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What is the best brow lift approach, subperiosteal or subcutaneous?
There is no best way as each person has different results from each procedure. I prefer the subcutaneous technique because it's simple, effective, predictable, and easy to redo if it doesn't hold up satisfactorily as admittedly, many do not. But it is much more durable the second time around. Subperiosteal lifts require an operating room and when done right, are durable but you have the probability of losing sensation over the top of the head, posterior to the incision and if it isn't right, you have to go back to the operating room which adds considerably to cost.
Bottom line, both will elevate your brow. Ask your surgeon which one he is better at and consider going with that one.
C.S. Wong, MD
The subperiosteal approach for a browlift (another term for forehead lift) usually involves the endoscopic technique, so there are only a few small incisions just behind the hairline. The periosteum is the layer on the surface of the bone so the whole thickness of the skin and muscle layers are moved up. This can also raise the hairline, and doesn't work as well if the hairline is already high (more than 5 or 6 cm.). For the subcutaneous technique, the incision - and therefore the scar - is at the hairline, all the way across. This can be used to lower the hairline at the same time if needed. I usually use the endoscopic/subperiosteal technique if the hairline isn't too high.
R.A. Baxter, MD
Coronal Brow lifting is one of the most effective ways to dramatically improve the aging face when it is indicated. While most plastic surgeons switched to a endoscopic brow lift, I have continued to believe that coronal is the best way to obtain the best results that are not only the most natural but also the most permanent. With this technique I make an incision in the scalp from just above the ear all the way across the top of the head. Depending on the level of the hair line, I make the incision either in just at the hair line or behind it. If the hair line is low, then it is best to put the incision behind the hair line and then the hair growth covers any scar. If the hair line is high, then I usually put the incision behind the hair line in the temporal area (the area on the side of the head just above the ear) and then at the hair line across the middle. This allows the hair line to be improved in both cases. When the incision is at the hair line I cut the scalp obliquely, so when the incision is put back together the hair will grow in front of the incision and through the incision thereby hiding the scar.
I believe that this gives me the best opportunity to remove the muscles which cause the heavy creases at the top of the nose and between the eye brows. This will completely and permanently get rid of the deep wrinkles in these areas. The lateral brow is lifted by suturing the deep fascia in the temporal area. The wrinkles across the forehead will also go away since the brow is no longer being pulled down by these muscles and the fore head muscles will relax.
The level of my dissection is above the periosteum and below the galea which is the thick fibrous layer in the scalp.
While the endoscopic brow lift was a big favorite for a long time, its popularity is waning. I never found that the same excellent and more permanent results could be obtained with the endoscopic brow lift compared to the coronal brow lift. The incisions with a endoscopic brow lift are just as long in total, it is just that they are separated and longitudinal.
C.W. Lentz, MD
I cannot understand why your doctor would offer you a choice you cannot make. Both methods work well, but have different uses. It is up to the surgeon to select what will work best for you. See an ASAPS surgeon with significant experience in brow lifting.
R.T. Buchanan, MD
Both procedures offer excellent results in the right candidates. A board certified plastic surgeon may have a personal preference, based on his or her personal experience and outcomes. Because there is an artistic component to plastic surgery, you may hear various recommendations from plastic surgeons. It is important to view before and after pictures of a surgeons's work to ensure that you admire expected results.
I prefer an endoscopic or subperiosteal approach in the right candidate, as I find it minimally invasive, relatively easy to recover from, predictable, and I like the natural look it achieves.
I prefer the subgaleal approach as this provides for ease of access to remove the corrugator muscle and is less discomfort for the patient as well. The most important thing is to release the area you want to elevate and how you reshape the lateral brow area.
If there is a facial rejuvenation surgery that is over-recommended and often overdone these days, it is without question the browlift. Look no further than the celebrity photo magazines for pictures of stars who look like they have just sat down on a plate of tacks. The goal of aesthetic plastic surgery should be to make a person look better and more youthful, not merely different, and certainly not as though one is perpetually surprised. My goal is to provide my patients with results which appear natural, and an unnatural-appearing brow is a dead giveaway that a person has had facial plastic surgery.
I rarely see a patient that has such significant brow descent that I recommend elevation of the entire brow. However, I frequently see browlift patients for whom conservative elevation of the lateral brow produces a more rested, bright, and even elegant appearance. This is very easily simulated with gentle upward traction on the skin of the lateral forehead. If you feel that this may apply to you then try it in the mirror and the improvement will be quite obvious.
A youthful, feminine brow rests above the level of the orbital rim, which is the upper margin of the bony socket in which the eye resides. An aesthetically pleasing brow is somewhat arched laterally, and the lateral end or tail of the brow is higher than the medial end. It is quite common for the female brow to assume an essentially flat or horizontal orientation as a person ages.
If the skin and soft tissues lose enough elasticity with age and sun exposure, the lateral brow may even descend to a level below the orbital rim, producing a tired or even surly appearance. The medial brow is relatively fixed in position and in most cases does not descend much, if any. In years past, a browlift surgery required an incision across the top of the head, from ear to ear. This was replaced in the 1990's, for most surgeons, by the endoscopic browlift, which allowed the same procedure to be performed through small incisions just behind the hairline.
While I used endoscopic browlift techniques for several years to treat brow descent, more recently I have transitioned to performing a limited incision lateral browlift that does not require the use of an endoscope. The relatively short incision is hidden behind the temporal hairline, and no incisions are required in the scalp directly above the eyes. The advantage is as follows: this approach allows me to not only redrape the lateral brow (conservatively!) in a higher position, but it also allows me to reposition the skin and soft tissues of the lateral periorbital area in an upward direction, producing a more complete rejuvenation of the periorbital area. Additionally, through this same incision I can perform suspension of the midface (cheek) if that is part of the surgical plan. Rejuvenation of the brow by means of a lateral browlift will also, in most cases, improve the appearance of the upper eyelids. When the lateral brow is repositioned above the orbital rim, the vertical elevation may eliminate the appearance of wrinkled or crepey upper eyelid skin. If the lateral upper lid skin is hooded over the lateral corner of the eye, this improves as well. While upper blepharoplasty (upper lid skin excision) is often performed in concert with a lateral browlift, for many patients the upward positioning of the brow eliminates the need for skin excision.
M.M. Law, MD