Forehead lift

Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [mailto:Newmanm@ccf.org]; Michel C. Samson, M.D., FRCSC, FACS [mailto:samsonm1@ccf.org]

Overview
A forehead lift, also known as a browlift or browplasty, is a cosmetic surgery procedure used to elevate a drooping eyebrow that may obstruct vision and/or to remove the deep “worry” lines that run across the forehead and may portray to others anger, sternness, hostility, fatigue or other unintended emotions.

Patients commonly request rejuvenation surgery on the forehead because the area is large enough to comprise the major focal and expression point of the upper face, the eyes notwithstanding. Given time and gravity, the muscles that hold the forehead smooth become loose and weak, allowing deep wrinkles to appear. Correction of a wrinkled forehead usually leads to a more youthful look. Patients requesting the procedure commonly range in age from 40 to 60.

A forehead lift is often used in combination with eyelid surgery to reduce sagging skin found on the upper eyelids.

Multiple surgical approaches can be utilized. A direct brow lift is performed by removing an ellipse of skin and muscle just above the eyebrows. The incision is hidden within the brow hair. This technique does not address wrinkles or lines within the forehead and surgical scars may be prominent. It is typically reserved for older patients or for men with thick eyebrow hair and male pattern baldness.

A mid-forehead lift is intended for patients older than 65 who have heavy sagging eyebrows and the deepest forehead wrinkles. To bring about a more youthful look, the surgeon makes incisions within the deep forehead wrinkles and removes the excess skin, fat and muscle. Incisions are made within the deep wrinkles so that the resulting scars are hidden and not very noticeable after healing.

A coronal forehead lift is performed by making an ear to ear incision across the forehead and elevating the entire forehead and brow.

The most current technique, called an endoscopic forehead lift, involves the use of a surgical telescope to elevate the brows and smooth forehead wrinkles through small incisions made behind the hairline.

History
The first documented medical discussion about a forehead lift was written in 1910 by the famous German surgeon Erich Lexer.

The main surgical method of lifting the forehead from Lexer’s time up until the 1950s was then known as a coronal, or open, forehead lift.

While the procedure is currently used far less frequently, the surgeon began the procedure by making one, long incision running from ear to ear over the top of the head through the hairline. The surgeon lifted the skin and muscles upwards and free from the bone, pulled the tissues up toward the top of the head, trimmed the excess and closed the incision with sutures. The incision was initially made well into the hairline so the scar could not later be seen.

In some cases, especially those in which the eyebrows and forehead skin are not too heavy, the upper eyelids are also elevated. In most cases, the procedure provides the smoother appearance which many patients want to help look younger and more refreshed and rested In the late 1950s, and 60s some surgeons achieved the younger appearance on the forehead by scoring or removing some of the small forehead muscles -- most notably the frontalis muscle which causes frowning and grimacing.

Current surgical techniques
Since the advent of the hugely popular wrinkle remover, Botox (Dysport in the United Kingdom and Europe) many consumers have eschewed the invasive surgery altogether, opting for Botox injections every four to six months to get the same results. Botox is also used after some forehead lift procedures to increase the effects of the surgeries.

Endoscopic surgery is often employed in forehead lifts. An endoscope is a surgical system with thin, pencil-sized arms that are inserted through three to five incisions about 3/8 of an inch long. One of the instrument’s arms is a lighted camera that displays what it sees under the patient’s skin on a television monitor. Other arms on the Endoscope carry actual surgical tools that perform cutting, or grasping functions. The surgeon watches the television monitor to guide his movements.

Yet another advancement to endoscopic forehead lift surgery is with a fixation device known as an Endotine The bioabsorbable Endotine implant is: First, the surgeon frees the tissues of the forehead from the skull, then lifts them upwards and engages them onto the implant tines which hold them in place. The upside is the surgeon can readjust the height of the lift by simply moving the tissues up on the Endotine. If left undisturbed for 30 to 60 days, the forehead tissues heal to the bone at the higher position. The body absorbs the Endotine in about four to seven months. However, patients report they can feel the Endotines under the skin for some months after their procedures.
 * Essentially a hanger with five small tines
 * Affixed by inserting a flanged post into a drill hole in the skull

Risks
When surgeons have problems with an endoscopic forehead lift, -- in about one percent of cases -- they finish the procedure by switching to the open forehead lift method.

Complications are said to be rare and minor when a forehead lift is done by a surgeon trained in the technique. Facial plastic surgeons certified by the American Board of Plastic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery have been adequately trained to perform this procedure. However, it is possible for the surgical process to damage the nerves that control eyebrow and forehead movements. Hair loss can also occur along the scar edges in the scalp when an incision is made through the hairline. Moreover, infection and bleeding are possible with any surgical procedure.

Patients who have Endotine implants in their foreheads risk moving their newly adjusted tissues with relatively small movements just after the operation and before complete healing takes place. While the implant absorbs into the body, the Endotine generally does not support the very thick forehead flesh and heavy brows often seen in some overweight males.