Lowering of the High Eyelid Crease in Revision Upper Eyelid Surgery

Recovery of subcutaneous orbital fascia under preserved skin below the original crease in the repair of excessively high double-eyelid folds

BACKGROUND

High-eyelid fold is a common complication of upper eyelid surgery. This study proposed a novel technique for correcting high-eyelid fold in Asian patients with little eyelid skin and thick orbital fascia to improve cosmetic outcomes and patient satisfaction.

METHODS

We retrospectively analysed the clinical data of 38 patients with high-eyelid fold repaired at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences, from July 2017 to April 2022. All patients were treated using this method of preserving the high-eyelid fold and reconstructing the subcutaneous orbital fascia. Postoperative outcomes were reviewed and analysed using objective measures and subjective surgeon and patient evaluations.

RESULTS

Thirty-eight patients (71 eyes) were included. Postoperative follow-up was for 6-25 months. At 6 months postoperatively, the mean anatomic crease height decreased from 10.45 mm to 6.22 mm, mean pretarsal show decreased from 3.20 mm to 1.61 mm, and mean margin reflex distance in 1 of the 31 patients with ptosis increased from 2.93 mm to 3.87 mm (P < 0.001). The compliance rate between the surgeon's assessment and patient satisfaction was 89.5%, with 31 cases considered good by both the surgeon and patient and one case considered poor by both (undercorrected ptosis), though a satisfactory result was achieved after reoperation. Neither recurrence of the original crease nor serious complications were reported.

CONCLUSION

By preserving high-eyelid folds and reconstructing the subcutaneous orbital fascia, unnaturally high- and deep-eyelid folds were converted to lower, nondepressed folds.

Revisional Asian Blepharoplasty of the High Eyelid Fold: Tarsus-Orbicularis Fixation Combined With Orbital Fat Repositioning Technique

BACKGROUND

Abnormally high eyelid fold is a common unsatisfactory esthetic outcome after double eyelid surgery. At present, successful correction of high eyelid fold among Asians remains one of the most challenging procedures for eyelid plastic surgeons.

OBJECTIVES

This article aims to propose a novel technique for correcting high eyelid fold to improve the cosmetic outcomes and patient satisfaction.

MATERIALS AND METHODS

This is a retrospective study of 86 patients (154 eyelids) with high eyelid folds who underwent revision blepharoplasty. A new proper height incision line was designed during the operation, and the adhesion between skin and levator aponeurosis was fully released. The residual orbital fat was adequately separated. If necessary, orbital fat from lower eyelid will be harvested for free fat grafting. The tarsus-orbicularis fixation combined with orbital fat repositioning technique was used to create a double eyelid fold and reconstruct the gliding zone. The surgical outcome and patient satisfaction are reviewed.

RESULTS

Among the 154 eyelids with high eyelid fold, mean lid crease height decreased from 9.8 mm preoperation to 6.8 mm ( P <0.001) and mean pretarsal show decreased from 3.5 mm preoperation to 1.9 mm 6 months postoperation ( P <0.001). The esthetic outcome was fully satisfied in 78 patients (90.7%) and basically satisfied in 6 patients (7.0%). Two patients (2.3%) were unsatisfied because of ptosis undercorrection in 1 patient and asymmetry in the other. They both got satisfied results after reoperation.

CONCLUSIONS

The tarsus-orbicularis fixation combined orbital fat repositioning technique is a simple and effective method to correct high eyelid folds with high satisfaction and rare complications.

Double-Eyelid Blepharoplasty: Dermis-Outer Orbicularis Fascia-Orbicularis-Levator Fixation Technique with Preorbicular Venous Network Preservation

BACKGROUND

This article presents a new method using a dermis-outer orbicularis fascia-orbicularis-levator (DOOL) fixation technique for double-eyelid blepharoplasty.

METHODS

Our surgical technique preserves the preorbicular venous network (POVN) and uses mattress sutures to fix the dermis, outer fascia of the orbicularis oculi muscle, and orbicularis oculi muscle with pretarsal levator aponeurosis (DOOL). Between January 2016 and July 2018, 335 patients were treated with this POVN-preserving DOOL technique (321 women and 14 men; mean age, 29.6 y). The patients were followed up for 6-30 months. The complications were documented, and the overall outcomes of the upper eyelid folds were evaluated by both surgeons and patients as good, fair, or poor.

RESULTS

Among 335 patients, 307 (91.6%) had good results, 17 (5.1%) had fair results, and 11 (3.3%) had poor results. Postoperative complications included partial (n=4) or complete (n=3) loss of the double-eyelid line and asymmetric folds (n=4). Hypertrophic/depressed scars did not occur.

CONCLUSIONS

With less invasiveness and secure internal fixation, the DOOL fixation technique with POVN preservation can achieve a stable and natural double-eyelid appearance.

LEVEL OF EVIDENCE IV

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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.

Complications of Asian Double Eyelid Surgery: Prevention and Management

Double eyelid surgery remains one of the most popular aesthetic surgeries, especially among East Asian populations. Complications related to double eyelid surgery can be divided into various categories: (1) patient dissatisfaction, (2) problems with the eyelid crease, (3) problems with the eyelid height, (4) suture-related complications, and (5) complications related to eyelid surgery in general. As with all eyelid surgeries, it is important to understand and appreciate the normal and abnormal function and anatomy of the Asian eyelid to reduce the risk of complications. It is also important to recognize the various complications and their underlying causes so that the surgeon can confidently revise the surgery to achieve optimal outcomes.

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.