ASIAN BLEPHAROPLASTY

AND THE EYELID

CREASE
 “Asian blepharoplasty is a highly specific form
of upper blepharoplasty, adapted to each
individual’s findings and demands the highest level
of understanding, a focused mind and manual
dexterity to achieve the proper result.”
ASIAN
BLEPHAROPLASTY
AND THE EYELID
CREASE THIRD EDITION

William Pai-Dei Chen MD FACS

Clinical Professor of Ophthalmology
Department of Ophthalmology
University of California, Los Angeles, School of Medicine
Los Angeles, California, USA

Senior Attending Surgeon

Ophthalmic Plastic Surgery Service
Harbor-UCLA Medical Center
Torrance, California, USA

Private Practice
Irvine and Newport Beach, California, USA
www.asianeyelid.com

Illustrations by
Paul Kim

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2016
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First edition 1995

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Third edition 2016

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Notices

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broaden our understanding, changes in research methods, professional practices, or medical
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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
With a contribution from

(the late) Khoo Boo-Chai MD

Formerly Surgeon Director, Khoo Plastic Surgery
Clinic, Singapore
Visiting Professor, Third Teaching Hospital,
Department of Plastic Surgery
Beijing University, PR China
Visiting Professor, Shanghai Second Medical University
Ninth Hospital, Department of Plastic Surgery
Shanghai, PR China
 To my parents, Fred and Katie,
my family (Lydia, Katherine and Andrew),
and my mentor Dr Clinton (Sonny) McCord
 VIDEO TABLE OF CONTENTS
All videos are supplied by Dr WPD Chen
1 Primary Asian blepharoplasty for a 29-year-old
female, desired nasally tapered crease, shows treat-
ment of medial canthal fold and up-knotting
2 Primary Asian blepharoplasty for a 26-year-old
female, who desired parallel crease. Video shows
up-knotting
3 Revisional Asian blepharoplasty on a woman who
desired parallel crease shape
4 Revisional Asian blepharoplasty for a 19-year-old
female who showed shallowing of crease from resid-
ual fat
5 Primary Asian blepharoplasty for a 36-year-old
female. Desired nasally-tapered crease shape, and of
above-average crease height. Shows down-knotting
6 Primary Asian blepharoplasty combined with ptosis
repair for a 65-year-old female
7 Primary Asian blepharoplasty for 62-year-old female
with presence of sulcus and multiple wrinkles, without
true eyelid crease
8 Repeat Asian blepharoplasty for 41-year-old male,
previous Asian blepharoplasty by Chen was 9 years
prior. One can identify the compartments well
9 Primary Asian blepharoplasty for a 48-year-old
female. Has sulcus preoperatively; desires a nasally-
tapered crease shape, with lower-than-average crease
height
10 Revisional Asian blepharoplasty in 28-year-old female
who presented with crease asymmetry. Desired
medium height NTC crease and excised 1 mm scarred
skin. Shows down-knotting
11 An introductory case showing the general concepts
and steps involved in Primary AB on a right upper
eyelid
12 Another case showing the general steps involved in
Primary AB on a right upper eyelid
13 Primary case of a 30-year-old female with OD absent
crease and OS rudimentary crease desiring a higher
than average parallel crease
14 Primary case of a 22-year-old female desiring a paral-
lel crease, having previously used adhesive tape over
pretarsal area
15 Primary case of a 22-year-old male with left eye
fissure appearing larger. Patient desires a low-set par-
allel crease
viii
16 Primary case of a 31-year-old male with an absent
crease, desiring an average height parallel crease
17 Revisional surgery on a 41-year-old Korean female
who had previously undergone upper blepharoplasty
18 Revisional surgery on a 60-year-old female who had
previously undergone blepharoplasty and a subse-
quent revisional attempt whereby abdominal fat had
been injected into the upper lids two years previously
19 Primary case of a 31-year-old female with absent
crease desiring average height NTC
20 Primary case of a 52-year-old male with no crease and
moderate hooding
21 Revisional surgery on a 68-year-old female with per-
manent eyeliner. This patient had deepened sulcus
from blepharoplasty and a scarred crease at 8 mm
22 Revisional surgery on a 43-year-old female present-
ing for RUL revision
23 Revisional surgery on a 43-year-old female present-
ing for LUL revision
24 Revisional surgery on a 35-year-old male presenting
for NTC
25 Primary case of a 28-year-old female with fatty, heavy
lids
26 Primary case of a 31-year-old male with an absent
crease and a truncated upper lid hooding, desiring a
parallel crease of average height
27 Primary case of a 37-year-old female with a shielded
NTC crease OU with more hooding of the left eye,
desiring greater than average NTC
28 Revisional surgery on a 38-year-old female who had
previously undergone revision, desiring the crease to
be reset again
29 Revisional surgery on a 46-year-old female who
had previously undergone three separate crease
procedures
30 Primary case of a 26-year-old male with an absent
crease, desiring a parallel crease
31 Demonstration of effect of high crease placement on
levator muscle function
32 Paper model demonstration of effect of higher-than-
normal attachment on sheets of paper relative to each
other
33 Demonstration of orbital pulley fixation of medial
rectus muscle with recession in strabismus repair for
congenital esotropia in a 3 year-old boy

This new edition of my book on the topic of Asian eyelid
surgery, specifically on the ‘double-eyelid crease’ opera-
tion, is a complete update and further expands on what I
feel to be highly relevant functional topics related to the
eyelid crease. Its readership will include house officers/
residents in training, practitioners and seasoned surgeons
in the fields of plastic surgery, ophthalmology (including
oculoplastic surgery), facial plastic/head and neck sur-
geons (ears, nose and throat), cosmetic surgeons and der-
matologists interested in learning about aesthetic surgery
of the Asian eyelid. (I have also had some patients who
have read the book prior to seeing me.) In essence, it is
a manual for learning upper blepharoplasty at a highest
level of precision.
There are two main schools of techniques, the external
incision methods and the buried sutures methods. (I
prefer to avoid using the misleading terms of ‘non-
incisional’ or ‘no-cut’ method for the buried sutures
method. These are terms often used indiscriminately in
Asia, with patients often unaware of the use of perma-
nent, non-dissolvable buried sutures.) Overall the data
are unclear about the incidence for each main category,
but it is probably in the range of 70–90% of cases world-
wide using external incisional methods. (My own discus-
sion with Dr Khoo Boo-Chai from Singapore 10 years
ago was that in his busy practice he would select only
about 5% of his patients as appropriate candidates for the
buried sutures technique.) This figure is highly variable
region to region, as there are physicians who do either
one or the other method exclusively. Based on statistics
published by the American Society for Aesthetic Plastic
Surgery, there has been a doubling of surgical cosmetic
procedures over the last 15 years in the United States. (If
one adds nonsurgical cosmetic procedures, defined as
Botox, fillers, chemical peels and micro-dermabrasion,
the increase over the 15 years is almost seven-fold.) It is
reasonable to expect this similar explosion in procedures
in Asia, perhaps even more in China and Korea. Even
though there have been more than a dozen papers on
variations of buried suture methods published in the last
five years (in first- and second-level journals), I am unsure
whether this translates into an increase in cases using the
small incision buried sutures methods.
As compared to the original text, Asian Blepharoplasty:
A Surgical Atlas (1995), which described the basic
techniques and concepts, and the second edition, Asian
Blepharoplasty and the Eyelid Crease (2006), which provided
an introduction to the lid crease’s functional dynamics,
this new edition includes a detailed analysis of the biody-
namics of the lid crease as well as its functional vulner-
ability. Therefore in a sense the book has come full circle,
PREFACE
and could be titled just as well as The Eyelid Crease and
Application in Asian Blepharoplasty. The content here is a
meticulous discussion of the eyelid crease: it is the portal
to the upper lid whenever a physician plans upper eyelid
surgery, whether functional or aesthetic. For an eyelid
surgeon, learning how to enter and exit the upper lid with
functional integrity and ideal wound healing, while con-
trolling the appearance of the lid crease, is an essential
skill.
The book’s 26 chapters offer an extensive treatment of
the arrays of techniques available up to present. Seven
new chapters are included on more advanced understand-
ing. The advanced concepts start with Chapter 17 on the
concept of the preaponeurotic space and fat as a ‘glide
zone’, followed by Chapter 18 on the beveled approach
in revisional Asian blepharoplasty. (These two chapters
have been carried over from the second edition and are
an essential bridge to advanced understanding.) A greater
emphasis is now placed on correlating the sensitivity and
vulnerability of the lid crease formation to various aspects
of techniques and suture placement. The new advanced
chapters include observation and measurement of crease
height based on head position (Chapter 19), the effect of
tarsal tilt in various clinical conditions (Chapter 20), the
impeding effect of misplacement of buried sutures
and high anchoring (the Faden effect) (Chapter 21), an
advanced summary of eyelid crease factors (Chapter 22),
and a new concept chapter on the eyelid crease as a
stringed series of unipoints (Chapter 23). In addition, I
have added Chapter 25 on my own techniques that may
be used to reduce the medial upper lid fold during Asian
blepharoplasty without the need for more exaggerated
epicanthoplasty cuts – a trend that seems to have reached
a frenzy for the moment in Korea and China. The con-
cluding Chapter 26 covers a novel hybrid technique for
those surgeons favoring a less-than-full skin incision,
combining a partial incision with use of a single buried
suture medially. There has been a proliferation of pub-
lished papers in the last 10 years, especially from Asia,
the birthplace for this procedure, and I have made great
efforts to be inclusive of these references. However, I
apologize if the need for conciseness and clarity have
prevented me from being all-inclusive, and at times for
taking a subjective, judgmental viewpoint.
The illustration content in this new edition has
doubled, in both photos and drawings, and the use in this
edition of colored three-dimensional cross-sectional
drawings facilitates a quick grasp of the concepts. Detailed
intraoperative findings are included in many of the clini-
cal cases from the author’s personal notebook. The
accompanying surgical videos are accessible through
ix
x Preface
ExpertConsult and have been expanded to 30 surgical
cases. The added videos were recorded using current
generation equipment and provide greater detail.
The current project involved the use of high resolu-
tion cameras from Canon, Nikon, Panasonic Lumix with
Leica lens and even an iPhone camera. I use a MacBook
Pro and a Mac Mini computer with a 27” Thunderbolt
display to collate most of the work. For some photo-
graphs, only cropping and brightness adjustments were
used. All of the drawings from the previous edition have
been redrawn and colorized; all of the added drawings
are paired with detailed captions.
Favorite features such as ‘Pearls’ and ‘Pitfalls’ have
been carried over from the previous edition, as well as
convenient comprehensive spreadsheet listings of rele-
vant literature in the Appendices, which has been brought
fully up to date. There is an additional new Appendix
listing recent papers on epicanthoplasty.
I have been involved in resident-teaching for over 30
years and with teaching the concepts of Asian blepharo-
plasty through the American Academy of Ophthalmology
for 25 years, during which time I have published seven
textbooks. My preference, supported by feedback that I
receive from readers, has always been to use a simple
writing style that focuses on conveying ideas rather than
getting entangled in complicated anatomic terms and
medical English. This new edition is offered in that same
style. The popularity of the second edition was soon fol-
lowed by an unforeseen global recession, and it is a joy
for me now to be able to continue my exploration on this
topic.
The book is meant for use by medical professionals in
learning the techniques and concepts of Asian blepharo-
plasty, as well as being a comprehensive treatise on this
topic from 1896 to present. It is not meant in any way
for use as an illustrative guide for physicians to show to
their patients, nor for patients searching for medical
guidance or as a substitute for proper medical consulta-
tion. The final determinant in surgical outcome always
depends on full understanding as well as an open dialogue
between physician and patient. One should not draw on
these illustrations as examples applicable to any particular
individual nor as a basis to arrive at medical decisions.
As before, I wish to thank Dr Kenichiro Kawai of
Osaka University Graduate School of Medicine for
allowing me to re-use his anatomic drawing and stereo-
scopic photograph from his upper eyelid vascular arcade
research paper, as well as sincerely acknowledging with
remembrance the late Dr Khoo Boo-Chai of Singapore,
a pioneer in this field, for his generous teaching when I
first asked him about his techniques and his views on
suture methods versus external incision techniques.
 ACKNOWLEDGMENTS
I am blessed with a great team from Elsevier in making
this edition possible; their assistance along the way was
highly significant in keeping me on track. As the subject
gets complicated and the demand for detail increases, the
precision I require of myself as an author and what I ask
of the team members rises significantly. The recipients of
this demand included our team leader Rus Gabbedy,
Executive Content Strategist of Elsevier (London),
Carole McMurray (Content Development Specialist,
Edinburgh) and John Leonard (London), who assisted
with manuscript development; and the art team, who
included Karen Giacomucci (Elsevier, Philadelphia) and
her art team members Paul Kim (New Jersey), Vicky
Heim (Atlanta, Georgia) and Jade Myers. The video
effort and online resource development at Inkling is led
by Jonathan Davis, Multimedia Producer of UK/EMEA–
Elsevier Ltd (based in Oxford). Julie Taylor (Publishing
Project Manager, Oxford) and Elaine Leek (copy editor)
helped organize the text and illustrations and correct all
our mistakes. To them, I wish to offer my greatest acco-
lades for a job well done, working with me through dif-
ferent time zones and work schedules, via emails and
phone calls. I really appreciate their guidance.
I could not have completed the project without the
support of my family, Lydia, Andrew and Katherine, as
well the foundation of knowledge imparted to me during
my formative training under my mentor, Dr Sonny
McCord in Atlanta, Georgia. I am grateful.
xi
 CHAPTER 1

WHAT IS AN UPPER LID CREASE?

In common usage, the eyelid crease is often meant to

describe a natural inward creasing of the skin seen in the
upper eyelid, typically dividing it into a lower segment
adjacent to the upper eyelashes, and an upper segment of
skin that runs from the crease to the border of the
eyebrow.
The crease is present in about 50% of the Asian popu-
lation, and found to be more prevalent in all non-Asians.
The presence of a crease in an Asian subject is what dif-
ferentiates a double eyelid (with a crease unequally divid-
ing the lid into two sections, hence ‘double’) from a single
eyelid (or mono-lid).
Double-eyelid crease surgery (procedures) is a form of
surgery to add or supplement an eyelid crease to an indi-
vidual who seeks it. This is often for an individual who
FIGURE 1-2 ■ Japanese Kanji characters for ‘single eyelid’ (left)
does not have a crease, or who finds their crease is insuf- and ‘double [two] eyelid’ (right).
ficient, or in whom the crease is unbalanced between the
two sides.
The configuration of the upper lid crease in Asians
varies greatly. The terminology used to describe these
configurations also varies, depending on the ethnic group
and language concerned. Figure 1-1 illustrates the
Chinese characters for the words ‘double-eyelid fold’.
Figure 1-2 shows the Japanese Kanji writing for ‘single
[one] lid eye’ and ‘double [two] lid eye’. The characters
common to Chinese and Japanese for the operation to
construct a lid crease are illustrated in Figure 1-3.

FIGURE 1-3 ■ Characters common to Chinese and Japanese for

the procedure to construct an eyelid crease, or ‘double-eyelid
procedure’.

FIGURE 1-1 ■ Chinese written characters for ‘double eyelid

[skin]’.

1
2 Asian Blepharoplasty and the Eyelid Crease

As described in previous publications by the author,1–9 Figure 1-4 shows the various configurations of the
the crease may be asymmetric in its presentation, or be Asian eyelid.
absent in one eye and present in the other. It may be
continuous or segmented (fragmented).

A B

C D

E F

G H

FIGURE 1-4 ■ Chen1 has previously described the various forms of Asian eyelids, as illustrated. (A) Single eyelid without crease.
(B) Same size eyelid fissure with crease. (C) Segmented or non-continuous crease. (D) Partial or incomplete crease. (E) Multiple
creases. (F) Asian eyelid with a nasally tapered crease; in a small percentage of cases it shows some lateral flare. (G) Asian eyelid
with a parallel crease. (H) Typical Caucasian semilunar crease.
 1 What Is an Upper Lid Crease? 3

Figure 1-5 shows an eyelid without a crease. There trates an eyelid with a distinctive crease. This is
is a mild degree of upper lid hooding, causing sec- the parallel configuration. Figure 1-7 is an eyelid in
ondary downward rotation of the lashes. Figure 1-6 illus- which a portion of the crease has been obliterated.

FIGURE 1-5 ■ Asian lid without crease.

This patient has moderate upper
lid hooding causing downward
rotation of the lashes. Note the
apparent upper lid hooding (fold)
that overshadows the smaller palpe-
bral fissure laterally. Strategic place-
ment of a crease would make the
palpebral fissure seem larger.

FIGURE 1-6 ■ Asian eyelid with a parallel crease.

FIGURE 1-7 ■ Partial obliteration of crease.

4 Asian Blepharoplasty and the Eyelid Crease

An eyelid with an incomplete or partial crease is web) and extends halfway across the upper lid. Multiple
shown in Figure 1-8. The crease originates in the creases are illustrated in Figure 1-9, where two
medial canthus and medial upper lid fold (supracanthal well-defined creases run parallel to each other.

FIGURE 1-8 ■ (A, B) Incomplete or

B partial crease.

FIGURE 1-9 ■ Asian subject with two

well-defined creases that run parallel
to each other but in a nasally tapered
configuration.
 1 What Is an Upper Lid Crease? 5

Figure 1-10 shows a minimal nasally tapered crease. The lateral third of the crease is further from the lash margin
lateral third of the crease may be the same distance from than the central third. A Caucasian upper lid crease is
the eyelash margin as the central third, or it may rise shown in Figure 1-11, where the central third of the
slightly to form a laterally flared crease, in which the crease is farthest from the lash margin.

FIGURE 1-10 ■ Minimal nasally tapered

crease with a mild lateral flare.

FIGURE 1-11 ■ Caucasian upper lid crease with a

semilunar shape. Note that the widest separation of
the crease from the ciliary border occurs centrally.
6 Asian Blepharoplasty and the Eyelid Crease

In Asians with a continuous eyelid crease, the crease
may be of the nasally tapering type (NTC) (a less desir-
able term is ‘inside’ fold) in which the crease converges
toward the medial canthus, coming closer to the lashes
as it reaches the medial canthal angle (Figure 1-12A), or
it may be a parallel crease (PC) (a less desirable term is
‘outside’ fold), in which the crease runs fairly parallel to
the lash margin from the medial canthus to the lateral
canthus (Figure 1-12B).

FIGURE 1-12 ■ (A) Asian eyelid with a nasally tapered crease. Note the merging of the crease medially into the medial upper lid fold
and the relatively parallel course from the central third of the lid outward. (B) Asian eyelid with a parallel crease.
 1 What Is an Upper Lid Crease? 7

In eyelids with a nasally tapered crease the crease may nasally tapering crease may run level to the eyelash
gently flare away from the lid margin as it approaches the margin from the central third of the eyelid laterally
lateral canthal region, forming a laterally flared crease (Figure 1-14).
(LTC) (Figure 1-13). Another configuration is that the

FIGURE 1-13 ■ Nasally tapered crease with a variant form showing a lateral flare. The widest separation of the crease from the ciliary
border occurs laterally like that shown in Figure 1-10.

FIGURE 1-14 ■ Nasally tapered crease that runs

level to the eyelash from the central third of the
eyelid outward (see Figure 1-12A).
8 Asian Blepharoplasty and the Eyelid Crease

Asians rarely have a lid crease that is semilunar in
shape, as is common in Caucasians (see Figure 1-4H). In
a semilunar crease each end of the crease is closer to the
respective lid margin than the central portion of the
crease. Having a semilunar crease is by far the most
frequent complaint heard from Asian patients who have
had blepharoplasty performed in the United States2
(Figure 1-15). This crease is often unnatural, high and
harsh (termed the ‘uhh’ syndrome).

FIGURE 1-15 ■ Asian patient after blepharoplasty. Note asymmetry of the two creases and the high placement of the semilunar crease.

A high crease is one located 8–11 mm from the ciliary
margin. A high crease may result if a surgeon adheres to
an empiric formula for the height of the lid crease, or
uses techniques of supratarsal fixation in which a distance
of 8 mm or more is applied without regard to ethnicity.
Either method results in a crease that looks excessively
high on an Asian patient. To summarize, such a regi-
mented approach is counter-effective in Asian blepharo-
plasty for the following reasons:
FIGURE 1-16 ■ When a semilunar
crease is placed more than 10–12 mm
in an Asian upper lid, the crease is in
the mid level of the eyelid, halfway to
the brow.
1 What Is an Upper Lid Crease? 9
• Asians are usually smaller in build; correspondingly,
the upper tarsus measures only 6.5–8.0 mm in
height on average.
• The distance between the eyebrow and the upper
lid margin is smaller on Asians than on Caucasians.
A crease located 10–12 mm from the lash margin
would look much closer to the mid level of the
upper lid than is natural (Figure 1-16).
10 Asian Blepharoplasty and the Eyelid Crease
Not only should ethnicity be a factor in blepharo-
plasty, but also each individual’s features. When the
crease is high, it is farther from the lid margin than the
height of the tarsus, the surgically applied crease traverses
thick dermis as it approaches the brow and is likely to be
associated with hypertrophic scarring. The large distance
between the lash margin and the crease also allows little
camouflage by the upper eyelashes, and the crease is
exposed to scrutiny. A crease is harsh when it is overtly
prominent, deep and indurated with dermal reaction.
An unnatural crease describes a shape that is not aes-
thetically pleasing on the face of the person. The most
frequent complaint is a semilunar crease. The overall
impression of a crease positioned high and semilunar in
shape is unnatural for Asians. Removal of an excessive
amount of preaponeurotic fat also can cause an unnatural
crease. When all the fat pads are removed from the
preaponeurotic space, the result is a hollowed eye or
‘famined’ look that appears incongruous on the relatively
flat face of an Asian2 (Figure 1-17). For Caucasians, the
same complete excision of preaponeurotic fat pads used
FIGURE 1-17 ■ Asian patient who underwent blepharoplasty with excessive removal of preaponeurotic fat. Note the hollow supratarsal
sulcus and the formation of multiple creases.
to be a necessary step in the performance of a total cos-
metic blepharoplasty.
It is important to recognize that there is a high degree
of variation in the anatomy of the upper eyelids of Asians.
A common misconception is that all Asians are born
without an upper lid crease. In fact, half the Asian popula-
tion does have a natural crease. For each person, the
shape and height of the crease and the relation of the
crease to facial configuration should be part of the overall
assessment before a cosmetic surgical procedure is
performed.
The reasons for electing this type of cosmetic enhance-
ment may be myriad, and no individuals tend to have the
same reasons. The commonly cited and reasonable indi-
cations will include a desire to have the eyelid opening
(fissure) more apparent, since a single eyelid (without
crease) often has a small fold of skin overhanging the
opening, which makes it look covered over and smaller
than it actually is; it is narrower in vertical as well as
perceived horizontal dimensions.

Other reasons may be to enhance the ability to apply
make-up without smudging, to save time, to correct
asymmetry, to create consistency and constancy, or to
fulfill individuals’ often correct impression that having a
crease that simulates a natural crease makes the eye more
attractive. The important word here is ‘natural’. The
single-lidded individual almost always wants the crease to
mimic the dimensions of an Asian double eyelid. Figure
1-18 illustrates two drawings of palpebral fissures of equal
size; visual perception is that the eye opening for the
eyelid with a crease is bigger.
The means by which this can be achieved, over the last
hundred years or more, has been along two surgical
routes: the suture method and the incision method. They
are two totally different approaches, not only in terms of
philosophy but also in the surgical and anatomical bench-
marks that each sets (although practitioners may not be
consciously aware of it). This will be explained in greater
details in the ensuing chapters of this book.
The natural infolding of an eyelid crease can be
thought of as the end points of fine muscle fibers from
the opening muscle (levator aponeurosis, a curtain-like
sheet of elevating muscle within the upper lid, like a
garage door motor) of the upper lid attaching onto the
underside of skin; its action contracts the muscle up and
dynamically pulls on the skin to form the upper lid crease.
This levator muscle pulls on the small segment of skin
A B
FIGURE 1-18 ■ (A) A left upper eyelid without a crease; (B) the same upper lid with a parallel crease. The palpebral fissure (eye
opening) is the same in each and yet the visual perception is that this is bigger in (B) than that seen in (A).
1 What Is an Upper Lid Crease? 11
below the crease, the lashes, the lid margin and the tarsus
(a fibrous plate along the upper lid margin). When the
lids open, the lifting levator muscle is active (by turning
on the oculomotor or third nerve’s upper branch), that
resting section of skin and deeper soft tissues above the
crease (preseptal, above the upper boundary of the tarsus/
fibrous plate) relaxes by inhibition of the facial or seventh
nerve, whose normal function is contraction of the orbic-
ularis oculi and facial muscles. There is therefore a facili-
tation of the skin that is at the narrow boundary of a
natural crease to fold inward, and it is almost always along
the upper border of the tarsal plate. It is along the inter-
face between an active layer of tissues contracting (levator
pulling up on tarsus and small amount of skin adherent
to it) and passively gravitating skin on top (with all its
underlying muscle strands and fat) which is the larger
upper proportion you see in a double eyelid. This is
normal physiology in a natural crease. The crease is just
demonstrating the net force result of a healthy levator
terminating its attachment to the skin’s undersurface.
The reverse happens when the eyelid closes: seventh
nerve ON, third nerve OFF – the orbicularis oculi muscle
that wraps around the eyelid fissure is active and contracts
[ON] shut, while the levator is not lifting due to inhibi-
tion [OFF]. (The small skin above, overhanging the
inward crease, is the upper lid fold.)
12 Asian Blepharoplasty and the Eyelid Crease

Figure 1-19 shows the cross-section of the eyebrow, both. (Pink layer is levator muscle, with the 10 mm
closed eyelids and eye. The upper tarsus, which contains length of this pink tissue above the upper tarsus being the
oil glands is usually 10 mm in Caucasian and 6.5–7.5 mm aponeurosis segment of the levator.)
in Asian women. The inferior tarsus is 3.9–4.0 mm in

Orbicularis oculi

Septum orbitale

Preaponeurotic fat

Levator aponeurosis

Müller's muscle

Inferior tarsus

Inferior oblique

Inferior rectus

FIGURE 1-19 ■ Cross-section of the eyebrow, closed eyelids and eye.


Figures 1-20 and 1-21 show the basic difference
between a natural Asian eyelid without an eyelid crease
versus the eyelid of a person born naturally with one.
Figure 1-22 shows an upper lid with scarring involving
the anterior skin–orbicularis and the preaponeurotic fat
space.
The issues often raised at academic meetings in recent
times are: ‘If one sees a crease line anywhere on the upper
lid, whether it is lower than the normal insertion point
of the levator aponeurosis on the upper lid skin (which
normally should be precisely along the upper border of
the tarsal plate), or at any point unrelated to the levator,
like one or more wrinkled skin crease lines within the
upper concavity of the upper lid, aren’t these the eyelid
crease also?’ The answer is No! Technically they are just
wrinkles, because they are not caused by contraction of
the levator muscle. Just like a true elbow crease is formed
Periorbital zone
Preseptal zone
Pretarsal zone
FIGURE 1-20 ■ Diagram showing a simplistic representation of an Asian upper eyelid; here it is shown as in the 50% of subjects who
are without a crease (single eyelid). Zone 1 corresponds to the area in front of the tarsal plate (Pretarsal zone), with its height usually
being 7–8 mm. (Copyright W.P.D. Chen.)
1 What Is an Upper Lid Crease? 13
by the biceps pulling on the forearm bones (radius
and ulnar), and not simply because of any skin wrinkle
left on the arm, or of skin damage or adipose tissue
changes. Nor should we call a sunken sulcus (concavity)
a crease that ‘has migrated upward’. If one adheres to this
biodynamic and anatomically accurate definition of an
eyelid crease, there will be much less confusion among
practitioners as to what a crease is and where to apply a
crease, as well as what form of surgery or procedure
represents a physiologic route. It is indeed curious that
there are just as many medical practitioners who are
unclear about this as there are patients seeking informa-
tion on this very point.
The divergence between the suture method and inci-
sion method lies at the core of understanding the natural
mechanism of an eyelid crease, and the approaches by
which this can be achieved.
14 Asian Blepharoplasty and the Eyelid Crease

FIGURE 1-21 ■ A representation of an Asian upper lid with crease (‘double eyelid’). The levator muscle endings (pink layer) have
some attachment to the undersurface of the eyelid skin along the upper border of the tarsal plate, where it forms the crease. The
thin arrow indicates the eyelid crease; the darker arrow indicates the overhanging lid fold. (Copyright W.P.D. Chen.)
 1 What Is an Upper Lid Crease? 15

FIGURE 1-22 ■ A representation of one form of scarring involving the skin and the middle space (between the front and back layers)
of the eyelid. There is absence of fat and obliteration of the preaponeurotic space. (Copyright W.P.D. Chen.)

REFERENCES 6. Chen WPD. Expert commentary on blepharoplasty and blepharop-

1. Chen WPD. Asian blepharoplasty. Ophthalmol Plast Reconstr Surg
1987;3:135–140.
2. Chen WPD. Review of Aguilar G. Complications of oriental blepha-
roplasty. In: Mauriello J, ed. Management and avoidance of compli-
cations of eyelid surgery. Vol. 3. Philadelphia: Field & Wood, 1994.
3. Chen WPD. Concept of triangular, rectangular and trapezoidal
debulking of eyelid tissues: application in Asian blepharoplasty. Plast
Reconstr Surg 1996;97:212–218.
4. Chen WPD. Eyelid and eyelid skin diseases. In: Lee D, Higgin-
botham E, eds. Clinical guide to comprehensive ophthalmology.
Stuttgart: Thieme, 1999: 137–182.
5. Chen WPD. Upper eyelid blepharoplasty in the Asian patient.
In: Putterman AM, ed. Cosmetic oculoplastic surgery, 3rd edn.
Philadelphia: WB Saunders, 1999: 101–111.
tosis surgery in Asians. In: Mauriello J, ed. Unfavorable results of
eyelid and lacrimal surgery. Oxford: Butterworth–Heinemann, 2000:
68–71.
7. Chen WPD. Aesthetic eyelid surgery in Asians: an East–West view.
Hong Kong J Ophthalmol 2000;3:27–31.
8. Chen WPD. Oculoplastic surgery – the essentials. Stuttgart:
Thieme, 2001.
9. Chen WPD, Khan J. Color atlas of cosmetic oculofacial surgery
(with DVD), 2nd edn. Philadelphia: Elsevier Science/Saunders;
2010.
 CHAPTER 2

HISTORICAL CONSIDERATIONS

COSMETIC OCULOPLASTIC
SURGERY: EVOLUTION OF
DOUBLE-EYELID COSMETIC SURGERY
IN THE JAPANESE LITERATURE
Publications in the early Japanese medical literature
favored the suture ligation method. The first description
of this method, by Mikamo,1 was published in 1896 (see
Appendix 1, and Appendix 2 under Shirakabe, 1985).
Mikamo performed the procedure on a Japanese woman
who did not have a crease in one of her upper eyelids.
The crease was designed to be 6–8 mm from the ciliary
margin. Three 4-0 braided silk sutures were used, passing
through the full thickness of the lid from the conjunctiva
to the outer layer of skin. The depth of the crease was
adjusted by the number of days the sutures were left in
place, the range being 2–6 days.
As early as 1926, Uchida2 described his suture ligation
method for the double-eyelid operation. He performed
the procedure on 1523 eyelids in 396 male and 444 female
patients. Uchida described the crease configuration as a
fan shape, that is, a somewhat rounded crease. The crease
was designed to be 7–8 mm from the ciliary margin.
Three buried catgut sutures were used on each lid, encom-
passing approximately 2 mm of eyelid tissue horizontally.
The sutures were removed 4 days after placement.
The first mention of an external incision method dates
to 1929, when Maruo3 reported on both his suturing
technique and his incision technique. Maruo’s incision
technique required a crease incision across the lid,
designed to be 7 mm from the ciliary margin. The wound
closure technique was a translid passage from the con-
junctival side just above the superior tarsal border to the
anterior skin surface. One 5-0 catgut suture was used to
imbricate four throws along the superior tarsal border,
attaching the skin edges to the underlying tarsal plate.
The spacing between each throw of the stitch was about
5–6 mm. Maruo also discussed subcutaneous dissection
5 mm superior and inferior to the incision line.
In 1933, preference for a higher placement of the
crease became evident when Hata4 reported his suture
ligation method. The crease line was placed 10 mm from
the ciliary margin. Hata used three double-armed 5-0
braided silk sutures, passing them from tarsus to skin and
fixing them to the skin surface using small beads. Each
arm of the suture required 1 mm spacing for the bead to
be tied. Stitches were removed after 8–10 days.
In a comprehensive and scholarly article in 1938,
Hayashi5 described the two methods of crease formation.
His suture ligation technique was modeled after
17
18 Asian Blepharoplasty and the Eyelid Crease
H1
W1
(W2, H2) > (W1, H1)
FIGURE 2-1 ■ The addition of a crease that is appropriate in nature adds to the apparent width (W2) and height (H2) of the eyelid
fissure.
Mikamo’s method but was novel in that it was designed
for a nasally tapered crease. Three sutures were used on
each lid. The central and lateral sutures were applied
superior to the crease line or tarsal plate, whereas the
medial suture was deliberately applied below the crease
line or tarsal plate. Hayashi’s incision method was also
revolutionary, in that he advocated excision of the pre-
tarsal orbicularis oculi muscle at the area of the incision.
He also advocated the use of interrupted skin–tarsus–skin
sutures, and in between skin–skin stitches consisting of
4-0 silk for wound closure. The crease was designed so
that medially it was 5 mm from the ciliary margin, cen-
trally 6 mm from the margin, and laterally 7 mm from
the margin; in essence it was a nasally tapered crease. The
sutures were removed after 4 days.
Inoue6 in 1947 proposed dissecting the ‘connective
tissues’ in the subcutaneous plane between the incision
line and the ciliary margin. Sutures of 5-0 braided silk
were used for skin–tarsus–skin closure; sutures were
removed after only 2–3 days.
In 1950, Mitsui7 continued the evolution of the double-
eyelid crease procedure when he described the dissection
and removal of pretarsal connective tissue, including pre-
tarsal orbicularis muscle and pretarsal fat pads. Wound
closure was carried out in two steps. First, five separate
nylon sutures were used to stitch the inferior skin border
to the anterior surface of the superior tarsal border and
were tied individually. Second, 5-0 braided silk was used to
close the incision site skin to skin. The nylon sutures were
removed after 2–3 days, the silk sutures after 7–8 days.
Ohashi8 described a double-eyelid crease operation
using an electric coagulator. The cautery needle was
applied vertically to the skin surface along the crease line
until the skin blistered; two more rows of cauterization
below the crease line followed. Hirose9 and Ikegami10 in
1951 briefly discussed incision methods but did not offer
any new information.
The foregoing procedures were described only in the
Japanese literature and were not readily available to
H1 H2
W1
W2
Western readers. As a result, the publication of articles
on this procedure in Western medical journals in the
1950s made the procedure seem new (and Western) in
concept. Between 1896 and 1950, 11 articles relating to
the suture ligation methods and eight articles on external
incision methods were published in the Japanese medical
literature (see Appendix 1 for selected articles).
Much of the later Western literature on this subject
described techniques quite similar to those described in
the early Japanese publications (see Chapters 6 and 7 for
a continuation of historical publications from the 1950s
onwards).
Figure 2-1 illustrates the visual expansion of the eye
size when a natural crease is added.11 From the original
eye size of Width (W1), and Height (H1), the apparent
fissure size is expanded to W2, and H2 when a crease is
there, either through surgery, eyelid tape, glue or attached
thin strings or fibers.
REFERENCES
1. Mikamo K. A technique in the double eyelid operation. J Chu-
gaishinpo 1896.
2. Uchida K. The Uchida method for the double-eyelid operation in
1,523 cases. Jpn J Ophthalmol 1926;30:593.
3. Maruo M. Plastic construction of a ‘double-eyelid’. Jpn Rev Clin
Ophthalmol 1929;24:393–406.
4. Hata B. Application of eyelid clamp and beads in ‘double-eyelid’
operation. Jpn Rev Clin Ophthalmol 1933;28:491–494.
5. Hayashi K. The double eyelid operation. Jpn Rev Clin Ophthalmol
1938;33:1000–1010, 1098–1110.
6. Inoue S. The double eyelid operation. Jpn Rev Clin Ophthalmol
1947;27:306.
7. Mitsui Y. Plastic reconstruction of a double eyelid. Jpn Rev Clin
Ophthalmol 1950;44:19.
8. Ohashi K. The double eyelid operation using electrocautery. Jpn
Rev Clin Ophthalmol 1951;46:723.
9. Hirose K. The double eyelid operation. Jpn Rev Clin Ophthalmol
1950;45:374.
10. Ikegami T. Brief discussion on the double eyelid operation. Jpn Rev
Clin Ophthalmol 1951;46:706–707.
11. Chen WPD. Revision and correction of suboptimal results. In
Asian blepharoplasty: a colour atlas. Oxford: Butterworth–
Heinemann; 1995: p. 97, Figure 7-23.
 CHAPTER 3

COMPARATIVE ANATOMY
OF THE EYELIDS

THE UPPER LID AND CREASE
Studies have shown that about 50% of Asians do not
have an upper eyelid crease; the other 50% have at
least some form of crease. Eyes without a lid crease
are described as having a ‘single eyelid’ (Figure 3-1),
whereas those with two segments of lid between
the eyebrow and the eyelashes have ‘double eyelids’
(Figure 3-2). Most of the plastic surgery literature of the
1950s1,2 was based on the assumption that all Asians are
without an eyelid crease and that all Caucasians have an
upper lid crease.

FIGURE 3-1 ■ Partially shielded crease

over the right upper lid. Absent
crease or ‘single eyelid’ over left
upper lid.

FIGURE 3-2 ■ Double eyelid. Parallel

crease configuration.

19
20 Asian Blepharoplasty and the Eyelid Crease
Asians born with a crease appear to have a wider palpe-
bral fissure and larger eyes and are culturally perceived
to be more alert and friendly than those with a single
eyelid (Figure 3-3). The cultural ideal of feminine beauty
also influences the desire for a double eyelid: having a
double eyelid allows greater latitude in the application of
cosmetics to make the eyes and face more aesthetically
pleasing. It is therefore understandable that some women
without a crease may wish for one, provided the means
are available.
To some Westerners, who presume that all Asians have
eyelids without a crease, such an endeavor equates
to ‘Westernization’ or ‘occidentalization’. In the author’s
opinion, however, it merely represents an attempt to look
like their fellow Asians who do have a crease over their
upper eyelids.3
The growing popularity of Asian blepharoplasty has
been incorrectly interpreted as resulting from the influ-
ence of Western culture after World War II and the
Korean war, a manifestation of which was believed to be
A B
FIGURE 3-3 ■ Left palpebral fissure. (A) Without crease. (B) With crease. The crease gives the impression of a larger eye opening.
a desire on the part of Asians to blend in with Caucasians,
to look Westernized or occidental. Having traveled and
taught extensively in Asia, it is the author’s perception
that the idea of beauty transcends time, geographic
boundaries and ethnicity. For a growing number of
patients undergoing Asian blepharoplasty it has more to
do with an increasing awareness that such procedures are
available than with the cultural influence of the West.
Clinical experience teaches that Asians do not want to
look Caucasian. A frequent postoperative complaint is
that the procedure results in a semilunar crease, a feature
that, although characteristic of Caucasians, is aestheti-
cally displeasing in Asians.4
The essential differences in the upper eyelid structure
between Caucasians and Asians have been studied in
cadaver samples by Doxanas5 and Jeong et al.6 The funda-
mental difference between the subset of those Asian eyelids
without a crease and a Caucasian eyelid that possesses a
crease appears to be the lower point of fusion of the orbital
septum onto the levator aponeurosis in Asians.

Individuals with a Lid Crease
In Caucasians who have a crease5 (Figure 3-4), the orbital
septum fuses with the levator aponeurosis approximately
5–10 mm above the superior tarsal border. Below this
point, the terminal interdigitations of the levator aponeu-
rosis insert towards the subdermal surface of the pretarsal
and preseptal upper lid skin, with maximal concentration
along the superior tarsal border and spreading inferiorly.7
Collin8 has detailed electron microscopic findings of
fusion of the terminal fibers of the levator aponeurosis
with the septae that are between the pretarsal and presep-
tal orbicularis muscle fibers; he was unable to show any
direct attachment to the skin in that particular study.
FIGURE 3-4 ■ A typical Caucasian eyelid with a natural upper eyelid crease. Aponeurotic fibers form interdigitations to the pretarsal
orbicularis oculi muscle and a subdermal attachment along the superior tarsal border.
3 Comparative Anatomy of the Eyelids 21
There has been a subsequent study in China using
scanning electron microscopy that described the presence
of aponeurotic fibers penetrating the orbicularis fibers to
fuse with the skin underneath a crease. In this study,
published in 2001, Cheng and Xu9 reported using
scanning electron microscopy and detecting bunched
fibers of levator aponeurosis penetrating through the
orbicularis muscle and fusing with the skin on the area
of the eyelid crease in those patients born with a crease,
versus those without. These differences were not detect-
able using conventional light microscopy. The authors
described the arrangement of these bundled fibers as
being different from that of the fibers in the intermuscu-
lar septum. The bundles were thinner, unidirectional and
Orbicularis oculi
Septum orbitale
Preaponeurotic fat
Levator aponeurosis
Müller's muscle
Inferior tarsus
Inferior oblique
Inferior rectus
22 Asian Blepharoplasty and the Eyelid Crease
aligned as threads. They noted that where these fibers
pass through the orbicularis to attach to the subcutaneous
fibers they were linear in shape, closely aligned and
clearly visualized, whereas the fibers of the intermuscular
septum were thicker and aligned in a disorderly fashion.
Of interest is the observation that in those eyelids with a
crease the orbicularis bundles lying transversely were
arrayed sparsely and loosely in a single layer, in contrast
to those in a single eyelid (i.e. without a crease), which
had muscle tissues that were dense and muscle bundles
arrayed in a stratified manner. Their overall conclusion
is that a fiber link between levator aponeurosis and the
upper eyelid skin results in the formation of the palpebral
sulcus (crease) in the double eyelid. They draw the infer-
ence that the purpose of most double-eyelid procedures
should be to establish a stable attachment between levator
aponeurosis and the eyelid skin. They further stated that
the obstructing effect of the orbicularis in single-lidded
individuals could explain why the surgical outcome is
unpredictable with the suturing method. Using the inci-
sion method, the excision of a suitable amount of orbicu-
laris muscle changes the dynamics of the upper eyelid and
assures a good aesthetic outcome. The authors recom-
mended the incision method with supratarsal fixation in
order to establish a stable attachment between the levator
aponeurosis and the eyelid skin.
A similar study published in the same year by Mori-
kawa et al.10 described the scanning electron microscopic
findings in single- versus double-eyelid samples taken
from Japanese cadaver specimens. They were able to
trace the collagen fibers that branched off from the
levator aponeurosis, running through the orbicularis
oculi muscle layer and inserting at the subcutaneous layer
just within the crease space indentation. These fibers do
not contact the skin directly, but become continuous with
the collagen fibers in the subcutaneous tissues.
Hwang et al.11 attempted to show that the orbital
septum consists of an outer (whitish, superficial) layer and
an inner layer which, upon meeting the levator aponeu-
rosis inferiorly, then reflects superiorly and continues
with the sheath of the levator muscle, which they termed
the levator sheath. Several line drawings in their article
attempted to illustrate this concept, and a light micro-
scopic slide showed what purported to be the inner layer
of the orbital septum and the sheath of the levator, but
the higher-magnification slide did not have a portion
showing that the one continues into the other, which was
their premise. There had been a previous description of
the anterior lining of the levator (levator sheath) descend-
ing and then reflecting up the back surface of the orbital
septum to reach the superior orbital rim,12 but there had
been no concrete study illustrating that the reverse is
true, i.e. that the orbital septum has two layers – a pos-
terior layer that actually reflects back on to the levator
surface to form its sheath. Hwang et al. further postulate
that the reason for some crease procedures failing to form
a crease is owing to the presence of remnants of the inner
layer of the orbital septum on the aponeurotic surface,
which may have been attached to skin surgically instead
of the desired skin–aponeurosis attachment. They also
stated that there may be remnants of fat behind this
fourth layer, the inner layer of the orbital septum lying
on the anterior surface of the aponeurosis and the under-
lying levator aponeurosis, and that these need to be
reflected away before carrying out the skin–aponeurosis
fixation.
Bang et al.13 argued against the conventional theory
that the levator termination inserts into the skin to form
the crease. The authors proposed that this theory is more
accurate, i.e. that the absence of a crease is associated with
a lower position of the septum in a single eyelid without
a crease, hence there is more inferiorly migrated fat and
the eyelid is thicker than one that has a crease, which is
thinner and has a tighter pretarsal skin zone. The crease
in this theory corresponds to the lowermost edge of the
orbital fat, or the lower level of the orbital septum, which
is usually 2–3 mm above the highest point of insertion of
the levator aponeurosis. In an excellent brief discussion
following the above-mentioned paper by Bang et al.,
Khoo Boo-Chai14 stated that below the lowermost edge
of the orbital fat there are fine filamentous condensations
of the connective tissue that connect the aponeurosis to
the connective tissue septa between the fibers of the
orbicularis oculi muscles. The crease lies in the pretarsal
skin at the superior insertion of these fibers and serves as
a useful external landmark of the common boundary
between the lowermost edge of the orbital fat and the
filamentous connective tissue condensation fibers. When
the eye opens, the pull of the levator is transmitted via
these fibers to the pretarsal skin–muscle complex. The
pretarsal skin below the crease moves as a single unit
upward and backward, like the visor of a helmet. The
orbital fat moves back into the orbit, and the superior
palpebral fold is formed by the lid skin scrolling down at
the upper lid crease. Khoo Boo-Chai further observed
that the pretarsal skin is soft and very thin, with little
space between the dermis and the subcutaneous areolar
plane to the orbicularis beneath. The skin above the
upper lid crease is comparatively thick, with some subcu-
taneous fat, with the crease lying at the junction of this
region. He favored the continued use of the term levator
expansion (extension).
THE FAT PADS OF THE UPPER LIDS
In terms of fat distribution and compartments, Uchida15
described the presence of four areas of fat pads in Asian
upper eyelids. He described the subcutaneous fat, the
pretarsal fat, the ‘central’ (submuscular or preseptal) fat
pads and the ‘orbital’ fat pad, which is now better known
as the preaponeurotic fat pad (see Figure 3-7).
Miyake et al.16 described upper eyelid MRI findings in
those with a crease versus those without. He observed
that the ‘orbital fat’ normally returns into the orbit as the
upper eyelid opens in someone with a crease, but that
when the fat does not return then crease formation is
prevented. He correctly observed that the crease folds in
at the junction between the thin skin without subcutane-
ous fat (pretarsal area) and the thick skin with subcutane-
ous fat (preseptal area).
The preaponeurotic fat pad is limited in its inferior-
most position by the junction (or reflection) of the septum
with the levator aponeurosis and does not tend to
 3 Comparative Anatomy of the Eyelids 23

interfere with the terminal insertions of the aponeurotic
fibers. When the levator contracts and pulls the tarsal
plate up, the lid forms a crease just above the superior
tarsal border, with the skin superior to the crease forming
the fold (Figure 3-5). The rigidity of the upper tarsus and
the firm adherence of the skin over the pretarsal region
effectively results in a pretarsal platform vectoring
superoposteriorly underneath the overhanging fold of
skin and the preaponeurotic tissue platform. In elderly
people there is frequently a lack of preaponeurotic fat
pads and the presence of dermatochalasis causing hooding
over the previously distinctive lid crease (Figure 3-6).

FIGURE 3-5 ■ Caucasian upper lid

creases that are high and semilunar
in shape.

FIGURE 3-6 ■ Elderly Caucasian patient

before blepharoplasty. Redundant
preaponeurotic fat pads and dermato-
chalasis of the upper lid form a hood
over the previously distinctive crease.
24 Asian Blepharoplasty and the Eyelid Crease

In those Asians who do not have a lid crease aponeurosis, frequently as low as the superior
(Figure 3-7) the anatomic studies of Doxanas5 and tarsal border. The author has seen patients whose
Anderson7 appeared to confirm that they have a lower orbital septum fuses with the upper tarsus below the
point of attachment of the orbital septum to the levator superior tarsal border, halfway down its anterior surface

FIGURE 3-7 ■ Asian upper eyelid without a crease. Note the absence of terminal interdigitations of the levator aponeurosis and the
relatively lower point of fusion of the orbital septum.
 3 Comparative Anatomy of the Eyelids 25

(Figure 3-8). This lower point of fusion permits the pres- the attachment of the terminal interdigitations of the
ence of the preaponeurotic fat pad at a lower point on levator aponeurosis along the superior tarsal border to
the aponeurosis, giving the eyelid a fuller appearance. the pretarsal orbicularis oculi muscle fibers.
The lower preaponeurotic fat pad may in turn prevent

FIGURE 3-8 ■ Right upper lid with a

very low point of fusion of the orbital
septum along the anterior surface of
the upper tarsus. Preaponeurotic fat
can be seen posterior to the surgi-
cally opened septum.
26 Asian Blepharoplasty and the Eyelid Crease
Subcutaneous fat, sub-brow (submuscular, suborbicu-
laris, or preseptal) fat and pretarsal fat infiltration as
described by Uchida15 may be seen. The presence of pre-
tarsal fat pads may also disrupt the terminal interdigita-
tions of the aponeurosis, if we are to presume that Collin’s8
and Cheng’s9 scanning electron microscopy findings are
accurate and applicable to those eyelids in Asians that are
without a crease. The clinical picture is a puffy ‘single
eyelid’ without a crease (Figure 3-9). With age, the inter-
val change in Caucasians tends to be an increase in
prominence of the preaponeurotic and nasal fat pads as
they migrate forward and inferiorly. The elderly Asian
eyelid tends to simply manifest more skin redundancy, as
the lid has always been comparatively full owing to the
lower position of the preaponeurotic fat and fascial tissues
(Figure 3-10). Some degree of gravitational inward set-
tling of the orbital fat in the upper half of the orbital space
does occur with aging, therefore the volume of fat seen
clinically over the upper eyelid may be variable.
FIGURE 3-9 ■ Single eyelid with upper
eyelid hooding.
FIGURE 3-10 ■ Elderly Asian patient
before blepharoplasty. The patient
has redundant dermatochalasis rather
than an active prolapse of preaponeu-
rotic fat pads.

An intriguing hypothetical explanation for the findings
of Collin8 and Cheng9 that in upper eyelids with a crease
there are interdigitations of the terminal aponeurotic
fibers to the septae8 between the pretarsal and preseptal
orbicularis muscle, or insertion9 into the subcutaneous
area of the crease, giving a firm pretarsal platform to ‘tele­
scope’ back to form a crease, is that in those Asians who
have only a rudimentary crease the crease is not obvious,
owing to the presence of pretarsal fat pads in the pretarsal
orbicularis muscles (Figure 3-11). The presence of these
fine fat pads may dilute the effect of the aponeurotic fiber
interdigitations among the pretarsal orbicularis fibers,
creating a ‘puffier’ and less rigid pretarsal platform, and in
conjunction with the inferior migration of the orbital
FIGURE 3-11 ■ The presence of pretar-
sal fat pads within pretarsal orbicula-
ris oculi muscle in an Asian upper lid
without a crease.
3 Comparative Anatomy of the Eyelids 27
septum and preaponeurotic fat pads it produces a full lid
with no opportunity for the clear demarcation of a crease.
A corollary to this would be that in those Asians who do
have a crease, there is a paucity of pretarsal fat pads: the
terminal fibers from the aponeurosis interdigitate with the
pretarsal orbicularis muscle as before, and they still have a
rigid pretarsal platform to form a crease, even though their
preaponeurotic fat pads are at a lower level than in Cauca-
sians. Caucasians who previously had a crease may lose it
with age, as the pretarsal platform loses its rigidity owing
to dehiscence of the orbicularis fibers and infiltration of
fat into that area (see Figure 3-6). In both Asians and Cau-
casians who do not have an eyelid crease it is possible to
create one by placing sutures that attach the skin to the
28 Asian Blepharoplasty and the Eyelid Crease

levator aponeurosis. Excessive pretarsal dissection and
debulking can lead to multiple crease formation (Figure
3-12).
Yoo17 formed a crease simply by trimming the pretarsal
fat and placing ‘basting’ sutures. This procedure elimi-
nated the dead space formed by the removal of pretarsal
tissues but did not involve direct stitch attachment of the
levator aponeurosis or tarsal plate. The net result was
a rigid pretarsal platform that allowed crease formation.
It is highly unlikely, however, that there would be no
aponeurotic adhesions to the pretarsal tissues after such
a maneuver.

FIGURE 3-12 ■ Multiple creases and a hollow supratarsal sulcus secondary to excessive dissection in the pretarsal and supratarsal
space. The patient has undergone a lid crease procedure through an anterior approach.
 3 Comparative Anatomy of the Eyelids 29

THE MEDIAL CANTHUS epicanthus inversus. Epicanthus supraciliaris is very

uncommon. It originates from the brow and curves down
According to Johnson,18 the epicanthal folds can be towards the lacrimal sac (Figure 3-13). Epicanthus palpe-
divided into at least four clinical types: epicanthus supra- bralis rises above the upper tarsus and extends to the
ciliaris, epicanthus palpebralis, epicanthus tarsalis and inferior orbital rim (Figure 3-14). Epicanthus tarsalis

FIGURE 3-13 ■ Mild epicanthus supraciliaris.

FIGURE 3-14 ■ Two-year-old Eurasian child with epicanthus palpebralis.

30 Asian Blepharoplasty and the Eyelid Crease
rises from the upper lid crease and merges into the skin
near the medial canthus (Figure 3-15). Johnson called
this configuration ‘Mongolian eye’. In epicanthus inver-
sus, the fold rises from the lower lid and extends to the
upper lid over the medial canthus (Figure 3-16).
Of the four types of epicanthus described by
Johnson,18 Asians usually have epicanthus tarsalis. This
configuration is a subtle fold of skin that arises from the
medial canthal angle and courses laterally, forming a
small medial upper lid fold, toward a point between the
FIGURE 3-15 ■ Six-year-old Eurasian
child with epicanthus tarsalis.
FIGURE 3-16 ■ Child with epicanthus
inversus, part of the congenital
blepharophimosis syndrome.
 3 Comparative Anatomy of the Eyelids 31

medial third and the medial half of the upper lid. Some and lower lids equally across the medial canthus. With
Asian children may appear to have an epicanthus palpe- growth and development, however, the fold appears to
bralis (Figure 3-17), in which the fold covers the upper be transformed into a medial upper lid fold. This may

FIGURE 3-17 ■ (A) A 3-year-old child

and (B) a 1-year-old child with slight
epicanthal fold (a more appropriate
term would be medial upper lid fold).
The presence of this fold in Asian chil-
dren frequently makes them appear
to have esotropia (inward turning of B
the visual axis).
32 Asian Blepharoplasty and the Eyelid Crease
be the result of the development of the nasal bridge
(Figure 3-18). The medial upper lid fold is often seen in
patients who already have a natural crease (Figure 3-19).
Most articles19–21 in the literature seem to focus on the
correction of epicanthus palpebralis and epicanthus
inversus. The latter is a condition more often associated
with the syndrome of congenital blepharophimosis. Most
repairs are a variation of the double-Z- or Y–V-plasty.
These techniques are ill-suited to the correction of the
medial upper lid fold in Asians.
The author3,4,22,23 tends to be conservative in the cor-
rection of these medial upper lid folds, for the following
reasons. First, it is hard to call something pathologic
when it occurs naturally in a large percentage of the
population, considering that there are at least 2–3 billion
Asians living on this planet. Second, Asians tend to have
thicker skin near the nasal bridge, which is more reactive
and prone to hypertrophic scarring in the thick medial
canthal skin area. Third, a medially tapered crease that
merges with the origin of a mild medial upper lid fold
or ‘epicanthus tarsalis’ provides an aesthetically natural
crease, as seen in those Asians who do have a lid crease.
Fourth, the fold often evolves and regresses as the indi-
vidual reaches adulthood. These small medial canthal
folds are almost always a very small version of a true
epicanthus and do not warrant being labeled with a term
implying pathologic status.
UPPER TARSUS
Asians tend to be smaller built than Caucasians. Their
upper tarsus is often only 6.5–8.5 mm in vertical dimen-
sion compared to Caucasians,22,23 in whom the average is
10 mm, ranging from 9.5 mm upwards.
FIGURE 3-18 ■ Same child as in Figure
3-14, now 6 years of age and showing
much less of the epicanthus palpe-
bralis, with development of the nasal
bridge.
FIGURE 3-19 ■ Medial upper lid fold in
an Asian teenager born with a nasally
tapered crease.
 3 Comparative Anatomy of the Eyelids 33

VASCULAR SUPPLY OF THE
UPPER EYELID
Kawai et al.24 studied the upper eyelids in seven fresh
cadaver specimens, presumably of Asian origin. The spec-
imens were systemically injected with a lead oxide–gelatin
mixture and stereoscopic radiographic records of the anas-
tomotic vessels were made, followed by macroscopic dis-
section. The authors found four main arterial arcades in
the upper eyelids, i.e. marginal, peripheral, superficial
orbital and deep orbital. They described vertical branches
arising from each arcade, with the vertical branches of the
superficial orbital arcade lying anterior to the preseptal
orbicularis, the vertical branches of the deep orbital arcade
behind the same orbicularis, and the vertical branches
between the marginal and peripheral arcades lying both
in front of and beneath the upper tarsal plate (Figure
3-20).
The marginal and peripheral arcades were formed by
the anastomosis of the medial and lateral palpebral arteries,
which were branches of the ophthalmic and lacrimal arter-
ies. The marginal arcade was situated between the orbicu-
laris and the tarsal plate; it lay just anterior to the lower
margin of the tarsal plate and gave off small vertical branches
that ascended tortuously on both sides of the orbicularis
and on both sides of the tarsal plate. These branches
provided fine vessels to the skin, muscle and tarsal plate.
In addition to these small vertical branches, the marginal
arcades provided fine vessels to the free edge of the upper
lid. The peripheral arcade coursed in Müller’s muscle
along the superior tarsal border, and gave off vertical
branches that descended on both sides of the tarsal plate.

SOA DOA
FB
SOA DOA
STA

ZOA

PA
PA

MA
LPA

MA

Orbicularis oculi muscle

Tarsal plate

FIGURE 3-20 ■ There are four arterial arcades in the upper eyelid: the marginal arcade (MA), the peripheral arcade (PA), the superficial
orbital arcade (SOA), and the deep orbital arcade (DOA). Each provides small vertical branches running on both sides of the orbicu-
laris oculi muscle or on both sides of the tarsal plate. From these small vertical branches, fine vessels branch off to the skin, muscle
and tarsal plate. FB, frontal branch of the superficial temporal artery; ZOA, zygomatico-orbital artery; LPA, lateral palpebral artery;
STA, supratrochlear artery. (Reproduced with permission from Kawai et al.,24 Journal of Plastic and Reconstructive Surgery. Lippincott,
Williams and Wilkins.)
34 Asian Blepharoplasty and the Eyelid Crease

The descending branches (of the peripheral arcade)
running over the tarsal plate anastomosed with the ascend-
ing branches arising from the marginal arcade, whereas
the descending branches running beneath the tarsus sepa-
rated into fine vessels and formed a vascular plexus with
the ascending branches arising from the marginal arcade
(Figure 3-21).
The superficial and deep orbital arcades were formed
by the anastomosis of the branches of the zygomatico-
orbital artery, the transverse facial artery, or the frontal
branch of the superficial temporal artery laterally and the
branches of the supratrochlear artery, the ophthalmic
artery, or the medial palpebral artery medially. Of these,
the supratrochlear artery contributed significantly to
both the superficial and deep orbital arcades, the
latter running along the superior orbital rim. The terms
‘superficial’ and ‘deep’ refer to the level of the preseptal
orbicularis oculi layer. Both the superficial and deep
orbital arcades gave off vertical branches that descended
anterior and posterior to the orbicularis and anasto-
mosed with ascending branches from the marginal arcade.
The authors further noted that the vertical vessels running
over the orbicularis oculi traversed obliquely (connecting
the marginal to the superficial arcade) rather than verti-
cally, as with those that ran under the orbicularis, which
connected the deep orbital arcade to the marginal arcade.
They did not observe any single dominant intramuscular
vessel within the orbicularis and deduced that its blood
supply must therefore come from the fine vessels from
the vertical branches. The authors implied that their
method of study provided an undistorted assessment of
the arterial structure of the upper eyelid.
Kim et al.25 reported an incidence of 25 among 230
eyelids where an artery thought to be a variation of
the lacrimal artery was found superficial to the orbital
septum and inferolateral to the levator muscle, at a
location 4–5 mm medial from the lateral canthus. After
piercing the levator it was observed to connect with
the lateral palpebral artery behind the levator muscle.
This lateral vessel was nicked in 14 cases and the bleeding
arterial end retracted posteriorly behind the levator
to form a hematoma in the postaponeurotic space.
This resulted in swelling, secondary ptosis and difficulty
in designing the lateral portion of the eyelid crease.

FIGURE 3-21 ■ Stereoscopic radiographic angiograms of the right upper lid. To superimpose the images of the left and right black
dots, the reader should cross (converge) their eyes and then elevate their gaze towards the center of the paired images, which for
someone with binocular vision will then yield a stereoscopic view. It should be observed that each arcade branches off the small
vertical vessels (large and small arrows), and that the vertical vessels from the marginal arcade (MA) anastomoses with the vertical
vessels from the other three arcades. Large single arrow, vertical vessel connecting the marginal arcade and the deep orbital arcade
(DOA); large double arrows, vertical vessel connecting the marginal arcade and the superficial orbital arcade (SOA); small arrows,
vertical vessels connecting the marginal arcade and the peripheral arcade (PA). (Reproduced with permission from Kawai et al.,24 Journal
of Plastic and Reconstructive Surgery. Lippincott, Williams and Wilkins.)

Clamping the bleeding vessel was noted to be more effec-
tive than electrocautery when this occurred. Besides pos-
tulating that this might be a variant of a branch of the
lacrimal artery, the authors also mentioned the possibility
of a communicating artery between the peripheral arcade
and the marginal arcade, or that this might be a medially
displaced lacrimal artery. They mentioned that a cadaver
dissection with latex injected into the ophthalmic artery
was in progress.
In a somewhat similar study, Hwang et al.26 described
the occasional presence of a laterally located artery,
named the lateral septoaponeurotic artery (LaSA), as a
branch of the superior lateral palpebral artery after it
divides into the peripheral arcade, the other being the
marginal arcade. It was detected in 50 eyelids (11%) out
of 460 operated on. (The superior lateral palpebral artery
is a branch of the lacrimal artery, itself a branch of the
ophthalmic artery.) The LaSA arises from the superior
portion of the peripheral arcade, which runs along the
superior tarsal border. From the peripheral arcade it
pierces the levator aponeurosis and orbital septum at the
upper level of the tarsal plate and is seen coursing on the
surface of the orbital septum, about 5 mm inside the
FIGURE 3-22 ■ Lateral septoaponeu-
rotic artery found on the left upper
eyelid during blepharoplasty: the
skin-orbicularis layer had been peeled
off after incision on the upper and
lower skin edges using Ellmann’s
radiofrequency unit. (Image courtesy
of W.P.D. Chen.)
3 Comparative Anatomy of the Eyelids 35
lateral canthus (Figure 3-22). It anastomoses with a
branch of the supraorbital artery at the superior aspect
of the orbit. The authors commented that care should
be taken in incising the lateral aspect of the septum,
as severance of the LaSA may cause severe bleeding,
hematoma formation and temporary ptosis, as well as
retraction of the bleeding point and the formation of a
hematoma in the postaponeurotic plane. This may occur
during use of the incisional method as well as the stitch
method, which involves the placement of stitches over
the lateral portion of the upper eyelid. This makes the
surgeon’s task of following the designed crease difficult.
The authors recommended specific visual examination of
the lateral aspect of the orbital septum prior to any hori-
zontal transection.
Hematoma may also occur separately following injury
to the perforating branch of the marginal arcade. There
is occasionally a larger branch of the arcade running
perpendicularly upward and piercing the aponeurosis
near its insertion on the anterior surface of the upper
tarsus, where it may be injured when the lower incisional
skin edge is manipulated during surgery. This, however,
is separate from the LaSA.
36 Asian Blepharoplasty and the Eyelid Crease
FACIAL ANATOMY
Onizuka and Iwanami27 noted that the Japanese charac-
teristically have a flat face, a mesocephalic head shape and
eyes that are not as deeply recessed in the orbit as in
Caucasians. They noted that the lateral canthus is often
10° superior to the medial canthus. To produce an aes-
thetically pleasing result, they made an upper lid crease
and removed any upper lid hooding to make the palpe-
bral fissure appear wider and more open. Although the
present author does not believe the contention that most
1⁄5 1⁄5 1⁄5 1⁄5
Asians have a lateral canthus 10° above the medial
canthus, some of Onizuka and Iwanami’s observations
may be correct.
CONCEPT OF FACIAL SYMMETRY
Song,28 in 1988, wrote that since ancient times Chinese
portrait artists have followed the rule of ‘horizontal
thirds, vertical fifths’ when portraying the ideal face
(Figure 3-23). An ideal palpebral fissure should be equal
1⁄5
1
⁄3
1⁄3
FIGURE 3-23 ■ Rule of horizontal
thirds and vertical fifths. The sym-
1⁄3 metric thirds are the distances from
the hairline to the brow, from the
brow to the base of the nose, and
from the base of the nose to the chin.
The fifths are the distances from the
auditory canal to the lateral canthus,
from the lateral canthus to the medial
canthus, from the medial canthus to
the opposite medial canthus, from
the medial canthus to the lateral
canthus and from the lateral canthus
to the external auditory canal.

to one-fifth the width of the face. Interestingly, most
patients with a single eyelid who seek to have a lid crease
tend to have a palpebral fissure that is narrower than the
ideal (Figure 3-24); their eyes appear inharmonious with
the rest of the face.
In attempting to match eyelid and crease configuration
to the facial configuration, Song also mentioned six facial
shapes and the eight factors that influence a crease. The
six possible facial shapes seen in the average Asian popu-
lation include square, rectangular, round, oval, triangular
(with the base down) and diamond.
The eight factors that influence a crease are really
the three variants of crease height (broad, average
and narrow) and the five combinations of crease
shape:
1. Parallel crease, favored by Song for a person with
a stable temperament and a mild personality, a
cheerful and happy person.
2. Medially narrow (<7–8 mm) and laterally broad
crease (7–10 mm). Used for a person with a rectan-
gular, stern face, a serious person.
FIGURE 3-24 ■ Asian patient before
Asian blepharoplasty. Note that the
width of the palpebral fissure appears
to be less than the intercanthal dis-
tance or the distance from the lateral
canthus to the ear canal.
3 Comparative Anatomy of the Eyelids 37
3. Laterally narrow and medially broad crease. The
eyelid appears hooded down laterally, producing a
sad face and a triangular eye configuration. Not
recommended.
4. Broader medially and laterally than centrally. Con-
sidered inharmonious and not recommended.
5. Broader centrally than medially and laterally. Con-
sidered inharmonious and not recommended.
A broad crease (>10 mm) was advocated by Song
for people with a rectangular face and a strong
character, such as performers and actors. An average
crease (7–8 mm) is chosen most often. A narrow crease
(4–5 mm) is recommended for people who want a crease
but are self-conscious about others knowing about the
operation. A nasally tapered crease and a parallel crease
based on tarsal height give the face the most aesthetic
harmony.
The conclusion is similar to what the present author
stated a year earlier in 1987,22 i.e. that a nasally tapered
crease and a parallel crease based on tarsal height meas-
urement give the best aesthetic appearance to the face.13
38 Asian Blepharoplasty and the Eyelid Crease
SUMMARY
It is apparent that there is more than a superficial differ-
ence between Asian and Caucasian eyelids. In addition to
the readily apparent differences in the size of the lids,
crease shape and crease height, there are also anatomic
differences in the tarsus and fat pads, differences in the
structure of the medial canthus, differences in facial con-
figuration and differences in the concept of beauty. All
these factors should be taken into account in the per-
formance of Asian blepharoplasty.
REFERENCES
1. Millard DR Jr. Oriental peregrinations. Plast Reconstr Surg
1955;16:319–336.
2. Millard DR Jr. The oriental eyelid and its surgical revision. Am J
Ophthalmol 1964;57:646–649.
3. Chen WPD. Upper blepharoplasty in the Asian patient. In: Putter-
man AM, ed. Cosmetic oculoplastic surgery, 3rd edn. Philadelphia:
WB Saunders; 2000: ch. 11.
4. Chen WPD. Review of Aguilar G. Complications of oriental
blepharoplasty. In: Mauriello J, ed. Management and avoidance of
complications of eyelid surgery. Vol. 3. Philadelphia: Field &
Wood; 1994.
5. Doxanas MT, Anderson RL. Oriental eyelids: anatomic studies.
Arch Ophthalmol 1984;102:1232–1235.
6. Jeong S, Lemke B, Dortzbach R. Comparison of Asian and Cau-
casian upper eyelid. Arch Ophthalmol 1999;117:907–912.
7. Anderson RL, Beard C. The levator aponeurosis. Arch Ophthalmol
1977;95:1437–1441.
8. Collin JR, Beard C, Wood I. Experimental and clinical data on the
insertion of the levator palpebrae superioris muscle. Am J Ophthal-
mol 1978;85:792–801.
9. Cheng J, Xu Feng-Zhi. Anatomic microstructure of the upper
eyelid in the oriental double eyelid. Plast Reconstr Surg 2001;
107:1665–1668.
10. Morikawa K, Yamamoto H, Uchinuma E, Yamashina S. Scanning
electron microscopic study on double and single eyelids in Orien-
tals. Aesth Plast Surg 2001;25:20–24.
11. Hwang K, Kim DJ, Chung RS, Lee SI, Hiraga Y. An anatomical
study of the junction of the orbital septum and the levator aponeu-
rosis in Orientals. Br J Plast Surg 1998;51:594–598.
12. Fink WH. An anatomic study of the check mechanism of the verti-
cal muscles of the eyes. Am J Ophthalmol 1957;44:800–811.
13. Bang YH, Chu HH, Park SH, Kim JH, Cho JW, Kim YS. The
fallacy of the levator expansion theory. Plast Reconstr Surg
1999;103:1788–1791.
14. Boo-Chai K. [Discussion following paper by Bang13.] Plast Recon-
str Surg 1999;103:1792–1793.
15. Uchida J. A surgical procedure for blepharoptosis vera and for
pseudo-blepharoptosis orientalis. Br J Plast Surg 1962;15:
271–276.
16. Miyake I, Tange I, Hirage Y. MRI findings of the upper eyelid and
their relationship with single and double-eyelid formation. Aesth
Plast Surg 1994;88:183–187.
17. Yoo HB. The double eyelid operation without supratarsal fixation.
Plast Reconstruct Surg 1991;88:12–17.
18. Johnson CC. Epicanthus. Am J Ophthalmol 1968;66:939–946.
19. Khoo BC. The Mongolian fold (plica Mongolia). Singapore Med
J 1962;3:132–136.
20. Lessa S, Sebastia R. Z-epicanthoplasty. Aesth Plast Surg
1984;8:159–163.
21. del Campo AF. Surgical treatment of the epicanthal fold. Plast
Reconstr Surg 1984;73:566–570.
22. Chen WPD. Asian blepharoplasty. Ophthalmol Plast Reconstr
Surg 1987;3:135–140.
23. Chen WPD. A comparison of Caucasian and Asian blepharoplasty.
Ophthalm Pract 1991;9:216–222.
24. Kawai K, Imanishi N, Nakajima H, et al. Arterial anatomic features
of the upper palpebra. Plast Reconstr Surg 2004;113:479–484.
25. Kim BG, Youn DY, Yoon ES, et al. Unexpected bleeding caused by
arterial variation inferolateral to levator palpebrae. Aesth Plast Surg
2003;27:123–125.
26. Hwang K, Kim BG, Kim YJ, Chung IH. Lateral septoaponeurotic
artery: source of bleeding in blepharoplasty performed in Asians.
Ann Plast Surg 2003;50:16–159.
27. Onizuka T, Iwanami M. Blepharoplasty in Japan. Aesth Plast Surg
1984;8:97–100.
28. Song RY. Further comment on double eyelid operation. [In
Chinese] Chin J Plast Surg Burn 1988;4:6–9.

THE EYELID CREASE:
GOALS AND BENCHMARKS
In the opening chapter of this book I discussed, in
common terms but in an exacting way, what an eyelid
crease is, both from a layman’s point of view as well as
from a scientific neuromuscular standpoint. The two are
complementary. Figure 4-1 shows a typical Asian eyelid
FIGURE 4-1 ■ A normal Asian eyelid without an upper lid crease.
CHAPTER 4
without a crease, usually denoted as a ‘single eyelid’ or
‘mono-lid’ (but remember that the incidence of absent
crease among Asians is 50%, meaning the other 50% are
born with an eyelid crease).
39
40 Asian Blepharoplasty and the Eyelid Crease
A crease that is located at a height of 8–10 mm from
the ciliary margin is considered ‘too high’ for Asians.
This may be a result of surgeons adhering to an empirical
formula for the height of the lid crease; or following
techniques of supratarsal fixation where a distance of
9–10 mm or more is applied without regard to ethnicity,
since for Caucasians the upper tarsus usually measures
10 mm in its vertical dimension. In either case, the crease
looks excessively high when it is applied on an Asian
patient for the following reasons. First, Asians are usually
smaller in build and their upper tarsus measures only
6.5–8 mm in height on the average. Second, the distance
between the eyebrow and the upper lid margin is propor-
tionately less in Asians. Therefore, if one were to apply
a crease at 10–12 mm from the lash margin, it would look
much closer to the mid section of the upper lid.
When the crease is farther from the lid margin than
the height of the tarsus for that patient, the surgically
applied crease traverses through thicker dermis as we get
closer to the brow and is more likely to be associated with
hypertrophic scarring. Being farther away results in less
camouflage by the upper eyelashes and the crease is more
exposed to scrutiny by the individual and their peers. It
also brings in an associated functional problem that will
be covered later (in Chapter 21). I consider a crease as
harsh when it is overtly prominent, deep and indurated
with dermal reaction.
By ‘unnatural’, I mean that the crease assumes a shape
that is aesthetically not attractive on the face of the indi-
vidual. The main offender is a semilunar crease. The
overall impression created by a crease positioned high
and with a semilunar shape is of an unnatural look for an
Asian individual. Another cause for an unnatural crease
is if an excessive amount of the preaponeurotic fat pad is
removed. When a major portion of the fat pad is removed
in the preaponeurotic space the result is a hollowed-eye
(‘famined’) look which appears incongruous in the rela-
tively flat facies of an Asian person.1 By contrast, removal
of preaponeurotic fat may be a necessary step in age-
related cosmetic blepharoplasty for those Caucasian
patients who in their youth had a deep-set supratarsal
sulcus. (Of course, not all Caucasians have a deep-set
sulcus and for those who had full eyelids, some fat pres-
ervation is desirable.)
 4 The Eyelid Crease: Goals and Benchmarks 41

Figure 4-2 shows arbitrary placement of a high, 10 mm
crease on an Asian upper eyelid. It shows a 10 mm crease
that is semilunar in shape, hypothetically applied to an
Asian eye anatomy (upper lid margin with black eye-
lashes). This would be considered a very high crease and
not the typical Asian crease configuration. (The effect can
be mimicked by using temporary devices like lid crease
tape or glue.)
The red arrows represent a line connecting the two
ends of the abnormally high semilunar crease to the Asian
eyelid’s true canthi. They cross at an angle of θ2 as
it passes through each canthus. If one superimposes
a Caucasian eyelid opening whose horizontal dimensions
are 5–10% larger (which they often are), assuming and
keeping the same vertical opening (brown upper eyelashes)

Semilunar
crease

Caucasian
eyelid fissure

Asian eyelid
fissure

q2

(θ2 > θ1)

A crease height of 10mm subtends a greater arc-angle θ2

in Asian eyelid than Caucasian ș1.
The crease-palpebral fissure complex will therefore be
q1 more rounded.

FIGURE 4-2 ■ Arbitrary placement of a high, 10 mm, crease on an Asian upper lid.
42 Asian Blepharoplasty and the Eyelid Crease
with the exact same semilunar crease shape and height,
the end-of-crease to end-of-canthus lines (green arrows)
will form a smaller angle of θ1 for the Caucasian eye.
Angle of θ2 > θ1
This helps explain why a semilunar crease applied to an
Asian patient will make the eyelid fissure visually appear
rounder than it should, though it may be perfectly suited
for a Caucasian anatomy.
It is important to recognize that there is a high degree
of variation in the anatomy of the upper eyelids of Asians.
It is a common misconception that all Asians are born
without an upper lid crease when in actuality half the
Asian population does have a natural crease. For each
person, the shape and height of the crease and the rela-
tion of the crease to facial configuration should be part
of the overall assessment before a cosmetic surgical pro-
cedure is performed.
STITCH METHODS COMPARED TO
INCISIONAL METHODS
Stitch Method (Buried Sutures Method)
If one is to describe any externally applied skin/eyelid
compression (like using a paper clip wire, or a device like
the externally applied lid crease thread fiber from Japan),
or several buried stitches that actually course through the
eyelid’s full thickness from front to back (skin to conjunc-
tiva) or back to front (conjunctiva to skin), and then refer
to these resulting indentations as an eyelid crease, one
would be mimicking a crease, at a location that is not
always physiologic. The sutures used in the buried suture
method are often necessarily permanent (meaning they
do not dissolve, such as nylon); dissolvable sutures would
not be very effective in these suture methods. The result-
ing crease is passive and noticeably present on downgaze,
which is unnatural. This mimicking crease is generated
from externally applied and compressive (constricting)
sutures inserted over and through a physiologic muscle,
at 90° to its normal axis of function and at several dispa-
rate points. It is my view that this is dampening to its
normal function.
External Incision Methods
Use of the incision method entails a greater learning
curve on the part of the surgeon, but offers several advan-
tages once the surgeon has diligently mastered the con-
cepts and practices. The method allows for the redundant
skin fold hanging down onto a single eyelid to be reduced
to expose a larger eyelid opening, greater control of
crease height and shape, greater control in creation of a
physiologic crease, a dynamic lively crease that should
naturally fade (shallows, diminishes) when the lid is
relaxed as in looking downward (without seeing the
stitch-induced dimpling on the skin surface), and it can
be achieved without having to use buried permanent
stitches. It simulates a natural crease, through fine strands
of the end portion of the levator aponeurosis attaching
to the undersurface of skin along where a natural crease
would have formed, if the person were to have been born
with a crease. All sutures are removed after 7–10 days as
there is really no need to use anchoring stitches, whether
dissolvable or permanent. The simulation is close to
being natural as the crease arises from internally gener-
ated contractile force of the levator muscle, going with
the flow.
One can compare the two methods as if one is trying
to create an elbow crease on the crease-less arm of an
imaginary model. The suture method can be used to
create a ‘crease’ almost anywhere on the forearm and arm
that has skin. If applied too short or low down on the
arm, like a tourniquet, it is on the forearm side of the
elbow joint; it may not be physiologic but you will see
the indented mark that mimics an elbow crease. If done
too high (on the arm or biceps portion), the crease will
look unnatural and may actually hamper the contractile
function of the biceps. Besides, the recipient will feel its
presence within its muscle tissues.
Patients’ complaints regarding their lid crease sutures
after buried stitch methods are not hyperbole, as we see
high placement of a crease from the suture method often
resulting in ptosis, and generating muscle-awareness on
blinking, and even foreign body sensation when the
sutures are buried close to the surface. Low placement of
buried sutures often results in eventual disappearance of
a crease, or it leaves behind a dimple scar.
Finally there is the issue of permanence. It is generally
accepted that the buried stitch method has a higher rate
of crease disappearance (failure rate), which can occur
since the method does not normally perform any removal
of excess and interfering tissues, unless the lateral or
central small stab incision has been extended significantly
to allow removal of some fat. Buried sutures can also lose
effectiveness as they are tied relatively tight to achieve a
compressive ligature effect, and are thereby prone to cut
(‘cheese-wire’) through their target tissues.
Sometimes one stitch among the three or four buried
stitches may come loose or lose its effectiveness while in
place, and that segment of the compressed crease will
then regain its previous fullness, so the crease will look
incomplete or lose its continuity as well as not achieve
permanence.
We have touched on the fact that, historically and
from a population standpoint, the most natural crease
shape in an Asian eyelid is either a nasally tapered (where
the upper crease narrows towards the inner corner of the
eyelid skin and touches it) or a parallel shape, where the
crease runs parallel like a ribbon along the eyelash line
(lid margin). These descriptions are of course somewhat
arbitrary; in reality there are probably many intermediate
forms between a parallel and a tapered crease – for
example, a crease may dip close to but not quite touch
the inner corner: is this ‘mostly parallel’ or ‘tapered yet
not touching’? [It would be my personal opinion that
such a crease should be still considered parallel, as the
upper and lower lid always join at the medial canthus with
the upper lid margin sloping downward.]
In terms of height of crease (i.e. how broad is the mid-
section of the eyelid opening), it is this author’s opinion
that there is a very narrow corridor for variation in the

crease height (measured in millimeters). It should be
linked to the actual physical dimension of the person’s
upper eyelid tarsal plate (discussed in Chapter 1) and
palpebral opening. The superior tarsal border often dic-
tates where the crease should be located on the mid-
section of the skin side of the upper lid. One can go a bit
lower, but not much higher than this level to be ‘natural’,
without treading into areas of possible complications and
sub-optimal results.
We will revisit shape, height, continuity and permanence
as specific parameters in the following chapter on Con-
sultation and Counseling.
PHYSIOLOGY OR FAD?
I would like to share some personal views. In medicine,
the majority of patients are less knowledgeable than the
physician, and it is the medical practitioner’s duty to
advise the patient on what is proper, normal and natural
in terms of treatment outcome and expectations. The
physician is sworn to the Hippocratic Oath of Healing of
4 The Eyelid Crease: Goals and Benchmarks 43
‘do no harm’. In aesthetic surgery, however, this perspec-
tive is somewhat warped in that, for whatever reason,
there are both patients as well as doctors who feel that
their opinions and preferences over-rule everybody else’s,
as well as any conventional wisdom. Besides patients with
body dysmorphic issues, there are also those occasional
patients who feel they would like a very high crease, and
without understanding the risk involved, will request that
the procedure be done that way – and the surgeon com-
plies. In a situation like this, it is crucial for the surgeon
to be knowledgeable and to have the discipline to advise
the patient of the surgical concerns when faced with such
an unconventional request. The surgeon must not be
swayed to go the patient’s way. It is especially important
not to go with the current fashion or media fad. This
discrepancy in knowledge level may be skewed in either
direction, through the ignorance of the patient, or an
over-bearing patient facing a less than informed surgeon.
REFERENCE
1. Chen WPD. Asian blepharoplasty. Ophthal Plast Reconstr Surg
1987;3:135–140.
 CHAPTER 5

CONSULTATION AND COUNSELING

We have touched on the cultural diversity and linguistic

differences among the Asian races. Ethnically the Asians
who often request this type of cosmetic surgery include
Chinese, Japanese, Koreans, Philippinos and South-East
Asians. It is important to note that in these ethnic groups
often more than half of the overall population do have an
upper lid crease and that you may be consulting with a
patient who wants to look like their fellow Asians, rather
than looking like a Caucasian fashion model.
It is crucial for the practitioner to be aware of com-
munication gaps and misunderstanding that may exist
between the surgeon and the patient.1-3 This is especially
critical at the first meeting, when I always have as my goal
to try to find out the patient’s needs and assess whether
FIGURE 5-1 ■ Results after blepharoplasty show multiple high,
they can be met. semilunar creases caused by excessive removal of preaponeu-
It is interesting to observe that in Japan, China and rotic fat.
Korea it is common and acceptable for young adults who
do not have a lid crease to undergo cosmetic eyelid
surgery. It is often socially acceptable for mothers to
encourage their daughters to have the procedure, as com-
pared to the stigma usually associated with rhinoplasty,
breast implant or cheek augmentation. The concept that
eyelid surgery is a way to improve on the beauty of the
person, to ‘open up’ the face while being relatively non-
invasive, is in sharp contrast to their views towards other
cosmetic surgeries, which involve implantation of syn-
thetic materials in the body, rendering the body ‘not
whole’.
This somewhat cavalier attitude on the part of the
patients or family members towards eyelid surgery is
problematic if the physician and the patient have not
come to a mutual understanding. Often I see patients
coming in for consultation who had the surgery done by
FIGURE 5-2 ■ Postoperative asymmetric crease.
reputable and capable physicians, but are dissatisfied with
the result. They are justified when they complain that
despite their insistence on a ‘low, natural crease’ the
surgeon has given them a high crease (Figure 5-1); the
creases are asymmetric (Figure 5-2); the crease disap-
peared with time (Figure 5-3); or the surgeon gave them
a ‘hollow’ over the upper lid crease, usually from over-
excision of preaponeurotic fat pads (Figure 5-4). Perhaps
the surgeon had his own perception of what the proce-
dure is, as is performed in a traditional blepharoplasty,
and applied it to the Asian patient.
The unhappy patients who have suboptimal results
often express the opinion afterwards that they ‘did not
think that it would be so noticeable’. Not infrequently,
they may want the whole process to be reversed. A prop-
erly performed placement of crease over the upper lid is FIGURE 5-3 ■ Fading of surgically constructed crease in the left
natural and blends in with the configuration of that upper lid.

45
46 Asian Blepharoplasty and the Eyelid Crease
particular patient’s eyes and face. A suboptimal crease
may be very noticeable since the eyes are a focus of atten-
tion in human interaction.
The patients here in America are often bicultural, and
may have a preconceived perception of how the proce-
dure might be performed. This is often their first surgery
ever. I find that most patients prefer that their friends
not know that they are having it performed, although an
equal number are very jubilant and will tell everyone
once their wounds have healed to a desirable level. Some
patients expect minimal or no swelling following surgery.
Some expect no sutures at all, while some expect no inci-
sion. Other patients may expect all swelling to subside in
a week. Almost all patients are invariably surprised at the
height of the crease during the first few weeks, which
usually goes down with proper healing.
THE CONSULTATION
My first face-to-face interaction with a new patient
coming in for an office consultation is a relaxed meeting
where we get to know each other’s viewpoints. The
patient would express his/her concerns, goals to achieve,
perhaps reasons for the goals.
Among the important items that should form part of
the ensuing consultation are:
• A basic eye evaluation: record of the patient’s
best corrected vision, past history of dry eyes,
injuries, scar formation or keloid, the sizes of the
eyelid opening (vertically and horizontally), the dis-
tance between the two eyes, any ptosis or lid retrac-
tion, presence or absence of crease on each side,
asymmetry, levator function (excursion) of each
upper lid. If there is a history of previous surgery in
the area, document the extent of scars in each layer
of the lid and any crease abnormality, perform
various assessments for skin shortage or mid-
lamellar scarring.
FIGURE 5-4 ■ Elderly patient after blepha-
roplasty in which excessive fat was
removed. Note the presence of multiple
creases and folds.
• A demonstration from the patient of what the indi-
vidual would like to achieve, as well as the surgeon
showing the patient what can possibly be achieved,
which may be followed by a preview of some crease
shapes and of different crease heights.
• Going over the patient’s facial attributes, which
might favor certain crease dimensions over others.
Discuss appropriate remedies and prioritize the
steps. With knowledge, the patient may then express
their preferred choice of crease shape and dimen-
sion. The physician may advise or concur.
• Discussion of the procedure: going over preopera-
tive steps and preparations, postoperative care first
day, first week, two months. Inform the patient of
what to expect in wound healing. Discuss overall
success rate or likelihood for secondary touchup,
rate of touchup revision, and what the policy of
your practice is. If proceeding to surgery, explain
possible complications (see below) and sign informed
consent.
• Preoperative photography for the record, including
straight-ahead, upgaze, downgaze, oblique views.
For revisional cases I take close-up macro-photo-
graphic images of the previous incisional scar for
documentation. Preoperative instructions are given
including avoidance of anticoagulants and herbal
medications.
• Postoperative dietary advice – do’s and don’ts.
• Postoperative eye movement exercises for some
individuals: timing and schedules.
Complications are similar to those seen in any blepha-
roplasty surgery and may include hemorrhage, transient
asymmetry in crease form, obliteration or fading of the
crease, prolonged postoperative edema, hypertrophic
scar formation and formation of multiple creases.

Further Discussion on Height, Shape,
Continuity and Permanance
Crease configuration has four contributing parameters:
height, shape, continuity and permanence (Figure 5-5).
These are each discussed further at the consultation.
Height
In the previous chapter, I mentioned the normal height
of the upper tarsus as being only 6.5–7.5 mm in Asian
women (rarely 8 mm). The clinical significance of this is
that a crease arbitrarily positioned at 10 mm as suggested
in some plastic surgery literature will be too high for
Asians.2,3 The crease placement should therefore be pred-
icated on measuring the true anatomical height of the
upper tarsus in that patient, using it as a relative guideline
in defining where the crease should be positioned.
In my first office consultation with a new patient, I
listen first to their complaints and try to classify the
complaints into relative orders (or a wish-list), which
includes those that can be improved upon, versus tran-
sient improvement or no improvement at all. Ultimately
the surgeon and the patient need to mutually agree on
what is beneficial and worthwhile for the patient to
undertake. I always try to encourage patients to speak
their mind, even if they may be embarrassed, and I try to
facilitate this in an environment free of stress. Very often
Height
Permanence
Continuity
FIGURE 5-5 ■ Interrelated parameters of the configuration of an eyelid crease.
5 Consultation and Counseling 47
patients may be overly self-conscious about an issue that
matters very little to anyone they interact with, or one
may need to point out an extreme condition that needs
to be corrected before the aesthetic outcome can be
achieved, for example, ptosis. It is important to customize
individual aspects of your particular technique for that
patient. I have never performed two exactly identical pro-
cedures on any of my patients who have come to me to
have Asian blepharoplasty surgery.
I inform the patient that a properly applied crease will
invariably appear higher than expected postoperatively,
and that this is a result of tissue swelling. The patient is
told to expect a certain degree of postoperative edema to
last for at least a few weeks, and that the crease configura-
tion may vary from month to month and from one eyelid
to the other. The patient is instructed not to expect a stable
and satisfactory appearance for at least three months. I find
that having been given this information, patients are a lot
more accepting of the normal wound healing process.
Shape
The shape of the crease is clearly an important factor for
discussion before surgery. A large percentage of patients
I encounter know what they want in terms of the crease
configuration and its degree of prominence. For those
patients who do not know, they are informed of the desir-
ability of a nasally tapered or parallel crease, and the
Shape
48 Asian Blepharoplasty and the Eyelid Crease
undesirability of a semilunar crease, which is an occiden-
tal (Western) crease that appears incongruous on the face
of an Asian. The ultimate decision, of course, rests with
the patient. None of my patients, however, has chosen
the semilunar crease after having had the different crease
configurations and their prevalence in Asians explained
to them.
Continuity and Permanence
These are surgical goals that I try to achieve in all cases.
Post-surgically the crease should be continuously formed
along the width of the eyelid fissure without any inter-
ruption or multiplicity. Permanence refers to the fact that
the crease should be present well beyond 24 months. I
mention these two factors because even though there are
a great number of techniques in the literature, not all of
them are predictable and long-lasting in their results.
I inform my patients to expect a 5% probability of
needing touch-up revisions if the creases are uneven in
depth. This is a realistic estimate in my practice, and most
patients feel comfortable with it. Other surgeons may
prefer to inform their patients of a probability rate for
touch-up revisions of 10–20%.
After an adequate prioritization of goals with the patient,
I then explain what the procedure involves, before, during
and after the surgery and what is expected of the patient.
This includes the preoperative mandatory cessation of
aspirin products, any herbal formulas, ginseng com-
pounds and herbal teas, which frequently may contain
therapeutics with anticoagulative properties.
The patient is given a detailed written list of preopera-
tive as well as postoperative instructions, including bed
rest during the first day, use of ice compresses as well as
antibiotic ointments, what to expect and instructions to
call me should there be any concern. The office staff are
trained to make a follow-up telephone call to the patient
the next day after surgery, both to verify that the patient
is stable and to confirm a return date for suture removal
by me.
In the patient’s chart, I record particular aspects of
their facial structure (ptosis, forehead brow over-action,
prominent sulcus), what was mentioned to them (for
example, one upper lid margin is half a millimeter lower
than the other, one eye shows a more prominent sulcus),
what was the patient’s response and what were their pref-
erences (slightly high crease, slightly low crease, shape of
FIGURE 5-6 ■ A patient with palsy of the superior rectus muscle of right eye, which normally would elevate the eye on upgaze.
crease line selected as well as skin texture observed) as
well as whether we discussed that, despite their stated
preference, their desired result can be achieved. It will
also be noted onto the plan of management if a patient
has thick dry skin, or oily complexion, superficial furun-
cles, or rosacea.
Figure 5-6 shows a patient who appeared to have nor-
mally functioning eyes, but extraocular motility testing
showed palsy of the right superior rectus muscle (left side
of photo). Often there may be deficit in the levator
muscle, also controlled by the superior branch of the
oculomotor nerve (third nerve). Levator function may be
impaired and this will influence outcome of any proce-
dure to enhance the eyelid crease.
Postoperative dietary recommendations are also offered
to facilitate uneventful healing after the surgery (this is
an aspect of Traditional Chinese Medicine that somewhat
baffles and perplexes Western medical practitioners).
In California, informed consent for surgery is manda-
tory and we implement it in the office as well as the
outpatient surgical facilities. All aesthetic patients must
have adequate photographic documentation of their
current conditions. This typically includes a frontal view,
oblique side-views, upgaze and downgaze and, most
importantly if the patient has had previous surgeries, a
close-up macro view of the existent surgical lines or lid-
crease scar. This last item has been very useful for fully
informing the patients in many of the revision cases that
I perform. In this very litigious climate, adequate docu-
mentation is truly the best policy.
If a patient seemed extremely nervous at the office
consultation, I may try to call them the night before the
procedure to make sure all is well. On the day of surgery,
in the preoperative area, I greet the patient again and
reiterate the goal(s) of the surgery. If there is any discrep-
ancy between what I have told them and what they expect
of the surgery, I will always defer the surgery until another
day, although this is extremely rare.
The following are examples of preoperative advice
given to patients on postoperative expectations:
1. The wound is to be cared for by local ice com-
pressing during the first 24 hours. One can expect
a mild degree of swelling to start after the first day,
with minimal to mild swelling over the preseptal
area.
2. The swelling will begin to decrease by day 4. At the
seventh day, a normal looking crease form will be

located at a level 40–50% higher than the eventual
outcome. (In other words, a perpendicularly viewed
and measured crease will look like 140% of what
was originally designed.)
3. The swelling will have subsided by 80% by the end
of two weeks postoperatively.
4. The remaining 20% swelling will take another six
weeks to resolve; the {80% : 2 weeks / 20% : 8 weeks}
rule.
5. The crease height does not move; it is merely
inflated up and down as wound swelling occurs and
then subsides.
6. The incisional wound tension peaks at 5–6 weeks.
7. The healing wound may be pruritic (itchy). This
may intensify and become reddened if the patient
consumes spicy and/or fried foods. Comedogenic
foods like chocolate, high cholesterol foods like
5 Consultation and Counseling 49
shell fish (shrimps, clams, lobsters) should be
avoided as a general rule.
8. Wound induration (‘your wound will feel leathery’)
may occur during the period from 4–12 weeks.
Topical corticosteroid ointment may be prescribed
by the physician as needed.
9. Minimal residual swelling that is clinically insignifi-
cant may linger for 6 months before total
resolution.
REFERENCES
1. Chen WPD. Insights from a series on Asian blepharoplasty. Pre-
sented at the 21st Annual Scientific Symposium of the American
Society of Ophthalmic Plastic and Reconstructive Surgery, Atlanta,
1990.
2. Chen WPD. Asian blepharoplasty. Ophthal Plast Reconstr Surg
1987;3:135–140.
3. Chen WPD. A comparison of Caucasian and Asian blepharoplasty.
Ophthal Pract 1991;9:216–222.
 CHAPTER 6

SUTURE LIGATION METHODS

This chapter provides an overview of buried suture liga-

tion methods (also known inaccurately in Asian languages
as ‘non-incisional’ or ‘no-cut’ methods). Historical per-
spective and variances in technique are covered.

EVOLUTION OF DOUBLE-EYELID
COSMETIC SURGERY IN THE
JAPANESE LITERATURE
Publications in the early Japanese medical literature
favored the suture ligation methods. The first description
of the suture ligation method, by Mikamo,1 was published
in 1896. Mikamo performed the procedure on a Japanese
woman who did not have a crease in one of her upper
eyelids. The crease was designed to be 6–8 mm from the
ciliary margin. Three 4-0 braided silk sutures were used;
they passed through the full thickness of the lid from the
conjunctiva to the outer layer of skin. The depth of the
crease was adjusted by the number of days the sutures
were left in, the range being 2–6 days.
As early as 1926, Uchida2 described his suture ligation
method for the double-eyelid operation. He performed
the procedure on 1523 eyelids in 396 male and 444 female
patients. Uchida described the crease configuration as a
fan shape, that is, a somewhat rounded crease. The crease
was designed to be 7–8 mm from the ciliary margin.
Three buried catgut sutures were used on each lid,
encompassing approximately 2 mm of eyelid tissue
horizontally. The sutures were removed 4 days after
placement.
The first mention of an external incision method dates
to 1929, when Maruo3 reported on both his suturing
technique and his incision technique. Maruo’s incision
technique required a lid crease incision across the lid,
designed to be 7 mm from the ciliary margin. The wound
closure technique was a translid passage from the con-
junctival side just above the superior tarsal border to the
anterior skin surface. One 5-0 catgut suture was used to
imbricate four throws along the superior tarsal border,
attaching skin edges to the underlying tarsal plate. The
spacing between each throw of the stitch was about
5–6 mm. Maruo also discussed subcutaneous dissection
5 mm superior and inferior to the incision line.
In 1933, preference for a higher placement of crease
became evident when Hata4 reported his suture ligation
method. The crease line was placed 10 mm from the
ciliary margin. Hata used three double-armed 5-0 braided
silk sutures, passing them from tarsus to skin, fixing them
to the skin surface using small beads. Each arm of the
suture required 1 mm spacing for the bead to be tied.
Stitches were removed after 8–10 days.
51
52 Asian Blepharoplasty and the Eyelid Crease
In a comprehensive and scholarly article in 1938,
Hayashi5 described the two methods of crease formation.
His suture ligation technique was modeled after Mika-
mo’s method but was novel in that it was designed for a
nasally tapered crease. Three sutures were used on each
lid. The central and lateral sutures were applied superior
to the crease line or tarsal plate, whereas the medial
suture was deliberately applied below the crease line or
tarsal plate. Hayashi’s incision method was also revolu-
tionary in that he advocated excision of pretarsal orbicu-
laris oculi muscle at the area of the incision. He also
advocated the use of interrupted skin–tarsus–skin sutures
and in between skin–skin stitches consisting of 4-0 silk
for wound closure. The crease was designed so that medi-
ally it was 5 mm from the ciliary margin, centrally 6 mm
from the margin and laterally 7 mm from the margin; in
essence it was a nasally tapered crease. The sutures were
removed after 4 days.
Inoue6 in 1947 proposed dissecting the ‘connective
tissues’ in the subcutaneous plane between the incision
line and the ciliary margin. Sutures of 5-0 braided silk
were used for skin–tarsus–skin closure; sutures were
removed after only 2–3 days.
In 1950, Mitsui7 continued the evolution of the
double-eyelid crease procedure when he described the
dissection and removal of pretarsal connective tissue,
including pretarsal orbicularis muscle and pretarsal fat
pads. Wound closure was carried out in two steps. First,
five separate nylon sutures were used to stitch the inferior
skin border to the anterior surface of the superior tarsal
border and were tied individually. Second, 5-0 braided
silk was used to close the incision site skin to skin. The
nylon sutures were removed after 2–3 days, the silk
sutures after 7–8 days.
Ohashi8 described a double eyelid crease operation
using an electric coagulator. The cautery needle was
applied vertically to the skin surface along the crease line
until the skin blistered; two more rows of cauterization
below the crease line followed. Hirose9 and Ikegami10 in
1951 briefly discussed incision methods but did not offer
any new information.
The foregoing procedures were described only in the
Japanese literature and were not readily available to
Western readers. As a result, the publication of articles
on this procedure in Western medical journals in the
1950s made the procedure seem new (and Western) in
concept. Between 1896 and 1950, 11 articles relating to
the suture ligation methods and eight articles on external
incision methods were published in the Japanese medical
literature. Much of the early Western literature on this
subject described techniques quite similar to those
described in the early Japanese publications.
In 1954, Sayoc11–17 wrote the first article published in
the English literature on the external incision technique.
Millard18 in 1955 described his Korean Armed Service
experience. He mentioned that Koreans at that time
desired to look ‘round-eyed’ like Westerners rather than
‘slant-eyed’. Millard believed that the absence of a crease
in Koreans was a result of excessive skin and supraorbital
fat. One patient Millard described underwent excision of
a 3 mm strip of skin, dissection under both upper and
lower skin edges, trimming of the orbicularis muscles
along the inferior skin incision, and complete excision of
the supraorbital (preaponeurotic) fat pads. Although he
used crease-enhancing silk sutures from skin to tarsus to
skin, Millard believed such sutures were not always nec-
essary. A small Z-plasty was performed selectively to
eliminate an epicanthal fold. Millard’s article is an inter-
esting illustration of the interaction between Western
surgeons and Asian patients in the 1950s.
In 1961, Pang19 described his ‘trans-lid’ full-thickness
eyelid sutures placement to form an upper lid fold: three
double-armed 4-0 black silk sutures were placed from the
conjunctival side towards the skin side, they were tied and
left in for 10 days.
Fernandez,20 Uchida21 and Khoo Boo-Chai22 also
wrote articles on the external incision technique. In 1962,
Uchida described the presence of different fat compart-
ments and variations of fat distribution in the upper
eyelids of Asians. His incision method involved selective
excision of pretarsal subcutaneous tissues, including skin,
pretarsal orbicularis muscle and fat, preaponeurotic fat
and even some preseptal fat pads.
In 1964, Khoo Boo-Chai23–26 advocated the simpler
transconjunctival suturing technique for younger patients
with a minimum amount of excess fat and skin.
Mutou and Mutou27 in 1972 also described the suture
ligation technique. In this classic paper, Mutou and
Mutou detailed their interpretation of their concepts of
the double eyelid and their less invasive method for
patients with thin eyelid skin and scarce subcutaneous fat.
They performed 4805 procedures between 1965 and
1969, of which about 90% were in women. One-quarter
preferred the parallel shape and three-quarters preferred
the ‘unfolded fan type’ (equivalent to a nasally tapered
crease but with gradual widening towards the lateral end
of the lid fissure). To make the crease nasally tapered, the
authors turned the ligature over the inner canthus down-
ward. They explained that three options in the crease
height were available to the patients: the lowest level, at
4–5 mm, was called the ‘deep double eyes’ (the deep here
connotes more of the sense of inferior anatomic loca-
tion), the usual was 6–8 mm crease height, and the highest
was 9–12 mm and is available for those with large eyes.
The actual technique basically involved passing two
double-armed 6-0 sutures from the conjunctival side:
each traverses horizontally for 5 mm at a position 3 mm
above the superior tarsal border in a subconjunctival
fashion (see Faden effect in Chapter 21). Each arm is then
reinserted through the conjunctiva (within 1 mm of its
exit) towards the skin side. One arm of the suture thus
exited on the skin side is then passed subcutaneously and
tied with the second arm on the skin side. These authors’
placement of the double-armed sutures was such that
the medial ligature straddled the junction of the medial
one-third and central one-third of the upper lid; the
lateral ligature straddled the lateral one-third of the
upper eyelid. The sutures were meant to be buried per-
manently. They stated that mild transient ptosis was seen
in almost all cases. Mutou and Mutou27 had initially
reported in 1972 a disappearance rate of 1.3% among
their patients who underwent an intradermal double-
eyelid procedure with buried sutures. Two sutures were
used but subsequently, due to a significant postoperative

FIGURE 6-1 ■ Young Asian adult who
underwent crease placement by
the conjunctival suturing technique
(buried sutures). The crease over the
right upper lid has remained while
the left has disappeared after a year.
ptosis (weakness and drooping of eyelid muscle), Mutou
modified the technique to using a single stitch in 1973.
This observation of postoperative ptosis reflects the
Faden effect (impairment of contractile function of
levator muscle), which I discuss in Chapter 21, that is
often associated with high placement of sutures, as well
as use of permanent buried sutures that bind the anterior
and posterior lamellae together.
The buried suture method has the short-term advan-
tage of being relatively non-invasive and usually causes
less postoperative swelling (amount and time of resolu-
tion). The main disadvantage is that the crease may disap-
pear with time (Figure 6-1). I will discuss further the
implications of use of buried sutures in Chapter 21.
In 1979, Dr Yukio Shirakabe28 modified the compres-
sive beads method of Hata4 (1933); his method consisted
of making an external skin incision followed by under-
mining of the pretarsal area, followed by closure and
crease fixation using six double-armed 4-0 nylon stitches,
with each arm of each pair of the stitches looped and tied
down with a small bead (total = 12 beads).
In their paper of 2000, Homma and colleagues29
reported that Mutou had a crease regression rate of 3.4%
out of 1457 patients during a seven-year period from
1986. They indicated that the technique is applicable for
those patients with little fat tissue or mild puffiness only.
They quoted the advantages as including minimal post-
operative swelling, that the crease can be reversed by
cutting the stitch and no apparent scar. The procedure
involved everting the tarsus and applying 7-0 nylon
through the conjunctiva at a point 3 mm above the supe-
rior tarsal border. It traverses the conjunctiva for 5 mm.
One arm is reinserted through the conjunctiva 1 mm
adjacent to where it came out, exiting through the ante-
rior skin surface. This is followed by the second arm of
the conjunctival suture exiting the skin in the same
fashion. The first suture is then passed subcutaneously to
join the second suture, now on the skin side, and the two
are tied and cut close to the knot.
Other authors, including Tsurukiri,30 had reported a
regression rate of 10%. Satou and Ichida31 reported a
regression rate of 16.8%. Homma and colleagues29 pos-
tulated that the disappearance rate is higher among those
6 Suture Ligation Methods 53
individuals with thicker skin or who possess excess sub-
cutaneous fat. They acknowledged the difficulty in assess-
ing the true rate of disappearance since patients often do
not return for follow-up, and that often patients seek
other doctors for revision when the first procedure was
suboptimal. A significant factor not discussed is the fact
that most of the patients who undergo the stitch methods
realize that when the crease does disappear they are often
then candidates for the incision methods, and therefore
may proceed directly to seek consultation with those who
practice the open incision methods.
In general, the suture ligation method has always been
touted as being a relatively non-invasive procedure that
usually results in less postoperative swelling. Its main
disadvantage is that the crease may disappear with time.
It can be a significant disadvantage when it happens, as
time and resources have been invested. (This is a case
where little was done, and little can therefore be expected
in the long term. See Chapter 21 on the effect of high
stitch placement above the tarsus, the hindering ‘Faden
effect’ when the levator is tied within loops of sutures,
and the effect of the use of buried permanent suture.)
There are other papers published that described the
use of small incisional approach with removal of tissues
along the superior tarsal area, coupled with passage of
buried sutures. For example, Lee, Baek and Chung’s
paper32 described use of 7-0 nylon through small skin
incision wounds, applying it as a buried figure-of-eight
continuous suture, forming three hexagonal loops span-
ning the width of the crease; this was combined with
removal of tissues (muscle, preseptal fat and septum).
They applied it in 327 patients with a mean follow-up of
13 months only.
From the years 1970 to 1990, there were at least a dozen
papers describing the external incision methods. Among
them, Zubiri’s33 article in 1981 described the measurement
of the vertical dimension of the upper tarsus as a way to
guide the placement of the lid crease incision. This is a
logical and anatomically correct way of tailoring the inci-
sion lines. It approximates a true crease position and is the
method I favor. Since 1995 when my Asian Blepharoplasty:
A Surgical Atlas was published, there have been at least an
additional 40 publications whose range of topics included
54 Asian Blepharoplasty and the Eyelid Crease
epicanthoplasty as well as papers describing smaller skin
incision or variations of ‘partial’ incision methods, and
various forms of crease fixation, including ‘septodermal’
and ‘orbicularis-levator’ fixation.
VARIATIONS AMONG SUTURE
LIGATION METHODS
In the suture ligation technique, the method ties together
the tissues between the levator aponeurosis along the
superior tarsal border and the subdermal tissue overlying
it, without skin excision, although there are insertions of
needles through skin, conjunctiva or small skin incisions.
I have conceptually categorized all the suture method
papers published in Asian languages and in the English
medical literature into the following six variations,
depending on the entry and exit sides for the passage of
the sutures (see Appendices).
Generally, the lid is first anesthetized using local infil-
tration of lidocaine hydrochloride (Xylocaine). The
upper eyelid is everted and three double-armed sutures
are placed from the conjunctival side in a transconjunc-
tival approach above the superior tarsal border (Step 1).
One of the following three alternatives may be performed
to complete this transconjunctival approach.
 6 Suture Ligation Methods 55

Alternative 1: Full-Thickness Suture
Technique (Figure 6-2)
After passing through the conjunctiva with the lid everted,
both ends of the suture pass through to the skin surface
(Step 2); then one end is again passed subcutaneously
to exit through the exit site of the second needle on the
skin (Step 3). The two ends are tied and buried
subcutaneously.

2
3

Skin

Orbicularis muscle

Levator aponeurosis

Müller's muscle
Conjunctiva
2 2 1
1
FIGURE 6-2 ■ Alternative 1: Full-thickness suture technique.
56 Asian Blepharoplasty and the Eyelid Crease

Alternative 2: Full-Thickness
Suture Technique with Stab
Incisions (Figure 6-3)
After each end passes through on the conjunctival side
(Step 1 as in previous variant), one end of the suture
passes through the lid and exits through a stab skin inci-
sion (Step 2). The other end goes through skin next to
the stab incision and is re-passed subcutaneously to join
the first suture, which again exited through the stab inci-
sion (Step 3). The two ends of the suture are tied in the
stab incision and buried (see Khoo Boo-Chai24). As in
Alternative 1, the suture knot encompasses the Müller
muscle, levator aponeurosis and some pretarsal orbicula-
ris oculi muscle, producing a scar between the subdermal
tissues along the superior tarsal border and the levator
aponeurosis–Müller muscle complex. This variant is most
commonly used among the suture ligation methods.

3
Stab incision
2

Stab incision

Skin

Orbicularis muscle

Levator aponeurosis

Müller's muscle
Conjunctiva
1 2 2 1
FIGURE 6-3 ■ Alternative 2: Full-thickness suture technique with stab incisions.
 6 Suture Ligation Methods 57

The line drawing in Figure 6-4 (upper) shows Khoo involves everting the upper lid margin and passing it
Boo-Chai’s method originally published about 50 years subconjunctivally for a couple of millimeters (A′–B′), at a
ago. In Dr Boo-Chai’s method, a typical suture used may level typically several millimeters above the superior
be a double-armed 5-0 or 6-0 nylon. The first passage (1) tarsal border. The second passage (2) directs one needle

B’ 1 A’

2 3

B 4 A

LA
M
C

FIGURE 6-4 ■ Line drawing showing Khoo Boo-Chai’s method originally published about 50 years ago. LA, Levator aponeurosis;
M, Müller’s muscle; C, conjunctiva.
58 Asian Blepharoplasty and the Eyelid Crease
towards the skin side, aiming just along the upper border
of the tarsus (B′–B). Similarly for the other arm of the
suture, the third passage (3) goes from A′–A. (If the two
ends on the skin side are tied on the skin at this moment,
it will be a full-thickness compression ligature encom-
passing Müller’s muscle, levator aponeurosis, as well as
orbicularis oculi muscle in a posterior–superiorly biased
fashion, plus skin. It also inadvertently creates a Faden
effect (see Chapter 21) at each of the two locations
of B′–B and A′–A, and a horizontal contraction of the
width of levator aponeurosis at A′–B′.) In fact the second
needle exiting the skin at A is re-passed (4) subcutane-
ously across to join B, exiting at a small skin opening
there. The nylon ends are ‘firmly’ tied and the knot sinks
into the small surgical opening. Traditionally, the suture
methods use three sets of these sutures, medial, central
and laterally.
Figure 6-4 (lower) shows a cross-section of Khoo Boo-
Chai’s method. Note the position of the buried suture
encompassing the active levator muscle (pink) at a point
higher than the tarsal border, together with the passive
orbicularis oculi muscle (grey).
 6 Suture Ligation Methods 59

Alternative 3: Transconjunctival
Intramuscular Suture Technique
(Figure 6-5)
Without piercing the skin, one end of the double-armed
suture is passed through the Müller muscle and levator
aponeurosis to the subcutaneous plane along the superior
tarsal border. The needle remains in the subcutaneous
plane; the suture arm is reversed through the same tissue
and exits through the conjunctiva. The other needle on
the conjunctival side is then passed subconjunctivally to
meet the first needle on the conjunctival surface (Step 2).
The two ends of the suture are knotted and buried within
the conjunctiva above the superior tarsal border. Some
surgeons prefer to cut out a small piece of tarsus and bury
the knot within the space to prevent corneal or conjunc-
tival irritation.
There are three other variations of the suture ligation
methods, which approach from the skin side. These are
as follows.

Strategic placement
of intramuscular
sutures creates
infolding of crease

Indentation of skin

Skin

Orbicularis muscle

Levator aponeurosis
Exit
Müller's muscle
2 1 Conjunctiva
Entry for both needles
of double-armed sutures

FIGURE 6-5 ■ Alternative 3: Transconjunctival intramuscular suture technique.

60 Asian Blepharoplasty and the Eyelid Crease

levator aponeurosis and some Müller muscle. Suture

Alternative 4: Transcutaneous
Intramuscular Suture Technique
(without Piercing the Conjunctiva)
(Figure 6-6)
Two small stab incisions are made on the skin side at the
level of the eyelid crease. Sutures of 6-0 nylon or poly-
propylene are passed from the first stab incision through
material is then passed a short distance along the pro-
posed level of the crease before being returned on the
skin side through the second stab incision (Step 1). This
end of the suture is re-passed subcutaneously at this
second stab incision to join the first half of the suture in
the first stab incision; it is then tied and buried subcutane-
ously (Step 2). Mutou and Mutou27 used two of these
sutures to form the crease.

1 First stab incision

Skin

Orbicularis muscle
1

Levator aponeurosis

Müller's muscle

Conjunctiva
FIGURE 6-6 ■ Alternative 4: Transcutaneous intramuscular suture technique (without piercing the conjunctiva).
 6 Suture Ligation Methods 61

subcutaneous plane and then the suborbicularis planes

Alternative 5: Twisted Needle and
Compression Method (Transcutaneous
and Intratarsal Suturing with Twisted
Needle Tracking Method) (Figure 6-7)
A fifth variation was reported by Yang34 in China, whereby
several stab incisions are made along the superior tarsal
border. A needle with screw threads (or equivalent tool
like a No. 6 root canal dental file ) is twirled through the
along the pretarsal region of the upper lid (Step A), first
from lateral to the central stab incisions, and then from
the central to the medial incision. (The suborbicularis
plane along the superior tarsal border would have con-
tained the anterior lamella of levator aponeurotic termi-
nations on the tarsal surface.) 4-0 silk is then used to close
the wound in a continuous fashion, taking a bit of the
tarsus and passing back to the skin side, choosing either
of Step B or C in looping the suture. At the same time,

Skin

Subcutaneous tissue

Pretarsal orbicularis

Tarsus

Continuous
subcutaneous
suturing

Continuous
reverse-loop
suturing

C
FIGURE 6-7 ■ Alternative 5: Twisted needle and compression method (transcutaneous and intratarsal suturing with twisted needle
tracking method).
62 Asian Blepharoplasty and the Eyelid Crease
a half section of a rubber catheter measuring about 2 mm
wide is sutured across the pretarsal region. It is postulated
that scarring as a result of passage of the screw-threaded
needle and the compressive effect of the rubber catheter
results in aponeurotic–subcutaneous attachment and for-
mation of the lid crease. The original authors reported
that the advantages include rapid resolution of
postoperative edema and swelling, the lack of an open
skin incision, and it was effective in 100 out of 102 cases
as of three years postoperatively. Contraindications
include patients with excessive fat, scarcity of skin or an
excess of dermatochalasis. It is not suitable in patients
with lid retraction, prominent palpebral fissures or reop-
erative cases.
 6 Suture Ligation Methods 63

Alternative 6: Transcutaneous
Intradermal and Intratarsal Suturing
Technique (Figure 6-8)
Song,35 from China, reported a variation in which a
No. 11 blade is used to make two stab incisions 3–5 mm
apart over each of the medial, central and lateral
thirds of the upper lid; the incisions extend down to
the tarsal plate from the skin. One end of a suture needle
is passed from one stab incision on the skin through
the tarsal plate superficially, and exiting out the second
stab incision (Step 1). The second needle enters through
that same initial stab incision taken by the first suture
needle, this time tracking intradermally and exiting
through the second stab wound as did the first needle
(Step 2). The sutures are tied and buried in the subcuta-
neous plane (Step 3). The previous steps are repeated
over each third of the superior tarsal border. It is impor-
tant to make sure that the sutures are tracking intrader-
mally rather than subcutaneously as the latter tends to
result in disappearance of the crease shortly after the
procedure.

Epidermis
Dermis
Pretarsal orbicularis

Levator aponeurosis
Tarsus

A Conjunctiva

Through dermis

Through tarsus

Dermis

Pretarsal orbicularis

Levator aponeurosis

Tarsus

C
FIGURE 6-8 ■ Alternative 6: Transcutaneous intradermal and intratarsal suturing technique.
64 Asian Blepharoplasty and the Eyelid Crease
FIGURE 6-9 ■ Intraoperative view (from a surgeon’s position at the head of the operating table) of the right upper eyelid.
In Alternatives 3, 4 and 6, both needles enter and exit
through the same points on the eyelid. Alternatives 4, 5
and 6 involve transcutaneous passage. Alternatives 5 and
6 involve intratarsal passage. Even though these suture
ligation techniques avoid making wide skin incisions, five
of the six options (with the exception of Alternative 3)
require multiple stab incisions through skin or the passage
of needles through the skin surface; all require placement
of permanent buried sutures and some form of encircling
sutures around sections of, or portions of, levator
aponeurosis.
The main short-term advantage of buried suture
methods may be that the eyelid recovers quickly, since,
of course, little is done. I quite often see patients who
give a history of having had the procedure between one
and a few years before. Some may complain of its inef-
fectiveness or of a foreign body sensation. Others may
show more substantial side effects that are not initially
noticeable. (These will be covered in the more advanced
Chapters 15 and 21). Other symptoms may include hin-
drance or fatigue associated with opening of the lids.
Revision is not particularly difficult and often involves an
external incision approach; the buried sutures can often
be removed, as seen in Figures 6-9 and 6-10.
Figure 6-9 is an intraoperative view (from a surgeon’s
position at the head of the operating table) of the right
upper eyelid, and shows a linear buried synthetic thread
coursing several millimeters above the superior tarsal
border in a patient who complained of lid fatigue and a
scratchy feeling (he had had prior surgery using the
suture method which did not result in his having any
crease). A buried black nylon suture (Figure 6-10) ran
back and forth continuously like a U-shaped hair pin, and
measured close to 30 mm (more than one inch) each way.
It was removed, and a lid crease was constructed by the
method described in Chapters 8, 9 and 18. The patient’s
symptoms were relieved.

FIGURE 6-10 ■ Removed buried black nylon suture.
REFERENCES
1. Mikamo K. A technique in the double eyelid operation. J Chu-
gaishinpo 1896.
2. Uchida K. The Uchida method for the double-eyelid operation in
1,523 cases. Jpn J Ophthalmol 1926;30:593.
3. Maruo M. Plastic construction of a ‘double-eyelid’. Jpn Rev Clin
Ophthalmol 1929;24:393–406.
4. Hata B. Application of eyelid clamp and beads in ‘double-eyelid’
operation. Jpn Rev Clin Ophthalmol 1933;28:491–494.
5. Hayashi K. The double eyelid operation. Jpn Rev Clin Ophthalmol
1938;33:1000–1010, 1098–1110.
6. Inoue S. The double eyelid operation. Jpn Rev Clin Ophthalmol
1947;27:306.
7. Mitsui Y. Plastic reconstruction of a double eyelid. Jpn Rev Clin
Ophthalmol 1950;44:19.
8. Ohashi K. The double eyelid operation using electrocautery. Jpn
Rev Clin Ophthalmol 1951;46:723.
9. Hirose K. The double eyelid operation. Jpn Rev Clin Ophthalmol
1950;45:374.
10. Ikegami T. Brief discussion on the double eyelid operation. Jpn Rev
Clin Ophthalmol 1951;46:706–707.
11. Sayoc BT. Plastic construction of the superior palpebral fold. Am
J Ophthalmol 1954;38:556–559.
12. Sayoc BT. Simultaneous construction of the superior palpebral fold
in ptosis operation. Am J Ophthalmol 1956;41:1040–1043.
13. Sayoc BT. Absence of superior palpebral fold in slit eyes (an
anatomic and physiologic explanation). Am J Ophthalmol 1956;
42:298–300.
14. Sayoc BT. Surgical management of unilateral almond eye. Am J
Ophthalmol 1961;52:122.
15. Sayoc BT. Blepharo-dermachalasis. Am J Ophthalmol 1962;
53:1020–1022.
6 Suture Ligation Methods 65
16. Sayoc BT. Anatomic considerations in the plastic construction of a
palpebral fold in the full upper eyelid. Am J Ophthalmol 1967;
63:155–158.
17. Sayoc BT. Surgery of the oriental eyelid. Clin Plast Surg
1974;1:157–171.
18. Millard DR Jr. Oriental peregrinations. Plast Reconstr Surg 1955;
16:319–336.
19. Pang HG. Surgical formation of upper lid fold. Arch Ophthalmol
1961;65:783–784.
20. Fernandez LR. Double eyelid operation in the oriental in Hawaii.
Plast Reconstr Surg 1960;25:257–264.
21. Uchida J. A surgical procedure for blepharoptosis vera and for
pseudo-blepharoptosis orientalis. Br J Plast Surg 1962;15:271–276.
22. Boo-Chai K. Plastic construction of the superior palpebral fold.
Plast Reconstr Surg 1963;31:74–78.
23. Boo-Chai K. Further experience with cosmetic surgery of the
upper eyelid. In: Broadbent TR, ed. Transactions of the Third
International Congress of Plastic Surgery. Amsterdam: Excerpta
Medica; 1964:518–524.
24. Boo-Chai K. Some aspects of plastic (cosmetic) surgery in orientals.
Br J Plast Surg 1969;22:60–69.
25. Boo-Chai K. Aesthetic surgery for the oriental. In: Barron JN, Saad
MN, eds. Operative plastic and reconstructive surgery, Vol. 2.
Edinburgh: Churchill–Livingstone; 1980:761–781.
26. Boo-Chai K. Surgery for the oriental eyelid. In: Lewis JR Jr, ed.
The art of aesthetic plastic surgery, 2nd ed. Boston: Little, Brown;
1989:611–617.
27. Mutou Y, Mutou H. Intradermal double eyelid operation and its
follow-up results. Br J Plast Surg 1972;25:285–291.
28. Shirakabe Y, Kinugasa T, Kawata M, Kishimoto T, Shirakabe T.
The double eyelid operation in Japan: its evolution as related to
cultural changes. Ann Plast Surg 15(3):224–241, 1985. [A historical
summary paper.]
66 Asian Blepharoplasty and the Eyelid Crease
29. Homma K, Mutou Y, Mutou H, Ezoe K, Fujita T. Intradermal
stitch for orientals: does it disappear? Aesth Plast Surg
2000;24:289–91.
30. Tsurukiri K. Double eyelid plasty: reliability and unfavorable
results to the patients [Abstract]. J Jpn Aesth Plast Surg 1999;20:38.
31. Satou H, Ichida M. The reliability of buried double eyelid opera-
tion and the assessment of unfavorable results at our clinic. Panel
discussion at the annual meeting of the Japan Society of Aesthetic
Plastic Surgery, Gifu, Japan, October 1998.
32. Lee YJ, Baek RM, Chung WJ. Nonincisional blepharoplasty using
the debulking method. Aesth Plast Surg 2003;27:434–437.
33. Zubiri JS. Correction of the oriental eyelid. Clin Plast Surg
1981;8:725–737.
34. Yang PY. Double eyelid operation by the twisted needle and compres-
sive suturing technique. Chin J Plast Surg Burn 1987;3:191–192.
35. Song RY. Further discussion on the improved suturing technique
for double eyelid operation. Chin J Plast Surg Burn 1990;6:96–97.
[Intradermal and intratarsal suturing technique.]
 CHAPTER 7

EXTERNAL INCISION METHODS

A survey of the various papers in the literature on the

external incision approach reveals that there is a wide
variation in techniques and preferences when it comes to
whether skin and orbicularis are routinely removed after
making the skin incision. Likewise, some surgeons prefer
to open the orbital septum and remove a variable amount
of preaponeurotic fat.
There are other proponents for smaller skin incisions
(or partial incision) only, and further differentiations in
the way crease fixations are carried out including skin–
levator aponeurosis–skin, inferior orbicularis–levator
fixation, septodermal fixation as well as skin–tarsus–skin
fixation. Each variant has its own set of pros and cons that
need to be weighed according to the technical skills,
aesthetic sense and level of effort it involves, as well as
the patient’s comfort level and acceptance. For example:
the skin incision and skin excision school favors making
an incision to accurately define the placement of the
crease. These practitioners are comfortable with these
techniques and with the subsequent wound healing
process, and are likely to be less concerned about imme-
diate healing. Those who open the orbital septum
routinely are likewise comfortable with the anatomic
landmarks and aim to clear the preaponeurotic zone
along the superior tarsal border. Overall, the external
incision surgeons feel more comfortable with the predict-
ability and permanence of this approach, which aims for
a longer-lasting crease form and lesser need for interval
adjustment surgeries. This approach, especially when
carried out without the need for placement of buried
sutures, frequently yields a crease form that is subjectively
comfortable for the patient on upgaze and downgaze,
without the often-heard complaint of tightness of the
upper lid and sensation of the buried sutures poking at
the pretarsal zone. The partial-incisional methods sur-
geons, who tend to make a limited 5–8 mm incision, try
to accomplish the debulking of soft tissues through a
smaller than full incision, although the wound often
appears much wider than published. One drawback may
be a crease form that appears deeply formed over the
central skin incision compared to the medial and lateral
edge of it.
In closure techniques, the choice of suture material
varies greatly. The prevalent ways to perform wound
closure are:
1. skin–levator–skin (or skin–tarsus–skin), and
2. levator aponeurosis to inferior subcutaneous plane
(or superior tarsal border [STB] to inferior subcu-
taneous plane).
67
68 Asian Blepharoplasty and the Eyelid Crease

SKIN–LEVATOR–SKIN APPROACH
0.12 mm forceps
In this first technique, which is favored by the author, the
sutures are placed such that it first bites the inferior skin Levator aponeurosis
edge (Figure 7-1), then the distal fibers of the levator
aponeurosis along the superior tarsal border, and then the
upper skin edge. This creates an attachment between
the levator aponeurosis and the subdermal area along the
superior tarsal border, mimicking the natural insertion of Superior
tarsal
the levator aponeurosis. Fernandez1 described this tech- border
nique in 1960 and stated that it gives a ‘dynamic and
superficial crease’ (Figure 7-2), as opposed to skin–tarsus– Tarsus
skin, which tends to give a ‘static’ crease (Figure 7-3) (see
the 1954 paper by Sayoc2).

FIGURE 7-1 ■ Skin–levator–skin closure. The stitch first passes

through the lower skin border, taking a bite into the levator aponeu­
rosis along the superior tarsal border (STB), and then through the
upper skin border.

FIGURE 7-2 ■ Skin–levator–skin (SLS) closure, which produces a dynamic and superficial crease.
 7 External Incision Methods 69

B
FIGURE 7-3 ■ Skin–tarsus–skin (STS) closure, which tends to produce a static crease.
70 Asian Blepharoplasty and the Eyelid Crease
LEVATOR APONEUROSIS TO INFERIOR
SUBCUTANEOUS PLANE
In the second category, several buried 6-0 nylon, or
Dexon (polyglycolic acid) or Prolene (polypropylene)
sutures are applied to create adhesions between the
levator aponeurosis and the subcutaneous tissue of the
inferior incision along the superior tarsal border (Figure
7-4). According to Fernandez,1 this also creates a
‘dynamic’ crease, but a deeper and permanent one as
compared with the first method of closure, which tends
to be not quite as deep. It could be the result of tissue
fixation with buried Prolene sutures at a deeper level.
Sheen’s articles3,4 in 1974 and 1977 on supratarsal fixation
described application of this closure technique on Cau-
casian patients undergoing upper blepharoplasty, where
sutures were applied from levator aponeurosis to the infe-
rior orbicularis – in essence, the inferior subcutaneous
tissue.
In 1976, Putterman5 and Weingarten6 in separate
articles described the technique of applying sutures from
the superior tarsal border to the inferior subcutaneous
plane (Fig 7-5). Park7 also published his technique of
FIGURE 7-4 ■ Placement of suture securing the inferior skin edge’s tissues (including orbicularis oculi) to the distal portion of levator
aponeurosis. According to Fernandez11 this technique results in a deeper and more permanent dynamic crease.
orbicularis levator fixation in double-eyelid procedures
for Asians. He used three 6-0 nylon sutures to fixate a
folded portion of the levator aponeurosis to the inferior
skin edge’s orbicularis oculi muscle. (Permanent buried
sutures are used here.)
Yoo8 has described crease formation simply by trim-
ming of pretarsal fat and placement of ‘basting sutures’
that eliminate the dead space formed after the removal
of pretarsal tissues, but without attaching any aponeuro-
sis or tarsal plate. Yoo assumes that the reduction of the
soft tissue between levator and the skin is a more impor-
tant factor in the formation of a crease than levator inser-
tion to the skin. He used a continuous 6-0 silk and three
interrupted sutures to close the wound. Conceptually the
three interrupted basting sutures were used to close
the skin, orbicularis and pretarsal soft tissues; however,
the function of these interrupted sutures is uncertain
since closure of the dead space (as Yoo implied) following
removal of soft tissue will inherently anastomose the infe-
rior and superior skin margins, over the levator aponeu-
rosis along the superior tarsal margin. The net result
would be a firm pretarsal platform allowing crease forma-
tion, and very likely there would be secondarily associ-
ated levator aponeurotic adhesions to the pretarsal tissues

FIGURE 7-5 ■ The buried suture secures the orbicularis oculi along the inferior skin edge and fixates it to the anterior surface of the
tarsal plate, over its superior border.
after such a maneuver. In addition, there is still the pres-
ence of other impeding factors such as tissue redundancy
in the preaponeurotic space above this pretarsal region,
consisting of preseptal orbicularis, suborbicularis fat and
septum as well as inferiorly migrated preaponeurotic fat
pads. Of the series of 48 patients reported by Yoo, some
of the photos seem to show significant regression
(decrease) of the height of the lid crease after 1–2 years.
Lee, Park, Shin and Song,9 in 1997, advocated attach-
ment of the orbital septum to the skin to form the eyelid
crease. It is their stated opinion that there are distinct
layers of fascia anterior to the orbital septum which origi-
nates from the septum and inserts onto the pretarsal
aponeurotic expansion. Seeing that the preaponeurotic
fat and septum hang below the fusion line of the septum
and aponeurosis in Asian eyelids, the authors advocated
the septodermal fixation technique, where the hanging
portion of the orbital septum was dissected from the
aponeurosis, plicated and then sutured to the skin of
the pretarsal flap. The septum is not routinely opened
but the redundant portion of the septum hanging below
the fusion line is sutured to the pretarsal skin–muscle
7 External Incision Methods 71
flap. In 60% of their patients, the pretarsal fibro-fatty
layers are removed to promote adhesion between the
pretarsal orbicularis fascia and the pretarsal aponeurotic
expansion. A series of 512 patients were followed for
more than 3 years. The advantages reported by the
authors include less postoperative edema, less discomfort
and pain and a satisfactory lid crease formation. It is
unclear whether these septal fascial sheaths are always
detectable – and what was performed if they were not
seen and able to be used – and what role the removal of
redundant pretarsal tissues in a majority of their patients
actually contributed to the success of crease formation.
At the opposite end of the spectrum, Flowers,10 in
1993, described his approach towards upper blepharo-
plasty and crease fixation in Caucasians and Asians, utiliz-
ing ‘anchor blepharoplasty’. He discussed the challenge
when a crease fold was allowed to remain in an upper
blepharoplasty – the pretarsal skin appeared excessive and
wrinkly. His solution was to correlate the amount of
pretarsal skin that is allowed to remain (the location of
the lid incision) with the tarsal height, excising the desired
skin with its supratarsal crease, and then recreating a new
72 Asian Blepharoplasty and the Eyelid Crease
precise crease fold by attaching the dermis of the pretar-
sal (inferior edge) skin flap to the aponeurosis and the
tarsus. It is in essence picking up both tarsus and
aponeurosis.
In Flowers’ technique, the tarsus is everted and its
height measured. It is marked on the skin side with the
same distance from the lash line, which adds 2 mm to the
distance as measured from the actual lid margin. Flowers’
operative rule is that there should be 26–30 mm of skin
on the upper lid between the eyebrow and the lid margin
for normal contour and invagination as well as for closure.
This is broken down into approximately 10 mm for the
invagination of the eyelid fold, a minimum of 12 mm
from the eyelid fold to the brow, and 3–6 mm of visible
pretarsal skin; 1–2 mm are allowed for the curvature of
the lid fold as it bends into the crease. If the amount is
less than 26–30 mm there will be problems with invagi-
nation of the fold, as well as a restricted brow position
and inadequate lid closure owing to shortage of skin. The
amount of eyelid skin that overhangs and obstructs the
desired view of the pretarsal skin is measured using a
caliper, or estimated visually; this is doubled (×2) to arrive
at the amount of skin that ought to be removed. This
may be performed at different points along the eyelid.
Flowers discussed the treatment of fat and its partial exci-
sion over the lateral quadrant, and the possibility of rotat-
ing and translocating the fat onto the medial aspect of
the supratarsal sulcus. He believed that trimming pretar-
sal connective tissues and thinning of the pretarsal orbic-
ularis on the underside of the pretarsal skin flap helps
both to reduce postoperative edema in that region and to
produce a smooth pretarsal skin surface as a result of
adherence of the skin and orbicularis to the tarsus.
In this approach the plane between the pretarsal orbic-
ularis and the distal insertion of the levator aponeurosis
over the anterior surface of the upper tarsus is separated
with scissors down to the lash margin. Any inferior
attachment of the aponeurotic fibers to the skin is thus
transected. The filmy pretarsal connective tissues, includ-
ing portions of pretarsal orbicularis that may be excessive,
are excised with scissors over the anterior tarsal surface.
The dermis of the pretarsal skin flap (lower skin edge) is
sutured subcuticularly to the superior margin of the
tarsus as well as the free terminal edge of the aponeurosis
using absorbable 6-0 Vicryl. Flowers usually applies three
or four of these sutures centrally, and one or two laterally
as well as medially along the new crease. (The trimming
of the pretarsal tissues and excision of some of the ante-
rior portion of the distal levator aponeurosis will invari-
ably leave behind a free edge; this does not mean that
the levator aponeurosis has been entirely transected.) In
addition, the upper and lower skin edges are closed with
a running non-dissolving suture, incorporating the
aponeurosis in each bite.
Alternative methods of closure mentioned by Flowers
were:
1. To use interrupted nylon sutures alone, incorporat-
ing all layers together: the lower skin edge, the
superior tarsal border, the free edge of the aponeu-
rosis, and the upper skin edge. No Vicryl is then
used for the skin–tarsus–levator aponeurosis alone.
2. The incorporation of the upper and lower skin
edges into the deeper 6-0 Vicryl that binds the
superior tarsal border as well as the free edge of the
aponeurosis. No nylon or non-dissolving suture is
then used.
The reason for incorporating the levator aponeurosis,
according to Flowers, is that it exerts a small amount of
tension on the pretarsal skin and thereby keeps it taut.
By the same reasoning, he anchors the pretarsal skin flap
to the tarsus to prevent excessive pull by the aponeurosis
on the pretarsal skin, resulting in eyelash eversion and
excessive showing of the upper lid margin itself. The
author stated that patients often experience some degree
of ptosis, as well as a tugging feeling on upgaze. He stated
that complete recovery requires 2–3 years, but that
patients generally look very satisfactory by 2 weeks after
surgery.
The concept of a ‘dynamic’ versus a ‘static’ crease is
worth elaborating: In a patient who has a natural crease,
whether an Asian or a Caucasian, the upper eyelid shows
a crease that is well defined when the subject is looking
straight ahead (Figure 7-6A). On downgaze, the inferior
rectus (and superior oblique) contracts while the superior
rectus, levator and inferior oblique all relax. The upper
lid follows the inferior rotation of the eyeball and the
upper lid crease becomes much less prominent, some-
times becoming barely observable (Figure 7-6B). A crease
that is present when the levator contracts and fades when
the levator relaxes on downgaze is termed a ‘dynamic’
crease.
Along the opposite spectrum, a surgically applied
crease that is present and noticeable even on downgaze
(when the levator is relaxing) is termed a ‘static’ crease.
This is more often seen in patients who have had inferior
skin edge sutured to superior tarsal border and upper skin
edge (inferior skin–STB–upper skin; see Figure 7-3A,B)
and in patients who have undergone buried suture
methods (see Chapter 6).
In actual practice, the matter is never quite clearly
defined as we do not always see a static crease as a result of
skin–tarsus–skin closure; nor do we always see a dynamic
crease when we perform skin–levator–skin, or levator
aponeurosis to inferior subcutaneous plane closure.
To conclude, I favor my version of the external incision
method11–15 as I believe it is a more precise and permanent
technique. I remove a small, variable amount of skin,
based on evaluation of the patient’s eye. The orbital
septum is opened superiorly in a transverse fashion via a
beveled approach; and based on clinical assessment a vari-
able, but usually minimal, amount of fat may be trimmed,
but never completely removed. I resect some orbicularis
oculi, usually several millimeters along the preseptal as
well as a small sliver along the inferior edge of the pre-
tarsal plane. To give a dynamic, superficial crease, I favor
crease formation using transient application of non-
absorbable, non-reactive sutures, applying them skin to
levator aponeurosis to skin. These are always removed in
my technique; no buried sutures of any kind are used.
Sutures that envelop the levator aponeurosis in any way
are never applied (see Faden effect in Chapter 21).
 7 External Incision Methods 73

B
FIGURE 7-6 ■ (A) A dynamic crease is apparent on straight-ahead gaze but disappears on downgaze (B).
74 Asian Blepharoplasty and the Eyelid Crease
REFERENCES
1. Fernandez LR. Double eyelid operation in the Oriental in Hawaii.
Plast Reconstr Surg 1960;25(3):257–264.
2. Sayoc BT. Plastic construction of the superior palpebral fold. Am
J Ophthalmol 1954;38:556–559.
3. Sheen JH. Supratarsal fixation in upper blepharoplasty. Plast
Reconstr Surg 1974;54(4):424–431.
4. Sheen JH. A change in the technique of supratarsal fixation in
upper blepharoplasty. Plast Reconstr Surg 1977;59(6):831–834.
5. Putterman AM, Urist MJ. Reconstruction of the upper eyelid
crease and fold. Arch Ophthalmol 1976;94:1941–1954.
6. Weingarten CZ. Blepharoplasty in the Oriental eye. Trans Am
Acad Ophthalmol Otol 1976;82:442–446.
7. Park JI. Orbicularis–levator fixation in double-eyelid operation.
Arch Facial Plast Surg 1999;1:90–95.
8. Yoo Hyun Bang. The double eyelid operation without supratarsal
fixation. Plast Reconstr Surg 1991;88(1):12–17.
9. Lee JS, Park WJ, Shin MS, Song IC. Simplified anatomic method
of double-eyelid operation: septodermal fixation technique. Plast
Reconstr Surg 1997;100(1):170–178.
10. Flowers RS. Upper blepharoplasty by eyelid invagination – anchor
blepharoplasty. Clin Plast Surg 1993;20(2):193–207.
11. Chen WPD. Asian blepharoplasty. Ophthal Plast Reconstr Surg
1987;3(3):135–140.
12. Chen WPD. A comparison of Caucasian and Asian blepharoplasty.
Ophthalmic Pract 1991;9(5):216–222.
13. Chen WPD. The concept of a glide zone as it relates to upper lid
crease, lid fold, and application in upper blepharoplasty. Plast
Reconstr Surg 2007;119(1):379–386.
14. Chen WPD. Beveled approach for revisional surgery in Asian
blepharoplasty. Plast Reconstr Surg 2007;120(2):545–552.
15 Chen WPD, Khan J. Color atlas of cosmetic oculofacial surgery
(with DVD), 2nd edn. Philadelphia: Elsevier-Science/Saunders,
2010.
 CHAPTER 9

ASIAN BLEPHAROPLASTY II:

THE SECOND VECTOR
Continuing to describe the Asian blepharoplasty tech-
nique used by the author, this chapter looks at the
handling of the middle layer structures of the eyelid
once the preaponeurotic (middle) space has been reached.
The chapter will take the procedure up to closure of the
eyelid crease. Figure 9-1 shows the cleared preaponeu-
rotic plane being readied for construction of the eyelid
crease.

FIGURE 9-1 ■ Primary Asian blepharoplasty.

85
86 Asian Blepharoplasty and the Eyelid Crease

FOLLOWING OPENING OF scissors are used to separate the preaponeurotic fat

beneath it from the orbicularis in front and levator below
THE ORBITAL SEPTUM it. This central preaponeurotic fat pad is often adherent
by fascial attachment to its underlying levator muscle
Rotation of Myocutaneous Strip Away fibers (Figure 9-2B).
From Underlying Levator Aponeurosis
and Preaponeurotic Fat Pad, Hinging
It Along Superior Tarsal Border
A Blair’s retractor is used to retract the opened upper
incision (skin and orbicularis) (Figure 9-2A); Westcott

FIGURE 9-2 ■ (A) The skin–orbicularis–orbital

septum flap is retracted inferiorly using a
tissue retractor, allowing access to the
preaponeurotic fat pad (right upper lid). (B)
Dissection and elevation of the preaponeu-
B rotic fat pad from the underlying levator
aponeurosis (right upper lid).

The fat should be repositioned and allowed to fill in
the space between the levator and anterior aspect of the
superior orbital rim (the supratarsal sulcus).
In Figure 9-3 the skin–muscle flap is being retracted
in the upper portion of this photograph using a Blair
retractor along the upper incision line (surgeon’s view
from the head of the table). Pristine levator muscle with
fine blood vessels can be seen running vertically over
the levator, as well as within the preaponeurotic fat pad
(vessels running horizontally here).
FIGURE 9-3 ■ Skin–muscle flap retracted using a Blair retractor along the upper incision line (surgeon’s view from head of table).
9 Asian Blepharoplasty II: The Second Vector 87
PEARLS
• After separating the initial fine adhesions of fat from
the overlying orbicularis, it is often safer to use
moist cotton tip applicators to separate fat from the
underlying aponeurosis.
• No attempt is made to remove fat pads unless the
fat is grossly interfering with crease formation along
the superior tarsal border. A Wetfield bipolar cautery
may be used to reduce it if it is potentially hindering
the construction of a good crease due to its presence
directly over the superior tarsal border.
PITFALLS
• Avoid pointing the scissors posteriorly towards the
levator as you elevate the myocutaneous flap.
• After the myocutaneous flap has been elevated,
avoid cutting any fat that may be intertwined on the
underbelly of the myocutaneous strip; this may
cause bleeding of the intra-fat blood vessels, as well
as unintended reduction in the volume of preaponeu­
rotic fat left behind.
88 Asian Blepharoplasty and the Eyelid Crease

Partial Excision of Preaponeurotic

Fat (Figure 9-4)
Occasionally in patients with very full upper lids, signifi-
cant fat is seen centrally or plastered low down on to the
aponeurosis. This may interfere with any attempt to form
a crease. In these patients, instead of partial shrinkage
with bipolar cautery, one may opt to excise a small
fraction of the preaponeurotic fat seen within the
surgical field.
A bipolar cautery is used to treat any prominent blood
vessels first, then cutting monopolar cautery is used to
cut the fat pad 2–3 mm at a time; then the bipolar cautery
applications are repeated. It may take two to three repeti-
tions before this step is completed.
If an older patient with dermatochalasis and oblitera- A
tion of the crease shows even a very minimal concavity
in the supratarsal sulcus, one should not remove any fat
as this will worsen the hollowness and result in multiple
redundant folds superior to where one would want the
crease to be. Instead of excision of the fat, one should
reposit it above.

PEARLS
• Extra care and time is allotted to this step of reduc-
tion of fat pads, if elected. Hemorrhage from un­
detected bleeders following transection of the
intra-fat vessels may lead to serious consequences,
including orbital hematoma and blindness.
• A prolapsed lacrimal gland may look like a fat lobule.
It must be recognized and needs to be re-anchored
to a point behind the superior lateral orbital rim.

PITFALLS
• It is important to clearly identify the nasal fat pad
and central preaponeurotic fat pad from the lacrimal
gland lobule.
• Transection of the lacrimal gland may lead to
varying degree of dry eye.

B
FIGURE 9-4 ■ (A) Partial excision of inferior portion of the
preaponeurotic fat pad (left upper lid). (B) A very small amount
of preaponeurotic fat pad may be excised (here, from right
upper eyelid). The fat excision often requires a small supple-
ment of lidocaine injection in the space underneath the
preaponeurotic fat pad.

The Second Vector: Excision of
Myocutaneous Flap (Skin, Orbicularis,
Inferior Remnants of Septum) along
Superior Tarsal Border (Figure 9-5)
This is carried out by grasping the lateral end of the
myocutaneous flap of the right upper lid (or medial end
of the left upper lid myocutaneous flap) with the instru-
ment in your left hand, then using the monopolar needle
tip on cutting mode to cut along a plane between the
orbicularis within the flap and the superior tarsal border/
aponeurotic junction.
PEARLS
• When the myocutaneous flap is incised, the orbicu-
laris muscle will bleed. As one proceeds, one should
control each new bleeder with bipolar cautery as
soon as it arises, rather than cutting off the whole
strip first before coming back to control a group of
bleeders. In my view, it seems to decrease postop-
erative edema and hematoma formation.
• There is a tendency to go too shallow over the
medial starting point of the left upper lid during this
phase of the excision of the myocutaneous strip,
leaving behind too much orbicularis. An inade-
quately anchored crease over the medial one-third
of the lid may result from this subtle oversight.
PITFALLS
• One must take care to avoid inadvertent partial
transection of the distal fibers of the levator
aponeurosis.
• Avoid transection of the superior tarsal vascular
arcade, which may bleed and cause segmental swell-
ing and postoperative secondary ptosis.
Advanced Discussion
The excision of a strip of skin is not necessary in every
case; however it is my belief that it facilitates the removal
of underlying layers of the lid tissue in this location to
form a good crease. The flap of myocutaneous and fascial
tissues hinged along the superior tarsal border that is
excised measures approximately 2–3 mm. It typically
contains more orbicularis than skin, hence it resembles
a trapezoid in cross-sectional view, with the narrower
of the two parallel planes being the external skin, and
the lengthier opposite side being the orbicularis muscle
fibers.
This second vector of dissection is performed perpen-
dicular to the eyelid’s skin surface, and tracing along the
lower line of skin incision (the future crease line).
9 Asian Blepharoplasty II: The Second Vector 89
FIGURE 9-5 ■ The flap of skin, orbicularis muscle and septum
superior to the superior tarsal border is excised.
The goal is to eliminate or thin the redundant fascial
tissues that are in the preaponeurotic plane, along
the superior tarsal border. This platform of tissues may
be designated as the ‘preaponeurotic platform’ since it
consists of all tissues anterior to the levator aponeurosis,
and includes orbital septum, preseptal fat if any, presep-
tal orbicularis (orbicularis superior to the superior
tarsal border), subcutaneous fat (if any) and skin. This
platform of tissues is removed in a uniform and equal-
depth fashion, conceptually as a trapezoidal block of
tissues in cross-section.
This trapezoidal debulking of tissues involved only
two vectors (moves): the first was a slightly beveled plane
through orbicularis until the orbital septum is reached
(Chapter 8), and the second when the myocutaneous–
septal flap is excised by transecting the orbicularis along
the crease line. Bleeding can therefore occur only in these
two steps – minimizing the potential for crease irregular-
ity and discrepancy in crease height during the immediate
postoperative period.
If the skin, orbicularis and septum are removed layer
by layer, the extra steps needed (two moves with the skin
– upper and lower lines of incision – two moves cutting
the orbicularis and two moves opening the septum) may
generate more bleeding, as well as at the interface between
the layers while removing them (skin from orbicularis,
orbicularis from septum and septum from levator). The
potential for bleeding can be lessened by using this
en-bloc trapezoidal debulking of the preaponeurotic
platform.
90 Asian Blepharoplasty and the Eyelid Crease

There are several ‘intermediate’ variations of the

Inferior edge of pretarsal
external incision methods:
orbicularis muscle
1. Some surgeons prefer to keep most of the septum
intact and create just a single central opening
through the septum to tease out the preaponeurotic
fat for excision. A challenge one may encounter is
that most fat pads are located centrolaterally and
the excision of a portion of the fat without the
benefit of a full view of its distribution may predis-
pose to crease irregularity.
2. Some advocate making a 5–8 mm skin incision at
each of the three sites usually used in traditional
suture-ligation methods. Here again the orbital A
septum is then partially opened at each of the three
sites, and the fat selectively removed. The skin inci-
sional length when combined is still 15–24 mm (at
the three sites). One is at the mercy of whether
these three wound sites will ‘merge’ together to
form a nice crease, or whether it may appear seg-
mented (like bamboo) in certain positions of the
eyelid when viewed.
3. Some authors describe making a single 5–8 mm
skin incision, and through the orbital septum they
perform the excision of preaponeurotic fat by
pulling fat centrally from the medial and lateral
sectors. Crease fixation in the central portion of the
upper lid is then carried out as in any of the typical
external incision methods. The supporting clinical
photographs of the paper describing this method,
however, appeared to show a much wider skin inci-
sion. One problem that may be experienced follow- B
ing this approach is that the crease may be better FIGURE 9-6 ■ (A, B) A small strip of pretarsal orbicularis muscle
formed centrally and less well-formed medially and is trimmed along the inferior skin incision below the superior
laterally. tarsal border.

Treatment of Inferior Edge of Wound
(Orbicularis Oculi) (Figure 9-6)
Following the previous steps, there may remain a com-
bination of a small residue of preseptal orbicularis as well
as well-developed pretarsal orbicularis muscle fibers,
interspersed with occasional clusters of pretarsal fat
patches. They are situated just over the superior tarsal
border where one is trying to create a crease. In this situ-
ation it is advisable to excise this 2–3 mm strip of inferior
orbicularis tissues along the lower incision edge (Figure
9-6). It allows a partial flattening of the tissues along
the pretarsal plane as well as thinning of the inferior
wound edge.
Some surgeons routinely debulk the entire pretarsal
subcutaneous tissues including all muscle fibers, believing
it is better to have only skin over the anterior surface of
the tarsus. This may be because of concerns that there
are competing distal fibers of the levator aponeurosis
within the pretarsal plane. In reality, within the pretarsal
plane of a crease-less Asian eyelid, there are few if any
functional remnants of the levator aponeurosis to the
dermis.
My experience differs, and I remove pretarsal tissue
only if pretarsal fat is quite abundant and threatens the
surgical formation of the desired upper lid crease. I
refrain from vigorous dissection along the pretarsal plane
because it leads to prolonged postoperative edema and
can risk the undesirable sequela of multiple wrinkle for-
mation (Figure 5-4). Furthermore, it is quite natural for
Asians born with a natural crease to have some degree of
pretarsal fullness along the area between the crease and
the eyelashes (Figure 1-13).
PEARLS
One should reduce pretarsal tissues partially only when
pretarsal fat is moderately abundant and threatens the
surgical formation of the desired upper lid crease.
PITFALLS
Leaving behind redundant tissues along the inferior
border may result in only partial formation of the crease
or late obliteration of an initially acceptable crease.

Formation of Lid Crease and Closure
of Wound
Any surgical drapes over the patient’s mid-forehead and
upper eyelid skin are then loosened, to decrease any
upward traction over the incision wound, tarsus and
eyelid margin. The upper lid is redraped over the levator–
tarsus layer. The anterior lamella of the lid (skin, orbicu-
laris, septum) has been ‘re-set’ naturally over fat and the
underlying posterior lamella of levator, Müller’s muscle,
conjunctiva and tarsus. One can ask the patient to look
up and down here and check to see the adequacy of the
crease infolding.
For a dynamic crease, the terminal fibers of the levator
aponeurosis above the superior tarsal border should be
directed to the subdermal plane of the lower line of skin
Levator aponeurosis
Subcutaneous tissue
A of inferior skin edge
C continuous 7-0 suture is applied.
9 Asian Blepharoplasty II: The Second Vector 91
incision, mimicking natural anatomy of a crease. (Since I
have to close the upper skin edge to the lower skin edge,
I believe it is an academic exercise to argue on the merits
of allowing adhesions to form solely from the terminal
aponeurotic fibers to the lower skin edge or to both the
upper and lower skin edges.)
I use 6-0 non-absorbable suture (silk or nylon) to pick
up the lower skin edge and subcutaneous tissue, the
levator aponeurosis along the superior tarsal border and
the upper skin edge. Each of these sutures is tied in an
interrupted manner (Figure 9-7A).
(It is interesting to debate whether to include the
lower skin edge with its subcutaneous tissue or only the
inferior subcutaneous tissue in the closure to the aponeu-
rosis. In my method, the sutures are removed. The second
method of anchoring inferior subcutaneous tissue to the
FIGURE 9-7 ■ (A) Skin–levator–skin closure along the superior
tarsal border. (B) Use of five to six skin–levator–skin stitches.
(C) Use of a single continuous suture over the wound edges.
(D) Appearance of right upper lid wound closure following
placement of five skin–levator–skin stitches and before a
92 Asian Blepharoplasty and the Eyelid Crease
levator aponeurosis frequently involves placing buried,
non-absorbable sutures.)
In addition to the stitch over the mid-point of the
crease, I apply two or three sutures medially and three
sutures laterally. With these five or six crease-forming
sutures in place, the rest of the incision may be closed
with a 6-0 or 7-0 suture in a continuous fashion. This
gives the best chance for the formation of a dynamic
crease (Figure 9-7D). (As discussed in Chapter 7, a
dynamic crease of the upper eyelid is a surgically created
crease that fades on downgaze, mimicking a natural
crease. A static crease remains obvious on downgaze and
is considered less desirable.)
Some surgeons often apply permanent stitches along
the superior tarsal border, fixating the inferior edge of
the pretarsal orbicularis to the levator muscle. This
method tends to give a static crease. Some patients com-
plain of a persistent foreign body sensation within the
muscle layers of the lid many years after buried perma-
nent sutures were used. These often have to be removed
secondarily.
PEARLS
• The medial end of the crease may require additional
placement of crease-forming sutures as the medial
extent of the levator muscle is often rudimentary
and underdeveloped. The sutures then need to
pick up tendinous fibrous tissues instead of levator
aponeurotic muscle fibers.
• In a patient with a medial canthal fold, if a nasally
tapered crease shape was selected, the crease line
can often be designed to merge medially into the
fold itself.
• In applying the crease-forming stitch, each bite on
the aponeurosis should be along the superior tarsal
border and not any higher, to prevent the formation
of a ‘high, harsh and semilunar crease’.
• Optional technique: To deepen a crease (which is
very unusual and performed only for good
indications), one may apply three double-armed 5-0
Vicryl sutures transcutaneously to the underlying
tarsus along the superior tarsal border (positioning
these over the medial, central and lateral one-thirds
of the eyelid) and exit each arm of the stitch on the
lower skin edge. The sutures are then tied exter-
nally. After one week, the knot is entirely cut off
the skin surface leaving behind only the buried loop
of the absorbable Vicryl, which is only 2–3 mm
at most.
• Check crease symmetry bilaterally upon completion
of closure. Measure the crease height with a caliper.
If there is a discrepancy, it is better to correct the
difference in crease height between the two sides by
revising the higher crease down through an excision
of 0.5–1.00 mm of skin from the inferior skin edge
of this side. This is a general rule and should be
applied only with individual evaluation.
PITFALLS
• One may end up with upper eyelid retraction
or secondary ectropion if the layers of the eyelids
have not been allowed to lie freely back onto the
natural plane prior to surgical closure (reset
the anterior and posterior layers prior to closing the
wound).
• Insufficient inclusion of levator aponeurosis will
result in partial crease formation or late
obliteration.
• Excessively deep or high bite along the levator
aponeurosis may result in a high crease or an
acquired secondary ptosis, with secondary lagoph-
thalmos on downgaze and limitation on upgaze.
• Patients with pre-existing ptosis will tend to have
poor crease formation. It is best to proceed to ptosis
repair first and return later to create a crease.
• Inclusion of residual fat pads along the superior
tarsal border will result in obliteration of the crease.

FIGURE 9-8 ■ Application of transcutaneous skin–tarsus fixation sutures along the lower skin edge.
CREASE-ENHANCING MANEUVERS:
McCORD’S ANCHORING/RETENTION
STITCHES (Figure 9-8)
To enhance or deepen a crease, one may apply three
double-armed 5-0 soluble Vicryl sutures transcutane-
ously from the inferior skin edge to the underlying tarsal
plate along the superior tarsal border (applying them over
the medial, central and lateral thirds of the eyelid) in
addition to regular skin closure. The sutures are then tied
externally. After 1 week each of these three knots is
trimmed off the skin and the buried loops are left behind.
The method works well for non-reactive skin.
FURTHER READING
1. Chen WPD. Asian blepharoplasty. Ophthal Plast Reconstr Surg
1987;3(3):135–140.
2. Chen WPD. Insights from a series of Asian blepharoplasty. Pre-
sented at the Annual Scientific Symposium of the American Society
of Ophthalmic Plastic and Reconstructive Surgery, Atlanta,
Georgia, 1990.
3. Chen WPD. A comparison of Caucasian and Asian blepharoplasty.
Ophthalmic Pract 1991;9(5):216–222.
4. Chen WPD. Upper blepharoplasty in the Asian patient. In:
Putterman AM, ed. Cosmetic oculoplastic surgery, 2nd edn.
Philadelphia: WB Saunders; 1993: ch 11.
9 Asian Blepharoplasty II: The Second Vector 93
5. Chen WPD. Review of Aguilar G. Complications of oriental
blepharoplasty. In: Mauriello J, ed. Management and avoidance of
complications of eyelid surgery. Vol. 3. Philadelphia: Field &
Wood; 1994.
6. Sayoc BT. Plastic construction of the superior palpebral fold. Am
J Ophthalmol 1954;38:556–559.
7. Hayashi K. The double eyelid operation. Jpn Rev Clin Ophthalmol
1938;33:1000–1010 (Part 1) and 33:1098–1110 (Part 2).
8. Fernandez LR. Double eyelid operation in the Oriental in Hawaii.
Plast Reconstr Surg 1960;25(3):257–264.
9. Inoue S. The double eyelid operation. Jpn Rev Clin Ophthalmol
1947;42:306.
10. Mitsui Y. Plastic construction of a double eyelid. Jpn Rev Clin
Ophthalmol 1950;44:19.
11. Sayoc BT. Anatomic considerations in the plastic construction
of a palpebral fold in the full upper eyelid. Am J Ophthalmol
1967;63:155–158.
12. Collin JR, Beard C, Wood I. Experimental and clinical data on the
insertion of the levator palpebrae superioris muscle. Am J Ophthal-
mol 1978;85:792–801.
13. Chen WPD. Concept of triangular, rectangular and trapezoidal
debulking of eyelid tissues: application in Asian blepharoplasty.
Plast Reconstr Surg 1996;97(1):212–218.
14. Chen WPD. The concept of a glide zone as it relates to upper lid
crease, lid fold and application in upper blepharoplasty. Plast
Reconstr Surg 2007;119(1):379-386.
15. Chen WPD. Beveled approach for revisional surgery in Asian
blepharoplasty. Plast Reconstr Surg 2007;120(2):545–552.
16. Chen WPD, Khan J. Color atlas of cosmetic oculofacial surgery
(with DVD), 2nd edn. Philadelphia: Elsevier Science/Saunders;
2010.
 CHAPTER 10

ASIAN BLEPHAROPLASTY III: FACTORS

THAT INFLUENCE OUTCOME

OPTIMAL CREASE DESIGN
It is my experience that the nasally tapered crease is
slightly easier to achieve surgically than the parallel
crease. Most Asians who are not born with a crease have
a medial canthal fold, to a varying degree. It is therefore
not necessary in the design of a nasally tapered crease to
excise the entire medial fold, but sufficient to reduce it
and allow the crease’s infolding to merge into a much-
reduced medial fold of skin.
For a patient who wants a parallel crease, a more
thorough reduction of the medial canthal fold needs to
be carried out: this includes skin and subcutaneous tissues
such that webbing does not result, or inadequate crease
formation at the medial end of the crease. Special anchor-
ing of the medial end of the crease to retain the parallel
nature of the crease may be necessary.
therefore the surgical scars might be the lesser of
two evils. If true epicanthoplasty as described in those
original papers for these abnormal conditions were to be
performed in an otherwise normal Asian, the probable
risk for visible scar would be much greater than any pos-
sible benefits gleaned, since often the small fold can be
handled easily through excision of the skin fold that over-
laps while closing the medial end of an Asian blepharo-
plasty. Most surgeons, including the present author, are
aware of this and simply perform the reduction of the
fold, not evoking the word ‘epicanthoplasty’ for these
small steps. The few that actually perform or promote
the whole procedure risk leaving their patient with a
noticeable scar. Those that perform small trimming but
nonetheless call the procedure ‘medial epicanthoplasty’
are using the term in a very broad sense and are probably
perpetuating misinformation among patients and confus-
ing surgeons alike.

EPICANTHOPLASTY
The term medial epicanthoplasty is often mentioned in
conjunction with Asian eyelid surgery and reflects sur-
geons’ concern that construction of the crease alone will
be inadequate. The source of the term was in connection
with abnormal epicanthus inversus seen in blepharophi-
mosis patients or those with trisomy syndromes. The
surgical solutions often involved complicated V–Y-plasty
or W-plasty with multiple steps in a patient with con-
genital abnormalities (like telecanthus) if not treated, and
DEPTH OF CREASE
The level to which one may attempt to control the crease
depth surgically is related to whether skin is attached to
tarsus, levator aponeurosis, orbicularis oculi muscle, or
to subcutaneous tissues only; and to whether any perma-
nent sutures are used in a tightly fixed fashion, or remov-
able sutures are used. Table 10-1 shows a reasonable
proposition for control of crease construction that varies
from deep crease indentation to superficial levels.

TABLE 10-1 The Nine Levels of Depth of Crease

Level Description

Level VIII Closed approach (buried ligatures, compression generated crease).

Level VII Subcutaneous skin–tarsus–skin (buried knots; static crease).
Level VI Subcutaneous skin–levator aponeurosis–skin (if buried knots were
used).
Level V Inferior edge orbicularis–aponeurosis fixation sutures (buried,
dissolvable).
Level IV Skin–tarsus–skin (removable sutures).
Level III Skin–levator aponeurosis–skin (removable, yields dynamic crease).
Level II Skin–orbital septum/aponeurotic–skin (higher fail rate than Level III).
Level I Skin–orbicularis oculi–skin (removable, yields shallow or no crease).
Level 0 Skin–skin (removable, usually does not yield crease in a person who
was born without crease).

95
96 Asian Blepharoplasty and the Eyelid Crease
COMMON OVERSIGHTS IN
ASIAN EYELID SURGERY,
INCISIONAL METHODS
1. Location for the crease placement. At the medial
end of the incision, there may be only fibrous or
tendinous tissues rather than levator aponeurosis.
There may not be any significant levator muscle
fibers to apply a suture. In this situation, the suture
is applied to fibrous tissues or epitarsal tissues,
the location depending on the crease shape one
desires. Similarly at the lateral end of the wound
closure, there may be indistinct levator aponeuro-
sis fibers mixed with fibrous sheaths. Again the
suture attachment should be to tissues that are at
the level of the superior tarsal border.
2. Bleeding along the levator aponeurosis. We have
mentioned the presence of the superior tarsal
arcade, a variant of the lacrimal artery, as well as
the lateral septoaponeurotic artery, all of which
can cause sudden bleeding if traversed with place-
ment of a needle near the aponeurosis (whether
simply taking a small bite on its anterior surface
or full-thickness traversing through the levator
aponeurosis as in suture ligation methods). When
this occurs, it is prudent to attempt to control the
capillary oozing or hematoma formation before
going further along.
3. Residual orbicularis along the inferior edge of
the incision hinders crease formation. This can
be from a less than perpendicular excision
(second vector) of the skin–orbicularis flap, leaving
behind orbicularis still riding over the superior
tarsal border at the inferior skin edge. It should
be trimmed. It can also be seen in an individual
whose pretarsal orbicularis muscle is well devel-
oped or intermixed with fibro-adipose tissues.
These can be reduced to allow better inward
creasing from both the upper as well as the lower
skin incisions.
4. Fat interference. Preaponeurotic fat may be
encroaching along the superior tarsal border as
well as the lower portion of the preaponeurotic
platform. Here fat can be trimmed back through
partial excision or application of bipolar cautery
on the moistened fat, or repositing the fat superi-
orly with resetting of the tissue planes, or through
a combination of all three. The key is not to be
overly aggressive as one does not want complete
removal of fat.
5. Inadvertent high anchoring of crease. This will be
covered in Chapter 21 on the Faden effect.
6. Drifting of marking superiorly. Drift can result in
a higher crease incision if the operator does not
repeatedly verify the crease placement with a
caliper.
7. Working on an individual who has latent or undi-
agnosed ptosis (droopy eyelid muscle); not detect-
ing a patient with borderline levator excursion
preoperatively. The crease will not fold in com-
pletely or evenly along the length of the superior
tarsal border. Pre-existent ptosis must be cor-
rected first. Those with only fair levator excursion
should be advised preoperatively that there is a
higher probability that their muscle may not be
strong enough to fold into a good crease using a
dynamic crease technique with the incisional
approach. The incisional method, however, is still
the better choice in creating a crease in those who
needed ptosis correction first.
8. Individuals with a large palpebral fissure (eye
opening) will often do quite well with a crease
height that is low–normal; they do not need a high
crease to magnify the fissure size.
9. Individuals with a small phimotic eye certainly do
not need a crease height that is higher than average.
The challenge for significantly small-eyed indi-
viduals may be that often there is some associated
ptosis, and the levator excursion is weak. These
latter individuals may need the inferior edge
orbicularis-to-aponeurosis fixation sutures (Level
V ) to be applied prior to closure, using Vicryl
sutures that slowly dissolve over several weeks.
10. Bleeding and swelling along the orbicularis can
occur quite often in individuals with well-
developed orbicularis oculi. Such patients need to
be individually controlled as the resultant swelling
distorts the tissue plane and leads to less than
accurate placement of the crease, as well as pro-
longing the recovery process. Excess blood can
interfere with levator function in the postopera-
tive period as well as long term if the accumulated
blood swelling is very significant.
INVOLUTIONAL CHANGES
Elderly Asian patients, with or without an upper lid
crease, may present with dermatochalasis alone, derma-
tochalasis with fatty prolapse, or dermatochalasis with
ptosis. Evaluation of aging-related changes may detect
mild ptosis, skin redundancy, loss of natural fat and lateral
hooding (Figure 10-1). Wrinkles are a natural part of skin
changes with loss of elasticity and use. These additional
factors present extra steps and precautions that need to
be taken in handling combined factors in elderly patients.
As summarized in Figure 10-2, in an elderly Asian
patient with a pre-existing crease and:
1. Dermatochalasis alone – it is corrected by preserv-
ing the crease, and performing a skin-excision
blepharoplasty.
2. Dermatochalasis with fatty prolapse – it is best
handled by preserving the crease and performing a
blepharoplasty with trimming of only enough fat
above the superior tarsal border to allow preserva-
tion of the crease (excess fat excision will result in
deepening of the supratarsal sulcus).
3. Dermatochalasis with ptosis – the crease has often
migrated upward; the crease should be reset based
 10 Asian Blepharoplasty III: Factors that Influence Outcome
FIGURE 10-1 ■ Elderly woman showing mild involutional ptosis,
supratrasal sulcus, skin redundancy and lateral hooding.
on the individual’s tarsal height using Asian blepha-
roplasty, with skin excision plus levator aponeurotic
repair (resection and/or advancement).
When the elderly Asian patient does not have a pre-
existing crease, there is the option to add a crease:
1. Dermatochalasis alone – corrected by Asian blepha-
roplasty with excision of the dermatochalasis
and creation of a lid crease (if the patient desires to
have one).
2. Dermatochalasis with fatty prolapse – corrected by
Asian blepharoplasty with excision of the dermato-
chalasis and creation of a lid crease and trimming
of only enough fat to allow creation of a crease.
3. Dermatochalasis with ptosis – skin-excision only
Asian blepharoplasty, with creation of a lid crease,
plus levator aponeurotic repair (resection and/or
advancement).
When the elderly Asian patient does not have a pre-
existing crease and prefers to stay crease-less:
1. Dermatochalasis alone – corrected by skin excision
blepharoplasty and closure without crease fixation.
2. Dermatochalasis with fatty prolapse – corrected by
skin excision blepharoplasty, minimal fat excision
and closure without crease fixation.
3. Dermatochalasis with ptosis – corrected by skin
excision blepharoplasty plus levator aponeurotic
repair (resection and/or advancement), and closure
without crease fixation.
97
When a patient that does not have a crease wants
a crease and has co-existent ptosis, it is essential that
the ptosis be repaired first, as the levator muscle needs to
have adequate excursion (‘function’) and contractility
for the lid to have a reasonable chance at creasing. If
the suture ligation (buried suture) method is used in
someone with uncorrected ptosis, it will simply aggravate
the ptosis, as well as fail to form an acceptable crease
indentation.
FINESSE IN CONTROLLING
CREASE DEPTH
The pioneers in this field published in the Japanese
medical literature a century ago how they varied the
depth by using larger caliber stitches and/or leaving the
suture knots in place longer postoperatively. The sutures
we use today are more delicate (6-0 to 7-0 caliber) and it
is indeed possible to leave some of them several days
longer in order to assure a more predictable crease
formation. In my practice, if on occasion after removing
half of the sutures I may feel that the individual’s
crease can be bettered, the remaining sutures are left in
for 2–3 more days. The factors one has to balance this
against are the fact that there will be more suture
reaction and more irritation to the patient, though
this can be easily remedied using topical antibiotic/anti-
inflammatory ointment.
EYE MUSCLE VERSION EXERCISE
(VERTICAL EXCURSION)
An occasional patient may be so sensitive and guarded
after surgery with sutures in place that he or she will be
afraid to use their eyelids other than in a barely opened
position. The levator here may not be exercised at all
during the first week until the patient is seen. I encourage
patients by the third day after the procedure to move
their lids normally, including looking up. The levator
then has a chance to adapt to its new function partly
terminating along the subcutaneous tissues at the supe-
rior tarsal border. Neuromuscular memory can be gradu-
ally learnt. The resultant crease will eventually be natural
and dynamic.
LOCAL CARE, DIETARY ADVICE
The usual mandatory wound care applies – cleaning,
avoidance of direct sun on the incisions – that one would
expect for healing following surgery. There are a host of
dietary recommendations along traditional Chinese
medicine lines that may apply to some Asians more
than others.
98 Asian Blepharoplasty and the Eyelid Crease

Upper lid of elderly Asian patient

With crease Without crease

Dermatochalasis Dermatochalasis
Dermatochalasis
+ fat + ptosis

Skin excision Skin + minimal Aponeurotic repair,

blepharoplasty, fat removal, reset crease to
preserve crease preserve crease Asian's tarsal height

Patient wants crease Stay with no crease

Dermatochalasis Dermatochalasis
Dermatochalasis
+ fat + ptosis

Asian
Asian
Asian blepharoplasty
blepharoplasty
blepharoplasty minimal fat
aponeurotic repair,
plus crease excision,
plus crease
formation plus crease
formation
formation

Dermatochalasis Dermatochalasis
Dermatochalasis
+ fat + ptosis

Asian Asian Asian

blepharoplasty blepharoplasty blepharoplasty
minimal fat + aponeurotic
excision repair

FIGURE 10-2 ■ A clinical pathway for Asian blepharoplasty in elderly patients. (From Chen WP. Oculoplastic surgery – the essentials.
Stuttgart: Thieme; 2001: 221, Fig. 15-18.)

CONCEPT OF TRIANGULAR,
TRAPEZOIDAL AND RECTANGULAR
DEBULKING – APPLICATION IN
UPPER BLEPHAROPLASTY
This chapter deals with the technique used by the author
to facilitate the likelihood of forming a crease in a single-
lidded individual: by effective removal of redundant
hindering tissues (proper orientation of the removal of
different layers so as to allow natural closure), minimiza-
tion of scar from tension, and thorough completion of
each step with lessened postoperative swelling. The steps
are applicable to any form of upper blepharoplasty,
whether primary or revisional, in Asians or non-Asians.
In previous publications,1–6 I discussed the concept of
upper eyelid crease configurations and the essential steps
required for predictable placement of a lid crease for
single-eyelid patients. This method is based on accurate
measurement of the central height of the upper tarsus,
using it to guide placement of the external incision line
for formation of the crease. As has been mentioned in
previous chapters, the ideal crease tends to be either the
nasally tapered crease or the parallel crease configuration.
Medial upper lid fold is often present in the medial
portion of the upper eyelid of Asians, whether they have
a crease or not, and should not be considered pathologic
and radically removed.
SURGICAL STEPS
Marking of Crease
It is my practice to use the shaved-off tip of a wooden
cotton-tip applicator dipped in methylene blue to mark
the proposed crease. Between 0.5 and 0.75 ml of anes-
thetic is used to achieve sensory anesthesia of the upper
lid several minutes previously. I evert the upper lid and
measure the vertical height of the tarsus over the central
portion of the lid with a caliper. This measurement is
usually between 6.5 and 7.5 mm. It is carefully tran-
scribed onto the external skin surface, again over the
central part of the eyelid skin. This point directly overlies
the superior tarsal border and will serve as a reference
point for the overall crease height along the central one-
third of the eyelid, whether the crease shape is to be
nasally tapered, parallel, or laterally flared. For those
patients who have a crease, I also measure the tarsus to
CHAPTER 11
confirm that the crease that I am observing – if I am
planning to preserve or enhance it – is indeed the correct
crease line to use. If the crease is to be nasally tapered, I
mark the medial one-third of the incision line to taper
toward the medial canthal angle or to merge with the
medial upper lid fold. The lateral one-third is marked in
either a leveled or flared configuration. For a parallel
crease, the measured height of the superior tarsal border
is drawn across the eyelid skin. To recapitulate, the height
of the tarsus determines the overall central position of
the surgical crease; the shape is determined by how you
design the medial and lateral thirds of this according to
the patient’s preference (Figures 8-4 and 8-5).
Skin Incision/Skin Excision
To create adequate adhesions, it is necessary to remove
some skin plus subdermal tissue. A strip of skin measur-
ing approximately 2 mm is then marked above and paral-
lel to this lower line of incision. In the patient who desires
a nasally tapered configuration, I taper this upper line of
incision toward the medial canthal angle or merge with
any medial upper lid fold that may be present. As a result,
the skin excision is often less than 2 mm over the medial
portion of the crease. The incision is then carried out
with a No. 15 surgical blade (Bard–Parker) along the
upper and lower lines, incising just beyond the subcuta-
neous plane. I control any fine capillary oozing with a
bipolar cautery. (The strip of skin bounded by the upper
and lower lines of incision may be excised with scissors,
or preferably, it is excised after the orbital septum is
opened along the superior line of incision and the skin
orbicularis–orbital septum flap is turned inferiorly along
the superior tarsal border, see below.) The excision of a
strip of skin is not necessary in every case; however,
it is my belief that it facilitates removal of subsequent
layers of the lid tissues, thereby allowing adequate
crease formation (Figure 8-6).
Opening of Orbital Septum
At this point, the superior tarsal border is still covered
by pretarsal and supratarsal orbicularis oculi muscle,
99
100 Asian Blepharoplasty and the Eyelid Crease
possibly some of the terminal portions of the septum
orbitale and the anteriorly directed terminal fibers of the
levator aponeurosis beneath the septum. To open the
septum, I retract the upper incision wound superiorly and
use a fine-tipped monopolar cautery, in the cutting mode,
to incise through the orbicularis and orbital septum in a
beveled fashion along the upper skin incision line. In
Asians, the orbital septum may be only 2–3 mm above
the superior tarsal border. It is readily opened, exposing
the underlying preaponeurotic fat pads (Figure 8-7).
Excision of Preseptal Orbicularis
and Orbital Septum (Figure 9-5)
After the septum is opened horizontally, the strip of skin,
supratarsal orbicularis and orbital septum hinged along
the superior tarsal border is excised. It consists of approx-
imately 2–3 mm of skin, a greater amount of supratarsal
orbicularis muscle and a variable amount of the orbital
septum (trapezoidal debulking of preaponeurotic tissues).
Preaponeurotic Fat Pads
Depending on the degree of fullness of the upper lid, I
may use a sharp scissors to excise a small amount of the
preaponeurotic fat pad. I control any bleeding points
with a bipolar cautery. (The fat excision often requires a
small supplement of lidocaine in the space beneath the
preaponeurotic fat pads.) If a patient with dermatochala-
sis and obliteration of the crease displays even a very
minimal concavity in the supratarsal sulcus, I do not
remove any fat, since it will worsen the hollowness and
result in multiple redundant folds superior to where one
wants the crease to be (Figure 9-4).
Excision of Pretarsal Orbicularis
To facilitate in-folding of the new crease, I excise a
1–2 mm strip of pretarsal orbicularis muscle along
the inferior skin incision edge. There are some authors
who routinely debulk the entire pretarsal subcutaneous
tissue, believing that it is better to have only skin covering
the anterior surface of the tarsus. My experience differs,
and I remove some pretarsal tissue only if pretarsal fat is
quite abundant and threatens the surgical formation of
the desired upper lid crease. In the pretarsal plane of a
creaseless Asian eyelid, there are few, if any, terminal
interdigitations of the levator aponeurosis to the dermis.
I refrain from vigorous dissection along the pretarsal
plane, as I feel that it creates prolonged postoperative
edema and can risk undesirable formation of more than
one crease. Furthermore, it is quite natural for Asians
born with a natural crease to have some degree of pre-
tarsal fullness along the area between the crease and the
eyelashes (Figure 9-6 A,B).
Formation of Lid Crease and
Closure of Wound
In order to form a dynamic crease, the terminal fibers of
the levator aponeurosis above the superior tarsal border
should be directed to the subdermal plane of the lower
line of skin incision. I use 6-0 non-absorbable suture (6-0
silk or nylon) to pick up the lower skin edge and subcu-
taneous tissue to the levator aponeurosis along the supe-
rior tarsal border and then the upper skin edge and tie
each of these as an interrupted suture.
Besides the stitch over the center of the crease, I place
two or three sutures medially and two laterally. With
these five or six crease-forming sutures in place, the rest
of the incision may be closed with 6-0 or 7-0 nylon in a
continuous or subcuticular fashion (Figure 9-7 A–D).
CONCEPT OF TRIANGULAR,
TRAPEZOIDAL AND RECTANGULAR
DEBULKING OF EYELID TISSUES
During a double-eyelid procedure by way of the external
incision method, leaving behind a platform of tissues
anterior to the superior tarsal border will interfere with
the definition and formation of the proposed crease. The
various approaches of removing skin,7 skin with orbicu-
laris,8,9 skin with pretarsal fat,10 and skin with muscle and
septum and preaponeurotic fat11,12 are all attempts at cre-
ating a clear platform for the formation of adhesions
between fibers of the levator aponeurosis and the subcu-
taneous structure of the surgically created crease.
Triangular and trapezoidal debulking allow a systemic
and uniform cleaning of the preaponeurotic space along
the superior tarsal border and the pretarsal plane.
Figure 11-1 is a schematic drawing of an Asian upper
eyelid without an upper lid crease. As the drawing shows:
1. When skin excision (<2 mm) is carried out in con-
junction with the lid crease placement, retracting
the upper skin incision edge allows an upwardly
beveled plane of dissection to proceed across the
supratarsal orbicularis oculi muscle and the lower
portion of the orbital septum. (In Asians who do
not have a crease in the upper lid, the orbital septum
is frequently fused to the levator aponeurosis at
2–4 mm above the superior tarsal border, and it can
be as low as halfway down the anterior surface of
the tarsus.) The septum and underlying preaponeu-
rotic fat pads are easily identified.
2. The septum orbitale is opened horizontally. The
trapezoid of preaponeurotic tissues (viewed in
this cross-section) includes occasionally a minimal
amount of preaponeurotic fat, the orbital septum,
supratarsal orbicularis, subcutaneous fat and over-
lying skin (2 mm), all of which hinge along the
superior tarsal border and may be debulked. The
anterior surface of this conceptual trapezoid con-
sists of the skin, while the posterior portion of the
trapezoid is wider and includes all preaponeurotic
tissues from the opened orbital septum down to the
superior tarsal border.
3. A small strand of the pretarsal orbicularis along the
inferior skin incision may be trimmed off. The
trapezoidal debulking allows easy inward folding of
the skin edges toward the underlying aponeurosis,
 11 Concept of Triangular, Trapezoidal and Rectangular Debulking – Application in Upper Blepharoplasty 101

Orbicularis

Septum

Upper
incision

Single
incision
line

FIGURE 11-1 ■ Cross-sectional drawing of trapezoidal debulking of the preaponeurotic platform. Black dots correspond to potential
lines of skin incision. Arrows correspond to transorbicularis vector from skin to orbital septum and show possible planes of dissec-
tion through the preaponeurotic fat pads. Trapezoidal debulking of preaponeurotic tissues in Asian blepharoplasty may include all
tissues bounded by the upper (beveled) and lower (perpendicular) transorbicularis vectors and the tissue between the skin and the
orbital septum. Minimal fat excision may be included.
102 Asian Blepharoplasty and the Eyelid Crease
facilitating surgical formation of the crease.
(Collin’s13 electron microscopic study described
insertions of distal strands of the levator aponeuro-
sis into the septa in between pretarsal orbicularis
muscle fibers rather than into any subdermal tissue
along the lid crease in those eyelids that had a
crease. Should this be the case, formation of a
crease may be facilitated by the preceding surgical
maneuver because it links the aponeurosis to the
upper border of the pretarsal platform. Vigorous
dissection and debulking of pretarsal tissues is to
be avoided because they tend to lead to persistent
edema and formation of multiple creases.)
If debulking is carried out without including any skin
excision, the block of tissue removed resembles a trian-
gular configuration in cross-sectional view.
If the patient has a great deal of skin redundancy, the
amount of skin included for excision is increased by
expanding the upper line of skin incision. The plane of
dissection through the orbicularis becomes less beveled
and the trapezoidal debulking gradually turns into more
of a rectangular configuration.
In the conceptual cross-section of the upper lid in
Figure 11-2, the right boundary is the skin surface and
the left boundary the sheath of the orbital septum;
between these two layers is the orbicularis oculi muscle.
The lower edge is the superior tarsal border (STB). The
pink zone denotes one scenario of the amount of orbicu-
laris oculi that can be removed.
The diagram shows the transorbicularis vector (Step
2) for the dissection plane rotating counterclockwise and
leveling off as one removes more skin and the upper line
of skin incision [Step l (U)] moves further from the supe-
rior tarsal border.
The first surgical step (1) involves upper and lower
lines of incision, 1 (U) and 1 (L), above the superior tarsal
border, which are skin incisions.
The second step (2) involves an oblique transec-
tion through the orbicularis by the transorbicularis
vector line.
In the third step (3), upon reaching and opening of the
orbital septum, one dissects inferiorly toward the supe-
rior tarsal border.
Step 4 shows a leveled excision of orbicularis and
redundant skin above the superior tarsal border.
The first transorbicularis vector (Step 2) rotates and
levels off as more skin needs to be removed such that the
cross-section of soft tissues that are debulked changes
from a triangular to a trapezoidal, and finally rectangular
configuration.
This can be represented as:
Triangular debulking < trapezoidal debulking
< rectangular debulking
where < represents less than.
In triangular debulking (without skin removal):
Orbicularis ÷ Skin = Infinity ( or n, with n >> 1)
( vertical measurement of either tissue)
Therefore, in young individuals:
δ orbicularis
>> 1.0
δ skin
As you proceed to trapezoidal and rectangular debulk-
ing, the ratio of orbicularis to skin removal (as measured
vertically) approaches 1 : 1 (n getting close to 1).
In an elderly individual:
δ orbicularis
= 1.0 ( occasionally < 1.0)
δ skin
This ratio will be less than 1.0 only when the amount
of skin redundancy is truly excessive, as in an elderly
individual, allowing the removal of excessive skin
without compromising wound closure and predisposi-
tion to ectropion and lagophthalmos of the upper lid.
In this situation, a ‘reverse’ trapezoidal block of tissue
is removed, with the height over the skin side greater
than the height of the preseptal orbicularis excised.
Even with a great deal of skin removal, the traverse
through the orbicularis muscle (transorbicularis vector,
Step 2) should remain perpendicular to the levator
palpebrae superioris muscle.
In conclusion, the applications and advantages of
trapezoidal debulking in Asian blepharoplasty are as
follows:
1. Easier approach through the orbital septum when
the plane of dissection is beveled. It lessens poten-
tial injury to the levator aponeurosis when there is
a buffer of preaponeurotic fat pad underneath the
septum.
2. Allows for a controlled, uniform debulking of the
preaponeurotic platform in the supratarsal and pre-
tarsal regions.
3. Allows optimal formation of adhesions between the
levator aponeurosis and the inferior subcutaneous
tissues of skin along the superior tarsal border, or
to intermuscular septa within pretarsal orbicularis
muscle fibers (pretarsal platform).
4. Allows crease formation to be based on the indi-
vidual’s tarsus height.
5. Reduces the complication rate: including issues
with asymmetry, shape, height, continuity, per­
manence, segmentation of the crease due to
uneven planes of dissection, fading and late disap-
pearance of crease, multiple creases and persistent
edema.
 11 Concept of Triangular, Trapezoidal and Rectangular Debulking – Application in Upper Blepharoplasty 103

Orbital St
ep
septum 2 Skin

Step 3
Step
1 (U)
Orbicularis

Step 4
1 (L)

Level of STB
FIGURE 11-2 ■ Anterior lamella of upper eyelid; the orbicularis muscle of the supratarsal region and the skin lie anterior
to the orbital septum. The first surgical step involves upper and lower lines of incisions [1 (U)] and [1 (L)] above the superior tarsal
border (STB). The second step (2) involves an oblique transection through the orbicularis muscle along the transorbicularis vector
line. When the orbital septum is reached and opened in the third step (3), the dissection is carried inferiorly toward the superior
tarsal border. Step four (4) is a leveled excision of orbicularis muscle and redundant skin above the superior tarsal border. The
transorbicularis vector rotates and levels off as more skin is removed. The cross-section of soft tissues that are debulked changes
from triangular to trapezoidal, and finally a rectangular configuration as more skin is removed. The first transorbicularis vector (Step
2) rotates and levels off as more skin needs to be removed such that the cross-section of soft tissues that are debulked changes
from a triangular to a trapezoidal, and finally rectangular configuration.
104 Asian Blepharoplasty and the Eyelid Crease

complications of eyelid surgery. Vol. 3. Philadelphia: Field &

REFERENCES Wood; 1994.
1. Chen WPD. Asian blepharoplasty and the eyelid crease (with 7. Sayoc BT. Plastic construction of the superior palpebral fold. Am
DVD), 2nd edn. Oxford: Butterworth–Heinemann/Elsevier; J Ophthalmol 1954:38:556.
2006. 8. Hayashi K. The double eyelid operation. Jpn Rev Clin Ophthalmol
2. Chen WPD. Asian blepharoplasty. Ophthal Plast Reconstr Surg 1938;33:1000–1010 (Part 1) and 33:1098–1110 (Part 2).
1987;3(3):135–140. 9. Fernandez LR. Double eyelid operation in the Oriental in Hawaii.
3. Chen WPD. Insights from a series of Asian blepharoplasty. Pre- Plast Reconstr Surg 1960;25:257.
sented at the Annual Scientific Symposium of the American Society 10. Inoue S. The double eyelid operation. Jpn Rev Clin Ophthalmol
of Ophthalmic Plastic and Reconstructive Surgery, Atlanta, GA, 1947;42:306.
1990. 11. Mitsui Y. Plastic construction of a double eyelid. Jpn Rev Clin
4. Chen WPD. A comparison of Caucasian and Asian blepharoplasty. Ophthalmol 1950;44:19.
Ophthalmic Pract 1991;9:216. 12. Sayoc BT. Anatomic considerations in the plastic construction
5. Chen WPD. Upper blepharoplasty in the Asian patient. In: of a palpebral fold in the full upper eyelid. Am J Ophthalmol
Putterman AM, ed. Cosmetic oculoplastic surgery, 2nd edn. 1967;63:155.
Philadelphia: Saunders; 1993. 13. Collin JR, Beard C, Wood I. Experimental and clinical data on the
6. Chen WPD. Review of Aguilar G. Complications of oriental insertion of the levator palpebrae superioris muscle. Am J Ophthal-
blepharoplasty. In: Mauriello J, ed. Management and avoidance of mol 1978;85:792.

OPTIMAL CLOSURE AND
MANAGEMENT OF WOUND HEALING
It is always desirable to be able to enter and exit the eyelid
(through an existing crease) without leaving too much of
a footprint. If one can strive to enter, perform the neces-
sary task to the exact degree one had planned for, execute
the plan without significant trauma, and exit without
causing new impairment compared to before, leaving the
area accessible for re-entry if indicated in the future – that
would be ideal. In essence, the ninja way (Figure 12-1).
(The popularity of endoscopic and robotic-assisted sur-
geries is basically following this premise.) Of course,
none of us is ever as good as these fabled characters. I do
insist, however, that one should think, analyze and plan
to perform in this fashion.
There are many factors that contribute to optimal
wound healing. We commonly think of the way we apply
stitches, how we tie them, dressing the wound and remov-
ing the sutures as the major factors. While these are all,
of course, important, there are facets of specially adopted
surgical techniques that contribute just as significantly to
the overall natural healing, allowing the skin wound to
heal, appear natural and function as it has been designed
to do.
The previous chapters have touched on the design of
the crease incision, where the crease is strategically placed
FIGURE 12-1 ■ Sun-and-moon cartoon caricature working 24/7,
with a scalpel toe, holding surgical scissors.
CHAPTER 12
so that it is in line with the biodynamics of the lid struc-
ture, the beveled (oblique) plane through which the dif-
ferent layers of the eyelid are traversed, and the closure
of the wound. It is my opinion that by distributing the
surgical plane in an oblique plane and performing the
excision of tissue in a one-piece fashion, the wound reac-
tion is lessened for these vulnerable layers. The control
of minor bleeding is performed away from the immediate
vicinity of the skin incision, the septum is opened further
away from the skin wound, fat is preserved and the trap-
ezoidal block excision allows more of the orbicularis than
the skin to be excised. The upper skin incisional edge is
then laid down in a relatively tension-free fashion prior
to closure, and upon closure yields a perfect rotational
point for the upper skin to fold over the crease as the
eyelid folds. Similarly, the trimming of a small sliver of
excessive subcutaneous tissue along the inferior skin
wound also permits tension-free closure. As much as pos-
sible, therefore, one should set a high benchmark in cre-
ating conditions ideal for wound healing, and minimizing
surgical trauma.
The various suturing techniques used in external inci-
sion methods have already been discussed. They include
attaching the skin over the tarsus, attaching the skin
towards the levator aponeurosis, or along the superior
tarsal border, and attaching the inferior orbicularis to the
distal portion of the levator aponeurosis.
All of these are basic plastic closure techniques,
but one may not have thought of carrying them this
far, to this detailed extent (indeed to an extent some
would criticize as ‘minute’). I can even state that the
way in which the surgical blade’s handle is held by
the surgeon, or the angle of the blade’s tip in relation
to the skin surface as the incision is made, are all
important.
THE CONCEPT OF A DYNAMIC VERSUS
A STATIC CREASE
A dynamic upper lid crease is one that is apparent in
straight-ahead and upgaze but which tends to fade on
downgaze, and is barely noticeable when viewed at 90°
to the skin surface. A static crease would be one that is
noticeable in all three positions: upgaze, straight-ahead
and downgaze, when the observing angle is 90°. A
dynamic crease therefore resembles a natural crease.
In order to form a dynamic crease, the terminal fibers
of the levator aponeurosis above the superior tarsal
105
106 Asian Blepharoplasty and the Eyelid Crease
border must be directed to the subdermal plane of the
lower skin incision line. As one is obliged to close the
upper skin edge to the lower skin edge, I believe that it
is academic to argue on the merits of creating adhesions
solely from the terminal aponeurotic fibers to the lower
skin edge, or to both the upper and lower skin edges. It
is essential to loosen and reposition any adhesive surgical
drape that may be used, to allow the upper lid skin to fall
along the lower pretarsal skin without tension. The
patient is instructed to look up and down to check the
adequacy of crease formation and contour before any
stitching is begun.
Suturing skin–tarsus–skin tends to yield a static-
looking crease. In my technique I use 6-0 silk or nylon
interrupted sutures to connect the lower skin edge to the
levator aponeurosis along the superior tarsal border, and
then to the upper skin edge. Besides the stitch over the
center of the crease, I apply three sutures medially and
two to three laterally. With these six or seven crease-
forming sutures in place, the rest of the incision may be
closed using 6-0 or 7-0 nylon in a continuous or subcu-
ticular fashion. This continuous suture involves only the
dermis, without the need to pick up any orbicularis
muscle fibers. The objective here would be to avoid hem-
orrhage from the orbicularis muscle and to provide an
optimal plane of closure of the skin incision site. In this
method all the sutures are removed.
The method of anchoring inferior subcutaneous tissue
alone, or orbicularis to the levator aponeurosis, frequently
involves placing buried, non-absorbable sutures. I have
come across patients who complain of the static nature
of the crease resulting from the use of buried sutures, and
some complain of a kinesthetic awareness and often irri-
tation from these buried elements in their eyelids.
CREASE FORMATION AND
CREASE DYNAMICS
Dynamic Interaction of the Pretarsal
Platform and the Preaponeurotic Zone
One can divide the upper eyelid into three zones: the
eyelid crease (which acts as the junctional zone or the
rotating nano-balls, see Chapter 23), the pretarsal zone
below it and the preseptal zone above it (Figure 12-2).
The objective of the surgeon in forming or enhancing an
upper eyelid crease should be:
1. To facilitate the inward folding of the crease
(through the nano-balls) by reducing the soft tissue
overlay through limited debulking of redundant
preaponeurotic soft tissue, which may be hindering
the infolding, or by tightening this pivoting zone
through suture ligation (which is less effective by
comparison, and more prone to regression). By
providing a clear demarcation zone, one achieves a
good pivot or nano-ball junction.
2. The pretarsal area (lower zone) can be made
firmer through (a) excision of some orbicularis
oculi muscle along the inferior incisional skin edge,
or (b) suture ligation, through conjunctiva to
subcutaneous plane buried sutures, or through
external skin to levator aponeurosis buried sutures.
3. The fullness of the preseptal area (upper zone)
should be preserved by conserving and reposition-
ing most of its preaponeurotic fat superiorly into its
sulcus or the upper quadrant of the orbit. There
should be no excessive skin removal to avoid fore-
shortening of the anterior lamella of this upper zone.
These three focal points serve to create an opportunity
for the firm pretarsal platform and tarsus (the tarsal–
crease unit) to vector upwards and slide under the presep-
tal soft tissue zone above it, without much effort or
encountering any tissue resistance over the crease. The
preseptal zone bellows freely over the pretarsal zone,
with a crease formed in between.
Conceptually, the crease is thought to form above the
highest point of insertion of the distal terminations of the
levator aponeurosis through the orbicularis oculi’s inter-
muscular septa, as well as skin along the crease line. That
is not to say that there is absolutely zero presence of
terminal fibers of the levator aponeurosis above the
dominant crease. My trapezoidal debulking approach
(Chapter 11) allows a skin–aponeurosis–skin closure,
with a 1–2 mm zone where the transected orbicularis
(along the upper beveled skin–muscle wound plane) may
become adherent to the aponeurosis just above the supe-
rior tarsal border, thereby reforming the ‘limiting bound-
ary’ previously described as the posterior reflection of the
orbital septum on to the levator aponeurosis sheath, and
acting as an inferior limit to the repositioned preaponeu-
rotic fat. The surgically created crease simply forms
directly above this zone. Therefore, although the lid
crease wound is formed along the superior tarsal border,
by taking skin to aponeurosis to skin, the upper lid crease
thus formed may lie just above this junction. Another way
to conceptualize this is that the aponeurosis is attached
to both upper and lower wound skin edges, with the
crease thus created lying above it.
Several factors in the upper/preseptal zone can lead
to poor infolding of the crease. If fat excision in the
preaponeurotic space was excessive, there is now direct
physical contact between the aponeurosis and the orbicu-
laris, as the septum has been opened. There is then an
attenuation of the preaponeurotic space, which can pre-
dispose to cicatrix formation and an increase in rigidity
of this zone. If there was inadvertent tissue handling,
injury, or above-normal hemorrhaging, there can be
increased scarring and consequent rigidity. If there was
excessive skin excision in this upper zone, there is a
greater probability that the pretarsal–eyelid crease unit
will be unable to form a crease by vectoring upward
under these scarred and therefore tighter preseptal tissues
(of skin, orbicularis, septum and possibly attenuated
fibrosed fat tissues). These seemingly benign factors can
combine to substantially hinder crease formation.
In Caucasians born with a natural crease, the relatively
higher point of fusion of the orbital septum on to the
levator aponeurosis limits the preaponeurotic fat to above
this fusion point. The crease may have formed from distal
terminations of the aponeurosis in towards the inferior
orbicularis muscle septa, actual subcutaneous attachment
 12 Optimal Closure and Management of Wound Healing 107

Periorbital zone

Preseptal zone

Eyelid crease

Pretarsal zone

FIGURE 12-2 ■ The upper eyelid and crease can be thought of conceptually as consisting of three zones: the eyelid crease (which
acts as the junctional zone or the telescoping pivot), the pretarsal zone below it and the preseptal zone above it.
108 Asian Blepharoplasty and the Eyelid Crease
or ‘extensions’ from the levator, and inferior limitation of
fat through a postero-upward reflection of the posterior
layer of the orbital septum on to the levator aponeurosis
(this latter scenario may simply yield a prominent supra-
tarsal sulcus in Occidentals who have never had eyelid
surgery). This, combined with a softer and thin-skinned
preseptal zone, allows the firm tarsal complex to easily
vector upward against it to form a crease.
In Asians with a single eyelid, this attempt to form a
crease is more difficult for a variety of reasons: the pre-
tarsal soft tissue (skin and boggy orbicularis) is often
softer and more redundant; the septum fuses on to the
levator aponeurosis and tarsus at a lower point; preaponeu­
rotic fat is present at a lower level; the preseptal zone may
have significant fullness and is often positioned more
forward in the orbit (Asians have comparatively less deep-
set eyes, owing to a less prominent forward extension of
the superior orbital rim). These factors are more likely
to yield a single lid without a crease.
Following an Asian eyelid crease enhancement proce-
dure, with preservation of fat in the preaponeurotic
middle space, coupled with reduction of the pretarsal
inferior edge soft tissue, as well as clearance along the
superior tarsal border and controlled debulking of the
preaponeurotic platform, it will be easier for the crease to
indent up. The levator’s dynamic pull (up-vector) is most
effective when the muscle can glide up against a cushion
of non-adherent preaponeurotic fat (middle space) as well
as overlying anterior skin–orbicularis. In essence, the
tarsal plate and skin are allowed to invaginate against a
multilayered soft tissue complex (preaponeurotic fat,
septum, orbicularis, subcutaneous fat and skin). It will be
more difficult if the preaponeurotic space is obliterated
through ablation of its fat; cicatrization forms between the
anterior layer of skin–orbicularis–orbital septum and the
posterior layer of levator–Müller’s muscle–conjunctiva
through tissue damage or excessive hemorrhage and
subsequent hemosiderin deposition. The resultant rigid
multilayered tissue complex presents a far greater mass of
tissue, as well as a challenge for the tarsal plate to indent
against to form a crease. We may see this clinically as a
firm band of skin/muscle/anterior lamella in the preseptal
region, accompanied by a static-looking crease.
On occasion, postoperative swelling can mask an
otherwise well-formed crease; and when the swelling
resolves, the tarsal plate vectors up well against the presep-
tal soft tissue and a crease then appears appropriately.
The suture ligation methods create a crease by tight-
ening the soft tissue overlying the superior tarsal border,
creating a firmer constriction between the subcutaneous
skin and the levator aponeurosis (through either an ante-
rior skin or a posterior conjunctival approach). It allows
an increased force-gradient where the tarsal plate uplifts
in and under the preseptal soft tissues. With no removal
of redundant soft tissue, it is effective in the short term
(perhaps up to 5 years). However, with aging and a
gradual increase in soft tissue redundancy, the crease thus
created may become shielded from view or shallow out
with time (fading) owing to the unavoidable shredding
forces of the buried sutures used in these methods. (The
ligatures’ effect may diminish in time, not from the dis-
solution, loosening, or breaking apart of the sutures, but
more from the ligature working and cutting through the
tissue layers which it was meant to tie together.)
The application of the crease-forming sutures depends
on accurate placement along the superior tarsal border’s
levator aponeurotic fibers. The appropriate number of
these interrupted sutures is applied to form a uniform
continuous crease invagination. Upon tying of these
sutures, we should avoid excess tension or strangulation
effect on the tissues. The running stitch after this merely
approximates the skin edges together.
The choice of suture material depends on the prefer-
ence of the surgeon, balancing potential wound reaction,
discomfort or comfort for the patient, and desired healing
that enhances the crease construction. It determines the
number of days for which the sutures are left in place
before removal, again balancing success rate for crease
formation versus skin reaction.
Postoperative wound cleaning and dressing is standard.
This involves the use of antibiotic and anti-inflammatory
(steroid) combination ophthalmic ointment.
In patients with oily skin one may elect to add the
prophylactic use of oral antibiotics, and anti-comedogenic
skin preparations. There are also a wide range of dietary
recommendations that can be given for Asian patients
according to their ethnic food cultures, based on the
traditional Chinese medical belief system.
Other factors that may affect healing first and fore-
most will include the patient’s own tissues (genotype and
phenotype), exposure to external environment (sun expo-
sure, local hygiene), past history of sun damage or wound
stress, dermatological conditions like eczema and psoria-
sis, and how recently any surgery was performed in the
deeper and superficial layers of the eyelid.
SURGICAL FINESSE, NUANCES
AND PEARLS
In the earlier Japanese literature the pressure to which
surgical knots are applied on to the skin surface was used
to enhance the formation of a crease. Excessive pressure
can lead to compression ischemia and poor wound
healing. Buried sutures often may show through the skin
surface, and absorbable buried sutures may generate
granulomatous suture reaction as the sutures dissolve.
A properly healed wound in a dynamic crease needs
to be aesthetically pleasing, permanently effective, not
noticeable in downgaze, without wound spreading or dis-
coloration, and not bumpy.
Suture Type. In my Asian blepharoplasty I use two
types of suture:
1. Crease enhancement sutures – usually 6-0 caliber
braided silk (black), used as five to six interrupted
sutures, to unite skin–levator aponeurosis–skin
along the wound located at the superior tarsal
border. The newly formed crease should invaginate
easily with these in place. They are removed after
one week.
2. A continuous running 7-0 silk suture to close the
skin edges. This is removed at one week also.
 12 Optimal Closure and Management of Wound Healing
No buried or absorbable stitches are ever used. The soft
texture of the silk suture material ensures that the stitch
is not too stiff (as in nylon or Prolene), which can be
irritative. It is less reactive than sutures like chromic
catgut, Vicryl or Dexon.
Manipulation of Suture Knot and Running
Suture. The knots can be placed directly over the junc-
tion of the two skin edges, or skewed to favor one side
or the opposite side. The length of running suture can
be used to secure the knot placement by looping it below
the interrupted suture knot or above it.
Technique in Medial Eyelid Fold. The medial fold
often needs to be reduced through excision of overlap-
ping skin. During closure, again the suture knots can be
manipulated to favor greater compressive force across the
wound itself, such as to result in a more likely tapering
crease or parallel crease configuration.
In developing a parallel crease, although the incision
was designed, carried out and intended to be parallel as
it courses towards the medial canthus, when a prominent
medial fold is present, the fold should be reduced. If not,
it will hinder the desired crease shape (turning it more
towards a nasally-tapered crease).
Treatment of Lateral Wound Edges. Often the skin is
thicker here; the underlying orbicularis oculi fibers are
abundant and strong. This may result in wound spread.
Careful assessment should be used on each individual,
and the closure here may require more sophisticated
suturing using non-reactive stitch like nylon, and leaving
the sutures in a longer period to gain better wound
coaptation.
Cautions. The wound edges should not be closed under
tension, which is more likely if the upper or lower part
of the eyelid crease incision is wrapped tight by the surgi-
cal draping. If the wounds are stitched under tension side
effects include high crease, lagopthalomos, and ectropion
of the tarsal plate or of the upper lid margin.
Repeated measurement and confirmation of crease
height at different steps during the procedure helps mini-
mize asymmetry.
POSTOPERATIVE CARE
During the immediate postoperative period the wound
is cleaned daily and covered with antibiotic ointment.
Compressive or occlusive eye dressings are to be
avoided. Diuretics and steroids are not usually prescribed.
Depending on the material used, the sutures are removed
7 days after the operation. It is my practice to leave in
interrupted sutures (skin–levator aponeurosis–skin) for a
slightly longer period if the crease appears slow in
forming, as this seems to help ensure proper attachment
of the levator aponeurosis to the incision line along the
superior tarsal border.
About 80% of the postoperative swelling should have
disappeared a week after the sutures are removed, or at
2 weeks postoperatively. The remaining 20% will regress
109
by 2 months. The crease migrates closer to the ciliary
margin when pretarsal tissue edema subsides as a result
of lymphatic and vascular rechanneling. Patients are told
that even if all goes well their surgically placed crease will
take 3–6 months to stabilize.
Should there be a need for revision touch-up, for
example if the crease does not form distinctively, the
author performs this no earlier than at 6 months, as the
crease continues to mature. The author does not advo-
cate secondary revision in patients seeking consultation
after having had previous procedure(s) elsewhere unless
a 12-month period has elapsed.
The patient is given a short list of instructions to
follow postoperatively.
Postoperative Regimen for Asian
Blepharoplasty Patients
• Bed rest for 24 hours.
• Ice compresses for 1 day.
• No reading, watching television or computer use.
No computer-gaming.
• Wound and facial hygiene: clean face and incision
wounds three to four times daily with clean water.
• Avoid the use of cosmetics over the incision wound
and sutures.
• Apply antibiotic ointment four times daily for 7
days.
• Patient may shower that day.
• Avoid hot-spa or swimming.
• Avoid strenuous activities or workout for at least 1
week.
• Avoid aspirin compounds or anything containing
ibuprofen.
• Avoid spicy food, chocolate, dairy products and
fried foods for 2 months.
Crease-Enhancing Eye Exercises for
Patients without a Pre-Existing Crease
For some individuals, practice excursions of the upper
lids are recommended, from downgaze to upgaze, without
involving the brow and forehead muscles and without
allowing the head to be tilted backwards in any way, start-
ing on the third day after the operation and continuing
for 2 weeks. These exercises help initiate formation of
the lid crease in selected patients. The levator movement
should be deliberately slow in order to allow good crease
infolding without pulling on any fine blood vessels and
causing postoperative hematoma.
The last point bears further explanation. Some patients
may have such low pain tolerance that they dare not look
up or even straight ahead, as the skin sutures may cause
some local irritation. They may stay in a head-tilted-back
position all week without activating any levator move-
ment or upgaze. The crease may not form well if there
have been no attempts at upgaze during the first 10 days.
This form of eye movement is best performed slowly,
hence the term ‘Eye-Chi’, coined by the author (as in the
110 Asian Blepharoplasty and the Eyelid Crease
slow graceful excursions of Tai-Chi). It is important to
initiate upgaze and thereby contract the levator muscle
to assist in forming a proper crease. Slow daily movement
of the eyelids helps reduce the swelling over the pretarsal
and preseptal regions. It also helps ingrain muscle
memory, as a number of patients who lack a crease also
have a relative inability for full upgaze, and a still smaller
percentage may have a concomitant ptosis, although this
is usually mild and often subclinical, their levator func-
tion often being less than 10 mm. Such muscle memory
training may be entirely new for these patients. It helps
them become aware that they often have an overaction
of their forehead and eyebrows to start with.
The surgeon should expect panic calls from patients
and should provide reassurance. I often see my patients
more frequently than is medically necessary to help allay
their concerns.
The importance of meticulous attention to the contour
and placement of the crease cannot be overemphasized.
These factors are dictated by the design of the incision
line and the placement of the interrupted sutures on the
levator aponeurosis. One must diligently avoid the con-
struction of an excessively high crease, or one that is too
deep or too harsh. One should avoid the removal of an
excessive amount of preaponeurotic fat. When the sutures
are removed, whether all at once or in two separate stages
several days apart, it is not unusual to see tissue indura-
tion over the incision wound and the suture tracts (Figure
12-3). In some cases, because the sutures that anchor the
lid crease are under tension, the dermal reaction may be
more intense than one would normally expect. When I
encounter this type of reaction I prescribe a short course
of topical fluometholone (FML) ophthalmic ointment to
be applied over the wound. These indurations tend to
regress within several weeks; reactions such as hyper-
trophic scarring may linger longer. According to the lit-
erature, keloids are seldom seen over the upper eyelids.
I have found this to be true, having seen no true keloid
formation over the crease. The same is not true of keloid
formation over the thicker skin of the medial canthal
region, however, where very prominent scars from
FIGURE 12-3 ■ Natural wound induration visible 1 week postoperatively.
attempts at medial canthoplasty, intercanthal fixation and
VY-plasty have been observed.
Patients may still present with a variety of concerns or
complaints, which may include:
1. Unevenness of the crease, even within the first
hours, day or week. This is often caused by different
degrees of swelling between the two lids. It may be
in the pretarsal area, which will broaden a crease
(through increase in crease height), or in the presep-
tal and periorbital region, which may depress and
diminish the apparent height of a crease. Often post-
operatively the height of the crease may be influ-
enced by the position of the side of the face during
sleep: the dependent side will tend to have corre-
spondingly more edema and therefore the crease
may appear higher, owing to pretarsal fullness.
2. A crease may not appear to be adequately folded in
after sutures are removed at 1 week postoperatively.
The explanation could be residual swelling, or
newly formed swelling can temporarily shallow out
a crease.
3. A crease may still appear to be hooded or shielded
even after surgery: this is likely to be due to presep-
tal tissue swelling overhanging the crease or asym-
metric brow positions.
4. Bleeding and hematoma beyond the first 2 days.
This happens infrequently, but usually arises
from excessive physical activities several days after
surgery.
5. Infection, cellulitis, erysipelas, accompanied by
redness, itching and tenderness to touch.
6. Itching, usually due to allergic dermatitis or a reac-
tion to topical antibiotic ointment.
7. Crease not folding in well over the medial one-
third of the lid margin: the skin–levator attachment
may be suboptimal, the levator muscle may not be
well formed medially, or the swelling may have
temporarily obliterated the infolding of the crease.
The crease may still appear after 2–3 months.
 12 Optimal Closure and Management of Wound Healing 111

8. Late complaints: In general, the postoperative care of Asian patients

• Induration over the medial one-third of the inci-
sion wound (the dermis is thicker there)
• Suture tract cyst formation
• Blackhead (comedo) formation from early use of
cosmetics during the postoperative period
• Wound dehiscence (rare)
• Persistent fullness over the pretarsal area (rare if
the Asian blepharoplasty techniques described in
this text are followed)
• Chemosis of conjunctiva (rare).
who undergo cosmetic upper lid operations requires
patience and understanding on the part of both patient
and surgeon. Patients should understand the normal
healing course for Asian eyelid skin, so that they have a
proper time frame in which to observe the progression
of wound healing. Surgeons should be sympathetic to the
patient’s psychological needs and their anxiety, should
provide ample reassurance and should render sound
medical care in the extended postoperative period.
Figures 12-4 to 12-15 are preoperative and postopera-
tive paired photos illustrating cases of typical Asian
blepharoplasty surgery with expected outcomes.

B
FIGURE 12-4

B
FIGURE 12-5
112 Asian Blepharoplasty and the Eyelid Crease

B
FIGURE 12-6
 12 Optimal Closure and Management of Wound Healing 113

C
FIGURE 12-7
114 Asian Blepharoplasty and the Eyelid Crease

B
FIGURE 12-8

B
FIGURE 12-9
 12 Optimal Closure and Management of Wound Healing 115

B
FIGURE 12-10

B
FIGURE 12-11
116 Asian Blepharoplasty and the Eyelid Crease

B
FIGURE 12-12 ■ Before and after view at one week postoperative visit.

B
FIGURE 12-13
 12 Optimal Closure and Management of Wound Healing 117

B
FIGURE 12-14
118 Asian Blepharoplasty and the Eyelid Crease

C
FIGURE 12-15
 CHAPTER 13

PRIMARY ASIAN BLEPHAROPLASTY

RESULTS (BEFORE AND AFTER)
The images presented in this chapter are intended to certainty can be implied nor result guaranteed from the
show a variety of cases solely for educational purposes. images shown here.
Individual outcomes are unique and no degree of

CASE 1 (Figure 13-1 A–C)

(A, B) Young adult with average eyelid fissure opening and absent crease.

Continued

119
120 Asian Blepharoplasty and the Eyelid Crease

CASE 1 (Figure 13-1 A–C)—cont’d

(C) After placement of a medium (classic) parallel crease.

CASE 2 (Figure 13-2 A, B)

(A) Young adult with multiple wrinkles and without any crease. (B) With slightly high-average crease height, nasally tapered
shape.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 121

CASE 3 (Figure 13-3 A, B)

(A) Middle-aged woman with absent crease and some skin hooding. (B) Postoperative appearance: lower than average crease
height, parallel shape crease.

CASE 4 (Figure 13-4 A, B)

(A) Middle-aged woman with single lid, and triangular eyelid opening from lateral hooding. (B) After Asian blepharoplasty,
with medium crease height, nasally tapered crease shape. Triangular fissure shape has been eliminated.

B
122 Asian Blepharoplasty and the Eyelid Crease

CASE 5 (Figure 13-5 A, B)

(A) Young adult with absent crease. (B) Postoperative appearance: slightly higher than average crease height, parallel shape.
Note that the medial upper fold remains despite the fact that the caruncles can be plainly seen.

CASE 6 (Figure 13-6 A, B)

(A) Young adult with inconsistent crease and asymmetry; parallel right eyelid crease, nasally tapered shape over left eye.
(B) Patient chose higher than average crease height and parallel shape.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 123

CASE 7 (Figure 13-7 A–C)

(A) Young man with absent crease, slightly triangular fissure on right eye, with a shielded look bilaterally. (B, C) Formation of
a natural nasally tapered crease; the medial canthal fold is preserved.

C
124 Asian Blepharoplasty and the Eyelid Crease

CASE 8 (Figure 13-8 A, B)

(A) Young man with absent crease on left eyelid. (B) Postoperative appearance: creation of a matching crease for the left
upper lid.

CASE 9 (Figure 13-9 A, B)

(A) Young man with absent crease and narrow palpebral fissure. (B) Postoperative appearance: creation of a parallel crease.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 125

CASE 10 (Figure 13-10 A, B)

(A) Young man with absent crease and slightly rectangular look. The eyelid is not droopy (eye muscle healthy, no ptosis).
(B) Postoperative appearance: creation of a low parallel crease; at one month postoperative, with some healing to go.

B
126 Asian Blepharoplasty and the Eyelid Crease

CASE 11 (Figure 13-11 A, B)

25 y.o. female for primary Asian blepharoplasty with asymmetry in eyelid opening sizes. Pre- and postoperative appearance.

CASE 12 (Figure 13-12 A, B)

41 y.o. male. Pre- and postoperative appearance.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 127

CASE 13 (Figure 13-13 A, B)

37 y.o. male. Pre- and postoperative appearance.

CASE 14 (Figure 13-14 A, B)

19 y.o. male. Pre- and postoperative appearance: lowering of right crease and addition of crease to LUL.

B
128 Asian Blepharoplasty and the Eyelid Crease

CASE 15 (Figure 13-15 A, B)

27 y.o. female. Desires parallel crease. (A) Preoperative and (B) postoperative 10 days after.

CASE 16 (Figure 13-16 A, B)

27 y.o. female. Desires parallel-shaped crease. Levator excursion of 13 mm right eye and 14 mm left eye was unchanged after
the procedure. Pre- and postoperative appearance.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 129

CASE 17 (Figure 13-17 A, B)

28 y.o. female Caucasian with Asian features and heavy lids. Pre- and postoperative appearance.

CASE 18 (Figure 13-18 A, B)

46 y.o. female. Pre- and postoperative appearance at one week only.

B
130 Asian Blepharoplasty and the Eyelid Crease

CASE 19 (Figure 13-19 A–D)

24 y.o. female with right eyelid multiple wrinkles; the left side has shielding of a low-set nasally tapered crease. (A, B) Preop-
erative appearance. (C, D) The same patient after the procedure: both sides have a distinct nasally tapered crease.

A B

C D
 13 Primary Asian Blepharoplasty Results (Before and After) 131

CASE 20 (Figure 13-20 A, B)

30 y.o. female. (A) Preoperative appearance and (B) postoperatively after one week, with some residual blood layering over
corners of the lower eyelids, which always resolves.

CASE 21 (Figure 13-21 A, B)

12 y.o. female with abnormally spongy tissues of RUL and absent crease. Surgical correction was performed for medical indi-
cations. Pre- and postoperative photo at one month show some residual fullness of that lid.

B
132 Asian Blepharoplasty and the Eyelid Crease

CASE 22 (Figure 13-22 A, B)

35 y.o. female with wrinkled crease and crease asymmetry. Pre- and postoperative appearance.

CASE 23 (Figure 13-23 A, B)

54 y.o. female. Pre- and postoperative appearance.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 133

CASE 24 (Figure 13-24 A, B)

27 y.o. male with crease asymmetry. Pre- and postoperative appearance.

CASE 25 (Figure 13-25 A, B)

25 y.o. male with absent crease and ptosis of RUL. Pre- and postoperative appearance following Asian blepharoplasty with
ptosis repair, 2 months view.

B
134 Asian Blepharoplasty and the Eyelid Crease

CASE 26 (Figure 13-26 A, B)

33 y.o. female with high crease and asymmetry. She preferred a lower NTC. It was not necessary to perform any ptosis repair.

CASE 27 (Figure 13-27 A, B)

25 y.o. female. Pre- and postoperative appearance.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 135

CASE 28 (Figure 13-28 A, B)

47 y.o. female. Desires parallel crease. Pre- and postoperative at 2 months.

CASE 29 (Figure 13-29 A–D)

34 y.o. female. Preoperative (A) and postoperative (B, C, D) appearance.

A B

C D
136 Asian Blepharoplasty and the Eyelid Crease

CASE 30 (Figure 13-30 A, B)

28 y.o. female. Pre- and postoperative appearance after lid crease enhancement, changing from a nasally tapered to a parallel
crease.

CASE 31 (Figure 13-31 A, B)

63 y.o. female. Pre- and postoperative appearance, with excellent functional and aesthetic improvement.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 137

CASE 32 (Figure 13-32 A, B)

62 y.o. female. Pre- and postoperative appearance, with good functional and cosmetic improvement.

B
138 Asian Blepharoplasty and the Eyelid Crease

CASE 33 (Figure 13-33 A–C)

37 y.o. female. Preoperative (A) and 1 month (B) and 4 months (C) postoperative view.

C
 13 Primary Asian Blepharoplasty Results (Before and After) 139

CASE 34 (Figure 13-34 A, B)

38 y.o. male. Pre- and postoperative appearance.

B
140 Asian Blepharoplasty and the Eyelid Crease

CASE 35 (Figure 13-35A–C)

18 y.o. female. Preoperative (A) and 2 months (B) and 3 years (21 y.o.) (C) postoperative view.

C
 13 Primary Asian Blepharoplasty Results (Before and After) 141

CASE 36 (Figure 13-36 A, B)

75 y.o. female. Pre- and postoperative appearance after upper and lower blepharoplasty.

CASE 37 (Figure 13-37 A, B)

39 y.o. female with triangular-shaped eyelid fissure. Pre- and postoperative view taken at one week.

B
142 Asian Blepharoplasty and the Eyelid Crease

CASE 38 (Figure 13-38 A, B)

41 y.o. female. Pre- and postoperative appearance after bilateral ptosis repair with preservation of crease.

CASE 39 (Figure 13-39 A, B)

32 y.o. female. Pre- and postoperative at 1 month. There were no findings suggestive of ptosis.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 143

CASE 40 (Figure 13-40 A, B)

22 y.o. male. Pre- and postoperative appearance following creation of NTC.

B
144 Asian Blepharoplasty and the Eyelid Crease

CASE 41 (Figure 13-41 A, B)

23 y.o. female, absent crease, smaller fissure OD, 5′0″, prefers parallel crease. Had mild medial canthal fold (A).
I/O: tarsus floppy and measured 6 mm only. Designed 6 mm parallel crease.
RUL had large sheet of amorphous preaponeurotic fat, down to below the superior tarsal border. This was dissected off the
underlying shiny healthy aponeurosis, and excised. Excised larger than usual amount of myocutaneous strip, which appeared
boggy from fatty infiltration of the orbicularis muscle.
Treatment of Medial Canthal Fold
Small redundant ‘dog-ear’ over the medial end of the crease wound is based along the lower border. It was overlapped onto
the upper skin edge and excised appropriately. The two edges are then anchored with 6-0 silk. The bite along the upper skin
edge is exaggerated in terms of the amount of skin taken as well as the depth of the orbicularis that is secured. The knot is
pulled and tied onto the upper side of the wound. It will then heal imperceptibly, as the edges are perfectly aligned and without
tension.
LUL: also excised larger strip of mycocutaneous tissues. Medial dog-ear similarly treated.
(B) One week postoperative appearance.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 145

CASE 42 (Figure 13-42 A, B)

22 y.o. female, intermittent creasing over RUL, LUL never creases and has smaller fissure. Prefers parallel crease with lateral
flare. Levator function OD 9 mm, OS 12–13 mm. 5′3″ (A).
I/O: tarsus 8 mm. Designed minimally tapering parallel crease, plus 2 mm redundancy. Excised moderate amount of
preaponeurotic fat that migrated over the STB, although it was not apparent clinically on preoperative examination. Excised
M/C strip.
(B) One week postoperative appearance.

CASE 43 (Figure 13-43)

34 y.o. female with mild lid retraction. Upper lid margin at superior corneal limbus. Had rudimentary multiple partial lines OU.
Wanted NTC. 5′3″.
I/O: tarsus 9 mm. Used 7 mm and designed NTC, + 2 mm skin. RUL has 3+ fat over lateral 2 3 of lid, LUL 2+ fat lateral 2 3 of
lid. The inferior orbicularis was very vascular over the lateral end of the incision.
146 Asian Blepharoplasty and the Eyelid Crease

CASE 44 (Figure 13-44 A, B)

27 y.o. female, high brows, moderate fat OU, large eyes with OS being larger. 5′7″. Desires NTC.
I/O: designed 6.5 mm NTC OU. Found amorphous fat and preaponeurotic fat close to STB; they were reduced. Also excised
a strip of fibroadipose tissue along the anterior aspect of the STB. Formed crease with 6-0 and 7-0 silk.

CASE 45 (Figure 13-45 A, B)

28 y.o. female, absent crease, desires low-set NTC. 5′3″. Had severe brow overaction with some head-tilt backward position
(A).
I/O: tarsus 8 mm. Designed 7.5 mm + 2 mm skin redundancy. Had prominent preaponeurotic fat requiring excision OU. Had
abundant soft, mosaic tissue redundancy along the STB which was excised.
(B) One week postoperative appearance.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 147

CASE 46 (Figure 13-46 A, B)

23 y.o. female, wears lid crease tape constantly for her RUL, and occasionally for LUL. Has hooded shielded skin over lateral
RUL, and incomplete non-joining crease lines over lateral pretarsal area of LUL. Prefers NTC (A).
I/O: tarsus 7.5 mm. Designed 7 mm NTC.
RUL: reduced significant preaponeurotic fat; excised a band of fibroadipose tissue along the STB.
LUL: rechecked drawn crease to ensure it is 7 mm. Same procedure as RUL.
(B) One week postoperative appearance.

CASE 47 (Figure 13-47 A, B)

28 y.o. female, uses lid crease tape and make-up to help crease formation. Pretarsal skin is pink from taping. Desires parallel
crease (A).
I/O: tarsus 8.5 mm. Designed 7.5 mm parallel crease. Preaponeurotic fat appeared fibrotic and inferiorly located. Reduced
with Wetfield bipolar cautery. Mycocutaneous strip, which was very vascular, was excised. The crease may look broader on
one side than the other during the immediate healing period due to hematoma.
(B) One week postoperative appearance.

B
148 Asian Blepharoplasty and the Eyelid Crease

CASE 48 (Figure 13-48 A, B)

25 y.o. male, absent crease. Triangular hooding. Prefers NTC with average crease height. 5′10″ (A).
I/O: tarsus 7.5 mm. Designed 7 mm NTC. There was no preaponeurotic fat. Cleared preaponeurotic platform. Formed crease.
(B) One week postoperative appearance.

CASE 49 (Figure 13-49 A, B)

35 y.o. female, upper lid hooding with shielded NTC. Desired a more prominent crease. 5′5″.
I/O: tarsus 7.5 mm. Designed same 7.5 mm NTC + 2 mm skin. (Beware of tendency of right-handed surgeon or right-eye
dominant individual to mark the LUL crease’s lateral extent shorter than it should be. Always compare both sides.)

B
 13 Primary Asian Blepharoplasty Results (Before and After) 149

CASE 50 (Figure 13-50 A, B)

18 y.o. female, absent crease with mild ptosis, more over the left side. Desires standard height NTC. 5′3″.
I/O: tarsus 8 mm. Designed 7.5 mm NTC. Removed fraction of fat. Had to lyse some adhesion between the inferior skin
edge and orbicularis to the aponeurosis along the STB, in order to better place the 6-0 silk.
LUL: medial canthal dog-ear treated with direct excision of inferior dog-ear and supraplacement of suture knot.

CASE 51 (Figure 13-51)

21 y.o. female, absent crease, with medial canthal fold. Prefers parallel crease with average height.
I/O: tarsus 7 mm. Designed 7 mm parallel crease. Large amount of inferiorly migrated preaponeurotic fat was reduced with
bipolar cautery. Large roll of subcutaneous intraorbicularis fat along the STB was excised. Used multiple 6-0 interrupted sutures
to enhance crease construction.
150 Asian Blepharoplasty and the Eyelid Crease

CASE 52 (Figure 13-52 A, B)

26 y.o. female, RUL has no crease, LUL has a shallow low pseudo-crease line at 3 mm from lashes. 5′4″. Desires NTC (A).
I/O: tarsus 7 mm. Designed 7 mm NTC + 2 mm skin. Partial excision of preaponeurotic fat OU.
(B) RUL formed crease well.
LUL medial half required additional reinforcement with 6-0 interrupted sutures.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 151

CASE 53 (Figure 13-53 A, B)

19 y.o. female, uses glue over pretarsal skin for crease formation. Heavily hooded lid with fat. 5′5″. Prefers NTC (A).
I/O: tarsus 7.5 mm. Designed 7 mm NTC OU + 2 mm skin. Used beveled approach to orbital septum.
RUL had abundant fat which required partial excision. Formed crease at 7 mm.
LUL: also excised part of fat. The crease thus formed appeared shifted down to 6.5 mm. This could be due to different
amount of fat excision between the two sides, and the subsequent change in skin tension as fat has been reduced.
(B) One week postoperative appearance.

CASE 54 (Figure 13-54)

30 y.o. female, absent crease OU. Prefers NTC with standard height. 5′7″.
I/O: tarsus 8 mm. Used 7 mm to draw NTC + 3 mm skin. No fat was removed. The orbital septum was observed to be fused
to the levator aponeurosis in a very ill-defined manner. Had to delineate the STB by using the cutting cautery to create a ‘mini-
trough’ over and along the STB, then attached multiple 6-0 fixation sutures. Worked well.
152 Asian Blepharoplasty and the Eyelid Crease

CASE 55 (Figure 13-55 A–C)

24 y.o. female, 5′2″. Previous Asian crease procedure by this author. (A) Preoperative appearance.
LUL has a residual skin fold above the original crease incision, which gives the appearance of two crease lines.
(B) Appearance following first procedure.
Revision I/O: tarsus 7 mm. Designed 7 mm NTC and included 1.5 mm skin-scar. Beveled approach along the upper edge
toward the preaponeurotic space. Found preaponeurotic fat, which appeared almost untouched, though I knew I had partially
excised it before. Excised M/C strip and some redundant fibroadipose tissue along the STB. Formed crease. (C) Postoperative
appearance following revision enhancement of left upper lid.

C
 13 Primary Asian Blepharoplasty Results (Before and After) 153

CASE 56 (Figure 13-56 A–C)

35 y.o. male, heavy eyelid with fat bulge. Hooding appears to cover 4 mm of cornea, but lid margin is actually 2 mm on to
cornea. 5′5″. Prefers NTC (A).
I/O: tarsus 9.0 mm. During the first procedure I used 7 mm to design NTC. Thick skin with amorphous orbicularis, orbital
septum and very little preaponeurotic fat. Formed crease with 6-0 silk and 7-0 silk.
(B) RUL crease obliterated at 6 months and required enhancement.
I/O (revision): boggy lid tissue with amorphous infiltrated fat over the preaponeurotic space as well as within levator itself.
These were left untouched. Excised M/C strip that included scarred tissues; created mini-trough along the STB. Formed crease
with 6-0 and 7-0 sutures. (C) One week postoperative appearance.

C
154 Asian Blepharoplasty and the Eyelid Crease

CASE 57 (Figure 13-57 A, B)

23 y.o. female, uses nail file to manipulate eyelid skin to form crease. Multiple rudimentary crease lines. Prefers parallel crease
on her highest crease line.
I/O: tarsus 7 mm. Designed 7.5 mm parallel crease + 2.5 mm skin redundancy. Little fat. Excised M/C strip. Formed crease.

B
 13 Primary Asian Blepharoplasty Results (Before and After) 155

CASE 58 (Figure 13-58 A, B)

34 y.o. female, Chinese/Hawaiian, 5′4″. RUL has hooded NTC. LUL has sulcus above multiple rudimentary creases. Very tanned
skin (A).
I/O: tarsus 6.5–7 mm.
RUL included 2 mm skin, LUL + 3 mm skin. Has very thin skin, very vascular orbicularis. Both sides had very little preaponeu-
rotic fat and appeared bound down; these were released and repositioned superiorly. Good crease formation.
(B) Postoperative appearance (patient wearing colored contact lenses).

CASE 59 (Figure 13-59)

30 y.o. female, has no crease RUL, LUL has occasional crease. Prefers above average parallel crease OU.
I/O: tarsus 8.5 mm. Designed 7.5 mm (7 + 0.5) parallel crease line with 2 mm skin.
RUL: preaponeurotic fat very soft, repositioned superiorly. Orbicularis was vascular. Excised M/C strip.
LUL: preaponeurotic fat plastered down over lateral half of aponeurosis; vascular and therefore left alone.
156 Asian Blepharoplasty and the Eyelid Crease

CASE 60 (Figure 13-60 A, B)

22 y.o. female, 5′7″. She had a single lid up until 16 y.o. Now has incomplete or partial creases. Used tape daily (A).
I/O: tarsus 7.5 mm. Designed 8 mm parallel crease as the lid was edematous from xylocaine. Included 2 mm skin in M/C
strip. Orbicularis was very spongy and vascular. Used superiorly beveled approach through septum. The preaponeurotic fat
appeared bound down over the lateral half. This was released and repositioned superiorly. Excised M/C strip and inferior
orbicularis edge of right side. Formed crease.
(B) One week postoperative appearance.

CASE 61 (Figure 13-61)

22 y.o. male, absent crease OU. Left fissure appears larger than right. Desired low-set parallel crease.
I/O: tarsus 8.5 mm. Used 7 mm design for parallel crease. Very vascular over orbicularis. Little preaponeurotic fat. Excised
M/C flap but did not vigorously debulk preaponeurotic platform. Used eight 6-0 silk sutures for crease construction, plus 7-0
silk running stitch.
 13 Primary Asian Blepharoplasty Results (Before and After) 157

CASE 62 (Figure 13-62 A, B)

31 y.o. male, absent crease. Heavy lids, large face. 5′10″ (A).
I/O: tarsus 8.5 mm. Designed 7 mm parallel crease. Skin very thin and stretched; orbicularis was vascular, with fibromosaic
preaponeurotic fat plastered down. Excised around 3.5 mm M/C strip. Crease formed well.
(B) One week postoperative appearance.

CASE 63 (Figure 13-63 A, B)

31 y.o. female, absent crease. 5′2″. Prefers average height NTC.
I/O: tarsus 7.5 mm. Designed 7.5 mm NTC + 2 mm skin. Observed inferiorly migrated preaponeurotic fat that was bound
down. Released and repositioned into superior sulcus. Excised M/C strip. Formed crease.
(B) One week postoperative appearance.

B

SUBOPTIMAL FACTORS
The revision of suboptimal results is a necessary part of
any surgeon’s skills. Known factors that lead to subopti-
mal results include inaccurate placement of the crease
incision, the use of reactive suture materials, excessive
bleeding, excessive fat removal, inadequate or excessively
tight wound closure, inappropriate technique and lack of
knowledge on the part of the surgeon (Figure 14-1).
There are often intangible factors that may be beyond
the control of the surgeon. Examples are the patient’s lack
of compliance with postoperative wound care instruc-
tions; overly vigorous physical exercises performed too
soon after the procedure, resulting in prolonged edema
of the eyelid margin; latent hypertension with rebleeding;
C
FIGURE 14-1 ■ Examples of asymmetry.
CHAPTER 14
weight gain; unpredictable wound healing in patients
who have had multiple prior revisions; obsession on the
part of patients who are not happy with the results even
though the results are satisfactory; or unrealistic precon-
ceived notions on the part of patients about what they
expect the crease to do for them, such as launching a
career in a certain field.
Assuming the physician is knowledgeable and capable,
deviations from an ideal course may still occur inadvert-
ently or even unnoticed, arising from an unusual coincid-
ing of an event relating to the patient and an event
relating to the physician. Suboptimal results may there-
fore occur even with the very best surgeon.
159
160 Asian Blepharoplasty and the Eyelid Crease
A physician may not be aware that the patient has
anemia, or a low platelet count, or poor coagulative func-
tion, was on aspirin therapy, or was consuming herbal
remedies. During surgery, intraoperative bleeding may
thus be significant and disruptive. This requires extra
countermeasures using unipolar or bipolar cautery. Under
local anesthesia that same patient may become even more
anxious and the blood pressure may escalate, resulting in
the formation of a hematoma. Cautery and aggressive
manipulation to reach the source of the bleeding blood
vessel often results in postoperative ptosis. This further
compromises the ability of the eyelid to form the desired
crease. Swelling of tissue planes can result in unevenness
of the crease, resembling the segmentation seen in bamboo,
or crease asymmetry between the two sides. It may even
cause an incision line to appear crooked, even though the
surgeon has perfectly stable hands. An overly anxious
patient may suddenly become claustrophobic and move
during a critical part of the incision or excision process,
resulting in a less than ideal outcome. The Asian blepha-
roplasty procedure requires total concentration, and even
a friendly and talkative patient or innocent questions from
staff in the operating theater may distract the surgeon.
There are other scenarios when physicians have abso-
lutely nothing to do with the untoward outcome of par-
ticular cases, for example:
• A slender young woman underwent successful Asian
blepharoplasty. She was happy, and upon recovery
from her borderline anorexia nervosa apparently
gained 30 lb. The crease on one side of the eye
became obliterated, requiring an enhancement pro-
cedure with further excision of her newly gained
preseptal fat pads.
• A dentist had undergone successful Asian blepharo-
plasty. Six months postoperatively the crease looked
excellent. While camping in the wild for a week he
was bitten over the lid margin by an unknown
insect. That upper lid crease became shallow and
the pretarsal tissues broadened, resulting in a higher
crease on that eyelid. It required a revision to reset
the crease to a lower level.
• A 30-year-old lawyer developed erysipelas during
the latter half of the first week after surgery. Both
creases turned red and the pretarsal segment became
wider, accompanied by scaly eruptions over the
cheek skin area. A systemic oral antibiotic was used
and the infection promptly subsided.
These varied cases reveal why I now hesitate to use
the term ‘complication’ in Asian eyelid surgery. The term
‘suboptimal result’ is more appropriate; and it may at
times follow an otherwise properly performed technique.
We think of complications in medicine and surgery being
more related to serious illnesses, with often known risk
factors (age, disease conditions, vascular status, tolerance
for anesthesia, etc.) in the individual pre-existing and
subsequently complicating a procedure’s outcome. This
is less clear in aesthetic upper lid surgery, especially in
Asian eyelid surgery, where there may not have been
any significant hemorrhage nor risk factors, but simply
because the interrelation of various factors (which we will
go into in further detail in later chapters and videos) may
be so complex as to defy detection preoperatively by a
specialty physician. It is difficult to say whether a lack of
attention to certain findings may have led to the outcome
if it turned out to be suboptimal. Observation, detection
and appropriate execution to maximize the probability of
successful outcome is always a persistent goal.
In my clinical practice, I continue to be consulted by
referred patients who seek a second opinion after having
undergone seemingly straight-forward procedures else-
where, and who are unhappy about their outcome.
The detailed discussion that follows almost always
returns to some aspect of the patient–doctor interaction
where certain aspects of the surgery or results were
assumed, missed, not discussed or misinterpreted. This
ranges from the type of anesthesia one should expect, to
discomfort level or excessive swelling all the way to sig-
nificant issues such as selection of crease height.
Invariably, we return to the four parameters that are
most important: the height, the shape, whether it remains
as a continuous crease line and whether it lasts perma-
nently (Figure 14-2).
HEIGHT
The crease may be placed too high or too low, each pre-
senting unique problems. A high crease is often seen in
conjunction with overzealous removal of preaponeurotic
fat pads. It results in a high supratarsal sulcus or a
‘famined’ look that is difficult to correct (Figure 14-3).
For a patient who has a slight hollow below the superior
orbital rim preoperatively, the removal of preaponeurotic
fat may give rise to a prominent supratarsal sulcus and
the formation of multiple skin folds over the high crease
(Figure 14-4). In this situation the removal of more skin
to eliminate these folds without addressing the problem
of the sulcus usually leads to an even greater degree of
deformity.
A crease that is placed higher than it should will often
lead to a noticeably prominent skin segment in the pre-
tarsal zone, often with side effects involving motility
impairment of the levator besides aesthetic imbalance
(covered in detail in Advanced: Chapter 21).
A crease that is placed too low in a physiologically
inconsistent location, will not support a crease that can
adequately fold in. One would have created a potential
surgical scar in the pretarsal region; and if one is fortu-
nate, it may fade with healing.
One of the common factors in a suboptimal outcome
involves excessive fat excision in patients who are suscep-
tible to volume deficit. Excess fat removal results in
deficit in the volume of the sulcus. Often the surgeon
ends up placing the crease stitches high over the levator
aponeurosis and this crease ends up merging into the
deepened sulcus.
 14 Suboptimal Factors 161

Shape

Height Continuity

Permanence

FIGURE 14-2 ■ Interrelated parameters that determine a normal crease as well as suboptimal results.

FIGURE 14-3 ■ Hollow sulcus as a result of excessive removal of preaponeurotic fat.

162 Asian Blepharoplasty and the Eyelid Crease

B
FIGURE 14-4 ■ Formation of multiple creases and false folds as a result of excessive fat removal.

FIGURE 14-5 ■ A high crease of semilunar shape.
Figure 14-5 illustrates a commonly encountered clini-
cal situation where a high crease is placed, often of a
semilunar shape. If there are skin remnants left that are
still pliable, correction can proceed through resetting the
crease into a parallel crease of lowered height. More chal-
lenging will be trying to achieve conversion to a nasally
tapered crease (dotted line-and-arrow in the figure).
Precise placement of the central crease height is para-
mount in designing the parallel crease or nasally tapered
crease, and avoidance of a semilunar shape.
Asymmetry in crease height can occur even if the
surgeon had measured the crease on each side, since
tissue turgor may change with injection, incision, and
bleeding during and after the procedure when the patient
has been discharged home. Variance in crease height
could be part of the normal postoperative course and may
not be predictive of outcome. Maneuvers during surgery
can result in one side having slightly more tissues removed
and this can also result in asymmetry.
SHAPE
The face may appear incongruous if a semilunar (half-
moon) crease is applied to an Asian eyelid (Figure 14-6).
In operations to produce a nasally tapered crease in
14 Suboptimal Factors 163
Parallel crease
Nasally tapered crease
High or semilunar crease
*
the eyes of patients who have a small medial upper lid
fold, if the medial extent of the crease was not
deliberately tailored to merge under the web and has
come to be located above it, the result may be an
upper-bifid crease above the medial end of the proper
crease (Figure 14-7). If the medial portion of the crease
is overly tapered down and has come to be located infe-
rior to the medial upper lid fold, a rare lower-bifid crease
is seen. The author has seen patients in whom the lateral
portion of a crease was flared up excessively from the
lateral canthus, encroaching on the thicker dermis of the
eyebrow area. A ‘lateral flare’ should be avoided since
there are no real levator aponeurotic fibers there to attach
the skin to.
One of the greatest dissatisfactions is when the patient
ends up with a semilunar crease. The crease here is widest
in the middle and tapers towards each corner. This Cau-
casian half-moon crease shape is simply incongruous in
an Asian eye. It tends to give a ptotic looking upper lid,
as well as a more than usually swollen pretarsal segment.
Dissatisfaction about crease shape may occur if neither
surgeon nor patient had discussed it beforehand. The
choice of crease shape should have a major input from an
informed patient. If he or she is not familiar with this
aspect, the physician should step in and discuss the pros
and cons of each shape category. Ultimately, however, it
164 Asian Blepharoplasty and the Eyelid Crease

FIGURE 14-6 ■ Excessively high semilunar crease.

FIGURE 14-7 ■ Upper bifid crease 1 month postoperatively. With time and resolution of tissue edema the bifid crease may merge
into the medial upper lid fold.

should still be down to the patient to state their
preferences.
In suture methods (see Figure 14-8) the indented
crease results from compressing skin towards the levator,
and this crease is seen with the eyelid opened as well as
when the eyelid is looking down or closed. There is a
shortening effect on the levator due to the superior–
posterior passages of buried sutures, like a plicating
stitch, which explains the often noticeable widened eyelid
opening and slight stare, with some discomfort on the
part of the patient; while the horizontal passages crimp
the horizontal band width of the levator, perhaps weaken-
ing its capability.
The net long-term effect of these sutures is often
a decrease in levator excursion as well as strength,
manifesting as mild secondary ptosis and/or lagophthal-
mos. Interestingly, in cases where the sutures are
tied very tight and eventually lose their intended effect
due to cheese-wiring through eyelid tissues, the restric-
tive effect may be lessened somewhat, though the func-
tional impairment may be more permanent in some
patients.
Figure 14-9 shows high crease placement of three
buried permanent sutures, in the range of 10–12 mm
from the lid margin, with obvious bumps on the eyelid
when the lid is looking downward or closed.
Too high (incorrect incision marking, suture placement, edema) Shape

Asymmetry
Excessive fat removal (high sulcus)
Exaggerated lateral flare

Too low Bifid

Semilunar crease

Height Continuity

Multiple creases

Fading of medial 1/3 crease

Fragmented crease (discontinuous)

Downward shifting
Shallow crease

Partial or complete obliteration

Permanence

FIGURE 14-8 ■ Circle of suboptimal parameters, etiology and interrelatedness.

14 Suboptimal Factors
165
166 Asian Blepharoplasty and the Eyelid Crease
FIGURE 14-9 ■ High crease placement of three buried permanent sutures, in the range of 10–12 mm from the lid margin, with obvious
bumps on the eyelid when the lid is looking downward or closed.
Figure 14-10 shows a suture ligation method, typically
using three sets of a double-armed 5-0 or 6-0 nylon
suture.
The first passage (1 in diagram) involves everting the
upper lid margin and passing it subconjunctivally for a
couple of millimeters, at a level typically several milli­
meters above the superior tarsal border (A′–B′). The
second passage (2) directs one needle towards the skin
side, aiming just along the upper border of the tarsus
(B′–B). Similarly for the other arm of the suture, the third
passage (3) goes from A′–A. If the two ends on the skin
side are tied on the skin at this point, it will be a full-
thickness compression ligature encompassing Müller’s
muscle, levator aponeurosis, as well as orbicularis oculi
muscle in a posterior–superiorly biased fashion. It also
inadvertently creates a Faden-like effect (see Chapter 21)
axially at each of the two locations of B′–B and A′–A, and
a horizontal contracture of the width of levator aponeu-
rosis at A′–B′. In fact, the second needle exiting the skin
at A is re-passed (4) subcutaneously across to join B,
exiting at a small surgical opening there (A–B). There are
therefore two horizontal contracture points along the
transverse axis of the levator, A′–B′ and A–B. The nylon
ends are ‘firmly’ tied and the knot sinks into the small
surgical opening. Traditionally the suture method uses
three sets of these sutures: medial, central and lateral.
Functionally, a Faden (impairing) effect has been created
at six locations vertically along the functional axis of
levator muscle, and six horizontal segments of the levator
(A′–B′ and A–B) are inadvertently narrowed.
See the demonstration video clip in Chapter 21
showing the dampening effect of placement of three
higher-anchoring stitches.
CONTINUITY AND PERMANENCE
Continuity refers to the smoothness and evenly distrib-
uted depth of the crease formed from surgery. Sometimes
a crease that appears deep-set at the appropriate height
may degrade or shallow with time. This may occur over
a portion of the crease or in its entirety. The crease may
become truncated in appearance or only partially present.
The sutures method often results in creases that fade due
to the tendency for a buried suture to relax its indentation
with time, perhaps through a cheese-wiring effect or
inability to overcome the thickness of the redundant skin,
orbicularis muscle and fat without any precise reduction.
A crease is fragmented when a section of it is missing.
There are times when the entire crease disappears with
the suture ligation methods as well as the external inci-
sion methods, though more often we still see remnants
of the buried sutures with the suture methods.
Problems associated with continuity are linked to per-
manence in the following way. If the crease is not well
connected to its underlying aponeurosis in a continuous
manner, it may present as a discontinuous or broken
crease and become evident soon after the operation. A
continuous crease may be well formed initially but then
became obliterated, resulting in a shallow crease or no
crease at all – in essence a non-permanent crease; or the
crease may break apart later in a segmental manner,
becoming discontinuous but permanent (Figure 14-11).
The incidence of crease disappearance appears to be
higher when the suture ligation methods are used.
Patients who have multiple creases often have had
more than one operation. The multiple creases arise from
unpredictable scar formation after reoperations, and
from an excessive degree of dissection in the pretarsal
region of the upper eyelid (Figure 14-12).
As with any aspect of medicine, a procedure should
withstand the test of time, in this case for several years at
the least. Permanence refers to the preservation of a
crease over time. Often a subtle downward shift may be
seen. There are several factors that can result in this. One
is the gradual relaxation of the crease attachment if the
levator aponeurotic attachment to the skin is not strong
enough, or the buried sutures may fail. The crease may
 14 Suboptimal Factors 167

B’ 1 A’

2 3

B 4 A

Levator
Müller's muscle
Conjunctiva

FIGURE 14-10 ■ Suture ligation method. For details, see text.

168 Asian Blepharoplasty and the Eyelid Crease

FIGURE 14-11 ■ Lid crease placement by the external incision method. The right upper crease covers about 80% of the width of the
lid. The left lid crease has become obliterated.

FIGURE 14-12 ■ Postoperative formation of multiple creases over the pretarsal region of the left upper lid. The most likely cause of
this suboptimal result is vigorous surgical maneuvering in the pretarsal region.

appear to have shifted down after initial postoperative
edema has subsided, to reveal a lower-than-normal
attachment. It may appear shifted downward through
interposition of residual pretarsal fat along the superior
tarsal border. Sometimes excessive hemorrhage during
surgery or postoperatively can lead to delayed resolution
of swelling and this can partially undo an otherwise well-
placed crease set.
The medial one-third of the crease is more challeng-
ing to construct in that the anatomy there works against
any attempt to form an even crease for some patients.
The medial segment of the levator aponeurosis may be
sparing or fibrous in nature, making it difficult to attach
any aponeurotic fixation sutures there. It may have less
than adequate upward vector or lack any slip-slide (nano-
ball action, see Chapter 23) between the anterior and
posterior layers of the lid.
The two vectors, lifting of the levator and relaxing
of the orbicularis layer, are not moving in opposite,
180-degree phases here. The medial upper lid fold
may be prominent and require partial reduction in order
to fold in the skin nicely. Interestingly, the patient
may complain that the inner portion (medial one-third)
of the crease is ‘too high’, when in fact the crease is fading
there.
A lack of precise control of the crease height can lead
to a change in shape. A lack of control of shape can lead
to asymmetry as well as inaccurate depth and location
placement, both of which factors can lead to discontinu-
ity. A lack of continuity obviously contributes to failure
to achieve permanence. A lack of permanence is accom-
panied by fading of the crease, frank disappearance or
shrinkage of the crease downward. The circularity of
these linked factors is intriguing.

REVISION PARAMETERS
THE CIRCLE OF SUBOPTIMAL
PARAMETERS, ETIOLOGY AND
INTERRELATEDNESS
Of all the parameters that influence the outcome of
surgery, perhaps the single most important factor will be
the height of the crease, as drawn from the mid-ciliary
margin. The crease should be designed based on the
central height of the tarsal plate, and no higher. In Asians
this is often between 6.5 and 7.5 mm. When designed in
this range, the crease often proves natural in appearance
and well formed. When designed above the measured
height of the tarsus, the result is often a crease that is
unnatural in appearance, restrictive in upgaze and associ-
ated with increased lymphedema in the pretarsal region,
manifesting as a ‘fat’ eyelid border. A crease that is
designed lower than the lowest range of normal will often
lead to a scar in the pretarsal skin region which is hard
to camouflage, or the lymphatic stasis and eventual reso-
lution lead to multiple creases and folds (see Figure 15-1).
Next in importance is the shape of the crease design,
i.e. nasally tapered or parallel. The nasally tapered crease
is popular and compatible with almost any Asian ethnic-
ity. Its distinctive feature is a gradual convergence towards
the medial canthus, and it converges on and joins the
medial canthal angle. As it courses medially, the indented
Too high (incorrect incision
marking, suture placement, edema)
Excessive fat removal (high sulcus)
Too low
Height
Multiple creases
Fading of medial 1/3 crease
Downward shifting
Permanence
FIGURE 15-1 ■ Circle of suboptimal parameters, etiology and interrelatedness.
CHAPTER 15
crease would join and merge towards any mild medial
canthal fold the patient may already have. The nasally
tapered crease seems more prevalent in southern Chinese,
as well as in south-eastern ethnic groups such as Malay-
sians, Thais, Vietnamese and Cambodians. The parallel
crease is more often seen in northern Chinese as well as
northern Asians. The crease is uniform in width as it
arches from one corner of the lid to the other. It appears
to be aesthetically more compatible for someone with
larger facial features, a more rectangular or squarish face,
or someone who is tall and hence has a proportionately
larger face. The parallel crease may be observed among
southern Asians and the nasally tapered crease may like-
wise be seen in northerners.
If a crease is designed with the correct shape but with
a height above the normal range, it becomes conspicuous
and artificial in appearance. When a crease is designed
without following the normal geometric contour for that
particular crease shape, again one has the impression of
artificiality, for example a crease that flares up medially,
or one that converges laterally (both opposite to what
may normally occur in those locations). This applies
when one is comparing the symmetry of design between
two eyelids: again, it would be less than ideal to have a
crease shape on one side that differs from what is on the
opposite side (although in the overall picture this is far
less suboptimal than other outcomes). There are times
Shape
Asymmetry
Exaggerated lateral flare
Bifid
Semilunar crease
Continuity
Fragmented crease (discontinuous)
Shallow crease
Partial or complete obliteration
169
170 Asian Blepharoplasty and the Eyelid Crease

when a surgeon finds that a semicircular crease is created to see revision attempts aimed at the excision of multiple
unintentionally on one side. This can be revised back to folds or a high crease lead to severe skin shortage, lagoph-
the desired shape at the appropriate time, provided there thalmos and corneal exposure. Likewise, injection of free
are some skin reserves to work with. fat grafts may lead to mechanical ptosis, hypertrophy of
During the design as well as the construction phase of injected fat, or lumpy fat grafts. Acquired ptosis is a
the crease, and especially for a nasally tapered crease, if common sequela following revision attempts and can be
the surgeon does not steer the medial end towards and cicatricial (owing to high crease fixation) or mechanical
to merge with the medial canthal fold, then a bifid crease (stiffened preseptal platform) in origin. Scarring in the
can be the result – a crease that splits either above or middle zone and involving the levator muscle can lead to
below the medial canthal fold. both lagophthalmos and ptosis, as well as poor closure of
An artificially high crease incision will naturally lead the palpebral fissure and corneal exposure.
the surgeon to encounter a greater amount of fat in the It is hoped that with knowledge, skill and careful pre-
preaponeurotic space because of its high entry. There is operative discussion, the surgeon can avoid the factors
a chance that the surgeon will then be unknowingly that lead to suboptimal results (as discussed in Chapter
steered towards a greater than normal degree of fat exci- 14). There will, however, always be patients who seek
sion. This leads to: revisions and this chapter will discuss some of the prob-
lems the author has encountered in the treatment of such
1. A more hollowed preseptal region (enhanced supra­ patients, and their solutions.
tarsal sulcus). The revision techniques for the various suboptimal
2. A greater chance of the formation of multiple configurations are discussed below.
creases or folds above the incision wound, in the
preseptal region. There is then a confusing picture
of competing creases, rather than a predominant CREASE ASYMMETRY
and primary crease being formed.
3. A greater chance of a comparatively rigid preseptal By far the most frequently encountered problem is crease
segment of skin–muscle anterior lamella bounded asymmetry. This includes creases that are unequal in
to the posterior lamella. height (Figure 15-2), uneven in shape and continuity,
have undergone shifting (downward migration or partial
It is therefore apparent that excess fat excision has a or complete obliteration of the crease) or have faded in
multiplying and cascading effect in terms of its influence the medial one-third of the lid (Figure 15-3).
on eventual formation of the lid crease. Not only does it
not help in crease formation or the eventual aesthetics of
the upper eyelid, it makes subsequent revision attempts
far more challenging.
Continuity relates to factors in the construction of a
crease: the efforts must be uniform and deliberate, with
varying techniques tailored to the particular terrain across
the width of the eyelid fissure. If the effort should succeed
in most of the length of the crease but fail in a small loca-
tion, the result is a discontinuous or partial crease (or a
partially obliterated crease). The crease may become indis-
tinct, either medially, centrally (less often) or laterally.
Permanence refers to the ideal goal of achieving a
crease that remains for more than 3–5 years. When the
entire crease fades out over a 6-month period it is usually
due to insufficient clearance of the soft tissue corridor
along the preaponeurotic platform, with regression of the FIGURE 15-2 ■ Asymmetric creases (left crease higher than right).
soft tissue barrier, including fat, along the zone where the
crease would ideally form. It can also occur as a result of
an excessively low incision path along the pretarsal plane.
Continuity, therefore, relates more to the overall
effort of crease fixation, assuming the path is already on
the correct level and plane. Permanence includes the
effort made to ensure continuity but relates to long-term
success and the efficacy of a particular method, as applied
to an individual patient.
The challenge is that with any of the factors men-
tioned above and shown in the circle of suboptimal
parameters, each may have a slight imperfection that can
lead to less than perfect results. Aggregation of several
suboptimal factors can pose a greater degree of challenge
when it comes to revision attempts. It is not uncommon FIGURE 15-3 ■ Fading of medial third of left upper lid crease.
 15 Revision Parameters 171

Inequality in Crease Height Repair of a Low Crease

When the crease of one eyelid appears higher than that For patients who have some redundant skin, the best
of the other, often the higher crease is the abnormal one. method is simple excision of the scar associated with the
It is essential to detect any acquired ptosis in that eyelid, low crease, allowing it to heal, and then performing a
because the levator aponeurosis often appears to have subsequent crease procedure a minimum of 6 months
dehisced some of its lower terminal interdigitations later. In my experience, simultaneous revision and con-
and has only a portion of its superior lid crease attach- struction of a new crease often gives suboptimal control
ments remaining (Figure 15-4). Correction of the ptosis of crease height.
eliminates the apparently higher crease without any need When the skin is taut and has no redundancy, simple
to reposition the crease. excision cannot be performed because it may result in
A higher than normal crease can arise from inappro- cicatricial ectropion or a prominent scar (Figure 15-6).
priate marking of the incision lines, from inaccurate An acceptable option for a low crease with a scarcity of
placement of the interrupted crease-forming sutures over skin is complete excision of the crease and the adjacent
the levator aponeurosis, or from persistent edema in the pretarsal skin, replacing them with a full-thickness skin
pretarsal plane. If a crease still appears high 6–9 months graft and reshaping the crease at the same time. This
after the operation, the repair can be accomplished in the procedure is used if the graft covers only the pretarsal
following manner. region. The patient should be forewarned that the crease
will appear high for at least 6 months.
If the skin graft required spans both the pretarsal and
Repair of a High Crease the supratarsal regions, it is best to defer crease recon-
The eyelid is everted and the central height of the tarsus struction for at least 6 months (Figure 15-7).
measured (see Chapter 7). This serves as a reference
point for crease placement. When the tarsal height is
transposed on the skin side and is found to be closer to
the eyelash line than the current crease, the difference in
millimeters of skin can be excised with the previous inci-
sion scar, as long as a shortage of skin does not result
and complete eyelid closure is not compromised
(Figure 15-5). It is helpful to lyse any subcutaneous
aponeurotic attachment along the superior edge of the
incision. Any scar tissue that may overlie the aponeurotic
attachment along the superior tarsal border should be
removed to allow for the construction of the new crease.
If the transcribed tarsal height on the skin side is
higher than the supposedly high crease, one should
examine the contralateral upper lid crease to see if it has
an excessively low crease.

Low Crease
It is more difficult to repair an excessively low crease (one
that is close to the lash margin) than to repair an exces-
sively high one. The correction is tailored to whether
FIGURE 15-5 ■ This patient had a higher than acceptable crease
there is any redundancy of skin. (dotted line); it was corrected by Asian blepharoplasty.

FIGURE 15-4 ■ Acquired ptosis of the right upper eyelid and a

higher crease compared to the left upper lid. The crease asym-
metry is corrected when the underlying ptosis is corrected. FIGURE 15-6 ■ Mild cicatricial retraction and prominent scar.
172 Asian Blepharoplasty and the Eyelid Crease

FIGURE 15-9 ■ Partially shielded and partially obliterated crease

several years after external incision with buried sutures.

FIGURE 15-7 ■ Cicatricial retraction and corneal exposure that

necessitated skin grafting superior to the pretarsal region. Plan
for the formation of a lid crease is deferred for at least 6 months.

FIGURE 15-8 ■ Obliteration of the entire crease over the right

upper lid. FIGURE 15-10 ■ Design of nasally tapered crease. Skin incision
has been made.

Late Obliteration of a Crease

Late obliteration includes a shallow crease, shifting of a
crease, fading of the medial third of a crease and oblitera-
tion of the entire crease (Figure 15-8).

Repair of Late Obliteration

As long as there is some redundant healthy skin with
which to work, the Asian blepharoplasty described in
Chapters 7, 8 and 9 can be performed either partially or
entirely along the width of the eyelid (Figures 15-9 to
15-11). The most common findings at the time of
the operation include excessive subdermal scarring
and inadequate clearance of the underlying orbicularis
oculi muscle, orbital septum, or fat pads (pretarsal or
preaponeurotic) along the junction of the pretarsal region
and the preaponeurotic space (Figure 15-12).
Segmental obliteration results in a discontinuous
crease, which will fare better if it is completely revised. FIGURE 15-11 ■ During the operation, previously placed levator-
It is essential to trim away any underlying platform of to-inferior subcutaneous sutures were an incidental finding.
scar tissue between the skin and the healthy levator
aponeurosis along the superior tarsal border. A patient using at least three interrupted crease-forming sutures
may have an inadequate crease over the medial third over the medial half of the crease (Figure 15-13). It may
(or less) of the upper lid (see Figure 15-3). This problem also require more debulking of the underlying soft tissue
is usually the result of insufficient subdermal attachment in that region to allow for solid subcutaneous aponeurotic
during the first operation, and can be prevented by linkage.

FIGURE 15-12 ■ Platform of redundant tissue along the superior
tarsal border includes skin, orbicularis muscle, scar tissue and
orbital septum.
FIGURE 15-13 ■ Placement of extra interrupted sutures over the
medial half of the incision lines in revision for inadequate crease
formation over the medial third of the eyelid.
15 Revision Parameters 173
MULTIPLE CREASES
Patients may have multiple creases over each eyelid.
These cases can be divided into those who had multiple
faint creases to start with, but end up with several com-
peting and prominent creases, and those who were
without any crease from the beginning.
Postsurgical Creases Competing
with Original Creases
In the first category are patients who may have had
several equally rudimentary creases to start with (Figure
15-14), or who had one noticeable crease with several less
obvious ones that became more prominent after surgery.
In my experience, this problem is seen in patients who
have undergone vigorous dissection in the pretarsal
and preaponeurotic spaces (Figure 15-15), excessive
removal of pretarsal tissues in an attempt to remove all
pretarsal fat, or overzealous removal of preaponeurotic
fat pads. These multiple creases tend to be low and in the
pretarsal region.
Repair of Multiple Creases
The anatomically based method of Asian blepharoplasty
using tarsal height as a guide to crease placement is
still the best way to condense several creases into a rela-
tively more dominant one, provided there is enough
skin with which to work. Frequently, several closely
spaced creases can be completely excised, with good
results (see Figure 15-15). When a patient who presents
with multiple creases has a severe shortage of skin, func-
tional correction of the shortage with a full-thickness skin
graft takes precedence over the aesthetic repair. The
redundant creases may be excised when the skin graft is
performed, and a secondary procedure may be performed
later to produce a single crease.
Postsurgical Multiple Creases in
Patients without an Original Crease
Almost all multiple creases in the eyelids of patients who
did not have a crease to start with result from the exces-
sive removal of preaponeurotic fat pads. These patients
frequently had excessively high placement of their main
crease, and the redundant creases are all high in the
supratarsal region; they are really the interspaces between
multiple folds of skin left after the removal of the
preaponeurotic fat.
Hollow Supratarsal Sulcus with or
without Multiple Creases
An already hollow sulcus may be exaggerated by the
removal of preaponeurotic fat, or a hollow sulcus may
arise iatrogenically because of the operation.
Repair of a Hollow Supratarsal Sulcus
The medical literature contains myriad corrections for a
hollow supratarsal sulcus, including the placement of
174 Asian Blepharoplasty and the Eyelid Crease

FIGURE 15-14 ■ Asian patient with several rudimentary creases.

FIGURE 15-15 ■ A different Asian patient after blepharoplasty with multiple creases in the pretarsal and supratarsal regions of both
lids.

silicone implants and the injection of collagen, silicone
oil or free fat globules in the sulcus. The author has
not found a good, permanent solution to correcting the
problem of excessive removal of preaponeurotic fat. A
dermis–fat graft interspaced in the superior conjunctival
fornix has been used with some success. In my practice,
patients who have a hollow sulcus and multiple folds of
redundant skin are given the option of having the folds
converted into one crease based on tarsal height.
SEMILUNAR CREASE
Patients with a semilunar (half-moon) crease are often
unhappy with the result. The primary surgeon may have
designed the crease on the basis of the traditional blepha-
roplasty technique, placing it in such a way that the great-
est distance between the crease and the lash margin
occurred in the midportion of the eyelid and the ends
tapered down toward each canthus. The result is often a
round-eyed look. It is especially evident in Asians because
they tend to have a narrower eyelid fissure than Cauca-
sians. The same 10 mm separation from crease to lash
line, arching toward each canthus, subtends a greater
angle in Asians than in Caucasians (Figure 15-16), hence
a greater degree of ‘round-eye’. This is the opposite
of what most Asians desire. By contrast, a nasally
tapered crease with a slight lateral flare or a parallel
crease makes the fissure appear wider horizontally,
Semilunar
crease
Caucasian
eyelid fissure
Asian eyelid
fissure
FIGURE 15-16 ■ In Asians, a semilunar crease that
is 10 mm from the ciliary margin gives an undesir-
able round-eyed appearance.
15 Revision Parameters 175
more open-ended and larger in the apparent vertical
dimension.
Repair of a Semilunar Crease
A tarsal height-based technique of Asian blepharoplasty
is preferred, utilizing a crease height of 6.5–8.5 mm, with
a nasally tapered or parallel configuration. An ‘external’
skin incision approach allows accurate placement of
sutures over the aponeurosis and provides greater control
over crease formation.
1. Crease Height 10 mm or Less. If the maximum
height of the crease to be revised is 10 mm or less, the
central 50% of the crease may be moved down in the
following manner:
A. Patients with Some Redundancy of Skin. 6–9
months after the last operation, the central tarsal height
is measured and transcribed on to the eyelid skin. The
segment of skin, usually not more than 2–3 mm wide,
between this preferred crease line and the undesirable
higher semicircular crease is marked. The central 50% of
the semilunar crease is excised, together with the 2 mm
strip of skin between it and the preferred lower crease
(Figure 15-17). This maneuver has the effect of convert-
ing the crease to a nasally tapered configuration.
A mild degree of undermining is performed along the
upper edge of the semilunar crease to free any subcutane-
ous attachment of septum and levator aponeurosis. The
q2
(θ2 > θ1)
A crease height of 10mm subtends
a greater arc-angle θ2 in Asian
q1 eyelid than Caucasian ș1.
The crease-palpebral fissure
complex will therefore be more
rounded.
176 Asian Blepharoplasty and the Eyelid Crease

Semilunar crease; central Preferred crease

height 10 mm or under (nasally tapered or parallel)

Parallel crease

Nasally tapered
crease

FIGURE 15-17 ■ Design of a nasally tapered or parallel crease in the surgical correction of a semilunar crease within 10 mm of the
ciliary margin.

medial 25% of the semilunar crease becomes the nasally Semilunar crease under
tapered portion of the preferred crease. The central 50% 10 mm with skin shortage
is reshaped at a lower level in a parallel continuous crease; Orbicularis oculi
the lateral 25% is excised and revised so that it is either
parallel or flares slightly upward, by deliberately anchor-
ing it higher than it was. This maneuver is facilitated by
undermining of the subcutaneous tissue around the
lateral canthal region. The challenge arises when there is
very little skin between the lateral portion of the semi­
lunar crease and the lateral canthus. I find it effective to
excise the lateral 25% of the crease and to perform a
simple plastic closure. Six months later I perform a lateral
crease revision.
B. Patients with a Shortage of Skin. A semilunar
crease is not easily revised unless the crease, with its FIGURE 15-18 ■ In the surgical correction of a semilunar crease
underlying scar and the skin between it and the desired that is within 10 mm of the ciliary border but in which there is
new crease (based on tarsal height), is completely excised. a skin shortage, the scar line of the semilunar crease and the
A full-thickness graft is used to correct the skin shortage very small segment of pretarsal skin between it and the new
crease must be excised (shaded area).
above the proposed crease and to allow for reconstruction
of the new crease (Figures 15-18, 15-19), which will be
formed at the junction of the pretarsal skin and the margin (Figure 15-20) (see also Figure 1-15 and Chapter
applied skin graft. 1; unnatural, high and harsh (‘uhh’) syndrome). The cor-
rection of this involves working closer to the thick dermis
2. Crease More than 10 mm from Lid Margin. An of the eyebrow, which provides little camouflage and
extremely challenging situation exists when the semilunar increases the risk of hypertrophic scarring.
crease is more than 10 mm from the lid margin. I have A. Patients with Some Redundancy of Skin. On the
seen patients with creases as high as 12–14 mm from the rare occasion when there is some redundant skin in

Full-thickness skin graft
FIGURE 15-19 ■ Full-thickness skin grafting.
Tarsus
FIGURE 15-20 ■ A semilunar crease (solid line) that has been
placed more than 10 mm from the ciliary border, almost halfway
to the eyebrow for an Asian. The dotted line shows the desired
crease, which is based on the central tarsal height. The area
above the high, semilunar crease shows a hollow supratarsal
sulcus (shaded area), from which fat has been aggressively
removed.
conjunction with a highly placed semilunar crease (more
than 10 mm from the ciliary margin), one may try the
same steps as described for patients with a semilunar
crease less than 10 mm (see above).
B. Patients with a Shortage of Skin. Unfortunately,
most patients whose crease is more than 10 mm from the
lid margin have undergone excessive skin removal and
have little left for plastic reconstruction. The repair
requires a full-thickness skin graft (as above), and the
upper edge of the graft will be quite conspicuous (please
refer to Chapter 18).
COMPLETE CREASE REVERSAL
The author’s most challenging operations have been on
the few patients who genuinely wanted their surgically
placed crease completely reversed. For these patients I
15 Revision Parameters 177
have used a variety of methods, some with better results
than others (see Chapter 16, Case 31), and these are rated
by me in the next section.
Effectiveness of Corrective Measures
to Reverse a Crease
Significant Improvement
Significant improvement is achieved with excision of the
crease and scar, and recession of the levator aponeurosis
coupled with placement of autologous temporalis fascia
or fascia lata, or Alloderm (cadaveric dermis).
Some Improvement
Some improvement is achieved with excision of the crease
and scar, with interposition of pedicled orbicularis muscle
fibers to block the aponeurosis–subdermal attachment.
Some improvement is also achieved by excising the
crease and the scar and applying 1 4 ″ sterile adhesive strips
to the sutured skin wound. Patients are encouraged to
avoid looking up during the first week after the operation
to avoid contraction of the levator aponeurosis.
Minimal Improvement
1. Minimal improvement is achieved with excision of
the crease and the scar and the application of trac-
tion sutures inferiorly (reverse Frost sutures).
2. Subcutaneous lysis of adhesions using a small
tenotomy scissors also usually results in minimal
improvement.
SUMMARY OF SOLUTIONS IN
REVISIONAL BLEPHAROPLASTY
As the surgeon acquires expertise, previously unsolvable
suboptimal results can be logically analyzed, much as a
biochemist analyzes the different factors of a complex
reaction. When the different parameters can be clearly
and accurately delineated, it may be possible to formulate
a plan to correct the problem in a harmonious way.
Clearly, the correction should never lead to worsening of
the existing problem.
Figure 15-21 offers a matrix in which the vertical
columns list suboptimal factors that can occur in the area
above the crease, the preseptal (supratarsal) region, and the
horizontal rows list suboptimal factors occurring in the
area below the crease, the pretarsal regions. Since subop-
timal results seldom occur in one zone only, the surgical
solutions listed in each box (cell) show the correction for
the upper preseptal region as well as the lower pretarsal
region, with the crease indicated by the dotted line.
The matrix was first designed about 25 years ago and
was meant to serve as a basic framework for extremely
challenging cases where no other management method
might be available. Towards that goal, it still has its
purpose as a useful guide. Note that the use of a full-
thickness skin graft (FTSG) around the eyelids should
only be attempted by very skilled surgeons.
 178

Preseptal region

Upper
and Cicatrix to
Hollow sulcus Multiple lines Skin shortage Immobile dense skin levator aponeurosis
Lower
solutions

Add fat Lyse adhesions, Beveled revision Beveled revision Correct ptosis
Multiple revise into primary crease + FTSG + FTSG
lines
Revise, reset crease lower Revise, reset crease Revise, reset crease Revise, reset crease Revise, reset crease

Add fat Lyse adhesions, Beveled revision Beveled revision Correct ptosis
Asian Blepharoplasty and the Eyelid Crease

revise into primary crease + FTSG FTSG

Skin
shortage
FTSG FTSG FTSG Pretarsal FTSG FTSG

Add fat Lyse adhesions, Beveled revision Beveled revision Correct ptosis

Pretarsal region
revise into primary crease + FTSG + FTSG
Scarred
platform
Excise, revise Excise, revise Excise Excise, revise Excise, revise
vs FTSG vs FTSG + /-- FTSG vs FTSG vs FTSG

High Add fat Lyse adhesions, Beveled revision Beveled revision Correct ptosis
revise into primary crease + FTSG + FTSG
crease,
edema,
fullness
Revise/reset crease lower Revise/reset crease lower Revise/reset crease lower Revise/reset crease lower Revise/reset crease lower

FIGURE 15-21 ■ Matrix of solutions in revisional blepharoplasty in Asian upper eyelids.


Zone 3
Zone 2
Zone 1
FIGURE 15-22 ■ The three zones – pretarsal
(1), preseptal (2) and periorbital (3).
Figure 15-22 shows the three zones – pretarsal, presep-
tal and periorbital. In the pretarsal zone (Zone 1) close
to the upper lid margin (the rows in the matrix in Figure
15-21), possible deviations include high crease set, excess
skin removal with resultant shortage, excess scar over the
pretarsal platform and multiple wrinkle lines there.
A high crease set can occur from inaccurate marking
of the incision, or use of high anchoring maneuvers that
15 Revision Parameters 179
involve either removable or permanently buried sutures.
Injury to the levator muscle causing a dehiscence of the
levator insertion on the tarsus can give a segmental ptosis
and an apparently higher crease.
Excess pretarsal skin removal usually follows inexperi-
ence or failure to recognize where the crease should be
set, and inadvertently removing too much skin above it
such that when the wound is closed, an eversion of the
180 Asian Blepharoplasty and the Eyelid Crease

B
Restriction on upgaze, poor crease indentation, possible ptosis.

FIGURE 15-23 ■ (A) Eyelid is looking down or at rest (closed). (B) Eyelid is open, looking ahead. Levator is impaired with increased
load.

tarsal plate and margin occurs. This is a challenging
problem, and if not resolved spontaneously will often
require subsequent addition of skin graft.
Excessive dissection in the pretarsal region is associ-
ated with the following two problems: scarring as well as
chronic edema and subsequent formation of multiple
lines. There have been published papers where authors
advocate complete excision of pretarsal subcutaneous
tissues and orbicularis, leaving behind only skin and
tarsus. What follows is often chronic edema. The solu-
tions may involve excision of scar, revision of crease set,
or full-thickness skin graft (FTSG).
In the larger preseptal zone (Zone 2), more danger
awaits. Most often seen associated with a high crease
is excessive fat removal, giving a prominent concave
sulcus or hollowed eyes. Over the last decade the enthu-
siasm for use of fat graft as a means to replenish volume
deficit has been tempered by follow-up reports of unpre-
dictable fibrous hardening and hypertrophy of fat grafts.
Continued advances in the preparation of free fat grafts
have yielded some improvement in maintaining the con-
sistency of the fat grafts, although the incidence of
forming undesirable lumps is still very significant.
Volume augmentation through the use of hyaluronic
acid (Juvederm, Restylane) has been popular; its longevity
has been improved upon with products like Radiesse
(containing calcium-based microspheres), which report-
edly last up to 9–12 months. However, it is my impression
that these products also hamper the biodynamics of the
eyelid through mechanical impedance.
Multiple crease formation can usually be corrected if
there is some skin reserve for revision attempts. Lysis
of adhesion coupled with resetting of tissue planes is
mandatory.
Skin shortage comes from excessive skin removal. It
can result in lagophthalmos on downgaze as well as a
consecutive ptosis.
Skin graft is necessary for vision protection if the skin
shortage is significantly hampering lid closure and the
eye protective mechanism during sleep.
Excessive dissection or rough handling of preseptal
tissues can lead to heightened scarring of the preseptal skin
15 Revision Parameters 181
to the underlying levator. The result is scarring in the glide
zone (preaponeurotic space) resulting in an inability of the
skin to move relative to the underlying levator.
One may see a dense immobile plaque of scar tissue
that sits in the preseptal zone, and it is impossible to pick
up the anterior skin–muscle layer without also lifting the
posterior layer, in essence, the entire eyelid. One sees a
lack of crease indentation as well as ptosis due to a
restricted levator (Figure 15-23). Excision of scar and
replacement with healthy skin graft (for skin shortage),
coupled with release of the levator and its possible repair,
may be made based on intraoperative assessment.
In some cases when applicable, the advanced revision
technique described in Chapter 18 may be used to recruit
skin and reset an abnormally high crease to a lower
position.
These are by no means the only possible complica-
tions one can see. The detailed analysis of each individual
possible combination of solution sets in Figure 15-21
goes well beyond the purpose I envision this basic text is
designed for. It will depend greatly on each candidate’s
unique set of presenting features.
Lysis of adhesions and resetting of crease height
requires knowledge and clinical skills, as with any type
of advanced intervention. Each case will require
careful evaluation, balancing potential gains versus pos-
sible further aggravation of the existing problem, and a
mutual understanding from the patient as to the steps
involved in achieving correction of the problem. Some-
times the solutions may improve on a problem to an
acceptable, comfortable level for the patient. A compre-
hensive discussion as well as informed consent as to the
unpredictability of results from a revisional attempt
should be a good practice routine.
FURTHER READING
Chen WPD. Management of the eyelid crease: advanced techniques.
In: Chen WPD, Khan J. Color atlas of cosmetic oculofacial surgery
(with DVD), 2nd edn. Philadelphia: Elsevier Science/Saunders; 2010:
ch 15.
 CHAPTER 16

REVISIONS IN SUBOPTIMAL CASES

This chapter illustrates various conditions that required between Asian eyelids and those of Caucasians, and the
revision (correction of suboptimal results), all with diversity even among Asians themselves, are what
prior surgery that may have included buried sutures makes Asian eyelid surgery such an interesting and
methods and/or incisional methods. The contrast challenging art.

CASE 1 (Figure 16-1)

Skin blanching following application of local anesthetic in a patient undergoing revision or touch-up correction. The previously
operated skin here is tighter and shows less spreading of the injected solution.

183
184 Asian Blepharoplasty and the Eyelid Crease

CASE 2 (Figure 16-2 A, B)

25 y.o. female who had previous surgery with high crease and shape asymmetry. (A) Before and (B) after revision.

CASE 3 (Figure 16-3 A–C)

22 y.o. female who had crease procedure at age 10. (A) She has trichiasis (in-grown eyelash) of the upper lids.
(B, C) Postoperative view.

A B

C
 16 Revisions in Suboptimal Cases 185

CASE 4 (Figure 16-4 A, B)

32 y.o. male who had buried suture method procedure previously. (A) There is a shielded crease on the RUL and no crease on
the LUL. During revision the crease was reset to 7 mm.
(B) Post-revision photograph.

CASE 5 (Figure 16-5 A, B)

47 y.o. female who had incision method with skin removal. She sought a more noticeable crease height. (A) Before and
(B) following revision.

B
186 Asian Blepharoplasty and the Eyelid Crease

CASE 6 (Figure 16-6 A, B)

23 y.o. female who had four previous procedures. Absent crease in the LUL. Desired a NTC. (A) Before and (B) following
revision.

CASE 7 (Figure 16-7 A, B)

48 y.o. female has ptosis of LUL. (A) Before and (B) after crease revision, combined with ptosis correction of the left eye.

B
 16 Revisions in Suboptimal Cases 187

CASE 8 (Figure 16-8 A, B)

22 y.o. female had incision method. Both sites show spreading of skin scar.

A B

CASE 9 (Figure 16-9 A, B)

45 y.o. female having had buried suture method showing shallowing and duplication of creases of LUL. (A) Before revision
and (B) 7 days following revision bilaterally, with normal swelling.

B
188 Asian Blepharoplasty and the Eyelid Crease

CASE 10 (Figure 16-10 A, B)

55 y.o. female with moderately high crease. (A) Before and (B) following revision to lower the crease on both sides.

B
 16 Revisions in Suboptimal Cases 189

CASE 11 (Figure 16-11 A–C)

Young woman with absence of crease, or very low-set indented crease at the lower section of the pretarsal eyelid skin. Pho-
tographs show fullness of the lid, often seen despite having had buried sutures method 10 years previously.

C
190 Asian Blepharoplasty and the Eyelid Crease

CASE 12 (Figure 16-12 A–D)

(A) 22 y.o. female with high crease, semilunar shape. There are redundant double crease lines, with scarce skin left.
(B, C) The ratio of pretarsal/preseptal is almost 1 : 1.
After revision (D), with the crease reset to a lower position and transition to a parallel shape.

B C

D
 16 Revisions in Suboptimal Cases 191

CASE 13 (Figure 16-13 A, B)

55 y.o. female with high crease: RUL at 9 mm, LUL measured at 10 mm.
(A) Before and (B) following revision to 7 mm crease height. The crease is now less harsh and more natural.

CASE 14 (Figure 16-14 A, B)

Young woman who had a high crease set. (A) Note the aspect ratio between the pretarsal (lower) segment and the preseptal
(upper) segment is almost 1 : 1. There is some acquired ptosis and limitation on upgaze , as well as lagophthalmos.
(B) Two weeks after a revision attempt utilizing the author’s beveled approach and resetting of crease height. The ptosis is
released and the crease height will continue to settle down over the next few months. The aspect ratio has improved between
pretarsal segment and preseptal region. (The patient returned to her overseas residence shortly after.)

B
192 Asian Blepharoplasty and the Eyelid Crease

CASE 15 (Figure 16-15 A, B)

This patient underwent a lid crease procedure. (A) Notice that the crease does not merge into the fold medially. The medial
aspect of the crease overrides the supracanthal fold, resulting in an upper bifid crease.
(B) Higher magnification of RUL.

B
 16 Revisions in Suboptimal Cases 193

CASE 16 (Figure 16-16 A, B)

50 y.o. female with a left seventh nerve palsy who underwent a lid crease procedure. Note the poor closure of her left upper
lid owing to facial paresis and probable mid-lamellar contracture.

CASE 17 (Figure 16-17)

35 y.o. female who has had excessive fat removal high over her supratarsal sulcus. Note the inadequate formation of the lid
crease and the hollow sulcus.
194 Asian Blepharoplasty and the Eyelid Crease

CASE 18 (Figure 16-18 A–C)

Female university student who presented after lid crease placement. (A) She showed a high crease over the left upper lid and
a segmented crease over the medial extent of the right upper lid and scar over the lateral half of the crease. I recommended
enhancement and revision of the right upper crease, and repositioning to a lower level for the left upper crease. She elected
to have only the right lid revised. A tarsal height-based Asian blepharoplasty was performed on the right upper lid, cicatrix
was released from the lateral half (B).
(C) One week postoperative appearance.

C
 16 Revisions in Suboptimal Cases 195

CASE 19 (Figure 16-19)

Incomplete and ‘bifid’ crease: the upper crease did not extend to the medial one-third of the fissure width. The splitting of the
crease is more noticeable over the right upper lid.

CASE 20 (Figure 16-20 A, B)

A patient with asymmetric creases. The right upper lid crease was too close to the lid margin, and is scarred down to the
anterior surface of the upper tarsus. The left upper lid crease is high, harsh and semilunar in shape.

B
196 Asian Blepharoplasty and the Eyelid Crease

CASE 21 (Figure 16-21 A, B)

This patient had an asymmetric crease made more evident by the acquired ptosis of the right upper lid. This is an example of
a static crease.

B
 16 Revisions in Suboptimal Cases 197

CASE 22 (Figure 16-22 A–C)

(A) 30 y.o. female with multiple creases over RUL (with one dominant and several less distinct creases over the medial half) and
multiple indistinct high creases over LUL. (B) Note the enhanced supratarsal sulcus on the LUL, probably due to excessive fat
removal. (C) Correction of the LUL consisted of crease enhancement with excision of the small strip of skin encompassing the
multiple creases. No attempts were made to correct the supratarsal hollow because (a) this is a difficult procedure to perform, and
placement of synthetic fillers frequently leads to complications; and (b) the conversion of several faint lines to a main crease often
creates enough inward folding, especially on upgaze, to make the hollow less noticeable.

CASE 23 (Figure 16-23)

50 y.o. female with high creases, some of which are bifid and multiple.
198 Asian Blepharoplasty and the Eyelid Crease

CASE 24 (Figure 16-24 A–D)

(A) 30 y.o. female who had two lid crease procedures in Asia. She complained that the crease tapered excessively towards the
lateral canthi and of fullness in that area when she smiled. (B) Asian blepharoplasty was performed laterally. Intraoperatively,
scar tissues were excised until the underlying aponeurosis was clearly seen.
(C) Appearance immediately after the procedure.
(D) Appearance 1 month postoperatively. Some residual pretarsal edema can still be seen.

B
 16 Revisions in Suboptimal Cases 199

CASE 24 (Figure 16-24 A–D)—cont’d

D
200 Asian Blepharoplasty and the Eyelid Crease

CASE 25 (Figure 16-25 A–E)

(A, B) 25 y.o. female had undergone placement of a reddish tattoo line in an attempt to form a pseudo-crease over the RUL.
She had minimal ptosis of the same lid.
(C) The tattooed crease line, which measured less than 1 mm wide, was excised. (D) A new crease was formed based on
the author’s technique.
(E) Closure of the wound over the RUL.

B
 16 Revisions in Suboptimal Cases 201

CASE 25 (Figure 16-25 A–E)—cont’d

Continued
202 Asian Blepharoplasty and the Eyelid Crease

CASE 25 (Figure 16-25 A–E)—cont’d

CASE 26 (Figure 16-26)

55 y.o. female with a high, harsh, incomplete crease. The crease spanned only 60% of the width of the fissure.
 16 Revisions in Suboptimal Cases 203

CASE 27 (Figure 16-27 A–C)

(A) This patient had a crease deformity of the RUL due to laceration by broken windshield glass during an automobile accident,
with embedded glass fragments. The LUL had a ‘shielded’ crease. (B, C) Postoperative views after crease revision.

C
204 Asian Blepharoplasty and the Eyelid Crease

CASE 28 (Figure 16-28 A–D)

(A) 28 y.o. female before Asian blepharoplasty.
(B) Immediately after the procedure.
(C) Six months after the operation the patient reported a 30% weight gain (from 90 to 120 lb) and obliteration of the LUL
crease. (D) Surgical exploration of left upper lid showed hypertrophy of the suborbicularis (preseptal) fat pads, which may
have obliterated previous crease-forming attachment.

B
 16 Revisions in Suboptimal Cases 205

CASE 28 (Figure 16-28 A–D)—cont’d

D
206 Asian Blepharoplasty and the Eyelid Crease

CASE 29 (Figure 16-29 A–I)

(A) 19 y.o. female with absence of lid crease. (B) Design of a NTC over the right upper lid. (C) Opening of the orbital septum
and excision of some preaponeurotic fat pads. (D) Eyelid before surgical closure.
(E) Closure with both interrupted and continuous 6-0 nylon. (F) Three months postoperatively the crease appeared shallow
over the RUL, and was incomplete over the lateral portion of the LUL. Retrospectively, the patient related that because of her
anxiety and intolerance to pain she never looked upwards during the first week after the surgery ‘for fear of scarring’. It is
most likely that the surgical adhesions did not form adequately during the first week, as the levator muscle was not actively
contracted in any way. (G) I performed revisional Asian blepharoplasty over the RUL.
(H) Enhancement was performed segmentally over the lateral one-third of the LUL. (I) Appearance immediately after the
operation.

D
 16 Revisions in Suboptimal Cases 207

CASE 29 (Figure 16-29 A–I)—cont’d

I
208 Asian Blepharoplasty and the Eyelid Crease

CASE 30 (Figure 16-30 A–E)

(A) 50 y.o. female had previously undergone blepharoplasty and presented with a high parallel crease and some residual
hooding of the upper lids.
(B) Upper and lower lines of incision during revision: the design of the crease allowed for excision of the area of the previ-
ous crease incision (dotted line outlined with methylene blue ink) to remove some redundant skin and reposition the crease
closer to the lid margin, based on the tarsal height.
(C) The orbital septum was opened superiorly, revealing minimal preaponeurotic fat pads, which I did not remove.
(D) Excision of skin and redundant underlying preseptal orbicularis muscles. The methylene blue tip points to a previously
buried 6-0 Prolene suture that had functioned as a levator aponeurosis–inferior subcutaneous fixation suture. (E) Closure of
the wound following revision.

B
 16 Revisions in Suboptimal Cases 209

CASE 30 (Figure 16-30 A–E)—cont’d

D
210 Asian Blepharoplasty and the Eyelid Crease

CASE 31 (Figure 16-31 A–D)

(A) 35 y.o. male had seen another surgeon for placement of a lid crease. He later wanted the crease removed or lightened.
(B) The creases and the underlying scar tissues on both lids were removed. A persistent crease remained over the lateral half
of the RUL; the LUL appeared satisfactory. A second procedure was carried out 6 months later to release the subdermal
aponeurotic attachment. This resulted in minimal improvement.
(C, D) A year later, I performed a recession of the RUL coupled with placement of autologous temporalis fascia. Although
the crease faded on downgaze , it could be seen on straight-ahead and upgaze.

C D
 16 Revisions in Suboptimal Cases 211

CASE 32 (Figure 16-32 A, B)

23 y.o. female 5 years s/p previous crease procedure done by me. Crease has disappeared. Her height is 5′ 5″. Mild degree of
fat persisted, with small left medial canthal web (A).
I/O: tarsus only 6.5 mm. I used 7 mm to design a NTC. Very soft fluctuant pretarsal and preseptal tissues. Lysed along
superior edge’s cicatrix and orbicularis. Had amorphous inferiorly migrated fibromosaic fat (preseptal fat) which is then repo-
sitioned superiorly. Excised scar and M/C strip.
(B) Postoperative appearance.

B
212 Asian Blepharoplasty and the Eyelid Crease

CASE 33 (Figure 16-33 A, B)

46 y.o. male 2 years s/p removal of upper lid hooding. Has rudimentary crease, low-set and dark incisional line with spreading;
3 mm cornea covered (ptosis). Medial incision line measures only 3 mm from lashes. (A, B) Preoperative appearance.
I/O: designed a single 5 mm parallel incisional line as there was no skin redundancy. Lysed along upper edge of incision
until large amount of preseptal and preaponeurotic (postseptal) fat was seen. Debulked scar along the STB such that a new
crease could form along there.

B
 16 Revisions in Suboptimal Cases 213

CASE 34 (Figure 16-34 A, B)

27 y.o. male 6 years s/p lid crease procedure; has high crease and pretarsal fullness. NTC. Right crease height is 9 mm, left is
11–12 mm. Patient feels irritation of the eyelid when blinking (A).
I/O: tarsus 6 mm. In this revisional attempt for the LUL, 8.5 mm was chosen to mark an NTC and included 2.5 mm as the
amount of skin and scar to be excised. Lysed along the upper incisional edge to reach the preaponeurotic space. Found and
removed two buried stitches. Then excised M/C strip of skin and scar. Reconstructed a shallower NTC.
(B) Appearance at 2 months postoperatively. Patient reported a greater degree of comfort when he blinks.

B
214 Asian Blepharoplasty and the Eyelid Crease

CASE 35 (Figure 16-35)

30-y.o. female with obliterated crease. She had surgery 6 years ago with incisional approach; uses tape daily OU. Has rudi-
mentary crease in RUL; LUL has pigmented incisional spots along medial end of eyelid.
I/O: tarsus 8 mm. Designed 7.5 mm NTC with 1 mm skin, such that the lower incision line was below her previous scar,
and included 1 mm of scarred skin only.
RUL: beveled approach along the upper edge to reach the preaponeurotic fat within the remnants of the preaponeurotic
space. Although I initially reduced the abundant fat partially with bipolar cautery, the crease did not form well owing to its
location along the STB. I reopened the wound and excised the preaponeurotic fat that was along the STB, leaving the upper
half mostly intact. It was only then that the crease formed well. Three buried nylon stitches were removed.
LUL: also included scar excision. Again excised preaponeurotic fat. The central crease fixation suture did not perform well
and was removed; more of the inferior edge tissues were cleared and excised; the 6-0 suture then fixed well, with better crease
formation.

CASE 36 (Figure 16-36 A, B)

20 y.o. female 4 years s/p surgery elsewhere using two-stitch technique from conjunctival side. Has rudimentary crease line.
Small fissures with horizontal palpebral width ~0.75″. 4+ brow action, 3 mm ptosis. Wanted a NTC (A).
I/O: tarsus 8 mm; designed 7 mm NTC + 2 mm skin. Found large infiltrate of fibrous preseptal fat that appeared to have
migrated inferiorly, as well as preaponeurotic fat; both were partially reduced through excision. She had limited upgaze and
therefore crease construction relied exclusively on interrupted sutures.
(B) Two months postoperatively.

B
 16 Revisions in Suboptimal Cases 215

CASE 37 (Figure 16-37)

37 y.o. male 12 years s/p upper blepharoplasty, with first revision done same year to enhance crease. RUL had been revised
by me and was satisfactory. Now desires revision of LUL. Lid has segmentation of medial one-third of crease, with peaking
there. Crease measured 8.5 mm and chronic edema had caused an extra fold of skin to appear, as if hanging over the lateral
portion of the crease.
I/O: scar at ~8.5 mm. I used 7 mm to design a NTC, encompassing his scar in the 1.5 mm of skin–scar tissues. Used superior
beveled approach for this revision to reach the preaponeurotic space. Removed three buried nylon stitches. His voluntary
upgaze then showed good crease formation.

CASE 38 (Figure 16-38 A, B)

Left eye with congenital ptosis in 21 y.o. male who had levator resection 2 years previously. Six months s/p suture technique
OU to form crease. RUL medial end has tapered crease; absent crease over LUL. Left upper lid’s incision line is only 2–3 mm
from lid margin; feels as if lid has resistance and discomfort (A).
I/O: left eye tarsus 8 mm. Designed incision at 7 mm + 1 mm skin. Removed buried 4-0 Mersilene stitch centrally above
STB. Used beveled approach to reach preaponeurotic space. Little fat remains. Excised M/C strip. Used cutting cautery to clear
a small trough along the anterior tarsal surface just inferior to STB. Used crease fixation sutures from skin to tarsus/aponeurosis
and skin.
(B) Appearance 2 months postoperatively.

B
216 Asian Blepharoplasty and the Eyelid Crease

CASE 39 (Figure 16-39 A, B)

42 y.o. female who had upper lid surgery at age 27. Has very high 11–12 mm parallel crease OU. Has slight ptosis, with 2 mm
cornea covered OU (A).
I/O: tarsus 6.5 mm only. Patient had heavily tattooed permanent eyeliner, which measured 2.5 mm in width from the ciliary
margin. Designed crease at 6.5 mm from the upper edge of this permanent eyeliner, therefore at about 9 mm from ciliary
margin, as she did not have any residual skin for an ideal revision. Lysed adhesion through superior incision edge. Released
traction and freed up the levator (‘up-release’) from anterior skin/orbicularis layer; upgaze appeared unrestricted on the operat-
ing table. Preaponeurotic fat OU was left untouched. Excised superficial skin scar, 2 mm strip only; avoided injury to levator
as patient has mild ptosis. Reformed crease. The pretarsal skin has been freed from its attachment to the anchor point of the
previously high crease, therefore it has been ‘down-released’. When the crease is thus reconstructed, it looks better than the
9 mm that was planned and actually measured at about 7.5 mm from the lid margin, or 5 mm from the upper edge of the
permanent eyeliner’s border. It has therefore appeared to migrate from an incisional distance of 6.5 mm from the permanent
eyeliner to now being at 5 mm from the same margin.
(B) Appearance at one week following revision. Patient subsequently informed us that she underwent a brow lift elsewhere
at day 4 following our procedure for her.

B
 16 Revisions in Suboptimal Cases 217

CASE 40 (Figure 16-40 A, B)

60 y.o. female 2 years s/p revisional upper blepharoplasty where injection of abdominal free fat graft to upper lid sulcus was
performed. Now has prominent hypertrophied and permanent rubbery fat over sulcus and along the superior orbital rim of
LUL > RUL, and multiple folds and significant asymmetry (A).
I/O: tarsus 6 mm only. Designed crease with 2 mm skin included for excision. Beveled approach to lyse skin adhesion along
upper edge of incision first, then secondly through orbicularis/orbital septum complex to reach preaponeurotic space. Observed
yellow preaponeurotic fat. Superior to this was consolidated and indurated pale-yellow fat located over the sulcus and anteriorly
along the superior orbital rim. Over the LUL a 10 × 30 mm roll of indurated fat graft was excised. Excised M/C strip. Closed
wound with 6-0 and 7-0 sutures.
RUL: did not remove fat; just excised 2 mm skin to revise the crease.
(B) Appearance at one week postoperative visit.

B
218 Asian Blepharoplasty and the Eyelid Crease

CASE 41 (Figure 16-41)

66 y.o. female 5 years s/p upper and lower blepharoplasty. Complains of incisional scar over lateral portion of LUL incision
that arches towards the lateral canthal angle. Has prominent sulcus.
I/O: beveled approach along upper edge of incision, which was over lateral half of lid only. Levator aponeurosis appears
infiltrated by fat; excised 4 mm of M/C strip. Reformed crease with greater separation from her lateral canthus.
 16 Revisions in Suboptimal Cases 219

CASE 42 (Figure 16-42 A, B)

30 y.o. female s/p upper and lower blepharoplasty. Upper crease incisional scar is high and has spread (with right higher than
left), with medial angulation over LUL; lower lid subciliary incision line too far from lid margin. Desires revision of upper crease
OU and lateral portion of LLL incision line. (A, B) Pre-revisional appearance.
I/O: tarsus 7 mm. Designed 7 mm crease + 1 mm skin/scar tissue medially, and 2 mm skin/scar laterally.
RUL: beveled approach along upper edge, preserved orbicularis. Made mini-trough along the STB. Applied three 6-0 Vicryl
sutures from inferior orbicularis to levator aponeurosis, plus the usual 6-0 interrupted skin–levator–skin sutures as well as 7-0
running suture for skin to skin.
LUL: used only 6-0 interrupted as well as 7-0 running in the usual approach.
LLL: infraciliary approach, excised scar. Tightened inferior limb of lateral canthal ligament by plicating it with 6-0 Vicryl
suture.

B
220 Asian Blepharoplasty and the Eyelid Crease

CASE 43 (Figure 16-43 A–C)

Female patient had surgery 4 years ago and a second time a year prior to being seen.
RUL: deep NTC, converging, with 3 mm ptosis.
LUL: medial bifurcation of crease as it approaches the medial canthal fold.
Levator function: right 12 mm, left 15 mm. Appears esotropic. Height 5′ 0″.
I/O: right upper lid harsh and static 12 mm crease, bound down. Tarsus measured 6 mm. Designed 6 mm NTC. Incision
with No. 15 blade, then used blunt-tipped Westcott spring scissors to lyse adhesions along superior edge until preaponeurotic
fat is seen (no true septum left). Used cutting cautery to remove scar and redundancy along preaponeurotic platform, plus
removal of 8-0 nylon buried sutures that were used for crease formation. Formed crease with 6-0 and 7-0 silk sutures that were
removed after 5 days.
(A, B) Pre-revisional appearance.

C
 16 Revisions in Suboptimal Cases 221

CASE 44 (Figure 16-44 A, B)

Female patient underwent lid crease procedure 7 years ago. RUL: hooded and rudimentary crease. LUL: high crease with bifid
ending at both corners.
I/O: tarsus measured 7 mm. Designed NTC OU.
RUL: removed 2 mm skin and orbicularis. Used scissors to go through upper edge of incision, staying beveled to reach
preaponeurotic plane.
LUL: eliminated bifid crease, removed buried nylon sutures.

B
222 Asian Blepharoplasty and the Eyelid Crease

CASE 45 (Figure 16-45 A, B)

47 y.o. female patient with first surgery 20 years ago coupled with ‘W-plasty’. Then revision 12 years ago.
I/O: observed prominent medial preaponeurotic fat as well as nasal fat pad. Removed fat pads. Use 6-0 Vicryl to fixate
inferior orbicularis to levator and then superior edge of orbicularis; kept suture knot buried.

B
 16 Revisions in Suboptimal Cases 223

CASE 46 (Figure 16-46 A, B)

29 y.o. female. Had surgery at 18 in Korea. Crease appears high OU. RUL appears deep-set. Has moderate fullness over pre-
tarsal area. LUL is more converged medially than RUL.
I/O: tarsus was only 5.5–6 mm. RUL crease measured at 11 mm, LUL at 10 mm. Designed 8.5 mm parallel crease over RUL
with some tapering medially; and 8 mm over LUL in an attempt to equalize two asymmetric high creases. Used blunt scissors
to reach preaponeurotic space superiorly. Large amount of cicatrix over preseptal as well as pretarsal zones. Excised strip of
myocutaneous flap OU. Excised strip of pretarsal inferior orbicularis muscle to reduce fullness. Checked levator’s excursion
on the table and appeared normal OU.

B
224 Asian Blepharoplasty and the Eyelid Crease

CASE 47 (Figure 16-47 A, B)

55 y.o. had four-lid blepharoplasty 10 years previously in Hawaii. Has high bifid semilunar creases OU, measured to be
10–11 mm in sulcus.
I/O: designed parallel crease OU at 7.5 mm (tarsus measured 7 mm). Excised old crease with 1 mm clear skin superior to
it, with the lower skin incision edge at 7.5 mm. Found very attenuated levator muscle with fatty infiltration. Formed parallel
crease.

B
 16 Revisions in Suboptimal Cases 225

CASE 48 (Figure 16-48 A, B)

29 y.o. had crease procedure 9 years earlier: stitch method alone, with adjustment attempted twice. LUL has no crease. RUL
has shallow NTC. Patient prefers parallel crease.
I/O: very vascular. Removed buried nylon sutures from along the STB. Used 6-0 silk and 6-0 Prolene with significant attach-
ment towards the levator aponeurosis.

B
226 Asian Blepharoplasty and the Eyelid Crease

CASE 49 (Figure 16-49 A, B)

36 y.o. 3 years s/p lid crease procedure. Currently has shielded crease over RUL, and LUL has wider separation from lid margin
than the RUL. Wants parallel crease.
I/O: designed 7 mm crease height to encompass RUL scar. Excised moderate amount of preaponeurotic fat from RUL as
well as inferior orbicularis strip.
LUL: reduced the crease height medially. Fat not as excessive and therefore only reduced some with bipolar Wetfield cautery.
Excised inferior orbicularis strip. Closed with 6-0 silk. Inspection revealed this LUL crease still high. Took down and re-excised
small amount of skin from lower edge. Result was more symmetrical look.

B
 16 Revisions in Suboptimal Cases 227

CASE 50 (Figure 16-50 A, B)

24 y.o. had lid crease procedure in Hong Kong 8 years previously. RUL crease never formed and is now shallow; LUL crease
is deeper, but central portion slightly peaked. Desired NTC.
I/O: RUL tarsus measures 6.5 mm. Used 7 mm to design an NTC. Resected scar tissue, no fat. Used 6-0 and 7-0 silk.
LUL: ‘square-well’ excision of strip of scar tissue along the STB. Mid-section underwent some dissection superiorly to release
fibrosis down to the aponeurosis. Reformed smooth NTC, with good result.

B
228 Asian Blepharoplasty and the Eyelid Crease

CASE 51 (Figure 16-51 A, B)

Male patient, 9 years previously had lid crease procedure. The crease did not fold in well by the end of the first week. Revised
2 months later, with same finding. Has very faint rudimentary line OU. Patient wanted the medial one-third of the crease to
be lifted higher. However, this would lead to a triangular or rectangular look. After careful discussion, the patient chose a
parallel crease.
I/O: tarsus measured 8 mm. We designed a 7 mm parallel crease. Lysed scar tissues along the upper incisional edge, through
orbicularis. Observed amorphous fat plastered against levator muscle. After the skin muscle flap was trimmed there were still
remnants of preseptal tissues along the STB; as the patient looks up, this redundant tissue would bunch up and make the
crease look low and ‘rope-like’. This was then excised to show a clean insertion of the aponeurosis along the STB. The lower
skin edge was pulled up and united with the aponeurosis along the STB, forming a nice parallel 7 mm crease.

B
 16 Revisions in Suboptimal Cases 229

CASE 52 (Figure 16-52 A, B)

30 y.o. who was 10 years s/p external incision crease procedure. The lateral extent of the RUL appears to downslant towards
the lateral canthus. The incisional line has spread over the left side. Desires parallel crease to be of above-average height.
I/O: tarsus measured 8 mm. Used a parallel 8 mm incision line, included 2.5 mm skin. Very vascular orbicularis oculi muscle.
Preaponeurotic fat pad protruded inferiorly over the lateral half and required partial excision. The rest of the fat seemed spread
out and plastered down. Formed crease with 6-0 and 7-0 silk.

B
230 Asian Blepharoplasty and the Eyelid Crease

CASE 53 (Figure 16-53 A, B)

19 y.o. Heavy upper lid hooding with fat. Some brow action. Wants to have hooding and fat removed but does not want crease
formation. Height 5′ 3″.
I/O: tarsus measured 7 mm. Used hyaluronidase in local injection. Made lower incision line at 5 mm and included 3 mm of
skin in a parallel configuration. After using blade through skin, I used cutting cautery with very fine tip to traverse through the
upper edge of the orbicularis. Reached septum and opened it. Excised 80% of prolapsing preaponeurotic fat. Excised M/C strip
that consisted mostly of skin, leaving behind half of the orbicularis along the STB. Closed orbicularis to orbicularis with 6-0
Vicryl. Skin closed with 6-0 nylon in a running fashion, taking bites of skin only. No interrupted sutures were used on the skin.

B
 16 Revisions in Suboptimal Cases 231

CASE 54 (Figure 16-54 A–C)

22 y.o. who was 4 years s/p lid crease procedure and attempted ptosis repair of RUL. RUL crease is deep set and height was
8 mm, with 1.5 mm of cornea covered. LUL has deep-set 6 mm crease, 0.5 mm cornea is covered. (A, B) Preoperative
appearance.
I/O: measured right tarsus and it was only 5.5 mm, probably had tarsectomy. LUL tarsus measured 7 mm.
RUL very vascular. Created 7 mm NTC and included 2 mm skin. Found three blue nylon stitches, scarred levator/tarsus
junction. Performed external resection of 3 mm of aponeurosis. Dissected epitarsally to smooth out already swollen tarsal area.
Formed crease with 6-0 and 7-0 silk.
LUL: also set crease height at 7 mm, and NTC. Found three nylon stitches and removed them. Excised 1.5 mm skin–muscle
strip. Formed crease.

A
232 Asian Blepharoplasty and the Eyelid Crease

CASE 55 (Figure 16-55 A–C)

36 y.o. who was 10 years post first crease procedure (A).
RUL had 12 mm crease height with broad medial portion.
LUL had 14 mm deep crease. Height is 5′ 7″.
I/O: tarsus measured 7 mm. Used 8 mm as crease. Included 3 mm skin segment. Opened preaponeurotic plane with beveled
Westcott scissors along the upper edge. No fat seen. Formed crease with 6-0 and 7-0 silk.
(B) Postoperative appearance at 3 weeks.

C
 16 Revisions in Suboptimal Cases 233

CASE 56 (Figure 16-56 A, B)

66 y.o. RUL with 3 mm ptosis, hollow sulcus and absent crease. LUL has high crease. Levator function RUL 7 mm, LUL 14 mm.
I/O: RUL has had previous tarsectomy-type procedure. Applied frontal nerve block. Performed lysis of adhesion along the
superior edge of the skin incision. Levator was extremely attenuated. The aponeurosis was elevated from underlying conjunc-
tiva and 10 mm was resected. The edge of the muscle was then advanced and reanastomosed inferiorly along the STB using
6-0 Vicryl. Formed crease with multiple 6-0 and 7-0 silk sutures.
LUL: created 6 mm crease line incision, then dissected upwards towards scar to reach preaponeurotic plane. Resected the
old cicatrix and fragment of skin between it and the new lower edge of the crease incision.

B
234 Asian Blepharoplasty and the Eyelid Crease

CASE 57 (Figure 16-57 A–C)

23 y.o. female with small palpebral fissure and mild ptosis OU. (A) Prior to any procedure. (B) One year following Asian
blepharoplasty she developed shallowing of crease over both upper eyelids.
I/O: RUL tarsus measured 6.5 mm. Designed crease including less than 1 mm of previous incision line. Lysed superior edge
of incision through orbicularis. No unusual fat seen. Thick fluctuant preseptal orbicularis was seen; this was excised.
LUL: crease form was borderline after closure. Released the sutures and re-fixated by deeper placement on to aponeurosis.
The medial portion of the levator aponeurosis appeared to have some fat infiltration.

C
 16 Revisions in Suboptimal Cases 235

CASE 58 (Figure 16-58 A, B)

46 y.o. from South America. Two years ago had undergone upper blepharoplasty with incision placed 3 mm from the lash
margin. Now has recurrent hooding such that the crease is shielded and there is dark-colored skin along the incision. Wanted
parallel crease. Lid margin rests 3 mm down on cornea.
I/O: upper lid skin appears short prior to intervention. Used 5 mm parallel line to incise skin, then lysed along the superior
skin edge until large amount of preseptal and preaponeurotic fat was seen. Made a small trough above STB, just enough to
facilitate skin closure. No skin excision at all.

B
236 Asian Blepharoplasty and the Eyelid Crease

CASE 59 (Figure 16-59 A, B)

40 y.o. from South-East Asia wanting upper eyelid crease and fat removal. Had prominent eye fissures, mild fat and some hooding.
Wanted ‘natural, conservative nasally tapered crease’.
I/O: tarsus 7.5 mm. Designed crease with 2 mm skin. Excised portion of preaponeurotic fat bilaterally.

B
 16 Revisions in Suboptimal Cases 237

CASE 60 (Figure 16-60 A, B)

18 y.o. male complains of intermittent or absence of crease over right side. Height is 5’ 7″.
I/O: tarsus measured to be 7.5 mm. His rudimentary crease appears to be at 7 mm; therefore designed 7 mm NTC, plus
2 mm of skin. Fat was reduced with bipolar cautery. Excised orbicularis along the path of the STB. Medially there was some
web formation and these were reduced and the crease anchored deeper here with 6-0 silk to prevent web formation
medially.

B
238 Asian Blepharoplasty and the Eyelid Crease

CASE 61 (Figure 16-61 A, B)

34 y.o. with hooding and single eyelid of the right and shielding with multiple creases over left side. The fissure size is smaller
over the right side. Levator function: RUL 11 mm, LUL 12 mm.
I/O: tarsus measured 7 mm. Used NTC shape and included 2.5 mm skin. M/C flap excised; some fat excision. The crease
formed well.

B
 16 Revisions in Suboptimal Cases 239

CASE 62 (Figure 16-62 A, B)

25 y.o. with single eyelid desires crease placement. Upper lid contour has slight peaking over medial one-third. Prefers higher-
than-average parallel crease.
I/O: tarsus measured 7 mm. Designed a 7 mm parallel crease shape. Had large amount of preaponeurotic fat, which was
excised partially. A large roll of fatty infiltrate overlay the STB and required clearance on each side for optimal crease
formation.

B
240 Asian Blepharoplasty and the Eyelid Crease

CASE 63 (Figure 16-63 A, B)

24 y.o. Narrow crease with some shielding. RUL has shallower NTC; LUL has deeper-set low NTC. Desired crease
enhancement.
I/O: tarsus measured 7.5 mm. Used 7.5 mm to design NTC with 2 mm redundancy; excised fatty infiltrate along inferior
edge of pretarsal orbicularis on both sides.

B
 16 Revisions in Suboptimal Cases 241

CASE 64 (Figure 16-64 A, B)

57 y.o. with heavily hooded lid and fatty prolapse, more over right side. RUL rests 2 mm onto cornea. LUL rests 1 mm. Has
small palpebral fissure size bilaterally.
I/O: could not evert tarsus to measure. Set crease at 7 mm parallel shape. There was a large amount of amorphous fat
inferior to the preaponeurotic fat, which in itself was inferiorly placed. Excised fat.
RUL: reinforced usual closure of 6-0 and 7-0 silk with one double-armed 6-0 Vicryl, passing from inferior pretarsal skin to
aponeurosis.

B
 CHAPTER 17

ADVANCED CONCEPT OF A GLIDE

ZONE AS IT RELATES TO UPPER LID
CREASE, LID FOLD AND APPLICATION
IN ASIAN BLEPHAROPLASTY
This chapter deals with the author’s concept of the natural
biodynamic of the eyelid layers, the importance of fat
within the eyelid’s preaponeurotic space, its facilitation
and hindrance of the natural eye opening mechanism
(Figure 17-1).
Classically, the normal eyelid anatomy can be concep-
tualized as consisting of two layers: the anterior skin/
orbicularis oculi muscle layer and the posterior layers of
the levator muscle and aponeurosis, Müller’s muscle and
the tarsal plate.
Anterior layer

Posterior
layer

* Glide zone

FIGURE 17-1 ■ The natural biodynamic of

the eyelid layers. Pink: levator muscle;
yellow: preaponeurotic fat; gray: orbicu­
laris oculi muscle with subcutaneous
tissues.

243
244 Asian Blepharoplasty and the Eyelid Crease

In general, Caucasian eyelids with a crease are thinner
than those of their Asian counterparts. This is attribut-
able to a combination of factors that include a higher
point of fusion of the orbital septum onto the levator
aponeurosis, the relatively higher position of preaponeu-
rotic fat pads and the resultant thinner lower segment of
eyelid, less preseptal fat and thinner orbicularis. Com-
paratively, Caucasians with an eyelid crease possess a
greater number of distal fibers of the levator aponeurosis
that terminate toward the skin along the superior tarsal
border and the area above it to form the eyelid crease.
When the levator contracts, the tarsal plate vectors
upward and the eyelid crease invaginates easily. Cauca-
sians may often have a deep-set supratarsal sulcus (Figure
17-2).

Lid open (looking ahead)

Lid (levator) at rest

FIGURE 17-2 ■ Caucasian eyelid with a crease. In general, Caucasian eyelids with a crease are thinner than their Asian counterparts.
This is due to a combination of factors, including a higher point of fusion of the orbital septum on to the levator aponeurosis, the
relatively higher position of the preaponeurotic fat pads and the resultant thinner eyelid segment, the greater number of distal fibers
of the levator aponeurosis that terminate towards the skin along the superior tarsal border and above to form the eyelid crease,
less preseptal fat, and a thinner orbicularis. When the levator contracts, the tarsal plate vectors upward and the eyelid crease invagi­
nates easily.
 17 Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease 245

In Asians who are born with a natural crease, although
the eyelid may still be thicker than in Caucasians with an
upper lid crease, there are distal fibers of the levator
aponeurosis terminating toward the skin along the supe-
rior tarsal border.1 Despite the low point of fusion of the
orbital septum, when the levator contracts, there is an
invagination of skin along the superior tarsal margin to
form a clinically apparent upper eyelid crease.2 When the
lids are open and the subject is looking ahead, there is a
greater degree of fullness in the preseptal region com-
pared with a Caucasian with a crease, but less than that
which is typically seen in Asians without an upper lid
crease (Figure 17-3).

Lid open (looking ahead)

Lid (levator) at rest

FIGURE 17-3 ■ Asian eyelid with a crease. Although the eyelid may still be thicker than in Caucasians with an upper lid crease, there
are distal fibers of the levator aponeurosis terminating towards the skin along the superior tarsal border. Despite the low point of
fusion of the orbital septum, when the levator contracts there is an invagination of the skin along the superior tarsal margin to form
a clinically apparent upper eyelid crease. When the lids are open and the subject is looking ahead, there is a greater degree of full­
ness in the preseptal region than in a Caucasian eyelid with a crease, but less than that typically seen in Asians without an upper
lid crease.
246 Asian Blepharoplasty and the Eyelid Crease

Asians who are without an eyelid crease typically have
thicker eyelids because of the presence of a hypertrophied
orbicularis and the presence of fat in the pretarsal, presep-
tal and preaponeurotic areas. The orbital septum fuses
with the levator aponeurosis at a lower point compared
with those Caucasians with an upper eyelid crease. There
are relatively few fibers or no attachment from the levator
aponeurosis toward the skin along the superior tarsal
border. Their pretarsal and preseptal zones are thicker
compared with Caucasians or Asians who have an eyelid
crease (Figure 17-4).

Lid open (looking ahead)

Lid (levator) at rest

FIGURE 17-4 ■ Asian eyelid without a crease. The upper eyelid is often thicker owing to the presence of hypertrophied orbicularis as
well as preseptal fat in the pretarsal as well as the supratarsal area. The orbital septum fuses with the levator aponeurosis at a lower
point than in Caucasians with an upper eyelid crease. There are relatively few fibers or no attachments from the levator aponeurosis
towards the skin along the superior tarsal border. Both the pretarsal and the preseptal zones are thick compared to Asians or Cau­
casians with an upper eyelid crease.
 17 Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease
In aesthetic Asian blepharoplasty, where the goal has
always been to create an ethnically appropriate crease,
there are two categories of methods used to achieve this
goal. The first consists of the suture ligation methods,3–5
which are often described as being less invasive and
simpler to perform, and use several buried sutures to
tighten the soft tissues along the superior tarsal border,
which includes orbicularis, levator aponeurosis and
Müller’s muscle. The other category is the external inci-
sional approach, whereby a skin incision is made along
the designed crease and varying amounts of skin, muscle
and soft tissues may be removed; this is then coupled with
various methods of crease construction by means of fixa-
tion or attachment of skin to the levator aponeurosis, skin
to the tarsus, or orbicularis to aponeurosis fixation.
The surgical results often depend on a complex inter-
action between the degree of excessive tissue overlying
the pretarsal and preseptal areas, the presence of fat, the
thickness of skin over each of the two areas mentioned
above, the position of the globe, the brow position,
levator function and whether there is a firm adhesion of
skin to orbicularis in the pretarsal area. In a normal upper
eyelid, when the eyes are looking straight ahead and the
lids are open, the anterior layer is in passive relaxation,
allowing the posterior levator/Müller’s muscle/tarsus to
actively contract and pull the lid margin upward into an
open position. The posterior layer only has to retract
(glide) up and inward for 2–4 mm relative to the anterior
layer for a reasonable crease to be observed. The vertical
span (in millimeters) of the eyelid fold overhanging the
crease can be measured simply by subtracting the
247
‘observed crease height’ (from eyelash to inferior border
of eyelid fold) from the anatomical crease height (meas-
ured with the lid fold retracted away to expose the true
crease line). (In Advanced: Chapter 20, we can say
Dimension of the fold = Tilted crease height
− Apparent crease height.
However, since the fold is best observed and measured in
a frontal position with gravity in place, the first clinical
definition suffices.) The fold varies between 2 and 4 mm.
The anterior layer therefore offers very little resistance
and does not present a significant ‘resisting platform’
against the levator muscle/tarsus; exceptions to this will
include heavy eyelids (those with abundant preaponeu­
rotic or suborbicularis fat, and loose subcutaneous areolar
tissues) with poor levator function, including true ptosis.
The role of the preaponeurotic space and fat is often
mentioned as a hindrance to any attempt at surgical con-
struction of a crease, and surgical dictum requires that at
least a portion of the fat be excised. There is nothing
inherently wrong with this concept; in fact, when the
patient presents with excessive soft tissues along the
preaponeurotic platform, this author has advocated using
a beveled approach6 toward the preaponeurotic space
along the upper line of the incision and performing a trap-
ezoidal debulking of the skin, orbicularis, a small amount
of septum and inferiorly migrated fat. Should one need
to re-enter this space later using a beveled approach, one
can identify the preaponeurotic space and its fat quite
readily.7
248 Asian Blepharoplasty and the Eyelid Crease
The problem arises when the initial procedure
may have involved aggressive excision of the preaponeu-
rotic fat or been accompanied by excessive hemorrhage
within that space, which is surrounded by orbicularis
oculi in front and vertical communicating arterial
branches of the marginal arcade, the peripheral arcade
and the deep orbital arcade (see Chapter 3). The patient
often develops a sunken supratarsal sulcus, with total loss
of fullness to the preseptal zone, and may have poor
crease invagination and stiffened eyelid skin, with under-
lying cicatrix involving the pretarsal and preseptal areas
(Figure 17-5).
During revision, one sees a collapse or obliteration of
the preaponeurotic space and absence of preaponeurotic
fat. The anterior and posterior layers appear fused into a
single layered complex. One can visualize this as if the
levator muscle now has to carry or lift the upper tarsal plate
against the weight of a double load of eyelid layers, as
opposed to the usual scenario where the tarsal plate glides
up and under the anterior layers of skin and orbicularis.
FIGURE 17-5 ■ Scarred upper lid. Stiffened eyelid skin with underlying cicatrix overlying the pretarsal as well as the preseptal area.
The skin/orbicularis is now acting as a ‘resisting layer’
toward the posterior layer of the levator muscle. The
absence or presence of this ‘glide zone’ (with slippery
preaponeurotic fat within its space) in the middle between
the two layers can therefore hinder or facilitate formation
of the crease. The author has observed the presence of
tightly bound preaponeurotic fat in some individuals pre-
senting for a primary lid crease addition procedure, where
this amorphous infiltrated fat in the glide zone may have
contributed to the lack of a crease. Careful repositioning
of this fibrosed fat to a higher level seems to facilitate the
up-vectoring of the lid and crease formation.
The properly functioning eyelid crease was described
by Dr Khoo Boo-Chai8,9 in his 1963 article as being like
the visor of a motorcycle helmet. Additionally, Flowers10
had mentioned in his article on anchor blepharoplasty the
idea that the inferior extent of the preaponeurotic fat acts
like a ball-bearing at the orbital septum-to-aponeurosis
fusion point (the inferior extent of the preaponeurotic
space).
 17 Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease 249

My own concept varies from these authors in the fol-
lowing way: the preaponeurotic space, its presence and
its preservation with some fat within it, is a necessary
‘third layer’ and should be preserved pristinely as much
as is feasible (Figure 17-6). In the diagram, the middle
zone (glide zone) where the preaponeurotic fat pads are
located is colored yellow and acts like a friction-free layer
that allows the posterior layer (dark pink) to glide up.
The up-vectoring of the tarsal plate is facilitated by this
glide zone, which allows it to slide upward against the
passively resisting eyelid fold to form an upper lid crease.
The skin passively glides over the posterior layer (the
upper part of the tarsal plate) for several millimeters in
the process of forming the upper lid crease and becomes
the eyelid fold.

Anterior layer

Posterior
layer

* Glide zone

FIGURE 17-6 ■ Concept of the glide zone. The glide zone consists of the space occupied by the preaponeurotic fat pads, as well as
all potential space between the anterior orbicularis oculi muscle–orbital septum layers and the posterior layers of the levator–levator
aponeurosis–Müller’s muscle–tarsal plate. The middle zone (glide zone) where the preaponeurotic fat pads are located acts like a
frictionless lubricating layer which allows the posterior layer to glide upwards. When the patient looks from down to straight ahead
with the eyelid open, the levator (agonist) contracts and the sphincter-like pretarsal, preseptal and periorbital layers of the orbicularis
relax. The orbicularis muscle of the upper lid is anchored at the medial and lateral canthal commissures, fusing there as a compo­
nent of the medial and lateral canthal ligaments. The anterior layer therefore acts like a passive layer, affected by gravity as the
posterior layer of the active levator and Müller’s muscle contracts to open the eyelid from a closed position. The up-vectoring of
the semirigid tarsal plate therefore depends on the middle layer to allow it to hinge upwards against the passively resisting anterior
layer to form an upper lid crease. The anterior layer glides passively over the posterior layer (upper part of the tarsal plate) for
several millimeters in the process of forming the upper lid crease; the portion of skin overhanging the tarsal plate is the eyelid fold.
250 Asian Blepharoplasty and the Eyelid Crease
The absence of adhesion and the presence of natural
fat within this glide zone allows the pretarsal platform
(posterior layer) to shift and glide slightly posterosuperi-
orly under the preseptal eyelid (anterior layer) to form a
physiologic upper lid crease. As previously mentioned,
this glide can be as little as 2–4 mm for the crease to
indent inward under the overhanging lid fold, which con-
sists of skin, orbicularis and orbital septum arising from
the arcus marginalis of the superior orbital rim. The
anterior layer therefore hangs from the superior orbital
rim and the area superficial to it, whereas the posterior
layer originates from the orbital apex and contracts pos-
terosuperiorly as it lies on the surface of the eye.
Typical findings following a suboptimal lid crease pro-
cedure for Asians and any upper blepharoplasty may
include an unusual amount of swelling (tissue edema),
hemorrhage from the orbicularis, or any of the vascular
arcades, excessive removal of fat within the preaponeu-
rotic space, and inadequate construction of the crease
based on physiologic principles. As the swelling recedes,
one or more of the following may appear: ptosis, a hollow
sulcus, an inadequate formation or absence of crease, or
multiple wrinkle lines (with or without a primary crease).
These are all signs relating to excessive manipulation or
inappropriate management of tissues within the glide
zone, with adhesions involving orbicularis, septum and
levator aponeurosis. By this I mean the obliteration of
this glide space by aggressive fat excision, from cicatriza-
tion following excessive hemorrhage or handling within
the preaponeurotic space, or adhesions involving the
orbicularis, orbital septum and levator aponeurosis.
As healing progresses, the upper eyelid continues to
manifest some degree of ptosis or resistance to upgaze,
with poor crease invagination. The patient may complain
of effort in keeping the lids open, difficulty gazing upward
and having a portion of the superior visual field obstructed.
(With time, an initially restrictive-type ptosis may develop
into an acquired ptosis with true weakening of the levator
muscle.) The pretarsal as well as the preseptal eyelid skin
may appear as a single zone of relatively flattened and
convex plaque of thickened skin overlying the globe. This
is indicated by one or all of the following.
 17 Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease 251

Step 1. With the patient looking downward, the

examiner gently places his or her index finger super-
ficially over the mid-portion of the preseptal skin
superior to the upper tarsus to push or glide the
anterior skin/muscle layer upward. If the anterior
skin/muscle layer fails to be moved upward for
2 mm or more without the upper lid margin also
moving upward, it is indicative of an abnormal ‘glide
sign’ (Figure 17-7) (the patient should avoid closing
his or her eyelids because this elicits active contrac-
tion of the orbicularis).

FIGURE 17-7 ■ A normal glide sign in a normal subject, here

showing that the superficial dermis can glide superiorly or infe­
riorly over the deeper layers in normal eyelid. An abnormal
finding indicates adherence of the anterior and posterior layers.

Step 2. With the patient looking downward, the

examiner uses his or her thumb and index finger to
try to pinch the preseptal zone’s anterior skin layer
from the lid tissue underneath it. If this is not pos-
sible, as indicated by the posterior layer and upper
eyelid margin also coming off the surface of the
globe, this is suggestive of an obliteration of the
glide zone, constituting an abnormal pinch sign
(Figure 17-8).

FIGURE 17-8 ■ The normal pinch sign. When the glide zone is
intact, the preseptal skin/muscle (anterior) layer can be lifted
away from the posterior layer of the eyelid for several millim­
eters without the tarsus coming off the globe. An abnormal
pinch sign where the tarsal plate is lifted off indicates adherence
of the anterior and posterior layers.

Step 3. The patient is asked to look down, and the

ipsilateral eyebrow is splinted by the examiner’s
other hand to prevent brow action on upgaze. Then,
with the examiner pinching the preseptal skin, the
patient is asked to look upward. As the patient
looks up, the superior rectus and levator muscle
both contract. A normal finding should be the upper
eyelid margin underneath moving up independently
without the pinched skin going upward. If the
pinching fingers should feel an upward tug, it indi-
cates that the levator and preseptal skin are fused
together and is an abnormal ‘upgaze skin traction
sign’ (Figure 17-9).

FIGURE 17-9 ■ The upgaze skin traction sign. The patient is asked
to look up while the skin is secured with the examiner’s fingers,
here a normal sign showing a lack of adhesion. A direct pulling
force from the levator indicates an abnormal upgaze skin trac-
tion sign and suggests that there is obliteration of the preapone­
urotic space or glide zone.
252 Asian Blepharoplasty and the Eyelid Crease
The above findings apply more to adults who have had
surgery and not undergone significant involutional
changes, and would not be accurate in those unlikely
revisional cases where there is still redundant skin remain-
ing in the preseptal area or in patients who have devel-
oped age-related dehiscence between the preseptal skin
and orbicularis such that a false-normal finding may
occur (in a situation where, although the glide zone has
been obliterated, it is still possible to glide and pinch the
skin relative to the orbicularis that became adherent to
the levator and showed no skin traction on upgaze). It is
possible that a patient with fused anterior and posterior
layers may manifest a false-negative finding in any one or
two of the above tests, but it is unlikely that all three
would be normal on examination. This combination of
glide sign, pinch sign and upgaze skin traction sign have
been helpful for this author and are additional tools one
can use to help in the clinical assessment of those patients
with revisional issues.
In my previous article on trapezoidal debulking of the
preaponeurotic platform,7 I observed that the excision of
skin and some orbicularis in a beveled fashion removes
no more than several millimeters of orbital septum along
FIGURE 17-10 ■ Intraoperative appearance of the intraoperative crease form in a revision patient prior to the application of crease-
fixation sutures and closure. The globe is protected by a black corneal protector.
the upper wound edge. With wound closure, the septum’s
inferior edge is still allowed to lay back on the front
surface of the distal aponeurosis at or slightly above the
superior tarsal border, preserving and forming the ante-
rior boundary of this glide zone.
During attempts at revision, it is crucial to be able to
identify and reach this third space and restore a glide
zone. At the same time, any scar tissue within this poten-
tial space can be approached and cleared, including
removal of any buried sutures and correction of any cause
that is impeding this glide (shift) of the posterior layer.
The skin/orbicularis layers may have been improperly
laid onto the levator during previous surgery because of
the lack of proper loosening of the surgical drape on the
forehead. The re-establishment of the glide zone, and
downward and appropriate positioning of the skin and
eyebrow–forehead complex allows the now ‘released’
tarsal plate to be properly pulled upward by the freed
levator muscle, the contraction of which then yields a
crease at the superior tarsal border. This can be apparent
as the patient lies on the surgical table even without any
sutures closing the wound (Figure 17-10).
 17 Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease
The various methods of crease construction, including
the tightening of the tarso-aponeurotic junctional zone
by suture ligation or external incision methods, all work
in facilitating the upward vectoring of the tarsus against
the anterior eyelid layer to form the crease, provided that
the glide zone is preserved or has not been greatly
disturbed.
Complications that are challenging to correct often
follow obliteration of the glide zone. During the simpler
techniques of transconjunctival and transcutaneous suture
ligation, unexpected and sudden bleeding has been
reported and may be caused by injury to the vertically
oriented anastomotic vessels of the marginal and periph-
eral arcades of the upper lid11 and the deep orbital
arcade,12,13 and can also involve the recently described
lateral septoaponeurotic artery found in a certain per-
centage of the population.14,15 The bleeding may occur in
the postaponeurotic plane if the vessels retract after
transection in front of the tarsus or aponeurosis, or within
the preaponeurotic space (the glide zone) itself. Residual
adhesion may follow resolution of blood clots and lead
to irregularity in the crease thus created. Over the long
term, partial, segmental, or complete disappearance of
the crease may be seen.
In conclusion, the upper eyelid crease is an anatomical
invagination of the eyelid skin along the superior tarsal
border. Its originates from a complex interaction of
vector forces consisting of the following: a healthy levator
muscle (posterior layer), the presence of healthy skin/
orbicularis over the preseptal region that rolls over pas-
sively as an eyelid fold (anterior layer), the presence of a
third layer called the glide layer with healthy preaponeu-
rotic fat within it, and the absence of mid-lamellar scar-
ring that may bond the anterior and posterior layers of
the upper lid together. The theoretical basis for preserva-
tion of this third layer – the glide zone – and the role it
plays in upper blepharoplasty, as described in this chapter,
253
should provide greater understanding in the management
of blepharoplasty and complex revisional issues.
REFERENCES
1. Cheng J, Xu FZ. Anatomic microstructure of the upper eyelid in
the Oriental double eyelid. Plast Reconstr Surg 2001;107:1665.
2. Hwang K, Kim DJ, Chung RS, Lee SI, Hiraga Y. An anatomical
study of the junction of the orbital septum and the levator aponeu-
rosis in Orientals. Br J Plast Surg 1998;51:594.
3. Mutou Y, Mutou H. Intradermal double eyelid operation and its
follow-up results. Br J Plast Surg 1972;25:285.
4. Tsurukiri K. Double eyelid plasty: reliability and unfavorable
results to the patients (Abstract). J Jpn Aesth Plast Surg 1999;20:38.
5. Homma K, Mutou Y, Mutou H, Ezoe K, Fujita, T. Intradermal
stitch for Orientals: Does it disappear? Aesth Plast Surg 2000;24:
289.
6. Chen WPD. Concept of triangular, rectangular and trapezoidal
debulking of eyelid tissues: application in Asian blepharoplasty.
Plast Reconstr Surg 1996;97(1):212–218.
7. Chen WPD. Beveled approach for revisional surgery in Asian
blepharoplasty. Plast Reconstr Surg 2007;120(2): 545–552.
8. Boo-Chai K. Further experience with cosmetic surgery of the
upper eyelid. Proceedings of the Third International Congress of
Plastic Surgery, reprinted from Excerpta Medica International
Congress Series No. 66; 1963: 518.
9. Boo-Chai K. Secondary blepharoplasty in Orientals. In: Problems
in plastic and reconstructive surgery. Philadelphia: Lippincott,
1999: 520–535.
10. Flowers RS. Upper blepharoplasty by eyelid invagination: anchor
blepharoplasty. Clin Plast Surg 1993;20:193.
11. Chen WPD. The concept of a glide zone as it relates to upper lid
crease, lid fold, and application in upper blepharoplasty. Plast
Reconstr Surg 2007;119(1):379–386.
12. Kawai K, Imanishi N, Nakajima H, Aiso S, Kakibuchi M, Hoso-
kawa K. Arterial anatomic features of the upper palpebra. Plast
Reconstr Surg 2004;113:479.
13. Boo-Chai K. Perioperative bleeding in the pretarsal (postaponeu-
rotic) space in Oriental blepharoplasty. Br J Plast Surg 2001;54:370.
14. Kim BG, Youn DY, Yoon ES et al. Unexpected bleeding caused by
arterial variation inferolateral to levator palpebrae. Aesth Plast Surg
2003;27:123.
15. Hwang K, Kim BG, Kim YJ, Chung IH. Lateral septoaponeurotic
artery: source of bleeding in blepharoplasty performed in Asians.
Ann Plast Surg 2003;50:16.

ASIAN BLEPHAROPLASTY I:
THE FIRST VECTOR
Japanese Kanji (Chinese-based characters) and Hiragana writing
denoting ‘double-eyelid crease technique’. (Courtesy of, and in
remembrance of, Kazuko Chin.)
It is my belief that a modified external incision technique
allows maximum control and flexibility in order to achieve
the goal of creating an optimal crease. This is based on
setting a high benchmark of achieving an ideal crease
height, with an appropriate crease shape, continuity of
the crease line and permanence of the crease thus created
(beyond at least several years).
The steps involved are as follows:
1. Medications and surgical setup
2. Anesthetics
CHAPTER 8
3. Surgical steps:
• marking of incision and crease placement
• the first vector – beveled surgical plane and
opening of orbital septum (Chapter 8)
• treatment of fat (continued to Chapter 9)
• the second vector – excision of orbicularis oculi
and septum
• treatment along superior tarsal border and
preaponeurotic space
• construction of lid crease
• closure of incision.
PRE-MEDICATIONS AND
SURGICAL SETUP
The patient usually receives 10 mg of diazepam (Valium)
and one Vicodin (acetaminophen and hydrocodone)
tablet (5 mg) orally 60 minutes before the procedure.
The patient is placed in a supine position and intravenous
line and electrocardiographic monitors are applied. A
pulse oximeter that provides a real time readout of the
patient’s PaO2 (arterial blood gas) is applied. All patients
are given a nasal cannula with 1–2 liters/minute of room
air flowing through it.
ANESTHETIC MIXTURE AND
INJECTIONS
Two mixtures of local anesthetics are prepared.
First: 1 ml of 2% xylocaine with 1 : 100 000 dilution
epinephrine is diluted by 10× with 9 ml of injectable
normal saline. This mixture now has a pH closer to
neutrality since it has been diluted with the buffer­
ing action of injectable normal saline. The epin­
ephrine is now diluted to 1 : 1 000 000. (This is
labeled ‘Diluted’.)
Second: 5 ml of 2% lidocaine (Xylocaine) containing
1 : 100 000 dilution of epinephrine is drawn. (This is
labeled ‘Full strength’.)
I apply a drop of topical anesthetic, 0.5% proparacaine
hydrochloride, on each eye for comfort prior to surgical
preparation and draping.
Using a No. 30 or 32 gauge needle, I infiltrate
0.1–0.2 ml of the diluted anesthetic subcutaneously along
75
76 Asian Blepharoplasty and the Eyelid Crease
the superior tarsal border (Figure 8-1). During the next
few minutes, anesthesia takes effect and one can observe
blanching of the eyelid skin from the powerful vasocon­
strictive effect of the diluted epinephrine–anesthetic mix
(Figure 8-2).
I then inject the regular strength 2% lidocaine with
epinephrine in the suborbicularis plane along the supe­
rior tarsal border, usually giving less than 0.5 ml per
eyelid.
The purpose of this two-staged injection of local anes­
thetic is to allow for a relatively painless pre-infiltration
to anesthetize the surgical field before the full strength
of acidic 2% lidocaine is given.1 (One may add sodium
bicarbonate to the 2% mixture to achieve the same effect.)
When confronted with a patient with low threshold
for pain, one may supplement the local field infiltra­
tion with a frontal nerve block. A 30 gauge half-inch
FIGURE 8-1 ■ Initial subcutaneous injection of diluted,
pH-balanced anesthetic mixture.
FIGURE 8-2 ■ Blanching of eyelid skin caused by epinephrine in the anesthetic mixture.
needle may be used to apply 0.5 ml of the anesthetic
into the supraorbital space just lateral to the supraorbital
notch. (Frontal nerve infiltration is rarely necessary or
performed.) Intravenous sedation or analgesic may be
given.
The eyelids and face are then prepared in the usual
fashion for surgery. The eyes again receive a drop
of topical anesthetic, this time using tetracaine hydro­
chloride for longer-lasting corneal anesthesia. To elimi­
nate the sensation of claustrophobia that often occurs
with full draping over the nostrils and mid-face, nasal
delivery of room air through a nasal cannula is used.
Opaque black corneal protectors are then applied over
each eye.
PEARLS
• The use of diluted anesthetic solution helps to:
• decrease pain upon injection
• decrease volume of anesthetic needed for
injection
• create less tissue distortion as a result of less
volume expansion and lessened bleeding; it allows
the surgeon to stay focused on the surgical plane.
• The use of nasally delivered room air or low-flow
oxygen serves to decrease patient’s sense of
claustrophobia.
PITFALLS
• Never use nasal oxygen in an open system exposed
to monopolar or bipolar cautery as it may cause
ignition and flaming.
• Always apply pulse oximetry to measure the PaO2
arterial blood oxygen saturation. Preoperative seda­
tion and intraoperative sedation may easily cause
apnea in a sensitive patient.

SURGICAL STEPS
Measure Tarsal Height
The height of the tarsus determines the overall central
position of the crease you are designing; the shape is
determined by how you design the medial one-third and
lateral one-third of this lower line of incision, according
to the patient’s preference.
The upper lid is everted and the vertical height of the
tarsus is measured over the central portion of the lid with
a caliper (Figure 8-3). This measurement is usually
between 6.5 and 7.5 mm in Asians. This is the range
between low, medium and high crease height. The
Nasally tapered crease
Laterally flared or leveled crease line
Central height of underlying tarsus
B
FIGURE 8-3 ■ (A) The upper lid is everted and the tarsal height is measured over the central portion. (B) Design of a nasally tapered
crease. The lateral portion may be designed to be level or flared slightly upward.
8 Asian Blepharoplasty I: The First Vector 77
shaved-off tip of a wooden cotton-tip applicator dipped
with methylene blue is ideal for drawing a thin crease
line. The crease height is carefully transcribed onto the
external skin surface over the central part of the eyelid
skin.
This point directly overlies the superior tarsal border
and will serve as a reference point for the overall crease
height along the central one-third of the eyelid, whether
the crease shape is to be nasally tapered, parallel or later­
ally flared on rare occasions. For those patients who
already have a crease, you should still measure the tarsus
to confirm that the apparent crease you are seeing is
indeed the correct crease line to use, whether you are
planning to preserve or enhance it.
78 Asian Blepharoplasty and the Eyelid Crease

Design of Nasally Tapered Crease
Shape (Figure 8-4)
The medial one-third of the incision line is marked such
that it tapers towards the medial canthal angle or merges
with the medial upper lid fold. The lateral one-third is
usually marked in a leveled configuration although occa­
sionally a patient may request a slight upward widening
over the lateral segment of the crease.

FIGURE 8-4 ■ (A) The nasally tapered crease

B is marked; the lateral portion is leveled.
(B) Nasally tapered crease with a lateral flare.

PEARLS
• Using the shaft of a thin wooden-tip applicator and
slightly pressing on the lower incision line (new
crease location), instruct the patient to look upwards
even before the incision starts in order to assess how
the crease may appear. (Note that since the eyelid
tissue has been injected, the crease will appear more
swollen and further from the ciliary margin.)
• The use of an inked tapered tip of a wooden stick
allows precise drawing and redrawing, as compared
to the usual marking pens that are available in an
operating theater.
• In Asian blepharoplasty with skin excision, the lower
line of incision will determine the shape and height
of the surgically created crease. A strip of skin meas­
uring approximately 2 mm is then marked above
and parallel to this lower line of incision. This upper
line of incision is tapered towards and merged with
the medial canthal angle, or merged with any medial
upper lid fold that may be present. This segment of
skin to be excised is often less than 2 mm over the
medial portion of the crease.
• Repeated measurements and confirmation of inci­
sion lines are important.
8 Asian Blepharoplasty I: The First Vector 79
Design of Parallel Crease Shape
(Figure 8-5)
The measured height of the superior tarsal border is
drawn across the width of the eyelid skin in a parallel
fashion (equidistant from the lash line).
To create adequate adhesions, it is necessary to remove
some subdermal tissue above the superior tarsal border.
A strip of skin measuring approximately 2 mm is then
marked above and parallel to this lower line of incision.
PEARLS
In designing the parallel crease, there is an unconscious
tendency to converge towards the medial canthal angle,
thereby turning it into a nasally tapered crease. I often
intentionally draw the tapering crease first and then use
it as a visual guide to decide how a parallel crease should
be designed near the medial one-third of the upper lid,
to remind myself to stay parallel.
PITFALLS
• Medially the parallel crease does not flare exces­
sively upward away from the medial canthus.
• The medial end of the crease line design should not
go past an imaginary vertical line aligned with the
medial canthal angle for both nasally tapered as well
as parallel creases.
• Laterally, the crease design should not traverse past
the lateral canthal angle.
80 Asian Blepharoplasty and the Eyelid Crease

Upper line

Lower line

B
FIGURE 8-5 ■ (A) Design for a parallel crease. (B) Design for a parallel crease including the upper and lower lines of incision.

Incision
The incision is then carried out using a No. 15 surgical
blade (Bard–Parker) along the upper and lower lines
(Figure 8-6), incising just through the dermis and within
the fascia overlying the orbicularis oculi muscles. Fine
capillary bleeding is controlled using a bipolar Wetfield
cautery.
The excision of a strip of skin is not necessary in every
case; however, it is the author’s belief that it facilitates the
removal of subsequent layers of the lid tissues, thereby
allowing adequate crease formation. At this point the
superior tarsal border is still covered by pretarsal and
supratarsal orbicularis oculi muscle, with possibly some
terminal portions of the orbital septum, and the terminal
fibers of the levator aponeurosis beneath the septum.
PEARLS
• It is important to stabilize the tarsal plate and over­
lying soft tissues and skin when making a continu­
ous incision, especially along the lower line of
incision which is to become the crease line; this is a
critical step in the outcome of the designed crease.
• The continuous incision may be performed in three
steps so that one may check and recheck the passage.
FIGURE 8-6 ■ Incision through the upper
and lower lines of incision has been
made with a No. 15 surgical blade.
8 Asian Blepharoplasty I: The First Vector 81
For a right-handed surgeon seated at the head of
the table, for the right upper lid it is best to start
medially; and for the left upper lid one may start
from the lateral tip of the incision line.
• Any bleeding is best controlled with bipolar cautery
via a fine jeweler’s tip. This allows the surgeon to
lessen any immediate tissue swelling and obscura­
tion of the tissue planes, thereby maintaining a clear
operative field. Furthermore, it allows one to stay
within the planned incision line.
PITFALLS
It is easy to incise too deeply and cause a small steady
bleed from the orbicularis muscle, which will soon
develop into a hematoma and distort the incision line as
well as incisional planes, blurring the distinction between
fat, orbicularis, orbital septum and levator aponeurosis
along the superior tarsal border. It may also result in
transient postoperative secondary ptosis. (This can
happen quite easily with suture ligation methods as well,
since needles are passed repeatedly through the full thick­
ness and layers of the eyelids, for example, six passages
when three sets of stitches were used.)
82 Asian Blepharoplasty and the Eyelid Crease

Preaponeurotic
fat pad

Skin/orbicularis
flap retracted
inferiorly

FIGURE 8-7 ■ (A) With the superior line of skin incision retracted superiorly, the orbital septum is opened through the orbicularis
muscle with a monopolar cautery tip at the lowest setting of cutting mode. (B) Orbital septum is opened along the superior line of
incision. Preaponeurotic fat pads can be seen from where the septum is opened.

First Vector (Plane of Passage through
the Front Layers of the Eyelid): Beveled
Transection through Orbicularis along
Upper Incision Line and Opening of
Orbital Septum
After the initial skin incision, one may use the left fingers
to slightly retract the upper incision wound edge, then
aim a Bovie cautery tip in an angled fashion pointing
upward to transect through the preseptal orbicularis oculi
layer there, knowing that although this upper incision
line is only 2–3 mm above the superior tarsal border, with
the upward beveling the Bovie tip is aiming at a point
above where the septum fuses with the aponeurosis. (In
Asians, the orbital septum may join the aponeurosis as
low as 2–3 mm above the superior tarsal border.) The use
of the cutting cautery tip is in a feather-light fashion so
as to gently reach the orbital septum. Along the way you
may see some preseptal fat in front of the septum. When
the septum over the central one-third is opened, one
can see the slightly bulging preaponeurotic fat pad pro­
lapsing through the opening of the orbital septum (see
Figure 8-7B). A blunt-tipped Westcott’s spring scissors is
then used to open the orbital septum along the superior
line of incision; the skin–orbicularis–orbital septum flap
is turned inferiorly along the superior tarsal border using
a retractor (Figure 8-7AB).
8 Asian Blepharoplasty I: The First Vector 83
PEARLS
Always tilt the tips of the scissors upward when extending
the horizontal release of the orbital septum to either side.
The purpose is to avoid inadvertent injury to the vessels
within the fat pads, the fat pads themselves, the underly­
ing levator aponeurosis, or lobe of the lacrimal gland
situated over the lateral end.
PITFALLS
• In opening the orbital septum medially, the levator
aponeurosis may be injured.
• In opening of the lateral extent of the septum, the
lacrimal gland can be injured.
• Avoid the use of monopolar cautery over the supero­
nasal aspect of the orbital space to avoid the trochlea
of the superior oblique muscle; when cauterized it can
lead to fourth nerve palsy and torsional diplopia.
• Avoid cauterizing the lacrimal gland over the supe­
rolateral aspect of the anterior orbital rim, which
can affect tear production.
REFERENCES
1. Tenzel RR, Hustead RF, Schietroma J, Hustead J. The best trick I
learned this year. Presented at the Annual Scientific Symposium of
the American Society of Ophthalmic Plastic and Reconstructive
Surgery, New Orleans, 1986.

ADVANCED: BEVELED APPROACH AND
MID-LAMELLAR CLEARANCE IN
REVISIONAL ASIAN BLEPHAROPLASTY
It is my view that the trapezoidal debulking of the
preaponeurotic platform using a beveled approach
(along the upper incision line) in Asian blepharoplasty is
a logical and efficient way of performing primary cases.
I advocate this approach because it offers the following
advantages:
1. An easier and safer approach to the preaponeurotic
space through the orbital septum when the plane
of dissection is beveled.
2. A controlled, uniform debulking of junctional
tissues overlying the preseptal (supratarsal) and
pretarsal areas.
3. Optimal adhesions between levator aponeurosis
and the subcutaneous tissues along the lower inci-
sion line, or to intermuscular septa within pretarsal
orbicularis muscle fibers (pretarsal platform).
4. Crease formation can be based on the individual’s
tarsus height.
5. Virtual elimination of any potential for an uneven
plane of surgical dissection, thereby lessening the
complication rate, which includes problems with
asymmetry, height, shape, continuity, permanence,
segmentation of the crease, fading and late disap-
pearance of the crease, multiple creases and persist-
ent edema.
The clinical findings in patients seeking revisional
surgery are myriad. The eyelid may show spreading of
the incision scar, high placement of the crease, induced
lagophthalmos on downgaze, and acquired secondary
ptosis on straight-ahead as well as upgaze. Intraopera-
tively, one sees thickened middle lamellar scar involving
the orbicularis oculi as well as the orbital septum, or the
presence of dense scar tissue plaques that may bind the
anterior orbicularis oculi as well as the posterior levator
aponeurosis (Figure 18-1). Instead of having a physiolog-
ically preserved ‘glide zone’ where significant preaponeu-
rotic fat pads are still present in the lowest aspect of the
glide space, there is now a condensed apron (plaque)
of tissue that is preventing the posterior layer from
up-vectoring properly against a passive and flexible skin–
orbicularis layer. Despite all efforts, there is no observ-
able crease formation. Patients often complain of lid
fatigue, a feeling of tightness and may show brow and
forehead overaction.
In dealing with revision cases, whether simple or com-
plicated, one of the greatest dilemmas is where to make
CHAPTER 18
the incision so that it does not compound the already
scarred field of operation, both from an anterior
skin viewpoint (and therefore an aesthetic concern)
and as regards middle lamellar scarring and contracture
(with further functional compromise). To succeed with
improved aesthetic results as well as without further func-
tional setbacks is a major triumph for any surgeon famil-
iar with and undertaking this type of revision surgery.
Not only is the operation difficult, but often the patient
is anxious for a rapid and successful outcome, something
that is never easily realized when dealing with scarring
and suboptimal outcomes. I am often struck by how dev-
astated these patients are and how grateful when the
improvement proves significant. It is important for both
patient and surgeon to be realistic in their expectations,
as well as their projection of the time course of healing
following revisional surgery.
Having said that, the following are the minimal
requirements in revisional surgery that I have striven for
in my practice:
1. That we do not cause further skin shortage.
2. That we do not cause increased midlamellar con-
traction, with lid retraction and poor eyelid closure.
3. That neither of the two factors above leads to con-
secutive symptoms of exposure and dryness of the
ocular surface.
4. That the patient understands from the first that the
surgeon will not be able to achieve a level of aes-
thetic improvement rivaling that obtained within
the practice in primary cases, where conditions are
ideal, the amount of skin is adequate and patient
expectations are closer to being normal and fair.
5. That the patient be informed that for each revision
operation one can try to correct only one item from
a list of goals. By this I mean that it is impossible,
for example, to correct an abnormally high crease,
lid margin contour deformity, pre-existing ptosis
and a shortage of skin all at the same time.
All these factors funnel into the same conclusion: if
there is insufficient skin in reserve, it is unlikely that there
is any chance of revisional improvement unless one
wishes to supplement the skin with a free full-thickness
skin graft. This latter will require precise techniques,
experience and special splinting over the graft in order to
place it in an aesthetically acceptable fashion. There are,
however, many young adults or middle-aged patients who
255
256 Asian Blepharoplasty and the Eyelid Crease

Lid open (looking ahead)

Lid (levator) at rest

Restriction on upgaze, poor

crease indentation, possible ptosis

FIGURE 18-1 ■ Scarring seen in suboptimal cases of aesthetic surgery of the Asian upper eyelid may include spreading of the inci-
sional skin, high placement of the crease, induced lagophthalmos on downgaze, and acquired secondary ptosis on straight gaze as
well as upgaze. Intraoperatively, one sees middle lamellar scar involving the orbicularis oculi as well as the orbital septum, or the
presence of dense scar tissue plaques that may bind the anterior orbicularis oculi as well as the posterior levator aponeurosis.
Instead of having a physiologically preserved ‘glide zone’ where preaponeurotic fat pads are still present in the lowest aspect of
the glide space, there is now a condensed apron-like plaque of tissue that is preventing the posterior layer from up-vectoring prop-
erly against a passive and flexible skin–orbicularis layer. Despite all efforts, there is no observable crease formation. Patients often
complain of fatigue, a feeling of tightness, and may show brow and forehead overaction.

need revisional surgery, whose problems are severe and
who are unlikely to have any skin reserves in the future
because of natural aging. Patients with just enough eyelid
closure to avoid corneal exposure can develop such symp-
toms if the usual method of excision of the scar and lysis
of adhesion of the middle lamella is followed. The amount
of skin removed can be as little as 2 mm, and poor eyelid
closure can be the result.
An ideal solution to this dilemma is to approach the
scarred anterior and middle lamellar complex through a
superiorly beveled approach. To do this, the following
conditions must be met.
The crease height is evaluated, and if it is high then
the degree of planned lowering (in millimeters) will
determine the minimum amount of skin redundancy
above the existing crease (over the preseptal region) that
needs to be in reserve. For example, if the suboptimal
crease is currently at 10.5 mm and you plan to lower it
to 7.5 mm, then the patient will need to have 3 mm of
skin in reserve above the crease before this is feasible. If
there is only 2 mm, then this needs to be discussed with
the patient, as the crease can only be revised down to
8.5 mm in the current situation, or the patient can opt to
wait for some skin to become available as a result of
natural aging (and they may proceed to revision at that
time). If this cannot be achieved and the patient is desper-
ate, for either functional or psychological reasons, then
one must discuss the option of a free skin graft.
For the majority who may be candidates for revision
without the need for skin grafting, my surgical approach
proceeds initially along the same path as in primary cases,
the major exception being that the upper and lower inci-
sion lines are marked directly next to each other on either
side of the existing scar. Patients in this category are more
likely to have had their lid crease incision made in the
8–9 mm range, as measured from the central lid margin.
The separation of the upper and lower incision lines
should be no more than 1 mm, and very rarely 2 mm. A
No. 15 Bard–Parker blade is used to make a full-thickness
incision along the marked upper and lower lines (Figure
18-2). Now, instead of using cutting cautery to go through
the orbicularis to reach the orbital septum, one uses a
sharp-tipped Westcott spring scissors to incise across the
upper line of incision in a superiorly beveled fashion
(Figure 18-3). At this stage, one is cutting through skin–
orbicularis adhesions. Small scissoring motions are then
 18 Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty 257

FIGURE 18-2 ■ A full-thickness skin

incision has been made along the
upper and lower lines of the crease
marking (left upper lid).

FIGURE 18-3 ■ A Westcott spring scis-

sors is used to lyze along the upper
incisional edge in a beveled fashion.
It is cutting through skin–orbicularis
adhesions (left upper lid).

used as the scissor blades transect the middle lamellar
scar, opening through the whitish, scarred fascial layers
between the orbicularis and the underlying levator
aponeurosis (Figure 18-4). This is carried out through
the width of the incision along the previous scar. The
beveled approach is quite similar, but steeper than in
primary cases (Figure 18-5). In this scarred middle zone
there will be much less preaponeurotic fat, as it will have
been previously excised; some residual fat globules, com-
bined with scattered smaller amorphous globules or
aprons of scattered fat droplets, may be seen (Figure
18-6). The scarred tissues in the anterior layer as well as
in the mid-lamellar zone – encompassed by the tissues
between the dotted superiorly beveled vector and the
lower skin incision (along the superior tarsal border) in
Figure 18-5 – may be excised after the forehead/eyebrow/
preseptal skin layers are carefully reset (by releasing any
restrictive surgical adhesive or drapes on the patient’s
forehead), for as long as the remaining skin still allows
passive eyelid closure. All fat is preserved. The levator
and levator aponeurosis can be identified when the scar
is released, and it is important to check for restriction
objectively (by gently pulling the tarsal plate down) as
well as subjectively by asking the patient to perform
258 Asian Blepharoplasty and the Eyelid Crease

FIGURE 18-4 ■ Small scissoring motions

are applied as the scissor blades
transect the middle lamellar scar,
going through whitish, scarred fascial
layers between the orbicularis and the
underlying levator aponeurosis (left
upper lid).

A Primary Asian blepharoplasty B Revisional blepharoplasty

FIGURE 18-5 ■ (A) Beveled approaches in primary Asian blepharoplasty: trapezoidal debulking of the skin and preaponeurotic plat-
form. (B) Superiorly beveled approach in revisional Asian blepharoplasty. Note the gentler beveled approach used in the primary
case versus the much steeper (oblique) approach taken in revisional attempts. This is necessary in the latter situation to preserve
skin and to allow identification of the former preaponeurotic zone. In this scarred middle zone one frequently finds some residual
larger fat pads combined with scattered smaller amorphous fat globules or aprons of scattered fat droplets. The scarred tissues in
the anterior layer as well as the mid-lamellar zone, encompassed by the tissues between the dotted superiorly beveled vector in
the diagram and the lower skin incision (along the superior tarsal border), may be excised after the forehead/eyebrow/preseptal
skin layers are carefully reset, as long as the remaining skin allows passive eyelid closure. All fat is preserved.
 18 Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty
FIGURE 18-6 ■ After the preaponeu-
rotic space is reached, within this
scarred middle zone one frequently
finds some residual larger fat glob-
ules combined with scattered smaller
amorphous fat globules or aprons
of scattered fat droplets (right
upper lid).
upgaze and downgaze. The benefits and advantages of
this approach are as follows:
1. By approaching the preaponeurotic space very
close to and barely superior to the suboptimal
scarred crease line, one can avoid taking out a pre-
cious 0.5 or 1 mm of good skin.
2. By making the upper line of incision close to the
scarred crease line, one avoids creating an extra
incisional scar.
3. This beveled approach to the previously explored
preaponeurotic space allows the space to be entered
safely again, without injury to underlying levator
muscle and Müller’s muscle, as well as avoiding any
anastomotic vascular arcades in Müller’s muscle
and the superior tarsal arteriolar arcade.
4. In some cases, this beveled maneuver towards the
preaponeurotic space frees up the vertical excursion
of the upper eyelid significantly, releasing any
restriction that may have contributed to lagoph-
thalmos and acquired ptosis. This maneuver in
itself may correct the mild ptosis, such that reset-
ting of the previously high crease is then feasible.
5. Approaching the preaponeurotic space in any revi-
sional upper blepharoplasty allows one to identify
residual preaponeurotic fat that may have spread
out and become plastered down on the levator
muscle. This residual fat can be peeled off and
repositioned at a higher level within the sulcus to
help reverse some of the hollow sulcus often seen
in patients needing revisional blepharoplasty.
6. Mid-lamellar scarring that has previously bonded
the anterior and posterior layers can be safely
259
removed or reduced, allowing partial restoration of
the glide zone.
Following revisional Asian blepharoplasty using a
superiorly beveled approach, the glide space has been
partially restored and the scar carefully removed (Figure
18-7). The preaponeurotic platform is cleared of any
interfering tissues. Although the surgeon is often forced
to make a skin incision that is still further from the lid
margin than one would for a primary Asian blepharo-
plasty, upon closure the incision wound is free to indent
inwards when the levator contracts, forming a better
crease. The residual fat pads in the middle (glide) zone
are preserved and allowed to fill in this space where
appropriate. (In severe cases a fat graft may be considered
in this space.) Skin above the incision is now free to hang
down and around to form the contrasting eyelid fold.
DYNAMICS OF THE UPPER
EYELID CREASE
In a traditional approach to primary upper blepharo-
plasty, the upper and lower lines of incision are normally
made with the surgical blade perpendicular (90°) to the
skin. The skin, muscle and preaponeurotic fat are reduced
by excision in an appropriate fashion. Upon closure of
the wound and reformation of the crease (incision line
closure), the preaponeurotic space is allowed to be set
inferiorly and now reaches an area over the superior tarsal
border. Three scenarios follow.
1. If the exposed preaponeurotic fat was com-
pletely excised, what remains of the septum and
overlying preseptal orbicularis is now lying over
260 Asian Blepharoplasty and the Eyelid Crease

Lid open (looking ahead)

Lid (levator) at rest

FIGURE 18-7 ■ Following revisional Asian blepharoplasty using a superiorly beveled approach (see Figure 18-5), the glide space has
been partially restored and the scar removed. The preaponeurotic platform is cleared of any interfering tissues. Although the surgeon
is often forced to make a skin incision that is still further from the lid margin than one would for a primary Asian blepharoplasty,
upon closure the incision wound (white dot) is free to indent inwards when the levator contracts, forming a better crease. The
residual fat pads in the middle (glide) zone are preserved and allowed to fill in this glide space where appropriate. Skin denoted by
the red and blue dots above the incision is now free to hang down and around to form the contrasting eyelid fold.

and directly in contact with the levator aponeurosis,
with no fat buffering. There is a good chance that
the preaponeurotic space (glide zone) will be oblit-
erated. The result is a deep-set supratarsal sulcus as
well as poor crease formation.
2. If there were only partial or conservative removal
of fat, there is the possibility that some fat will still
be interposed between the preseptal orbicularis
muscle (anterior layer) and the aponeurosis (poste-
rior layer).
3. In my beveled approach towards the upper incision
line, upon surgical closure of the incision the upper
skin edge alone is attached to aponeurosis along the
superior tarsal border as well as the lower skin edge;
there is also preservation of the preaponeurotic
space and fat down to the superior tarsal border,
coupled with some fat buffering in the glide zone.
More orbicularis fibers are removed along the
upper incisional edge, as the orbicularis was
transected in an upwardly beveled fashion. This
allows the immediate vicinity of the upper inci-
sional skin edge to be in contact with the preaponeu­
rotic space thus created.
In the last two situations, where fat was only partially
excised (or repositioned superiorly), whether via a tradi-
tional rectangular debulking of the preaponeurotic plat-
form or via a trapezoidal debulking of the soft tissues, the
preaponeurotic space over the preseptal mid-region of
the upper lid has been preserved. There is fat buffering
(preservation of the preaponeurotic space or glide zone)
as well as a soft tissue mass (consisting of the preseptal
skin, orbicularis, orbital septum, and preaponeurotic fat)
bellowing on top of a dynamically elevating tarsal plate.
The redundant soft tissue platform (previously referred
to as preaponeurotic platform) has been reduced by an
appropriate amount. The crease formed is dynamic and
natural from an aesthetic viewpoint.
The restoration and preservation of the preaponeu-
rotic space is an essential element in the primary addition
of a crease for an Asian with a creaseless eyelid, for it is
 18 Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty
the up-vectoring of the tarsal plate, coupled with the
attendant presence of fat in the preserved preaponeurotic
space, that helps create the appearance of a well-formed
crease under a preseptal eyelid fold contour of the mid-
section of the upper eyelid.
It would be undesirable to completely excise fat,
thereby obliterating the preaponeurotic space, flatten the
preseptal mid-section and create a supratarsal sulcus on
an Asian upper lid.
The following reasoning is applied to revisional
blepharoplasty. By utilizing the superiorly beveled approach
along the upper line of incision, I aim to preserve the
integrity of the preaponeurotic space. If the patient has
previously undergone a traditional rectangular debulking
with partial excision of fat, this approach will allow one
to locate the preaponeurotic space without much diffi-
culty. If the previous surgeon carried out the trapezoidal
debulking method,1 it is relatively easy to find the
preaponeurotic space, as I do when performing touch-up
enhancement of the crease. If the patient has undergone
rectangular debulking with total fat removal, the beveled
approach still gives a greater chance of reaching a familiar
surgical landscape, that is, the preaponeurotic space.
(The fourth scenario of trapezoidal debulking with com-
plete fat removal has not so far been encountered by this
B
FIGURE 18-8 ■ (A) Preoperative appearance prior to revision. (B) Postoperative appearance after revision.
261
author, as most surgeons nowadays know not to remove
too much fat in Asian eyelids; however, not so many are
familiar with trapezoidal debulking using a beveled
approach as applied to Asians.)
Often a patient will present with a history of upper lid
aesthetic surgery and exhibit a flattened or absent crease
with a mild hollowing of the sulcus. The patient may have
poor crease formation for a number of reasons, including
poor surgical adhesion between the skin edges and the
aponeurosis, or the presence of an amorphous sheet of
fat that appears plastered down over the entire aponeu­
rosis within the preaponeurotic space between skin and
levator.
The beveled approach as applied in revisional Asian
blepharoplasty allows the surgeon to reach the preaponeu­
rotic space safely, to reposition any remaining preaponeu­
rotic fat superiorly to fill in the hollow, and to approach
the preaponeurotic space without having to sacrifice pre-
cious millimeters of skin along the upper skin incision
line through excision. In other words, you are making
sure that your incision will not add to the problem, while
allowing yourself access to the eyelid’s preaponeurotic
space to excise middle lamellar scar, re-establish a glide
interface and to recreate a relatively physiologic and
dynamic crease (Figure 18-8).
262 Asian Blepharoplasty and the Eyelid Crease

Scarring seen in suboptimal cases of aesthetic surgery
of the Asian upper eyelid may include spreading of the
incisional skin, high placement of the lid crease, induced
lagophthalmos on downgaze, and acquired secondary
ptosis on straight-ahead as well as upgaze. Intraopera-
tively, one sees middle lamellar scar involving the orbicu-
laris oculi as well as the orbital septum, or the presence
of dense scar tissue plaques that may bind the anterior
orbicularis oculi as well as the posterior levator aponeu-
rosis. Instead of having a physiologically preserved ‘glide
zone’ where preaponeurotic fat pads are still present in
the lowest aspect of the glide space, there is now a con-
densed apron (plaque) of tissue preventing the posterior
layer from up-vectoring properly against a passive and
flexible skin–orbicularis layer.
Within the author’s practice, a series of 26 patients and
48 eyelids underwent revisional blepharoplasty over four
years for the specific purpose of revising a post-surgical
high crease to a lower position.6 Excluded from this series
were all primary Asian blepharoplasties, including any
patients with a pre-existent high crease, touch-up surgery
for the purpose of enhancing (deepening) an existing or
surgically created crease, correction of incomplete crease
or crease shape alone, and simultaneous correction of
acquired or involutional ptosis in conjunction with
primary Asian blepharoplasty. There were five males and
21 females, and with the exception of four patients who
requested unilateral crease revisions, all others were
bilateral.
The data were arranged in two sets of columns (Table
18-1): OD for the right upper lid, OS for the left upper
lid. The third column of each of these two clusters of data
reflects the difference between the preoperative and post-
operative measurements. There were 24 eyelids in each
category, for a total of 48 eyelids. The data were pooled
to arrive at the overall statistical mean. The pre-revisional
crease height was measured in the office using a milli­
meter scale and ranged between 8 and 14 mm, with the
overall mean being 9.9 mm. The crease height designed
during revision (in 0.5 mm increments) varied between
6.0 and 8.5 mm based on the circumstances, with the
mean being 7.15 mm; and 7 mm was the most often
applied measurement during surgery under local anes-
thetic. The effective lowering of the crease height ranged
from 1 to 6 mm when reassessed during 2-month post-
revisional visits. The mean lowering of crease height was
2.75 mm in this series, based on 2 months follow-up. The
typical course is such that the crease height will continue

TABLE 18-1 Revisional Data in a Series of 48 Eyelids, Showing Age, Gender and Degree of Lowering
of Crease Height in Millimeters
Age and Gender Preop OD Postop OD Change Preop OS Postop OS Change
1 42F 12 7.5 4.5 11 7.5 3.5
2 38F 11 7.5 3.5 10 7.5 2.5
3 46F 11 7 4 10 7 3
4 60F 10 6 4 10 6 4
5 54F 9.5 7.5 2 9.5 7.5 2
6 32F 9 7 2 9 7 2
7 32F 8.5 6.5 2
8 22F 8.5 7 1.5 8.5 7 1.5
9 23M 8 7 1 8 7 1
10 63F 9 7 2 9 7 2
11 36F 12 8 4 14 8 6
12 58F 12 7 5 12 7 5
13 65F 11 7 4 11 7 4
14 29F 9 7 2 9 7 2
15 22F 9 8 1 9 8 1
16 55F 10 7.5 2.5 10 7.5 2.5
17 66F 9 6 3 8.5 6 2.5
18 30F 11 8.5 2.5 10 8 2
19 34F 9.5 8 1.5
20 25F 8.5 7 1.5 8.5 7 1.5
21 39F 9 7 2 9 7 2
22 47F 11 8 3 11 8 3
23 28F 8 6.5 1.5
24 63F 10 7 3
25 26F 9.5 6.5 3 9.5 6.5 3
26 28F 12 6 6 12 8 4
Subtotal = 240.5 172 68.5 235 171.5 63.5
Statis. Mean = 10.02 7.17 2.85 9.79 7.15 2.65
Total (OD + OS) = 475.5 343.5 132
Overall Mean = 9.9 7.15 2.75
 18 Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty
to settle down with egress of swelling and wound healing,
such that the effective lowering of the crease would likely
increase had it been possible for all these patients to
return after a lengthier follow-up period.
The use of a superiorly beveled approach in revisional
Asian blepharoplasty can allow the glide zone to be par-
tially restored and the middle lamellar scar removed. The
preaponeurotic platform can be cleared of any interfering
tissues. The combination of techniques described in this
chapter often allows an abnormally high and static scar
line to be repositioned into a lower and more dynamic
crease, to the point of being acceptable for the patient.
The need for skin grafting may often be avoided.
263
REFERENCES AND FURTHER READING
1. Chen WPD. Concept of triangular, rectangular and trapezoidal
debulking of eyelid tissues: application in Asian blepharoplasty. Plast
Reconstr Surg 1996;971:212–218.
2. Chen WPD. Asian blepharoplasty: a surgical atlas. Oxford:
Butterworth–Heinemann, 1995.
3. Chen WPD. Asian blepharoplasty – update on anatomy and tech-
nique. J Ophthalmol Plast Reconstr Surg 1987;3:135–140.
4. Chen WPD. Aesthetic eyelid surgery in Asians: an East–West view.
Hong Kong J Ophthalmol 2000;3:27–31.
5. Chen WPD, Khan JA. Color atlas of cosmetic oculofacial surgery
(with DVD), 2nd edn. Philadelphia: Elsevier Science/Saunders,
2010.
6. Chen WPD. Beveled approach for revisional surgery in Asian
blepharoplasty. Plast Reconstr Surg 2007;120(2):545–552.
 CHAPTER 19

ADVANCED: ANGLE OF
OBSERVATION, CREASE HEIGHT AND
ITS EFFECTS ON CLINICAL OUTCOME
OF UPPER BLEPHAROPLASTY

This chapter deals with the author’s concepts regarding ANATOMIC DEFINITION OF AN UPPER
the height and depth of an eyelid crease, which change
in different view positions with respect to the patient’s
EYELID CREASE
gaze, as well as the clinician’s observing angle.
The upper eyelid crease is a natural indentation of the
An individual’s upper eyelid crease height varies in its
eyelid skin, usually found along the level of the superior
measurement and is influenced by various factors, includ-
tarsal border, which is apparent when the subject opens
ing resting position, angle of observation and presence of
their eyelid (Figure 19-1). It is believed to be a result of
associated ocular abnormality. Its effects should be taken
contraction of the distal fibers of the levator aponeurosis,
into consideration in planning primary aesthetic and revi-
pulling up on the tarsus as well as the pretarsal skin and
sional surgery of the eyelids.
orbicularis in a superior–posterior direction against a
relaxed preseptal segment of the anterior lamella of the
upper lid (skin, orbicularis, orbital septum and preaponeu­
rotic fat).

FIGURE 19-1 ■ The position of the upper

eyelid crease.

265
266 Asian Blepharoplasty and the Eyelid Crease

POSITION OF THE UPPER LID AND ITS
EYELID CREASE
Depending on the tilt of the face, there is an observable
variance in the apparent height of the upper lid crease.
Most individuals with an upper eyelid crease will show
the crease optimally in a straight-ahead gaze position
(Figure 19-2).

CH 2

FIGURE 19-2 ■ This shows the patient with eyelids open and looking straight ahead. The lid crease is an indentation of the skin that
corresponds with the superior tarsal border, where levator aponeurosis inserts on to as well as branching forward into orbicularis
muscle sheaths and skin under the eyelid crease. CH 2 refers to the crease height observed when the observer and subject are both
in a neutral gaze position.

VISUAL AXIS ANGLE (Vax)
Downgaze (Figure 19-3)
In downgaze, the inferior rectus and superior oblique
muscles contract while the superior rectus and levator
muscle relax, stretching the latter to its longest length. For
a person who has a natural crease, downgaze results in the
shallowing or disappearance of the upper crease, though
there is still a faint skin line that is observable on its skin.
is presumably maximally contracted and at its shortest
length. The angle of upgaze as measured from horizontal
can be designated as a positive (+) Vax (Vax = patient’s
visual axis angle, relative to the horizontal axis).
If this same person should tilt the vertex (top of head)
backward slightly (in a chin-forward position) and still
maintain forward gaze with a posterior head tilt, as far as
the eyeball is concerned this is similar to a downgaze and
therefore the crease is less deep and obvious.

Upgaze (Figure 19-4)

The crease is deepest when the upper eyelids are open
and looking upward maximally – where the levator muscle
 19 Advanced: Angle of Observation, Crease Height and Its Effects on Clinical Outcome 267

(–) Vax

FIGURE 19-3 ■ The patient’s visual axis is looking down-

ward, Vax is negative and crease indentation is minimal.

(+) Vax

FIGURE 19-4 ■ With the eyes of the patient looking up, the
levator muscle is maximally contracted and the crease is
deepest when viewed externally.
268 Asian Blepharoplasty and the Eyelid Crease
Posterior Head Tilt
Interestingly, a significant proportion of Asians with
a single eyelid tend to have a detectable vertex-back,
posterior head-tilt. This is analogous to a slight down-
ward gaze with a negative (−) Vax, inclining their levator
muscle towards a more relaxed state, and further dimin-
ishing the pull on the pretarsal segment. There may be
several reasons: in single-lidded individuals, their single
lid fold tends to obstruct the upper 5–10 degrees of their
superior field of vision, and this posterior head-tilt may
be a compensatory move in an attempt to see better.
There is also the possible co-occurrence of latent ptosis
or presence of detectable mild ptosis. Since birth, these
individuals may adapt and use a slight head-back posture
to clear their visual axis. They are often quite surprised
when this is pointed out to them using photography from
their sides or mirrors. Indeed, even after successful surgi-
cal enhancement or addition of an upper eyelid crease,
many patients often shallow their newly found crease
without knowing it when they assume their previously
accustomed head-back position. The well-formed crease
may not fully invaginate until the person’s face is fully
frontal with straight-ahead gaze (at zero Vax).
(+) ao
FIGURE 19-5 ■ The patient’s visual axis is looking upward, Vax is positive and crease indentation is maximal. If the examiner is stand-
ing, the angle of observation (ao) will be higher than that of the patient’s eyelids, and can be denoted as a positive angle of obser-
vation. CH 1 represents an artificially shortened crease height when the upper lid is retracted on upgaze.
Positive Vax
As mentioned before, the levator muscle is at its maximum
contraction on upgaze; here the eyelid crease appears the
deepest. We can consider the patient’s visual axis angle
(Vax) in this maximal upgaze position as being its maxi-
mally positive angle away from a straight-ahead zero
angle (Figure 19-5).
Positive ao
When the examiner is standing in a higher observing
position relative to the patient’s eyes, with the patient
looking back at the observer’s higher position, the crease
will appear deeper due to a positive angle of observation
(+ ao) from the observer as well as having the patient look
up with a positive Vax (see Figure 19-5). This is similar
to asking the patient to tuck his/her chin in towards the
sternum while looking ahead with the examiner in a level
position observing back towards the patient, essentially
placing the patient’s eye in an upgaze position relative to
its orbit. CH 1 is less than CH 2.
CH 1
(+) Vax
 19 Advanced: Angle of Observation, Crease Height and Its Effects on Clinical Outcome 269

Negative Vax Negative ao

The levator is at its most relaxed state when the eyes look
down, with the upper lid as well as superior rectus in a
relaxed state (Figure 19-6). Here the visual axis angle (as
measured downward from the straight-ahead zero angle)
is at its maximally negative angle, and the crease’s invagi-
nation would naturally shallow or fade as downgaze
progresses.
If the patient is located at a higher position than the
examiner, the examiner is at a lower position and looking
up (creating a negative ao) while the patient is looking
down and has a negative Vax. The crease looks shallowed
(see Figure 19-6). CH 3 is greater than CH 2 and repre-
sents the anatomic crease height.

CH 3

(–) Vax

(–) ao

FIGURE 19-6 ■ The patient’s visual axis is looking downward, Vax is negative and crease indentation is minimal. If the examiner’s
eyes are looking up from an inferior position relative to the patient, the angle of observation (ao) up at the patient can be denoted
as a negative angle of observation. CH 3 represents the true anatomic crease height as seen upon downgaze or lid closure.
270 Asian Blepharoplasty and the Eyelid Crease
Neutral Vax (= Zero)
When a person with a natural crease is looking straight
ahead with a horizontally-leveled gaze (set as zero Vax),
the crease is optimally manifested, neither too deep nor
too shallow. In this author’s view, the same dynamic
feature should be expected of a crease that is surgically
constructed. The surgical method thus chosen for an
Asian eyelid crease should reflect and demonstrate these
objectives.
ANGLE OF OBSERVATION (AO)
The examiner’s angle of observation (‘ao’) should also be
standardized. It should be level and perpendicular to the
subject’s upright face; this will be the examiner’s zero
angle of observation (ao = 0) looking straight ahead (see
Figure 19-2).
Therefore with either the Vax or ao schema, a positive
value of each is associated with a deepening of the crease,
and a negative value of either is associated with a lessen-
ing of the crease.
For study or documentation purpose, the Vax and ao
should always be observed in a zero value position (patient
and observer looking level and straight ahead at each
other).
In elderly patients with involutional ptosis, often we
see what was a normally positioned crease during the
individual’s youth eventually giving way to a higher, less
distinctive crease with onset of ptosis. The reasons are
three-fold: there is an age-related weakening of levator
aponeurotic muscle and its attachment along the superior
tarsal border, a weakening of pretarsal and preseptal
orbicularis muscle near the area in front of the superior
tarsal zone, and a drop in upper lid margin (causing a
slight posterior head tilt and inducing a negative Vax),
plus shallowing of their crease indentation. The weaken-
ing of orbicularis fibers between the superior tarsal
border and its overlying skin results in lessening of distal
aponeurotic fibers that had previously pulled in the eyelid
crease at its original position. The few aponeurotic
branches that remain are superior to this zone of dehis-
cence, which then constitutes what clinicians describe as
the ‘crease that migrated upward’; this remnant of the
crease is shallower and not a true anatomic crease since
it does not indent well at this higher position.
The significance of these concepts is that the ‘crease
depth’ often comes into discussion between patients and
doctors and it is best to have a clear understanding of
what a well-formed natural crease does, what a surgical
crease should do (dynamic, soft and natural etc.) and what
qualifies as an inadequate crease (in terms of depth, con-
tinuous or incomplete etc.). Even more importantly, it is
surprising for this author to hear how often the doctors
and patients may not have discussed in detail the goals of
where the crease height ought to be.

ADVANCED: THE CONCEPT OF
TARSAL TILT – ITS EFFECTS IN
NORMAL AND ABNORMAL
CLINICAL CONDITIONS
This chapter deals with the author’s original finding that
the natural tilt of the eyelid’s tarsal segment is at approxi-
mately 45° when the eyelids are open. The crease height
is inaccurate when measured vertically and actually cor-
responds to the true anatomic crease height through a
factor of √2 ÷1.0, assuming a 45° isosceles triangle, or is
1.41 X, with X being the frontally measured vertical
extent. In other words, the vertical measurement with
opened eye underestimates the true crease height by a
factor of 1/√2. Inaccuracy in discussion and measure-
ment of crease height are a major cause of problematic
suboptimal outcomes.
Figure 20-1A shows the author’s concept of tarsal tilt,
with the sloping angle of the tarsal plate and pretarsal
CHAPTER 20
segment (where the crease is located) varying between 45
and 50°. This angle can be investigated through mathe-
matical modeling and clinical measurements using pho-
tography and MRI.
Proper understanding of the effect of the tarsal tilt and
its effect on apparent crease height is critical for any
practitioner contemplating eyelid surgery. The tarsal
tilting reduces the apparent crease height as well as influ-
encing Caucasians’ and Asians’ anatomy differentially in
both normal state and various conditions of eyelid mal-
positions. Using mathematical modeling as well as clini-
cal examples, this chapter will relate the effects of this
with respect to common errors seen in aesthetic upper
blepharoplasty.
271
272 Asian Blepharoplasty and the Eyelid Crease

,°

Anatomic
crease height

Tilted crease
height (Tch)
A
FIGURE 20-1 ■ (A) The incline angle (I°) represents the tarsal tilt when the lid is open with eyes looking ahead. The height of the
tarsus is represented as the line in red, and corresponds to the Anatomic crease height. It is best measured when the eye is looking
down or both upper and lower lids are apposed. The vertical measurement of this is the blue Tilted crease height (Tch).
 20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions 273

I°

Apparent crease height

Anatomic crease height
Tilted crease height (Tch)
I° Incline angle

I°

B
FIGURE 20-1, cont’d ■ (B) When there is an eyelid fold over the crease as in this drawing, what we are left to see in place is the blue
line minus the height of the lid fold to yield the green Apparent crease height. Patients often deal with the blue and green line
measurements while physicians should measure the red line, and be aware of the implications of these other factors.
274 Asian Blepharoplasty and the Eyelid Crease

a similar position. To get the true anatomic crease height,

DISCREPANCY BETWEEN OBSERVED
APPARENT CREASE HEIGHT AND TRUE
ANATOMIC CREASE HEIGHT
We often see teaching staff demonstrating to house staff
the nuances of measuring levator function (excursion) by
placing a millimeter ruler along the face and eyelid,
perhaps at the central portion of the upper lid margin.
The measurement of the crease height is often taken in
we should have the patient looking downward, such that
the upper lid pretarsal zone is almost vertical, or measure
the eyelid crease height with the lids closed; we then
obtain the true anatomic crease height, which is usually
located at and corresponds to the height of the central
tarsus.
In the figure we see here of a young adult (Figure
20-2), the upper tarsus is measured to be at a tilt angle
of 41° from the horizontal axis.

41°

FIGURE 20-2 ■ Side view of a young woman positioned in front of a slit-lamp biomicroscope with the frontal plane aligned vertically.
The surface of pretarsal skin and underlying upper tarsus is measured to be at an incline (tilt angle) of 41° relative to the horizontal
axis.
 20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions 275

ASIAN ANATOMY
Take for example a natural 7 mm crease for an Asian
upper eyelid. Figure 20-3A shows the upper lid in a
closed or down-turned position, while Figure 20-3B
illustrates the lid in its normal, open position looking
ahead. When the face is vertical and the eyes are looking
ahead, the crease is optimally manifested and tucked in
under its eyelid fold. The superior tarsal platform is
angled supero-posteriorly in a tilted direction, close to a
tilted incline angle (I) of 45°. The tarsus therefore mani-
fests tarsal tilt.
Inclined crease height (Ich) or ‘tilted crease height’
(Tch) (blue in Figure 20-1) is the crease height as seen
and measured vertically by an observer sitting across
from the subject (eyes are open), and is always less than
the true anatomic crease height.
An anatomic crease height of 7 mm (pretarsal skin or
tarsus, red line in Figure 20-1) can be thought of as being
aligned on the hypotenuse of a 45° isosceles triangle, Crease
while the two remaining sides of this hypothetical trian- line
gle are the vertical axis and the horizontal axis (each of
the two sides will be approximately 7 mm × (1/√2),
equaling 5 mm vertically and horizontally). Therefore a
natural 7 mm crease will appear to the examiner as occu-
pying 5 mm in vertical height from the most indented
part of the crease to the eyelash margin (inclined or Anatomic
crease
‘tilted’ crease height, Tch), and about 3 mm only if there height
is 2 mm of eyelid fold overhanging it (the portion showing
below the edge of the lid fold will be the clinically ‘appar-
ent crease height’). Therefore it is quite normal for a
single-eyelid patient to ask for a 3 mm crease for an end
result; the practitioner should realize that it needs to
come from a 7 mm anatomic crease placement.

Tilted crease
FIGURE 20-3 ■ (A) The diagram shows the upper lid in height (Tch)
a closed or down-turned position, while (B) illustrates
the lid in its normal, open position looking ahead. When
the face is vertical and the eyes are looking ahead, the I°
crease is optimally manifested and tucked in under its
eyelid fold. The superior tarsal platform is angled supero-
posteriorly in a tilted direction, close to a tilted incline
angle (I) of 45°. The tarsus therefore manifests tarsal tilt. B
276 Asian Blepharoplasty and the Eyelid Crease

Apparent crease height < Inclined crease height ( often Tilted crease height − Fold = Apparent crease height
measured vertically ) < Anatomic crease height Apparent crease height + Fold = Tilted crease height
or
Tilted crease height is not worth measuring clinically,
though it is usually approximately equal to 1/√2 (= 0.72
Anatomic crease height > Inclined crease height
or five-sevenths) of the true anatomic crease height; the
> Apparent crease height
anatomic crease height should be measured with the
eyelids closed or looking down.
implying that the surgical design of a crease height is
Another crude method of measuring the tarsal tilt in
inherently higher, up to a certain anatomic boundary,
an open eye is through MRI scan. In Figure 20-4 we see
than what the patient observes or perceives.
an image of a patient showing the measured angle of the
The apparent height of the crease is less than the tilted
open eyelid’s tarsal segment to be 44.45°.
crease height we see, by the millimeters of overhanging
lid fold:

FIGURE 20-4 ■ MR scan image of a patient

showing the digitally-measured angle of
the open upper eyelid’s tarsal segment
to be inclined (tilted) at 44.45° to the
horizontal.
 20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
METHODS OF INVESTIGATION AND
ANALYSIS: MATHEMATICAL MODELING
Mathematical modeling is often used by engineers and
physicists to simulate real life scenarios when it is not
feasible to measure complex events at the current stage
of technology available, for example weather patterns,
earthquake predictions, nuclear weapon testings, or aero-
dynamics of rocketry. Next to feasible actual measure-
ment, it is considered the gold standard when it comes
to accuracy; I will attempt to do the same here using basic
geometry and trigonometry.
When the eyes are open, the tilt angle of the pretarsal
segment of the upper lid (including skin, orbicularis,
tarsal plate) as it lies on the eyeball may vary between 40
and 50° (assuming that the upper lid margin, hence
tarsus, rests at the location of the upper corneal limbus
and the tarsal plate extends superiorly beyond this point);
we shall designate this tarsal resting angle as the incline
angle, I.
Normal Eye Schema
The human eye has an axial diameter of 25 mm, with a
radius of 12.5 mm and a circumference of 78.5 mm. Each
millimeter on the globe surface will subtend 4.6° as meas-
277
ured from the center point of the eye (360° ÷ 78.5 mm
= 4.6° per millimeter of circumference).
[Optional reading: We will make several assumptions.
Although various eye specialists may consider the resting
position of the upper lid in an open eye as between supe-
rior corneal limbus (in youngsters) and one millimeter
below superior corneal limbus (adults), we will assume it
is at superior limbus to eliminate the difference in corneal
and scleral curvatures affecting the calculations, if there
is any. We will also discuss the two abnormal clinical
conditions of upper lid retraction of 2 mm above limbus
(2 mm scleral show), as well as ptosis when the upper lid
covers 4 mm down from limbus (4 mm of superior cornea
covered). This is similar to if we should adopt that 1 mm
coverage of superior cornea is the natural position of the
upper lid in the open eye position, and then these two
abnormal clinical conditions stated above will be equal to
3 mm of retraction from the original resting upper lid
position (of 1 mm covering cornea) with a resultant
2 mm scleral show; while the 4 mm ptosis down from
superior limbus is essentially a 3 mm ptosis from the
defined resting upper lid margin at 1 mm corneal cover-
age. You can also think of this as trying to simulate what
happens with a non-linear function like sine function,
when we deviate upward and downward an equal amount
of 3 mm in each direction, if we assume the resting upper
lid margin is located at 1 mm below the superior limbus.]
278 Asian Blepharoplasty and the Eyelid Crease
Caucasian with 10 mm Tarsus
(Figure 20-5)
Let us consider a Caucasian adult with the upper tarsus
measuring 10 mm in vertical size (height), measured
from the widest (central) portion of the tarsal plate. With
the upper lid completely opened, assume the eyelid
margin rests at the superior corneal limbus. Its crease will
be 10 mm from the ciliary margin. The tarsus itself will
subtend 46°of the circumference of the eye. The upper
half of the cornea, which is 5 mm, will subtend 23°. The
tarsus subtends 46°. From the knowledge that the two
radii connecting from center of the globe to the lid
margin and similarly to the crease indentation are equal,
we can calculate the incline angle (I) relative to the hori-
zontal axis for a Caucasian to be I = (180° − 46°)/2 − 23°
= 44° (see Figure 20-5).
Figure 20-5 shows a model of a Caucasian eye with a
10 mm upper tarsus. The solid circle is the eyeball. The
upper lid is not drawn here but its margin lies from the
top of the superior corneal limbus on upward. The blue
outline is an average clear cornea of 10 mm diameter.
The 10 mm arc represents the upper lid tarsus when the
eyelid is opened. (The horizontal line with the arrow is
drawn parallel to the axial line that runs from the center
of cornea to the back of the eyeball.) The dotted line is
the slope of the tarsus rather than its true location in
67°
10 mm
I°
5 mm
46°
23°
FIGURE 20-5 ■ Model for a Caucasian eye with a 10 mm upper tarsus. For details see text.
space (hence the tilt of the tarsus is I° when it indents to
form the crease at the blue arrow where the upper border
of the tarsus is located).
The magnitude of the tilt angle I (based on the lid
position) can be used to relate what we apparently see
(Tch) versus what we measure correctly when the lids are
looking down (or closed): we may recall from trigonom-
etry that {sine function of an angle = opposite/hypotenuse}.
Therefore, the sine function of value I (incline angle
from tarsal tilt) is equal to the observed vertical compo-
nent of the crease in space (Tch, which is not yet known),
divided by the anatomic height (the hypotenuse) of the
tarsus (whose superior tarsal border usually correspond
to the location of the eyelid crease), which is known to
be usually 10 mm in Caucasians (see also Figure 20-3):
Sine 44° = Tch 10 mm
Sine 44° = 0.69
Therefore Tch = 10 mm × 0.69 = 6.9 mm for Caucasians.
The Caucasian tarsus projects a 6.9 mm vertical compo-
nent when examined with the eyelids opened, even
though it is actually 10 mm. The crease height appears
to be 6.9 mm when it should be 10 mm assuming that
the crease folds in at an area along the superior tarsal
border.
r = 12.5 mm
 20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
Caucasian with 4 mm Ptosis (Figure 20-6)
We will now model a Caucasian eye with 4 mm ptosis.
The solid circle is the eyeball. The upper lid is not drawn
here but its margin lies on the cornea with ptosis covering
4 mm of the upper cornea and is only 1 mm from totally
occluding the central optical axis. The blue outline is an
average clear cornea of 10 mm diameter. The 10 mm arc
(that covers the dotted line) represents the upper lid
tarsus. The dotted line is the congruent slope of the
tarsus at its mid-height (hence the tilt of the eyelid crease
is I° when it indents to form the crease at the blue arrow
where the upper border of the tarsus is located).
If this Caucasian had a 4 mm ptosis, the upper lid
would be covering 4 mm of the upper cornea. (Note that
ophthalmologists usually measure from a reference point
of normal upper lid margin as covering 1 mm of the
67°
10 mm
I°
1 mm 46°
4.6°
FIGURE 20-6 ■ Model for a Caucasian eye with 4 mm ptosis. For details see text.
279
cornea, so 4 mm on the cornea would actually be a 3 mm
ptosis. For simplicity’s sake and modeling purpose, we
shall use this position of 4 mm ptosis from the superior
corneal limbus. See previous discussions on assumptions
in mathematical modeling. )
Using a similar calculation as previously shown, we
know that each millimeter on the globe’s surface will
subtend 4.6°. When the lid is down 4 mm, it is only
1 mm above the equator of the eye, so that angle is 4.6°
as labeled in the model of the globe.
I (incline angle) = 67° − 4.6° = 62°, sine I = 0.89 =
Tch/10 mm, with a Tch of 8.9 mm. We will therefore see
more of the true crease height (Tch approaches closer to
10 mm) with a moderate ptosis; in this case, the value of
Tch is 8.9 mm. Stated similarly, when the upper lid drops
down, we see a greater pretarsal zone and it shows closer
to its true anatomic crease dimension.
r = 12.5 mm
280 Asian Blepharoplasty and the Eyelid Crease

Caucasian with 2 mm of Upper Lid
Retraction (Figure 20-7)
Now we model a Caucasian eye with 2 mm of upper lid
retraction. The solid circle is the eyeball. The upper lid
is not drawn here but its retracted margin lies above
the superior corneal limbus with 2 mm of white sclera
showing. The blue outline is an average clear cornea
of 10 mm diameter. The 10 mm arc (peripheral to the
dotted line) represents the upper lid tarsus when the
eyelid is opened. The dotted line is the congruent slope
of the tarsus at its mid-height (hence the tilt of the eyelid
crease is I° when it indents to form the crease at the blue
arrow where the upper border of the tarsus is located).
With 2 mm of retracted upper lid margin beyond the
superior corneal limbus (or 3 mm retraction according to
ophthalmologists’ convention of 1mm covering the upper
cornea as normal upper lid position with an open eye),
the upper lid margin now rests 7 mm from the optical
center of the cornea or the equator of the globe.
We know that each millimeter on the globe’s surface
will subtend 4.6°. An upper lid margin at 7 mm above
equator will subtend 32°. This allows us to calculate: I
value = 67° − 32° = 35°.
Sine I = sine 35° = Tch 10 mm = 0.57
Tch is 10 mm × 0.57 = 5.7 mm.
To an observer, the retracted upper lid with a tarsus of
10 mm will show a vertical component of the crease
height of only 5.7 mm vertically.

67°
10 mm

I°
2 mm

46°
32°

r = 12.5 mm

FIGURE 20-7 ■ Model for a Caucasian eye with 2 mm of upper lid retraction. For details see text.
 20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions 281

Asian with Upper Lid Tarsus of 7 mm
(Figure 20-8)
We will apply analogous calculations to Asian anatomy
for normal resting position, ptosis of 4 mm, and upper
lid retraction of 2 mm above superior limbus.
Figure 20-8 shows an Asian eye with upper lid tarsus
of 7 mm vertical height. The eyeball is still 25 mm diam-
eter. The 7 mm arc represents the upper lid tarsus when
the eyelid is opened and its lid margin is right along the
superior corneal limbus (top of the cornea). The dotted
line is the congruent slope of the tarsus at its mid-height
(hence the tilt of the eyelid crease is I° when it indents
to form the crease at the brown arrow where the upper
border of the tarsus rests).
The average Asian tarsal plate measures between 6.5
and 7.5 mm, with the majority averaging 7 mm centrally
(Figure 20-8). Remember that 4.6° is the angle subtended
(covered) by each millimeter of the globe’s circumfer-
ence. A 7 mm tarsus therefore covers 32°, and 5 mm of
the cornea (upper half) covers 23°.
With the lids opened, the tarsus has an incline angle
(I) of (180−32)/2, then minus 23°: 74 − 23 = 51°.
Sine I = sine 51° = 0.77 = Tch 7 mm
Tch ( vertical component of the crease height )
= 0.77 × 7 mm = 5.4 mm for Asians.
An anatomic crease height of 7 mm in a normal Asian
will look like it is a 5.4 mm crease when viewed frontally
(vertical component is 5.4 mm). If there is an overhang-
ing skin fold of 2 mm, the observable crease height will
then appear to be (and possibly be measured incorrectly
as) 3.5 mm. (When a patient asks for a ‘lower-than-aver-
age’ crease height and the physician incorrectly interprets
an average crease as being located at 3.5 mm and then
makes an incision lower than that, it is foreseeable that
suboptimal results may follow.)

74°
7 mm

I°

5 mm
32°
23°
r = 12.5 mm

FIGURE 20-8 ■ Model for an Asian eye with upper lid tarsus of 7 mm vertical height. For details see text.
282 Asian Blepharoplasty and the Eyelid Crease

Asian Eye with 7 mm Tarsus, with 4 mm I = 74.0 − 4.6 = 69.4°

Ptosis (Figure 20-9)
We will model an Asian eye with 4 mm of ptosis. The
upper lid is not drawn here but the upper lid margin rests
4 mm below the upper corneal limbus (boundary). The
brown outline is an average clear cornea of 10 mm diam-
eter. A 7 mm arc represents the upper tarsus. The dotted
line is the congruent slope of the tarsus at mid-height
(hence the tilt of the eyelid crease is I° when it indents
to form the crease at the brown arrow where the upper
border of the tarsus rests).
For an Asian with a 4 mm ptosis, I = (180−32)/2,
minus 4.6°:
Sine I = sine 69.4 = 0.936 = Tch 7 mm
Tch = sine I × 7 mm = 0.936 × 7 mm = 6.5 mm.
In an Asian eye with a 4 mm ptosis, we see the tilted
crease height as 6.5 mm. Conversely, if a Tch appears to
be 6.5 mm (instead of a normal Tch of 5.4 mm in a non-
ptotic eye), one should look carefully for ptosis. One will
need a high index of suspicion to detect ptosis as the dif-
ference in Tch we see between normal and severe ptosis
is only 1.1 mm.

74°

7 mm

I°
1 mm 32°

r = 12.5 mm
4.6°
5 mm

FIGURE 20-9 ■ Model for an Asian eye with 4 mm of ptosis. For details see text.
 20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions 283

Asian with 2 mm of Upper Lid Retraction
(Figure 20-10)
We will now model an Asian patient with 2 mm of upper
lid retraction. The solid circle is the eyeball. The upper
lid is not drawn here but its margin lies above the supe-
rior corneal limbus with 2 mm of white sclera showing.
The brown outline is an average clear cornea of 10 mm
diameter. A 7 mm arc represents the upper lid tarsus
when the eyelid is opened. The dotted line is the congru-
ent slope of the tarsus at its mid-height (hence the tilt of
the eyelid crease is I° when it indents to form the crease
at the brown arrow where the upper border of the tarsus
rests). The tarsus subtends 32° since it is 7 mm in dimen-
sion from lid margin to its superior tarsal border; the lid
margin is also resting 32° above the equator.
For the Asian with a 2 mm retracted upper lid margin,
the 7 mm tarsus presents a vertical component of only
4.7 mm.
I = (180 − 32) 2 − 32° = 74 − 32 = 42°
Sine I = Sine 42° = 0.67 = Tch 7 mm
Tch = sine I × 7 mm = 0.67 × 7 mm = 4.7 mm.

7 mm 74°

I°
2 mm

5 mm
32°

32°
r = 12.5 mm

FIGURE 20-10 ■ Model for an Asian patient with 2 mm of upper lid retraction. For details see text.
284 Asian Blepharoplasty and the Eyelid Crease
The data from these models have been inputted into
a graph plotting tarsal tilt (or incline angle, I; x-axis)
against tilted crease height, Tch (the vertical component
of the tilted segment of the crease, y-axis) (Figure 20-11).
The red squares represent Asian 7 mm tarsal anatomy;
the blue diamonds represent a Caucasian’s 10 mm tarsus.
The Condition of Ptosis in Caucasian
versus Asian
When the lid margin drops closer to the equator, the
visual gain in the crease height even without any true
clinical ‘anatomic dehiscence’ of the terminal fibers of the
aponeurosis is substantial. For a 10 mm tarsus (Caucasian,
blue diamond in Figure 20-11) with moderately severe
ptosis, the perceived dimension of an otherwise normal
crease expands by 2 mm (from ‘normal’ of 6.9 mm to
8.9 mm). The same ptosis for a 7 mm tarsal plate (Asian,
red square) only visually expands the crease from a Tch
of 5.4 mm to 6.5 mm, a visual elongation of 1.1 mm. Part
of this multiplying effect we see in Caucasian anatomy is
due to the larger dimension of the tarsus; the other reason
is that in any ptosis the crease location is dropped closer
to the center of the cornea, in effect the tilt (incline) angle
I of the tarsus is greater, and therefore the sine function
value is greater. Together, the sine function of I multiplied
by tarsal dimension (of 10 mm instead of Asian’s 7 mm
tarsus) gives a larger value for Tch in Caucasian anatomy.
This visual distortion from this more frontally observed
position no doubt contributes to the perception that the
‘crease has migrated higher in acquired ptosis’.
The Condition of Upper Lid Retraction in
Caucasian versus Asian
With a mild upper lid retraction of 2 mm in a Caucasian,
the Tch is changed from 6.9 to 5.7 mm, with the
difference being 1.2 mm. For an Asian’s 7 mm tarsus,
retraction of the same amount changes the Tch from 5.4
to 4.7 mm, a difference of merely 0.7 mm from a normal-
looking crease. The greater reduction in a Caucasian’s
Tch follows the same reasoning as before in ptosis: the
Caucasian crease along the upper boundary of tarsal
plate, now retracted 2 mm upward from the superior
corneal limbus, is sitting 17 mm of arc length away from
the corneal center (I = 35°); while the equally affected
Asian lid’s crease sits at 14 mm of arc length away from
the corneal center (I = 42°). That means the Caucasian
Tch values are affected more rapidly. The further upward
and backward the upper lid goes (as in Caucasians), then
the more flattening of tilt (I), as well as rapid changes in
the sine function value and its effect on Tch. This is due
to the fact that the sine function has a greater incremental
change as it approaches lower (lesser) angle values.
Equivalent clinical conditions of the same degree
(4 mm ptosis and 2 mm retraction) appear to be almost
twice (2 x) as manifested in magnitude for Caucasians,
starting from their larger tarsal plate relative to Asians.
This near-doubling effect in Caucasian anatomy can be
seen from the slope of a line plotting the red data points
as well as the blue data points in Figure 20-11: the Cau-
casians’ blue points are at a steeper slope than the Asians’
red points. One can also think of this as showing that
inaccuracy in planning the placement of eyelid crease
height has a greater likelihood of adverse consequences
for the smaller Asian anatomy.
CLINICAL APPLICATIONS
There is a lack of clarity among plastic surgeons and
ophthalmologists as to the ideal location for placement
of the lid crease in aesthetic blepharoplasty as well as for
reconstructive efforts. The following categories of sub-
optimal findings come to mind.
 10

4 mm ptosis
9
(62°, 8.9 mm)

Normal
7
(44°, 6.9 mm) 4 mm ptosis
(69.4°, 6.5 mm)
6 2 mm retracted UL Normal
(35°, 5.7 mm) (51°, 5.4 mm)
5
2 mm retracted UL
(42°, 4.7 mm)
4

Tilted crease height (mm)

3

2
10 mm tarsus 7 mm tarsus
1

0
0 10 20 30 40 50 60 70 80

I = Incline/Tilt angle (degrees)

FIGURE 20-11 ■ This graph plots tarsal tilt (or incline angle, I; on x-axis) against tilted crease height, Tch (the vertical component of the tilted segment of the crease; on y-axis).
The red squares represent Asians’ 7 mm upper tarsal height as measured centrally; the blue diamonds represent a Caucasian’s 10 mm upper tarsus. For the purpose of
20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions

mathematical modeling, we will assume the normal position with the upper lid opened is set at the superior corneal limbus (at its boundary with sclera), and that a moder-
ate ptosis is when the superior lid margin is 4mm down from the superior limbus (4mm ptosis, with a MRD of 1-1.5mm), which is equivalent to a 3mm ptosis if it is measured
from a normal opening position of upper lid margin covering 1mm of cornea. We will arbitrarily set the modeling of upper lid retraction as 2 mm of upper lid scleral show,
which is a “2mm retracted upper lid” as plotted on this graph, and corresponds to a 3mm upper lid retraction from normal open-eye position clinically if we assume normal
285

(open eye position) is measured from having the upper lid margin rest and covering 1mm of cornea.
286 Asian Blepharoplasty and the Eyelid Crease
High Crease
Often I see Asian patients for revisional consultations
where the issue centers around excess skin removal with
placement of a high crease (Figures 20-12, 20-13). The
original thought process that led to this could perhaps
arise from the following faulty train of logic: ‘If a Cauca-
sian’s lid crease is aesthetically ideal at 10–11 mm, then
Asians who desire the construction of a crease should
have similar result if the crease is designed at that height.’
An undesirable outcome can be averted with a proper
understanding of anatomy, crease-vectoring biodynamics
and the effect of tarsal tilt. Even if the surgeon
conscientiously designs the crease slightly lower with
proper understanding of Asian anatomy being smaller in
scale, and sets it 1–2 mm lower than he normally would
plan for Occidentals, with the incision mark at 8–9 mm,
the set crease will still end up being too high.
This predisposes to secondary ptosis, brow compensa-
tion and lagophthalmos. Subsequently, well-meaning
attempts at resetting a high crease often remove the
initial scarred skin as well as some skin above it, further-
ing the crisis associated with skin shortage, leading to
poor closure of the palpebral fissure, as well as a persist-
ent high crease.
FIGURE 20-12 ■ An Asian patient whose
left upper eyelid crease was set higher
than she preferred after a lid crease pro-
cedure. One can see a deep crease inden-
tation even while the eye is on downgaze.
The nasally-tapered crease shows evi-
dence of spreading of the wound skin,
and the lateral end converges towards
the lateral canthus, and may give the
impression of a high semilunar crease.
FIGURE 20-13 ■ A young woman who
developed a deeply set, partial crease of
the right upper eyelid that is static on
downgaze, with crease height that is
excessive for her. Pretarsal fullness is
seen.
 20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions 287

Low Crease, Poor Crease Formation
If an Asian’s natural upper lid crease looks good and its
vertical dimension measured with a ruler is 5 mm (which
is that person’s Tch) with the patient’s face upright and
eyes opened, and the surgeon then decides to use this
measurement on a single-eyelid patient, marking it at
5 mm with the lids closed, the result will be a static scar
on the front surface of the pretarsal skin, or a temporary
crease with eventual disappearance.
A second scenario is that if the surgeon thinks the
crease should be set at 5 mm (when in fact it is 7 mm),
and the patient desires the crease on the ‘low’ side of
normal and the surgeon complies and marks it at 3–4 mm,
it is then even more unlikely to achieve a crease than in
the previous scenario. In double-eyelid procedures utiliz-
ing the suture ligation methods, this may well be a factor
that tends towards eventual crease disappearance.
Figure 20-14 shows the gradual disappearance of a
crease on a patient’s right eye, and a persistent high crease
with disjunction medially on the left eye. Revision
attempts will be more challenging for the left eye.
Following a low-set static crease, any attempts at revi-
sion through the same site of 3–5 mm from the ciliary
margin risks persistent scarring in the pretarsal platform,
and lack of proper invagination along the superior tarsal
border to form a crease.

FIGURE 20-14 ■ Asian woman showing the gradual disappearance of a crease on right upper lid, and a persistent high crease with
disjunction medially on the left eye following lid crease procedure though external incision.
288 Asian Blepharoplasty and the Eyelid Crease

Excess Fat Removal and Attempts
at Fat Grafting
Following excess fat removal, we often see a deepened
supratarsal sulcus with wrinkle lines that appears espe-
cially incongruous among Asian patients. This is often
seen without a true crease or one may see a deeply set
high pseudo-crease.
Revisional attempts that follow then tend to make the
incisions too low and result in a low scar situated between
3 and 5 mm in the pretarsal platform. This can be averted
by proper understanding of the effects of tarsal tilt on
crease height as well as crease dynamics.
With deeply sculpted sulcal deformity following excess
fat removal, revision attempts using fat injection or
autogenous fat grafting coupled with attempts to reform
the crease are highly unpredictable. Fat injection alone
can lead to more scarring in the mid-lamellar preaponeu-
rotic space since there is no longer a healthy glide zone/
plane (see Chapter 17) nor a clear-cut space into which
one can direct the cannula needle. Even with awareness
of the effects of tarsal tilt, the importance of the glide
zone, and the beveled approach to revision of a high
crease with shortage of skin, any attempt to achieve an
improved crease at a correct position in the face of a deep
sulcus or in conjunction with fat grafting is a hit-and-miss
endeavor fraught with unpredictable outcome. The fat
graft, whether it is in the form of pearl fat or a block of
fat, may shrink or hypertrophy as well as undergo fibrous
infiltration to form a hardened mass (as seen in Figure
20-15, where the left upper lid sulcus has been filled with
fat grafts that have hypertrophied and fibrosed). This
leads to further revisional attempts.
FURTHER MATHEMATICAL MODELING
For an individual with tarsal anatomy of 8 mm vertical
height and who possesses a natural crease, I value is cal-
culated to be:
(180 − 36.6° ) 2 − 23° = 71.6 − 23 = 48.6°
Sine I = 0.75 = Tch 8 mm ; Tch 0.75 × 8 mm = 6 mm
The tilted crease height for 8 mm tarsus is 6 mm.
For an individual with 9 mm tarsus and who possesses
a natural crease, I equals:
(180 − 41.4° ) 2 − 23° = 69.3 − 23° = 46.3°
Sine 46.3 = 0.72 = Tch 9 mm ; Tch = 0.72 × 9 mm
= 6.48 mm ( round out to 6.5 mm )
The tilted crease height for 9 mm tarsus is 6.5 mm.

FIGURE 20-15 ■ Elderly lady who developed severe sunken sulcus, worse over the left side following upper blepharoplasty. This was
followed by an attempt at autologous fat graft by injecting pearl fat. The fat graft hypertrophied and formed a solid fibrous mass
(as seen here) that further impeded the functioning of the levator muscle as well as the slip-sliding between the posterior tarso-
levator-Müller’s muscle complex and the anterior lamella.
 20 Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
PEARLS AND PITFALLS
1. We observe that the consequences of designing an
8 mm and 9 mm crease line yields a tilted crease
height (Tch) of 6 mm and 6.5 mm, respectively.
Looking at Figure 20-11, these points occupy the
same crease height level one would see in an Asian
who has approximately a 2 mm ptosis and 4 mm
ptosis condition, respectively. (These numbers are
very close to what one sees for an average Caucasian
with a 10 mm tarsus who has a Tch of 6.9 mm.)
2. Asian eyelids, with smaller overall anatomic ratios,
are more prone than Caucasian to develop acquired
ptosis, lagophthalmos and poor closure if the crease
incision is anchored high, if excessive skin is
removed, or if the glide zone is obliterated through
overzealous excision of fat.
3. It is reasonable to suspect ptosis when you see an
eyelid that has a higher than normal crease height,
whether it is in a primary or revisional case.
4. A paradoxical truth: Looking at the 10 mm Cauca-
sian crease height line and the 7 mm Asian line on
the graph in Figure 20-11, the Caucasian’s 10 mm
tarsus yields a Tch of 6.9 mm (the tarsal tilt created a
visual drop of 3.1 mm from 10 mm), while the Asian’s
7 mm tarsus has a Tch of 5.4 mm (a drop of 1.6 mm).
It seems that the abnormal condition of ptosis and
the opposite condition of upper lid retraction have a
narrower range of expansion and contraction values
in Tch among Asians (7 mm tarsus) in a normally
positioned crease and for pathologic conditions as
compared to Caucasians with identical conditions.
The paradox here is that Asian anatomy will show a
greater vulnerability and manifest deviation from
the norm in a greater magnitude and likelihood if
the crease height is set higher or lower than where
an ideal crease ought to be. In other words, any
suboptimal planning and execution of procedural
steps can easily ‘jump’ the ethnic features into a
Caucasian feature-set, which most well-informed
Asian patients may not wish for nowadays.
5. For Asian anatomy, if one should design an 8 or
9 mm crease incision for a 7 mm tarsus for any type
289
of upper lid surgery (see Further Mathematical
Modeling), one will be quite off the path, leading
to a higher probability of acquired ptosis and less
than ideal invagination of the crease. Instead of a
crease developing along the superior tarsal border
junction with levator aponeurosis, one may develop
some restriction on upgaze as well as some degree
of ptosis. The crease is higher and often static in
nature, meaning it is obvious and unchanged on the
lid skin when viewed as the patient looks down. The
crease (and pretarsal segment) arising from a
8–9 mm incision may appear to exceed the tilted
crease height for even a 3–4 mm acquired ptosis
(which has a Tch of 6.5 mm, see red square points
for Asian anatomy in Figure 20-11). Therefore, the
acquired ptosis from high anchoring of the crease
will compound the static, high and unnatural nature
of the crease thus created.
6. Since the visually apparent crease height in a natural
crease is the value of the tilted crease height (Tch)
minus the overhanging lid fold, i.e. a 7 mm natural
or surgical crease has a Tch of 5 mm and an appar-
ent crease height of only 3.5 mm when there is a
1.5 mm fold overhanging, or
Apparent crease height = Tch − Overhanging fold ( mm );
in a situation where there had been a high-anchored,
surgically created crease that is set at 8 mm or
beyond, and excessive amount of skin had been
removed with a relative lack of lid fold remaining,
the undesirable and visually apparent crease height
could be two to three times what is expected or
desired since the overhanging fold of skin is absent
owing to excision.
7. With secondary or consecutive ptosis following aes-
thetic surgery, the lid margin is down and ptotic,
the lid fold may be lessened, and the value of the
apparent crease height may be increased.
One cannot help but realize that we are working with
much tighter constraints in Asian eyelid surgery.

ADVANCED: EFFECT OF
HIGH ANCHORING OF THE
CREASE, FADEN-LIKE EFFECT
AND USE OF BURIED SUTURES
This very advanced chapter deals with the author’s current
views regarding the practice of applying buried sutures
to create or magnify an eyelid crease. An in-depth analy-
sis of its adverse hindering effects is accompanied by two
demonstration video clips.
It was not long ago that the proper way for plastic
surgeons and eye surgeons to perform traditional upper
blepharoplasty was to take off as much skin and fat as
possible, and to apply a high crease fixation. The result
is a sculpted look, with a prominent and showy pretarsal
segment of skin along the lid margin, and a concave
sulcus that stretches back towards the apex of the orbit.
This look eventually lost favor when it became evident
that there is an age-related spontaneous reduction of fat
volume in the upper portion of the orbit (whether due to
shrinkage or posteroinferior movement of fat). An often
unnoticed side effect that ophthalmologists come across
from these techniques, which utilized high fixation of
crease on the lid, is that there seems to be a greater inci-
dence of consecutive ptosis (droopy upper eyelid follows
high fixation above the distal insertion of the levator
aponeurosis). Therefore, empirically:
High anchoring of crease ( wound closure )
→ may lead to consecutive ptosis .
Bear in mind that when I say high anchoring, in my mind
it applies to something that may be only 1–2 mm off the
norm; with the norm being along the superior tarsal
border. To me 1–2 mm superior to the superior tarsal
border is enough to cause a result to be less than ideal.
(See Chapter 14 on suboptimal results and illustrations.)
Anchoring a crease at a point more proximal (closer
to orbital apex origin) than its natural likely insertional
point is akin to decreasing the contractile strength as well
as the effective contractile length of levator (along its
40 mm course from its origin at the orbital apex to its
insertion at the lid crease). Is it the strength or length
that is affected? Or both?
To understand this, ophthalmologists and house offic-
ers may recall learning how to do a posterior fixation
suture (Faden procedure1–3) when trying to weaken the
effective pull of the medial rectus muscle in strabismus
surgery, especially in large angle congenital esotropia,
CHAPTER 21
where children are born with severely crossed eyes. The
placement of a posterior fixation suture is often done in
conjunction with a recession of the particular extraocular
muscle’s insertion. The idea is that by moving back from
the insertion of the medial rectus muscle and placing an
intrascleral non-penetrating lamellar stitch there (e.g.
3–5 mm posteriorly), one can further magnify the weak-
ening effect of surgical recession of the pull of the
extraocular muscle, which is the goal of repair in esotropia.
Furthermore, placement of a Faden posterior fixation
suture alone (that is, placing a suture proximal to its
insertion on the eyeball) without recessing the tendinous
insertion of the medial rectus can provide a recessional
effect. (Faden means a piece of thread in German; here it
means suture.)
Traditional theories have stated that this is due to a
loss of effective arc rotation of the globe when the contact
point is moved backward (proximally) resulting in a
decrease in rotational efficiency, or that one has rendered
the muscle’s rotation less effective through a decrease in
contractile length, or through a tethering effect when a
segment of the muscle closer to the mid-belly of it is
attached to the globe.
Oculoplastic surgeons understand that when the
levator is deliberately recessed as a form of treatment in
patients with retracted upper lids, there is lessened levator
excursion and less crease indentation owing to disinser-
tion of the levator aponeurosis. This recession of upper
lid pull can be enhanced with the interposition of spacer
graft. The lessened levator excursion leads to a secondary
ptosis, and is often protective of an over-exposed cornea.
Clark et al.,4–7 through several published papers, have
demonstrated that there may be additional factors at play,
including the rotational pulley effect where orbital tissues
can be tethered when the medial rectus is incorporated
towards the anterior muscle–orbital sheath (which invari-
ably consists of fat and fibro-connective tissue septae)
at its original insertion on the globe using a buried
stitch, and duplicating the effect of Faden posterior fixa-
tion without having to apply any intrascleral stitch pos-
terior to the medial rectus insertion. Clark attributes
the majority of the dampening effect of Faden as being
due to a change in the surrounding orbital pulley rather
than a loss of effective arc contact of the rectus muscle
on the globe. The stitch initiates the change, while the
291
292 Asian Blepharoplasty and the Eyelid Crease
change occurs in the tissues thus incorporated into the
insertional end of the medial rectus (at its superior and
inferior poles).
This is interesting because it shows that at least over
the insertional end of a muscle like the medial rectus,
posterior fixation suturing underneath it towards the
sclera of the eye (which I will refer to as ‘endo-Faden’,
or fixated to the inner or under layer), as well as suturing
that same location (pole) of the medial rectus towards its
surrounding soft tissues (orbital sheath and pulley mech-
anism, which I will refer to it as ‘ecto-Faden’, fixated to
adjacent or overlying layer), can each independently result
in a decrease in net function of that muscle along its
primary axis of action. Therefore:
Faden ( endo- or ecto- )
→ can lead to weakening of
pull of medial rectus .
This coincides nicely with the observation of second-
ary ptosis that we see in patients (whether Caucasians or
Asians) who have had their crease placed in a higher than
normal physiologic position, as well in those who under-
went permanently buried sutures methods using non-
dissolvable sutures that encircled the levator–Müller’s
muscle complex through a high reach posteriorly. (‘High
reach’ means further above the superior tarsal border).
This is likely from a decrease in net function of the
levator muscle, when the levator aponeurosis is attached
(tethered to adjacent tissues) at a point more proximal
(higher) than its usual termination along the superior
tarsal border and adjacent skin.
The net decrease in levator function can be a combined
effect of restrictive length of contraction with a higher
crease (by placing stitching closer to the levator muscle
mass, and closer towards its origin from the orbital apex
is likely to incrementally affect the optimal length-tension
point on the contractility curve of the muscle), as well as
increasing the load (by adding tissue impedance) to its
ability to lift the eyelid. This latter scenario comes from
the portion of levator and aponeurosis bounded by the
high fixation or encircling suture loops (in buried suture
methods) now having to carry a greater load of tissues (lid
margin, pretarsal segment of skin/orbicularis, tarsal plate
and preseptal skin/orbicularis and aponeurosis below and
bounded by this higher anchor). Fixating (or associating)
additional anterior lamella tissues for the levator aponeu-
rosis and Müller’s muscle (which are the posterior lamella
of eyelid) to bear is akin to the medial rectus being fixated
to adjacent orbital tissues near its pole of insertion (Clark
et al.4–7); the latter re-creates the deadening effect of pos-
terior fixation (Faden technique) where medial rectus is
stitched through partial thickness to the underlying sclera
at a location just posterior to its original insertion. The
high placement of buried sutures both traps additional
tissues as well as creates a high ‘Faden effect’ since it
tethers the levator anteriorly at a point higher than its
original insertion. The levator being tethered to skin–
orbicularis muscle anteriorly is similar to medial rectus
being intentionally tethered to orbital tissues or underly-
ing sclera. The patient often complains of heaviness of the
lids. Eventually we see the levator wearing out and the lid
may develop ptosis.
We can conceptually think of a high-anchored crease
as having an ‘ecto-Faden’, since the blepharoplasty
closure stitch is often placed anteriorly, within the levator
muscle’s distal portion.
We can see how a crease incision that is placed
higher than normal, even if only a millimeter too
high, can unintentionally lead to a restriction on the
uplift.
High fixation of crease sutures on levator
→ Faden-like effect ( in external
incisional blepharoplasty ).
The effect can be seen even if buried sutures were not
used, as long as the external sutures used were placed
higher than the ideal position and postoperatively the
constructed crease stayed at this high position.
 21 Advanced: Effect of High Anchoring of the Crease, Faden-like Effect and Use of Buried Sutures 293

In suture methods (Figure 21-1), a typical suture used
may be a double-armed 6-0 or 7-0 nylon. The first
passage (1) involves everting the upper lid margin and
passing it subconjunctivally for a couple of millimeters,
at a level typically several millimeters above the superior
tarsal border (A′–B′). The second passage (2) directs one
needle towards the skin side, aiming just along the upper
border of the tarsus (B′–B). Similarly for the other arm
of the suture, the third passage (3) goes from A′–A.
If each of the suture threads is tied on the skin at this
moment, it will be a full-thickness compression ligature
encompassing Müller’s muscle, levator aponeurosis, as
well as orbicularis oculi muscle in a posterosuperiorly
biased fashion. It also inadvertently creates a Faden effect
at each of the two locations of B′–B and A′–A, and a
horizontal contracture of the width of levator aponeuro-
sis at A′–B′. In fact, the second needle exiting the skin at
A is re-passed (4) subcutaneously across to join B (A–B),
exiting at a mini-stab skin opening there. The nylon ends
are ‘firmly’ tied and the knot sinks into the small surgical
opening. Traditionally the suture methods use three sets
of these sutures, medial, central and laterally. With three
sets of sutures, the restrictive effect is tripled. With
methods that run back and forth across the width of
the levator, the unintentional effect is amplified several
fold.

B' A'

B
4 A

FIGURE 21-1
294 Asian Blepharoplasty and the Eyelid Crease
(One can argue that there is a ligamentous-plicating
effect when the posteriorly biased suture loops are tight-
ened over that portion of the distal levator aponeurosis;
perhaps this explains why most of the patients who have
undergone buried sutures [non-incisional] surgery for
double eyelids tend to have a lid retraction immediately
post-procedure.)
Figure 21-2 shows a cross-sectional interpretation of
the buried sutures method. Note the position of buried
FIGURE 21-2
suture encompassing the active levator muscle (pink), and
Müller’s muscle, with the passive orbicularis oculi muscle
(grey) with the lids open. The posterior loop of the closed
suture is located at A′B′ in the previous drawing (Figure
21-1) while the buried surgical knot is under the skin at
A–B at the level for a proper crease (along the upper tarsal
border).
 21 Advanced: Effect of High Anchoring of the Crease, Faden-like Effect and Use of Buried Sutures 295

Figure 21-3 shows high placement of three buried
permanent sutures on each upper lid (corresponding to
A–B, step 4 of suture passage, in Figure 21-1); the sutures
were tied under the skin. One can see obvious bumps on
the eyelid when the lid is looking downward or closed.
Functionally then, with three sets of buried stitches, a
Faden (impairing) effect has been created at six locations
vertically along the functional axis of levator muscle, and
three horizontal segments of the levator (A′–B′ and A–B)
are bunched together inadvertently. (See Video clip
Case 31 showing the dampening effect of placement of
high-anchoring stitches.)
The indented crease is created from compressing skin
towards the levator, and is seen with the lid open as well
as when the eyes are looking down or the lids closed.
There is a shortening effect on the levator due to the
vertical passages of sutures, like a plicating stitch, which
explains the often noticeable widened palpebral fissure
(eyelid opening) or slight stare, with some discomfort
on the part of the patient; while the horizontal passage
crimps the horizontal width of the levator, perhaps
weakening its capability. If the average width of the
levator aponeurosis above the superior tarsal border is
24–27 mm, one can surmise that three sets of buried
sutures will result in 3x(2–3) mm of levator with each
buried stitch = 6–9 mm of the aponeurosis (25–33%)
crimped horizontally.

FIGURE 21-3
296 Asian Blepharoplasty and the Eyelid Crease

The net long-term effect of these sutures is often a
decrease in levator function, with its manifested mild sec-
ondary ptosis or lagophthalmos (Figure 21-4 A, B). Inter-
estingly, in cases where the sutures are tied very tight and
eventually lose their intended effect due to cheese-wiring
through eyelid tissues, the restrictive effect on the levator
may be lessened somewhat with time, and the crease shal-
lows, though the functional impairment can be permanent
in some patients. One may see a disappearance (oblitera-
tion) of the intended crease but the burden of the levator-
weakening effect is retained since the placement of buried
sutures is permanent (in most cases).

FIGURE 21-4 ■ (A) Case of a patient who had a high crease set with acquired ptosis. (B) Same patient after revision involving the
resetting of the crease to a more acceptable position and release of the induced ptosis. (Photograph taken two weeks after revision
correction.)
 21 Advanced: Effect of High Anchoring of the Crease, Faden-like Effect and Use of Buried Sutures
Within suture methods, this effect is seen often from
the trans-lid (transcutaneous) approach, and sometimes
from the transconjunctival position. The latter direction
is more prone to result in corneal (eye) irritation.
When coming from the skin side (transcutaneous), the
suture encompasses and ties together the levator aponeu-
rosis, and possibly Müller’s muscle fibers, and orbicularis
and then the knot is buried just under skin. What is
damaging is often that the loops that tie the posterior
layers are often higher above the upper margin of the
tarsal plate (superior tarsal border); as the loop crosses
the thickness of the lid and exits on the front side, it dips
down and is biased towards a lower point to form the
desired crease indentation. When one combines the
effect of three of these ‘ecto-Faden’ lid stitches (actually
ecto- as well as endo-), and tightens them to form a liga-
ture on the soft tissues within, keeping them buried per-
manently (often 6-0 nylon or polypropylene), one can
observe that a ptosis effect is often seen after several
years, unless the stitches become ineffective (cheese-wire
through tissues) and release. The crease may then partly
disappear or completely fade, but the patient may still feel
these buried stitches.
Buried sutures : typically placed higher
( posteriorly ) above su
uperior tarsal
border → endo- and ecto-Faden.
(This is seen in ‘non-incisional’ buried sutures methods,
as well as incisional blepharoplasty methods when a
surgeon decides to enhance crease position by placing
high-anchoring permanent buried sutures. I personally
believe that the Faden effect is even greater with the use
of a single continuous buried loop, like the DST (‘double
stitches thread’) or twisted needle methods.)
When the buried sutures methods are used via a
transconjunctival direction, meaning the sutures are
applied through the underside or back side of the upper
lid, again the same layers of dynamic tissues are incorpo-
rated into the noose, again they are tightened and biased
in a backside-higher placement (superiorly biased on the
conjunctival side). There are then three ‘endo-Faden’
stitches. The adverse results are the same, and one also
sees secondary ptosis after a year or two; except one has
to deal with the sometimes immediate complaints of
foreign body sensation as the knots are buried within the
conjunctiva/subconjunctival tissues, directly over the
front of the cornea.
Table 21-1 outlines a comparison of normal anatomy
among Caucasians with a crease, Asians with and without
a crease (with existing excess tissues that may be imped-
ing a crease formation), as compared to the load effect
on an eyelid after undergoing the buried sutures (‘non-
incisional’) methods, as well as the external incisional
method (using the author’s preferred Asian blepharo-
plasty technique).
In the buried suture methods, occasionally some sur-
geons decide to place the anterior buried knots lower
than the superior tarsal border (the posterior loop is just
above the upper border of the tarsal plate, therefore ante-
riorly it is skewed inferiorly). Initially the suture has a
tightening and shortening effect giving one a false sense
297
that it has made the vertical palpebral fissure more open
(‘a slight lift’). The long-term effect may often be that
the sutures are no longer effective as the knots cheese-
wire through the lid tissue resulting in no gain in height
nor formation of a permanent crease. At worst, occasion-
ally a decrease in levator excursion can result due to the
burden of having had tissues disrupted there. An exag-
gerated oblique crossing through the pretarsal segment
of the lid can result in tarsal ectropion (outward turning
of the eyelid margin as the tarsal plate is lifted off the
eyeball surface).
As for the popular DST (double stitches thread)
method, it involves a back-and-forth double passage of
buried suturing where a U-shaped hairpin loop of non-
dissolvable suture is left buried. In front of, as well as
behind the dynamic levator, we will get double the Faden
effects (ecto- + endo-Faden).
There are occasional surgeons who venture to use
buried sutures crossing the integrity of the tarsus (trans­
tarsal): the sutures are applied directly through the back
surface of the tarsal plate, maybe 2–3 mm below the
upper border of the tarsal plate (the tarsus is typically
6.5–7.5 mm in the vertical dimension for Asians, and
10 mm for Caucasians). To avoid irritation facing the
cornea, the loops of the sutures are tied tight to become
buried through the back surface of the tarsus, partially
cheese-wiring through. I imagine it does reduce its effec-
tiveness through time, and there is really nothing to gain
by violating the tarsus. The crease thus formed anteriorly
is likely a low-set static crease.
If one were to reverse-bias the passage of this suture,
going through tarsus and then tilting higher to catch
more levator (skewed superiorly), one again runs into the
problem of high anchoring. Here it is more like an ecto-
Faden in terms of its side effects on the function of the
levator, although the passage started from the backside of
tarsus.
In each of the variants of the buried sutures methods,
high anchoring tends to give a round-eyed look, with
fullness or swelling over the pretarsal segment. Some
have coined the term ‘Anime eye’ for this look.
In Table 21-1 the fifth column heading of ‘Net load
for levator’ refers to the resultant added work through
impedance to the normal action of the levator muscle
when buried sutures are used at various levels on the
levator. The term ‘resisting load’ is easier to understand,
although the term impeding load is more accurate.
It may seem that I have a negative bias towards the
buried suture methods. Indeed I should state that most
buried sutures methods may work sufficiently well for a
period of time due to the tight ligature on tissues to
create a compression-induced crease, and that most cases
do not lead to any significant complications or sequelae.
But patients are very tolerant and remain silent regarding
their discomfort for the sake of their aesthetic goals; and
also the long-term consequence of placing permanent
sutures encircling contractile muscle fibers are not well
published nor understood and only occasionally men-
tioned by clinicians, such as myself who is only just
coming to understand this after 30-plus years of clinical
work, to the point where I can now try to present it in a
more objective scientifically based framework.
 298

TABLE 21-1 Biodynamics of Effects of Crease Fixation Techniques

Levator Burdening volume of
excursion anterior lamella
Patient Anatomy (scaled) tissues Net load for levator
Caucasian With crease + Few Less

Asian With crease Set as norm Average Set as norm of 0

of 0
Asian With single lid Born with 0 or − Above average Increase
After Asian blepharoplasty* Simulate normal physiology Often +1 or 0 Lessened Lightened
Asians with single lid after buried Buried knots are placed: Often worse Not removed, all
suture methods: sutures stay, most
Asian Blepharoplasty and the Eyelid Crease

are non-dissolvable
1. Trans-skin (anterior approach: A. Above STB −2, −3 Not removed Created resisting load (ecto-Faden)
knots under skin catches) −2,−3
Levator aponeurosis and orbicularis B. At level of STB −1, −2 Not removed Ecto-Faden −1, −2
C. The deep loop is below STB Initially slight Not removed May have slight scar, slight Faden
(front of tarsus) resection effect, no crease
effect
2. Trans-conjunctival/posterior A. Above STB Worsen −2, −3 Not removed Created resisting load endo-Faden
approach (knots under −2, −3
conjunctiva)
Chief complaint: foreign body B. At level of STB −1, −2 Not removed Endo-Faden −1, −2
sensation
Deep loop catches (pretarsal C. Deep loop is below STB (front May worsen −1 Not removed Endo-Faden −1. May have tarsal
orbicularis and aponeurosis) of tarsus) ectropion
3. Trans-lid/Trans-tarsus (anterior Deep loop is under STB, needle May worsen −1 Not removed Corneal risk, compression scar,
knot under skin) pierces through tarsus loss of efficacy

STB, Superior tarsal border.

*Technique by Chen.
 21 Advanced: Effect of High Anchoring of the Crease, Faden-like Effect and Use of Buried Sutures
While the association of secondary ptosis following
the buried sutures method is a known observation to
clinicians who perform this type of surgery, I believe it is
under-reported. Patients are more often than not reluc-
tant to go back to the original surgeon when their crease
disappears with time (and thereby spontaneously releas-
ing some of the Faden effect); this adds to the reported
‘success rate’ from the sutures method, and is even
acknowledged in some of the earlier reports from giants
in the field of single-eyelid surgery using the suture
methods.
Reviewing our discussion then, we have developed the
following concepts:
1. Surgical Faden (posterior fixation
with Faden) (adjacent orbital tissues
fixation) → can lead to weakening
of pull of the rectus muscle (in
strabismus correction).
2. Levator recession (weakening via
surgery) → weakens levator
(contractility and excursion).
3. High anchoring of crease (wound
closure) → consecutive ptosis.
4. High fixation of crease sutures on
the front surface of levator → (ecto-)
Faden effect.
5. In buried suture methods, the deeper
posterior loop is typically superiorly
biased → (endo-)Faden effect,
dampening the underbelly of levator.
6. Buried sutures: when placed higher
(posteriorly) above superior tarsal
border → endo- and ecto-Faden*
effects.
(*Often the anterior exit of the buried sutures through
skin is also higher in an attempt by the surgeon to raise
the lid fold, which is not removed or corrected in the
minimal-incisional suture method.)
In a sense, the levator muscle is like our deep abdomi-
nal muscles that flex our spine (ilio-psoas). The analogy
is obvious to anyone who has tried yoga, pilates or core
muscle strengthening exercises. Often these disciplines
involve working with an exercise ball and stretching our
back while lying with the small of our back supported by
the inflated ball. In stretching the back and intra-
abdominal muscle out to its maximal length, we are then
asked to do either hip flexion exercise or contract our
rectus abdominis. The reason this is effective is that we
are conditioning the distal (terminal) portion of our
lower back flexor muscle at its most stretched (and there-
fore relaxed) length on a length–tension curve. This is
299
the essential portion of the muscle, as opposed to working
the less stretched portion and building that up without
much flexibility and joint mobility.
We can think of the effective portion of the levator
(total length is 40 mm from its origin within the orbital
apex) as being the distal segment, and this is the levator
aponeurosis and measures about 10 mm. This is the
portion we are working with in blepharoplasty or ptosis
repair. In high crease anchoring and buried sutures
methods where the suture loops encircle the aponeurosis,
one is basically inhibiting the full extension of the levator
aponeurosis. One is in effect plicating the levator aponeu-
rosis and hindering its effective contraction as well as
maximal relaxation (extension). The levator function
(levator excursion being one measure of it) is therefore
affected in an adverse fashion.
Video Case 31 shows the surgical sequence in a Cau-
casian patient for functional blepharoplasty of the upper
lids. In this video, one can see the preoperative unanes-
thetized movement of the patient’s upper lid is around
14–15 mm. After injection with local anesthetic into just
skin and orbicularis, with the patient lying flat, the levator
still moves 12 mm from the surgeon’s view (which is
slightly different from the camera lens). The edge of the
paper scale was positioned as zero against the upper lash
margin. The crease for this patient based on her anatomy
should be set at 8 mm. When a crease is anchored 3 mm
higher with three stitches (at 11 mm), it restricts the
movement to 8 mm. Of course, these demo sutures
were removed and the crease is then properly placed at
8 mm. After wound closure, levator movement is restored
to 13–14 mm while still under local anesthetic. The
dampening effect of improper crease setting or wound
closure can be as much as 3–6 mm, as seen from this
demonstration.
We can now understand how high anchoring of an
eyelid crease often leads to secondary ptosis. The effort
by the patient to see leads to brow compensation (BrOA:
Brow Over-Action) and elevation of any lid fold (plus
sometimes head-tilt backwards). With the Faden effect
on the levator, the odds of having a crease indentation
are lessened.
Hence:
High anchor → consecutive ptosis
→ brow overaction ( BrOA )
+ Faden-like effect
→ incomplete crease +
high scar line.
The beveled approach for revision of a high crease
(covered in Chapter 18) allows for a resetting of the tissue
plane (between anterior and posterior lamella) and a
release of the Faden effect caused by the high crease set.
Ptosis is partially or completely reversed, there is then
reduced brow compensation. The levator regains its
excursion while some recruitment of skin accompanies
the resetting of tissue plane. The net effect is a less-
hindered levator, and a better crease indentation with a
better lid fold, which is allowed to relax itself downward.
300 Asian Blepharoplasty and the Eyelid Crease
If you were to place a virtual nano-sphere at this inter-
phase of crease and lid fold, the back of the nano-sphere
on the levator side will be vectoring upward, the front
surface of the nano-sphere rests along the lid crease,
underneath the lid fold (skin and orbicularis, both ante-
rior lamella) and is gravitating downward.
With a high crease, the proper surgical correction can:
Reset tissue plane, crease reset to a lower ,
more physiologic position → decreases
Faden effect , less ptosis → improved
levator excursion → less BrOA
→ better crease indent at a more
natural position.
Video Case 32 is a simple demonstration video involv-
ing two sheets of papers, several paper clips and a paper
scale. I try to show the impairing effect of having paper
clips attached higher than the upper tarsal border, in
analogy to buried sutures being applied through the distal
aponeurotic part of the levator. It is meant to give a
qualitative sense, literally through the person’s hands
holding the two sheets of paper (skin and levator muscle),
appreciating the difference in effort and increase in resist-
ance among the clinical situations presented here. The
measuring scale right of frame is a sheet of paper marked
with a 5x-magnified millimeter scale. The black iPad
cover (background surface) was slanted at 45° to mimic
a normal tarsal-tilt angle or slant of the upper lid when
opened. The proportions were: vertical span of upper
eyelid = 25–30 mm.
A typical Asian upper tarsal plate is represented by
7 mm; 10 mm represents a Caucasian tarsus or a location
chosen to demonstrate an abnormal high-anchored
crease. The normal up-and-down levator excursion
(function) in an Asian is about 10–12 mm so the posterior
sheet of paper was moved the same amount.
REFERENCES
1. Cuppers C. The so-called ‘fadenoperation’ (surgical corrections by
well-defined changes in the arc of contact). In: Fells P, eds. Congress
of the International Strabismological Association; 1976. Marseilles,
France: Diffusion Générale de Librarie; 1976: 395–400.
2. Scott AB. The fadenoperation: mechanical effects. Am Orthopt J
1977;27:44–47.
3. Guyton DL. The posterior fixation suture (mechanism and indica-
tions). Int Ophthalmol Clin 1985;25:79–88.
4. Clark RA, Miller JM, Demer JL. Three-dimensional location of
human rectus pulleys by path inflections in secondary gaze positions.
Invest Ophthalmol Vis Sci 2000;41:3787–97.
5. Clark RA, Isenberg SJ, Rosenbaum AL, Demer JL. Posterior fixa-
tion sutures (a revised mechanical explanation based on rectus
extraocular muscle pulleys). Am J Ophthalmol 1999;128:702–714.
6. Clark RA, Ariyasu R, Demer JL. Medial rectus pulley posterior fixa-
tion is as effective as scleral posterior fixation for acquired esotropia
with a high AC/A ratio. Am J Ophthalmol 2004;137:1026–1033.
7. Clark RA, Ariyasu R, Demer JL. Medial rectus pulley posterior fixa-
tion: a novel technique to augment recession. J AAPOS,
2004;8(5):451–456.

ADVANCED: SUMMARY OF EYELID
CREASE FACTORS
C =
∫
( Latt , LC, F , afi, pf , gz, h )
( s, m, f , ( − ) Vax , eypo, BrPt , BrOA , h +, h −)
This summarizing chapter covers the author’s current
concept of various anatomical factors that contribute to
or adversely affect a crease formation. Familiar drawings
will help illustrate the concepts and factors that have been
discussed in the advanced chapters, and how these can be
applied clinically.
I am continually fascinated by the unpredictability of
the eyelid crease; some of its factors can be represented
by the expression above. This chapter will reveal the
significance of each of these factors, and we will return
to this expression again at the end.
WHAT IS AN UPPER EYELID CREASE?
Let us start gently as an initial attempt to answer the
question posed here. An upper eyelid crease can be
described as an inward folding of the upper lid skin above
the eyelid margin, and is positioned along the superior
tarsal border.
In common usage, the lid crease is less anatomically
defined, and it can be confused to include anything from
a faint wrinkle above the lid margin where tight skin
becomes looser, to a well-formed crease invagination
along the superior tarsal border, to describing what in
actuality is the upper eyelid sulcus. I have personal expe-
riences of well-educated patients describing what to them
constitutes an eyelid crease: from anything that occasion-
ally appears in the morning, the evening, after a drink
or two, after crying, after reading, after they turn 17, 30
or whatever age, or after a voluntary attempt using a
co-contracting stare-and-frown maneuver (staring acti-
vates the levator through the third nerve, frowning
tightens the periorbital orbicularis oculi and frontalis
muscle, mediated through the seventh nerve), to a fold
that forms as a result of where they applied their lid
CHAPTER 22
crease glue, tape or special fiber string. These various
positions are seldom the correct location for an anatomi-
cally natural crease.
Most of the above do not appear natural, and therefore
it is just as important for us to try to define what are the
characteristics of a natural crease.
Firstly, a natural crease is present shortly after birth,
is seen in most head positions and is effortless in its
formation. It may be of different shape and height in
different ethnicity, but should share these common
characteristics.
Secondly, a true eyelid crease has a faint crease line on
the skin which can be seen when the upper lid margin is
turned down (or when the eyelid margins oppose
together); its location typically corresponds to the upper
boundary of the superior tarsus. Anatomically it corre-
sponds to where the distal fibers of the levator aponeu-
rosis terminate into the pretarsal section of orbicularis
oculi1 or skin along the superior tarsal border. Recent
scientific studies using more refined electron microscopy
were able to see attachment of aponeurotic fibers actually
terminating under the skin where the natural crease line
forms, confirming some previous assumptions. When the
eyelids are open, the ‘reinforced’ pretarsal platform of
tarsal plate/orbicularis muscle and attached pretarsal skin
will vector upward as a unit against a passive preseptal
skin–orbicularis: the invagination is the crease, the over-
hang is the eyelid fold. The interface for this to occur is
the preaponeurotic fat, which I conceptually describe as
the glide zone.
Thirdly, a true crease is a dynamic crease; it has the
characteristic of fading on downgaze (when the levator
of the lid is relaxed as the inferior rectus contracts to roll
the globe downward), unlike what one sees with an arbi-
trarily anchored eyelid crease indentation or one induced
through compression (encircling, buried) sutures.
301
302 Asian Blepharoplasty and the Eyelid Crease

Most individuals who have an upper eyelid crease will
manifest the full crease in a straight-ahead gaze position
(Figure 22-1).
In downgaze, the inferior rectus and superior oblique
muscles contract while the superior rectus and levator
muscles relax (the relaxed levator is at its longest length
in downgaze). Downgaze results in the shallowing or
disappearance of the upper crease (Figure 22-2) in a
person who is born with a crease, though there is still a
faint skin line.

CH 2

FIGURE 22-1

(–) Vax

FIGURE 22-2
 22 Advanced: Summary of Eyelid Crease Factors 303

Head Tilt and the Eyelid Crease Height of Crease

Why is there a difference in apparent depth to the upper
eyelid crease depending on the frontal posture of the face?
The crease is most apparent when the eyelids are open
and the eyes are looking straight upward – where the
levator muscle is presumably maximally contracted (and
at its shortest length). Compare this to when the person
tilts the head’s vertex backward slightly (in a slight chin-
forward position) but still maintains forward horizontal
gaze; as far as the eyeball is concerned, this is similar to
a downgaze and therefore the crease is less manifested
and observable here.
What about the ‘width’ of the crease? (It should be meas-
ured and named as the ‘height’ of the crease, from ciliary
margin to the crease indentation with the lids closed.)
This is the anatomic crease height (Figure 22-3).
Is the crease the observable step-in between the larger
fold of skin above the crease and the exposed pretarsal
skin with the vectored-in lid crease hidden beneath it?

Crease
line

Anatomic
crease
height

FIGURE 22-3
304 Asian Blepharoplasty and the Eyelid Crease
The observed apparent crease height as measured from
the eyelash border will be 1–3 mm narrower than if
measured all the way towards the hidden apex of the
crease, which is the tilted crease height (Tch). The eyelid
crease should be defined by the faint crease line we see
with the lids closed (in the absence of acquired ptosis),
and when measured should seem to correspond to the
superior tarsal border’s central measured height; we shall
denote this as the anatomic crease height.
(Note that the tilted crease height is the vertical com-
ponent of the sloped pretarsal segment (Figure 22-4).
When there is an overhanging lid fold of x mm, the
apparent crease height is the vertical component of Tch
minus the obstructing (shielding) portion of the lid fold
of x mm, where x may be 1–3 mm.)
Anatomic crease height > Tilted crease height ( Tch )
> Apparent crease height
(Remember that anatomic crease height is the true height;
it is always greater than the frontally observed tilted
crease height, and similarly the apparent crease height is
what you see with the hanging fold.)
Should one adopt this location of the anatomic crease
height as the true crease? I firmly believe so. This ambi-
guity underlies some of the confusion that occurs between
patients and physicians. Most patients will use their
description of apparent crease for their impression of a
Tilted crease
height (Tch)
I°
FIGURE 22-4 ■ Tilted crease height (Tch) is further reduced by the overhanging fold; the seen portion is then the apparent crease
height. ‘I’ stands for incline angle of the tarsus, pretarsal skin or levator aponeurosis (Tch − Fold = Apparent crease height).
crease; and although some physicians will be clear about
the concepts involved and will subscribe to the anatomic
crease, a significant portion of physicians will also think
like a lay person. The problem occurs not only during
preoperative discussion, but also intraoperatively when
facing the actual challenge of constructing a crease.
The desired crease a patient outlines may be some-
thing quite low, and an inexperienced physician may
believe that this is achievable in surgery. A patient may
just as well describe a crease that is abnormally high,
and the practitioner may also think it is achievable
and ‘natural’ when it is not, essentially creating a high-
anchored crease that, when combined with significant fat
excision, will yield a hollow sulcus and a myriad of long-
term issues as described in previous chapters.
The margin of tolerance for error in placement of
crease height is extremely narrow. The knowledge that a
surgically constructed crease needs to mimic nature in
its biodynamics and be positioned along the superior
tarsal border for it to function permanently as a natural
crease requires us to adopt the anatomic definition of a
crease. To create an aesthetically pleasing crease for the
patient, whose only concept of a crease is the ‘apparent’
crease we discussed earlier, the finesse in this type of upper
lid surgery lies in factoring in how much skin we intention-
ally allow to be left above the crease, as we construct a
physiological, permanent crease and not just a ‘tied-in’
crease.
 22 Advanced: Summary of Eyelid Crease Factors 305

In Caucasians, who often have deep-set globes semicircular shape. With age-related recession of
(eyeballs) or greater prominence of the superior orbital (preaponeurotic) fat, a crease may appear flattened and
rim (Figure 22-5), the crease may be quite high (10– disappear into a supratarsal sulcus.
11 mm) and curves posteriorly into a relative half-moon,

Orbicularis oculi

Septum orbitale

Preaponeurotic fat

Levator aponeurosis
..
Muller's muscle

Inferior tarsus

Inferior oblique

Inferior rectus

FIGURE 22-5 ■ A classical representation of Caucasian anatomy, showing a higher point of fusion of the orbital septum on the levator
aponeurosis.
306 Asian Blepharoplasty and the Eyelid Crease

In Asians with a crease (Figure 22-6), the crease height the pretarsal platform vectoring upward relative to the
is lower than a non-Asian’s. They have good levator func- preseptal–periorbital soft tissues (skin, orbicularis, fat) is
tion, good terminal aponeurotic fibers that terminate into such that it favors crease formation.
the pretarsal section, and the net force-relation between

FIGURE 22-6
 22 Advanced: Summary of Eyelid Crease Factors 307

Asians without a crease (‘single eyelid’) (Figure 22-7)
may have only fair to good levator function. Here the force-
relation between preseptal skin/muscle/fat (Zone 2) over
the underlying pretarsal segment plus levator (Zone 1) does
not favor crease invagination. There may be an increased
amount of skin and fat (preaponeurotic, as well as preseptal
fat), or even increased presence of pretarsal orbicularis and
fat to further complicate crease indentation.
The dominant factor in this category is the relative
absence of distal interdigitations of levator aponeurotic
fibers within the pretarsal orbicularis zone or attachment
towards the skin. The bellowing skin and fat rolling over
the superior tarsal border is secondary. There is no
attachment towards the skin, and therefore no crease.

Zone 3

Zone 2

Zone 1

FIGURE 22-7
308 Asian Blepharoplasty and the Eyelid Crease
Shape of Crease
In Asians, the two main categories of shape are the paral-
lel crease and the nasally tapered crease (see Chapter 4).
A parallel crease runs parallel and equidistant above the
lid margin. The parallel nature is relative to the eyelid
margin’s curve so it curls around with the natural lid
margin. Near the medial end, whether there is a medial
upper lid fold or not, the crease ends there without con-
verging towards the medial commissure.
In the nasally tapered crease, there is often a medial
upper lid fold that overhangs, and the nasal portion of
this crease often converges towards and joins the medial
commissure, appearing as a nasally tapered crease that
tapers to a point. Both these are natural and ideal crease
shapes for Asians.
PREDICTORS OF CREASE
Among the factors that determine the presence of an
upper lid crease, first and foremost is the presence or
absence of the distal ‘attachment’ of the levator aponeu-
rotic fibers (‘Latt’); they course towards the subcutaneous
area along the superior tarsal border as well as inferiorly
in the pretarsal orbicularis, terminating as distal inter-
digitating fibers within the pretarsal orbicularis. This
determines whether the patient has an eyelid crease on
the skin or not. Furthermore, the ‘tightness’ to which
these aponeurotic fibers (afi) are able to wind around and
insert into these intermuscular septae determines the
relative rigidity (‘firmness’) of the pretarsal skin–muscle,
which moves up together with the tarsal plate as the
levator contracts. The firmer this pretarsal skin–muscle-
tarsal plate is, the better the invagination of crease.
Assuming the presence of these attachments, the con-
tractile strength of the levator is indirectly measured
(and poorly assessed) by millimeters of lid margin excur-
sion, and incorrectly labeled as indicative of the ‘levator
function’. It is partly indicative of the robustness of the
levator, and correlates somewhat with whether a normal
superoposteriorly directed pull is capable of invaginating
the pretarsal segment (Zone 1) against the preseptal
segment (Zone 2) to give a clinically apparent crease. We
observe that those with poor to borderline levator excur-
sion (under 10 mm) are far more likely to have incomplete
manifestation of the crease. Yet those with 11 mm or
greater levator excursion do seem to form a crease more
readily.
Is this a function simply determined by one or two
millimeters? Or is it more likely that a correlation exists
between those with excursion of 11 mm or more are
having a qualitatively stronger levator muscle contractil-
ity (‘LC’) compared with those with excursion of 10 mm
or under? This latter scenario is far more likely. There
are many clinical examples of elderly patients who had a
true crease previously, then developed ptosis with aging
and yet retained adequate levator excursion greater than
11 mm, but no longer manifest a normally positioned
crease. It is likely that their levator excursion now reflects
the remaining viable levator fibers as well as current con-
tractility, and has actually decreased from its former
15–16 mm measurement as the lid became increasingly
ptotic. In other words, this otherwise healthy excursion
of 11 mm represents a relative decline for the patient in
whom excursion may previously have been greater. Other
aging changes that can affect levator excursion will
include the recent research findings that correlate a
decrease in horizontal palpebral width with each decade
of aging. A shorter eyelid margin width can affect the
tensile relationship within the lid closure mechanism and
so it should not be surprising that levator excursion will
drop slightly with aging. (During ptosis surgery, one can
often observe thinning, degenerative and fatty infiltration
of the levator and aponeurosis as well as the canthal
tendons.) In other words, the patient’s levator function in
terms of contractility has truly decreased, though we still
inaccurately use levator excursion, a linear parameter, as
an indicator of three-dimensional health and express this
measurement of 11 mm as indicative of ‘normal levator
function’ (it is a single sampling without comparison to
the same subject’s past, longitudinal changes). Therefore
the use and measurement of what is currently labeled as
‘levator function’ is actually flawed in terms of its true
function as well as setting of the norm.
The above two factors (Latt and LC) are only some of
the early obstacles that determine whether a crease is
clinically manifested. Additionally, the prominence of a
crease is positively influenced by F, afi, pf, gz and h, and
inversely affected by s, m, f, negative Vax, eypo, BrPt,
BrOA, h+, h−.
The anterior soft tissue mass over the supratarsal
region (preseptal segment) consists of skin, orbicularis
and preaponeurotic fat. The normal amount of skin (‘s’)
and muscle (‘m’) acts as a passive weight against which
the posterior lamella (of tarsus, levator and Müller’s
muscle) vectors upward; excess skin tends to shield the
crease from view. Excess orbicularis muscle in the front
decreases the chance of distal fibers of levator aponeuro-
sis penetrating towards the subcutaneous plane of the
eyelid crease.
Healthy preaponeurotic fat (healthy fat represented as
‘F’) in the preseptal portion (Zone 2) of the lid acts as a
friction-less glide plane, where the posterior layer vectors
up over the passive weight of the anterior layer.2,3,4 The
posterior lamella has to move only 2–3 mm with respect
to the anterior lamella to give a crease with an overhang-
ing eyelid fold.

In a less pristine condition where there is fibrotic fat
(represented as ‘f’ ), whether in untouched lid tissue or
secondary to prior surgery with complete obliteration of
this desirable glide zone (‘gz’), there is more hindrance
to the smooth gliding between these two lamellae of
tissues, and it is less likely that one can attain a 2–3 mm
relative shift of the two layers4 (Figure 22-8).
In some single-lidded individuals (see Figure 22-7),
one may see an abundance of preaponeurotic fat at a
lower than normal position (normal being 5–10 mm
above the superior tarsal border), in association with
absence of crease and a lower point of fusion of the
orbital septum towards the aponeurosis. I believe these
are associative factors rather than necessarily showing
absolute causation of the one leading to the other.
Preaponeurotic (post-septal) fat pads may occasionally
penetrate as far inferiorly as the pretarsal position (mani-
festing as Zone 1 preaponeurotic or post-septal fat) and
disrupts any chance of crease formation.
Fat lying in front of the orbital septum within the
pretarsal orbicularis should be labeled pretarsal fat;
FIGURE 22-8
22 Advanced: Summary of Eyelid Crease Factors 309
technically the fat here may be an accumulation of fat in
front of the orbital septum, or Zone 1 preseptal fat. It
may also disrupt crease formation. In essence almost any
excessive fat in the pretarsal location may affect crease
formation.
In fatty upper eyelids, the combined weight of the
three subcomponents of skin (s), orbicularis muscle (m)
and preaponeurotic fat (F), may be too heavy for the
posterior levator–tarsus complex to lift and it can result
in an absence of crease. Eventually this may even lead to
acquired ptosis of the upper lid at an earlier age than
normal. Of course, an excess of any of these components
or in combination can lead to absent crease. Healthy
preaponeurotic fat (F) can assist as a glide layer, and
facilitates crease formation, while excess of it can impede.
(When F exceeds a certain quantitative value, it can be
seen as a denominator factor, with an inverse function).
A normal patient with large palpebral fissure size (‘pf’)
as measured both vertically and horizontally will tend to
have a large levator muscle complex, both in width as well
as greater vertical excursion. One can infer that a larger
width of levator will span a longer convex arc of the tarsal
plate as it sweeps upward, and that its central midpoint
insertion along the superior tarsal margin will traverse a
greater distance (vertical excursion of the upper lid
margin).
In the negatively affecting cluster of parameters
(denominator), the lower case ‘s’ stands for floppy eyelid
skin, thickened eyelid skin and excess redundancy of
skin. Some individuals even manifest tight eyelid skin,
observable through tissue resistance when their eyelid
skin is being infiltrated with local anesthetic solution
prior to surgery. They show a much delayed resorption
of the injected anesthetic, as well as needing greater
efforts with infolding of a surgically constructed crease
despite extra steps being taken to enhance the crease
formation. Therefore loose skin adds bulk, tight skin adds
resistance.
The lowercase ‘m’ stands for excessive mass of orbicu-
laris muscle, and dehiscence of preseptal- or pretarsal-
based orbicularis muscle layers. Fat may also be
intertwined within the orbicularis fibers.
The lowercase ‘f’ represents fat located in the glide
plane which is obstructive rather than facilitative in
nature. The clinical condition is often observed during
surgery for single-lidded individuals – where instead of
observing globular fat, we see plastered-down amorphous
fat strands, or mosaic clusters of ill-defined fat globules
without clear demarcation of where the septum lies in
front of the aponeurosis. It may occur thus in primary
cases; at other times, during revisional blepharoplasty, the
entire glide zone is a solid scarred plaque. The probabil-
ity of having a natural crease is obviously an inverse
function to ‘f’ (imagine it as a sort of adverse fat residual),
or proportional to 1/f. Crease construction is easier if
adverse fat (f) is minimal or not present.
310 Asian Blepharoplasty and the Eyelid Crease

The levator muscle is at its maximum contraction maximum upgaze position as being its maximally positive
on upgaze; here the crease appears the deepest (we can angle away from a straight-ahead view [zero angle])
consider the patient’s visual axis angle [Vax] in this (Figure 22-9).

(+) Vax

FIGURE 22-9
 22 Advanced: Summary of Eyelid Crease Factors 311

The levator is at its most relaxed state when the eyes maximally negative angle. With this negative Vax, the
look down, with the levator as well as superior rectus in crease’s invagination should naturally shallow or decrease
a relaxed state. Here the visual axis angle (as measured (Figure 22-10).
away from the arbitrary point of zero angle) is at its

(–) Vax

FIGURE 22-10
312 Asian Blepharoplasty and the Eyelid Crease

When a person with a natural crease is looking straight the patient’s frontal plane perpendicular to the floor and
ahead with a level gaze (set as zero value Vax), the crease his/her forehead’s frontal boundary and chin aligned like
is optimally manifested, neither too deep nor too shallow a plumb line); this is the examiner’s zero angle of observa-
(Figure 22-11). The same should be observed in a dynamic tion (zero ao), looking straight ahead.
crease that is surgically constructed.
The examiner’s angle of observation (‘ao’) should also
be level and perpendicular to the subject’s erect face (with

CH 2

FIGURE 22-11

If the observer is standing in a relatively higher observ-
ing position (Figure 22-12), with the patient looking back
at the observer in this higher position, the crease will
appear deeper due to the patient looking up with a posi-
tive Vax as well as a positive angle of observation (+ ao)
from the observer.
(+) ao
FIGURE 22-12
22 Advanced: Summary of Eyelid Crease Factors 313
This is similar to asking the patient to tuck the chin
in towards the sternum while looking ahead, with the
examiner observing from a level position, essentially
placing the patient’s eyes in an upgaze position relative
to its orbit.
CH 1
(+) Vax
314 Asian Blepharoplasty and the Eyelid Crease
If the patient sits at a higher position than the exam-
iner, the examiner is at a lower position and looking up
(a negative ao) and the patient looking down (a negative
Vax); the crease then looks shallowed (Figure 22-13).
Therefore with either the Vax or ao schema, a positive
value of each is associated with a deepening of the crease,
and a negative value is associated with a shallowing of the
crease. For study purpose, the crease should always be
evaluated with a neutral or zero Vax and ao value.
In elderly patients with involutional ptosis, we often
see what was a normally positioned crease during the
individual’s youth eventually give way to a higher, less
distinctive crease with onset of ptosis. The reasons are
three-fold: there is an overall weakening of levator
aponeurotic muscle (elevator for the eyelids) as well as its
attachment along the superior tarsal border, a weakening
of pretarsal and preseptal orbicularis muscle organization
near the area in front of the superior tarsal zone (less
pulling in of crease line), and a drop in upper lid level
(causing negative Vax on the part of the patient) and a
shallowing of their crease indentation. The weakening of
orbicularis fibers between the superior tarsal border and
(–) ao
FIGURE 22-13
its overlying skin results in lessening of attachment of
distal aponeurotic fibers to skin along the original crease
line. The few aponeurotic branches that remain superior
to this zone of dehiscence then constitute the higher
‘migrated crease’ (a misnomer), which is shallower and
not a true anatomic crease since it had not previously
indented at this higher position.
Ironically, many Asians with a single eyelid have a ten-
dency to have a noticeable posterior head-tilt. This is
analogous to a slight downward gaze, inclining their
levator muscle more towards a rested state, and further
diminishing the pull on the pretarsal–superior tarsal
border junction. I am uncertain why this is so, but factors
may include the following. In single-lidded patients, their
pretarsal lid fold tends to obstruct the upper 5–10° of their
superior field of vision, and this backward head-tilt may
be a compensatory move for visual improvement, or the
possible co-occurrence of latent ptosis or even presence
of minimal ptosis. Since birth, these individuals may have
adopted a slight head-back posture to clear their visual
axis. They are often quite surprised when this is pointed
out to them using photography from the side or mirrors.
CH 3
(–) Vax

Indeed, even after successful surgical addition of an
upper eyelid crease, patients often shallow their newly
found crease without knowing it when they assume their
previously accustomed slight head-back position. The
well-formed dynamic crease may not fully invaginate
unless the person’s forehead–chin line is vertical and the
face fully frontal. It is to be expected that a dynamic
crease should shallow on downgaze. I routinely advise
my patients ahead of surgery such that they can fully
incorporate this understanding into their postoperative
routine, that the optimal head posture and facial position
to show the crease is with the face pointing straight ahead
(where the forehead–chin line is perpendicular to the
floor). It is not unusual for the patient to take several
months to fully adopt this more normal head position.
The relative eye position (‘eypo’) of the globe within
the orbit is a much more subtle influence towards the
probable outcome of a crease. A slightly more forwardly
positioned eye and thus upper lid, has the levator in a
comparatively more flattened position (excluding patients
with thyroid eye disease where their levator muscles are
often over-stimulated, or fibrotic and shortened as it
recovers). The passive weight of its anterior skin–muscle
layers is lessened as it is distributed over a more horizon-
tal plane, resulting in less gravitational weight per surface
area. A forward position tends to somewhat shallow the
crease.
Conversely, a slightly more posteriorly placed (sunken
in) globe and upper lid now has the levator in a more
vertically biased position as well as having a better rela-
tionship for the skin–muscle layer to render an apparent
crease.
The eyebrow participates as a natural scaffold-support
for the upper portion of the upper eyelid, as the frontalis
muscle interacts with the upper periorbital portion (Zone
3) of the orbicularis oculi muscle (see Figure 22-7).
When there is brow ptosis (BrPt, or brow droop), a
crease may become shielded from view or totally obliter-
ated due to the avalanche of eyebrow soft tissue mass.
The brow may become overactive (BrOA) in involutional
ptosis, as well as in secondary ptosis following high
anchoring of the lid crease stitches onto levator muscle.
In these situations, the lid fold on top of the crease is
partly lifted up by the overacting brow and the true crease
may now be observed, while in some cases it appears less
indented (more shallow) since the passive anterior skin–
orbicularis layer has been lifted up.
Lastly, and of major significance, is the position of
placement of the crease, that is, the crease height (‘h’).
One will notice that height both facilitates (‘h’ in the
numerator) as well as hinders (h+ or h− in the denomina-
tor), and in different ways. The optimal height (‘hopt’) that
mimics a physiological crease is usually matched along
the area equivalent to the height of the middle section of
C =
∫
( Latt , LC, F , afi, pf , gz, h )
( s, m, f , ( − ) Vax , eypo, BrPt , BrOA , h + , h −)
22 Advanced: Summary of Eyelid Crease Factors 315
the superior tarsal border. A crease set too high (h+) will
risk lagophthalmos, pretarsal fullness and secondary
ptosis in addition to other aesthetic ramifications. A
crease that has been arbitrarily set too low (h−) through
a low incision will also adversely affect the outcome,
including failure of crease formation, subsequent fading
and disappearance of crease, obvious incisional scar that
cannot be easily hidden, as well as segmentation of crease
form. An ideal crease height (h) that is in line with natural
anatomy offers the best aesthetic result and least chance
of complications. Therefore here, h is on the top (numer-
ator) line; h+ and h− can be adverse factors, and sit as
denominators.
In an occasional patient we see a dehiscence of the
lateral canthus, showing a thinning of the superior and
inferior crus (limb) of the lateral canthal tendon. Often
one sees rounding and a thinned web-like skin over where
the lateral canthal angle once was. The upper eyelid
crease will be less indented laterally as a result of associ-
ated weakening of the lateral portion of the levator
muscle. The pretarsal orbicularis, which normally
attaches itself at the lateral orbital rim, is also weakened,
together with the tarsal attachment near the lateral orbital
tubercle – laterally, the crease indent is weak due to weak-
ness of the tarsal–levator complex.
At the opposite end, with the medial canthus, a patient
with medial ptosis as a result of dehiscence of the
medial horn of levator and lateral migration of their tarsal
plate typically shows a similar loss of medial crease
indentation.
A dehiscence over the lateral canthal region of the
upper eyelid typically leads to less effective levator-uplift
at the lateral end of the lid. The weakening of levator
coupled with post-surgical hemorrhage from within
orbicularis can lead to an acquired ptosis position. The
crease now appears shallower as well as a bit further from
the ciliary margin.
Having a comprehensive understanding of the physio­
logical parameters that form a crease, and its accentuating
and distracting factors, will allow the surgeon to tailor
each individual’s needs and come forth with a set of ideal
surgical solutions with each of these factors in mind. The
Asian eyelid crease procedure thus chosen should have
the capacity to allow the surgeon to make intraoperative
assessment, and to correct those applicable factors fully
in order to optimize crease formation.
The current evolution of the Asian blepharoplasty
technique used by this author has allowed such assess-
ments and corrections, and is one of many reasons for
favoring the external incision techniques over the histori-
cally cited suture ligation methods.
Returning to the formula that opened this chapter,
which allows us to consider all the factors that play a role
in creating an eyelid crease:
316 Asian Blepharoplasty and the Eyelid Crease
the formula’s legend now reads: C represents the prob-
ability of crease formation and is proportional to the
summation (∫) of various enabling factors including
levator attachment and contractility, preaponeurotic
fat, aponeurotic fibers of the levator aponeurosis, the
palpebral fissure size, intactness of the glide zone
with healthy normal fat, and correct optimal placement
of crease height; it is adversely influenced by the
factors in the denominator, which include texture and
quantity of eyelid skin, muscle, presence of scarred
fat, patient’s negative visual axis angle, eyeball position,
brow ptosis and brow compensatory overaction, and
excessively high or low deviation from the proper crease
height.
ADDITIONAL EXPLANATION OF
CREASE HEIGHT (previously covered in
Chapters 19 and 20)
If we have a patient lying supine and measure the eyelid
crease height with the lids closed, we obtain the true
location of an anatomic crease, which is usually along the
superior tarsal border. Let us assume the anatomic crease
height is 7 mm for an Asian with a natural crease. When
the patient is sitting up and the face is vertically aligned,
with the patient looking ahead, the crease is optimally
manifested and tucked in under its eyelid fold. The supe-
rior tarsal platform is tilted posteriorly in an oblique
direction. The measured anatomic crease height of 7 mm
(pretarsal skin) can be thought of as being tilted on the
hypotenuse of a 45° isosceles triangle, while the two
remaining sides of this triangle form the vertical axis and
the horizontal axis (each of these two sides will be approx-
imately 5 mm each, as it is 7 mm × 1/√2). Therefore the
measured 7 mm crease will appear to the examiner (or
patient’s view through a mirror) to occupy 5 mm in verti-
cal height at its apex (tilted crease height), and about
2–4 mm only (apparent crease height) when a 1–3 mm
eyelid fold hanging over it is subtracted out. Therefore,
it is quite normal for a single-eyelid patient to ask for a
3 mm crease as their preferred end result; the practi-
tioner must realize that it needs to come from a 7 mm
crease placement.
The question as to whether there are some factors
relating the finding of increased failure rate (fading of
crease) after surgery among patients with borderline
levator excursion (within the 9–11 mm range), or an asso-
ciation of minimal to mild ptosis among single-lidded
individuals, is harder to delineate.
This chapter is a synthesis of all the concepts discussed
in this book so far. Some may be too esoteric, but I hope
that for most readers it serves the function of bringing
the concepts together into a coherent scheme such that
it may be helpful in patient care.
REFERENCES
1. Collin JR, Beard C, Wood I. Experimental and clinical data on the
insertion of the levator palpebrae superioris muscle. Am J Ophthal-
mol 1978;85:792–801.
2. Chen WPD. Concept of triangular, rectangular and trapezoidal
debulking of eyelid tissues: application in Asian blepharoplasty. Plast
Reconstr Surg 1996;97(1):212–218.
3. Chen WPD. The concept of a glide zone as it relates to upper lid
crease, lid fold, and application in upper blepharoplasty. Plast
Reconstr Surg 2007;119(1):379–386.
4. Chen WPD. Beveled approach for revisional surgery in Asian
blepharoplasty. Plast Reconstr Surg 2007;120(2):545–552.

ADVANCED CONCEPT
OF THE EYELID CREASE
AS A STRINGED SERIES OF UNIPOINTS
Concluding this group of chapters, I present my current
thinking with respect to the functional biodynamics of
the eyelid crease.
In 1993 when I was preparing the manuscript for the
original Asian Blepharoplasty atlas, in its last chapter I
made an analogy that the eyelid crease is somewhat like
the Great Wall of China, where from outer space an
astronaut may merely observe a line crawling across the
planet’s surface while in actuality the Wall meanders
along, covering vastly different terrain and with forts
scattered every 80–120 meters. These outposts were built
with different functions in mind, their interiors having
varying sub-sections serving as sleeping quarters, grain
storage, weapon depots, animal shelters, signal and
command stations. Similarly, the eyelid crease changes
subtly as you traverse across the width of the eyelid. It is
attaching to various substrates of tissues as the curvature
of the lid margin, the tarsus and its opposing canthal liga-
mentous attachments come into play.
FIGURE 23-1 ■ The slightly different sizes of
the yellow dots represent unipoints that have
different magnitudes of vector forces exert-
ing on them.
CHAPTER 23
As with a naturally born eyelid crease, there are differ-
ent techniques that you can apply within sections of the
single eyelid as you create (or add) a natural crease, cours-
ing continuously across the upper eyelid with its outer
appearance showing as a homogeneous line. (We have
discussed the depth of a crease and how to titrate this, the
apparent crease versus the tilted crease height, as well as
attachment to different anatomic terrain across the width
of the crease.) Here we are discussing the linearity of the
crease with respect to the curvature of the eye.
What about the opposing vectors that act across the
length of the eyelid crease? In other words, what about the
forces acting along the crease which allow the anterior
lamella (preseptal layer) to slide down relative to the pos-
terior lamella of levator and tarsus when the eyelid opens?
I prefer to conceptualize the eyelid crease as the
external manifestation of a stringed series of unipoints
(unipoint = single point in space). In Figure 23-1 the dif-
ferently sized yellow dots represent unipoints that have
317
318 Asian Blepharoplasty and the Eyelid Crease

vector forces of different magnitudes acting on them.
Each of the yellow dots (Figure 23-2) represents a highly
magnified unipoint (vector interface), where the red vector
is in line with the pull of the levator, and the blue arrow,
the gravitating weight of the anterior skin–muscle layer
when the facial nerve input is relaxed. Note that the blue
vector’s direction may vary between 45° relative to hori-
zontal, to almost vertical (90°) if the facial features are
comparatively flat, as is often the case with Asian eyes.
Let us conceptualize that each unipoint is a nano-
scaled virtual point (like rotating nano ball-bearings, or
mathematical definitions of a point in space) that is
bounded by vector forces going in opposite directions
(sloped-up on the backside, and sloped-down on its front
side). This string of unipoints is like a string of nano-
scaled rosary beads that straddles the two lamellae of the
upper lid at a location approximately along the superior
tarsal border. When the levator is activated (‘ON’ for
third nerve) and pulls the upper lid open, there is an
inhibitory nerve signal that happens at the same time
towards the orbicularis muscle (supplied by seventh
nerve), turning it ‘OFF’. The weight of the relaxed
preseptal layer of skin and orbicularis slides down pas-
sively, and covers part of the pretarsal skin and becomes
the eyelid fold. The exact interphase between the poste-
rior layer going up and the skin–orbicularis layer coming
down occurs under the skin and within the eyelid, and its
external manifestation on the skin side is the eyelid crease.
The phasic change is where these virtual unipoints (or
virtual nano-balls) are located. The slip-slide is facilitated
by healthy fat in the middle space that I have termed the
glide zone (see Chapter 17).
A good analogy is the wise saying that ‘an avalanche
can start with the added weight of a snowflake’. We can

FIGURE 23-2 ■ Each of the yellow spheres represents a highly magnified unipoint (vector interface) where the red vector is in line
with the pull of the levator, and the blue arrow, the gravitating weight of the anterior skin-muscle layer when the facial nerve input
is relaxed. Note that the blue vector’s direction may vary between 45 degrees relative to horizontal, to almost vertical (90 degrees)
if the facial features are comparatively flat, as is often the case with Asian eyes.
 23 Advanced Concept of the Eyelid Crease as a Stringed Series of Unipoints 319

see this easily by watching layers of fine colored sand
trapped in liquid between two panes of glass. As we rotate
the glass panel, we can see sand dunes topple, and slip-
slides as the layers on top gain just a bit more sand.
In mimicking a crease through surgery, it is important
to recognize where this occurs. To create it accurately,
the precise placement of the crease along where these
phasic changes (series of unipoints) naturally may occur
(with surgical clearance of impeding tissues) should be
the most important goal. Deviation from it has significant
physiological and functional side effects.
Figure 23-3 shows pre-and postoperative images of a
single-lidded individual, after undergoing Asian blepha-
roplasty performed by the author. Yellow conceptual uni-
points are pasted here to show the lower pretarsal zone
vectoring against a relaxed upper preseptal zone.

FIGURE 23-3 ■ (A,B) Pre- and postoperative images of a single-lidded individual, after undergoing Asian blepharoplasty by Chen. Yellow
conceptual unipoints are superimposed here to show the lower pretarsal zone vectoring against a relaxed upper preseptal zone.
320 Asian Blepharoplasty and the Eyelid Crease

This concept can explain why buried ligatures that high crease height and acquired ptosis (Figure 23-4)
encircle the levator muscle, or a high-anchoring crease Note the unipoint function is restricted within the confine
on the aponeurosis, often lead to problems including of the buried ligature.

FIGURE 23-4 ■ Note the unipoint function is restricted within the confine of the buried ligature.
 23 Advanced Concept of the Eyelid Crease as a Stringed Series of Unipoints 321

Here we see that any chance for forming a normal
unipoint pivot is lost when a buried suture traverses
through the orbicularis of the anterior lamella, which is
supposed to relax, and the posterior levator muscle, which
is trying to lift the eyelid (Figure 23-5).
A Faden-like fixation effect is created on the lid in at
least three high locations due to placement of the three
buried permanent sutures. The compression ligatures
create an unintentional drag (increased impedance) on
the contractile function of both levator and Müller’s
muscles. (In this case, the Faden effect is both ecto- and
endo- as the fixation location[s] is both anterior to and
beneath the plane of the levator aponeurosis, shown in
Figure 23-5 as a pink layer. The fixation location is often
superior to the tarsal border by several millimeters.)
The magnified inset view of this same drawing (Figure
23-5, Inset) shows the impediment imposed on the uni-
point’s two vectors. The high placement on the levator
reduces the effective contractile range of the levator
aponeurosis. The contractile (lifting) force represented
by the green vector arrow parallel to the levator plane is
reduced. Levator excursion is reduced. Load is increased
when more tissues are piled on to the wagon, so to speak.
The inclusion of more orbicularis oculi muscle and
subcutaneous fascia in this buried suture loop similarly
affects the ability of the orbicularis to relax when the
seventh nerve is inhibited and gravity is supposed to allow
the eyelid fold to form over the crease, resulting in a
lessened blue vector. There is a restricting or braking
force holding the anterior lamella up, and less tissue can
come down. The apparent crease height is magnified, and
we see ptosis. The gray orbicularis layer is prevented
from gravitating down at the desired location along the
superior tarsal border, but is hitched up at a higher point
– a high crease may be the result, or a faded crease is the
eventual result when the tissue tension releases with the
suture eventually having worked its way through tissues.
In severe cases, we may see lagophthalmos.

FIGURE 23-5 ■ Here we see that any chance for forming a normal unipoint pivot is lost when a buried suture traverses through the
orbicularis of the anterior lamella (blue vector), which is supposed to relax, and the posterior levator muscle (green vector), which
is trying to lift the eyelid.
322 Asian Blepharoplasty and the Eyelid Crease

canthus, and firmer with less potential space within

VARIATION IN FUNCTION
OF THE UNIPOINTS
Are there variations in the functions of these unipoints
that are located along the crease line? The answer is most
certainly yes. One can surmise that the maximal direc-
tional change in vectors for these unipoints occurs along
the mid-section of the eyelid crease, in other words, the
maximal directional change occurs centrally (along these
nano-dots). It lessens as you approach each canthal
angle (medial and lateral corners of the eyelid opening).
Towards the corners of the eyelid opening, the vector
forces pulling upward are likely to be less (less functional
levator muscle fibers present), and directionally the
levator aponeurotic vector will be flatter and more side-
ways oriented. Similarly, the downward weight of the
relaxed anterior skin–orbicularis muscle layer is likely to
be lessened as one approaches each corner too. At the
same time, the skin is relatively thicker towards each
its strata. Additionally, the blue vector may be flatter
or less vertically positioned (smaller incline angle, I) at
each canthal region, so that the phasic change between
the two vectors (green and blue) is not directionally
opposite (close to 180°) as in the central portion of the
crease. It will be less fluid, and occur at a slower pace
(speed), since even though it takes the same time per
blink medially or centrally, the distance covered is less.
So the net force-reversal (or vector-reversal) along the
medial and lateral sections of the crease is likely to be less
abrupt.
Figure 23-6 shows nano-dots placed along the crease
of a patient who underwent successful Asian blepharo-
plasty. The smaller-sized dots indicate lesser vector-
reversal. Note the slightly smaller yellow dots I have
positioned on the medial and lateral sections of the
crease; these represent smaller-scaled vectors interaction
as well as a less directionally opposite relationship
between the green and blue vectors.

FIGURE 23-6 ■ Nano-dots placed along the crease of a patient who underwent successful Asian blepharoplasty. The smaller sized
dots indicate lesser vector-reversal. Note the slightly smaller yellow dots I superimposed on the medial and lateral sections of the
crease; they represent smaller scaled vectors interaction as well as a less directionally opposite relationship between the green and
blue vectors.
 23 Advanced Concept of the Eyelid Crease as a Stringed Series of Unipoints
With the force-reversal being more forceful centrally
and less so medially and laterally, one should expect the
crease indentation to be greater centrally, and lessen
towards the two ends. Clinically, it helps to explain why
it is more challenging to form the crease well in medial
and lateral areas.
The direction of the blue vector is worth further dis-
cussion. You may often see in Caucasians who have deep-
set eyes that their levator muscles pull up and their crease
indents effortlessly. This is seen often with a hanging lid
fold that almost appears to have a reverse cant (slope)
from the superior orbital rim heading backwards; in other
words, the skin above is hung from their eyebrow and
sloping down and backwards (inferoposteriorly). In
Asians who typically may have a flatter-appearing eyelid-
to-orbital rim spatial relationship, that fold of skin is far
more likely to be sloping down and forward (inferoante-
riorly), therefore pushing down against the uprising
green levator force, which is acting at an incline angle
near the tarsal plate of 45–50°. For Caucasians, this
downward blue vector (representing skin and orbicularis)
does not impede crease formation as much, owing to a
higher probability that its angle of action is not directly
opposing at 180° the lifting green vector.
One can tailor the crease construction based on topo-
graphical variations of the levator along the pretarsal
segment (skin, orbicularis, superior tarsal border), its
spatial location with respect to the orbit, findings regard-
ing the hindering elements towards crease formation, size
of the palpebral fissures and specific individualized design
factors for crease height, shape and continuity. The tech-
nique used on one eyelid may need to encompass a com-
bination of several specific crease-enhancing skills to be
applied over different sections of that crease. The oppo-
site eyelid may need something different.
DIFFERENT POINTS ALONG THE
UPPER LID CREASE
In clinical observation, with a naturally born upper lid
crease the crease indentation is often sufficiently promi-
nent over the central one-third as well as the medial one-
third (here, it could be that the net balance of a younger
adult’s levator muscle is still strong and the relaxed weight
of the medial canthal fold allows a good crease to occur
medially). The lateral one-third of the crease often
323
shallows to a certain degree for a natural crease as the
vector force decreases in its magnitude and directional
shifts. In a surgically created crease using the external
incision approach such as the author’s Asian blepharo-
plasty, one would expect the mid-section of the con-
structed crease (with maximal phasic changes along the
unipoints) to be easily noticeable and permanence easily
attained, while the medial one-third of the crease is
enhanced by special wound closure techniques and man-
agement of the medial upper lid fold, and the lateral-one
third may be allowed to shallow somewhat like a natural
crease does. These conclusions are largely predicated
on the presumption that the patient has healthy levator
function and an adequate-sized eyelid opening, vertically
as well as horizontally, and that a healthy glide zone
(preaponeurotic space and fat) exists.
In complicated cases where there is cicatrix along
the anterior lamella (skin–orbicularis) or glide zone
(preaponeurotic space), where there is rigidity of skin or a
lack of a slip-slide (vector-reversal), then there is lessened
possibility for formation of a crease. Revisional attempts
will be needed in order to re-establish these biodynamics.
(Here again, further revisional attempts using suture tech-
niques are almost always unsuccessful for obvious reasons.)
IN CONCLUSION
In the first edition of this book, I suggested some poten-
tial directions for surgical research regarding crease for-
mation. Unfortunately there has not been any significant
progression in the medical literature using external means
like newer, novel lasers or implantable bio-dissolvable
material for this purpose. Besides, even if there were,
with the vigorous benchmark we have set and an improved
understanding of biodynamics, it is unlikely that any
technique can reach these ideals entirely, in terms of
optimal control and placement of crease height, control
of crease shape, having a natural continuous appearance,
and to achieve permanence, as well as avoid long-term
harm. One should aim to reach all four parameters in one
surgical session, however one should note that due to
variability of each patient’s intrinsic eyelid anatomy and
associated conditions like ptosis, some patients will need
staged procedures since the objectives may exceed what
can be achieved in one procedure, whether it is primary
or revisional blepharoplasty.

ASIAN EYELID SURGERY:
MY THOUGHTS
by Khoo Boo-Chai (manuscript prepared by William PD Chen MD)
Khoo Boo-Chai of Singapore, a pioneer in this field since
the 1960s, kindly furnished all the information in this
chapter, which was abstracted by W.P.D. Chen and
reviewed by Dr Boo-Chai for the second edition of this
book. This was based on his 40 years of hands-on experi-
ence with aesthetic (cosmetic) surgery of the upper eyelid.
Boo-Chai1 reported on his experience over five years
with 625 cases of Asian lid crease procedures using the
conjunctival stitch method. He recommended that this
procedure is best used in patients with little upper lid fat
and without a heavy fold that hangs down over the lid
margin. Non-absorbable suture materials are used to
connect the levator aponeurosis to the eyelid skin at a
desired level 5–8 mm from the lid margin. If there is
excessive supraorbital (preaponeurotic) fat, it is first
removed through an additional central skin incision
about one-quarter the width of the crease line designed.
The lid is everted and treated locally with 5% topical
lidocaine solution; 0.5 ml of 1% lidocaine is given sub-
conjunctivally. A needle bearing 4-0 nylon suture is
passed through the conjunctiva in a horizontal fashion for
2–3 mm over the superior tarsal border. Each arm is then
repassed through the conjunctiva towards the skin side
overlying it. One arm of the externalized skin stitch is
then passed subcutaneously towards the second arm,
which is often itself passed through a small stab incision
on the skin to facilitate the passage and subsequent
burying of the knot. The two ends are tied, and the knot
is tied down and buried under the skin surface. Usually
three of these pairs of stitches are used.
Boo-Chai evaluated his patients 1 month postopera-
tively using the following parameters for a perfect result:
1. The creases on both sides must match in position,
height, length and contour.
2. The position and contour of the upper lid margin
must match, without any notching or peaking.
3. The eyelashes must not be distorted or missing.
4. Blinking must be normal.
5. Both eyelids must close normally during sleep.
6. There must be minimal scarring and no ectropion.
7. The results must be permanent.
According to Boo-Chai, the advantages of this method
include reversibility, minimal swelling and the absence of
an external linear scar.
Boo-Chai2 also discussed the correction of the follow-
ing three conditions: discrepancies in the height or shape
of the crease, the absence of crease formation (‘failed
double-eyelid operation’) and a hollowed supratarsal
recess due to excess removal of fat. In the introductory
CHAPTER 24
paragraphs he commented on the two main types of tech-
nique: the non-incisional suture techniques versus the
incisional techniques with clearing of skin, fat, and use of
skin–levator–skin fixation.
In the first category, when revising a previous non-
incisional technique to eliminate discrepancies in crease
height and shape, it is important to eliminate the crease
by removing the loops of suture material that connected
the levator to the skin. Boo-Chai prefers to apply the new
crease-forming sutures usually three at the same setting
after the previous loops have been removed.
For those with crease height and contour problems as
a result of previous incisional techniques, he discussed
two options:
1. If the patient wants an excessively low or shielded
crease (caused by residual excess skin) to be cor-
rected to a higher level to match the opposite side,
he starts along the existing crease scar and designs
an upper line of incision several millimeters above
this. The excess skin is excised and the crease
reconstructed.
2. In situations where there is no excess skin, he
prefers to use a non-incisional buried suture loop
technique to create the new higher crease without
forming a second skin cut or scar.
He eliminates the previously created crease by going
through the small stab incisions (used for the non-
incisional method) and effectively undermining the adhe-
sion between the aponeurosis and the dermis. The
dissolution of this crease is verified intraoperatively by
having the patient look upwards.
He also discussed lowering creases if both sides are
higher than optimal, the emphasis being to include the
existing scar line within the tissues to be excised.
In the second category, correction of poor crease for-
mation, the revision involves excision of the previous
fibrous tissue connection between levator and skin, as well
as excision of the previous incisional scar. He then uses six
or seven 4-0 sutures to connect skin to levator to skin.
The third category of revisional blepharoplasty
involves the correction of a deepened sulcus caused by
excess fat removal. Boo-Chai uses fat harvested from a
lower blepharoplasty and the fat is then divided into
numerous 3 × 4 mm pellets. These are then placed behind
the anterior layer of the orbital septum on top of the
levator aponeurosis (with its closely attached posterior
layer/reflection of orbital septum). He prefers to place
more fat over the medial side of the upper lid. He notes
that when observed 6 months later, these fat pellets
seemed to have coalesced to form one piece.3
325
326 Asian Blepharoplasty and the Eyelid Crease
Boo-Chai3 described the occasional presence of a mar-
ginal arterial arcade with perforating branches that pierce
the levator aponeurosis near the insertion of the aponeu-
rosis on the tarsus. These perforating vessels run perpen-
dicularly in a vertical fashion, and lie within the
suborbicularis areolar fatty tissues. They are not common
and are difficult to detect unless specifically sought. When
the lower skin flap is surgically manipulated or cleared,
these perforators may be damaged and bleed, retracting
within the aponeurosis to lie close to the marginal arterial
arcade in the pretarsal (postaponeurotic) space, giving rise
to a hematoma. Boo-Chai observed this in three cases,
with an incidence of 1 in 500 cases. He went on to explain
that the marginal arterial arcade normally lies on the tarsus
3 mm from the lid margin. It receives a contribution
A sign’.
B forming posterior to the levator
medially from the superior medial palpebral branch of the
ophthalmic artery and laterally from a branch of the lac-
rimal artery. In Asians, the marginal arterial arcade is
covered by the levator aponeurosis, owing to its low inser-
tion on the tarsus. This is in contrast to Caucasians, where
the marginal arcade is not covered by the aponeurosis
because its insertion is high up on the upper part of the
tarsus. He stated that his preferred management of bleed-
ing in such incidents was to apply ice compresses, and that
the bleeding is self-limiting. He has subsequently called
this form of bleeding the ‘Boo-Chai sign’. It is unusual in
the sense that the bleeding occurs suddenly posterior to
the levator aponeurosis, and spreads widely within an area
not usually touched during incisional methods of Asian
eyelid surgery (Figure 24-1 A, B).
FIGURE 24-1 ■ (A) Left upper eyelid
of a 25-year-old Chinese woman
undergoing Asian blepharoplasty.
A strip of skin and orbicularis oculi
has been removed from the left
upper lid, revealing giant branches of
the marginal arcade running verti-
cally upward. These branches
emerge from underneath the anterior
extent of the distal portion of the
aponeurosis on the tarsal plate, and
pierce the levator aponeurosis. They
then course up vertically and lie in the
retromuscular (suborbicularis) fat.
Accidental damage to these branches
when dissecting the skin flap will give
rise to bleeding, with the formation of
a hematoma behind and deep to the
levator aponeurosis: the ‘Boo-Chai
FIGURE 24-1 ■ (B) Right upper eyelid
illustrating a self-limiting hematoma
aponeurosis.

Dr Boo-Chai’s Personal Comments
‘In 2001, besides describing its clinical features for the
first time in the British Journal of Plastic Surgery,3 I also
postulated its causation. I surmised that it was due to
damage to an abnormally large branch of the marginal
arterial arcade. That was only an educated guess, because
the detailed anatomy of the vasculature of the upper
eyelid was not then available in an anatomy text.
‘Two years after this publication, in 2003, a group of
Korean plastic surgeons independently confirmed the
clinical features of this bleeding complication in 25 of
their cases.4 They postulated that the bleeding occurred
from damage to a blood vessel lying in the inferolateral
part of the levator palpebrae. As to the exact vessel, they
said that their research was ongoing and that they would
publish a report as soon as they had arrived at a definitive
conclusion.
‘Unbeknown to me and to them, however, a group of
Japanese anatomists and plastic surgeons5 performed a
detailed anatomic study of the vasculature of the upper
eyelid in seven Asian cadavers. They published their find-
ings in 2004 in the Journal of Plastic and Reconstructive
Surgery. This study confirmed my findings of the arrange-
ment of the blood vessels and that the source of the mys-
terious bleeding was from an abnormally large branch of
the marginal arterial arcade. Their study showed (a) that
there are four arterial arcades in the upper lid, one lying
about 3 mm from the margin (marginal arcade), to which
I had called attention; (b) the other, the peripheral arcade,
is situated at the upper border of the tarsal plate (the other
two are the superficial and deep orbital arcades, and they
communicate with the marginal arterial arcade); (c) the
arcades are interconnected by thin vertically oriented
vessels. The small vertical branches running between the
marginal and peripheral arcades, as well as that between
the marginal arcade and the deep orbital arcade, lie in a
plane posterior to the orbicularis oculi muscle. This also
confirms my previous observations during surgery.
‘I stated that very rarely a few (two or three) of these
fine vertically running vessels become larger, penetrating
FIGURE 24-2 ■ Points A and B are on
the lid skin side, 4–5 mm apart. A′ and
B′ are on the conjunctival side 6 mm
superior to points A and B, and are
also 4–5 mm apart. The conjunctival
surface is moist and difficult to mark
with ink. The lid is everted gently with
forceps or with the forefinger, and
0.5 ml of xylocaine is applied locally
through the conjunctiva. This provides
anesthesia as well as turgidity to the
conjunctiva for easier passage of the
needle (right upper lid).
24 Asian Eyelid Surgery: My Thoughts 327
the overlying levator aponeurosis and lying within the
suborbicularis oculi fat. This was confirmed in the Japa-
nese paper, which showed that the two arterial arcades
are interconnected by vertically running vessels. When
any of these abnormal branches of the marginal arcade
are damaged during surgery, they can retract and end up
lying posterior to the levator aponeurosis, resulting in a
hematoma there.’3–5
THE BOO-CHAI METHOD
The following is a step-by-step description of Boo-Chai’s
conjunctival suture method, as practised by him (in 2006)
among approximately 5–10% of his Asian patients seeking
placement of an upper eyelid crease.
Principle
Using exogenous monofilament nylon slings to connect
the levator palpebrae superioris to the eyelid skin at a
desired level.
Medications and Instruments
Local anesthetic, 1–2% xylocaine with 1 : 100000 dilution
epinephrine; intravenous sedation as needed. Needle
holder, three strands of 4-0 or 5-0 monofilament nylon,
to be applied on a 14–16 mm curved, tapering non-
cutting needle with an eyelet.
The desired level of the eyelid crease is marked with
indelible ink on the skin side. It is important for the levels
on both sides to be exactly the same, otherwise, at the
end of the operation one may notice asymmetry, which
is the most common cause of suboptimal results. The
half-moon-shaped crease is very popular. To achieve this
using three slings, the middle sling should be about
2–3 mm higher than the other two.
The following figures show Khoo Boo-Chai’s tech-
nique step by step (Figures 24-2 to 24-7).
B' A'
B A
328 Asian Blepharoplasty and the Eyelid Crease

FIGURE 24-3 ■ Using a curved non-cutting

needle (14–16 mm diameter) and either 4-0
or 5-0 nylon sutures, the needle is passed
from A′ to B′ subconjunctivally just beneath
the surface and exiting through B′ (right
upper lid). (Step 1.)

1
B' A'

B
A

FIGURE 24-4 ■ (A, B) The needle coming out of

B′ is regripped and passed through B on the
B skin side in a trans-lid fashion (right upper lid).
(Step 2.)
 24 Asian Eyelid Surgery: My Thoughts 329

B' A'

B
A

B
FIGURE 24-5 ■ (A, B) The needle itself is removed from the suture at B, and used to rethread the other end of the same suture coming
from A′. It is similarly passed through the lid and exits through A on the skin side (right upper lid). (Step 3.)
330 Asian Blepharoplasty and the Eyelid Crease

B' A'

B 4 A

FIGURE 24-6 ■ Using the needle at A, the suture is passed subcutaneously towards B (Step 4). This is repeated for the other two sets
of nylon slings. With light pressure, check to verify that they are all in place. The tying is done only when all three sets of slings
are in place, as it is difficult to evert the lids once the ends are tied. To facilitate the tied knot being buried under the skin surface
at B, one may elect to make a small skin incision there and excise a small amount of subcutaneous tissue, so that the knot can be
buried and remain flat. There is no need to close this small incision. Postoperative dressing is unnecessary. Topical antibiotic oint-
ment is applied for the skin wound.
 24 Asian Eyelid Surgery: My Thoughts 331

LA

FIGURE 24-7 ■ Cross-sectional drawing showing the suture sling encompassing the subcutaneous tissues, orbicularis, levator aponeu-
rosis and Müller’s muscle. Dr Boo-Chai further commented that although this technique looks simple, it is technically difficult to
execute unless one is experienced. The postoperative period is brief and the patient can go back to work after several days. The
only drawback is that it is not always easy to obtain an equal crease width on both lids. The crease can be revised by removing the
previously placed nylon slings and reapplying them at the desired level to correct any asymmetry. LA, levator aponeurosis; M,
Müller’s muscle; C, conjunctiva. (William PD Chen MD.)
332 Asian Blepharoplasty and the Eyelid Crease
REFERENCES
1. Boo-Chai K. Further experience with cosmetic surgery of the upper
eyelid. Proceedings of the Third International Congress of Plastic
Surgery. Excerpta Medica International Congress Series 1963;No.
66:518–524.
2. Boo-Chai K. Secondary blepharoplasty in Orientals. In: Lehman J
ed., Problems in plastic and reconstructive surgery, Vol. 1. Philadel-
phia: JB Lippincott, 1991:520–535.
3. Boo-Chai K. Perioperative bleeding in the pretarsal (post-
aponeurotic) space in oriental blepharoplasty. Br J Plast Surg
2001;54:370.
4. Kim BG, Youn DY, Yoon ES et al. Unexpected bleeding caused by
arterial variation inferolateral to levator palpebrae. Aesth Plast Surg
2003;27:123–125.
5. Kawai K, Imanishi N, Nakajima H et al. Arterial anatomic features
of the upper palpebra. Plast Reconstr Surg 2004;113:479–484.
FURTHER READING
Boo-Chai K. Some aspects of plastic (cosmetic) surgery in Orientals.
Br J Plast Surg 1969;22:60–69.
Boo-Chai K. The surgical anatomy of the oriental upper lid. World
Plast 1996;1:230–236.
Boo-Chai K. Aesthetic surgery for the Oriental. In: Barron JN, Saad
MN, eds. Operative plastic and reconstructive surgery, Vol. 2. Edin-
burgh: Churchill Livingstone, 1980: 761–781.
Boo-Chai K. Surgery for the oriental eyelid. In: Lewis JR Jr, ed. The
art of aesthetic plastic surgery. Boston: Little, Brown, 1989:
611–617.

TREATMENT OF MEDIAL UPPER LID
FOLD AND THE FOG SURROUNDING
EPICANTHOPLASTY
The treatment of a clinically prominent medial fold of
the upper lid often elicits a spontaneous reaction from
clinicians that an epicanthoplasty is necessary. This idea
has reached an almost epidemic proportion from patients
searching for information on the Internet, and seeing
informational pages on different websites that profess
their expertise in these corrections. Johnson wrote the
first paper on epicanthus, and there have been several
early papers describing the treatment for truly pathologi-
cal epicanthus.1–5
I have often been insistent on the notion that the term
epicanthal folds1 refers to a distinct entity seen as a patho-
logical condition in association with blepharophimosis
syndrome and other congenital disorders, often with
ptosis, telecanthus and euryblepharon. As such, the papers
(including Mustarde’s) originally written for correction
of these conditions were as much for correction of tele-
canthus (through intercanthal wiring), treatment of con-
genital ptosis and reduction/elimination of the epicanthus.
The findings of epicanthus tarsalis were generalized to
normal Asians who are single-lidded (with no upper lid
crease) who happen to have a fold similarly located. Here
is where I have a problem. First of all, there are many
normal Asians who present with a mild medial upper lid
fold (consider that there are probably at least 3 billion
Asians on earth); secondly, the folds we see in these
normal healthy Asians are smaller in extent compared to
the ones we occasionally see in the rare congenital blepha-
rophimosis syndrome; and thirdly, they are not really
obscuring the caruncle. So we have a dilemma: do we call
someone who is ‘pre-diabetic’ a diabetic? Is someone who
has a medial upper lid fold considered as having an
‘abnormal epicanthus’, or merely a single-lidded person
with a heavier fold of skin medially that may have a
resemblance to that seen in blepharophimosis, but lacks
any blockage of view of the caruncle, and without ptosis
or telecanthus, or euryblepharon of the lower lids?
We see the drastic techniques for the treatment of
congenital epicanthus being modified to treat these more
benign medial upper lid folds (common in normal Asians)
but we have retained the term epicanthoplasty, as a dis-
tinct add-on selection choice on the plastic surgery menu.
So now, medial canthal skin manipulations through
complex stick-man figures, flap transpositions and many
CHAPTER 25
variants of these same ideas of Mustarde are being pub-
lished, followed and performed, for very simple promi-
nent medial upper lid folds (folds that this author feels
can be eliminated as part of the Asian blepharoplasty,
with some simple techniques applicable to the medial end
of the incisions, which we will go over very soon in this
chapter).
I feel this is a wrong direction to go for many reasons.
There is an expansion of unnecessary complexity added
to the medial canthal region where there is not much
pathology. Medial canthal skin near the nasal bridge is
being worked on in normal otherwise-attractive facies.
Often the surgical results in epicanthoplasty (as practiced
now on normal single-lidded Asians) shows an exagger-
ated show of the caruncles, and there is a higher than
expected problem of delayed skin healing (and perhaps
complications) through maneuvers over these anatomic
regions as practiced by aesthetic surgeons dealing with
eyelids. It is common to see residual scars – or at least, I
do. That is why in the first edition of this book (Asian
Blepharoplasty – A Surgical Atlas, Butterworth–Heinemann;
1995) I stated that a prominent medial upper lid fold in
a single-lidded individual can be simply excised through
the main body of steps involved in Asian blepharoplasty,
with the crease shape designed to merge medially into
the remnant of the medial fold, and gives a very natural
nasally tapered crease similar to what we see in those
Asian individuals born with a nasally tapered crease shape.
This is very apparent to those of us who work with Asian
patients. Their caruncles are seen easily, or only half-
shielded, they do not have telecanthus, and their palpe-
bral dimensions to inter-canthal distance, as well as
proportion to the width of face, falls within the ideal
ratios after simple Asian blepharoplasty.
To this day I feel that the term epicanthal fold has been
massively mis-applied, commercially exploited and epi-
canthoplasty unnecessarily recommended. There is con-
fusion among those who are shopping for surgeries/
surgeons as well as pressure among surgeons who follow
the trend. I often see less-than-satisfied Korean-American
patients coming in for revision consultation, who did not
know what they had undergone overseas, and who show
me a medical invoice itemizing at least three charges:
double-eyelid crease procedure, ptosis repair and
333
334 Asian Blepharoplasty and the Eyelid Crease
epicanthoplasty. Perhaps this is the trend, a trend that is
not beneficial to doctors and their patients. (The overuse
of ptosis correction in non-ptotic Asian patients who
simply have a prominent eyelid fold over their upper lid
margin is another issue that has similar repercussions.)
SOLUTIONS FOR REDUCTION OF
MEDIAL UPPER LID FOLD IN RELATION
TO CREASE SHAPE DESIGN
In my practice the majority of single-eyelid patients who
may have a narrowed palpebral fissure medially may
simply have a prominent medial upper lid fold of skin (a
FIGURE 25-1 ■ Reduction of medial upper lid fold with selection of nasally-tapered crease shape.
term I favor). In recommending crease shape, I often will
show these patients illustrations of a natural nasally
tapered crease so they have an idea.
(1) If they understand and choose a nasally tapered
crease (NTC), during the procedure the medial end
of the crease design may include a greater degree of
excision of skin tissues between the crease line (lower
line of incision) and the upper line of incision; for
example, while normally there may be only 1–1.5 mm
of skin marked for excision there, I may design and
include 2.5–3.0 mm (Figure 25-1 A). Their medial
upper lid fold mostly consists of skin and a few strands
of pretarsal orbicularis oculi fibers, and can be easily
excised through the lower skin incision line (crease line).
 25 Treatment of Medial Upper Lid Fold and the Fog Surrounding Epicanthoplasty 335

Residual skin still present on the end of the lower line The simple maneuvers that have worked for me
of incision can be carefully undermined and trimmed include:
(Figure 25-2 B) so the closure fits in nicely under the
(a) a slight oblique down-snip (cut) of skin towards the
natural lid fold that you have just constructed as a nasally
medial canthus to eliminate dog-ear (Figure 25-1
tapered crease. One seldom sees a prominence of orbicu-
C), and
laris oculi as one does in blepharophimosis syndrome,
nor does one see an elongation of the superficial portion (b) down-knotting the most medial interrupted crease-
of the upper limb of the medial canthal tendon. The fixation suture (Figure 25-1 D).
reduction of medial upper lid fold is performed within
and is included in the Asian blepharoplasty that I perform.

B C

FIGURE 25-1, cont’d

336 Asian Blepharoplasty and the Eyelid Crease
(2) For the single-lidded individual with a noticeable
medial upper lid fold who prefers to have a parallel
crease shape, the parallel crease design proceeds as always,
and will include a greater degree of excision of skin
tissues on both sides of the eventual parallel crease form.
There is a more than usual amount of skin included
for excision medially (by 2.0–3.0 mm), and it involves
the skin area that curls around under the overhanging
medial upper lid fold while you should still maintain the
desired parallel crease height at the terminus of that
crease. (The medial end of a parallel crease is slightly
A
FIGURE 25-2 ■ Reduction of medial upper lid fold with selection of parallel crease shape.
narrower [closer to the lid margin] than what is designed
centrally, while still staying unconnected to the medial
canthal commissure.)
(a) You may find that residual medial upper lid
fold along the lower line of incision will need
more undermining, and that the amount of skin
dog-ear you need to free up and eliminate is greater in
a parallel crease than for the design of a nasally tapered
crease. An oblique down-snip (cut) is necessary (Figure
25-2 A).
 25 Treatment of Medial Upper Lid Fold and the Fog Surrounding Epicanthoplasty 337

(b) Since this is a parallel crease design at the medial
end, the crease terminus is millimeters further
away from the medial canthal angle and upper lid
margin. There are therefore more pretarsal orbic-
ularis muscle fibers, there is more vascularity
and it requires more effort in careful reduction
and removal of subcutaneous tissue remnants and
muscle fibers until you can reach the medial
horn fibers of the levator aponeurosis, though no
more than what others are doing with flaps in
epicanthoplasty (Figures 25-2 B–C).
(c) The most medial crease fixation suture is passed
from the inferior skin edge to pick up remnants of
the medial canthal aponeurotic tissue (often fibrous
or tendinous), then the upper skin edge and tied
with an up-knot (up-knotting) (Figure 25-2 D).

B C

D
FIGURE 25-2, cont’d
338 Asian Blepharoplasty and the Eyelid Crease
Once again, the reduction of medial upper lid fold is
performed within and included as part of the Asian
blepharoplasty that I perform. The extra step that is taken
is minor, subtle in execution and only takes several
minutes. The skin area medial to and beyond the medial
canthal angle is never cut. In my hands, these maneuvers
serve to eliminate the medial upper lid fold without the
need to transect tissues in the intercanthal zone. We will
not see the skin depression, stria, or dimplings often
observed in patients who have undergone epicantho-
plasty performed in conjunction with double-eyelid
crease surgery.
Recent papers on Asian eyelid surgery show a pro-
liferation of papers reporting on mini-incision tech-
niques as well as epicanthoplasty combined with
double-eyelid surgery. The ‘mini-open incisions com-
bined with three buried sutures’ methods certainly can
easily combine three separate 3–4 mm incisions across,
making the combined length of the skin cuts 10–12 mm,
so it certainly does not seem ‘minute’, ‘micro’, or even
‘mini’ in any sense; it is more appropriate to call them
partial incisional techniques. There are cases seen that
present as segmental depression in locations along the
upper eyelid where partial tissue debulking was per-
formed combined with placements of permanently
buried non-dissolvable sutures, and occasional dysjunc-
tion and segmentation of the crease line due to lack of
smooth wound healing between the incised areas and
untouched skin areas.
Finally, I have included in the literature review at the
end of the book 16 papers on epicanthoplasty published
over the last 20 years (see Appendix 4):
• Many of the papers are quite similar, listing solu-
tions for a small region of the eyelid.
• Each paper proclaimed success and excellent results.
One should bear in mind, however, that the problem
may not be inherently significant, and that it is fairly
effortless to report excellent results if the condition
is even questionably pathologic.
• The details are more reflective of how the various
authors judged the medial upper lid fold.
REFERENCES
1. Johnson CC. Epicanthus. Am J Ophthalmol 1968;66:939–946.
2. Khoo BC. The Mongolian fold (plica Mongolia). Singapore Med J
1962;3:132–136.
3. Lessa S, Sebastia R. Z-epicanthoplasty. Aesth Plast Surg
1984;8:159–163.
4. del Campo AF. Surgical treatment of the epicanthal fold. Plast
Reconstr Surg 1984;73:566–570.
5. Chen WPD. Asian blepharoplasty. Ophthalmol Plast Reconstr Surg
1987;3:135–140.

NOVEL TECHNIQUE,
CHALLENGES AND OUTLOOK FOR
THE FUTURE IN AESTHETIC
SURGERY OF THE ASIAN EYELID
COMBINED APPROACH OF
PARTIAL INCISION TECHNIQUE
WITH MEDIAL TUNNEL FIXATION
(INCORPORATING A BURIED
ORBICULARIS–APONEUROSIS SUTURE)
An ideal compromise would be to combine an external
incision approach across the central 50% of the proposed
area for an eyelid crease, combined with buried suture
ligation over the medial end by way of the open central
wound. This avoids any incision through the thicker
medial canthal skin and still achieves a crease as well as
some control over the shape of the crease there, whether
the crease is to be nasally tapered or parallel.
Surgical Steps
A corneal protector is applied. The central incision
involves excision of a 2–3 mm segment of skin–orbicularis,
FIGURE 26-1 ■ Shows partial incision technique with incision spanning 50-70% of the width of the palpebral fissure.
CHAPTER 26
application of the usual Asian blepharoplasty technique
with a beveled approach through the orbicularis and
septum, 50–70% transverse opening of the orbital
septum, and graded excision of preaponeurotic fat (Figure
26-1), followed by the following.
One may elect to create a medial suborbicularis tunnel
space along the superior tarsal border, using a small
hemostat, needle-tipped cutting cautery and cotton-tip
applicators. The location and height of this medial sub-lid
tunnel space will correlate with the desired shape and
height of the medial end of the crease. One end of a 6-0
PDS or Vicryl suture (with tapering needle) is passed
through the external skin surface along the desired crease
line. It is passed down through levator aponeurosis and
Müller’s muscle above the superior tarsal border, but
without penetrating the conjunctiva (the needle passage
may also be started directly above the levator aponeurosis
fibers along the superior tarsal border). It takes a bite in
a lateral direction for 3 mm, along the crease form
desired. This needle and suture is retrieved through the
339
340 Asian Blepharoplasty and the Eyelid Crease
FIGURE 26-2 ■ 6-0 vicryl suture needle takes a superficial bite of the distal levator aponeurosis along the superior tarsal border in
the medial tunnel.
medial tunnel and looped out through the central wound.
One may then choose as follows:
Option 1: Cut off the second needle of the remaining
arm of the suture that has not yet been passed. This
free end is then looped out through the suborbicu-
laris medial tunnel using a strabismus hook. It is
reloaded on a free needle, and used to take a bite of
the orbicularis muscle that lines the roof space
within this medial tunnel. The two ends are tied,
bringing together the layers of the levator aponeu-
rosis, the orbicularis and subcutaneous fascia.
Option 2: The second needle is left intact and pulled
through a small stabbed-skin slit along the same
tract where the first arm passed, and retrieved within
the medial tunnel. It is then re-armed on a needle
holder and used to secure a small amount of the
orbicularis along the proposed crease line and then
tied with the other end from the first passage.
Instead of entering the skin through a most-medial
location, a second approach is to come in from a slightly
more lateral position but still over the medial one-third
to one-fourth of the eyelid. After creating the medial
suborbicularis tunnel:
Option 3: The surgeon holds a half-circled 6-0 Vicryl
suture needle that is back-handed, and this is passed
from the central open wound through levator
aponeurosis on the bottom of the tunnel space
(Figure 26-2), and then immediately back towards
fibers of the suborbicularis tissues over the top of
the tunnel space to form a complete 180° hair-pin
loop (Figure 26-3 A). This contains the posterior
lamella tissues of levator aponeurosis and Müller’s
muscle along the superior tarsal border as well as
subcutaneous fascia and orbicularis oculi. A knot is
tied and buried within this medial tunnel space.
Option 4: Still over the medial one-fourth of the eyelid
as in Option 3, a back-loaded needle approaches the
medial horn of the aponeurosis from the central
open wound and takes a 2–3 mm bite of it. The
overlying orbicularis in the tunnel directly over this
needle’s passage is denuded (removed) using cutting
cautery or a radiofrequency knife. The first needle
that had passed through the aponeurosis is then
used to secure some subcutaneous fascia in this
orbicularis-denuded sector of the tunnel space
(Figure 26-3 B). A knot is tied and buried within
this medial tunnel space. This tied knot brings
together the levator aponeurosis to the subcutane-
ous fascia and is similar to the crease construction
used in skin–levator–skin closure with the external
incision method.
 26 Novel Technique, Challenges and Outlook for the Future in Aesthetic Surgery of the Asian Eyelid 341

FIGURE 26-3A ■ Passage of suture

through the overlying orbicularis oculi
fibers directly above the first bite.

FIGURE 26-3B ■ One can excise some

overlying orbicularis oculi such that the
passage of the overlying suture loop is
through subcutaneous fascia rather
than orbicularis, as shown here.
342 Asian Blepharoplasty and the Eyelid Crease
FIGURE 26-4 ■ Closure of partial incision wound with 6/0 interrupted sutures as well as 7-0 continuous suture.
The passage of the needle through tight and vascular
compartments will lead to occasional hemorrhage from
the orbicularis, levator aponeurosis, Müller’s muscle and
the peripheral arcade that runs along the superior tarsal
border.
The location of the medial end of the crease will
depend on where the medial tunnel is fashioned and
where the buried stitches are applied. For a nasally
tapered crease that converges normally, the medial end
of the crease is usually applied at a distance from the lid
margin equal to one-half of the measured central height
of the tarsal plate. When there is a coincidental medial
canthal fold this maneuver will uplift the medial lid fold.
For those patients who desire a rapidly converging nasally
tapered crease (rapid convergence), one may place the
medial end of the crease at one-third of the measured
central height of the tarsus. This is lower than the actual
height of the tarsal plate there, though the needle should
still be aimed towards aponeurotic fibers along the medial
aspect of the superior tarsal border.
Over the external skin incision, which spans 50–60%
of the normal width of the eyelid crease, the wound
is closed using four interrupted 6-0 silk sutures in the
usual fashion for Asian blepharoplasty, taking lower
skin edge–aponeurosis–upper skin. These four external
stitches cover over an area of about 15–18 mm
(Figure 26-4). A 7-0 suture is then placed as a running
skin-skin closure. The lateral one-fourth of the eyelid
skin is uncut and has no buried sutures. The medial sector
is also uncut, but has a buried suture to help form the
medial end of the crease without any risk of residual hyper-
trophic scarring.
In this combined approach, the central crease is created
using open technique, and the medial crease is created
using sutures applied through a semi-open wound.
A further option relates to the placement of the exter-
nal skin incision. One can maintain a half-eyelid width
incision and shift (skew) it more laterally, such that the
medial end of the eyelid has an uncut skin zone that
extends about 10 mm, rather than only 6 mm as above.
This has the added advantage of allowing a greater resec-
tion of the laterally situated orbicularis and skin, as often
we see a significant amount of hooding there; partial
reduction of the preaponeurotic fat pad can be more
easily approached due to its location. These excess tissues
need to be debulked to avoid subsequent fading of the
lateral extent of the crease.
The essential points to remember for this combined
approach are:
1. The whole length of the crease should be
marked from medial to lateral (even though the
central 50% is the intended incision line). This
helps in coordinating the central crease with the
medial crease to avoid disjunction of the two
segments.
2. The buried medial suture should be applied under
magnification and direct vision. Be mindful of the
superior tarsal arcade as well as Müller’s blood
vessels.
3. There are few, if any, preaponeurotic fat pads
located medially in young adults, which if abundant
can potentially interfere with crease formation.
4. The levator is relatively ineffective over the medial
one-fourth of the tarsus. It is more fibrous in
nature, and combines with the pretarsal and presep-
tal orbicularis to form the medial canthal ligamen-
tous complex.
5. A lateral shift of this limited skin incision allows
excision of skin fold and access to the laterally situ-
ated preaponeurotic fat.
6. The use of buried suture over the medial quadrant
avoids any incision scar over the thicker skin there.
 26 Novel Technique, Challenges and Outlook for the Future in Aesthetic Surgery of the Asian Eyelid
However if there is significant medial eyelid fold or
dermatochalasis there, it will need a full incision.
7. The medial buried suture approach combined with
partial incision can always be converted to a full
incision approach, should the need arise.
The levator muscle and aponeurosis located over the
central half of the upper tarsus has good dynamic excur-
sion as compared to its medial and lateral segments. The
vertical excursion of the levator is maximal over the
central area of the upper eyelid, and is the reason why
some partial incision methods with some excision of fat
also seem to work. Although the medial one-fourth of the
eyelid has levator aponeurotic tissues, it has relatively
limited vertical movement. A surgically created crease
here will need to rely on passive fixation of skin to the
underlying aponeurosis, or fixation of the orbicularis to
the levator aponeurosis. Likewise, the lateral one-third of
the levator aponeurosis shows little vertical excursion,
and mostly coalesces with the lateral extent of the pretar-
sal and preseptal orbicularis muscle to form the fibrous
lateral canthal raphe. Crease formation here often
depends on skin–orbicularis fixation.
There are additional surgical options involving these
partial* incision methods of crease construction that
require delivery through a centrally located skin incision.
[*Partial refers to limited or incomplete opening of the
horizontal extent of the upper lid skin.]
1. Within the medial subcutaneous tunnel space, one
may apply bipolar cautery with tying forceps plat-
forms to cauterize the epi-tarsal tissues at mid-
tarsal height to the superior tarsal border to create
a tightened platform.
2. Excision of subcutaneous soft tissues can be carried
out medially within the tunnel space using an Elle-
mann radiofrequency unit (Empire needle tip) for
precise tissue excision, or monopolar cautery
(Colorado needle tip). Bipolar cautery can be used
for added hemostatic control.
3. Excision of subcutaneous soft tissues can also be
carried out laterally within a lateral tunnel space,
again created via a central skin incision. Even in the
lateral quadrant, buried orbicularis–aponeurotic
sutures may be applied, keeping in mind the abun-
dance of orbicularis oculi and the vascularity (due
to the occasional presence of lateral septo-
aponeurotic artery, peripheral arcade, communicat-
ing branches from the marginal arcade to the
peripheral arcade and subaponeurotic bleeding in
the pretarsal area).
Kim and Lee1 have described the use of Nd-YAG laser
in dealing with the medial and lateral ends of their Asian
blepharoplasty cases.
In the end, it comes down to the comfort level of each
surgeon, in terms of whether the individual feels more
comfortable performing their crease enhancement proce-
dure through a limited incisional access (partial, or through
several smaller stab incisions) or through a complete
opening across the superior tarsal border, and whether one
believes that the resultant crease indents better through
linkages of several skin stab incisions, or through partial
343
incision, as compared to a full incisional approach with
aponeurotic attachments, which is favored by this author.
THE CHALLENGE OF AESTHETIC
SURGERY FOR THE ASIAN EYELID
The most important point in the variety of techniques
available is a clear understanding that the external inci-
sion methods are an attempt to produce surgical connec-
tions between the distal fibers of the levator aponeurosis
(or superior tarsal border) with the eyelid skin, or to the
inferior subcutaneous tissues, or to the tarsal platform as
well as skin. The properly configured tarso-aponeurotic
lamella contracts and ‘glides up’ at its junction with the
relaxed and gravitating supratarsal fold to form the
crease-and-fold relationship.
The suture ligation techniques try to produce a tight
tissue compression using permanently buried ligatures
between the distal portion of the levator aponeurosis and
Müller’s muscle (above the upper portion of the tarsus)
and the pretarsal soft tissues, whether they are subcutane-
ous tissues or orbicularis oculi, or by eliminating dead
space between pretarsal skin and tarsus. In these buried
sutures methods, there is often a plication effect shorten-
ing the distal levator aponeurosis somewhat.
The Challenges
When progressing from preoperative planning to the
actual surgical performance of an Asian blepharoplasty,
the surgeon must shift from a two-dimensional thought
process of crease placement into a three-dimensional
mode, in approaching the layers of the upper eyelids. I
prefer to think of the progression from one end of the lid
incision to the other end as traveling through different
terrains. The challenge in working on the eyelid is to
construct a functional and continuous structure, i.e. the
lid crease even as it passes through areas with varying
topographic features.
Each vertical section of the eyelid is composed of a
different subset of tissues of varying sizes and density. For
example, the vertical height of the tarsus is shorter over
the medial and lateral extents; there is more pretarsal fat
over the central portion of the eyelid; the levator aponeu-
rotic attachments on the tarsal plate at the medial and
lateral horns are thin and less vertically oriented; the
medial upper lid fold may interfere with crease forma-
tion; the lacrimal gland may interfere with lateral crease
placement; the lateral dermis is thicker and less likely to
invaginate when one attempts to make a crease; and the
presence of well-developed preaponeurotic fat pad can
obliterate an otherwise well positioned crease. In each
section of the upper lid, factors that can interfere with
the optimal formation of a dynamic crease have to be
corrected. The result should be a crease that provides
optimal height, shape, continuity and permanence.
A Look to the Future
The evolution of this popular cosmetic operation has
been quite steady from 1896 to the present. The early
344 Asian Blepharoplasty and the Eyelid Crease
Japanese medical literature blazed the trail for the subse-
quent modifications of both the suture ligation and
the external incision methods as used today. The future
looks bright for the continued refinement of Asian
blepharoplasty.
I anticipate the availability of better suture materials,
perhaps made of polymers that are fully non-reactive and
tissue-compatible. If these new materials can be made to
last 6–12 months before dissolving, it would reduce sub-
optimal results and allow more creativity in technique.
Biocompatible polymers could be designed to be
implanted within the eyelid. For example, implanting a
thin film in the pretarsal plane (that promotes a selective
desirable ingrowth) could result in adhesions between the
pretarsal orbicularis muscle and the overlying skin and
produce a firm pretarsal platform without causing notice-
able scarring. Similarly, biocompatible polymers or com-
posites may be engineered into micro-clips or tacks, such
that they can be inserted along the superior tarsal border
as an expansion or extension of the distal fibers of the
levator aponeurosis. Innovative lasers using elements
other than the argon lasers, YAG (yttrium–aluminum–
garnet) laser, or KTP–YAG (potassium titanyl-phosphate
YAG) laser may become available in the future and could
be used to produce controlled aponeurotic adhesions,
simulating the physiologic adhesions and interdigitations
seen in eyelids that have natural creases.
I see further analysis on the dynamics of the eyelid
crease (as the author has done over the past 15 years). I
see research methods using already available real-time
tools, such as the PET scan and functional magnetic
resonance imaging (f-MRI), or yet to be invented nano-
devices, that can study and record the dynamics of levator
aponeurosis and Müller’s muscle, tarsus and preaponeu-
rotic fat space (glide zone, tarso-ligamentous junction),
and the localization of the author’s nano-ball concept.
There will be continued innovation in new suture
materials and synthetic implants that can be used to facili-
tate lid crease formation. (Suborbicularis oculi thermo-
plastic cauterization using micro-voltage current on a
needle tip, and radiofrequency cold needles in cautery
mode have already been tried.)
We can expect some of these future trends: minimally
invasive means of excision of tissue redundancy using
endoscopic principles; partial incision over the central
half of the upper lid with preaponeurotic fat debulking
coupled with medial and lateral suborbicularis cautery or
aponeurotic anchoring (described above); as well as rela-
tively non-invasive modes/means that promote highly
specific and targeted tissue adhesions, for example, within
the subcutaneous tissue overlying the superior tarsal
border. This can be combined with a small centrally
located or laterally located wound to remove any
preaponeurotic fat.
REFERENCE
1. Kim JW, Lee JO. Asian blepharoplasty using short-pulsed contact
Nd–Yag laser: limited incision resectable laser double fold with
internal medial and lateral functional epicanthoplasty. Aesth Plast
Surg 1998;22(6):433–438.
 APPENDIX 1

PRE-1952 JAPANESE LITERATURE

ON COSMETIC EYELID SURGERY
(IN JAPANESE)

Pre-1952 Japanese Literature on Cosmetic Eyelid Surgery (in Japanese)

Author K Mikamo K Uchida M Maruo B Hata
Year 1896 1926 1929 1933
Journal J Chugaishinpo Jpn J Ophthalmol Jpn Rev Clin Ophthalmol Jpn Rev Clin
30(5):593 24:393–405 Ophthalmol
28:491–494
Country Japan Japan Japan Japan
Crease height 6–8 mm 7–8 mm fan shape 7 mm 10 mm
(semilunar)
Suture method Yes Yes Yes
Incision method Incise skin
Remove skin No No No
Orbicularis Sub Q dissection superiorly
and inferiorly to incision
Orbital septum
Preaponeurotic fat
Crease formed by Three trans-lid Three trans-lid sutures, Four throws with single 5-0 Three trans-lid sutures
sutures from ligate 2 mm tissue catgut suture
conjunctiva to skin horizontally
Suture 4-0 silk Buried catgut Catgut suture skin/tarsus/ 5-0 silk through tarsus
skin to skin; tied down
with beads
Days left in 2–6 4 8–10
Variations Depth of crease Alternatively, trans-lid
related to days suture from conjunctiva
sutures left in above STB to anterior
skin surface

Continued

345
346 Asian Blepharoplasty and the Eyelid Crease

Pre-1952 Japanese Literature on Cosmetic Eyelid Surgery (in Japanese)

Author K Hayashi K Hayashi S Inoue Y Mitsui
Year 1938 1938 1947 1950
Journal Jpn Rev Clin Ophthalmol Jpn Rev Clin Jpn Rev Clin Jpn Rev Clin
33:1000–1010 Ophthalmol 33:1098– Ophthalmol Ophthalmol 44:19
1110 27(11):306
Country Japan Japan Japan Japan
Crease height Medially 5 mm; centrally
6 mm; laterally 7 mm.
Creates medially tapered
crease
Suture method Yes
Incision method Yes Yes Yes
Remove skin
Orbicularis Excision of pretarsal Dissection of Removes pretarsal
orbicularis subcutaneous orbicularis, and fat
connective tissue
between crease
incision line and
eyelid margin
Orbital septum
Preaponeurotic fat
Crease formed by Central and lateral stitches Interrupted skin/tarsus/ Skin/tarsus/skin Five 5-0 nylon
above crease; medial skin closure, plus sutures: Inferior
stitch below crease line in-between skin/skin skin edge to
and passes through stitch tarsus (2–3 days)
tarsus Skin/skin closure
with 5-0 silk
Suture 4-0 silk 5-0 silk
Days left in 4 2–3 7–8
Variations

Pre-1952 Japanese Literature on Cosmetic Eyelid Surgery (in Japanese)

Author K Hirose K Ohashi T Ikegami
Year 1950 1951 1951
Journal Jpn Rev Clin Ophthalmol Jpn Rev Clin Ophthalmol 46:723 Jpn Rev Clin Ophthalmol
45:374 46:706–708
Country Japan Japan Japan
Crease height
Suture method Cautery method
Incision method Yes Yes
Remove skin
Orbicularis
Orbital septum
Preaponeurotic fat
Crease formed by Electrocoagulation needle; 7 burns along the
crease line and 2 rows of burns below it
Suture
Days left in
Variations
 APPENDIX 2

MODERN LITERATURE ON ASIAN

EYELID SURGERY (IN ENGLISH)

Modern Literature on Asian Eyelid Surgery (in English)

Author BT Sayoc DR Millard LR Fernandez LR Fernandez
Year 1954 1955 1960 1960
Journal Am J Ophthalmol Plast Reconstr Surg Plast Reconstr Surg Plast Reconstr Surg
38(4):556–559 16(5):319–336 25:257–264 25:257–264
Country Philippines USA/Korea USA/Hawaii USA/Hawaii
Conjunctival suturing
Skin incision Yes Simple Radical
Remove skin 3 mm 7–8 mm 8–10 mm
Orbicularis 1–3 mm orbicularis Trim inf. edge 3–5 mm orbicularis
Orbital septum Open Open 3–5 mm
Preaponeurotic fat Lipectomy Excised fat
Crease form Inf. skin/tarsus Skin to tarsus Inf. skin/levator Inf. subcut. tissue/
levator
Suture Buried 6-0 silk or chromic Interrupted silk Three buried 5-0 nylon Three 5-0 nylon and
catgut 6-0 nylon
Days left in 5 For skin sutures, 3 3
Effectiveness ’Static’ crease Superficial Deep, permanent
Comments Related articles published See also Am J ’Dynamic’ ’Dynamic’
in Ophthalmol
AJO 1956;41:1040 1964;57:646
AJO 1956;42:298
AJO 1961;52:122
AJO 1967;63:155
Included fat excision Clin
Plast Surg 1974;1:157

Continued

347
348 Asian Blepharoplasty and the Eyelid Crease

Modern Literature on Asian Eyelid Surgery (in English)

Author HG Pang J Uchida Khoo Boo-Chai Khoo Boo-Chai
Year 1961 1962 1963 1969
Journal Arch Ophthalmol Br J Plast Surg Plast Reconstr Surg Br J Plast Surg
65:783–784 18:271–276 31:74–78 22(1):60–69
Country USA/Hawaii Japan Malaysia/Singapore Singapore
Conjunctival suturing Yes (3)
Skin incision Yes Yes Three nicks
Remove skin Sometimes
Orbicularis Thins pretarsal Thins pretarsal orbicularis
orbicularis
Orbital septum Open Open
Preaponeurotic fat Trim some fat Removes some fat
Crease form Double-armed suture, Tarsus/inf. skin Skin–tarsus–skin
from skin to
conjunctiva to skin
Suture Three 4-0 silk Three 2-0 chromic Silk 6-0 silk
Days left in 10 Remove in 3 10
Effectiveness May disappear
Comments Discussed pretarsal, Skin–levator–skin method Mostly a discussion on
subcutaneous, discussed in Barron trends of plastic
submuscular, and JN, Saad MN, eds. surgery in Asians.
orbital fat Operative plastic and Also discussed skin
reconstructive surgery. incision and excision
Edinburgh: Churchill of skin, orbicularis
Livingstone; muscle, and fat
1980:761–781
 Appendix 2 Modern Literature on Asian Eyelid Surgery (in English) 349

Modern Literature on Asian Eyelid Surgery (in English)

Author S Ohmori Y Mutou, H Mutou JH Sheen CZ Weingarten
Year 1972 1972 1974 1976
Journal Ch. 19. Transformation of Br J Plast Surg Plast Reconstr Surg Trans Am Acad
the Oriental eye into the 25(3):285–291 54(4):424–431 Ophthalmol
Western eye. In Otolaryngol
Goldwyn RM (ed.). The 82:442–446
unfavourable results in
plastic surgery:
avoidance and
treatment. Boston: Little,
Brown; 1972: 275–282
Country Japan Japan USA USA/Thailand
Conjunctival suturing Yes (2)
Skin incision Yes Yes Yes
Remove skin Sometimes Yes Variable
Orbicularis Thins pretarsal orbicularis Remove orbicularis Trim inferior edge
Orbital septum Thins submuscular fat Open Open
Preaponeurotic fat Remove variable amounts Excised Excised
of preaponeurotic fat
Crease form Conjunctiva to skin Levator/inf. orbicularis STB/inf. subcut. tissue
Suture 3-0 chromic catgut and 6-0 Buried 6-0 nylon or Buried 7-0 silk Buried 6-0 chromic
nylon synthetic catgut catgut
Days left in 3 Routine closure
Effectiveness Crease is not obvious
with eyelids closed
Comments Also described Surgery performed on
tarsus-to-orbicularis Thai patients
and tarsus-to-skin
closure

Continued
350 Asian Blepharoplasty and the Eyelid Crease

Modern Literature on Asian Eyelid Surgery (in English)

Author AM Putterman, MJ Urist R Rubenzik Y Hiraga JS Zubiri
Year 1976 1977 1980 1981
Journal Arch Ophthalmol Ann Ophthalmol Clin Plast Surg Clin Plast Surg 8(4):725–737
94(11):1941–1954 9(9):1189–1192 7(4):553–567
Country USA USA Japan Philippines
Conjunctival suturing
Skin incision Yes Yes Yes Yes
Remove skin Yes
Orbicularis Trim inferior edge Trim orbicularis 2–3 mm
Orbital septum Open Open Excise 2 mm
Preaponeurotic fat Excised Excised Excised
Crease form STB/inf. subcut. tissue Skin–levator–skin Skin–levator–skin Skin–STB–levator
Suture Buried 6-0 polyester plus 6–0 nylon or silk Nylon Buried 6-0 nylon,
Pang’s 6-0 silk Plus skin 6-0 nylon
Days left in 5 6
Effectiveness
Comments

Modern Literature on Asian Eyelid Surgery (in English)

Author LC Hin KC Chua JA McCurdy T Onizuka, M Iwanami
Year 1981 1982 1982 1984
Journal Ann Plast Surg Aesthet Plast Surg Otolaryngol Head Aesthet Plast Surg
7(5):362–374 6(4):221–223 Neck Surg 8(2):97–100
90(1):142–145
Country Singapore Singapore USA Japan
Conjunctival suturing
Skin incision Yes Yes Yes
Remove skin Yes Variable Yes
Orbicularis 3–5 mm
Orbital septum Open Open
Preaponeurotic fat Excised Variable
Crease form Skin–levator–skin Levator–inf. subcut. Skin–levator–skin
tissue
Suture 5-0 silk Buried 6-0 polyglycolic 6-0 nylon (7 days);
sutures; skin closure: 6-0 nylon subcut.
6–0 nylon (3 days)
Days left in 5 5
Effectiveness
Comments See also Ann Plast Surg Discussion of why
1985;14(6):523–534 people prefer
double eyelids
 Appendix 2 Modern Literature on Asian Eyelid Surgery (in English) 351

Modern Literature on Asian Eyelid Surgery (in English)

Author Y Shirakabe et al. RS Matsunaga RY Song WPD Chen
Year 1985 1985 1985 1987
Journal Ann Plast Surg Arch Otolaryngol Aesthet Plast Surg Ophthal Plast Reconstr
15(3):224–241 111(3):149–153 9(3):173–180 Surg 3(3):135–140
Country Japan USA China USA
Conjunctival suturing
Skin incision Yes Yes Three small incisions Yes
Remove skin No Variable
Orbicularis Undermine pretarsal Trim pretarsal 2–3 mm
connective tissue orbicularis muscle
and fat
Orbital septum Open
Preaponeurotic fat Variable Variable
Crease form Translid suturing with 6 Skin–STB–skin Tarsus–subcut. Skin–levator–skin
double-armed sutures tissue
tied with beads
Suture 6-0 nylon Buried 6-0 polyglycolic Buried 6-0 nylon 6-0 and 7-0 nylon or
acid sutures silk
Days left in 8 5–7
Effectiveness
Comments Gave account of First coined the term
Japanese techniques: Asian
1896 Mikamo blepharoplasty;
1912 Onishi discussed crease
1926 Uchida shapes and
1926 Nakamura technique
1927 Kitajima
1929 Maruo*
1933 Hata
1938 K Hayashi*
1947 Inoue*
1949 Hirai*
1950 Mazume
1950 Mitsui*
1950 M Hayashi
1950 Takano
1950 Ohashi
1951 Hirose*
1951 Hirai*
1951 Ikegami*
1950 Momo
(* = incision)

Continued
352 Asian Blepharoplasty and the Eyelid Crease

Modern Literature on Asian Eyelid Surgery (in English)

Author PY Yang KY Song SM Baek EJ Weng
Year 1987 1988 1989 1989
Journal Chin J Plast Surg Burn Chin J Plast Surg Burn Plast Reconstr Surg Plast Reconstr Surg
3(3):191–192 4(1):6–9 83(2):236–243 83(4):622–628
Country China China Korea Taiwan
Conjunctival suturing Ligature technique
Skin incision Two stab incisions in Yes
skin; single stitch
Remove skin Puncture with threaded
needle then tunnel
under orbicularis and
levator aponeurosis
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form Skin–tarsus–skin Single stitch Levator–inf. subcut.
continuous or reverse encompasses tissue
looping subconj.–levator–
subcut. tissues
Suture 4–0 silk; compress with Buried 6-0 Buried 6-0
rubber catheter polypropylene polypropylene
(Prolene) sutures (Prolene) sutures
Days left in 7
Effectiveness Crease disappeared
in 2.9% of cases
per author
Comments ’Twisted needle’ may elicit A general discussion of Discussed
hematoma concepts of beauty complications
and double eyelid of oriental
blepharoplasty
 Appendix 2 Modern Literature on Asian Eyelid Surgery (in English) 353

Modern Literature on Asian Eyelid Surgery (in English)

Author KY Song YH Bang WPD Chen
Year 1990 1991 1994
Journal Chin J Plast Surg 6:96–97 Plast Reconstr Surg 88:12–17 Asian Blepharoplasty (A Surgical
Atlas) Butterworth–Heinemann
(First Edition)
Country China Korea USA
Conjunctival suturing
Skin incision Three stab incisions Yes
Remove skin No
Orbicularis Trims orbicularis muscle,
connective tissue, and
pretarsal fat
Orbital septum
Preaponeurotic fat Remove fat if prolapsed
inferiorly
Crease form Transcutaneous intratarsal Skin to orbicularis: basting
and intradermal sutures
suturing
Suture Three buried stitches Three 6-0 silk
Days left in 5–6
Effectiveness
Comments First textbook on this topic:
Detailed terminology, cultural
perception, comparative
anatomy, crease variation, shape,
height, continuity and
permanence; main schools of
technique, complications,
revisions and literature
publications

Continued
354 Asian Blepharoplasty and the Eyelid Crease

Modern Literature on Asian Eyelid Surgery (in English)

Author Li Dong et al. WPD Chen JI Park JS Lee, WJ Park, MS
Shin, IC Song
Year 1994 1996 1996 1997
Journal Chin J Plast Surg Burns Plast Reconstr Surg Plast Reconstr Surg Plast Reconstr Surg
10:436, Plast Reconstr 97(1):212–218 98(4):602–609 100(1):170–178
Surg 1996;98(5):919 Triangular, Z-epicanthoplasty ‘Septodermal’
trapezoidal and fixation technique
rectangular
debulking of eyelid
tissues in Asian
blepharoplasty
Country China (Beijing Med Univ) USA USA Korea (Samsung Med
Center)
Conjunctival suturing
Skin incision Yes Yes Variable placement of
skin/septum–levator
attachment
Remove skin Yes By flap transposition
Orbicularis Trims orbicularis
Orbital septum Opens septum
Preaponeurotic fat Variable
Crease form Skin–apon.–skin
Suture 6-0 interrupted
sutures and 7-0
continuous suture
Days left in 5–7 days
Effectiveness Permanent
Comments Emphasizes removal of Arch Facial Plast
fascial tissues in Surg 2000;2(10):
double blepharoplasty 43–47 Modified
(review by Boo-Chai in Z-epicanthoplasty
Int Abstracts of Plast
Reconstr Surg)
 Appendix 2 Modern Literature on Asian Eyelid Surgery (in English) 355

Modern Literature on Asian Eyelid Surgery (in English)

Author Sergile, Obata JW Kim, JO Lee KC Yoon, S Park YS Kao, CH Lin, RH Fang
Year 1997 1998 1998 1998
Journal Plast Reconstr Surg Aesthet Plast Surg Plast Reconstr Surg Plast Reconstr Surg
99(3):662–667 22(6):433–438 Asian 102(2):502–508 102(6): 1835–1841
translation of blepharoplasty with Selective tissue Epicanthoplasty with
Mikamo’s 1896 short-pulsed contact removal in Y–V advancement
paper ND-Yag laser: limited blepharoplasty for
incision young Asians
Country USA Korea Korea (Univ of Ulsan) Taiwan (Vet Gen Hosp)
Conjunctival suturing
Skin incision Yes
Remove skin Yes
Orbicularis Yes
Orbital septum Yes
Preaponeurotic fat Yes
Crease form Levator–tarsus–skin
Suture 7-0 nylon, or tissue glue
Days left in
Effectiveness
Comments A general discussion
on incisional
technique

Modern Literature on Asian Eyelid Surgery (in English)

Author JI Park SL Jeong, BN Lemke, YH Bang, HH Chu, SH YW Kim, HJ Park, S Kim
RK Dortzbach et al. Park et al.
Year 1999 1999 1999 2000
Journal Arch Facial Plast Surg Arch Ophthalmol Plast Reconstr Surg Plast Reconstr Surg
1(2):90–95 Orbic.– 117(7):907–912 103(6):1788–1791 106(6):1399–1404
levator fixation Comparison of The fallacy of the Revisional correction
Asian and Cauc. levator expansion by interposing
upper lid anatomy theory preaponeurotic fat
Country USA Korea (Chonnam Korea (Inha Gen Korea (Ewha Women
Univ), USA Hosp) Univ)
Conjunctival suturing
Skin incision Yes
Remove skin Yes
Orbicularis
Orbital septum Opens
Preaponeurotic fat
Crease form Orbic.–levator
Suture
Days left in
Effectiveness
Comments

Continued
356 Asian Blepharoplasty and the Eyelid Crease

Modern Literature on Asian Eyelid Surgery (in English)

Author RS Sim, JD Smith, AS Y Lee, E Lee, WJ Park DH Kang, SH Koo, JH Yang
Chan Choi et al.
Year 2000 2000 2001 2001
Journal Arch Facial Plast Surg Plast Reconstr Surg Plast Reconstr Surg Ann Plast Surg
2(2):113–120 105(5):1872–1880 107(7): 1884–1889 46(4):364–368
Comparison of Anchor Use of CO2 laser Double eyelid: a
aesthetic facial epicanthoplasty limited incision
proportions of combined with technique
Chinese and outer-type lid crease
Caucasian women procedure
Country Singapore (National Korea (Seoul National Korea (Univ MC) Korea (Catholic Univ)
Univ) Univ)
Conjunctival suturing
Skin incision Yes 4 mm skin incision
Remove skin Yes
Orbicularis
Orbital septum Opened
Preaponeurotic fat Optional Optional removal
Crease form 6-0 vicryl: inf. Levator–tarsus to
skin–tarsus–levator skin–muscle
Suture
Days left in
Effectiveness
Comments General aesthetics
 Appendix 2 Modern Literature on Asian Eyelid Surgery (in English) 357

Modern Literature on Asian Eyelid Surgery (in English)

Author J Cheng, FZ Xu Miyake, Hiraga MT Yen, DR Jordan, RL BC Cho, KY Lee
Anderson
Year 2001 2001 2002 2002
Journal Plast Reconstr Surg Jpn J Plast Reconstr Ophthalm Plast Reconstr Plast Reconstr Surg
107(7):1665–1668 Surg 44:815 Surg 18(1):40–44 110(1):293–300 Med.
Microstructure of Selection of skin Epicanthoplasty: epicanthoplasty
Asian eyelid crease resection or subcut. approach combined with
double eyelid through ext. skin pilcation of med.
operation incision canth. tendon
Country China (Hangzhou Japan USA Korea (Kyungpook
Zhejiang Univ. National Univ Hosp)
Med School)
Conjunctival suturing
Skin incision
Remove skin
Orbicularis Excise offending
orbicularis underlying
the epicanthal fold
Orbital septum
Preaponeurotic fat
Crease form
Suture
Days left in
Effectiveness
Comments Scanning EM Basing skin resection
showed on whether brow
aponeurotic fibers position is ptotic
penetrate
orbicularis to fuse
with skin

Continued
358 Asian Blepharoplasty and the Eyelid Crease

Modern Literature on Asian Eyelid Surgery (in English)

Author WM Yoo, SH Park, DR Hwang, Kim et al. Lam, Kim SH Chen, Mardini S,
Kwang Chen HC et al.
Year 2002 2003 2003 2004
Journal Plast Reconstr Surg Ann Plast Surg Aesthet Surg J Plast Reconstr Surg
109(6):2067–2071 Root 50(2):156–159 23(3):170–176 114(5): 1270–1277
Z-epicanthoplasty in Partial-incision Corrective Asian
Asian eyelid technique blepharoplasty
after failed
revisions
Country Korea Korea (Inha and Yonsei USA/Korea Taiwan (Chang
Univ) Gung Univ)
Conjunctival suturing
Skin incision 15–18 mm wide skin
incision
Remove skin No
Orbicularis Through orbic.
Orbital septum Open
Preaponeurotic fat Partial excision
Crease form Levator–inf. skin edge
Suture
Days left in
Effectiveness
Comments (See JI Park’s 1996 Plast Lateral Clin photo shows skin A general
Reconstr Surg article septoaponeurotic incision spans 3 4 of discussion of
on Z-epicanthoplasty) artery as source of width of ciliary factors that lead
bleeding during margin. Crease may to failures and
upper blepharoplasty appear deeper their corrections
centrally. (See
Yang’s 2001 paper)
 APPENDIX 3

RECENT LITERATURE
(1998–2014) ON ASIAN EYELID
SURGERY (IN ENGLISH)
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author Hwang, Kim et al. Kim, Lee Mutou, Homma Morikawa, Yamamoto
Year 1998 1998 2000 2001
Journal Br J Plast Surg 51(8): Aesthet Plast Surg Aesthet Plast Surg Aesthet Plast Surg
594–598 22(6):433–438 24(4):289–291 25(1):20–24
An anatomical study of Asian blepharoplasty using Intradermal stitch Scanning EM study
the junction of orbital short-pulsed contact blepharoplasty for on double and
septum and levator Nd–Yag laser: limited- Orientals: does it single eyelids in
aponeurosis in incision resectable laser disappear? Orientals
Orientals double fold with internal
medial and lateral
functional epicanthoplasty
Country Korea Japan Japan
Conjunctival Intradermal stitch;
suturing over 7 yr,
1,570 pts
Skin incision
Remove skin No
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form
Sutures
Days left in
Effectiveness 3.4% ‘revisited’ their
clinic re. loss of
crease
Comments Septum has outer Reflective of interests at the 30% loss within first Confirms branches of
(superficial) layer time for use of various year, 88% lev. apon. running
and inner (deep) laser modalities occurred within through orbicularis
layer that lies 5 yr. Failure rate to skin in Japanese
adjacent to the based on only born with crease
levator sheath those who
returned for Rx

Continued

359
360 Asian Blepharoplasty and the Eyelid Crease

Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)

Author Liao, Tung et al. A Chuangsuwanich Kim, Youn WPD Chen
Year 2005 2006 2006 2007
Journal Aesthet Plast Surg Aesthet Surg J Plast Reconstr Surg Plast Reconstr Surg
29(6):540–545 26(3):280–286 117(3):782–789 119(1):379–386
Celebrity arcade Short incisional Management of The concept of a glide
suture double-eyelid adhesion using zone as it relates to
blepharoplasty for blepharoplasty for a pretarsal upper lid crease, lid
double-eyelid; CAS Asian pts fibromuscular flap or fold, and application
graft in secondary in upper
blepharoplasty blepharoplasty
Country RO China, Taiwan Thailand Korea USA
Conjunctival suturing Trans-tarsal suturing
Skin incision Stab incision(s) Partial incision Revisional Yes
blepharoplasty
Remove skin No Yes
Orbicularis
Orbital septum
Preaponeurotic fat Removed centrally Treatment and
preservation of fat
Crease form ‘Bridge connection’ Skin-to-tarsal plate Skin–apon.–skin
fixation
Sutures ? 6-0, 7-0
Days left in 7
Effectiveness Partial incision
technique. 652 pts,
10 lost crease
within a year, 8 pts
with asymmetry
Comments Use of pretarsal Concept paper on fat
fibromuscular flap or as a glide zone
free graft to prevent
re-adhesion
 Appendix 3 Recent Literature (1998–2014) on Asian Eyelid Surgery (in English) 361

Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)

Author WPD Chen Fengzhi, Wei et al. A Kruavit Choi, Eo
Year 2007 2009 2009 2010
Journal Plast Reconstr Surg Ann Plast Surg Aesthet Surg J Ann Plast Surg
120(2):545–552 63(3):242–248 29(4):272–283 64(4):376–380
Beveled approach for Double-eyelid Asian blepharoplasty: Tissue thread
revisional surgery in operation recreating 18 yr in 6,215 pts grafting:
Asian blepharoplasty the anatomic nonincisional
microstructure Double-eyelid
operation
Country USA PR China Thailand Korea
Conjunctival suturing
Skin incision Yes. Revisional On middle-third of Likely through small
blepharoplasty eyelid only incisions
Remove skin Minimal Dissect medially,
laterally, superiorly
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form Skin–apon.–skin Three inverted Thread was passed in
stitches, skin to lev. ‘same pattern as
apon. or inf. edge other non-incisional
dermo-orbic. technique’
junction (subcut.)
buried
Sutures 6-0, 7-0 Threads made from
autogenous
temporal fascia,
CPF, or cadaveric
dermis
Days left in 7 9.3
Effectiveness Partial incision
technique
Comments Technique and series of EM and light In 70%, author could Unclear about the
patients that microscopic study use medial anchor techniques used for
underwent revision confirms presence stitch to create an passing thread,
blepharoplasty for of levator fibers to outer fold without since such variants
correction of high pretarsal skin epicanthoplasty exist
crease. Net lowering
is 2.75 mm in crease
height

Continued
362 Asian Blepharoplasty and the Eyelid Crease

Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)

Author Cho, Byun Ma, Cheng Liu et al. Choi, Eo
Year 2010 2010 2010 2010
Journal Plast Reconstr Surg Aesthet Surg J Plast Reconstr Surg Plast Reconstr Surg
125(1):324–331 30(3):329–334 126(6):2133–2139 126(3):1048–1057
New technique Mini-incision double Transcut., subcut. and A new crease fixation
combined with eyelidplasty intratarsal suturing technique for double
suture and incision in double-eyelid eyelidplasty using
method surgery mini-flaps derived
from pretarsal
levator tissues
Country Korea Hong Kong PR China Korea
Conjunctival suturing
Skin incision Partial incision + Mini-incision; two Five stab skin
buried continuous 3 mm incisions incisions; transcut.
suture approach, takes
bites of tarsal plate
Remove skin No No
Orbicularis Debulk pretarsal soft
tissues
Orbital septum
Preaponeurotic fat
Crease form Levator is fixed to Transcut.–intratarsal
tarsus, just below suturing
end of apon. to
tarsus
Sutures One continuous suture Four buried 7-0 nylon
is buried sutures
Days left in Permanent
Effectiveness Partial incision + 11% revision rate, 89.6% satisfied over 3
buried continuous 6% crease months to 3 years
suture with single disappearance period. 10.4%
knot dissatisfied
Comments Combined approaches. Hard to tell as period Uses miniflaps of lev.
Benefit vs risks? of observation apon. and attach to
spans 3 months to skin–muscle layers
3 years, both short
duration when it
comes to judging
permanence
 Appendix 3 Recent Literature (1998–2014) on Asian Eyelid Surgery (in English) 363

Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)

Author Bi, Zhou et al. Li, Lin et al. Lew, Kang, Cho Zhang, Yang
Year 2011 2011 2011 2012
Journal J Plast Reconstr J Plast Reconstr Plast Reconstr Surg Aesthet Plast Surg
Aesthet Surg Aesthet Surg 127(3):1323–1331 36(5):1039–1046
64(9):1138–1144 64(8):993–999 Surgical correction of Removal of large
Small-incision Double-eyelid multiple upper eyelid amount of pretarsal
orbicularis–levator blepharoplasty folds in East Asians tissue via 3
fixation technique: incorporating mini-incisions
double-eyelid ptosis surgery
blepharoplasty for for ‘latent’
treating trichiasis aponeurotic ptosis
Country PR China PR China Korea PR China
Conjunctival suturing
Skin incision Small incisions External incision Revisional Partial incision; 3
medial, central approach blepharoplasty incisions, each
and lateral 3–4 mm
Remove skin
Orbicularis Debulk soft tissues Excised inferiorly, and
to each side of
wounds
Orbital septum
Preaponeurotic fat
Crease form Orbicularis–levator
fixation
Sutures
Days left in
Effectiveness Improved eyelash
up-curling in
medial, mid- and
lateral sections
Comments Clinical importance Augmented preorbital Similar paper in
for detection and area using eyelid Aesthet Plast Surg
correction of mild tissues (orbicularis and 2013;37(1):22–28
ptosis orbital fat) to prevent An uncut strip of
re-adhesion of the orbicularis removed
orbicularis and levator through 3
mini-incisions

Continued
364 Asian Blepharoplasty and the Eyelid Crease

Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)

Author Tung, Tsai et al. Moon, Yoon, Lee JS Zubiri T Mizuno
Year 2012 2013 2013 2013
Journal Aesthet Plast Surg Arch Plast Surg 40(4): Aesthet Surg J J Plast Reconstr
36(4): 842–845 409–413 33(5):722–732 Aesthet Surg
Simultaneous fat Modified Subdermal placement of 66(4):e95–e100
removal with blepharoplasty using sutures in double Two modified
suture upper single-knot eyelid surgery techniques to
blepharoplasty continuous buried decrease
non-incisional complications of
technique buried suture
double-lid
blepharoplasty
Country RO China, Taiwan Korea Philippines Japan
Conjunctival suturing CA suturing Yes, back and forth Buried suture
through dermis and technique.
conjunctiva First technique:
transconjunctiva
only
Skin incision Combine with a Needle through four Full incisional method Second technique:
4 mm lateral skin stab skin incisions small skin incision
incision to reduce
fat pad
Remove skin No Yes No
Orbicularis Buried suture in orbic. Yes Second technique:
oculi through lateral resected some
stab incision pretarsal orbicularis
Orbital septum Yes
Preaponeurotic fat Remove portion of Removal as needed
fat
Crease form Take {skin–tarsus
+aponeurosis–skin}
fixation sutures x 5
buried 6-0 nylon
Sutures Buried sutures 7-0 nylon back and Continuous 6-0 nylon Buried suture over
forth anterior surface of
STB
Days left in Permanent Remove on 5th day Buried suture is
permanent
Effectiveness Follow-up period Follow-up period Follow-up period
unknown unknown unknown.
Fail rate of 26% with
buried suture alone;
9.6% if combined
with resection of
pretarsal orbic.
Comments Hardly Skin fixation to tarsus as
‘non-incisional’? well as to levator
Any Faden-like effect? aponeurosis;
combined effect
 Appendix 3 Recent Literature (1998–2014) on Asian Eyelid Surgery (in English) 365

Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)

Author Jinghe, Huifang et al.
Year 2014
Journal Ann Plast Surg
72(2):141–144
Three mini-incisions
double-eyelid
blepharoplasty
Country PR China
Conjunctival
suturing
Skin incision Partial incision; 3 incisions,
each 3–4 mm
Remove skin
Orbicularis Excise inferior skin edge’s
orbicularis
Orbital septum
Preaponeurotic fat Reduce fat
Crease form
Sutures
Days left in
Effectiveness
Comments Author described incisions
as ‘minute’
 APPENDIX 4

RECENT LITERATURE ON
EPICANTHOPLASTY (IN ENGLISH)

Recent Literature on Epicanthoplasty (in English)

Author S Ma Y Lee, E Lee et al. SD Lin
Year 1996 2000 2000
Journal Zhonghua Yan Ke Za Zhi Plast Reconstr Surg Br J Plast Surg 53(2):95–99
32(3):194–196 105(5):1872–1880 Correction of the epicanthal fold
Epicanthoplasty during Anchor epicanthoplasty combined using the VM-plasty
double-fold eyelid with out-fold type double PMID: 10878829
operation eyelidplasty for Asians: do we
PMID: 9590860 have to make an additional scar
to correct the Asian epicanthal
fold?
PMID: 10809119
Country PR China Korea RO China, Taiwan
Skin incision Various epicanthoplasty Anchor epicanthoplasty, used for VM-plasty with three V-flaps
performed in 183 cases out-fold crease (parallel crease
shape), anchoring medial end of
incision to deep tissue
Remove:
Skin 38 cases (shuttle form), Trimming skin
120 (cuneiform), Z-plasty
in 25 cases
Orbicularis And soft tissue under medial fold
Orbital septum
Preaponeurotic fat
Crease form Parallel crease Outer (parallel)
Effectiveness 183 cases, performed 67 cases; 28 cases followed. Used alone in 8 cases, with
together with double- Disadvantages include technical double-eyelid procedure in 51
eyelid procedures difficulty and chance for active young patients, and with
bleeding as stated by authors. upper blepharoplasty and
Blends into medial end of parallel crease procedure in 26 cases
crease
Comments Three techniques This technique is based on the Redness of incisions was
depending on severity concept of trimming of muscle common but all faded away
and soft tissue under the Asian within 2–3 mth
epicanthal fold and downward
medial advancement and
anchoring of the medial canthal
skin to the deep tissue. Avoids
incision over medial canthal skin
(medial to the medial canthal
angle)

366
 Appendix 4 Recent Literature on Epicanthoplasty (in English) 367

Recent Literature on Epicanthoplasty (in English)

Author Y Yang, HM Zhang et al. H Zhang, H Zhuang et al. SK Yi, HW Paik et al.
Year 2006 2006 2007
Journal Zhonghua Zheng Xing Wai Ke Plast Reconstr Surg Aesthet Plast Surg
Za Zhi 22(2):130–132 118(4):900–907 31(4):350–353
[A new method for medial A new Z-epicanthoplasty and a Simple epicanthoplasty with
canthoplasty combined concomitant double minimal scar
double eyelid formation] eyelidplasty in Chinese eyelids PMID: 17486401
(article in Chinese) PMID: 16980849
PMID: 16736618
Country PR China PR China Korea
Skin incision Performed with double-eyelid Z-epicanthoplasty
procedure
Remove:
Skin
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form
Effectiveness 86 cases; 67 cases followed 230 cases together with 52 cases, 2 showed a depressed
up. Designed for parallel double-eyelid procedure, scar on the lower lid
shape crease included congenital and
traumatic medial epicanthi.
Followed 67 cases. Stated that
it is suitable for all types
except epicanthus inversus
Comments Suitable for mild to moderate Mild scar in early postop period,
epicanthal folds, all except then fade into gray–white line
epicanthus inversus

Continued
368 Asian Blepharoplasty and the Eyelid Crease

Recent Literature on Epicanthoplasty (in English)

Author JI Park, MS Park FC Li, LH Ma W Chen, S Li et al.

Year 2007 2008 2009

Journal Facial Plast Surg Clin J Plast Reconstr Aesthet Surg J Plast Reconstr Aesthet Surg
North Am 15(3):343– 61(8):901–905 Epub 2007 Jul 2 62(12):1621–1626
352, vi Double-eyelid blepharoplasty Medial epicanthoplasty using the
Park Z-epicanthoplasty incorporating epicanthoplasty palpebral margin incision method
PMID: 17658430 using Y–V advancement PMID: 19028154
procedure
PMID: 17606424
Country USA PR China PR China
Skin incision Z-epicanthoplasty, Y–V advancement incorporated Palpebral margin incision.
correcting type II and III into crease incision Performed together with double-
epicanthal fold eyelid procedure.
Remove:
Skin
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form Outer-parallel
Effectiveness Best suited for outer- 92 cases, performed with 82 cases (through upper and lower
parallel crease shape, double-eyelid procedure. Only 3 palpebral margin incisions; trims
patients who desire cases with scar off orbic. oculi under epicanthal
‘higher’ double fold fold, as well as superficial head of
medial canthal ligament)
Comments Authors stated: ‘The size of the
epicanthal fold in Asians is
usually relatively small, and
thus aesthetically successful
effacement rarely requires more
complex procedures as
performed in the West.’
 Appendix 4 Recent Literature on Epicanthoplasty (in English) 369

Recent Literature on Epicanthoplasty (in English)

Author JJ Lu, K Yang et al. Y Liu, J Huang L Liu, S Li et al.
Year 2011 2011 2012
Journal J Plast Reconstr Aesthet Surg Aesthet Plast Surg J Plast Reconstr Aesthet Surg
64(4):462–466 35(6):1112–1116 65(1):43–47
Epicanthoplasty with double A modified and accurately Inverted ‘V–Y’ advancement
eyelidplasty incorporating designed Z-epicanthoplastic medial epicanthoplasty
modified Z-plasty for technique PMID: 21816696
Chinese patients PMID: 21607535
PMID: 20682462 (Interepicanthal distances longer
than a palpebral fissure and
lacrimal caruncles obviously
covered by epicanthic folds
were considered an indication)
Country PR China PR China PR China
Skin incision Modified Z-plasty Modified Z-plasty Inverted V–Y
Remove:

Skin
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form
Effectiveness 322 cases(with double-eyelid 62 cases (42 simultaneous
procedures); technique double-eyelid surgery); stated
includes cutting off 60 patients were satisfied
malpositioned superficial
head of preseptal orbic.
oculi
Comments Stated that it can be applied to 263 cases. Stated it can avoid
all types except epicanthus overly Westernizing the inner
inversus canthus architecture

Continued
370 Asian Blepharoplasty and the Eyelid Crease

Recent Literature on Epicanthoplasty (in English)

Author YH Shin, PJ Hwang et al. X Hu, X Lin et al. S Wang, F Shi et al.

Year 2012 2012 2013

Journal J Craniofac Surg 23(4):e278–820 Aesthet Plast Surg J Plast Reconstr Aesthet Surg
V–Y and rotation flap for 36(4):788–794 66(5):682–687
reconstruction of the epicanthal Two-Z-epicanthoplasty in Epicanthal fold correction: our
fold. a three-dimensional experience and comparison
(to treat overcorrected model of Asian eyelids. among three kinds of
epicanthoplasty cases) PMID: 22437335 epicanthoplasties.
PMID: 22801149 PMID: 23499505
Country Korea PR China PR China
Skin incision V–Y 20 out of 23 cases Three methods, 252 cases
underwent (220 together with double-
simultaneous double- eyelid procedure): horizontal
eyelid procedures incision (mild), Z-plasty
(moderate) and V–W-plasty
(severe cases)
Remove:
Skin
Orbicularis Excise orbicularis and thick
subcut. tissues
Orbital septum
Preaponeurotic fat
Crease form
Effectiveness 246 cases, 62 cases followed up; 6 Stated that intercanthal Majority cases were mild,
cases needed reoperation. distance decreased underwent horizontal
Intercanthal distance lengthened from 37± 2.1 mm incision which left
from 31.7 to 33.8 mm mean preop. to 31.4±1.9 mm inconspicuous scar. Severe
postop. Inconspicuous cases (underwent V–W-
scar plasty) may leave obvious
scar
Comments Used to repair overcorrection of
epicanthoplasty (overly exposed
caruncle)
 Appendix 4 Recent Literature on Epicanthoplasty (in English) 371

Recent Literature on Epicanthoplasty (in English)

Author L Wang, X Chen et al.
Year 2013
Journal Aesthet Plast Surg 37(4):704–708
A modified Z-epicanthoplasty combined with
blepharoplasty used to create an in-type
palpebral fissure in Asian eyelids.
PMID: 23824058
Country PR China
Skin incision To create an in-type crease shape (NTC).
Performed together with double-eyelid
surgery
Remove:
Skin
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form In-type (nasally tapered)
Effectiveness Reported ‘no scarring’ in 873 cases
Comments
 APPENDIX 5

AESTHETIC EFFECTS OF
ASIAN BLEPHAROPLASTY

Author Yu, Liao Tsai, Wu et al. Kim Kim, Lee et al.

Year 2000
Journal Hua Xi Kou Qiang Yi Xue
Za Zhi 18(3):165–167 (in
Chinese)
PMID:12539668
Classification of eyelids,
design of double-eyelid
operations
Country PR China
Skin incision Design based on
morphological characters
of eyelids
Comments Classified according to
eyes’ length and height,
eyelid skin thickness,
eyeball protrusion and
eye shape, including
eyelids with long and
narrow eyes, eyelids with
thin and soft skin, eyelids
with thick subcut. tissue,
eyelids with small and
round eyes, eyelids with
protruding eyeball and
eyelids with triangle eyes
2012 2013 2013
J Plast Reconstr Aesthet Plast Surg J Craniofac Surg
Aesthet Surg 37(5):863-868 24(5):1582–1585
65(6):e141–145 Effects in the upper What causes increased
Ocular surface area face of Far East contrast sensitivity and
changes after Asians after Oriental improved functional
double eyelidplasty blepharoplasty visual acuity after upper
eyelid blepharoplasty?
RO China, Taiwan Korea Korea
Increase in ocular Their series of 612 pts Improved contrast
surface area after shows an increase sensitivity and
double eyelidplasty in palpebral fissure functional visual acuity
vertical dimension after upper
and relaxation of blepharoplasty were
brow position after caused by changes in
double-eyelid ocular high-order
surgery. (These aberration and the
findings are not degree of lash ptosis
unique to Asians) after surgery. There
were no changes in
corneal topography or
astigmatism

Author Hwang, Spiegel

Year 2014
Journal Aesthet Surg J 34(3):374–382
The effect of ‘single’ vs ‘double’
eyelids on the perceived
attractiveness of Chinese women
Country USA
Skin incision
Comments 19 Chinese women were judged by
Chinese as well as non-Chinese
observers: creases were digitally
added as low, medium and high in
height.
Both Chinese and non-Chinese
observers considered the medium-
height upper eyelid crease most
attractive (P < 0.00001). An absent
upper eyelid crease was deemed
the least attractive (P < 0.00001)

372
 APPENDIX 6

RECENT LITERATURE ON ANATOMY

Recent Literature on Anatomy

Author O Galatoire, V Touitou et al.
Year 2007
Journal Orbit 26(3):165–171
High-resolution MRI of the upper
eyelid: correlation with the
position of the skin crease in
the upper eyelid
PMID: 17891644
Country
Comments MRI provides excellent images
and allows a good analysis of
the upper eyelid components. It
permits a detailed analysis of
the architecture for a better
understanding of its appearance
and of the crease position
H Kakizaki, I Leibovitch et al.
2009
Ophthalmology 116(10):2031–2035
Orbital septum attachment on the
levator aponeurosis in Asians: in
vivo and cadaver study
PMID: 19592104
(To examine the anatomic
relationships between the
preaponeurotic fat pad, orbital
septum, and the distal end of the
anterior layer of the levator
aponeurosis [DEALLA] in relation
to the superior tarsal plate border)
In vivo, the DEALLA was always
located above the STB, and the
lower margin of the preapon. fat
was always positioned below the
DEALLA and around the STB.
Orbital septum attachment on the
levator aponeurosis in Asians
seems to be situated above the
STB border in vivo
BS Kotlus, DE Heringer, RM Dryden
2010
Ophthal Plast Reconstr Surg
26(6):395–397
Evaluation of homeopathic Arnica
montana for ecchymosis after
upper blepharoplasty: placebo-
controlled, randomized, double-
blind study
PMID: 20683279
The authors find no evidence that
homeopathic A. montana, as
used in this study, is beneficial
in the reduction or the resolution
of ecchymosis after upper-eyelid
blepharoplasty

Recent Literature on Anatomy

Author Q Zhou, L Zhang et al.

Year 2012
Journal J Plast Reconstr Aesthet Surg
65(9):1175–1180
Preoperative asymmetry of upper
eyelid thickness in young
Chinese women undergoing
double-eyelid blepharoplasty
PMID: 22647567
Country PR China
Comments Using high-def. MRI and high-
precision weighing of tissue:
Demonstrated that the
orbicularis muscle and orbital
fat pad are consistently thicker
on the right side than on the
left. Concluded that upper
eyelid thickness asymmetry is a
common phenomenon in young
Chinese women

373