Color Atlas of Cosmetic Oculofacial Surgery

The skin–orbicularis flap is retracted inferiorly
using a Blair retractor, exposing the preaponeurotic
fat, junctional fat (transitional fat), and, occasionally,
the nasal fat pad. I use forceps and scissors to clear
the preaponeurotic fat from the underlying levator
aponeurosis. A small infiltrate of Xylocaine may be
injected to the back of the preaponeurotic fat pad at
this time, as well as over the nasal fat pad region.
Depending on the amount of excessive and prolap s-
ing preaponeurotic fat, part of it or most of it may be
excised. A combination of bipolar and monopolar
Bovie cautery, as well as Westcott scissors, are used
to transect the fat pedicle a small portion at a time,
until the intended amount is removed, in a careful and
controlled fashion.
51
Surgical Technique
Figure 5.8

Clinical pearls
■ Using a hemostat to apply the clamp–cut–cautery
technique of fat excision often yields some level of
discomfort or a reactive jerk from the patient.
■ After 0.5mL of Xylocaine has been applied, the gentle
teasing and cutting using the combination of bipolar
as well as Bovie cautery is usually very atraumatic. It
allows an even distribution of fat excision across the
width of the preaponeurotic space.
■ It is important to reposit the remaining fat pedicle
carefully into the antero-superior orbital space, under
the orbital septum. I try to avoid directly placing the
cut edge of the fat near any cut edges of the
orbicularis or orbital septum to avoid any possibility of
cicatrix formation.
■ In the prominent-eyed patient, one should be
conservative in preaponeurotic fat removal so as not
to accentuate the height of the upper crease, which
may make the eye appear even more prominent.

Pitfalls
■ Avoid deep placement of the Bovie needle into the
supero-medial orbital space behind the orbital rim, to
avoid injury to the trochlea and the superior oblique
tendon.
■ The clamp–cut–cautery maneuver of fat excision may
tend to focus the fat removal over only the central
one-third or one-half of the preaponeurotic space. It
may create a central ‘divot’ of excision.
A
B

Located over the medial extent of the incision is a
distinctive and separate fat pad – the nasal fat pad.
When clinically prominent, it may be excised. A Blair
retractor is placed in the inner canthus, and with
pressure on the globe, an incision is made with a cut-
ting Bovie needle through the capsule covering the
pale-yellow nasal fat. The nasal fat pad is teased out
with forceps and a cotton applicator stick.
Often a prominent vessel is seen and it can be selec-
tively cauterized with bipolar cautery; then, a combi-
nation of scissors and coagulation Bovie is used to excise
the nasal fat pad. Bipolar cautery is used to reduce the
fat and to cauterize the remaining stump vessels. The fat is
reinspected for any potential bleeding vessels.
52
Chapter 5: Upper Blepharoplasty

Clinical pearls
■ It is important to recognize and identify the much
larger vessels here in the nasal fat pad, so that it is
adequately cauterized before allowing it to retract into
the deep orbital space.
■ The placement and successive replacement of a
retractor, as well as gentle ballotment on the globe,
helps in identifying the nasal fat pad.
■ An application of bipolar cautery (instead of Bovie
cautery) on the fat pad’s capsule prior to incision with
Westcott scissors is an alternative to what was stated
above. It helps to open the nasal fat pocket without
having to use Bovie cautery in this important sector of
the orbital space, where the superior oblique trochlea
and tendon are located.

Pitfalls
■ Deep placement of the Bovie cautery tip in the nasal
fat pad space is to be avoided. There is the potential
for pain and discomfort, as well as injury to the
fourth-nerve structures.
Figure 5.9 (A) Nasal fat pad.
Figure 5.9 (B) Space after nasal fat pad has been excised.
A
B

There is a separate area of fat in the transitional
zone between the preaponeurotic fat and the white
nasal fat. This transitional fat (junctional fat) invests
the conjoined septum and extension of Whitnall’s
ligament that forms the interpad septum.
53
Surgical Technique

Clinical pearls
■ Removal of the transitional fat will produce a
depression in the eyelid crease nasally; thus, it should
not be removed.

Pitfalls
■ Avoid inadvertent weakening of the medial aspect of
the levator aponeurosis. Dehiscence may lead to
segmental ptosis.
Figure 5.10

After fat reduction, the myocutaneous flap (redun-
dant upper lid hooding) that is now hinged along the
superior tarsal border can be trimmed along the
lower line of the incision (Fig. 5.12A–D). (The more tra-
ditional blepharoplasty stages involve removal of the
skin and orbicularis muscle in two steps, as well as
the opening of the septum as a third step.) The flap is
elevated with gentle traction, separating the edges of
the skin incision while it is being excised. I use a
Bovie tip on cutting mode to tease (cut) through
the orbicularis that is holding the myocutaneous
flap down along the superior tarsal border. Straight
scissors may also be used, slanting away from the
insertions of the levator aponeurosis so as not to dis-
rupt them. Crease sutures that will be used in closure
will repair any dehiscences in the levator, but it is wise
to avoid any disruption in the levator attachments.
Potential bleeding areas are in the orbicularis and
subcutaneous layer of the lower crease incision. The
pretarsal skin is retracted with cotton applicator
sticks to expose the inferior edge of the pretarsal
orbicularis muscle, and bipolar cautery is used to
cauterize any bleeding vessels in this area.
54
Chapter 5: Upper Blepharoplasty
An open view of the preaponeurotic platform is
now possible. If there should be any prolapsed lobe of
the lacrimal gland (Fig. 5.11A), it can be repositioned
by first securing its capsule with a 5-0 Vicryl, then
passing the needle to a point behind the supero-nasal
orbital rim, taking a bite of the inner periorbita
within the lacrimal gland fossa. When tied, the suture
should retract the lacrimal gland behind the orbital
rim (Fig. 5.11B).
Figure 5.11

Clinical pearls
■ If left without repositioning, the prolapsed lacrimal
gland tends to leave a bulge that is noticeable and
unsightly over the lateral preseptal area of the eyelid.
■ Never excise any portion of the lacrimal gland lobe.
■ Do not cauterize it in an attempt to reduce the
lacrimal gland.

Pitfalls
■ The repositioning stitch should engage only the
capsule of the gland as you reposition it behind the
orbital rim in the lacrimal gland fossa.
■ Do not encircle the lacrimal gland lobe with any
suture element.
A
B

55
Surgical Technique
Figure 5.12 (A)

Clinical pearls
■ It is important to be conservative during the first
passage using the cutting Bovie tip as you sever the
flap of redundant skin–orbicularis tissues along the
lower skin incision. This will allow you some
separation from the underlying levator.
■ One may elect to further clean up the strip of
orbicularis/fascial tissues that appear excessive and
overlie the superior tarsal border, by further excision
along the lower skin edge.
■ It is helpful to pause and control bleeders from the
orbicularis with bipolar cautery as you cut along with
the Bovie cautery.
■ At the lateral end of the myocutaneous flap, I try to
shallow my plane of excision to reduce my chance of
cutting across any of the larger arterioles present
within the periorbital orbicularis muscle.

Pitfalls
■ Do not apply any coagulative Bovie cautery as it may
excessively char and damage the levator muscle
fibers.
■ If one encounters partial dehiscence of the levator, it
should be repaired with 7-0 silk or 6-0 Vicryl.
Figure 5.12 (B)
Figure 5.12 (C)
Figure 5.12 (D)
A
B
C
D

Before final skin closure, the interpad septum is
lysed to reduce tethering of closure of the upper lid
(Fig. 5.13).
56
Chapter 5: Upper Blepharoplasty
Figure 5.13 Lysis of interpad septum.

Figure 5.14 (C) Crease fixation sutures using Vicryl sutures, applying them
from pretarsal skin to levator aponeurosis along the superior tarsal border.
Crease fixation
For patients who desire to have further enhancement
of the upper lid crease, the crease may be reinforced
by applying five to six 6-0 silk stitches, placing them
in an interrupted fashion from the lower skin inci-
sion, including a small bite of the levator aponeurosis
directly above the superior tarsal border, to upper lid
skin edge (Fig. 5.14A & B).
Instead of skin–levator–skin interrupted stitches, an
approach using additional 6-0 Vicryl sutures may be
used to fixate the pretarsal skin–muscle edge to the
levator aponeurosis. Fig. 5.14(C) it is applied just 1mm
below the inferior skin edge, in a transcutaneous fashion
and picking up a bite of the aponeurosis above the
superior tarsal border. The knot is then double-tied
over the anterior pretarsal skin surface. It is usually
applied in three locations: central, medial, and lateral
third of the wound. It corrects any dehiscence of the
levator that could have occurred with excision of the
myocutaneous-septal flap. The three knots are cut
away at 1 week after the operation, while each of
their residual loops are left behind underneath the
pretarsal tissues to promote some wound reaction.
This maneuver:
■ ensures crease position; and
■ prevents ptosis that may occur from undetected
injury to the levator.
57
Surgical Technique
Figure 5.14

Clinical pearls
■ Without crease fixation and anchoring, the upper lid
preseptal skin muscle layers may balloon down and
cover over the pretarsal platform space.
A
B
C

Skin closure
The upper blepharoplasty wound is normally closed
with 6-0 nylon, 6-0 Prolene, or 7-0 silk (Fig. 5.15A & B).
I favor starting at the medial end of the incision and
working towards the lateral end, as the wound stress
is greater at the lateral end.
At the lateral end of the upper blepharoplasty inci-
sion, I use an interlocking ‘baseball stitch’ (first popu-
larized by Dr Clinton McCord) to terminate the
closure. Essentially, it is a far–far–near–near stitch
that is then interlocked to give stability and symmetry
to the wound edges. (Similarly, I use this stitching in
the lateral portion of lower blepharoplasty closure as
well as direct brow lift.)
58
Chapter 5: Upper Blepharoplasty
Figure 5.15
A
B

The flowchart in Figure 5.16 outlines the approach
to the treatment of patients with upper eyelid derma-
tochalasis and brow ptosis.
FURTHER READING
McCord CD. Techniques in blepharoplasty.
Ophthalmic Surg 1979;10:40–55.
McCord CD. Upper blepharoplasty. In: McCord CD,
ed. Eyelid surgery: principles and techniques.
New York: Lippincott-Raven; 1995;179–95.
Sheen JH. Supratarsal fixation in upper
blepharoplasty. Plast Reconstr Surg
1974;54:424–31.
59
Surgical Technique
Figure 5.16 Decision tree for management of upper lid dermatochalasis and eyebrow ptosis. (Reproduced with permission from Chen WP.
Oculoplastic surgery: the essentials. New York: Thieme; 2001:145.)
Endoscopic brow forehead lift
(always + int. browpexy)
Upper lid dermatochalasis and brow ptosis
Women
Internal browpexy
Mild or severe
nasal 2/3 brow ptosis
Upper blepharoplasty
Upper blepharoplasty plus internal browpexy
Men
Severe
Direct suprabrow lift
(Ignore)
Lateral 1/3
brow ptosis
Nasal 2/3
brow ptosis
Lateral 1/3
brow ptosis
Moderate
Mild

61
Chapter 6
In the evaluation of patients with upper eyelid skin
redundancy and hooding, it is important to note the
upper brow position and check for eyebrow ptosis.
The upper eyebrow normally rests above the superior
orbital rim in females and at the level of the supra-
orbital rim in males. With aging, the brow may sag
down to below the orbital rim. A ptotic brow can
gravitate into the upper lid skin area, creating a sec-
ondary eyelid hooding, which is relieved when the eye-
brow is repositioned to its normal location. Symptoms
may include visual fatigue, visual field obstruction,
and fatigue of the forehead muscles, as well as
headaches. This process of brow ptosis also produces
a narrowed spacing between the eyebrow hairs and
the lashes, which can cause a frowning appearance in
the patient. The presence of brow ptosis therefore
needs to be addressed either before upper blepharo-
plasty or handled concurrently.
The following eyebrow procedures that are com-
monly used in conjunction with upper lid blepharo-
plasty are covered in detail in this chapter:
■ Endoscopic-assisted eyebrow forehead lift (see
Chapter 4) is used more commonly in females for
the nasal two-thirds of the brow and glabellar
area. (It is commonly supplemented with the
internal browpexy.)
■ Direct eyebrow lift (p. 62) is used, generally, in
males. It involves direct skin incision over the
area above the brow. It is also commonly
supplemented with the internal browpexy, which
corrects for lateral brow ptosis.
■ Temporal forehead lift (p. 65) is used for the
lateral third of the brow when there is severe skin
laxity lateral to the brow, beyond the lateral
orbital rim. Performed through a subgaleal
approach, it is commonly used as a supplement to
the cheeklift procedure.
■ Internal browpexy (p. 68) is performed through
the upper blepharoplasty incision for correction
of laxity in the lateral third of the brow. It is
commonly used by itself in conjunction with
upper lid blepharoplasty or used as a supplement
to the endoscopic eyebrow forehead lift or the
direct eyebrow lift for elevation of the lateral
third or tail of the brow.
■ Browplasty (p. 70) is used to correct fullness due
to abundance of retro-orbicularis oculi brow fat
(ROOF).
Direct Browlift, Internal Browpexy,
Browplasty
William PD Chen

Direct Browlift
A sagging eyebrow can be corrected by a direct
brow lift. After the eyebrow area is locally anes-
thetized, an above-brow incision line is designed from
the medial to the lateral extent of the upper eyebrow
hair, in a gentle curve with a slight lateral flare
upward. A segment of the ptotic forehead skin, usu-
ally between 8 and 10mm, is marked out parallel to
this lower incision. A No. 15 blade is used to incise
the upper and lower brow markings. The strip of
ptotic forehead skin and subcutaneous tissue, down
to the level of the frontalis muscle, is excised using
cutting Bovie cautery with a needle tip. The deep
frontalis muscles are reapproximated to those at the
deep plane of the upper incisional edge, using mul-
tiple interrupted 4-0 Polydek sutures (ME-2 needle,
Deknatel). The subcutaneous tissues are then closed
using subcuticular placement of 5-0 Vicryl. The skin
is closed with 4-0 nylon in an interlocking running
stitch. The nylon stitches may be kept in place for
10–14 days. In Figure 6.12, the long strand of the
suture is locked under the loop of the “far–far”
passage.
62
Chapter 6: Direct Browlift, Internal Browpexy, Browplasty
Figure 6.1
Figure 6.2
Figure 6.3
Figure 6.4

63
Direct Browlift
Figure 6.5
Figure 6.6
Figure 6.7
Figure 6.8
Figure 6.9
Figure 6.10

64
Chapter 6: Direct Browlift, Internal Browpexy, Browplasty
Figure 6.11
Figure 6.12

Clinical pearls
■ Direct browlift is well suited for men with a receding
hairline, as it avoids further migration of the hairline.
■ The wound can be easily disguised in patients with
deep forehead furrows.
■ The medial incision lines should taper well before the
medial border of the brow hair is reached.
■ The sutures need to be left in longer to avoid wound
spreading due to the strength of frontalis muscle.
■ Wound edges need to be closed in a slightly everted
and tension-free fashion.

Pitfalls
■ A prominent incision line will form medially in the thick
skin of the forehead if the incision is extended too far
medially.
■ One should avoid anchoring any of the deeper plane
tissues to the underlying periosteum as this will cause
an immobile brow.
■ Often, patients may complain of hypoesthesia over
the forehead region.
Figure 6.13
Figure 6.14

Temporal Forehead Lift
A lateral brow sag can be corrected by a direct
lateral brow lift, with the excision of the ptotic fore-
head skin concentrating on the lateral extent of the
supra-brow region (Fig. 6.15). Closure may be per-
formed using baseball stitching or interrupted sutures.
65
Temporal Forehead Lift
Figure 6.15

Clinical pearls
■ A direct lateral brow lift is great for lateral sagging of
the tail of the eyebrows.
■ The incision is well hidden behind the hairline.

Mid-forehead Brow Lift
The mid-forehead brow lift is another variation of
the direct brow lift. It is suitable for individuals with
deep furrows of the forehead and significant brow
ptosis, and in patients who would benefit from for-
ward advancement of the hairline. The procedure is
especially appropriate for men with receding hairline
or baldness (Fig. 6.16).
66
Chapter 6: Direct Browlift, Internal Browpexy, Browplasty
Figure 6.16 Preoperative view of a patient being considered for
mid-forehead brow lift. (Reproduced with permission from McCord CD.
Eyelid surgery: principles and techniques. Philadelphia: Lippincott-Raven;
1995:177.)
Figure 6.17 Coronal forehead lift, mid-forehead incision. Surgical view
showing the area of skin and forehead tissue to be excised in this patient.
(Reproduced with permission from McCord CD. Eyelid surgery: principles
and techniques. Philadelphia: Lippincott-Raven; 1995:177.)
After the forehead is anesthetized with frontal
nerve block and local infiltration, McCord mentions
that when planning for the skin incisions, one should
try to find two furrows and plan to make the initial
incision in the upper one and develop the flap for
advancement inferiorly. If the amount of forehead
skin to be resected coincides with a lower furrow, this
will result in an ideal scar (Fig. 6.17).

The resection of skin and development of the flap
can occur in either the subgaleal or subcutaneous
plane. The subgaleal flap is easier to elevate and to
close with less scar. However, it transects the sensory
nerves, with significant forehead numbness postoper-
atively. The subcutaneous flap does not cause quite as
much sensory loss but closure is more difficult, with
tension on the skin edges. When the wound is closed,
separate galeal closure is needed if it is incised. The
forehead skin is closed with everting vertical mattress
sutures (4-0 Prolene) and vertical mattress sutures (6-0
nylon) (Fig. 6.18A & B).
67
Mid-forehead Brow Lift

Clinical pearls
■ Typically, the second forehead wrinkle tends to cross
the midline; therefore, the tissues between the second
and the third forehead wrinkles are excised, counting
from the brow upward.
Figure 6.18 Coronal forehead lift, mid-forehead incision. (A) The skin segment has been excised in this patient with closure of the galea and vertical
mattress skin closure. (B) Same patient, 6 weeks postoperatively. (Reproduced with permission from McCord CD. Eyelid surgery: principles and
techniques. Philadelphia: Lippincott-Raven; 1995:177.)
A
B

Lateral Brow Procedures Performed
in Conjunction with Upper
Blepharoplasty Approach
If there are certain aging changes in the brow that will
not be corrected by upper lid blepharoplasty alone,
and lateral brow procedures are appropriate, the
following can be used at this stage of the upper lid
blepharoplasty.
Internal browpexy
If there is enough laxity in the temporal one-third of
the brow so that there is concern that residual skin
folds may persist there or that the lateral eye-shadow
space may not form well postoperatively, an internal
browpexy should be performed laterally. This is an
effective, convenient procedure for correction of
mild-to-moderate brow ptosis that can be performed
through the wound of, and at the same time as, an
upper blepharoplasty.
Steps of browpexy
Three to four double 4-0 Prolene sutures are used.
Each of the sutures is passed transcutaneously from
the skin below the ptotic brow through the eyelid
skin (below the inferior eyebrow hairs) and exiting
into the sub-brow space over the superior orbital rim
(Fig. 6.19A). The exit site under the brow flap is
marked with methylene blue. The needle is then
passed through the periosteum at a location 5–10mm
above the superior orbital rim (Fig. 6.19B). The
suture is then passed to the underside of the brow
flap, near the methylene blue marking. The transcuta-
neous end of the suture is then passed through and
exits under the brow flap. When the two ends are
tied, this will result in the lower boundary of the ptotic
brow being elevated back to a point above the superior
orbital rim, correcting the brow ptosis (Fig. 6.20).
The upper blepharoplasty wound may then be
closed as described in the previous chapter.
68
Chapter 6: Direct Browlift, Internal Browpexy, Browplasty
Figure 6.19 Internal browpexy of right brow. (A)
Dissection in the planes superficial to the periosteum
and deep temporal fascia, exposing the juncture of
the deep temporal fascia to the skull, the fusion
point, and the orbital ligament. (B) A fixating 4-0
Prolene suture has been placed in the deep
temporal fascia at its point of fusion to the skull
periosteum. The suture will subsequently be inserted
into the fat and orbicularis fibers under the flap at
the level of the inferior eyebrow hairs and then tied
for brow support. (Reproduced with permission
from Chen WP. Oculoplastic surgery: the essentials.
New York: Thieme; 2001:129–30.)
A
B
6.1

69
Lateral Brow Procedures Performed in Conjunction with Upper Blepharoplasty Approach
Figure 6.20 Steps showing internal browpexy performed over left brow.
A
B
C
D

Browplasty
Excessive lateral brow fullness or prominence
can sometimes be a major complaint of the patient
presenting for an upper lid blepharoplasty. This
excessive fullness may not be corrected by the usual
excision of skin and muscle using the standard upper
lid blepharoplasty technique. This fullness can be
caused by a prominent bony superior rim, but is most
commonly caused by an abundance of the retro-
orbicularis oculi brow fat (ROOF). When the ROOF
layer hypertrophies, it may extend downward into
the eyelid proper, where it becomes preseptal fat. In
these patients, sculpting and surgical excision of the
ROOF can allow reduction in this overly prominent
area. It is performed in conjunction with upper
blepharoplasty through the same lid crease access.
Approach
It is performed by approaching the fat pads in a
sub-orbicularis plane towards the superior orbital
rim and as far lateral as the lateral orbital rim. An
internal browpexy may be performed at the same
time, if necessary, to correct for any brow ptosis.
Surgical technique
The upper edge of the blepharoplasty incision is
retracted to expose the brow fat at the superior
orbital rim (Fig. 6.21, showing left upper lid). Two
Blair rake retractors are inserted to retract the
skin–muscle edge. The area of fat on the rim to be
removed is marked with methylene blue and is then
excised by grasping the fat with Adson forceps and
dissecting it free of the periosteum using the Bovie
coagulating needle. Dissection should not extend
nasally to the superior orbital notch so as to avoid
damaging the nerves and vessels in that area. The
upward dissection is performed until one is approxi-
mately 1cm above the rim. A segment of fat usually
measuring 1.0–1.5cm in vertical dimension and then
tapering nasally and temporally is removed (Fig. 6.22).
The resection should extend laterally to the frontozy-
gomatic suture. The periosteum is left intact to
prevent the occurrence of postoperative adhesions
that may hinder brow movement. Additional redun-
dant skin may be produced after brow fat excision,
and any redundant fold should be excised to prevent
double folding in the crease area.
70
Chapter 6: Direct Browlift, Internal Browpexy, Browplasty
Figure 6.21
Figure 6.22

FURTHER READING
Bostwick J, Eaves FF, Nahai F. Endoscopic plastic
surgery. St Louis: Quality Medical Publishing;
1995.
Codner MA. Endoscopic forehead lift. In: McCord
CD, ed. Eyelid surgery: principles and
techniques. New York: Lippincott-Raven;
1995:368–79.
Daniel RK, Tirkantits B. Endoscopic forehead lift: an
operative technique. Plast Reconstr Surg
1996;98:1148–57.
Isse NG. Endoscopic facial rejuvenation:
endoforehead, the functional lift, case reports.
Aesth Plast Surg 1994;18:21–9.
Kinze DM. An anatomically based study of the
mechanism of eyebrow ptosis. Plast Reconstr
Surg 1996;97:1321–32.
Kinze DM. Limited incision forehead lift for
eyebrow elevation to enhance upper
blepharoplasty. Plast Reconstr Surg
1996;97:1334–42.
Lempke BN, Stasior GO. The anatomy of eyebrow
ptosis. Arch Ophthalmic 1982;100:981–6.
Loomis MG. Endoscopic brow fixation without
brow fixation or miniscrews. Plast Reconstr
Surg 1996;98:373–4.
McCord CD, Doxanas MT. Browplasty and
browpexy: an adjunct to blepharoplasty. Plast
Reconstr Surg 1990;86:248–54.
McCord CD. Brow surgery. In: McCord CD, ed.
Eyelid surgery: principles and techniques. New
York: Lippincott-Raven; 1995:166–170.
Pakkanen M, Salisbury AV, Ersek RA. Biodegradable
positive fixation for the endoscopic brow lift.
Plast Reconstr Surg 1996;98:1087–90.
Steinsapir KD, Shorr N, Hoenig J, Goldberg RA,
Baylis HI, Morrow D. The endoscopic forehead
lift. Ophthalmic Plast Reconstr Surg
1998;14:107–18.
Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA.
Anatomy of the frontal branch of the facial
nerve: the significance of the temporal fat pad.
Plast Reconstr Surg 1989;83:265–71.
Vasconez LO. Coronal facelift with endoscopic
techniques. Plast Surg Forum 1992;15:229.
71
Lateral Brow Procedures Performed in Conjunction with Upper Blepharoplasty Approach

73
Chapter 7
The main reasons why Asians without an upper
eyelid crease may elect to have a crease created have
been discussed in Chapter 1. There are many fallacies
in discussions of eyelid surgery for Asians. The
conventional view that Asian eyelid surgery started
only after the Second World War, with industrali-
zation and westernization of Asia, is in my opinion
erroneous. There has always been a demand for this
type of cosmetic surgery in Asia; the earliest 20 descrip-
tions of the double eyelid crease pro ce dures were
reported in the Japanese medical literature between
1896 and 1940. In the Western Hemisphere over the
last 40 years, there has been a simultaneous rise in
demand as more Asians leave their homeland and
settle abroad. Demography shows that Asians seeking
eyelid crease procedures are a relatively young,
affluent, and educated group. However, despite being
educated, the patients’ understanding of what they
want, and of what can be achieved, may not be
equivalent to the surgeon’s own beliefs. They may not
be aware of the normal wound healing processes
and have unrealistic expectations. In addition, the
physician may not be fully informed of the nuances of
this specialized and peculiar aspect of aesthetic eyelid
surgery. Most of the complications and suboptimal
results may be linked to a lack of communication
between the patient and the surgeon, and the failure
of the surgeon to observe certain basic concepts and
hidden dangers.
One of the most common fallacies is the notion
that most Asians do not have an upper eyelid crease.
This may be because, typically, only those subjects
without a crease would consult an aesthetic surgeon.
The lid crease occurs in varying incidence among
different ethnic subsets of Asians,1 whether Chinese,
Korean, or Japanese, etc. It shows provincial and
geographic variance (e.g. northern versus southern
Chinese; Japanese who are from the northern island
of Hokkaido versus those from the more southern
province of Kyushu). Overall, among Han ethnic
groups (Chinese, Koreans, and Japanese), the preva-
lence of a crease is 50% (Fig. 7.1). Consequently, one
in two Asians is likely to have an upper eyelid crease.
This ratio holds true even among parents and their
offspring – for instance, two out of four siblings will
have an upper eyelid crease, or one of the two parents
will have a crease. The crease height often correlates
with the vertical dimension of the superior tarsal
plate, as measured over the central portion above
the pupillary aperture. Asians are, in general, smaller
in physical dimensions relative to non-Asians. Their
tarsal plate height averages 6.5–8.0mm, and the
upper lid crease, if present, is usually not greater
than this distance from the eyelid margin (ciliary
border). With respect to the depth of inward fold-
ing of the crease line, the crease is not any less
prominent in Asians as compared with non-Asians.
One of the reasons that the lateral canthus appears
more upslanted may be the presence medially of a
fold of skin over the crease, partially blocking the
upper medial half of the palpebral fissure. There have
been recent reports describing a higher lateral canthal
position among certain ethnic subset of Asians,
although one certainly cannot deduce or generalize
this finding to all Asians.
Asian Blepharoplasty of the
Upper Eyelid
William PD Chen
Figure 7.1 Single eyelid without upper lid crease.

The current hypothesis regarding the lid crease is
that it results from the presence of subcutaneous
terminal interdigitations of the levator aponeurosis
in the pretarsal as well as along the superior tarsal
border area. The distal terminations of the levator
aponeurosis fibers blend into the intermuscular septal
and connective tissue fibers of the pretarsal orbicula-
ris oculi muscle,2 resulting in an infolding along the
superior tarsal border when the levator is contracting
the tarsus upward (Figs 7.2 & 7.3).
74
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
Figure 7.2 Cross-sectional view of an Asian upper eyelid without lid
crease. The orbital septum tends to fuse with the levator aponeurosis in a
variable fashion from down over the anterior tarsal surface up to 5mm
above the superior tarsal border. Besides the typical preaponeurotic
(postseptal or orbital) fat pad, there is often presence of submuscular
(suborbicularis oculi muscle, or preseptal) islands of fat pads, as well as
pretarsal fat globules. The submuscular or preseptal fat may appear as
an inferior extension of the sub-brow fat (or retro-orbicularis oculi fat). The
upper tarsal plate measures from 6.5 to 8.0mm in Asians. (See Fig. 2.3.)
(Reproduced with permission from Chen WP. Oculoplastic surgery: the
essentials. New York: Thieme; 2001:212.)
Sub-brow fat
(ROOF)
Orbital septum
Submuscular fat
Pretarsal fat
Figure 7.3 Cross-sectional view of a typical Caucasian eyelid with a
natural upper eyelid crease. Aponeurotic fibers form interdigitations to the
pretarsal orbicularis oculi muscle and a subdermal attachment along the
superior tarsal border. The lid crease is often a composite of the vector
forces from several of these creases. The pretarsal region is more
anchored and firmer due to the presence of interdigitations of the terminal
aponeurotic fibers. The orbital septum fuses with the levator aponeurosis
at a higher level as compared with most Asians. There is less presence of
the preaponeurotic fat inferiorly. There may be less submuscular fat as
well as pretarsal fat. The upper tarsus is often 8.0–11.0mm in
Caucasians. (Reproduced with permission from Chen WP. Oculoplastic
surgery: the essentials. New York: Thieme; 2001:212.)
Sub-brow fat
(ROOF)
Orbital septum

The term ‘westernizing blepharoplasty’ is still quite
often used to describe the crease procedure that
Asians elect to undergo.3 This can be complicating
and misleading to the patient and physician alike.
Such Asians really do not want to select the height
and crease configuration of a Caucasian’s or a
Westerner’s eye. Rather, most Asians who elect to
have Asian blepharoplasty want to look like other
Asians who have a crease – a very different crease as
compared with that of a Caucasian.
Communication between patients and physicians is
further weakened by additional confusion in ter-
minology. The terms ‘outer double eyelid’ and ‘inner
double eyelid’ do not refer to the higher crease found
in a Caucasian (Fig. 7.4) versus the lower crease seen
in those Asians who possess a crease, nor to any
upslanting of the crease over the lateral canthus.
Instead, they relate to the medial configuration
(shape) of the crease among Asians. The term ‘outer
double’ simply signifies a crease that does not
converge to the medial canthus – I believe ‘parallel’ is
a more appropriate term anatomically (Fig. 7.5). The
term ‘inner double eyelid’ refers to a medially con-
verging crease – I consider the term ‘nasally tapered
crease’ as more accurate here (Fig. 7.6). The original
terms make sense only if one appreciates the Chinese
origin of these words, as they are English translations
from Kanji (literal meaning: ‘words of the Han race’),
the language of the Han people. The abstract concepts
are distorted in straight translation. Interestingly, the
classical literature and Imperial court correspondences
of Korean as well as Japanese cultures from the last
500 years both utilized Chinese Kanji. Overall, these
terms are quite confusing for anyone who is not
native to the Chinese written language. It is best to
avoid using them for medicolegal reasons, since
Chinese as well as non-Chinese Asians may be using
them inaccurately.
75
Asian Blepharoplasty of the Upper Eyelid
Figure 7.4 A typical semilunar crease for Caucasians. The crease is high
by Asian norm and appears more separated from the lid margin over the
central one-third of the eyelid.
Figure 7.5 A parallel crease configuration. The crease runs equidistant
from the lid margin as it courses from the medial to lateral canthus.
Figure 7.6 A nasally tapered crease configuration. The crease converges
to the medial canthus and may either merge into it or stay converging
but separated.

The term ‘Asian blepharoplasty’ was first used in a
paper published in 1987 by this author.1 The paper
described a distinctive surgical procedure customized
specifically for those Asians without a crease who
desire to have a crease, and included details concern-
ing the height and shape of such, and the surgical
maneuvers needed to yield a crease that appears
continuous, is predictable, and remains permanent in
nature.
Through an external incision approach, the objec-
tive of Asian blepharoplasty is to clear a trapezoidal
block of preaponeurotic tissues along the superior
tarsal border, including the skin, orbicularis, orbital
septum, as well as minimal preaponeurotic fat, in an
equidepth and uniform fashion, to allow for optimal
surgical apposition of the terminal fibers of the leva-
tor aponeurosis to the undersurface of the skin along
the superior tarsal border.4–7 For a nasally tapered
crease, one would design the crease to converge medi-
ally. For a parallel crease, one would stay more level
and equidistant along the lid margin.
Surgical method
The concept of upper eyelid crease configurations
and the essential steps needed for predictable place-
ment of a lid crease among those Asians without a
crease have been covered in my previous publica-
tions.1,4,5 My method is founded on accurate meas-
urement of the central height of the upper tarsus,
using it to determine the placement of the external
incision line for creation of the crease. The ideal
crease tends to be of either the nasally tapered type or
of the parallel configuration. A medial upper lid fold
is often present to some degree in the medial portion
of the upper eyelid of Asians, whether they have a
crease or not, and should not be considered patho-
logic, nor should it be automatically removed.
Interestingly, the same small medial upper lid fold can
be seen readily in non-Asians and even Europeans.
(At present, the term ‘epicanthal fold’ seems to be
indiscriminately applied to any degree of fold, no
matter how small, and selectively applied to Asians, a
practice I believe is unfortunate.)
Premedications and surgical setup
The patient usually receives 10mg of diazepam
(Valium) and one tablet of Vicodin or Tylenol with
codeine, orally, an hour before the procedure. The
patient is placed in a supine position, and an intra-
venous line and electrocardiographic monitors are
applied. A pulse oximeter that provides a real-time
readout of the patient’s pAO2 is applied. All patients
are given a nasal cannula with 1–2L/min of room air
flow (or oxygen). Intravenous Versed (midazolam)
may be used in small aliquots of 0.5mg (0.5mL of
1mg/mL).
Anesthetic mixture and injections
Two mixtures of local anesthetics are then prepared:
1. 10mL of 2% lidocaine (Xylocaine) containing
1:100 000 dilution of epinephrine is mixed with 150
units of hyaluronidase, if available, and labeled
‘regular’. (This mixture is still acidic in nature.)
2. 1mL of the above mixture is further diluted with
9mL of injectable normal saline. This mixture now
has a pH closer to neutrality since it has been diluted
with the buffering action of injectable normal saline.
The epinephrine concentration is now 1:1 000 000
(labeled ‘diluted’).
A drop of topical anesthetic, 0.5% proparacaine
hydrochloride (Ophthaine, Ophthetic) is applied over
each cornea for comfort prior to surgical preparation
and draping. Using a 30-gauge half-inch needle,
0.25–0.5mL of the diluted mixture is infiltrated sub-
cutaneously over the superior tarsal border of the
mid-portion of the lid. During the next 2 minutes,
anesthesia takes effect and one can observe blanching
of the eyelid skin from the powerful vasoconstrictive
effect of the diluted epinephrine (Fig. 7.7).
The regular mixture is then injected in the sub-
orbicularis plane along the mid-section of the upper
lid, usually applying less than 1.0mL per eyelid.
76
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
7.1
7.2
7.3

The purpose of this two-staged injection of local
anesthetic is to allow for a relatively painless pre-
infiltration to anesthetize the surgical field before
the full strength of acidic 2% Xylocaine is given.1
(One may add sodium bicarbonate to the 2% mix
to achieve the same effect: for a 10% volume mix-
ture, 1mL of 8.4% sodium bicarbonate, containing
100mEq or 8.4g per 100mL, is mixed with 9mL of
the 2% Xylocaine.) The hyaluronidase promotes
dispersion of the anesthetic and greatly reduces any
tissue distortion, facilitating the identification of any
crease line that the patient may have.
When confronted with a patient with a low thresh-
old for pain, one may supplement the local field
infiltration with a frontal nerve block: a 30-gauge
half-inch needle may be used to apply 1mL of the
anesthetic into the supraorbital space just lateral to
the supraorbital notch.
The eyelids and face are then prepared in the usual
fashion for ophthalmic plastic surgery. The eyes again
receive a drop of topical anesthetic, this time using
tetracaine hydrochloride for longer-lasting corneal
anesthesia. To eliminate the possible sensation of
claustrophobia that may occur with draping over the
nose and midface, a single layer of sterile, moistened,
porous gauze may be placed over the patient’s
exposed nose and mouth. Black opaque corneal
protectors are then applied under the eyelids.
77
Asian Blepharoplasty of the Upper Eyelid
Figure 7.7 Blanching of skin following injection of
anesthetic mixture containing diluted epinephrine. Intense
vasoconstriction is seen even with dilution of 1:1 000 000
epinephrine.

Clinical pearls
■ The use of diluted anesthetic solution helps to:
■ decrease pain upon injection;
■ decrease volume of anesthetic needed for injection;
and
■ create less tissue distortion as a result of less
volume expansion and lessened bleeding.
■ It allows the surgeon to stay focused on the surgical
plane.
■ The use of nasally delivered room air or low-flow
oxygen serves to decrease the patient’s sense of
claustrophobia.

Pitfalls
■ Never use nasal oxygen in an open system exposed
to monopolar cautery, as it may cause ignition and
flaming.
■ Always apply pulse oximetry to measure the pAO2
saturation. Preoperative sedation and intraoperative
sedation may easily cause apnea in a sensitive patient.

Surgical stages
The height of the tarsus determines the overall central
position of the surgical crease; the shape is deter-
mined by how you design the medial one-third and
lateral one-third of this lower line of incision, accord-
ing to the patient’s preference.
The shaved-off tip of a wooden cotton-tipped applica-
tor dipped with methylene blue is used to indicate the
proposed crease. The upper lid is everted and the verti-
cal height of the tarsus is measured over the central
portion of the lid with a caliper (Fig. 7.8). This meas-
urement – which is usually between 6.5 and 8.0mm –
is carefully transcribed onto the external skin surface,
again over the central part of the eyelid skin. This
point directly overlies the superior tarsal border and
will serve as a reference point for the overall crease
height along the central one-third of the eyelid,
whether the crease shape is to be nasally tapered, par-
allel, or, in rare cases, laterally flared. For those
patients who have a crease, one should also measure
the tarsus to confirm that the apparent crease is
indeed the correct crease line to use, whether one is
planning to preserve or enhance it.
78
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
Figure 7.8 This right upper eyelid is everted and a
caliper used to measure the central height of the
tarsus. This point is transcribed onto the
external surface of the skin and serves as a
central reference point for the lower line of
incision.

If the crease is to be nasally tapered, the medial
one-third of the incision line is marked such that it
tapers towards the medial canthal angle or merges
with the medial upper lid fold (Fig. 7.9). The lateral
one-third is usually marked in a leveled configura-
tion, although occasionally a patient may request a
slight upward widening over the lateral segment of
the crease.
79
Asian Blepharoplasty of the Upper Eyelid

Clinical pearls
■ The use of an inked tapered tip of a wooden stick
allows precise drawing and redrawing, as compared
with the usual marking pen available in operating
theaters.
■ In Asian blepharoplasty involving skin excision, the
lower line of incision will determine the shape and
height of the surgically created crease.
■ Repetitive measurement and confirmation of incision
lines are important.
■ Usually, 1–3mm of skin may be included in the
incision line for excision.
■ Using the thinned wooden-tipped applicator and
applying very gentle pressure on the lower incision
line (proposed line for new crease formation), instruct
the patient to look upward even before the incision
starts, in order to assess how the crease may appear.
Since the eyelid has been injected, the crease will
appear more swollen and further from the ciliary
margin than it will postoperatively, after it has
eventually healed.
Figure 7.9 Marking and design of a nasally tapered crease.
The medial one-third of the incision lines taper towards the
medial canthal angle. The lateral one-third may be either
leveled or flared slightly upward.

For the parallel crease, the measured height of the
superior tarsal border is drawn across the width of
the eyelid skin (Fig. 7.10).
To create adequate adhesions, some subdermal tis-
sue must be removed. A strip of skin measuring about
2–3mm is then marked above and parallel to this lower
line of incision. In patients who want a nasally
tapered configuration, this upper line of incision is
tapered towards the medial canthal angle, or to
merge with any medial upper lid fold that may be
present. The segment of skin to be excised is frequently
less than 2mm over the medial portion of the crease.
80
Chapter 7: Asian Blepharoplasty of the Upper Eyelid

Pitfalls
■ Medially, the parallel crease does not flare upward
from the medial canthal angle.
■ The medial end of the crease design should not go
past an imaginary vertical line aligned with the medial
canthal angle, both for nasally tapered and for parallel
creases.
■ Laterally, the crease design should not traverse past
the lateral canthal angle.

Clinical 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.
Figure 7.10 Marking and design of a parallel
crease.

The incision is then carried out using a No. 15 sur-
gical blade (Bard-Parker) along the upper and lower
lines, incising just through the dermis and within the
superficial orbicularis oculi muscles. Fine capillary
bleeding is controlled using bipolar wetfield cautery
(Fig. 7.11).
The excision of a strip of skin is not required in
every case; however, I believe that it facilitates the
removal of subsequent layers of the lid tissues, thereby
permitting adequate crease formation. At this point,
the superior tarsal border is still covered by pretarsal
and supratarsal* (favored over the term ‘preseptal’)
orbicularis oculi muscle, with possibly some terminal
portions of the orbital septum, and the terminal fibers
of the levator aponeurosis beneath the septum.
81
Asian Blepharoplasty of the Upper Eyelid

Clinical pearls
■ It is important to stabilize the tarsal plate and
overlying soft tissues and skin when making a
continuous incision, especially along the lower line of
incision; 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. For right-handed surgeons, for the right
upper lid, it is best to start medially; and for the left
upper lid, one may start from the lateral end 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 obscuration
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 incision 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.
Figure 7.11 Upper and lower lines of incision have been opened with a
No. 15 surgical blade, with wetfield bipolar cautery applied to vascular
oozing that may arise from orbicularis muscle.
*Semantically, in Asians, the supratarsal area is an area
directly above the tarsus, while the true preseptal region
may be quite a few millimeters superior to this, since the
orbital septum may fuse with the levator aponeurosis a
variable distance from the superior tarsal border.

One may use the left fingers to slightly retract the
upper incision wound edge, then aim a Bovie cautery
tip (or radiofrequency unit’s Empire tip needle) supe-
riorly to transect through the preseptal orbicularis
oculi muscle there, knowing that although the uppe r
incision line is only 2–3mm 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 2–3mm above the
82
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
Figure 7.12 After traversing through the
supratarsal orbicularis in a beveled fashion, the
orbital septum is reached and opened horizontally,
exposing the underlying preaponeurotic fat pads.

Clinical 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 pad, the fat pad
itself, the underlying levator aponeurosis, or the lobe
of the lacrimal gland situated over the lateral end.

Pitfalls
■ In opening of the orbital septum medially, the levator
aponeurosis may be injured.
■ In opening of the lateral extent of the septum, the
lacimal gland can be injured.
■ Avoid the use of monopolar cautery over the superior
medial aspect of the orbital space to avoid the
trochlea of the superior oblique muscle, which can
lead to fourth-nerve palsy and torsional diplopia.
■ Avoid cauterizing the lacrimal gland over the superior
lateral aspect of the anterior orbital rim.
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, one 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 prolapsing
through the opening of the orbital septum (Fig. 7.12).
Blunt-tipped Westcott’s spring scissors are then used
to open the orbital septum.

The orbital septum is opened along the superior
line of incision and the skin–orbicularis–orbital sep-
tum flap turned inferiorly along the superior tarsal
border (Fig. 7.13).
Westcott scissors are used to open the potential
space that is present between the preaponeurotic fat
and the overlying orbicularis muscle within the redun-
dant myocutaneous strip, retracting it with a Blair’s
tissue retractor. The central preaponeurotic fat pad is
dissected and separated from its fascial attachment
to its underlying levator muscle fibers (the latter is salmon-
colored with vertically oriented muscle striations).
The fat should be repositioned, allowing it to fill in
the space between the levator and anterior aspect of
the superior orbital rim (the supratarsal sulcus).
83
Asian Blepharoplasty of the Upper Eyelid
Figure 7.13 The skin–orbicularis–septal flap may be
retracted inferiorly to facilitate exposure to the
preaponeurotic fat pads and the underlying levator
aponeurosis (upside-down view of right upper lid).

Clinical pearls
■ After separating the initial fine adhesions of fat from
the overlying orbicularis, it is often safer to use moist
cotton-tipped applicators to separate fat from the
underlying superior tarsal border, levator aponeurosis,
and levator muscle.
■ No attempt is made to remove the fat pad unless it is
grossly interfering with crease formation along the
superior tarsal border. Wetfield bipolar cautery may
be used to shrink it away if it is potentially
‘threatening’ the construction of a good crease
because of its presence directly over the
preaponeurotic platform.

Pitfalls
■ Avoid pointing the scissors posteriorly towards the
levator as you elevate the myocutaneous flap.
■ After the myocutaneous flap has been elevated, avoid
cutting any fat that may be intertwined on the
underbelly of the myocutaneous strip; this may cause
bleeding of the intra-fat blood vessels, as well as
inadvertent reduction in the volume of preaponeurotic
fat left behind.

Occasionally, in patients with very full upper lids,
significant fat is seen centrally and in an inferiorly
placed position. This may significantly abort/interfere
with any attempt to form a crease. In these patients,
instead of mild reduction with bipolar cautery, one
may opt to excise 25–50% of the preaponeurotic fat
seen within the surgical field (Fig. 7.14). Wetfield
cautery is used to treat the intra-fat vessels first; then
cutting monopolar cautery is used to cut the fat pad
2–3mm at a time. These maneuvers are then repeated.
It may take two to three repetitions before this stage
84
Chapter 7: Asian Blepharoplasty of the Upper Eyelid

Clinical pearls
■ Extra care and time is allotted to this step of
reduction of fat pads, if elected. Hemorrhage from
undetected bleeders following transection of the
intra-fat vessels may lead to serious consequences,
including orbital hematoma and blindness.
■ A prolapsed lacrimal gland may look like a lobe of fat.
It must be recognized and needs to be reanchored to
a point behind the superior-lateral orbital rim (see
Chapter 5).

Pitfalls
■ It is important to clearly distinguish the nasal fat pad
and central preaponeurotic fat pad from the lacrimal
gland lobule.
■ Transection of the lacrimal gland may lead to varying
degrees of dry eyes.
Figure 7.14 Optional reduction of some preaponeurotic fat.
is completed. (The fat excision often necessitates a
small supplement of lidocaine in the space under-
neath the preaponeurotic fat pad.)
If a patient with dermatochalasis and obliteration
of crease should manifest even a very minimal con-
cavity in the supratarsal sulcus, one should not
remove any fat, as this will worsen the hollowness
and cause multiple redundant folds superior to where
one wants the crease to be. Instead of excision of the
fat, one should reposition it superiorly.
A
B

Figure 7.15 shows excision of the myocutaneous
flap (skin, orbicularis, and inferior remnants of sep-
tum) along the superior tarsal border. This is carried
out by grasping the lateral end of the myocutaneous
flap of the right upper lid (or medial end of the left
upper lid myocutaneous flap) with the instrument in
your left hand, then using the radiofrequency unit or
monopolar needle tip on cutting mode to cut along a
plane between the orbicularis within the flap and the
superior tarsal border/aponeurotic junction.
85
Asian Blepharoplasty of the Upper Eyelid

Clinical pearls
■ When the myocutaneous flap is incised, the
orbicularis muscle will bleed. As one proceeds, one
should control each of the new bleeders as soon as
they arise, using bipolar cautery, rather than cutting
off the whole strip first, before coming back to control
a group of bleeders. This seems to decrease
postoperative edema and hematoma formation.
■ There is a tendency to go too shallow over the medial
starting point of the left upper lid during this phase of
the excision of the myocutaneous strip, leaving
behind too much orbicularis. An inadequately
anchored crease over the medial segment may
therefore result from this subtle oversight.

Pitfalls
■ One must take care to avoid inadvertent partial
transection of the distal fibers of the levator
aponeurosis.
■ Avoid transection of the superior tarsal vascular
arcade, which may bleed and cause segmental
swelling and postoperative secondary ptosis.
Figure 7.15 The myocutaneous flap is then trimmed
horizontally along the superior tarsal border.

Figure 7.16 represents a three-dimensional line
drawing of trapezoidal debulking of the preapo neu-
rotic platform.
86
Chapter 7: Asian Blepharoplasty of the Upper Eyelid

Clinical pearls
■ This trapezoidal ‘one-plane’ debulking of the
preaponeurotic platform is an efficient, elegant, and
controlled technique of excising a whole block of
redundant tissues, with full control of tissues excised
in an equidepth fashion.
■ The beveled plane allows the tissues to appose nicely
during surgical closure.
■ Instruct the patient to look up, to evaluate your
attempt at crease formation. Any incomplete
formation of crease should be investigated at this
point.
Figure 7.16 Cross-sectional drawing of trapezoidal debulking of the
preaponeurotic platform in Asian blepharoplasty.

87
Asian Blepharoplasty of the Upper Eyelid

Clinical pearls
■ The pretarsal tissue may be reduced only if pretarsal
fat is moderately abundant and threatens the surgical
formation of the desired upper lid crease.
■ There are some surgeons who routinely debulk the
entire pretarsal subcutaneous tissue, believing that it
is better to have only skin over the anterior surface of
the tarsus. This may come about because of
concerns that there are competing distal fibers of the
levator aponeurosis within the pretarsal plane. In
reality, within the pretarsal plane of a creaseless Asian
eyelid, there are few, if any, functional terminal
interdigitations of the levator aponeurosis to the
dermis.

Pitfalls
■ Vigorous dissection along the pretarsal plane is not
advisable as it creates prolonged postoperative
edema and can risk undesirable formation of multiple
creases. Furthermore, it is quite normal for Asians
born with a natural crease to have some degree of
pretarsal fullness along the area between the crease
and the eyelashes.
■ Leaving behind redundant tissues along the inferior
border may result in only partial formation of the
crease or late obliteration of an initially acceptable
crease.
Figure 7.17 A strip of pretarsal orbicularis
muscle is trimmed along the lower skin incision.
After excision of the myocutaneous strip, often
there is some residual fascial tissue along the lower
skin incision wound. This is composed of a combi-
nation of preseptal and pretarsal orbicularis muscle
fibers, interspersed with occasional pretarsal fat
patches. This may occupy the path along which one is
planning to form the crease, just over the superior
tarsal border. In this situation, it is advisable to
excise this 2–3mm strip of orbicularis tissues along
the inferior skin incision edge (Fig. 7.17). It allows a
smoothing and mild flattening of the tissues along the
pretarsal plane, as well as thinning of the inferior
wound edge.

The adhesive surgical drapes over the patient’s mid-
forehead and upper eyelid skin are then loosened, to
decrease any upward traction over the incision wound,
tarsus, and eyelid margin. This ‘resetting’ maneuver
allows the anterior layer to settle into a proper position
relative to the underlying levator–tarsus.
In order to form a dynamic crease*, the terminal fi -
bers of the levator aponeurosis above the superior tarsal
border should be directed to the subdermal plane of the
lower line of skin incision. A 6-0 nonabsorbable suture
(6-0 silk or nylon) is used to pick up the lower skin edge
and subcutaneous tissue, the levator aponeurosis along
the superior tarsal border, and then the upper skin edge.
Each of these is tied as an interrupted suture.
Besides the stitch over the center of the crease, three
interrupted sutures are placed medially and two to
three stitches laterally. With these six to seven crease-
forming sutures in place, the rest of the incision may
be closed using 6-0 or 7-0 silk/nylon in a continuous
or subcuticular fashion (Fig. 7.18). This gives the best
chance for the formation of a dynamic crease.
Some surgeons prefer to bury either dissolvable or
permanent stitches along the superior tarsal border, fix-
ating the inferior edge of the pretarsal orbicularis to the
levator muscle. This method, in my experience, tends to
give a static crease. Many patients complain of persist-
ent foreign body sensation within the muscle layers of
the lid years after buried permanent sutures have been
applied. These often have to be removed secondarily.
88
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
*A dynamic crease of the upper eyelid is a surgically created
crease that fades on downgaze. A static crease shows inden-
tation that remains obvious on downgaze.
Figure 7.18 In this patient, the wound was closed with five interrupted
6-0 sutures and a continuous 7-0 nylon suture.

89
Asian Blepharoplasty of the Upper Eyelid

Clinical pearls
■ The medial end of the crease may require additional
placement of crease-forming (skin/levator/skin)
sutures, as the medial extent of the levator muscle is
often rudimentary and underdeveloped.
■ In a patient with a medial canthal fold, if a nasally
tapered crease shape was preselected, the crease
line can often be designed to merge medially into the
fold itself.
■ In applying the crease-forming stitch, each bite on the
aponeurosis should be at the superior tarsal border
and not any higher, to prevent the formation of a
‘high, harsh and semilunar crease’.
■ To enhance or deepen a crease, one may apply three
double-armed 5-0 Vicryl sutures transcutaneously to
the underlying tarsus along the superior tarsal border
(locating these over the medial, central, and lateral
one-thirds of the eyelid) just below the crease line, in
addition to the skin closure (Fig. 5.14C). The sutures
are then tied externally. After 1 week, the knot is
trimmed off the skin, leaving behind the buried loop of
the absorbable Vicryl.
■ Check crease symmetry bilaterally upon completion
of closure. Measure the crease height with a caliper. If
there is a discrepancy, it is better to correct the
difference in crease height between the two sides by
revising the higher crease down, through excision of
0.5–1.0mm of skin from the inferior skin edge of this
side. This is a general rule and should be applied only
with individual evaluation.

Pitfalls
■ One is likely to end up with upper eyelid retraction or
secondary ectropion if the tissues have not been
allowed to lay back to their natural plane prior to
surgical closure.
■ Insufficient inclusion of the levator aponeurosis will
result in partial crease formation or late obliteration.
■ Excessively deep or high bite along the levator
aponeurosis may result in a high crease or an
acquired secondary ptosis, with secondary
lagophthalomos on upgaze.
■ Patients who manifest ptosis will tend to have poor
crease formation. It is best to address the ptosis
repair first and return later to create a crease.
■ Inclusion of residual fat pads along the superior tarsal
border will result in obliteration of crease.

Postoperative Regimen for Dr Chen’s
Asian Blepharoplasty Patients
■ Ice compresses for 1 day.
■ Bed rest for 24 hours.
■ No reading, viewing of television, or computer
use for 24 hours.
■ Wound and facial hygiene – clean face and incision
wounds three to four times daily with clean water.
■ Apply antibiotic ointment four times daily for
7 days.
■ Patient may shower that first day.
■ Avoid hot-spa or swimming.
■ Avoid strenuous activities or workout for at least
a week.
■ Avoid aspirin compounds or anything with
ibuprofen (Moltin). Steroids are not routinely
prescribed.
■ Avoid consumption of spicy foods, chocolate,
dairy products, and fried foods for 2 months.
Patients without any pre-existing crease should
undertake the following crease-enhancing eye version
exercise: Patients are instructed to try looking
upward (actuation of the levator function) from the
third postoperative day onward. The patient is taught
to assume a normal, vertically aligned frontal-to-chin
head posture and refrain from using the frontalis
muscle of the forehead, then to look from a
downgaze to an upward position, at least ten repeti-
tions, twice a day. The speed of levator movement
should be deliberately slow in order to allow good
crease in-folding without pulling on any fine blood
vessels and causing postoperative hematoma.
Suture removal is at 1 week.
The patients are told that 80% of the postoperative
swelling should disappear a week after the sutures
have been removed or at 2 weeks postoperatively.
The remaining swelling may linger for 2 months.
They are instructed that the crease may change over a
period of 3–6 months.
Should there be a need for revision touch-up – for
example, when the crease did not form distinctively –
the touch-up is performed no earlier than 6 months,
as the crease continues to mature. This author does
not advocate secondary revision on patients seeking
consultation after having had previous procedure(s)
elsewhere unless a 12-month period has elapsed.
Some preoperative photos and postoperative results
are shown in Figures 7.19–7.30.
90
Chapter 7: Asian Blepharoplasty of the Upper Eyelid

91
Postoperative Regimen for Dr Chen’s Asian Blepharoplasty Patients
Figure 7.20 (A) Before and (B) after.
Figure 7.19 (A) Before and (B) after.
A
B
A
B

92
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
Figure 7.21 (A) Before and (B) after.
Figure 7.22 (A) Before and (B) after.
A
B
A
B

93
Postoperative Regimen for Dr Chen’s Asian Blepharoplasty Patients
Figure 7.23 (A) Before, (B) after and (C) after - oblique view.
A
B
C

94
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
Figure 7.24 (A) Before and (B) after.
Figure 7.25 (A) Before and (B) after.
A
B
A
B

95
Postoperative Regimen for Dr Chen’s Asian Blepharoplasty Patients
Figure 7.26 (A) Before and (B) after.
Figure 7.27 (A) Before and (B) after.
A
B
A
B

96
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
Figure 7.28 (A) Before and (B) after.
Figure 7.29 (A) Before and (B) after.
A
B
A
B

97
Postoperative Regimen for Dr Chen’s Asian Blepharoplasty Patients
Figure 7.30 (A) Before and (B, C) after.
A
B
C

Clinical Use
Elderly Asian patients, with or without a pre-existing
upper lid crease, may present with:
■ dermatochalasis alone (Fig. 7.31);
■ dermatochalasis with fatty prolapse; or
■ dermatochalasis with ptosis (Fig. 7.32).
Surgical solutions for such are as follows (Fig. 7.33):
1. Elderly Asian patients with a pre-existing crease
■ Dermatochalasis alone is corrected by preserving
the crease, and carrying out a skin-excision
blepharoplasty.
■ Dermatochalasis with fatty prolapse is best
managed by preserving the crease, and
performing a blepharoplasty with trimming of
only sufficient fat above the superior tarsal
border to permit preservation of the crease.
(Excess fat excision will result in deepening of the
supratarsal sulcus.)
■ In dermatochalasis with ptosis, the crease has
often migrated upward; the crease should be reset
based on the individual’s tarsal height using Asian
blepharoplasty, performing only skin excision
plus levator aponeurotic repair (resection and/or
advancement).
2. Elderly Asian patients without a pre-existing
crease
These patients can opt to have a crease added.
■ Dermatochalasis alone is corrected by Asian
blepharoplasty with excision of the
dermatochalasis and creation of a lid crease (if
the patient wants one).
■ Dermatochalasis with fatty prolapse is corrected
by Asian blepharoplasty with excision of the
dermatochalasis and creation of a lid crease (if
the patient wants one), with trimming of only
sufficient fat to permit making of a crease.
■ Dermatochalasis with ptosis is rectified using
skin-excision-only Asian blepharoplasty, with
creation of a lid crease, plus levator aponeurotic
repair (resection and/or advancement).
When the elderly Asian patient does not have a
pre-existing crease and prefers to stay crease-less:
■ Dermatochalasis alone is corrected by skin
excision blepharoplasty and closure without
crease fixation.
■ Dermatochalasis with fatty prolapse is corrected
by skin excision blepharoplasty, minimal fat
excision, and closure without crease fixation.
■ Dermatochalasis with ptosis is corrected by skin
excision blepharoplasty plus levator aponeurotic
repair (resection and/or advancement), and
closure without crease fixation.
98
Chapter 7: Asian Blepharoplasty of the Upper Eyelid
Figure 7.31 Asian patient showing dermatochalasis of the upper eyelid.
Figure 7.32 Asian patient showing dermatochalasis and ptosis.

99
Clinical Use
Figure 7.33 Surgical solutions for Asian
blepharoplasty in elderly patients. (Reproduced
with permission from Chen WP. Oculoplastic
surgery: the essentials. New York: Thieme;
2001:221.)
Upper lid of elderly Asian patient
With crease
Without crease
Dermatochalasis
+ ptosis
Aponeurotic repair,
reset crease to Asians'
tarsal height
Dermatochalasis
+ fat
Skin + minimal
fat removal,
preserve crease
Dermatochalasis
Skin excision
blepharoplasty,
preserve crease
Patient wants crease
Stay with no crease
Dermatochalasis
+ ptosis
Asian
blepharoplasty
aponeurotic repair,
plus crease
formation
Dermatochalasis
+ fat
Asian
blepharoplasty
minimal fat
excision,
plus crease
formation
Dermatochalasis
Asian
blepharoplasty
plus crease
formation
Dermatochalasis
+ ptosis
Asian
blepharoplasty
plus aponeurotic
repair
Dermatochalasis
+ fat
Asian
blepharoplasty
minimal fat
excision
Dermatochalasis
Asian
blepharoplasty

The Suture Ligation Method
There are alternatives to the external incision method
of the double eyelid crease procedure, one of which is
using suture ligation alone without extensive incision
and excision. The surgical objective of the ligation
(suturing) approach is to create a surgical adhesion
between the soft tissues just above the tarsal plate to
the overlying skin, whether the surgical ligature is
first inserted through the conjunctival side or from
the skin side, and whether it is ligated with the suture
knot buried under the subconjunctival side or the
subcutaneous side. The key element is a lack of tissue
removal and this is also its limitation. There are usu-
ally one to five stitches used among variations of
this method. The method does not involve any exten-
sive relayering, excision, or removal of soft tissue,
and so will not correct for any anatomic soft tissue
redundancy. It works relatively well for young adults
aged up to the early 20s. Beyond this age group,
the natural increase in soft tissue mass over the
preaponeurotic platform, whether due to aging or
to gravitational sagging, renders the suture ligation
method less effective. Satisfaction levels, on a short term,
seem high among patients in Japan. If a patient is
willing to consider a crease that may vanish or be
shielded-over from view after 2 to 5 years, and is
willing to undergo repeat surgery, this is an alter-
native. Patients’ complaints may include persistent
foreign body sensation, irregularity in the contour
of the crease (e.g. ‘bamboo-like’ truncation of por-
tions of the crease), unevenness in the depth of
the crease in the medial, central, or lateral third
of the eyelid, granuloma formation, and ‘static’
appearance of the crease on downgaze.
100
Chapter 7: Asian Blepharoplasty of the Upper Eyelid

101
The Suture Ligation Method
Figure 7.34 Full-thickness suturing technique. (Reproduced with
permission from Chen WPD. Asian blepharoplasty: a surgical atlas.
Newton, MA: Butterworth and Heinemann; 1995:38.)
Figure 7.35 Full-thickness suturing technique with stab incisions.
(Reproduced with permission from Chen WPD. Asian blepharoplasty:
a surgical atlas. Newton, MA: Butterworth and Heinemann; 1995:39.)
Skin
2
2
3
3
2
2
1
Orbicularis muscle
Levator aponeurosis
Müller's muscle
Conjunctiva
Skin
2
1
1
2
Stab skin
Stab
incision
2
2
3
3
Orbicularis muscle
Levator aponeurosis
Müller's muscle
Conjunctiva
Figure 7.37 Transcutaneous intramuscular suturing technique.
(Reproduced with permission from Chen WPD. Asian blepharoplasty: a
surgical atlas. Newton, MA: Butterworth and Heinemann; 1995:41.)
1
2
2
1
1
Skin
First stab
incision
Orbicularis muscle
Levator aponeurosis
Müller's muscle
Conjunctiva
Figure 7.36 Transconjunctival intramuscular suturing technique. Note
the absence of passage through skin. (Reproduced with permission from
Chen WPD. Asian blepharoplasty: a surgical atlas. Newton, MA:
Butterworth and Heinemann; 1995:40.)
Skin
Indentation of skin
Strategic placement
of muscular sutures
create infolding
of crease
Exit
Entry for
both needles
Orbicularis muscle
Levator aponeurosis
Müller's muscle
Conjunctiva
1
2