Table of Contents
This article tries to answer the question about “What is the single most appropriate procedure for each patient among Upper Blepharoplasty, Infra-brow Lift, and Forehead Lift?”
This article has been published in the Aesthetic Plastic Surgery journal, one of the world-renowned publications in this field. The idea of this study has been written in a more readable format in my previous article.
Introduction
In cosmetic surgery, one of the most common requests in middle-aged patients is to enhance the appearance of the eyelids. Even without mentioning the various statistical results, all plastic surgeons worldwide experience periorbital rejuvenation as one of the most popular procedures in their daily practices. Because there are sayings that the eyes are paramount to beauty or a window to one’s soul, middle-aged patients regard upper lid surgery as the first option for achieving a youthful appearance. Undoubtedly, periorbital surgery resulted in the most noticeable changes in all facial rejuvenation procedures.
There are three common treatment strategies for upper eyelid rejuvenation:
- upper blepharoplasty (UB)
- infra-brow lift (IL)
- forehead lift (FL)
While upper blepharoplasty is a well-known procedure among patients, getting the best results can be quite difficult, especially in Asian individuals. This is because they have a more narrow range of acceptable double eyelid crease, compared to Caucasians. Even after the removal of excessive skin laxity that causes hooded eyelids, many middle-aged patients expect the double-eyelid crease to appear subtle, delicate, and symmetrical, similar to how it was in their youth. Removing a substantial amount of eyelid skin can effectively address laxity; however, it can potentially lead to heavy angry-looking folds. Choi et al. reported that removing a considerable portion of thin pretarsal skin can lead to the formation of a chubby crease. This is due to the fact that the thickness of the skin and subcutaneous fat increases as it moves cephalad. Conversely, if small amounts are excised to prevent these problems, patients often complain of residual hooding of their upper eyelids.
While the infra-brow lift or subbrow excision may be an excellent choice to prevent these dilemmas, this procedure seems to be more suitable for high-positioned brows.
A forehead lift can address the sagging of the upper eyelids and treat glabellar wrinkles. However, the improvement in skin laxity achieved through a forehead lift may be somewhat limited compared to an upper blepharoplasty or infra-brow lift.
This study aimed to provide a comprehensive guide in selecting the most appropriate procedure among the three commonly performed surgical options: upper blepharoplasty, infra-brow lift, and forehead lift.
Methods
A retrospective cohort study of 518 patients, consisting of 46 males and 472 females, with an average age of 56 years (range, 40–78 years) was selected to participate in this study. The data was collected from October 2020 to May 2022. Among these individuals, 310 patients underwent upper blepharoplasty, 144 received an infra-brow lift, and 64 patients elected to have a forehead lift; each procedure was tailored to their unique needs and goals.
Upper blepharoplasty was performed, involving the removal of skin and partial excision of the orbicularis oculi muscle. In some cases, ptosis surgery with levator advancement technique was done if necessary. To create a double-crease, suture fixation using the SAJT(septoaponeurosis junctional thickening) method was used for all cases. The SAJT structure is a dense tissue that lies in between the inner and outer layers of the caudal orbital septum. Kim et al. recommended incorporating this structure during suture fixation for double eyelid crease; as SAJT can transmit the action of levator aponeurosis to the upper lid margin thus creating a dynamic and natural fold crease.
For the infra-brow lift, the caudal orbicularis oculi muscle was fixed in the upward direction, known as the frontalis sling technique, to achieve long-lasting effects.
The forehead lift was held with an endoscope, and the Endotine® (MicroAire, Charlottesville, Virginia, USA) was used for fixation. The endoscopic forehead lift was conducted following a technique that closely resembled the approach described by Nahai. Open forehead lift was not considered in this study due to the author’s personal philosophy, which will be discussed later.
Nk Park carried out all the surgical procedures and photographic documentation. To ensure accurate capturing of each patient’s progress, a Nikon 7200 camera with an AF-S Nikkor 58 mm lens was used with camera settings of manual mode, F10 aperture, and a shutter speed of 1/80 s to ensure consistency and precision. The distance between patients and the camera was set to a 1.5-meter and photographs were captured with both eyes open and closed. These comprehensive pre- and postoperative images were subjected to analyze the changes in lid-brow distance. Notably, patients who habitually engaged their frontalis muscle (commonly known as brow compensation) to compensate for upper lid redundancy exhibited considerable variations in the lid-brow distance when observed in preoperative eyes-open and eyes-closed photographs. All patients agreed to the use and analyses of their data. The written consent was provided, and the study was conducted in accordance with the guidelines set forth in the Declaration of Helsinki.
Results
The findings of this study firmly corroborate the existing research that skin-excising procedures, such as upper blepharoplasty or infra-brow lift, can lead to a discernible reduction in the lid-brow distance. This phenomenon is primarily attributed to the inevitable loss of frontalis muscle activity. Our research revealed that these changes in the lid-brow distance showed relatively linear relationships with preoperative changes in brow height with eyes open and closed.
However, surgical planning is a complex task as the degree of compensatory brow movement varies significantly among individuals. Furthermore, the study found that changes in the lid-brow distance before and after surgery do not always correlate with the amount of tissue excised. Instead, a myriad of interdependent factors, such as the extent of excision, preoperative brow compensation, postoperative residual brow compensation, and remnant laxity of the upper lid, collectively influence the final outcome. Therefore, these intricacies made predicting postoperative brow height more challenging in periorbital surgery.
Discussion
The initial purpose of this study was to predict brow positions following eyelid surgery through a retrospective analysis of patient data and photographic assessment. The excision amount and degree of brow compensation were documented, and all photographs were taken under consistent conditions, including the same light and distance, to ensure accuracy and consistency. However, it was found that postoperative brow height was influenced by multiple factors beyond patient habits or excision amounts. Consequently, these results were challenging to establish specific formulas for predicting brow levels after surgery, contrary to the initial aim. Many factors appear to be connected to the final positions of the brows, including the extent of tissue excision, preoperative brow compensation, postoperative residual brow compensation, and remaining laxity of the upper lid. However, due to the study’s retrospective cohort design, these multifaceted factors were not entirely gathered. As a hope, the initial purpose of the study could potentially be achieved in the future through more meticulous data collection and a deliberate study design.
One of the most frequent errors made by plastic surgeons is the treatment of pseudodermatochalasis with a blepharoplasty alone, which results in a sad and tired appearance. The inherent difference in upper lid skin thickness also contributes to this unfavorable and poor outcome. Therefore, it is essential to consider factors beyond double eyelid creases or skin laxity when deciding whether to perform blepharoplasty. Evaluating the entire face and considering the relationships between the eyes, brows, and forehead is recommended. Assessing the ratio of the ‘lid-brow distance’ to ‘brow-hairline distance’ and noting the use of compensatory frontalis action is crucial.
Although the study failed in its initial purpose, based on the analysis of 518 cases and by rating the lid-brow distance into three categories, the author could suggest treatment algorithms for eyelid rejuvenation in a more predictable and satisfying manner.
This recommendation can be clearly understood by analyzing case examples below.
How to analyze the patient
1) first step
The algorithm suggests evaluating the ratio of the lid-brow distance to the brow-hairline distance as the first step. The distance was mentally measured by the surgeon’s eyes; from the medial canthus to the superior margin of the eyebrow, and to the pretrichial hairline. When analyzing the lid-brow distance, patients’ habit of brow compensation was also included. The ratio was then subsequently categorized as Short, Average, or Long. Choi et al. suggested that the optimal brow position is in the lower one-third of the vertical line drawn from the pupil to the hairline. However, since their study focused on a younger age group, it was somewhat impractical to apply their findings directly to our research. Consequently, in our study, we utilized the 1:2 ratio as a flexible reference guide.
Based on my experience, the majority of patients in the Short ratio group, who were primarily planned for a forehead lift, showed a lid-brow distance of 2.4 ~ 2.5cm, although the study did not collect comprehensive objective measurements for all participants. However, it is important to emphasize that analyzing facial harmony should prioritize facial proportion indices and ratios between the lid, brow, and hairline, rather than focusing solely on individual metric data. The measurements themselves should not be rigidly applied as a “cookbook” for different races and cultural backgrounds. Instead, it is crucial to consider racial and cultural aesthetics when assessing lid-brow distance. Gender-related differences primarily appear in the upper third of the face, and the male brow is typically positioned lower compared to females. And it is also important to recognize that individual preferences for femineity or masculinity can vary, and should be taken into account on a case-by-case basis.
2) second step
In the second step, patients were instructed to open and close their eyes repeatedly, and the presence of habitual brow compensation was assessed. If there was a significant change in brow height during the eye-opening (as shown in the first figure), it suggested that surgical removal of upper lid redundancy might lead to a lowering of the eyebrows after surgery. To predict the post-operative brow level, patients were asked to close their eyes while the physician gently massaged the patient’s eyebrow to return it to its relaxed position. Closing the eyes helped diminish the influence of frontalis muscle activity, and manual massages effectively alleviated the impact of chronic forehead muscle strain on brow height. Omitting these massages could potentially result in an inaccurate assessment of brow compensation, particularly in patients who have relied on their frontalis muscles for an extended period. The history of Botox injections should also be considered. During the consultation, simulating a double eyelid crease can also help to estimate the presence of frontalis muscle activity.
3) third step
In the last step, it is essential to discuss the patient’s tolerance for the potential risk of exacerbating glabellar wrinkles after surgery as well as their desire for a double eyelid crease.
Informed by these guides, the algorithm suggests the most suitable procedure. This systematic approach facilitates precise and well-organized surgical planning for upper eyelids, eliminating any arbitrary surgical decisions.
Regarding the surgical technique, I believe that forehead lift can be done with or without an endoscope in the suggested algorithm, if the glabellar muscles can be ablated enough to make the surgical results. However, the author only included an endoscopic forehead lift approach in the study. Since experiencing over 200 cases of forehead reduction surgery by using pretrichial incisions which were well described by Guyuron, the author experienced that most of the vellus hair did not grow, resulting in a bizarre appearance. Even though scar perceptibility can be minimized with fine wound closure, this absence of vellus hair makes hallmarks of an operated look, so the author discarded hairline incision brow lift or forehead lift with simultaneous hairline reduction procedures in his practices. But even though the study only included the case of endoscopic brow lift, the algorithm may work for open brow lift too, and that’s why we described the procedure as a forehead lift without using the ‘endoscope’.
Classify patients into three category
1) Short ratio
For patients who have a short lid-brow distance with frontalis compensation, a forehead lift should be recommended as the primary option. This procedure is crucial for achieving a balanced and harmonious result, especially for individuals with low-set eyebrows. Performing eyelid surgeries without combining forehead lifts can lead to appearance issues in this particular group of patients(note the first figure above) . If brow compensation is minimal, it is important to assess glabellar wrinkles and plan for their treatment.
In such cases, addressing glabellar wrinkles can be a significant aspect of the overall treatment plan to achieve the desired aesthetic outcome. Although the algorithm suggests upper blepharoplasty or infra-brow lift, a simultaneous forehead lift can enhance the overall appearance around the eyes and prevent an angry-looking outcome in patients with a short lid-brow distance.
2) Average ratio
Patients with an average ratio pose a challenge as there is no clear-cut optimal surgery among the three available choices. In addition, various factors related to each patient’s specific condition must be carefully considered. They must have a clear understanding of how surgery may affect their appearance, including what will be corrected and what may be worsened. If the main goal of surgery is to create double eyelids or make the eyes appear larger, upper blepharoplasty should be considered as the initial approach.
However, if excess upper lid skin is the primary concern, infra-brow lift should be considered as the first option.
It is important to note that there may still be the possibility of low-set eyebrows even if they do not exhibit brow compensation.
It is worth emphasizing that many doctors may encounter frustration when patients express dissatisfaction and complain about low-set eyebrows and worsened glabellar wrinkles, even though these potential outcomes were thoroughly discussed during consultation. As described by Knize, elderly patients often rely on the frontalis muscle to lift their brows and improve their field of vision. By addressing skin laxity through infra-brow excision or upper blepharoplasty, the stimulus for frontalis muscle action is reduced, leading to true brow ptosis. Despite doctors’ efforts to inform and educate patients about possible results and associated risks, individual perceptions and expectations can vary, leading to instances where patients may not fully comprehend or recall the information provided. Therefore, patients should be further examined with case photographs, as verbal explanations alone may not suffice. Additionally, if the amount of brow compensation is significantly greater than the average, a forehead lift should be the primary recommendation, even if the patient desires double eyelid folds.
3) Long ratio
Estimating the extent of glabellar wrinkle exacerbation becomes crucial when patients exhibit a significant lid-brow distance and engage the frontalis muscle.
In the above case, the patient displayed brow compensation, but her main concern was her drooping eyelids, and she was willing to accept negative changes in the glabellar area. Therefore, upper blepharoplasty with ptosis correction was prioritized over other eyelid surgeries. Interestingly, in the author’s observations, not all the patients exhibited brow compensation as noted in previous case examples. However, examining patients with open and closed eyes while their brows are relaxed can help predict the amount of brow descent after eyelid surgery.
The main limitation of this paper lies in the lack of quantitative data. While all clinical photography was meticulously carried out under standardized conditions by the author, the study’s reliability and reproducibility could have been enhanced by recording objective data, such as lid-brow distance, excised skin amount, the degree of frontalis compensation, and brow descent amount. Nevertheless, since beauty is inherently immeasurable and subject to vary across cultural and social backgrounds, the author contends that cultivating an artistic eye holds greater significance than numerical data. That’s why this research provides flexibility for readers to determine Short, Average, and Long ratios, recognizing that the ideal range can be subjective and may be different across races and cultures. For instance, Korean women often prefer slightly wider distances than other Southeast Asians or Caucasians. However, with a keen eye and thorough examination, doctors can assess the aesthetic ratio for each individual patient, even if there is no study of the ideal proportion for their specific population.
Conclusions
To achieve successful outcomes in periorbital surgery, a comprehensive aesthetic plan, and exceptional technical proficiency are paramount. It is of utmost importance to exercise extreme caution and prudence when contemplating the prospect of performing upper blepharoplasty in individuals who may not possess the ideal candidacy, as the delicate and intricate nature of the eyelid area renders it remarkably unforgiving. The primary objective of this meticulously conducted study was to provide judicious recommendations aimed at averting outcomes that elicit feelings of anger or fatigue-look after periorbital rejuvenation procedures administered to middle-aged patients. Although the definition of short, average, and long lid-brow distance needs some modification for each subjective, I strongly believe that implementing this algorithm can effectively reduce patient dissatisfaction.