Asian Blepharoplasty and the Eyelid Crease 3

16  Revisions in Suboptimal Cases
207
CASE 29 (Figure 16-29 A–I)—cont’d
E
F
G
H
I

208
Asian Blepharoplasty and the Eyelid Crease
CASE 30 (Figure 16-30 A–E) 
(A) 50 y.o. female had previously undergone blepharoplasty and presented with a high parallel crease and some residual
hooding of the upper lids.
(B) Upper and lower lines of incision during revision: the design of the crease allowed for excision of the area of the previ-
ous crease incision (dotted line outlined with methylene blue ink) to remove some redundant skin and reposition the crease
closer to the lid margin, based on the tarsal height.
(C) The orbital septum was opened superiorly, revealing minimal preaponeurotic fat pads, which I did not remove.
(D) Excision of skin and redundant underlying preseptal orbicularis muscles. The methylene blue tip points to a previously
buried 6-0 Prolene suture that had functioned as a levator aponeurosis–inferior subcutaneous fixation suture. (E) Closure of
the wound following revision.
A
B

16  Revisions in Suboptimal Cases
209
CASE 30 (Figure 16-30 A–E)—cont’d
C
D
E

210
Asian Blepharoplasty and the Eyelid Crease
CASE 31 (Figure 16-31 A–D) 
(A) 35 y.o. male had seen another surgeon for placement of a lid crease. He later wanted the crease removed or lightened.
(B) The creases and the underlying scar tissues on both lids were removed. A persistent crease remained over the lateral half
of the RUL; the LUL appeared satisfactory. A second procedure was carried out 6 months later to release the subdermal
aponeurotic attachment. This resulted in minimal improvement.
(C, D) A year later, I performed a recession of the RUL coupled with placement of autologous temporalis fascia. Although
the crease faded on downgaze , it could be seen on straight-ahead and upgaze.
A
B
C
D

16  Revisions in Suboptimal Cases
211
CASE 32 (Figure 16-32 A, B) 
23 y.o. female 5 years s/p previous crease procedure done by me. Crease has disappeared. Her height is 5′ 5″. Mild degree of
fat persisted, with small left medial canthal web (A).
I/O: tarsus only 6.5 mm. I used 7 mm to design a NTC. Very soft fluctuant pretarsal and preseptal tissues. Lysed along
superior edge’s cicatrix and orbicularis. Had amorphous inferiorly migrated fibromosaic fat (preseptal fat) which is then repo-
sitioned superiorly. Excised scar and M/C strip.
(B) Postoperative appearance.
A
B

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Asian Blepharoplasty and the Eyelid Crease
CASE 33 (Figure 16-33 A, B) 
46 y.o. male 2 years s/p removal of upper lid hooding. Has rudimentary crease, low-set and dark incisional line with spreading;
3 mm cornea covered (ptosis). Medial incision line measures only 3 mm from lashes. (A, B) Preoperative appearance.
I/O: designed a single 5 mm parallel incisional line as there was no skin redundancy. Lysed along upper edge of incision
until large amount of preseptal and preaponeurotic (postseptal) fat was seen. Debulked scar along the STB such that a new
crease could form along there.
A
B

16  Revisions in Suboptimal Cases
213
CASE 34 (Figure 16-34 A, B) 
27 y.o. male 6 years s/p lid crease procedure; has high crease and pretarsal fullness. NTC. Right crease height is 9 mm, left is
11–12 mm. Patient feels irritation of the eyelid when blinking (A).
I/O: tarsus 6 mm. In this revisional attempt for the LUL, 8.5 mm was chosen to mark an NTC and included 2.5 mm as the
amount of skin and scar to be excised. Lysed along the upper incisional edge to reach the preaponeurotic space. Found and
removed two buried stitches. Then excised M/C strip of skin and scar. Reconstructed a shallower NTC.
(B) Appearance at 2 months postoperatively. Patient reported a greater degree of comfort when he blinks.
A
B

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Asian Blepharoplasty and the Eyelid Crease
CASE 35 (Figure 16-35) 
30-y.o. female with obliterated crease. She had surgery 6 years ago with incisional approach; uses tape daily OU. Has rudi-
mentary crease in RUL; LUL has pigmented incisional spots along medial end of eyelid.
I/O: tarsus 8 mm. Designed 7.5 mm NTC with 1 mm skin, such that the lower incision line was below her previous scar,
and included 1 mm of scarred skin only.
RUL: beveled approach along the upper edge to reach the preaponeurotic fat within the remnants of the preaponeurotic
space. Although I initially reduced the abundant fat partially with bipolar cautery, the crease did not form well owing to its
location along the STB. I reopened the wound and excised the preaponeurotic fat that was along the STB, leaving the upper
half mostly intact. It was only then that the crease formed well. Three buried nylon stitches were removed.
LUL: also included scar excision. Again excised preaponeurotic fat. The central crease fixation suture did not perform well
and was removed; more of the inferior edge tissues were cleared and excised; the 6-0 suture then fixed well, with better crease
formation.
CASE 36 (Figure 16-36 A, B) 
20 y.o. female 4 years s/p surgery elsewhere using two-stitch technique from conjunctival side. Has rudimentary crease line.
Small fissures with horizontal palpebral width ~0.75″. 4+ brow action, 3 mm ptosis. Wanted a NTC (A).
I/O: tarsus 8 mm; designed 7 mm NTC + 2 mm skin. Found large infiltrate of fibrous preseptal fat that appeared to have
migrated inferiorly, as well as preaponeurotic fat; both were partially reduced through excision. She had limited upgaze and
therefore crease construction relied exclusively on interrupted sutures.
(B) Two months postoperatively.
A
B

16  Revisions in Suboptimal Cases
215
CASE 37 (Figure 16-37) 
37 y.o. male 12 years s/p upper blepharoplasty, with first revision done same year to enhance crease. RUL had been revised
by me and was satisfactory. Now desires revision of LUL. Lid has segmentation of medial one-third of crease, with peaking
there. Crease measured 8.5 mm and chronic edema had caused an extra fold of skin to appear, as if hanging over the lateral
portion of the crease.
I/O: scar at ~8.5 mm. I used 7 mm to design a NTC, encompassing his scar in the 1.5 mm of skin–scar tissues. Used superior
beveled approach for this revision to reach the preaponeurotic space. Removed three buried nylon stitches. His voluntary
upgaze then showed good crease formation.
CASE 38 (Figure 16-38 A, B) 
Left eye with congenital ptosis in 21 y.o. male who had levator resection 2 years previously. Six months s/p suture technique
OU to form crease. RUL medial end has tapered crease; absent crease over LUL. Left upper lid’s incision line is only 2–3 mm
from lid margin; feels as if lid has resistance and discomfort (A).
I/O: left eye tarsus 8 mm. Designed incision at 7 mm + 1 mm skin. Removed buried 4-0 Mersilene stitch centrally above
STB. Used beveled approach to reach preaponeurotic space. Little fat remains. Excised M/C strip. Used cutting cautery to clear
a small trough along the anterior tarsal surface just inferior to STB. Used crease fixation sutures from skin to tarsus/aponeurosis
and skin.
(B) Appearance 2 months postoperatively.
A
B

216
Asian Blepharoplasty and the Eyelid Crease
CASE 39 (Figure 16-39 A, B) 
42 y.o. female who had upper lid surgery at age 27. Has very high 11–12 mm parallel crease OU. Has slight ptosis, with 2 mm
cornea covered OU (A).
I/O: tarsus 6.5 mm only. Patient had heavily tattooed permanent eyeliner, which measured 2.5 mm in width from the ciliary
margin. Designed crease at 6.5 mm from the upper edge of this permanent eyeliner, therefore at about 9 mm from ciliary
margin, as she did not have any residual skin for an ideal revision. Lysed adhesion through superior incision edge. Released
traction and freed up the levator (‘up-release’) from anterior skin/orbicularis layer; upgaze appeared unrestricted on the operat-
ing table. Preaponeurotic fat OU was left untouched. Excised superficial skin scar, 2 mm strip only; avoided injury to levator
as patient has mild ptosis. Reformed crease. The pretarsal skin has been freed from its attachment to the anchor point of the
previously high crease, therefore it has been ‘down-released’. When the crease is thus reconstructed, it looks better than the
9 mm that was planned and actually measured at about 7.5 mm from the lid margin, or 5 mm from the upper edge of the
permanent eyeliner’s border. It has therefore appeared to migrate from an incisional distance of 6.5 mm from the permanent
eyeliner to now being at 5 mm from the same margin.
(B) Appearance at one week following revision. Patient subsequently informed us that she underwent a brow lift elsewhere
at day 4 following our procedure for her.
A
B

16  Revisions in Suboptimal Cases
217
CASE 40 (Figure 16-40 A, B) 
60 y.o. female 2 years s/p revisional upper blepharoplasty where injection of abdominal free fat graft to upper lid sulcus was
performed. Now has prominent hypertrophied and permanent rubbery fat over sulcus and along the superior orbital rim of
LUL > RUL, and multiple folds and significant asymmetry (A).
I/O: tarsus 6 mm only. Designed crease with 2 mm skin included for excision. Beveled approach to lyse skin adhesion along
upper edge of incision first, then secondly through orbicularis/orbital septum complex to reach preaponeurotic space. Observed
yellow preaponeurotic fat. Superior to this was consolidated and indurated pale-yellow fat located over the sulcus and anteriorly
along the superior orbital rim. Over the LUL a 10 × 30 mm roll of indurated fat graft was excised. Excised M/C strip. Closed
wound with 6-0 and 7-0 sutures.
RUL: did not remove fat; just excised 2 mm skin to revise the crease.
(B) Appearance at one week postoperative visit.
A
B

218
Asian Blepharoplasty and the Eyelid Crease
CASE 41 (Figure 16-41) 
66 y.o. female 5 years s/p upper and lower blepharoplasty. Complains of incisional scar over lateral portion of LUL incision
that arches towards the lateral canthal angle. Has prominent sulcus.
I/O: beveled approach along upper edge of incision, which was over lateral half of lid only. Levator aponeurosis appears
infiltrated by fat; excised 4 mm of M/C strip. Reformed crease with greater separation from her lateral canthus.

16  Revisions in Suboptimal Cases
219
CASE 42 (Figure 16-42 A, B) 
30 y.o. female s/p upper and lower blepharoplasty. Upper crease incisional scar is high and has spread (with right higher than
left), with medial angulation over LUL; lower lid subciliary incision line too far from lid margin. Desires revision of upper crease
OU and lateral portion of LLL incision line. (A, B) Pre-revisional appearance.
I/O: tarsus 7 mm. Designed 7 mm crease + 1 mm skin/scar tissue medially, and 2 mm skin/scar laterally.
RUL: beveled approach along upper edge, preserved orbicularis. Made mini-trough along the STB. Applied three 6-0 Vicryl
sutures from inferior orbicularis to levator aponeurosis, plus the usual 6-0 interrupted skin–levator–skin sutures as well as 7-0
running suture for skin to skin.
LUL: used only 6-0 interrupted as well as 7-0 running in the usual approach.
LLL: infraciliary approach, excised scar. Tightened inferior limb of lateral canthal ligament by plicating it with 6-0 Vicryl
suture.
A
B

220
Asian Blepharoplasty and the Eyelid Crease
CASE 43 (Figure 16-43 A–C) 
Female patient had surgery 4 years ago and a second time a year prior to being seen.
RUL: deep NTC, converging, with 3 mm ptosis.
LUL: medial bifurcation of crease as it approaches the medial canthal fold.
Levator function: right 12 mm, left 15 mm. Appears esotropic. Height 5′ 0″.
I/O: right upper lid harsh and static 12 mm crease, bound down. Tarsus measured 6 mm. Designed 6 mm NTC. Incision
with No. 15 blade, then used blunt-tipped Westcott spring scissors to lyse adhesions along superior edge until preaponeurotic
fat is seen (no true septum left). Used cutting cautery to remove scar and redundancy along preaponeurotic platform, plus
removal of 8-0 nylon buried sutures that were used for crease formation. Formed crease with 6-0 and 7-0 silk sutures that were
removed after 5 days.
(A, B) Pre-revisional appearance.
A
B
C

16  Revisions in Suboptimal Cases
221
CASE 44 (Figure 16-44 A, B) 
Female patient underwent lid crease procedure 7 years ago. RUL: hooded and rudimentary crease. LUL: high crease with bifid
ending at both corners.
I/O: tarsus measured 7 mm. Designed NTC OU.
RUL: removed 2 mm skin and orbicularis. Used scissors to go through upper edge of incision, staying beveled to reach
preaponeurotic plane.
LUL: eliminated bifid crease, removed buried nylon sutures.
A
B

222
Asian Blepharoplasty and the Eyelid Crease
CASE 45 (Figure 16-45 A, B) 
47 y.o. female patient with first surgery 20 years ago coupled with ‘W-plasty’. Then revision 12 years ago.
I/O: observed prominent medial preaponeurotic fat as well as nasal fat pad. Removed fat pads. Use 6-0 Vicryl to fixate
inferior orbicularis to levator and then superior edge of orbicularis; kept suture knot buried.
A
B

16  Revisions in Suboptimal Cases
223
CASE 46 (Figure 16-46 A, B) 
29 y.o. female. Had surgery at 18 in Korea. Crease appears high OU. RUL appears deep-set. Has moderate fullness over pre-
tarsal area. LUL is more converged medially than RUL.
I/O: tarsus was only 5.5–6 mm. RUL crease measured at 11 mm, LUL at 10 mm. Designed 8.5 mm parallel crease over RUL
with some tapering medially; and 8 mm over LUL in an attempt to equalize two asymmetric high creases. Used blunt scissors
to reach preaponeurotic space superiorly. Large amount of cicatrix over preseptal as well as pretarsal zones. Excised strip of
myocutaneous flap OU. Excised strip of pretarsal inferior orbicularis muscle to reduce fullness. Checked levator’s excursion
on the table and appeared normal OU.
A
B

224
Asian Blepharoplasty and the Eyelid Crease
CASE 47 (Figure 16-47 A, B) 
55 y.o. had four-lid blepharoplasty 10 years previously in Hawaii. Has high bifid semilunar creases OU, measured to be
10–11 mm in sulcus.
I/O: designed parallel crease OU at 7.5 mm (tarsus measured 7 mm). Excised old crease with 1 mm clear skin superior to
it, with the lower skin incision edge at 7.5 mm. Found very attenuated levator muscle with fatty infiltration. Formed parallel
crease.
A
B

16  Revisions in Suboptimal Cases
225
CASE 48 (Figure 16-48 A, B) 
29 y.o. had crease procedure 9 years earlier: stitch method alone, with adjustment attempted twice. LUL has no crease. RUL
has shallow NTC. Patient prefers parallel crease.
I/O: very vascular. Removed buried nylon sutures from along the STB. Used 6-0 silk and 6-0 Prolene with significant attach-
ment towards the levator aponeurosis.
A
B

226
Asian Blepharoplasty and the Eyelid Crease
CASE 49 (Figure 16-49 A, B) 
36 y.o. 3 years s/p lid crease procedure. Currently has shielded crease over RUL, and LUL has wider separation from lid margin
than the RUL. Wants parallel crease.
I/O: designed 7 mm crease height to encompass RUL scar. Excised moderate amount of preaponeurotic fat from RUL as
well as inferior orbicularis strip.
LUL: reduced the crease height medially. Fat not as excessive and therefore only reduced some with bipolar Wetfield cautery.
Excised inferior orbicularis strip. Closed with 6-0 silk. Inspection revealed this LUL crease still high. Took down and re-excised
small amount of skin from lower edge. Result was more symmetrical look.
A
B

16  Revisions in Suboptimal Cases
227
CASE 50 (Figure 16-50 A, B) 
24 y.o. had lid crease procedure in Hong Kong 8 years previously. RUL crease never formed and is now shallow; LUL crease
is deeper, but central portion slightly peaked. Desired NTC.
I/O: RUL tarsus measures 6.5 mm. Used 7 mm to design an NTC. Resected scar tissue, no fat. Used 6-0 and 7-0 silk.
LUL: ‘square-well’ excision of strip of scar tissue along the STB. Mid-section underwent some dissection superiorly to release
fibrosis down to the aponeurosis. Reformed smooth NTC, with good result.
A
B

228
Asian Blepharoplasty and the Eyelid Crease
CASE 51 (Figure 16-51 A, B) 
Male patient, 9 years previously had lid crease procedure. The crease did not fold in well by the end of the first week. Revised
2 months later, with same finding. Has very faint rudimentary line OU. Patient wanted the medial one-third of the crease to
be lifted higher. However, this would lead to a triangular or rectangular look. After careful discussion, the patient chose a
parallel crease.
I/O: tarsus measured 8 mm. We designed a 7 mm parallel crease. Lysed scar tissues along the upper incisional edge, through
orbicularis. Observed amorphous fat plastered against levator muscle. After the skin muscle flap was trimmed there were still
remnants of preseptal tissues along the STB; as the patient looks up, this redundant tissue would bunch up and make the
crease look low and ‘rope-like’. This was then excised to show a clean insertion of the aponeurosis along the STB. The lower
skin edge was pulled up and united with the aponeurosis along the STB, forming a nice parallel 7 mm crease.
A
B

16  Revisions in Suboptimal Cases
229
CASE 52 (Figure 16-52 A, B) 
30 y.o. who was 10 years s/p external incision crease procedure. The lateral extent of the RUL appears to downslant towards
the lateral canthus. The incisional line has spread over the left side. Desires parallel crease to be of above-average height.
I/O: tarsus measured 8 mm. Used a parallel 8 mm incision line, included 2.5 mm skin. Very vascular orbicularis oculi muscle.
Preaponeurotic fat pad protruded inferiorly over the lateral half and required partial excision. The rest of the fat seemed spread
out and plastered down. Formed crease with 6-0 and 7-0 silk.
A
B

230
Asian Blepharoplasty and the Eyelid Crease
CASE 53 (Figure 16-53 A, B) 
19 y.o. Heavy upper lid hooding with fat. Some brow action. Wants to have hooding and fat removed but does not want crease
formation. Height 5′ 3″.
I/O: tarsus measured 7 mm. Used hyaluronidase in local injection. Made lower incision line at 5 mm and included 3 mm of
skin in a parallel configuration. After using blade through skin, I used cutting cautery with very fine tip to traverse through the
upper edge of the orbicularis. Reached septum and opened it. Excised 80% of prolapsing preaponeurotic fat. Excised M/C strip
that consisted mostly of skin, leaving behind half of the orbicularis along the STB. Closed orbicularis to orbicularis with 6-0
Vicryl. Skin closed with 6-0 nylon in a running fashion, taking bites of skin only. No interrupted sutures were used on the skin.
A
B

16  Revisions in Suboptimal Cases
231
CASE 54 (Figure 16-54 A–C) 
22 y.o. who was 4 years s/p lid crease procedure and attempted ptosis repair of RUL. RUL crease is deep set and height was
8 mm, with 1.5 mm of cornea covered. LUL has deep-set 6 mm crease, 0.5 mm cornea is covered. (A, B) Preoperative
appearance.
I/O: measured right tarsus and it was only 5.5 mm, probably had tarsectomy. LUL tarsus measured 7 mm.
RUL very vascular. Created 7 mm NTC and included 2 mm skin. Found three blue nylon stitches, scarred levator/tarsus
junction. Performed external resection of 3 mm of aponeurosis. Dissected epitarsally to smooth out already swollen tarsal area.
Formed crease with 6-0 and 7-0 silk.
LUL: also set crease height at 7 mm, and NTC. Found three nylon stitches and removed them. Excised 1.5 mm skin–muscle
strip. Formed crease.
A

232
Asian Blepharoplasty and the Eyelid Crease
CASE 55 (Figure 16-55 A–C) 
36 y.o. who was 10 years post first crease procedure (A).
RUL had 12 mm crease height with broad medial portion.
LUL had 14 mm deep crease. Height is 5′ 7″.
I/O: tarsus measured 7 mm. Used 8 mm as crease. Included 3 mm skin segment. Opened preaponeurotic plane with beveled
Westcott scissors along the upper edge. No fat seen. Formed crease with 6-0 and 7-0 silk.
(B) Postoperative appearance at 3 weeks.
A
B
C

16  Revisions in Suboptimal Cases
233
CASE 56 (Figure 16-56 A, B) 
66 y.o. RUL with 3 mm ptosis, hollow sulcus and absent crease. LUL has high crease. Levator function RUL 7 mm, LUL 14 mm.
I/O: RUL has had previous tarsectomy-type procedure. Applied frontal nerve block. Performed lysis of adhesion along the
superior edge of the skin incision. Levator was extremely attenuated. The aponeurosis was elevated from underlying conjunc-
tiva and 10 mm was resected. The edge of the muscle was then advanced and reanastomosed inferiorly along the STB using
6-0 Vicryl. Formed crease with multiple 6-0 and 7-0 silk sutures.
LUL: created 6 mm crease line incision, then dissected upwards towards scar to reach preaponeurotic plane. Resected the
old cicatrix and fragment of skin between it and the new lower edge of the crease incision.
A
B

234
Asian Blepharoplasty and the Eyelid Crease
CASE 57 (Figure 16-57 A–C) 
23 y.o. female with small palpebral fissure and mild ptosis OU. (A) Prior to any procedure. (B) One year following Asian
blepharoplasty she developed shallowing of crease over both upper eyelids.
I/O: RUL tarsus measured 6.5 mm. Designed crease including less than 1 mm of previous incision line. Lysed superior edge
of incision through orbicularis. No unusual fat seen. Thick fluctuant preseptal orbicularis was seen; this was excised.
LUL: crease form was borderline after closure. Released the sutures and re-fixated by deeper placement on to aponeurosis.
The medial portion of the levator aponeurosis appeared to have some fat infiltration.
B
A
C

16  Revisions in Suboptimal Cases
235
CASE 58 (Figure 16-58 A, B) 
46 y.o. from South America. Two years ago had undergone upper blepharoplasty with incision placed 3 mm from the lash
margin. Now has recurrent hooding such that the crease is shielded and there is dark-colored skin along the incision. Wanted
parallel crease. Lid margin rests 3 mm down on cornea.
I/O: upper lid skin appears short prior to intervention. Used 5 mm parallel line to incise skin, then lysed along the superior
skin edge until large amount of preseptal and preaponeurotic fat was seen. Made a small trough above STB, just enough to
facilitate skin closure. No skin excision at all.
A
B

236
Asian Blepharoplasty and the Eyelid Crease
CASE 59 (Figure 16-59 A, B) 
40 y.o. from South-East Asia wanting upper eyelid crease and fat removal. Had prominent eye fissures, mild fat and some hooding.
Wanted ‘natural, conservative nasally tapered crease’.
I/O: tarsus 7.5 mm. Designed crease with 2 mm skin. Excised portion of preaponeurotic fat bilaterally.
A
B

16  Revisions in Suboptimal Cases
237
CASE 60 (Figure 16-60 A, B) 
18 y.o. male complains of intermittent or absence of crease over right side. Height is 5’ 7″.
I/O: tarsus measured to be 7.5 mm. His rudimentary crease appears to be at 7 mm; therefore designed 7 mm NTC, plus
2 mm of skin. Fat was reduced with bipolar cautery. Excised orbicularis along the path of the STB. Medially there was some
web formation and these were reduced and the crease anchored deeper here with 6-0 silk to prevent web formation
medially.
A
B

238
Asian Blepharoplasty and the Eyelid Crease
CASE 61 (Figure 16-61 A, B) 
34 y.o. with hooding and single eyelid of the right and shielding with multiple creases over left side. The fissure size is smaller
over the right side. Levator function: RUL 11 mm, LUL 12 mm.
I/O: tarsus measured 7 mm. Used NTC shape and included 2.5 mm skin. M/C flap excised; some fat excision. The crease
formed well.
A
B

16  Revisions in Suboptimal Cases
239
CASE 62 (Figure 16-62 A, B) 
25 y.o. with single eyelid desires crease placement. Upper lid contour has slight peaking over medial one-third. Prefers higher-
than-average parallel crease.
I/O: tarsus measured 7 mm. Designed a 7 mm parallel crease shape. Had large amount of preaponeurotic fat, which was
excised partially. A large roll of fatty infiltrate overlay the STB and required clearance on each side for optimal crease
formation.
A
B

240
Asian Blepharoplasty and the Eyelid Crease
CASE 63 (Figure 16-63 A, B) 
24 y.o. Narrow crease with some shielding. RUL has shallower NTC; LUL has deeper-set low NTC. Desired crease
enhancement.
I/O: tarsus measured 7.5 mm. Used 7.5 mm to design NTC with 2 mm redundancy; excised fatty infiltrate along inferior
edge of pretarsal orbicularis on both sides.
A
B

16  Revisions in Suboptimal Cases
241
CASE 64 (Figure 16-64 A, B) 
57 y.o. with heavily hooded lid and fatty prolapse, more over right side. RUL rests 2 mm onto cornea. LUL rests 1 mm. Has
small palpebral fissure size bilaterally.
I/O: could not evert tarsus to measure. Set crease at 7 mm parallel shape. There was a large amount of amorphous fat
inferior to the preaponeurotic fat, which in itself was inferiorly placed. Excised fat.
RUL: reinforced usual closure of 6-0 and 7-0 silk with one double-armed 6-0 Vicryl, passing from inferior pretarsal skin to
aponeurosis.
A
B

ADVANCED CONCEPT OF A GLIDE
ZONE AS IT RELATES TO UPPER LID
CREASE, LID FOLD AND APPLICATION
IN ASIAN BLEPHAROPLASTY
C H A P T E R 1 7 
This chapter deals with the author’s concept of the natural
biodynamic of the eyelid layers, the importance of fat
within the eyelid’s preaponeurotic space, its facilitation
and hindrance of the natural eye opening mechanism
(Figure 17-1).
Classically, the normal eyelid anatomy can be concep­
tualized as consisting of two layers: the anterior skin/
orbicularis oculi muscle layer and the posterior layers of
the levator muscle and aponeurosis, Müller’s muscle and
the tarsal plate.
Anterior layer
Posterior
layer
* Glide zone
FIGURE 17-1  ■  The natural biodynamic of
the eyelid layers. Pink: levator muscle;
yellow: preaponeurotic fat; gray: orbicu­
laris oculi muscle with subcutaneous
tissues.
243

244
Asian Blepharoplasty and the Eyelid Crease
greater number of distal fibers of the levator aponeurosis
that terminate toward the skin along the superior tarsal
border and the area above it to form the eyelid crease.
When the levator contracts, the tarsal plate vectors
upward and the eyelid crease invaginates easily. Cauca­
sians may often have a deep-set supratarsal sulcus (Figure
17-2).
In general, Caucasian eyelids with a crease are thinner
than those of their Asian counterparts. This is attribut­
able to a combination of factors that include a higher
point of fusion of the orbital septum onto the levator
aponeurosis, the relatively higher position of preaponeu­
rotic fat pads and the resultant thinner lower segment of
eyelid, less preseptal fat and thinner orbicularis. Com­
paratively, Caucasians with an eyelid crease possess a
FIGURE 17-2  ■  Caucasian eyelid with a crease. In general, Caucasian eyelids with a crease are thinner than their Asian counterparts.
This is due to a combination of factors, including a higher point of fusion of the orbital septum on to the levator aponeurosis, the
relatively higher position of the preaponeurotic fat pads and the resultant thinner eyelid segment, the greater number of distal fibers
of the levator aponeurosis that terminate towards the skin along the superior tarsal border and above to form the eyelid crease,
less preseptal fat, and a thinner orbicularis. When the levator contracts, the tarsal plate vectors upward and the eyelid crease invagi­
nates easily.
Lid (levator) at rest
Lid open (looking ahead)

17  Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease
245
form a clinically apparent upper eyelid crease.2 When the
lids are open and the subject is looking ahead, there is a
greater degree of fullness in the preseptal region com­
pared with a Caucasian with a crease, but less than that
which is typically seen in Asians without an upper lid
crease (Figure 17-3).
In Asians who are born with a natural crease, although
the eyelid may still be thicker than in Caucasians with an
upper lid crease, there are distal fibers of the levator
aponeurosis terminating toward the skin along the supe­
rior tarsal border.1 Despite the low point of fusion of the
orbital septum, when the levator contracts, there is an
invagination of skin along the superior tarsal margin to
FIGURE 17-3  ■  Asian eyelid with a crease. Although the eyelid may still be thicker than in Caucasians with an upper lid crease, there
are distal fibers of the levator aponeurosis terminating towards the skin along the superior tarsal border. Despite the low point of
fusion of the orbital septum, when the levator contracts there is an invagination of the skin along the superior tarsal margin to form
a clinically apparent upper eyelid crease. When the lids are open and the subject is looking ahead, there is a greater degree of full­
ness in the preseptal region than in a Caucasian eyelid with a crease, but less than that typically seen in Asians without an upper
lid crease.
Lid (levator) at rest
Lid open (looking ahead)

246
Asian Blepharoplasty and the Eyelid Crease
are relatively few fibers or no attachment from the levator
aponeurosis toward the skin along the superior tarsal
border. Their pretarsal and preseptal zones are thicker
compared with Caucasians or Asians who have an eyelid
crease (Figure 17-4).
Asians who are without an eyelid crease typically have
thicker eyelids because of the presence of a hypertrophied
orbicularis and the presence of fat in the pretarsal, presep­
tal and preaponeurotic areas. The orbital septum fuses
with the levator aponeurosis at a lower point compared
with those Caucasians with an upper eyelid crease. There
FIGURE 17-4  ■  Asian eyelid without a crease. The upper eyelid is often thicker owing to the presence of hypertrophied orbicularis as
well as preseptal fat in the pretarsal as well as the supratarsal area. The orbital septum fuses with the levator aponeurosis at a lower
point than in Caucasians with an upper eyelid crease. There are relatively few fibers or no attachments from the levator aponeurosis
towards the skin along the superior tarsal border. Both the pretarsal and the preseptal zones are thick compared to Asians or Cau­
casians with an upper eyelid crease.
Lid (levator) at rest
Lid open (looking ahead)

17  Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease
247
In aesthetic Asian blepharoplasty, where the goal has
always been to create an ethnically appropriate crease,
there are two categories of methods used to achieve this
goal. The first consists of the suture ligation methods,3–5
which are often described as being less invasive and
simpler to perform, and use several buried sutures to
tighten the soft tissues along the superior tarsal border,
which includes orbicularis, levator aponeurosis and
Müller’s muscle. The other category is the external inci­
sional approach, whereby a skin incision is made along
the designed crease and varying amounts of skin, muscle
and soft tissues may be removed; this is then coupled with
various methods of crease construction by means of fixa­
tion or attachment of skin to the levator aponeurosis, skin
to the tarsus, or orbicularis to aponeurosis fixation.
The surgical results often depend on a complex inter­
action between the degree of excessive tissue overlying
the pretarsal and preseptal areas, the presence of fat, the
thickness of skin over each of the two areas mentioned
above, the position of the globe, the brow position,
levator function and whether there is a firm adhesion of
skin to orbicularis in the pretarsal area. In a normal upper
eyelid, when the eyes are looking straight ahead and the
lids are open, the anterior layer is in passive relaxation,
allowing the posterior levator/Müller’s muscle/tarsus to
actively contract and pull the lid margin upward into an
open position. The posterior layer only has to retract
(glide) up and inward for 2–4 mm relative to the anterior
layer for a reasonable crease to be observed. The vertical
span (in millimeters) of the eyelid fold overhanging the
crease can be measured simply by subtracting the
‘observed crease height’ (from eyelash to inferior border
of eyelid fold) from the anatomical crease height (meas­
ured with the lid fold retracted away to expose the true
crease line). (In Advanced: Chapter 20, we can say
Dimension of the fold
Tilted crease height
Apparent crease
=
−
height.
However, since the fold is best observed and measured in
a frontal position with gravity in place, the first clinical
definition suffices.) The fold varies between 2 and 4 mm.
The anterior layer therefore offers very little resistance
and does not present a significant ‘resisting platform’
against the levator muscle/tarsus; exceptions to this will
include heavy eyelids (those with abundant preaponeu­
rotic or suborbicularis fat, and loose subcutaneous areolar
tissues) with poor levator function, including true ptosis.
The role of the preaponeurotic space and fat is often
mentioned as a hindrance to any attempt at surgical con­
struction of a crease, and surgical dictum requires that at
least a portion of the fat be excised. There is nothing
inherently wrong with this concept; in fact, when the
patient presents with excessive soft tissues along the
preaponeurotic platform, this author has advocated using
a beveled approach6 toward the preaponeurotic space
along the upper line of the incision and performing a trap­
ezoidal debulking of the skin, orbicularis, a small amount
of septum and inferiorly migrated fat. Should one need
to re-enter this space later using a beveled approach, one
can identify the preaponeurotic space and its fat quite
readily.7

248
Asian Blepharoplasty and the Eyelid Crease
FIGURE 17-5  ■  Scarred upper lid. Stiffened eyelid skin with underlying cicatrix overlying the pretarsal as well as the preseptal area.
The problem arises when the initial procedure
may have involved aggressive excision of the preaponeu­
rotic fat or been accompanied by excessive hemorrhage
within that space, which is surrounded by orbicularis
oculi in front and vertical communicating arterial
branches of the marginal arcade, the peripheral arcade
and the deep orbital arcade (see Chapter 3). The patient
often develops a sunken supratarsal sulcus, with total loss
of fullness to the preseptal zone, and may have poor
crease invagination and stiffened eyelid skin, with under­
lying cicatrix involving the pretarsal and preseptal areas
(Figure 17-5).
During revision, one sees a collapse or obliteration of
the preaponeurotic space and absence of preaponeurotic
fat. The anterior and posterior layers appear fused into a
single layered complex. One can visualize this as if the
levator muscle now has to carry or lift the upper tarsal plate
against the weight of a double load of eyelid layers, as
opposed to the usual scenario where the tarsal plate glides
up and under the anterior layers of skin and orbicularis.
The skin/orbicularis is now acting as a ‘resisting layer’
toward the posterior layer of the levator muscle. The
absence or presence of this ‘glide zone’ (with slippery
preaponeurotic fat within its space) in the middle between
the two layers can therefore hinder or facilitate formation
of the crease. The author has observed the presence of
tightly bound preaponeurotic fat in some individuals pre­
senting for a primary lid crease addition procedure, where
this amorphous infiltrated fat in the glide zone may have
contributed to the lack of a crease. Careful repositioning
of this fibrosed fat to a higher level seems to facilitate the
up-vectoring of the lid and crease formation.
The properly functioning eyelid crease was described
by Dr Khoo Boo-Chai8,9 in his 1963 article as being like
the visor of a motorcycle helmet. Additionally, Flowers10
had mentioned in his article on anchor blepharoplasty the
idea that the inferior extent of the preaponeurotic fat acts
like a ball-bearing at the orbital septum-to-aponeurosis
fusion point (the inferior extent of the preaponeurotic
space).

17  Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease
249
My own concept varies from these authors in the fol­
lowing way: the preaponeurotic space, its presence and
its preservation with some fat within it, is a necessary
‘third layer’ and should be preserved pristinely as much
as is feasible (Figure 17-6). In the diagram, the middle
zone (glide zone) where the preaponeurotic fat pads are
located is colored yellow and acts like a friction-free layer
that allows the posterior layer (dark pink) to glide up.
The up-vectoring of the tarsal plate is facilitated by this
glide zone, which allows it to slide upward against the
passively resisting eyelid fold to form an upper lid crease.
The skin passively glides over the posterior layer (the
upper part of the tarsal plate) for several millimeters in
the process of forming the upper lid crease and becomes
the eyelid fold.
Anterior layer
Posterior
layer
* Glide zone
FIGURE 17-6  ■  Concept of the glide zone. The glide zone consists of the space occupied by the preaponeurotic fat pads, as well as
all potential space between the anterior orbicularis oculi muscle–orbital septum layers and the posterior layers of the levator–levator
aponeurosis–Müller’s muscle–tarsal plate. The middle zone (glide zone) where the preaponeurotic fat pads are located acts like a
frictionless lubricating layer which allows the posterior layer to glide upwards. When the patient looks from down to straight ahead
with the eyelid open, the levator (agonist) contracts and the sphincter-like pretarsal, preseptal and periorbital layers of the orbicularis
relax. The orbicularis muscle of the upper lid is anchored at the medial and lateral canthal commissures, fusing there as a compo­
nent of the medial and lateral canthal ligaments. The anterior layer therefore acts like a passive layer, affected by gravity as the
posterior layer of the active levator and Müller’s muscle contracts to open the eyelid from a closed position. The up-vectoring of
the semirigid tarsal plate therefore depends on the middle layer to allow it to hinge upwards against the passively resisting anterior
layer to form an upper lid crease. The anterior layer glides passively over the posterior layer (upper part of the tarsal plate) for
several millimeters in the process of forming the upper lid crease; the portion of skin overhanging the tarsal plate is the eyelid fold.

250
Asian Blepharoplasty and the Eyelid Crease
The absence of adhesion and the presence of natural
fat within this glide zone allows the pretarsal platform
(posterior layer) to shift and glide slightly posterosuperi­
orly under the preseptal eyelid (anterior layer) to form a
physiologic upper lid crease. As previously mentioned,
this glide can be as little as 2–4 mm for the crease to
indent inward under the overhanging lid fold, which con­
sists of skin, orbicularis and orbital septum arising from
the arcus marginalis of the superior orbital rim. The
anterior layer therefore hangs from the superior orbital
rim and the area superficial to it, whereas the posterior
layer originates from the orbital apex and contracts pos­
terosuperiorly as it lies on the surface of the eye.
Typical findings following a suboptimal lid crease pro­
cedure for Asians and any upper blepharoplasty may
include an unusual amount of swelling (tissue edema),
hemorrhage from the orbicularis, or any of the vascular
arcades, excessive removal of fat within the preaponeu­
rotic space, and inadequate construction of the crease
based on physiologic principles. As the swelling recedes,
one or more of the following may appear: ptosis, a hollow
sulcus, an inadequate formation or absence of crease, or
multiple wrinkle lines (with or without a primary crease).
These are all signs relating to excessive manipulation or
inappropriate management of tissues within the glide
zone, with adhesions involving orbicularis, septum and
levator aponeurosis. By this I mean the obliteration of
this glide space by aggressive fat excision, from cicatriza­
tion following excessive hemorrhage or handling within
the preaponeurotic space, or adhesions involving the
orbicularis, orbital septum and levator aponeurosis.
As healing progresses, the upper eyelid continues to
manifest some degree of ptosis or resistance to upgaze,
with poor crease invagination. The patient may complain
of effort in keeping the lids open, difficulty gazing upward
and having a portion of the superior visual field obstructed.
(With time, an initially restrictive-type ptosis may develop
into an acquired ptosis with true weakening of the levator
muscle.) The pretarsal as well as the preseptal eyelid skin
may appear as a single zone of relatively flattened and
convex plaque of thickened skin overlying the globe. This
is indicated by one or all of the following.

17  Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease
251
FIGURE 17-7  ■  A normal glide sign in a normal subject, here
showing that the superficial dermis can glide superiorly or infe­
riorly over the deeper layers in normal eyelid. An abnormal
finding indicates adherence of the anterior and posterior layers.
Step 1. With the patient looking downward, the
examiner gently places his or her index finger super­
ficially over the mid-portion of the preseptal skin
superior to the upper tarsus to push or glide the
anterior skin/muscle layer upward. If the anterior
skin/muscle layer fails to be moved upward for
2 mm or more without the upper lid margin also
moving upward, it is indicative of an abnormal ‘glide
sign’ (Figure 17-7) (the patient should avoid closing
his or her eyelids because this elicits active contrac­
tion of the orbicularis).
Step 2. With the patient looking downward, the
examiner uses his or her thumb and index finger to
try to pinch the preseptal zone’s anterior skin layer
from the lid tissue underneath it. If this is not pos­
sible, as indicated by the posterior layer and upper
eyelid margin also coming off the surface of the
globe, this is suggestive of an obliteration of the
glide zone, constituting an abnormal pinch sign
(Figure 17-8).
FIGURE 17-8  ■  The normal pinch sign. When the glide zone is
intact, the preseptal skin/muscle (anterior) layer can be lifted
away from the posterior layer of the eyelid for several millim­
eters without the tarsus coming off the globe. An abnormal
pinch sign where the tarsal plate is lifted off indicates adherence
of the anterior and posterior layers.
FIGURE 17-9  ■  The upgaze skin traction sign. The patient is asked
to look up while the skin is secured with the examiner’s fingers,
here a normal sign showing a lack of adhesion. A direct pulling
force from the levator indicates an abnormal upgaze skin trac­
tion sign and suggests that there is obliteration of the preapone­
urotic space or glide zone.
Step 3. The patient is asked to look down, and the
ipsilateral eyebrow is splinted by the examiner’s
other hand to prevent brow action on upgaze. Then,
with the examiner pinching the preseptal skin, the
patient is asked to look upward. As the patient
looks up, the superior rectus and levator muscle
both contract. A normal finding should be the upper
eyelid margin underneath moving up independently
without the pinched skin going upward. If the
pinching fingers should feel an upward tug, it indi­
cates that the levator and preseptal skin are fused
together and is an abnormal ‘upgaze skin traction
sign’ (Figure 17-9).

252
Asian Blepharoplasty and the Eyelid Crease
The above findings apply more to adults who have had
surgery and not undergone significant involutional
changes, and would not be accurate in those unlikely
revisional cases where there is still redundant skin remain­
ing in the preseptal area or in patients who have devel­
oped age-related dehiscence between the preseptal skin
and orbicularis such that a false-normal finding may
occur (in a situation where, although the glide zone has
been obliterated, it is still possible to glide and pinch the
skin relative to the orbicularis that became adherent to
the levator and showed no skin traction on upgaze). It is
possible that a patient with fused anterior and posterior
layers may manifest a false-negative finding in any one or
two of the above tests, but it is unlikely that all three
would be normal on examination. This combination of
glide sign, pinch sign and upgaze skin traction sign have
been helpful for this author and are additional tools one
can use to help in the clinical assessment of those patients
with revisional issues.
In my previous article on trapezoidal debulking of the
preaponeurotic platform,7 I observed that the excision of
skin and some orbicularis in a beveled fashion removes
no more than several millimeters of orbital septum along
the upper wound edge. With wound closure, the septum’s
inferior edge is still allowed to lay back on the front
surface of the distal aponeurosis at or slightly above the
superior tarsal border, preserving and forming the ante­
rior boundary of this glide zone.
During attempts at revision, it is crucial to be able to
identify and reach this third space and restore a glide
zone. At the same time, any scar tissue within this poten­
tial space can be approached and cleared, including
removal of any buried sutures and correction of any cause
that is impeding this glide (shift) of the posterior layer.
The skin/orbicularis layers may have been improperly
laid onto the levator during previous surgery because of
the lack of proper loosening of the surgical drape on the
forehead. The re-establishment of the glide zone, and
downward and appropriate positioning of the skin and
eyebrow–forehead complex allows the now ‘released’
tarsal plate to be properly pulled upward by the freed
levator muscle, the contraction of which then yields a
crease at the superior tarsal border. This can be apparent
as the patient lies on the surgical table even without any
sutures closing the wound (Figure 17-10).
FIGURE 17-10  ■  Intraoperative appearance of the intraoperative crease form in a revision patient prior to the application of crease-
fixation sutures and closure. The globe is protected by a black corneal protector.

17  Advanced Concept of a Glide Zone as It Relates to Upper Lid Crease
253
The various methods of crease construction, including
the tightening of the tarso-aponeurotic junctional zone
by suture ligation or external incision methods, all work
in facilitating the upward vectoring of the tarsus against
the anterior eyelid layer to form the crease, provided that
the glide zone is preserved or has not been greatly
disturbed.
Complications that are challenging to correct often
follow obliteration of the glide zone. During the simpler
techniques of transconjunctival and transcutaneous suture
ligation, unexpected and sudden bleeding has been
reported and may be caused by injury to the vertically
oriented anastomotic vessels of the marginal and periph­
eral arcades of the upper lid11 and the deep orbital
arcade,12,13 and can also involve the recently described
lateral septoaponeurotic artery found in a certain per­
centage of the population.14,15 The bleeding may occur in
the postaponeurotic plane if the vessels retract after
transection in front of the tarsus or aponeurosis, or within
the preaponeurotic space (the glide zone) itself. Residual
adhesion may follow resolution of blood clots and lead
to irregularity in the crease thus created. Over the long
term, partial, segmental, or complete disappearance of
the crease may be seen.
In conclusion, the upper eyelid crease is an anatomical
invagination of the eyelid skin along the superior tarsal
border. Its originates from a complex interaction of
vector forces consisting of the following: a healthy levator
muscle (posterior layer), the presence of healthy skin/
orbicularis over the preseptal region that rolls over pas­
sively as an eyelid fold (anterior layer), the presence of a
third layer called the glide layer with healthy preaponeu­
rotic fat within it, and the absence of mid-lamellar scar­
ring that may bond the anterior and posterior layers of
the upper lid together. The theoretical basis for preserva­
tion of this third layer – the glide zone – and the role it
plays in upper blepharoplasty, as described in this chapter,
should provide greater understanding in the management
of blepharoplasty and complex revisional issues.
REFERENCES
1. Cheng J, Xu FZ. Anatomic microstructure of the upper eyelid in
the Oriental double eyelid. Plast Reconstr Surg 2001;107:1665.
2. Hwang K, Kim DJ, Chung RS, Lee SI, Hiraga Y. An anatomical
study of the junction of the orbital septum and the levator aponeu­
rosis in Orientals. Br J Plast Surg 1998;51:594.
3. Mutou Y, Mutou H. Intradermal double eyelid operation and its
follow-up results. Br J Plast Surg 1972;25:285.
4. Tsurukiri K. Double eyelid plasty: reliability and unfavorable
results to the patients (Abstract). J Jpn Aesth Plast Surg 1999;20:38.
5. Homma K, Mutou Y, Mutou H, Ezoe K, Fujita, T. Intradermal
stitch for Orientals: Does it disappear? Aesth Plast Surg 2000;24:
289.
6. Chen WPD. Concept of triangular, rectangular and trapezoidal
debulking of eyelid tissues: application in Asian blepharoplasty.
Plast Reconstr Surg 1996;97(1):212–218.
7. Chen WPD. Beveled approach for revisional surgery in Asian
blepharoplasty. Plast Reconstr Surg 2007;120(2): 545–552.
8. Boo-Chai K. Further experience with cosmetic surgery of the
upper eyelid. Proceedings of the Third International Congress of
Plastic Surgery, reprinted from Excerpta Medica International
Congress Series No. 66; 1963: 518.
9. Boo-Chai K. Secondary blepharoplasty in Orientals. In: Problems
in plastic and reconstructive surgery. Philadelphia: Lippincott,
1999: 520–535.
10. Flowers RS. Upper blepharoplasty by eyelid invagination: anchor
blepharoplasty. Clin Plast Surg 1993;20:193.
11. Chen WPD. The concept of a glide zone as it relates to upper lid
crease, lid fold, and application in upper blepharoplasty. Plast
Reconstr Surg 2007;119(1):379–386.
12. Kawai K, Imanishi N, Nakajima H, Aiso S, Kakibuchi M, Hoso­
kawa K. Arterial anatomic features of the upper palpebra. Plast
Reconstr Surg 2004;113:479.
13. Boo-Chai K. Perioperative bleeding in the pretarsal (postaponeu­
rotic) space in Oriental blepharoplasty. Br J Plast Surg 2001;54:370.
14. Kim BG, Youn DY, Yoon ES et al. Unexpected bleeding caused by
arterial variation inferolateral to levator palpebrae. Aesth Plast Surg
2003;27:123.
15. Hwang K, Kim BG, Kim YJ, Chung IH. Lateral septoaponeurotic
artery: source of bleeding in blepharoplasty performed in Asians.
Ann Plast Surg 2003;50:16.

75
C H A P T E R 8 
ASIAN BLEPHAROPLASTY I:
THE FIRST VECTOR
3. Surgical steps:
• marking of incision and crease placement
• the first vector – beveled surgical plane and
opening of orbital septum (Chapter 8)
• treatment of fat (continued to Chapter 9)
• the second vector – excision of orbicularis oculi
and septum
• treatment along superior tarsal border and
preaponeurotic space
• construction of lid crease
• closure of incision.
PRE-MEDICATIONS AND
SURGICAL SETUP
The patient usually receives 10 mg of diazepam (Valium)
and one Vicodin (acetaminophen and hydrocodone)
tablet (5 mg) orally 60 minutes before the procedure.
The patient is placed in a supine position and intravenous
line and electrocardiographic monitors are applied. A
pulse oximeter that provides a real time readout of the
patient’s PaO2 (arterial blood gas) is applied. All patients
are given a nasal cannula with 1–2 liters/minute of room
air flowing through it.
ANESTHETIC MIXTURE AND
INJECTIONS
Two mixtures of local anesthetics are prepared.
First: 1 ml of 2% xylocaine with 1 : 100 000 dilution
epinephrine is diluted by 10× with 9 ml of injectable
normal saline. This mixture now has a pH closer to
neutrality since it has been diluted with the buffer­
ing action of injectable normal saline. The epin­
ephrine is now diluted to 1 : 1 000 000. (This is
labeled ‘Diluted’.)
Second: 5 ml of 2% lidocaine (Xylocaine) containing
1 : 100 000 dilution of epinephrine is drawn. (This is
labeled ‘Full strength’.)
I apply a drop of topical anesthetic, 0.5% proparacaine
hydrochloride, on each eye for comfort prior to surgical
preparation and draping.
Using a No. 30 or 32 gauge needle, I infiltrate
0.1–0.2 ml of the diluted anesthetic subcutaneously along
Japanese Kanji (Chinese-based characters) and Hiragana writing
denoting ‘double-eyelid crease technique’. (Courtesy of, and in
remembrance of, Kazuko Chin.)
It is my belief that a modified external incision technique
allows maximum control and flexibility in order to achieve
the goal of creating an optimal crease. This is based on
setting a high benchmark of achieving an ideal crease
height, with an appropriate crease shape, continuity of
the crease line and permanence of the crease thus created
(beyond at least several years).
The steps involved are as follows:
1. Medications and surgical setup
2. Anesthetics

76
Asian Blepharoplasty and the Eyelid Crease
the superior tarsal border (Figure 8-1). During the next
few minutes, anesthesia takes effect and one can observe
blanching of the eyelid skin from the powerful vasocon­
strictive effect of the diluted epinephrine–anesthetic mix
(Figure 8-2).
I then inject the regular strength 2% lidocaine with
epinephrine in the suborbicularis plane along the supe­
rior tarsal border, usually giving less than 0.5 ml per
eyelid.
The purpose of this two-staged injection of local anes­
thetic is to allow for a relatively painless pre-infiltration
to anesthetize the surgical field before the full strength
of acidic 2% lidocaine is given.1 (One may add sodium
bicarbonate to the 2% mixture to achieve the same effect.)
When confronted with a patient with low threshold
for pain, one may supplement the local field infiltra­
tion with a frontal nerve block. A 30 gauge half-inch
FIGURE
8-1  ■  Initial
subcutaneous
injection
of
diluted,
pH-balanced anesthetic mixture.
FIGURE 8-2  ■  Blanching of eyelid skin caused by epinephrine in the anesthetic mixture.
needle may be used to apply 0.5 ml of the anesthetic
into the supraorbital space just lateral to the supraorbital
notch. (Frontal nerve infiltration is rarely necessary or
performed.) Intravenous sedation or analgesic may be
given.
The eyelids and face are then prepared in the usual
fashion for surgery. The eyes again receive a drop
of topical anesthetic, this time using tetracaine hydro­
chloride for longer-lasting corneal anesthesia. To elimi­
nate the sensation of claustrophobia that often occurs
with full draping over the nostrils and mid-face, nasal
delivery of room air through a nasal cannula is used.
Opaque black corneal protectors are then applied over
each eye.
PEARLS
•  The use of diluted anesthetic solution helps to:
•  decrease pain upon injection
•  decrease volume of anesthetic needed for
injection
•  create less tissue distortion as a result of less
volume expansion and lessened bleeding; it allows
the surgeon to stay focused on the surgical plane.
• The use of nasally delivered room air or low-flow
oxygen serves to decrease patient’s sense of
claustrophobia.
PITFALLS
• Never use nasal oxygen in an open system exposed
to monopolar or bipolar cautery as it may cause
ignition and flaming.
• Always apply pulse oximetry to measure the PaO2
arterial blood oxygen saturation. Preoperative seda­
tion and intraoperative sedation may easily cause
apnea in a sensitive patient.

8  Asian Blepharoplasty I: The First Vector
77
shaved-off tip of a wooden cotton-tip applicator dipped
with methylene blue is ideal for drawing a thin crease
line. The crease height is carefully transcribed onto the
external skin surface over the central part of the eyelid
skin.
This point directly overlies the superior tarsal border
and will serve as a reference point for the overall crease
height along the central one-third of the eyelid, whether
the crease shape is to be nasally tapered, parallel or later­
ally flared on rare occasions. For those patients who
already have a crease, you should still measure the tarsus
to confirm that the apparent crease you are seeing is
indeed the correct crease line to use, whether you are
planning to preserve or enhance it.
SURGICAL STEPS
Measure Tarsal Height
The height of the tarsus determines the overall central
position of the crease you are designing; the shape is
determined by how you design the medial one-third and
lateral one-third of this lower line of incision, according
to the patient’s preference.
The upper lid is everted and the vertical height of the
tarsus is measured over the central portion of the lid with
a caliper (Figure 8-3). This measurement is usually
between 6.5 and 7.5 mm in Asians. This is the range
between low, medium and high crease height. The
FIGURE 8-3  ■  (A) The upper lid is everted and the tarsal height is measured over the central portion. (B) Design of a nasally tapered
crease. The lateral portion may be designed to be level or flared slightly upward.
Laterally flared or leveled crease line
Central height of underlying tarsus
Nasally tapered crease
B
A