plastic surgery performed to raise the brow. Facial muscles affecting the eyebrows can be classified as those that pull the eyebrows toward the midline & downward (corrugator & orbicularis muscles) & those that raise the eyebrows upward (frontalis muscle). These muscles work in an agonist/antagonist fashion much in the same way as flexor & extensor muscles affect wrist, hand & finger motion. The downward/inward muscle action is focused on a narrow area while the elevating frontalis muscle works over a broader area-between the outer edges of both eyebrows. Thus over time the downward/inward muscles win, the eyebrow hairline moves southward & a permanent vertical skin crease is created above the nose between the eyebrows. Although the frontalis loses over time its overactivity results in the formation of horizontal forehead skin creases.
After a long period of time these creases become very deep. Scar tissue can even form between the undersurface of the skin & the muscle or bone. When the creases are milder they readily respond to botox injections which temporarily paralyze the muscles that create these creases/wrinkles. For more severe prolonged cases excess forehead skin is created by this process that complicates the treatment. For permanent treatment of the problem the inward/downward muscles are removed via endoscopic forehead lifts, eyelid/blepharoplasty incisions, regular open forehead lift (an incision from ear to ear over the top of the head) or even through nasal incisions during rhinoplasty/nose jobs. If there is a large excess of forehead skin this has to be removed by open forehead lift surgery. Removal of the muscles does not result in much functional deficit because these muscles are only activated when exposed to bright light or sunlight, when straining the eyes to compensate for poor eyesight or when the eyes are exposed to noxious stimuli such as smoke.
In the early stages treatment can include botox to temporarily paralyze muscles, alpha hydroxy acid creams or laser treatments to lighten creases, being fit for proper eyeglasses or contacts to prevent squinting, stop smoking (the noxious fumes cause reflex squinting), regular use of sunglasses to prevent squinting while exposed to bright sunlight…
The classical open forehead lift surgery or coronal browlift involves placing a incision from ear to ear over the top of the head. Loss of hair in the scar line &/or hair thinning in front of the scar line are the most common complications. To prevent a visible scar the incision should be placed about 3 inches behind the hairline & the incision bevelled to prevent damage to hair follicles that normally are situated at a less than 90 degree angle to the skin surface. The only way to treat this complication is hairgrafting because if you just cut out the area lacking hair the new scar line will stretch & thicken becoming even more visible.
The endoscopic approach was introduced to prevent this complication by placing 3 to 5 less than a half inch incisions near the hairline & introducing endoscopic equipment through these incisions to perform the procedure. This technique though is not without it’s own possible complications which include loss of hair at the access incisions & incomplete removal of the corrugator muscles (the muscles that create frown lines between the eyebrows & that are removed in browlift/foreheadplasty procedures). In the past most physicians also placed some sort of fixation (a screw or suture) to keep the brow elevated during the initial healing period.If you have a lot of excess forehead skin especially after the age of 50 or 60 it just will not shrink after the endoscopic approach so you need to have the open approach procedure. Thus the endoscopic approach is probably best for those with milder aging changes of the forehead.
The issue of too high a forehead is separate & not necessarily due to which specific technique was used. In a middle aged or older adult the forehead height also know as upper face height should be 1 to 2cm more than the midface height (the distance
between the eyebrow level & the level where the nose meets the upper lip). If browlifting is over done the eyebrow can be raised too high giving a constant startled look. In a women the eyebrow should lie about 5mm above the upper boney rim of the eye socket. You could place grafts in front of the frontal hairline if too much scalp has been removed by the open procedure but this would not address the high eyebrows which presumably would be present. Recently procedures have been developed to raise the brows without raising the frontal hairline for people who already have high foreheads.
Dr. Stone has performed all 3 procedures endoscopic, coronal & removal via eyelid blepharoplasty incisions. Clearly all of these methods are valid but different patients are better candidates for one approach vs. the others. He no longer uses screw or suture fixation in endoscopic brow surgery as they seemed to be more trouble than they were worth.