BLEPHAROPLASTY

A.

78

Oriental Cosmeti-c Blepharop las ty

Marwali

Hatrzrhap

An upper 1id blepharopl asty and 1ipr"<_-t.r,my rs

used routinely to recre.lte tlrLr trlall)rbr;rl 1-o.l cj in
the aging Occidental.
In the Orient, the creatj.()rr of sul:r:r i()l
I)alpebral fold ranhs as the Ill(]!i1 (.()lltftt()n . { I ( 1 .r
surgical operation amonq the Ori.rrta,I and jl
accounts for more than haf f (Jl t hc Loi,.rl nuullrc,r of
patients requesting cosmetic surgcry (1). IL lrr:came popular after the Second Worl.l War. ,lu$t why
many Orientals prefer to "Westernize" Llr('jr ,y,.: is
not known , although iL is though L t:o sj L('lr f r-Onr Lhe
influence of motion pictures and l,h(,, irr<,r.irLirL,I
-intermarriage of Asian women and C.rucasri.trr rtro|,
particularly
since the Second Worfd WarThe s1i l--cye of the Orient-at j r: a r:r,r'rrll I r,,rr
cr>mmon Ly seen amongst those of Mon!t().1 i;rrl iit i)(il.i ,
j.e.. the Chinese. the Japanese and the l(or(j.uts.
'1.'he typical Mongoloid type of uppe:: eye1ir,l pres;ents
the foflowing intcresting features:
I. 'J'h('
superior palpebral fold is absent. 2. !i1r1.1.1orblta1 fat is in excess. 3. An r'picanIlr;r I ir-,Id
spans the medial canthus with a web whjc--lr ir.i clr,:; the
caruncfe. This epicanthal fold is al,se (.ir I l('(l
Lhe Mongofian fo1d. (Fig. 1) Many Oriental people have uppcr .l.id I o lr1:;, but
approximatefy half of them do not- Sorno ot-jr(.'nt.rfs
refer to the eye without a pafpebral. fo.l cl as th.l
"single eye" and the eye with the fold as Llrt.
"double eye".
The Orientaf, striving for a more Occid.ntaf
appear:ance turns to surgery for ti]e crcaljon of
a palpebral fold.
,

I\TARWAL

HAF.qHAP,

M.

D.

Department of DermatologY
cnool of Med ic ine

o r-1t6?TE
univerETtf
-

Fffi sEfiF-i.-s

suna

rra

F1rnsadi
Medan. Indone s ia

Bfepharoplasty is a surgical operation performed by

ptaitj-c iurgeons and ophthalmologists. Nevertheiess this surgical procedure is performed also by
surgically oriented dermatologists. Re i erence s
periainini to this operation performed by dermatologists are among others:
Petre

?J

and Hundeiker, M.:

Springer Verlag.
Berlin. 1978 .

Dermatosurgery '

New

York' Heidelberg

Tapernoux, B.: Dermatology abroad: Switzerland'

The Journ ' of Derm. Surg' l:7I, I975'
BrendLer, R.: Beitrage zur korrektiven
Dermatologie. Dre operative Behandlung
Hautarzt' 5:468, L954'
der Lidfalten.

Stough, D. B.: Corrective surgical olfice

cedures of the iace. Aft' Fair' '
PhYsician. 7:68, L9J3,

pro-

Course on BLepharoplasty for dermatologists'

Fourth World Congress of the Inter-

national SocietY of Tropical

Dermatology ' New orleans '

L97 9 '

I r I

ANA'IOMY

The absence of the superior palpebral fold

in the Oriental may be expl.rincrcl as follows:
In
the Occidental upper 1id thc: I ('virl()r musclc
inserts into the superior borcl.r of the t.arsus and
into the skin at the fo1d. lt'lri' Occ jdenLal upper
lid is therefore lifted p.rrt i.r.l .ly by t.he skin a1_
the fold (Figs- 2 and 3) . In ihc t'oldfess
orientaf upper 1id no lcvat()r trul;cIe inserts into
the skin. The levator in LIrr:sr' Iicls exerts its
liull only on the antet:jot- s1tIf ;rc-.(, of the tarsus.
llccausc LIr| sl<iD is noi- pulJc'<1 irp by the levartor,
no foiil iir |r orluc<,d (2) . (Tliqs. 4 and 5) .

r
Blcpharopl:rsty

Figure 4-1.

79

The slit-eye of the Oriental p:resents

the folfowing interestinq f eatut:es:
The superior palpebral fold is absent,
supraol:bital fat is in excess and an
epicanthal fold spans the mediaf
canthus with a web which hides tht:
caruncle.

Oriental upper lid afso appears ,'fuller,,

- The
than
the Occidental 1id because of a difference
in the anatomy of the orbital septum. In the
Occidental lid the orbital septum meets the
levator B to 10 mm above the upper tarsaf border.
The pre-aponeurotic (orbital) iat aoes not extend
into the lid.
In the Oriental lid the pre_
aponeurotic fat extends into the lid.
ihe presence
of this fat within the lid gives the tid a ihick
appearance.
The epicanthus is a semilunar fofd of skin
extending fron the upper lid across the medial
canthal area to the margin of the fower lid
medially. Procedures to eliminate the epicanthal
fold have been utilized by tt ansposition of Ltssue
or Z-plasty of one type or anothet:. This is done
mucl-r less often than the creation of the superior

80

Marwali lJarllraP

Fiqu c 4-2-

O'

cjJentaI

nv

fold probably because of the hic'li

palpebral
'i.,"ia"ta" of prominent or hypertrophic scitrs
postoperativelY.
'- - S"u"tul te"hniquos havc appeared jn tlr'
fiteiature dealing with the surcJical creati()n oi
tn" t\]p"tlot palpebral folds of the Orielltal
eyetid (3, 4, 5, 6, and 7) '
OPERATIVE TECI]N IQUES

are performed on an. oLltpat-ient

A11 procedures
'patients
instructed to wash their iaces
are
lasis.
(Phisohex)
before surgery'
witlr hexachlorophene
is condocumentatiol.t
photographic
Preoperative
demonstr'rted
be
can
fold
proposed
the
and
f irrnccl ,

gent1e p:::"ut(]
to thlr paticnt in a mirror by
(Fiq'
6)' This sitc
rid
the
a:l.ong
\,iitn'-" i,."rr"
3nd
can bc nr, irst]rccl relative to the ciliary 7mal:gin
B
ntnr
to
located
it--"i"nl l\' 1()r.rnd to be idealfy
margin'
,'rrr,i 1,.rr:a11c1 to Lhc ciliary
is used
sling-lype
""1r.,i1,,'
the
or
r
1(
cl,nique
llrl,l,
r
r;
'l'lrr
whom
group
in
, ,,, i
' ' ' 1;" l6unucr age
',, ,',.,,',

Blcpharoplasty

81

82

Marwal i IlarahaP

;)
!-"

Figure 4-3.

In the Occidental upper lid the

levator muscle inserts into the
superior border of the tarsus and
into the skin at the fold.

there is a minimum of excess fat and skin.

This simpler technique utilizes fine nonabsorbab.le suture material (silk 7-0) to connect
the levator palpebrae superioris to the eyelid
skin at the desired level (Fig. 7). In Asian
adults, this level varies al from 5 - B mm from
the ciliary margin. When the eye opens, these
tiny slings of non-absorbable sutures puf l- the
eyelid skin the:reby forming a superior palpebral
l:old. The acticn of these sfings simufates very
closcly the aclion of the lervator nuscle f jbcr:s

Figure 4-4 -

oriental

eye'

r jori s
which pJSS lrom Lhe levaior l"Itt"!f"l..:Y1"
cyrrr r(rto Lhe skin in the occidcnLal upper
these.lc'vator
slit-eyes
with
ii i'n"t""-o.r.t,ttr=
insert into the ski.'(3'
;il';t;";,-;;;'-'J"
8):
' -'";;"-;;;;;"t
""t
technique is as follows
with 2?'
l.' ' 'l'hr ('(r pairs of points
-solutionareonmarked
eyr'1 i d '
upper
the
i,,'I', i;rii violet
on
made
'l:t,,,,,, 1,,,i nt-s must match with B]points
;i;
I1 ,rr.i rt: tYcliLJ' tt'jq'
'"vith a 2? lI'ln'aine
:t- |1. i:'r,r i:: ir,l illr.rr...l
jnr-'
,l'i1"';
Lr
wrll.
r.,.' 'r' r,

Blepharoplasty

#i

83

Mar-wali H:rrahap

84

fr.jg

ft

Iriqur:e 4*6 " 1'he proposecl fold can be dolrol)51 r- rted

to the patient in a mirr:or by gerrt-le
pressure with a probe 'rlonlj tlrc Iid'
Buried. mattress sutures are placed trans
which connect points A1 - Bl conjunctivally,
(Fiq.
Three buried mattress
11).
B- A
sutures oi this type on each eyelid fix the
levator to the eyelid skin. These sutures
are carefulfy placed to construct a normal
shape and curve to the fold.
No post-operative dressing is necessary and
1,he patient is affowed home the same dalr'
ihis technique is simple in execution and
has the advantage of being reversibfeTwo months after the operation, when the
edema has completely subsided, both superior
palpebral folds must match in position, height,
i""qt}r and contour. If this is not the case, by
.r.tlitrg the number of mattress sutures and their
spa-tiai relationships one to another and to thc
eyelid marqi.n, we "in vary the height, length and
I I ol d conlour o F Lhe supe r ior pa Lpebra
Fiqs. 12 and i3 show, t'The b"for" and after"

5.

Figur:e 4-5.

3^

4.

In the foldless Oriental upper lld

no levator muscle inserts into the
skin-

The eyelid is everted exposing the conjunctiva,

which has been treated beforehand with a

topical application of l? tetracaine

(pontocainb) solution.
A subconj unctival
infiltration
is carried out with 0.5 ml of
2? lidocaine solution.
Two points, A1 and 81, 2 - 3 llm1 apart are
sefected on the conjunctival surface. These
two points 1ie directly above points A and B on
Ll-rcr r.yeJ id skin (Fiqs - 9 and l0) .

Blcpharoplasty

85

86

Marwal i Harahap

#r

rlveroa

lgturt,

SrCqCl:q.
It

ig ure 4-7

Fine non-absor:bab1e suture connects

thc levaLor p.r lpebral superior is
to the eyelid skin at a desired
1eve1.

pictur:e of the operation.

Afthough this simpler technique can provide
natural resufts, unfortr.rnately the resufts are
not afways of a permanent nature. Besidesr the
simpler technlque is not suitable for those who
havc too much supra-orbital fat.
l'herefore we prefer a more radical approach
vi.r a Jong supratarsal incision and removal of
;rI I c.xccss supra*orbital fat.
This method
r,,r;Lr ll s in a pcrmanent fold-

rhree pairs of points are mark'(l

with 2? Gentian violet solution on the
upper eyelid.

The radical technique is as follows (4' 5, 1,91 :

1. The Iine of the proposed palpebral fold is
marked with 2? Gentian Violet solution about
B fiun above the ciliary margin of the upper
eyel id. (Fig. -14 ) .

Local anesthesia is achieved by injecting

2B lidocaine solution with epinephrine.
3- Skin incision is made along the line of the
future palpebral fold and carried down
through subcutaneous tissue and orbicufaris
muscle. (Fi9- l5).
4. The skin and orbicularis ocu1i muscle is
drawn aside; the fat comes into view. (FiS.
16). The supra-orbital fat is picked up with
for.ccps and triruned off with scj,ssors. (Fi917). Thjs st-ep rcnoves the puffy look of the
2.

Blcphanrplasty

87

8B

M:rr-w:rli Haruha1.r

ll:Sjlc,!,z.

I$

3r At
Two points (At and B,) 2 - 3 mm anarl
are selecled on the coni unctival
suri ace -

f:]!-

!:fg!4

Bur j r:d

nr.r L Lres:j suLur Lrs trre placed

t-t:.rns-coni unctival f y, wliich connect

points Al - B1 -B*A.

I,'igure 4*10.

Points Al and Bt on the conj unctival

surface lie d ir6ctly above points A
arnd B on the eyelid skin.

It is impol:tant to excise equal

upper eyelid.
fat from each eyelid
of
supra-orbitaf
amounts
for better syrnmetry ' Careful and complete
hemostasis is necessarY.
5. The dermal fayer of the fower sk'i n Ilap js
anchored to the anterior surfac<: ol the exposed tarsus. Three to five such buried
This encourages f ibr:ous
suLures are insertcd.
l i sslre formation and adhesion between the skin
and tarsaf plate at the predetermined levelIrar this purpose 7 - 0 monofilament nylon
i s used .
(
'J']r., skin is closed with 6 - 0 silk or nylon
;rlong the line of the pafpebral fold.
/, l!,rr r()w strjp <lressings are applied to the in('rr;i()rr. The parti{rnt is allowed home the same
trittr,. lrl ,,rrrl l!) -.ih()w: "thc b,:fore and after"
I!l{

r,l

llr.

i,l,,.t,rt

i()Il

pic-

BIcpha r,.,plasty

89

90

Marw:rli

Har-:rhzrp

t
{

I.'i

qlr]:o 4-12.

Bef

ore the operation.

SUMI4ARY

'l'lrc creation of palpebral folds in the Or:iental

ir; I cosmetic operation requested by patients
t() "W(.sternize" their eyes. The anatomy of the
0ri(.rr1.rl and Occidental eyelis is discussed- The
rrrrrlicirl technique is described and illustrated.

Figure 4-13.

After the operation.

I
Blcphzrroplasly

9l

92

Mar-wali l{ar:rhap

'",'.iS

!
i.: L

i.t

!l

lfirlrrrr.:4

14.

The fine oF the proPoscd palpel)ral

fold is marked \,iith 2t centian
Violet sofulion.

Fiqure 4-15.

Skin incision is made along the line

of the future palpebral fold and
carried down through subcutaneous
tissue and orbicularis muscle.

r
Blephlr',,;rl.rstv

93

()l

Marwali lJarahap

\,.

,ry

"q."

..,,'

ft*

&,

M#
Figure 4-16.

The skin and the orbicularis

oculi muscle are drarirn aside, Lhe
fat comes into view.

lilture

4-17.

The supra-orbital fat is picked up

with forceps and trimmed off with
scissors.

r
Blcphzrroplasty

:rrrf1.1'Wffi"'.

95

Marwali l-larahap

W;:
,t",@

,g!iffi@,,

lligU:q3:f g. Before the operat.ion.

Figure 4-19.

'"-:*

After the operation.