My doctor offered me two options for a brow lift - subperiosteal or subcutaneos.  Both would be with incisions back and close to the hairline.  Which would be the best approach for this surgery?

There is no "best" way as each person has different results from each procedure.  I prefer the subcutaneous technique because its 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.

One of the most important determinant of a Brow Lift can be your pre operative Brow Height. You do not want to be left with a tall brow or a startled appearance.  Many patients if possible request the subperiosteal approach to a brow lift because there can be less incidence of nerve injury/damage which could cause loss of sensation on the top of your head.  Further, your surgeon would normally have to have access to very expensive endoscopic equipment for a subperiosteal brow lift.  First, discuss these issues with your surgeon.  If your concerns are not addressed, then consider one of the many members of the ASAPS. They are experts in facial plastic surgery procedures. 

Best,

Gary R. Culbertson, ,MD, FACS

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.

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. 

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.