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Fat Preservation and Other Tips for Upper Blepharoplasty
Cat Nguyen Burkat
I prefer using the Ellman radiofrequency unit with a microdissection tip or the monopolar unit with a Colorado tip to incise the skin, as these afford simultaneous cutting and excellent hemostasis. The skin and orbicularis muscle are removed as single flaps generally, although a skin flap alone could be removed if there is preoperative concern for poor eyelid closure function. Next, the fat pads are addressed if prominent on the preoperative evaluation (Figure 27.1). In general, limited fat removal should be performed in order to avoid the appearance of a hollow superior sulcus. The trend in upper eyelid blepharoplasty has shifted to preservation, repositioning, or filling of the upper lid fat, rather than aggressive removal. If debulking is indicated, the fat should be conservatively removed over a curved hemostat in order to avoid orbital hemorrhage. Medial fat pad removal should bear in mind the location of the trochlea and superior oblique tendon, as well as the numerous fibrous attachments of these structures to the orbital fat. Generally, the orbital fat pads can be thermally sculpted with the Ellman roundball tip or the Colorado tip over an intact orbital septum, which limits the risk of hemorrhage or injury to adjacent structures, as well as requires much less operative time.
In the lateral upper eyelid, a prolapsed lacrimal gland may be found in up to 10–15% of young patients undergoing blepharoplasty (Figure 27.2). The lacrimal gland will exhibit a characteristic pink color, with a lobulated shape. Failure to recognize this during surgery may lead to inadvertent lacrimal lobectomy and possible postoperative hemorrhage or dry eye. On the other hand, if left uncorrected, this may result in eyelid asymmetry, persistent lateral fullness, and therefore, poor cosmesis. The lacrimal gland, if prolapsed, should be resuspended under the superolateral orbit with several interrupted sutures.
Any additional eyelid or eyebrow procedures may also be performed through the blepharoplasty incision: these include external levator repair, internal browpexy with or without implants, ectropion repair, and/or weakening of glabellar musculature (Figure 27.3).
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Chapter 27 Fat Preservation and Other Tips for Upper Blepharoplasty 85
Meticulous layered closure is performed using 7.0 Vicryl to close the orbicularis muscle at three to four sites, followed by 6-0 fast-absorbing plain gut suture to approximate the skin edges in a running fashion, taking care to evert the skin edges. Although some surgeons prefer nonabsorbable prolene or nylon suture, patients greatly appreciate the absorbable aspect, and this also saves time in the clinic without compromising the final appearance to the incisions. Closure is performed from medial to lateral, as any dog-ear deformity, if present, is better addressed and camouflaged laterally. In Asian eyelids, closure of the orbicularis muscle layer should incorporate the levator aponeurosis at several sites to recreate a defined eyelid crease, and the incision should blend nicely into the medial epicanthal fold.
Figure 27.1. Introperative view of upper eyelid fat pads posterior to the orbital septum. The levator aponeurosis lies posterior to the orbital fat pads. MFP, medial fat pad; CFP, central fat pad; LV, levator aponeurosis.
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Figure 27.2. A prolapsed lacrimal gland may be seen lateral to the central fat pad and should not be mistaken for fat and inadvertently excised. LB, lacrimal gland; CFP, central fat pad; LV, levator aponeurosis.
Figure 27.3. The medial eyebrow depressors may be weakened or excised through the medial aspect of the blepharoplasty incision. CSM-O, corrugator supercilii muscle oblique head; CSM-T, corrugator supercilii muscle transverse head; SM, depressor supercilii muscle; F, frontalis; P, procerus muscle; ZA, zygomatic arch; OOM, orbigularis oculi muscle.
28
Asian Blepharoplasty
Samuel M. Lam
Asian blepharoplasty is a distinct challenge for the Western surgeon who may not have frequent encounters with the Asian patient and thereby may lack the technical knowledge of how to perform the procedure as well as cultural sensitivity in approaching the Asian patient. There are as many different styles of creating a supratarsal crease in the Asian patient as there are practicing surgeons who undertake this procedure.
I will discuss the personal strategy that I have developed and the accompanying pearls and pitfalls that I have encountered along the way.
All of the methods can be more broadly classified as one of three major types: suture, partial or limited incision, and full incision. For younger patients, I have come to rely on the partial-incision method that employs a simple 1.5-cm incision in the central aspect of the upper eyelid (Figure 28.1). However, when I encounter patients who have some incipient or pronounced dermatochalasis, I prefer to use the full-incision method, which permits some removal of redundant skin (Figure 28.2). Due to the ephemeral nature of the suture method with the potential for fold loss over time, I do not use this method.
The partial incision method developed by Young-Kyoon Kim is a reliable and expedient method to create a supratarsal crease in the younger patient.* The abbreviated incision permits a relatively shorter recovery time with a result that can look socially acceptable occasionally after 1 week , but more often after 1 month, can look very good by 3 months, and at the desired endpoint by the 7th to 8th month. However, what I have learned from Dr. Kim is the very important lesson to use only permanent sutures—so-called internal fixation sutures—to fixate the levator to the skin.
Also, each suture must not only bite the levator and skin edge, but also pass through approximately a half to a full millimeter of the epidermis to engender a foreign body reaction and thereby establish greater permanence of the fold.
*The surgical methods described in this chapter are recounted in stepwise fashion in my book, Cosmetic Surgery of the Asian Face (2nd ed.), Thieme Medical Publishers, Inc., New York, 2005.
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When I first started performing the partial-incision method, a high percentage of my patients lost their fold principally due to my not adhering to this admonition. The major limitation of this technique is the potential for fold loss due to the short distance of levator-skin fixation. Besides the above caveats, the surgeon should also not remove any fixation sutures that become exposed until at least 3 months have transpired to ensure that a durable scar has developed.
Fortunately, the short incision of this technique permits an easier revision procedure, if needed, which is always difficult no matter what technique is pursued.
Caution: Never undertake revision surgery in only one eyelid, as the edema that results on one side alone makes discernment of symmetry elusive. If asymmetry persists by the second week, the surgeon should elect to undertake revision surgery when the scar has not matured, facilitating a far easier, faster, and safer revision procedure.
For patients who manifest dermatochalasis, I prefer the full-incision method of Dr. John A. McCurdy, Jr., in Hawaii, to remove some of this extra skin. This method will result in a longer convalescence that may look unnatural for even several months. Unfortunately, most patients who undergo a full incision in my office are older and are less tolerant of having a longer period of looking unnatural. It is also harder to perform a revision surgery when the full-incision method is used. In the partial-incision method, a revision procedure can be undertaken by extending the incision to the full length and then working down to the levator in virgin territory to avoid injury to this muscle. This luxury is not possible with the full-incision method. In revision surgery after a full-incision double-eyelid procedure, one should stay more superiorly and use the nondominant hand to apply pressure to the eyelid/globe so as to elicit herniation or propulsion of the preaponeurotic fat, which is the safety landmark from injury of the levator.
The old term “westernization” of the Asian eyelid is quite outdated for many reasons. First and foremost, many Asians do not desire to look Caucasian per se but to look more like the paragons of beauty from their own culture. Large creases with hollow upper eyelids simply never look good on Asians but render them looking very strange and unnatural. In fact, I often do not remove any fat from the upper eyelid in the Asian, especially if there already is a paucity of preaponeurotic fat to begin with.
I have devised a classification of the aging Asian eyelid that may be helpful for surgeons who would like to understand when and how to apply judgment for Asian blepharoplasty in the aging Asian eyelid and even for those who simply would like to know if they could proceed without having to create a crease. This classification scheme divides the aging Asian eyelid into three categories:
1.Aging Asian eyelids with a natural crease
2.Aging Asian eyelids without a crease
3.Aging Asian eyelids with a man-made crease
The first category, aging Asian eyelids with a natural crease, seems intuitively straightforward. If there is a crease present, then the surgeon
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should assume that a standard blepharoplasty could be undertaken without concern of levator fixation, symmetry, etc. However, there are some subtle but important considerations. First, what constitutes a crease in some Asian eyelids may be far less than what is traditionally encountered in the Caucasian upper eyelid. The crease may be as small as 1– 2 mm and only partially visible or only established on one side. If this is the case, the surgeon should really deem this rudimentary crease as no crease at all and treat the patient accordingly. The surgeon should also be wary with indiscriminate removal of skin in these very low creases as the levator that lies in close apposition to the skin at this inferior level can be damaged if the skin incision is cut too deeply. For the patient with a standard Occidental-like natural crease, the surgeon should still be cautious because Asians are very sensitive about the position of their lid fold. Caucasians tend not to care if they show more lid crease or less. If the surgeon removes a substantial amount of skin from above the crease, as would be performed during a standard blepharoplasty, the crease can be overly elevated in position and deemed unnatural. Any crease elevation in fact may be considered unacceptable. Accordingly, the surgeon should have a detailed discussion with the patient about this likelihood. Always err on the side of conservative skin removal for this reason.
The patient that has a surgically fabricated supratarsal crease probably had it constructed when he or she was much younger during an era when westernization procedures were popularized. Therefore, the initial crease could have been excessively high and with time either become much smaller or altogether disappeared due to brow ptosis, fat absorption, and dermatochalasis. The surgeon should inspect the original crease height by lifting upward on the overlying skin to evaluate whether it is very high. If so, the surgeon is advised to warn the patient that removal of skin during a standard blepharoplasty could result in re-creation of that very high lid fold that may be unacceptable to the patient. In general, it is almost impossible to lower a crease that has already been made too high. It is also quite difficult to fill in using fat grafting a completely vacuous eyelid either due to aging, prior surgery, or both owing to the prolonged recovery time and risk of morbidity associated with possible lumpiness in the thinner skin when putting that much fat in the upper eyelid. Furthermore, the surgeon can potentially lose the fold during a conventional blepharoplasty if a suture technique was undertaken since the tenacity of this created fold is very weak.
Finally, a patient with aging Asian eyelids without a discernible crease can be approached using a standard full-incision double-eyelid blepharoplasty technique. If the surgeon tries to remove simply skin in a premeasured marked line in the upper eyelid skin without taking some preaponeurotic fat with it, the fullness of the Asian eyelid due to the low position of the levator insertion or lack of insertion altogether must be addressed. However, removal of preaponeurotic fat along with skin without addressing the levator fixation may lead to a problem with variable crease formation due to random adhesion of the postseptal tissue to the skin. Besides these problems, Asian double-eyelid blepharoplasty also carries with it some additional issues. First, creation of a supratarsal fold at a later age in life may alter an individual’s self-perceived identity,
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a condition more prevalently suffered by the male. Preoperative counseling about this matter should be incorporated to minimize this outcome. Also, even 1–2 mm of lid edema that can persist for months may be deemed unacceptable, especially in men, who have a harder time adjusting to changes and recovery and who do not normally wear any mascara to camou age the swelling. I tend to ask if the patient associates more with Asians or Caucasians simply because Asians know about this procedure and would recognize the postoperative stigma, whereas Caucasians and other minorities would most likely not know anything was done since they are not very sensitive about lid crease height and have never heard about a double-eyelid procedure.
A 
B
Figure 28.1. This 24-year-old Chinese woman underwent a partial-incision double eyelid blepharoplasty and shows a favorable aesthetic result 3 months postoperatively. Of note, she started with asymmetric lid creases and therefore asymmetric palpebral fissures, which was corrected by a symmetric double-eyelid blepharoplasty.
Chapter 28 Asian Blepharoplasty 91
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Figure 28.2. This 39-year-old Japanese woman underwent a full-incision doubleeyelid blepharoplasty and is shown 7 months postoperatively. Of note, she has asymmetric creases preoperatively that have been rectified by symmetric crease
xation.