External Incision Methods

William P.D. Chen

Chapter

A review of the literature on the external incision method (see Appendix 2) shows considerable variations in technique and preference regarding skin incisions and whether or not skin and orbicularis muscle should be routinely removed. Likewise, some prefer to open the orbital septum and remove a variable amount of the preaponeurotic fat pad. There are other proponents for small skin incisions or partial incision only, and further differentiations in the way crease fixation is carried out, including skinlevator aponeurosisskin, inferior orbicularis levator, septodermal, and skintarsusskin fixation. Each variation has pros and cons that needs to be weighed according to the technical skills, aesthetic sense and level of effort involved, as well as the patients comfort level and acceptance. For example, both the skin incision and the skin excision schools favor making an incision to accurately dene the placement of the crease. These practitioners are comfortable with these techniques as well as the wound healing process, and are likely to be less concerned about instant recovery. Specialists who routinely open the orbital septum are likewise comfortable with the anatomic landmarks and aim to clear the preaponeurotic zone along the superior tarsal border. Overall, the proponents of the external incision feel more comfortable with the predictability and permanence of this approach, and aim for a longer-lasting crease and less need for interval adjustment procedures. This approach, especially when carried out without the need for buried sutures, frequently yields a crease form that is subjectively comfortable for the patient on upgaze and downgaze, without the often-voiced complaint of tightness of the upper lid and a sensation of the buried sutures poking the pretarsal zone. The surgeon who operates through a 58 mm skin incision may be able to accomplish limited debulking of soft tissues. One drawback may be a crease that appears better formed over the central skin incision than over the medial and lateral portions of the lid.
51

Asian Blepharoplasty and the Eyelid Crease 52

The choice of suture material varies greatly, as do the closure techniques applied in the external incision methods. The techniques for construction of the upper eyelid crease fall into two broad categories: skin levatorskin (or skintarsusskin) and levator aponeurosis to inferior subcutaneous plane (or superior tarsal border to inferior subcutaneous plane: STB/inf.subQ).

tal bers of the levator aponeurosis along the superior tarsal border, and the third is into the upper skin edge (Fig. 6-1). This maneuver allows an adhesion to form between the levator aponeurosis and the subdermal area along the superior tarsal border, closely approximating the distal interdigitations of the levator aponeurosis. Fernandez1 wrote that this technique gives a dynamic and supercial crease (Fig. 6-2), in contrast to the skintarsusskin method, which tends to give a static crease (Fig. 6-3).

SkinLevatorSkin Approach
In this approach, sutures are placed so that the rst bite is into the inferior skin edge, the second is into the dis-

0.12 mm forceps

Fig. 6-1 Skinlevatorskin closure. The stitch rst passes through the lower skin border, taking a bite into the levator aponeurosis along the superior tarsal border (STB), and then through the upper skin border.

Levator aponeurosis Superior tarsal border Tarsus

Chapter 6 External Incision Methods 53

Fig. 6-2 Skin (S)levator (L)skin (S/L/S) closure, which produces a dynamic and supercial crease.

Levator Skin Upper tarsus

Suture passage from: Skin

Levator

Skin

Asian Blepharoplasty and the Eyelid Crease 54

Fig. 6-3 Skin (S)tarsus (T)skin (S/T/S) closure, which tends to produce a static crease.

Skin Tarsus

Suture passage from: Skin

Tarsus

Skin

Levator Aponeurosis to Inferior Subcutaneous Plane Approach

In the levator aponeurosis to inferior subcutaneous plane approach, several buried 6/0 nylon, polyglycolic acid, or polypropylene sutures are applied to allow adhesions to form between the levator aponeurosis and the subcutaneous tissue of the inferior incision along the superior tarsal border (Fig. 6-4). According to Fernandez,1 this procedure also produces a dynamic crease, but a more deep and permanent one than in the skinlevatorskin method of closure. In 1974 and 1977, Sheen2,3 described performing this technique on Caucasian patients who underwent upper blepharoplasty. Sutures were applied from the levator aponeurosis to the inferior orbicularis muscle (in essence the

inferior subcutaneous tissue). In 1976, Putterman and Urist,4 and Weingarten5 described the technique of applying sutures from the superior tarsal border to the inferior subcutaneous plane (Fig. 6-5). In 1999 Park6 published his technique of orbicularislevator fixation in double-eyelid procedures for Asians. He used three 6/0 nylon sutures to x a folded portion of the levator aponeurosis to the orbicularis oculi of the inferior skin edge. Yoo7 described crease formation simply by trimming of pretarsal fat and the placement of basting sutures that eliminate the dead space formed by removal of pretarsal tissues, but without attaching any aponeurosis or tarsal plate. The author assumed that the reduction of the soft tissue between levator and skin was a more important factor in the formation of a crease than levator insertion to the skin. He advocated an open

Chapter 6 External Incision Methods 55

Fig. 6-4 Placement of ligature buried between the inferior subcutaneous tissues and the levator aponeurosis. According to Fernandez1 this procedure results in a deeper and more permanent dynamic crease.

Levator / inferior subcutaneous knot

Fig. 6-5 Placement of ligature buried between tarsus and subcutaneous tissues of inferior skin edge.

Tarsus / inferior subcutaneous knot

Asian Blepharoplasty and the Eyelid Crease 56

incisional method using removal of excessive soft tissue and closure without supratarsal xation. He used a continuous 6/0 silk and three interrupted sutures to close the wound. Conceptually the three interrupted basting sutures were used to close the skin, orbicularis, and pretarsal soft tissues; however, the exact function of these interrupted sutures is debatable, as the closure of the dead space implied by the author following the removal of soft tissue will inherently anastomose the upper and lower skin margins together and over the levator aponeurosis along the superior tarsal margin. The net result would also be a rigid pretarsal platform allowing crease formation, and there would very likely be secondarily induced aponeurotic adhesions to the pretarsal tissues after such a maneuver. In addition, there is still the presence of other impeding factors, such as tissue redundancy in the preaponeurotic space above this region, which consists of the preseptal orbicularis, suborbicularis fat and septum as well as inferiorly migrated preaponeurotic fat pads. In Yoos series of 48 patients, some appeared to show significant regression of the height of the crease after 12 years. Lee et al.8 advocated attachment of the orbital septum to the skin to form the eyelid crease. They stated that there are distinct layers of fascia anterior to the orbital septum that originate from the septum and insert on to the pretarsal aponeurotic expansion. Seeing that the preaponeurotic fat and orbital septum hang below the fusion line of the orbital septum and aponeurosis in Asian single eyelids, the authors advocated the septodermal xation technique, where the hanging portion of the orbital septum is dissected from the aponeurosis, plicated, and then sutured to the skin of the pretarsal flap. The septum is not routinely opened, but the redundant portion hanging below the fusion line is sutured to the pretarsal skinmuscle ap. In 60% of their patients the pretarsal fibrofatty layers are removed to promote adhesion between the pretarsal orbicularis fascia and the pretarsal aponeurotic expansion. The authors followed 512 patients over 3 years, and the advantages they claim include less postoperative edema, less discomfort and pain, and satisfactory crease formation. At the opposite end of the spectrum, in 1993 Flowers9 described his approach towards upper blepharoplasty and crease fixation in Caucasians and Asians, utilizing his approach of anchor blepharo-

plasty. He discussed the challenge when a crease fold was allowed to remain in an upper blepharoplasty the pretarsal skin appeared excessive and wrinkled. His solution was to correlate the amount of pretarsal skin that is allowed to remain (the location of the lid incision) with the tarsal height, excising the desired skin with its supratarsal crease and then recreating a new precise crease fold by attaching the dermis of the pretarsal skin ap to the aponeurosis and tarsus. The tarsus is everted and its height measured. It is marked on the skin side with the same distance from the lash line, which adds 2mm to the distance as measured from the actual lid margin. Flowers operative rule is that there should be 2630 mm of skin on the upper lid between the eyebrow and the lid margin for normal contour and invagination as well as for closure. This is broken down into approximately 10mm for the invagination of the eyelid fold, a minimum of 12 mm from the eyelid fold to the brow, and 36 mm of visible pretarsal skin; 12mm are allowed for the curvature of the lid fold as it bends into the crease. If the amount is less than 2630 mm there will be problems with invagination of the fold, as well as a restricted brow position and inadequate lid closure owing to shortage of skin. The amount of eyelid skin that overhangs and obstructs the desired view of the pretarsal skin is measured using a caliper, or estimated visually; this is doubled (2) to arrive at the amount of skin that ought to be removed. This may be performed at different points along the eyelid. Flowers discussed the treatment of fat and its partial excision over the lateral quadrant, and the possibility of rotating and translocating the fat on to the medial aspect of the supratarsal sulcus. He believed that trimming pretarsal connective tissues and thinning of the pretarsal orbicularis on the underside of the pretarsal skin flap helps both to reduce postoperative edema in that region and to produce a smooth pretarsal skin surface as a result of adherence of the skin and orbicularis to the tarsus. In this approach the plane between the pretarsal orbicularis and the distal insertion of the levator aponeurosis over the anterior surface of the upper tarsus is separated with scissors down to the lash margin. Any inferior attachment of the aponeurotic bers to the skin is thus transected. The lmy pretarsal connective tissues, including portions of pretarsal orbicularis that may be excessive, are excised with scissors over the anterior tarsal surface. The dermis of the pretarsal skin

Chapter 6 External Incision Methods 57

Fig. 6-6 (A) A dynamic crease is apparent on forward gaze but disappears on downgaze (B).

Asian Blepharoplasty and the Eyelid Crease 58

ap (lower skin edge) is sutured subcuticularly to the superior margin of the tarsus as well as the free terminal edge of the aponeurosis using absorbable 6/0 Vicryl. Flowers usually applies three or four of these sutures centrally, and one or two laterally as well as medially along the new crease. (The trimming of the pretarsal tissues and excision of some of the anterior portion of the distal levator aponeurosis will invariably leave behind a free edge; this does not mean that the levator aponeurosis has been entirely transected.) In addition, the upper and lower skin edges are closed with a running non-dissolving suture, incorporating the aponeurosis in each bite. Alternative methods of closure mentioned by Flowers were: 1. To use interrupted nylon sutures alone, incorporating all layers together: the lower skin edge, the superior tarsal border, the free edge of the aponeurosis, and the upper skin edge. No Vicryl is then used for the skintarsuslevator aponeurosis alone. 2. The incorporation of the upper and lower skin edges into the deeper 6/0 Vicryl that binds the superior tarsal border as well as the free edge of the aponeurosis. No nylon or non-dissolving suture is then used. The reason for incorporating the levator aponeurosis, according to Flowers, is that it exerts a small amount of tension on the pretarsal skin and thereby keeps it taut. By the same reasoning, he anchors the pretarsal skin ap to the tarsus to prevent excessive pull by the aponeurosis on the pretarsal skin, resulting in eyelash eversion and excessive showing of the upper lid margin itself. The author stated that patients often experience some degree of ptosis, as well as a tugging feeling on upgaze. He stated that complete recovery requires 23 years, but that patients generally look very satisfactory by 2 weeks after surgery. The concept of a dynamic versus a static crease is worth elaborating. When a person has a natural crease in the upper eyelid, the crease is well dened when that person looks straight ahead (Fig. 6-6A). On downgaze, the inferior rectus and superior oblique muscles contract, whereas the superior rectus, levator, and inferior oblique muscles relax. As the eyes look downward, the

upper lid follows and the upper lid crease loses prominence, sometimes becoming barely observable (Fig. 6-6B). A crease that is present when the levator is active and which fades from view when the levator relaxes is called a dynamic crease. A surgically formed upper lid crease that is present and noticeable even on downgaze (when the levator is relaxed) is called a static crease. This type of crease is often seen in patients who have had the inferior skin edge sutured to the superior tarsal border and upper skin edge. In practice the matter is not always predictable: a static crease is not always seen as a result of skin tarsusskin closure, and a dynamic crease does not always occur when skinlevatorskin or levator aponeurosisinferior subcutaneous plane closure is performed.

This author1013 prefers the external incision method because it is more controlled and permanent. I remove a variable amount of skin depending on the patients needs. I also resect some orbicularis oculi usually several millimeters along the preseptal and the pretarsal segments. The orbital septum is opened superiorly and, depending on the situation, a variable amount of preaponeurotic fat may be trimmed, but never completely removed. The lid crease-enhancing sutures are placed skinlevator aponeurosisskin. To give a dynamic, supercial crease I use non-absorbable nonreactive suture materials that are then removed. I do not use any buried suture materials.

References
1. Fernandez LR. Double eyelid operation in the Oriental in Hawaii. Plast Reconstruct Surg 1960;25:256264. 2. Sheen JH. Supratarsal xation in upper blepharoplasty. Plast Reconstruct Surg 1974;54:424431. 3. Sheen JH. A change in the technique of supratarsal xation in upper blepharoplasty. Plast Reconstruct Surg 1977;59:831834. 4. Putterman AM, Urist MJ. Reconstruction of the upper eyelid crease and fold. Arch Ophthalmol 1976;94:19411954.

Chapter 6 External Incision Methods 59

5. Weingarten CZ. Blepharoplasty in the oriental eye. Trans Am Acad Ophthalmol Otol 1976;82:442446. 6. Park JI. Orbicularislevator xation in doubleeyelid operation. Arch Facial Plast Surg 1999;1:9095. 7. Yoo H-B. The double eyelid operation without supratarsal xation. Plast Reconstruct Surg 1991;88:1217. 8. Lee JS, Park WJ, Shin MS, Song IC. Simplied anatomic method of double-eyelid operation: septodermal xation technique. Plast Reconstruct Surg 1997;100:170178. 9. Flowers RS. Upper blepharoplasty by eyelid invagination anchor blepharoplasty. Clin Plast Surg 1993;20:193207.

10. Chen WPD. Asian blepharoplasty. Ophthalm Plast Reconstruct Surg 1987;3:135140. 11. Chen WPD. A comparison of Caucasian and Asian blepharoplasty. Ophthalm Pract 1991;9:216222. 12. Chen WPD. Upper blepharoplasty in the Asian patient. In: Putterman AM, ed. Cosmetic oculoplastic surgery, 3rd edn. Philadelphia: WB Saunders, 2000: Chapter 11. 13. Chen WPD, Khan J, McCord CD Jr. Color atlas of cosmetic oculofacial surgery. Oxford: ButterworthHeinemann, 2004.