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Small-incision orbicularis–levator fixation technique: A modified double-eyelid blepharoplasty for treating trichiasis in young Asian patients
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1138e1144
Small-incision orbiculariselevator fixation technique: A modified double-eyelid blepharoplasty for treating trichiasis in young Asian patients Y.L. Bi*, Q. Zhou, X.S. Hu, W. Xu Division of Ophthalmic Plastic Surgery, Department of Ophthalmology, Tongji Hospital, Affiliated to Tongji University School of Medicine, 389 Xin Cun Road, Shanghai 200065, People’s Republic of China Received 29 August 2010; accepted 1 April 2011
KEYWORDS Double-eyelid blepharoplasty; Trichiasis; Young Asians; Small incision; Puffy eyelid
Summary Upper-eyelid trichiasis often occurs with a single puffy eyelid or shallow eyelid crease in young Asian patients. This study presents a novel modified trichiasis correction method to simultaneously treat trichiasis and create a natural eyelid crease. It combines the modified small-incision debulking procedure and the orbiculariselevator fixation technique. The eyelash lift angle (LA), body curl angle (BCA) and end curl angle (ECA) were quantitatively analysed. A total of 90 patients (152 trichiasis eyelids) were followed up for approximately 22 months. The LA changed from 24.32 9.21 e54.12 10.32 in the nasal section of the eyelid (section 1), from 21.03 11.34 e52.03 10.56 in the middle section of the eyelid (section 2) and from 23.31 8.12 e63.15 8.43 in the temporal section of the eyelid (section 3). All patients were satisfied with the eyelid-fold appearance. In conclusion, for young Asian patients with upper-eyelid trichiasis, the small-incision orbicularis-levator fixation technique is able to acquire a stable up-curved position of the eyelashes and satisfactory aesthetic results. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Upper-eyelid trichiasis and eyelashes’ downward growth are often associated with functional and cosmetic problems. The abnormally positioned eyelashes often touch the cornea or conjunctiva when looking up or even when looking forward. Conventionally, causes of upper-eyelid trichiasis have been categorised as follows: (1) infectious,
* Corresponding author. Tel.: þ86 21 66111464. E-mail address: [email protected] (Y.L. Bi).
such as with trachoma and herpes zoster infection; (2) auto-immune and inflammatory, such as with ocular cicatricial pemphigoid, StevenseJohnson syndrome or chronic blepharitis; (3) traumatic, such as with thermal or chemical burns; (4) iatrogenic, such as after enucleation with insufficient orbital volume refilling or inappropriate lid margin surgery; and (5) involutional upper-eyelid entropion, which is often found in Asian population.1,2 Clinically, another type of trichiasis is often found in young Asian patients with a normal eyelid margin and tarsal
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.04.003
Small-incision orbiculariselevator fixation technique Table 1
1139
Patient characteristics.
Patient no./gender /age
Trichiasis Side (B/R/L)
Trichiasis eyelid no.
Medial epicanthal fold (%)
TCS beforehand (%)
Operation side
Levator function (mm)
28/F/16e22 years 22/M/16e22 years 30/F/2327 years 10/M/2327 years
18/8/2 15/6/1 21/6/3 8/2/0
46 37 51 18
71.4% (20/28) 68.2%(15/22) 66.7% (20/30) 60% (6/10)
3.6% (1/28) 0% (0/22) 6.7% (2/30) 0% (0/10)
B B B B
13.5 14.1 13.8 14.9
2.4 2.5 2.2 2.5
follow-up (months)
Trichiasis recurrence
12e14 13e15 12e20 13e16
No 1/R No 2/R
M: male; F: female; B: bilateral; R: right; L:left; TCS: trichiasis correction surgery.
plate position, which gradually becomes severe with ageing. Different from trichiasis secondary to eyelid diseases,3 which is seldom found in this group of patients, it can be termed non-entropion trachiasis.4 When using a conventional treatment method, a long skin incision, orbicularis oculi muscle excision and, sometimes, wedge tarsal resection may be performed.5 With the consideration that the tarsus and lid margin positions were normal, in this study, we applied a novel, alternative method combining the modified small-incision debulking procedure and firm orbicularis-levator aponeurosis fixation technique to form a solid upper-eyelid crease and with a natural doubleeyelid appearance. The aim was to achieve long-lasting elevation of the angle of the eyelashes as well as take aesthetic aspects into consideration.
Materials and methods Patients A retrospective study was conducted on 90 cases (152 trichiasis eyelids) that consecutively presented to our department from 1 June2006, to 1 June2008. For the purpose of symmetry, both eyes were surgically treated and the same method was used for all patients. The ages of the patients ranged from 16 to 27 years (average 23.4 years). Patient demographics were recorded and are shown in Table 1. All patients exhibited trichiasis for more than one-fourth of the upper-eyelid length, evaluated by slitlamp microscope examination. The criteria for inclusion were that patients had relatively tight upper-eyelid skin and were young Asians. Patients with trachomatous trichiasis, obviously redundant skin, week levator function,
Table 2
after t-value P-value
Surgical procedure The highest intended crease point was usually set 5e7 mm above the eyelid margin. After injection with 2% lidocaine containing 1:100,000 epinephrine into the superficial intra-orbicularis oculi muscle, three 2-mm long skin incisions were created using a no. 11 blade. Through the small-incisions, the orbicularis oculi muscle was dissected with small ophthalmic scissors in a spreading manner along two layers. The first layer was under the superficial orbicularis oculi muscle and the second layer was under the deep orbicularis oculi muscle. The dissected area was between 1 mm above the lid margin and 1 mm above the marked intended crease line (Figure 1(A)). An integral strip of deep orbicularis muscle was then dissected and, in turn, pulled out from the small skin incisions, and then was resected (Figure 2(A) and (B)). During dissection, to avoid damaging the levator palpebral aponeurosis, the eyes were always looking down to spread the aponeurosis and a tensile force was always kept when pulling the strip of orbicularis out of the skin incisions. In patients with puffy eyelids, one more tunnel dissection was needed to remove the thick pre-tarsal or preseptal fat pads. Through the centre and temporal small-incisions, the orbital septum was locally opened and resected, the orbital fat was selectively removed and the underlying lavator palpebral aponeurosis was then exposed (Figure 2(B)). Three interrupted sutures, using 6/0 nylon, were buried to
Eyelash’ angles changes 12 months after surgery (degree) (n Z 152). LA
Before
within 3 months after previous upper-eyelid surgery, trichiasis with severe symblepharon or severe ocular surface disease and recurrent trichiasis secondary to a failed terminal tarsal rotation procedure, were excluded from the study.
BCA
ECA
S1
S2
S3
S1
S2
S3
S1
S2
S3
24.32 9.21 54.12 10.32 4.63 P < 0.01
21.03 11.34 52.03 10.56 5.85 P < 0.01
23.31 8.12 63.15 8.43 5.89 P < 0.01
12.28 5.72 14.96 8.24 1.46 0.15
12.05 6.57 15.80 5.11 1.21 0.23
11.05 6.48 13.37 5.74 1.21 0.24
26.41 14.44 32.75 18.59 1.47 0.17
27.02 18.76 33.4 12.58 1.01 0.32
26.35 17.45 33.33 16.35 1.73 0.10
P-value was determined using Student’s t-test. S: sections of eyelashes; Before: before surgery; After: 12 months after surgery.
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Figure 1 Details of the procedure. (A) Schematic designing diagram demonstrating the 3 skin incisions, the first incision is on the vertical line through the center between nasal corneal margin and medial canthus; the second incision is on the vertical line through the center of pupil; the third incision is on the vertical line through 2e5 mm outside lateral corneal margin. The solid curved line demonstrates the desired eyelid crease, the dotted line (1 mm above the eyelid margin and 1 mm above the solid line) circles the area that the deep orbicularis and fat pads should be trimmed. (B) After an integral strip of deep orbicularis was resected and the orbital fat was released, three fixation sutures were buried under the superficial orbicularis.
fix the superficial orbicularis muscle and the aponeurosis (Figure 1(B)). The height and tightness of the fixation determined the up-curved angle of the corrected eyelashes. The nasal, centre and temporal sutures helped to elevate the eyelashes of sections 1, 2 and 3, respectively, and each had their own function for eyelid crease formation. The centre fixation was mainly responsible for
the double-eyelid formation, the temporal fixation determined the height and length of the temporal crease and the nasal fixation helped to form a smooth crease transition in the inner canthus. The three small skin incisions were closed spontaneously without additional sutures (Figure 2(C) and (D)). The follow-up period was 14e30 months (average 22.3 7.5 months).
Small-incision orbiculariselevator fixation technique
1141
Eyelash angle evaluation The technique of using photographs for comparison of eyelash angles was established in a previous study.6 Several modifications were made in this study. The upper eyelashes were divided into three sections (Figure 3(A) and (B)). Photographs were taken using a high-resolution camera from a lateral view at an angle of 67 to the frontal axis (the head tilted temporally to make the lid margin of section 1 horizontal), at an angle of 113 to the frontal axis (the head was upright to make the lid margin of section 2 horizontal) and at an angle of 159 to the frontal axis (the head tilted medially to make the lid margin of section 3 horizontal). ImageJ 1.38X software (National Institutes of Health, USA) was used to measure the eyelash lift angle (LA), body curl angle (BCA) and end curl angle (ECA) (Figure 3(C) and (G)).
Statistical analysis A paired t-test was used to analyse changes of LA, BCA and ECA. P < 0.01 was considered to be statistically significant.
Results Twelve months after surgery, the LAs of the three sections were all increased significantly (P < 0.01), but the BCAs and ECAs were unchanged (Table 2). Shallow creases combined with trichiasis recurrence happened in three eyelids of three patients at 3e6 months after surgery. Stable and long-lasting creases were formed in all other patients (Figures 3 and 4). There were no severe postoperative complications, such as obvious asymmetry, failure of crease formation, sunken or triple eyelids, lid retraction, blepharoptosis, hypertrophic scarring or persistent oedema. At the end of follow-up, all patients were satisfied with the therapeutic and cosmetic results.
Discussion
Figure 2 Details of the procedure. (A) This patient had a moderate upper-eyelid trichiasis with puffy single eyelid. (B) An integral strip of deep orbicularis was resected, the orbital fat was released through the medial and temporal incisions. (C) After sutural fixation, the superior lamellar of the pre-tarsal tissue was spread out and the inward curved eyelashes were lift-up. (D) The small skin incisions were closed well spontaneously without additional removable sutures.
Approximately 50% of eyelids in Asians lack the adhesion of pre-tarsal skin to the tarsus.7 With non-incisional or even incisional double-eyelid surgery, a 10e11-mm crease height is often reduced to 4e5 mm when the eyelids are raised.8 Non-entropion trichiasis in young Asian patients occurs often with a single upper-eyelid or shallow lid crease, and the pre-tarsal orbicularis oculi muscle is often loose and hypertrophic.3,4,7,9 With ageing, blinking and gravity will exacerbate a further downward movement of the orbicularis to the lid margin, and will aggravate the inward angle of the eyelashes. In the case of non-entropion trichiasis, if only a non-incisional suture buried technique is used, the sutures could not resist thousands of blinkings during a day, and usually leads to their early loosening, which causes a shallow crease and/or trichiasis recurrence.8,10,11 Conversely, the incisional techniques or the technique combined with tarsal-wedge-resection procedure have characteristics of long-lasting eyelid creases and low rate of trichiasis recurrence, but usually with a permanent skin scar formation and sometimes inevitable meibomian gland
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Y.L. Bi et al.
Figure 3 Eyelash’ angles changes in a 21-year-old trichiasis patient. (A) frontal view before surgery, the eyelashes were all downward growing. (B) Three sections were equally divided. (C) S3 of the right eye, showing obviously trichiasis. (D) Immediately after surgery, three small-incisions were closed well. (E) Twenty months after surgery, a natural double-eyelid was presented. (F) With only slight scars. (G) The eyelashes of S3 were up-curved and with good aesthetic appearance. (S: section; LA: lift angle; BCA: body curl angle; ECA: End curl angle).
destruction.1e3,5,12 Furthermore, some of these techniques will inevitably evert the eyelid margin, which is usually unnecessary for this group of patients. We previously reported a technique,13 by which the anterior lamellar of the upper-eyelid was shifted upward to move the inward curved eyelashes away from the globe. However, with this method, skin scar formation could not be avoided, and,
often, a long time was needed for lid margin reepithelisation. The position, angle and length of the eyelashes have an intimate relation to face aesthetics.6 In this study, we aimed to achieve a long-lasting correction of trichiasis while considering improving aesthetic results. Park reported and reviewed an orbicularis-levator fixation technique for
Small-incision orbiculariselevator fixation technique
1143
Figure 4 (A) Left eyelid trichiasis of a 22-year-old girl with failed previously non-incision suture buried method. (B) S1 before surgery (eyelashes touch globe). (C) Fourteen months after surgery, with a natural double eyelid. (D) With only slight scars. (E) S1 after surgery with no trichiasis.
creating a solidly fixed, pre-tarsal skin outstretched doubleeyelid.8,11 On the basis of his theory, in our method, after fully debulking deep orbicularis, suborbicularis fat pad and orbital fat, three interrupted sutures were buried to make a solid binding between the superficial orbicularis muscle and the levator aponeurosis. As one buried suture has a 3-mm length of tissue adhesion, three sutures could have an approximately 9 mm length of orbiculariselevator adhesion. The created iatrogenic wound surface benefits the adhesion of the superficial orbicularis to the pre-tarsal surface. This adhesion is firm enough to resist blinkinginduced strain and helps to keep a stable crease. During surgery, although the two-layer dissection inevitably leads to a large wound surface, the tight ligations of the three buried sutures ensure no active bleeding occurs. As for the
skin and the superficial orbicularis oculi muscle move as a unit.8,11 After orbiculariselevator fixation, the LAs of the three eyelashes’ sections were dramatically increased and the eyelashes’ bottoms were exposed, which acquires a much longer and aesthetically pleasing visual effect. A compensatory intensive overcorrection, which is often used in other trichiasis correction methods, is not advocated with our method because the orbicularis oculi muscle is tightly fixed to the levator aponeurosis but not to the dermis. Several authors have reported small-incision doubleeyelid techniques; unlike Yang and Cho’s single centralincision method,14,15 we used three interrupted skin incisions, and as the length of each incision was small and the buried sutures produced inward traction, no additional removable skin stitches were necessary. It is asserted that the
1144 interrupted small skin scars formed postoperatively were not apparently visible. The essential difference from Lees16 debulking procedure is that the orbicularis was not locally resected, but was trimmed to be a certain length and height in our method because we believe that a thinner pre-tarsal area could acquire a more natural and stable double-eyelid appearance, especially for patients with trichiasis. Megumi also incorporated debulking of orbital fat in his suture technique to prevent the disappearance of the crease; however, this step was performed through the conjunctival route.17 In conclusion, this is the first report on using small skin incisions combined with an orbiculariselevator fixation technique to form a double-eyelid in young Asian trichiasis patients and it is also the first method that considers both therapeutic and cosmetic effects. This technique gives a durable, natural crease, and can be applied to patients with puffy eyelids. This method possesses the merits of both incisional and non-incisional double-eyelid techniques, while avoiding some of their disadvantages.
Conflict of interest/funding
Y.L. Bi et al.
5. 6.
7. 8. 9. 10.
11.
12.
13.
None.
References
14. 15.
1. Ferreira IS, Bernardes TF, Bonfioli AA, et al. Trichiasis Semin Ophthalmol 2010;25:66e71. 2. Jie Y, Xu L, Ma K, et al. Prevalence of trachoma in the adult Chinese population. The Beijing eye study. Eye (Lond) 2008;22: 790e1. 3. Lee TE, Lee JM, Lee H, et al. Lash ptosis and associated factors in Asians. Ann Plast Surg 2010;65:407e10. 4. Yan-long Bi, Qi Zhou, Han-min Wang, et al. Clinical effects of intra-lamellar orbicularis dissecting micro-traumatic double
16.
17.
eyelid surgery for the treatment of adolescent upper eyelid trichiasis. Chin J Med Aesth Cosmet 2009;12:391e4. Urinovsky E, Chen V, Cahane M, et al. Treatment for trichiasis. Plast Reconstr Surg 1993;92:767e8. Na JI, Kwon OS, Kim BJ, et al. Ethnic characteristics of eyelashes: a comparative analysis in Asian and Caucasian females. Br J Dermatol 2006;155(6):1170e6. Ichinose A, Tahara S. Extended preseptal fat resection in Asian blepharoplasty. Ann Plast Surg 2008;60:121e6. Park JI. Orbicularis-levator fixation in double-eyelid operation. Arch Facial Plast Surg 1999;1:90e5. Choo C. Correction of oriental epiblepharon by anterior lamellar reposition. Eye (Lond) 1996;10:545e7. Homma K, Mutou Y, Mutou H, et al. Intradermal stitch blepharoplasty for orientals: does It disappear? Aesthetic Plast Surg 2000;24:289e91. Park JI, Park MS. Double-eyelid operation: orbicularis oculilevator aponeurosis fixation technique. Facial Plast Surg Clin North Am 2007;15:315e26. Kakizaki H, Selva D, Leibovitch I. Cilial entropion: surgical outcome with a new modification of the Hotz procedure. Ophthalmology 2009;116:2224e9. Bi YL, Zhou Q, Xu W, et al. Anterior lamellar repositioning with complete lid split: a modified method for treating upper eyelids trichiasis in Asian patients. J Plast Reconstr Aesthet Surg 2009;62:1395e402. Yang SY. Oriental double eyelid: a limited-incision technique. Ann Plast Surg 2001;46:364e8. Cho BC, Byun JS. New technique combined with suture and incision method for creating a more physiologically natural double-eyelid. Plast Reconstr Surg 2010;125:324e31. Lee YJ, Baek RM, Chung WJ. Nonincisional blepharoplasty using the debulking method. Aesthetic Plast Surg 2003;27: 434e7. Megumi Y. Double eyelid procedure by removal of transconjunctival orbital fat and buried sutures combined with sling technique to avoid wounding the eyelid. Aesthetic Plast Surg 1997;21:254e7.
Small-incision orbiculariselevator fixation technique: A modified double-eyelid blepharoplasty for treating trichiasis in young Asian patients Y.L. Bi*, Q. Zhou, X.S. Hu, W. Xu Division of Ophthalmic Plastic Surgery, Department of Ophthalmology, Tongji Hospital, Affiliated to Tongji University School of Medicine, 389 Xin Cun Road, Shanghai 200065, People’s Republic of China Received 29 August 2010; accepted 1 April 2011
KEYWORDS Double-eyelid blepharoplasty; Trichiasis; Young Asians; Small incision; Puffy eyelid
Summary Upper-eyelid trichiasis often occurs with a single puffy eyelid or shallow eyelid crease in young Asian patients. This study presents a novel modified trichiasis correction method to simultaneously treat trichiasis and create a natural eyelid crease. It combines the modified small-incision debulking procedure and the orbiculariselevator fixation technique. The eyelash lift angle (LA), body curl angle (BCA) and end curl angle (ECA) were quantitatively analysed. A total of 90 patients (152 trichiasis eyelids) were followed up for approximately 22 months. The LA changed from 24.32 9.21 e54.12 10.32 in the nasal section of the eyelid (section 1), from 21.03 11.34 e52.03 10.56 in the middle section of the eyelid (section 2) and from 23.31 8.12 e63.15 8.43 in the temporal section of the eyelid (section 3). All patients were satisfied with the eyelid-fold appearance. In conclusion, for young Asian patients with upper-eyelid trichiasis, the small-incision orbicularis-levator fixation technique is able to acquire a stable up-curved position of the eyelashes and satisfactory aesthetic results. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Upper-eyelid trichiasis and eyelashes’ downward growth are often associated with functional and cosmetic problems. The abnormally positioned eyelashes often touch the cornea or conjunctiva when looking up or even when looking forward. Conventionally, causes of upper-eyelid trichiasis have been categorised as follows: (1) infectious,
* Corresponding author. Tel.: þ86 21 66111464. E-mail address: [email protected] (Y.L. Bi).
such as with trachoma and herpes zoster infection; (2) auto-immune and inflammatory, such as with ocular cicatricial pemphigoid, StevenseJohnson syndrome or chronic blepharitis; (3) traumatic, such as with thermal or chemical burns; (4) iatrogenic, such as after enucleation with insufficient orbital volume refilling or inappropriate lid margin surgery; and (5) involutional upper-eyelid entropion, which is often found in Asian population.1,2 Clinically, another type of trichiasis is often found in young Asian patients with a normal eyelid margin and tarsal
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.04.003
Small-incision orbiculariselevator fixation technique Table 1
1139
Patient characteristics.
Patient no./gender /age
Trichiasis Side (B/R/L)
Trichiasis eyelid no.
Medial epicanthal fold (%)
TCS beforehand (%)
Operation side
Levator function (mm)
28/F/16e22 years 22/M/16e22 years 30/F/2327 years 10/M/2327 years
18/8/2 15/6/1 21/6/3 8/2/0
46 37 51 18
71.4% (20/28) 68.2%(15/22) 66.7% (20/30) 60% (6/10)
3.6% (1/28) 0% (0/22) 6.7% (2/30) 0% (0/10)
B B B B
13.5 14.1 13.8 14.9
2.4 2.5 2.2 2.5
follow-up (months)
Trichiasis recurrence
12e14 13e15 12e20 13e16
No 1/R No 2/R
M: male; F: female; B: bilateral; R: right; L:left; TCS: trichiasis correction surgery.
plate position, which gradually becomes severe with ageing. Different from trichiasis secondary to eyelid diseases,3 which is seldom found in this group of patients, it can be termed non-entropion trachiasis.4 When using a conventional treatment method, a long skin incision, orbicularis oculi muscle excision and, sometimes, wedge tarsal resection may be performed.5 With the consideration that the tarsus and lid margin positions were normal, in this study, we applied a novel, alternative method combining the modified small-incision debulking procedure and firm orbicularis-levator aponeurosis fixation technique to form a solid upper-eyelid crease and with a natural doubleeyelid appearance. The aim was to achieve long-lasting elevation of the angle of the eyelashes as well as take aesthetic aspects into consideration.
Materials and methods Patients A retrospective study was conducted on 90 cases (152 trichiasis eyelids) that consecutively presented to our department from 1 June2006, to 1 June2008. For the purpose of symmetry, both eyes were surgically treated and the same method was used for all patients. The ages of the patients ranged from 16 to 27 years (average 23.4 years). Patient demographics were recorded and are shown in Table 1. All patients exhibited trichiasis for more than one-fourth of the upper-eyelid length, evaluated by slitlamp microscope examination. The criteria for inclusion were that patients had relatively tight upper-eyelid skin and were young Asians. Patients with trachomatous trichiasis, obviously redundant skin, week levator function,
Table 2
after t-value P-value
Surgical procedure The highest intended crease point was usually set 5e7 mm above the eyelid margin. After injection with 2% lidocaine containing 1:100,000 epinephrine into the superficial intra-orbicularis oculi muscle, three 2-mm long skin incisions were created using a no. 11 blade. Through the small-incisions, the orbicularis oculi muscle was dissected with small ophthalmic scissors in a spreading manner along two layers. The first layer was under the superficial orbicularis oculi muscle and the second layer was under the deep orbicularis oculi muscle. The dissected area was between 1 mm above the lid margin and 1 mm above the marked intended crease line (Figure 1(A)). An integral strip of deep orbicularis muscle was then dissected and, in turn, pulled out from the small skin incisions, and then was resected (Figure 2(A) and (B)). During dissection, to avoid damaging the levator palpebral aponeurosis, the eyes were always looking down to spread the aponeurosis and a tensile force was always kept when pulling the strip of orbicularis out of the skin incisions. In patients with puffy eyelids, one more tunnel dissection was needed to remove the thick pre-tarsal or preseptal fat pads. Through the centre and temporal small-incisions, the orbital septum was locally opened and resected, the orbital fat was selectively removed and the underlying lavator palpebral aponeurosis was then exposed (Figure 2(B)). Three interrupted sutures, using 6/0 nylon, were buried to
Eyelash’ angles changes 12 months after surgery (degree) (n Z 152). LA
Before
within 3 months after previous upper-eyelid surgery, trichiasis with severe symblepharon or severe ocular surface disease and recurrent trichiasis secondary to a failed terminal tarsal rotation procedure, were excluded from the study.
BCA
ECA
S1
S2
S3
S1
S2
S3
S1
S2
S3
24.32 9.21 54.12 10.32 4.63 P < 0.01
21.03 11.34 52.03 10.56 5.85 P < 0.01
23.31 8.12 63.15 8.43 5.89 P < 0.01
12.28 5.72 14.96 8.24 1.46 0.15
12.05 6.57 15.80 5.11 1.21 0.23
11.05 6.48 13.37 5.74 1.21 0.24
26.41 14.44 32.75 18.59 1.47 0.17
27.02 18.76 33.4 12.58 1.01 0.32
26.35 17.45 33.33 16.35 1.73 0.10
P-value was determined using Student’s t-test. S: sections of eyelashes; Before: before surgery; After: 12 months after surgery.
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Figure 1 Details of the procedure. (A) Schematic designing diagram demonstrating the 3 skin incisions, the first incision is on the vertical line through the center between nasal corneal margin and medial canthus; the second incision is on the vertical line through the center of pupil; the third incision is on the vertical line through 2e5 mm outside lateral corneal margin. The solid curved line demonstrates the desired eyelid crease, the dotted line (1 mm above the eyelid margin and 1 mm above the solid line) circles the area that the deep orbicularis and fat pads should be trimmed. (B) After an integral strip of deep orbicularis was resected and the orbital fat was released, three fixation sutures were buried under the superficial orbicularis.
fix the superficial orbicularis muscle and the aponeurosis (Figure 1(B)). The height and tightness of the fixation determined the up-curved angle of the corrected eyelashes. The nasal, centre and temporal sutures helped to elevate the eyelashes of sections 1, 2 and 3, respectively, and each had their own function for eyelid crease formation. The centre fixation was mainly responsible for
the double-eyelid formation, the temporal fixation determined the height and length of the temporal crease and the nasal fixation helped to form a smooth crease transition in the inner canthus. The three small skin incisions were closed spontaneously without additional sutures (Figure 2(C) and (D)). The follow-up period was 14e30 months (average 22.3 7.5 months).
Small-incision orbiculariselevator fixation technique
1141
Eyelash angle evaluation The technique of using photographs for comparison of eyelash angles was established in a previous study.6 Several modifications were made in this study. The upper eyelashes were divided into three sections (Figure 3(A) and (B)). Photographs were taken using a high-resolution camera from a lateral view at an angle of 67 to the frontal axis (the head tilted temporally to make the lid margin of section 1 horizontal), at an angle of 113 to the frontal axis (the head was upright to make the lid margin of section 2 horizontal) and at an angle of 159 to the frontal axis (the head tilted medially to make the lid margin of section 3 horizontal). ImageJ 1.38X software (National Institutes of Health, USA) was used to measure the eyelash lift angle (LA), body curl angle (BCA) and end curl angle (ECA) (Figure 3(C) and (G)).
Statistical analysis A paired t-test was used to analyse changes of LA, BCA and ECA. P < 0.01 was considered to be statistically significant.
Results Twelve months after surgery, the LAs of the three sections were all increased significantly (P < 0.01), but the BCAs and ECAs were unchanged (Table 2). Shallow creases combined with trichiasis recurrence happened in three eyelids of three patients at 3e6 months after surgery. Stable and long-lasting creases were formed in all other patients (Figures 3 and 4). There were no severe postoperative complications, such as obvious asymmetry, failure of crease formation, sunken or triple eyelids, lid retraction, blepharoptosis, hypertrophic scarring or persistent oedema. At the end of follow-up, all patients were satisfied with the therapeutic and cosmetic results.
Discussion
Figure 2 Details of the procedure. (A) This patient had a moderate upper-eyelid trichiasis with puffy single eyelid. (B) An integral strip of deep orbicularis was resected, the orbital fat was released through the medial and temporal incisions. (C) After sutural fixation, the superior lamellar of the pre-tarsal tissue was spread out and the inward curved eyelashes were lift-up. (D) The small skin incisions were closed well spontaneously without additional removable sutures.
Approximately 50% of eyelids in Asians lack the adhesion of pre-tarsal skin to the tarsus.7 With non-incisional or even incisional double-eyelid surgery, a 10e11-mm crease height is often reduced to 4e5 mm when the eyelids are raised.8 Non-entropion trichiasis in young Asian patients occurs often with a single upper-eyelid or shallow lid crease, and the pre-tarsal orbicularis oculi muscle is often loose and hypertrophic.3,4,7,9 With ageing, blinking and gravity will exacerbate a further downward movement of the orbicularis to the lid margin, and will aggravate the inward angle of the eyelashes. In the case of non-entropion trichiasis, if only a non-incisional suture buried technique is used, the sutures could not resist thousands of blinkings during a day, and usually leads to their early loosening, which causes a shallow crease and/or trichiasis recurrence.8,10,11 Conversely, the incisional techniques or the technique combined with tarsal-wedge-resection procedure have characteristics of long-lasting eyelid creases and low rate of trichiasis recurrence, but usually with a permanent skin scar formation and sometimes inevitable meibomian gland
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Y.L. Bi et al.
Figure 3 Eyelash’ angles changes in a 21-year-old trichiasis patient. (A) frontal view before surgery, the eyelashes were all downward growing. (B) Three sections were equally divided. (C) S3 of the right eye, showing obviously trichiasis. (D) Immediately after surgery, three small-incisions were closed well. (E) Twenty months after surgery, a natural double-eyelid was presented. (F) With only slight scars. (G) The eyelashes of S3 were up-curved and with good aesthetic appearance. (S: section; LA: lift angle; BCA: body curl angle; ECA: End curl angle).
destruction.1e3,5,12 Furthermore, some of these techniques will inevitably evert the eyelid margin, which is usually unnecessary for this group of patients. We previously reported a technique,13 by which the anterior lamellar of the upper-eyelid was shifted upward to move the inward curved eyelashes away from the globe. However, with this method, skin scar formation could not be avoided, and,
often, a long time was needed for lid margin reepithelisation. The position, angle and length of the eyelashes have an intimate relation to face aesthetics.6 In this study, we aimed to achieve a long-lasting correction of trichiasis while considering improving aesthetic results. Park reported and reviewed an orbicularis-levator fixation technique for
Small-incision orbiculariselevator fixation technique
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Figure 4 (A) Left eyelid trichiasis of a 22-year-old girl with failed previously non-incision suture buried method. (B) S1 before surgery (eyelashes touch globe). (C) Fourteen months after surgery, with a natural double eyelid. (D) With only slight scars. (E) S1 after surgery with no trichiasis.
creating a solidly fixed, pre-tarsal skin outstretched doubleeyelid.8,11 On the basis of his theory, in our method, after fully debulking deep orbicularis, suborbicularis fat pad and orbital fat, three interrupted sutures were buried to make a solid binding between the superficial orbicularis muscle and the levator aponeurosis. As one buried suture has a 3-mm length of tissue adhesion, three sutures could have an approximately 9 mm length of orbiculariselevator adhesion. The created iatrogenic wound surface benefits the adhesion of the superficial orbicularis to the pre-tarsal surface. This adhesion is firm enough to resist blinkinginduced strain and helps to keep a stable crease. During surgery, although the two-layer dissection inevitably leads to a large wound surface, the tight ligations of the three buried sutures ensure no active bleeding occurs. As for the
skin and the superficial orbicularis oculi muscle move as a unit.8,11 After orbiculariselevator fixation, the LAs of the three eyelashes’ sections were dramatically increased and the eyelashes’ bottoms were exposed, which acquires a much longer and aesthetically pleasing visual effect. A compensatory intensive overcorrection, which is often used in other trichiasis correction methods, is not advocated with our method because the orbicularis oculi muscle is tightly fixed to the levator aponeurosis but not to the dermis. Several authors have reported small-incision doubleeyelid techniques; unlike Yang and Cho’s single centralincision method,14,15 we used three interrupted skin incisions, and as the length of each incision was small and the buried sutures produced inward traction, no additional removable skin stitches were necessary. It is asserted that the
1144 interrupted small skin scars formed postoperatively were not apparently visible. The essential difference from Lees16 debulking procedure is that the orbicularis was not locally resected, but was trimmed to be a certain length and height in our method because we believe that a thinner pre-tarsal area could acquire a more natural and stable double-eyelid appearance, especially for patients with trichiasis. Megumi also incorporated debulking of orbital fat in his suture technique to prevent the disappearance of the crease; however, this step was performed through the conjunctival route.17 In conclusion, this is the first report on using small skin incisions combined with an orbiculariselevator fixation technique to form a double-eyelid in young Asian trichiasis patients and it is also the first method that considers both therapeutic and cosmetic effects. This technique gives a durable, natural crease, and can be applied to patients with puffy eyelids. This method possesses the merits of both incisional and non-incisional double-eyelid techniques, while avoiding some of their disadvantages.
Conflict of interest/funding
Y.L. Bi et al.
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References
14. 15.
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