Outlook for Aesthetic Asian Eyelid Surgery: 未来展望





COMBINED APPROACH OF PARTIAL INCISION TECHNIQUE WITH MEDIAL TUNNEL FIXATION (INCORPORATING A BURIED ORBICULARIS–APONEUROSIS SUTURE)


An ideal compromise would be to combine an external incision approach across the central 50% of the proposed area for an eyelid crease, combined with buried suture ligation over the medial end by way of the open central wound. This avoids any incision through the thicker medial canthal skin and still achieves a crease as well as some control over the shape of the crease there, whether the crease is to be nasally joining or parallel.


Surgical Steps


A corneal protector is applied. The partial central incision is 50%–60% wide and involves excision of a 2–3 mm segment of skin–orbicularis, application of the usual Asian blepharoplasty technique with a beveled approach through the orbicularis and septum, 50–70% width transverse opening of the orbital septum, and graded excision of preaponeurotic fat ( Figure 29-1 ), followed by:



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    One may elect to create a medial suborbicularis tunnel space along the superior tarsal border, using a small hemostat, needle-tipped cutting cautery and cotton-tip applicators. The location and height of this medial sub-lid tunnel space will correlate with the desired shape and height of the medial end of the crease.


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    One end of a 6-0 Vicryl suture (with spatula needle) or polydioxanone (PDS) suture is passed through the external skin surface along the desired crease line. It is passed down through levator aponeurosis above the superior tarsal border, but without penetrating the conjunctiva. It takes a bite in a lateral direction for 3 mm, along the crease form desired. This initial needle and suture is retrieved through the medial tunnel and looped out through the central wound. One may then choose as follows:




    • Option 1 Transcutaneous: Cut off the second needle of the remaining arm of the suture that has not yet been passed. This free end is then looped out through the suborbicularis medial tunnel using a strabismus hook. The first needle that took a bite of the aponeurosis is then used to take a bite of the orbicularis muscle that lines the roof space within this medial tunnel. The two ends are tied, bringing together the layers of the levator aponeurosis, the orbicularis and subcutaneous fascia ( Figure 29-2 ).




      FIGURE 29-2


      6-0 vicryl suture needle takes a superficial bite of the distal levator aponeurosis along the superior tarsal border in the medial tunnel.



    • Option 2 Transcutaneous: The second needle is left intact and pulled through a small stabbed-skin slit along the same tract where the first arm passed, and retrieved within the medial tunnel. It is then used to secure a small amount of the orbicularis along the proposed crease line and then tied with the other end from the first passage.





FIGURE 29-1


Shows partial incision technique with incision spanning 50%–70% of the width of the palpebral fissure.


Instead of entering the skin through a most-medial location, a second approach (via suborbicularis tunnel space ) is to come in from a slightly more central position but still within the medial one-quarter of the eyelid. After creating the medial suborbicularis tunnel:




  • Option 3 (Suborbicularis tunnel): The surgeon holds a half-circled 6-0 Vicryl suture needle that is back-handed, and this is passed from the central open wound through levator aponeurosis on the bottom of the tunnel space, and then immediately back towards fibers of the suborbicularis tissues over the top of the tunnel space to form a complete 180° hair-pin loop ( Figure 29-3A ). This contains the levator aponeurosis along the superior tarsal border as well as subcutaneous fascia and orbicularis oculi. A knot is tied and buried within this medial tunnel space.




    FIGURE 29-3


    (A) Passage of suture through the overlying orbicularis oculi fibers directly above the first bite. (Option 3). (B) One can excise some overlying orbicularis oculi such that the passage of the overlying suture loop is through subcutaneous fascia rather than orbicularis, as shown here (Option 4).





  • Option 4 (Suborbicularis tunnel): Still over the medial one-quarter of the eyelid as in Option 3, a back-loaded needle approaches the medial horn of the aponeurosis from the central open wound and takes a 2–3-mm bite of it. The overlying orbicularis in the tunnel directly over this needle’s passage is denuded (removed) using cutting cautery or a radiofrequency knife. The original needle that had passed through the aponeurosis is then used to secure some subcutaneous fascia beneath the overlying skin in this orbicularis-denuded sector of the tunnel space ( Figure 29-3B ). A knot is tied and buried within this medial tunnel space. This tied knot brings together the levator aponeurosis to the subcutaneous fascia and is similar to the crease construction used in skin–levator–skin closure with the external incision method.


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    The passage of the needle through tight and vascular compartments located medially will lead to occasional hemorrhage from the orbicularis, levator aponeurosis, Müller’s muscle and the peripheral arcade that runs along the superior tarsal border.


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    The external manifestation of the medial end of the crease will depend on where the medial tunnel is fashioned and where the buried stitches are applied. For a nasally joining crease (NJC) that converges normally, the medial end of the crease is usually applied at a distance from the lid margin equal to one-half of the measured central height of the tarsal plate. When there is a noticeable component of the medial aspect of the mono-lid fold, the levator aponeurosis-to-orbicularis buried suture will uplift the medial lid fold somewhat. For those patients who desire a rapidly converging NJC (rapid convergence), one may place the aponeurosis-to-orbicularis attachment buried suture at one-third of the measured central height of the tarsus. This is lower than the actual height of the tarsal plate there, though the needle should still be aimed towards aponeurotic fibers over the pretarsal surface.


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    Over the external skin incision, which spans 50%–60% of the normal width of the eyelid crease, the wound is closed using four interrupted 6-0 silk sutures in the usual fashion for Asian blepharoplasty, taking lower skin edge–aponeurosis–upper skin. These four external stitches cover an area of about 15–18 mm ( Figure 29-4 ). A 7-0 suture is then placed as a running skin–skin closure. The lateral one-fourth of the eyelid skin is uncut and has no buried sutures. The medial sector is also uncut, but has a buried suture to help form the medial end of the crease without any risk of residual hypertrophic scarring.


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Apr 6, 2024 | Posted by in General Surgery | Comments Off on Outlook for Aesthetic Asian Eyelid Surgery: 未来展望

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