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Concept of Triangular, Trapezoidal and Rectangular Debulking – Application in Upper Blepharoplasty
This chapter deals with the technique used by the author to facilitate the likelihood of forming a crease in a single-lidded individual: by effective removal of redundant hindering tissues (proper orientation of the removal of different layers so as to allow natural closure), minimization of scar from tension, and thorough completion of each step with lessened postoperative swelling. The steps are applicable to any form of upper blepharoplasty, whether primary or revisional, in Asians or non-Asians.
In previous publications, I discussed the concept of upper eyelid crease configurations and the essential steps required for predictable placement of a lid crease for single-eyelid patients. This method is based on accurate measurement of the central height of the upper tarsus, using it to guide placement of the external incision line for formation of the crease. As has been mentioned in previous chapters, the ideal crease tends to be either the nasally tapered crease or the parallel crease configuration. Medial upper lid fold is often present in the medial portion of the upper eyelid of Asians, whether they have a crease or not, and should not be considered pathologic and radically removed.
Surgical Steps
Marking of Crease
It is my practice to use the shaved-off tip of a wooden cotton-tip applicator dipped in methylene blue to mark the proposed crease. Between 0.5 and 0.75 ml of anesthetic is used to achieve sensory anesthesia of the upper lid several minutes previously. I evert the upper lid and measure the vertical height of the tarsus over the central portion of the lid with a caliper. This measurement is usually between 6.5 and 7.5 mm. It is carefully transcribed onto the external skin surface, again over the central part of the eyelid skin. This point directly overlies the superior tarsal border and will serve as a reference point for the overall crease height along the central one-third of the eyelid, whether the crease shape is to be nasally tapered, parallel, or laterally flared. For those patients who have a crease, I also measure the tarsus to confirm that the crease that I am observing – if I am planning to preserve or enhance it – is indeed the correct crease line to use. If the crease is to be nasally tapered, I mark the medial one-third of the incision line to taper toward the medial canthal angle or to merge with the medial upper lid fold. The lateral one-third is marked in either a leveled or flared configuration. For a parallel crease, the measured height of the superior tarsal border is drawn across the eyelid skin. To recapitulate, the height of the tarsus determines the overall central position of the surgical crease; the shape is determined by how you design the medial and lateral thirds of this according to the patient's preference ( Figures 8-4 and 8-5 ).
Skin Incision/Skin Excision
To create adequate adhesions, it is necessary to remove some skin plus subdermal tissue. A strip of skin measuring approximately 2 mm is then marked above and parallel to this lower line of incision. In the patient who desires a nasally tapered configuration, I taper this upper line of incision toward the medial canthal angle or merge with any medial upper lid fold that may be present. As a result, the skin excision is often less than 2 mm over the medial portion of the crease. The incision is then carried out with a No. 15 surgical blade (Bard–Parker) along the upper and lower lines, incising just beyond the subcutaneous plane. I control any fine capillary oozing with a bipolar cautery. (The strip of skin bounded by the upper and lower lines of incision may be excised with scissors, or preferably, it is excised after the orbital septum is opened along the superior line of incision and the skin orbicularis–orbital septum flap is turned inferiorly along the superior tarsal border, see below.) The excision of a strip of skin is not necessary in every case; however, it is my belief that it facilitates removal of subsequent layers of the lid tissues, thereby allowing adequate crease formation ( Figure 8-6 ).
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