Operative technique: Because so many very different operations exist, presenting the specifics of each is beyond the scope of this summary. Depending upon the operation, the actual lift may be achieved by a combination of skin and muscle removal, tucking of underlying muscle, or loosening of forehead and scalp periosteum with resuspension at a higher level. Incisions may be closed by using simple sutures, staples, bone screws, or sutures placed through bone tunnels.
Variations: The number of different surgical approaches to brow elevation is large and include:
• Coronal forehead lift, in which the scalp is incised from ear to ear over the top of the head
• Endoscopic forehead lift, in which the forehead is elevated through small incisions in the scalp using an instrument called an "endoscope"
• Temporal lift, in which the incision is made over the temple and only the outer portion of the brow is lifted
• Midforehead lift, in which the incision is placed within a wrinkle on the middle of the forehead
• Direct brow lift, in which the incision is made just above the eyebrow
• Internal brow lift, in which the brow is lifted through the upper blepharoplasty incision (no second incision needed)
Advantages: If the brow and forehead are drooping noticeably from weak support, a blepharoplasty will not only not remedy the problem but may actually aggravate it by pulling the brow even lower; forehead surgery is then the better choice. If both brow and eyelid changes are present, the two procedures may be performed during the same operation.
Limitations: See "Comments" below
Care and recovery: Bruising, swelling, and pain are more pronounced than with blepharoplasty, especially with the more invasive variations of the operation. Recovery is usually rapid, especially with endoscopic-assisted surgery skillfully performed.
Risks and complications: The most common complication is objectionable scarring. When surgery is performed from the hairline, the scars are hidden but may still become depressed and be associated with hair loss. When the incisions are made in visible skin, the scars are noticeable, slow to fade, and not always well hidden by natural creases. Only the internal brow lift (browplasty, browpexy) creates no additional scar (but is, unfortunately, a rather weak procedure that doesn't hold up well with time). Other less common complications include nerve damage, hematoma (large blood clot), asymmetry, excessive bruising and swelling, numbness, and scalp itching. If combined with upper eyelid blepharoplasty, the risk of lagophthalmos (inability to close eyes fully) is increased. Contrary to popular opinion, a recent survey conducted by the American Society of Plastic Surgeons found that the complication rates of the open coronal method and closed endoscopic method were comparable, while the coronal lift method was generally believed to be more efficacious.
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