Mí-Mắt-full

352
Asian Blepharoplasty and the Eyelid Crease
Modern Literature on Asian Eyelid Surgery (in English)
Author
PY Yang
KY Song
SM Baek
EJ Weng
Year
1987
1988
1989
1989
Journal
Chin J Plast Surg Burn
3(3):191–192
Chin J Plast Surg Burn
4(1):6–9
Plast Reconstr Surg
83(2):236–243
Plast Reconstr Surg
83(4):622–628
Country
China
China
Korea
Taiwan
Conjunctival suturing
Ligature technique
Skin incision
Two stab incisions in
skin; single stitch
Yes
Remove skin
Puncture with threaded
needle then tunnel
under orbicularis and
levator aponeurosis
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form
Skin–tarsus–skin
continuous or reverse
looping
Single stitch
encompasses
subconj.–levator–
subcut. tissues
Levator–inf. subcut.
tissue
Suture
4–0 silk; compress with
rubber catheter
Buried 6-0
polypropylene
(Prolene) sutures
Buried 6-0
polypropylene
(Prolene) sutures
Days left in
7
Effectiveness
Crease disappeared
in 2.9% of cases
per author
Comments
’Twisted needle’ may elicit
hematoma
A general discussion of
concepts of beauty
and double eyelid
Discussed
complications
of oriental
blepharoplasty

Appendix 2  Modern Literature on Asian Eyelid Surgery (in English)
353
Modern Literature on Asian Eyelid Surgery (in English)
Author
KY Song
YH Bang
WPD Chen
Year
1990
1991
1994
Journal
Chin J Plast Surg 6:96–97
Plast Reconstr Surg 88:12–17
Asian Blepharoplasty (A Surgical
Atlas) Butterworth–Heinemann
(First Edition)
Country
China
Korea
USA
Conjunctival suturing
Skin incision
Three stab incisions
Yes
Remove skin
No
Orbicularis
Trims orbicularis muscle,
connective tissue, and
pretarsal fat
Orbital septum
Preaponeurotic fat
Remove fat if prolapsed
inferiorly
Crease form
Transcutaneous intratarsal
and intradermal
suturing
Skin to orbicularis: basting
sutures
Suture
Three buried stitches
Three 6-0 silk
Days left in
5–6
Effectiveness
Comments
First textbook on this topic:
Detailed terminology, cultural
perception, comparative
anatomy, crease variation, shape,
height, continuity and
permanence; main schools of
technique, complications,
revisions and literature
publications
Continued

354
Asian Blepharoplasty and the Eyelid Crease
Modern Literature on Asian Eyelid Surgery (in English)
Author
Li Dong et al.
WPD Chen
JI Park
JS Lee, WJ Park, MS
Shin, IC Song
Year
1994
1996
1996
1997
Journal
Chin J Plast Surg Burns
10:436, Plast Reconstr
Surg 1996;98(5):919
Plast Reconstr Surg
97(1):212–218
Triangular,
trapezoidal and
rectangular
debulking of eyelid
tissues in Asian
blepharoplasty
Plast Reconstr Surg
98(4):602–609
Z-epicanthoplasty
Plast Reconstr Surg
100(1):170–178
‘Septodermal’
fixation technique
Country
China (Beijing Med Univ)
USA
USA
Korea (Samsung Med
Center)
Conjunctival suturing
Skin incision
Yes
Yes
Variable placement of
skin/septum–levator
attachment
Remove skin
Yes
By flap transposition
Orbicularis
Trims orbicularis
Orbital septum
Opens septum
Preaponeurotic fat
Variable
Crease form
Skin–apon.–skin
Suture
6-0 interrupted
sutures and 7-0
continuous suture
Days left in
5–7 days
Effectiveness
Permanent
Comments
Emphasizes removal of
fascial tissues in
double blepharoplasty
(review by Boo-Chai in
Int Abstracts of Plast
Reconstr Surg)
Arch Facial Plast
Surg 2000;2(10):
43–47 Modified
Z-epicanthoplasty

Appendix 2  Modern Literature on Asian Eyelid Surgery (in English)
355
Modern Literature on Asian Eyelid Surgery (in English)
Author
Sergile, Obata
JW Kim, JO Lee
KC Yoon, S Park
YS Kao, CH Lin, RH Fang
Year
1997
1998
1998
1998
Journal
Plast Reconstr Surg
99(3):662–667
translation of
Mikamo’s 1896
paper
Aesthet Plast Surg
22(6):433–438 Asian
blepharoplasty with
short-pulsed contact
ND-Yag laser: limited
incision
Plast Reconstr Surg
102(2):502–508
Selective tissue
removal in
blepharoplasty for
young Asians
Plast Reconstr Surg
102(6): 1835–1841
Epicanthoplasty with
Y–V advancement
Country
USA
Korea
Korea (Univ of Ulsan)
Taiwan (Vet Gen Hosp)
Conjunctival suturing
Skin incision
Yes
Remove skin
Yes
Orbicularis
Yes
Orbital septum
Yes
Preaponeurotic fat
Yes
Crease form
Levator–tarsus–skin
Suture
7-0 nylon, or tissue glue
Days left in
Effectiveness
Comments
A general discussion
on incisional
technique
Modern Literature on Asian Eyelid Surgery (in English)
Author
JI Park
SL Jeong, BN Lemke,
RK Dortzbach et al.
YH Bang, HH Chu, SH
Park et al.
YW Kim, HJ Park, S Kim
Year
1999
1999
1999
2000
Journal
Arch Facial Plast Surg
1(2):90–95 Orbic.–
levator fixation
Arch Ophthalmol
117(7):907–912
Comparison of
Asian and Cauc.
upper lid anatomy
Plast Reconstr Surg
103(6):1788–1791
The fallacy of the
levator expansion
theory
Plast Reconstr Surg
106(6):1399–1404
Revisional correction
by interposing
preaponeurotic fat
Country
USA
Korea (Chonnam
Univ), USA
Korea (Inha Gen
Hosp)
Korea (Ewha Women
Univ)
Conjunctival suturing
Skin incision
Yes
Remove skin
Yes
Orbicularis
Orbital septum
Opens
Preaponeurotic fat
Crease form
Orbic.–levator
Suture
Days left in
Effectiveness
Comments
Continued

356
Asian Blepharoplasty and the Eyelid Crease
Modern Literature on Asian Eyelid Surgery (in English)
Author
RS Sim, JD Smith, AS
Chan
Y Lee, E Lee, WJ Park
DH Kang, SH Koo, JH
Choi et al.
Yang
Year
2000
2000
2001
2001
Journal
Arch Facial Plast Surg
2(2):113–120
Comparison of
aesthetic facial
proportions of
Chinese and
Caucasian women
Plast Reconstr Surg
105(5):1872–1880
Anchor
epicanthoplasty
combined with
outer-type lid crease
procedure
Plast Reconstr Surg
107(7): 1884–1889
Use of CO2 laser
Ann Plast Surg
46(4):364–368
Double eyelid: a
limited incision
technique
Country
Singapore (National
Univ)
Korea (Seoul National
Univ)
Korea (Univ MC)
Korea (Catholic Univ)
Conjunctival suturing
Skin incision
Yes
4 mm skin incision
Remove skin
Yes
Orbicularis
Orbital septum
Opened
Preaponeurotic fat
Optional
Optional removal
Crease form
6-0 vicryl: inf.
skin–tarsus–levator
Levator–tarsus to
skin–muscle
Suture
Days left in
Effectiveness
Comments
General aesthetics

Appendix 2  Modern Literature on Asian Eyelid Surgery (in English)
357
Modern Literature on Asian Eyelid Surgery (in English)
Author
J Cheng, FZ Xu
Miyake, Hiraga
MT Yen, DR Jordan, RL
Anderson
BC Cho, KY Lee
Year
2001
2001
2002
2002
Journal
Plast Reconstr Surg
107(7):1665–1668
Microstructure of
Asian eyelid crease
Jpn J Plast Reconstr
Surg 44:815
Selection of skin
resection or
double eyelid
operation
Ophthalm Plast Reconstr
Surg 18(1):40–44
Epicanthoplasty:
subcut. approach
through ext. skin
incision
Plast Reconstr Surg
110(1):293–300 Med.
epicanthoplasty
combined with
pilcation of med.
canth. tendon
Country
China (Hangzhou
Zhejiang Univ.
Med School)
Japan
USA
Korea (Kyungpook
National Univ Hosp)
Conjunctival suturing
Skin incision
Remove skin
Orbicularis
Excise offending
orbicularis underlying
the epicanthal fold
Orbital septum
Preaponeurotic fat
Crease form
Suture
Days left in
Effectiveness
Comments
Scanning EM
showed
aponeurotic fibers
penetrate
orbicularis to fuse
with skin
Basing skin resection
on whether brow
position is ptotic
Continued

358
Asian Blepharoplasty and the Eyelid Crease
Modern Literature on Asian Eyelid Surgery (in English)
Author
WM Yoo, SH Park, DR
Kwang
Hwang, Kim et al.
Lam, Kim
SH Chen, Mardini S,
Chen HC et al.
Year
2002
2003
2003
2004
Journal
Plast Reconstr Surg
109(6):2067–2071 Root
Z-epicanthoplasty in
Asian eyelid
Ann Plast Surg
50(2):156–159
Aesthet Surg J
23(3):170–176
Partial-incision
technique
Plast Reconstr Surg
114(5): 1270–1277
Corrective Asian
blepharoplasty
after failed
revisions
Country
Korea
Korea (Inha and Yonsei
Univ)
USA/Korea
Taiwan (Chang
Gung Univ)
Conjunctival suturing
Skin incision
15–18 mm wide skin
incision
Remove skin
No
Orbicularis
Through orbic.
Orbital septum
Open
Preaponeurotic fat
Partial excision
Crease form
Levator–inf. skin edge
Suture
Days left in
Effectiveness
Comments
(See JI Park’s 1996 Plast
Reconstr Surg article
on Z-epicanthoplasty)
Lateral
septoaponeurotic
artery as source of
bleeding during
upper blepharoplasty
Clin photo shows skin
incision spans 34 of
width of ciliary
margin. Crease may
appear deeper
centrally. (See
Yang’s 2001 paper)
A general
discussion of
factors that lead
to failures and
their corrections

359
RECENT LITERATURE
(1998–2014) ON ASIAN EYELID
SURGERY (IN ENGLISH)
A P P E N D I X 3
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Hwang, Kim et al.
Kim, Lee
Mutou, Homma
Morikawa, Yamamoto
Year
1998
1998
2000
2001
Journal
Br J Plast Surg 51(8):
594–598
An anatomical study of
the junction of orbital
septum and levator
aponeurosis in
Orientals
Aesthet Plast Surg
22(6):433–438
Asian blepharoplasty using
short-pulsed contact
Nd–Yag laser: limited-
incision resectable laser
double fold with internal
medial and lateral
functional epicanthoplasty
Aesthet Plast Surg
24(4):289–291
Intradermal stitch
blepharoplasty for
Orientals: does it
disappear?
Aesthet Plast Surg
25(1):20–24
Scanning EM study
on double and
single eyelids in
Orientals
Country
Korea
Japan
Japan
Conjunctival
suturing
Intradermal stitch;
over 7 yr,
1,570 pts
Skin incision
Remove skin
No
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form
Sutures
Days left in
Effectiveness
3.4% ‘revisited’ their
clinic re. loss of
crease
Comments
Septum has outer
(superficial) layer
and inner (deep)
layer that lies
adjacent to the
levator sheath
Reflective of interests at the
time for use of various
laser modalities
30% loss within first
year, 88%
occurred within
5 yr. Failure rate
based on only
those who
returned for Rx
Confirms branches of
lev. apon. running
through orbicularis
to skin in Japanese
born with crease
Continued

360
Asian Blepharoplasty and the Eyelid Crease
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Liao, Tung et al.
A Chuangsuwanich
Kim, Youn
WPD Chen
Year
2005
2006
2006
2007
Journal
Aesthet Plast Surg
29(6):540–545
Celebrity arcade
suture
blepharoplasty for
double-eyelid; CAS
Aesthet Surg J
26(3):280–286
Short incisional
double-eyelid
blepharoplasty for
Asian pts
Plast Reconstr Surg
117(3):782–789
Management of
adhesion using
a pretarsal
fibromuscular flap or
graft in secondary
blepharoplasty
Plast Reconstr Surg
119(1):379–386
The concept of a glide
zone as it relates to
upper lid crease, lid
fold, and application
in upper
blepharoplasty
Country
RO China, Taiwan
Thailand
Korea
USA
Conjunctival suturing
Trans-tarsal suturing
Skin incision
Stab incision(s)
Partial incision
Revisional
blepharoplasty
Yes
Remove skin
No
Yes
Orbicularis
Orbital septum
Preaponeurotic fat
Removed centrally
Treatment and
preservation of fat
Crease form
‘Bridge connection’
Skin-to-tarsal plate
fixation
Skin–apon.–skin
Sutures
?
6-0, 7-0
Days left in
7
Effectiveness
Partial incision
technique. 652 pts,
10 lost crease
within a year, 8 pts
with asymmetry
Comments
Use of pretarsal
fibromuscular flap or
free graft to prevent
re-adhesion
Concept paper on fat
as a glide zone

Appendix 3  Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
361
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
WPD Chen
Fengzhi, Wei et al.
A Kruavit
Choi, Eo
Year
2007
2009
2009
2010
Journal
Plast Reconstr Surg
120(2):545–552
Beveled approach for
revisional surgery in
Asian blepharoplasty
Ann Plast Surg
63(3):242–248
Double-eyelid
operation recreating
the anatomic
microstructure
Aesthet Surg J
29(4):272–283
Asian blepharoplasty:
18 yr in 6,215 pts
Ann Plast Surg
64(4):376–380
Tissue thread
grafting:
nonincisional
Double-eyelid
operation
Country
USA
PR China
Thailand
Korea
Conjunctival suturing
Skin incision
Yes. Revisional
blepharoplasty
On middle-third of
eyelid only
Likely through small
incisions
Remove skin
Minimal
Dissect medially,
laterally, superiorly
Orbicularis
Orbital septum
Preaponeurotic fat
Crease form
Skin–apon.–skin
Three inverted
stitches, skin to lev.
apon. or inf. edge
dermo-orbic.
junction (subcut.)
buried
Thread was passed in
‘same pattern as
other non-incisional
technique’
Sutures
6-0, 7-0
Threads made from
autogenous
temporal fascia,
CPF, or cadaveric
dermis
Days left in
7
9.3
Effectiveness
Partial incision
technique
Comments
Technique and series of
patients that
underwent revision
blepharoplasty for
correction of high
crease. Net lowering
is 2.75 mm in crease
height
EM and light
microscopic study
confirms presence
of levator fibers to
pretarsal skin
In 70%, author could
use medial anchor
stitch to create an
outer fold without
epicanthoplasty
Unclear about the
techniques used for
passing thread,
since such variants
exist
Continued

362
Asian Blepharoplasty and the Eyelid Crease
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Cho, Byun
Ma, Cheng
Liu et al.
Choi, Eo
Year
2010
2010
2010
2010
Journal
Plast Reconstr Surg
125(1):324–331
New technique
combined with
suture and incision
method
Aesthet Surg J
30(3):329–334
Mini-incision double
eyelidplasty
Plast Reconstr Surg
126(6):2133–2139
Transcut., subcut. and
intratarsal suturing
in double-eyelid
surgery
Plast Reconstr Surg
126(3):1048–1057
A new crease fixation
technique for double
eyelidplasty using
mini-flaps derived
from pretarsal
levator tissues
Country
Korea
Hong Kong
PR China
Korea
Conjunctival suturing
Skin incision
Partial incision +
buried continuous
suture
Mini-incision; two
3 mm incisions
Five stab skin
incisions; transcut.
approach, takes
bites of tarsal plate
Remove skin
No
No
Orbicularis
Debulk pretarsal soft
tissues
Orbital septum
Preaponeurotic fat
Crease form
Levator is fixed to
tarsus, just below
end of apon. to
tarsus
Transcut.–intratarsal
suturing
Sutures
One continuous suture
is buried
Four buried 7-0 nylon
sutures
Days left in
Permanent
Effectiveness
Partial incision +
buried continuous
suture with single
knot
11% revision rate,
6% crease
disappearance
89.6% satisfied over 3
months to 3 years
period. 10.4%
dissatisfied
Comments
Combined approaches.
Benefit vs risks?
Hard to tell as period
of observation
spans 3 months to
3 years, both short
duration when it
comes to judging
permanence
Uses miniflaps of lev.
apon. and attach to
skin–muscle layers

Appendix 3  Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
363
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Bi, Zhou et al.
Li, Lin et al.
Lew, Kang, Cho
Zhang, Yang
Year
2011
2011
2011
2012
Journal
J Plast Reconstr
Aesthet Surg
64(9):1138–1144
Small-incision
orbicularis–levator
fixation technique:
double-eyelid
blepharoplasty for
treating trichiasis
J Plast Reconstr
Aesthet Surg
64(8):993–999
Double-eyelid
blepharoplasty
incorporating
ptosis surgery
for ‘latent’
aponeurotic ptosis
Plast Reconstr Surg
127(3):1323–1331
Surgical correction of
multiple upper eyelid
folds in East Asians
Aesthet Plast Surg
36(5):1039–1046
Removal of large
amount of pretarsal
tissue via 3
mini-incisions
Country
PR China
PR China
Korea
PR China
Conjunctival suturing
Skin incision
Small incisions
medial, central
and lateral
External incision
approach
Revisional
blepharoplasty
Partial incision; 3
incisions, each
3–4 mm
Remove skin
Orbicularis
Debulk soft tissues
Excised inferiorly, and
to each side of
wounds
Orbital septum
Preaponeurotic fat
Crease form
Orbicularis–levator
fixation
Sutures
Days left in
Effectiveness
Improved eyelash
up-curling in
medial, mid- and
lateral sections
Comments
Clinical importance
for detection and
correction of mild
ptosis
Augmented preorbital
area using eyelid
tissues (orbicularis and
orbital fat) to prevent
re-adhesion of the
orbicularis and levator
Similar paper in
Aesthet Plast Surg
2013;37(1):22–28
An uncut strip of
orbicularis removed
through 3
mini-incisions
Continued

364
Asian Blepharoplasty and the Eyelid Crease
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Tung, Tsai et al.
Moon, Yoon, Lee
JS Zubiri
T Mizuno
Year
2012
2013
2013
2013
Journal
Aesthet Plast Surg
36(4): 842–845
Simultaneous fat
removal with
suture upper
blepharoplasty
Arch Plast Surg 40(4):
409–413
Modified
blepharoplasty using
single-knot
continuous buried
non-incisional
technique
Aesthet Surg J
33(5):722–732
Subdermal placement of
sutures in double
eyelid surgery
J Plast Reconstr
Aesthet Surg
66(4):e95–e100
Two modified
techniques to
decrease
complications of
buried suture
double-lid
blepharoplasty
Country
RO China, Taiwan
Korea
Philippines
Japan
Conjunctival suturing
CA suturing
Yes, back and forth
through dermis and
conjunctiva
Buried suture
technique.
First technique:
transconjunctiva
only
Skin incision
Combine with a
4 mm lateral skin
incision to reduce
fat pad
Needle through four
stab skin incisions
Full incisional method
Second technique:
small skin incision
Remove skin
No
Yes
No
Orbicularis
Buried suture in orbic.
oculi through lateral
stab incision
Yes
Second technique:
resected some
pretarsal orbicularis
Orbital septum
Yes
Preaponeurotic fat
Remove portion of
fat
Removal as needed
Crease form
Take {skin–tarsus
+aponeurosis–skin}
fixation sutures x 5
buried 6-0 nylon
Sutures
Buried sutures
7-0 nylon back and
forth
Continuous 6-0 nylon
Buried suture over
anterior surface of
STB
Days left in
Permanent
Remove on 5th day
Buried suture is
permanent
Effectiveness
Follow-up period
unknown
Follow-up period
unknown
Follow-up period
unknown.
Fail rate of 26% with
buried suture alone;
9.6% if combined
with resection of
pretarsal orbic.
Comments
Hardly
‘non-incisional’?
Any Faden-like effect?
Skin fixation to tarsus as
well as to levator
aponeurosis;
combined effect

Appendix 3  Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
365
Recent Literature (1998–2014) on Asian Eyelid Surgery (in English)
Author
Jinghe, Huifang et al.
Year
2014
Journal
Ann Plast Surg
72(2):141–144
Three mini-incisions
double-eyelid
blepharoplasty
Country
PR China
Conjunctival
suturing
Skin incision
Partial incision; 3 incisions,
each 3–4 mm
Remove skin
Orbicularis
Excise inferior skin edge’s
orbicularis
Orbital septum
Preaponeurotic fat
Reduce fat
Crease form
Sutures
Days left in
Effectiveness
Comments
Author described incisions
as ‘minute’

366
A P P E N D I X 4
RECENT LITERATURE ON
EPICANTHOPLASTY (IN ENGLISH)
Recent Literature on Epicanthoplasty (in English)
Author
S Ma
Y Lee, E Lee et al.
SD Lin
Year
1996
2000
2000
Journal
Zhonghua Yan Ke Za Zhi
32(3):194–196
Epicanthoplasty during
double-fold eyelid
operation
PMID: 9590860
Plast Reconstr Surg
105(5):1872–1880
Anchor epicanthoplasty combined
with out-fold type double
eyelidplasty for Asians: do we
have to make an additional scar
to correct the Asian epicanthal
fold?
PMID: 10809119
Br J Plast Surg 53(2):95–99
Correction of the epicanthal fold
using the VM-plasty
PMID: 10878829
Country
PR China
Korea
RO China, Taiwan
Skin incision
Various epicanthoplasty
performed in 183 cases
Anchor epicanthoplasty, used for
out-fold crease (parallel crease
shape), anchoring medial end of
incision to deep tissue
VM-plasty with three V-flaps
Remove:
  Skin
38 cases (shuttle form),
120 (cuneiform), Z-plasty
in 25 cases
Trimming skin
  Orbicularis
And soft tissue under medial fold
  Orbital septum
  Preaponeurotic fat
Crease form
Parallel crease
Outer (parallel)
Effectiveness
183 cases, performed
together with double-
eyelid procedures
67 cases; 28 cases followed.
Disadvantages include technical
difficulty and chance for active
bleeding as stated by authors.
Blends into medial end of parallel
crease
Used alone in 8 cases, with
double-eyelid procedure in 51
young patients, and with
upper blepharoplasty and
crease procedure in 26 cases
Comments
Three techniques
depending on severity
This technique is based on the
concept of trimming of muscle
and soft tissue under the Asian
epicanthal fold and downward
medial advancement and
anchoring of the medial canthal
skin to the deep tissue. Avoids
incision over medial canthal skin
(medial to the medial canthal
angle)
Redness of incisions was
common but all faded away
within 2–3 mth

Appendix 4  Recent Literature on Epicanthoplasty (in English)
367
Recent Literature on Epicanthoplasty (in English)
Author
Y Yang, HM Zhang et al.
H Zhang, H Zhuang et al.
SK Yi, HW Paik et al.
Year
2006
2006
2007
Journal
Zhonghua Zheng Xing Wai Ke
Za Zhi 22(2):130–132
[A new method for medial
canthoplasty combined
double eyelid formation]
(article in Chinese)
PMID: 16736618
Plast Reconstr Surg
118(4):900–907
A new Z-epicanthoplasty and a
concomitant double
eyelidplasty in Chinese eyelids
PMID: 16980849
Aesthet Plast Surg
31(4):350–353
Simple epicanthoplasty with
minimal scar
PMID: 17486401
Country
PR China
PR China
Korea
Skin incision
Performed with double-eyelid
procedure
Z-epicanthoplasty
Remove:
  Skin
  Orbicularis
  Orbital septum
  Preaponeurotic fat
Crease form
Effectiveness
86 cases; 67 cases followed
up. Designed for parallel
shape crease
230 cases together with
double-eyelid procedure,
included congenital and
traumatic medial epicanthi.
Followed 67 cases. Stated that
it is suitable for all types
except epicanthus inversus
52 cases, 2 showed a depressed
scar on the lower lid
Comments
Suitable for mild to moderate
epicanthal folds, all except
epicanthus inversus
Mild scar in early postop period,
then fade into gray–white line
Continued

368
Asian Blepharoplasty and the Eyelid Crease
Recent Literature on Epicanthoplasty (in English)
Author
JI Park, MS Park
FC Li, LH Ma
W Chen, S Li et al.
Year
2007
2008
2009
Journal
Facial Plast Surg Clin
North Am 15(3):343–
352, vi
Park Z-epicanthoplasty
PMID: 17658430
J Plast Reconstr Aesthet Surg
61(8):901–905 Epub 2007 Jul 2
Double-eyelid blepharoplasty
incorporating epicanthoplasty
using Y–V advancement
procedure
PMID: 17606424
J Plast Reconstr Aesthet Surg
62(12):1621–1626
Medial epicanthoplasty using the
palpebral margin incision method
PMID: 19028154
Country
USA
PR China
PR China
Skin incision
Z-epicanthoplasty,
correcting type II and III
epicanthal fold
Y–V advancement incorporated
into crease incision
Palpebral margin incision.
Performed together with double-
eyelid procedure.
Remove:
  Skin
  Orbicularis
  Orbital septum
  Preaponeurotic fat
Crease form
Outer-parallel
Effectiveness
Best suited for outer-
parallel crease shape,
patients who desire
‘higher’ double fold
92 cases, performed with
double-eyelid procedure. Only 3
cases with scar
82 cases (through upper and lower
palpebral margin incisions; trims
off orbic. oculi under epicanthal
fold, as well as superficial head of
medial canthal ligament)
Comments
Authors stated: ‘The size of the
epicanthal fold in Asians is
usually relatively small, and
thus aesthetically successful
effacement rarely requires more
complex procedures as
performed in the West.’

Appendix 4  Recent Literature on Epicanthoplasty (in English)
369
Continued
Recent Literature on Epicanthoplasty (in English)
Author
JJ Lu, K Yang et al.
Y Liu, J Huang
L Liu, S Li et al.
Year
2011
2011
2012
Journal
J Plast Reconstr Aesthet Surg
64(4):462–466
Epicanthoplasty with double
eyelidplasty incorporating
modified Z-plasty for
Chinese patients
PMID: 20682462
Aesthet Plast Surg
35(6):1112–1116
A modified and accurately
designed Z-epicanthoplastic
technique
PMID: 21607535
(Interepicanthal distances longer
than a palpebral fissure and
lacrimal caruncles obviously
covered by epicanthic folds
were considered an indication)
J Plast Reconstr Aesthet Surg
65(1):43–47
Inverted ‘V–Y’ advancement
medial epicanthoplasty
PMID: 21816696
Country
PR China
PR China
PR China
Skin incision
Modified Z-plasty
Modified Z-plasty
Inverted V–Y
Remove:
  Skin
  Orbicularis
  Orbital septum
  Preaponeurotic fat
Crease form
Effectiveness
322 cases(with double-eyelid
procedures); technique
includes cutting off
malpositioned superficial
head of preseptal orbic.
oculi
62 cases (42 simultaneous
double-eyelid surgery); stated
60 patients were satisfied
Comments
Stated that it can be applied to
all types except epicanthus
inversus
263 cases. Stated it can avoid
overly Westernizing the inner
canthus architecture

370
Asian Blepharoplasty and the Eyelid Crease
Recent Literature on Epicanthoplasty (in English)
Author
YH Shin, PJ Hwang et al.
X Hu, X Lin et al.
S Wang, F Shi et al.
Year
2012
2012
2013
Journal
J Craniofac Surg 23(4):e278–820
V–Y and rotation flap for
reconstruction of the epicanthal
fold.
(to treat overcorrected
epicanthoplasty cases)
PMID: 22801149
Aesthet Plast Surg
36(4):788–794
Two-Z-epicanthoplasty in
a three-dimensional
model of Asian eyelids.
PMID: 22437335
J Plast Reconstr Aesthet Surg
66(5):682–687
Epicanthal fold correction: our
experience and comparison
among three kinds of
epicanthoplasties.
PMID: 23499505
Country
Korea
PR China
PR China
Skin incision
V–Y
20 out of 23 cases
underwent
simultaneous double-
eyelid procedures
Three methods, 252 cases
(220 together with double-
eyelid procedure): horizontal
incision (mild), Z-plasty
(moderate) and V–W-plasty
(severe cases)
Remove:
  Skin
  Orbicularis
Excise orbicularis and thick
subcut. tissues
  Orbital septum
  Preaponeurotic fat
Crease form
Effectiveness
246 cases, 62 cases followed up; 6
cases needed reoperation.
Intercanthal distance lengthened
from 31.7 to 33.8 mm mean
Stated that intercanthal
distance decreased
from 37± 2.1 mm
preop. to 31.4±1.9 mm
postop. Inconspicuous
scar
Majority cases were mild,
underwent horizontal
incision which left
inconspicuous scar. Severe
cases (underwent V–W-
plasty) may leave obvious
scar
Comments
Used to repair overcorrection of
epicanthoplasty (overly exposed
caruncle)

Appendix 4  Recent Literature on Epicanthoplasty (in English)
371
Recent Literature on Epicanthoplasty (in English)
Author
L Wang, X Chen et al.
Year
2013
Journal
Aesthet Plast Surg 37(4):704–708
A modified Z-epicanthoplasty combined with
blepharoplasty used to create an in-type
palpebral fissure in Asian eyelids.
PMID: 23824058
Country
PR China
Skin incision
To create an in-type crease shape (NTC).
Performed together with double-eyelid
surgery
Remove:
  Skin
  Orbicularis
  Orbital septum
  Preaponeurotic fat
Crease form
In-type (nasally tapered)
Effectiveness
Reported ‘no scarring’ in 873 cases
Comments

372
A P P E N D I X 5
AESTHETIC EFFECTS OF
ASIAN BLEPHAROPLASTY
Author
Yu, Liao
Tsai, Wu et al.
Kim
Kim, Lee et al.
Year
2000
2012
2013
2013
Journal
Hua Xi Kou Qiang Yi Xue
Za Zhi 18(3):165–167 (in
Chinese)
PMID:12539668
Classification of eyelids,
design of double-eyelid
operations
J Plast Reconstr
Aesthet Surg
65(6):e141–145
Ocular surface area
changes after
double eyelidplasty
Aesthet Plast Surg
37(5):863-868
Effects in the upper
face of Far East
Asians after Oriental
blepharoplasty
J Craniofac Surg
24(5):1582–1585
What causes increased
contrast sensitivity and
improved functional
visual acuity after upper
eyelid blepharoplasty?
Country
PR China
RO China, Taiwan
Korea
Korea
Skin incision
Design based on
morphological characters
of eyelids
Comments
Classified according to
eyes’ length and height,
eyelid skin thickness,
eyeball protrusion and
eye shape, including
eyelids with long and
narrow eyes, eyelids with
thin and soft skin, eyelids
with thick subcut. tissue,
eyelids with small and
round eyes, eyelids with
protruding eyeball and
eyelids with triangle eyes
Increase in ocular
surface area after
double eyelidplasty
Their series of 612 pts
shows an increase
in palpebral fissure
vertical dimension
and relaxation of
brow position after
double-eyelid
surgery. (These
findings are not
unique to Asians)
Improved contrast
sensitivity and
functional visual acuity
after upper
blepharoplasty were
caused by changes in
ocular high-order
aberration and the
degree of lash ptosis
after surgery. There
were no changes in
corneal topography or
astigmatism
Author
Hwang, Spiegel
Year
2014
Journal
Aesthet Surg J 34(3):374–382
The effect of ‘single’ vs ‘double’
eyelids on the perceived
attractiveness of Chinese women
Country
USA
Skin incision
Comments
19 Chinese women were judged by
Chinese as well as non-Chinese
observers: creases were digitally
added as low, medium and high in
height.
Both Chinese and non-Chinese
observers considered the medium-
height upper eyelid crease most
attractive (P < 0.00001). An absent
upper eyelid crease was deemed
the least attractive (P < 0.00001)

373
A P P E N D I X 6
RECENT LITERATURE ON ANATOMY
Recent Literature on Anatomy
Author
O Galatoire, V Touitou et al.
H Kakizaki, I Leibovitch et al.
BS Kotlus, DE Heringer, RM Dryden
Year
2007
2009
2010
Journal
Orbit 26(3):165–171
High-resolution MRI of the upper
eyelid: correlation with the
position of the skin crease in
the upper eyelid
PMID: 17891644
Ophthalmology 116(10):2031–2035
Orbital septum attachment on the
levator aponeurosis in Asians: in
vivo and cadaver study
PMID: 19592104
(To examine the anatomic
relationships between the
preaponeurotic fat pad, orbital
septum, and the distal end of the
anterior layer of the levator
aponeurosis [DEALLA] in relation
to the superior tarsal plate border)
Ophthal Plast Reconstr Surg
26(6):395–397
Evaluation of homeopathic Arnica
montana for ecchymosis after
upper blepharoplasty: placebo-
controlled, randomized, double-
blind study
PMID: 20683279
Country
Comments
MRI provides excellent images
and allows a good analysis of
the upper eyelid components. It
permits a detailed analysis of
the architecture for a better
understanding of its appearance
and of the crease position
In vivo, the DEALLA was always
located above the STB, and the
lower margin of the preapon. fat
was always positioned below the
DEALLA and around the STB.
Orbital septum attachment on the
levator aponeurosis in Asians
seems to be situated above the
STB border in vivo
The authors find no evidence that
homeopathic A. montana, as
used in this study, is beneficial
in the reduction or the resolution
of ecchymosis after upper-eyelid
blepharoplasty
Recent Literature on Anatomy
Author
Q Zhou, L Zhang et al.
Year
2012
Journal
J Plast Reconstr Aesthet Surg
65(9):1175–1180
Preoperative asymmetry of upper
eyelid thickness in young
Chinese women undergoing
double-eyelid blepharoplasty
PMID: 22647567
Country
PR China
Comments
Using high-def. MRI and high-
precision weighing of tissue:
Demonstrated that the
orbicularis muscle and orbital
fat pad are consistently thicker
on the right side than on the
left. Concluded that upper
eyelid thickness asymmetry is a
common phenomenon in young
Chinese women

Page numbers followed by 'f' indicate figures, 't' indicate tables, and 'b' indicate boxes. Asian eyelid surgery, 325-332 Absent crease, 19f, 186b, 186f, 189b, 189f,| Boo-Chai method, 327, 327f-331f 206b, 206f-207f, 233b, 233f, 2376, 237f, medications and instruments, 327 2501 principle, 327 blepharoplasty for, results (before and Boo-Chai's personal comments, 327 after), 122b, 122f, 124b, 124f, 146b, modern literature sources on, 347-358, 146f, 151b, 151f, 156b-157b, 156f-157f 347t-358t recent literature sources on, 359-365, with average eyelid fissure opening, 359t-365t 119b-120b, 119f-120f Asymmetric crease, 184b, 184f, 195b-196b, with medial canthal fold, 149b, 149f 195f-196f, 223b, 223f with narrow palpebral fissure, 124b, 124f Asymmetry, examples of, 159f with ptosis, 133b, 133f, 149b, 149f with skin hooding, 121b, 121f with slightly rectangular look, 125b, 125f| with spongy tissues of RUL, 131b, 131lf with triangular fissure, 123b, 123f with triangular hooding, 148b, 148f Acetaminophen, 75 Acquired ptosis, 250-251 Aesthetic Asian blepharoplasty, goal of, 247 Aesthetic surgery, of Asian eyelid challenge of, 343-344 novel technique, challenges and outlook for the future in, 339-344 Anatomic crease height, 247, 272f-273f, 275-276, 275f, 303f, 304, 316 Anatomy, recent literature on, 373-374, 373t Anatomy of eyelids, 19-38 Asians, 275-276, 275f with crease, 245, 245f, 306, 306f vs. Caucasian, 20, 284 without crease, 24-25, 24f, 246, 246f, 307, 307f Caucasians with crease, 19, 21, 244, 244f| and facial anatomy, 36 fat pads of the upper lids, 22-28 individuals with a lid crease, 21-22 medial canthus, 29-32 single, 19-20, 19f-20f, 26, 26f upper, four arterial arcades, 33, 33f upper lid and crease, 19-22 upper tarsus, 32 vascular supply of the upper eyelid, 33-35 Anchor blepharoplasty, 71-72 Angle of observation, 265-270, 312 negative, 269, 269f, 314, 314f crease height and, 269, 269f positive, 268, 268f, 313, 313f| crease height and, 268, 268f \poneurotic fibers (afi), 308 Apparent crease height, 272f-273f, 275-276, 304. 316 effect on tarsal tilt. 271 measurement of, 276 us. true anatomic crease height, 274 Asian Blepharoplasty: A Surgical Atlas, 53-54 Asian eye anatomy, 41 Asian eyelid, aesthetic surgery of challenge of, 343-344 novel technique, challenges and outlook for the future in, 339-344 Bard-Parker blade, 256-259 Basting sutures, 70-71 Beveled approach on preaponeurotic space, 247, 259f, 261 in primary Asian blepharoplasty, 258f advantages of, 256-259 revision and, 218b-219b, 218f-219f in revisional Asian blepharoplasty, 258f, 261, 261f, 262t Beveled transection through orbicularis, 83 Bifid creases, 163, 195b, 195f, 197b, 197f| lower, 163 upper, 163, 164f Bilateral ptosis repair, blepharoplasty and, 1426, 142f Biocompatible polymers, 344 Bipolar cautery, 88 Blair's retractor, 86, 87f Blepharophimosis syndrome, 30f Blepharoplasty, 85f, 108-109, 198b, 198f-199f, 204b, 204f-207f, 206b for absent crease, 1196-124b, 119f-124f, 146b, 146f, 151b, 151f, 1556-157b, 155f-157f with abnormally spongy tissues of RUL, 1316, 131/ heavy lids and, 157b, 157f with medial canthal fold, 149b, 149f with mild ptosis, 149b, 149f with narrow palpebral fissure, 124b, 124f with ptosis of RUL, 133b, 133f with rectangular look, 125b, 125f with triangular hooding, 148b, 148f aesthetic, goal of, 247 aesthetic effects of, 372, 372t with aesthetic improvement, 136b, 136f anchor, 71-72 Asian patient after, 8f excessive removal of preaponeurotic fat, 10, 10f for asymmetry in eyelid opening, 126b, 126f beveled approach, 255-263 with cosmetic improvement, 137b, 137f for crease asymmetry, 1326-134b, 132f-134f dietary advice for, 97 in elderly patients, 46f, 98f| INDEX ethnicity and, 10 for eyelid without any crease, 120b, 120f factors that influence outcome of, 95-97 first vector, 75-83 anesthetic mixture and injections, 75-76, 76b, 76f incision in, 81, 81f| measurement of tarsal height, 77, 77f nasally tapered crease shape, design of, 78-79, 78f arallel crease shape, design of, 79, 80 re-medications and surgical setup, 7 surgical steps, 77-83 for heavily hooded lid with fat, 151b, 151f r heavy eyelids, 129b, 12' ith fat bulge, 153b, 153 with heavy lids, 157b, 157f high brows, moderate fat OU, 146b, 146f for high crease and asymmetry, 134b, 134f in hooded shielded skin over lateral RUL, 147b, 147f for inconsistent crease and asymmetry, 122b, 122f for intermittent creasing, 144, 145b involutional changes in, 96-97, 97f levator excursion and, 128b, 128f with lid retraction, 145b, 145f local care for, 97 for medial canthal fold, 144b, 144f mid-lamellar clearance, 255-263 for multiple rudimentary crease lines, 154b-155b, 154f-155f for multiple wrinkles, eyelid with, 130b, 130f nano-dots placed along crease after, 322f for palpebral fissure, 124b, 124f for parallel crease, 119f-120f, 128b, 128f, 1356-136b, 135f-136f, 147b, 147f with partial excision of preaponeurotic fat OU, 150b, 150f postoperative regimen for, 109, 111f-118f pre- and postoperative, 126b-127b, 126f-127f, 129b, 129f, 1316-1326, 131f-132f, 134b-135b, 134f-135f, 1386-143b, 138f-143f, 152b, 152f images of a single-lidded individual, after undergoing, 319f with ptosis repair, 133b, 133f bilateral, 1426. 142f results, 45f, 119-158 revision, 215b, 215f, 2176-2196, 217f-219f,| 224b, 224f second vector, 85-93 for single lid, 121b, 121f, 156b, 156f suboptimal results, 110 surgical technique. see Surgical techniques tarsal height-based, 194b, 194f for triangular-shaped eyelid fissure, 141b, 141f upper, 99-104 for upper lid hooding, with shielded NTC, 1486, 148f for wrinkled crease, 132b, 132f| 375

376 INDEX KIM NHUNG Block of fat, 288 Boo-Chai, Khoo, 325 personal comments on Asian eyelid surgery, 327 Boo-Chai method, 56-58, 57f, 327, 327f-331f medications and instruments, 327 principle, 327 Boo-Chai sign, 326, 326f British Journal of Plastic Surgery, 327 Brow, overactive (BrOA), 315 Brow compensation, 286, 299 Brow droop, 315 Brow ptosis (BrPt), 315 Buried black nylon suture, 64, 65f Buried orbicularis-aponeurosis suture, 106 Buried suture, 71f Buried suture method, 42, 53, 53f, 294, 294f| adverse results of, 297 cross-sectional interpretation of, 294, 294f 'ecto-Faden' lid stitches and, 297 Faden effect and, 295, 295f on levator muscle, 292 long-term effect of, 296, 296f near-term advantage of, 64 ptosis and, 296, 296f 189f transconjunctival, 297, 298t corneal (eye) irritation from, 297 transcutaneous, 297 transtarsal, 297 use of, 291-300 C Canthal fold, medial, blepharoplasty on, 144b, 144f, 149b, 149f Canthoplasty, medial, 110 Canthus, medial. see Medial canthus. Cautery needle, 52 Central fat pad, 22 'Cheese-wire', 42 Cicatricial retraction, and prominent scar, 171f Closure, wound. see Surgical techniques. Collagen, 22 Colorado needle tip, 343 Complete crease reversal, 177 Compressive beads method, 53 Congenital blepharophimosis, 32 Congenital ptosis, 215, 215f Conjunctiva, 56f-57f transcutaneous intramuscular suture technique without piercing, 60, 60f Conjunctival suture placement, 52 Consultation, 45-49 Continuity, 166, 170 and permanence, 166-168 Corneal protector, 339, 339f Cosmetic surgery double-eyelid, 51-54 eyelid, pre-1952 Japanese literature on 345-346. 345t-3461 oculoplastic, 17-18, 18f Counseling, 45-49 Crease, 1, 19-22, 303 asymmetric, 2, 45, 45f, 170-172, 170f| revision parameters, 169-181 broad, 371 broader centrally than medially and laterally, 37 broader medially and laterally than centrally, 37 Caucasian semilunar, 2f Caucasians with, 21 continuity and permanence, 47f, 48-49 creating, formula for, 315-316 depth of, 95, 95t finesse in controlling, 97 dynamic, 91 nd superficial, 68, 68t, 73 • static, 68f-69f. 72, 73f. 105-10 eyelid, 1 factors that influence, 37 fading, 45, 45f formation of, 91-92, 92b correction of, 325 high, 9, 160, 166f, 286, 286f| high anchoring of 'ecto-Faden' and, 292 effect of, 291-300 ptosis and, 296, 296f, 299 surgical correction on, 300 individuals with a lid, 21-22 laterally narrow and medially broad, 37 location of, 40 low, 287, 287f low obliteration of, 172, 172f marking of, 99 medially narrow and laterally broad, 37 methods of construction, 253 'migrated', 314 mimicking of, 319 minimal nasally tapered, 5f multiple, 2f, 173-175, 197b, 197f, 2386, 238f formation of, 162f hollow supratarsal sulcus with/without, 173-175 postoperative formation of, 168f postsurgical, in patients without an original crease, 173 repair of. 173. 174f nano-dots on, 322, 322f nasally tapered, 6, 6f, 37, 123b, 123f, 130b, 130f, 136b, 136f, 143b, 143f, 1456-146b, 145f-146f, 148b, 148f, 157b, 157f, 308, 334, 336f-337f natural, characteristics of, 301 normal, interrelated parameters that determine, 161f optimal design of, 95 parallel, 6, 6f, 37, 1196-122b, 119f-122f, 1246-125b, 124f-125f, 128b, 128f, 1356-136b, 135f-136f, 1446-145b, 144f-145f, 147b, 147f, 149b, 149f, 1546-1576, 154f-157f, 2086, 208f-209f, 2256-2266, 225f-226f, 2286, 228f, 2356, 235f, 308 partial or incomplete, 2f, 4f predictors of, 308-316 regression rate of, 53 segmental obliteration in, 170f, 172, 173f segmented or non-continuous, 2f semilunar, 2f, 8, 9f, 20, 40, 175-177, 175f, 177f static, 68, 69f, 72, 105-106, 1966, 196f suboptimal, 45-46 unnatural, 10, 40 upper eyelid, position of, 266, 266f upper lid, 1-15 Crease deformity, 203b, 203f, 255 Crease-enhancing eye exercises, 109-111 Crease-enhancing maneuvers, 93, 93f Crease-forming stitch, applying, 92 Crease height, 40, 42-43, 47, 47f, 109, 160-163, 265-271, 303-307, 303f, 315-316 anatomic, 303f, 304, 316 angle of observation and, 270 apparent, 304, 316 vs. true anatomic, 274 of Asians, 306, 306f of Caucasians, 305, 305f evaluation of, 256 inequality in, 171, 171f 'lower-than-average', 281 measurement of, 274, 274f anatomic, 275-276 apparent, 276 inclined/tilted, 275-276 observed, 247 and shape, non-incisional technique, 325 tilted, 304, 304f, 316 Crease reversal, 53 complete, 177 effectiveness of corrective measures in, 177 Crease shape, 47-48, 47f, 163-166, 164f,| 308 design, solutions for reduction of medial upper lid fold in relation, 334-338 Deep double eyes, 52-53 Deep orbital arcade, 34 Dermatochalasis, 22-23, 23f, 96 Jexon (polyglycolic acid) suture, 70 Diazepam (Valium), 75 Double eyelid, 1, 19-20, 19f Chinese characters for, 1f cosmetic surgery, evolution of, 17-18, Japanese Kanji and Hiragana writing, 75f procedure, Chinese and Japanese for, If Double stitches thread (DST), 297 Double-Z plasty, 32 Down-knotting, 335, 334f-335f Dynamic crease, 91, 105-108 and superficial, 68, 68f, 73f vs. static, 68f-69f, 72, 73f, 105-106 'Ecto-Faden', 292 Edema, postoperative, 47, 110, 166-168 Elderly patients, blepharoplasty in, 46f, 98f Electric coagulator, 18, 52 Ellemann radiofrequency unit, 343 Empire needle tip, 343 'Endo-Faden', 292 Epicanthal folds, 29-30, 52, 333-334 Epicanthoplasty, 95 recent literature sources on, 366-371, 366t-371t treatment of medial upper lid fold and the fog surrounding, 333-338, 334f-337f Epicanthus inversus, 29-30, 30f Epicanthus palpebralis, 29-32, 29f, 31f Epicanthus supraciliaris, 29-30, 29f Epicanthus tarsalis, 29-30, 30f, 333 Epinephrine, 75, 76f Excess fat removal, 1936, 193f, 288, 288f see also Preaponeurotic fat pad Excision, skin. see Surgical techniques. External incision methods, 42-43, 53-54, 67-75, 67f, 247 intermediate variations of, 90 levator aponeurosis to inferior subcutaneous plane, 70-72, 70f-71f skin-levator-skin approach, 68, 68f

Eye cross-section of, 12f evaluation, 46 hollowed, 40, 160 palsy of the right superior rectus muscle, 48, 48f Eye muscle version exercise, 97 Eye position (eypo), 315 Eye schema, normal, 277 Eyebrow, cross-section of, 12, 12f Eyelid Asian arbitrary placement of high crease on, 41,41f nasally tapered, 42 parallel shape, 42 various forms of, 2f without crease, 39, 39f Caucasian upper lid crease, 3-5, 5f cross-section of, 12f double, 1, 1f, 19-20, 19f| Chinese characters for, 1f procedure, Chinese and Japanese for, If fissure with crease, 2f fold, vertical span of, 247 incisional of, 96 incomplete or partial crease, 3-5, 4f layers, biodynamic of, 243, 243f multiple creases, 2f partial obliteration of crease, 3-5, 3f partial or incomplete crease, 2f plane of passage through front layers of, 83 right upper, intraoperative view, 64, 64f with scarring, 13, 15f segmented or non-continuous crease, ?f semilunar crease, 8, 8f-9f single, 19-20, 19f-20f, 26, 26f, 39, 268, 275-276, 307, 307f, 309 Japanese Kanji writing for, 1, lf without crease, 2f surgery of, 96 tissues, 100-102 two well-defined creases, 3-5, 4f vertical section of, 343 with vs. without crease, 13, 13f-14f without crease, 3-5, 3f Eyelid anatomy. see Anatomy of eyelids. Eyelid crease, 1, 107f, 303 in Asians, 245, 245f without, 246, 246f in Caucasians, 244, 244f| description of, 248 goals and benchmarks, 39-43 nasally tapered Asians, 2f, 6, 6f lateral flare, 7, 7f minimal, 3-5, 5f runs level to the eyelash, 7, 7f parallel, 3-5, 3f Asians, 2f, 6, 6f as stringed series of unipoints, 317-323, 317f-321f different points along upper lid crease, 323 variation in function of unipoints, 322-323, 322f upper anatomic definition of, 265, 265f dynamics of, 259-263 incision of, 256-259, 257f position of, 266, 266f scar in, 255, 256f, 262 Eyelid crease factors, summary of, 301-316 F Facial anatomy, 36 Facial shapes, 37 Facial symmetry, 36-37, 36f Fad, 431 Faden effect, 52-53, 57-58, 292, 295, 295f| buried suture methods and, 293, 293f, 295, 295f high-anchored crease and, 292 on levator muscle, 299 Faden-like effect, 166 Faden-like fixation effect, 321, 321f| Faden posterior fixation suture dampening effect of, 291-292 definition of, 291 Fading crease, 45f Famined look, 10, 10f, 40, 160, 161f Fat fibrotic, 309 preaponeurotic, 10, 10f, 248, 305f blepharoplasty on, results of, 1446-147b, | 144f-147f, 1506, 150f role of, 308 pretarsal, 90, 90b, 309 removal of excess, 288 role of, 247 subcutaneous, 22, 26 Fat grafting, 288, 288f Fat injection, 288 Fat pads four areas of, 22 preaponeurotic, 22, 24f, 40, 52, 82f, 86-87, 86f, 100, 309 partial excision of, 88, 88b, 88f pretarsal, 18 of upper lids, 22-28 Fibrotic fat (f), 309 First vector, Asian blepharoplasty, 75-83 eyelid, blepharoplasty on, 119b-120b, 119f-120f palpebral, 124b, 124f palpebral, revision with, 234b, 234f Fixation inferior orbicularis-levator, 67 intercanthal, 110 medial tunnel combined approach of partial incision technique with, 339-343 surgical steps in, 339-343, 339f orbicularis levator, 70 septodermal, 67 skin-levator aponeurosis-skin, 67 skin-tarsus-skin, 67-68, 69f supratarsal, 70 transcutaneous skin-tarsus, 93f Flowers' technique, 72 Fog, surrounding epicanthoplasty, treatment of medial upper lid fold and, 333-338, 334f-337f Formula, for creating eyelid crease, 315-316 Full-thickness skin graft, 177 Full-thickness suture technique, 52, 55, 55f with stab incisions, 56-58, 56f G Glide sign, 251, 251f| Glide zone, 255, 288 amorphous infiltrated fat in, 248 concept of, 243-253, 249f friction-free layer and, 249 obliteration of, 250-251, 251f, 309, 309f| re-establishment of, 252 INDEX 377 restoration of, 259, 260f| revision and, 252, 252f H Half-moon-shaped crease, 327 Head tilt, 303 Hematoma, after injury, 35 High crease, 9, 160, 166f, 286, 286f| placement, 166f repair of, 171, 171f Hinders (h+, h-), 315 Historical considerations, 17-18, 17f Hollow sulcus, 161f excessive manipulation of tissues and, 250 supratarsal repair of, 173-175 with/without multiple creases, 173-175 Hollowed eye, 40, 160 Hooding skin, 121b, 121f triangular, 148b, 148f upper lid, 230b, 230f with shielded NTC, 148b, 148f Hydrocodone, 75 Hypertrophic scarring, 110 Incision wound, closure of partial, 342, 342f Incisional methods vs. stitch methods, 42-43 Incisions, 67, 81, 81b, 81f crease, 256-259, 257f revision with, 187b, 187f with skin removal, revision of, 185b, 185f Incline angle (I°), 272f-273f measurement of, 278-279, 281-283 Inclined crease height (Ich), 275, 275f| Induration, of natural wound, 110f Inferior oblique, 305f Inferior orbicularis-levator fixation, 67 Inferior rectus, 305f Inferior tarsus, 305f Informed consent, 46, 48 Infraciliary approach, 219 Injection, fat, 288 Inside fold. see Nasally tapered crease (NTC). Intercanthal fixation, 110 Interrupted sutures, 70-71 Intraoperative crease, appearance of, 252f J Japanese literature, pre-1952, on cosmetic eyelid surgery, 345-346, 345t-3461 Japanese medical literature, 51 Fournal of Plastic and Reconstructive Surgery, 3271 K Keloids, 110 L Lagophthalmos, 102, 255, 286 buried suture and, 296, 296f Late obliteration of crease, 172, 172f repair of, 170f, 172, 172f-173f| Lateral flare, 163 Lateral septoaponeurotic artery (LaSA), 35, 35f

378 INDEX KIM NHUNG Lateral wound edges, treatment of, 109 Laterally flared crease (LTC), 7, 7f see also Nasally tapered crease (NTC) Levator aponeurosis, 11, 56-58, 56f-57f, 72, 86-87, 105-106, 250, 256-259, 258f, | 305f buried sutures on, 295 to inferior subcutaneous plane, 70-72, 70f-71f Levator aponeurotic fibers (Latt), 308 Levator excursion, results (before and after), 128b, 128f Levator expansion, 22 'Levator function', 308 Levator muscle, 11, 259, 308 abdominal muscles and, 299 anchoring of crease on, 291 buried sutures on, 292 downgaze, 311, 311f Faden effect on, 299 upgaze, 310, 310f Levator muscle contractility (LC), 308 Lid physiologic upper crease of, 250 upper, 19-22, 23f position of, 266, 266f right, stereoscopic radiographic, 34f Lid crease, 21-22, 301 formation of, 91-92, 926, 100 placement, 168f in external incision method, 168f procedure, 1926-193b, 192f-193f, 213b, 213f, 221b, 221f, 2266-2276, 226f-227f, 231b, 231f tape, on crease formation, 147b, 147f Lid hooding. see Hooding. Lidocaine, 75, 325 Lidocaine hydrochloride (Xylocaine), 54 Literature sources modern, on Asian eyelid surgery, 347-358, 347t-358t recent on Asian eyelid surgery, 359-365, 359+-365t on epicanthoplasty, 366-371, 366t-371t Local anesthetic, skin blanching following application of, 183, 183f| Low crease, 171, 287, 287f| repair of, 171, 171f-172f Lower-bifid crease, 163 'Lower-than-average' crease height, 281 Lysis, of adhesions, 181 M Magnetic resonance imaging (MRI), tarsal tilt measured by, 276, 276f Varginal arcade, 33-34 Vathematical modeling, 277-284, 288-289 Matrix of solutions, in revisional blepharoplasty, 178f McCord's anchoring/retention stitches, 93, 93f Medial canthal skin, 333 Medial canthoplasty, 110 Medial canthus, 29-32 Medial evelid fold, technique in, 109 Medial tunnel fixation combined approach of partial incision technique with, 339-343 surgical steps in, 339-343, 339f Medial upper lid fold, 32f, 334, 336f-337f| solutions for reduction of, in relation to crease shape design, 334-338, 334f-337f treatment of, 333-338 Mid-lamellar clearance, in revisional Asian blepharoplasty, 255-263 'Migrated crease', 314 Mongolian eye, 29-30 Mono-lid, 39| Monopolar cautery, 343 Müller's muscle, 56-58, 56f-57f, 259, 292, buried suture method on, 294, 294f Multiple creases, 2f, 173-175, 197b, 197f, 238b, 238f formation of, 162f| hollow supratarsal sulcus with/without, 173-175 postoperative formation of, 168f postsurgical, in patients without an original crease, 173 repair of, 173, 174f Myocutaneous flap, excision of, 89, 89b Myocutaneous strip, rotation of, 86-87, Nano-dots, on crease, 322, 322f Nasal bridge, development of, 30-32, 32f Nasally tapered crease (NTC), 6, 6f, 123b, 123f, 130b, 130f, 136b, 136f, 143b, 143f,| 1456-1466, 145f-146f, 1486, 148f, 1576, 157f, 308, 334, 336f-337f revision and, 214b, 214f, 2206, 220f, 2276, 227f, 236b, 236f shape, design of, 78-79, 78f, 796 Natural crease, characteristics of, 301 Needle. see Twisted needle and compression method. Neutral Vax, 270 Normal eye schema, 277 'Normal levator function', 308 Oblique down-snip (cut), 335, 334f-335f Observed crease height, 247 Oculoplastic surgery, cosmetic, 17-18, 18f Optimal height (hop), 315 Orbicularis levator fixation, 70 Orbicularis oculi, 21f, 22, 56, 56f, 90, 90b, 90f, 305f, 315 passage of suture, 341f Orbital fat pad, 22 Orbital septum, 22, 24-25, 25f, 67, 72, 81, 82f, 83, 836, 86-92, 876, 103f attachment of, 71 excision of, 100 opening of, 99-100 Outside fold. see Parallel crease. Palpebral fissure, 11, 11f, 20, 36-37, 37f, 309 left, 20f revision with, 234b, 234f Palpebral fold, 22 Parallel crease, 6, 6f, 37, 1196-1226, 119f-122f, 1246-1256, 124f-125f, 1286, 128f, 1356-136b, 135f-136f, 144b-145b, 144f-145f, 147b, 147f, 149b, 149f, 1546-157b, 154f-157f, 208b, 208f-209f, 225b-226b, 225f-226f, 228b, 228f, 235b, 235f, 308 shape, 336, 336f-337f design of, 79, 79b, 80f Parameters, revision, 169-181 Patient elderly, 22-23 Asians, 26, 26f blepharoplasty in, 46f, 98f Caucasians, 23f postoperative complaint, 20 Periorbital portion, 307f, 315 Peripheral arcade, 33-34 Permanence, 170 continuity and, 166-168 Pinch sign, 251, 251f Plaque, 255, 262 Poor crease formation, 287, 287f Postoperative asymmetric crease, 45f Postoperative edema, 47, 110, 166-168 Postsurgical creases competing with original creases, 173, 174f multiple, in patients without an original crease, 173 Pre-medications, for blepharoplasty, 75 Preaponeurotic fat, 10, 10f, 248, 305f blepharoplasty on, results of, 144b-147b, 144f-147f, 150b, 150f role of, 308 Preaponeurotic fat pad, 22, 24f, 40, 52, 82f, 86-87, 86f, 100, 309 see also Supratarsal sulcus partial excision of, 88, 88b, 88f Preaponeurotic platform, 89 Preaponeurotic space, 249, 249f fat injection effects on, 288 preservation of, beveled approach on, 261 role of, 247 Preaponeurotic tissues, debulking, 100 Preaponeurotic zone, 106-108 Preoperative photography, 46 Preseptal orbicularis, excision of, 100 Preseptal segment, 307, 307f Preseptal zone, 107f, 179f-180f, 181 Pretarsal dissection, excessive, 27-28, 28f Pretarsal fat, 90, 906, 309 Pretarsal fat pads, 18, 22, 26-28, 27f Pretarsal orbicularis, excision of, 100 Pretarsal platform, 106-108, 107f, 301 Pretarsal segment, 307, 307f Pretarsal skin flap, dermis of, 72 Pretarsal tissue, 90, 90b Pretarsal zone, 179, 179f Prolene (polypropylene) suture, 70 Proparacaine hydrochloride, 75 Род с 1235,209 3031 Asian with, 282, 282f brow, 315 buried suture method and, 296-297, 296f Caucasian with, 279, 279f condition of, in Caucasian vs. Asian, 284, 285f congenital, 215, 215f excessive manipulation of tissues and, 250 high anchoring of crease and, 291, 299 levator excursion and, 291 restrictive-type, 250-251 revision with, 186b, 186f, 191b, 191f, 200b, 200f-202f, 212b, 212f, 215b, 215f, 220b, 220f, 233b, 233f Ptosis repair, blepharoplasty with, 133b, 133f bilateral, 1426, 142f R Rectangular debulking, 99-104 beveled approach and, 261 Rectus, inferior, 305f

Residual adhesion, 253 Residual skin, 335, 336f-337f Restrictive-type ptosis, 250-251 Retraction, upper lid Asian with, 283-284, 283f Caucasian vs. Asian, condition of, 284, 285f Caucasian with, 280, 280f| Revision parameters, 169-181 crease asymmetry, 170-172 inequality in crease height, 171 Revisions absent crease, 186b, 186f, 189b, 189f, 206b, 206f-207f, 233b, 233f, 2376, 237f beveled approach, 214b, 214f, 218b-219b, 218f-219f 'bifid' crease, 195b, 195f, 1976, 197f) blepharoplasty, 208b, 208f-209f, 215b, 215f, 2176-2196, 217f-219f, 2246, 224f matrix of solutions in, 178f summary of solutions in, 177-181, 178f third category of, 325 buried suture method procedure, 185b, 185f, 187b, 187f, 189b, 189f candidate for, 256-259 clinical findings, 255 crease asymmetry, 184b, 184f, 1956-196b,| 195f-196f, 2236, 223f crease bifurcation, 220b, 220f crease deformity, 203b, 203f crease enhancement, 240b, 240f dealing with, 255 excess fat removal, 193b, 193f, 288, 288f external incision crease procedure, 229b, 229f fat excision, 241b, 241f| fat grafting, 288, 288f glide zone and, 252, 252f high crease, 184b, 184f, 1906-191b, 190f-191f, 197b, 197f, 2026, 202f, 213b, 213f, 286, 286f incision method, 185b, 185f, 187b, 187f| incomplete crease, 195b, 195f, 2026, 202f | lid crease placement, 194b, 194f, 210b, 210f, 239b, 239f lid crease procedure, 198b, 198f-199f low crease, 287, 287f moderately high crease, 188b, 188f multiple creases, 197b, 197f, 238b, 238f| nerve palsy, 193b, 193f NTC, 186b, 186f, 2136-215b, 213f-215f, 2206-2216, 220f-221f, 227b, 227f, 2316, 231f, 236b, 236f obliterated crease, 214b, 214f palpebral fissure, 234b, 234f parallel crease, 208b, 208f-209f, 216b, 216f, 225b-226b, 225f-226f, 228b, 228f, 235b, 235f previous crease procedure, 2116, 211f, 2326, 232f pseudo-crease, 200b, 200f-202f ptosis, 186b, 186f, 191b, 191f, 200b, 200f-202f, 2126, 212f, 2156-216b, 215f-216f, 220b, 220f, 233b, 233f "shielded' crease, 2036, 203f skin blanching for, 183b, 183f static crease, 196b, 196f in suboptimal cases, 183-242 trichiasis, 184b, 184f two-stitch technique and, 214b, 214f| upper lid hooding, 2306, 230f removed, 2126, 212f upper lid surgery, 216b, 216f "W-plasty, 222b, 222f Running suture, 109 Scanning electron microscopy, 21-22 Scar, in upper eyelid, 255, 256f, 262 Scarred upper lid, 248f Second vector, 85-93 Semilunar crease, 2f, 8, 9f, 20, 40, 175-177, crease more than 10 mm from lid margin, 176-177, 177f with redundancy of skin, 176f with shortage of skin, 176, 176f-177f surgical correction of, 176f Semilunar shape, high crease of, 163, 163f Septum, orbital, 22, 24-25, 25f, 67, 71-72, 81, 82f, 83, 83b, 86-92, 87b, 103f, 305f 'Shielded' crease, revision of, 203b, 203f Single eyelid, 19-20, 19f-20f, 26, 26f, 39, 268, 275-276, 307, 307f, 309 Japanese Kanji writing for, 1, lf without crease, 2f Skin flap of, 89, 89f removal of, incision method with, revision for, 185b, 185f Skin graft, 255-256 Skin incision, 67, 99 Skin-levator aponeurosis-skin fixation, 67 Skin-levator-skin approach, 68, 68f Skin-levator-skin closure, 91f Skin-orbicularis-orbital septum flap, 82f, 83, Skin-tarsus-skin fixation, 67-68, 69f Skin-tarsus-skin method, 106 Skin-tarsus-skin sutures, 17-18 Small scissoring motions, 256-259, 258f| 'Square-well' excision, revision and, 227 Stab incisions, full-thickness suture technique, 56-58, 56f Stare-and-frown maneuver, 301 Static crease, 68, 69f, 72, 105-106, 196b, absent crease, 186b, 186f, 189b, 189f, 206b. 206f-207f, 233b, 233f, 2376, 237f asymmetric crease, 184b, 184f, 1956-196b, 195f-196f, 223b, 223f 'bifid' crease, 195b, 195f, 1976, 197f crease deformity, 203b, 203f crease enhancement, 240b, 240f crease lid procedure, 1926-193b, 192f-193f crease placement, 194b, 194f, 210b, 210f, external incision crease procedure, 229b, high crease, 1886, 188f, 1906-191b, 190f-191f, 1976, 197f, 2026, 202f incomplete crease, 195b, 195f, 202b, 202f multiple crease, 197b, 197f, 238b, 238f parallel crease, 208b, 208f-209f, 225b- 226b, 225f-226f, 2286, 228f, 2356, pseudo-crease, 200b, 200f-202f semilunar crease, 190b, 190f INDEX 379 "shielded' crease, 203b, 203f static crease, 196b, 196f Suboptimal factors, 159-168 Suboptimal lid crease procedure, findings following, 250 Suboptimal parameters circle of, 165f, 169f etiology and interrelatedness, 169-170 Suboptimal results, 45-46, 110, 160 high crease, 160 interrelated parameters that determine, 161f Sulcus hollow, 16lf excessive manipulation of tissues and, 250 sunken, 13 supratarsal, hollow repair of, 173-175 with/without multiple creases, 173-175 Superficial arcade, 34 Superior tarsal border, 21, 51, 86-87, 89, 89f, 307 see also Levator aponeurosis, to inferior subcutaneous plane Superiorly beveled approach, 258f conditions for, 256 glide space and, 259, 260f revisional blepharoplasty and, 261, 263 Supracanthal web, 3-5 Supratarsal fixation, 70 Supratarsal sulcus, 40, 87, 106-108 deep-set, in Caucasians, 244 sunken, 248, 248f Surgery aesthetic. see Aesthetic surgery cosmetic, double-eyelid, 51-54 double-eyelid crease, 1 Surgical finesse, 108-109 Surgical setup, for blepharoplasty, 75 Surgical steps, in blepharoplasty, 77-83 Surgical techniques beveled approach, 255-263 incision, 256-259 crease formation, 106-108 revisions, requirements in, 255 wound closure, 100 Suture knot, 109 Suture ligation methods, 17, 51-66, 51f, buried orbicularis-aponeurosis, 106 disadvantages of, 53 full-thickness suture technique, 52, 55, 55f with stab incisions, 56-58, 56f non-invasive procedure, 53 transconjunctival intramuscular suture technique, 53f, 59, 59f transcutaneous intradermal and intratarsal suturing technique, 63-64, 63f with twisted needle tracking method, 61-62 transcutaneous intramuscular suture technique, 60, 60f twisted needle and compression method, 61-62, 6lf variations among, 54-64 Sutures for buried suture method. 42 for skin-tarsus-skin closure, 52 Suturing levator aponeurosis to inferior subcutaneous plane, 67 materials, 108, 159 skin-levator-skin, 67 translid, 17

380 INDEX KIM NHUNG Swelling, postoperative, 48-49 Symmetry, facial. see Facial symmetry. Tarsal height, measurement of, 77, 77f Tarsal tilt, 271, 272f-273f concept of, 271-289, 272f-273f, 289b effect on apparent crease height, 271 MRI measurement of, 276, 276f Tarsus Asian with 7mm, 282, 282f| Caucasian with 10 mm, 278, 278f| inferior, 305f upper, 12, 32 Asian with 7 mm, 281, 281f Three zones-pretarsal, 179, 179f Tilted crease height (Tch), 272f-273f, 275-276, 275f, 304, 304f, 316 measurement of, 276, 278, 280-283 Touch-up correction, skin blanching for, 1831 Transconjunctival buried suture method, 297, 298t Transconjunctival intramuscular suture technique, 52, 53f, 59, 59f Transconjunctival suture ligation, complications of, 253 Transcutaneous buried suture method, 297 Transcutaneous intradermal suturing technique, 63-64, 63f Transcutaneous intramuscular suture technique, 60, 60f Transcutaneous intratarsal suturing technique, 63-64, 63f Transcutaneous skin-tarsus fixation, 93f Transcutaneous suture ligation, 253 Transorbicularis vector, 102 Trapezoidal debulking, 99-104, 101f beveled approach and, 261 advantage of, 255 of preaponeurotic platform, 252 Triangular debulking, 99-104 Trichiasis, revision for, 184b, 184f True anatomic crease height, us. apparent crease height, 274 Twisted needle and compression method, Twisted needle tracking method, transcutaneous and intratarsal suturing Two-stitch technique, revision and, 214b, 'Uhh' syndrome, 8 'Unfolded fan type' crease, 52-53 Unipoints, eyelid crease as stringed series of, different points along upper lid crease, 323 variation in function of unipoints, Up-knotting, 337, 336f-337f Upgaze skin traction sign, 251, 251f Upper eyelid crease, 301-308, 302f anatomic definition of, 265, 265f dynamics of, 259-263 incision of, 256-259, 257f position of, 266, 266f scar in, 255, 256f, 262 Upper lid, position of, 266, 266f Upper lid crease, 1-15 points along, 323 Upper lid retraction Asian us. Caucasian, condition of, 284, Caucasian with 2mm, 280, 280f| Upper lid tarsus, Asian with 7 mm, 281, V Valium. see Diazepam (Valium). Vascular supply, 33-35 Vertical excursion, 97 Vicodin, 75 Vicryl sutures, 72, 92, 339-340, 340f| Visual axis angle (Vax), 266-270 downgaze, 266, 269f negative, 269, 269f, 311, 311f neutral, 266f, 270 positive, 266, 268, 268f, 310, 310f| posterior head tilt, 268 upgaze, 266-268, 267f Volume augmentation, with hyaluronic acid, 181 "W-plasty', revisions and, 222b, 222f Westcott spring scissors, 83, 256-259, 257f Western culture, influence of, 20 treatment of inferior edge of, 90, 90b Wound closure, 91-92, 92b, 100 technique, 17, 51 Wound healing management of, 105-111, 105J postoperative care, 109-111 X Xylocaine. see Lidocaine hydrochloride (Xylocaine). Y Y-V-plasty, 32 Z Z-plasty, 52 Zero value Vax, 270, 312, 312f