The Clinical Problem
Synopsis
Upper eyelid blepharoplasty in Asians often refers to double-eyelid plasty and epicanthoplasty because about half of Asians lack an upper eyelid crease, so-called single eyelids. Many procedures for double-eyelid plasty have been reported since the suture technique was described by Mikamo in 1896. Although the surgical principles are similar to those for occidental eyelids, the surgical design and operative technique are different because there are distinct anatomic differences in Asian eyelids.
The Aesthetic Problem
Asian upper eyelids are anatomically different from that of white upper eyelids. Single eyelids are one of the most characteristic features of Asians. There are many causes, such as lower fusion point of the septum and levator, lack of levator aponeurosis penetration into the pretarsal orbicularis oculi muscle, and lower penetration of preaponeurotic fat into the pretarsal area ( Fig. 7.1 ).
Epicanthus is another feature of the Asian eye. The epicanthus covers the lacrimal lake and width of the interepicanthal distance. Patients who have surgery for epicanthic folds and desire concurrent double-eyelid surgery often develop aesthetically unpleasant results.
Indications and Counseling
The indications for the upper eyelid blepharoplasty are as follows:
- 1.
Type of crease—lacking, low-set, incomplete, asymmetric, multiple creases
- 2.
Epicanthal fold
- 3.
Entropion
- 4.
Puffy eyelid without exophthalmos
- 5.
Blepharoptosis
Creating a lid crease is not the most challenging operation of Asian blepharoplasty. Creating a symmetric and natural crease is more important but difficult to achieve. In the East Asian individual, the natural crease typically parallels the lid margin in the outer two-thirds of the eyelid, closing toward the eyelid margin as it proceeds nasally. On the other hand, there are some variations in the medial area. Medially, the crease ends above the epicanthus, fuses with the epicanthus, or dives beneath epicanthus.
The surgeon should evaluate the presence of blepharoptosis, morphology of the upper eyelid crease, and eyebrow position, then simulate the upper eyelid crease by pressing a bougie onto the lid skin. Simulating several heights of the crease can help both the surgeon and patient realize the ideal position of the crease. The surgeon should ask about the patient’s desire for the medial area. When the patient chooses the parallel type, medial epicanthoplasty should be taken into consideration.
Some patients choose a semilunar crease. A semilunar crease in an Asian face is quite unnatural, so the surgeon should not agree with making a semilunar crease.
Surgical Preparation and Technique
Buried Suture Method
The main purpose of this operation is to make an upper eyelid crease without an incision scar. The indication for this operation is the patient who does not have blepharoptosis, excessive skin, and an excessive fat pad. Although many procedures of a buried suture technique have been described, the principle is to create a connection between the skin and tarsal palate or levator aponeurosis.
This technique has several advantages other than a no-scar operation. The procedure is comparatively simple, the down time is relatively short (usually a few days), and it can be reversed by pulling out the suture(s) if the patient is not satisfied with the result. On the other hand, this technique tends to relapse more easily than incision techniques. Other complications are asymmetry, skin or eye irritation, and a suture granuloma.
Design
The appropriate height of upper eyelid crease is 6 to 8 mm above the ciliary margin at the center of the pupil. First, the height of the crease should be determined at the center of the pupil by simulating several heights, from 6 to 8 mm. The line of the crease is extended medially and laterally. The surgeon can control the relationship between the crease and the epicanthus to some extent. Then, three points on the medial, middle, and lateral sides of the designed crease line are marked with dots ( Fig. 7.2 ).
Procedure
Three 2- to 3-mm incisions are made at the dots, designed as described above. Then, 6-0 or 7-0 nylon sutures are passed through the skin side to the conjunctiva, slightly above the tarsal border. The needle reenters at the exit point and goes through 2 mm horizontally at the level of the aponeurosis. Then, the needle exits and reenters at the conjunctiva side and goes through another edge of the skin incision point. The needle reenters and goes through the dermal plane to the first entry point. Finally, the nylon sutures are buried ( Figs. 7.3 and 7.4 ).
Surgical Preparation and Technique
Buried Suture Method
The main purpose of this operation is to make an upper eyelid crease without an incision scar. The indication for this operation is the patient who does not have blepharoptosis, excessive skin, and an excessive fat pad. Although many procedures of a buried suture technique have been described, the principle is to create a connection between the skin and tarsal palate or levator aponeurosis.
This technique has several advantages other than a no-scar operation. The procedure is comparatively simple, the down time is relatively short (usually a few days), and it can be reversed by pulling out the suture(s) if the patient is not satisfied with the result. On the other hand, this technique tends to relapse more easily than incision techniques. Other complications are asymmetry, skin or eye irritation, and a suture granuloma.
Design
The appropriate height of upper eyelid crease is 6 to 8 mm above the ciliary margin at the center of the pupil. First, the height of the crease should be determined at the center of the pupil by simulating several heights, from 6 to 8 mm. The line of the crease is extended medially and laterally. The surgeon can control the relationship between the crease and the epicanthus to some extent. Then, three points on the medial, middle, and lateral sides of the designed crease line are marked with dots ( Fig. 7.2 ).
Procedure
Three 2- to 3-mm incisions are made at the dots, designed as described above. Then, 6-0 or 7-0 nylon sutures are passed through the skin side to the conjunctiva, slightly above the tarsal border. The needle reenters at the exit point and goes through 2 mm horizontally at the level of the aponeurosis. Then, the needle exits and reenters at the conjunctiva side and goes through another edge of the skin incision point. The needle reenters and goes through the dermal plane to the first entry point. Finally, the nylon sutures are buried ( Figs. 7.3 and 7.4 ).
