| | Asian Blepharoplasty: An 18-Year Experience in 6215 PatientsAccepted 1 April 2009. BackgroundReconstruction of the suprapalpebral fold (SPF) to create a double eyelid is a popular procedure in many East Asian countries. However, the traditional long-incision, double-eyelid blepharoplasty procedure can result in eyelid swelling that lasts for months, resulting in the temporary appearance of an excessively high SPF. ObjectiveThe author describes 18 years of experience using a short-incision technique for Asian blepharoplasty in 6215 patients. MethodsA short incision to minimize eyelid trauma and surgical scarring was made on only the middle one-third of the upper eyelid. The dissection was extended far enough superiorly, medially, and laterally above the levator aponeurosis to obtain maximum upward movement of the globe. Three anchoring sutures were placed for the creation of the permanent SPF, with inverted stitches between either the levator aponeurosis or the lower border of the stripped orbital septum, to either the dermis or the dermomuscular junction of the lower margin of the incised skin. Intraoperative adjustment of the curvature and the lateral flare of the SPF was accomplished by changing or releasing the point of the anchoring suture in four different ways: to either the upper or lower dermal or dermomuscular junction of either the lower or upper margin of the incised wound or, on rare occasions, by a small elliptical excision of the upper skin flap. In 70% of patients, changing the medial anchoring suture to the proper position resulted in the creation of suprapalpebral outside fold, without any need to perform epicanthoplasty. ResultsThe average operative time was 33 minutes. Most patients did not need to refrain from attending work or school. The postoperative complication rate was 3.8%. The most common temporary unfavorable results were minimal swelling, bruising, and eversion of the eyelid margin. Minor complications included asymmetrical fold, fading of the fold, depressed scar, and drooping of lateral eyelid skin. All of the minor complications were treated successfully. There were no severe complications. ConclusionsThe short central incision is a semi-open blepharoplasty technique for creating the double eyelid that is suitable for all patients without loose upper eyelid skin.
Most East Asian people in Japan, Korea, the People's Republic of China, Taiwan, Singapore, Vietnam, and Mongolia have no upper eyelid crease or suprapalpebral fold (SPF)—the so-called “Asian eyelid” or single eyelid. Most double eyelids in Asian populations are characterized by epicanthal folds or hidden suprapalpebral inside folds. Some Asians have suprapalpebral acute outside folds, but not many have suprapalpebral parallel outside folds like those found in white populations (Figure 1).
In Thailand, many people are of Chinese descent. Some have no SPF, while some have a small, visible, unilateral or bilateral SPF with or without an epicanthal fold. These are defined as a typical Asian and atypical Asian eyelid, respectively. Most people in both categories prefer prominent double eyelids to single eyelids (Figure 2).
The primary concern with respect to eyelid anatomy is the aponeurotic expansion of the levator palpebral superioris muscle. There is some controversy as to whether the upper eyelid crease is formed primarily by traction on the cutaneous fibers or by the more substantial orbicularis oculi muscle insertions.1 In the eyelids of white patients, the levator aponeurosis centrally fuses with the orbital septum above the superior tarsal border; it inserts primarily into the orbicularis oculi muscle and skin of the upper eyelid, and secondarily on the anterior, inferior one-third of the tarsus. By contrast, in the Asian eyelid, the orbital septum fuses with the levator aponeurosis below the superior tarsal border, while the inferior extension of the orbital septum acts as an anatomic barrier for cutaneous insertion of the superficial aponeurotic fibers. The eyelid crease is therefore not developed.2 It is generally understood that the SPF is created by the insertion of levator expansion to the skin. In white populations, the level of insertion is high; in Asians and East Asians, it is low. When the insertion of the aponeurosis it is too close to the ciliary rim (as can be observed during eye closure), it can appear that there is no levator expansion insertion, resulting in a single eyelid.
Asians with double eyelids are usually admired by those with single eyelids. Most Asians with double eyelids prefer the appearance of suprapalpebral parallel and acute outside folds to suprapalpebral hidden folds. Consequently, blepharoplasty focusing on reconstruction of the SPF is a popular aesthetic procedure in Thailand and many other East Asian countries. The purpose of this procedure is to enhance the Asian eye rather than to Westernize it to resemble whites, in whom the orbital skeletal framework (ie. the superior orbital rim) is more prominent than in Asians. Some patients have attached a small elliptically-shaped piece of tape—either transparent or skin-colored—to the upper eyelid skin to create artificial, temporary double eyelids rather than undergoing surgery.
One of the most common minor complications associated with traditional long-incision, double-eyelid blepharoplasty is eyelid swelling that results in an excessively high SPF that lasts for months. Most patients with this complication have to wear sunglasses to hide their eyes for an extended period of time and some have to refrain from going to work. Severe complications following this procedure are rare. However, any disturbance to or loss of visual acuity or ocular function can be bothersome (or even devastating) to patients. It is also a major problem for surgeons.
In 1983, in the course of performing a traditional long-incision, double-eyelid blepharoplasty, the author observed that placement of just one anchoring suture in the middle of the upper eyelid could create a curved (if not perfect) SPF. This finding raised a question as to whether a long incision was needed at all, because a shorter incision would induce less trauma and consequently less edema, given that edema is a normal and inevitable physiologic response to trauma. Therefore, when performing double-eyelid blepharoplasty, the author began using a short incision on the middle one-third of the upper eyelid. The vertical height of the fold was 7 mm, as high as it had been in the author's previously-performed long-incision, double-eyelid blepharoplasty. Although a natural-looking SPF with minimal swelling was achieved with the use of only three anchoring stitches, the SPF became too small after a few months and needed revision. In later procedures, the vertical height of the fold was increased through intraoperative adjustment of the tenting effect of the three anchoring sutures, to make the SPF a permanent curvature with lateral flare (Figure 3). Although the author did not perform this procedure between 1984 and 1986 during continued study in the United Kingdom, it was later reported at scientific meetings held in Thailand and other Asian countries. The technique is being presented here for international publication for the first time.
Methods  Between 1986 and 2004, 6215 patients underwent this procedure, including 5818 females and 397 males. Patient ages ranged from seven to 54 years (average 23.6 years). Among those treated were 2012 children and teenagers (1845 females, 167 males; seven–19 years of age), 3415 young adults (3234 women, 181 men; 20–40 years of age), and 788 middle-aged patients (739 women, 49 men; 41–54 years of age; Figure 4). One hundred twenty-seven patients had undergone blepharoplasty performed by other surgeons, but were not satisfied with the results. The technique was briefly described to the patients in preoperative consultations. Some patients asked to see preoperative and postoperative photographs. All patients were advised to expect minimal swelling, bruising, and eversion of the upper eyelid margins in the early postoperative period. They were also informed that a feeling of tightness or a “tugging” sensation during eye opening might develop immediately after the operation, but would disappear after several weeks. Patients were also advised not to refrain from attending work or school, even on the first day after the operation. They were informed that the surgeon would correct any complications; for example, an asymmetrical or fading SPF would be revised. Surgical technique No premedication was employed for this procedure. All patients were instructed to clean their facial skin with an antiseptic skin cleanser immediately before the operation. While lying on the operating table, the procedure was described to the patient in a step-by-step fashion; patients were also told that they would experience no pain. One drop of ophthalmic anesthetic solution (tetracaine 0.5%) was applied to each eye. The skin was again gently cleansed with an antiseptic solution diluted in sterile water. Special care was taken to avoid corneal irritation and a sterile dry gauze was used to swab the solution from the eyelid skin, particularly in the medial canthal region. Once the facial skin was prepped using these aseptic/antiseptic techniques and draped, the procedure was performed using only local anesthesia containing epinephrine, so that the patient could cooperate by opening and closing their eyes during the surgery. The difference between success or failure in double-eyelid blepharoplasty can be a matter of millimeters. Patients generally have high expectations and require symmetrical SPFs, even though the folds in many people with aesthetically-pleasing double eyelids are not necessarily symmetrical. To achieve the desired symmetry, the vertical height of the lid fold was routinely measured with a caliper while the patient's eyes were closed. The upper eyelid skin was held slightly taut. The inferior border of the measurement was at the uppermost row of the eyelash line (not at the ciliary rim) and at the midpupillary vertical line. The vertical height of the lid fold ranged from 8.5 mm to 10 mm (average 9.2 mm) in females and 8 mm to 9 mm (average 8.5 mm) in males. Postoperatively, SPF height was lower than indicated by the measurements because the skin later dropped down to cover the incisional scar. The height chosen depended on both the patient's and the surgeon's preferences; the author gave priority to the patient's wishes. It is also necessary to keep cultural preferences among different nationalities in mind to avoid overcorrection; for instance, Japanese and Korean women do not want double eyelids as wide as those preferred by most Thai and some Chinese or Vietnamese women. Dipping one end of the caliper tip in methylene blue or gentian violet facilitated marking of the superior line. The line was drawn in the middle one-third of the upper eyelid, about 1 cm long. While drawing, the lateral part of the incision was marked slightly higher than the medial part; this technique can help create lateral flare of the SPF (Figure 5). Symmetry of the markings on both sides was checked and revised as necessary. Using either a 30- or 27-gauge needle, the marked line was slowly infiltrated with either 1% or 2% lidocaine with epinephrine. The total anesthetic solution used for both sides was less than 0.5 mL. Care was taken to inject the anesthetic solution just superficial to the orbicularis oculi muscle when skin blanching was observed. Light pressure was applied to both upper eyelids immediately after the injection on each side for hemostasis; otherwise, subcutaneous bleeding could cause bruising and additional eyelid edema. After the vasoconstrictive effect of the anesthetic solution was noted, an incision on each side was made using a no. 15 scalpel. The skin was incised deep to the orbicularis oculi muscle with no skin excision. Either a fine-tooth forceps or a jeweler's forceps was used to hold the exposed tissues and sharp scissors were used to trim the tissues layer by layer, removing a tiny strip of the muscle and retro-orbicularis oculus fibrofatty tissue in small pieces. Debulking the pretarsal muscle attached to the lower skin incision helped to reduce postoperative edema in the eyelid. However, more muscle was excised on the medial aspect, so that more swelling of the fold would occur on the lateral part than on the medial part. This technique also helped to create lateral flare of the SPF. The orbital septum and its vertical vascularity were identified. When the orbital septum (which anteriorly fuses with the shiny, dense, and grayish-white band of the levator aponeurosis below the superior border of the tarsus) was cut, the excess orbital fat extruded through the opening of the stripped orbital septum without pressure on the upper eyelid over the globe. Therefore, the outer sheath of fat capsule and its horizontal vascularity could be seen. The excess fat of the puffy eyelid evaluated before the operation was teased out from the thin transparent inner sheath of the middle pocket after additional local anesthetic solution was injected into the fat area. The base of the excess protruding fat was clamped with a curved arterial clamp, trimmed off with sharp scissors, and electrocauterized. To ensure meticulous hemostasis, repeat electrocoagulation was performed after the arterial clamp was removed. The orbital fat was removed only when indicated preoperatively. Only the levator aponeuroris was identified. If the central fat was not to be removed, the orbital septum was not cut. If medial pocket fat was to be removed, the incision was extended medially in a curved fashion. The bulging fat was dissected and partially removed. Care was taken to avoid arterial bleeding in this area, including the performance of meticulous hemostasis. The lower border of the remaining orbital septum and/or the levator aponeurosis were identified for later use as inverted anchoring sutures to either the lower dermis or the dermomuscular junction. Confirmation of the remaining orbital septum or levator aponeurosis was attained by asking the patient to open the eyelids while the structure was being grasped with the forceps; if correctly identified, the patient was not able to open that eye (while the other was open) and the surgeon could feel the excursion. Although only a short central incision was employed, the dissection was adequately carried out under the upper eyelid skin flap far from the incision (Figure 6). This technique allowed for greater division of the muscle, the retro-orbicularis oculus fibrofatty tissue, and the orbital septum both medially and laterally. The anterior surface of the identified levator aponeurosis was also dissected free from the surrounding tissues superiorly, laterally, and medially to obtain maximum upward movement of the globe and a curved and prominent SPF, so that pseudoptosis from adhesion and a “tugging” sensation would not develop when the patient was looking upward during and after the procedure. In those patients who had undergone previous upper blepharoplasty, the old sutures within the operative field and the soft tissues were removed and completely released from adhesion with the levator aponeurosis or the tarsus. Meticulous hemostasis during this step was necessary and required additional local anesthesia, especially if a more extended incision was made, until it could be observed that the operative field was completely dry without any oozing of blood. The three anchoring sutures were used in a fashion similar to three poles being used to support a curvilinear tent. Each anchoring suture could be placed in any one of four different manners (Figure 7). Intraoperative adjustments of each anchoring suture could be used to create different double-eyelid crease contours. Only those that resulted in satisfactory contours were kept. The first inverted anchoring suture (6–0 nonabsorbable monofilament) was placed centrally in the midpupillary line. This middle stitch was taken from the levator aponeurosis or the remaining stripped orbital septum to the lower dermis or the dermomuscular junction (not purely the muscle) of the lower eyelid skin. Each surgical knot was tied four times to prevent any slippage and to strengthen the suture, and to prevent late disappearance of the SPF. When the patient was asked to open the eyelids, the SPF was immediately visible. However, the second and third inverted anchoring sutures were placed on the medial and lateral sides of the first suture if that suture alone did not achieve a sufficiently wide fold. The patient was asked to open and close the eyelids after each of these sutures was completed. The SPF was evaluated and revised as necessary until a satisfactory fold was achieved (Figure 8). If the medial fold was too narrow or if a prominent epicanthal fold developed, the medial anchoring suture was stitched off and removed. A new and higher anchoring suture was created by suturing to the dermis, the dermomuscular junction of the upper border of the incision, or a bit higher and/or more medial to the upper border of the incision. This technique resulted in the development of a suprapalpebral parallel or acute outside fold in more than 70% of patients, without the need for epicanthoplasty. Epicanthoplasty was performed in conjunction with this technique if requested by the patient; however, patients were advised that this procedure could result in minimal but possibly noticeable scarring in the medial canthal region. If the SPF on the medial side was angulated rather than curved, the surgical knot at the medial side was cut; the suture was then removed and replaced with a new anchoring suture slightly lower and/or more lateral than the previous one, in order to obtain a curved medial fold that was narrower than the central part of the eyelid (Figure 9). If the fold on the lateral part was narrower than the central part, the lateral anchoring suture was stitched off, removed, and replaced with a new anchoring suture placed somewhat higher, at the lower dermis or dermomuscular junction of the upper border of the incision and/or slightly more lateral on an extended incision (Figure 10). This technique can help tilt the SPF upward from the medial to the lateral canthus. The patient was asked to open and close the eyes to further evaluate both the SPF and lateral flare of the SPF. The technique could also be modified by performing a small elliptical excision of the more lateral upper lid skin flap, with or without the use of an additional anchoring stitch to obtain a lateral flare of the SPF. In this technique, which is most often used after long-term follow-up or in the aging eyelid, an extended incision is made laterally and the surgical scar will be longer (Figure 11). In those patients with both lateral brow ptosis and hooding of lateral upper eyelid, only a lateral brow lift can correct the problems. During eye opening, if the central part of the SPF was observed to be flat while the surgeon gently pushed the eyebrow inferiorly, the central stitch was adjusted to obtain a natural, curved SPF by placing a new, higher anchoring stitch at the lower dermis or dermomuscular junction of the upper border of the incision. A small elliptical excision of the excess central skin, especially in eyelids of older patients, was occasionally made to obtain a curved SPF if the skin drooped during eye opening with the patent in a sitting position (Figure 12). In addition to the creation of symmetrical SPFs, the direction of the eyelashes on both sides and the optimum eversion of the lid margins must also be symmetrical and not overly everted. If they were not symmetrical, they were adjusted intraoperatively by raising the point of the anchoring suture either at the levator aponeurosis or the remaining stripped orbital septum to obtain more eversion, lower the point, and attain less eversion of the lid margin. Eversion of the lid margins could also be reduced by using a tiny cut around the anchoring stitch to release its tension. In the author's experience, the technique of changing and releasing the anchoring sutures can be applied with care to help in upper lid blepharoplasty of the aging eyelid in both Asian and white patients, using a traditional long-incision technique. Two or three interrupted skin sutures were usually employed for accurate skin closure, although subcuticular stitches were sometimes used. Antibiotic ointment was applied to the wounds only once. No dressing was used to cover the wound and cold compresses were only occasionally applied over the eyelids. Postoperative antibiotics were not routinely prescribed. Immediate postoperative eyelid swelling was so minimal that most patients did not have to refrain from attending either work or school. The stitches were removed from five to seven days postoperatively and were sometimes removed as soon as three days after the procedure. Results The operating time varied from 25 to 51 minutes (average 33 minutes). Immediately after the operation, the SPF usually appeared too high in both eyes because of temporary swelling and bruising of the tissue. The folds dropped to the intended height within four weeks or less. Any asymmetry related to swelling resolved when the swelling subsided. Any temporary eversion of the eyelids that developed resolved over time. During the first week after the operation, most patients did not refrain from attending either work or school. The initial small SPF in the atypical Asian eyelid disappeared after the new SPF was created. Two patients were not satisfied with the postoperative results. One was an 18-year-old woman who returned for surgery a week after the procedure to convert the double eyelids into the original single eyelids. She could not accept the drastic postoperative change in her facial appearance. To solve her problem, all three anchoring sutures were removed and the skin was directly closed. The SPF disappeared from both eyelids and only short incisional scars remained. The other patient was a 23-year-old man who felt that the surgery had not provided results superior to those he achieved when simply using transparent skin tape to create an artificial double eyelid, but he did not request revision and did not come back for the further follow-up. These events serve as a reminder that the psychological motivation of the patient should be carefully considered before performing any aesthetic procedure. Apart from these two patients, all patients (including those who had undergone a previous first upper blepharoplasty elsewhere) were satisfied with both the immediate and long-term postoperative results (Figure 13, Figure 14, Figure 15). There were no severe postoperative complications. Minor complications developed in 236 patients (3.8%; Table), including asymmetrical folds in 72 patients (63 women, nine men) and partial or complete fold disappearance in 11 patients (six women, five men). They were corrected by placing new, satisfactory anchoring suture(s). Forty-three patients (33 women, 10 men) developed depressed, noticeable scars that required scar revision; there were no cases of wound dehiscence or hypertrophic scars. One hundred men and 10 women (age range 38–54 years) developed progressive drooping of the lateral eyelid skin that was corrected by simple elliptical skin excision (with or without an additional anchoring stitch) and direct skin closure. In some cases, excision of the orbicularis oculi muscle and the retro-orbicularis oculus fibrofatty tissue was also performed, with or without any additional anchoring stitches. In these cases, the upper eyelid scar was longer. No patients developed wound infection, even though no oral antibiotic prophylaxis was employed in some patients. There was no lagophthalmos because this technique did not excise the skin. There was no incidence of vision problems or chemosis. Assessment of long-term complications was difficult since some patients were lost during follow-up because of incorrect addresses or because they were overseas patients unavailable for follow-up. All patients requesting Asian blepharoplasty have high expectations. If the postoperative results were successful, most of them would not come back for follow-up even if requested to do so. Only those 236 patients who came back for revisions were assumed to have complications. These minor complications were addressed until the patients were satisfied with the final results. Discussion In 1896, Kotaro Mikamo,3 a Japanese physician, reported the first results of a double-eyelid procedure to make the Japanese eyelid more attractive. The technique he described is still the most commonly performed procedure in present-day East Asian double-eyelid surgery. In 1929, Maruo4 reported the first incisional technique using fixation of the skin edge to the tarsus. Since then, some 40 variations of the double-eyelid procedure have been reported in Japan.5 When the author began using his technique for Asian blepharoplasty in 1983, there were two different operative concepts for this procedure. One was the suturing technique, also referred to as the closed or nonincision technique.6, 7, 8 The intradermal stitch nonincision blepharoplasty is still very popular in Japan9, 10 and Korea11 and has been modified to include a tiny skin incision. The other concept was the open or long-incision technique,7, 12, 13, 14, 15 which is most commonly performed using a long incision with or without skin, muscle, and fat excision. In both concepts, the SPF or double-eyelid crease can be created by suturing either the levator aponeurosis or the tarsus to the lower border of the eyelid skin, the muscle, or to both the skin and the muscle. The author used only the traditional long-incision technique, because the open technique allows the surgeon to clearly see what needs to be done. In the author's experience, hematoma has never been a problem as long as meticulous hemostasis is maintained. The author still uses the traditional long-incision technique when treating patients with aging eyelids or loose skin. Since 1983, the author has been using a semi-open technique with a short (but not tiny) incision at the middle one-third of the upper eyelid. The dissection just above the levator aponeurosis extends far beyond the incision. A satisfactory SPF is attained by changing or releasing the point of the anchoring sutures intraoperatively in four different ways. Tarsal fixation is not used, in order to avoid a permanent noticeable depressed scar. It should be mentioned that a lower or a higher incision will not always result in a lower or a higher SPF. Rather, the height of the SPF depends on whether the anchoring suture is at the lower or the upper border of the incision. Changing or releasing the point of the anchoring suture is similar to a “cut (anchor) as you go” surgical principle, and this technique can be modified and applied to upper blepharoplasty in all aging eyelids. Progressive drooping of the aging lateral eyelid skin is a common problem. To reduce the incidence of this minor complication, attention must be paid to the lateral anchoring suture. The lateral flare must be visible immediately after the operation. Changing the medial anchoring suture to the proper position results in the creation of a suprapalpebral outside fold (either acute or parallel) in more than 70% of patients and eliminates the need for epicanthoplasty. The SPF makes the eyes look larger, longer, and more attractive; it is therefore demanded by most Thai patients. The lateral flare of the SPF is an additional patient concern. It can be obtained in four ways: (1) by making the incision higher laterally; (2) by excision of additional muscle medially; (3) by shifting the lateral anchoring suture to a slightly higher and/or more lateral position on the extended incision (1 or 2 mm); or (4) by a small elliptical excision of the upper lateral skin flap above the incision (with or without an extended incision). However, in some patients with a combination of lateral eyebrow ptosis and minimal drooping of the lateral double eyelid, only a lateral brow lift can correct both deformities. The benefit of an atraumatic or minimally traumatic technique is evident when a short incision with minimal adequate dissection and meticulous hemostasis is carefully performed. The reduction in trauma results in less tissue edema. Immediate postoperative minimal swelling, bruising, and an unnoticeable (or barely noticeable) scar are the advantages of this technique. The incidence of minor complications requiring correction is low (3.8%) and includes asymmetrical SPF, partial or complete disappearance of the SPF, noticeable depressed scars, and progressive drooping of the lateral upper eyelid skin. The number of such complications will decline as surgeons gain experience with the technique. However, the procedure is not recommended for the middle-aged or elderly patients with redundant eyelid skin. Conclusions The short central incision technique is a semi-open form of Asian blepharoplasty focusing on intraoperative adjustment of the SPF by changing or releasing the three anchoring sutures. It is simple, straightforward, and easily mastered once the relevant anatomy is understood. It is indicated for children, teenagers, young adults, and middle-aged patients who do not have much loose upper eyelid skin. The bulging central and/or medial fat can be removed. A small elliptical excision of the middle one-third or more lateral upper eyelid skin flap, with or without an extended incision, may be required to obtain a satisfactorily curved symmetrical SPF with lateral flare. Most patients will not need to refrain from attending either work or school. References 1.
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MEDLINE  Reprint requests: Arthi Kruavit, MD, Division of Plastic and Maxillofacial Surgery, Department of Surgery, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok 10400, Thailand
DISCLOSURES The author has no disclosures with respect to the contents of this article. PII: S1090-820X(09)00256-8 doi:10.1016/j.asj.2009.04.004 © 2009 The American Society for Aesthetic Plastic Surgery, Inc. Published by Elsevier Inc All rights reserved. | |
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