Incision below the brow, does the cutting method change the outcome? Choosing based on how the lateral canthus is covered

Incision below the brow has several cutting methods: the basic technique of removing skin in an oval shape, refinements to lift the lateral canthus side, and methods that also adjust the muscle[1][2]. With the oval cutting method, unnatural wrinkles may appear at the lateral canthus, and the stronger the lateral canthus coverage, the more the difference in cutting method affects the outcome[2]. However, if the eyebrow or eyelid itself is drooping, the combination of surgical techniques is a prior consideration to the cutting method[3][4].

What types of cutting methods are there for incision below the brow?

Incision below the brow is a method often used for rejuvenation of the upper eyelid in Asian people, and there are also several types of cutting methods[1]. These include the method of removing skin in an oval shape, methods that expand the cutting range toward the lateral canthus or upward, and methods that re-anchor the muscle that closes the eyelid (orbicularis oculi) to the periosteum or other structures[1].

As age progresses and lateral canthus coverage becomes stronger, the general method of cutting along the double eyelid line becomes difficult to refine without cutting all the way to the lateral canthus[1]. Incision below the brow is characterized by the ability to address this lateral canthus sagging beneath the brow[1].

What is the difference between the oval cutting method and refined methods?

Differences are most apparent in the wrinkles at the lateral canthus and the remaining coverage. It has been pointed out that the basic oval design has the drawback of tending to create unnatural wrinkles at the lateral canthus[2].

To address this, a refinement has been reported that lifts the skin and muscle on the lateral canthus side diagonally upward and inward[2]. In a report of 41 people who were at least 6 months post-procedure using this method, the subjects had sufficient eyelid-opening strength (muscle movement exceeding 10 mm)[2].

With a method that cuts skin parallel and removes muscle more broadly, 93 people (186 eyelids) were followed for an average of 2 years and recovered without major complications[1]. The average height of the removed skin was 9.75 mm[1]. Both are retrospective studies and do not directly compare methods, so superiority has not yet been clearly established[1][2].

How does incision below the brow differ compared to cutting along the double eyelid line?

Incision below the brow is a method that better preserves the natural transition in skin thickness. Since the upper eyelid skin is thinnest near the lash line and becomes thicker toward the brow, removing skin along the double eyelid line disrupts this gradation and the area above the line tends to appear covered[5].

The method of cutting along the double eyelid line may take longer to recover because it involves working with eyelid structures, and creating a clean double eyelid also requires high technical skill[5]. On the other hand, when there is eyelid ptosis, fullness, or hollowing, the method of cutting along the double eyelid line is considered more suitable[6].

The incisional method is appropriate for skin sagging, thick eyelid skin, excess fat, and moderate or greater eyelid ptosis[7]. However, it is also noted that traditional double eyelid incision tends to leave sharp, deep double eyelids and noticeable scars[6].

If the eyebrow or eyelid is drooping, which surgery should you choose?

If the eyebrow itself is drooping, incision below the brow alone may not be sufficient[3]. Incision below the brow is a surgery to remove eyelid skin sagging; it does not raise the position of the eyebrow[3].

If there is eyebrow ptosis, at the same time as upper eyelid surgery, a brow-lifting procedure is performed, and typically the brow is lifted first[4]. In 100 people who underwent an endoscopic forehead lift, the distance between the eyebrow and pupil widened from 19.0 mm preoperatively to 24.0 mm at 6 months postoperatively[8].

If there is ptosis with weakened eyelid-opening strength, surgery for the ptosis must also be performed[4]. A method has been reported in which a brow-lift incision is used to perform a procedure that suspends the eyelid using the forehead muscle[9].

Guidelines for finding the right method for you

The guidelines are the location of sagging and the height of the eyebrow and eyelid.

Lateral canthus coverage is the primary concern, and eyebrow height is maintained: Incision below the brow is a candidate, and the refinement of lateral canthus lifting should also be confirmed[1][2]

There is also eyelid ptosis or fat fullness: Discussion shifts to double eyelid line incision or combined ptosis surgery[6][4]

The eyebrow itself is drooping, or the brow is naturally low: Brow-lifting surgery is considered first[3][4]

What should be confirmed during consultation?

Which cutting method is suitable cannot be determined without directly examining the eyelid-opening strength, eyebrow height, and lateral canthus coverage[2][3]. If sutured too tightly, the eyebrow may paradoxically drop[3].

A study examining 138 complaints about eyelid surgery found that the most common reason was asymmetry[10]. During consultation, ask how the amount of skin to be removed will be determined and how asymmetry or scar visibility will be addressed if it occurs[5].