Fig. 13.11 Closure of conjunctival wound. (a) The nasal arm of the plain gut suture is run in a continuous fashion in a temporal direction incorporating the superior tarsal border, Müller’s muscle, and conjunctiva; each suture pass should be 2–3 mm apart. (b) Once the nasal arm of the plain gut suture reaches the temporal aspect of the wound, each arm of the suture is passed through conjunctiva and Müller’s muscle into the wound

13.5Postoperative Management

A topical antibiotic ointment is generously applied over the surface of the eye at the completion of the procedure. The ointment should be applied 2–3 times daily for the first week and prior to bedtime for an additional week. A systemic antibiotic is not necessary following this procedure; however, if this procedure is combined with other periorbital rejuvenation procedures, prophylactic oral antibiotics may be added. Topical

Fig. 13.12 Completion of upper blepharoplasty. (a) The eyelid skin or skin/orbicularis muscle flap is excised using scissors or an electrocautery knife. (b) Several 6–0 interrupted sutures reinforce eyelid crease reconstruction. The wound is closed with a 6–0 running permanent suture

and/or systemic anti-inflammatory agents, such as steroids, are not necessary, but may be given as deemed appropriate in selected cases.

Cold compresses are applied over the eyelids for the first 24 h to help prevent postoperative edema and may be used thereafter for patient comfort. It is important that patients recognize that there may be continued sensory anesthesia to the eyelid 4–6 h after the procedure and that they should cycle the cold compresses to prevent superficial irritation.

Frequent use of ocular lubricants (drops and ointments) is important to prevent postoperative keratopathy and patient discomfort. Patients should be encouraged to use artificial tears throughout the day for sutureand exposure-associated symptoms.

Patients should be counseled on worsening eyelid swelling and ocular discomfort for the first 48–72 h following the

Fig. 13.13 A 56-year-old Caucasian woman presenting with bilateral upper eyelid ptosis. (a) Prior to instillation of 10% phenylephrine drops. (b) Five minutes after instilling several drops of 10% phenylephrine onto bilateral superior fornices. (c) Six weeks following bilateral Müller’s muscle-conjunctival resection ptosis procedure combined with bilateral upper and lower blepharoplasty

procedure. Vision is often blurred and distorted secondary to uneven tear film and frequent ocular lubricant administration. As the eyelid swelling and ocular discomfort improves, the patient is instructed to use the artificial tears in lieu of the more viscous ocular lubricants. The eyelid usually attains its final level 3–6 weeks postoperatively (Fig. 13.13).

overcorrection occurs, downward massage of the eyelid while fixating the brow may be used in the early postoperative period. If the overcorrection persists, a levator recession procedure can be performed [13]. In cases of undercorrection, a repeat posterior eyelid ptosis procedure may be performed; however, results are frequently unpredictable; more often a levator advancement or resection ptosis procedure is employed.

In rare cases, persistent hemorrhage from the Müller’s muscle may occur. The Müller’s muscle is a highly vascularized structure and patients on anticoagulation therapy, or those who restart anticoagulation shortly after the procedure, are at increased risk. Firm pressure over the eyelid for approximately 5 min will often stop the hemorrhage; however, persistent hemorrhage may require exploration and cauterization.

13.7Conclusion

Posterior eyelid ptosis repair via the Müller’s muscleconjunctival resection procedure is a safe and effective technique for periorbital rejuvenation in the aesthetic patient. Although posterior eyelid approach techniques can be daunting for the novice eyelid surgeon, with experience and patience this procedure is easily mastered. As opposed to levator advancement/resection ptosis repair, this surgery requires no patient cooperation, is quick, easier, and probably more appropriate for the surgeon not comfortable with advanced eyelid dissection techniques. Surgical outcomes are reliably consistent and reproducible, and typically yield high patient satisfaction.

The most common complication from posterior eyelid ptosis repair is corneal irritation and/or abrasion [7]. The combination of exposed suture material, postoperative eyelid edema, and relative increase in exposed ocular surface area may contribute to corneal epithelial derangement. Patients with postoperative lagophthalmos are at particular risk of developing corneal abnormalities and should be strongly encouraged to maintain an aggressive ocular lubrication regimen. A bandage contact lens or collagen shield may be used in symptomatic patients. Rarely, a corneal abrasion may develop into a corneal ulcer. These patients should be referred for urgent ophthalmologic evaluation to prevent vision-threatening complications.

Overor undercorrection of eyelid position is observed in approximately 3–5% of cases [13]. If a significant

1.Beard C. Müller’s superior tarsal muscle: anatomy, physiology and clinical significance. Ann Plast Surg. 1985;14:324–33.

2.Müller H. Über glatte Muskeln an der Augenlidern des Menschen und der Säugetiere. Würzberg, Germany: Verhandl PMG; 1859; IX: 244. Cited by: Whitnall SE. The anatomy of the human orbit, 2nd ed. London: Oxford University Press; 1932. p. 145.

3.Dutton JJ. The eyelids and anterior orbit. In: Dutton JJ, editor. Atlas of clinical and surgical orbital anatomy. Philadelphia, PA: WB Saunders; 1994. p. 113–38.

4.Putterman AM, Urist MJ. Müller’s muscle-conjunctival resection. Arch Ophthalmol. 1975;93(8):619–23.

5.Glatt HJ, Putterman AM, Fett DR. Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis. Ophthalmic Surg. 1990;21:114–22.

6.Ben Simon GJ, Lee S, Schwarcz RM, et al. External levator advancement vs. Müller’s muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol. 2005; 140(3):426–32.

7.Putterman AM, Fett DR. Müller’s muscle in the treatment of upper eyelid ptosis: a ten-year study. Ophthalmic Surg. 1986;17:354–60.

8.Mercandetti M, Putterman AM, Cohen ME, et al. Internal levator advancement by Müller’s muscle-conjunctival resection: technique and review. Arch Facial Plast Surg. 2001;3:104–10.

9.Ben Simon GJ, Lee S, Schwarcz RM, et al. Müller’s muscleconjunctival resection for correction of upper eyelid ptosis: relationship between phenylephrine testing and the amount of tissue resected with final eyelid position. Arch Facial Plast Surg. 2007;9(6):413–7.

10.Ayala E, Galvez C, Gonzalez-Candial M, et al. Predictability of conjunctival-Müllerectomy for blepharoptosis repair. Orbit. 2007;26: 217–21.

11. Dresner SC. Further modifications of the Müller’s muscleconjunctival resection procedure for blepharoptosis. Ophthal Plast Reconstr Surg. 1991;7:114–22.

12. Perry JD, Kadakia A, Foster JA. A new algorithm for ptosis repair using conjunctival Müllerectomy with or without tarsectomy. Ophthal Plast Reconstr Surg. 2002;18(6):426–9.

13. Putterman AM, Fagien S. Müller’s muscle-conjunctival resection ptosis procedure combined with upper blepharoplasty. In: Fagien S, editor. Putterman’s cosmetic oculoplastic surgery. 4th ed. Philadelphia, PA: Saunders Elsevier; 2008. p. 123–33.

14. Hildreth HR, Silver B. Sensory block of the upper eyelid. Arch Ophthalmol. 1976;77:202–31.

Key Points

•The desires and expectations of Asian patients undergoing upper lid blepharoplasty are vastly different than those of Caucasian patients.

•It is critical to understand the ethnic characteristics of Asian eyelids before performing blepharoplasty on this group of patients.

•A lower attachment of the orbital septum on the levator aponeurosis with associated inferior fat displacement and crease attenuation; and the presence of a preseptal fat layer account for the anatomic differences of Asian upper lids from Caucasian upper lids.

•These anatomic differences cause Asian upper lids to be fuller than their Caucasian counterparts, and manifest a lower, indistinct, or fully absent crease.

•The presence or absence of a naturally occurring or previously created eyelid crease is essential to the preoperative assessment.

•The surgical plan should focus primarily on whether or not the patient desires a single eyelid (no crease), or a double eyelid (presence of a crease).

•Depending of preoperative findings and patient needs, surgery can involve one or all of the following: skin excision, fat excision, crease formation, or fat grafting.

•Conservative surgery is imperative.

•Westernization of eyelids should be avoided at all times.

•Revisional surgery in this patient population is very challenging.

14.1Introduction

The pathogenesis of upper-eyelid aging involves degenerative changes in the skin, soft-tissue excess, and volume loss. The goal of facial rejuvenation is to restore a youthful look without

S.M. Lam (*)

Director, Willow Bend Wellness Center, Plano, TX, USA e-mail: drlam@lamfacialplastics.com

altering appearance in an unnatural way. This is especially true in aesthetic rejuvenation of the Asian upper eyelid. This surgery can lead to loss of ethnic identity with resultant negative impression both from the patient, friends, and family. Successful upper eyelid rejuvenation in the Asian patient requires a thorough comprehension of the periorbital aging process specific to this population and a detailed understanding of the cultural nuances related to upper eyelid cosmetic surgery inherent to this group. What makes Asian blepharoplasty unique is the management of the eyelid crease. Although the presence of an eyelid crease can be a naturally occurring anatomic finding in the Asian population (double eyelid), individuals who lack this anatomic trait (single eyelid) will often seek “double eyelid” formation. The desire to have a double eyelid is largely cultural, as this feature is considered attractive. Consequently, it is necessary for the surgeon performing Asian blepharoplasty to have experience with upper eyelid crease formation, to meet patient needs.

There has been a paradigm shift away from Westernization of Asian upper lids. Traditionally, surgery has consisted of aggressive removal of skin, muscle, and fat. This has often led to a volume depleted upper lid with a deep sulcus and higher crease. The modern approach is aimed at restoring a more youthful and healthier appearing upper-eyelid region, which translates to performing conservative excision of skin, formal crease formation when necessary, coupled with some level of volume augmentation of the lateral eyebrow and infrabrow region. This approach is aimed at creating a less deflated and “fuller” eyelid, which will more accurately approximate the youthful Asian appearance. In this chapter, we will evaluate the aging process affecting the upper-eyelid region in the Asian patient, how to manage and treat the different anatomic types of the eyelid crease, how to perform an upper eyelid blepharoplasty in the Asian patient, and how to utilize complementary treatments to restore the youthful structure of this area.