D and Thomas M Biggs MD stanbul Turkey and Houston Texas Abstract This is a retrospective review of our experience with the endoscopic brow lift We reviewed 128 procedures per formed by two senior faculty members over the last 5 years We evaluated th ID: 48012
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OurExperiencewithEndoscopicBrowLiftsOzanSozer,M.D.,andThomasM.Biggs,M.D.stanbul,TurkeyandHouston,TexasThisisaretrospectivereviewofourexperiencewiththeendoscopicbrowlift.Wereviewed128proceduresper-formedbytwoseniorfacultymembersoverthelast5years.Weevaluatedtheage,gender,operatingtime,complications,andoutcomeandconcludethatendoscopicbrowliftisasafe,ef-ficientprocedurewithalowcomplicationrate.Theoperatingtimeisshort,andthereisaveryhighpatientacceptance.Theprocedurehastakenitsplaceasanintegralpartoffacialreju-venationinourpractice.Keywords:EndoscopicbrowliftÐComplicationsÐSurgical Endoscopicbrowlifthasgainedpopularitysinceitsin-troductionin1994[1]andwehaveperformed218browliftsatSt.JosephHospitalsincethen.Thisisaretro-spectivereviewof128casesperformedoverthelast5yearsbytwoseniorfacultymembers.MaterialsandMethodsChartsofpatientswhohadhadendoscopicbrowliftsbeforeDecember31,1998werereviewedandthetech-niquewasanalyzed.Age,gender,operatingtime,otherproceduresperformed,andoutcomeswereevaluated.Anobjectivemeasurementofthebrowelevationwasnotpossiblebecauseoftheretrospectivenatureofthere-view.Wechoserandompatientsandperformedsubjec-tiveanalysisoftheelevationbylookingatthebrowposition,frownlines,transverseforeheadrhytids,andbymakingcomparisonswiththepreoperativepictures.Thetechniquehasundergonevariousmodifications,mostofwhichinvolvedtheplacementofincisionsandthewaytheelevationwassecured.Westartedwithver-ticalincisionswheretheincisionwasclosedinatrans-versefashionfollowingresectionofbilateraldogears(Fig.1).Thenweplacedascrewintheoutertableoftheskullthroughaverticalincisionandsecuredtheeleva-tionwithaProlenesuturewrappedaroundthescrew(Fig.2).Withourcurrentfixationtechniquetheforeheadandtemporalandparietalscalpareinfiltratedwith0.5%lidocainewithepinephrine.ThreeverticalincisionsÐoneinthemidlineandoneoneachsideleveledwiththeapicesofthebrowsÐareplaced1±2cmbehindthehairline(Fig.3A).Theinfiltratedposteriorscalpiselevatedinasubgalealplane(B)andtheforeheadiselevatedtoapoint2cmcephaladtothesupraorbitalriminasubperi- CorrespondencetoThomasM.Biggs,M.D.,1315St.JosephParkway,Suite900,Houston,Texas77002,USA Fig.1.(A)Theverticalincision.Theverticalincisionisapproximatedtransverselyandthedogearsaremarked.Thedogearsareexcisedandincisionisclosed.Fig.2.(A)ThescrewisplacedintheoutertablethroughtheTheelevationoftheforeheadissecuredbywrap-pingaprolenesuturearoundthescrew.TheincisionisAesth.Plast.Surg.24:90±96,2000DOI:10.1007/s002660010017 2000Springer-VerlagNewYorkInc. ostealplane(C).Bilateral3cmincisionsareplacedoverthetemporalareasandareperpendiculartothelinethatconnectsthenasalalaetotheipsilateralcommissureoftheeye(D).Wetrytokeeptheseincisionsasatemporalextensionofthepreauricularincisionifweareperform-ingafaceliftatthesametime.Theseincisionsaretakendowntothedeeptemporalfasciabutnotthroughit.Aplanejustsuperficialtothedeeptemporalfasciaisde-velopedandjoinsthesubperiostealplaneoftheforeheadthroughthetemporalfusionline(E).Anendoscopeisplacedthroughthemid-verticalinci-sion(Fig.4A)andafterthispointtheoperationrequiresadifferenteyeandhandcoordinationwherethesurgeonfacesthemonitorratherthanthepatient(B).Underthedirectvisualizationoftheendoscopethesubperiostealdissectioniscarrieddowntothesupraorbitalrim(C),the Fig.3.(A)Locationofincisions.Notethattheactualincisionsarebehindthehairlineandthearrowispointingtothelocation.Oneandahalfand2.5cmmarkingsindicatethelocationofsupratrochlearandsupraorbitalneurovascularbundles,respectively.Theinfiltratedposteriorscalpiselevatedinasubgalealplane.Theforeheadiselevatedtoapoint2cmcephaladtothesuperorbitalriminasubperiostealplane.Thedeeptemporalfasciaareexposedthroughthetemporalincision.Theextentoftemporaldissection.O.SozerandT.M.Biggs nervesareidentified(D),andtheperiosteumisdividedwithareverseelevatordirectlyoverthesupraorbitalrim(E).Procerusandcorrugatormusclesareidentifiedanddividedbluntlywiththeelevator(F)orwiththeuseofalligatorforceps.Theareaisirrigatedandnodrainsareplaced.Screws(13mm)areplacedthroughtheverticalincisions(Fig.5A)andelevatedforeheadissecuredbe-hindthescrewwithstaples(B).Temporalincisionsareclosedprimarilywithstaples,orsmallfusiformsegmentscanbeexcisedfromtheanteriorportionoftheincisionandthispartoftheincisioncanbeelevatedandsecuredtothedeeptemporalfasciawithanabsorbablesutureandthenclosedprimarily.Ifafaceliftisdoneatthesametime,temporalincisionsareclosedattheendofthefaceScrewsarekeptinplaceuntiltheperiosteumadherestoitsnewposition.Currentlywekeepitfor1±2weeks.Therewere128patients(120female,8male)includedinthestudy.Theyoungestpatientwas32yearsold,theoldest74yearsold(average53.8,median53)(Fig.6).Welookedintoaverageageofpatientsbyyearand Fig.4.(A)Endoscopeisplacedthroughamid-verticalincision.Thereafter,theoperationrequiresadifferenteyeandhandThedissectioniscarrieddowntothesupra-orbitalrim.Thenervesareidentified.Theperiosteumisdivided(fatexposed).Themusclesarevisualized(whitearrow)anddivided.Neurovascularbundle(bluearrow).EndoscopicBrowLifts compareditwiththeaverageageofpatientswhohadbrowliftin1993whenwewereperformingonlyopencoronalbrowlifts(Fig.7).Thiscomparisonshowedthatwiththeintroductionofendoscopicbrowliftwehavestartedtoperformthisprocedureonayoungergroupofpatientsaswell.Themostcommoncomplicationinourserieswaslo-calalopecia(Table1).Allofthesepatientshadtheel-evationsecuredbyeitherutilizingT-shapedincisionsorusingProlenesuturewrappedaroundascrewwhichwasplacedontheoutertable.Evenwiththesepatientsthedegreeofalopeciawasverymild,oralmostnegligible(Fig.8).WithourcurrenttechniquewehavenothadanyWehadtwopatientswithasymmetry,bothofwhomhadmildasymmetrybeforesurgerybutitbecamepro-nouncedaftersurgery.Theonlywounddehiscencewasinthethirdpatientinourseriesandthishealedwithsecondaryintention.Allthesecomplicationsoccurredduringthefirst2yearsofourexperience.Forthelast3yearsthisprocedurehasbeencomplication-free.Theoperatingtimerangedbetween50and70minutesinitially;currentlyitisbetween15and30minutes.Sev-enty-fivepercentofthepatientshadfaceliftsatthesametime,43%hadupperblepharoplasty,and41%hadlowerblepharoplasty.Wedidnotutilizebotulinumtoxininjec-tionswithanyofthepatients.Weinvestigatedthepercentageofpatientswhohadfaceliftsoverthelast6yearsandbrowliftsatthesametime.Ourdataindicatethatwiththeintroduc-tionoftheendoscopicbrowliftthereisasignificantincreaseinthenumberofpatientshavingthetwooperationssimultaneously(Fig.9).Currently,75%ofthepatientswhohadfaceliftsalsohadendoscopicbrowWecouldnotobjectivelyanalyzethebrowelevationanditspersistenceovertheyearsbecauseoftheretro-spectivenatureofthestudy.Weperformedasubjectiveanalysisbychoosingrandompatientsandcomparingpre-andpostoperativepicturesaswellasthefollow-uppictures.Weevaluatedthepresenceoffrownlines,trans-verserhytids,andpositionofthebrows.Inourexperi-ence,upto5yearsoffollow-uprevealsthatelevationpersists(Figs.10±13A,B).Malesontheotherhandhaveheavy-setbrowsandforeheadtissueisthicker.Theelevationachievedwithmalesislesscomparedwithfemales,butthereisdefiniteimprovementoftheappearanceoftheforehead(Fig.14A,B).Deeprhytidsontheforeheadrespondpartiallytotheendoscopicbrowlift,butwhencombinedwithlaserre-surfacing,betterresultscanbeachieved(Fig.15A,B).Inourseries,thereisnoincreaseincomplicationratewhenthesetwoproceduresarecombined. Fig.5.(A)ThescrewisbeingplacedattheouterElevationissecuredbystaplesplacedbehindthescrew. Fig.6.DistributionofthepatientsaccordingtotheageO.SozerandT.M.Biggs Endoscopicbrowlifthasbecomeapopularprocedure;wehavebeenperformingitforthelast5years.Reviewofourexperiencehasrevealedthatthisisasafeandeasyprocedure.Thecomplicationrateislow,withthemostcommoncomplicationbeingmildalopecia.Withtheon-goingrefinementsofthetechniqueitisalmostacom-plication-freeprocedure.Theoperatingtimeisshortwhichgivesustheopportunitytosafelycombineitwithotherprocedures.Theminimallyinvasivenatureoftheprocedurebringsahighpatientacceptancerateandayoungergroupofpatientshaveacceptedthisoperation.Sinceitsintroduc-tion,thenumberofpatientshavingbrowandfaceliftsatthesametimehasincreasedsignificantly.Currently,inourpractice,75%ofourfaceliftpatientsalsohaveen-doscopicbrowliftatthesametime.Upto5yearsoffollow-uphasshownthatelevationpersists,thoughlesswithmales,butthereisstillimprovementintheappear-anceoftheforehead.Deeprhytidsontheforeheadcanbetreatedwithen-doscopicbrowliftcombinedwithlaserresurfacing.Thereisnoincreaseinthecomplicationratewhenthesetwoproceduresarecombined.Inconclusion,endoscopicbrowlifthasbecomeour Fig.8.Filmofapatientwithmildalopeciaafteranendoscopicbrowlift. Fig.9.Comparisonofthenumberofpatientswhohadfaceliftwiththenumberofpatientswhohadfaceliftandbrowliftatthesametime. Fig.7.Averageagedistributionofpatientsbyyearwhohadbrowlift.Table1.Complicationsofpatientsundergoingendoscopicbrowlift ComplicationNo.ofpatientsPercentAlopecia65Asymmetry21.6Wounddehiscence10.8Skinburn10.8Conjunctivitis10.8Nervedamage10.8Doublevision10.8Total1310EndoscopicBrowLifts Fig.10.(A)Preoperativebrowlift.Browlift4.5yearspostoperative. Fig.11.(A)Preoperativebrowlift.Browlift3.5yearspostoperative. Fig.12.(A)Preoperativebrowlift.Twoyearspostoperative. Fig.13.(A)OneyearO.SozerandT.M.Biggs firstchoiceprocedureforbrowlift.Thenumberofbrowliftsweperformhasincreasedsignificantlyandithasbecomeanintegralpartofourmethodsforfacialreju-1.BostwickJ,EavesEF,NahaiF(eds):Endoscopicplasticsurgery.QualityMedicalPublishing,St.Louis;19952.IsseNG:Endoscopicfacialrejuvenation:EndoForehead:thefunctionallift.Casereports.AesthPlastSurg21,19943.RamirezOM,DanielRK:Endoscopicplasticsurgery.Springer-Verlag,NewYork;1996Addendum:ThomasM.Biggs,M.D.Thedecadeofthe90shasbeenonewithsignificantleapsintechnology.Thelasers,ultrasonicdevices,bothinter-nalandexternal,variousmachinesforfacialskinreju-venation,andendoscopicapproachestotheanatomyhaveoccupiedamajorportionofourliterature,scientificpresentations,andexhibitsatCongresses.Ihaveintuitivelybeenreluctanttoembracethesenewtools,thinkingthatinsomewaytheyweretoreplacesoundjudgmentandskillfulscissors,scalpel,andsuturetechniques.ItiswiththissamereluctancethatIap-proachedendoscopicbrowlift.Thecoronalapproachusinganincisionfromthetopofoneeartothetopoftheotherhasbeenmyapproachtoraisingtheforeheadandeyebrowsinpatientswhoeithergeneticallyorasaresultofagingshowedundueheavinessontheupperlids.Inthosepatientsforwhomthedirectapproachthroughblepharoplastywouldnotamelioratetheproblem,thisoperationwassuggested.Asisalwaysthecase,wewoulddescribethebenefitsbutalsothedifficulties.Theseincludedalongscar,thepossibilityofalopeciaalongthescarline,somealterationofnervesupplyceph-aladtothescar,andanadditional45minutestoonehouroperatingtime.Inmanyinstancespatientswoulddeclinethisportionofthesurgery,andwewouldrelyonblepha-roplastyalone,orwouldperformsomeformofbrowelevationthroughtheblepharoplastyincision,andoftenwouldhaveanaestheticallyinadequateresult.Sincetheintroductionofthisendoscopictechniqueforbrowlifting,wehavebeenabletoprovidetheelevationofthebrowswithoutthelongscar,muchlessalopecia,andnotablesensoryprotectioncarriedoutinaprocedurerarelytakinglongerthan20minutes.Wehavebeenabletocreateamuchmorefavorablerisk/rewardratio.Fur-thermore,wenowhavesignificantexperiencewiththistechniquetobeconfidentofitsdurability.Becauseofthesefavorableoutcomesourpatientsaremoreacceptingofbrowliftsinconjunctionwithrhytidectomy,andtheoverallresultsofthesurgicalexperiencearemorefruit-ful.Theprocedurehasbeentestedandproventobesuccessfulandisnowastrongcomponentofourfacialrejuvenationprogram.Inthesecasestheendoscopehastakenitsplacebesidescissors,scalpel,needleholder,andsutureandcanbeusedtochangetheanatomywithmini-maldownside.Utilizedwithsoundjudgmentandskill,theendoscopicbrowliftoffersthepatientsomethingmoreforless,whichisalwaysourgoal. Fig.14.(A)Preoperativebrowlift. Fig.15.(A)Postoperativefromlaserresurfacingandendoscopicbrowlift.EndoscopicBrowLifts