Phẫu Thuật Tạo Hình Thẩm Mỹ Khuôn Mặt Người Á Đông

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6. Adams WP Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JB Jr.
The rate of warping in irradiated and nonirradiated homo-
graft rib cartilage: a controlled comparison and clinical impli-
cations. Plast Reconstr Surg 1999;103(1):265–270
7. Park JH, Mangoba DC, Mun SJ, Kim DW, Jin HR. Lengthen-
ing the short nose in Asians: key m aneuvers and surgical
results. JAMA Facial Plast Surg 2013;15(6):439–447
8. Erol OO. The Turkish delight: a pliable graft for rhinoplasty.
Plast Reconstr Surg 2000;105(6):2229–2241, discussion
2242–2243
9. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty
surgery. Plast Reconstr Surg 2004;113(7):2156–2171
10. Daniel RK. Grafts. In: Daniel RK. Mastering Rhinoplasty: A
Comprehensive Atlas of Surgical Technique. New York, NY:
Springer; 2004:225–267
References
1. Na cy S, Baker SR. Lengthening the short nose. Arch Oto-
laryngol Head Neck Surg 1998;124(7):809–813
2. Sunwoo WS, Choi HG, Kim DW, Jin HR. Characteristics of
rib cartilage calci cation in Asian patients. JAMA Facial
Plast Surg 2014;16(2):102–106
3. Fry H. Nasal skeletal trauma and the interlocked stresses
of the nasal septal cartilage. Br J Plast Surg 1967;20(2):
146–158
4. Harris S, Pan Y, Peterson R, Stal S, Spira M. Cartilage
warping: an experim ental m odel. Plast Reconstr Surg
1993;92(5):912–915
5. Kim DW, Shah AR, Toriumi DM. Concentric and eccentric
carved costal cartilage: a comparison of warping. Arch Fa-
cial Plast Surg 2006;8(1):42–46

135
11 Management of Alloplast-Related Complications
Eunsang Dhong
The complication rates in using silicone implants vary
from 2 to 7% according to many reports. In other reports, the
removal rate for both Gore-Tex and Medpor was reported
as 3.1%, whereas the removal rate for silicone implants was
signi cantly higher, at 6.5%.2,3 This analysis may be accurate
for simple rhinoplasty, which consists of putting an allo-
plastic implant on the nasal dorsum in less than an hour.
Yet the concept of simple “augmentation rhinoplasty” has
long disappeared in Korea. In East Asians, the complicated
procedure of open septorhinoplasty is frequently per-
formed. As the incidence of complicated septorhinoplasty
increases, the rate of severe complication is also on the rise.
The septal extension graft is very popular for the correction
of short nose in East Asia, increasing the average operation
time. More severe complications have appeared recently
in patients in whom complicated septal surgery was per-
formed with alloplasts inserted simultaneously (Fig. 11.1).
Therefore, analyzing the complication rates of alloplasts
according to past reports is meaningless. The complication
rates for various types of alloplasts should be classi ed
according to the complexity of the operation performed.
The perspective of using an alloplastic implant in com -
plicated septorhinoplasty is completely di erent from that
used for simple dorsal augmentation. In this chapter, the

■Introduction
The most popular alloplasts in Asian rhinoplasty are poly-
meric silicone, expanded polytetra uoroethylene (ePTFE,
or Gore-Tex [W. L. Gore and Associates]), porous high-den-
sity polyethylene (pHDPE, or Medpor), and acellular human
dermis (AlloDerm).1 Silicone is the most widely used, fol-
lowed by Gore-Tex. Medpor is preferred as the strut for tip-
plasty and AlloDerm is used for various types of soft tissue
enhancement. For many decades, the conventional meth-
ods for primary East Asian rhinoplasty have used these
alloplasts for dorsal augmentation. The general consensus
has been that dorsal implantation of silicone or Gore-Tex
is a novel technique for augmentation for a low nasion and
bony dorsum. Besides the probable complications of apply-
ing alloplasts, in many cases of secondary rhinoplasty, the
septum and the concha cartilage have already been used
previously for the donor grafts. Therefore, usually the
only donor site left for the autograft is the rib cartilage.
Sometimes the surgeon has no choice but to use alloplasts
according to the patient’s demand. Even after several revi-
sional operations, patients are still left with the uncorrect-
able nasal deformity.
Pearls
• The perspective of using an alloplastic implant in
complicated septorhinoplasty is completely di erent
from that of using a simple dorsal augmentation.
The location of the patient’s sellion is altered
following implantation. It might be higher or lower
than the original position, and it usually migrates
cephalically from the original site.
• A long-standing implant destroys not only the bony
dorsum, but the cartilaginous dorsum as well.
• The capsule surrounding a silicone implant does not
dissolve even after the implant is extracted. Therefore,
if a patient undergoes multiple revisions, various
layers of the capsule can be seen during surgery.
• A healthy capsule can be reused while it is attached
for the substitution of soft tissue in a secondary
rhinoplasty.
• Contracture around the capsule moves the nasal tip
cephalically, with the patient ending up with a short
nose deformity. All contracted tissues, including
the capsule, should be removed to correct this
deformity.
• Using Medpor (Stryker) as a septal support or as a
spreader graft because extension frequently leads to
septal perforation.
• Multilayered AlloDerm (LifeCell) may form avascular
scar tissue in the center.
• Since an alloplastic implant for rhinoplasty has a
nite lifespan, patients should be informed about
the limited bene ts of using an alloplastic implant.
• Placing an alloplastic implant over an open roof
or dissected upper lateral cartilage from the high
septum may lead to disastrous results.
• Most implant-related complications result from
a shortage of proper soft tissue coverage. In such
cases, implants are often exposed to the nasal cavity
through a concealed mucosal laceration.

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6. The intranasal environment, including the inferior
turbinate and traces of previous submucosal
resection of the septum, should be identi ed
using intranasal inspection including endoscopic
evaluation.
7. A lateral X-ray (nasal bone view) is helpful for the
evaluation of the original location of the nasion and
for measuring the thickness of the implant and the
overlying skin ap.
8. A long-standing implant destroys not only the
bony dorsum but also the cartilaginous dorsum.
For the evaluation of bony destruction under the
implant, computed tomography (CT) including
3D reconstruction is helpful. It is useful for
patients su ering from nasal obstruction and for
patients undergoing secondary septoplasty and/or
turbinoplasty.
9. It is di cult to predict the amount of scarring
around an implant and the severity of the
destruction adjacent to the lower lateral cartilage
(LLC) and upper lateral cartilage (ULC), even after the
evaluation of CT scans. Preoperative predictions may
di er from the actual intraoperative ndings.
An implant on the nasion blurs the actual location of the
sellion. The thickness of the capsule around the implant
also a ects the estimation of the thickness of the overly-
ing skin ap (Fig. 11.2). The location of the patient’s sel-
lion changes after implantation. It might be higher or lower
than its original position, and it usually migrates cephali-
cally from the original site.
Alloplasts used on the nasal tip destroy the adjacent
cartilage, and the tip loses support after the removal of
alloplasts. The tip projection usually cannot be maintained
without grafts due to the weakness of the remaining LLC.
One of the issues in dealing with silicone implants is
the management of the capsule around the implant. There
are two capsules around the silicone implant: the anterior
and posterior capsules (Fig. 11.3). Various layers of capsules
are found in patients who were operated on many times
previously. The capsule surrounding the silicone implant
does not dissolve spontaneously after implant extraction
(Fig. 11.4).
A healthy capsule can be reused while it is attached
for the substitution of soft tissue in a secondary rhino-
plasty. The anterior capsule is left almost intact, so as not
to endanger the viability of the dorsal skin ap. Even the
posterior capsule may be reused if found in a good state for
soft tissue reinforcement.
The entire capsule should be removed in the case of
implant calci cation and capsular contracture. Contracture
around the capsule displaces the implant cephalically, and
results in short nose deformity (see Case 1). Removal of the
capsule and the adjacent soft tissue contracture results in
soft tissue de ciency (Fig. 11.5).
management of various problems in using alloplasts will be
discussed, with special attention to doctors outside of East
Asia and to beginners in rhinoplasty.

■Patient Evaluation
A careful assessment is needed for secondary rhinoplasty,
especially when alloplasts have been applied. The presence
of destroyed structures under the concealed scar tissue is
usually unpredictable. Secondary rhinoplasty takes a dif-
ferent route from the beginning, depending on whether a
patient has alloplastic materials in the nose or not. Most
alloplastic implants inserted previously should be removed
in the secondary operation. The anatomy underlying the
alloplasts has been destroyed; therefore, the amount of
autograft that is needed in reconstruction is usually much
greater than expected. In most cases of East Asian primary
rhinoplasty, an alloplastic implant is used with autografts
at the nasal tip. Thus, in secondary procedures, surgeons
encounter a shortage of donor source for autografts.
Here is the author’s personal checklist for examining
a patient:
1. Do not overlook any previous history of surgery.
2. Through close inspection, make a problem list.
Patients will be more satis ed with the results if
they rst approve the surgeon’s problem list.
3. The hardness of the scar and the soft tissue resilience
around the nasal tip should be assessed with digital
palpation, and this may include pulling down on the
nostrils.
4. The extent of pocket dissection is determined by the
hardness and the extent of scar mass.
5. The caudal intranasal pathology may be determined
by simple rhinoscopic evaluation.
Fig. 11.1 Popular techniques in East Asian rhinoplasty for dorsum
and tip projection. Septal extension graft using septal cartilage
after submucosal resection with dorsal silicone implanting.

11 Management of Alloplast-Related Complications
137
Fig. 11.2 Bone destruction after long-standing dorsal implanting. (a) The rhinion after 5 years’ presence of a silicone implant. (b)
Another patient with a silicone implant for 14 years.
Fig. 11.3 Capsules after dorsal silicone implanting. There are two
capsules around the silicone implant at the anterior (orange) and
posterior (red) sides.
Fig. 11.4 Multiple layers of capsules from quarterly revision.
A capsule does not dissolve spontaneously postoperatively, even
after more than 10 years.
Fig. 11.5 Removal of the capsule and the adjacent soft tissue
contracture. Resection of capsules results in de ciency of soft tis-
sue at the dorsum with thin dorsal skin.
There is no or very little formation of capsule around
Gore-Tex implants. The soft tissue destruction found during
implant removal is less for Gore-Tex than for silicone or Med-
por. The dissection around the Medpor implant is relatively
di cult, due to the soft tissue integration into the pores of
the implant. However, the removal of a Medpor implant
located in the subperichondrial space is easier than for one
located in the supraperichondrial space. The use of Med-
por in the caudal or anterior septum for a septal extension
graft or spreader graft frequently leads to septal perforation
(Fig. 11.6). This is due to the relative physical weakness of
the septal mucosa. Even its application at the membranous
septum for columellar strut is complicated. The nasal tip is
the most mobile portion of the nose. Frequent movement
of the membranous septum cannot overcome the physical
toughness of Medpor, even if the implantation during the
immediate postoperative period was successful.
a
b

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underneath: an exposed nasal cavity beneath the implant
or concealed mucosal laceration after osteotomy of the
nasal bone.

■Surgical Techniques
Correcting Noninfectious Conditions
Deviated Implant
If the pocket is dissected wider than the actual size of the
implant, the implant has a tendency to deviate to one side
of the lateral nasal wall. Moreover, if the implant is longer
In the nasal tip area, rigid scar tissue is frequently
found. In most cases, it is the result of multilayered Allo-
Derm application. The central portion of the scar tissue
lacks vascular supply; hence, an avascular scar mass forms
(Fig. 11.7).
Severe contracture associated with implants is fre-
quently found in patients who underwent complicated
septal surgery simultaneously. Septal support is usually
lost after submucosal resection (SMR), and the gravity and
tension from the alloplastic implant may be troublesome
over an open roof or dissected ULC from the high septum.
Mucocele is one of the frequent pathologic ndings result-
ing from this situation. This may be found in intranasal
or extranasal areas (Fig. 11.8). Most of the mucocele may
be related to the shortage of proper soft tissue coverage
Fig. 11.6 Septal perforation found after removal of intranasal Medpor. (a) Before removal of the Medpor in the left side of the nasal cav-
ity. (b) A huge defect at the high septum.
Fig. 11.7 Common nding in revision tip surgery. (a) Huge scar mass with conchal cartilage on the top of the tip. Underneath it multiple
layers of Alloderm were found. (b) After removal of allografts, the LLCs underneath were destroyed to some extent.
a
b
a
b

11 Management of Alloplast-Related Complications
139
Mobile Implant
If the pocket is dissected subcutaneously at the bony dor-
sum, the silicone implant has a tendency to be mobile.
Precise pocket dissection is performed subperiosteally
for re-implanting. Gore-Tex has a lesser tendency toward
mobility.
Implant Calci cation
In long-standing alloplastic implants, dystrophic calci ca-
tion around the implant and capsule is occasionally found
(Fig. 11.9). The mechanism of calci cation is still under
debate, but degenerated tissue around the capsule (dense
scar) may play a role in calci cation.4 Complete extirpation
of the anterior and posterior capsules is needed, and a der-
mofat graft is substituted for the implant.
Implant Protrusion
Most protrusions result from the usage of amounts of allo-
plastic implants exceeding the threshold of skin tension.
The implant should be removed immediately. If the implant
is transparent but not protruded, then the operation can
be performed as a single stage. However, if the implant is
already protruding, reconstruction should be performed
separately.
than the dissected pocket, the implant is distorted due to
its axial pressure. The underlying discrepancy between
the nasal bony axis and cartilaginous axis results in devia-
tion of the implant even after careful sculpting of the
undersurface.
For correction, thorough bilateral capsulotomy is help-
ful in re-implanting if the capsule has already formed. A
lateral nasal osteotomy and high septal spreader graft are
needed for the discrepancy between the bony axis and
high septal axis. In these cases, replacing the implant with
a dermofat graft is strongly recommended. Secure taping
and immobilization during the immediate postoperative
period are crucial.
Dorsal Skin Redness and Visible Implant
In patients who have very thin skin, the implant may be
visible under direct sunlight. Especially in cases w ith Gore-
Tex, the dorsal contour may be seen through the dorsal
skin. As for the Gore-Tex, due to its lack of capsule forma-
tion, the implant has a tendency to skeletonize and shrink.
The redness of the dorsal skin can remain long after
the operation in thin-skinned patients. Substitution of
implants with dermofat grafts is needed in most cases.
Wrapping the implant w ith autologous super cial tempo-
ral fascia may be helpful. However, wrapping the implant
with allograft is controversial due to poor vascularization
and higher chances of postoperative infection.
Fig. 11.8 Mucocele formation by silicone
implant. (a) Before the surgery. Epidermal cyst-
like protrusion at the right nasal root with blunted
hard nasal tip. (b) After the surgery. The thin
dorsal skin was salvaged after total extirpation
of mucocele. Tip-plasty using conchal cartilage
with dorsal dermal graft was also performed. (c)
Thick peri- and intracapsular mucocele dissected
after removal of the silicone implant.
a
b
c

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Correcting Infectious Conditions
In ammation
Relapsing in ammation is not rare during the immediate
postoperative period. Removal of the alloplastic implant
is usually recommended; however, complications must be
approached on an individual basis. In some cases, delayed
hematoma at the nasion may be misdiagnosed as a uc-
tuation of in ammation, but this can be salvaged by needle
aspiration.
Relapsing edema, in many patients, is due to the unsta-
ble scar (capsule) formation around the implant. Micro-
communication between the external environment and the
intra-capsular area may result in the uctuation of short-
term edema. Relapsing subclinical in ammation does not
drain pus and may improve with the use of broad-spectrum
antibiotics. The decision on removing the implant is a con-
troversial one. Although conservative treatment may be
pursued in mild in ammation, this route frequently results
in unsuccessful results. The relapsing in ammation fre-
quently results in capsular contracture.
Hard Nasal Tip
The application of AlloDerm has been accepted in many
elds of facial plastic surgery as an option for soft tissue
enhancement.5,6 But multilayered AlloDerm on the nasal
tip frequently forms an avascular scar mass. The central
portion of the grafted AlloDerm is found to be avascular
after scalpel incision. The nasal tip will feel very rigid w ith
this scar tissue. After removal of this scar tissue, a large
amount of soft tissue must be replaced.
Mucocele
After humpectomy, there may be a small degree of expo-
sure to the nasal mucosa, and the ingrow th of mucosa into
the dissected pocket may result in mucocele formation
(Fig. 11.10). The endothelial ingrow th or metaplasia of the
capsular pocket is still uncertain and needs to be studied
further.7 Once the mucocele is identi ed, total extirpation
is needed.
Fig. 11.9 Implant calci cation. (a) Removed calci ed silicone implant and
entire capsules. (b) Double-layer dermal graft for the dorsum and cymba con-
cha for the tip. (c) Before the surgery. Transparent implant through the skin
with thinning and telangiectasia is noted. (d) After the surgery.
a
b
c
d

11 Management of Alloplast-Related Complications
141
Correcting Short Nose Deformity
In severe contracture associated with short nose deformity,
the dissection should be made wider (Fig. 11.11). Simulta-
neous resection of the capsule and the contracted soft tis-
sue around the implant should be performed.
In removing the capsule there are two di erent options,
dissecting the anterior capsule rst or dissecting the pos-
terior capsule rst. For total resection of the anterior and
posterior capsules, it is easier to dissect the anterior cap-
sule rst.
To dissect the anterior capsule rst:
1. Perform hydro-dissection between the skin ap and
the anterior capsule.
2. Try to retain the integration of the anterior capsule
up to the most cephalic portion.
3. Remove the implant after the completion of anterior
capsule dissection.
Infected Implant
The rare acute infection in septorhinoplasty manifests as
toxic shock syndrome, sepsis, meningitis, and endocardi-
tis. Drainage of pus through the incisional site is not a rare
complication.
Surgery using alloplasts is complicated and prone to
infection, so prophylactic and postoperative antibiotic
treatment is essential. Irrigation of the pocket intraopera-
tively is more bene cial than treating with antibiotics. Seg-
regating the instruments that were used within the nasal
cavity from those used for pocket dissection is also impor-
tant. Silicone implants that were already in contact with
the skin should be cleansed by saline or alcohol. Gore-Tex is
better prepared by soaking it in betadine.
Implants draining pus cannot be salvaged and should
be removed. If the removal is delayed, the structural defor-
mity may get worse. Reconstruction should be postponed
for at least 6 months to a year until complete resolution.
Fig. 11.10 Mucocele formation after humpectomy with dorsal silicone implant.
(a) Preoperative X-ray reveals previous humpectomy (dots) with migrated L-type
implant with thick scar. (b) Removed mucocele with thick capsules. (c) Before
the surgery. Short nose deformity in patient with mucocele, who su ered from
relapsing edema and drainage of intranasal discharge. (d) After the surgery.
After total extirpation of previous alloplasts, dorsal augmentation with autograft
was performed (dermofat graft with concha cartilage graft).
a
b
c
d

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■Key Technical Points
1. Consider the silhouette of the skin ap rst. If the
skin ap is too thin, it is better to reuse the anterior
capsule. If there is a relatively thick scar band lateral
to the implant, bilateral capsulotomy is needed.
2. Make a dorsal pocket subperiosteally for the
reimplantation.
3. Complete removal of the capsule is needed in cases
of implant calci cation and mucocele.
4. Prepare proper autografts considering the
destruction of the underlying bony and cartilaginous
structures. The amount of autograft is much greater
than expected when total extirpation of the capsule
and contracture is performed.
4. If the cephalic capsule was not dissected completely,
bilateral capsulotomy should be performed to
remove any soft tissue irregularities that may arise
at the nasion lateral to the implant.
5. Dissect the undersurface of the posterior capsule;
this plane is usually adherent to the periosteum.
To reuse the anterior capsule, the posterior capsule is dis-
sected rst, after the removal of the retaining implant. To
dissect the posterior capsule rst:
1. Perform a caudal capsulotomy, then remove the
implant.
2. Irrigate the pocket vigorously.
3. Dissect the undersurface of the posterior capsule;
this plane is usually the subperiosteal space.
4. Bilateral capsulotomy should be performed through
the entire longitudinal plane so as not to create any
lateral band-like deformity.
Fig. 11.11 Correction of short nose deformity. (a) Schematic of dissection:
myotomy of the bilateral transverse nasalis, bilateral subperiosteal dissection
around the bony pyramid, separation between the septum and ULCs, caudal nasal
bone and ULCs, and ULCs and LLCs (the scroll area) was performed incrementally.
(b) Sculpted rib cartilage for septal reconstruction and rectus fascia for wrapping
the diced cartilage. (c) Before the surgery. (d) After the surgery.
a
b
c
d

11 Management of Alloplast-Related Complications
143
physiology of poor ciliary clearance, conchal hypertrophy,
and disruption of the nasal mucosal barrier. Long operation
time, nasal packing, wide dissection, and allo- and auto-
transplantation are other intraoperative factors that pre-
dispose patients to infection.
One report on the correlation of septorhinoplasty and
bacteremia revealed that 15% of 53 cases of septoplasty and
septorhinoplasty showed bacteremia postoperatively, and
16.9% did so after removal of nasal packing.10 In another
study, it was reported that 3% of the patients experienced
bacteremia after septoplasty and 13% after septorhino-
plasty.11 In the perspective of surgical contamination, rhi-
noplasty without septal work may be categorized as a clean
surgery, but septorhinoplasty is categorized as a clean con-
taminated surgery.12
Regarding the prophylactic antibiotic treatment,
a study of 100 cases of revision rhinoplasty revealed 5
patients with severe infection and 9 patients with localized
infection. These patients were not covered by prophylac-
tic antibiotics. On the other hand, in the treated group 1
showed severe infection and 3 showed localized infection.13
Antibiotic packing proved to be e ective in decreasing the
colony two to seven times compared with placebo packing
in a study of 110 cases of septoplasty.14
There are debates on the sensitivity and speci city of
preoperative nasal swabs. The author’s protocol depends on
the results of colonization and sensitivity test in preparing
for complicated septorhinoplasty and rhinoplasty involving
alloplastic implanting. The primary choice of antibiotics in
colonizing MSSA and MSSE are rst- or second-generation
cephalosporins and Augmentin (Beacham Pharmaceuti-
cals). In the cases of MRSE, MRSA, and Enterobacter, apply-
ing susceptible antibiotics has been considered a primary
choice.

■Case Studies
Case 1
In a 38-year-old female, rhinoplasty using an L-type sili-
cone implant had been performed 11 years previously
(Fig. 11.12). She complained of upturned tip and short
nose. The operation was performed and included lowering
the sellion, removing the entire capsule, reconstruction of
the remaining L-strut using costal cartilage, projecting the
dorsal soft tissue pro le with fascia of the rectus abdomi-
nis, and projecting the nasal tip using costal cartilage
(Fig. 11.13). Results are shown in Fig. 11.14.
5. After capsule manipulation, re-drape the skin ap.
If the skin ap is not moving freely, myotomy of the
bilateral transverse nasalis or bilateral subperiosteal
dissection may be performed around the bony
pyramid.
6. If the skin ap looks unnatural due to the scar
band around the tip, careful cross-hatching or
morselization of the anterior capsule may be
performed.
7. If the tripod of the tip is not elongated well after
the posterior capsulectomy, further dissection is
performed. The septum and ULCs, caudal nasal bone
and ULCs, and ULCs and LLCs (the scroll area) are
dissected and separated accordingly (Fig. 11.11a).
8. If the tip is not elongated even after all of the
e orts listed, meticulous vertical scoring at the
subperichondrium of the membranous septum may
be performed. However, this should be done with
caution as it is a very hazardous procedure.

■Infections in Septorhinoplasty
The infection rate for rhinoplasty is reported as 1 to 4%, and
that of septoplasty between 2 and 7%. However, the infec-
tion rate for septorhinoplasty varies from 2 to 14%, depend-
ing on whether it is a primary, secondary, or complicated
septorhinoplasty.8 Complicated septorhinoplasty is surgery
that includes septal reconstruction, osteotomy, submuco-
sal resection, and free transplantation that results in long
operation time. Most East Asian rhinoplasties using allo-
plasts fall into this category.
Perichondritis and septal abscess are not rare in acute
infection. The major concern is the cosmetic outcome after
the destruction of the remaining septal L-strut. The patient
may complain of severe saddle nose deformity and short
nose deformity.
The normal ora of the nasal cavity includes diph-
theroids (Corynebacterium ), micrococci (Staphylococcus
epiderm idis), Staphylococcus aureus, Streptococcus (α, β,
hemolytic), enterococci, yeast (Candida spp.), fungi, etc.
They are not always pathologic.9
Methicillin-resistant Staphylococcus aureus (MRSA),
methicillin-susceptible Staphylococcus epidermidis (MSSE),
and Enterobacter spp. are potentially infectious nasal ora
(PINF), and the routine prophylactic antibiotics are use-
less if the colony sprouts. Some 20 to 60% of the normal
population are reported to have PINF in their nasal cavities.
The predisposing factors of infection are the status of nasal

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Fig. 11.12 Case 1. (a–c) Patient photos before the surgery.
Fig. 11.13 Case 1. Operative procedures.
(a) Original nasion (green arrow) and low-
ered sellion (yellow arrow). (b) Intraopera-
tive removal of L-type silicone. (c) Septal
reconstruction with costal cartilage and
dorsal rectus fascia.
a
b
c
b
a
c

11 Management of Alloplast-Related Complications
145
Case 3
In a 25-year-old female, rhinoplasty using an I-type silicone
implant and an unknown material (presumably AlloDerm)
was performed twice by the same surgeon; 1 and 3 years
previously (Fig. 11.16). The patient su ered from relaps-
ing in ammation and consequent drainage of pus from
the tip. The former surgeon had injected ancillary ller to
the tip, but this resulted in tip deformity. The patient com -
plained of tip deformity and high nasal dorsum. Multilay-
ered capsule was removed and the radix was reduced. The
dorsal silicone implant was changed to a thinner one. Tip-
plasty using the cymba and cavum concha was performed
(Fig. 11.17). Results are shown in Fig. 11.18.
Case 2
In a 42-year-old female, rhinoplasty using I-type silicone
had been performed with a nasal tip onlay graft using con-
chal cartilage 8 years previously. She was dissatis ed with
the dorsal demarcation of the silicone implant and long nose
appearance. The operation included lowering the sellion
by changing the silicone implant and shortening the nasal
length (Fig. 11.15). Additional procedures were reusing the
posterior capsule to smooth out the dorsal demarcation,
and grafting of the folded cymba concha at the caudal sep-
tum as a septal strut to project the nasal tip and to elevate
the subnasale using cavum concha at the dorsum. Folded
Gore-Tex was inserted to augment the alar crease junction.
Fig. 11.14 Case 1. (a–c) Patient after the surgery.
a
b
c

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146
Fig. 11.15 Case 2. (a,b) Before the surgery.
(c,d) After lowering the sellion, elevating the
subnasale, and augmenting the alar crease
junction.
a
b
c
d

11 Management of Alloplast-Related Complications
147
Fig. 11.16 Case 3. (a–c)
Patient photos before the
surgery.
Fig. 11.17 Multilayered capsules, dorsal silicone implant, and
columellar Medpor was removed, and the implant was changed
with a thinner silicone; tip-plasty using the cymba and cavum con-
cha cartilage, and a soft tissue graft using super cial mastoid fascia
were performed.
Fig. 11.18 Case 3. (a–c)
Patient photos after the
surgery.
a
b
c
a
b
c

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7. Swelam W, Ida-Yonemochi H, Saku T. Angiogenesis in m u-
cous retention cyst: a hum an in vivo–like m odel of en-
dothelial cell di erentiation in m ucous substrate. J Oral
Pathol Med 2005;34(1):30–38
8. Georgiou I, Farber N, Mendes D, Winkler E. The role of anti-
biotics in rhinoplasty and septoplasty: a literature review.
Rhinology 2008;46(4):267–270
9. Haug RH. Microorganism s of the nose and paranasal si-
nuses. Oral Maxillofac Surg Clin North Am 2012;24(2):
191–196, vii–viii
10. Kaygusuz I, Kizirgil A, Karlidağ T, et al. Bacteriem ia in sep-
toplasty and septorhinoplasty surgery. Rhinology 2003;
41(2):76–79
11. Okur E, Yildirim I, Aral M, Ciragil P, Kiliç MA, Gul M.
Bacterem ia during open septorhinoplasty. Am J Rhinol
2006;20(1):36–39
12. Cruse P. Surgical infection: incisional wounds. In: Bennett
JV, Brachm ann PS, eds. Hospital Infections. 2nd ed. Boston,
MA: Little, Brown; 1986:423–436
13. Schäfer J, Pirsig W. [Preventive antibiotic administration in com-
plicated rhinosurgical interventions—a double-blind study.]
Laryngol Rhinol Otol (Stuttg) 1988;67(4):150–155
14. Bandhauer F, Buhl D, Grossenbacher R. Antibiotic prophy-
laxis in rhinosurgery. Am J Rhinol 2002;16(3):135–139
References
1. Ferril GR, Wudel JM, Winkler AA. Managem ent of compli-
cations from alloplastic implants in rhinoplasty. Curr Opin
Otolaryngol Head Neck Surg 2013;21(4):372–378
2. Hong JP, Yoon JY, Choi JW. Are polytetra uoroethylene
(Gore-Tex) implants an alternative m aterial for nasal
dorsal augmentation in Asians? J Craniofac Surg 2010;
21(6):1750–1754
3. Peled ZM, Warren AG, Johnston P, Yaremchuk MJ. The use
of alloplastic m aterials in rhinoplasty surgery: a m eta-
analysis. Plast Reconstr Surg 2008;121(3):85e–92e
4. Park CH. Histological study of expanded polytetra uoro-
ethylene (Gore-Tex) implanted in the hum an nose. Rhinol-
ogy 2008;46(4):317–323
5. Gurney TA, Kim DW. Applications of porcine derm al colla-
gen (ENDURAGen) in facial plastic surgery. Facial Plast Surg
Clin North Am 2007;15(1):113–121, viii
6. Bee YS, Alonzo B, Ng JD. Review of AlloDerm acellular hu-
m an dermis regenerative tissue matrix in m ultiple types
of oculofacial plastic and reconstructive surgery. Ophthal
Plast Reconstr Surg 2015;31(5):348–351

III
Blepharoplasty

151
12 Double-Eyelid Surgery: Nonincisional Suture
Techniques
Jin Joo Hong and Hae Won Yang

■Introduction
Double Eyelid and Single Eyelid
One of the most important functions of the upper eyelid is
to alternately protect and expose the eye with its repetitive
shutter-like excursion movement. Along with the alternat-
ing motion of the closing and opening phases, the upper
eyelid changes its external shape continuously. In the clos-
ing phase, the lid is extended w ide to cover the cornea and
bulbar conjunctiva of the eyeball; in the opening phase, the
lid is retracted to expose them. During the opening period,
the enveloping cover (skin and palpebral conjunctiva)
should be folded to eliminate redundancy in temporary cov-
erage. Although conjunctival folding is not observed when
looking at the face, the pattern of skin fold formation in the
opening phase of the upper eyelid is characteristic of each
East Asian individual.1 This pattern and manner of folding
the outer skin determines the shape of the eyes, particu-
larly in the upper border of the palpebral aperture. Usually,
the skin is folded at the middle of the eyelid, and the edge
of the skin fold is located above the eyelash to expose the
cornea completely in the fully opened state. The edge of the
skin fold and the eyelid margin with the eyelashes parallel
to each other form the upper border of the palpebral aper-
Pearls
• The pattern of skin fold formation in the opening
phase of the upper eyelid is characteristic of the
East Asian individual. In a double eyelid, the upper
border of the eye consists of two outlines, as if the
upper eyelid were composed of dual layers.
• The creation of an arti cial connection of skin (anterior
lamella) and levator (posterior lamella) at a higher level
is the main feature of the double-eyelid procedure.
• Nonincisional suture ligation creates a fold without
dissection. It is a simple, noninvasive, and e cient
technique to make a double fold, but it has also
many contraindications. For example, revision
blepharoplasty is performed to reduce the height
of the fold, especially after a previous incisional
blepharoplasty.
• The nonincisional suture technique needs to be
modi ed considering various factors such as pu y
eyelid, weak levator function, and exophthalmos. For
a pu y eyelid, the septal fat should be removed as
much as possible, and the new crease line designed
to be as low as possible. Too high a fold may hinder
the full opening of the aperture and yield opening
discomfort, especially in a subclinical or clinical
ptotic eyelid. If exophthalmos is prominent, the line
of the crease should be lowered more than usual to
avoid an excessively high fold.
• The lid margin may be closed (“inside fold”) or
open (“outside fold”) at the medial end according to
whether or not the two upper outlines of the eye,
the edge of the skin fold, and the true lid margin
with the eyelashes are joined together medially.
• The middle portion of the double fold should be
su ciently higher than the medial and lateral
portions in the closed state to prevent straightening
of the double fold when the eyes are open.
• After preoperative design, ve punctures or small
slits should be made with a needle or no. 11 blade.
A 7–0 nonabsorbable suture is passed through the
skin to the upper margin of the tarsus and returned
through the same site of the tarsus to the skin. Then
the lid skin is xed on the tarsal plate.
• When removing the septal fat, the position of the
fat must be considered. The septal fat moves to an
upper and lateral area in the supine position.
• For Müller muscle tucking, 7–0 nylon thread is
introduced through the skin to the upper margin of
the tarsus. The suture is passed through the tarsus
to the point of the conjunctiva near the superior
fornix and returned through the same point on the
conjunctiva to the tarsus, tucking the Müller muscle.
The suture exits through the tarsus to the skin and is
knotted to tighten the thread.
• When the suture passes through the tarsus, the
suture may appear on the conjunctival side, which
can induce a foreign body sensation and severe pain.
If the patient complains of a foreign body sensation,
the eyelid is everted and the tarsal plate is carefully
scrutinized.

III Blepharoplasty
152
anatomy, the inverted triangle-shaped upper eyelid has a
thick upper portion with three distinctly separated lamel-
lae and a thin distal lid margin in which the anterior and
posterior lamellae are attenuated and condensed rmly
together (the skin, orbicularis oculi muscle, and tarsus).
The intervening orbital septum and orbital fat (middle
lamellae) extend only to the fusion line, which can be iden-
ti ed as a skin crease on the outer surface. The condensed
distal lid margin is attached to the levator mechanism
(levator aponeurosis, superior levator palpebralis muscle,
and Müller muscle) and actively retracts at the beginning
of the opening phase (Fig. 12.3). Meanwhile, the anterior
and middle lamellae above the fusion line (transverse
skin crease) are passively folded according to the opening
movement.
With the superior levator palpebralis muscle contract-
ing, the distal lid margin (red-colored surface) directly con-
nected to the levator mechanism begins to retract upward,
leaving the upper anterior lamella (above the fusion line,
green- and blue-colored surface) static in situ. As the
degree of opening increases, the anterior lamella just above
the crease is passively lifted from its distal end (green-
colored surface). At this level, the transverse skin crease
becomes prominent and is folded further as opening pro-
ture (double eyelid) together. In a double eyelid, the upper
border of the eye consists of two outlines as if the upper
eyelid were composed of dual layers (Fig. 12.1).
In contrast, the single eyelid has only one border,
because the skin fold is formed below the lid margin. The
edge of the skin fold hides the real lid margin and pushes
the eyelashes from above in the opening phase (Fig. 12.2).
Compared with the double eyelid, the palpebral aperture
is reduced by the lower skin fold. The single-lined upper
border is a unique feature of East Asian individuals (Korean,
Chinese, Japanese, and Mongolian), while the double line is
the most prominent eyelid fold pattern in Caucasian, Afri-
can American, and South Asian individuals.
Anatomy of the Upper Eyelid
The upper eyelid is a layered structure, divided into the
anterior, middle, and posterior lamellae. The anterior
lamella is composed of the skin and underlying orbicularis
oculi muscle. The posterior lamella consists of the tarsus
and underlying conjunctiva. The middle lamella consists of
the orbital septum and fat separating the orbital contents
from the preseptal structures.2 In the sagittal sectional
Fig. 12.1 Typical double eyelid in South Asian
women. In a double eyelid, the upper border
of the eye consists of two outlines because the
edge of the transverse skin fold is formed above
the lid margin. The edge of the skin and lid mar-
gin create the dual-lined upper border of the
eye, and the eye is fully exposed when opened.
Fig. 12.2 Typical single eyelid of East Asian
women. (a) In the opening phase, the skin is
folded at a level too low, and the skin crease is
hidden under the upper part of the palpebral
aperture and (b) the eyelashes get pushed
down. In comparison with the double eyelid,
the palpebral aperture looks reduced by the
distal skin fold, which lies at a lower level.
a
b
a
b

12 Double-Eyelid Surgery: Nonincisional Suture Techniques
153
the fold lies above the lid margin and does not obstruct the
normal visual eld (Fig. 12.4).3,4
Nonincision Suture Ligation for
Double-Eyelid Formation
The most important anatomic di erence between a single
and double eyelid is the level of the lid crease and skin fold
formation, which is the result of the thinning and fusion of
the anterior and posterior lamellae. In a double eyelid, the
skin fold lies within the lid above the eyelash in a relaxed
forward gaze, because the fold-forming lid crease is well
de ned and su ciently high. The creation of an arti cial
connection of skin (anterior lamella) and levator (posterior
lamella) at a higher level is the main feature of the double-
eyelid procedure.
Traditionally, the procedure can be divided into two
major categories: nonincisional suture ligation (buried
suture technique) and the external-incision technique.
While the nonincisional technique connects the skin and
the deeper active levator mechanism with a simple thread
loop, the external-incision technique consists of reducing
the volume of both lamellae and xing them together with
scar adhesion. The external-incision technique also requires
a buried suture to connect the skin and levator mechanism,
so a suture loop ligation is common to both techniques.
Regardless of the use of an incision, a buried suture loop in
the lid is an essential part of double-eyelid creation. In fact,
the nonincision suture ligation technique entails forming a
fold with suture ligation without dissection. Various surgi-
cal approaches for nonincisional suture ligation have been
reported. The nonincision suture ligation technique has
been developed for correction of blepharoptosis as well as
for the simple formation of the double-eyelid fold. From the
conjunctival side, the retractor can be plicated to increase
the tension of the levator mechanism.
gresses. With further opening, the distal skin of the ante-
rior lamella (green) is ipped up and enters just behind its
upper skin (blue-colored surface) to create a fold.
In the single eyelid, the middle lamella is well devel-
oped and abundant orbital fat extends to a lower level.
Therefore, the anterior and posterior lamellae fuse at a
lower level than they do in a double eyelid, and the height
of the condensed distal lid margin (red) is too low. As a
consequence, the skin of the anterior lamella is folded at a
much lower level (lower tarsal crease) in the opening phase
and hides the entire lid margin, including the eyelashes.
Furthermore, the upper portion of the palpebral aperture
is partially eclipsed by the skin fold, despite the full open-
ing of the eyelid. Hence, in a severe case, the frontalis acts
to lift the eyelid skin fold to provide adequate vision, as in
a patient with a blepharoptosis. Meanwhile, in a double
eyelid, the fold is formed at a higher level and the edge of
Fig. 12.3 Opening process of the upper eyelid. (a) In the rest-
ing phase, the outer skin of the upper eyelid is expanded. (b) At
the beginning of eyelid opening, the skin just above the crease
(green zone) is rolled up with the lid margin elevated. (c) In the
fully opened phase, the green zone skin is completely behind the
upper skin.
Resting phase
Opening phase
Resting phase
Opening phase
Single eyelid
Double eyelid
Fig. 12.4 Single and double eyelid. The most important anatomic di erence between a single and double eyelid is the level at which the
fusion between the anterior and posterior lamellae occurs, and thus the level at which the anterior skin is folded. The pattern of the skin
fold in the opening phase determines the shape of the eye. (a) In a single eyelid of an Asian, the skin fold is formed at a lower level and the
folding skin hides the real lid margin and eyelashes as well as the upper part of the palpebral aperture. (b) In contrast, the skin fold of a
double eyelid lies at the upper level and the fold edge is formed far above the eyelashes.
a
b
c
a
b

III Blepharoplasty
154
the center of the eyeball. If exophthalmos is prominent, the
line of the crease should be lowered more than usual to
avoid an excessively high fold.
Shape of the Lid Margin Exposure
Double-eyelid surgery not only opens the hidden upper
portion of the palpebral aperture but also changes the
upper border from having a single to a double outline. The
newly formed outer line is determined by the edge of the
fold rather than by the supratarsal crease itself. The lid
margin (skin between the fold edge and the lid margin) is
the fringe of the eye that is an attractive feature and a good
place to add makeup to make the eye appear wider. There-
fore, one of the main purposes of double-eyelid surgery is
to obtain an adequate and beautiful lid margin. Because the
lid margin changes according to the viewing direction or
degree of openness in a gaze, it should be designed during
a relaxed forward gaze. The lid margin is the area between
the height of the supratarsal crease and the vertical depth
of the fold. The fold is deepest at the midpoint due to the
maximal vertical opening of the aperture, which means
that the lid retracts higher in the middle than at both sides.
Therefore, the middle portion of the crease line should be
adequately elevated to avoid a narrow lid margin in the mid-
dle (Fig. 12.5). The shape of the lid margin is determined by
the edge of the fold and the distal border of the lid.
Inside and Outside Folds
The lid margin may be closed (“inside fold”) or open (“out-
side fold”) at the medial end according to whether or not
the two upper outlines of the eye, the edge of the skin
fold and the true lid margin with the eyelashes, are joined
together medially. In an eye with an inside fold, the trans-
verse skin fold is conjoined to the epicanthal fold. To open
medially, the fold crease should be located separately and
higher than the start of the epicanthal fold. Currently, one
of the most popular lid margin shapes is midway between
the inside and outside folds. However, there cannot be a
position midway between open and closed. Therefore,
in the “in/out” or “neutral” fold, the medial side is open
with a small gap, but the height of the double lid gradu-
ally increases laterally. Thus, it is actually an outside fold,
but because of its minimal opening medially and increas-
ing height laterally, it can be seen as an inside fold from a
distance (Fig. 12.6).
Revision Case
Because the anterior lamella just above the fusion line is
passively folded by the retraction of the posterior lamella,
even an unnoticeable subcutaneous scar can disrupt the
continuity of the even skin fold. In a severe case, the scar

■Patient Evaluation
With the exception of severe blepharoptosis with weak
levator function or extremely thick lid soft tissue, the
nonincision suture ligation technique can be applied to
transform the lid from single to double in most patients.
However, the procedure is selected based on the speci c
requirements of the case and the anatomic and functional
conditions of the patient.
Pu y Eyelid
A stable adhesion of the previously separated anterior and
posterior lamellae at a higher level is the primary goal of
double-eyelid surgery. The intervening loose voluminous
tissue (orbicularis oculi muscle and preseptal and septal
fat) between the skin (anterior lamella) and levator mecha-
nism (posterior lamella) is the main hindrance to the fusion
of the lamellae. Hence, excessive soft tissue in the upper
eyelid is an unfavorable factor for double-eyelid formation
using either the external-incision or nonincisional suture
ligation procedure. While the septal fat can be removed
with a small incision before suture ligation (partial incision
suture ligation), the preseptal fat and orbicularis oculi mus-
cle cannot be reduced w ithout a full-length incisional tech-
nique. For a pu y eyelid, the septal fat should be removed
as much as possible, and the new crease line should be
designed to be as low as possible in a nonincision suture
ligation procedure (strictly speaking, this should be named
“partial incision suture ligation” because the fat is removed
through a small incision before suture ligation).
Weak Levator Function
Although Müller muscle tucking can resolve mild blepha-
roptosis, it is contraindicated in most cases of severe bleph-
aroptosis with a loose levator aponeurosis that requires
direct levator advancement. The creation of a higher fold-
ing crease increases the load of the dynamic part of the lid.
Furthermore, the upper portion of eyelid skin is thicker and
requires more force to fold. Too high of a fold may hinder
the full opening of the aperture and yield opening discom -
fort, especially in a subclinical or clinical ptotic eyelid.
Exophthalmos
Eyelid excursion is in uenced by the anatomy of the neigh-
boring structure, relative volume of the fat, depth of the
orbit, degree of eyeball protrusion, and other factors. The
suspension of the skin fold is tighter in exophthalmos than
in enophthalmos because the eyeball pushes the lid for-
ward. The edge of the fold is relatively high and the under-
lying lid margin is exposed at a higher level, especially in

12 Double-Eyelid Surgery: Nonincisional Suture Techniques
155
Suture Material
Because no dissection is performed during nonincisional
suture ligation, the adhesion of the anterior and posterior
lamellae is maintained only by the tensile strength of the
suture material and knot clamping. Therefore, the choice
should be excised (using an incisional technique) or the
designed line should be put higher than the scar (using a
nonincisional technique) to keep the skin just above the
crease uniform. For this reason, the nonincisional method
cannot be used to reduce the height of the fold, especially
after a previous incisional blepharoplasty.
Fig. 12.5 Di erent shapes of lid margin. (a) The shape of the lid margin is determined by the edge of the fold and the distal border of
the lid. If the middle portion of the lid margin is too wide, the shape of the eye looks too round or oval-shaped. (b) If the middle portion
of the lid margin is too narrow, the eye appears as though it is frowning. (c) The upper and lower sides of the lid margin should be parallel
or gradually grow farther apart.
Fig. 12.6 Three types of double fold. (a,b) The lid margin may be closed (“inside” fold)
or open (“outside” fold) at the medial end according to whether or not the two upper
outlines of the eye, the edge of the skin fold and the true lid margin with the eyelashes,
join together medially. (c) In the “in/out” or “neutral” fold, the medial side is open with a
small gap, but the height of the lid margin is gradually increasing laterally. (d) Design of
the outside fold (red), in/out or neutral fold (yellow), and inside fold (blue).
a
b
c
a
b
c
d

III Blepharoplasty
156
vent straightening of the double fold when the eyes open.
If the patient has thin eyelid skin and good levator func-
tion, a higher double fold is possible. On the contrary, if the
patient has thick eyelid skin and poor levator function, it is
better to make the double fold line lower because it tends
to look unnatural if a higher fold is made in such a patient.
The ve markings vertical to the double fold line interrupt
and divide this line into four areas (Fig. 12.7). The medial
end should be at or immediately lateral to the upper end of
the epicanthal fold. The lateral end should be at the lateral
end of the palpebral ssure.
This surgical procedure is usually performed under
local anesthesia using 2% lidocaine mixed with 1/100,000
epinephrine and mild intravenous sedation. For skin anes-
thesia, shallow insertion of a 26-gauge needle into the sub-
dermal layer is performed, because if the needle is inserted
deep, bleeding and swelling may occur and the surgeon
may not be able to predict the outcome of surgery. The
conjunctiva is also anesthetized with lidocaine injection.
A 0.5% ophthalmic solution of proparacaine hydrochloride
is used to anesthetize the cornea. A plastic cornea protec-
tor can be used to protect the eyeball. The surgical steps
of the nonincisional suture technique for a double-eyelid
operation are shown in Fig. 12.8. During local anesthesia,
the points previously marked with gentian violet are punc-
tured with the 26-gauge needle. These temporary mark-
ings can indicate the entrances and exits of the 7–0 nylon
suture. Instead of a puncture, a small stab incision can be
made with a no. 11 blade.
If the orbital septal fat volume is very bulky and the
upper eyelid appears pu y, septal fat removal can be per-
formed through a small incision on the lateral portion of
the double fold. While holding the septum with toothed
forceps, a small incision is made on the septum with sharp
scissors, and the septal fat is extracted with smooth forceps.
of suture material is important. Frequently used nylon
(polyamide, 7–0 nylon) is a nonabsorbable, mono lament
suture material. Although a mono lament nylon suture has
a great memory to return to its previous shape and a pro-
clivity for knot slippage, it has a low infection rate. Undyed
translucent nylon is preferred for a nonincision suture liga-
tion procedure, because undyed nylon has a greater tensile
strength than the dyed form, which includes impurities.
However, translucent suture material is hard to nd in a
revision procedure.5,6
Choice of Needle
Needle choice depends on the anticipated location of the
suture loop in the eyelid tissue. Connecting loop(s) can be
made by perforating the full thickness of the lid or by par-
tial tagging of the lid skin to the tarsus. For a perforation
procedure, a long, circular needle is convenient (24 mm
round ⅜ circular needle with 7–0 white nylon). However,
a smaller needle is preferred for the partial tagging proce-
dure. A triangular cutting needle can damage large vessels,
so a round or rectangular cutting needle is chosen.

■Surgical Techniques
Nonincisional Suture Technique of a
Double-Eyelid Operation
It is better to design a double eyelid with the client in an
upright position because the shape of the eyes and the
double fold can change in a supine position. The surgeon
can better predict the surgical outcome for the patient in
an upright position.
There are three classi cations for the starting point of
the double fold. An inside fold is one in which the double
fold line starts below the epicanthal fold. It tends to be more
natural but the eyes can look smaller than with other forms
of fold. An outside fold is one in which the double fold line
starts above the epicanthal fold. The eyes look bigger than
with an inside fold, but the appearance may be unnatural. A
neutral fold or in/out fold is a type of outside fold in which
the starting point is lower than it is for the classical outside
fold. It looks natural and the eyes look bigger; many Asian
clients prefer this fold (Fig. 12.6d).7
The preoperative design of the double fold line should
be marked with a sharp surgical marking pen along the
natural curvature of the eyelid skin. Generally, the mean
height of a double fold is 6 to 8 mm from the eyelash, and
the height ranges from 4 to 10 mm. The range of tarsal
width in Asian individuals is usually 6 to 8 mm, so a suture
that penetrates the skin can be xed on the tarsal plate.8
The middle portion of the fold should be higher than
the medial and lateral portions in the closed state, to pre-
Fig. 12.7 Preoperative design of the nonincisional suture tech-
nique. The midportion of the fold should be higher than the medial
and lateral portions in the closed state to prevent straightening of
the double fold when the eyes open.

12 Double-Eyelid Surgery: Nonincisional Suture Techniques
157
of the skin side exceeds that of the conjunctival side, the
double fold will be deeper and the eyelashes will be everted.
If the skin side is shorter than the conjunctival side, the skin
below the double fold will sag. After the suture exits the
hole of the skin again, it is passed through the subdermal
layer to the next skin puncture, with the procedure repeated
on each puncture. The sequence of the procedure can be
changed. Numbering skin entry points as 1 through 5 from
medial to lateral, the authors proceed in the order 5–3–1–
2–4–5. When the septal fat is removed, the order proceeds
as 4–5–3–1–2–4 (Fig. 12.9). The ends of the sutures are tied
at the lateral position and the knot is buried within the sub-
dermal layer. The knot can be placed in any location, but
the central area is avoided because the knots can be visible
there. The skin incision is closed with nylon 7–0, or may not
need to be closed when the incision is very small.
The patient opens his/her eyes and the surgeon checks the
shape of the double fold and the symmetry of both eyes. An
ice bag is applied to the periorbital area for 2 days to reduce
swelling. The skin stitches are removed 3 to 5 days later.
The extracted fat is coagulated with an electrical coagulator
and then cut. Meticulous coagulation is necessary because
there are small vessels within the septum.
A 7–0 mono lament nonabsorbable suture with a
tapered 24-mm ⅜c needle is used. A round needle suture
is used because an angled needle may cut the nylon acci-
dentally. The suture is passed through the skin to the upper
margin of the tarsus and returned through the same site
of the tarsus to the skin. Then the lid skin is xed on the
tarsal plate.
When the suture is being passed, the upper eyelid is
everted with a wide smooth forceps, or another type of
forceps for the tarsus. There are many types of forceps for
handling the tarsus. To penetrate the tarsus in the shortest
distance, the needle should be vertical to the tarsus. If the
needle is not vertical to the tarsus, the soft tissue beneath
the skin can be xed to the tarsus and unwanted dimpling
will develop. The distance from the eyelid margin to the
hole in the skin side should be similar to the distance from
the eyelid margin to the conjunctival entrance. If the length
Fig. 12.8 Surgical procedures for the nonincisional suture technique. (a) After local anesthesia using 2% lidocaine mixed with 1/100,000
epinephrine and mild intravenous sedation, the points previously marked with gentian violet are punctured with a no. 26G needle. These
temporary tattoos can be the entrance and exit points for 7–0 nylon sutures. (b) Septal fat removal can be done through a small incision on
the lateral portion of the double fold. (c) The suture is passed through the skin to the upper margin of the tarsus. As the suture is passed,
the upper eyelid is everted with wide smooth forceps or other forceps for the tarsus. (d) The suture needle is returned through the same
site at the tarsus to the skin. (e) The suture is passed through the subdermal layer to the next puncture of the skin. (f) The same procedure
is repeated on the following punctures.
a
b
c
d
e
f

III Blepharoplasty
158
2. When removing the septal fat, the position of the fat
must be considered. The septal fat moves to an upper
and lateral area in the supine position.
3. During the suture pass through the tarsus, an
unwanted knot can be made on the conjunctival side
that can induce a foreign-body sensation and severe
pain. If the patient complains of the sensation of
a foreign body, the eyelid is everted and the tarsal
plate is observed rst.
4. For transconjuntival Müller tucking, an assistant
should pull the traction suture and push the eyelid
in the opposite direction with a cotton swab to make
the procedure easier to perform.
5. It is best if the point of the conjunctiva at which the
suture exits is near the superior fornix.

■Complications and
Their Management
Relapse
Because there is no tissue adhesion between the anterior
and posterior lamellae of the upper eyelid, unlike the case
in an incisional blepharoplasty technique, the connection
between the two structures depends only on the suture
loop in a nonincisional technique. A suture loop inevitably
loses its hold on tissues over the postoperative months and
the amount of tissue held by each loop gradually reduces
over time. Hence, the xation between the two lamellae
loosens, even with a tight relationship at the beginning.
Although moderate loosening is a normal, natural drift
toward an equilibrium, excessive loosening e aces the skin
fold or makes multiple skin folds in other creases (relapse).
This relapse is the main drawback of the nonincision suture
ligation blepharoplasty technique. Various authors have
Transconjunctival Müller Tucking
In the unilateral or bilateral mild ptosis case, transconjunc-
tival Müller tucking can be done with the double-eyelid
operation (Fig. 12.10). The preoperative design of the dou-
ble fold line should be performed along the natural skin
crease. The locations of Müller tucking sutures are marked
on the vertical line of the medial and lateral limbi. The sur-
gical procedure is usually performed under local anesthesia
using 2% lidocaine mixed with 1/100,000 epinephrine and
mild intravenous sedation. Small incisions are made with
a needle or no. 11 blade on points that the needle would
penetrate. Everting the upper lid, a traction suture is made
on the upper margin of the tarsus with nylon 5–0.
For Müller muscle tucking, 7–0 nylon thread is intro-
duced through the skin to the upper margin of the tarsus.
The suture is passed through the tarsus to the point of the
conjunctiva near the superior fornix and returned through
the same point on the conjunctiva to the tarsus, tucking the
Müller muscle. The suture exits through the tarsus to the
skin and is knotted to tighten the thread. The same proce-
dure should be performed at other sites of Müller muscle
tucking, and then the traction suture is removed. Next, the
common procedure for the double fold is performed. The
knots of the threads should be buried within the skin so
that they are not exposed.9,10

■Key Technical Points
1. In the design of the double fold, the height of
the middle portion of the double fold should be
su ciently higher than the medial and lateral
portions in the closed state to prevent straightening
of the double fold when the eyes are open.
Fig. 12.9 Typical sequence of needle passes in the nonincisional suture technique. Numbering skin entry points as 1 through 5 from
medial to lateral, the authors proceed in the order 5–3–1–2–4–5. The ends of the sutures are tied at the lateral position and the knot is
buried within the subdermal layer.

12 Double-Eyelid Surgery: Nonincisional Suture Techniques
159
the crease becomes gradually deeper as the globe exposure
widens. Because the fold hangs over the skin crease, a lin-
ear shadow of the fold appears parallel to the crease and
fold. At this time, unless the crease is parallel to the relaxed
skin tension line (RSTL), multiple partial oblique folds can
be created, disrupting the continuity of this fold shadow.
Unwanted oblique folds near the crease during the opening
movement diminish the natural look of the double-eyelid
crease. The crease should be designed perfectly parallel to
the RSTL in any case.
Although the irregularity of the skin folds can be
prominent at the site of the suture loop in the immediate
postoperative period due to local pinched tissue, the skin
can recoil and the irregularity fades away within 3 months.
However, dimpling in an area of scar tissue cannot easily
fade away because scar tissue has less recoiling power. In
addition, a scar in the skin prevents even fold formation,
so the scar should be located below the skin folding crease
(Fig. 12.11).
reported their own relapse rates, but these are not clinically
meaningful. In patients with unfavorable features (e.g.,
those with pu y eyelids), the rate of fold relapse increases.
The most common cause of relapse is a suture loop
holding tissue with less brous components. Theoretically,
the surgeon should distribute the tension of each loop
evenly, and include more brous tissue in each loop as a
supporting structure. Another cause of relapse is weakness
of the suture material. Pure nylon is translucent and very
extensible, but colored nylon mixed with pigment loses its
extensibility and breaks easily. However, a simple suture
material problem occurs infrequently.11,12,13
Irregular Fold
Fold formation of the upper lid skin during eye opening
from the closing phase proceeds dynamically and gradu-
ally. At the beginning of the opening, the skin fold along
Fig. 12.10 Transconjunctival Müller tucking. (a) Preoperative design for transconjunctival Müller tucking. The points 2 and 4 are for Mül-
ler tucking suture. The points 1, 3, 5, and 6 are for the double fold procedure. (b) A traction suture is located on the upper margin of the
tarsus. (c) The suture is passed through the skin to the upper margin of the tarsus. (d) The Müller tucking suture is passed through the
tarsus to a point of the conjunctiva near the superior fornix. The surgeon’s assistant should pull the traction suture and push the eyelid in
the opposite direction using a cotton swab to facilitate the procedure. (e) The Müller tucking suture returns through the same point of the
conjunctiva to the tarsus to tuck the Müller muscles.
a
b
c
d
e

III Blepharoplasty
160
Lid Margin Tension Eversion
The heights of the suture penetration sites from the lid mar-
gin on the outer and inner surfaces can di er. If the level at
the posterior lamella (aponeurosis or tarsus) is higher than
that at the anterior lamella (skin), the skin below the crease
is stretched. Within a normal range, mild stretching of the
skin looks good, with the eyelashes lifting up slightly. How-
ever, in a severe case, the stretched lower skin becomes too
thin while the pushed upper skin becomes thick. An abrupt
di erence in skin thickness along the crease looks unnatu-
ral and arti cial (Fig. 12.12a). In addition, the eyelashes
might be everted to a large extent, and the hidden conjunc-
tival mucosa might appear abnormal (Fig. 12.12b). Tension
is usually relieved with time, unlike the situation with the
incision technique. However, the prospective crease would
be lowered and would undulate into an unnatural curve
(Fig. 12.12c). Achieving adequate skin tension of the ante-
rior lamella is important in making a double-eyelid crease.
Stitch Abscess and Exposure of the Knot
Because mono lament nylon has a long memory and poor
knot security, it should be tied in multiple square knots to
prevent slipping or knot loosening. The multi-tied bulky
knot should be buried in an appropriate deep site to avoid
palpation or exposure. Because the central portion of the
eyelid is thinner than the medial and lateral portions due
to the oval shape of the globe protrusion beneath the upper
eyelid in the closing phase, a knot in the midportion can be
easily noticeable and is exposed much more readily than if
it were in another location. Choosing a deep location for the
knot is also important, and it should be placed beneath the
orbicularis oculi muscle layer. Improper position and depth
of knots may cause stitch abscess or exposure, in which
case all linked stitches should be removed.
Strangulation
The suture loop holding the tissue prevents normal blood
circulation and may cause venous or lymphatic congestion.
Simple lid margin congestion without tissue injury does
not cause long-term problems, although it causes tempo-
rary blepharoptosis or problems with eye opening in the
immediate postoperative period. It can delay recovery with
the weight of the lid margin increased. The amount of tis-
sue encircled by loops should be minimal and the tension
should be distributed evenly.
Fig. 12.11 Prominent scar. Dimpling in an area of scar tissue does
not easily fade away because scar tissue has less recoiling power. In
addition, a scar in the skin prevents even fold formation, so the scar
should be located below the skin folding crease.
Fig. 12.12 Tension eversion. (a) Lid margin skin tension should be adequate and considered in the design at the beginning of the proce-
dure. An abrupt di erence in skin thickness along the crease looks unnatural and arti cial. (b) In addition, the eyelashes might be everted
to a large extent, and the hidden conjunctival mucosa might appear abnormal. (c) The prospective crease would be lowered and would
undulate into an unnatural curve.
a
b
c

12 Double-Eyelid Surgery: Nonincisional Suture Techniques
161
Case 2: Transconjunctival Müller
Tucking
A 35-year-old female patient presented with ptosis of the
left eyelid and an asymmetric double fold (Fig. 12.14a).
She had had an incisional double-eyelid operation 1 month
previously. Transconjunctival Müller tucking was done on
the left side only. The height of the double fold was not
changed. After 2 weeks, ptosis of the left side resolved and
a symmetric double fold was achieved (Fig. 12.14b).

■Case Studies
Case 1: Nonincision Suture Ligation
for Double Fold Formation
A 25-year-old female patient with a low and asymmetric
double fold wanted a neutral or outside fold and a higher
double fold (Fig. 12.13a). Septal fat removal and noninci-
sion suture ligation for double-eyelid formation was per-
formed. Symmetric and slightly higher outside folds were
observed after 6 months (Fig. 12.13b).
Fig. 12.13 Case 1. Nonincision suture ligation for double fold for-
mation. (a) This 25-year-old female patient with a low and asym-
metric double fold wanted a neutral or outside fold and a higher
double fold. (b) Six months after septal fat removal and nonincision
suture ligation, she has a symmetric and higher double fold.
Fig. 12.14 Case 2. Transconjunctival Müller tucking. (a) A 35-year-
old female patient with ptosis of the left eyelid and asymmetric
double fold. She had an incisional double-eyelid operation 1 month
previously. (b) Two weeks after transconjunctival Müller tucking on
the left side only, the ptosis of the left side and asymmetry of the
double fold have resolved.
References
1. Zide BM, ed. Surgical Anatomy around the Orbit: The Sys-
tem of Zones. Philadelphia, PA: Lippincott, Williams &
Wilkins; 2006
2. Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids.
Facial Plast Surg Clin North Am 2005;13(4):487–492, v
3. Fralick FB. Anatomy and physiology of the eyelid. Trans Am
Acad Ophthalm ol Otolaryngol 1962;66:575–581
4. Reid RR, Said HK, Yu M, Haines GK III, Few JW. Revisiting
upper eyelid anatomy: introduction of the septal exten-
sion. Plast Reconstr Surg 2006;117(1):65–66, discussion
71–72
5. Moy RL, Lee A, Zalka A. Commonly used suture materials in skin
surgery. Am Fam Physician 1991;44(6):2123–2128
6. Lober CW, Fenske NA. Suture m aterials for closing the
skin and subcutaneous tissues. Aesthetic Plast Surg 1986;
10(4):245–248
7. Spelzini F, Konstantinovic ML, Guelinckx I, et al. Tensile
strength and host response towards silk and type I polypro-
pylene implants used for augmentation of fascial repair in a rat
model. Gynecol Obstet Invest 2007;63(3):155–162
8. Cho IC, Eed. The Art of Blepharoplasty. Seoul, Korea: Koon-
ja; 2013
9. Wong JK. A method in creation of the superior palpebral
fold in Asians using a continuous buried tarsal stitch
(CBTS). Facial Plast Surg Clin North Am 2007;15(3):
337–342, vi
10. Park JW. Non-incision transconjunctival Muller tucking in
blepharoplasty. Arch Aesth Plast Surg. 2012;18:31–34
11. Ahn YJ. Cases of m ild ptosis correction with suture-meth-
od. Arch Aesth Plast Surg. 2012;18:15–20
12. Hom ma K, Mutou Y, Mutou H, Ezoe K, Fujita T. Intradermal
stitch blepharoplasty for orientals: does it disappear? Aes-
thetic Plast Surg 2000;24(4):289–291
13. Ko RY, Baek RM, Oh KS, Lim JH. Complication of non-in-
cision Oriental blepharoplasty: is disappearance of the lid
crease a fearful complication? J Korean Soc Plast Reconstr
Surg 2000;27:199–203
a
b
a
b

162
13 Double-Eyelid Surgery: Incisional Techniques
Jae Woo Jang
gery is considered by East Asians to make the eye appear
larger and more aesthetically pleasing.4
Eyelid crease surgery is performed not only for aes-
thetic purposes, but also for the correction of problems
such as entropion, lash ptosis, pseudoptosis, and ptosis.
Most patients tend to want the surgeon to perform eyelid
crease surgery simultaneously while correcting these other
problems. When patients with blepharoptosis undergo
eyelid crease surgery, the palpebral ssures become wider
and can create a more pleasing eye shape.5
It is important to recognize that Asian upper blepharo-
plasty is not a Westernization procedure, and the aim is to
create an upper eyelid crease similar to a naturally occur-
ring one.

■Anatomy of the East Asian
Eyelid
The most obvious characteristics of the Asian eyelid are
the absent or very low lid crease, and fuller upper eyelid.
Asian eyelids with no lid crease are referred to as “single
eyelids.” Although not visible, a small fold commonly exists
under the overhanging eyelid skin. Caucasian eyelids typi-

■Introduction
Upper lid blepharoplasty is the most common cosmetic
surgical procedure in East Asia (Korea, Japan, and China).
Asian blepharoplasty, also known as “double-eyelid sur-
gery,” involves the surgical creation of a supratarsal crease.
However, because the creation of a supratarsal crease does
not actually involve the formation of another eyelid, the
term double eyelid is actually a misnomer.1,2,3
It is generally agreed that ~ 50% of Asians are born with
naturally occurring upper eyelid creases. However, for most
of this population, the height of the double-eyelid crease
is low, and well-de ned double eyelids are present in only
~ 10% of Asian men and 33% of Asian women. The goal of
blepharoplasty for Asians, with or without related pro-
cedures, is fresh, youthful, and attractive eyes that retain
their ethnic appearance. The Asian upper eyelid has several
distinct anatomic characteristics, including a low, poorly
de ned or absent eyelid crease; narrow palpebral ssure;
and epicanthal fold. The upper eyelid margin of a single
eyelid in East Asians is in most cases covered by upper lid
skin. Therefore, when double-eyelid surgery is performed,
the upper eyelid skin is pulled upward, resulting in an
apparent increase in the size of the eyes. Double-eyelid sur-
Pearls
• The East Asian upper eyelid has several distinct
anatomic characteristics, including a low, poorly
de ned, or absent eyelid crease; narrow palpebral
ssure; and epicanthal fold.
• The goal of upper blepharoplasty for the Asian
patient is to make eyes fresh, youthful, and
attractive while maintaining their ethnic appearance
by surgically creating a supratarsal crease.
• The indications for the incisional technique are
redundant skin, bulky eyelids due to soft tissue and
fat, disappearance of the eyelid crease after suture
or partial incisional technique, and reoperation
due to various complications after eyelid crease
surgery. Scarring is not a problem if the technique is
delicately performed.
• The eyelid crease height in East Asians is 6 to 8
mm in females and slightly lower in males. A 2- to
3-mm pretarsal show, 20 to 30% of the length of the
interpalpebral ssure, is optimal in East Asians.
• The height and shape of the eyelid crease should
be individualized depending on a patient’s eyelid
ssure or epicanthal fold. The favorite types of eyelid
creases are the inside crease and outside crease—
fan type or mixed type—in East Asians, especially
Koreans.
• Proper removal of the orbicularis muscle and orbital
fat is necessary to create a more secure eyelid crease.
Sometimes retro-orbicularis orbital fat (ROOF)
removal is required depending on the pu ness of
the individual’s eyelid.
• Appropriately designed double-eyelid height and
proper xation result in a natural and aesthetically
pleasing double eyelid.

13 Double-Eyelid Surgery: Incisional Techniques
163
that patients recover more quickly with no scarring, while
the disadvantages include the inability to remove pre-apo-
neurotic fat and soft tissue, which leads to the disappear-
ance of the double fold.
The indications for the incisional technique are (1)
redundant skin, (2) bulky eyelid due to soft tissue and fat,
(3) disappearance of the eyelid crease after the use of a
nonincisional suture technique or partial incisional tech-
nique, and (4) an additional operation due to various com -
plications after eyelid crease surgery (Fig. 13.2).
The major disadvantage to the incisional technique is
the long recovery time (usually 1 week is required to reduce
postoperative swelling and edema). Scarring is not a prob-
lem when the procedure is performed precisely and deli-
cately. The incision line is more prominent w ith the partial
incision technique compared with the incisional technique
because there is an apparent abrupt ending with the more
limited incisional method.8

■Patient Evaluation
Most patients desire permanent and natural-looking eyelid
creases. At the initial consultation, the patient’s goals and
expectations should be identi ed. The eyelid crease height
usually depends on the interpalpebral ssure size and tar-
sal plate height. The proper eyelid crease height in East
Asians is 6 to 8 mm in females and slightly lower in males.
The rst step is to simulate the estimated eyelid crease
in front of the mirror by pushing the eyelid skin with
devices such as a forceps, a lacrimal probe, a paperclip, or a
wooden cotton-tipped applicator; the di erent shapes and
widths of the eyelid crease can be created and visualized
using these tools. The height and shape of the eyelid crease
required for a natural look should be decided via discus-
sion with patient. Should the patient request a height and
shape that do not match the eyelid shape, a more thor-
ough explanation will be required to assist in the decision
making process. Some patients may not fully express their
desires, which can make these cases very di cult to man-
age. As mentioned previously, most Asians want a crease
that is consistent with those that occur naturally in the
population.
cally have an eyelid crease, but Asian eyelids can be catego-
rized into three types: single eyelid, low eyelid crease, and
double eyelid.
The causes of an absent or lower crease in an Asian
upper eyelid include the following: (1) The orbital septum
fuses to the levator aponeurosis below the superior tarsal
border. (2) Preaponeurotic fat pad protrusion and a thick
subcutaneous fat layer prevent levator bers from extend-
ing toward the skin near the superior tarsal border. (3) The
primary insertion of the levator aponeurosis into the orbi-
cularis muscle and into the upper eyelid skin occurs closer
to the eyelid margin in Asians (Fig. 13.1).6,7 Asian single
eyelids have more prominent subcutaneous and retro-orbi-
cularis fat in the supratarsal region. Several components,
such as a submuscularis bro-adipose tissue layer and a
lower-positioned transverse ligament, have been identi ed
and are found exclusively in the Asian eye.
The primary goal of double-eyelid surgery is not sim -
ply to create a supratarsal crease but to create a crease that
is consistent with the natural con guration present in the
general East Asian population.

■When Should the Incisional
Technique for Double-Eyelid
Surgery Be Performed?
The types of double-eyelid surgery include the simple
suture technique, the partial incisional technique, and
the incisional technique. The choice of technique is based
on patient preference, skin quality, and the volume of fat
tissue in the upper eyelid. There are advantages and dis-
advantages to the incisional technique and nonincisional
techniques. The advantages of nonincisional techniques are
Fig. 13.1 Di erences in upper eyelid anatomy between (a) East
Asians and (b) Caucasians. In Asians, the orbital septum fuses with
the levator aponeurosis below the superior tarsal border. The pro-
truded pre-aponeurotic fat and thick subcutaneous fat layer disturb
extension from the levator aponeurotic bers toward the skin.
Fig. 13.2 A typical indication for the incisional technique for eye-
lid crease surgery. The eyelids show pu ness, skin laxity, and an
epicanthal fold in a 25-year-old woman.
a
b

III Blepharoplasty
164
with a natural crease have either a nasally tapered crease
or a parallel crease, as described in various reports. Chen
noted that inside fold and outside fold are less appropriate
terms; however, in Korean populations, the inside crease is
well matched with the nasally tapered crease, but the par-
allel crease does not exactly match the outside fold.2 There-
fore, in this chapter, the author will use the terms inside
crease and outside crease instead of nasally tapered crease
and parallel crease.
1. Inside crease. A natural, lower crease that converges
toward the medial canthus and runs parallel across
the ciliary margin, over the central portion, and
ares away from the ciliary margin as it approaches
the lateral canthus (fan type) (Fig. 13.3a).
2. Outside crease. The crease runs fairly parallel to the
lash margin from the medial canthus to the lateral
canthus. The outside crease is divided into three
types: (a) fan type, (b) fan-parallel or mixed type
(the eyelid crease gradually ares away from the
lid margin toward the center portion and then runs
parallel to the ciliary margin toward the lateral
canthus), and (c) parallel type (the crease runs at the
same width from the medial to the lateral canthus)
(Fig. 13.3b,c).
Usually an inside crease becomes a fan type and an out-
side crease becomes a fan, fan-parallel, or parallel type.
In general, there is a greater tendency to create an inside
crease than an outside crease in patients with a strong
medial epicanthal fold. The inside fold is considered to be
more natural and conservative, whereas the outside fold is
considered to be more modern and outgoing. Although the
higher outside-crease eye was once trendy, it is unnatural-,
arti cial-, and Western-looking (Fig. 13.4), East Asians,
especially Koreans, prefer the inside crease and outside
crease fan type or outside crease mixed type. Moreover, it
is now uncommon for East Asians to choose a semilunar
crease like that of Caucasians.
It is reported that epicanthal folds are found in 50 to
80% of South Koreans. Due to the epicanthal fold, in 70% of
eyelids the caruncle and lacrimal lake are not overtly vis-
Ptosis of the upper eyelid is assessed by measuring the
palpebral ssure width and margin re ex distance 1 (MRD1,
from the light re ex on the patient’s cornea to the central
upper eyelid margin). Lash ptosis or downward angulation
of the lashes owing to relaxation of the anterior lamella of
the eyelid should also be noted and corrected during upper
lid blepharoplasty.9 Early myasthenia gravis symptoms are
similar to those of ptosis and require a di erential diagnosis.
Periorbital fat is important for blepharoplasty, espe-
cially when subbrow fat (retro-orbicularis orbital fat, or
ROOF) is distributed up to the orbital septum level and full-
ness in the upper eyelid can be seen; this is distinguishable
from orbital fat herniation.7 The orbital fat of the upper eye-
lid is divided into two groups: central and medial. Central
orbital fat has a yellow, butter color, while medial orbital
fat is whitish in color and is composed of smaller lobules.
Blepharoplasty may be adapted according to the qual-
ity of the eyelid skin. The surgeon will consider eyelid skin
thickness (thin or thick), dehydration of the skin, and the
loss of elastic and collagen bers, depending on the degree
of aging. With a greater degree of aging, blepharoplasty for
thick eyelid skin requires that the skin incision be made at
a lower level and the procedure not involve excessive skin
removal.
Before surgery, the patient’s eyebrow shape and posi-
tion, the appearance of the eyelids and degree of sagging,
and the degree of fat bulging should be recorded using
paintings or photographs. These records can also play an
important role in resolving any complaints or con icts that
may occur following surgery.

■What Is the Favorite Type
of Double Fold in Asians
in Relation to the Medial
Epicanthal Fold?
The shape of an eyelid crease can be characterized as
nasally tapered, parallel, or semilunar. Asians rarely have
a semilunar shape, which is common in Caucasians. Asians
Fig. 13.3 Variations of East Asian creases. (a) Inside crease. (b) Outside crease, fan type. (c) Outside crease, parallel type.
a
b
c

13 Double-Eyelid Surgery: Incisional Techniques
165
ity of the supratarsal skin draping the crease and pretarsal
skin (Fig. 13.6b).11 The amount of redundant skin excision
depends on the pre-determined pretarsal show when the
incisional technique is performed. Even though designed
at the same height as the eyelid crease, the height of the
crease is determined according to the amount of skin. If the
amount of excised skin is large, the eyelid crease will be
high after eyelid crease surgery. The double-eyelid crease
can be created with or without a pretarsal show by man-
aging the excised amount of the skin as per the patient’s
desires.

■Surgical Techniques
Design of the Double-Eyelid Crease
The method for deciding the height of the eyelid crease has
been described as follows in previous reports. The upper lid
is everted and the vertical height of the tarsus over the cen-
tral portion of the lid is measured using calipers. The point
is marked at the same height as the external eyelid skin.
The author does not usually use calipers, but rather deter-
mines the natural crease by simply pushing the eyelid with
a cotton-tipped applicator. In general, a high-set crease
makes an outside crease, whereas a moderate- to low-set
crease makes an inside crease. The shape of the eyelid
crease depends on the epicanthal fold. There is a greater
tendency to create an inside crease in patients with an epi-
canthal fold. If a larger and more pleasing eyelid crease is
sought, medial epicanthoplasty is usually done simultane-
ously during eyelid crease surgery.
After the shape and height of the eyelid crease has been
determined, the proposed crease is marked with a mark-
ing pen or the shaved-o tip of a cotton-tipped applicator
dipped in gentian violet. The upper incision line is marked
according to the skin laxity on a 1- to 2-mm strip without
skin laxity (Fig. 13.7). The medial third of the incision line
is marked such that it tapers toward the medial canthal
area or merges with the epicanthal fold. The lateral third
ible. The shape of the eyelid crease depends on the height,
the degree, and the shape of the epicanthal folds. The eyelid
crease may be two lines at the medial canthus and be oper-
ative in appearance if the outside crease is made without
medial epicanthoplasty (Fig. 13.5). To make eyes larger and
more attractive, medial epicanthoplasty is recommended
at the same time as the double-eyelid surgery, especially
for moderate to severe epicanthal folds.
What Is the Best Height of the
Double Eyelid?
The eyelid crease height usually depends on the interpal-
pebral ssure size and tarsal plate height. The eyelid crease
height of East Asians is 6 to 8 mm in females and slightly
lower in males. In patients with a large interpalpebral s-
sure or thin eyelid skin, making a higher-set eyelid crease is
better. Otherwise, a lower-set eyelid crease is preferable for
patients with a small interpalpebral ssure.
Eyeball protrusion and vertical/horizontal interpalpe-
bral ssures are important for determining the height of
the eyelid crease. If the horizontal ssure of the eye is small,
the high eyelid crease will appear unnatural and arti cial.
A higher eyelid crease looks natural in patients with a large
horizontal ssure of the eye. However, high eyelid creases
do not look natural in patients with thick eyelid skin and a
large amount of pretarsal soft tissue. East Asians often have
protruding eyeballs; a high eyelid crease is strong-looking
in these cases.
With regard to Asian eyelid creases, the crease is par-
tially covered by the fold of skin that overlays it. The width
of the eyelid crease during eye opening is called the pre-
tarsal show (Fig. 13.6a).10 The height of the eyelid crease (or
designed incisional line) is determined from the pretarsal
show. The pretarsal show in East Asians is optimal at ~ 2 to
3 mm or 20 to 30% of the interpalpebral ssure, but it may
depend on the height of the supratarsal fold and the lax-
Fig. 13.4 The higher outside crease. The high outside creases
may look cool, but they also look unnatural, arti cial, and Western.
Fig. 13.5 Webbing of the crease. Webbing is noted at the
medial canthus because the outside crease was made without
epicanthoplasty.

III Blepharoplasty
166
taken to inject the anesthetic solution only in the super cial
area of the orbicularis oculi muscle to avoid the occurrence
of a hematoma due to muscle injury. To avoid bleeding, light
pressure is applied to the area where the needle enters the
skin. The surgeon takes care to administer the anesthetic
solution throughout the proposed lesion of incised skin.
Skin Incision
The incision is made with a no. 15 surgical blade (Bard-
Parker, Aspen Surgical) along the upper and lower lines.
To reduce bleeding, a CO2 laser or radiofrequency wave
can be used on the skin incision (Fig. 13.8a). The strip of
skin is excised with scissors or monopolar cautery with a
Colorado needle tip (Stryker) just below the subcutaneous
plane, throughout the planned incision line.
Removal of Skin and Orbicularis
Muscle
The orbicularis muscle is excised together with the skin
by the strip of myocutaneous ap or excised after the skin
removal. Elevating the skin with forceps can protect the
orbital septum from iatrogenic damage during the excision.
Excessive debulking of the orbicularis muscle is not usu-
ally recommended. Some orbicularis muscle should be left
around the upper skin ap as a triple fold is commonly seen
when the entire orbicularis muscle is removed around the
upper skin ap (Fig. 13.8b).
is usually marked in a leveled or are con guration. The
markings on the opposite eye should be designed to be as
symmetrical as possible.
Anesthesia
Usually, surgery is performed under local anesthesia. A mix-
ture of 2% lidocaine (Xylocaine, AstaZeneca) at a 1:100,000
dilution of epinephrine is commonly used. When a surgeon
wants to use hyaluronidase, 10 mL of 2% lidocaine contain-
ing a 1:100,000 dilution of epinephrine is mixed with 150
units of hyaluronidase. Hyaluronidase promotes anesthetic
dispersion and tissue permeability, which facilitates the
e ects of the anesthetic and reduces the amount of anes-
thetic required. If the operation time is long, a 50:50 mix-
ture of 2% lidocaine and 0.5% or 0.75% bupivacaine is used.
The anesthetic is slowly injected to reduce pain. Care is
x
y
z
Supratarsal crease
Pretarsal show
(width of double eyelid)
Double eyelid fold
Fig. 13.6 Pretarsal show. (a) The width of the eyelid crease during eye opening.
(b) The pretarsal show depends on managing the amount of skin excised using the
incisional technique: height of incision line (x) = 6–8 mm; pretarsal show (y) = 2
mm; amount of skin excision is z × 2.
Fig. 13.7 Eyelid crease design and marking. The upper incision
line is marked according to skin laxity on a 1- to 2-mm strip without
skin laxity.
a
b

13 Double-Eyelid Surgery: Incisional Techniques
167
fat pad, the orbital septum is incised m edially. The color of
the protruding fat is m ore whitish than that of the central
fat pad. When rem oving the nasal fat pad, care is taken not
to dam age the arteries that are running m edially, or the
arteries should be cauterized in advance to avoid bleed-
ing. Supplem entary local anesthesia injection is needed
for pain control before rem oving the nasal fat pad. It is
important to rem ove the sam e am ount of fat pad from
each eye.
Sometimes lateral-half ROOF removal is necessary in
patients with thick redundant tissues even after removing
the pre-aponeurotic fat (Fig. 13.9c). Care should be taken
not to remove the ROOF that is close to the muscle.
Excessive removal of fat or the pretarsal orbicularis
muscle along the lower incision line can cause multiple
folds in young patients after the incisional eyelid crease
surgery. The surgeon may tape the fold or inject absorbable
ller in minor cases (Fig. 13.10).
Lower-Positioned Transverse
Ligament
The lower-positioned transverse ligament (LPTL) is the
other transverse ligament in the upper eyelid, with less elas-
ticity than Whitnall’s ligament. It originates from the ante-
rior surface of the trochlea, extends inferolaterally toward
the white line, and is re ected onto the orbital septum,
inserting into the lateral orbital rim. The LPTL is thought to
prevent eyelid opening, and severing this ligament allows
further excursion of the upper eyelid and is recommended
when performing eyelid crease surgery (Fig. 13.11).12,13
If pretarsal soft tissue is abundant, its removal is neces-
sary to create adequate adhesions. Care should be taken not
to incise the tarsus upper margin to prevent damage to the
terminal interdigitation of the levator aponeurosis when
excising the pretarsal soft tissue. Excessive removal of pre-
tarsal soft tissue may result in tight adhesion between the
skin and tarsus, which may lead to a static double-eyelid
crease. If there is not su cient pretarsal soft tissue in the
high eyelid crease, an additional operation surgery from a
high to low crease is very di cult and tricky.
Removal of Orbital Fat and ROOF
The orbital septum can easily be distinguished from the
protruded pre-aponeurotic fat by pressing the eyeball gen-
tly when the eyes are closed. The upper eyelid should be
retracted tightly anteriorly and slightly downward while
forceps apply counter-traction to tense the orbital septum.
The exposed orbital septum is penetrated by the tip of the
scissors or Colorado needle to create a window and the pre-
aponeurotic fat is exposed through the opening (Fig. 13.9a).
The orbital septum is divided medially and laterally with
scissors or by cautery to expose the levator aponeurosis and
pre-aponeurotic fat. Yellowish central pre-aponeurotic fat is
observed when the orbital septum is opened.
The fat pad is grasped w ith a hem ostat and excised
across a closed hem ostat. Bleeding is controlled to the end
of the excised fat pad by ensuring that the hem ostat is
not loosened. The clamp is loosened only after adequate
hem ostasis. If a CO2 laser is used, the fat pad is excised
w ithout the hem ostat (Fig. 13.9b). To rem ove the m edial
Fig. 13.8 Skin incision and orbicularis
removal. (a) Skin incision with a CO2 laser.
(b) Some orbicularis muscle (arrow) should
be left around the upper skin ap to prevent
a triple fold.
Fig. 13.9 Opening of the septum and fat removal. (a) Tenting of the orbital septum during opening is necessary for preventing damage
to the levator aponeurosis. After opening the septum, the glistening levator aponeurosis is seen under the orbital fat. (b) Orbital fat is
removed with a CO2 laser. (c) Descended ROOF can be removed if desired.
a
b
a
b
c

III Blepharoplasty
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skin is thin, the buried knots might be visible through the
skin.
In making the low eyelid crease, xation to the tarsal
plate can be more e ective than xation to the levator apo-
neurosis. Excessively high bite along the levator aponeu-
rosis results in a deep crease with lifting of the eyelashes
due to the pulling-up action of the skin. This can produce
a strong impression and make a sunken groove when the
patient closes the eyes. If the patient has proptosis, the
surgeon needs to avoid creating a deep crease. Conversely,
too low xation compared with the designed crease height
can cause wrinkles and bulging (Fig. 13.13). The prominent
depression or notching will occur if the internal or external
xations to the levator aponeurosis are not appropriate and
are too high compared with other xations.
Appropriate eyelid crease xation can correct the eye-
lash direction in patients with lash ptosis and entropion.
The degrees of lash direction should be adjusted during the
xing of the sutures. In East Asians, a higher xation with
a low-designed eyelid crease can produce more eversion of
the eyelashes. This may bring about an anatomically inap-
propriate or aesthetically undesirable eyelid crease and
poor cosmetic result. It is preferable to correct the eyelash
direction at ~ 90°. An appropriately designed eyelid crease
height and proper xation will result in a natural and aes-
thetically pleasing double eyelid.
Fixation Suture of the Eyelid Crease
The methods for xation of the eyelid crease depend on
the surgeon’s preference and include (1) skin-levator-skin,
(2) skin-tarsus-skin, (3) levator aponeurosis to the inferior
subcutaneous plane (or orbicularis muscle), and (4) tarsal
plate to the inferior subcutaneous plane.13
Eyelid crease xation is performed either externally or
internally using 6–0 or 7–0 nylon or Prolene (Ethicon). In
the internal xation method, the 7–0 nylon or Prolene is
passed through the subdermal tissue and xed to the tar-
sal plate or levator aponeurosis; the suture is tied and then
the knots are buried. In the external xation method, 6–0
nylon or Prolene is passed through the edge of the lower
skin incision to the tarsus or levator aponeurosis, exiting
through the edge of upper skin incision.14 There is no dif-
ference in permanence or continuity between these meth-
ods, but the author prefers the skin-levator-skin xation
technique (Fig. 13.12). Usually, three xation sutures are
required, but in the author’s practice more xation sutures
are placed on each side to prevent late obliteration. The x-
ation suture to the tarsus can result in a strong eyelid and a
clearly visible crease during closing of the eyes. In internal
xation to the tarsus or levator aponeurosis, if the eyelid
Fig. 13.10 Triple fold. (a) The triple fold occurred after eyelid crease surgery due to excessive orbicularis muscle excision. (b) The triple
fold was managed by hyaluronic acid ller.
Fig. 13.11 Lower-positioned transverse ligament or LPTL (arrow).
Severing this ligament helps further excursion of the upper eyelid
and is recommended when performing eyelid crease surgery.
Fig. 13.12 Fixation suture for the eyelid crease and the skin clo-
sure. The wound is closed in skin-levator-skin xation fashion.
a
b

13 Double-Eyelid Surgery: Incisional Techniques
169
carry out full ptosis correction, it is better not to make an
eyelid crease. Otherwise, the eyelid crease may be very high
or faint, giving the appearance of sleepy eyes, which is not
aesthetically acceptable. Full ptosis correction is manda-
tory before eyelid crease surgery (Fig. 13.15).

■Key Technical Points
1. In general, a high-set crease makes an outside crease,
whereas a moderate- to low-set crease makes an
inside crease. The shape of the eyelid crease also
depends on the epicanthal fold; there is a greater
tendency to create an inside crease in patients
w ith an epicanthal fold. The creation of outside
crease fan-type or mixed-type lids requires the
modi cation or removal of the epicanthal fold.
2. The pretarsal show in East Asians is optimal at 2 to
3 mm or 20 to 30% of the interpalpebral ssure. The
amount of redundant skin excision depends on the
pre-determined pretarsal show.
3. Appropriately designed eyelid crease height and
proper xation result in a natural and aesthetically
pleasing double eyelid.
Skin Suture
After xation of the eyelid crease, the eyelid skin suture is
performed with a ne suture after con rmation of complete
hemostasis. In Korea, the interrupted or continuous suture with
6–0 nylon or 6–0 fast-absorbing sutures are commonly used.
The skin of Asians is di erent from that of Caucasians, with the
former requiring a greater number of sutures (Fig. 13.14).
Levator Advancement or Ptosis
Correction
In East Asia, when a patient with normal levator function and
without pathologic ptosis desires the appearance of a larger
eye, levator aponeurosis advancement or levator aponeurosis
plication are commonly performed simultaneously during
double-eyelid surgery.1 However, the e ect of plication of the
levator is not predictable and disappears at long-term follow-
up. After dissection of the levator aponeurosis, the amount of
aponeurosis advancement is decided by observing the eyelid
level and degree of symmetry in the seated position.
In asymmetric or unilateral ptosis, the height of the
eyelid crease should be a little less than that for a normal
eyelid. In bilateral ptosis, the height of the eyelid crease is
1 or 2 mm less than the normal 6 to 8 mm.5 If you do not
Fig. 13.13 Skin bulging after upper blepharoplasty. Too-low xa-
tion rather than the designed crease height can cause skin bulging.
Fig. 13.14 Interrupted skin closure was performed with 6–0
nylon sutures. In general, Asians require a higher number of sutures
than Caucasians.
Fig. 13.15 The asymmetric eyelid crease after a nonincisional
technique due to the missed ptosis. (a) The preoperative photo.
(b) The right eyelid crease is high compared with the left eyelid
crease after the nonincisional technique because blepharoptosis
was missed. (c) After levator advancement of the right eye, the
eyelid creases are symmetric.
a
b
c

III Blepharoplasty
170
sional method, which requires de-bulking of the fat and
underlying soft tissue; the surgeon must then tightly suture
the levator aponeurosis and skin with multiple knots. If
the patient previously underwent the incisional method,
the surgeon can conduct the nonincisional method or the
incision method, which requires strong adhesion by tight
xation sutures. If the patient has mild ptosis, levator apo-
neurosis advancement should be conducted with the dou-
ble-eyelid surgery.
High or Low Eyelid Crease
If the eyelid crease is too high, an unnatural crease is
made, and if the double eyelid is too low, the crease m ay
be unclear. For low crease correction, creating a new fold
above the previous low crease is needed. In the case of a
high fold, if there is enough rem aining skin, the surgeon
will decide the new crease height and then excise the
skin together w ith the previous incision line. However, if
there is not enough skin, a full-thickness skin graft could
be needed. During the operation, surgeons tend to avoid
making the high crease at the sam e level as is prevalent in
Western practice because correction surgery from a high
to a low crease is m ore complex and the surgical results
are som etimes undesirable. An additional operation to
correct a high outside crease to a low outside crease or
inside crease is very di cult.

■Case Studies
Case 1: Correction from the Short
Inside Crease to the Outside Crease
A 22-year-old woman visited the author’s clinic for eyelid
crease surgery (Fig. 13.16a). She wanted an outside crease.
She had a low and short inside crease in both eyes. Inci-
sional blepharoplasty with medial epicanthoplasty was
performed. After eyelid crease surgery, the inside crease
changed to an outside crease (Fig. 13.16b).

■Postoperative Management
After the operation, the wound is cleaned daily and anti-
biotic eye ointment is applied for 3 weeks. The patient is
instructed to continue ice compression to reduce swelling
and ecchymosis for 24 to 48 hours after surgery. The use
of oral antibiotics for 3 days is usually not necessary, but
is often done for the prevention of uneventful infection.
Sutures are removed within 5 to 7 days depending on the
suture material. Eye makeup may be used after 2 weeks.
Sometimes a scar-reducing ointment (e.g., Contratubex,
Merz) or oral drug (Rizaben capsule, Kissel Pharmaceutical)
is used to prevent scarring after incision surgery in Korea.

■Complications and
Their Management
Asymmetry
A commonly occurring complication after double-eyelid
surgery is asymmetry, which is caused by design fault,
asymmetric skin resection, asymmetric fat removal, di er-
ent xation height of levator aponeurosis or tarsus to create
a double-eyelid crease, or di erences in adhesion between
subcutaneous tissue and levator aponeurosis. Therefore, a
surgeon must always keep in mind the various factors that
may cause asymmetry during the operation.
Disappearance of the Eyelid Crease
The fading or disappearance of the eyelid crease is caused
by incorrectly xed sutures from the subdermal tissue
below the skin incision to the levator aponeurosis or tarsus,
or by unstable xation due to postoperative hematoma.
This condition is more common with suture techniques
than with the incisional technique. If the patient has pre-
viously undergone the nonincisional method, the surgeon
can perform the nonincisional method again or the inci-

13 Double-Eyelid Surgery: Incisional Techniques
171
wanted to have a lower eyelid crease. First, the author
removed all of the buried suture materials that could pre-
vent or reduce the adhesion. After 3 months, the right eyelid
crease disappeared and the left high eyelid crease remained
(Fig. 13.17b). Good, natural-looking inside creases were
made in an additional operation using the incisional tech-
nique after 6 months (Fig. 13.17c).
Case 2: Correction from High Crease
to Low Crease
A 22-year-old woman visited the author’s clinic because
of eyelid creases that were too high (Fig. 13.17a). She had
undergone eyelid crease surgery via the nonincisional
technique 4 weeks previously. She was very unhappy and
Fig. 13.16 Case 1. From the short inside crease to the outside crease with the incisional technique. (a) The preoperative photo revealed a
short inside fold in both eyes. (b) The patient had an outside fold after the incisional technique with medial epicanthoplasty.
Fig. 13.17 Case 2. From the high crease to the low crease with the
incisional technique. (a) The high eyelid creases were made after
nonincisional eyelid crease surgery. (b) The right eyelid crease disap-
peared and the left high eyelid crease still remained 3 months after
removal of buried suture materials. (c) Good, natural-appearing
inside creases were created after an additional operation with the
incisional technique.
a
b
a
c
b

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8. Lam SM, Karam AM. Supratarsal crease creation in the
Asian upper eyelid. Facial Plast Surg Clin North Am 2010;
18(1):43–47
9. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash pto-
sis and associated factors in Asians. Ann Plast Surg
2010;65(4):407–410
10. Park JI, Torumi DM. Double eyelid operation: orbicularis-
levator xation technique. In: Park JI, Torum i DM, eds.
Asian Facial Cosmetic Surgery. Philadelphia, PA: Elsevier
Saunders; 2007:49–59
11. Flowers RS. Asian blepharoplasty. Aesthet Surg J 2002;
22(6):558–568
12. Kakizaki H, Malhotra R, Selva D. Upper eyelid anatomy: an
update. Ann Plast Surg 2009;63(3):336–343
13. Ban M, Matsuo K, Ban R, Yuzuriha S, Kaneko A. Developed
lower-positioned transverse ligam ent restricts eyelid
opening and folding and determ ines Japanese as being
with or without visible superior palpebral crease. Eplasty
2013;13:e37
14. Wong JK. Aesthetic surgery in Asians. Curr Opin Otolaryn-
gol Head Neck Surg 2009;17(4):279–286
References
1. Lee CK, Ahn ST, Kim N. Asian upper lid blepharoplasty sur-
gery. Clin Plast Surg 2013;40(1):167–178
2. Chen WPD, Park JDJ. Asian upper lid blepharoplasty: an
update on indications and technique. Facial Plast Surg
2013;29(1):26–31
3. Kang DH, Koo SH, Choi JH, Park SH. Laser blepharoplasty
for m aking double eyelids in Asians. Plast Reconstr Surg
2001;107(7):1884–1889
4. Scawn R, Joshi N, Kim YD. Upper lid blepharoplasty in
Asian eyes. Facial Plast Surg 2010;26(2):86–92
5. Park DH, Kim CW, Shim JS. Strategies for simultaneous double
eyelid blepharoplasty in Asian patients with congenital bleph-
aroptosis. Aesthetic Plast Surg 2008;32(1):66–71
6. Jeong S, Lemke BN, Dortzbach RK, Park YG, Kang HK. The
Asian upper eyelid: an anatomical study with comparison
to the Caucasian eyelid. Arch Ophthalm ol 1999;117(7):
907–912
7. Saonanon P. Update on Asian eyelid anatomy and clinical rel-
evance. Curr Opin Ophthalmol 2014;25(5):436–442

173
14 Aging-Related Upper Blepharoplasty
Hokyung Choung and Namju Kim
appearance while maintaining the person’s ethnic char-
acteristics is the goal of Asian eyelid surgery.1 The goal of
aging-related blepharoplasty is to restore the individual’s
youthful appearance, not to create a morphologic change
that brings a novel look. This is especially true in the case of
treating the Asian upper eyelid. Loss of ethnic identity can
result in a negative reaction both from the patient as well
as from his or her friends and family.2
In the past it was generally accepted that Asian patients
wanted to have double eyelids to project a more Western
appearance, which they found more attractive. However,

■Introduction
East Asians are the world’s largest ethnic group, and the
eyelids’ position in the center of the face is a distinguishing
feature and makes a strong impression. Blepharoplasty is
the most common and a rapidly growing cosmetic surgery
procedure in Asia. Understanding anatomic di erences
related to eyelid surgery is the key to achieving optimal
results. A typical Asian eyelid is a single eyelid with an
epicanthal fold or Mongoloid slant. Improving a patient’s
Pearls
• Understanding anatomic di erences and
involutional changes in the eyelids of East Asians,
which are speci c to age and gender, is the key to
achieving optimal results.
• Too much is as unwelcome as too little. The trend
in Asian aging-related blepharoplasty is toward
conservative excision of skin and fat, making a
natural-looking, low-positioned double eyelid (or
not making an arti cial double eyelid).
• It is important to have a realistic understanding
of the outcome of blepharoplasty through an
in-depth discussion between the surgeon and the
patient before surgery. The goal of aging-related
blepharoplasty is to restore the individual’s
youthful appearance while retaining the ethnic
characteristics. This is especially true in the case of
treating the Asian upper eyelid.
• The upper crease is usually low or absent in the
Asian eyelid. Slightly folded upper eyelid skin over
the double-eyelid crease, or a low double-eyelid
crease (e.g., 3–4 mm in height) looks more natural
and blends well. Usually, a double-eyelid crease over
7 to 8 mm in height looks very unnatural in Asians,
even in female patients.
• Brow ptosis usually occurs after middle age, and
dermatochalasis and blepharoptosis may appear
accentuated due to brow ptosis. Therefore, the
surgeon must recognize brow ptosis before
surgery and decide whether to perform a brow
lift in advance or do it in conjunction with the
blepharoplasty.
• Many aged people who want blepharoplasty may
have blepharoptosis of some degree but may
not be aware of it because it is concealed by the
dermatochalasis.
• If the patient complains of ocular irritation symptoms,
problems with tear secretion such as dry eye syndrome
could be present. The surgeon should make the patient
understand that ocular irritation may be aggravated
after blepharoplasty and that such problems need to be
managed before blepharoplasty.
• The most di cult cases of aging-related
blepharoplasty in Asians involve patients who had
undergone previous blepharoplasty with excessive
skin and fat removal, with a very high-positioned
double-eyelid crease. In these cases, autologous fat
or ller injection along the brow and upper eyelid
complex is more helpful in improving the cosmetic
outcome than a blepharoplasty.
• The lacrimal gland is located laterally just behind
the orbital rim, and normally it is not seen during
blepharoplasty. With aging it prolapses, which
might be mistaken for lateral fat prolapse, especially
in Asian patients who have thick skin over the
lacrimal gland.
• Complications after aging-related blepharoplasty are
usually the result of excessive skin or fat resection,
lack of hemostasis, an inadequate preoperative
assessment, or careless postoperative management.
Every e ort should be made to minimize or prevent
complications during or after blepharoplasty by
recognizing known risk factors and paying careful
attention during and after surgery.

III Blepharoplasty
174
ptosis results from stretching or weakening of the levator
palpebralis due to involutional change or disinsertion of
the levator aponeurosis from the tarsal plate. It causes
not only cosm etic problem s but also visual discom fort
such as obscuring the view. Although the superior visual
eld is prim arily involved, m any patients complain of dif-
culty w ith reading because the ptosis is aggravated w ith
down-gazing. Park et al reported that Koreans age 50 years
or older showed a very high frequency (54.9%) of pto-
sis, and as the age increases, the frequency of ptosis also
increases.5 The exam iner should note the patient’s head
position, chin-up position, or brow position to detect the
presence of ptosis.
Patients often involuntarily attempt to compensate for
dermatochalasis by chronic use of the frontalis muscle and
this can lead to high-positioned eyebrow and deep (promi-
nent) transverse furrows in the forehead (Fig. 14.1). Unlike
other areas of the body, where there is descent of soft tis-
sues, there may be paradoxical elevation of eyebrows with
aging, especially the medial and midbrow. So the clinician
should try to determine the eyebrow morphology and
position of the individual patient and selectively elevate the
lateral brow to have a rejuvenating e ect on the upper third
of the female face.6
On the other hand, brow ptosis frequently accompanies
dermatochalasis, and the patient can be over-diagnosed as
having very severe drooping of the upper eyelid skin and
excessive excision of skin with subsequent further drag-
ging of the eyebrow downward. Therefore, the examiner
should check for any history of facial nerve palsy in case
of unilateral brow ptosis (Fig. 14.2). Seo and Ahn analyzed
the morphologic changes of the eyelid according to gender
among di erent age groups in Koreans and reported that
the degree of brow ptosis showed a statistically signi cant
increase from the seventh decade of life in men and from
the sixth decade in women. In particular, the lateral brow
drooped more than the center brow. The lateral hood width
of the eyelid showed a statistically signi cant increase from
the seventh decade of life in men and from the sixth decade
in women.7
the trend these days in Asian aging-related blepharoplasty
is toward conservative excision of skin and fat, giving a nat-
ural-looking, low-positioned double eyelid and not creating
an arti cial-appearing double eyelid. Nowadays most aging
Asian patients want to restore their youthful appearance
but at the same time retain their ethnic characteristics, not
Westernize their eyelids, through blepharoplasty surgery.
Periorbital changes with aging include dermatochala-
sis, crow’s feet, and periorbital fat prolapse, and these lead
to changes in eyelid contour. The goal of blepharoplasty in
aging patients is to correct these processes and to allow the
patient to look younger. Blepharoplasty in elderly people
is mostly incisional blepharoplasty. To improve the perior-
bital wrinkles or superior hollowness, ller or botulinum
toxin injections may follow. Periorbital change with aging
is a dynamic process involving the aging of facial tissue and
bony structures, and several changes are common. Epider-
mal thinning and decreased collagen cause the skin to lose
its elasticity. Loss of fat, coupled with gravity and muscle
pull, leads to wrinkling and the formation of dynamic
lines. The aging process has also been shown to a ect facial
bones. Multiple studies suggest that bone aging of the orbit
and midface occur primarily due to contraction and mor-
phologic changes. This loss of bony volume and projec-
tion may contribute to the aged appearance. The e ort to
understand each patient’s individual involutional changes,
which are speci c to age and gender, is mandatory. There-
fore, identifying the patient’s personal needs and selecting
the right treatment accordingly is crucial for achieving the
best outcome both for the clinician and for the patient.3
The eyelid is important not only in its functional
aspects such as tear distribution from blinking, but also in
its cosmetic aspects because it greatly a ects other people’s
impressions by de ning one’s facial characteristics. The
drooped brow and eyelid skin can obscure one’s view and
look heavy, and lateral eyelid skin can be folded and thus
cause eczema.4 The eyelid becomes pu y due to the pro-
lapse of orbital fat from the loosening of the orbital septum.
Blepharoptosis refers to drooping or infratransposi-
tion of the upper lid. The m ost com m on type of acquired
Fig. 14.1 Typical pattern of blepharoptosis in an aged female. Blepharoptosis caused elevated eyebrow by compensation and this
resulted in forehead creases.
a
b

14 Aging-Related Upper Blepharoplasty
175
The Degree of Blepharoptosis and
Levator Function
Many aged people who want blepharoplasty may have
blepharoptosis of varying degrees. To check the degree of
blepharoptosis and levator function, the patient should
stay comfortable and should not use the frontalis muscle.
First, examine whether the position of the lower lid is nor-
mal. Second, check the margin-re ex distance (MRD), the
distance from the upper eyelid margin to the corneal light
re ex in the primary position, which is the most e ective
measurement in describing the amount of blepharoptosis
(Fig. 14.4). Patients with severe dermatochalasis may also
have blepharoptosis; however, these patients can be over-
looked because dermatochalasis can conceal their blepha-
roptosis. The most simple and e ective way to nd hidden
blepharoptosis is to curl up redundant skin and nd the real
MRD from the eyelid margin to the re ex, not the manifest
MRD, from the skin margin to the re ex (Fig. 14.5).
Third, measure the levator function by determining the
distance (in millimeters) the upper eyelid margin moves
from down-gaze to up-gaze while the brow is xated with
the examiner’s ngers (Fig. 14.6). Decreased lifting force
might also explain lash ptosis, which is not only present
in the single eyelid but also increases in prevalence in the
double eyelid with aging.10 The degree of lash ptosis corre-
lates w ith the degree of blepharoptosis and decreased lift-
ing force of the levator aponeurosis.11
Brow Position
The brow is normally positioned at the level of the supe-
rior orbital rim, and the male brow is lower than the female
brow. Brow position and contour determine youthful
appearance to some degree. With aging, the temporal brow
starts to droop more prominently because the frontalis

■Patient Evaluation
Dermatochalasis
Elderly people commonly complain of “blepharoptosis,”
but most cases are not real ptosis but rather dermatocha-
lasis: simple skin and muscle drooping. To distinguish real
ptosis from simple dermatochalasis, raise the drooped skin
and check the position of the eyelid margin. Patients with
simple dermatochalasis show normal eyelid height similar
to that of young people, and those cases usually need exci-
sion of the skin and muscle only.
Deep Superior Sulcus
The dehiscence of the levator aponeurosis from the upper
tarsal plate can cause high placement of multiple creases
and hollow superior sulcus (Fig. 14.3). Dehiscence of the
levator also causes ptosis, and subsequent brow elevation
to compensate for this ptosis can aggravate superior sul-
cus deepening.8,9 Sometimes previous excessive fat removal
may cause a deep and hollow superior sulcus with involu-
tional changes.
Fig. 14.2 Brow ptosis masquerading as blepharoptosis. A patient
with prior left facial nerve palsy had left brow ptosis and an asym-
metric eyebrow.
Fig. 14.3 Typical presentation of involutional blepharoptosis.
Patients with involutional blepharoptosis frequently show high-
located multiple creases and hollow superior sulcus.
Fig. 14.4 Method of measuring margin-re ex distance (MRD).
MRD is measured by the distance from the upper eyelid margin to
the corneal light re ex in the primary position.

III Blepharoplasty
176
in advance or in conjunction with the blepharoplasty. The
medical history must be checked for facial nerve palsy in
cases of unilateral brow ptosis or more prominent droop-
ing of the unilateral upper eyelid skin. If brow ptosis was
overlooked, iatrogenic postoperative lagophthalmos can
result from the resection of too much skin and muscle.
Therefore, to get good results, the brow lift has to precede
blepharoplasty.
muscle is not present in the lateral brow area. Drooping of
the brow is called brow ptosis. Brow ptosis occurs usually
after middle age, and dermatochalasis and blepharoptosis
may appear accentuated due to brow ptosis. The surgeon
must recognize the brow ptosis accompanying derma-
tochalasis as a contributing factor in the patient’s aged
appearance before surgery. In the presence of brow ptosis,
the surgeon must decide whether to perform a brow lift
Fig. 14.5 Di erentiation between dermatochalasis and blepharoptosis. (a) Young male patient who worried about right blepharoptosis.
(b) After curling up redundant skin, margin-re ex distances were symmetric and there was no real blepharoptosis. (c) Older female patient
complained of “drooped skin” of the right upper eyelid. It looks like there is dermatochalasis in her right eye. (d) However, after curling
up the right upper eyelid skin, margin-re ex distance was smaller than on the left side. This patient had both right upper blepharoptosis
and dermatochalasis.
Fig. 14.6 Method of measuring the levator function. It was de ned as the movement of the upper eyelid margin in millimeters from (a)
down-gaze to (b) up-gaze while xating the brow with the examiner’s ngers.
a
b
c
d
a
b

14 Aging-Related Upper Blepharoplasty
177
fat pocket to extend laterally and cover the anterior
aspect of the lacrim al gland. In a previous study based on
Korean aged people, the eyelid fat was m ost protruded at
the central lower part.7
Corneal Protection Mechanism
Ocular motility and Bell’s phenomenon should be checked
carefully before surgery. Con rm that the eyelid is com -
pletely closed with a blink. Poor Bell’s phenomenon can
cause exposure keratitis or corneal ulcer postoperatively.
Bell’s phenomenon must be normal.
Tear Secretion
If the patient complains of ocular irritation sym ptom s, it
is likely that the patient has a problem w ith tear secre-
tion such as dry eye syndrom e. Tear film breakup tim e,
the presence of lagophthalm os, and symptom s or signs
of dryness should also be assessed preoperatively. Dry-
ness can be aggravated after surgery, especially in the
elderly patient. The surgeon w ho is not fam iliar w ith
those ocular exam inations can consult an ophthalm olo-
gist to check the presence and severit y of dry eye. Also,
the patient should be notified that his or her sym ptom s
w ill not improve and m ay even be aggravated after
blepharoplasty. So if the patient com plains of severe
symptom s of dry eye, the surgeon should m ake the
patient understand that ocular irritation m ay be aggra-
vated after blepharoplasty. After a thorough discus-
sion of the risk factors, a decision should be m ade on
w hether to proceed w ith the blepharoplasty procedure
as planned or not.
Lacrimal Gland Position
The lacrimal gland is located laterally just behind the orbital
rim, and normally it is not seen during blepharoplasty.
With aging and the thinning of the fascial system support-
ing the lacrimal gland, it prolapses and might be mistaken
for lateral fat prolapse, especially in Asian patients who
have thick skin over the lacrimal gland, and this prolapsed
lacrimal gland can be easily overlooked.
Eyelid Wrinkles
Horizontal and vertical wrinkles from the procerus and
corrugator muscles at the glabella and crow’s-feet from
the orbicularis at the lateral eyelid form with aging. These
wrinkles can be partially removed with blepharoplasty,
but most of the time botulinum toxin or ller injection is
necessary.
Upper Eyelid Crease
The upper eyelid crease is m ade by attachm ent of the
levator aponeurosis extending through the orbicularis
into the skin. The upper eyelid crease is higher in fem ales
than in m ales. The upper eyelid crease is usually low
or absent in the Asian eyelid. The average Asian eyelid
crease is 2 m m lower compared w ith Caucasians,12 w ith
a height of 6 to 8 m m in fem ales and 4 to 6 m m in m ales.
Asym m etric height or m ultiple double-lid creases m ay
reflect stretching or disinsertion of the levator aponeu-
rosis. The double-eyelid crease itself is usually elevated
w ith involutional changes, but the overlying derm ato-
chalasis m ay conceal that, especially in the Asian elderly.
High duplicated eyelid creases m ay indicate disinsertion
of the levator aponeurosis.
The Asian patient with a double-eyelid crease created
during previous surgery is treated in the same way as the
patient with a natural crease. But the most di cult com -
plication in aging-related blepharoplasty in Asians is a
very high-positioned double-eyelid crease in the patient
who underwent excessive skin and fat removal at a young
age, and who is aging now. These patients have little skin
remaining to resect and may have some adhesions with
underlying tissues. Therefore, removing more skin or lifting
the brow can make an unnatural eyelid crease noticeable. If
the patient has some drooping skin over the eyelid crease,
making the “visible” eyelid crease look natural and not too
high, it is better not to do surgery and just leave it as it is.
Instead, autologous fat or ller injection along the brow and
upper eyelid complex may be helpful in improving cosme-
sis. Only the patient with profound blepharoptosis needs
to undergo corrective surgery by levator advancement or
by resection to elevate the eyelid and to make the visible
eyelid crease look smaller.
Orbital Fat Prolapse
Periorbital fat is very important in blepharoplasty, espe-
cially in aged people. In some patients, subbrow fat can
droop down to the orbital septal area, and it makes for a
pu y upper eyelid appearance. It should be di erentiated
from orbital fat prolapse.
The pre-aponeurotic fat pockets are important sur-
gical landm arks, as they identify the plane im m ediately
posterior to the orbital septum and im m ediately anterior
to the levator aponeurosis. There are two fat pockets in
the upper eyelid, one m edial and one central, separated
by fascial connections continuous w ith the trochlea. The
m edial fat pocket is w hiter than the central fat pocket.
With aging, the septum becom es thin and lax, resulting
in fat prolapse and pu y eyelid. Although it is generally
know n that there is no lateral fat pocket in the upper eye-
lid, it is quite com m on for the central pre-aponeurotic

III Blepharoplasty
178
patients do not want an arti cial-looking crease, the inci-
sion line can be marked very close to the eyelid margin. If
the patient has lateral hooding of the skin, the incision may
be extended to the lateral canthal area, but no more than 1
cm from the lateral canthal angle. This design is intended to
excise more lateral skin than skin from the medial or cen-
tral side.
Using smooth forceps, the redundant skin is grasped
and marked. Lidocaine mixed with epinephrine (1:100,000)
is injected subcutaneously along the previous marking line.
The incision is made with a no. 15 or 15T Bard-Parker blade
or scissors Recently CO2 lasers and radiofrequency waves
have been used to minimize bleeding.
Redundant Skin Excision
The skin and orbicularis muscle are incised and dissected
from the septum (Fig. 14.8). The skin and orbicularis are
excised in one layer. This skin-muscle excision technique
causes less bleeding and makes it easy to protect the orbital
septum. Care should be taken not to cause injury to the
orbital septum, which is a whitish membranous structure.
Skin Texture and Thickness
Skin texture change in aging patients is highly variable
among individuals but is usually proportional to the indi-
vidual’s environmental sun exposure.13 Epidermal thinning
and decrease in collagen cause skin to lose its elasticity. Loss
of fat, coupled with gravity and muscle pull, leads to wrin-
kling and the formation of dynamic lines. The aging process
has also been shown to a ect facial bones. In Asians, who
have relatively thicker skin, a lower double-eyelid fold and
conservative skin resection are recommended in such cases.

■Surgical Techniques
Anesthesia
Blepharoplasty can be performed under general, seda-
tive, or local anesthesia, but local anesthesia is preferable.
Recently, monitored anesthesia care (MAC) has been gain-
ing popularity in blepharoplasty. MAC is a planned proce-
dure during which the patient undergoes local anesthesia
together with sedation and analgesia. Patients undergoing
conscious sedation are able to answer to orders appropri-
ately and have the eyelid height and contour checked in
the sitting position during surgery. Two percent lidocaine
mixed with epinephrine (1:100,000) is usually used as the
local anesthetic. Local anesthesia is to be injected slowly
to reduce pain during injection and should not be injected
into the muscle layer to avoid bleeding. After the local anes-
thesia injection, light compression is applied to prevent
pressure and to distribute the anesthetic drug evenly to the
surgical eld.
Designing the Eyelid Crease and
Skin Excision
The most important step in blepharoplasty is design-
ing, which is deciding the amount of skin and muscle to
be excised. It is important that the same amount of skin
between the brow and eyelid fold be kept in both eyes, rather
than removing symmetrical amounts of skin (Fig. 14.7).
After designing the eyelid crease line with the patient
in the supine position, the patient is turned to the sitting
position. The surgeon grasps the skin and decides how
much of the redundant skin is to be excised while the
patient is asked to open and close the eye. When grasping
the skin to excise, development of a 1-mm lagophthalmos
or slight eversion of the eyelash is proper. Caution should
be taken to leave at least 15 mm of skin between the eye-
brow and double-eyelid fold. In case of designing a double
lid, care should be taken to ensure a symmetric height. The
incision line is marked at 4 to 7 mm from the eyelid margin
and is recommended not to exceed 10 mm. In cases where
Fig. 14.7 Surgical techniques of Asian upper eyelid blepharo-
plasty. The skin to be excised was demarcated by grasping redun-
dant skin and marking.
Fig. 14.8 Skin and orbicularis muscle were incised along previous
marking and dissected from the septum.

14 Aging-Related Upper Blepharoplasty
179
then removed after hemostasis is secured. This procedure
can cause pain; therefore, additional local anesthesia injec-
tion before fat removal is recommended.
Eyelid Crease Formation
There are several ways to approach eyelid crease formation,
and the authors mainly use one of two methods: levator
xation or tarsal xation. We prefer tarsal xation: Non-
absorbable sutures such as 7–0 nylon are applied through
the skin, epitarsal tissue, and the skin of the opposite side
(Fig. 14.10). In the levator xation method, sutures are
applied between the fused septum -levator end and the
subcutaneous tissue of the lower incision margin.
Skin Closure
The skin is closed with 6–0 or 7–0 nonabsorbable
sutures and antibiotic ointment is applied to the wound
(Fig. 14.11). Before suturing the skin, the patient sits and
the symmetry of the eyelid contour and the height of the
double lid are checked by both the patient and surgeon. The
orbital septum should not be sutured.
Fat Removal
At this point orbital fat can be seen behind the thin septum.
Orbital fat prolapses easily when the eyeball is compressed
(Fig. 14.9a). When the septum is incised, attention should
be paid to make sure the incision line is above the line
where the aponeurosis and septam are fused. A rake retrac-
tor is placed at the upper incision margin, pulling this edge
upward and slightly elevating it, and the patient is asked to
open and close the eyes; then the dynamic dimpling line
becomes visible. This line is where the aponeurosis and
septum are fused. The incision should be made above this
line to avoid injury of the levator aponeurosis.
The orbital septum is then partially opened and the
pre-aponeurotic fat is exposed and removed (Fig. 14.9b).
Orbital fat removal is not an indispensable procedure and
depends on the amount of fat prolapse present or the indi-
vidual’s desire. It is also important that the volume and dis-
tribution of remaining fat be almost the same bilaterally.
Once the fat is identi ed and separated from surrounding
tissues such as the septum and levator aponeurosis, it is
clamped with a ne-toothed mosquito forceps (Fig. 14.9c)
and cut w ith scissors or electrocautery needle tip. Electro-
coagulation is applied to the remaining fat while the clamp
is still engaged (Fig. 14.9d). The grasping instrument is
Fig. 14.9 (a–d) The orbital septum was opened and orbital fat was identi ed. Orbital fat was grasped, cut, and cauterized using mono-
polar cautery.
a
b
c
d

III Blepharoplasty
180

■Complications and
Their Management
Many di erent blepharoplasty techniques have been intro-
duced and all of these are associated with certain prevent-
able complications. In this section, the most common and
signi cant complications and their prevention and man-
agement will be described.
Under-Correction or
Patient Dissatisfaction
The most common complication of blepharoplasty in
elderly people is under-correction or patient dissatisfaction.
It is important to promote a realistic understanding of the
outcome of blepharoplasty through an in-depth discussion
between the surgeon and the patient before the surgery.
Usually a double-eyelid crease over 7 to 8 mm in height
looks very unnatural in Asians, even in female patients.
Slightly folded upper eyelid skin over the double-eyelid
crease or a low double-eyelid crease, such as 3 to 4 mm,
looks more natural and blends well. Sometimes, patients
have di erent or unrealistic expectations; thus a thorough
preoperative discussion of the anticipated results is critical.
Surgeons should explain reasonable postoperative expec-
tations and possible complications before surgery.
Most doctors would expect a patient to be satis ed
with wider vision after the correction of obscured vision
due to upper eyelid drooping in an elderly patient. How-
ever, patients were found to be satis ed only with an excel-
lent cosmetic outcome even though that was not their
primary concern prior to the surgery. A small blunder in
the cosmetic appearance postoperatively can easily cause
disappointment in a patient even though the visual eld is
greatly improved, to the extent that some may even con-
sider the surgery a useless one.

■Postoperative Care
Ice pack compression is applied during the rst 48 hours
after surgery to minimize bleeding and edema. In nondia-
betic patients, intravenous steroid injection can be helpful
to decrease in ammation and edema. The skin sutures are
removed after 5 to 7 days.

■Key Technical Points
1. Design of the surgery is the most important step in
blepharoplasty. When determining the amount of
skin and muscle to excise, it is important that the
same amount of skin between the brow and eyelid
fold remain in both eyes, avoiding the removal of an
asymmetric amount of skin.
2. In the case of designing a double lid, the incision line
is marked at 4 to 7 mm from the eyelid margin and is
recommended not to exceed 10 mm.
3. Fat is removed after grasping with a ne-toothed
mosquito forceps, and electrocoagulation is applied
to the remaining fat while keeping the forceps
engaged. The grasping instrument is removed after
hemostasis is con rmed.
4. At the nal stage of the surgery, the patient is asked
to sit up and symmetry of the eyelid contour and
height of the double lid are checked by both the
patient and the surgeon.
Fig. 14.10 A crease was made using tarsal xation suture: sutures
are applied through the skin, epitarsal tissue, and the skin of the
opposite side.
Fig. 14.11 Skin was closed using a continuous running suture.

14 Aging-Related Upper Blepharoplasty
181
mosquito forceps should be maintained, and after releasing
the clamp, hemostasis of the remaining fat edge should be
secured. Hemorrhage from the orbital fat can cause retro-
bulbar hemorrhage and optic nerve compression, leading to
visual impairment. If retrobulbar orbital hemorrhage caus-
ing visual impairment is suspected, the wound should be
opened up immediately, the bleeding focus should be found
and coagulated, and the drain should be left for some time.
Exposure Keratopathy
Upper eyelid blepharoplasty can a ect the blinking func-
tion, and in elderly patients dryness may be aggravated.
Therefore, it is important to evaluate tear breakup time and
Bell’s phenomenon before making the decision in favor of
blepharoplasty. Proper explanation and management of
the dry eye syndrome is mandatory.
Lacrimal Gland Injury
A prolapsed lacrimal gland may not be recognized preop-
eratively, or intraoperatively. If prolapse of a lacrimal gland
is identi ed, the prolapsed gland should be returned to
the original position by xating it to the adjacent perios-
teum and should not be excised. A normal lacrimal gland is
pale pinkish in color, has a nely lobulated structure, and
is rmer than a fat component. If it is not corrected prop-
erly, lateral upper eyelid fullness will be left after blepha-
roplasty. Therefore, if lacrimal gland prolapse is noticeable
after surgery, the patient may be brought back to the oper-
ating room to have the lacrimal gland repositioned.
Too-High Double-Lid Fold
In Asians, an absent or low-positioned double-eyelid fold is
natural-looking. During detailed preoperative consultation,
the surgeon and patient should decide whether an eyelid
crease will be made and how high it should be. Sometimes
a toothpick and a mirror are useful in determining the
height of the eyelid crease. Some elderly Asians will not
want arti cial eyelid creases.
Deep Superior Sulcus
Excessive fat removal is usually preventable at the time of
surgery. Nowadays, patients want to have a natural, semi-
pu y, young-looking eyelid rather than a hollow superior
sulcus; therefore, fat removal should be cautiously per-
formed, with care taken not to excise the entire eyelid fatty
tissue. Moreover, excessive fat removal can cause multiple
eyelid creases and it is hard to correct due to the strong
adhesion between the levator and orbicularis.
Asymmetric or Unnatural Eyelid
Contour
Severe dermatochalasis can obscure pre-existing eyelid
asymmetry, and many patients do not realize this before sur-
geons point it out to them. In these patients, cautious design
is mandatory to maintain symmetric skin and fat, instead of
removing a symmetrical amount of skin and fat. Surgeons
should also pay attention to the position of the eyebrow,
because asymmetric eyebrow can cause postoperative asym-
metry or under-correction. Aging-related blepharoplasty is
usually performed in conjunction with levator aponeurosis
manipulation, and xation sutures between the levator apo-
neurosis and the tarsal plate can lead to an asymmetric or
unnatural contour. To prevent this complication the xation
should be carefully placed.
Excessive Skin Removal
Excessive removal of skin is a serious complication and very
di cult to correct. The authors have seen many patients
who had too much upper eyelid skin excised during cos-
metic blepharoplasty, especially in the elderly, and are in
agreement with Flowers’s dictum that 20 mm of anterior
lamella is necessary for normal functioning of the upper
eyelid.14 If brow ptosis is present, the surgeon must confer
w ith the patient and decide whether to correct it or not;
depending on the result, the amount of skin resection then
has to be decided.
Lagophthalmos
Lagophthalmos is not a complication but an unavoidable out-
come of aging-related blepharoplasty, especially in patients
with decreased levator function. A topical lubricant and
ointment are helpful during the early postoperative stage,
and many will resolve over time without surgical interven-
tion. Skin grafts may be needed in cases of severe lagoph-
thalmos and keratitis caused by excessive skin excision.
Orbital Hemorrhage
Antiplatelet medications, aspirin, and nonsteroidal anti-
in ammatory agents are commonly used by other depart-
ments in elderly patients. The medical history and records
should be carefully checked and consultations should be
made about stopping drugs that may a ect coagulation. It
is also important to ascertain that the patient is normoten-
sive preoperatively and during surgery. It is also crucial to
understand and identify the anatomy of upper eyelid vas-
culature in the surgical eld. When removing and cauter-
izing pre-aponeurotic fat, clamping with a ne-toothed

III Blepharoplasty
182
His brow position was symmetric and had minimal fat
prolapse. The main problem was droopy eyelid skin that
caused visual eld impairment and lateral canthal eczema.
Intraoperatively, redundant skin, including the lateral
canthal droopy skin, was carefully removed, leaving sym -
metric amounts of skin bilaterally.
After skin removal and formation of a low-sitting eyelid
crease, he could see more comfortably and the eczema at
the lateral canthal angle also disappeared (Fig. 14.12b).

■Case Studies
Case 1
A 65-year-old Asian man who did not want the creation
of noticeable eyelid creases visited the authors’ clinic
(Fig. 14.12a). He just wanted to remove droopy eyelid skin
and to have a natural eyelid crease so that he could have a
wider visual eld.
Fig. 14.12 Case 1. Blepharoplasty making a natural eyelid crease. (a) A 65-year-old man has a droopy eyelid skin that causes visual eld
impairment and lateral canthal eczema. (b) After the excision of the droopy skin with low-sitting eyelid crease formation, he could see
more comfortably and the eczema at the lateral canthal angle disappeared.
Case 2
A 59-year-old man did not want to have an eyelid crease
created, but just wanted the droopy skin removed and to
have the eyelid height lifted (Fig. 14.13a). The main prob-
lem was droopy eyelid skin that caused visual eld impair-
ment and lateral canthal eczema.
Intraoperatively, redundant skin, including the lateral
canthal angle skin droop, was carefully removed to leave
symmetric amounts of skin bilaterally. A larger amount of
skin and muscle was excised in the lateral eyelid. After skin
and muscle was removed, the skin was closed with contin-
uous sutures without making an eyelid fold (Fig. 14.13b).
Fig. 14.13 Case 2. Blepharoplasty without creation of an eyelid crease. (a) A 59-year-old man who has droopy eyelid skin with lateral
canthal eczema. (b) After the skin and muscle excision but without creation of an eyelid fold.
a
b
a
b