a segmental approach to browlift

A Segmental Approach

To Endoscopic Brow Lift

M. Sean Freeman MD, FACSCharlotte, NC

Endoscopic Brow LiftSegmental Approach

• Brow surgery, like many other aesthetic procedures, presents the surgeon with what I call the “Goldilocks conundrum”– We don’t want the surprised look!– Nor do we want a dissatisfied patient because we didn’t provide the

lift or improvement they were hoping for– We want something right in the middle

Endoscopic Brow Lift

Segmental Approach

There is no magic equation or arithmetic measurements that one can use to measure the exact lift needed from patient to patient!!!!

Endoscopic Brow LiftSegmental Approach

• How to accomplish this feat– Analyze the preoperative position of the brow when at rest

– Include in your evaluation a determination of the patients skin thickness– In addition an assessment of the relative strength of their brow depressors

– Understand that as we age the brow moves medially and inferiorly– To correct this we must rotate the brow laterally and superiorly during

surgery

Endoscopic Brow LiftSegmental Approach

• Use the preoperative analysis of the brows to determine the release of the periorbital fascia and/or the brow depressor muscles– Lateral brow release

– Ptosis of the lateral brow with normal position of the medial brow without mitigating factors– Unusually thick skin and/or strong medial depressors

– Release the periorbital fascia lateral to the supraorbital nerve leaving the corrugator and procerus muscle intact

– Weaken the orbicularis oculi in lateral brow area if the patient has significant accordion affect

Supraorbital n.

3/4 brow lift RLateral brow lift L

Endoscopic Brow LiftSegmental Approach

• Use the preoperative analysis of the brows to determine the release of the periorbital fascia and/or the brow depressor muscles– 3/4 brow release

– Ptosis of the lateral brow with pinched look of the medial brow without mitigating factors– Unusually thick skin and/or strong medial depressors

– Release the periorbital fascia lateral to the supraorbital nerve as well as the lateral head of the corrugator muscle leaving the procerus intact

– Weaken the orbicularis oculi in lateral brow area if the patient has significant accordion affect

Supraorbital n.

¾ brow release on RLateral brow release on L

Endoscopic Brow LiftSegmental Approach

• Use the preoperative analysis of the brows to determine the release of the periorbital fascia and/or the brow depressor muscles– Full brow release

– Ptosis of the lateral brow with medial and inferior migration of the medial brow– Very thick skin and/or strong brow depressors (men)

– Release the periorbital fascia lateral to the supraorbital nerve as well as the corrugator and procerus muscle

– Weaken the orbicularis oculi in lateral brow area if the patient has significant accordion affect

Supraorbital n.

¾ brow lift on RFull brow lift on L

Endoscopic Brow LiftSegmental Approach

42 male patients since 1995

lateral brow release 3/4 brow releasefull brow release

411 female patients since 1995

lateral brow release 3/4 brow releasefull brow release

Incision for female5 ~ 2 cm. incisions Incisions for male

3 incisions that varyin length and orientation

Subperiosteal plane

Subgaleal plane

On top of deepTemporal fascia

Subperiosteal plane important!

Allows for selective release ofperiorbital fascia

Periosteum adheres to bonegiving better post op longevity

Brow and hair line move about same distance so little to noperceived elevation of the hairline

Pull for femaleFrom superficial temporalfascia to deep temporal fascia with a 30 degree angle at lateral incision

Further fixation from the periosteum to bone medialto the temporal line usuallyin a paramedian location

Pull for maleFrom superficial temporalfascia to deep temporal fascia with a horizontal direction at lateral incision

Further fixation from the periosteum to bone medialto the temporal line usuallyin a median location

When trying to solve the“Goldilocks conundrum”

as it relates to endoscopicbrow surgery hopefully the idea

of a segmental approachwill improve the predictability

of your results!!