Advanced: Angle of Observation, Crease Height and its Effects on Clinical Outcome of Upper Blepharoplasty

This chapter deals with the author’s concepts regarding the height and depth of an eyelid crease, which change in different view positions with respect to the patient’s gaze, as well as the clinician’s observing angle.

An individual’s upper eyelid crease height varies in its measurement and is influenced by various factors, including resting position, angle of observation and presence of associated ocular abnormality. Its effects should be taken into consideration in planning primary aesthetic and revisional surgery of the eyelids.

Anatomic Definition of an Upper Eyelid Crease

The upper eyelid crease is a natural indentation of the eyelid skin, usually found along the level of the superior tarsal border, which is apparent when the subject opens their eyelid ( Figure 19-1 ). It is believed to be a result of contraction of the distal fibers of the levator aponeurosis, pulling up on the tarsus as well as the pretarsal skin and orbicularis in a superior–posterior direction against a relaxed preseptal segment of the anterior lamella of the upper lid (skin, orbicularis, orbital septum and preaponeu­rotic fat).


The position of the upper eyelid crease.

Position of the Upper Lid and Its Eyelid Crease

Depending on the tilt of the face, there is an observable variance in the apparent height of the upper lid crease. Most individuals with an upper eyelid crease will show the crease optimally in a straight-ahead gaze position ( Figure 19-2 ).


This shows the patient with eyelids open and looking straight ahead. The lid crease is an indentation of the skin that corresponds with the superior tarsal border, where levator aponeurosis inserts on to as well as branching forward into orbicularis muscle sheaths and skin under the eyelid crease. CH 2 refers to the crease height observed when the observer and subject are both in a neutral gaze position.

Visual Axis Angle (Vax)

Downgaze ( Figure 19-3 )

In downgaze, the inferior rectus and superior oblique muscles contract while the superior rectus and levator muscle relax, stretching the latter to its longest length. For a person who has a natural crease, downgaze results in the shallowing or disappearance of the upper crease, though there is still a faint skin line that is observable on its skin.


The patient’s visual axis is looking downward, Vax is negative and crease indentation is minimal.

Upgaze ( Figure 19-4 )

The crease is deepest when the upper eyelids are open and looking upward maximally – where the levator muscle is presumably maximally contracted and at its shortest length. The angle of upgaze as measured from horizontal can be designated as a positive (+) Vax (Vax = patient’s visual axis angle, relative to the horizontal axis).

Jan 26, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Advanced: Angle of Observation, Crease Height and its Effects on Clinical Outcome of Upper Blepharoplasty

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