chapter 6 - external incision methods

8/14/2019 Chapter 6 - External Incision Methods

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A review of the literature on the external incisionmethod (see Appendix 2) shows considerable variationsin technique and preference regarding skin incisionsand whether or not skin and orbicularis muscle shouldbe routinely removed. Likewise, some prefer to openthe orbital septum and remove a variable amount of the preaponeurotic fat pad.

There are other proponents for small skin incisions

or partial incision only, and further differentiationsin the way crease fixation is carried out, includingskin–levator aponeurosis–skin, inferior orbicularis–levator, septodermal, and skin–tarsus–skin fixation.Each variation has pros and cons that needs to beweighed according to the technical skills, aestheticsense and level of effort involved, as well as thepatient’s comfort level and acceptance.

For example, both the skin incision and the skinexcision schools favor making an incision to accuratelydefine the placement of the crease. These practitionersare comfortable with these techniques as well as the

wound healing process, and are likely to be less con-cerned about instant recovery. Specialists whoroutinely open the orbital septum are likewisecomfortable with the anatomic landmarks and aim toclear the preaponeurotic zone along the superior tarsalborder. Overall, the proponents of the external incisionfeel more comfortable with the predictability and per-manence of this approach, and aim for a longer-lastingcrease and less need for interval adjustment procedures.This approach, especially when carried out without theneed for buried sutures, frequently yields a crease form

that is subjectively comfortable for the patient onupgaze and downgaze, without the often-voiced com-plaint of tightness of the upper lid and a sensation of the buried sutures poking the pretarsal zone. Thesurgeon who operates through a 5–8mm skin incisionmay be able to accomplish limited debulking of softtissues. One drawback may be a crease that appearsbetter formed over the central skin incision than overthe medial and lateral portions of the lid.

Chapter6

William P.D. Chen

External Incision Methods



tal fibers of the levator aponeurosis along the superiortarsal border, and the third is into the upper skin edge(Fig. 6-1). This maneuver allows an adhesion to formbetween the levator aponeurosis and the subdermalarea along the superior tarsal border, closely approxi-mating the distal interdigitations of the levator aponeu-rosis. Fernandez1 wrote that this technique gives a‘dynamic’ and superficial crease (Fig. 6-2), in contrastto the skin–tarsus–skin method, which tends to give a‘static’ crease (Fig. 6-3).

Asian Blepharoplasty and the Eyelid Crease

52

The choice of suture material varies greatly, as dothe closure techniques applied in the external incisionmethods. The techniques for construction of the uppereyelid crease fall into two broad categories: skin–levator–skin (or skin–tarsus–skin) and levator aponeu-rosis to inferior subcutaneous plane (or superiortarsal border to inferior subcutaneous plane:STB/inf.subQ).

Skin–Levator–Skin Approach

In this approach, sutures are placed so that the first biteis into the inferior skin edge, the second is into the dis-

Levator aponeurosis

Superior tarsal border

Tarsus

0.12 mm forceps

Fig. 6-1 Skin–levator–skin closure. The

stitch first passes through the lower skin

border, taking a bite into the levator

aponeurosis along the superior tarsal

border (STB), and then through the

upper skin border.



Chapter 6 External Incision Methods

Upper tarsus

Skin

Levator

Suture passage from: Skin Levator Skin

Fig. 6-2 Skin (S)–levator (L)–skin (S/L/S)

closure, which produces a dynamic and

superficial crease.




54

Levator Aponeurosis to Inferior

Subcutaneous Plane Approach

In the levator aponeurosis to inferior subcutaneousplane approach, several buried 6/0 nylon, polyglycolicacid, or polypropylene sutures are applied to allowadhesions to form between the levator aponeurosis and

the subcutaneous tissue of the inferior incision alongthe superior tarsal border (Fig. 6-4). According toFernandez,1 this procedure also produces a dynamiccrease, but a more deep and permanent one than in theskin–levator–skin method of closure. In 1974 and1977, Sheen2,3 described performing this technique onCaucasian patients who underwent upper blepharo-plasty. Sutures were applied from the levator aponeu-rosis to the inferior orbicularis muscle (in essence the

inferior subcutaneous tissue). In 1976, Putterman andUrist,4 and Weingarten5 described the technique of applying sutures from the superior tarsal border to theinferior subcutaneous plane (Fig. 6-5).

In 1999 Park6 published his technique of orbicu-laris–levator fixation in double-eyelid procedures forAsians. He used three 6/0 nylon sutures to fix a foldedportion of the levator aponeurosis to the orbicularis

oculi of the inferior skin edge.Yoo7 described crease formation simply by trimming

of pretarsal fat and the placement of ‘basting sutures’that eliminate the dead space formed by removal of pretarsal tissues, but without attaching any aponeuro-sis or tarsal plate. The author assumed that the reduc-tion of the soft tissue between levator and skin was amore important factor in the formation of a crease thanlevator insertion to the skin. He advocated an open

SkinTarsus

Suture passage from: Skin Tarsus Skin

Fig. 6-3 Skin (S)–tarsus (T)–skin (S/T/S)

closure, which tends to produce a static

crease.




Levator / inferior

subcutaneous knot

Fig. 6-4 Placement of ligature buried

between the inferior subcutaneous

tissues and the levator aponeurosis.

According to Fernandez1 this procedure

results in a deeper and more permanent

dynamic crease.

Tarsus / inferior

subcutaneous knot

Fig. 6-5 Placement of ligature buried

between tarsus and subcutaneous

tissues of inferior skin edge.




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incisional method using removal of excessive soft tis-sue and closure without supratarsal fixation. He useda continuous 6/0 silk and three interrupted sutures toclose the wound. Conceptually the three interruptedbasting sutures were used to close the skin, orbicularis,and pretarsal soft tissues; however, the exact functionof these interrupted sutures is debatable, as the closureof the dead space implied by the author following theremoval of soft tissue will inherently anastomose theupper and lower skin margins together and overthe levator aponeurosis along the superior tarsal mar-gin. The net result would also be a rigid pretarsal plat-form allowing crease formation, and there would verylikely be secondarily induced aponeurotic adhesions tothe pretarsal tissues after such a maneuver. In addition,there is still the presence of other impeding factors,

such as tissue redundancy in the preaponeuroticspace above this region, which consists of the presep-tal orbicularis, suborbicularis fat and septum as wellas inferiorly migrated preaponeurotic fat pads. In Yoo’sseries of 48 patients, some appeared to show signifi-cant regression of the height of the crease after 1–2years.

Lee et al.8 advocated attachment of the orbital sep-tum to the skin to form the eyelid crease. They statedthat there are distinct layers of fascia anterior to theorbital septum that originate from the septum andinsert on to the pretarsal aponeurotic expansion.

Seeing that the preaponeurotic fat and orbitalseptum hang below the fusion line of the orbital sep-tum and aponeurosis in Asian single eyelids, theauthors advocated the septodermal fixation technique,where the hanging portion of the orbital septum is dis-sected from the aponeurosis, plicated, and then suturedto the skin of the pretarsal flap. The septum is notroutinely opened, but the redundant portion hangingbelow the fusion line is sutured to the pretarsalskin–muscle flap. In 60% of their patients the pretarsalfibrofatty layers are removed to promote adhesion

between the pretarsal orbicularis fascia and the pre-tarsal aponeurotic expansion. The authors followed512 patients over 3 years, and the advantages theyclaim include less postoperative edema, less discomfortand pain, and satisfactory crease formation.

At the opposite end of the spectrum, in 1993Flowers9 described his approach towards upper ble-pharoplasty and crease fixation in Caucasians andAsians, utilizing his approach of ‘anchor blepharo-

plasty’. He discussed the challenge when a crease foldwas allowed to remain in an upper blepharoplasty –the pretarsal skin appeared excessive and wrinkled. Hissolution was to correlate the amount of pretarsal skinthat is allowed to remain (the location of the lid inci-sion) with the tarsal height, excising the desired skinwith its supratarsal crease and then recreating a newprecise crease fold by attaching the dermis of the pre-tarsal skin flap to the aponeurosis and tarsus.

The tarsus is everted and its height measured. It ismarked on the skin side with the same distance fromthe lash line, which adds 2mm to the distance as meas-ured from the actual lid margin. Flowers’ operative ruleis that there should be 26–30mm of skin on the upperlid between the eyebrow and the lid margin for normalcontour and invagination as well as for closure. This is

broken down into approximately 10mm for the invagi-nation of the eyelid fold, a minimum of 12mm fromthe eyelid fold to the brow, and 3–6mm of visible pre-tarsal skin; 1–2mm are allowed for the curvature of thelid fold as it bends into the crease. If the amount is lessthan 26–30mm there will be problems with invagina-tion of the fold, as well as a restricted brow positionand inadequate lid closure owing to shortage of skin.The amount of eyelid skin that overhangs and obstructsthe desired view of the pretarsal skin is measured usinga caliper, or estimated visually; this is doubled (×2) toarrive at the amount of skin that ought to be removed.

This may be performed at different points along theeyelid. Flowers discussed the treatment of fat and itspartial excision over the lateral quadrant, and the pos-sibility of rotating and translocating the fat on to themedial aspect of the supratarsal sulcus. He believedthat trimming pretarsal connective tissues and thinningof the pretarsal orbicularis on the underside of the pre-tarsal skin flap helps both to reduce postoperativeedema in that region and to produce a smooth pretarsalskin surface as a result of adherence of the skin andorbicularis to the tarsus.

In this approach the plane between the pretarsalorbicularis and the distal insertion of the levatoraponeurosis over the anterior surface of the upper tar-sus is separated with scissors down to the lash margin.Any inferior attachment of the aponeurotic fibers to theskin is thus transected. The filmy pretarsal connectivetissues, including portions of pretarsal orbicularis thatmay be excessive, are excised with scissors over theanterior tarsal surface. The dermis of the pretarsal skin




A

B

Fig. 6-6 (A) A dynamic crease

is apparent on forward gaze but

disappears on downgaze (B).




58

upper lid follows and the upper lid crease loses promi-nence, sometimes becoming barely observable (Fig.6-6B). A crease that is present when the levator is activeand which fades from view when the levator relaxes iscalled a dynamic crease.

A surgically formed upper lid crease that is presentand noticeable even on downgaze (when the levator isrelaxed) is called a static crease. This type of crease isoften seen in patients who have had the inferior skinedge sutured to the superior tarsal border and upperskin edge.

In practice the matter is not always predictable: astatic crease is not always seen as a result of skin–tarsus–skin closure, and a dynamic crease does notalways occur when skin–levator–skin or levatoraponeurosis–inferior subcutaneous plane closure is

performed.

This author10–13 prefers the external incision methodbecause it is more controlled and permanent. I removea variable amount of skin depending on the patient’sneeds. I also resect some orbicularis oculi – usually sev-eral millimeters along the preseptal and the pretarsalsegments. The orbital septum is opened superiorlyand, depending on the situation, a variable amount of preaponeurotic fat may be trimmed, but nevercompletely removed. The lid crease-enhancing sutures

are placed skin–levator aponeurosis–skin. To give adynamic, superficial crease I use non-absorbable non-reactive suture materials that are then removed. I donot use any buried suture materials.

References

1. Fernandez LR. Double eyelid operation in theOriental in Hawaii. Plast Reconstruct Surg1960;25:256–264.

2. Sheen JH. Supratarsal fixation in upperblepharoplasty. Plast Reconstruct Surg1974;54:424–431.

3. Sheen JH. A change in the technique of supratarsal fixation in upper blepharoplasty.Plast Reconstruct Surg 1977;59:831–834.

4. Putterman AM, Urist MJ. Reconstruction of theupper eyelid crease and fold. Arch Ophthalmol1976;94:1941–1954.

flap (lower skin edge) is sutured subcuticularly to thesuperior margin of the tarsus as well as the free termi-nal edge of the aponeurosis using absorbable 6/0Vicryl. Flowers usually applies three or four of thesesutures centrally, and one or two laterally as well asmedially along the new crease. (The trimming of thepretarsal tissues and excision of some of the anteriorportion of the distal levator aponeurosis will invariablyleave behind a free edge; this does not mean that thelevator aponeurosis has been entirely transected.) Inaddition, the upper and lower skin edges are closedwith a running non-dissolving suture, incorporating theaponeurosis in each bite.

Alternative methods of closure mentioned byFlowers were:

1. To use interrupted nylon sutures alone,incorporating all layers together: the lower skinedge, the superior tarsal border, the free edge of the aponeurosis, and the upper skin edge. NoVicryl is then used for the skin–tarsus–levatoraponeurosis alone.

2. The incorporation of the upper and lower skinedges into the deeper 6/0 Vicryl that binds thesuperior tarsal border as well as the free edge of the aponeurosis. No nylon or non-dissolvingsuture is then used.

The reason for incorporating the levator aponeuro-sis, according to Flowers, is that it exerts a smallamount of tension on the pretarsal skin andthereby keeps it taut. By the same reasoning, heanchors the pretarsal skin flap to the tarsus to preventexcessive pull by the aponeurosis on the pretarsalskin, resulting in eyelash eversion and excessive show-ing of the upper lid margin itself. The author statedthat patients often experience some degree of ptosis,as well as a tugging feeling on upgaze. He stated thatcomplete recovery requires 2–3 years, but that patients

generally look very satisfactory by 2 weeks aftersurgery.

The concept of a dynamic versus a static crease isworth elaborating. When a person has a natural creasein the upper eyelid, the crease is well defined when thatperson looks straight ahead (Fig. 6-6A). On downgaze,the inferior rectus and superior oblique muscles con-tract, whereas the superior rectus, levator, and inferioroblique muscles relax. As the eyes look downward, the




5. Weingarten CZ. Blepharoplasty in the orientaleye. Trans Am Acad Ophthalmol Otol1976;82:442–446.

6. Park JI. Orbicularis–levator fixation in double-eyelid operation. Arch Facial Plast Surg1999;1:90–95.

7. Yoo H-B. The double eyelid operation withoutsupratarsal fixation. Plast Reconstruct Surg1991;88:12–17.

8. Lee JS, Park WJ, Shin MS, Song IC. Simplifiedanatomic method of double-eyelid operation:septodermal fixation technique. PlastReconstruct Surg 1997;100:170–178.

9. Flowers RS. Upper blepharoplasty by eyelidinvagination – anchor blepharoplasty. Clin PlastSurg 1993;20:193–207.

10. Chen WPD. Asian blepharoplasty. OphthalmPlast Reconstruct Surg 1987;3:135–140.

11. Chen WPD. A comparison of Caucasian andAsian blepharoplasty. Ophthalm Pract1991;9:216–222.

12. Chen WPD. Upper blepharoplasty in the Asianpatient. In: Putterman AM, ed. Cosmeticoculoplastic surgery, 3rd edn. Philadelphia: WBSaunders, 2000: Chapter 11.

13. Chen WPD, Khan J, McCord CD Jr. Color atlasof cosmetic oculofacial surgery. Oxford:Butterworth–Heinemann, 2004.

chapter 6 - external incision methods

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