This chapter deals with the technique used by the author to facilitate the likelihood of forming a crease in a single-lidded individual: by effective removal of redundant hindering tissues (proper orientation of the removal of different layers so as to allow natural closure), minimization of scar from tension, and thorough completion of each step with lessened postoperative swelling. The steps are applicable to any form of upper blepharoplasty, whether primary or revisional, in Asians or non-Asians.
In previous publications, I discussed the concept of upper eyelid crease configurations and the essential steps required for predictable placement of a lid crease for single-eyelid patients. This method is based on accurate measurement of the central height of the upper tarsus, using it to guide placement of the external incision line for formation of the crease. As has been mentioned in previous chapters, the ideal crease tends to be either the nasally tapered crease or the parallel crease configuration. Medial upper lid fold is often present in the medial portion of the upper eyelid of Asians, whether they have a crease or not, and should not be considered pathologic and radically removed.
Marking of Crease
It is my practice to use the shaved-off tip of a wooden cotton-tip applicator dipped in methylene blue to mark the proposed crease. Between 0.5 and 0.75 ml of anesthetic is used to achieve sensory anesthesia of the upper lid several minutes previously. I evert the upper lid and measure the vertical height of the tarsus over the central portion of the lid with a caliper. This measurement is usually between 6.5 and 7.5 mm. It 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 laterally flared. For those patients who have a crease, I also measure the tarsus to confirm that the crease that I am observing – if I am planning to preserve or enhance it – is indeed the correct crease line to use. If the crease is to be nasally tapered, I mark the medial one-third of the incision line to taper toward the medial canthal angle or to merge with the medial upper lid fold. The lateral one-third is marked in either a leveled or flared configuration. For a parallel crease, the measured height of the superior tarsal border is drawn across the eyelid skin. To recapitulate, the height of the tarsus determines the overall central position of the surgical crease; the shape is determined by how you design the medial and lateral thirds of this according to the patient’s preference ( Figures 8-4 and 8-5 ).
Skin Incision/Skin Excision
To create adequate adhesions, it is necessary to remove some skin plus subdermal tissue. A strip of skin measuring approximately 2 mm is then marked above and parallel to this lower line of incision. In the patient who desires a nasally tapered configuration, I taper this upper line of incision toward the medial canthal angle or merge with any medial upper lid fold that may be present. As a result, the skin excision is often less than 2 mm over the medial portion of the crease. The incision is then carried out with a No. 15 surgical blade (Bard–Parker) along the upper and lower lines, incising just beyond the subcutaneous plane. I control any fine capillary oozing with a bipolar cautery. (The strip of skin bounded by the upper and lower lines of incision may be excised with scissors, or preferably, it is excised after the orbital septum is opened along the superior line of incision and the skin orbicularis–orbital septum flap is turned inferiorly along the superior tarsal border, see below.) The excision of a strip of skin is not necessary in every case; however, it is my belief that it facilitates removal of subsequent layers of the lid tissues, thereby allowing adequate crease formation ( Figure 8-6 ).
Opening of Orbital Septum
At this point, the superior tarsal border is still covered by pretarsal and supratarsal orbicularis oculi muscle, possibly some of the terminal portions of the septum orbitale and the anteriorly directed terminal fibers of the levator aponeurosis beneath the septum. To open the septum, I retract the upper incision wound superiorly and use a fine-tipped monopolar cautery, in the cutting mode, to incise through the orbicularis and orbital septum in a beveled fashion along the upper skin incision line. In Asians, the orbital septum may be only 2–3 mm above the superior tarsal border. It is readily opened, exposing the underlying preaponeurotic fat pads ( Figure 8-7 ).
Excision of Preseptal Orbicularis and Orbital Septum ( Figure 9-5 )
After the septum is opened horizontally, the strip of skin, supratarsal orbicularis and orbital septum hinged along the superior tarsal border is excised. It consists of approximately 2–3 mm of skin, a greater amount of supratarsal orbicularis muscle and a variable amount of the orbital septum (trapezoidal debulking of preaponeurotic tissues).
Preaponeurotic Fat Pads
Depending on the degree of fullness of the upper lid, I may use a sharp scissors to excise a small amount of the preaponeurotic fat pad. I control any bleeding points with a bipolar cautery. (The fat excision often requires a small supplement of lidocaine in the space beneath the preaponeurotic fat pads.) If a patient with dermatochalasis and obliteration of the crease displays even a very minimal concavity in the supratarsal sulcus, I do not remove any fat, since it will worsen the hollowness and result in multiple redundant folds superior to where one wants the crease to be ( Figure 9-4 ).
Excision of Pretarsal Orbicularis
To facilitate in-folding of the new crease, I excise a 1–2 mm strip of pretarsal orbicularis muscle along the inferior skin incision edge. There are some authors who routinely debulk the entire pretarsal subcutaneous tissue, believing that it is better to have only skin covering the anterior surface of the tarsus. My experience differs, and I remove some pretarsal tissue only if pretarsal fat is quite abundant and threatens the surgical formation of the desired upper lid crease. In the pretarsal plane of a creaseless Asian eyelid, there are few, if any, terminal interdigitations of the levator aponeurosis to the dermis. I refrain from vigorous dissection along the pretarsal plane, as I feel that it creates prolonged postoperative edema and can risk undesirable formation of more than one crease. Furthermore, it is quite natural for Asians born with a natural crease to have some degree of pretarsal fullness along the area between the crease and the eyelashes ( Figure 9-6 A,B).
Formation of Lid Crease and Closure of Wound
In order to form a dynamic crease, the terminal fibers of the levator aponeurosis above the superior tarsal border should be directed to the subdermal plane of the lower line of skin incision. I use 6-0 non-absorbable suture (6-0 silk or nylon) to pick up the lower skin edge and subcutaneous tissue to the levator aponeurosis along the superior tarsal border and then the upper skin edge and tie each of these as an interrupted suture.
Besides the stitch over the center of the crease, I place two or three sutures medially and two laterally. With these five or six crease-forming sutures in place, the rest of the incision may be closed with 6-0 or 7-0 nylon in a continuous or subcuticular fashion ( Figure 9-7 A–D).
Concept of Triangular, Trapezoidal and Rectangular Debulking of Eyelid Tissues
During a double-eyelid procedure by way of the external incision method, leaving behind a platform of tissues anterior to the superior tarsal border will interfere with the definition and formation of the proposed crease. The various approaches of removing skin, skin with orbicularis, skin with pretarsal fat, and skin with muscle and septum and preaponeurotic fat are all attempts at creating a clear platform for the formation of adhesions between fibers of the levator aponeurosis and the subcutaneous structure of the surgically created crease.
Triangular and trapezoidal debulking allow a systemic and uniform cleaning of the preaponeurotic space along the superior tarsal border and the pretarsal plane.
Figure 11-1 is a schematic drawing of an Asian upper eyelid without an upper lid crease. As the drawing shows:
When skin excision (<2 mm) is carried out in conjunction with the lid crease placement, retracting the upper skin incision edge allows an upwardly beveled plane of dissection to proceed across the supratarsal orbicularis oculi muscle and the lower portion of the orbital septum. (In Asians who do not have a crease in the upper lid, the orbital septum is frequently fused to the levator aponeurosis at 2–4 mm above the superior tarsal border, and it can be as low as halfway down the anterior surface of the tarsus.) The septum and underlying preaponeurotic fat pads are easily identified.
The septum orbitale is opened horizontally. The trapezoid of preaponeurotic tissues (viewed in this cross-section) includes occasionally a minimal amount of preaponeurotic fat, the orbital septum, supratarsal orbicularis, subcutaneous fat and overlying skin (2 mm), all of which hinge along the superior tarsal border and may be debulked. The anterior surface of this conceptual trapezoid consists of the skin, while the posterior portion of the trapezoid is wider and includes all preaponeurotic tissues from the opened orbital septum down to the superior tarsal border.
A small strand of the pretarsal orbicularis along the inferior skin incision may be trimmed off. The trapezoidal debulking allows easy inward folding of the skin edges toward the underlying aponeurosis, facilitating surgical formation of the crease. (Collin’s electron microscopic study described insertions of distal strands of the levator aponeurosis into the septa in between pretarsal orbicularis muscle fibers rather than into any subdermal tissue along the lid crease in those eyelids that had a crease. Should this be the case, formation of a crease may be facilitated by the preceding surgical maneuver because it links the aponeurosis to the upper border of the pretarsal platform. Vigorous dissection and debulking of pretarsal tissues is to be avoided because they tend to lead to persistent edema and formation of multiple creases.)
If debulking is carried out without including any skin excision, the block of tissue removed resembles a triangular configuration in cross-sectional view.
If the patient has a great deal of skin redundancy, the amount of skin included for excision is increased by expanding the upper line of skin incision. The plane of dissection through the orbicularis becomes less beveled and the trapezoidal debulking gradually turns into more of a rectangular configuration.
In the conceptual cross-section of the upper lid in Figure 11-2 , the right boundary is the skin surface and the left boundary the sheath of the orbital septum; between these two layers is the orbicularis oculi muscle. The lower edge is the superior tarsal border (STB). The pink zone denotes one scenario of the amount of orbicularis oculi that can be removed.
The diagram shows the transorbicularis vector (Step 2) for the dissection plane rotating counterclockwise and leveling off as one removes more skin and the upper line of skin incision [Step l (U)] moves further from the superior tarsal border.
The first surgical step (1) involves upper and lower lines of incision, 1 (U) and 1 (L), above the superior tarsal border, which are skin incisions.
The second step (2) involves an oblique transection through the orbicularis by the transorbicularis vector line.
In the third step (3), upon reaching and opening of the orbital septum, one dissects inferiorly toward the superior tarsal border.
Step 4 shows a leveled excision of orbicularis and redundant skin above the superior tarsal border.
The first transorbicularis vector (Step 2) rotates and levels off as more skin needs to be removed such that the cross-section of soft tissues that are debulked changes from a triangular to a trapezoidal, and finally rectangular configuration.
This can be represented as:
Triangular debulking < trapezoidal debulking < rectangular debulking