Asian Upper Blepharoplasty: The Partial-Incision and Suture Techniques

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Asian Upper Blepharoplasty: The Partial-Incision and Suture Techniques

♦ General and Anatomic Considerations

Creation of a supratarsal crease for the Asian patient may be achieved through a variety of surgical strategies. In fact, the number of permutations of surgical technique that exists closely matches the number of surgeons who practice double-eyelid surgery, as every surgeon performs a slightly different modification to suit his or her own preference. Perhaps the simplest categorization that can offer the reader comprehension of the myriad techniques that exist for double-eyelid surgery is to divide the techniques into three major types: full-incision, partial-incision, and suture technique.1 This simplified classification is not meant to imply that all techniques fall neatly into these groupings. For instance, some surgeons prefer to perform a near full incision but stop short laterally. Other practitioners advocate a suture technique via a limited, partial-incision approach.^2,3 Alternatively, a full incision can be undertaken, and only part of the levator length fixated to the dermis, as performed in the partial-incision method. All of these many techniques have been proven with considerable clinical experience and are viable in the right surgical hands.

The full-incision technique has already been thoroughly covered in Part I of this book and will not be reiterated herein.⁴ This chapter is devoted to a detailed review of the two major alternative strategies for double-eyelid creation: the partial-incision and the suture technique. After reviewing numerous permutations of these two principal methods, the author has selected two techniques that celebrate simplicity and elegance and that are established upon a substantial clinical experience. The author relies principally on the partial-incision method to undertake most of his surgical endeavors and selects the full-incision technique only when redundant skin must be removed, such as in the older individual seeking double-eyelid creation. The suture technique is reserved for patients who have relatively little adipose tissue (that would otherwise obstruct a favorable dermal-levator adhesion) and who express interest in this surgical modality.

♦ The Partial-Incision Technique

Method of Young Kyoon Kim Preoperative Remarks

The partial-incision technique developed by Young Kyoon Kim offers an ideal balance between the full-incision and the suture methods.⁵ The limited incision that spans only about one-third of the total eyelid length offers a rapid and reliable method for double-eyelid creation and limits postoperative edema and risk of scarring (Fig. 8-1). Unlike the aging eyelid, the medial fat compartment is rarely addressed in double-eyelid creation. Even if a full incision is undertaken, only the central fat compartment is resected, as removal of the medial fat may predispose toward scarring and is simply not necessary. Accordingly, the abbreviated incision involved with the partial incision affords easy access to the central fat compartment to reduce the “puffy” eyelid appearance characteristic of the Asian upper eyelid. Furthermore, an incision that extends toward the medial canthus increases the risk of cutaneous scarring and webbing, as the medial aspect of the Asian eyelid has a natural propensity for cicatricial formation. Therefore, the partial-incision technique permits removal of the only fat compartment that needs to be addressed and access to the levator aponeurosis for placement of fixation sutures that will yield a fold that extends across the entire eyelid despite the relatively short length of suture fixation.

Figure 8-1 This schematic illustration demonstrates the stepwise approach to the partial-incision double-eyelid technique. The incision measures ~1.5 cm in diameter and begins medially at the medial limbus to span one-third of the eyelid distance. Symmetry should be well established with Castroviejo calipers before commencing surgery. Step 1: After a precise amount of local anesthesia is infiltrated into each incision (0.3 cc per side), the incision is made through the skin and muscle with a no.15 Bard-Parker blade. Hemostasis is achieved with bipolar cautery. Step 2: The orbital septum is incised and excised until the underlying postseptal adipose tissue is freely released. Step 3: With the preaponeurotic (postseptal) fat exposed, the contralateral eyelid should be approached in the same fashion until the fat is similarly encountered. Step 4: A 1-cm cuff of fat should be retained on each side to avoid a hollow-eye appearance. Step 5: The levator (a) to dermis (b) should be fixated passing the suture in a partial thickness fashion through the levator from superiorly to inferiorly then through the dermis up to include 0.1 to 0.2 mm of the epidermal edge from superiorly to inferiorly. The suture is tied down with one knot and the patient is asked to open his or her eyes to confirm adequate fixation and height of the eyelid crease as well as observation of slight eyelash eversion. The contralateral eyelid is undertaken in the same manner, and symmetry is confirmed. A total of seven levator-dermal fixation sutures are placed in each eyelid. Step 6: The skin is then closed with interrupted sutures between the buried levator sutures.

The partial-incision method offers the distinct advantage over the suture method in that the central fat compartment can be readily addressed and the longevity of crease fixation may be superior as well (although this point may be debated). As the length of fixation is shorter than with the full-incision technique, the chance of crease loss is potentially higher, but correction of this problem is simpler than with the full-incision technique. The full incision also permits modulation of the medial-canthal region by extending the incision toward the epicanthus if an epicanthoplasty is required. Nevertheless, an epicanthoplasty can still be undertaken concurrently with the partial-incision method using a separate, abbreviated incision along the epicanthus. The full-incision method also permits creation of a fold that follows a more precisely prescribed contour (e.g., an inside vs. outside fold). With the full-incision method, the outer shape of the eyelid can also be more effectively adjusted, for example, shaping an oval or round eyelid appearance.* In addition, excessive eyelid skin or muscle cannot be readily addressed with the partial-incision method. Accordingly, the partial-incision technique is ideally suited for younger patients who are in their teenage years and 20s. To compensate for the patient with excessive skin redundancy, the incision height may need to be adjusted superiorly to achieve the desired crease height. (The reader is referred to the following section on surgical technique for details.) Depending on the amount of skin redundancy and the height of the incision, an inside or outside fold will arise with the partial-incision method: greater skin redundancy and a lower crease height will predispose toward an inside-fold configuration, whereas less skin redundancy and a higher crease height will most likely yield an outside fold. If the patient does not express any significant desire to have one type of fold or the other, the partial-incision method may be undertaken for its technical ease, rapidity, and faster postoperative recovery. If the patient desires a precise shape and contour of the fold, then a full-incision method may be warranted. If revision surgery is required, the partial-incision method facilitates a faster, less labor-intensive undertaking compared with one that follows the full-incision method. As part of this spectrum, the suture technique is associated with the simplest and fastest revision surgery.

The patient should receive a detailed preoperative consultation that enumerates all of the potential advantages and disadvantages of each of the surgical methods so that an educated and informed judgment can be rendered as to the optimal technique for that individual.

Surgical Technique

The first step is to confirm with the patient the desired crease height in the following manner. Typically, the proposed incision should be measured ~8 mm above the ciliary margin for a low crease and at times slightly higher at 10 mm if the patient desires a larger crease. The incision should be marked out when the patient is in a supine position with the eyes closed, and the skin is placed under tension until the eyelashes begin to evert to a perpendicular position (Fig. 8-2). Use of Castroviejo calipers provides the most accurate method of measurement. Before formal marking of the entire incision length, a single point is marked with gentian violet at the desired crease height in the middle of the proposed incision on one eyelid using a toothpick dipped in gentian violet solution or a fine surgical marking pen. The patient is asked to return to a sitting position, and a curved wire is pressed into the marked point. When the patient returns to a sitting position, the lid height typically diminishes by half (e.g., a 10 mm marked lid height becomes 5 mm upon sitting). However, the greater amount of skin present and the larger proportion of fat removed may cause the crease ultimately to be lower than anticipated due to the draping of excessive skin over the incision line. While seated, the patient confirms that the crease height matches his or her aesthetic wishes, and the height is adjusted as necessary before continuing.
The technique, as for all double-eyelid surgeries, begins with careful, symmetrical marking of the proposed upper-eyelid folds. The desired lid crease is marked out with gentian violet, confirming the height with a pair of calipers in the manner described previously. The partial incision extends ~1.5 cm in length, with the medial extent of the incision situated at the medial border of the pupil, or medial limbus. The patient is asked to gaze directly forward in a neutral position to determine that the medial extent of the incision in fact aligns with the medial limbus. Because the patient’s forward gaze may not be the most reliable indicator for precise symmetrical marking of the medial incision, the distance from the medial canthus to the medial extent of the incision is confirmed to be the same for both eyelids with Castroviejo calipers. In addition, the incision length and height are confirmed for symmetry with Castroviejo calipers before continuing.
Local anesthesia of 1 to 2% lidocaine with 1:100,000 epinephrine is infiltrated immediately below the incision line in the subcutaneous plane. Only 0.3 cc is used for each side. This limited amount of anesthetic contributes to less postoperative edema and permits accurate assessment of symmetry during the operation.† Injection should be placed in the central aspect of the incision and allowed to disperse naturally across the incision length rather than tunneling the needle across the proposed incision: this technique minimizes discomfort and ecchymosis. The anesthetic can be more evenly distributed by gently pinching the skin to disperse the anesthetic across the entire incision. Ten minutes are allowed to transpire for hemostatic and anesthetic effects to take effect.
Both incisions are then made with a no. 15 Bard-Parker blade through the skin and muscle to expose the underlying orbital septum. The surgeon should make both incisions from the same side of the patient for simplicity and also to ensure that the angle of transection is the same. Bipolar cautery is used to achieve hemostasis along the transected muscle fibers and subdermal plexus before continuing on with the procedure. (The surgeon will consistently notice two parallel vessels that run transversely across the incision, which should be adequately cauterized before continuing.)
Attention is then paid to only one eyelid for dissection. The lateral portion of the orbital septum is gently lifted up with a pair of forceps, and a small wedge of orbital septum is removed with scissors along the superior border of the incision to expose the underlying preaponeurotic fat (Fig. 8-3). Excision of a small portion of orbital septum must usually be repeated several times until the fat can be atraumatically teased out of its native position (Fig. 8-4). (For patients with very little adipose tissue, the skin surrounding the incision can be depressed to encourage the fat to herniate through the incision to identify it more readily.)
With the central fat pad retracted out of the way, closed-tip scissors are passed under the orbital septum to ensure that an unrestricted plane exists between the overlying septum and the underlying levator. The remaining orbital septum can then be safely transected with the scissors along its entire length from a lateral to a medial direction (Fig. 8-5). This maneuver is important to expose the entire levator complex for fixation.
A cotton-tipped applicator can then be used to sweep the fat pad away from the underlying levator complex, which should appear as a glistening white surface below the fat. (At times a false preaponeurotic plane is identified that may be confused with the levator. Fixation of the suture to this plane will contribute to early fold loss. If uncertain, the surgeon should grasp the tissue and ask the patient to open his or her eyes, with the inability to comply consistent with proper identification of the levator.)
Before the fat is removed, the exact same procedure is performed in the contralateral lid.
With both fat pads in view, a symmetrical amount of fat removal may be ensured. Both fat pads are first infiltrated with a small amount of 1% plain lidocaine: the reader is reminded never to infiltrate lidocaine with a vasoconstrictive agent (e.g., epinephrine) into the postseptal tissues to avoid the risk of vascular spasm and related blindness. Also, the same amount of anesthetic should be placed into each side so that a symmetrical amount of fat removal may be ensured.
It is important that an excessive amount of fat not be excised: exuberant removal of adipose tissue may eventually lead to an aged, hollow appearance to the upper lid (the “sunken eye” deformity). The intended fat pad to be excised is first clamped with a fine hemostat so that a 1 cm cuff of fat is retained under the clamp. The overlying fat is excised with scissors (Fig. 8-6), and a small cuff of adipose should be retained above the clamp so that it can be cauterized with bipolar cautery before clamp removal. The fat pad is then carefully inspected for hemostasis before venturing to the contralateral side.
The same technique of fat excision is applied to the other side, being mindful to retain the same 1 cm cuff of fat intact. Of note, an asymmetrical amount of fat may be removed, as patients often naturally have asymmetrical adipose deposits. Accordingly, a symmetrical amount of fat that is retained is more important than a symmetrical amount that is removed.
Next, 7-0 nylon or 8-0 polyglycolic acid (e.g., Dexon, US Surgical, Norwalk, CT)‡ is used as the levator-skin fixation suture. With the levator in full view, the aponeurosis is pierced with the suture needle at the midheight (the levator that lies immediately superior to the tarsal plate) and central aspect of the incision from a superior to inferior direction. Only a fraction of a millimeter of the levator (about the width of the needle) and only partial thickness need be purchased with the needle (Fig. 8-7). Then, the needle is driven through the inferior skin edge, purchasing the full thickness of the dermis and ~0.1 to 0.2 mm of the epidermis (Fig. 8-8). (The needle should pass into the cornified layer of the epithelium, which will promote better levator-skin adherence by virtue of a limited foreign-body reaction. The index finger of the nondominant hand can be used to roll the skin and apply countertraction while the needle is being passed through the skin edge to ensure a more complete purchase of the above described layers of skin. If the suture is placed correctly through a small portion of the epidermis, the suture will tent the skin edge in a gull-wing configuration (Fig. 8-9

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