**3. Endoscopic facelift (forehead lift, brow lift, midface lift)**

As humans age, lines and wrinkles naturally form on the forehead due to constant muscle movement, making one look older than he/she would like. Additionally, those horizontal lines across the forehead, or vertical lines between the brows, can cause one to look angry, stressed, or simply unpleasant and unapproachable. Fortunately, with the help of endoscopic surgery, one can achieve a fresh-faced, smooth, youthful appearance.

#### **3.1. Technique**

In preparation for a classic forehead lift, the hair is tied back with rubber bands in front and behind the incision area. An incision is usually made across the top of the head, just behind the hairline. Forehead skin is gently lifted and portions of facial muscle and excess skin are removed. The incision is then closed with stitches or clips. The result of a forehead lift is a younger, more rested look (Figure 4).

In an endoscopic forehead lift, the muscles and tissues that cause the furrowing or drooping are removed or altered to smooth the forehead, raise the eyebrows and minimize frown lines. Surgeons may use the conventional surgical method, in which the incision is hidden just behind the hairline; or it may be performed with the use of an endoscope. Both techniques yield similar results, smoother forehead skin and a more animated appearance.

Low, heavy "V" shaped eyebrows create a tired, older, masculine, unfriendly appearance. Opening up the eyes and brows and smoothing the forehead is both powerful and subtle. Patients look more awake, fresh, healthy and youthful. Forehead surgery is normally done in combination with an eye lift (blepharoplasty) for best results.

In preparation for a classic forehead lift, the hair is tied back with rubber bands in front and

behind the incision area. An incision is usually made across the top of the head, just behind the

hairline. Forehead skin is gently lifted and portions of facial muscle and excess skin are removed.

The incision is then closed with stitches or clips. The result of a forehead lift is a younger, more

#### **Figure 4.** Classic forehead lift incision

Before the operation, motivations and demands of the patients must be analyzed. A careful study of the upper facial region and its relations with the rest of the face should be made. A preoperative assessment is normally conducted as required. The anesthesiologist will be seen in consultation at the latest 48 hours before surgery. No medication containing aspirin should be taken within 10 days prior to surgery. Smoking cessation is strongly recommended at least one month before and one month after surgery. An antiseptic shampoo should be used the night before and / or in the morning. It is essential to fast (not eat or drink) 6 hours before surgery. **Figure 4 : Classic forehead lift incision** In an endoscopic forehead lift, the muscles and tissues that cause the furrowing or drooping are removed or altered to smooth the forehead, raise the eyebrows and minimize frown lines. Surgeons may use the conventional surgical method, in which the incision is hidden just behind the hairline; or it may be performed with the use of an endoscope. Both techniques yield similar

#### **3.2. Type of anesthesia** results, smoother forehead skin and a more animated appearance.

Two methods are possible: Low, heavy "V" shaped eyebrows create a tired, older, masculine, unfriendly appearance.


9

The choice between these different techniques will be the result of a discussion between patient, surgeon and the anesthesiologist. Patients look more awake, fresh, healthy and youthful. Forehead surgery is normally done in combination with an eye lift (blepharoplasty) for best results.

Hospitalization is short. The admission is in the morning (or even the day before in the afternoon) and the discharge is permitted either in the evening or the day after the operation. Before the operation, motivations and demands of the patients must be analyzed. A careful

#### **3.3. Technique of endoscopic forehead and eyebrow lift** study of the upper facial region and its relations with the rest of the face should be made. A

Each surgeon adopts his/her own technique that he/she adapts to in each case in order to obtain the best results. However, some common basic principles are as follows: preoperative assessment is normally conducted as required. The anesthesiologist will be seen in

Incisions are between 5 and 10 mm long, are three to five in number and are placed in the scalp, a few centimeters behind the forehead hairline. One of them will allow the passage of the endoscope connected to a mini video camera, the other giving way to the different instruments consultation at the latest 48 hours before surgery. No medication containing aspirin should be taken within 10 days prior to surgery. Smoking cessation is strongly recommended at least one

specifically adapted to endoscopic surgery. The path of these incisions is of course the future location of scars, which are therefore virtually invisible since they are very short and hidden in the hair. Detachment includes the temples and facial bones (Figures 5 and 6). specifically adapted to endoscopic surgery. The path of these incisions is of course the future location of scars, which are therefore virtually invisible since they are very short and hidden in the hair. Detachment includes the temples and facial bones (**Figures 5 and 6**).

month before and one month after surgery. An antiseptic shampoo should be used the night

The choice between these different techniques will be the result of a discussion between

Hospitalization is short. The admission is in the morning (or even the day before in the

Each surgeon adopts his/her own technique that he/she adapts to in each case in order to

Incisions are between 5 and 10 mm long, are three to five in number and are placed in the

obtain the best results. However, some common basic principles are as follows:

afternoon) and the discharge is permitted either in the evening or the day after the operation.

before and / or in the morning. It is essential to fast (not eat or drink) 6 hours before surgery.

**Figure 5.** Incision sites for endoscopic forehead (brow) lift surgery

**Figure 5: Incision sites for endoscopic forehead (brow) lift surgery**

10

 

**Type of anesthesia**

Two methods are possible:

General anesthesia

patient, surgeon and the anesthesiologist.

**Technique of endoscopic forehead and eyebrow lift**

Local anesthesia deepened by intravenous tranquilizer

Before the operation, motivations and demands of the patients must be analyzed. A careful study of the upper facial region and its relations with the rest of the face should be made. A preoperative assessment is normally conducted as required. The anesthesiologist will be seen in consultation at the latest 48 hours before surgery. No medication containing aspirin should be taken within 10 days prior to surgery. Smoking cessation is strongly recommended at least one month before and one month after surgery. An antiseptic shampoo should be used the night before and / or in the morning. It is essential to fast (not eat or drink) 6 hours before

In preparation for a classic forehead lift, the hair is tied back with rubber bands in front and

behind the incision area. An incision is usually made across the top of the head, just behind the

hairline. Forehead skin is gently lifted and portions of facial muscle and excess skin are removed.

The incision is then closed with stitches or clips. The result of a forehead lift is a younger, more

In an endoscopic forehead lift, the muscles and tissues that cause the furrowing or drooping are

removed or altered to smooth the forehead, raise the eyebrows and minimize frown lines.

Surgeons may use the conventional surgical method, in which the incision is hidden just behind

the hairline; or it may be performed with the use of an endoscope. Both techniques yield similar

Low, heavy "V" shaped eyebrows create a tired, older, masculine, unfriendly appearance.

Opening up the eyes and brows and smoothing the forehead is both powerful and subtle.

Patients look more awake, fresh, healthy and youthful. Forehead surgery is normally done in

Before the operation, motivations and demands of the patients must be analyzed. A careful

study of the upper facial region and its relations with the rest of the face should be made. A

preoperative assessment is normally conducted as required. The anesthesiologist will be seen in

consultation at the latest 48 hours before surgery. No medication containing aspirin should be

The choice between these different techniques will be the result of a discussion between patient,

results, smoother forehead skin and a more animated appearance.

Hospitalization is short. The admission is in the morning (or even the day before in the afternoon) and the discharge is permitted either in the evening or the day after the operation.

combination with an eye lift (blepharoplasty) for best results.

Each surgeon adopts his/her own technique that he/she adapts to in each case in order to obtain

Incisions are between 5 and 10 mm long, are three to five in number and are placed in the scalp, a few centimeters behind the forehead hairline. One of them will allow the passage of the endoscope connected to a mini video camera, the other giving way to the different instruments

surgery.

**3.2. Type of anesthesia**

**•** General anesthesia

9

Two methods are possible:

**Figure 4.** Classic forehead lift incision

rested look (**Figure 4**).

494 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

surgeon and the anesthesiologist.

**•** Local anesthesia deepened by intravenous tranquilizer

**Figure 4 : Classic forehead lift incision**

**3.3. Technique of endoscopic forehead and eyebrow lift**

the best results. However, some common basic principles are as follows:

Replacement: Loose tissue will be retightened to soften the "crow's feet", move the tail of the eyebrows upward, and above all the cheek and fat under the eyes that had accumulated over

**Sutures**: The small incisions are closed, often with skin staples that are easily removed or with

taken within 10 days prior to surgery. Smoking cessation is strongly recommended at least one **Figure 6: Dissection and suturing during endoscopic surgery Figure 6.** Dissection and suturing during endoscopic surgery

buried absorbable sutures.

the nasolabial folds will be held in position by deep fixation.

11

Replacement: Loose tissue will be retightened to soften the "crow's feet", move the tail of the eyebrows upward, and above all the cheek and fat under the eyes that had accumulated over the nasolabial folds will be held in position by deep fixation.

**Sutures**: The small incisions are closed, often with skin staples that are easily removed or with buried absorbable sutures.

Depending on the surgeon, the extent of improvements and the possible need for additional procedures, the intervention may take 2 to 3 hours. Possibly some discomfort with a feeling of tension on the temples and cheek may occur. The postoperative course is mainly marked by the appearance of edema (swelling) and ecchymosis (bruising) the size and duration of which is highly variable from one individual to another. The dressing should be removed between the 1st and 3rd days. Staples are removed between the 8th and 15th day. The stigma of the intervention will diminish gradually, allowing the return to normal social and profes‐ sional life after a few more days (10-20 days depending on the magnitude of the surgery). Some numbness of the operated area, possibly some itching on the skull, may be observed during the first weeks. They gradually disappear. A delay of 3 to 6 months is necessary to assess the final outcome. This is the time for all of the edema to be reabsorbed and for the tissues to regain their flexibility. In most cases, intervention results in improvement and significant rejuvena‐ tion of the upper face, with an attenuation of nasolabial folds, padding the area under the eyes and cheeks (with disappearance of the "valley tears") and a decrease of the lower eyelid height.

The results are generally durable, although the aging process is not stopped by the interven‐ tion, the benefit of the lift will be present many years after.

#### **3.4. Ideal candidates**

Most patients opting for lifting are aged between 40 and 50 years, when brow lines and eyelids begin to sag noticeably and wrinkles or creases begin to appear along the forehead. Heredity sometimes causes these problems for people in their 20s and 30s, in which case a brow lift can help. Anyone considering this procedure should have a thorough understanding of what it can and cannot accomplish. After an in-depth discussion, some decide that a brow lift performed in conjunction with other procedures (e.g. a facelift (rhytidectomy) or eyelid surgery (**blepharoplasty**) will provide the best results

### **3.5. Facelift complications**

All surgical procedures carry some uncertainty and risk. Even in the best hands, complications do occur. Fortunately, these are usually treatable. Patients vary in their anatomy, physical reaction to surgery, anesthesia, and healing capabilities, so that the outcome is never com‐ pletely predictable. Surgeons know from experience that two operations in different patients, done almost exactly the same way, may have very different outcomes. Even operations on two sides of the same face or body can have different outcomes, particularly in terms of discomfort, bruising and swelling. Patients are often surprised at this.

It is best if patients anticipate having a complication, and if they do not that is a bonus. There is a well-known phrase in surgery: "The only way to avoid complications is by not operating." Experienced surgeons, particularly toward the end of their careers, are often very candid and admit that they've seen just about every complication in their practice over the years. It is important for the patient and doctor to have a mutual trustful relationship to manage com‐ plications when they develop.

A complication rate of 1% is commonly quoted. It seems small, only one in a hundred, and perhaps this is a rate that is comfortable from a psychological standpoint, an event that sometimes happens to other people. But it should not be too reassuring, even if it is correct. If patients encounter a complication, it's 100 percent as far as they are concerned. They have to understand that it could happen to them. They should have the surgery only if they can tolerate the risks.

#### **Facelift risks and complications may include:**

Replacement: Loose tissue will be retightened to soften the "crow's feet", move the tail of the eyebrows upward, and above all the cheek and fat under the eyes that had accumulated over

**Sutures**: The small incisions are closed, often with skin staples that are easily removed or with

Depending on the surgeon, the extent of improvements and the possible need for additional procedures, the intervention may take 2 to 3 hours. Possibly some discomfort with a feeling of tension on the temples and cheek may occur. The postoperative course is mainly marked by the appearance of edema (swelling) and ecchymosis (bruising) the size and duration of which is highly variable from one individual to another. The dressing should be removed between the 1st and 3rd days. Staples are removed between the 8th and 15th day. The stigma of the intervention will diminish gradually, allowing the return to normal social and profes‐ sional life after a few more days (10-20 days depending on the magnitude of the surgery). Some numbness of the operated area, possibly some itching on the skull, may be observed during the first weeks. They gradually disappear. A delay of 3 to 6 months is necessary to assess the final outcome. This is the time for all of the edema to be reabsorbed and for the tissues to regain their flexibility. In most cases, intervention results in improvement and significant rejuvena‐ tion of the upper face, with an attenuation of nasolabial folds, padding the area under the eyes and cheeks (with disappearance of the "valley tears") and a decrease of the lower eyelid height. The results are generally durable, although the aging process is not stopped by the interven‐

Most patients opting for lifting are aged between 40 and 50 years, when brow lines and eyelids begin to sag noticeably and wrinkles or creases begin to appear along the forehead. Heredity sometimes causes these problems for people in their 20s and 30s, in which case a brow lift can help. Anyone considering this procedure should have a thorough understanding of what it can and cannot accomplish. After an in-depth discussion, some decide that a brow lift performed in conjunction with other procedures (e.g. a facelift (rhytidectomy) or eyelid

All surgical procedures carry some uncertainty and risk. Even in the best hands, complications do occur. Fortunately, these are usually treatable. Patients vary in their anatomy, physical reaction to surgery, anesthesia, and healing capabilities, so that the outcome is never com‐ pletely predictable. Surgeons know from experience that two operations in different patients, done almost exactly the same way, may have very different outcomes. Even operations on two sides of the same face or body can have different outcomes, particularly in terms of discomfort,

It is best if patients anticipate having a complication, and if they do not that is a bonus. There is a well-known phrase in surgery: "The only way to avoid complications is by not operating."

the nasolabial folds will be held in position by deep fixation.

496 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

tion, the benefit of the lift will be present many years after.

surgery (**blepharoplasty**) will provide the best results

bruising and swelling. Patients are often surprised at this.

buried absorbable sutures.

**3.4. Ideal candidates**

**3.5. Facelift complications**


**8.** General dissatisfaction with the cosmetic results, possibility of revision surgery, depres‐ sion or emotional mood changes may also develop.

#### **3.6. Preoperative instructions**

Before undergoing brow lift surgery, we must provide pre-operative instructions; these may include:


#### **3.7. Benefits of brow lift surgery**

All men and women over the age of 40 see signs of aging in the face. The forehead is usually one of the first places where lines and wrinkles appear due to excessive muscle movement. Fortunately, brow lift surgery can do away with a number of cosmetic flaws on the upper third portion of the face. The many benefits of brow lift surgery include: Increase confidence with enhanced appearance, rejuvenated appearance, alleviation of tension in the forehead muscles, causes minimal side effects, fast recovery, excellent, long-lasting results (up to 10 years or more), incisions are well hidden and scarring is minimal, natural-looking results and few potential risks or complications.
