Dr. Rohrich

REJUVENATION RANGE "Botulinum toxin injection can provide temporary improvement for relatively minor degrees of wrinkling and can elevate the eyebrows if done properly, while the endoscopic brow lift provides more durable results for persons [desiring] modest to moderate changes. For older individuals with more advanced signs of aging, including deep wrinkles and frown lines, or for patients who are seeking maximum elevation of the brows, a traditional incisional brow lift is indicated," Dr. Rohrich tells Cosmetic Surgery Times. "Then, depending on the patient's features, a hairline or transcoronal approach may be preferred," he explains.

The endoscopic technique allows the surgeon to address specific brow asymmetry, transverse forehead rhytids and glabellar frown lines. It is generally considered for persons without significant brow ptosis (5 mm or less) and only moderate wrinkling. Such candidates usually include patients ranging in age from 30 to 55 years old, although given individual differences in facial aging, chronologic age itself provides only a rough guide, Dr. Rohrich observes.

"The endoscopic technique can achieve 80 percent of the result of an open procedure with 80 percent less incision burden," Dr. Rohrich says. "Mild headache can occur short-term after either type of procedure, but otherwise pain and discomfort are relatively minimal. However, while patients can be out and about within a day or two after an endoscopic brow lift, they may need to wait four to five days after open surgery."

Scalp and forehead sensory loss is also less and much shorter-lasting with the endoscopic approach, he adds. Numbness after the open surgery is usually only temporary as well, but recovery can still take up to a year.

ELEMENTS OF TECHNIQUE Dissection in the endoscopic brow lift can be performed in either the subperiosteal or subgaleal plane. Of the two, Dr. Rohrich prefers the subperiosteal approach, which he finds to be associated with less swelling, an overall faster recovery and improved results. Procedural issues that are more important determinants of outcome than the plane of dissection include where and by how much the brow is released and fixated in the skull, as well as how much of the central brow depressor muscles are released and removed.

"Removing too much of the central depressor muscles can result in a splayed central brow appearance, which looks very operated and abnormal," Dr. Rohrich cautions.

In his current approach, Dr. Rohrich fixes the elevation into the outer skull by drilling cortical tunnels.

"This is a simple, safe and cost-effective method and it holds the scalp up in an effective manner," he explains. "Lifting without fixating does not work well, and I believe use of foreign materials, such as screws, plates, anchors and absorbable wires, is best avoided in a cosmetic surgery patient."

"They [foreign materials] are basically a nuisance because they necessitate more post-operative care and perhaps removal," he continues. "Fixing the elevation into the skull minimizes post-operative recovery and maximizes results."

OPEN OPTIONS In choosing between a hairline or transcoronal approach to the open brow lift, the characteristics of the upper face and hair should be taken into account, he emphasizes. The hairline procedure is best for patients with a very long forehead and a high, but good, anterior hairline, especially if the hair is thick, preferably dark, and the patient likes to wear bangs or comb the hair forward. While the scar resulting from this procedure fades over time and becomes well-camouflaged as hair eventually grows through it, concealing it initially with an appropriate hairstyle is helpful.

"The incision in this procedure is placed parallel to the hairline, and with the hair growing through it, it becomes a nice way to bring the hairline forward and shorten the forehead. However, the scar can be red and visible for the first three to six months after surgery," Dr. Rohrich adds.

Appropriate candidates for the transcoronal approach are individuals with a short brow, deep wrinkles, thick skin and a good head of hair who desire or would benefit from a maximal type of brow lift and central brow depressor correction.