Case Studies in Asian Blepharoplasty

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1 Aesthetic Surgery Journal XX(X) Takayanagi INTERNATIONAL CONTRIBUTION Oculoplastic Surgery Review Article Case Studies in Asian Blepharoplasty Aesthetic Surgery Journal 31(2) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Susumu Takayanagi, MD Abstract Many techniques have been reported for rejuvenation of the upper eyelids. As the facial structure and skin of Asians differ from those of other races and nationalities (specifically, Caucasians), the operative strategy and technique for treating these patients should take into account their specific anatomy. In this article, the author illustrates his techniques for Asian blepharoplasty (including skin-muscle resection, subeybrow resection, filler or fat injections, double eyelid procedures, block fat grafting, and/or levator shortening), concluding that thorough preoperative evaluation and proper technique selection are key for successful results. Keywords blepharoplasty, oculoplastics, fat grafting, ptosis Accepted for publication May 26, Multiple deformities may occur as a result of aging in the upper eyelid. These deformities include sagging eyelid skin, the sunken-eye deformity, and ptosis. Preferred techniques for treating these facial changes include skinmuscle resection, subeyebrow excision, fat injection, the double-eyelid procedure, block fat grafting, and levator shortening. When treating the upper eyelids of Asian patients, it is important to take into account their unique anatomy when performing the preoperative evaluation and selecting from among the available treatments. Subeyebrow Resection The postoperative eyelid contour desired by the patient determines how much tissue should be removed and, therefore, which procedure is appropriate. With the patient in the upright position, in front of a mirror, the surgeon should slowly push the eyebrow superiorly with his or her fingers until the eyelid (or the double eyelid) reaches the desired shape, as specified by the patient. When the eyebrow is released, it will move downward again; the preoperative position should be marked and the distance between the preoperative and postoperative location can thus be specified. The required skin excision should be calculated as twice the measured distance plus 1 mm when the eyelid skin is thin or plus 2 mm when the skin is thick (Figure 1A,B). If the amount of skin excision is 7 mm or less, resection of skin and orbicularis oculi muscle is appropriate. The new double eyelid is formed by placing an incision superior and very slightly inferior to the original double eyelid line. 1-3 In Asian eyelids, there are often wrinkles or areas of skin redundancy inferior to the double eyelid; this part of the skin should be stretched by excising a small amount of skin immediately inferior to the original double eyelid line. The width between these two incisions is the area in which the eyelid skin should be removed (Figure 2). If the width of the area to be removed is more than 7 mm, the skin just above the newly-formed double eyelid will appear bulky, swollen, and unnatural since the skin in the upper eyelid region of Asian patients is always thicker than the inferior eyelid skin. 3 To avoid this type of result, it is preferable to remove the skin just beneath the eyebrow when the sagging deformity of the upper eyelid is Dr. Takayanagi is a plastic surgeon in private practice in Osaka, Japan. Corresponding Author: Dr. Susumu Takayanagi, Mega Clinic, Higashinakajima, Higashiyodogawa-ku, Osaka , Japan. info@mega-clinic.com

2 172 Aesthetic Surgery Journal 31(2) Figure 1. (A) A tape measure is fixed to the double eyelid line. (B) As the surgeon pushes the eyebrow superiorly, the margin of the double eyelid is lifted and the postoperative result can be estimated. By keeping the tape measure in the original fixed position, the distance of the movement of the double eyelid line can also be accurately measured. Original double eyelid Superior incision Figures 3 to 7 show the clinical results of patients who have undergone this type of subeyebrow resection in the author s clinic, including those whose results appeared swollen (Figures 5 and 6). Fat Injection inferior incision Figure 2. The inferior incision should be placed slightly inferior to the original double eyelid line, to stretch the skin below the new double eyelid line. severe. 3 However, as the quality of the skin differs from patient to patient, this may result in a visible under-eyelid scar. Patients who are particularly prone to this type of scarring are those with dark and/or dry skin, atopic dermatitis, or asthma. When planning scar location, it is also important to evaluate patients for a tendency toward pigmentation or hypertrophic scarring 1 by examining existing scars on the patient s body (including those on the face). Patients who have this tendency are not good candidates for subeyebrow incision. To ensure precision and an accurate result, it is preferable to place the patient in an upright (sitting) position during surgery. The wound is tentatively closed to check its shape (and the width of the new double eyelid), as the eyebrow may move slightly downward after skin excision and suture. If the skin elevation is insufficient, the suture can be removed, and further excision can be carried out to obtain the desired result. Fat injection can be an effective treatment for the sunken eyelid deformity, but no more than 1 ml of material should be injected into the upper eyelid area since complications such as cyst formation, surface irregularities, and increased reabsorption of the fatty tissue may occur. 4 Underfilling is preferable to overfilling, since touch-ups can be performed in an additional session one to two months after the initial injection if the area becomes flat or convex. The ideal method for obtaining fat is through an 18-gauge needle or cannula from the abdominal fat via the umbilicus. The fat is then injected (also through an 18-gauge cannula) beneath the orbicularis oculi muscle, with special care taken not to overlap the injection sites and not to inject the filler deep into the eyelid. The injection site can be closed with one 7-0 nylon stitch; the area should also be massaged immediately postinjection to ensure a smooth result. Figures 8 and 9 show the clinical results of patients who have undergone this type of fat injection in the author s clinic. Double Eyelid Procedure Skin-muscle resection can not only remove lid redundancy and form a double eyelid, but also help to correct a sunken eye deformity. The double-folded skin will push up the surface of the eyelid, which may also remedy a sunken eyelid. 1,4,5 Since the upper eyelid skin in patients who need rejuvenation is generally heavy and ptotic, both patient and

3 Takayanagi 173 Figure 3. (A) This 51-year-old woman presented with a concern of overlying eyelid skin above her double eyelid crease. Her diagnosis was dermatochalasis of the upper eyelids. (B) The width of the planned excision was 3 mm. The blue line shows the patient s original double eyelid line. (C) Five months after skin-muscle excision, including the original double eyelid. Her postoperative result appeared natural and she experienced no complications. Figure 4. (A) This 67-year-old woman presented with dermatochalasis of her upper eyelids. The width of the planned excision was 6 mm. (B) Eight months after skin-muscle excision, including the original double eyelid and the underlying orbicularis oculi muscle. The postoperative appearance was natural and the patient was satisfied with the result.

4 174 Aesthetic Surgery Journal 31(2) Figure 5. (A) This 59-year-old woman presented with dermatochalasis of her upper eyelids, along with pseudoptosis. A 9-mm skin-muscle resection was planned. (B) Six months after skin-muscle excision, including the original double eyelid. This patient s postoperative result had a slightly unnatural appearance, as the skin just above the new double eyelid was slightly bulky. Care should be taken with this type of patient, who may be best suited for another technique. Figure 6. (A) This 63-year-old woman presented with dermatochalasis of her upper eyelids, along with pseudoptosis. (B) A 10-mm skin-muscle resection was planned to correct the ptotic upper eyelid. (C) Nine months after skin-muscle excision, the patient demonstrates an unnatural and puffy eyelid skin just above the double eyelid. Care should be taken with this type of patient, who may be best suited for another technique.

5 Takayanagi 175 Figure 7. (A) This 68-year-old man presented with dermatochalasis of his upper eyelids, along with pseudoptosis. (B) It was estimated that more than 6 to 7 mm of skin excision would be required to solve the problem, so an 11-mm resection of the skin was planned along the subeyebrow line. (C) Four months after skin-muscle excision, the patient s result was natural without any complications. Figure 8. (A) This 39-year-old woman presented with sunken eye deformity. The patient s eyelid crease was shallow. (B) Immediately after the third session of fat injection, the patient was satisfied with the results.

6 176 Aesthetic Surgery Journal 31(2) Figure 9. (A) This 31-year-old woman presented with unilateral sunken eye deformity and a shallow crease on her right upper eyelid. (B) Four months after fat injection, the patient s eyelid is flat and symmetrical. Only one session was necessary to correct the deformity. Figure 10. (A) This 40-year-old woman presented with a single Asian eyelid appearance. She desired a more youthful upper lid. (B) Five months after treatment with a double eyelid incision technique. The width of the skin-muscle resection was 2 mm. surgeon must take into account that the disappearance rate of the double eyelid may be higher in other double eyelid procedures. 6,7 With this procedure, by cutting the skin and muscle, it is possible to generate adherence between the skin and tarsus, which provides a more permanent result when the double eyelid is successfully created. Other techniques are unable to duplicate this strong adherence between skin and tarsus, as it is impossible to remove the fatty tissue between these structures with other procedures. Figures 10 and 11 show the clinical results of patients who have undergone this type of double eyelid procedure in the author s clinic. Block Fat Grafting When a patient presents with a deeply sunken eyelid, one solution is block fat grafting. 4,8 The donor site for the fat tissue is often the axilla, as the quality of the tissue is similar to the eyelid, and any scarring in the axillary area would not be visible. The area of the sunken eyelid is marked and an incision is made in the double eyelid line. After identifying the orbicularis oculi muscle, the inferior surface of the orbicularis oculi muscle is undermined. The undermined area for the fat graft should be 2 to 3 mm superior to the marked area, as the grafted fat tissue will move inferiorly with gravity as time goes on. Four or five resorbable stitches are placed through the graft, and these sutures are fixed to the skin by tape after penetrating the upper eyelid skin. The sutures are removed on the fifth or sixth postoperative day. The grafted area should remain compressed with sponges and tape for five days. After this period, patients are advised to maintain the same compression for two to three weeks when they are at home. Figure 12 shows the clinical results of a patient who underwent this type of block fat grafting in the author s clinic.

7 Takayanagi 177 Figure 11. (A) This 63-year-old woman presented with dermatochalasis with excess rhytids. She requested removal of her wrinkles and the concave deformity of the upper eyelid. (B) Five months after treatment with a double eyelid incision technique. The width of skin-muscle resection was 3 mm. By removing some skin from the eyelid, the wrinkles were smoothed. The double eyelid incision pushed the patient s skin forward and corrected the sunken eyelid. Figure 12. (A) This 59-year-old woman presented with sunken eyelid deformity. (B) Since the patient s eyelid deformity was deep, fat grafting was selected as the preferred technique. Fat tissue was obtained from her left axilla and grafted 3 mm superiorly to the marked area of the deformity through a double eyelid incision. The length of the incision was about 1.5 cm and the fat was grafted beneath the orbicularis oculi muscle. (C) Seven months after block fat grafting.

8 178 Aesthetic Surgery Journal 31(2) Figure 13. A, This 53-year-old woman presented with a sunken eyelid deformity and ptosis. B, As the levator function had been 12 and 13mm, the tucking technique was performed with 2mm skin-muscle resection. C, Three months after levator shortening, the patient s ptotic appearance was corrected and the sunken eyelid was much improved. The author suggested fat injection to correct slight shallow crease, but the patient was satisfied with the result. Levator Shortening Blepharoptosis is one of the features of aging eyelids. This problem can be corrected by levator shortening, 9-12 which elevates the lid margin, thereby decreasing the depth of the lid sulcus and lessening the concavity of the upper lid. However, the volume of orbital fat tissue that will move forward is unpredictable, so fat injection or the block fat grafting may be performed simultaneously or following a levator shortening procedure to create youthful eyelids. Although there are several options for levator shortening, resection of the levator muscle or a tucking technique is used for most cases of eyelid rejuvenation. When the levator muscle function is less than 9 mm, the muscle should be resected. When the function is over 10 mm, the tucking technique without any resection of the muscle is preferable. In most patients who present for rejuvenation, levator muscle function is over 10 mm, so advancement of the levator muscle aponeurosis and fixation to the tarsus without any resection of the levator muscle are performed. This procedure is also usually performed with excision of the excess skin. Figures 13 and 14 show the clinical results of patients who have undergone this type of levator shortening procedure in the author s clinic. Discussion There are several techniques available to surgeons who are treating patients presenting for upper eyelid rejuvenation (including the treatment of wrinkles, ptosis, and sunken eyes), but proper selection from among the available procedures should include a thorough analysis of the patient s physical anatomy. Although injections with fillers such as hyaluronic acid or collagen are an option 13,14 and are popular in Asian countries, these measures are temporary. More permanent procedures are outlined above. Patients who have a single eyelid and present for wrinkle treatment are good candidates for skin-muscle resection. Other techniques for creating a double eyelid would not

9 Takayanagi 179 Figure 14. (A) This 52-year-old woman presented with a sunken eyelid deformity and ptosis. As the levator muscle function was 11 mm, advancement of the levator muscle aponeurosis was performed. Intraoperatively, the volume of the orbital fat tissue, which came forward with the muscle-aponeurosis advancement, was not enough to correct the sunken eye deformity, so fat tissue from the left axilla was obtained and grafted beneath the orbicularis oculi muscle simultaneously. (B) Five months after completion of the procedure. Three months after the first operation, the survived grafted fat tissue was slightly larger on the patient s left eyelid and a small amount of the fat tissue was removed to generate symmetry. be appropriate, as skin-muscle resection cannot be performed simultaneously. 1,7 When patients present with wrinkles and a ptotic eyelid, levator shortening may work to correct both deformities. 12 If a patient is concerned about sagging eyelid skin, one of the solutions may be resection of skin and orbicularis oculi muscle from the upper eyelid, which can be performed along the double eyelid line as long as the planned skin excision is less than 7 mm; otherwise, the incision should be made immediately underneath the eybrow. 1,12 Sunken eye deformity may be treated with fat injection, block fat grafting, or levator shortening. 4,8,12 Conclusions Sagging, hollowing, and ptosis are deformities that may arise alone or in combination as a result of aging in any eyelid, but the anatomy of Asian patients deserves special consideration when selecting the appropriate course of treatment. Skin-muscle resection, subeyebrow excision, fat injection, block fat grafting, and levator shortening are effective therapeutic modalities to correct these changes. Critical to the success of these procedures is understanding of the patient s aesthetic desires, appreciation of the unique anatomy of the Asian lid, and precision in planning and execution. Disclosures The author declared no conflicts of interest with respect to the authorship and publication of this article. Funding The author received no financial support for the research and authorship of this article. References 1. Takayanagi S. Asian upper blepharoplasty double-fold procedure. Aesthetic Surg J 2007;27: Makino T, Maegawa J, Daigo K. A retrospective study on the relationship between the amount of excised skin and preoperative measurements of lid heights in senile blepharoptosis. J Jpn Aesthetic Plast Surg 2006;28: Hayashi T, Fujimori R, Hirota R, Obata Y. Usefulness of sub-eyebrow rhytidectomy. J Jpn Aesthetic Plast Surg 2003;25: Takayanagi S. Surgical treatment for sunken eyes. J Jpn Aesthetic Plast Surg 1999;21: Ishihara N. Eyelid crease formation for sunken eyes. J Jpn Soc Aesthetic Surg 2002;39: Lam SM, Kim YK. Partial-incision technique for creation of the double eyelid. Aesthetic Surg J 2003;23: Homma K, Mutou Y, Ezoe K, Fujita T. Intradermal stitch blepharoplasty for Orientals: does it disappear? Aesthetic Plast Surg 2000;24: Gulyas G. Improving the lateral fullness of the upper eyelid. Aesthetic Plast Surg 2006;30: Carraway JH. Combining blepharoplasty with upper eyelid ptosis correction. Aesthetic Surg J 2003;23: Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthalmol 1975;93: Torre JI, Marten SA, Cordier BC, et al. Aesthetic eyelid ptosis correction: a review of technique and cases. Plast Reconstr Surg 2003;112: Utsugi R, Matsuo K, Uchinuma E. Recent concepts of blepharoplasty for aging eyelids. Jpn J Plast Reconstr Surg 2003;46: Klein AW, Rish PC. Injectable collagen: an adjunct to facial plastic surgery. Facial Plast Surg 1987;4: Duranti F, Salti G, Bonani B, et al. Injectable hyaluronic acid gel for soft tissue augmentation. Dermatol Surg 1998; 24:

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