- Forehead wrinkles/frontalis hyperactivity.
- Glabellar vertical wrinkles _ Scowl appearance.
- Root nose horizontal wrinkles.
- Frontal bossing/prominent orbital rims (ancillary procedures).
- Brow ptosis.
Goals of endoscopic forehead lifting are: (Keller GS)
- Reduce forehead rhytids.
- Elevate the brows.
- Diminish lateral hooding.
- Diminish infrabrow skin overhang.
- Reduce forehead scarring.
- Reduce or eliminate hair loss.
- Diminish forehead elevation.
- Reduce degree of morbidity.
- Reduce postoperative recovery time.
- Reduce incidence of parasthesias.
Fig. 18 – 12. (A)Incisions for a bald male. (B) Anatomy and general principles of endoscope forehead lift
Advantages of endoscopic forehead lifting are:
- Decreased scarring (scalp).
- Reduce numbness (scalp).
- More acceptable to the patient.
- Good for patients with thin hair or baldness.
- Less bleeding.
- Less eodema.
Disadvantages of endoscopic forehead lifting are:
- Technique may be difficult and needs instructed cadaver workshop.
Technique: the author recommends the Anthony Geroulis method.
- The incisions are marked while the patient is in a sitting position. Five incisions may be made for the dissection: one along the midline of the forehead as a semi-circle, one above each iris and one in each of the temporal areas (Fig. 18 – 9A). For male patients, the iris incision is usually placed in the scalp directly above the midline of the iris. In most female patients, the scalp incision is made at the lateral border of the iris. The position of the temporal incisions are determined by the use of a straight line from the nasal ala across the lateral canthus of the eye to the temporal area. In men, attention is also paid to the placement of the incisions according to the patient’s hair line. There are three general types of incisions in male patients: standard incisions for male (Figs. 18 – 11A,12B), incisions for male with thinning hair (Fig. 18 – 11B) and incisions for a bald male (Fig. 18 – 10A). The latter simply eliminates the central incision of the other two techniques, which avoids a possibly obvious scar.
- Local anaesthesia with sedation: 1% Xylocaine with 1:200,000 adrenaline. This is injected at the incision sites and subgaleal across the entire top of the skull and forehead. When the patient is adequately sedated and anaesthetized, the incisions are made. The dissection begins in the lateral temporal area. The deep temporalis fascia is identified and several small pinpoint marks with the electrocautery on the temporalis fascia. This marks the original position of the scalp and allows for assessment of the degree of the skin retraction on the forehead. This becomes important in the analysis of correction for fascia symmetry.
- A drill-hole mark is made in the skull at the anterior aspect of both the right and left iris incisions with a hand-held drill system. The surgeon will use this mark at the end of the procedure to measure the distance of the skin retraction of the brows. This is particularly important in the correction for an asymmetry of the brows.
- The dissection continues through the midline incision and through the right and left iris incisions with a periosteal elevator or a mastoid elevator. This dissection is in the subgaleal plane anterior over the forehead. The extent of the dissection in this plane is determined by the extent of the male patient’s rhytids. For severe forehead rhytids, the subgaleal dissection extends to just above the brow. Posteriorly, the dissection is subgaleal to the occipital area to the occipitalis muscle (Fig. 18 – 12B). The periosteal flap is then elevated to about two finger-breadths above the eyebrows. At this point, the two flaps have been established; the galeal flap and the periosteal flap, and the scalp is fully mobile. Once this is completed, dissection continues endoscopically with the subperiosteal elevation.
- Now, an endoscope is inserted into the temporal incision. A five mm, 300 endoscope is preferred, with light source and an auto-exposure video camera. The dissection continues with an elevator on the deep temporalis fascia toward the zygomatic