Keywords
blepharoptosis - double-eyelid surgery - partial incision - vertical mattress suture
- marginal reflex distance
The partial-incision double-eyelid surgery has become a popular aesthetic surgical
procedure among East Asians because of its advantages, such as creating a more durable
fold, less visible scar, and shorter postoperative recovery time.[1] The incidence of blepharoptosis is much higher in East Asians than in other areas
worldwide because of their distinctive eyelid anatomy. However, patients who want
to undergo double-eyelid surgery frequently have mild blepharoptosis.[2]
[3]
[4]
Due to high clinical demands, some surgical techniques have been used to correct blepharoptosis
and create double-eyelid creases simultaneously.[4] However, these techniques are somewhat complex and require a long learning curve,
which is not conducive to clinical popularization. Here, we introduce a simple technique
for mild blepharoptosis correction with a three-point vertical mattress suture in
partial-incision double-eyelid surgery.
Materials and Methods
The medical records and preoperative and postoperative images of 57 patients who underwent
simultaneous mild blepharoptosis correction and partial-incision double-eyelid surgery
from January 2018 to July 2021 in the Plastic Surgery Department of the China-Japan
Friendship Hospital and MAGIC BeauCare Clinic were retrospectively reviewed. All patients
had mild blepharoptosis with good levator function (LF > 10 mm). The procedures conformed
to the ethical guidelines of the Declaration of Helsinki and clinical practice guidelines
from the ethical committee of the hospital and clinic. All participants were fully
informed about the treatment protocol and potential risks, and signed informed consent
and photo release forms were obtained preoperatively.
All medical records were reviewed, and demographic data, including age and sex, examination
findings, and measurements (including preoperative marginal reflex distance [MRD1]),
were collected. Postoperative information such as postoperative MRD1, follow-up period,
and complications was also collected. All pre- and postoperative images were obtained.
A paired t-test was used to analyze MRD1 changes pre- and postoperatively. A value of p less than 0.05 was considered to indicate a statistically significant difference.
Preoperatively, the patient was instructed to remain in an upright sitting position,
and the upper lid was retracted upward until incipient eyelash eversion was observed.
The proper lid crease was designed as the superior border of the tarsal plate, and
a dot was 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 the lateral limbus and outer canthus angle, and the middle of the medial
limbus and inner canthus angle of approximately 2 mm in length were made and marked
at the crease line ([Fig. 1]). The lid creases and incisions were confirmed several times preoperatively to confirm
bilateral symmetry.
Fig. 1 A proper lid crease was designed as the superior border of the tarsal plate when
the upper lid was retracted upward.
Surgical procedures were performed under local anesthesia. A solution containing 1%
lidocaine and 0.5% bupivacaine with 1:100,000 epinephrine was infiltrated subcutaneously
below the marked incisions. Only 0.05 mL was used to minimize edema for each incision
and ensure symmetrical evaluation of the crease height intraoperatively. A 10-minute
duration was given to permit maximal hemostasis and anesthesia, and three skin incisions
were created using a no. 11 blade. Through small incisions, the orbicularis muscle
was dissected with small ophthalmic scissors in a spreading manner under the deep
orbicularis muscle layer. Dissection was performed in an upward direction from the
superior border of the tarsal plate, followed by preaponeurotic fat pad identification
and levator aponeurosis exposure of approximately 5 mm higher than the superior border
of the tarsal plate (not higher than the musculoaponeurotic junction level) ([Fig. 2]). In patients with puffy eyelids, the orbital septum was locally opened, and the
central preaponeurotic fat was selectively removed via the small incision in the temporal
region ([Fig. 3]).
Fig. 2 Dissection was performed in an upward direction from the superior border of the tarsal
plate, and the levator aponeurosis was exposed.
Fig. 3 The central preaponeurotic fat was exposed and selectively removed through a small
incision temporally.
A three-point vertical mattress suture was then used with 7–0 nylon with three suture
points, including the orbicularis muscle under the inferior skin edge, levator aponeurosis
at the superior border of the tarsal plate, and levator aponeurosis at the proper
height (∼3–5 mm higher than the superior border of the tarsal plate) below the musculoaponeurotic
junction at the center of the small incision ([Fig. 4]). This three-point vertical mattress suture had several functions: first, the levator
aponeurosis was plicated to correct mild blepharoptosis; second, the levator aponeurosis
and orbicularis muscle were fixed to create a double-eyelid crease; and third, the
eyelashes were everted to correct lash ptosis.
Fig. 4 The plication fixation suture was implemented, and the eyelid height and contour,
the lid crease height, and the eyelash eversion were confirmed.
The suture was tied with a surgeon's knot, and a slip knot is placed over the surgeon's
knot. Then, the patient was asked to sit up and open his or her eyes. The eyelid height
and contour and the lid crease height were confirmed as favorable indicators before
completely securing the suture with additional knots ([Fig. 4]). If the eyelid height and contour and the lid crease height or symmetry remain
unsatisfactory after suturing, repositioning the suture site was adjusted in the levator
aponeurosis. After the suture was tied down, suture tails were trimmed, and the suture
was buried beneath the skin. Small skin incisions involving levator aponeurosis were
closed using 7–0 nylon sutures to strengthen the double-eyelid crease. These skin
sutures were removed on postoperative day 7, and three-point vertical mattress sutures
remained beneath the skin permanently.
Results
A total of 57 patients underwent surgery from January 2018 to July 2021. All patients
underwent bilateral partial-incision double-eyelid surgery: 10 unilateral and 47 bilateral
blepharoptosis corrective surgeries. Patients' average age was 25.3 ± 7.4 (range:
18–38) years. The mean operative and follow-up time was 50 (range: 36–71) minutes
and 13 (range 3–35) months, respectively.
The pre- and postoperative mean MRD1s were 3.04 ± 0.27 mm and 3.75 ± 0.35 mm, respectively.
A statistically significant improvement was observed between pre- and postoperative
MRD1 values (p < 0.01). The overall surgical success rate was 93%. Undercorrection was noted in
three patients (5.3%), asymmetry in four patients (7.0%), and double-eyelid crease
disappearance in three patients (5.3%). The three patients with undercorrection (two
also had double-eyelid crease disappearance) were corrected by widening the small
incisions slightly and placing double same three-point vertical mattress suture in
widened small incisions. One patient with double-eyelid crease disappearance was satisfied
with the correction of blepharoptosis and did not undergo double-eyelid surgery again.
No severe postoperative complications such as lid retraction, lagophthalmos, corneal
keratopathy, infection, hypertrophic scarring, or persistent edema were observed during
the follow-up period ([Fig. 5] and [Fig. 6]).
Fig. 5 A 22-year-old woman underwent bilateral simultaneous blepharoptosis correction, partial-incision
double-eyelid surgery, and medial epicanthoplasty, with a ptosis correction of 2 mm
on both sides. Preoperative view of the opened and closed eyes. Postoperative view
of opened and closed eyes at 2 months.
Fig. 6 A 26-year-old woman underwent bilateral simultaneous blepharoptosis correction and
partial-incision double-eyelid surgery, with a ptosis correction of 2 mm on the left
side and 1.5 mm on the right side. Preoperative view of opened and closed eyes. Postoperative
view of opened and closed eyes at 6 months.
Discussion
Small-incision blepharoptosis correction surgery became well known since its introduction
by Lucarelli and Lemke.[5] Recently, a central minimal incision levator resection was used to correct blepharoptosis
in two main areas: for reducing the incision size and for reducing the dissection
and resection. The advantages of this technique include minimal tissue damage, bleeding,
and edema, allowing a faster wound healing and recovery and more accurate intraoperative
assessment of the eyelid position and a shorter operation time and less scarring,
facilitating further dissection if reoperation was indicated in case of unsatisfactory
results.[6]
[7]
[8]
[9]
[10]
[11]
The creation of a proper and persistent double-eyelid crease is considered the primary
and important step during blepharoptosis surgery in East Asian patients.[12] For the central small incisional procedure, the fixation of the double-eyelid crease
is limited toward the center, and the double-eyelid crease is not fully established
in the medial and lateral parts of fuller East Asian upper eyelids, causing lateral
eyelid hooding and double-eyelid crease asymmetry.[13]
[14] Lee et al[4] presented a surgical technique to correct mild or moderate blepharoptosis with levator
aponeurosis–Müller muscle complex advancement through three partial incisions, the
levator aponeurosis–Müller muscle complex, and the upper border of the tarsal plate,
which were fixed using the horizontal mattress suture technique and double-eyelid
crease was performed with additional suturing of the orbicularis muscle. However,
these techniques are somewhat complex and require a long learning curve, which is
not conducive to clinical popularization.
In our study, three skin incisions were created the same as the traditional three
small-incision double-eyelid blepharoplasties, and dissection of the levator aponeurosis
was just a little larger than traditional three small-incision double-eyelid blepharoplasties
and very easy to perform; the three-point vertical mattress suture was also very simple.
Due to the simplicity of our technique, our operative time was relatively short. Because
of these characteristics, namely minimally invasive, easy to perform, and short operation
time, our technology have certain comparative advantages.
The three points, namely the orbicularis muscle under the inferior skin edge, levator
aponeurosis at the superior border of the tarsal plate, and levator aponeurosis at
the proper height (∼3–5 mm higher than the superior border of the tarsal plate), were
fixed together using the vertical mattress suture in our surgery. This procedure not
only can correct mild blepharoptosis but also can produce a persistent adhesion between
the orbicularis muscle and levator aponeurosis to maintain a stable double-eyelid
crease, and the disappearance or deformity of the double-eyelid crease after this
technique was only observed in four patients, indicating that our technique is suitable
for East Asian patients.
Ranno et al[15] have evaluated the outcomes of standard incision levator advancement with a small-incision
technique, which showed success rates of 95.2% and 94.7% with standard and small incision
methods in patients with good LF (>10 mm). The technique presented by Lee et al[4] shows excellent results in 83.8% and good results in 14.9% of patients. In our study,
success rates were 93%, a finding slightly inferior to Ranno et al's and Lee et al's
studies. We think the reason may be the small incision, insufficient dissection, and
unresected hypertrophic fascial tissue in front of the levator aponeurosis and tarsal
plate, resulting in aponeurosis not sufficiently and accurately plicated during suture.
This deficiency can be addressed by slightly widening small incisions and placing
double the same three-point vertical mattress suture in the widened small incisions.
Makeeva et al[16] found that a 4-mm advancement resulted in an average MRD1 increase of 2.26 mm and
a 5-mm advancement resulted in an average MRD1 increase of 2.74 mm. Alkeswani et al[17] found that a 4-mm average advancement led to an average of 2.2 mm increase in MRD1,
whereas a 5-mm advancement led to an average increase of 2.9 mm. These studies suggested
that a consistent relationship between the levator advancement distance and improvement
in MRD1 measurement can be used to plan the amount of advancement required to elevate
the eyelid. In our study, a successful operation was confirmed by the eyelid height
and contour and lid crease height when the patient was in an upright sitting position
rather than the levator advancement distance.
However, our technique has some disadvantages, i.e., the small incision, minimized
surgical dissection, and limited exposure to the complete correction of blepharoptosis.
Thus, this technique is not considered suitable for severe blepharoptosis with poor
LF.
Our study has several limitations. First, this study included a retrospective design,
and thereby, prospective, randomized studies comparing our technique with the usual
small incisional approaches and independent evaluation by blinded observers were considered
better for assessing surgical success. Second, the small sample size allowed only
a weak statistical power. Third, the overall follow-up period was short to confirm
the effects in the long run. Finally, all measurements and evaluations were performed
by one of the authors who is also the operator. Thus, recordings by an independent
investigator should be conducted to reduce the risk of measurement bias.
In summary, we think that the three-point vertical mattress suture is an effective,
safe, and simple technique for mild blepharoptosis correction in partial-incision
double-eyelid surgery.
