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129
aaps
Archives of
Aesthetic Plastic Surgery
REVIEW
ARTICLE
http://dx.doi.org/10.14730/aaps.2014.20.3.129
Arch Aesthetic Plast Surg 2014;20(3):129-139
pISSN: 2234-0831 eISSN: 2288-9337
Comprehensive Review of Asian Cosmetic Upper Eyelid
Oculoplastic Surgery: Asian Blepharoplasty and the Like
INTRODUCTION
The field of Asian Aesthetic Oculoplastic Surgery is a rapidly grow-
ing area – with upper eyelid blepharoplasty ranking as the most
commonly performed procedure in Asian aesthetic surgery.
The main objective of this article is to provide simplification and
reorganization to the surgical procedures of this topic, namely su-
pratarsal crease surgery and epicanthoplasty techniques. In addition,
a recommendation for unified terminology and an enhanced expla-
nation of the aesthetic goals of the procedures will be offered. This
paper will also evaluate some of the advantages and disadvantages of
various surgical approaches in an objective fashion, based on ana-
tomic and physiological criteria of the individual patient at hand.
The imprecise use of terminologies in Asian Aesthetic Oculo-
plastic Surgery has always been a problem with doctor/patient in-
teraction. This leads to miscommunication, unrealized expecta-
tions, and suboptimal results. Because the Asian languages inher-
ently have the capacity to hold multiple meanings even within the
same word, there is an even greater importance in using unified
language to optimize doctor/patient communication (Table 1).
Too often, complications occur due to faulty primary surgery
based on incorrect concepts and choices. Although the choice in
Suzie H. Chang1, William P. Chen2,
In Chang Cho3, Tae Joo Ahn4
1Department of Plastic Surgery,
University of Texas Southwestern Medical
Center and Veterans Affairs North Texas
Health Care System, Dallas, Texas;
2Harbor-UCLA Medical Center, Torrance,
California, USA; 3BIO Plastic Surgery
Clinic, Seoul; 4Gyalumhan Plastic Surgery,
Seoul, Korea
Background Asian Aesthetic Oculoplastic Surgery is a fast-growing field, both within
the United States and abroad. With growing interest, there have also been multiple
terminologies used for the same concepts. This has created redundant and confusing
language - prone to errors in patient-physician communication. In addition, there has
been an upsurge of various techniques or variations to existing techniques that has
created unnecessary confusion among plastic surgeons. The objective of this article is
to provide organization and simplification to the terminology and to the techniques
used in what some broadly refer to as “Asian Blepharoplasty” or perhaps more cor-
rectly termed Asian Aesthetic Oculoplastic Surgery.
Methods Unified terminology, aesthetic goal and detailed operative technique of com-
monly conducted Asian blepharoplasty were suggested by experienced oculoplastic
surgeons.
Results The main procedures of Asian Aesthetic Oculoplastic Surgery including supra-
tarsal crease surgery and medial epicanthoplasty were presented with figure and video
in this paper. We also have provided author’s preferred selection of the major tech-
niques with evaluation of its advantages and disadvantages.
Conclusions The most important element in patient satisfaction is clear communica-
tion of surgical expectations. Then, proper selection of the most suitable pre-operative
design, type of surgery performed, and specific crease configuration based on the indi-
vidual’s anatomic and physiological characteristics can be achieved.
Keywords Asian blepharoplasty, Asian oculoplastic surgery, Epicanthoplasty, Supratar-
sal crease, Double eyelidplasty
None of the authors has a financial interest in
any of the products, devices, or drugs men-
tioned in this manuscript.
Received: Oct 21, 2014 Revised: Oct 25, 2014 Accepted: Oct 26, 2014
Correspondence: Suzie H. Chang Department of Plastic Surgery, University
of Texas Southwestern Medical Center, Veterans Affairs North Texas Health
Care System, VISN 17, 1801 Inwood Rd., Dallas, TX 75390, USA.
E-mail: suzie.chang@utsouthwestern.edu
Copyright © 2014 The Korean Society for Aesthetic Plastic Surgery.
This is an Open Access article distributed under the terms of the Creative Commons At-
tribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited. www.e-aaps.org
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terminology may seem to be a minor detail, these are challenging
issues when handling patient complaints and suboptimal results in
revisional cases. Therefore, it is critical to surgical success to clearly
communicate expectations and desires of the patient at the first op-
portunity.
ANATOMICAL BASIS OF ASIAN
AESTHETIC OCULOPLASTIC SURGERY
The anatomical basis of Asian Aesthetic Oculoplastic Surgery re-
volves around two unique entities, the supratarsal crease and the
epicanthal fold. The absence and presence of these two entities dis-
tinguishes the aesthetics of the Asian eye from other ethnicities.
Anatomy and etiology of supratarsal crease
Historically, the most commonly used explanation on the etiology
of the supratarsal crease is commonly explained by the Levator Ex-
pansion Theory - where the levator aponeurosis sends distal inser-
tions into the overlying dermis of the upper eyelid skin approximate-
ly at the level of the superior border of the tarsal plate [1].
However, there have been more recent microanatomic studies
that demonstrate how the levator sends distal insertions to overly-
ing orbicularis oculi muscle and subcutaneous tissues, not into the
dermis itself [2]. In addition, the general consensus of updated thou-
ght is that the contributing factors to the upper lid without a supra-
tarsal crease are the increased thickness of skin, the increase in sub-
orbicularis adipose tissue, the variance in fusional height of the or-
bital septum and levator aponeurosis, the existence of a pretarsal
fat pad, and the increase in preaponeurotic adipose tissues [3-6].
Anatomy and etiology of epicanthal fold
Most Asian epicanthal folds can be categorized as the epicanthus
tarsalis variant [7,8]. It is a normal anatomic entity unique to the
Asian patient population and is not considered a deformity. The
epicanthal fold is comprised of redundant skin, subcutaneous tis-
sue, and a portion of the preseptal orbicularis oculi muscle. When
the epicanthal fold is eliminated in the case of epicanthoplasty pro-
cedures, there have been no functional deficits found [9].
There have been several anatomical studies published showing
the composition of the epicanthal fold [5]. It is located nasally be-
tween the upper and lower eyelid, at an epicenter of opposing skin
tension vectors. When the upper eyelid opens through the action
of the levator muscle and aponeurosis, it is noted that the medial
skin of the upper eyelid moves in a superolateral direction and the
lateral upper eyelid skin moves in a superomedial direction [10].
(Fig. 1). These vectors of upper eyelid skin tension are more pro-
nounced when the eyelid is open rather than when closed. Addi-
tionally, it is prudent to perform an epicanthoplasty procedure con-
comitantly with a supratarsal crease surgery in order to eliminate
and disperse these deterring forces from blunting the supratarsal
crease formation.
SUPRATRASAL CREASE SURGERY
The first known published account of the Asian supratarsal crease
procedure is in the Japanese literature. In 1896, Mikamo published
a suture technique to creating the supratarsal crease [11]. In 1929,
Maruo reported the first incisional method [12]. Since then, there
have been numerous publications on variations and combinations
of these two techniques [13-18], including laser application [19] and
the use of microsurgical mini-flaps [20].
There are distinct advantages and disadvantages to each tech-
Table 1. Terminology in Asian aesthetic oculoplastic surgery
Identity Current common terms Proposed term – Term used in this manuscript
Supratarsal crease creation surgery Asian blepharoplasty, double eyelid surgery, lid crease
surgery, Asian upper lid procedure
Supratarsal crease surgery
Parallel oriented supratarsal crease “Outfold”, “outer-oriented” crease, parallel crease Parallel crease
Nasally tapered supratarsal crease “Infold”, “inner-oriented” crease, “unfolded fan” fold Nasally tapered crease
Epicanthal fold “Mongolian fold” Epicanthal fold
Hypertrophic orbicularis roll along lower lash line “Love-roll”
Microincisional buried suture technique Non-incisional, suture technique Minimal incision supratarsal crease surgery
Fig. 1. Skin tension vectors.
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Table 2. Incisional vs minimal incision techniques in supratarsal crease surgery
Incisional Minimal incision
Ideal patient All patients, especially useful in revision cases, thick-lid cases,
or patients with dermatochalasis
Thin-lid patient
Advantages Direct visualization, can perform ptosis correction concomitantly,
ability to perform selective tissue debulking, Better ability to
control for hemostasis, Previse preservation/repositioning of
preapoenurotic fat
Minimal external scarring, shorter recovery time
Disadvantages Longer recovery time, possibly greater learning curve Decreased visualization of tissues, more difficulty in creating a
parallel-oriented crease (with disappearance of medial crease),
permanent buried sutures placed, potential Faden Effect [30]
Complications Possibility of static crease deformity, asymmetry Suture failure (recurrence), suture erosion, suture palpability, asymmetry,
partial crease formation, feeling of “strain” in eyelids
Fig. 3. Nasally-tapered configuration.
Fig. 2. Parallel configuration.
Fig. 4. Parallel vs nasally-tapering supratarsal crease design.
nique. Accordingly, one should select the appropriate technique for
the individualized patient based on his/her unique anatomic and
physiological qualities (eg thin vs thick upper eyelid, age, ocular
history, etc.) (Table 2). This is critical to successful surgical outcome
and patient satisfaction.
In addition to selecting the appropriate supratarsal crease surgi-
cal technique, it is equally important to select the appropriate crease
configuration. Clearly establishing the desire crease configuration
of the patient is critical to surgical success.
CREASE CONFIGURATION
Supratarsal crease placement - Height
In general, the supratarsal crease should not be placed higher than
the superior border of the tarsal plate. This is due to the fact that
placement of a crease higher than the superior tarsal border tends
to decrease the contractility of the levator muscle and that it is more
difficult to lower the crease than to raise it. In addition, a high crease
can look unnatural. Unless the patient specifically desires a high
placement of the supratarsal crease it is advised to err on the side of
conservative, more inferior, placement.
Supratarsal crease configuration - Shape
There are two common crease configurations of the supratarsal
crease among Asians: parallel configuration and nasally-tapering
configuration (Fig. 2-4). In order to achieve patient satisfaction,
there must be a preoperative consensus between patient and sur-
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geon on the selection of the specified crease configuration.
Dynamic crease
The most important aesthetic ideal in the supratarsal crease is the
dynamic nature of the crease. The dynamic crease is defined as one
that is present when the upper eyelid is open and one that is imper-
ceptible when the eyelid is closed or looking down. To create a su-
pratarsal crease, a component of the anterior lamella (eg dermis)
must be fixated to an element of the posterior lamella (eg levator
aponeurosis), which is responsible for lid elevation. Whether the
incisional technique is utilized or a minimal incision suture tech-
nique is utilized, all supratarsal crease surgeries fixate the anterior
lamella to the posterior lamella. In order to create a dynamic crease
and avoid an uncomely static crease deformity, it is important not
to directly anchor the skin to the tarsal plate. The skin flap should
instead be fixated to the septoaponeurotic tissues [18,21,22]. This
is described in detail in later sections.
Static crease deformity
There are generally two types of static crease deformity: a depress-
ed scar or an overly deep fold. The depressed scar occurs when ex-
cessive orbicularis oculi muscle excision was performed – thereby
creating a significant muscle gap. The overly-deep fold variant oc-
curs when the lower skin incision flap is anchored too far superior-
ly onto the tarsus or levator apoenurosis [22].
Aesthetic goals
The aesthetic goals of Asian Oculoplastic surgery are to provide
the appearance of a naturally appearing, well-defined, and wide-
open palpebral fissure within the normal variations of Asian anat-
omy. It is important to note that the aesthetic goal of these proce-
dures is not “Westernization” but to create the appearance of a nat-
uralappearing, relatively larger, and open palpebral fissure [23].
The perception of size and shape of the eye is actually based on
the perception of the size or shape of the white scleral triangles on
either side of the cornea: the nasal scleral triangle and the lateral
scleral triangle [26]. The reduction or elimination of the epicanthal
fold uncovers, increases, and clearly delineates the nasal scleral tri-
angle - thereby creating the perception of a larger eye. In the case of
the supratarsal crease, the presence of a supratarsal crease creates
the illusion of a vertically larger palpebral fissure (Fig. 5, 6).
In simple terms, the procedures discussed today – incisional su-
pratarsal crease surgery, minimal-incision supratarsal crease sur-
gery, and epicanthoplasty – all strive to create a larger and naturally
appearing palpebral fissure.
In the following section we will discuss the authors’ preferred
techniques for Incisional Supratarsal Crease Surgery, Minimal Inci-
sion Supratarsal Crease Surgery, and Epicanthoplasty Surgery.
INCISIONAL SUPRATARSAL CREASE
SURGICAL TECHNIQUE
Author Chen’s preferred method
The author Chen prefers this incisional method as it provides su-
perior control of crease height and shape to create a permanent,
natural crease with lessened incidence of complications. He reports
an overall consensus of ~5-10% need for revision among all practi-
tioners of this method. In addition, by fixating the skin to the apo-
neurotic tissues, this procedure recreates the anatomy thought to
be found in naturally-occurring supratarsal creases. This technique
also utilizes the same incision for the supratarsal crease creation to
reduce the medial canthal upper lid fold, thereby reducing the need
for a separate medial epicanthoplasty incision (See below).
Operative technique – Full incision technique [18,27-31]
(Video 1. Incisional Technique)
The appropriate oral premedications (one tablet of Vicodin/hydro-
codone acetaminophen as analgesic and 10 milligrams of Valium/
diazepam as sedative) are given one hour prior to surgery. Intrave-
nous line is started. The upper lid skin and sub-orbicularis layers
are infiltrated with 2% xylocaine with 1:100,000 dilution of epine-
phrine, along the incision line (A #30 gauge needle is used and the
volume injected is seldom over 0.5-0.75 mL for each eyelid). After
a 5 minutes period for the anesthetic to disperse, the operative field
is prepped and vital signs monitors are applied.
Step 1: Marking of crease incision
Attention is turned to the right eye. A black protective corneal eye
Fig. 5. Absence of supratarsal crease. Fig. 6. Presence of supratarsal crease – after supratarsal crease
surgery.
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shield is applied. The upper lid’s tarsal plate is everted (Fig. 7) and a
caliper used to measure the vertical height of the central portion of
the tarsal plate. The lid is returned to its normal position and meth-
ylene blue ink is used to transpose the measured central tarsal height
to the lid skin as the central point of the crease incision(lower line),
usually at about 7 mm from the lashes.
Step 2: Skin incision
Depending on clinical finding, typically a segment of skin measur-
ing about 2-3 mm centrally and laterally, and 1 mm medially is in-
cluded in the upper and lower lines of incision (Fig. 8). Skin inci-
sion is made using a #15 blade.
Step 3: Beveled transection through orbicularis oculi layer [27]
When the orbicularis muscle is seen, control of capillary oozing is
carried out using bipolar cautery. This layer is carefully traversed
using surgical blade or monopolar cautery with cutting mode on a
low energy setting. The cautery tip is intentionally beveled superi-
orly along the orbicularis such that the orbital septum is reached at
a slightly higher level from the superior tarsal border. The beveled
approach allows a safer route to the preaponeurotic space while
avoiding inadvertent touch of the levator muscle.
Step 4: Opening of orbital septum
When the preaponeurotic fat is seen through a small opening of
the septum, the septum is opened horizontally with a blunt scissors
(Westcott’s), avoiding blood vessels in the fat pads or the levator
aponeurosis underneath.
Step 5: Treatment of fat pads
The strip of skin-muscle bounded by the two skin incisions, is re-
tracted inferiorly using a Blair retractor. If preaponeurotic fat is pro-
Fig. 7. Everted Lid. Right upper lid is everted and the height of the
tarsus is measured centrally with a caliper from the posterior lid mar-
gin to the superior tarsal border.
Fig. 8. Incision. Skin incision has been made, first along the lower
line of incision - which will become the new crease line, and then along
the upper line of incision.
Fig. 9. Preaponeurotic space. Preaponeurotic space and Trapezoidal
debulking and trimming of the skin-muscle strip – This maneuver
often facilitates the glide mechanism [28] (glide plane) of the levator
relative to the anterior skin/orbicularis oculi layer, allowing an eyelid
crease pulled by the levator/Muller’s to indent dynamically against a
relaxed preseptal skin-orbicularis layer which forms the eyelid fold.
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lapsing significantly down and overlaps the superior tarsal border
where the crease construction is to occur, it can be partially excised.
Step 6: Trapezoidal debulking and trimming of the skin-muscle
strip along the lower skin incision at level of superior tarsal border
(Fig. 9)
The preaponeurotic platform has been cleared for optimal inter-
play between the posterior lamella of levator and Mueller’s muscle
with its attached tarsus, and the relaxed anterior skin and orbicu-
laris oculi; there is now less hindrance (impedance) to dynamic
crease construction. The crease forms well even without wound
closure at this point.
Step 7: Resetting of tissue plane
At this point, it is essential to release the forehead drapes and prop-
erly reposition the brow and upper lid tissues in relation to the un-
derlying levator aponeurosis and lower pretarsal tissues. It avoids
setting an exaggerated crease height, induction of secondary ptosis,
lagopthalmos on downgaze, and a secondary higharched brow as a
compensatory reaction. This is a most under-appreciated step in
upper blepharoplasty. In revisional cases, this resetting allows some
skin recruitment and brings in additional soft tissues to partially
fill in any deep sulcus from fat excision associated with previous
blepharoplasty.
At this point is where management of medial upper lid fold comes
in: Often among patients who present a clinically evident medial
upper lid fold, there may be a need to reduce the prominence of
this fold. The author uses the following technique as an added so-
lution set:
(i) In the design of the nasally-tapered crease, the incision lines
are drawn to converge towards the medial canthus as well as
the medial fold. To enhance the crease invagination to blend
in under the fold, the area is slightly undermined, and excess
skin tissue is cut just below the converging crease line (infra-
crease cut, first snip); the lower edge’s skin is migrated up and
a second cut takes care of the small dog-ear. The crease is clos-
ed with an interrupted suture placed with the knot on the
lower side of the wound edge (infraanchoring of knot,“down-
knot” the crease). The goal is to have the nasal-tapering crease
indent to beneath (inferior to) the natural residual fold. (Al-
ternatively one may also make the first snip along the crest of
the medial canthal fold, and then migrate the lower edge’s ex-
cess skin upward to trim it; then infra-anchor its closing knot.
It has a slightly higher chance of postoperative induration since
the skin along the crest of the medial fold is slightly thicker.)
(ii) With a parallel shape design, after the main steps are carried
out and the tissue planes have been reset, the area under the
medial fold is slightly undermined. The first relaxing snip
near the medial end of the undermined redundant skin is bi-
ased towards the lower incision in a slightly oblique fashion
(infra-crease cut); the lower edge’s excess skin is migrated
upward such that the medial fold is reduced with the second
cut removing the dog ear and based along the medial direc-
tion of the parallel crease shape. The closure at this end is with
a fine interrupted suture tied very lightly and laid on the su-
perior side of the incision (supra-placement of knot without
anchoring; “up-knot” the tie loosely, the rationale being that
the medial end of a natural parallel crease tends to be shal-
low). These delicate techniques I used have handled the eth-
nic non-pathologic medial upper lid fold quite well without
the complicated steps usually associated with treatment of
epicanthal fold (Epicanthus), which is usually reserved for
findings in Down’s syndrome, or patients born with blepha-
rophimosis [32].
Step 8: Crease construction and wound closure
#6-0 sutures are applied from the lower skin edge, picking up small
strands of the levator aponeurosis just above the superior tarsal bor-
Fig. 10. Crease construction and wound closure. (A) procedure completed – eyelid in passive repose. (B) Upper lid opened, crease indents naturally
prior to closure without any skin stitched. (C) Completion of wound closure, the lid opens freely with good crease indentation.
A B C
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Fig. 11. Pre-operative and post-operative photos.
Fig. 12. The 5-point triangular continuous suture technique.
der, then through the upper skin edge and then tied down. Six to
nine interrupted sutures are typically used. The rest of the skin gap
is closed using 7-0 prolene, nylon or silk (Fig. 10C). The eye shield
is removed from the right eye and applied to the left eye where the
procedure is repeated. When completed, each eye is flushed with
normal saline. The surgeon checks for symmetry in the crease and
makes necessary adjustment.
Post-operative management
The patient receives ice compresses to the upper eyelids and is in-
structed to continue icing and bed rest for one day. The patient is
told to have restricted physical exertion the first week. Topical to-
bramycin or gentamicin-prednisolone ophthalmic ointment (Pred-
G, by Allergan) is applied four times daily for one week. Suture re-
moval is usually in one week. Fig. 11 shows three female patients
before and at two months postoperatively; with the first patient’s
crease height set at a slightly below-average crease height of 6.5 mm,
the middle set is at medium-average crease height of 7.0 mm, while
the right set is at higher than average crease height of 7.5 mm.
MINIMAL INCISION SUPRATARSAL
CREASE SURGERY
Author Ahn’s preferred minimal incision method -
triangular 5-microincision suture method
The author Ahn prefers this method over the classic rectangular
3-microincisional suture technique as the additional micro-inci-
sions and triangular configuration creates a more even crease, in-
creases the fixation of anterior to posterior lamella, and decreases
the overall area of potential tissue strangulation with triangles over
rectangles (Fig. 12). Of note, addition of a Muller-muscle loop pli-
cation to this technique can create a simultaneous mild ptosis cor-
rection [17] (Fig. 13).
Operative technique – 5 point triangular continuous
suture technique [17] (Video 2. Minimal Incision – 5 Point
Triangular Continuous Suture Technique)
Step 1: Preoperative markings are made with the patient in sitting
upright position
It is critical to determine whether the patient desires a parallel or
a nasally-tapering crease configuration.
Step 2: The patient is brought to the operating room and placed in
supine position
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The procedure is performed under conscious sedation and local
anesthetics. After reconfirmation of all markings, the anterior la-
mella and posterior lamella is injected with a half-inch #26 gauge
needle containing 2% lidocaine and 1:50,000 epinephrine. Anes-
thetic eye-drops are placed as well.
Step 3: Using a #11 scalpel tip, five micro-incisions are made at equal
intervals just above the level of the superior border of the tarsal plate.
Number the slits from 1 through 5, starting medially and ending
laterally. Use iris scissors to dissect through the micro-incisions for
a larger opening subdermally. By utilizing a lateral microincision,
the risk of inadvertent levator injury is decreased. Through the 4th
microincision, grab the orbicularis oculi muscle with 0.5 forceps
and cauterize the muscle carefully through the forceps. Do not al-
low the forceps to come in contact with the skin. (This allows access
to the post-septal region for debulking the thicker-lidded patient.)
Step 4: In those patients with thicker lids, carefully grab the preapo-
neurotic fat through the 4th micro-incision. Through gentle pull-
ing and teasing motions, carefully deliver a conservative amount of
adipose tissue to be removed. Using a mosquito clamp, carefully
clamp the adipose tissue, cut the adipose tissue, and cauterize the
stump before removal of the clamp. Allow the cauterized adipose
stump to retract back into the lid.
Step 5: Utilize corneal protection with either a corneal shield or use
of a Jaeger lid plate. The suture used is a #7-0 blue nylon on a long
tapered needle. The suture is introduced through the 4th slit sub-
cutaneously and passed out through the 3rd slit. From the 3rd slit,
the suture is passed posteriorly through the conjunctiva from the
everted lid right above the superior edge of the tarsal plate (~1-2
mm). Then, the suture is passed back out from the same point in
the conjunctiva out of the 2nd skin micro-incision. Next, pass the
suture subcutaneously from the 2nd to the 1st skin micro-incision.
The suture is then passed again back through the conjunctiva of
the everted lid right above the superior edge of the tarsal plate. Then,
the suture is passed back out from this point to the 2nd skin micro-
incision. Repeat this pattern back to the 4th skin micro-incision,
utilizing all 5 micro-incisions. This completes triangular-shaped
continuous suture path (Fig. 12).
Step 6: When the triangular-shaped continuous suture run is com-
plete, the suture should be exiting the same hole that the suture was
first introduced, the 4th microincision. At this point, tie the knot
over a blunt needle or a cotton-tip at the appropriate tension to avoid
purse-stringing and strangulation of the lid tissues. Cut the knot
and allow knot to retract into the lid. Note, over-tightening the knot
can cause increased tissue strangulation when post-operative ede-
ma sets in.
Step 7: Repeat on the contralateral lid.
Step 8: If the patient has normal levator function and mild ptosis
(1-2 mm), a Müller muscle plication loop can be added during the
triangular-shaped continuous suture path (between the 3rd and
4th micro-incision in the conjunctiva side) by plicating the Müller’s
muscle subconjunctivally from the level at the superior border of
the tarsal plate to approximately 10-15 mm cephalad (average is
between 12-13 mm) towards the superior sulcus and back to the
superior border of the tarsal plate before passing the suture back
out of the 4th skin micro-incision (Fig. 13).
Postoperative management
Instruct patient to maintain head elevation when possible and to
use ice for comfort as needed.
EPICANTHOPLASTY
General overview/patient selection
In many publications, measurements of various periorbital values
are used to determine whether the epicanthoplasty procedure should
be performed. These include values such as interepicanthal distance,
intercanthal distance, and horizontal palpebral fissure dimensions
[33,34]. At times, these calculations can be complicated and con-
fusing. It is simple to note that the main aesthetic effect of the epic-
Fig. 13. Coronal section of the 5-Point Triangular Continuous Suture
Technique with Muller-Muscle Loop Plication.
Levator
aponeurosis
Conjoint fascial
sheath (check
ligament of
superior fornix
Müller’s
muscle
Levator aponeurosis
Tarsus
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Fig. 14. With the patient sitting upright and in primary gaze, use a
finger to retract the epicanthal fold in a horizontal vector towards
the nasal direction. With the medial canthus/caruncle uncovered by
the retracted epicanthal fold, mark a dot (B) 2 mm nasal to the lacri-
mal lake of the medial canthal region.
Fig. 15. Then lift the marker off of point B and while holding the mark-
er in place in the air, release the digitally retracted epicanthal fold
and place a mark (A1) where the marker lands (superimposed point).
anthoplasty procedure is that of enlarging the nasal scleral triangle
and creating the perception of a larger palpebral fissure. Also, in the
patient with an epicanthal fold, performing the supratarsal crease
procedure alone diminishes its effect by leaving the blunted nasal
scleral triangle made by the persistent epicanthal fold.
Generally speaking, in the Asian patient who desires a parallel-
oriented crease, it is aesthetically pleasing to have a small or non-
existent epicanthal fold. Also, in those patients with very large ca-
runcles, it might be advised not to perform epicanthoplasty to keep
the caruncle from over-exposure.
Skin-Redraping Epicanthoplasty [33]
There are multitude of published epicanthoplasty techniques rang-
ing from simple direct excision, Z-plasty, Y-V advancement meth-
od, W-plasty, etc. Among those, the more popular techniques are
the Uchida split V-W technique [7,35], modified Mustarde tech-
nique [36], and the half Z-plasty technique. Recently, the skinre-
draping technique has become one of the more popular techniques.
[33]
Operative technique – Skin redraping technique
(Video 3. Epicanthoplasty – Skin-Redraping Technique)
Step 1: With the patient sitting upright and in primary gaze, use a
finger to retract the epicanthal fold in a horizontal vector towards
the nasal direction. With the medial canthus/caruncle uncovered
by the retracted epicanthal fold, mark a dot (B) 2 mm nasal to the
lacrimal lake of the medial canthal region (Fig. 14).
Step 2: Then lift the marker off of point B and while holding the
marker in place in the air, release the digitally retracted epicanthal
fold and place a mark (A1) where the marker lands (superimposed
point). (Of note, point B and A1 should lie along the same horizon-
tal axis parallel to the floor) (Fig. 15).
Step 3: Next, draw a dotted line that is perpendicular to this hori-
zontal axis at point A1. At a point that is approximately 70-80% of
the distance between A1 and B, mark point A2. (Of note, point A2
should be along the same horizontal axis as points A1 and B). The
distance from A1 to A2 in relationship to the distance from A2 to
B should be a 2:8 ratio (Fig. 16).
Step 4: Next, draw a solid line that is perpendicular to the horizon-
tal axis through point A2. At a point that is nasal to the medial lim-
bus of the iris, mark point C along the subciliary line. Now, mark
point D between A2 and B but at a location slightly higher/cepha-
lad than the horizontal axis where point A1, A2 and B lay. Note,
the incision line will be from point A2, through point D, point B,
Fig. 16. At a point that is approximately 70-80% of the distance be-
tween A1 and B, mark point A2. (Of note, point A2 should be along
the same horizontal axis as points A1 and B).
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Aesthetic Plastic Surgery VOLUME 20. NUMBER 3. OCTOBER 2014
Fig. 18. Undermining is done superior (cephalad) and inferiorly (cau-
dad) to the incision line.
Fig. 19. The skin will now redrape into the configuration shown in
this Figure.
Fig. 17. Incision is made with a #15 scalpel through skin and subcu-
taneous tissues along the marked incision line.
and ends at point C (Fig. 16).
Step 5: After these preoperative markings are made, the area is in-
filtrated with local anesthesia.
Step 6: Incision is made with a #15 scalpel through skin and subcu-
taneous tissues along the marked incision line (Fig. 17).
Step 7: Undermining is done superior (cephalad) and inferiorly
(caudad) to the incision line (Fig. 18).
Step 8: The orbicularis muscle of the epicanthal fold is transected
sharply and trimmed. Once this is done, meticulous hemostasis is
achieved. The skin will now redrape into the configuration shown
in Fig. 19. The inferior skin flap will have a tendency to move more
laterally and the superior skin flap will have a tendency to move in
a more cephalad direction. As you start closure of the skin incision
by closing point A2 to the upper skin flap’s B point, a dog-ear will
form around the upper skin flap’s point D. This dog-ear can be di-
rectly excised or can be treated with laser resurfacing. In addition,
during closure, a length discrepancy will be noted between the two
skin edges. It is important to redistribute the skin incision flaps
evenly to evenly disperse and eliminate this length discrepancy
during meticulous closure.
If an epicanthoplasty is performed with the primary intent to re-
lieve the tension created by the fold, use a much shorter incision
where point A2 is halfway or less between point A1 and point B
(60:40 ratio). On the reverse side, if point A2 is made at a point larg-
er than 70-80% of the distance between A1 and B (e.g. 1:9), there
will be a great overcorrection and the patient will have a stretched
and pronounced caruncular show.
Postoperative management
In normal postoperative course, most epicanthoplasty scars will
mature to imperceptible state with at least 3 months time. In the
case where there appears to be hypertrophic scarring after this time,
adjuvant CO2 laser resurfacing at the site can improve the scarring.
Some surgeons advocate steroid micro-injection at the time of sur-
gery and postoperatively as well. With proper preoperative coun-
seling of expected 3 month course of healing, most patient expec-
tations can be managed.
CONCLUSIONS
This paper has highlighted the need for unified terminology in the
field of Asian Aesthetic Oculoplastic Surgery. In addition, we have
re-examined and simplified the aesthetic goals of the main proce-
dures. We have provided author’s preferred selection of the major
techniques with evaluation of its advantages and disadvantages.
In conclusion, the most important element in patient satisfac-
tion is clear communication of surgical expectations. Then, proper
selection of the most suitable pre-operative design, type of surgery
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Aesthetic Plastic Surgery
Chang SH et al. Asian Blepharoplasty
performed, and specific crease configuration based on the individ-
ual’s anatomic and physiological characteristics can be achieved.
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