Phẫu Thuật Tạo Hình Thẩm Mỹ Khuôn Mặt Người Á Đông

184
15 Epicanthoplasty and Aesthetic Lateral
Canthoplasty
Yongho Shin
cles represent ~ 10%. The hook shape (37%) is accompanied
by a down-pointing medial palpebral commissure (Fig. 15.2).3
For triangular and round caruncles, the extent of
epicanthal release is determined considering the whole
proportion of the eyes. However, hook-shaped caruncles
require a di erent approach because epicanthal tendons
run downward along the outer curvature. If too much of
this epicanthal fold is eliminated, the outcome will be an
aggressive appearance that will most likely to be unac-
ceptable to the patient. The size of visible caruncle after
epicanthoplasty is an important consideration. In East
Asian patients, the caruncle is visible for 3 to 5 mm at the
medial side. If the epicanthal fold covers the caruncle and
the externally visible part of the caruncle is 1 mm or less, a
more drastic intervention may be required.
Epicanthal folds can be divided into four types: epi-
canthus supraciliaris, epicanthus palpebralis, epicanthus
tarsalis, and epicanthus inversus (Fig. 15.3).1 Epicanthal
folds represent a wide spectrum of soft tissue con gura-
tions with varying etiologies, and thus there cannot be a
single operation that is suited for all patients and situa-
tions. The sheer numbers and variations of epicanthoplasty
techniques serve to demonstrate this fundamental concept
in epicanthoplasty.

■Epicanthoplasty
The epicanthal fold is excessive brous tissue that lies in a
vertical, semilunar orientation, and it is a distinctive fea-
ture of the Asian eyelid. Cosmetic epicanthoplasty releases
the epicanthal fold and modi es the medial corner of the
palpebral ssure. The operation reveals more of the medial
portion of the eye while simultaneously decreasing the
interepicanthal distance (Fig. 15.1).
In East Asian populations, the mean interepicanthal
distance is reported to be 3.48 to 3.6 cm.1 Among beauty
contestants in the 2003 “Miss Korea” contest, this distance
was 3.17 cm on average, which is shorter than the mean
value, and this implies that the contestants probably did
not have highly conspicuous epicanthal folds. The interepi-
canthal distance should be interpreted in the context of the
overall relationship between the epicanthal fold and the
remainder of the eye. Epicanthal folds appear most natural
when less than half of the caruncle is covered. Usually, 80
to 90% exposure of the caruncle is aesthetically pleasing.1,2
The shape of the lacrimal caruncle can be triangular,
round, or hook-shaped. Triangular caruncles account for 53%
and are mostly found among Asian patients. The round carun-
Pearls
• Cosmetic epicanthoplasty releases the epicanthal
fold and modi es the medial corner of the palpebral
ssure, thus revealing more of the medial portion of
the eye and decreasing the interepicanthal distance.
• The lacrimal caruncle can be triangular, round,
or hook-shaped, and these variations need
to be considered in selecting an approach for
epicanthoplasty.
• When modifying the canthus for aesthetic reasons,
a conservative approach is recommended because
an over-corrected epicanthus is extremely di cult
to revise.
• Right and left lacrimal caruncles have di erent
scales of grow th and direction, which needs
consideration in the design of epicanthoplasty.
• When a double-fold operation is combined with
epicanthoplasty, redundant skin from the upper ap
of the double eyelid should be rotated toward the
de cient skin on the inner part of the lower eyelid to
decrease the risk of partial ectropion.
• The two most frequent complications of
epicanthoplasty are scarring and the aggravation
of the epicanthus inversus. These risks can be
reduced by designing the skin incisions along the
relaxed skin tension lines and avoiding a connection
between the epicanthoplasty and blepharoplasty
incisions.
• In aesthetic lateral canthoplasty, not only horizontal
palpebral extension but also proper posterior
deepening is important to maintain a proper contact
between the eyeball and palpebral conjunctiva.
• Combined lateral canthoplasty and lowering of
lower eyelid slant will make the eyes look mild
and big. Mongolian slant lowering can be done by
suturing between the tarsus and capsulopalpebral
fascia.

15 Epicanthoplasty and Aesthetic Lateral Canthoplasty
185
a more natural-looking epicanthus with double fold. East
Asians tend to have thicker skin near the nasal bridge and
epicanthal area than in the upper eyelid, which is more
reactive and prone to hypertrophic scarring after epic-
anthoplasty. Preoperatively, patients should always be
informed that under-corrected or asymmetric epicanthus
may develop as a complication.
Each epicanthal fold can be divided into upper, mid-
dle, and lower thirds. For each portion, anatomic features
should be thoroughly examined, such as skin redundancy,
extent of skin hooding, and amount of soft tissue tension.
Even in a single patient, the sizes of the bilateral lacrimal
caruncles may di er, so the side of the smaller caruncle
should be opened more widely to make for symmetry after
epicanthoplasty. Therefore, it is crucial to prepare a precise
medical examination and diagnosis.
Double-Fold Operation and
Epicanthoplasty
In East Asian patients, the double-fold operation is com -
monly performed in conjunction with epicanthoplasty. In
such a combined operation, the redundant skin from the
upper ap of the double eyelid should be rotated toward
the de cient skin on the inner part of the lower eyelid. This
redistribution of soft tissue is helpful in decreasing the risk
of partial ectropion caused by epicanthoplasty (Fig. 15.4).
If epicanthoplasty is performed without the double-
fold operation, a dog-ear might form on the upper and
medial parts of the epicanthal fold and will need excision.
Occasionally, this excision can result in a new, unwanted
double-eyelid line. To prevent this new double-eyelid line,
Early in its development, epicanthoplasty consisted
only of skin excision with the idea that epicanthal folds
were manifestations of redundant skin around the medial
canthus. However, a common complication of this method
was visible scarring caused by excessive tension in the skin,
especially in the lower one-third of the medial canthus. On
one hand, skin redundancy in the upper third of the epi-
canthal fold is usually accompanied by a skin de ciency of
the lower third. In such con guration, the redundant skin
should be used as a ap to relieve the tension on the lower
third, which is crucial in the prevention of ectropion along
the medial portion of the lower eyelid. On the other hand,
skin redundancy of the lower section indicates that the epi-
canthal fold is caused by multiple factors. Even if the lower
skin is not de cient, upper excessive skin excision should
be minimized in such cases.
Patient Evaluation
It is important to measure the interepicanthal distance and
the amount of exposed lacrimal caruncle. Patients with
extreme epicanthal fold and w ide interepicanthal dis-
tance can realize a dramatic bene t from this procedure.
A patient can inspect the changes after epicanthoplasty
by nger traction of the inner canthus. Under-correction
is safer than over-correction because an under-corrected
epicanthal fold can be revised much more easily than an
over-corrected epicanthal fold.
Of the four types of epicanthal folds, epicanthus tar-
salis is most common in East Asians. Not all epicanthal
folds require correction, and epicanthus tarsalis allows for
A
B
Fig. 15.1 Distance between the eyes. A, intercanthal distance; B,
interepicanthal distance
Fig. 15.2 Three shapes of lacrimal caruncle. (a) Triangular shape.
(b) Round shape. (c) Hook shape.
a
b
c
Fig. 15.3 Classi cation of epicanthal folds as proposed by John-
son. (a) Epicanthus supraciliaris. (b) Epicanthus palpebralis. (c) Epi-
canthus tarsalis. (d) Epicanthus inversus.
a
b
c
d

III Blepharoplasty
186
3. Can the transverse incision be placed in a nonvisible
area or along a relaxed skin tension line?
4. Is it possible to leave a skin bridge between the
epicanthoplasty incision and the double-eyelid
incision?
5. Of the appropriate operative techniques, which am I
most comfortable with?
Simple Skin Excision
Simple skin excision is not complicated and can be per-
formed even by inexperienced surgeons. Although skin-only
excision can be suitable for some cases, excessive tension in
the lower ap is a concern and can result in postoperative
scarring. To decrease tension, the soft tissue must be dis-
sected and the perpendicular accessory ber must be tran-
sected. This method is not commonly performed nowadays.
V-Y Advancement Methods
There are several known variations of V-Y advancement.
The Roveda method involves advancement of the nasal side
skin and removal of the remaining skin from the top and
bottom to prevent dog-ear. Uchida modi ed the Roveda
the dog-ear should be resected as close to the upper cilia
as possible. If the skin is insu cient on the lid margin of
the medial caruncle, the dog-ear portion of the upper ap
should be preserved and turned into a triangular ap to
be rotated into the inner portion of the new canthotomy
structure (Fig. 15.5). Another possibility is to release the
band-shaped epicanthus inversus on the lower part of the
epicanthal fold by rotating the ap made by the dog-ear
and advancing the triangular ap perpendicularly to the
epicanthus inversus.
Surgical Techniques
There is no single technique that can address the full spec-
trum of epicanthal folds, and the surgeon must rely on a set
of techniques that are applicable to speci c types of epican-
thal folds. Most epicanthoplasty techniques are variations
and combinations of a few fundamental concepts: simple
skin excision, V-Y advancement, Z-plasty, and W-plasty.
The following ve questions must be answered before the
appropriate epicanthoplasty technique can be chosen.
1. How will I manage the skin redundancy and
de ciency?
2. How will I control the extent of caruncle exposure?
Fig. 15.4 The reverse Fuente's design. (a,b) The triangular ap from the inner upper part of the epicanthal fold is rotated toward the
incision site of the lower eyelid to hide the scar. (c) A 19-year-old girl wanting epicanthoplasty and double-eyelid surgery. Medial epican-
thoplasty with reverse Fuente’s design and incisional double-eyelid surgery were performed. (d) After surgery, more exposed caruncle
with double eyelids makes the eyes more beautiful.
a
b
c
d

15 Epicanthoplasty and Aesthetic Lateral Canthoplasty
187
Skin Redraping Method
Another frequently used epicanthoplasty technique is the
skin redraping method. It can be performed simultaneously
with the double-eyelid fold operation. The skin redraping
design was originally rectilinear but the design needs to be
modi ed from a rectilinear line to a round or slightly trian-
gular line. This modi cation can prevent ectropion at the
medial side of the lower eyelid (Fig. 15.8). When epicantho-
plasty is performed without the double-eyelid fold opera-
tion, the triangular ap should be placed as close to the
ciliary line as possible. In addition, the incision should be
extended to allow adequate resection of the redundant skin.
Underdeveloped lacrimal caruncle cases are extremely
challenging to address. In such patients, the medial canthal
tendon requires plication to reveal more of the medial cor-
ner of the eye. The canthal tendon can be secured through a
hole drilled through the nasal bone using either metal wire
or thick nylon suture.5

■Complications and
Their Management
The two most frequent complications of epicanthoplasty
are scar and the aggravation of the epicanthus inversus.
The risk of these complications can be reduced by design-
ing the skin incisions along the relaxed skin tension lines
and avoiding a connection between the epicanthoplasty
and blepharoplasty incisions. It is better to separate epic-
anthoplasty and blepharoplasty incision lines because the
movement of the upper eyelid can transmit tension from
the upper blepharoplasty incision to the epicanthoplasty
incision in case these two incisions are continuous. Rota-
tion of the redundant upper skin to the lower portion of the
epicanthus reduces the tension ectropion. Iatrogenic epi-
canthus inversus is aggravated by perpendicular tension,
method, but the Uchida design was too close to the lacrimal
caruncle to prevent noticeable scars. The Uchida method
has been further modi ed to the periciliary epicanthal fold
incision method, which involves a large V-shaped incision
followed by dissection and excision of the surrounding skin
to completely hide the scar (Fig. 15.6).4
Z-Plasty Flap
This is a frequently used technique with many variations to
allow for exibility in the location and size of the two skin
aps. Fuente’s design incorporates half of a Z-plasty, which
takes the triangular ap from the lower part of the epican-
thal fold and transfers it to the middle part, and extends the
double-eyelid fold incision line toward the inner upper part.
This method is recommended for patients with a pre-exist-
ing double-eyelid fold. However, resection of redundant
skin is necessary, if the technique is performed simultane-
ously with the double-fold line operation (Fig. 15.7).
Park’s method is a modi cation of Fuente’s method and
incorporates partial resection of redundant skin between
the double-eyelid fold line and the epicanthoplasty site. This
method rotates skin from the lower epicanthal fold to the
middle portion. The redundant skin in the upper epicanthal
fold is resected. This procedure is suitable for patients who
have the redundant skin in the lower epicanthal fold with
high tension in the middle portion. The technique is also
useful in addressing the dog-ear from the redundant skin
along the upper blepharoplasty incision line.
The reverse design of Fuente’s method can be used
for patients with redundant skin on the upper part of the
epicanthal fold and lack of skin on the lower part. In such
cases, the triangular ap should be made on the upper
inner part and rotated downward (Fig. 15.4). If less than 1
mm of lacrimal caruncle is visible, then the triangular ap
from the upper part of the epicanthal fold is rotated into
the medial canthotomy site (Fig. 15.5).
Fig. 15.5 Rotation of the triangular ap into the canthotomy site
allows greater exposure of the caruncle.
x'
x
y
z
Fig. 15.6 Design of periciliary V-Y advancement epicanthoplasty.
The innermost point of the lacrimal caruncle x becomes x’ after V-Y
advancement. Extended skin incision along the upper and lower
ciliary margin (y, z) is necessary for dog-ear removal.

III Blepharoplasty
188
The epicanthoplasty site is treated with topical steroid
ointment for 6 weeks after surgery to limit the proliferation
of broblasts between 2 to 6 weeks. Patients with a history
of hypertropic scar or keloid are prescribed tranilast (oral
T-cell grow th factor [TGF] β-inhibitor) for 6 to 12 weeks.
Under-corrected epicanthal folds can be revised within
the rst week of the initial operation. Beyond this period,
however, revisions should not be attempted until after 6
months, or until the hypertrophic response has subsided.
Frequently, revisions are required due to asymmetry in
and is prevented by transecting the accessory ber of the
orbicularis muscle. The transected bers should be reori-
ented by advancing the skin ap transversely.
The postoperative scar should be placed in a hidden
area, as much as the surgical design allows. The tension
across the surgical wound should be held by absorbable
dermal sutures, not by super cial skin sutures. The skin
layer should be closed with the thinnest suture needed (i.e.,
7–0) under the surgical loupe.
Modified Uchida’s method
Matsunaga’s modified “M”-plasty method
Fuente’s transposition flap
Jordan’s “a deep tissue approach” method
Yoon’s “one-armed jumping man” method
Wu’s square-flap method
Park’s “Z-plasty” method
Fig. 15.7 Various types of epicanthoplasty commonly used in
Asian patients
w
x'
x y

z
x'
w
w

x

y
z
x'
Fig. 15.8 (a,b) Skin redraping method of epicanthoplasty. To
avoid ectropion, the skin redraping design is modi ed from a rec-
tilinear line to a round or slightly triangular line. For example, the
point x is moved to x′ to avoid ectropion.
a
b

15 Epicanthoplasty and Aesthetic Lateral Canthoplasty
189
prevents back-cut scars and avoids the relapse of excessive
exposure of the lacrimal caruncle (Fig. 15.10).
Even after reconstructive epicanthoplasty, recurrence
of skin extension and asymmetry of the eyes may develop.
Thus, it is strongly recommended that the surgeon inform
patients about the possibility of developing micro di er-
ence between the left and the right, the possibility of addi-
tional operations, and the limits of these operations before
surgery.2

■Aesthetic Lateral Canthoplasty
Generally, lateral canthoplasty refers to all of the surgeries
transforming the lateral canthus. Notably, a lot of Western
studies have commonly introduced lateral canthoplasty as
a surgical method that corrects canthal laxity or lower lid
malposition and relieves aging-related signs on the lower
eyelid and midface. “Lateral canthus extension” surgery
performed for Asians as a cosmetic procedure is also con-
sidered lateral canthoplasty. However, to be precise, lateral
canthoplasty is an expansion of the lateral canthus and a
reshaping of the lateral canthal area including the angle of
lateral canthus. Since the eyeball is spherical in shape, the
palpebra is a three-dimensional structure. For cosmetic lat-
eral canthoplasty, not only horizontal palpebral extension,
but also proper posterior deepening should be performed
so that a proper contact between eyeball and palpebral
conjunctiva can be maintained.6
Patient Evaluation
As with every cosmetic eyelid surgery, it is necessary to
check the patient’s eye condition before undergoing lateral
canthoplasty. Considerations in the selection of good can-
the nal shapes of the epicanthal fold and medial canthal
angle. To prevent unnecessary reconstructive surgeries,
patients should be provided with su cient explanations
about how the two lacrimal caruncles have di erent scales
of grow th and direction.
Hypertrophic scar is treated with triamcinolone injec-
tion, but the triamcinolone must be diluted four times
more than the usual dose. Otherwise, there could be some
visible white powders appearing through translucent skin
for a long period. Without dilution of the triamcinolone,
dermis atrophy and telangiectasia may develop.
Reconstructive Epicanthoplasty
If the interepicanthal distance is less than 3 cm, then the eyes
look too close together. In addition, if more than 5 mm of
lacrimal caruncle is exposed on both sides, it could cause an
uncomfortable look. Besides excessive exposure of the lacri-
mal caruncle, there could be some prominent epicanthoplasty
scarring. Reconstructive epicanthoplasty reduces and conceals
this scarring and changes the unnatural parallel fold (outfold)
into a more favorable natural-shaped epicanthal fold.
A fundamental workhorse for reconstructive epican-
thoplasty is the V-Y advancement ap. Mostly, the epi-
canthus inversus appears around the lower part of the
epicanthus due to perpendicular tension of the upper part.
One method to treat such a condition could be a back-cut
skin incision in the lower part of the epicanthus (Fig. 15.9).
Another method is to make a long, inferiorly directed
V- ap in the V-Y advancement ap design to prevent epi-
canthus inversus. The lower incision of the V- ap starts
from the more lateral side of the back-cut site and passes
parallel to the lower cilia and extends to the medial side.
Instead of the back-cut design, the V- ap is rotated and
lls the skin de ciency. By this V- ap rotation, the surgeon
Fig. 15.9 V-Y advancement and low back-cut design for
epicanthal reconstruction. (a) Design without skin traction.
(b) Design with skin traction. (c) Sutured state after V-Y
advancement. (d) Back-cut for avoiding epicanthus inversus.
(e) Sutured state with no skin tension.
a
b
c
d
e

III Blepharoplasty
190
Surgical Techniques
Western literature has detailed the surgical methods for
expansion of the lateral canthus and horizontal expan-
sion of the palpebral ssure. Because lateral canthoplasty
has been introduced as a treatment for blepharophimosis
and reconstructive surgery, some surgical methods are
not suitable for Asians who want this surgery for cosmetic
improvement only.
Von Ammon’s Method
Von Ammon’s method is the oldest procedure for lateral
canthus expansion and has been used as a lateral cantho-
plasty method for Asians. Incise the full layer of lateral can-
thus horizontally as desired. Elevate the conjunctival ap
medially from the lateral end (Fig. 15.11a). Pull the end of
the conjunctival ap and suture it to the skin of the lateral
corner. The remaining skin incision is closed separately. A
double-armed suture is passed through the conjunctiva at
the canthus, brought out lateral to the canthus, and tied
over a peg (Fig. 15.11b). This will prevent the newly formed
fornix from getting round and at and will make the new
lateral canthus deeper. Disadvantages of this method are
the exposure of red conjunctiva when the conjunctiva is
pulled too much and a visible scar at the lateral part of the
lower eyelid.10
Blaskovics’ Method
To perform Blaskovics’ method, make a V-shaped incision
on the lateral canthus and lean the triangular ap upward
(Fig. 15.12a). Make a full-layer incision of the lateral canthus
horizontally as in Von Ammon’s method (Fig. 15.12b). Suture
the wedge-shaped incision site made by elevation of the tri-
angular ap. Trim the skin of the triangular ap and suture to
didates include the degree of exophthalmos and the loca-
tion of orbital bone and cilia. Generally, people who have
exophthalmic eyes have better attachment between eyeball
and palpebral conjunctiva after lateral canthoplasty than
people who have enophthalmic eyes. In addition, patients
with exophthalmic eyes show more visible expansion of
the lateral canthus from the frontal view. When the dis-
tance between the lateral canthus and the lateral orbital
rim is very small, patients have lower satisfaction after
surgery due to the decreased horizontal expansion e ect.
Lateral canthoplasty is not recommended in patients who
have severe ptosis because the power of the vector occur-
ring from the lateral and posterior extension of the canthus
tends to aggravate upper eyelid ptosis.7,8
Good candidates for aesthetic lateral canthoplasty are
patients with (1) exophthalmic eyes, (2) a distance of 4 mm
or more between the lateral canthus and lateral orbital rim,
and (3) a lateral fornix deeper than 3 mm.9
Fig. 15.11 Von Ammon’s method for lateral canthoplasty. (a) After a lateral canthal incision, the conjunctiva is undermined. (b) The
conjunctiva is pulled out and sutured to the skin edges. Double-armed sutures are passed through the conjunctiva, brought out lateral to
the canthus, and tied over a peg.
a
b
Fig. 15.10 Epicanthal reconstruction with V-Y advancement and
rotation ap. (a) V ap design with skin traction. (b) V-Y ap partial
advanced state. (c) Remnant ap rotation. (d) The rotated ap was
inset and sutured.
a
b
c
d

15 Epicanthoplasty and Aesthetic Lateral Canthoplasty
191
canthoplasty is performed on patients with Mongolian
slant, the lateral canthus will not seem to be extended
enough and the eyes will look more slanted. Combining
lowering of the slant with lateral canthoplasty will make
the eyes look bigger and milder at the same time and
enhance patient satisfaction. However, these procedures
should be applied only to the patients who have eyes with
steep Mongolian slant.
the upper and lateral part of the upper eyelid (Fig. 15.12c).
Because this surgical method uses skin tension only in the
lateral canthus, the e ect of expansion is not dramatic.
Fox’s Method
To apply Fox’s method, select a desired lateral extension
point ~ 4 mm away from the indigenous lateral canthus
(Fig. 15.13a). Split one-quarter of the lateral part of the
upper and lower eyelids between the anterior and poste-
rior lamellae. Extend the split upper palpebral line 4 mm
more following the extension line of the upper palpebral
border. Connect the three points of x, y, z and elevate the
ap (Fig. 15.13b,c). Pull y to x and suture them. Elevate the
lower eyelid ap considering x′ as the vertex and pull x′ to z
and suture them. Elevate a conjunctival ap of appropriate
size from the lateral and suture to the skin (Fig. 15.13d,e).
Shin’s Method
In Shin’s m ethod, 2 m m of the upper crus and 3 m m
of the lower crus of the lid m argin are elevated for a
rotation flap (Fig. 15.14a,b). The elevated flap is used
for low lateral lid extension. The lateral end of the ele-
vated flap is sutured to the periosteum w ith nylon 6–0
to extend the lateral canthus laterally and dow nward
(Fig. 15.14c). Close all the incisions of the lateral can-
thus and the conjunctiva (Fig. 15.14d). Eventually, the
lateral canthus w ill be extended laterally and dow n-
ward. This procedure is relatively sim ple and com plica-
tions are not frequent; however, the lateral canthus w ill
be lowered in every patient.
Lateral Canthoplasty Combined with
Mongolian Slant Lowering
East Asians are more likely to have upward-slanted eyes
compared w ith Europeans. Individuals who have Mongol-
oid slant may give the impression of being angry. If lateral
Fig. 15.12 Blaskovics’ method for lateral canthoplasty. (a) The lateral canthus is incised as a V shape and a skin ap is made. (b) The skin
ap is elevated and the transverse incision is made. (c) The wedge-shaped incision site on the lower lid is closed. The upper eyelid lateral
skin ap is trimmed and sutured.
a
b
c
x'
x
z
y
xz
x'
y
xz
yx'
xz
yx'
y
Fig. 15.13 Fox’s method of lateral canthoplasty. (a) Find a desired
lateral extension point y ~ 4 mm away from the indigenous lateral
canthus. Split one-quarter of the lateral part of the upper and lower
eyelids between the anterior and posterior lamellae. Extend the
split upper palpebral line 4 mm more following the extension line
of the upper palpebral border. (b,c) Connect the three points of x,
y, z and elevate the ap. Pull z to x and suture them. (d,e) Elevate
the lower eyelid ap considering x′ as vertex, and pull x′ to y and
suture them. Elevate a conjunctival ap of appropriate size from the
lateral end of the conjunctiva toward the medial side and suture the
the end of the ap to y.
a
b
c
d
e

III Blepharoplasty
192
Lateral canthal extension w ith lowering of the Mongo-
lian slant is possible if a triangular ap can be made on the
upper, lateral part of the lateral canthus as in Shin’s method
of lateral canthoplasty. Usually, it is not easy to make the
triangular ap in revision cases due to scar. Even in primary
surgery, it is hard to make the triangular ap if the distance
between the lid margin and cilia is too close or if the cilia
are located in this area.
Use the following technique:
1. According to the slope between the lateral part of
the upper eyelid and the lateral canthus, perform an
oblique canthotomy starting from the lateral canthus
and extending laterally and inferiorly. The length
of the incision is usually 4 to 5 mm, although it can
be longer or shorter based on the desired extended
length (Fig. 15.15).
2. Incise the conjunctiva less than 1 cm at 1–2 mm
lower part of the tarsal plate of the lower eyelid.
During the procedure, coagulate the visible vessels.
3. Make a dissection between the orbicularis oculi
muscle and the orbital septum to secure a clear view,
and make a minimal incision of the orbital septum
so that the lateral orbital fat can be exposed.
4. While an assistant takes the exposed orbital fat
downward, nd the capsulopalpebral fascia (CPF) at
the rear of the exposed orbital fat and grab it with
the forceps.
Palpebral
conjunctiva
Cornea
2 mm
3 mm
5 mm
Fig. 15.14 Shin’s cosmetic lateral canthoplasty. (a) The
palpebaral conjunctiva is exposed with traction. (b,c)
Two millimeters of the upper crus and 3 mm of lower the
crus of the lid margin were elevated for the rotation ap.
The elevated ap is used for low lateral lid extension. The
lateral end of the elevated ap is sutured to the perios-
teum with nylon 6–0 (star) to extend the lateral canthus
laterally and downward. (d) After closure.
a
b
c
d
5. Penetrate the CPF using nylon 7–0 and then
penetrate the area you wish to lower on the lower
border of the tarsus from side to side, and suture
them.8,11 The xation location can be changed
depending on the amount of desired lid lowering.
Usually, two areas of the CPF are xed on the tarsal
plate (Fig. 15.16).
6. Suture the incision site of the upper eyelid margin
exposed by canthotomy and x the lateral end of
the lower eyelid to the periosteum of the lateral
orbital rim using nylon 6–0. Ensure that a new lateral
canthus is formed as desired.
7. To remove the dog-ear skin surrounding the lateral
canthus, make the minimual incision following the
cilia on the lower eyelid, resect the remaining skin,
and close the wound.12,13
Postoperative Care
Due to the nature of the lateral canthal area, the dressing of
a lateral canthoplasty is di cult. Applying ointment to the
surgical site is enough as postoperative care. Stitch removal
is performed on postoperative day 7 or 8.

15 Epicanthoplasty and Aesthetic Lateral Canthoplasty
193
Enlargement of lateral scleral triangle
Lowering
Canthotomy
Mongoloid slant change
Lateral canthal expansion &
Mongoloid slant change
Fig. 15.15 Cosmetic lateral canthoplasty and Mongolian slant lowering. (a) The area of lateral scleral expansion is triangular and colored
pink. (b) Following the slope of the upper eyelid, a lateral oblique canthotomy with preseptal dissection is performed. The lateral part of
the lower eyelid tarsal plate is xed to the capsulopalpebral fascia (CPF) in two sites, using nylon 7–0. (c) Fix the lateral end of lower eyelid
to the periosteum of lateral orbital rim using nylon 6–0. The slope of palpebral ssure becomes less steep (from pink to red line). (d) The
lateral canthus is extended laterally and downward exposing more sclera.
a
b
c
d
CPF
TM
IO
3.1
5.4
OS
Dissection plane
Suture
Lid
lowering
IO
CPF
OS
3.1
5.4

TM
Fig. 15.16 Mongolian slant lowering. (a) Open the lateral orbital septum and reach the capsulopalpebral fascia (CPF) using the transcon-
junctival preseptal approach (blue line). (b) Suture the CPF and lower border of the tarsus with nylon 7–0 to lower the lower eyelid (red line).
a
b

III Blepharoplasty
194
Case 2: Lateral Canthoplasty with
Mongoloid Slant Lowering
A 26-year-old woman wanted to make her eyes more beau-
tiful. A physical exam showed small eyes with an invis-
ible caruncle by the epicanthal fold, no double fold, and
anthoplasty (Fig. 15.17a). Epicanthal reconstruction was
done with V-Y advancement and a rotation ap. The ap
was elevated from the depressed scar of the nasal side.
After surgery, a decreased caruncle exposure and more
natural-looking intercanthal area without noticeable scar
are observed (Fig. 15.17b).

■Case Studies
Case 1: Epicanthal Reconstruction
A 24-year-old woman complained of over-exposed car-
uncle with a noticeable depressed scar after medial epic-
Fig. 15.18 Case 2. Lateral canthoplasty and Mongoloid slant lowering. (a) A 26-year-old woman with epicanthal fold, no double fold,
and Mongolian slanting had an epicanthoplasty, double-eyelid surgery, and lateral canthoplasty with Mongoloid slant lowering. (b) After
surgery, the caruncle is more visible and her eyes look bigger and milder than before surgery.
a
b
Fig. 15.17 Case 1. Before (a) and after (b) epicanthal fold reconstruction. A 24-year-old woman with noticeable depressed scar after
medial epicanthoplasty had epicanthal reconstruction with V-Y advancement and a rotation ap. After surgery, caruncle exposure
decreased and the intercanthal area looks natural without noticeable scar.
a
b
Mongolian slanting (Fig. 15.18a). Epicanthoplasty was
performed with Z-plasty (reverse Fuente’s design). Double-
eyelid surgery was performed using the incisional method.
A lateral canthal expansion w ith Mongoloid slant lowering
was also done. After surgery, the caruncle is more visible
and her eyes look bigger and milder than before surgery
(Fig. 15.18b).

15 Epicanthoplasty and Aesthetic Lateral Canthoplasty
195
References
1. Cho IC, ed. The Art of Blepharoplasty. Seoul: Koonja; 2013
2. Baek BS, Park DH, Nahai F. Cosm etic and Reconstructive
Oculoplastic Surgery. 3rd ed. Seoul: Koonja; 2009:29
3. Kao YS, Lin CH, Fang RH. Epicanthoplasty with m odi ed
Y-V advancem ent procedure. Plast Reconstr Surg 1998;
102(6):1835–1841
4. Shin YH, Hwang PJ, Hwang K. V-Y and rotation ap for
reconstruction of the epicanthal fold. J Craniofac Surg
2012;23(4):e278–e280
5. Oh YW, Seul CH, Yoo WM. Medial epicanthoplasty us-
ing the skin redraping m ethod. Plast Reconstr Surg
2007;119(2):703–710
6. Shin YH, Hwang K. Cosm etic lateral canthoplasty. Aesthetic
Plast Surg 2004;28(5):317–320
7. Baek BS, Park DH, Nahai F. Cosm etic and Reconstructive
Oculoplastic Surgery. 3rd ed. Seoul: Koonja; 2009:300
8. Hwang K, Choi HG, Nam YS, Kim DJ. Anatomy of arcuate
expansion of capsulopalpebral fascia. J Craniofac Surg
2010;21(1):239–242
9. Fox SA. Ophthalm ic Plastic Surgery. 5th ed. New York, NY:
Grune & Stratton; 1976:223–225
10. Von Am m on FA. Klinishedarstellungen der angehorenen
krankheiten und bildlungsfhler des m enschlichen der aug-
es und der augenlider. Berlin, Germ any: G. Reim er; 1841:6
11. Hwang K, Kim DJ, Hwang SH, Chung IH. The relationship of
capsulopalpebral fascia with orbital septum of the lower
eyelid: an anatomic study under m agni cation. J Craniofac
Surg 2006;17(6):1118–1120
12. Park DH. Anthropometric analysis of the slant of palpebral
ssures. Plast Reconstr Surg 2007;119(5):1624–1626
13. Hirohi T, Yoshimura K. Vertical enlargement of the palpebral
aperture by static shortening of the anterior and posterior
lamellae of the lower eyelid: a cosmetic option for Asian
eyelids. Plast Reconstr Surg 2011;127(1):396–406

196
16 Lower Blepharoplasty
Yoon-Duck Kim and Kyung In Woo
characterized by a fuller appearance than those of Cauca-
sians, which is caused by protruded orbital fat.3 Asians have
heavier soft tissue and larger amounts of malar fat, which
are subjected to greater gravitational force.2 The eyelid and
adjacent structures are tight; sometimes wider incisions
and exposures have been advocated in periocular surger-
ies for Asian patients.4,5 Therefore, preoperative evaluation,
judicious skin manipulation, and proper postoperative care
are important to ensure a good surgical outcome for Asian
lower eyelid blepharoplasty.
The concept of aging in lower blepharoplasty has been
changed. In conventional thought, the periocular aging
change was regarded as the result of the descent of midface,
unopposing, weakened supporting structures and orbital

■Introduction
The demand for blepharoplasty among persons of East
Asian descent is increasing in the United States. In a 2013
plastic surgery statistics report, Asians/Paci c Islanders
accounted for 6.2% of all cosmetic blepharoplasty proce-
dures in the United States; the proportion for this procedure
was the highest among all cosmetic surgical procedures.1
For successful blepharoplasty for Asians, understand-
ing of the characteristic features of the eyelid is most
important. Asian faces have more melanin pigment and
thicker skin, so the incision scar from surgery can be hyper-
trophied or hyperpigmented.2 Lower eyelids of Asians are
Pearls
• The surgical procedure of lower blepharoplasty
evolved from fat and skin excision into volume
enhancement. A customized approach considering
each patient’s lower eyelid con guration is essential
to the success of surgery.
• Surgeons must discuss what they can or cannot do
with patients. Fine or dynamic wrinkles, local skin
pigmentation, or skin scars cannot be addressed
with lower blepharoplasty, and this should be
acknowledged to the patients who want lower
blepharoplasty.
• The surgeon should choose an approach:
transconjunctival versus transcutaneous. A
transconjunctival approach is ideal for patients
who show fat prolapse without skin or eyelid laxity.
A transconjunctival approach is also applicable
for those who don’t want a skin scar, who are
undergoing reoperation for fat prolapse, or who have
a tendency to develop hyperpigmentation on a skin
incision site.
• The surgeon must decide how much orbital fat
is to be removed or redistributed. If tear trough
depression is evident relative to fat prolapse,
fat redistribution is recommended to avoid a
postoperative hollow appearance. Gentle pressure
to the globe is helpful in deciding whether or how
much fat excision is needed because lying down on
a surgical table does not simulate the conditions of
sitting up.
• The surgeon must assess the degree of lower eyelid
laxity with a snap-back test or a lid distraction
test and must perform a horizontal lid tightening
procedure if the laxity is signi cant enough to a ect
postoperative lower lid retraction.
• During the fat redistribution procedure, ocular
movement should not be restricted on a fat
anchoring suture. If there is movement restriction,
release the suture, perform further dissection, and
con rm that movement is not hindered by a re-
xation suture.
• Proper hemostasis is needed during orbital fat
resection to avoid the disastrous complication
of orbital hemorrhage. Traction on the fat tissue
should be minimized to avoid hemorrhage from the
deeper orbit, and a clamp-cut-cautery technique is
recommended for resection of the medial fat pocket
harboring relatively large-bored blood vessels.
• The skin excision should be conservative to avoid
lower eyelid retraction during transcutaneous
blepharoplasty. It is helpful to have the patient open
his or her mouth and look up when the skin excision
amount is measured with a draping method, to
minimize skin over-resection.
• Postoperative caution should be stressed to the
patient to prevent orbital hemorrhage. Cold
compression is recommended for 48 hours, and
avoidance of head down positioning and of physical
exertion should be emphasized.

16 Lower Blepharoplasty
197
sion was the most signi cant contributing factor, followed
by orbital fat prolapse, loss of skin elasticity, eyelid uid,
orbicularis prominence, and triangular malar mound. In an
analysis of lower eyelid aging in an Asian population, Asians
showed a tendency toward less contribution of tear trough
defect and more contribution of fat prolapse to eyelid bags
compared with Caucasian patients.13 The periocular aging
changes can be assessed by analyzing these categories.
Tear Trough Depression and
Palpebromalar Groove
Tear trough depression occurs at the inferomedial aspect of
the lower eyelid. With aging, this deformity is seen more
prominently (Fig. 16.1). Tear trough depression is known
to be characterized by loss of subcutaneous fat and skin
thickness along w ith the inferomedial orbital rim, which
is accentuated by fat prolapse and cheek descent.14 In a
microscopic study comparing the young and the aged, the
elderly individuals showed signi cant tissue atrophy in
various layers, malar fat atrophy and descent, and orbital
fat bulging.15
To correct tear trough depression, various techniques
have been tried, including fat redraping blepharoplasty,
various injections, and tear trough implants of various
designs. Fat injection is not a recommended procedure for
this region because injected fat tends to leave small, rm
nodules of fat and scarring, and provides irregularity and
shadows. Filler injection such as hyaluronic acid gel is
increasing in this region and gets favorable results; how-
ever, repeated injections are needed.16
The volume change in the tear trough area was addressed
by Hamra with fat preservation blepharoplasty, which corre-
fat prolapse. After the volume de ation concept was intro-
duced in the interpretation of the aging process, aesthetic
approaches to patients have been modi ed tremendously.
In the historical view of surgical management of the
lower eyelid aging process, the prototype procedure was
orbital fat excision with a transcutaneous approach. Lower
lid tightening procedures were developed to prevent or
treat eyelid malposition, which was the most common
complication of the conventional technique.6,7,8 The trans-
conjunctival approach subsequently became popular in
blepharoplasty, as it could prevent postoperative eyelid
retraction and leave no visible scar while providing wide
exposure.9 Since the transconjunctival approach was appli-
cable only to patients who did not need skin excision, the
concomitant skin pinch technique was used to address the
excess skin in transconjunctival blepharoplasty.
However, for patients who had pseudoherniation of the
fat and tear trough depression, removing lower eyelid fat
can create a concave contour deformity of the lower eyelids
and cause a hollow appearance.10 In addition, deepening
of the superior sulcus has been noted after the orbital fat
removal procedure.11 Therefore, volume enhancement has
become an important issue in rejuvenation of the lower eye-
lid. Consequently, a customized approach to each patient is
essential; the speci c con guration of each patient needs
to be assessed and addressed.12

■Patient Evaluation
Goldberg et al analyzed the con guration of aging lower
eyelids in patients seeking aesthetic surgery and revealed
anatomic factors contributing to eyelid bags.12 They assessed
patients in six anatomic categories; tear trough depres-




Fig. 16.1 Aging changes in the lower eyelid. (a) Orbital fat prolapse is prominent. Tear trough depression (black arrows) and palpebroma-
lar groove (open arrows) are noted. (b) Negative vector con guration with pseudoherniation of fat. Malar depression is noted (arrowhead).
(c,d) Oblique line (arrow) is accentuated with facial expression due to prominent orbicularis oculi muscle.
a
b
c
d

III Blepharoplasty
198
Even though the presentation of eyelid uid was found
to be very rare in a Korean study, it should be one of the dif-
ferential diagnoses of fat prolapse in Asian people.13
Orbicularis Prominence
Orbicularis oculi prominence also contributes to lower eye-
lid aging features, with static and dynamic w rinkles. Hori-
zontal or oblique lines accentuated w ith facial expressions
can be noticed in many patients, and may be more common
in Asian patients (Fig. 16.1c,d).13,24
Orbicularis prominence can be dealt with by the orbi-
cularis oculi suspension procedure in blepharoplasty.
Triangular Malar Mound
The triangular malar mound is a uid sponge bound above
by the orbital rim ligament and below by the orbitozygo-
matic ligament.13 This is relatively rare in Asian patients.13
Position of the Globe and the
Inferior Orbital Rim
The relative position of the globe and inferior orbital rim
should be examined preoperatively because this is help-
ful in deciding which procedure is appropriate for each
patient. In the sagittal plane, when the anterior margin of
the inferior orbital rim is posterior to the anterior-most
point of the cornea, the patient has a negative vector anat-
omy (Fig. 16.1b). Patients with a negative vector tend to
have preoperative scleral show due to midfacial hypopla-
sia. Simple excision of the orbital fat often leads to exacer-
bation of the tear trough depression and increased scleral
show. Patients in this category should be considered for fat-
preserving blepharoplasty.
If the anterior margin of the inferior orbital rim is ante-
rior to the anterior-most point of the cornea, the patient
has a positive vector anatomy. For a patient with positive
vector, conservative excision of fat is recommended.
Lower Eyelid Laxity
The most signi cant complication related to lower bleph-
aroplasty is eyelid malposition such as retraction or
ectropion.6 To prevent these complications, preoperative
evaluation of the lower eyelid laxity is important.8
First of all, the eyelid position needs to be recorded as
margin-to-re ex distance 2 (MRD2), which is de ned as the
distance from the lower eyelid to the corneal light re ex, to doc-
ument the amount of preoperative eyelid retraction, if present.
Eyelid laxity can be determined by the snap-back test
or the distraction test. With a snap-back test, the restoring
force of the lower eyelid can be assessed after downward
eversion of the eyelid. If the eyelid goes back to its normal
position instantly, the horizontal tightening procedure
sponded to an epoch in lower blepharoplasty.10 Since then, sev-
eral modi cations have been introduced. The procedure can be
performed transconjunctivally or transcutaneously, and the fat
can be transposed subperiosteally or supraperiosteally.4,17,18,19,20
To address the palpebromalar groove, an orbital rim
depression of the central to lateral region, orbital retaining
ligament release is an important step that can be combined
with suborbicularis oculi fat (SOOF) elevation or the orbi-
cularis tightening procedure.15,19
Since Asian patients have relatively thicker skin and
subcutaneous tissue at the tear trough or palpebromalar
region, the fat resection procedure alone can achieve a
good cosmetic outcome in selected cases.21
Orbital Fat Prolapse
Three orbital fat compartments are separated by inferior
oblique and arcuate expansion. The pockets are called medial,
central, and lateral fat pockets. It is important to have the
patient look up during examination because the fat pockets are
more noticeable when the patient is looking up. It is also useful
to have the patient lie down, mimicking intraoperative state,
and to see the degree of retroposition of fat preoperatively.
The total volumes of intraorbital fat and fat anterior
to the inferior orbital rim have been shown to increase
until 60 years of age and then decrease, in a study of com -
puted tomography (CT) analysis for Koreans.22 Therefore,
an increase in orbital fat volume is considered to contrib-
ute to lower eyelid prominence in Asian patients. As Asian
patients have substantially more protruded orbital fat,
many articles have asserted the importance of fat resection
during lower blepharoplasty for Asians.15 Fat removal was
also stressed in another group, saying that an Asian patient
with a brachiocephalic face may not be a good candidate
for the fat transposition procedure unless it is modi ed
by more fat removal.5 Of note, fat resection should be per-
formed judiciously, especially for the aged, to avoid a hol-
low look postoperatively.
Loss of Skin Elasticity
The lower eyelid skin shows wrinkles and grooves result-
ing from sun damage and subcutaneous volume loss. A skin
tightening procedure is considered if a signi cant amount
of skin laxity is encountered, including surgical resection,
chemical peeling, or laser skin resurfacing. In Asian patients,
skin erythema and hyperpigmentation can result from skin
surface ablation treatment; therefore, care should be taken
in deciding the treatment modality for each patient.23
Eyelid Fluid
If uid is accumulated in the lower eyelid from systemic
or local edema, it can mimic fat prolapse. It can be distin-
guished by its di use nature, uctuation in degree, lack of
compartmentalization, or purplish color when it is severe.12

16 Lower Blepharoplasty
199
the subconjunctival space and fat pockets. Make a conjunc-
tival incision 3 to 4 mm below the inferior margin of the
tarsus (Fig. 16.2), and proceed to dissect toward the infe-
rior orbital rim until the orbital fat pockets are exposed
(Fig. 16.3). With this approach, there is no scar formation
on the orbital septum because the septum is not violated.
This retroseptal transconjunctival approach can avoid the
common complications of lower lid blepharoplasty such as
eyelid retraction and scleral show.
A preseptal transconjunctival lower blepharoplasty is
also performed by some surgeons: a conjunctival incision
is made below the tarsus, dissection then proceeds inferi-
orly, and a preseptal space is assessed. The orbital septum is
opened to expose the orbital fat. Proponents of the presep-
tal approach suggest that the scar formation on the septum
may bolster against the pseudo-herniation postoperatively.
No signi cant di erence in eyelid position between pre-
and retro-septal approaches has been reported.27,28
won’t be necessary. If the eyelid goes back after blinking,
horizontal tightening procedures such as orbicularis oculi
suspension might be needed. If the eyelid does not go back
even after blinking, a lateral tarsal strip procedure is rec-
ommended to avoid eyelid retraction after blepharoplasty.
With a distraction test (forward traction test), medial
and lateral canthal ligament and eyelid laxity can be
assessed. If the eyelid can be pulled over 8 mm from the
cornea with forward traction of the eyelid, a horizontal
tightening procedure is recommended.
Surgical Considerations in
Asian Patients
For patients requiring lower eyelid blepharoplasty, signi -
cant factors in the aging process in each patient should be
assessed and suggestive surgical methods discussed with
the patient.25
If a patient shows fairly good skin tone, simple fat exci-
sion with the transconjunctival approach is the rst choice
for primary eyelid bags.21,25 If a patient has redundant skin
and wrinkles without signi cant laxity of the eyelid, trans-
conjunctival fat removal with pinch skin excision or trans-
cutaneous fat excision blepharoplasty can be performed.24
The orbicularis muscle tightening procedure can be added
to transcutaneous blepharoplasty for those who show
moderate eyelid laxity.
If a patient has a tear trough depression and midface
sagging resulting in signi cant volume depletion at the
inferomedial orbital rim, fat transposition blepharoplasty
is needed transconjunctivally or transcutaneously.26 If the
patient shows signi cant palpebromalar groove, orbicu-
laris retaining ligament release and orbicularis suspension
and/or SOOF lift are recommended.
Photographs should be taken preoperatively with eye-
lid closed and open and with the patient looking up and
down. These photos are for legal protection or in case of
postoperative patient dissatisfaction.

■Surgical Techniques
Transconjunctival Fat Excision
Blepharoplasty
With the transconjunctival approach, the integrity of the
orbicularis muscle and the orbital septum can be main-
tained. Equal exposure to the fat pads is provided with the
transcutaneous approach, and the skin pinch technique is
allowed for redundant skin.
Conjunctival Incision
Before surgery, assess the amount of prolapsed orbital fat
from each compartment while the patient sits up. Wait 15
minutes for hemostasis after local anesthetic injection into
Fig. 16.2 Surgical procedure for transconjunctival fat resection
and skin resection with the pinch technique. Conjunctiva is incised
3 to 4 mm below the tarsus (arrowheads).
Fig. 16.3 Capsulopalpebral fascia and conjunctiva are pulled with
forceps and the lower eyelid is retracted with a Desmarres retractor
to expose orbital fat.

III Blepharoplasty
200
is grasped with forceps before releasing the clamp, and
should be checked for bleeding on clamp release. The fat
pedicle can also be resected with a monopolar cautery; the
fat pedicle should be draped on a cotton swab to protect
the tissues below and excised with a monopolar cautery
using a Colorado needle tip (Stryker). Thorough hemostasis
is important. If small vessels in the fat pocket retract and
bleed inside the orbit, it is hard to nd and treat the bleed-
ing focus.
Gentle pressure to the globe is helpful in determin-
ing whether and how much fat excision is needed because
lying down in a surgical table does not represent the condi-
tions of sitting up. The amount of fat resection from each
pocket should be determined by checking preoperative
photographs and intraoperative observation. The amounts
of removed fat are compared between compartments for
symmetry of the eyes. The conjunctival incision is closed
Fat Pocket Exposure
Incising the conjunctiva and pulling it back with a lower
eyelid retractor, fat pockets become visible, especially
medial and central fat pockets. When the globe is pressed
gently, the orbital fat can be easily accessed.28 Three fat
pockets are identi ed with fascial dissection between the
pockets (Fig. 16.4). The inferior oblique muscle, which sep-
arates the medial and central fat pads, should not be dam -
aged to avoid postoperative diplopia (Fig. 16.5).
Fat Excision
A base of herniated orbital fat is clamped with hemo-
stats, and fat tissue is cut with scissors and cauterized
with a bipolar cautery (Fig. 16.6). The base of fat pedicle


Fig. 16.4 Gentle pressure to the eyeball facilitates fat extrusion.
Fascial tissue between two fat pockets is visible (arrow).
Fig. 16.5 Inferior oblique muscle (arrow) is identi ed with dissec-
tion between two fat pockets.
Fig. 16.6 (a) Medial fat pedicle is clamped with a hemostat. (b) The pedicle is excised and the cut end is cauterized for hemostasis.
a
b

16 Lower Blepharoplasty
201
Transcutaneous Approach
The transcutaneous approach can be used when there is
extensive skin excess, malar bags, or festoon formation.
When concurrent lid tightening procedures are planned, the
transcutaneous approach is preferred by many surgeons.28
After local anesthetic is injected, a subciliary skin inci-
sion is made 1 mm below the lash line (Fig. 16.9). Since a
surgical scar over 10 mm lateral to the lateral canthus can
be noticeable, the lateral extension should be minimized to
an amount just suitable to remove the redundant skin and
orbicularis muscle. The lateral portion of the incision takes
a horizontal or downwardly inclined path to the wrinkle
lines, keeping a minimum of 5 mm distance from the upper
skin incision line to avoid webbing in case upper blepha-
roplasty is concomitantly performed. Then, a skin-muscle
ap is raised and dissected from the orbital septum using
blunt and sharp dissection (Fig. 16.10). The three compart-
ments of orbital fat are subsequently exposed by incising
the septum (Fig. 16.11). The orbital fat is in ltrated with
the anesthetic solution and removed up to the amount
where gentle globe pressure shows the anterior surface of
the fat to be the same as the inferior orbital rim level.
A small amount of lower lid pretarsal skin can then be
judiciously excised. It is recommended that the surgeon
have the patient look up and open the mouth while deter-
mining the amount of resection to avoid over-resection
(Fig. 16.12).
Buried closure with a 6–0 absorbable suture is needed
at the lateral canthal region to align the skin-muscle aps
and to lessen skin tension. Skin margins are then closed
continuously with a 7–0 nylon suture; meticulous closure
is required for the lateral portion to minimize scar forma-
tion. The sutures are removed 4 to 5 days after surgery.
interruptedly with 6–0 plain gut or 7–0 Vicryl (Ethicon) in
a buried fashion so as not to irritate the eyeball.
Pinch Skin Excision
For the patients who have redundant skin after trans-
conjunctival blepharoplasty, the excessive skin can be
addressed using the pinch technique skin excision while
preserving the orbicularis muscle.29 This technique is suited
to Asian patients at risk for pigmentary changes with laser
or chemical peel resurfacing.
Using two ne Brown-Adson forceps, the excess skin is
rmly pinched, creating a skin fold from the lateral canthus
extending medially (Fig. 16.7). The fold forms a maximum
height below the lateral canthus, and is tapered medially
and laterally. Throughout this pinching procedure, the posi-
tion of the lower eyelid should not be drawn downward. If
the eyelid position is changed, the amount of skin pinched
should be reduced. Straight scissors are used to excise the
skin fold, leaving the orbicularis muscle intact (Fig. 16.8).
After hemostasis, the skin is closed continuously with a
6–0 fast-absorbing plain gut or a 7–0 nylon suture.
Postoperative Care
For postoperative care, cold compression is recommended
for 24 to 48 hours to constrict blood vessels showing
increased permeability from surgery. Patients should take
a rest with the head elevated and should check their vision
for 24 hours by self-exam. Thereafter, warm compression
is recommended to decrease edema and bruising because
vascular permeability recovers at that moment. Antibiotic
eye drops with corticosteroid are administrated for 1 week.
Fig. 16.7 Excess skin is rmly pinched to create a skin fold from
the lateral canthus to the medial side.
Fig. 16.8 Straight scissors are used to excise the skin fold.

III Blepharoplasty
202
Subperiosteal Transposition
A subperiosteal approach is claimed to provide easier dis-
section in the subperiosteal plane, with less chance of
bleeding and better contour after fat transposition com -
pared with the supraperiosteal approach.17
After reaching the inferior orbital rim, a periosteal inci-
sion is made with a monopolar cautery. Subperiosteal dis-
section is then performed below the infraorbital rim and
lateral to the point where fat transfer is needed. If excess
fat is present, partial resection is performed to improve
contouring. Since orbital fat is connected with the orbital
fascial system–related ocular motility system, care should
be taken not to cause any restriction in fashioning fat ped-
Fat Preservation Blepharoplasty
Fat preservation blepharoplasty is bene cial, especially for
those who have negative vector and tear trough depression.
Hamra originally described a septal reset procedure for fat-
preserving blepharoplasty, which has been modi ed.10,20
For the fat transposition procedure, surgical dissection
proceeds to the inferior orbital rim after conjunctival or
transcutaneous incision, and the orbital septum is opened
inferiorly. The medial and central fat pockets are to be
transposed over the orbital rim, and usually a lateral pocket
needs to be resected. After fat transposition, complete sep-
tal release is recommended to prevent septal tethering.19
There are two approaches to fat transposition.
Fig. 16.9 Transcutaneous lower eyelid blepharoplasty. Skin inci-
sion is made with a no.15 B-P blade.
Fig. 16.10 A skin muscle ap is raised and dissected.
Fig. 16.11 The fat pocket is excised with a monopolar cautery.
Fig. 16.12 Excessive skin is excised judiciously while the patient
is looking up.

16 Lower Blepharoplasty
203
(Fig. 16.14). Due to the super cial plane of dissection,
orbital fat can be more apparent or lumpy after surgery.
This short-term hardening of the transposed fat resolves
with time and intralesional steroid injection.
SOOF Lifting
This procedure is very useful for palpebromalar groove
correction. A palpebromalar groove is exacerbated by the
descent and decreased volume of the malar fat pads and
SOOF. Therefore, the SOOF lift procedure along with an
orbicularis-retaining ligament release technique can ll the
defect.19,27
Orbicularis-Retaining Ligament Release
and Orbitomalar Suspension
After reaching the inferior orbital rim, the orbicularis-
retaining ligament is released; the attachments of the
orbicularis-retaining ligament are liberated inferiorly and
laterally with blunt dissection and cutting cautery in the
preperiosteal plane. The origin of the orbicularis-retaining
ligament and SOOF can be suspended with a 5–0 Prolene
(Ethicon) suture to the superior-most part of the lateral
orbital rim. They can also be suspended to the superolat-
eral orbital rim of the lateral orbital wall via the upper eye-
lid blepharoplasty incision in case upper blepharoplasty is
performed simultaneously. More suture resuspension is
performed to the preseptal orbicularis in case signi cant
orbicularis laxity is found.19
icles. A forced duction test should be administered before
transposition to verify that there is no extraocular motil-
ity abnormality. Then two mattress percutaneous 4–0 or
5–0 sutures are needed to secure the fat pedicles inferiorly.
Con rming the adequacy of e acement of the tear trough
by the transposed fat, the sutures are tied over bolsters. The
sutures and bolsters are removed in 1 week.
Supraperiosteal Transposition
A bene t of the supraperiosteal approach is easier anes-
thesia and dissection compared with the subperiosteal
approach because subperiosteal dissection along the orbital
rim is not easy.18
For the supraperiosteal approach, dissection is per-
formed down to the inferior orbital rim after transcon-
junctival or transcutaneous incision. Then careful blunt
dissection is completed in the plane of the suborbicularis
oculi fat (SOOF) to a level 8 to 12 mm below the orbital
rim (Fig. 16.13). Preservation of the zygomatic branch of
the facial nerve during dissection is essential; the critical
zone is a circle with a diameter of 1 cm located 2.5 cm away
from the lateral canthus at an angle of 30 degree.30 If the
dissection is done too far inferiorly, orbicularis denervation
and ectropion might result.18 The vascularity of this plane
necessitates proper hemostasis; in fact, it is claimed that
this may contribute to increased survival of the fat pedicle.18
Each fat pocket is opened, and the fat is allowed to
prolapse over the inferior orbital rim. Partial fat excision
is done as necessary. One or two mattress 5–0 sutures are
applied to the fat pedicle and periosteum or SOOF pocket
Fig. 16.13 Surgical procedures of fat repositioning blepharo-
plasty. A blunt dissection is made below the orbital rim.
Fig. 16.14 The fat pedicle is transposed and xed to the
periosteum.

III Blepharoplasty
204
Lateral Tarsal Strip Procedure
The lateral tarsal strip procedure is a traditional method
of horizontal laxity correction. A lateral canthal incision is
made, which is followed by release of the inferior crus of
the lateral canthal tendon to mobilize the lower eyelid com -
pletely. The proper amount of tarsus to shorten is marked
and the lateral tarsal strip is made; the eyelid margin is
trimmed, the lower tarsal border is severed from the eye-
lid retractor, and the tarsal conjunctiva is scraped o . The
tarsal strip is resuspended to the periosteum just inside the
lateral orbital rim with 5–0 Prolene suture. Lateral canthal
forming suture, a buried suture re-aligning the gray lines of
the upper and lower eyelids, is then placed with 7–0 Vicryl.

■Key Technical Points
1. As East Asian patients tend to have thicker and
darker skin than Caucasians, skin manipulation
should be minimized to avoid hypertrophic scar
formation.
2. Skin resection should be conservative during
transcutaneous blepharoplasty. Having the patient
gaze upward w ith the mouth open is a valuable
maneuver to prevent skin over-resection.
3. Orbital fat is covered with thin sheaths containing
blood vessels. Traction on orbital fat can tear
deep orbital vessels and may precipitate orbital
hemorrhage.
4. Fat over-resection should be avoided. Under-corrected
fat can be addressed with a second procedure;
however, overzealous removal results in a hollow
appearance and precludes further corrective surgery.
5. Orbicularis suspension is a useful technique for Asian
patients not only for horizontal laxity correction, but
also for cosmetic outcomes. This is due to the very
large number of Asians having severe laxity of the
orbicularis muscle and deep skin wrinkles associated
w ith it.
6. An intraoperative sitting position for the patient
is helpful to check for the presence of ectropion,
retraction, or the presence of residual fat because
these conditions can be camou aged in a supine
position.
7. The essential factors in minimizing the complication
of lower eyelid malposition in a transcutaneous
blepharoplasty are maximizing pretarsal orbicularis,
conservative excision of lower eyelid skin, correcting
eyelid laxity, and suspension of the orbicularis
muscle to the lateral orbital rim.27
Horizontal Laxity Correction
Procedures
For patients with preoperative eyelid laxity or eyelid mal-
position such as lower scleral show, a lower eyelid tight-
ening procedure should be performed at the same time as
lower blepharoplasty. Among the various methods per-
formed for horizontal laxity correction, some easily appli-
cable and e ective procedures are described next.
Orbicularis oculi suspension is an e ective method for
the patient with mild lower eyelid laxity and is an adjunc-
tive procedure to transcutaneous approach blepharoplasty.
Minimally invasive lateral canthoplasty is another good
procedure, one which doesn’t violate the anatomy of the
mucocutaneous lateral canthal angle. If more signi cant
lower eyelid laxity is found, a horizontal eyelid strength-
ening procedure such as the lateral tarsal strip procedure
is needed to prevent postoperative eyelid ectropion or
retraction.
Orbicularis Oculi Suspension
Mild horizontal laxity can be addressed by this procedure
with the transcutaneous approach. After orbital fat resec-
tion or the transposition maneuver is completed, the skin-
muscle ap is draped and orbicularis muscle suspension
is performed. The preseptal orbicularis muscle is sutured
to the periosteum of the lateral orbital rim with a 5–0
mono lament suture. The tension and xation point of the
orbicularis should be tailored so as not to result in lateral
canthal position abnormality.
Minimally Invasive Lateral Canthoplasty
This procedure can be added to either the transconjuncti-
val or transcutaneous approach. Through a small lateral or
standard upper crease incision for upper blepharoplasty,
the lateral orbital rim and the lateral canthal tendon are
exposed. Then the lateral canthal tendon is dissected from
its periosteal attachment. If lateral fat is prominent, the
orbital fat pad can be debulked through the same inci-
sion. If eyelid laxity is signi cant, the lateral lower tarsus
is trimmed. A double-armed, 4–0 absorbable suture is used
to re-attach the lateral canthus to Whitnall’s tubercle. After
two needles are passed through the same spot of the lat-
eral part of the lower eyelid at the gray line, one arm passes
the lower half of the tarsus and the other, more super cial
arm passes the upper tarsus. The sutures are then tied and
secured below the crease skin incision.31

16 Lower Blepharoplasty
205
Ectropion
Ectropion can occur temporarily due to lower eyelid swell-
ing in case of eyelid laxity, or permanently with the anterior
lamellar shortage from excessive skin excision (Fig. 16.15).
Judicious skin excision during surgery is essential as a pre-
ventive measure.
If ectropion occurs a few days after surgery with in am-
matory signs, upward eyelid taping and an intrafat pad steroid
injection can lessen the condition, reducing the postsurgical
in ammation reaction. If ectropion persists, watchful waiting
with massaging and use of steroid ointment is recommended
for 3 to 6 months before surgical correction is performed.
Horizontal eyelid tightening procedures are needed if
lower eyelid laxity is signi cant. A SOOF lift or skin graft
can be applied to anterior lamellar lengthening. The SOOF
lift procedure should be tried primarily, if possible, because
a skin graft may leave cosmetic blemish and unacceptable
scarring in the Asian population.
Asymmetric or Lumpy Appearance
Faulty estimation of fat prolapse preoperatively or improper
debulking of fat pads during surgery may result in an asym -
metric appearance between the two eyelids. Residual fat
prolapse can be corrected with further resection after 6 to
8 weeks, while a sunken appearance can be revised with a
fat graft from the contralateral fat pad or elsewhere.
A prominent lateral fat pad may be found after trans-
conjunctival blepharoplasty for patients who have exces-
sive fat protrusion in the lateral fat pad. Reresection
through a new, small skin incision at the lateral canthal
area may relieve the lumpy appearance.

■Complications and
Their Management
Complications of lower blepharoplasty should be prevented
during surgery and treated properly if they occur. The most
frequent complication resulting from lower blepharoplasty
is eyelid malposition, although more serious complications
such as visual loss have been reported.
Eyelid Retraction
Eyelid retraction can result from several factors related to
lower blepharoplasty. Patients who have negative vector
con guration are predisposed to eyelid retraction, and loss
of orbicularis muscle function from surgical intervention
also contributes to the eyelid position. Furthermore, mid-
dle eyelid lamellar shortening and tightening from surgery
also a ect lower eyelid position.32,33
As time elapses after surgery, eyelid swelling and
in ammation subside and orbicularis tone is gained. There-
fore, supportive care is important in the early postoperative
period, including eyelid taping, steroid injection, and the
use of an anti-in ammatory agent.
If the retraction is associated with signi cant middle
lamellar shortening and tightening, surgical intervention
is unavoidable. Forced upward traction testing to see if the
eyelid can be elevated with a surgeon’s nger is important to
evaluate the tightness in the middle lamella. In case middle
lamellar contracture is evident, middle lamellar release and
a spacer graft to relieve the vertical tightness are needed.
For a middle lamellar spacer, hard palate, ear cartilage, or a
cellular dermis (AlloDerm, LifeCell) is frequently used.
Fig. 16.15 Ectropion complicated lower blepharoplasty on the left eye. (a) SOOF lift and lateral tarsal strip were performed to correct
anterior lamellar shortage and horizontal laxity. (b) Three months after surgery.
a
b

III Blepharoplasty
206
If chemosis persists, surgical intervention is warranted.
Treatments including perilimbal needle manipulation and
conjunctivoplasty have been reported.39,40 High-frequency
radio wave electrosurgery has been performed for persis-
tent chemosis, with encouraging results.41
Orbital Hemorrhage
The most detrimental complication of cosmetic blepharo-
plasty is visual loss related to orbital hemorrhage, which
can occur in 1 of 22,000 surgeries.42 Preoperative evaluation
of medication history is important, and anticoagulation
drugs and herbal supplements should be discontinued to
prevent this problem. Intraoperatively, gentle manipulation
is required as orbital hemorrhage can result from vascular
ruptures in the deeper orbit from inadvertent dragging of
the fat pedicle. Patients should be informed of the need for
emergency care if orbital pain and visual impairment occur.
Preseptal hematoma may occur after lower blepha-
roplasty and is managed with local cold compression and
head elevation without hematoma drainage.43 Usually, pre-
septal hematoma does not a ect visual acuity or the nal
outcome unless a retrobulbar hematoma coexists.
Retrobulbar hematoma can a ect vision from retinal
vascular compromise or optic nerve compression due to
increased intraorbital pressure. Severe pain, exophthalmos,
visual impairment, limitation of extraocular movement,
and increased intraocular pressure can be manifested. If
central retinal artery occlusion is detected with fundus
examination, emergency care should be provided without
delay, because this is a true ophthalmic emergency and is
associated w ith poor prognosis for visual recovery.
If a tense orbit from retrobulbar hem atom a is pres-
ent, em ergent lateral canthotomy and inferior can-
tholysis should be perform ed to decompress the orbital
pressure; then surgical wound exploration should be
done.43 A system ic corticosteroid can be adm inistered to
prevent or m anage ischem ic optic neuropathy. If visual
acuity is not regained, bony orbital decompression can
be considered.

■Case Studies
Case 1
A 62-year-old female patient had fat prolapse and promi-
nent orbicularis without signi cant skin or eyelid laxity.
She underwent fat removal and orbicularis suspension
with the transcutaneous approach (Fig. 16.16).
Diplopia
Diplopia can result, temporarily, from swelling of extra-
ocular muscles or from e ects of local anesthetics, which
typically reverse postoperatively. If diplopia persists in
the postoperative period, the causes of diplopia should be
assessed with complete examinations.
Inferior oblique muscle injury can result from inadver-
tent medial and central fat pad excision because the muscle
is located between two fat pockets. Inferior rectus paresis
and mechanical restriction have also been reported.34,35
In fat preservation blepharoplasty, extraocular move-
ment abnormality also has been reported in relation to
fat pedicle transposition.36 A forced duction test needs to
be performed after fat pedicle xation to avoid this com -
plication. If a restriction on eyeball movement is found
intraoperatively, the xation suture ought to be released
and further dissection should be performed. Then a re x-
ation suture is placed. If the restriction is noticed after the
surgery, mild symptoms will usually be relieved by verti-
cal forced ocular movement exercise and waiting. In case
the restriction is not recovered, the fat pedicle and adja-
cent tissues can be released or strabismus surgery may be
performed.34 Mechanical oscillopsia has also been reported
after transcutaneous fat repositioning blepharoplasty, and
can be ameliorated by severing the cicatrix between the
inferior oblique muscle and the anterior super cial mus-
culo-aponeurotic system.37
Conjunctival Chemosis
The m anagem ent of persistent conjunctival chem osis
after lower blepharoplasty is challenging. Lower blepha-
roplasty using either a transconjunctival or a transcu-
taneous approach can be complicated w ith chem osis.
Though the exact m echanism has not been established,
increased vascular perm eability after surgery and block-
age in lymphatic and venous drainage are considered to
e ect conjunctival chem osis. The risk factors for devel-
oping dry eye symptom s and chem osis were reported to
increase w ith intraoperative canthopexy, postoperative
temporary lagophthalm os, concurrent upper and lower
blepharoplasty, and transcutaneous approaches violat-
ing the orbicularis m uscle.38
In the early postoperative period, a pressure patch with
steroid eye ointment and oral steroid medication can help
to lessen an in ammatory reaction. As most cases recover
in several weeks to months, arti cial tear drops and oint-
ment usage are required without speci c treatment in the
early postoperative period.

16 Lower Blepharoplasty
207
Case 2
A 58-year-old female patient showed tear trough depres-
sion, palpebromalar groove, and mild orbicularis promi-
nence. Each component was addressed. Fat repositioning,
orbitomalar ligament release and SOOF lift to the upper
part of the lateral orbital wall, and orbicularis muscle
resuspension were performed (Fig. 16.17).




Fig. 16.16 Case 1. Transcutaneous blepharoplasty with the orbicularis oculi suspension procedure was done in a 62-year-old female.
(a) Preoperative photo showing prominent orbicularis (arrow). (b) One year after surgery.
Fig. 16.17 Case 2. A 58-year-old female patient with a negative vector con guration. Fat repositioning, SOOF lift, and orbicularis muscle
anchoring with the transcutaneous approach were performed. (a) Before the surgery. (b) One year after the surgery. A skin wrinkle line is
moved upward with this procedure (arrows).
a
b
a
b

III Blepharoplasty
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18. Mohadjer Y, Holds JB. Cosmetic lower eyelid blepharoplas-
ty with fat repositioning via intra-SOOF dissection: surgi-
cal technique and initial outcomes. Ophthal Plast Reconstr
Surg 2006;22(6):409–413
19. Korn BS, Kikkawa DO, Cohen SR. Transcutaneous lower
eyelid blepharoplasty with orbitom alar suspension: ret-
rospective review of 212 consecutive cases. Plast Reconstr
Surg 2010;125(1):315–323
20. Hamra ST. The role of the septal reset in creating a youthful
eyelid-cheek complex in facial rejuvenation. Plast Reconstr
Surg 2004;113(7):2124–2141, discussion 2142–2144
21. Kim SW, Kim WS, Cho MK, Whang KU. Transconjunctival la-
ser blepharoplasty of lower eyelids: Asian experience with
1,340 cases. Dermatol Surg 2003;29(1):74–79
22. Lee JM, Lee H, Park M, Lee TE, Lee YH, Baek S. The volum et-
ric change of orbital fat with age in Asians. Ann Plast Surg
2011;66(2):192–195
23. Richter AL, Barrera J, Markus RF, Brissett A. Laser skin
treatment in non-Caucasian patients. Facial Plast Surg Clin
North Am 2014;22(3):439–446
24. Ren L, Yang D, Song Z, Ying L. Transconjunctival lower
blepharoplasty for Chinese patients com bined with a
subciliary incision for skin rem oval. Aesthetic Plast Surg
2011;35(4):677–680
25. Guo L, Bi H, Xue C, et al. Comprehensive considerations in
blepharoplasty in an Asian population: a 10-year experi-
ence. Aesthetic Plast Surg 2010;34(4):466–474
26. Mom osawa A, Kurita M, Ozaki M, et al. Transconjunctival
orbital fat repositioning for tear trough deformity in young
Asians. Aesthet Surg J 2008;28(3):265–271
27. Grant JR, Laferriere KA. Periocular rejuvenation: lower
eyelid blepharoplasty with fat repositioning and the
suborbicularis oculi fat. Facial Plast Surg Clin North Am
2010;18(3):399–409
28. Peng GL, Jacono A, Massry GG. Globe retropulsion and
eyelid depression (GRED)—a surgeon-controlled, uni-
m anual maneuver to access postseptal fat in transconjunc-
tival lower blepharoplasty. Ophthal Plast Reconstr Surg
2014;30(3):273–274
29. Rosen eld LK. The pinch blepharoplasty revisited. Plast
Reconstr
Surg
2005;115(5):1405–1412,
discussion
1413–1414
30. Hwang K. Surgical anatomy of the lower eyelid relat-
ing to lower blepharoplasty. Anat Cell Biol 2010;43(1):
15–24
31. Taban M, Nakra T, Hwang C, et al. Aesthetic lateral cantho-
plasty. Ophthal Plast Reconstr Surg 2010;26(3):190–194
32. Goldberg RA. Review of prophylactic lateral canthopexy
in lower blepharoplasties. Arch Facial Plast Surg 2003;
5(3):272–275
33. McCord CD, Boswell CB, Hester TR. Lateral canthal anchor-
ing. Plast Reconstr Surg 2003;112(1):222–237, discussion
238–239
34. Syniuta LA, Goldberg RA, Thacker NM, Rosenbaum AL. Ac-
quired strabism us following cosmetic blepharoplasty. Plast
Reconstr Surg 2003;111(6):2053–2059
35. Pirouzian A, Goldberg RA, Dem er JL. Inferior rectus pulley
hindrance: a m echanism of restrictive hypertropia follow-
ing lower lid surgery. J AAPOS 2004;8(4):338–344
References
1. American Society of Plastic Surgeons. 2013. Plastic Surgery
Statistics Report. Available at:
Documents/news-resources/statistics/2013-statistics/plastic-
surgery-statistics-full-report-2013.pdf. Accessed 2015
2. Shirakabe Y, Suzuki Y, Lam SM. A new paradigm for the aging
Asian face. Aesthetic Plast Surg 2003;27(5):397–402
3. Carter SR, Sei SR, Grant PE, Vigneron DB. The Asian lower
eyelid: a comparative anatom ic study using high-resolu-
tion magnetic resonance im aging. Ophthal Plast Reconstr
Surg 1998;14(4):227–234
4. Liao SL, Wei YH. Fat repositioning via supraperiosteal dis-
section with internal xation for tear trough deform ity in
an Asian population. Graefes Arch Clin Exp Ophthalmol
2011;249(11):1735–1741
5. Kawamoto HK, Bradley JP. The tear “TROUF” procedure:
transconjunctival repositioning of orbital unipedicled fat.
Plast Reconstr Surg 2003;112(7):1903–1907, discussion
1908–1909
6. McCord CD Jr, Shore JW. Avoidance of complications in
lower lid blepharoplasty. Ophthalm ology 1983;90(9):
1039–1046
7. Shorr N, Fallor MK. “Madame Butter y” procedure: com-
bined cheek and lateral canthal suspension procedure for
post-blepharoplasty, “round eye,” and lower eyelid retraction.
Ophthal Plast Reconstr Surg 1985;1(4):229–235
8. Jacobs SW. Prophylactic lateral canthopexy in lower blepha-
roplasties. Arch Facial Plast Surg 2003;5(3):267–271
9. Zarem HA, Resnick JI. Expanded applications for trans-
conjunctival lower lid blepharoplasty. Plast Reconstr Surg
1991;88(2):215–220, discussion 221
10. Hamra ST. Arcus marginalis release and orbital fat pres-
ervation in m idface rejuvenation. Plast Reconstr Surg
1995;96(2):354–362
11. Schiller JD, Lin S, Neigel JM. Deepening of the superior sul-
cus after isolated lower transconjunctival blepharoplasty.
Ophthal Plast Reconstr Surg 2004;20(6):433–435
12. Goldberg RA, McCann JD, Fiaschetti D, Ben Sim on GJ. What
causes eyelid bags? Analysis of 114 consecutive patients.
Plast Reconstr Surg 2005;115(5):1395–1402, discussion
1403–1404
13. Lee H, Ahn SM, Chang M, Park M, Baek S. Analysis of
lower eyelid aging in an Asian population for customized
lower eyelid blepharoplasty. J Craniofac Surg 2014;25(2):
348–351
14. Flowers RS. Tear trough implants for correction of tear trough
deformity. Clin Plast Surg 1993;20(2):403–415
15. Yang C, Zhang P, Xing X. Tear trough and palpebrom alar
groove in young versus elderly adults: a sectional anatomy
study. Plast Reconstr Surg 2013;132(4):796–808
16. Lam bros V. Models of facial aging and implications for
treatment. Clin Plast Surg 2008;35(3):319–327, discussion
317
17. Goldberg RA. Transconjunctival orbital fat repositioning:
transposition of orbital fat pedicles into a subperiosteal
pocket. Plast Reconstr Surg 2000;105(2):743–748, discus-
sion 749–751

16 Lower Blepharoplasty
209
40. Jones YJ, Georgescu D, McCann JD, Anderson RL. Snip con-
junctivoplasty for postoperative conjunctival chem osis.
Arch Facial Plast Surg 2010;12(2):103–105
41. Woo KI, Choi CY. High-frequency radiowave electrosur-
gery for persistent conjunctival chem osis following cos-
m etic blepharoplasty. Plast Reconstr Surg 2014;133(6):
1336–1342
42. Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence
of postblepharoplasty orbital hem orrhage and associ-
ated visual loss. Ophthal Plast Reconstr Surg 2004;20(6):
426–432
43. Whipple KM, Korn BS, Kikkawa DO. Recognizing and m an-
aging complications in blepharoplasty. Facial Plast Surg
Clin North Am 2013;21(4):625–637
36. Goldberg RA, Yuen VH. Restricted ocular m ovem ents fol-
lowing lower eyelid fat repositioning. Plast Reconstr Surg
2002;110(1):302–305, discussion 306–308
37. Thinda S, Vaphiades MS, Mawn LA. Mechanical oscillopsia
after lower eyelid blepharoplasty with fat repositioning. J
Neuroophthalm ol 2013;33(1):71–73
38. Prischmann J, Sufyan A, Ting JY, Ru n C, Perkins SW. Dry
eye symptoms and chemosis following blepharoplasty: a
10-year retrospective review of 892 cases in a single-sur-
geon series. JAMA Facial Plast Surg 2013;15(1):39–46
39. Cheng JH, Lu DW. Perilimbal needle manipulation of conjunc-
tival chemosis after cosmetic lower eyelid blepharoplasty.
Ophthal Plast Reconstr Surg 2007;23(2):167–169

210
17 Correction of Ptosis
Woong Chul Choi and Juwan Park

■History of Ptosis Surgery
Ptosis surgery has shown many revolutionary changes as
our knowledge of anatomic and physiologic processes has
expanded. In addition, expansion of the variety of materi-
als has revolutionized the eld of ptosis surgery since its
ancient history. References show that the earliest treat-
ments were performed by ancient Arabian ophthalmolo-
gists. More recent descriptions were provided by Scarpa, an
Italian anatomist and surgeon, in 1806.1,2 However, the refer-
ences from the early days regarding the treatment of ptosis,
resecting the upper part of the eyelid, were insu cient and
of only temporary relevance. Therefore, alternative ways to
elevate the eyelid had to be researched and developed.
The levator muscle and aponeurosis, Müller’s muscle,
and the frontalis muscle are the upper lid retractors that
are the primary tissues targeted during ptosis surgery.
Ptosis surgery restores or reinforces the natural power
of the eyelid retractor muscles (levator muscle or Müller
muscle resection). It can also produce new mechanical
lifting power (frontalis suspension) with or without ancil-
lary procedures to shorten the eyelid length or to reduce
the burden factors (tarsus, skin, and fat resection). Surgical
techniques along with anatomical discoveries and surgical
materials have developed as follows.

■Introduction
Upper eyelid ptosis is evaluated by m argin-re ex distance
1 (MRD1), which is the distance from the corneal light
re ex to the upper lid m argin and norm ally ranges from
3.5 to 4.5 m m in Caucasians. However, MRD1 depends on
age, sex, and race and tends to show lower values in the
elderly, m ales, and Asians. Unilateral ptosis is diagnosed
when one eyelid is positioned over 2 m m lower than the
other eyelid.
The levator palpebral m uscle is the prim ary upper
eyelid retractor. The Müller and frontalis m uscles are
also involved in lifting the upper eyelid. Functional
or anatom ic abnorm alities of the upper eyelid retrac-
tors (m ostly the levator m uscle and aponeurosis) are
the m ain reasons for blepharoptosis. Patients w ith pto-
sis usually show brow elevation because the frontalis
m uscle is overused to compensate for the weak prim ary
upper eyelid retractor.
In contrast to true blepharoptosis, pseudoptosis is not
associated with abnormalities of the retractors. Common
causes of pseudoptosis are contralateral lid retraction,
hypotropia, enophthalmos or contralateral exophthalmos,
pu y lid in Asians, and dermatochalasis (skin redundancy
without aponeurotic ptosis).
Pearls
• Margin-re ex distance 1 (MRD1, distance from the
corneal light re ex to the upper lid margin) in a
sitting position is the most important parameter for
ptosis evaluation.
• History, levator function test, and measurement of
lid lag on down-gaze help di erentiate between
aponeurotic and congenital ptosis.
• Levator function is the most important parameter
in determining the surgical method (levator
advancement, frontalis sling, etc.) and the most
reliable predictor of surgical response.
• Mild ptosis with good levator function can be
treated with conjunctivo-Müllerectomy.
• Bilateral surgery is more likely to be predictable and
reliable than unilateral surgery, especially in elderly
patients or patients with poor levator function.
• The burden factors such as redundant skin,
orbicularis muscle, and fat should be addressed
because they can aggravate the ptosis or cause
subclinical ptosis.
• Structural weakness and the pretarsal fat pad are
more easily seen in the medial part among elderly
East Asians, and an e ort to overcome those factors
is required for better results.
• Additional procedures to form a lid crease after
ptosis correction are usually required for a durable
lid crease formation in Asian patients.
• Meticulous hemostasis and intraoperative
cooling are helpful in improving the accuracy of
intraoperative adjustment.
• Asymmetry after ptosis repair can be xed in the
early postoperative period of a week or so.

17 Correction of Ptosis
211
a modi cation that resects Müller’s muscle and conjunc-
tiva while sparing the tarsus (Müller’s muscle conjunctiva
resection, or MMCR).26,27
To avoid corneal irritation by sutures, Lauring reported
a sutureless Fasanella-Servat operation and Bodian used
external securing with 5–0 nylon suture.28,29,30 While Wein-
stein described a marking suture to more easily isolate
Müller’s muscle and place the Putterman clamp, Ili incor-
porated levator aponeurosis into the operative site with a
Fasanella-Servat-like approach.31,32

■Patient Evaluation
In blepharoptosis evaluation, not only the lid but also the
w rinkles on the forehead, height of both eyebrows, and
the presence of lid crease should be evaluated. If there is a
lid crease, checking w hether the crease is distinct or m ul-
tiple is necessary. Occasionally, ptosis is m asked by redun-
dant eyelid skin or fat bulge, leading to an apparent ptosis
after simple upper blepharoplasty. Moreover, in patients
who have ptosis in the dom inant eye, the other eye m ight
have retracted due to Hering’s law. Therefore, it is impor-
tant to evaluate the patient carefully prior to the surgery
to detect any m asked problem s and thus reduce the rate
of revision.
Anatomic structures of Asian lids without creases
(lower orbital septum–levator fusion level with pre-apo-
neurotic fat hanging over the tarsal plate; more prominent
subcutaneous, subdermal, suborbicularis, and pretarsal
fat; and lower primary insertion of the levator aponeuro-
sis onto the upper lid dermis) interfere with eye opening
and can be regarded as a category of ptosis.33 By removing
those burden factors instead of doing levator surgery, the
surgeon can obtain excellent cosmetic improvement on a
pu y, small, and droopy Asian lid.
History Taking and
Physical Examination
In severe unilateral ptosis, the eyebrow on one side can be
elevated relative to the other with predominant forehead
wrinkles. In addition to the patient’s history and age, upper
lid lag is a helpful clue in distinguishing congenital ptosis
from aponeurotic ptosis. If a down-gaze makes one eyelid
bigger than the other, or if an up-gaze makes the eyeball
hide behind the upper eyelid, congenital ptosis with poor
levator function can be suspected (Fig. 17.1). Such a phe-
nomenon occurs because of the levator muscle’s inherent
inability to relax due to dysgenesis and brofatty degen-
eration. Patients with aponeurotic ptosis can have a deep
superior sulcus due to the retraction of the pre-aponeu-
rotic fat pad. The lid crease of an eye with ptosis gets higher
due to the levator’s stretch or dehiscence (Fig. 17.2).
Frontalis Sling
Dransart adapted exogenous material as a suspender and
applied it to buried catgut sutures in 1880. Hess introduced
a temporary placement of silk suture in 1893.3,4 De Wecker
employed the rst autogenous sling with a combination of
skin, orbicularis muscle, and silk suture as a suspender.5
In 1909 Payr introduced a thigh fascia that marked a
signi cant advance in frontalis slings and still remains
one of the gold standard materials.5 Yasuna described a
frontalis sling using cadaveric fascia lata, which received
extensive attention during the 1970s.6,7,8,9,10,11 In 1966 Til-
let recommended the use of silicone strips, which received
further attention and are still in use. In 1986 Anderson sug-
gested that sling material be placed behind the septum.
This resulted in a more cosmetically acceptable appearance
and a more natural-looking lid crease.12
Levator Muscle and Aponeurosis Repair
Levator surgery did not gain popularity until the end of the
19th century. More reliable alternatives such as the fronta-
lis sling were preferred. It was Bowman who targeted the
retractor muscle instead of weakening the protractor mus-
cle for the rst time.13 In 1857 he resected both the levator
muscle and the tarsus using an internal/external approach.
Interest in levator surgery was revived w ith the intro-
duction of an external approach, levator tucking, by Ever-
busch and levator aponeurosis resection by Snellen in
1883.14,15 In 1896 Wol devised a procedure for isolating,
mobilizing, and advancing the levator muscle.16 On the
other hand, Blaskovics suggested an internal approach with
excision of the tarsus and levator in 1909.17
Interest in the external approach was continued by
Jones, who devised a surgery that advances the levator
aponeurosis while preserving Müller’s muscle in 1960.18
Anderson, a great investigator of levator surgery, published
his work extensively on eyelid anatomy and levator apo-
neurosis surgery in neuromyopathic, involutional, and mild
cases of congenital ptosis, making the 1980s “the Age of
Aponeurotic Awareness.”19,20,21,22 During this period, various
techniques were introduced, including the manner of apo-
neurotic repair, the number of xation sutures, adjustable
suture techniques, and alternatives in the size or location of
the incision made by a variety of instruments.21,22,23,24
Müller Muscle Surgery
Conjunctival tarsal Müllerectomy, otherwise known as
the Fasanella-Servat procedure, was introduced in 1961.25
It was regarded as a type of levator resection initially but
was later understood to work due to its action on Müller’s
muscle. In 1972 Putterman devised a clamp and reported

III Blepharoplasty
212
Diagnosis of Ptosis
It is important to m easure the MRD and levator function
to obtain proper evaluations. MRD1 is know n to be the
m ost predictable m easurem ent for ptosis evaluation.34
MRD1 m ust be exam ined w ith the patient in a prim ary
position w ith no excessive use of the frontalis m uscle or
orbicularis m uscle. For an accurate exam , a light source (a
pen light or ash) m ust be positioned at the sam e height
as the patient’s eyes. MRD1 is the distance from the cor-
neal light re ex to the upper eyelid m argin, not the hang-
ing skin m argin. If the hanging upper lid skin is covering
the upper lid m argin of a patient w ith derm atochalasis,
the skin should be gently pulled up and the lid m argin
should be observed during the exam . MRD2 (distance
from the corneal light re ex to the lower lid m argin)
depends on the position of the lower lid. The sum of these
two is the interpalpebral ssure (IPF).
The levator function is determ ined by m easuring
the excursion of the eyelid m argin, or the total distance
traveled by the lid m argin from dow n-gaze to up-gaze.
A norm al levator function is ~ 15 m m . Levator excursion
is considered to be poor when the distance is less than
4 m m , m oderate when the distance is between 5 and 10
m m , and good w hen the distance is above 10 m m . To pre-
vent frontalis recruitm ent during these m easurem ents,
it is advisable to either have the forehead leaning on a
support bar or using one’s hands to hold the forehead.
By using a ruler attached to the side bar of the slit lamp,
the values of MRD1, IPF, levator function, and lid lag are
recorded in detail (Fig. 17.3). Using these kind of reliable
records to objectively express patients’ status often builds
patients’ trust.
The most common clinical ptosis occurs from stretch-
ing and dehiscence of the levator aponeurosis. Typical apo-
neurotic ptosis is found in cases of frequent eye rubbing
due to atopy or wearing contact lenses for a long time, and
senile changes due to aging. Similar cases can be found in
patients after ophthalmic surgery, trauma, or frequent lid
Since Asians often have m edial epicanthal folds,
m edial epicanthoplasty can be perform ed at the sam e
tim e as the ptosis surgery. It is essential to take photos
before the surgery for docum entation, review, educa-
tion, and m edicolegal purposes. Patients norm ally do not
rem em ber their preoperative features. By comparing the
preoperative and postoperative photos, the results of the
surgery can be objectively analyzed and evaluated. This
helps to establish trust between the patient and the sur-
geon. When the patient complains, review the photos; if
som ething is found lacking, discuss it w ith the patient and
consider perform ing a revision surgery for better results.
If a patient does not want photos to be taken before the
surgery, the operation should be reconsidered. Photos are
taken while the patient is looking ahead, up, and down. To
check the conditions of the eyelashes, additional lateral
view photos should be taken. If there are any important
or unique occurrences during the surgery, intraoperative
photos should be taken as well. To evaluate the progress
of the surgery, photos are taken 1 week, 1 m onth, and 3
m onths after the surgery.
Fig. 17.1 Congenital ptosis. This 13-year-old boy who has (a) right congenital ptosis (b) shows poor levator function on up-gaze and
(c) lid lag on down-gaze.
Fig. 17.2 Aponeurotic ptosis. This 65-year-old female has apo-
neurotic ptosis of the right eye and shows right eyebrow elevation,
multiple lid creases, and a deep superior sulcus.
a
b
c

17 Correction of Ptosis
213
in situations of ptosis owing to aponeurotic dehiscence.37
Levator function in patients with aponeurotic ptosis is
good in general. However, if the levator aponeurosis totally
detaches from the tarsal plate, the levator function will
be very poor.38 This is especially true for elderly patients
who have had ophthalmic surgery several times and whose
levator aponeurosis is often totally detached from the tar-
sal plate (Fig. 17.4).
Most aponeurotic ptosis results from aging and is com -
monly detected in elderly patients. On the other hand, con-
genital ptosis is the most common type in children. Unlike
aponeurotic ptosis, congenital ptosis shows poor to fair
levator function and lid lag on down-gaze due to the loss of
swelling.35,36 General clinical characteristics of aponeurotic
ptosis include
• Eyebrow elevation of the a ected eye
• Deep superior sulcus
• Higher or multiple lid creases
• Lid drooping
• Good levator function
The lid crease height is the distance between the lid margin
and the crease formed by the attachment of levator apo-
neurosis bers to the subcutaneous tissue. This can vary
among races and by sex. Lid crease height may increase
Fig. 17.3 Measuring MRD1, MRD2, IPF, and levator function. (a) Precise measurements of levator function using a ruler attached to the
slit lamp. (b) The blue line is MRD1, and the yellow line is MRD2. The sum of these two is IPF.
Fig. 17.4 (a–c) Poor levator function in aponeurotic ptosis. This 72-year-old
female shows very poor levator function on upward gaze and severe lid drooping
on downward gaze. (d) Operative dissection shows a total detachment of the
levator aponeurosis from the tarsal plate.
a
b
a
b
c
d

III Blepharoplasty
214
rine is instilled in cases of mild ptosis with good levator
function. Once the eyelid goes up to a normal position, it
is regarded to be a good candidate for a conjunctivo-Mül-
lerectomy. This method is advantageous for patients who
need unilateral surgery and do not want skin excision or
any chance of getting a skin scar.

■Preoperative Considerations
Eye Protective Function
Since ptosis surgery basically pulls the upper lids upward,
lagophthalmos may occur temporarily in the early post-
operative stage or become permanent. To avoid this com -
plication, one should check the patient’s eye protective
mechanisms and inform the patient of inevitable problems
such as lid lag and lagophthalmos. Conditions such as sig-
ni cant dry eye syndrome, facial palsy, dysfunction of the
superior rectus muscle, and absence of Bell’s phenomenon
must be checked prior to the surgery. If the protective func-
tion is weak or absent, overcorrection should be avoided.
Visual Field Test
A visual eld test is often needed for insurance coverage
purposes in the Republic of Korea. Surgery on a droopy
upper lid blocking the pupil is covered by insurance there.
Hering’s Law and Latent Ptosis
The levator muscles are yoke muscles, which enable them
to work in synchrony with each other. As a result, a er-
ent input from one eyelid can a ect the position of both
eyelids. When the degree of ptosis di ers between the two
eyes, there is an excessive nerve impulse to open the more
ptotic eye. Due to Hering’s law, the less ptotic eye will seem
like a normal eye. However, this eye will show a drooping
phenomenon (latent ptosis) after surgery on the eye with
manifest ptosis.44,45,46 There is a lower incidence of blepha-
roptosis in the dominant eye and a higher incidence of
postoperative contralateral eyelid droop when the domi-
nant eye is ptotic. These ndings support the hypothesis of
increased innervation to the dominant eye.47
Hering’s law dependence can be assessed by gentle
mechanical elevation of the ptotic eyelid with the patient’s
eye xed on a distant target. The contralateral eyelid is then
assessed for any changes in position. Any decrease in the MRD1
can be considered as a positive test, and the new MRD1 should
then be documented. If there is no change in the eyelid posi-
tion after 30 seconds, the test is considered to be negative.48
Another method to diagnose latent ptosis is to occlude
the ptotic eye for more than 15 seconds and instill 10% or
2.5% phenylephrine to the ptotic eye. If the opposite eyelid
droops at this time, it is better to correct both eyelids.
levator muscle elasticity. In some cases, incomplete lid clo-
sure (lagophthalmos) is also present. The histologic nd-
ing of congenital ptosis is dystrophy of the striate muscle
bers.39 Some patients with mild congenital ptosis are not
diagnosed till adulthood.
Contact Lens–Induced Ptosis
Prolonged contact lens usage is well known to potentially
cause acquired ptosis.40,41 The clinical features of aponeu-
rotic blepharoptosis induced by the use of contact lenses do
not di er from those related to other causes. Contact lens-
induced ptosis can be caused by an allergic reaction to the
preservatives in the contact lens solution, tarsal conjuncti-
val irritation by the contact lens edge, and levator aponeu-
rosis damage by physical opening of the eyelid for contact
lens placement. Ptosis induced by hard contact lenses is
caused by brosis of the Müller muscles.42
In most cases of contact lens–induced ptosis, the leva-
tor aponeurosis is connected to the tarsal plate since sur-
geries are performed in young and middle-aged patients.
Temporary ptosis caused by contact lens usage is treated by
prohibiting the use of contact lenses and prescribing anti-
in ammatory eye drops to reduce conjunctival swelling.
Although dehiscence or rarefaction of the levator aponeu-
rosis is more often found in patients with contact lens–
induced ptosis, gross ndings of aponeurotic disinsertion
or defects can be observed (Fig. 17.5).
Phenylephrine Test
It was Dortzbach who found that a phenylephrine test is
useful to predict the postoperative lid position after Mül-
ler’s muscle resection.43 A drop of 10% or 2.5% phenyleph-
Levator aponeurosis
Müller muscle
Superior border
of tarsal plate



Fig. 17.5 Contact lens–induced ptosis. This 53-year-old female
has a history of 40 years of hard contact lens wearing. Operative
ndings show levator aponeurosis disinsertion from the tarsal plate.

17 Correction of Ptosis
215
Although levator surgery is the most popular technique
to correct ptosis, one should consider performing a fronta-
lis sling if the levator function is poor (LF < 4 mm). MMCR
can be chosen for patients with mild ptosis and good leva-
tor function (LF > 10 mm). Intraoperatively, the condition
of the levator is examined from tarsal plate to Whitnall’s
ligament, regardless of the levator function and ptosis
degree. In a case where it is hard to expect good results due
to severe fatty degeneration and brotic changes, immedi-
ate conversion to a frontalis sling is advised. Therefore, in
case of severe ptosis or poor levator function, the surgeon
should discuss with the patient preoperatively the pos-
sibility of changing the surgical plan. Even though some
patients worry about scarring above the eyebrow, scar is
usually not a major concern since it won’t be noticeable 2
to 3 months after the surgery.

■Surgical Techniques
Instruments
Instruments used include a caliper, Wescott and Stevens
scissors, ne tissue forceps, locking needle holder, and
straight hemostat (Fig. 17.7).
Preoperative Preparation
The authors design the incision line preoperatively with
the patient in a sitting position. After makeup removal, the
desired incision line is marked, using a ne marking pen,
Despite a negative Hering’s test, there are patients who
still develop a postoperative decrease in their MRD and
resulting ptosis.43,44,45,46,47,49
Unilateral or Bilateral Surgery?
In patients with asymmetric or unilateral ptosis, latent ptosis
of the normal-appearing eye should be identi ed by elevat-
ing, closing, or instilling phenylephrine to the ptotic eye. Any
decrease in the contralateral lid position is considered to be a
positive test. In such a case, the patient should be informed of
the increased likelihood of postoperative ptosis in the contra-
lateral eye, and bilateral ptosis surgery should be considered.44
When there is no latent ptosis in the opposite eye after
the screening tests, you can correct one side only. In cases
of unilateral surgery, 1.0 to 2.0 mm of overcorrection is
needed compared with the nonptotic eye. This is done both
to compensate for the e ect of local anesthetics mixed with
epinephrine to paralyze the orbicularis muscle and stimu-
late the Müller muscle, and to counteract the postopera-
tive fall after ptosis repair. However, bilateral ptosis surgery
provides functional and cosmetic advantages because a
patient with unilateral ptosis and a negative Hering’s test
may develop postoperative contralateral ptosis.
Direction of the Eyelashes
Harrison categorized the direction of eyelashes into four
types (normal, mild, moderate, severe) in Caucasians.50 But
the eyelashes of Koreans are usually classi ed into grades 1
to 5, with 15-degree increments in each grade (Fig. 17.6).
Grade 1 is where eyelashes protrude perpendicularly to the
vertical plane of the face. Grade 5 is the case where the eye-
lashes are positioned 60 degrees downward.
Lash ptosis is more commonly noticed in ptotic eyes
than in normal ones,51 and thus it should be veri ed that
the lash ptosis has been corrected by observing the direc-
tion of the eyelashes at the end of the surgery. Satisfactory
postoperative results can be con rmed by checking the lash
direction in the supine position, where it should appear
slightly over-corrected, instead of checking it in the sitting
position during the operation. It is fairly common for medial
lash ptosis in Asians to be aggravated by epicanthal folds as
well as by loosening of medial structures such as medial
pretarsal muscle attachments to the tarsus. Therefore, addi-
tional attention to medial lash ptosis is required, and if nec-
essary, medial epicanthoplasty with a preferred technique
to reduce the burden factor should be considered.
Selection of Repair Method
In general, there are three types of surgery in ptosis correc-
tion: (1) levator surgery—tucking, advancement, resection;
(2) conjunctivo-Müllerectomy (MMCR or the Fasanella-
Servat procedure); and (3) the frontalis sling.
1
2
3
4
5
15°
Fig. 17.6 Grading of lash ptosis in Koreans. Grades have a
15-degree di erence.

III Blepharoplasty
216
The anatomic structure that is found after the skin incision
is the orbicularis muscle. An orbicularis muscle strand is
removed to approach the orbital septum (Fig. 17.10). When
excising the orbicularis muscle, an oblique superior direc-
tion should be used to prevent levator aponeurosis injury.
The next structure that can be observed is the orbital sep-
tum (Fig. 17.11).
Dissection
The surgeon and an assistant should hold the inferior ap
and superior aps with ne tissue forceps and approach the
septum carefully to avoid any damage to the levator apo-
where the patient wants his or her eyelid crease (Fig. 17.8).
If the patient has ptosis in one eye, the lid crease line is
made 0.5 mm smaller on the eye with ptosis since the
upper lid level will go down as time goes on.
Anesthesia
Ptosis surgeries can be performed using local anesthesia for
adults. If the patient is too nervous, intravenous sedative
medicine such as midazolam (dosage based on patient’s
age and weight) can be administered. The same anesthe-
sia that is used for a dental procedure, consisting of a mix-
ture of 2% lidocaine and 1:100,000 epinephrine, is used.
If the surgery is expected to take longer, bupivacaine can
be added. However, it is usually enough to use lidocaine
mixed with epinephrine, as ptosis surgery usually does not
take too long. When local anesthesia is performed, inject
slowly from the lateral side using a ne 30-gauge needle
(Fig. 17.9). Normally 1.0 to 1.5 mL per eyelid is injected.
Incision
The surgeon uses the ngers to stretch the eyelid outward
and incises the skin in one smooth step using a Bard-Parker
(Aspen Surgical) no. 15 knife, to avoid a zigzag incision.
Fig. 17.7 Instruments used in ptosis surgery: Castroviejo caliper,
6–0 nylon suture material, straight hemostat, Castroviejo needle
holder, Westcott tenotomy scissors, Adson micro tissue forceps,
Castroviejo suturing forceps, surgical blade holder (in a clockwise
direction from the left upper corner).
Fig. 17.8 Surgical techniques of ptosis correction. With a lid
crease maker and a very ne marking pen, the lid crease line is
designed where the patient wants it.
Fig. 17.9 Injection of local anesthetic subcutaneously with a
30-gauge needle from the lateral side.

17 Correction of Ptosis
217
If the surgeon needs more levator advancement, then
the aponeurosis can be further delaminated up to the level
of Whitnall’s ligament. The Müller muscle tends to bleed, so
you should coagulate the vessels carefully to prevent bleed-
ing before dissection (Fig. 17.14). If cautery of the Müller
muscle is conducted with a corneal protector in place, it will
not cause inadvertent thermal damage to the cornea. Alter-
natively, the surgeon should pull the eyelid up with forceps
to distance it from the cornea before using the cautery.
Fixation of Levator-Müller
Muscle Flap
When performing a levator advancement, the surgeon
should separate the levator aponeurosis rst from the tar-
sal plate, and then from the Müller muscle with Westcott
neurosis. The next structure beneath the orbital septum is
the pre-aponeurotic fat. If there is di culty in nding the
fat, the eyeball can be gently pressed with a nger from the
lower eyelid. Then the fat will bulge out. The surgeon needs
to remove only the fat that naturally comes out at this time
(Fig. 17.12). A deep superior sulcus will resolve after the
ptosis correction because the eyebrows will go down after
the surgery, except in cases of severe fat de ciency. Sau-
sage deformity, which might occur after the surgery, can
be prevented by removing the pretarsal orbicularis muscle.
This procedure should especially be performed on Asians,
who have very thick eyelids. After the surgeon lifts the
aponeurosis, which is loosely attached to the anterior tar-
sal surface, and delaminates it using scissors in an upward
direction up to the superior tarsal border, the peripheral
palpebral arcade can be observed, which runs on the Mül-
ler muscle (Fig. 17.13).
Fig. 17.10 Removal of the orbicularis muscle strand with West-
cott scissors.
Fig. 17.11 After removal of the orbicularis muscle, the orbital
septum is revealed.
Fig. 17.12 After opening of the septum, bulging fat is clamped
with a hemostat and resected.
Fig. 17.13 Dissecting the levator aponeurosis up to the superior
border of the tarsal plate after lifting the levator aponeurosis that is
loosely attached to the tarsal plate.

III Blepharoplasty
218
low, eyelash ectropion w ill occur. If the suture is placed too
high, entropion will occur.
A shallow xation to the tarsal plate may result in easy
loosening or under-correction. Therefore, when suturing to
the tarsal plate, it is better to anchor with levator aponeu-
rosis 3 to 4 mm in width. If the suture is passed through the
tarsal plates too deeply, it may penetrate the tarsal plates. It
can be checked whether the needle has passed through the
tarsal plate or not by everting the eyelid during the surgery
(Fig. 17.17).
Photographs in Sitting Position
Have the patient sit up after suturing the two parts, and
let the assistant take pictures using a digital cam era w ith
the ash on w hile asking the patient to look straight and
then dow n (Fig. 17.18). Enlarge the pictures and evalu-
ate w hether the degree of correction and contouring of
the eyelids are proper or not. If the height or contour-
ing is not satisfactory, release the bow tie and try again.
Once a satisfactory lid height and contour are obtained,
the excessive aponeurotic rem nants should be trim m ed
below the xation points after the levator advancem ent. It
is better to rem ove the fat that naturally bulges after leva-
tor advancem ent to avoid upper lid pu ness. The brow
and retroorbicularis oculi fat (ROOF) w ill com e dow n after
the ptosis correction.
Lash Ptosis Correction
At the end of the surgery, lash ptosis should be checked
and corrected to obtain a better cosmetic result. In case
of severe lash ptosis, the surgeon should suture the tar-
sal plate to the inferior ap of the orbicularis muscle and
overturn the direction w ith buried sutures. The lash ptosis
scissors while carefully cauterizing the large vessels in the
Müller muscle. The surgeon can advance the levator-Müller
complex 3 to 4 mm, attaching it to the superior tarsal bor-
der medial to the pupil rst and then lateral to the limbus
using 6–0 nonabsorbable suture material. The rst suture
should be placed medially to the pupil. This area is the
highest part of the upper lid. When dealing with involu-
tional patients who have lateral displacement of the tarsal
plate, it is advisable to suture more medially to the tarsal
plate to avoid lateral aring. Pass mattress sutures between
the levator aponeurosis and tarsal plate using 6–0 nylon,
6–0 Prolene (Ethicon), or 5–0 Vicryl (Ethicon) (Fig. 17.15).
The suture bites should be ~ 3 to 4 mm to prevent loosen-
ing and should not be too super cial to ensure that they
securely xate onto the tarsal plate (Fig. 17.16). The next
suture is placed between the pupil and the lateral limbus.
Both sutures should be placed 3 to 4 mm below the supe-
rior border of the tarsal plate. If the suture is placed too
Fig. 17.14 Dissecting a larger portion of the levator aponeurosis.
Fig. 17.16 The levator is sutured to the tarsal plate not super -
cially, but deeply, and tied with mattress suture.
Fig. 17.15 A needle is passed through the levator aponeurosis at
the part medial to the pupil.

17 Correction of Ptosis
219
ing from medial to temporal and then exiting through
the temporal skin stab incision. Tie the suture ends, and
remove the stitches in a week.
Frontalis Sling
Frontalis sling is a very e ective surgery for revision cases
after multiple levator surgeries or in cases showing poor
levator function below 4 mm (Fig. 17.19). There are diverse
sling materials such as autologous fascia lata, preserved
fascia lata, silicone rod, Supramid (S. Jackson), expanded
polytetra uoroethylene (ePTFE, or Gore-Tex [W. L. Gore]),
and others. The authors prefer the single rhomboid sling
method with ePTFE sutures (Gore-Tex CV-3).
The surgeon incises the skin 3 to 5 mm above the lid
margin, exposes the tarsal plates, and passes the Gore-Tex
suture horizontally through the tarsal plate ~ 3 mm inferior
to the superior tarsal border. The needle should be passed
under the anterior surface of the tarsal plate deep enough
to prevent loosening of the suture. However, if the suture
is passed too deeply, the needle will penetrate the tarsal
conjunctiva. Therefore, the upper eyelids should be everted
to check whether the sling material is exposed or not. The
sling material passed through the tarsal plate is xated
with 6–0 nylon sutures at the medial and temporal sites.
This prevents loosening after the surgery.
can be corrected by making skin–levator aponeurosis–skin
sutures. This also acts as a security suture for longevity of
the upper lid crease.
Levator Resection
The di erence between levator resection and levator
advancement is a vertical incision of the medial and lateral
horns to release and advance the levator muscle more. The
surgeon should remove remnants of the levator aponeuro-
sis at this time.
Conjunctivo-Müllerectomy
The simplicity and predictability of this procedure make it
attractive. This technique is preferred in mild ptosis cor-
rection.27,52,53 If the eyelid rises to the level of the opposite,
normal eyelid after the instillation of 2.5% or 10% phenyl-
ephrine eye drops and shows good function of the levator
muscle, good postoperative results with this technique can
be expected. In contrast to levator surgery, which requires a
skin incision, this technique will not leave an external scar.
In addition, a relatively precise result can be predicted.
Inject 1 mL of 2% lidocaine into the subconjunctival space
and 0.5 mL into the lateral third of the upper eyelid. Evert
the upper eyelid, and then mark the amount of conjunctiva
to be excised. Hold the conjunctiva with a Putterman clamp
or two hemostats.
Make a stab incision through the skin temporally. Pass
a 6–0 nylon suture through the stab incision and weave a
continuous suture 1 mm below the clamp from temporal
to medial. Remove the clamp after cutting below it, then
suture the cut stump by continuing the suture, now weav-
Fig. 17.17 Check whether the needle has passed through the tar-
sal plate by everting the lid.
Fig. 17.18 Photographs taken at the sitting position during
the correction of congenital ptosis in a 25-year-old woman show
(a) 1 to 1.5 mm over-correction of the right eye on primary gaze
and (b) lid lag on down-gaze.
a
b

III Blepharoplasty
220
6. Make a levator-Müller muscle ap while very
carefully cauterizing the large vessels in the Müller
muscle.
7. Advance the levator-Müller complex 3 to 4 mm,
attaching it to the superior tarsal border medial to
the pupil rst and then lateral to the limbus.
8. Evert the upper eyelid and check whether the needle
has passed the tarsal plate not in full thickness, but
in partial thickness.
9. Take photos to evaluate lid height (MRD1), contour,
and lid lag in the sitting position.

■Postoperative Care
Antibiotic ointment is applied to the incision after the sur-
gery and an ice pack is held to the closed eyelid for 20 to
30 minutes in the recovery room. If the amount of levator
advancement is large or the patient has severe lagophthal-
mos due to a frontalis sling, arti cial tears and lubricant
ointment are bene cial. The surgeon should advise the
patient to apply arti cial tears frequently and lift up the
lower eyelid to distribute the tears evenly onto the cornea
during the day, as well as putting the ointment into the
eyes before sleep.
The patient is advised to use a plastic eye shield to pre-
vent rubbing of the eyes by the hands during sleep. Stitches
are normally removed 6 to 7 days after the surgery, and an
antibiotic ointment is applied for an additional 3 to 4 days
following the removal of the stitches.

■Complications and
Their Management
Over-correction and
Under-correction
Over-correction is more common in patients with good
levator function, in revision cases, and in posttraumatic
ptosis. Postoperative downward traction massage will eas-
ily overcome a mild over-correction (less than 1 mm). If the
eyelid is slightly over-corrected postoperatively, stretching
the upper lid downward in the early postoperative period
will correct such a mild over-correction.
Under-correction can occur in cases of poor leva-
tor function. Possible reasons for under-correction are
improper xation of the levator-Müller muscle ap onto
the tarsal plate and loosening of suture knots. Performing
a revision at 1 week after levator advancement is recom -
mended if the eyelid is 1.0 mm above or below the target
height, or if there is asymmetry between the two eyelids of
1.0 mm or more (Fig. 17.20).
The surgeon creates medial, central, and temporal slit
incisions above the eyebrow. Using a Wright needle, each
end of the sling material from the tarsal plate is passed
deeply in front of the forehead periosteum through the
medial and temporal brow incisions. Then the ends are
passed through the central brow incision. The upper eye-
lid incision is closed with 6–0 nylon before tying the sling
material at the central brow incision. The sling material is
tied at the central brow incision and stitch knots using 5–0
Vicryl sutures are used to prevent loosening. The skin inci-
sion above the eyebrow is closed with deep 6–0 nylon or
Prolene sutures so that the sling material is not exposed.

■Key Technical Points
1. One-smooth-step skin incision is recommended to
avoid creating a zigzag incision.
2. Excise the orbicularis muscle in an oblique superior
direction to prevent indeterminate aponeurosis injury.
3. To nd the fat, gently push the eyeball by pressing
the lower eyelid with the ngers.
4. Identify the levator aponeurosis under the
preaponeurotic fat.
5. Hold the levator aponeurosis, which is loosely
attached to the tarsal plate and dissect it up to the
superior border of the tarsal plate.
Fig. 17.19 Frontalis sling to correct ptosis. (a) This 35-year-old
woman has had two previous ptosis surgeries and still has ptosis.
(b) Postoperative photo shows correction of ptosis after use of
bilateral ePTFE (Gore-Tex CV-3) frontalis slings.
a
b

17 Correction of Ptosis
221
Keratitis
The causes of keratitis after ptosis surgery are corneal
exposure and poor corneal protective mechanisms (dry eye
syndrome, facial nerve palsy, poor or absent Bell’s phenom -
enon). Lubricants should be prescribed and Frost sutures
can be performed to lift up the lower lid.
Conjunctival Prolapse
Conjunctival prolapse can be seen in cases of signi cant leva-
tor advancement. It is caused by damage to the suspensory
ligament in the superior fornix. If it does not improve with
pressure patching, partial conjunctival resection is needed.
Early Postoperative Revision
If the lid levels of the two eyes are not even after upper
blepharoplasty or ptosis surgery, simple revision might
be needed at 1 week postoperatively. As supported by the
long-term ndings of many other reports, 1 week postop-
erative lid height is a reliable indicator of the nal result.48
For early revision surgery, the surgeon does not need
to use local anesthesia. However, if a patient is nervous or
complains of pain during the surgery, injection of a small
amount of lidocaine without epinephrine is standard. The
revised eyelid height is generally very accurate because
there is little swelling. The general recovery period after
a revision is not signi cantly di erent from that follow-
ing the primary surgery. Postoperative downward traction
massage will easily overcome a mild over-correction (less
than 1 mm). If the eyelid is slightly over-corrected postop-
eratively, stretching the upper lid downward in the early
postoperative period might x the problem. However, in
the case of persistent asymmetry over 3 months, revision
surgery should be considered.

■Case Studies
Case 1
A 27-year-old male patient visited the clinic with a tired
look and prominent forehead wrinkles (Fig. 17.21a). An
eye examination showed MRD1 of –1 mm without frontalis
action and levator function of 10 mm in both eyes. His real
MRD1 with lifting of the upper redundant skin showed 1.5
mm in both eyes. His brow elevation was due to the pres-
ence of blepharoptosis and lash ptosis.
Burden factors were removed, levator advancement
was performed, and lash ptosis was repaired in both eyes.
Postoperatively, the patient had larger interpalpebral s-
sures, no longer needed to use his frontalis muscle for lid
elevation, and was more comfortable (Fig. 17.21b).
Contour Deformity
Contour deformity is caused by an incorrect xation of the
levator-Müller muscle ap onto the tarsal plate or uneven
tension on the tarsal plate in cases of maximum levator
advancement. When a contour deformity occurs, it can be
treated by early postoperative revision.
Entropion and Ectropion
Entropion and ectropion occur when the levator-Müller mus-
cle ap is xated too high or too low, respectively, onto the
tarsal plate. Changing the xation point can solve these prob-
lems. Mild lash ptosis can be xed with buried lash eversion
sutures (aponeurosis–inferior ap of orbicularis sutures).
Lid Lag and Lagophthalmos
Lid lag and lagophthalmos are inevitable complications
after maximum levator advancement and frontalis sling
procedures. Patients should be instructed to use arti cial
tears and ointment frequently.
Fig. 17.20 Under-correction and early postoperative revision. (a)
A 27-year-old patient had levator advancement for contact lens–
induced ptosis. (b) On day 7 after surgery, the right eyelid was a lit-
tle droopy. (c) After early postoperative revision (re-advancement)
on the right eye, the eyelids look symmetric.
a
b
c

III Blepharoplasty
222
MRD1 of 0 and 2.5 mm, levator function of 8 and 12 mm,
and lid lag of 5 and 4 mm for the right and left eyes, respec-
tively. The authors performed levator advancement of the
right eye and upper blepharoplasty of both eyes. Postop-
eratively, her right droopy lid was improved, her inferior
scleral show was resolved, and both eyebrows were no lon-
ger elevated (Fig. 17.22b).
Case 2
A 25-year-old female patient presented to the clinic with
a droopy right lid since birth and constant brow elevation
(Fig. 17.22a). She complained of a ghost-like appearance
due to her inferior scleral show. She had ptosis surgery
when she was 9 years of age. Eye examination showed
Fig. 17.21 Case 1. (a) A 27-year-old male with a tired look and prominent forehead wrinkles with brow elevation due to bilateral blepha-
roptosis and lash ptosis. (b) After levator advancement and lash correction, he does not use his forehead muscle any more and feels
comfortable.
Fig. 17.22 Case 2. (a) A 25-year-old female with congenital ptosis. She has a history of ptosis correction at 9 years old. (b) After levator
advancement of the right eye and bilateral upper blepharoplasty, the right, droopy lid improved, inferior scleral show resolved, and both
eyebrows are down.

■Conclusion
A proper preoperative evaluation of ptosis w ill guide the
appropriate surgical management. It is necessary to eval-
uate the patient’s protective functions, such as dry eye
syndrome, facial palsy, dysfunction of the superior rectus
muscle, and absence of Bell’s phenomenon. In cases of
asymmetric ptosis, the surgeon must evaluate for contra-
lateral ptosis by performing a manual elevation test, occlu-
sion test, or phenylephrine test. When there is a positive
Hering’s test on preoperative examination, the surgeon
should consider bilateral ptosis repair.
Generally, there are three types of surgery in ptosis
correction: levator surgery, conjunctivo-Müllerectomy
(MMCR or the Fasanella-Servat procedure), and frontalis
sling. Selection of the repair method is based on consider-
ation of the degree of ptosis and levator function.
The possibility of revision is always present due to
numerous intraoperative and postoperative variables as
well as patient-related factors. Obtaining optimal height
and contour for both eyelids can be di cult in ptosis sur-
gery. For the most satisfying results, the surgeon should try
to minimize the controllable variables as much as possible.
If the levels of the two eyelids after ptosis correction are not
symmetric, postoperative revision should be performed at
1 week postoperatively to achieve good results.
a
b
a
b

17 Correction of Ptosis
223
23. Putterman AM, Urist MJ. Müller’s muscle-conjunctival re-
section in the treatm ent of ptosis. Modi cation, theory and
clamp for the Fasanella-Servat ptosis operation. Arch Oph-
thalmol 1972;87:665–667
24. Putterman AM, Urist MJ. Müller m uscle-conjunctiva resec-
tion. Technique for treatm ent of blepharoptosis. Arch Oph-
thalmol 1975;93(8):619–623
25. Lauring L. Letter: sutureless Fasanella-Servat blepharopto-
sis correction. Am J Ophthalm ol 1975;80(4):778
26. Lauring L. Blepharoptosis correction with the suture-
less
Fasanella-Servat
operation.
Arch
Ophthalmol
1977;95(4):671–674
27. Bodian M. A revised Fasanella-Servat ptosis operation. Ann
Ophthalm ol 1975;7(4):603–605
28. Weinstein GS, Buerger GF Jr. Modi cation of the Müller’s
m uscle-conjunctival resection operation for blepharopto-
sis. Am J Ophthalmol 1982;93(5):647–651
29. Duane TD, ed. Clinical Ophthalm ology. Hagerstown, MD:
Harper & Row; 1976
30. Jeong S, Lem ke BN, Dortzbach RK, Park YG, Kang HK.
The Asian upper eyelid: an anatomical study with com -
parison to the Caucasian eyelid. Arch Ophthalmol 1999;
117(7):907–912
31. Takahashi Y, Kakizaki H, Mito H, Shiraki K. Assessm ent
of the predictive value of intraoperative eyelid height
m easurem ents in sitting and supine positions during
blepharoptosis repair. Ophthal Plast Reconstr Surg 2007;
23(2):119–121
32. Ahuero AE, Hatton MP. Eyelid m alposition after cataract
and refractive surgery. Int Ophthalm ol Clin 2010;50(1):
25–36
33. Gri n RY, Sarici A, Unal M. Acquired ptosis secondary to
vernal conjunctivitis in young adults. Ophthal Plast Recon-
str Surg 2006;22(6):438–440
34. Finsterer J. Ptosis: causes, presentation, and m anagement.
Aesthetic Plast Surg 2003;27(3):193–204
35. McCord CD, Tanenbaum M, Nunery WR. Oculoplastic Sur-
gery. 3rd ed. New York, NY: Raven; 1995:176
36. Sutula FC. Histological changes in congenital and acquired
blepharoptosis. Eye (Lond) 1988;2(Pt 2):179–184
37. Kitazawa T. Hard contact lens wear and the risk of ac-
quired blepharoptosis: a case-control study. Eplasty 2013;
13:e30
38. Epstein G, Putterman AM. Acquired blepharoptosis sec-
ondary to contact-lens wear. Am J Ophthalmol 1981;
91(5):634–639
39. Watanabe A, Araki B, Noso K, Kakizaki H, Kinoshita S.
Histopathology of blepharoptosis induced by prolonged
hard contact lens wear. Am J Ophthalm ol 2006;141(6):
1092–1096
40. Dortzbach RK. Superior tarsal muscle resection to correct bleph-
aroptosis. Ophthalmology 1979;86(10):1883–1891
41. Zoum alan CI, Lism an RD. Evaluation and managem ent of
unilateral ptosis and avoiding contralateral ptosis. Aesthet
Surg J 2010;30(3):320–328
42. Meyer DR, Wobig JL. Detection of contralateral eyelid re-
traction associated with blepharoptosis. Ophthalmology
1992;99(3):366–375
References
1. Beard C. History of ptosis surgery. Adv Ophthalmic Plast
Reconstr Surg 1986;5:125–131
2. Servat J, Mantilla M. The history of ptosis surgery. Adv
Ophthalm ic Plast Reconstr Surg 1986;5:133–137
3. Dransart HN. Un cas de blepharoptose opere par un pro-
cede special a l’auteur. Ann Ocul 1880;84:88
4. Hess C. Operation methode gegen ptosis. Arch Augenheilkd
1893;28:22
5. Payr E. Plastik m ittels freier faszien transplantation bei
ptosis. Dtsch Med Wochenschr 1909;35:822
6. Yasuna E. Use of prepared fascia lata in correction of ptosis.
Am J Ophthalm ol 1962;54:1097–1103
7. Argam aso RV. An adjustable fascia lata sling for the cor-
rection of blepharoptosis. Br J Plast Surg 1974;27(3):
274–275
8. Argam aso RV, Lewin ML. Fascia lata sling in blepharoptosis:
enhancem ent of result by postoperative adjustm ent. J Pe-
diatr Ophthalm ol 1976;13(1):51–55
9. Crawford JS. Repair of ptosis using frontalis muscle and
fascia lata: a 20-year review. Ophthalm ic Surg 1977;8(4):
31–40
10. Patrinely JR, Anderson RL. The septal pulley in frontalis sus-
pension. Arch Ophthalmol 1986;104(11):1707–1710
11. Bowm an WP. cited by Bader D. Report of the chief op-
erations perform ed at the Royal Ophthalmic Hospital for
the quarter ending Septem ber 1857. Ophthal Hosp Rep
1857;1:1857–1859
12. Everbusch O. Zur operationen der congenitalen blepharop-
tosis. Klin Monatsbl Augenheilkd 1883;21:100
13. Snellen H. Levator Tendon Shortening for Ptosis. Heidel-
berg: Report of the German Ophthalm ology Society; 1883
14. Wol H. Der verlagerung des m usculus levator palpebrae
superioris mit durchtrennung der insertion: Zwei neue
Methoden gegen ptosis congenital. Arch Augenheilkd
1896;33:125
15. Blaskovics L. A new operation for ptosis with shortening of
the levator and tarsus. Arch Ophthalmol 1923;52:563
16. Anderson RL, Beard C. The levator aponeurosis. Attach-
m ents and their clinical signi cance. Arch Ophthalmol
1977;95(8):1437–1441
17. Anderson RL, Dixon RS. Neuromyopathic ptosis: a new surgical
approach. Arch Ophthalmol 1979;97(6):1129–1131
18. Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch
Ophthalm ol 1979;97(6):1123–1128
19. Anderson RL. Age of aponeurotic awareness. Ophthal Plast
Reconstr Surg 1985;1(1):77–79
20. Baker SS, Muenzler WS, Sm all RG, Leonard JE. Carbon di-
oxide laser blepharoplasty. Ophthalm ology 1984;91(3):
238–244
21. Meltzer MA, Elahi E, Taupeka P, Flores E. A simpli ed tech-
nique of ptosis repair using a single adjustable suture. Oph-
thalmology 2001;108(10):1889–1892
22. Fasanella RM, Servat J. Levator resection for m inim al
ptosis: another simpli ed operation. Arch Ophthalmol
1961;65:493–496

III Blepharoplasty
224
49. Morris CL, Morris WR, Fleming JC. A histological analysis
of the Müllerectomy: rede ning its mechanism in ptosis
repair. Plast Reconstr Surg 2011;127(6):2333–2341
50. Jang SY, Chin S, Jang JW. Ten years’ experience with uni-
lateral conjunctival Mullerectomy in the Asian eyelid. Plast
Reconstr Surg 2014;133(4):879–886
51. Steinkogler FJ, Kuchar A, Huber E, Arocker-Mettinger E.
Gore-Tex soft-tissue patch frontalis suspension technique
in congenital ptosis and in blepharophimosis-ptosis syn-
drome. Plast Reconstr Surg 1993;92(6):1057–1060
52. Karesh JW. Polytetra uoroethylene as a graft material
in ophthalmic plastic and reconstructive surgery. An ex-
perim ental and clinical study. Ophthal Plast Reconstr Surg
1987;3(3):179–185
53. Bajaj MS, Sastry SS, Ghose S, Betharia SM, Pushker N.
Evaluation of polytetra uoroethylene suture for frontalis
suspension as compared to polybutylate-coated braid-
ed polyester. Clin Experim ent Ophthalm ol 2004;32(4):
415–419
43. Bodian M. Lip droop following contralateral ptosis repair.
Arch Ophthalm ol 1982;100(7):1122–1124
44. Lyon DB, Gonnering RS, Dortzbach RK, Lem ke BN. Unilat-
eral ptosis and eye dom inance. Ophthal Plast Reconstr Surg
1993;9(4):237–240
45. Worley MW, Gal O, Anderson RL, al Hariri A. Eye dominance
and Hering’s law e ect on bilateral blepharotosis repair.
Ophthal Plast Reconstr Surg 2013;29(6):437–439
46. Erb MH, Kersten RC, Yip CC, Hudak D, Kulwin DR, McCul-
ley TJ. E ect of unilateral blepharoptosis repair on con-
tralateral eyelid position. Ophthal Plast Reconstr Surg
2004;20(6):418–422
47. Malik KJ, Lee MS, Park DJJ, Harrison AR. Lash ptosis in con-
genital and acquired blepharoptosis. Arch Ophthalm ol
2007;125(12):1613–1615
48. 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

225
18 Management of Double-Eyelid Surgery
Complications
In-chang Cho and Aram Harijan
seek further surgical treatment. This understanding comes
only if the patient is given ample opportunities to tell the
story. Physical examination must correlate with the history.
Any discrepancies between the story and physical nding
should serve as a warning, and the surgeon must perform
due diligence in attempting to rediscover pertinent aspects
of the patient’s medical and surgical history.
More often than not, the patient with an unsatisfac-
tory outcome will have multiple complaints. In assessing
and counseling the patient, the surgeon must try to o er
the ideal operation, which is the one that addresses all of
these complaints at once. If no such operation is possible,
the surgeon must then o er the optimal solution, which
will address as many of the problems as possible at once.
For example, a patient may present with a high crease, deep
fold, and excessive pretarsal fullness of the upper eyelid. If
the surgeon understands that both deep fold and pretarsal
fullness are intrinsically tied to the problem of high crease,
he or she can appreciate that all three of the problems may
be solved by a single procedure: lower the crease.2
Once the simplest solution has been identi ed, the
surgeon must share this information. The patient should
understand that the intention is to improve all of the unde-
sirable features to an acceptable degree, rather than to
completely solve only a small fraction of the problems. If
the surgeon can o er an approach and the patient accepts
it, meeting the expectation becomes a mere problem of
technicality.

■Introduction
Aesthetic standards for eyelids vary across ethnic groups
and cultures. While a certain contemporary aesthetic stan-
dard may be satisfactory to a large number of patients,
complications after double-eyelid operations are speci c to
the individual patient. Therefore, the authors believe that
an outcome that fails to meet realistic patient expectations
quali es as a practical de nition for a complication of an
aesthetic operation.
In the context of East Asian blepharoplasty, the most
common complications are problems of crease height (low
versus high), fold depth (shallow versus deep), extrane-
ous creases (triple folds), pretarsal fullness, ptosis, and
asymmetry arising from any number of previous condi-
tions.1 This chapter will identify the mistake or the prob-
lem behind each complication and present the solution the
senior author has developed over his career as an oculo-
plastic surgeon.

■Patient Evaluation
Proper operation depends on proper indication. And
proper indication originates from proper diagnosis. In each
new preoperative consultation, the surgeon must under-
stand the course of events that prompted the patient to
Pearls
• Identify and nd ways to avoid the original mistake.
Otherwise, secondary and tertiary operations will
only compound the problem from the rst operation.
• Railroad scar from delayed removal of stitches
should never happen.
• Mechanical resistance to folding of the eyelid skin
varies from patient to patient. This resistance is
evaluated by observing how long a temporary crease
stays after using a bougie.
• Deeper folds usually accompany high creases, but
crease height is not the same as fold depth.
• In secondary eyelid operations, the rst goal should
be deconstruction of layers through release of
adhesion and separation of appropriate planes.
• The second goal is the prevention of further
complications.
• The third goal is to create the desired eyelid shape,
including new crease height and fold depth.
• The problem behind pretarsal fullness is in
the height (not the volume) of the pretarsal
compartment. Rather than removing soft tissue, the
high crease should be replaced with a lower one.
• It is the surgeon’s job to help the patient
understand that there is no way to rem ove an
eyelid crease and m ake the eyes look like their
original form s. A better solution is to lower the
crease to the eyelid m argin and to bury the incision
scar w ithin the fold.

III Blepharoplasty
226

■Surgical Techniques
Scar
Eyelid skin does not develop hypertrophic response in most
cases. When hypertrophic response is observed after an
eyelid operation, the fundamental problem could be the
patient’s tendency to develop hypertrophic scar. In many
instances, however, the problem is not with the patient but
with the surgeon who performed the index operation.
The most common technical mistake is a lack of under-
standing of the distribution of the superior-posterior force
vector of the levator muscle. If this vector is unequally
distributed to the lower ap, it is possible to dislocate the
lower ap from the upper ap (Fig. 18.1). This occurs more
frequently in the lateral portion of the upper eyelid because
the aponeurosis is deeper in the tissue. To minimize such a
risk, the surgeon must ensure that the upward pull of the
levator is transferred to the tarsus—not the skin—via a su -
cient number of bites of the plate. In younger patients, skin
excisions do not have to be extended along the full length
of the eyelid to create a crease of desirable length; a shorter
incision design is usually su cient. A less technical but
still common mistake is leaving sutures in for more than
5 days; epithelial tunnels form around sutures only 7 days
after operation. Railroad track scars from delayed suture
removal are unacceptable. Eyelid scars are more noticeable
when they are depressed. Such scars result from exces-
sive removal of the orbicularis muscle, connective tissue
(Fig. 18.2), or deep fold (Fig. 18.3).3,4
An eyelid scar revision must obey the wound heal-
ing principles that govern all aspects of surgical care. The
operation must be aseptically possible. Both surgeon and
instrument must be atraumatic with respect to the eyelid
tissues. All layers—not just skin—should be approximated
with as little tension as possible.
Excision and re-approximation of the skin does noth-
ing to address scars that are depressed. The missing layer
of orbicularis oculi must be reconstructed by undermin-
ing and advancing the muscle edges from both upper and
lower aps. Such undermining is also bene cial if the
problem is that the skin adjacent to the pre-existing scar is
inverted. When appropriate, undermining of the skin aps
signi cantly mitigates the tension placed directly across
the dermis (Fig. 18.4). Simple continuous suture can place
diagonal tension across the wound. An interlocking contin-
uous suture will maintain an even perpendicular tension.
Inclusion cysts result from a prolonged foreign body
reaction to the suture placed between the upper and lower
skin aps or from sebaceous gland activity. These cysts
may develop over weeks to months after an operation and
should be excised if they do not resolve spontaneously
(Fig. 18.5). Inclusion cysts are best avoided by using the
orbicularis muscle—not the dermis itself—as the anchoring
point for the sutures.
Fig. 18.1 On opening the eyes, the lower ap is dislocated as it
is pulled inward by the xation suture there. For prevention, skin
sutures must be done closely to su ciently bite the tarsal plate.
Loss of Fold
All surgically created eyelid creases attenuate during the
rst few months. This change might be minimal, or the fold
might disappear altogether. The degree to which a postop-
erative fold softens is determined by patient characteristics
and surgical technique.
Fig. 18.2 Depressed scars from excessive removal of orbicularis
muscle. Depression is seen beneath the fold from removal of orbi-
cularis muscle.
Fig. 18.3 Depressed crease line from ectropion. The lower ap is
stretched upward.

18 Management of Double-Eyelid Surgery Complications
227
and/or disappear over time because the repetitive move-
ment and shifting of various layers are enough to disrupt
this adhesion between the layers. To prevent such changes,
the adhesions—not the suture material—must be stronger.4
The resistance of an eyelid against forming a fold is esti-
mated during the preoperative consultation. Fold-resistant
eyelids tend to require signi cantly more force when using
the stylus, and the created fold disappears rather quickly
compared with the eyelids, which maintain postoperative
creases without signi cant changes. Patient factors that
predict high resistance to fold formation include thick skin,
abundant soft tissue, blepharoptosis, highly elastic skin in
younger patients, sunken eyelids, enophthalmos, history
of failed double-eyelid operation, and adhered lower ap.
Eyelids with epicanthal folds show high resistance along
the medial side. Though this is not a preoperative patient
factor, weight gain in the intermediate postoperative period
can precipitate loss of a surgically created fold.
To prevent loss of folds, the surgeon must tie the suture
while avoiding the intrusion of soft tissue between the
levator aponeurosis and dermis or the orbicularis muscle
into the loop. If a patient has fold-resistant eyelids, it is
important to create a fold that is deep enough to result in
the slightest ectropion that will subside after a short post-
operative duration. Excessively deep xations can result in
persistent ectropion, even if the fold becomes shallower
over time.
Shallow or Deep Fold
Shallow Fold
At times, there is extraneous fat or connective tissue in the
pretarsal space. This is especially common on the medial
side of the upper eyelid, where pretarsal fat is abundant.
Partial resection of this connective tissue can aid in form-
ing an adhesion. If a patient has blepharoptosis or a de nite
epicanthal fold, these elements must be dealt with rst to
reduce fold resistance. Otherwise, a deeper fold is necessary.
The patient-related factors that promote softening or
loss of crease are as follows: (1) thick skin and abundant
soft tissue, (2) blepharoptosis, (3) sunken eyelid, (4) enoph-
thalmos, (5) history of failed double-eyelid operation, (6)
younger age, (7) low-lying preoperative crease, (8) presence
of epicanthal fold, and (9) extreme weight gain. Operative
factors associated with technical failure are as follows: (1)
inaccurate approximation of connective tissue, (2) insu -
cient xation to tarsal plate, (3) low-set xation, and (4)
loosening of the xation due to hematoma or edema.
Inadequate soft tissue removal along the top margin
of the tarsal plate can prevent close approximation of the
connective tissue as well as bunching of fat tissue into the
loop of the suture. Fat tissue within the loop can introduce
mechanical redundancy w ith expansion from edema and/
or hematoma and subsequent disappearance of the surgi-
cally created crease.
Although the importance of sutures cannot be over-
emphasized, a ne distinction must be made between a
strong xation and a proper xation. A surgically created
eyelid fold is a consequence of the adhesion between the
anterior and posterior lamellae. Postoperative folds soften
Fig. 18.4 Correction of depressed scar. (a) The inci-
sional scar is resected. (b) The upper orbicularis mus-
cle ap is minimally undermined. (c) Skin and muscle
are repaired together.
Fig. 18.5 Inclusion cyst. If anchoring is done on the dermis, and
inclusion cyst may be formed from foreign body reaction, due to
the thin nature of the upper eyelid skin.
a
b
c

III Blepharoplasty
228
There are three approaches to correct a low fold. The
rst is an open blepharoplasty by which the skin and orbi-
cularis muscle are excised above the previous crease. The
second approach is to create a mechanically overriding
crease above the previous one. The third combines soft tis-
sue excision and mechanical xation above the prior crease
(Fig. 18.8).4
The rst approach (open blepharoplasty) can incorpo-
rate scar revision and allows for excision of redundant skin
in older patients. However, the surgeon must leave enough
eyelid skin to minimize the risk of postblepharoplasty brow
ptosis. In patients without signi cant redundancy of eyelid
skin, excision of the orbicularis muscle above the old crease
is more important than excision of the skin. Maximum ele-
vation of the eyebrows should result in 80 to 90% elevation
of the upper eyelid margin in patients with an appropri-
ate amount of skin excised. This is an important part of the
preoperative and intraoperative guideline on estimating
how much of the upper eyelid skin is redundant.
The second approach (tarsal xation) allows consider-
able elevation of the fold crease but will create an additional
scar, if secondary incisions are necessary. This approach
If there is adhesion in the lower ap with softening of
the fold, the adhesion will interfere with the formation of a
new crease. In such cases, the lower ap must be released
and redraped prior to tarsal xation. In patients whose
eyelid skin lacks elasticity after the previous operation, the
newly created fold should be deeper than usual to prevent
a repetitive loss of fold (Fig. 18.6).
Deep Folds or Ectropion
Deep folds and ectropion are caused by creases that were
xated too high on the eyelid. This places an undue upward
tension on the lower ap and everts the eyelid margin. A
patient often complains about the unintended impres-
sion of aggression conveyed by the everted eyelids. The
depressed scar is visible when the eyes are closed. The
patient may also complain of a tugging sensation in the
eyelids. The palpebral ssure may become larger. The skin
just superior to the fold tends to bulge.
High xations inadvertently increase the palpebral s-
sure because the levator aponeurosis is plicated when the
lower ap is xed at a high point on the levator aponeuro-
sis. In case of severe ectropion, the conjunctiva is exposed.
The mucocutaneous junction becomes keratinized, leading
to dry eye syndrome.
The rst step in correcting the deep fold is to release
the adhesions and re-approximate the layers at a lower
point along the eyelid. If this part of the operation does not
resolve the ectropion, the lower ap must be undermined
and redraped over the tarsal plate to decrease the everting
force of the adhesion in the lower ap. The second portion
of the operation is to prevent the formation of triple folds.
The surgeon must take care not to allow re-adhesion by
introducing the orbital fat into the space between the apo-
neurosis and orbicularis muscle.
Deep crease is often accompanied by a high fold, and
the operations to correct these two features are very simi-
lar. The only signi cant di erence between the two correc-
tion methods is that the location of the previous crease is
maintained in cases of deep crease without high fold, the
new crease is designed lower than the previous crease, and
the skin in between is excised in cases of high fold alone.
Correction of deep crease will be described again along
with correction of high fold in the following section.
Low Crease
In a crease that is too low, very little skin will show between
the eyelid margin and the crease. This is usually a problem
of the actual crease design being too low, but a shallow
fold can sometimes give the appearance of a low crease
(Fig. 18.7). Redundancy of skin can also make a crease
appear lower than it really is.
Adhesion
Fig. 18.6 Correction of a shallow crease. Release the previous
adhesion at the pretarsal area. Since elasticity is compromised from
brous change and a relapse is common, xate at a higher point
than usual.
Fig. 18.7 Low fold due to a shallow crease.

18 Management of Double-Eyelid Surgery Complications
229
that failed to address the mechanical etiology behind the
ptosis (Fig. 18.9).
High creases can be observed w ith deep, normal, or
shallow fold depths. The most common form is a fold that is
both high and deep, which is often accompanied by ectro-
pion. At times, patients might have folds of varying depth
(e.g., a fold that is shallow on the medial side but deep over
the pupils).4
Correction of High Creases
Like other complications, high creases should be corrected
according to the cause. Generally, the secondary operation
incorporates an open blepharoplasty with skin excision.
The upper margin of this excision is along the fold that is
to be revised, and the lower margin marks the new crease
height. If the skin lacks redundancy and lagophthalmos
is expected, skin is not resected. Rather, a lower incision
can be used to undermine the upper ap and release the
high fold through either the pre-aponeurotic layer or pre-
septal layer. Releasing the fold through the pre-aponeurotic
layer minimizes the risk of re-adhesion because it is in the
deeper layer. In patients with blepharoptosis, this deeper
dissection plane is a natural choice, as it allows the opera-
tor to access the levator mechanism. For the same reason,
however, this plane of dissection can injure the levator
aponeurosis and result in postoperative blepharoptosis. In
contrast, releasing through the pre-septal layer minimizes
this risk but is associated with increased risk for triple fold
formation.
Deep folds respond better to dissection of the upper ap
through the deeper plane. However, a deep fold may remain,
even with adequate release beneath the upper ap. In such
situations, the lower ap might also contribute to fold depth
and should be released from the underlying tissue. The
lower ap should then be xed at the desired height. This
also addresses the problem of ectropion, if present.
is more appropriate for patients who have inconspicuous
scars from the rst operation and wish for the eyelid fold
to be higher. If the previous fold is strongly de ned (i.e., too
deep), then a simple mechanical xation may result in mul-
tiple eyelid folds. To minimize such risk, the lower ap can
be undermined through a small incision window. This can
signi cantly attenuate the primary fold to a faint appear-
ance. Patients should be warned of the potential for pretar-
sal fullness from the scar tissue after the initial operation.
The combined approach of open blepharoplasty and
mechanical xation is reserved for patients with very low
folds and great redundancy of skin.
High Crease
In many East Asian cultures, high eyelid crease is associated
with an aggressive or antagonistic personality. High creases
are usually accompanied by deep folds, and patients com -
plain of unnatural appearance, depressed scar, and exces-
sive eversion of the eyelashes. Patients may also complain
about pretarsal fullness that has not improved with time.
Slight blepharoptosis can be seen in patients with an adhe-
sion between the skin and levator aponeurosis that pre-
vents recursion of the levator muscle.
Causes
High creases can be caused by high-positioned skin crease
design, high xation, excessive skin excision, unintended
adhesion, blepharoptosis, or sunken eyelid. Among these,
high crease design from the initial operation is the most
common. Fixation of the lower ap to a high point can
result in high folds with ectropion. The problem can also
result from excessive skin resection, which leaves insu -
cient skin to cover the crease. Patients with blepharopto-
sis tend to develop high folds after an eyelid fold operation
Skin and
OOM excision
Previous
incision
line
New line
Soft tissue
excision
New line
Fig. 18.8 Methods of raising low fold. (a) The skin and orbicularis oculi muscle (OOM) are removed around the previous incision line.
(b) A new crease is made above the previous incision line, by a buried suture method or a short incision method. (c) Combination of a and
b methods; excision of soft tissue is performed above the previous incision line.
a
b
c

III Blepharoplasty
230
primary and secondary operations, where the lower crease
is the desired crease and the higher crease reappeared at
the site of the initial operation. Even after complete adhe-
siolysis, the posterior lamella can re-adhere to the anterior
lamella. The problems of triple folds are so common that it
is discussed as a distinct topic in a later part of this chapter.
To prevent these secondary complications, the sur-
geon must maintain su cient tissue volume, thoroughly
free the adhered tissue planes, and make e orts to prevent
re-adhesion. To accomplish these goals, it is important to
abide by the following guidelines:
1. Resect only the skin and leave the scar tissue to
reinforce the upper ap (Fig. 18.10).
2. If the upper ap lacks su cient soft tissue bulk, the
orbital fat along with the septum can be lowered
to add volume to the upper ap and also provide
a gliding membrane between the orbicularis oculi
and the levator aponeurosis. This latter function of
interposition ap is extremely important in preventing
re-adhesion of separated elements (Fig. 18.11).
3. In the same manner, the orbicularis muscle can be
used as an interposition ap (Fig. 18.12).
4. If there is insu cient orbital fat or orbicularis
muscle, a connective tissue ap can be elevated for
reinforcement. Dermofat graft, fat graft, or microfat
injection deep to the orbicularis oculi are possible
alternative solutions and are also e ective in
lowering the risk of re-adhesion.
High creases w ith neutral fold depth can be addressed
by simple open blepharoplasty, as described previously.
Shallow eyelid folds are corrected in a similar manner to
neutral folds, by open blepharoplasty. Even with a com -
plete loss of fold, however, the lower ap can still have
severe adhesions and require adhesiolysis. If no such adhe-
sions are present, the lower ap should have enough laxity
to allow adequate xation at the desired height.1
Failures after Correction of High Crease
The two major problems that occur after high fold correc-
tion are ectropion and multiple folds. Failure rates for high
fold correction can be unacceptably high for surgeons who
do not grasp the fundamental principle behind second-
ary operations: that unwanted adhesion is the enemy. The
primary reason of failure in revising the high lid crease is
an incomplete release of the tissue around the old eyelid
crease. The failure may also be caused by re-adhesion of the
tissue that was adequately freed.
Incomplete lysis of adhesions or re-adhesion may result
in ectropion with an eyelid crease that appears to change
height with movement. With the eyes closed, the crease
will appear lowered, as intended. However, the same crease
does not appear lowered when the eyes are open because
the skin is expanded and bunched from the everted eyelid.
Multiple eyelid creases can form after correction
of high creases. In such postsecondary blepharoplasty
patients, each crease represents the xations performed in
Fig. 18.9 Causes of high fold. (a) High incision line. (b) High fold from ectropion. (c) High fold from blepharoptosis. (d) High fold from
sunken eyelid.
a
b
c
d

18 Management of Double-Eyelid Surgery Complications
231
5. To increase the resistance to inward folding of skin at
the initial operative site, a bulky roll of upper ap can
be made by suturing the skin and orbicularis together
after skin closure. The needle is passed through the
skin and orbicularis oculi beneath the new crease, then
through the orbicularis oculi and skin of the upper
ap. In addition to increasing eyelid resistance along
the length of the old crease, it separates the anterior
lamella from the posterior lamella (Fig. 18.13).
6. DuoDERM dressing (ConvaTec) and adhesive tape
can be used as a splint to increase fold resistance
over the lower edge of the upper ap (Fig. 18.14).
7. If correction of eversion is di cult due to severe
adhesion, injecting or spraying diluted steroids may
help in the postoperative period.
Fig. 18.10 Correction of high fold. (a) Resection of skin down to the newly created lower
crease. Resect only the skin, without resecting any scar tissue. (b) Adhesiolysis at the pre-
aponeurotic layer. (c) Con rm complete adhesiolysis by holding the upper skin ap. If ever-
sion remains, undermine the lower ap. (d) Fixate the lower ap at a lower point and close
the skin.
Previous adhesion site
New fixation site
Previous adhesion site
New fixation site
Fig. 18.11 Failure in high fold correction.
(a) If the previous adhesion is incompletely
lysed, eversion of eyelid develops because
the lower ap is pulled up and adhered.
(b) Triple fold may also develop due to re-
adhesion of the previous adhesion site.
Fig. 18.12 Remove only the skin and use the resected orbicu-
laris muscle and scar tissue as an interposition ap to reinforce the
upper ap volume.
a
b
c
d
a
b
a
b

III Blepharoplasty
232
Partially High Crease or
Undesirable Curvature
A common mistake in correcting a partially high crease is to
partially address the problem. For example, a partial revi-
sion of only the medial side will introduce a kink to the cur-
vature of the crease such that the outer portion will appear
higher than the medial portion. This could also introduce a
triple fold appearance along the medial side.
Partially high creases should be repaired using the same
principles as high crease correction: skin excision, lysis of
adhesions, and xation. The new crease should be allowed
to partially overlap the course of the previous crease.
Pretarsal Fullness
Commonly observed with high creases, pretarsal fullness is
also described as “sausage eyelid” among Korean patients.
It refers to the unwanted soft tissue projection in the area
over the tarsal plate in postblepharoplasty eyelids. Preop-
erative factors that predict pretarsal fullness include thick
eyelid skin and orbicularis muscle. Patients with these fea-
tures should receive eyelid folds that are designed lower
than usual to counteract this propensity.
Pretarsal fullness increases in proportion to the
square of the height of the pretarsal soft tissue compart-
ment, which implies that small changes in height can
result in great changes in the volume of this compartment
(Fig. 18.16). For example, an eyelid crease that changes
height from 4 to 3 mm when opening the eye will have a
volume reduction close to 50% (9/16).
8. Excessive skin excision will result in the lower crease
being pulled up toward the eyebrows, resulting in
eversion. To prevent this, the lower ap can be xed
by securing it to a partial purchase in the tarsal plate
during closure. This is e ective in counteracting the
upward pull from the tight eyelid skin (Fig. 18.15).
9. Skin de ciency can be partially o set by undermining
a 2-mm margin of skin in the upper ap.
Fig. 18.13 Correction or prevention of triple fold. Creating a skin–
orbicularis oculi roll prevents re-adhesion.
Fig. 18.14 Adhesive tape or DuoDERM dressing can be used as a
splint to increase fold resistance over the lower edge of the upper
ap.
Fig. 18.15 To prevent eversion in eyelids with de cient skin, x
the lower ap to the tarsal plate by biting through the tarsal plate
partially during skin closure.