In suboptimal results of aesthetic surgery of the Asian upper eyelid, one may see spreading of the wound scar, high placement of the upper eyelid crease, induced lagophthalmos on downgaze, and induced secondary ptosis on straight gaze as well as in upgaze. Intraoperatively, one may observe middle lamellar scar involving the orbicularis oculi as well as orbital septum, or presence of dense scar tissue plaques that may bind the anterior orbicularis oculi as well as the posterior levator aponeurosis. Instead of having a physiologically preserved ‘glide zone’ where preaponeurotic fat pads are still present in the lowest aspect of the glide space, there is now a condensed apron (or plaque) of tissue that is not allowing the posterior layer from up-vectoring properly against a passive and flexible skin–orbicularis. The use of a superiorly beveled approach in revisional Asian blepharoplasty can allow the glide zone to be partially restored and the middle lamellar scar removed. The preaponeurotic platform can be cleared of any interfering tissues. The combination of techniques described in this chapter often allows an abnormally high and static scar line to be repositioned into a lower and more dynamic crease, to the point of being acceptable for the patient. The need for skin grafting may often be avoided.
This author has advocated the trapezoidal debulking of preaponeurotic platform through a beveled approach (along the upper incision line) in Asian blepharoplasty as a logical and efficient way of performing primary cases. Included among the advantages are a safe approach to the preaponeurotic space through the orbital septum, allowance for a controlled, uniform debulking of junctional tissues overlying the supratarsal and pretarsal areas, as well as providing an optimal adhesion between levator aponeurosis and the subcutaneous tissues along the lid crease incision line. This approach virtually eliminates any potential for an uneven plane of surgical dissection, thereby lowering the complication rate.
The Preaponeurotic Space and the Glide Zone
The upper eyelid consists of the anterior skin–orbicularis oculi layers as well as the posterior levator–Muller’s muscle–conjunctival layers. In between is the middle zone, where the orbital septum and preaponeurotic fat reside. Normally, the preaponeurotic fat is fluctuant and acts as a glide layer and offers relatively little resistance to movement between the anterior and posterior layers of the upper lid. This middle zone may be conceptualized as a glide zone. Following primary upper blepharoplasty, skin, muscle, and preaponeurotic fat are reduced through limited excision. Upon closure, the preaponeurotic space is set inferiorly towards the superior tarsal border.
Three scenarios may follow after primary blepharoplasty. If there has been total excision of exposed preaponeurotic fat, the septum and overlying preseptal orbicularis is now lying directly in contact with the levator aponeurosis, without any buffering fat. There is a good probability that the preaponeurotic space (glide zone) is obliterated. One sees a deep supratarsal sulcus as well as poor crease formation. Secondly, if there were only partial or minimal removal of fat, some fat may remain interposed between the preseptal orbicularis (anterior layer) and aponeurosis (posterior layer). Thirdly, in a beveled approach, the upper skin edge is attached to the underlying aponeurosis along the superior tarsal border as well as lower skin edge; there is also a preservation of the preaponeurotic space and some fat buffering in the glide zone. There are more orbicularis fibers removed along the upper incisional edge since the orbicularis was transected in an upwardly beveled fashion. This allows the immediate vicinity of the upper incisional skin edge to be in contact with the preaponeurotic space thus created. In these last two scenarios, where fat was only partially excised (or repositioned superiorly), the preaponeurotic space over the preseptal midregion of the upper lid has been preserved. There is fat buffering as well as a soft tissue mass (consisting of the preseptal skin, orbicularis, orbital septum and preaponeurotic fat) billowing on top of a dynamically elevating tarsal plate. The crease formed is dynamic and natural from an aesthetic viewpoint.
The restoration and preservation of this preaponeurotic space is an essential element in the surgical creation of a lid crease for an Asian, for it is the up-vectoring of the tarsal plate coupled with the attendant presence of fat in the preserved preaponeurotic space that helps create the aesthetic appearance of a well-formed crease.
Patients seeking revisional surgery may present a complex combination of findings. Often, a patient will exhibit a flattened or absent upper lid crease with a mild hollowing of the sulcus. The patient may have poor crease formation due to a combination of factors including poor surgical adhesion between the skin edges and the aponeurosis after the first operation, or the presence of an amorphous sheet of preaponeurotic fat that appears plastered down over the entire aponeurosis within the preaponeurotic space between skin and levator. This latter finding may be intrinsic or secondary following postoperative hemorrhage into fat. The eyelid may show spreading of the incisional scar, high placement of the eyelid crease, induced lagophthalmos on downgaze, and induced secondary ptosis on straight gaze as well as upgaze. Intraoperatively, one sees thickened middle lamellar scar involving the orbicularis oculi as well as orbital septum, or presence of dense scar tissue plaques that may bind the anterior orbicularis oculi as well as the posterior levator aponeurosis ( Fig. 17.1 ). Instead of having a physiologically preserved ‘glide zone’ where significant preaponeurotic fat pads are still present in the lowest aspect of the glide space, there is now a condensed apron (plaque) of tissue that is not allowing the posterior layer to up-vector properly against a passive and flexible skin–orbicularis. Despite efforts by the patient, there is no observable crease formation. Patient often complains of fatigue, a feeling of tightness and may show brow and forehead overaction.
In dealing with revisional cases, one of the greatest dilemmas one faces is where to make the incision such that it does not add to or compound the already compromised area, from both an anterior viewpoint (and therefore aesthetic concern) as well as through lamellar scarring and contracture (with further functional compromise). To finish with improved aesthetic results as well as without any further functional setback is a major triumph for any surgeon familiar with and undertaking this type of re-operative surgery. Not only is the surgery difficult, the patient often has a heavily burdened heart and is anxious for a rapid outcome, something that is never easily realized in practice when dealing with cicatrix and suboptimal outcome. One is often struck by how devastated these patients are and how grateful they are when the improvement turned out to be significant. It is important for both patient and doctor to be realistic in their expectation as well as their projection of the time course for healing following revisional surgery.
It is critical that one does not cause further skin shortage or increased midlamellar contraction, with lid retraction and poor eyelid closure leading to symptoms of exposure and dryness. If there is insufficient skin in reserve, it is unlikely that there is any probability of revisional improvement, unless one wants to supplement it with full-thickness skin graft. This latter will require exquisite techniques, experience, and special splinting over the skin graft in order to get the skin graft placed in an esthetically acceptable fashion. There are, however, many young adults or middle-aged patients who need revisional surgery, where their problems are severe and they are unlikely to have any skin reserve ‘in the bank’ any time soon from natural involutional changes. These patients who possess just enough eyelid closure to avoid corneal exposure problems can develop these problems if one proceeds to the usual method of performing excision of skin scar and lysis of adhesion of the middle lamella. The amount of skin removed can be as little as one to two millimeters and they may become symptomatic of poor eyelid closure.
An ideal solution to this quagmire is to approach this scarred anterior and middle lamellar complex through a superiorly beveled approach. To do this, the following condition must be met. The crease height is evaluated and if it should be high, then the degree of lowering planned (in millimeters) by the surgeon will determine the minimal amount of skin redundancy above the existent crease height (over the preseptal region) that needs to be in reserve. For example, if the suboptimal crease is currently at 10.5mm and ideally it needs to be lowered to 7.5mm, then the patient will need to have 3mm of reserve skin above the crease before this is feasible. If the patient should have only 2mm, then the patient should be informed that one can only revise it down to 8.5mm in the current situation, or the patient can opt to wait further for some skin to be made available ‘in reserve’ from the natural aging before proceeding to revision at a later time. If this cannot be met and the patient is desperate due to either functional and/or psychological reasons, then one has to discuss the choice for a free skin graft.
Technique of Beveled Approach in Revisional Asian Blepharoplasty
For the majority who may be candidates for revisions without the need for skin grafting, the author’s surgical approach to the revision proceeds initially along the same way as does his primary cases, with the major difference being that the upper and lower lines of incisions are marked directly adjacent to each other on each side of the existing incisional scar of the lid crease. Patients in this category are more likely to have had their lid crease incision made in the 8–9mm range, as measured from the central lid margin. The separation of the upper and lower line of incisions should be no more than 1mm (and, very rarely, 2mm). A No. 15 Bard-Parker blade is used to make a full-thickness skin incision along the marked upper and lower incisional lines ( Fig. 17.2 ). Instead of using cutting cautery to go through orbicularis to reach the orbital septum, one uses a sharp-tipped Westcott spring scissors to incise across the upper line of incision in a superiorly beveled fashion, involving skin-to-orbicularis adhesions ( Fig. 17.3 ). Small, scissoring motions are then applied as the scissor blades transect the middle lamella scar, going through whitish, scarred fascial layers that are between orbicularis and underlying levator aponeurosis (involving orbicularis-to-levator adhesions ) ( Fig. 17.4 ). This is carried out through the width of the incision along the previous scar. The beveled approach is quite similar but at a steeper tilt (plane) compared to primary cases ( Fig. 17.5 ). In this scarred middle zone, one will not see much of the preaponeurotic fat pad as it may have already been excised; one may observe some residual fat lobules combined with scattered, smaller amorphous fat globules or aprons of scattered fat droplets may be seen ( Fig. 17.6 ). The scarred tissues in the anterior layer as well as midlamellar zone, encompassed by the tissues between the dotted superiorly beveled vector in the drawing and the lower skin incision (along the superior tarsal border), may be excised after the forehead–eyebrow–preseptal skin layer are carefully reset by releasing any restrictive surgical adhesive or head drapes on the patient’s forehead, for as long as the remaining skin still allows passive eyelid closure. All fat is preserved. The levator and aponeurosis can be identified when the scar is released and it is important to check for restriction objectively (by gently pulling the tarsal plate down), as well as subjectively by asking the patient to perform upgaze and downgaze.
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