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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 34  |  Issue : 2  |  Page : 101-105

A prospective study on the role of removal of pretarsal tissue in Asian blepharoplasty


Department of Plastic and Reconstructive Surgery, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission05-Dec-2020
Date of Decision06-Dec-2020
Date of Acceptance09-Dec-2020
Date of Web Publication25-Jan-2021

Correspondence Address:
Akoijam Ibohal Singh
Department of Plastic and Reconstructive Surgery, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_123_20

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  Abstract 


Background: Surgical creation of a superior palpebral fold, known as the double-eyelid operation (Blepharoplasty), has become the most popular cosmetic surgery in Asia. One of the distinguishing features between an individual of Asian descent and western descent is the absence or presence of an upper eyelid crease. An eye with a double-eyelid looks fresh, youthful, and attractive. Several techniques to create a unique esthetic kind of double eyelid in the Asian population has been reported.
Aims: Keeping up with the recent evolving techniques, our study is designed to study the role of removal of pretarsal tissue in Asian Blepharoplasty and to analyze the esthetic outcome.
Materials and Methods: Study Variables used were age, sex, address, maximum crease height, height of eyebrow, intercanthal distance, and interpupillary distance. Outcome Measures were symmetry of both the eyelid crease and subjective aesthetic appearance.
Settings and Design: An interventional prospective study was a tertiary hospital setup in Manipur, India, or a period of 2 years. Double-eyelid operation (Blepharoplasty) was performed on a total of 91 cases, with removal of pretarsal tissues along with a strip of pretarsal orbicularis oculi.
Statistical Analysis: The data analyzed with IBM SPSS Statistics 21 developer. Descriptive statistics mean were used for statistical analysis and paired t-test for quantitative data.
Results: A total of 91 operated cases were analyzed, taking variables - age, sex, address, maximum crease height, height of eyebrow, intercanthal distance, and interpupillary distance. Outcome measures were symmetry of both the eyelid crease and subjective esthetic appearance. It was found out that majority of the crease height remain unchanged from the intraoperative marking level. Making the preoperative planning a reliable representation of final outcome, and 76 cases (83.5%) were in Grade I subjective esthetic outcome and only 1 case was in Grade III (unsatisfied).
Conclusion: Remove the pretarsal connective tissue and part of orbicularis muscle allowed for better fixation, smooth skin surface and leaving less tissue to become postoperatively edematous. Along with minimal fat excision helps to avoid a sunken sulcus. This technique gives good esthetic outcome. The procedure makes the newly created double-eyelid appear natural and more beautiful after complete recovery.

Keywords: Asian eyelids, blepharoplasty, double eyelids, esthetic surgery


How to cite this article:
Suiyibangbe, Singh AI, Choudhary AK, Das S, Singh LO, Singh NS. A prospective study on the role of removal of pretarsal tissue in Asian blepharoplasty. J Med Soc 2020;34:101-5

How to cite this URL:
Suiyibangbe, Singh AI, Choudhary AK, Das S, Singh LO, Singh NS. A prospective study on the role of removal of pretarsal tissue in Asian blepharoplasty. J Med Soc [serial online] 2020 [cited 2021 Feb 25];34:101-5. Available from: https://www.jmedsoc.org/text.asp?2020/34/2/101/307890




  Introduction Top


Surgical creation of a superior palpebral fold, known as the double-eyelid operation (Blepharoplasty) has become the most popular cosmetic surgery in Asia and the third most frequently requested surgery (including noncosmetic procedures) among Asian Americans.[1]

One of the distinguishing features between an individual of Asian descent and western descent is the absence or presence of an upper eyelid crease. Double-eyelid fold is formed by the fibers of levator palpebrae superioris (LPS) which sends fibers to skin. LPS originates superior to the orbit and is attached to the anterior surface of the tarsal plate. Thin fibers penetrate the orbicularis oculi muscle to exit from and adhere to the dermis anterior to the tarsal plate, so the overlying skin region is depressed when the levator palpebrae muscles contracts.[2]

Asians tend to possess a greater number of eyelid fat pads and a larger amount of subcutaneous and suborbicularis fat than persons of other ethnic groups, and the periorbital fat is lower. These qualities of the periorbital fat compartment in the upper eyelids contribute to the puffiness of the single eyelid, which further obscure the supratarsal crease, and may produce pseudoptosis.[3] The anatomical difference between the upper eyelids of Asians and Caucasians is the presence of an epicanthal fold, which obscures the medial canthus (inner corner) and gives the eye a relatively narrow appearance.[1] This fold is universally present among humans at birth but is only seen in 2% of non-Asian adults, while the incidence in Asians may be as high as 90%.[4]

The Japanese surgeon Mikamo was the first to publish on the double-eyelid technique, detailing the creation of a supratarsal crease in the upper eyelid in 1896; this innovation occurred in the context of the cultural westernization of Japan in this era.[2] Several authors reported techniques to create a unique Japanese esthetic that mirrored the kind of double eyelid that occurs naturally in the Asian population.[5]

The literature on blepharoplasty has focused mainly on the evolving technical aspects; fewer works have discussed the ethical implications of a surgery that has the potential to alter a feature characteristic of ethnicity. An eye with a single eyelid has a profound influence on a person's appearance. On the other hand, an eye with a double-eyelid looks fresh, youthful, and attractive.[6]

Keeping up with the recent evolving techniques, our study is designed to study the role of removal of pretarsal tissue in Asian Blepharoplasty and to analyze the esthetic outcome.


  Materials and Methods Top


This hospital-based descriptive interventional prospective study was conducted in a tertiary hospital setup in Manipur for 2 years from November 2016 to November 2018. All cases of Asian eyelid blepharoplasty performed during the time frame were included. The inclusion criteria were (a) 18 years and above with Asian eyelid (b) both males and females (c) who give consent for the study. Exclusion Criteria were (a) refusal to participate in the study, (b) who has undergone previous eyelid surgery, (c) congenital deformities, and (d) ptosis and facial paralysis. A total of 91 cases were selected as sample size.

All patients were admitted a day before operation, routine investigations performed. Preoperatively, in the operation theater, the height of upper lid crease was measured with caliper at three points, i.e., the midpupillary point and above the medial and lateral canthi. The three points were joined using a permanent skin marker, to outline the desired lid crease. The symmetry was assessed on both sides by asking the patients to open their eyes. Procedure was performed under local anesthesia. One milliliter injection 2% Lox (lignocaine with adrenaline 1:200,000) was injected subcutaneously along the incision line. A strip of pretarsal orbicularis was removed after dissecting till the tarsal plate. Bipolar Cautery was used for hemostasis. To create the eyelid crease, three to four buried polypropylene 6-0 sutures were placed between the tarsal plate and dermis of the inferior margin of the incision. The symmetry between the two eyelids was assessed by turning away the light and asking the patients to open their eyes. The skin was closed with polypropylene 6-0 cutting suture subcuticularly. Postoperatively, ice cubes were placed over the eyelid intermittently to effect vasoconstriction and reduce edema. Stitches were removed on 7th postoperative day. Follow-up was done at 3 months and the patients reassessed, and photographically documented for height of crease, prominence of crease, and symmetry on both sides.

Study variables used were age, sex, address, maximum crease height, height of eyebrow, intercanthal distance, and interpupillary distance. Outcome measures were symmetry of both the eyelid crease and subjective esthetic appearance.

Statistics analysis

The data collected was entered into a data-based program namely IBM SPSS Statistics 21 developer. Descriptive statistics mean were used for statistical analysis and paired t-test for quantitative data.

Ethical issues

The study was carried out after obtaining approval from the Research Ethics Board, Regional Institute of Medical Sciences, Imphal, Manipur, India. All the participants were informed about the nature of the project and those who agree to participate were asked to sign in the informed consent form. Participants were assured that they can withdraw from the project at any time.


  Results Top


The study was conducted in 91 cases of Asian eyelid undergoing blepharoplasty with removal of pretarsal plates. Out of the 91 cases who underwent blepharoplasty, 85 cases were female accounting for 93.4% and males 6 cases accounting for 6.6%, respectively. Age ranged from 15 to 40 years. The maximum number of patients who underwent blepharoplasty belonged to the age group of 21–25 years [Figure 1]. Maximum cases of Asian eyelid blepharoplasty belonged to the urban areas with 86 cases accounting for 94.5%. The remaining five cases (5.5%) hailed from the rural areas.
Figure 1: Age in years

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Preoperatively, majority of the cases had a preexisting lid crease. Out of 91 cases of blepharoplasty, 75 cases (82.4%) had a crease height ranging from 1 to 4 mm. Whereas in 8 cases, crease height was from 6 to 10 mm, and 8 cases did not have any crease (absent) accounting only 8.8% [Table 1].
Table 1: Preoperative crease height

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Proposed crease height was marked at different positions depending on patient's choice. In 66 cases (72.5%), the crease height was made at 9 mm–11 mm from the mid horizontal of the upper eyelid (eyelid lash) and in 25 cases (27.5%) were marked at 12 mm–14 mm, respectively [Table 2].
Table 2: Intraoperative crease height

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On follow-up after 3 months of blepharoplasty, crease height was measured using caliper. It was found out that majority of the crease height remain unchanged from the intraoperative marking level. Out of 91 cases, 75 cases (82.41%) the crease height was within 9 mm–11 mm. In 15 cases (16.5%), the crease height was within 12 mm–14 mm and finally 1 case had a crease of 7 mm [Table 3].In 52 cases the eyebrow height was within 21 mm–25 mm and in 32 cases the eyebrow height was within 16 mm–20 mm whereas in 7 cases the eyebrow height was within 26 mm–30 mm [Table 4]. The intercanthal distance in out of the 91 cases, 58 cases (63.7%) were within the range of 31 mm–35 mm, 31 cases (34.1%) were within 25 mm–30 mm and only 2 cases were within 41 mm–45 mm [Table 5].The interpupillary distance in 58 cases (63.7%) was within the range of 41 mm–50 mm and in 32 cases (35.2%), the IPD were within 31 mm–40 mm whereas in one case, it was within 51 mm–60 mm, respectively [Table 6].
Table 3: Postoperative crease height after 3 months

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Table 4: Eyebrow height

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Table 5: Intercanthal distance

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Table 6: Interpupillary distance

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The esthetic outcomes were analyzed on postoperative follow-up after 3 month and were categorized into Grade I, II, and III by subjective appearance and symmetry of both upper eyelids. 76 cases (83.5%) were in Grade I where the patient was very much satisfied with the result of blepharoplasty. Fourteen cases were in Grade II, where the patients were just satisfied with the procedure, whereas only one case was in Grade III where there was asymmetry over left and right upper eyelid, hence not satisfied [Figure 2] and [Figure 3].
Figure 2: Esthetic outcomes

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Figure 3: Preoperative and postoperative images

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  Discussion Top


Upper-eyelid Blepharoplasty is a common procedure in esthetic plastic surgery.

The goal of blepharoplasty in Asians is to make the eyes fresh, youthful, and attractive.

Oriental people have different periorbital anatomic characteristics, their motivation for seeking eyelid surgery is different, and therefore, operative techniques have been modified consequently.

There are also many eyelid shapes among Oriental population, mostly with regard to the presence and location of the supratarsal fold and/or the presence of an epicanthal fold. The surgeon must therefore master a range of surgical procedure to treat these variations adequately.[7]

There are many types of procedures to create the double eyelid. Techniques for double-eyelid surgery can be roughly classified into open, nonincisional, and semi-open procedures.[8]

In this study, out of 91 cases, 85 subjects were female, and 6 subjects were male. This may reflect that women are more beauty conscious than their male counterparts. Our study shows that maximum cases fall within the age group of 21–25 years, followed by 26–30 years of group. Weng[8] also reported that 70% of cases requesting upper eye lid blepharoplasty in Asian are below 30 years of age. In our study, 95% of the subjects are below the age of 30 years.

Majority of the cases are from the urban area accounting 94.5% whereas only 5.5% cases are from rural areas. The reason behind the marked increase in eyelid surgery in urban areas could be due to westernization of culture, easy accessibility to health care system, awareness of the facility. The absence of eyelid crease account 8.8% which is slightly lower than that reported in the earliest literature on the prevalence of double eyelid as by Mikamo[2] in Japanese blepharoplasty (17%–18%).The upper lid crease height in 75 out of 91 cases (82.4%) were ranging from 1 to 4 mm, which is very much similar among the Malay population (2.9 mm–3.0 mm) by Dharap and Reddy[9] and Chinese population (2.4 mm–2.6 mm) by Chen et al.[10] The eyebrow height was slightly higher than Wu et al.[11] studies in Chinese female population (12.50 mm) where our studies shows maximum number was within 21 mm–25 mm. Maximum intercanthal distance (63.7%) were within the range of 31 mm–35 mm, which is similar to Jayaratne et al.[12] study on Hongkong Chinese subject (40.01 mm for male and 38.27 mm for female). The interpupillary distance ranged from 31 to 51 mm, which is similar to the study of Aljunid and Ngeow[13] in Chinese population (34.7 mm to 40.01 mm). The absence of eyelid crease in this study account 8.8% which is slightly lower than that reported in the earliest literature on the prevalence of double eyelid as by Mikamo[2] in Japanese blepharoplasty (17%–18%).

In this study, we remove the pretarsal connective tissue and part of orbicularis muscle for better fixation, a flat smooth skin surface and leaving less tissue to become postoperatively edematous. Fat excision is kept to a minimum to avoid a sunken sulcus. The puffy eyelids are thus changed into slim eyelids which and appears more natural. After 3 months' postoperative follow-up, the appearance of the upper eyelids is similar to almost natural eyelid creases. The procedure makes the newly created double-eyelid appear natural and more beautiful after complete recovery. Out of 91 cases, 76 cases accounting for 83.5% were in Grade I, where the patients were very much satisfied with the result of the blepharoplasty. Fourteen cases were in Grade II, where the patients were just satisfied with the procedure. Only one case was in Grade III, where there was asymmetry over left and right upper eyelid, hence not satisfied. Thus, the role of removal of pretarsal tissue in Asian Blepharoplasty gives a highlighted esthetic result.

This study outcome was not directly compared to other techniques and demographic limited. Moreover, outcome analysis was for a short period of follow-up. Further studies will be required to overcome these limitations.


  Conclusion Top


Remove the pretarsal connective tissue and part of orbicularis muscle allowed for better fixation, smooth skin surface and leaving less tissue to become postoperatively edematous. Along with minimal fat excision helps to avoid a sunken sulcus. This technique gives good aesthetic outcome.The procedure makes the newly created double-eyelid appear natural and more beautiful after complete recovery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nguyen MQ, Hsu PW, Dinh TA. Asian blepharoplasty. Semin Plast Surg 2009;23:185-97.  Back to cited text no. 1
    
2.
McCurdy JA Jr. Beautiful eyes: Characteristics and application to aesthetic surgery. Facial Plast Surg 2006;22:204-14.  Back to cited text no. 2
    
3.
Cheng J, Xu FZ. Anatomic microconstructure of the upper eyelid of the oriental double fold. Plast Reconstr Surg 2001;107:1665-8.  Back to cited text no. 3
    
4.
Gradinger GP. Cosmetic upper blepharoplastic. Clin Plast Surg 1988;15:289-97.  Back to cited text no. 4
    
5.
Mikamo M. Plastic operation of the eyelid. J Chugaii Jishimpo 1896;17(2):1197-8.  Back to cited text no. 5
    
6.
Lee JY, Cho K, Choi DD, Park KA, Woo KI, Kim YD, et al. Superior rectus muscle insertion injury following cosmetic upper lid blepharoplasty: A case report. BMC Ophthalmol 2018;18:187.  Back to cited text no. 6
    
7.
Weng CJ. Oriental upper blepharoplasty. Semin Plast Surg 2009;23:5-15.  Back to cited text no. 7
    
8.
Liao WC, Tung TC, Tsai TR, Wang CY, Lin CH. Celebrity arcade suture blepharoplasty for double eyelid. Aesthetic Plast Surg 2005;29:540-5.  Back to cited text no. 8
    
9.
Dharap AS, Reddy SC. Upper eyelid and eyebrow dimensions in Malays. Med J Malaysia 1995;50:377-81.  Back to cited text no. 9
    
10.
Chen MC, Ma H, Liao WC. Anthropometry of pretarsal fullness and eyelids in oriental women. Aesthetic Plast Surg 2013;37:617-24.  Back to cited text no. 10
    
11.
Wu XS, Jian XC, He ZJ, Gao X, Li Y, Zhong X, et al. Investigation of anthropometric measurements of anatomic structures of orbital soft tissue in 102 young Han Chinese adults. Ophthalmic Plast Reconstr Surg 2010;26:339-43.  Back to cited text no. 11
    
12.
Jayaratne YS, Deutsch CK, Zwahlen RA. Normative findings for periocular anthropometric measurements among Chinese young adults in hong kong. Biomed Res Int 2013;2013:821428.  Back to cited text no. 12
    
13.
Aljunid ST, Ngeow WC. The intercanthal and interpupillary distances of three major ethnics in Malaysia. J Malaysian Oral Maxillofac Surg 2007;5:3-5.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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