PRIME Journal Vol. 11 Issue 4

muscle that lifts the upper eyelid), and they should be treated accordingly (for correction of their ptosis). Moderately severe cases of ptosis may need to be treated first, with double-eyelid surgery as a second- stage procedure. The medial epicanthal area should be addressed in discussion with the patient. If the patient has no preference, the author generally prefers to avoid an epicanthoplasty unless the epicanthal fold is very marked. The patient often makes his or her preference clear on this matter, which of course, influences the size of the fold the surgeon needs to create in order to accomplish the desired result. Figure 4 Immediate postoperative appearance (performed with CO 2 -laser technique), open incisional double eyelid blepharoplasty Figure 5 (A) Pre- and (B) postoperative photos. The patient (Chinese origin) underwent open incisional double eyelid bleferoplasty. Result: High crease with semilunar shape Figure 3 Preoperative assessment for open incisional double eyelid blepharoplasty Semi-open suture method The semi-open method incorporates the natural appearance and low morbidity of the closed suture method with the permanence associated with the open method. The lower portion of the eyelid fat is removed through a small incision. This procedure is best suited for younger patients with little forehead ptosis (e.g. high brows) and no prior crease surgery. The upper eyelid skin should be relatively thin, with thin muscle incorporated. The most irreversible deformity that can occur with Asian eyelid surgery is the resection of too much fat. The open suture or semi-open method precludes this complication. The steps of the operation are as follows: ■ The eyelids are marked ■ After administering intravenous or oral sedation, local anaesthesia is administered beneath the eyelid skin ■ After allowing the local anaesthetic to take effect, a 1-cm incision is made. A small sliver of muscle is resected and then small volumes of fat ■ Next, four sutures equidistant to each other through the full thickness of the eyelid are placed ■ The skin is then closed and a light compression dressing is applied. Open incisional method The preferred height of the incision has already been determined with the patient in the upright position, taking into account the patient’s forehead anatomy. Skin markings are thenmade ( Figure 3 ). The height is set at the mid pupil, with the rest of the marking continuing at the same height to the side until reaching the bone rim to the temporal side. Toward the nose, the marking tapers smaller toward the caruncle but stops approximately 2–3mm above the lash line. An incision is made with a knife or CO 2 laser, and the skin can be excised—the amount depends on the degree of preoperative skin excess. A sliver ofmuscle is removed. Gentle pressure on the globe helps verify the presence of eyelid fat. Fat can be excised through the septum, and then 6–9 equidistant sutures are placed between the skin and the deep connective plate in the lid in order to make the fold for the globe line. Skin closure is performedusing running sutures as in traditional blepharoplasty. After surgery Eye ointment is administered, and a light cooling compression dressing is applied. The patient is instructed on the use of eye drops and eye ointment. Themedial epicanthal area should be addressed in discussionwith the patient. If the patient has no preference, the author generally prefers to avoid an epicanthoplasty unless the epicanthal fold is verymarked. AESTHETIC FEATURE | BLEPHAROPLASTY | 36 September/October 2021 | prime-journal.com