Supratarsal fixation is really an antiquated method that invites the surgeon to form a crease that is simply too high for virtually every patient. The natural eyelid crease is caused by connective tissue fibers that firmly connect the eyelid platform skin to the underlying levator aponeurosis tendon. This tendon connects the upper eyelid to the levator palpebrae superioris muscle in the orbit. This muscle is responsible for opening the eyes. The connective tissue fibers from the levator aponeurosis to the skin form the upper eyelid crease and support the eyelid platform skin and upper eyelid lashes. If these fibers stretch out, which happens as we age, or are not present, which is seen in some Asian eyelids, the skin of the eyelid platform will be loose and the eye lashes will hang down (eye lash ptosis).
Anchor Blepharoplasty (Eyelid Surgery)
Anchor blepharoplasty is a blepharoplasty technique where the levator aponeurosis is exposed at the time of surgery, and stitches are placed from the cut upper eyelid platform skin and muscle to the exposed levator aponeurosis. By doing this in a very precise fashion, the upper eyelid lashes are supported and perky and the eyelid platform skin is snugged over the eyelid platform much like someone might pull a bed sheet taut. This technique requires both absolute precision to be done well and a very detailed knowledge of eyelid anatomy. In Dr. Steinsapir’s experience less than 2% of all eyelid surgeons are able to perform an anchor blepharoplasty.
So-called supratarsal fixation should be another name for an anchor blepharoplasty. However, it is seldom actually practiced this way. Surgeons often interpret this procedure to mean “above the top of the tarsus.” Effectively they do away with the surgical dissection needed to identify the levator aponeurosis. Instead they interpret supratarsal to mean sewing the cut edge of the eyelid platform skin somewhere above the top of the tarsus. Effectively this often means sewing the skin to something much more superficial such as the orbital septum. This is not the same thing. The levator aponeurosis is a mobile structure. When you open the eyes, the levator aponeurosis slides up and back. Anything attached to the levator will also slide up and back. When the eyelid platform skin and underlying muscle are accurately attached to the levator aponeurosis, the eyelid platform skin stays well snugged and the eye lashes well supported whether the eyelids are open or closed. In contrast, if the skin is “supratarsally” fixed, the skin is snug (or too tight i.e. the eyelids are short of skin) when the eyes are closed and loose when the eyes are open.
Another issue with so-called supratarsal fixation is that it is often associated with a surgical look. This is because the upper eyelid crease is made too high. The top of the tarsus is 10 mm from the actually eyelid margin. To fixate above the tarsus, the crease is being made north of 10 mm. In addition, with healing the crease normally creeps even higher by one or two millimeters. It is not unusually to see crease height of 12 or even 14 mm. This height is at the expense of the upper eyelid fold which is often surgically wiped-out. This makes the upper eyelid look too hollow-think Barbra Walters.
In contrast, a properly done anchor blepharoplasty can be done at almost any height above the eyelid margin with preservation of the upper eyelid fold.
About Dr. Steinsapir
Dr. Steinsapir 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.
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