The indication for surgery is the patient whose forehead has slumped down over the eyes &/or has excessive forehead lines &/or has excessive vertical lines between the eyebrows.
Essentially the procedure is to draw back the skin of the forehead into its previous position – the aesthetic surgeon has critical guidelines for designing how that should be achieved.
The endoscope (an illuminated telescope) allows the surgeon to perform his operation through several small incisions, but does not alter the principle of the procedure performed.
Occipito-frontalis is a muscle with two bellies and a flat tendon (aponeurosis) between them. The “Frontalis” portion is the muscle that raises the eyebrows and wrinkles the forehead. Part of the aging phenomenon is a lowering of the forehead skin over the orbits, so the once clearly distinguishable orbital margin is now blurred, the hairy eyebrows descend in front of the orbit and the upper portion of the eyes is hidden.
The surgery achieves a repositioning, a pulling back, of the Frontalis muscle. Several small (1-2 cms) incisions are made at the margins of the hair line, in the temples and in the midline these permit a degree of “blind” surgery, and the use of the endoscope as indicated. They replace the previous ear to ear incision, peeling the skin of the forehead forwards.
The deep fascia is penetrated, the aponeurosis (also called galea) is blindly and bluntly removed from the bone until approaching the orbital margins and peripheral attachments to the zygomatic arch.
It is desirable to preserve the supraorbital nerve and trochlear nerve, and this is where the endoscope is useful; the tool is inserted through one small incision, then guided by the appearance on the TV screen the surgeon can, through another incision, release the fibrous attachments from the orbital margins and other peripheral anchorage without damaging the neuro-vascular bundles.
At the conclusion of this “liberation,” the forehead is mobile and can be drawn up and stabilized at the desired position. This may be achieved with non-absorbable (or very slowly absorbed) sutures to the deep fascia, by plicating it, or some surgeons use an implanted anchoring device. The face is left exposed during the procedure which permits direct visualization of the “handiwork” and an assurance that symmetrical tautening and elevation has been achieved before the wounds are finally closed.