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Revisional Asian Blepharoplasty: Beveled Approach and Resetting of Eyelid Lamellas

Chen, William P. D. MD

Author Information
Plastic and Reconstructive Surgery – Global Open: August 2018 - Volume 6 - Issue 8 - p e1785
doi: 10.1097/GOX.0000000000001785
  • Open
  • United States


Following double eyelid surgery, Asian patients may present with postsurgical complications of high-anchored upper lid crease, excess amount of skin removal and fat reduction. Associated findings include poor crease indentation, static crease, asymmetry, hollow sulcus, lagophthalmos, and acquired ptosis.


Beveled approach and Resetting of Eyelid Lamellas in Revisional Asian Blepharoplasty.1–3 This video shows the author's beveled approach, allowing the surgeon to REACH high toward residual preaponeurotic space, REPOSIT residual fat, REMOVE scarred elements of skin and mid-lamellar tissues, RESET the anterior and posterior lamella, resulting in RECRUITMENT of skin, and partial RESTORATION of the {Preseptal/Pretarsal} ratio.

Preoperative Discussion and Preparation

Often, the goal is to set the high crease lower, with skin shortage being a major obstacle. Photo documentation of the crease height. (Preseptal/pretarsal) ratio is often abnormally reduced with higher crease height for the pretarsal zone. (Pretarsal zone is apparent crease height measured from central eyelid margin to lid crease; preseptal zone is measured vertically from lid crease to lower border of eyebrow.)

Oral diazepam and analgesic are given an hour before, with IV sedation as an option. Topical anesthetic eyedrop (proparacaine) is instilled, and 1 mL or less of 2% xylocaine (with 1:100,000 dilution of epinephrine) is injected. Corneal protector is applied.


  1. Marking—The desired crease is marked, typically inferior to the scar and becomes the lower incision line.1,2 The upper incision line may be marked to include the previous scar if there is sufficient skin remaining, and it will not result in a compromised lid closure. When there is insufficient skin for this scar excision, a more conservative goal will need to be adopted. The separation between the upper and lower incision may be less than 1 mm of scarred skin to preserve skin.
  2. Skin incision is made first along the lower line, followed by the upper line.
  3. Westcott scissors is used to lyse adhesion along the upper incision line in a steep, superiorly beveled approach (REACH). It traverses through skin-orbicularis adhesion.
  4. Small scissoring motion traverses the next layer of adhesion between the orbicularis and underlying septal remnants. This second layer of dissection may be less angled as one search for the collapsed preaponeurotic space from prior fat removal.
  5. Orbital septal remnant is opened transversely across the upper lid. Preaponeurotic fat is freed and REPOSITED.4
  6. Thin strip of scarred skin-orbicularis along the superior tarsal border may be REMOVED using scissors or bovie.
  7. Release the drapes to allow the forehead and preseptal layers to RESET against a dynamic posterior lamella of levator, Mueller’s muscle, and tarsus.
  8. 6-0 Silk is used to pass through the lower skin edge, picking up some aponeurotic fibers just above the superior tarsal border, and then to the upper skin edge, tying them as 6 or 7 interrupted sutures. 7-0 Suture is applied skin-to-skin in between those single sutures. They are removed after 1 week.

In a series of 48 eyes over a 4-year period, the average lowering of crease height is 2.75 mm.1


  1. The beveled approach allows access to the compromised preaponeurotic space and removal of the scarred mid-lamellar tissues.
  2. Recruitment of skin from above the crease helps with crease construction and Restoration of (preseptal/pretarsal) ratio with reduction of abnormal crease height.
Video Graphic 1.
Video Graphic 1.:
See video 1, which illustrates a revisional Asian upper blepharoplasty as performed for a patient with an abnormal high crease following lid crease procedure. This video is available in the “Related Video” section of or at At the beginning of video: 1. Beveled approach and clearance of preaponeurotic platform in revisional Asian upper blepharoplasty. Compared with primary Asian blepharoplasty, the beveled approach used for revision is much steeper, removal of skin is minimal, and mostly confined to removal of the mid-lamellar scar of orbicularis, septum, and fibrosed fat that may be hindering upper lid excursion and crease invagination. 2. The concept of {Preseptal/Pretarsal} ratio: The red line represents the pretarsal segment; it is the apparent crease height as measured from the ciliary margin to lid crease (when measured with the eyes looking ahead, the apparent crease height may appear to be only 5 mm with a true crease height of 7 mm). The green line is measured from the lower edge of the eyebrow to the lid crease and represents the preseptal (and periorbital) dimension, assuming the eyebrow is in its normal resting position above the superior orbital rim. This PS/PT ratio is normally 3.0–4.0 among Asians with lid crease, creating a sense of proportion and separation from the eyebrow. As this ratio drops closer to 1.0, the eye and palpebral fissure appears more rounded. Near end of video: 3. Preoperative photograph of patient with high redundant creases: the abnormal high crease height reduces the {preseptal/pretarsal} ratio to 1.0–1.5. Same patient 3 months postoperatively: the revised crease has settled nicely into a single crease. The apparent crease height is reduced, {preseptal/pretarsal} ratio is now 2.5–4.0, which is more normal for Asians.


1. Chen WPD. Beveled approach for revisional surgery in Asian blepharoplasty. Plast Reconstr Surg. 2007;120:545–552; discussion 553–5.
2. Chen WPD. Asian Blepharoplasty and the Eyelid Crease. 2016.3rd ed. Edinburgh, London: Elsevier Sciences; (textbook, with video resources).
3. Chen WP. Concept of triangular, trapezoidal, and rectangular debulking of eyelid tissues: application in Asian blepharoplasty. Plast Reconstr Surg. 1996;97:212–218.
4. Chen WP. The concept of a glide zone as it relates to upper lid crease, lid fold, and application in upper blepharoplasty. Plast Reconstr Surg. 2007;119:379–386.

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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.