Supratarsal CreaseCreation in the AsianUpper Eyelid

Samuel M. Lam, MDa,*, Amir M. Karam, MDb,c

KEYWORDS

� Supratarsal crease � Eyelid � Blepharoplasty � Asian

What makes blepharoplasty on Asian patientsunique is the management of the supratarsalcrease. Although the presence of a supratarsalcrease is a naturally occurring anatomic finding inthe Asian population, many of those who lack thisanatomic trait will often seek surgical creation denovo . The desire to have a double eyelid is largelycultural, as this feature is considered attractive.

The primary goal of this procedure is not only tocreate a supratarsal crease but also to createa crease that is consistent with the natural config-uration present in the population. From a surgicalpoint of view, this requires a thorough under-standing of the natural crease shape and charac-teristic and mastery of the unique skills requiredto create it. Asian upper-eyelid blepharoplastyhas a rich and complex history. The first reportedcase was performed and reported in the late nine-teenth century.1,2 Since then, several innovativesurgeons began to describe their techniques andconcepts. The era of westernization upper blepha-roplasty, which focused on creating a high supra-tarsal crease consistent with the White norm, hasgiven way to methods that preserve ethnic charac-teristics. The current strategies can be broadlycategorized into suture-based, full-incision, andpartial-incision techniques.

The method that is advocated in this article isthe full-incision technique. The rationale for thispreference can be summarized as follows:

(1) Relative permanence compared with othermethods

a Willow Bend Wellness Center, Lam Facial Plastic SurgeryBoulevard, Suite 101, Plano, TX 75093, USAb Carmel Valley Facial Plastic Surgery, San Diego, CA, USc University of California, San Diego School of MedicineCA 92130, USA* Corresponding author.E-mail address: drlam@lamfacialplastics.com (S.M. Lam).

Facial Plast Surg Clin N Am 18 (2010) 43–47doi:10.1016/j.fsc.2009.11.0041064-7406/10/$ – see front matter ª 2010 Elsevier Inc. All

(2) No need to rely on any buried permanentsutures to hold the fixation

(3) Ease in identifying postseptal tissues througha wider aperture

(4) Ability to modulate excessive skin (dermato-chalasis) in the aging eyelid.

The major drawback of the full-incision methodis the protracted recovery time, in which thepatient can look grossly abnormal for 1 to 2 weeks,and still not entirely natural for months, if not a fullyear. Scarring has proven to be a nonissue if thedelicate tissues near the epicanthus are carefullyavoided. In the authors’ opinion, the incision lineis more difficult to observe with the full-incisionthan with the partial-incision method becausethere is no abrupt ending as is apparent with themore limited-incision technique.

OPERATIVE TECHNIQUEDetermination of the Eyelid Crease Position

The first step is designing the proposed eyelidcrease. There are several variations ranging frominside fold (the medial incision terminates lateralto the epicanthus) and outside fold (the medialincision extends medial to the epicanthus by 1–2mm). There are 2 variations to the shape of theincision. The first is an oval shape (slight flare ofthe crease height laterally above the ciliary margin)versus rounded, in which the line runs parallel tothe ciliary margin. Our preference is for the insidefold paired with an oval configuration (Fig. 1).

Center & Hair Restoration Institute, 6101 Chapel Hill

A, 4765 Carmel Mountain Road, Suite 201, San Diego,

rights reserved. faci

alpl

asti

c.th

ecli

nics

.com

Fig. 1. The surgical marking of the inside fold pairedwith an oval configuration.

Fig. 2. Incision and removal of the overlying skin.Note that the obicularis muscle is left down at thisstage. A no. 15 blade is used to incise the skin downthrough the orbicularis oculi muscle.

Fig. 3. The excision of a strip of obicularis musclealong the inferior edge of the incision. This excisionwill expose the underlying septum.

Lam & Karam44

Surgical Marking

The patient should be placed in the supine positionand the upper-eyelid skin is held taut to the pointthat the eyelashes are just beginning to evert.The supratarsal crease should be marked ata distance of 7 mm from the ciliary crease to createa natural, low crease design (which constitutes thenaturally occurring shape). The degree of skinexcision to be performed should err on the sideof conservatism with about 3 mm between theupper and lower limbs.

Anesthesia

Deep sedation should be avoided, as patientcooperation is vital to ensure symmetry towardthe end of the procedure. A mixture of 0.5 mL of1% lidocaine with 1:100,000 epinephrine and 0.5mL of 0.25% bupivicaine with 1:100,000 epineph-rine attached to a 30-gauge needle is used to infil-trate the upper-eyelid skin by raising 2 to 3subcutaneous wheals, which are then manuallydistributed by pinching the skin along the entirelength of the incision. This method avoids thread-ing the needle and limits the chance of a hematomathat can lead to difficulty in gauging symmetryduring the procedure. A total of only 1 mL of thelocal anesthesia mixture described earlier is infil-trated along each proposed incision to maintainsymmetry.

Surgical Exposure

A no.15 blade is used to incise the skin downthrough the orbicularis oculi muscle, taking carenot to pass the blade much further than that initialdepth (Fig. 2). Bipolar cautery is used to coagulatethe vascular arcades that run perpendicularlyacross the incision line to limit unnecessarybleeding and thereby mitigate swelling and distor-tion during this delicate procedure. The depth of

the incision can be further deepened with theno.15 blade down toward the orbital septumbefore removing the skin island with curved irisscissors. Additional cautery is used as needed.At this point, the same procedure is performedon the contralateral side and is continued in thisalternating fashion to ensure symmetry.

The same iris scissors are then used to excisean additional 1 to 2 mm strip of tissue along theinferior edge of the wound to remove any remain-ing orbicularis oculi fibers and some initial fibers ofthe underlying orbital septum (Fig. 3).

With the assistant gently balloting the eyeballabove and below the incision line to help herniatethe postseptal adipose, the surgeon makes a smallfenestration along the lateral extent of the woundedge just at the point where the strip of orbiculariswas previously removed. With the countertractionand balloting of the eyeball mentioned earlier, thesurgeon continues to excise thin films of tissueuntil the yellow postseptal adipose tissue isencountered (Fig. 4). The reason for the smallfenestration and the constant attention by theassistant to ballot around the incision to push the

Fig. 4. Exposure of the postseptal fat.

Fig. 6. The postseptal fat is swept away and thelevator aponeurosis is fully exposed.

Supratarsal Crease Creation in the Upper Eyelid 45

fat through the defect is that identifying the post-septal fat is the safety landmark for avoiding injuryto the deeper levator aponeurosis.

Once the fat is identified, a fine-toothed curvedmosquito clamp is inserted into the fenestrationand gently spread medially to lift the remainingorbital septum away from the deeper fat pad andlevator aponeurosis. Repeated entry and exit ofthe tines through the defect can help ensure thatthe correct tissue plane of dissection is main-tained. With the tines open and the orbital septumtented upward, a bipolar cautery with iris scissorscan be used to open the remaining orbital septumto expose fully the deeper postseptal adipose andunderlying levator aponeurosis (Fig. 5).

A cotton-tipped applicator is used to sweep thepreaponeurotic (postseptal) fat pad away from theglistening white levator (Fig. 6). At times, a thinposterior leaf of the orbital septum can be seenbetween the levator and the fat pad. Gentledissection (using a fine-toothed mosquito clampfollowed by scissors) of this thin orbital septumaway from the fat pad can be undertaken to revealthe levator more fully. The same technique isundertaken on the contralateral side to this point.

Levator-to-Skin Fixation Sutures

Many surgeons believe that excessive adiposetissue must be removed to attain a more open

Fig. 5. The use of the mosquito clamp to lift theseptum up to protect the underlying levator aponeu-rosis. An iris scissor is used to divide the septum alongthe entire length of the incision.

eyelid configuration. It is our position that in morethan 80% of cases a simple levator-to-skin fixationis all that is necessary to attain the desired eyelidshape configuration and perceived opening ofthe palpebral aperture. Accordingly, preaponeur-otic fat is rarely removed. At this point, the firstlevator-to-skin fixation suture can be placed.

With the 5-0 nylon loaded backhanded on theneedle driver, the patient is asked to open his/her eyes to determine the position of the midpupilon forward gaze so as to place the suture throughthe upper skin edge at the midpupil. The suturebite is through the entire epidermis and dermis,as this suture will be removed 7 dayspostoperatively.

With the 5-0 nylon now loaded normally in a fore-hand fashion, a horizontal bite is placed throughthe levator at the approximate lower edge of theexposed levator, again aligned at the midpupil(Fig. 7). Next, with the 5-0 nylon loaded in a back-hand fashion, the final throw of the needle isplaced through the lower skin edge, again alignedwith the midpupil. The patient is then asked toopen his/her eyes after 1 suture knot to determineproper eyelash position (Fig. 8). The eyelashesshould be slightly everted, and that should be thedesired end point. The crease height will seem

Fig. 7. The positioning of the 5-0 nylon suture used tocreate the new crease.

Fig. 8. Once each of the sutures is placed, patients areasked to open their eyes to assess positioning andsymmetry.

Lam & Karam46

grossly too high and should not be used as thedesired end point. If the eyelash position isdeemed appropriate, the remaining 4 square knotsare thrown to anchor the suture knot. The sametechnique is undertaken on the contralateral side,and symmetry of the creases is noted and canbe adjusted if necessary. A higher crease iscreated by placing the horizontal bite through thelevator more superiorly, and lowered by placingthe suture more inferiorly, along the levator.

Fig. 9. Before (A) and after (B) comparison of a 24-year-oldeyelid procedure.

With the initial fixation suture placed bilaterallyand symmetry observed, the 4 remaining fixationsutures per side can be placed in the samefashion. The second fixation suture is alignedwith the medial limbus and the third fixation suturepositioned halfway between the lateral limbus andthe lateral canthus. Two additional fixation suturesare used between these points to fine-tune anyperceived asymmetry. A total of 5 fixation suturesare placed per side. The skin is then approximatedwith a running, nonlocking 7-0 nylon suture. Fig. 9illustrates a patient following the this procedurebefore and 18 months after the procedure.

POSTOPERATIVE CARE

Postoperative care is straightforward, consistingof icing the eyelid areas for the first 48 to 72 hoursand cleansing the incision line twice daily withhydrogen peroxide and dressing it with bacitracinointment for the first postoperative week. Thepatient returns on the seventh postoperative dayfor the removal of all 5 fixation sutures per side(5-0 nylon) and the running skin closure (7-0 nylon).At times the patient may complain of difficultyopening his/her eyes due to excessive edema ortemporary levator dysfunction, which disappearsover the first several days but can linger even up

Chinese woman 1.5 years after a full-incision double-

Supratarsal Crease Creation in the Upper Eyelid 47

to 3 to 6 weeks following the procedure. Thepatient is reassured that it often takes 1 full yearto achieve a natural crease configuration owingto persistent pretarsal edema that can lingerfor many months. Narrow rectangular-shapedeyeglasses can camouflage some of the exorbi-tant edema in the immediate postoperative period;and, for female patients, mascara can be used tohelp hide the abnormal height of the crease duringthe initial few months following the surgery.

SUMMARY

Supratarsal crease fixation in the Asian patient canprovide a more open-eyed, awake look withoutcompromising their ethnic appearance. A conser-vative supratarsal crease height and conservativeto no removal of postseptal fat help to ensurethis natural-appearing result. With the full-incisionmethod, the senior author (SML) has been ableto achieve consistently excellent results with

durable crease fixation despite a prolongedrecovery time. The supratarsal crease fixationprovides an excellent method for the youngerpatient seeking cosmetic eyelid enhancement.However, for the aging Asian patient, thecomplexity of the strategy is greater; for detailsregarding this approach the reader is referred tothe senior author’s accompanying article in thispublication entitled A New Paradigm for the AgingFace.

REFERENCES

1. Lam SM. Mikamo’s double-eyelid blepharoplasty &

the westernization of Japan. Arch Facial Plast Surg

2002;4:201–2.

2. McCurdy JA Jr, Lam SM. Cosmetic surgery of the

Asian face. 2nd edition. New York: Thieme Medical

Publishers; 2005.