Medial Epicanthoplasty with the Skin Re-Draping Technique: Technical Refinements for Predictable outcomes

The epicanthus is a common feature of the Asian eyes. A prominent medial epicanthal fold gives the impression of a blunted affect and the procedure for its removal, the medial epicanthoplasty, is a very commonly requested by Asian patients. This may be performed as an isolated procedure or more commonly in combination with the upper blepharoplasty. Many conventional medial epicanthoplasty techniques are based on skin flaps transposition and excisions, usually variations of the V-Y, W or Z-plasties (1-4). While these have been variably successful at correcting the epicanthal fold, the common problem is significant scarring in the medial canthal and lower eyelid regions (5-8). This is particularly problematic in Asian patients with greater tendencies for hypertrophic scarring and scar hypo or hyper-pigmentation (9). Recently, the skin re-draping method, designed with incisions limited within the margins of the medial canthus and precise and targeted disruption of the underlying fibromuscular tissues, has emerged as the preferred surgical technique for many Asian surgeons because of its effectiveness and superior aesthetic outcomes(6, 10-12). This technique delivers the most inconspicuous incisions and is advantageous because it is effective in eliminating epicanthal folds of various severities. Precise execution of this technique is difficult, given the complex 3-dimensional anatomy of the epicanthus. This paper presents a detailed explanation of surgical concepts of the skin re-draping epicanthoplasty and provide a step-by-step guide to performing this procedure in a safe and effective manner.

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 .

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

INTRODUCTION

Upper eyelid ptosis correction is a challenging procedure. Here we report a novel approach to this procedure which we have found to be more accurate and predictable compared to conventional approaches.

MATERIALS AND METHODS

A pre-operative 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. The factors considered include 1) the amount of upper lid elevation required, 2) degree of compensatory brow elevation present 3) eye dominance. Our pre-operative assessment and surgical technique are presented in a series of detailed operative videos. The levator advancement is performed as planned pre-operatively with final adjustment made intraoperatively to achieve correct lid height and symmetry.

RESULTS

Seventy-seven patients (154 eyelids) were prospectively analyzed in this study. We have 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. Our revision rate was 4.

CONCLUSIONS

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

Delayed prosthetic seroma: a localized inflammatory response to COVID vaccination and infection?

We present a patient whom we believe developed a late abdominal mesh collection in response to COVID-19 mRNA vaccination booster and COVID-19 infection. A polypropylene mesh was placed during her right breast reconstruction operation 2 years ago where she underwent a right transverse abdominis rectus muscle (TRAM) free flap. She recovered uneventfully from this operation. This lady, though vaccinated, developed respiratory symptoms and tested positive for COVID-19 infection 3 days after her booster injection. She then noticed right-sided abdominal swelling 3 days after the onset of respiratory symptoms. She only presented 1 month later due to a 7-day history of pain at the site of abdominal swelling. A computed tomography scan confirmed the presence of a seroma, and she underwent ultrasound-guided percutaneous drainage. A COVID Antigen Rapid Test of the fluid returned positive, though the PCR swab returned negative. There have been no published reports of periprosthetic mesh seroma after COVID-19 vaccination or infection to date. We wanted to share our experience so that other surgeons may be aware of this potential presentation given the current ongoing pandemic. Level of evidence: Level V, risk/prognostic.

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 Face Lift with the Composite Face Lift Technique

BACKGROUND

The composite face lift is becoming increasingly popular following recent advances in understanding of facial anatomy that enable safe sub-superficial musculoaponeurotic system (SMAS) dissection. This article presents the authors' technique for composite face lift in Asian patients and reviews their experience and outcome with this procedure.

METHODS

Composite face lifts were performed on 128 Asian patients between January of 2010 and June of 2020. Ninety-four were primary face lifts, and 34 were secondary or tertiary face lifts. The authors' surgical technique and adaptations for the specific requirements of Asian patients are described in detail. The mean follow-up was 26 months (range, 6 to 108 months). Fat grafting was an integral part of our procedure, with 95 percent having concomitant facial fat grafting with their face lift.

RESULTS

Patients were followed up in accordance with a standardized schedule. The majority of patients reported high satisfaction with the aesthetic outcome of the technique, with natural, long-lasting results. The face lift plane of dissection is through the facial soft-tissue spaces, which provide atraumatic sub-SMAS access with precise release of the intervening retaining ligaments for effective flap mobilization. By emphasizing tension on the composite flap with no tension on the skin closure, the scars were discrete in the great majority of patients. Complications were few, with no hematomas or skin flap necrosis. The temporary nerve injury rate was 1.5 percent, with no patient having a permanent nerve injury.

CONCLUSION

The composite face lift is an ideal technique for Asian patients, as it delivers natural, long-lasting results; a quick recovery; and high patient satisfaction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Comprehensive Approach to Asian Upper Eyelid Ptosis Correction: The Levator Musculo-Aponeurotic Junction Formula

BACKGROUND

The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement technique for ptosis correction to achieve predictable and reproducible outcomes.

OBJECTIVES

The levator musculo-aponeurotic junction was employed as they key landmark. With a formula developed by the authors, the location of fixation relative to this landmark can be predicted preoperatively. The authors' clinical experience and outcomes with this technique are presented.

METHODS

Inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with acquired or congenital ptosis and primary and revisional cases were all included. The location for placement of the advancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was determined by a formula that considers (1) the amount of elevation of the upper eyelid margin needed, (2) the degree of compensatory brow elevation present, and (3) eye dominance.

RESULTS

A total 156 Asian patients were included in this prospective study. Of these, 148 were bilateral and 8 were unilateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point on the levator was accurate to within ±1 mm in the majority of patients. The aperture revision rate was 2%.

CONCLUSIONS

This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in Asian patients.

LEVEL OF EVIDENCE: 4