The appearance of the periorbital region is closely correlated with an individual’s facial aging profile. Asian women are characterized as having higher eyebrows and wider upper eyelids and possessing more orbital fat compared with Caucasian women.1 The main clinical manifestations of periorbital aging in Asian women include lateral hooding of the upper eyelid skin, eyebrow ptosis, and obvious periorbital wrinkles.2,3 A survey indicated that Asian women are more likely to accept procedures that would solve the issues of upper eyelid hooding and periorbital wrinkles instead of issues with eyebrow ptosis.4
Parkes et al.5 first performed subbrow blepharoplasty for dermatochalasis in Caucasian patients. Subbrow blepharoplasty has several advantages, such as minimal swelling, rapid postoperative recovery, removal of redundant thick skin, and preservation of local anatomical features.5 Considering the ethnic features of Asian women, Kim et al.6 reported a modified subbrow blepharoplasty in which the elliptical pieces of skin and orbicularis oculi muscle are excised. This method is popular among Asian women because the outcome is considered compatible with their ethnic features. Recently, Lee introduced an advanced subbrow blepharoplasty in which a periosteal suture fixation technique is used to maintain the surgical result and reduce the risk of relapse, and this method was further modified by Kim,7 so that the potential injuries to a deep branch of the supraorbital nerve can be avoided.
Despite the above advantages, subbrow blepharoplasty is still restricted because of postoperative descent of the eyebrow and the limited amount of infrabrow skin excision.8 In addition, subbrow blepharoplasty does not effectively solve the problem of periorbital wrinkles, such as glabellar frown lines and crow’s feet. To correct these shortcomings, we propose a new technique using subbrow blepharoplasty combined with periorbital muscle manipulation that can revive the patient’s own natural eyelid shape while the eyebrow position is stabilized effectively, and the periorbital wrinkles are markedly alleviated in Asian women.
PATIENTS AND METHODS
Sixty-six female patients who were considered suitable for subbrow blepharoplasty combined with periorbital muscle manipulation were selected from June of 2016 to August of 2017. The patients ranged in age from 37 to 68 years, with a mean age of 47.5 ± 7.11 years. The primary indications for the procedure included the following: (1) lateral lid hooding being the primary concern; (2) wanting to preserve the original brow position; and (3) obvious periorbital wrinkles (glabellar frown lines and crow’s feet).
Preoperative and Postoperative Photographs
Before and again at 6 months after surgery, all patients were photographed in the frontal view with their head in the upright position and eyebrows in a maximally relaxed position (Fig. 1). Objective measurements were performed using Adobe Photoshop (Adobe Systems, Inc., San Jose, Calif.). A metric ruler was taped to the midforehead. Upper eyelid and eyebrow positions were measured bilaterally. The vertical distances from the midpupillary horizontal plane to the upper eyelid margins were measured at three points: the medial limbus, the mid pupil, and the lateral canthus. The vertical distances from the midpupillary horizontal plane to the upper brow margins were measured at three points: the medial limbus, the mid pupil, and the lateral canthus.
With the patient in the standing position and her eyes looking straight forward, a point was marked on the inferior edge of the peak point of the eyebrow. Next, the excess upper eyelid skin below the eyebrow was clamped by a pair of smooth forceps so that the upper eyelid was elevated to a position with eyelashes curling slightly. Then, another point was marked and the distance between the two points was the greatest width of the skin area to be excised was measured. Its length was approximately 6 to 12 mm, and a spindle-shaped region of skin was marked with its upper incision line precisely at the lower margin of the natural or tattoo brow and the lower incision line having a curved shape. The medial and lateral points of the removed skin region were at the supraorbital nerve notch and the temporal tip of the eyebrow, respectively. The incision was usually a straight line measuring 3.5 to 5.0 cm (Fig. 2).
The operation was performed under local anesthesia (2% lidocaine combined with epinephrine 1:100,000). An incision was made with a no. 15 blade and deepened to the subcutaneous level. The upper incision was beveled along the inferior margin of the eyebrow to prevent damage to the hair follicles. The incision along the lower incision line was made vertical. Then, the skin and subcutaneous tissue within the marked area were elevated off the muscle inferiorly and superiorly (Figs. 3 and 4). The orbicularis oculi muscle exposed after removal of the skin and subcutaneous tissue was divided by a transverse incision into the upper one-third and the lower two-thirds, forming two muscle flaps. In addition, the incision of the orbicularis oculi muscle extended 0.5 to 1 cm to both sides to reduce the longitudinal strength of the muscle as much as possible. Then, the lower muscle flap was separated from the preseptal fat by approximately 1.5 cm to make it easier for the lower muscle flap to be lifted, and the skin and subcutaneous tissue on the muscle flap were dissected downward approximately 0.5 cm for subsequent insertion and suture of the upper muscle flap. The upper muscle flap lying on the lateral side of the supraorbital nerve notch was separated from the subbrow fat pad by approximately 1 to 1.5 cm to facilitate subsequent lower muscle flap insertion and anchoring (Figs. 3 and 4). In cases of puffy eyelids, the orbital septum was opened and an appropriate amount of fat tissue was moved.
At the medial portion, careful dissection was performed at the supraorbital nerve notch area to avoid injuring the supraorbital nerve notch. In addition, the corrugator muscle was exposed, cut off, and separated by 1 to 2 mm. For some patients with strong frown muscles, the corrugator muscle was exposed, cut off, and separated by 4 to 6 mm (Fig. 5).
At the temporal portion, the lateral border of the orbicularis oculi muscle is separated from the subcutaneous tissue. The most lateral detachment of the orbicularis oculi muscle was within 5 mm lateral to the orbital rim. Then, the lateral orbicularis oculi muscle was splayed out and sutured upward and inward to the periosteum in this spread position. The typical extent of the lateral orbicularis oculi muscle anchoring to the lateral orbital rim was 7 to 10 mm (Fig. 3).
The lower muscle flap was pulled up and inserted into the space between the upper musculocutaneous flap and the subbrow fat pad, forming a cross muscle flap with the upper muscle (Figs. 3 and 4). Simultaneously, the upper end of the lower muscle flap was fixed to the supraorbital rim periosteum and subbrow fat temporally to the supraorbital nerve notch with three to five transverse 3-0 absorbable sutures, and the bottom end of the upper muscle flap was inserted downward between the lower muscle flap and the subcutaneous tissue and sutured with the lower muscle with three to five transverse 4-0 absorbable sutures, to form an overlap of the muscle flaps (Figs. 3 and 4). The height of the lower muscle flap lift depended on correction of upper eyelid hooding, recurrence of a natural eyelid crease when patients opened their eyes. and no occurrence of hypophasis when patients closed their eyes. In general, the typical extent of the muscle flap anchoring to the superior orbital rim was 7 to 10 mm. As a result, the two sides of the skin incision were close after the muscle flaps were cross-stitched, so that closure of the operative incision had less tension (Fig. 4). After carefully achieving hemostasis, the subcutaneous layer was closed by modified fully buried vertical mattress sutures using 5-0 absorbable sutures. The dermis and skin layers were closed with interrupted sutures. Pressure was applied to the operative incision area by means of an elastic bandage that was in place continuously. The bandage and skin sutures were removed on the third and the fifth postoperative days, respectively.
Patients were evaluated for scarring, forehead numbness, modification of crow’s feet and glabellar frown lines, and satisfaction. To evaluate scarring, each patient was asked to complete the Patient Scar Assessment Questionnaire at least 6 months after surgery.9 All photographs taken before surgery, 6 months after surgery, and at the time of this evaluation were randomized and scored by three independent reviewers (two plastic surgeons and one layperson) by means of the wrinkle assessment scale developed by Lemperle et al.3 At 6 months after surgery, the patients were queried regarding their self-assessment of apparent improvement in the lateral hooding of the upper eyelid skin (question 1) and brow position (question 2). The responses to questions 1 and 2 were graded in five levels (none, minimal, modest, very good, and complete).
A total of 66 patients aged 37 to 68 years underwent this procedure from June of 2016 to August of 2017 and were followed up for an average period of 10 months (6 months to 1 year). The tissue swelling at the surgical sites subsided at 1 to 3 months after surgery. Five patients who were not satisfied with their former eyebrow tattoos underwent eyebrow tattoo excisions and new eyebrow tattoos 6 months after surgery. Aesthetic outcomes were evaluated during the 6-month follow-up. In answer to question 1, all patients reported an improvement as a result of surgery, with 63 patients (95.5 percent) describing their appearance as very good or complete and three patients (4.5 percent) describing their appearance as modest. In answer to question 2, 60 patients (90.9 percent) described their appearance as very good or complete and six patients (9.1 percent) described their appearance as modest (Figs. 6 and 7).
Subbrow blepharoplasty combined with periorbital muscle manipulation significantly improved the lateral hooding of the upper eyelid skin with stability. As shown by the measurements at 6 months postoperatively in Table 1, the greatest mean elevation of the upper eyelids was seen at the sites above the lateral canthus; moderate elevation was observed at the sites above the midpupil points; and the least elevation was seen at the eyelids above the medial limbus. When the measurements at each of the three sites that were obtained at 6 months postoperatively were compared with those obtained at 1 month postoperatively, the data indicated that the positions of the lower margins of the upper eyelids at 6 months postoperatively descended slightly, although with statistically nonsignificant differences. To evaluate the likely effects of the subbrow blepharoplasty combined with periorbital muscle manipulation procedure on the eyebrow height and morphology, the upper eyebrow height measurements at the medial limbus, midpupil, and lateral canthus points were compared between those measured preoperatively and those measured at 6 months postoperatively. Our results showed that there were no statistically significant differences between the measurements of corresponding sites obtained at the two different time points, indicating that the change in eyebrow position after the subbrow blepharoplasty combined with periorbital muscle manipulation procedure was not remarkable (Table 1).
Table 1. -
Changes in Eyelid Height and Eyebrow Position of 66 Chinese Women after Surgery*
||Medial Limbus (mm)
||Mid Pupil (mm)
||Lateral Canthus (mm)
|Change of upper eyelid height
|1 mo postoperatively
||0.87 ± 0.71
||1.46 ± 0.77
||2.06 ± 0.96
|6 mo postoperatively
||0.85 ± 0.61
||1.41 ± 0.66
||2.00 ± 0.78
||22.5 ± 2.63
||23.0 ± 2.51
||23.9 ± 2.25
|6 mo postoperatively
||22.9 ± 2.31
||23.5 ± 2.19
||24.0 ± 2.11
*Data are shown as mean of distance (in millimeters) measured from digital images. Statistical analysis was performed with IBM SPSS Version 22.0 (IBM Corp., Armonk, N.Y.).
†No significant differences (paired t test, p > 0.05).
To further evaluate the effects of the subbrow blepharoplasty combined with periorbital muscle manipulation procedure on the aging status over the patient’s orbital regions, subjective comparisons of the appearances of the intercilium and lateral orbital wrinkles shown at rest or when smiling before and after surgery were performed by two plastic surgeons and one layperson using the digital images of each patient. In addition, aesthetic results were graded by them using a standardized photographic rhytide scale. The mean rhytide scores of crow’s feet and glabellar frown lines before surgery were 1.58 and 1.42, respectively. Crow’s feet were obviously alleviated after surgery, as evaluated at the 6-month follow-up [mean rhytide score, 0.39; an equivalent to 75.3 percent of theoretical maximum improvement (p < 0.05)]. Glabellar frown lines were obviously alleviated after surgery, as evaluated at the 6-month follow-up [mean rhytide score, 0.64; an equivalent to 54.9 percent of theoretical maximum improvement (p < 0.05)]. The results indicated that all patients had not only reductions in glabellar frown lines but also alleviated frowning activities of corrugator muscle. All patients had reductions in crow’s feet, without any compromise in upper eyelid movements after the subbrow blepharoplasty combined with periorbital muscle manipulation procedure (Fig. 8). [See Figure, Supplemental Digital Content 1, which shows preoperative views of a 59-year-old patient who was not satisfied with the former eyebrow tattoo and underwent eyebrow tattoo excisions and new eyebrow tattoos 6 months after surgery. (Above) In repose while smiling (above, left) and while frowning (above, right). (Below) At 6 months postoperatively, in repose while smiling (below, left) and while frowning (below, right), http://links.lww.com/PRS/D736.]
Postoperative complications, such as forehead numbness over the forehead region and obvious incisional scarring, were also evaluated during the follow-up period. Thirteen patients reported forehead numbness that gradually subsided within 6 months. Subscale scores for appearance (9.56 ± 0.88), symptoms (6.38 ± 0.78), scar consciousness (6.24 ± 0.61), satisfaction with appearance (8.47 ± 0.86), and satisfaction with symptoms (5.33 ± 0.77) were very low, indicating no obvious incisional scarring in any patients at 6 months after surgery. (See Figure, Supplemental Digital Content 2, which shows no obvious postoperative scarring of a 40-year-old patient with a preexisting eyebrow tattoo, http://links.lww.com/PRS/D737. See Figure, Supplemental Digital Content 3, which shows no obvious postoperative scarring of a 42-year-old patient with a native eyebrow, http://links.lww.com/PRS/D738.)
A 58-year-old woman presented with a moderate degree of aging eyelids and obvious crow’s feet. The patient had not undergone any previous plastic surgery. Subbrow blepharoplasty combined with periorbital muscle manipulation was performed. The results achieved at 6 months postoperatively showed resolution of the lateral lid hooding and crow’s feet. In addition, there was no change in the position of the eyebrows (Fig. 6).
A 42-year-old woman presented with a moderate degree of aging eyelids and obvious crow’s feet. The patient had not undergone any previous plastic surgery. Subbrow blepharoplasty combined with periorbital muscle manipulation was performed. The 1-year postoperative view showed improvement in the patient’s natural appearance. In addition, the position of the eyebrows changed only slightly, which was accepted by the patient (Fig. 7).
The periorbital region comprises the eyebrow and upper eyelid and is an important area for improvement in rejuvenation of the aging face.10 Periorbital aging among women older than 40 years is usually characterized by the presence of evident signs of lateral hooding of the upper eyelid skin, eyebrow ptosis, and periorbital wrinkles. Currently, the rejuvenation of periorbital aging remains at the top of the list in cosmetic consultations in the clinics of departments of plastic surgery throughout China. To cope with such aging issues surgically, the eyebrows, the upper eyelids, the periorbital muscle tissues, and their intricate interactions need to be considered as integral parts when planning the treatment approach.10 In addition, the ideal aesthetic proportion of the upper eyelid to the eyebrow is vital for achieving an ideal outcome and avoiding complications in rejuvenation surgery of the periorbital region.11,12 Based on subbrow blepharoplasty, we simultaneously adjusted the structure and function of the periorbital muscles in the subbrow blepharoplasty combined with periorbital muscle manipulation procedure. As a consequence, upper eyelid hooding, glabellar frown lines, and crow’s feet were notably improved and the scars were inconspicuous after 6 months postoperatively.
Because of the anatomical and aesthetic characteristics of Asian women, subbrow blepharoplasty is considered an appropriate surgical procedure with which to solve lateral hooding of the upper eyelid skin.6 Subbrow blepharoplasty removes redundant eyelid skin and preserves the original features of the eyelid. A drawback to subbrow blepharoplasty in some patients is an unpredictable degree of relapse. Many surgeons have reported that elevating the orbicularis oculi muscle and suturing it to the orbital periosteum is also an effective method of ensuring the long-term stability of brow-lift surgery.13 Compared with subbrow blepharoplasty, our new technique fixes lower muscle flaps to the supraorbital rim periosteum and the upper muscle flaps, forming a cross flap for interlocking fixation. In our follow-up, the elevated upper eyelid was stable. The long-term efficacy of this procedure requires further observation.
Eyebrows occupy a prominent and expressive position in the upper third of the face, and there is still controversy over whether the location of the eyebrow descends with age.14 Asian women, in general, have wider upper eyelids and a higher eyebrow level (measured from the pupil) compared with Caucasian women.1 In our experience, most Asian women who seek periorbital rejuvenation surgery request preservation of the eyebrow position. Therefore, such a requirement may be a contraindication for subbrow blepharoplasty because this procedure seems inevitably accompanied by postoperative eyebrow reduction or distortion.6 Anatomically, a neutral position of the eyebrow is maintained by the balance of tug-of-war vectors, mainly including the upward-pulling force generated from the frontalis muscle and the downward-pulling forces derived from the orbicularis oculi and corrugator supercilii muscles.15,16 In addition, Yun et al.17 reported that the activities of the orbicularis oculi and corrugator supercilii muscles may be intensified in the aged population. Other investigators also reported that postoperative descent of the eyebrow position may result from frontal muscle relaxation. To prevent these inherent problems, we partly dissected the orbicularis oculi muscle and cut off the corrugator supercilii muscle to alleviate the depressing force, which may reinstitute the dynamic balance between the eyebrow muscles.8,18 Although we extended the incision by 0.5 to 1 cm on both sides, the medial extension should not exceed the inner extent of the medial canthus, and the lateral extension should not extend beyond the lateral orbital rim, to avoid paralysis of the upper eyelid. In addition, we pulled up the lower muscle flap by 1 to 2 cm and fixed it to the periosteum and the upper muscle flaps. The height of the lower muscle flap lift depended on correction of upper eyelid hooding and no occurrence of hypophasis. As a consequence, the lower edge of the skin incision would also be lifted up and was close to the upper edge of the skin incision. This procedure can reduce tension at the skin suture line and traction of the elevated upper eyelid. Therefore, the skin of the eyebrow may not descend because of the reduction of downward muscle strength and reduced skin tension. We compared the height of the eyebrows before and 6 months after surgery and confirmed our hypothesis.
In addition to the alleviation of upper eyelid hooding, our technique can evidently relieve periorbital wrinkles. With advancing age, hyperactive orbicular muscles exert relatively more force to the eyelid tissues, leading to apparent crow’s feet wrinkles. Thus, by suspending the orbicularis oculi muscle in a stretching and spreading state, our procedure effectively hinders the effects of muscle contraction on the overlying skin and the consequent formation of crow’s feet wrinkles. Similarly, glabellar frown lines are caused mainly by the action of the corrugator supercilii muscle and functional disruption.19 Cutting off the corrugator muscles has been proved effective for diminishing these wrinkle lines,20 and our procedure satisfactorily improved the intercilium appearances in all enrolled patients.
Postoperative scarring in the infrabrow region was inconspicuous and acceptable for all patients in this study. The infrabrow region is thought to be an area less prone to conspicuous scarring because of the special nature and quality of skin in this area.6 The reduced wound tension and design of the surgical incision line along the inferior margin of the eyebrow that would likely be covered by regrowth of hair all contribute to the visual inconspicuousness of wound scarring. In addition, intermittent suturing of the dermis and skin and pressure bandaging may be another reason. Compared with the traditional subbrow blepharoplasty, the results in this study showed that a few patients presented with transient numbness over the forehead region. Despite the numbness of the 13 enrolled patients gradually disappearing within a few months, it is necessary to carefully preserve the supraorbital nerve notch and supratrochlear nerve branches when performing the surgical procedure around the supraorbital nerve notch and glabellar areas.
We describe a novel technique by means of subbrow blepharoplasty combined with periorbital muscle manipulation and present our experience with it here. As observed in recent postoperative results, subbrow blepharoplasty combined with periorbital muscle manipulation was clinically and statistically effective in correcting lateral hooding of the upper eyelid skin, and eyebrow position was effectively stabilized and periorbital wrinkles were markedly alleviated in Asian women. In addition, 63 of 66 patients (95.4 percent) were satisfied with apparent improvement in the lateral hooding of the upper eyelid skin, and 60 of 66 patients (90.9 percent) were satisfied with brow position. The procedure is simple, effective, and comprehensive for improving periorbital aging in Asian women.
Patients provided written consent for the use of their images.
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