High Double Eyelid Fold Correction Using Wide Dual-Plane Dissection (2024)

Abstract

PATIENTS AND METHODS

From January 2000 to September 2011, 256 patients (227 women, 29 men) underwent high double eyelid fold-lowering revision surgery. There were no primary cases. The average age was 39 years. Although the patient was seated, the fold height was measured by lifting the brow until the upper eyelashes started to evert. The average fold height which was measured from the gray line of the eyelash margin to the double eyelid fold at the midpupillary line was on average 13.5 mm.

RESULTS

From January 2000 until September 2011, 256 patients underwent correction of high double eyelid folds. There were 227 women and 29 men. The average age was 39 years.

For at least 6 months, height of the new double eyelid folds, recurrence of prior eyelid folds, and asymmetry of the eyelid folds were measured and monitored. Average follow-up was 1.3 years. On average, the newly created double eyelid fold height was 7.8 mm. This was a 57.7% reduction from the average preoperative fold height of 13.5 mm (Figs. 5, 6). 83.24% of patients were satisfied with the results, and there was minimal visibility of the prior high fold (Fig. 7). Complications included fold asymmetry in 10 cases, persistence or recurrence of prior folds in 5 cases, and excess upper eyelid skin needing further skin excision in 25 cases. The recurrence of prior folds occurred within 2 weeks. There were 127 cases of mild to moderate eyelid ptosis that needed concomitant ptosis correction surgery (Table 1).

DISCUSSION

Double eyelid revision surgery is highly common in Asian patients. Common reasons for revision surgery are high fold, low fold, and weakened fold (loosening of the fold). Among these revision surgeries, high fold correction is the most difficult. High folds can occur for 2 reasons. One reason is excessively high placement of the fold during initial surgery. The other reason is underlying or borderline eyelid ptosis.

In cases where the upper eyelid skin has redundant skin, prior high folds can be excised, and a lower fold can be made. In cases where there is minimal or no excess upper eyelid skin, the amount a fold could be lowered was limited when prior techniques were used. The excision of the high fold creates greater tightening of the upper eyelid skin and leads to upper eyelid ectropion or lagophthalmos. Relying on the principle that only scar excision can eliminate prior folds created a limitation to fold reduction in upper eyelids that lack redundant skin. Simply releasing the upper fold adhesion during creation of a lower fold leads to recurrence of the upper fold in addition to development of a new lower fold scar. This creates a triple fold.^5–7 A triple fold occurs when the original high double eyelid fold and the newly created lower double eyelid fold form simultaneously.

To solve the problem of having an insufficient amount of skin in patients with an undesired high fold, we made an incision at the desired lower fold height. The dissection then proceeded in cephalic direction to release the adhesions. We performed a dual-plane dissection to interrupt the levator aponeurosis connection to the prior fold at 2 separate layers (between the orbicularis oculi muscle and orbital fat and between the orbital fat and levator aponeurosis). Another key point is the need to make a wide dissection to allow sufficient mobility of the anterior, middle, and posterior lamellae. Thus, the contact point of the prior scar from the posterior orbicularis muscle separates from the anterior orbital septum. Also, the contact point of the prior scar from the posterior orbital septum/fat separates from the anterior levator aponeurosis. Wide, dual-plane dissection and the unique mobility of the upper eyelid prevent the scars from readhering at the same contact points (Fig. 4).

Rather than fully releasing the prior adhesions, Kim and Youn² corrected high folds by placing a fibromuscular flap or graft in the region of the prior fold after resecting the entire depth of the prior fold scar. Other techniques relied on using fat or dermal fat grafts as a buffer to prevent prior folds from reattaching to the levator aponeurosis.^1,5,8 Fat grafting has a negative effect of unpredictable resorption. In addition, fat grafting can lead to prolonged swelling, graft necrosis, clumping, migration, or an unnatural appearance. We did not excise the prior fold scar or apply grafts. Because we used the preexisting scar, there was no volume deficit so we did not need additional tissue. In addition, contour irregularity was minimized. Another disadvantage of using prior techniques that resect scar tissue to lower the fold is that the shape or design of the double eyelid fold cannot be changed. Because our technique is not limited by the prior fold scar, we can design a new lower fold that best matches the patient’s face and overall eye shape. Also with eyes open and closed, the resultant scarring from the prior high fold is minimal.

In cases where there is concomitant eyelid ptosis, ptosis correction brings the levator aponeurosis down to the tarsus.^9–11 Therefore, there is a greater shift in tissue planes between the middle lamella and the posterior lamella. This increased movement of the tissue aids in preventing a prior fold from reoccurring as the scar edges of the upper and lower layers are further separated. In addition, we placed the tarsal fixation lower than that in typical tarsal fixation (2 mm below the upper border of the tarsal plate).¹² By bringing the levator aponeurosis farther down (caudal) to the level of the new fold height, the double eyelid fixation point was at the same level as the height of the new low fold. If the levator was fixated 2 mm below the upper border of the tarsus, then a deep double eyelid fold and eyelash ectropion could occur as the skin of the lower flap gets pulled cephalad by the cephalically located levator aponeurosis.

In terms of the causes of high fold occurrence, besides placing the fold excessively high, the other reason is underlying or borderline eyelid ptosis. During consultation, some patients bring photographs of high folds and express their desire for their double eyelid folds to look like the photos. These pictures often reveal patients with excellent levator function and thin eyelids. However, some patients desiring double eyelid surgery present with underlying or borderline eyelid ptosis. Borderline eyelid ptosis refers to cases when eyelid ptosis is not present but likely to occur when any additional weight is loaded onto the levator aponeurosis (by connecting the high fold to the levator aponeurosis). The diagnosis of eyelid ptosis can be missed at the time of consultation because patients tend to open their eyes fully when looking at the mirror with the surgeon. In addition, the excitement or nervousness of being in a doctor's office induces a sympathetic response that activates the Müller muscle, thus masking borderline eyelid ptosis.^13,14 When a high double eyelid fold is created in these patients, the levator muscle has to lift the extra weight that is attached to the levator aponeurosis (Fig. 8).

We created a spring model to demonstrate the effect of a high fold vs a low fold on levator muscle weight load. The physics calculation based on the spring model equation reveals that a high fold induces a greater weight load on the levator muscle compared to a low fold. Therefore, high double eyelid folds can induce eyelid ptosis without any intrinsic effect from the levator muscle. By contrast, eyelid elevation increases (resolution of eyelid ptosis) with lowered double eyelid folds (Figs. 5 and 6). Incision in itself and excessive use of cautery can induce scarring on eyelid soft tissue. In addition, when a firm anchoring fixation of the skin to the levator aponeurosis is performed to create the fold, it obstructs the lymphatic flow of the lower flap.^1,16 Increased fibrosis and swelling from the lymphatic obstruction adds to the weight the levator muscle has to lift, compared to the motion of the prior non-fettered levator. This can induce iatrogenic eyelid ptosis. Therefore, it is imperative that eyelid ptosis correction be performed at the time of double eyelid surgery in patients with eyelid ptosis or borderline eyelid ptosis, who wish to have a high double eyelid fold.

CONCLUSIONS

Excessively high double eyelid folds can create deep folds and an unnatural appearance. The 3 lamellar structures of the upper eyelid and the mobile component of the posterior lamella allow for a dual-plane dissection method to effectively correct a high fold without contour irregularity of the lid. Converting a high fold to a low fold reduces the weight load on the levator aponeurosis. This in turn can resolve iatrogenic ptosis occurring from high double eyelid folds that burden the eye-elevating mechanism in patients without preexisting ptosis. The technique is applicable to patients without redundant skin, and a lower double eyelid fold can be created without being limited by prior high fold design. Scarring of the prior high fold is minimally noticeable with eyes open and closed.

Supplementary Material

Footnotes

REFERENCES

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