For the last few years, I have seen more and more Asian patients asking for an "occidental" lid crease in the upper lid and that is why I developed a specific technique for these patients. Moreover, most Asian patients are very specific and concrete about their desires and expectations. Some of them do not have any lid crease at all and just want a (typically) low Asian fold in the upper eyelid: they desire a double eyelid without changing the ethnic character of it. Other patients want a complete occidentalization with a high lid crease and a resection of prolapsing orbital fat pockets. Indeed they frequently complain of lid heaviness. Furthermore there is a third group of patients with a true blepharoptosis, i.e. with a real lower lid margin that (partially) covers the pupil. These patients may just want their eyelids to be lifted without altering the character of the lids. Here the skin incision must be lower, either in a preexisting crease or, if the patient does not have a crease at all, no higher than 4 to 5 mm above the lid margin. Also the contralateral lid crease incision must be measured and reproduced exactly. So the procedure must be individualized for each patient and his desires must be discussed before surgery. It is also important that the patients know the limitations of the intervention; on the other hand in most cases small changes will already give excellent results. So I recommend only subtle, very natural changes in the height and contour of the upper lid crease. Avery important step in the surgery is the demarcation of the upperlid incision and skin resection with the patient in upright position. For the infiltration of the anesthetic with put the patient in supine position. All incisions are done with a Radiosurgical unit because in this way the incision is pressureless and that gives the best results especially for the delicate skin of the upper eyelid.. Moreover, Radiosurgery limits the bleeding and swelling during and after the surgery what results in faster recovery. It is known that Asian patients have greater propensity for hypertrophic scarring ant that is why, especially in these patients, I always use Radiosurgery and never a salpel or CO2 laser. Contrary to conventional surgery I do not begin the intervention with a deep skin-muscle resection but only perform a very superficial skin excision. After that, I switch to a different radiosurgical wave , not only to contract the underlying orbicularis muscle to accentuate the lid crease but also to push the fat pockets back into the orbit. Only in very rare cases the orbicularis muscle is incised to perform a conservative fat resection.. If the muscle is incised for fat resection, it is sutured with absorbable 6/0 Vicryl sutures. The skin is closed with separate Prolene 6/0 sutures that can be taken out after 6 days. We put a cooling mask on the eyes to prevent swelling and eventual postop bleeding. The surgery itself tekes not more than 45 minutes. The patient stays in our recovery room for another 30 minutes and then returns home. Patients acceptance of this type of surgery is excellent and because in most cases the muscle does not need to be incised, the risks and complications of the Radiosurgically assisted upper lid blepharoplasty are minimal.
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