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

The Role of Pretarsal Fascia in Upper Eyelid Crease Formation and its Implications in East Asians

OBJECTIVE

This study aims to investigate the role of pretarsal fascia in the formation of upper eyelid crease in East Asians.

METHODS

Through intraoperative fascia retraction observation, fascia-stretching test, histological examination, and anatomical analysis of pretarsal fascia and surrounding tissues, we explored the mechanical consequences and their impact on upper eyelid crease formation.

RESULTS

The levator aponeurosis extension comprises three parts to impact sub-orbicularis fat pad mechanically. The pretarsal fascia is anatomically distinct from the aponeurosis extension but is influenced by its mechanic forces. Differential distribution of collagen fiber bundles within the pretarsal fascia can buffer and transmit the forces of aponeurosis extension, leading to diverse upper eyelid crease patterns.

CONCLUSION

The factors determining upper eyelid crease are multifaceted, and the buffering-conduction theory of pretarsal fascia can explain both physiological and postoperative crease in East Asians. It determines the presence, depth, and stability of crease, laying the foundation for the formation of upper eyelid crease in East Asians.

LEVEL OF EVIDENCE V

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Clinical Efficacy of Bionic Blepharoplasty Using the Flexible Suspension and Semiflexible Suspension Double-Insurance Methods

OBJECTIVE

To investigate the clinical effect of the double insurance method of flexible suspension and semiflexible suspension in bionic blepharoplasty.

METHODS

Between January 2020 and January 2022, a total of 115 patients (230 eyes) underwent double eyelid plastic surgery with flexible suspension and semiflexible suspension. Herein, we present a new type of double eyelid surgery that preserves the orbicular muscle of the anterior tarsus without removing the tissue. First, the loose fatty fascia layer between the anterior tarsus and the orbicularis oculi muscle was completely removed to a distance of 2 mm from the base of the eyelashes, leaving the compact pretarsal levator aponeurosis. Then, the anterior tarsus orbicularis oculi muscle and the upper levator aponeurosis were sutured and fixed (flexible suspension). Finally, the skin and the upper levator aponeurosis were sutured in the flexible suspension space (semiflexible suspension).

RESULTS

Six months after surgery, the patient's double eyelid shape had recovered well, and the satisfaction rate reached 97.3%. Among the unsatisfied patients, 1 patient had a single-focused shallow eyelid line which was associated with postoperative hematoma, and 2 patients felt that the double eyelid line was narrow. All 3 patients achieved satisfactory results after reoperation.

CONCLUSIONS

The bionic double eyelid method with flexible suspension and semiflexible suspension can restore the natural double eyelid anatomy very well by reconstructing the connection between the orbicularis oculi muscle or skin and the upper palpebral levator aponeurosis. After the operation, the incisions healed quickly and smoothly. The eyelid depression and fleshy feeling were not obvious when the eyes were closed. Consequently, the patient's satisfaction was very high.

Single Mini-incisional Blepharoplasty with the Orbicularis-Orbital Septum Fixation Technique for the Creation of a Natural Double Eyelid

BACKGROUND

Mini-incisional double-eyelid blepharoplasty has increasingly gained popularity in oriental populations. Moreover, many related studies have made a detailed technical introduction to this topic. This study aims to introduce a simple single mini-incisional blepharoplasty procedure with orbicularis-orbital septum fixation technique to create a physiologically natural double eyelid with no visible scar and a short postoperative recovery time.

METHODS

A single mini-incisional blepharoplasty with orbicularis-orbital septum fixation technique is described in detail and is illustrated with pictures. Patients who underwent this procedure in our department from November 2020 to May 2023 were retrospectively reviewed RESULTS: This study included 159 patients who underwent a single mini-incisional blepharoplasty with the orbicularis-orbital septum fixation technique. Surgery duration ranged from 16 to 42 minutes (mean 27 minutes). The majority of the swelling was reduced in 5 days and completely disappeared in 2 weeks for most patients. The follow-up period ranged from 2 to 31 months. All the double eyelids were natural and dynamic, and the creases were stable with no visible scar. Asymmetries occurred in 1.2% (2 of 159), and crease disappeared in 0.6% (1 of 159) of patients; during the follow-up period, no other complications were reported. Of the 159 patients, 99.4% (158) were satisfied with the surgical outcomes CONCLUSIONS: The single mini-incisional blepharoplasty with the orbicularis-orbital septum fixation technique offers a simple, safe, and effective approach to creating double eyelids. It provides natural, stable, scarless, and rapid recovery results with a low risk of complication.

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 .

Skin-Tarsus-Skin Combined with Orbicularis-Tarsus-Orbicularis Fixation Technique Creates a Double Eyelid: A Case Series

Background

The skin-tarsus-skin and orbicularis-tarsus-orbicularis fixation methods are widely used in double-eyelid surgery. Both methods have limitations. In this study, the two surgical methods were integrated and applied to form a stable double eyelid that mimics the natural physiological structure with minimal visible scarring.

Methods

At the inner, middle, and outer sites of the double-eyelid line, 7-0 silk sutures were passed successively through the orbicularis oculi muscle at the lower edge of the incision, the tarsus/anterior tarsus tissue, and the orbicularis oculi muscle at the upper edge of the incision, and the skin was sutured with 8-0 thread. The remaining parts were fixed with 8-0 silk sutures successively passed through the skin at the lower edge of the incision, tarsus/anterior tarsus tissue, and skin at the upper edge of the incision. Scar formation, incidence of complications, and patient satisfaction were observed and recorded during follow-up.

Results

Fifty-eight patients were included. The follow-up ranged from 3 to 24 months (mean, 8 months) with 47 patients undergoing primary and 11 secondary/revision surgery. Twelve cases showed slight linear scars and in 46 cases, surgical marks were almost invisible, and there were no dynamic depressed scars. Evaluation of patient satisfaction showed high satisfaction scores (VAS score, 8.56 ± 0.51). The main reason for dissatisfaction was asymmetry of the double eyelid. There were no significant complications.

Conclusion

A skin-tarsus-skin combined with orbicularis-tarsus-orbicularis fixation technique can produce a long-lasting, natural-looking double eyelid.

The Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat: A New Strategy for Correction of Sunken Eyelid Deformity in Revision Upper Blepharoplasty for Asian Patients

BACKGROUND

With an increasing number of East Asians undergoing blepharoplasty, the number of patients with secondary upper eyelid deformities is increasing. The sunken eyelid deformity is a common deformity after upper blepharoplasty in Asians due to over-resection, retraction, or atrophy of the nasal and central orbital fat pads. Herein, we present a novel procedure, the pendulum movement of orbital fat and retro-orbicularis oculi fat ("POR" technique), for correction of sunken eyelid deformity in secondary Asian blepharoplasty.

METHODS

Patients who underwent secondary upper blepharoplasty with the POR technique by the senior author between January 2020 and October 2021 were identified retrospectively. Those with fewer than 6 months of follow-up were excluded. Patient charts and images were reviewed for demographic data, comorbidities, concomitant eyelid deformities, and postoperative complications. Pre- and postoperative aesthetics, including degree of sunken eyelid deformity, were assessed by two independent raters and by self-reported patient satisfaction.

RESULTS

Forty-nine consecutive patients were identified, all of whom were female and had grade I or II sunken eyelid deformity. Median follow-up was 8 months. Concomitant deformities included high tarsal crease (N = 31 patients, 63.3%), ptosis (N = 13, 26.5%), and upper eyelid retraction (N = 5, 10.2%). Almost patients had improvement in their eyelid volume, and 95.9% had improvement in their aesthetic rating. Approximately 93.9% of patients were satisfied with the outcome.

CONCLUSIONS

The POR technique is an effective technique for correction of sunken eyelid deformity and can be utilized in conjunction with other techniques during secondary blepharoplasty.

LEVEL OF EVIDENCE III

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 .

Application of Trapezoid Orbital Septum Membrane Flap in Double-Eyelid Blepharoplasty

BACKGROUND

For a long time, to achieve the natural shape of double-eyelid crease, multiple techniques of double-eyelid plastic surgery have been developed. We describe the trapezoid orbital septum membrane flap in blepharoplasty to achieve a dynamic double-eyelid crease and avoid a depressed static scar.

METHODS

The authors developed a trapezoid orbital septum membrane flap in double-eyelid blepharoplasty. The flap base is fixed on the pretarsal plate with the distal end of the flap positioned between the superior and inferior edges of the incision. Layer-by-layer contraposition suturing is then performed.

RESULTS

One hundred ninety-one cases of double-eyelid blepharoplasty were performed by a senior surgeon using the trapezoid orbital septum flap method. Patients were followed for 6 to 17 months. Twelve cases were revised secondarily. Patients were satisfied with the palpebral folds, which showed a dynamic crease followed with movements of the eyelids.

CONCLUSIONS

The authors introduce a trapezoid orbital septum flap in upper eyelid blepharoplasty. The flap relies on the elasticity of the orbital septum flap as the levator aponeurosis extension segment to produce a natural crease without a depressed static scar.

Global Research Trends and Perspectives of Blepharoplasty: A 20-Year Bibliometric Analysis Based on Web of Science

BACKGROUND

The number of publications on blepharoplasty is increasing rapidly. Bibliometric analysis can help surgeons quickly and systematically understand the current state of development. To our knowledge, there are no bibliometric studies on blepharoplasty, and therefore, we conducted this study to reveal research trends and perspectives of blepharoplasty.

METHODS

Relevant publications from 2002 to 2021 were extracted from the Web of Science Core Collection database. After manual screening, VOSviewer software and CiteSpace software were used to collect and analyze the acquired data.

RESULTS

A total of 1125 publications were included and the publications per year increased annually. Contributions from the USA led both quantity and quality. The University of California System was one of the most influential academic institutions. Aesthetic Plastic Surgery had the most publications, and Plastic and Reconstructive Surgery was the most frequently cited or co-cited journal. Massry GG and Hamra ST were the most prolific and co-cited authors, respectively. Additionally, Rohrich RJ had the highest number of citations per publication. References co-cited analysis identified that lower eyelid research was a hotspot. Keywords were mainly divided into 6 clusters, namely "lower lid blepharoplasty," "complications," "facial rejuvenation," "blepharoptosis," "upper blepharoplasty," and "Asian blepharoplasty and epicanthoplasty."

CONCLUSIONS

Blepharoplasty research is flourishing, and three clusters may be the hotspots: "Lower blepharoplasty and mid-face rejuvenation," "overall facial outcome and quality-of-life," and "Asian blepharoplasty and epicanthoplasty."

LEVEL OF EVIDENCE III

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 .

Depth of Upper Lid Crease Construction in Asian Blepharoplasty

The elegance of retrospective analysis of crease construction based on the levels of attachment is that it may be used to correlate a crease’s construction method with an outcome of crease depth based on medical record review. It expands on the current knowledge beyond simply describing a crease as being superficial or deep, and is useful for objective analysis of a technique’s merit.

Orbicularis-Tarsus-Orbital Septum Fixation Technique in Asian Double-Eyelid Blepharoplasty: a Retrospective Study

BACKGROUND

The skin-tarsus-skin and orbicularis-levator fixation approaches are the 2 most applied techniques for double-eyelid blepharoplasty in China. However, both approaches have their own disadvantages. To achieve stable and dynamic upper eyelid creases, we take the merits of the 2 techniques. In this study, our orbicularis-tarsus-orbital septum fixation technique is introduced and evaluated.

METHODS

By transversely opening and turning down the anterior orbital septum, we created the septum roll anchored to the tarsus and the pretarsal muscular flap. As the motion transmitter, the roll could receive the pulling power of the levator aponeurosis transmitted to the tarsus and the septum respectively. With the help of the skin-septum roll-skin sutures, the roll passed on the pulling power directly to the pretarsal skin and thus the upper eyelid crease was formed.

RESULTS

This study identified 105 Chinese patients (210 eyes) who underwent this technique in our department between September 2020 and May 2021. The follow-up ranged from 7 to 15 months. 90, 6, and 7 patients were satisfied, somewhat satisfied, and somewhat unsatisfied with the postoperative outcome, respectively. The satisfaction rate was 91.43% (96/105). Two patients were unsatisfied with the outcome, including 1 case of bilateral crease disappearance and 1 case of sunken upper eyelid.

CONCLUSIONS

The orbicularis-tarsus-orbital septum fixation technique is safe and effective for double-eyelid blepharoplasty. This technique helps to form stable upper eyelid creases. Meanwhile, it is easy to achieve ideal curve and symmetry. By preserving the pretarsal tissue and using the orbital septum, sunken scar formation can be avoided.

Tarsus-Orbicularis-Septum Fixation in Double-Eyelid Blepharoplasty: A Reliable and Flexible Technique

Purpose

Incisional double eyelid blepharoplasty is the most common cosmetic operation in East Asia. Although numerous articles on surgical techniques have been published, complications, such as fold loss, asymmetry, and visible scars, still exist. To create a stable and dynamic double-eyelid crease, the author has introduced a modified technique of double-eyelid blepharoplasty.

Patients and Methods

The authors introduced a new surgical technique to reduce complications and create reliable and dynamic double eyelids. The orbicularis oculi muscle of the lower flap was anchored on the tarsus and sutured with the distal part of the septal flap. The skin incision was closed by skin–septal flap–skin suture. Postoperative evaluations were assessed at the twelfth postoperative month.

Results

One hundred ninety-three patients underwent double eyelidplasty with the TOS fixation technique. The mean follow-up duration was 18.6 months (range, 12–30 months). In the aesthetic outcome evaluation, 88 (45.6%) patients had very much improved results, 56 (29.0%) had much improved results, 29 (15.0%) had improved results, 8 (4.1%) had no change and 12 (6.2%) had worse results. Complications included crease asymmetry (n=7, 3.6%), partial fold loss (n=8, 4.1%) and complete fold loss (n =5, 2.6%).

Conclusion

Tarsus-orbicularis-septum (TOS) fixation is a reliable and flexible surgical technique for creating stable and dynamic double-eyelid creases.

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A Modified Palpebral Marginal Incision Technique Using Levator Aponeurotic Flap in Blepharoplasty

BACKGROUND

Double-eyelid surgery is one of the most common cosmetic surgeries performed in Asians. The palpebral marginal incision technique (PMIT) conceals the incision scar and creates natural-looking double eyelids. However, the amount of eyelid skin removed by conventional PMIT is limited, which potentially results in an unnatural crease or swollen-like inferior skin below the palpebral crease.

OBJECTIVES

To introduce a modified PMIT which creates scarless, dynamic and natural double eyelids with a limited amount of eyelid skin excision.

METHODS

From January 2018 to December 2020, 382 patients (764 eyelids) underwent double eyelid surgeries using the described technique. The key point was to form a pretarsal levator aponeurotic flap, acting as a soft motor transmission to bridge tarsus, orbicularis oculi muscle (OMM), and skin dermis. The overall aesthetic outcomes, which are indicated by surgeon and patient self-assessed satisfaction, and complications, were postoperatively evaluated at different follow-ups.

RESULTS

The mean follow-up period was 7.6 months (range, 6-12 months). Of the patients, 332 (86.9%) reported a satisfactory self-assessment of outcomes and 37 (9.7%) as fair. Secondary operations were required for 13 (3.4%) patients for double-eyelid asymmetry or crease curve malformations. Early-stage hematoma (12 cases) and lagophthalmos (19 cases) were observed and completely recovered within 1 month.

CONCLUSIONS

Our modified PMIT technique was capable of achieving scarless and natural-looking double eyelids with biomimetic anatomical structure.

Asian Upper Blepharoplasty with the Hinge Technique

Asian upper blepharoplasty is one of the most commonly requested procedures in Asian patients. Many incisional and suture methods have been described in the literature. While the suture method is advantageous for its simplicity and quick recovery, the incision method is more versatile and able to deliver predictable and reproducible results for Asian patients presenting with a diverse range of anatomy and requests. Accordingly, the incision method remains the preferred approach for many surgeons performing Asian upper blepharoplasty. In this paper, we detail our open incision hinge upper blepharoplasty technique to create dynamic upper eyelid creases in Asian patients. The surgical videos associated with this paper present our surgical technique in detail, highlighting technical refinements and surgical nuances to perform the surgery precisely and predictably. The conceptual core of our approach is the use of a vascularized orbital septum as a flap to create a fibrous extension from the levator aponeurosis to the dermis at the location of eyelid crease. This vascularized flap securely connects the posterior lamella with the anterior lamella to securely form the eyelid crease with eye opening. This most accurately recreates the anatomy that is present in attractive Asian patients with naturally occurring double eyelid and predictably creates a dynamic and crisp upper eyelid crease. LEVEL OF EVIDENCE V: 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 .

Unsatisfactory Upper Blepharoplasty Revision Technique: Reconstruction of the Upper Orbital Septum and its Fusion Point

BACKGROUND

The orbital septum prevents both superficial eyelid infection and the spread of bleeding into the orbit. The fusion point between the upper eyelid orbital septum and the levator aponeurosis or the tarsal plate plays an important role in determining the width of the natural double eyelid. We observed a number of unsatisfactory upper eyelid blepharoplasty outcomes resulting from improper handling of the orbital septum-such as excessive destruction of orbital septum tissue and failure to form a firm attachment point between the orbital septum and the levator aponeurosis or palpebrae plate-during primary surgery.

OBJECTIVES

The three most common types of unsatisfactory upper blepharoplasty outcomes include abnormally high double eyelid creases, multiple creases, and disappearance of creases. In the repair operation, we try to determine the remaining orbital septum tissue for reconstruction and form a firm attachment between the orbital septum and the levator aponeurosis or tarsal plate. Follow-up after surgery was performed to observe whether our technique can ensure effective and favorable long-term natural-looking upper eyelid blepharoplasty outcome.

METHODS

From January 2018 to January 2020, secondary blepharoplasty involving the above-mentioned unsatisfactory double eyelid results was performed in 83 patients, including 63 patients (141 eyes) with abnormally high skin creases, 6 patients (8 eyes) with multiple creases, and 14 patients (24 eyes) with double eyelid disappearance. The outcomes were assessed 6 months to 2 years after the surgery by reviewing the photographs to evaluate the esthetic outcomes including stability of double eyelid, double fold curve, symmetry, patient satisfaction, and the incidence of complications.

RESULTS

After an average follow-up of 12 months, most patients achieved a better double eyelid appearance. The esthetic outcome was graded as good in 80 patients, poor due to recurrence of double eyelid disappearance in 2, and poor because of asymmetry of the double eyelid curve in length or width in 1 patient. All patients had acceptable scars. No cases of infection or ptosis were observed.

CONCLUSION

Reconstructing the orbital septum and ensuring a firm fixation with the levator aponeurosis or tarsal plate is an effective method to repair unsatisfactory upper eyelid blepharoplasty. Moreover, it is very important to protect the orbital septum and proper treatment during the initial surgery.

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 .

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.