William P. Chen, MD, FACS
In previous publications,1-7 I discussed the concept of upper eyelid crease configurations and the essential steps required for predictable placement of a lid crease among Asian patients without a crease. My method relies on accurately measuring the central height of the upper tarsus and using it to guide placement of the external incision line for formation of the crease. The ideal crease shape for Asians of Han origin tends to be either a nasally tapered crease or a parallel crease configuration. Medial upper lid fold often is present in the medial portion of the upper eyelid of Asians regardless of whether they have a crease and should not be considered pathologic nor should it be automatically removed.
The concept of trapezoidal debulking of pre-aponeurotic platform is an essential component of anatomic clearance of any redundant tissues along the superior tarsal border of the upper eyelid, such that a proper vectoring can occur on straight-ahead gaze as well as upgaze between the distal components of the levator aponeurosis and the skin to create a lid crease. Tissues that may form a barrier for proper vectoring over a narrow 2-mm to 3-mm zone overlying the upper boundary of the upper eyelid tarsus are eliminated by excising a small amount of skin, orbicularis, and distal orbital septum (the most inferior extent of any septum), as well as selectively excising or repositioning preaponeurotic fat.4 An in-depth discussion of the anatomic differences and cultural viewpoints toward this type of aesthetic surgery, as well as the management of complications, has been published previously.3 In addition to the method described below, there are other alternatives using suture ligation methods, with minimal skin incisions and no removal of redundant skin, muscle, or fat.
Surgical Technique
Marking the crease
One milliliter of anesthetic (2% lidocaine with 1:100,000 dilution of epinephrine) is used to achieve sensory anesthesia of the upper lid. I use the shaved-off tip of a wooden cotton tip applicator dipped with methylene blue to mark the proposed crease. The tarsus is everted, and the central width of the tarsal plate, which is usually between 6.5 mm and 8.5 mm, is measured with a caliper (Slide 1). This is transcribed onto the external skin surface, again over the central part of the eyelid skin (Slide 2). This point directly overlies the superior tarsal border and serves as a reference point for the overall crease height along the central one third of the eyelid, regardless of whether the crease shape will be nasally tapered, parallel, or laterally flared. For patients who already have a crease, I also measure the tarsus to confirm that the existing crease, if I am planning to preserve or enhance it, is the correct crease line to use.
If the crease is to be nasally tapered, with either a laterally leveled or flared configuration, I mark the medial one third of the incision line to taper toward the medial canthal angle or to merge with the medial upper lid fold. The lateral one third is marked in either a leveled or flared configuration as chosen. For the parallel crease, the measured height of the superior tarsal border is drawn across the width of the eyelid skin.
In summary, the height of the tarsus determines the overall central position of the surgical crease. The shape is determined by how the medial one third and lateral one third of this crease (lower line of incision) will be designed according to the patient's preference.
Making the skin incision
To create adequate adhesions, it is necessary to remove some subdermal tissue. A strip of skin measuring approximately 2 mm to 3 mm is marked above and parallel to the lower incision line. For a nasally tapered configuration, I taper this upper line of incision toward the medial canthal angle or merge it with any medial upper lid fold that may be present. As a result, the segment of skin to be excised is often less than 2 mm over the medial portion of the crease.
The incision is then made out using a no. 15 Bard-Parker surgical blade along the upper and lower lines, incising just below the subcutaneous plane. Any fine capillary oozing is controlled using a bipolar wetfield cautery. The strip of skin bounded by the upper and lower lines of incision is excised only after the orbital septum is opened along the superior line of incision and the skin-orbicularis-orbital septum flap is turned inferiorly along the superior tarsal border. Excision of this strip of skin is not necessary in every case; however, I believe it facilitates the removal of subsequent layers of the lid tissues, thereby allowing adequate crease formation.
Opening the orbital septum
At this point, the superior tarsal border is still covered by pretarsal and supratarsal orbicularis oculi muscle, with possibly some distal portions of the septum orbitale and the anteriorly directed terminal fibers of the levator aponeurosis beneath the septum.
To open the septum, I retract the upper incision wound superiorly and use a fine-tipped monopolar Bovie cautery in the cutting mode to incise through the orbicularis and orbital septum in a beveled fashion along the upper skin incision line.
In Asians, the orbital septum may be only 2 mm to 3 mm above the superior tarsal border. It is readily opened, exposing the underlying preaponeurotic fat pads (Slide 3).
Excising the pre-aponeurotic fat pads
Depending on the degree of fullness of the upper lid, I may use a pair of sharp scissors or a monopolar Bovie cautery in a low-power cutting mode to excise a small amount of the pre-aponeurotic fat pad (Slide 4). Any bleeding points are controlled with a bipolar wetfield cautery. The fat excision often requires a small local supplement of lidocaine in the space underneath the pre-aponeurotic fat pad.
If a patient with dermatochalasis and crease obliteration manifests minimal concavity in the supratarsal sulcus, I do not remove any fat as it will worsen the hollowness and result in multiple redundant folds superior to where the crease is wanted. Instead, I reposit any pre-aponeurotic fat upward into the supratarsal sulcus.
Excising the skin, preseptal orbicularis, and orbital septum
After the septum is opened horizontally, the strip of skin, supratarsal orbicularis, and orbital septum hinged along the superior tarsal border are excised. This myocutaneous strip consists of approximately 2 mm to 3 mm of skin, a greater amount of supratarsal orbicularis muscle, and a variable amount of the orbital septum (Slide 5A and Slide 5B).
Excising the pretarsal orbicularis
To facilitate infolding of the new crease, a 1-mm to 2-mm strip of pretarsal orbicularis muscle is excised along the lower skin incision edge. Some authors routinely debulk the entire pretarsal subcutaneous tissue, believing it is better to have only skin over the anterior surface of the tarsus. I prefer to remove pretarsal tissue only if pretarsal fat is apparent and threatens the surgical formation of the desired upper lid crease. In the pretarsal plane of a creaseless Asian eyelid, there are few if any terminal interdigitations of the levator aponeurosis to the dermis. I refrain from vigorous dissection along the pretarsal plane as it creates prolonged postoperative edema and can risk undesirable formation of more than one crease. Furthermore, it is natural for Asians with a natural crease to have some degree of pretarsal fullness along the area between the crease and eyelashes.
Forming the lid crease and closing the wound
To form a dynamic crease, the terminal fibers of the levator aponeurosis above the superior tarsal border should be directed to the subdermal plane of the lower line of skin incision along the superior tarsal border.
This is necessary to create the proper vectoring to form a dynamic crease.
I use 6-0 nonabsorbable silk or nylon sutures to pick up the lower skin edge and subcutaneous tissue to the levator aponeurosis along the superior tarsal border, and then the upper skin edge and tie each of these as an interrupted suture (Slide 6A and Slide 6B). Besides the stitch over the center of the crease, I place two or three sutures medially and three laterally. With these six or seven crease-forming sutures in place, the rest of the incision may be closed using 6-0 or 7-0 nylon in a continuous or subcuticular fashion (Slide 7).
Postoperative Care
During the immediate postoperative period, topical antibiotic ointment (such as polymyxin and bacitracin) are applied directly on the wound and stitches three to four times daily. The crease forms as a result of anatomic debulking of the pre-aponeurotic platform, as well as proper alignment of tissue planes along the crease-forming zone. For patients whose crease may not be apparent during the immediate postoperative period (first few days), this is typically due to excessive swelling. By the fourth or fifth day, the patient is encouraged to practice upward gaze such that proper vectoring of the crease may commence (Slide 8A and slide 8B). The sutures are typically removed 5 to 7 days postoperatively. No buried sutures are used or left behind.
References
- Chen WP. Asian blepharoplasty. Update on anatomy and technique. Ophthal Plast Reconstr Surg. 1987;3:135-140.
- Chen WP. A comparison of Caucasian and Asian blepharoplasty. Ophthalmic Practice. 1991;9:216-222.
- Chen WPD. Asian blepharoplasty. In: A Surgical Atlas. Butterworth-Heinemann; 1995.
- Chen WPD. Concept of triangular, rectangular and trapezoidal debulking of eyelid tissues: application in Asian blepharoplasty. Plast Reconstr Surg. 1996;97:212-218.
- Chen WPD. Eyelid and eyelid skin diseases. In: Lee D, Higginbotham E, eds. Clinical Guide to Comprehensive Ophthalmology. New York, NY: Thieme Medical Publishers Inc; 1998.
- Chen WPD. Oculoplastic Surgery: The Essentials. New York, NY: Thieme Medical Publishers Inc; 2001.
- Chen WPD, Khan J, McCord CD Jr. Color Atlas of Cosmetic Oculofacial Surgery. Butterworth-Heinemann/Elsevier Science; 2004.