Endoscopic brow lift

What it treats

• Brow droop (brow ptosis) usually starts in the outer (lateral) brow; in 20 cadaver heads the lateral brow had less deep support than the inner brow (PMID 8643714).
• Forces on the lateral brow: frontalis resting tone holds the brow up only medial to the temporal fusion line; lateral to it, soft tissue slides down over the temporalis fascia; the corrugator and lateral orbicularis oculi pull the brow down (PMID 8643714).
• The brow does not fall evenly with age: women aged 50 to 60 (34) had brows 19.1, 22.4 and 22.4 mm above the medial canthus, pupil and lateral canthus; women aged 20 to 30 (36) had 15.7, 19.8 and 21.3 mm (PMID 19935315).
• The same study concludes that raising the medial and mid brow does not give a youthful result and that selective lateral lifting does (PMID 19935315).
• The supraorbital nerve has a superficial division over the frontalis and a deep division running between the galea and the bone covering to the scalp; injury to the deep division causes most scalp numbness after forehead lifts (24 half-heads, 30 volunteers) (PMID 7638280).

How it is done

Origins

• Vasconez 1994: cadaver studies and 32 patients; corrugators, procerus and frontalis divided or weakened; excess skin taken up by dissecting the scalp back toward the occiput (PMID 7972423).
• Isse 1994: 61 endoscopic forehead lifts in 11 months, with results comparable to coronal lifts (PMID 8122572).

Standard steps

• Dissection under the periosteum through three small incisions, release of the periosteum at the upper orbital rims, removal of the glabellar frown muscles, and temporary suspension until the periosteum reattaches; 400 procedures in 393 patients, 1994-2000 (PMID 12409778).
• A 35-year single-practice account: wide subperiosteal dissection to the zygomatic arch and orbit, cuts through the brow depressor muscles, and lateral suture fixation (PMID 41203333).
• Three dissection planes are in use (subgaleal, subperiosteal, and combined); they differ in risk to the deep branch of the supraorbital nerve (PMID 42465865).
• 50 cadaver hemifaces: supraorbital nerve tension limited the lift; nerve slack allowed 2.5 to 5.5 mm (mean 4.1 mm); the galeal fat pad accounted for 60% of brow mobility (PMID 36727814).

Fixation

• Scoping review, 27 papers, 2,519 patients, 11 fixation methods; most common were sutures (906), bone tunnels (649), Endotine implants (333) and screws (216) (PMID 40804547).
• 538 patients: brow elevation with sutures through bone tunnels was 6.21 mm at 1 month and 6.16 mm at more than 3 months (mean 9.4 months); with fibrin glue it fell from 5.93 mm to 3.79 mm (PMID 15083028).
• Percutaneous K-wire fixation, 284 patients (1996-2018): 2 hematomas; 1.8% needed a second one-sided lift (PMID 31361803).
• 14 cadaver skulls: cortical tunnels drilled at 45 degrees and Mitek anchors never went through the inner skull table; one Endotine post and three miniscrews did (PMID 16977357).

Frown muscles

• 23 patients followed 12 months: corrugator and procerus removal improved moving frown-line scores more than no removal (2.56 vs 1.07) (PMID 31046060).
• 312 lifts without frown-muscle removal (2016-2023): brows rose 2-3 mm medially, centrally and laterally in 113 measured cases; complications 0.6%, revisions 1.9% (PMID 40820940).

High or receding hairline

• Incisions and Endotine anchors placed in forehead creases: brow elevation 2.78 mm medially to 5.05 mm laterally, with forehead length proportion unchanged (PMID 34593745).

Results and evidence

• Meta-analysis, 12 studies (1994-2024): long-term elevation 3.25 mm medial, 3.86 mm central, 4.35 mm lateral (PMID 39542644).
• Meta-analysis of all brow lift types, 22 studies, 2,127 brows, weighted mean follow-up 20.9 months: lateral 3.8 mm, central 3.02 mm, medial 2.41 mm (PMID 40788666).
• Review 2026: the highest long-term elevation in any study did not exceed 5.6 mm; elevation fell gradually over time, and the medial brow was least elevated (PMID 42077543).
• 650 patients, mean follow-up 7.1 years: satisfaction 96.6 at 6 months and 79.9 at 2 years or more (0-100 scale); reoperation 1.2% (PMID 34269765).
• 65 patients, mean 6 years: endoscopic and pretrichial open lifts both kept a significant elevation, with no difference between them (PMID 35653546).
• 50 endoscopic against 22 pretrichial lifts: more early elevation with endoscopic (21% vs 13% change in brow height ratio); long-term retention and complications similar (PMID 41239801).
• Endoscopic temporal brow lift, 71 patients: mean elevation 1.8 mm at midpupil, 1.9 mm at medial canthus, 1.8 mm at lateral canthus; complications 1.4% (PMID 31764641).
• Endotine fixation with upper blepharoplasty, 35 patients: mean elevation 1.6 mm, stable up to 55 months (PMID 33631951).
• 140 patients, one surgeon: endoscopic and coronal/pretrichial lifts gave comparable elevation at 1 year; coronal/pretrichial brow position dropped gradually over 5 years (PMID 11322395).
• 628 cases, 1997-2001: 70% of patients satisfied, 50% of 21 surveyed surgeons pleased with long-term results; the hospital's endoscopic brow lift volume fell 70% (PMID 12900626).
• 35 patients analyzed with eyes closed by AI: forehead height did not change; the increase seen with eyes open was attributed to a relaxed frontalis (PMID 42012844).

Risks and complications

• Systematic review, 82 studies, endoscopic subperiosteal lifts: numbness or tingling (paresthesia) 6.2%, asymmetry 3.6%, hair loss 3.0%, incomplete eye closure 2.7% (PMID 23388642).
• Systematic review, 76 studies: endoscopic lifts had the highest hair-loss rate of all brow lift types, 2.8% (PMID 30534495).
• 650 patients: temporary itching 13.7%, headache 6.3%, one-sided facial nerve weakness 5.8%; permanent undercorrection 7.1%, hair loss 4.2%, forehead irregularity 2.3%, surprised look 2.2% (PMID 34269765).
• 805 cosmetic forehead/eyebrow lifts (open and endoscopic): excessive bleeding during surgery 3.7%, early bleeding after surgery 1.5%, hematoma drainage 0.7%; bleeding more frequent in men (PMID 41870876).
• Fixation review: neurological complications 11.69%, aesthetic 6.27%, wound 1.19%; bone tunnels had the lowest complication profile and screws the highest (PMID 40804547).
• Meta-analysis, 13 studies: pooled complication rates under 3% with few exceptions; permanent fixation had more asymmetry, contour irregularity, cysts and corrective surgery than temporary fixation (PMID 41697229).
• Double vision from superior oblique muscle weakness after endoscopic brow lift, 2 cases, resolved within 3 months (PMID 39746538).
• Vertical internal brow suspension, 118 cases: suture extrusion 6.8%, temporary hair loss at incisions 5.1% (PMID 39378135).

Recovery

• Telephone survey, 57 patients: 89% used pain medicine for under 1 week, 95% had swelling for under 2 weeks, 63% had some numbness, 28% noticed hair loss at an incision, 77% rated scars unnoticeable (PMID 23699709).
• Forehead numbness took a mean 2.3 months to recover in 650 patients (PMID 34269765).
• 21 prospective and 58 retrospective patients: open lifts left less scalp sensation than endoscopic lifts at 1 to 14 weeks and at 6 to 18 months, with no difference after 18 months; 57 of 58 said numbness would not stop them repeating the surgery (PMID 21079105).
• Bone-tunnel series: small areas of temporal hair loss recovered in under 3 months; one frontal branch weakness recovered by 4 months (PMID 15083028).
• The same authors cite experimental evidence that periosteal fixation must hold for at least 6 weeks to be secure (PMID 15083028).
• 8 of 16 patients with headaches before surgery reported fewer or milder headaches afterward (PMID 23699709).

Combined procedures

• Kaye 1977 described the forehead lift as an adjunct done alone or with facelift and blepharoplasty (PMID 887657).
• 400 endoscopic forehead lifts: the complication rate did not markedly increase when combined with other facial procedures (PMID 12409778).
• 57 patients: those who also had a facelift more often took 2 weeks or longer to return to normal activities; pain medicine use, swelling, numbness, hair loss and satisfaction did not differ from brow lift alone (PMID 23699709).
• 93 deep-plane facelift patients, including groups with forehead lift and endoscopic forehead lift: result ratings did not correlate with procedure group (PMID 20966814).
• Frown-muscle study: 19 of 23 patients had the endoscopic brow lift with other procedures to the brow, midface, jowl and neck (PMID 31046060).
• CosmetAssure database, 6,126 patients: brow lift with blepharoplasty had the same major complication rate as either alone (0.4% combined, 0.4% blepharoplasty, 0.7% brow lift) (PMID 29369102).
• Upper blepharoplasty at the same operation (214 of 538 patients) did not change long-term brow height (PMID 15083028).

Current questions

• Durability: pooled long-term elevation of 3.25-4.35 mm (PMID 39542644) against a 2026 review that finds long-term maintenance poor, especially laterally (PMID 42077543).
• Fixation: a randomized trial of 36 patients found bone tunnels held the brow better than temporary tape at 9 months, with longer operating time (PMID 42441344); a meta-analysis found no difference in revision for lost fixation between permanent and temporary bone fixation (PMID 41697229).
• Tined implants gave more lateral elevation and more dysesthesia than sutures in pooled data (PMID 40788666).
• Lateral relapse: vertical internal brow suspension proposed to prevent it (PMID 39378135).
• Frown-muscle removal: routine myectomy (PMID 31046060) against lifts without it (PMID 40820940).
• Forehead lengthening: eyes-closed AI analysis reports no true elongation (PMID 42012844).
• Neuromodulators: frequent use among surveyed surgeons rose from 11.2% to 88.5%, and nearly 30% think they have replaced formal brow lifting to a significant degree (PMID 37409963).
• Nerve limit: supraorbital nerve tension may cap elevation at 2.5-5.5 mm (PMID 36727814).

Terms

• Brow ptosis: an eyebrow lower than its youthful position; the lateral segment usually drops first (PMID 8643714).
• Endoscope: a thin camera passed through small incisions to see and dissect under the scalp (PMID 7972423).
• Subperiosteal plane: the layer under the periosteum, the membrane covering the skull (PMID 12409778).
• Periosteal release: cutting the periosteum at the upper orbital rim so the brow can move up (PMID 12409778).
• Corrugator and procerus: frown muscles between the brows, weakened or removed during the lift (PMID 31046060).
• Fixation: holding the lifted forehead with bone tunnels, screws, implants such as Endotine, sutures or glue while it heals (PMID 40804547).
• Deep branch of the supraorbital nerve: sensory nerve to the scalp that runs under the galea; injury causes scalp numbness (PMID 7638280).
• Temporal fusion line: ridge on the side of the skull where frontalis support of the brow ends (PMID 8643714).
• Galea aponeurotica: the tough fibrous layer of the scalp (PMID 7638280).
• Lagophthalmos: incomplete eye closure (PMID 23388642).

Papers