Chen's Double Eyelid Fold Ratio

Subclinical Upper Eyelid Ptosis in Asian Patients: The Role of Levator Advancement in Optimizing Outcomes in "Cosmetic" Upper Blepharoplasty

BACKGROUND

Subclinical ptosis is prevalent in Asian patients presenting for aesthetic upper blepharoplasty. To achieve predictable and satisfactory results in these patients, addressing the ptosis component is critical. In this paper, we present a precision levator advancement technique that enabled us to predictably incorporate the levator advancement into our upper blepharoplasty to deliver more predictable results in these patients.

MATERIALS AND METHODS

Asian patients with normal or near normal margin to reflex distance 1 (MRD 1 of ≥ 3.5 mm) and symptoms and signs of straining of the frontalis with eyelid opening were diagnosed with subclinical upper eyelid ptosis and included in this prospective study. The advancement required was estimated pre-operatively using a formula that we developed. Our surgical technique is presented in detail here, and our long-term results were analysed.

RESULTS

From December 2019 to August 2022, 97 patients were included in this study. Sixty-five patients were primary cases and 32 were revision cases. The mean follow-up was 15 months. Of the 192 eyelids analysed, our formula was able to correctly identify the required fixation location in 69% of eyelids. In majority of the eyelids (94%), the correct location of fixation location within +/- 1 mm of the estimated location. All patients (100%) were satisfied with their long-term results. Our revision rate was 3%.

CONCLUSIONS

Incorporating a precisely done levator advancement into the upper blepharoplasty in patients with subclinical ptosis is critical for optimizing the aesthetic and functional outcomes. This approach has enabled us to perform this procedure greater predictably in this group of patients.

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 .

Photo-Assisted Anthropometric Analysis of Double Eyelid Blepharoplasty in Young Chinese

BACKGROUND

Double eyelid blepharoplasty has gained popularity over decades among Asians. Quantitative assessment of the morphologic changes after double eyelid blepharoplasty remains obscure. A photo-assisted digital method was introduced to measure the outcomes of double eyelid surgery in young Chinese.

METHODS

A total of 168 Chinese patients who underwent esthetic upper blepharoplasty were recruited from October 2018 to October 2020. The participants were divided into mini-incision, full-incision, and full-incision double with epicanthoplasty (FIDE) groups. Changes in the eyeball exposure area (EEA), brow eyelid margin distance [brow eyelid distance (BED)], and palpebral crease height after surgery were analyzed using ImageJ software.

RESULTS

There was an overall increase in EEA in the 3 groups after upper blepharoplasty surgery. The FIDE group showed the most increase in EEA among these groups. Furthermore, BED was significantly decreased in each group after upper eyelid blepharoplasty; however, the mini-incision double group showed the least BED reduction. The palpebral crease height at 90 days was significantly lower than that at 7 days after surgery.

CONCLUSIONS

The photo-assisted anthropometric analysis offers a simple and objective measurement for double eyelid blepharoplasty. The eyes appear larger because of the increase in EEA and decrease in BED after double eyelid blepharoplasty. Distinct results were produced by different surgical techniques. The FIDE group showed the maximum increase in EEA and a decrease in BED. These findings provide important references for preoperative planning and postoperative measurement.

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.

Impact of Single Eyelid on Superior Visual Field

ABSTRACT

A puffy eyelid without a crease, also known as single eyelid, is a common characteristic in East Asians. Existence of a lid crease is generally considered an aesthetic concern for both patients and surgeons, and postoperative evaluations have mainly focused on the appearance of the eye. The aim of this study was to clarify the functionality of the superior visual field (SVF) with single eyelid.This prospective cohort study compared edge of the upper eyelid to central corneal light reflex distance (edge reflex distance [ERD]) preoperatively and postoperatively and examined the SVF, as measured by Goldmann perimetry, in single-eyelid patients who underwent blepharoplasty.Twenty patients (40 eyelids) with a median age of 21 years were examined. The median preoperative and postoperative ERDs were 1.45 and 3.4 mm, respectively. The median areas of the SVF preoperatively and postoperatively were 34,443 and 50,796 degrees2, respectively. Although a positive correlation existed between preoperative ERD and SVF, no correlation was observed between postoperative ERD and SVF.The SVF of the single eyelid is narrower than that of the double eyelid, even under circumstances of equivalent palpebral fissure height. The single eyelid commonly found in East Asian populations is associated with both cosmetic and functional issues.

Anthropometry Analysis of Beautiful Upper Eyelids in Oriental: New Eyelid Crease Ratio and Clinical Application

BACKGROUND

Beautiful upper eyelids can make one feel more attractive and confident. However, the definition of a beautiful upper eyelid in Orientals is still not defined. The aim of this study was to define the most beautiful upper eyelids in Orientals.

METHODS

Participants, who met the inclusion criteria such as Asian ethnic, ages between 18 and 25 years, and double eyelid fold, were conducted. Double upper eyelids were classified into three groups, group A: most beautiful; group B: average; and group C: less beautiful upper eyelid, by plastic surgeons and beauty contestant winners. Eleven linear measurements and type of epicanthal fold were analyzed.

RESULTS

A total of 153 participants were included, 66 were male and 87 were female. The mean ages were 21.45 years in males and 21.41 years in the female group. The vertical distances of the palpebral fissure, height of the double fold, height of the lid crease and height of the closed upper eyelid were found to be significantly different between the most, average and less beautiful upper eyelids in both males and females. The type 1 epicanthal fold was the most common in the most beautiful upper eyelid group.

CONCLUSION

The most beautiful double upper eyelids in Orientals demonstrated a higher vertical palpebral fissure, double eyelid fold, and height of eyelid crease than the average and the less beautiful double upper eyelids. The ratio of height of lower margin of eyebrow to eyelid crease: Height of eyelid crease is 1.2:1 to create the beautiful double upper eyelids. However, preoperative consultation with realistic expectations is important.

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.

Double eyelid surgery by using palpebral marginal incision technique in Asians

BACKGROUND

Approximately 50% of Asians do not have upper eyelid creases. Full-incision methods may leave obvious scars and buried-suture methods cannot remove excess tissues to create a double eyelid. The new palpebral marginal incision technique masked the incision at the upper palpebral margin and removed the excess tissue, thereby achieving scarless and natural double eyelids.

METHODS

The modified technique involved the incision site and positioning processes. The incision line is 1.0-1.5 mm above the palpebral margin. A strip of orbicularis muscle beneath the positioned double eyelid must be removed. The orbital septum is then exposed, and a certain amount of orbital fat is removed. Next, the dermis and tarsal plate are sutured in an orderly manner. Finally, a strip of the redundant skin located approximately 1-3 mm above the incision is excised to correct blepharochalasis before the skin is closed.

RESULTS

This new technique was performed in 212 patients including 56 patients with blepharochalasis who had their skin excised during the surgery. The follow-up period ranged from 6 months to 3 years. Ninety-five percent of the patients rated excellent and good and that they were satisfied with their surgery, and no significant complications occurred.

CONCLUSIONS

The following are the advantages of the authors' technique: (1) minimal or even no surgical scarring is discernible on the eyelids even when they are closed; (2) solves the problem of excessive tissue and correct blepharochalasis; and (3) the double eyelid fold is stable and natural for a long time.

Chen's Double Eyelid Fold Illusion: An Eye Size Assimilation Illusion Induced by a Supratarsal Fold in the Brow-Eye Unit, A Preliminary Report

BACKGROUND

Double eyelidplasty can enhance the eye size and facial attractiveness of Asian individuals with single eyelids. The authors hypothesize that a supratarsal fold can induce an eye size assimilation illusion to enhance eye dimensions and aesthetics, and seek to define the optimum vertical proportion between a supratarsal fold and the eye fissure associated with maximal induction of the size assimilation illusion.

METHODS

A photometric study of the replicated photographs of ten female Taiwanese patients after double eyelidplasty was designed. Each photograph was edited by shifting the supratarsal folds vertically at a regular fold/eye ratio increment of 0.1. The perceived attractiveness of edited photographs of each patient was rated by 100 adult observers using a score of 1-5. The palpebral parameters were measured and analyzed.

RESULTS

The mean rating score increased gradually when a supratarsal fold was added and peaked when the fold/eye ratio was 0.3 and the mean Chen's double eyelid fold ratio was 0.631 ± 0.023. After the peak, the mean score decreased gradually and was lower than the photograph without a fold when the fold/eye ratio exceeded 0.5 and the mean Chen's ratio exceeded 0.729 ± 0.027.

CONCLUSION

Within the optimal ranges of the fold/eye ratio and Chen's double eyelid fold ratio, eyes are perceived as larger and more attractive due to a hybrid presentation of two interdependent eye size assimilation illusions induced by a supratarsal fold in the brow-eye unit. "Chen's double eyelid fold illusion" is proposed to describe this complex visual phenomenon.

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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Clinical efficacy analysis of myocutaneous flap in blepharoplasty]

Objective

To introduce the myocutaneous flap in blepharoplasty and summarize its clinical efficacy.

Methods

Between January 2013 and March 2016, 1 560 patients underwent blepharoplasty with myocutaneous flap. Of them, 158 patients were followed up over 6 months and included in the study. There were 18 males and 140 females with the average age of 23.4 years (range, 18-35 years). The unilateral side was involved in 13 cases and bilateral sides in 145 cases. The patients had narrow double eyelid, shallow double eyelid, single eyelid, bloated upper eyelid, and upper eyelid skin relaxation. During operation, the tissue between the orbicular muscle of eye and the tarsus was trimmed layer by layer; the orbicularis oculi muscle, capillary network, and the front fascia of tarsus were retained, and the full-thickness skin, muscle, and the front fascia of tarsus were sutured by anatomical apposition.

Results

Incision healed at stage I. All patients were followed up 6 months to 2 years (mean, 8.3 months). During follow-up period, shallow or extinctive double-eyelid line was observed in 9 cases (12 eyes), and satisfactory results were achieved after trimming front fascia of tarsus and suturing. Good clinical results were obtained in the other patients, who had natural and coherent double eyelid without obvious scar or depression at resection margin.

Conclusion

Myocutaneous flap for blepharoplasty has many advantages of fast recovery, little wound, light swelling, permanent effects, and good appearance.