BEFORE AND AFTER PHOTOS
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With aging, the eyebrows may descend and frown lines may develop, causing an unflattering stern or disapproving facial expression.
In the past, forehead lifts (synonymous with brow lifts) required a long incision across the top of the head (the “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 may be understandably reluctant to have this procedure after seeing it on TV or the internet.
Even today, there are plastic surgeons who continue to use the old coronal incision (from ear-to-ear) because they have found it effective and they are simply accustomed to doing it. Some old-school surgeons believe the endoscopic approach does not work. However, recent photometric studies have confirmed the effectiveness of the endoscopic forehead lift, which makes use of much smaller incisions and avoids the dreaded “perpetually surprised” look that an overdone coronal lift can produce. There is no doubting its advantages in terms of less operating time, scarring, recovery time, and better preservation of scalp sensation.
A facelift treats the middle (cheek) and lower (jowl) thirds of the face in addition to the neck. A forehead lift rejuvenates the upper third of the face, completing a full facial rejuvenation for the top of the head to the neck.
A 1990s Breakthrough
In the early 1990s, endoscopic technique found an excellent application in forehead lift surgery. Endoscopic instruments had already had a tremendous impact in the fields of gynecology and general surgery. Now the incisions could be made much smaller. No more long cut across the top of the head. The release of tissue over the eyebrows could be done using endoscopic visualization. Fine instruments could be passed through small openings hidden behind the hairline.
Prior to doing my first endoscopic forehead lift in 1995, I was reluctant to offer coronal 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 was hair loss along the scar, which could be visible. The coronal lift was also a long procedure with substantial bleeding. It was possible to overdo the lift and create an overly surprised expression. The coronal forehead lift seemed like a long way to go to produce a marginal improvement. The cost/benefit ratio was equivocal. Before 1995, I performed only about one coronal brow lift 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, truly minimally invasive procedure, with a very favorable cost/benefit ratio. Surprisingly, despite working through smaller openings, visualization is actually improved, due to magnification and illumination on the monitor. With this technique, there is less elevation of the hairline and less likelihood of over-elevating the eyebrows, which can happen if too much scalp tissue is removed using the old open technique.
Before adopting the endoscopic technique, I rarely offered a forehead lift. Now I was doing forehead lift on just over half (53%) of my facelift patients. The operative time was reduced from about 2 hours to just 30 minutes, with much less blood loss. The scars were usually negligible. The discomfort level was minimal. The forehead could 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 eyebrows 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 (“chemical lift”) with simultaneous relaxation of the orbicularis muscles in the area of the crow’s feet. Of course, this effect wears off in about 3 to 4 months.
Botox injection is a good option for patients who want some of the effects of a forehead lift, but are not ready for surgery. The limitation is brow elevation. An endoscopic forehead lift is usually more effective than Botox in raising the brow position (if this is desired), and the duration of the result is likely to be longer.
A forehead lift does not mean that Botox will no longer be needed. Many patients still benefit from Botox injections even after having a forehead lift. The corrugator muscles are weakened by surgery but not eliminated. It can be helpful to inject these muscles and the crow’s feet to maintain a youthful upper face.
Similar to Botox injections, an endoscopic forehead lift may be useful for people who suffer from migraine headaches. An endoscopic forehead lift makes use of physical decompression of the sensory nerves to the forehead, as opposed to chemical relaxation of the corrugator muscles provided by Botox. Accordingly, it may offer a more lasting benefit. A study among migraine sufferers found that migraine headaches were eliminated in 57% of patients compared with just 4% in a sham group (patients who did not have muscle decompression). This is good news for the 30 million Americans who suffer migraines. A procedure conceived for cosmetic improvement has real and potent physical benefits too.