Asian Blepharoplasty

Philip A Young, MDAesthetic Facial Plastic Surgery, PLLC

Face to FaceHo Chi Minh City, Vietnam 2014

This talk is on Asian BlepharoplastyThis talk is on Asian BlepharoplastyI will take about creating the double eyelid I will take about creating the double eyelid crease and my experience with treating crease and my experience with treating the epicanthal foldthe epicanthal fold

Preoperative assessment:1. Single Eyelid

Crease2. Epicanthal

Folds3. Asian or

Westernization4. Physiognomy,

deference to surgeons, communication

5. Personal Assessment: wire, image, desires

The Asian Eyelid can sometimes be characterized and identified as eyelids that have The Asian Eyelid can sometimes be characterized and identified as eyelids that have a single eyelid crease and | or epicanthal foldsa single eyelid crease and | or epicanthal foldsYou can treat each one separately but most of the time you are doing the eyelid You can treat each one separately but most of the time you are doing the eyelid crease procedure and adding possibly the epicanthal foldscrease procedure and adding possibly the epicanthal foldsMost surgeons falsely think that asians want to look caucasian when in fact most Most surgeons falsely think that asians want to look caucasian when in fact most want to maintain there ethnicity but just want prettier eyeswant to maintain there ethnicity but just want prettier eyesThis occurs 95% percent of the time in my population IN AMERICAThis occurs 95% percent of the time in my population IN AMERICAPhysiognomy is the belief that a certain appearance of the body part will impart Physiognomy is the belief that a certain appearance of the body part will impart fortune for the person, ie large earlobes = money, nostrils showing = losing money fortune for the person, ie large earlobes = money, nostrils showing = losing money from your nose, etcfrom your nose, etcAsians are also less likely to tell you what they really want although they are getting Asians are also less likely to tell you what they really want although they are getting pretty americanized in America, This might apply here more than in the statespretty americanized in America, This might apply here more than in the statesThere are many different way to assess what a patient wants. I use a lacrimal probe There are many different way to assess what a patient wants. I use a lacrimal probe 00 01 small to determine where they want the crease and I use a very fine almost 00 01 small to determine where they want the crease and I use a very fine almost needle like marking pendneedle like marking pendI also have them hold a tissue to make sure to dry the mark so there are no bleedsI also have them hold a tissue to make sure to dry the mark so there are no bleedsSometimes I will use 2 probes to entertain unique preferences like a fold that is higher Sometimes I will use 2 probes to entertain unique preferences like a fold that is higher medial versus laterally medial versus laterally When they get to particular I start thinking this person may be a red flagWhen they get to particular I start thinking this person may be a red flagMost of the time you get some relaxation of the crease so you have to understand Most of the time you get some relaxation of the crease so you have to understand that the crease you are identifying with the probe may be lower by 1-2 mm you there that the crease you are identifying with the probe may be lower by 1-2 mm you there are ways to ensure that it stays closer to what you want but this is sort of a general are ways to ensure that it stays closer to what you want but this is sort of a general finding that I see happening with resultsfinding that I see happening with results

Preoperative assessment:

6. Inside / outside fold

7. Double eyelid crease, epicanthal folds, puffy eyelids

8. Greater than 3mm for the supratarsal fold?

9. Avoid postoperative signs that indicate surgery (ie hypertrophic scarring, pretarsal tissue bulging, round eye look, westernization?)

You should ask them whether want an inside fold or outside foldYou should ask them whether want an inside fold or outside foldThe outside fold is less common than the inside fold. Some feel this is more of a The outside fold is less common than the inside fold. Some feel this is more of a caucasian conformation and could make your results look operated on. This is caucasian conformation and could make your results look operated on. This is something to discuss with your patientssomething to discuss with your patientsWe discuss how how they want the fold and we discuss and show them what it would We discuss how how they want the fold and we discuss and show them what it would look like with their epicanthal folds alteredlook like with their epicanthal folds alteredI worry when patients want their folds too high, anything over 3mm may not be I worry when patients want their folds too high, anything over 3mm may not be considered Asian and I have a long discussion with them and document that they considered Asian and I have a long discussion with them and document that they wanted a fold higher than what I warn them may not be considered Asianwanted a fold higher than what I warn them may not be considered AsianI avoid signs of surgery and I tell them what I like to avoid ie hypertrophic scarring, I avoid signs of surgery and I tell them what I like to avoid ie hypertrophic scarring, pretarsal bulging, round eye look and westernization (crease too high, outside fold, pretarsal bulging, round eye look and westernization (crease too high, outside fold, too much skin excision)too much skin excision)

The Single Eyelid Crease is due to a variable extent of the post septal fat reaching in The Single Eyelid Crease is due to a variable extent of the post septal fat reaching in front of the tarsal platefront of the tarsal plateIt is highly possible to cut through the levator so you have to know the anatomyIt is highly possible to cut through the levator so you have to know the anatomyThis would be bad to cut through the levator and correctable intraoperatively but This would be bad to cut through the levator and correctable intraoperatively but better to avoid this. Some say this is a disaster.better to avoid this. Some say this is a disaster.Be careful of the fatty levator and the realize the asian eyelid has more layers than Be careful of the fatty levator and the realize the asian eyelid has more layers than depicted in this drawing when you actually do surgery!!depicted in this drawing when you actually do surgery!!

General rule stay high and identify the pre aponeurotic fat!!General rule stay high and identify the pre aponeurotic fat!!

Epicanthal Folds:-Excessive skin, muscle, fat, long MCT-Smaller, less open eye vertically and horizontally-Illusion of narrow-set eyes-Obscures the lacrimal lake region and eyelashes -Important in considering the outside fold double eyelidplasty

Approximately 90% of Asians exhibit epicanthal folds

Epicanthal folds are extra skin, muscle, fat, tissue at the medial canthusEpicanthal folds are extra skin, muscle, fat, tissue at the medial canthusIt is thought to be due to the lack of development of the nasal bridgeIt is thought to be due to the lack of development of the nasal bridgeIt can obscure the lacrimal lake variably and make the person seem to have narrow It can obscure the lacrimal lake variably and make the person seem to have narrow set eyes and smaller eyes vertically and horizontally in the medial areaset eyes and smaller eyes vertically and horizontally in the medial area

Epicanthal fold classification system (Duke,Park):

Type 1, epicanthus supraciliaris

Type 2, epicanthus palpebralis

Type 3, epicanthus tarsalis

Type 4, epicanthus inversus

Type 2 and 3 are the most common in Asians

There are four types of epicanthal foldsThere are four types of epicanthal folds1.1.The caucasian type where there is no epicanthal foldThe caucasian type where there is no epicanthal fold2.2.Type 2 where there is a small amount of the lacrimal lake showingType 2 where there is a small amount of the lacrimal lake showing3.3.Type 3 where all of the lacrimal lake is blocked from viewType 3 where all of the lacrimal lake is blocked from view4.4.Type 4 where most of the fold is coming from the lower lid in some congenital Type 4 where most of the fold is coming from the lower lid in some congenital anomaliesanomalies

Type 2 and 3 are most likely what you will be operating on.Type 2 and 3 are most likely what you will be operating on.

Epicanthal Folds and Double Eyelid Surgery:-Increase tension on the epicanthal fold -Increase vertical dimension-Persistent short horizontally-Round eye deformity-Startled appearance

Round Eye Deformity

Epicanthoplasty-Increase horizontal dimension-Reveal the lacrimal lake-Beautify the results

When you dont do a medial epicanthoplasty with a double eyelid crease surgery you When you dont do a medial epicanthoplasty with a double eyelid crease surgery you sometimes can get tension mediallysometimes can get tension mediallyWhen the fold is greater than 4mm- 5mm high you can get a round eye deformity When the fold is greater than 4mm- 5mm high you can get a round eye deformity where there is tension at the epicanthal fold, increased vertical dimension yet where there is tension at the epicanthal fold, increased vertical dimension yet persistently short horizontally, and sometimes a started appearance. At this point you persistently short horizontally, and sometimes a started appearance. At this point you may want to consider an epicanthoplasty.may want to consider an epicanthoplasty.This is a sign of Asian eyelid surgery that is obvious, unnatural and should be This is a sign of Asian eyelid surgery that is obvious, unnatural and should be avoidedavoidedAlso in this picture the crease is tapered too aggressively at the lateral ends and Also in this picture the crease is tapered too aggressively at the lateral ends and because the crease is about 6mm high with the eyes open the transition to the medial because the crease is about 6mm high with the eyes open the transition to the medial canthus is also too abruptcanthus is also too abrupt

Epicanthoplasty and Past Procedures:

1. Complex incisions running in diverse directions2. Inability to incorporate the medial canthal incisions 3. Lack of clear landmarks / reference points to achieve desired flaps

There are many different approaches with the epicanthoplasty that included there There are many different approaches with the epicanthoplasty that included there problems:problems:

1. Complex incisions running in diverse directions1. Complex incisions running in diverse directions2. Inability to incorporate the medial canthal incisions 2. Inability to incorporate the medial canthal incisions 3. Lack of clear landmarks / reference points to achieve desired flaps3. Lack of clear landmarks / reference points to achieve desired flaps

Epicanthoplasty for the Asian Eye: More common method

The two most common methods today are the The two most common methods today are the Modified Uchida method and the park z epicanthoplasty which I like to useModified Uchida method and the park z epicanthoplasty which I like to useWhen I first started doing epicanthoplasty about 6 years ago I did a lot of research When I first started doing epicanthoplasty about 6 years ago I did a lot of research and observations and found that the park z was the most logical way to approach this and observations and found that the park z was the most logical way to approach this areaarea

Surgical Steps:1. Marking the crease2. Local anesthesia, iv sedation3. Skin incision /excision4. Opening of Orbital Septum5. Identifying the Levator.6. Formation of the crease, intraop confirmation,

skin levator traditional, orbicularis levator fixation technique

I will now go into the surgical steps of this procedure I will now go into the surgical steps of this procedure The most important thing in this procedure is marking the creaseThe most important thing in this procedure is marking the creaseI have 3 ways of doing it and I do this multiple times and compare with the other side I have 3 ways of doing it and I do this multiple times and compare with the other side to insure symmetryto insure symmetryIdentifying the levator is the next most important thing to doIdentifying the levator is the next most important thing to doAnd identifying the pre aponeurotic fat is paramount!!!And identifying the pre aponeurotic fat is paramount!!!I will then discuss the types of approaches to form the crease and to carry out the I will then discuss the types of approaches to form the crease and to carry out the medial epicanthoplastymedial epicanthoplasty

Mark the crease:-Medial Canthus: Inside or Outside-Consider Setting Crease Only-Taper towards medial for inside fold -Markings before your local: 3 ways to measure1.Grey line2.White line above lashes3.Elevating eyebrow and “eyeing” symmetry-Trust your markings

6-10 mm above ciliary margin can translate into 1-3mm pending skin removal

Tense skin to the point of lash eversion prior to marking. Be consistent

Blending it into med epi

Grey Line

I first remember to tense the skin and have the same amount of lash eversion on both I first remember to tense the skin and have the same amount of lash eversion on both sidessidesBased on my preoperative determination I have made my mark on where the crease Based on my preoperative determination I have made my mark on where the crease should beshould beI usually do not remove any skin and considering doing so only in an aged asian I usually do not remove any skin and considering doing so only in an aged asian blepharoplasty and when I do I’m very conservativeblepharoplasty and when I do I’m very conservativeThe markings are based on the grey line, the same transition point from the top of the The markings are based on the grey line, the same transition point from the top of the lashes and the white clearing above the lashes,lashes and the white clearing above the lashes,Lastly I do a visual inspection to see if the markings are symmetricalLastly I do a visual inspection to see if the markings are symmetricalSo I do 3 measurements. My measurements take about 30-45 minutes themselves.So I do 3 measurements. My measurements take about 30-45 minutes themselves.Also remember your crease has a tendency to relax 1-2 mm but more on the 1mm Also remember your crease has a tendency to relax 1-2 mm but more on the 1mm range there are ways to make sure it is tighterrange there are ways to make sure it is tighterWhat are the variables.What are the variables.

1 what technique you use1 what technique you use2. How much eversion on the lashes?2. How much eversion on the lashes?3 combining techniques for a tighter crease3 combining techniques for a tighter crease

Mark the crease:

Lash line white area

-The line is even from lateral canthus to the medial canthus with medial epicanthoplasty-tapered to the fold without medial epicanthoplasty-you will see a relaxed skin tension line that will guide you

I taper the markings for the crease towards the epicanthal fold, you should be able to I taper the markings for the crease towards the epicanthal fold, you should be able to see a relaxed skin tension line that directs you where to draw this linesee a relaxed skin tension line that directs you where to draw this lineThe height is even from 5mm lateral to the lateral canthus and to the medial limbusThe height is even from 5mm lateral to the lateral canthus and to the medial limbusIn other words, if the height is 8 mm from the grey line it will be 8mm at the lateral In other words, if the height is 8 mm from the grey line it will be 8mm at the lateral canthus from the grey line and 8mm from the grey line at the plane of the medial canthus from the grey line and 8mm from the grey line at the plane of the medial limbuslimbusIf you don’t do this your crease will not “appear” even as the crease should be even If you don’t do this your crease will not “appear” even as the crease should be even up until the medial limbus.up until the medial limbus.I then taper it from this medial limbus plane point to the epicanthal fold where it ends I then taper it from this medial limbus plane point to the epicanthal fold where it ends 5mm from the medial canthus5mm from the medial canthus

Of course patient preferences dominate your decision making ultimatelyOf course patient preferences dominate your decision making ultimately

Mark the crease:-Laterally is about 5mm lateral to lateral canthus-medially 5mm from medial canthus without medial epicanthoplasty-Point A medial point of lacrimal lake-Point B Transition to lower lid

-Point C perpendicular to margin -Point E Intersection of AE, CE, EB even-Point D medial mark of Point A

A

B

E

C

If I’m doing the epicanthoplasty, this is drawn firstIf I’m doing the epicanthoplasty, this is drawn firstWhen you stretch the medial canthus and skin of the upper eyelid medially you can When you stretch the medial canthus and skin of the upper eyelid medially you can continue the markings of the crease toward the medial canthus about where the continue the markings of the crease toward the medial canthus about where the lacrimal lake begins and it should maintain the height of the crease that you had lacrimal lake begins and it should maintain the height of the crease that you had throughout.throughout.This can then be tapered gradually to point CThis can then be tapered gradually to point CAs I mentioned there are multiple ways to do the epicanthoplastyAs I mentioned there are multiple ways to do the epicanthoplastyMy preferred method is the Park Z modified epicanthoplasty. I know Dr. Park and I My preferred method is the Park Z modified epicanthoplasty. I know Dr. Park and I talk to him from time to time.talk to him from time to time.This method is based on a flap transpositionThis method is based on a flap transpositionHere are the points that you need to mark for the medial epicanthoplastyHere are the points that you need to mark for the medial epicanthoplastyPoint A is the medial most point of the lacrimal lake’s skin surface representationPoint A is the medial most point of the lacrimal lake’s skin surface representationPoint B is the transition of the epicanthal fold to the lower lidPoint B is the transition of the epicanthal fold to the lower lidPoint C is the extension that meets with the crease and is draw perpendicular to the Point C is the extension that meets with the crease and is draw perpendicular to the tarsal plate and is usually in a straight line from the B to Atarsal plate and is usually in a straight line from the B to APoint D is the other side of A. Point D is the other side of A. A and D are the most important you can skew this based on how you do the pinching A and D are the most important you can skew this based on how you do the pinching of your pickupof your pickupPoint E is variable and it really is the point where A gradually transitions into the the Point E is variable and it really is the point where A gradually transitions into the the line CEline CENotice that the spacing is even from AE and from CENotice that the spacing is even from AE and from CE

Modified Z epicanthoplasty:-C extension 90° as opposed to 45 ° relative to palpebral fold

EC parallel to supratarsal fold

-Avoids redundancy of the supratarsal fold at the medial canthal area

This procedure use to be done where C Formed an angle from BACThis procedure use to be done where C Formed an angle from BACAs I said the line BAC really is almost a straight lineAs I said the line BAC really is almost a straight lineThis modification avoids skin redundancy in the medial canthal areaThis modification avoids skin redundancy in the medial canthal area

Park’s Z epicanthoplasty: B: fold transition to lower lid

C: eyelid nasal junction

A: medial most lac lake

BD=AB=AC

E,B can be arbitrary

D: medial lac lake coinciding with A

Here is a review of the pointsHere is a review of the pointsNote importantly Note importantly BD=AB=ACBD=AB=AC

Mark the crease:

Visual inspect the markings to ensure symmetry

Again you want to visually inspect the drawingsAgain you want to visually inspect the drawingsSometimes in my mind I might notice that one eyebrow is lower than the other or one Sometimes in my mind I might notice that one eyebrow is lower than the other or one crease is lower than the other in the case where the fold is too low andcrease is lower than the other in the case where the fold is too low andIn this situation I may want to make the incision at the top of the thin line on one side In this situation I may want to make the incision at the top of the thin line on one side and bottom on the other side to try to make it evenand bottom on the other side to try to make it evenI do this only when I’m sure that there is some asymmetry that might be improved a I do this only when I’m sure that there is some asymmetry that might be improved a little with thislittle with thisIt probably doesn’t have a lot of an effectIt probably doesn’t have a lot of an effectPoint C should not encroach on the nasal skin or you will have more chance of Point C should not encroach on the nasal skin or you will have more chance of scarringscarring

Surgery:-Lidocaine 1% with epi 1-2 cc max-1cc better-Marcaine 0.5-1.0% is an option-Always start with medial epicanthoplasty-First incision from BD-then ABC

-EAC is removed incrementally, Classically it is totally removed-Total removal of EAC tapers the crease to the med canthus

I do the medial epicanthoplasty firstI do the medial epicanthoplasty firstI use the least amount of local necessary to make the area numb and not distort I use the least amount of local necessary to make the area numb and not distort thingsthingsFirst incision is BD with a 15 bladeFirst incision is BD with a 15 bladeThen ABCThen ABCYou can decide later how far to take C to EYou can decide later how far to take C to EThe key stitch is from A to D Make sure with the drawing that they are close together The key stitch is from A to D Make sure with the drawing that they are close together so when you actually have to sewn them together there is not tensionso when you actually have to sewn them together there is not tensionA to D stich will help with moving triangle ABD to the space made up by ECAA to D stich will help with moving triangle ABD to the space made up by ECAECA is excised traditionally but I incrementally remove this to make sure I don’t take ECA is excised traditionally but I incrementally remove this to make sure I don’t take too muchtoo muchAfter this is done I then continue with the Crease forming procedureAfter this is done I then continue with the Crease forming procedureSome inject steroids into the medial canthal area and epicanthoplasty and eyelid Some inject steroids into the medial canthal area and epicanthoplasty and eyelid crease forming procedural areas, I don’t like to do this because I think it affects crease forming procedural areas, I don’t like to do this because I think it affects healing and the tissues to heal together by the time you remove sutures.healing and the tissues to heal together by the time you remove sutures.

I think one of the most important markings is A and D depending on how you orient I think one of the most important markings is A and D depending on how you orient your pickup you could be producing a future tension point.your pickup you could be producing a future tension point.So make sure the A point is directly above the D pointSo make sure the A point is directly above the D point

Also don’t keep taking D further to the corner and create more future tensionAlso don’t keep taking D further to the corner and create more future tension

Skin incision /excision:-Orbital septum inserts 2-4 mm above superior tarsal border or half way down, don’t cut LA-Conservative on skin excision always, option for future resection if needed

Usually excise at least twice for what you want to increase for the crease

Small Lid 2-3mmMedium ½ maxLarge 2-3mm < max

After the medial epicanthoplasty, I make the incision for the crease formationAfter the medial epicanthoplasty, I make the incision for the crease formationIn the aged asian eyelid some say that:In the aged asian eyelid some say that:For a Small Lid 2-3mmFor a Small Lid 2-3mmFor a Medium ½ maxFor a Medium ½ maxFor a Large 2-3mm < maxFor a Large 2-3mm < max

This means maximum that you can pinch with the pinch techniqueThis means maximum that you can pinch with the pinch techniqueAfter determining where you want your crease set you can assess how much skin to After determining where you want your crease set you can assess how much skin to take in your preoperative assessmenttake in your preoperative assessmentYou need to take at least 2 times what you want to increase the height of the upper You need to take at least 2 times what you want to increase the height of the upper eyelid creaseeyelid creaseWhen the crease setting point during your initial preoperative marking and When the crease setting point during your initial preoperative marking and determination starts to get to be greater than 9-10mm above the grey line, you may determination starts to get to be greater than 9-10mm above the grey line, you may wish to start considering to take out some skin to get greater pretarsal showwish to start considering to take out some skin to get greater pretarsal showIn general be conservative in your skin excisionIn general be conservative in your skin excision

Opening of Orbital Septum

Preaponeurotic fat

Leave 3-5 mm orbicularis inferior edge

-Done under IV Sedation to help identify the levator-Important to get down to the right layer-Helps to keep crease consistent

You have to identify the levator aponeurosis and this is very important that you don’t You have to identify the levator aponeurosis and this is very important that you don’t go too deep and injure the levatorgo too deep and injure the levatorI do this procedure with mild sedation to have them open their eyelids to find it betterI do this procedure with mild sedation to have them open their eyelids to find it betterThere are many fibers and undefined layers before you get thereThere are many fibers and undefined layers before you get thereI leave 1-5mm of orbicularis at the inferior edgeI leave 1-5mm of orbicularis at the inferior edgeUnderstand that in the Asian eyelid eyelid tissue is thicker and it may take some time Understand that in the Asian eyelid eyelid tissue is thicker and it may take some time to get down to the right layerto get down to the right layerWhat is consistent is the pre aponeurotic fat What is consistent is the pre aponeurotic fat Be careful of the fatty levator aponeurosis and other layers of the Asian eyelid that Be careful of the fatty levator aponeurosis and other layers of the Asian eyelid that tend to be fatty that can confuse youtend to be fatty that can confuse you

Why is this important, I think finding the right layer helps with achieving a consistent Why is this important, I think finding the right layer helps with achieving a consistent creasecrease

Fear will keep you from getting down to the right layerFear will keep you from getting down to the right layer

Often during this dissection I find that I can be following the orbital septum to a Often during this dissection I find that I can be following the orbital septum to a deeper layerdeeper layerThe separation is clear and if the anatomy is obscure you are probably in the wrong The separation is clear and if the anatomy is obscure you are probably in the wrong layerlayerI usually completely expose the pre aponeurotic fat to get to the right layer I usually completely expose the pre aponeurotic fat to get to the right layer I don’t want any think fascia covering the fat and keeping me from the right layerI don’t want any think fascia covering the fat and keeping me from the right layer

Puffy Eyelid:Muscular hypertrophy

Retromuscular Fat

Pretarsaltissue

Preaponeurotic Fat

Peri-incisional

Avoid hollow look and multiple supratarsal creases

There are multiple papers on resecting tissue to debulk the Asian eyelidThere are multiple papers on resecting tissue to debulk the Asian eyelidI don’t agree with them and don’t resect any tissue other than a conservative skin I don’t agree with them and don’t resect any tissue other than a conservative skin resectionresectionI always have the option of doing a little more skin later to get it right and I explain this I always have the option of doing a little more skin later to get it right and I explain this to the patientto the patientResecting tissue leads to problems: hollow eye, multiple creases, asymmetric Resecting tissue leads to problems: hollow eye, multiple creases, asymmetric creases, abnormal adhesionscreases, abnormal adhesions

Excise 1-2 mm of Pretarsal Orbicularis along lower skin edge

-Pretarsal excision:Risks multiple creases*Tension on pretarsal skin-Pretarsal bulging: *Sign of surgery*Natural element in Asians

-Alternative: undermine pretarsal region several mm, longer recovery?

Leads to depression / improvement of scar

People have advocated resecting muscle at the inferior edge, this doesn’t help in my People have advocated resecting muscle at the inferior edge, this doesn’t help in my opinionopinionI don’t undermine the pretarsal area as some do, scarring, bulging, longer recovery I don’t undermine the pretarsal area as some do, scarring, bulging, longer recovery and other complications are associated with thisand other complications are associated with thisSo in short don’t undermine the pretarsal areaSo in short don’t undermine the pretarsal area

6. Formation of the crease:

-6-0 silk, prolene or nylon-Levator Apo, Tarsus, SubQ of upper / lower skin edges-Creation of outside fold: tack lower skin edge to canthal ligament by exposing LA fully-Orbicularis Levator Fixation

Sutures placed medial to lateral, interrupted

2 main open technique in my opinion2 main open technique in my opinion1. Dermal fixation where in your closure you catch the levator either all the way 1. Dermal fixation where in your closure you catch the levator either all the way across or at defined pointsacross or at defined pointsThis is based on scar tissue creating the creaseThis is based on scar tissue creating the crease>95% surgeons do this and it has been successful over many years>95% surgeons do this and it has been successful over many years

2.2. Orbicularis Fixation Technique is a technique where the orbicularis is attached to the Orbicularis Fixation Technique is a technique where the orbicularis is attached to the levator and the sutures here are left inlevator and the sutures here are left inWhy can this work? Because the orbicularis is tightly associated with the pretarsal Why can this work? Because the orbicularis is tightly associated with the pretarsal skin and it is essentially like tacking the skin to the levatorskin and it is essentially like tacking the skin to the levator

I do both methods but prefer the orbicularis fixation techniqueI do both methods but prefer the orbicularis fixation technique

The way you do this is by using a suture to grab the orbicularis even catching some The way you do this is by using a suture to grab the orbicularis even catching some dermis and then suturing this to the levatordermis and then suturing this to the levatorOften you can grab 3-5mm of levator and then tying the suture needs to be Often you can grab 3-5mm of levator and then tying the suture needs to be incrementalincrementalYou should try to achieve the same lash eversion on both sides.You should try to achieve the same lash eversion on both sides.

You get relaxation with both approaches, maybe even more with the orbicularis You get relaxation with both approaches, maybe even more with the orbicularis fixationfixationYou can combine the techniques for a tighter deeper creaseYou can combine the techniques for a tighter deeper crease

6. Formation of the crease:

1. Midway from medial canthus to medial limbus

2. Med limbus3. Pupillary plane4. Lat limbus5. Midway lat limbus

to lateral canthus6. Incorporating

skin?7. More crease

forming sutures?

Sutures placed medial to lateral, interrupted

The crease forming sutures are placed at least in these areas:The crease forming sutures are placed at least in these areas:1.1. Midway from medial canthus to medial limbusMidway from medial canthus to medial limbus2.2. Med limbusMed limbus3.3. Pupillary planePupillary plane4.4. Lat limbusLat limbus5.5. Midway lat limbus to lateral canthusMidway lat limbus to lateral canthus

There are some cases where I think I need to do more I will place some more in There are some cases where I think I need to do more I will place some more in between these key areas:between these key areas:Revision cases where the creases have come undone or are not evenRevision cases where the creases have come undone or are not evenTo make the crease even stronger I consider adding dermal levator fixation sutures To make the crease even stronger I consider adding dermal levator fixation sutures with the closure as wellwith the closure as well

More simply place one every 5mm and make it easier for yourself More simply place one every 5mm and make it easier for yourself

Preventing Complications:-Blepharoptosis: levator, muller’s muscle,

Wait at least 6 months -Must ensure symmetry with markings, dissect in exact planes, resect identical amounts of skin, muscle, fat-Measure and measure again, note preop asymmetries, assess intraoperatively-Pretarsal edema: can last 6 mo-Multiple key sutures prevent discontinuous creases-Overresecting fat: unwanted adhesions, supratarsal depressions, scarring

Here are some post operative keys as well as some things to think about when it Here are some post operative keys as well as some things to think about when it comes to complications:comes to complications:-Ptosis, this can happen very commonly and will get better over the next 6 months. I -Ptosis, this can happen very commonly and will get better over the next 6 months. I would not do anything for at least 6 monthswould not do anything for at least 6 months-markings are the key to getting symmetry-markings are the key to getting symmetry-Be compulsive about getting the markings exact-Be compulsive about getting the markings exact-the pretarsal edema can last for 3-6 months. Sometimes steroid injections can help -the pretarsal edema can last for 3-6 months. Sometimes steroid injections can help like 0.05-0.1 kenalog 10mg/ml be conservativelike 0.05-0.1 kenalog 10mg/ml be conservative-avoid resecting too much tissue-avoid resecting too much tissue

But be careful injecting steroids as depending on the person you can really lead to But be careful injecting steroids as depending on the person you can really lead to tissue degeneration and thinning to concavitytissue degeneration and thinning to concavityI haven’t had this but when I talked to Dr. Park he was very anxious about this subjectI haven’t had this but when I talked to Dr. Park he was very anxious about this subject

10mg/ml kenalog and use like 0.05 more or less10mg/ml kenalog and use like 0.05 more or lessAlways better injecting lessAlways better injecting less

Spaced 4-6 weeks apartSpaced 4-6 weeks apart

Long term postop

Immediate postop

Here are some post op photosHere are some post op photosImmediate post operatively from a crease forming procedure, and medial Immediate post operatively from a crease forming procedure, and medial canthoplastycanthoplastyAnd the long term postopAnd the long term postop

Long term postop

Preoperative

This is the same girl showing what she looks like preoperativelyThis is the same girl showing what she looks like preoperativelyNotice how her eyelid skin is encroaching over her eyelid margin making her eyes Notice how her eyelid skin is encroaching over her eyelid margin making her eyes that much smallerthat much smaller

The above before and after is with just a crease forming procedureThe above before and after is with just a crease forming procedureThe below picture is with a medial epicanthoplasty as wellThe below picture is with a medial epicanthoplasty as well

This is another before and after of an asian blepharoplasty double eyelid procedure This is another before and after of an asian blepharoplasty double eyelid procedure without a medial epicanthoplasty. I think she would have looked a lot better with the without a medial epicanthoplasty. I think she would have looked a lot better with the epicanthal folds treatedepicanthal folds treated

Asian Blepharoplasty in the Caucasian Pt:

Here is how you can improve a caucasian eyelid with a crease forming procedure Here is how you can improve a caucasian eyelid with a crease forming procedure with removing some of the skin as well.with removing some of the skin as well.