RESULTS
From the medical records of 123 patients (246 eyelids), a total of 93 patients (186 eyelids) with moderate-to-severe bilateral dermatochalasis between May 2012 and July 2017 were selected. The subjects included 19 men and 74 women (ratio of male to female, approximately 1:4). The mean age of the patients was 53.9 years, with a range of 21–75 years. The total mean followup period was 2 years (range, 0.5–3.5 years). The mean skin excision height and width were 9.75 mm (range, 5–16 mm) and 58.51 mm (range, 42–75 mm), respectively. All patients who underwent surgery recovered without major complications; one patient underwent a minor revision. Postoperative redness and swelling disappeared quickly, and cases with dog ear formation were resolved using triamcinolone injection. After the sutures were removed 4–5 days postoperatively, the patients were able to continue with their daily lives by applying simple eyebrow makeup or wearing sunglasses. After 3 months, the scars became inconspicuous due to regrowth of the eyebrows. All patients also reported high levels of satisfaction with eyelid function, since the patients experienced ease in eye opening and improvements in their visual fields. Additional details of postoperative changes after infrabrow blepharoplasty using parallel excision are shown in
Table 1.
Although some patients reported transient numbness around the medial eyebrow, this improved gradually and was followed by sensations of tingling or itching. These sensations gradually disappeared approximately 1 month after surgery for most patients, but took 3 months for three patients.
The objective Strasser grading system for the evaluation of surgical results was applied and the patients’ subjective impressions of their aesthetic appearance were collected at 6 months postoperatively. All patients had scores between 0 and 4 points (
Table 2), indicating good results. Additionally, 92.5% of the patients were satisfied with the cosmetic outcome and improvement in dermatochalasis after surgery, as evidenced by results rated excellent or good. Of the 15 patients whose results were rated fair or insufficient, only three rated their level of satisfaction as insufficient; these ratings were due to the formation of dog ears, which vanished with either one or three administrations of triamcinolone injection (1:50 dilution) with a month between injections.
Representative preoperative and postoperative photographs are shown in
Fig. 3.
DISCUSSION
We retrospectively reviewed a total of 93 patients (186 eyelids) with moderate-to-severe bilateral dermatochalasis who underwent parallel excision infrabrow blepharoplasty with manipulation of the orbicularis oculi muscle. The total mean follow-up period was 2 years (range, 0.5–3.5 years). The mean skin excision height and width were 9.75 mm (range, 5–16 mm) and 58.51 mm (range, 42–75 mm), respectively. All patients who underwent surgery recovered without major complications.
The eyes of Asian individuals tend to have small horizontal and vertical pupillary fissures with lateral puffiness and weak double folds [
12,
13]. In addition to the above features, 70% of patients have frontalis muscle compensation. The greater the ptosis of the eyelid, the stronger the action of the frontalis muscle to compensate. In Asians, another characteristic of the eyes is the presence of more pretarsal and suborbicularis fat than in Caucasians; thus, the distance between the eyebrows and eyelids is longer in Asians than in Caucasians, corresponding to a higher position of the eyebrow [
14-
17]. With aging, as the inferior projection of fat progresses, the distance between the eyelids and eyebrows increases further, resulting in marked blepharoptosis with dermatochalasis [
18,
19].
Previously, Lee and Law [
5] and Ichinose et al. [
2] excised only the skin layer while preserving the orbicularis oculi muscle, whereas Kim et al. [
3] performed
en bloc excision, including both the muscles and the skin. Although Sugamata and Yoshizawa [
9] performed muscle excision, this excision was only 1–2 mm deeper than the skin excision. Lee and Hwang [
7] divided the depressor muscle by splitting the orbicularis oculi muscle.
In our study, we excised the orbicularis oculi muscle more extensively in parallel than could be excised with an elliptical incision; as such, the medial and lateral vertical portions of the orbicularis oculi muscles were fully removed. This approach enabled (1) reduction of the depression, or downward-pulling, forces exerted by the orbicularis oculi muscles; (2) reduction of weight of the eyelid itself; and (3) the clearance of the obstacle posed by the tissue (orbicularis oculi muscle) while gliding superiorly, resulting in easier eye opening [
8].
In excision of the orbicularis oculi, the lower end of the muscle is easily moved upward using sutures in the upper ends of the muscle. The superficially-seated eyelid tissues (skin, orbicularis oculi muscle, and fat) on the same gliding plane are also easily moved upward. These characteristics make the lid structures tension-free during eye opening and closing, which spontaneously allows for dynamic elevation of the upper eyelid and restores the distance between the eyelid and eyebrow so that it resembles that seen at a younger age [
8,
9]. Postoperatively, the eyes have a more natural and youthful appearance, which is long-lasting. In addition, during manipulation of the orbicularis oculi muscle, the sagging contours of the submuscular, pretarsal, and septal fat are corrected by fat tucking that leads to immediate correction of sunken eyelids and translation of the vector in the superior direction [
10].
The depression force was also reduced through the shortening of the medial and lateral vertical parts of the orbicularis oculi muscle. Here, “shortening” refers to suturing the end of the mobile lower orbicularis oculi muscle to the end of the immobile upper orbicularis oculi muscle after performing a parallel excision about 1 cm in height at the medial and lateral vertical aspects of the orbicularis oculi, which presumably exert the greatest depression forces [
20-
23]. These methods cause an apparent reduction in the depression force exerted by the orbicularis oculi muscle, resulting in easier opening of the eyes and a lower probability of relapse as the orbicularis oculi muscle tone increases with aging [
23]. This is because in addition to the two muscles used for elevation (the frontalis and levator palpebrae), the muscles used for depression—the orbicularis oculi—are recruited during eye opening [
23].
In every case of upper eyelid surgery, such as the double fold operation, ptosis correction, or infrabrow blepharoplasty, we focused on the manipulation of the orbicularis oculi muscle, not only the excision of the skin. Three main advantages of the parallel design over the elliptical incision method are: reduction in frontalis compensation, correction of sunken eyelids, and improvement of lateral hooding.
In conventional infrabrow approaches, either a strip excision or an elliptical excision is utilized for the orbicularis oculi muscle [
5,
19,
24], or fixation to the periosteum, frontalis, or galea aponeurotica is performed after elliptical excision [
3,
4,
8,
10,
25]. These methods involve insufficient excision of the medial and lateral vertical portions of the orbicularis oculi muscle, causing greater medial and lateral depression forces. The central portion is excised more extensively than the peripheral portion, which results in unnatural upward stretching of the upper eyelid and the formation of a concave surface marked by a depression (
Fig. 4). In conventional infrabrow blepharoplasty cases, inadequate excision of the orbicularis oculi muscle results in incomplete correction of frontalis compensation that leads to a sunken eyelid and transverse forehead wrinkles. In such cases, unnecessary additional procedures, such as fat grafting and forehead lifting, are performed. The conventional methods also tend to be associated with a relapse of lateral hooding due to the persistent downward depression force exerted by the orbicularis oculi muscle.
This study had no major limitations. We observed only a few cases of transient numbness in the upper periorbital area. Abnormal sensations usually began a few weeks after surgery, but could occur as early as a few days after the procedure and gradually disappeared within a few months. Careful preservation of the supraorbital nerve and supratrochlear nerve branches reduces the development of these sensations. The surgeon should inform the patient that irritation is a good sign, as it is indicative of the restoration of normal sensation.
Parallel excision infrabrow blepharoplasty is a good option for middle-aged and older Asian women with moderate-to-severe dermatochalasis or frontalis compensation; however, it can also be used in male and young female Asians. This modality can also meet the expectations of patients with aesthetic concerns. For most patients, we now recommend parallel excision infrabrow blepharoplasty as a first choice, unless the patient rejects infrabrow scarring or eyebrow-to-eyelid height reduction.
The parallel excision method of infrabrow blepharoplasty is a reproducible, safe, and effective technique to yield more natural-and youthful-looking eyelids. Through manipulation of the orbicularis oculi muscle, this technique accomplishes a reduction in frontalis compensation, the resolution of sunken eyelids, and the correction of lateral hooding.