We have touched on the cultural diversity and linguistic differences among the Asian races. Ethnically the Asian patients who often request this type of cosmetic surgery include Chinese, Japanese, Koreans, Filipinos and South-East Asians. It is important to note that in these ethnic groups often more than half of the overall population do have an upper lid crease and that you may be consulting with a patient who wants to look like their fellow Asians, rather than looking like a Caucasian.
In my first office consultation with a new patient, I listen first to their complaints and try to classify the complaints into relative orders (or a wish-list), which includes those that can be improved upon, versus transient improvement or no improvement at all. Ultimately the surgeon and the patient need to mutually agree on what is beneficial and worthwhile for the patient to undertake. I always try to encourage patients to speak their mind, even if they may be embarrassed, and I try to facilitate this in an environment free of stress.
It is crucial for the practitioner to be aware of communication gaps and misunderstanding that may exist between the surgeon and the patient. This is especially critical at the first meeting, when I always have as my goal to try to find out the patient’s needs and assess whether they can be met.
It is interesting to observe that in Japan, China and Korea it is common and acceptable for young adults who do not have a lid crease to undergo cosmetic eyelid surgery. It is often socially acceptable for mothers to encourage their daughters to have the procedure, as compared with the stigma usually associated with rhinoplasty, breast implant or cheek augmentation. The concept that eyelid surgery is a way to improve on the beauty of the person, to ‘open up’ the face while being relatively non-invasive, is in sharp contrast to their views towards other cosmetic surgeries, which involve implantation of synthetic materials in the body, rendering the body “not whole”. This somewhat cavalier attitude on the part of the patients or family members towards eyelid surgery is problematic if the physician and the patient have not come to a mutual understanding. Often, I see patients coming in for consultation who had the surgery done by reputable and capable physicians, but are dissatisfied with the result. They are justified when they complain that despite their insistence on a “low, natural crease” the surgeon has given them a high crease ( Figure 3-1 ); the creases are asymmetric ( Figure 3-2 ); the crease disappeared with time ( Figure 3-3 ); or the surgeon gave them a “hollow” over the upper lid crease, usually from over-excision of preaponeurotic fat pads ( Figure 3-4 ). Perhaps the surgeon had his own perception of what the procedure is, as is performed in a traditional blepharoplasty, and applied it to the Asian patient.
The unhappy patients who have suboptimal results often express the opinion afterwards that they “did not think that it would be so noticeable”. Not infrequently, they may want the whole process to be reversed. A properly performed placement of crease over the upper lid is natural and blends in with the configuration of that particular patient’s eyes and face. A suboptimal crease may be very noticeable since the eyes are a focus of attention in human interaction.
The patients here in America are often bicultural, and may have a preconceived perception of how the procedure might be performed. This is often their first surgery ever. I find that most patients prefer that their friends not know that they are having it performed, although an equal number are very jubilant and will tell everyone once their wounds have healed to a desirable level. Some patients expect minimal or no swelling following surgery. Some expect no sutures at all, while some expect no incision. Other patients may expect all swelling to subside in a week. Almost all patients are invariably surprised at the height of the crease during the first few weeks, which usually goes down with proper healing.
THE CONSULTATION
My first face-to-face interaction with a new patient coming in for an office consultation is a relaxed meeting where we get to know each other’s viewpoints. The patient would express his/her concerns, goals to achieve, perhaps reasons for the goals.
Among the important details that should occur are:
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A basic eye evaluation: record of the patient’s best corrected vision, past history of dry eyes, injuries, scar formation or keloid, the sizes of the eyelid opening (vertically and horizontally), the distance between the two eyes, any ptosis or lid retraction, presence or absence of crease on each side, asymmetry, levator function (excursion) of each upper lid. If there is a history of previous surgery in the area, document the extent of scars in each layer of the lid and any crease abnormality; perform various assessments for skin shortage or mid-lamellar scarring.
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A demonstration from the patient of what the individual would like to achieve, as well as the surgeon showing the patient what can possibly be achieved, which may be followed by a preview of some crease shapes and of different crease heights.
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Going over the patient’s facial attributes, which might favor certain crease dimensions over others. Discuss appropriate remedies and prioritize the steps. With knowledge, the patient may then express their preferred choice of crease height and shape. The physician may advise or concur.
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Discussion of the procedure: going over preoperative preparations, postoperative care first day, first week, 2 months. Inform the patient of what to expect in wound healing. Discuss overall success rate or likelihood for secondary touch-up, rate of touch-up revision, and what the policy of your practice is. If proceeding to surgery, explain possible complications (see below) and sign informed consent.
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Preoperative photography for the record, including straight-ahead, upgaze, downgaze, oblique views. For revisional cases I take close-up macro-photographic images of the previous incisional scar for documentation. Preoperative instructions are given including avoidance of anticoagulants and herbal medications.
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Postoperative dietary advice – dos and don’ts.
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Postoperative eye movement exercises for some individuals: timing and schedules.
Complications are similar to those seen in any blepharoplasty surgery and may include hemorrhage, transient asymmetry in crease form, obliteration or fading of the crease, prolonged postoperative edema, hypertrophic scar formation and formation of multiple creases.
It is interesting that most patients who seek upper blepharoplasty know they are hoping to look better. A recent paper by Bater et al. reports on what seems obvious, which is that the procedure allow the subjects to appear more youthful and attractive, as well as to be perceived as having a greater energy level.
HOW DO STITCH METHODS COMPARE WITH INCISIONAL METHODS?
Stitch Method (Buried Sutures Method)
If one is to describe any externally applied skin/eyelid compression (like using a paper clip wire, tissue glue, or a device like the externally applied lid-crease thread fiber from Japan), or several buried stitches that actually course through the eyelid’s full thickness from front to back (skin to conjunctiva) or back to front (conjunctiva to skin), and then refer to these resulting indentations as an eyelid crease, one would be mimicking a crease at a location that is not always physiologic. The sutures used in the buried suture method are often necessarily permanent (meaning they do not dissolve, examples being prolene or nylon) since dissolvable sutures would not be very effective in these suture methods. The resulting crease is passive and its indentations are noticeably obvious on downgaze, which is unnatural. This mimicking crease is generated from externally applied and compressive (constricting) sutures inserted over and through a physiologic muscle, at 90° to its normal axis of function and at several disparate points. It is my view that this is dampening to its normal function.
Patients’ complaints of strain and discomfort regarding their lid-crease sutures retained after buried stitch methods are not hyperbole, as we see high placement of a crease from the suture method often resulting in ptosis, generating muscle-awareness on blinking, and even foreign body sensation when the sutures are buried close to the surface. Mizuno in a recent paper discussed suture-related complications of buried suture double eyelid-plasty in 116 cases, that required suture-removal surgeries. Three treatment methods were used in suture removal: full skin incision method (54%); limited (small) skin incision approach (40%); and conjunctival approach (6%), which was used when buried sutures eroded through conjunctiva. Full incision allowed removal in 95%+, while limited skin approach was successful in 63% only. The paper confirmed that suture-removal surgery is indicated for treatment of complication following buried suture, double-eyelid blepharoplasty. Within the sutures methods, low placement of buried sutures often results in eventual disappearance of a crease, or it leaves behind a dimple scar.
External Incision Methods
Use of the incision method entails a greater learning curve on the part of the surgeon but offers several advantages once the surgeon has diligently mastered the concepts and practices. The method allows for the redundant eyelid fold to be reduced to expose a larger eyelid opening, greater control of crease height and shape, greater control in creation of a physiologic crease, a lively dynamic crease that should naturally fade (shallows, lightens) when the lid is relaxed as in looking downward (without seeing the stitch-induced dimpling on the skin surface), and it can be achieved without having to use buried permanent stitches. It simulates a natural crease, through fine strands of the end portion of the levator aponeurosis attaching to the undersurface of skin along where a natural crease would have formed, if the person were to have been born with a crease. All sutures are removed after 7–8 days as there is really no need to use anchoring stitches, whether dissolvable or permanent. The simulation is close to being natural as the crease arises from internally generated contractile force of the levator muscle, going with the flow.
One can compare the two methods as if one is trying to create an elbow crease on the crease-less arm of an imaginary model. The suture method can be used to create a constriction-induced “crease” almost anywhere on the forearm and arm that has skin. If applied too short or low down on the arm, like a tourniquet, it is on the forearm side of the elbow joint; it may not be physiologic but you will see the indented mark that mimics an elbow crease. If done too high (on the arm or biceps portion), the crease will look unnatural and may actually hamper the contractile function of the biceps. Besides, the recipient will feel its presence within its muscle tissues.
Finally, there is the issue of permanence . It is generally accepted that the buried stitch method has a higher rate of crease disappearance (failure rate), which can occur since the method does not normally perform any removal of excess and interfering tissues, unless the lateral or central small stab incision has been extended significantly to allow removal of some fat. Buried sutures can also lose effectiveness as they are tied relatively tight to achieve a compressive ligature effect, and are thereby prone to cut (“cheese-wire”) through their target tissues. Sometimes one stitch among the three or four buried stitches may come loose or lose its effectiveness, and that segment of the compressed crease will look incomplete or lose its continuity as well as not achieve permanence.
FURTHER DISCUSSION ON HEIGHT, SHAPE, CONTINUITY AND PERMANANCE
Crease configuration has four contributing parameters: height, shape, continuity and permanence ( Figure 3-5 ). These are each discussed further at the consultation.
