Estimation of skin removal in aging asian blepharoplasty

Authors

  • Amy K Hsu MD,

    Corresponding author
    1. Department of Otorhinolaryngology , New York Presbyterian Hospital–Weill Medical College of Cornell University, New York
    2. Department of Otolaryngology–Head and Neck Surgery , New York Presbyterian Hospital–Columbia University College of Physicians and Surgeons, New York, New York, U.S.A.
    • Department of Otorhinolaryngology, Weill Medical College of Cornell University, 1305 York Avenue, 5th Floor, New York, NY 10021
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  • Albert Jen MD

    1. Department of Otolaryngology–Head and Neck Surgery , New York Presbyterian Hospital–Columbia University College of Physicians and Surgeons, New York, New York, U.S.A.
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  • Presented at the Triological Society Annual Meeting at the Combined Otolaryngology Spring Meetings, Chicago, Illinois, U.S.A., April 27–May 1, 2011.

  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

Objectives/Hypothesis:

To describe a novel method for estimating the amount of skin to resect in upper blepharoplasty in the aging Asian eyelid and to report our experience with this technique.

Study Design:

Retrospective review of patients in a single private practice.

Methods:

Resection of skin in upper blepharoplasty in an Asian eyelid can often be less forgiving than in other ethnicities due to the unique anatomy of the supratarsal fold. Excising a maximal amount of excess skin will result in an unfavorable appearance of the upper eyelid in an Asian patient. We applied a technique of pinching the skin while the patient is awake until the patient is satisfied with the appearance. The skin is then measured and the precise amount resected during blepharoplasty. The supratarsal crease is always recreated even in patients who have a preexisting crease. We conducted a retrospective review of 99 consecutive patients who underwent upper blepharoplasty using this technique. All patients were Asian and aged 40 years or older.

Results:

The study group included 99 patients with a mean age of 55.7 years (range, 42–78 years). The mean follow-up time was 24 months (range, 12–30 months). The amount of desired skin overhang superior to the supratarsal crease varied considerably among patients. Complications included asymmetry in nine patients (9.1%), scarring in three patients (3.0%), and unfavorable cosmetic result in two patients (2.0%). No patients experienced infection, bleeding, or visual changes.

Conclusions:

In upper blepharoplasty in the aging Asian eyelid, it is necessary to resect less skin than in the Caucasian patient to achieve the desired appearance of the upper eyelid complex. Using a patient-assisted approach to estimate the amount of skin to remove, a favorable cosmetic result with a low incidence of complications was achieved in a consecutive series of patients. Laryngoscope, 2012

INTRODUCTION

A common indication for upper lid blepharoplasty in the aging patient is excess skin or dermatochalasis of the upper eyelid skin. An improved upper lid appearance is achieved by resection of excess upper lid skin. Although removal of more skin may improve the cosmetic result, excess skin removal may result in functional issues of the upper lid, such as ptosis or lagophthalmos. In addition to these concerns, resection of skin in upper blepharoplasty in the aging Asian eyelid can often be less forgiving aesthetically than in other ethnicities due to the unique characteristics of the Asian upper eyelid complex. The Asian upper eyelid tends to be fuller and often lacks a supratarsal crease while maintaining an epicanthal fold. Additionally, hooding of the upper lid can be seen even in the youthful appearing eyelid. Removal of skin in an Asian upper eyelid must be approached with caution, as excess skin removal will result in an unnatural appearance. The goal of upper blepharoplasty in the aging Asian upper eyelid is to improve cosmetic appearance without losing the ethnic characteristics of the upper eyelid. We describe a technique for estimation of the amount of skin to remove during Asian upper blepharoplasty that uses patient input to determine the amount of skin to resect.

MATERIALS AND METHODS

The medical records of a consecutive series of patients who underwent upper lid blepharoplasty were reviewed. All procedures were performed by the senior author (A.J.). Inclusion criteria were Asian patients aged 40 years or older undergoing bilateral upper lid blepharoplasty for dermatochalasis. Patients were not excluded if they had a history of prior upper blepharoplasty. Records were reviewed for patient demographics, primary indications for procedure, and complications. Complications were defined as infection, hematoma, dry eye, ptosis, or lagophthalmos. Aesthetic complications were defined as asymmetry, scarring, and unfavorable cosmetic result.

Technique

During preoperative evaluation, the subbrow upper lid skin is pinched with bayonet forceps with the patient awake in the sitting position with eyes open (Fig. 1A). While pinching, the surgeon visualizes the appearance of the lid with the eyelids open, closed, and blinking. Increasing amounts of skin are pinched until the patient is satisfied with the appearance. The upper lid skin is then measured and marked so that the precise amount can be resected during blepharoplasty (Fig. 1B). The inferior incision is made at the existing supratarsal crease if present. If the patient does not have a supratarsal crease, an incision is marked for creation of a crease from 6 mm to 8 mm from the ciliary margin, with the amount determined by patient preference. The superior incision is made at the distance previously determined by the preoperative pinching to facilitate excision of the measured amount of excess skin.

Figure 1.

Preoperative evaluation demonstrating pinching of upper lid skin using bayonet forceps (A) and precise skin measurement using calipers (B). Patient is positioned upright with eyes open.

RESULTS

The study group included 99 patients with a mean age of 55.7 years (range, 42–78 years). The mean follow-up time was 24 months (range, 12–30 months). The indications for the procedure were cosmetic in all cases, including dermatochalasis or asymmetry from prior surgery. Twenty percent of patients had undergone prior upper blepharoplasty. The amount of desired skin overhang superior to the supratarsal crease varied considerably between patients. The amount of skin resected ranged from 8 to 11 mm (mean, 10 mm).

No patients experienced infection, bleeding, dry eye, ptosis, lagophthalmos, or other medical complications. Cosmetic complications included asymmetry in nine patients (9.1%), scarring in three patients (3.0%), and unfavorable cosmetic result two patients (2.0%). Of the nine patients who noted asymmetry, one patient underwent revision blepharoplasty. The remaining eight patients noted asymmetry in the immediate postoperative period that improved after several months; these patients did not wish to undergo revision surgery. Three patients had hypertrophic scarring postoperatively that was treated with triamcinolone (Kenalog; Bristol-Myers Squibb, New York, NY) injections. Resolution occurred after one injection in one patient and two injections in the remaining two patients. The two patients who noted unfavorable cosmetic results felt that there was overresection of skin; there was no revision surgery performed in these cases.

Figure 2 shows preoperative and postoperative views of a patient who underwent upper and lower blepharoplasty with correction of redundant supratarsal creases. The patient in Figure 3 had both redundant upper lid skin and supratarsal folds. The patient in Figure 4 had excess upper lid hooding that was corrected with upper blepharoplasty; the patient desired a small crease with overhang to disguise the crease. Figure 5 shows preoperative and postoperative views of a patient with redundant supratarsal creases that were corrected with upper blepharoplasty.

Figure 2.

(A) Preoperative image of patient showing redundant supratarsal folds. (B) Postoperative photo after upper and lower blepharoplasty showing uniform supratarsal creases.

Figure 3.

Preoperative (A) and postoperative (B) images of patient with upper eyelid hooding and redundant supratarsal creases who underwent upper and lower blepharoplasty.

Figure 4.

Patient with upper lid fullness and hooding (A) who underwent upper and lower blepharoplasty (B). The patient desired a small crease with overhang to disguise the crease.

Figure 5.

Redundant supratarsal fold (A) with uniform crease after undergoing upper blepharoplasty (B). The patient also had excess skin resected.

DISCUSSION

Many unique characteristics define the Asian upper eyelid, including the lack of or a low supratarsal fold, more pretarsal and suborbicularis fat, and a medial epicanthal fold.1–2 Asians also tend to have higher-set eyebrows and less prominent supraorbital rims than Caucasians. In contrast, Caucasians tend to have lower-set eyebrows, less postseptal fat, and thinner upper eyelid skin.2 A visible supratarsal fold is present in approximately 30% to 60% of Asians at birth.3 The palpebral fold in these patients is usually 6 to 7 mm from the lash line with the eyelid closed, as compared to 8 to 12 mm in Caucasians. The visible height of the fold is approximately 1 to 3 mm with the eyes open on forward gaze.4–5 Most Asians tend to prefer eyelids with a supratarsal, or double crease, and many techniques have been described and popularized for the creation of this crease.1, 6–8 However, it should be noted that the general trend has been away from techniques that aim to Westernize the eyelid. Rather, the goal of double eyelid surgery is to create a more attractive eye that enhances the ethnic features. The same principles apply in blepharoplasty for rejuvenation of the aging Asian eyelid.

An important component of upper eyelid rejuvenation is the resection of excess sagging skin that occurs as a result of aging. Previously described techniques of upper eyelid rejuvenation of the Western eyelid have involved resecting the maximum or a percentage of the maximum amount of skin that can be pinched without affecting function of the upper lid. However, in an Asian eyelid, removal of a comparable amount of skin would result in an unnatural appearance, as the Asian eyelid naturally has some degree of fullness and hooding, even in the youthful lid. Rejuvenation blepharoplasty can be especially challenging in Asian patients who have previously undergone surgery to create a supratarsal crease, particularly if a Westernization procedure was performed with aggressive skin resection.4

In our study we performed upper blepharoplasty in a consecutive series of patients using an awake pinching technique to determine the amount of skin to resect. The authors found that many Asian patients actually desired to have some skin overhang in the upper lid, and that the degree of desired overhang varied among patients. Some authors have advocated removing 75% of the maximal skin in the Asian eyelid.9 A fixed percentage of skin removal may not address the individual patient preferences for the amount of lateral hooding. Although pinching techniques have been previously described, a key difference with this particular approach is that the skin estimation is a dynamic rather than static process. The amount of skin is precisely tailored while the patient is awake and blinking. This enables the surgeon to consider the appearance of the lid while open, closed, and moving. The skin is deliberately pinched beneath the brow rather than closer to the eyelid margin. This position is preferred because it allows the patient to visualize the amount of lateral overhang. The authors found that the subbrow position of the pinching did not affect the measurement of the necessary amount of skin resection needed to achieve the desired result. By involving the patient in the decision process of determining how much skin to remove, a favorable cosmetic result could be achieved that was consistent with the patients' preoperative expectations. This technique allows flexibility in the amount of skin taken out in different patients and also enables correction of asymmetry between the two eyes that was either natural or from prior surgery.

As in patients of other ethnicities, brow ptosis in Asian individuals should be addressed prior to upper lid blepharoplasty to avoid overresection of skin. In patients who are undergoing a simultaneous brow lift and upper blepharoplasty, the brow is first taped to the desired location. After the brow is taped, the eyelid skin is then pinched in the same manner as in other patients until the desired appearance is achieved. None of the patients in this series underwent simultaneous brow lift and blepharoplasty. Unconscious elevation of the brow is another important consideration during awake marking. The degree of movement should be minimized by asking the patient to focus on looking straight ahead. The surgeon should also be cognizant of this tendency during marking and take note of whether the patient is raising the brow.

A potential complication of aging Asian blepharoplasty is overresection of skin resulting in an unnatural appearance of the eyelid. Although the appearance of the upper lid can be modified with fillers with some improvement, surgical correction of an overresected lid is difficult. Contrarily, excess skin can easily be removed later in a revision procedure, as occurred in one patient in this series. Thus, the authors tend to err on the conservative side of skin resection in the upper lid. The Asian eyelid is different in that it is natural to have redundant skin laterally, a feature that looks unnatural in other ethnic groups. The eyelids of most other ethnic groups have an upper crease and can tolerate a degree of excess resection. The awake pinching technique allows a very conservative resection by taking the minimal amount of skin required to achieve the desired result. As prolonged edema may occur, particularly with creation of the supratarsal crease, revision procedures are delayed until at least 6 months postoperatively.

Limitations of the study include its retrospective design and the subjective nature of determining a positive aesthetic result. Because the study was retrospective in nature, only the actual amount of skin resected was documented. There was no way of comparing how much skin a patient wanted removed relative to the maximal amount that could have been removed without affecting upper lid function.

CONCLUSION

The goal of rejuvenation of the Asian eyelid is to create a more youthful-appearing eye that preserves its unique ethnic characteristics. Skin resection in an Asian eyelid should be conservative to maintain a natural appearance. A degree of upper lid fullness and skin overhang is still considered favorable and youthful in an Asian eye. We describe a novel technique for pinching the upper lid skin with the patient awake to determine the amount of skin to be removed during blepharoplasty. This technique allows the patient's desired amount of skin overhang and height of the supratarsal crease to be determined precisely. By involving the patient in the decision process, a cosmetic result consistent with each individual patient's preoperative expectations can be achieved. The dynamic nature of the estimation process also allows for a more conservative estimation of skin for removal. The flexibility of the pinching technique enables the creation of a youthful appearing eyelid with varying degrees of overhang while still preserving its Asian features.

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