Robert S. Hamas, MD

Endoscopic brow lifting has gained popularity among both surgeons and patients, mainly because of the small incisions used in the procedures. However, the effect on the position of the hairline has not been addressed. All of the endoscopic brow lifting techniques previously described slide the forehead and scalp posteriorly, which raises the hairline relative to fixed orbital landmarks. Is raising the hairline an important issue? No men and very few women want a higher hairline. If given a choice, patients will almost always choose the endoscopic brow lifting method that does not raise their hairline. Hair stylists also prefer that their clients’ hairlines not be raised because they must style hair to compensate for higher hairlines.

Surgical Strategy

To avoid hairline elevation from an endoscopic brow lift, I devised the galea aponeurosis plication (GAP) technique. This subgaleal method involves no dissection posterior to the incisions, and only the forehead - not any scalp - is advanced. As a result, the hairline is not raised.

Operative Technique

Since the first GAP brow lift was performed 3 years ago, the technique has been improved and refined. Lateral incisions have been deleted to avoid scars in the temporal scalp that show if the patient’s hair is thin or wet from swimming. The direction of pull for each plication suture is vertical to counteract the effects of gravity. Any lateral vector of pull should be avoided because this does not counteract gravity and tends to pull the eyebrows apart.

Summary

Open brow lifts with long coronal or pre-hairline incisions are increasingly being replaced by endoscopic procedures. Unfortunately, hairline elevation has been a consequence of these new techniques. The GAP brow lift method features very inconspicuous incisions and vertical vectors of pull, and does not raise the hairline. This improves patient satisfaction with brow lifting.

A 50-year-old patient A, before undergoing galea aponeurosis plication brow lift and B, 1 year after the operation.

“Surgical Strategies” focuses on refinements in aesthetic surgical techniques. Contributors are Aesthetic Society members or other recognized experts.