10.1 Patient History Leading to the Specific Problem

The patient is a 66-year-old white woman who underwent bilateral upper eyelid blepharoplasty 1 year previously. She was unhappy with the cosmetic appearance of the right eye and presented requesting additional skin removal from the right upper eyelid to obtain better symmetry with the left eye (Fig. 10-1).

10.2 Anatomic Description of the Patient’s Current Status

This patient demonstrates a common problem after upper eyelid blepharoplasty—asymmetry of the level of the upper eyelid folds. The most common cause of this appearance is removal of unequal amounts of skin, muscle, or fat at the time of the original blepharoplasty. In such a case (all other things being equal), the side with more redundancy will have a lower upper eyelid skin fold postoperatively. This situation is easily remedied by removal of additional tissue from the lid with greater redundancy. This case is different, however, in that although equal amounts of skin were removed from each upper eyelid, the incision was placed at a lower level on the right than on the left. This resulted in a lower crease on the right side. This is obvious in the downgaze photo where one can observe the unequal height of the two lid creases (Fig. 10-2). This gives the appearance of excess skin remaining on the right upper lid. Since removing additional skin from the right upper eyelid in this particular patient might lead to lagophthalmos, this solution is not viable.

10.3 Recommended Solution to the Problem

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  Elevate the crease in the right upper eyelid.

  
  
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  Measure the height of the eyelid crease in the left upper eyelid.

  
  
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  Transpose those measurements to the right upper eyelid and create a new lid crease at this level.

10.4 Technique

Before injecting with local anesthetic, measure from the lash line to the crease in the left upper eyelid centrally, medially, and laterally with the lid in downgaze. Transpose those measurements to the right upper eyelid. Fig. 10-3 shows the old crease as the lower line and the proposed new crease as the higher line. Anesthetic may be injected at this time. Incise with a blade through skin and orbicularis across the right upper eyelid in the new crease line. Expose the levator aponeurosis in this area by undermining superiorly below the level of the orbicularis muscle across the length of the wound. This may necessitate opening tissue over any preaponeurotic fat that may remain from the prior surgery. If fat remains, dissect the fine attachments between the underside of the fat to the levator muscle to expose the levator. With scissors (I prefer blunt or sharp Westcott scissors), undermine deep to the level of the orbicularis on the anterior surface of the tarsal plate to a point inferior to the old, lower eyelid crease (Fig. 10-4). It is important to do this across the entire old eyelid crease in order to divide all the fibrotic attachments from the tarsus to the underside of skin that form the old crease.

Reform the new, higher eyelid crease using three 6–0 polyester or 6–0 polyglactin buried sutures. Take a bite of the levator aponeurosis at the level of the new crease (Fig. 10-5) and then a bite of the orbicularis at the lower edge of the incision (Fig. 10-6). Fig. 10-7 shows this in cross-section. Do this centrally, medially, and laterally (Fig. 10-8). Close the skin with a running monofilament suture.

Alternatively, the crease can be formed with three 6–0 silk or 6–0 plain gut sutures placed centrally, medially, and laterally. To do this, first take a bite of the skin on the lower edge of the incision as shown in Fig. 10-9. Next, take a bite of the levator aponeurosis just deep to the skin edge (Fig. 10-10). Then, take a bite of the upper skin edge (Fig. 10-11). This is shown diagrammatically in cross-section in Fig. 10-12. Then, tie the knot (Fig. 10-13). A 6–0 silk or 6–0 gut sutures are good for this technique since they are relatively strong and inflammatory and will create a “spot-weld” at each location. This may be easier to perform than the first technique but occasionally results in loss of the crease when the silk sutures are removed the following week or the gut sutures dissolve.

A third and simplest way to reform the crease is to incorporate the levator aponeurosis into the running monofilament suture closure of the skin. This is done by taking a bite of the levator aponeurosis with every second or third passage of the needle through the skin edges (Fig. 10-14). This is shown diagrammatically in Fig. 10-15. Like the second technique described in the previous paragraph, the crease is sometimes lost after removal of the running monofilament suture. Additionally, suture removal is somewhat more difficult and uncomfortable because of the deeper bites into the levator.