Ординатура / Офтальмология / Английские материалы / Asian Blepharoplasty and the Eyelid Crease_Chen_2006
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Chapter 5 Suture Ligation Methods
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2
3
2 
3
Skin
Orbicularis muscle
Levator aponeurosis
..
Muller's muscle
Conjunctiva
1 2 2
Fig. 5-2 Variation 1. Full-thickness suturing technique.
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|
2 |
|
|
3 |
Stab incision |
2 |
|
|
|
|
3
Stab incision
Skin
Orbicularis muscle
Levator aponeurosis
..
Muller's muscle
Conjunctiva
1 2 2 1
Fig. 5-3 Variation 2. Full-thickness suturing technique with stab incisions.
Exit
21
Entry for both needles of double-armed sutures
Chapter 5 Suture Ligation Methods
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Strategic placement of intramuscular sutures creates infolding of crease
Indentation of skin
Skin
Orbicularis muscle
Levator aponeurosis
..
Muller's muscle
Conjunctiva
Fig. 5-4 Variation 3. Transconjunctival intramuscular suturing technique. Note the absence of passage through the skin.
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|
2 |
1 |
First stab incision |
1
2
Skin
1 |
Orbicularis muscle |
|
Levator aponeurosis
..
Muller's muscle
Conjunctiva
Fig. 5-5 Variation 4. Transcutaneous intramuscular suturing technique.
Chapter 5 Suture Ligation Methods
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Fig. 5-6 Variation 5. (Top) Twisted needle and compression technique with transcutaneous intratarsal
suturing. (Bottom) Root canal dental files.
Skin
Subcutaneous tissue
Pre-tarsal orbicularis
Tarsus
A
Continuous subcutaneous suturing
B
Continuous reverse-loop suturing
C
D
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|
1 |
|
Epidermis |
|
Dermis |
|
Pretarsal orbicularis |
|
Levator aponeurosis |
|
Tarsus |
A |
Conjunctiva |
2
Through skin
B |
Through tarsus |
3
Dermis
Pretarsal orbicularis
Levator aponeurosis
C |
Tarsus |
Fig. 5-7 Variation 6. Transcutaneous intradermal and intratarsal suturing technique.
C. At the same time, a half-section of a rubber catheter about 2mm wide is sutured across the pretarsal region. It is postulated that scarring caused by passage of the screw-threaded needle and the compressive effect of the rubber catheter causes aponeurosis–subcutaneous attachment and formation of the lid crease.
Yang reported that the advantages of this procedure include rapid resolution of postoperative edema and swelling and the lack of an open skin incision. Yang reported the procedure to be effective for 100 of 102 patients 3 years postoperatively. Contraindications to the procedure include excessive fat, scarcity of skin, or an excess of dermatochalasis. The technique is not suitable for patients with lid retraction or prominent palpebral fissures, or those undergoing reoperation.
Variation 6: Transcutaneous Intradermal
and Intratarsal Suturing Technique
In China, Song28 reported a variation in which a no. 11 blade is used to make two stab incisions 3–5 mm apart over the medial, central, and lateral thirds of the upper lid; the incisions extend down to the tarsal plate from the skin (Fig. 5-7). One end of a suture needle is passed from one stab incision on the skin through the tarsal plate superficially and exits through the second stab incision (Step 1). The second needle enters through the same stab incision used by the first, this time tracking intradermally and exiting through the second stab wound, as did the first needle (Step 2). The sutures are tied and buried in the subcutaneous plane (Step 3). The previous steps are repeated over each third of the superior tarsal border. According to Song, it is important to make sure that the sutures track intradermally rather than subcutaneously, because when subcutaneous sutures are used the crease tends to disappear soon after the operation.
In alternatives 3, 4, and 6, both needles enter and exit through the same points on the eyelid. Alternatives 4, 5, and 6 involve transcutaneous passage. Alternatives 5 and 6 involve intratarsal passage.
Even though these suture ligation techniques avoid making wide skin incisions, four of the six options (with the exception of alternatives 1 and 3) require several stab incisions through the skin or multiple needle passages through the skin surface.
Chapter 5 Suture Ligation Methods
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References
1.Mikamo K. A technique in the double eyelid operation. J Chugaishinpo 1896.
2.Uchida K. The Uchida method for the doubleeyelid operation in 1523 cases. Jpn J Ophthalmol 1926;30:593.
3.Maruo M. Plastic construction of a ‘doubleeyelid’. Jpn Rev Clin Ophthalmol 1929;24:393–406.
4.Sayoc BT. Plastic construction of the superior palpebral fold. Am J Ophthalmol 1954;38:556–559.
5.Sayoc BT. Simultaneous construction of the superior palpebral fold in ptosis operation. Am J Ophthalmol 1956;41:1040–1043.
6.Sayoc BT. Absence of superior palpebral fold in slit eyes (an anatomic and physiologic explanation). Am J Ophthalmol 1956;42:298–300.
7.Sayoc BT. Surgical management of unilateral almond eye. Am J Ophthalmol 1961;52:122.
8.Sayoc BT. Blepharo-dermachalasis. Am J Ophthalmol 1962;53:1020–1022.
9.Sayoc BT. Anatomic considerations in the plastic construction of a palpebral fold in the full upper eyelid. Am J Ophthalmol 1967;63:155–158.
10.Sayoc BT. Surgery of the oriental eyelid. Clin Plast Surg 1974;1:157–171.
11.Millard DR Jr. Oriental peregrinations. Plast Reconstruct Surg 1955;16:319–336.
12.Pang HG. Surgical formation of upper lid fold. Arch Ophthalmol 1961;65:783–784.
13.Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstruct Surg 1960;25:257–264.
14.Uchida J. A surgical procedure for blepharoptosis vera and for pseudoblepharoptosis orientalis. Br J Plast Surg 1962;15:271–276.
15.Boo-Chai K. Plastic construction of the superior palpebral fold. Plast Reconstruct Surg 1963;31:74–78.
16.Boo-Chai K. Further experience with cosmetic surgery of the upper eyelid. In: Broadbent TR, ed. Transactions of the Third International Congress of Plastic Surgery. Amsterdam: Excerpta Medica, 1964: 518–524.
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17.Boo-Chai K. Some aspects of plastic (cosmetic) surgery in Orientals. Br J Plast Surg 1969;22:60–69.
18.Boo-Chai K. Aesthetic surgery for the Oriental. In:Barron JN, Saad MN, eds. Operative plastic and reconstructive surgery. Vol. 2. Edinburgh:
Churchill Livingstone, 1980: 761–781.
19.Boo-Chai K. Surgery for the oriental eyelid. In: Lewis JR Jr, ed. The art of aesthetic plastic surgery. Boston: Little, Brown, 1989: 611–617.
20.Mutou Y, Mutou H. Intradermal double eyelid operation and its follow-up results. Br J Plast Surg 1972;25:285–291.
21.Shirakabe Y. Mikamo’s double-eyelid operation: The advent of Japanese aesthetic surgery. Plast Reconstr Surg 1997;99:668–669.
22.Hata B. Application of eyelid clamp and beads in ‘double-eyelid’ operation. Jpn Rev Clin Ophthalmol 1933;28:491–494.
23.Homma K, Mutou Y, Mutou H, Ezoe K, Fujita T. Intradermal stitch for orientals: does it disappear? Aesth Plast Surg 2000;24:289–291.
24.Tsurukiri K. Double eyelid plasty: reliability and unfavorable results to the patients [Abstract]. J Jpn Aesth Plast Surg 1999;20:38.
25.Satou H, Ichida M. The reliability of buried double eyelid operation and the assessment of unfavorable results at our clinic. Panel discussion at the annual meeting of the Japan Society of Aesthetic Plastic Surgery, Gifu, Japan, October 1998.
26.Lee YJ, Baek RM, Chung WJ. Nonincisional blepharoplasty using the debulking method. Aesth Plast Surg 2004;27:434–437.
27.Zubiri JS. Correction of the oriental eyelid. Clin Plast Surg 1981;8:725–737.
28.Yang PY. Double eyelid operation by the twisted needle and compressive suturing technique. Clin J Plast Surg Burns 1987;3:191–192.
29.Song RY. Further discussion on the improved suturing technique for double eyelid operation (intradermal and intratarsal suturing technique). Chin J Plast Surg Burn 1990;6:96–97.
External Incision Methods |
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Chapter 6 |
William P.D. Chen
A review of the literature on the external incision method (see Appendix 2) shows considerable variations in technique and preference regarding skin incisions and whether or not skin and orbicularis muscle should be routinely removed. Likewise, some prefer to open the orbital septum and remove a variable amount of the preaponeurotic fat pad.
There are other proponents for small skin incisions or partial incision only, and further differentiations in the way crease fixation is carried out, including skin–levator aponeurosis–skin, inferior orbicularis– levator, septodermal, and skin–tarsus–skin fixation. Each variation has pros and cons that needs to be weighed according to the technical skills, aesthetic sense and level of effort involved, as well as the patient’s comfort level and acceptance.
For example, both the skin incision and the skin excision schools favor making an incision to accurately define the placement of the crease. These practitioners are comfortable with these techniques as well as the wound healing process, and are likely to be less concerned about instant recovery. Specialists who routinely open the orbital septum are likewise comfortable with the anatomic landmarks and aim to clear the preaponeurotic zone along the superior tarsal border. Overall, the proponents of the external incision feel more comfortable with the predictability and permanence of this approach, and aim for a longer-lasting crease and less need for interval adjustment procedures. This approach, especially when carried out without the need for buried sutures, frequently yields a crease form that is subjectively comfortable for the patient on upgaze and downgaze, without the often-voiced complaint of tightness of the upper lid and a sensation of the buried sutures poking the pretarsal zone. The surgeon who operates through a 5–8mm skin incision may be able to accomplish limited debulking of soft tissues. One drawback may be a crease that appears better formed over the central skin incision than over the medial and lateral portions of the lid.
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Asian Blepharoplasty and the Eyelid Crease
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The choice of suture material varies greatly, as do the closure techniques applied in the external incision methods. The techniques for construction of the upper eyelid crease fall into two broad categories: skin– levator–skin (or skin–tarsus–skin) and levator aponeurosis to inferior subcutaneous plane (or superior tarsal border to inferior subcutaneous plane: STB/inf.subQ).
tal fibers of the levator aponeurosis along the superior tarsal border, and the third is into the upper skin edge (Fig. 6-1). This maneuver allows an adhesion to form between the levator aponeurosis and the subdermal area along the superior tarsal border, closely approximating the distal interdigitations of the levator aponeurosis. Fernandez1 wrote that this technique gives a ‘dynamic’ and superficial crease (Fig. 6-2), in contrast to the skin–tarsus–skin method, which tends to give a ‘static’ crease (Fig. 6-3).
Skin–Levator–Skin Approach
In this approach, sutures are placed so that the first bite is into the inferior skin edge, the second is into the dis-
0.12 mm forceps
Levator aponeurosis
Superior tarsal border 
Tarsus
Fig. 6-1 Skin–levator–skin closure. The stitch first passes through the lower skin border, taking a bite into the levator aponeurosis along the superior tarsal border (STB), and then through the upper skin border.