Color Atlas of Cosmetic Oculofacial Surgery

Revision and Correction of
Suboptimal Results
Revision of suboptimal results is a necessary part of
any surgeon’s repertoire of skills if they are to perform
the type of surgery we have been discussing. There are
various known factors that will lead to a suboptimal
result;1–7 these include inaccurate placement of crease
incision, use of reactive suture materials, excessive
bleeding, excessive fat removal, inadequate or exces-
sively tight wound closure, inappropriate techniques,
and lack of knowledge on the part of the surgeon.
There are, however, other intangible factors that
may be beyond the control of the surgeon – for
example, non-compliance to postoperative wound
care instructions on the part of the patient; vigorous
and immediate postoperative exercises, resulting in
prolonged edema of the eyelid margin; latent
hypertension with rebleed; unrelated weight gain;
unpredictable wound healing in patients who have
had multiple revisions before; obsessive patients who
are not happy with the results even though the results
are fine; or patients who have a preconceived notion
of what they expect the crease to do for them (e.g.
launch a career in a certain field), even though it may
not be attainable.
As previously discussed, the four factors that deter-
mine a crease’s formation are also the factors that may
lead to a suboptimal crease, namely:
257
Revision and Correction of Suboptimal Results
■ height;
■ shape;
■ continuity; and
■ permanency.
From a patient’s perspective, the subjective com-
plaints I encounter most often from patients seeking
secondary consultation in my practice are as follows:
1. ‘The shape is wrong’.
2. ‘The crease is too high’ (wrong height).
3. ‘My two eyelids are unequal’ (asymmetry of
crease height on each side, different crease shape
on each side, different crease length of each lid
[it determines whether the crease looks complete
or partial], differences in crease depth [determines
the quality or visual softness versus harshness of
the eyelid crease]).
4. ‘My crease disappeared’ (early or late
obliteration).
5. ‘There is more than one crease’ (multiple creases).
6. ‘My eyelids look hollowed’ (excess fat removal or
excessively high anchoring of crease in supertarsal
sulcus).
7. ‘I want my crease removed!’ (rejection of
surgically created outcome, wants removal or
‘erasure’ of crease).

When dealing with the wrong shape, a semilunar
(half-moon) crease applied onto an Asian eyelid will
result in a rounded face (Fig. 15.9). For the patient
who has a small medial canthal web (medial upper
lid fold) and desires a nasally tapered crease, if
the medial extent of the crease was not deliberately
tailored to merge into and just behind the medial lid
fold and it should end up above the fold, one may see
a upper bifid crease over the medial end (Fig. 15.4).
Rarely, if the medial portion of the crease was overly
tapered and went underneath the medial canthal fold,
one will see a lower bifid crease. I have seen cases
where the lateral portion of a crease was flared up
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Chapter 15: Management of the Eyelid Crease: Advanced Techniques
excessively from the lateral canthus, encroaching on
the thicker dermis of the eyebrow area.
In terms of height, the crease may be placed too
high or too low. Each represents its unique problems.
A high crease often looks artificial or surgically
created. A low incision may not result in a good
crease formation or it may present as an obvious
aesthetic blemish over the pretarsal skin platform.
Often seen in conjunction with a high crease is an
overzealous removal of the preaponeurotic fat pads.
It results in a high supratarsal sulcus or ‘famined’
look, which is difficult to correct (Fig. 15.10).
Figure 15.10 High sunken crease.
Figure 15.9 High, arched, semilunar crease on an Asian face.

In a patient who has a pre-existent hollow below
the superior orbital rim, further removal of preapo-
neurotic fat may exaggerate it into a prominent
supra tarsal sulcus with formation of multiple skin
folds over the high crease (Fig. 15.11). In this situa-
tion, removal of more skin to eliminate these folds
without addressing the problem of the high crease
will usually lead to an even more obvious crease.
Problems associated with differences in crease
depth between two lids are a more subtle aspect of
asymmetry that may not be apparent to clinicians
but can be an issue with some patients. The difference
in softness (a soft crease readily disappears on down-
gaze, is considered ‘dynamic’, and imitates a physio-
logic crease) or harshness (a surgical-looking ‘static’
crease which does not shallow on downgaze and is
readily apparent like a skin incision scar over the pre-
tarsal skin) may be the combined result of interaction
of the surgeon’s variations in depth-placement of the
crease-forming stitches between the two sides, versus
the possible unequal responses of the patient’s two
eyelids in regards to crease formation (both in post-
operative healing response as well as intrinsic levator
function, which is an indication of the quality of
levator muscle).
A crease may disappear relatively early (within 2
months) or late (after 6–9 months). In my experience,
early disappearance, shallowing, or obliteration is
most often due to insufficient clearing of the preapo-
neurotic platform of tissues along the superior tarsal
border which results in an interference in the creation
of a crease. It may occur due to other factors beyond
the clinician’s control – these include hemorrhage
over the crease line, insect bite over the wound, acne
and chalazion (stye) formation, cellulitis, and weak
levator muscle. Undetected iatrogenic weakening of
the levator aponeurosis can cause a segmental ptosis
and poor crease formation.
Late disappearance of an otherwise well-formed
crease can occur following significant weight gain
and increase in the preseptal or sub-brow fat pads, or
hypertrophy of the remaining central preaponeurotic
(postseptal) or nasal fat pads. I recall one happy
patient who in retrospect was probably borderline
anorexic preoperatively, who had partial disappear-
ance of one crease following resumption of her
appetite after aesthetic improvement to her eyelids.
Problems associated with continuity are linked to
the permanency issue discussed above, in the follow-
ing fashion: if the crease is not well formed to its
underlying aponeurosis in a continuous fashion, it
may present as a discontinuous or broken crease and
become evident soon after the surgery. A continuous
crease may be well formed initially but then become
obliterated, resulting in a shallow crease or no crease
at all – in essence, a non-permanent crease. Or it may
break apart later, in a segmental fashion, giving a dis-
continuous but permanent crease. There appears to
be a much higher incidence of disappearance of
crease associated with the suture ligation methods
(see Chapter 7).
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Revision and Correction of Suboptimal Results
Figure 15.11 Prominent supratarsal sulcus with formation of multiple skin
wrinkles over the high crease.

Patients who have multiple creases often may have
undergone more than one surgery already. Pseudo-
skin folds may become more apparent following
creation of a dominant crease among multiple rudi-
mentary creases or folds. The multiple creases may
also arise from unpredictable scar formation in re-
operative cases and in those patients who have under-
gone an excessive degree of dissection in the pretarsal
region of the upper eyelid. In revision cases, it is vital
to obtain close-up preoperative photographs of the
crease in a frontal as well as downgaze position (to
expose the crease), as well as documenting it in the
patient’s chart, drawing it and including it as part of
the Informed Consent and disclosure/education to the
patient. Any lack of understanding must be resolved
prior to any procedure being offered.
The eyelids may look hollow from an excessive
removal of fat pads. This may be further accentuated
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Chapter 15: Management of the Eyelid Crease: Advanced Techniques
when the crease is placed higher than anatomically
indicated. High anchoring of the crease line may also
lead to a limited ability to elevate the lid upward
(resulting in secondary ptosis) as well as cicatricial
lagophthalmos (causing poor excursion of the upper
lid margin) on downgaze.
At the opposite extreme, I have had the opportu-
nity to work with several patients who desired to
have their surgically placed crease reversed.
I will now go through some of the actual revision
techniques for each of the suboptimal configurations.
By far the most often encountered revision prob-
lem is asymmetry. This includes creases that are
unequal in height (Fig. 15.12), uneven in shape and
continuity, shifting of the crease (downward migra-
tion of the crease; partial or complete obliteration of
the crease) (Fig. 15.8), and fading of the medial one-
third of the crease (Fig. 15.13).
Figure 15.12 Asymmetry in height of crease between two upper lids.
Figure 15.13 Fading of the medial one-third of the crease on each side,
with asymmetry.

A. Excessively high crease
In evaluating patients in whom the eyelid crease on
one side appears higher than on the other, often the
higher crease is the abnormal one. It is essential to
detect any acquired ptosis that may be present in this
eyelid, as the levator aponeurosis often appears to
have dehisced some of its lower terminal interdigita-
tion and only has some of its more superior lid crease
attachments left in this condition (Fig. 15.14). If such
is the case, correction of the ptosis will eliminate the
apparently higher crease without any attempts at
repositioning of the crease.
A higher-than-normal crease can arise from inap-
propriate marking of the lines of incision, from inac-
curate placement of the interrupted crease-forming
sutures over the levator aponeurosis, or from persis-
tent edema in the pretarsal plane. If a crease still
appears high after an adequate time period (at least
6–9 months), the repair can be accomplished in the
following fashion.
261
Revision and Correction of Suboptimal Results
The lid with the higher crease is everted and the cen-
tral height of the tarsus is measured. This meas urement
will serve as a reference, a point as to where the crease
ought to be placed. When the tarsal height is transcribed
on the skin side and is found to be closer to the eyelash
line than the current crease, then the difference in mil-
limeters of skin can be excised together with the previ-
ous incision scar, as long as there is not a shortage of
skin that may prevent complete eyelid closure (Fig.
15.15). It is helpful to lyse any subcutaneous aponeu-
rotic attachment along the superior edge of the incision.
Any scar tissue that may overlie the aponeurotic attach-
ment along the superior tarsal border should also be
removed to allow for the reconstruction of the new
crease.
If the transcribed tarsal height on the skin side is
higher than your supposedly ‘high’ crease, then one
should examine the contralateral upper lid crease to
see if it has an excessively low crease.
Figure 15.14 Relative acquired ptosis of right upper lid causing higher
crease.
Figure 15.15 (A) A
patient showing high
crease after surgery
elsewhere.
Figure 15.15 (B) Excision
of old incision line
straddles the high crease
in a revision case.
A
B
15.1

B. Excessively low crease
The challenge is greater in an excessively low crease
(close to the lash margin). The correction is tailored
as to whether there is any redundancy of skin.
For those who have some skin redundancy, I have
found that the best method is still simple excision of
the scar associated with this low crease, allowing it
to heal, and then performing a subsequent crease
procedure at least 6 months later. In my experience,
simultaneous revision and construction of a new
crease often results in suboptimal control of the
crease height.
When the skin is taut and without any redundancy,
simple excision is not possible since it may result in
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Chapter 15: Management of the Eyelid Crease: Advanced Techniques
cicatricial ectropion or a prominent scar (Fig. 15.16).
An acceptable option in a low crease with scarcity of
skin is complete excision of the crease and the adja-
cent pretarsal skin, replacing it with a full-thickness
skin graft and reforming the crease at the same time.
This applies if the full-thickness skin graft covers the
pretarsal region only. The patient should be fore-
warned that the crease will appear ‘high’ for at least
6 months.
Should the skin graft required span over the pre-
tarsal region and the supratarsal region (Fig. 15.17),
it is best to defer crease construction until several
months after the skin grafting.
Figure 15.16 Caucasian with cicatricial lid retraction of right upper eyelid
following upper blepharoplasty.
Figure 15.17 Same patient as in Figure 15.16, five days after
full-thickness skin graft to the pretarsal zone, with sutures still in place.

C. Problems with permanency and/or continuity
Late obliteration of the crease includes patients with
shallow crease, shifting of their crease, fading of the
medial one-third of their crease, or obliteration of the
entire crease (Fig. 15.18).
As long as there is some redundant healthy skin
to work with, the Asian blepharoplasty technique
described in Chapter 7 can be performed either
partially or entirely along the width of the eyelid. I use
spring Westcott scissors instead of the monopolar
263
Revision and Correction of Suboptimal Results
cautery needle tip to lyse the adhesion along the upper
edge of the skin incision to reach the preaponeurotic
space by first identifying the preaponeurotic fat pads.
The most common findings at the time of surgery may
include excessive subdermal scar and/or inadequate
clearance of underlying orbicularis oculi, orbital sep-
tum, or fat pads (pretarsal or preaponeurotic) along
the superior tarsal border at the junction of the pre-
tarsal region and preaponeurotic space. The previous
scar is excised and minimal skin is removed. The skin
removed may be barely 1.0–1.5mm (Fig. 15.19).
Figure 15.19 (A) Minimal straddling of the previous incision wound in a
revision case with very tight skin.
Figure 15.18 Late disappearance of left upper eyelid crease.
Figure 15.19 (B) Westcott scissors were used to carefully lyse through
the cicatrix of the orbicularis/septal complex along the superior edge of
the incision wound.
A
B

A crease that is discontinuous will fare better if it
is completely revised. Again, it is essential to trim
away any underlying platform of scar tissue between
the skin and healthy levator aponeurosis along the
superior tarsal border.
Patients may present with an inadequate crease
over the medial one-third (or less) of the upper lid
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Chapter 15: Management of the Eyelid Crease: Advanced Techniques
(Fig. 15.13). This usually arises from insufficient sub-
dermal attachment during the first operation and can
be prevented by using at least three interrupted
crease-forming sutures over the medial half of the
crease (Fig. 15.20). It may also require more debulk-
ing of underlying soft tissue in that region in order to
allow for a solid subcutaneous aponeurotic linkage.
Figure 15.20 Three stitches were applied medially, to enhance an inadequately formed crease in a revision case involving a high crease.
A
B

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Revision and Correction of Suboptimal Results
Figure 15.21 A patient who has never had surgery,
illustrating the presence of multiple rudimentary
creases.
D. Multiple creases
Patients may present with multiple creases over each
eyelid. Such patients can be divided into two groups:
■ those who had, for example, multiple faint
creases to start with, but who end up with several
competing and prominent creases; and
■ those who were without any crease to start with.
Patients in the former group may have had several
rudimentary creases (Fig. 15.21) or one noticeable
crease with several less obvious ones at the outset but
nevertheless finish up with several even more prom-
inent creases. In my experience, this phenomenon is
seen in those patients who have undergone vigorous
dissection in the pretarsal and preaponeurotic space,
or who have undergone excessive removal of pre-
tarsal tissues in an attempt to ‘remove all pretarsal
fat’, or overzealous removal of preaponeurotic fat
pad. These multiple creases tend to be low, occurring
in the pretarsal region.
In such cases, the anatomical-based method of
Asian blepharoplasty using the tarsal height as a
guide to crease placement is still the best way to ‘con-
dense’ several creases into a relatively more dominant
crease, provided that there is redundant skin to work
with. Frequently, several closely spaced creases can
be completely excised with good results. When there
is severe skin shortage in a patient who presents
with multiple creases, functional correction of the
skin shortage using a full-thickness skin graft takes
precedence over the aesthetic aspect. The redundant
creases may be excised when performing the skin
graft, and a secondary procedure carried out later to
form the crease.
With regard to the subtype of patients who were
without any crease to start with but end up with mul-
tiple creases, in my experience almost all result from
excessive removal of preaponeurotic fat pads. They
frequently have had excessively high placement of
their main crease, and the redundant creases are all
high in the supratarsal region. In my observation,
these ‘creases’ are really the interspaces between mul-
tiple folds of skin left behind from excessive removal
of preaponeurotic fat pads (see Fig. 15.5).

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Chapter 15: Management of the Eyelid Crease: Advanced Techniques
E. Hollow supratarsal sulcus, with or without
multiple creases
Hollowness of the sulcus may be pre-existent but
exaggerated with removal of preaponeurotic fat, or
arise iatrogenically from surgery.
In the medical literature, there is a myriad of cor-
rections – placement of methylmethacrylate implants
in the supratarsal sulcus, injections of collagen and
silicone, and autogenous free fat grafts have all been
tried. I have not found any good, permanent solution
to correcting the problem of excessive removal of
preaponeurotic fat. The use of a dermis–fat graft,
interspacing it in the superior conjunctival fornix, has
been used with some success.
For patients who have a hollow sulcus and mul-
tiple folds with adequate redundancy of skin, I offer
them the option of converting the multiple folds into
a single tarsal height-based crease.
F. Half-moon crease
Patients with a semilunar crease configuration are
often unhappy. The primary surgeon may have
designed the crease based on a traditional blepharo-
plasty technique, placing the crease such that the
widest separation to the lash margin occurs in the
mid-portion of the eyelid, with the ends of the crease
tapering down towards each canthus. The result is
often a ‘round-eye’ look. It is especially evident on
Asians since they tend to have a smaller eyelid fissure
width. The same 10mm separation from crease to
lash line, arching towards each canthus, will subtend
a greater arc angle in Asians than in Caucasians, as
Asians have smaller palpebral width (Fig. 15.22) –
hence, a greater degree of ‘round eye’. This is the
exact opposite of what most Asians desire. By con-
trast, a nasally tapered crease, or a parallel crease,
will make the eyelid fissure appear wider in its
horizon dimension, more ‘open-ended’, and larger in
its apparent vertical dimension (Fig. 15.23).
Figure 15.22 The smaller Asian eyelid fissure subtends a larger angle
with a given width of crease versus that which occurs in a Caucasian
eyelid. (Reproduced with permission from Chen WP. Asian blepharoplasty:
a surgical atlas. Newton, MA: Butterworth–Heinemann; 1995:96.)
Figure 15.23 The visual effect of a crease over the left upper eyelid, with
the eyelid fissure drawn exactly of the same dimension. In reality, single
eyelids (without crease) often have a small fold of skin overhanging and
therefore the fissure size is even smaller as measured vertically before
any procedure. When the excess is artfully removed and a crease
applied, it adds a great degree to the aesthetic appeal. (Reproduced
with permission from Chen WP. Asian blepharoplasty: a surgical atlas.
Newton, MA: Butterworth–Heinemann; 1995:3.)
A crease of 20mm
subtends a greater
arc-angle in Asian
eyelids than in
Caucasians and
non-Asians
Asian eyelid fissure
V2 > V1
V1
V2
Caucasian
and
non-Asian
eyelid fissure

267
Revision and Correction of Suboptimal Results
Surgical solution in revisions:
A tarsal height-based technique of Asian blepharo-
plasty is preferred, using a crease height of 6.5–8.0mm,
with a nasally tapered or parallel crease configuration.
The open-sky skin incision approach allows for accu-
rate placement of sutures over the aponeurosis, and
provides a greater control over crease formation.
1. Semilunar crease £ 10mm from lid margin
When confronted with a semilunar crease, as long as
the maximum height of the abnormal crease to be
revised is 10mm or less, the central 50% of the crease
may be moved down in the following fashion.
(a) For the patient with some redundancy of skin
After 6 to 9 months from the last surgery, the central
tarsal height is measured and transcribed onto the
eyelid skin. The segment of skin between this pre-
ferred crease line and the undesirable, higher semi-
circular crease is marked out (usually not more than
2–3mm). The central 50% of the semilunar crease is
excised by removing the 2mm strip of skin between it
and the preferred lower crease (Fig. 15.24). This has
the net effect of converting the crease into a nasally
tapered configuration. A mild degree of undermining
is performed along the upper edge of the semilunar
crease, to free any subcutaneous attachment of sep-
tum and levator aponeurosis. The medial 25% of the
semilunar crease now becomes the nasally tapered
portion of the preferred crease; the central 50% is
re-formed at a lower level in a parallel continuous
crease, while the lateral one-quarter of the semilunar
crease is excised and revised so that it is either
parallel or slightly flared upward by deliberately
anchoring it higher than it was. This is facilitated
by undermining the subcutaneous tissue around the
lateral canthal region.
The challenge arises when there is very little skin
between the lateral portion of the semilunar crease
and the lateral canthus. I find it more effective to
excise the lateral one-quarter of the crease and per-
form simple plastic closure; then return 6 months
later to perform a lateral crease revision.
Figure 15.24 Surgical conversion of a semilunar crease (solid line) to a
narrower parallel crease (hyphenated line) or a nasally tapered crease
(dotted line). (Reproduced with permission from Chen WP. Asian
blepharoplasty: a surgical atlas. Newton, MA: Butterworth–Heinemann;
1995:97.)
Semilunar crease;
central height 10mm
Preferred crease
(nasally tapered,
parallel or laterally
flared)
LFC
PC
PC
NTC
PC = parallel crease
NTC = nasally-tapered crease
LFC = laterally-flared crease

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Chapter 15: Management of the Eyelid Crease: Advanced Techniques
(b) For those patients with skin shortage
The semilunar crease is not easily revised unless the
crease with its underlying scar and the skin between
the semilunar crease and the new crease (based on
tarsal height) are completely excised. Full-thickness
skin grafts are used to correct the skin shortage above
the proposed crease and to allow for reconstruction
of a lower crease (Figs 15.25A & B). The crease is to
be formed at the junction of the pretarsal skin and the
skin graft.
Figure 15.25 (A) Shortage of skin in a patient with a semilunar high
crease. The segment has been excised and the crease shape converted
to a lower parallel configuration. (Reproduced with permission from
Chen WP. Asian blepharoplasty: a surgical atlas. Newton, MA:
Butterworth–Heinemann; 1995:99.)
Figure 15.25 (B) A full-thickness skin graft is then added over the
recipient area of the lid. The new crease is to be formed at the junction of
the pretarsal skin and the lower border of the skin graft. (Reproduced
with permission from Chen WP. Asian blepharoplasty: a surgical atlas.
Newton, MA: Butterworth–Heinemann; 1995:99.)
Semilunar crease,
10mm, with
skin shortage
FTSG
A
B

269
Revision and Correction of Suboptimal Results
2. Semilunar crease >10mm from lid margin
A much more challenging situation exists when the
semilunar crease is more than 10mm from the lid
margin. I have seen patients with creases as high as
12–15mm (Fig. 15.26).7 The correction of this crease
involves working closer to the eyebrow’s thicker der-
mis, with less camouflage and a greater chance for
hypertrophic scarring.
On the rare occasion when there is some redundant
skin in conjunction with a highly placed semilunar
crease (>10mm), one may try the same steps as
described in subsection 1(a).
Unfortunately, most of these patients have under-
gone excessive skin removal and present with little
skin left for plastic reconstruction. The repair will
require a full-thickness skin graft as detailed in sub-
section 1(b), noting that the upper edge of the skin
graft will be quite conspicuous.
Figure 15.26 High-arched crease in two patients following upper blepharoplasty.
A
B

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Chapter 15: Management of the Eyelid Crease: Advanced Techniques
G. Removal of surgically placed crease
My most challenging clinical cases have been the
few patients who want their surgically placed crease
completely reversed. In these patients, I have tried
to remove an existing surgically created crease using
a variety of methods, some with better results than
others:
■ Excision of crease and scar, application of
traction sutures inferiorly (reverse Frost sutures) –
minimum improvement.
■ Subcutaneous lysis of adhesions using small
tenotomy scissors – minimum improvement.
■ Excision of crease and scar, with interposition of
orbicularis fibers to block the aponeurotic–
subdermal attachment – mild improvement.
■ Excision of crease and scar, and closure of the
wound with ¼” Steri-Strip tape; patients are
encouraged to avoid looking up during the first
week (avoid contraction of the levator
aponeurosis) – mild improvement.
■ Excision of crease and scar, recession of the
levator aponeurotic muscle, and placement of
autologous temporalis fascia (Fig. 15.27) –
significant improvement.
Figure 15.27 Pre- and postoperative view of a man who elected to have crease reversal. Temporalis fascia was used to obliterate the crease. The
result was satisfactory, although a faint but noticeable crease is still seen over the lateral portion of the right upper lid.
A
B

271
Commentaries
Figure 15.28
We will now discuss some of the surgical solutions
I
have
used
on
complicated
revision
cases:
Figures 15.28–15.57 illustrate 30 patients with revi-
sion and challenging crease management problems.
Commentary:
Had surgery 4 years ago and a second time a year prior to being seen.
Right upper lid – deep crease, converging and touching NTC, with 3mm ptosis.
Left upper lid – medial bifurcation of crease as it approaches the medial canthal fold.
Levator function: R 12mm, L 15mm.
Appears esotropic.
Body height: 5’ 0”.
Intraoperatively: Right side harsh and static 12mm crease, bound down.
Tarsus measured 6mm.
Designed 6mm NTC.
Incision with No. 15 blade, then used blunted-tipped Westcott spring scissors to lyse adhesions along
superior edge until preaponeurotic fat is seen (no true septum left).
Used cutting cautery to remove scar and redundancy along preaponeurotic platform, plus removal of 8-0
nylon buried sutures that were used for crease formation.
Formed crease with 6-0 and 7-0 silk sutures that were removed after 5 days.
A
B

272
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.29
Commentary:
Patient from out of state.
7 years status post lid crease. RUL hooded and
rudimentary crease. LUL has high crease with bifid
ending both corners.
Intraoperatively: Tarsus measured 7mm.
Designed NTC O.U.
RUL – removed 2mm skin and orbicularis. Used
scissors to go through upper edge of incision, staying
beveled to reach preaponeurotic plane.
LUL – eliminated bifid crease, removed buried nylon
sutures.

273
Commentaries
Figure 15.30
Commentary:
47-year-old patient with first surgery 20 years ago
coupled with ‘W-plasty’; then revision 12 years ago.
Intraoperatively: Prominent medial aponeurotic fat
as well as nasal fat pad. Removed fat pads. Use 6-0
Vicryl to fixate inferior orbicularis to levator and
then superior orbicularis; keep suture knot buried.

274
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.31
Commentary:
33-year-old who has never had surgery but has used
adhesive tapes since 17 years of age to create crease.
Shows mild sulcus. Practices yoga and kick-boxing.
Intraoperatively: Tarsus measured 8.5mm. I used
8mm as lower line of incision. Designed NTC,
included 2mm skin.
Preserved all preaponeurotic fat and reposited it
within the sulcus. Excised strip of myocutaneous
flap. Formed crease with 6-0 and 7-0 silk sutures,
which were removed at 1 week.

275
Commentaries
Commentary:
29-year-old housewife. Had surgery at 18 years of
age in Korea.
RUL 9–10mm crease position OU and appears
deepset. Has moderate fullness over pretarsal area
LUL is more converged medially than that of the
RUL.
Intraoperatively: Her tarsus was only 5.5–6.0mm.
RUL crease measured 11mm, LUL at 10mm.
Designed 8.5mm parallel crease over RUL with some
tapering medially; and 8mm over LUL in attempt to
equalize two asymmetric high creases.
Use blunt scissors to reach preaponeurotic space
superiorly. Large amount of cicatrix over preseptal
as well as pretarsal zones. Excised strip of
myocutaneous flap OU. Excised strip of pretarsal
inferior orbicularis muscle to reduce fullness.
Checked levator’s excursion on the table and
appeared full OU.
Figure 15.32

276
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Commentary:
55-year-old had four-lid blepharoplasty 10 years
prior in Hawaii. Has high bifid semilunar creases
OU, measured to be 10–11mm in sulcus.
Intraoperatively: Designed parallel crease OU at
7.5mm (tarsus measured 7mm).
Excised old crease with 1mm clear skin superior to
it, with the lower skin incision edge at 7.5mm.
Found very attenuated levator muscle with fatty
infiltration.
Formed parallel crease.
Figure 15.33

277
Commentaries
Figure 15.34
Commentary:
29-year-old had crease procedure 9 years prior –
stitch method alone with adjustment twice. LUL has
no crease. RUL has shallow NTC. Patient prefers
parallel crease.
Intraoperatively: Very vascular. Removed nylon
sutures from along the superior tarsal border. Used
6-0 silk and 6-0 Prolene with significant attachment
towards the levator aponeurosis.

278
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.35
Commentary:
25-year-old. RUL with rudimentary crease. LUL
none. Right side has medial canthal fold. Has
permanent eyeliner in place and is thicker over the
right compared with the left.
Intraoperatively: Tarsus measured 7mm; thick skin,
acniform.
Preaponeurotic fat appears mosaic and ill-defined,
creeping to a point well below the superior tarsal
border, interlaced with fibrotic strands.
Used 6-0 silk and 6-0 Prolene.

279
Commentaries
Figure 15.36
Commentary:
36-year-old.
Three years status post lid crease procedure.
Currently has shielded crease over RUL, and LUL
has wider separation from lid margin than the RUL.
Wants parallel crease.
Intraoperatively: Designed 7mm crease height to
encompass RUL scar. Excised moderate amount of
preaponeurotic fat from RUL as well as inferior
orbicularis strip.
LUL – reduced the crease height medially. Fat not as
excessive and therefore only reduced some with
bipolar wetfield cautery. Excised inferior orbicularis
strip. Closed with 6-0 silk. Inspection revealed crease
still high. Take down and re-excised 1mm skin from
lower edge. Result was more symmetrical look.

280
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.37
Commentary:
22-year-old Asian. 5’ 7” with low-set NTC, partially
shielded. 2mm cornea covered OU. Using cotton-tipped
application, patient indicated a crease height closer
to 9–10mm as being her preferred configuration.
Desires slight lateral up-flare.
Intraoperatively: Used 8mm to define an NTC;
including 1mm of scar adhesion. Upon reaching
preaponeurotic space, fat was not abundant.
Excised strip of skin/muscle/scar tissues, as well as
preseptal strip of orbicularis above and along the
superior tarsal border. Designed slight lateral
up-flare.

281
Commentaries
Figure 15.38
Commentary:
24-year-old had lid crease procedure in Hong Kong
8 years prior. RUL crease never did form and is now
shallow; LUL crease is deeper but central portion
slightly peaked.
Desired NTC.
Intraoperatively: RUL tarsus measured 6.5mm. Used
7mm to design an NTC. Resected scar tissues, no
fat. Used 6-0 and 7-0 silk.
LUL – ‘square-well’ excision of strip of scar tissue
along superior tarsal border. Mid section underwent
some dissection superiorly to make it less fibrosed
down to the aponeurosis. Re-formed smooth NTC
with good result.

282
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.39
Commentary:
Male patient. Nine years previously had lid crease
procedure. The crease did not fold in well by the end
of the first week. Revised 2 months later with same
finding. Has very faint rudimentary line OU. Patient
wanted the medial one-third of the crease to be lifted
higher. However, this would lead to a triangular or
rectangular look. After careful discussion, the patient
chose a parallel crease.
Intraoperatively: Tarsus measured 8mm. We
designed a 7mm parallel crease. Lysed scar tissues
along the upper incisional edge, through orbicularis.
Observed amorphous fat plastered against levator
muscle.
After the skin muscle flap was trimmed, there were
still remnants of preseptal tissues along the superior
tarsal border; as the patient looks up, this redundant
tissue would bunch up and make the crease look low
and ‘rope-like’. This was then excised to show a
clean insertion of the aponeurosis along the superior
tarsal border. The lower skin edge was pulled up and
united with aponeurosis along the superior tarsal
border, forming a nice parallel 7mm crease.

283
Commentaries
Commentary:
30-year-old who was 10 years after external incision
crease procedure. The lateral extent of the RUL
appears downslant towards the lateral canthus. The
incisional line has spread over the left side. Desires
parallel crease to be of above-average height.
Intraoperatively: Tarsus measured 8mm. Used a
parallel 8mm incision line, included 2.5mm skin.
Very vascular orbicularis oculi muscle.
Preaponeurotic fat pad protrudes inferiorly over the
lateral half and required partial excision. The rest of
the fat seemed spread out and plastered down.
Formed crease with 6-0 and 7-0 silk.
Figure 15.40

284
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.41
Commentary:
24-year-old male was told that crease procedure will
not be successful due to weak muscle.
Patient is 6 feet tall and has mild hooding.
Levator function: RUL 10mm, LUL 12 mm.
Wanted ‘natural Asian crease’.
Intraoperatively: Tarsus measured 8mm. However,
the lid margin distance to his lower border of the
eyebrow is narrow and therefore opted to design a
6.5mm minimally tapered, almost parallel crease.
Orbicularis was soft, fluctuant, and vascular.
Opened the orbital septum and patient had large
amount of otherwise unsuspected preaponeurotic fat
pad. Removed 80% of this in this particular case.
Excised myocutaneous flap. Formed crease with 6-0
and 7-0 silk.

285
Commentaries
Figure 15.42
Commentary:
19-year-old. Heavy upper lid hooding with fat. Some
brow action. Wants to have hooding and fat
removed but does not want crease formation.
Height is 5’ 3”.
Intraoperatively: Tarsus measured 7mm. Used
hyaluronidase in local injection. Made lower incision
line at 5mm and included 3mm of skin in a parallel
configuration. After using blade through skin, used
cutting cautery with very fine tip to traverse through
the upper edge of the orbicularis. Reached septum
and opened it. Excised 80% of prolapsing
preaponeurotic fat. Excised myocutaneous strip that
consisted mostly of skin, leaving behind half of the
orbicularis along the superior tarsal border. Closed
orbicularis to orbicularis with 6-0 Vicryl. Skin closed
with 6-0 nylon in a running fashion, taking bites of
skin only. No interrupted sutures were used on the
skin.

286
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.43
Commentary:
22-year-old.
Four years status post lid crease procedure and attempted ptosis repair of the right upper lid. RUL crease is
deep set and crease height was 8mm, with 1.5mm of cornea covered. LUL has deep-set 6mm crease, 0.5mm
cornea is covered.
Intraoperatively: Measured right tarsus and it was only 5.5mm, probably had tarsectomy. LUL tarsus
measured 7mm.
RUL: Very vascular. Created 7mm NTC and included 2mm skin. Found three blue nylon stitches, scarred
levator/tarsus junction. Performed external resection of aponeurosis, measuring 3mm (see Chapter 12).
Dissected epitarsally to smooth out already swollen tarsal area. Formed crease with 6-0 and 7-0 silk.
LUL: Set crease height at 7mm also, and NTC. Found three nylon stitches and removed them. Excised
1.5mm skin–muscle strip. Formed crease.
A
B

287
Commentaries
Figure 15.44
Commentary:
36-year-old with shielded rudimentary crease over
both sides. Small but noticeable medial canthal web.
Has rectangular (trapezoidal) appearance to
palpebral fissures. Patient was informed of likely eye
shape change if has procedure. Patient wanted
parallel crease. He is 6 feet tall.
Intraoperatively: Tarsus measured 8mm. However,
short distance from upper lid margin to inferior edge
of brow. Therefore, despite the fact that he is tall,
I used 7.5mm and designed a parallel crease.
RUL – large amount of preaponeurotic fat excised
OU. The inferior orbicularis area is infiltrated with
fat and is trimmed. Medial canthal web acceptable
and untouched.
LUL – same as RUL. Medial canthal fold here had
small dog-ear that required excision. Used 7-0 silk to
close this area.

288
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Commentary:
32-year-old who used eyelid tape bilaterally to help
crease formation. RUL crease rudimentary, with
2mm cornea covered. LUL has crease with
competing folds and dysjunction medially. LUL
margin covers 1mm of cornea. Height 5’ 5”.
Prefers parallel crease.
Intraoperatively: Tarsus measured 7mm. Used 7mm
to design parallel crease. Debulked preaponeurotic
fat. Used McCord’s crease fixation method with 6-0
Vicryl in addition to usual 6-0 and 7-0 silk method.
Figure 15.45

289
Commentaries
Commentary:
36-year-old who was 10 years after first crease procedure. RUL had 12mm crease height with broad medial
portion; LUL had 14mm deep crease. Height is 5’ 7”.
Intraoperatively: Her tarsus measured 7mm. Used 8mm as crease.
Included 3mm skin segment. Opened preaponeurotic plane with Westcott scissors along the upper edge. No
fat seen. Formed crease with 6-0 and 7-0 silk. Figure (B) was taken two weeks after revision by author.
Figure 15.46
A
B

290
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.47
Commentary:
18-year-old with absent crease. Prefers nasally
tapered crease. Height is 5’ 2”.
Intraoperatively: Tarsus measured 8mm. Used 7mm
to design crease, included 2mm skin – very spongy
pretarsal tissues. Has layer of fatty tissue along
superior tarsal border which was excised but
without well-defined preaponeurotic fat.
RUL crease appeared high centrally at end of case
and this area was adjusted down by excising 1mm of
skin along the lower edge over the central two-thirds
of the lid width.

291
Commentaries
Figure 15.48
Commentary:
66-year-old. Right upper lid with 3mm ptosis,
hollow sulcus, and absent crease.
LUL has high crease. Levator function: RUL 7mm,
LUL 14 mm.
Intraoperatively: RUL has had previous tarsectomy-
type procedure. Applied frontal nerve block.
Performed lysis of adhesion along the superior edge
of the skin incision. Levator was extrememly
attenuated. The aponeurosis was elevated from
underlying conjuntiva and then 10mm resected.
The edge of the muscle was then advanced and
re-anastomosed inferiorly along the STB using 6-0
Vicryl. Formed crease with multiple 6-0 and 7-0 silk.
LUL – created six crease line incisions, then dissected
upwards towards cicatrix to reach preaponeurotic
plane. Resected the old cicatrix and fragment of skin
between it and the new lower edge of the crease
incision.

292
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.49
Commentary:
23-year-old with rudimentary crease OU. The upper
lid margin appeared to peak over the medial one-
third. Desired nasally tapered crease.
I performed Asian blepharoplasty. Five years later,
patient now in residency training; creases have
disappeared from both eyes. Eyelids now appear just
as full, even though first procedure had involved
preaponeurotic fat excision.
Intraoperatively: Tarsus measured 6.5mm. Used
7mm to mark crease. Had very soft fluctuant
pretarsal and preseptal tissues. Had amorphous
downwardly migrated preseptal (sub-brow) fat,
which was disrupting the crease formation. This was
reposited superiorly. Excised scar and myocutaneous
flap. Formed crease with 6-0 and 7-0 silk in a nasally
tapered configuration.

293
Commentaries
Figure 15.50
Commentary:
46-year-old from South America. Two years ago had
undergone upper blepheroplasty with incision placed
3mm from lash margin. Now has recurrent hooding
such that the crease is shielded and there is dark-
colored skin along incision. Wanted parallel crease.
Lid margin rests 3mm down on cornea.
Intraoperatively: Upper lid skin appears short prior
to intervention. Used 5mm parallel line to incise
skin, then lysed along the superior skin edge until
large amount of preseptal and preaponeurotic fat
was seen. Made a small trough above the superior
tarsal border, just enough to facilitate skin closure.
No skin excision at all.

294
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.51
Commentary:
40-year-old from South-East Asia, wanting to have
upper eyelid and fat removal.
Had prominent eye fissures, mild fat, and some
hooding. Wanted ‘natural, conservative nasally
tapered crease’.
Intraoperatively: Tarsus 7.5mm. Designed crease
with 2mm skin. Excised portion of preaponeurotic
fat bilaterally.

295
Commentaries
Commentary:
18-year-old complains of intermittent or absence of
crease over the right side. Height is 5’ 7”.
Intraoperatively: Tarsus measured to be 7.5mm. His
rudimentary crease appears to be at 7mm; therefore
designed 7mm NTC, plus 2mm of skin. Fat was
reduced with bipolar cautery. Excised orbicularis
along the path of the superior tarsal border. Medially
there was some web formation and these were
reduced and the crease anchored deeper here with
6-0 silk to prevent web formation medially.
Figure 15.52

296
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.53
Commentary:
34-year-old with hooding and single eyelid of the
right and shielded with multiple creases over left
side. The fissure size is smaller over the right side.
Levator function: RUL 11mm, LUL 12mm.
Intraoperatively: Tarsus measured 7mm. Used NTC
shape and included 2.5mm skin. Myocutaneous flap
excised; some fat excision. The crease formed well.

297
Commentaries
Figure 15.54
Commentary:
25-year-old with single eyelid desires crease
placement. Upper lid contour has slight peaking over
medial one-third. Prefers higher-than-average
parallel crease.
Intraoperatively: Tarsus measured 7mm. Designed a
7mm parallel crease shape. Had large amount of
preaponeurotic fat, which was excised partially. A
large roll of fatty infiltrate overlay the superior tarsal
border and required clearance on each side for
optimal crease formation.

298
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Figure 15.55
Commentary:
24-year-old. Narrow crease with some shielding.
RUL has shallower NTC; LUL has deeper-set low
NTC. Desired crease enhancement.
Intraoperatively: Tarsus measured 7.5mm. Used
7.5mm to design NTC with 2mm redundancy;
excised fatty infiltrate along inferior edge of
pretarsal orbicularis on both sides.

299
Commentaries
Commentary:
57-year-old patient with heavily hooded lid and fatty
prolapse, more over the right side. RUL rest 2mm
onto cornea. LUL rest 1mm. Has small palpebral
fissure size bilaterally.
Intraoperatively: Could not evert tarsus to measure.
Set crease at 7mm parallel shape. There was a large
amount of amorphous fat inferior to the
preaponeurotic fat, which in itself was inferiorly
placed. Excised fat.
RUL – reinforce usual closure of 6-0 and 7-0 silk,
with one double-armed 6-0 Vicryl passing from
inferior pretarsal skin to aponeurosis.
Figure 15.56

300
Chapter 15: Management of the Eyelid Crease: Advanced Techniques
Commentary:
23-year-old with small palpebral fissure size, who is 1 year status post Asian blepharoplasty. Developed
shallowing of crease over both upper eyelids.
RUL – tarsus measured 6.5 mm. Designed crease including less than 1mm of previous incision line. Lysed
superior edge of incision through orbicularis. No unusual fat seen. Thick presence of preseptal orbicularis
that was fluctuant was seen; this was excised.
LUL – crease was borderline after closure. Released the sutures and refixated by deeper placement onto
aponeurosis. The medial portion of the levator aponeurosis appeared to have some fat infiltration.
Figure 15.57 (A) Before and (B) 1 year after Asian blepharoplasty. Returning for crease enhancement of left upper eyelid and possible right upper lid
crease.
A
B

REFERENCES
1. Chen WP. Asian blepharoplasty – anatomy and
technique. J Ophthalmol Plast Reconstr Surg
1987;3:135–40.
2. Chen WP. A comparison of Caucasian and
Asian blepharoplasty. Ophthalmic Pract
1991;9:216–22.
3. Chen WPD. Asian blepharoplasty and the eyelid
crease. Philadelphia: Elsevier; 2006.
4. Chen WPD. Concept of triangular, rectangular
and trapezoidal debulking of eyelid tissues:
application in Asian blepharoplasty. Plast
Reconstr Surg 1996;97:212–8.
5. Chen WPD. Eyelid and eyelid skin diseases. In:
Lee D, Higginbotham E, eds. Clinical guide to
comprehensive ophthalmology. New York:
Thieme; 1998.
6. Chen WPD. Oculoplastic surgery: the essentials.
New York: Thieme; 2001.
7. Chen WPD. Asian blepharoplasty: a surgical atlas.
Newton, MA: Butterworth–Heinemann; 1995.
301
Commentaries

303
Chapter 16
Classically, the normal eyelid anatomy can be concep-
tualized as consisting of two layers: the anterior skin–
orbicularis oculi muscle layer, and the posterior layers
of the levator muscle and aponeurosis, Muller’s muscle
and tarsal plate.
In general, the Caucasians upper eyelids that shows
a lid crease are thinner than the Asian counterpart. This
arises from a combination of factors which include a
higher point of fusion of the orbital septum onto the
levator aponeurosis, the relatively higher position of
preaponeurotic fat pads and resultant thinner lower
segment of eyelid, less preseptal fat and thinner orbicu-
laris. Comparatively, Caucasians with an eyelid crease
possess a greater number of distal fibers of the levator
aponeurosis that terminates towards the skin along the
superior tarsal border as well as the area above it to
form the eyelid crease. When the levator contracts, the
tarsal plate vectors upward and the eyelid crease invagi-
nates easily. In addition, Caucasians may often have a
deep-set supratarsal sulcus (Fig. 16.1).
Asians’ upper eyelid anatomy is further divided into
two groups: those with an upper eyelid crease and
those without any crease. In Asians with a crease, the
upper eyelid may still be thicker than a Caucasian’s
with a crease, yet there is the presence of distal fibers
of the levator aponeurosis terminating towards the
Advanced Concept of a Glide Zone
as it relates to Upper Lid Crease,
Lid Fold, and Application in Upper
Blepharoplasty
William PD Chen
Lid open
(looking ahead)
Lid (levator)
at rest
Figure 16.1 Caucasian eyelid with presence of
crease. In general, Caucasians eyelids with
crease are thinner than the Asian counterpart.
This is due to a combination of factors
including a higher point of fusion of the orbital
septum onto the levator aponeurosis, the
relatively higher position of preaponeurotic fat
pads and resultant thinner lower segment of
eyelid, greater number of distal fibers of the
levator aponeurosis that terminates towards
the skin along the superior tarsal border and
above to form the eyelid crease, less preseptal
fat, and thinner orbicularis. When the levator
contracts, the tarsal plate vectors upward and
the eyelid crease invaginates easily.

304
Chapter 16: Advanced Concept of a Glide Zone
Lid open
(looking ahead)
Lid (levator)
at rest
Figure 16.2 Asian with crease. Although the eyelid
may still be thicker than a Caucasian’s with an
upper lid crease, there are distal fibers of the levator
aponeurosis terminating towards the skin along the
superior tarsal border. Despite the low point of
fusion of the orbital septum, when the levator
contracts, there is an invagination of skin along the
superior tarsal margin to form a clinically apparent
upper eyelid crease. When the lids are open and the
subject is looking ahead, there is a greater degree
of fullness in the preseptal region compared to a
Caucasian with a crease, but less than that typically
seen in Asians without an upper lid crease.
Lid open
(looking ahead)
Lid (levator)
at rest
Figure 16.3 Asian without an eyelid crease. The
upper eyelid is often thicker due to the presence of
hypertrophied orbicularis as well as presence of
preseptal fat in the pretarsal as well as supratarsal
area. The orbital septum fuses with the levator
aponeurosis at a lower point compared to
Caucasians with an upper eyelid crease. There are
relatively few fibers or no attachment from the
levator aponeurosis towards the skin along the
superior tarsal border. Both the pretarsal and
preseptal zones are thick compared to Asians or
Caucasians with presence of an upper eyelid
crease.

305
Advanced Concept of a Glide Zone
skin along the superior tarsal border.1 Despite the lower
point of fusion of the orbital septum, when this levator
contracts, there is an invagination of skin along the supe-
rior tarsal margin to form a clinically apparent upper eye-
lid crease.2 When the lids are open and the subject is
looking ahead, there is a greater degree of fullness in the
preseptal region compared to a Caucasian with a crease,
but less than that typically seen in Asians who do not pos-
sess an upper lid crease (Fig. 16.2). Asians with absent
eyelid crease typically have thicker eyelids due to the pres-
ence of hypertrophied orbicularis as well as the presence
of fat in the pretarsal, preseptal, and preaponeurotic areas.
The orbital septum fuses with the levator aponeurosis at a
lower point compared to those Caucasians with an upper
eyelid crease. There are relatively few fibers or no attach-
ment at all from the levator aponeurosis towards the skin
along the superior tarsal border. Their pretarsal and
preseptal zones are thicker compared to Caucasians or
Asians who have an eyelid crease (Fig. 16.3).
In aesthetic Asian blepharoplasty by way of the exter-
nal incisional approach, a skin incision is made along the
designed crease and varying amounts of skin, muscle,
and soft tissues may be removed; this is then coupled
with various ways of crease construction via fixation or
attachment of skin to the levator aponeurosis, skin to the
tarsus, or orbicularis-to-aponeurosis fixation.
The surgical results often depends on a complex inter-
action between the degree of excessive tissues overlying
the pretarsal and preseptal areas, the presence of fat, the
thickness of skin over each of the two areas mentioned
above, the position of the globe, the brow position, leva-
tor function, as well as whether there is a firm adhesion
of skin to orbicularis in the pretarsal area. Normally,
when the eyes are looking straight ahead and the lids are
open, the anterior layer is in passive relaxation, allowing
the posterior levator–Muller’s–tarsus to actively contract
and pull the lid margin upward into an open position.
The posterior layer only has to retract (glide) up and
inward for 2–4mm relative to the anterior layer for a
reasonable crease to be observed. The vertical width (in
millimeters) of the eyelid fold overhanging the crease can
be measured simply by subtracting the ‘observed crease
width’ (from eyelash to inferior border of eyelid fold)
from the anatomic crease width (measured with eyelid
fold moved away to expose the true crease line). This
varies between 2 and 4mm. The normal anterior layer
offers little resistance and is not a ‘resisting platform’
against the levator muscle–tarsus when the posterior
layer contracts; exception to this will include heavy eye-
lid, those with abundant preaponeurotic or suborbicula-
ris fat and loose subcutaneous areolar tissues, and those
with poor levator function, including true ptosis.
The role of the preaponeurotic space and fat is often
mentioned as hindering any attempt at surgical con-
struction of a crease, and the surgical dictum requires
that at least a portion of the fat be excised. There is
nothing inherently wrong with this concept; in fact,
when the patient presents with excessive soft tissues
along the preaponeurotic platform, this author has
advocated a beveled approach towards the preaponeu-
rotic space along the upper line of incision and perform-
ing a trapezoidal debulking of the skin, orbicularis, small
amount of septum as well as inferiorly migrated fat.3
The problem arises when there is an overly aggressive
excision of the preaponeurotic fat, or the procedure is
accompanied by excessive hemorrhage within the
preaponeurotic space, which is surrounded by orbicula-
ris oculi in front as well as vertical communicating arte-
rial branches of the marginal arcade, the peripheral
arcade as well as the deep orbital arcade. The patient
often develops a sunken supratarsal sulcus with total
loss of fullness to the preseptal zone, and may have poor
crease invagination, a stiffened eyelid skin with underly-
ing cicatrix involving the pretarsal and preseptal
area (Fig. 16.4). During revision, one sees a collapse or
Figure 16.4 A scarred upper lid. Stiffened eyelid skin with underlying
cicatrix in the pretarsal and preseptal areas.

306
Chapter 16: Advanced Concept of a Glide Zone
obliteration of the preaponeurotic space and absence of
preaponeurotic fat. The anterior and posterior layers
appear fused into a single layered complex. One can
visualize this as if the levator muscle now has to carry
or lift the upper tarsal plate against the weight of a
double load of eyelid layers, as opposed to the usual
scenario where the tarsal plate glides up and under the
anterior layers of skin and orbicularis, with preaponeu-
rotic fat acting normally as a glide layer. In the scarred
scenario, the skin–orbicularis is now acting as a ‘resist-
ing layer’ towards the posterior layer of levator muscle.
The absence or presence of this ‘glide zone’ (with non-
adhering preaponeurotic fat within its space) in the
middle between the two layers can therefore hinder or
facilitate the formation of the crease. The author has
observed the presence of tightly bound preaponeurotic
fat in some ‘single-eyelid’ (creaseless) individuals com-
ing in for primary surgery where the amorphous infil-
trated fat in the zone between the skin–orbicularis and
posterior levator muscle may have contributed to the
lack of a crease. Careful repositioning of this fibrosed
fat to a higher level seems to facilitate the up-vectoring
of the lid and crease formation, perhaps by eliminating
its ‘Velcro’ effect on the two lamellae.
The properly functioning eyelid crease was once
described by Dr Boo-Chai4,5 in his 1963 paper as
being like the visor of a motorcycle helmet; in addi-
tion, Dr Robert Flower6 had mentioned in his paper
on ‘anchor blepharoplasty’ the idea that the inferior
extent of the preaponeurotic fat acts like a ‘ball bear-
ing’ at the orbital septum-to-aponeurosis fusion point
(the inferior extent of the preaponeurotic space).
This author’s concept varies from the above authors
in the following way. The preaponeurotic space, its
presence, as well as its preservation with some fat
within it is a necessary ‘third layer’ and should be pre-
served pristinely as much as is feasible (Fig. 16.5). In
this figure, the middle zone (glide zone) where the
preaponeurotic fat pads are located acts like a friction-
free layer which allows the posterior layer to glide up.
The up-vectoring of the tarsal plate is facilitated by
this glide zone, which allows it to slide upwards
against the passive eyelid fold to form an upper lid
crease. The skin passively glides over the posterior
Figure 16.5 The concept of glide zone. The glide zone consists of the
space occupied by the preaponeurotic fat pads, as well as all potential
space between the anterior orbicularis–orbital septum layers (light
purple) and the posterior layers of levator–aponeurosis–Muller’s muscle–
tarsal plate (red). The middle zone (glide zone; beige) acts like a
frictionless lubricating layer which allows the posterior layer to glide up.
When the patient look from downgaze to straight ahead, the levator
contracts and the sphincter-like orbicularis relaxes. The anterior skin–
muscle layer therefore acts passively as the levator contracts to open
the eyelid fissure. The up-vectoring of the semirigid tarsal plate therefore
depends on the glide layer to allow it to hinge upward under the anterior
layer for several millimeters in the process of forming the upper lid
crease; the overlapping portion of skin over the tarsus is the eyelid fold.