Asian Upper Blepharoplasty

Review the indications and technique of upper blepharoplasty with crease formation—which is the basis of Asian upper blepharoplasty in many patients.

Indications

  • Removal of redundant skin that is obstructing visual field or causing symptoms of heaviness and fatigue.
  • Cosmetic improvement in patients of any age.
  • Upper blepharoplasty may be used as an adjunct to ptosis surgery in patients with lid droop and excess upper lid skin.

Note: Asian blepharoplasty is indicated to obtain a more open and attractive Asian eyelids. So-called Westernization of the eyelid is rarely desirable.

Pre-operative Procedure

  1. Complete lid and eye examination to determine detailed operative plan.
  2. Measure position of existing lid crease if any. (If lid crease is indistinct or malpositioned, formation of new crease may be indicated.)
  3. Evaluate presence and location of herniated orbital fat. (Cosmetically unacceptable fat prolapse is often located medially.)
    • a. Review old photographs showing presence/absence of crease. (Note: false creases may reveal themselves with age).
    • b. Review shape, height, and symmetry of proposed crease.
  4. Evaluate brow position. (A brow lift may be required if brow droop is present.)
  5. Evaluate lid position. (A ptosis procedure may be indicated in combination with the blepharoplasty.) Overhanging eyelid skin may mask ptosis and not be apparent until after blepharoplasty.
  6. Check for corneal staining to evaluate potential impact of any postoperative lagophthalmos.
  7. Obtain photographs in frontal and side view to document preoperative appearance.

Instrumentation

  • Marking pen
  • Toothed forceps
  • Scalpel (e.g., #15 Bard-Parker blade)
  • Stevens scissors
  • Westcott scissors
  • Cautery
  • Needle holder
  • Hemostat
  • Sutures 6–0 Prolene
  • Sutures 6–0 Vicryl

Operative Procedure

  1. Mark location of desired lid crease with tissue marking pen usually at the upper border of the tarsal plate. The height of the crease may vary from 5.5 to 8 mm. (Figure 1)
    • a. In general, when a natural crease exists, use the existing lid crease because it is easier to make symmetric marks and less likely to cause unintended asymmetries.
    • b. Generally, the eyelid crease is ~7 mm above lashes at the lateral canthus, 7 mm centrally, and 5 mm nasally.
  2. Ascertain upper border of planned skin resection, noting the preoperative appearance of eyelids and size of desired eyelid fold.
    • a. Do not use “pinch or other techniques to maximize excision.
    • b. Proper placement of an eyelid crease will reveal the eyelashes without extensive tissue removal. (Figure 2)
  3. Apply topical anesthetic.
  4. Subcutaneous infiltration with a 50:50 mixture of lidocaine 2% plus 1:100,000 epinephrine and 0.75% bupivacaine.
  5. Sterile preparation and draping of the face (keep full face exposed for comparison during procedure).
  6. Incise skin along marks with scalpel.
  7. Use Westcott scissors, Stevens scissors, cutting cautery, or CO2 laser to remove a skin or skin with very superficial muscle flap along the marked lines, exposing the orbital septum (Figure 3). (CO2 laser requires metal eye shields for patients, protective lenses for all operating room personnel, avoidance of supplemental oxygen.)
  8. Grasp the orbicularis muscle at the inferior aspect of the incision with forceps.
  9. Use Westcott scissors to dissect through orbicularis muscle and expose the levator aponeurosis below. (Figure 4)
    • a. Continue to dissect through the orbicularis muscle medially and laterally.
    • b. The levator is exposed across the entire eyelid.
  10. (Optional): In select patients, orbital fat may be removed from the medial and central pockets.
  11. Form eyelid crease with 6-8 horizontal mattress sutures of 6-0 vicryl. (Figure 5)
    • a. Pass suture from inferior skin edge and out the orbicularis muscle.
    • b. Advance the suture into the levator aponeurosis slightly above the exit site of the suture.
    • c. Complete mattress suture by reengaging levator aponeurosis and exiting through the skin.
    • d. Tie knots.
  12. Close skin edges with running suture of 6-0. (Figure 6)
  13. Apply ointment to the suture line.

Asian Blepharoplasty Figures Bay Area

Postoperative Procedure

  1. Apply ice packs to decrease swelling.
  2. Keep head of bed elevated 30 degrees to decrease swelling.
  3. Apply antibiotic ointment to suture line twice daily.
  4. Remove skin sutures in 4 to 6 days.

Potential Complications

  1. Orbital hemorrhage with possibility of consequent blindness
  2. Exposure keratopathy secondary to lagophthalmos or “dry eye”
  3. Malpositioned, asymmetric, incomplete or indistinct lid crease
    Ptosis
  4. Failure of crease to form is disappointing but not a complication. Repeat surgery is recommended with deeper fixation