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Double Eyelid Operation for the Aging Patient
7
Double Eyelid Operation for the Aging Patient Jung I. Park
Concerns regarding older patients include redundancy of the upper eyelid skin and brow ptosis. Patients who do not have double eyelids often wish to have it done at the same time. Obviously, redundant skin needs to be excised to reveal a newly formed double fold. Otherwise, the excess skin will droop and hide the effect of the double eyelid operation. The upper eyelid skin and the orbicularis oculi muscle are thin in the pretarsal area and become thicker as they approach the eyebrow.1 The double eyelid fold formed by the thin skin is delicate and cosmetically pleasing. Unfortunately, resection of the excess skin during blepharoplasty requires a removal of this thin pretarsal portion of eyelid skin. The remaining skin and muscle above the incision are much thicker. A double eyelid fold created by this thicker remaining tissue appears edematous and unnatural (Figure 7-1, A and B). This puffy-looking fold is not the result of temporary edema, but it is permanent because of the thickness of the tissue. Brow ptosis adds to this problem by causing the upper eyelid to appear fuller. Although brow ptosis in Caucasians produces the
appearance of a hood over the sunken orbit, brow ptosis in Asians gives the appearance of fullness. A common complaint after double eyelid surgery in an older patient is fullness of the upper eyelid. The patient invariably blames the surgeon for not removing enough fat. When a surgeon uses an aggressive approach to remove excess fat and skin, the result is a sunken groove that is unsightly and often uncorrectable. This sunken groove is one of the most common unfavorable results of upper eyelid surgery performed on Asian patients using the principles from Caucasian blepharoplasty (Figure 7-2). The redundancy over the lateral orbital rim and crow’s feet should be addressed. The incision should extend to the orbital rim. Untreated skin redundancy in this area creates a round eye with a surprised look. Ideally the surgeon should first perform a forehead lift to correct brow ptosis and eliminate some of the skin redundancy, then perform double eyelid surgery and possibly remove a small amount of remaining excess skin. However, the majority of patients refuse such extensive and expensive surgery.
A
B
Figure 7-1 Upper lid blepharoplasty in an older Asian patient. A, Preoperative view. B, 1-month postoperative view. Despite a well-formed double eyelid fold, a puffy unnatural look persists. 61
DOUBLE EYELID OPERATION FOR THE AGING PATIENT
Figure 7-2 Sunken look after a blepharoplasty based on Caucacian blepharoplasty principles.
Consultation
Figure 7-3 Simulation of the brow lift demonstrates the beneficial effect of thinning the double eyelid fold and widening the pretarsal show.
A forehead lift is strongly recommended for older patients who request double eyelid surgery, elimination of eyelid redundancy, or both. The surgery’s benefits are best demonstrated when the patient looks in a mirror and watches the change that occurs as the surgeon simulates the forehead lift by lifting the eyebrows (Figure 7-3, A and B). The surgeon should emphasize the possibilities of persistent edema, swelling, and permanent puffiness of the eyelids after eyelid surgery. Patients are often familiar with the expected outcome because their acquaintances have had the same surgery. These patients frequently request removal of orbital fat to eliminate upper eyelid fullness. This fullness is almost always the result of brow fat in the upper eyelid. The removal of preaponeurotic fat creates an unsightly upper eyelid depression, deep extra creases, or a sunken look. It is crucial that the patient fully understands these implications before consenting to the surgery.
Figure 7-4 The lower incision is made conservatively at 7 mm from the ciliary margin. Conservative placement is necessary with the orbicularis oculi–levator aponeurosis fixation technique because it tends to create deep fixation and widen pretarsal skin. An older incision scar is shown at a higher level. The distance from the eyebrow to the proposed mark for the upper incision is indicated by 1 cm. See Figure 7-6 for the determination of the upper incision.
Preoperative Care, Premedication, and Anesthesia See Chapter 6 for more information.
Procedure Patients with Single Eyelids or Poorly Defined Supratarsal Creases The patient is marked while in a seated position with the eyes closed. The eyebrow is gently lifted with the left thumb until the upper eyelashes begin to rise. A caliper is used to measure 7 mm from the eyelash line, and an extrafine felt-tipped marker is used to mark a dot on the upper eyelid at the midpupillary line. Then, two additional 7-mm marks are made. One mark is placed near the medial 62
Figure 7-5 The lateral extension of the lower incision follows the crow’s feet to the lateral orbital rim. canthus, and the other is placed near the lateral canthus. These three dots are connected in a gentle curve that is parallel to the tarsal margin (Figure 7-4). At the lateral end, the line is continued in a gentle upward curve that follows a laugh line. This extension reaches as far as is necessary to contain lateral orbital skin sagging (Figure 7-5). Next, the
PROCEDURE
patient is asked to open the eyes in a primary gaze position as the eyebrow resumes its normal relaxed position. The height of the double eyelid fold is determined by marking the upper incision 2 to 3 mm above the ciliary margin (Figure 7-6). Marking the upper incision is equally as or even more important than determining the height of the lower incision. To create a higher double fold with a wider pretarsal show, the dot may be marked 3 to 4 mm from the lash line. A series of dots are then marked at the same distance from and parallel to the eyelash line. These dots are connected to form an upper incision line (Figure 7-7). The patient is asked to close the eyes again, the eyebrow is lifted, and a line that extends medially and laterally to meet the lower incision line is drawn. Often the skin redundancy is more abundant at its lateral orbital area but scanty near the medial canthus. Thus the ellipse of the skin island is narrow and sharply tapered medially but wide at the orbital rim (Figure 7-8, A and B). Usually the same amount of skin is excised on each side. The markings on the opposite eye may be made with a caliper as the patient lies on
the operating table in a prone position; this will allow the excision lines to be as symmetric as possible. However, when one eyelid requires more excision or the eyebrow position between the eyes is not similar, the markings on the opposite side are best made with the patient in a seated, relaxed position. The height of the upper eyelid between the eyebrow and the ciliary margin may be different between the eyes. This discrepancy may be the result of unevenly excised eyelid skin from a previous surgery, a congenital difference, or a different relaxation of each eye during the aging process. Occasionally the achievement of symmetry may be further ensured by measuring the distance between the eyebrow and the upper incision line (see Figures 7-4 and 7-9). Skin redundancy over the crow’s feet area is more abundant and requires a rather aggressive excision. Lateral extension is designed to eliminate lateral hooding as much as possible. Aggressive excision of eyelid skin in this area is permitted because potential development of ectropion or lagophthalmos is not a concern. Aggressive excision eliminates some of the crow’s feet and prevents an
Figure 7-6 The upper incision line is marked with the eyes open in a primary gaze position. The upper incision is marked 2 to 3 mm above the ciliary margin.
Figure 7-7 The upper incision runs parallel to the ciliary margin with the eyes open.
A
B
Figure 7-8 The skin muscle excision is narrow and sharply tapered medially and wide at the orbital rim. A, Eyes open. B, Eyes closed. 63
DOUBLE EYELID OPERATION FOR THE AGING PATIENT
Figure 7-9 The upper incision line was marked 12.5 cm from the ciliary margin. Measurement to confirm the symmetry revealed a discrepancy in the distance between the eyebrow and the incision line.
A
B
A
B Figure 7-11 The eyebrows remain symmetric at rest (A) and become asymmetric when the eyebrows are raised (B). unsightly round-eye phenomenon secondary to a descent of the lateral aspect of the double eyelid fold. A sharpened cotton applicator is applied to the marked inferior incision line. The skin is then pushed upward and folded over the tip of the cotton applicator (Figure 7-10, A). The location of the cotton applicator is marked on the surface of the fold. This point becomes the upper incision site. The point is then connected to the upper incision line on the upper eyelid and the lateral end of the lower incision marking. The pinch technique can also be used safely 64
Figure 7-10 A, The amount of the lateral skin-muscle excision is determined using a cotton-tipped applicator. B, The pinch technique.
in this area (see Figure 7-10, B). The eyebrow positions of some patients are symmetric when relaxed but become asymmetric when alert (Figure 7-11, A and B). When the skin is excised based on the measurement taken with the patient in a relaxed, premedicated state, both the patient and the surgeon may be surprised by an asymmetry when the patient returns for a follow-up visit. This embarrassing situation is best prevented with preoperative detection of the condition and patient education regarding the possibility of dynamic asymmetry. The surgeon may give the patient the choice of achieving symmetry in a relaxed or an alert state. The patient with thick edematous skin requires a smaller possible skin excision to minimize unsightly puffiness (Figure 7-12, A to C). The face is washed with Phisohex soap and thoroughly rinsed with water before the markings are made. It is crucial to mark after soap removal and before local anesthetic infiltration; it is almost impossible to obtain symmetry once the marking is lost after local anesthetic infiltration. A solution of 2% lidocaine with 1:100,000 epinephrine is then infiltrated under the skin. The incision is made along the markings. The skin-muscle island is excised (Figure 7-13, A). Ptotic brow fat may be excised if necessary (see Figure 7-13, B).
PROCEDURE
A
B
C Figure 7-12 A, Preoperative view of thick eyelid skin. B, Conservative excision of the skin. C, The patient with thick skin tends to develop a puffier fold. Conservative skin excision lessens the puffiness. The orbital septum is divided (see Figure 7-13, C to E). The levator aponeurosis is identified (see Figure 7-13, F). The supratarsal crease is created by fixating the pretarsal orbicularis oculi muscle to the levator aponeurosis as described in Chapter 6. The skin is then closed with 6-0 black nylon or 6-0 fast-absorbing gut in a continuous subcuticular fashion (see Figure 7-13, G).
Patients with Well-Defined Supratarsal Creases The lower incision is marked along the preexisting supratarsal crease. Generally, the same marking is made for
the upper incision, approximately 2 to 3 mm above the ciliary margin with the patient’s eyes in a primary gaze position. However, this distance varies depending on the tightness of the supratarsal crease. The patient with natural double eyelids tends to have a higher, more solid supratarsal crease. The upper incision markings may be made at 1 to 2 mm above the ciliary margin on the average patient who desires a double eyelid fold that is conservative in width. In a patient with a surgically created double fold, a conservative incision is chosen if the crease is located high and tightly fixated, similar to the patient with a natural fold. A new and tighter supratarsal crease fixation is necessary in the patient who has previously had double eyelid surgery but in whom the supratarsal crease is poorly fixated and loose. The markings are made similar to those on patients without preexisting double folds. Although a 1- to 3-mm incision line above the ciliary margin with the eyes in a primary position does not seem to be significant, a fairly wide skin excision can be made with these markings (see Figure 7-8, A and B). This amount of skin excision is still far smaller than that of the Caucasian eyelid when the pinch technique is used. The lower incision should be made with extreme care in the patient who has had previous double eyelid surgery. The skin–levator aponeurosis fixation can be accidentally detached during the incision at the supratarsal crease. It is less likely to happen in the eyelid with a natural double fold because of the broader adhesion between the pretarsal skin and the levator aponeurosis. When the attachment is severed, the surgeon may find the eyelid drooping during the surgery. At times it is difficult to judge whether a true ptosis has occurred or whether the droopiness found during the surgery is the result of eyelid swelling, anesthesia of the levator aponeurosis, or both. The surgeon may have to wait until after the surgery, when the swelling and edema has subsided, before determining the cause of the droopiness.
Asian Males with Upper Eyelid Redundancy The Asian male with upper eyelid redundancy often desires to eliminate the excess without creating a double eyelid. The usual measurement for the female patient does not apply to the male patient. An older Asian male may be embarrassed by a postoperative double eyelid with a puffy fold. The lower incision should be 5 to 6 mm from the ciliary margin. The upper incision is placed approximately 1 mm from the ciliary margin with the eyes open in a primary gaze position. The pretarsal skin fixation should 65
DOUBLE EYELID OPERATION FOR THE AGING PATIENT
A
B
C
D
E
F Figure 7-13 A, En bloc skin–muscle excision. B, Ptotic eyebrow fat is removed. C, The orbital septum is snipped with the scissors. Tension is applied to the septum as it is pulled up and detached from the underlying orbital fat and levator. D, The septal window is created. E, The septum is incised through the septal window. F, View of the orbital fat and the levator aponeurosis. G, The orbicularis oculi–levator aponeurosis fixation is completed. The incision lines are in complete apposition without skin closure.
G
66
CASE REVIEWHEAD 1
A
B
Figure 7-14 A, Preoperative view. B, One-month postoperative view showing a significant amount of puffiness and a red incision line.
A
B
Figure 7-15 A, Preoperative view. B, One-year postoperative view showing a well-formed crease and persistent puffiness.
A
B
Figure 7-16 A, Preoperative view. B, The fold appears less puffy when the fixation is incomplete. be conservative. However, excision of the redundant skin at the lateral aspect over the lateral orbital rim should be as aggressive as in the female patient. The skin redundancy is mostly in the lateral half of the upper eyelid and over the lateral orbital rim. The Asian male tolerates the temporary redness of the lateral incision better than a puffy double eyelid.
Postoperative Care and Recovery See Chapter 6.
Case Review See Figures 7-14 to 7-18. 67
DOUBLE EYELID OPERATION FOR THE AGING PATIENT
A
B
Figure 7-17 A, Preoperative view. B, Postoperative view. Conservative skin excision without the creation of a double eyelid fold is preferred for the male patient because it avoids the appearance of an unnatural thick fold. Earlier relapse is expected with further aging.
A
B
Figure 7-18 A, Preoperative view. B, Postoperative view. An aggressive approach was used for this older male patient after the expected outcome was explained. The patient happily accepted the result.
Reference
1. Lee JS: Simplified anatomic method of double-eyelid operation: septodermal fixation technique, Plast Reconstr Surg 100:170, 1997.
68
Double Eyelid Operation for the Aging Patient Jung I. Park
Concerns regarding older patients include redundancy of the upper eyelid skin and brow ptosis. Patients who do not have double eyelids often wish to have it done at the same time. Obviously, redundant skin needs to be excised to reveal a newly formed double fold. Otherwise, the excess skin will droop and hide the effect of the double eyelid operation. The upper eyelid skin and the orbicularis oculi muscle are thin in the pretarsal area and become thicker as they approach the eyebrow.1 The double eyelid fold formed by the thin skin is delicate and cosmetically pleasing. Unfortunately, resection of the excess skin during blepharoplasty requires a removal of this thin pretarsal portion of eyelid skin. The remaining skin and muscle above the incision are much thicker. A double eyelid fold created by this thicker remaining tissue appears edematous and unnatural (Figure 7-1, A and B). This puffy-looking fold is not the result of temporary edema, but it is permanent because of the thickness of the tissue. Brow ptosis adds to this problem by causing the upper eyelid to appear fuller. Although brow ptosis in Caucasians produces the
appearance of a hood over the sunken orbit, brow ptosis in Asians gives the appearance of fullness. A common complaint after double eyelid surgery in an older patient is fullness of the upper eyelid. The patient invariably blames the surgeon for not removing enough fat. When a surgeon uses an aggressive approach to remove excess fat and skin, the result is a sunken groove that is unsightly and often uncorrectable. This sunken groove is one of the most common unfavorable results of upper eyelid surgery performed on Asian patients using the principles from Caucasian blepharoplasty (Figure 7-2). The redundancy over the lateral orbital rim and crow’s feet should be addressed. The incision should extend to the orbital rim. Untreated skin redundancy in this area creates a round eye with a surprised look. Ideally the surgeon should first perform a forehead lift to correct brow ptosis and eliminate some of the skin redundancy, then perform double eyelid surgery and possibly remove a small amount of remaining excess skin. However, the majority of patients refuse such extensive and expensive surgery.
A
B
Figure 7-1 Upper lid blepharoplasty in an older Asian patient. A, Preoperative view. B, 1-month postoperative view. Despite a well-formed double eyelid fold, a puffy unnatural look persists. 61
DOUBLE EYELID OPERATION FOR THE AGING PATIENT
Figure 7-2 Sunken look after a blepharoplasty based on Caucacian blepharoplasty principles.
Consultation
Figure 7-3 Simulation of the brow lift demonstrates the beneficial effect of thinning the double eyelid fold and widening the pretarsal show.
A forehead lift is strongly recommended for older patients who request double eyelid surgery, elimination of eyelid redundancy, or both. The surgery’s benefits are best demonstrated when the patient looks in a mirror and watches the change that occurs as the surgeon simulates the forehead lift by lifting the eyebrows (Figure 7-3, A and B). The surgeon should emphasize the possibilities of persistent edema, swelling, and permanent puffiness of the eyelids after eyelid surgery. Patients are often familiar with the expected outcome because their acquaintances have had the same surgery. These patients frequently request removal of orbital fat to eliminate upper eyelid fullness. This fullness is almost always the result of brow fat in the upper eyelid. The removal of preaponeurotic fat creates an unsightly upper eyelid depression, deep extra creases, or a sunken look. It is crucial that the patient fully understands these implications before consenting to the surgery.
Figure 7-4 The lower incision is made conservatively at 7 mm from the ciliary margin. Conservative placement is necessary with the orbicularis oculi–levator aponeurosis fixation technique because it tends to create deep fixation and widen pretarsal skin. An older incision scar is shown at a higher level. The distance from the eyebrow to the proposed mark for the upper incision is indicated by 1 cm. See Figure 7-6 for the determination of the upper incision.
Preoperative Care, Premedication, and Anesthesia See Chapter 6 for more information.
Procedure Patients with Single Eyelids or Poorly Defined Supratarsal Creases The patient is marked while in a seated position with the eyes closed. The eyebrow is gently lifted with the left thumb until the upper eyelashes begin to rise. A caliper is used to measure 7 mm from the eyelash line, and an extrafine felt-tipped marker is used to mark a dot on the upper eyelid at the midpupillary line. Then, two additional 7-mm marks are made. One mark is placed near the medial 62
Figure 7-5 The lateral extension of the lower incision follows the crow’s feet to the lateral orbital rim. canthus, and the other is placed near the lateral canthus. These three dots are connected in a gentle curve that is parallel to the tarsal margin (Figure 7-4). At the lateral end, the line is continued in a gentle upward curve that follows a laugh line. This extension reaches as far as is necessary to contain lateral orbital skin sagging (Figure 7-5). Next, the
PROCEDURE
patient is asked to open the eyes in a primary gaze position as the eyebrow resumes its normal relaxed position. The height of the double eyelid fold is determined by marking the upper incision 2 to 3 mm above the ciliary margin (Figure 7-6). Marking the upper incision is equally as or even more important than determining the height of the lower incision. To create a higher double fold with a wider pretarsal show, the dot may be marked 3 to 4 mm from the lash line. A series of dots are then marked at the same distance from and parallel to the eyelash line. These dots are connected to form an upper incision line (Figure 7-7). The patient is asked to close the eyes again, the eyebrow is lifted, and a line that extends medially and laterally to meet the lower incision line is drawn. Often the skin redundancy is more abundant at its lateral orbital area but scanty near the medial canthus. Thus the ellipse of the skin island is narrow and sharply tapered medially but wide at the orbital rim (Figure 7-8, A and B). Usually the same amount of skin is excised on each side. The markings on the opposite eye may be made with a caliper as the patient lies on
the operating table in a prone position; this will allow the excision lines to be as symmetric as possible. However, when one eyelid requires more excision or the eyebrow position between the eyes is not similar, the markings on the opposite side are best made with the patient in a seated, relaxed position. The height of the upper eyelid between the eyebrow and the ciliary margin may be different between the eyes. This discrepancy may be the result of unevenly excised eyelid skin from a previous surgery, a congenital difference, or a different relaxation of each eye during the aging process. Occasionally the achievement of symmetry may be further ensured by measuring the distance between the eyebrow and the upper incision line (see Figures 7-4 and 7-9). Skin redundancy over the crow’s feet area is more abundant and requires a rather aggressive excision. Lateral extension is designed to eliminate lateral hooding as much as possible. Aggressive excision of eyelid skin in this area is permitted because potential development of ectropion or lagophthalmos is not a concern. Aggressive excision eliminates some of the crow’s feet and prevents an
Figure 7-6 The upper incision line is marked with the eyes open in a primary gaze position. The upper incision is marked 2 to 3 mm above the ciliary margin.
Figure 7-7 The upper incision runs parallel to the ciliary margin with the eyes open.
A
B
Figure 7-8 The skin muscle excision is narrow and sharply tapered medially and wide at the orbital rim. A, Eyes open. B, Eyes closed. 63
DOUBLE EYELID OPERATION FOR THE AGING PATIENT
Figure 7-9 The upper incision line was marked 12.5 cm from the ciliary margin. Measurement to confirm the symmetry revealed a discrepancy in the distance between the eyebrow and the incision line.
A
B
A
B Figure 7-11 The eyebrows remain symmetric at rest (A) and become asymmetric when the eyebrows are raised (B). unsightly round-eye phenomenon secondary to a descent of the lateral aspect of the double eyelid fold. A sharpened cotton applicator is applied to the marked inferior incision line. The skin is then pushed upward and folded over the tip of the cotton applicator (Figure 7-10, A). The location of the cotton applicator is marked on the surface of the fold. This point becomes the upper incision site. The point is then connected to the upper incision line on the upper eyelid and the lateral end of the lower incision marking. The pinch technique can also be used safely 64
Figure 7-10 A, The amount of the lateral skin-muscle excision is determined using a cotton-tipped applicator. B, The pinch technique.
in this area (see Figure 7-10, B). The eyebrow positions of some patients are symmetric when relaxed but become asymmetric when alert (Figure 7-11, A and B). When the skin is excised based on the measurement taken with the patient in a relaxed, premedicated state, both the patient and the surgeon may be surprised by an asymmetry when the patient returns for a follow-up visit. This embarrassing situation is best prevented with preoperative detection of the condition and patient education regarding the possibility of dynamic asymmetry. The surgeon may give the patient the choice of achieving symmetry in a relaxed or an alert state. The patient with thick edematous skin requires a smaller possible skin excision to minimize unsightly puffiness (Figure 7-12, A to C). The face is washed with Phisohex soap and thoroughly rinsed with water before the markings are made. It is crucial to mark after soap removal and before local anesthetic infiltration; it is almost impossible to obtain symmetry once the marking is lost after local anesthetic infiltration. A solution of 2% lidocaine with 1:100,000 epinephrine is then infiltrated under the skin. The incision is made along the markings. The skin-muscle island is excised (Figure 7-13, A). Ptotic brow fat may be excised if necessary (see Figure 7-13, B).
PROCEDURE
A
B
C Figure 7-12 A, Preoperative view of thick eyelid skin. B, Conservative excision of the skin. C, The patient with thick skin tends to develop a puffier fold. Conservative skin excision lessens the puffiness. The orbital septum is divided (see Figure 7-13, C to E). The levator aponeurosis is identified (see Figure 7-13, F). The supratarsal crease is created by fixating the pretarsal orbicularis oculi muscle to the levator aponeurosis as described in Chapter 6. The skin is then closed with 6-0 black nylon or 6-0 fast-absorbing gut in a continuous subcuticular fashion (see Figure 7-13, G).
Patients with Well-Defined Supratarsal Creases The lower incision is marked along the preexisting supratarsal crease. Generally, the same marking is made for
the upper incision, approximately 2 to 3 mm above the ciliary margin with the patient’s eyes in a primary gaze position. However, this distance varies depending on the tightness of the supratarsal crease. The patient with natural double eyelids tends to have a higher, more solid supratarsal crease. The upper incision markings may be made at 1 to 2 mm above the ciliary margin on the average patient who desires a double eyelid fold that is conservative in width. In a patient with a surgically created double fold, a conservative incision is chosen if the crease is located high and tightly fixated, similar to the patient with a natural fold. A new and tighter supratarsal crease fixation is necessary in the patient who has previously had double eyelid surgery but in whom the supratarsal crease is poorly fixated and loose. The markings are made similar to those on patients without preexisting double folds. Although a 1- to 3-mm incision line above the ciliary margin with the eyes in a primary position does not seem to be significant, a fairly wide skin excision can be made with these markings (see Figure 7-8, A and B). This amount of skin excision is still far smaller than that of the Caucasian eyelid when the pinch technique is used. The lower incision should be made with extreme care in the patient who has had previous double eyelid surgery. The skin–levator aponeurosis fixation can be accidentally detached during the incision at the supratarsal crease. It is less likely to happen in the eyelid with a natural double fold because of the broader adhesion between the pretarsal skin and the levator aponeurosis. When the attachment is severed, the surgeon may find the eyelid drooping during the surgery. At times it is difficult to judge whether a true ptosis has occurred or whether the droopiness found during the surgery is the result of eyelid swelling, anesthesia of the levator aponeurosis, or both. The surgeon may have to wait until after the surgery, when the swelling and edema has subsided, before determining the cause of the droopiness.
Asian Males with Upper Eyelid Redundancy The Asian male with upper eyelid redundancy often desires to eliminate the excess without creating a double eyelid. The usual measurement for the female patient does not apply to the male patient. An older Asian male may be embarrassed by a postoperative double eyelid with a puffy fold. The lower incision should be 5 to 6 mm from the ciliary margin. The upper incision is placed approximately 1 mm from the ciliary margin with the eyes open in a primary gaze position. The pretarsal skin fixation should 65
DOUBLE EYELID OPERATION FOR THE AGING PATIENT
A
B
C
D
E
F Figure 7-13 A, En bloc skin–muscle excision. B, Ptotic eyebrow fat is removed. C, The orbital septum is snipped with the scissors. Tension is applied to the septum as it is pulled up and detached from the underlying orbital fat and levator. D, The septal window is created. E, The septum is incised through the septal window. F, View of the orbital fat and the levator aponeurosis. G, The orbicularis oculi–levator aponeurosis fixation is completed. The incision lines are in complete apposition without skin closure.
G
66
CASE REVIEWHEAD 1
A
B
Figure 7-14 A, Preoperative view. B, One-month postoperative view showing a significant amount of puffiness and a red incision line.
A
B
Figure 7-15 A, Preoperative view. B, One-year postoperative view showing a well-formed crease and persistent puffiness.
A
B
Figure 7-16 A, Preoperative view. B, The fold appears less puffy when the fixation is incomplete. be conservative. However, excision of the redundant skin at the lateral aspect over the lateral orbital rim should be as aggressive as in the female patient. The skin redundancy is mostly in the lateral half of the upper eyelid and over the lateral orbital rim. The Asian male tolerates the temporary redness of the lateral incision better than a puffy double eyelid.
Postoperative Care and Recovery See Chapter 6.
Case Review See Figures 7-14 to 7-18. 67
DOUBLE EYELID OPERATION FOR THE AGING PATIENT
A
B
Figure 7-17 A, Preoperative view. B, Postoperative view. Conservative skin excision without the creation of a double eyelid fold is preferred for the male patient because it avoids the appearance of an unnatural thick fold. Earlier relapse is expected with further aging.
A
B
Figure 7-18 A, Preoperative view. B, Postoperative view. An aggressive approach was used for this older male patient after the expected outcome was explained. The patient happily accepted the result.
Reference
1. Lee JS: Simplified anatomic method of double-eyelid operation: septodermal fixation technique, Plast Reconstr Surg 100:170, 1997.
68