Comparative Outcomes of Traditional Versus Endoscopic Brow Lift Techniques: A Systematic Review

Abstract

Background:

Age-related changes in the brow region, such as sagging, asymmetry, and deepening of forehead lines, pose significant cosmetic and functional challenges. Various surgical approaches have been developed over the decades to address these issues. This systematic review compared traditional open techniques versus endoscopic and minimally invasive brow lift techniques in terms of aesthetic outcomes and complication rates.

Methods:

A comprehensive search was conducted in PubMed, MEDLINE, the Cochrane Library, Embase, and ClinicalTrials.gov. Studies published during the past 20 years that met our predefined eligibility criteria were included. The quality of randomized controlled trials was assessed using the Cochrane Risk of Bias 2 tool, and nonrandomized studies were evaluated with risk of bias in non-randomized studies of interventions (ROBINS-I). Data on aesthetic outcomes and complications were extracted and compared across studies.

Results:

Fifteen studies were included in this review. The evidence suggests that although various open brow lift techniques provide satisfactory elevation, they are generally associated with higher complication rates and less favorable cosmetic results. In contrast, endoscopic and minimally invasive techniques, including the use of Endotine devices and gliding brow lifts, demonstrate comparable or superior aesthetic outcomes with lower complication rates and reduced recovery times. However, heterogeneity in outcome measures and study designs limits the strength of these conclusions.

Conclusions:

Endoscopic and minimally invasive brow lift procedures seem to offer cosmetically favorable results with lower complication rates compared with traditional open techniques. Nevertheless, further high-quality, prospective studies are needed to definitively establish the long-term efficacy and safety of these approaches.

Takeaways

Question: Which surgical brow lift approach is better: traditional open techniques or endoscopic?

Findings: A systematic review of 15 studies, including 4 randomized controlled trials, showed that endoscopic and minimally invasive brow lifts provide comparable or superior aesthetic results with lower complication rates and shorter recovery times than traditional open techniques.

Meaning: Patients and surgeons should consider endoscopic and minimally invasive brow lifts as a preferred option for achieving a better aesthetic result with a lower risk of complications.

INTRODUCTION

The age-related descent and reshaping of the brow, characterized by medial elevation, lateral drooping, hooded eyelids, forehead wrinkling, and temporal volume loss, have long posed both cosmetic and functional concerns. These changes have been addressed surgically since the early 20th century.^1,2 A brow lift is a surgical technique aimed at rejuvenating the upper third of the face by correcting brow ptosis, eyelid hooding, and frown lines. It can involve various approaches depending on facial anatomy and patient preferences.³

Traditionally, brow lifts involved open surgical techniques that required large scalp or hairline incisions, often resulting in visible scarring, sensory deficits, and prolonged recovery.⁴ Over time, these have been replaced by less invasive methods due to their reduced complications and faster healing.⁵ Although the coronal approach, extending from one temporal fossa to the other, offers significant lifting, it remains invasive and is less commonly used today.⁶

Direct brow lifts were historically common in patients with facial nerve paralysis, orbital deformities, or in male patients with receding hairlines. Although they allow for precise adjustment, the risk of visible scarring limits their use.⁷ More recently, techniques such as pretrichial (hairline) lifts and temporal brow lifts have emerged. These are often combined with procedures such as glabellar myoplasty or internal browpexy (IBP) to enhance stability, although aggressive combinations may compromise contour or movement.^8,9

Minimally invasive methods, such as the gliding brow lift with transcutaneous netting and endoscopic lifts via small incisions, offer reduced scarring and quicker recovery.^10,11 These are typically best suited for mild to moderate ptosis. Among these, endoscopic brow lifts (EBLs) with cortical fixation have gained popularity due to their lasting outcomes and minimal invasiveness.^12–14

The choice of surgical technique depends on anatomical variables, patient-specific goals, and available resources. Numerous reviews have compared individual brow lift strategies, but only 1 systematic review in 2011 comprehensively analyzed open versus endoscopic approaches.⁴ Since then, advancements such as gliding brow lift and cortical tunnel fixation have transformed the field.¹⁵

Despite the growing adoption of endoscopic and minimally invasive techniques, a standardized consensus on their long-term efficacy and safety relative to traditional open approaches remains lacking due to heterogeneous outcome measures and limited randomized evidence.¹²

This systematic review aimed to compare traditional and EBL techniques in terms of aesthetic outcomes and complication rates. The findings provide updated insights to aid surgeons and patients in selecting the most appropriate approach for brow rejuvenation.¹⁵

Objectives

1. To compare aesthetic outcomes of open brow lift (OBL) and EBL techniques.

2. To evaluate complication rates associated with each technique.

METHODOLOGY

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive literature search was carried out in PubMed, MEDLINE, Embase, and Cochrane Library databases using the keywords: “brow lift,” “forehead lift,” “endoscopic brow lift,” “open brow lift,” “direct brow lift,” “coronal brow lift,” “temporal brow lift,” and “gliding brow lift.” The search included articles published from inception to December 2023.¹⁶

Two independent reviewers screened the titles and abstracts of all retrieved studies. Full-text reviews were then conducted to identify studies that met the eligibility criteria. Any disagreements were resolved through discussion or by a third reviewer.

Studies were included if they met the following criteria: (1) involved adult patients undergoing brow lift surgery; (2) reported on EBL or traditional OBL techniques; (3) included outcome data such as aesthetic results, complication rates, or patient satisfaction; and (4) were written in English. Case reports, editorials, conference abstracts, and non-English articles were excluded.

Data extracted included author name, publication year, study design, sample size, surgical technique, complication rates, aesthetic outcomes, and follow-up duration. Due to heterogeneity in study design and outcome reporting, a meta-analysis was not feasible. Instead, a narrative synthesis was conducted to compare outcomes across different techniques.

The risk of bias was assessed using a modified version of the Newcastle–Ottawa scale for nonrandomized studies. The quality of each included study was independently evaluated by 2 reviewers, with discrepancies resolved through consensus.

RESULTS

Study Selection and Screening Process

A total of 5304 records were identified through database searching (PubMed, Embase, Cochrane Library, MEDLINE, ClinicalTrials.gov). After removing duplicates, 98 studies remained. Following title and abstract screening, 27 studies were retrieved for full-text assessment. Fifteen studies met the eligibility criteria and were included in this systematic review. The study selection process is illustrated in Figure 1 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram).

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram of screening process.

Study Characteristics

Of the 15 included studies, 4 were randomized controlled trials (RCTs), and 11 were non-RCTs or cohort studies. The mean participant age across studies ranged from 38 to 72 years. Four studies involved female-only samples. The surgical techniques assessed included IBP, frontotemporal lift, endoscopic lift (with various fixation methods such as Endotine devices, concentric cables, and cortical tunnels), and gliding brow lifts. Outcome measures included brow elevation and complication rates. Minor complications such as brow relapse, temporary numbness, or tenderness were reported in 13 studies. Major complications were not observed in any study. Among the 15 included studies, endoscopic approaches consistently demonstrated superior or comparable cosmetic outcomes in 11 studies, with reported complication rates generally under 5%, whereas traditional open techniques were more frequently associated with prolonged numbness and visible scarring.

A detailed summary of patient numbers, follow-up intervals, and complication rates for both open and endoscopic techniques is presented in Supplemental Digital Content 1. (See table, Supplemental Digital Content 1, which displays a detailed summary of patient numbers, follow-up intervals, and complication rates for both open and endoscopic techniques, https://links.lww.com/PRSGO/E690.)

Risk of Bias Assessment

The 4 RCTs were evaluated using the Cochrane Risk of Bias 2 tool. Two studies had “some concerns” related to the randomization process and selective reporting. The 11 nonrandomized studies were assessed using the ROBINS-I tool. Among them, 3 studies showed concerns across multiple domains, including confounding and outcome measurement bias. No studies were found to have a high risk of bias. Risk assessments are presented in Figures 2 and 3.

Fig. 2.

Cochrane Risk of Bias 2 of included RCTs.

Fig. 3.

ROBINS-I of nonrandomized trials.

Open Surgical Brow Lift Techniques

Internal Browpexy

Two out of 5 studies compared IBP with concomitant upper blepharoplasty with traditional blepharoplasty and brow lift/suspension with nonbraissiere sutures, whereas the other 2 compared the said technique with upper blepharoplasty alone. The fifth of these is a triple-arm trial where quantitated IBP was compared with Endotine browpexy and traditional blepharoplasty alone. Zandi et al¹⁷ described that IBP with upper blepharoplasty was superior to temporal brow lift with blepharoplasty in terms of lateral brow elevation and long-lasting stability as well as cosmetic benefit, whereas Sugino et al¹⁸ did not find any difference in outcomes between eyelid suspension with or without nonbraissiere sutures. Figueiredo et al¹⁹ associated IBP with blepharoplasty with a greater increase in lateral brow/lid volume than blepharoplasty alone, whereas another such study found no difference between the 2 techniques at all.²⁰ Baker et al²¹ found average stable or elevated lateral brow with IBP blepharoplasty, whereas 2 cases showed descent compared with significant elevation with Endotine blepharoplasty, which is more invasive with longer recovery time.

Frontotemporal Lift

Tuccillo et al²² performed a frontotemporal lift in 32 women with their operating technique, which began with subperiosteal dissection, followed by superior orbicularis myotomy to obtain a tension free flap. Dissection of medial galea and lateral temporoparietalis fascia was then performed, whereas suspension was done using periosteal flap imbrications and fixation using nylon sutures, sometimes combined with cortical tunnels for medial elevation. The procedure was performed either through an open or endoscopic approach, combined with cervicofacial lift/blepharoplasty in some patients, providing an average lateral brow elevation of 5 mm with partial relapse in only 5 cases.²²

Endoscopic Approaches

Concentric Cable Fixation

Massoud and Aboelatta²³ found that endoscopic double cable fixation provided brow tail and body elevation while being a relatively inexpensive, less invasive method with lower postoperative complications and long-term stability compared with traditional endoscopic fascia sutures and mini-screw placement.

Endotine Device Versus Cortical Bone Tunnels

Hönig et al²⁴ compared the Gore-Tex suture fixation of elevated forehead flap in the form of cortical bone tunnels with the Endotine device and observed greater stability in the transposed position in the medial third of eyebrow with the Endotine device obtaining a mean higher elevation of 1.5 ± 0.6 mm due to better distribution of tension and greater strength as a result of broad-base fixation.

EBL With Lateral Brow Fixation

Badin et al²⁵ performed a basic endoscopic forehead lift using subperiosteal periorbital detachment, orbicular myotomy, and subgaleal temporal detachment, followed by transcutaneous fixation at 2 points using braided nylon sutures. They estimated significantly higher postoperative elevation at 1–1.5 and 3–5 years, with long-term maintenance of elevation. However, 4 cases of some medial fall and 1 case of lateral fall were reported collectively at follow-ups.

Endotine Device

Two of the included studies evaluated the postoperative effectiveness of Endotine-assisted brow lift and found no postoperative complications with its use, except for mild tenderness for 3 months in 1 patient, as described by Byrne et al.²⁶ Byrne et al²⁶ associated the use of Endotine with a negligible postoperative brow descent of less than 1 mm on average, thus emphasizing its long-term efficacy, whereas Berkowitz et al²⁷ reported an average brow elevation of 4.2–4.8 mm with the use of 2 different Endotine devices for EBL.

EBL Versus OBL

Endotine Device–assisted Brow Lift Versus Open Approach Control

Two of the included RCTs compared EBL with traditional or minimally invasive open surgical brow lift techniques in double- or triple-arm trials. Perez et al²⁸ compared patients who underwent Endotine forehead device–assisted EBL and blepharoplasty with traditional blepharoplasty (positive control) and a negative control. They reported that despite significantly lower preoperative brow height in the endoscopic group, both the EBL with blepharoplasty and the positive control achieved significant postoperative lift, but their difference was insignificant. Although 5 relapses were reported, only 3 of these underwent revision surgery. Baker et al²⁰ compared Endotine browpexy with quantitated internal suture browpexy and upper blepharoplasty alone and found it superior to the latter 2 groups in achieving brow elevation. However, they reported it as an invasive, complicated procedure requiring greater recovery time, emphasizing the need for taking patients’ desires into account for the choice of surgical intervention. A comparison of the change in brow height after Endotine brow lift and upper blepharoplasty is shown in Figure 4.

Fig. 4.

Comparison of change in brow height (mm).

Endoscopic Mesh Lift Versus Gliding Brow Lift

Sibar et al²⁹ found in an RCT that the gliding brow lift technique was associated with greater loss in brow height as per the brow positioning grading scale, whereas endoscope-assisted propylene mesh lift achieved greater aesthetic improvement as per GAIS while the 2 groups had similar complication rates.

EBL Versus Limited Incision Nonendoscopic/Open Approaches

In a comparative study, Tabatabai and Spinelli³⁰ performed initial endoscopic subperiosteal dissection in the subperiosteal plane over the superior orbital rim, including the lateral orbital rim to obtain a free forehead flap. The subsequent last 2-cm subperiosteal dissection over the superior orbital rim was endoscope-assisted in 1 group, whereas in the other group it was performed using palpation of a notch or foramen and anatomical data, preferring a more vertical dissection to preserve the supraorbital nerve. Both techniques were associated with a similar 4-mm brow elevation, but the nonendoscopic technique was reported to be less time-consuming with a smaller incision and was associated with 1 complaint of postoperative granuloma, whereas a patient from the endoscopic group developed permanent parasthesia.³⁰

Another controlled study compared forehead and scalp sensation between EBL and OBL and found that objective testing in the prospective group reported significantly less mechanoceptive and thermoceptive sensitivity with OBL than EBL on the scalp after 1–2 weeks and on the forehead after 4–6 weeks and 12–14 weeks, but the difference was insignificant after 24–26 weeks. The retrospective group also reported significantly lower scalp sensations with OBL than EBL at 6–18 months on both objective and subjective testing, with a simultaneous significant decrease in forehead sensations in EBL on subjective testing. However, after 18 months, sensations returned to normal, showing the temporary nature of the loss.³¹

Cross-comparison

Endotine-assisted endoscopic approaches are somewhat more complicated and invasive but are associated with significantly superior and long-lasting effects compared with traditional as well as advanced open surgical approaches but require greater recovery time and may not be patients’ first choice due to these factors.²¹ Upper blepharoplasty alone still holds much of the clinical and cosmetic value, as is evident in the literature, and adjuvant browpexy and suture or sling suspension add to its efficacy.^17,20 The rest of the EBL procedures hold similar lid elevation and stability to open or minimally invasive surgical techniques, but endoscopic techniques are favored for their cosmetic benefits.^28,29 Some endoscopic procedures offer the same clinical outcome with lower complication rates, long-term stability, and cost, thus suggesting a better alternative.²³ However, open surgical procedures have been associated with temporary numbness for a considerable postoperative period, and patients opted not to recommend OBL during the period of numbness.³¹ This suggests that endoscopic procedures are an aesthetically important alternative to open surgical techniques, but while taking into consideration the correction in some cases, traditional procedures hold value depending on the degree of dermatochalasis. Although some of the minimally invasive procedures, such as gliding brow lift²⁹ and limited incision nonendoscopic lift using palpation of the notch and foramen,³⁰ offer superior brow lift elevation and symmetry or are less time-consuming and cosmetically favorable, some of the evidence is controversial due to results that are unsupported by the literature.

Summary of Findings

Open techniques such as IBP and frontotemporal lift showed moderate lateral brow elevation with varied results in long-term stability. Endoscopic approaches demonstrated favorable outcomes, particularly those involving Endotine devices or concentric cable fixation, offering long-lasting elevation with minimal complications. The gliding brow lift was associated with reduced surgical time and minimal scarring but showed some relapse in brow position. Two RCTs comparing endoscopic and open techniques suggested comparable aesthetic outcomes, though endoscopic procedures were preferred for recovery (Table 1).

Table 1.

A Summarized Comparison of Key Outcome Measures Across the Different Brow Lift Techniques Discussed in the Included Studies

Technique	Aesthetic Outcome	Complication Rate	Recovery Time
Endotine device (endoscopic)	High	Low (some tenderness)	Short
Gliding brow lift	Moderate	Low	Very short
Frontotemporal lift	Good elevation (~5 mm)	Partial relapse in 5/32 cases	Moderate
IBP	Variable	Low	Short
Traditional open (coronal, direct)	High (esp. in severe ptosis)	High (numbness, scarring)	Long
Concentric cable fixation	Stable long term	Low	Short

DISCUSSION

This systematic review aimed to compare the outcomes and complications between traditional OBL and EBL techniques. Although both methods aim to address brow ptosis and facial aging, the findings across the included studies reveal nuanced differences in clinical outcomes, recovery, and patient-reported satisfaction.

Traditional OBL techniques, such as the coronal or pretrichial approaches, have historically been considered the gold standard for achieving substantial and long-lasting brow elevation. Several studies in this review reported favorable long-term results with these techniques, particularly in terms of the correction of severe ptosis.^32,33 However, these advantages often come at the cost of increased invasiveness, longer recovery times, and a higher risk of complications such as scalp numbness or visible scarring.³¹

In contrast, EBL methods demonstrated comparable effectiveness in mild to moderate ptosis correction, with the added benefits of reduced scarring, shorter operative times, and faster recovery.³⁴ Most studies reported lower complication rates with endoscopic techniques,^34,35 although recurrence of ptosis over time was noted in some cases. It is important to note the heterogeneity among the included studies in terms of patient demographics, surgical techniques, surgeon expertise, and outcome measurement tools.³⁴ The time span of the studies also varied significantly, with traditional open techniques being more prevalent in earlier studies and endoscopic methods gaining prominence in recent decades.³² This temporal variation introduces potential bias related to evolving surgical standards and technological advancements.

Considering these findings, this review emphasized the evolving landscape of brow rejuvenation surgery, where minimally invasive and endoscopic methods are increasingly preferred for their cosmetic advantages and reduced morbidity. By integrating recent studies including those introducing techniques such as gliding brow lift and cortical tunnel fixation, this work provided an updated synthesis that builds upon earlier literature and highlights the trend toward individualized, anatomy-driven decision-making. These insights may help guide surgeons in selecting the most appropriate surgical approach for optimal patient outcomes.

Limitations of this review include the retrospective nature of most included studies, relatively small sample sizes, lack of standardized outcome reporting, and inconsistency in follow-up duration. Additionally, variations in surgeon experience and technique may have influenced outcomes but were not uniformly reported across studies. These limitations should be considered when interpreting the comparative findings.

Another limitation of this review is the variation in study design quality, as many retrospective studies lacked standardized outcome measures and blinding, which may have introduced measurement bias. Moreover, advances in surgical tools and fixation devices over the study period could have influenced outcomes, making direct comparisons challenging. Addressing these limitations in future studies will be crucial for establishing clear guidelines.

Despite these challenges, this review highlighted the shifting trend toward minimally invasive brow lift techniques, driven by patient preference and advancements in technology.³³ However, the selection of surgical approach must remain individualized, based on patient anatomy, goals, and surgeon expertise. Future prospective, randomized trials with standardized reporting are essential to provide stronger evidence for clinical decision-making in brow lift surgery.³⁵

Furthermore, it is important to recognize that the included studies spanned nearly 2 decades, during which surgical techniques and technologies have significantly evolved. Earlier studies predominantly focused on traditional open approaches, whereas more recent publications have favored endoscopic and minimally invasive techniques. This temporal distribution may introduce inherent bias, as improvements in instruments, fixation methods, and surgical training could have influenced the reported outcomes. To strengthen the current body of evidence, future prospective RCTs directly comparing OBL and EBL techniques with standardized outcome measures are strongly recommended.

CONCLUSIONS

In conclusion, this systematic review highlighted the comparative outcomes of traditional OBL versus EBL techniques. Although both approaches are effective in achieving aesthetic improvements, endoscopic techniques generally offer advantages such as reduced scarring, faster recovery, and lower complication rates. However, traditional techniques may still be appropriate for select patients with advanced ptosis or specific anatomical considerations. Given the limitations of the current literature, including variability in outcome reporting and small sample sizes, further high-quality, standardized studies are necessary to establish definitive clinical guidelines and optimize patient outcomes.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

This study was supported by funding from Prince Sattam bin Abdulaziz University (project no. PSAU/2025/R/1446).

Supplementary Material

gox-14-e7477-s001.pdf ^{(86.2KB, pdf)}