Asian Blepharoplasty Treatment & Management
- Author: Charles S Lee, MD, FACS; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC more...
The 2 general categories of repair include the open method and the suture method. The suture method is preferable for patients with thin skin or Asian eyelids so thin that they fold spontaneously on an intermittent basis. If the patient has some excess fat, this fat can be removed through a small stab incision. The fat in the central portion of the eyelid should be preserved, but the portion near the lateral orbital rim can be removed to yield better definition. The open technique is preferred for patients with thicker skin, thick pretarsal orbicularis muscle, or excess skin, or for those for which permanence is a premium. Both techniques are described in Intraoperative details.
Consider upper eyelid position in conjunction with the forehead. The visible amount of pretarsal skin on straightforward gaze depends on the degree of brow ptosis and upper lid skin redundancy. Even young patients may have a congenitally low brow position, as evidenced by frontalis strain. Set the lid height higher in these patients.
For a natural looking fold, the ideal amount of pretarsal show with the eyes open and at straight gaze is 2-3 mm. The rest of the pretarsal skin should be hidden behind the overhanging upper lid skin. This height is usually obtained by creating an incision at 7-10 mm above the lash line at the mid pupil with the skin slightly stretched, as shown below. This measurement corresponds to the tarsal height. Although this is a general guideline, a patient with brow ptosis should have the incision set slightly higher because the brow drops in the postoperative period, decreasing the amount of pretarsal show. On the other hand, patients who are slightly exophthalmic should have the crease set slightly lower, closer to 6 or 7 mm.
Most patients have some degree of brow asymmetry, with 80% of patients having a right brow lower than the left. This asymmetry should be compensated for by setting the crease slightly higher or removing slightly more skin from the lower eyebrow. Failure to compensate for the asymmetric brow is one of the frequent causes for crease asymmetry.
Although much discussion has been made about the different shapes of the crease fold, a natural crease will present itself when a key point has been placed just medial to the pupil, roughly corresponding to the medial edge of the tarsal plate. As the patient opens his or her eyelid, a fold will present itself medial and lateral to this key point. The crease can then be carefully marked out.
Most patients have some minor degrees of asymmetry of the lid margin. The marginal reflex distance 1 (MRD1) determines those patients who have true ptosis, and they should be treated accordingly. Moderately severe cases of ptosis may need to be treated first, with the double-eyelid surgery as a second-stage procedure.
Ptosis can be masked by a retracted brow. An evaluation with the brow in resting position is recommended in order to better assess the degree of potential ptosis.
The medial epicanthal area should be addressed in discussion with the patient. If the patient has no preference, the author generally prefers to avoid a medial epicanthoplasty unless the patient is of the Flowers type III or IV. As for placing the fold on the inside or outside of the epicanthus, this author prefers a very small outside fold. This can be hard to control, but in general, the larger the fold at mid pupil, the more likely it is to fold on the outside. A very small fold usually folds on the inside. The patient often makes his or her preference clear on this matter, which of course influences the size of the fold the surgeon needs to create in order to accomplish the desired result.
Semiopen or suture method
The semiopen method incorporates the natural appearance and low morbidity of the suture method with the permanence associated with the open method. Prelevator fat is removed through a stab incision, effectively raising the septoaponeurotic sling. This procedure is best suited for younger patients with little forehead ptosis and no prior crease surgery. The upper eyelid skin should be relatively thin, with thin pretarsal orbicularis muscle. Surgeons less experienced in operating on Asian eyelids may prefer this procedure because of its potential reversibility. The most irreversible deformity that can occur with Asian eyelid surgery is overresection of prelevator fat. The suture or semiopen method precludes this complication. The steps of the operation are as follows:
Mark the patient's eyelid while he or she is on the operating table. After administering intravenous or oral sedation, administer topical 4% tetracaine to the conjunctiva and inject 1 mL of 1% lidocaine with 1:100,000 epinephrine into the skin.
If a medial epicanthoplasty is planned, perform this first because the epicanthoplasty alters the medial anatomy of the skin. Total height of a V-W plasty is approximately 5 X 5 mm, with each arm of the V and W being approximately 2 mm, as shown below.Perform the medial epicanthoplasty first. Mark the V-W plasty; each limb measures approximately 2 mm. Mark the W portion on the surface of the epicanthal fold. The tip of the central flap of the W sits at the edge of the epicanthal fold, and the V component lies on the undersurface of the epicanthal fold. The markings represent skin that will be resected.
After allowing the local anesthetic to take effect, use a No. 11 blade to cut each arm of the flap. Remove the subdermal muscle along with the skin, and use 6-0 nylon sutures to close the incision (see below).
Make a 1-cm incision along the lateral aspect of the upper lid marking. Remove a small sliver of orbicularis and then septum to enter the prelevator space. Ignore retro-orbicularis fat, which should not be removed. Identify prelevator fat by the glistening levator aponeurosis along the floor of the space, which also retracts when the patient opens the eyelid. Remove approximately 1-2 mL of fat, as depicted below.
Next, place a 6-0 nylon suture to the lash line of the upper lid for retraction. Flip the upper lid to expose the conjunctival surface, and take a 5-mm bite of tissue at the mid pupil along the superior border of the tarsal plate using double-armed 5-0 nylon (see below).
Reenter the conjunctiva through the same needle hole so that a full-thickness buried suture exits on the skin surface of the upper lid along the lid markings (see the first image below). Secure the knot and let it retract into the deep recesses of the orbicularis muscle (see the second image below). Place 4 sutures equidistant to each other.Arm the free end of the suture with a free needle, and then pass it through to the other side of the eyelid using the same needle hole as the initial conjunctival bite.
Incision method (Flowers anchor blepharoplasty)
The author's preferred method for the open approach is the Flowers anchor blepharoplasty. The markings are made as described above, including plans for the medial epicanthoplasty if that has been decided upon preoperatively. The steps of the operation are depicted in the images below and then described.
See the list below:
The preferred height of the incision has already been determined with the patient in the upright position, taking into account the patient's forehead anatomy (larger [~10 mm] if the patient has brow ptosis) and globe position (smaller [~6 mm] if the patient is exophthalmic).
Place tetracaine 4% drops into each eye, and then evert the eyelid and use Castroviejo calipers to measure the height of the tarsal plate on each eyelid. The usual height is 10-11 mm. The tarsal height yields an accurate measurement of where on the tarsal plate the skin will be affixed at a future step in the procedure. For instance, if the planned fold is at 8 mm and the tarsal height is 10 mm, the skin will be affixed to the tarsal plate 2 mm below the upper edge of the tarsal plate.
Skin markings are then made. The height is set at the mid pupil, with the rest of the marking continuing at the same height laterally until reaching the orbital rim. Medially, the marking tapers smaller toward the caruncle but stops approximately 2-3 mm above the lash line. The marking should not connect to the medial epicanthoplasty, if one has been planned.
An incision is made with the knife, and 1-2 mm of skin is excised if necessary (eg, because of brow ptosis). This author generally prefers to not remove skin in patients younger than 25 years. A sliver of orbicularis muscle is removed, and the orbital septum identified. Gentle pressure on the globe helps verify the presence of prelevator fat just beneath the septum.
The orbital septum is entered laterally, and the prelevator fat is allowed to herniate out. The presence of this fat defines the septoaponeurotic junction (or "sling"). The Iris scissors are introduced, and the septoaponeurotic sling is opened. Keep in mind the direction of this sling. It runs parallel to the lid margin when the eyes are open, but when the eyes are closed, the sling travels away (cephalad) from the lid margin. Failure to recognize this fact is a frequent cause of iatrogenic ptosis.
The pretarsal orbicularis muscle is thinned to expose the underlying pretarsal aponeurosis. Some of this muscle must be preserved because it assists in lid closure. At this point, the filmy soft tissue (Flowers refers to it as bursa) lying above the tarsal plate is excised. Although Flowers prefers to completely lay bare the tarsal plate, a less experienced surgeon may find it to his or her advantage to leave some of this levator aponeurosis intact in order to reduce the risk of creating a retraction or ptosis. If the levator aponeurosis is completely removed from the tarsal plate (as is preferred by Flowers, the advantage being less pretarsal edema and perfectly smooth pretarsal skin), tremendous precision is required to reattach the aponeurosis to the tarsal plate. If, however, some of the aponeurosis has been preserved, the risk of creating problems with the levator mechanism is reduced.
Closure is with 6-0 Vicryl on a reverse cutting or atraumatic needle, taking a bite of dermis, tarsal plate, and levator aponeurosis in one ligature. This is performed in 6 equidistant positions. Laterally, the tarsal plate fades out and only the dermis and levator aponeurosis are attached.
Skin closure is with 6-0 Prolene in an interrupted fashion, taking a bite of skin, tarsal plate, and levator aponeurosis in 5 equidistant positions. The remainder of the closure is performed using running 6-0 Prolene.
Place eye ointment into the conjunctiva, and apply a light compression dressing. Instruct the patient on the use of eye drops and eye ointment. Remove the surface sutures on the third or fourth day.
Remove any bandages on the first day after surgery. Remove sutures on subsequent days.
One of the most common causes of asymmetry is unrecognized preoperative ptosis. A careful examination of preoperative photographs measuring the marginal reflex distance 1 (MRD1) to assess potential ptosis is a critical part of the preoperative examination to preclude this potential complication.
Another common cause of postoperative asymmetry is the failure to compensate for the asymmetric brow. Most people have one brow lower than the other; in most cases, the right brow is lower. The 2 creases should compensate for the asymmetry by removing additional upper lid skin from the lower brow. Alternatively, the crease can be set slightly higher on the side with the lower brow.
A technical point that contributes to asymmetry is intraoperative swelling that distorts the anatomy. This can be alleviated by minimal injection of local anesthetic (0.5-1 mL per side) and performing each step of the operation one side at a time.
Unrecognized preoperative ptosis is another frequent cause of postoperative ptosis. In such cases, immediate ptosis repair may be warranted.
Reoperation to correct asymmetry is usually performed after 3-6 months.
Loss of crease
The most common cause of crease loss or indistinct crease in either the suture or incisional method is unrecognized preexisting ptosis. The is due to the ptotic patient’s dependence on brow retraction in order to open the eyes. In the ptotic eye, the underfunctioning levator is unable to form a complete crease.
There are other causes of fold failure. In the suture technique, a common cause is the cheese-wiring effect of the suture through the soft tissues. Alternative suture techniques have evolved to address this problem; the most common technique is anchoring one end of the suture to the tarsal plate and then interlocking the 2 ends of the suture to each other.
In the incisional technique, another common cause of fold failure is the lack of adequate fixation between the dermis and the underlying structures. Fold failure is more common in surgical techniques designed to preserve the pretarsal soft tissue structures. The author's preference is to create a wide surface area to allow for dermal adherence, as seen in the anchor technique.
The most common cause of postoperative ptosis is failure to recognize a preexisting ptotic condition. In the Asian eyelid, this can sometimes be difficult to assess because of overhanging skin that creates a pseudoptosis. The lid margin must be carefully assessed preoperatively. In the Asian eyelid, ptosis is defined as a lid margin that is lower than halfway between the limbus and the pupil. This is approximately 1 mm lower than in a non-Asian eyelid.
If the patient has preexisting ptosis, the open approach should be used to correct this condition simultaneously with the creation of a pretarsal crease. If the suture method was used, the eye should return to its preexisting state without intervention, or one may wish to correct the problem by converting to an open approach. If the open approach was used, the most common iatrogenic reason for ptosis is damage in the medial half of the levator aponeurosis, due to the anatomical considerations described above. The author prefers to correct iatrogenic ptosis as soon as it is recognized. Attention to the medial portion of the levator aponeurosis often reveals the cause of the problem.
If the suture method was used, retraction is almost always a self-limited condition that corrects over time. If an open approach was used, this author prefers to address the retraction as soon as it is recognized. First and foremost, the surgeon should verify that the patient is not compensating for a contralateral ptosis, which is more common. The author prefers to examine each eye individually, with the other eye closed, to determine which eye has the problem. If the patient does have retraction, the incision is reentered and any offending sutures are adjusted. Using minimal local anesthetic at half strength and having the patient sit upright at the termination of the procedure can help optimize the outcome.
Outcome and Prognosis
The semiopen method has many benefits; its relative simplicity and potential reversibility lend its use to less experienced surgeons. Scars are less noticeable. Although less permanent than an open procedure, its flexibility makes it a good option for young patients with no previous eye surgery.
The open method, including the Flowers anchor blepharoplasty, is preferred for patients with thicker skin or thick pretarsal orbicularis muscle. The procedure is ideal for more advanced surgeons experienced with the anatomy of the inferior portion of the upper eyelid and those comfortable with ptosis surgery.
Future and Controversies
The surgeon must decide whether to use the open or closed suture method for pretarsal crease placement. With proper patient selection, the semiopen method combines the best of the suture method (a natural appearance) with the best of the open method (ability to remove fat and give a more permanent appearance).
For advanced surgeons, the Flowers anchor blepharoplasty offers a precise, crisp eyelid fold that is inherently permanent and precise.
A study by Chung et al indicated that retrotarsal tucking of the Müller muscle-levator aponeurosis, performed in conjunction with aesthetic blepharoplasty, is an effective means of correcting borderline to moderate blepharoptosis in Asian patients. The study included 51 eyelids (26 patients), with satisfactory results achieved in 49 of them.
A study by Park et al indicated that epicanthoplasty should be performed in combination with blepharoptosis correction in Asian patients as a means of avoiding a rounded nasal scleral triangle and providing the best cosmetic results. The study included 99 patients who underwent the two procedures concurrently, with the authors reporting that periciliary or V-W epicanthoplasty is indicated for severe epicanthal folds.
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