Subbrow blepharoplasty reveals a natural eyelid crease with appropriate skin removal

Subbrow blepharoplasty reveals a natural eyelid crease with appropriate skin removal | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Subbrow blepharoplasty reveals a natural eyelid crease with appropriate skin removal Shinjiro Kono, motohiro Kamei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7698791/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Studies have quantitatively assessed changes in skin laxity before and after subbrow blepharoplasty; however, none of the reports have mentioned the effects of double eyelid clarification and visual function improvement with this procedure. Therefore, in this study, we aimed to examine the method for revealing natural double eyelids in subbrow blepharoplasty. Methods In this study, we included 30 patients (60 eyelids) who underwent bilateral subbrow blepharoplasty. During surgery, after removing excess skin to reveal natural double eyelids, we measured the distance from the edge of the eyelid to the lower incision below the eyebrow at the lateral canthus and medial cornea. All cases were observed for at least 6 months postoperatively. Results Double eyelids were revealed in all 60 cases. The width from the eyelid margin to the lower incision line below the eyebrow, which is necessary for the exposure of double eyelids, was 21.72 ± 0.98 mm on the lateral canthus and 22.60 ± 1.32 mm on the medial cornea. In 36 cases followed up for 1 year, the distance from the pupil center to the upper eyelid showed significant improvement at all postoperative time points compared to preoperative levels. Conclusions Subbrow blepharoplasty reveals a natural eyelid crease with appropriate skin removal, aiding in visual function restoration and cosmetic improvement. subbrow blepharoplasty double eyelids natural eyelid crease upper eyelid skin laxity Figures Figure 1 Figure 2 Figure 3 Introduction Subbrow blepharoplasty is a surgical procedure for removing excess skin in cases of upper eyelid skin laxity. Although this surgery is mainly performed on Asians, it is also sometimes performed on Caucasians and African Americans [ 1 – 3 ]. This procedure is effective for patients who have thick, heavy excess skin because it significantly lifts the upper eyelids and results in a more refined appearance [ 2 – 16 ]. The procedure requires skill in designing the incision based on the individual characteristics of the patient's eyelid. Once the design is complete, the excess skin is removed, and the incision is carefully sutured to complete the procedure. Although the basic procedure is simple, modification techniques for a better appearance have been reported [ 4 – 6 , 8 , 10 , 11 , 12 , 14 , 16 ]. Previous reports have emphasized the rejuvenating effects and cosmetic benefits achieved by subbrow blepharoplasty [ 4 – 6 , 8 , 10 – 12 ]. Several studies have quantitatively assessed changes in skin laxity before and after surgery; however, none of the reports have mentioned the effects of double eyelid clarification and visual function improvement with this procedure [ 14 – 16 ]. In addition to restoring the original double eyelids that were hidden by excess skin, this procedure can make the extremely low crease line in patients with single eyelids more prominent, revealing natural-looking double eyelids; this transformation effectively rotates the eyelashes outward without adding an incision to the eyelid margin. The pupil and iris, partially hidden due to skin laxity, become visible, enhancing visibility along the line of sight and upward vision. Herein, we evaluated the extent of skin to be excised for double eyelid formation and the distance from the pupil center to the upper eyelid before and after subbrow blepharoplasty. Methods Study Design and Data Collection This study included 30 patients (60 eyelids) who underwent bilateral subbrow blepharoplasty by one of the authors (S.K.) at the Aichi Medical University Day Surgery Center for Ophthalmology between October 2022 and October 2024. All patients presented with upper eyelid skin laxity. Sixteen patients had single eyelids with skin laxity, and 14 patients had double eyelids with skin laxity. All cases were followed up for at least 6 months after surgery. Of these, 18 patients (36 eyelids) were followed up for 1 year after surgery. Patients with a history of other eyelid surgeries were excluded. Patients who did not want an alteration in their natural crease and those with concomitant ptosis were excluded. Data on age, sex, and surgical time were collected. Bilateral subbrow blepharoplasty surgery was performed on all patients. During surgery, after the excess skin was removed, we measured the distance from the eyelid margin to the lower incision line over the medial cornea and the lateral canthus. The distance from the pupil center to the upper eyelid and presence of double eyelid crease were evaluated before and after surgery. Surgery was considered successful if the skin overhanging the true lid margin was removed and double eyelid clarification was achieved at 6 months postoperatively. For the 18 patients (36 sides) followed up to 1 year postoperatively, the distance from the pupil center to the upper eyelid were measured at baseline, 3 months, 6 months, and 1 year postoperatively, and the degree of improvement was evaluated. To evaluate the improvement in this distance, we measured the Pseudo-Margin Reflex Distance (P-MRD) defined as the distance from the skin overhanging the true lid margin to the corneal light reflex preoperatively. Postoperatively, after excess skin was removed, we measured the Margin Reflex Distance 1 (MRD-1). These measurements were taken in the natural frontal view. Surgical Procedure We designed the area of skin to be excised below the eyebrow after confirming the presence of a hidden double eyelid (Fig. 1 a–c). Skin laxity is often more pronounced on the outer side, but it may also extend widely inward; therefore, we adjusted the design according to the patient's condition. With the patient in the supine position, we grasped the excess skin so that the eyelashes stood up and designed the excision area in a spindle shape below the eyebrow. After injection of 1% lidocaine with epinephrine (1:100000) into the upper eyelids, we incised the skin using a scalpel down to the layer of the orbicularis oculi muscle. We grasped the excess skin with toothed forceps and removed it using a radio frequency cutting device (Surgitron Dual EMC®, Ellman-Japan; Osaka Japan) (Fig. 1d). After achieving a thorough hemostasis in the skin excision area, it was temporarily sutured with 5-0 nylon monofilament (Bear medic, Tokyo, Japan) sutures and the appearance checked. Additional design and skin excision was performed as necessary. If the patient's natural crease became visible, upper eyelids were sufficiently lifted, and shape of the upper eyelid was satisfactory in the seated position, then temporary sutures were removed. Before final closure, the distance from the edge of the eyelid to the incision was measured at four points (over the right lateral canthus, medial cornea, left lateral canthus, and medial cornea) (Fig. 1e–g). The next step was to suture the subcutaneous tissue with 5-0 PDS® (Polydioxanone, Ethicon, Inc., Somerville, NJ, USA)(Fig 1h). This was followed by skin suturing with 6-0 Asflex® (polyvinylidene fluoride, Kono Seisakusho Co., Ltd., Tokyo, Japan) to complete the procedure (Fig. 1h–k) Statistical Analyses The patient’s age and other measurement results are expressed as the mean ± standard deviation. The distance from the pupil center to the upper eyelid was compared among the four measurement periods using Friedman’s test and Bonferroni correction because the measurement results did not show normal distribution. All statistical analyses were performed using SPSS ver. 26 software (IBM Corp., Armonk, NY, USA). Statistical significance was set at P < 0.050. Results All 60 cases were followed up for more than 6 months. The average surgical time was 43.7 ± 6.3 minutes. The width from the eyelid margin to the incision line below the eyebrow was 21.72 ± 0.98 mm over the lateral canthus and 22.60 ± 1.31 mm over the medial cornea, showing a significant difference (p < 0.05). Double eyelids were revealed immediately after the procedure and remained in their shape across all cases (Table 1). In patients with single eyelids with a deeply hidden eyelid line, a natural double eyelid line was exposed (Figs. 1, 2). In cases where a double eyelid line was present but obscured by skin laxity, the double eyelid line became clear (Fig. 3). The distance from the pupil center to the upper eyelid showed significant improvement at all postoperative time points compared to preoperative levels (Tables 2 and 3). Discussion To the best of our knowledge, this is the first study to evaluate the double eyelid formation and visual function improvement effects of subbrow blepharoplasty. All patients demonstrated natural double eyelids at 6 months postoperatively. Additionally, no postoperative scar-related issues were observed, and no patients exhibited recurrence of dermatochalasis at 1 year postoperatively, with eyelid elevation maintained. Our surgical procedure involved removing excess skin according to the design that would reveal natural double eyelids, followed by careful suturing of the subcutaneous tissue and epidermis to complete the procedure. If hemostasis is adequately achieved, the surgery is typically completed within the scheduled timeframe. Patients may express concerns about postoperative scars, but these scars are usually hidden beneath the eyebrows and can be easily concealed with eyeglass frames or eyebrow makeup. Scars typically fade or become barely noticeable within 3 to 6 months. Patients in this study reported no issues related to scars. In the surgical technique adopted in this study, no postoperative abnormal skin wrinkles, depressions, or scar contractures were observed. To avoid these problems, in addition to the reports on classical skin excision, improved surgical techniques combining skin excision with manipulation of the orbicularis oculi muscle, periorbital muscles, and retro-orbicularis oculi fat for primarily aesthetic purposes have been reported [3, 4, 8, 10–12, 14]. We believe that these aesthetic issues can be adequately avoided with precise skin incision planning and meticulous suturing, without complex manipulation of the orbicularis oculi muscle or orbital fat, provided there is no extreme asymmetry caused by trauma or facial nerve palsy, or pathological reduction of orbital fat. For minor asymmetry in eyebrow height, adjusting the amount of skin excised is sufficient. If absolutely necessary, adding a brow lift procedure can also be considered to resolve the issue [17]. In this study, by leaving approximately 20–26 mm of skin from the brow to the eyelid margin and removing excess skin, the eyelashes were properly rotated outward, revealing a natural double eyelid line. A previous study showed that at least 20 mm of skin was preserved between the lash line and inferior brow cilia to avoid lagophthalmos and maintain aesthetic proportions in Africans, which is similar to our measurements [2]. Since age and skin laxity do not always correlate, it is essential to adjust the surgical approach during the procedure based on individual skin tension and excess skin. Many patients had a large amount of skin laxity on the lateral side, resulting in a wider skin resection width on the lateral side compared to that in the medial side. During the intraoperative measurement, the appropriate amount of skin to be removed was determined by ensuring that the eyelashes properly rotate outward when the eyes were open. Some reports have indicated that additional incisions are required along the eyelid margin to create double eyelids, but in this study, no patients required incisions along the eyelid margin [3, 6, 9]. In the procedure mentioned herein, for patients who have single eyelids and do not want double eyelids, it is possible to minimize the amount of skin removed so that double eyelids are not revealed. However, to improve and preserve visual function, it is preferable to excise enough skin to reveal a double eyelid. Even people who did not have problems with single eyelids in their young age may become aware of vision difficulties arising from eyelashes rotating slightly inward as a result of skin laxity due to aging. In such cases, if excess skin is insufficiently removed, it may not be possible to notice an improvement in visual function if eyelash ptosis remains. Therefore, unless the patient strongly refuses, it is best to perform skin removal until double eyelid clarification is achieved. In cases where eyelid ptosis is present with dermatochalasis, the eyelid may droop postoperatively, causing the double eyelid to disappear or the double eyelid width to appear unnaturally wide. In such cases, removing excess skin may fail to raise the eyelid sufficiently and result in unnatural vertical wrinkles in the skin or skin tightening and wrinkles on the inner side. Therefore, it is preferable to add ptosis surgery before subbrow blepharoplasty in such patiens [18]. This study has some limitations that warrant discussion. First, we only included Japanese patients because of known racial differences in the eyelid anatomy; thus, these results may not apply to other races. Second, all measurements were performed by a single examiner, which may have introduced a bias in the results. In conclusion, subbrow blepharoplasty surgery can improve visual function while revealing natural-looking double eyelids by adjusting the amount of skin removed. This procedure can aid in the achievement of visual function restoration and cosmetic improvement. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Shinjiro Kono. The first draft of the manuscript was written by Shinjiro Kono and Motohiro Kamei commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. The institutional review board (IRB) of Aichi Medical University Hospital approved this study (approval number 2024-134). The IRB granted a waiver of informed consent for this study based on the ethical guidelines for medical and health research involving human participants established by the Japanese Ministry of Education, Culture, Sports, Science and Technology and the Ministry of Health, Labor and Welfare. Consent to participate A waiver was granted as the study was not interventional. Nevertheless, at the request of the IRB, an outline of the study was published on the Aichi Medical University website, which was available for public viewing and gave patients the option to refuse to participate in the study, although none did. Personal identifiers were removed from the records prior to data analysis. Consent to publish The authors affirm that human research participants provided informed consent for publication of the in Figures 1, 2, and 3 . References Eid L, Tsirbas A (2021) Subbrow blepharoplasty in Caucasians. Plast Reconstr Surg 147:604–607. https://doi.org/10.1097/PRS.0000000000007633. Osaki TH, Lee BW, Osaki MH (2020) Sub-brow skin excision as an alternative to classic blepharoplasty in select non-Asian patients. Ophthalmic Plast Reconstr Surg 36:207. https://doi.org/10.1097/IOP.0000000000001563. Osaki MH, Osaki TH, Osaki T (2017) Infrabrow skin excision associated with upper blepharoplasty to address significant dermatochalasis with lateral hooding in select Asian patients. Ophthalmic Plast Reconstr Surg 33:53–56. https://doi.org/10.1097/IOP.0000000000000644. Hu X, Wang C. (2025) The effects of orbicularis muscle and suborbicularis fat fixation in subbrow blepharoplasty. J Craniofac Surg 36:2088-2092. https://doi.org/10.1097/SCS.0000000000011097. Liang Z, Liu J, Guo L et al (2024) Modified blepharoplasty combined with autologous fat transplantation into the orbital septum for the correction of dermatochalasis and sunken eyelids. J Plast Reconstr Aesthet Surg 99:362–368. https://doi.org/10.1016/j.bjps.2024.09.073. Li SL, Li KY, Song T et al (2023) Long-term effects of extended upper blepharoplasty combined with subbrow skin removal for correction of lateral hooding in Asian women. J Craniofac Surg 34:1550–1555. https://doi.org/10.1097/SCS.0000000000009348. Qu L, Liang Z, Wang J et al (2022) Comparison of postoperative scarring in Asian women after supra-brow and sub-brow blepharoplasty: A retrospective study. Aesthetic Plast Surg 46:2280–2286. https://doi.org/10.1007/s00266-022-02954-z. Jin S, Cui L, She J et al (2022) Sub-brow lift combined with orbicularis oculi folding for periorbital rejuvenation. Br J Oral Maxillofac Surg 60:779–784. https://doi.org/10.1016/j.bjoms.2021.11.003. Guo P, Zhang J, Yu Z et al (2021) Double-incision approach with suspension of the orbicularis oculi muscle and relieving of tension for upper eyelid rejuvenation in Asian women. J Plast Reconstr Aesthet Surg 74:1900–1907. https://doi.org/10.1016/j.bjps.2020.12.024. Jung GS (2020) Modified infrabrow excision blepharoplasty for severity of medial blepharochalasia. Plast Surg (Oakv) 28:167–171. https://doi.org/10.1177/2292550320928555. Wang J, Su Y, Zhang J et al (2020) A randomized, controlled study comparing subbrow blepharoplasty and subbrow blepharoplasty combined with periorbital muscle manipulation for periorbital aging rejuvenation in Asians. Aesthetic Plast Surg 44:788–796. https://doi.org/10.1007/s00266-020-01630-4. Kim YS (2014) Subbrow blepharoplasty using supraorbital rim periosteal fixation. Aesthetic Plast Surg 38:27–31. https://doi.org/10.1007/s00266-013-0189-y. Lee D, Law V (2009) Subbrow blepharoplasty for upper eyelid rejuvenation in Asians. Aesthet Surg J 29:284–288. https://doi.org/10.1016/j.asj.2009.02.008. Cui J, Zhang Y, Cang Z et al (2025) Effect of orbicularis oculi muscle suspension combined with overlap in modified sub-brow blepharoplasty: A prospective study. J Cosmet Dermatol 24:e70103. https://doi.org/doi: 10.1111/jocd.70103. Xu L, Zhong X, Wang T (2024) Quantitative and aesthetic analysis of changes in eyebrow position after subbrow blepharoplasty. Aesthetic Plast Surg 48:4299–4306. https://doi.org/10.1007/s00266-024-04255-z. Qiu Y, Liu F, Yang J, Zhou X (2024) A modified subbrow blepharoplasty for correction of severe upper eyelid skin laxity. Aesthetic Plast Surg 48:2634–2641. https://doi.org/10.1007/s00266-024-03973-8. Jawad BA, Raggio BS (2025) Direct Brow Lift. In: StatPearls [Internet]. Treasure Island (FL): StatPearls; 2025. PMID: 32644687. Lee TY, Shin YH, Lee JG (2020) Strategies of upper blepharoplasty in aging patients with involutional ptosis. Arch Plast Surg 47:290–296. https://doi.org/10.5999/aps.2020.01361. Tables Table 1 Demographic data and measurements Patient number/sides 30/60 Male/female 10/20 Bilateral 30 Single eyelid with skin laxity 16 Double eyelid with skin laxity 14 Patient age (years) 70.8 ± 9.7 Range 50–90 Surgical time of bilateral surgery (minutes) 43.7 ± 6.3 Range 32–57 Previous eyelid surgery at other hospitals 0 Success rate 100% Postoperative incision scar and deformity 0 Eyelid margin to incision (over lateral canthus) (mm) 21.72 ± 0.76 Range 20–24 Eyelid margin to incision (over medial corn) (mm) 22.60 ± 1.32 Range 20–26 P < 0.05 Table 2 Preoperative and postoperative distance from the pupil center to the upper eyelid The distance from the pupil center to the upper eyelid (mm) Mean value Minimum to maximum Preoperative 2.57 ± 1.36 0–4.5 Postoperative 3 months 3.83 ± 0.85 1.5–5.0 Postoperative 6 months 4.00 ± 0.59 3.0–5.0 Postoperative 12 months 3.99 ± 0.55 3.0-5.0 P-value < 0.05 Table 3. Bonferroni correction for the distance from the pupil center to the upper eyelid The distance from the pupil center to the upper eyelid margin Postoperative 3 months Postoperative 6 months Postoperative 12 months Preoperative < 0.001 < 0.001 < 0.001 Postoperative 3 months - 1.000 1.000 Postoperative 6 months 1.000 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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16:38:28","extension":"html","order_by":41,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75284,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7698791/v1/0d26be63d226e161d9df9d3c.html"},{"id":96653317,"identity":"b5dfe199-3e7d-4340-b1d8-f3767300442f","added_by":"auto","created_at":"2025-11-24 16:38:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1536867,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical procedure: subbrow blepharoplasty for a 54-year-old woman with single eyelids\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea: \u003c/strong\u003ePreoperative bilateral eyelid. The skin laxity is mild, but the patient complained of drooping eyelashes and difficulty seeing upward. Originally single eyelids.\u003cstrong\u003e b:\u003c/strong\u003e The skin is pinched so that the hidden double eyelid became visible.\u003cstrong\u003e c: \u003c/strong\u003eThe skin excision area is designed such that the eyelashes are upright and the hidden double eyelid become visible.\u003cstrong\u003e d: \u003c/strong\u003eThe excess skin is grabbed with toothed forceps and removed.\u003cstrong\u003e e: \u003c/strong\u003eBefore suturing, the distance from the edge of the eyelid to the incision is measured at four points (over the right lateral canthus, medial cornea, left lateral canthus, and medial cornea).\u003cstrong\u003e f: \u003c/strong\u003eMeasuring the distance over the right lateral canthus, which was 20 mm. \u003cstrong\u003eg. \u003c/strong\u003eMeasuring the distance over the left medial cornea, which was 20 mm. \u003cstrong\u003eh: \u003c/strong\u003eThe eyebrow is folded toward the head with skin tape to prevent tangling, and subcutaneous suturing is performed with 5-0 PDS.\u003cstrong\u003e i. \u003c/strong\u003eSkin suturing is performed with 6-0 Asflex, and the wound is closed. \u003cstrong\u003ej. \u003c/strong\u003eDouble eyelids revealed after surgery. \u003cstrong\u003ek.\u003c/strong\u003e Six months postoperatively,double eyelids are revealed and maintained. The scar is inconspicuous.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7698791/v1/00810bdc784407de5bc588fb.png"},{"id":96709526,"identity":"40f35bfb-1a82-4077-9893-d71dc8e541c4","added_by":"auto","created_at":"2025-11-25 10:09:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":755480,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative case: A 66-year-old woman with single eyelids\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea: \u003c/strong\u003eBefore surgery. Eyes closed naturally due to the weight of the eyelids. \u003cstrong\u003eb:\u003c/strong\u003e Before surgery. Even when the patient tried hard to keep her eyes open, they remained almost closed. The distance from the pupil center to the upper eyelid are 0 mm on both sides. \u003cstrong\u003ec:\u003c/strong\u003e One week after surgery, double eyelids are revealed, and the eyes can be opened widely. The intraoperative measurements of the distances were 23 mm over the right lateral canthus, 25 mm over the right medial cornea, 21 mm over the left lateral canthus, and 23 mm over the left medial cornea. \u003cstrong\u003eD.\u003c/strong\u003eThree months after surgery, the surgical site is no longer noticeable, and the distance from the pupil center to the upper eyelid is maintained at 5.0 mm on both sides.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7698791/v1/0c41deddc2b4e2d371bfa990.png"},{"id":96653332,"identity":"70821d96-983b-46dd-881b-b9943b63f40c","added_by":"auto","created_at":"2025-11-24 16:38:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":419340,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative case: An 80-year-oldman with double eyelids\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ea: \u003c/strong\u003ePreoperatively, there is substantial excess skin laxity on the lateral side.\u003cstrong\u003e \u003c/strong\u003eSevere skin laxity hides his double eyelids. The distances from the pupil center to the upper eyelid are 1 mm on the right side and 2.5 mm on the left side. \u003cstrong\u003eb: \u003c/strong\u003eSix months postoperatively, the excess skin is removed and double eyelids are revealed. The distance from the pupil center to the upper eyelid improved to 4.0 mm on both sides. The intraoperative measurements of the distances were 22 mm over the right lateral canthus, 23 mm over the right medial cornea, 22 mm over the left lateral canthus, and 23 mm over the left medial cornea\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7698791/v1/c53ab29336477372c9845927.png"},{"id":97033450,"identity":"18e99af3-7e37-4018-a1b4-510a31409e5e","added_by":"auto","created_at":"2025-11-29 04:08:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3220214,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7698791/v1/0db06a19-f1c8-4825-9716-1f2df6040d58.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Subbrow blepharoplasty reveals a natural eyelid crease with appropriate skin removal","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSubbrow blepharoplasty is a surgical procedure for removing excess skin in cases of upper eyelid skin laxity. Although this surgery is mainly performed on Asians, it is also sometimes performed on Caucasians and African Americans [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This procedure is effective for patients who have thick, heavy excess skin because it significantly lifts the upper eyelids and results in a more refined appearance [\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The procedure requires skill in designing the incision based on the individual characteristics of the patient's eyelid. Once the design is complete, the excess skin is removed, and the incision is carefully sutured to complete the procedure. Although the basic procedure is simple, modification techniques for a better appearance have been reported [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious reports have emphasized the rejuvenating effects and cosmetic benefits achieved by subbrow blepharoplasty [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Several studies have quantitatively assessed changes in skin laxity before and after surgery; however, none of the reports have mentioned the effects of double eyelid clarification and visual function improvement with this procedure [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition to restoring the original double eyelids that were hidden by excess skin, this procedure can make the extremely low crease line in patients with single eyelids more prominent, revealing natural-looking double eyelids; this transformation effectively rotates the eyelashes outward without adding an incision to the eyelid margin. The pupil and iris, partially hidden due to skin laxity, become visible, enhancing visibility along the line of sight and upward vision.\u003c/p\u003e\u003cp\u003eHerein, we evaluated the extent of skin to be excised for double eyelid formation and the distance from the pupil center to the upper eyelid before and after subbrow blepharoplasty.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included 30 patients (60 eyelids) who underwent bilateral subbrow blepharoplasty by one of the authors (S.K.) at the Aichi Medical University Day Surgery Center for Ophthalmology between October 2022 and October 2024. All patients presented with upper eyelid skin laxity. Sixteen patients had single eyelids with skin laxity,\u0026nbsp;and\u0026nbsp;14\u0026nbsp;patients had double eyelids with skin laxity.\u0026nbsp;All cases were followed up for at least 6 months after surgery.\u0026nbsp;Of these, 18\u0026nbsp;patients (36\u0026nbsp;eyelids)\u0026nbsp;were followed up for 1 year after surgery. Patients with a history of other eyelid surgeries were excluded. Patients who did not want an alteration in their natural crease and those with concomitant ptosis were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData on age, sex, and surgical time were collected. Bilateral subbrow blepharoplasty surgery was performed on all patients. During surgery,\u0026nbsp;after the excess skin was removed, we measured the distance from the eyelid margin to the lower incision line over the medial cornea and the lateral canthus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe distance from the pupil center to the upper eyelid and presence of double eyelid crease were evaluated before and after surgery. Surgery was considered successful if the skin overhanging the true lid margin was removed and double eyelid clarification was achieved at 6 months postoperatively. For the 18 patients (36 sides) followed up to 1 year postoperatively, the distance from the pupil center to the upper eyelid were\u0026nbsp;measured at baseline, 3 months, 6 months, and 1 year postoperatively, and the degree of improvement was evaluated.\u0026nbsp;To evaluate the improvement in this distance, we measured the Pseudo-Margin Reflex Distance (P-MRD) defined as the distance from the skin overhanging the true lid margin to the corneal light reflex preoperatively. Postoperatively, after excess skin was removed, we measured the Margin Reflex Distance 1 (MRD-1).\u003c/p\u003e\n\u003cp\u003eThese measurements were taken in the natural frontal view.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe designed the area of skin to be excised below the eyebrow after confirming the presence of a hidden double eyelid (Fig. 1 a\u0026ndash;c). Skin laxity is often more pronounced on the outer side, but it may also extend widely inward; therefore, we adjusted the design according to the patient\u0026apos;s condition. With the patient in the supine position, we grasped the excess skin so that the eyelashes stood up and designed the excision area in a spindle shape below the eyebrow.\u0026nbsp;After injection of 1% lidocaine with epinephrine (1:100000)\u0026nbsp;into the\u0026nbsp;upper\u0026nbsp;eyelids, we incised the skin using a scalpel\u0026nbsp;down\u0026nbsp;to the layer of the orbicularis oculi muscle. We grasped the excess skin with\u0026nbsp;toothed forceps and\u0026nbsp;removed it\u0026nbsp;using a radio frequency cutting device (Surgitron Dual EMC\u0026reg;, Ellman-Japan; Osaka Japan) (Fig. 1d).\u0026nbsp;After achieving a thorough hemostasis in the skin excision area, it was temporarily sutured with 5-0 nylon\u0026nbsp;monofilament (Bear medic, Tokyo, Japan)\u0026nbsp;sutures and the appearance checked. Additional design and skin excision was performed as necessary.\u0026nbsp;If the patient\u0026apos;s natural crease became visible, upper\u0026nbsp;eyelids\u0026nbsp;were sufficiently\u0026nbsp;lifted, and\u0026nbsp;shape of the upper eyelid was satisfactory\u0026nbsp;in the\u0026nbsp;seated\u0026nbsp;position, then\u0026nbsp;temporary sutures were removed.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eBefore final closure, the distance from the edge of the eyelid to the incision was measured at four points (over the right lateral canthus, medial cornea, left lateral canthus, and medial cornea) (Fig. 1e\u0026ndash;g). The next step was to suture the subcutaneous tissue with 5-0 PDS\u0026reg; (Polydioxanone, Ethicon, Inc., Somerville, NJ, USA)(Fig 1h). This was followed by skin suturing with 6-0 Asflex\u0026reg; (polyvinylidene fluoride, Kono Seisakusho Co., Ltd., Tokyo, Japan) to complete the procedure (Fig. 1h\u0026ndash;k)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient\u0026rsquo;s age and other measurement results are expressed as the mean \u0026plusmn; standard deviation. The distance from the pupil center to the upper eyelid was compared among the four measurement periods using Friedman\u0026rsquo;s test and Bonferroni correction because the measurement results did not show normal distribution. All statistical analyses were performed using SPSS ver. 26 software (IBM Corp., Armonk, NY, USA). Statistical significance was set at \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.050.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll 60 cases were followed up for more than 6 months. The average surgical time was 43.7 \u0026plusmn; 6.3 minutes. The width from the eyelid margin to the incision line below the eyebrow was 21.72 \u0026plusmn; 0.98 mm over the lateral canthus and 22.60 \u0026plusmn; 1.31 mm over the medial cornea, showing a significant difference (p \u0026lt; 0.05). Double eyelids were revealed immediately after the procedure and remained in their shape across all cases (Table 1). In patients with single eyelids with a deeply hidden eyelid line, a natural double eyelid line was exposed (Figs. 1, 2). In cases where a double eyelid line was present but obscured by skin laxity, the double eyelid line became clear (Fig. 3). The distance from the pupil center to the upper eyelid showed significant improvement at all postoperative time points compared to preoperative levels (Tables 2 and 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study to evaluate the double eyelid formation and visual function improvement effects of subbrow blepharoplasty. All patients demonstrated natural double eyelids at 6 months postoperatively. Additionally, no postoperative scar-related issues were observed, and no patients exhibited recurrence of dermatochalasis at 1 year postoperatively, with eyelid elevation maintained.\u003c/p\u003e\n\u003cp\u003eOur surgical procedure involved removing excess skin according to the design that would reveal natural double eyelids, followed by careful suturing of the subcutaneous tissue and epidermis to complete the procedure. If hemostasis is adequately achieved, the surgery is typically completed within the scheduled timeframe. Patients may express concerns about postoperative scars, but these scars are usually hidden beneath the eyebrows and can be easily concealed with eyeglass frames or eyebrow makeup. Scars typically fade or become barely noticeable within 3 to 6 months. Patients in this study reported no issues related to scars.\u003c/p\u003e\n\u003cp\u003eIn the surgical technique adopted in this study, no postoperative abnormal skin wrinkles, depressions, or scar contractures were observed. To avoid these problems, in addition to the reports on classical skin excision, improved surgical techniques combining skin excision with manipulation of the orbicularis oculi muscle, periorbital muscles, and retro-orbicularis oculi fat for primarily aesthetic purposes have been reported [3, 4, 8, 10\u0026ndash;12, 14]. We believe that these aesthetic issues can be\u0026nbsp;adequately\u0026nbsp;avoided with precise skin incision planning and meticulous suturing, without complex manipulation of the orbicularis oculi muscle or orbital fat, provided there is no extreme asymmetry caused by trauma or facial nerve palsy, or pathological reduction of orbital fat. For minor asymmetry in eyebrow height, adjusting the amount of skin excised is sufficient. If absolutely necessary, adding a brow lift procedure can also be considered to resolve the issue [17].\u003c/p\u003e\n\u003cp\u003eIn this study, by leaving approximately 20\u0026ndash;26 mm of skin from the brow to the eyelid margin and removing excess skin, the eyelashes were properly rotated outward, revealing a natural double eyelid line. A previous study showed that at least 20\u0026thinsp;mm of skin was preserved between the lash line and inferior brow cilia to avoid lagophthalmos and maintain aesthetic proportions in Africans, which is similar to our measurements [2].\u0026nbsp;Since age and skin laxity do not always correlate, it is essential to adjust the surgical approach during the procedure based on individual skin tension and excess skin. Many patients had a large amount of skin laxity on the lateral side, resulting in a wider skin resection width on the lateral side compared to that in the medial side. During the intraoperative measurement, the appropriate amount of skin to be removed was determined by ensuring that the eyelashes properly rotate outward when the eyes were open. Some reports have indicated that additional incisions are required along the eyelid margin to create double eyelids, but in this study, no patients required incisions along the eyelid margin [3, 6, 9].\u003c/p\u003e\n\u003cp\u003eIn the procedure mentioned herein,\u0026nbsp;for patients who have single eyelids and do not want double eyelids, it is possible to minimize the amount of skin removed so that double eyelids are not revealed. However, to improve and preserve visual function, it is preferable to excise enough skin to reveal a double eyelid. Even people who did not have problems with single eyelids in their young age may become aware of vision difficulties arising from eyelashes rotating slightly inward as a result of skin laxity due to aging. In such cases, if excess skin is insufficiently removed, it may not be possible to notice an improvement in visual function if eyelash ptosis remains. Therefore, unless the patient strongly refuses, it is best to perform skin removal until double eyelid clarification is achieved.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn cases where eyelid ptosis is present with dermatochalasis, the eyelid may droop postoperatively, causing the double eyelid to disappear or the double eyelid width to appear unnaturally wide. In such cases, removing excess skin may fail to raise the eyelid sufficiently and result in unnatural vertical wrinkles in the skin or skin tightening and wrinkles on the inner side. Therefore, it is preferable to add ptosis surgery before\u0026nbsp;subbrow\u0026nbsp;blepharoplasty in\u0026nbsp;such patiens\u0026nbsp;[18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has some limitations that warrant discussion. First, we only included Japanese patients because of known racial differences in the eyelid anatomy; thus, these results may not apply to other races. Second, all measurements were performed by a single examiner, which may have introduced a bias in the results.\u003c/p\u003e\n\u003cp\u003eIn conclusion, subbrow blepharoplasty surgery can improve visual function while revealing natural-looking double eyelids by adjusting the amount of skin removed. This procedure can aid in the achievement of visual function restoration and cosmetic improvement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Shinjiro Kono. The first draft of the manuscript was written by Shinjiro Kono and Motohiro Kamei commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis study was performed in line with the principles of the Declaration of Helsinki.\u0026nbsp;\u003c/em\u003eThe institutional review board (IRB) of Aichi Medical University Hospital approved this study (approval number 2024-134). The IRB granted a waiver of informed consent for this study based on the ethical guidelines for medical and health research involving human participants established by the Japanese Ministry of Education, Culture, Sports, Science and Technology and the Ministry of Health, Labor and Welfare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA waiver was granted as the study was not interventional. Nevertheless, at the request of the IRB, an outline of the study was published on the Aichi Medical University website, which was available for public viewing and gave patients the option to refuse to participate in the study, although none did. Personal identifiers were removed from the records prior to data analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors affirm that human research participants provided informed consent for publication of the in Figures 1, 2, and 3\u003c/em\u003e.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEid L, Tsirbas A (2021) Subbrow blepharoplasty in Caucasians.\u003cem\u003e \u003c/em\u003ePlast Reconstr Surg 147:604\u0026ndash;607. https://doi.org/10.1097/PRS.0000000000007633.\u003c/li\u003e\n\u003cli\u003eOsaki TH, Lee BW, Osaki MH (2020) Sub-brow skin excision as an alternative to classic blepharoplasty in select non-Asian patients.\u003cem\u003e \u003c/em\u003eOphthalmic Plast Reconstr Surg\u003cem\u003e \u003c/em\u003e36:207. https://doi.org/10.1097/IOP.0000000000001563.\u003c/li\u003e\n\u003cli\u003eOsaki MH, Osaki TH, Osaki T (2017) Infrabrow skin excision associated with upper blepharoplasty to address significant dermatochalasis with lateral hooding in select Asian patients. Ophthalmic Plast Reconstr Surg 33:53\u0026ndash;56. https://doi.org/10.1097/IOP.0000000000000644.\u003c/li\u003e\n\u003cli\u003eHu X, Wang C. (2025) The effects of orbicularis muscle and suborbicularis fat fixation in subbrow blepharoplasty. J Craniofac Surg\u003cem\u003e \u003c/em\u003e36:2088-2092.\u003cem\u003e \u003c/em\u003ehttps://doi.org/10.1097/SCS.0000000000011097. \u003c/li\u003e\n\u003cli\u003eLiang Z, Liu J, Guo L et al (2024) Modified blepharoplasty combined with autologous fat transplantation into the orbital septum for the correction of dermatochalasis and sunken eyelids.\u003cem\u003e \u003c/em\u003eJ Plast Reconstr Aesthet Surg 99:362\u0026ndash;368. https://doi.org/10.1016/j.bjps.2024.09.073.\u003c/li\u003e\n\u003cli\u003eLi SL, Li KY, Song T et al (2023) Long-term effects of extended upper blepharoplasty combined with subbrow skin removal for correction of lateral hooding in Asian women. J Craniofac Surg 34:1550\u0026ndash;1555. https://doi.org/10.1097/SCS.0000000000009348.\u003c/li\u003e\n\u003cli\u003eQu L, Liang Z, Wang J et al (2022) Comparison of postoperative scarring in Asian women after supra-brow and sub-brow blepharoplasty: A retrospective study. Aesthetic Plast Surg 46:2280\u0026ndash;2286. https://doi.org/10.1007/s00266-022-02954-z.\u003c/li\u003e\n\u003cli\u003eJin S, Cui L, She J et al (2022) Sub-brow lift combined with orbicularis oculi folding for periorbital rejuvenation. Br J Oral Maxillofac Surg 60:779\u0026ndash;784. https://doi.org/10.1016/j.bjoms.2021.11.003.\u003c/li\u003e\n\u003cli\u003eGuo P, Zhang J, Yu Z et al (2021) Double-incision approach with suspension of the orbicularis oculi muscle and relieving of tension for upper eyelid rejuvenation in Asian women. J Plast Reconstr Aesthet Surg 74:1900\u0026ndash;1907. https://doi.org/10.1016/j.bjps.2020.12.024.\u003c/li\u003e\n\u003cli\u003eJung GS (2020) Modified infrabrow excision blepharoplasty for severity of medial blepharochalasia. Plast Surg (Oakv) 28:167\u0026ndash;171. https://doi.org/10.1177/2292550320928555.\u003c/li\u003e\n\u003cli\u003eWang J, Su Y, Zhang J et al (2020) A randomized, controlled study comparing subbrow blepharoplasty and subbrow blepharoplasty combined with periorbital muscle manipulation for periorbital aging rejuvenation in Asians. Aesthetic Plast Surg 44:788\u0026ndash;796. https://doi.org/10.1007/s00266-020-01630-4.\u003c/li\u003e\n\u003cli\u003eKim YS (2014) Subbrow blepharoplasty using supraorbital rim periosteal fixation. Aesthetic Plast Surg 38:27\u0026ndash;31. https://doi.org/10.1007/s00266-013-0189-y.\u003c/li\u003e\n\u003cli\u003eLee D, Law V (2009) Subbrow blepharoplasty for upper eyelid rejuvenation in Asians. Aesthet Surg J 29:284\u0026ndash;288. https://doi.org/10.1016/j.asj.2009.02.008.\u003c/li\u003e\n\u003cli\u003eCui J, Zhang Y, Cang Z et al (2025) Effect of orbicularis oculi muscle suspension combined with overlap in modified sub-brow blepharoplasty: A prospective study. J Cosmet Dermatol 24:e70103. https://doi.org/doi: 10.1111/jocd.70103.\u003c/li\u003e\n\u003cli\u003eXu L, Zhong X, Wang T (2024) Quantitative and aesthetic analysis of changes in eyebrow position after subbrow blepharoplasty. Aesthetic Plast Surg 48:4299\u0026ndash;4306. https://doi.org/10.1007/s00266-024-04255-z.\u003c/li\u003e\n\u003cli\u003eQiu Y, Liu F, Yang J, Zhou X (2024) A modified subbrow blepharoplasty for correction of severe upper eyelid skin laxity. Aesthetic Plast Surg 48:2634\u0026ndash;2641. https://doi.org/10.1007/s00266-024-03973-8.\u003c/li\u003e\n\u003cli\u003eJawad BA, Raggio BS (2025) Direct Brow Lift. In: StatPearls [Internet]. Treasure Island (FL): StatPearls; 2025. PMID: 32644687.\u003c/li\u003e\n\u003cli\u003eLee TY, Shin YH, Lee JG (2020) Strategies of upper blepharoplasty in aging patients with involutional ptosis. Arch Plast Surg 47:290\u0026ndash;296. https://doi.org/10.5999/aps.2020.01361.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eDemographic data and measurements\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003ePatient number/sides\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e30/60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eMale/female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e10/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eSingle eyelid with skin laxity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eDouble eyelid with skin laxity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003ePatient age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e70.8 \u0026plusmn;\u0026nbsp;9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eRange 50\u0026ndash;90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eSurgical time of bilateral surgery (minutes)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e43.7 \u0026plusmn; 6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eRange 32\u0026ndash;57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003ePrevious eyelid surgery at other hospitals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eSuccess rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003ePostoperative incision scar and deformity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eEyelid margin to incision (over lateral canthus)\u0026nbsp;(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e21.72\u0026nbsp;\u0026plusmn; 0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eRange 20\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eEyelid margin to incision\u0026nbsp;(over medial corn) (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;22.60 \u0026plusmn; 1.32 \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eRange 20\u0026ndash;26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;P\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003ePreoperative and postoperative distance from the pupil center to the upper eyelid \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eThe distance from the pupil center to the upper eyelid (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003eMean value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eMinimum to maximum\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e2.57 \u0026plusmn; 1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u0026ndash;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003ePostoperative 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e3.83 \u0026plusmn; 0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e1.5\u0026ndash;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003ePostoperative 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e4.00 \u0026plusmn; 0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3.0\u0026ndash;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003ePostoperative 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e3.99 \u0026plusmn; 0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3.0-5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026lt; 0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eBonferroni correction for the distance from the pupil center to the upper eyelid \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eThe distance from the pupil center to the upper eyelid margin\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003ePostoperative 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003ePostoperative 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePostoperative 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003ePostoperative 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e1.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003ePostoperative 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"subbrow blepharoplasty, double eyelids, natural eyelid crease, upper eyelid skin laxity","lastPublishedDoi":"10.21203/rs.3.rs-7698791/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7698791/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eStudies have quantitatively assessed changes in skin laxity before and after subbrow blepharoplasty; however, none of the reports have mentioned the effects of double eyelid clarification and visual function improvement with this procedure. Therefore, in this study, we aimed to examine the method for revealing natural double eyelids in subbrow blepharoplasty.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn this study, we included 30 patients (60 eyelids) who underwent bilateral subbrow blepharoplasty. During surgery, after removing excess skin to reveal natural double eyelids, we measured the distance from the edge of the eyelid to the lower incision below the eyebrow at the lateral canthus and medial cornea. All cases were observed for at least 6 months postoperatively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eDouble eyelids were revealed in all 60 cases. The width from the eyelid margin to the lower incision line below the eyebrow, which is necessary for the exposure of double eyelids, was 21.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98 mm on the lateral canthus and 22.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.32 mm on the medial cornea. In 36 cases followed up for 1 year, the distance from the pupil center to the upper eyelid showed significant improvement at all postoperative time points compared to preoperative levels.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eSubbrow blepharoplasty reveals a natural eyelid crease with appropriate skin removal, aiding in visual function restoration and cosmetic improvement.\u003c/p\u003e","manuscriptTitle":"Subbrow blepharoplasty reveals a natural eyelid crease with appropriate skin removal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 16:38:13","doi":"10.21203/rs.3.rs-7698791/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80402338-adb6-4147-a01c-ae03fa4816a2","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-16T18:38:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 16:38:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7698791","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7698791","identity":"rs-7698791","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}