| BackgroundThe orbital area includes the centrally located eye and surrounding tissue structures and organs.With advancing age,the orbital area often appears aging first.According to cosmetic anatomical characteristics,the orbital area is defined as the area surrounded by the orbital margin,including the eyebrow area,upper eyelid area,lower eyelid area,temporal area and condyle area.The upper eyelid area is the earliest and most obvious part of aging in the orbital area.There are individual differences in upper eyelid aging,which can be attributed to orbital bone resorption and periosteal retraction,reduced skin moisture and thinner texture,enhanced local muscle contraction,reduced fat capacity and fat shift,and ligament relaxation.The characteristics of upper eyelid aging in middle-aged and elderly people are:(1)With advancing age and the effect of gravity,the upper eyelid skin and the supporting ligament undergo degenerative changes,the adhesion of skin and muscle is poor,which leads to more wrinkles on the upper eyelid skin and upper eyelid skin sagging,even exceeding the edge of the eyelid,covering double-fold eyelids and part of the eyelid fissure,affecting the visual field.In severe cases,the edge of the eyelid is pushed inwardly,causing trichiasis and conjunctivitis;(2)Periorbital orbicularis oculi muscles become thinner,ligaments and orbital septum relax,orbital fat bulges or shifts,and upper eyelid appears bloated or depressed;(3)The uneven absorption of the orbital bone leads to an increase in the length of the orbital bone,the retraction of the orbital bone and the depression of the orbit.Reviewing published literature at home and abroad in recent years.At present,there are many surgical methods for the treatment of upper eyelid aging,including: upper eyelid blepharoplasty,double eyelid surgery,eyebrow lift.Although these surgical methods can basically solve the aging problem of the upper eyelid,there are still many limitations:(1)It is difficult to fully remove the laxity skin of the upper eyelid in a single operation;(2)After upper eyelid blepharoplasty,the upper eyelid often presents bloated and thick appearance;(3)The laxity skin at the lateral canthus is difficult to remove through double eyelid surgery,meanwhile this method probably increase crow’s feet after surgery;(4)The scar is obvious after the suprabrow blepharoplasty,and it cannot solve the aging problem of the upper eyelid area.The transbrow blepharoplasty is not suitable for patients who want to retain the eyebrow.Subbrow blepharoplasty often affects the original double eyelid,and eyebrow position may decline in the long-term follow-up.Based on the anatomical and functional characteristics and clinical experience of the upper eyelid aging,we adopt a surgical method: combination of subbrow blepharoplasty and double eyelid surgery(CSD).It is improved of the subbrow blepharoplasty(SBB),and implemented with double eyelid surgery(DES)at the same time.It can completely remove the excess upper eyelid skin,reasonably and effectively treat the orbicularis oris muscles,and fully relieve the tissue tension in the upper eyelid.This method can solve the problem of upper eyelid aging,including upper eyelid skin laxity,lateral hooding,eyebrows drooping,wrinkles,and asymmetry of the double eyelid.ObjectiveTo evaluate the surgical effect of subbrow blepharoplasty combined with double eyelid surgery through real world study,then compared with the previous surgical effect of subbrow blepharoplasty and double eyelid surgery,and analysis the surgical effect of applying three methods for upper eyelid rejuvenation.Explore a more innovative and practical method for upper eyelid rejuvenation.At present,there are no reports about the comparison and analysis of the postoperative effects of subbrow blepharoplasty combined with double eyelid surgery,subbrow blepharoplasty and double eyelid surgery at home and abroad.MethodsOn the approval by the Ethics Committee of Xijing Hospital of Air Force Medical University,thirty patients who underwent subbrow blepharoplasty combined with double eyelid surgery for upper eyelid rejuvenation were selected from September 2018 to September 2019 in Xijing Hospital.From January 2017 to March 2019,retrospective analysis the surgical effect of applying two methods for upper eyelid rejuvenation which including subbrow blepharoplasty and double eyelid surgery.Each of the two groups included in the study was thirty patients.All patients were female and the surgeries were performed by the same surgeon.There was no significant difference in gender,age,and degree of skin laxity on the upper eyelid among the three groups(P>0.05).In CSD group,advanced SBB was operated first,and then DES was performed.Excess skin was removed through the sub-brow incision,and then the orbicularis oculi muscle was suspended.Then the orbicularis muscle flap was covered and sutured with the muscle flap of the upper edge of the incision.Through an eyelid crease incision,the supratarsal upper eyelid skin,muscle,and orbital fat were excised,excessive tension was fully alleviated,and double-fold eyelids were adjusted and reshaped.In SBB group,only excess skin was removed through the sub-brow incision.In DES group,the supratarsal upper eyelid skin,muscle,and orbital fat were excised,and double-fold eyelids were adjusted and reshaped.Facial photos of patients were taken preoperative,1 month,3 months,and 6 months postoperative,and Photoshop software version 12.0 was used to measure upper eyelid data.The data include: upper eyelid skin resection width,marginal reflex distance 1(MRD1),medial corneal margin-fold distance(MCMFD),middle pupil margin-fold distance(MPMFD),lateral canthus margin-fold distance(LCMFD),medial corneal brow height(MCBH),middle pupil brow height(MPBH),lateral canthus brow height(LCBH),improvement of upper eyelid wrinkle lemperle score,visual analogue score(VAS),postoperative complications,and patient satisfaction.The results were expressed as mean±standard deviation,comparison between groups was performed by ANOVA and pairwise comparison between groups was performed by LSD-t test.Count data was expressed as percentage(%),and Chi-square test was used.The statistical tests were two sided,and a p-value of less than 5% was considered statistically significant.Statistical analysis was performed using SPSS version 23.0.ResultsAll patients’ incisions heal well,the swelling time in the CSD group was from 14 to21 days postoperative,and the SBB group and the DES group were from 7 to 14 days postoperative.Patients were followed up for 6-24 months,with an average of 12.5±3.5months.Upper eyelid aging was obviously correction in all cases after operation.1.Upper eyelid skin resection width.At the medial corneal,middle pupil and lateral canthus,the upper eyelid skin resection width in the CSD group was 5.52±0.35 mm7.38±0.31 mm,11.41±0.45 mm,in the SBB group was 5.51±0.36 mm,7.30±0.43 mm,11.48±0.48 mm,in the DES group was 3.49±0.40 mm,5.29±0.39 mm,6.33±0.69 mm.There was a statistically significant difference between the three groups(P<0.001).There was no statistically significant difference between the CSD group and the SBB group(P>0.05).There were statistically significant differences between the SBB group and the DES group,and the CSD group and the DES group(P<0.001).2.The effect of upper eyelid skin laxity correction(MRD1,MCMFD,MPMFD,and LCMFD).Upper eyelid skin laxity was obviously correction in all cases after operation.One month after operation,comparison between groups,the difference was statistically significant(P<0.001).There were statistically significant differences between the CSD group and the SBB group,and the SBB group and the DES group(P<0.001).There was no statistically significant difference between the CSD group and the DES group(P >0.05).Three months after operation,comparison between groups,the difference was statistically significant(P<0.001).In the improvement of MRD1,MPMFD,and LCMFD,there were statistically significant differences between the CSD group and the SBB group,the SBB group and the DES group,and the CSD group and the DES group(P<0.05).However in the improvement of MCMFD,there were statistically significant differences between the CSD group and the SBB group,and the SBB group and the DES group(P<0.001),there was no statistically significant difference between the CSD group and the DES group(P>0.05).The trend of statistical results at six months after operation was not significantly different from that at three months.3.Stability of upper eyelid skin laxity correction(MRD1,MCMFD,MPMFD,and LCMFD).One month,three months and six months after operation,the lifted upper eyelid skin in the CSD group was stable.But six months postoperatively,MCMFD showed a significant decline(P < 0.05).Three months and six months after operation,the lifted upper eyelid skin in the SBB group and the DES group showed a tendency to fall back(P<0.05).4.Brow height(MCBH,MPBH,and LCBH).In the CSD group,one month after operation,due to the relaxation of the frontal muscles and the increase of skin tension,the height of the brows declined slightly,but there was no significant difference compared with the preoperative brow height(P > 0.05).The brow height gradually rose to the preoperative level three months after operation,and the brow height was stable at the fixed height six months after operation,and the difference of LCBH was statistically significant compared with preoperative(P<0.05).In the SBB group,one month after operation,brow height drops significantly(P<0.05),three months and six months after operation,brow height was stable but there was significant difference compared with the preoperative brow height(P<0.05).There was no significant change in brow height in the DES group because the brow area was not treated(P>0.05).5.Improvement of upper eyelid wrinkle lemperle score.Upper eyelid wrinkle was obviously correction in all cases after operation.One month,three months and six months after operation,improvement of upper eyelid wrinkle lemperle score in the CSD group was 1.77±0.86,1.57±0.86,1.20±0.66,in the SBB group was 1.00±0.79,0.80±0.61,0.70±0.53,in the DES group was 0.70±0.65,0.60±0.57,0.50±0.41.Comparison between groups,the difference was statistically significant(P<0.001).There were statistically significant differences between the CSD group and the SBB group,and the CSD group and the DES group(P<0.001),there was no statistically significant difference between the SBB group and the DES group(P>0.05).6.Visual analogue score.One month,three months and six months after operation,surgeon score was: 3.50±0.51,3.80±0.66,4.07±0.45 in the CSD group,2.17±0.46,2.47±0.57,2.80±0.61 in the SBB group,1.87±0.43,2.03±0.32,2.27±0.58 in the DES group.Comparison between groups,the difference was statistically significant(P<0.001).The differences between the CSD group and the SBB group,the SBB group and the DES group,the CSD group and the DES group were statistically significant(P<0.001).Patient score was: 3.27±0.58,3.60±0.49,3.90±0.31 in the CSD group,2.00±0.59,2.27±0.45,2.77±0.57 in the SBB group,1.77±0.50,1.97±0.32,2.17±0.38 in the DES group.Comparison between groups,the difference was statistically significant(P<0.001).The differences between the CSD group and the SBB group,the SBB group and the DES group,the CSD group and the DES group were statistically significant(P<0.001).7.Postoperative complications.No serious complications such as infection,vision loss,and incomplete eyelid closure were found in the three groups of patients,with the exception of 2(6.7 percent)cases of vomiting and 1(3.3 percent)case of scalp numbness of CSD group,none of the patients had the above complications in the SBB group and the DES group.Comparison between groups,the difference was statistically significant(P<0.05).No severe scars appeared in the three groups,and the scars under the brows were effectively covered by the decorative brows,the scars on the double eyelid were covered by the double-fold eyelids.8.Patients satisfaction.Six months after operation,23 cases were satisfied,6 cases were basically satisfied,and 1 case was not satisfied,satisfaction rate is 96.7 percent in the CSD group.18 cases were satisfied,6 cases were basically satisfied,and 6 cases were not satisfied,satisfaction rate is 80.0 percent in the SBB group.15 cases were satisfied,7cases were basically satisfied,and 8 cases were not satisfied,satisfaction rate is 73.3percent in the DES group.Comparison between groups,the difference was statistically significant(P<0.05).ConclusionCSD,SBB,and DES can effectively correct the upper eyelid aging and achieve upper eyelid rejuvenation.However,CSD is superior to SBB and DES in the improvement effect and stability of upper eyelid skin laxity,brow height,upper eyelid wrinkle lemperle score,visual analogue score,and patients’ satisfaction.CSD is worse than SBB and DES only in terms of postoperative complications.This study demonstrates CSD method through double incisions approaches,is an effective way to excise upper eyelid skin,keep brow height stable,reduce wrinkles,adjust the shape of the double eyelid,implement the concept of brow-eyelid continuum,and reshape the good brow-eyelid aesthetic relationship.It should be considered as a better method for solving the problem of upper eyelid aging.However,this method is complicated,large in scope,has a long postoperative swelling and recovery time.Its postoperative complications are difficult to avoid.The simultaneous operation of the two incision approaches has the potential risk of mutual interference,which requires the surgeon to have extensive surgical experience and to communicate fully with the patients before surgery. |
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