scalp (a coronal incision) (PMID 7972423).
• In 1994 Vasconez and Isse each reported lifting the forehead through small scalp incisions with an endoscope, with results comparable to the open lift (PMID 7972423, PMID 8122572).
• In the mid-1990s Knize described why the outer brow falls and which branch of the forehead nerve causes most scalp numbness after a forehead lift (PMID 8643714, PMID 7638280).
• By 2003 enthusiasm had cooled at one center: patients were mostly satisfied, but only half of surveyed surgeons were pleased with long-term results, and the number of endoscopic lifts at that hospital fell (PMID 12900626).
• It remained the most used brow lift among plastic surgeons surveyed in 2000 and 2020, while routine use of muscle-relaxing injections rose sharply, and nearly a third of surgeons think injections have replaced brow lifting to a significant degree (PMID 37409963).

Who it suits

• A brow that sits low, especially at the outer end, with heavy upper lids that are partly due to the brow (PMID 8643714, PMID 19935315).
• Deep frown lines between the brows, since the frown muscles can be weakened in the same operation (PMID 31046060).
• People with a normal hairline. With a high or receding hairline, incisions in the forehead creases can lift the brow without lengthening the forehead (PMID 34593745).
• A smaller outer-brow lift through incisions in the temple suits people who need less lift (PMID 31764641).

How it is done

• Through a few short incisions behind the hairline, the surgeon lifts the forehead tissue off the bone under camera view and releases it at the rim of the eye socket (PMID 12409778, PMID 41203333).
• Surgeons work in different layers (under the scalp's fibrous layer, under the bone lining, or both), which differ in risk to the scalp nerve (PMID 42465865).
• The frown muscles (corrugator and procerus) are weakened or removed; some surgeons leave them and still raise the brow by 2 to 3 mm (PMID 31046060, PMID 40820940).
• The brow is held up while the tissue reattaches to bone, which takes at least six weeks (PMID 15083028). Fixation choices include stitches through small bone tunnels, absorbable implants (Endotine), screws, wires and glue (PMID 40804547).
• Bone tunnels held the brow better than fibrin glue, which lost about a third of its lift (PMID 15083028), and better than temporary tape in a randomized trial (PMID 42441344).

Results and how long they last

• Pooled long-term lift is about 3.3 mm at the inner brow, 3.9 mm in the middle and 4.4 mm at the outer brow (PMID 39542644). No study has kept more than about 5.6 mm long term, and the lift slowly declines (PMID 42077543).
• The scalp nerve may limit how far the brow can be raised, to about 2.5 to 5.5 mm in a cadaver study (PMID 36727814).
• In a large series followed about seven years, satisfaction was very high at six months and lower after two years, and about 1 in 80 patients had a second operation (PMID 34269765).
• Endoscopic and hairline (pretrichial) lifts gave similar lift at about six years (PMID 35653546); the endoscopic lift gave more early lift with similar long-term results in another comparison (PMID 41239801).
• Endoscopic lifts and open coronal lifts were similar at one year, and the open lifts slowly dropped over five years (PMID 11322395).
• Removing the frown muscles softened moving frown lines more than leaving them (PMID 31046060).
• The forehead does not truly lengthen: photos with the eyes closed showed no change in forehead height (PMID 42012844).

Risks and how surgeons lower them

• In pooled studies, numbness or tingling followed about 1 in 16 endoscopic lifts, uneven brows about 1 in 28, hair loss at the incisions about 1 in 33 and incomplete eye closure about 1 in 37 (PMID 23388642). Endoscopic lifts had the highest hair-loss rate of all brow lifts (PMID 30534495).
• In a large long-term series, temporary itching affected about 1 in 7, headache about 1 in 16 and temporary facial nerve weakness on one side about 1 in 17; a lasting undercorrection about 1 in 14, hair loss about 1 in 24 and a surprised look about 1 in 45 (PMID 34269765).
• Bleeding needing drainage followed about 1 in 140 forehead lifts and was more common in men (PMID 41870876).
• Fixation matters: bone tunnels had the fewest complications and screws the most (PMID 40804547); permanent fixation brought more unevenness, contour problems and cysts than temporary fixation (PMID 41697229). Screws and one implant post went through the inner skull layer in a cadaver test, while angled bone tunnels did not (PMID 16977357).
• Double vision from weakness of an eye muscle is rare and resolved within three months (PMID 39746538).

Recovery

• Most patients needed pain medicine for under a week and had swelling for under two weeks; about 2 in 3 had some numbness, about 1 in 4 noticed hair loss at an incision, and most rated their scars unnoticeable (PMID 23699709).
• Forehead numbness took an average of about two months to recover (PMID 34269765). Open lifts left the scalp numb longer than endoscopic lifts, with no difference after 18 months (PMID 21079105).
• Small patches of hair loss at the temples recovered in under three months (PMID 15083028).
• Half of patients who had headaches before surgery reported fewer or milder headaches afterward (PMID 23699709).

With a facelift

• Complications did not rise markedly when the endoscopic lift was combined with other facial operations (PMID 12409778).
• Patients who also had a facelift more often took two weeks or longer to return to normal activities; pain, swelling, numbness, hair loss and satisfaction were otherwise similar (PMID 23699709).
• Brow lift with eyelid surgery had the same major complication rate as either alone, about 4 to 7 in 1,000 (PMID 29369102). Eyelid surgery at the same time did not lower the long-term brow height (PMID 15083028).

Questions to ask a surgeon

• Is my brow low, and which part of it? (PMID 19935315)
• How will you hold the brow up while it heals? (PMID 40804547)
• How much lift should I expect at one year and later? (PMID 42077543)
• Where will the scars be, and how often do patients lose hair there? (PMID 30534495)
• Would injections or a smaller temple lift be enough for me? (PMID 37409963)

Open questions

• Durability: pooled long-term lift of 3 to 4.5 mm (PMID 39542644) against a review that finds the lift poorly maintained, especially at the outer brow (PMID 42077543).
• Fixation: bone tunnels held better than tape in a randomized trial (PMID 42441344); permanent and temporary bone fixation had the same revision rate for lost fixation (PMID 41697229).
• Tined implants gave more outer-brow lift and more abnormal sensation than stitches (PMID 40788666).
• Outer-brow relapse: an internal suspension stitch has been proposed to prevent it (PMID 39378135).
• Frown-muscle removal: routine removal (PMID 31046060) against lifts without it (PMID 40820940).

Terms

• Brow ptosis: an eyebrow lower than its youthful position; the outer end usually drops first (PMID 8643714).
• Endoscope: a thin camera passed through small incisions to see and work under the scalp (PMID 7972423).
• Subperiosteal plane: the layer under the periosteum, the membrane covering the skull (PMID 12409778).
• Periosteal release: cutting the periosteum at the upper eye socket rim so the brow can move up (PMID 12409778).
• Corrugator and procerus: frown muscles between the brows, weakened or removed during the lift (PMID 31046060).
• Fixation: holding the lifted forehead with bone tunnels, screws, implants such as Endotine, stitches or glue while it heals (PMID 40804547).
• Deep branch of the supraorbital nerve: the sensory nerve to the scalp that runs under the galea; injury causes scalp numbness (PMID 7638280).
• Temporal fusion line: the ridge on the side of the skull where the forehead muscle's support of the brow ends (PMID 8643714).
• Galea aponeurotica: the tough fibrous layer of the scalp (PMID 7638280).
• Lagophthalmos: incomplete eye closure (PMID 23388642).

Papers