Endoscopic Brow Lift in Ukraine

The upper third of the face ages in its own way. The brow gradually descends, above all its outer part, and over the years the depressor muscles that pull the brow down work harder than the frontalis muscle, which lifts it. The eyes start to look heavy, and an expression of tiredness or displeasure appears that the person does not intend.

An endoscopic brow lift returns the brow to its anatomical position and weakens the muscles that pull it down. The surgeon does not remove forehead skin but shifts the whole block of tissue upwards and secures it in the new position. The forehead skin is lifted together with the brow, so horizontal forehead lines usually become shallower, and frown lines between the brows soften after the muscles are treated. Exactly how much depends on skin quality and the depth of the lines, and only a surgeon can predict this for an individual patient, after an in-person examination.

The operation is indicated for drooping brows, when the outer end of the brow lies below the upper rim of the eye socket; for deep frown lines caused by overactive muscles; for a habit of constantly raising the brows that leaves permanent horizontal lines on the forehead; for brow asymmetry; and, as a special case, when excess upper eyelid skin is actually a drooping brow.

Not everyone needs it. If the main complaint is overhanging eyelid skin itself and the brow sits normally, surgery on the forehead will not solve anything: blepharoplasty is the answer here. If the eyelid droops because the muscle that lifts the upper eyelid is weak, that is blepharoptosis, a different procedure on the muscle itself. If the concern is the cheeks, nasolabial folds and jawline, a brow lift does not change them: it works only above the brow line.

Surgery is declined or postponed with uncontrolled high blood pressure, blood clotting disorders and anticoagulants that cannot be interrupted, uncontrolled diabetes, serious heart and lung disease, active inflammation of the scalp, scarring alopecia in the incision area, pregnancy and breastfeeding. It is also declined when expectations are unrealistic: if the patient expects the operation to change the shape of the eyes or remove age-related changes across the whole face, the conversation should end at the consultation, not in the operating room. MediUkraine is a treatment search and coordination service, not a clinic: we select the surgeon and medical centre, while the decision on surgery is made by the doctor after an in-person examination.

Access is through 3–5 small incisions, 1–2 cm long, in the hair-bearing scalp, 1.5–2 cm behind the hairline: one in the midline or two paramedian, plus two temporal. The incisions are angled parallel to the hair follicles so that hair later grows through the scar and it is not visible in a parting. An endoscope is inserted through one of the incisions: 4–5 mm optics with a camera whose image is shown magnified on a monitor. The surgeon sees what an open approach would show only through a long incision: the supraorbital and supratrochlear neurovascular bundles, the sentinel vein in the temple, and the layer in which the temporal branch of the facial nerve runs. The other instruments are inserted through neighbouring incisions, and the surgeon works guided by the image on the screen.

The tissues are lifted in one of two planes. The subperiosteal plane runs between the periosteum and the skull bone: it is almost bloodless, its landmarks are clear and fixation to bone is more secure, so it is chosen more often. The subgaleal plane lies under the galea aponeurotica, above the periosteum; swelling goes down faster after it, but the tissues hold less well in the new position. In the temples the surgeon works on top of the deep temporal fascia: this layer separates the instrument from the temporal branch of the facial nerve. The two areas are joined by releasing the adhesions along the temporal line.

The key stage is releasing the tissues along the upper rim of the eye socket. The periosteum there is firmly attached to the bone, and until this band is released the brow does not move: pulling the scalp back simply stretches the forehead without changing the position of the brows. The release is done under the endoscope, avoiding the supraorbital and supratrochlear nerves, which emerge from openings or notches along the edge of the eye socket.

Next the depressor muscles, those that pull the brow down, are treated. The corrugator supercilii draws the brows together and down, and it is what creates the vertical lines between the brows. The procerus lowers the inner end of the brow and produces the horizontal line at the root of the nose. The orbital part of the orbicularis oculi works as a ring-shaped sphincter and presses the brow down along its whole length. Under the endoscope, the fibres of these muscles are partly divided or removed in fragments: frown lines usually soften, and the brow stops being pulled back down by constant muscle tension, so the lift is more likely to last longer. Over-resection of the corrugator leaves a hollow between the brows that then has to be filled with a fat or fascia graft, so the muscle is weakened rather than removed completely. Deep static lines already etched into the skin are not removed by muscle work; they need resurfacing or fillers.

The lifted tissues have to be held in place until they reattach in the new position, and there are several methods of fixation. The basic option is sutures to the periosteum or to the deep temporal fascia: this is how the tail of the brow is lifted in the temples. Bone tunnels are two openings in the outer layer of bone near the incision through which a suture is passed: an old, cheap and reliable method. Endotine absorbable fixation devices are a small plate with tines that holds the tissue against the bone and dissolves over several months; it spreads the tension evenly, but it is an imported consumable and its cost is noticeable in the quote. Cortical screws that are removed after 10–14 days and fibrin glue are also used. None of the methods has shown a decisive advantage in studies, so the surgeon chooses the one they are confident with and that suits the tissue quality of the individual patient.

Before the endoscope, the same operation was done through a coronal incision, a cut across the whole top of the head from ear to ear. It gave a wide view and allowed a strip of scalp to be removed, but the price was a long scar, permanent numbness of the whole area behind the incision, a hairless strip along the scar and an inevitable rise of the hairline: the scalp was shortened and the forehead became higher. The endoscope made it possible to perform the same manoeuvres (releasing the rim of the eye socket, working on the muscles, fixation) through small incisions, with less blood loss and a shorter recovery, and above all without removing scalp. That is why the open coronal approach is now rarely used in aesthetic surgery, only in isolated cases.

The method has an honest limitation that you should know about before surgery. The endoscopic approach shifts the whole block of tissue upwards together with the hairline: only by a few millimetres, but it does shift it. For patients with a high forehead, when the distance from the brow to the hairline exceeds about 6 cm, this spoils the proportions: the forehead becomes even higher. For them a different approach is chosen, a pretrichial or trichophytic incision along the hairline itself: the excess is removed in front of it, and if needed the forehead can even be shortened slightly. The price of this solution is a scar on a visible boundary, which is disguised by hair growing through it. Some patients are not offered the operation at all, and the procedure is limited to lifting the tail of the brow through a temporal approach. The second limitation concerns hair: with thin hair, androgenetic alopecia with a receding hairline or early baldness, the incisions are more visible, and their placement has to be reconsidered.

The scope of the procedure also varies. An isolated temporal lift through two incisions raises only the tail of the brow: it is less invasive and suits younger patients; the full version covers the whole forehead including the area between the brows; and a transblepharoplasty approach through an upper eyelid incision allows the corrugator to be treated and the outer part of the brow to be secured when the patient is having blepharoplasty anyway.

And the main thing to distinguish: excess upper eyelid skin is often not an eyelid problem but a drooping brow. When the brow slides down, it brings forehead skin with it, which gathers in a fold above the lashes. If eyelid skin is removed in this situation, the brow will drop even lower, since nothing holds it back any more; the distance from the brow to the lashes will shorten, and the eyes will look heavier than before surgery. The right order is the reverse: first lift the brow, and only then assess how much eyelid skin is really excess. After a brow lift, blepharoplasty is often needed on a much smaller scale, and sometimes not at all.

You can check this at home. Stand in front of a mirror in normal lighting, relax your forehead and look straight ahead. Then place a finger on the outer part of the brow and lift it 3–5 mm towards the hairline. If the "excess" skin above the lashes disappears and the eye opens up, the problem is the brow, and the forehead is where to start. If the fold still hangs over the lashes even with the brow lifted, this is true excess eyelid skin, and blepharoplasty is needed. The test often shows both at once: then the operations are combined under one anaesthetic, but the surgeon plans how much eyelid skin to remove taking the lifted brow into account.

You spend the first day at the clinic under supervision. An elastic dressing is applied to the head, sometimes a drain is left in for a day, and cold is applied to the forehead. A headache and a feeling of tightness in the first days are expected and are relieved by ordinary painkillers.

Swelling does not behave the way patients expect: it drains down from the forehead, so on day 2–3 the eyelids swell and bruising appears around the eyes, even though it was the forehead that was operated on. This is gravity, not a complication. It peaks on day 2–3, most of it goes down within 7–10 days, and residual puffiness lasts up to 3–4 weeks. For the first two weeks it is better to sleep with the head of the bed raised.

Stitches or staples are removed from the incisions on day 7–10, unless absorbable material was used. You are usually allowed to wash your hair on day 2–3; the surgeon will tell you the exact day. Do not colour your hair for at least a month. You can wear glasses straight away, unlike after nose surgery.

Numbness and itching of the scalp behind the incisions are a typical sensation, not a malfunction. Small sensory nerve branches are divided during the dissection and recover gradually: most patients notice sensation returning within 3–6 months, sometimes longer. The itching is in fact a sign that the nerves are growing back.

People return to office work after 10–14 days, and to the gym and exertion after 3–4 weeks. For the first weeks you must not bend with your head down, go to a sauna or swimming pool or lift weights. For patients from abroad, the flight home is planned after the stitches are removed and the surgeon has examined you, usually on day 10–14.

In the first weeks the brows often look higher than you would like: this is the effect of swelling and fresh fixation. The surgeon deliberately slightly overcorrects, because the tissues settle over 4–8 weeks. An interim result is assessed after 3 months and the final one after 6, once the scars have matured and the swelling has gone down completely. An honest estimate of how long it lasts is about 5–10 years: the tissues continue to age, and the brow eventually descends again, although usually not to its original level. The effect of the work on the depressor muscles on frown lines lasts longer than the lift itself.