Received: 8 September 2023 Accepted: 27 September 2023

DOI: 10.1111/srt.13498

ORIGINAL ARTICLE

Evaluation of eyebrow position and upper eyelid laxity after

endolift laser treatment

Elaheh Lotfi1,2 Roberto DellAvanzato3 Najmeh Ahramiyanpour4

Fatemeh Shadmanyazdi1 Somayeh Khosravi5

1
Yousef Abad Skin and Hair Center, Tehran,
Iran Abstract
2
Ambers Laserklinik, Gothenburg, Sweden The periorbital area is one of the most sensitive areas in the face, and many techniques
3
La Madonnina Clinic, Milano, Italy are used to change the eyelid laxity and position of the eyebrows. Recently the use of
4
Department of Dermatology, Afzalipour noninvasive or minimally invasive techniques is developed so, the amount of surgical
faculty of Medicine, Afzalipour Hospital,
Kerman University of Medical Sciences, procedures has decreased. In the present study. We evaluate the effect of Endolift laser
Kerman, Iran as a non-invasive method on upper eyelid laxity and eyebrow position. Nine patients
5
Imam Khomeini Hospital Complex, Advanced underwent Endolift laser and evaluated for eyelid laxity and change in eyebrow posi-
Medical Technologies & Equipment Institute,
Tehran, Iran tion. Two blinded physicians assessed the cosmetic outcome of improvement in upper
eyelid tightening via photography 6 months post-treatment. The physicians evaluated
Correspondence
Elaheh Lotfi, Yousef Abad Skin and Hair
the patient’s improvement degree using the photographs by two clinical factors: skin
Center, Tehran, 1416753955, Iran; laxity and total cosmetic result. Also, eyebrow height from the center of the pupil
Ambers Laserklinik, Gothenburg, Sweden.
Email: elahehlotfiii@gmail.com
(CPEBH), Central eyebrow height (CEBH), Lateral eyebrow height (LEBH), Medial eye-
brow height (MEBH) were measured by ImagJ before and 6 months post Endolift laser
treatment. Our results showed eyelid laxity and eyebrow height were significantly
changed after treatment.

KEYWORDS
endolift laser, eyebrow position, treatment, upper eyelid laxity

1 INTRODUCTION
Aging causes the appearance of extra skin nearby the eyelids with
increasing skin laxity and eyebrow ptosis so this is a common dis-
order that many patients suffer from. Improvement of eyelid skin
texture, excessive eyelid skin laxity and tightening of eyelid skin, and
increase height of eyebrows are the common reasons that people visit
a dermatologist. Eyelid skin tightening and excessive eyelid skin lax-
ity correction can be done in a variety of methods such as dermal
filler and chemical peels injections and laser therapy besides multiple
plastic surgery methods.1–3 Because of specific skin structure the eye
area is one of the most difficult regions to use aesthetic techniques.4
Eyebrow lift and blepharoplasty are surgical techniques that are com-
monly used for the treatment of periorbital aging but it is accompanied
by pain and need long recovery time and possible side effects.4 Sev-
eral nonsurgical treatments are studied as an alternative to surgical
blepharoplasties, like, erbium-YAG laser, ablative CO2 and fractional
ablative CO2 laser and non-ablative fractional laser, soft tissue fillers,
radio-frequency technology.3,5 Some of these methods may be com-
bined to get better results. Each technique has its weaknesses and
strengths. To evade the significant potential side effects of ablative
techniques, the non-ablative methods are advanced. Generally, in the
field of skin resurfacing the gold standard is ablative CO2 resurfacing.6
Among nonsurgical techniques for eyelid skin laxity treatment,

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© 2023 The Authors. Skin Research and Technology published by John Wiley & Sons Ltd.

Skin Res Technol. 2023;29:e13498. wileyonlinelibrary.com/journal/srt 1 of 5

https://doi.org/10.1111/srt.13498
2 of 5
F I G U R E 1 Measured indicators for eyebrow position: Eyebrow height from the center of the pupil named as (CPEBH), central eyebrow height
named as (CEBH), lateral eyebrow height named as (LEBH), medial eyebrow height named as (MEBH).
ablative carbon dioxide (CO2 ) resurfacing has been very successful.6–8
However, some serious possible side effects like long-lasting pigmen-
tary changes, scarring, and infection caused these modalities ineligible
and have caused the development of a variety of non-ablative laser
resurfacing modalities. Non-invasive methods in aesthetic rejuvena-
tion is rising at a notable rate.9,10 One of the nonsurgical non-ablative
successful modalities for the eyelid skin laxity and eyebrow ptosis
treatment is Endolift laser.11 In the present study we used Endo lift
laser for excessive eyelid skin laxity and eyebrow ptosis.
1.1 Patients and methods
Ten healthy subject (age from 35 to 60 years old) came to our depart-
ment for desired treatment of eyebrow ptosis and upper eyelid laxity.
The patients underwent the Endolift method. Patients with any cos-
metic procedures were excluded from the study; eyelid and peeling
eye inflammations, filer injection, blepharoplasty, and ptosis improve-
ment. Informed consent was gained from the patients before the start
of the treatment. Treatment was administered to the upper eyelids
with Endolift™ (LASEMAR1500TM machine) was utilized at settings
of power 3–5 W, T on 15 and T off 45, 3 pulse, and 300 µs pause.
Before the procedure, the treatment area was carefully cleaned. A lido-
caine was injected with cannula before treatment. Patients received
one treatment session. The patients were evaluated 6 months after
treatment. Incidence of side effects of edema, swelling, and erythema
were evaluated at 1 week. Photos were taken from the patients before
and 6 months after the procedure. Six months after the Endolift treat-
ment, physicians evaluated the patient’s improvement degree using
the photographs by two clinical factors: skin laxity and total cosmetic
result. The grading scales were as follows; 0.0 as Non, 1 as Minimal, 2
as Mild, 3 as Moderate, 4 as Advanced, and 5 as Sever. Also, the amount
of improvement was analyzed as the % improvement between before
and after the procedure. Also, the changes of eyebrow position were
LOTFI ET AL .
evaluated by measuring some indicators by ImagJ program before and
after treatment as follow (Figure 1).
Eyebrow height from the center of the pupil is named as (CPEBH),
Central eyebrow height named as (CEBH), Lateral eyebrow height
named as (LEBH), and Medial eyebrow height named as (MEBH).
1.2 Statistical analysis
The statistical analyses were prepared via SPSS software version 12.0.
Evaluations of change in lid parameters after the procedure were done
with the paired t-test and p value < 0.05 were considered statistically
significant.
2 RESULTS
A total of nine patients were received Endolift procedure. Six months
post-treatment, patients were evaluated for final clinical results. The
possible side effects were evaluated at 1 week (erythema and edema).
Throughout the procedure, lidocaine was injected to minimize and
improve the possible pain. Two blinded physicians assessed the upper
eyelid tightening improvement as a cosmetic result via photography 6
months post-treatment. The score of skin laxity reduced from 3.5 pre-
treatment to 1.0 at 6 months post-treatment (p < 0.05) with a 71.5%
improvement (Table 1). The total cosmetic result score reduced from
3.5 pre-treatment to 1.2 at 6 months post-treatment (p < 0.05) for a
71.1% improvement (Table 1). Figure 2 show the clinical photographs
of patients before and after treatment. After Endolift laser treatment,
measurement of eyebrow heights, comprising CPEBH, CEBH, LEBH,
and MEBH, were significantly higher post-treatment compared to
pre-treatment (Table 2). All lid parameters improved significantly
after Endolift laser treatment: Before treatment, the mean of CPEBH,
CEBH, LEBH, and MEBH were 16.11, 14.08, 16.15, 19.13 mm and
LOTFI ET AL . 3 of 5

TA B L E 1 Quantitative patient improvement in skin laxity, and to some side effects like hyperpigmentation, erythema, prolonged
total cosmetic result. swelling, and crusting. Furthermore, this treatment may cause severe
p value long-term risks such as, scarring, permanent dyspigmentation, and
Pre-treatment other textural abnormalities.6,8,12,13 Fitzpatrick et al. compared the
vs. effectiveness of ablative CO2 versus Er:YAG on tissue tightening. The
Mean scores for all Total cosmetic Post-treatment
results were almost identical with both techniques. The important
patients Skin laxity result score
dissimilarity was the scarring that was saw in the Er:YAG treated.12
Pre-treatment 3.5 3.5 <0.05
Some studies has been introduced Radiofrequency (RF) as a novel tech-
Post-treatment 1 1.2
nique that can improve skin laxity with contraction that caused by
Mean improvement 71.5 71.1 heat.7,13–17 RF is revealed that can lift the eyebrow, increase eyelid
tightening, and contract the lower face and cheeks, and tight off the
face.7,13–17 In the Biesman et al. study the usage of RF was evaluated
after treatment CPEBH, CEBH, LEBH, and MEBH increased 1.40, 1.49, for the treatment of eyelids and their results showed 88% improve-
1.37, and 1.15 mm, respectively (Table 2). Patients reported no side ment in upper eyelid tightening and about 74% improvement in lower
effects. This treatment technique does not need general anesthesia eyelid.17 Ruiz-Esparza et al. reported the RF is effective for laxity of the
and recovery time. lower eyelids.15 In a pilot study, Carruthers et al. determined that RF is
effective and safe for upper and lower eyelid improvement and tighten-
ing with mild to moderate efficacy.16 However, RF method is laborious,
3 DISCUSSION slow and it takes a long time (about up to 1 h for a single eyelids treat-
ment session). In the present study the effect of the Endolift laser
Our results showed that Endolift laser can significantly improve eye- was evaluated on upper eyelid laxity improvement and the outcomes
lids skin laxity and tightening. The ablative laser devices like CO2 presented that Endolift procedure which is a non-ablative laser can
and erbium-doped:yttrium-aluminumgarnet (Er:YAG) were applied for improve the upper eyelid tightening. Also, our results showed that eye-
resurfacing of eyelid. These ablative laser treatments were related brow position change and eyebrow heights increase significantly after

FIGURE 2 Evaluation of the patients clinical photographs using Image (before and after treatment).
4 of 5
TA B L E 2 Change in lid parameters 6 months after Endolift laser
treatment.
CPEBH CEBH LEBH MEBH
Before treatment 16.11 14.08 16.15 19.13
After treatment 17.51* 15.57* 17.52* 20.28*
*p < 0.05.
treatment. Some studies have investigated the position of the eyebrow
following blepharoplasty. In the Frankel et al. study they compared the
eyebrow position in two groups; the group after upper blepharoplasty
and the control group; their results showed that there was not signifi-
cant difference in eyebrow height in the treated and control groups.18
In Starck et al. study, photographic analysis of patients with bilat-
eral upper blepharoplasty displayed that eyebrow location and upper
eyelid height were not significantly changed after blepharoplasty.19
In another study in patients with eyebrow ptosis, eyebrow position
was analyzed after blepharoplasty and they reported an insignificant
change in eyebrow position.20 Balzani et al. used fractional ultrapulse
CO2 laser for upper eyelid dermatochalasis treatment and periorbital
rejuvenation.21 Their results demonstrate that fractional ultrapulse
CO2 laser is not only safe and effective for the treatment of upper
eyelid dermatochalasis but also can have a nonsurgical eyebrow lift
effect.21 In the present study we used ImagJ for eyebrow changes after
Endolift laser treatment. In the Zheng et al. study the eyelid and eye-
brow position were evaluated after CO2 Laser-assisted blepharoptosis
surgery by digital analysis. They used the digital image before and after
the surgery. They analyzed the images with the ImageJ. They proved
that digital image analysis is valuable in measuring the eyebrow and
eyelid modifications after ptosis surgery.22 Using the ImageJ software
for analyzing the images has some advantages. The analysis is easy and
detailed, the images can be analyzed in less than 5 min and the images
and information can be saved forever in the PC.
4 CONCLUSION
The periorbital area is one of the most sensitive areas in the face,
and many techniques are used to change the eyelid laxity and position
of the eyebrows. Recently the use of noninvasive or minimally inva-
sive techniques is developed. Our results showed that Endolift laser
method is an effective non-ablative technique for upper eyelid tighten-
ing and can increase the eyebrow height. This technique does not need
general anesthesia and recovery time.
ACKNOWLEDGMENTS
We admiringly acknowledge the colleagues and staffs in Yousef Abad
Skin and Hair Center, Tehran, Iran.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
STUDY LIMITATION
Further studies are needed to assess more numbers of patients.
LOTFI ET AL .
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ORCID
Elaheh Lotfi https://orcid.org/0000-0002-5262-0231
Najmeh Ahramiyanpour https://orcid.org/0000-0003-3171-5933
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