Scanning electron microscopic study on double and single eyelids in Orientals

Upper blepharoplasty in Asian population: A novel technique based on functional zoning and dynamic reconstruction with anatomical structure

BACKGROUND

Double eyelid blepharoplasty is the most popular cosmetic operation in Asian population. Various surgical techniques have been developed in order to create dynamic eyelid folds with natural-looking in recent years, but postoperative complications like so-called sausage-like appearance have not been resolved completely.

AIMS

To create natural-looking dynamic folds, we propose a new method imitating the original anatomical structure of congenital double-eyelid.

PATIENTS AND METHODS

Eighty-six patients who underwent the double-eyelid surgery from June 1st, 2018 to October 31st, 2020 were included in this retrospective study, including 10 males and 76 females, aged 18-39 years (mean 27.4 ± 5.6 years). All the included patients received double eyelid surgery performed by the same senior doctor, using the pretarsal orbicularis oculi muscle-releasing technique. Patient Reported Outcome Measures questionnaires were administrated to assess the severity of scarring, pain, and asymmetry, as well as functional and appearance issues. Surgical outcome was assessed through objective and subjective evaluation forms (PROM and patient satisfaction rate).

RESULTS

Among the 86 patients, 5 were lost during the follow-up period. The absolute number of enrolled patients is 81. 91.36% of the enrolled patients reported minimal or non-visible scarring at the double eyelid incision. As to functional and appearance issues, the main problem were asymmetry (12.35%) and the narrowing of the supratarsal crease width (8.64%). No supratarsal depression and "sausage-like" appearance occurred in this study. 95.1% of patients reported either good or excellent outcome (mean score: 108 of 120) based on analysis of PROM results, and 96.3% of patients reported either high or very high satisfaction (mean score: 96 of 120) for the patient satisfaction assessment.

CONCLUSIONS

This new surgical method of double-eyelid blepharoplasty provides comparatively safe and effective results.

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach in Double-Eyelid Blepharoplasty Revision

BACKGROUND

Incisional double-eyelid blepharoplasty is the main surgical technique to obtain an artificial crease. Postoperative complications decrease patients' satisfaction, and patients with prominent depressed groove and persistent pretarsal swelling (sausage phenomenon) usually need revision surgery. To resolve the sausage phenomenon after blepharoplasty, we adopt Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach to create natural double eyelids.

METHODS

We included 68 patients in the study. The inclusion criteria for revision surgery were as follows: (1) pretarsal OOM remained after primary surgery, (2) prominent depressed surgical scar/groove and persistent pretarsal bulge (sausage phenomenon), (3) postsurgical abnormally wide crease. The surgical procedure involved releasing the pretarsal OOM, forming OFOOM-OOM flap, and OFOOM-OOM flap fixed with aponeurosis. Outcome observations were assessed using the FACE-Q questionnaire, and the follow-up period ranged from 6 to 36 months (mean=18 months).

RESULTS

The depressed groove and pretarsal bulge showed significant improvements, and FACE-Q scores of the 68 patients before surgery (mean scores=66) compared with those after surgery (mean scores=90) were significantly different (P<0.01). Four patients with palpebral fold asymmetry and two patients with shallow eyelids received revision surgery, and patients were satisfied with the secondary surgery effects. Six patients presented with unnatural curves of folds and revision surgery alleviated these situations.

CONCLUSIONS

Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach is an effective way to resolve the sausage phenomenon. The OFOOM-OOM flap is a reliable and flexible structure to create natural double eyelids.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Small-Incisional Double Eyelid Blepharoplasty: A Retrospective Study of Our Minimally Invasive Technique with Three Mini Incisions

BACKGROUND

Small-incisional double eyelid surgery has been increasingly performed these years and achieved good aesthetic results, but the techniques vary greatly between literatures. The authors reviewed the cases of three-small-incisional double eyelid surgery performed in the past three years and introduced their surgical technique in detail.

METHODS

A total of 87 patients receiving bilateral three-small-incisional double eyelid surgery were included in this retrospective study. The pretarsal folds were designed meticulously, along which three evenly distributed 2 mm-long incisions were made. A minimal amount of orbicularis oculi muscle and pretarsal soft tissue were removed to expose the pretarsal fascia for further fixation. An appropriate amount of orbital septal fat was removed through the lateral incision if required. The superficial orbicularis oculi muscle and dermis on the lower margin of the incision were fixed onto the pretarsal fascia with some underlying tarsus on the upper margin of the tarsus. The skin was closed by one stitch for each incision.

RESULTS

The average follow-up was 9.9 ± 5.2 months (range: 6-27 months). All the patients were satisfied with the result. None of them experienced loss of the pretarsal fold, bilateral asymmetry, scar hyperplasia, or persistent swelling after surgery.

CONCLUSIONS

Our three-small-incisional technique with minor soft tissue debulking offers a simple, safe, and reproducible approach to double eyelids. It can create a stable and natural-looking pretarsal fold with a short recovery period.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Principle and Mechanism of Double Eyelid Formation

Some of Asian eyelids have double fold and some do not. Many people tend to prefer double eyelid in aesthetic and functional reasons. Since the mechanism of double eyelid is bonding the eyelid skin to the eye-opening tissue, the principle of double eyelid surgery is also connecting the eyelid skin to levator component. Double eyelids are differentiated by their shape according to the height and curvature. The double eyelid surgery procedure is divided into incision method and nonincision method. And the incision method is subdivided into double fold line design, skin and oculi muscle incision or excision, pretarsal or preaponeurotic soft tissue excision, fixation of posterior lamella to anterior lamella, and skin suture. The nonincision method is to connect the posterior lamella and the anterior lamella as a thread only without an incision. A successful double eyelid surgery creates a fold well-balanced in height, curvature, and depth of the fold based on patient's preference. In this article, the author's own methods of performing surgery are described, with a step-by-step guide and surgical tips.

Small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique: A modified partial-incision double-eyelid blepharoplasty

BACKGROUND

The partial-incision double-eyelid surgery remains a popular esthetic procedure in Asia, most of the previous partial-incision double-eyelid operations involved resection of the pretarsal orbicular muscle, resulting in a depressed and firm eyelid crease. In order to create a more natural, dynamic, and durable double-eyelid crease with less visible scar and shorter postoperative recovery time, we describe a modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique for Chinese patients.

METHODS

A total of 132 patients who underwent bilateral modified partial-incision double-eyelid surgery were retrospectively reviewed. In this technique, three 2 mm incisions were designed, the orbicularis oculi muscle was preserved and conservatively dissected to expose the levator aponeurosis, and buried suture was used to fix the orbicularis oculi muscle to levator aponeurosis. The skin and orbicularis oculi muscle were then sutured together with the levator aponeurosis.

RESULTS

With a follow-up period of more than 6 months, most of the double eyelids were natural and dynamic, and the crease was stable. The majority of the swelling faded in 2 weeks and completely faded in the first month for most patients. The scars of the small incision became invisible after 3 months of recovery. One patient (0.8%) complained of bilateral fold disappearance. Asymmetries occurred in 4.5% (6 of 132) patients. 97.7% (129 of 132) patients were satisfied with the postoperative appearance. No severe complications were reported during the follow-up period.

CONCLUSION

The modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation double-eyelid blepharoplasty technique can create a more natural, dynamic, and durable double-eyelid crease with fast recovery and no visible scar or serious complications.

Mini-Incision Eyelidplasty in Single Eye to Correct Congenital Upper Eyelid Crease Asymmetry

OBJECTIVE

This study aims to evaluate the clinical effect of mini-incision double eyelidplasty in single eye for correcting congenital upper eyelid crease asymmetry.

METHODS

Mini-incision double eyelidplasty was performed on 24 patients in single eye to treat congenital upper eyelid crease asymmetry between May 2016 and September 2018. The postoperative surgical results were classified as "excellent," "fair," and "poor." The subjective satisfaction and incidence of complications were documented.

RESULTS

The mean patient age at the time of surgery was 24.6 ± 3.1 years (21-28 years), and the mean follow-up time was 15.4 ± 8.7 (12-34 months). All patients showed "excellent" surgical outcomes according to symmetry of upper eyelid creases. All patients are "very satisfied" with the cosmetic outcomes. There were no cases of recurrence or other complications.

CONCLUSIONS

Mini-incision double eyelidplasty method in single eye was effective and endurable in the treatment of congenital upper eyelid crease asymmetry. The recovery rate was fast, and no cases of upper eyelid crease disappearance were observed in this study.

A Composite Tissue Flap for Double-Eyelid Blepharoplasty in Asian Patients: A Retrospective Study

ABSTRACT

Double-eyelid blepharoplasty, the procedure to create supratarsal crease, has been one of the most popular cosmetic operations in Asia for many years. This study aimed to assess the effectiveness and safety of a surgical procedure using a composite tissue flap for double-eyelid blepharoplasty. A surgical technique was introduced and patients having blepharoplasty with this technique from January 2017 to August 2019 were retrospectively studied. In this technique, a composite tissue flap consisted of the posterior septum and levator aponeurosis was formed and fixed with orbicularis oculi muscle and tarsus. The cosmetic outcomes, patient satisfaction, and complications from the documented medical records were analyzed. Eighty female and 1 male patients had blepharoplasty with the proposed technique and were followed up from 6 months to 42 months. Six patients were found to have mild blepharoptosis. As for cosmetic outcomes, 71patients were graded as good, 7 patients were graded as fair, and only 1 patient was graded as poor. Those patients who were not graded as good had visible scarring, shallow eyelid crease, or asymmetry. The overall patient satisfaction was as high as 95.1%. Mild hematoma formation occurred in 3 patients and no infection or blepharoptosis was observed. One patient complained of asymmetry and 2 patients complained of unilateral crease fading as the complications. The technique is effective to develop durable and natural-looking double eyelids with minimal complications. It could also be an option for mild ptotic patients who ask for double-eyelid blepharoplasty.

Tarsal-Fixation With Aponeurotic Flap Linkage in Blepharoplasty: Bridge Technique

BACKGROUND

Double eyelid blepharoplasty is the most popular cosmetic surgery among Asian populations. Although various surgical procedures have been reported, certain complications still arise, including asymmetry or the disappearance of the double eyelid crease, an unnatural double eyelid crease curve, and distinct scars.

OBJECTIVES

The aim of this study was to describe a new blepharoplasty technique intended to reduce the various complications and create dynamic, natural-looking double eyelids.

METHODS

From September 2018 to June 2019, the new technique was performed on 92 Chinese patients. The core of our technique was to construct a reliable motion transmitter, the orbital septum-levator aponeurosis flap, which was sutured to the tarsus. The outcomes were assessed 6 months after the surgery by reviewing medical records and photographs to assess the aesthetic outcomes, the relapse rate, and the incidence of complications.

RESULTS

In the aesthetic outcome assessment, 86 patients were graded as good and 4 were graded as fair; of the latter, 2 had uneven scars and 2 showed showed a slight asymmetry of the double eyelid curve in length or width. Two patients were graded as poor because of the disappearance of the double eyelid crease. The relapse rate was 2.2%. Two patients had temporary hematoma. Six patients had lagophthalmos that subsided within 30 days. No cases of infection or ptosis were observed.

CONCLUSIONS

The bridge technique is an effective method for creating dynamic, natural-looking double eyelids. However, the long-term outcome of this new surgical approach requires further study.

LEVEL OF EVIDENCE: 4

Modified double-eyelid blepharoplasty with the combined partial- And minimal-incision method

BACKGROUND

Double-eyelid surgery remains a popular esthetic surgery in East Asian people. The partial-incision method provides the benefits of full-incision and nonincision techniques. It can create a predictable and durable double-eyelid crease.

AIMS

To create a long-lasting double-eyelid crease with a minimal scar, the author has described the modified partial incision technique with a small and minimal incision.

PATIENTS/METHODS

A preoperative design was developed with the patient in an upright sitting position. A partial incision was made between the medial limbus and the middle pupillary line; the minimal incision was made just adjacent to the lateral limbus. After local anesthesia, a strip of orbicularis oculi below the incision was dissected, and the pretarsal orbicularis oculi, anterior tarsal fascia and part of the anterior tarsal fat were removed. The skin, dermis and orbicularis oculi were sutured together with the pretarsal fascia.

RESULTS

From July 2016 to September 2018, 138 patients received a modified partial-incision double-eyelid surgery. A total of 119 patients were followed up. The postoperative shape and height were stable. Five patients developed loss of the unilateral fold (2.17%), and one patient complained of bilateral narrow eyelid folds (0.87%). No serious complications were noted.

CONCLUSION

The modified partial-incision technique for creating a double eyelid described here provides stable results with no visible scar and no serious complications.

The Eyelid Crease Height, Depth, and Shape: A Scoring System for Revisional Asian Blepharoplasty

This study reports on a series of challenging revisional Asian blepharoplasty cases with various suboptimal factors, including high or low crease height, shallow or deep crease indentation (depth), and suboptimal crease shape. The study also presents a simple scoring scale that combines these challenges into a composite score, which has helped in the management of these cases.

Methods

Data on 64 revisional cases were collected between January 1, 2006, and June 30, 2019, with 126 upper eyelids. These were cases with little skin remaining after previous surgeries, and each eyelid was scored based on a height, depth, shape scoring method. A composite score (H + D + S) is then summed up, which ranged from 1 to 10, with the higher number being the most challenging. The logic and rules behind this scoring scale are explained.

Results

Data regarding age, gender, and eyelid crease characteristics of the cases were collected; photographs, notes, and diagrams in the medical records were used to complete each eyelid's scoring. The age of the patients (57 women and 7 men) ranged from 21 to 74 years. The revision score distribution, age distribution, and averaged scores within each age group were investigated for those starting at 24 years or younger, and for each added decade until over 65 years. Patients with revisional effort scores of 5-8 were found in all age groups surveyed.

Conclusions

In this study, the author presents a practical scoring scale that recognizes the factors responsible for the suboptimal results in double eyelid plasty and helps clinicians in management, patient-counseling, and planning of surgical solutions.

Techniques, Principles and Benchmarks in Asian Blepharoplasty

Supplemental Digital Content is available in the text.

Background:

Asian blepharoplasty is a deceptively simple procedure where the goal is to create an upper lid crease. The author presents a retrospective self-analysis of 362 cases performed over the past 12 years.

Methods:

362 cases that fits the inclusion criteria were tabulated into spreadsheet data format. Recorded were age, gender, date of service and follow-ups, whether the AB performed was for primary or revisional purpose; the preoperative lid crease status, the patient-chosen crease height as well as shape preferred. Intraoperative observation included presence or absence of preaponeurotic fat, whether partially resected, or reposited were noted.

Results:

Of 362 patients (724 upper lids), primary AB constituted 81% (295) and revisional AB contributed 19% (67). The gender distribution was 87% female (315) and 13% male (47). The age distribution ranged from 12 to 75 years. The crease height selected ranged from 6.0 to 8.0 mm, with the median being 7.0 mm. Of the crease shape chosen, parallel shape was 65% (236) and nasally-joining crease shape was 35% (126).

Conclusions:

Asian blepharoplasty via trapezoidal debulking of preaponeurotic platform is a safe, effective and anatomically-based technique that does not involve the use of permanent buried sutures. The article discussed the 5 essential factors (aponeurotic attachment, selective block clearance of preaponeurotic space, precise positioning of the crease formation loci, detection of latent droopy eyelids and avoidance of Faden-like suture effect) and the author’s benchmarks to achieve a better success rate. Results for primary and revisional Asian blepharoplasty, strategies and potential pitfalls are presented. (http://links.lww.com/PRSGO/B141)

Primary Double Eyelid Surgery-Trapezoidal Debulking of Upper Eyelid Tissues

Supplemental Digital Content is available in the text.

The video illustrates the steps of Asian blepharoplasty of the upper eyelids, using the author's principle of beveled approach and trapezoidal debulking of preaponeurotic platform to allow safe access, minimization of wound injury, and creating a physiologically dynamic crease, without resorting to the use of buried sutures.

Aponeurosis of the levator palpebrae superioris in Chinese subjects: A live gross anatomy and cadaveric histological study

An accurate understanding of the anatomy of the levator palpebrae superioris aponeurosis (LPSA) is critical for successful blepharoplasty of aponeurotic ptosis. We investigated the macroscopic and microscopic anatomy of the LPSA.This prospective live gross anatomy study enrolled 200 adult Chinese patients with bilateral mild ptosis undergoing elective blepharoplasty. Full-thick eyelid tissues and sagittal sections from the eyelid skin to the conjunctiva were examined with Masson trichrome staining or antismooth muscle actin (SMA) immunohistochemistry.Gross anatomy showed that the space between the superficial and deep layers of the LPSA could be accessed after incising the overlying superficial fascia, by retracting the white line. Adipose layers were clearly observed in 195 out of 200 patients with bilateral mild ptosis, among which 180 cases had the superficial layer connected to the uncoated adipose. Fifteen cases had the superficial layer connected to the smoothly coated layer, and 5 cases had the superficial layer directly connected to the deep loose fiber, almost without adipose. In previously untreated patients, the LPSA space was located beneath the intact orbital septum. In those with previous surgeries, it was beneath the superficial layer of the LPSA, underlying the destructed orbital septum. Cadaveric histology showed that the deep layer of the LPSA extended into the anterior layer of the tarsal plate and the superficial layer reflexed upward in continuity with the vertical orbital septum. An occult space existed between the 2 layers of the LPSA, with a smooth lining on the deep layer. The superficial layer of the LPSA was SMA-immunonegative but the deep layer was slightly immunopositive for SMA. An occult anatomic space exists between the superficial and deep layers of the LPSA, in proximity to the superior tarsal plate margin. Recognition of the more anatomically significant LPSA deep layer may help improve the aesthetic outcome of blepharoplasty.

Visual, Physiological, and Aesthetic Factors and Pitfalls in Asian Blepharoplasty

Double eyelid surgery to create an upper-lid crease in Asian patients is one of the more popular aesthetic surgeries among people of Asian descent. Much has been written about the myriad methods, but little has been written about the underlying factors that predispose a patient to complications and suboptimal results. This article touches on some of the possible errors in placement of crease height in upper blepharoplasty and the pitfalls that can be associated with permanent placement of nondissolvable sutures that encircle the complex layers of the upper eyelid, as well as the ideal eyelid crease wound closure and its biodynamics. One should consider these factors in any form of upper eyelid procedure, as they are not merely applicable to upper blepharoplasty.

The Asian Eyelid: Relevant Anatomy

The eyelid of Asians has its own unique characteristics. If the surgeon does not acknowledge this, aesthetically pleasing results will seldom be achieved. Here the authors review and summarize important up-to-date anatomical and relevant clinical studies of the Asian upper eyelid, aiming to help surgeons thoroughly understand its unique features, including Asian eyelid morphology, anatomical details, and the mechanisms of upper eyelid crease formation. Hopefully, an in-depth understanding of the Asian eyelid will aid surgeons to accomplish their work and lead to novel new techniques in this field.

Mechanical analysis of eyelid morphology

From a mechanical instability perspective a double eyelid is a double-folded thin film structure on a curved substrate, caused by compression as the film "slides" on the substrate. The underlying mechanics issues, in particular the requirements for forming a double folded structure, are studied using a modeling/simulation framework. A minimalist model is employed to explore the wrinkle to fold transition. Refined and enriched models are further developed based on anatomical structures, which demonstrate three critical factors for the formation of double layer folding of the eyelid. First, a crease line in the eyelid is essential where the local bending rigidity is relatively weak. Second, the skin above the crease line should be thin and wide enough. Third, the skin below the crease line should have a relatively large effective stiffness so it can be lifted as a whole when the eyes open. When the eye is opened beyond about 40% of its initial wrinkle wavelength, the double-folded structure emerges. Various types of eyelid morphologies are discussed based on the mechanistic model. The study provides useful insights for surgery, cosmetics, and morphogenesis, as well as microfabrication.

The causative factors or characteristics of the Asian double eyelid: an anatomic study

PURPOSE

To clarify the causative factor of Asian double eyelid.

DESIGN

Experimental anatomic study.

PARTICIPANTS

Twenty-six upper eyelids (13 right and 13 left) from 17 Japanese cadavers (9 males and 8 females, mean age at death: 73.1 years).

METHODS

The specimens, obtained from the central part of the upper eyelids, were dehydrated, embedded in paraffin, cut into 7-μm thick slices and stained with Masson trichrome. Statistical analysis was based on the Mann-Whitney U test. Statistical significance was defined as p < 0.05.

MAIN OUTCOME MEASURES

Orbicularis oculi muscle thickness and shape, with or without the levator extension, orbicularis oculi muscle bundle spacing, thickness of upper eyelid skin and subcutaneous tissue, fusional site between the levator aponeurosis and the orbital septum, with or without inferior drooping of fat tissue.

RESULTS

The orbicularis muscle was thinner at the skin crease of a double eyelid than at 10 mm from the eyelid margin in the single eyelid group (p = 0.029). In 3 specimens the skin crease of double eyelid was at the tip of the bending orbicularis muscle, which was thick. Although the skin crease in the region of a double eyelid was thinner than in other parts of the skin, excluding the simple crease regions, other outcome measures were not shown as definite causative factors in creating the Asian double eyelid.

CONCLUSIONS

The thickness of orbicularis oculi muscle or its bending shape, and the thickness of the skin at the skin crease, are major causative factors in Asian double eyelid formation.

Upper Blepharoplasty in the Asian Eyelid

Upper-eyelid blepharoplasty in the Asian patient poses unique challenges. The anatomy is complex and highly variable, and the esthetic goals vary from patient to patient. The surgeon must perform more complicated maneuvers than in Caucasian blepharoplasty in an anatomic field with features that predispose for complications. The successful surgeon must identify the features of the eyelid to be modified through a detailed consultation with the patient, formulate a sound surgical plan based on a mastery of the complex anatomy, and execute all maneuvers with conservatism and exact precision.

Upper blepharoplasty in the Asian eyelid

Upper eyelid blepharoplasty is a major component of cosmetic surgery in the Asian face. The complicated and variable anatomy of the Asian upper eyelid is reviewed, stressing the major differences between Asian and Caucasian eyes. The authors' preferred surgery for the creation of a double eyelid is discussed, including the preoperative assessment, intraoperative maneuvers, and laser techniques. The article concludes with a discussion of the complications specifically related to Asian blepharoplasty and strategies to avoid them.