F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am 14 (2006) 203–211

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Endoscopic Brow-Lift with DeepTemporal Fixation Only (DTFO)Paul S. Nassif, MD, FACSa,b,c,*

- Patient selectionPsychologic considerationsAnatomic considerations

- Surgical goals- Endoscopic brow-lift- Endoscopic brow-lift with deep temporal

fixation only- Temporal lift- Treatment of the depressor muscles with

botulinum toxin- Surgical technique

IncisionsLocal anesthesiaDissection over frontal and parietal bonesTemporal dissection and release of the

periosteum and lateral supraorbitalorbicularis oculi muscle

Release of the brow depressor musclesBrow elevation and fixation

- Postoperative care principles- Complications- Results- References

Although different regions of the face age at vari-able rates and are influenced primarily by geneticfactors, the upper third of the face ages in its ownunique fashion (Fig. 1) [1]. As skin elasticity de-clines, the forehead, temple, and glabellar skin de-scends. The brow, especially in its temporalaspect, descends to or below the supraorbital rimwith the effects of gravity causing temporal hood-ing. If brow ptosis is severe, a visual deficit may de-velop in the superior and temporal quadrant. Thesupratarsal crease disappears by overhanging ptoticupper eyelid skin. Crow’s feet (rhytids at the lateralcanthus) appear secondary to gravity and repeatedcontraction of the orbicularis oculi muscle. Deepforehead creases appear owing to the repetitive ac-tions of the primary brow elevator, the frontalis

1064-7406/06/$ – see front matter ª 2006 Elsevier Inc. All rightfacialplastic.theclinics.com

muscle, in an effort to elevate the heavy ptotic brow.Vertical, oblique, and horizontal rhytids appear inthe glabella and nasion from contractions of thebrow depressors, the corrugator, procerus, and de-pressor supercilii muscles.

Patient selection

Psychologic considerations

As is true for any facial plastic surgery procedure,careful patient selection is paramount. Realistic ex-pectations and proper motivations of the patientare extremely important in achieving a successfuloutcome, a satisfied patient, and a pleased facialplastic surgeon. Despite a visually pleasing surgical

a Department of Otolaryngology, University of Southern California School of Medicine, 2025 Zonal Avenue,KAM-100B, Los Angeles, CA, USAb Department of Otolaryngology, University of California, Los Angeles School of Medicine, 10833 Le ConteAvenue, Los Angeles, CA, USAc Spalding Drive Cosmetic Surgery & Dermatology,120 South Spalding Drive, Suite 315, Beverly Hills, CA90212, USA* Spalding Drive Cosmetic Surgery & Dermatology, 120 South Spalding Drive, Suite 315, Beverly Hills, CA90212E-mail address: drnassif@spaldingplasticsurgery.com

s reserved. doi:10.1016/j.fsc.2006.04.004

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result, if the surgeon does not perform proper pa-tient screening, patient dissatisfaction may be en-countered. Educating patients about the differentsurgical procedures and goals requires excellentphysician-patient communication and guidance.Computer imaging of the proposed brow elevationmay enhance the communication of surgical goalsbecause few patients are aware that brow ptosis isresponsible for their orbital changes. Often, pa-tients think and are told that droopy eyelid skinin the presence of a ptotic brow is the etiology oftheir ‘‘saddened’’ look. If upper blepharoplasty isperformed in this situation, the eyebrow-lid marginis potentially narrowed, obliterating adequate de-lineation of the supratarsal anatomy by sacrificingexcessive upper eyelid skin [2]. Following the edu-cation process, informed consent must be obtainedfrom candidates for aging brow surgery discussingpossible adverse outcomes, complications, andrisks of the selected surgical procedure.

Anatomic considerations

Analysis of the upper third of the face, from the eye-brows to the hairline, should begin with the assess-ment of interpersonal factors that may significantly

Fig. 1. Characteristics of the aging brow, temple, eye-lids, and face. Although environmental influencesmay worsen or hasten aging changes, each person’sgenetic disposition has the predominant role in theaging process. (Adapted from Nassif PS, Thomas JR.Management of the aging brow and forehead. In:Cummings CW, Flint PW, Harker LA, et al, editors. Oto-laryngology Head & Neck Surgery. 4th edition. Phila-delphia: Elsevier Mosby; 2005. p. 752; with permission.)

affect the patient’s interpretation of successful surgi-cal intervention. Age, gender, race, body habitus,and personality are the main interpersonal compo-nents that must receive consideration when assess-ing the eyebrow complex [3].

When determining what brow-lifting procedureshould be employed, specific anatomic criteriashould be evaluated when examining the patient.The patient should be examined in a sitting posi-tion and in facial repose. Manually elevating thebrow will reveal the favorable effect of brow eleva-tion. Individuals with ptotic eyebrows often invol-untarily attempt to elevate the brow with frontalismuscle contraction. To eliminate ‘‘pseudo-eleva-tion’’ of the brow, the patient should be asked toclose her or his eyes and then slowly open up theireyes after allowing the frontalis muscle to relax. Thetrue position of the eyebrow can than be evaluatedin repose by the surgeon. Additionally, the eyebrowposition can be examined with the eyes closed.

Surgical goals

The goals associated with rejuvenation surgery ofthe brow and upper third of the face include the fol-lowing [4]:

Elevation of ptotic eyebrowsReduction of lateral hooding and redundant up-per eyelid skinElevation of lateral canthus (if needed)Reduction of glabellar and corrugator rhytidsReduction of transverse forehead rhytidsReduction of lateral canthal ‘‘crow’s feet’’ rhytidsCorrection of eyebrow asymmetry

In general, the selected brow elevation procedureshould be performed before upper blepharoplastyso that the facial plastic surgeon can judge the pre-cise amount of upper eyelid skin to be removed.This staging helps prevent excessive elevation ofthe brow-lid complex with the potential for causinglagophthalmos. In some cases, the need for upperblepharoplasty may be eliminated after brow-liftingprocedures.

Endoscopic brow-lift

Traditional methods of forehead and brow rejuve-nation, such as coronal, pretrichial, and directbrow-lifts, have provided facial plastic surgeonswith effective brow elevation for many years. Often,the traditional methods have been consideredtraumatic and invasive, fraught with lengthy postop-erative rehabilitation, and burdened with complica-tions objectionable to the esthetic patient (eg, hairloss, anesthesia, scars). In the past decade, the endo-scopic forehead and brow-lift has rapidly become

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accepted as part of the surgical armamentarium andis frequently the technique of choice [5–7].

As is true for all new surgical procedures, a periodof trial and error and a steep learning curve are inher-ent to the development and improvement of thetechnique. This learning curve has been especiallytrue for the endoscopic brow-lift, because most cos-metic surgeons, regardless of their particular back-ground and specialty training, were not familiarwith this technology when the procedure firstemerged. As in the development of all new technol-ogy, perseverance, hard work, and diligent study and

Frontalis muscle

Corrugatormuscle

Orbicularisoculi

muscle

Depressorsupercillimuscle

Procerus muscle

Fig. 2. Frontal illustration of brow muscles. (Adaptedfrom Nassif PS, Thomas JR. Management of the agingbrow and forehead. In: Cummings CW, Flint PW,Harker LA, et al, editors. Otolaryngology Head & Neck.4th edition. Philadelphia: Elsevier Mosby; 2005. p. 756;with permission.)

Fig. 3. Supraorbital orbicularis oculi Botox injectionsites (X). Two injections totaling 4 U. (Adapted fromZimbler MS, Nassif PS. Adjunctive applications forbotulinum toxin in facial aesthetic surgery. FacialPlast Surg Clin North Am 2003;11(4): 477–82; withpermission.)

observation eventually define the significance andfeasibility of a technique. This paradigm has heldtrue with endoscopic brow-lifting. Contemporarysurgeons who routinely perform the procedure havefound that it has become an integral part of theirsurgical armamentarium that has revolutionized,modernized, and simplified eyebrow-lifting surgery.

Endoscopic brow-lift with deep temporalfixation only

Endoscopic brow-lifting techniques have been pro-gressively refined through experience and improve-ments in equipment [5–7]. In general, the temporaldissection and temporal fixation have been stan-dardized; however, different options for foreheaddissection are available. Subperiosteal dissection

Fig. 4. Marking of the temporal incision (large arrow)parallel to the tail of the brow with its medial extentat the temporal conjoint fascia (small arrow). (FromCummings CW, Flint PW, Harker LA, et al, editors.Otolaryngology Head & Neck Surgery, Vol. 1. 4th edi-tion. Philadelphia: Elsevier Mosby; 2005. p. 757; withpermission.)

Fig. 5. The temporal incision has been made andtaken down to the deep temporal fascia (arrow).(From Cummings CW, Flint PW, Harker LA, et al, edi-tors. Otolaryngology Head & Neck Surgery, Vol. 1.4th edition. Philadelphia: Elsevier Mosby; 2005. p.757; with permission.)

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with release (elevation, incision, and spread) ofperiosteum and subgaleal dissection and releaseof brow depressor musculature to the supraorbitalrim are effective techniques used in endoscopicbrow-lifts [8]. Bony fixation remains a controversialtopic because there are numerous methods. Someof these methods include absorbable and nonab-sorbable screws [5], bone tunnels with sutures, fix-ation to soft tissue using absorbable attachmentdevices such as Endotine (Coapt Systems, Palo Alto,California), and fibrin glue [9,10]. We advocatedeep temporal fixation only (DTFO) without bonefixation [11].

To maximize brow elevation with the endoscopictechnique, the surgeon must release the periosteumfrom one inferolateral orbit to the other and release

Fig. 6. Endoscopic photograph of dissection over thedeep temporalis fascia (large arrow) exposing thesentinel vein (small arrow). (From Cummings CW,Flint PW, Harker LA, et al, editors. OtolaryngologyHead & Neck Surgery, Vol. 1. 4th edition. Philadel-phia: Elsevier Mosby; 2005. p. 757; with permission.)

Fig. 7. To prevent elevation of the lateral canthus, thesurgeon or the assistant places a finger in the interioraspect of the lateral rim at the lateral canthus. (FromCummings CW, Flint PW, Harker LA, et al, editors.Otolaryngology Head & Neck Surgery, Vol. 1. 4th edi-tion. Philadelphia: Elsevier Mosby; 2005. p. 758; withpermission.)

the brow depressor musculature (corrugator, proce-rus, depressor supercilii, and supraorbital orbicula-ris oculi) (Fig. 2) [8,12,13]. Following the brow-lift,all depressor vector forces should be eliminated topromote maintenance of the newly elevated browposition, because periosteal reattachment to bonetakes approximately 6 to 12 weeks [14].

Temporal lift

In patients who have adequate medial brow posi-tion and ptotic lateral brow and lateral canthalhooding, an endoscopic temporal (temple) liftmay be performed. A temporal lift is performed us-ing the same principles and technique as the endo-scopic brow-lift with the exception that the medialborder of the periosteal and brow depressor muscu-lature release is the supraorbital neurovascularcomplex. The supraorbital orbicularis oculi muscleis the only brow depressor treated. The medial browand glabellar region is not dissected, resulting in el-evation of the lateral two thirds of the brow–lateralcanthal complex.

Treatment of the depressor muscles withbotulinum toxin

Botulinum toxin may be used synergistically withthe surgical brow depressor musculature release inan effort to weaken the inferior vector forces andpromote maintenance of the newly elevated brow.Botulinum toxin is used to block the depressorfunction of the corrugator, procerus, depressorsupercilii, and lateral supraorbital orbicularis oculimuscles [15]. Two weeks before surgery, patientsare injected with botulinum toxin. The corrugator,procerus, and depressor supercilii muscles (medial

Fig. 8. Following periosteal and brow depressor mus-cle release, the supraorbital neurovascular complex(arrow) is visualized without obstruction from overly-ing muscle fibers. (From Cummings CW, Flint PW,Harker LA, et al, editors. Otolaryngology Head & NeckSurgery, Vol. 1. 4th edition. Philadelphia: ElsevierMosby; 2005. p. 758; with permission.)

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Fig. 9. Patient before (A)and 1 week after (B) endo-scopic brow-lift with DTFO.(C) Intraoperative photo-graph of the patient’s ele-vated brow complex to anunnaturally high positionafter a complete release ofall periosteum and browdepressor musculatureprior fixation. (From Cum-mings CW, Flint PW, HarkerLA, et al, editors. Otolaryn-gology Head & Neck Sur-gery, Vol. 1. 4th edition.Philadelphia: Elsevier Mos-by; 2005. p. 759; withpermission.)

brow depressors) are typically injected with a totalof 20 U of botulinum toxin, and the lateral supraor-bital orbicularis oculi muscles (lateral brow depres-sor) are injected with about 4 U of botulinum toxinon each side (Fig. 3). No botulinum toxin is in-jected into the frontalis muscle because it acts asthe only brow elevator.

Surgical technique

Following photographic documentation of the pa-tient’s forehead and brows, the patient is broughtinto the operating suite. In most situations, an anes-thesiologist administers general anesthesia with a la-ryngeal mask.

Incisions

The incisions are marked—one midline and twotemporal (two paramedian incisions are made ifbone fixation is to be performed). The anteroposte-rior midline incision is approximately 2 cm poste-rior to the hairline and is 1 cm in length, justlarge enough to allow the introduction of periostealelevators into the subperiosteal space. The temporalincisions are 3 cm in length and are approximately2 cm posterior to the hairline. The key to obtaina natural looking brow is to create a temporal inci-sion parallel to the tail of the brow with its medialextent at the temporal conjoint fascia (Fig. 4). Thetemporal incision orientation will help elevate thelateral half of the brow in a superolateral vector.

Local anesthesia

Local anesthesia consists of 10–15 mL of 1%lidocaine (Xylocaine) with 1:100,000 epinephrine

injected into the corrugator, procerus, and depres-sor supercilii muscles, the proposed incision sites,and for supraorbital and supratrochlear nerveblocks. The rest of the central forehead, parietalscalp, and temporal region are infiltrated withapproximately 50 mL of a solution consisting of500 mL of normal saline mixed with 0.5 mL of1:1000 epinephrine, 5 mL of sodium bicarbonate,and 25 mL of 2% lidocaine without epinephrine.The high volume of this solution acts as a vasculartourniquet primarily used in the temporal region.The patient is prepared and draped in the usualsterile fashion. Approximately 15 minutes is allowedfor anesthesia and hemostasis to take place.

Fig. 10. Intraoperative photograph of a patient’s ele-vated left brow complex after a unilateral completerelease of all periosteum and brow depressor muscu-lature before fixation. Cotton-tipped applicators arepositioned at the inferior border of the supraorbitalrim. (From Cummings CW, Flint PW, Harker LA, et al,editors. Otolaryngology Head & Neck Surgery, Vol.1. 4th edition. Philadelphia: Elsevier Mosby; 2005. p.759; with permission.)

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Fig. 11. Frontal view of a 32-year-old-woman with severe brow ptosis and blepharochalasis (A) before and (B)after surgery. Right oblique view (C) before and (D) 1 year after DTFO endoscopic brow-lift and bilateral upperblepharoplasty. The oblique view documents significant improvement in the temporal hooding, lateral canthal,and eyelid regions. (From Cummings CW, Flint PW, Harker LA, et al, editors. Otolaryngology Head & Neck Sur-gery, Vol. 1. 4th edition. Philadelphia: Elsevier Mosby; 2005. p. 760; with permission.)

Dissection over frontal and parietal bones

A midline vertical incision is made and extendedthrough the periosteum. Without the use of the en-doscope, a periosteal elevator is used to create a sub-periosteal pocket posteriorly over the parietalforehead and anteriorly over the central foreheadto approximately 1 cm above the brow with carenot to injury the supraorbital and supratrochlearneurovascular bundles.

Temporal dissection and release of theperiosteum and lateral supraorbitalorbicularis oculi muscle

The temporal incisions are made and extended tothe deep temporal fascia (Fig. 5). A blunt elevatordissects over the deep temporal fascia inferiorly un-til a branch of the zygomaticotemporal vein, the‘‘sentinel vein,’’ is encountered (Fig. 6). This pointis the inferior limit of the dissection without the

use of the endoscope. A face-lift scissors is used toconnect the temporal incision to the central fore-head incision by severing the temporal conjoint fas-cia (fusion of the galea and the temporoparietalfascia). The conjoint fascia is released with a perios-teal elevator in an inferior direction to the level ofthe supraorbital rim. Near the supraorbital rim,a thickening of periosteum termed the conjoint ten-don is incised sharply or bluntly. Adequate release ofthe conjoint tendon at the lateral supraorbital rim isan essential factor of the periosteal release.

The endoscope is placed into the temporal dissec-tion along with the elevator, visualizing the sentinelvein. This vein is a reliable marker for the frontalbranch of the facial nerve, which lies superficial tothe dissection on the undersurface of the temporo-parietal fascia [16,17]. If possible, the sentinel veinis preserved and the dissection performed medialand inferior to the vein. If the vein is cauterized,bipolar forceps are placed at the base of the

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Fig. 12. Frontal view of a middle-aged patient with brow ptosis and fat herniation of the lower eyelids (A) be-fore and (B) after surgery. Left oblique view (C) before and (D) 20 months after DTFO endoscopic brow-lift andbilateral lower fat repositioning blepharoplasty. Notice the orbital region is rejuvenated with the natural shapeof the eyebrow kept intact. (From Cummings CW, Flint PW, Harker LA, et al, editors. Otolaryngology Head &Neck Surgery, Vol. 1. 4th edition. Philadelphia: Elsevier Mosby; 2005. p. 761; with permission.)

sentinel vein to help prevent a thermal neuropraxicinjury to the frontal branch of the facial nerve. Lat-eral and slightly inferior to the sentinel vein, the zy-gomaticotemporal sensory nerve is encounteredand is usually considered the lateral border of thedissection.

With dissection continued in a medial diagonaldirection toward the malar eminence over the su-perficial temporal fat pad, the periosteum is pene-trated just inferomedial to the lateral canthus overthe frontal process of the zygoma and malar

eminence. To prevent elevation of the lateralcanthus, an assistant places his or her finger in the in-terior aspect of the lateral rim at the lateral canthus(Fig. 7). If the surgical plan calls for lateral canthalangle elevation, the lateral canthus is released. Theperiosteal release (elevation, incision, and spread-ing) begins inferior to the lateral canthus onto themedial malar eminence and extends medially tothe supraorbital neurovascular complex with carenot to injure the nerve. Following the periosteal re-lease, the lateral supraorbital orbicularis oculi muscle

Fig. 13. (A) Right oblique view of a 43-year-old-man status post an upper blepharoplasty 4 years ago who pre-sented with the complaint of a ‘‘tired look.’’ The brow, especially in the temporal region, descends below thesupraorbital rim causing temporal hooding, and the supratarsal crease is covered by overhanging ptotic uppereyelid skin. (B) Following a DTFO endoscopic brow-lift, the patient’s brow ptosis was moderately improved.

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Fig. 14. Frontal view of a 41-year-old-patient with brow ptosis and fat herniation of the lower eyelids (A) beforeand (B) after surgery. Left oblique view (C) before and (D) after DTFO endoscopic brow-lift and bilateral lowertransconjunctival blepharoplasty. Note the significant medial brow elevation.

is meticulously released from the inferomedial orbitto the supraorbital nerve, exposing the yellow browfat. This same procedure is performed on the contra-lateral temporal region.

Release of the brow depressor muscles

For the temporal lift, this portion of the procedureis eliminated. The endoscope remains placedthrough the temporal incision, and the periostealelevator is placed through the central incision.The dissection is carried to the central supraorbitalregion and radix of the nose, releasing the perios-teum and avoiding injury to the supraorbital andsupratrochlear nerves. Thorough corrugator, proce-rus, and depressor supercilii myotomies are per-formed. To ensure that complete myotomies havebeen performed, each nerve of the supratrochlearand supraorbital neurovascular complexes (Fig. 8)should be easily visualized without obstructionfrom overlying muscle fibers. Harvested deep tem-poralis fascia placed at the myotomy site of thecorrugator muscles may prevent reanastomosis ofmuscle fibers.

Brow elevation and fixation

Before fixation, a 10-F drain is placed and fed fromone temporal dissection to the other positionedacross the inferior extent of the dissection and exit-ing a puncture site superior to the right temporal in-cision. If a complete release of all periosteum and

brow depressor musculature is performed, the en-tire brow complex will elevate to an unnaturallyhigh position without any tension (Figs. 9A–Cand 10). Brow fixation is achieved by securing thesuperficial temporal fascia medially to the deeptemporal fascia in a superolateral vector with two2-0 polydioxanone horizontal mattress sutureswhile the brow is lifted laterally and overcorrected.The overcorrected brow will gradually drop to itsfinal position after 3 weeks. The incisions are closedwith surgical staples.

Postoperative care principles

Incisions are dressed with antibiotic ointment with-out a head dressing. Patients may experience head-aches and minimal pain initially. The drain isusually removed on the first postoperative day.Shampooing with gentle cleaning of the hair canbe performed at 48 hours, when the hair may beblow-dried on a cool setting. For 4 days, patientsare instructed to maintain a semi-upright positionwhen sleeping or resting. The staples are removedat 7 days. Full activities may resume in 3 weeks.

Complications

Few complications result from brow-lifting. It hasbeen our experience that fewer complications occurwith the endoscopic brow-lift when compared withthe coronal lift. Hematoma, seroma, hypesthesia,

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tingling, pruritis, a ‘‘bandlike’’ forehead sensation,temporary paresis of the frontal branch of the facialnerve, temporary or permanent alopecia, infection,stitch abscess, brow asymmetry, relapse of browptosis, paramedian incision depressions with screwfixation, and hypertrophic scars have been reported[4,11].

Results

Since January 2000, the author has performed en-doscopic brow-lifts with DTFO in more than 150patients with good results (Figs. 11–14). This proce-dure has the advantage of addressing the ptotic eye-brow while avoiding bony fixation. The endoscopicbrow-lift with DTFO can be combined with an en-doscopic subperiosteal transtemporal transbuccalmidface-lift to rejuvenate the aging forehead, brow,and midface.

As with any new procedure, thorough knowledgeof the current literature, familiarity with anatomy,and observation of the procedure as performed byan experienced surgeon should precede any at-tempt in performing the endoscopic brow-lift withDTFO.

References

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[14] Sclafani AP, Fozo MS, Romo T, et al. Strengthand histological characteristics of periosteal fixa-tion to bone after elevation. Arch Facial PlastSurg 2003;5:63.

[15] Zimbler MS, Nassif PS. Adjunctive applicationsfor botulinum toxin in facial aesthetic surgery.Facial Plast Surg Clin North Am 2003;11(4):477–82.

[16] Larrabee WF, Makielski KH, Cupp C. Faceliftanatomy. Facial Plast Surg Clin North Am1993;1:135–52.

[17] Pitanguy I, Ramos AS. The frontal branch ofthe facial nerve: the importance of its variationsin face lifting. Plast Reconstr Surg 1966;38:352–6.