2 Innovative Techniques in Endoscopic Forehead Lifting & Their Outcomes
Endoscopic forehead lifting continues to be an innovative solution for facial rejuvenation, offering patients a minimally invasive option for addressing brow ptosis and forehead wrinkles. Two recent studies have introduced advanced methods to enhance the effectiveness of this procedure: the technique presented by Wang et al. (2020) and the Three-Incision Endoscopic Forehead Lift (3-IEFL) detailed by Omranifard et al. (2024). This blog article will explore both techniques in detail, highlighting their unique approaches, procedural steps, key innovations, and patient outcomes. Both techniques aim to achieve a more youthful appearance with minimal scarring and recovery time, but they differ in their approach to treating forehead aesthetics.
1. Wang et al. (2020) Technique: Resection of Glabella Muscles and Parallel Incisions on Frontalis
The "Resection of Glabella Muscles and Parallel Incisions on Frontalis" technique is a minimally invasive method used for forehead rejuvenation. It involves the removal of the glabella muscles responsible for frown lines, followed by the creation of parallel incisions along the frontalis muscle. This allows for a natural lift of the forehead skin while preserving facial expressions. The technique addresses forehead wrinkles and brow ptosis without the use of lifting devices or fixation sutures, offering a more youthful appearance with minimal scarring and a quicker recovery.
Procedure
The procedure is performed under local anesthesia with intravenous sedation, ensuring that patients are comfortable and relaxed throughout. The patient is positioned supine to allow for optimal access to the forehead and brow area.
1. Anesthesia and Preparation
The first step in the procedure is the administration of a vasoconstricting solution. This typically consists of 0.5% lidocaine and 1:200,000 noradrenaline. The solution is injected in the superficial plane of the periosteum, which helps reduce bleeding during dissection. The injection covers the supraorbital margin, extending to the temporal fusion lines and into the hairline to ensure adequate numbing for the procedure.
2. Creating Incisions
After waiting about 20 minutes for the anesthetic solution to take effect, the surgeon makes several small incisions:
A 5-mm median incision is made along the center of the forehead.
Two 5-mm paramedial incisions are made 1 cm inside the hairline, following the natural direction of hair growth. These incisions are discreet and placed within the hairline, ensuring minimal visible scarring post-procedure.
3. Dissection and Muscle Identification
With the incisions in place, periosteal elevators are used for blunt dissection. This technique separates the frontalis muscle from the periosteum, with careful dissection reaching the supraorbital margin and temporal fusion lines. At this point, a 5-mm endoscope with a 30-degree angle is introduced to offer real-time visualization of the dissection area. This allows the surgeon to clearly identify and isolate the targeted muscles without causing unnecessary trauma to surrounding structures.
4. Resection of the Glabella Muscles
Through the endoscopic view, the surgeon can now precisely identify the corrugator supercilii, depressor supercilii, and procerus muscles, which are responsible for creating frown lines and forehead wrinkles. Using biopsy forceps under endoscopic guidance, the surgeon carefully excises these muscles, taking care to avoid damaging the supraorbital bundle and trochlear nerves that supply the forehead area.
5. Parallel Incisions on the Frontalis Muscle
The next step in the procedure involves the creation of incisions on the frontalis muscle. A 2 cm horizontal incision is made 2 cm above the eyebrow, extending from the left to right temporal ridges. This incision is placed parallel to the natural eyebrow line to ensure the most aesthetic result. For patients with severe forehead wrinkles, an additional incision may be made 2 cm above the original incision to further enhance the lift and tightening effect on the forehead skin.
6. Tissue Adjustment and Final Details
To ensure that the frontalis muscle adheres properly to the periosteum, the surgeon cleans away any loose connective tissue in the deep plane. This step allows for optimal muscle tension and a smooth and lasting lift. The surgeon ensures that the upper portion of the frontalis muscle is sufficiently released, while leaving enough of the muscle intact to allow for natural facial expressions, particularly brow-lifting movements.
7. Post-Operative Care
After the surgical adjustments are made, drainage tubes are placed around the glabella and behind the hairline to help prevent hematoma formation. The skin incisions are closed with nonabsorbable sutures, and an elastic bandage is applied to minimize swelling in the days following the surgery. Drainage tubes are typically removed 24 hours post-surgery, and skin stitches are taken out 7 days later.
Key Innovations in This Technique
While many traditional forehead lift techniques focus on soft tissue elevation, this approach brings two innovative elements to the forefront:
Blunt Dissection Between the Frontalis Muscle and Periosteum: Instead of dissecting directly in the subperiosteal plane, this technique uses a blunt dissection that separates the frontalis muscle from the periosteum. This avoids the risks associated with breaking through the periosteum, thus reducing complications and shortening operation time.
Parallel Incisions on the Frontalis Muscle: Drawing inspiration from the traditional open coronal approach, the use of parallel incisions on the frontalis muscle helps achieve a more even and natural lift. By excising muscle in this controlled manner, the surgeon can significantly reduce dynamic wrinkles while preserving the patient’s ability to express themselves, especially when it comes to brow movement.
Benefits and Considerations
This surgical technique offers several advantages:
Reduced risk of uneven forehead contours: Parallel incisions help avoid the possible irregularities that can occur with other methods of muscle excision.
Preserved natural expressions: By carefully controlling the amount of muscle removed, the patient retains their ability to raise their brows and maintain a youthful, expressive appearance.
Minimal scarring: The incisions are small and strategically placed along the hairline, ensuring they are discreet.
Faster recovery: With less tissue disruption and more precise dissection, patients tend to experience faster recovery times and fewer complications compared to traditional methods.
However, like any surgical procedure, careful planning and execution are crucial. Ensuring that the incisions are made with precision to avoid over-tightening or leaving visible irregularities on the forehead is necessary.
Evaluation & Outcomes
In assessing the success of this endoscopic forehead lift technique, the QFACE scale provides a structured method for evaluating patient outcomes. This scale collects patient feedback across several domains, including satisfaction with forehead and eyebrow appearance, appraisal of forehead lines, psychological function, and social function. It also captures information about recovery symptoms (such as numbness, scarring, or hairline changes). The responses are then scored using Rasch-transformed values (0–100), where higher scores indicate better outcomes.
High satisfaction rates, with patients reporting improved facial appearance, increased brow lift, and a refreshed look.
Minimal complications, with only minor postoperative issues such as mild swelling and bruising.
High functional outcomes, such as improved forehead mobility and natural brow movement, especially in cases where the brow lift was subtle and well-adjusted to the patient's anatomy.
2. Omranifard et al. (2024) Technique: The Three-Incision Endoscopic Forehead Lift (3-IEFL)
Omranifard and colleagues introduced the Three-Incision Endoscopic Forehead Lift (3-IEFL) as a more extensive technique compared to Wang’s, designed for patients with more pronounced brow ptosis or deeper forehead wrinkles. This method allows for more significant repositioning of the forehead tissues, providing a more dramatic lift when required. The 3-IEFL technique is often preferred in cases where a substantial elevation of the forehead is needed, and it achieves a balanced and natural aesthetic.
Procedure Details:
Preoperative Planning: Preoperative marking is performed while the patient is seated, allowing accurate positioning of the incisions. Three distinct marks are made: one for the central incision and two temporal incisions. The central elliptical incision (1.00×0.5 cm) starts at the nasion, traverses the forehead midline, and terminates just posterior to the hairline. The two temporal incisions are placed 2.00 cm into the hairline, parallel and posterior to the temporal hairline. These sagittal incisions are 1.50 to 2.00 cm long, ensuring that critical landmarks such as the supraorbital and supraorbital nerves are identified and preserved during dissection.
Anesthesia and Preparation: After the patient is placed under general anesthesia in a reverse Trendelenburg position, a tumescent solution is injected subperiosteally. This solution aids in controlling bleeding and providing pain management during the procedure.
Incision and Dissection: The surgeon begins with an elliptical central incision through all scalp layers, reaching the subperiosteal plane. An additional elliptical incision (1.50×1.00 cm) is made in the periosteum to create access ports for endoscopic instruments. Using these access points, blind dissection is performed through the midline and paramedian ports, moving anteriorly towards the supraorbital rims and laterally along the lateral orbital rims to the lateral canthus.
Muscle Resection and Tissue Elevation: After periosteum elevation and muscle resection (including the frontalis and corrugator muscles), a curved elevator is inserted via the temporal port to dissect the tissue plane between the superficial temporal fascia and the deep temporal fascia overlying the temporalis muscle. This dissection is performed under direct visualization to avoid injury to important structures, particularly the facial nerve. The tissue plane is released anteriorly, posteriorly, and inferiorly, ensuring that no damage occurs to the facial nerve as it crosses the zygomatic arch. Special attention is paid to the sentinel vein, located near the frontozygomatic suture line, to minimize the risk of nerve injury.
Connection of Dissection Areas: The lateral and central dissection cavities are connected by sharply dividing the zone of adhesion at the superior temporal line. The conjoint tendon is opened above the supraorbital rim and extended posteriorly, establishing a complete connection between the lateral and central dissection pockets. This step ensures optimal tissue mobilization for the desired lift.
Fixation: Fixation begins at the temporal ports and is followed by the paramedian ports. A large permanent or semi-permanent suture (typically 4-0 nylon) is used to secure the temporoparietal fascia to the deep temporalis fascia along a vector following the line from the ala to the lateral canthus. Holes are drilled in the skull through the paramedian incisions to place fixation devices bilaterally. The frontal scalp flap is then lifted off the bone and suspended superiorly onto the device prongs, with the assistance of an operating partner. Screws are typically placed at the superior extent of the paramedian incisions to hold the scalp in place. After 40 days, these screws can be removed in the clinic under local anesthesia.
Postoperative Care: Postoperative care includes effective pain management, particularly during the initial 24 to 72 hours. Ice packs are applied around the eyes to reduce swelling, and the patient is advised to sleep with the head elevated at 30 degrees for one week. This reduces swelling and enhances the healing process.
Key Findings and Evaluation of Outcomes
The Three-Incision Endoscopic Forehead Lift (3-IEFL) technique is highly effective in providing significant lift, especially for patients with pronounced brow ptosis and deep forehead wrinkles. It results in a smoother, youthful brow contour while maintaining the integrity of the patient’s natural facial expression. The incisions are strategically placed within the hairline, minimizing visible scarring.
Studies evaluating this method report high patient satisfaction, with improvements in brow position, symmetry, and overall forehead aesthetics. The technique demonstrates long-lasting results, particularly for those with severe forehead sagging, and due to controlled dissection and precise fixation, complications such as nerve injury or asymmetry are rare. Recovery is generally straightforward, with initial swelling and temporary numbness that resolves over time.
Choosing the Right Technique
Selecting the right procedure depends largely on the patient’s individual needs, including the severity of brow ptosis, the presence of forehead wrinkles, and overall facial aesthetics. Here’s a quick comparison to guide the decision-making process:
Wang’s Technique: Ideal for patients with moderate forehead wrinkles and brow ptosis. This method offers minimal invasion and quick recovery with an emphasis on muscle resection and repositioning for a more subtle lift.
3-IEFL: Best suited for patients with significant brow ptosis and deeper forehead wrinkles. The three-incision approach offers more control and allows for a more pronounced lift, making it perfect for patients seeking a dramatic transformation.
Conclusion: Innovation in Endoscopic Forehead Lifting
Both techniques—Wang et al.'s muscle resection approach and Omranifard et al.'s 3-IEFL method—offer distinct advantages, providing patients with a customized solution depending on their aesthetic goals and severity of facial aging. Surgeons must carefully evaluate the patient’s needs and anatomical considerations to select the best technique. Whether choosing the less invasive method for moderate concerns or the more extensive lift for pronounced sagging, these endoscopic techniques represent the cutting edge of forehead rejuvenation, offering minimal downtime and optimal results.
References:
Wang, G., Tao, L., & Xie, H. (2020). A Novel Endoscopic Forehead Lift Technique for Patients with Upper Facial Wrinkles: Morphometric Evaluation and Patient-Reported Outcome using FACE-Q Scales. Facial Plastic Surgery. doi:10.1055/s-0039-3401802
Omranifard M, Mirzaei M, Mahabadi M, Omranifard D, Gharavi MK, et al. (2024) Clinical and Aesthetic Outcomes of Three-Incision Endoscopic Forehead Lift: A Retrospective Case Series. J Med Case Rep Case Series 5(14): https://doi.org/10.38207/JMCRCS/2024/NO
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