- Email: [email protected]
Double-Eyelid Operation: Orbicularis Oculi–Levator Aponeurosis Fixation Technique
315
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 15 (2007) 315–326
Double-Eyelid Operation: Orbicularis Oculi–Levator Aponeurosis Fixation Technique Jung I. Park, -
a,
MD, PhD
*, Min S. Park,
Preoperative consideration Preoperative analysis Patient preparation Surgical technique
The goal of blepharoplasty of the Asian eyelid is to create double-eyelid fold, which forms only when the eye is open, by creating a supratarsal crease. Although the presence of a crease and fold on the upper eyelid is universal in many races, many individuals of East Asian descent do not have this fold. Eyelid with double fold exhibits a characteristic feature where the upper eyelid skin folds over the supratarsal crease. This crease is formed by the adhesion of the levator aponeurosis to the pretarsal skin [1,2]. As the levator muscle pulls the tarsal plate to open the eye, the skin over the tarsus is pulled up by its attachment to the levator aponeurosis. The eyelid without a double fold exhibits certain characteristics. The eyelid, which lacks the skin-levator aponeurosis adhesion, allows the skin over the tarsal plate to lag behind as the tarsal plate lifts upward during eye opening. As a result, the upper eyelid skin droops over the eyelashes. The skin pushes the eyelashes down and makes the eyelashes appear shorter and less full. The palpabral fissure also looks narrower because of this overhanging
-
b
MD
Recovery Complications Case review References
eyelid skin [3]. Eyelid without a supratarsal crease is described as single eyelid, as opposed to double eyelid with a crease and an eyelid fold. Converting a single eyelid into a double eyelid creates an image of a large eye with long eyelashes and large palpabral fissure. The double-eyelid surgery is one of the most frequently performed cosmetic procedures in East and Southeastern Asian countries. Although there is a desire to preserve ethnic identities, an even stronger desire exists to beautify the eyes. For descriptive purposes, the eyelid is divided into pretarsal and supratarsal portions bordered by a supratarsal crease. The skin that folds over the supratarsal crease is described as the doubleeyelid fold. The double-eyelid fold covers a portion of the pretarsal skin. A portion of pretarsal skin remains visible below the double-eyelid fold when the eye is open in a primary gaze position. The author describes this area as the pretarsal show [4,5]. The shape and width of the pretarsal show is the most important feature in Asian eyelid surgery. Patients are often more concerned with the width of
a Department of Surgery, Northwest Campus, School of Medicine, Indiana University, 8825 Crestwood Avenue, Munster, IN 46321, USA b School of Medicine, University of San Diego, 200 West Arbor Drive, Mailcode 8893, San Diego, CA 92103, USA * Corresponding author. E-mail address: [email protected] (J.I. Park).
1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2007.04.002
316
Park & Park
the pretarsal show than the height of the supratarsal crease. The pretarsal show is also referred to as the width or height of the double-eyelid fold. The final width is a product of the interaction between the tightness or redundancy of the eyelid skin and the height of the supratarsal crease. If two individuals undergo double-eyelid operations with placement of the supratarsal crease 10 mm above the ciliary margin, there can be differences in the final location of the supratarsal crease. This occurs following relaxation of the initial fixation approximately 1 year following surgery, even in patients with the same amount of pretarsal show. Two individuals with 3 mm pretarsal show may have different locations of the supratarsal crease. One individual may have the supratarsal crease at 10 mm above the ciliary margin in primary gaze, whereas the other may have the crease descend to 5 mm above the ciliary margin. In the end, the level of the lower margin of the double-eyelid fold determines the amount of pretarsal show. An eyelid with a 10-mm supratarsal crease has twice as much pretarsal skin over the tarsus as compared with one with a 5-mm crease. In these instances, the lengths of the double fold from the supratarsal crease to the lower border of the double-eyelid fold are 7 and 2 mm, respectively. Double-eyelid folds with high supratarsal creases appear thicker than ones with low creases. Folds with high creases have more distinctive, wellformed fold margins and less of a tendency to relapse. The quality of the pretarsal skin is thinner and smooth when tightly draped (Fig. 1). Ones with a low crease are more delicate because of less folding of tissue (ie, fat and orbicularis oculi muscle) underneath the skin. Low creases have a tendency to show an indistinctive, ill-defined, and an incomplete double-eyelid fold line. This type also
Fig. 1. The pretarsal skin is thinner, smooth, and tighter when the supratarsal fixation is solid.
Fig. 2. The pretarsal skin is loose, puffy, redundant, and wrinkled resulting in an accordion effect when the supratarsal fixation becomes loose.
has a greater tendency to relapse. The pretarsal skin is often loose, thick, puffy, redundant, and wrinkled resulting from an accordion effect (Fig. 2) [4]. Eyelids with low supratarsal creases often result from a progressive descent of the supratarsal crease from its original high location because of a lack of firm fixation between the skin and levator aponeurosis. The pretarsal skin between the crease and the ciliary margin becomes contracted, shortened, wrinkled, redundant, and thickened. Two of the most prevalent methods used in the past for double-eyelid surgeries have been described as the nonincision suture technique and the incision technique with fixation. The author was an early advocate of the nonincision technique because of its quickness and simplicity. This enthusiasm has been abandoned in favor of the incision technique with fixation because of the higher relapse rate with the nonincision technique (Fig. 3) [5,6]. The nonincision technique also has difficulty addressing the epicanthal fold. All of the incision techniques in the past focused on fixing the pretarsal skin to either the tarsal plate
Fig. 3. The patient following a nonincisional suture fixation technique.
Double-Eyelid Operation
Fig. 4. Illustration demonstrating a wide contact between the folded levator aponeurosis and the orbicularis oculi muscle in the author’s technique.
or to the levator aponeurosis. Although the relapse rate is lower than in the suture technique, this remains one of the main concerns in double-eyelid surgery. To address these issues, the author developed a pretarsal orbicularis oculi muscle–levator aponeurosis fixation technique (Fig. 4) [4,5]. This technique results in better fixation between the skin and the levator aponeurosis by recruiting a bulky, pretarsal orbicularis oculi muscle in the fixation mechanism. Thin skin is replaced by the thick muscle in fixation with the levator aponeurosis.
Adhesion between the thick muscle and folded levator aponeurosis provides firmer and longer-lasting cicatrization between the two structures. Although the skin is not sutured directly to the levator aponeurosis, effective skin retraction in response to the levator muscle contraction is possible by a natural, tight adhesion between the skin and the pretarsal orbicularis oculi muscle (Fig. 5). As the pretarsal orbicularis oculi muscle is pulled up by the levator aponeurosis, the pretarsal skin is pulled up as the underlying muscle is stretched. This technique provides for a solidly fixed, tightly stretched pretarsal skin when the eyes are open with significantly reduced chances of relapse. The accordion effect is also minimized with this technique.
Preoperative consideration
Fig. 5. A tight adhesion between the pretarsal orbicularis oculi muscle and the skin allows an effective pull of the skin by fixation of the muscle to the levator aponeurosis. The tightness of adhesion is being demonstrated by retracting the skin with forceps.
During the initial consultation, the surgeon must determine the desired shape of the double eyelid. Some patients wish to maintain the epicanthal fold, allowing the supratarsal crease height to gradually enlarge as it approaches the lateral aspect of the eyelid. Others prefer to have the crease run more or less parallel to the tarsal margin without the epicanthal fold. Some patients seek a very narrow pretarsal show with a low double-eyelid fold, whereas others wish to have a large pretarsal show with a high fold [7]. Still other patients want fat
317
318
Park & Park
Fig. 6. (A) Measurements and markings are made with the eyelids stretched. (B) A line is drawn parallel to the tarsal margin maintaining a 7-mm distance from the ciliary margin throughout the entire length. (C) Although the line is drawn parallel to the ciliary margin, it appears as if the line is tapering toward the ciliary margin medially because of skin laxity. The marking runs parallel to and about 1 to 2 mm from the ciliary margin with the eyes open and without stretching the eyelids.
removed from the upper eyelid to prevent the appearance of bulkiness. The author usually dissuades these patients from defatting the upper eyelid for reasons described later. Although Asian patients can be demanding and unforgiving of imperfections, it is important to stress that some degree of imperfection, especially asymmetry, is unavoidable and prepare the patient for these results.
Preoperative analysis Because gravity changes the distribution of the eyelid skin, preoperative marking is done with the patient in a sitting position. Every effort is made to make the lines symmetric. A fine, felt-tip pen is used to minimize errors created by incising along a thick line. An error of as much as 2 mm, or 20% to 30% between the two eyelids, is possible when following a thicker line. With the patient’s eyes closed, the eyebrow is gently lifted with the surgeon’s left thumb to stretch the upper eyelid skin. The eyelashes should point in
a horizontal plane without showing the tarsal margin during this maneuver. Using a caliper, a dot is placed about 7 mm from the ciliary margin (Fig. 6A). For a smaller pretarsal show, the mark may be placed 5 or 6 mm from the ciliary margin. As this distance decreases, however, the chance of relapse increases. For a larger pretarsal show, an 8or 9-mm measurement can be used. For those with an excess of eyelid skin, an ellipse of skin may be excised. Skin excision should be avoided whenever possible with younger patients. In these patients, the measurement for the crease height can be larger than 7 mm. Conversely, if only a conservative excision of an ellipse of the eyelid skin is performed, the skin measurement can remain at 7 mm. A line is then drawn parallel to the tarsal margin from the medial canthal area to the lateral canthal area maintaining the same 7 mm distance in both the medial and lateral canthal areas (Fig. 6B, C). If this distance is not preserved, there is a tendency of the skin to sag in the lateral and medial aspect of
Fig. 7. (A) The muscle is retracted and the orbital septum is exposed. The fat layer deep to the orbicularis oculi muscle is shown as a thin, yellow fat layer covering the orbital septum. (B) The orbital septum is a solid, white fibrous tissue distinct from the pearly white, glistening levator aponeurosis and is tightly adherent to the orbicularis oculi muscle.
Double-Eyelid Operation
Fig. 8. (A, B) The orbital septum is penetrated by the tip of the scissors or by needle cautery. The upper eyelid should be retracted tightly anteriorly and slightly downward while counter traction is applied with forceps to create tension on the orbital septum.
the eyelids. This results in a round eye appearance with a high double fold in the midpupillary point and low folds medially and laterally. This tendency for inferior migration of the crease in the medial aspect is caused by the weaker fixation between the skin and levator aponeurosis in this region. The levator aponeurosis in the medial area is deeper and buried under a bulky layer of fibrofatty tissue. The skin is often fixed to the fibrofatty tissue instead of the levator aponeurosis. If necessary, the crease height near the medial canthal area can be modified to produce a smooth transition with epicanthoplasty. Conversely, the levator aponeurosis is distinctive and more easily found in the lateral area. The excursion of the levator aponeurosis in response to levator contraction is less in the lateral-most part of the levator expansion, however, compared with the midpupillary point. If the line is not
perfectly straight and instead curves downward at the extremes, there is an accentuation of the natural tendency for the medial and lateral areas to descend. Even if the lateral fixation is at the same level as the midpupillary point, there may still be a tendency for the double-eyelid fold to sag laterally.
Patient preparation The patient is premedicated with oral administration of broad-spectrum antibiotics, 1.5 to 2 mg alprazolam (Xanax), and 100/650 mg propoxyphene napsylate-acetaminophen (Darvocet N-100). Adequate sedation either relaxes the patient or induces a light sleep. Patient cooperation is necessary to identify and confirm the levator muscle excursion and to evaluate the symmetry of the folds during and after surgery. Most inks used for ultrafine marking can be partially or totally erased with water. Sterile preparation of the skin is done before skin marking to avoid disruption of the lines. The surgeon also should make every effort to maintain the line drawing during the infiltration of local anesthetic. If the marks are erased, redrawing following the local infiltration of anesthetics can cause significant asymmetry from tissue distortion.
Surgical technique
Fig. 9. A window is created through the orbital septum. An empty preaponeurotic space is created by applying proper traction.
Skin incision is made with #15 Bard-Parker blade while the skin is stretched in all directions to ensure tightness of the eyelid. This minimizes the chances of an irregular incision. A carbon-dioxide laser or ultrafine needle tip cautery is used to dissect the deeper tissue including the fat and orbicularis oculi muscle. It is important to have enough space
319
320
Park & Park
Fig. 10. (A, B) The preaponeurotic pocket is widened and the orbital septum is incised medially and laterally.
between the skin edges before the application of the laser or cautery tip to prevent lateral thermal damage and invisible burns to the skin edge. A small discrepancy in the skin dimensions altered by lateral thermal damage may result in asymmetry of the double-eyelid fold height between the eyes. This asymmetry is poorly tolerated by Asian patients, often requiring later revision. When the skin is properly stretched, the orbicularis oculi muscle is clearly visualized during incision with laser or cautery. Gentle upward retraction of the upper eyelid skin and muscle flap reveals a tightly stretched orbital septum (Fig. 7A). This septum is a solid, white fibrous tissue distinct from the pearly white, glistening levator aponeurosis (Fig. 7B). It is not uncommon to find some fusion between the orbital septum and the levator aponeurosis superior to the skin-muscle incision. In these instances, incision through the orbital septum includes the levator aponeurosis resulting in an iatrogenic ptosis. If the levator is divided, obtaining symmetry between the eyes is extremely difficult. Repair of the incision is often not enough to
Fig. 11. The shiny, white levator aponeurosis and preaponeurotic fat within a thin, transparent capsule are exposed.
recreate symmetry and may require multiple revision surgeries to correct the ptosis. A preaponeurotic fat compartment separates the septum from the levator aponeurosis above the fusion point. The incision through the orbital septum must be carried into the preaponeurotic compartment. Several key rules help to achieve this important goal. First, the incision through the orbicularis oculi muscle must be made precisely to identify clearly and widely expose the orbital septum. Exposure should be directed more cephalad above the potential fusion point. Using a wide double-prong skin hook, the upper skin-muscle flap is lifted superiorly and slightly anteriorly. This maneuver lifts the orbital septum away from the underlying preaponeurotic fat compartment and the levator aponeurosis. The orbit is then gently depressed. The preaponeurotic fat can often be seen bulging through the orbital septum. If the preaponeurotic fat compartment is not easily visualized, an incision through the orbital septum is made in a more cephalad
Fig. 12. Pretarsal orbicularis oculi muscle cuff is ready to be used for fixation.
Double-Eyelid Operation
Fig. 13. (A) The needle should pass through the muscle cuff from the undersurface, close to the skin margin, taking a small bite of the dermis along the way. Shown is passage from the surface. Depending on the position of the surgeon, it may be more convenient to take the levator first and then pass the needle through the muscle from the surface. The surgeon must ensure that the knot is buried. (B) The needle passes through the levator aponeurosis taking a thick bite of the aponeurosis. The needle passes upward when the levator is sutured first. It passes downward when the orbicularis oculi is sutured first.
position. This incision can be lowered once the preaponeurotic compartment is identified. While the septum is tented up with a retractor, a small stab incision is made (Fig. 8). When the incision is made in the correct location, an empty space with loose areolar tissue is encountered (Fig. 9). Next, the orbital septum is incised medially and laterally while maintaining a tight orbital septum and continually viewing the deep, loose areolar tissue (Fig. 10). One blade of tenotomy scissors is inserted into the space under the septum for the septal incision. Once the orbital septum is completely divided, the preaponeurotic fat and the inferior portion of the levator aponeurosis are clearly identified. In some instances, the tissue plane is not clearly developed and positive conformation
of the orbital septum and the levator aponeurosis is necessary. The patient is asked to open the eyes while the upper skin-muscle flap is retracted. The orbital septum remains still or shows only minor excursion during this maneuver. The levator aponeurosis exhibits a distinct contraction pattern in the superior and posterior direction along the curvature of the orbit. If the surgeon grasps the tissue with a pair of forceps and asks the patient to open their eyes, the eyelid moves up without restriction when the orbital septum is grasped. If, however, the levator aponeurosis is grasped, the patient is not able freely to open the eyes. The preaponeurotic fat is contained within a thin, transparent, filmy membrane. With more experience, the levator aponeurosis can be adequately
Fig. 14. (A) The levator aponeurosis is distinctive in the lateral aspect. (B) The needle passes through the muscle cuff laterally. The knot should always be deeply buried.
321
322
Park & Park
Fig. 15. (A) The needle passes through the medial muscle cuff. (B) The levator aponeurosis is deep and poorly defined in the medial compartment. A thick bite through the fibrofatty tissue is necessary medially.
exposed without exposure of the preaponeurotic fat within this membrane (Fig. 11). Full and adequate exposure of the entire levator aponeurosis is necessary for successful fixation. At this stage, a strip of the pretarsal orbicularis oculi muscle is visualized beyond the lower skin incision margin (Fig. 12). This muscle strip is gently grasped with fine-tip tissue forceps. A 6-0 or 70 clear nylon suture is passed through the muscle from the under surface closest to the skin margin, taking care not to traverse through the skin (Fig. 13A). Although the skin is not penetrated with the needle, incorporating the dermis at the edge of the skin allows for more tightening of the pretarsal skin. The distal portion of the levator aponeurosis is then gently grasped with forceps. The needle passes through this folded levator aponeurosis (Fig. 13B). The suture is tightened just enough to approximate the muscle and levator aponeurosis without
strangulation of the tissues. The knot should be buried in the deep tissue plane. The fixation point in the levator aponeurosis determines the tightness of the pretarsal skin and the height of the supratarsal crease. This fixation technique may raise the height of the tarsal margin resulting in a wider palpebral fissure. The eyes often appear larger following this procedure. The author’s approach is to tighten the pretarsal skin to the point where the upper eyelashes remain in its normal direction or barely rise forward. Asian eyelashes tend to run in a slightly downward direction, unlike white eyelashes, which run in a horizontal or slightly upward plane. One may choose to create a slight eversion of the tarsus when the suturing is complete. This maneuver, however, may result in a permanent show of the red tarsal margin. Even though in long-term follow-up this may result in a tighter pretarsal skin, many Asian patients do not appreciate the initial results.
Fig. 16. (A) The long-term scar is barely visible. (B) Marking demonstrates the old scar.
Double-Eyelid Operation
Fig. 17. (A) Preoperative view. (B) Inner-type double fold. Pretarsal skin is tight and crispy.
The first suture is placed in the midpupillary line. The author’s preference is to expose levator aponeurosis bilaterally and place the midpupillary sutures simultaneously. The patient is then asked to open the eyes to compare the initial results. This suture is most important in obtaining symmetry between the eyes. The second suture is placed near the lateral end of the incision. Ideally, the fixation should be made at the lateral end of the incision (Fig. 14). The end point of the incision is usually over the lateral orbital rim, however, where the levator aponeurosis is not available. Fixation to the orbital periosteum does not maintain the crease long term. The fixation point usually lies about 1 cm medial to the lateral end where the levator aponeurosis joins the lateral canthal ligament. This portion, called a lateral horn, is located quite deeply, and requires a deeper dissection to reach the aponeurosis. The levator aponeurosis is well developed and well defined in this area.
A vessel crossing the fat compartment in this area is often encountered [8]. If this vessel is accidentally disrupted, a small hematoma can develop quickly in the levator aponeurosis and the muscle. A hematoma in the levator aponeurosis often causes temporary ptosis posing difficulty in the assessment of symmetry. The pretarsal orbicularis oculi muscle is then sutured to the levator aponeurosis in a similar fashion. The levator aponeurosis in the medial canthal area is rather flimsy and may appear to be missing or may blend in with the fatty fibrous tissue. The dissection plane is often deeper in this area. Unless the aponeurosis is easily identified, the orbicularis oculi muscle can be fixed to the fibrofatty tissue instead of the aponeurosis, avoiding encountering potentially disastrous bleeding from several prominent vessels in the fibrofatty tissue. In these instances, a bigger bite can be taken through the fibrofatty tissue at the higher location to
Fig. 18. (A) Preoperative view with parallel crease and Park Z-epicanthoplasty marking. (B) Postoperative view of parallel double-eyelid fold and open medial canthal area.
323
324
Park & Park
Fig. 19. (A) Preoperative view. (B) Postoperative view.
compensate for the lack of traction by the levator muscle. This suture is placed as medially as possible (Fig. 15). Patients often complain of inadequate pretarsal show and indistinct double folds in the medial aspect. If the fixation is not tight, the fold may droop toward the lid margin, creating multiple fine wrinkles in the pretarsal skin medially. When the pretarsal orbicularis oculi muscle–levator aponeurosis fixation is complete, the lower skin incision is almost in complete approximation with the upper incision without the use of skin sutures; scarring is minimized (Fig. 16). The skin incision is closed with either 6-0 fast absorbing gut or 6-0 black nylon in a continuous subcuticular fashion.
Recovery The patient is taken to the recovery room and placed in the semireclining position. Moist 4 4 gauze is
placed over the eyelids followed by an ice pack. Surgical gloves or self-sealing plastic bags filled with ice cubes make adequate ice packs. A surgeon’s mask can be tied around the head or looped around the ears of the patient to hold the ice packs in place. The patient is then required to rest for 30 to 60 minutes before discharge. If the patient complains of pain toward the end of the procedure, an additional narcotic tablet is generally sufficient to control the pain. Postoperatively, only several additional dosages of pain medications are necessary. Antibiotics are administered for 2 days following the surgery. The patient is given instructions to apply ice packs in 30-minute intervals on and off for the first 2 days. The patient is allowed to see and ambulate as needed following discharge. The first postoperative visit is recommended on the seventh postoperative day. Vigorous physical activities, such as heavy weight lifting, can be resumed after 2 weeks. Skin thickness, extent of surgery, and patient age
Fig. 20. (A) Redundant upper eyelid skin and compensatory high eyebrow position. (B) Postoperative view shows lower brow position and double-eyelid fold.
Double-Eyelid Operation
Fig. 21. (A) Single eyelid with type II epicanthal fold. (B) Postoperative view.
determines the degree of postoperative edema. There is generally less edema in patients with thinner eyelid skin. Older patients can have prolonged edema, lasting 6 months to 1 year. Younger patients may look quite natural within 2 weeks. The patient may return to work with shaded glasses during the first week of surgery. Patients who wear contact lenses may be advised to wear regular glasses to camouflage the unnatural appearance during the recovery period.
Complications Ecchymosis is common following conventional eyelid surgery. The use of laser or fine-tipped cautery reduces the chances of ecchymosis formation.
Fig. 22. (A) Preoperative view. (B) Prolonged and sometime permanent puffiness of the double fold is typical for the older Asian patients.
Infection and hematoma formation are rare complications. Excessive stretching of the pretarsal skin may cause an unsightly show of the red tarsal margin or may result in dry eyes. Lagophthalmos is rare because the eyelid skin is either not removed in most cases or is removed conservatively. Ptosis results if the levator aponeurosis is partially or completely severed during the procedure. It is somewhat more common in the medial one third of the upper eyelid. When this occurs, a portion of the superomedial aspect of the pupil is covered resulting in partial obstruction of the visual field and creation of an asymmetric palpebral fissure. Temporary ptosis caused by diffusion of local anesthetics into the levator muscle or development of a hematoma in the levator muscle is not uncommon. This, however, resolves within days to weeks following surgery. If the suture material migrates to the surface, caused by either a long tail of suture or from thinness of the covering skin, it can result in redness or nodule, cyst, or pustule formation. This resolves quickly with the removal of the offending suture. If the suture migrates internally, it can lead to corneal or conjunctival irritation. Cosmetic complications include asymmetric folds, poorly defined folds, incomplete
Fig. 23. Extra crease formation following excessive preaponeurotic fat removal.
325
326
Park & Park
Excessive removal of fat in the Asian eyelid also results in unsightly deep folds or a sunken appearance. This creates eyelids that are neither Asian nor white in appearance. Relapse is another condition that is seen frequently. Inadequate identification of the levator aponeurosis or improper suturing of the pretarsal muscle to the orbital septum or to the orbital fat may cause relapse. To prevent disruption of the fixation and potential relapse, the patient should be discouraged from rubbing or applying pressure to their eyes during the early stages of healing.
Case review Figs. 17–24 illustrate a case review.
References Fig. 24. (A) Nonincisional suture technique. (B) Orbicularis oculi-levator aponeurosis fixation technique.
supratarsal crease formation, wide scarring, keloid formation, and so forth. Asymmetry, one of the most common complications, can be prevented by precision in the design and execution of the procedure. It is also important to stress to the patient that there is always some degree of asymmetry. One or more extra creases may form in the orbital portion of the upper eyelid skin above the doubleeyelid fold if there is excessive removal of the orbital fat. This phenomenon is unique in Asian eyelids because of the inherent thickness of the skin and muscle [7,9]. If there is a lack of support from insufficient underlying fat, the overlying skin and muscle blanket folds at the weak point forming a crease or multiple creases. Unlike thin and soft tissue, thick and rigid tissue does not have the ability to conform to the underlying tissue and glide with fine evenly distributed wrinkles. When fat tissue is removed, the skin tends to dimple rather than spread the redundancy evenly.
[1] Marcos TD, Anderson RL. Oriental eyelids: an anatomic study. Arch Ophthalmol 1984;102: 1232–5. [2] Collins JRO, Beard C, Wood I. Experimental and clinical data on the insertion of the levator palpabra superioris muscle. Am J Ophthalmol 1978;85: 742–801. [3] Sayoc BT. Surgery of the oriental eyelid. Clin Plast Surg 1974;1(1):157–70. [4] Park JI. Orbicularis-levator fixation in double eyelid operation. Arch Facial Plast Surg 1999;1:90–5. [5] Park JI. Orbicularis-levator fixation technique. In: Park JI, editor. Asian facial cosmetic surgery. Philadelphia: Saunders Elsevier; 2006. p. 49–59. [6] Matsunaga RS. Westernization of the Asian eyelid. Arch Otolaryngol 1985;111:149. [7] Liu D, Hsu WM. Oriental eyelids: anatomic difference and surgical consideration. Ophthal Plast Reconstr Surg 1986;2(2):59–64. [8] Kim BG, Youn DY, Yoon ES, et al. Unexpected bleeding caused by arterial variation inferolateral to levator palpabrae. Aesthetic Plast Surg 2003; 27:123–5. [9] Lee Y, Hwang K. Skin thickness of Korean adults. Surg Radiol Anat 2002;24:183–9.
FACIAL PLASTIC SURGERY CLINICS OF NORTH AMERICA Facial Plast Surg Clin N Am 15 (2007) 315–326
Double-Eyelid Operation: Orbicularis Oculi–Levator Aponeurosis Fixation Technique Jung I. Park, -
a,
MD, PhD
*, Min S. Park,
Preoperative consideration Preoperative analysis Patient preparation Surgical technique
The goal of blepharoplasty of the Asian eyelid is to create double-eyelid fold, which forms only when the eye is open, by creating a supratarsal crease. Although the presence of a crease and fold on the upper eyelid is universal in many races, many individuals of East Asian descent do not have this fold. Eyelid with double fold exhibits a characteristic feature where the upper eyelid skin folds over the supratarsal crease. This crease is formed by the adhesion of the levator aponeurosis to the pretarsal skin [1,2]. As the levator muscle pulls the tarsal plate to open the eye, the skin over the tarsus is pulled up by its attachment to the levator aponeurosis. The eyelid without a double fold exhibits certain characteristics. The eyelid, which lacks the skin-levator aponeurosis adhesion, allows the skin over the tarsal plate to lag behind as the tarsal plate lifts upward during eye opening. As a result, the upper eyelid skin droops over the eyelashes. The skin pushes the eyelashes down and makes the eyelashes appear shorter and less full. The palpabral fissure also looks narrower because of this overhanging
-
b
MD
Recovery Complications Case review References
eyelid skin [3]. Eyelid without a supratarsal crease is described as single eyelid, as opposed to double eyelid with a crease and an eyelid fold. Converting a single eyelid into a double eyelid creates an image of a large eye with long eyelashes and large palpabral fissure. The double-eyelid surgery is one of the most frequently performed cosmetic procedures in East and Southeastern Asian countries. Although there is a desire to preserve ethnic identities, an even stronger desire exists to beautify the eyes. For descriptive purposes, the eyelid is divided into pretarsal and supratarsal portions bordered by a supratarsal crease. The skin that folds over the supratarsal crease is described as the doubleeyelid fold. The double-eyelid fold covers a portion of the pretarsal skin. A portion of pretarsal skin remains visible below the double-eyelid fold when the eye is open in a primary gaze position. The author describes this area as the pretarsal show [4,5]. The shape and width of the pretarsal show is the most important feature in Asian eyelid surgery. Patients are often more concerned with the width of
a Department of Surgery, Northwest Campus, School of Medicine, Indiana University, 8825 Crestwood Avenue, Munster, IN 46321, USA b School of Medicine, University of San Diego, 200 West Arbor Drive, Mailcode 8893, San Diego, CA 92103, USA * Corresponding author. E-mail address: [email protected] (J.I. Park).
1064-7406/07/$ – see front matter ª 2007 Elsevier Inc. All rights reserved.
facialplastic.theclinics.com
doi:10.1016/j.fsc.2007.04.002
316
Park & Park
the pretarsal show than the height of the supratarsal crease. The pretarsal show is also referred to as the width or height of the double-eyelid fold. The final width is a product of the interaction between the tightness or redundancy of the eyelid skin and the height of the supratarsal crease. If two individuals undergo double-eyelid operations with placement of the supratarsal crease 10 mm above the ciliary margin, there can be differences in the final location of the supratarsal crease. This occurs following relaxation of the initial fixation approximately 1 year following surgery, even in patients with the same amount of pretarsal show. Two individuals with 3 mm pretarsal show may have different locations of the supratarsal crease. One individual may have the supratarsal crease at 10 mm above the ciliary margin in primary gaze, whereas the other may have the crease descend to 5 mm above the ciliary margin. In the end, the level of the lower margin of the double-eyelid fold determines the amount of pretarsal show. An eyelid with a 10-mm supratarsal crease has twice as much pretarsal skin over the tarsus as compared with one with a 5-mm crease. In these instances, the lengths of the double fold from the supratarsal crease to the lower border of the double-eyelid fold are 7 and 2 mm, respectively. Double-eyelid folds with high supratarsal creases appear thicker than ones with low creases. Folds with high creases have more distinctive, wellformed fold margins and less of a tendency to relapse. The quality of the pretarsal skin is thinner and smooth when tightly draped (Fig. 1). Ones with a low crease are more delicate because of less folding of tissue (ie, fat and orbicularis oculi muscle) underneath the skin. Low creases have a tendency to show an indistinctive, ill-defined, and an incomplete double-eyelid fold line. This type also
Fig. 1. The pretarsal skin is thinner, smooth, and tighter when the supratarsal fixation is solid.
Fig. 2. The pretarsal skin is loose, puffy, redundant, and wrinkled resulting in an accordion effect when the supratarsal fixation becomes loose.
has a greater tendency to relapse. The pretarsal skin is often loose, thick, puffy, redundant, and wrinkled resulting from an accordion effect (Fig. 2) [4]. Eyelids with low supratarsal creases often result from a progressive descent of the supratarsal crease from its original high location because of a lack of firm fixation between the skin and levator aponeurosis. The pretarsal skin between the crease and the ciliary margin becomes contracted, shortened, wrinkled, redundant, and thickened. Two of the most prevalent methods used in the past for double-eyelid surgeries have been described as the nonincision suture technique and the incision technique with fixation. The author was an early advocate of the nonincision technique because of its quickness and simplicity. This enthusiasm has been abandoned in favor of the incision technique with fixation because of the higher relapse rate with the nonincision technique (Fig. 3) [5,6]. The nonincision technique also has difficulty addressing the epicanthal fold. All of the incision techniques in the past focused on fixing the pretarsal skin to either the tarsal plate
Fig. 3. The patient following a nonincisional suture fixation technique.
Double-Eyelid Operation
Fig. 4. Illustration demonstrating a wide contact between the folded levator aponeurosis and the orbicularis oculi muscle in the author’s technique.
or to the levator aponeurosis. Although the relapse rate is lower than in the suture technique, this remains one of the main concerns in double-eyelid surgery. To address these issues, the author developed a pretarsal orbicularis oculi muscle–levator aponeurosis fixation technique (Fig. 4) [4,5]. This technique results in better fixation between the skin and the levator aponeurosis by recruiting a bulky, pretarsal orbicularis oculi muscle in the fixation mechanism. Thin skin is replaced by the thick muscle in fixation with the levator aponeurosis.
Adhesion between the thick muscle and folded levator aponeurosis provides firmer and longer-lasting cicatrization between the two structures. Although the skin is not sutured directly to the levator aponeurosis, effective skin retraction in response to the levator muscle contraction is possible by a natural, tight adhesion between the skin and the pretarsal orbicularis oculi muscle (Fig. 5). As the pretarsal orbicularis oculi muscle is pulled up by the levator aponeurosis, the pretarsal skin is pulled up as the underlying muscle is stretched. This technique provides for a solidly fixed, tightly stretched pretarsal skin when the eyes are open with significantly reduced chances of relapse. The accordion effect is also minimized with this technique.
Preoperative consideration
Fig. 5. A tight adhesion between the pretarsal orbicularis oculi muscle and the skin allows an effective pull of the skin by fixation of the muscle to the levator aponeurosis. The tightness of adhesion is being demonstrated by retracting the skin with forceps.
During the initial consultation, the surgeon must determine the desired shape of the double eyelid. Some patients wish to maintain the epicanthal fold, allowing the supratarsal crease height to gradually enlarge as it approaches the lateral aspect of the eyelid. Others prefer to have the crease run more or less parallel to the tarsal margin without the epicanthal fold. Some patients seek a very narrow pretarsal show with a low double-eyelid fold, whereas others wish to have a large pretarsal show with a high fold [7]. Still other patients want fat
317
318
Park & Park
Fig. 6. (A) Measurements and markings are made with the eyelids stretched. (B) A line is drawn parallel to the tarsal margin maintaining a 7-mm distance from the ciliary margin throughout the entire length. (C) Although the line is drawn parallel to the ciliary margin, it appears as if the line is tapering toward the ciliary margin medially because of skin laxity. The marking runs parallel to and about 1 to 2 mm from the ciliary margin with the eyes open and without stretching the eyelids.
removed from the upper eyelid to prevent the appearance of bulkiness. The author usually dissuades these patients from defatting the upper eyelid for reasons described later. Although Asian patients can be demanding and unforgiving of imperfections, it is important to stress that some degree of imperfection, especially asymmetry, is unavoidable and prepare the patient for these results.
Preoperative analysis Because gravity changes the distribution of the eyelid skin, preoperative marking is done with the patient in a sitting position. Every effort is made to make the lines symmetric. A fine, felt-tip pen is used to minimize errors created by incising along a thick line. An error of as much as 2 mm, or 20% to 30% between the two eyelids, is possible when following a thicker line. With the patient’s eyes closed, the eyebrow is gently lifted with the surgeon’s left thumb to stretch the upper eyelid skin. The eyelashes should point in
a horizontal plane without showing the tarsal margin during this maneuver. Using a caliper, a dot is placed about 7 mm from the ciliary margin (Fig. 6A). For a smaller pretarsal show, the mark may be placed 5 or 6 mm from the ciliary margin. As this distance decreases, however, the chance of relapse increases. For a larger pretarsal show, an 8or 9-mm measurement can be used. For those with an excess of eyelid skin, an ellipse of skin may be excised. Skin excision should be avoided whenever possible with younger patients. In these patients, the measurement for the crease height can be larger than 7 mm. Conversely, if only a conservative excision of an ellipse of the eyelid skin is performed, the skin measurement can remain at 7 mm. A line is then drawn parallel to the tarsal margin from the medial canthal area to the lateral canthal area maintaining the same 7 mm distance in both the medial and lateral canthal areas (Fig. 6B, C). If this distance is not preserved, there is a tendency of the skin to sag in the lateral and medial aspect of
Fig. 7. (A) The muscle is retracted and the orbital septum is exposed. The fat layer deep to the orbicularis oculi muscle is shown as a thin, yellow fat layer covering the orbital septum. (B) The orbital septum is a solid, white fibrous tissue distinct from the pearly white, glistening levator aponeurosis and is tightly adherent to the orbicularis oculi muscle.
Double-Eyelid Operation
Fig. 8. (A, B) The orbital septum is penetrated by the tip of the scissors or by needle cautery. The upper eyelid should be retracted tightly anteriorly and slightly downward while counter traction is applied with forceps to create tension on the orbital septum.
the eyelids. This results in a round eye appearance with a high double fold in the midpupillary point and low folds medially and laterally. This tendency for inferior migration of the crease in the medial aspect is caused by the weaker fixation between the skin and levator aponeurosis in this region. The levator aponeurosis in the medial area is deeper and buried under a bulky layer of fibrofatty tissue. The skin is often fixed to the fibrofatty tissue instead of the levator aponeurosis. If necessary, the crease height near the medial canthal area can be modified to produce a smooth transition with epicanthoplasty. Conversely, the levator aponeurosis is distinctive and more easily found in the lateral area. The excursion of the levator aponeurosis in response to levator contraction is less in the lateral-most part of the levator expansion, however, compared with the midpupillary point. If the line is not
perfectly straight and instead curves downward at the extremes, there is an accentuation of the natural tendency for the medial and lateral areas to descend. Even if the lateral fixation is at the same level as the midpupillary point, there may still be a tendency for the double-eyelid fold to sag laterally.
Patient preparation The patient is premedicated with oral administration of broad-spectrum antibiotics, 1.5 to 2 mg alprazolam (Xanax), and 100/650 mg propoxyphene napsylate-acetaminophen (Darvocet N-100). Adequate sedation either relaxes the patient or induces a light sleep. Patient cooperation is necessary to identify and confirm the levator muscle excursion and to evaluate the symmetry of the folds during and after surgery. Most inks used for ultrafine marking can be partially or totally erased with water. Sterile preparation of the skin is done before skin marking to avoid disruption of the lines. The surgeon also should make every effort to maintain the line drawing during the infiltration of local anesthetic. If the marks are erased, redrawing following the local infiltration of anesthetics can cause significant asymmetry from tissue distortion.
Surgical technique
Fig. 9. A window is created through the orbital septum. An empty preaponeurotic space is created by applying proper traction.
Skin incision is made with #15 Bard-Parker blade while the skin is stretched in all directions to ensure tightness of the eyelid. This minimizes the chances of an irregular incision. A carbon-dioxide laser or ultrafine needle tip cautery is used to dissect the deeper tissue including the fat and orbicularis oculi muscle. It is important to have enough space
319
320
Park & Park
Fig. 10. (A, B) The preaponeurotic pocket is widened and the orbital septum is incised medially and laterally.
between the skin edges before the application of the laser or cautery tip to prevent lateral thermal damage and invisible burns to the skin edge. A small discrepancy in the skin dimensions altered by lateral thermal damage may result in asymmetry of the double-eyelid fold height between the eyes. This asymmetry is poorly tolerated by Asian patients, often requiring later revision. When the skin is properly stretched, the orbicularis oculi muscle is clearly visualized during incision with laser or cautery. Gentle upward retraction of the upper eyelid skin and muscle flap reveals a tightly stretched orbital septum (Fig. 7A). This septum is a solid, white fibrous tissue distinct from the pearly white, glistening levator aponeurosis (Fig. 7B). It is not uncommon to find some fusion between the orbital septum and the levator aponeurosis superior to the skin-muscle incision. In these instances, incision through the orbital septum includes the levator aponeurosis resulting in an iatrogenic ptosis. If the levator is divided, obtaining symmetry between the eyes is extremely difficult. Repair of the incision is often not enough to
Fig. 11. The shiny, white levator aponeurosis and preaponeurotic fat within a thin, transparent capsule are exposed.
recreate symmetry and may require multiple revision surgeries to correct the ptosis. A preaponeurotic fat compartment separates the septum from the levator aponeurosis above the fusion point. The incision through the orbital septum must be carried into the preaponeurotic compartment. Several key rules help to achieve this important goal. First, the incision through the orbicularis oculi muscle must be made precisely to identify clearly and widely expose the orbital septum. Exposure should be directed more cephalad above the potential fusion point. Using a wide double-prong skin hook, the upper skin-muscle flap is lifted superiorly and slightly anteriorly. This maneuver lifts the orbital septum away from the underlying preaponeurotic fat compartment and the levator aponeurosis. The orbit is then gently depressed. The preaponeurotic fat can often be seen bulging through the orbital septum. If the preaponeurotic fat compartment is not easily visualized, an incision through the orbital septum is made in a more cephalad
Fig. 12. Pretarsal orbicularis oculi muscle cuff is ready to be used for fixation.
Double-Eyelid Operation
Fig. 13. (A) The needle should pass through the muscle cuff from the undersurface, close to the skin margin, taking a small bite of the dermis along the way. Shown is passage from the surface. Depending on the position of the surgeon, it may be more convenient to take the levator first and then pass the needle through the muscle from the surface. The surgeon must ensure that the knot is buried. (B) The needle passes through the levator aponeurosis taking a thick bite of the aponeurosis. The needle passes upward when the levator is sutured first. It passes downward when the orbicularis oculi is sutured first.
position. This incision can be lowered once the preaponeurotic compartment is identified. While the septum is tented up with a retractor, a small stab incision is made (Fig. 8). When the incision is made in the correct location, an empty space with loose areolar tissue is encountered (Fig. 9). Next, the orbital septum is incised medially and laterally while maintaining a tight orbital septum and continually viewing the deep, loose areolar tissue (Fig. 10). One blade of tenotomy scissors is inserted into the space under the septum for the septal incision. Once the orbital septum is completely divided, the preaponeurotic fat and the inferior portion of the levator aponeurosis are clearly identified. In some instances, the tissue plane is not clearly developed and positive conformation
of the orbital septum and the levator aponeurosis is necessary. The patient is asked to open the eyes while the upper skin-muscle flap is retracted. The orbital septum remains still or shows only minor excursion during this maneuver. The levator aponeurosis exhibits a distinct contraction pattern in the superior and posterior direction along the curvature of the orbit. If the surgeon grasps the tissue with a pair of forceps and asks the patient to open their eyes, the eyelid moves up without restriction when the orbital septum is grasped. If, however, the levator aponeurosis is grasped, the patient is not able freely to open the eyes. The preaponeurotic fat is contained within a thin, transparent, filmy membrane. With more experience, the levator aponeurosis can be adequately
Fig. 14. (A) The levator aponeurosis is distinctive in the lateral aspect. (B) The needle passes through the muscle cuff laterally. The knot should always be deeply buried.
321
322
Park & Park
Fig. 15. (A) The needle passes through the medial muscle cuff. (B) The levator aponeurosis is deep and poorly defined in the medial compartment. A thick bite through the fibrofatty tissue is necessary medially.
exposed without exposure of the preaponeurotic fat within this membrane (Fig. 11). Full and adequate exposure of the entire levator aponeurosis is necessary for successful fixation. At this stage, a strip of the pretarsal orbicularis oculi muscle is visualized beyond the lower skin incision margin (Fig. 12). This muscle strip is gently grasped with fine-tip tissue forceps. A 6-0 or 70 clear nylon suture is passed through the muscle from the under surface closest to the skin margin, taking care not to traverse through the skin (Fig. 13A). Although the skin is not penetrated with the needle, incorporating the dermis at the edge of the skin allows for more tightening of the pretarsal skin. The distal portion of the levator aponeurosis is then gently grasped with forceps. The needle passes through this folded levator aponeurosis (Fig. 13B). The suture is tightened just enough to approximate the muscle and levator aponeurosis without
strangulation of the tissues. The knot should be buried in the deep tissue plane. The fixation point in the levator aponeurosis determines the tightness of the pretarsal skin and the height of the supratarsal crease. This fixation technique may raise the height of the tarsal margin resulting in a wider palpebral fissure. The eyes often appear larger following this procedure. The author’s approach is to tighten the pretarsal skin to the point where the upper eyelashes remain in its normal direction or barely rise forward. Asian eyelashes tend to run in a slightly downward direction, unlike white eyelashes, which run in a horizontal or slightly upward plane. One may choose to create a slight eversion of the tarsus when the suturing is complete. This maneuver, however, may result in a permanent show of the red tarsal margin. Even though in long-term follow-up this may result in a tighter pretarsal skin, many Asian patients do not appreciate the initial results.
Fig. 16. (A) The long-term scar is barely visible. (B) Marking demonstrates the old scar.
Double-Eyelid Operation
Fig. 17. (A) Preoperative view. (B) Inner-type double fold. Pretarsal skin is tight and crispy.
The first suture is placed in the midpupillary line. The author’s preference is to expose levator aponeurosis bilaterally and place the midpupillary sutures simultaneously. The patient is then asked to open the eyes to compare the initial results. This suture is most important in obtaining symmetry between the eyes. The second suture is placed near the lateral end of the incision. Ideally, the fixation should be made at the lateral end of the incision (Fig. 14). The end point of the incision is usually over the lateral orbital rim, however, where the levator aponeurosis is not available. Fixation to the orbital periosteum does not maintain the crease long term. The fixation point usually lies about 1 cm medial to the lateral end where the levator aponeurosis joins the lateral canthal ligament. This portion, called a lateral horn, is located quite deeply, and requires a deeper dissection to reach the aponeurosis. The levator aponeurosis is well developed and well defined in this area.
A vessel crossing the fat compartment in this area is often encountered [8]. If this vessel is accidentally disrupted, a small hematoma can develop quickly in the levator aponeurosis and the muscle. A hematoma in the levator aponeurosis often causes temporary ptosis posing difficulty in the assessment of symmetry. The pretarsal orbicularis oculi muscle is then sutured to the levator aponeurosis in a similar fashion. The levator aponeurosis in the medial canthal area is rather flimsy and may appear to be missing or may blend in with the fatty fibrous tissue. The dissection plane is often deeper in this area. Unless the aponeurosis is easily identified, the orbicularis oculi muscle can be fixed to the fibrofatty tissue instead of the aponeurosis, avoiding encountering potentially disastrous bleeding from several prominent vessels in the fibrofatty tissue. In these instances, a bigger bite can be taken through the fibrofatty tissue at the higher location to
Fig. 18. (A) Preoperative view with parallel crease and Park Z-epicanthoplasty marking. (B) Postoperative view of parallel double-eyelid fold and open medial canthal area.
323
324
Park & Park
Fig. 19. (A) Preoperative view. (B) Postoperative view.
compensate for the lack of traction by the levator muscle. This suture is placed as medially as possible (Fig. 15). Patients often complain of inadequate pretarsal show and indistinct double folds in the medial aspect. If the fixation is not tight, the fold may droop toward the lid margin, creating multiple fine wrinkles in the pretarsal skin medially. When the pretarsal orbicularis oculi muscle–levator aponeurosis fixation is complete, the lower skin incision is almost in complete approximation with the upper incision without the use of skin sutures; scarring is minimized (Fig. 16). The skin incision is closed with either 6-0 fast absorbing gut or 6-0 black nylon in a continuous subcuticular fashion.
Recovery The patient is taken to the recovery room and placed in the semireclining position. Moist 4 4 gauze is
placed over the eyelids followed by an ice pack. Surgical gloves or self-sealing plastic bags filled with ice cubes make adequate ice packs. A surgeon’s mask can be tied around the head or looped around the ears of the patient to hold the ice packs in place. The patient is then required to rest for 30 to 60 minutes before discharge. If the patient complains of pain toward the end of the procedure, an additional narcotic tablet is generally sufficient to control the pain. Postoperatively, only several additional dosages of pain medications are necessary. Antibiotics are administered for 2 days following the surgery. The patient is given instructions to apply ice packs in 30-minute intervals on and off for the first 2 days. The patient is allowed to see and ambulate as needed following discharge. The first postoperative visit is recommended on the seventh postoperative day. Vigorous physical activities, such as heavy weight lifting, can be resumed after 2 weeks. Skin thickness, extent of surgery, and patient age
Fig. 20. (A) Redundant upper eyelid skin and compensatory high eyebrow position. (B) Postoperative view shows lower brow position and double-eyelid fold.
Double-Eyelid Operation
Fig. 21. (A) Single eyelid with type II epicanthal fold. (B) Postoperative view.
determines the degree of postoperative edema. There is generally less edema in patients with thinner eyelid skin. Older patients can have prolonged edema, lasting 6 months to 1 year. Younger patients may look quite natural within 2 weeks. The patient may return to work with shaded glasses during the first week of surgery. Patients who wear contact lenses may be advised to wear regular glasses to camouflage the unnatural appearance during the recovery period.
Complications Ecchymosis is common following conventional eyelid surgery. The use of laser or fine-tipped cautery reduces the chances of ecchymosis formation.
Fig. 22. (A) Preoperative view. (B) Prolonged and sometime permanent puffiness of the double fold is typical for the older Asian patients.
Infection and hematoma formation are rare complications. Excessive stretching of the pretarsal skin may cause an unsightly show of the red tarsal margin or may result in dry eyes. Lagophthalmos is rare because the eyelid skin is either not removed in most cases or is removed conservatively. Ptosis results if the levator aponeurosis is partially or completely severed during the procedure. It is somewhat more common in the medial one third of the upper eyelid. When this occurs, a portion of the superomedial aspect of the pupil is covered resulting in partial obstruction of the visual field and creation of an asymmetric palpebral fissure. Temporary ptosis caused by diffusion of local anesthetics into the levator muscle or development of a hematoma in the levator muscle is not uncommon. This, however, resolves within days to weeks following surgery. If the suture material migrates to the surface, caused by either a long tail of suture or from thinness of the covering skin, it can result in redness or nodule, cyst, or pustule formation. This resolves quickly with the removal of the offending suture. If the suture migrates internally, it can lead to corneal or conjunctival irritation. Cosmetic complications include asymmetric folds, poorly defined folds, incomplete
Fig. 23. Extra crease formation following excessive preaponeurotic fat removal.
325
326
Park & Park
Excessive removal of fat in the Asian eyelid also results in unsightly deep folds or a sunken appearance. This creates eyelids that are neither Asian nor white in appearance. Relapse is another condition that is seen frequently. Inadequate identification of the levator aponeurosis or improper suturing of the pretarsal muscle to the orbital septum or to the orbital fat may cause relapse. To prevent disruption of the fixation and potential relapse, the patient should be discouraged from rubbing or applying pressure to their eyes during the early stages of healing.
Case review Figs. 17–24 illustrate a case review.
References Fig. 24. (A) Nonincisional suture technique. (B) Orbicularis oculi-levator aponeurosis fixation technique.
supratarsal crease formation, wide scarring, keloid formation, and so forth. Asymmetry, one of the most common complications, can be prevented by precision in the design and execution of the procedure. It is also important to stress to the patient that there is always some degree of asymmetry. One or more extra creases may form in the orbital portion of the upper eyelid skin above the doubleeyelid fold if there is excessive removal of the orbital fat. This phenomenon is unique in Asian eyelids because of the inherent thickness of the skin and muscle [7,9]. If there is a lack of support from insufficient underlying fat, the overlying skin and muscle blanket folds at the weak point forming a crease or multiple creases. Unlike thin and soft tissue, thick and rigid tissue does not have the ability to conform to the underlying tissue and glide with fine evenly distributed wrinkles. When fat tissue is removed, the skin tends to dimple rather than spread the redundancy evenly.
[1] Marcos TD, Anderson RL. Oriental eyelids: an anatomic study. Arch Ophthalmol 1984;102: 1232–5. [2] Collins JRO, Beard C, Wood I. Experimental and clinical data on the insertion of the levator palpabra superioris muscle. Am J Ophthalmol 1978;85: 742–801. [3] Sayoc BT. Surgery of the oriental eyelid. Clin Plast Surg 1974;1(1):157–70. [4] Park JI. Orbicularis-levator fixation in double eyelid operation. Arch Facial Plast Surg 1999;1:90–5. [5] Park JI. Orbicularis-levator fixation technique. In: Park JI, editor. Asian facial cosmetic surgery. Philadelphia: Saunders Elsevier; 2006. p. 49–59. [6] Matsunaga RS. Westernization of the Asian eyelid. Arch Otolaryngol 1985;111:149. [7] Liu D, Hsu WM. Oriental eyelids: anatomic difference and surgical consideration. Ophthal Plast Reconstr Surg 1986;2(2):59–64. [8] Kim BG, Youn DY, Yoon ES, et al. Unexpected bleeding caused by arterial variation inferolateral to levator palpabrae. Aesthetic Plast Surg 2003; 27:123–5. [9] Lee Y, Hwang K. Skin thickness of Korean adults. Surg Radiol Anat 2002;24:183–9.