Endoscopically assisted forehead-brow rhytidoplasty: theory and practice

Forehead-brow rhytidoplasty has evolved from a procedure primarily advocated for brow ptosis, to one in which a group of deformities are routinely addressed. It has also become evident that the surgical results stem from wide undermining with release of the periosteum and the concomitant alteration of the forehead muscles and not necessarily from skin lifting using elevation/excision ratios. Therefore, with the introduction of endoscopically assisted techniques to plastic surgery, the indications for a long forehead incision and its untoward sequelae have to be reconsidered. The anatomic basis for minimally invasive forehead-brow rhytidoplasty and three types of procedures are discussed. These include Type I--complete, endoscopically assisted forehead-brow rhytidoplasty; Type II--segmental, in conjunction with facelift surgery; and Type III--isolated, frown-muscle modification. The role of fixation (external support, internal suspension, or excision techniques) is described. Results suggest that these options provide a worthwhile alternative to traditional "open" techniques in certain circumstances, although some relevant questions remain unresolved.