Plastic construction of the superior palpebral fold

Correction of Primary Multiple Upper Eyelid Folds by Three Mini-Incision Upper Blepharoplasty and Simultaneous Orbital Fat Pad Repositioning in East Asians

BACKGROUND

This study aims to assess the feasibility and efficacy of a three mini-incision upper blepharoplasty combined with simultaneous orbital fat pad repositioning for correcting primary multiple upper eyelid folds in East Asians.

METHODS

A retrospective analysis of 75 patients who underwent three mini-incision double-eyelid blepharoplasty in conjunction with orbital fat pad repositioning for the correction of multiple upper eyelid folds between January 2018 and January 2022 was conducted. During the surgery, the lateral extension of the central upper eyelid fat mass was anchored medially to the upper medial eyelid via three small skin incisions. Postoperative follow-up was carried out to evaluate the improvement in multiple upper eyelid folds, and patient satisfaction was measured.

RESULTS

The follow-up period ranged from 6 to 36 months, with an average of 12 months. Post-surgery, the multiple fold lines were completely resolved in 71 patients (95%), while relapse occurred in 4 patients (5%). The overall satisfaction rate was 88%.

CONCLUSIONS

The three mini-incision double-eyelid blepharoplasty combined with simultaneous orbital fat repositioning is an effective method for correcting primary multiple upper eyelid folds. This technique presents a novel alternative for patients with primary multiple eyelid folds, particularly those who are hesitant to undergo a full-incision double-eyelid procedure.

LEVEL OF EVIDENCE IV

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A Retrospective study of anatomical differences in levator aponeurosis angle and length in East-Asian blepharoplasty

This study aimed to analyze the anatomical differences in levator aponeurosis angle and length between both sides in double eyelidplasty in East Asians. The retrospective study included patients with mild blepharoptosis who underwent upper blepharoplasty with levator aponeurosis. In the study, 140 patients were enrolled, 126 females and 14 males, with an age range of 16-73 years. The mean levator aponeurosis angle was 19.2 ± 2.9° on the right and 17.0 ± 3.8° on the left, which was significantly different (95% CI, p < 0.001). The mean length was 24.1 mm on the right and 23.2 mm on the left, a difference that was also statistically significant (95% CI, p < 0.001). The relationship between the dominant eye and levator aponeurosis prominence was also investigated, although there was no apparent correlation. Within the limitations of the study, it seems that this is the first study of the anatomical differences of the levator aponeurosis between both sides, leading to a greater predictability of surgery to maximize postoperative symmetry.

Ultrasound-based histological differences of pretarsal fat fascia before and after double eyelid blepharoplasty with the orbital septum method

OBJECTIVE

To observe the changes of pretarsal fat fascia histological structure after double eyelid blepharoplasty with the orbital septum method.

METHODS

From December 2019 to February 2022, the patients with congenital single eyelid who underwent double eyelid blepharoplasty with the orbital septum method at the Plastic and cosmetic surgery department of Hunan provincial people's Hospital and the same number of congenital double eyelid volunteers. Then divided into three groups: preoperative eyelid ultrasound images in Group A, postoperative eyelid ultrasound images in Group B, and congenital double eyelid volunteers in Group C. To study the histological differences of pretarsal fat fascia before and after double eyelid blepharoplasty with the orbital septum method and congenital double eyelid by ultrasound.

RESULTS

Ninety-eight patients who underwent double eyelid blepharoplasty with the orbital septum method met the inclusion criteria. All 98 patients aged 22.88 ± 3.00 years, including 7 males and 91 females, followed up for 6-12 months. Included 98 volunteers with congenital double eyelid, aged 23.58 ± 2.59 years, including 49 males and 49 females. Ultrasound showed that the pretarsal fat fascia was divided into two layers. The dense layer adhered closely to the surface of the tarsus with no statistically significant differences. There was a statistically significant difference in the thickness of the pretarsal loose fat fascia layer between Group A and B. The points a b c in Group A were significantly thicker than those in Group B and C, and there was no significant difference between Group B and C. Postoperative evaluation: 83 cases were satisfied, 11 cases were basically satisfied and 4 cases were unsatisfied.

CONCLUSION

After double eyelid blepharoplasty using orbital septum, the histological structure of pretarsal fat fascia is similar to that of congenital double eyelid, suggesting that double eyelid blepharoplasty with the orbital septum method can change the structure of pretarsal fat fascia and make it similar to congenital double eyelid, which is one of the anatomical bases for its good clinical effect.

Comparison of the Clinical Effect of Double Eyelid Blepharoplasty with the Orbital Septum Method and the Classical Method

OBJECTIVE

To observe the clinical effect between orbital septum incision and classical incision of double eyelid plasty.

METHODS

We retrospectively analyzed 381 patients who underwent double eyelid blepharoplasty in the Department of Plastic and Laser Cosmetology of Hunan Provincial People's Hospital from January 2019 to December 2019. The patients were divided into two groups according to different surgical methods: group A (n = 146) received the classical method and group B (n = 235) received the orbital septum method. The incidence of early postoperative complications, scar depression from 6 months to 1 year after the operation, the condition of 'meat strip' (the accumulation of soft tissue in front of the tarsal plate after double eyelid surgery, including skin, muscle, and fascia fat, results in a hypertrophic appearance of the upper eyelid) below the double eyelid line, and the symmetry of double eyelids were analyzed and evaluated.

RESULTS

The total number of early postoperative complications in group A was seven cases (incidence rate: approximately 4.80%), and the total number of early postoperative complications in group B was two cases (incidence rate: approximately 0.85%), with a statistically significant difference (P < 0.05). The degree of scar depression in group B was significantly lighter than that in group A from 6 months to 1 year after the operation (P < 0.05). The score of 'meat strip' below the double eyelid line in group B was significantly lighter than that in group A (P < 0.05). The symmetry of double eyelids in group B was better than that in group A (P < 0.05) CONCLUSION: Compared to the classical double eyelid method, the orbital septum method has the advantages of reducing early postoperative complications, reducing the severity of the scar, slighting the 'meat strip,' and improving symmetry, which results in higher postoperative satisfaction 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 https://www.springer.com/00266 .

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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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

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 .

Secondary Upper Blepharoplasty: Converting Static Folds Into Dynamic Folds

BACKGROUND

For the patients seeking secondary upper blepharoplasty, a static double-eyelid fold featuring an immobile lower flap and depression of the fold is common.

OBJECTIVES

In this study, the authors propose a novel technique of reconstructing pretarsal tissue defects (PTDs) to converting static folds to dynamic folds.

METHODS

A total of 203 patients with static folds underwent revision surgery. After complete adhesion release of the lower flap, a PTD was identified, which was defined as an area deficient of orbicularis oculi muscle in front of the tarsal plate. If the width of the PTD was over 2 mm, tissue transfer was performed to reconstruct the PTD, usually with a free retro-orbicularis oculus fat graft or a pretarsal orbicularis oculi flap.

RESULTS

Among the 105 patients with severe static folds, 67 received retro-orbicularis oculus fat grafts and 38 received orbicularis oculi muscle flaps. This technique converted a static fold into a dynamic fold. The surgery satisfaction rate was 86.7%. Complications included partial fold loss (n = 7, 3.4%), complete fold loss (n = 3, 1.5%), sunken upper eyelids (n = 5, 2.5%), multiple folds (n = 3, 1.5%), an unnatural curve of the double fold (n = 5, 2.5%), and asymmetric folds (n = 4, 2.0%).

CONCLUSIONS

To convert a static fold to a dynamic fold, we devised a technique that releases adhesion of the lower flap and reconstructs the PTD with retro-orbicularis oculus fat graft or an orbicularis oculi muscle flap. Our study achieved a high patient satisfaction rate, and the resulting fold mimicked the dynamics of the congenital double-eyelid fold.

LEVEL OF EVIDENCE: 4

Repair Techniques for Failed Double-Eyelids Involving Restoration of Eyelid Anatomical Structure and Function

BACKGROUND

This study aimed to evaluate techniques for repairing previously failed double-eyelid surgeries based on different anatomical structure injuries.

METHODS

A total of 120 patients with failed double-eyelids in our hospital were enrolled and classified into four types according to their anatomical structure damage: type I, unsmooth radians of the double-eyelid line; type II, upper socket depression; type III, iatrogenic ptosis; and type IV, comprehensive damage. Accordingly, methods of restoration included orbital septum fat supplement, repair of levator palpebrae superioris, and treatment of scar. Postoperative follow-up time points were 1 week, 1 month, and 6 months. Outcome observations were binocular symmetry, fluency of double-eyelid, scar recovery, height and contour profile of the upper eyelid margin, and plumpness of the upper eyelid. The eyelid morphological score was evaluated using photographs of preoperative and 6-month postoperative data, and the effect of eyelid repair was evaluated objectively by statistical analysis.

RESULTS

At 1 month after surgery, the height of the upper palpebral margin was maintained in most patients and located at 1-2 mm below the superior limbus. At 6 months after surgery, most patients had better restorative effects. Comparison of mean eyelid morphological scores showed a statistically significant improvement following surgery (P < 0.001).

CONCLUSIONS

The technique of restoring eyelid anatomical structure in failed double-eyelids not only recovered the normal function of injured eyelids but also produced satisfactory aesthetic effects.

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 modified mini-incisional technique for double-eyelid blepharoplasty

BACKGROUND

Double-eyelid blepharoplasty is one of the most popular cosmetic surgeries in Asia.

OBJECTIVE

To introduce a modified mini-incisional technique to form a double eyelid.

METHODS

A total of 372 patients (325 women, 47 men) were involved in the study between July 2008 and August 2014. Their age ranged from 16 to 34 years, with a mean age of 24 years. All patients underwent the modified mini-incisional upper blepharoplasty. In the technique, four 2 mm incisions were made along the designed fold. The orbicularis muscle overlying the levator aponeurosis was removed. The removal of the lateral fat pad was completed accordingly. The medial fat pad was also removed if necessary. Suture was used to fix the skin to pretarsal fascia along the double-eyelid line. The double-eyelid crease was formed after the operation.

RESULTS

The follow-up period was three to 12 months (mean nine months). Most of the double eyelids were natural. During the follow-up period, 92% (342 of 372) patients were satisfied with the blepharoplasty. The most common complications were swelling within first week after the operation, which subsided spontaneously. Asymmetries occurred in 17 patients; six patients had multiple eyelids and seven patients experienced shifting of the fold. These were corrected six months after the operation. Disappearance of the fold was not observed. The scars of the stab incision became invisible after one full year of recovery. No other severe complications were found.

CONCLUSION

The four mini-incisional blepharoplasty technique was successful for the formation of a natural-appearing and long-lasting double eyelid. Except for individuals with obvious skin redundancy, patients with a single eyelid are suitable candidates for the technique.

A modified mini-incisional technique for double-eyelid blepharoplasty

Background

Double-eyelid blepharoplasty is one of the most popular cosmetic surgeries in Asia.

Objective

To introduce a modified mini-incisional technique to form a double eyelid.

Methods

A total of 372 patients (325 women, 47 men) were involved in the study between July 2008 and August 2014. Their age ranged from 16 to 34 years, with a mean age of 24 years. All patients underwent the modified mini-incisional upper blepharoplasty. In the technique, four 2 mm incisions were made along the designed fold. The orbicularis muscle overlying the levator aponeurosis was removed. The removal of the lateral fat pad was completed accordingly. The medial fat pad was also removed if necessary. Suture was used to fix the skin to pretarsal fascia along the double-eyelid line. The double-eyelid crease was formed after the operation.

Results

The follow-up period was three to 12 months (mean nine months). Most of the double eyelids were natural. During the follow-up period, 92% (342 of 372) patients were satisfied with the blepharoplasty. The most common complications were swelling within first week after the operation, which subsided spontaneously. Asymmetries occurred in 17 patients; six patients had multiple eyelids and seven patients experienced shifting of the fold. These were corrected six months after the operation. Disappearance of the fold was not observed. The scars of the stab incision became invisible after one full year of recovery. No other severe complications were found.

Conclusion

The four mini-incisional blepharoplasty technique was successful for the formation of a natural-appearing and long-lasting double eyelid. Except for individuals with obvious skin redundancy, patients with a single eyelid are suitable candidates for the technique.

Three mini-incision double-eyelid blepharoplasty

Although there are many procedures reported in the literature regarding the partial incision double-eyelid blepharoplasty, the current methods still have potential problems such as unstable and limitation of application. In this study, the authors developed a 3-mini-incision technique that minimizes tissue injury and provides a tough connection between the levator aponeurosis and skin. With this method, 3 minute incisions (3-4 mm) are made in the upper eyelid. Through these incisions, the whole strip of pretarsal orbicularis oculi muscle under the inferior incision line and the excessive fat can be removed. This technique gives a stable and natural-looking supratarsal fold, with invisible scar, minimal complications, and a short recovery period; and can be applied to patients with fatty eyelids. This method has the benefits of both nonincisional and full-incisional techniques, and avoids the disadvantages of the current partial incisional methods.

[Evaluation of a short incision double eyelidplasty for Asian patients]

BACKGROUND

Creation of a double upper eyelid is a popular procedure in Asian countries. Many incisional and non-incisional approaches have been described to create a new suprapalpebral fold.

OBJECTIVE

The authors recommended a short incision technique to create a double eyelid and evaluated the results.

METHODS

The location of the partial incision was determined pre-operatively with the patient. A one-centimeter partial incision was made on the middle one-third of the upper eyelid, and the orbicularis oculi muscle was dissected. Three anchoring stitches were placed for the creation of the permanent suprapalpebral fold. Those stitches were inverted single knots which linked the tarsal plate to the lower margin's dermis or dermomuscular junction of the incised skin. Intra-operative adjustment of position and curvature of the new fold was done by the active opening of the upper eyelid. Global results, symmetry and design were evaluated by the patient and one independent surgeon.

RESULTS

Between January 2012 and January 2013, a total of 10patients were operated using this technique. All patients were satisfied, with 8results graded excellent and 2results graded good. The average operation time was 20minutes. There were no serious complications, the only unfavorable outcome was one persistent bruise. The follow-up period was one year. Recovery time varied from 2weeks to a month. No correction procedure was needed.

CONCLUSIONS

The short central incisional technique for creation of a double eyelid described here provides excellent permanent and natural results, with no visible scar nor serious complications.

Tension and distortion of the upper double eyelid by a nonincision method

The aim of this study was to compare the suture tension and the extent of distortion according to the continuous and interrupted suture methods. An in vitro eyelid model of 10-cm length and 5 layers was made with a 3-layer skin pad for the skin, muscle, and aponeurosis and silicone sheet and sponge for the tarsal plate and conjunctiva. The thickness of the model was 11.8 mm. All interrupted sutures were used in Khoo's method, the buried method, and Mikamo's method, and a continuous suture was applied in the 2-loop en bloc method, the subconjunctival buried method, and Maruo's method. The thickness of the eyelid was measured with a custom-made micrometer that had tacks attached on a measuring bar. The tension was measured with a force-gauge. The distortion in the interrupted suture methods was 15.2% ± 3.4% of the original thickness, and it was significantly greater than the 3.3% ± 2.8% of the original thickness in the continuous suture methods (P = 0.000, t- test). In the interrupted suture methods, Khoo's method showed the greatest rate of distortion (16.9% ± 4.5%), and this was followed by Mikamo's technique (14.5% ± 2.5%) and the buried suture method (13.6% ± 1.4%). For the continuous suture methods, the 2-loop en bloc method showed the least tension (0.33 ± 0.05 N), and this was followed by Maruo's method (0.41 ± 0.07 N) and the subconjunctival buried suture method (0.45 ± 0.07 N). The tension of the suture at each loop was significantly greater (P = 0.000, t-test) in the interrupted suture methods (0.52 ± 0.07 N) than that in the continuous suture methods (0.41 ± 0.08 N). For the interrupted suture methods, Khoo's methods showed the greatest rate of tension (0.54 ± 0.06 N) compared with the buried suture technique (0.51 ± 0.08 N) and Mikamo's technique (0.48 ± 0.07 N). For the continuous suture methods, the 2-loop en bloc method showed the least tension (0.33 ± 0.05 N), followed by Maruo's method (0.41 ± 0.07 N) and the subconjunctival buried suture method (0.45 ± 0.07 N). We contend that a continuous suture method causes minimum notching, whereas an interrupted suture method causes less incidence of double-fold fading.

Asian blepharoplasty

One of the defining features between an individual of Asian descent and someone of Western descent is the presence of an upper eyelid crease. Approximately 50% of Asians do not have an upper eyelid crease. The double eyelid operation, or creation of a supratarsal crease, is the most common cosmetic procedure requested in Asia and the third most common procedure requested by Asian Americans. In this comprehensive article, we explore the art of creating an eyelid crease in the individual who either does not have a crease or has an indistinct crease. We will review the history of the development of Asian blepharoplasty, explain the anatomy of the Asian eyelid and how it differs from the Caucasian eyelid, and clarify how this anatomy then translates to differences in external appearance. The two main schools of surgical techniques will be discussed along with pearls, pitfalls, and personal observations.

Oriental upper blepharoplasty

Aesthetic surgery of the upper eyelids is a very common procedure performed in cosmetic practices around the world. The word blepharoplasty, however, has a different meaning in Asia than it does elsewhere. Orientals have different periorbital anatomic characteristics, their motivations for seeking eyelid treatment are different, and operative techniques have been adapted consequently. There are also many eyelid shapes among Orientals, mostly with regard to the presence and location of the supratarsal fold and/or presence of an epicanthal fold. The surgeon must therefore master a range of surgical procedures to treat these variations adequately. It is critical to know the indications for each blepharoplasty technique as well as their complications to select the right surgery and avoid unfavorable results. Epicanthoplasty performed on the right patient can greatly improve aesthetic results while retaining ethnic characteristics. This article will discuss Oriental eyelid characteristics, preoperative patient assessment, commonly used corrective techniques for the "double-eyelid" creation, and complications and how to avoid them.

Asian blepharoplasty--an overview

Asian blepharoplasty has evolved over the years as greater understanding of the differences between the Asian and Caucasian eyelid anatomy has led to the development of modified techniques for upper lid blepharoplasty. The aim of Asian upper blepharoplasty is to create a pleasing and permanent upper lid crease. This article reviews the differences in the anatomy and the various techniques currently employed.

A Method in Creation of the Superior Palpebral Fold in Asians Using a Continuous Buried Tarsal Stitch (CBTS)

A simple stitch method in constructing the superior palpebral fold in Asian upper eyelids is described. Using a 7-O SurgiPro continuous stitch and securing six consecutive transcutaneous intratarsal fixations, the author was able to produce a consistent natural result with high success rates and no noticeable scar in over 500 cases over a 5-year period.

Upper eyelid gold weight implantation in the Asian patient with facial paralysis

Patients with facial paralysis may develop ophthalmic complications. Poor eyelid closure and lagophthalmos place the patient at increased risk for the development of corneal problems such as epithelial defects, stromal thinning, bacterial infection, and even perforation. Initial treatment should be conservative and include the use of ocular lubricants, moisture chambers, and taping of the lower eyelid into proper position. Surgical intervention may be required in patients who have failed medical therapy or in whom the facial paralysis is not expected to improve. Gold weight implantation in the upper eyelid has become a popular procedure to correct upper eyelid retraction and to improve corneal coverage. Previous descriptions of gold weight placement in the upper eyelid have focused on Caucasian eyelid anatomy. However, there are distinct anatomic differences between the Caucasian and Asian eyelids, which dictate the overlying aesthetic differences. We describe our technique for placement of a gold weight in the Asian upper lid, with attention to the maintenance of symmetric eyelid creases. We reviewed the charts of six Asian patients with facial paralysis who underwent gold weight placement in the upper eyelid for the correction of lid retraction. All patients did well functionally and aesthetically, and none developed an extrusion of the implant with this approach.

Orbicularis-levator fixation in double-eyelid operation

One of the characteristic features of the East Asian person's eyelids is the lack of a supratarsal fold. A relaxed upper eyelid skin, due to the lack of supratarsal fixation, causes coverage of the tarsal margin of the upper eyelid. Thus the palpebral fissure looks smaller, giving a slit-eye appearance. Unlike those lids with a natural supratarsal crease, the levator palpebrae muscle and/or aponeurosis does not extend and attach to the pretarsal skin. The purpose of the double-eyelid operation is to create a supratarsal fold in the eyelids of Asian patients. Numerous surgical procedures have been developed to establish adherence between the levator aponeurosis and the eyelid skin. There are 2 main goals for this procedure: (1) a smooth, tight skin below the newly created supratarsal crease and (2) firm fixation between the levator aponeurosis and the skin to prevent relapse to a single eyelid. Most procedures described rely on loose cicatrization between the skin and the levator aponeurosis.

Systematic approach and selective tissue removal in blepharoplasty for young Asians

Although the double eyelid operation was initially designed to create supratarsal folds in Asians, it has evolved into a cosmetic procedure to make Asian eyelids more aesthetically pleasing. Therefore, it is appropriate to call it "blepharoplasty for young Asians." All the candidates for this operation desired natural-looking attractive eyelids with double folds, which is far from puffiness and severe epicanthus. Two hundred forty-one patients underwent "blepharoplasty for young Asians" from 1991 to 1996 at Asan Medical Center, and they were performed by one surgeon (Yoon). A systemic approach has been adopted for the procedure: first, the size of the folds is determined; second, debulking of the upper eyelids and handling of the epicanthus is taken into consideration in relationship with future folds. In addition to creating folds, half Z-plasty is used to alleviate the epicanthus, and a selective tissue removal technique is applied to titrate the amount of puffiness in the upper lids.

Double eyelid operations

The double eyelid in the Chinese population is a desirable physical feature, which is now increasingly popular and demands modern up-to-date aesthetic operations for its formation. The author describes 3 types of double eyelid operations, e.g., the ligation method, the incision method, and the skin grafting method. The advantages, disadvantages, and indications for each of these methods are evaluated and discussed. The creation of a double eyelid from an anatomic point of view is especially emphasized, with the illustrations of the anatomy and the operation made by the senior author.

Blepharoplasty for orientals

The creation of palpebral folds in the upper eyelids of Orientals is a cosmetic operation requested by patients who wish to "Westernize" their eyes. The anatomy of the Oriental and Occidental eyelid is discussed. Two surgical techniques of operation are described and illustrated.

Blepharoplasty to form the orbitopalpebral sulcus and nasal bone graft in oriental subjects (Occidentalization)

The procedures of blepharoplasty and rhinoplasty have been applied successfully, alone or in combination, to the occidentalization of Oriental patients for aesthetic reasons. The blepharoplasty, using the Sayoc-Millard technique, and the rhinoplasty, using an autogenous osteoperiosteal graft from the crest of tibia, are described in detail.

Surgery for oriental eyelids: Some refinements in technique

Surgery of Oriental eyelids falls into two broad groups. One method uses the conjunctival approach, and the other, the external skin approach. Technical refinements in the skin approach method which the author has developed over the last 10 years are described.

Aesthetic surgery of Oriental eyelids

The technique for creation of a double eyelid with simultaneous reduction of the mongolian fold is presented as representative of aesthetic surgery of Oriental eyelids. The author's principle in correcting the mongolian fold is to first reduce the lining layer as a framework of the fold and then trim excess skin.

Surgical revision of the upper eyelid fold

We performed surgery on 107 patients primarily with blepharoptosis and eyelid fold abnormalities, between 1973 and 1974. Production of an eyelid fold at the time of an initial blepharoptosis procedure should be a primary goal. Lack of a distinct symmetrical upper eyelid fold constituted a cosmetic blemish and necessitated revision.