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Small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique: A modified partial-incision double-eyelid blepharoplasty

Open AccessPublished:October 11, 2022DOI:https://doi.org/10.1016/j.bjps.2022.10.010

      Summary

      Background

      The partial-incision double-eyelid surgery remains a popular esthetic procedure in Asia, most of the previous partial-incision double-eyelid operations involved resection of the pretarsal orbicular muscle, resulting in a depressed and firm eyelid crease. In order to create a more natural, dynamic, and durable double-eyelid crease with less visible scar and shorter postoperative recovery time, we describe a modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique for Chinese patients.

      Methods

      A total of 132 patients who underwent bilateral modified partial-incision double-eyelid surgery were retrospectively reviewed. In this technique, three 2 mm incisions were designed, the orbicularis oculi muscle was preserved and conservatively dissected to expose the levator aponeurosis, and buried suture was used to fix the orbicularis oculi muscle to levator aponeurosis. The skin and orbicularis oculi muscle were then sutured together with the levator aponeurosis.

      Results

      With a follow-up period of more than 6 months, most of the double eyelids were natural and dynamic, and the crease was stable. The majority of the swelling faded in 2 weeks and completely faded in the first month for most patients. The scars of the small incision became invisible after 3 months of recovery. One patient (0.8%) complained of bilateral fold disappearance. Asymmetries occurred in 4.5% (6 of 132) patients. 97.7% (129 of 132) patients were satisfied with the postoperative appearance. No severe complications were reported during the follow-up period.

      Conclusion

      The modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation double-eyelid blepharoplasty technique can create a more natural, dynamic, and durable double-eyelid crease with fast recovery and no visible scar or serious complications.

      Keywords

      Introduction

      Double-eyelid blepharoplasty has become a popular esthetic surgical procedure among the East Asians, as up to 60% of the population have a single upper eyelid or a narrow supratarsal crease.
      • Ichinose A.
      • Tahara S.
      Extended preseptal fat resection in Asian blepharoplasty.
      There are essentially three methods of double-eyelid blepharoplasty, including the nonincision, the partial-incision, and the full-incision techniques. The nonincision suture method is simple with fast recovery time and no visible scar, but it does not make possible the correction of burden tissues and leads to loosen of the fold.
      • Yoon H.S.
      • Park B.Y.
      • Oh K.S.
      Tarsodermal suture fixation preceding redundant skin excision: a modified non-incisional upper blepharoplasty method for elderly patients.
      • Fan J.
      • Low D.W.
      A two-way continuous buried-suture approach to the creation of the long-lasting double eyelid: surgical technique and long-term follow-up in 51 patients.
      • Baek J.S.
      • Ahn J.H.
      • Jang S.Y
      Comparison between continuous buried suture and interrupted buried suture methods for double eyelid blepharoplasty.
      The full-incision method is more versatile and predictable but results in obvious incision scar and longer recovery time.
      • Liu X.
      • Fan D.
      • Guo X.
      A transcutaneous, subcutaneous, and intratarsal suturing procedure in double-eyelid surgery.
      • Lam S.M.
      • Karam A.M.
      Supratarsal crease creation in the Asian upper eyelid.
      • Wang Y.
      • Cao Y.
      • Xie A.
      A modified procedure for blepharoplasty: physiological structure reconstruction of upper eyelids.
      The partial-incision method has the advantages of both full-incision and nonincision techniques, including creating a more durable fold, less visible scar, and shorter postoperative recovery time. In most of the previous partial-incision double-eyelid operations, the pretarsal orbicular muscle is partially resected, making the eyelid crease depressed and firm. In this study, the author introduces a modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique, which can create a more natural, dynamic, and durable double-eyelid crease with less visible scar and shorter postoperative recovery time.

      Patients and methods

      Patients

      A total of 132 patients (115 females and 17 males) who underwent bilateral modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation double-eyelid surgery at our department from July 2017 to August 2020 were retrospectively reviewed. Patients with obviously redundant skin, blepharoptosis, previous upper eyelid surgery, and upper lid skin disease were excluded from the study. The procedures performed in this study were in accordance with the ethical standards of the Helsinki declaration and the clinical practice guidelines from the ethic committee of the hospital. The written informed consent was obtained from all patients before surgery. Patient consents were obtained to publish identifiable photograph for academic use. Postoperative evaluation included the swelling of eyelids, stability of double eyelid, asymmetry, double-eyelid fold curve, and scar formation. Patients’ satisfaction and complications of the surgery were also recorded.

      Surgical technique

      Design

      Preoperatively, the patient was instructed to remain in an upright sitting position and keep both eyes level with a mirror. The appropriate lid crease was designed according to the superior border of the tarsal plate. A stainless probe was pressed on the superior border of the tarsal plate while the patient's eyes were closed, and the upper lid was made retracted upward until incipient eyelash eversion was noted. With the probe maintained in position, the patient was then asked to open his/her eyes and look forward into the mirror. The lines could then be moved upward or downward not more than 1 mm until the desired position was confirmed by the patient, and a dot would be placed at the central aspect of the proposed crease line. A line was marked at the supine position and a typical height of approximately 8 to 10 mm was measured when the eyelid was retracted upward. Three small incisions corresponding to the pupil, the middle of lateral limbus and outer canthus angle, the middle of medial limbus and inner canthus angle of about 2 mm in length were made and marked at the crease line. The lid creases and the incisions were confirmed several times before surgery to confirm bilateral symmetry (Figure 1).
      Figure 1
      Figure 1A proper lid crease was designed as the superior border of tarsal plate when the upper lid was retracted upward, and the small incisions were marked.

      Operative procedure

      Local anesthesia was achieved by injecting a small amount of 1% lidocaine and 0.5% bupivacaine with 1:100,000 epinephrine subcutaneously below the marked incisions. A 10-min period was given to allow maximum hemostasis and anesthesia, and 3 skin incisions were created using No.11 blade. Through the small skin incisions, the orbicularis oculi muscle was dissected with a small ophthalmic scissor in a spreading manner until the levator aponeurosis at the superior border of the tarsal plate was exposed. The levator aponeurosis was confirmed by picking up the tissue with forceps and pulling it anteriorly and inferiorly, and then the patient was asked to open his/her eye. If the patient had difficulty opening the eye that means the picked-up tissue was the levator aponeurosis (Figure 2). In patients with puffy eyelids, the orbital septum was locally opened and the central preaponeurotic fat was selectively removed through a small lateral incision (Figure 3).
      Figure 2
      Figure 2The levator aponeurosis was confirmed by picking up the tissue with forceps and pulled anteriorly and inferiorly.
      Figure 3
      Figure 3The central preaponeurotic fat was exposed and selectively removed through a small incision temporally.
      A buried 7–0 nylon suture was then used to anchor the orbicularis oculi muscle under inferior skin edge and levator aponeurosis at the superior border of the tarsal plate (Figure 4), and the orbicularis-levator aponeurosis fixation suture was done at all the 3 small incisions. These fixation sutures not only create double-eyelid crease formation at the superior border of the tarsal plate but also evert the eyelashes to correct the lash ptosis. The 3 small skin incisions were closed with two 7–0 nylon sutures incorporating the skin and orbicularis oculi of the inferior incision, the levator aponeurosis at the superior border of the tarsal plate, and the skin and orbicularis oculi of the superior incision on both sides of buried sutures to strengthen the eyelid crease. The same procedure was performed on the opposite eyelid.
      Figure 4
      Figure 4The orbicularis oculi muscle under inferior skin edge and levator aponeurosis at the superior border of the tarsal plate were sutured together with 7–0 nylon suture.

      Postoperative care

      The erythromycin eye ointment was applied over the incision immediately after the surgery; the patient was instructed to sit in a reclining position, and the eyelids were compressed with sterile gauze and ice compress for half an hour before discharge. The patient was advised to apply ice compress as frequently as possible and avoid strenuous exercise for the first 48 h. Oral antibiotics were administered for 3 days, and the sutures were removed on the seventh postoperative day. Patients could wear makeup 3 days after suture removal and was advised not to wear contact lenses or rub their upper eyelids for 1 month. All patients were welcomed to return for follow-up if they experienced any problems or complications, and we guaranteed a free reoperation within a year if the crease disappeared or became shallow.

      Results

      A total of 132 patients (115 females and 17 males) were involved in the study, their age ranging from 18 to 48 years, with a mean age of 27 years. All patients were followed-up for 6 to 24 months postoperatively. Most of the double eyelids were natural and dynamic, and the shape and height were stable. The majority of the edema faded in 2 weeks and completely faded in the first month after the operation for most patients. The scars of the small incision became invisible after 3 months of recovery. One patient (0.8%) complained of bilateral fold disappearance at 2 months after the operation. Asymmetries occurred in 4.5% (6 of 132) patients. 97.7% (129 of 132) patients were satisfied with the postoperative appearance (Table 1). No severe complications such as blepharoptosis, lagophthalmos, corneal keratopathy, or infection were reported during the follow-up period (Figure 5, Figure 6).
      Table 1Complications and satisfaction of the modified partial-incision double-eyelid blepharoplasty.
      Complications and satisfactionCasesIncidence(n = 132)
      Fold disappearance10.8%
      Asymmetry64.5%
      Satisfaction12997.7%
      Figure 5
      Figure 5A 26-year-old man underwent bilateral modified partial-incision double-eyelid blepharoplasty. Preoperative view of open and closed eyes. Postoperative view of open eyes and closed eyes at 2 weeks.
      Figure 6
      Figure 6A 22-year-old woman underwent bilateral modified partial-incision double-eyelid blepharoplasty and medial epicanthoplasty simultaneously. Preoperative view of open and closed eyes. Postoperative view of open and closed eyes at 2 months.

      Discussion

      People with double eyelids have levator aponeurosis fibers that pass through the orbicularis oculi muscle and attach to the subcutaneous tissue of the eyelid skin, while this fibrous structure is absent in people with single-eyelids.
      • Collin J.R.
      • Beard C.
      • Wood I.
      Experimental and clinical data on the insertion of the levator palpebrae superioris muscle.
      • Morikawa K.
      • Yamamoto H.
      • Uchinuma E.
      • Yamashina S.
      Scanning electron microscopic study on double and single eyelids in orientals.
      • Cheng J.
      • Xu F.Z.
      Anatomic microstructure of the upper eyelid in the Oriental double eyelid.
      Meanwhile, the low fusion site of the orbital septum with the levator aponeurosis, abundant retro-orbicular fat, and thick pretarsal subcutaneous tissue prevent the levator aponeurosis from extending to the pretarsal orbicularis muscle and dermis, also resulting in a single upper eyelid.
      • Hwang K.
      • Kim D.J.
      • et al.
      An anatomical study of the junction of the orbital septum and the levator aponeurosis in Orientals.
      • Saonanon P.
      Update on Asian eyelid anatomy and clinical relevance.
      • Kakizaki H.
      • Takahashi Y.
      • Nakano T.
      • et al.
      The causative factors or characteristics of the Asian double eyelid: an anatomic study.
      Therefore, all types of double-eyelid procedures aim to remove redundant tissue and create the connection between skin and levator aponeurosis to form durable double eyelids.
      There are essentially three methods of double-eyelid blepharoplasty, including the nonincision, the partial-incision, and the full-incision techniques. The nonincision suture method is simple with fast recovery time and no visible scar, but it does not make possible the correction of burden tissues and leads to loosen of the fold.
      • Yoon H.S.
      • Park B.Y.
      • Oh K.S.
      Tarsodermal suture fixation preceding redundant skin excision: a modified non-incisional upper blepharoplasty method for elderly patients.
      • Fan J.
      • Low D.W.
      A two-way continuous buried-suture approach to the creation of the long-lasting double eyelid: surgical technique and long-term follow-up in 51 patients.
      • Baek J.S.
      • Ahn J.H.
      • Jang S.Y
      Comparison between continuous buried suture and interrupted buried suture methods for double eyelid blepharoplasty.
      The full-incision method is more versatile and predictable but results in obvious incision scar and longer recovery time.
      • Liu X.
      • Fan D.
      • Guo X.
      A transcutaneous, subcutaneous, and intratarsal suturing procedure in double-eyelid surgery.
      • Lam S.M.
      • Karam A.M.
      Supratarsal crease creation in the Asian upper eyelid.
      • Wang Y.
      • Cao Y.
      • Xie A.
      A modified procedure for blepharoplasty: physiological structure reconstruction of upper eyelids.
      To create a more durable double-eyelid crease, less visible scar, and shorter postoperative recovery time, the partial-incision method has become more and more popular in recent years.
      • Lam S.M.
      • Kim Y.K.
      Partial-incision technique for creation of the double eyelid.
      • Chuangsuwanich A.
      Short incisional double-eyelid blepharoplasty for Asian patients.
      • Hu X.
      • Ma H.
      • Xue Z.
      • et al.
      A modified mini-incisional technique for double-eyelid blepharoplasty.
      • Zhang M.Y.
      • Yang H.
      • Li C.Y.
      • et al.
      Removal of a large amount of pretarsal tissue through three mini incisions in the construction of a double eyelid.
      • Shen X.
      Modified double-eyelid blepharoplasty with the combined partial and minimal incision method.
      In most of the previous partial-incision double-eyelid operations, the pretarsal orbicular muscle is partially resected in order to adhere the skin to the tarsus to create double eyelids. The resection of orbicularis oculi muscle could make the eyelid crease depressed, and the adhesion between the skin and the tarsus makes it difficult for the pretarsal tissue to move along with eye movements and results in a stiff appearance. Therefore, to obtain a natural and dynamic supratarsal crease, we choose to keep the orbicularis oculi muscle without excision. After exposing the levator aponeurosis at the superior border of the tarsal plate, we fix the orbicularis oculi muscle to the exposed levator aponeurosis. The preservation of the orbicularis muscle can effectively prevent eyelid crease depression. Since the levator aponeurosis and orbicularis oculi muscle are both dynamic anatomical structures, the double-eyelid crease was created by their flexible fixation rather than excessive scar formation between the skin and tarsal plate, making possible the movement along with the palpebral fissures and the formation of dynamic double eyelids.
      • Park J.I.
      • Park M.S.
      Double-eyelid operation: orbicularis oculi-levator aponeurosis fixation technique.
      In our technique, the lid crease was designed according to the superior border of the tarsal plate, with the upper lid retracted upward until eyelash eversion was noted. While in operation, we pull the pretarsal tissue cephalad to suture the orbicularis oculi muscle to the levator aponeurosis at the superior border of the tarsal plate. With this step, the stretch of the skin and orbicularis muscle makes the eyelashes to evert to correct the lash ptosis and makes the pretarsal tissue thinner, and the sausage-like appearance is avoided.
      The buried suture creates a permanent connection between the orbicularis oculi muscle and the levator aponeurosis at the superior border of the tarsal plate to form supratarsal crease with our technique, and the skin incision sutures on both sides of buried sutures can strengthen the skin attachment to the levator aponeurosis. These adequate adhesions of the levator aponeurosis and the skin could secure the supratarsal crease of double eyelids, and the relapse rate can be reduced.
      Compared to the previous partial-incision double eyelid operations, our technique reconstructs the physiological structure of double eyelids. The preservation of the orbicularis oculi muscle can prevent eyelid crease depression. The buried suture and skin suture can form adequate adhesion to the levator aponeurosis and the skin and secure durable supratarsal crease. The conservative dissection shortens the recovery time. The supratarsal creases created by our procedure are more natural and dynamic, with shorter recovery time than before.
      This technique also has some disadvantages in that it is less suitable to patients with excessive upper eyelid fat and skin redundancy, who have a possibility of fold asymmetry and disappearance. This technique also requires a more detailed knowledge regarding the upper eyelid anatomy to identify the levator aponeurosis and tarsal plate.

      Conclusion

      The modified small-incision, mini-dissection, orbicularis-preservation, and orbicularis-levator aponeurosis fixation technique can create a natural, dynamic and durable double-eyelid crease with fast recovery and no visible scar or serious complications.

      Declaration of Competing interest

      None of the authors received financial support or have any financial interest related to this manuscript.

      Acknowledgments

      None.

      Ethical approval

      The procedures performed in this study were in accordance with the ethical standards of the Helsinki declaration and the clinical practice guidelines from the ethic committee of the hospital. The written informed consent was obtained from all patients before surgery.

      Patient consent

      Received.

      Funding

      None.

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        Tarsodermal suture fixation preceding redundant skin excision: a modified non-incisional upper blepharoplasty method for elderly patients.
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        A two-way continuous buried-suture approach to the creation of the long-lasting double eyelid: surgical technique and long-term follow-up in 51 patients.
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