Original Investigation
Infrabrow Skin Excision Associated with Upper
Blepharoplasty to Address Significant Dermatochalasis
with Lateral Hooding in Select Asian Patients
Midori Hentona Osaki, M.D., M.B.A., Tammy Hentona Osaki, M.D., Ph.D. and Teissy Osaki, M.D., Ph.D.
Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology
and Visual Sciences, Federal University of São Paulo, São Paulo, Brazil
Purpose: In Asian patients, lateral hooding in the aging
upper eyelid is prominent and frequently seen. Removal of
the redundant skin of this region during classic blepharoplasty
tends to produce a resultant prolonged scar. Furthermore, as
the height of the eyelid skin excision increases, suturing of the
thick upper skin to the thin pretarsal skin can result in upper
lid fullness. This study documents the combination of infrabrow
skin excision and upper blepharoplasty to address lateral
hooding in select patients of Asian ancestry.
Methods: This study is a retrospective chart review of patients
who underwent infrabrow skin excision associated with upper
blepharoplasty. The inclusion criteria were moderate and severe
upper eyelid dermatochalasis in patients with high eyebrows
and lateral hooding; residual lateral hooding following previous
blepharoplasty.
Results: Thirty-two eyelids of 16 female patients of Japanese
ancestry underwent infrabrow skin excision associated with
upper blepharoplasty. The mean age of patients was 68.87 ±  This article documents the use of ISE extending laterally
7.88 years (57–82 years). Mean follow up was 37.25 ± 18.96
months (9–72 months). Patients were evaluated at 1, 3, 6, and
9 months at least. The Strasser system for evaluation of surgical
results was applied at 3 months. All patients had scores indicating
good results and were satisfied with the cosmetic outcome and
improvement of visual field after surgery. No complications
related to wound dehiscence, lagophthalmos, hypertrophic scars,
or sensory changes were observed.
Conclusion: The combination of infrabrow skin excision
and upper blepharoplasty was effective to address moderate and
severe dermatochalasis with lateral hooding in select patients of
Japanese ancestry.
(Ophthal Plast Reconstr Surg 2016;XX:00–00)
T he preoperative comprehensive examination of aging Asian
patients seeking upper facial rejuvenation is essential. Due to
inherent anatomical characteristics typically present in patients of
Asian ancestry, such as thicker eyelid skin, eyebrows in a higher
position, and variable presence of an eyelid crease (absent in
Accepted for publication December 12, 2015.
This paper was presented in part at the ASOPRS Fall Meeting, Las Vegas,
NV, 2015.
The authors have no financial or conflicts of interest to disclose.
Address correspondence and reprint requests to Midori Hentona Osaki,
M.D., M.B.A., Division of Ophthalmic Plastic and Reconstructive Surgery,
Department of Ophthalmology and Visual Sciences, Federal University of
São Paulo, Rua Botucatu, 821, 2o. andar, São Paulo, SP 04023-062, Brazil.
E-mail: midori_osaki@yahoo.com.br
DOI: 10.1097/IOP.0000000000000644
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016 1
Copyright © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
approximately 50% of Asians), the surgical approach must con-
sider these characteristics and the patient’s desires, which must be
balanced with conserving ocular protective mechanisms, to obtain
a satisfactory aesthetic result.1–3 In these patients, skin redundancy
is most prominent in the lateral two-thirds of the eyelid, where
the skin is thicker. Nevertheless, surgical correction of this lateral
hooding is difficult to attain with classic blepharoplasty alone.4–6
The shortcomings that are inherent to a standard upper
blepharoplasty (UB) performed on Asian patients with signifi-
cant dermatochalasis and lateral hooding include insufficient
removal of the lateral redundant skin of the upper eyelid. The
removal of this tissue during UB tends to result in a scar beyond
the lateral canthus, leading to an unnatural postoperative aspect.
Furthermore, as the height of the eyelid skin excision increases,
suturing of the thick upper skin to the thin pretarsal skin can
result in upper eyelid fullness.1,4–6 In such UB candidates, an
approach that combines infrabrow skin excision (ISE) and con-
ventional blepharoplasty is appealing.
to the lateral canthus, which is aimed at improving UB results in
cases of significant lateral hooding, in select cases of patients of
Asian ancestry. The authors’ experience during the last 6 years
is presented and reviewed.
METHODS
This study was approved by the institutional review board of
the Federal University of São Paulo and adhered to the tenets of the
Declaration of Helsinki.
The surgical logs of 2 surgeons (MHO, THO) were reviewed to
identify all patients who underwent ISE associated with UB. Clinical
data (age, gender, eyebrow position, duration of follow up, and compli-
cations) were then extracted from these patients’ charts. Patient com-
plaints included upper eyelid skin redundancy, limitation of upper visual
field, and lateral hooding following previous UB.
The inclusion criteria to undergo ISE associated with UB were
moderate and severe upper eyelid dermatochalasis in patients with high
eyebrows (defined as distance from the ciliary margin to the eyebrow,
in the midpupillary line, of at least 28 mm) and lateral hooding; residual
lateral hooding following previous blepharoplasty. Figure 1A, B shows
the features of patients who underwent the combined procedure.
The Strasser grading system7 was used to evaluate the surgical
results. According to this objective grading system, 5 parameters (malpo-
sition, distortion, asymmetry, contour deformity, and scar) were assessed
and classified according to severity: perfect (zero points), noticeable
(1 point), obvious (5 points), and obvious and deforming (15 points). An
excellent result is assigned a score of zero. Scores of 1 to 4 indicate good
results, 5 to 14 are mediocre, and 15 or greater are poor.
Aesthetic improvement was assessed by 3 blinded oculoplastic
surgeons, who judged preoperative and 6-month-postoperative digital
 Osaki et al. Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016
FIG. 1.  Female patients of Asian ancestry who underwent
infrabrow skin excision associated with upper blepharoplasty pro-
cedure. A, A 76-year-old female patient with single eyelid, thick
skin, and high eyebrow presenting with severe dermatochalasis
and prominent lateral hooding. B, A 68-year-old female patient
with a more arched eyebrow laterally, thinned, high located and
tattooed eyebrow, presenting with moderate dermatochalasis
and lateral hooding. C, Marking of the infrabrow and upper
eyelid excision area. Initially, the eyelid crease is marked at a dis-
tance of 5 mm to 7 mm from the ciliary margin and the medial
third of the superior limit is also marked. Marking of the remain-
ing superior excision area is only completed after finalizing the
ISE procedure. Preoperative distance from the ciliary margin to
the eyebrow varied from 28 mm to 35 mm, in the midpupillary
line, among patients who underwent this procedure. D, Beveled
infrabrow incision to prevent damage to hair follicles.
photographs. Photographs were rated using a 5-point Likert-type scale,
where 1 indicated much worse than preoperative and 5 indicated much
better than preoperative for preoperative versus postoperative aesthetic
improvement analysis, and 1 indicated poor aesthetic appearance and
5 excellent aesthetic appearance for pre- and post-operative appearance.
Wilcoxon signed rank tests were performed to assess for statistically sig-
nificant differences in the scores returned by the independent blinded ob-
servers. p values less than 0.05 were considered statistically significant.
Surgical Technique
All procedures were performed under local anesthesia with
sedation. Initially, the infrabrow excision area and eyelid crease were
marked. During preoperative evaluation, the infrabrow skin was pinched
using bayonet forceps with the patient in a sitting position and eyes
open. While pinching, the surgeon observed the appearance of the eye-
lids while open and closed.
Infrabrow Skin Excision Marking
A line following the lower margin of the eyebrow was drawn.
Using forceps, the amount of excess skin to be resected was pinched
in the infrabrow region, and then the inferior limit of the elliptical skin
excision area was determined accordingly. The widest skin excision area
should be enough to correct lateral drooping of the skin. Extension of
the skin ellipse varied medially according to the severity of each pa-
tient’s dermatochalasis, while laterally, it extended to the lateral end of
the eyebrow. In most patients, a greater amount of skin was marked and
excised from the infrabrow lateral region (Fig. 1C), where it is thicker.
Classic Upper Blepharoplasty Marking
Initially, the inferior line was drawn at the existing supratarsal
crease, if present. If the patient did not have a supratarsal crease, the
2 © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
height of the upper eyelid crease was marked at a distance of 5 mm to
7 mm from the ciliary margin (Fig. 1C). The medial third of the superior
limit was also marked. Marking of the remaining superior excision area
was only performed after finalizing the ISE procedure.
Infrabrow Skin Excision Procedure
The infrabrow and upper eyelid area were infiltrated with 2%
lidocaine with epinephrine 1:100,000. Using a #15 blade, an incision was
made to the depth of the subcutaneous fat layer. The infrabrow incision
was beveled by tilting the blade at an angle of approximately 30° to prevent
damage to hair follicles (Fig. 1D). Using a Colorado needle, only infrabrow
skin was excised to avoid prolonged and conspicuous scarring. Hemostasis
was obtained with bipolar cauterization. The orbicularis layer was closed
using 6-0 white polyglycolic acid inverted sutures (Vicryl; Ethicon) and
the infrabrow skin was closed with interrupted 6-0 nylon (Ethicon) sutures.
Skin sutures were removed on the seventh postoperative day.
Upper Blepharoplasty
An adequate amount of excess skin to be resected was pinched
using forceps. After confirming that there would be no excess skin re-
moval leading to lagophthalmos, marking of the superior eyelid incision
line was completed. A #15 blade was used to incise the skin, and only
skin was excised.
Redundant preaponeurotic fat was removed after opening the or-
bicularis and septum using a Colorado needle. To avoid the appearance
of an upper eyelid depression postoperatively, the authors do not remove
fat in excess. An eyelid crease (double eyelid was desired by most of
the patients) was created by fixing the pretarsal orbicularis oculi to the
levator aponeurosis using 6-0 white polyglycolic acid sutures (Vicryl;
Ethicon) and the skin was closed using 6-0 nylon (Ethicon) interrupted
sutures. Skin sutures were removed on the seventh postoperative day.
RESULTS
Thirty-two eyelids of 16 female Japanese Brazilian pa-
tients underwent ISE associated with UB. The mean age was 68.87 ± 
7.88 years (57–82 years). Mean follow up was 37.25 ± 18.96 months
(9–72 months).
Sutures were removed 7 days after surgery and patients were
evaluated at 1, 3, 6, and 9 months (at least). One month postoperatively,
6 patients still experienced slight redness in the infrabrow region, but in
all cases, the infrabrow scarring faded markedly within 3 months after
surgery and was almost unnoticeable by 6 months without the use of
makeup. Figure 2 shows pre- and post-operative photographs.
The Strasser objective system7 for evaluation of surgical results
was applied at 3 months. All patients had scores between 0 and 1 point
(Table 1), indicating good results (0–4 points) and were satisfied with the
cosmetic outcome and improvement of visual field after surgery. No com-
plications related to wound dehiscence, lagophthalmos, sensory changes,
hematoma, infection, or hypertrophic scars were observed. Eyebrow mal-
position or eyelid crease discrepancy requiring additional surgery was
not observed. Table 1 summarizes patients’ data and the Strasser grading
system scores. Table 2 shows the scores of the Likert type scale analysis.
Significant narrowing between eyelid margin and eyebrow was not
clinically observed, since only patients with anatomically high eyebrows
(preoperative distances from the eyelid ciliary margin to the eyebrow in
the midpupillary vertical line ranged from 28 mm to 35 mm) have under-
gone the combined procedure. Postoperatively, all patients presented with
eyebrows located above the supraorbital rim and a minimal distance of
20 mm from the ciliary margin to the eyebrow, in the midpupillary line,
was kept in all patients to avoid lagophthalmos and to preserve harmonic
proportions between the upper eyelid and the eyebrow.
DISCUSSION
The ISE technique was first described by Parkes et al.8 as a method
to correct skin redundancy between the eyebrow and upper eyelid,
 Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016 Infrabrow Skin Excision Associated with Upper Blepharoplasty

The Korean upper eyelid was found to be thicker than that of

FIG. 2.  Female patients of Asian ancestry with high eyebrows
and thick skin presenting with significant dermatochalasis
and prominent lateral hooding who underwent infrabrow
skin excision + upper blepharoplasty + double eyelid creation.
An 82-year-old female patient before (A) and 6 months after
(B) the combined procedure. A 74-year-old female patient
before (C) and 6 months after (D) the combined approach.
A 65-year-old female patient before (E) and 1 month after
(F) the combined procedure.
especially in revision UB. Sugimoto9 was the first to describe the
use of this technique among Asian patients. The ISE technique
has been described as a quick procedure to be performed in Asian
patients who do not desire a noticeable change in the periorbital
expression, preserving the eyelid original features, and as an
alternative to avoid true eyelid scars in these patients.4,10,11
The city of Sao Paulo in Brazil has the largest Japanese
community outside Japan. It is likely that due to the climatic
conditions inherent to a tropical country, elderly Japanese
Brazilians tend to present with more significant dermatochalasis
associated with more prominent lateral hooding than Japanese
people in Japan, especially if these Japanese descendants have
had high sun exposure during their life (e.g., due to professional
activities, such as agriculture workers).
A study performed on Korean cadavers evaluated the dif-
ferences of thickness in the upper eyelid skin at different levels.
Caucasians. The upper eyelid skin was thinnest near the cili-
ary margin, suddenly thickened approximately 2 mm from the
margin, and then thickened gradually upward. The skin just
below the eyebrow was significantly thicker than the upper tar-
sal border.1 Another study performed in Japanese cadavers by
Kakizaki et al.12 showed that the infrabrow thicker skin was rich
in elastic fibers, whereas the thinner skin closer to the the cili-
ary margin showed a small amount of elastic fibers. Because of
a significant difference in skin thickness and amount of elastic
fibers, suturing of the thick upper skin to the thin pretarsal skin
in Asian classic UB can result in undesirable upper lid fullness
and unnatural cosmetic appearance.1,12 Furthermore, redundant
lateral skin of the upper eyelid is one limitation associated with
classic blepharoplasty in these patients, since its removal dur-
ing this approach tends to result in an extended scar beyond the
lateral canthus.4–6
To address the drawbacks associated with classic blepha-
roplasty in Asian patients with lateral hooding, several stud-
ies have described their results using ISE and its variations
as a single surgical modality (infrabrow excision blepharo-
plasty).4–6,10,11,13 Several authors do not recommend a single ISE
approach for severe dermatochalasis cases.4,14 Nevertheless, in
the authors experience, Japanese Brazilian patients presented
with more severe dermatochalasis associated with more promi-
nent lateral hooding, and the authors found that the combination
of ISE and UB was effective at addressing such difficult cases.
The ISE helped to alleviate the lateral skin redundancy that
could not be addressed by a single blepharoplasty procedure in
these select cases.
During the last 6 years of performing this combined
approach, the authors have attained a high level of satisfac-
tion among patients regarding functional results (all patients
reported subjective improvement in superior visual field) and
the final aesthetic result.
The authors observed that healing in the infrabrow region
is much more inconspicuous than in the suprabrow region,
which was also noted by Kim et al.4 and Ichinose et al.10 The
use of eyebrow makeup and cosmetic cream by women helps
to attenuate the scar in this region while the scar is still appar-
ent. Furthermore, permanent eyebrow tattoos can be performed

TABLE 1.  Summary of patients’ data and surgical results according to the Strasser objective system
Follow up Contour
Patient Age Procedure (month) Malposition Distortion Asymmetry deformity Scar

1 67 UB + ISE* 72 0 0 0 0 0
2 69 UB + ISE* 60 0 0 0 0 0
3 74 UB + ISE* 54 0 0 0 0 0
4 58 UB + ISE* 52 0 0 0 0 0
5 65 UB + ISE* 48 0 0 0 0 0
6 82 UB + ISE* 48 0 0 0 0 0
7 59 UB + ISE* 45 0 0 0 0 0
8 57 UB + ISE* 42 0 0 0 0 1
9 73 UB + ISE* 36 0 0 0 0 0
10 71 UB + ISE* 36 0 0 0 0 0
11 68 UB + ISE* 30 0 0 0 0 0
12 59 UB + ISE* 28 0 0 0 0 1
13 79 UB + ISE 14 0 0 0 0 0
14 76 UB + ISE* 12 0 0 0 0 0
15 78 UB + ISE 10 0 0 0 0 0
16 67 UB + ISE* 9 0 0 0 0 0
Strasser objective system for evaluating sugical results: perfect = 0 points; noticeable = 1 point; obvious = 5 points; deforming = 15 points.
*Underwent double eyelid creation.
ISE, infrabrow skin excision; UB, upper blepharoplasty.

© 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 3
Copyright © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
 Osaki et al. Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016
TABLE 2.  Blinded Likert type-scale analysis: before and
6-month-postoperative photographs
Preoperative vs. Preoperative Postoperative
postoperative aesthetic aesthetic
appearance appearance appearance p
Observer 1 4.88 ± 0.34 1.88 ± 0.81 4.81 ± 0.40 0.0002
Observer 2 4.75 ± 0.45 1.63 ± 0.50 4.63 ± 0.50 0.0004
Observer 3 4.81 ± 0.40 1.63 ± 0.62 4.75 ± 0.45 0.0004
Likert type-scale analysis: preoperative vs. postoperative appearance:1 = much
worse than preoperative; 3 = same as preoperative; 5 = much better than preoperative;
aesthetic appearance: 1 = poor; 5 = excellent. p values: calculated by comparing
pre- and post-operative scores.
6 weeks after surgery. Infrabrow skin excision scarring becomes
almost unperceivable after 3 to 6 months, as long as beveled
incisions and precise suturing techniques are performed.
Similarly to Lee et al.6 and Ichinose et al.,10 the authors
excise the skin layer only, while Kim et al.4 perform en bloc
excision of the skin and orbicularis oculi muscle when perform-
ing ISE. The authors preserve the orbicularis muscle in order
to avoid unpleasing scars. Furthermore, a superficial approach
reduces the risk of nerve injury and consequent local sensory
alterations.
The authors have performed the ISE technique only in
patients with high eyebrows. The authors do not recommend
this combined approach for patients with severe brow ptosis.
However, in cases of mild lateral brow ptosis, direct brow
suspension techniques could be associated with the ISE tech-
nique.5,14 Previous studies do not recommend the ISE approach
when blepharoptosis is present. Nevertheless, when a com-
bined procedure is performed (as presented here), blepharop-
tosis could also be easily corrected by the anterior approach
using the same UB access, or by the posterior approach, if
applicable.
As mentioned, the presented approach is indicated for
select cases only. Individuals who “qualify” for this procedure
are preferably women (for the use of makeup while the scar is
still visible) with high eyebrows, thick skin, significant derma-
tochalasis in the upper eyelids, and lateral hooding. Infrabrow
skin excision is also a good alternative as a single procedure
to address mild residual lateral hooding in patients who have
undergone previous blepharoplasty, as well as older patients
who desire upper eyelid rejuvenation but do not desire a notice-
able procedure. Infrabrow skin excision is not indicated for
individuals with severe brow ptosis or for those who cannot tol-
erate an infrabrow scar for a few months (usually male patients).
Although some degree of postoperative descent of the eyebrow
and shortening of the distance between eyelid margin and brow
may be a concern related to the ISE technique, in most patients,
4 © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
a larger amount of infrabrow skin is excised from the lateral
region (Fig. 1C), which is more arched in many Asian patients
(Fig. 1B). Furthermore, the procedure is usually performed
bilaterally, so that a possible eyebrow descent does not usually
cause cosmetic problems.13
In summary, ISE associated with UB has been found to
be a good option for addressing moderate and severe derma-
tochalasis with lateral hooding in elderly Japanese Brazilian
patients. The advantages of these combined procedures include
removal of redundant lateral thick skin in the upper eyelid and
inconspicuous scarring in the infrabrow region, resulting in
a rejuvenated and harmonic upper eyelid area in these select
patients.
ACKNOWLEDGMENTS
We acknowledge Aline Miki Hentona Nakauchi for the illustrations.
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