Sub-brow lift: improving droopy eyelids through an incision below the brow

What is a sub-brow lift?

With age, the upper eyelid skin can stretch and hang down (dermatochalasis), sometimes appearing as lateral hooding, where loose skin covers the outer corner of the eye ^[2]. Conventional upper eyelid surgery has limits in correcting this outer hooding, and the sub-brow lift is used to make up for that ^[1].

According to one study, the surgeon makes an upper incision along the lower edge of the brow, sets the lower incision line according to how much skin needs to be removed, and then removes the skin and the muscle around the eye (orbicularis oculi muscle) between the two lines ^[1]. Because the incision sits below the brow rather than at the eyelid crease, a notable feature is that the existing double eyelid crease can be preserved ^[2].

Who is it considered for?

In older East Asian eyelids, the research recommends evaluating loose skin, droopy eyelids, and a sagging brow together ^[4]. When the outer brow and the outer eyelid sag noticeably, the literature notes that removing skin below the brow can offer additional functional and cosmetic benefits ^[4].

A study that performed this surgery on 64 East Asian women included people who met at least one of the criteria below, and excluded the most severe forms of eyelid skin sagging ^[3].

• Previous surgery to remove skin below the brow
• Wanting to keep a natural double eyelid crease as it is
• Multiple previous double eyelid procedures
• Sagging at the outer eyelid as the main concern
• Having or planning eyebrow tattooing
• Aged from the late 30s to the mid-50s

How is it different from double eyelid surgery?

Eyelid surgery in younger East Asian patients often focuses on creating a double eyelid crease, whereas in older eyelids the sagging skin, eyelid, and brow need to be evaluated together ^[4]. Because a sub-brow lift reduces skin below the brow, it can address outer hooding while preserving the original double eyelid crease ^[2].

One group of surgeons presented the sub-brow lift as an alternative that achieves the same goals as conventional upper eyelid surgery while looking less operated on ^[3]. They concluded that it can be a simple and satisfying alternative for selected patients ^[3].

In a systematic review of the literature from 2012 to 2018, there were 9 studies on incisional techniques for upper eyelid surgery and 1 study on a below-the-brow approach ^[5]. The review summarized that recent eye-area surgery is moving toward preserving soft-tissue volume, avoiding skin incisions or using hidden ones, and considering the position of the brow and midface together ^[5].

Results reported in studies

In the study of 64 East Asian women, the average follow-up was 13 months, and there were no complications related to scarring or changes in sensation around the eyes ^[3]. No cases were observed in which the brow became noticeably flattened or the double eyelid crease was misaligned enough to require additional surgery, and patient satisfaction was reported to be very high ^[3].

A study that tried to reduce recurrence by stitching the tissue layer behind the muscle to the bone lining below the brow followed 36 patients for an average of 27 months (8 months to 6 years), and the average age at surgery was 55 ^[1]. In all, 34 patients (94.4%) were satisfied with the results, and 2 (5.6%) reported a dimple at the fixation site, which went away after two local injection treatments ^[1].

In a study of 50 Western patients (average age 71.4), all 50 were satisfied with the results, and none reported problems at the incision site ^[2]. However, the doctors' assessment found that 2 patients had red scars at 3 months, which improved over 12 months of follow-up ^[2]. Because this study involved older Western patients, its results are hard to apply directly to East Asian patients.

Risks and limits of the evidence

A sub-brow lift uses an incision just below the brow, so it leaves a scar there. In the 64-patient study, there were no scar-related complications ^[3]. In other studies, red scars or a dimple at the fixation site were reported in some patients ^{[1, 2]}.

If you have a condition around the eyes, such as thyroid eye disease (Graves' orbitopathy), more needs to be checked before surgery. The literature explains that, when possible, the surgeon should operate after the disease has become inactive and stable, distinguish orbital fat that has pushed forward from the fat pad below the brow (subbrow fat pad), avoid missing a drooping tear gland, and remove skin conservatively ^[6].

The studies used for this article describe experience with a few dozen patients without a comparison group, and they include studies rated at level of evidence 4 ^{[1, 2]}. None of these sources include randomized studies comparing the sub-brow lift with other operations, so it cannot be said which method is better.

What to ask during your consultation

Whether a sub-brow lift suits you depends on whether the sagging comes from the eyelid skin and whether a sagging brow or a droopy eyelid is also present ^[4]. The shape and height of your brows, your existing double eyelid crease, and any previous surgery also need to be considered, and results vary from person to person. We recommend checking the following points during your appointment.

• Whether the sagging is mainly at the outer corner or across the whole eyelid
• Whether a sagging brow or a droopy eyelid is also present
• Whether you want to keep your existing double eyelid crease
• Where the scar below the brow will be and how it will heal
• Whether additional steps such as fixation to the bone lining are needed, and their risks