Asian Blepharoplasty and the Eyelid Crease 3

105
OPTIMAL CLOSURE AND
MANAGEMENT OF WOUND HEALING
C H A P T E R 1 2 
It is always desirable to be able to enter and exit the eyelid
(through an existing crease) without leaving too much of
a footprint. If one can strive to enter, perform the neces­
sary task to the exact degree one had planned for, execute
the plan without significant trauma, and exit without
causing new impairment compared to before, leaving the
area accessible for re-entry if indicated in the future – that
would be ideal. In essence, the ninja way (Figure 12-1).
(The popularity of endoscopic and robotic-assisted sur­
geries is basically following this premise.) Of course,
none of us is ever as good as these fabled characters. I do
insist, however, that one should think, analyze and plan
to perform in this fashion.
There are many factors that contribute to optimal
wound healing. We commonly think of the way we apply
stitches, how we tie them, dressing the wound and remov­
ing the sutures as the major factors. While these are all,
of course, important, there are facets of specially adopted
surgical techniques that contribute just as significantly to
the overall natural healing, allowing the skin wound to
heal, appear natural and function as it has been designed
to do.
The previous chapters have touched on the design of
the crease incision, where the crease is strategically placed
so that it is in line with the biodynamics of the lid struc­
ture, the beveled (oblique) plane through which the dif­
ferent layers of the eyelid are traversed, and the closure
of the wound. It is my opinion that by distributing the
surgical plane in an oblique plane and performing the
excision of tissue in a one-piece fashion, the wound reac­
tion is lessened for these vulnerable layers. The control
of minor bleeding is performed away from the immediate
vicinity of the skin incision, the septum is opened further
away from the skin wound, fat is preserved and the trap­
ezoidal block excision allows more of the orbicularis than
the skin to be excised. The upper skin incisional edge is
then laid down in a relatively tension-free fashion prior
to closure, and upon closure yields a perfect rotational
point for the upper skin to fold over the crease as the
eyelid folds. Similarly, the trimming of a small sliver of
excessive subcutaneous tissue along the inferior skin
wound also permits tension-free closure. As much as pos­
sible, therefore, one should set a high benchmark in cre­
ating conditions ideal for wound healing, and minimizing
surgical trauma.
The various suturing techniques used in external inci­
sion methods have already been discussed. They include
attaching the skin over the tarsus, attaching the skin
towards the levator aponeurosis, or along the superior
tarsal border, and attaching the inferior orbicularis to the
distal portion of the levator aponeurosis.
All of these are basic plastic closure techniques,
but one may not have thought of carrying them this
far, to this detailed extent (indeed to an extent some
would criticize as ‘minute’). I can even state that the
way in which the surgical blade’s handle is held by
the surgeon, or the angle of the blade’s tip in relation
to the skin surface as the incision is made, are all
important.
THE CONCEPT OF A DYNAMIC VERSUS
A STATIC CREASE
A dynamic upper lid crease is one that is apparent in
straight-ahead and upgaze but which tends to fade on
downgaze, and is barely noticeable when viewed at 90°
to the skin surface. A static crease would be one that is
noticeable in all three positions: upgaze, straight-ahead
and downgaze, when the observing angle is 90°. A
dynamic crease therefore resembles a natural crease.
In order to form a dynamic crease, the terminal fibers
of the levator aponeurosis above the superior tarsal
FIGURE 12-1  ■  Sun-and-moon cartoon caricature working 24/7,
with a scalpel toe, holding surgical scissors.

106
Asian Blepharoplasty and the Eyelid Crease
subcutaneous plane buried sutures, or through
external skin to levator aponeurosis buried sutures.
3. The fullness of the preseptal area (upper zone)
should be preserved by conserving and reposition­
ing most of its preaponeurotic fat superiorly into its
sulcus or the upper quadrant of the orbit. There
should be no excessive skin removal to avoid fore­
shortening of the anterior lamella of this upper zone.
These three focal points serve to create an opportunity
for the firm pretarsal platform and tarsus (the tarsal–
crease unit) to vector upwards and slide under the presep­
tal soft tissue zone above it, without much effort or
encountering any tissue resistance over the crease. The
preseptal zone bellows freely over the pretarsal zone,
with a crease formed in between.
Conceptually, the crease is thought to form above the
highest point of insertion of the distal terminations of the
levator aponeurosis through the orbicularis oculi’s inter­
muscular septa, as well as skin along the crease line. That
is not to say that there is absolutely zero presence of
terminal fibers of the levator aponeurosis above the
dominant crease. My trapezoidal debulking approach
(Chapter 11) allows a skin–aponeurosis–skin closure,
with a 1–2 mm zone where the transected orbicularis
(along the upper beveled skin–muscle wound plane) may
become adherent to the aponeurosis just above the supe­
rior tarsal border, thereby reforming the ‘limiting bound­
ary’ previously described as the posterior reflection of the
orbital septum on to the levator aponeurosis sheath, and
acting as an inferior limit to the repositioned preaponeu­
rotic fat. The surgically created crease simply forms
directly above this zone. Therefore, although the lid
crease wound is formed along the superior tarsal border,
by taking skin to aponeurosis to skin, the upper lid crease
thus formed may lie just above this junction. Another way
to conceptualize this is that the aponeurosis is attached
to both upper and lower wound skin edges, with the
crease thus created lying above it.
Several factors in the upper/preseptal zone can lead
to poor infolding of the crease. If fat excision in the
preaponeurotic space was excessive, there is now direct
physical contact between the aponeurosis and the orbicu­
laris, as the septum has been opened. There is then an
attenuation of the preaponeurotic space, which can pre­
dispose to cicatrix formation and an increase in rigidity
of this zone. If there was inadvertent tissue handling,
injury, or above-normal hemorrhaging, there can be
increased scarring and consequent rigidity. If there was
excessive skin excision in this upper zone, there is a
greater probability that the pretarsal–eyelid crease unit
will be unable to form a crease by vectoring upward
under these scarred and therefore tighter preseptal tissues
(of skin, orbicularis, septum and possibly attenuated
fibrosed fat tissues). These seemingly benign factors can
combine to substantially hinder crease formation.
In Caucasians born with a natural crease, the relatively
higher point of fusion of the orbital septum on to the
levator aponeurosis limits the preaponeurotic fat to above
this fusion point. The crease may have formed from distal
terminations of the aponeurosis in towards the inferior
orbicularis muscle septa, actual subcutaneous attachment
border must be directed to the subdermal plane of the
lower skin incision line. As one is obliged to close the
upper skin edge to the lower skin edge, I believe that it
is academic to argue on the merits of creating adhesions
solely from the terminal aponeurotic fibers to the lower
skin edge, or to both the upper and lower skin edges. It
is essential to loosen and reposition any adhesive surgical
drape that may be used, to allow the upper lid skin to fall
along the lower pretarsal skin without tension. The
patient is instructed to look up and down to check the
adequacy of crease formation and contour before any
stitching is begun.
Suturing skin–tarsus–skin tends to yield a static-
looking crease. In my technique I use 6-0 silk or nylon
interrupted sutures to connect the lower skin edge to the
levator aponeurosis along the superior tarsal border, and
then to the upper skin edge. Besides the stitch over the
center of the crease, I apply three sutures medially and
two to three laterally. With these six or seven crease-
forming sutures in place, the rest of the incision may be
closed using 6-0 or 7-0 nylon in a continuous or subcu­
ticular fashion. This continuous suture involves only the
dermis, without the need to pick up any orbicularis
muscle fibers. The objective here would be to avoid hem­
orrhage from the orbicularis muscle and to provide an
optimal plane of closure of the skin incision site. In this
method all the sutures are removed.
The method of anchoring inferior subcutaneous tissue
alone, or orbicularis to the levator aponeurosis, frequently
involves placing buried, non-absorbable sutures. I have
come across patients who complain of the static nature
of the crease resulting from the use of buried sutures, and
some complain of a kinesthetic awareness and often irri­
tation from these buried elements in their eyelids.
CREASE FORMATION AND
CREASE DYNAMICS
Dynamic Interaction of the Pretarsal
Platform and the Preaponeurotic Zone
One can divide the upper eyelid into three zones: the
eyelid crease (which acts as the junctional zone or the
rotating nano-balls, see Chapter 23), the pretarsal zone
below it and the preseptal zone above it (Figure 12-2).
The objective of the surgeon in forming or enhancing an
upper eyelid crease should be:
1. To facilitate the inward folding of the crease
(through the nano-balls) by reducing the soft tissue
overlay through limited debulking of redundant
preaponeurotic soft tissue, which may be hindering
the infolding, or by tightening this pivoting zone
through suture ligation (which is less effective by
comparison, and more prone to regression). By
providing a clear demarcation zone, one achieves a
good pivot or nano-ball junction.
2. The pretarsal area (lower zone) can be made
firmer through (a) excision of some orbicularis
oculi muscle along the inferior incisional skin edge,
or (b) suture ligation, through conjunctiva to

12  Optimal Closure and Management of Wound Healing
107
FIGURE 12-2  ■  The upper eyelid and crease can be thought of conceptually as consisting of three zones: the eyelid crease (which
acts as the junctional zone or the telescoping pivot), the pretarsal zone below it and the preseptal zone above it.
Pretarsal zone
Preseptal zone
Eyelid crease
Periorbital zone

108
Asian Blepharoplasty and the Eyelid Crease
more from the ligature working and cutting through the
tissue layers which it was meant to tie together.)
The application of the crease-forming sutures depends
on accurate placement along the superior tarsal border’s
levator aponeurotic fibers. The appropriate number of
these interrupted sutures is applied to form a uniform
continuous crease invagination. Upon tying of these
sutures, we should avoid excess tension or strangulation
effect on the tissues. The running stitch after this merely
approximates the skin edges together.
The choice of suture material depends on the prefer­
ence of the surgeon, balancing potential wound reaction,
discomfort or comfort for the patient, and desired healing
that enhances the crease construction. It determines the
number of days for which the sutures are left in place
before removal, again balancing success rate for crease
formation versus skin reaction.
Postoperative wound cleaning and dressing is standard.
This involves the use of antibiotic and anti-inflammatory
(steroid) combination ophthalmic ointment.
In patients with oily skin one may elect to add the
prophylactic use of oral antibiotics, and anti-comedogenic
skin preparations. There are also a wide range of dietary
recommendations that can be given for Asian patients
according to their ethnic food cultures, based on the
traditional Chinese medical belief system.
Other factors that may affect healing first and fore­
most will include the patient’s own tissues (genotype and
phenotype), exposure to external environment (sun expo­
sure, local hygiene), past history of sun damage or wound
stress, dermatological conditions like eczema and psoria­
sis, and how recently any surgery was performed in the
deeper and superficial layers of the eyelid.
SURGICAL FINESSE, NUANCES
AND PEARLS
In the earlier Japanese literature the pressure to which
surgical knots are applied on to the skin surface was used
to enhance the formation of a crease. Excessive pressure
can lead to compression ischemia and poor wound
healing. Buried sutures often may show through the skin
surface, and absorbable buried sutures may generate
granulomatous suture reaction as the sutures dissolve.
A properly healed wound in a dynamic crease needs
to be aesthetically pleasing, permanently effective, not
noticeable in downgaze, without wound spreading or dis­
coloration, and not bumpy.
Suture Type.  In my Asian blepharoplasty I use two
types of suture:
1. Crease enhancement sutures – usually 6-0 caliber
braided silk (black), used as five to six interrupted
sutures, to unite skin–levator aponeurosis–skin
along the wound located at the superior tarsal
border. The newly formed crease should invaginate
easily with these in place. They are removed after
one week.
2. A continuous running 7-0 silk suture to close the
skin edges. This is removed at one week also.
or ‘extensions’ from the levator, and inferior limitation of
fat through a postero-upward reflection of the posterior
layer of the orbital septum on to the levator aponeurosis
(this latter scenario may simply yield a prominent supra­
tarsal sulcus in Occidentals who have never had eyelid
surgery). This, combined with a softer and thin-skinned
preseptal zone, allows the firm tarsal complex to easily
vector upward against it to form a crease.
In Asians with a single eyelid, this attempt to form a
crease is more difficult for a variety of reasons: the pre­
tarsal soft tissue (skin and boggy orbicularis) is often
softer and more redundant; the septum fuses on to the
levator aponeurosis and tarsus at a lower point; preaponeu­
rotic fat is present at a lower level; the preseptal zone may
have significant fullness and is often positioned more
forward in the orbit (Asians have comparatively less deep-
set eyes, owing to a less prominent forward extension of
the superior orbital rim). These factors are more likely
to yield a single lid without a crease.
Following an Asian eyelid crease enhancement proce­
dure, with preservation of fat in the preaponeurotic
middle space, coupled with reduction of the pretarsal
inferior edge soft tissue, as well as clearance along the
superior tarsal border and controlled debulking of the
preaponeurotic platform, it will be easier for the crease to
indent up. The levator’s dynamic pull (up-vector) is most
effective when the muscle can glide up against a cushion
of non-adherent preaponeurotic fat (middle space) as well
as overlying anterior skin–orbicularis. In essence, the
tarsal plate and skin are allowed to invaginate against a
multilayered soft tissue complex (preaponeurotic fat,
septum, orbicularis, subcutaneous fat and skin). It will be
more difficult if the preaponeurotic space is obliterated
through ablation of its fat; cicatrization forms between the
anterior layer of skin–orbicularis–orbital septum and the
posterior layer of levator–Müller’s muscle–conjunctiva
through tissue damage or excessive hemorrhage and
subsequent hemosiderin deposition. The resultant rigid
multilayered tissue complex presents a far greater mass of
tissue, as well as a challenge for the tarsal plate to indent
against to form a crease. We may see this clinically as a
firm band of skin/muscle/anterior lamella in the preseptal
region, accompanied by a static-looking crease.
On occasion, postoperative swelling can mask an
otherwise well-formed crease; and when the swelling
resolves, the tarsal plate vectors up well against the presep­
tal soft tissue and a crease then appears appropriately.
The suture ligation methods create a crease by tight­
ening the soft tissue overlying the superior tarsal border,
creating a firmer constriction between the subcutaneous
skin and the levator aponeurosis (through either an ante­
rior skin or a posterior conjunctival approach). It allows
an increased force-gradient where the tarsal plate uplifts
in and under the preseptal soft tissues. With no removal
of redundant soft tissue, it is effective in the short term
(perhaps up to 5 years). However, with aging and a
gradual increase in soft tissue redundancy, the crease thus
created may become shielded from view or shallow out
with time (fading) owing to the unavoidable shredding
forces of the buried sutures used in these methods. (The
ligatures’ effect may diminish in time, not from the dis­
solution, loosening, or breaking apart of the sutures, but

12  Optimal Closure and Management of Wound Healing
109
by 2 months. The crease migrates closer to the ciliary
margin when pretarsal tissue edema subsides as a result
of lymphatic and vascular rechanneling. Patients are told
that even if all goes well their surgically placed crease will
take 3–6 months to stabilize.
Should there be a need for revision touch-up, for
example if the crease does not form distinctively, the
author performs this no earlier than at 6 months, as the
crease continues to mature. The author does not advo­
cate secondary revision in patients seeking consultation
after having had previous procedure(s) elsewhere unless
a 12-month period has elapsed.
The patient is given a short list of instructions to
follow postoperatively.
Postoperative Regimen for Asian
Blepharoplasty Patients
• Bed rest for 24 hours.
• Ice compresses for 1 day.
• No reading, watching television or computer use.
No computer-gaming.
• Wound and facial hygiene: clean face and incision
wounds three to four times daily with clean water.
• Avoid the use of cosmetics over the incision wound
and sutures.
• Apply antibiotic ointment four times daily for 7
days.
• Patient may shower that day.
• Avoid hot-spa or swimming.
• Avoid strenuous activities or workout for at least 1
week.
• Avoid aspirin compounds or anything containing
ibuprofen.
• Avoid spicy food, chocolate, dairy products and
fried foods for 2 months.
Crease-Enhancing Eye Exercises for
Patients without a Pre-Existing Crease
For some individuals, practice excursions of the upper
lids are recommended, from downgaze to upgaze, without
involving the brow and forehead muscles and without
allowing the head to be tilted backwards in any way, start­
ing on the third day after the operation and continuing
for 2 weeks. These exercises help initiate formation of
the lid crease in selected patients. The levator movement
should be deliberately slow in order to allow good crease
infolding without pulling on any fine blood vessels and
causing postoperative hematoma.
The last point bears further explanation. Some patients
may have such low pain tolerance that they dare not look
up or even straight ahead, as the skin sutures may cause
some local irritation. They may stay in a head-tilted-back
position all week without activating any levator move­
ment or upgaze. The crease may not form well if there
have been no attempts at upgaze during the first 10 days.
This form of eye movement is best performed slowly,
hence the term ‘Eye-Chi’, coined by the author (as in the
No buried or absorbable stitches are ever used. The soft
texture of the silk suture material ensures that the stitch
is not too stiff (as in nylon or Prolene), which can be
irritative. It is less reactive than sutures like chromic
catgut, Vicryl or Dexon.
Manipulation
of
Suture
Knot
and
Running
Suture.  The knots can be placed directly over the junc­
tion of the two skin edges, or skewed to favor one side
or the opposite side. The length of running suture can
be used to secure the knot placement by looping it below
the interrupted suture knot or above it.
Technique in Medial Eyelid Fold.  The medial fold
often needs to be reduced through excision of overlap­
ping skin. During closure, again the suture knots can be
manipulated to favor greater compressive force across the
wound itself, such as to result in a more likely tapering
crease or parallel crease configuration.
In developing a parallel crease, although the incision
was designed, carried out and intended to be parallel as
it courses towards the medial canthus, when a prominent
medial fold is present, the fold should be reduced. If not,
it will hinder the desired crease shape (turning it more
towards a nasally-tapered crease).
Treatment of Lateral Wound Edges.  Often the skin is
thicker here; the underlying orbicularis oculi fibers are
abundant and strong. This may result in wound spread.
Careful assessment should be used on each individual,
and the closure here may require more sophisticated
suturing using non-reactive stitch like nylon, and leaving
the sutures in a longer period to gain better wound
coaptation.
Cautions.  The wound edges should not be closed under
tension, which is more likely if the upper or lower part
of the eyelid crease incision is wrapped tight by the surgi­
cal draping. If the wounds are stitched under tension side
effects include high crease, lagopthalomos, and ectropion
of the tarsal plate or of the upper lid margin.
Repeated measurement and confirmation of crease
height at different steps during the procedure helps mini­
mize asymmetry.
POSTOPERATIVE CARE
During the immediate postoperative period the wound
is cleaned daily and covered with antibiotic ointment.
Compressive or occlusive eye dressings are to be
avoided. Diuretics and steroids are not usually prescribed.
Depending on the material used, the sutures are removed
7 days after the operation. It is my practice to leave in
interrupted sutures (skin–levator aponeurosis–skin) for a
slightly longer period if the crease appears slow in
forming, as this seems to help ensure proper attachment
of the levator aponeurosis to the incision line along the
superior tarsal border.
About 80% of the postoperative swelling should have
disappeared a week after the sutures are removed, or at
2 weeks postoperatively. The remaining 20% will regress

110
Asian Blepharoplasty and the Eyelid Crease
attempts at medial canthoplasty, intercanthal fixation and
VY-plasty have been observed.
Patients may still present with a variety of concerns or
complaints, which may include:
1. Unevenness of the crease, even within the first
hours, day or week. This is often caused by different
degrees of swelling between the two lids. It may be
in the pretarsal area, which will broaden a crease
(through increase in crease height), or in the presep­
tal and periorbital region, which may depress and
diminish the apparent height of a crease. Often post­
operatively the height of the crease may be influ­
enced by the position of the side of the face during
sleep: the dependent side will tend to have corre­
spondingly more edema and therefore the crease
may appear higher, owing to pretarsal fullness.
2. A crease may not appear to be adequately folded in
after sutures are removed at 1 week postoperatively.
The explanation could be residual swelling, or
newly formed swelling can temporarily shallow out
a crease.
3. A crease may still appear to be hooded or shielded
even after surgery: this is likely to be due to presep­
tal tissue swelling overhanging the crease or asym­
metric brow positions.
4. Bleeding and hematoma beyond the first 2 days.
This happens infrequently, but usually arises
from excessive physical activities several days after
surgery.
5. Infection, cellulitis, erysipelas, accompanied by
redness, itching and tenderness to touch.
6. Itching, usually due to allergic dermatitis or a reac­
tion to topical antibiotic ointment.
7. Crease not folding in well over the medial one-
third of the lid margin: the skin–levator attachment
may be suboptimal, the levator muscle may not be
well formed medially, or the swelling may have
temporarily obliterated the infolding of the crease.
The crease may still appear after 2–3 months.
slow graceful excursions of Tai-Chi). It is important to
initiate upgaze and thereby contract the levator muscle
to assist in forming a proper crease. Slow daily movement
of the eyelids helps reduce the swelling over the pretarsal
and preseptal regions. It also helps ingrain muscle
memory, as a number of patients who lack a crease also
have a relative inability for full upgaze, and a still smaller
percentage may have a concomitant ptosis, although this
is usually mild and often subclinical, their levator func­
tion often being less than 10 mm. Such muscle memory
training may be entirely new for these patients. It helps
them become aware that they often have an overaction
of their forehead and eyebrows to start with.
The surgeon should expect panic calls from patients
and should provide reassurance. I often see my patients
more frequently than is medically necessary to help allay
their concerns.
The importance of meticulous attention to the contour
and placement of the crease cannot be overemphasized.
These factors are dictated by the design of the incision
line and the placement of the interrupted sutures on the
levator aponeurosis. One must diligently avoid the con­
struction of an excessively high crease, or one that is too
deep or too harsh. One should avoid the removal of an
excessive amount of preaponeurotic fat. When the sutures
are removed, whether all at once or in two separate stages
several days apart, it is not unusual to see tissue indura­
tion over the incision wound and the suture tracts (Figure
12-3). In some cases, because the sutures that anchor the
lid crease are under tension, the dermal reaction may be
more intense than one would normally expect. When I
encounter this type of reaction I prescribe a short course
of topical fluometholone (FML) ophthalmic ointment to
be applied over the wound. These indurations tend to
regress within several weeks; reactions such as hyper­
trophic scarring may linger longer. According to the lit­
erature, keloids are seldom seen over the upper eyelids.
I have found this to be true, having seen no true keloid
formation over the crease. The same is not true of keloid
formation over the thicker skin of the medial canthal
region, however, where very prominent scars from
FIGURE 12-3  ■  Natural wound induration visible 1 week postoperatively.

12  Optimal Closure and Management of Wound Healing
111
FIGURE 12-4 
A
B
8. Late complaints:
•  Induration over the medial one-third of the inci­
sion wound (the dermis is thicker there)
• Suture tract cyst formation
• Blackhead (comedo) formation from early use of
cosmetics during the postoperative period
• Wound dehiscence (rare)
• Persistent fullness over the pretarsal area (rare if
the Asian blepharoplasty techniques described in
this text are followed)
• Chemosis of conjunctiva (rare).
In general, the postoperative care of Asian patients
who undergo cosmetic upper lid operations requires
patience and understanding on the part of both patient
and surgeon. Patients should understand the normal
healing course for Asian eyelid skin, so that they have a
proper time frame in which to observe the progression
of wound healing. Surgeons should be sympathetic to the
patient’s psychological needs and their anxiety, should
provide ample reassurance and should render sound
medical care in the extended postoperative period.
Figures 12-4 to 12-15 are preoperative and postopera­
tive paired photos illustrating cases of typical Asian
blepharoplasty surgery with expected outcomes.
FIGURE 12-5 
A
B

112
Asian Blepharoplasty and the Eyelid Crease
FIGURE 12-6 
A
B

12  Optimal Closure and Management of Wound Healing
113
A
B
C
FIGURE 12-7

114
Asian Blepharoplasty and the Eyelid Crease
A
B
FIGURE 12-8 
FIGURE 12-9 
A
B

12  Optimal Closure and Management of Wound Healing
115
FIGURE 12-10 
A
B
FIGURE 12-11 
A
B

116
Asian Blepharoplasty and the Eyelid Crease
FIGURE 12-12  ■  Before and after view at one week postoperative visit.
A
B
FIGURE 12-13 
A
B

12  Optimal Closure and Management of Wound Healing
117
FIGURE 12-14 
A
B

118
Asian Blepharoplasty and the Eyelid Crease
FIGURE 12-15 
A
B
C

119
PRIMARY ASIAN BLEPHAROPLASTY
RESULTS (BEFORE AND AFTER)
C H A P T E R 1 3
The images presented in this chapter are intended to
show a variety of cases solely for educational purposes.
Individual outcomes are unique and no degree of
certainty can be implied nor result guaranteed from the
images shown here.
CASE 1 (Figure 13-1 A–C) 
(A, B) Young adult with average eyelid fissure opening and absent crease.
A
B
Continued

CASE 2 (Figure 13-2 A, B)
(A) Young adult with multiple wrinkles and without any crease. (B) With slightly high-average crease height, nasally tapered
shape.
A
B
120
Asian Blepharoplasty and the Eyelid Crease
CASE 1 (Figure 13-1 A–C)—cont’d
C
(C) After placement of a medium (classic) parallel crease.

13  Primary Asian Blepharoplasty Results (Before and After)
121
CASE 3 (Figure 13-3 A, B)
(A) Middle-aged woman with absent crease and some skin hooding. (B) Postoperative appearance: lower than average crease
height, parallel shape crease.
A
B
CASE 4 (Figure 13-4 A, B)
(A) Middle-aged woman with single lid, and triangular eyelid opening from lateral hooding. (B) After Asian blepharoplasty,
with medium crease height, nasally tapered crease shape. Triangular fissure shape has been eliminated.
A
B

122
Asian Blepharoplasty and the Eyelid Crease
CASE 5 (Figure 13-5 A, B)
(A) Young adult with absent crease. (B) Postoperative appearance: slightly higher than average crease height, parallel shape.
Note that the medial upper fold remains despite the fact that the caruncles can be plainly seen.
A
B
CASE 6 (Figure 13-6 A, B)
(A) Young adult with inconsistent crease and asymmetry; parallel right eyelid crease, nasally tapered shape over left eye.
(B) Patient chose higher than average crease height and parallel shape.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
123
CASE 7 (Figure 13-7 A–C)
(A) Young man with absent crease, slightly triangular fissure on right eye, with a shielded look bilaterally. (B, C) Formation of
a natural nasally tapered crease; the medial canthal fold is preserved.
A
B
C

124
Asian Blepharoplasty and the Eyelid Crease
CASE 8 (Figure 13-8 A, B)
(A) Young man with absent crease on left eyelid. (B) Postoperative appearance: creation of a matching crease for the left
upper lid.
A
B
CASE 9 (Figure 13-9 A, B)
(A) Young man with absent crease and narrow palpebral fissure. (B) Postoperative appearance: creation of a parallel crease.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
125
CASE 10 (Figure 13-10 A, B)
(A) Young man with absent crease and slightly rectangular look. The eyelid is not droopy (eye muscle healthy, no ptosis).
(B) Postoperative appearance: creation of a low parallel crease; at one month postoperative, with some healing to go.
A
B

126
Asian Blepharoplasty and the Eyelid Crease
CASE 11 (Figure 13-11 A, B)
25 y.o. female for primary Asian blepharoplasty with asymmetry in eyelid opening sizes. Pre- and postoperative appearance.
A
B
CASE 12 (Figure 13-12 A, B)
41 y.o. male. Pre- and postoperative appearance.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
127
CASE 13 (Figure 13-13 A, B)
37 y.o. male. Pre- and postoperative appearance.
A
B
CASE 14 (Figure 13-14 A, B)
19 y.o. male. Pre- and postoperative appearance: lowering of right crease and addition of crease to LUL.
A
B

128
Asian Blepharoplasty and the Eyelid Crease
CASE 15 (Figure 13-15 A, B)
27 y.o. female. Desires parallel crease. (A) Preoperative and (B) postoperative 10 days after.
A
B
CASE 16 (Figure 13-16 A, B)
27 y.o. female. Desires parallel-shaped crease. Levator excursion of 13 mm right eye and 14 mm left eye was unchanged after
the procedure. Pre- and postoperative appearance.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
129
CASE 17 (Figure 13-17 A, B)
28 y.o. female Caucasian with Asian features and heavy lids. Pre- and postoperative appearance.
A
B
CASE 18 (Figure 13-18 A, B)
46 y.o. female. Pre- and postoperative appearance at one week only.
A
B

130
Asian Blepharoplasty and the Eyelid Crease
CASE 19 (Figure 13-19 A–D)
24 y.o. female with right eyelid multiple wrinkles; the left side has shielding of a low-set nasally tapered crease. (A, B) Preop-
erative appearance. (C, D) The same patient after the procedure: both sides have a distinct nasally tapered crease.
A
B
C
D

13  Primary Asian Blepharoplasty Results (Before and After)
131
CASE 20 (Figure 13-20 A, B)
30 y.o. female. (A) Preoperative appearance and (B) postoperatively after one week, with some residual blood layering over
corners of the lower eyelids, which always resolves.
A
B
CASE 21 (Figure 13-21 A, B)
12 y.o. female with abnormally spongy tissues of RUL and absent crease. Surgical correction was performed for medical indi-
cations. Pre- and postoperative photo at one month show some residual fullness of that lid.
A
B

132
Asian Blepharoplasty and the Eyelid Crease
CASE 22 (Figure 13-22 A, B)
35 y.o. female with wrinkled crease and crease asymmetry. Pre- and postoperative appearance.
A
B
CASE 23 (Figure 13-23 A, B)
54 y.o. female. Pre- and postoperative appearance.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
133
CASE 24 (Figure 13-24 A, B)
27 y.o. male with crease asymmetry. Pre- and postoperative appearance.
A
B
CASE 25 (Figure 13-25 A, B)
25 y.o. male with absent crease and ptosis of RUL. Pre- and postoperative appearance following Asian blepharoplasty with
ptosis repair, 2 months view.
A
B

134
Asian Blepharoplasty and the Eyelid Crease
CASE 26 (Figure 13-26 A, B)
33 y.o. female with high crease and asymmetry. She preferred a lower NTC. It was not necessary to perform any ptosis repair.
A
B
CASE 27 (Figure 13-27 A, B)
25 y.o. female. Pre- and postoperative appearance.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
135
CASE 28 (Figure 13-28 A, B)
47 y.o. female. Desires parallel crease. Pre- and postoperative at 2 months.
A
B
CASE 29 (Figure 13-29 A–D)
34 y.o. female. Preoperative (A) and postoperative (B, C, D) appearance.
A
C
B
D

136
Asian Blepharoplasty and the Eyelid Crease
CASE 30 (Figure 13-30 A, B)
28 y.o. female. Pre- and postoperative appearance after lid crease enhancement, changing from a nasally tapered to a parallel
crease.
A
B
CASE 31 (Figure 13-31 A, B)
63 y.o. female. Pre- and postoperative appearance, with excellent functional and aesthetic improvement.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
137
CASE 32 (Figure 13-32 A, B)
62 y.o. female. Pre- and postoperative appearance, with good functional and cosmetic improvement.
A
B

138
Asian Blepharoplasty and the Eyelid Crease
CASE 33 (Figure 13-33 A–C)
37 y.o. female. Preoperative (A) and 1 month (B) and 4 months (C) postoperative view.
A
B
C

13  Primary Asian Blepharoplasty Results (Before and After)
139
CASE 34 (Figure 13-34 A, B)
38 y.o. male. Pre- and postoperative appearance.
A
B

140
Asian Blepharoplasty and the Eyelid Crease
CASE 35 (Figure 13-35A–C)
18 y.o. female. Preoperative (A) and 2 months (B) and 3 years (21 y.o.) (C) postoperative view.
A
B
C

13  Primary Asian Blepharoplasty Results (Before and After)
141
CASE 36 (Figure 13-36 A, B)
75 y.o. female. Pre- and postoperative appearance after upper and lower blepharoplasty.
A
B
CASE 37 (Figure 13-37 A, B)
39 y.o. female with triangular-shaped eyelid fissure. Pre- and postoperative view taken at one week.
A
B

142
Asian Blepharoplasty and the Eyelid Crease
CASE 38 (Figure 13-38 A, B)
41 y.o. female. Pre- and postoperative appearance after bilateral ptosis repair with preservation of crease.
A
B
CASE 39 (Figure 13-39 A, B)
32 y.o. female. Pre- and postoperative at 1 month. There were no findings suggestive of ptosis.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
143
CASE 40 (Figure 13-40 A, B)
22 y.o. male. Pre- and postoperative appearance following creation of NTC.
A
B

144
Asian Blepharoplasty and the Eyelid Crease
CASE 41 (Figure 13-41 A, B)
23 y.o. female, absent crease, smaller fissure OD, 5′0″, prefers parallel crease. Had mild medial canthal fold (A).
I/O: tarsus floppy and measured 6 mm only. Designed 6 mm parallel crease.
RUL had large sheet of amorphous preaponeurotic fat, down to below the superior tarsal border. This was dissected off the
underlying shiny healthy aponeurosis, and excised. Excised larger than usual amount of myocutaneous strip, which appeared
boggy from fatty infiltration of the orbicularis muscle.
Treatment of Medial Canthal Fold
Small redundant ‘dog-ear’ over the medial end of the crease wound is based along the lower border. It was overlapped onto
the upper skin edge and excised appropriately. The two edges are then anchored with 6-0 silk. The bite along the upper skin
edge is exaggerated in terms of the amount of skin taken as well as the depth of the orbicularis that is secured. The knot is
pulled and tied onto the upper side of the wound. It will then heal imperceptibly, as the edges are perfectly aligned and without
tension.
LUL: also excised larger strip of mycocutaneous tissues. Medial dog-ear similarly treated.
(B) One week postoperative appearance.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
145
CASE 42 (Figure 13-42 A, B)
22 y.o. female, intermittent creasing over RUL, LUL never creases and has smaller fissure. Prefers parallel crease with lateral
flare. Levator function OD 9 mm, OS 12–13 mm. 5′3″ (A).
I/O: tarsus 8 mm. Designed minimally tapering parallel crease, plus 2 mm redundancy. Excised moderate amount of
preaponeurotic fat that migrated over the STB, although it was not apparent clinically on preoperative examination. Excised
M/C strip.
(B) One week postoperative appearance.
A
B
CASE 43 (Figure 13-43)
34 y.o. female with mild lid retraction. Upper lid margin at superior corneal limbus. Had rudimentary multiple partial lines OU.
Wanted NTC. 5′3″.
I/O: tarsus 9 mm. Used 7 mm and designed NTC, + 2 mm skin. RUL has 3+ fat over lateral 23 of lid, LUL 2+ fat lateral 23 of
lid. The inferior orbicularis was very vascular over the lateral end of the incision.

146
Asian Blepharoplasty and the Eyelid Crease
CASE 44 (Figure 13-44 A, B)
27 y.o. female, high brows, moderate fat OU, large eyes with OS being larger. 5′7″. Desires NTC.
I/O: designed 6.5 mm NTC OU. Found amorphous fat and preaponeurotic fat close to STB; they were reduced. Also excised
a strip of fibroadipose tissue along the anterior aspect of the STB. Formed crease with 6-0 and 7-0 silk.
A
B
CASE 45 (Figure 13-45 A, B)
28 y.o. female, absent crease, desires low-set NTC. 5′3″. Had severe brow overaction with some head-tilt backward position
(A).
I/O: tarsus 8 mm. Designed 7.5 mm + 2 mm skin redundancy. Had prominent preaponeurotic fat requiring excision OU. Had
abundant soft, mosaic tissue redundancy along the STB which was excised.
(B) One week postoperative appearance.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
147
CASE 46 (Figure 13-46 A, B)
23 y.o. female, wears lid crease tape constantly for her RUL, and occasionally for LUL. Has hooded shielded skin over lateral
RUL, and incomplete non-joining crease lines over lateral pretarsal area of LUL. Prefers NTC (A).
I/O: tarsus 7.5 mm. Designed 7 mm NTC.
RUL: reduced significant preaponeurotic fat; excised a band of fibroadipose tissue along the STB.
LUL: rechecked drawn crease to ensure it is 7 mm. Same procedure as RUL.
(B) One week postoperative appearance.
A
B
CASE 47 (Figure 13-47 A, B)
28 y.o. female, uses lid crease tape and make-up to help crease formation. Pretarsal skin is pink from taping. Desires parallel
crease (A).
I/O: tarsus 8.5 mm. Designed 7.5 mm parallel crease. Preaponeurotic fat appeared fibrotic and inferiorly located. Reduced
with Wetfield bipolar cautery. Mycocutaneous strip, which was very vascular, was excised. The crease may look broader on
one side than the other during the immediate healing period due to hematoma.
(B) One week postoperative appearance.
A
B

148
Asian Blepharoplasty and the Eyelid Crease
CASE 48 (Figure 13-48 A, B)
25 y.o. male, absent crease. Triangular hooding. Prefers NTC with average crease height. 5′10″ (A).
I/O: tarsus 7.5 mm. Designed 7 mm NTC. There was no preaponeurotic fat. Cleared preaponeurotic platform. Formed crease.
(B) One week postoperative appearance.
A
B
CASE 49 (Figure 13-49 A, B)
35 y.o. female, upper lid hooding with shielded NTC. Desired a more prominent crease. 5′5″.
I/O: tarsus 7.5 mm. Designed same 7.5 mm NTC + 2 mm skin. (Beware of tendency of right-handed surgeon or right-eye
dominant individual to mark the LUL crease’s lateral extent shorter than it should be. Always compare both sides.)
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
149
CASE 50 (Figure 13-50 A, B)
18 y.o. female, absent crease with mild ptosis, more over the left side. Desires standard height NTC. 5′3″.
I/O: tarsus 8 mm. Designed 7.5 mm NTC. Removed fraction of fat. Had to lyse some adhesion between the inferior skin
edge and orbicularis to the aponeurosis along the STB, in order to better place the 6-0 silk.
LUL: medial canthal dog-ear treated with direct excision of inferior dog-ear and supraplacement of suture knot.
B
A
CASE 51 (Figure 13-51)
21 y.o. female, absent crease, with medial canthal fold. Prefers parallel crease with average height.
I/O: tarsus 7 mm. Designed 7 mm parallel crease. Large amount of inferiorly migrated preaponeurotic fat was reduced with
bipolar cautery. Large roll of subcutaneous intraorbicularis fat along the STB was excised. Used multiple 6-0 interrupted sutures
to enhance crease construction.

150
Asian Blepharoplasty and the Eyelid Crease
CASE 52 (Figure 13-52 A, B)
26 y.o. female, RUL has no crease, LUL has a shallow low pseudo-crease line at 3 mm from lashes. 5′4″. Desires NTC (A).
I/O: tarsus 7 mm. Designed 7 mm NTC + 2 mm skin. Partial excision of preaponeurotic fat OU.
(B) RUL formed crease well.
LUL medial half required additional reinforcement with 6-0 interrupted sutures.
A
B

13  Primary Asian Blepharoplasty Results (Before and After)
151
CASE 53 (Figure 13-53 A, B)
19 y.o. female, uses glue over pretarsal skin for crease formation. Heavily hooded lid with fat. 5′5″. Prefers NTC (A).
I/O: tarsus 7.5 mm. Designed 7 mm NTC OU + 2 mm skin. Used beveled approach to orbital septum.
RUL had abundant fat which required partial excision. Formed crease at 7 mm.
LUL: also excised part of fat. The crease thus formed appeared shifted down to 6.5 mm. This could be due to different
amount of fat excision between the two sides, and the subsequent change in skin tension as fat has been reduced.
(B) One week postoperative appearance.
A
B
CASE 54 (Figure 13-54)
30 y.o. female, absent crease OU. Prefers NTC with standard height. 5′7″.
I/O: tarsus 8 mm. Used 7 mm to draw NTC + 3 mm skin. No fat was removed. The orbital septum was observed to be fused
to the levator aponeurosis in a very ill-defined manner. Had to delineate the STB by using the cutting cautery to create a ‘mini-
trough’ over and along the STB, then attached multiple 6-0 fixation sutures. Worked well.

152
Asian Blepharoplasty and the Eyelid Crease
CASE 55 (Figure 13-55 A–C)
24 y.o. female, 5′2″. Previous Asian crease procedure by this author. (A) Preoperative appearance.
LUL has a residual skin fold above the original crease incision, which gives the appearance of two crease lines.
(B) Appearance following first procedure.
Revision I/O: tarsus 7 mm. Designed 7 mm NTC and included 1.5 mm skin-scar. Beveled approach along the upper edge
toward the preaponeurotic space. Found preaponeurotic fat, which appeared almost untouched, though I knew I had partially
excised it before. Excised M/C strip and some redundant fibroadipose tissue along the STB. Formed crease. (C) Postoperative
appearance following revision enhancement of left upper lid.
A
B
C

13  Primary Asian Blepharoplasty Results (Before and After)
153
CASE 56 (Figure 13-56 A–C)
35 y.o. male, heavy eyelid with fat bulge. Hooding appears to cover 4 mm of cornea, but lid margin is actually 2 mm on to
cornea. 5′5″. Prefers NTC (A).
I/O: tarsus 9.0 mm. During the first procedure I used 7 mm to design NTC. Thick skin with amorphous orbicularis, orbital
septum and very little preaponeurotic fat. Formed crease with 6-0 silk and 7-0 silk.
(B) RUL crease obliterated at 6 months and required enhancement.
I/O (revision): boggy lid tissue with amorphous infiltrated fat over the preaponeurotic space as well as within levator itself.
These were left untouched. Excised M/C strip that included scarred tissues; created mini-trough along the STB. Formed crease
with 6-0 and 7-0 sutures. (C) One week postoperative appearance.
A
B
C