The extended browlift.

The endoscopic extended browlift adds to the armamentarium against aging, serving as an excellent stand alone procedure in the younger patient in whom the lower face and neck are minimally affected. It accomplishes a repositioning of the orbital portion of the orbicularis oculi muscle thereby minimizing resection of eyelid skin, muscle, and fat. Its lift of the malar pad causes a pleasing transition onto the upper face blending nicely into the lower face. In more advanced aging, the extended browlift serves as a powerful adjunct to procedures on the eyelids, lower face, and neck. It corrects troublesome orbital festoons and malar bags and reduces the upper third of the nasolabial fold. Its transition effect in the lower face has allowed an alternative procedure with more limited SMAS-skin undermining to be performed in smokers. The primary disadvantage of the procedure is the necessity of thoroughly understanding and familiarizing oneself with the somewhat confusing temporal anatomy, the location of the retaining ligaments of the cheek, and the relationship of the facial nerve to the deep plane. A failure to recognize and release the retaining structures will limit significantly the outcome of the procedure. Careless or misdirected dissection over the zygomaticus major muscle may directly injure the muscle or the nerve branches to the orbicularis oculi muscle. Forty-two patients who underwent an endoscopic extended browlift now have been followed from 6 to 18 months. The patient representing the first endoscopic attempt had unilateral weakness of the forehead and bitemporal fat atrophy. The forehead weakness resolved at 4 weeks postoperatively. The temporal fat atrophy was corrected at 1 year postoperatively with micro fat grafts. A second patient done as a demonstration at another institute had forehead weakness and excessive tension on one side. The weakness and tension reportedly resolved at 3 months. No patients have had permanent weakness. The most frequent occurrence following the procedure was the return of brow asymmetry that was present before surgery. Attempts at correcting this preoperative finding were generally unsuccessful.