Welcome to our July Newsline.


Brow & Forehead Lift

In past updates, we have discussed blepharoplasty (eyelid surgery). First of all, it is important to recognize that brow and eyelid surgery are closely related, but there are significant differences. Brow lifting can lead to improvement in the appearance of the eyelid, while eyelid surgery does not significantly effect the appearance of the brow; although overzealous upper eyelid surgery can result in some brow droop.The most important question that patients ask is “when should brow elevation be carried out.”  The answer, while obvious, is often overlooked.  Brow surgery is indicated when the patient feels that a drooping brow detracts from his or her appearance. In many cases, a low brow can be very attractive,  Many attractive models and actresses have a droopy brow which can impart a very sultry or sexy appearance.  The actress, Brooke Shields is only one example.
Let’s assume for our discussion today, that both the patient and surgeon agree on a goal of brow elevation.  What are the alternatives? The simplest is a procedure that lifts the brow through the placement of a suture that is attached to the scalp – a very simple operation that we tried several years ago with initial promising results but unfortunately failed in the long run.  This supports our overall contention that simple suture techniques currently being widely promoted are not substitute for more definitive operations.  Basically, mini-surgery leads to mini results.

Direct Brow Lift:  Among the more definitive operations, there are several choices.  The simplest is an operation called the direct brow lift.  In this operation, an incision is made in the brow, after which skin is removed above and the brow is sutured to its elevated position.   The operation works quite well except for one major problem.  Unfortunately, the scar, even when hidden in the brow, is quite unpredictable and often becomes rather apparent.  For this reason, the operation is rarely recommended.  Exceptional cases would include those where there is a great deal of excess brow and where a scar would be more acceptable.  An example would be and older patient where the brow droop is actually  contributing to visual impairment

Mid Forehead Lift:  In this operation, an incision is made in the forehead within a forehead crease.  Again, skin excision is used to lift the forehead and brow.  Once again, the limitation is the fact that the scar may prove overly visible.  Its indications, while unusual, include patients (almost always men) with natural deep forehead lines which are likely to hide the scar, combined with a receding hairline which can make other techniques more difficult or impossible.

Endoscopic Forehead/Brow Lift: This has certainly become the most common form of brow and forehead lifting today.  Like the traditional lift, it frees up the forehead, brow and scalp, allowing an upward rotation with strong fixation.  The advantage over the traditional lift lies in the fact that very small incisions are used with dissection carried out largely under endoscopic visualization.  All of the incisions are within the hairline and so there is virtually no visible scarring. In our practice, this operation is most commonly carried out in conjunction with traditional facelifting in patients seeking a combined upper, mid and lower lift.  It does add some operating time, but in general, does not increase recovery time.

Coronal Forehead/Brow Lift: This was the original approach to lifting the forehead and brow.  The surgery is carried out through a long incision – usually across the top of the head, but sometimes made right at the top of the hair line.  The original technique involved lifting through excision of skin and tightening  through the closure of the incision, although now, we no longer routinely remove tissue, but, rather, use fixation similar to the endoscopic technique.  In rare cases, excision of forehead skin can be used to reduce an overly long forehead.  the main advantage of the open coronal lift lies in the fact that the increase surgical exposure allows for additional contour of bone, or the use of implants for structural improvement.

Extended Subperiosteal Coronal Lift: This operation is actually an extension of the traditional coronal lift that allows us to also provide a strong lift to the mid face as well as the forehead and brow.  It is one of the most powerful facelifts that we offer.  Our experience has shown us that the results are far more lasting than other types of facelift procedures.  This operation is primarily indicated in younger patients who are concerned about upper and mid face rejuvenation with less concern about the neck.  It offers improvement down to the jowl but not into the neck.  Of course, it can be combined with other procedures to rehabilitate the neck.  Highlights of the procedure are: brow elevation, an elevation of the outer corner of the eye, a natural elevation of the cheekbone area and an elevation, albeit slight, of the corner of the mouth.As you can see, we have quite a few options when it comes to treating the brow.  The actual choices you make will require a personal consultation, but this should at least give you some background information that will assist you in asking the right questions during your visit with a cosmetic surgeon.

Medical Liability Reform – The Pros & Cons


There is little question that liability reform was long overdue in Texas.  For years, there was a growing shortage of physicians in the state because of the high cost and relative unavailability of insurance for doctors practicing here.  For example, in 1999, there were 17 companies offering insurance to doctors while in 2003, the number had dropped to 5.  The problem largely stemmed from huge awards for so called “non economic damages.”  These are damages that do not relate to costs incurred by the patient or wages lost, but rather relate to non specific entities such as “pain and suffering” or “loss of consortium.”  In fact, in 1999, economic damages averaged only 35% of total verdicts.  In that year, the average award for economic damage was $364,000 versus $1.38,000,000 for non economic damage.  Although painful to admit, no physician would deny that there are occasions where patients suffer damage because of error or negligence.  In those cases they deserve fair compensation.  However, when the system is out of control, everyone suffers through increased cost of healthcare and a lack of physicians.

In 2003, Texans supported a constitutional amendment that provided for meaningful tort reform.  Since then, there has been a major improvement in that doctors and insurance companies are returning to Texas and insurance costs are dropping.  While the Senate has passes bills providing for similar reform for the country as a whole, the House of Representatives has opposed these bills.  Texas Senator, Kay Bailey Hutchison spoke to the Senate on the Texas experience.  Her comments to the Senate are well worth reading, and if you are interested, you can read them by following the link: http://www.texmed.org/Template.aspx?id=780


Battle in Isreal
In happier times, The Tobins, on right side of picture, visit with Dr. & Mrs Leonid Kogan, seated center and left, and another doctor in the training group, while in Israel in 2004.

As many of you may remember, about a year and a half ago, Gail & I travelled to Israel to take a course in disaster medicine as part of a group called ERG (Emergency Response Group).  As part of the training, we agreed to be available to travel to Israel in time of war to assist the doctors at the Western Galilee Hospital, if needed.  As of the time of this writing, I am advised that the situation is well under control in spite of the large number of casualties that come into the hospital daily.  The hospital is located in Nahariha, only about 5 miles from the Lebanese border and has continuously been under rocket fire.  Nevertheless, the staff has continued to work, taking care of war casualties, general emergencies as well as routine care.  So far, I have not been  needed, but remain prepared to go if called. To read more, follow this link to an article appearing in the Abilene Reporter News.

That’s it for this month.  I That’s it for this edition. As always your comments and suggestions are always welcome.


Howard A. Tobin, M.D., F. A. C. S.

For general information: askdena@newlook.org or n41gt@newlook.org