AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Asian blepharoplasty, commonly termed double-eyelid surgery, refers to surgery designed to place a pretarsal crease in Asian eyes that are absent a fold. Patients typically desire to look more bright-eyed and want to make applying eyeliner easier. Patients also seek to remove the puffy and tired look associated with a fatty upper lid. In current American society, Asian patients almost never seek to westernize their appearance, and surgeons should be wary of modifying a patient's ethnic appearance, even in the rare case when it is requested.

History of the Procedure

The earliest reference to upper lid fold creation appears in the Japanese literature in the late 1800s. The case involves a surgeon who created a fold in the second eye of a patient born with a fold in only 1 eye.

In the English literature, Sayoc and Millard furnished early descriptions of the procedure.^{1, 2} In addition to securing the aponeurosis to the skin, Millard, a plastic surgeon, relied on orbital lipectomy to create the fold. This technique was specifically to westernize the eyelid at the patient's request (D. R. Millard, verbal communication, August 1993). 

Leabert Fernandez, also a plastic surgeon trained by James Barrett Brown, developed the technique of suturing pretarsal skin to the levator aponeurosis expansion.³ Fernandez's technique remains the hallmark of the modern double eyelid operation and remains probably the most common technique of incisional double eyelid surgery. Plastic surgeon Robert Flowers' anchor blepharoplasty (described below) expanded the artistic possibilities of the Fernandez procedure by emphasizing the creation of a crisp line and smooth pretarsal skin by securing the fold to the tarsal plate in addition to the levator aponeurosis.⁴

Problem

Asian patients with a puffy upper lid and an absent crease may dislike such an appearance. The patient may report difficulty applying eyeliner because of the overhanging fat and may wish to have a crease similar in appearance to Asian friends who were born with such a crease. Patients generally do not want to change their ethnic appearance.

Frequency

Approximately 50% of people of Pacific Asian descent (eg, Korean, Japanese, Chinese) have a pretarsal crease.

Etiology

Traditional theory states that the pretarsal fold represents the insertion of the levator aponeurosis expansion into the dermis. Presumably, Asians have a lower insertion point than white persons, leading to smaller or absent folds. An alternative theory is that the fold corresponds to the level of the septoaponeurotic sling. Lower height of the sling in Asians allows the fat to sit lower in the eyelid, leading to a smaller fold.

Pathophysiology

Traditional approaches to placing a pretarsal crease involve suturing the dermis to the levator expansion at the appropriate height. Alternative approaches attempt to create a septoaponeurotic sling at the desired lid height.

Clinical

Most commonly, the patient for this procedure is female and presents in mid adolescence with her mother or is female and is in her early 20s. Male patients, seen occasionally, tend to be slightly older, aged in the late 20s to early 30s. Female patients may report difficulty applying eyeliner. Not infrequently, females may apply cellophane tape to create a fold as part of the daily makeup ritual; the patient desires surgery to spare herself this inconvenience.

Occasionally, an older patient presents to report problems related to the aging upper eyelid and/or periorbital area. The patient may have had prior pretarsal crease placement.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgeons should consider the maturity of patients when they request such surgery. Occasionally, a mother brings a young teenaged daughter in for surgery. Patients should be mature enough to participate in oral or intravenous sedation for surgery and should understand and accept the risk of complications.

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

In Asians with a fold, the height of the normal lid fold lies 8-10 mm from the lash line with the skin gently stretched. Nasally, it begins close to the lash line and then reaches a maximum height at mid pupil. It stays at this height, extending to the orbital rim laterally. In contrast, folds in non-Asians tend to be larger and have less orbitopalpebral fat.

The primary difference between the non-Asian versus Asian eyelids is that the prelevator fat lies in a more inferior level; ie, the septo-aponeurotic sling hangs lower. In non-Asians, the supratarsal fold marks the inferior limit of the prelevator fat. This inferior limit is also the point at which the levator aponeurosis attaches to the dermis, creating an upper lid crease. In the Asian eyelid, this dermal attachment rests lower, resulting in a smaller crease, or it does not attach to the skin at all, resulting in an absent fold.

The surgical strategy for creating an Asian eyelid fold is either to recreate the dermal attachment of the levator aponeurosis or to prevent the fat from descending below the desired eyelid fold height. The nonincision suture method of eyelid surgery creates the fold by recreating this dermal attachment using nonabsorbable sutures. The incisional method of Asian eyelid surgery recreates the fold by removing the inferior portion of the prelevator fat and sealing off this area. A hybrid version, the semi-open method, combines aspects of both techniques by using buried nylon sutures to recreate the fold but also removing a portion of the prelevator fat through a small incision. The incisional method and semi-open method are described in Surgical therapy. In any case, the surgeon should not remove too much fat from the Asian eye because this results in a westernized appearance, which should be avoided.

The nasal area of the fold bears a variable relationship to the medial epicanthus. A fold may begin on the undersurface of the epicanthal fold or on the visible outer surface. These are referred to as an "inside" fold or an "outside" fold, respectively. When the fold is set relatively high, the crease usually folds on the outside.

The medial epicanthal fold can be variable in configuration. The Flowers classification is based on the how much of the caruncle is visible. In type I, the caruncle is visible and resembles a white person's anatomy. In type II, the caruncle is partially obstructed, while in type III, the fold is prominent and has an inversus component. Type IV resembles type I, except that the medial epicanthal fold is thick. A medial epicanthoplasty is recommended for patients with type III or IV and is optional for patients with type II.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Consider the maturity level of the patient, especially if he or she is young. At age 15-16 years, many teenagers do not have adequate coping mechanisms for potential complications. For these patients, consider the simplest and least morbid procedure.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical Therapy

The 2 general categories of repair include the open method and the suture method. The suture method is preferable for patients with thin skin or Asian eyelids so thin that they fold spontaneously on an intermittent basis. If the patient has some excess fat, this fat can be removed through a small stab incision. The fat in the central portion of the eyelid should be preserved, but the portion near the lateral orbital rim can be removed to yield better definition. The open technique is preferred for patients with thicker skin, thick pretarsal orbicularis muscle, or excess skin, or for those for which permanence is a premium. Both techniques are described in Intraoperative details.

Preoperative Details

Consider upper eyelid position in conjunction with the forehead. The visible amount of pretarsal skin on straightforward gaze depends on the degree of brow ptosis and upper lid skin redundancy. Even young patients may have a congenitally low brow position, as evidenced by frontalis strain. Set the lid height higher in these patients.

For a natural looking fold, the ideal amount of pretarsal show with the eyes open and at straight gaze is 2-3 mm. The rest of the pretarsal skin should be hidden behind the overhanging upper lid skin. This height is usually obtained by creating an incision at 7-10 mm above the lash line at the mid pupil with the skin slightly stretched (see Image 1). This measurement corresponds to the tarsal height. Although this is a general guideline, a patient with brow ptosis should have the incision set slightly higher because the brow drops in the postoperative period, decreasing the amount of pretarsal show. On the other hand, patients who are slightly exophthalmic should have the crease set slightly lower, closer to 6 or 7 mm.

Most patients have some degree of brow asymmetry, with 80% of patients having a right brow lower than the left. This asymmetry should be compensated for by setting the crease slightly higher or removing slightly more skin from the lower eyebrow. Failure to compensate for the asymmetric brow is one of the frequent causes for crease asymmetry.

Although much discussion has been made about the different shapes of the crease fold, a natural crease will present itself when a key point has been placed just medial to the pupil, roughly corresponding to the medial edge of the tarsal plate. As the patient opens his or her eyelid, a fold will present itself medial and lateral to this key point. The crease can then be carefully marked out.

The medial epicanthal area should be addressed in discussion with the patient. If the patient has no preference, the author generally prefers to avoid a medial epicanthoplasty unless the patient is of the Flowers type III or IV. As for placing the fold on the inside or outside of the epicanthus, this author prefers a very small outside fold. This can be hard to control, but in general, the larger the fold at mid pupil, the more likely it is to fold on the outside. A very small fold usually folds on the inside. The patient often makes his or her preference clear on this matter, which of course influences the size of the fold the surgeon needs to create in order to accomplish the desired result.

Intraoperative Details

Semiopen or suture method

The semiopen method incorporates the natural appearance and low morbidity of the suture method with the permanence associated with the open method. Prelevator fat is removed through a stab incision, effectively raising the septoaponeurotic sling. This procedure is best suited for younger patients with little forehead ptosis and no prior crease surgery. The upper eyelid skin should be relatively thin, with thin pretarsal orbicularis muscle. Surgeons less experienced in operating on Asian eyelids may prefer this procedure because of its potential reversibility. The most irreversible deformity that can occur with Asian eyelid surgery is overresection of prelevator fat. The suture or semiopen method precludes this complication. The steps of the operation are as follows:

• Mark the patient's eyelid while he or she is on the operating table. After administering intravenous or oral sedation, administer topical 4% tetracaine to the conjunctiva and inject 1 mL of 1% lidocaine with 1:100,000 epinephrine into the skin.
• If a medial epicanthoplasty is planned, perform this first because the epicanthoplasty alters the medial anatomy of the skin. Total height of a V-W plasty is approximately 5 X 5 mm, with each arm of the V and W being approximately 2 mm (see Image 2).
• After allowing the local anesthetic to take effect, use a No. 11 blade to cut each arm of the flap. Remove the subdermal muscle along with the skin, and use 6-0 nylon sutures to close the incision (see Image 3).
• Make a 1-cm incision along the lateral aspect of the upper lid marking. Remove a small sliver of orbicularis and then septum to enter the prelevator space. Ignore retro-orbicularis fat, which should not be removed. Identify prelevator fat by the glistening levator aponeurosis along the floor of the space, which also retracts when the patient opens the eyelid. Remove approximately 1-2 mL of fat (see Image 4).
• Next, place a 6-0 nylon suture to the lash line of the upper lid for retraction. Flip the upper lid to expose the conjunctival surface, and take a 5-mm bite of tissue at the mid pupil along the superior border of the tarsal plate using double-armed 5-0 nylon (see Images 5-6).
• Reenter the conjunctiva through the same needle hole so that a full-thickness buried suture exits on the skin surface of the upper lid along the lid markings (see Image 7). Secure the knot and let it retract into the deep recesses of the orbicularis muscle (see Image 8). Place 4 sutures equidistant to each other.
• Have the patient open and close his or her eye to verify that the crease extends sufficiently laterally and medially. Close the skin incision (see Image 9).

Incision method (Flowers anchor blepharoplasty)

The author's preferred method for the open approach is the Flowers anchor blepharoplasty. The markings are made as described above, including plans for the medial epicanthoplasty if that has been decided upon preoperatively. The steps of the operation are as follows (see Images 11-16):

• The preferred height of the incision has already been determined with the patient in the upright position, taking into account the patient's forehead anatomy (larger [~10 mm] if the patient has brow ptosis) and globe position (smaller [~6 mm] if the patient is exophthalmic).
• Place tetracaine 4% drops into each eye, and then evert the eyelid and use Castroviejo calipers to measure the height of the tarsal plate on each eyelid. The usual height is 10-11 mm. The tarsal height yields an accurate measurement of where on the tarsal plate the skin will be affixed at a future step in the procedure. For instance, if the planned fold is at 8 mm and the tarsal height is 10 mm, the skin will be affixed to the tarsal plate 2 mm below the upper edge of the tarsal plate.
• Skin markings are then made. The height is set at the mid pupil, with the rest of the marking continuing at the same height laterally until reaching the orbital rim. Medially, the marking tapers smaller toward the caruncle but stops approximately 2-3 mm above the lash line. The marking should not connect to the medial epicanthoplasty, if one has been planned.
• An incision is made with the knife, and 1-2 mm of skin is excised if necessary (eg, because of brow ptosis). This author generally prefers to not remove skin in patients younger than 25 years. A sliver of orbicularis muscle is removed, and the orbital septum identified. Gentle pressure on the globe helps verify the presence of prelevator fat just beneath the septum.
• The orbital septum is entered laterally, and the prelevator fat is allowed to herniate out. The presence of this fat defines the septoaponeurotic junction (or "sling"). The Iris scissors are introduced, and the septoaponeurotic sling is opened. Keep in mind the direction of this sling. It runs parallel to the lid margin when the eyes are open, but when the eyes are closed, the sling travels away (cephalad) from the lid margin. Failure to recognize this fact is a frequent cause of iatrogenic ptosis.
• The pretarsal orbicularis muscle is thinned to expose the underlying pretarsal aponeurosis. Some of this muscle must be preserved because it assists in lid closure. At this point, the filmy soft tissue (Flowers refers to it as bursa) lying above the tarsal plate is excised. Although Flowers prefers to completely lay bare the tarsal plate, a less experienced surgeon may find it to his or her advantage to leave some of this levator aponeurosis intact in order to reduce the risk of creating a retraction or ptosis. If the levator aponeurosis is completely removed from the tarsal plate (as is preferred by Flowers, the advantage being less pretarsal edema and perfectly smooth pretarsal skin), tremendous precision is required to reattach the aponeurosis to the tarsal plate. If, however, some of the aponeurosis has been preserved, the risk of creating problems with the levator mechanism is reduced.
• Closure is with 6-0 Vicryl on a reverse cutting or atraumatic needle, taking a bite of dermis, tarsal plate, and levator aponeurosis in one ligature. This is performed in 6 equidistant positions. Laterally, the tarsal plate fades out and only the dermis and levator aponeurosis are attached.
• Skin closure is with 6-0 Prolene in an interrupted fashion, taking a bite of skin, tarsal plate, and levator aponeurosis in 5 equidistant positions. The remainder of the closure is performed using running 6-0 Prolene.

Postoperative Details

Place eye ointment into the conjunctiva, and apply a light compression dressing (see Image 9). Instruct the patient on the use of eye drops and eye ointment. Remove the surface sutures on the third or fourth day.

Follow-up

Remove any bandages on the first day after surgery. Remove sutures on subsequent days.

COMPLICATIONS

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Asymmetry

One of the most common causes of asymmetry is failure to compensate for the asymmetric brow. Most people have one brow lower than the other; in most cases, the right brow is lower. The 2 creases should compensate for the asymmetry by removing additional upper lid skin from the lower brow. Alternatively, the crease can be set slightly higher on the side with the lower brow.

A technical point that contributes to asymmetry is intraoperative swelling that distorts the anatomy. This can be alleviated by minimal injection of local anesthetic (0.5-1 mL per side) and performing each step of the operation one side at a time. 

Unrecognized preoperative ptosis is another frequent cause of postoperative ptosis. In such cases, immediate ptosis repair may be warranted.

Reoperation to correct asymmetry is usually performed after 3-6 months.

Loss of crease

The most common cause of crease loss with a suture technique is the cheese-wiring effect of the suture through the soft tissues. Alternative suture techniques have evolved to address this problem; the most common technique is anchoring one end of the suture to the tarsal plate and then interlocking the 2 ends of the suture to each other.

The most common cause of crease failure in the incisional technique is the lack of adequate fixation between the dermis and the underlying structures. Fold failure is more common in surgical techniques designed to preserve the pretarsal soft tissue structures. The author's preference is to create a wide surface area to allow for dermal adherence, as seen in the anchor technique.

Ptosis

The most common cause of postoperative ptosis is failure to recognize a preexisting ptotic condition. In the Asian eyelid, this can sometimes be difficult to assess because of overhanging skin that creates a pseudoptosis. The lid margin must be carefully assessed preoperatively. In the Asian eyelid, ptosis is defined as a lid margin that is lower than halfway between the limbus and the pupil. This is approximately 1 mm lower than in a non-Asian eyelid.

If the patient has preexisting ptosis, the open approach should be used to correct this condition simultaneously with the creation of a pretarsal crease. If the suture method was used, the eye should return to its preexisting state without intervention, or one may wish to correct the problem by converting to an open approach. If the open approach was used, the most common iatrogenic reason for ptosis is damage in the medial half of the levator aponeurosis, due to the anatomical considerations described above. The author prefers to correct iatrogenic ptosis as soon as it is recognized. Attention to the medial portion of the levator aponeurosis often reveals the cause of the problem.

Retraction

If the suture method was used, retraction is almost always a self-limited condition that corrects over time. If an open approach was used, this author prefers to address the retraction as soon as it is recognized. First and foremost, the surgeon should verify that the patient is not compensating for a contralateral ptosis, which is more common. The author prefers to examine each eye individually, with the other eye closed, to determine which eye has the problem. If the patient does have retraction, the incision is reentered and any offending sutures are adjusted. Using minimal local anesthetic at half strength and having the patient sit upright at the termination of the procedure can help optimize the outcome.

OUTCOME AND PROGNOSIS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The semiopen method has many benefits; its relative simplicity and potential reversibility lend its use to less experienced surgeons. Scars are less noticeable. Although less permanent than an open procedure, its flexibility makes it a good option for young patients with no previous eye surgery.

The open method, including the Flowers anchor blepharoplasty, is preferred for patients with thicker skin or thick pretarsal orbicularis muscle. The procedure is ideal for more advanced surgeons experienced with the anatomy of the inferior portion of the upper eyelid and those comfortable with ptosis surgery.

FUTURE AND CONTROVERSIES

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The surgeon must decide whether to use the open or closed suture method for pretarsal crease placement. With proper patient selection, the semiopen method combines the best of the suture method (a natural appearance) with the best of the open method (ability to remove fat and give a more permanent appearance).

For advanced surgeons, the Flowers anchor blepharoplasty offers a precise, crisp eyelid fold that is inherently permanent and precise.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Measure the desired height of the fold. Typically, an 8-mm fold yields a medium-sized fold in young patients. If one brow lies lower, then mark the fold 1 mm higher on that side to compensate for the increased overhang of skin.
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Media file 2:  Perform the medial epicanthoplasty first. Mark the V-W plasty; each limb measures approximately 2 mm. Mark the W portion on the surface of the epicanthal fold. The tip of the central flap of the W sits at the edge of the epicanthal fold, and the V component lies on the undersurface of the epicanthal fold. The markings represent skin that will be resected.
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Media file 3:  Use 6-0 nylon to suture the apex of each flap, as well as one in between them, for a total of 7 sutures.
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Media file 4:  Remove thin slivers of tissue, going through orbicularis muscle, retro-orbicularis fat, and septum until reaching prelevator fat. Do not confuse the proper fat layer. Verify prelevator fat by the glistening levator aponeurosis underneath, which moves when the patient opens his or her eyelid.
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Media file 5:  Pass 6-0 nylon through the conjunctiva along the upper border of the tarsal plate.
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Media file 6:  Pass one arm of the needle through the full thickness of the eyelid.
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Media file 7:  Arm the free end of the suture with a free needle, and then pass it through to the other side of the eyelid using the same needle hole as the initial conjunctival bite.
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Media file 8:  Tie the suture and sink the knot deeply into the space previously created to accommodate it.
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Media file 9:  Close the skin and place a light compression dressing.
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Media file 10:  Preoperative (top) and 2-wk postoperative (bottom) photos of a patient who underwent semiopen procedure (without medial epicanthoplasty).
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Media file 11:  After the skin markings and incision, a sliver of orbicularis muscle is excised to expose the underlying orbital septum.
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Media file 12:  The prelevator fat is identified and used as an anatomical guide to open the entire septoaponeurotic sling.
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Media file 13:  After the lateral portion of the fat is excised, the pretarsal soft tissue "bursa" is cleared, exposing the relevant anatomy. The skin flap has been everted; the tarsal plate fully exposed; and the levator aponeurosis lies just cephalad to the tarsal plate, under the forceps.
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Media file 14:  Use 6-0 Vicryl to secure the dermis to the tarsal plate and levator aponeurosis.
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Media file 15:  The suture has been tied.
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Media file 16:  The sutures have been placed in 6 positions along the incision. Closure is with 6-0 Prolene.
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Media file 17:  Preoperative (top) and postoperative (bottom) photos of a 22-year-old patient after anchor blepharoplasty and medial epicanthoplasty.
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REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

1. Sayoc BT. Plastic construction of the superior palpebral fold in slit eyes. Bull Phil Ophthal Otolaryngol Soc. 1953;1:2.
2. Millard DR Jr. Oriental peregrinations. Plast Reconstr Surg. Nov 1955;16(5):319-36. [Medline].
3. Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstr Surg. Mar 1960;25:257-64. [Medline].
4. Flowers RS. Upper blepharoplasty by eyelid invagination. Anchor blepharoplasty. Clin Plast Surg. Apr 1993;20(2):193-207. [Medline].
5. Chen SH, Mardini S, Chen HC, et al. Strategies for a successful corrective Asian blepharoplasty after previously failed revisions. Plast Reconstr Surg. Oct 2004;114(5):1270-7; discussion 1278-9. [Medline].
6. Flowers RS. Surgical treatment of the epicanthal fold (invited essay). Plast Reconstr Surg. 1983;73:571.
7. McCurdy JA. Upper blepharoplasty in the Asian patient: the "double eyelid" operation. Facial Plast Surg Clin North Am. Feb 2005;13(1):47-64. [Medline].
8. Mikamo KA. Method of palpebral plasty. J Chugaishinpo. 1986;396:9.
9. Ohmori K. Esthetic surgery in the Asian patient. In: McCarthy JG, ed. Plastic Surgery. Vol 3. Philadelphia, Pa: WB Saunders Company; 1990:2415-35.

Article Last Updated: Feb 13, 2008