Keywords

Introduction

To maximize brow elevation with the endoscopic technique, the surgeon must release the periosteum from one inferolateral orbit to the other and release the brow depressor musculature (corrugator, procerus, depressor supercilii, and supraorbital orbicularis oculi). Following the browlift, all depressor vector forces should be eliminated to promote the maintenance of the newly elevated brow position since periosteal reattachment to bone takes approximately 6–12 weeks.

Temporal Lift

In patients with adequate medial brow position and ptotic lateral brow and lateral canthal hooding, an endoscopic temporal (temple) lift may be performed. A temporal lift is performed with the same principles and technique as the endoscopic browlift (surgical technique described below) except that the medial border of the periosteal and brow depressor musculature release is the supraorbital neurovascular complex. The supraorbital orbicularis oculi muscle is the only brow depressor treated. The medial brow and glabellar region is not dissected, resulting in elevation of the lateral two thirds of the brow–lateral canthal complex.

Treatment of the Depressor Muscles with Botulinum Toxin

Botulinum toxin may be used synergistically with the surgical brow depressor musculature release in an effort to weaken the inferior vector forces and promote the maintenance of the newly elevated brow. Botulinum toxin is used to block the depressor function of the corrugator, procerus, depressor supercilii, and lateral supraorbital orbicularis oculi muscles. Two weeks prior to surgery, the corrugator, procerus, and depressor supercilii muscles (medial brow depressors) are typically injected with a total of 20 units of botulinum toxin (botulinum toxin), and the lateral supraorbital orbicularis oculi muscles (lateral brow depressor) are injected with about 4 units of botulinum toxin on each side. No botulinum toxin is injected into the frontalis muscle since it acts as the only brow elevator. Some surgeons are reticent to do this prior to surgery because in the rare instance that blepharoptosis occurs, the patient may cancel surgery. These same injections can be performed 2 weeks postoperatively with similarly beneficial results.

Surgical Technique

Incisions

Most procedures are performed under general anesthesia. The incisions are then marked: one midline and two temporal (two paramedian incisions are made if bone fixation is to be performed). The anteroposterior midline incision is approximately 2 cm posterior to the hairline and is 1 cm in length, just large enough to allow the introduction of periosteal elevators into the subperiosteal space. The temporal incisions are 3 cm in length. The key to obtain a natural-looking brow is to create a temporal incision parallel to the tail of the brow with its medial extent close to the temporal hairline (Fig. 96.1). The temporal incision orientation will help elevate the lateral half of the brow in a superomedial vector.

Fig. 96.1
figure 1

Marking of the temporal incision (arrow) parallel to the tail of the brow with its medial extent near the temporal hairline

Full size image

Temporal Dissection and Release of the Periosteum and Lateral Supraorbital Orbicularis Oculi Muscle

The temporal incisions are made and extended to the deep temporal fascia. A blunt elevator dissects over the deep temporal fascia inferiorly until a branch of the zygomaticotemporal vein called the “sentinel vein” is encountered (Fig. 96.2). This is the inferior limit of the dissection without the use of the endoscope. A facelift scissors is used to connect the temporal incision to the central forehead incision by severing the conjoint tendon, which is released with a periosteal elevator in a superior to inferior direction to the level of the supraorbital rim. Near the supraorbital rim, a thickening of the periosteum is encountered, which Moss et al. termed the “ligamentous adhesion” (Moss et al. 2000). Release continues inferiorly through the orbicularis retaining ligament and its more robust expansion near the lateral canthus, called the lateral orbital thickening. Adequate release of the conjoint tendon, ligamentous adhesion, and orbicularis retaining ligament are essential to obtaining an effective lift.

Fig. 96.2
figure 2

The temporal incision has been made, and dissection over the deep temporal fascia has been performed inferiorly to the sentinel vein. The frontal branch of the facial nerve passes in the deepest layers of the flap that has been elevated. The sentinel vein should be preserved if at all possible to minimize risk to the frontal branch. If it must be cauterized, this should be done at the base, away from the nerve

Full size image

The endoscope is placed into the temporal dissection along with the elevator to visualize the sentinel vein. This vein is a reliable marker for the frontal branch of the facial nerve, which lies superficial to the dissection on the undersurface of the temporoparietal fascia (Agarwal et al. 2010). Usually, the sentinel vein is preserved, and the dissection is performed circumferentially around the vein. If the vein is cauterized, the bipolar forceps are placed at the base of the sentinel vein to help prevent a thermal injury to the frontal branch of the facial nerve. If the sentinel vein is cauterized, it may increase the prominence of temporal and lower lid veins which is aesthetically displeasing.

Dissection stops at the level of the lateral canthus. To prevent elevation of the lateral canthus, an assistant places a finger in the interior aspect of the lateral rim at the lateral canthus. In the rare instance that the surgical plan calls for lateral canthal angle elevation, the lateral canthus is released. The periosteal release (elevation, incision, and spreading) begins superior to the lateral canthus and extends medially to the supraorbital neurovascular complex; care is taken not to injure the nerve. Following the periosteal release, the lateral supraorbital orbicularis oculi muscle is meticulously released from the inferomedial orbit to the supraorbital nerve, exposing the yellow brow fat. This same procedure is performed on the contralateral temporal region.

Release of the Brow Depressor Muscles

For the temporal lift, this portion of the procedure is eliminated. The endoscope remains placed through the temporal incision, and the periosteal elevator is placed through the central incision. The dissection is carried to the central supraorbital region and radix of the nose, releasing the periosteum and avoiding injury to the supraorbital and supratrochlear nerves. Thorough corrugator, procerus, and depressor supercilii myotomies are performed. To ensure that complete myotomies have been performed, each nerve of the supratrochlear and supraorbital neurovascular complexes should be easily visualized without obstruction from overlying muscle fibers. There is a tendency for these muscles to regain activity even after an aggressive release. Some authors place temporalis fascia or Alloderm at the myotomy site to limit regeneration. This is less necessary in the age of botulinum toxin.

Brow Elevation and Fixation

Prior to fixation, a 10 French drain is placed and fed from one temporal dissection to the other positioned across the inferior extent of the dissection and exiting a puncture site superior to the right temporal incision. If a complete release of all periosteum and brow depressor musculature is performed, the entire brow complex will elevate to an unnaturally high position without any tension (Figs. 96.3 and 96.4). Brow fixation is achieved by securing the superficial temporal fascia medially to the deep temporal fascia in a superomedial vector with two 2-0 PDS horizontal mattress sutures while the brow is lifted superiorly and overcorrected. The overcorrected brow will gradually drop to its final position after 3 weeks. The incisions are closed with surgical staples.

Fig. 96.3
figure 3

Patient before (a) and 1 week after (b) endoscopic browlift with deep temporal fixation only (DTFO). (c) Intraoperative photograph of the patient’s elevated brow complex to an unnaturally high position after a complete release of the entire periosteum and brow depressor musculature prior fixation

Full size image
Fig. 96.4
figure 4

Intraoperative photograph of a patient’s elevated left brow complex after a complete unilateral release of all periosteum and brow depressor musculature prior to fixation. Q-tips positioned at the inferior border of the supraorbital rim

Full size image

Results (Before and After Photographs)

Since January 2000, the author has performed endoscopic browlifts with DTFO in more than 150 patients with good results (Figs. 96.5 and 96.6). This procedure has the advantage of addressing the ptotic eyebrow while avoiding bony fixation. The endoscopic browlift with DTFO may be combined with the endoscopic subperiosteal transtemporal transbuccal midface lift to rejuvenate the aging forehead, brow, and midface.

Fig. 96.5
figure 5

(a) A 43-year-old-male status post of an upper blepharoplasty 4 years ago now complaining of a “tired look”: right oblique of before (left) and after (right). The brow, especially in the temporal region, descends below the supraorbital rim causing temporal hooding, and the supratarsal crease is covered by overhanging ptotic upper eyelid skin. (b) Following a DTFO endoscopic browlift, the patient’s brow ptosis is moderately improved

Full size image
Fig. 96.6
figure 6

A 41-year-old-patient with brow ptosis and fat herniation of the lower eyelids. Following DTFO endoscopic browlift and bilateral lower transconjunctival blepharoplasty, notice the significant brow elevation. (a) Frontal of before (left) and after (right). (b) Left oblique of before (left) and after (right)

Full size image

As with any new procedure, thorough knowledge of the current literature and anatomy, and observation of this procedure by an experienced surgeon, should prelude your attempt at performing the endoscopic browlift with DTFO.