Forehead (Endoforehead Lift)

Background

With age, the upper third of the face from the tissue just above the upper eyelids to the hairline can begin to descend and wrinkles can develop not only horizontally across the forehead, but also between the eyebrows, giving one a tired or even sometimes angry appearance. The procedure known as a forehead lift or browlift reverses this appearance, restoring a more youthful, rested countenance. Often when patients feel they have sagging upper eyelids, in fact they have a sagging browline. Though no absolute aesthetic ideal exists for every person, typically if one manually raises the eyebrows it becomes clear what a forehead rejuvenation can accomplish.

There are two basic approaches to lifting the forehead and treating the frown muscles in between the eyebrows. The more traditional approach involves making an incision across the top of the scalp and after working directly on the frown muscles, removing a strip of scalp and re-approximating the edges. This is a time-tested method with a good track record for producing predictable and long-lasting results.

A more recent method is known as an endoscopic forehead lift, or “endoforehead lift”, and involves an indirect approach of repositioning the scalp in an upward direction after freeing up the forehead from the underlying bone using an illuminated tube with a camera attached to it and using special instrumentation designed to work through several small incisions in the scalp. Under video guidance, the surgeon works on the frown muscles and frees up the attachments of the eyebrows around the eye sockets so they can be shifted upward to a more youthful position. The forehead is shifted upward and anchored directly to the skull from inside, and the tissues adhere in their new, more youthful position.

The advantages of the traditional approach are that a more controlled contouring of the shape of the eyebrow can be obtained. The procedure has been in use for a long time, and the results are long-lived. Complications are few, but include the possibility of a prominent scalp scar, with possible loss of hair along the incision line. Many people develop numbness in a small patch of scalp at the top of their head. Dr. Creasman almost never does this form of the procedure any longer.

The advantages of the endoforehead lift are that the scars are less lengthy and therefore less noticeable. There is less risk of numbness of the scalp. The recovery may be slightly shorter without the need to heal a long incision line. Though complications are few, they include loss of hair at the small incision sites (unusual), inability to obtain significant shape change of the brow because of a mainly vertical vector of pull (as opposed to an upward and outward direction of lift with the open technique), and relapse. Results at 5 years appear to be at least as stable as the open procedure, and issues of numbness, hair loss, and scarring have virtually been eliminated.

Dr. Creasman prefers the endobrowlift for most patients undergoing the procedure, but in very heavy scalps an open approach may occasionally be necessary.

The Consultation

Dr. Creasman will evaluate you for the forehead lift in the context of evaluating your facial aesthetics in their totality. This evaluation involves examining your upper and lower eyelids, your mid-facial aging, your neck, and your skin itself in addition to what is going on with your forehead. No one area of the face can reasonably be viewed in isolation, without considering the adjacent areas and overall balance of your features. An important issue to discuss is the status of your hair growth (or loss). Hair treatments, such as bleaching and permanent wave applications can adversely affect the health of the hair follicles. Meticulous attention to the manner in which the scalp is closed, either with an open or endoscopic approach, is of critical importance in achieving a cosmetically attractive outcome

During his examination, Dr. Creasman also looks at the symmetry of your brows, the position of your brow with respect to your bony socket, and how you animate your forehead during conversation. Particularly expressive individuals will often carry their eyebrows in an asymmetrical posture. This cannot be corrected surgically and should be appreciated prior to surgical intervention.

After discussing his findings and the approach he would recommend, Dr. Creasman will likely want to show you what sort of result you can reasonably expect with your procedure by the use of a special computer imaging program. Results of other patients’ procedures can be found in Dr. Creasman’s Photogallery.

Risks of Browlift

Though complications are infrequent, every operation entails some level of risk. In the case of a browlift the complications seen include bleeding, infection, loss of sensation, muscle weakness with the inability to elevate the forehead, temporary or even permanent hair loss, asymmetry, and recurrence of sagging brows. All of these complications are rare. The most common concern we hear is the fear that the forehead lift will result in a “surprised look”. This is an issue Dr. Creasman is very conscious of, and he attempts to give you a natural yet rested appearance.

Before Your Procedure

It is imperative that patients refrain from ingesting any medications or other substances that could potentially be the cause of surgical complications. A list of medications should be reviewed and discontinued at least two weeks prior to operation. Patients are seen two weeks prior to their surgery date for a general physical examination to ensure that no underlying medical problems exist that may interfere with the safety of their surgery. Specifically, any infections that arise prior to operation, however seemingly trivial, should be reported to our office. Even an otherwise innocent infection can result in a surgical wound infection, and must be treated prior to surgery. If you have hypertension, this must be under very good control with your medications prior to surgery; you should plan to take your blood pressure medication right up to the time of your operation.

Avoid hair bleaching, coloring or permanent wave treatments for two weeks before and two weeks after your forehead lift.

CIGARETTE SMOKING MUST BE DISCONTINUED FOR AT LEAST SIX WEEKS PRIOR TO OPERATION. Serious wound healing complications can occur in patients who are exposed to smoke, even passively.

Prophylactic antibiotics are administered intravenously just prior to surgery to reduce the risk of surgical wound infection. A prescription for pain medication is given at the preoperative visit, so that you have your pain pills when you return home from the operation. Dr. Creasman recommends the use of homeopathic pills to minimize swelling and bruising. This is available for purchase in our office.

Specific instructions regarding the date and time of your procedure will be given to you in writing. You will need to arrange for an escort to drive you to and from our office on the day of the operation and for the first post-operative visit. DO NOT SHAVE your scalp prior to surgery; this may increase your risk of infection. Appropriate hair trimming will be done on the morning of your procedure and is very minimal.

Here is a preoperative checklist for you to follow prior to your forehead lift:

1. Please pick up liquid Ivory hand soap and cleanse the skin of your face with it for the three days prior to your operation. Shampoo the morning of surgery and dry your hair well. Do not apply any hair care products afterwards.
2. Report any signs or symptoms of infection, such as fever, inflamed body parts, burning with urination, cough, diarrhea, or flu symptoms.
3. You should avoid treating your hair with bleach or get a permanent wave for two weeks before and two weeks after surgery.
4. Wear a non-pullover shirt to your operation. We suggest a zipper front sweatshirt. Wear slip on shoes with smooth soles for ease of ambulation. Wear cotton underwear and clean white socks. Do not wear makeup.
5. Please remove any artificial nail material from both of your index fingers. We monitor your oxygen levels through your nail beds, and artificial nail products interfere with this.
6. Do not wear jewelry or bring other valuables to the office on the day of your surgery. Pierced body parts need to be free of jewelry for your safety.
7. Take any prescribed medications as directed.
8. DO NOT EAT OR DRINK ANYTHING FOR SIX HOURS PRIOR TO YOUR ARRIVAL.
9. Avoid smoking for six weeks prior to surgery.
10. Avoid alcohol for 48 hours prior to surgery. It can lead to dehydration and can interfere with clearance of your anesthetic medications.
11. Stock up on Coca Cola Classic. It may help with any nausea you might feel after your anesthetic.

The balance of your surgical fee is due at this pre-operative visit. Please visit our Financial Center for our payment policies. You can find out the current fee for this procedure by contacting our office.

The Operation

On the morning of surgery, you will be greeted by Dr. Creasman’s nurse and an intravenous line will be started. Dr. Creasman will need to draw lines on your face and scalp to provide him with guidelines during your procedure. Your hair will be minimally trimmed appropriate to the approach used and otherwise gathered into bundles with rubber bands. A single dose of antibiotics is given intravenously to reduce your risk of surgical wound infection.

Dr. Creasman performs this procedure either nuder general anesthesia or local anesthesia with intravenous (IV) sedation. If you have general anesthesia, this will be administered by a board-certified anesthesiologist. You would be completely unaware of the operation, and this is a brief and very well tolerated process. If you decide on local anesthesia with sedation, Dr. Creasman administers this. Through the I.V., sedative medications will be administered which will place you into a “twilight” level of consciousness. Prior to the administration of the local numbing medication, you will be given a deeper, short-acting sedative which will enable the injection of numbing medicine without any awareness on your part. You will then return to your previous level of sedation, and gradually be allowed to awaken toward the conclusion of the procedure. There is more awareness of the procedure using the IV sedation method. General anesthesia is usually preferable, but does entail slightly more cost to you.

The forehead lift typically takes about an hour, and a dressing will be placed around your entire head. After an appropriate period of observation in our recovery room, you will be discharged into the company of an adult. Patients cannot be discharged into the company of a minor or to a taxi service.

The Post-Operative Period

You will most likely feel like sleeping for the rest of the day. Often, patients do develop a headache from the tension placed on their scalp. Dr. Creasman uses a long-lasting local anesthetic block to provide a measure of pain relief for several hours after surgery, but it will be necessary for you to take pain medication for about 3-5 days afterwards. You will need someone to stay with you for at least the first 24 – 48 hours. You will not be able to wash your hair until after your first post-operative visit. You should plan to apply ice compresses to your eyes to diminish swelling and bruising. You should anticipate some swelling and bruising around the eye area, which typically resolves in under 2 weeks.

You will be seen 2-3 days after surgery, and your dressings removed. You need someone to drive you to this first follow-up visit. After this visit, you will be allowed to begin washing your hair. You will return for removal of wound clips on day 5 or 6.
Most patients return to work at one week or less. Final results are usually evident at 3-6 weeks, though there may be some minimal swelling which needs to disappear over the first three months.