According to Arch Plast Surg 2020;47:171‑177, what is the recommended surgical design for a temporal subcutaneous sub‑brow lift in healthy adult Asian patients with mild‑to‑moderate brow ptosis and upper‑eyelid skin laxity?

Recommended Surgical Design for Temporal Subcutaneous Sub-Brow Lift

The recommended surgical design involves creating an elliptical excision below the eyebrow with dissection in the subcutaneous plane above the orbicularis oculi muscle, followed by fixation of the lower orbicularis muscle flap to the frontalis muscle using horizontal mattress sutures in three areas. 1

Incision Design and Tissue Excision

• Mark an elliptical area of skin for excision below the eyebrow, with average dimensions of approximately 55 mm × 8 mm, though this should be adjusted based on the degree of ptosis and skin laxity present 1
• The upper incision is made along the inferior margin of the eyebrow 2, 3
• The lower incision is positioned to achieve the desired amount of skin excision 4, 3

Dissection Technique

Upper Flap Creation

• From the upper skin incision, dissect cephalad in the subcutaneous plane just above the orbicularis oculi muscle until the frontalis muscle becomes visible 1
• This subcutaneous dissection preserves the natural gliding plane of the periorbita and maintains natural eyebrow movement 1

Lower Flap Creation

• Incise the orbicularis oculi muscle 5 mm cephalad to the distal (lower) skin incision, creating a 5-mm muscle stump 1
• From this muscle stump, dissect caudally in the plane between the orbicularis muscle and the orbital septum 1
• The dissection should extend vertically deep to the posterior fascia of the orbicularis oculi muscle 3

Muscle Fixation Technique

The critical step involves attaching the 5-mm orbicularis muscle stump from the lower flap to the exposed frontalis muscle using horizontal mattress sutures in three areas. 1 This frontalis sling technique provides:

• Long-lasting elevation without relying on periosteal fixation 1
• Preservation of the eyebrow's natural gliding plane 1
• Maintenance of natural eyebrow movement 1

Alternative Fixation Method

An alternative approach involves suturing the posterior fascia of the orbicularis oculi muscle in the inferior flap to the supraorbital rim periosteum at the margin of the upper flap, using three transverse 5-0 nylon sutures placed temporally to the supraorbital nerve 3. However, this periosteal fixation method may violate the natural gliding plane compared to the frontalis sling technique 1.

Additional Considerations for Asian Patients

• The redundant orbicularis oculi muscle should be excised while keeping the frontalis muscle intact 4
• In cases of puffy eyelids with orbital fat prominence, partial orbital fat removal can be performed through the infra-brow incision 4
• The lateral border of the orbicularis oculi muscle may be detached from subcutaneous tissue, splayed out, and sutured upward and inward to the periosteum for additional lateral support 2

Critical Anatomical Limitations

Be aware that in the lateral third of the brow where the frontalis muscle does not exist, slight lowering may occur despite proper technique. 1 This represents an inherent limitation of the frontalis sling approach in the temporal region.

Wound Closure and Scar Management

• Close the skin incision in layers after completing muscle fixation 1
• The incision typically heals well without keloid or hypertrophic scarring when proper technique is employed 1
• Postoperative scars are inconspicuous in the vast majority of cases (>99%) when meticulous closure is performed 4, 2

Common Pitfalls to Avoid

• Avoid periosteal fixation if preservation of natural eyebrow gliding is a priority, as this can restrict natural movement 1
• Do not extend dissection beyond the superficial peri-orbital plane, as deeper dissection can allow orbital fat to adhere and form fibrotic bands extending deep into the orbit 5
• Exercise extreme caution with fat handling if any orbital fat is manipulated, as inadvertent entrapment or adhesion can produce restrictive strabismus—a serious complication that is difficult to correct surgically 6, 5
• Avoid injury to the supraorbital nerve by keeping dissection temporal to the nerve and maintaining awareness of its location 2, 3

Expected Outcomes

• Improvement in orbital laxity and upper eyelid hooding in >95% of cases 1
• Patient satisfaction rates of approximately 95% at 6-month follow-up 4, 2
• No significant complications such as superior orbital nerve entrapment or sensory problems when proper technique is followed 1
• Transient forehead numbness may occur in a small percentage of cases but typically resolves 4, 2