tissue adhesives, such as autologous fibrin glue or N-butyl-2-cyanoacrylate, can be used for wound closure, in place of, or to reduce the amount of, sutures required. This option may not be applicable for cosmetic blepharoplasty due to poor eversion of wound edges and higher rates of wound dehiscence [39].

11.4.3 Suture Milia

Suture milia are cystic elevations that appear approximately 7 days postoperatively at the sites of suture skin penetration (Fig. 11.16). Milia occur with most suture material, including silk, mild chromic gut, and polypropylene. Joshi et al. [39] have demonstrated that a running/locking Prolene suture had the highest percentage of milia formation, followed by running plain gut, subcuticular Prolene, running fast-absorb- ing gut, and interrupted Prolene.

11.4.3.1 Medical Management

Suture milia may spontaneously resolve over a period of weeks to months [43]. Subcuticular closure and/or early suture removal may reduce the occurrence of milia.

11.4.3.2 Surgical Management

In the rare instance when milia persist, they can be treated surgically similar to other types of irregular scarring. Typically one waits 4–6 months after the primary surgery before intervening. Individual milia may be removed in the office with minimal local anesthesia. Wescott scissors are used to make “snip” excisions of the milia, which are allowed to heal by granulation.

11.5Asymmetry

11.5.1 Lid Crease and Fold

A symmetrical and correctly positioned lid crease is crucial for the successful outcome of cosmetic upper blepharoplasty. The surgeon must have an understanding of the correct position of a natural eyelid crease in men and women, and be aware of racial variations in crease height. Men have a low and less distinct lid crease, while women have a high and more definitive lid crease. Poorly positioned and asymmetrical lid creases or folds can result from poorly positioned lid crease markings, preexisting asymmetry, asymmetric lid tissue debulking, improper incision placement, or dissimilar wound healing on the two sides (Fig. 11.17). Brow asymmetry is often a factor in lid fold asymmetry and should be recognized during the surgical planning stage.

11.5.1.1 Medical Management

When lid crease or fold asymmetry occurs, a period of at least 6 months should pass before revision, especially if surgery involved formal crease formation or was on Asian patients. Postoperative swelling and inflammation can be prolonged and persistent in these instances, and any intervention can only occur when stability has been reached. A trial of oral or injectable steroids may be of benefit in these cases.

11.5.1.2 Surgical Management

Surgical correction can include a combination of skin excision, fat excision or grafting, and crease formation depending on the findings (crease asymmetry, fold asymmetry, or both). A lid crease can be formed by incorporation of the levator aponeurosis into the eyelid incision closure (supratarsal fixation – see Chap. 9). When closing the skin incision, the needle pass should engage the levator aponeurosis at the desired location of crease placement before exiting the skin. Alternatively, buried suture can secure the orbicularis muscle

Fig. 11.16 Suture milia of the left upper eyelid marked with purple surgical marker

Fig. 11.17 This patient has asymmetric lid creases and also asymmetric lid folds following upper blepharoplasty