What is an Endoscopic Brow Lift?
An excellent way to describe an Endoscopic Brow Lift is to contrast it to the “classic” coronal Brow Lift. In earlier decades, Plastic Surgeons lifted the brow line by making an incision that stretched from ear to ear along the hairline. The longer incision increased the chances of infection, hair loss and scarring after the procedure. A Browlift is the surgical procedure used to help rejuvenate the upper third of the face.
The advanced endoscopic technique used by Dr. Slupchynksyj employs a series of tiny incisions in the scalp, rather than a long, continuous incision along the hairline. The endoscope (a small camera at the end of a flexible tube) is inserted into an incision. The camera allows Dr. S. to see how the muscles, tendons, and skin connect. A blade at the end of another flexible tube is inserted in a different incision. Dr. S. follows the image from the camera to make the proper surgical maneuvers, then he anchors the muscle and skin in place.
Benefits of Brow Lift
Lines along the forehead and along the brow line are either reduced or eliminated. Before the surgery, patients may have a dour, angry look due to lowered eyebrows, which actually sit below the browbone. After the procedure, the eyebrows sit correctly on the brow bone, which opens up the eyes and restores a youthful look of enthusiasm and energy.
The endoscopic procedure allows for more accurate and subtle changes to the brow line without the need for a long incision. The smaller surgical cuts, along with the endoscopic camera, enable Dr. Slupchynksyj to operate at a level of precision not available in the classic form of the procedure. Also, the small incisions heal faster and carry less noticeable scarring, with a recovery period of only a few days.
The benefits of a Brow Lift has extended beyond those related to external appearances, as reported by Dr. Slupchynskyj’s patients. A patient can often translate their refreshed appearance into an internal source of energy that can carry over into other aspects of life. The boost in self-esteem from the new facial features can lead to improvements in business efforts, social situations, and personal relationships.
Good Candidates for a Browlift
Numerous prospective patients tell Dr. Slupchynskyj that their friends, family and business associates often tell them that they appear aggravated, worn out or distressed, even at times when they are cheerful and have had a good night’s sleep. A Brow Lift can decrease or remove the wrinkles and furrows that appear along the forehead, as well as those that show up at the top of the bridge of the nose. A Brow Lift also treats what are typically known as “frown lines” and shifts a low or drooping brow line.
Besides the cosmetic reasons, patients also consider Brow Lift Surgery to repair other defects in the facial structure. One of the defects that occur with age is brow ptosis, the lowering of the brow and the fat pads along the brow line. Brow ptosis can also occur as a symptom of diseases that result in facial paralysis, such as Bell’s palsy, myasthenia gravis, and some forms of muscular dystrophy.
The Brow Lift can also be performed in conjunction with other forms of facial plastic surgery procedures such as Eyelid Lift or Belpharoplasty Surgery, as well as Facelift Surgery. When combined, these procedures can produce a more complete and consistent appearance to the patient’s new look. Our mission is to make the patient look younger and healthier, and never to replace their entire appearance with a new, or unrecognizable face.
Risks of Brow Lift Surgery
The risks of a Brow Lift procedure are greatly reduced when the patient is working with an experienced Board Certified Facial Plastic Surgeon. Browlift Surgery involves the intricate and delicate muscles of the face, which only a Facial Plastic Surgeon is formerly and properly trained to operate on. Patients who had Browlift Surgery with another surgeon have sought out Dr. Slupchynskyj for help since, in some of the cases which he has seen, the nerves that connect to the muscles around the eyebrow have been damaged on either side or both sides. This situation can occur due to surgical errors. This damage can inhibit or prevent the patient from creasing the forehead or raising the eyebrows. The problem can be temporary, but could last for several months or it becomes a permanent condition. For the most part, patients should only experience minor bruising or swelling, and tenderness in the areas around the incisions for about a week after the procedure, but this is a normal part of the healing process.
Another potential risk is the “perpetually surprised” expression that can occur if a surgeon incorrectly removes too much skin around the brow area. Patients may also experience hair loss near the incision areas due to scarring. In the “classic” Brow Lift procedure, patients also reported a loss of feeling in the brow area, but these incidents are greatly reduced in the endoscopic form of the surgery Dr. Slupchynskyj, a Board Certified Facial Plastic Surgeon, performs Brow Lifts.
Anatomy of the Brow and Forehead
The major muscle in the area, the frontalis muscle, runs the entire span of the forehead. This muscle controls the lift of the eyebrows and the creasing of the forehead, allowing for a full range of facial expressions from surprise to anger to worry. When this muscle gets overworked, the activity can create deep wrinkles in the skin along the forehead.
The glabella muscles sit between the eyebrows and above the bridge of the nose. Doctors often tap on the glabella muscles to test a patient’s blinking reflex. The proceurus muscle lies along the bridge of the nose and pulls down the skin between the eyebrows. Both of these muscle groups are also affected during the Brow Lift procedure, as their movement can cause lines between the eyebrows.
The nerves that lie between the eyes are also responsible for sensitivity in the forehead and hairline. As a consequence of the procedure, these nerves can be damaged to prevent the patient from developing further wrinkles. The damage typically heals in a few weeks to a few months, allowing sensation to the area to return slowly and prevent more wrinkles from occurring.
Brow Lift vs. BOTOX®™
Many patients go to Dr. Slupchynskyj to receive BOTOX®™ injections, which can elevate the brow area in addition to reversing Crow’s Feet around the eyes. While BOTOX®™ injections are less expensive than a Brow Lift operation, and results last are temporary (lasting 3 to 6 months), BOTOX®™ is not entirely effective at removing forehead wrinkles present at rest especially with patients who have extensive aging in that area.
A Brow Lift procedure can bring a more youthful and vital expression to a patient’s face. The improvements in both external appearance and internal gratification often bring patients a high level of satisfaction.
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Brow Lift for Migraines
Approximately 35 million people in the United States, or approximately 17% of women and 6% of men in America suffer from Migraines. Frequent Headache symptoms can last from 4 hours to several days and include: severe pain nausea, aura, light sensitivity, appetite loss, dizziness, and exhaustion. Spontaneous Migraines can radically hinder work, the individual’s ability to concentrate, as well as being present, family events, relationships and virtually every facet of life.
Many Migraine suffers manage Migraine Headaches prescription medication. The yearly cost of these Migraine medications is roughly $1.5 billion. Presently, there is no generally established, permanent cure, and the majority of patients continue to endure symptoms, even with pharmacologic treatment.
Even though the pathophysiology of Migraine Headaches continues to cause controversy, studies have exemplified that trigeminal nerve irritation causes the release of calcitonin gene-related peptide and neurokinin A into the cell bodies of the trigeminal nerve. These proteins cause inflammation and pain in the region surrounding the trigeminal nerve. The hypothesis is that the musculature, vessels, bony foramen, and perhaps the fascia bands surrounding the trigeminal nerve branches in the head and neck inflame the nerves, causing inflammation. Based on this theory, Migraine Surgery has progressed to include removal of various surrounding superficial muscles, fascia, or vessels to decrease irritation, diminishing Migraine Headache occurrence.
Benefits of Surgery for Migraines
It has been proven that Surgery for Migraines has provide relief for 5 years or more, with a 50% reduction in frequency, duration and intensity in more than 80% of patients. Migraine Surgery can be performed at 4 common trigger sites: the frontal site is the most widespread, where the glabellar muscles (depressor supercilii, corrugator supercilii, procerus muscle) and connected vessels, overlying fascia bands and the foramina apply unwanted pressure on the supratrochlear nerve and the supraorbital nerve, causing Migraine Headaches. Additional trigger sites include temporal, septonasal and occipital regions. Accessing the frontal trigger site requires the resection of glabellar muscle group, cauterization of vessels surrounding the nerves, uncovering the supraorbital foramen when present, and, if accessible, release the fibrous band across the supraorbital notch. These surgical techniques alleviate supratrochlear nerve and supraorbital nerve inflammation.
For the past 15 years, endoscopic nerve decompression has been used on patients undergoing concomitant endoscopic treatment of zygomaticotemporal branch of the trigeminal nerve. Endoscopic nerve decompression was not performed on patients with long foreheads (> 8 cm measured from the anterior hairline to the supraorbital ridge) or on patients with considerable forehead curvature, since endoscopic access would have been nearly impossible. Transpalpebral nerve decompression was performed when there was no related endoscopic site surgery, as transpalpebral nerve decompression offered closer access to the glabellar muscle group and did not require endoscopic equipment. Efficacy of transpalpebral nerve decompression was compared to endoscopic nerve decompression in frontal Migraine Headache reduction.
Migraine Surgery Patient Selection
Patients selected by Migraine Doctors in NYC were comprised of individuals who received Frontal Migraine Surgery. A successful surgical outcome resulted in a 50% decrease in Migraine manifestation after 1 year.
Overview of Transpalpebral Nerve Decompression Surgical Technique
An incision was placed in the supratarsal crease, including up to two-thirds of the central limit of the center segment of the conventional upper blepharoplasty incision. The upper eyelid glabellar area and the lower forehead were penetrated 1% Lidocaine containing
1:1000,000 epinephrine and 0.5% ropivacaine HCL. After the incision is completed, a skin-orbicularis oculi muscle flap was elevated above the level of the septum and the orbicularis muscle in a cephalic direction. The dissection was continued to the supraorbital rim. The depressor supercilii muscle was exposed and removed, protecting the supraorbital nerve and supratrochlear nerve. This enabled the unveiling of the corrugator supercilii muscle, which is a darker color and more fragile when compared with the depressor supercilii muscle. The corrugator supercilii muscle was excised with electrocautery, and lateral fibers of the procerus muscle covering the supratrochlear nerve were also removed. Fat was harvested either from the medial fat pad of the upper lid or from a region vast to the deep temporal fascia above the zygomatic arch, if endoscopic tissue removal of the zygomaticotemporal branch of the trigeminal nerve was completed concomitantly, and plated to fill the depression left after removal of the corrugator supercilii muscle and to protect the nerves
Overview of Endoscopic Nerve Decompression Surgical Technique
A midline incision or two paramedian incisions were marked 1.5 cm long, approximately 3.5 cm apart in the frontal area and 1 or 2 similar incisions in the temple if decompression of the temple trigger site was also indicated. The hair-bearing forehead scalp was infiltrated with 0.5% Lidocaine mixed with 1:2000,000 epinephrine, and the remaining forehead area was infiltrated with a mixture of 0.5% ropivacaine HCL and 1% Lidocaine with 1:1000,000 epinephrine. If this was performed in conjunction with Migraine Trigger Site Surgery, 5 or 6 1 cm incisions were made for access to the glabellar muscle group and the zygomaticotemporal branch of the trigeminal nerve. Migraine Surgery was preformed first, and fat was harvested from beneath the deep temporal fascia above the zygomatic arch medially. To remove the muscles, the incisions were made and endoscopic access devices were used. The dissection was completed caudally and medially in a subperiosteal plane to reveal the glabellar muscle group. The corrugator supercilii muscle and the depressor supercilii muscle were completely removed, along with the lateral fibers of the procerus muscle under direct endoscopic visualization, being careful to protect the supraorbital and supratrochlear nerves
Outcome: Transpalpebral Nerve Decompression vs. Endoscopic Nerve Decompression
The majority of patients received endoscopic nerve decompression; only a select few underwent transpalpebral nerve decompression. Of the transpalpebral nerve decompression patients, 79% experienced a 50% reduction in frontal Migraine occurrence, with 52% no longer experiencing Migraine Headaches. Of the endoscopic nerve decompression patients, 89% experienced 50% reduction in frontal Migraine occurrence, with 67% experiencing complete elimination. Endoscopic Nerve Decompression provided Migraine Headache suffers with slightly more relief than transpalpebral nerve decompression patients received.
Chronic Migraines (CM), or Transformed Migraine, is a complication of periodic Migraines with 2.5% progressing annually from intermittent to full-fledged CM. Symptoms can arise with or without excessive medication use. The pain level is typically mild to moderate and not always associated with photophobia, phonophobia, nausea, or vomiting and may appear to be a blend of Migraine and Tension Headache with sporadic Migraines. Depression is present in 80% of patients. Risk factors that contribute to Chronic Migraines include: medication overuse (particularly opiates taken in conjunction with barbiturates), high caffeine intake, female gender, stressful events, anxiety, baseline high attack frequency, individuals from lower educational and socioeconomic backgrounds, Caucasian parents, previously married individuals, permanent head or neck injuries, obesity, snoring, Arthritis, and Diabetes.
Only 20% of patients with CM are properly diagnosed with Chronic Migraines by healthcare providers and instead are given a constellation of alternate sinus, stress, cervical spine, and allergies. Or they believe their bad Headaches are Migraines and they have other diagnoses for the milder Headaches. Only 33% of patients with CM are using preventive medications.
Although the evidence should be carefully considered, medication rebound can transpire when opiates are used 8 more days per month with effect more obvious in men, triptans in individuals with a high Headache frequency at baseline, or butalbital combinations 5 or more days per month with the effect more prominent in women. Triptans on 10 or more days per month, or OTC analgesics or any combination of triptans and analgesic opioids for 15 or more days per month on a regular basis for more than 3 months without overuse of any particular class can result in Medication-overuse Headache (MOH). Obviously, in addition to inducing medication overuse, constant use of butalbital and opiates can prompt addiction and other unwanted side effects.
Protocol to Treat Medication Overuse
Withdrawal of the overused medication alone, which can be combined with a preventive medication, may lead to a decrease in Headache frequency in most patients. Caffeine should be avoided, as ingestion of as little as 200 mg daily in vulnerable patients can lead to MOH, and some individuals with withdrawal symptoms with even low does of 100 mg daily. Decrease overused medications. For individuals taking high-frequency butalbital combinations, phenobarbital 30 mg twice a day (bid) can be substituted for 2 weeks, followed by 15 mg bid for 2 weeks (sudden withdrawal my cause seizures). For patients taking high doses of opioids, clonidine 0.1-0.2 mg three times daily (tid) increased or decreased based on symptoms or clonidine patch 0.1-0.2 mg 24 hours for 1-2 weeks.
There are various transitional therapy options. Naproxen 500 mg bid for 1-2 weeks may be used alone or in conjunction with tizanidine, starting at 2 mg at bedtime (hs).
Are there Any FDA-Approved Treatments for CM?
Yes, BOTOX® Cosmetic (onabotulinumtoxinA), approved by the FDA in October 2010, based on the 2 phase 3 research evaluating Migraine Prophylaxis Therapy (PREEMPT) trials. The approved treatment involves administering 155 units in 31 fixed-site, fixed dose injections of 5 units in each of the following muscles: the procerus and bilateral corrugators, frontalis, temporalis, occipitalis, cervical paraspinals, and superior trapezius muscles.
Migraines and BOTOX®
At 24 weeks, 47.1% of patients treated with onabotulinumtoxinA had a >50% decrease from baseline in Headache frequency days compared with 35.1% of placebo-treated patients. BOTOX® treatment for Migraines was as effective in 65.3% of the patients from 2 studies with medication overuse as the total PREEMPT population of 1384 adults with and without medication overuse.
Even though Migraine treatment with BOTOX® is expensive, the costs can be reduced by less triptan use. Additionally, a retrospective study of 223 patients with CM who were treated with 2 injection cycles found a 39% counterbalance of estimated injection costs by a reduction in Migraine-related emergency department visits, hospitalizations, and urgent care visits.
Effective Migraine Headache Management with BOTOX®
BOTOX® has been used off label since 2000 for Migraine Headache treatment. PREEMPT 1 and 2 trails provide class 1A evidence that treatment with BOTOX® decreases Migraine Headache severity and improves Headache-related quality of life. As a result of these evidence-based statics, the U.S. Food and Drug Administration approved BOTOX® for Chronic Migraine treatment on October 15, 2010. This approval ultimately and to an extent confirms surgical treatment of Migraine Headache because the physiologic device behind BOTOX® treatment and surgical Migraine Headache treatment is in all probability comparable.
Both work to relax peripheral nerves, BOTOX® chemically, while in contrast surgery automatically removes physical anomalies. Indeed, due to this cohesion, BOTOX® has been used time and again as a diagnostic tool in Migraine Surgery trigger site identification. Although a recent study demonstrates that BOTOX® injection may not be required in trigger identification, FDA approval of BOTOX® for Chronic Migraine Headache treatment in increase its use among Migraine patients.
Patient response to BOTOX® varies from no decrease in Migraine Headache to complete Migraine Headache eradication.
The peripheral trigger point for Migraine Headaches can be deactivated either chemically through BOTOX® injection or routinely via surgery. Even though BOTOX® injection is a powerful Migraine trigger point deactivator, Migraine Surgery attains permanent, successful outcome Juxtaposed with BOTOX® injection. Patients typically mention exacerbated Migraine Headaches 2.5 to 3 months after injection, which coincides with the recurrence of dynamic muscle contraction. In addition to offering temporary reduction of Migraine Headaches, BOTOX® injections are also integral to Migraine Surgery. BOTOX® can be utilized to determine possible Migraine Surgery trigger sites. A detailed patient history and physical exam is comparable to BOTOX® injection in identifying possible trigger sites.
Most of the patients who require Migraine Surgery have had previous onabotulinumtoxinA injections, for either diagnostic or therapeutic reasons. The figure will only increase, due to the recent approval of onabotulinumtoxinA by the U.S. Food and Drug Administration for therapeutic Migraine treatment. A vast majority of patients (53.3%) have received onabotulinumtoxinA prior to surgery.
Generally, Migraine Surgery yields a more positive outcome in patients who respond favorably to onabotulinumtoxinA injections, regardless of whether the onabotulinumtoxinA injection and surgery are administered in the same region (surgery success rate, 90.3% vs. 73.7%.
The affiliation between onabotulinumtoxinA injection reaction and Migraine Surgery reaction is intensified when patients who have the same onabotulinumtoxinA injection and surgery site were examined.
Are Nerve Blocks an effect treatment?
In an open-label, single treatment arm study of 150 patients suffering from Migraine Headaches with a pronounced cervicogenic component (at least 50% of their most severe Headaches occurred from one side of the base of the skull or both) who received unilateral or bilateral occipital nerve blocks with local anesthetic and steroid, 52% encountered a 50% decrease in Headache days over the month after the procedure, compared with the pretreatment baseline month.
A prospective open-label included 218 patients with intractable CM, without butalbital or opioid medication overuse who received a fixed-dose (0.1 cc of 0.25% Bupivacaine) and a fixed-site (10 at greater and lesser occipital nerves, 5 at auriculotemporal and zygomaticotemporal, 2 at supraorbital and supratrochlear areas bilaterally) pericranial injections every 3 months. After 1 year, 53.2% of patients had a more than 50% decease in frequency of Headache days.
Are there Effective Alternative or Complementary Treatments for CM?
Acupuncture can offer some relive of CM symptoms, with an additional benefit when used in tandem with medical management. Safflower seed acupuncture point injection can be more effective than NS in patients with daily, chronic Headache. In a study of 66 CM patients randomly selected for acupuncture treatment administered during 24 sessions over 12 weeks or topiramate measured to a maximum of 100 mg daily, the average monthly number of moderate/severe Headache days decreased from 20.2 to 9.8 in the acupuncture group, compared to 19.8 to 12.0 in the topiramate group, with benefit observed in patients with medication overuse.
Behavioral sleep modification can be beneficial for Transformed Migraine. Although biofeedback, relaxation therapy and cognitive behavioral therapy have proven efficiency for preventing Episode Migraines, there is limited data for CM treatment. In a study of 91 subjects with Episodic Migraine randomized to treatment groups, physical exercise, relaxation therapy and topiramate were equally effective for CM prevention. Biofeedback-assisted relaxation may supplement prescription medications based on a 3-year follow-up study of chronic daily Headache related to medication overuse.
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