It is always desirable to be able to enter and exit the eyelid (through an existing crease) without leaving too much of a footprint. If one can strive to enter, perform the necessary task to the exact degree one had planned for, execute the plan without significant trauma, and exit without causing new impairment compared with before, leaving the area accessible for re-entry if indicated in the future – that would be ideal. In essence, the way of least disturbance (like a ninja? Figure 9-1 ). (The popularity of endoscopic and robotic-assisted surgeries is basically following this premise.) One should think, analyze and plan to perform in this fashion.
There are many factors that contribute to optimal wound healing. We commonly think of the way we apply stitches, how we tie them, dress the wound and remove the sutures as the major factors. While these are all, of course, important, there are facets of specially adopted surgical techniques that contribute just as significantly to the overall natural healing, allowing the skin wound to heal, appear natural and function as it has been designed to do.
The previous chapters have touched on the design of the crease incision, where the crease is strategically placed so that it is in line with the biodynamics of the lid structure, the beveled (oblique) plane through which the different layers of the eyelid are traversed, and the closure of the wound. It is my opinion that by distributing the surgical plane in an oblique plane and performing the excision of tissue in a one-piece fashion, the wound reaction is lessened for these vulnerable layers. The control of minor bleeding is performed away from the immediate vicinity of the skin incision, the orbital septum is opened further away from the skin incision wound, fat is managed (positioned appropriately) and the trapezoidal block excision allows more of the orbicularis than the skin to be excised. The upper skin incisional edge is then laid down in a relatively tension-free fashion prior to closure, and upon its closure yields a perfect rotational point for the upper skin to fold over the crease as the upper lid fold. Similarly, the trimming of a small sliver of excessive subcutaneous tissue (which includes redundant orbicularis) along the inferior skin wound also permits tension-free closure. As much as possible, therefore, one should set a high benchmark in creating conditions ideal for wound healing, and minimizing surgical trauma.
The various crease construction used in external incision methods may include attaching the skin over the tarsus, attaching the skin towards the levator aponeurosis, or along the superior tarsal border, and attaching the inferior orbicularis to the distal portion of the levator aponeurosis.
All of these are basic plastic closure techniques, but one may not have thought of carrying them this far, to this detailed extent. I can even state that the way in which the surgical blade’s handle is held by the surgeon, or the angle of the blade’s tip in relation to the skin surface as the incision is made, are all important.
THE CONCEPT OF A DYNAMIC VERSUS A STATIC CREASE (A REVISIT)
A dynamic upper lid crease is one that is apparent in straight-ahead and upgaze but which tends to fade on downgaze, and is barely noticeable when viewed at 90° to the skin surface. A static crease would be one that is noticeable in all three positions: upgaze, straight-ahead and downgaze, when the observer is positioned in front of the subject. A dynamic crease mimics a natural crease.
In order to form a dynamic crease, the terminal fibers of the levator aponeurosis above the superior tarsal border must be directed to the subdermal plane of the lower skin incision line. As one is obliged to close the upper skin edge to the lower skin edge, I believe that it is academic to argue on the merits of creating adhesions solely from the terminal aponeurotic fibers to the lower skin edge, or to both the upper and lower skin edges. It is essential to loosen and reposition any adhesive surgical drape that may be used, to allow the upper lid skin to reset along the lower pretarsal skin without tension. The patient is instructed to look up and down to check the adequacy of crease formation and contour before any stitching is begun.
Suturing skin–tarsus–skin tends to yield a static-looking crease. In my technique I use 6-0 silk or nylon interrupted sutures to connect the lower skin edge to a lamellar (partial-thickness) bite of the levator aponeurosis along the superior tarsal border, and then to the upper skin edge. Besides the stitch over the center of the crease, I apply three sutures medially and two to 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, subcuticular fashion. This continuous closing suture involves only the dermis, without the need to pick up any orbicularis muscle fibers. The objective here would be to avoid hemorrhage from the orbicularis muscle and to provide an optimal plane of closure of the skin incision site. All sutures are removed in this technique.
The method of anchoring inferior subcutaneous tissue alone, or orbicularis to the levator aponeurosis, frequently involves placing buried, non-absorbable sutures. I have come across patients who complain of the static appearance of the crease resulting from the use of buried sutures, and some complain of a kinesthetic awareness and often irritation from these buried elements in their eyelids.
CREASE DYNAMICS
Dynamic Interaction of the Tarsal–Crease Unit and the Preaponeurotic Zone
One can divide the upper eyelid into three zones: the eyelid crease (which acts as the junctional zone or the rotating nano-balls, see Chapter 21 ), the pretarsal zone below it and the preseptal zone above it ( Figure 9-2 ). The objective of the surgeon in forming or enhancing an upper eyelid crease should be:
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To facilitate the inward folding of the crease (through the nano-ball junctional action ) by reducing the soft tissue overlay through limited debulking of redundant preaponeurotic soft tissue, which may be hindering the infolding, or by tightening this pivoting zone through suture ligation (which is less effective by comparison, and more prone to regression). By providing a clear demarcation zone, one achieves a good pivot or nano-ball junctional action.
- 2.
The pretarsal area (lower zone) can be made firmer through (a) excision of some orbicularis oculi muscle along the inferior incisional skin edge, or (b) suture ligation method, through conjunctiva to subcutaneous plane buried sutures, or through external skin to levator aponeurosis buried sutures.
- 3.
The fullness of the preseptal area (upper zone) should be modified by: (a) conserving and repositioning most of its preaponeurotic fat superiorly into its sulcus, or (b) when indicated, partial reduction of preaponeurotic fat, freeing up and repositioning the rest superiorly into its sulcus. There should be no excessive skin removal to avoid foreshortening of the anterior lamella of this upper zone.
These three focal points serve to create an opportunity for the firm lower pretarsal platform and tarsus (the tarsal–crease unit) to vector upwards and slide under the upper preseptal soft tissue zone above it, without much effort nor encountering any tissue resistance over the crease. The preseptal zone bellows slightly over the pretarsal zone, with the newly formed crease in between.
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Conceptually, the upper eyelid crease is thought to form close to the highest point of insertion of an intact terminal fiber of the levator aponeurosis through the orbicularis oculi’s intermuscular septa, as well as skin along the crease line. That is not to say that there is absolutely zero presence of terminal fibers of the levator aponeurosis above the dominant crease. My trapezoidal debulking approach (see Chapter 8 ) allows a skin–aponeurosis–skin closure, with a 1–2-mm zone where the transected orbicularis (along the upper beveled skin–muscle wound plane) may become adherent to the aponeurosis just above the superior tarsal border (see Figure 8-1 ), thereby reforming the “limiting boundary” previously described as the posterior reflection of the orbital septum on to the levator aponeurosis sheath, and acting as an inferior limit to the repositioned preaponeurotic fat. The surgically created crease simply forms directly in front of this zone. Therefore, although the lid crease wound is formed along the superior tarsal border, by taking skin to aponeurosis to skin, the upper lid crease thus formed may lie just in front of this junction. Another way to conceptualize this is that the aponeurosis is attached to both upper and lower wound skin edges, with the crease thus created lying in front of it.
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Several factors in the upper/preseptal zone can lead to poor infolding of the crease:
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If fat excision in the preaponeurotic space was excessive, there is now an attenuation of the preaponeurotic space, which can predispose to cicatrix formation and an increase in rigidity of this zone.
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If there was excessive tissue handling, injury, or unusual hemorrhaging, there can be increased scarring and consequent rigidity.
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If there was excessive skin excision in this upper zone, there is a greater probability that the tarsal–crease unit will be unable to form a crease due to inability to vector upward under these tightly scarred preseptal tissues of skin, orbicularis, septum and, possibly, fibrosed fat. These seemingly benign factors can combine to substantially hinder crease formation.
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In those Caucasians born with a natural crease , the relatively higher point of fusion of the orbital septum on to the levator aponeurosis limits the preaponeurotic fat to the space above this fusion point. The crease may have formed from distal terminations of the aponeurosis in towards the inferior orbicularis muscle septa, actual subcutaneous attachment or “extensions” from the levator, and inferior limitation of fat through a postero-upward reflection of the posterior sheath of the orbital septum on to the levator aponeurosis (this latter scenario may simply yield a prominent supratarsal sulcus in Occidentals who have never had eyelid surgery). This, combined with a softer and thin-skinned preseptal zone, allows the firm tarsal complex to easily vector upward against it to form a crease.
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In Asians with a single eyelid , this attempt to form a crease is more difficult for a variety of reasons: the pretarsal soft tissue (skin and boggy orbicularis) is often softer and well developed; the septum fuses on to the levator aponeurosis and tarsus at a lower point; preaponeurotic fat is present at a lower level; the preseptal zone may have significant fullness and is often positioned more forward in the orbit (Asians have comparatively less deep-set eyes, owing to a less prominent forward extension of the superior orbital rim). These factors are more likely to yield a single lid without a crease.
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Following an Asian eyelid crease enhancement procedure, with a graded preservation of fat in the preaponeurotic space, coupled with reduction of the pretarsal inferior edge soft tissue, as well as controlled debulking of the preaponeurotic platform and along the superior tarsal border, it will be easier for the crease to invaginate upward. The levator–Müller’s dynamic pull (up-vector) is most effective when the muscle can glide (slip-slide) up against a cushion of non-adherent preaponeurotic fat (middle space) as well as overlying anterior skin–orbicularis. In essence, the tarsal plate and skin are allowed to invaginate against a passive multi-layered soft tissue complex (preaponeurotic fat, septum, orbicularis, subcutaneous fat and skin). It will be more difficult if the preaponeurotic space is obliterated through ablation of its fat; cicatrization forms between the anterior layer (of skin–orbicularis–orbital septum) and the posterior layer (of levator–Müller’s muscle–conjunctiva) through tissue damage or excessive hemorrhage and subsequent hemosiderin deposition. The resultant rigid multi-layered tissue complex presents a far greater mass of tissue, as well as a challenge for the tarsal plate to indent against to form a crease. We may see this clinically as a firm plaque of skin/muscle/anterior lamella in the preseptal region, accompanied by a static-looking crease or without a crease at all.
On occasion, postoperative swelling can mask an otherwise well-formed crease; and when the swelling resolves, the tarsal plate vectors up well against the preseptal soft tissue and a crease then appears appropriately.
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The suture ligation methods create a crease by tightening the soft tissue overlying the superior tarsal border, creating a firmer constriction between the subcutaneous skin and the levator aponeurosis (through either an anterior skin entry or a posterior conjunctival approach). Due to the fact that the reach towards the levator muscle is skewed posteriorly towards the levator several millimeters above the superior tarsal border, it plicates the levator aponeurosis and creates a shortening effect on this muscle, and we often see an “improved” stare from the subject after such procedures. It allows an increased force-gradient where the tarsal plate uplifts in and under the preseptal soft tissues. With no removal of redundant soft tissue in suture ligation (buried sutures) methods, it is effective in the short term, perhaps up to 2–10 years. However, with aging and a gradual increase in soft tissue redundancy in the upper preseptal zone, the crease thus created may become shielded from view or shallow out with time (fading) owing to the unavoidable shredding forces of the buried sutures used in these methods. (The ligatures’ effect may diminish in time, not from the dissolution, loosening, or breaking apart of the sutures, but more from the ligature working and cutting through the tissue layers that it was meant to tie together.)
SURGICAL FINESSE, NUANCES AND PEARLS
A properly healed wound in a dynamic crease needs to be aesthetically pleasing, permanently effective, not noticeable in downgaze, without wound spreading or discoloration, and not bumpy.
In the earlier Japanese literature, the pressure to which surgical knots are applied on to the skin surface was used as a means to enhance the formation of a crease. Excessive pressure can lead to compression ischemia and poor wound healing. Buried sutures often may show through the skin surface, and absorbable buried sutures may generate granulomatous suture reaction as the sutures dissolve.
In external incision methods, the application of the crease-forming sutures depends on accurate placement along the superior tarsal border’s levator aponeurotic fibers in a partial-thickness fashion. The appropriate number of these interrupted sutures is applied to form a uniform continuous crease invagination. Upon tying of these sutures, one should avoid excess tension or strangulation effect on the tissues. The running stitch after this merely approximates the skin edges together.
The choice of suture material depends on the preference of the surgeon, balancing potential wound reaction, discomfort or comfort for the patient, and desired healing that enhances the crease construction. It determines the number of days for which the sutures are left in place before removal, again balancing success rate for crease formation versus skin reaction.
Suture Type
In my Asian blepharoplasty, which is an external incision method, I use two types of suture:
- 1.
Crease construction sutures – usually 6-0 caliber, braided silk (black), applied as six to seven interrupted sutures, to unite skin–levator aponeurosis–skin along the wound located at the superior tarsal border. The newly formed crease should invaginate easily with these in place. They are removed after 1 week.
- 2.
A continuous running 7-0 silk suture to close the skin edges. This is removed at 1 week also.
No buried or absorbable stitches are ever used. The soft texture of the silk suture material ensures that the stitch is not too stiff, compared with nylon or Prolene, which can be irritative. It is less reactive than sutures like chromic catgut, Vicryl or Dexon because the silk sutures are removed.
Manipulation of Suture Knot and Running Suture
The interrupted sutures’ knots can be placed directly over the junction of the two skin edges, or skewed to favor one side or the opposite side. The length of skin-to-skin running suture can be used to secure the knot placement by looping it below the interrupted suture knot or above it. Both of these can be used to perform supplemental adjustment of the crease height at completion of closure.
Technique in Medial Upper Lid Fold
The mono-lid’s overhanging fold is excised as part of the blepharoplasty-excision of tissues. At its medial end, there may be minor dog-ears that can be simply eliminated through excision of overlapping wound inequality. Upon closure, the medial suture knot(s) can be manipulated to favor slightly greater compressive force across the wound itself, such as to result in a more likely nasally joining crease (NJC) or parallel crease shape (see Chapter 20 ).
In developing a parallel crease, although the incision was designed, carried out and intended to be parallel as it courses towards the medial canthus, when a prominent medial upper lid fold is present, the fold should be removed to a greater degree compared to one without such prominent medial fold. If not, it will hinder the desired crease shape (turning it more towards an NJC shape).
Treatment of Lateral Wound Edges
Often the skin is thicker here; the underlying orbicularis oculi fibers are abundant and strong. This may result in wound spread. Careful assessment should be used on each individual, and the closure here may require more sophisticated suturing using non-reactive material like nylon, and leaving the sutures in a longer period to gain better wound coaptation.
Sometimes the lateral extent of mono-lid fold may extend past the lateral canthus and require reduction (excision) followed by non-crease forming closure there, but one should not intentionally create a lid crease that extends beyond the lateral canthal angle . There are surgeons who attempt this through use of buried sutures (static means of crease construction) beyond the lateral canthal commissure; in this thicker skin area the results are often prominent scarring or wound spread as well as an unnatural look since the lid crease as driven by the levator would not be located extra-orbitally.
Cautions
The wound edges should not be closed under tension, which is more likely if the upper or lower part of the eyelid crease incision is wrapped tight by the surgical draping. If the wounds are stitched under tension, then side effects may include high crease, lagophthalmos, ectropion of the tarsal plate or of the upper lid margin.
Repeated measurement and confirmation of crease height at different steps during the procedure helps minimize asymmetry.
POSTOPERATIVE CARE
During the immediate postoperative period the wound is cleaned daily and covered with antibiotic-steroid ophthalmic-prep ointment. Compressive or occlusive eye dressings are to be avoided. Diuretics and steroids are not usually prescribed. Depending on the material used, the sutures are removed 7 days after the operation. It is my practice to leave in interrupted sutures (skin–levator aponeurosis–skin) for a slightly longer period if the crease appears slow in forming, as this seems to help ensure proper attachment of the levator aponeurosis to the incision line along the superior tarsal border.
In patients with oily skin, the physician may elect to add the prophylactic use of oral antibiotics, and anti-comedogenic skin preparations. There are also a wide range of dietary recommendations that can be given for Asian patients according to their ethnic food cultures, based on the traditional Chinese medical belief system.
Other factors that may affect healing first and foremost will include the patient’s own tissues, exposure to external environment (sun exposure, local hygiene), past history of sun damage or wound stress, dermatological conditions like eczema and psoriasis, and how recently any other surgery was performed in the deeper and superficial layers of the eyelid.
About 80% of the postoperative swelling should have disappeared a week after the sutures are removed, equivalent to 2 weeks postoperatively. The residual 20% swelling will regress by 2 months. The surgically-inflated crease height invariably reduces closer to the ciliary margin when pretarsal tissue edema subsides as a result of lymphatic and vascular rechanneling. Patients are told that even if all goes well, their surgically placed crease will take 2.5–3 months to stabilize.
Should there be a need for revision touch-up, for example if the crease does not form distinctively or some residual skin is present, these are performed no earlier than at 6 months (and often up to 12 months), as the crease and its underlying tissue layers continue to evolve. The author does not advocate secondary revision in outside patients seeking your consultation unless a 12-month period has elapsed.
Postoperative Regimen for Asian Blepharoplasty Patients
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Bed rest for 24 h.
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Cold compresses (with crushed ice and gauze) for 1 day.
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No reading, watching television or cell phone/computer use.
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Wound and facial hygiene: clean face and incision wounds two to three times daily with clean water.
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Avoid the use of cosmetics over the incision wound and sutures.
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Apply antibiotic ointment four times daily for 7 days.
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Patient may shower or bath that day.
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Avoid sauna, jacuzzi or swimming.
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Avoid strenuous activities or workout for at least 1 week.
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Avoid aspirin compounds or anything containing anticoagulants.
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Avoid spicy food, chocolate, dairy products and fried foods for 2 months.
Crease-Enhancing Eye Version Exercises for Selective Mono-lid Patients
For some individuals, specific movement exercise of the levator muscle is recommended; these exercises help initiate formation of the lid crease in selective patients . The selective candidates who may benefit are those with only borderline (or fair) levator excursion measured (in the range of 10–12 mm) during initial office examination, questionable latent ptosis, noticeable head-tilt backward (with chin-forward, head-slant back), and for whatever reason at postoperative days 1 and 2 still did not show good crease invagination, those too scared to look up or open their eyelid fissures (whether it is pain-related or pain-imagined because of the placed sutures). Starting on the third day after the operation, it is best started by having the patient in front of you in your clinic. The patient is instructed to sit and keep the top of the head aligned vertically to the ceiling. As demonstrated by you, they are asked to look from complete downgaze to complete upgaze (i.e., from floor to ceiling), without involving the brow and forehead muscles and without allowing the head to be tilted backward in any way; they are instructed to repeat this 10 times twice a day, for 1 week. The levator movement should be deliberately slow in order to allow good crease infolding without pulling on any fine blood vessels and causing postoperative hematoma. Furthermore, it may be a new neuromuscular sensation that they have not been previously aware of. This has the further benefit of making them cognizant of the importance of head position in manifesting the newly formed eyelid crease.
This last point bears further explanation. Some patients may have such low pain tolerance that they dare not look up or even look straight ahead, as the skin sutures may cause some local irritation. They may stay in a head-tilted-back position all week without activating any levator movement nor any upgaze. (When the head is tilted back, and the patient is looking forward, the globe is still in a relative downgaze position, hence the levator is still in a down-relaxed position within the orbit, as compared with a normal open-eyelid position looking straight ahead with vertex of the head aligned vertical.) The crease may not form well if there has been no attempt at upgaze during the first 10 days. This form of eye movement is best performed slowly, hence the term ‘Eye-chi’, coined by the author (as in the slow pace of Tai-Chi Chuan). It is important to initiate upgaze and thereby activate the levator muscle to assist in forming a proper crease, as we are constructing the dynamic crease using skin–levator–skin mechanism. Slow daily movement of the eyelids helps reduce the swelling over the pretarsal and preseptal regions. It also helps ingrain muscle memory, as a number of mono-lid patients have a relative inability for full upgaze, and a still smaller percentage may have a concomitant ptosis, although this is usually minimal and often subclinical, their levator function (excursion) measured being less than 10 mm. Such muscle memory training may be entirely new for these patients. It helps them become aware that they may have developed a compensatory overaction of their forehead and eyebrows as a means to look up.
Normal Postoperative Concerns and Occurrences
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The surgeon should expect panic calls from patients and should provide reassurance. I often see my patients more frequently than is medically necessary to help allay their concerns.
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The importance of meticulous attention to the contour and placement of the crease cannot be overemphasized. These factors are dictated by the design of the incision line and the placement of the interrupted sutures on the levator aponeurosis.
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One must diligently avoid the construction of an excessively high crease, or one that is too deep or too harsh.
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One should avoid the removal of an excessive amount of preaponeurotic fat.
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When the sutures are removed, whether all at once or in two separate stages several days apart, it is not unusual to see tissue induration over the incision wound and the suture tracts ( Figure 9-3 ). In some cases, because the sutures that anchor the lid crease are under tension, the dermal reaction may be more intense than one would normally expect. When I encounter this type of reaction I prescribe a short course of topical corticosteroid ophthalmic ointment to be applied over the wound (this may be fluorometholone, Decadron, Maxitrol, Tobradex). These indurations tend to regress within several weeks; reactions such as hypertrophic scarring may linger longer. According to the literature, keloids are seldom seen over the upper eyelids; I have found this to be true. The is not the case with keloid formation seen over the thicker skin of the medial canthal region, where noticeable scars from attempts at medial canthoplasty, intercanthal fixation and VY-plasty have been observed.
