2 Infrabrow Excision Techniques For Aged Asian Eyelids

Eyelid rejuvenation is a cornerstone of facial aesthetic surgery, especially for Asian patients, where the unique anatomical characteristics demand precision and innovation. Among the various procedures available, septo-myocutaneous flap repositioning and parallel excision infrabrow blepharoplasty stand out as transformative techniques. This article, based on studies by Lee et al. (Arch Plast Surg. 2020) and Park & Lim (Arch Aesthetic Plast Surg. 2023), breaks down their methods, applications, and benefits, equipping surgeons with insights for improved outcomes.

Understanding the Infrabrow Anatomy

To perform infrabrow excision procedures effectively, a thorough understanding of the anatomy is essential.

Eyebrow and Skin Layers:
- The infrabrow region includes the lower eyebrow margin and the underlying skin. Hair follicles in the eyebrow require careful handling to minimize scarring.
Orbicularis Oculi Muscle (OOM):
- The OOM is a circular muscle crucial for eyelid closure. It has superficial and deep layers. Infrabrow procedures often manipulate this muscle to address lateral hooding, sagging, or puffiness.
Orbital Septum:
- A thin fibrous layer separating the orbital fat from the eyelid, it often becomes lax with age, leading to fat protrusion and puffy eyelids. Tightening or repositioning this layer is central to advanced techniques.
Supraorbital Rim and Periosteum:
- The supraorbital rim provides structural anchoring points during flap repositioning. Care is taken to avoid injury to supraorbital and supratrochlear nerve branches.
Fat Pads:
- Retro-orbicularis oculi fat (ROOF) and orbital fat play roles in both the youthful contour and aging appearance of the eyelid. Techniques that reposition or remove fat can significantly enhance outcomes.

This layered understanding allows for a tailored approach based on patient-specific needs and avoid complications such as nerve injury or inadequate correction.

Technique 1: Septo-Myocutaneous Flap Repositioning

This innovative method addresses the aging eyelid by repositioning a flap that includes the orbicularis oculi muscle (OOM) and orbital septum. By correcting structural laxity, it tackles puffy and sunken eyelids simultaneously. This method addresses key concerns with traditional infrabrow surgeries, such as recurrence, insufficient structural correction, and over-reliance on skin excision alone.

Park & Lim (2023) highlighted issues like unpredictable recurrence rates and insufficient correction of orbital septum laxity in traditional methods. By incorporating orbital septum anchoring, this technique achieves superior long-term results compared to simple skin excision or OOM manipulation alone.

Technique Overview

Design and Incision:
- Mark the upper excision line along the lower eyebrow margin.
- Determine the lower incision based on the required skin excision.
- Use a beveled incision to minimize damage to hair follicles.
Dissection:
- Remove skin and incise the OOM approximately 2 mm above the lower margin.
- Dissect preseptal layers to expose the orbital septum.
Flap Repositioning:
- Anchor the septo-myocutaneous flap to the supraorbital rim periosteum using absorbable sutures.
- Overlap OOM and subcutaneous layers for additional support.
Closure:
- Suture the skin and muscle layers separately for optimal tension and aesthetics.

Patient Outcomes

Patients undergoing this technique reported:

Decreased Recurrence: A lower likelihood of requiring revision surgery due to stable anchoring of the orbital septum.
Natural Results: Improved correction of puffiness and hollowness, with maintained eyebrow positioning.
Quick Recovery: Minimal swelling and downtime, enabling patients to return to normal activities sooner.

Indications

Patients with loose, sagging skin and mild sunken or puffy eyelids due to orbital fat laxity.
Ideal for moderate dermatochalasis and mild volume loss.

Benefits

Addresses the underlying cause of puffiness and hollowing.
Provides durable results with minimal recurrence rates.
Natural postoperative outcomes with reduced risk of complications.

Drawbacks

Limited correction of severe volume deficits compared to fat grafting.
Technically demanding and may require extended operative time.

Technique 2: Parallel Excision Infrabrow Blepharoplasty

The parallel excision method refines traditional elliptical excision by enabling more extensive manipulation of the OOM. It has been shown to reduce recurrence rates, improve lateral hooding correction, and address concerns about unnatural or concave postoperative eyelid contours. Lee et al. (2020) noted that traditional elliptical excision methods often fail to address lateral hooding effectively and may lead to unnatural stretching of the central eyelid, resulting in a concave appearance. The parallel excision method overcomes these issues by enabling better OOM manipulation and comprehensive muscle excision.

Technique Overview

Design and Marking:
- Create two parallel incision lines along the inferior eyebrow margin.
- Design medial and lateral tapered areas for seamless blending with natural contours.
Excision:
- Remove the skin, subcutaneous tissue, and OOM en bloc.
- Extend muscle excision medially (5–6 mm) and laterally (7–8 mm) for improved contouring.
Muscle Manipulation:
- Suture the upper and lower OOM flaps to correct sunken eyelids and lateral hooding.
Closure:
- Employ fine sutures for muscle and skin closure, with postoperative scar concealment aided by hair regrowth.

Patient Outcomes

Patients treated with this technique experienced:

High Satisfaction: Over 90% of patients rated their results as excellent or good using the Strasser grading system.
Improved Functionality: Enhanced visual field and reduced need for frontalis muscle compensation.
Long-Lasting Aesthetics: Reduced lateral hooding and a more youthful, symmetrical brow position.

Indications

Patients with moderate-to-severe dermatochalasis and lateral hooding.
Individuals with strong frontalis muscle compensation.

Benefits

Reduces frontalis muscle compensation, improving brow symmetry and minimizing wrinkles.
Simultaneously addresses sunken eyelids and lateral hooding.
Offers long-lasting, natural-looking results.

Drawbacks

Risk of transient numbness near the medial eyebrow due to nerve proximity.
Scarring may concern some patients, although it diminishes with time.

Comparative Analysis

Feature	Septo-Myocutaneous Flap Repositioning	Parallel Excision Infrabrow Blepharoplasty
Complexity	High	Moderate
Indication	Mild puffiness, sunken eyelids	Lateral hooding, frontalis compensation
Recurrence	Low	Low
Downtime	Minimal	Minimal
Scarring	Discreet, along the brow line	Concealed under eyebrow hair
Unique Advantage	Corrects structural causes	Enhanced natural contour and symmetry
Limitations	Limited volume correction	Risk of transient numbness

Considerations for Infrabrow Surgeries

Performing infrabrow surgeries requires a combination of anatomical knowledge, technical expertise, and patient-centered planning. Below are key considerations specific to these procedures:

Patient Assessment: Evaluate the degree of dermatochalasis, brow positioning, and underlying anatomical characteristics such as levator function, fat distribution, and skin laxity. Consider factors like eyebrow symmetry and patient concerns about scarring.
Anatomy Awareness: A detailed understanding of the infrabrow region, including the orbicularis oculi muscle, orbital septum, and supraorbital rim, is essential. This knowledge ensures precise dissection and flap manipulation while minimizing nerve injury risks.
Technique Selection: Choose the surgical method based on the patient’s specific needs:
- Opt for septo-myocutaneous flap repositioning in cases of mild puffiness or hollowness with a need for structural correction.
- Use parallel excision for patients with significant lateral hooding, frontalis muscle compensation, or moderate-to-severe dermatochalasis.
Scar Management: Carefully design incisions to blend with natural eyebrow contours and consider postoperative scar care. Both techniques minimize visible scarring, but patients should be informed of realistic outcomes.
Postoperative Follow-Up: Monitor for complications like numbness, asymmetry, or recurrence of symptoms. Provide patients with detailed aftercare instructions to ensure optimal healing and scar maturation.

By addressing these considerations, surgeons can achieve precise, aesthetically pleasing outcomes while maintaining the functional integrity of the eyelid and brow area. Conclusion

Both septo-myocutaneous flap repositioning and parallel excision infrabrow blepharoplasty offer tailored solutions for rejuvenating aging eyelids in Asian patients. While the former excels in addressing structural issues, the latter shines in refining aesthetic contours. Surgeons should choose the technique based on individual patient needs, ensuring both functionality and aesthetic harmony.

Reference:

Lee YJ, Kim S, Lee J, Chung JG, Jun YJ. Parallel-excision infrabrow blepharoplasty with extensive excision of the orbicularis oculi muscle in an Asian population. Arch Plast Surg. 2020 Mar;47(2):171-177. doi: 10.5999/aps.2019.01102. Epub 2020 Mar 15. PMID: 32203995; PMCID: PMC7093278.
Park, Jong & Lim, Nam. (2023). Infrabrow excision with septo-myocutaneous flap repositioning in aged eyelids in Asians. Archives of Aesthetic Plastic Surgery. 29. 123-126. 10.14730/aaps.2022.00521.

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2 Infrabrow Excision Techniques For Aged Asian Eyelids

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