Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty

It is my view that the trapezoidal debulking of the preaponeurotic platform using a beveled approach (along the upper incision line) in Asian blepharoplasty is a logical and efficient way of performing primary cases. I advocate this approach because it offers the following advantages:

1.

An easier and safer approach to the preaponeurotic space through the orbital septum when the plane of dissection is beveled.
2.

A controlled, uniform debulking of junctional tissues overlying the preseptal (supratarsal) and pretarsal areas.
3.

Optimal adhesions between levator aponeurosis and the subcutaneous tissues along the lower incision line, or to intermuscular septa within pretarsal orbicularis muscle fibers (pretarsal platform).
4.

Crease formation can be based on the individual’s tarsus height.
5.

Virtual elimination of any potential for an uneven plane of surgical dissection, thereby lessening the complication rate, which includes problems with asymmetry, height, shape, continuity, permanence, segmentation of the crease, fading and late disappearance of the crease, multiple creases and persistent edema.

The clinical findings in patients seeking revisional surgery are myriad. The eyelid may show spreading of the incision scar, high placement of the crease, induced lagophthalmos on downgaze, and acquired secondary ptosis on straight-ahead 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 ( Figure 18-1 ). Instead of having a physiologically preserved ‘glide zone’ where significant preaponeurotic fat pads are still present in the lowest aspect of the glide space, there is now a condensed apron (plaque) of tissue that is preventing the posterior layer from up-vectoring properly against a passive and flexible skin–orbicularis layer. Despite all efforts, there is no observable crease formation. Patients often complain of lid fatigue, 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 already scarred field of operation, both from an anterior skin viewpoint (and therefore an aesthetic concern) and as regards middle lamellar scarring and contracture (with 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 and undertaking this type of revision surgery. Not only is the operation difficult, but 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 their projection of the time course of healing following revisional surgery.

Having said that, the following are the minimal requirements in revisional surgery that I have striven for in my practice:

1.

That we do not cause further skin shortage.
2.

That we do not cause increased midlamellar contraction, with lid retraction and poor eyelid closure.
3.

That neither of the two factors above leads to consecutive symptoms of exposure and dryness of the ocular surface.
4.

That the patient understands from the first that the surgeon will not be able to achieve a level of aesthetic improvement rivaling that obtained within the practice in primary cases, where conditions are ideal, the amount of skin is adequate and patient expectations are closer to being normal and fair.
5.

That the patient be informed that for each revision operation one can try to correct only one item from a list of goals. By this I mean that it is impossible, for example, to correct an abnormally high crease, lid margin contour deformity, pre-existing ptosis and a shortage of skin all at the same time.

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. This latter will require precise techniques, experience and special splinting over the graft in order to place it in an aesthetically acceptable fashion. There are, however, many young adults or middle-aged patients who need revisional surgery, whose problems are severe and who are unlikely to have any skin reserves in the future because of natural aging. Patients with just enough eyelid closure to avoid corneal exposure can develop such symptoms if the usual method of excision of the scar and lysis of adhesion of the middle lamella is followed. The amount of skin removed can be as little as 2 mm, and poor eyelid closure can be the result.

An ideal solution to this dilemma is to approach the scarred anterior and middle lamellar complex through a superiorly beveled approach. 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 (over the preseptal region) that needs to be in reserve. For example, if the suboptimal crease is currently at 10.5 mm 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 can 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 they may proceed to revision at that time). If this cannot be achieved and the patient is desperate, for either functional or psychological reasons, then one must discuss the option of a free skin graft.

For the majority who may be candidates for revision 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 directly next to each other on either side of the existing scar. Patients in this category are more likely to have had their lid crease incision made in the 8–9 mm range, as measured from the central lid margin. The separation of 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 ( Figure 18-2 ). 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 ( Figure 18-3 ). At this stage, one is cutting through skin–orbicularis adhesions. Small scissoring motions are then used as the scissor blades transect the middle lamellar scar, opening through the whitish, scarred fascial layers between the orbicularis and the underlying levator aponeurosis ( Figure 18-4 ). This is carried out through the width of the incision along the previous scar. The beveled approach is quite similar, but steeper than in primary cases ( Figure 18-5 ). 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 globules or aprons of scattered fat droplets, may be seen ( Figure 18-6 ). The scarred tissues in the anterior layer as well as in the mid-lamellar zone – encompassed by the tissues between the dotted superiorly beveled vector and the lower skin incision (along the superior tarsal border) in Figure 18-5 – may be excised after the forehead/eyebrow/preseptal skin layers are carefully reset (by releasing any restrictive surgical adhesive or drapes on the patient’s forehead), for as long as the remaining skin still 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 approach are as follows:

1.

By approaching the preaponeurotic space very close to and barely superior to the suboptimal scarred crease line, one can avoid taking out a precious 0.5 or 1 mm of good skin.
2.

By making the upper line of incision close to the scarred crease line, one avoids creating an extra incisional scar.
3.

This beveled approach to the previously explored preaponeurotic space allows the space to be entered safely again, without injury to underlying levator muscle and Müller’s muscle, as well as avoiding any anastomotic vascular arcades in Müller’s muscle and the superior tarsal arteriolar arcade.
4.

In some cases, this beveled maneuver towards the preaponeurotic space frees up the vertical excursion of the upper eyelid 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.
5.

Approaching the preaponeurotic space in any revisional upper blepharoplasty 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 at a higher level within the sulcus to help reverse some of the hollow sulcus often seen in patients needing revisional blepharoplasty.
6.

Mid-lamellar scarring that has previously bonded the anterior and posterior layers can be safely removed or reduced, allowing partial restoration of the glide zone.