Asian Blepharoplasty and the Eyelid Crease 3

13  Primary Asian Blepharoplasty Results (Before and After)
155
CASE 58 (Figure 13-58 A, B)
34 y.o. female, Chinese/Hawaiian, 5′4″. RUL has hooded NTC. LUL has sulcus above multiple rudimentary creases. Very tanned
skin (A).
I/O: tarsus 6.5–7 mm.
RUL included 2 mm skin, LUL + 3 mm skin. Has very thin skin, very vascular orbicularis. Both sides had very little preaponeu-
rotic fat and appeared bound down; these were released and repositioned superiorly. Good crease formation.
(B) Postoperative appearance (patient wearing colored contact lenses).
A
B
CASE 59 (Figure 13-59)
30 y.o. female, has no crease RUL, LUL has occasional crease. Prefers above average parallel crease OU.
I/O: tarsus 8.5 mm. Designed 7.5 mm (7 + 0.5) parallel crease line with 2 mm skin.
RUL: preaponeurotic fat very soft, repositioned superiorly. Orbicularis was vascular. Excised M/C strip.
LUL: preaponeurotic fat plastered down over lateral half of aponeurosis; vascular and therefore left alone.

156
Asian Blepharoplasty and the Eyelid Crease
CASE 60 (Figure 13-60 A, B)
22 y.o. female, 5′7″. She had a single lid up until 16 y.o. Now has incomplete or partial creases. Used tape daily (A).
I/O: tarsus 7.5 mm. Designed 8 mm parallel crease as the lid was edematous from xylocaine. Included 2 mm skin in M/C
strip. Orbicularis was very spongy and vascular. Used superiorly beveled approach through septum. The preaponeurotic fat
appeared bound down over the lateral half. This was released and repositioned superiorly. Excised M/C strip and inferior
orbicularis edge of right side. Formed crease.
(B) One week postoperative appearance.
A
B
CASE 61 (Figure 13-61)
22 y.o. male, absent crease OU. Left fissure appears larger than right. Desired low-set parallel crease.
I/O: tarsus 8.5 mm. Used 7 mm design for parallel crease. Very vascular over orbicularis. Little preaponeurotic fat. Excised
M/C flap but did not vigorously debulk preaponeurotic platform. Used eight 6-0 silk sutures for crease construction, plus 7-0
silk running stitch.

13  Primary Asian Blepharoplasty Results (Before and After)
157
CASE 62 (Figure 13-62 A, B)
31 y.o. male, absent crease. Heavy lids, large face. 5′10″ (A).
I/O: tarsus 8.5 mm. Designed 7 mm parallel crease. Skin very thin and stretched; orbicularis was vascular, with fibromosaic
preaponeurotic fat plastered down. Excised around 3.5 mm M/C strip. Crease formed well.
(B) One week postoperative appearance.
A
B
CASE 63 (Figure 13-63 A, B)
31 y.o. female, absent crease. 5′2″. Prefers average height NTC.
I/O: tarsus 7.5 mm. Designed 7.5 mm NTC + 2 mm skin. Observed inferiorly migrated preaponeurotic fat that was bound
down. Released and repositioned into superior sulcus. Excised M/C strip. Formed crease.
(B) One week postoperative appearance.
A
B

159
SUBOPTIMAL FACTORS
C H A P T E R 1 4 
The revision of suboptimal results is a necessary part of
any surgeon’s skills. Known factors that lead to subopti­
mal results include inaccurate placement of the crease
incision, the use of reactive suture materials, excessive
bleeding, excessive fat removal, inadequate or excessively
tight wound closure, inappropriate technique and lack of
knowledge on the part of the surgeon (Figure 14-1).
There are often intangible factors that may be beyond
the control of the surgeon. Examples are the patient’s lack
of compliance with postoperative wound care instruc­
tions; overly vigorous physical exercises performed too
soon after the procedure, resulting in prolonged edema
of the eyelid margin; latent hypertension with rebleeding;
weight gain; unpredictable wound healing in patients
who have had multiple prior revisions; obsession on the
part of patients who are not happy with the results even
though the results are satisfactory; or unrealistic precon­
ceived notions on the part of patients about what they
expect the crease to do for them, such as launching a
career in a certain field.
Assuming the physician is knowledgeable and capable,
deviations from an ideal course may still occur inadvert­
ently or even unnoticed, arising from an unusual coincid­
ing of an event relating to the patient and an event
relating to the physician. Suboptimal results may there­
fore occur even with the very best surgeon.
A
B
C
FIGURE 14-1  ■  Examples of asymmetry.

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

14  Suboptimal Factors
161
FIGURE 14-2  ■  Interrelated parameters that determine a normal crease as well as suboptimal results.
Shape
Height
Continuity
Permanence
FIGURE 14-3  ■  Hollow sulcus as a result of excessive removal of preaponeurotic fat.

162
Asian Blepharoplasty and the Eyelid Crease
FIGURE 14-4  ■  Formation of multiple creases and false folds as a result of excessive fat removal.
A
B

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

164
Asian Blepharoplasty and the Eyelid Crease
FIGURE 14-7  ■  Upper bifid crease 1 month postoperatively. With time and resolution of tissue edema the bifid crease may merge
into the medial upper lid fold.
FIGURE 14-6  ■  Excessively high semilunar crease.
should still be down to the patient to state their
preferences.
In suture methods (see Figure 14-8) the indented
crease results from compressing skin towards the levator,
and this crease is seen with the eyelid opened as well as
when the eyelid is looking down or closed. There is a
shortening effect on the levator due to the superior–
posterior passages of buried sutures, like a plicating
stitch, which explains the often noticeable widened eyelid
opening and slight stare, with some discomfort on the
part of the patient; while the horizontal passages crimp
the horizontal band width of the levator, perhaps weaken­
ing its capability.
The net long-term effect of these sutures is often
a decrease in levator excursion as well as strength,
manifesting as mild secondary ptosis and/or lagophthal­
mos. Interestingly, in cases where the sutures are
tied very tight and eventually lose their intended effect
due to cheese-wiring through eyelid tissues, the restric­
tive effect may be lessened somewhat, though the func­
tional impairment may be more permanent in some
patients.
Figure 14-9 shows high crease placement of three
buried permanent sutures, in the range of 10–12 mm
from the lid margin, with obvious bumps on the eyelid
when the lid is looking downward or closed.

14  Suboptimal Factors
165
FIGURE 14-8  ■  Circle of suboptimal parameters, etiology and interrelatedness.
Shape
Height
Continuity
Permanence
Too high (incorrect incision marking, suture placement, edema)
Excessive fat removal (high sulcus)
Too low
Fragmented crease (discontinuous)
Shallow crease
Partial or complete obliteration
Asymmetry
Exaggerated lateral flare
Semilunar crease
Fading of medial crease
Downward shifting
Bifid
Multiple creases
13/

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

14  Suboptimal Factors
167
FIGURE 14-10  ■  Suture ligation method. For details, see text.
A’
B’
B
A
Levator
Müller's muscle
Conjunctiva
1
3
2
2
4

168
Asian Blepharoplasty and the Eyelid Crease
FIGURE 14-11  ■  Lid crease placement by the external incision method. The right upper crease covers about 80% of the width of the
lid. The left lid crease has become obliterated.
FIGURE 14-12  ■  Postoperative formation of multiple creases over the pretarsal region of the left upper lid. The most likely cause of
this suboptimal result is vigorous surgical maneuvering in the pretarsal region.
appear to have shifted down after initial postoperative
edema has subsided, to reveal a lower-than-normal
attachment. It may appear shifted downward through
interposition of residual pretarsal fat along the superior
tarsal border. Sometimes excessive hemorrhage during
surgery or postoperatively can lead to delayed resolution
of swelling and this can partially undo an otherwise well-
placed crease set.
The medial one-third of the crease is more challeng­
ing to construct in that the anatomy there works against
any attempt to form an even crease for some patients.
The medial segment of the levator aponeurosis may be
sparing or fibrous in nature, making it difficult to attach
any aponeurotic fixation sutures there. It may have less
than adequate upward vector or lack any slip-slide (nano-
ball action, see Chapter 23) between the anterior and
posterior layers of the lid.
The two vectors, lifting of the levator and relaxing
of the orbicularis layer, are not moving in opposite,
180-degree phases here. The medial upper lid fold
may be prominent and require partial reduction in order
to fold in the skin nicely. Interestingly, the patient
may complain that the inner portion (medial one-third)
of the crease is ‘too high’, when in fact the crease is fading
there.
A lack of precise control of the crease height can lead
to a change in shape. A lack of control of shape can lead
to asymmetry as well as inaccurate depth and location
placement, both of which factors can lead to discontinu­
ity. A lack of continuity obviously contributes to failure
to achieve permanence. A lack of permanence is accom­
panied by fading of the crease, frank disappearance or
shrinkage of the crease downward. The circularity of
these linked factors is intriguing.

169
REVISION PARAMETERS
C H A P T E R 1 5 
THE CIRCLE OF SUBOPTIMAL
PARAMETERS, ETIOLOGY AND
INTERRELATEDNESS
Of all the parameters that influence the outcome of
surgery, perhaps the single most important factor will be
the height of the crease, as drawn from the mid-ciliary
margin. The crease should be designed based on the
central height of the tarsal plate, and no higher. In Asians
this is often between 6.5 and 7.5 mm. When designed in
this range, the crease often proves natural in appearance
and well formed. When designed above the measured
height of the tarsus, the result is often a crease that is
unnatural in appearance, restrictive in upgaze and associ­
ated with increased lymphedema in the pretarsal region,
manifesting as a ‘fat’ eyelid border. A crease that is
designed lower than the lowest range of normal will often
lead to a scar in the pretarsal skin region which is hard
to camouflage, or the lymphatic stasis and eventual reso­
lution lead to multiple creases and folds (see Figure 15-1).
Next in importance is the shape of the crease design,
i.e. nasally tapered or parallel. The nasally tapered crease
is popular and compatible with almost any Asian ethnic­
ity. Its distinctive feature is a gradual convergence towards
the medial canthus, and it converges on and joins the
medial canthal angle. As it courses medially, the indented
crease would join and merge towards any mild medial
canthal fold the patient may already have. The nasally
tapered crease seems more prevalent in southern Chinese,
as well as in south-eastern ethnic groups such as Malay­
sians, Thais, Vietnamese and Cambodians. The parallel
crease is more often seen in northern Chinese as well as
northern Asians. The crease is uniform in width as it
arches from one corner of the lid to the other. It appears
to be aesthetically more compatible for someone with
larger facial features, a more rectangular or squarish face,
or someone who is tall and hence has a proportionately
larger face. The parallel crease may be observed among
southern Asians and the nasally tapered crease may like­
wise be seen in northerners.
If a crease is designed with the correct shape but with
a height above the normal range, it becomes conspicuous
and artificial in appearance. When a crease is designed
without following the normal geometric contour for that
particular crease shape, again one has the impression of
artificiality, for example a crease that flares up medially,
or one that converges laterally (both opposite to what
may normally occur in those locations). This applies
when one is comparing the symmetry of design between
two eyelids: again, it would be less than ideal to have a
crease shape on one side that differs from what is on the
opposite side (although in the overall picture this is far
less suboptimal than other outcomes). There are times
FIGURE 15-1  ■  Circle of suboptimal parameters, etiology and interrelatedness.
Shape
Height
Continuity
Permanence
Too high (incorrect incision
marking, suture placement, edema)
Excessive fat removal (high sulcus)
Too low
Fragmented crease (discontinuous)
Shallow crease
Partial or complete obliteration
Asymmetry
Exaggerated lateral flare
Semilunar crease
Fading of medial crease
Downward shifting
Bifid
Multiple creases
13/

170
Asian Blepharoplasty and the Eyelid Crease
when a surgeon finds that a semicircular crease is created
unintentionally on one side. This can be revised back to
the desired shape at the appropriate time, provided there
are some skin reserves to work with.
During the design as well as the construction phase of
the crease, and especially for a nasally tapered crease, if
the surgeon does not steer the medial end towards and
to merge with the medial canthal fold, then a bifid crease
can be the result – a crease that splits either above or
below the medial canthal fold.
An artificially high crease incision will naturally lead
the surgeon to encounter a greater amount of fat in the
preaponeurotic space because of its high entry. There is
a chance that the surgeon will then be unknowingly
steered towards a greater than normal degree of fat exci­
sion. This leads to:
1. A more hollowed preseptal region (enhanced supra­
tarsal sulcus).
2. A greater chance of the formation of multiple
creases or folds above the incision wound, in the
preseptal region. There is then a confusing picture
of competing creases, rather than a predominant
and primary crease being formed.
3. A greater chance of a comparatively rigid preseptal
segment of skin–muscle anterior lamella bounded
to the posterior lamella.
It is therefore apparent that excess fat excision has a
multiplying and cascading effect in terms of its influence
on eventual formation of the lid crease. Not only does it
not help in crease formation or the eventual aesthetics of
the upper eyelid, it makes subsequent revision attempts
far more challenging.
Continuity relates to factors in the construction of a
crease: the efforts must be uniform and deliberate, with
varying techniques tailored to the particular terrain across
the width of the eyelid fissure. If the effort should succeed
in most of the length of the crease but fail in a small loca­
tion, the result is a discontinuous or partial crease (or a
partially obliterated crease). The crease may become indis­
tinct, either medially, centrally (less often) or laterally.
Permanence refers to the ideal goal of achieving a
crease that remains for more than 3–5 years. When the
entire crease fades out over a 6-month period it is usually
due to insufficient clearance of the soft tissue corridor
along the preaponeurotic platform, with regression of the
soft tissue barrier, including fat, along the zone where the
crease would ideally form. It can also occur as a result of
an excessively low incision path along the pretarsal plane.
Continuity, therefore, relates more to the overall
effort of crease fixation, assuming the path is already on
the correct level and plane. Permanence includes the
effort made to ensure continuity but relates to long-term
success and the efficacy of a particular method, as applied
to an individual patient.
The challenge is that with any of the factors men­
tioned above and shown in the circle of suboptimal
parameters, each may have a slight imperfection that can
lead to less than perfect results. Aggregation of several
suboptimal factors can pose a greater degree of challenge
when it comes to revision attempts. It is not uncommon
FIGURE 15-2  ■  Asymmetric creases (left crease higher than right).
FIGURE 15-3  ■  Fading of medial third of left upper lid crease.
to see revision attempts aimed at the excision of multiple
folds or a high crease lead to severe skin shortage, lagoph­
thalmos and corneal exposure. Likewise, injection of free
fat grafts may lead to mechanical ptosis, hypertrophy of
injected fat, or lumpy fat grafts. Acquired ptosis is a
common sequela following revision attempts and can be
cicatricial (owing to high crease fixation) or mechanical
(stiffened preseptal platform) in origin. Scarring in the
middle zone and involving the levator muscle can lead to
both lagophthalmos and ptosis, as well as poor closure of
the palpebral fissure and corneal exposure.
It is hoped that with knowledge, skill and careful pre­
operative discussion, the surgeon can avoid the factors
that lead to suboptimal results (as discussed in Chapter
14). There will, however, always be patients who seek
revisions and this chapter will discuss some of the prob­
lems the author has encountered in the treatment of such
patients, and their solutions.
The revision techniques for the various suboptimal
configurations are discussed below.
CREASE ASYMMETRY
By far the most frequently encountered problem is crease
asymmetry. This includes creases that are unequal in
height (Figure 15-2), uneven in shape and continuity,
have undergone shifting (downward migration or partial
or complete obliteration of the crease) or have faded in
the medial one-third of the lid (Figure 15-3).

15  Revision Parameters
171
FIGURE 15-4  ■  Acquired ptosis of the right upper eyelid and a
higher crease compared to the left upper lid. The crease asym­
metry is corrected when the underlying ptosis is corrected.
FIGURE 15-5  ■  This patient had a higher than acceptable crease
(dotted line); it was corrected by Asian blepharoplasty.
Repair of a Low Crease
For patients who have some redundant skin, the best
method is simple excision of the scar associated with the
low crease, allowing it to heal, and then performing a
subsequent crease procedure a minimum of 6 months
later. In my experience, simultaneous revision and con­
struction of a new crease often gives suboptimal control
of crease height.
When the skin is taut and has no redundancy, simple
excision cannot be performed because it may result in
cicatricial ectropion or a prominent scar (Figure 15-6).
An acceptable option for a low crease with a scarcity of
skin is complete excision of the crease and the adjacent
pretarsal skin, replacing them with a full-thickness skin
graft and reshaping the crease at the same time. This
procedure is used if the graft covers only the pretarsal
region. The patient should be forewarned that the crease
will appear high for at least 6 months.
If the skin graft required spans both the pretarsal and
the supratarsal regions, it is best to defer crease recon­
struction for at least 6 months (Figure 15-7).
FIGURE 15-6  ■  Mild cicatricial retraction and prominent scar.
Inequality in Crease Height
When the crease of one eyelid appears higher than that
of the other, often the higher crease is the abnormal one.
It is essential to detect any acquired ptosis in that eyelid,
because the levator aponeurosis often appears to have
dehisced some of its lower terminal interdigitations
and has only a portion of its superior lid crease attach­
ments remaining (Figure 15-4). Correction of the ptosis
eliminates the apparently higher crease without any need
to reposition the crease.
A higher than normal crease can arise from inappro­
priate marking of the incision lines, from inaccurate
placement of the interrupted crease-forming sutures over
the levator aponeurosis, or from persistent edema in the
pretarsal plane. If a crease still appears high 6–9 months
after the operation, the repair can be accomplished in the
following manner.
Repair of a High Crease
The eyelid is everted and the central height of the tarsus
measured (see Chapter 7). This serves as a reference
point for crease placement. When the tarsal height is
transposed on the skin side and is found to be closer to
the eyelash line than the current crease, the difference in
millimeters of skin can be excised with the previous inci­
sion scar, as long as a shortage of skin does not result
and complete eyelid closure is not compromised
(Figure 15-5). It is helpful to lyse any subcutaneous
aponeurotic attachment along the superior edge of the
incision. Any scar tissue that may overlie the aponeurotic
attachment along the superior tarsal border should be
removed to allow for the construction of the new crease.
If the transcribed tarsal height on the skin side is
higher than the supposedly high crease, one should
examine the contralateral upper lid crease to see if it has
an excessively low crease.
Low Crease
It is more difficult to repair an excessively low crease (one
that is close to the lash margin) than to repair an exces­
sively high one. The correction is tailored to whether
there is any redundancy of skin.

172
Asian Blepharoplasty and the Eyelid Crease
FIGURE 15-7  ■  Cicatricial retraction and corneal exposure that
necessitated skin grafting superior to the pretarsal region. Plan
for the formation of a lid crease is deferred for at least 6 months.
FIGURE 15-8  ■  Obliteration of the entire crease over the right
upper lid.
FIGURE 15-9  ■  Partially shielded and partially obliterated crease
several years after external incision with buried sutures.
FIGURE 15-10  ■  Design of nasally tapered crease. Skin incision
has been made.
FIGURE 15-11  ■  During the operation, previously placed levator-
to-inferior subcutaneous sutures were an incidental finding.
Late Obliteration of a Crease
Late obliteration includes a shallow crease, shifting of a
crease, fading of the medial third of a crease and oblitera­
tion of the entire crease (Figure 15-8).
Repair of Late Obliteration
As long as there is some redundant healthy skin with
which to work, the Asian blepharoplasty described in
Chapters 7, 8 and 9 can be performed either partially or
entirely along the width of the eyelid (Figures 15-9 to
15-11). The most common findings at the time of
the operation include excessive subdermal scarring
and inadequate clearance of the underlying orbicularis
oculi muscle, orbital septum, or fat pads (pretarsal or
preaponeurotic) along the junction of the pretarsal region
and the preaponeurotic space (Figure 15-12).
Segmental obliteration results in a discontinuous
crease, which will fare better if it is completely revised.
It is essential to trim away any underlying platform of
scar tissue between the skin and the healthy levator
aponeurosis along the superior tarsal border. A patient
may have an inadequate crease over the medial third
(or less) of the upper lid (see Figure 15-3). This problem
is usually the result of insufficient subdermal attachment
during the first operation, and can be prevented by
using at least three interrupted crease-forming sutures
over the medial half of the crease (Figure 15-13). It may
also require more debulking of the underlying soft tissue
in that region to allow for solid subcutaneous aponeurotic
linkage.

15  Revision Parameters
173
FIGURE 15-12  ■  Platform of redundant tissue along the superior
tarsal border includes skin, orbicularis muscle, scar tissue and
orbital septum.
FIGURE 15-13  ■  Placement of extra interrupted sutures over the
medial half of the incision lines in revision for inadequate crease
formation over the medial third of the eyelid.
MULTIPLE CREASES
Patients may have multiple creases over each eyelid.
These cases can be divided into those who had multiple
faint creases to start with, but end up with several com­
peting and prominent creases, and those who were
without any crease from the beginning.
Postsurgical Creases Competing
with Original Creases
In the first category are patients who may have had
several equally rudimentary creases to start with (Figure
15-14), or who had one noticeable crease with several less
obvious ones that became more prominent after surgery.
In my experience, this problem is seen in patients who
have undergone vigorous dissection in the pretarsal
and preaponeurotic spaces (Figure 15-15), excessive
removal of pretarsal tissues in an attempt to remove all
pretarsal fat, or overzealous removal of preaponeurotic
fat pads. These multiple creases tend to be low and in the
pretarsal region.
Repair of Multiple Creases
The anatomically based method of Asian blepharoplasty
using tarsal height as a guide to crease placement is
still the best way to condense several creases into a rela­
tively more dominant one, provided there is enough
skin with which to work. Frequently, several closely
spaced creases can be completely excised, with good
results (see Figure 15-15). When a patient who presents
with multiple creases has a severe shortage of skin, func­
tional correction of the shortage with a full-thickness skin
graft takes precedence over the aesthetic repair. The
redundant creases may be excised when the skin graft is
performed, and a secondary procedure may be performed
later to produce a single crease.
Postsurgical Multiple Creases in
Patients without an Original Crease
Almost all multiple creases in the eyelids of patients who
did not have a crease to start with result from the exces­
sive removal of preaponeurotic fat pads. These patients
frequently had excessively high placement of their main
crease, and the redundant creases are all high in the
supratarsal region; they are really the interspaces between
multiple folds of skin left after the removal of the
preaponeurotic fat.
Hollow Supratarsal Sulcus with or
without Multiple Creases
An already hollow sulcus may be exaggerated by the
removal of preaponeurotic fat, or a hollow sulcus may
arise iatrogenically because of the operation.
Repair of a Hollow Supratarsal Sulcus
The medical literature contains myriad corrections for a
hollow supratarsal sulcus, including the placement of

174
Asian Blepharoplasty and the Eyelid Crease
FIGURE 15-14  ■  Asian patient with several rudimentary creases.
FIGURE 15-15  ■  A different Asian patient after blepharoplasty with multiple creases in the pretarsal and supratarsal regions of both
lids.

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

176
Asian Blepharoplasty and the Eyelid Crease
FIGURE 15-17  ■  Design of a nasally tapered or parallel crease in the surgical correction of a semilunar crease within 10 mm of the
ciliary margin.
Semilunar crease; central
height 10 mm or under
Preferred crease
(nasally tapered or parallel)
Parallel crease
Nasally tapered
crease
medial 25% of the semilunar crease becomes the nasally
tapered portion of the preferred crease. The central 50%
is reshaped at a lower level in a parallel continuous crease;
the lateral 25% is excised and revised so that it is either
parallel or flares slightly upward, by deliberately anchor­
ing it higher than it was. This maneuver is facilitated by
undermining of the subcutaneous tissue around the
lateral canthal region. The challenge arises when there is
very little skin between the lateral portion of the semi­
lunar crease and the lateral canthus. I find it effective to
excise the lateral 25% of the crease and to perform a
simple plastic closure. Six months later I perform a lateral
crease revision.
B.  Patients with a Shortage of Skin.  A semilunar
crease is not easily revised unless the crease, with its
underlying scar and the skin between it and the desired
new crease (based on tarsal height), is completely excised.
A full-thickness graft is used to correct the skin shortage
above the proposed crease and to allow for reconstruction
of the new crease (Figures 15-18, 15-19), which will be
formed at the junction of the pretarsal skin and the
applied skin graft.
2.  Crease More than 10 mm from Lid Margin.  An
extremely challenging situation exists when the semilunar
crease is more than 10 mm from the lid margin. I have
seen patients with creases as high as 12–14 mm from the
FIGURE 15-18  ■  In the surgical correction of a semilunar crease
that is within 10 mm of the ciliary border but in which there is
a skin shortage, the scar line of the semilunar crease and the
very small segment of pretarsal skin between it and the new
crease must be excised (shaded area).
Orbicularis oculi
Semilunar crease under
10 mm with skin shortage
margin (Figure 15-20) (see also Figure 1-15 and Chapter
1; unnatural, high and harsh (‘uhh’) syndrome). The cor­
rection of this involves working closer to the thick dermis
of the eyebrow, which provides little camouflage and
increases the risk of hypertrophic scarring.
A.  Patients with Some Redundancy of Skin.  On the
rare occasion when there is some redundant skin in

15  Revision Parameters
177
have used a variety of methods, some with better results
than others (see Chapter 16, Case 31), and these are rated
by me in the next section.
Effectiveness of Corrective Measures
to Reverse a Crease
Significant Improvement
Significant improvement is achieved with excision of the
crease and scar, and recession of the levator aponeurosis
coupled with placement of autologous temporalis fascia
or fascia lata, or Alloderm (cadaveric dermis).
Some Improvement
Some improvement is achieved with excision of the crease
and scar, with interposition of pedicled orbicularis muscle
fibers to block the aponeurosis–subdermal attachment.
Some improvement is also achieved by excising the
crease and the scar and applying 14 ″ sterile adhesive strips
to the sutured skin wound. Patients are encouraged to
avoid looking up during the first week after the operation
to avoid contraction of the levator aponeurosis.
Minimal Improvement
1. Minimal improvement is achieved with excision of
the crease and the scar and the application of trac­
tion sutures inferiorly (reverse Frost sutures).
2. Subcutaneous lysis of adhesions using a small
tenotomy scissors also usually results in minimal
improvement.
SUMMARY OF SOLUTIONS IN
REVISIONAL BLEPHAROPLASTY
As the surgeon acquires expertise, previously unsolvable
suboptimal results can be logically analyzed, much as a
biochemist analyzes the different factors of a complex
reaction. When the different parameters can be clearly
and accurately delineated, it may be possible to formulate
a plan to correct the problem in a harmonious way.
Clearly, the correction should never lead to worsening of
the existing problem.
Figure 15-21 offers a matrix in which the vertical
columns list suboptimal factors that can occur in the area
above the crease, the preseptal (supratarsal) region, and the
horizontal rows list suboptimal factors occurring in the
area below the crease, the pretarsal regions. Since subop­
timal results seldom occur in one zone only, the surgical
solutions listed in each box (cell) show the correction for
the upper preseptal region as well as the lower pretarsal
region, with the crease indicated by the dotted line.
The matrix was first designed about 25 years ago and
was meant to serve as a basic framework for extremely
challenging cases where no other management method
might be available. Towards that goal, it still has its
purpose as a useful guide. Note that the use of a full-
thickness skin graft (FTSG) around the eyelids should
only be attempted by very skilled surgeons.
conjunction with a highly placed semilunar crease (more
than 10 mm from the ciliary margin), one may try the
same steps as described for patients with a semilunar
crease less than 10 mm (see above).
B.  Patients with a Shortage of Skin.  Unfortunately,
most patients whose crease is more than 10 mm from the
lid margin have undergone excessive skin removal and
have little left for plastic reconstruction. The repair
requires a full-thickness skin graft (as above), and the
upper edge of the graft will be quite conspicuous (please
refer to Chapter 18).
COMPLETE CREASE REVERSAL
The author’s most challenging operations have been on
the few patients who genuinely wanted their surgically
placed crease completely reversed. For these patients I
FIGURE 15-19  ■  Full-thickness skin grafting.
Full-thickness skin graft
FIGURE 15-20  ■  A semilunar crease (solid line) that has been
placed more than 10 mm from the ciliary border, almost halfway
to the eyebrow for an Asian. The dotted line shows the desired
crease, which is based on the central tarsal height. The area
above the high, semilunar crease shows a hollow supratarsal
sulcus (shaded area), from which fat has been aggressively
removed.
Tarsus

178
Asian Blepharoplasty and the Eyelid Crease
FIGURE 15-21  ■  Matrix of solutions in revisional blepharoplasty in Asian upper eyelids.
Upper
and
Multiple lines
Skin shortage
Immobile dense skin
Cicatrix to
levator aponeurosis
Lower
solutions
Multiple
lines
Add fat
Revise, reset crease lower
Lyse adhesions,
revise into primary crease
Revise, reset crease
Beveled revision
+ FTSG
Revise, reset crease
Beveled revision
+ FTSG
Revise, reset crease
Correct ptosis
Revise, reset crease
Skin
shortage
Add fat
FTSG
Lyse adhesions,
revise into primary crease
FTSG
Beveled revision
+ FTSG
FTSG
Beveled revision
FTSG
Pretarsal FTSG
Correct ptosis
FTSG
Scarred
platform
Add fat
Excise, revise
vs FTSG
Lyse adhesions,
revise into primary crease
Excise, revise
vs FTSG
Beveled revision
+ FTSG
Excise
/ FTSG
+ --
Beveled revision
+ FTSG
Excise, revise
vs FTSG
Correct ptosis
Excise, revise
vs FTSG
High
crease,
edema,
fullness
Add fat
Revise/reset crease lower
Lyse adhesions,
revise into primary crease
Revise/reset crease lower
Beveled revision
+ FTSG
Revise/reset crease lower
Beveled revision
+ FTSG
Revise/reset crease lower
Revise/reset crease lower
Correct ptosis
Pretarsal region
Preseptal region
Hollow sulcus

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

180
Asian Blepharoplasty and the Eyelid Crease
FIGURE 15-23  ■  (A) Eyelid is looking down or at rest (closed). (B) Eyelid is open, looking ahead. Levator is impaired with increased
load.
Restriction on upgaze, poor crease indentation, possible ptosis.
B
A

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

183
REVISIONS IN SUBOPTIMAL CASES
C H A P T E R 1 6 
This chapter illustrates various conditions that required
revision (correction of suboptimal results), all with
prior surgery that may have included buried sutures
methods and/or incisional methods. The contrast
between Asian eyelids and those of Caucasians, and the
diversity even among Asians themselves, are what
makes Asian eyelid surgery such an interesting and
challenging art.
CASE 1 (Figure 16-1) 
Skin blanching following application of local anesthetic in a patient undergoing revision or touch-up correction. The previously
operated skin here is tighter and shows less spreading of the injected solution.

184
Asian Blepharoplasty and the Eyelid Crease
CASE 2 (Figure 16-2 A, B) 
25 y.o. female who had previous surgery with high crease and shape asymmetry. (A) Before and (B) after revision.
A
B
CASE 3 (Figure 16-3 A–C) 
22 y.o. female who had crease procedure at age 10. (A) She has trichiasis (in-grown eyelash) of the upper lids.
(B, C) Postoperative view.
A
B
C

16  Revisions in Suboptimal Cases
185
CASE 4 (Figure 16-4 A, B) 
32 y.o. male who had buried suture method procedure previously. (A) There is a shielded crease on the RUL and no crease on
the LUL. During revision the crease was reset to 7 mm.
(B) Post-revision photograph.
A
B
CASE 5 (Figure 16-5 A, B) 
47 y.o. female who had incision method with skin removal. She sought a more noticeable crease height. (A) Before and
(B) following revision.
A
B

186
Asian Blepharoplasty and the Eyelid Crease
CASE 6 (Figure 16-6 A, B) 
23 y.o. female who had four previous procedures. Absent crease in the LUL. Desired a NTC. (A) Before and (B) following
revision.
A
B
CASE 7 (Figure 16-7 A, B) 
48 y.o. female has ptosis of LUL. (A) Before and (B) after crease revision, combined with ptosis correction of the left eye.
A
B

16  Revisions in Suboptimal Cases
187
CASE 8 (Figure 16-8 A, B) 
22 y.o. female had incision method. Both sites show spreading of skin scar.
A
B
CASE 9 (Figure 16-9 A, B) 
45 y.o. female having had buried suture method showing shallowing and duplication of creases of LUL. (A) Before revision
and (B) 7 days following revision bilaterally, with normal swelling.
A
B

188
Asian Blepharoplasty and the Eyelid Crease
CASE 10 (Figure 16-10 A, B) 
55 y.o. female with moderately high crease. (A) Before and (B) following revision to lower the crease on both sides.
A
B

16  Revisions in Suboptimal Cases
189
CASE 11 (Figure 16-11 A–C) 
Young woman with absence of crease, or very low-set indented crease at the lower section of the pretarsal eyelid skin. Pho-
tographs show fullness of the lid, often seen despite having had buried sutures method 10 years previously.
A
B
C

190
Asian Blepharoplasty and the Eyelid Crease
CASE 12 (Figure 16-12 A–D) 
(A) 22 y.o. female with high crease, semilunar shape. There are redundant double crease lines, with scarce skin left.
(B, C) The ratio of pretarsal/preseptal is almost 1 : 1.
After revision (D), with the crease reset to a lower position and transition to a parallel shape.
A
B
C
D

16  Revisions in Suboptimal Cases
191
CASE 13 (Figure 16-13 A, B) 
55 y.o. female with high crease: RUL at 9 mm, LUL measured at 10 mm.
(A) Before and (B) following revision to 7 mm crease height. The crease is now less harsh and more natural.
A
B
CASE 14 (Figure 16-14 A, B) 
Young woman who had a high crease set. (A) Note the aspect ratio between the pretarsal (lower) segment and the preseptal
(upper) segment is almost 1 : 1. There is some acquired ptosis and limitation on upgaze , as well as lagophthalmos.
(B) Two weeks after a revision attempt utilizing the author’s beveled approach and resetting of crease height. The ptosis is
released and the crease height will continue to settle down over the next few months. The aspect ratio has improved between
pretarsal segment and preseptal region. (The patient returned to her overseas residence shortly after.)
A
B

192
Asian Blepharoplasty and the Eyelid Crease
CASE 15 (Figure 16-15 A, B) 
This patient underwent a lid crease procedure. (A) Notice that the crease does not merge into the fold medially. The medial
aspect of the crease overrides the supracanthal fold, resulting in an upper bifid crease.
(B) Higher magnification of RUL.
A
B

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CASE 16 (Figure 16-16 A, B) 
50 y.o. female with a left seventh nerve palsy who underwent a lid crease procedure. Note the poor closure of her left upper
lid owing to facial paresis and probable mid-lamellar contracture.
A
B
CASE 17 (Figure 16-17) 
35 y.o. female who has had excessive fat removal high over her supratarsal sulcus. Note the inadequate formation of the lid
crease and the hollow sulcus.

194
Asian Blepharoplasty and the Eyelid Crease
CASE 18 (Figure 16-18 A–C) 
Female university student who presented after lid crease placement. (A) She showed a high crease over the left upper lid and
a segmented crease over the medial extent of the right upper lid and scar over the lateral half of the crease. I recommended
enhancement and revision of the right upper crease, and repositioning to a lower level for the left upper crease. She elected
to have only the right lid revised. A tarsal height-based Asian blepharoplasty was performed on the right upper lid, cicatrix
was released from the lateral half (B).
(C) One week postoperative appearance.
A
B
C

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195
CASE 19 (Figure 16-19) 
Incomplete and ‘bifid’ crease: the upper crease did not extend to the medial one-third of the fissure width. The splitting of the
crease is more noticeable over the right upper lid.
CASE 20 (Figure 16-20 A, B) 
A patient with asymmetric creases. The right upper lid crease was too close to the lid margin, and is scarred down to the
anterior surface of the upper tarsus. The left upper lid crease is high, harsh and semilunar in shape.
A
B

196
Asian Blepharoplasty and the Eyelid Crease
CASE 21 (Figure 16-21 A, B) 
This patient had an asymmetric crease made more evident by the acquired ptosis of the right upper lid. This is an example of
a static crease.
A
B

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197
CASE 22 (Figure 16-22 A–C) 
(A) 30 y.o. female with multiple creases over RUL (with one dominant and several less distinct creases over the medial half) and
multiple indistinct high creases over LUL. (B) Note the enhanced supratarsal sulcus on the LUL, probably due to excessive fat
removal. (C) Correction of the LUL consisted of crease enhancement with excision of the small strip of skin encompassing the
multiple creases. No attempts were made to correct the supratarsal hollow because (a) this is a difficult procedure to perform, and
placement of synthetic fillers frequently leads to complications; and (b) the conversion of several faint lines to a main crease often
creates enough inward folding, especially on upgaze, to make the hollow less noticeable.
A
B
C
CASE 23 (Figure 16-23) 
50 y.o. female with high creases, some of which are bifid and multiple.

198
Asian Blepharoplasty and the Eyelid Crease
CASE 24 (Figure 16-24 A–D) 
(A) 30 y.o. female who had two lid crease procedures in Asia. She complained that the crease tapered excessively towards the
lateral canthi and of fullness in that area when she smiled. (B) Asian blepharoplasty was performed laterally. Intraoperatively,
scar tissues were excised until the underlying aponeurosis was clearly seen.
(C) Appearance immediately after the procedure.
(D) Appearance 1 month postoperatively. Some residual pretarsal edema can still be seen.
A
B

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199
CASE 24 (Figure 16-24 A–D)—cont’d
C
D

200
Asian Blepharoplasty and the Eyelid Crease
CASE 25 (Figure 16-25 A–E) 
(A, B) 25 y.o. female had undergone placement of a reddish tattoo line in an attempt to form a pseudo-crease over the RUL.
She had minimal ptosis of the same lid.
(C) The tattooed crease line, which measured less than 1 mm wide, was excised. (D) A new crease was formed based on
the author’s technique.
(E) Closure of the wound over the RUL.
A
B

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201
CASE 25 (Figure 16-25 A–E)—cont’d
C
D
Continued

202
Asian Blepharoplasty and the Eyelid Crease
CASE 25 (Figure 16-25 A–E)—cont’d
E
CASE 26 (Figure 16-26) 
55 y.o. female with a high, harsh, incomplete crease. The crease spanned only 60% of the width of the fissure.

16  Revisions in Suboptimal Cases
203
CASE 27 (Figure 16-27 A–C) 
(A) This patient had a crease deformity of the RUL due to laceration by broken windshield glass during an automobile accident,
with embedded glass fragments. The LUL had a ‘shielded’ crease. (B, C) Postoperative views after crease revision.
A
B
C

204
Asian Blepharoplasty and the Eyelid Crease
CASE 28 (Figure 16-28 A–D) 
(A) 28 y.o. female before Asian blepharoplasty.
(B) Immediately after the procedure.
(C) Six months after the operation the patient reported a 30% weight gain (from 90 to 120 lb) and obliteration of the LUL
crease. (D) Surgical exploration of left upper lid showed hypertrophy of the suborbicularis (preseptal) fat pads, which may
have obliterated previous crease-forming attachment.
A
B

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205
CASE 28 (Figure 16-28 A–D)—cont’d
C
D