A pair of beautiful, sparkling eyes occupies an important place in the human features. Although the beauty of the eyes is not assessed by single or double eyelids, by and large, single eyelids are smaller and lack eyes. The eyes with double eyelids are wider and longer, and the eyelashes are upturned, making them appear brighter and more luminous. Having double eyelids has been a boon to girls who love beauty.
Due to racial differences, eyelids have their own anatomical characteristics. The Caucasian race has a wide upper eyelid crease, a large eyelid fissure, thin eyelids, a depressed supraorbital area, and a short distance between the upper eyelid margin and the brow arch. The eyelids of Oriental peoples have the following characteristics: 50% of Orientals are missing the upper lid crease; the upper lid is thick and rich in fatty tissue; the distance between the inner canthus of the eyes is wider due to the flattened nasal bridge; and the distance between the lid margin and the brow arch is farther. Although double eyelids are not the only determinant of eye aesthetics, in general, eyes with double eyelids appear larger and more luminous than those with single eyelids.Regardless of the fact that the aesthetic significance of heavy eyelids has never been absolute in theory, blepharoplasty is by far the largest part of cosmetic surgery.
I. Aesthetics of the eye and eyebrow
1. The aesthetic position of the eyes
The “three stops” – the length of the human face is divided into three equal parts, with the eyes located above the middle stop.
”Five eyes” – the human face can be divided into five equal parts according to the width of the eye fissure on the eye level, i.e. the width of the eyelid fissure, the distance between the inner canthus, and the distance from the outer canthus to the ear are approximately equal.
2. The interrelationship of the eyes, eyebrows, and nose.
3. Important aesthetic parameters of the eye.
The upper lid sulcus is 7-8mm from the lid margin
The tilt of the lid fissure is 10°
The projection of the eye is 12-14mm and the corneal exposure rate is 80%
The inner canthus is slightly blunt and rounded at 48°-50°; the outer canthus is sharper at 30°-40°
II. Preoperative design
Principle: Harmony and unity, bilateral symmetry. A specific, coordinated blepharoplasty is designed according to the age, personality, occupation, facial shape, eye shape and individual facial organs of the candidate.
The shape of the eyelid.
Three types of classification
Wide-tailed: Most commonly used.
Parallel: Suitable for round and square faces.
Crescent-shaped: used sparingly.
Width of the heavy lid.
Wider Width >8mm, suitable for long face types, a few dancers and theater actors.
Moderate Width 5.5-7.0mm, suitable for most people.
Narrower Width <5mm, for those with small lids and those who do not want to be noticed as having a blepharoplasty.
Method.
The upper eyelid sulcus is generally located 6-7mm from the upper lid margin, where the line is most natural.
Three-point fixation method
A bamboo stick or forceps is gently pressed into the intended line to observe the result.
Iodine fixation
Indications
1.Single eyelid in good health and normal spirit, who request for surgery without contraindications.
2, monolids with bloated upper eyelids (commonly known as blister eyes).
3. Monolids with internal canthus.
4. mild upper eyelid entropion.
5, mild upper lid ptosis (combined with levator muscle shortening).
6, upper lid skin laxity and ptosis, affecting the visual field. Most often seen in the elderly.
7, one single and one double in both eyes, single lid side can be operated. or both eyes with different widths of creases and different sizes of lid fissures.
8. Inner double or hidden double where the heavy lid is not obvious when contending for the eye.
The age at which blepharoplasty should be performed is usually not too early, because eyelids change a lot in early childhood, sometimes single and sometimes double, so it is better to wait until around puberty before starting to consider surgery.
Contraindications
1. Mental disorders or psychological disorders, lack of recognition of one’s own condition, and the pursuit of an unrealistic eyelid shape.
2. patients with bleeding disorders and hypertension, as well as active and progressive diseases of the heart, lungs, liver, kidneys and other vital organs, uncontrolled diabetes and those suffering from infectious diseases
3, congenital amblyopia, inner or outer eye, and those with acute or chronic periocular infectious diseases that have not been controlled and have not healed on their own.
4, those with facial paralysis with incomplete lid closure
5, those with various causes of ocular hyperopia, hyperconcave or receding eyelids
6. those whose families are firmly opposed to it
7. Those with ptosis.
V. Preoperative examination and preparation
Preparation for the whole body examination
Take a medical history to find out if there are any contraindications to systemic surgery.
Stop taking steroid hormones and anticoagulant drugs such as aspirin 7~10 days before surgery.
Eye examination and preparation
VI. Common surgical methods and their advantages and disadvantages
1.Buried wire method.
It is a method that uses a small incision to bury sutures under the skin. It is suitable for young people with little orbital fat and thin, tight skin on the upper eyelid, for those with a single lid on one side, or for those who have an occasional heavy lid, or for those who have a partial shallowing or disappearance of the heavy lid fold after double eyelid surgery.
The advantages and disadvantages of the buried wire method, which can be divided into two types: interrupted buried wire method and continuous buried wire method, are
(1) The interrupted buried wire method is easy to perform, lightly traumatized, with no scars on the skin, light post-operative swelling and bruising, and quick recovery, with swelling generally subsiding 15 to 20 days after surgery and the eyelid approaching natural. The disadvantage is that nodules appear under the skin and the eyelid fold lasts for a shorter period of time.
(2) The continuous laparoscopic method is safe and reliable, with short surgery time, little pain, and quick swelling. Because of the continuous laparoscopic method, there are 6 to 10 contact points for the lid tissue or prefascia sutures (compared to 3 to 6 for the interrupted laparoscopic method), which increases the area of skin-lid tissue adhesion, making the surgery more reliable and with a higher success rate. The intermittent method requires 3 to 5 knots, which can cause hard knots to develop after surgery, while the continuous method has only one knot that can be buried deep under the skin, making it less likely that hard knots will form.
2. Suture method.
This is a suture ligature that penetrates the upper lid skin and the fornix of the lid conjunctiva. The sutures are changed daily after surgery and the stitches are removed after l weeks. The edema is more obvious after this surgery, the recent effect is not ideal and the double eyelids made are not natural, but they usually look natural in about 3 months, and the effect is better after 6 months.
3. Incision method.
The incision method refers to the method of cutting open the eyelid, removing the muscle and fat, removing the loose down skin according to the situation and then connecting the dermis to the upper eyelid lift muscle that supports the eyelid.
For people with loose upper eyelid skin, bloated upper eyelids, triangular eyes, and canthus, the incision method is the most effective way to perform blepharoplasty, and for those with unsatisfactory results after double eyelid surgery with the buried or suture method, this method can be used to remedy the problem, and it is less likely to recur after surgery.
It has the disadvantage of long surgery time and long recovery period compared to the buried suture method, but recovery is usually possible in 5-7 days. The stitches can be removed 3-5 days after surgery and you can resume your daily life 1 week after surgery. The results will be visible for at least six months to a year.
VII. Complications
1. Swelling and bruising: Eyelid edema and bruising are inevitable after surgery, and conjunctival bruising is occasionally seen. The swelling usually begins to subside in 7 to 8 days, and it takes about 1 to 3 months for the swelling to completely subside. The procedure should aim to be noninvasive, rapid, and thorough in stopping bleeding, with pressure bandages and cold compresses applied within 24 hours after surgery. In case of severe postoperative bleeding, the wound must be opened to stop bleeding.
2.Infection: It is rare. The main preventive measures are: strict disinfection of the surgical area, thorough hemostasis, avoiding rough surgical operation and long surgical time. Once signs of infection appear, local drainage should be performed promptly, sutures should be removed as soon as possible, and antibiotics should be applied.
3. Transient ptosis: Mild ptosis can occur within 1 week after surgery due to swelling and upper eyelid muscle weakness, which does not require treatment and can recover naturally.
4. Uneven width of the upper eyelid crease: Mostly related to the design of the drawing line, cutting technique, and height of the fixed lid plate. In some patients, the width of the eyelid crease is not equal on both sides and should be corrected during surgery. However, due to surgical trauma and post-operative edema, inconsistencies in the width of the eyelid can occur on both sides in the near future, so there is no urgency to correct them. It can be reoperated 3-6 months after the upper lid swelling has subsided. On the higher side, the incision is designed according to the lower side, the skin is cut, and the skin between the two eyelid lines is loosened and or removed and sutured to the new position of the lid. On the narrower side, the skin is incised and or sutures are applied to correct the skin according to the crease line on the higher side. The exact side to be corrected depends on the width and patient requirements.
5. Narrowing or disappearance of the eyelid line Suture method: the buried thread does not hang on the lid or the sutures are not tied tightly enough to make the lid plate adhere to the skin; incision method: the tissue in front of the lid plate is not removed enough and the upper lid skin is not firmly bonded to the lid plate; the operator’s surgical method is not chosen properly. For young people with thin eyelids and lighter medial canthus, the suture method can be used; loose upper lid skin and heavy medial canthus: incision method.
Treatment: For partially inconspicuous ones, if the interrupted suture method is used, only the inconspicuous part needs to be buried again; this method can also be used to repair the heavy eyelid line if it is inconspicuous after the incision method. If the entire blepharoplasty line is inconspicuous, the surgery needs to be redone; incision is made through the original incision and enough prelid tissue is removed, paying attention to the sutures to bring in the lid or prelid fascia and hang the skin on the fascia or lid plate with exact and firm sutures. The time for re-repair can be within 7 days or 3 months after surgery.
6. Upper lid and heavy lid sulcus depression: Excessive removal of the orbicularis oculi and fat makes the depression more pronounced when the eye is turned upward, especially in the central part of the heavy lid sulcus. Treatment: Separate the adherent portion of the orbital septum from the skin and implant the dermis, dermal fat, or fascia. If sutures are placed in the orbital septum or sutured very high in the levator muscle, this can also cause a sunken heavy lid sulcus, and the treatment is an elective release procedure.
7. Triple eyelid: One to two more creases than the normal heavy eyelid, seen only with incisional blepharoplasty. The reason for this is that after the orbital septum is cut and the fat is removed, the septum opens up and adheres directly to the skin above the blepharoplasty incision, which may result in trichiasis when the eyes are opened after surgery. There is no need to worry about the appearance of trichiasis, and then the repair method.
(1) For early mild trichiasis, the upper eyelid can be pulled frequently to potentially loosen the adhesions.
(2), If the degree of trichiasis is heavy, surgical repair is also required, i.e. the skin is cut through the original heavy eyelid line, the adhesions are loosened, the skin at the lower edge of the incision is sutured upwards over the original suture point and then to the lid, and then the incision skin is sutured together so that the trichiasis can be corrected.
(3), you can also remove the skin between the heavy eyelid line and the eyelid and then re-suture the incision.
8. Excessive width of the eyelid: Failure to tense the loose skin upward when designing the eyelid line, too much upper lid skin removal, too much orbital fat trimming, adhesions between the orbital septum and fascia, and over-hanging sutures can all cause excessive width of the eyelid. Treatment: If the design line is too wide, it can be corrected by designing a new eyelid line at the normal eyelid width of 6-8mm and removing the skin between the old and new eyelid lines. The latter types are more difficult to treat and can be treated by thoroughly loosening the adhesions between the skin, orbicularis oculi, orbital septum, and levator aponeurosis until the skin crease disappears when the eyes are opened. If there is still orbital fat, it is loosened so that the lower edge reaches the upper edge of the lid and the lower edge of the incision is intermittently sutured with 5-0 silk or 60 absorbable thread to the lower edge of the dermis, the levator aponeurosis, and the lower edge of the fat with a few stitches to block the adhesions between the levator aponeurosis and the orbital septum, orbicularis oculi muscle, and skin. If no orbital fat is available, only autologous fascia or dermis or fat can be taken for the septum.
9. Narrow eyelid: too narrow in design, offset when cutting the skin, insufficient excision of loose skin, too low fixation position during suturing. This can be treated symptomatically.
10. Sagging eyelashes, loose skin under the lid line: the height of the skin suture under the lid line is lower than the width of the skin under the lid line and or the lid line design is too wide and the skin under the lid line is wider than the lid width. Treatment: Excision of a strip of skin and or suturing to the lid plate 1-2mm above the width of the skin under the lid line so that the skin is taut and the eyelashes are uplifted. The eyelashes can be made to upturn slightly too much during surgery, but the upper lid should not be turned out, and the eyelashes can be restored partly downward after the stitches are removed and the swelling subsides.
11. Triangular eye deformity: This occurs because the inner canthus is designed too wide or the outer canthus is designed too narrow, or because the amount of outer skin removed is insufficient for those with lax eyelid skin, or because the orbital fat is not sutured after the outer orbital fat is removed, resulting in downward prolapse of the orbital fat. Symptomatic treatment after six months.
12. Ptosis: The upper eyelid tendon membrane is mistakenly cut during surgery, or there is extensive adhesion between the tendon membrane and the orbital septum, or there is mild ptosis before surgery, which is ignored before surgical examination and becomes more obvious after surgery. Symptomatic treatment is performed.
13. Incomplete closure of the eye fissure: too much skin is removed, or the skin incision is fixed too high to the upper edge of the lid fascia. In mild cases, this can be recovered over time, while in severe cases, relaxation or implantation is feasible.
14. scarring: bad cuts, rough sutures such as too thick stitches, too large margins, misalignment of the skin edge, and infection can cause significant scarring.
(D) Time for repair again
The tissues are not yet fully bonded and easily separated within one week after surgery. If it is more than one week, especially within two months after surgery, because it is in the tissue repair period, the tissue is brittle, adhesions are heavy, anatomical relationship is unclear, the skin is easily torn by the sutures, bleeding more during surgery, and scar growth is heavy, so it is better to repair after two months or longer. The surgeon should explain to the patient patiently, and often cannot achieve good results if the surgery is rushed.