Modified Infrabrow Excision Blepharoplasty for Severity of Medial Blepharochalasia

Abstract

Infrabrow excision blepharoplasty can be a satisfactory and useful alternative for patients with blepharochalasia. Sixty patients underwent modified infrabrow excision blepharoplasty from March 2017 to February 2018. The design of the skin excision was modified according to the severity of the medial blepharochalasia: (1) excision up to the medial limbus was performed if there was no medial blepharochalasia, (2) excision up to the medial epicanthus was performed if there was mild medial blepharochalasia, and (3) excision with triangular back cut was performed if there was moderate-to-severe medial blepharochalasia. The surgical method included (1) skin excision, (2) orbicularis oculi muscle excision, (3) orbicularis oculi muscle closure, and (4) skin closure. The mean postoperative follow-up period was 9 months, and the photographic results were collected retrospectively and evaluated. There were no complications related to surgery in terms of the resulting scar and dysesthesia. The mean operative time was 55 minutes. Patient satisfaction was very high in terms of both aesthetic outcome and comfort. Modified infrabrow excision blepharoplasty can be an easy and satisfactory alternative in a selected group of patients.

Introduction

Blepharoplasty by infrabrow excision is a procedure that can address various potential problems associated with generic blepharoplasty. Double-eyelid surgery may produce unsatisfactory outcomes such as an unnatural post-operative appearance as a result of newly formed or altered double-eyelid creases.¹ It is commonly observed that as the width of the skin excision increases, the thin pretarsal skin is bound to be sutured to a thick upper flap. This discrepancy in the nature and thickness of the skin that meets along the crease line then accentuates the overhanging appearance.² This surgery is easy and simple because only sagging skin is being corrected, and it has the major advantage of simply returning the sagging skin to its original state with a very short recovery period. On the other hand, its disadvantages include scars below the eyebrow and horizontal creases due to brow sagging postoperatively.³ Infrabrow excision blepharoplasty is usually a satisfying and useful alternative for patients only with lateral blepharochalasia. However, we have achieved satisfactory outcomes by modifying the design according to the severity of both medial and lateral blepharochalasia.

Materials and Methods

In total, 120 lids of 60 patients were subjected to this operation from March 2017 to February 2018. All patients were women, and the average patient age was 40.2 years. The mean postoperative follow-up period was 9 months, and the photographic results were collected retrospectively and evaluated. The indications for this procedure included (1) postoperative scarring following previous infrabrow blepharoplasty; (2) not wanting a new double-eyelid crease to be created or existing double-eyelid crease to be corrected; (3) history of multiple double-eyelid surgeries due to unsatisfactory outcomes; (4) the presence of lateral lid hooding; (5) people with eyebrow tattoos; (6) people with thick or high brows; (7) the desire of a speedy recovery, normal daily life, and a simple surgery; and (8) aged 30 to 80 years. The exclusion criteria included a distance of ≤28 mm between the eye and eyebrow.

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients for being included in the study.

Surgical Procedure

Preoperative Design

This procedure was performed in the sitting position. The upper excision line was placed along the eyebrow, at 1 mm below the eyebrow or an eyebrow tattoo, if applicable. With the frontalis relaxed and the patient comfortably opening their eyes, the upper part of the eyelid and eyebrow were gently pulled upward and the amount of skin that was moved was marked to design the lower excision line. Because a scar contracture can easily occur, the excision does not extend medially beyond the inner canthus toward the nose, so as to not invade the nasal skin. Laterally, the excision is designed to not extend beyond 2 cm from the lateral orbital fissure. If the excision line is continued beyond that point, the skin may thicken and leave a large scar.⁴ The design of skin excision was modified according to the severity of medial blepharochalasia: (1) excision up to the medial limbus was performed if there was no medial blepharochalasia, (2) excision up to the medial epicanthus was performed if there was mild medial blepharochalasia, and (3) excision with triangular back cut was performed if there was moderate-to-severe medial blepharochalasia (Figure 1). When designing the back cut, the triangle could not be too wide to ensure that there was no hypertrophic scar or band in that area due to skin tension. Lines vertical to the skin excision were marked on 8 to 10 spots to serve as markers during skin suturing.

Figure 1.

Modified infrabrow excision blepharoplasty by severity of medial blepharochalasia. A, Excision up to the medial limbus was performed if there was no medial blepharochalasia. B, Excision up to the medial epicanthus was performed if there was mild medial blepharochalasia. C, Excision with triangular back cut was performed if there was moderate-to-severe medial blepharochalasia.

Operative Technique

The procedure was performed under local anesthesia using 2% lidocaine with 1:100 000 epinephrine. Subsequently, the surgeon waited at least 7 minutes to allow the operative field to be infiltrated and hemostatic effect to appear. A No. 15 blade was used to excise the skin and subcutaneous tissue along the design that had already been drawn. During this step, the excision made with the surgical blade slanted downward while maintaining a 30° angle between the surgical blade and the skin surface to prevent cutting the hair root below the eyebrow. When making the skin excision in the lower excision line, the surgical blade was slanted in the same direction. After removing the skin, a part of the orbicularis oculi muscle located 3 to 4 mm medially was also excised (Figures 2 and 3). After using 5 to 0 vicryl to suture the muscle first, along the 8 to 10 vertical lines that were already marked, the subcutaneous tissue was sutured. Subsequently, 6 to 0 ethilon was used to perform repair the interrupted suture (Figure 4). In cases of excision with the addition of a back cut, 10 units of botulinum toxin were injected into the corrugator muscle. Postoperatively, an ice pack was applied for 3 days, and the stitches were removed after 7 days.

Figure 2.

Sagittal view of surgical method. A, Skin excision. B, Orbicularis oculi muscle excision. C, Excision of the orbicularis oculi muscle should be outside 3 cm from the midline of the entire face to preservation supratrochlear nerve and supraorbital nerve. D, Orbicularis oculi muscle closure. E, Skin closure.

Figure 3.

Sagittal view of surgical method. A, Skin and orbicularis oculi muscle excision. B, Orbicularis oculi muscle closure. C, Skin closure.

Figure 4.

Photographs of a 68-year-old woman with severe medial blepharochalasia. A, Preoperative photo. B, Preoperative design with triangular back cut. C, Immediate postoperative photo. D, Four-week postoperative view.

Results

In total, 120 infrabrow excision blepharoplasties were performed on 60 women. Patients ranged in age from 39 to 79 years. The follow-up period was 6 months to 1 year, with an average of 9 months. The mean operation time was 55 minutes. All patients were satisfied with the result, and no complications related to sensory abnormalities and visible scars were observed.

Excisions that extended to the medial limbus and medial epicanthus were made on 21 and 15 patients, respectively, whereas excisions with a triangular back cut were used in 24 patients. Patients were informed preoperatively of the possibility of slight flattening of the brows and possible necessity of makeup-assisted shaping of the brow in selected cases. Interestingly, no patient complained or was concerned of any change in the brow position or shape.

Discussion

Infrabrow excision blepharoplasty is common in Japan and Korea in patients with blepharochalasis, although the optimal method has been debated by surgeons. Described in 1954 as an option for blepharochalasis in Caucasian patients, this method has been widely accepted for use among Asians in recent years.⁵ According to our knowledge, Sugimoto (1991) documented the use of infrabrow excision blepharoplasty in Asian patients for the first time.⁶

Because previous upper eyelid surgeries removed significant amounts of thin skin above the double-eyelid crease, the thick skin above the eyelid is placed on top of the eyelid, which gives a thick and natural-looking double-eyelid crease. Because of these reasons, the skin remaining on the upper eyelid can be excised and removed from the thick portion below the eyebrows, which can make the upper eyelid appear more natural looking.^7,8

Asian women may have their eyebrows tattooed because their natural eyebrows are not the desired location or shape. Therefore, many Asian women who require rejuvenating eyelid surgery are potential candidates for infrabrow excision blepharoplasty. On the other hand, as a periorbital rejuvenating procedure, the more well-known suprabrow excision procedure may produce the “surprised look” in many Asian women who already tend to have higher than average eyebrows.^9,10

Skin sagging tends to be more severe in the lateral aspect than in the medial aspect. Eyebrow ptosis also tends to be more severe in the lateral aspect, whereas there is relatively less skin sagging in the medial aspect. Depending on the degree of medial skin sagging, the structures were designed differently as described below. In cases of mild medial skin sagging, because the width of the medial skin excision was small, the difference between the length of the lower and upper lines was small. In cases of moderate medial skin sagging, because of the difference between the length of the lower and upper lines, the excision line was extended more medially to overcome this difference.¹⁰ In cases of severe medial skin sagging, wrinkles in the medial skin and even on the nose may occur. In such cases, a back cut was designed to prevent skin wrinkling caused by the difference between the length of the lower and upper lines. When designing the back cut, the triangle must not be too wide to ensure that there are no hypertrophic scars or bands in that area due to skin tension.¹¹

Caution should be taken to prevent injuries on the supraorbital and supratrochlear nerves located medially to the excision site. Because of this, it is better not to excise the inner portion when removing the orbicularis oculi muscle. The authors did not excise the orbicularis oculi muscle within 3 cm from the midline of the entire face, and there were no cases of nerve injury.¹²