Asian Blepharoplasty and the Eyelid Crease 3

8  Asian Blepharoplasty I: The First Vector
79
PEARLS
• Using the shaft of a thin wooden-tip applicator and
slightly pressing on the lower incision line (new
crease location), instruct the patient to look upwards
even before the incision starts in order to assess how
the crease may appear. (Note that since the eyelid
tissue has been injected, the crease will appear more
swollen and further from the ciliary margin.)
• The use of an inked tapered tip of a wooden stick
allows precise drawing and redrawing, as compared
to the usual marking pens that are available in an
operating theater.
• In Asian blepharoplasty with skin excision, the lower
line of incision will determine the shape and height
of the surgically created crease. A strip of skin meas­
uring approximately 2 mm is then marked above
and parallel to this lower line of incision. This upper
line of incision is tapered towards and merged with
the medial canthal angle, or merged with any medial
upper lid fold that may be present. This segment of
skin to be excised is often less than 2 mm over the
medial portion of the crease.
• Repeated measurements and confirmation of inci­
sion lines are important.
Design of Parallel Crease Shape
(Figure 8-5)
The measured height of the superior tarsal border is
drawn across the width of the eyelid skin in a parallel
fashion (equidistant from the lash line).
To create adequate adhesions, it is necessary to remove
some subdermal tissue above the superior tarsal border.
A strip of skin measuring approximately 2 mm is then
marked above and parallel to this lower line of incision.
PEARLS
In designing the parallel crease, there is an unconscious
tendency to converge towards the medial canthal angle,
thereby turning it into a nasally tapered crease. I often
intentionally draw the tapering crease first and then use
it as a visual guide to decide how a parallel crease should
be designed near the medial one-third of the upper lid,
to remind myself to stay parallel.
PITFALLS
• Medially the parallel crease does not flare exces­
sively upward away from the medial canthus.
• The medial end of the crease line design should not
go past an imaginary vertical line aligned with the
medial canthal angle for both nasally tapered as well
as parallel creases.
• Laterally, the crease design should not traverse past
the lateral canthal angle.

80
Asian Blepharoplasty and the Eyelid Crease
A
Upper line
Lower line
B
FIGURE 8-5  ■  (A) Design for a parallel crease. (B) Design for a parallel crease including the upper and lower lines of incision.

8  Asian Blepharoplasty I: The First Vector
81
For a right-handed surgeon seated at the head of
the table, for the right upper lid it is best to start
medially; and for the left upper lid one may start
from the lateral tip of the incision line.
• Any bleeding is best controlled with bipolar cautery
via a fine jeweler’s tip. This allows the surgeon to
lessen any immediate tissue swelling and obscura­
tion of the tissue planes, thereby maintaining a clear
operative field. Furthermore, it allows one to stay
within the planned incision line.
PITFALLS
It is easy to incise too deeply and cause a small steady
bleed from the orbicularis muscle, which will soon
develop into a hematoma and distort the incision line as
well as incisional planes, blurring the distinction between
fat, orbicularis, orbital septum and levator aponeurosis
along the superior tarsal border. It may also result in
transient postoperative secondary ptosis. (This can
happen quite easily with suture ligation methods as well,
since needles are passed repeatedly through the full thick­
ness and layers of the eyelids, for example, six passages
when three sets of stitches were used.)
Incision
The incision is then carried out using a No. 15 surgical
blade (Bard–Parker) along the upper and lower lines
(Figure 8-6), incising just through the dermis and within
the fascia overlying the orbicularis oculi muscles. Fine
capillary bleeding is controlled using a bipolar Wetfield
cautery.
The excision of a strip of skin is not necessary in every
case; however, it is the author’s belief that it facilitates the
removal of subsequent layers of the lid tissues, thereby
allowing adequate crease formation. At this point the
superior tarsal border is still covered by pretarsal and
supratarsal orbicularis oculi muscle, with possibly some
terminal portions of the orbital septum, and the terminal
fibers of the levator aponeurosis beneath the septum.
PEARLS
• It is important to stabilize the tarsal plate and over­
lying soft tissues and skin when making a continu­
ous incision, especially along the lower line of
incision which is to become the crease line; this is a
critical step in the outcome of the designed crease.
• The continuous incision may be performed in three
steps so that one may check and recheck the passage.
FIGURE 8-6  ■  Incision through the upper
and lower lines of incision has been
made with a No. 15 surgical blade.

82
Asian Blepharoplasty and the Eyelid Crease
FIGURE 8-7  ■  (A) With the superior line of skin incision retracted superiorly, the orbital septum is opened through the orbicularis
muscle with a monopolar cautery tip at the lowest setting of cutting mode. (B) Orbital septum is opened along the superior line of
incision. Preaponeurotic fat pads can be seen from where the septum is opened.
B
A
Preaponeurotic
fat pad
Skin/orbicularis
flap retracted
inferiorly

8  Asian Blepharoplasty I: The First Vector
83
First Vector (Plane of Passage through
the Front Layers of the Eyelid): Beveled
Transection through Orbicularis along
Upper Incision Line and Opening of
Orbital Septum
After the initial skin incision, one may use the left fingers
to slightly retract the upper incision wound edge, then
aim a Bovie cautery tip in an angled fashion pointing
upward to transect through the preseptal orbicularis oculi
layer there, knowing that although this upper incision
line is only 2–3 mm above the superior tarsal border, with
the upward beveling the Bovie tip is aiming at a point
above where the septum fuses with the aponeurosis. (In
Asians, the orbital septum may join the aponeurosis as
low as 2–3 mm above the superior tarsal border.) The use
of the cutting cautery tip is in a feather-light fashion so
as to gently reach the orbital septum. Along the way you
may see some preseptal fat in front of the septum. When
the septum over the central one-third is opened, one
can see the slightly bulging preaponeurotic fat pad pro­
lapsing through the opening of the orbital septum (see
Figure 8-7B). A blunt-tipped Westcott’s spring scissors is
then used to open the orbital septum along the superior
line of incision; the skin–orbicularis–orbital septum flap
is turned inferiorly along the superior tarsal border using
a retractor (Figure 8-7AB).
PEARLS
Always tilt the tips of the scissors upward when extending
the horizontal release of the orbital septum to either side.
The purpose is to avoid inadvertent injury to the vessels
within the fat pads, the fat pads themselves, the underly­
ing levator aponeurosis, or lobe of the lacrimal gland
situated over the lateral end.
PITFALLS
• In opening the orbital septum medially, the levator
aponeurosis may be injured.
• In opening of the lateral extent of the septum, the
lacrimal gland can be injured.
• Avoid the use of monopolar cautery over the supero­
nasal aspect of the orbital space to avoid the trochlea
of the superior oblique muscle; when cauterized it can
lead to fourth nerve palsy and torsional diplopia.
• Avoid cauterizing the lacrimal gland over the supe­
rolateral aspect of the anterior orbital rim, which
can affect tear production.
REFERENCES
1. Tenzel RR, Hustead RF, Schietroma J, Hustead J. The best trick I
learned this year. Presented at the Annual Scientific Symposium of
the American Society of Ophthalmic Plastic and Reconstructive
Surgery, New Orleans, 1986.

255
ADVANCED: BEVELED APPROACH AND
MID-LAMELLAR CLEARANCE IN
REVISIONAL ASIAN BLEPHAROPLASTY
C H A P T E R 1 8 
It is my view that the trapezoidal debulking of the
preaponeurotic platform using a beveled approach
(along the upper incision line) in Asian blepharoplasty is
a logical and efficient way of performing primary cases.
I advocate this approach because it offers the following
advantages:
1. An easier and safer approach to the preaponeurotic
space through the orbital septum when the plane
of dissection is beveled.
2. A controlled, uniform debulking of junctional
tissues overlying the preseptal (supratarsal) and
pretarsal areas.
3. Optimal adhesions between levator aponeurosis
and the subcutaneous tissues along the lower inci­
sion line, or to intermuscular septa within pretarsal
orbicularis muscle fibers (pretarsal platform).
4. Crease formation can be based on the individual’s
tarsus height.
5. Virtual elimination of any potential for an uneven
plane of surgical dissection, thereby lessening the
complication rate, which includes problems with
asymmetry, height, shape, continuity, permanence,
segmentation of the crease, fading and late disap­
pearance of the crease, multiple creases and persist­
ent edema.
The clinical findings in patients seeking revisional
surgery are myriad. The eyelid may show spreading of
the incision scar, high placement of the crease, induced
lagophthalmos on downgaze, and acquired secondary
ptosis on straight-ahead as well as upgaze. Intraopera­
tively, one sees thickened middle lamellar scar involving
the orbicularis oculi as well as the orbital septum, or the
presence of dense scar tissue plaques that may bind the
anterior orbicularis oculi as well as the posterior levator
aponeurosis (Figure 18-1). Instead of having a physiolog­
ically preserved ‘glide zone’ where significant preaponeu­
rotic fat pads are still present in the lowest aspect of the
glide space, there is now a condensed apron (plaque)
of tissue that is preventing the posterior layer from
up-vectoring properly against a passive and flexible skin–
orbicularis layer. Despite all efforts, there is no observ­
able crease formation. Patients often complain of lid
fatigue, a feeling of tightness and may show brow and
forehead overaction.
In dealing with revision cases, whether simple or com­
plicated, one of the greatest dilemmas is where to make
the incision so that it does not compound the already
scarred field of operation, both from an anterior
skin viewpoint (and therefore an aesthetic concern)
and as regards middle lamellar scarring and contracture
(with further functional compromise). To succeed with
improved aesthetic results as well as without further func­
tional setbacks is a major triumph for any surgeon famil­
iar with and undertaking this type of revision surgery.
Not only is the operation difficult, but often the patient
is anxious for a rapid and successful outcome, something
that is never easily realized when dealing with scarring
and suboptimal outcomes. I am often struck by how dev­
astated these patients are and how grateful when the
improvement proves significant. It is important for both
patient and surgeon to be realistic in their expectations,
as well as their projection of the time course of healing
following revisional surgery.
Having said that, the following are the minimal
requirements in revisional surgery that I have striven for
in my practice:
1. That we do not cause further skin shortage.
2. That we do not cause increased midlamellar con­
traction, with lid retraction and poor eyelid closure.
3. That neither of the two factors above leads to con­
secutive symptoms of exposure and dryness of the
ocular surface.
4. That the patient understands from the first that the
surgeon will not be able to achieve a level of aes­
thetic improvement rivaling that obtained within
the practice in primary cases, where conditions are
ideal, the amount of skin is adequate and patient
expectations are closer to being normal and fair.
5. That the patient be informed that for each revision
operation one can try to correct only one item from
a list of goals. By this I mean that it is impossible,
for example, to correct an abnormally high crease,
lid margin contour deformity, pre-existing ptosis
and a shortage of skin all at the same time.
All these factors funnel into the same conclusion: if
there is insufficient skin in reserve, it is unlikely that there
is any chance of revisional improvement unless one
wishes to supplement the skin with a free full-thickness
skin graft. This latter will require precise techniques,
experience and special splinting over the graft in order to
place it in an aesthetically acceptable fashion. There are,
however, many young adults or middle-aged patients who

256
Asian Blepharoplasty and the Eyelid Crease
FIGURE 18-1  ■  Scarring seen in suboptimal cases of aesthetic surgery of the Asian upper eyelid may include spreading of the inci­
sional skin, high placement of the crease, induced lagophthalmos on downgaze, and acquired secondary ptosis on straight gaze as
well as upgaze. Intraoperatively, one sees middle lamellar scar involving the orbicularis oculi as well as the orbital septum, or the
presence of dense scar tissue plaques that may bind the anterior orbicularis oculi as well as the posterior levator aponeurosis.
Instead of having a physiologically preserved ‘glide zone’ where preaponeurotic fat pads are still present in the lowest aspect of
the glide space, there is now a condensed apron-like plaque of tissue that is preventing the posterior layer from up-vectoring prop­
erly against a passive and flexible skin–orbicularis layer. Despite all efforts, there is no observable crease formation. Patients often
complain of fatigue, a feeling of tightness, and may show brow and forehead overaction.
Restriction on upgaze, poor
crease indentation, possible ptosis
Lid (levator) at rest
Lid open (looking ahead)
need revisional surgery, whose problems are severe and
who are unlikely to have any skin reserves in the future
because of natural aging. Patients with just enough eyelid
closure to avoid corneal exposure can develop such symp­
toms if the usual method of excision of the scar and lysis
of adhesion of the middle lamella is followed. The amount
of skin removed can be as little as 2 mm, and poor eyelid
closure can be the result.
An ideal solution to this dilemma is to approach the
scarred anterior and middle lamellar complex through a
superiorly beveled approach. To do this, the following
conditions must be met.
The crease height is evaluated, and if it is high then
the degree of planned lowering (in millimeters) will
determine the minimum amount of skin redundancy
above the existing crease (over the preseptal region) that
needs to be in reserve. For example, if the suboptimal
crease is currently at 10.5 mm and you plan to lower it
to 7.5 mm, then the patient will need to have 3 mm of
skin in reserve above the crease before this is feasible. If
there is only 2 mm, then this needs to be discussed with
the patient, as the crease can only be revised down to
8.5 mm in the current situation, or the patient can opt to
wait for some skin to become available as a result of
natural aging (and they may proceed to revision at that
time). If this cannot be achieved and the patient is desper­
ate, for either functional or psychological reasons, then
one must discuss the option of a free skin graft.
For the majority who may be candidates for revision
without the need for skin grafting, my surgical approach
proceeds initially along the same path as in primary cases,
the major exception being that the upper and lower inci­
sion lines are marked directly next to each other on either
side of the existing scar. Patients in this category are more
likely to have had their lid crease incision made in the
8–9 mm range, as measured from the central lid margin.
The separation of the upper and lower incision lines
should be no more than 1 mm, and very rarely 2 mm. A
No. 15 Bard–Parker blade is used to make a full-thickness
incision along the marked upper and lower lines (Figure
18-2). Now, instead of using cutting cautery to go through
the orbicularis to reach the orbital septum, one uses a
sharp-tipped Westcott spring scissors to incise across the
upper line of incision in a superiorly beveled fashion
(Figure 18-3). At this stage, one is cutting through skin–
orbicularis adhesions. Small scissoring motions are then

18  Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty
257
FIGURE 18-2  ■  A full-thickness skin
incision has been made along the
upper and lower lines of the crease
marking (left upper lid).
used as the scissor blades transect the middle lamellar
scar, opening through the whitish, scarred fascial layers
between the orbicularis and the underlying levator
aponeurosis (Figure 18-4). This is carried out through
the width of the incision along the previous scar. The
beveled approach is quite similar, but steeper than in
primary cases (Figure 18-5). In this scarred middle zone
there will be much less preaponeurotic fat, as it will have
been previously excised; some residual fat globules, com­
bined with scattered smaller amorphous globules or
aprons of scattered fat droplets, may be seen (Figure
18-6). The scarred tissues in the anterior layer as well as
in the mid-lamellar zone – encompassed by the tissues
between the dotted superiorly beveled vector and the
lower skin incision (along the superior tarsal border) in
Figure 18-5 – may be excised after the forehead/eyebrow/
preseptal skin layers are carefully reset (by releasing any
restrictive surgical adhesive or drapes on the patient’s
forehead), for as long as the remaining skin still allows
passive eyelid closure. All fat is preserved. The levator
and levator aponeurosis can be identified when the scar
is released, and it is important to check for restriction
objectively (by gently pulling the tarsal plate down) as
well as subjectively by asking the patient to perform
FIGURE 18-3  ■  A Westcott spring scis­
sors is used to lyze along the upper
incisional edge in a beveled fashion.
It is cutting through skin–orbicularis
adhesions (left upper lid).

258
Asian Blepharoplasty and the Eyelid Crease
FIGURE 18-4  ■  Small scissoring motions
are applied as the scissor blades
transect the middle lamellar scar,
going through whitish, scarred fascial
layers between the orbicularis and the
underlying levator aponeurosis (left
upper lid).
FIGURE 18-5  ■  (A) Beveled approaches in primary Asian blepharoplasty: trapezoidal debulking of the skin and preaponeurotic plat­
form. (B) Superiorly beveled approach in revisional Asian blepharoplasty. Note the gentler beveled approach used in the primary
case versus the much steeper (oblique) approach taken in revisional attempts. This is necessary in the latter situation to preserve
skin and to allow identification of the former preaponeurotic zone. In this scarred middle zone one frequently finds some residual
larger fat pads combined with scattered smaller amorphous fat globules or aprons of scattered fat droplets. The scarred tissues in
the anterior layer as well as the mid-lamellar zone, encompassed by the tissues between the dotted superiorly beveled vector in
the diagram and the lower skin incision (along the superior tarsal border), may be excised after the forehead/eyebrow/preseptal
skin layers are carefully reset, as long as the remaining skin allows passive eyelid closure. All fat is preserved.
A Primary Asian blepharoplasty
B Revisional blepharoplasty

18  Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty
259
FIGURE 18-6  ■  After the preaponeu­
rotic space is reached, within this
scarred middle zone one frequently
finds some residual larger fat glob­
ules combined with scattered smaller
amorphous fat globules or aprons
of
scattered
fat
droplets
(right
upper lid).
upgaze and downgaze. The benefits and advantages of
this approach are as follows:
1. By approaching the preaponeurotic space very
close to and barely superior to the suboptimal
scarred crease line, one can avoid taking out a pre­
cious 0.5 or 1 mm of good skin.
2. By making the upper line of incision close to the
scarred crease line, one avoids creating an extra
incisional scar.
3. This beveled approach to the previously explored
preaponeurotic space allows the space to be entered
safely again, without injury to underlying levator
muscle and Müller’s muscle, as well as avoiding any
anastomotic vascular arcades in Müller’s muscle
and the superior tarsal arteriolar arcade.
4. In some cases, this beveled maneuver towards the
preaponeurotic space frees up the vertical excursion
of the upper eyelid significantly, releasing any
restriction that may have contributed to lagoph­
thalmos and acquired ptosis. This maneuver in
itself may correct the mild ptosis, such that reset­
ting of the previously high crease is then feasible.
5. Approaching the preaponeurotic space in any revi­
sional upper blepharoplasty allows one to identify
residual preaponeurotic fat that may have spread
out and become plastered down on the levator
muscle. This residual fat can be peeled off and
repositioned at a higher level within the sulcus to
help reverse some of the hollow sulcus often seen
in patients needing revisional blepharoplasty.
6. Mid-lamellar scarring that has previously bonded
the anterior and posterior layers can be safely
removed or reduced, allowing partial restoration of
the glide zone.
Following revisional Asian blepharoplasty using a
superiorly beveled approach, the glide space has been
partially restored and the scar carefully removed (Figure
18-7). The preaponeurotic platform is cleared of any
interfering tissues. Although the surgeon is often forced
to make a skin incision that is still further from the lid
margin than one would for a primary Asian blepharo­
plasty, upon closure the incision wound is free to indent
inwards when the levator contracts, forming a better
crease. The residual fat pads in the middle (glide) zone
are preserved and allowed to fill in this space where
appropriate. (In severe cases a fat graft may be considered
in this space.) Skin above the incision is now free to hang
down and around to form the contrasting eyelid fold.
DYNAMICS OF THE UPPER
EYELID CREASE
In a traditional approach to primary upper blepharo­
plasty, the upper and lower lines of incision are normally
made with the surgical blade perpendicular (90°) to the
skin. The skin, muscle and preaponeurotic fat are reduced
by excision in an appropriate fashion. Upon closure of
the wound and reformation of the crease (incision line
closure), the preaponeurotic space is allowed to be set
inferiorly and now reaches an area over the superior tarsal
border. Three scenarios follow.
1. If the exposed preaponeurotic fat was com­
pletely excised, what remains of the septum and
overlying preseptal orbicularis is now lying over

260
Asian Blepharoplasty and the Eyelid Crease
allows the immediate vicinity of the upper inci­
sional skin edge to be in contact with the preaponeu­
rotic space thus created.
In the last two situations, where fat was only partially
excised (or repositioned superiorly), whether via a tradi­
tional rectangular debulking of the preaponeurotic plat­
form or via a trapezoidal debulking of the soft tissues, the
preaponeurotic space over the preseptal mid-region of
the upper lid has been preserved. There is fat buffering
(preservation of the preaponeurotic space or glide zone)
as well as a soft tissue mass (consisting of the preseptal
skin, orbicularis, orbital septum, and preaponeurotic fat)
bellowing on top of a dynamically elevating tarsal plate.
The redundant soft tissue platform (previously referred
to as preaponeurotic platform) has been reduced by an
appropriate amount. The crease formed is dynamic and
natural from an aesthetic viewpoint.
The restoration and preservation of the preaponeu­
rotic space is an essential element in the primary addition
of a crease for an Asian with a creaseless eyelid, for it is
and directly in contact with the levator aponeurosis,
with no fat buffering. There is a good chance that
the preaponeurotic space (glide zone) will be oblit­
erated. The result is a deep-set supratarsal sulcus as
well as poor crease formation.
2. If there were only partial or conservative removal
of fat, there is the possibility that some fat will still
be interposed between the preseptal orbicularis
muscle (anterior layer) and the aponeurosis (poste­
rior layer).
3. In my beveled approach towards the upper incision
line, upon surgical closure of the incision the upper
skin edge alone is attached to aponeurosis along the
superior tarsal border as well as the lower skin edge;
there is also preservation of the preaponeurotic
space and fat down to the superior tarsal border,
coupled with some fat buffering in the glide zone.
More orbicularis fibers are removed along the
upper incisional edge, as the orbicularis was
transected in an upwardly beveled fashion. This
FIGURE 18-7  ■  Following revisional Asian blepharoplasty using a superiorly beveled approach (see Figure 18-5), the glide space has
been partially restored and the scar removed. The preaponeurotic platform is cleared of any interfering tissues. Although the surgeon
is often forced to make a skin incision that is still further from the lid margin than one would for a primary Asian blepharoplasty,
upon closure the incision wound (white dot) is free to indent inwards when the levator contracts, forming a better crease. The
residual fat pads in the middle (glide) zone are preserved and allowed to fill in this glide space where appropriate. Skin denoted by
the red and blue dots above the incision is now free to hang down and around to form the contrasting eyelid fold.
Lid (levator) at rest
Lid open (looking ahead)

18  Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty
261
author, as most surgeons nowadays know not to remove
too much fat in Asian eyelids; however, not so many are
familiar with trapezoidal debulking using a beveled
approach as applied to Asians.)
Often a patient will present with a history of upper lid
aesthetic surgery and exhibit a flattened or absent crease
with a mild hollowing of the sulcus. The patient may have
poor crease formation for a number of reasons, including
poor surgical adhesion between the skin edges and the
aponeurosis, or the presence of an amorphous sheet of
fat that appears plastered down over the entire aponeu­
rosis within the preaponeurotic space between skin and
levator.
The beveled approach as applied in revisional Asian
blepharoplasty allows the surgeon to reach the preaponeu­
rotic space safely, to reposition any remaining preaponeu­
rotic fat superiorly to fill in the hollow, and to approach
the preaponeurotic space without having to sacrifice pre­
cious millimeters of skin along the upper skin incision
line through excision. In other words, you are making
sure that your incision will not add to the problem, while
allowing yourself access to the eyelid’s preaponeurotic
space to excise middle lamellar scar, re-establish a glide
interface and to recreate a relatively physiologic and
dynamic crease (Figure 18-8).
the up-vectoring of the tarsal plate, coupled with the
attendant presence of fat in the preserved preaponeurotic
space, that helps create the appearance of a well-formed
crease under a preseptal eyelid fold contour of the mid-
section of the upper eyelid.
It would be undesirable to completely excise fat,
thereby obliterating the preaponeurotic space, flatten the
preseptal mid-section and create a supratarsal sulcus on
an Asian upper lid.
The following reasoning is applied to revisional
blepharoplasty. By utilizing the superiorly beveled approach
along the upper line of incision, I aim to preserve the
integrity of the preaponeurotic space. If the patient has
previously undergone a traditional rectangular debulking
with partial excision of fat, this approach will allow one
to locate the preaponeurotic space without much diffi­
culty. If the previous surgeon carried out the trapezoidal
debulking method,1 it is relatively easy to find the
preaponeurotic space, as I do when performing touch-up
enhancement of the crease. If the patient has undergone
rectangular debulking with total fat removal, the beveled
approach still gives a greater chance of reaching a familiar
surgical landscape, that is, the preaponeurotic space.
(The fourth scenario of trapezoidal debulking with com­
plete fat removal has not so far been encountered by this
FIGURE 18-8  ■  (A) Preoperative appearance prior to revision. (B) Postoperative appearance after revision.
A
B

262
Asian Blepharoplasty and the Eyelid Crease
TABLE 18-1 Revisional Data in a Series of 48 Eyelids, Showing Age, Gender and Degree of Lowering
of Crease Height in Millimeters
Age and Gender
Preop OD
Postop OD
Change
Preop OS
Postop OS
Change
1
42F
12
7.5
4.5
11
7.5
3.5
2
38F
11
7.5
3.5
10
7.5
2.5
3
46F
11
7
4
10
7
3
4
60F
10
6
4
10
6
4
5
54F
9.5
7.5
2
9.5
7.5
2
6
32F
9
7
2
9
7
2
7
32F
8.5
6.5
2
8
22F
8.5
7
1.5
8.5
7
1.5
9
23M
8
7
1
8
7
1
10
63F
9
7
2
9
7
2
11
36F
12
8
4
14
8
6
12
58F
12
7
5
12
7
5
13
65F
11
7
4
11
7
4
14
29F
9
7
2
9
7
2
15
22F
9
8
1
9
8
1
16
55F
10
7.5
2.5
10
7.5
2.5
17
66F
9
6
3
8.5
6
2.5
18
30F
11
8.5
2.5
10
8
2
19
34F
9.5
8
1.5
20
25F
8.5
7
1.5
8.5
7
1.5
21
39F
9
7
2
9
7
2
22
47F
11
8
3
11
8
3
23
28F
8
6.5
1.5
24
63F
10
7
3
25
26F
9.5
6.5
3
9.5
6.5
3
26
28F
12
6
6
12
8
4
Subtotal =
240.5
172
68.5
235
171.5
63.5
Statis. Mean =
10.02
7.17
2.85
9.79
7.15
2.65
Total (OD + OS) =
475.5
343.5
132
Overall Mean =
9.9
7.15
2.75
Scarring seen in suboptimal cases of aesthetic surgery
of the Asian upper eyelid may include spreading of the
incisional skin, high placement of the lid crease, induced
lagophthalmos on downgaze, and acquired secondary
ptosis on straight-ahead as well as upgaze. Intraopera­
tively, one sees middle lamellar scar involving the orbicu­
laris oculi as well as the orbital septum, or the presence
of dense scar tissue plaques that may bind the anterior
orbicularis oculi as well as the posterior levator aponeu­
rosis. Instead of having a physiologically preserved ‘glide
zone’ where preaponeurotic fat pads are still present in
the lowest aspect of the glide space, there is now a con­
densed apron (plaque) of tissue preventing the posterior
layer from up-vectoring properly against a passive and
flexible skin–orbicularis layer.
Within the author’s practice, a series of 26 patients and
48 eyelids underwent revisional blepharoplasty over four
years for the specific purpose of revising a post-surgical
high crease to a lower position.6 Excluded from this series
were all primary Asian blepharoplasties, including any
patients with a pre-existent high crease, touch-up surgery
for the purpose of enhancing (deepening) an existing or
surgically created crease, correction of incomplete crease
or crease shape alone, and simultaneous correction of
acquired or involutional ptosis in conjunction with
primary Asian blepharoplasty. There were five males and
21 females, and with the exception of four patients who
requested unilateral crease revisions, all others were
bilateral.
The data were arranged in two sets of columns (Table
18-1): OD for the right upper lid, OS for the left upper
lid. The third column of each of these two clusters of data
reflects the difference between the preoperative and post­
operative measurements. There were 24 eyelids in each
category, for a total of 48 eyelids. The data were pooled
to arrive at the overall statistical mean. The pre-revisional
crease height was measured in the office using a milli­
meter scale and ranged between 8 and 14 mm, with the
overall mean being 9.9 mm. The crease height designed
during revision (in 0.5 mm increments) varied between
6.0 and 8.5 mm based on the circumstances, with the
mean being 7.15 mm; and 7 mm was the most often
applied measurement during surgery under local anes­
thetic. The effective lowering of the crease height ranged
from 1 to 6 mm when reassessed during 2-month post-
revisional visits. The mean lowering of crease height was
2.75 mm in this series, based on 2 months follow-up. The
typical course is such that the crease height will continue

18  Advanced: Beveled Approach and Mid-Lamellar Clearance in Revisional Asian Blepharoplasty
263
REFERENCES AND FURTHER READING
1. Chen WPD. Concept of triangular, rectangular and trapezoidal
debulking of eyelid tissues: application in Asian blepharoplasty. Plast
Reconstr Surg 1996;971:212–218.
2. Chen WPD. Asian blepharoplasty: a surgical atlas. Oxford:
Butterworth–Heinemann, 1995.
3. Chen WPD. Asian blepharoplasty – update on anatomy and tech­
nique. J Ophthalmol Plast Reconstr Surg 1987;3:135–140.
4. Chen WPD. Aesthetic eyelid surgery in Asians: an East–West view.
Hong Kong J Ophthalmol 2000;3:27–31.
5. Chen WPD, Khan JA. Color atlas of cosmetic oculofacial surgery
(with DVD), 2nd edn. Philadelphia: Elsevier Science/Saunders,
2010.
6. Chen WPD. Beveled approach for revisional surgery in Asian
blepharoplasty. Plast Reconstr Surg 2007;120(2):545–552.
to settle down with egress of swelling and wound healing,
such that the effective lowering of the crease would likely
increase had it been possible for all these patients to
return after a lengthier follow-up period.
The use of a superiorly beveled approach in revisional
Asian blepharoplasty can allow the glide zone to be par­
tially restored and the middle lamellar scar removed. The
preaponeurotic platform can be cleared of any interfering
tissues. The combination of techniques described in this
chapter often allows an abnormally high and static scar
line to be repositioned into a lower and more dynamic
crease, to the point of being acceptable for the patient.
The need for skin grafting may often be avoided.

265
ADVANCED: ANGLE OF
OBSERVATION, CREASE HEIGHT AND
ITS EFFECTS ON CLINICAL OUTCOME
OF UPPER BLEPHAROPLASTY
C H A P T E R 1 9 
This chapter deals with the author’s concepts regarding
the height and depth of an eyelid crease, which change
in different view positions with respect to the patient’s
gaze, as well as the clinician’s observing angle.
An individual’s upper eyelid crease height varies in its
measurement and is influenced by various factors, includ­
ing resting position, angle of observation and presence of
associated ocular abnormality. Its effects should be taken
into consideration in planning primary aesthetic and revi­
sional surgery of the eyelids.
FIGURE 19-1  ■  The position of the upper
eyelid crease.
ANATOMIC DEFINITION OF AN UPPER
EYELID CREASE
The upper eyelid crease is a natural indentation of the
eyelid skin, usually found along the level of the superior
tarsal border, which is apparent when the subject opens
their eyelid (Figure 19-1). It is believed to be a result of
contraction of the distal fibers of the levator aponeurosis,
pulling up on the tarsus as well as the pretarsal skin and
orbicularis in a superior–posterior direction against a
relaxed preseptal segment of the anterior lamella of the
upper lid (skin, orbicularis, orbital septum and preaponeu­
rotic fat).

266
Asian Blepharoplasty and the Eyelid Crease
FIGURE 19-2  ■  This shows the patient with eyelids open and looking straight ahead. The lid crease is an indentation of the skin that
corresponds with the superior tarsal border, where levator aponeurosis inserts on to as well as branching forward into orbicularis
muscle sheaths and skin under the eyelid crease. CH 2 refers to the crease height observed when the observer and subject are both
in a neutral gaze position.
CH 2
VISUAL AXIS ANGLE (Vax)
Downgaze (Figure 19-3)
In downgaze, the inferior rectus and superior oblique
muscles contract while the superior rectus and levator
muscle relax, stretching the latter to its longest length. For
a person who has a natural crease, downgaze results in the
shallowing or disappearance of the upper crease, though
there is still a faint skin line that is observable on its skin.
Upgaze (Figure 19-4)
The crease is deepest when the upper eyelids are open
and looking upward maximally – where the levator muscle
POSITION OF THE UPPER LID AND ITS
EYELID CREASE
Depending on the tilt of the face, there is an observable
variance in the apparent height of the upper lid crease.
Most individuals with an upper eyelid crease will show
the crease optimally in a straight-ahead gaze position
(Figure 19-2).
is presumably maximally contracted and at its shortest
length. The angle of upgaze as measured from horizontal
can be designated as a positive (+) Vax (Vax = patient’s
visual axis angle, relative to the horizontal axis).
If this same person should tilt the vertex (top of head)
backward slightly (in a chin-forward position) and still
maintain forward gaze with a posterior head tilt, as far as
the eyeball is concerned this is similar to a downgaze and
therefore the crease is less deep and obvious.

19  Advanced: Angle of Observation, Crease Height and Its Effects on Clinical Outcome
267
FIGURE 19-4  ■  With the eyes of the patient looking up, the
levator muscle is maximally contracted and the crease is
deepest when viewed externally.
(+) Vax
FIGURE 19-3  ■  The patient’s visual axis is looking down­
ward, Vax is negative and crease indentation is minimal.
(–) Vax

268
Asian Blepharoplasty and the Eyelid Crease
FIGURE 19-5  ■  The patient’s visual axis is looking upward, Vax is positive and crease indentation is maximal. If the examiner is stand­
ing, the angle of observation (ao) will be higher than that of the patient’s eyelids, and can be denoted as a positive angle of obser­
vation. CH 1 represents an artificially shortened crease height when the upper lid is retracted on upgaze.
(+) Vax
(+) ao
CH 1
Posterior Head Tilt
Interestingly, a significant proportion of Asians with
a single eyelid tend to have a detectable vertex-back,
posterior head-tilt. This is analogous to a slight down­
ward gaze with a negative (−) Vax, inclining their levator
muscle towards a more relaxed state, and further dimin­
ishing the pull on the pretarsal segment. There may be
several reasons: in single-lidded individuals, their single
lid fold tends to obstruct the upper 5–10 degrees of their
superior field of vision, and this posterior head-tilt may
be a compensatory move in an attempt to see better.
There is also the possible co-occurrence of latent ptosis
or presence of detectable mild ptosis. Since birth, these
individuals may adapt and use a slight head-back posture
to clear their visual axis. They are often quite surprised
when this is pointed out to them using photography from
their sides or mirrors. Indeed, even after successful surgi­
cal enhancement or addition of an upper eyelid crease,
many patients often shallow their newly found crease
without knowing it when they assume their previously
accustomed head-back position. The well-formed crease
may not fully invaginate until the person’s face is fully
frontal with straight-ahead gaze (at zero Vax).
Positive Vax
As mentioned before, the levator muscle is at its maximum
contraction on upgaze; here the eyelid crease appears the
deepest. We can consider the patient’s visual axis angle
(Vax) in this maximal upgaze position as being its maxi­
mally positive angle away from a straight-ahead zero
angle (Figure 19-5).
Positive ao
When the examiner is standing in a higher observing
position relative to the patient’s eyes, with the patient
looking back at the observer’s higher position, the crease
will appear deeper due to a positive angle of observation
(+ ao) from the observer as well as having the patient look
up with a positive Vax (see Figure 19-5). This is similar
to asking the patient to tuck his/her chin in towards the
sternum while looking ahead with the examiner in a level
position observing back towards the patient, essentially
placing the patient’s eye in an upgaze position relative to
its orbit. CH 1 is less than CH 2.

19  Advanced: Angle of Observation, Crease Height and Its Effects on Clinical Outcome
269
Negative Vax
The levator is at its most relaxed state when the eyes look
down, with the upper lid as well as superior rectus in a
relaxed state (Figure 19-6). Here the visual axis angle (as
measured downward from the straight-ahead zero angle)
is at its maximally negative angle, and the crease’s invagi­
nation would naturally shallow or fade as downgaze
progresses.
Negative ao
If the patient is located at a higher position than the
examiner, the examiner is at a lower position and looking
up (creating a negative ao) while the patient is looking
down and has a negative Vax. The crease looks shallowed
(see Figure 19-6). CH 3 is greater than CH 2 and repre­
sents the anatomic crease height.
CH 3
(–) Vax
(–) ao
FIGURE 19-6  ■  The patient’s visual axis is looking downward, Vax is negative and crease indentation is minimal. If the examiner’s
eyes are looking up from an inferior position relative to the patient, the angle of observation (ao) up at the patient can be denoted
as a negative angle of observation. CH 3 represents the true anatomic crease height as seen upon downgaze or lid closure.

270
Asian Blepharoplasty and the Eyelid Crease
Neutral Vax (= Zero)
When a person with a natural crease is looking straight
ahead with a horizontally-leveled gaze (set as zero Vax),
the crease is optimally manifested, neither too deep nor
too shallow. In this author’s view, the same dynamic
feature should be expected of a crease that is surgically
constructed. The surgical method thus chosen for an
Asian eyelid crease should reflect and demonstrate these
objectives.
ANGLE OF OBSERVATION (AO)
The examiner’s angle of observation (‘ao’) should also be
standardized. It should be level and perpendicular to the
subject’s upright face; this will be the examiner’s zero
angle of observation (ao = 0) looking straight ahead (see
Figure 19-2).
Therefore with either the Vax or ao schema, a positive
value of each is associated with a deepening of the crease,
and a negative value of either is associated with a lessen­
ing of the crease.
For study or documentation purpose, the Vax and ao
should always be observed in a zero value position (patient
and observer looking level and straight ahead at each
other).
In elderly patients with involutional ptosis, often we
see what was a normally positioned crease during the
individual’s youth eventually giving way to a higher, less
distinctive crease with onset of ptosis. The reasons are
three-fold: there is an age-related weakening of levator
aponeurotic muscle and its attachment along the superior
tarsal border, a weakening of pretarsal and preseptal
orbicularis muscle near the area in front of the superior
tarsal zone, and a drop in upper lid margin (causing a
slight posterior head tilt and inducing a negative Vax),
plus shallowing of their crease indentation. The weaken­
ing of orbicularis fibers between the superior tarsal
border and its overlying skin results in lessening of distal
aponeurotic fibers that had previously pulled in the eyelid
crease at its original position. The few aponeurotic
branches that remain are superior to this zone of dehis­
cence, which then constitutes what clinicians describe as
the ‘crease that migrated upward’; this remnant of the
crease is shallower and not a true anatomic crease since
it does not indent well at this higher position.
The significance of these concepts is that the ‘crease
depth’ often comes into discussion between patients and
doctors and it is best to have a clear understanding of
what a well-formed natural crease does, what a surgical
crease should do (dynamic, soft and natural etc.) and what
qualifies as an inadequate crease (in terms of depth, con­
tinuous or incomplete etc.). Even more importantly, it is
surprising for this author to hear how often the doctors
and patients may not have discussed in detail the goals of
where the crease height ought to be.

271
ADVANCED: THE CONCEPT OF
TARSAL TILT – ITS EFFECTS IN
NORMAL AND ABNORMAL
CLINICAL CONDITIONS
C H A P T E R 2 0 
This chapter deals with the author’s original finding that
the natural tilt of the eyelid’s tarsal segment is at approxi­
mately 45° when the eyelids are open. The crease height
is inaccurate when measured vertically and actually cor­
responds to the true anatomic crease height through a
factor of √2 ÷1.0, assuming a 45° isosceles triangle, or is
1.41 X, with X being the frontally measured vertical
extent. In other words, the vertical measurement with
opened eye underestimates the true crease height by a
factor of 1/√2. Inaccuracy in discussion and measure­
ment of crease height are a major cause of problematic
suboptimal outcomes.
Figure 20-1A shows the author’s concept of tarsal tilt,
with the sloping angle of the tarsal plate and pretarsal
segment (where the crease is located) varying between 45
and 50°. This angle can be investigated through mathe­
matical modeling and clinical measurements using pho­
tography and MRI.
Proper understanding of the effect of the tarsal tilt and
its effect on apparent crease height is critical for any
practitioner contemplating eyelid surgery. The tarsal
tilting reduces the apparent crease height as well as influ­
encing Caucasians’ and Asians’ anatomy differentially in
both normal state and various conditions of eyelid mal­
positions. Using mathematical modeling as well as clini­
cal examples, this chapter will relate the effects of this
with respect to common errors seen in aesthetic upper
blepharoplasty.

272
Asian Blepharoplasty and the Eyelid Crease
Anatomic
crease height
Tilted crease
height (Tch)
,°
A
FIGURE 20-1  ■  (A) The incline angle (I°) represents the tarsal tilt when the lid is open with eyes looking ahead. The height of the
tarsus is represented as the line in red, and corresponds to the Anatomic crease height. It is best measured when the eye is looking
down or both upper and lower lids are apposed. The vertical measurement of this is the blue Tilted crease height (Tch).

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
273
(B) When there is an eyelid fold over the crease as in this drawing, what we are left to see in place is the blue
line minus the height of the lid fold to yield the green Apparent crease height. Patients often deal with the blue and green line
measurements while physicians should measure the red line, and be aware of the implications of these other factors.
I°
Apparent crease height
I°
Anatomic crease height
Tilted crease height (Tch)
Incline angle
B
I°
FIGURE 20-1, cont’d  ■

274
Asian Blepharoplasty and the Eyelid Crease
FIGURE 20-2  ■  Side view of a young woman positioned in front of a slit-lamp biomicroscope with the frontal plane aligned vertically.
The surface of pretarsal skin and underlying upper tarsus is measured to be at an incline (tilt angle) of 41° relative to the horizontal
axis.
41°
DISCREPANCY BETWEEN OBSERVED
APPARENT CREASE HEIGHT AND TRUE
ANATOMIC CREASE HEIGHT
We often see teaching staff demonstrating to house staff
the nuances of measuring levator function (excursion) by
placing a millimeter ruler along the face and eyelid,
perhaps at the central portion of the upper lid margin.
The measurement of the crease height is often taken in
a similar position. To get the true anatomic crease height,
we should have the patient looking downward, such that
the upper lid pretarsal zone is almost vertical, or measure
the eyelid crease height with the lids closed; we then
obtain the true anatomic crease height, which is usually
located at and corresponds to the height of the central
tarsus.
In the figure we see here of a young adult (Figure
20-2), the upper tarsus is measured to be at a tilt angle
of 41° from the horizontal axis.

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
275
ASIAN ANATOMY
Take for example a natural 7 mm crease for an Asian
upper eyelid. Figure 20-3A shows the upper lid in a
closed or down-turned position, while Figure 20-3B
illustrates the lid in its normal, open position looking
ahead. When the face is vertical and the eyes are looking
ahead, the crease is optimally manifested and tucked in
under its eyelid fold. The superior tarsal platform is
angled supero-posteriorly in a tilted direction, close to a
tilted incline angle (I) of 45°. The tarsus therefore mani­
fests tarsal tilt.
Inclined crease height (Ich) or ‘tilted crease height’
(Tch) (blue in Figure 20-1) is the crease height as seen
and measured vertically by an observer sitting across
from the subject (eyes are open), and is always less than
the true anatomic crease height.
An anatomic crease height of 7 mm (pretarsal skin or
tarsus, red line in Figure 20-1) can be thought of as being
aligned on the hypotenuse of a 45° isosceles triangle,
while the two remaining sides of this hypothetical trian­
gle are the vertical axis and the horizontal axis (each of
the two sides will be approximately 7 mm × (1/√2),
equaling 5 mm vertically and horizontally). Therefore a
natural 7 mm crease will appear to the examiner as occu­
pying 5 mm in vertical height from the most indented
part of the crease to the eyelash margin (inclined or
‘tilted’ crease height, Tch), and about 3 mm only if there
is 2 mm of eyelid fold overhanging it (the portion showing
below the edge of the lid fold will be the clinically ‘appar­
ent crease height’). Therefore it is quite normal for a
single-eyelid patient to ask for a 3 mm crease for an end
result; the practitioner should realize that it needs to
come from a 7 mm anatomic crease placement.
FIGURE 20-3  ■  (A) The diagram shows the upper lid in
a closed or down-turned position, while (B) illustrates
the lid in its normal, open position looking ahead. When
the face is vertical and the eyes are looking ahead, the
crease is optimally manifested and tucked in under its
eyelid fold. The superior tarsal platform is angled supero-
posteriorly in a tilted direction, close to a tilted incline
angle (I) of 45°. The tarsus therefore manifests tarsal tilt.
Anatomic
crease
height
Crease
line
Tilted crease
height (Tch)
I°
A
B

276
Asian Blepharoplasty and the Eyelid Crease
Apparent crease height
Inclined crease height often
measu
<
(
red vertically
Anatomic crease height
) <
or
Anatomic crease height
Inclined crease height
Apparent cre
>
>
ase height
implying that the surgical design of a crease height is
inherently higher, up to a certain anatomic boundary,
than what the patient observes or perceives.
The apparent height of the crease is less than the tilted
crease height we see, by the millimeters of overhanging
lid fold:
FIGURE 20-4  ■  MR scan image of a patient
showing the digitally-measured angle of
the open upper eyelid’s tarsal segment
to be inclined (tilted) at 44.45° to the
horizontal.
Tilted crease height
Fold
Apparent crease height
−
=
Apparent crease height
Fold
Tilted crease height
+
=
Tilted crease height is not worth measuring clinically,
though it is usually approximately equal to 1/√2 (= 0.72
or five-sevenths) of the true anatomic crease height; the
anatomic crease height should be measured with the
eyelids closed or looking down.
Another crude method of measuring the tarsal tilt in
an open eye is through MRI scan. In Figure 20-4 we see
an image of a patient showing the measured angle of the
open eyelid’s tarsal segment to be 44.45°.

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
277
METHODS OF INVESTIGATION AND
ANALYSIS: MATHEMATICAL MODELING
Mathematical modeling is often used by engineers and
physicists to simulate real life scenarios when it is not
feasible to measure complex events at the current stage
of technology available, for example weather patterns,
earthquake predictions, nuclear weapon testings, or aero­
dynamics of rocketry. Next to feasible actual measure­
ment, it is considered the gold standard when it comes
to accuracy; I will attempt to do the same here using basic
geometry and trigonometry.
When the eyes are open, the tilt angle of the pretarsal
segment of the upper lid (including skin, orbicularis,
tarsal plate) as it lies on the eyeball may vary between 40
and 50° (assuming that the upper lid margin, hence
tarsus, rests at the location of the upper corneal limbus
and the tarsal plate extends superiorly beyond this point);
we shall designate this tarsal resting angle as the incline
angle, I.
Normal Eye Schema
The human eye has an axial diameter of 25 mm, with a
radius of 12.5 mm and a circumference of 78.5 mm. Each
millimeter on the globe surface will subtend 4.6° as meas­
ured from the center point of the eye (360° ÷ 78.5 mm
= 4.6° per millimeter of circumference).
[Optional reading: We will make several assumptions.
Although various eye specialists may consider the resting
position of the upper lid in an open eye as between supe­
rior corneal limbus (in youngsters) and one millimeter
below superior corneal limbus (adults), we will assume it
is at superior limbus to eliminate the difference in corneal
and scleral curvatures affecting the calculations, if there
is any. We will also discuss the two abnormal clinical
conditions of upper lid retraction of 2 mm above limbus
(2 mm scleral show), as well as ptosis when the upper lid
covers 4 mm down from limbus (4 mm of superior cornea
covered). This is similar to if we should adopt that 1 mm
coverage of superior cornea is the natural position of the
upper lid in the open eye position, and then these two
abnormal clinical conditions stated above will be equal to
3 mm of retraction from the original resting upper lid
position (of 1 mm covering cornea) with a resultant
2 mm scleral show; while the 4 mm ptosis down from
superior limbus is essentially a 3 mm ptosis from the
defined resting upper lid margin at 1 mm corneal cover­
age. You can also think of this as trying to simulate what
happens with a non-linear function like sine function,
when we deviate upward and downward an equal amount
of 3 mm in each direction, if we assume the resting upper
lid margin is located at 1 mm below the superior limbus.]

278
Asian Blepharoplasty and the Eyelid Crease
FIGURE 20-5  ■  Model for a Caucasian eye with a 10 mm upper tarsus. For details see text.
10 mm
r = 12.5 mm
5 mm
67°
46°
23°
I°
Caucasian with 10 mm Tarsus
(Figure 20-5)
Let us consider a Caucasian adult with the upper tarsus
measuring 10 mm in vertical size (height), measured
from the widest (central) portion of the tarsal plate. With
the upper lid completely opened, assume the eyelid
margin rests at the superior corneal limbus. Its crease will
be 10 mm from the ciliary margin. The tarsus itself will
subtend 46°of the circumference of the eye. The upper
half of the cornea, which is 5 mm, will subtend 23°. The
tarsus subtends 46°. From the knowledge that the two
radii connecting from center of the globe to the lid
margin and similarly to the crease indentation are equal,
we can calculate the incline angle (I) relative to the hori­
zontal axis for a Caucasian to be I = (180° − 46°)/2 − 23°
= 44° (see Figure 20-5).
Figure 20-5 shows a model of a Caucasian eye with a
10 mm upper tarsus. The solid circle is the eyeball. The
upper lid is not drawn here but its margin lies from the
top of the superior corneal limbus on upward. The blue
outline is an average clear cornea of 10 mm diameter.
The 10 mm arc represents the upper lid tarsus when the
eyelid is opened. (The horizontal line with the arrow is
drawn parallel to the axial line that runs from the center
of cornea to the back of the eyeball.) The dotted line is
the slope of the tarsus rather than its true location in
space (hence the tilt of the tarsus is I° when it indents to
form the crease at the blue arrow where the upper border
of the tarsus is located).
The magnitude of the tilt angle I (based on the lid
position) can be used to relate what we apparently see
(Tch) versus what we measure correctly when the lids are
looking down (or closed): we may recall from trigonom­
etry that {sine function of an angle = opposite/hypotenuse}.
Therefore, the sine function of value I (incline angle
from tarsal tilt) is equal to the observed vertical compo­
nent of the crease in space (Tch, which is not yet known),
divided by the anatomic height (the hypotenuse) of the
tarsus (whose superior tarsal border usually correspond
to the location of the eyelid crease), which is known to
be usually 10 mm in Caucasians (see also Figure 20-3):
Sine
Tch
mm
Sine
Therefore Tch
mm
mm f
44
10
44
0 69
10
0 69
6 9
° =
° =
=
×
=
.
.
.
or Caucasians.
The Caucasian tarsus projects a 6.9 mm vertical compo­
nent when examined with the eyelids opened, even
though it is actually 10 mm. The crease height appears
to be 6.9 mm when it should be 10 mm assuming that
the crease folds in at an area along the superior tarsal
border.

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
279
Caucasian with 4 mm Ptosis (Figure 20-6)
We will now model a Caucasian eye with 4 mm ptosis.
The solid circle is the eyeball. The upper lid is not drawn
here but its margin lies on the cornea with ptosis covering
4 mm of the upper cornea and is only 1 mm from totally
occluding the central optical axis. The blue outline is an
average clear cornea of 10 mm diameter. The 10 mm arc
(that covers the dotted line) represents the upper lid
tarsus. The dotted line is the congruent slope of the
tarsus at its mid-height (hence the tilt of the eyelid crease
is I° when it indents to form the crease at the blue arrow
where the upper border of the tarsus is located).
If this Caucasian had a 4 mm ptosis, the upper lid
would be covering 4 mm of the upper cornea. (Note that
ophthalmologists usually measure from a reference point
of normal upper lid margin as covering 1 mm of the
FIGURE 20-6  ■  Model for a Caucasian eye with 4 mm ptosis. For details see text.
10 mm
r = 12.5 mm
1 mm
67°
46°
4.6°
I°
cornea, so 4 mm on the cornea would actually be a 3 mm
ptosis. For simplicity’s sake and modeling purpose, we
shall use this position of 4 mm ptosis from the superior
corneal limbus. See previous discussions on assumptions
in mathematical modeling. )
Using a similar calculation as previously shown, we
know that each millimeter on the globe’s surface will
subtend 4.6°. When the lid is down 4 mm, it is only
1 mm above the equator of the eye, so that angle is 4.6°
as labeled in the model of the globe.
I (incline angle) = 67° − 4.6° = 62°, sine I = 0.89 =
Tch/10 mm, with a Tch of 8.9 mm. We will therefore see
more of the true crease height (Tch approaches closer to
10 mm) with a moderate ptosis; in this case, the value of
Tch is 8.9 mm. Stated similarly, when the upper lid drops
down, we see a greater pretarsal zone and it shows closer
to its true anatomic crease dimension.

280
Asian Blepharoplasty and the Eyelid Crease
FIGURE 20-7  ■  Model for a Caucasian eye with 2 mm of upper lid retraction. For details see text.
10 mm
r = 12.5 mm
2 mm
67°
46°
32°
I°
Caucasian with 2 mm of Upper Lid
Retraction (Figure 20-7)
Now we model a Caucasian eye with 2 mm of upper lid
retraction. The solid circle is the eyeball. The upper lid
is not drawn here but its retracted margin lies above
the superior corneal limbus with 2 mm of white sclera
showing. The blue outline is an average clear cornea
of 10 mm diameter. The 10 mm arc (peripheral to the
dotted line) represents the upper lid tarsus when the
eyelid is opened. The dotted line is the congruent slope
of the tarsus at its mid-height (hence the tilt of the eyelid
crease is I° when it indents to form the crease at the blue
arrow where the upper border of the tarsus is located).
With 2 mm of retracted upper lid margin beyond the
superior corneal limbus (or 3 mm retraction according to
ophthalmologists’ convention of 1mm covering the upper
cornea as normal upper lid position with an open eye),
the upper lid margin now rests 7 mm from the optical
center of the cornea or the equator of the globe.
We know that each millimeter on the globe’s surface
will subtend 4.6°. An upper lid margin at 7 mm above
equator will subtend 32°. This allows us to calculate: I
value = 67° − 32° = 35°.
Sine I
sine
Tch
mm
Tch is
mm
mm
=
° =
=
×
=
35
10
0 57
10
0 57
5 7
.
.
.
.
To an observer, the retracted upper lid with a tarsus of
10 mm will show a vertical component of the crease
height of only 5.7 mm vertically.

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
281
FIGURE 20-8  ■  Model for an Asian eye with upper lid tarsus of 7 mm vertical height. For details see text.
7 mm
r = 12.5 mm
5 mm
74°
23°
32°
I°
Asian with Upper Lid Tarsus of 7 mm
(Figure 20-8)
We will apply analogous calculations to Asian anatomy
for normal resting position, ptosis of 4 mm, and upper
lid retraction of 2 mm above superior limbus.
Figure 20-8 shows an Asian eye with upper lid tarsus
of 7 mm vertical height. The eyeball is still 25 mm diam­
eter. The 7 mm arc represents the upper lid tarsus when
the eyelid is opened and its lid margin is right along the
superior corneal limbus (top of the cornea). The dotted
line is the congruent slope of the tarsus at its mid-height
(hence the tilt of the eyelid crease is I° when it indents
to form the crease at the brown arrow where the upper
border of the tarsus rests).
The average Asian tarsal plate measures between 6.5
and 7.5 mm, with the majority averaging 7 mm centrally
(Figure 20-8). Remember that 4.6° is the angle subtended
(covered) by each millimeter of the globe’s circumfer­
ence. A 7 mm tarsus therefore covers 32°, and 5 mm of
the cornea (upper half) covers 23°.
With the lids opened, the tarsus has an incline angle
(I) of (180−32)/2, then minus 23°: 74 − 23 = 51°.
Sine I
sine
Tch
mm
Tch vertical component o
=
° =
=
51
0 77
7
.
(
f the crease height
mm
mm for Asians
)
.
.
.
=
×
=
0 77
7
5 4
An anatomic crease height of 7 mm in a normal Asian
will look like it is a 5.4 mm crease when viewed frontally
(vertical component is 5.4 mm). If there is an overhang­
ing skin fold of 2 mm, the observable crease height will
then appear to be (and possibly be measured incorrectly
as) 3.5 mm. (When a patient asks for a ‘lower-than-aver­
age’ crease height and the physician incorrectly interprets
an average crease as being located at 3.5 mm and then
makes an incision lower than that, it is foreseeable that
suboptimal results may follow.)

282
Asian Blepharoplasty and the Eyelid Crease
FIGURE 20-9  ■  Model for an Asian eye with 4 mm of ptosis. For details see text.
7 mm
r = 12.5 mm
5 mm
1 mm
74°
4.6°
32°
I°
Asian Eye with 7 mm Tarsus, with 4 mm
Ptosis (Figure 20-9)
We will model an Asian eye with 4 mm of ptosis. The
upper lid is not drawn here but the upper lid margin rests
4 mm below the upper corneal limbus (boundary). The
brown outline is an average clear cornea of 10 mm diam­
eter. A 7 mm arc represents the upper tarsus. The dotted
line is the congruent slope of the tarsus at mid-height
(hence the tilt of the eyelid crease is I° when it indents
to form the crease at the brown arrow where the upper
border of the tarsus rests).
For an Asian with a 4 mm ptosis, I = (180−32)/2,
minus 4.6°:
I
Sine I
sine
Tch
mm
Tch
sine I
mm
=
−
=
°
=
=
=
=
×
74 0
4 6
69 4
69 4
0 936
7
7
.
.
.
.
.
=
×
=
0 936
7
6 5
.
.
.
mm
mm
In an Asian eye with a 4 mm ptosis, we see the tilted
crease height as 6.5 mm. Conversely, if a Tch appears to
be 6.5 mm (instead of a normal Tch of 5.4 mm in a non-
ptotic eye), one should look carefully for ptosis. One will
need a high index of suspicion to detect ptosis as the dif­
ference in Tch we see between normal and severe ptosis
is only 1.1 mm.

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
283
Asian with 2 mm of Upper Lid Retraction
(Figure 20-10)
We will now model an Asian patient with 2 mm of upper
lid retraction. The solid circle is the eyeball. The upper
lid is not drawn here but its margin lies above the supe­
rior corneal limbus with 2 mm of white sclera showing.
The brown outline is an average clear cornea of 10 mm
diameter. A 7 mm arc represents the upper lid tarsus
when the eyelid is opened. The dotted line is the congru­
ent slope of the tarsus at its mid-height (hence the tilt of
the eyelid crease is I° when it indents to form the crease
FIGURE 20-10  ■  Model for an Asian patient with 2 mm of upper lid retraction. For details see text.
7 mm
r = 12.5 mm
5 mm
2 mm
74°
32°
32°
I°
at the brown arrow where the upper border of the tarsus
rests). The tarsus subtends 32° since it is 7 mm in dimen­
sion from lid margin to its superior tarsal border; the lid
margin is also resting 32° above the equator.
For the Asian with a 2 mm retracted upper lid margin,
the 7 mm tarsus presents a vertical component of only
4.7 mm.
I
Sine I
Sine
Tch
mm
Tch
sin
=
−
−
° =
−
=
°
=
° =
=
=
(
)
.
180
32 2
32
74
32
42
42
0 67
7
e I
mm
mm
mm
×
=
×
=
7
0 67
7
4 7
.
.
.

284
Asian Blepharoplasty and the Eyelid Crease
The data from these models have been inputted into
a graph plotting tarsal tilt (or incline angle, I; x-axis)
against tilted crease height, Tch (the vertical component
of the tilted segment of the crease, y-axis) (Figure 20-11).
The red squares represent Asian 7 mm tarsal anatomy;
the blue diamonds represent a Caucasian’s 10 mm tarsus.
The Condition of Ptosis in Caucasian
versus Asian
When the lid margin drops closer to the equator, the
visual gain in the crease height even without any true
clinical ‘anatomic dehiscence’ of the terminal fibers of the
aponeurosis is substantial. For a 10 mm tarsus (Caucasian,
blue diamond in Figure 20-11) with moderately severe
ptosis, the perceived dimension of an otherwise normal
crease expands by 2 mm (from ‘normal’ of 6.9 mm to
8.9 mm). The same ptosis for a 7 mm tarsal plate (Asian,
red square) only visually expands the crease from a Tch
of 5.4 mm to 6.5 mm, a visual elongation of 1.1 mm. Part
of this multiplying effect we see in Caucasian anatomy is
due to the larger dimension of the tarsus; the other reason
is that in any ptosis the crease location is dropped closer
to the center of the cornea, in effect the tilt (incline) angle
I of the tarsus is greater, and therefore the sine function
value is greater. Together, the sine function of I multiplied
by tarsal dimension (of 10 mm instead of Asian’s 7 mm
tarsus) gives a larger value for Tch in Caucasian anatomy.
This visual distortion from this more frontally observed
position no doubt contributes to the perception that the
‘crease has migrated higher in acquired ptosis’.
The Condition of Upper Lid Retraction in
Caucasian versus Asian
With a mild upper lid retraction of 2 mm in a Caucasian,
the Tch is changed from 6.9 to 5.7 mm, with the
difference being 1.2 mm. For an Asian’s 7 mm tarsus,
retraction of the same amount changes the Tch from 5.4
to 4.7 mm, a difference of merely 0.7 mm from a normal-
looking crease. The greater reduction in a Caucasian’s
Tch follows the same reasoning as before in ptosis: the
Caucasian crease along the upper boundary of tarsal
plate, now retracted 2 mm upward from the superior
corneal limbus, is sitting 17 mm of arc length away from
the corneal center (I = 35°); while the equally affected
Asian lid’s crease sits at 14 mm of arc length away from
the corneal center (I = 42°). That means the Caucasian
Tch values are affected more rapidly. The further upward
and backward the upper lid goes (as in Caucasians), then
the more flattening of tilt (I), as well as rapid changes in
the sine function value and its effect on Tch. This is due
to the fact that the sine function has a greater incremental
change as it approaches lower (lesser) angle values.
Equivalent clinical conditions of the same degree
(4 mm ptosis and 2 mm retraction) appear to be almost
twice (2 x) as manifested in magnitude for Caucasians,
starting from their larger tarsal plate relative to Asians.
This near-doubling effect in Caucasian anatomy can be
seen from the slope of a line plotting the red data points
as well as the blue data points in Figure 20-11: the Cau­
casians’ blue points are at a steeper slope than the Asians’
red points. One can also think of this as showing that
inaccuracy in planning the placement of eyelid crease
height has a greater likelihood of adverse consequences
for the smaller Asian anatomy.
CLINICAL APPLICATIONS
There is a lack of clarity among plastic surgeons and
ophthalmologists as to the ideal location for placement
of the lid crease in aesthetic blepharoplasty as well as for
reconstructive efforts. The following categories of sub­
optimal findings come to mind.

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
285
FIGURE 20-11  ■  This graph plots tarsal tilt (or incline angle, I; on x-axis) against tilted crease height, Tch (the vertical component of the tilted segment of the crease; on y-axis).
The red squares represent Asians’ 7 mm upper tarsal height as measured centrally; the blue diamonds represent a Caucasian’s 10 mm upper tarsus. For the purpose of
mathematical modeling, we will assume the normal position with the upper lid opened is set at the superior corneal limbus (at its boundary with sclera), and that a moder­
ate ptosis is when the superior lid margin is 4mm down from the superior limbus (4mm ptosis, with a MRD of 1-1.5mm), which is equivalent to a 3mm ptosis if it is measured
from a normal opening position of upper lid margin covering 1mm of cornea. We will arbitrarily set the modeling of upper lid retraction as 2 mm of upper lid scleral show,
which is a “2mm retracted upper lid” as plotted on this graph, and corresponds to a 3mm upper lid retraction from normal open-eye position clinically if we assume normal
(open eye position) is measured from having the upper lid margin rest and covering 1mm of cornea.
I = Incline/Tilt angle (degrees)
Tilted crease height (mm)
4 mm ptosis
(62°, 8.9 mm)
Normal
(44°, 6.9 mm)
2 mm retracted UL
(35°, 5.7 mm)
10
9
8
7
6
5
4
3
2
1
0
0
10
20
30
40
50
60
70
80
2 mm retracted UL
(42°, 4.7 mm)
4 mm ptosis
(69.4°, 6.5 mm)
Normal
(51°, 5.4 mm)
10 mm tarsus
7 mm tarsus

286
Asian Blepharoplasty and the Eyelid Crease
FIGURE 20-12  ■  An Asian patient whose
left upper eyelid crease was set higher
than she preferred after a lid crease pro­
cedure. One can see a deep crease inden­
tation even while the eye is on downgaze.
The nasally-tapered crease shows evi­
dence of spreading of the wound skin,
and the lateral end converges towards
the lateral canthus, and may give the
impression of a high semilunar crease.
FIGURE 20-13  ■  A young woman who
developed a deeply set, partial crease of
the right upper eyelid that is static on
downgaze, with crease height that is
excessive for her. Pretarsal fullness is
seen.
High Crease
Often I see Asian patients for revisional consultations
where the issue centers around excess skin removal with
placement of a high crease (Figures 20-12, 20-13). The
original thought process that led to this could perhaps
arise from the following faulty train of logic: ‘If a Cauca­
sian’s lid crease is aesthetically ideal at 10–11 mm, then
Asians who desire the construction of a crease should
have similar result if the crease is designed at that height.’
An undesirable outcome can be averted with a proper
understanding of anatomy, crease-vectoring biodynamics
and the effect of tarsal tilt. Even if the surgeon
conscientiously designs the crease slightly lower with
proper understanding of Asian anatomy being smaller in
scale, and sets it 1–2 mm lower than he normally would
plan for Occidentals, with the incision mark at 8–9 mm,
the set crease will still end up being too high.
This predisposes to secondary ptosis, brow compensa­
tion and lagophthalmos. Subsequently, well-meaning
attempts at resetting a high crease often remove the
initial scarred skin as well as some skin above it, further­
ing the crisis associated with skin shortage, leading to
poor closure of the palpebral fissure, as well as a persist­
ent high crease.

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
287
it is then even more unlikely to achieve a crease than in
the previous scenario. In double-eyelid procedures utiliz­
ing the suture ligation methods, this may well be a factor
that tends towards eventual crease disappearance.
Figure 20-14 shows the gradual disappearance of a
crease on a patient’s right eye, and a persistent high crease
with disjunction medially on the left eye. Revision
attempts will be more challenging for the left eye.
Following a low-set static crease, any attempts at revi­
sion through the same site of 3–5 mm from the ciliary
margin risks persistent scarring in the pretarsal platform,
and lack of proper invagination along the superior tarsal
border to form a crease.
Low Crease, Poor Crease Formation
If an Asian’s natural upper lid crease looks good and its
vertical dimension measured with a ruler is 5 mm (which
is that person’s Tch) with the patient’s face upright and
eyes opened, and the surgeon then decides to use this
measurement on a single-eyelid patient, marking it at
5 mm with the lids closed, the result will be a static scar
on the front surface of the pretarsal skin, or a temporary
crease with eventual disappearance.
A second scenario is that if the surgeon thinks the
crease should be set at 5 mm (when in fact it is 7 mm),
and the patient desires the crease on the ‘low’ side of
normal and the surgeon complies and marks it at 3–4 mm,
FIGURE 20-14  ■  Asian woman showing the gradual disappearance of a crease on right upper lid, and a persistent high crease with
disjunction medially on the left eye following lid crease procedure though external incision.

288
Asian Blepharoplasty and the Eyelid Crease
Excess Fat Removal and Attempts
at Fat Grafting
Following excess fat removal, we often see a deepened
supratarsal sulcus with wrinkle lines that appears espe­
cially incongruous among Asian patients. This is often
seen without a true crease or one may see a deeply set
high pseudo-crease.
Revisional attempts that follow then tend to make the
incisions too low and result in a low scar situated between
3 and 5 mm in the pretarsal platform. This can be averted
by proper understanding of the effects of tarsal tilt on
crease height as well as crease dynamics.
With deeply sculpted sulcal deformity following excess
fat removal, revision attempts using fat injection or
autogenous fat grafting coupled with attempts to reform
the crease are highly unpredictable. Fat injection alone
can lead to more scarring in the mid-lamellar preaponeu­
rotic space since there is no longer a healthy glide zone/
plane (see Chapter 17) nor a clear-cut space into which
one can direct the cannula needle. Even with awareness
of the effects of tarsal tilt, the importance of the glide
zone, and the beveled approach to revision of a high
crease with shortage of skin, any attempt to achieve an
improved crease at a correct position in the face of a deep
sulcus or in conjunction with fat grafting is a hit-and-miss
endeavor fraught with unpredictable outcome. The fat
graft, whether it is in the form of pearl fat or a block of
fat, may shrink or hypertrophy as well as undergo fibrous
infiltration to form a hardened mass (as seen in Figure
20-15, where the left upper lid sulcus has been filled with
fat grafts that have hypertrophied and fibrosed). This
leads to further revisional attempts.
FURTHER MATHEMATICAL MODELING
For an individual with tarsal anatomy of 8 mm vertical
height and who possesses a natural crease, I value is cal­
culated to be:
(
.
)
.
.
.
;
.
180
36 6
2
23
71 6
23
48 6
0 75
8
0 75
8
−
°
−
° =
−
=
°
=
=
×
Sine I
Tch
mm Tch
mm
mm
The tilted crease height for
mm tarsus is
mm
= 6
8
6
.
For an individual with 9 mm tarsus and who possesses
a natural crease, I equals:
(
.
)
.
.
.
.
;
180
41 4
2
23
69 3
23
46 3
46 3
0 72
9
0
−
°
−
° =
−
° =
°
=
=
=
Sine
Tch
mm Tch
.
.
(
.
)
72
9
6 48
6 5
×
=
mm
mm round out to
mm
The tilted crease height for
mm tarsus is
mm
9
6 5.
.
FIGURE 20-15  ■  Elderly lady who developed severe sunken sulcus, worse over the left side following upper blepharoplasty. This was
followed by an attempt at autologous fat graft by injecting pearl fat. The fat graft hypertrophied and formed a solid fibrous mass
(as seen here) that further impeded the functioning of the levator muscle as well as the slip-sliding between the posterior tarso-
levator-Müller’s muscle complex and the anterior lamella.

20  Advanced: The Concept of Tarsal Tilt – Its Effects in Normal and Abnormal Clinical Conditions
289
PEARLS AND PITFALLS
1. We observe that the consequences of designing an
8 mm and 9 mm crease line yields a tilted crease
height (Tch) of 6 mm and 6.5 mm, respectively.
Looking at Figure 20-11, these points occupy the
same crease height level one would see in an Asian
who has approximately a 2 mm ptosis and 4 mm
ptosis condition, respectively. (These numbers are
very close to what one sees for an average Caucasian
with a 10 mm tarsus who has a Tch of 6.9 mm.)
2. Asian eyelids, with smaller overall anatomic ratios,
are more prone than Caucasian to develop acquired
ptosis, lagophthalmos and poor closure if the crease
incision is anchored high, if excessive skin is
removed, or if the glide zone is obliterated through
overzealous excision of fat.
3. It is reasonable to suspect ptosis when you see an
eyelid that has a higher than normal crease height,
whether it is in a primary or revisional case.
4. A paradoxical truth: Looking at the 10 mm Cauca­
sian crease height line and the 7 mm Asian line on
the graph in Figure 20-11, the Caucasian’s 10 mm
tarsus yields a Tch of 6.9 mm (the tarsal tilt created a
visual drop of 3.1 mm from 10 mm), while the Asian’s
7 mm tarsus has a Tch of 5.4 mm (a drop of 1.6 mm).
It seems that the abnormal condition of ptosis and
the opposite condition of upper lid retraction have a
narrower range of expansion and contraction values
in Tch among Asians (7 mm tarsus) in a normally
positioned crease and for pathologic conditions as
compared to Caucasians with identical conditions.
The paradox here is that Asian anatomy will show a
greater vulnerability and manifest deviation from
the norm in a greater magnitude and likelihood if
the crease height is set higher or lower than where
an ideal crease ought to be. In other words, any
suboptimal planning and execution of procedural
steps can easily ‘jump’ the ethnic features into a
Caucasian feature-set, which most well-informed
Asian patients may not wish for nowadays.
5. For Asian anatomy, if one should design an 8 or
9 mm crease incision for a 7 mm tarsus for any type
of upper lid surgery (see Further Mathematical
Modeling), one will be quite off the path, leading
to a higher probability of acquired ptosis and less
than ideal invagination of the crease. Instead of a
crease developing along the superior tarsal border
junction with levator aponeurosis, one may develop
some restriction on upgaze as well as some degree
of ptosis. The crease is higher and often static in
nature, meaning it is obvious and unchanged on the
lid skin when viewed as the patient looks down. The
crease (and pretarsal segment) arising from a
8–9 mm incision may appear to exceed the tilted
crease height for even a 3–4 mm acquired ptosis
(which has a Tch of 6.5 mm, see red square points
for Asian anatomy in Figure 20-11). Therefore, the
acquired ptosis from high anchoring of the crease
will compound the static, high and unnatural nature
of the crease thus created.
6. Since the visually apparent crease height in a natural
crease is the value of the tilted crease height (Tch)
minus the overhanging lid fold, i.e. a 7 mm natural
or surgical crease has a Tch of 5 mm and an appar­
ent crease height of only 3.5 mm when there is a
1.5 mm fold overhanging, or
Apparent crease height
Tch
Overhanging fold mm
=
−
(
);
in a situation where there had been a high-anchored,
surgically created crease that is set at 8 mm or
beyond, and excessive amount of skin had been
removed with a relative lack of lid fold remaining,
the undesirable and visually apparent crease height
could be two to three times what is expected or
desired since the overhanging fold of skin is absent
owing to excision.
7. With secondary or consecutive ptosis following aes­
thetic surgery, the lid margin is down and ptotic,
the lid fold may be lessened, and the value of the
apparent crease height may be increased.
One cannot help but realize that we are working with
much tighter constraints in Asian eyelid surgery.

291
C H A P T E R 2 1 
ADVANCED: EFFECT OF
HIGH ANCHORING OF THE
CREASE, FADEN-LIKE EFFECT
AND USE OF BURIED SUTURES
This very advanced chapter deals with the author’s current
views regarding the practice of applying buried sutures
to create or magnify an eyelid crease. An in-depth analy­
sis of its adverse hindering effects is accompanied by two
demonstration video clips.
It was not long ago that the proper way for plastic
surgeons and eye surgeons to perform traditional upper
blepharoplasty was to take off as much skin and fat as
possible, and to apply a high crease fixation. The result
is a sculpted look, with a prominent and showy pretarsal
segment of skin along the lid margin, and a concave
sulcus that stretches back towards the apex of the orbit.
This look eventually lost favor when it became evident
that there is an age-related spontaneous reduction of fat
volume in the upper portion of the orbit (whether due to
shrinkage or posteroinferior movement of fat). An often
unnoticed side effect that ophthalmologists come across
from these techniques, which utilized high fixation of
crease on the lid, is that there seems to be a greater inci­
dence of consecutive ptosis (droopy upper eyelid follows
high fixation above the distal insertion of the levator
aponeurosis). Therefore, empirically:
High anchoring of crease wound closure
may lead to con






(
)
sec
→
utive ptosis

.
Bear in mind that when I say high anchoring, in my mind
it applies to something that may be only 1–2 mm off the
norm; with the norm being along the superior tarsal
border. To me 1–2 mm superior to the superior tarsal
border is enough to cause a result to be less than ideal.
(See Chapter 14 on suboptimal results and illustrations.)
Anchoring a crease at a point more proximal (closer
to orbital apex origin) than its natural likely insertional
point is akin to decreasing the contractile strength as well
as the effective contractile length of levator (along its
40 mm course from its origin at the orbital apex to its
insertion at the lid crease). Is it the strength or length
that is affected? Or both?
To understand this, ophthalmologists and house offic­
ers may recall learning how to do a posterior fixation
suture (Faden procedure1–3) when trying to weaken the
effective pull of the medial rectus muscle in strabismus
surgery, especially in large angle congenital esotropia,
where children are born with severely crossed eyes. The
placement of a posterior fixation suture is often done in
conjunction with a recession of the particular extraocular
muscle’s insertion. The idea is that by moving back from
the insertion of the medial rectus muscle and placing an
intrascleral non-penetrating lamellar stitch there (e.g.
3–5 mm posteriorly), one can further magnify the weak­
ening effect of surgical recession of the pull of the
extraocular muscle, which is the goal of repair in esotropia.
Furthermore, placement of a Faden posterior fixation
suture alone (that is, placing a suture proximal to its
insertion on the eyeball) without recessing the tendinous
insertion of the medial rectus can provide a recessional
effect. (Faden means a piece of thread in German; here it
means suture.)
Traditional theories have stated that this is due to a
loss of effective arc rotation of the globe when the contact
point is moved backward (proximally) resulting in a
decrease in rotational efficiency, or that one has rendered
the muscle’s rotation less effective through a decrease in
contractile length, or through a tethering effect when a
segment of the muscle closer to the mid-belly of it is
attached to the globe.
Oculoplastic surgeons understand that when the
levator is deliberately recessed as a form of treatment in
patients with retracted upper lids, there is lessened levator
excursion and less crease indentation owing to disinser­
tion of the levator aponeurosis. This recession of upper
lid pull can be enhanced with the interposition of spacer
graft. The lessened levator excursion leads to a secondary
ptosis, and is often protective of an over-exposed cornea.
Clark et al.,4–7 through several published papers, have
demonstrated that there may be additional factors at play,
including the rotational pulley effect where orbital tissues
can be tethered when the medial rectus is incorporated
towards the anterior muscle–orbital sheath (which invari­
ably consists of fat and fibro-connective tissue septae)
at its original insertion on the globe using a buried
stitch, and duplicating the effect of Faden posterior fixa­
tion without having to apply any intrascleral stitch pos­
terior to the medial rectus insertion. Clark attributes
the majority of the dampening effect of Faden as being
due to a change in the surrounding orbital pulley rather
than a loss of effective arc contact of the rectus muscle
on the globe. The stitch initiates the change, while the

292
Asian Blepharoplasty and the Eyelid Crease
the portion of levator and aponeurosis bounded by the
high fixation or encircling suture loops (in buried suture
methods) now having to carry a greater load of tissues (lid
margin, pretarsal segment of skin/orbicularis, tarsal plate
and preseptal skin/orbicularis and aponeurosis below and
bounded by this higher anchor). Fixating (or associating)
additional anterior lamella tissues for the levator aponeu­
rosis and Müller’s muscle (which are the posterior lamella
of eyelid) to bear is akin to the medial rectus being fixated
to adjacent orbital tissues near its pole of insertion (Clark
et al.4–7); the latter re-creates the deadening effect of pos­
terior fixation (Faden technique) where medial rectus is
stitched through partial thickness to the underlying sclera
at a location just posterior to its original insertion. The
high placement of buried sutures both traps additional
tissues as well as creates a high ‘Faden effect’ since it
tethers the levator anteriorly at a point higher than its
original insertion. The levator being tethered to skin–
orbicularis muscle anteriorly is similar to medial rectus
being intentionally tethered to orbital tissues or underly­
ing sclera. The patient often complains of heaviness of the
lids. Eventually we see the levator wearing out and the lid
may develop ptosis.
We can conceptually think of a high-anchored crease
as having an ‘ecto-Faden’, since the blepharoplasty
closure stitch is often placed anteriorly, within the levator
muscle’s distal portion.
We can see how a crease incision that is placed
higher than normal, even if only a millimeter too
high, can unintentionally lead to a restriction on the
uplift.
High fixation of crease sutures on levator
Faden like effe






-

→
ct in external
incisional blepharoplasty
(
).



The effect can be seen even if buried sutures were not
used, as long as the external sutures used were placed
higher than the ideal position and postoperatively the
constructed crease stayed at this high position.
change occurs in the tissues thus incorporated into the
insertional end of the medial rectus (at its superior and
inferior poles).
This is interesting because it shows that at least over
the insertional end of a muscle like the medial rectus,
posterior fixation suturing underneath it towards the
sclera of the eye (which I will refer to as ‘endo-Faden’,
or fixated to the inner or under layer), as well as suturing
that same location (pole) of the medial rectus towards its
surrounding soft tissues (orbital sheath and pulley mech­
anism, which I will refer to it as ‘ecto-Faden’, fixated to
adjacent or overlying layer), can each independently result
in a decrease in net function of that muscle along its
primary axis of action. Therefore:
Faden endo or ecto
can lead to weakening of
pull of medi
(
)
-






-
→
al rectus

.
This coincides nicely with the observation of second­
ary ptosis that we see in patients (whether Caucasians or
Asians) who have had their crease placed in a higher than
normal physiologic position, as well in those who under­
went permanently buried sutures methods using non-
dissolvable sutures that encircled the levator–Müller’s
muscle complex through a high reach posteriorly. (‘High
reach’ means further above the superior tarsal border).
This is likely from a decrease in net function of the
levator muscle, when the levator aponeurosis is attached
(tethered to adjacent tissues) at a point more proximal
(higher) than its usual termination along the superior
tarsal border and adjacent skin.
The net decrease in levator function can be a combined
effect of restrictive length of contraction with a higher
crease (by placing stitching closer to the levator muscle
mass, and closer towards its origin from the orbital apex
is likely to incrementally affect the optimal length-tension
point on the contractility curve of the muscle), as well as
increasing the load (by adding tissue impedance) to its
ability to lift the eyelid. This latter scenario comes from

21  Advanced: Effect of High Anchoring of the Crease, Faden-like Effect and Use of Buried Sutures
293
FIGURE 21-1 
B'
B
A'
A
3
1
2
4
In suture methods (Figure 21-1), a typical suture used
may be a double-armed 6-0 or 7-0 nylon. The first
passage (1) involves everting the upper lid margin and
passing it subconjunctivally for a couple of millimeters,
at a level typically several millimeters 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 each of the suture threads is tied on the skin at this
moment, it will be a full-thickness compression ligature
encompassing Müller’s muscle, levator aponeurosis, as
well as orbicularis oculi muscle in a posterosuperiorly
biased fashion. It also inadvertently creates a Faden effect
at each of the two locations of B′–B and A′–A, and a
horizontal contracture of the width of levator aponeuro­
sis at A′–B′. In fact, the second needle exiting the skin at
A is re-passed (4) subcutaneously across to join B (A–B),
exiting at a mini-stab skin opening there. The nylon ends
are ‘firmly’ tied and the knot sinks into the small surgical
opening. Traditionally the suture methods use three sets
of these sutures, medial, central and laterally. With three
sets of sutures, the restrictive effect is tripled. With
methods that run back and forth across the width of
the levator, the unintentional effect is amplified several
fold.

294
Asian Blepharoplasty and the Eyelid Crease
FIGURE 21-2 
(One can argue that there is a ligamentous-plicating
effect when the posteriorly biased suture loops are tight­
ened over that portion of the distal levator aponeurosis;
perhaps this explains why most of the patients who have
undergone buried sutures [non-incisional] surgery for
double eyelids tend to have a lid retraction immediately
post-procedure.)
Figure 21-2 shows a cross-sectional interpretation of
the buried sutures method. Note the position of buried
suture encompassing the active levator muscle (pink), and
Müller’s muscle, with the passive orbicularis oculi muscle
(grey) with the lids open. The posterior loop of the closed
suture is located at A′B′ in the previous drawing (Figure
21-1) while the buried surgical knot is under the skin at
A–B at the level for a proper crease (along the upper tarsal
border).

21  Advanced: Effect of High Anchoring of the Crease, Faden-like Effect and Use of Buried Sutures
295
as when the eyes are looking down or the lids closed.
There is a shortening effect on the levator due to the
vertical passages of sutures, like a plicating stitch, which
explains the often noticeable widened palpebral fissure
(eyelid opening) or slight stare, with some discomfort
on the part of the patient; while the horizontal passage
crimps the horizontal width of the levator, perhaps
weakening its capability. If the average width of the
levator aponeurosis above the superior tarsal border is
24–27 mm, one can surmise that three sets of buried
sutures will result in 3x(2–3) mm of levator with each
buried stitch = 6–9 mm of the aponeurosis (25–33%)
crimped horizontally.
Figure 21-3 shows high placement of three buried
permanent sutures on each upper lid (corresponding to
A–B, step 4 of suture passage, in Figure 21-1); the sutures
were tied under the skin. One can see obvious bumps on
the eyelid when the lid is looking downward or closed.
Functionally then, with three sets of buried stitches, a
Faden (impairing) effect has been created at six locations
vertically along the functional axis of levator muscle, and
three horizontal segments of the levator (A′–B′ and A–B)
are bunched together inadvertently. (See Video clip
Case 31 showing the dampening effect of placement of
high-anchoring stitches.)
The indented crease is created from compressing skin
towards the levator, and is seen with the lid open as well
FIGURE 21-3

296
Asian Blepharoplasty and the Eyelid Crease
FIGURE 21-4  ■  (A) Case of a patient who had a high crease set with acquired ptosis. (B) Same patient after revision involving the
resetting of the crease to a more acceptable position and release of the induced ptosis. (Photograph taken two weeks after revision
correction.)
A
B
The net long-term effect of these sutures is often a
decrease in levator function, with its manifested mild sec­
ondary ptosis or lagophthalmos (Figure 21-4 A, B). Inter­
estingly, in cases where the sutures are tied very tight and
eventually lose their intended effect due to cheese-wiring
through eyelid tissues, the restrictive effect on the levator
may be lessened somewhat with time, and the crease shal­
lows, though the functional impairment can be permanent
in some patients. One may see a disappearance (oblitera­
tion) of the intended crease but the burden of the levator-
weakening effect is retained since the placement of buried
sutures is permanent (in most cases).

21  Advanced: Effect of High Anchoring of the Crease, Faden-like Effect and Use of Buried Sutures
297
that it has made the vertical palpebral fissure more open
(‘a slight lift’). The long-term effect may often be that
the sutures are no longer effective as the knots cheese-
wire through the lid tissue resulting in no gain in height
nor formation of a permanent crease. At worst, occasion­
ally a decrease in levator excursion can result due to the
burden of having had tissues disrupted there. An exag­
gerated oblique crossing through the pretarsal segment
of the lid can result in tarsal ectropion (outward turning
of the eyelid margin as the tarsal plate is lifted off the
eyeball surface).
As for the popular DST (double stitches thread)
method, it involves a back-and-forth double passage of
buried suturing where a U-shaped hairpin loop of non-
dissolvable suture is left buried. In front of, as well as
behind the dynamic levator, we will get double the Faden
effects (ecto- + endo-Faden).
There are occasional surgeons who venture to use
buried sutures crossing the integrity of the tarsus (trans­
tarsal): the sutures are applied directly through the back
surface of the tarsal plate, maybe 2–3 mm below the
upper border of the tarsal plate (the tarsus is typically
6.5–7.5 mm in the vertical dimension for Asians, and
10 mm for Caucasians). To avoid irritation facing the
cornea, the loops of the sutures are tied tight to become
buried through the back surface of the tarsus, partially
cheese-wiring through. I imagine it does reduce its effec­
tiveness through time, and there is really nothing to gain
by violating the tarsus. The crease thus formed anteriorly
is likely a low-set static crease.
If one were to reverse-bias the passage of this suture,
going through tarsus and then tilting higher to catch
more levator (skewed superiorly), one again runs into the
problem of high anchoring. Here it is more like an ecto-
Faden in terms of its side effects on the function of the
levator, although the passage started from the backside of
tarsus.
In each of the variants of the buried sutures methods,
high anchoring tends to give a round-eyed look, with
fullness or swelling over the pretarsal segment. Some
have coined the term ‘Anime eye’ for this look.
In Table 21-1 the fifth column heading of ‘Net load
for levator’ refers to the resultant added work through
impedance to the normal action of the levator muscle
when buried sutures are used at various levels on the
levator. The term ‘resisting load’ is easier to understand,
although the term impeding load is more accurate.
It may seem that I have a negative bias towards the
buried suture methods. Indeed I should state that most
buried sutures methods may work sufficiently well for a
period of time due to the tight ligature on tissues to
create a compression-induced crease, and that most cases
do not lead to any significant complications or sequelae.
But patients are very tolerant and remain silent regarding
their discomfort for the sake of their aesthetic goals; and
also the long-term consequence of placing permanent
sutures encircling contractile muscle fibers are not well
published nor understood and only occasionally men­
tioned by clinicians, such as myself who is only just
coming to understand this after 30-plus years of clinical
work, to the point where I can now try to present it in a
more objective scientifically based framework.
Within suture methods, this effect is seen often from
the trans-lid (transcutaneous) approach, and sometimes
from the transconjunctival position. The latter direction
is more prone to result in corneal (eye) irritation.
When coming from the skin side (transcutaneous), the
suture encompasses and ties together the levator aponeu­
rosis, and possibly Müller’s muscle fibers, and orbicularis
and then the knot is buried just under skin. What is
damaging is often that the loops that tie the posterior
layers are often higher above the upper margin of the
tarsal plate (superior tarsal border); as the loop crosses
the thickness of the lid and exits on the front side, it dips
down and is biased towards a lower point to form the
desired crease indentation. When one combines the
effect of three of these ‘ecto-Faden’ lid stitches (actually
ecto- as well as endo-), and tightens them to form a liga­
ture on the soft tissues within, keeping them buried per­
manently (often 6-0 nylon or polypropylene), one can
observe that a ptosis effect is often seen after several
years, unless the stitches become ineffective (cheese-wire
through tissues) and release. The crease may then partly
disappear or completely fade, but the patient may still feel
these buried stitches.
Buried sutures typically placed higher
posteriorly
above




:
(
)
superior tarsal
border
endo and ecto Faden


-

-
→
.
(This is seen in ‘non-incisional’ buried sutures methods,
as well as incisional blepharoplasty methods when a
surgeon decides to enhance crease position by placing
high-anchoring permanent buried sutures. I personally
believe that the Faden effect is even greater with the use
of a single continuous buried loop, like the DST (‘double
stitches thread’) or twisted needle methods.)
When the buried sutures methods are used via a
transconjunctival direction, meaning the sutures are
applied through the underside or back side of the upper
lid, again the same layers of dynamic tissues are incorpo­
rated into the noose, again they are tightened and biased
in a backside-higher placement (superiorly biased on the
conjunctival side). There are then three ‘endo-Faden’
stitches. The adverse results are the same, and one also
sees secondary ptosis after a year or two; except one has
to deal with the sometimes immediate complaints of
foreign body sensation as the knots are buried within the
conjunctiva/subconjunctival tissues, directly over the
front of the cornea.
Table 21-1 outlines a comparison of normal anatomy
among Caucasians with a crease, Asians with and without
a crease (with existing excess tissues that may be imped­
ing a crease formation), as compared to the load effect
on an eyelid after undergoing the buried sutures (‘non-
incisional’) methods, as well as the external incisional
method (using the author’s preferred Asian blepharo­
plasty technique).
In the buried suture methods, occasionally some sur­
geons decide to place the anterior buried knots lower
than the superior tarsal border (the posterior loop is just
above the upper border of the tarsal plate, therefore ante­
riorly it is skewed inferiorly). Initially the suture has a
tightening and shortening effect giving one a false sense

298
Asian Blepharoplasty and the Eyelid Crease
TABLE 21-1 Biodynamics of Effects of Crease Fixation Techniques
Patient
Anatomy
Levator
excursion
(scaled)
Burdening volume of
anterior lamella
tissues
Net load for levator
Caucasian
With crease
+
Few
Less
Asian
With crease
Set as norm
of 0
Average
Set as norm of 0
Asian
With single lid
Born with 0 or −
Above average
Increase
After Asian blepharoplasty*
Simulate normal physiology
Often +1 or 0
Lessened
Lightened
Asians with single lid after buried
suture methods:
Buried knots are placed:
Often worse
Not removed, all
sutures stay, most
are non-dissolvable
1. Trans-skin (anterior approach:
knots under skin catches)
A. Above STB
−2, −3
Not removed
Created resisting load (ecto-Faden)
−2,−3
Levator aponeurosis and orbicularis
B. At level of STB
−1, −2
Not removed
Ecto-Faden −1, −2
C. The deep loop is below STB
(front of tarsus)
Initially slight
resection
effect
Not removed
May have slight scar, slight Faden
effect, no crease
2. Trans-conjunctival/posterior
approach (knots under
conjunctiva)
A. Above STB
Worsen −2, −3
Not removed
Created resisting load endo-Faden
−2, −3
Chief complaint: foreign body
sensation
B. At level of STB
−1, −2
Not removed
Endo-Faden −1, −2
Deep loop catches (pretarsal
orbicularis and aponeurosis)
C. Deep loop is below STB (front
of tarsus)
May worsen −1
Not removed
Endo-Faden −1. May have tarsal
ectropion
3. Trans-lid/Trans-tarsus (anterior
knot under skin)
Deep loop is under STB, needle
pierces through tarsus
May worsen −1
Not removed
Corneal risk, compression scar,
loss of efficacy
STB, Superior tarsal border.
*Technique by Chen.

21  Advanced: Effect of High Anchoring of the Crease, Faden-like Effect and Use of Buried Sutures
299
While the association of secondary ptosis following
the buried sutures method is a known observation to
clinicians who perform this type of surgery, I believe it is
under-reported. Patients are more often than not reluc­
tant to go back to the original surgeon when their crease
disappears with time (and thereby spontaneously releas­
ing some of the Faden effect); this adds to the reported
‘success rate’ from the sutures method, and is even
acknowledged in some of the earlier reports from giants
in the field of single-eyelid surgery using the suture
methods.
Reviewing our discussion then, we have developed the
following concepts:
1. Surgical Faden (posterior fixation
with Faden) (adjacent orbital tissues
fixation) → can lead to weakening
of pull of the rectus muscle (in
strabismus correction).
2. Levator recession (weakening via
surgery) → weakens levator
(contractility and excursion).
3. High anchoring of crease (wound
closure) → consecutive ptosis.
4. High fixation of crease sutures on
the front surface of levator → (ecto-)
Faden effect.
5. In buried suture methods, the deeper
posterior loop is typically superiorly
biased → (endo-)Faden effect,
dampening the underbelly of levator.
6. Buried sutures: when placed higher
(posteriorly) above superior tarsal
border → endo- and ecto-Faden*
effects.
(*Often the anterior exit of the buried sutures through
skin is also higher in an attempt by the surgeon to raise
the lid fold, which is not removed or corrected in the
minimal-incisional suture method.)
In a sense, the levator muscle is like our deep abdomi­
nal muscles that flex our spine (ilio-psoas). The analogy
is obvious to anyone who has tried yoga, pilates or core
muscle strengthening exercises. Often these disciplines
involve working with an exercise ball and stretching our
back while lying with the small of our back supported by
the inflated ball. In stretching the back and intra-
abdominal muscle out to its maximal length, we are then
asked to do either hip flexion exercise or contract our
rectus abdominis. The reason this is effective is that we
are conditioning the distal (terminal) portion of our
lower back flexor muscle at its most stretched (and there­
fore relaxed) length on a length–tension curve. This is
the essential portion of the muscle, as opposed to working
the less stretched portion and building that up without
much flexibility and joint mobility.
We can think of the effective portion of the levator
(total length is 40 mm from its origin within the orbital
apex) as being the distal segment, and this is the levator
aponeurosis and measures about 10 mm. This is the
portion we are working with in blepharoplasty or ptosis
repair. In high crease anchoring and buried sutures
methods where the suture loops encircle the aponeurosis,
one is basically inhibiting the full extension of the levator
aponeurosis. One is in effect plicating the levator aponeu­
rosis and hindering its effective contraction as well as
maximal relaxation (extension). The levator function
(levator excursion being one measure of it) is therefore
affected in an adverse fashion.
Video Case 31 shows the surgical sequence in a Cau­
casian patient for functional blepharoplasty of the upper
lids. In this video, one can see the preoperative unanes­
thetized movement of the patient’s upper lid is around
14–15 mm. After injection with local anesthetic into just
skin and orbicularis, with the patient lying flat, the levator
still moves 12 mm from the surgeon’s view (which is
slightly different from the camera lens). The edge of the
paper scale was positioned as zero against the upper lash
margin. The crease for this patient based on her anatomy
should be set at 8 mm. When a crease is anchored 3 mm
higher with three stitches (at 11 mm), it restricts the
movement to 8 mm. Of course, these demo sutures
were removed and the crease is then properly placed at
8 mm. After wound closure, levator movement is restored
to 13–14 mm while still under local anesthetic. The
dampening effect of improper crease setting or wound
closure can be as much as 3–6 mm, as seen from this
demonstration.
We can now understand how high anchoring of an
eyelid crease often leads to secondary ptosis. The effort
by the patient to see leads to brow compensation (BrOA:
Brow Over-Action) and elevation of any lid fold (plus
sometimes head-tilt backwards). With the Faden effect
on the levator, the odds of having a crease indentation
are lessened.
Hence:
High anchor
consecutive ptosis
brow overaction BrOA
Faden



→
→
+
(
)
-
.
like effect
incomplete crease
high scar line




→
+
The beveled approach for revision of a high crease
(covered in Chapter 18) allows for a resetting of the tissue
plane (between anterior and posterior lamella) and a
release of the Faden effect caused by the high crease set.
Ptosis is partially or completely reversed, there is then
reduced brow compensation. The levator regains its
excursion while some recruitment of skin accompanies
the resetting of tissue plane. The net effect is a less-
hindered levator, and a better crease indentation with a
better lid fold, which is allowed to relax itself downward.

300
Asian Blepharoplasty and the Eyelid Crease
If you were to place a virtual nano-sphere at this inter­
phase of crease and lid fold, the back of the nano-sphere
on the levator side will be vectoring upward, the front
surface of the nano-sphere rests along the lid crease,
underneath the lid fold (skin and orbicularis, both ante­
rior lamella) and is gravitating downward.
With a high crease, the proper surgical correction can:
Reset tissue plane crease reset to a lower
more physiologi





,
,
c position
decreases
Faden effect less ptosis
improved
le





→
→
,
vator excursion
less BrOA
better crease indent at a more







→
→
natural position

.
Video Case 32 is a simple demonstration video involv­
ing two sheets of papers, several paper clips and a paper
scale. I try to show the impairing effect of having paper
clips attached higher than the upper tarsal border, in
analogy to buried sutures being applied through the distal
aponeurotic part of the levator. It is meant to give a
qualitative sense, literally through the person’s hands
holding the two sheets of paper (skin and levator muscle),
appreciating the difference in effort and increase in resist­
ance among the clinical situations presented here. The
measuring scale right of frame is a sheet of paper marked
with a 5x-magnified millimeter scale. The black iPad
cover (background surface) was slanted at 45° to mimic
a normal tarsal-tilt angle or slant of the upper lid when
opened. The proportions were: vertical span of upper
eyelid = 25–30 mm.
A typical Asian upper tarsal plate is represented by
7 mm; 10 mm represents a Caucasian tarsus or a location
chosen to demonstrate an abnormal high-anchored
crease. The normal up-and-down levator excursion
(function) in an Asian is about 10–12 mm so the posterior
sheet of paper was moved the same amount.
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well-defined changes in the arc of contact). In: Fells P, eds. Congress
of the International Strabismological Association; 1976. Marseilles,
France: Diffusion Générale de Librarie; 1976: 395–400.
2. Scott AB. The fadenoperation: mechanical effects. Am Orthopt J
1977;27:44–47.
3. Guyton DL. The posterior fixation suture (mechanism and indica­
tions). Int Ophthalmol Clin 1985;25:79–88.
4. Clark RA, Miller JM, Demer JL. Three-dimensional location of
human rectus pulleys by path inflections in secondary gaze positions.
Invest Ophthalmol Vis Sci 2000;41:3787–97.
5. Clark RA, Isenberg SJ, Rosenbaum AL, Demer JL. Posterior fixa­
tion sutures (a revised mechanical explanation based on rectus
extraocular muscle pulleys). Am J Ophthalmol 1999;128:702–714.
6. Clark RA, Ariyasu R, Demer JL. Medial rectus pulley posterior fixa­
tion is as effective as scleral posterior fixation for acquired esotropia
with a high AC/A ratio. Am J Ophthalmol 2004;137:1026–1033.
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