11.1 Introduction

Variation in the position of the upper eyelid crease is a common postoperative finding following upper blepharoplasty. There are myriad factors that can challenge the surgeon’s attempt to set the crease at an intended height. The following are some of the factors that come to mind immediately:

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  Variable interpretation (definitions) of what an eyelid crease really is.

  
  
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  Unequal brow position between two sides.

  
  
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  Variable residual skinfold affecting the apparent crease height.

  
  
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  Different state of levator function between the two eyes.

  
  
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  Latent ptosis of one or both eyes.

  
  
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  Variable ratios of pretarsal versus preseptal segment.

Variation of crease height between two upper lids and higher than expected crease-anchoring are especially distressing to Asian patients as well as surgeons performing this type of aesthetic surgery, commonly called double eyelid surgery in Asia.

11.2 Technique of Resetting a High Crease Height

For the purpose of discussion, this author defines an upper lid crease as the area where the upper lid skin invaginates, typically along the level of the superior tarsal border (STB), due to terminal insertions of levator aponeurotic fibers along the STB as well as the upper boundary of the pretarsal segment (skin, orbicularis oculi, upper tarsus). Various authors have identified histological as well as evidences that showed microfibrils (microtubules) emanating from the distal levator aponeurosis ending in the subcutaneous space along the STB, or fusion with the intermuscular septa and muscle sheath within fibers of the orbicularis oculi. Excluded are skin wrinkle lines as a result of dermatochalasis or depression as a result of supratarsal sulcus, whether they were congenital, acquired from fat excision following blepharoplasty, or involutional. The author ascribes to a dynamic definition for an upper lid crease, one that is a result of levator action through an animated posterior lamella (levator muscle/aponeurosis, Müller’s muscle, and tarsal plate) against a passive, gravitating anterior lamella (composed of upper lid fold of skin, orbicularis oculi, and orbital septum; the preaponeurotic fat can be considered as part of the anterior layer while acting as an intermediary “glide zone interface” between the two lamellae’ opposing actions). This definition is highly specific, physiologic, and conforms to known anatomy.

The abnormally high crease height we see in consideration for revisional upper blepharoplasty often fails this physiological definition of a crease. There are subcutaneous scar tissues along the vicinity of the STB, which interferes with the normal vectoring of the posterior tarsoaponeurotic segment against a fluidic anterior lamella. The result is a thickened band of skin–fibrous tissue scar attached to levator aponeurotic tissues that extends from the STB upward to a variable height. Physiologically, the levator aponeurosis here is tethered and fails to indent the eyelid crease. The resultant “crease” may appear to be a static crease line or wrinkle, a line that is part of a wrinkled placoid area of immobile lid tissue (glide zone). The most common etiological reasons include high anchoring where the surgeon places sutures to help form the crease on the levator aponeurosis above the STB, placement of buried, nondissolvable sutures toward this attempt, and less-than-meticulous tissue handling and hemorrhage intraoperatively.

11.3 Clinical Findings Seen in Patients Seeking Revisional Surgery

The eyelid may show spreading of the incision scar, high placement of the crease, secondary lagophthalmos on downgaze, and acquired secondary ptosis on straight gaze as well as upgaze. Intraoperatively, one sees thickened middle lamellar scar involving the orbicularis oculi as well as the orbital septum, or the presence of dense scar tissue plaques that may bind the anterior orbicularis oculi as well as the posterior levator aponeurosis (Fig. 11-1). Rather than having a physiologically preserved “glide zone” of preaponeurotic fat pad, there is now an apronlike plaque of fibrosis that is preventing the posterior layer from vectoring upward against a passive skin–orbicularis layer. Despite all efforts, there is no observable crease formation. Patients often complain of strain and fatigue, and a feeling of tightness, and may show brow and forehead overaction.

In dealing with revision cases, whether simple or complicated, one of the greatest dilemmas is where to make the incision so that it does not compound the scarring, both from an anterior aesthetic viewpoint middle lamellar scarring and contracture that may cause further functional compromise. To succeed with improved aesthetic results as well as without further functional setbacks is a major triumph for any surgeon familiar with this type of revision surgery. Not only is it difficult, but also often the patient is anxious for a rapid and successful outcome, something that is never easily realized when dealing with scarring and suboptimal outcomes. I am often struck by how devastated these patients are and how grateful when the improvement proves significant. It is important for both patient and surgeon to be realistic in their expectations, as well as projection of the time course of healing following revision.

All these factors funnel into the same conclusion: if there is insufficient skin in reserve, it is unlikely that there is any chance of revisional improvement unless one wishes to supplement the skin with a free full-thickness skin graft. The latter will require precise techniques and experience, with special splinting over the graft in order to end up with an aesthetic improvement. There are, however, many young adults or middle-aged patients who need revisions and whose problems are severe but are unlikely to have any skin reserves in the near future from aging. Patients with just enough eyelid closure to avoid corneal exposure may develop ocular exposure symptoms if the usual methods of excision of scars and lysis of adhesion of the middle lamella are followed. The amount of skin fragment removed may be only as well as, and poor eyelid closure may result.

An ideal solution to this dilemma is to approach the scarred anterior and middle lamellar complex through a superiorly beveled approach without significant removal of viable skin. To do this, the following conditions must be met.

The crease height is evaluated, and if it is high then the degree of planned lowering (in millimeters) will determine the minimum amount of skin redundancy above the existing crease in the preseptal region that needs to be in reserve. For example, if the height of an abnormally high crease is currently at 10.5 mm, which is considered extremely high, and you plan to lower it to 7.5 mm, then the patient will need to have 3 mm of skin in reserve above the crease before this is feasible. If there is only 2 mm, then this needs to be discussed with the patient, as the crease most probably may only be revised down to 8.5 mm in the current situation, or the patient can opt to wait for some skin to become available as a result of natural aging (and then they may proceed to revision at that time). If the patient is desperate for either functional or psychological reasons, then one must discuss the option of a skin graft.

For the majority of revision candidates who can get by without the need for skin grafting, my surgical approach proceeds initially along the same path as in primary cases, the major exception being that the upper and lower incision lines are marked across from each other on either side of the existing scar. Patients in this category for revision are more likely to have had their lid crease incision made in the 8- to 9-mm range, as measured from the central lid margin. The space between the upper and lower incision lines should be no more than 1 mm, and very rarely 2 mm. A no. 15 Bard-Parker blade is used to make a full-thickness incision along the marked upper and lower lines (Fig. 11-2). Now, instead of using cutting cautery to go through the orbicularis to reach the orbital septum, one uses a sharp-tipped Westcott spring scissors to incise across the upper line of incision in a superiorly beveled fashion (Fig. 11-3). At this stage, it is cutting through skin–orbicularis adhesions. Small scissoring motions are then used as the scissor blades transect the middle lamellar scar, opening the whitish, scarred fascial layers between the orbicularis and the underlying levator aponeurosis (Fig. 11-4). This is carried out across the width of the incision along the previous scar. This beveled approach is similar but steeper than in primary Asian blepharoplasty cases (Fig. 11-5). In this scarred middle zone, there will be much less preaponeurotic fat as it will have been previously excised; some residual fat globules, combined with scattered smaller amorphous specks or thin apron of scattered fat droplets, may be seen (Fig. 11-6). After the forehead/eyebrow/preseptal skin layers are carefully reset by loosening the surgical drape over the patient’s forehead, the scarred tissues within the space between the dotted superiorly beveled vector and the lower skin incision along the STB may be excised, for as long as the remaining skin allows passive eyelid closure. All fat is preserved. The levator and levator aponeurosis can be identified when the scar is released, and it is important to check for restriction objectively (by gently pulling the tarsal plate down) as well as subjectively by asking the patient to perform upgaze and downgaze.

The benefits and advantages of this beveled approach for revisional Asian upper blepharoplasty are as follows:

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   By approaching the preaponeurotic space very close to and barely above the scarred crease, one can avoid removal of any skin.

   
   
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   By making the upper line of incision close to the scarred crease, one avoids adding an incisional scar.

   
   
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   This beveled approach provides a safer passage to the already-explored preaponeurotic space, without injury to underlying levator muscle and Müller’s muscle, as well as avoiding any anastomotic vessels of the superior tarsal arcade.

   
   
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   In some cases, the beveled maneuver toward the preaponeurotic space frees up the levator excursion significantly, releasing any restriction that may have contributed to lagophthalmos and acquired ptosis. This maneuver in itself may correct the mild ptosis, such that resetting of the previously high crease is then feasible.

   
   
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   By approaching the preaponeurotic space in a beveled fashion, it allows one to identify residual preaponeurotic fat that may have spread out and become plastered down on the levator muscle. This residual fat can be peeled off and repositioned to a higher level within the sulcus to help reverse some of the hollow sulcus often seen in patients needing revisional blepharoplasty.

   
   
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   The midlamellar scarring that has previously bounded the anterior and posterior lamellae of the upper lid can be safely removed or reduced, allowing partial restoration of the glide zone.

Following revisional Asian blepharoplasty with a superiorly beveled approach, the glide space has been partially restored and the scar carefully removed (Fig. 11-7).

The preaponeurotic platform is cleared of most of the interfering tissues. Although the surgeon is often forced to make a skin incision that is still further from the lid margin than one would for a primary Asian blepharoplasty, upon closure the incision wound (white dot) is free to indent inward when the levator contracts, forming a better crease. The residual fat pads in the middle (glide) zone are preserved and allowed to fill in this glide space where appropriate. Supratarsal skin denoted by the red and blue dots above the incision is now free to gravitate and form the upper lid fold.

The restoration and preservation of the preaponeurotic space is an essential element in the surgical creation of a crease for an Asian with single eyelid, for it is the up-vectoring of the tarsal plate initiated by levator muscle and the presence of preaponeurotic fat in the glide space that facilitates a well-formed crease to form under a lid fold. In primary Asian blepharoplasty, it would be undesirable to excise all preaponeurotic fat, thereby obliterating the glide function of the preaponeurotic space, collapsing the supratarsal midsection of the lid, and creating a hollow sulcus on an Asian upper lid.

These reasonings are applied to revisional blepharoplasty as well, especially when it comes to resetting a high crease. This beveled approach allows the surgeon to reach the preaponeurotic space safely, to reposition any remaining preaponeurotic fat superiorly to fill in the hollow sulcus, and to approach the preaponeurotic space without having to excise precious millimeters of skin along the upper skin incision line (Fig. 11-8; Fig. 11-9).

In the author’s practice, a series of 26 patients and 48 eyelids underwent revisional blepharoplasty over a four-year period for the specific purpose of revising a postsurgical high crease to a lower position. Excluded from this series were all primary Asian blepharoplasty candidates including any patients with preexistent high crease, touch-up surgery for the purpose of enhancing (deepening) an existing or surgically created crease that was in the correct position, correction of incomplete crease or crease shape alone, and simultaneous correction of acquired or involutional ptosis in conjunction with primary Asian blepharoplasty. There were 5 males and 21 females, and with the exception of 4 patients who requested unilateral crease revisions, all others were bilateral. The data were arranged in two separate sets of columns (Table 11-1).

OD stands for the right upper lid and OS for the left upper lid. The third column of each of these two clusters of data reflects the difference between the preoperative and postoperative measurements. There were 24 eyelids in each category, for a total of 48 eyelids. The data were pooled together to arrive at the overall statistical mean. The prerevisional crease height was measured in the office using a millimeter scale and varied between 8 and 14 mm, with the overall mean being 9.9 mm. The crease height designed during revision (in 0.5-mm increments) varied between 6.0 and 8.5 mm based on the circumstances, with the mean being 7.15 mm; and 7 mm was the most often applied measurement during surgery under local anesthetic.

The effective lowering of the crease height ranges from 1 to 6 mm when reassessed during their 2-month postrevisional visits. The mean lowering of crease height is 2.75 mm in this series based on 2-month follow-up. Therefore, a 10-mm crease height on average can be reduced and reset to a height of 7.0 to 7.5 mm, which is a very acceptable position. The typical course is such that the crease height will continue to settle down with egress of swelling and wound healing, such that the effective lowering of the crease will likely increase had it been possible for all these patients to return for a longer follow-up period.

The use of a superiorly beveled approach in revisional Asian blepharoplasty allows the glide zone to be partially restored and the middle lamellar scar reduced through removal. The preaponeurotic platform can be cleared of any interfering tissues. This combination of techniques described here often allows an abnormally high, static scar line to be repositioned and formatted into a lower, more dynamic crease to the point of being acceptable for the patient. The need for skin grafting may often be avoided.