Asian Blepharoplasty and the Eyelid Crease 3

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 θ
θ
2
1
>
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

4  The Eyelid Crease: Goals and Benchmarks
43
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
‘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.

45
C H A P T E R 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
they can be met.
It is interesting to observe that in Japan, China and
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
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
natural and blends in with the configuration of that
FIGURE 5-1  ■  Results after blepharoplasty show multiple high,
semilunar creases caused by excessive removal of preaponeu­
rotic fat.
FIGURE 5-2  ■  Postoperative asymmetric crease.
FIGURE 5-3  ■  Fading of surgically constructed crease in the left
upper lid.

46
Asian Blepharoplasty and the Eyelid Crease
• 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.
FIGURE 5-4  ■  Elderly patient after blepha­
roplasty in which excessive fat was
removed. Note the presence of multiple
creases and folds.
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.

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
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
FIGURE 5-5  ■  Interrelated parameters of the configuration of an eyelid crease.
Height
Permanence
Shape
Continuity

48
Asian Blepharoplasty and the Eyelid Crease
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
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.

5  Consultation and Counseling
49
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
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.

51
C H A P T E R 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.

52
Asian Blepharoplasty and the Eyelid Crease
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
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

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
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
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.

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
FIGURE 6-2  ■  Alternative 1: Full-thickness suture technique.
2
2
3
Skin
Orbicularis muscle
Levator aponeurosis
Müller's muscle
Conjunctiva
1
1
2
2
3
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.

56
Asian Blepharoplasty and the Eyelid Crease
FIGURE 6-3  ■  Alternative 2: Full-thickness suture technique with stab incisions.
Skin
Orbicularis muscle
Levator aponeurosis
Müller's muscle
Conjunctiva
3
Stab incision
2
2
3
Stab incision
2
2
1
1
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.

6  Suture Ligation Methods
57
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.
A’
B’
B
A
LA
M
C
1
3
2
2
4
The line drawing in Figure 6-4 (upper) shows Khoo
Boo-Chai’s method originally published about 50 years
ago. In Dr Boo-Chai’s method, a typical suture used may
be a double-armed 5-0 or 6-0 nylon. The first passage (1)
involves everting the upper lid margin and passing it
subconjunctivally for a couple of millimeters (A′–B′), at a
level typically several millimeters above the superior
tarsal border. The second passage (2) directs one needle

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
FIGURE 6-5  ■  Alternative 3: Transconjunctival intramuscular suture technique.
Strategic placement
of intramuscular
sutures creates
infolding of crease
2
1
Exit
Entry for both needles
of double-armed sutures
Indentation of skin
Skin
Orbicularis muscle
Levator aponeurosis
Müller's muscle
Conjunctiva
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.

60
Asian Blepharoplasty and the Eyelid Crease
FIGURE 6-6  ■  Alternative 4: Transcutaneous intramuscular suture technique (without piercing the conjunctiva).
First stab incision
1
2
1
2
1
Skin
Orbicularis muscle
Levator aponeurosis
Müller's muscle
Conjunctiva
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
levator aponeurosis and some Müller muscle. Suture
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.

6  Suture Ligation Methods
61
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
subcutaneous plane and then the suborbicularis planes
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,
FIGURE 6-7  ■  Alternative 5: Twisted needle and compression method (transcutaneous and intratarsal suturing with twisted needle
tracking method).
Skin
Subcutaneous tissue
Pretarsal orbicularis
Tarsus
Continuous
subcutaneous
suturing
Continuous
reverse-loop
suturing
A
B
C

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
FIGURE 6-8  ■  Alternative 6: Transcutaneous intradermal and intratarsal suturing technique.
Epidermis
Dermis
Pretarsal orbicularis
Levator aponeurosis
Conjunctiva
Through dermis
Through tarsus
Dermis
Pretarsal orbicularis
Levator aponeurosis
Tarsus
Tarsus
1
2
3
A
B
C
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.

64
Asian Blepharoplasty and the Eyelid Crease
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 6-9  ■  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

6  Suture Ligation Methods
65
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.
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.]

67
EXTERNAL INCISION METHODS
C H A P T E R 7 
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).

68
Asian Blepharoplasty and the Eyelid Crease
SKIN–LEVATOR–SKIN APPROACH
In this first technique, which is favored by the author, the
sutures are placed such that it first bites the inferior skin
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
the levator aponeurosis. Fernandez1 described this tech­
nique in 1960 and stated that it gives a ‘dynamic and
superficial crease’ (Figure 7-2), as opposed to skin–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.
Levator aponeurosis
Superior
tarsal
border
Tarsus
0.12 mm forceps
FIGURE 7-2  ■  Skin–levator–skin (SLS) closure, which produces a dynamic and superficial crease.

7  External Incision Methods
69
FIGURE 7-3  ■  Skin–tarsus–skin (STS) closure, which tends to produce a static crease.
A
B

70
Asian Blepharoplasty and the Eyelid 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
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.

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
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
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.

72
Asian Blepharoplasty and the Eyelid Crease
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).
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.

7  External Incision Methods
73
FIGURE 7-6  ■  (A) A dynamic crease is apparent on straight-ahead gaze but disappears on downgaze (B).
A
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.

85
ASIAN BLEPHAROPLASTY II:
THE SECOND VECTOR
C H A P T E R 9 
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.
FIGURE 9-1  ■  Primary Asian blepharoplasty.
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.

86
Asian Blepharoplasty and the Eyelid Crease
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
rotic fat pad from the underlying levator
aponeurosis (right upper lid).
A
B
FOLLOWING OPENING OF
THE ORBITAL SEPTUM
Rotation of Myocutaneous Strip Away
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
scissors are used to separate the preaponeurotic fat
beneath it from the orbicularis in front and levator below
it. This central preaponeurotic fat pad is often adherent
by fascial attachment to its underlying levator muscle
fibers (Figure 9-2B).

9  Asian Blepharoplasty II: The Second Vector
87
FIGURE 9-3  ■  Skin–muscle flap retracted using a Blair retractor along the upper incision line (surgeon’s view from head of table).
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).
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
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.
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.
A
B

9  Asian Blepharoplasty II: The Second Vector
89
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).
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
external incision methods:
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
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
ing this approach is that the crease may be better
formed centrally and less well-formed medially and
laterally.
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.
FIGURE 9-6  ■  (A, B) A small strip of pretarsal orbicularis muscle
is trimmed along the inferior skin incision below the superior
tarsal border.
B
A
Inferior edge of pretarsal
orbicularis muscle
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.

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
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
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
continuous 7-0 suture is applied.
A
B
C
Levator aponeurosis
Subcutaneous tissue
of inferior skin edge
D

92
Asian Blepharoplasty and the Eyelid Crease
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.
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

9  Asian Blepharoplasty II: The Second Vector
93
FIGURE 9-8  ■  Application of transcutaneous skin–tarsus fixation sutures along the lower skin edge.
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.
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.

95
ASIAN BLEPHAROPLASTY III: FACTORS
THAT INFLUENCE OUTCOME
C H A P T E R 1 0
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.
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
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.
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).

96
Asian Blepharoplasty and the Eyelid Crease
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
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

10  Asian Blepharoplasty III: Factors that Influence Outcome
97
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.
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
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.)
Upper lid of elderly Asian patient
With crease
Without crease
Dermatochalasis
Dermatochalasis
+ fat
Dermatochalasis
+ ptosis
Skin excision
blepharoplasty,
preserve crease
Skin + minimal
fat removal,
preserve crease
Aponeurotic repair,
reset crease to
Asian's tarsal height
Stay with no crease
Patient wants crease
Dermatochalasis
Dermatochalasis
+ fat
Dermatochalasis
+ ptosis
Dermatochalasis
Dermatochalasis
+ fat
Dermatochalasis
+ ptosis
Asian
blepharoplasty
plus crease
formation
Asian
blepharoplasty
minimal fat
excision,
plus crease
formation
Asian
blepharoplasty
aponeurotic repair,
plus crease
formation
Asian
blepharoplasty
Asian
blepharoplasty
minimal fat
excision
Asian
blepharoplasty
+ aponeurotic
repair

99
CONCEPT OF TRIANGULAR,
TRAPEZOIDAL AND RECTANGULAR
DEBULKING – APPLICATION IN
UPPER BLEPHAROPLASTY
C H A P T E R 1 1 
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
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,

100
Asian Blepharoplasty and the Eyelid Crease
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,
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

11  Concept of Triangular, Trapezoidal and Rectangular Debulking – Application in Upper Blepharoplasty
101
Orbicularis
L
M
C
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
where < represents less than.
In triangular debulking (without skin removal):
Orbicularis
Skin
Infinity or
with
vertical measureme
÷
=
>>
(
,
)
(
n
n
1
nt of either tissue)
Therefore, in young individuals:
δ
δ
orbicularis
skin
>>1 0.
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
δ
orbicularis
skin
occasionally
=
<
1 0
1 0
. (
. )
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.
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 deb
<
<
ulking

11  Concept of Triangular, Trapezoidal and Rectangular Debulking – Application in Upper Blepharoplasty
103
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.
Orbital
septum
Step 3
Orbicularis
Level of STB
Step 4
Step
1 (U)
1 (L)
Step 2
Skin