As we age, the eyebrows may descend and frown lines may develop. This can cause an unflattering "stern" or disapproving facial expression.

In the past, forehead lifts required a long incision across the top of the head ("coronal" or "open" approach) or surgeons made an incision along the hairline and then raised a big flap, exposing the frontal skull. This is quite a sight for a layperson, who is understandably reluctant to have this procedure after seeing such a dissection on TV.

In fact, there are plastic surgeons today that continue to use the old coronal incision (from ear-to-ear) because they have found it effective and are used to doing it. Some surgeons believe the endoscopic approach is not as effective. However, recent photometric studies have confirmed the effectiveness of the endoscopic forehead lift, which makes use of much smaller incisions and avoids the unwanted "perpetually surprised" look that an overdone coronal lift can produce.

Endoscopic Forehead Lifts: A Revolution

In the early 1990's, endoscopic technique found an excellent application in forehead lift surgery. These instruments had already had a tremendous impact in the fields of gynecology and general surgery. Now, the incisions could be made much smaller. The release of tissue over the eyebrows could be done using endoscopic visualization and fine instruments passed through these small openings. Prior to doing my first endoscopic forehead lift in 1995, I was reluctant to offer forehead lifts to my patients because of the morbidity of the long scalp incision, which left a long scar. Although the scar was within the hair-bearing scalp, there could still be hair loss along the scar which could be troublesome. It was also a long procedure with substantial bleeding. It was possible to overdo the lift and create an "overly surprised" expression. It seemed like a long way to go to produce a marginal improvement. I did only about one a year and the eyebrows had to be pretty saggy before I'd recommend it.

The endoscopic lift totally changed my approach. It removed the negatives associated with the open procedure. It now became an "elegant" procedure, with a cost-benefit ratio strongly in the "benefit" category. Surprisingly, despite working through smaller openings, visualization was actually improved, due to magnification and illumination on the monitor. There is less elevation of the hairline and it is less likely to over-elevate the brows, which can happen if too much tissue is removed using the older open technique.

Prior to adopting the endoscopic technique, I may have done one forehead lift in ten facelift patients. Now I perform forehead lifts on the majority of my facelift patients.

The operative time for then endoscopic forehead lift is much less than it used to be: thirty minutes versus two hours for the old coronal approach, with much less blood loss. The scars are typically negligible and there is minimal patient discomfort. Now, the forehead can be rejuvenated along with the rest of the face without substantially affecting the level of discomfort or length of recovery.

Botox^® as an alternative

Botox^® can be very helpful in relieving the frown lines between the eyes by relaxing the underlying corrugator muscles that create these frown lines in the first place. There can even be a slight elevation in brow position with simultaneous relaxation of the orbicularis muscles in the area of the crow's feet. Of course, this effect wears off in about four months.