Visual, Physiological, and Aesthetic Factors and Pitfalls in Asian Blepharoplasty

Abstract

Double eyelid surgery to create an upper-lid crease in Asian patients is one of the more popular aesthetic surgeries among people of Asian descent. Much has been written about the myriad methods, but little has been written about the underlying factors that predispose a patient to complications and suboptimal results. This article touches on some of the possible errors in placement of crease height in upper blepharoplasty and the pitfalls that can be associated with permanent placement of nondissolvable sutures that encircle the complex layers of the upper eyelid, as well as the ideal eyelid crease wound closure and its biodynamics. One should consider these factors in any form of upper eyelid procedure, as they are not merely applicable to upper blepharoplasty.

Figure 1.

Geometric measurement of the tarsal tilt of this 33-year-old woman from a lateral view, in front of a slit-lamp microscope with head steadied vertically using forehead rest. Photograph was taken and a simple geometric protractor used to measure the slope of the surface of the pretarsal skin segment. This is probably subject to individual variations due to variability in the soft-tissue content in that location among different individuals.

Figure 2.

Mathematical model of an Asian globe with upper lid tarsus of 7 mm central height. Eyeball is 25 mm diameter. The upper lid is not drawn here but its margin lies from the top of the cornea upward, with the exposed cornea measuring 10 mm diameter. The 7 mm arc here represents the upper tarsus when the eyelid is opened and its lid margin is resting along the superior corneal limbus. (The horizontal arrow is drawn parallel to the axial line that runs from the center of cornea to the back of the eyeball.) The dotted line is the slope of the tarsus (hence the tilt of the pretarsal segment is of angle “I” relative to horizontal; the upper lid crease indents at the superior tarsal border at the site indicated by the short black arrow).

Figure 3.

Model of a Caucasian globe with a 10 mm upper tarsus. The solid circle is the eyeball. The upper lid is not drawn here but its margin lies from the top of the cornea upward, with the exposed cornea measuring 10 mm diameter. The 10 mm arc above the cornea represents the upper lid tarsus when the eyelid is opened. (The horizontal arrow is drawn parallel to the axial line that runs from the center of cornea to the back of the eyeball.) The dotted line is the slope of the tarsus rather than its true location in space (hence the tilt of the tarsus is of angle I relative to horizontal; the upper lid crease indents at the superior tarsal border at the site indicated by the short black arrow). Additional information about how I can be calculated is available online as Supplementary Material.

Figure 4.

Illustrating the concept of anatomic crease height represented by the black line spanning the actual dimension of the tarsal plate, tilted crease height (Tch, in blue vertical, or inclined crease height, Ich) represents the vertical visual component of the tilted tarsus when observed frontally. When there is a lid fold partly shielding the crease, the segment of pretarsal skin we see frontally is measured as the apparent crease height (red, vertical). Neither the Tch nor the apparent crease height represents the true extent of the anatomic crease height.

Figure 5.

Cross-section drawing showing placement of buried sutures that encircle the orbicularis oculi, levator aponeurosis, and underlying Mueller's muscle. Here it is shown as a blue 7-0 nylon or Prolene suture loop. Often a small fragment of preaponeurotic fat pad and orbital septum may be inadvertently included in the ligature.

Figure 6.

In buried-suture methods, a typical suture used may be 3 double-armed 6-0 or 7-0 nylon. In this drawing showing a right upper eyelid, it is showing the typical passages for the medial set of buried suture. The first passage (1) involves everting the upper lid margin and passing it subconjunctivally for 3-4 mm, at a level typically several millimeters above the superior tarsal border (A′-B′). The second passage (2) directs 1 needle toward the skin side along the path of B′-B, aiming just over the upper border of the tarsus. Similarly for the other arm of the suture, the third passage (3) goes from A′ to A. If each of the suture threads are tied on the skin at this moment, it will be a full thickness compression ligature encompassing (plicating) Muller's muscle, levator aponeurosis, and the orbicularis oculi muscle in a postero-superiorly biased fashion along the axis of levator muscle's contractility. It also inadvertently creates a Faden-like effect at each of the 2 locations of B′-B and A′-A. In actuality, the second needle exiting the skin at A is repassed (4) subcutaneously across to join B, exiting at a ministab skin opening there. The nylon ends are firmly tied and the knot sunken into the small surgical opening. In addition to the Faden-like effect, this results in a horizontal contraction in the width of levator aponeurosis at the 2 locations of A′-B′ as well as A-B. Traditionally, the suture methods use 3 sets of these sutures, 1 each at medial one-third, central, and lateral one-third. With 3 sets of sutures, the restrictive effect is tripled. Adapted from Chen WP, ed. Asian Blepharoplasty and the Eyelid Crease, 2nd ed. Oxford, UK: Butterworth-Heinemann, Elsevier Sciences; 2006. P. 271.

Figure 7.

This illustration shows the concept of trapezoidal and triangular debulking of eyelid tissues as applied in Asian upper blepharoplasty. The beveled approach allows a selective removal of those tissues that may be impeding crease construction and optimally aligns the wound for closure. After making the initial lid-crease incision plus an upper skin incision separated from it by 1.5-2 mm of skin, the green and red (returning) transorbicularis arrows represent the sides of a conceptual trapezoid, with the skin and front surface of levator aponeurosis being the 2 other sides essentially running parallel to each other. Depending on the limited amount of skin that needs to be removed, the excision of soft tissues can be performed in an elegant, trapezoidal block.^, This preserves more of the orbicularis oculi than traditional excision and allows a greater surface of the aponeurosis to be cleared. In most cases, a small amount of skin is necessarily removed to reduce the lid fold. One would not have to remove these tissues layer-by-layer and risks nonuniform treatment through the tissue planes. (In the very rare occasion when skin is not removed, only a single lid crease mark is incised and then after a beveled passage through the orbicularis oculi [now represented as the blue colored vector of transaction], the red-arrowed transaction across the orbicularis oculi allows a triangular cross segment of orbicularis oculi plus some septal remnant to be cleared.)

Figure 8.

(A) This 33-year-old woman underwent lid crease addition combined with ptosis repair. The previous surgeon set an external incision at 9 mm crease height; levator was exposed and aponeurosis was plicated to the tarsus with 6-0 nylon × 2. This was followed by 5-point suture fixation with continuous clear 7-0 nylon that remain buried. Crease did not form well and the surgeon went in a second time 4 months later and repeated the 5-point fixation with buried sutures through 5 stab incisions on each lid. The patient complained of redundant high creases in the mid-section of the crease with shallowing at medial and lateral one-thirds of the crease and a feeling of strain when opening her eyelids as well as on downgaze. (B) The patient was advised to wait for a year and a half before further revision attempt by this author. This image was taken 1 year and 2 weeks postoperatively after revision of the right upper-lid crease by author, resetting her high crease down to 6 mm height, with lysis of scar, and resetting the tissue plane. The patient reports relief of strained sensation as well as being happier with her more natural and predictable crease. Right eye is more open.

Figure 9.

This 36-year-old woman presented for primary Asian blepharoplasty with enhancement of her shielded asymmetric crease. (B) Postoperative view at 7.5 months shows improvement in crease height and symmetry. Eyes are more open.