The main reasons why Asians without an upper eyelid crease may elect to have a crease created have been discussed in Chapter 1 . There are many fallacies in discussions of eyelid surgery for Asians. The conventional view that Asian eyelid surgery started only after the Second World War, with industralization and westernization of Asia, is in my opinion erroneous. There has always been a demand for this type of cosmetic surgery in Asia; the earliest 20 descriptions of the double eyelid crease procedures were reported in the Japanese medical literature between 1896 and 1940. In the Western Hemisphere over the last 40 years, there has been a simultaneous rise in demand as more Asians leave their homeland and settle abroad. Demography shows that Asians seeking eyelid crease procedures are a relatively young, affluent, and educated group. However, despite being educated, the patients’ understanding of what they want, and of what can be achieved, may not be equivalent to the surgeon’s own beliefs. They may not be aware of the normal wound healing processes and have unrealistic expectations. In addition, the physician may not be fully informed of the nuances of this specialized and peculiar aspect of aesthetic eyelid surgery. Most of the complications and suboptimal results may be linked to a lack of communication between the patient and the surgeon, and the failure of the surgeon to observe certain basic concepts and hidden dangers.
One of the most common fallacies is the notion that most Asians do not have an upper eyelid crease. This may be because, typically, only those subjects without a crease would consult an aesthetic surgeon. The lid crease occurs in varying incidence among different ethnic subsets of Asians, whether Chinese, Korean, or Japanese, etc. It shows provincial and geographic variance (e.g. northern versus southern Chinese; Japanese who are from the northern island of Hokkaido versus those from the more southern province of Kyushu). Overall, among Han ethnic groups (Chinese, Koreans, and Japanese), the prevalence of a crease is 50% ( Fig. 7.1 ). Consequently, one in two Asians is likely to have an upper eyelid crease. This ratio holds true even among parents and their offspring – for instance, two out of four siblings will have an upper eyelid crease, or one of the two parents will have a crease. The crease height often correlates with the vertical dimension of the superior tarsal plate, as measured over the central portion above the pupillary aperture. Asians are, in general, smaller in physical dimensions relative to non-Asians. Their tarsal plate height averages 6.5–8.0mm, and the upper lid crease, if present, is usually not greater than this distance from the eyelid margin (ciliary border). With respect to the depth of inward folding of the crease line, the crease is not any less prominent in Asians as compared with non-Asians. One of the reasons that the lateral canthus appears more upslanted may be the presence medially of a fold of skin over the crease, partially blocking the upper medial half of the palpebral fissure. There have been recent reports describing a higher lateral canthal position among certain ethnic subset of Asians, although one certainly cannot deduce or generalize this finding to all Asians.
The current hypothesis regarding the lid crease is that it results from the presence of subcutaneous terminal interdigitations of the levator aponeurosis in the pretarsal as well as along the superior tarsal border area. The distal terminations of the levator aponeurosis fibers blend into the intermuscular septal and connective tissue fibers of the pretarsal orbicularis oculi muscle, resulting in an infolding along the superior tarsal border when the levator is contracting the tarsus upward ( Figs 7.2 & 7.3 ).
The term ‘westernizing blepharoplasty’ is still quite often used to describe the crease procedure that Asians elect to undergo. This can be complicating and misleading to the patient and physician alike. Such Asians really do not want to select the height and crease configuration of a Caucasian’s or a Westerner’s eye. Rather, most Asians who elect to have Asian blepharoplasty want to look like other Asians who have a crease – a very different crease as compared with that of a Caucasian.
Communication between patients and physicians is further weakened by additional confusion in terminology. The terms ‘outer double eyelid’ and ‘inner double eyelid’ do not refer to the higher crease found in a Caucasian ( Fig. 7.4 ) versus the lower crease seen in those Asians who possess a crease, nor to any upslanting of the crease over the lateral canthus. Instead, they relate to the medial configuration (shape) of the crease among Asians. The term ‘outer double’ simply signifies a crease that does not converge to the medial canthus – I believe ‘parallel’ is a more appropriate term anatomically ( Fig. 7.5 ). The term ‘inner double eyelid’ refers to a medially converging crease – I consider the term ‘nasally tapered crease’ as more accurate here ( Fig. 7.6 ). The original terms make sense only if one appreciates the Chinese origin of these words, as they are English translations from Kanji (literal meaning: ‘words of the Han race’), the language of the Han people. The abstract concepts are distorted in straight translation. Interestingly, the classical literature and Imperial court correspondences of Korean as well as Japanese cultures from the last 500 years both utilized Chinese Kanji. Overall, these terms are quite confusing for anyone who is not native to the Chinese written language. It is best to avoid using them for medicolegal reasons, since Chinese as well as non-Chinese Asians may be using them inaccurately.
The term ‘Asian blepharoplasty’ was first used in a paper published in 1987 by this author. The paper described a distinctive surgical procedure customized specifically for those Asians without a crease who desire to have a crease, and included details concerning the height and shape of such, and the surgical maneuvers needed to yield a crease that appears continuous, is predictable, and remains permanent in nature.
Through an external incision approach, the objective of Asian blepharoplasty is to clear a trapezoidal block of preaponeurotic tissues along the superior tarsal border, including the skin, orbicularis, orbital septum, as well as minimal preaponeurotic fat, in an equidepth and uniform fashion, to allow for optimal surgical apposition of the terminal fibers of the levator aponeurosis to the undersurface of the skin along the superior tarsal border. For a nasally tapered crease, one would design the crease to converge medially. For a parallel crease, one would stay more level and equidistant along the lid margin.
Surgical method
The concept of upper eyelid crease configurations and the essential steps needed for predictable placement of a lid crease among those Asians without a crease have been covered in my previous publications. My method is founded on accurate measurement of the central height of the upper tarsus, using it to determine the placement of the external incision line for creation of the crease. The ideal crease tends to be of either the nasally tapered type or of the parallel configuration. A medial upper lid fold is often present to some degree in the medial portion of the upper eyelid of Asians, whether they have a crease or not, and should not be considered pathologic, nor should it be automatically removed. Interestingly, the same small medial upper lid fold can be seen readily in non-Asians and even Europeans. (At present, the term ‘epicanthal fold’ seems to be indiscriminately applied to any degree of fold, no matter how small, and selectively applied to Asians, a practice I believe is unfortunate.)
Premedications and surgical setup
The patient usually receives 10mg of diazepam (Valium) and one tablet of Vicodin or Tylenol with codeine, orally, an hour before the procedure. The patient is placed in a supine position, and an intravenous line and electrocardiographic monitors are applied. A pulse oximeter that provides a real-time readout of the patient’s pAO 2 is applied. All patients are given a nasal cannula with 1–2L/min of room air flow (or oxygen). Intravenous Versed (midazolam) may be used in small aliquots of 0.5mg (0.5mL of 1mg/mL).
Anesthetic mixture and injections
Two mixtures of local anesthetics are then prepared:
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10mL of 2% lidocaine (Xylocaine) containing 1:100 000 dilution of epinephrine is mixed with 150 units of hyaluronidase, if available, and labeled ‘regular’. (This mixture is still acidic in nature.)
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1mL of the above mixture is further diluted with 9mL of injectable normal saline. This mixture now has a pH closer to neutrality since it has been diluted with the buffering action of injectable normal saline. The epinephrine concentration is now 1:1 000 000 (labeled ‘diluted’).
A drop of topical anesthetic, 0.5% proparacaine hydrochloride (Ophthaine, Ophthetic) is applied over each cornea for comfort prior to surgical preparation and draping. Using a 30-gauge half-inch needle, 0.25–0.5mL of the diluted mixture is infiltrated subcutaneously over the superior tarsal border of the mid-portion of the lid. During the next 2 minutes, anesthesia takes effect and one can observe blanching of the eyelid skin from the powerful vasoconstrictive effect of the diluted epinephrine ( Fig. 7.7 ).
The regular mixture is then injected in the suborbicularis plane along the mid-section of the upper lid, usually applying less than 1.0mL per eyelid.
The purpose of this two-staged injection of local anesthetic is to allow for a relatively painless pre-infiltration to anesthetize the surgical field before the full strength of acidic 2% Xylocaine is given. (One may add sodium bicarbonate to the 2% mix to achieve the same effect: for a 10% volume mixture, 1mL of 8.4% sodium bicarbonate, containing 100mEq or 8.4g per 100mL, is mixed with 9mL of the 2% Xylocaine.) The hyaluronidase promotes dispersion of the anesthetic and greatly reduces any tissue distortion, facilitating the identification of any crease line that the patient may have.
When confronted with a patient with a low threshold for pain, one may supplement the local field infiltration with a frontal nerve block: a 30-gauge half-inch needle may be used to apply 1mL of the anesthetic into the supraorbital space just lateral to the supraorbital notch.
The eyelids and face are then prepared in the usual fashion for ophthalmic plastic surgery. The eyes again receive a drop of topical anesthetic, this time using tetracaine hydrochloride for longer-lasting corneal anesthesia. To eliminate the possible sensation of claustrophobia that may occur with draping over the nose and midface, a single layer of sterile, moistened, porous gauze may be placed over the patient’s exposed nose and mouth. Black opaque corneal protectors are then applied under the eyelids.
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The use of diluted anesthetic solution helps to:
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decrease pain upon injection;
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decrease volume of anesthetic needed for injection; and
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create less tissue distortion as a result of less volume expansion and lessened bleeding.
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It allows the surgeon to stay focused on the surgical plane.
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The use of nasally delivered room air or low-flow oxygen serves to decrease the patient’s sense of claustrophobia.
Clinical pearls - ▪
Never use nasal oxygen in an open system exposed to monopolar cautery, as it may cause ignition and flaming.
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Always apply pulse oximetry to measure the pAO 2 saturation. Preoperative sedation and intraoperative sedation may easily cause apnea in a sensitive patient.
Pitfalls Surgical stages
The height of the tarsus determines the overall central position of the surgical crease; the shape is determined by how you design the medial one-third and lateral one-third of this lower line of incision, according to the patient’s preference.
The shaved-off tip of a wooden cotton-tipped applicator dipped with methylene blue is used to indicate the proposed crease. The upper lid is everted and the vertical height of the tarsus is measured over the central portion of the lid with a caliper ( Fig. 7.8 ). This measurement – which is usually between 6.5 and 8.0mm – is carefully transcribed onto the external skin surface, again over the central part of the eyelid skin. This point directly overlies the superior tarsal border and will serve as a reference point for the overall crease height along the central one-third of the eyelid, whether the crease shape is to be nasally tapered, parallel, or, in rare cases, laterally flared. For those patients who have a crease, one should also measure the tarsus to confirm that the apparent crease is indeed the correct crease line to use, whether one is planning to preserve or enhance it.
If the crease is to be nasally tapered, the medial one-third of the incision line is marked such that it tapers towards the medial canthal angle or merges with the medial upper lid fold ( Fig. 7.9 ). The lateral one-third is usually marked in a leveled configuration, although occasionally a patient may request a slight upward widening over the lateral segment of the crease.
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The use of an inked tapered tip of a wooden stick allows precise drawing and redrawing, as compared with the usual marking pen available in operating theaters.
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In Asian blepharoplasty involving skin excision, the lower line of incision will determine the shape and height of the surgically created crease.
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Repetitive measurement and confirmation of incision lines are important.
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Usually, 1–3mm of skin may be included in the incision line for excision.
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Using the thinned wooden-tipped applicator and applying very gentle pressure on the lower incision line (proposed line for new crease formation), instruct the patient to look upward even before the incision starts, in order to assess how the crease may appear. Since the eyelid has been injected, the crease will appear more swollen and further from the ciliary margin than it will postoperatively, after it has eventually healed.
Clinical pearls For the parallel crease, the measured height of the superior tarsal border is drawn across the width of the eyelid skin ( Fig. 7.10 ).
To create adequate adhesions, some subdermal tissue must be removed. A strip of skin measuring about 2–3mm is then marked above and parallel to this lower line of incision. In patients who want a nasally tapered configuration, this upper line of incision is tapered towards the medial canthal angle, or to merge with any medial upper lid fold that may be present. The segment of skin to be excised is frequently less than 2mm over the medial portion of the crease.
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In designing the parallel crease, there is an unconscious tendency to converge towards the medial canthal angle, thereby turning it into a nasally tapered crease. I often intentionally draw the tapering crease first and then use it as a visual guide to decide how a parallel crease should be designed near the medial one-third of the upper lid, to remind myself to stay parallel.
Clinical pearls - ▪
Medially, the parallel crease does not flare upward from the medial canthal angle.
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The medial end of the crease design should not go past an imaginary vertical line aligned with the medial canthal angle, both for nasally tapered and for parallel creases.
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Laterally, the crease design should not traverse past the lateral canthal angle.
Pitfalls The incision is then carried out using a No. 15 surgical blade (Bard-Parker) along the upper and lower lines, incising just through the dermis and within the superficial orbicularis oculi muscles. Fine capillary bleeding is controlled using bipolar wetfield cautery ( Fig. 7.11 ).
The excision of a strip of skin is not required in every case; however, I believe that it facilitates the removal of subsequent layers of the lid tissues, thereby permitting adequate crease formation. At this point, the superior tarsal border is still covered by pretarsal and supratarsal *
* Semantically, in Asians, the supratarsal area is an area directly above the tarsus, while the true preseptal region may be quite a few millimeters superior to this, since the orbital septum may fuse with the levator aponeurosis a variable distance from the superior tarsal border.
(favored over the term ‘preseptal’) orbicularis oculi muscle, with possibly some terminal portions of the orbital septum, and the terminal fibers of the levator aponeurosis beneath the septum.- ▪
It is important to stabilize the tarsal plate and overlying soft tissues and skin when making a continuous incision, especially along the lower line of incision; this is a critical step in the outcome of the designed crease.
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The continuous incision may be performed in three steps so that one may check and recheck the passage. For right-handed surgeons, for the right upper lid, it is best to start medially; and for the left upper lid, one may start from the lateral end of the incision line.
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Any bleeding is best controlled with bipolar cautery via a fine jeweler’s tip. This allows the surgeon to lessen any immediate tissue swelling and obscuration of the tissue planes, thereby maintaining a clear operative field. Furthermore, it allows one to stay within the planned incision line.
Clinical pearls - ▪
It is easy to incise too deeply and cause a small steady bleed from the orbicularis muscle, which will soon develop into a hematoma and distort the incision line as well as incision planes, blurring the distinction between fat, orbicularis, orbital septum, and levator aponeurosis along the superior tarsal border. It may also result in transient postoperative secondary ptosis.
Pitfalls One may use the left fingers to slightly retract the upper incision wound edge, then aim a Bovie cautery tip (or radiofrequency unit’s Empire tip needle) superiorly to transect through the preseptal orbicularis oculi muscle there, knowing that although the upper incision line is only 2–3mm above the superior tarsal border, with the upward beveling, the Bovie tip is aiming at a point above where the septum fuses with the aponeurosis. (In Asians, the orbital septum may join the aponeurosis as low as 2–3mm above the superior tarsal border.) The use of the cutting cautery tip is in a feather-light fashion, so as to gently reach the orbital septum. Along the way, one may see some preseptal fat in front of the septum. When the septum over the central one-third is opened, one can see the slightly bulging preaponeurotic fat pad prolapsing through the opening of the orbital septum ( Fig. 7.12 ). Blunt-tipped Westcott’s spring scissors are then used to open the orbital septum.
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Always tilt the tips of the scissors upward when extending the horizontal release of the orbital septum to either side. The purpose is to avoid inadvertent injury to the vessels within the fat pad, the fat pad itself, the underlying levator aponeurosis, or the lobe of the lacrimal gland situated over the lateral end.
Clinical pearls - ▪
In opening of the orbital septum medially, the levator aponeurosis may be injured.
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In opening of the lateral extent of the septum, the lacimal gland can be injured.
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Avoid the use of monopolar cautery over the superior medial aspect of the orbital space to avoid the trochlea of the superior oblique muscle, which can lead to fourth-nerve palsy and torsional diplopia.
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Avoid cauterizing the lacrimal gland over the superior lateral aspect of the anterior orbital rim.
Pitfalls The orbital septum is opened along the superior line of incision and the skin–orbicularis–orbital septum flap turned inferiorly along the superior tarsal border ( Fig. 7.13 ).
Westcott scissors are used to open the potential space that is present between the preaponeurotic fat and the overlying orbicularis muscle within the redundant myocutaneous strip, retracting it with a Blair’s tissue retractor. The central preaponeurotic fat pad is dissected and separated from its fascial attachment to its underlying levator muscle fibers (the latter is salmon-colored with vertically oriented muscle striations).
The fat should be repositioned, allowing it to fill in the space between the levator and anterior aspect of the superior orbital rim (the supratarsal sulcus).
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After separating the initial fine adhesions of fat from the overlying orbicularis, it is often safer to use moist cotton-tipped applicators to separate fat from the underlying superior tarsal border, levator aponeurosis, and levator muscle.
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No attempt is made to remove the fat pad unless it is grossly interfering with crease formation along the superior tarsal border. Wetfield bipolar cautery may be used to shrink it away if it is potentially ‘threatening’ the construction of a good crease because of its presence directly over the preaponeurotic platform.
Clinical pearls - ▪
Avoid pointing the scissors posteriorly towards the levator as you elevate the myocutaneous flap.
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After the myocutaneous flap has been elevated, avoid cutting any fat that may be intertwined on the underbelly of the myocutaneous strip; this may cause bleeding of the intra-fat blood vessels, as well as inadvertent reduction in the volume of preaponeurotic fat left behind.
Pitfalls Occasionally, in patients with very full upper lids, significant fat is seen centrally and in an inferiorly placed position. This may significantly abort/interfere with any attempt to form a crease. In these patients, instead of mild reduction with bipolar cautery, one may opt to excise 25–50% of the preaponeurotic fat seen within the surgical field ( Fig. 7.14 ). Wetfield cautery is used to treat the intra-fat vessels first; then cutting monopolar cautery is used to cut the fat pad 2–3mm at a time. These maneuvers are then repeated. It may take two to three repetitions before this stage is completed. (The fat excision often necessitates a small supplement of lidocaine in the space underneath the preaponeurotic fat pad.)
