Endoscopic Brow lift: Everything You Need to Know

눈썹거상술 brow lift

An endoscopic brow lift, a forehead lift, is a minimally invasive cosmetic procedure designed to rejuvenate the periorbital area. It addresses forehead wrinkles, frown lines, and hooded eyes by just making small incisions in the scalp. This article provides in-depth information about the brow lift’s indications, surgical sequence, and side effects.


Q : Which method is better for forehead lift: Endotine or bone tunneling?

endotine brow lift

A : Neither method has been proven to be superior since Endotine has first introduced 20 years ago. It is best to choose the method that the surgeon is most familiar with and has a good track record of success. However, among Korean plastic surgeons, bone tunneling is currently the preferred method.

Q : Why do patients experience numbness after a forehead lift?

A : During a forehead lift, the sensory nerves responsible for forehead and scalp sensation may be pulled or compressed by surgical instruments, as they run between the corrugator muscles that need to be cut. Nerves generally recover slower than other tissues in our body, and it can take anywhere from 2 to 12 months for sensory disturbances to resolve. Fortunately, the discomfort is typically not significant enough to interfere with daily activities, and most people become accustomed to the intermittent symptoms after three months.

Q : Why does hair loss occur after a forehead lift?

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A : Although hair loss after forehead lift is a very rare complication, temporary or permanent hair loss can occur. Temporary hair loss is a result of the normal hair growth cycle, which includes growth, resting, and shedding phases, with the resting phase lasting about 3-6 months. Most people will see their hair grow back within 3-6 months, similar to the process seen after hair transplantation.
Permanent hair loss can occur due to damage to hair follicle stem cells, but it is not common as the depth of surgery is different from the depth where the stem cells exist.

Q : How long does the effect of a forehead lift last?

A : The duration of the effect of a forehead lift varies from patient to patient and depends on the surgeon. However, if the brow muscles are adequately released, the raised eyebrows can typically last 5-10 years.

1. What is an Endoscopic Forehead Lift?

An endoscopic forehead lift is a surgical procedure that lifts the forehead with the help of an endoscope. In the past, long incisions along the hairline were used to treat forehead wrinkles. With advancements in technology however, it is now possible to achieve similar results with small incisions in the scalp. The procedure addresses wrinkles on the forehead, the horizontal folds on the nasal bridge, and the 11 lines on the glabella, resulting in lighter hooded eyes.

2. Effect of Endoscopic Forehead Lift: Pros and Cons, Candidates

A forehead lift offers numerous benefits, including elevating the eyebrows, reducing upper eyelid sagging, eliminating puffy eyelids, and smoothing out frown lines and forehead wrinkles.

However, there are also potential risks to consider such as loss of sensation on the scalp and hair loss. The procedure can produce a youthful lid crease in elderly patients, but the change in double eyelid fold shape is subtle in those under 40. Additionally, patients with severe eyelid skin excess may need to consider additional blepharoplasty if their expectations are high. The pros and cons, indications and contraindications of the brow lift are as follows.

1) Advantage

  • improves forehead and glabellar wrinkles
  • can change brow shape
  • rejuvenate moderate amount of upper lid skin excess
  • natural looks
  • less visible scar

2) Disadvantage

  • limited change in the eyelid crease
  • slightly widens the forehead (0.3 ~ 0.5cm)
  • decrease sensation on forehead and scalp (lasts maximum 12month)
  • risk of alopecia on incision site

3) Proper candidate

  • who wants to improve wrinkles in the forehead and glabella
  • who regularly have botox treatment
  • angry-looked brow shape (diagonal or angled brow)
  • puffy upper eyelid (young)
  • descended brow (elderly)
  • narrow lid-brow distance
  • not good results are expected after double eyelid surgery
  • want natural change

4) Improper candidate

  • convex forehead
  • severe upper lid skin excess
  • thick forehead skin
  • limited forehead mobility on physical examination

3. Precautions Before Surgery

1) Fasting:

It is recommended to fast for at least 8 hours before the procedure. Avoid eating or drinking anything in the morning on the day of surgery.

2) Taking the medication:

It is also essential to inform the surgeon of any medications taken and follow their advice on discontinuing certain drugs, such as anticoagulants. Discontinue should be done according to the opinion of your primary care physician, and more detailed information about preparing for surgery is linked in this article. Drugs like medicine for hypertension or diabetes should not arbitrarily be stopped.

4. Surgical Sequence of Brow Lift

The surgical sequence for a brow lift involves the following steps:

1) Preparation

The hair near the incision site is tied up in the operating room, and shaving is rarely necessary.

2) Incision and dissection

4 to 5 small incisions are made within the hairline, each about 1 inch long. The extent of dissection varies based on the surgical goal. The approximate incision and dissection area are as follows.

brow lift
Red = incision placement. Light blue = dissection area

3) Frowning muscle manipulation

The critical step in the procedure is to weaken the muscles that pull the eyebrows downward.

frowning lines
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This process is similar to the effects of Botox, but it does not eliminate 100% of the glabellar muscle movement which saves natural expression.

frown lines before and after
Frown lines before and after surgery.
Above: with no facial expression.
Below: with facial frowning.

4) Fixation

The elevated tissue is secured with absorbable anchor pins(Endotine®) or surgical sutures.

5) Suture

The incision sites are sutured, and a drainage tube may be inserted if necessary. The drainage is usually removed within 1 to 3 days, and the sutures are removed within 10 to 14 days.

5. Precautions After Surgery

1) Swelling

Swelling is normal after surgery and usually peaks for 3 days. Still, it can be managed by avoiding physical activities that increase pressure on the face and applying cold compresses for the first three days. After that, switch to warm compresses, keep your head elevated while sleeping and avoid lying down outside of bedtime. Sleeping late and waking up early for the initial three days will help you minimize the swelling.

2) Bruises

Bruises usually appear red or purple and gradually fade to yellow over 7 to 10 days. Good blood circulation and warm compresses from the fourth day can help reduce bruises. Please click for more detailed information on how to shorten the recovery period after surgery.

3) Compression

Applying light pressure with an elastic bandage for 1 to 3 days can stabilize the fixation and reduce swelling and bruises.

4) Shampoo

Light shampooing is possible from the third to fourth day after surgery if the drain tube has been removed. Avoid rubbing the incision area with your fingers, but scrubbing is possible after one week of stitch removal.

5) Decreased sensation of forehead and scalp

Sensory nerves are located near frowning muscles, so it’s unavoidable to experience partial numbness or tingling after surgery. Fortunately, these symptoms usually resolve over time.

6) Palpable pin

If the forehead was fixed with Endotine®, the pin can be felt on the scalp but is not visible. It’s usually absorbed after 6 to 9 months and doesn’t require surgical removal.

7) Rare symptoms

  • Nausea and vomiting
    This symptom can happen within the first two weeks of surgery in less than 5%. Still, they can be reduced with a commercial scopolamine drug patch(‘Kimite’). A special medical prescription may be required if this symptom lasts longer than 2-3 months.
  • Brow palsy
    Decreased brow movement can occur if the motor nerves are injured, but most cases are temporary. A surgeon who is skilled in nerve paths rarely damages motor function. However, this complication may be crucial if the brow does not move more than 1-year after the surgery.
  • Temporary hair loss
    Temporary hair loss is a rare occurrence after surgery. It is typically a short-term condition, and hair regrows within six months if there has been no hair follicle damage during the procedure. This event is due to the normal hair growth cycle, which includes the phases of growth (anagen), regression (catagen), and resting (telogen). It’s important to wait at least six months before seeking further treatment if you experience temporary hair loss after surgery. Moreover, working with a seasoned and knowledgeable surgeon reduces the risk of hair follicle injury as they know that damage can occur when surgical instruments are inserted.

8) Other Considerations

Swelling or bruising below the eyes often happens as the ligament attached to the orbital bone should be released. You may feel self-conscious for the first three days after surgery, but you can start shampoo and light exercise to reduce swelling. People may notice your bruises, so it’s recommended to wait 7 to 10 days before resuming daily activities, though makeup will cover it.

6. Controversy Regarding Fixation: Endotine® vs. Bone tunneling

The core step of brow lift surgery is weakening the glabellar muscles, while the fixation method is secondary.

forehead lift fixation
Fixation is like the left hand in a basketball.
Live surgery at 2003 Baker Gordon Symposium. Stuzin asks to Nahai about fixation method(2:38).

Nevertheless, there is controversy surrounding the fixation method, with three main options available:

  • external fixation: using a visible tool such as a suture thread or screw
  • internal fixation: using medical glue, bone tunneling, or a tool like Endotine® or Mitek®
  • no fixation: where a compression dressing is left on the forehead without any fixation.

The most common method among Korean plastic surgeons is internal fixation using Endotine® and bone tunneling.

endotine brow lift
Endotine vs. Bone tunneling.
The Endotine®: A New Biodegradable Fixation Device for Endoscopic Forehead Lifts

1) Endotine®: A leading solution for plastic surgeons

Endotine®, a triangular device made of polylactide homopolymer, was released in 2002 by Coapt Systems, California and is now sold under the license and name of MicroAire. Over the last 20 years, it has gained immense popularity among plastic surgeons and has been demonstrated in academic symposiums. As a result, it has become widely used globally.
One of the advantages of Endotine® is that it dissolves in the human body within eight months, eliminating the need for surgical removal.

2) Bone tunneling (Thread fixation): A versatile tissue fixation method

Bone tunneling, also known as thread fixation, is a surgical method that fixes tissue through a tunnel-shaped hole in the bone using a surgical drill. The technique allows for multiple fixation points and provides the advantage of being non-palpable immediately after the procedure. With practice, the technique can be easily performed.

7. Endotine® vs. Bone tunneling: Pros and Cons

EndotineADVANTAGEstrong fixationDISADVANTAGEcostly
EndotineADVANTAGEno surgical removal needed (self-dissolves)DISADVANTAGEpalpable within 8month post-op
EndotineADVANTAGEeasily applicable for the surgeonDISADVANTAGEnot eligible for thin-skin patient
EndotineADVANTAGEdecrease operative timeDISADVANTAGErequire removal if infection occurs
Bone tunnellingADVANTAGEsave expensesDISADVANTAGEfixation may vary depending on the surgeon
Bone tunnellingADVANTAGEless palpable or visibleDISADVANTAGEmore operative time

Despite ongoing debates, there is still no agreement on which method is the best for a brow lift. The critical factor for a successful outcome is the surgeon’s expertise with the chosen technique.

8. Conclusion

The endoscopic brow lift is an effective procedure with many benefits and few drawbacks. The biggest challenge with a forehead lift is overcoming common misconceptions and fears among patients seeking upper eyelid rejuvenation. However, it is a minimal-invasive surgery with little incision and fewer scars. This article aims to provide comprehensive information about the brow lift procedure and I hope these thoughts helped you to understand the procedure.

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