Combined Approach of Partial Incision Technique with Medial Tunnel Fixation (Incorporating a Buried Orbicularis–Aponeurosis Suture)
An ideal compromise would be to combine an external incision approach across the central 50% of the proposed area for an eyelid crease, combined with buried suture ligation over the medial end by way of the open central wound. This avoids any incision through the thicker medial canthal skin and still achieves a crease as well as some control over the shape of the crease there, whether the crease is to be nasally tapered or parallel.
A corneal protector is applied. The central incision involves excision of a 2–3 mm segment of skin–orbicularis, application of the usual Asian blepharoplasty technique with a beveled approach through the orbicularis and septum, 50–70% transverse opening of the orbital septum, and graded excision of preaponeurotic fat ( Figure 26-1 ), followed by the following.
One may elect to create a medial suborbicularis tunnel space along the superior tarsal border, using a small hemostat, needle-tipped cutting cautery and cotton-tip applicators. The location and height of this medial sub-lid tunnel space will correlate with the desired shape and height of the medial end of the crease. One end of a 6-0 PDS or Vicryl suture (with tapering needle) is passed through the external skin surface along the desired crease line. It is passed down through levator aponeurosis and Müller’s muscle above the superior tarsal border, but without penetrating the conjunctiva (the needle passage may also be started directly above the levator aponeurosis fibers along the superior tarsal border). It takes a bite in a lateral direction for 3 mm, along the crease form desired. This needle and suture is retrieved through the medial tunnel and looped out through the central wound. One may then choose as follows:
Option 1: Cut off the second needle of the remaining arm of the suture that has not yet been passed. This free end is then looped out through the suborbicularis medial tunnel using a strabismus hook. It is reloaded on a free needle, and used to take a bite of the orbicularis muscle that lines the roof space within this medial tunnel. The two ends are tied, bringing together the layers of the levator aponeurosis, the orbicularis and subcutaneous fascia.
Option 2: The second needle is left intact and pulled through a small stabbed-skin slit along the same tract where the first arm passed, and retrieved within the medial tunnel. It is then re-armed on a needle holder and used to secure a small amount of the orbicularis along the proposed crease line and then tied with the other end from the first passage.
Instead of entering the skin through a most-medial location, a second approach is to come in from a slightly more lateral position but still over the medial one-third to one-fourth of the eyelid. After creating the medial suborbicularis tunnel:
Option 3: The surgeon holds a half-circled 6-0 Vicryl suture needle that is back-handed, and this is passed from the central open wound through levator aponeurosis on the bottom of the tunnel space ( Figure 26-2 ), and then immediately back towards fibers of the suborbicularis tissues over the top of the tunnel space to form a complete 180° hair-pin loop ( Figure 26-3 A ). This contains the posterior lamella tissues of levator aponeurosis and Müller’s muscle along the superior tarsal border as well as subcutaneous fascia and orbicularis oculi. A knot is tied and buried within this medial tunnel space.
Option 4: Still over the medial one-fourth of the eyelid as in Option 3, a back-loaded needle approaches the medial horn of the aponeurosis from the central open wound and takes a 2–3 mm bite of it. The overlying orbicularis in the tunnel directly over this needle’s passage is denuded (removed) using cutting cautery or a radiofrequency knife. The first needle that had passed through the aponeurosis is then used to secure some subcutaneous fascia in this orbicularis-denuded sector of the tunnel space ( Figure 26-3 B ). A knot is tied and buried within this medial tunnel space. This tied knot brings together the levator aponeurosis to the subcutaneous fascia and is similar to the crease construction used in skin–levator–skin closure with the external incision method.
The passage of the needle through tight and vascular compartments will lead to occasional hemorrhage from the orbicularis, levator aponeurosis, Müller’s muscle and the peripheral arcade that runs along the superior tarsal border.
The location of the medial end of the crease will depend on where the medial tunnel is fashioned and where the buried stitches are applied. For a nasally tapered crease that converges normally, the medial end of the crease is usually applied at a distance from the lid margin equal to one-half of the measured central height of the tarsal plate. When there is a coincidental medial canthal fold this maneuver will uplift the medial lid fold. For those patients who desire a rapidly converging nasally tapered crease (rapid convergence), one may place the medial end of the crease at one-third of the measured central height of the tarsus. This is lower than the actual height of the tarsal plate there, though the needle should still be aimed towards aponeurotic fibers along the medial aspect of the superior tarsal border.
Over the external skin incision, which spans 50–60% of the normal width of the eyelid crease, the wound is closed using four interrupted 6-0 silk sutures in the usual fashion for Asian blepharoplasty, taking lower skin edge–aponeurosis–upper skin. These four external stitches cover over an area of about 15–18 mm ( Figure 26-4 ). A 7-0 suture is then placed as a running skin-skin closure. The lateral one-fourth of the eyelid skin is uncut and has no buried sutures. The medial sector is also uncut, but has a buried suture to help form the medial end of the crease without any risk of residual hypertrophic scarring.