Asian Facial Cosmetic Surgery

SKIN-LEVATOR-SKIN FIXATION TECHNIQUE
46
skin over the anterior surface of the tarsus. This author
removes pretarsal tissue only when pretarsal fat is quite
apparent and threatens the surgical formation of the
desired upper lid crease. Few, if any, terminal interdigita-
tions of the levator aponeurosis to the dermis are present
in the pretarsal plane of a creaseless Asian eyelid. This
author refrains from vigorous dissection along the pre-
tarsal plane, which creates prolonged postoperative edema
and can lead to undesirable formation of more than one
crease. Furthermore, Asians born with a natural crease
often have some degree of pretarsal fullness along the area
between the crease and the eyelashes.
Formation of Lid Crease and Closure of Wound
To form a dynamic crease, direct the terminal fibers of
the levator aponeurosis above the superior tarsal border
to the subdermal plane of the lower line of skin incision
along the superior tarsal border. This is necessary to create
the proper vectoring for a dynamic crease.
Use 6-0 nonabsorbable suture (6-0 silk or nylon) to pick up
the lower skin edge and subcutaneous tissue, the levator
aponeurosis along the superior tarsal border, and then the
upper skin edge. Tie each of these as an interrupted suture.
In addition to the stitch over the center of the crease,
place two or three sutures medially and three laterally
(Figure 5-7). With these six or seven crease-forming
sutures in place, use 6-0 or 7-0 nylon to close the rest of
the incision in a continuous or subcuticular fashion
(Figure 5-8).
With selective debulking of tissues along the preaponeu-
rotic plane, it is possible to facilitate the best possible
formation of an anatomically dynamic crease as illustrated
in Figure 5-9, which shows the eyelid on upgaze after the
procedure is completed but before the wound is closed
with stitches.
PEARLS—A dynamic crease of the upper eyelid is a crease
that fades on downgaze. A static crease remains obvious on
downgaze.
Figure 5-7
Crease construction is enhanced with the placement of 6-0 interrupted sutures
through skin, levator aponeurosis, and then skin.
Figure 5-8
7-0 sutures are used in a continuous fashion to close the remaining skin edges.
Figure 5-9
When the patient is instructed to look straight ahead, a dynamic crease can be seen
to fold inward after preaponeurotic debulking of the soft tissues in front of the
superior tarsal border, even before sutures are placed.

POSTOPERATIVE CARE
47
Postoperative Care
During the immediate postoperative period (Figures 5-10
and 5-11, Patient A), topical antibiotic ointment (e.g.,
Polymixin, Bacitracin) is applied directly to the wound and
stitches three to four times daily. The crease forms as a
result of anatomic debulking of the preaponeurotic
platform and proper alignment of tissue planes along the
crease-forming zone. If a patient’s crease is not apparent
during the immediate postoperative period (i.e., the first
few days), the typical reason is excessive swelling. By the
fourth or fifth day, the patient is encouraged to practice
upward gaze so that proper vectoring of the crease may
begin. The sutures are typically removed at 5 to 7 days after
surgery. Buried sutures are neither used nor left behind.
Figures 5-12 and 5-13 illustrate the pre- and postoperative
appearances of Patient B; here the postoperative image was
taken 2 months after revisional Asian blepharoplasty.
References
1. Chen WP: Asian blepharoplasty—anatomy and technique, J
Ophthal Plast Reconstr Surg 3(3):135-140, 1987.
2. Chen WP: A comparision of Caucasian and Asian
blepharoplasty, Ophthal Pract 9(5): 216-222, 1991.
3. Chen WPD: Asian blepharoplasty and the eyelid crease,
2nd ed. Philadelphia, PA, 2006, Elsevier/
Butterworth-Heinemann.
4. Chen WPD: Concept of triangular, rectangular and
trapezoidal debulking of eyelid tissues: application in
Asian blepharoplasty, Plast Reconstr Surg 97(1):212-218,
1996.
5. Chen WPD: Eyelid and eyelid skin diseases. In Lee D,
Higginbotham E (eds): Clinical guide to comprehensive
ophthalmology, New York, 1998, Thieme Medical.
6. Chen WPD: Oculoplastic surgery: the essentials, New York,
2001, Thieme Medical.
7. Chen WPD, Khan JA, McCord CD: Color atlas of cosmetic
oculofacial surgery, Philadelphia, PA, 2004,
Butterworth-Heinemann.
Figure 5-10
Preoperative photograph of Patient A.
Figure 5-11
Immediate postoperative photograph of Patient A.
Figure 5-12
Revisional Asian blepharoplasty: preoperative photograph of Patient B.
Figure 5-13
Revisional Asian blepharoplasty: 2-month postoperative photograph of Patient B.

49
Why the Incision Technique?
Despite the popularity of the simple suture technique,
this author prefers the incision technique. The chance of
creating a permanent fold is certainly increased.1-7 The
author’s priority is to avoid repeat surgery at the cost of
simplicity and fast postoperative recovery. Although some
cases involve a distinctive fold and tight pretarsal skin after
the suture technique, often the crease is less distinctive and
the pretarsal skin is loose and wrinkled. With the incision
technique, particularly using the orbicularis oculi–levator
aponeurosis fixation technique,8 the supratarsal crease
is distinctive and the pretarsal skin is tightly stretched,
especially when the patient opens the eyes. The height of
the supratarsal crease and the tightness of the skin change
minimally over time. The result is predictable.
Why Orbicularis-Levator Fixation?
Since the inception of the double eyelid operation, all the
techniques developed are based on the creation of a
supratarsal crease by fixating pretarsal skin to the tarsus or
levator aponeurosis. Variations in techniques have focused
on methods to approach, dissect, eliminate tissue, or use
different sutures. The prevention of relapse has been the
main stimulus for the development of new techniques
throughout the past century. The use of skin as a fixating
medium is a simple and straightforward idea. The only
(and probably a serious) concern is thinness of the skin.
Relapse occurs because of the lack of sufficient contact
surface for fixation. Even permanent sutures are only
temporary vehicles that allow tissue adhesion. The eyelid
skin is unique in that it is firmly bound to the underlying
orbicularis oculi muscle. The movement of the muscle is
Orbicularis-Levator Fixation
Technique
Jung I. Park
fully reflected on the skin surface. Fixating the orbicularis
oculi muscle to the levator aponeurosis is equivalent to
skin-levator fixation. The greatest benefit of using the
muscle as a fixating medium is that its large volume
provides a large contact surface. A broad fixation surface
ensures an unyielding, firm scar fixation that is not
attainable through skin-levator fixation (Figure 6-1).
Consultation
The patient is counseled about the operative procedure
and the desire or need for epicanthoplasty. The size and
shape of the fold are determined. Attitudes and outlooks
vary greatly among patients who seek double eyelid
surgery. Although some patients are quite forthcoming and
have many questions and detailed requests for surgery,
others completely rely on the surgeon. Regardless of the
patient’s approach, the surgeon must try to fully under-
stand the ultimate goal of the patient. This is especially true
for those who depend on the surgeon’s perspective and
prefer a certain eye shape but do not seem to have an
opinion as to the way that eye shape is attained. If their
desires are not thoroughly discussed preoperatively, such
patients may return with complaints about the post-
operative results.
Preoperative Care
The patient is asked not to wear any eye cosmetics or
facial products. Aspirin and products with anticoagulant
activity are prohibited for 7 days before surgery. The patient
should not have food or water for 8 hours before surgery
and should not wear contact lenses.
6

ORBICULARIS-LEVATOR FIXATION TECHNIQUE
50
Premedication
Alprazolam(1.5 to 2.0 mg), propoxyphen napsylate and aceta-
minophen 100 mg/650 mg (1 tablet) and a broad-spectrum
antibiotic are given orally 30 minutes before the surgery.
Marking
The incision line is marked with the patient sitting up in
front of a mirror. An extra-fine felt-tip pen is used for the
markings. Even the finest medical marking pen draws a line
that is too wide. Methylene blue may smear through the
wrinkles and is hard to change after the mark is made.
While the patient sits up in a chair with the eyes open in
a primary gaze position, the pretarsal eyelid skin is
pressed upward with a sharpened cotton-tipped applicator,
creating a double eyelid fold (Figure 6-2). The ideal size is
determined after several trials. Next, the patient is asked to
close the eyes, and the point at which the applicator
pressed the skin is marked. The distance from the ciliary
margin to the marking is measured with a caliper while the
eyebrow is lifted until the eyelid skin becomes tight and the
eyelashes begin to rise (Figure 6-3). The caliper is locked at
this distance. The average distance of the crease marking is
7 mm from the ciliary margin. Several dots are then placed
in the eyelid skin at the same distance and parallel to the
ciliary margin. The same distance is maintained from the
Supratarsal orbicularis
oculi m.
Preponeurotic fat
Levator aponeurosis
Pretarsal orbicularis
ocularis m.
A
B
Figure 6-1
Illustration demonstrating a wide contact between the folded levator aponeurosis and the orbicularis oculi muscle.
Figure 6-2
The double eyelid fold is created by strategic placement of a cotton-tipped applicator.
Figure 6-3
Measurements and markings are made with the eyelids stretched.

ANESTHESIA
51
medial third to the level of the lateral canthus (Figure 6-4).
Medially the line tapers downward, only slightly closer to
the tarsal margin. The medial line curves inferiorly even
when the line is drawn completely parallel to the ciliary
margin. This is because the skin is more compressed in the
medial third of the eyelid. Upon careful examination of the
eyelid, a faint line is visible parallel to the ciliary margin at
about the level of the marking. Often, the author draws a
line along or parallel to this natural line, which may be the
vestige of an unformed supratarsal crease (Figure 6-5, A
and B). The marking stops approximately 3 to 4 mm
from the medial canthus. When the epicanthoplasty is
performed, the line stays parallel to the ciliary margin even
beyond the medial canthus level. To some extent, the size
of the palpabral fissure dictates the size of the double eyelid
fold. A smaller fold looks more attractive in a person
with a small eye. A large fold on a small eye makes the eye
appear unnatural and somewhat mongoloid in appearance.
The patient should be advised against such a desired result.
The patient with a large eye would look more natural and
attractive with a larger fold. Skin redundancy varies widely
even among patients in the same age-group. A person with
fatty pretarsal skin does not form adequate skin indenta-
tion and eyelid fold. The eyelashes may even roll up and
show the red tarsal margin when the surgeon tries to create
a fold close to the eyelash. This group of patients has a
somewhat higher risk of relapse. Although the aesthetic
outcome may not be ideal, the incision marking may need
to be placed somewhat higher than usual in those
individuals to create a more permanent fold. For patients
with loose skin, a conservative resection of skin ellipse is
necessary (Figure 6-6, A and B).
Anesthesia
A solution of 2% lidocaine with 1:100,000 epinephrine
solution buffered with sodium bicarbonate in a 1:10 ratio is
Rudimentary
supratarsal
fold
Figure 6-4
A, Although the incision line is drawn parallel to the ciliary margin, it appears as though the line is tapering toward the ciliary margin, both medially and laterally, as a result of
skin laxity. B, Marking runs parallel to the ciliary margin at a distance of approximately 2 mm.
Figure 6-5
A, A rudimentary line of supratarsal crease is often found in the individual with a
single eyelid. The incision line can be marked on or parallel to this line. B, Illustration
of the rudimentary supratarsal crease.
A
B
A
B

ORBICULARIS-LEVATOR FIXATION TECHNIQUE
52
injected through a 30-gauge, 1-inch-long needle. The
solution is injected in two layers. The first is in the
subdermal plane. The least amount possible is used to
minimize the distortion of the anatomy and the potential
development of asymmetry. The second layer of injection
is through the orbicularis oculi muscle plane. A somewhat
generous amount is used on this plane. About 1.5 ml of
solution is used on each eyelid. Injection into the levator
aponeurosis may cause ptosis. Ptotic change of the eyelids
complicates the determination of upper eyelid tarsal
margin symmetry after the fixation sutures are placed. The
fat layer may be infiltrated if necessary, but only after the
fat compartment is completely isolated.
Instruments
Instruments used include a caliper, wide, two-prong sharp
skin hook, a pair of iris scissors and forceps, bipolar fine-
tip cautery, and the eye shield (Figure 6-7).
Dissection
The skin incision is made along the markings using a #15
Bard Parker blade. A CO2 laser with a continuous wave
or a fine-needle-tip cautery is used for the dissection
thorough the subcutaneous tissue and orbicularis oculi
muscle (Figure 6-8, A and B). The exposed orbital septum
is divided with a pair of scissors or needle-tip cautery while
it is held tense using the skin hook and forceps (see Figure
6-8, C and D). Thus a small opening is created. The loose
areolar tissue and the shiny levator aponeurosis are visible
through the opening (see Figure 6-8, E). While the septum
is still held up tightly, the loose preaponeurotic space is
widely dissected, and the orbital septum is divided medially
and laterally with the scissors to expose the levator
aponeurosis and preaponeurotic fat compartment (see
Figure 6-8, F to H). In the majority of cases, the levator
aponeurosis can be identified inferior to the fat compart-
ment as soon as the orbital septum is divided. The fat
compartment is encased in a thin, filmy, transparent mem-
brane (see Figure 6-8, I). For patients with low preaponeu-
rotic fat, it is safe to open the fat pad and find the levator
aponeurosis by retracting the fat content. Identification
of the levator aponeurosis is confirmed by grasping the
aponeurosis with a forceps and asking the patient to
attempt to open the eyes. The patient is unable to open the
eyes when the levator is grasped; on the other hand,
grasping the orbital septum does not prevent the patient
from opening the eyes. If a surgeon mistakenly identifies
the orbital septum as the levator aponeurosis, suture
fixation would be performed between the orbicularis and
the septum. In that case, the supratarsal crease will be
incomplete and relapse will occur. Dividing the orbital
septum below its fusion with the levator aponeurosis
would be a potential disaster. Because independent orbital
septum is not found beyond the fusion point, the surgeon
is actually cutting the levator aponeurosis at this lower level
and thus causing ptosis (Figure 6-9).
Figure 6-6
A, Skin is excised only on eyelids with excessive redundancy. B,View with the eyes
opened.
Figure 6-7
Instruments used in the procedure.
A
B

DISSECTION
53
Figure 6-8
A, A skin incision is made. The muscle fibers are visible. B,The muscle is divided. C,The muscle is retracted and the orbital septum is exposed. The orbital septum is
distinguished from the levator aponeurosis by its adherence to orbicularis oculi muscle and the lack of glistening surface of the levator aponeurosis. D,The orbital septum is
penetrated by the tip of the scissors or needle cautery. The upper eyelid should be retracted tightly anteriorly and slightly downward while forceps apply a countertraction to
tense the orbital septum. E, A window is created through the orbital septum. An empty preaponeurotic space is created by applying proper traction. F, The preaponeurotic
pocket is widened medially and laterally.
(Continued)
A
B
C
D
E
F

ORBICULARIS-LEVATOR FIXATION TECHNIQUE
54
Pretarsal Orbicularis Oculi
Muscle–Levator Aponeurosis Fixation
When the skin is incised, a 3- to 4-mm-wide strip of
orbicularis oculi muscle is exposed between the retracted
upper and lower skin edges (see Figure 6-8, A). The muscle
incision is made 2 to 3 mm above the lower skin edge. This
cuff of pretarsal orbicularis oculi muscle is used for the
fixation (Figure 6-10, A and B). Clear nylon (6-0) on a P-3
needle is used. First, the needle is passed through the
muscle from its undersurface and exited at the edge of
the lower skin incision (Figure 6-11, A). A small portion
of the dermis may be removed by the needle’s passage. Next,
the levator aponeurosis is pinched with a pair of forceps
and picked up approximately 5 to 10 mm above the relaxed
upper edge of the pretarsal orbicularis oculi muscle. The
same needle then is passed through this plicated aponeu-
Figure 6-8, cont’d
G, The orbital septum is divided medially. H, The oribital septum is divided laterally.
I, The levator aponeurosis (shiny white) and preaponeurotic fat (within a thin,
transparent capsule) are exposed.
G
H
I
Figure 6-9
The levator aponeurosis may be cut accidentally if it is mistaken for orbital septum.
Such a mistake may occur on the eyelid with high septum-levator fusion. Therefore it
is safest to divide the septum at the higher location and identify the preaponeurotic
fat behind the septum by gently pushing the eyeball to observe bulging fat.

RECOVERY
55
rosis from the superior aspect and exited through the
inferior aspect (see Figure 6-11, B). As the suture is tied,
the muscle is gradually pulled in an upward direction. As
the muscle is pulled up, the pretarsal skin is also stretched
tightly along with the muscle. The suture is tied just
enough to approximate the muscle with the levator apo-
neurosis. The surgeon should refrain from strangulating
the tissue by tightening the suture; overtightening will only
cut through the tissue and shorten the longevity of the
fixation. As the pretarsal skin is stretched upward, the
eyelashes are viewed as rising from their normal downward
orientation. The fixation suture is tightened just enough
to achieve this change. If the muscle is overstretched by
either excessive tightening or heightening of the levator
aponeurosis, the eyelashes turn up and unsightly reddish
tarsal margin begins to show. The first suture is made at the
midpupillary level; this suture dictates the final position of
the upper eyelid tarsal margin. This fixation method often
heightens the upper eyelid tarsal margin, resulting in a
larger palpabral fissure (Figure 6-12, A and B). Although
the technique creates an attractive large eye, inaccurate
fixation between the eyes could cause asymmetric eyes.
More so than with any other technique, precision is
essential. More fixation sutures are placed on each side of
the primary suture for half the distance of the incision. The
last suture is made 1 cm medial to the lateral end of
the incision. This suture provides a necessary lateral lift
of the pretarsal skin, which is essential to maintain the
parallel relationship between the tarsal margin and the
double eyelid fold (see Figure 6-11, C and D). The lack
of suture at the medial end of incision allows a natural
downward curve of the double eyelid fold at the medial
canthus. If the patient desires a parallel double eyelid fold
throughout the entire length similar to that of the
Caucasian eye, suture fixation should be done at the medial
canthal area in addition to the Z-epicanthoplasty (see
Figure 6-11, E and F).9,10 After the fixation sutures are
completed, the skin edges are in complete approximation,
even without skin closure (see Figure 6-11, G and H). The
skin is then closed with either 6-0 fast-absorbing plain gut
or 6-0 black nylon in a running subcuticular fashion.
Continuous running cuticular sutures may be used in some
cases to prevent troublesome ecchymosis secondary to a
needle puncture through the rich subdermal capillary
network that is often seen in the Asian upper eyelid.
Postoperative Care
An ice bag is applied to the eyes immediately after the
surgery. It is beneficial to continue using the ice bag during
the following 2 days with a regimen of 30 minutes on, 30
minutes off while the patient is awake. Although infection
is rarely been a problem with this procedure, ophthalmic
eye ointment is applied to the wound and prophylactic
antibiotics are given for 2 days. The patient may bathe or
shower after 2 days. If the patient lives nearby, a 1-week
follow-up appointment is scheduled.
Recovery
Recovery is quick and uneventful. Although swelling is
visible during the first 2 weeks, a natural appearance is
Figure 6-10
A,The pretarsal orbicularis oculi muscle cuff is ready to be used for fixation. B, The forceps grasp the orbicularis oculi muscle, and the levator aponeurosis is exposed.
A
B

ORBICULARIS-LEVATOR FIXATION TECHNIQUE
56
Figure 6-11
A,The needle passes through the full thickness of the pretarsal orbicularis oculi muscle cuff. B,The needle then passes through the levator aponeurosis, taking a thick bite by
grasping the aponeurosis (not shown). The needle passes upward if the levator is sutured first, and it passes downward if the orbicularis oculi is sutured first. C, The needle
passes through the muscle cuff laterally. D, The levator aponeurosis is distinctive in the lateral aspect. E, The levator aponeurosis is deep and poorly defined in the medial
compartment. It is necessary to take a thick bite through the fibrofatty tissue medially. F, The needle passes through the medial muscle cuff.
Continued
A
B
C
D
E
F

CASE STUDY
57
regained rapidly, especially in younger patients. The patient
may return to work within 2 days, wearing lightly tinted
glasses. Vigorous exercise or heavy lifting is permitted after
2 weeks.
Case Study
Pretarsal show may vary in width (i.e., height of double
fold), depending on the height of the supratarsal crease
and the laxity of the supratarsal skin that drapes over the
pretarsal skin (Figure 6-13). Tightness of fixation results
in a different height of the supratarsal crease on the
eyelids, even with the incision lines placed at the same
distances from the ciliary margin. When the fixation is
tight, the pretarsal skin becomes thin and smooth. The
double eyelid can be created without pretarsal show,
or it may be as high as the patient desires (Figures 6-12
and 6-14). The removal of excessive fat, muscle, or both
may cause a subtle crease or depression above the fold
(Figure 6-15, A and B). Double eyelid surgery often
lowers the eyebrow position by eliminating the need
for the compensatory brow elevation (Figure 6-16, A
and B). The greatest benefit of the orbicularis-levator
fixation technique is the tightness of the pretarsal skin
and longevity (Figure 6-17, A and B).
Figure 6-11, cont’d
G, Levator-orbicularis fixation is completed. Modified Z-epicanthoplasty was also performed. Complete apposition of the incision without skin suture was accomplished.
H, View with the eyes opened.
G
H
Figure 6-12
A, Preoperative view. B,The double eyelids are hidden, but the eyes are opened wider as a result of levator fixation.
A
B

ORBICULARIS-LEVATOR FIXATION TECHNIQUE
58
Figure 6-14
A, Preoperative view. B, Average height of the double eyelid.
A
B
A
B
Figure 6-15
A, Preoperative view. B, Excessive removal of fat caused an extra crease on the left eyelid.
Double eyelid fold
Pretarsal eyelid
(width of double eyelid
pretarsal show)
Supratarsal crease
Figure 6-13
The supratarsal crease is the line of fixation; when the eye is opened, a double fold is created. The portion of pretarsal eyelid that remains exposed when the eye is open is the
pretarsal show. The amount of pretarsasl show is often referred to as the double fold height.

CASE STUDY
59
References
1. Fernandez LR: Double eyelid operation in the Oriental in
Hawaii, Plast Reconstr Surg 25:257-264, 1960.
2. Moutou Y, Moutou H: Intradermal double eyelid operation
and its follow-up results, Br J Plast Surg 25:285, 1972.
3. Weingarten CZ: Blepharoplasty in the oriental eye, Tram
Acad Ophth Otol 82:442, 1976.
4. Matsunaga RS: Westernization of the Asian eyelid, Arch
Otolaryngol 111:149, 1985.
5. Hiraga Y: Blepharoplasty in orientals. Problems in plastic
and reconstructive surgery, JOURNAL TITLE 1:504,
1991.
6. Chen WPD: Revision and correction of suboptimal results.
In Chen WPD, ed: Asian blepharoplasty, Newton, MA,
1995, Butterworth-Heinemann, p 84.
7. Lee JS: Simplified anatomic method of double-eyelid
operation: septodermal fixation technique, Plast Reconstr
Surg 100:170, 1997.
8. Park JI: Orbicularis-levator fixation in double-eyelid
operation, Arch Facial Plast Surg 1(Apr-June):90-95, 1999.
9. Park JI: Z-epicanthoplasty in Asian eyelids, Plast Reconstr
Surg 98:602, 1996.
10. Park JI: Modified Z-epicanthoplasty in the Asian eyelid,
Arch Facial Plast Surg 2:43, 2000.
A
B
A
B
Figure 6-16
A, Preoperative view shows a high eyebrow position, the result of an unconscious effort to keep loose upper eyelid skin elevated in order to see well. B, Postoperative view
shows a lowered eyebrow position by eliminating the need for compensating brow elevation.
Figure 6-17
A, Preoperative view of orbicularis-levator fixation. B, Five-year-postoperative view shows tight and crisp pretarsal skin and well-maintained double eyelid folds.

61
Concerns regarding older patients include redundancy of
the upper eyelid skin and brow ptosis. Patients who do not
have double eyelids often wish to have it done at the same
time. Obviously, redundant skin needs to be excised to
reveal a newly formed double fold. Otherwise, the excess
skin will droop and hide the effect of the double eyelid
operation. The upper eyelid skin and the orbicularis oculi
muscle are thin in the pretarsal area and become thicker as
they approach the eyebrow.1 The double eyelid fold formed
by the thin skin is delicate and cosmetically pleasing.
Unfortunately, resection of the excess skin during bleph-
aroplasty requires a removal of this thin pretarsal portion
of eyelid skin. The remaining skin and muscle above the
incision are much thicker. A double eyelid fold created by
this thicker remaining tissue appears edematous and
unnatural (Figure 7-1, A and B). This puffy-looking fold is
not the result of temporary edema, but it is permanent
because of the thickness of the tissue. Brow ptosis adds
to this problem by causing the upper eyelid to appear
fuller. Although brow ptosis in Caucasians produces the
Double Eyelid Operation
for the Aging Patient
Jung I. Park
appearance of a hood over the sunken orbit, brow ptosis in
Asians gives the appearance of fullness. A common
complaint after double eyelid surgery in an older patient is
fullness of the upper eyelid. The patient invariably blames
the surgeon for not removing enough fat. When a surgeon
uses an aggressive approach to remove excess fat and skin,
the result is a sunken groove that is unsightly and often
uncorrectable. This sunken groove is one of the most
common unfavorable results of upper eyelid surgery
performed on Asian patients using the principles from
Caucasian blepharoplasty (Figure 7-2). The redundancy
over the lateral orbital rim and crow’s feet should be
addressed. The incision should extend to the orbital rim.
Untreated skin redundancy in this area creates a round eye
with a surprised look. Ideally the surgeon should first
perform a forehead lift to correct brow ptosis and eliminate
some of the skin redundancy, then perform double eyelid
surgery and possibly remove a small amount of remaining
excess skin. However, the majority of patients refuse such
extensive and expensive surgery.
7
A
B
Figure 7-1
Upper lid blepharoplasty in an older Asian patient. A, Preoperative view. B, 1-month postoperative view. Despite a well-formed double eyelid fold, a puffy unnatural look
persists.

DOUBLE EYELID OPERATION FOR THE AGING PATIENT
62
Consultation
A forehead lift is strongly recommended for older patients
who request double eyelid surgery, elimination of eyelid
redundancy, or both. The surgery’s benefits are best
demonstrated when the patient looks in a mirror and
watches the change that occurs as the surgeon simulates
the forehead lift by lifting the eyebrows (Figure 7-3, A and
B). The surgeon should emphasize the possibilities of
persistent edema, swelling, and permanent puffiness of the
eyelids after eyelid surgery. Patients are often familiar with
the expected outcome because their acquaintances have
had the same surgery. These patients frequently request
removal of orbital fat to eliminate upper eyelid fullness.
This fullness is almost always the result of brow fat in the
upper eyelid. The removal of preaponeurotic fat creates an
unsightly upper eyelid depression, deep extra creases, or a
sunken look. It is crucial that the patient fully understands
these implications before consenting to the surgery.
Preoperative Care, Premedication,
and Anesthesia
See Chapter 6 for more information.
Procedure
Patients with Single Eyelids or Poorly Defined
Supratarsal Creases
The patient is marked while in a seated position with
the eyes closed. The eyebrow is gently lifted with the left
thumb until the upper eyelashes begin to rise. A caliper is
used to measure 7 mm from the eyelash line, and an extra-
fine felt-tipped marker is used to mark a dot on the upper
eyelid at the midpupillary line. Then, two additional 7-mm
marks are made. One mark is placed near the medial
canthus, and the other is placed near the lateral canthus.
These three dots are connected in a gentle curve that is
parallel to the tarsal margin (Figure 7-4). At the lateral end,
the line is continued in a gentle upward curve that follows
a laugh line. This extension reaches as far as is necessary to
contain lateral orbital skin sagging (Figure 7-5). Next, the
Figure 7-2
Sunken look after a blepharoplasty based on Caucacian blepharoplasty principles.
Figure 7-3
Simulation of the brow lift demonstrates the beneficial effect of thinning the double
eyelid fold and widening the pretarsal show.
Figure 7-5
The lateral extension of the lower incision follows the crow’s feet to the lateral orbital
rim.
Figure 7-4
The lower incision is made conservatively at 7 mm from the ciliary margin.
Conservative placement is necessary with the orbicularis oculi–levator aponeurosis
fixation technique because it tends to create deep fixation and widen pretarsal skin.
An older incision scar is shown at a higher level. The distance from the eyebrow to
the proposed mark for the upper incision is indicated by 1 cm. See Figure 7-6 for the
determination of the upper incision.

PROCEDURE
63
patient is asked to open the eyes in a primary gaze position
as the eyebrow resumes its normal relaxed position. The
height of the double eyelid fold is determined by marking
the upper incision 2 to 3 mm above the ciliary margin
(Figure 7-6). Marking the upper incision is equally as or
even more important than determining the height of the
lower incision. To create a higher double fold with a wider
pretarsal show, the dot may be marked 3 to 4 mm from
the lash line. A series of dots are then marked at the same
distance from and parallel to the eyelash line. These dots
are connected to form an upper incision line (Figure 7-7).
The patient is asked to close the eyes again, the eyebrow is
lifted, and a line that extends medially and laterally to meet
the lower incision line is drawn. Often the skin redundancy
is more abundant at its lateral orbital area but scanty near
the medial canthus. Thus the ellipse of the skin island is
narrow and sharply tapered medially but wide at the orbital
rim (Figure 7-8, A and B). Usually the same amount of skin
is excised on each side. The markings on the opposite
eye may be made with a caliper as the patient lies on
the operating table in a prone position; this will allow the
excision lines to be as symmetric as possible. However,
when one eyelid requires more excision or the eyebrow
position between the eyes is not similar, the markings on
the opposite side are best made with the patient in a seated,
relaxed position. The height of the upper eyelid between the
eyebrow and the ciliary margin may be different between
the eyes. This discrepancy may be the result of unevenly
excised eyelid skin from a previous surgery, a congenital
difference, or a different relaxation of each eye during the
aging process. Occasionally the achievement of symmetry
may be further ensured by measuring the distance between
the eyebrow and the upper incision line (see Figures 7-4
and 7-9). Skin redundancy over the crow’s feet area is more
abundant and requires a rather aggressive excision. Lateral
extension is designed to eliminate lateral hooding as much
as possible. Aggressive excision of eyelid skin in this area is
permitted because potential development of ectropion
or lagophthalmos is not a concern. Aggressive excision
eliminates some of the crow’s feet and prevents an
A
B
Figure 7-6
The upper incision line is marked with the eyes open in a primary gaze position. The
upper incision is marked 2 to 3 mm above the ciliary margin.
Figure 7-7
The upper incision runs parallel to the ciliary margin with the eyes open.
Figure 7-8
The skin muscle excision is narrow and sharply tapered medially and wide at the orbital rim. A, Eyes open. B, Eyes closed.

DOUBLE EYELID OPERATION FOR THE AGING PATIENT
64
unsightly round-eye phenomenon secondary to a descent
of the lateral aspect of the double eyelid fold.
A sharpened cotton applicator is applied to the marked
inferior incision line. The skin is then pushed upward and
folded over the tip of the cotton applicator (Figure 7-10, A).
The location of the cotton applicator is marked on the
surface of the fold. This point becomes the upper incision
site. The point is then connected to the upper incision line
on the upper eyelid and the lateral end of the lower incision
marking. The pinch technique can also be used safely
in this area (see Figure 7-10, B). The eyebrow positions of
some patients are symmetric when relaxed but become
asymmetric when alert (Figure 7-11, A and B). When the
skin is excised based on the measurement taken with the
patient in a relaxed, premedicated state, both the patient
and the surgeon may be surprised by an asymmetry when
the patient returns for a follow-up visit. This embarrassing
situation is best prevented with preoperative detection
of the condition and patient education regarding the
possibility of dynamic asymmetry. The surgeon may give
the patient the choice of achieving symmetry in a relaxed
or an alert state. The patient with thick edematous skin
requires a smaller possible skin excision to minimize un-
sightly puffiness (Figure 7-12, A to C). The face is washed
with Phisohex soap and thoroughly rinsed with water
before the markings are made. It is crucial to mark after
soap removal and before local anesthetic infiltration; it is
almost impossible to obtain symmetry once the marking is
lost after local anesthetic infiltration. A solution of 2%
lidocaine with 1:100,000 epinephrine is then infiltrated
under the skin. The incision is made along the markings.
The skin-muscle island is excised (Figure 7-13, A). Ptotic
brow fat may be excised if necessary (see Figure 7-13, B).
A
B
A
B
Figure 7-9
The upper incision line was marked 12.5 cm from the ciliary margin. Measurement to
confirm the symmetry revealed a discrepancy in the distance between the eyebrow
and the incision line.
Figure 7-10
A,The amount of the lateral skin-muscle excision is determined using a
cotton-tipped applicator. B, The pinch technique.
Figure 7-11
The eyebrows remain symmetric at rest (A) and become asymmetric when the
eyebrows are raised (B).

PROCEDURE
65
The orbital septum is divided (see Figure 7-13, C to E). The
levator aponeurosis is identified (see Figure 7-13, F). The
supratarsal crease is created by fixating the pretarsal orbi-
cularis oculi muscle to the levator aponeurosis as described
in Chapter 6. The skin is then closed with 6-0 black nylon
or 6-0 fast-absorbing gut in a continuous subcuticular
fashion (see Figure 7-13, G).
Patients with Well-Defined Supratarsal Creases
The lower incision is marked along the preexisting
supratarsal crease. Generally, the same marking is made for
the upper incision, approximately 2 to 3 mm above the
ciliary margin with the patient’s eyes in a primary gaze
position. However, this distance varies depending on the
tightness of the supratarsal crease. The patient with natural
double eyelids tends to have a higher, more solid supra-
tarsal crease. The upper incision markings may be made at
1 to 2 mm above the ciliary margin on the average patient
who desires a double eyelid fold that is conservative in
width. In a patient with a surgically created double fold, a
conservative incision is chosen if the crease is located high
and tightly fixated, similar to the patient with a natural fold.
A new and tighter supratarsal crease fixation is necessary
in the patient who has previously had double eyelid surgery
but in whom the supratarsal crease is poorly fixated and
loose. The markings are made similar to those on patients
without preexisting double folds. Although a 1- to 3-mm
incision line above the ciliary margin with the eyes in a
primary position does not seem to be significant, a fairly
wide skin excision can be made with these markings (see
Figure 7-8, A and B). This amount of skin excision is still far
smaller than that of the Caucasian eyelid when the pinch
technique is used. The lower incision should be made with
extreme care in the patient who has had previous double
eyelid surgery. The skin–levator aponeurosis fixation
can be accidentally detached during the incision at the
supratarsal crease. It is less likely to happen in the eyelid
with a natural double fold because of the broader adhesion
between the pretarsal skin and the levator aponeurosis.
When the attachment is severed, the surgeon may find the
eyelid drooping during the surgery. At times it is difficult to
judge whether a true ptosis has occurred or whether the
droopiness found during the surgery is the result of eyelid
swelling, anesthesia of the levator aponeurosis, or both.
The surgeon may have to wait until after the surgery, when
the swelling and edema has subsided, before determining
the cause of the droopiness.
Asian Males with Upper Eyelid Redundancy
The Asian male with upper eyelid redundancy often
desires to eliminate the excess without creating a double
eyelid. The usual measurement for the female patient does
not apply to the male patient. An older Asian male may be
embarrassed by a postoperative double eyelid with a puffy
fold. The lower incision should be 5 to 6 mm from the
ciliary margin. The upper incision is placed approximately
1 mm from the ciliary margin with the eyes open in a
primary gaze position. The pretarsal skin fixation should
Figure 7-12
A, Preoperative view of thick eyelid skin. B, Conservative excision of the skin. C, The
patient with thick skin tends to develop a puffier fold. Conservative skin excision
lessens the puffiness.
A
B
C

DOUBLE EYELID OPERATION FOR THE AGING PATIENT
66
Figure 7-13
A, En bloc skin–muscle excision. B, Ptotic eyebrow fat is removed. C,The orbital
septum is snipped with the scissors. Tension is applied to the septum as it is pulled
up and detached from the underlying orbital fat and levator. D,The septal window is
created. E,The septum is incised through the septal window. F,View of the orbital
fat and the levator aponeurosis. G,The orbicularis oculi–levator aponeurosis fixation
is completed. The incision lines are in complete apposition without skin closure.
A
B
C
D
E
F
G

CASE REVIEWHEAD 1
67
be conservative. However, excision of the redundant skin at
the lateral aspect over the lateral orbital rim should be as
aggressive as in the female patient. The skin redundancy is
mostly in the lateral half of the upper eyelid and over the
lateral orbital rim. The Asian male tolerates the temporary
redness of the lateral incision better than a puffy double
eyelid.
Postoperative Care and Recovery
See Chapter 6.
Case Review
See Figures 7-14 to 7-18.
A
B
A
B
Figure 7-14
A, Preoperative view. B, One-month postoperative view showing a significant amount of puffiness and a red incision line.
Figure 7-15
A, Preoperative view. B, One-year postoperative view showing a well-formed crease and persistent puffiness.
Figure 7-16
A, Preoperative view. B,The fold appears less puffy when the fixation is incomplete.
A
B

DOUBLE EYELID OPERATION FOR THE AGING PATIENT
68
Reference
1. Lee JS: Simplified anatomic method of double-eyelid
operation: septodermal fixation technique, Plast Reconstr
Surg 100:170, 1997.
A
B
A
B
Figure 7-17
A, Preoperative view. B, Postoperative view. Conservative skin excision without the creation of a double eyelid fold is preferred for the male patient because it avoids the
appearance of an unnatural thick fold. Earlier relapse is expected with further aging.
Figure 7-18
A, Preoperative view. B, Postoperative view. An aggressive approach was used for this older male patient after the expected outcome was explained. The patient happily
accepted the result.

69
Despite the many unsatisfactory outcomes, serious com-
plications are extremely rare. The unfavorable results listed
in Tables 8-1 and 8-2 may range from normal, expected
outcomes to obvious and significant deformities. The
incidence of unfavorable outcomes may also be related to
the expectations of the patient. Both the surgeon and the
patient often forget that surgically created beauty can be,
and often is, imperfect.
Complications, Unfavorable
Results, and Critical Analysis
Jung I. Park
Size dissatisfaction may stem from poor communication
between the surgeon and the patient during the initial
consultation. It could also be the result of an incomplete
fixation that results in a gradual descent of the fold. In
fact, the first six listings in Box 8-1 may be attributable to
incomplete fixation. All the innovations made during the
past century have been the result of a number of trials
aimed at perfection of the fixation technique. The recent
popularity of the suture technique has reduced the
incidence of complications at the expense of a possibly
higher likelihood of relapse1-7 or somewhat less-defined
double eyelid fold. Asymmetry may be caused by unequal
design, dissection, or fixation between the eyes (Figure 8-1).
Another important cause of asymmetry is unrecognized
ptosis of one eye. Descent of the tarsus as a result of ptosis
exposes more pretarsal skin and gives an illusion of a
higher fold in the ptotic eye. In fact, the fixation is solid and
the supratarsal crease is often well defined. Relapse may
occur from fixating an insufficient amount of solid tissue in
both the suture and the incision technique (Figure 8-2).
8
Table 8-1. Unfavorable Results
Size dissatisfaction
Asymmetry
Relapse
Incomplete fold
Droopy lateral fold
Crepe pretarsal skin
Puffy eyelids
Multiple creases
Sunken appearance
High fold
Thick fold
Table 8-2. Complications
Epihora
Conjunctival suffusion
Tarsal eversion or ectropion
Conjunctival irritation
Ptosis
Ocular injury
Hypertrophic scar
Milia
Suture granuloma
Figure 8-1
Asymmetric and relapsed double eyelids. Right upper eyelid shows pseudoptosis due
to droopy upper eyelid skin.

COMPLICATIONS, UNFAVORABLE RESULTS, AND CRITICAL ANALYSIS
70
Recent decreases in the relapse rate with the suture tech-
nique may be attributable to the fact that a larger segment
of the dermis is incorporated into the suture. Keeping the
tie loose to avoid strangulation of the tissue also helps
prolong the longevity of the double eyelid fold (Figure 8-3).
Tying the suture tightly in an attempt to secure two tissues
together for longevity may in fact cause earlier relapse in
both techniques. Excessive tightening strangulates the
tissues, chokes the circulation, and allows the suture
material to cut through the tissue faster. This also results in
an earlier loss of tissue before any significant firm adhesion
develops between two effacing tissues. On the other hand,
the incision technique relies heavily on the creation of a
broad scar between the skin and levator aponeurosis.
Although suture material holds two tissues together, the
ultimate fixation is accomplished by the scar tissue.
Various techniques may enhance the scar. One way to
accomplish this is to resect the orbicularis oculi muscle
from the lower skin edge at the incision site,8,9 which brings
the skin closer to the levator aponeurosis. Soft tissues,
including the pretarsal orbicularis muscle, are stripped to
create extensive scarring and a static fixation between the
skin and the tarsal plate.10-12 Wide debulking of the tissue
at the fixation site has also been advocated.10-14 However,
this author has advocated use of the pretarsal orbicularis
muscle cuff as a vehicle to bring the skin to the levator
aponeurosis, rather than muscle resection.15 If the host
factor is excluded, the surgeon’s ability to execute any of
the techniques with precision may dictate the relapse rate.
Often, during the revision surgery, the surgeon may find a
loop of suture on the surface of the orbital septum, which
suggests that the levator aponeurosis was never exposed
and the fixation was improperly done. Excessive subcutan-
eous and preseptal fatty tissues seem to adversely affect the
longevity of the double eyelid crease in both the suture and
incision techniques. To overcome the difficulty of bringing
the bulky and fatty pretarsal skin down to the levator
aponeurosis, a bulky pretarsal orbicularis oculi muscle
cuff is used as a fixating tissue.15 Incomplete and droopy
lateral folds are caused by the failure to provide solid
fixation between the lateral pretarsal skin and the lateral
levator aponeurosis and are more likely to occur after use
of the suture technique (Figure 8-4). Two maneuvers may
help reduce the chance of lateral hooding. First, the
incision line should remain parallel to the tarsal margin at
the lateral end. Second, the pretarsal orbicularis oculi
muscle should be fixated at a higher location on the levator
aponeurosis near the lateral canthal ligament. Crepe
wrinkled pretarsal skin is an imperfection that the
patient often accepts as a limitation of the surgery. This
unfavorable result could be the result of scarring from
Orbicularis oculi m
Levator aponeurosis
YES!
NO!
Figure 8-2
Relapsed double eyelid folds.
Figure 8-3
Approximation versus strangulation of the tissue.

COMPLICATIONS, UNFAVORABLE RESULTS, AND CRITICAL ANALYSIS
71
extensive pretarsal fatty and muscle tissue removal, or it
could be due to pretarsal skin fixation lengthening. When
the incision or suture is made low, loosening of the fixation
causes relapse. When the incision or fixation is set high on
the eyelid, even the lengthening of the fixation does not
cause relapse. Instead, it creates a loose and wrinkled
pretarsal skin. Puffiness of the eyelid is caused by excessive
subcutaneous and preseptal fat, and more importantly, by
the protrusion of the eye itself rather than the presence of
excessive preaponeurotic fat. Brow ptosis also contributes
to puffiness of the upper eyelid, especially among older
patients. A thick fold is often seen after double eyelid
surgery with resection of the skin redundancy. It is an
unavoidable consequence of removing the thin excess
pretarsal skin and replacing it with the thick orbital skin
and muscle to create a double fold (Figure 8-5). When the
patient requests elimination of eyelid puffiness, the
surgeon often responds by removing the preaponeurotic
fat. This results in disappointing extra/multiple creases
above the otherwise well-demarcated double eyelid fold
(Figure 8-6). Unlike the Caucasian upper eyelid, fat
removal in the Asian eyelid should be performed conser-
vatively (Figure 8-7). Excessive fat removal may result in an
unsightly sunken eye that loses its ethnic appearance
(Figure 8-8). An excessively high fold is caused by exces-
sive removal of upper eyelid skin redundancy, indicating
adaptation of Caucasian blepharoplasty principle to Asian
eyelid surgery (Figure 8-9). Although the forehead lift is
an answer to the problem, many patients opt to choose
simpler upper eyelid surgery and are willing to live with the
consequences. Epiphora is a transient problem due to
either temporary obstruction of the lacrimal canaliculus
secondary to postoperative swelling or conjunctival
irritation by the suture material. It resolves over time
(in the case of swelling) or by removing the suture material.
Conjunctival suffusion is a self-limited transient condi-
tion lasting only 2 to 3 days. Tarsal eversion or ectropion
is caused by the fixation of pretarsal skin to a high location
on the levator aponeurosis (Figure 8-10). It is not apparent
Figure 8-4
Incomplete, droopy lateral fold and ectropion of the eyelids after use of a suture
technique. This result is caused by excessively high and firm central fixation without
comparable medial and lateral fixation. Because of the anatomy of the levator, central
fixation tends to be readily accomplished and exaggerated while the medial crease
loosens and the lateral fold droops.
Figure 8-5
Postoperative view of puffy eyelids.
Figure 8-6
Formation of multiple creases after aggressive removal of preaponeurotic fat. This
may correct itself as the wound matures. Multiple creases become permanent when
the tissue under the extra crease adheres to the levator muscle because the
intervening fat is absent.
Figure 8-7
The preaponeurotic fat is contained within the thin, unnamed transparent capsule. It
is not necessary to open this capsule to complete the double eyelid operation.
Although it is tempting to remove it, aggressive removal of fat may initially cause
multiple creases and progressively sunken eyes as the person ages.

COMPLICATIONS, UNFAVORABLE RESULTS, AND CRITICAL ANALYSIS
72
while the patient’s eye is closed during surgery. When the
eye is opened, the levator pulls the pretarsal skin tightly
and begins to heighten the tarsal margin. This is usually
detected at the end of surgery and corrected. Mild cases of
ectropion tend to self-correct without further intervention.
Stretching exercises can help lengthen the fixation. This is
done by attempting to open the involved eye forcefully
while pressing on the cilia and tarsal plate with the fingers
to help lengthen the fixation. Unless the patient has a
lagophthalmos, conjunctival irritation is the result of
undetected suture material or a corneal abrasion. Buried
knots for the fixation could migrate and penetrate into the
conjunctival sac. The knot should be cut short, and the
needle should be managed so as to avoid penetrating the
conjunctive. Transient ptosis is caused by the swelling and
anesthetic effect of the levator muscle (Figure 8-11). Often
the surgeon finds that the first operated eye becomes ptotic
by the time the second side is completed. However, both
sides quickly and spontaneously equalize during the
recovery period. Disruption of the levator aponeurosis
during the dissection causes a permanent ptosis (Figure
8-12). Simple suturing of the levator aponeurosis may not
precisely correct the difference. In addition, it is difficult to
determine the necessary amount of correction because of
the presence of different swelling and anesthetic effect
between the eyes. Plication of the levator muscle during
fixation may result in differences in elevation of the tarsal
margin. Although it is not a true ptosis, the eyelid with less
tarsal elevation often appears to be ptotic. Contrary to the
long-held belief that the orbital septum fuses the levator
aponeurosis in a lower position in the Asian eyelid, accord-
ing to the author’s study (in press), the fusion point is at
least 9 to 10 mm above the ciliary margin. Because the
double eyelid incisions are made at a lower level than the
fusion point, the levator aponeurosis is vulnerable to injury.
The levator aponeurosis is also fairly thin at the upper
Figure 8-8
This sunken look is a result of excessive fat and skin removal.
Figure 8-9
Excessively high fold.
Figure 8-10
Tarsal eversion and extra crease. Tarsal eversion is the result of high fixation of the
pretarsal skin to the levator aponeurosis.
Figure 8-11
Temporary ptosis due to postsurgical edema from the unilateral revision. The eyes
resume symmetry as the wound matures.
Figure 8-12
Ptosis.

COMPLICATIONS, UNFAVORABLE RESULTS, AND CRITICAL ANALYSIS
73
tarsal border. The surgeon can mistakenly incise the levator
aponeurosis while attempting to cut the orbital septum.
Often the patient complains of tightness and a sense of
excessive pulling in the eye with excessive levator plication
and shortening. Ocular injury should be prevented by
careful instrumentation. A hypertrophic scar can be
avoided by carefully screening the patient before surgery.
Although the scar of the double eyelid operation easily
hides beneath the double eyelid fold, even a minor scar of
the epicanthoplasty is readily visible (Figure 8-13). Every
attempt should be made perform the epicanthoplasty
without any tension. Many epicanthoplasty techniques are
flawed in design because they necessitate pulling the tissue
and fixating it with a suture under tension.
Milia are occasional occurrences that may be resolved by
simply uncapping the overlying epidermis. Burial of the
knot and avoidance of too-superficial placement of perma-
nent sutures can prevent suture granuloma (Figure 8-14).
Suture material such as plain gut may cause exuberant
granuloma (Figure 8-15, A and B).
Figure 8-13
Hypertrophic epicanthoplasy scar.
Figure 8-14
Suture granuloma after use of the buried suture technique. (Courtesy B.G. Kim.)
A
B
Figure 8-15
A, 17-day postoperative view of suture granuloma, secondary to suture material (plain gut). B,Two-month postoperative view. Suture granuloma was resolved by removal of
suture, oral steroid, antibiotics, antihistamines, and local steroid injection of triamcinolone acetonide 10 mg/m.

COMPLICATIONS, UNFAVORABLE RESULTS, AND CRITICAL ANALYSIS
74
References
1. Chen WPD: Revision and correction of suboptimal results.
In Chen WPD, Ed.: Asian blepharoplasty, Newton, MA,
1995, Butterworth-Heinemann, p 84.
2. Fernandez LR: Double eyelid operation in the oriental in
Hawaii, Plast Reconstr Surg 25:257-264, 1960.
3. Lee JS: Simplified anatomic method of double-eyelid
operation: septodermal fixation technique, Plast Reconstr
Surg 100:170, 1997.
4. Hiraga Y: Blepharoplasty in orientals. Problems in plastic
and reconstructive surgery 1:504, 1991.
5. Matsunaga RS: Westernization of the Asian eyelid, Arch
Otolaryngol 111:149, 1985.
6. Weingarten CZ: Blepharoplasty in the oriental eye, Tram
Acad Ophth Otol 82:442, 1976.
7. Moutou Y, Moutou H: Intradermal double eyelid
operation and its follow-up results, Br J Plast Surg 25:285,
1972.
8. Hayashi K: The modification of the Hotz method for plastic
construction of a double eyelid, Jpn Rev Clin Ophthalmol
34:369, 1939.
9. Sayoc BT: Plastic construction of the superior palpabral
fold, Am J Ophthalmol 38:556-559, 1954.
10. Inoue S: The double-eyelid operation, Jpn Rev Clin
Ophthalmol 42:306, 1947.
11. Mitsui Y: Plastic construction of a “double eyelid”, Jpn Rev
Clin Ophthalmol 44:19, 1950.
12. Boo-Chai K: Plastic construction of the superior palpebral
fold, Plast Reconstr Surg 31:74, 1963.
13. Bang YH: The double-eyelid operation without supratarsal
fixation, Plast Reconstr Surg 88:12, 1991.
14. Chen WP: Concept of triangular, trapezoidal and
rectangular debulking of eyelid tissue: application in Asian
blepharoplasty, Plast Reconstr Surg 97:212, 1996.
15. Park JI: Orbicularis-levator fixation in double-eyelid
operation, Arch Facial Plast Surg 1(Apr-June):90-95, 1999.

75
The ideal shape and size of the double eyelid varies widely
depending on the patient and the culture. Patients may
complain of unfavorable results after the double eyelid
operation for the following reasons: scar, low fold, high
fold, shallow crease or loss of fold, deep crease, pretarsal
fullness, asymmetry, multiple creases or sunken eyelid,
ptosis, and removal of double eyelid fold.
Scar Revision
The two types of unsightly visible scars are wide and
depressed scars. In the case of a wide scar, generally the
same corrective procedures are used as in scar revision.
There are two categories of depressed scars; one is caused
by deficiency of the underlying soft tissue, and the other is
secondary to ectropion (see discussion later in this
chapter) (Figure 9-1).
Low Fold
Patients who have low folds and solid fixation with deep
creases do not need any new fixation. Excision of the
redundant skin and scar is an excellent way to eliminate
extensive scarring and raise the fold (Figure 9-2, A).
However, it can only slightly raise the fold, and it is not
effective for the patient whose crease is placed too low (i.e.,
less than 5 mm from the ciliary margin). Figure 9-2, B
illustrates a technique to make a new line above the
previous incision line using a buried suture method.
Although this technique has the disadvantage of leaving
two scar lines, the fold can be raised as needed and without
limitations. For eyelids with an inconspicuous scar and
Revision Double Eyelid
Operation
In-Chang Cho and Jung I. Park
redundant skin, a new, higher incision line is made with
the skin excision (see Figure 9-2, C). For the patient with
poor fixation and a low fold, either method B or C may be
used to recreate the creases (Figure 9-3).
High Fold
The three types of high folds are as follows:
1. High fold and shallow creases: An ellipse of the scar and
the skin inferior to the scar is excised. The underlying
soft tissue and pretarsal skin is then fixed to the tarsal
plate as in the primary double eyelid operation.
2. High fold and moderately deep creases: The same ellipse
of skin and scar is removed, but without additional
fixation.
3. High fold and deep creases: This is the most common
type. An ellipse of the skin and old scar is excised. The
upper incision is made at the previous incision scar,
and the lower incision is placed at the new, lower height.
Preservation of the underlying soft tissue bulk is critical
to prevent multiple crease formation (Figure 9-4, A).
The incision is deepened at the lower incision line until
it reaches the tarsal plate. An upper eyelid flap is
developed by releasing the adhesion from the tarsal
plate and the levator aponeurosis (see Figure 9-4, B, left
photo and illustration). A complete release of the adhe-
sion is confirmed when the patient is able to open the
eye without restriction as the upper flap is held with
forceps (see Figure 9-4, B, right photo). The lower flap is
undermined only if an ectropion is present (see Figure
9-4, C). The surgeon may need to advance the pre-
aponeurotic fat inferiorly or interpose a free fat graft
beneath the upper flap to avoid multiple creases. The
9

REVISION DOUBLE EYELID OPERATION
76
suborbicularis fascia is then anchored to the tarsus. The
suture fixation brings the skin of the upper flap down
to the tarsal plate at the lower level (see Figure 9-4, D).
Plaster tape is attached as a skin splint to prevent
multiple creases (Figure 9-5).
Mechanism of Failure in High Fold Correction
High fold correction has a high failure rate because of in-
complete release of adhesion or readhesion to the previous
site. The failure results in multiple creases or ectropion
(Figure 9-6).
Depth Problems
Depth problems include the following:
1. Shallow crease or loss of fold: In the case of loss of fold,
the same corrective procedure is applied as in the prim-
ary double eyelid operation. In some cases, a pretarsal
adhesion persists even when the double eyelid fixation
is loosened. The stronger the pretarsal adhesion in the
lower flap, the harder the formation of the crease due to
the tethering and rigidity of the pretarsal tissue. The
adhesion must be dissected, and the lower incision
should be pulled up to and fixed at a higher level. The
pretarsal adhesion is most likely the result of previous
pretarsal dissection during the primary double eyelid
operation. The revised crease tends to become
shallower than in the primary double eyelid operation
(Figures 9-7 and 9-8).
2. Deep crease, ectropion, or both: The adhesion is released
from the high location that formed a deep crease and is
moved to a lower part of the tarsal plate. This method
differs from the high fold correction only in that the skin
is not excised. An ectropion may also be caused by an
adhesion in the lower flap. Freeing the lower flap from
the adhesion will correct the ectropion (Figure 9-9).
Pretarsal Fullness
Korean patients often refer to pretarsal fullness as a
“sausage on the eyelid.” The illusionary effect of pretarsal
fullness doubles as the height of the double fold increases
in younger patients (Figure 9-10).
Pretarsal fullness is improved by reducing the tissue mass
from the pretarsal area. The height of the supratarsal
crease should be lowered to eliminate the perception of
pretarsal fullness. The pretarsal orbicularis oculi muscle
is excised in the midsegment (Figure 9-11). Segmental
excision of the muscle both reduces the mass and lowers
the height of the crease. When the muscle is removed at
A
B
C
Figure 9-1
Scar revision of the depressed scar. A, Excision of the scar. B, A short skin-orbicularis flap is made. C, The flap is advanced and sutured to the pretarsal skin and muscle. Excision
of the scar does not include the submuscular soft tissue.

PRETARSAL FULLNESS
77
A
Skin excision
Previous line
New line
Skin excision
New line
B
C
Figure 9-2
Three methods of raising the low double eyelid. A,The skin above the previous incision line and the scar are removed. B, A new crease line is created and fixated using a buried
suture method with short, interrupted stab incisions above the previous incision. C, A new line is made along a skin excision above the old incision scar.

REVISION DOUBLE EYELID OPERATION
78
the incision margin, cicatrical contracture causes a deeper
crease, which gives an illusion of relative pretarsal fullness.
The pretarsal orbicularis oculi muscle is injected with a
diluted triamcinolone solution (1:10 dilution of a 10 mg/ml
solution) before muscle excision. This allows for easier
muscle excision, and the steroid prevents postoperative
edema and excessive fibrosis (Figure 9-12).
Asymmetry
Asymmetry can often be corrected by changing only one
side. To lower the height of the double eyelid fold, the
pretarsal skin and scar are removed. The new incision is
made slightly lower than on the uncorrected side because
there will be less skin to fold on the corrected side and thus
the fold will ride higher if the incision remains the same as
on the uncorrected side (Figure 9-13).
A
Figure 9-3
A, Preoperative low fold. B, Postoperative higher fold. Only the skin was excised
above the previous incision line.
Figure 9-4
High fold correction. A, Excision of the skin between a previous high scar and the new lowered incision. B, Release of the adhesion to the levator aponeurosis (top). The patient
should be able to open the eyes as the upper flap is held in place with forceps (bottom).
Continued
A
B
B

PTOSIS
79
Sunken Eyelid and Multiple Creases
Both the sunken eyelid and multiple creases are created by
the overzealous removal of the preaponeurotic fat or orbi-
cularis oculi muscle. Correction requires the replacement
of the lost tissue with a fat or dermofat graft (Figure 9-15).
Replacement options are outlined in the following list:
1. Free fat or dermofat graft (Figure 9-16)
a. Preseptal
b. Preaponeurotic
2. Preseptal alloderm graft (Figure 9-17)
3. Fat injection into the orbicularis muscle or preseptal
space (Figure 9-18)
For slightly sunken eyelid with multiple creases, fat grafting
alone is adequate. After fat grafting is performed in the
preseptal space, the eyelids appear bulky when the eyes are
closed and sunken when the eyes are open. This problem is
avoided by grafting fat in the preaponeurotic space,
injecting fat into the orbicularis oculi muscle or retro
orbicularis oculi fat (R.O.O.F), or both. However, in most
cases, use of dermofat, fascial graft, or Alloderm® graft
(Life Cell, Branchburg, NJ) with release of the adhesion is
necessary.
Ptosis
The levator aponeurosis may be inadvertently disrupted
during the incision. The levator aponeurosis may simply be
sutured if the disrupted wound is fresh and severed ends
are easily identified. However, in most cases, the levator
aponeurosis and the Müller’s muscle retract. The levator
aponeurosis is then plicated, imbricated, or even advanced.
Postoperative ptosis may also be the result of upper level
C
Figure 9-4 (cont’d)
High fold correction. C, Undermine the lower flap only if an ectropion is present. D,The tarsal plate is fixated at the lower level.
A
B
Figure 9-5
A, Preoperative high fold. B, Postoperative lowered fold.
D

80
Old fixation site
reattaches to
previous adhesion site
Previous adhesion site
New fixation site
New fixation site
maintains its location
New fixation
migrates upward
and adheres to
old fixation site
A
B
A
B
Scar
Figure 9-6
Mechanism of failure in high fold correction. A, Ectropion occurs when the new skin scar migrates upward and readheres to the old fixation site. B, Multiple creases occur when
the new incision creates a new inferior fixation site and the old adhesion recurs at the previously released adhesion site.
Figure 9-7
A, Loss of the fold. The pretarsal tissue was migrated inferiorly and adhered to the tarsal plate. B, Release of the adhesion and fixation of the lower flap to a higher level.

PTOSIS
81
adhesion between the levator and the orbital septum. This
tethering of the levator muscle limits its normal excursion.
The problem can be solved by simply releasing the
adhesion (Figure 9-19).
A disrupted levator aponeurosis and extensive adhesion
with preaponeurotic tissue requires a careful isolation of
the levator aponeurosis and advancement (Figure 9-20).
A
B
Figure 9-8
Loss of fold. A, Preoperative view. B, Preoperative view.
Excision of
orbicularis m.
A
B
Figure 9-11
Removal of the midsegment of the pretarsal orbicularis oculi muscle.
Figure 9-12
Pretarsal fullness. A, Preoperative view. B, Postoperative view.
Height
Height
Bulging
Bulging
Figure 9-10
As the height of fold increases in a younger patient, the illusionary effect of bulging
doubles (left). Pretarsal fullness is not remarkable in the thin, wrinkled skin of the
older patient. An increase in the height of fold does not influence the degree of
bulging (right).
Figure 9-9
Deep crease. A, Preoperative view. B, Postoperative view.
A
B

REVISION DOUBLE EYELID OPERATION
82
Preseptal
fat injection
Preaponeurotic
fat injection
Muscle and
preseptal fat
injected
A
B
C
Figure 9-13
The higher crease on the left side is lowered to decrease the height of the fold.
Figure 9-14
Asymmetry. A, Preoperative view. B, Postoperative view.
Figure 9-15
Graft. Preseptal (A), preaponeurotic (B), and (C) fat injection into the orbicularis oculi muscle, R.O.O.F/preseptal space, or both.
A
B

REMOVAL OF THE EYELID FOLD
83
Removal of the Eyelid Fold
The expected outcome should be thoroughly explained to
the patient. The scar may be visible even when the eyes are
open because normal coverage is lost when the double
eyelid fold is removed. A double eyelid may reappear after
several years. The pretarsal eyelid may look bulky as a
result of fat displacement into the pretarsal eyelid. The
corrective procedure is as follows: An ellipse of skin is
excised, including the previous scar. The lower incision line
is made low in the pretarsal skin, in the same fashion as
correction of the high fold. The lower incision decreases
the chances that a double eyelid fold will form. The adhe-
sion at the double eyelid crease is released, and the soft
tissue is grafted to prevent readhesion. The preaponeurotic
fat may be displaced inferiorly into the pretarsal submus-
cular space. The location of the skin and muscle efface-
ment at closure should be at a different level and away from
the site of the previous adhesion. Unlike the correction of
high folds, no fixation suture is made into the levator
aponeurosis. The skin and muscle are closed with everting
sutures (Figures 9-21 and 9-22).
Figure 9-16
Sunken eyelid. Preoperative view (A), dermofat graft (B), and (C) postoperative view.
Figure 9-17
Alloderm® graft.
A
B
C
A
B
C

REVISION DOUBLE EYELID OPERATION
84
Figure 9-18
Fat injection in the sunken eyelid. A, Preoperative view. B, Postoperative view.
A
B
A
B
C
Figure 9-19
Ptosis of the left eye. A, Preoperative view. B, Operative view. Disinsertion of levator
aponeurosis is noted. C, Postoperative view.
A
B
Figure 9-20
Correction of iatrogenic ptosis after the double eyelid operation. Levator aponeurosis is exposed. A, Levator muscle/aponeurosis is elevated. B, Aponeurosis is advanced and
sutured to the tarsal plate, and the excess levator aponeurosis is being excised.

REMOVAL OF THE EYELID FOLD
85
Levator aponeurosis
advanced
Müller’s muscle
Tarsal plate
A
B
C
D
E
C
Figure 9-20–cont’d
Figure 9-21
A, Skin excision and release of the adhesion. B, Preaponeurotic fat displacement. C, Eversion suture.

REVISION DOUBLE EYELID OPERATION
86
References
1. Alloderm Grafting and Implantation in Facial Cosmetic
Surgery. World Congress and Workshop on Minimally
Invasive Facial Cosmetic Surgery, Kansas City, MO,
American Academy of Cosmetic Surgery, May 1–4, 1998.
2. Levator Muscle/Aponeurotic Lifting and Reconstruction-
Enhancement of Blepharoplasty. World Congress on Plastic,
Aesthetic & Reconstructive Surgery, Rome, Italy, September
1–5, 1992.
3. Levator Surgeries in the Aesthetic and Reconstructive
Blepharoplasty. Sixth International Symposium of Facial
Plastic and Reconstructive Surgery, San Francisco, CA, June
16–20, 1993.
A
B
Figure 9-22
Removal of the eyelid fold. A, Preoperative view. B, Postoperative view.

87
Medial Epicanthoplasty
The ideal Asian eyelid has the following properties:
1. Intercanthal distance: 3.0 to 3.6 cm
2. Distance ratio between intercanthal distance and
horizontal palpebral fissure: 0.90 to 1.15
3. Degree of slant of palpebral fissure: 5 to 10 degrees
4. No epicanthus
See Figure 10-1.
The author’s classification of epicanthoplasty is as follows:
1. Elliptical excision
2. Using Z-plasty
3. Using Y-V advancement
4. Using W-plasty
Medial epicanthoplasty is indicated in Asian patients for
the following reasons:
Medial Epicanthoplasty and
Lateral Canthoplasty
Dae-Hwan Park and Patrick R. Boulos
1. Easily visible, severe medial epicanthus
2. The distance ratio between the intercanthal distance
and horizontal fissure of eyelid is larger than 1.3
3. The distance ratio between the horizontal fissure and
vertical fissure of eyelid is less than 3
4. The distance ratio between the midpoint of pupil to the
medial epicanthus and the midpoint of pupil to lateral
epicanthus is less than 1
Elliptical Excision
Elliptical excision methods include the Von Ammon, Arlt,
Hiraga, and Watanabe methods.
1. Von Ammon method: Glabellar resection from radix
region
2. Arlt method: Elliptical resection of skin close to medial
epicanthus (Figure 10-2)
Ideal intercanthal
distance after correction
Interepicantual distance
Figure 10-1
The intercanthal distance and interepicanthal distance.
10

MEDIAL EPICANTHOPLASTY AND LATERAL CANTHOPLASTY
88
3. Hiraga method: Transverse incision and trimming of
dog ear (Figure 10-3)
4. Watanabe method: Modification of Hiraga method to
prevent acute angle formation (Figure 10-4)
Refinements of Hiraga Method
1. Preoperative design: Slant line shows resection area
2. Transverse incision of medial epicanthus
3. Excision of skin and a small amount of subcutaneous
soft tissue and orbicularis muscle
4. Subcutaneous dermal fixation with nylon 7-0
5. Trimming of “dog ear” and suturing (Figure 10-5)
Z-Plasty
Z-plasty options include single, double, or multiple Z-
plasty.
Single Z-plasty methods include the following:
1. Rogman method (Figure 10-6)
2. Sheehan method (Figure 10-7)
3. Imre method (Figure 10-8)
4. Ogawa method (Figure 10-9)
5. Park method (Figure 10-10)
The modified Park Z-epicanthoplasty is shown in
Figure 10-11.
Double or multiple Z-plasty methods are as follows:
1. Blair method (Figure 10-12)
2. Converse method (Figure 10-13)
3. Mustarde method (Figures 10-14 and 10-15, A and B):
The Mustarde method can be used for severe
epicanthus. It can be modified with a Z-plasty on the
lower part. The upper part is trimmed by dog-ear
excision. The modified Mustarde method is shown in
Figures 10-16 and 10-17 (case presentation).
4. Spaeth method (Figure 10-18)
Y-V Advancement Flap
Y-V methods include the Hughes simple Y-V advancement
flap (Figure 10-19) and Fuente del Campo method
(Figure 10-20).
W-Plasty
W-plasty methods include the following:
1. Mulliken-Hoopes method (Figure 10-21)
2. Uchida method (Figures 10-22 and 10-23)
3. Flowers method (Figures 10-24 and 10-25)
Lateral Canthoplasty
Lateral canthoplasty methods are as follows:
1. Von Ammon method (Figure 10-26)
2. Blair method: includes transverse incision, V-Y advance-
ment and lateral cantholysis (Figure 10-27)
3. Fox method (Figure 10-28). A modified Fox method
used in lateral epicanthoplasty is shown in Figure 10-29.
4. Blaskovics method (Figure 10-30)
5. Uchida method (Figures 10-31 and 10-32). Complica-
tions of the Uchida method are shown in Figure 10-33
and include hypertrophic scarring, scar contracture,
undercorrection, and overcorrection.

LATERAL CANTHOPLASTY
89
A
B
A
B
A
B
Figure 10-2
The Arlt method.
C
Figure 10-3
The Hiraga method. A, Preoperative view. B, Postoperative view.

MEDIAL EPICANTHOPLASTY AND LATERAL CANTHOPLASTY
90
C
A
B
Figure 10-4
The Watanabe method. A, Preoperative view. B, Postoperative view.

91
A
B
C
D
E
Figure 10-5
Refinements of the Hiraga method.

92
A
B
A
B
A
B
Figure 10-6
The Rogman method.
Figure 10-7
The Sheehan method: case presentation. A, Preoperative view. B, Postoperative view.
Figure 10-8
The Imre method.
A
B
Figure 10-9
The Ogawa method.

LATERAL CANTHOPLASTY
93
Figure 10-10
The Park Z-plasty. A, Marking for Z-epicanthoplasty incisions (dotted lines). B,
Marking for the inner epicanthus. C, Triangular excision. D, Flap elevation. E,
Suturing. F, Long-term result.
Figure 10-11
Modification of the Park Z-epicanthoplasty. A, Preoperative view (both eyes).
B, Postoperative view (both eyes). C, Preoperative view (one eye). D, Postoperative
view (one eye).
A
B
C
D
E
F
C
D
A
B

MEDIAL EPICANTHOPLASTY AND LATERAL CANTHOPLASTY
94
A
B
A
B
Figure 10-12
The Blair method.
Figure 10-13
The Converse method.

LATERAL CANTHOPLASTY
95
A
P1
B
P2
P1
C
P2
E
D
F
P1
Figure 10-14
The Mustarde method. A, P1: desired medial canthal position. B, P2: preoperative
medial canthal position. C, Design. D, Identification of medial canthal tendon.
E, Medial canthal tendon plication. F, Postoperative view. (Mustarde JC: Repair and
reconstruction in the orbital region, ed 2, New York, 1980, Churchill Livingstone,
pp 332-344.)
G
Figure 10-15
A case using the Mustarde method. A, Preoperative view. B, Postoperative view.
A
B

MEDIAL EPICANTHOPLASTY AND LATERAL CANTHOPLASTY
96
A
B
Figure 10-16
Modified Mustarde method.
Figure 10-17
Modified Mustarde method: case presentation.
Figure 10-18
The Spaeth method. A, Design. B, Postoperative view.