The Eyelid Crease Height, Depth, and Shape: A Scoring System for Revisional Asian Blepharoplasty

Abstract

This study reports on a series of challenging revisional Asian blepharoplasty cases with various suboptimal factors, including high or low crease height, shallow or deep crease indentation (depth), and suboptimal crease shape. The study also presents a simple scoring scale that combines these challenges into a composite score, which has helped in the management of these cases.

Methods: Data on 64 revisional cases were collected between January 1, 2006, and June 30, 2019, with 126 upper eyelids. These were cases with little skin remaining after previous surgeries, and each eyelid was scored based on a height, depth, shape scoring method. A composite score (H + D + S) is then summed up, which ranged from 1 to 10, with the higher number being the most challenging. The logic and rules behind this scoring scale are explained.

Results: Data regarding age, gender, and eyelid crease characteristics of the cases were collected; photographs, notes, and diagrams in the medical records were used to complete each eyelid's scoring. The age of the patients (57 women and 7 men) ranged from 21 to 74 years. The revision score distribution, age distribution, and averaged scores within each age group were investigated for those starting at 24 years or younger, and for each added decade until over 65 years. Patients with revisional effort scores of 5-8 were found in all age groups surveyed.

Conclusions: In this study, the author presents a practical scoring scale that recognizes the factors responsible for the suboptimal results in double eyelid plasty and helps clinicians in management, patient-counseling, and planning of surgical solutions.

Fig. 1.

Circle of parameters and of complications in Asian blepharoplasty—height, shape, continuity, and permanence. Reprinted with permission Chen WPD. Asian Blepharoplasty and the Eyelid Crease. 3rd ed. Edinburgh/New York: Elsevier; 2016.

Fig. 2.

Clinical pathway: selection criteria in this scoring study of revisional Asian blepharoplasty. Patients included are indicated in the yellow box; all had crease height, depth of scar, and/or crease shape issues and exhibited scarcity of skin. (The patients who had residual skin needed only standard revisional upper blepharoplasty with a proper design of crease height, proper technique to ensure ideal depth, and proper shape design; these are not included in this article.)

Fig. 3.

H (height) correction is based on whether the crease is abnormally high, normal, or abnormally low. Adjusting downward from high crease height toward the direction of normalcy requires an effort score of 5 (red arrow), while to raise an abnormally low crease height to a more ideal position is scored 3 (orange arrow). D (depth) is judged based on whether the existing crease form is abnormally deep (or showed wound spread or skin gaping), whether it is normal depth, or either too shallowed or without invagination at all. When showing deep-set crease or a wound spreading, the RES is assigned a value of 3 (up arrow). If the depth is too shallow, with a rudimentary indentation or frank absence of crease, the RES is also assigned 3 (down arrow). S (shape) is judged based on the existing state of the medial portion of the eyelid crease: If absent, and the need is to construct either a parallel shape (“open”) or a nasally joining crease (or “closed”), the RES is 1. Conversion of the shape from NJC to parallel requires an RES of 1; converting parallel to NJC is scored 2. An existing crease shape that is satisfactory and requires no change is scored zero. An existing crease that has an excessive medial upper fold shielding it and therefore requires partial reduction is assigned a score of 1.

Fig. 4.

Distribution of revisional effort scores {composite of H + D + S} for 126 upper eyelids of 64 patients. (Green, yellow, orange, and red are arbitrarily assigned to represent the progression of difficulty level with revisions.)

Fig. 5.

Age distribution of 64 patients.

Fig. 6.

Averaged HDS scores within each decade of age.

Fig. 7.

Incidence of high and low crease height abnormality among scored eyelids.

Fig. 8.

RES of 10: 30-year-old woman {5, 3, 2}; high, deep, parallel with persistent pretarsal swelling; desired NJC shape.

Fig. 9.

RES of 9: 27-year-old woman {5, 3, 1}; high semicircular, deep; convert to parallel shape.

Fig. 10.

RES of 8: 25-year-old woman {5, 3, 0}; high and deep; stayed with nasally joining shape.

Fig. 11.

RES of 7: 50-year-old woman {3, 3, 1}; had incisional method. Low, shallow, nasally joining crease shape. Preferred higher crease height and convert to parallel shape.

Fig. 12.

RES of 6: 31-year-old woman {3, 3, 0}; low crease, deep-set wound scar, with significant induration and medial fold more than 1 year beyond prior procedure. Stayed with NJC.

Fig. 13.

RES of 5: 28-year-old woman {5, 0, 0}; 10 years after sutures method; high crease height with multiple lines; stayed parallel.

Fig. 14.

RES of 4: 40-year-old woman {3, 0, 1}; had sutures method. Low crease height, nasally tapered; stay with NJC and needed medial fold reduction.

Fig. 15.

RES of 3: 50-year-old woman { 0, 3, 0 } 15 years after incisional Asian blepharoplasty at 35 y.o. Repeated blepharoplasty with crease height of 7.5 mm, NJC shape.

Fig. 16.

RES of 1: 40-year-old woman {0, 0, 1}; 10 years after external incisional upper blepharoplasty at 30 years. Preferred change to parallel shape.

Fig. 17.

Sequential steps after first traversing through 2 fascial planes (the skin-orbicularis oculi scar and orbicularis-orbital septum-fat scar) in the super-beveled approach in revisional Asian blepharoplasty, by Chen.^, “Restore” refers to improvement in the (preseptal/pretarsal) ratio or (upper/lower segment) ratio.