Techniques, Principles and Benchmarks in Asian Blepharoplasty

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.

The small incisions combined with interrupted buried suture blepharoplasty: flexible-rigid fixation

Background

The traditional full incision blepharoplasty is the most commonly used in Asia. However, it has significant drawbacks like long recovery period, excessive surgical marks etc. We offer a new suture idea and combine it with interrupted suture buried blepharoplasty to improve these disadvantages.

Methods

In our procedure, the orbital septum is opened and separating the levator aponeurosis-the retro-orbital septum complex under this 3-5 millimeters small incision, a flexible-rigid fixation would be made: suture fixation was made to the tarsus-the complex-lower lip orbicularis oculi muscle. We interrupted bury the sutures in the uncut skin between the two small incisions.

Results

This paper included 333 patients divided into small incision groups using flexible-rigid fixation (n = 244, 73.3%) and full incision groups using rigid fixation (n = 89, 26.7%). Both at 6-month and at 5-year postoperative follow-up, the satisfaction of small incision group was statistically higher than the full incision group. The overall postoperative complication rate was statistically significantly less in the small incision. The permanence was not statistically different. For Assignment of Postoperative Effort Score (PES) results, at 6 months postoperatively, the mean score was 8.29 ± 1.32 in the small incision group, 7.86 ± 1.54 in the full incision group. At 5 years postoperatively, the mean score was 7.48 ± 1.45 in the small incision group, 7.51 ± 1.73 in the full incision group. None were statistically different.

Conclusion

The small incisions group achieves a higher level of patient satisfaction and more mild trauma in the surgical area, has a low complication rate, and a decent degree of durability.

Concept of Double-eyelid Segments Ratio: Practical Application in Asian Blepharoplasty

Background

There have been few articles on the vertical dimension of the Asian upper eyelid, the eyelid crease segment, and the upper palpebral segment. The eyelid crease height manifests differently depending on whether it is closed (on extreme downgaze), open, or on upward gaze. This study will investigate a ratio practical for use in Asian blepharoplasty (external incisional method).

Methods

The central vertical dimensions of Asian upper eyelids were measured, together with the upper palpebral segment and eyelid crease height when present. These parameters were recorded preoperatively and following double-eyelid surgery, and remeasured at 1 week and 2 months postoperative with eyelids closed and with eyes open looking straight ahead. The ratios of anatomic upper/lower segments and apparent (eyes opened) upper/lower ratio were tabulated for each case.

Results

The mean vertical height of upper eyelid skin among Asian women 30 years of age and younger was 23.4 mm, and between 31 and 50 years of age was 25.4 mm. The design of Asian upper eyelid crease and determination of skin tissues that can be safely removed include designing crease height to be 7 mm or slightly less and leaving an upper eyelid segment of at least a length 2 times or more of the crease height, to yield an aesthetically desirable double-eyelid segments ratio.

Conclusions

The study confirms the practical application of the upper/lower segments ratio at surgery and at full recovery (2 mo) using such technique and shows its progression to a desirable range of double-eyelid segments ratio. It has proven effective and useful for patients seeking Asian blepharoplasty.

Upper Eyelid Ptosis Correction with Levator Advancement Using the Levator Musculoaponeurotic Junction Formula in White Patients

BACKGROUND

Upper eyelid ptosis correction is a challenging procedure. The authors report a novel approach to this procedure that is more accurate and predictable compared with conventional approaches.

METHODS

A preoperative system of assessment has been formulated to more accurately estimate the amount of levator advancement required. The levator advancement was referenced from a constant landmark: the musculoaponeurotic junction of the levator palpebrae superioris. The factors considered include the amount of upper lid elevation required, the degree of compensatory brow elevation present, and eye dominance. The preoperative assessment and surgical technique are presented in a series of detailed operative videos. The levator advancement is performed as planned preoperatively with final adjustment made intraoperatively to achieve correct lid height and symmetry.

RESULTS

Seventy-seven patients (154 eyelids) were analyzed prospectively in this study. The authors found this approach to be reliable and accurate in predicting the required amount of levator advancement. Intraoperatively, the formula correctly predicted the exact required fixation location in 63% of eyelids, and to within ±1 mm in 86% of cases. This may be used for patients with ptosis of varying severity, ranging from mild to severe eyelid ptosis. The revision rate was 4%.

CONCLUSION

This approach is accurate in determining the fixation location needed, enabling levator advancement for ptosis correction to be performed with more precision and predictability.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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 .

A Simplified Treatment for Mild to Moderate Epicanthal Folds

SUMMARY

Surgical treatments to the upper eyelid have evolved along with a better understanding of the aging upper eyelid anatomy and development of solutions that are aesthetically pleasing and that defy detection. It is not uncommon for patients to present before or after upper blepharoplasty with perceived deformities of the medial canthus. Epicanthal folds are sometimes a concern. Approaches to the varied presentations of epicanthal folds have derived from the belief that they relate to a dermal or orbicular (muscle) issue, and solutions have primarily involved traditional approaches to altering skin and muscle tension by means of complex flaps. Complications or unfavorable outcomes that relate to this approach mainly involve scarring or nonresolution. The author describes a novel and simple surgical approach for the treatment of mild to moderate epicanthal folds or medial canthal webbing that is in line with the goals of the balance of aesthetics, resolution, and undetectability.

Re-positioning pretarsal tissue layers for double-eyelid surgery: 6-year experience

Double-eyelid surgery is a very common practice in East Asian patients. The differential distribution of pretarsal tissue layers is considered to be the anatomical mechanism of natural Asiatic single eyelid, it is possible to form double-eyelid crease by re-positioning the pretarsal structure layers. The author presents a new double-eyelid surgery based on re-positioning of the pretarsal structure layers without tissue removal. Over a 6-year period, 1440 patients underwent new double-eyelid surgeries. With the pretarsal orbicularis oculi muscle incised, the pre-pretarsal levator aponeurosis fascia fibroadipose was first dissected to form a fibroadipose flap, and then repositioned with the eyelid lower lip orbicularis oculi muscle flap. The new composite structure was anchored at 3 points on the pretarsal levator aponeurosis fascia; the skin was sutured to form a smooth crease. Post-operative outcome and follow-up data were analyzed. Patients were followed up for an average of 2 years. esthetic outcomes were satisfactory for 97.91% of patients, who enjoyed new double upper eyelids with smooth creases and invisible incision lines. Outcomes were unsatisfactory for 2.08% of patients (double-eyelid regression, 0.76%; asymmetric creases, 1.32%). All patients who were not satisfied with their esthetic outcomes underwent second correction surgery. This new Pan-flap technique focuses on the correct dissection and repositioning of differentially thickened pre-pretarsal levator aponeurosis fascia fibroadipose tissue in East Asian patients. This new technique can generate broader and tighter attachment between pretarsal orbicularis oculi muscle and levator aponeurosis fascia, and form smooth double-eyelid crease without pretarsal soft tissue removal.

A graded approach in East Asian personalized lower blepharoplasty: A retrospective study spanning 12 years

Purpose

The aim of the study was to describe a graded approach for assessment and specific treatment, which can achieve satisfactory postoperative result in East Asian personalized lower blepharoplasty.

Methods

We reviewed 913 patients who underwent lower blepharoplasty from 2008 to 2020. We preoperatively classified patients with different characteristics to provide personalized treatment.

Results

There were 163 patients with fat herniation but no lower eyelid skin laxity, 259 patients with lower eyelid skin laxity accompanied by mild fat herniation, 313 patients with sagging lower eyelid skin accompanied by mild fat herniation and tear troughs, and a total of 178 patients with sagging skin accompanied by moderate to severe fat herniation and tear troughs. The overall success rate was 97.81%. Postoperative complications included the following: conjunctival chemosis, dry eye symptoms, and more.

Conclusion

For East Asian patients with different characteristics, we achieved satisfactory postoperative results through accurate preoperative clinical grading and personalized surgical plans. The success of the operation not only depends on correct manipulation during the procedure but also on the surgeon's accurate assessment and full grasp of the anatomy of each patient preoperatively.

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 .

Asian Upper Blepharoplasty in Women: A Comprehensive Approach for a Natural and Aesthetically Pleasing Outcome

BACKGROUND

Asian upper blepharoplasty is the most popular cosmetic procedure for Asian women. However, there is no standardized approach to this procedure and suboptimal results are still common.

OBJECTIVES

The aim of this article was to describe a comprehensive approach to Asian upper blepharoplasty in women and report the clinical outcomes obtained with this approach.

METHODS

The comprehensive approach described here for Asian upper blepharoplasty in women includes: (1) determining the height and length of the upper eyelid skin crease; (2) creating a more optimal anatomy of the upper eyelid by removing excess eyelid skin, a portion of the orbicularis oculi muscle, and septal fat; (3) reconstructing the desired anatomic structures of the upper eyelid skin crease through plication of the levator aponeurosis, if necessary, and closure of the upper eyelid skin incision through the septum and the mobile portion of the levator aponeurosis; (4) adding a medial epicanthoplasty if needed to enhance final cosmetic results.

RESULTS

Over a 5-year period, 332 Asian women underwent upper blepharoplasty for creation of double eyelids, or conversion from less visible to more ideal double eyelids, with the above comprehensive approach. There were no surgical complications postoperatively and 326 patients (98.2%) rated their outcome satisfactory over a 5-year follow-up. Only 6 patients (1.8%) required surgical revision for asymmetry or suboptimal shape of the upper eyelid.

CONCLUSIONS

The comprehensive approach to Asian upper blepharoplasty described here can be used for Asian women and produces a natural and aesthetically pleasing outcome and low revision rates.

LEVEL OF EVIDENCE: 4

A Modified Procedure for Single-eyelid Asian Females with Lacrimal Gland Prolapse: Lacrimal Gland Reposition combined with Fat Transposition in Double-eyelid Operation

BACKGROUND

The awareness and treatment of lacrimal gland prolapse (LGP) have been primarily improved with a further understanding of lateral eyelid bulging over the decades. However, for Asian single-eyelid females with LGP, a tailor-made procedure applicable to their comparatively young puffy eyes is needed.

METHODS

This is a retrospective study. From Jan. 2009 to Jan. 2019, two hundred and three Asian single-eyelid females with LGP, who met the inclusion criteria, underwent double-eyelid surgeries and adjunctive lacrimal gland repositions with preaponeurotic fat transposition. Pertinent demographics, complications, pre-and post-operative photography were collected.

RESULTS

A total of 167 patients completed the 4-24 months' follow-up (average: 16.3 months). One hundred and thirty-two cases (79.0%) were diagnosed as LGP preoperatively, and the rest (35/167, 21.0%) were diagnosed intraoperatively. All patients (average: 28.4 years old) received modified blepharoplasty. Postoperative symptoms involving local mild pain (2.9%, 5/167), upper eyelid tightness (3.6%, 6/167), and moderate epiphora (9.0%, 15/167) were all recovered spontaneously within one month. Prolapse recurrence and severe complications such as dry eye syndrome were not observed.

CONCLUSIONS

We proposed a modified procedure to enhance the diagnosis and treatment of LGP during Asian blepharoplasty. The lacrimal gland suspension and fat transposition assured the cosmetic outcome for selected young, puffy Asian eyes. The supratarsal creases were satisfactory, and the complication rate was low. Furthermore, the rearrangement of preaponeurotic fat smoothed the contour transition and preserved the orbital volume. Therefore, this is a safe and effective technique worth recommending.

Asian Blepharoplasty: The Indian Perspective

The upper eyelid crease is an indentation at the level where fibers from the levator aponeurosis insert into the skin. Typically, Asian eyes are described as creaseless and puffy and the aim of blepharoplasty is to achieve an eyelid crease, without losing the ethnicity of the individual. We aim to describe the most commonly performed technique as well as the peculiar points to be kept in mind from the Indian perspective.

The Causes and Management of Asymmetrical Double Eyelids

Blepharoplasty is a commonly performed aesthetic surgery, especially in Asians. Nevertheless, as in all surgeries, postoperative complications still occur. Asymmetry is the most common complication after double eyelid surgery. Preexisting asymmetries in patient appearance and technical faults during surgery are associated with postoperative asymmetrical double eyelids. In this review, we discuss how to prevent unfavorable outcomes after this procedure and how to manage asymmetrical double eyelids when they do occur.

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.