In older Asian patients in whom the upper eyelid skin has lost elasticity and stretched but who don't want to introduce a new eyelid crease or alter the crease currently present, a long incision may be made immediately below the brow and an elipse of excess skin removed, thus pulling the skin upward much like lifting a window shade.
Some surgeons go further and excise a strip of muscle just below the skin and/or tighten the orbital septum that normally holds back the orbital fat.
Best candidates are in their late forties and up and have enough skin wrinkling around the eyes to help hide what can be a very visible scar. Because of anatomical variations, the operation is better suited for those of Asian rather than Eurpoean descent.
While the procedure is most effective in relieving "lateral hooding," or droopiness of the skin along the outer end of the eyelids, any relief along the inner half of the eyelids, if needed, is limited due to easy scar visibility in this region.
Infrabrow blepharoplasty (also called subbrow blepharoplasty or infraeyebrow blepharoplasty) can be useful in patients who desire skin removal but have already undergone several previous double eyelid operations earlier in life and have substantial internal scarring.
Because the lower and mid-level of the eyelid is not undergoing surgery, the operation cannot easily address accompanying problems such as ptosis, fat bulging, or hollowness.
Instead, infrabrow upper blepharoplasty is most appropriate as a simple operation for older people whose primary reason for having upper lid surgery is to reduce any eyelid skin overhang (especially at the outside corners) that may be interfering with vision.
Infrabrow blepharoplasty is seldom an appropriate choice for younger patients and cannot be used to form a double eyelid. For those concerned about achieving the best aesthetic effect, traditional approaches using an incision placed lower down offer greater access to lid anatomy where it matters. Even in the journal articles describing and recommending such operations, the before and after photos are far from impressive.
While simple, the operation is not without risks.
When overdone, enough of the uncovered eyelid platform above the lashes can create the appearance of a crease, even when the operation is undertaken to try to avoid this outcome. Often such "pseduo-creases" appear uneven and so call attention to themselves.
If orbicularis muscle below the skin is excised, the final scar may be depressed. If the orbital septum is overly tightened to try push back any bulging fat, the eyelids may be difficult to close fully or even crack open during sleep.
It is also possible to pull the brows downward, especially in older patients in whom brow support may already be fairly weak. A lower brow can create the look of scowling and is almost never an aesthetic improvement.
And yes, the final scar below just below the brow is long, very much on display, and not easily modified if it ends up too objectionable.