Advanced Asian Blepharoplasty: Upper Blepharoplasty Techniques
According to Upper Eye Lid Blepharoplasty by Bhupendra C. Patel, Raman Malhotra (2022) Upper blepharoplasty, whether performed for cosmetic reasons or functional reasons, is one of the most frequent operations performed on the face.
Eyes and eyelids are the central features of the face that are seen by others and by patients every time they look into a mirror. We also converse by looking from eye-to-eye. This explains the popularity of products designed for use on brows, upper lids, lower lids, and eyelashes.
The eyes of Asians are relatively small with thick skin in the eyelids and periorbital area. They typically lack the upper eyelid crease (creating the so-called double eyelid) due to burden factors like thick skin, hypertrophied orbicularis oculi muscle (OOM), submuscular fibroadipose tissue, thick orbital septum, abundant preaponeurotic fat, and lower positioned transverse ligament.
Asian eyes may also have a superior visual field defect due to skin overriding the upper lid margin (skin-OOM-fat complex slide down). These burden factors result in the eyelashes appearing short and becoming misdirected and pressed toward the globe, causing functional discomfort.
As a compensatory mechanism, Asian people tend to engage the frontalis muscle to lift the eyebrow to help them open their eyes. Along with aesthetic enhancement, double-eyelid surgery in Asian burden lids can improve the functional deficiencies helping the patients to open the eyes more easily. In addition, treatment of the Mongolian fold (medial epicanthal fold), caused by medial hypertrophy of preseptal OOM, augments the surgical results. In this report, we present the appropriate preoperative assessment, surgical technique, and postoperative care that should be employed to achieve consistently good functional and aesthetic outcomes in these patients.
Upper blepharoplasty constitutes the surgical repair or reconstruction of the upper eyelid including management of upper eyelid skin, orbital septum, any underlying ptosis, and excess or deficient preaponeurotic and medial orbital fat.
Blepharoplasty may be performed for cosmetic or reconstructive reasons, often both. The most common issues relating to Asian Upper Blepharoplasty are Dermatochalasis & Steatoblepharon, both are usually noticed in the fourth decade but sometimes earlier.
The procedure was pioneered by Oriental plastic surgeons and oculoplastic surgeons in the early 1950s. This procedure has been refined and is still in use by some cosmetic surgeons.
There are several modifications of this method, but the basic principles remain the same. This simple procedure involves placing intradermal sutures to anchor the subcutaneous tissue or orbicularis muscle to the aponeurosis or tarsal plate. This creates an adherence and gives the impression of a supratarsal crease as the aponeurosis exerts traction to open the upper eyelid.
A classic suture anchoring technique is the “3-stitches” method. The center of the upper eyelid is marked 6 to 8 mm above the lid margin. A medial mark is made on the medial third of the eyelid and a lateral one is made on the lateral third. The mark on the lateral third can be marked 1 to 1.5 mm wider than the center one and the medial third can be marked at the same level of the center mark. This marking will eventually create a gentle curve that is 1–1.5 mm wider at the lateral side and gradually narrowing at the medial part to join and embed at the medial canthal fold after suture fixation is done.
After local anesthetic is injected, a 1- to 2-mm cut is made through the skin at the three skin marks. At each site, 6-0 Prolene (Ethicon, Somerville, NJ) is passed through all tissue layers and pulled through the conjunctiva. The same needle is passed in the opposite direction (from conjunctiva to subdermis) in a different track. The sutures are tied subcutaneously to create the new supratarsal fold. The skin punctures are left open and heal on their own.
Another variation of the suture method uses two stitches instead. The sutures are also full thickness, but modified mattress sutures are used instead. The needle tracks are spaced 2 to 3 mm apart. All suture material is hidden subcutaneously including knots.
Attention, of late, has quite correctly turned to volume augmentation rather than just subtractive surgery. It is not uncommon to have volume loss of the brow fat as well as the middle fat pad. The medial fat pad is often prominent. This is probably because the central fat pad gets pulled back together with the levator aponeurosis and the orbital septum with the inevitable enophthalmos that occurs with age and posterior movement of the orbital fat. The medial fat pad does not sit on the levator aponeurosis and becomes more prominent. The orbital septum is also less substantial over the medial fat pad, allowing the anterior dislocation of the fat. Fat grafting may be performed or fat may be preserved and transposed into the hollow areas.
Removal of Orbicularis
Stretching of the skin can cause some degree of redundancy of the orbicularis oculi muscle but care must be taken to remove conservative amounts of orbicularis muscle. Pretarsal orbicularis must always be preserved. A variable amount of orbicularis over the preseptal region is removed, depending upon the patient’s age, the degree of redundancy and whether any brow lifting is being performed.
Removal of a small strip of orbicularis, together with work on the septum and fat (see below) can create a more defined crease.
The Orbital Septum
In some cases, the orbital septum may not need to be opened. Simple cautery to the surface of the septum does not give long-term tightening as there is tissue restitution over time. In most cases, the orbital septum is opened and planned fat removal is performed.
Unsatisfactory blepharoplasty results may be seen if the medial fat pad is not adequately debulked.
On the other hand, if the central fad pad is removed aggressively, an “A frame” deformity with a hollow superior sulcus will form. In some patients, especially when a repeat blepharoplasty or revision blepharoplasty is being performed, fat transposition may be performed to reacquire the natural sub brow fullness of a healthy, attractive eyelid. On rare occasions, a pedicle from the medial fat pad can be brought to the central zone if there is volume deficiency there. The art of blepharoplasty is to know how much to remove, how much to preserve and how much to reposition.
Closure can be with interrupted 6-0 catgut sutures which allow for a good wound but 6-0 nylon or prolene may also be used.
Upper blepharoplasty for Asian is a commonly performed cosmetic and functional surgical procedure. However, since the eyelids protect the most important of the senses, vision, it is imperative that surgery is undertaken with careful assessment and planning. Surgeons should advise patients that they have the option of not undergoing surgery, but if they choose to have the surgery, they should provide detailed information on what the patients should expect as well as details of all possible outcomes that apply to the individual patient.
According to Upper Eye Lid Blepharoplasty by Bhupendra C. Patel, Raman Malhotra (2022)
Intricacies of Upper Blepharoplasty in Asian Burden Lids
by Ji Sun Paik, Ji Hyeong Lee, Sandeep Uppal, Woong Chul Choi (2020)
Dermatochalasis by Michael T Yen (2022)
Upper Eyelid Blepharoplasty by Coleman Eye Center (2023)
What’s involved in Asian Blepharoplasty? by ASAPS (2020)
What is Upper Blepharoplasty? by ID Hospital (2017)
Incisional Guidelines When Marking the Skin in Upper Eyelid Blepharoplasty by Sheri L. DeMartelaere MD, FACS, Todd R. Shepler MD, Sean M. Blaydon MD, Russell W. Neuhaus MD & John W. Shore MD
Oriental Upper Blepharoplasty by Chau-Jin Weng, M.D. (2009)
Learn the backgrounds, techniques & anatomy of Advanced Asian Upper Blepharoplasty in our upcoming Advanced Asian Blepharoplasty Mini Fellowship:
IFAAS Mini Fellowship (Observation)
Korean Advanced Facial Aesthetic Surgeries:
Advanced Asian Blepharoplasty
May 9-10, 2023 - Seoul, South Korea - [Register Now]
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