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Open Biplaner and Pure Endoscopic Brow Lift

Open Techniques and why they are no longer used...

Dr Zukowski and his staff at the Zukowski Center are renowned worldwide for being the best in FFS Facial Feminization Surgery. Based in Chicago America, Mark Zukowski is recognized within the transgender community as being the best.Endoscopic minimal scar surgery has revolutionized the way that all surgeries have been performed since the mid 1990s. People that badmouth this technique simply cant do it. The endoscope is a lighted fiberoptic camera system that magnifies the operative site 20 times and displays the image on a high definition screen.  The endoscopic biplaner variant browlift is an advanced 21st century technique that replaces open browlifts and takes into account the use of the endoscope which is a tool that helps a surgeon work in a more closed or distant space. Endoscopic techniques avoid some of the built in complications of open techniques, such as permanent hair loss, longer scars, cut sensory nerves with resultant permanent numbness to the six inches of scalp behind the scar, or cutting and invading into the sinus with the risk of permanent sinus dysfunction in the form of sinus headaches and runny, drippy noses. Of great concern to you, the patient, should be the fact that open techniques are fraught with complications that are independent of how good or how bad your surgeon is. They’re built into the technique.

It is for this reason that I abandoned open techniques over 22 years ago. I cannot subject my patients to the complications that come with open procedures regardless of who does them. To say I cannot do open techniques is foolhardy.  Every true board certified plastic surgeon learns open techniques in their training. 

 For instance, when you peel off the lining of the sinus from the bone, this is a very adherent tissue interface. It requires one to drill a series of pilot holes through the bone, to then use special tools to peel the lining off the bone. A modified jigsaw is used to cut that bone out. In the process of contouring it, you run the risks of fracturing bone or devascularizing it to the point that it will not heal properly and form an airtight seal. You could also damage the sinus lining to the point where one could get a temporary air leak through the sinus and an intermittent or permanent frontal  sinus headache with an intermittent or continuous runny, drippy nose. It is a dirty little secret that in 30% of patients undergoing open sinus techniques, there is an intermittent or continuous sinus headache and nasal drainage. This is due to the fact that damage to the lining of the sinus causes secretion of fluids that then drain into the nose. For people who already have the tendency toward sinus problems or nasal problems, this procedure can insure a lifetime of significant problems. 67% of patients with a traditional open FFS incisions will not get a normal return of sensation to the front scalp behind the scar for about the first six inches. Only 33% of patients have a normal return of sensitivity to testing. This leads to increased problems with hair loss as one ages. If this problem occurs, the front scalp itches and is numb for the rest of your life! If you like playing russian roulette, then open techniques will be great for you. Endoscopic techniques, on the other hand, allow one to approach forehead feminization with many more individualized options. In over 22 years of doing endoscopic forehead lifts, I have never had to convert to a open procedure.  In over 18 years of working with the gender community, I have never requested a patient to get a x-ray to determine sinus thickness. The anatomy is predictable and with experience and the 20x magnification capabilities of endoscopy, you can determine bone thickness. Besides, most sinus x-rays that patients show me are deliberately overpenetrated to make the bone seem thinner than it is- READ ON!

Endoscopic Biplaner Browlift

Dr Zukowski and his staff at the Zukowski Center are renowned worldwide for being the best in FFS Facial Feminization Surgery. Based in Chicago America, Mark Zukowski is recognized within the transgender community as being the best.If you would benefit from a forehead height reduction and a scalp advancement, then endoscopic techniques refered to as the biplaner variant is perfect for you. If you have no hair or a low  natural forehead hairline, a pure endoscopic version thru six smaller incisions may be ideal for you. You still have to make that incision at the edge of the hairline however, to get a scalp advancement. The scar is shorter and I no longer curve it into the temples and above the ear. Using endoscopic optical portals, you are able to keep the nerves, arteries and veins attached on a bridge of scalp tissue.  Through these optical portals, using specially-designed burrs for their longer length, one is able to take down the entire orbital rim, not just central sinus bone. The orbital rim is solid bone and is the buttress of the upper face and protects the brain. In fact, if you think back on your life, you have probably heard of every broken bone of the face and body.  Have you ever heard of a forehead fracture? Its very infrequent. That is because this bone of the orbital rim is  solid thick. If you believe the misinformation on the internet that the bone over the central sinus is only a few millimeters thick, then why has not almost every professional athlete broken their forehead sinus bone at least once?  You probably walked into the same walls and doors that I did in life and we never suffered a broken sinus forehead bone!  This is misinformation designed to sell the gender community on the old fashioned open techniques. The sinus is like a shock absorber and it is usually smaller in air volume and the bone thicker in non-genetic females. With open techniques, as we know from cutting wood, there are often gaps left between cuts. You have to use wires, or screws and metal plates to fix and secure the cut bone over the sinus with open techniques.  These cuts, as well as the wires and metal plates and screws can often be felt, and can attach by scar to the overlying forehead tissue so that when one animates you see the abnormalities and wrinkling of the forehead. The bone gaps may not fill in smoothly or grow bumpy with protrusions. This is not the case with endoscopic techniques. Also, with open techniques, you cut the major sensory nerves to the front scalp. Studies were performed on over 11,000 data points, which was presented in 1996 at the Aesthetic Society Meeting.1 This study reinforced the historical data that in only 1/3 of patients (33%) whose nerves are cut does the sensitivity return to normal with testing. The other 2/3 (67%) accept the abnormality even though this result in a lifetime of stinging, burning and painful "pins and needles" type sensations. Also, if you hit your scalp, you may not sense it the same. Abnormalities in vascularity and nerve sensitivity can lead to abnormal thinning of hair or loss of hair in the postoperative period that may not regrow. Open techniques also devascularize tissue, and often there can be areas of residual deformity. We all know from cutting the limb off of a tree that it will grow lumpy and bumpy and weepy unless one seals it with tar. Endoscopic techniques allow you to have the sensitivity return in over 95% of areas. There is no chance of damage to the internal sinus such as with open techniques. Even if you micro perforate into the sinus, it is very easy to fix with a bone substitute material – no different than what you have to be prepared to do in order to reinforce any cuts from open procedures. Also, people who tell you that only cuts into the sinus bone are needed to make you look more feminine  not being completely honest.  In fact, to get a good feminine result, you still have to burr the entire orbital rim. If you don't, you cannot make a three dimensional change to the bone!  I am the only FFS surgeon that does a global three dimensional contouring of the entire frontal forehead bone!

Dr Zukowski and his staff at the Zukowski Center are renowned worldwide for being the best in FFS Facial Feminization Surgery. Based in Chicago America, Mark Zukowski is recognized within the transgender community as being the best.This feminization takes out bone irregularities and bumps and smoothes out the entire frontal bone. I take down the entire orbital rim to the necessary individualized feminine depth and then back contour three dimensionally over the sinus, frontal bone and temporal lines of fusion that are the interface to the soft tissue flatness of the temples. This gives a true three dimensional reduction to the bone and by reducing the entire bone of the forehead I can get the most aggressive scalp advancements.  We can guarantee a minimum of a ½ inch centrally to ¾ inch in the temporal region of scalp advancement. We can get, depending on skin laxity, age and looseness, up to an inch and a half scalp advancement. You are able to get more out in the areas of the outside ‘male’ recession, since the eyebrow is always left a little higher on the outside to make the eye most feminine. If you do not take down the orbital rim along the outside of the eyebrow, the brows will look too high with a orbital rim fullness and bump in that area. Think back to high school geometry.  How is your forehead going to look more feminine three dimensionally if you just operate on the central sinus?  How is your forehead going to look more feminine three dimensionally if you just burr down the orbital rim? ITS NOT!  Three dimensional changes require one to completely contour all of the components of the ENTIRE forehead. Thats why our forehead feminizations stand above the rest because we aggressively contour the ENTIRE forehead and all of its component parts starting with the solid orbital rim and working backward. Cutting bone is old fashion and the complications are built in regardless of the surgeon. This is not your grandpa’s FFS. Endoscopy is a technique that you must explore.  Don't ask me-ask my patients.  Your complimentary consultation is just a click away.


Pure Endoscopic Browlift

Dr Zukowski and his staff at the Zukowski Center are renowned worldwide for being the best in FFS Facial Feminization Surgery. Based in Chicago America, Mark Zukowski is recognized within the transgender community as being the best.Overall, endoscopic techniques are the exclusive techniques used in the genetic female population. There are a number of genetic females who benefit from bone work in conjunction with the standard technique. I do not subject patients to a double standard of care in my practice. For people who have no hair whatsoever or a hairline/forehead height that is adequate, or for a female who does not want a prehairline incision, we have a pure endoscopic technique.There is no scalp advancement with this choice.  However, you have  either no hair or have a proper forehead height to have chosen this option. This procedure costs the same and achieves all of the aspects of forehead feminization including aggressive bone contouring and orbital rim reduction with three dimensional frontal bone contouring, elevation of eyebrows to a beautifully feminine position, and disruption of the corregator and procerous "botox muscle" group between the eye brows. These are the deep wrinkles between your eyebrows when you frown. We also do temporal filling of the hollows of the soft tissue with fat which gives a nice soft tissue feminine fullness to the temple area. This procedure is performed through six discontinous 1.5 inch incisions in the scalp and small screws are used as temporary anchoring posts in order to have the tissue scar down to the bone.  No hair is shaved.  The artist pictures have removed the hair for demonstration purposes.  These 2 millimeter screws are not readily noticeable and are easily and comfortably removed by your doctor or a technically competent friend two weeks after surgery. If someone says "you have a screw loose" then for the first time in your life they may be right (just kidding). Remember, everything is technically the same as with the Biplaner technique except that there is no scalp advancement or continous cut along the hairline.  The discontinous incisions are hidden in the hairline or placed in areas where hair once was.

Dr Zukowski and his staff at the Zukowski Center are renowned worldwide for being the best in FFS Facial Feminization Surgery. Based in Chicago America, Mark Zukowski is recognized within the transgender community as being the best.Typically, with all forehead procedures, the eyebrows seem overly elevated due to swelling in the first month.  The eyebrows settle so that by two months you can individualize their position by having a friend or professional who does good eyebrow sculpting take some off the top in order to reduce the height of your eyebrows or to take some off the bottom in order to increase the height of your eyebrows. Eyebrows continue to settle up to a year. The brow is the most important part of the face to feminize. This is the area of a woman that determines her sensuality. My experience with endoscopic techniques goes back to May 1993 when I performed my first series of endoscopic procedures after organizing a series of live demonstrations by Oscar Ramirez, M.D., one of the three founding fathers of endoscopic minimal scar soft tissue plastic surgery. This is a claim no other FFS surgeon in the world can make. These techniques involving bone removal are the standard of care in genetic females for a reason - they don't like the built in complications that come with open techniques.  Contact us today for a more in-depth discussion of your surgical plan.

1 Zukowski, M., Ash, K.: A Prospective Analysis of Sensation in Open vs. Endoscopic Assisted Brow Lifts. Presented at the 29th Annual American Society for Aesthetic Plastic Surgery meeting April 29-May 3rd, 1996 Orlando, FL.

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