Evolution EnBL

M y E v o l u t i o n wi t h
E n d o s c o p i c Brow - L i f t
Surgery
Renato Saltz, MD, FACSa,b,c,*, Alyssa Lolofie, BSd
KEYWORDS
Facial rejuvenation Endoscopic facial rejuvenation Endoscopic brow lift
KEY POINTS
Brow aesthetics and surgical options for brow lift and forehead rejuvenation.
Ideal candidates for the endoscopic brow-lift technique.
Forehead and periocular anatomy.
Surgical technique and the 4 key steps for endoscopic brow rejuvenation.
Long term results and complications.
INTRODUCTION shape, culture, and overall facial aging and pro-

portions. Currently, we consider the “ideal
The endoscopic approach for forehead rejuvena- aesthetic brow” with the medial brow at or below
tion and brow lift has many advantages.1–19 It pro- the level of the orbital rim, above the medial
vided excellent exposure for release of periorbital canthus, and with a gentle peak on the last two-
soft tissues combined with endoscopic magnifica- thirds toward the lateral end with the lateral tail
tion, shorter scars, and reduced risk of alopecia higher than the medial (Fig. 1). Men’s brows
and scalp sensory changes compared with the should be straight and located at the level of the
traditional open coronal brow lift. The technique supraorbital rim with no lateral temporal elevation,
has improved over the last 15 years with better fix- which is a characteristic of the female brow. With
ation devices, a better understanding of the facial aging, the eyebrows gradually fall and lose
longevity, and decreased complications of the volume, encroach on the orbit, and bunch the
procedure. The endoscopic brow lift offers the pa- skin over the lateral orbital rim, creating what is
tient a much easier and safer solution for the aging known as “temporal hooding.” Anatomically, there
forehead, active wrinkles from corrugator and is no levator mechanism on the lateral brow allow-
frontalis hyperactivity, and the ptotic, asymmetric ing tissue ptosis and loss of volume for causing the
brow. lateral or temporal brow ptosis. Eyebrow ptosis,
eyebrow asymmetry, temporal hooding, and fore-
CONTENT head wrinkles are all indications for forehead reju-
Indications venation and a brow lift (Fig. 2).
The generally accepted ideal for the shape and po-
sition of the brow has been changing over the
Patient Selection
years and through different cultures; therefore,
facialplastic.theclinics.com
brow aesthetics cannot be generalized and must Techniques for forehead rejuvenation include
be evaluated in relation to gender, ethnicity, orbital open coronal, lateral temporal brow lift, direct
a
University of Utah, 5445 South Highland Drive, Salt Lake City, UT 84117, USA; b ISAPS; c ASAPS; d University
of Utah School of Medicine, 5445 South Highland Drive, Salt Lake City, UT 84117, USA
* Corresponding author. Saltz Plastic Surgery, 5445 South Highland Drive, Salt Lake City, UT 84117.
E-mail address: [email protected]
Facial Plast Surg Clin N Am 29 (2021) 163–178

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164 Saltz & Lolofie
order to elevate the brow and forehead soft tissues

(Fig. 3).
The nerves that are encountered and preserved
during endoscopic brow lift include the supratro-
chlear and supraorbital nerves, the 2 main sen-
sory nerves, and the frontal nerve, the main
motor branch of the facial nerve. Care is taken
to appreciate and preserve these nerves during
dissection. Subgaleal dissection (below superfi-
cial temporal fascia) lateral to the temporal line
of fusion will maintain the plane of dissection
deep to the frontal branch. Inferior dissection to
the level of the sentinel vein while remaining the
dissection superficial to the deep temporal fascia
protects the frontal branch from direct division or
traction neuropraxia (injury). Appreciation that the
neurovascular bundles for the supratrochlear and
Fig. 1. Brow aesthetics. Arrows show the ideal brow supraorbital nerves exit the orbit 1.5 and 2.5 cm
position. from midline, respectively, allows gentle division
of the periosteum at that location to avoid division
of the associated vascular bundles or damage to
approach through the brow, transpalpebral brow the nerves (Fig. 4).
lift with direct excision of the corrugator muscles, The sentinel vein is inferior to the inferior tempo-
endoscopic brow lift, and neurotoxin injections.
ral septum and approximates the level of the fron-
Since the introduction of the endoscopic approach tal branch for the facial nerve.
to brow lift in 1993 by Vasconez and Core, I have The muscles of the forehead include the fronta-
not performed an open coronal brow lift. Almost lis, procerus, corrugator supercilii (with oblique
all of my facial rejuvenation cases today include
and transverse heads), the depressor supercilii,
forehead and brow rejuvenation through an endo- and the orbicularis muscles. The brow elevator is
scopic technique. The best candidates for endo- the frontalis muscle, whereas the other muscles
scopic forehead rejuvenation and brow lifts are
all act in various fashions as brow depressors.
patients with flat foreheads (flat frontal bone), no Although release and physical repositioning of
receding hairline (low hairline), and minimal redun- the brow and forehead elevate the brow, division
dant forehead skin. High hairlines and male-
and weakening of the brow depressors also cor-
pattern baldness add to the challenge of being rect dynamic brow ptosis and glabellar frown lines
able to see and remove the glabellar muscles (Fig. 5).
and achieve fixation. In patient selection, the key
problems to be addressed are eyebrow ptosis,
eyebrow position, brow asymmetry, hyperactive Preoperative Preparation
frontalis and corrugator muscles, and frontal and Assessment of the patient includes evaluation of
glabellar frown lines.
both the medial and the lateral brow position, the
ratio from brow to upper eyelid, glabella and fore-
head lines, forehead shape and height, and the
Anatomy (Brief Review)
hairline shape and position. To assess the strength
The anatomy of the forehead and periorbital re- of the muscle action, movement, and depth of soft
gions should be appreciated by the surgeon. The tissue folds, the patient should be asked to frown
temporal ridge is bound by the temporal line of as well as to raise the eyebrows. The eyebrows
fusion, which is a deep bony point of fixation of should also be assessed for the thickness, shape,
the overlying soft tissue. The junction of the facial position, and symmetry. In preoperative consulta-
bone periosteum with the deep temporal fascia is tion, the doctor should advise as to the number of
what is known as the temporal fusion line. It is incisions and type of fixations. Based on the pa-
most caudal extension named fusion ligament. In tient assessment, the operation can be planned.
order to adequately release and mobilize the Patient inclusion is important in that brow lifts are
lateral brow and temporal region, the temporal individualized. The preoperative evaluation in front
line of fusion should be released to the level of of a mirror with input from the patient is key for a
the supraorbital rim. There are also supraorbital successful outcome and reasonable expectations.
ligamentous attachments that require release in The discussion and markings should focus on
My Evolution with Endoscopic Brow-Lift Surgery 165
Fig. 2. Brow aging. (A) Age-related changes of the brow involve brow descent, furrowing, vertical and transverse
frown lines, and crow’s-feet. (B) Early signs of brow and periorbital aging include deflation and brow ptosis with
a lowering of the medial and lateral hair-bearing brown and development of vertical glabellar and horizontal
forehead lines. These changes often result in alterations to facial expression producing a tired, concerned, or
even angry look. There is also real or apparent excess skin on the upper eyelid. (From Foad N., et al. Endoscopic
Plastic Surgery. QMP (Thieme NY). 2008; with permission.)
166 Saltz & Lolofie
Fig. 3. Structural landmarks in the brow. The temporal fusion line lies at the junction of the periosteum and the
deep temporal fascia. It must be released to achieve brow mobility. The orbital retaining ligament, situated at the
lateral supraorbital rim, must also be released. (From Foad N., et al. Endoscopic Plastic Surgery. QMP (Thieme NY).
2008; with permission.)
possible elevation of the anterior hairline; medial also for all medical and nursing personnel involved
brow elevation; position, shape, and elevation of in the surgical case. The novice should take his or
the lateral brow; softening and spreading of the her first assistant to cadaver workshops and/or
intermedial brow space after corrugator resection courses to learn together. The equipment, from
(Fig. 6). endoscope to camera and monitors, is usually
The endoscopic technique is based on the use standard in centers where aesthetic surgeries are
of modern technology whereby the traditional performed. It has become important to test each
eye-hand surgical coordination is done through a system, inspect each instrument, and check for a
video-endoscopic system. Additional extensive backup system as a safeguard. The surgeon
training is necessary not only for the surgeon but must have knowledge of the principles extending
Equipment
Although use of the endoscopic brow lift has nearly
eliminated the need for open coronal brow lifts,
there are additional equipment requirements.
Equipment should be tested before induction of
anesthesia, and backup equipment should be avail-
able. The endoscopic equipment on the cart for
visualization includes a monitor (preferably high
definition), a 3-chip camera with the ability to record
the procedure digitally and take still photographs,
light source, electrocautery base unit, and suction.
The additional equipment on the field should
include an endoscope (most commonly a 4- to 5-
mm 30-degree Hopkins rod with an endoscopic
sheath), camera connector, light source connector,
endoscopic dissectors, endoscopic forceps, endo-
scopic scissors, endoscopic graspers, and a
malleable Durden suction cautery. The devices
Fig. 4. Sensory and motor nerve supply to the brow.
used for fixation can include a drill for a cortical tun-
The supraorbital and supratrochlear nerves are pro- nel, a drill for temporary screw fixation, a drill for use
tected during dissection. The frontal branches of the of the Endotine device (MicroAire, Charlottesville,
facial nerve lie anterior to the deep temporal fascia. Virginia, USA), or a variety of other fixation methods
(From Foad N., et al. Endoscopic Plastic Surgery. preferred by the surgeon. The endoscopic cart
QMP (Thieme NY). 2008; with permission.) should be positioned at the foot of the bed with
the surgeon positioned at the head of the bed
from training, equipment needs and operation, and (Fig. 7).
technical skills.
Fig. 5. Brow musculature. The muscles involved with brow movement are illustrated. The corrugators and proce-
rus contribute to vertical and transverse brow furrows, respectively. (From Knize DM. An anatomically based
study of the mechanism of eyebrow ptosis. Plast Reconstr Surg. 1996 Jun;97(7):1321-33. https://doi.org/10.1097/
00006534-199606000-00001. PMID: 8643714; with permission. (Figure 9 in original).)
168 Saltz & Lolofie
Fig. 6. (A) Ideal candidates for endoscopic brow lift. Ideal candidates for endoscopic brow lift are patients with
short flat foreheads with nonreceding, thick hairlines and normal skin, moderate rhytids, and minimal true skin
excess laterally and over the nasal radix. Poor candidates have high convex forehead, high receding hairline with
thin hair, thick skin, deep rhytids, and true excess skin on the forehead and brow. (B) Clinical candidates for endo-
scopic brow lift: (1) young woman, repeated user of neurotoxins for foreheads wrinkles; (2) young man with
brow asymmetry, hyperactive corrugator, and high forehead; (3) bald man with brow ptosis; (4) aging fore-
head/brow with temporal hooding “camouflaged” by artificially waxing/plucking the lateral brow. ([A] From
Foad N., et al. Endoscopic Plastic Surgery. QMP (Thieme NY). 2008; with permission.)
Position/Markings to that point in both temporal areas. The parame-

dian incisions should be in line with the desired
After adequate informed consent, the patient is
pull of the lateral brow peak; they are usually
marked for surgery in a standing position to use
located as straight lines from the mid pupil superi-
the natural positioning of the brows. The temporal
orly to the anterior frontal hairline. A 1-cm vertical
crest and border of the frontal bone and temporal
line posterior to the hairline is marked in those
fossa are identified; a temporal incision is marked
areas for the paramedian incisions. The location
along a superior lateral vector line from the nasal
of the supratrochlear and supraorbital nerves is
ala crossing the lateral canthus and continues to
also identified and marked. The location of the
a point approximately 2 cm behind the temporal
deep branch of the supraorbital nerve when it rea-
hairline. A 2-cm curved line is then marked medial
ches the hairline is also marked at approximately
Fig. 7. Surgical table and equipment. (From Foad N., et al. Endoscopic Plastic Surgery. QMP (Thieme NY). 2008;
with permission.)
1 cm medial to the temporal crest line. In addition, for underlying unilateral upper lid ptosis, which
the desired vector of brow elevation is also map- causes ipsilateral elevation of the brow to
ped (Fig. 8).20 compensate for upper lid ptosis. In the latter clin-
If the patient is found to have brow asymmetry ical setting, repair of eyelid ptosis often equalizes
on preoperative evaluation, careful examination brow position, avoiding overcorrection of 1 brow
should be performed for true brow asymmetry or compared with the other.
170 Saltz & Lolofie
Fig. 8. Preoperative markings. I prefer the 4-port approach with 2 temporal and 2 paramedian incisions. The tem-
poral incisions are placed on a straight line from the nasal ala in the direction of the lateral canthus, usually 2 cm
behind the temporal hairline. The paramedian incisions are at mid pupil line and start at the hairline. (From Saltz
R, Ohana B. Thirteen Years of Experience With the Endoscopic Midface Lift, Aesthetic Surgery Journal, Volume 32,
Issue 8, November 2012, Pages 927–936, https://doi.org/10.1177/1090820X12462714; with permission. (Figure 3 in
original).)
Anesthesia epinephrine solution in 140 mL of normal saline.

Infiltration is done using a 20-gauge spinal needle
Most commonly, the patient is placed under gen-
in a tumescent fashion. The patient is prepared
eral anesthesia using an endotracheal tube
and draped in a sterile fashion. The endotracheal
secured to the upper teeth with dental floss. Infil-
tube is wrapped with sterile plastic drape, so it is
tration is achieved using a mixture of 20 mL of
inside the sterile field and easily manipulated
2% lidocaine, 20 mL of 0.25% Marcaine, 1 mL of
when the head is turned to either side.
Surgical Technique 6 weeks, with permanent adherence requiring up

to 12 weeks. This work adds convincing support
The brow-lift procedure is divided into the
to the anecdotal observation that short-term fixa-
following 4 key steps:
tion often causes surgical relapse.
1. Blunt subperiosteal dissection over the frontal The temporal fixation is best achieved by using
bone down to the supraorbital rim interrupted 3-0 PDS sutures from the superficial
2. Meticulous division and spreading of the supra- temporal fascia (and galea) into a superior lateral
orbital rim periosteum under endoscopic direction to the deep temporal fascia. The central
visualization portion of the inferior scalp flap may be excised
3. Muscle resection under endoscopic in triangular wedges in order to prevent redun-
visualization dancy at the lateral brow. My experience on
4. Fixation in the temporal and paramedian brow fixation at paramedian incisions has evolved
wounds since 1994 from simple compressing dressings,
tissue glues, plain sutures, cortical tunnels,
The procedure starts approximately 20 minutes external screws, and absorbable screws that did
after infiltration is completed to obtain maximum not offer always adequate fixation and consistent
vascular constriction. The temporal incision allows long-term results. Since 2002, fixation of brow
visualization and dissection on top of the deep elevation at the paramedian areas is best achieved
temporal fascia. Periosteal dissectors are used with the Endotine device (Fig. 13). At this point, still
on the surface of the deep temporal fascia in the under general anesthesia, the patient is examined
lateral area and on the periosteum in the medial in a sitting position for brow position and brow
area. After these pockets are completed, the tem- symmetry; measurements for comparison include
poral line of fusion is released in a lateral-to-medial the mid pupil to top of the middle brow and the
direction, and subperiosteal dissection is lateral cantus to the tail of the brow. The 4 scalp in-
completed over the frontal bone. At this point, a cisions are then approximated with the 4-0 plain
4-mm 30-degree scope is introduced to continue gut. The hair is washed, and the patient is taken
the dissection (Fig. 9). to the recovery room. No dressings are applied.
The sentinel veins are identified and preserved
(Fig. 10). The “fusion ligament,” characterized by Postoperative Care
the junction of the forehead periosteum with the
deep temporal fascia at the level of the lateral su- In the recovery room, the position of the patient’s
praorbital rim, is identified and divided using the head is maintained as elevated to 30 to avoid
endoscopic scissors; it is a key component to airway obstruction and excessive facial edema.
allow full elevation of the lateral brow. The lack of The patient’s blood pressure must be carefully
proper identification and division of the fusion liga- monitored to avoid bleeding and hematomas, usu-
ment can cause suboptimal elevation of the lateral ally maintaining it at less than 120/80 mm Hg. Bags
brow and early relapse of the brow-lift result of crushed ice can be used over the eyes and fore-
(Fig. 11). head. The patient is allowed to shower on the first
The dissection continues medially where the su- postoperative day. Oral analgesia is given, and an-
praorbital nerve is identified and preserved. I do tibiotics are used for up to 24 hours. Lymphatic
not transect the periosteal attachments in be- drainage massage, starting at 48 to 72 hours post-
tween the corrugator muscles to minimize the operatively, can help with initial swelling improve-
medial brow elevation and the so-called surprised ment in the initial postoperative period and
look. At this point, the corrugator muscles are improve discomfort, bruising, and appearance in
identified and completely excised (Fig. 12). the early postoperative period.
Manual palpation and gentle pressure over the
skin avoid trauma to the dermis and possible in- Pitfalls and How to Correct
dentations during endoscopic corrugator resec- Despite the advantages, the endoscopic approach
tion. In the case of very thin skin and possible for forehead rejuvenation and brow lift is not
indentation, I recommend immediate placement without complications. Relapse has declined
of fat grafts with suture fixation. At this point, the over the years because of increased use of
surgeon should feel how mobile the lateral brow longer-term fixation. The “surprised look” has
is and be sure that both are equally mobile and been eliminated by preserving a bridge of perios-
symmetric in preparation for fixation. teum at the midline and by avoiding fixation in
Experimental work from Boutros and Romo in the para median incisions in patients that have
guinea pigs and rabbit periosteum demonstrated very mobile medial brows or a hyperactive medial
that periosteal partial adherence can take up to frontalis muscle. Alopecia has been eliminated in
172 Saltz & Lolofie
Fig. 9. (A, B) Forehead dissection. Dissection starts at the temporal region using periosteal dissectors on the sur-
face of the deep temporal fascia in the lateral area and on the periosteum in the medial area. After these pockets
are completed, the temporal line of fusion is released in a lateral-to-medial direction. This “blind dissection” is
kept above the supraorbital rim by approximately 1 cm. The index finger of the contralateral hand stays on
top of the supraorbital rim to protect the orbit and its contents. The 30-degree-angle 4-mm endoscope is only
introduced after the temporal and forehead regions are completely undermined. The temporal pocket is devel-
oped easily and safely by smooth dissection on top of the deep temporal, above the temporalis muscle and below
the superficial temporal fascia, protecting the intermediate fat pad and the frontal branch of the facial ner-
ve.DTF, deep temporal fascia; LZTN, lateral zygomatic temporal nerve; MZTN, medial zygomatic temporal nerve;
TPF, temporal parietal fascia also known as superfical temporal fascia; ZFN, zygomatic facial nerve. (From Foad N.,
et al. Endoscopic Plastic Surgery. QMP (Thieme NY). 2008; with permission.)
my practice after I abandoned percutaneous potential complication. It can be minimized by

screw fixation and changed to the completely adequate scalp incision placement, avoiding
buried Endotine device. The alopecia was caused trauma to the deep branch of the supraorbital
by improper local pressure in the surrounding nerve as well as gentle tissue manipulation and
scalp skin with the screw fixation technique. Anec- careful soft tissue retraction using the endoscope.
dotal reports have blamed the cortical tunnel tech- The subperiosteal dissection plane retains the
nique for fixation as the cause of an intracranial vascular blood supply within the forehead flap;
bleeding during an endoscopic brow-lift proced- therefore, subperiosteal dissection maximizes
ure. Injury to the supratrochlear and supraorbital flap blood supply and minimizes trauma to the
nerves causing temporary paresthesia is another deep branch of supraorbital nerve. Temporary
Fig. 10. Division of supraorbital periosteum, starting from lateral to medial with full release of the “fusion liga-
ment” and stopping short of the midline, which is the key to avoiding complete release from side to side and to
avoiding migration of the medial brow and the “surprised look.” (From Foad N., et al. Endoscopic Plastic Surgery.
QMP (Thieme NY). 2008; with permission.)
paresthesia and some irregularities of the frontalis

muscle are occasionally seen but usually improve
within 2 to 3 weeks. Correction of eyelid ptosis
with levator aponeurotic advancement corrects
lid malposition and brow asymmetry from
compensatory brow elevation. Early detection of
postoperative brow asymmetry (within 24–
48 hours) can be improved by repositioning the
paramedian fixation through reelevation and pos-
terior displacement of galea/skin from the Endo-
tine. Delayed temporary brow asymmetry can be
improved with Botox injections. If the brow asym-
metry persists and there is obvious recurrence of
brow ptosis, reintervention is advised.
Blind Brow Lifts

Nonendoscopic procedures for forehead rejuve-
nation are now very popular; I call them “blind
Fig. 11. Sentinel vein. The sentinel vein is encoun- brow lifts” because the better one can see, the
tered during endoscopic dissection. The identification more precise and safer the technique can be. Su-
of the sentinel vein identifies a standard landmark for
praorbital neve variations are common (Fig. 14).
the frontal branch of the facial nerve. Dissection
The operative time for blind brow lifts is no better
should not proceed beyond this. (Reproduced from
Saltz R, Codner M. Endoscopic brow lift. In: Nahai than endoscopic; one would have to dissect
FR, Nahai F, Codner M (eds). Techniques in Aesthetic widely around all potential anomalous variations
Plastic Surgery: Minimally Invasive Facial Rejuvena- of the supraorbital nerve to avoid injuries and per-
tion. Philadelphia, PA: Saunders Elsevier; 2009; with manent paresthesia in the forehead and anterior
permission. (Figure 3.23 in original).) scalp. They require larger incisions with potential
174 Saltz & Lolofie
Fig. 12. Corrugator muscle. The corrugator muscles may be resected endoscopically with grasping forceps, taking
care not to injure the supraorbital or supratrochlear nerves. (From Foad N., et al. Endoscopic Plastic Surgery. QMP
(Thieme NY). 2008; with permission.)
damage to the deep branch of the supraorbital coordination. The ability to master both skills
nerve with permanent sensory loss and alopecia. will affect the safety and quality of the results.
Nonendoscopic “blind brow lifts” are applicable It involves significant learning curve for the
in selected patients in whom only lateral lift is surgeon and staff.
needed and no forehead wrinkles and no corruga- Surgeon and operating room personnel
tor release is indicated or required. should be familiar with the endoscopic equip-
ment and advanced technology and be able
to troubleshoot problems.
Pearls
The procedure has basically 4 steps: (1)
Endoscopic brow lifts are dependent on tech- dissection of temporal and forehead soft tis-
nology and dissociation of eye-hand sues, (2) release of supraorbital rim
Fig. 13. Endotine fixation. The Endotine divot hole is drilled through the first layer of skull bone and situated at
the caudal extent of the incision. The Endotine is snapped into place. The scalp can then be repositioned vertically
and held into place by fixation tines. Arrow demonstrates applying pressure of skin over the endotine. (From
Foad N., et al. Endoscopic Plastic Surgery. QMP (Thieme NY). 2008; with permission.)
Fig. 14. Supraorbital nerve variations. Arrows demonstrate the many variations of supra orbital nerve position.
periosteum, (3) corrugator removal, and (4) muscle (unilateral or bilateral) for 2 to 4 weeks
forehead and temporal fixation. with all recovering full muscle function without
Keeping the dissector close to the deep tem- requiring any additional treatment besides reassur-
poral fascia is much safer and avoids any ance and occasional neurotoxin injections to soften
trauma to the frontal branch of the facial the temporary brow asymmetry. Endoscopic fore-
nerve. head rejuvenation is a safe and reproducible tech-
Knowledge of the anatomy of motor and sen- nique that requires proper endoscopic training
sory nerves and careful dissection during and learning curve with proper informed consent.
brow-lift surgery are essential to prevent The endoscopic approach for brow lift has many
complications. advantages and is the gold standard in forehead
Keeping the assistant’s fingers palpating the rejuvenation. It has many advantages: it provides
skin while avulsing the corrugators may pre- excellent exposure for safe release of periorbital
vent overresection of subcutaneous fat with tissues combined with endoscopic magnification;
resulting depression. it is performed through small scalp incisions with
Avoid dividing periosteum from side to side. reduced risk of alopecia and scalp sensory
Preserving the periosteum intact at midline changes compared with traditional open coronal
will prevent elevation of the medial brow and brow lift; and it can be combined with blepharo-
the “surprised look.” plasty when indicated and safe resurfacing tech-
In most cases, in women, the lateral brow needs niques (CO2 laser, trichloroacetic acid peels) to
to be elevated higher than the central and forehead and periocular areas. The technique
medial brow. In men, the elevation should be has improved over the years with a better under-
equal to avoid feminization of the male brow. standing of the periosteal adherence and conse-
Early failure is caused by inadequate release quently better fixation devices, a better
of periosteal septa and adhesions. Late failure understanding of the long-term results, and
is caused by inadequate fixation. decreased complications. It offers the patient a
much easier and safer solution for the aging fore-
SUMMARY head and the ptotic, asymmetric brow. The endo-
scopic brow lift is a time-tested method of
Our experience from 1994 to 2020 includes more providing highly accurate, precise, safe, long-
than 2000 cases with 80% of the endoscopic lasting, and aesthetically focused rejuvenation of
brow lifts combined with facelifts. The longest the entire forehead, brow, and periocular region
well-documented follow-up is 15 years with overall in a reasonable amount of time when done prop-
good long-term results and no visible scars. In our erly by a trained surgeon. It is also the safest and
series, 20% of patients report Endotine sensitivity easiest “gate” to the midface. (Figs. 15-19).20-22
for approximately 1 month and a weak frontalis
176 Saltz & Lolofie
Fig. 16. Case 2 - Endoscopic Brow Lift combined with

Endoscopic Midface Lift using 2 temporal and 2 para-
median scalp 1cm incisions. Fixation of the brow with
ultratines and fixation of the midface with the endo-
midface device. Follow up at 1 year
Fig. 15. Case 1 - Endoscopic Brow Lift combined to

Transconjuntival Blepharoplasty. Ultratines used for
paramedian fixation and 3-0 PDS for temporal fixa-
tion. Follow up at 1 year.
Fig. 18. Case 4 - Endoscopic Brow Lift 2 temporal and

2 paramedian scalp 1cm incisions combined to Facelift
and Necklift. Endotines used for paramedian fixation
and 3-0 PDS for temporal fixation. Follow up at 1 year.
Fig. 17. Case 3- Endoscopic Brow Lift combined to up-

per and lower blepharoplasty (transconjuntival) and
neck liposuction. Emdotines used for paramedian fix-
ation and 3-0 PDS for temporal fixation. Follow up at
2 years.
178 Saltz & Lolofie
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Fig. 19. Case 5 - Endoscopic Brow Lift 2 temporal and
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2 paramedian scalp 1cm incisions combined to Facelift
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Evolution EnBL

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Evolution EnBL

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M y E v o l u t i o n wi t h

INTRODUCTION shape, culture, and overall facial aging and pro-

Facial Plast Surg Clin N Am 29 (2021) 163–178

order to elevate the brow and forehead soft tissues

Position/Markings to that point in both temporal areas. The parame-

Anesthesia epinephrine solution in 140 mL of normal saline.

Surgical Technique 6 weeks, with permanent adherence requiring up

my practice after I abandoned percutaneous potential complication. It can be minimized by

paresthesia and some irregularities of the frontalis

Blind Brow Lifts

Fig. 16. Case 2 - Endoscopic Brow Lift combined with

Fig. 15. Case 1 - Endoscopic Brow Lift combined to

Fig. 18. Case 4 - Endoscopic Brow Lift 2 temporal and

Fig. 17. Case 3- Endoscopic Brow Lift combined to up-

4. Matarasso A, Matarasso SL. Endoscopic surgical

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