Notice: This article has been re-edited into HTML format. No words where changed, just the layout.
However all graphics have been removed

Best viewed in 600X800 pixel format
Ophthalmic Plastic and Reconstructive Surgery 3(3):135-140.
1987. ~ 1987 Raven Press, Ltd., New York

Update on Anatomy and Techniques

by William P. Chen, M.D., F.A.C.S.

Summary: Recent advances in the understanding of eyelid anatomy in Caucasians and Asians are presented. Various techniques of lid crease operations are then described. A modified technique, combining excision of the skin, orbicularis, orbital septum, and preaponeurotic fat pad, and coupled with supratarsal fixation of the skin to the levator aponeurosis, is used by the author to achieve more predictable and long-lasting postoperative results.

Keywords: Oriental blepharoplasty-Blepharoplasty- Double-eyelid operation-Lid crease-Superior palpebral fold. From Long Beach, California, U.S.A.

Address correspondence and reprint requests to:

Dr. William. P. Chen
2865 Atlantic Avenue. Suite 220
Long Beach, CA 90806 USA


Recent advances in the understanding of eyelid structure and anatomy have allowed eye surgeons to apply this knowledge toward more predictable surgical results. We have come to realize that the upper eyelid complex consists of skin, subdermal fat and connective tissue, orbicularis oculi, orbital septum, preaponeurotic fat pads, levator aponeurosis and muscle, Mueller's muscle, and conjunctive.

It is postulated that the lid crease is formed by attachment of levator aponeurosis fibers onto the orbicularis and subcutaneous tissues underneath the skin, and this appears to be supported by anatomic cross sectional studies (1). We realize that there are basic differences between Asian and Caucasian eyelids in that in a significant percentage of Asians, sometimes reaching 70%, the distal aponeurotic insertion is often rudimentary or absent, leading to the absence of a lid crease as found in Caucasians. An excellent study was recently published by Doxanas (1). He proposed that in Asians the orbital septum tends to fuse with the levator aponeurosis at a lower level on the anterior surface of the superior tarsus, thereby allowing preaponeurotic fat to migrate further down. This prevents the distal aponeurotic fibers from attaching anteriorly onto the orbicularis and subcutaneous tissues to form the lid crease. This gives the impression that Asians have more orbital and preaponeurotic fat. Figure la illustrates the absence of a lid crease, as seen in Asian eyelids. Figure lh shows a lid crease in a Caucasian eyelid. The lid crease, when present, may be continuous (Fig. 1b discontinuous (Fig. lc), incomplete (Fig. ld), or multiple (Fig. 1e). It may slant down or flare up at either canthal angle. Zubiri (2) used the term "foldless" or "inside fold" to describe a crease that tapers toward the medial canthal angle, as in Fig. If, and "outside fold" or "parallel fold" to describe a lid crease that stays parallel over the medial canthal angle (Fig. la). Asians frequently appear to have a shortened palpebral fissure owing to the presence of an epicanthal fold nasally, which fans out gently into the creaseless skin or merges into a shallow crease. It is significant that because of interracial marriages, one may see different subsets of the above findings. In lid fold procedures and blepharoplasty among Asians, the goal should therefore be to create an aesthetically pleasing lid crease that is in balance with the person's facial and orbital contour, one that complements the palpebral fissure, while maintaining a slight upslant of the lateral canthus in relation to the medial canthus.

In the last 30 years, different authors have described drastically different techniques in an attempt to create a lid crease, the permanency of such being as important as the aesthetic appeal. Sayoc (3) in 1953 described the technique where a skin muscle incision is made down to the tarsal surface, followed by excision of a strip of pretarsal orbicularis muscle. He then attached the inferior skin edge to the tarsal surface using 7-0 silk or 6-0 chromic catgut. Fernandez (4) in 1960 modified this by excising some skin, and the lid crease was formed by deliberate attachment of skin to the levator aponeurosis. With eyelids that appeared full, he routinely excised a small strip of orbicularis, septum orbitale, and preaponeurotic fat. Boo Chai (5) in 1964 used only three nylon sutures from the conjunctival surface toward the skin side to create the lid crease, not unlike Pang's full-thickness eyelid sutures used in conjunction with blepharotomy. Mutou and Mutou (6) in 1972 claimed only 0.1% failure rate when they used two silk or catgut sutures, placing them horizontally from the conjunctival surface and parallel to the superior tarsal border, and burying the ligatures on the conjunctival side. It is, however, the opinion of most surgeons that this method has a higher incidence of failure with disappearance of the lid crease. Flowers (personal communication per J. S. Zubiri, 1977) described excising the orbicularis and orbital septum, detaching and then reattaching the levator aponeurotic insertion on the tarsal plate. This is an overly drastic maneuver without any added advantage while at the same time creating the risk of lid contour deformity and secondary ptosis. Matsunaga (7) described a procedure of creating a supratarsal fold that is followed by removal of the epicanthal fold several months later.

The technique of performing lid crease enhancement in Asians should be tailored to the lid anatomy of the individual patient; this is the key to good results and a satisfied patient. In the preliminary evaluation of these patients, it is important to elicit any history of wound-healing irregularity, keloid formation and hypertrophic scar, systemic illnesses, steroid intake, allergic blepharoconjunctivitis, keratitis sicca, and any contraindication to surgery. One should then examine the patient and note the presence or absence of epi (FIG. 2. A strip of redundant skin being excised above the lid crease incision line.) (FIG. 3. The orbital septum is opened and a small amount of preaponeurotic fat removed.) canthal fold, characteristics of the lid crease (contour, extent, single or multiple, distance from the lid margin, nasal "dip," etc.), presence of eyelid fullness from excessive preaponeurotic fat, shallowness of orbital rims, nasal bridge, intercanthal distance, and whether there is a natural upslant of the lateral canthus. The author usually asks the patient to show him where they want the crease to be: whether they prefer the crease to be parallel or tapered at the medial canthal angle, and to be parallel or flare up at the lateral canthal angle.



The surgical technique consists of the following sequence of maneuvers: After adequate anesthesia is achieved, the lid is everted, and the tarsal plate is measured carefully with a calipers over the central, lateral, and medial portions. It is then transposed onto the skin side, which will constitute the new lid crease position. The lateral extent of the lid crease is made parallel or slightly higher than the central portion. Any excessive skin is marked out in an elliptical fashion. (FIG. 4. Supratarsal fixation. The stitches includes small portions of the levator aponeurosis between the upper and lower skin edges.) (FIG. 5. Closure of lid crease with 7-0 nylon in a continuous fashion) The author tries to stay within 8 mm from the lateral canthus. The skin removed usually does not exceed 3 mm (Fig. 2). The epicanthal fold is left untouched in the majority of cases. A 2- to 3-mm strip of pretarsal orbicularis muscle below the level of the superior tarsal border is then excised. The upper edge is pulled up slightly with a fine skin retractor, exposing the orbital septum, and again 2 mm of it is excised at its point of fusion with the distal levator aponeurosis. Excessive fat is removed (Fig. 3) by careful clamping, cutting, electrocautery, and reinspection for bleeding points. Supratarsal fixation is then carried out by the use of nonabsorbable sutures (Fig. 4). The author uses four 6-0 silk in an interrupted fashion, picking up the lower skin edge with small bites of the levator aponeurosis and then the upper skin edge; 6-0 nylon or polypropylene is used in those that tend to form hypertrophic scars and keloids. The rest of the closure consists of 7O silk or nylon in a running fashion, and the crease usually forms very nicely (Fig. 5). Stitches are removed (FIG. 6. Fifteen-year-old girl with absence of lid crease (top). Postoperative result (bottom).) by the end of 5 days for silk and 7 days for polypropylene or nylon. Postoperative swelling and ecchymosis are usually confined to the pretarsal portion of the lid incision and will recover in 4 weeks when the vascular and lymphatic channels reestablish themselves. (FIG. 8. Preoperative (top) and postoperative (bottom) views of 25-year-old woman who had had two previous lid crease procer1'~r"~:) (FIG. 7. Twenty-two-year old woman with indistinct lid crease (top). Postoperative photo (bottom) was taken 3 weeks after repair. Routinely the author advises patients to stop consuming any aspirin and anticoagulants for 2 weeks prior to and I week after the surgery. Diuretics and low-dose corticosteroids are seldom indicated postoperatively. The various methods described for excision of the epicanthal folds are all less than satisfactory as they create unsightly scars that cannot be easily hidden. The maneuver of transcribing the superior tarsal border onto the skin side for the lid crease incision will not result in an excessively high crease since the upper tarsus of most Asians measures between 6 and 8 mm. Potential complications include infection, hemor rhage, suture reaction, granuloma formation, secondary ptosis, lid retraction, and corneal exposure. Suboptimal results include uneven lid creases, insufficient lid crease, insufficient excision of fat pads, redundant lid creases, lid creases that disappear with time, unsightly epicanthal scar, and lash ptosis. In certain patients, there may be rarefaction or Partial disinsertion of the levator aponeurosis, and this must be corrected accordingly.



Figure 6 illustrates the preoperative appearance and ideal, postoperative result on a 15-year-old girl who underwent a lid crease procedure. Note the gentle tapering of the crease at the medial canthus, merging into the epicanthal fold. Figure 7 shows a 22-year-old woman who desired enhancement of her lid crease. The postoperative photo was taken 3 weeks after surgery and showed residual edema and slight ptosis. Both resolved by 6 weeks postoperatively. Figure 8 is of a 25-year-old woman who had had two previous lid crease corrections. She complained of excess downward sloping of her lid crease that caused it to appear fused to the lateral canthus. Correction was performed by enhancing the crease laterally and placing it at a higher level. Figure 9 shows the appearance of a 43-year-old woman with excessive hooding of her upper lid that caused obliteration of the lid crease. A blepharoplasty was performed. Figure 10 shows a 32-year-old man before and after the creation of a lid crease. Note the slightly lower placement of the crease; no attempts were made to remove any preaponeurotic fat pads.



In summary, the goal of the surgeon should be to create an attractively placed eyelid crease that is well suited to the Asian facial and eyelid configuration, and to avoid an excessively high lid crease with its round eyed appearance. The technique described in this article has yielded predictable and permanent results in the hands of the author.



  1. Doxanas MT. oriental eyelids. An anatomic study. Arch Ophthalmol 1984;102:1232-5.
  2. Zubiri JS. Correction of the Oriental eyelid. Cling Plast Surg 1981 ;8:725-37.
  3. Sayoc B. Plastic construction of the superior palpebral fold. Bull Phil Ophthalmol Otol Soc 1953;1:2.
  4. Fernandez L. Double eyelid operation in the oriental in Hawaii. Plast Reconstr Surg 1960;25:257.
  5. Boo Chai K. Plastic construction of the superior palpebral fold. Plast Reconstr Surg 1964;31:556.
  6. Mutou Y. Mutou H. Intradermal double-eyelid operation and its follow-up results. Br J Plast Surg 1972;25:285.
Copyright © 2001-2005 William P. Chen. All rights reserved.