gradually lowers and softens over the course of the healing process. Female patients often use mascara to camouflage the height of the upper eyelid crease until the edema resolves.

14.7Conclusion

Performing appropriate Asian upper eyelid blepharoplasty requires a detailed knowledge of Asian eyelid anatomy, an understanding of relevant periorbital aging changes and cultural preferences within this group, and experience with surgical crease formation. Traditional surgery tended to “Westernize” patients with creation of a high, arched crease. This result has fallen out of favor. Contemporary surgery focuses on volume preservation and restoration with less excision of tissue. A conservative excision of eyelid fat, with appropriate crease height, will contribute to ensuring a natural appearing result. The addition of fat grafting when appropriate can enhance outcome. With the full-incision method outlined in this chapter, the senior author (SML) has been

able to achieve consistently excellent results with stable crease position over time.

References

1.Zide BM. Anatomy of the eyelids. Clin Plast Surg. 1981;8(4): 623–34.

2.Aguilar GL, Nelson C. Eyelid and anterior orbital anatomy. In: Hornblass A, editor. Oculoplastic, orbital and reconstructive surgery. Vol. 1: Eyelids. Baltimore: Williams & Wilkins; 1988.

3.Jones LT. New concepts of orbital anatomy. In: Tessier P, Callahan A, Mustarde JC, et al., editors. Symposium on plastic surgery in the orbital region. St. Louis: CV Mosby; 1976.

4.Kure K, Minami A. A simple and durable way to create a supratarsal fold (double eyelid) in Asian patients. Aesthet Surg J. 2001;21(3):227–32.

5.Chen WP. Suture ligation methods. In: Asian blepharoplasty and the eyelid crease. London: Elsevier; 1995. p. 39–50.

6. Mikamo K. A technique in the double eyelid operation. J Chugaishinpo. 1896.

7.Uchida K. The Uchida method for the double-eyelid operation in 1523 cases. Jpn J Ophthalmol. 1926;30:593.

8.Maruo M. Plastic construction of a ‘double eyelid’. Jpn Rev Clin Ophthalmol. 1929;24:393–406.

9.Pang HG. Surgical formation of upper lid fold. Arch Ophthalmol. 1961;65:783–4.

Key Points

•Properly executed and in the appropriate patient, transcutaneous lower eyelid blepharoplasty has minimal added risk of lower lid malposition as compared to other techniques.

•A complete ophthalmologic history, examination, and identification of the need for canthal suspension are critical to avoid potential adverse sequelae.

•Premorbid lower eyelid malposition and/or laxity must be identified before surgery and addressed during the procedure.

•Incisions placed 2–3 mm below the ciliary margin will preserve the pretarsal orbicularis oculi muscle, making the desired aesthetic and functional outcome more likely.

•It is important to redrape the skin–muscle flap in a superiorlateral direction and suspend the pretarsal orbicularis oculi muscle to the inner surface of the lateral orbit to prevent poor aesthetic and functional outcomes.

•When upper blepharoplasty is performed simultaneously, the lateral aspect of the upper eyelid incision should be closed first to prevent a visible incision.

•Overresection of fat must be avoided to prevent a sunken appearance after surgery.

•Fat transposition should be considered for effacement of the nasojugal groove (“tear trough” deformity).

•Festoons and orbicularis oculi muscle redundancy can be addressed with the malar extension technique.

•Aggressive ocular lubrication in the immediate postoperative period will reduce dry eye symptoms, speed recovery, and increase patient satisfaction.

P.K. Holden (*)

Holden Facial Plastic Surgery, Scottsdale, AZ, USA e-mail: holdenpk@gmail.com

15.1Introduction

The transcutaneous approach to lower eyelid blepharoplasty is a commonly performed procedure and an important tool in the armamentarium of cosmetic surgeons. Although most consider it to be a relatively simple operation, proper patient selection and technique are crucial to achieve the best results while minimizing potentially vexing complications. The procedure best addresses true vertical excess of lower eyelid muscle and skin (dermatochalasis), offers ease of access to treat pseudoherniation of the orbital fat compartments, and is an ideal approach for adjunctive procedures such as malar extension, midface lift, lateral canthoplasty and fat transposition [1]. Additionally, the posterior lamella is preserved and the risk of corneal injury is minimized.

15.2Patient Selection

Before proceeding with surgery, every patient should be carefully evaluated to determine the most appropriate procedure for rejuvenating the lower eyelid complex. Employing a standardized, logical approach to these patients will ensure optimal outcomes.

The evaluation begins with a complete ocular history including a review of prior surgeries and medical conditions which affect the eyes (such as glaucoma, diabetes, thyroid myxedema, dry eye syndrome, etc.). All of the patient’s medications should be reviewed, especially those that may affect the eyes. For a patient without a history of ocular disease or complaints, and a normal examination, all that is required preoperatively is to perform a test of visual acuity and extraocular muscle movement. If a patient has any history of ocular problems or an examination that is unusual, then an evaluation by an ophthalmologist preoperatively is warranted. Common symptoms requiring referral include ocular pain, discomfort or irritation, a change in visual acuity, recurrent orbital edema, diplopia, dry eyes (especially in