Transpalpebral Brow
Lifting
New technologies have created a trend for less invasive procedures in all surgical specialties.
Over the past 2 decades, great advances have been made in the fields of minimal-incision and endoscopic surgeries. The endoscope, with its accompanying instrumentation, has been the key development supporting this trend. The endoscopic brow lift was the first procedures to gain widespread acceptance among plastic surgeons.
The subperiosteal dissection approach as applied to the forehead arose from the development of craniofacial techniques. Using this plane, the application of an endoscope to visualize and dissect the periorbita was described in 1994. In the mid-1990s a better understanding of the relevant anatomy and the evolving therapeutic modalities (including both open and closed tech-niques) have helped clinicians reach a renewed refinement in the aesthetic surgery of the forehead and brow area.
Endoscopic-assisted views of the anatomic landmarks and planes helped surgeons better understand the dynamics of brow ptosis. How-ever, some investigators realized that the endoscope was only necessary because of the long distance between the temporal port and the periorbita, making its dissection hazardous. Still in the mid-1990s, some investigators described forehead and brow limited-incision techniques that achieved reliable results without endoscopic support.
Despite the good results, much criticism arose concerning the safety of the procedure because there was no direct view of the anatomic landmarks as one elevates the flap further than 5 cm
from the scalp incision. This blind dissection increases the risk of damaging the temporal branch of the facial nerve and branches of the trigeminal nerve division, the supraorbital and supratrochlear nerve, as each leaves its respective foramen at the junction of the middle and medial one third of the orbital rim. Bleeding is also a major concern for two main reasons: first, because bleeding from vessels that cannot be directly visualized is impossible to stop and, second, because of the close relationship that such vessels as the sentinel vein and the frontal branch of the superficial temporal artery and vein have with nerves.8,7 To enable better visualization and address these problems, an upper blepharoplasty incision can be made for access to the inferior region of the forehead.
More patients present for eyelid surgery than for brow lift, and even those requesting a brow lift and those requesting upper facial rejuvenation also require upper blepharoplasty. Thus, it is natural to think of the upper eyelid incision as an alternative port because of its proximity to periorbital anatomic structures. Through this incision, direct visualization of the anatomic landmark in the orbital rim and inferior forehead is obtained and dissection proceeds upwards joining the downwards dissection done through a short temporal scalp incision. The combined-access forehead plasty allows direct visualization of all the anatomic structures that are not directly visualized through the temporal incision. Because this technique dispenses with endoscopic instrumentation. i it is less expensive and simpler than the endoscopic-assisted approach. With dissection through the upper blepharoplasty incision, the…