Revision of a high, asymmetric Asian upper eyelid crease is a challenging surgical problem. There are multiple etiologies including a high skin crease incision, excessive removal of orbital fat, damage to the levator, improper placement of crease formation sutures, and iatrogenic surgical trauma. Prior to undertaking surgical revision, the patient’s expectations should be kept low and the need for subsequent surgeries must be discussed. Alternative treatments, such as upper eyelid hyaluronic acid fillers, can be discussed if revision surgery is not an option.
The general principles of crease lowering are to excise an ellipse of skin and orbicularis to the desired level of the new crease and then inferior advancement of a preaponeurotic fat pedicle as a buffer to prevent multiple crease formation followed by placement of crease formation sutures.