This document summarizes key steps in performing Asian blepharoplasty and epicanthoplasty procedures. It discusses assessing patients to determine desired outcomes, marking the eyelid crease precisely using three measurement techniques, identifying important anatomical structures like the levator muscle and pre-aponeurotic fat, and performing skin excision and crease formation while avoiding complications. Epicanthal folds are classified and it is noted that combining double eyelid surgery with epicanthoplasty provides better cosmetic results by revealing more of the eye area.

1. Asian Blepharoplasty
Philip A Young, MD
Aesthetic Facial Plastic Surgery, PLLC
Face to Face
Ho Chi Minh City, Vietnam 2014

2. This talk is on Asian BlepharoplastyThis talk is on Asian Blepharoplasty
I will take about creating the double eyelidI will take about creating the double eyelid
crease and my experience with treatingcrease and my experience with treating
the epicanthal foldthe epicanthal fold

3. Preoperative assessment:
1. Single Eyelid
Crease
2. Epicanthal Folds
3. Asian or
Westernization
4. Physiognomy,
deference to
surgeons,
communication
5. Personal
Assessment:
wire, image,
desires

4. The Asian Eyelid can sometimes be characterized and identified as eyelids that haveThe 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 folds
You can treat each one separately but most of the time you are doing the eyelidYou 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 folds
Most surgeons falsely think that asians want to look caucasian when in fact mostMost 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 eyes
This occurs 95% percent of the time in my population IN AMERICAThis occurs 95% percent of the time in my population IN AMERICA
Physiognomy is the belief that a certain appearance of the body part will impartPhysiognomy is the belief that a certain appearance of the body part will impart
fortune for the person, ie large earlobes = money, nostrils showing = losing moneyfortune for the person, ie large earlobes = money, nostrils showing = losing money
from your nose, etcfrom your nose, etc
Asians are also less likely to tell you what they really want although they are gettingAsians 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 states
There are many different way to assess what a patient wants. I use a lacrimal probeThere 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 almost00 01 small to determine where they want the crease and I use a very fine almost
needle like marking pendneedle like marking pend
I 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 bleeds
Sometimes I will use 2 probes to entertain unique preferences like a fold that is higherSometimes I will use 2 probes to entertain unique preferences like a fold that is higher
medial versus laterallymedial 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 flag
Most of the time you get some relaxation of the crease so you have to understandMost 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 therethat 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 generalare 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

5. 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?)

6. You should ask them whether want an inside fold or outside foldYou should ask them whether want an inside fold or outside fold
The outside fold is less common than the inside fold. Some feel this is more of aThe 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 iscaucasian conformation and could make your results look operated on. This is
something to discuss with your patientssomething to discuss with your patients
We discuss how how they want the fold and we discuss and show them what it wouldWe 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 altered
I worry when patients want their folds too high, anything over 3mm may not beI 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 theyconsidered 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 Asian
I 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)

8. The Single Eyelid Crease is due to a variable extent of the post septal fat reaching inThe Single Eyelid Crease is due to a variable extent of the post septal fat reaching in
front of the tarsal platefront of the tarsal plate
It 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 anatomy
This would be bad to cut through the levator and correctable intraoperatively butThis 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 thanBe 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!!

9. 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

10. Epicanthal folds are extra skin, muscle, fat, tissue at the medial canthusEpicanthal folds are extra skin, muscle, fat, tissue at the medial canthus
It 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 bridge
It can obscure the lacrimal lake variably and make the person seem to have narrowIt 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

11. 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

12. There are four types of epicanthal foldsThere are four types of epicanthal folds
1.1.The caucasian type where there is no epicanthal foldThe caucasian type where there is no epicanthal fold
2.2.Type 2 where there is a small amount of the lacrimal lake showingType 2 where there is a small amount of the lacrimal lake showing
3.3.Type 3 where all of the lacrimal lake is blocked from viewType 3 where all of the lacrimal lake is blocked from view
4.4.Type 4 where most of the fold is coming from the lower lid in some congenitalType 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.

13. 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

14. When you dont do a medial epicanthoplasty with a double eyelid crease surgery youWhen you dont do a medial epicanthoplasty with a double eyelid crease surgery you
sometimes can get tension mediallysometimes can get tension medially
When the fold is greater than 4mm- 5mm high you can get a round eye deformityWhen 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 yetwhere there is tension at the epicanthal fold, increased vertical dimension yet
persistently short horizontally, and sometimes a started appearance. At this point youpersistently 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 beThis is a sign of Asian eyelid surgery that is obvious, unnatural and should be
avoidedavoided
Also in this picture the crease is tapered too aggressively at the lateral ends andAlso 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 medialbecause the crease is about 6mm high with the eyes open the transition to the medial
canthus is also too abruptcanthus is also too abrupt

15. Epicanthoplasty
and Past
Procedures:
1. Complex incisions
running in diverse
directions
2. Inability to incorporate
the medial canthal
incisions
3. Lack of clear
landmarks / reference
points to achieve
desired flaps

16. There are many different approaches with the epicanthoplasty that included thereThere are many different approaches with the epicanthoplasty that included there
problems:problems:
1. Complex incisions running in diverse directions1. Complex incisions running in diverse directions
2. Inability to incorporate the medial canthal incisions2. 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

17. Epicanthoplasty for the
Asian Eye: More common method

18. The two most common methods today are theThe 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 use
When I first started doing epicanthoplasty about 6 years ago I did a lot of researchWhen 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 thisand observations and found that the park z was the most logical way to approach this
areaarea

19. Surgical Steps:
1. Marking the crease
2. Local anesthesia, iv sedation
3. Skin incision /excision
4. Opening of Orbital Septum
5. Identifying the Levator.
6. Formation of the crease, intraop confirmation,
skin levator traditional, orbicularis levator fixation
technique

20. I will now go into the surgical steps of this procedureI 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 crease
I have 3 ways of doing it and I do this multiple times and compare with the other sideI have 3 ways of doing it and I do this multiple times and compare with the other side
to insure symmetryto insure symmetry
Identifying the levator is the next most important thing to doIdentifying the levator is the next most important thing to do
And 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 theI will then discuss the types of approaches to form the crease and to carry out the
medial epicanthoplastymedial epicanthoplasty

21. 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 measure
1.Grey line
2.White line above lashes
3.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

22. I first remember to tense the skin and have the same amount of lash eversion on bothI first remember to tense the skin and have the same amount of lash eversion on both
sidessides
Based on my preoperative determination I have made my mark on where the creaseBased on my preoperative determination I have made my mark on where the crease
should beshould be
I usually do not remove any skin and considering doing so only in an aged asianI 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 conservative
The markings are based on the grey line, the same transition point from the top of theThe 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 symmetrical
So 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 1mmAlso 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 tighter
What are the variables.What are the variables.
1 what technique you use1 what technique you use
2. 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

23. 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

24. I taper the markings for the crease towards the epicanthal fold, you should be able toI 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 line
The 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 limbus
In other words, if the height is 8 mm from the grey line it will be 8mm at the lateralIn 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 medialcanthus from the grey line and 8mm from the grey line at the plane of the medial
limbuslimbus
If you don’t do this your crease will not “appear” even as the crease should be evenIf 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 endsI 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

25. 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

26. If I’m doing the epicanthoplasty, this is drawn firstIf I’m doing the epicanthoplasty, this is drawn first
When you stretch the medial canthus and skin of the upper eyelid medially you canWhen 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 thecontinue 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 hadlacrimal 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 C
As I mentioned there are multiple ways to do the epicanthoplastyAs I mentioned there are multiple ways to do the epicanthoplasty
My preferred method is the Park Z modified epicanthoplasty. I know Dr. Park and IMy 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 transposition
Here are the points that you need to mark for the medial epicanthoplastyHere are the points that you need to mark for the medial epicanthoplasty
Point 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 representation
Point B is the transition of the epicanthal fold to the lower lidPoint B is the transition of the epicanthal fold to the lower lid
Point C is the extension that meets with the crease and is draw perpendicular to thePoint 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 A
Point 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 pinchingA and D are the most important you can skew this based on how you do the pinching
of your pickupof your pickup
Point E is variable and it really is the point where A gradually transitions into the thePoint E is variable and it really is the point where A gradually transitions into the the
line CEline CE
Notice that the spacing is even from AE and from CENotice that the spacing is even from AE and from CE

27. 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

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

29. 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

30. Here is a review of the pointsHere is a review of the points
Note importantlyNote importantly BD=AB=ACBD=AB=AC

31. Mark the crease:
Visual inspect the markings to
ensure symmetry

32. Again you want to visually inspect the drawingsAgain you want to visually inspect the drawings
Sometimes in my mind I might notice that one eyebrow is lower than the other or oneSometimes 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 and
In this situation I may want to make the incision at the top of the thin line on one sideIn 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 even
I do this only when I’m sure that there is some asymmetry that might be improved aI do this only when I’m sure that there is some asymmetry that might be improved a
little with thislittle with this
It probably doesn’t have a lot of an effectIt probably doesn’t have a lot of an effect
Point C should not encroach on the nasal skin or you will have more chance ofPoint C should not encroach on the nasal skin or you will have more chance of
scarringscarring

33. 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

34. I do the medial epicanthoplasty firstI do the medial epicanthoplasty first
I use the least amount of local necessary to make the area numb and not distortI use the least amount of local necessary to make the area numb and not distort
thingsthings
First incision is BD with a 15 bladeFirst incision is BD with a 15 blade
Then ABCThen ABC
You can decide later how far to take C to EYou can decide later how far to take C to E
The key stitch is from A to D Make sure with the drawing that they are close togetherThe 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 tension
A 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 ECA
ECA is excised traditionally but I incrementally remove this to make sure I don’t takeECA is excised traditionally but I incrementally remove this to make sure I don’t take
too muchtoo much
After this is done I then continue with the Crease forming procedureAfter this is done I then continue with the Crease forming procedure
Some inject steroids into the medial canthal area and epicanthoplasty and eyelidSome 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 affectscrease 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 orientI 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

35. 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 2-3mm
Medium ½ max
Large 2-3mm < max

36. After the medial epicanthoplasty, I make the incision for the crease formationAfter the medial epicanthoplasty, I make the incision for the crease formation
In the aged asian eyelid some say that:In the aged asian eyelid some say that:
For a Small Lid 2-3mmFor a Small Lid 2-3mm
For a Medium ½ maxFor a Medium ½ max
For 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 technique
After determining where you want your crease set you can assess how much skin toAfter determining where you want your crease set you can assess how much skin to
take in your preoperative assessmenttake in your preoperative assessment
You need to take at least 2 times what you want to increase the height of the upperYou need to take at least 2 times what you want to increase the height of the upper
eyelid creaseeyelid crease
When the crease setting point during your initial preoperative marking andWhen 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 maydetermination 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 show
In general be conservative in your skin excisionIn general be conservative in your skin excision

37. 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

38. You have to identify the levator aponeurosis and this is very important that you don’tYou 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 levator
I 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 better
There are many fibers and undefined layers before you get thereThere are many fibers and undefined layers before you get there
I leave 1-5mm of orbicularis at the inferior edgeI leave 1-5mm of orbicularis at the inferior edge
Understand that in the Asian eyelid eyelid tissue is thicker and it may take some timeUnderstand 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 layer
What is consistent is the pre aponeurotic fatWhat is consistent is the pre aponeurotic fat
Be careful of the fatty levator aponeurosis and other layers of the Asian eyelid thatBe 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 consistentWhy 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 aOften during this dissection I find that I can be following the orbital septum to a
deeper layerdeeper layer
The separation is clear and if the anatomy is obscure you are probably in the wrongThe separation is clear and if the anatomy is obscure you are probably in the wrong
layerlayer
I usually completely expose the pre aponeurotic fat to get to the right layerI 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

39. Puffy Eyelid:
Muscular
hypertrophy
Retro
muscular
Fat
Pretarsal
tissue
Preaponeurotic
Fat
Peri-incisional
Avoid hollow look and
multiple supratarsal
creases

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

41. 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

42. People have advocated resecting muscle at the inferior edge, this doesn’t help in myPeople have advocated resecting muscle at the inferior edge, this doesn’t help in my
opinionopinion
I don’t undermine the pretarsal area as some do, scarring, bulging, longer recoveryI 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 this
So in short don’t undermine the pretarsal areaSo in short don’t undermine the pretarsal area

43. 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

44. 2 main open technique in my opinion2 main open technique in my opinion
1. Dermal fixation where in your closure you catch the levator either all the way1. Dermal fixation where in your closure you catch the levator either all the way
across or at defined pointsacross or at defined points
This 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 theOrbicularis 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 in
Why can this work? Because the orbicularis is tightly associated with the pretarsalWhy 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 someThe 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 levator
Often you can grab 3-5mm of levator and then tying the suture needs to beOften you can grab 3-5mm of levator and then tying the suture needs to be
incrementalincremental
You 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 orbicularisYou get relaxation with both approaches, maybe even more with the orbicularis
fixationfixation
You can combine the techniques for a tighter deeper creaseYou can combine the techniques for a tighter deeper crease

45. 6. Formation of the crease:
1. Midway from
medial canthus to
medial limbus
2. Med limbus
3. Pupillary plane
4. Lat limbus
5. Midway lat limbus
to lateral canthus
6. Incorporating
skin?
7. More crease
forming sutures?
Sutures placed medial to
lateral, interrupted

46. 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 limbus
2.2. Med limbusMed limbus
3.3. Pupillary planePupillary plane
4.4. Lat limbusLat limbus
5.5. 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 inThere 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 even
To make the crease even stronger I consider adding dermal levator fixation suturesTo 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 yourselfMore simply place one every 5mm and make it easier for yourself

47. 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

48. Here are some post operative keys as well as some things to think about when itHere 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 toBut be careful injecting steroids as depending on the person you can really lead to
tissue degeneration and thinning to concavitytissue degeneration and thinning to concavity
I 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 less
Always better injecting lessAlways better injecting less
Spaced 4-6 weeks apartSpaced 4-6 weeks apart

49. Long term postop
Immediate postop

50. Here are some post op photosHere are some post op photos
Immediate post operatively from a crease forming procedure, and medialImmediate post operatively from a crease forming procedure, and medial
canthoplastycanthoplasty
And the long term postopAnd the long term postop

51. Long term postop
Preoperative

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

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

56. This is another before and after of an asian blepharoplasty double eyelid procedureThis 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 thewithout a medial epicanthoplasty. I think she would have looked a lot better with the
epicanthal folds treatedepicanthal folds treated

57. Asian Blepharoplasty in the Caucasian Pt:

58. Here is how you can improve a caucasian eyelid with a crease forming procedureHere 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.