Facial aging mostly starts from forehead laxity. Typically, it will then have increased forehead wrinkles or crow’s feet in mild cases and overall forehead and brow drooping that compresses the eyelids and eye tail in severe cases. This may result in a gradual loss of eyelids or excessively short distance between the brows and eyes and then induce typical aging signs such as “flat brows” or “splayed brows.” The surgical solution should be determined depending on the brow–eye distance. If the brows and upper eyelid folds are over 1.5 cm apart, simple double eyelid surgery can be considered first to improve the “tire look” of eyes; if the brow–eye distance is less than 1 cm, double eyelid surgery is not suitable in light of objective conditions whose results might also not be natural. In the latter case, patients should consider receiving forehead lift to lift the drooping brows to a relatively high position and raise the medial margin of the brow toward the lateral one-third to create feminine brow shapes. This can not only sculpt relatively young and soft brows and effectively widen the brow–eye distance to expose the double eyelid folds buried by the drooped eyelids but also preserve the original eye shapes and charms and avoid the potential risks of eyes with unequal sizes or shapes from double eyelid surgeries. Forehead lift will produce effects of both double eyelid enlargement and forehead tightening, which also underpins its most significant difference from eyelid plastic surgeries.
In recent years, endoscopes have been extensively applied to forehead and mid-face lift surgeries. It enters the deep layer of the skin and completely images internal tissues and structures via its high-resolution 4× magnification lens. Endoscopic forehead lift not only presents a clear surgical field for surgeons to avoid possible nerve or blood vessel injuries but also enables surgeons to conduct skin and periosteum separation without blind corners and effectively increases the range and extensibility of facelifts, enhancing the surgical results and improving the duration of the effects. This amounts to the least invasive and safest facelift with comprehensive results at present. During the surgery, 4 or 5 incisions of approximately 1.5 cm are created posterior to the scalp hairline, where the endoscope probe gets through the skin to boost the visual field. Dr. Chuang uses various forehead–periosteum dissectors to detach the forehead skin from the bone to the bilateral brow bridge margins, during which injuries of sensory and facial nerves adjacent to the brows are avoided with the aid of clear images provided by endoscopy. Then, after the overall forehead skin has been released without any tension, Dr. Chuang places a biodegradable Endotine fixation implant at bilateral scallop incisions to adhere the newly elevated skin to the bone, which would also concurrently elevate the brows and eyelids. Finally, the excess or loose scalp skin is excised to achieve long-lasting results. Endotine implants are highly compatible with the human body and are metabolized and absorbed within approximately half a year. It is kind of temporary subcutaneous implants that naturally disappear.