title: A new crease fixation technique for double eyelidplasty using mini-flaps derived from pretarsal levator tissues.
abstract: BACKGROUND
  Most double eyelid operations focus on using a levator insertion into the upper eyelid skin that induces adhesion. Although incision method provides a significant supratarsal fold, it has the disadvantage of causing a visible depression or scarring when eyes are closed in downward gaze.
  
  
  METHODS
  The authors elevated multiple comblike mini-flaps from upper eyelid pretarsal levator tissues under loupe magnification. Flap bases were anchored on the tarsus using 7-0 nylon sutures, and distal flap portions were pulled out to the skin through a separate incision line and then interposed between edges of orbicularis muscle using absorbable microsutures to achieve a complete myocutaneous layer-by-layer repair.
  
  
  RESULTS
  Five hundred twenty-two double eyelidplasties were performed by the senior surgeon (Y.C.) using the described miniflap method. Patients were followed for 6 to 38 months (mean, 26 months). Seven palpebral fold failures were encountered, especially on the medial side, and 12 cases of fold asymmetry occurred because of inappropriate anchoring of miniflaps; all 12 were revised secondarily. No granuloma formation or scar hypertrophy occurred on upper lids. Although mild erythematous skin changes inevitably occurred during the early postoperative period, patients were satisfied with the palpebral folds, which showed no scars during downward gaze at 2 years postoperatively.
  
  
  CONCLUSIONS
  The authors introduce a modified double eyelidplasty involving the interposition of multiple comblike mini-flaps derived from the pretarsal levator tissue of the upper eyelid. The procedure not only allows clean repair of the upper eyelid without disrupting tissue layer continuity but also enables double eyelidplasty with minimal scar formation.
authors.affiliation: Seoul and Ilsan, South Korea From Choi Yeop Plastic Surgery Clinic and the Department of Plastic and Reconstructive Surgery, DongGuk University International Hospital.
authors.forename: Yeop
authors.initials: Y
authors.lastname: Choi
authors.forename: SuRak
authors.initials: S
authors.lastname: Eo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D019882:Blepharoplasty / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013524:Surgical Flaps; D055815:Young Adult
references.citation: Shirakabe Y, Kinugasa T, Kawata M, Kishimoto T, Shirakabe T. The double-eyelid operation in Japan: Its evolution as related to cultural changes. Ann Plast Surg. 1985;15:224–241.
references.citation: McCurdy JA Jr. Upper blepharoplasty in the Asian patient: The “double eyelid” operation. Facial Plast Surg Clin North Am. 2002;10:351–368.
references.citation: Sheen JH. A change in the technique of supratarsal fixation in upper blepharoplasty. Plast Reconstr Surg. 1977;59:831–834.
references.citation: Zubiri JS. Correction of the oriental eyelid. Clin Plast Surg. 1981;8:725–737.
references.citation: Song RY, Song YG. Double eyelid operations. Aesthetic Plast Surg. 1985;9:173–180.
references.citation: Flowers RS. Upper blepharoplasty by eyelid invagination: Anchor blepharoplasty. Clin Plast Surg. 1993;20: 193–207.
references.citation: Kim DW, Bhatki AM. Upper blepharoplasty in the Asian eyelid. Facial Plast Surg Clin North Am. 2005;13:525–532.
references.citation: Homma K, Mutou Y, Mutou H, Ezoe K, Fijita T. Intradermal stitch blepharoplasty for orientals: Does it disappear? Aesthetic Plast Surg. 2000;24:289–291.
references.citation: Weng CJ, Noordhoff MS. Complications of Oriental blepharoplasty. Plast Reconstr Surg. 1989;83:622–628.
references.citation: Yang SY. Oriental double eyelid: A limited incision technique. Ann Plast Surg. 2001;46:364–368.
references.citation: Matsunaga RS. Westernization of the Asian eyelid. Arch Otolaryngol. 1985;111:149–153.
references.citation: Cook BE Jr, Lucarelli MJ, Lemke BN, et al. A search for drainage patterns in the monkey and correlations with human lymphatics. Ophthal Plast Reconstr Surg. 2002;18:99–106.
references.citation: Doxanas MT, Anderson RL. Oriental eyelids: An anatomical study. Arch Ophthalmol. 1984;102:1232–1235.
references.citation: Jeong SK, Lemke BN, Dortzbach RK, Park YG, Kang HK. The Asian upper eyelid: An anatomical study with comparison to the Caucasian eyelid. Arch Ophthalmol. 1999;117:907–912.
references.citation: Haramoto U, Kugo T, Tamatani M, Hosokawa MK. Anatomic study of the insertions of the levator aponeurosis and Müller's muscle in oriental eyelids. Ann Plast Surg. 2001;47:528–533.
references.citation: Kakizaki H, Zako M, Nakano T, Asamoto K, Miyaishi O, Iwaki M. The levator aponeurosis consists of two layers that include smooth muscle. Ophthal Plast Reconstr Surg. 2005;21:281–284.
references.citation: Stasior GO, Lemke BN, Wallow IH, Dortzbach RK. Levator aponeurosis elastic fiber network. Ophthal Plast Reconstr Surg. 1993;9:1–10.
references.citation: Morikawa K, Yamamoto H, Uchinuma E, Yamashina S. Scanning electron microscopic study on double and single eyelids in Orientals. Aesthetic Plast Surg. 2001;25:20–24.
references.citation: Anderson RL, Beard C. The levator aponeurosis: Attachment and their clinical significance. Arch Ophthalmol. 1977;95:1437–1441.
references.citation: Siegel R. Surgical anatomy of the upper eyelid fascia. Ann Plast Surg. 1984;13:263–273.
references.citation: Yuzuriha K, Matsuo K, Kushima H. An anatomical structure which results in puffiness of the upper eyelid and a narrow palpebral fissure in the Mongoloid eye. Br J Plast Surg. 2000;53:466–472.
references.citation: Cheng J, Xu FZ. Anatomic microstructure of the upper eyelid in the Oriental double eyelid. Plast Reconstr Surg. 2001;107:1665–1668.
references.citation: Sayoc BT. Plastic construction of the superior palpebral fold. Am J Ophthalmol. 1954;38:556–559.
references.citation: Fernandez LR. Double eyelid operation in the oriental in Hawaii. Plast Reconstr Surg. 1960;25:257–264.
references.citation: Matsunaga RS. Westernization of the Asian eyelid. Arch Otolaryngol. 1985;111:149–153.
references.citation: Baker SS, Muenzler WS, Small RG, Leonard JE. Carbon dioxide laser blepharoplasty. Ophthalmology 1984;91:238–244.
references.citation: Kang DH, Koo SH, Choi JH, Park SH. Laser blepharoplasty for making double eyelids in Asians. Plast Reconstr Surg. 2001;107:1884–1889.
references.citation: Black EH, Gladstone GJ, Nesi FA. Eyelid sensation after supratarsal lid crease incision. Ophthal Plast Reconstr Surg. 2002;18:45–49.