Bfepharoplasty is a surgical operation performed byptaitj-c iurgeons and ophthalmologists. Neverthe-iess this surgical procedure is performed also bysurgically oriented dermatologists. Re i erence s

periainini to this operation performed by dermatol-ogists are among others:

4 BLEPHAROPLASTY

A. Oriental Cosmeti-c Blepharop las ty

I\TARWAL I HAF.qHAP, M. D.

Department of DermatologY

-s

cnool of Med ic ine

Petre s ? J and Hundeiker, M.: Dermatosurgery 'Springer Verlag. New York' HeidelbergBerlin. 1978 .

Tapernoux, B.: Dermatology abroad: Switzerland'The Journ ' of Derm. Surg' l:7I, I975'

BrendLer, R.: Beitrage zur korrektivenDermatologie. Dre operative Behandlungder Lidfalten. Hautarzt' 5:468, L954'

Stough, D. B.: Corrective surgical olfice pro-cedures of the iace. Aft' Fair' 'PhYsician. 7:68, L9J3,

Course on BLepharoplasty for dermatologists'Fourth World Congress of the Inter-national SocietY of TropicalDermatology ' New orleans ' L97 9 '

78 Marwali Hatrzrhap

An upper 1id blepharopl asty and 1ipr"<_-t.r,my rsused routinely to recre.lte tlrLr trlall)€rbr;rl 1-o.l cj inthe aging Occidental.

In the Orient, the creatj.()rr of sul:r:r i()lI)alpebral fold ranhs as the Ill(]!i1 (.()lltftt()n . , { ) I i I r I ( , 1 .r a

.

surgical operation amonq the Ori.rrta,I and jlaccounts for more than haf f (Jl t hc Loi,.rl nuullrc,r ofpatients requesting cosmetic surgcry (1). IL lrr:-came popular after the Second Worl.l War. ,lu$t whymany Orientals prefer to "Westernize" Llr('jr ,y,.: isnot known , although iL is though L t:o sj L('lr f r-Onr Lheinfluence of motion pictures and l,h(,, irr<,r.irLirL,I-intermarriage of Asian women and C.rucasri.trr rtro|,particularly since the Second Worfd War-

The s1i l--cye of the Orient-at j r: a r:r,r'rrll I r,,rrcr>mmon Ly seen amongst those of Mon!t().1 i;rrl iit i)(il.i ,j.e.. the Chinese. the Japanese and the l(or(j.uts.'1.'he typical Mongoloid type of uppe:: eye1ir,l pres;entsthe foflowing intcresting features: I. 'J'h('superior palpebral fold is absent. 2. !i1r1.1.1-orblta1 fat is in excess. 3. An r'picanIlr;r I ir-,Idspans the medial canthus with a web whjc--lr ir.i clr,:; thecaruncfe. This epicanthal fold is al,se (.ir I l('(lLhe Mongofian fo1d. (Fig. 1) -

Many Oriental people have uppcr .l.id I o lr1:;, butapproximatefy half of them do not- Sorno ot-jr(.'nt.rfsrefer to the eye without a pafpebral. fo.l cl as th.l"single eye" and the eye with the fold as Llrt."double eye".

The Orientaf, striving for a more Occid.ntafappear:ance turns to surgery for ti]e crcaljon ofa palpebral fold.

ANA'IOMY

The absence of the superior palpebral foldin the Oriental may be expl.rincrcl as follows: Inthe Occidental upper 1id thc: I ('virl()r musclcinserts into the superior borcl.r of the t.arsus andinto the skin at the fo1d. lt'lri' Occ jdenLal upperlid is therefore lifted p.rrt i.r.l .ly by t.he skin a1_the fold (Figs- 2 and 3) . In ihc t'oldfessorientaf upper 1id no lcvat()r trul;cIe inserts intothe skin. The levator in LIrr:sr' Iicls exerts itsliull only on the antet:jot- s1tIf ;rc-.(, of the tarsus.llccausc LIr| sl<iD is noi- pulJc'<1 irp by the levartor,no foiil iir |r orluc<,d (2) . (Tliqs. 4 and 5) .

)

univerETtf o r-1t6?TE suna rraFffi - sEfiF-i.- F1rnsadi

Medan. Indone s ia

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Blcpharopl:rsty 79 80 Marwali lJarllraP

Figure 4-1. The slit-eye of the Oriental p:resentsthe folfowing interestinq f eatut:es:The superior palpebral fold is absent,supraol:bital fat is in excess and anepicanthal fold spans the mediafcanthus with a web which hides tht:caruncle.

- The Oriental upper lid afso appears ,'fuller,,than the Occidental 1id because of a differencein the anatomy of the orbital septum. In theOccidental lid the orbital septum meets thelevator B to 10 mm above the upper tarsaf border.The pre-aponeurotic (orbital) iat aoes not extendinto the lid. In the Oriental lid the pre_aponeurotic fat extends into the lid. ihe presenceof this fat within the lid gives the tid a ihickappearance.

The epicanthus is a semilunar fofd of skinextending fron the upper lid across the medialcanthal area to the margin of the fower lidmedially. Procedures to eliminate the epicanthalfold have been utilized by tt ansposition of Ltssueor Z-plasty of one type or anothet:. This is donemucl-r less often than the creation of the superior

Fiqu c 4-2- O' cjJentaI nv

palpebral fold probably because of the hic'li'i.,"ia"ta" of prominent or hypertrophic scitrspostoperativelY.'- - S"u"tul te"hniquos havc appeared jn tlr'fiteiature dealing with the surcJical creati()n oitn" t\]p"tlot palpebral folds of the Orielltaleyetid (3, 4, 5, 6, and 7) '

OPERATIVE TECI]N IQUES

A11 procedures are performed on an. oLltpat-ientlasis. 'patients are instructed to wash their iaceswitlr hexachlorophene (Phisohex) before surgery'Preoperative photographic documentatiol.t is con-f irrnccl , and the proposed fold can be demonstr'rtedto thlr paticnt in a mirror by gent1e p:::"ut(]\,iitn'-" i,."rr" a:l.ong the rid (Fiq' 6)' This sitccan bc nr, irst]rccl relative to the ciliary mal:gin 3nd

it--"i"nl l\' 1()r.rnd to be idealfy located 7 to B ntnr

""1r.,i1,,' ,'rrr,i 1,.rr:a11c1 to Lhc ciliary margin'

'l'lrr r; r llrl,l, r 1( cl,nique or the sling-lype is used

',, ,',.,,', , ,,, i ' ' ' 1;" l6unucr age group in whom

Blcpharoplasty 81

Figure 4-3. In the Occidental upper lid thelevator muscle inserts into thesuperior border of the tarsus andinto the skin at the fold.

there is a minimum of excess fat and skin.This simpler technique utilizes fine non-

absorbab.le suture material (silk 7-0) to connectthe levator palpebrae superioris to the eyelidskin at the desired level (Fig. 7). In Asianadults, this level varies al from 5 - B mm fromthe ciliary margin. When the eye opens, thesetiny slings of non-absorbable sutures puf l- theeyelid skin the:reby forming a superior palpebrall:old. The acticn of these sfings simufates verycloscly the aclion of the lervator nuscle f jbcr:s

Figure 4-4 - oriental eye'

which pJSS lrom Lhe levaior l"Itt"!f"l..:Y1" r jori s

to Lhe skin in the occidcnLal upper cyrrr r(r-

ii i'n"t""-o.r.t,ttr= with slit-eyes these.lc'vator;il';t;";,-;;;'-'J" ""t

insert into the ski.'' -'";;"-;;;;;"t technique is as follows (3' 8):

l. 'l'hr ('(r pairs of points are marked with 2?'' ' i,,'I', i;rii violet

-solution on the upper eyr'1 i d ''l:t,,,,,, 1,,,i nt-s must match with points made on

;i; I1 ,rr.i rt: tYcliLJ' tt'jq' B]

:t- |1. i:'r,r i:: ir,l illr.rr...l '"vith a 2? lI'ln'ainer.,.' 'r' r, wrll. ,l'i1"'; Lr jnr-'

82 Marwal i IlarahaP

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Blepharoplasty 83

Figur:e 4-5. In the foldless Oriental upper lldno levator muscle inserts into theskin-

3^ The eyelid is everted exposing the conjunctiva,which has been treated beforehand with atopical application of l? tetracaine(pontocainb) solution. A subconj unctivalinfiltration is carried out with 0.5 ml of2? lidocaine solution.Two points, A1 and 81, 2 - 3 llm1 apart aresefected on the conjunctival surface. Thesetwo points 1ie directly above points A and B onLl-rcr r.yeJ id skin (Fiqs - 9 and l0) .

Iriqur:e 4*6 " 1'he proposecl fold can be dolrol)51 r- rtedto the patient in a mirr:or by gerrt-lepressure with a probe 'rlonlj tlrc Iid'

5. Buried. mattress sutures are placed transconjunctivally, which connect points A1 - Bl -B - A (Fiq. 11). Three buried mattresssutures oi this type on each eyelid fix thelevator to the eyelid skin. These suturesare carefulfy placed to construct a normalshape and curve to the fold.No post-operative dressing is necessary and

1,he patient is affowed home the same dalr'ihis technique is simple in execution and

has the advantage of being reversibfe-Two months after the operation, when the

edema has completely subsided, both superiorpalpebral folds must match in position, height,i""qt}r and contour. If this is not the case, by.r.tlitrg the number of mattress sutures and theirspa-tiai relationships one to another and to thceyelid marqi.n, we "in vary the height, length andconlour o F Lhe supe r ior pa Lpebra I I ol d -

Fiqs. 12 and i3 show, t'The b"for" and after"

84 Mar-wali H:rrahap

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4.

Blcpharoplasty 85

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lgturt,

86 Marwal i Harahap

SrCqCl:q. rhreewithupper

The radical technique is as follows (4' 5, 1,91 :

1. The Iine of the proposed palpebral fold ismarked with 2? Gentian Violet solution aboutB fiun above the ciliary margin of the uppereyel id. (Fig. -14 ) .

2. Local anesthesia is achieved by injecting2B lidocaine solution with epinephrine.

3- Skin incision is made along the line of thefuture palpebral fold and carried downthrough subcutaneous tissue and orbicufarismuscle. (Fi9- l5).

4. The skin and orbicularis ocu1i muscle isdrawn aside; the fat comes into view. (FiS.16). The supra-orbital fat is picked up withfor.ccps and triruned off with scj,ssors. (Fi9-17). Thjs st-ep rcnoves the puffy look of the

pairs of points are mark€'(l2? Gentian violet solution on theeyelid.

It ig ure 4-7 Fine non-absor:bab1e suture connectsthc levaLor p.r lpebral superior isto the eyelid skin at a desired1eve1.

pictur:e of the operation.Afthough this simpler technique can provide

natural resufts, unfortr.rnately the resufts arenot afways of a permanent nature. Besidesr thesimpler technlque is not suitable for those whohavc too much supra-orbital fat.

l'herefore we prefer a more radical approachvi.r a Jong supratarsal incision and removal of;rI I c.xccss supra*orbital fat. This methodr,,r;Lr ll s in a pcrmanent fold-

Blcphanrplasty 87

B,) 2 - 3 mm anarlconi unctival

8B M:rr-w:rli Haruha1.r

s

!:fg!4 f:]!- Bur j r:d nr.r L Lres:j suLur Lrs trre placedt-t:.rns-coni unctival f y, wliich connectpoints Al - B1 -B*A.

upper eyelid. It is impol:tant to excise equalamounts of supra-orbitaf fat from each eyelidfor better syrnmetry ' Careful and completehemostasis is necessarY.

5. The dermal fayer of the fower sk'i n Ilap jsanchored to the anterior surfac<: ol the ex-posed tarsus. Three to five such buriedsuLures are insertcd. This encourages f ibr:ousl i sslre formation and adhesion between the skinand tarsaf plate at the predetermined level-Irar this purpose 7 - 0 monofilament nyloni s used .

( 'J']r., skin is closed with 6 - 0 silk or nylon;rlong the line of the pafpebral fold.

/, l!,rr r()w strjp <lressings are applied to the in-('rr;i()rr. The parti{rnt is allowed home the same

trittr,. lrl ,,rrrl l!) -.ih()w: "thc b,:fore and after" pic-I!l{ r,l llr. i,l,,.t,rt i()Il -

I

I$

3r At

ll:Sjlc,!,z. Two points (At andare selecled on thesuri ace -

Points Al and Bt onsurface lie d ir6ctlyarnd B on the eyelid

the conj unctivalabove points A

skin.

I,'igure 4*10.

BIcpha r,.,plasty 89 90 Marw:rli Har-:rhzrp

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I.'i qlr]:o 4-12. Bef ore the operation. Figure 4-13. After the operation.

SUMI4ARY

'l'lrc creation of palpebral folds in the Or:ientalir; I cosmetic operation requested by patientst() "W(.sternize" their eyes. The anatomy of the0ri(.rr1.rl and Occidental eyelis is discussed- Therrrrrlicirl technique is described and illustrated.

I

Blcphzrroplasly 9l 92 Mar-wali l{ar:rhap

Fiqure 4-15. Skin incision is made along the lineof the future palpebral fold andcarried down through subcutaneoustissue and orbicularis muscle.

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lfirlrrrr.:4 14.

!i.: Li.t!l

The fine oF the proPoscd palpel)ralfold is marked \,iith 2t centianViolet sofulion.

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Blephlr',,;rl.rstv 93

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Figure 4-16. The skin and the orbicularisoculi muscle are drarirn aside,fat comes into view.

()l Marwali lJarahap

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lilture 4-17. The supra-orbital fat iswith forceps and trimmedscissors.

picked upoff with

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Blcphzrroplasty

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lligU:q3:f g. Before the operat.ion.

Marwali l-larahap

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Figure 4-19. After the operation.

95

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