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.

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 .

Periorbital Fat Grafting: A New Paradigm for Rejuvenation of the Eyelids

Fat grafting represents the most important new addition to surgical procedures to rejuvenate the orbit since the inception of the "blepharoplasty" technique. Traditional blepharoplasty procedures do not always address the changes that occur with age in the orbital area and can actually degrade the appearance of the eye. Fat grafting allows treatment of age-associated loss of periorbital volume not addressed by traditional blepharoplasty procedures. Fat grafting is an artistically powerful method to rejuvenate the periorbital orbital area that often provides a more healthy, fit, youthful, and sensual appearance than traditional blepharoplasty procedures.

Corrective Strategies for a Complex Deformity Caused by "European-Style Double Eyelid" Blepharoplasty in Asians

BACKGROUND

"European-style double eyelid" blepharoplasty often leads to a complex deformity, which includes one or more of the following features: a high fold, upper eyelid depression, multiple folds, an obvious scar, blepharoptosis, and lower flap tumidness. However, there is still a lack of comprehensive research on evaluation and treatment strategies for this complex deformity.

METHODS

During a 6-year period, 65 patients (106 eyes) with a high fold and upper eyelid depression underwent corrective blepharoplasty. The authors classified this complex deformity as mild, moderate, or severe based on the extent of adhesion and tissue insufficiency, and we performed preaponeurotic fat flap transfer in 47 eyes (44.3%), free fat graft in 35 eyes (33%), and free dermis-fat graft in 24 eyes (22.6%), respectively.

RESULTS

The outcomes in 87 eyelids were judged as excellent; and the grading was excellent in 41 eyes (87.2%) that underwent preaponeurotic fat flap transfer, 30 eyes (85.7%) that received a free fat graft, and 16 eyes (66.7%) that received a free dermis-fat graft. The outcomes in only 3 eyes (2.8%) were evaluated as unsatisfactory.

CONCLUSIONS

The fundamental reasons behind this deformity were adhesion and tissue insufficiency above the supratarsal crease. The purpose of correction was to reconstruct the gliding system and restore the volume. The authors performed preaponeurotic fat flap transfer, free fat graft, and free dermis-fat graft and achieved satisfactory results. Great improvement in ptosis was achieved by releasing the adhesion and lowering the fold in patients with normal levator muscle function.

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 Blepharoplasty: Correction of the High Fold

BACKGROUND

Blepharoplasty is a common aesthetic surgery performed worldwide. In Asians, too high eyelid folds after blepharoplasty cause an unsatisfactory aesthetic outcome that is difficult to correct. In this article, the authors propose surgical techniques to correct the high eyelid fold after blepharoplasty.

METHODS

During a 4-year period, 213 secondary blepharoplasties were performed to correct high folds. Postoperative results were reviewed, graded, and analyzed.

RESULTS

Of 213 cases of secondary blepharoplasty to correct the high eyelid fold, almost all could achieve reduction of the fold size (98.59 %). One hundred and nine cases (51.17 %), 69 cases (32.40 %), and 32 cases (15.02 %) were classified as excellent, good, and fair results, respectively. Only three cases (1.41 %) were classified as poor results.

CONCLUSION

Secondary blepharoplasty to correct a high fold is a challenging procedure for aesthetic surgeons. Surgeons performing this operation need to have a thorough understanding of eyelid anatomy and its dynamics together with familiarity with secondary blepharoplasty to avoid any further injury to the levator muscle. The key points of this surgery are levator advancement and intervening between the levator aponeurosis and the overlying skin by in situ tissue or fat grafting.

LEVEL OF EVIDENCE V

This journal requires the authors to 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 .