Ординатура / Офтальмология / Английские материалы / Asian Blepharoplasty and the Eyelid Crease_Chen_2006

Scar formation is the most critical issue associated with epicanthoplasty. The common causes of unsightly scar formation are poor design and closure with tension. One critical issue is to determine point A in a more conservative location laterally, closer to the eye than to the nose. When point A is marked more medially and further from point D than it should be, point A has to be stretched laterally to meet point D during

closure, which will create tension on the closure and result in a thicker scar.6,7 Exact placement of point A and complete detachment of the flap at point D are two critical steps of the operation. Extremely conservative excision of triangle EAC is also an important aspect in preventing scar formation. Figures 19-14 and 19-15 illustrate pre and post operative appearance following double-eyelid operation and Z-epicanthoplasty.

Complications

Complications are related to the sutures and to scar formation. The medial canthal skin tolerates suture materials poorly owing to the delicate nature of the skin. Any permanent fixation suture should be placed deep to the orbicularis muscle. Even then, the suture material may migrate to the surface, causing redness and/or granuloma formation. It is better to free the epicanthal flap completely and avoid the use of anchoring sutures. A step formation at the closure line of A–B and D–B creates an annoying visible scar. This tiny scar on the medial part of the lower eyelid at the medial canthal area often gives an appearance of a foreign body. This problem is avoided by leveling the skin surface between lines A–B and D–B. At times defatting under line A–B is required to match the thin line D–B. Hypertrophic scarring is due to tension in the closure. The patient should be carefully screened for the possibility of keloid formation. Small doses of steroid injection may alleviate thick scars and keloid.

References

1.Liu D, Hsu WM. Oriental eyelids: anatomic difference and surgical consideration. Ophthalmol Plast Reconstruct Surg 1986;2:59–64.

2.Ohmori K. Aesthetic surgery in Asian eyelids. In: McCarthy JG. Plastic surgery. Vol 3. Philadelphia: WB Saunders, 1990: 2415–2435.

3.Park JI. Z-epicanthoplasty in Asian eyelids. Plast Reconstruct Surg 1996;98:602.

4.Park JI. Modified Z-epicanthoplasty in the Asian eyelid. Arch Facial Plast Surg 2000;2:43.

5.Park JI. Park Z-epicanthoplasty. In: Park JI, Toriumi D. Cosmetic surgery for the Asian face. Philadelphia: WB Saunders, [to be published].

6.Yoo WM, Park SH, Kwag DR. Root Z- epicanthoplasty in Asian eyelids. Plast Reconstruct Surg 2002;109:2067.

7.Park JI. Root Z-epicanthoplasty in Asian eyelids. Correspondence and brief communications. Plast Reconstruct Surg 2003;111:2477.

William P.D. Chen

The Challenge of Aesthetic Surgery on the Asian Eyelid

The most important point in the plethora of techniques available for the construction of an upper eyelid crease in Asians is that the external incision methods are an attempt to produce surgical adhesions between the distal fibers of the levator aponeurosis (or superior tarsal border) and the skin, inferior subcutaneous plane, or pretarsal platform. The myriad variants of the suture ligation techniques try to produce a tight tissue plane between the distal portion of the levator aponeurosis (or the upper portion of the tarsus) and the pretarsal tissues inferior and anterior to the aponeurosis, whether they be subcutaneous tissues or pretarsal orbicularis muscle, or to eliminate dead space between pretarsal skin and tarsus. In both the external incision and the suture ligation methods, a firm pretarsal platform is linked to the levator aponeurosis. This platform telescopes superiorly at its junction with the supratarsal skin to form the upper lid crease.

passes through different areas with different topographic features.

Each vertical section of the eyelid is composed of a different subset of tissues of varying sizes and thicknesses. For example, the vertical height of the tarsus is shorter over the medial and lateral extents; there is more pretarsal fat over the central portion of the eyelid; the levator aponeurotic attachment over the medial and lateral horns is thin and less vertically oriented; the medial upper lid fold may interfere with crease formation; the lacrimal gland may interfere with lateral crease placement; the upper lid dermis laterally is thicker and less likely to invaginate when one attempts to make a crease; and the central presence of the preaponeurotic fat pads can obliterate an otherwise well positioned and well formed crease.

The challenge is to produce a crease that is continuous and aesthetically pleasing as it traverses the different terrains of the upper lid. In each section of the upper lid, factors that can interfere with the optimal formation of a dynamic crease have to be eliminated. The result should be a crease that provides optimal height, shape, continuity, and permanence.

The Challenges

When progressing from preoperative planning to the actual surgical stages of an Asian blepharoplasty, the surgeon must shift from a two-dimensional mode of thinking with a clear concept of crease placement to a three-dimensional mode to approach the layers of the upper eyelids. I prefer to think of the progression from one end of the eyelid to the other as traveling through many different terrains. To digress with an analogy, the Great Wall of China is the only manmade structure that can be seen from space by orbiting astronauts. At ground level, it traverses through vastly different terrains and climate patterns, although the basic structures of its throughways, fortresses, and storage garrisons may appear similar they are not. The challenge in working on the eyelid is to construct a functional and continuous structure even though it

A Look to the Future

Progress in the development of this frequently performed Asian cosmetic operation has been quite steady from 1896 to the present. The early Japanese medical literature blazed the trail for the subsequent modifications of both the ligation techniques and the external incision methods used in the east and the west. The future looks bright for the continuing evolution of Asian blepharoplasty.

I anticipate the availability of better suture materials, perhaps made of polymers that are fully nonreactive and tissue compatible. Used in either the incision or ligation methods, such materials, especially if they can be made to last 3–12 months before dissolving, would reduce the incidence of suboptimal results

and allow more creativity in technique; biocompatible polymers could be designed to be implanted within the eyelid. For example, implanting a thin shield in the pretarsal plane could result in adhesions between the pretarsal orbicularis muscle and the overlying skin and produce a firm pretarsal platform without causing noticeable scarring. Biocompatible polymers or composite alloys may be engineered into microclips or tacks, such that several could be implanted along the superior tarsal border as an expansion or extension of the distal fibers of the levator aponeurosis. Lasers using elements other than argon, yttrium–aluminum–garnet (YAG), or potassium titanyl-phosphate (KTP-YAG), may be available in the future and could be used to produce controlled aponeurotic adhesions, simulating the physiologic adhesions and interdigitations seen in eyelids that have natural creases.

I see further research and analysis on the dynamics of the eyelid crease, perhaps using currently available

real-time tools such as the PET scan, or yet to be invented nano-devices, studying the levator aponeurosis, tarsus, and preaponeurotic tissues (tarsoligamentous junction). There will be continued innovation in new suture materials and synthetic implants that can be used to facilitate lid crease formation. Suborbicularis thermoplastic cauterization using microvoltage current on a needle tip, and radiofrequency cold needles in cautery mode have already been tried.

Look for future trends: minimally invasive means of excision of tissue redundancy using endoscopic principles; central partial incision with fat debulking coupled with medial and lateral suborbicularis cautery; as well as buried ligatures delivered through different avenues.

I wish you well in your continued journey for perfection in this type of aesthetic surgery.