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Can I get an anchor blepharoplasty using a double suture threading method?

Published on November 27, 2011

Let me jump right in and say no.

The double fold suture methods for Asian eyelid surgery, are ostensibly closed methods. Small incisions are made in the eyelid for the purpose of hiding the sutures used to form a crease. In contrast, anchor blepharoplasty is an open eyelid method. In order to perform an anchor blepharoplasty, the surgeon must make an upper eyelid crease incision. Through this incision, the orbital septum is identified and opened. A very clear operational understanding of eyelid anatomy to perform the surgical dissection needed to perform the surgery. Unfortunately, many eyelid surgeons lack this basic but specialized anatomic knowledge. In my experience operating with senior plastic surgeons, less than 5% of these surgeons possess the knowledge, skill, and experience to correctly perform this dissection.

Anchor blepharoplasty anchors the upper eyelid platform skin and the underlying orbicularis oculi muscle to the levator aponeurosis, the tendon like expansion of the levator palbeprae superioris muscle as it inserts into the upper eyelid tarsus. Attachments from this tendon to the skin are responsible for holding the upper eyelid platform skin firmly. As these attachments give way, the eyelid platform skin above the eyelashes becomes lax. Unfortunately this is precisely the area of the eyelid that must be taut to hold eyelid make up. Also when this skin lacks appropriate support, the upper eyelid lashes are not well supported and the upper eyelid lashes droop. This is known as lash ptosis. Lash ptosis is one of those subtle things that contribute to the eyelids looking tired.

For an Asian eyelid, a double fold is created when there are attachments under the skin between the upper eyelid crease and the levator muscle. For many Asians, these attachments are under developed. This accounts for the absence of a double fold. In some cases these under developed attachments may produce an incomplete partial fold. The suture methods force the crease to form along the path that the sutures are treaded. So long as the sutures remain intact, the crease is present. When the sutures break the scar tissue created by the passage of the sutures is seldom strong enough to maintain the crease and fold. This accounts for why the threading procedures do not hold up long term.

In contrast, the open double fold surgery produces eyelid structure that is permanent. The most critical aspect of successful double fold surgery is placing the crease at the correct position of the eyelid. The precisely height of the upper eyelid crease seems to be a bit of a mystery for most surgeons. Many surgeons being very diligent students have followed what is described in the textbooks. That would be great but for one fact. The appropriate height of this crease is not correctly reported in most plastic surgery textbooks. In Converse’s Textbook of Plastic Surgery, the height of a Western eyelid is noted to be 10 mm. Other texts note that for Asian eyelids the crease height should be 8 mm. These numbers are wrong on two counts. A surgeon making a crease at 10 mm will not find that the crease will heal to the desired position. As the upper eyelid wound heals, it migrates superiorly 1 to 1.5 mm. This means that a crease placed at 10 mm will heal at 11.5 mm above the eyelashes. An Asian crease cut at 8 mm will heal at 9.5 mm. At this height, the fold will never properly drape the upper eyelid. Most Asian women will feel that their eyelid is Westernized. Not the desired effect! I typically make my Asian upper eyelid crease incision at 5.5 to 6.5 mm. This means that the upper eyelid retains its quintessential Asian character.

With the eyelid open and the levator tendon carefully exposed, the presence of upper eyelid ptosis can be addressed with sutures that reinforce the upper eyelid tendon or, when necessary an actual anterior levator resection ptosis procedure can be performed. This permits as much or as little correction of upper eyelid ptosis as needed. Also this exposure is needed to anchor the upper eyelid skin and orbicularis to the levator tendon at the height of the new eyelid crease. No closed method permits this type of correction.

Not sure about your potential Asian eyelid surgeon? Have a frank conversation about their assessment of your eyelids. What height will they be placing the upper eyelid creases? How much skin do they intend to resect. Will the surgery only involve removal of skin, or skin, muscle, and fat, and why? Do they intend to open the orbital septum? (They should) If not, what is their plan to form a long-term upper eyelid crease and what height are they planning to place the crease? If the answers to these questions are lacking, you should consider interviewing more eyelid surgeons. These are very basic issues.

Dr. Steinsapir
Los Angeles

Dr. Steinsapir  of LidLift is a board certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology. Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA. Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician or surgeon and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

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