Khoo Boo-Chai of Singapore, a pioneer in this field since the 1960s, kindly furnished all the information in this chapter, which was abstracted by W.P.D. Chen and reviewed by Dr Boo-Chai for the second edition of this book. This was based on his 40 years of hands-on experience with aesthetic (cosmetic) surgery of the upper eyelid.
Boo-Chai reported on his experience over five years with 625 cases of Asian lid crease procedures using the conjunctival stitch method. He recommended that this procedure is best used in patients with little upper lid fat and without a heavy fold that hangs down over the lid margin. Non-absorbable suture materials are used to connect the levator aponeurosis to the eyelid skin at a desired level 5–8 mm from the lid margin. If there is excessive supraorbital (preaponeurotic) fat, it is first removed through an additional central skin incision about one-quarter the width of the crease line designed.
The lid is everted and treated locally with 5% topical lidocaine solution; 0.5 ml of 1% lidocaine is given subconjunctivally. A needle bearing 4-0 nylon suture is passed through the conjunctiva in a horizontal fashion for 2–3 mm over the superior tarsal border. Each arm is then repassed through the conjunctiva towards the skin side overlying it. One arm of the externalized skin stitch is then passed subcutaneously towards the second arm, which is often itself passed through a small stab incision on the skin to facilitate the passage and subsequent burying of the knot. The two ends are tied, and the knot is tied down and buried under the skin surface. Usually three of these pairs of stitches are used.
Boo-Chai evaluated his patients 1 month postoperatively using the following parameters for a perfect result:
The creases on both sides must match in position, height, length and contour.
The position and contour of the upper lid margin must match, without any notching or peaking.
The eyelashes must not be distorted or missing.
Blinking must be normal.
Both eyelids must close normally during sleep.
There must be minimal scarring and no ectropion.
The results must be permanent.
Boo-Chai also discussed the correction of the following three conditions: discrepancies in the height or shape of the crease, the absence of crease formation (‘failed double-eyelid operation’) and a hollowed supratarsal recess due to excess removal of fat. In the introductory paragraphs he commented on the two main types of technique: the non-incisional suture techniques versus the incisional techniques with clearing of skin, fat, and use of skin–levator–skin fixation.
In the first category, when revising a previous non-incisional technique to eliminate discrepancies in crease height and shape, it is important to eliminate the crease by removing the loops of suture material that connected the levator to the skin. Boo-Chai prefers to apply the new crease-forming sutures usually three at the same setting after the previous loops have been removed.
For those with crease height and contour problems as a result of previous incisional techniques, he discussed two options:
If the patient wants an excessively low or shielded crease (caused by residual excess skin) to be corrected to a higher level to match the opposite side, he starts along the existing crease scar and designs an upper line of incision several millimeters above this. The excess skin is excised and the crease reconstructed.
In situations where there is no excess skin, he prefers to use a non-incisional buried suture loop technique to create the new higher crease without forming a second skin cut or scar.
He also discussed lowering creases if both sides are higher than optimal, the emphasis being to include the existing scar line within the tissues to be excised.
In the second category, correction of poor crease formation, the revision involves excision of the previous fibrous tissue connection between levator and skin, as well as excision of the previous incisional scar. He then uses six or seven 4-0 sutures to connect skin to levator to skin.
The third category of revisional blepharoplasty involves the correction of a deepened sulcus caused by excess fat removal. Boo-Chai uses fat harvested from a lower blepharoplasty and the fat is then divided into numerous 3 × 4 mm pellets. These are then placed behind the anterior layer of the orbital septum on top of the levator aponeurosis (with its closely attached posterior layer/reflection of orbital septum). He prefers to place more fat over the medial side of the upper lid. He notes that when observed 6 months later, these fat pellets seemed to have coalesced to form one piece.
Boo-Chai described the occasional presence of a marginal arterial arcade with perforating branches that pierce the levator aponeurosis near the insertion of the aponeurosis on the tarsus. These perforating vessels run perpendicularly in a vertical fashion, and lie within the suborbicularis areolar fatty tissues. They are not common and are difficult to detect unless specifically sought. When the lower skin flap is surgically manipulated or cleared, these perforators may be damaged and bleed, retracting within the aponeurosis to lie close to the marginal arterial arcade in the pretarsal (postaponeurotic) space, giving rise to a hematoma. Boo-Chai observed this in three cases, with an incidence of 1 in 500 cases. He went on to explain that the marginal arterial arcade normally lies on the tarsus 3 mm from the lid margin. It receives a contribution medially from the superior medial palpebral branch of the ophthalmic artery and laterally from a branch of the lacrimal artery. In Asians, the marginal arterial arcade is covered by the levator aponeurosis, owing to its low insertion on the tarsus. This is in contrast to Caucasians, where the marginal arcade is not covered by the aponeurosis because its insertion is high up on the upper part of the tarsus. He stated that his preferred management of bleeding in such incidents was to apply ice compresses, and that the bleeding is self-limiting. He has subsequently called this form of bleeding the ‘Boo-Chai sign’. It is unusual in the sense that the bleeding occurs suddenly posterior to the levator aponeurosis, and spreads widely within an area not usually touched during incisional methods of Asian eyelid surgery ( Figure 24-1 A, B ).