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Asian Blepharoplasty II: The Second Vector
Continuing to describe the Asian blepharoplasty technique used by the author, this chapter looks at the handling of the middle layer structures of the eyelid once the preaponeurotic (middle) space has been reached. The chapter will take the procedure up to closure of the eyelid crease. Figure 9-1 shows the cleared preaponeurotic plane being readied for construction of the eyelid crease.
Primary Asian blepharoplasty.
Following Opening of the Orbital Septum
Rotation of Myocutaneous Strip Away From Underlying Levator Aponeurosis and Preaponeurotic Fat Pad, Hinging It Along Superior Tarsal Border
A Blair's retractor is used to retract the opened upper incision (skin and orbicularis) ( Figure 9-2A ); Westcott scissors are used to separate the preaponeurotic fat beneath it from the orbicularis in front and levator below it. This central preaponeurotic fat pad is often adherent by fascial attachment to its underlying levator muscle fibers ( Figure 9-2B ).
The fat should be repositioned and allowed to fill in the space between the levator and anterior aspect of the superior orbital rim (the supratarsal sulcus).
In Figure 9-3 the skin–muscle flap is being retracted in the upper portion of this photograph using a Blair retractor along the upper incision line (surgeon's view from the head of the table). Pristine levator muscle with fine blood vessels can be seen running vertically over the levator, as well as within the preaponeurotic fat pad (vessels running horizontally here).
Pearls
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After separating the initial fine adhesions of fat from the overlying orbicularis, it is often safer to use moist cotton tip applicators to separate fat from the underlying aponeurosis.
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No attempt is made to remove fat pads unless the fat is grossly interfering with crease formation along the superior tarsal border. A Wetfield bipolar cautery may be used to reduce it if it is potentially hindering the construction of a good crease due to its presence directly over the superior tarsal border.
Pitfalls
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Avoid pointing the scissors posteriorly towards the levator as you elevate the myocutaneous flap.
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After the myocutaneous flap has been elevated, avoid cutting any fat that may be intertwined on the underbelly of the myocutaneous strip; this may cause bleeding of the intra-fat blood vessels, as well as unintended reduction in the volume of preaponeurotic fat left behind.
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