Endoscopic brow lifting is my preferred method of aesthetic brow reshaping. I use the word reshaping because the primary lesson I have learned from 20 years of brow lifting is that the procedure should focus on brow shape and contour more than height. This is the single most important caveat of brow lifting and will allow better results and happier patients.
Over the last 4 years I have primarily utilized a temporal endoscopic plane approach (between the superficial and deep temporalis fascia) with or without the use of the endoscope to reshape the brow contour. My focus has been a temporal lift only. In my experience, in most cases, lifting the medial brow is an error which changes normal eyelid and periorbital, and ultimately, facial proportions. Most who need medial brow elevation also have bunching of glabellar tissue, and I have found benefit most from a central pretrichial approach (with tissue excision) combined with the temporal lift described below.
The procedure proceeds with standard temporal approach sub-superficial temporal fascia access to the canthus. This plane is made continuous with the central subperiosteal space by dividing the conjoint tendon. Dissection continues to the arcus marginalis periosteum at the superior orbital rim. The periosteum is released from the supraorbital neurovascular bundle laterally to the canthus. It is critical to release the lateral orbital thickening. The temporal brow is fixated with 2 sutures (2-0 PDS) from superficial to deep fascia. The lift is superior and nasal to avoid brow splaying and provide the best temporal elevation. No cautery is used for bleeding (vascular tourniquet is created with dilute anesthetic and added pure saline as needed – bleeding is controlled with mechanical pressure from volume of injection). Only staples close the wound and no scalp is excised. These are critical steps to avoid alopecia. Post-op regional supraorbital and lacrimal nerve blocks are given as is local anesthetic infiltration of staple sites – all to control pain. Preoperative Emend (substance P receptor antagonist) is a reliable way to control post-op nausea (I highly recommend this – look it up). Post-op pain control is with your narcotic of choice prn.
I have recently reviewed 162 such cases with the following findings.
94% of patients stated a high satisfaction with the brow lift.
The remaining patients were satisfied except for 2 who desired a revision for more temporal lift. Keep, in mind – all patients knew the procedure performed this way would not address glabellar or forehead rhytids. This was not their expectation. Most received post-op neuromodulation for this purpose. This avoids the numerous issues with selective myotomy/myectomy (another topic of discussion).
More than temporary motor nerve injury (first week or so) occurred in 2 patients (1.2%), which is slightly less than the reported 1.5% previously reported. Both these patients had previous coronal lifts (ie both revisions).
Sensory issues beyond 4 weeks (numbness, tingling, itching, etc) occurred in 3.8% of patients – far less than the previously reported 7%-8%. To achieve this, it is critical to stay subperiosteal when making the temporal sub-superficial temporal fascia plane continuous with the central subperiosteal plane (when dividing conjoint tendon). This protects the distal segment of the deep (lateral) branch of the supraorbital nerve. Also as the periosteal release is lateral to the supraorbital nerve egress, the proximal superficial (medial) branch of the nerve is less prone to damage.
We have paid more attention to motor injury than to sensory injury because morbidity is worse. However, always remember that sensory injury is more common.
It has been reported that post-op pain is present in up to 75% of traditional endolift surgery patients. In this technique, with injections described, I have noted its presence in approximately 30% of cases.
Alopecia at the incision site is a tough parameter to judge. Approximately 10% have made mention of it – close inspection most likely shows it is more common. However, at 1 year after surgery it is rarely suggested by patients.
It is important to share such knowledge as we continue to evolve our surgical procedures. I welcome other’s experiences so we can grow and learn together and deliver the best of care.
Cosmetic eyelid surgery (blepharoplasty) is a specialized surgery which can significantly enhance your appearance. However, it is important to understand that blepharoplasty, when performed by an inexperienced surgeon, can potentially lead to poor results with short term or permanent disability.
How can you avoid blepharoplasty complications?
Avoiding surgical complications requires the expertise of an eyelid specialist and expert, known as an oculoplastic surgeon. Dr. Guy Massry, MD is a Beverly Hills oculoplastic surgeon who performs cosmetic blepharoplasty routinely. He has over 20 years of experience with this surgery - having performed thousands of procedures. Oculoplastic surgeons, like Dr. Massry, are the most qualified surgeons to perform any sort of cosmetic eyelid surgery because they have dedicated their medical practice solely to procedures around the eyes. This precise practice means they perform more blepharoplasty surgeries than a general plastic surgeon, who is performing cosmetic procedure on the entire body. This focus not only helps them avoid surgical complications, but in the unfortunate chance that a complication does arise during a blepharoplasty procedure, they have the keen knowledge on how to minimize the risks.
Minimizing Lower Blepharoplasty Complications
Lower blepharoplasty is actually far more complex than upper eyelid surgery. The problem is that unless a surgeon is performing lower blepharoplasty procedures in high volume there is no way to develop the skills needed to attain consistent and predictable results with the surgery. For this reason you must understand that lower blepharoplasty is not simply a plastic surgical procedure – but rather an ophthalmic (eye related) plastic surgical procedure – BIG DIFFERENCE.
Dr. Massry performs many revision lower blepharoplasty procedures yearly. To avoid a revision surgery, it is imperative you see an expert like Dr. Massry the first time around!
Patient 1: Primary lower lid blepharoplasty with fat repositioning with Dr. Massry.
Patient 2: This woman was very unhappy with pulled down (retracted) lower lids from previous surgery by another doctor. After revisional surgery with Dr. Massry her appearance is significantly improved.
Non-Surgical Corrections For Unsatisfactory Results
In some cases, additional surgery is not the answer for patients who had poor results following a primary lower lid blepharoplasty. If surgery is not a patient's best option, Dr. Massry will recommend using dermal fillers to help improve the appearance. Below is a video of Dr. Massry performing filler injections on a patient who had surgery with another doctor that left him with drooping lower eyelids. The filler lifts the lower lids that are being pulled down and makes the eyes look less "buggy."
Contact Dr. Massry Today!
Whether you are thinking of having cosmetic eyelid surgery or you have already had surgery and are unhappy with the results, call us today to schedule your consultation with eyelid surgery specialist Dr. Massry - 310.657.4302!
More Information on Lower Eyelid Surgery