A survey of the various papers in the literature on the external incision approach reveals that there is a wide variation in techniques and preferences when it comes to whether skin and orbicularis are routinely removed after making the skin incision. Likewise, some surgeons prefer to open the orbital septum and remove a variable amount of preaponeurotic fat.
There are other proponents for smaller skin incisions (or partial incision) only, and further differentiations in the way crease fixations are carried out including skin–levator aponeurosis–skin, inferior orbicularis–levator fixation, septodermal fixation as well as skin–tarsus–skin fixation. Each variant has its own set of pros and cons that need to be weighed according to the technical skills, aesthetic sense and level of effort it involves, as well as the patient’s comfort level and acceptance. For example: the skin incision and skin excision school favors making an incision to accurately define the placement of the crease. These practitioners are comfortable with these techniques and with the subsequent wound healing process, and are likely to be less concerned about immediate healing. Those who open the orbital septum routinely are likewise comfortable with the anatomic landmarks and aim to clear the preaponeurotic zone along the superior tarsal border. Overall, the external incision surgeons feel more comfortable with the predictability and permanence of this approach, which aims for a longer-lasting crease form and lesser need for interval adjustment surgeries. This approach, especially when carried out without the need for placement of buried sutures, frequently yields a crease form that is subjectively comfortable for the patient on upgaze and downgaze, without the often-heard complaint of tightness of the upper lid and sensation of the buried sutures poking at the pretarsal zone. The partial-incisional methods surgeons, who tend to make a limited 5–8 mm incision, try to accomplish the debulking of soft tissues through a smaller than full incision, although the wound often appears much wider than published. One drawback may be a crease form that appears deeply formed over the central skin incision compared to the medial and lateral edge of it.
In closure techniques, the choice of suture material varies greatly. The prevalent ways to perform wound closure are:
skin–levator–skin (or skin–tarsus–skin), and
levator aponeurosis to inferior subcutaneous plane (or superior tarsal border [STB] to inferior subcutaneous plane).
In this first technique, which is favored by the author, the sutures are placed such that it first bites the inferior skin edge ( Figure 7-1 ), then the distal fibers of the levator aponeurosis along the superior tarsal border, and then the upper skin edge. This creates an attachment between the levator aponeurosis and the subdermal area along the superior tarsal border, mimicking the natural insertion of the levator aponeurosis. Fernandez described this technique in 1960 and stated that it gives a ‘dynamic and superficial crease’ ( Figure 7-2 ), as opposed to skin–tarsus–skin, which tends to give a ‘static’ crease ( Figure 7-3 ) (see the 1954 paper by Sayoc ).
Levator Aponeurosis to Inferior Subcutaneous Plane
In the second category, several buried 6-0 nylon, or Dexon (polyglycolic acid) or Prolene (polypropylene) sutures are applied to create adhesions between the levator aponeurosis and the subcutaneous tissue of the inferior incision along the superior tarsal border ( Figure 7-4 ). According to Fernandez, this also creates a ‘dynamic’ crease, but a deeper and permanent one as compared with the first method of closure, which tends to be not quite as deep. It could be the result of tissue fixation with buried Prolene sutures at a deeper level. Sheen’s articles in 1974 and 1977 on supratarsal fixation described application of this closure technique on Caucasian patients undergoing upper blepharoplasty, where sutures were applied from levator aponeurosis to the inferior orbicularis – in essence, the inferior subcutaneous tissue.
In 1976, Putterman and Weingarten in separate articles described the technique of applying sutures from the superior tarsal border to the inferior subcutaneous plane ( Fig 7-5 ). Park also published his technique of orbicularis levator fixation in double-eyelid procedures for Asians. He used three 6-0 nylon sutures to fixate a folded portion of the levator aponeurosis to the inferior skin edge’s orbicularis oculi muscle. (Permanent buried sutures are used here.)